Surviving Surveillance
The message seems to be emerging that for some diseases, clinical monitoring for relapse and recurrence has a strong evidence base, is safe, and is associated with lower costs.
Although estimates vary, the current number of cancer survivors in the United States is around 14 million; by 2030, this figure is expected to reach 20 million. In response to the growth of this population, increasing attention is being paid to issues of cancer survivorship, including management of late effects of therapy, promotion of healthy lifestyles and behaviors that may reduce the risk of recurrence, and the monitoring of health and compliance for those survivors who remain on long-term therapy for their disease.
As an oncologist whose practice is comprised almost entirely of patients with lymphoma, I have had to start rethinking my approach to survivorship. Until now, I have thought about survivorship care in the context of my clinic and have largely focused on detection of relapsed or progressive disease. Like many others, I am readjusting to the broader concept of survivorship care as a pathway to health maintenance and well-being for cancer survivors. The emergence of this new focus on survivorship care will challenge our accepted model of oncology care delivery. Speaking for myself, I don’t have the necessary expertise or experience to provide the level of general medical input these patients deserve. From an oncology workforce perspective, given the impending shortfall in medical and radiation oncologists that will begin to affect us in 2020, we need to develop new models for providing appropriate care for cancer survivors. This will need to be done within the framework of emerging guidelines for survivorship, such as those developed by the National Comprehensive Cancer Network and the American Society of Clinical Oncology. Although some centers regard primary care providers as the solution to the survivorship “burden,” a workforce shortage is likely there as well. Thus, we oncologists need to take ownership of this issue. For many centers, advanced practice clinicians are likely to be at least part of the solution.
As we all develop our survivorship care models and pathways, determining the highest-value strategies for surveillance for relapse or recurrence will be a key focus. In this issue of ONCOLOGY, Drs. Shah and Denlinger provide a comprehensive summary of surveillance guidelines for prostate, colorectal, and breast cancers, as well as a series of evidence-based recommendations.[1] It’s apparent from their article that for these diseases, intensive surveillance has not been shown to improve outcomes-and in many cases, it can have adverse effects, ranging from unnecessary anxiety and unneeded medical procedures (including biopsies) to the potentially harmful effects of unnecessary imaging or surgery. For many diseases, it appears that less may be more when it comes to surveillance.
Emerging data from patients with lymphoma support this concept. Recent studies in the follow-up of diffuse large B-cell lymphoma and Hodgkin lymphoma have demonstrated that clinical surveillance (which includes a history, physical examination, and basic laboratory evaluation-but which limits imaging to those patients with concerning symptoms, signs, or lab findings) is equivalent to more intensive surveillance strategies that incorporate routine imaging.[2,3] No differences in survival have been demonstrated between patients undergoing clinical surveillance and those who receive routine imaging. However, the latter approach is associated with increased costs. Furthermore, the use of functional imaging can yield a significant rate of false-positive findings, generating anxiety and additional, sometimes unnecessary biopsies.
The message seems to be emerging that for some diseases, clinical monitoring for relapse and recurrence has a strong evidence base, is safe, and is associated with lower costs. For now, the trend is towards less intensive surveillance. This could change as newer techniques emerge. For example, as new assays for circulating tumor cells or plasma-based tumor DNA are validated, these may come to be regarded as low-cost, reliable means of early detection of relapse. Until such a time, however, our follow-up strategies for relapse should be directed at providing safe, evidence-based, and reliable methods of detecting recurrent disease, with minimal potential for harm. We need to make sure our patients are not only survivors of cancer, but also of our surveillance strategies.
Financial Disclosure:Dr. Sweetenham has no significant financial interest or other relationship with the manufacturers of any products or providers of any service mentioned in this article.
References:
1. Shah M, Denlinger C. Optimal post-treatment surveillance in cancer survivors: Is more really better? Oncology (Williston Park). 2015;29:230-9.
2. Thompson CA, Ghesquieres H, Maurer MJ, et al. Utility of routine post-therapy surveillance imaging in diffuse large B-cell lymphoma. J Clin Oncol. 2014;32:3506-12.
3. Pingali SR, Jewell SW, Havlat L, et al. Limited utility of routine surveillance imaging for classical Hodgkin lymphoma patients in first complete remission. Cancer. 2014;120:2122-9.
