Imagine a situation where doctors discover you have breast cancer. Luckily, they found it early so your future prognosis is pretty good; you’re given treatment and told you will need follow-ups with your oncologist for several years in case the disease returns.
If it were up to you, how much follow-up would you like to receive from doctors? A lot or a little? Intensive or routine? And what regimen do you think would give you the best chances of long-term survival?
As breast cancer treatments improve, more and more women are surviving their first brush with the disease and questions like these are becoming increasingly important.
The conventional wisdom, widely held amongst patients and doctors alike, is that early detection and treatment is the most effective way of dealing with recurring breast cancer. It seems obvious then, that the best way to achieve this is by giving women frequent and intensive follow-ups, right?
But it seems this view may not be backed up by the evidence, as a review
of the literature conducted by clinicians from The Royal Marsden NHS Foundation Trust and The Institute of Cancer Research, London, has found. Prof Ian Smith and Dr Gaia Schiavon looked at data from clinical trials of breast cancer follow-up care and what they found was quite startling.
A previous study of four trials involving over 3000 women
with breast cancer compared intensive follow-up strategies - involving blood tests, biomarker assessments, scans etc. - against the standard follow-up of clinical assessments and mammograms. None of these trials saw intensive follow-up improve patients’ overall survival, the length of time until their disease returned, or their five year survival.
They also looked at a study
investigating whether PET Scans
could help with diagnosing breast cancer recurrence. While PET scans improved the accuracy of diagnosis, there was no evidence that they improved patient outcomes.
What’s more, intensive follow-ups were associated with a 10-50% false positive rate
, meaning thousands of women could be unduly worried their cancer has returned for no reason.
And beyond the questionable benefit of intensive follow-up strategies for patients, the economic cost can be prohibitive. The average cost of intensive follow-up care is double that of standard follow-up, and as more women survive cancer, bigger clinics and more resources will be required. Couple this with an ageing population prone to higher cancer rates, and intensive follow-ups just don’t look viable in the long term.
But the Royal Marsden hospital is offering a different sort of follow-up for breast cancer patients. They have introduced a nurse-led system of open access follow-up
(OAFU), where women have their yearly mammogram as standard, but they can contact a specialist nurse whenever they have any concerns. As most recurrences of cancer are initially identified by patients themselves, in between routine appointments, this system offers greater flexibility and control for the patient. It also frees up time for breast cancer specialists to focus on the patients who need them most.
While the current evidence doesn’t support the use of intensive follow up, new approaches may help to change the landscape. An exciting area of research is the development of experimental techniques to monitor circulating tumour cells (CTCs), to show when cancer cells have spread from the breast into the blood, which could help identify those women most in need of intensive-follow up. SUCCESS A
, the largest trial to investigate CTCs for breast cancer, looked at more than 3,700 women with early breast cancer. They found that women with at least 5 CTCs detected after surgery were four times as likely to see their breast cancer return and three times more likely to die than patients with no CTCs. In the future, these women could be placed on more intensive follow-up schedules which may help spot recurrence earlier.
An even more sophisticated non-invasive method that can detect circulating tumour DNA in blood samples is the subject of research in some centres, including The Institute of Cancer Research.
In the future these approaches could potentially help identify patients who remain at high risk of recurrence after completion of standard breast cancer treatments, enabling early detection of relapse during follow-up. Until then, the evidence suggests intensive follow-up for breast cancer is not beneficial enough to be widely used and a more flexible follow-up approach might benefit more women. Image © Wellcome Images, Wellcome Images, Creative Commons by-nc-nd 2.0 UK
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