Follow-up routines in gynecological cancer - time for a change?

Patient-initiated follow-up in women with early-stage endometrial cancer: A long-term follow-up of the OPAL trial

OBJECTIVE

A long-term follow-up of the OPAL trial to compare the effect of patient-initiated (PIFU) versus hospital-based (HBFU) follow-up on fear of cancer recurrence (FCR), quality of life (QoL) and healthcare use after 34 months of follow-up.

DESIGN

Pragmatic, multicentre randomised trial.

SETTING

Four Danish departments of gynaecology between May 2013 and May 2016.

POPULATION

212 women diagnosed with stage I low-intermediate risk endometrial carcinoma.

METHODS

The control group attended HBFU with regular outpatient visits (i.e., 8) for 3 years after primary treatment. The intervention group underwent PIFU with no prescheduled visits but with instructions about alarm symptoms and options of self-referral.

MAIN OUTCOME MEASURES

The endpoints were FCR as measured by the Fear of Cancer Recurrence Inventory (FCRI) and QoL as measured by the European Organisation for Research and Treatment of Cancer Quality of Life Core Questionnaire C-30 (EORTC QLQ C-30), and healthcare use as measured by questionnaires and chart reviews after 34 months of follow-up.

RESULTS

FCR decreased from baseline to 34 months in both groups and no difference was found between allocations (difference -6.31 [95% confidence interval -14.24 to 1.63]). QoL remained stable with no difference in any domains between the two arms at 34 months using a linear mixed model analysis. The use of healthcare was significantly lower in the PIFU group (P < 0.01).

CONCLUSION

Patient-initiated follow-up is a valid alternative to hospital-based follow-up for people who have been treated for endometrial cancer and have low risk of recurrence.

A systematic review of the effectiveness of patient-initiated follow-up after cancer

BACKGROUND

The traditional cancer follow-up (FU) model for cancer survivors is by scheduled clinic appointments; however, this is not tailored to patient needs and is becoming unsustainable. Patient-initiated follow-up (PIFU) may be a more effective and flexible alternative. This systematic review aims to analyse all existing evidence from randomised controlled trials (RCTs) on the effectiveness of PIFU compared with other FU models that include routinely scheduled appointments in adults who have been treated with curative intent for any type of cancer.

METHODS

Standard systematic review methodology aimed at limiting bias was used for study identification, selection and data extraction. MEDLINE, Embase, CINAHL, the Cochrane Database of Systematic Reviews and Epistemonikos were searched for systematic reviews to March 2022, and Cochrane CENTRAL was searched for RCTs from 2018 (April 2023). Ongoing trial registers were searched (WHO ICTRP, ClinicalTrials.gov, April 2023). Eligible studies were randomised controlled trials comparing PIFU with an alternative FU model in adult cancer survivors. Risk of bias assessment was via the Cochrane risk of bias tool-2. Meta-analysis was precluded by clinical heterogeneity and results were reported narratively.

RESULTS

Ten RCTs were included (six breast, two colorectal, one endometrial cancer and one melanoma, total n = 1754); all studies had risk of bias concerns, particularly relating to how missing data were handled, and populations were unlikely to be representative. Limited findings in breast cancer suggested that type of FU does not affect recurrence detection or patient-related outcomes, while PIFU may reduce the number of clinic visits. Adding patient-led surveillance to routine FU may increase melanoma detection. Evidence for other types of cancer is too limited to draw firm conclusions.

CONCLUSIONS

PIFU may be a viable FU model in breast cancer, but further research is needed for other types of cancer and on long-term outcomes. A protocol was registered with PROSPERO (CRD42020181424).

A NEw MOdel of individualized and patient-centered follow-up for women with gynecological cancer (the NEMO study)-protocol and rationale of a randomized clinical trial

BACKGROUND

Follow-up programs for gynecological cancer patients are currently under revision. There is limited evidence that traditional follow-up and clinical examinations improve survival in an early-stage gynecological setting. Further, traditional follow-up programs fail to accommodate the patient's need for psychosocial and sexual supportive care and to actively involve patients and their relatives in the follow-up process. Individualized programs may replace traditional routine follow-up with fixed intervals and length. Focusing on alarm-symptoms and self-reporting may ensure detection of recurrence while allowing a continuous attention to the patient's well-being and return to daily life. In this study, a nurse-led, individualized, and need-based intervention with a specific focus on patient empowerment is tested against a standard physician-led model primarily focusing on the detection of recurrence.

