Follow-up of Patients with Thoracic Malignancies

Reasons for fear of cancer recurrence after endoscopic treatment of T1 esophageal adenocarcinoma. A semi-structured interview study

Prior research has shown that patients with early Barrett's neoplasia treated endoscopically report at least the same level of fear for cancer recurrence as patients treated surgically for a more advanced disease stage. The aim of this qualitative study was to gain insight into the reasons why endoscopically treated patients fear or not fear cancer recurrence. Patients treated endoscopically for T1 esophageal adenocarcinoma participated in a semi-structured interview. Patients were asked open questions about their fear of cancer recurrence and presented an a priori list of possible reasons for experiencing or not experiencing fear of cancer recurrence. Data saturation was reached with 12 patients who added 7 new reasons. Reasons that induced fear of cancer recurrence were related to physical symptoms, if cancer was diagnosed as an accidental finding and experiences with cancer in close relations. Endoscopic surveillance was mentioned as a reason for not experiencing fear of cancer recurrence. Patients reduced their fear of cancer recurrence by talking to close relations and seeking distraction. Caregivers reduced patients fear of cancer recurrence by giving adequate information and by showing photo of the treatment and the results of the treatment. According to patients with early Barrett's neoplasia, receiving comprehensible information about the risk of recurrence and potential symptoms that may or may not be indicative of cancer recurrence, and continuing endoscopic surveillance, reduced fear of cancer recurrence. We recommend that healthcare providers discuss fear of cancer recurrence with their patients to enable tailoring information provision to their needs.

Long-term fear of cancer recurrence in patients treated endoscopically for early Barrett's neoplasia

Previous studies on fear of cancer recurrence after endoscopic treatment for early Barrett's neoplasia focused on fear during a relatively short period after the intervention. The aim of this study was to explore whether fear of cancer (recurrence) persists during long-term follow-up in patients treated endoscopically for Barrett's neoplasia compared to patients treated surgically for a more advanced stage of esophageal adenocarcinoma. Participants previously participated in a prospective longitudinal study investigating quality of life and fear of cancer recurrence and were treated endoscopically for early Barrett's neoplasia (high-grade dysplasia-T1sm1N0M0) or surgically for a more advanced esophageal adenocarcinoma (T1N0M0-T3N1M0). For the present study, participants were again invited to complete a set of questionnaires including the fear of cancer recurrence scale (FORS), worry for cancer scale (WOCS), and the anxiety subscale of the Hospital Anxiety and Depression Scale (HADS Anxiety). Thirty-nine patients were eligible in the endoscopy group and 28 in the surgical group. The median time between the baseline measurement (original study) and the long-term follow-up assessment was 4 years (interquartile range 3-5 years). Fear and worry for cancer recurrence and general anxiety diminished over time in both treatment groups. However, at long-term follow-up, endoscopically treated patients had significantly higher levels of worry for cancer and general anxiety than surgically treated patients. Fear of cancer recurrence did not significantly differ between endoscopically and surgically treated patients. We found that worry and fear of cancer recurrence and general anxiety in endoscopically treated patients declined over time, but not as much as in surgically treated patients.

An Unusual Presentation of a Posterior Mediastinal Schwannoma Associated with Traumatic Hemothorax

Schwannomas of the thoracic cavity are typically an asymptomatic, benign neurogenic neoplasm of the posterior mediastinum. In this case, we present a traumatic hemothorax as the initial presentation for a previously undiscovered mediastinal mass. The patient presented with shortness of breath and right-sided chest pain after being struck in the chest with a soccer ball. An operative exploration was pursued due to persistent hemothorax with hemodynamic instability despite resuscitation and adequate thoracostomy tube placement. The intraoperative etiology of bleeding was discovered to be traumatic fracture of a large hypervascular posterior mediastinal schwannoma. Surgical resection is the treatment of choice for these tumors. Specific serological markers do not exist for this tumor, and radiographic findings can be variable, so tissue diagnosis is of importance in differentiating benign from malignant schwannomas, as well as other posterior mediastinal tumors. However, most patients have excellent survival following complete resection.

Follow-up and surveillance of the lung cancer patient following curative intent therapy: ACCP evidence-based clinical practice guideline (2nd edition)

BACKGROUND

To develop an evidence-based approach to follow-up of patients after curative intent therapy for lung cancer.

METHODS

Guidelines on lung cancer diagnosis and management published between 2002 and December 2005 were identified by a systematic review of the literature, and supplemental material appropriate to this topic was obtained by literature search of a computerized database (Medline) and review of the reference lists of relevant articles.

