Less Is More in Cancer Survivor Care
Two oncologists from Fox Chase Cancer Center in Philadelphia have added their weight to the growing call for less intensive follow-up of cancer survivors whenever appropriate.
Megha Shah, MD, a hematologist/oncologist, and Crystal S. Denlinger, MD, an attending physician, both from the Department of Medical Oncology, Fox Chase Cancer Center, reviewed the current surveillance of prostate, colorectal, and breast cancer survivors (Oncology [Williston Park]. 2015;29:230-240).
Drs Shah and Denlinger recommend standardized, evidence-based surveillance practices that follow guidelines rather than overusing tests that do not increase quality of life or length of survival but add to the cost of care and patient anxiety.
“Providers need to understand the data and national guidelines regarding surveillance, and be willing to have open discussions with their patients regarding the current state of the data,” Dr Denlinger told Value-Based Cancer Care. “In addition, more studies focusing on optimal surveillance strategies are necessary in various cancers to better inform surveillance practices and guidelines. The assumption that more is better is not always true.”
The investigators noted that close monitoring of prostate-specific antigen (PSA) levels and PSA doubling time in men with nonmetastatic prostate cancer who have had radiation or prostatectomy can detect aggressive disease that may be treatable by salvage therapies. However, the investigators recommended against routine imaging in asymptomatic individuals, citing a 1997 literature review that indicated that using these imaging studies across the board after radiation or prostatectomy can reduce surveillance costs by $330 million per 1000 people over 10 years.
Drs Shah and Denlinger believe that similar approaches could be used in patients undergoing active surveillance, as well as in patients receiving androgen-deprivation therapy alone, or those who have metastatic disease, with PSA level monitoring key to watching the disease.
Overall, the researchers recommend a physician visit, physical examination, and PSA testing every 6 months for 5 years posttreatment for prostate cancer surveillance. They further state that imaging and digital rectal examinations are only useful for patients with rapid PSA elevations or for those who become symptomatic.
Whether PSA testing should be continued annually for more than 5 years posttreatment for prostate cancer should be based on the person’s age, comorbidities, and life expectancy.
Drs Shah and Denlinger also recommend limiting the surveillance period to 5 years for patients who have undergone primary treatment for colorectal cancer. The investigators remarked that until a consensus is reached on a more standardized, evidence-based approach, the consensus appears to be a physician visit every 3 to 6 months in the first 5 years after therapy, with a physical examination and carcinoembryonic antigen level testing. The patient should also undergo a colonoscopy 1 year after treatment and, if the results are normal, every 3 to 5 years thereafter.
Patients who are at high risk for the recurrence of colorectal cancer based on individual factors such as tumor characteristics can benefit from radiographic imaging with annual computed tomography scans for up to 5 years, Drs Shah and Denlinger noted. They do not recommend routine radiographic surveillance for low-risk colorectal cancer, and instead suggested individualized radiographic surveillance strategies.
Large randomized studies in breast cancer have demonstrated that intensive surveillance strategies with routine tumor marker testing, bone scans, and other radiology studies did not improve survival over clinical evaluation with annual mammography. Thus, the National Comprehensive Cancer Network and the American Society of Clinical Oncology (ASCO) surveillance guidelines call for follow-up visits after curative-intent treatment with surgery, chemotherapy, and/or radiation every 6 months for 5 years, as well as annual mammography.
“Intensive follow-up with additional imaging studies and routine tumor marker tests does not improve” clinical outcomes in breast cancer, the investigators noted. However, they observed, “oncologists continue to engage in intensive surveillance approaches.” One study using the Surveillance, Epidemiology, and End Results (SEER) database showed that patients who had follow-up with an oncologist had higher rates of nonrecommended tests than other patients (Keating NL, et al. J Clin Oncol. 2007;25:1074-1081). Another SEER database study showed that almost 50% of patients with early-stage breast cancer had ?1 tumor marker assessments within 2 years of diagnosis; this was associated with a 29% increase in overall medical costs (Ramsey SD, et al. J Clin Oncol. 2015;33:149-155).
“While outcomes with recurrent disease are best when patients are asymptomatic at the time of recurrence detection, there are no current data to suggest that intensive surveillance strategies using various imaging modalities and tumor marker tests improve those outcomes,” Drs Shah and Denlinger concluded. “Thus, adherence to the guidelines that recommend routine clinician visits with physical and clinical breast exam and annual mammography would reflect the optimal strategy in post treatment breast cancer surveillance.”
The researchers highlighted the important role played by ASCO’s Choosing Wisely initiative, together with interdisciplinary survivorship plans, in making the best choices for posttreatment surveillance of cancer survivors. They also called for more research on surveillance measures that takes into account cost-effectiveness, overall quality of life, and the physical and psychologic risks associated with overtesting.