METHODS

The study is designed as a clinical, randomized trial conducted in one of four national onco-gynecological centers in Denmark. Patients with early-stage cervical or endometrial cancer are eligible for inclusion. The intervention group undergoes individualized, nurse-led follow-up supporting patient empowerment including repeated use of electronic patient-reported outcome measures (ePROMs) before each contact as a dialogue support tool. The follow-up contacts are mainly conducted by telephone. All project nurses attended a special training program before project start and are all well-educated and dedicated onco-gynecological nurses. The control group receives standard, physician-led, follow-up without use of ePROMs or specific focus on empowerment. The effect of the intervention is evaluated by questionnaires completed by patients at baseline (3 months after surgery) and 12, 18, and 36 months after surgery. Outcomes include empowerment using the Skill and technique subscale of the HEI-Q questionnaire as the primary outcome while fear of cancer recurrence and health-related quality of life as well as the remaining subscales of the HEI-Q represent secondary outcomes. Data is collected by use of the REDCap technology, which also provides a customized visual support function for the dialogue tool.

DISCUSSION

This study will provide new information about follow-up in early-stage gynecological cancer settings and thereby contribute to improvement of future follow-up programs. Importantly, the study will provide knowledge about the impact of specific focus on patient empowerment in follow-up programs and, further, how to facilitate empowerment among patients.

TRIAL REGISTRATION

The study is registered at clinicaltrials.gov: ID no. NCT03838861. Registered on 6 February 2019. Protocol version 2, issue date 21 November 2022.

Effectiveness of Intensive Versus Minimalist Follow-Up Regimen on Survival in Patients With Endometrial Cancer (TOTEM Study): A Randomized, Pragmatic, Parallel Group, Multicenter Trial

PURPOSE

In the absence of clear evidence from randomized trials, the intensity of follow-up regimens after surgical treatment of endometrial cancer is highly variable in clinical practice. To reduce this uncertainty, we conducted a randomized trial to test whether an intensive (INT) versus a minimalist (MIN) follow-up regimen improves overall survival (OS) in patients undergoing operation for endometrial cancer.

METHODS

The TOTEM study was a large, pragmatic randomized trial, conducted in 42 hospitals (in Italy and France) including patients surgically treated for endometrial cancer, in complete clinical remission, International Federation of Gynecology and Obstetrics stage I-IV. After stratification by center and risk of relapse (low or high), patients were randomly assigned (1:1) to INT or MIN hospital-based follow-up regimens. The study was powered to demonstrate an absolute improvement of 5% of the 5-year OS with the INT regimen.

RESULTS

In total, 1,871 patients were randomly assigned between November 2008 and July 2018, and 1,847 patients (98.7%) were available for the final analysis (60% low risk). After a median follow-up of 69 months, the 5-year OS was 90.6% in the INT and 91.9% in the MIN arms (hazard ratio, 1.13, 95% CI, 0.86 to 1.50, P = .380). No differences in OS were found in subgroup analyses considering age, cancer treatment, risk of relapse, and degree of adherence of the center to the scheduled follow-up. The probability of detecting a relapse was slightly higher in the INT arm (hazard ratio, 1.17; 95% CI, 0.92 to 1.48; P = .194).

CONCLUSION

An INT follow-up in endometrial cancer-treated patients does not improve OS, even in high-risk patients. According to available evidence, there is no need to routinely add vaginal cytology, laboratory, or imaging investigations to the MIN regimens used in this trial.

Development of a Framework and the Content for a Psychoeducational Internet-Delivered Intervention for Women after Treatment for Gynecological Cancer

The number of women treated for gynecological cancer is increasing. At the same time, the duration of in-patient hospitalization has decreased, and follow-up with its primary focus on early recognition of recurrence does not meet all patients' needs. One method of follow-up may be digital intervention. This study describes the development of a psychoeducational Internet-delivered intervention targeting women's psychosocial needs during the follow-up period after treatment for gynecological cancer. The project consisted of three phases following the UK Medical Research Council Framework guidelines for the development of complex interventions. Phase one identified the evidence in the field, phase two identified the relevant theoretical framework, and phase three included a two-year work process including focus group interviews and think aloud interviews with users. Through the steps of literature review, theoretical framework, and an iterative development process with users and other stakeholders, a six-week program was developed. The program included psychoeducational information, multimedia, exercises, and weekly telephone follow-up with a dedicated nurse. This Internet-delivered intervention can be a novel method for addressing the gap in the provision of follow-up for women after treatment for gynecological cancer.

Lifestyle and Empowerment Techniques in Survivorship of Gynaecologic Oncology (LETSGO study): a study protocol for a multicentre longitudinal interventional study using mobile health technology and biobanking

INTRODUCTION

The number of gynaecological cancer survivors is increasing and there is a need for a more sustainable model of follow-up care. Today's follow-up model is time-consuming and patients have reported unmet needs regarding information about their cancer and strategies for managing the consequences of treatment. The main aim of this study is to assess health-related empowerment-in terms of patient education, psychosocial support, and promotion of physical activity-in a new follow-up model by comparing it to standard follow-up in a quasi-randomised study involving intervention hospitals and control hospitals.

