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  Table of Contents  
Year : 2017  |  Volume : 54  |  Issue : 1  |  Page : 241-252

A prospective study of telephonic contact and subsequent physical follow-up of radically treated lung cancer patients

1 Department of Radiation Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
2 Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
3 Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
4 Department of Nuclear Medicine, Tata Memorial Hospital, Mumbai, Maharashtra, India
5 Department of Pathology, Tata Memorial Hospital, Mumbai, Maharashtra, India
6 Department of Pulmonary Medicine, Tata Memorial Hospital, Mumbai, Maharashtra, India
7 Department of Radiology, Tata Memorial Hospital, Mumbai, Maharashtra, India
8 Department of Clinical Psychology, Tata Memorial Hospital, Mumbai, Maharashtra, India

Date of Web Publication1-Dec-2017

Correspondence Address:
Dr. J P Agarwal
Department of Radiation Oncology, Tata Memorial Hospital, Mumbai, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0019-509X.219599

Clinical trial registration NCT01133067

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 » Abstract 

BACKGROUND: We tested the hypothesis that telephonic follow-up (FU) may offer a convenient and equivalent alternative to physical FU of radically treated lung cancer patients. DESIGN: Prospective study carried out at a tertiary referral cancer care institute, Mumbai. MATERIALS AND METHODS: Two hundred consecutive lung cancer patients treated with curative intent were followed up regularly with telephonic interviews paired with their routine physical FU visits. Patient satisfaction with the telephonic call and the physical visit, the anxiety level of the patient after meeting the physician and the economic burden of the visit to the patient were noted in a descriptive manner. Kappa statistics was used to assess concurrence between the telephonic and physical impression of disease status. RESULTS: With a median FU duration of 21.5 months, the median satisfaction scores for telephonic and physical FU were 8 and 9, respectively. The prevalence and bias adjusted kappa (PABAK) score of the entire cohort of patients was 0.64 (95% confidence interval [CI] =0.58–0.70). Data analyzed up to first disease progression/relapse on FU had a PABAK score of 0.71 (95% CI = 0.64–0.77) indicating substantial agreement. Patients with disease controlled at the FU had a significant PABAK score of 0.88 (95% CI = 0.80–0.94) indicating excellent concurrence. On average, each patient spent Rs. 5117.10 on travel and Rs. 3079.06 on lodging per FU visit. CONCLUSION: Telephonic FU is substantially accurate in assessing disease status until the first relapse. In a resource-constrained country like India, it is worthwhile to further explore the benefits of such an alternative strategy.

Keywords: Follow-up, lung cancer, prospective, telephone

How to cite this article:
Mathew A S, Agarwal J P, Munshi A, Laskar S G, Pramesh C S, Karimundackal G, Jiwnani S, Prabhash K, Noronha V, Joshi A, Rangarajan V, Purandare N C, Jambhekar N, Tandon S, Mahajan A, Kumar R, Deodhar J. A prospective study of telephonic contact and subsequent physical follow-up of radically treated lung cancer patients. Indian J Cancer 2017;54:241-52

How to cite this URL:
Mathew A S, Agarwal J P, Munshi A, Laskar S G, Pramesh C S, Karimundackal G, Jiwnani S, Prabhash K, Noronha V, Joshi A, Rangarajan V, Purandare N C, Jambhekar N, Tandon S, Mahajan A, Kumar R, Deodhar J. A prospective study of telephonic contact and subsequent physical follow-up of radically treated lung cancer patients. Indian J Cancer [serial online] 2017 [cited 2021 Dec 8];54:241-52. Available from: https://www.indianjcancer.com/text.asp?2017/54/1/241/219599

