After Surgery for Breast Cancer: Which Mode of Surveillance?

Follow-up in breast cancer: does routine clinical examination improve outcome? A systematic review of the literature

Multiple guidelines exist for the follow-up of breast cancer, with no agreement on frequency or duration. The contribution of routine clinical examination for the detection of potentially treatable relapse, and the impact this has on survival, is unknown. In this study, we systematically review the literature to establish the proportion of potentially treatable locoregional relapses and new contralateral breast cancers detected by clinical examination, mammography and patient self-examination. We analyse whether method of detection of relapse influences outcome. The methods used were systematic review of the literature. MEDLINE, EMBASE, CancerLit, Web of Sciences and EBM reviews were the data sources for the systematic review. All studies with information on proportion of relapses detected by clinical examination, mammography and self-examination were included. A total of 30-40% of potentially treatable relapses are detected by patient self-examination. In studies published before 2000, 15% of such relapse is mammographically detected with 46% detected by routine clinical examination. In those published after 2000, 40% are mammographically detected with 15% detected on routine clinical examination. Patients with ipsilateral breast relapse detected clinically appear to do less well than those with relapse detected by self-examination or mammography. Routine clinical surveillance is responsible for detection of fewer potentially treatable relapses in more modern cohorts as experience with mammography increases. There is no evidence to suggest that clinical examination confers a survival advantage compared with other methods of detection. The data in this analysis suggest that a review of the guidelines on follow-up after breast cancer should be undertaken.

Effectiveness of routine visits and routine tests in detecting isolated locoregional recurrences after treatment for early-stage invasive breast cancer: a meta-analysis and systematic review

PURPOSE

To review the effectiveness of routine visits and routine tests in detecting isolated locoregional recurrences in asymptomatic patients after treatment for early-stage invasive breast cancer.

METHODS

Systematic review and meta-analysis. The proportion of isolated locoregional recurrences diagnosed during routine visits or routine tests in asymptomatic patients was compared with the proportion of isolated locoregional recurrences in symptomatic patients.

RESULTS

Twelve studies that involved a total of 5,045 patients and 378 isolated locoregional recurrences were identified. Pooling data showed an overall estimate of 40% of isolated locoregional recurrences diagnosed during routine visits or routine tests in asymptomatic patients (95% CI, 35 to 45). Of these, 47% (95% CI, 39 to 54) were diagnosed after mastectomy, and 36% (95% CI, 28 to 43) were diagnosed after breast-conserving therapy (relative risk, 1.327; 95% CI, 1.014 to 1.738). Apart from differences in therapy, we have not been able to discern subgroups of patients for whom results were different.

CONCLUSION

Approximately 40% of isolated locoregional recurrences are diagnosed during routine visits and routine tests in asymptomatic patients treated for early-stage invasive breast cancer. We could not assess whether these were detected by either physical examination or other tests, nor if the detection of asymptomatic isolated recurrences had any influence on potential for cure or quality of life. As the overall quality of the included studies and the overall incidence of isolated locoregional recurrences are low, this systematic review highlights the need for prospective comparative studies on cost-effective strategies for the follow-up of patients after a diagnosis of breast cancer.

Follow-up care of patients treated for breast cancer: a structured review

Breast cancer follow-up services vary, with little evidence to support which practice is best. A systematic review methodology was employed to identify and integrate primary research on the effectiveness of follow-up services. From 4418 articles identified by searches, 38 were eligible for review inclusion. Data were not sufficiently homogenous to integrate statistically, however the following patterns of findings were observed: patient survival and quality of life were not affected by intensity of follow-up or location of care; patients held positive attitudes towards follow-up but psychological distress was consistently high regardless of location of services; few studies assessed patient involvement in treatment choices; studies' research quality was poor with inadequate measures of effectiveness or research designs. There is insufficient primary empirical evidence to draw broad conclusions regarding best practice for breast cancer follow-up care in terms of (a) patient involvement in care, (b) reductions in morbidity, and (c) cost effectiveness of service provision.

Patient initiated follow up of breast cancer

This paper reports on a randomised controlled trial assessing two types of outpatient follow up for women previously treated for stage 1 breast cancer now in remission. These were standard clinic follow up (n = 31, age range: 48-83 years) and patient initiated follow up (n = 30, age range 53-87 years). The latter method involved giving the women written information on the signs and symptoms of recurrence and instructing them to telephone the Breast Care Nurse if they encountered any problems. The groups were compared in terms of cancer and breast cancer-specific quality of life, and psychological morbidity at recruitment, 6 months and 1 year. Satisfaction with follow up was assessed at 6 months and 1 year. Details regarding contact with healthcare professionals were collected at 1 year. There were no major differences in quality of life and psychological morbidity between the groups although more women in the standard clinic group reported reassurance and being checked as advantages whereas more women in the patient initiated follow up group reported convenience as an advantage. Patient initiated follow up is a potential alternative to standard clinic follow up for this group of women and appears to have no adverse effects. This could enable a cost saving to be made.

What are the benefits of routine breast cancer follow-up?

The value of follow-up after potentially curative treatment of breast cancer remains controversial. Recurrence-free women (n = 402) attending a breast clinic over a 3 month period were studied. The women attended 423 appointments, 412 of which were routine. Eleven were requested by the patient or general practitioner (interval appointments). All 11 interval and 19 of the routine appointments resulted in investigations for possible recurrence. Three (27%) interval appointments and four (1%) routine appointments resulted in the diagnosis of a recurrence (P < 10(-5). The attitudes of 285 patients to follow-up were investigated by questionnaire. Two hundred and twenty-three (78%) questionnaires were completed. Regular follow-up in the breast clinic was preferred to attendance only when symptomatic by 190 (85%) women and 169 (76%) preferred regular breast clinic visits to general practitioner follow-up. Most women (n = 174) (81%) said they felt reassured and less anxious having attended the breast clinic. Routine follow-up after potentially curative treatment of breast cancer is inefficient in the detection of recurrence. It is, however, highly rated for providing reassurance and reducing anxiety. Reassurance rather than detection of recurrence may be the most important function of the breast cancer follow-up clinic.