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Rapid Responses: Rapid Responses published:
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Risk stratification allows patient led breast cancer follow up
- Gordon C Wishart, Dawn Chapman, Elizabeth Cox (25 January 2008)
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Follow up after breast cancer. Where do we go now?
- Asmaa Al-Allak, Sasi Govindarajulu, Mike Shere Ajay K. Sahu, Simon J. Cawthorn (27 January 2008)
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Follow-up of breast cancer, time for further debate?
- Hisham Hamed, Michael Kontos, On behalf of Guy's Breast Unit (1 February 2008)
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Risk-adjusted breast cancer follow-up: The need for a national randomised controlled trial of hospital-based specialist versus alternative follow-up
- Peter K Donnelly, Louise Hiller, and Janet A. Dunn (19 February 2008)
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Follow up after breast cancer
- David A Montgomery, J. Michael Dixon (3 March 2008)
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Gordon C Wishart, Consultant Breast & Endocrine Surgeon Cambridge Breast Unit, Addenbrookes Hospital, Hills Road, Cambridge, CB2 2QQ, Dawn Chapman, Elizabeth Cox
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Dixon and colleagues are right to question the validity of the current NICE guidelines on breast cancer follow up (BMJ 2008; 336: 107-8). We also agree that breast cancer follow up should be evidence-based, flexible and tailored to the needs of individual patients. Breast cancer however is a heterogeneous disease with marked variation between different prognostic groups in terms of both local recurrence and survival. It is counter-intuitive therefore to presume that one follow up programme is suitable for all patients. We recently introduced a patient-led follow up (PLFU) programme for breast cancer patients at low risk of recurrence or death from their disease. These included postmenopausal patients who were node negative, or had a Nottingham Prognostic Index (NPI) score of < 3.4, or patients with ductal carcinoma in situ only. Following an exit interview at the end of their treatment, these patients entered a mammographic surveillance programme but did not undergo regular clinical examination as part of their routine follow up. They were given contact information, via a dedicated phone line, for nurse specialist psychological support and immediate access to a diagnostic clinic if they had any clinical concern. A recent audit of our PLFU programme has shown 100% satisfaction with the process set up to contact our unit and only 5 of the 78 respondents (6%) required a clinic appointment during the study period (Chapman et al, Eur J Cancer 2007; 5: 7-8). Based on these data the PLFU eligibility criteria have now been extended to include all breast cancer patients with a NPI of <4.4 and a telephone interview has been introduced three months post-treatment to ensure that we pick up patients who may require ongoing psychological support. This has released valuable clinical resource, to allow more time to be spent with follow up patients at higher risk of breast cancer recurrence, and has contributed to our unit achieving a two week wait for all new breast cancer referrals whether urgent or non-urgent. The use of risk stratification to tailor individual patient follow up allows all patients to undergo five year mammographic surveillance with access to clinical input if necessary. It also allows time to be spent with those patients at higher risk of recurrence as well as the increasing flow of new referrals with symptomatic disease. Introduction of this model will comply with guidelines to reduce unnecessary breast cancer follow up and contribute to UK breast units achieving the government target to see all breast cancer referrals within two weeks by December 2009. Competing interests: None declared |
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Asmaa Al-Allak, Specialist Registrar Breast Care Centre, Frenchay Hospital, Bristol BS16 1JE, Sasi Govindarajulu, Mike Shere Ajay K. Sahu, Simon J. Cawthorn
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In the recent editorial by Dixon and Montgomery(1) the issues surrounding breast cancer follow up were explored. They conclude that patients needs vary and follow up protocols need to be evidence based, flexible and tailored to their lifelong needs. For most patients, only two follow-up clinic visits at 1 and 2 years is what the Edinburgh unit recommends. They also advise that current National Institute for Clinical Excellence (NICE) guidelines need urgent revision as they do not meet their stated aims. This issue has been highlighted by an email survey that we recently carried out. ABS members were asked about their current follow up practice. Of the estimated 215 breast units across the UK we received 38 replies. Most units followed up their patients for five years with some centres seeing patients up to 10 years especially for those diagnosed at a young age. Only three units reported follow up for three years as recommended by NICE. Mammographic follow up also varied widely between centres. Although a small snap shot of clinical practice in the UK the survey clearly demonstrates the problem that we are facing as breast specialists. The current NICE guidelines state that ‘routine long-term follow-up has not been shown to be effective and should cease’. It also recommends that follow-up should be limited to between 2 and 3 years with the specific intention that this will release capacity hopefully making it possible for all women with breast symptoms to be seen within 2 weeks’. Our personal experience in North Bristol has been to offer one additional follow-up visit at 5 