A Munshi
Present Affiliation, Fortis Memorial Research Institute, Gurgaon, India

 » Introduction Top

Lung cancer has been the most common cancer in the world for several decades.[1] In 2012, there were an estimated 1.8 million new cases, representing 12.9% of all new cancers.[2] In India, lung cancer is the 4th most common cancer among both genders and the 2nd most common cancer among males, with approximately 70,000 new lung cancer cases being reported each year.[2] Traditionally, lung cancer patients are called at regular intervals for follow-up (FU) visits to the treating specialist once their curative treatment has been completed. These visits fulfill two purposes: first, they aid in monitoring and managing the side effects of the therapies administered and second, the visits detect recurrences early and allow early initiation of salvage therapies. Furthermore, these visits provide significant psychological support to cancer survivors.[3],[4] However, the FU visits involve logistic issues such as travel of patients over long distances to report to the hospital, incumbent burdens such as food, accommodation, and local travel of the patient, and accompanying attendants.

The limited data in literature on FU in lung cancer is contradictory. Some studies do not support intensive FU in patients with locally advanced lung cancer, reporting that only 65% of patients with even localized relapse could be treated with curative intent.[5] Other studies have shown a trend toward improving survival with intensive FU.[6] In resource-constrained countries like India, there is no published literature regarding the feasibility of alternative methods of FU of lung cancer patients, telephonic or nurse-led FU, despite the fact that lung cancer is widely prevalent in our country.[7],[8]

At our institution, all patients with non-small cell lung cancer (NSCLC) and small cell lung cancer (SCLC) are called in person at 3–6 monthly intervals for FU visits to the hospital. Being a tertiary referral center, we treat a large number of patients from outside the state in which we are situated, with almost 80% of patients residing outside our city. During the process of internal audit of curatively treated lung cancer patients, we realized that many of those staying outside the state found it very tedious and expensive to travel to our institution for each FU visit. It would be of potential benefit to know if these visits could be replaced by a telephonic conversation of the patient with the cancer specialist at the treating hospital. This study examined the utility of a telephonic interview between the healthcare provider and patient to assess the disease status.

 » Materials and Methods Top

Our institution is a tertiary care center dedicated to cancer treatment and registers an average of 1300 patients of lung cancer annually. Two hundred consecutive patients of NSCLC and SCLC who presented to our clinic from July 2010 to October 2013, i.e., over a period of 3½ years were accrued in the study. The study protocol was approved by the Institutional Ethics Committee, and informed consent was obtained from all individual participants. Patients who completed planned treatment with curative intent (e.g., surgery, chemoradiation, surgery followed by adjuvant treatment, or any other combination) and had, at least two telephone numbers were eligible for the study. Each patient who had a scheduled physical FU visit was interviewed telephonically about a week before their visit, and the comparison of the telephonic impression and physical impression of the same patient at the same point of time was conducted in a prospective, nonrandomized manner. Patients undergoing curative intent surgery were followed up with a physical examination and chest X-ray every 6 months for the first 2 years and annually thereafter. Patients who underwent radical radiotherapy or chemoradiation had response assessment imaging with computed tomography (CT) or positron emission tomography-CT (PET-CT) at 3 months after treatment in addition to the routine physical examination and were subsequently called quarterly in the first 2 years. Later, FU was biannual until 5 years posttreatment and annually thereafter and imaging was done only if patient's symptoms warranted it. The first FU visit of the patient after treatment completion was designated FU1, irrespective of when it took place, and subsequent visits were named FU2, FU3, etc.

On telephonic FU, a questionnaire was administered which comprised six questions to quickly screen the patient for symptoms suggestive of locoregional or systemic disease recurrence. The responses were recorded by a physician or a trained research nurse using Appendix A [Additional file 1]. The final telephonic impression of the interviewer regarding the disease status of the patient as apparent through the telephonic interview was recorded as controlled/local failure/distant failure/unknown. All telephonic call details were recorded in the telephonic call sheet (Appendix D) [Additional file 4].

At the physical FU, a different examining physician (to minimize bias) interviewed the patient using the same questions as in the telephonic conversation and responses were recorded. The physician's final subjective and objective impression of disease status was recorded as the gold standard for comparison. After the physical FU, the patient was administered questionnaires regarding their satisfaction with the telephonic and physical FUs and the resource burden incurred toward the physical FU (Appendix B [Additional file 2] and Appendix C [Additional file 3]).


