J. Michael Dixon, MBChB, MD
The 29th Annual Miami Breast Cancer Conference culminated in a thought-stirring last session. J. Michael Dixon, MBChB, MD, professor of surgery at the University of Edinburgh and clinical director of the Edinburgh Breast Unit at the Western General Hospital, Edinburgh, Scotland, and Patrick I. Borgen, MD, director of the Brooklyn Breast Cancer Program at Maimonides Breast Cancer Center in Brooklyn, New York, debated the pros and cons of long-term clinical follow-up care of patients with breast cancer.
The Con Argument: Clinical Exams Increase Costs and Psychological Distress
“It is always difficult to give up something that you are used to doing,” began Dixon’s argument against frequent follow-up for breast cancer patients in remission. There are numerous guidelines but very little guidance,” he said, highlighting the disparity in follow-up guidance in different parts of the world. Currently, North American guidelines suggest that clinical examinations take place every three to six months for the first three years, every six to 12 months for the next four to five years, and on an annual basis thereafter for women in remission from breast cancer.
Dixon challenged the notion that intense follow-ups improve outcomes for women previously treated for breast cancer. He highlighted studies that have looked at the detection of systemic recurrence in women previously diagnosed and treated for breast cancer.
A 1994 randomized study comparing patients undergoing intensive laboratory and x-ray-based follow-up assessments to standard of care found more metastases earlier in the intensely followed group—but at the expense of significant false-positive rates.1
Dixon concluded that because the five- and 10-year data analysis did not show any differences in overall survival in the two trial arms, the intense follow-up was not cost-effective.
A 1999 study compared the 10-year mortality rates in women who had undergone treatment for primary breast cancer. The women had either intense or standard clinical follow-up.2
The more intense protocol did not offer a survival advantage, the study concluded.
A more recent analysis from 2007 showed that traditional routine clinical checkups were not sufficient enough to prevent disease recurrence, questioning the need for frequent follow-ups.3
The study authors stated that alternative followup methods were acceptable for patients, as these did not decrease either quality of life or anxiety about recurrence. Less-frequent visits can, however, offer significantly lower costs and time savings.
“Just because you can, doesn’t mean you should,” Dixon stressed, pointing out that recurrent clinical follow-ups resulted not only in unnecessarily increased healthcare costs, but also in creating psychological distress that can negatively affect the health of a patient.
Dixon’s solution? More effective ways of achieving improved patient outcomes with minimal psychological stress by seeing regular physiotherapists or nurses, rather than undergoing regular clinical follow-up assessments.
Dixon discussed a recent United Kingdom study that followed a total of 32,877 women from the West Midlands Cancer Intelligence Unit Cancer registry; 18,706 of the included women had breast conservation surgery, and 15,171 had mastectomies following a breast cancer diagnosis. Analyses showed that earlier detection generally led to better outcomes. The study also showed that clinically detected recurrences did worse compared with detection via mammography or by the patient herself. Overall survival was very much dependent on the size of the second tumor detected. The aim should be to detect recurrence as early as possible, Dixon concluded.
How much does follow-up cost? Dixon discussed an economic model, in British pounds, that incorporated different treatment regimens, the estimated likely survival benefit per regimen, and the cost per incremental quality-adjusted lifeyears (QALYs), among other metrics, for a woman aged 57 years. The utilization of extra tests such as mammography, clinical examination, and magnetic resonance imaging (MRI) did not lead to added benefit, except for younger women. The top three most value-based options were mammography, followed by clinical examination and mammography, and clinical examination and an MRI.
“Current clinical follow-up programs waste time and resources,” Dixon said. They are much better off targeting specific groups that have clinical issues, he concluded. “Local recurrence rates are falling. Therefore, the cost detection of each recurrence is increasing.”