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Ann Thorac Surg 1995;60:1557-1558
© 1995 The Society of Thoracic Surgeons
Department of Surgery, Maine Medical Center, Portland, Maine
In a retrospective study reported in this issue, Walsh and colleagues [1] argue that neither the survival nor well-being of 358 patients who had undergone curative resection for non--small cell lung cancer was related to the intensity of follow-up. Put another way, looking for early recurrent tumor in asymptomatic individuals using physical examination, magnetic resonance imaging, sputum cytology, and computed tomography is futile. A periodic chest roentgenogram and a talk with a nurse is just as good and a lot less expensive. Fewer than 3% of individuals in Walsh and colleagues' study wound up with treatment different from what would have been instituted had the clinician investigated only patients with complaints.
Such news catches us off balance. It flouts our intuitive sense that a small and silent recurrence ought more easily to be struck down than a large and symptomatic one. But lung cancer has its own logic and is often dispersed from the start. The American Cancer Society ceased recommending tests for the early detection of cancer of the lung more than 15 years ago [2]. A similar reservation prevails for certain other tumors including breast [3] and colon cancer [4]. ``Early detection'' looks more and more like the shibboleth of overly optimistic health care planners.
We cling to the knowledge that retrospective screening programs are notoriously difficult to evaluate, in part because the survival of asymptomatic patients with newly detected recurrence can only be compared with the survival of symptomatic patients with recurrent growth. Less aggressive tumors may have a long subclinical phase and accordingly are more apt to be found with diligent screening [3]. What we need is a randomized study in which one cohort is never seen again.
If thoracic surgeons remain disengaged from the foregoing, the reported outpatient study cost of $15,072/year for each patient treated with curative intent at M.D. Anderson Cancer Center [1] is guaranteed to raise eyebrows of administrators of health maintenance organizations and insurance companies. Leaving aside the conspicuous lack of similar concern by third-party payers for visits of unproven value to physician colleagues, now may be a good time for thoracic surgeons to revisit the boundaries of our threatened and shrinking realm. For many, the recovery room is even now terra incognita. Intensivists and pulmonologists run intensive care units. Endoscopy is all but a memory. Is the follow-up clinic next? Were the sole criterion of its usefulness lengthening the patient's life through early discovery of recurrent tumor then the answer might be ``yes'' and the surgeon could bid farewell at the bedside on the day of discharge.
Follow-up visits are to scan and record. How has our patient fared? Did we hit the target organ and leave the others unscathed? Without follow-up, we grope, no more able to gauge results than Longfellow, the poet archer who ``shot an arrow into the air. It fell to earth, I knew not where.'' We look for signals that reassure, even as we search for evidence of complications: infection, wound healing, retained sutures, residual air space, empyema, atelectasis, chest wall pain, recurrent nerve palsy, and more. After pneumonectomy, overexpansion of the remaining lung and a prematurely shifted mediastinum may suggest correctable dyspnea. Is there evidence of an airway fistula or bronchial stump granuloma? A localized wheeze with distal atelectasis after sleeve resection raises the possibility of an anastomotic stricture. It seems obvious that the surgeon who once held the hilum in his or her hands is best able to read between the lines of the operative note and to relate what is found in the clinic to what was done in the operating room.
On later visits the surgeon will search for local recurrence. Central nervous system symptoms may herald a solitary metastasis amenable to cure. A new lung primary tumor develops in 11% of patients. New benign disease may have to be sorted out and the possibility of metachronous primary head, neck, or foregut cancers addressed. Most surgeons would agree with Martini and Ginsberg [5], who recommend outpatient visits every 3 months for the first year, every 4 months for the second year, and once or twice a year thereafter.
By closely following up patients the fledgling surgeon learns the natural history of lung cancer and how surgery may modify the course. Follow-up and curiosity are the engines of progress.
Habitual detachment from patients with asymptomatic cancer casts a shadow on the surgeons' rightful claim to the follow-up of patients operated on for benign conditions, too. Mastery of surgery for problems at the esophagogastric junction, for example, involves continual refinement of one's technique based on the reported ability of the patient to swallow, vent gas, vomit, and all the while remain free from heartburn. Belsey [6] cautions that ``the battlefields of surgery are strewn with the remains of promising new operations which perished in the follow-up clinic.'' Operations for both cancer and benign problems must prove their worth over the longest possible period.
Finally, there is the matter of human expectations. Who better than the surgeon to answer questions, explain reports, reassure when possible, and when all hope fades to remain a friend to the end? Several years ago I was asked to defend a surgeon accused of abandoning a patient on whom he had previously operated for lung cancer. The family was ostensibly concerned because the surgeon may have missed a further chance to cure, but it was obvious what really angered them was an unfulfilled need for compassionate care.
On a more personal note, a family doctor phoned from several hundred miles away to ask my advice about a cancer that had recurred a year after operation. I thought of the frail couple in their eighties, the 400-mile round trip, and the futility of it all, and told the doctor there was really nothing that I could do. The local press carried the news the next morning of their deaths. The coroner's file listed the cause as murder and suicide. Not mentioned were the words ``abandoned and unconsoled'' [7].
John Benfield has it right. We must remember the costs, but we must also remember we are treating not just cancer, but human beings [8]. Important as the operation may be, there is more to life than surgeons can remove.
Footnotes
Address reprint requests to Dr Hiebert, 368 Rt 115, Windham, ME 04062.
References
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  J. R. Benfield Systematic Postoperative Radiologic Follow-up in Patients With Non-Small Cell Lung Cancer for Detecting Second Primary Lung Cancer in Stage IA--Invited Critique Arch Surg, August 1, 2002; 137(8): 940 - 940. [Full Text] [PDF]
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 J. S. Donington, D. L. Miller, C. C. Rowland, C. Deschamps, M. S. Allen, V. F. Trastek, and P. C. Pairolero Subsequent pulmonary resection for bronchogenic carcinoma after pneumonectomy Ann. Thorac. Surg., July 1, 2002; 74(1): 154 - 159. [Abstract] [Full Text] [PDF]
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 R. B. Ponn Lightning Can Strike Twice : Second Primary Lung Cancers Chest, December 1, 2000; 118(6): 1526 - 1529. [Full Text] [PDF]
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K. S. Naunheim The right person for the job Ann. Thorac. Surg., June 1, 2000; 69(6): 1653 - 1654. [Full Text] [PDF]
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S. Gilbert, K. R. Reid, M. Y. Lam, and D. Petsikas Who should follow up lung cancer patients after operation? Ann. Thorac. Surg., June 1, 2000; 69(6): 1696 - 1700. [Abstract] [Full Text] [PDF]
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