The physical assessment of the patient was considered as the gold standard and the sensitivity, specificity, positive predictive value, and negative predictive value (NPV) of the telephonic assessment were calculated. The concurrence between telephonic and physical assessments was assessed by kappa statistics. Because of the high number of patients whose outcomes concurred telephonically and physically, prevalence and bias adjusted kappa scores (PABAK) were computed, which were more meaningful.[9] To generate 2 × 2 tables for this analysis, the telephonic impression and physical impression of disease status (controlled/local failure/distant metastases/uncertain) were modified as “disease present” or “no disease present.” We also evaluated the influence of demographic factors, tumor factors, treatment factors, and FU-related factors [Table 1] on the accuracy of telephonic FU using Pearson's Chi-square test. All patients were followed up until death.
Table 1: Demographic details of study subjects

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 » Results Top

The patient demographics and tumor characteristics are summarized in [Table 1].

One hundred and twenty-seven patients received concurrent chemoradiation as definitive therapy while 18 were treated with stereotactic body radiotherapy; 33 patients received surgery as the definitive modality with 16 of them receiving adjuvant radiotherapy also.

Fifteen patients died before their first telephonic FU interview; a majority of whom (12) had locally advanced disease. The number of patients who died before each FU visit and the numbers eligible for analysis at each visit is represented in [Figure 1] and [Table 2].
Figure 1: Follow-up status of patients. FU - Follow-up, TFU - Telephonic follow-up, PFU - Physical follow-up

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Table 2: Kappa, prevalence and bias adjusted kappa score, and measures of accuracy of telephonic versus physical follow-up

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In total, 185 patients were available for the final analysis. A total of 108 patients had died due to various causes, and the status of two patients was unknown as they were lost to FU (unable to contact in person and on telephone). Of the 90 patients alive, 19 were not attending physical FU visits regularly due to medical ill-health (9), financial limitations (2), and sociopersonal or other circumstances (8), but were contactable by phone.

All the 200 patients were followed up both telephonically as well as physically, however, several of them were unable to make physical visits to the hospital toward the end of their life but were still traceable by telephone, hence, the median duration of physical FU for the whole cohort was 20 months (range: 1–84 months), and that of telephonic FU was slightly longer-21.5 months (range: 1–85 months). Median overall survival for the entire cohort was 27 months with a mean overall survival of 40.9 months. The overall survival at 3 years of FU was 38.5% (standard error = 4.1%).

The kappa and PABAK scores for each of the 7 FU visits as well as that for all visits together are described in [Table 2]. For data up to the first event (i.e., data censored after the patient first showed disease progression/relapse on FU), the PABAK score was 0.71 (95% confidence interval = 0.64–0.78) and the NPV = 90.4%. All the visits showed a consistently high PABAK and NPV indicating substantial agreement between the telephonic and physical impression of disease [Table 3]. Patients whose disease were controlled at the respective FU were found to have a significant PABAK score (0.88) [Table 4].
Table 3: Statistics for data up to the first event after completion of treatment

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Table 4: Statistics according to disease status at the follow-up visit

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In the univariate analysis of factors affecting the accuracy of telephonic FU, performance status and the distance travelled by the patient for FU were found to be significant (P = 0.02 and 0.03, respectively). The status of the disease at the FU of the patient was the only factor which was found to be significantly and consistently influencing the telephonic assessment of patients disease status (P< 0.01). On multivariate analysis, none of the factors were found to be significant.

In total, 762 telephonic FU interviews were conducted, and 677 physical FU visits took place until October 2014. Only 25.8% of the telephonic interviews required more than one attempt at calling the patient before the interview took place. The average gap between telephonically calling the patient and his subsequent scheduled FU visit was 9 days (range: 0–119 days).

The median value of satisfaction score for telephonic FU was 8 while the median score for physical FU was 9. The time taken on telephonic FU was correlated with the satisfaction score of the patient with telephonic FU using Pearson's correlation test, and a significant negative correlation was seen between the two (r = −0.147, P = 0.002). In 70.27% of all visits, patients reported a decrease in anxiety after meeting the physician in person.

