The Utility of Follow-up Testing After Curative Cancer Therapy: A Critical Review and Economic Analysis

Abstract

OBJECTIVE:To review (1) basic principles of follow-up in patients who are in complete remission following curative therapy for cancer; (2) evaluate the available data on followup strategies for testicular cancer, Hodgkin's disease, nonHodgkin's lymphoma, breast cancer, colorectal cancer, small cell and non-small cell lung cancer, and prostate cancer; and (3) analyze the cost of follow-up strategies METHODS: The English language literature was reviewed utilizing MEDLINE headings for the specific malignancies and the text word "follow-up." Bibliographies of relevant articles also were reviewed. Emphasis was placed on prospective, randomized trials or large retrospective studies in which all patients who potentially could have been evaluated were accounted. The costs of various testing strategies were analyzed utilizing data from the Health Care Finance Administration. DATA SYNTHESIS:Proper follow-up strategies should take into account patterns and time course of recurrence and should be obtained if detection of recurrence would allow meaningful therapeutic intervention. Testing also should be directed at early detection of malignant and nonmalignant complications known to be associated with the primary disease. Testicular cancer is a "model" malignancy in that sensitive tests for recurrence are available and early detection of recurrence allows for potentially curative therapy.CONCLUSIONS: According to the currently available literature, repetitive follow-up laboratory and radiologic testing, except for nonseminomatous germ cell tumors, does not detect the vast majority of cancer relapses, nor does it result in a greater chance of cure or prolonged survival. The majority of recurrences at all disease sites will first be recognized as symptomatic changes in the patient's condition or alterations in the physical examination. A limited panel of blood tests and radiographic studies to detect recurrences, metachronous disease, and complications of therapy (malignant and nonmalignant), will suffice for most cancers. Though data are limited, this more restrictive policy of follow-up testing does not appear to adversely impact patient quality of life and results in dramatic cost of savings to the health care system.A great deal has been written about the utility of screening for cancer with great emphasis on costeffectiveness. 1-3 Relatively little information exists on the value of follow-up testing of asymptomatic patients after potentially curative cancer therapy. This review will outline the general principles that should guide follow-up testing and then examine how these principles can be applied to testicular cancer, Hodgkin's disease and nonHodgkin's lymphoma, and breast, colon, prostate, and lung cancers given currently available data. Economic analysis will demonstrate how this evidence-driven approach to follow-up testing can result in considerable savings without compromise of patient care. Testicular cancer will serve as a model to illustrate the rational application of follow-up testing. The lymphomas will be ...

Detection of relapse in non‐Hodgkin's lymphoma: Role of routine follow‐up studies

“…Another suggestion was to use galium scanning for relapse detection. However, its utility in long-term follow-up remains to be established [4]. On the other hand, another long-term follow-up strategy is based mainly on clinical parameters and supported by studies [3,4] and recent recommendations [8].…”

“…However, its utility in long-term follow-up remains to be established [4]. On the other hand, another long-term follow-up strategy is based mainly on clinical parameters and supported by studies [3,4] and recent recommendations [8]. Weeks et al [3] found that the vast majority of relapses were detected at unscheduled visits for symptomatic disease.…”

“…Also, they found that serum LDH was the only sensitive test in preclinical relapse. On this basis, Edelman et al [4] concluded that follow-up should consist solely of physical examination and serum LDH, whereas routine serum chemistries and blood count are not indicated. Recently, the National Cancer Institute (NCI) recommended that follow-up visits should include history, physical examination for lymphadenopathy, abdominal masses, or organomegaly, a complete blood cell count, and LDH.…”

“…These calculations are based on tertiary center estimated charges, because most lymphoma patients in remission are followed in these centers. The follow-up policy of Edelman et al [4], based on physical examination and serum LDH level evaluation, was calculated to be 70% less expensive than the more typical strategy that includes blood count, chest X-ray on each visit, and at least one CT scan per year. All the suggested strategies, including ours, have not been compared in accordance with their e ect on survival or morbidity.…”

“…On the other hand, there are clinicians who use mainly clinical parameters, namely, history and physical examination. Indeed, two studies reported that the vast majority of relapses are detected at unscheduled visits for symptomatic disease [3] and that it is uncertain what tests beyond history and physical examination are useful for relapse detection [4].…”