Some breast cancer survivors require fewer follow-up tests

The patient was panicked when she arrived in the office of internist Janet Pregler, MD, director of the Iris Cantor-UCLA Women's Health Center in Los Angeles. Her breast cancer had been successfully treated, but the last blood test done by her surgeon showed a slightly elevated tumor marker. She was convinced that the cancer had returned. She thought she would be dead in a year.

That was six years ago. The patient is still alive. The tumor marker is still slightly elevated. And the cancer still hasn't returned.

Stories like this illustrate how in some cases intensive follow-up of breast cancer survivors whose disease was detected early does little good while causing significant anxiety, increased costs and a lower quality of life. The evidence is leading many physicians to alter their approaches.

"There are definite things that we need to be doing for breast cancer survivors that are useful and helpful. Our focus really needs to be there because doing all these chest x-rays and liver tests and tumor markers is not helpful," said Dr. Pregler. "[This patient] had to see every different kind of specialist and have every different kind of test. The false positives are really distressing."

Most recently, a meta-analysis published in the Cochrane Library in January found that intensive testing did nothing to impact survival rates overall or to reduce time to detection of a recurrence.

"Less intensive follow-up strategies based on periodic clinical exam and annual mammography seem as effective as more intense surveillance schemes," wrote the researchers from the Mario Negri Institute in Milan, Italy.

Meeting needs of a growing population

The study also addresses in part a much larger question about how to care for the growing number of people who survive cancer. Increasing cancer screening has led to more cancers being detected at an earlier, more curable stage. For example, the most recent cancer statistics published by the American Cancer Society in the January/February issue of CA: A Cancer Journal for Clinicians found that many more breast cancers were being diagnosed and many more people were surviving.

But what the medical care for survivors should be, to address post-treatment issues as well as their usual medical care, is a matter of debate.

"The study of cancer survivors is a very hot topic right now," said Chris Desch, MD, research director at the Virginia Cancer Institute in Richmond.

Guidelines from the American Society of Clinical Oncology issued in 1998 recommend monthly breast self-exams and an annual mammogram unless symptoms call for additional testing. Patients should have a physical exam every three to six months for the first three years after treatment. For three to five years after, patients can come in every six to 12 months, but data were insufficient to recommend any of the additional tests for asymptomatic women.

"I tell my patients that I'm not going to do regular blood tests or CAT scans, but if they come to me with a symptom and we talk about it and I examine them and I'm concerned about it in any way, I will very promptly order a series of tests to get to the bottom of that," said Dr. Desch, who is chair-elect of ASCO's health services committee and participated in the development of the guidelines. "But I don't want to waste anyone's time and money by getting tests every three to six months that most of the time will show absolutely nothing, or if they show something, it may not be related to the cancer."

The ASCO guidelines are currently being revised. The organization is also setting up an expert panel specifically on survivorship to develop additional practice guidance in this area. "How do we transition these people from having cancer to a normal life, but be aware of special medical and psychological needs because they had cancer?" asked Dr. Desch.

But despite guidelines and increasing scientific evidence, physicians also acknowledge that not every doctor sticks to the less-is-more rule.

"There's a wide variation in testing patterns across the country," said Dr. Desch.

The role of the primary care physician

Why this happens is complicated. Some patients may demand more. Doctors may fear liability. A lack of collaboration between the numerous physicians that these patients see during the course and immediate aftermath of their disease including oncologists, surgeons and their primary care doctor may be a contributing factor. Also, as the cancer recedes further into the medical history, the primary care physician becomes increasingly important.

The Cochrane review found that patients prefer follow-up from primary care physicians. A primary care physician's lack of extensive experience with post-breast cancer care may lead to additional testing.

"Women who survive breast cancer see their primary care practitioners often," said Jennifer Potter, MD, an internist and director of the Women's Health Center at Beth Israel Deaconess Medical Center in Boston. "But many primary care clinicians are often uncomfortable with the management, and they're scared about liability and good patient care and, oh my gosh, what if I miss something?"

Meanwhile, though there is increasing acceptance that fewer tests may be the way to go, critics question how applicable this study is to current medical practice in the United States.

The meta-analysis included four very large randomized controlled trials, but they date from 20 years ago and were conducted in Europe.

Experts say that breast cancer screening, diagnosis and treatment has changed so much in the interim, and that these conclusions may not be suitable for the U.S. health care system.

"The size of breast cancer in the last 20 years has decreased remarkably, and the cancer that we treated 20 years ago is very different than the cancer we're treating today," said Jennifer Gass, MD, director of the Breast Health Center at Women & Infants Hospital of Rhode Island in Providence.