About 59.5% of the study patients had travelled to the institute from distant places–from other states in India or abroad while 31.5% were from within the state where our institution is located (distances up to 750 km). The mean time taken for travel to our institution and return to hometown of the patient was 40.36 h (range: 1–192 h.), i.e., almost 2 days. On an average, each patient spent Rs. 5117.10 on travel (ranging from nil to Rs. 80000) and Rs. 3079.06 on lodging (up to a maximum of Rs. 50,000) per FU visit.

 » Discussion Top

Substantial concurrence was observed between the subjective impression of the interviewer during telephonic interview and the physician at the subsequent physical visit. When we analyzed the data up to first event, the concurrence improved with PABAK score for entire cohort being 0.71 and individual FU scores ranging from 0.62 to 0.78. The NPVs are also consistently high; indicating that the telephonic FU is a reliable tool to determine that a patient is free of disease up to the first event in the course of the disease. Thereafter, due to multiple factors (interventions by the physician, therapy administered, and side effects of further treatments, etc.) telephonic FU becomes less reliable in assessing the patient's disease status. In addition, although sensitivity is low (53.2%), telephonic FU did have a high specificity (88.5%), and high NPV (87%) in the overall analysis. Further, our analysis of the patient-, tumor-, treatment-, and FU-related factors showed that the patient being free of disease at the FU significantly influenced the accuracy of the telephonic call. This could be a pointer to the fact that the telephonic call is accurate until the patient experiences a recurrence or progression of disease but thereafter multiple extrinsic factors affect its accuracy. The fact that other patient and tumor factors do not affect this accuracy suggests that this mode of FU is applicable to a broad population of lung cancer patients.

Evidence for telephonic FU mostly comes from Europe in sites such as breast cancer [10],[11] and also in lung cancer.[12],[13],[14],[15],[16] Similar to Cox et al.[13] our study showed higher median satisfaction scores with physical FU (median score = 9) than with telephonic interview (median satisfaction score = 8). Moore et al.[12] conducted the only randomized trial on nurse-led FU (involving telephonic calls) versus conventional physician-led FU in lung cancer patients. Although the primary endpoint, quality of life, was comparable between the groups at 3, 6, and 12 months, the patients who received nurse-led FU reported greater satisfaction with their care than the patients who received conventional FU. Although we cannot report any difference in parameters such as survival or quality of life, patient satisfaction with the telephonic FU appears to be high, although not higher than the satisfaction with physical FU.

Published economic analyses of telephonic FU in cancer are sparse.[17],[18],[19] In our study, considering that the cost of telephonic FU to the patient was negligible compared to the average amount each patient spends on travel and stay per FU (Rs. 5117.10 on travel and Rs. 3079.06 on stay), and the formidable distance they have to travel to reach our institute (60% travelled more than 750 km taking an average of 40 h. for travel), telephonic FU may be logistically advantageous to our patients. Furthermore, 21% patients alive at the time of analysis were unable to make the physical visit to the hospital, mostly due to ill-health (as some were terminally ill). Telephonic FU would provide an alternative approach, which may substantially reduce the burden on the health care system by identifying those patients in need of a physical check-up and would avoid physical examination and investigation of asymptomatic patients and the associated logistics.

There were several challenges in doing this study. An important concern in telephonic FU was getting connected to patients at the designated time. Constant change in the phone numbers and/or network connectivity problems in remote locations were other significant issues. However, with the telecom revolution and mobile telephony, connectivity has significantly improved in our country. In our study, most patients (74.2%) were contacted at the first attempt on the telephone numbers they provided. Overall 83.5% of patients were reachable on the phone before their scheduled FU over a period of 4½ years. Further, albeit nonrandomized and nonblinded, our study is prospective and deals with consecutive patients.

