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Editorials

The future of the primary medical workforce

BMJ 2011; 343 doi: https://doi.org/10.1136/bmj.d5006 (Published 22 August 2011) Cite this as: BMJ 2011;343:d5006

Cancer patients follow up and a new role for GPs

GPs are quite up to date with management of various cardio
respiratory conditions (eg CCF, angina, COPD), Diabetes and Arthritis even
though hospital based specialties exist for these conditions. But with
cancer, although GPs are quite aware of cancer 'red signals', many GPs are
not quite up to date with cancer treatment and subsequent follow up since
most of this activity, so far, has been almost exclusively a hospital
based activity. This is likely to change in the near future and there is
an urgent need for GPs to get up to date with follow up protocol of
various cancers.

With the introduction of Payment-by-Results (PbR: www.dh.gov.uk), the
follow-up visits are being scrutinised by commissioners. I understand in
some regions an unrealistic 'new to follow-up ratio' of 1:5 has been
mooted for cancer patients. There is likely to be opposition from patients
and scepticism from clinicians about the practicalities of this proposal.
But in the era of evidence based medicine and cost effective health care,
it is going to be hard to justify hospital follow-up of healthy patients
for many years without evidence of benefit. In fact, the evidence-base
supporting intensive hospital follow-up visits and investigations is weak
for most adult cancers.

Quite often patients and family find it difficult to accept that
intensive monitoring and frequent follow up scans do not prevent relapse.
Early diagnosis of a secondary cancer i.e. after cancer has spread does
not improve prognosis. This because most stage 4 cancers are incurable and
chemotherapy is only palliative for many patients. Hence symptom led
investigations are quite the norm for many cancers and GP led follow up
can be safely done, with referral to hospital at symptomatic stage only.

A lot of follow up studies suggest that intensive follow up
investigations and possibly hospital follow up are not beneficial and in
fact futile for many adult cancers.

In an ovarian cancer randomised study, no survival benefit was noted
for early diagnosis of cancer relapse using serum CA125. In fact, early
diagnosis of relapse, at an asymptomatic stage, impaired the quality of
life of patients. (1)

An Italian breast cancer follow-up study randomly assigned patients
to intensive follow up scans or symptom led follow up. The study found
that neither survival nor health-related quality of life was better with
intensive follow up of cancer and hence suggested that routine use of
these tests should be discouraged. (2)

A Cochrane Metanalysis of breast cancer follow up found no benefit
for intensive surveillance to detect cancer relapse at asymptomatic stage.
(''regular physical examinations and yearly mammography alone are as
effective as more intensive approaches''). The analysis also found that GP
led follow up is as effective. (3)

A large German follow up study of bladder cancer patients found no
benefit for early detection of recurrence at an asymptomatic stage and
hence advocated symptom guided follow-up examinations. (4).

In prostate cancer patients treated by radiotherapy, a Royal Marsden
study found that digital rectal examination (DRE) failed to detect any
local recurrences in the absence of a rising PSA. The authors questioned
the standard model of follow-up after radiotherapy for prostate cancer,
and suggested that alternatives, such as telephone clinics, should be
considered. (5).

In patients with locally advanced lung cancer, frequent cross-
sectional imaging was not found to improve survival after combined
modality therapy (6).

In contrast, with Colon cancer, a Cochrane Metanalysis found that
intensive follow up is associated with an improved all-cause survival. But
there was little information available about the harms and costs
associated with intensive follow up. Moreover some of the suggested tests
such as CEA and liver imaging could be organised by GPs rather than by
hospital based clinicians.(7)

Testicular cancers, along with childhood cancers and haematological
cancers are other possible malignancies which would benefit from intensive
hospital follow up.

But for considerable majority of patients with highly prevalent
cancers (breast, prostate, ovary, Lung), GP led follow up could be safely
done.

References:

1. Rustin GJ, van der Burg ME, Griffin CL, Guthrie D, Lamont A,
Jayson GC, Kristensen G, Mediola C, Coens C, Qian W, Parmar MK, Swart AM;
MRC OV05; EORTC 55955 investigators. Early versus delayed treatment of
relapsed ovarian cancer (MRC OV05/EORTC 55955): a randomised trial.
Lancet. 2010 Oct 2;376(9747):1155-63.

2. Liberati A. The GIVIO trial on the impact of follow-up care on
survival and quality of life in breast cancer patients. Interdisciplinary
Group for Cancer Care Evaluation. Ann Oncol. 1995;6 Suppl 2:41-6.

3. Rojas MPMP, Telaro E, Moschetti I, Coe L, Fossati R, Liberati A,
Rosselli MDT. Follow-up strategies for women treated for early breast
cancer. Cochrane Database of Systematic Reviews 2005, Issue 1. Art. No.:
CD001768. DOI: 10.1002/14651858.CD001768.pub2

4. Volkmer BG, Kuefer R, Bartsch GC Jr, Gust K, Hautmann RE.
Oncological followup after radical cystectomy for bladder cancer-is there
any benefit?J Urol. 2009 Apr;181(4):1587-93.

5. Doneux A, Parker CC, Norman A, Eeles R, Howich A, Huddart R,
Dearnaley D. The utility of digital rectal examination after radical
radiotherapy for prostate cancer. CLINICAL ONCOLOGY, 2005: 17 (3). pp. 172
-173.

6. Benamore R, Shepherd FA, Leighl N, Pintilie M, Patel M, Feld R,
Herman S. Does intensive follow-up alter outcome in patients with advanced
lung cancer?J Thorac Oncol. 2007 Apr;2(4):273-81.

7. Jeffery M, Hickey BE, Hider PN. Follow-up strategies for patients
treated for non-metastatic colorectal cancer. Cochrane Database of
Systematic Reviews 2007, Issue 1. Art. No.: CD002200. DOI:
10.1002/14651858.CD002200.pub2

Competing interests: No competing interests

29 August 2011
S Sundar
Consultant Oncologist
Nottingham University Hospitals NHS trust