RESULTS

Adequate follow-up by the specialist responsible for the curative intent therapy should be ensured to manage complications related to the curative intent therapy and should last at least 3 to 6 months. In addition, a surveillance program should be considered to detect recurrences of the primary lung cancer and/or development of a new primary lung cancer early enough to allow potentially curative retreatment. A standard surveillance program for these patients, coordinated by a multidisciplinary tumor board and overseen by the physician who diagnosed and initiated therapy for the original lung cancer, is recommended based on periodic visits with chest imaging studies and counseling patients on symptom recognition. Smoking cessation and, if indicated, facilitation in participation in special programs is recommended for all patients following curative intent therapy for lung cancer.

CONCLUSIONS

The current evidence favors follow-up of complications related to curative intent therapy, and a surveillance program at regular intervals with imaging and review of symptoms. Smoking cessation after curative intent therapy to prevent recurrence of lung cancer is strongly supported by the available evidence.

Preferences for Follow-up After Treatment for Lung Cancer

Pressure on lung cancer clinics is increasing with the "2-week wait" initiative. This initiative is one of the key targets set out in the National Health Service (NHS) Cancer Plan for the United Kingdom, whereby all patients presenting with symptoms which may be indicative of a cancer diagnosis will be seen by a consultant within 2 weeks of initial presentation at their primary care provider. This has resulted in busy clinics, with the potential for extended clinic waiting times and unmet needs for information and psychosocial support on the part of patients and families. There is increasing interest in the most appropriate mode of follow-up for patients with lung cancer who are under observation, many of whom have completed specific treatments. Such patients may benefit from specialist nurse review for symptom control and psychosocial support. Nurse-led clinics are safe and cost effective in the oncology and research-funded setting. This study aimed to assess the acceptability of nurse-led follow-up in a large general lung cancer clinic seeing approximately 250 new patients annually. Over a 34-week period, there were 487 follow-up attendances and 94 (19.3%) of these were made by 72 patients deemed eligible for nurse-led follow-up. Sixty patients were approached and 54 (90%) agreed to participate in the study. A questionnaire containing vignette scenarios of nurse-led, telephone, GP-led, and standard (hospital, medical) follow-up was completed by 34/54 (63%) of eligible patients, 10/20 (50%) carers, 20/31 (65%) staff, and 11/38 (29%) GPs. Respondents rated acceptability of the scenarios on a range of issues on a scale of 1 to 5. Patients also completed the EORTC QLQ C30 and lung module questionnaire. Subsequent interviews were carried out with samples of these respondent groups.Fatigue, dyspnea, cough, and pain were the most common general symptoms. Both standard and nurse-led follow-up scenarios were highly rated by patients and other respondents and both were highly significantly favored over GP follow-up, which was the least favored in all areas of the questionnaire. Telephone follow-up tended to elicit more polarized reactions, both positive and negative. In interviews, in relation to nurse-led follow-up, the importance of clear protocols, training, and easy access to medical review were highlighted.

Cost Effectiveness of Chest Computed Tomography After Lung Cancer Resection: A Decision Analysis Model

BACKGROUND

Postoperative surveillance with chest computed tomography (CT) is often performed in patients who have undergone resection of non-small cell lung cancer (NSCLC), despite lack of supporting data. This study involves the creation of a decision analysis model to predict the cost effectiveness of postoperative surveillance CT.

METHODS

A decision analysis model was created in which a hypothetical cohort of patients underwent annual chest CT after resection of a stage IA NSCLC. The incidence of second primary lung cancer (SPLC), sensitivity and specificity of CT, as well as survival after resection of initial primary and SPLC were derived from published literature. The cost of CT and other procedures prompted by a positive finding on CT was calculated from Medicare reimbursement schedules. Cost effectiveness was defined as a cost of less than 60,000 dollars per quality-adjusted life-year gained in the cohort under surveillance compared with controls under no surveillance.

RESULTS

In the initial (base case) analysis, the cost of surveillance CT was 47,676 dollars per quality-adjusted life-year gained, implying cost effectiveness. However, factors that rendered surveillance CT cost ineffective were (1) age at entry into the surveillance program greater than 65 years, (2) cost of CT greater than 700 dollars, (3) incidence of SPLC of less than 1.6% per patient per year of follow-up, and (4) a false positive rate of surveillance CT greater than 14%.

CONCLUSIONS

Surveillance with postoperative CT may be a cost-effective intervention to detect SPLC in selected patients with previously resected stage IA NSCLC.