METHODS AND ANALYSIS

At the intervention hospitals, patients will be stratified by risk of recurrence and late effects to either 1 or 3 years' follow-up. Nurses will replace doctors in half of the follow-up visits and focus in particular on patient education, self-management and physical activity. They will provide patients with information and guide them in goal setting and action planning. These measures will be reinforced by a smartphone application for monitoring symptoms and promoting physical activity. At the control hospitals, patients will be included in the standard follow-up programme. All patients will be asked to complete questionnaires at baseline and after 3, 6, 12, 24 and 36 months. Blood samples will be collected for biobanking at 3, 12 and 36 months. The primary outcome is health-related empowerment. Secondary outcomes include health-related quality of life, adherence to physical activity recommendations, time to recurrence, healthcare costs and changes in biomarkers. Changes in these outcomes will be analysed using generalised linear mixed models for repeated measures. Type of hospital (intervention or control), time (measurement point), and possible confounders will be included as fixed factors.

ETHICS AND DISSEMINATION

The study is approved by the Regional Committee for Medical Research Ethics (2019/11093). Dissemination of findings will occur at the local, national and international levels.

TRIAL REGISTRATION NUMBER

NCT04122235.

Gaining insight into the supportive care needs of women experiencing gynaecological cancer: A qualitative study

AIM AND OBJECTIVES

To gain insight into the supportive care needs of Western Australian women experiencing gynaecological cancer.

BACKGROUND

Meeting the supportive care needs of people living with cancer is becoming increasingly important as advances in cancer treatment contribute to growing numbers of survivors. International evidence suggests between 24%-56% of women with gynaecological cancer have unmet supportive care needs and that psychological challenges, information provision and holistic care are priorities. No qualitative investigation has previously explored women's journey of gynaecological cancer within the Australian setting.

DESIGN

A qualitative descriptive design was used.

METHODS

Women treated for gynaecological cancer were recruited from a tertiary public women's hospital in Western Australia. Thematic analysis was conducted on qualitative data collected from 190 women over 12 months through written open-ended survey responses and telephone interviews. The COnsolidated criteria for REporting Qualitative research (COREQ) guided presentation of results.

RESULTS

Analysis yielded five themes and four subthemes: (a) Communication style directs the experience (subthemes: feeling supported; absence of empathy); (b) It's not just about the disease (subthemes: life has changed; holistic care); (c) A desire for information; (d) Drawing upon resilience; and (e) Navigating the system.

DISCUSSION

Exploration of the women's needs leads to the discussion of three concepts. Communication styles, harnessing women's resilience and alternative models of care are evaluated for their capacity to improve care and women's quality of life into survivorship. Recommendations are made for further research and possible interventions that can be translated into the clinical setting.

CONCLUSION

Women with gynaecological cancer described complex often unmet supportive care needs and interactions with the healthcare system. Insight gained directs suggestions for improved service provision.

RELEVANCE TO CLINICAL PRACTICE

Improved patient-centred communication, harnessing resilience as a resource and alternative models of care for follow-up are encouraged as areas of improvement for clinicians and care services.

How Do We Follow Up Patients With Endometrial Cancer?

PURPOSE OF REVIEW

In this review, we present the existing evidence regarding follow-up care after endometrial cancer, including content of follow-up and type of provider. We furthermore discuss the future perspectives for follow-up care and research in the field.

RECENT FINDINGS

Recently published randomized controlled trials show that nurse-led telephone follow-up and patient-initiated follow-up are feasible alternatives to routine hospital-based follow-up. No randomized or prospective study has evaluated the effect of routine follow-up on survival. Hence, current knowledge is derived from retrospective studies with the inherent risk of bias. The most important method for recurrence detection is a review of symptoms. There is no evidence to support a survival benefit from the use of routine physical examinations, additional tests, or imaging. One in three of the women attending hospital-based follow-up experience unmet needs, and alternative models for follow-up focused on survivorship care and empowerment should be tested.

Lived experiences and quality of life after gynaecological cancer-An integrative review

Aim and objectives

To review the literature on Nordic women's lived experiences and quality of life (QoL) after gynaecological cancer treatment.

Background

While incidence and survival are increasing in all groups of gynaecological cancers in the Nordic countries, inpatient hospitalisation has become shorter in relation to treatment. This has increased the need for follow‐up and rehabilitation.

Design

Integrative literature review using the Equator PRISMA guidelines.

Methods

The review was selected, allowing inclusion of both experimental and nonexperimental research. The search included peer‐reviewed articles published 1995–2017. To frame the search strategy, we applied the concept of rehabilitation, which holds a holistic perspective on health.