The overall survival at 2 years of FU was 51.7% which is better than the Surveillance, Epidemiology and End Results program cancer statistics which reported 2-year survival rates ranging from 21.5-30%.[20] Our report is comparable to Indian data published earlier which reported a 30-month overall survival rate of 32% and 49%, respectively for smokers and nonsmokers.[21],[22]

 » Conclusion Top

The high concurrence between the telephonic and physical impressions (gold standard) up to the first event suggests that telephonic FU is a feasible and promising alternative to physical FU in radically treated lung cancer patients, at least, up to the first event in the natural history of the disease. Telephonic FU in our study has helped to maintain contact with several patients who would otherwise have been lost to FU due to logistic and/or medical reasons. With a randomized controlled trial on this issue unlikely to ever happen, our study demonstrates the benefit to the patient in terms of logistics and easing of the economic burden.


The contribution of the research nurse (Ms. Rupali Badhe) and support staff of the Thoracic Disease Management Group in this study is invaluable.

Financial support and sponsorship

This study was funded by an intramural grant awarded by Tata Memorial Centre, Mumbai through a competitive process. A preliminary report of the first 100 patients followed up till May 2012 was presented at the National Conference of the association of Radiation Oncologists of India, Kolkata 2012[23] and was awarded the Parvati Devi Gold Medal for Best Paper, 2012. The abstract of this paper was presented as an oral presentation at the 57th Annual Meeting of the American Society of Radiation Oncology (ASTRO) in San Antonio on October 21st, 2015.[24]

Conflicts of interest

Agarwal JP is a Member of the Editorial Board of the Indian Journal of Cancer. Prabhash K is Editor-in-Chief of the Indian Journal of Cancer. The remaining authors state that they have no conflict of interest to declare.

 » References Top

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Beaver K, Tysver-Robinson D, Campbell M, Twomey M, Williamson S, Hindley A, et al. Comparing hospital and telephone follow-up after treatment for breast cancer: Randomised equivalence trial. BMJ 2009;338:a3147.  Back to cited text no. 11
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Virgo KS, McKirgan LW, Caputo MC, Mahurin DM, Chao LC, Caputo NA, et al. Post-treatment management options for patients with lung cancer. Ann Surg 1995;222:700-10.  Back to cited text no. 15
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Virgo KS, Naunheim KS, McKirgan LW, Kissling ME, Lin JC, Johnson FE. Cost of patient follow-up after potentially curative lung cancer treatment. J Thorac Cardiovasc Surg 1996;112:356-63.  Back to cited text no. 17
Kodama K, Oda K, Okami J, Maeda J, Wang L, Higashiyama M, et al. The value of long-term postoperative follow-up after curative resection of lung cancer and common problems associated with it. Nihon Geka Gakkai Zasshi 2007;108:107-12.  Back to cited text no. 18
Beaver K, Hollingworth W, McDonald R, Dunn G, Tysver-Robinson D, Thomson L, et al. Economic evaluation of a randomized clinical trial of hospital versus telephone follow-up after treatment for breast cancer. Br J Surg 2009;96:1406-15.  Back to cited text no. 19
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Noronha V, Dikshit R, Raut N, Joshi A, Pramesh CS, George K, et al. Epidemiology of lung cancer in India: Focus on the differences between non-smokers and smokers: A single-centre experience. Indian J Cancer 2012;49:74-81.  Back to cited text no. 21
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Agarwal JP, Munshi A, Pramesh CS, Karimundackal G, Prabhash K, Mathew AS. A prospective study of telephonic contact and subsequent physical follow-up of radically treated lung cancer patients – A preliminary report (Abstract). JCRT 2012;8 Suppl 3:182-4.  Back to cited text no. 23
Mathew AS, Agarwal JP, Munshi A, Laskar SG, Pramesh CS, Prabhash K, et al. Aprospective study of telephonic contact and subsequent physical follow-up of radically treated lung cancer patients. Int J Radiat Oncol Biol Phys 2015;93:S120.  Back to cited text no. 24


  [Figure 1]

  [Table 1], [Table 2], [Table 3], [Table 4]

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