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PAPERS: Andrew G Renehan, Sarah T O'Dwyer, and David K Whynes Cost effectiveness analysis of intensive versus conventional follow up after curative resection for colorectal cancer BMJ 2004; 328: 81 [Abstract] [Full text]

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Update of Renehan et al's literature search

Joseph C Watine   (9 January 2004)

Need for follow-up protocols in all cancers

Adeola Olaitan, Mary McCormack   (13 January 2004)

Follow up after surgery for colorectal cancer: an adequately powered trial is essential

John N Primrose, David Mant, Alistair Gray   (23 January 2004)

Update of Renehan et al's literature search 9 January 2004
Joseph C Watine, Consultant, Laboratory Medicine Hôpital de Rodez, France Send response to journal: Re: Update of Renehan et al's literature search	In addition to the two meta-analysis published by Renehan et al and by a Cochrane review group [1, 2], the authors of the present work forget to mention that a third systematic review was published by Figreredo et al more than three months ago [3]. [1] Renehan AG, Egger M, Saunders MP, O'Dwyer ST. Impact on survival of intensive follow up after curative resection for colorectal cancer: systematic review and meta-analysis of randomised trials. BMJ 2002;324:813. [2] Jeffrey GM, Hickey BE, Hider P. Follow-up strategies for patients treated for non-metastatic colorectal cancer. In: Cochrane Library, Issue 1. Oxford: Update Software, 2002. [3] Figueredo A, Rumble RB, Maroun J, Earle CC, Cummings B, McLeod R, Zuraw L, Zwaal C. Follow-up of patients with curatively resected colorectal cancer: a practice guideline. BMC Cancer 2003;3:26. Competing interests: None declared
Need for follow-up protocols in all cancers 13 January 2004
Adeola Olaitan, Consultant Gynaecological Oncologist Dept of Gynaecological Oncology, The Elizabeth Garrett Anderson Hospital, Huntley Street,WC1E 6AU, Mary McCormack Send response to journal: Re: Need for follow-up protocols in all cancers	We were interested in Reneham et al's(1) conclusion that intensive follow up for patients with colorectal cancer is cost effective, particularly as the value of scheduled follow up in our specialty of gynaecological oncology (2) and in patients with breast cancer has recently been questioned. While Renehan et al have demonstrated a cost benefit for intensive follow up, there remain several questions about the most appropriate surveillance tools and where the patient should be followed up. The effect of scheduled follow up on the patient's psychological morbidity also requires assesment. Grunfeld at al's (3) paper showed that follow up by the General Practitioner did not increase time to detect recurrent disease or anxiety in patients after treatment for breast cancer. Olaitan et al (2) suggested that scheduled hospital- based follow up may increase anxiety without increasing the detection rate of recurrent disease. These questions illustrate the fact that follow up schedules for patients with recurrent disease have developed without supporting evidence and are mainly based on consensus. Few schedules have been subjected to robust randomised control trials. There is a clear need for thoughtful analysis on all aspects of follow up for patients treated for cancer at all sites so that, as well as being cost effective, we can offer our patients a follow up schedule best designed to detect recurrence without increasing anxiety. 1. Renehan et al, Cost effectiveness of intensive versus conventional follow up after curative resction for colorectal cancer BMJ 2004; 328: 81- 0 2. Olaitan A, Murdoch JB, Naderson RS, James J, Graham J. A critical evaluation of current protocols for the follow up of patients treated for gynaecological malignanacies. Int J Gynaecol Cancer, 2001:11:349-53 3. Grunfeld et al, Routine follow up for breast cancer in primary care: randomised trial. BMJ (1996)313;665-669 Competing interests: None declared
Follow up after surgery for colorectal cancer: an adequately powered trial is essential 23 January 2004
John N Primrose, Profrssor of Surgery, University of Southampton Southampton General Hospital, Tremona Rd, Southampton, SO16 6YD, David Mant, Alistair Gray Send response to journal: Re: Follow up after surgery for colorectal cancer: an adequately powered trial is essential	We read with interest the article by Renehan and co-workers on the cost effectiveness of follow up following resection of colorectal cancer (1). We write as principal investigators of the Follow-up After Colorectal Surgery (FACS) trial, a nation-wide multi-centre trial of colorectal cancer follow up in the UK (http//www.facs.soton.ac.uk email:facs@soton.ac.uk). We strongly support the use of economic analysis to inform clinical decision making, and the economic analysis itself appears to be sound. However, we do not believe that the clinical evidence on which it is based is currently robust enough to support a policy change. The limitations of the meta-analysis of clinical trial data underlying the economic analysis have already been pointed out in a previous letter to this journal which stated correctly that “the conclusion that there is an absolute reduction in mortality of 9 – 13% using modern follow up regimens (including computed tomography or frequent measurements of serum carcinoembryonic antigen or both) is not justified.” (2) The trials cited are not all of high methodological quality and they exhibit significant heterogeneity (with the least intensive arm in one study more intensive than the most intensive of another). The Cochrane Review on the issue concludes that “because of the wide variation in the follow-up programmes used in the included studies it is not possible to infer from the data the best combination and frequency of clinic (or family practice) visits, blood tests, endoscopic procedures and radiological investigations to maximise the outcomes for these patients. Nor is it possible to estimate the potential harms or costs of intensifying follow-up for these patients.” (3) Good economic analysis cannot make up for poor data on clinical effect. We strongly disagree with Renehan that intensive follow-up should now be widely adopted and become “normal practice” in the NHS. If this happens, we will never complete the FACS trial and we will never know if intensive follow-up is clinically effective. We are undertaking a trial because while we hope to prove that intensive follow-up lengthens life and improves life-quality, we also recognise that we may be wrong and it may actually do harm to patients. We strongly urge colleagues to ask their patients to consider intensive imaging and CEA follow-up, but only in the context of the FACS trial, which should resolve many of the current uncertainties. 1) Renehan AG, O'Dwyer ST, Whynes DK. Cost effectiveness analysis of intensive versus conventional follow up after curative resection for colorectal cancerBMJ2004; 328: 81 2)http://bmj.bmjjournals.com/cgi/eletters/324/7341/813 3) Jeffrey GM, Hickey BE, Hider P. Follow-up strategies for patients treated for non-metastatic colorectal cancer. In: Cochrane Library, Issue 1. Oxford: Update Software, 2002. Competing interests: The authors of this letter are principal investigators of the FACS Trial, the UK national colorectal cancer follow up trial