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  • br Keywords Follow up Surveillance Symptoms br Introduction


    Keywords: Follow-up, Surveillance, Symptoms
    Nonesmall-cell lung cancer (NSCLC) is the leading cause of cancer-related death in the United States and worldwide.1-3 Approximately half of newly diagnosed NSCLC patients present
    Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
    Address for correspondence: Thomas J. Dilling, MD, MS, Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, 12902 USF Magnolia Dr, Tampa, FL 33612 Fax: (813) 745-7231; e-mail contact: [email protected]
    with locally advanced unresectable disease, which is primarily managed with definitive chemoradiotherapy (CRT).4 Previous prospective trials have established that platinum-based doublet therapy concurrent with radiotherapy (RT) provides superior out-comes compared to sequential regimens.5 Recently RTOG 0617, a randomized phase 3 trial, demonstrated a median overall survival (OS) of 28.7 months, a new survival benchmark for this Chloroquine concurrent CRT approach.6 Yet despite advancements in multimodal ap-proaches, NSCLC continues to be an aggressive disease with a high risk of recurrence after CRT or surgery.
    Disease relapse dynamics after definitive therapy for NSCLC have mostly been described in heterogeneous retrospective surgical series,7-9 which have informed the American College of Chest
    Relapse Events After Chemoradiotherapy
    Physicians (ACCP) recommendations for postoperative surveil-lance.10 The European Society for Medical Oncology (ESMO) guidelines for NSCLC currently recommend chest computed to-mography (CT) imaging biannually for those deemed to be suitable for salvage treatment; otherwise CT imaging is recommended at least once at 12 and 24 months.11 The National Comprehensive Cancer Network (NCCN) NSCLC guidelines previously recom-mended a similar follow-up schedule, but this was recently changed to a shorter surveillance interval of every 3 to 6 months for the first
    3 years after definitive treatment.12 Although these recommenda-tions have been provided, there are no data from randomized trials and very few retrospective data that analyze posttreatment surveil-lance after definitive CRT.
    We evaluated time-based events of relapse in stage III NSCLC patients after definitive CRT to characterize posttreatment intervals at high risk for relapse. We also analyzed whether symptomatic presentation versus identification on surveillance imaging influenced patient outcomes after initial relapse.
    Patients and Methods
    Study Cohort
    After institutional review board approval, we performed a retro-spective review of a prospectively collected clinical database of pa-tients with pathologically confirmed unresectable locally advanced NSCLC treated with definitive CRT from 2005 through 2014. Over the span of this study, mediastinal staging was performed using combinations of imaging, endobronchial ultrasound, and mediastinoscopy or mediastinotomy. Patients were excluded if artificial selection presented with metastatic disease or had prior oncologic interven-tion for lung cancer.
    Patient, tumor, treatment, and outcome data were abstracted from the electronic medical charts. Particularly, patient de-mographics, Eastern Cooperative Oncology Group (ECOG) per-formance status (PS), disease stage according to American Joint Committee on Cancer (AJCC; 7th edition) staging for NSCLC,13 smoking status during treatment, and total pack-years were evaluated.
    Regarding treatment, all patients received concurrent platinum-based chemotherapy and RT delivered with 70 Gy in 35 fractions utilizing 3D-conformal RT or intensity-modulated RT planning, which has been the standard at our institution since 2005. Beginning in 2006, elective nodal irradiation was not part of the treatment approach. Additionally, treatment for all patients was planned with 4D-CT imaging, and strict normal tissue constraints were used.