Results

Fifty‐five articles were included and were contextualised within three themes. Physicalwell-being in a changed body encompasses bodily changes comprising menopausal symptoms, a changed sexual life, complications in bowels, urinary tract, lymphoedema and pain, bodily‐based preparedness and fear of recurrence. Mental well-being as a woman deals with questioned womanliness, the experience of revitalised values in life, and challenges of how to come to terms with oneself after cancer treatment. Psychosocial well-being and interaction deals with the importance of having a partner or close person in the process of coming to terms with oneself after cancer. Furthermore, the women needed conversations with health professionals around the process of coping with changes and late effects, including intimate and sensitive issues.

Conclusion

Years after gynaecological cancer, women have to deal with fundamental changes and challenges concerning their physical, mental and psychosocial well‐being. Future research should focus on how follow‐up programmes can be organised to target the multidimensional aspects of women's QoL. Research collaboration across Nordic countries on rehabilitation needs and intervention is timely and welcomed.

Relevance to clinical practice

To ensure that all aspects of cancer rehabilitation are being addressed, we suggest that the individual woman is offered an active role in her follow‐up.

Gynecological cancer patients' attitudes toward follow-up care after cancer treatment: Do preferences reflect patients' experience? A cross-sectional questionnaire study

INTRODUCTION

Due to an increasing number of cancer patients, new follow-up models are being debated, among them follow-up by general practitioners. Before changing surveillance, it is important to explore patients' views. The purpose of this study was to compare attitudes toward follow-up care among patients treated for gynecological cancer who had not yet started a follow-up regimen, with those who had been attending a hospital-based follow-up regimen for more than one year.

MATERIAL AND METHODS

We conducted a cross-sectional survey among gynecological cancer patients recruited from three Norwegian hospitals in 2013-2015: Sørlandet Hospital Kristiansand, Sørlandet Hospital Arendal and St. Olavs Hospital, Trondheim.

RESULTS

In all, 239 patients agreed to participate, 100 who had not yet started follow-up and 139 who had been attending more than one year of follow-up. Patients reported that they preferred to be followed up by a gynecologist rather than by their GP, whom they viewed as less competent for this purpose. However, patients who had not yet started follow-up were more willing to be followed up by a GP. Overall, patients rated detection of recurrence as the most important aspect of follow-up visits.

CONCLUSIONS

The gynecological cancer patients in our study preferred a hospital-based follow-up model. However, patients who had not yet started follow-up were more willing to be followed up by a GP. If follow-up is to be provided by GPs for selected patients, it is important that these patients are informed early of the value and limitations of follow-up visits, to ensure that they feel safe.

Cost-Consequence Analysis Alongside a Randomised Controlled Trial of Hospital Versus Telephone Follow-Up after Treatment for Endometrial Cancer

BACKGROUND

Regular outpatient follow-up programmes are usually offered to patients following treatment for gynaecological and other cancers. Despite the substantial resources involved in providing these programmes, there is evidence that routine follow-up programmes do not affect survival or the likelihood of detecting recurrence and may not meet patient needs. Alternative follow-up modalities may offer the same outcomes at lower cost. We examined the costs of using telephone-based routine follow-up of women treated for endometrial cancer undertaken by specialist gynaecology oncology nurses in comparison to routine hospital-based follow-up.

METHODS

The ENDCAT trial randomised 259 women at five centres in the north west of England with a known diagnosis of Stage I endometrial cancer who had completed primary treatment on a 1:1 basis to receive either standard hospital outpatient follow-up or a telephone follow-up intervention administered by specialist nurses. A cost-consequence analysis was undertaken in which we compared costs to the health system and to individuals with the trial's co-primary outcomes of psychological morbidity and participant satisfaction with information received.

RESULTS

Psychological morbidity, psychosocial needs, patient satisfaction and quality of life did not differ between arms. Patients randomised to telephone follow-up underwent more and longer consultations. There was no difference in total health service mean per patient costs at 6 months (mean difference £8, 95% percentile confidence interval: - £147 to £141) or 12 months (mean difference: - £77, 95% percentile confidence interval: - £334 to £154). Estimated return journey costs per patient for hospital consultations were £11.47. Productivity costs were approximately twice as high under hospital follow-up.

CONCLUSION

Telephone follow-up was estimated to be cost-neutral for the NHS and may free up clinic time for other patients. There was some evidence that telephone follow-up may be more efficient for patients and wider society, and is not associated with additional psychological morbidity, lower patient satisfaction or reduced quality of life.

TRIAL REGISTRATION

ISRCTN: 75220876, prospectively registered 28 October 2011.

