Breast Cancer :: Follow-up care for breast cancer patients is devalued & deregulated

Follow-up of breast cancer patients after their initial treatment is becoming “devalued and deregulated”, according to new research published online in the cancer journal, Annals of Oncology.

Yet, the authors say that if follow-up was well designed, co-ordinated and made better use of community-based teams of doctors and nurses, then health authorities could make large financial savings that could be put towards giving patients better access to new and expensive adjuvant drugs (such as aromatase inhibitors), as well as enabling them to see relevant hospital specialists more quickly.

Cancer specialists would gain more time to concentrate on patients with more complex needs, while patients would gain better care and psychological support in their local communities.

Peter Donnelly, the lead author of the study, is a consultant surgeon at Torbay Hospital, UK, and a member of the Breast Cancer Studies Group of the National Cancer Research Institute (NCRI), which initiated the study in conjunction with groups involved in the development of primary care. He said: “While this research looked at what is happening in the UK, its conclusions that good follow-up is important, is more complex than previously thought and requires careful planning and co-ordination between hospitals and community-based healthcare teams, are applicable in many other countries.”

The researchers found that only nine percent of cancer specialists discharged patients according to protocols that conformed with guidelines from NICE (the UK?s National Institute for Health and Clinical Excellence), the duration of follow-up by the specialists ranged between a year to more than ten years in some cases, and the frequency of mammographies for invasive and non-invasive disease varied between one and three years.

Specialists cited lack of confidence in general practitioners? experience and training in oncology and loss of data on patient outcome as their main concerns about discharging patients into the care of the local doctors and nurses.

The researchers sent a questionnaire to 562 cancer specialists in the UK, asking them about discharging patients and how follow-up was managed in their area, their perception of it and whether it followed any guidelines issued either at local or national level. They received 256 replies (46%) from a broad range of specialists (128 surgeons, 93 clinical oncologists, 32 medical oncologists and three radiologists).

Guidelines issued by NICE in 2002 stipulated that patients normally should be released from routine follow-up after no more than three years and that general practitioners (GPs) should take responsibility for looking after women on long-term treatments such as tamoxifen. The guidelines also said that at the end of primary treatment the specialist and the patient should agree a written care plan, and that there should be evidence-based policies on the frequency of mammographies for patients.

However, the research by Mr Donnelly and his colleagues revealed that:

although 84% of specialists had a protocol for managing follow-up, only 9% conformed to NICE guidelines;
only 18% of specialists offered patients a choice of follow-up protocol, of whom only 9% routinely gave patients a written plan;
for invasive disease, 67% arranged annual mammograms, 9% every 18 months, 18% two-yearly, and 3% three-yearly. For non-invasive disease, the figures were similar (62%, 10%, 19% and 2% respectively);
average follow-up time was five years, with variations from one year to over ten years. Discharge at three years was arranged most frequently for patients considered to be at low risk;
metropolitan hospitals tended to provide longer follow-up than district hospitals for patients at high risk from either recurrence or treatment-related problems.

The specialists recognised that reduced clinical workload was the major benefit of discharging their patients to primary care, but had concerns.


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