I have a remarkably delightful patient who initially developed a stage I NSCLC in 1998, and this was treated with standard surgery. Three years later, she was found on a routine follow-up scan to have disease in her mediastinum. This was biopsied and was found to look remarkably like her original cancer from several years earlier. At that time she received concurrent chemo and radiation, with curative intent. She did well with that, but unfortunately, a couple of years later she developed a single brain metastasis. This was treated with gamma knife stereotactic radiosurgery, and she hasn’t had any evidence of active disease since then.

   Although I am tempted to steal credit for her remarkable story, I actually didn’t meet her until she came to me for follow up in 2003, when I started in my practice at Swedish Cancer Institute. I’ve always had the easy part. We obtain CT scans and head MRI scans, now just yearly, although frankly I’d prefer to see her more frequently because she’s a highlight of my day when she comes in.

   I wish there were more patients like her. So how do we do with cancers detected after initial treatment?

   As mentioned in my last post, most recurrences of treated lung cancer are distant metastatic disease, outside of the chest. But as in the case above, most recurrences in the chest are treated with a non-surgical approach, often radiation.   There really isn’t much evidence on this issue, but it is possible to cure, just pretty unlikely.

   Surgery is certainly an option for some patients and tends to be more feasible in patients who develop a metachronous second primary cancer (new cancer, later time vs. original), but it’s not common. After an initial potentially curative lung surgery, patients have considerably reduced pulmonary reserve and are less likely to be able to tolerate the loss of more lung tissue with another surgery. And it’s still hard to catch a cancer before it’s spread beyond the surgical range. If surgery is performed, it’s not associated with as good a prognosis as an original lung cancer of the same stage. However, the 5-year survival rates for resected stage I NSCLC in a patient being monitored for recurrence are in the 30-53% range, as shown in the table below:

(Click on image to enlarge)

   These numbers are definitely not as good as a stage I patient with no history of prior lung cancer, but they still clearly illustrate that there’s a reason to follow patients after initial treatments. Recurrences and new cancers do develop, and they can be cured.  Regardless, I find that most patients don’t need a lot of convincing that it’s worth keeping in close contact with their doctor for follow-up.  It’s fair to say that there’s a huge amount of variability in practice styles about follow-up, and I think we all struggle to use good judgment even when we don’t have much evidence.  But the few cases of the “great save” of a recurrence after initial treatment compels many of us to push aside the absence of data and do the best we can groping with good judgement and minimal data.