ENdometrial cancer SURvivors' follow-up carE (ENSURE): Less is more? Evaluating patient satisfaction and cost-effectiveness of a reduced follow-up schedule: study protocol of a randomized controlled trial

Background

It has often been hypothesized that the frequency of follow-up visits for patients with early-stage endometrial cancer could be decreased. However, studies evaluating effects of a reduced follow-up schedule among this patient group are lacking. The aim of this study is to assess patient satisfaction and cost-effectiveness of a less frequent follow-up schedule compared to the schedule according to the Dutch guideline.

Methods

In this multicenter randomized controlled trial, patients diagnosed in the Netherlands with stage 1A and 1B low-risk endometrial cancer, for whom adjuvant radiotherapy is not indicated (n = 282), are randomized. Patients allocated to the intervention group receive four follow-up visits during three years. Patients allocated to the control group receive 10–13 follow-up visits during five years, according to the Dutch guideline. Patients are asked to fill out a questionnaire at baseline and after 6, 12, 36, and 60 months. Primary outcomes include patient satisfaction with follow-up care and cost-effectiveness. Secondary outcomes include healthcare use, adherence to schedule, health-related quality of life, fear of recurrence, anxiety and depression, information provision, recurrence, and survival. Linear regression analyses will be used to assess differences in patient satisfaction with follow-up care between intervention and control group.

Discussion

We anticipate that patients in the intervention arm have a similar satisfaction with follow-up care and overall outcomes, but lower healthcare use and costs than patients in the control arm. No differences are expected in quality-adjusted life-years and satisfaction, but the reduced schedule is expected to be cost-saving when implemented in the Netherlands.

Trial registration

ClinicalTrials.gov, NCT02413606. Registered on 10 April 2015.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2611-x) contains supplementary material, which is available to authorized users.

A national, prospective observational study of first recurrence after primary treatment for gynecological cancer in Norway

INTRODUCTION

Gynecological cancer patients are routinely followed up for five years after primary treatment. However, the value of such follow up has been debated, as retrospective studies indicate that first recurrence is often symptomatic and occurs within two to three years of primary treatment. We prospectively investigated time to first recurrence, symptoms at recurrence, diagnostic procedures, and recurrence treatment in gynecological cancer patients after primary curative treatment.

MATERIAL AND METHODS

Clinicians from 21 hospitals in Norway interviewed 680 patients with first recurrence of gynecological cancer (409 ovarian, 213 uterine, and 58 cervical cancer patients) between 2012 and 2016. A standardized questionnaire was used to collect information on self-reported and clinical variables.

RESULTS

Within two years of primary treatment, 72% of ovarian, 64% of uterine, and 66% of cervical cancer patients were diagnosed with first recurrence, and 54, 67, and 72%, respectively, had symptomatic recurrence. Of symptomatic patients, 25-50% failed to make an appointment before their next scheduled follow-up visit. Computer tomography was the most common diagnostic procedure (89% of ovarian, 76% of uterine, and 62% of cervical cancer patients), and recurrence treatment in terms of chemotherapy was most frequently planned (86% of ovarian, 46% of uterine, and 62% of cervical cancer patients).

CONCLUSIONS

A majority of patients experienced symptomatic recurrence, but many patients failed to make an appointment earlier than scheduled. Most first recurrences occurred within two years of primary treatment; the mean annual incidence rate for years 3-5 after primary treatment was <7%. New models for follow up of gynecological cancer patients could be considered.

Follow-up for cervical cancer: a Program in Evidence-Based Care systematic review and clinical practice guideline update

BACKGROUND

In 2009, the Program in Evidence-based Care (pebc) of Cancer Care Ontario published a guideline on the follow-up of cervical cancer. In 2014, the pebc undertook an update of the systematic review and clinical practice guideline for women in this target population.

METHODS

The literature from 2007 to August 2014 was searched using medline and embase [extended to 2000 for studies of human papillomavirus (hpv) dna testing]. Outcomes of interest were measures of survival, diagnostic accuracy, and quality of life. A working group evaluated the need for changes to the earlier guidelines and incorporated comments and feedback from internal and external reviewers.

RESULTS

One systematic review and six individual studies were included. The working group concluded that the new evidence did not warrant changes to the 2009 recommendations, although hpv dna testing was added as a potentially more sensitive method of detecting recurrence in patients treated with radiotherapy. Comments from internal and external reviewers were incorporated.

RECOMMENDATIONS SUMMARY

Follow-up care after primary treatment should be conducted and coordinated by a physician experienced in the surveillance of cancer patients. A reasonable follow-up strategy involves visits every 3-4 months within the first 2 years, and every 6-12 months during years 3-5. Visits should include a patient history and complete physical examination, with elicitation of relevant symptoms. Vaginal vault cytology examination should not be performed more frequently than annually. Combined positron-emission tomography and computed tomography, other imaging, and biomarker evaluation are not advocated; hpv dna testing could be useful as a method of detection of recurrence after radiotherapy. General recommendations for follow-up after 5 years are also provided.