years for those on hormone therapy and/or treated with breast conservation. Initially, as anticipated by NICE, limiting routine follow up led to a drop of 33% in patients seen. This drop created an estimated additional 270 hours for new patient referrals (approximately 5 hours per week) and the waiting time for non urgent referrals fell from 31 to 15 days. Unfortunately this was a short lived effect and increases in urgent referrals resulted in increased waiting times for non urgent referrals. Even more worrying was that when we looked at the incidence of breast cancer in the ‘urgent’ and ‘routine’ referrals more cancers were diagnosed in the latter group whose waiting times had increased(2). If we were to adopt the Edinburgh protocols across the UK, the additional capacity would help in achieving the government aim stated in the `Cancer Reform Strategy to see all patients with breast symptoms within 2 weeks if the variations from the NICE Guidance seen in our small survey are representative of practice across the country. We join our colleagues in the call for an urgent review of the NICE guidelines and in the mean time urge all breast clinics to adopt these sensible evidence-based Edinburgh guidelines. We certainly will in North Bristol. 1. J M Dixon, David Montgomery BMJ 2008;336:107-108 2. S. Potter, S. Govindarajulu, M. Shere, F. Braddon, G. Curran, R. Greenwood, A.K. Sahu, S.J. Cawthorn. Referral patterns, cancer diagnoses, and waiting times after introduction of two week wait rule for breast cancer: prospective cohort study. BMJ 2007;335:288. Competing interests: None declared |
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Hisham Hamed, Consultant Breast Surgeon Guy's Hospital, Breast Unit, Michael Kontos, On behalf of Guy's Breast Unit
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The editorial in the BMJ of 19th of January 2008 by Dixon and Montgomery [1] has addressed a very important but controversial issue of follow-up after breast cancer. The authors suggest that breast cancer patients cannot be completely discharged from all forms of follow-up after the first 2-3 years, as NICE recommends, but they should have mammographic long-term surveillance. They agree with NICE, however, that the value of clinical examination to detect treatable recurrences is questionable and it can be discontinued after the first two years, with which we disagree. Our unpublished data from Guy’s Breast Unit have shown that of 80 patients who received breast conserving treatment (BCT) between the years 1990-97 and relapsed locoregionally or in the contralateral breast, 34% had the recurrence detected during routine clinical examination. This is in contrast to only 14% in the editorial. Most importantly a significant percentage (15%) of these recurrences were detected only by the clinician in asymptomatic patients where mammography was either negative or not applicable. More worryingly, over 50% of regional recurrences were detected by the clinician only. Furthermore, the questionable value of follow-up beyond the first two years which was supported by the editorial is challenged by our data. Among patients who received BCT, the calculated incidence of clinically only detectable recurrence (in asymptomatic patients with normal or non- applicable mammography) is consistent over the years (0.48% in the first year, 0.34% in the second, 0.35% in the third and remains at around 0.20% up to year six). This incidence is even higher in patients who were treated by mastectomy. Of these 40% had their recurrence detected only by the clinician. The corresponding figures are 0.65% in the first year, 0.95% in the second, 0.25% in the third, 1.12% in the forth, 0.90% in the fifth and 0.32% in the sixth year of follow-up. The incidence of breast cancer in three-yearly screening rounds is 0.47% which is comparable to annual incidence of only clinically detectable recurrences. If we accept that screening mammography is a good method of detecting breast cancer it does not seem logical that an equally effective modality should be stopped. Therefore we suggest that follow-up recommendation should be subject to further evaluation. 1. Dixon MJ, Montgomery D. Follow-up after breast cancer. BMJ 2008;336:107-8. Competing interests: None declared |
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Peter K Donnelly, Consultant Surgeon and R&D Director South Devon Healthcare NHS Foundation Trust, TQ2 7AA & Warwick Clinical Trials Unit, Louise Hiller, and Janet A. Dunn
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In the recent editorial of Dixon and Montgomery(1), they recommend that breast cancer follow-up be evidence-based, flexible and tailored to patient needs. Unfortunately neither their proposal to provide only annual clinical review for 2 years nor the 2002 NICE guidelines which recommends hospital based follow up for no longer than 3 years for asymptomatic patients are evidence-based. A recent Cochrane review demonstrated a wide range of recommendations for follow-up practice and the urgent need for a large randomized controlled trial to assess the optimum model of care(2). A key question in the debate is the rationale for follow-up. A recent survey of 256 breast surgeons and oncologists demonstrated that follow up was principally aimed at managing treatment-related morbidity (93%), alongside detecting new abnormalities (82%), psychological morbidity (81%) and recurrences (80%)(3). Dixon’s optimism that (outside of Quality and Outcomes Framework guidance) “timely intervention by primary care doctors will reduce anxiety” or that “assessment by note review should identify need for input at the time of mammography” are not shared by colleagues who expressed concern for community support as a key factor in delaying discharge(3). If patients are to be given