Examination does not improve breast cancer follow-up outcomes
The NICE guideline for improving outcomes in breast cancer1 provides recommendations on how to detect and treat local recurrence, manage adverse effects and provide psychological support. A systematic review, in the British Journal of Cancer, has assessed if routine clinical examination improves outcomes in breast cancer follow-up and suggests that the NICE guideline recommendations need to be updated.
The review included 12 studies that provided information on the proportion of relapses detected by clinical examination, mammography and self-examination.
The proportion of potentially treatable local relapse and new contralateral breast cancer was analysed. The review also assessed if the method of detection affects outcome.
The review found that around 40% of potentially treatable relapses are detected by patient self-examination. In studies before 2000, 15% of relapses were detected by mammography and 46% by routine clinical examination. However, in studies after 2000, 40% were detected by mammography, with only 15% by routine clinical examination.
The authors suggest that this is because of improved mammography techniques.
The review concludes that there is no evidence that clinical examination confers a survival advantage compared with other methods of detection.
The duration of routine follow-up after breast cancer is a controversial issue. The rate of recurrence of ipsilateral breast disease is 0.5-1% per year for at least 10 years.
If contralateral new breast cancers are included, the rate increases to 1-1.5% per year.2
NICE recommends that specialist follow-up should be limited to three years after treatment, followed by discharge to general practice. Overall, however, 70% of recurrences occur after the first three years.
The authors suggest that a long-term annual mammography programme needs to be developed.
It has also been suggested that psychological support could be provided between mammograms by direct access to a specialist nurse or doctor.3
In my opinion, such patients also need rapid access to the specialist service.
I agree with the authors that a review of the NICE guideline is needed. Follow-up after breast cancer can then be based on the best available evidence, and the implications for primary care will become clearer.
Montgomery DA, Krupa K, Cooke TG. Follow-up in breast cancer: does routine clinical examination improve outcome? A systematic review of literature. Br J Cancer 2007;97:1632-41Reviewer
Dr Kavi Sharma
GP, Sunderland and GP adviser to Macmillan for the Northern Region