The expanding role of primary care in cancer control

The nature of cancer control is changing, with an increasing emphasis, fuelled by public and political demand, on prevention, early diagnosis, and patient experience during and after treatment. At the same time, primary care is increasingly promoted, by governments and health funders worldwide, as the preferred setting for most health care for reasons of increasing need, to stabilise health-care costs, and to accommodate patient preference for care close to home. It is timely, then, to consider how this expanding role for primary care can work for cancer control, which has long been dominated by highly technical interventions centred on treatment, and in which the contribution of primary care has been largely perceived as marginal. In this Commission, expert opinion from primary care and public health professionals with academic and clinical cancer expertise—from epidemiologists, psychologists, policy makers, and cancer specialists—has contributed to a detailed consideration of the evidence for cancer control provided in primary care and community care settings. Ranging from primary prevention to end-of-life care, the scope for new models of care is explored, and the actions needed to effect change are outlined. The strengths of primary care—its continuous, coordinated, and comprehensive care for individuals and families—are particularly evident in prevention and diagnosis, in shared follow-up and survivorship care, and in end-of-life care. A strong theme of integration of care runs throughout, and its elements (clinical, vertical, and functional) and the tools needed for integrated working are described in detail. All of this change, as it evolves, will need to be underpinned by new research and by continuing and shared multiprofessional development.

Paradoxes of follow-up - health professionals' views on follow-up after surgical treatment in gynecological cancer

OBJECTIVE

Evidence now reveals that attending a follow-up program may not improve survival for low-stage gynecological cancer patients. The aim of this study was to explore health professionals' experiences with the follow-up programs and their views on follow-up in the future.

METHODS

A qualitative approach was undertaken with semi-structured focus group interviews. Three focus group interviews were conducted at neutral ground. One group with onco-gynecologists, one group with specialist nurses, and one mixed group. The main themes of the interviewguide were: Existing follow-up program, life after cancer and future follow-up. The interviews were transcribed verbatim. Patterns and themes were uncovered from the data inspired by interpretive description.

RESULTS

The doctors described most advantages, such as: Quality control of their own work, detection of sequelae after surgery, and credit and appraisal from the patients. A disadvantage was the inadequate use of the nurses' main competencies. Some dilemmas were described by the nurses as well as doctors: First, both groups were aware of the existing evidence that attendance of follow-up programs may not improve survival and yet, health professionals still performed the follow-ups and most often did not address this paradox for the patients. Second, the existing follow-up program seemed to bring the patients comfort and security on one hand, but on the other hand it seemed to induce insecurity and anxiety. The health professionals agreed that future follow-up should be individualized with focus on the single patients' needs and psychological wellbeing. The health professionals identified a great challenge in communicating the evidence and the forthcoming changes in the follow-up programs to the patients.

CONCLUSIONS

This study revealed that the existing follow-up regime contains several dilemmas. According to the health professionals, future follow-up must be more individualized, and a shift in focus is needed from relapse to quality of life after cancer.

General practitioners' attitudes toward follow-up after cancer treatment: A cross-sectional questionnaire study

OBJECTIVE

An increasing number of cancer patients place a significant workload on hospital outpatient clinics, and health authorities are considering alternative follow-up regimens. It has been suggested that follow-up of cancer patients could be provided by GPs. This study aimed to explore GPs' experiences with the provision of follow-up care for cancer patients, and their views on assuming greater responsibility in the future.

DESIGN

Electronic questionnaire study.

SUBJECTS

GPs in seven regions in Norway.

RESULTS

A total of 317 GPs responded. Many GPs reported experience in providing follow-up care to cancer patients, during the years following initial diagnosis primarily in collaboration with hospital specialists. More than half of the GPs were satisfied with their collaboration. Most GPs preferred to be involved at an early stage in follow-up care and, generally, GPs felt confident in their skills to provide this type of service. Fewer than 10% were willing to assume responsibility for additional cancer patients, citing potentially increased workload as the main reason.

CONCLUSIONS

GPs acknowledged the importance of providing follow-up care to cancer patients, and the majority felt confident in their own ability to provide such care. However, they were hesitant to assume greater responsibility primarily due to fears of increased workload. Key Points It has been suggested that follow-up of cancer patients can be provided by general practitioners (GPs). The viewpoints and attitudes of GPs regarding such follow-up were investigated. GPs reported broad experience in providing follow-up care to patients after active cancer treatment. GPs acknowledged the importance of follow-up care, and they felt confident in their own ability to provide such care. Fewer than 10% of GPs were willing to assume responsibility for additional cancer patients, citing potentially increased workload as the main reason.

