Money Well Spent?
The 29th Annual Miami Breast Cancer Conference culminated in a thought-stirring last session. J. Michael Dixon, MBChB, MD, professor of surgery at the University of Edinburgh and clinical director of the Edinburgh Breast Unit at the Western General Hospital,Edinburgh, Scotland, and Patrick I. Borgen, MD, director of the Brooklyn Breast Cancer Program at Maimonides Breast Cancer Center in Brooklyn, New York, debated the pros and cons of longterm clinical follow-up care of patients with breast cancer.
The Con Argument: Clinical Exams Increase Costs and Psychological Distress
“It is always difficult to give up something that you are used to doing,” began Dixon’s argument against frequent follow-up for breast cancer patients in remission. “There are numerous guidelines but very little guidance,” he said, highlighting the disparity in follow-up guidance in different parts of the world. Currently, North American guidelines suggest that clinical examinations take place every 3 to 6 months for the first 3 years, every 6 to 12 months for the next 4 to 5 years, and on an annual basis thereafter for women in remission from breast cancer.
Dixon challenged the notion that intense follow-ups improve outcomes for women previously treated for breast cancer. He highlighted studies that have looked at the detection of systemic recurrence in women previously diagnosed and treated for breast cancer.
A 1994 randomized study comparingpatients undergoing intensive laboratory and x-ray—based follow-up assessments to standard of care found more metastases earlier in the intensely followed group—but at the expense of significant false-positive rates.1 Dixon concluded that because the 5- and 10-year data analysis did not show any differences in overall survival in the 2 trial arms, the intense follow-up was not cost-effective.
A 1999 study compared the 10-year mortality rates in women who had undergone treatment for primary breast cancer. The women had either intense or standard clinical follow-up.2 The more intense protocol did not offer a survival advantage, the study concluded.
A more recent analysis from 2007 showed that traditional routine clinical checkups were not sufficient enough to prevent disease recurrence, questioning the need for frequent follow-ups.3 The study authors stated that alternative follow-up methods were acceptable for patients, as these did not decrease either quality of life or anxiety about recurrence. Less-frequent visits can, however, offer significantly lower costs and time savings.
“Just because you can, doesn’t mean you should,” Dixon stressed, pointing out that recurrent clinical follow-ups resulted not only in unnecessarily increased healthcare costs, but also in creating psychological distress that can negatively affect the health of a patient.
Dixon’s solution? More effective ways of achieving improved patient outcomes with minimal psychological stress by seeing regular physiotherapists or nurses, rather than undergoing regular clinical follow-up assessments.
Dixon discussed a recent United Kingdom study that followed a total of 32,877 women from the West Midlands Cancer Intelligence Unit Cancer registry; 18,706 of the included women had breast conservation surgery, and 15,171 had mastectomies following a breast cancer diagnosis. Analyses showed that earlier detection generally led to better outcomes. The study also showed that clinically detected recurrences did worse compared with detection via mammography or by the patient herself. Overall survival was very much dependent on the size of the second tumor detected. The aim should be to detect recurrence as early as possible, Dixon concluded.
How much does follow-up cost? Dixon discussed an economic model, in British pounds, that incorporated different treatment regimens, the estimated likely survival benefit per regimen, and the cost per incremental quality-adjusted life-years (QALYs), among other metrics, for a woman aged 57 years. The utilization of extra tests such as mammography, clinical examination, and magnetic resonance imaging (MRI) did not lead to added benefit, except for younger women. The top 3 most cost-effective options were mammography, followed by clinical examination and mammography, and clinical examination and an MRI.
“Current clinical follow-up programs waste time and resources,” Dixon said. They are much better off targeting specific groups that have clinical issues, he concluded. “Local recurrence rates are falling. Therefore, the cost detection of each recurrence is increasing.”
The Pro Argument: Patient Care Is Personal
Borgen’s pro argument emphasized the soft side of the physician-patient relationship and the fundamental goal of patient follow-up—peace of mind and regular surveillance to catch recurrence as early as possible. Borgen believes that there is a survival benefit of patients seeing their oncologist regularly.
Borgen stated that he was surprised at the seemingly high rate of clinically detected first recurrences, 13.5%, cited by Dixon. “My guess is that the rate is actually far lower than this,” he commented.
Borgen discussed the subjective perspective of the relationship between the physician and the cancer patient,emphasizing the relationship of the patient
with the surgeon as the first point of contact and a help in “navigating the maze of diagnostic and treatment options.” Borgen said he believes that patients often are reassured by staying in close contact with their surgeon as a “source of information.”
From a physician’s perspective, the benefit of following a breast cancer patient in the long term is training. Longterm follow-up can be highly valuable for residents and physicians early in their careers. Understanding the longterm effects of surgery and therapy help better train surgeons and oncologists, argued Borgen.
Borgen concluded with something that hits home for most clinicians (and patients): the personal aspect of care. “It’s always problematic to apply national, aggregate numbers to the patient that is sitting in front of you,” he said. “The only way to really achieve what Dr Dixon discussed is a policy change in the [United States]. That policy change would likely be driven by insurance payers who would simply refuse to pay for follow-up care.”
Is this the future in the United States? Not without relevant, convincing, largescale patient follow-up data.Funding Source: None.
Author Disclosure: The author reports no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.
Authorship Information: Concept and design; drafting of the manuscript; and critical revision of the manuscript for important intellectual content.1. Del Turco MR, Palli D, Cariddi A, Ciatto S, Pacini P, Distante V. Intensive diagnostic followup after treatment of primary breast cancer: a randomized trial. JAMA. 1994;271(20):1593- 1597.
2. Palli D, Russo A, Saieva C, et al. Letter to the editor. Intensive vs clinical follow-up after treatment of primary breast cancer: 10-year update of a randomized trial. JAMA. 1999;281(17):1586.
3. Montgomery DA, Krupa K, Cooke TG. Alternative methods of follow up in breast cancer: a systematic review of the literature. Br J Cancer. 2007;96:1625-1632.