Evidence-Based Follow-Up Schedules After Primary Cancer Treatment
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EDITORIAL – MELANOMA
Evidence-Based Follow-Up Schedules After Primary Cancer Treatment Rachael L. Morton, PhD1,2, and John F. Thompson, MD1,3 Melanoma Institute Australia, The University of Sydney, North Sydney, NSW, Australia; 2NHMRC Clinical Trials Centre, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia; 3Discipline of Surgery, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
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It seems logical to assume that more-intensive patient follow-up after initial treatment of a primary malignancy will result in earlier diagnosis of recurrence, allowing earlier treatment of that recurrence and improving survival outcome. However, there is scant evidence that this assumption is true, and claimed survival benefits may be due to lead time bias, with earlier diagnosis of recurrent malignancy creating the false impression that survival time is extended. On the other hand, some studies have indicated that less-intensive follow-up schedules may be just as effective, are generally well accepted by patients, and do not have an adverse effect on survival outcomes, while providing substantial savings in healthcare costs.1–3 High-quality evidence from systematic reviews of randomized controlled follow-up trials is available for several cancer types, in particular non-metastatic colorectal cancer and breast cancer. A recent Cochrane review of randomized trials that has compared more-intensive and lessintensive follow-up schedules in colorectal cancer (19 trials, 13,216 participants) found no significant difference in overall survival (hazard ratio [HR] 0.91, 95% confidence interval [CI] 0.80–1.04); cancer-specific survival (HR 0.93, 95% CI 0.81–1.07); or relapse-free survival (HR 1.05, 95% CI 0.92–1.21). In seven trials that examined psychosocial outcomes, there were no differences in quality of life, anxiety, or depression. In addition, colonoscopies
Ó Society of Surgical Oncology 2020 First Received: 19 May 2020 J. F. Thompson, MD e-mail: [email protected]
performed as part of intensive follow-up for colorectal cancer resulted in an increased rate of complications (odds ratio 7.30, 95% CI 0.75–70.69)0.4 Similarly, a Cochrane review of early-stage breast cancer follow-up (five trials, 4023 participants) comparing more-intensive with less-intensive regimens found no significant difference in overall survival (HR 0.98, 95% CI 0.84–1.15) or disease-free survival (HR 0.84, 95% CI 0.71–1.00).5 One trial included in this review reported no significant difference in quality-of-life domains (including body image, emotional wellbeing, social functioning, symptoms, or satisfaction with care) at 1 or 5 years.6 A further Cochrane review of follow-up in multiple cancer types, i.e. colorectal, breast, non-small cell lung, testicular, and Hodgkin lymphoma (12 studies, 11,276 participants), concluded that less-intensive follow-up probably increased time to detection of recurrence (HR 0.85, 95% CI 0.79–0.92), but made no difference to overall survival (HR 1.05, 95%
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