Follow-up Care for Cancer: Making the Benefits Equal the Cost

The article by Schwartz and colleagues is important and timely, and brings into focus an essential component of the practice of oncology. Posttreatment follow-up is not often emphasized in the training of our residents and fellows, and is often based on opinions rather than evidence.

As in all patient encounters, one of the major aims of posttreatment follow-up should be, “Do no harm.” The authors point out the risk of unnecessary tests leading to unnecessary interventions, thereby potentially harming patients without improving outcomes. Unfortunately, the evidence is not always clear as to whether intervention may improve outcome when a recurrence is found.

Exceptions to the Rule

It is generally true, as Drs. Schwartz and coauthors point out, that “there is no curative salvage therapy for most solid tumors,” but there are exceptions. For instance, a randomized study of early hormonal intervention in asymptomatic bone scan–positive (and other locally advanced) prostate cancer patients demonstrated an improvement in outcome with early intervention.[1] Also in this setting, one has to consider the concept of “oligometastases”—ie, that there are substages within the stage of metastatic disease that are potentially curable.[2]

These exceptions do not diminish the message of this article; they simply point to the fact that the answers to many clinical research questions are still emerging and not yet ready to be incorporated into clinical practice guidelines. They show that we—the clinical oncologists—should be vigilant and continue to change our follow-up procedures as new evidence emerges.

Differing Perceptions

When we develop clinical practice guidelines, we should not forget that the perception of quality of care differs between patients and physicians. In a meta-analysis of 221 studies on consumer satisfaction with medical care, Hall and Dornan found that overall quality, humaneness, and competence precede outcome in the ranking of 11 factors that contribute to overall satisfaction among patients.[3]

Jun et al point out that, among 11 attributes that define quality of care and patient satisfaction, patient, physician, and administrator groups differ in the perceived importance of those factors.[4] Patients consider functional qualities more important, whereas physicians attach more significance to technical qualities, including competence and outcomes.

A Simple Solution

What should we do when we have no evidence showing that frequent follow-ups—especially the ordering of tests—lead to improved outcome, but patients feel better when physicians see them, talk to them, and comfort them? The solution is, in fact, simple: We should see our patients, listen to them, and talk to them, but order tests only based on evidence.

This approach does not contradict the thrust of the article by Schwartz et al. It will prevent the use of “costly, unproven regimens,” yet satisfy patients, and improve their quality of life. In fact, the authors do recommend many ways to “see” patients—through the primary care physician (whose efforts could be periodically supplemented by follow-up with clinical oncologists), by telephone follow-ups, through nurses, and perhaps even via Internet-based interactions.

We should remember that periodic follow-up visits serve the function of reassuring patients that “we are there for them” as oncologists and that they are not being abandoned. As clinicians, we often encounter patients who are unhappy when we say, “I will see you in a year.” Many respond, “After so long, doctor?” On the other hand, there are patients who note, “I also see my primary care doctor. Do you still have to see me?” Thus, we must tailor follow-up schedules to the needs of individual patients and families.

Conclusions

In summary, Schwartz et al raise important questions that should be answered systematically, by building evidence based on research. More research is needed to address these issues, and more funding is needed for such research. Meanwhile, let us approach follow-up care for cancer with an outcome-based mind and a patient’s need–based heart.

References:

1. The Medical Research Council Prostate Cancer Working Party Investigators Group: Immediate vs deferred treatment for advanced prostatic cancer: Initial results of the Medical Research Council Trial. Br J Urol 79:235-246, 1997.

2. Hellman S, Weichselbaum RR: Oligometastases (editorial). J Clin Oncol 13:8-10, 1995.

3. Hall JA, Dornan MC: What patients like about their medical care and how often they are asked: A meta-analysis of the satisfaction literature. Soc Sci Med 27:935-939, 1988.

4. Jun M, Peterson RT, Zsidisin GA: The identification and measurement of quality dimensions in health care: Focus group interview results. Health Care Manage Rev 23(4):81-96, 1998.