In 2006, the American Society of Clinical Oncology (ASCO) issued practice guidelines on the follow-up and management of patients with breast cancer who have completed primary therapy with curative intent. Since that time, ASCO completed a 6-year, systematic review and analysis of 14 publications in an effort to update these guidelines. ASCO reissued the recommendations from 2006 in the Journal of Clinical Oncology and came to the conclusion that no revisions to the existing recommendation were warranted.
“An important reason behind re-issuing the guidelines is that physicians and patients aren’t always following the recommendations,” explains Thomas J. Smith, MD, a member of the ASCO writing committee for the guidelines. “It has been estimated that more than $1 billion is spent each year on unnecessary breast cancer follow-up care. By re-issuing the guidelines, it’s hoped that clinicians will make greater efforts to adhere to these recommendations.”
Assessing Surveillance
Research indicates that routine surveillance with PET, CAT, and bone scans—in addition to routine blood tests—is unwarranted in asymptomatic patients with breast cancer. “Physicians tend to deny that they’re ordering these tests, but studies suggest that, in actuality, many clinicians are ordering these diagnostics,” says Dr. Smith. “However, there are no data to date that suggest these tests are beneficial in the management of asymptomatic patients.”
Meanwhile, Dr. Smith says other data suggest that patients and physicians do not always obtain tests that are recommended in the guidelines. “Research clearly indicates that patients should undergo a mammogram on the opposite side after definitive surgery for one breast cancer,” he says. “However, study after study has shown that many patients don’t have a mammogram on the other side every year as recommended.” Research also indicates that many patients do not adhere to a healthy lifestyle that includes ample exercise, a healthy diet, and daily aspirin when indicated.
Reinforcing Recommendations
The recommendations in the current ASCO guideline (Table 1) are based on evidence for which interventions are beneficial, but also can lead to other positive outcomes. Adherence to the guideline recommendations can save patients from unnecessary radiation exposure and may be beneficial to the environment due to the production of less radionuclide activity. In addition, better guideline adherence may drastically decrease associated costs of care.
“Physicians should be honest with patients and tell them that after definitive therapy, there aren’t good tests to detect recurrent breast cancer at an early enough stage to make a difference in their lives,” says Dr. Smith. “The exceptions would be use of mammography and, in select cases, use of breast MRI. Patients should be advised to make sure they receive physical examinations and mammography as recommended, achieve normal body weight, exercise regularly, and maintain bone and sexual health. They should also be educated on concerning symptoms, such as bone pain, lumps and bumps, trouble breathing, and persistent headaches.”
Several tests—complete blood count testing; CAT, PET, and bone scans; and ultrasound of the liver, among others—are not recommended for asymptomatic breast cancer patients at follow-up because studies indicate that they are either not useful or cause more harm than good (Table 2). “Many false positives occur with these tests, which can affect patients’ quality of life through unwarranted worrying,” Dr. Smith adds. “It’s also important to remember that 80% to 85% of recurrences happen between doctor visits and are found by women themselves.”
Assisting PCPs
The ASCO recommendations state that follow-up care provided by primary care physicians (PCPs) appears to lead to the same health outcomes as follow-up care from specialists, with good patient satisfaction rates seen in those going to PCPs. Dr. Smith says that a simple option for PCPs who are assuming follow-up care with these patients is to coordinate efforts with oncologists. For example, PCPs can ask for a one-page, easy-to-read summary of the patient’s recent history and the oncologist’s expected plan.
Another important approach that can be helpful for PCPs who are not confident in their abilities to assume care is to obtain a copy of the ASCO guidelines, either online (www.asco.org) or from the oncologist. “Most PCPs are adept at managing a wide variety of illnesses, and many are quite willing to take on this follow-up role,” says Dr. Smith. “It would be more beneficial, however, if oncologists provided PCPs a written approach that adheres to guideline recommendations.”
Further Research Needed
More research is needed to determine the comparative effectives of various breast cancer surveillance modes and the optimal frequency and duration of follow-up, according to the guidelines. Also needed are studies assessing the clinical utility of breast cancer tumor marker testing and the effectiveness and quality of various models of survivorship care. “Until this and other research emerges,” says Dr. Smith, “ASCO encourages clinicians to refer to the breast cancer surveillance recommendations for guidance when providing care following primary treatment for breast cancer patients.”
TimH