© 2007 European Society for Medical Oncology
editorials |
Breast cancer follow-up: just a burden, or much more?
1 Division of Medical Oncology, Breast Cancer Unit
2 Breast Surgical Unit, Ospedali Riuniti, Bergamo, Italy
* (E-mail: carlo.tondini{at}ospedaliriuniti.bergamo.it)
In the western world, breast cancer is the most common neoplastic disease in adult women. According to the World Health Organization, >1.2 million people will be diagnosed with breast cancer each year worldwide. With early detection and appropriate treatment, the percentage of women surviving at least 5 years after diagnosis and treatment has shifted from 70% in the early 1970s to 90% in the late 1990s. As of now, in the United States there are 
2.5 million women who are breast cancer survivors (http://progressreport.cancer.gov/). These women, following cancer treatment, will be kept under a surveillance strategy, called ‘follow-up’. From the patient's point of view, the purpose of follow-up care is to check for breast recurrence (including new breast primaries), distant metastases, ongoing problems due to cancer treatment, and physical and psychosocial effects that may develop months to years after treatment ends. From a health care point of view, follow-up information is essential for monitoring long-term efficacy and morbidity of cancer treatments. However, while it is widely accepted that all breast cancer survivors should have follow-up care, it is still uncertain how this might best be applied in current practice.
Earlier clinical practice adopted research follow-up principles. Research protocols often include intensive imaging work-up and biochemistry surveys for all patients, usually carried out under specialized supervision, as dictated by strict experimental rules. More recently, several studies have questioned the real utility of such intensive surveillance policies outside clinical trials. A recent metanalysis [1], systematic review [2], and practice guidelines [3] have clearly stated that intensive diagnostic follow-up care, as compared with clinical and mammography screening alone, does not provide a clear benefit for reducing breast cancer morbidity and mortality.
Recently, the debate has broadened beyond the appropriate imaging load, including several other issues. In a time of economic constraint and cost-containment policies, breast cancer follow-up has fallen under the ‘5-Ws’ scrutiny: Who, When, Where, What (with), and Why. In the present issue of Annals of Oncology, Donnelly et al. [4] analyze attitudes and behavior of breast cancer specialists on the issue of dismissing breast cancer survivors to primary care surveillance. Overall, while specialists do agree that a reduced workload from these scheduled visits is desirable, results of this analysis underline criticisms of this policy, including a lack of training for general practitioners (GPs) on specific issues of breast cancer detection and care, especially in relation to the development of new treatments and their long-term side-effects. Furthermore, lack of involvement of GPs in the multidisciplinary approach, a key aspect of high quality breast cancer care, might be detrimental for appropriate and timely patient handling.
Although we believe that optimizing follow-up strategies might require different solutions according to the different cultural and socioeconomic models that western health care systems have, it is of paramount importance to understand: Why? Why should we bother to follow-up our surviving patients and for how long? Is follow-up just a burden, or it is something else?
We firmly believe that following up our surviving patients is both a duty and an opportunity. First, it certainly is a duty towards our patients, women who have lived through a terrible experience and who keep feeling vulnerable. And they are vulnerable, both by cancer-related events and by short- and long-term physical and psychosocial side-effects of cancer treatments. We must provide these women with qualified medical attention. They must know they can always rely on and trust the people who take care of them. We can debate on Who, When, Where and What (with), but we must make sure they get what they need, i.e. qualified and prompt medical attention. Of course, we can set up models where GPs or specialized nurses might be involved in this process. However, as shown by Donnelly et al., this process will require adequate training and involvement in the multidisciplinary approach of breast cancer and in all modern aspects of breast cancer care and surveillance.
Secondly, follow-up is a resource for society. Long-term follow-up information is essential to continue our process of improving breast cancer care. New technologies and therapeutics are continuously transferred from clinical research into current practice. How does this process work? In fact, most of the clinical information gathered in the past decades is coming from experimental clinical research and refers to treatment efficacy. However, efficacy should also be evaluated in the context of real-life setting. In fact, doubts remain about the capacity to transfer experimental efficacy in a broader range of patients and in current clinical practice (effectiveness), where both patients and providers face natural barriers to care.
Outcomes research (OR) aims at evaluating effectiveness in the context of current practice and unselected set of patients, and without it ‘effectiveness’ can at best be guessed but not measured. OR ultimately helps patients, physicians, managers, policy makers, and the public make sounder decisions, based on a deeper knowledge of the effects of medical care on health outcomes [4, 5]. The whole process of guideline definition and evaluation of appropriateness of care should rely on sound scientific evidence coming from OR studies. Follow-up is an essential part of this process.
Following up breast cancer survivors is therefore a necessity, both for the patients and for the society. Taken together, available studies indicate that breast cancer survivors are best served by sensible medical attention, avoiding an excess of unnecessary diagnostic procedures. It is now clear that intensive diagnostic surveillance offers no real benefit as compared with clinical and mammography screening. Regardless of the model chosen, be it a hospital-based service or GPs-guided surveillance, we must make sure that follow-up provides both the patient and society with the expected benefits; for the patient, the certainty not to be left alone with the fear of cancer reappearance, and for the society, the certainty that we keep monitoring and optimizing effectiveness of cancer treatments. Therefore, while debating the 5-Ws and exploring which follow-up model best fits a given socioeconomic environment, we must remember that collecting prospectively follow-up data are of paramount importance to all of us.
References
1. Rojas MP, Telaro E, Russo A, et al. Follow-up strategies for women treated for early breast cancer. Cochrane Database Syst Rev (2005) (1). CD001768.
2. Collins RF, Bekker HL, Dodwell DJ. Follow-up care of patients treated for breast cancer: a structured review. Cancer Treat Rev (2004) 30(1):19–35.[CrossRef][Web of Science][Medline]
3. Khatcheressian JL, Wolff AC, Smith TJ, et al. American Society of Clinical Oncology 2006 update of the breast cancer follow-up and management guidelines in the adjuvant setting. J Clin Oncol (2006) 24(31):5091–5097.
4. Donnelly P, Hiller L, Bathers S, et al. Questioning Specialists' attitudes to breast cancer follow-up in primary care. Ann Oncol (2007) 18.
5. Lee SJ, Earle CC, Weeks JC. Outcomes research in oncology: history, conceptual framework, and trends in the literature. J Natl Cancer Inst (2000) 92(3):195–204.
6. Jefford M, Stockler MR, Tattersall MH. Outcomes research: what is it and why does it matter? Intern Med J (2003) 33(3):110–118.[CrossRef][Web of Science][Medline]
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