Aggressive Follow-up of Early Cancer Questioned

BALTIMORE--Intensive, laboratory-based follow-up programs forpatients treated for early stage breast cancer do not enhancesurvival or reduce morbidity, said John H. Fetting, MD, at a symposiumsponsored by Johns Hopkins Oncology Center, where he is co-directorof the Breast Service.

"There is little information on the cost effectiveness ofthese follow-up programs, and what information we have suggeststhat screening for metastases is not cost effective," hesaid.

Despite the use of physical examinations and laboratory studies,more than two thirds of breast metastases are discovered by thepatient's own reports of symptoms. "From a public healthperspective, laboratory tests are just not all that valuable asscreening tools," Dr. Fetting commented.

He referred to results from two randomized clinical trials inItaly comparing intensive use of blood tests, bone scans, mammograms,chest x-rays, and physical exams with less intensive follow-upconsisting of periodic physical exams and yearly mammograms.

A study from Florence showed a shortening of disease-free survivalin the intensive arm, probably because the cancer was picked upearlier (although only by a few months). But, Dr. Fetting noted,the survival rate was the same, suggesting that detecting cancerearly had no benefit, due largely to the "modest" successof current treatments for metastatic disease.

A second, multicenter study showed no difference between intensiveand min-imalist pathways in time to detection of metastases, survival,or quality of life.

"As for the value of mammography in detecting cancer in remainingbreast tissue," Dr. Fetting said, "there are no data.All we can do is make educated guesses." He hypothesizedthat, following irradiation, the ability to detect recurrencein the treated breast is not as good as in the untreated breast.The value of mammog-raphy screening may also vary according tothe prognosis from the original breast cancer, he said. Its valuewould be lower in high-risk patients than in node-negative patients.

Patients Want Intensive Follow-up

Yet, Dr. Fetting noted, research shows that most patients wantintensive follow-up. In one study, when patients were asked howoften they wanted to see their specialist, most said every 3 to6 months; two thirds wanted a chest x-ray every one or two visits;and half wanted a bone scan or mammogram at the same rate (AmJ Clin Oncol 14:55-59, 1991).

Patients may want testing because they are looking for reassuranceand some feeling of control. "Oddly enough," he said,"they have it backward. Patients think the history is theleast important and lab tests are the most important. They believethat a 'normal,' ie, negative, test puts them in the clear."

Designated Follow-up Physician?

Dr. Fetting urged physicians to "move away from redundancyin multidiscipli-nary follow-up." He suggested that thiscould be done by designating one physician as the lead contactwith the patient, to be determined by the patient's level of riskof recurrence. A medical oncologist, for example, might followa high-risk patient, while a surgeon or radiation oncologist mightbe assigned to a patient with a lower risk for recurrence.

At the same time, laboratory tests could be scaled back, Dr. Fettingsaid. Annual screening mammograms for the untreated breast areappropriate, he believes, but the frequency of mam-mography forthe treated breast is an unanswered question.

He called for patients to be evaluated for metastases only whenindicated by symptoms. Screening blood tests and chest x-rayswould be left to primary care physicians and, he added, "shouldbe left to them to justify."