Researchers have been taking a critical look at follow-up surveillance for cancer survivors. Their findings call for a shift from reliance on repetitive laboratory and radiographic tests to an emphasis on regular history taking and physical examinations coupled with patient education about recognizing signs of recurrence and contacting the medical provider if symptoms develop.
"With the exception of testicular cancer, the value of aggressive routine follow-up testing, characterized by frequent radiologic and biochemical testing, is questionable," wrote Martin J. Edelman, MD, and colleagues in a critical review of the literature on eight types of cancer (J Gen Intern Med. 1997; 12:318-31). They found utility of serum chemistries only for non-Hodgkin's lymphoma. Serologic markers are effective for detecting recurrences of testicular cancer, but questions remain on their utility in detecting colon and prostate cancers.
Edelman and coworkers recommend chest radiographs only for testicular cancer, Hodgkin's disease, and lung cancer; complete blood counts are not supported at all. The researchers recommend most frequent surveillance during the first 3 years after initial treatment, when relapse is most likely to occur. However, for breast cancer, risk for relapse continues for more than 20 years.
A review by an expert panel of the American Society of Clinical Oncology (ASCO) yielded similar guidelines for patients with breast cancer (J Clin Oncol. 1997; 15:2149-56). After a review of studies published in the past two decades, the ASCO panel concluded that patients with breast cancer who routinely undergo extensive testing to detect recurring disease do not necessarily fare better than patients who do not have such tests. For example, chest radiography, bone scans, and measurements of serologic markers do not have to be used routinely, the group said.
According to internist and panel member Thomas J. Smith, MD, an associate professor of medicine and health administration at the Massey Cancer Center at Virginia Commonwealth University in Richmond, two of the most convincing randomized trials (JAMA. 1994; 271:1587-92 and 1593-7) compared intensive follow-up with routine checkup and periodic mammography for patients with breast cancer. The researchers found no difference in patient survival or quality of life. "We don't have any evidence to support [routine use of high-tech tests]," confirmed Nancy E. Davidson, MD, breast cancer research chair at the Johns Hopkins Oncology Center in Baltimore, who co-chaired the ASCO panel.
On the basis of the panel's findings, ASCO released guidelines stating that routine postoperative care should include annual mammography, plus careful histories and physician examinations every 3 to 6 months for 3 years, then every 6 to 12 months for 2 years, and annually thereafter.
Another ASCO panel more recently published guidelines for treating lung cancer (J Clin Oncol. 1997; 15:2996-3018). After reviewing the literature on inoperable lung cancer, the group determined that routine use of such tests as bone scans and magnetic resonance imaging saved no additional lives and therefore may be unnecessary.
"We have routinely utilized many of the tests in the past, and not always with good reason," noted Robert F. Ozols, MD, senior vice president for medical science at Fox Chase Cancer Center in Philadelphia. For example, a rising value on the CA125 tumor marker test is used by some oncologists as a sign of recurring ovarian cancer. But without symptoms, Ozols argued, the patient should not be treated because the disease may not have progressed clinically. The fact that recurrence of ovarian cancer is often incurable must be part of the equation as well. "There's no good evidence that using such tests prolongs both length and quality of life," he added.
Managed care, with its emphasis on cost-effectiveness and efficiency, is one of the forces driving the medical profession to take a close look at which tests are necessary. Oncologists and general internists continue to be questioned by managed care organizations about the appropriateness of follow-up strategies, including testing. Ozols conceded that today's medical marketplace has many physicians and medical organizations reexamining their practices. "We're trained to use the tests available, but managed care may make us to some degree reexamine our training."
Increasingly, physician-researchers and medical societies are beginning to examine these issues through evidence-based studies, noted Davidson. "The evidence-driven approach to follow-up testing can result in considerable savings without compromise of patient care," according to Edelman.
Several studies now indicate that relapse is detected most often by patients noticing symptoms. A British team of researchers reviewed hospital records of 210 patients with Hodgkin's disease who had a partial or complete remission after chemotherapy and who had participated in a clinical trial between 1984 and 1990 (BMJ. 1997; 314:343-6). After looking at the number of follow-up clinic visits and relapses and the method by which relapses were detected, the researchers concluded that relapse is usually recognized through investigation of symptoms-not by routine checkups of asymptomatic patients.
Yet the idea of waiting for patients to present with symptoms remains controversial. Many physicians were trained to use available tests to monitor for recurrence. The patient's emotional well-being is also involved, Smith noted. In some cases, the patients themselves compel routine use of expensive tests because they prefer the security of routine screening. The patient may be willing to have such tests, even if they yield false-positive results, according to Smith.
At the same time, Ozols observed that patients who have routine testing occasionally have a high level of emotional anguish as they await test results. Rodger Winn, MD, chief of the section of community oncology at the University of Texas M.D. Anderson Cancer Center in Houston, agreed. According to Winn, although some patients actually like to be seen and tested regularly, having fewer tests is better for the psychological well-being of many patients. "Most patients feel relieved that they don't have to go through more testing," he said. "They just want to be sure they aren't missing something."
But Dean H. Gesme, MD, a medical oncologist in Cedar Rapids, Iowa, warned that there are few hard-and-fast testing rules. Gesme applauds ASCO's breast cancer guidelines but is concerned that guidelines that challenge the necessity of some types of routine testing may be misinter-preted. In the shadow of managed care, such guidelines may make it easier for insurers to dismiss valid follow-up tests, said Gesme, who is vice president for interorganizational development for the National Coalition for Cancer Survivorship in Silver Spring, Maryland. The ASCO guidelines are actually a call to increase both physician and patient education, he said. He stressed the need for patients-in particular-to be aware of potential symptoms of recurrent disease.
Ozols agreed, stating that patient education messages should be reinforced by patients' primary care providers as well as the specialists involved in their care. Ozols added that it is difficult to foresee the changes in practice that will result from the clinical guidelines. Costs may decline if fewer tests are used, but this has not yet been examined in a statistically rigorous manner. Many institutions are establishing clinical pathways that will determine which approaches are most efficient, cost-effective, and conducive to the highest level of patient compliance.
-Steven Benowitz
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