Follow-up care by GPs for breast cancer survivors
Women should be wary of conventional follow-up and use their GP to help improve quality of life, says Professor Michael Baum
Like any other medical activity, follow-up after cancer treatment should be evidence-based with the questions constantly in mind: does it improve length or quality of life and is it cost-effective? For breast cancer this is particularly problematic because of its perplexing natural history.
A rational strategy would depend on a biological premise, linked to a follow-up regimen, proven in randomised trials to improve either length or quality of life. Sadly this is far from the case and the subject is ruled by dogma or fear of litigation.
In this country the convention is to review the woman every three months for three years, then six-monthly for another two years – followed annually for the rest of her (or your) life.
In the UK we tend not to do any tests at follow-up, except perhaps a mammogram every one or two years.
In the USA the woman is subjected to blood tests for tumour markers at each visit, together with hepatic, skeletal and chest scans every six to 12 months. The evidence base for all of this is virtually zero. Those clinical trials that have been performed have shown no evidence of improvement in length or quality of life whatever schedule is used1,2.
Tumour markers and scans provide more false positives than true positives, more false reassurance than true reassurance and even if there is 'earlier' detection of distant metastases than normal there is no evidence this lead time provides a therapeutic window.
Furthermore, those women who develop loco-regional recurrence are more likely to note the changes between visits themselves than the surgeon is to detect local relapse at the follow-up appointment.
So why do we continue with this charade when the incidence is increasing and more women are surviving to the point that the outpatient clinics are approaching meltdown? In large part I think it is the expectation of the patients not to feel abandoned.
If they are on long-term endocrine therapy they may experience side-effects and there is the ever-increasing dilemma of the management of climacteric symptoms.
My patients also like to chat about life events or complain about their teenage children. Furthermore, about a third of such women suffer from long-lasting anxiety and depression that needs identification and management3,4. Against this is the terror many feel in the week leading up to the next appointment.
Given this situation it is immediately self-evident that the patient's GP can do a better job of it than an expensive super-specialist. So if that is the case, how should we proceed? I think progress can be made on two fronts: first, making use of the evidence we have so far and, second, setting up some really sophisticated research.
In the first instance we should start desensitising women to the follow-up convention. After the active treatments with surgery, radiotherapy and chemotherapy are completed and the patient is free of complications she should be placed on 'open access' to the clinic with the GP responsible for dealing with her psychosocial problems, advice on medication, reassurance about incidental symptoms and (rarely) referring her back to the hospital when relapse is suspected.
The only hospital-based follow-up that remains active should be for the purpose of research. For example, we now accept the hazard rate for relapse
is not constant but is biphasic with a peak at two-three years (see graph), probably related to the activation of dormant metastases by the act of surgery and a later flatter peak at about seven-nine years which might be related to the stochastic accumulation of adverse life events5.
We should then develop new and more specific tumour markers linked to the molecular biology of the disease and conduct clinical trials for the reintroduction of systemic therapy following a significant rise in one of these.
If this stands the test of time then in the future we can return to shared management with the hospital consultant improving length of life with biological monitoring and the GP improving the quality of life by psychological monitoring.
Professor Michael Baum is consultant breast surgeon at Portland Hospital, London
1 Loong S et al. The effectiveness of the routine clinic visit in the follow-up of breast cancer patients: analysis of a defined patient cohort.
Clin Oncol 1998;10(2):103-6
2 Churn M, Kelly V. Outpatient follow-up after treatment for early breast cancer: updated results after five years.
Clin Oncol 2001;13(3): 187-94
3 Fallowfield LJ et al. Effects of breast conservation on psychological morbidity associated with the dignosis and treatment of primary breast cancer.
4 Ganz PA et al. Quality of life in long-term, disease-free survivors of breast cancer: a follow up study.
J Natl Cancer Inst 2002 2;94:39-49
5 Demicheli R et al. Double-peaked time distribution for breast cancer patients undergoing mastectomy. Breast Cancer Res Treat 2002;75:127-34