an alternative to hospital-based follow- up, there needs to be evidence that alternative strategies work. Whilst there is some evidence from overseas that annual mammography is advantageous, the data are derived from health systems with strong private sector community support which does not currently exist in the UK(4). Set against a background whereby two-thirds of respondents were already undertaking annual mammography, median follow-up remains at 5 years (as per BASO guidance 2005), with many preferring hospital-based follow-up for poor prognostic patients(3). There are numerous innovative models of alternative follow-up including radiographer-led clinical review (Cardiff), nurse-led telephone review (Manchester), patient-led follow-up (Cambridge) and partnership with General Practice (Oxford) which could meet our needs. The new National Cancer Plan recommends follow-up which is risk-stratified but takes account of patient need for choice, whilst tracking survivorship issues. A national multicentre randomized trial of hospital-based specialist versus alternative follow-up, risk-stratified for Nottingham Prognostic Index is urgently needed. Such a trial could capitalize on and promote those innovative models of care which most meet patient needs whilst providing an effective means of auditing performance against NICE guidelines for Adjuvant Hormone-Blocking Therapy, Bone Health and Breast Imaging. A proposed trial (iBREAST) requires adequate nursing and training resources to implement these alternative models of care(5). 1.Dixon MJ, Montgomery D. Follow-up after breast cancer. BMJ 2008: 336: 107-8. 2.Rojas MP, Telaro E, Russo A et al. Follow-up strategies for women treated for early breast cancer (Cochrane review). In the Cochrane Library, issue 2. Chichester, UK: John Wiley & Sons, Ltd, 2004. 3.Donnelly P, Hiller L, Bathers S, Bowden S, Coleman R. Questioning Specialists’ attitudes to breast cancer follow-up in primary care. Annals of Oncology 2007 18:1467-1476. 4.National Multidisciplinary Care Demonstration Project. Multidisciplinary Care in Australia: a National Demonstration Project in Breast Cancer. Sydney, Australia: National Breast Cancer Centre 2003; http://www.nbcc.org.au/. 5.Dunn J A, Donnelly P K, Barrett-Lee P, Beaver K, Cameron D, McCabe C, Weller D, Wilcox M, Blowers E, et al. iBREAST protocol submitted to HTA (2008) Competing interests: None declared |
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David A Montgomery, RMRS Pfizer oncology Pfizer ltd, J. Michael Dixon
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We welcome the interest our article has generated, and the disparity of views among just three responses goes some way to highlighting the controversy which surrounds this area. Mr Wishart and colleagues make an excellent point about risk stratification in follow up. We did indicate in our article that follow up should be flexible and tailored to patient’s needs so having different strategies for follow up of different groups is not inconsistent with that recommendation. The use of a risk indicator like the Nottingham Prognostic Index has some basic appeal and we know a number of oncologists see their high risk women more regularly than once a year for the first few years after diagnosis. While risk has appeal and predicts for systemic disease and particularly early systemic recurrence, the rate of local and locoregional disease from our own studies and from those of a large multicentre UK study recently presented by Doughty at the San Antonio Breast Cancer conference was constant over the first 10 years. Moreover, in the patient group to which our editorial refers there were no factors which predicted for development of locoregional recurrence1. If low risk women are at no reduced risk of second cancers in the treated breast or contralateral disease, the overall length of follow up will require to be the same. Even NICE accepts that there are reasons for breast cancer follow up other than detecting recurrence and we know of no good evidence that risk predicts for the other issues outlined in our leader. It is worth remembering that a recent survey presented at the San Antonio Breast Cancer Conference showed that 80% of women taking tamoxifen and 66% of women taking anastrozole were compliant with their medication. The major reason for stopping medication was joint symptoms which increase in severity within the first year before stabilising. It is clear from our own studies that such symptoms are only evident if one asks patients either during direct telephone contact or at hospital visits. Satisfaction is difficult to measure and unless a randomised study has been performed and the patient has something to compare it with then this is a very soft end point. Fortunately we have been successful in securing an HTA grant together with Professor Fiona Gilbert in Aberdeen for a large data set to study patterns of recurrence and contralateral recurrence over time. The aim is also to look at sojourn times so we can define the ideal interval between mammograms in different age groups. This review will be completed within a relatively short period of time. The main aim is to target the interval between mammograms relevant to the patient’s needs and what we know about tumour biology. This is likely to result in greater intervals between mammograms in older patients which ultimately will mean a more efficient and cost effective mammographic surveillance programme for patients diagnosed with breast cancer. References 1. Montgomery DA, Krupa K, Jack WJ, Kerr GR, Kunkler IH, Thomas J, Dixon JM. Changing pattern of the detection of locoregional relapse in breast cancer: the Edinburgh experience. Br J Cancer. 2007;96(12):1802-7 Competing interests: None declared |
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