Surveillance computed tomography after complete resection for non–small cell lung cancer: Results and costs

OBJECTIVE

We sought to determine the prevalence of defined abnormalities on surveillance computed tomography after complete resection for non-small cell lung cancer, as well as the nature and cost of further testing prompted by these abnormalities. We also sought to determine whether resectable metachronous lung cancer can be detected with surveillance scans.

METHODS

A retrospective analysis was performed of all patients who presented for follow-up in 2002 after complete resection for non-small cell lung cancer. Data collected included demographics, clinicopathologic features of the initial lung cancer, the number and results of surveillance computed tomographic scans performed in 2002, the attending surgeons' impressions of the surveillance scans, the nature of any abnormalities and further diagnostic testing prompted by these abnormalities, and the nature of any lung cancer detected on surveillance scans, as well as the treatment rendered. The cost of surveillance scanning and associated diagnostics was computed by using Medicare fee schedules.

RESULTS

Two hundred thirteen patients met the criteria for inclusion in the study cohort. One hundred sixty-eight surveillance scans were performed in 140 of these patients. One hundred five scans were interpreted as abnormal by the radiologist with regard to pulmonary nodules, adenopathy, or pleural fluid, but the surgeon was suspicious for recurrent or new primary lung cancer in only 32 of 105 scans. Further workup revealed recurrent or new primary lung cancer in 16 of 32 patients, with 6 undergoing resection for localized disease. The cost of the surveillance scans and associated care in the study cohort were 16.6% higher than the cost of care in a hypothetically identical cohort not subjected to surveillance scanning.

CONCLUSIONS

Surveillance computed tomography is frequently abnormal after complete resection for non-small cell lung cancer; however, the majority of these abnormalities are not clinically suspicious. Resectable metachronous lung cancer is detected by using surveillance scanning; however, the use of this modality can be associated with increased cost.

Benefits of resection for metachronous lung cancer

OBJECTIVES

The benefits of resection for metachronous lung cancer are not well described. The objective of this study was to evaluate the safety and efficacy of surgical resection for metachronous lung cancers.

METHODS

We reviewed the charts of all patients who underwent a second resection for a metachronous lung cancer from July 1, 1988, to December 31, 2002. Type of resection, operative morbidity, mortality, and survival by stage were analyzed. Survival was determined by using the Kaplan-Meier survival method. All patients were pathologically staged by using the 1997 American Joint Committee on Cancer standards.

RESULTS

Pulmonary resections were performed in 69 patients who had undergone a previous resection. The mean interval between the first and second resection was 2.4 +/- 2.5 years. Seventy-three percent of patients presented with stage I cancers, 9% with stage II cancers, and 17% with stage III cancers. Lobectomy and wedge resection were performed with equal frequency (42% each) for the metachronous cancers. Operative mortality for the second resection was 5.8%. The mean follow-up after the second resection was 37 months. Overall 5-year actuarial survival for the entire group after the second resection was 33.4%.

CONCLUSIONS

Operations for metachronous cancers provided survival that approximated the expected survival for lung cancer. Surgical intervention should be considered as a safe and effective treatment for resectable metachronous lung cancer in patients with adequate physiologic pulmonary reserve.

Follow-up and surveillance of the lung cancer patient following curative-intent therapy

The following two distinctly different issues should be taken into account when planning patient care following curative-intent therapy for lung cancer: adequate follow-up to manage complications related to the curative-intent therapy; and surveillance to detect recurrences of the primary lung cancer and/or development of a new primary lung cancer early enough to allow potentially curative retreatment. Follow-up for complications should be performed by the specialist responsible for the curative-intent therapy and should last 3 to 6 months. Recurrences of the original lung cancer will be more likely during the first 2 years after curative-intent therapy, but there will be an increased lifelong risk of approximately 1 to 2% per year of developing a metachronous, or new primary, lung cancer. A standard surveillance program for these patients is recommended based on periodic visits, with chest-imaging studies and counseling patients on symptom recognition. Whether subgroups of patients with a higher risk of developing a metachronous lung cancer (eg, those patients whose primary lung cancer was radiographically occult or central and those patients surviving for > 2 years after treatment for small cell lung cancer) should have a more intensive surveillance program is presently unclear. The surveillance program should be coordinated by a multidisciplinary tumor board and overseen by the physician who diagnosed and initiated therapy for the original lung cancer. Smoking cessation is recommended for all patients following curative-intent therapy for lung cancer.