VHA study highlights gaps in posttreatment lung cancer surveillance

A new analysis of Veterans Health Administration (VHA) data suggests that fewer than half of eligible lung cancer survivors receive imaging surveillance consistent with clinical guidelines. The findings, published in Journal of Medical Internet Research (JMIR) Cancer in October 2025, indicate a substantial gap in recommended follow-up care for people treated for early-stage non-small cell lung cancer (NSCLC).

Lung cancer remains the leading cause of cancer mortality worldwide, and even after surgical removal, patients face a significant risk of recurrence. Expert groups recommend routine posttreatment surveillance, typically involving chest computed tomography (CT) within six months. Yet adherence to these guidelines varies widely, with prior studies estimating rates ranging from 25% to 71%.

Seeking to clarify true surveillance rates, senior author Leah Backhus, M.D., M.P.H., professor of cardiothoracic surgery at Stanford Medicine and chief of thoracic surgery at the Veterans Affairs Palo Alto Health Care System, and colleagues conducted a retrospective cohort study using national VHA data.

The cohort included 1,888 veterans treated for Stage 1 to 3 NSCLC between 2008 and 2016 who survived at least six months after treatment. Almost all (96%) of the study subjects were male, and most (71%) were White patients, with an average age of 66 years. More than half (57%) had Stage 1 disease at diagnosis, and surgery alone was the most common treatment method. Researchers reviewed clinical documentation and radiology reports to determine the indication for each imaging study, then estimated the cumulative probability of receiving guideline-concordant surveillance, defined as chest CT imaging within four to nine months after treatment.

Overall, fewer than half of patients received guideline-concordant surveillance imaging. Chest CT accounted for 44.5% of all imaging studies performed within the initial 120- to 270-day window, while chest X-ray accounted for 36.3%. Only 43.8% of the cohort underwent surveillance imaging consistent with recommended guidelines. Surveillance improved over time, though: patients treated between 2014 and 2016 were 42% more likely to have received guideline-concordant imaging than those treated between 2008 and 2010.

“In the study, we estimated the cumulative probability of receiving guideline-concordant surveillance, defined as chest computed tomography imaging within four to nine months after treatment, accounting for competing risks and censoring,” Backhus said in a Stanford news release.

The authors note that roughly one-third of patients did not receive any form of surveillance in the first posttreatment window. They attribute persistent variability in adherence to multiple factors, including differences in patient populations, access to specialized cancer care, and the unique stressors that may affect veterans’ health management behaviors.

The researchers used a statistical approach that helped them tell the difference between imaging done for routine follow-up and imaging prompted by symptoms. It also allowed them to factor in events like early cancer recurrence that might prevent a patient from getting routine surveillance. By accounting for these situations, the authors believe their method may offer a more accurate picture of how often patients truly receive recommended follow-up imaging.

In their paper, Backhus and colleagues say the findings highlight the need for more robust strategies to track and improve surveillance adherence, including patient education, health professional advocacy, and system-level interventions. Although use of chest CT for follow-up has increased over time, they wrote, overall adherence remains lower than many earlier studies have suggested. That result likely reflects the more precise methodology used in this analysis, they said.

Future research, they add, should examine how guideline adherence influences clinical outcomes, especially as recent literature has questioned whether routine surveillance imaging improves survival.