Session on Survivorship Outlines Surveillance Strategies in Non-Hodgkin Lymphoma

To scan or not to scan? Christopher R. Flowers, MD, MS, associate professor of hematology and oncology, Emory University School of Medicine, gave an overview of current thinking on when computed tomography (CT) and positron emission tomography scans still make sense to identify relapse in patients who had achieved a complete response (CR) in non-Hodgkin lymphoma (and other forms).

Dr Flowers’ presentation Sunday at the 56th Annual Meeting of the American Society of Hematology, convening at the Moscone Center in San Francisco, California, was part of an education session, “Survivorship in hematologic malignancies,” but the presentation with perhaps the greatest relevance for managed care.

As he and his co-author, Jonathan B. Cohen, MD, noted in a companion paper to the session, surveillance imaging “is costly, may expose patients to minimal risks of mortality due to radiation-related secondary malignancies, and can lead to false-positive findings, leading to unnecessary biopsies.”¹

But the most practical problem with the use of routine scans after the second year of CR, Dr Flowers said, is that they catch only a very small portion of relapses; after year 2, most cases of relapse are discovered due to the onset of clinical symptoms. In fact, he noted, ASH included routine scans as an area that needed improvement in its Choosing Wisely initiative, part of the ABIM Foundation campaign to reduce unnecessary tests and procedures for the benefit of patients. Among the studies Dr Flowers cited:

• In a report of 117 patients with DLBCL who achieved CR to 1 of several non rituximab-containing combinations, 35 patients had a median follow-up of 4.6 years, including 7 who relapsed within 3 months of therapy. Just 2 had asymptomatic relapse identified solely by a routine scan.^1,2
• A series of 100 relapsed patients with diffuse large B-cell lymphoma (DLBCL), all of whom had CR/unconfirmed CR to initial therapy, reported that 22% of the relapses were identified based on routine scans and the rest were found through physical exams, symptoms, or laboratory tests. There was no significant difference in OS from time to relapse between the group identified by routine scans and those identified through other means.^1,3

Close monitoring is not the issue, Dr Flowers cautioned—only the use of scans. As he and Cohen wrote, “The majority of relapses in patients with aggressive NHL occur within the first 2 years, although up to 19% of patients merit continued close follow-up, even if imaging evaluations are not included. Patients should be encouraged to report any symptoms and scans would certainly be used to investigate at that point.

On the flip side is the cost of imaging. Dr Flowers presented a chart showing various costs per death avoided using surveillance CT scans every 6 months for 2 years, which is the current recommendation, or every 3 months for 2 years, then every 6 months until the 5-year mark for various rates of risk reduction. If risk is reduced 5%, and 112 deaths are avoided, the cost per death avoided for the first scanning protocol would be $181,210, while the cost for the second protocol would be $634,236.

Moving away from routine imaging in follow-up care for patients who have achieved CR makes the other tools of the hematologist more important than ever, Dr Flowers said. “Good clinical judgment remains the cornerstone of patient care,” he said.

References

1. Cohen JB, Flowers CR. Optimal disease surveillance strategies in non-Hodgkin lymphoma. Hematology. 2014; 2014:481-487.
2. Guppy AE, Tebutt NC, Norman A, Cunningham D. The role of surveillance CT scans in patients with diffuse large B-cell non-Hodgkin’s lymphoma. Leuk lymphoma. 2003;44(1):123-125.
3. Lin TL, Kuo MC, Shih LY, et al. Value of Surveillance computed tomography in the follow-up of diffuse large B-cell and follicular lymphomas. Ann Hematol. 2012;91(11):1741-1745.