JMIR Publications

ABSTRACT

Background:

Several guidelines recommend post-treatment surveillance for non-small cell lung cancer (NSCLC). However, studies evaluating surveillance patterns often cannot distinguish between imaging ordered for surveillance versus symptoms suggestive of recurrence. Moreover, early recurrences and other competing events hamper efforts to determine true surveillance rates.

Objective:

Leveraging comprehensive Veterans Health Administration data, we develop a novel competing risks framework to describe patterns and predictors of NSCLC imaging surveillance.

Methods:

The study cohort comprised 1,888 patients treated for Stage I-III NSCLC between 2008-2016 who survived ≥6 months. Clinical documents and radiology reports were abstracted for image indication and clinical information. We estimated the cumulative probability of receiving guideline-concordant surveillance defined as chest CT within 4-9 months after treatment, accounting for competing risks and censoring. Multivariable cause-specific Cox regression estimated associations between patient factors and guideline-concordant surveillance and were subsequently adjusted for multiple comparisons.

Results:

Among 1,888 patients, 43.8% (CI, 41.6%-46.1%) received guideline-concordant surveillance within 9 months of treatment, whereas 15.2% (CI,13.7%-16.9%) received non-concordant surveillance and 33.4% (CI, 31.3%-35.5%) received no surveillance. The remaining 7.6% of patients were ineligible for surveillance due to recurrence or death. Compared to years 2008-2010, patients treated for NSCLC from 2014-2016 had a significantly higher likelihood of receiving guideline-concordant surveillance (HR 1.42, P=0.0002).

Conclusions:

In this unique application of a competing risks framework, the rate of guideline-concordant surveillance in this national cohort was lower than many previously reported studies. These data highlight a significant gap in surveillance among eligible, asymptomatic lung cancer survivors emphasizing the need to develop efficient strategies to ensure these patients continue to be monitored.