Follow-up of patients with Hodgkin's disease following curative treatment: the routine CT scan is of little value

Abstract

A total of 10 -40% of patients with Hodgkin's disease relapse following initial curative therapy. Intensive follow-up is resource intensive and may identify false relapses. We performed a retrospective review of all patients with Hodgkin's disease treated at our centre between 1990 and 1999 to evaluate the utility of the components of follow-up. A total of 107 patients met the inclusion and exclusion criteria. The median age was 33 years and the median duration of follow-up 38 months. The total number of follow-up visits was 1209 and total number of CT scans 283. There were 109 suspected relapses of which 22 proved to be true relapses. Of the latter, 14 were identified clinically, six radiologically and two via lab testing. The routine CT scan detected only two relapses (9%), yet accounted for 29% of the total follow-up costs. Based on data from our centre, the cost per true relapse was $6000 US, 49% incurred by radiological tests. The majority of the cost of follow-up was incurred by routine follow-up (84%) as opposed to the investigation of suspected relapses (16%). We conclude that most true relapses are clinically symptomatic and that the routine CT is an expensive and inefficient mode of routine follow-up.

Follow-Up Care for Survivors of Lymphoma Who Have Received Curative-Intent Treatment

“…The study reported by Pingali et al 11 compared the incidence of relapse in patients managed with clinical surveillance alone and in those who underwent routine surveillance imaging, reporting that differences between groups were not statistically significant (7.4% vs. 3.4%, p = 0.39). The two remaining studies reported that the proportion of relapses initially suspected by clinical manifestations ranged from a low of 13% 9 to a high of 64% 4 and that the proportion of relapses initially suspected by surveillance imaging ranged from a low of 8% 9 to a high of 27% 4 .…”

“…Nine studies reported on the followup care of asymptomatic survivors of lymphoma who had received curative-intent treatment [4][5][6][7][8][9][10][11][12] . Two studies involving patients with nhl in complete remission detected a statistically significant difference in the number of relapses initially suspected by clinical manifestations (patient-reported symptoms or physical examination) compared with relapses initially suspected by imaging before clinical manifestation 10,12 .…”

“…Overall, the body of evidence is limited mainly by designs based on retrospective analyses of electronic medical records and by relatively small sample sizes with a low number of relapses. The sample size of the included studies ranged from a low of 109 to a high of 1221 in a population-based study comparing the survival rate of patients with lymphoma undergoing different clinical follow-up policies 4,13 . In most of the studies, patients had nhl 5,7,8,10,[12][13][14] ; three studies focused on the follow-up of patients with Hodgkin lymphoma 4,9,11 , and one study reported on patients with both types of lymphoma 6 .…”

“…The sample size of the included studies ranged from a low of 109 to a high of 1221 in a population-based study comparing the survival rate of patients with lymphoma undergoing different clinical follow-up policies 4,13 . In most of the studies, patients had nhl 5,7,8,10,[12][13][14] ; three studies focused on the follow-up of patients with Hodgkin lymphoma 4,9,11 , and one study reported on patients with both types of lymphoma 6 . The number of relapses ranged from a low of 15 to a high of 163 in patients with nhl 10,12 , and from a low of 11 to a high of 42 in patients with Hodgkin lymphoma 6,11 .…”

Positron emission tomography/computed tomography surveillance in patients with Hodgkin lymphoma in first remission has a low positive predictive value and high costs

“…5 Conclusions from previous studies support a restrictive use of routine surveillance imaging, as the majority of relapses are preceded by symptoms or abnormalities on clinical examination, but these studies mainly used conventional radiograms and not whole-body computed tomography (CT), which is now more commonly performed. 6,7 Routine CT surveillance, however, also appears to have limited value; in a study by Dryver et al, only 9% of HL relapses were diagnosed by CT. 8 Besides, CT surveillance is probably not cost-effective and could decrease quality of life mainly by increasing patients' anxiety. 9,10 Thus, the extensive use of routine surveillance imaging for HL patients remains controversial, with no international consensus.…”