Follow-up patterns of cancer survivors: a survey of Canadian radiation oncologists

PURPOSE

With continual advancements in cancer care, improved outcomes, and increasing survivors, survivorship has become an important area of research. This project seeks to determine the current status of follow-up care in oncology.

METHODS

An electronic survey was sent to the Canadian Association of Radiation Oncology members. Based on brief clinical scenarios pertaining to various survivor populations, questions were posed to determine routine follow-up practices.

RESULTS

One hundred eleven radiation oncologists (RO) responded (44% response rate); 29% were female, 43% were in practice <10 years, and most of Canada was represented. Most worked in centers with >10 oncologists (69%) and saw >200 new consults per year (78%). Only 10% reported not following their patients routinely, mainly in those with breast cancer. Most would follow their central nervous system, gastrointestinal, head and neck, gynecologic, and genitourinary patients. Lack of resources and a belief that follow-up by family physicians (FPs) is equally effective were the top reasons for not following. Treatment toxicity and possibility of further treatment were the most common reasons for routine follow-up. The majority (55%) would follow patients for <5 years, with 36% for 5-10 years, and a minority (9%) for longer than 10 years; 54% would not change the frequency of follow-up, but 39% would decrease and only 7% would increase follow-up. Some felt transferring more care to other health professionals would require additional training and more guidelines. Survivorship care plans are underutilized.

CONCLUSIONS

Transfer of follow-up care to FPs is desired and feasible. This would allow for more comprehensive medical care and improve access to care for newly diagnosed patients. The development and usage of survivorship care plans would improve this care.

IMPLICATIONS FOR CANCER SURVIVORS

Survivors may be increasingly followed by family physicians. Better coordination between oncologists and family physicians, including the use of survivorship care plans, may facilitate this transition.

A retrospective study on telephone follow-up of anterior colporrhaphy by a specialized nurse

INTRODUCTION AND HYPOTHESIS

The aim of the study was to evaluate a new follow-up practice after anterior colporrhaphy for central cystocele involving nurse telephone follow-up.

METHODS

A retrospective follow-up of all 84 patients with an anterior colporrhaphy operation during 2011 was performed. Standard postoperative procedure in uncomplicated cases of cystocele operation (first-time cystocele operation, no preoperative incontinence or voiding difficulties, and no immediate postoperative complications) was a telephone interview performed by a continence nurse 3 months after patient surgery. A local checklist comprising questions concerning complications, voiding dysfunction, and sexual life, as well as questions from the International Consultation on Incontinence Vaginal Symptoms (ICIQ-VS) and the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI SF) were used. Complex cases were followed by the surgeon with a consultation including gynecological examination after 3 months.

RESULTS

Out of 84 patients with a cystocele operation, 59 were uncomplicated and had a telephone follow-up. Forty-four (75 %) were satisfied and needed no further consultation in the hospital. One patient could not be contacted. Fourteen patients had a consultation, three before the telephone consultation because of bleeding, five because of anxiety, and one each because of voiding dysfunction and prolapse symptoms. Four patients had persisting urinary incontinence and were incorrectly scheduled for a telephone interview.

CONCLUSIONS

Selecting uncomplicated cases for a nurse telephone follow-up after cystocele operation is feasible in a majority of cases. This allows doctors to see more new patients and focus on difficult cases, as well as saving time and money.

Patient-reported outcome measures for follow-up after gynaecological cancer treatment

BACKGROUND

Cancer is a leading cause of death worldwide. Gynaecologic cancer treatment is known to have the potential for a major impact on quality of life (QoL). Patient-reported outcome measures (PROMs) is an umbrella term that covers a range of potential types of measurement but is used specifically to refer to self reports by the patient of their health and well-being. Use of QoL and cancer-specific questionnaires as alternatives to follow-up may have immense psychological benefit to the patient and cost benefit to the healthcare system.

OBJECTIVES

To evaluate the effectiveness of PROMs as an alternative to routine follow-up of women after treatment for gynaecological cancers to identify recurrences, affect overall survival and assess psychological benefit.

SEARCH METHODS

We searched the Cochrane Gynaecological Cancer Group Trials Register, MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials (CENTRAL) up to November 2012. We also searched registers of clinical trials, abstracts of scientific meetings and reference lists of review articles.

SELECTION CRITERIA

We searched for randomised controlled trials (RCTs) and non-RCTs with concurrent comparison groups (of adequate quality that used statistical adjustment for baseline case mix using multivariable analyses) that compared PROMs or QoL questionnaires versus traditional follow-up with multiple visits to the hospital in women after treatment for gynaecological cancers. Studies that involved women completing PROMs at intervals and submitting results for assessment by their cancer care team or structured interviews of women during their follow-up were included in the analysis.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed whether potentially relevant studies met the inclusion criteria. We found no studies and therefore analysed no data.

