Follow up in breast cancerBMJ 1995; 310 doi: https://doi.org/10.1136/bmj.310.6981.685 (Published 18 March 1995) Cite this as: BMJ 1995;310:685
- John Dewar
- Consultant radiotherapist and oncologist Department of Radiotherapy and Oncology, Ninewells Hospital and Medical School, Dundee DDI 9SY
A suitable case for reappraisal
As the morning progresses the hospital waiting area fills up with anxious, mostly grey haired women. They have been treated for breast cancer in the past and are attending for “routine” follow up. For those who are apparently free of disease, what is the purpose of follow up, how often should it be done, and by whom, and what investigations, if any, should be performed routinely?
A recent consensus statement focuses on these issues1 and is particularly valuable in highlighting interventions of no value and areas of continued uncertainty. The main purpose of follow up is summarised as “the earliest possible diagnosis of a relapse with a view to applying a curative second line treatment.” How often do we achieve this?
Distant metastatic disease is currently incurable, so its detection is not part of the main purpose of follow up. In any case, routine follow up is a poor way of detecting distant metastatic relapse: three quarters of cases will present between scheduled visits.2 Two recent randomised controlled trials have shown that adding regular chest radiography, bone scanning, and liver scanning to clinical surveillance does not improve survival.3 4 In only one of the studies did it even significantly hasten the diagnosis of distant metastases.3
Local recurrence and a new cancer in the contralateral breast are therefore the only relapses that might be detected at routine follow up and that are potentially curable. Routine follow up after mastectomy can certainly detect local recurrence,2 but whether this is translated into improved local control is less certain. Most of these patients ultimately develop distant metastases so detection of local recurrence has no impact on overall survival. Nevertheless, doctors would regard local control as important and the avoidance of uncontrolled local disease is a major goal in any follow up programme. Detecting local relapse after breast conservation poses more problems. Compared with a relapse in the chest wall of a patient who has had a mastectomy, it is harder to detect, develops over a longer time, and is less likely to be associated with distant metastases.5 Recurrences are detected by a combination of clinical examination and mammography.
Mammography is thus used as a screening mechanism for both local and contralateral tumours. Its use has not, however, been subjected to quite as intensive an analysis as has its use in screening normal female populations. A Dutch study suggested that routine annual mammography for contralateral tumours leads to their diagnosis at an earlier clinical stage, but this will have at best only a modest impact on overall survival.6 The optimal frequency of mammography of the treated breast has not yet been established.7
What is the effect of follow up on the women themselves? The consensus statement emphasises that women have a right of access to care and continuity of care. What sort of care do the women want? Some women certainly seem reassured after a follow up visit (even if they find the days before the visit stressful). This reassurance may be less solidly based than they imagine, given that routine follow up has not been shown to improve survival. Conversely, some women may find that the visits serve only to remind them of their disease and remain a continuing source of anxiety. There is a paucity of data on the effect of follow up on the quality of patients' lives. There are certainly financial costs for the patients—such as time off work and the costs of travel—and also for any accompanying relatives or friends.
For the medical and nursing staff, the sheer numbers of patients attending follow up clinics can reduce the time available for patients with problems. Conversely, the presence of fit women in the clinic may serve as a useful counterbalance to the negative effect of their continuously seeing patients whose disease has relapsed. In addition, data on the morbidity of treatment can be acquired only if all patients are seen.
The final section of the consensus statement recommends three main areas for further research. Firstly, more effective salvage treatments for breast cancer are needed, but this will depend on advances in the overall treatment of the disease. Secondly, there is a need to define the most effective diagnostic tests to be used in follow up. Currently, the only one of any established value is mammography for both the treated breast and the contralateral breast, but the optimal frequency needs to be defined. Thirdly, what sort of clinical follow up (if any) do women need? Should this be regular attendance at a specialist centre, shared care with the patient's family doctor, or simply advice to the patient to return to the clinic if she has any problems?
We have performed numerous trials of primary treatment; it is now time to embark on trials of different follow up regimens and to apply the rigours of the assessment of screening programmes to follow up practices. The resource implications of follow up would alone justify such studies, but, more importantly, these studies would offer the opportunity to evaluate the needs of the patients themselves.