MAIN RESULTS

The search strategy identified 2524 unique references, of which all were excluded.

AUTHORS' CONCLUSIONS

We found no evidence to make an informed decision about PROMs for follow-up after gynaecological cancer. Ideally, RCTs which are multicentre or multinational or both, or well-designed non-randomised studies are needed that use multivariable analysis to adjust for baseline imbalances, to compare follow-up strategies and improve current knowledge.

Life after gynecologic cancer--a review of patients quality of life, needs, and preferences in regard to follow-up

OBJECTIVE

This article reviews the literature on quality of life (QoL) of gynecologic cancer survivors, their needs and preferences regarding follow-up, and possible predictors of long-term QoL.

METHODS

A systematic literature search was made in the following databases: MEDLINE (PubMed), Bibliotek.dk, CINAHL, Cochrane, EMBASE, PsycINFO, and SveMed+. We searched the period 1995-2012 for English-language literature. The search was made during July 2011 to February 2012. When possible, the search was made using MeSH terms. Additional reports were collected by systematically viewing the reference lists of the retrieved articles.

RESULTS

Overall studies indicate that survivors after gynecologic cancer do not have impaired QoL in the long term. In general, the patients are highly satisfied with the follow-up program. The patients' greatest concern is fear of recurrence. The most frequent reported unmet need is help in dealing and living with the fear of recurrence. It seems that psychosocial status at time of diagnosis is determining for QoL and well-being in the long term. Association has been found between coping style and QoL, risk of depression, and anxiety in the long term after cancer.

CONCLUSIONS

Even though long-term QoL does not seem to be impaired, the patients are struggling with fear of recurrence, and the way of coping with this fear is a possible predictor for long-term QoL after cancer. However, there is a lack of evidence on QoL, needs, and preferences regarding follow-up of the survivors after gynecologic cancer. The quality of the follow-up regimen is questionable, and it is not evidence based. Thus, it is extremely important to optimize the follow-up program and move focus to life quality. There is a need for an evidence-based strategy regarding follow-up for low-risk gynecologic cancer patients.

Follow-up of the tension-free vaginal tape operation in everyday practice

A retrospective study was performed on clinical follow-up after tension-free vaginal tape (TVT) operations for urinary stress incontinence in our department. Uncomplicated cases of TVT were followed with a telephone interview performed by a specialized nurse three months postoperatively and complex cases with a clinical examination after three months. During one year, 85/117 (73%) were followed by telephone interview and 32/117 (27%) clinically. Of those with a scheduled telephone interview, 73 (86%) were satisfied and without complications, while 12 had a clinical consultation either before or after the interview. Two patients with a scheduled telephone interview developed voiding dysfunction and contacted the operating department. Selecting uncomplicated cases for telephone interview after TVT operation is feasible for the majority of cases.

Gynaecological cancer follow-up: national survey of current practice in the UK

OBJECTIVE

To establish a baseline of national practice for follow-up after treatment for gynaecological cancer.

DESIGN

Questionnaire survey.

SETTING

Gynaecological cancer centres and units.

GEOGRAPHICAL LOCATION UK PARTICIPANTS

Members of the British Gynaecological Cancer Society and the National Forum of Gynaecological Oncology Nurses.

INTERVENTIONS

A questionnaire survey.

OUTCOME MEASURES

To determine schedules of follow-up, who provides it and what routine testing is used for patients who have had previous gynaecological cancer.

RESULTS

A total of 117 responses were obtained; 115 (98%) reported hospital scheduled regular follow-up appointments. Two involved general practitioners. Follow-up was augmented or replaced by telephone follow-up in 29 responses (25%) and patient-initiated appointments in 38 responses (32%). A total of 80 (68%) cancer specialists also offered combined follow-up clinics with other specialties. Clinical examinations for hospital-based follow-up were mainly performed by doctors (67% for scheduled regular appointments and 63% for patient-initiated appointments) while telephone follow-up was provided in the majority by nurses (76%). Most respondents (76/117 (65%)) provided routine tests, of which 66/76 (87%) reported carrying out surveillance tests for ovarian cancer, 35/76 (46%) for cervical cancer, 8/76 (11%) for vulval cancer and 7/76 (9%) for endometrial cancer. Patients were usually discharged after 5 years (82/117 (70%)), whereas three (3%) were discharged after 4 years, nine (8%) after three years and one (1%) after 2 years.

CONCLUSIONS

Practice varied but most used a standard hospital-based protocol of appointments for 5 years and routine tests were performed usually for women with ovarian cancer. A minority utilised nurse-led or telephone follow-up. General practitioners were rarely involved in routine care. A randomised study comparing various models of follow-up could be considered.