Patient follow up is a common part of clinical practice and typically takes up more time than seeing new patients. It is important to consider why oncologists follow patients after their treatment has been delivered.
Reasons for Follow Up
There are several sensible reasons patients should be followed up:
- To ensure resolution of primary malignancy
- Several cancers treated with primary radiotherapy (H&N, anal cancer, cervical cancer) may be surgically salvageable if there is not a complete response and it is essential to follow these patients up until they have complete resolution of their cancer. This may take months after treatment has completed.
- To detect salvageable recurrence of malignancy
- This is important after many radical treatments, for instance endometrial cancer, head and neck cancer, breast cancer etc.
- For early detection of a new, related primary
- Good examples of this include contralateral testicular tumour or second head and neck cancer
- To detect and manage treatment complications
- These change during the time period of follow up.
- An initial 6 week visit at the completion of treatment, or sooner if the patient has developed significant toxicity during treatment, is essential to ensure early effects have resolved
- Visits between 6 weeks and 6 months are used to evaluate intermediate toxicities such as radiation pneumonitis
- Visits after 6 months are for late effects such as fibrosis, bleeding other potentially treatable conditions
- Visits after 5 years are typically for very late toxicities, including second malignancies. Follow up after this time is more common in paediatric populations (late effects clinic)
- Assessment of family history
- Occasionally familial cancers may only become apparent when a relative of the patient is also diagnosed with cancer. It is important to detect these cases so that genetic testing can be implemented where appropriate
- Quality assurance
- Some treatment failures or toxicities may only become apparent with long term follow up.
- If there is a trend towards long term problems then it may relate to treatment delivery.
- Treatment outcomes should be documented in a prospective fashion so that data relating to this can be accessed for research purposes.
- Patient support
- Despite the lack of evidence of follow up improving survival for a number of cancers, patients are often reassured by close follow up which can help their psychosocial wellbeing.
Follow up patterns typically mirror those used in clinical trials that establish a particular treatment.
Negatives of Follow Up
For most cancer types, their is no evidence that follow up improves outcomes and for some sites there is evidence that follow up has no impact on outcomes. History and physical examination may be falsely reassuring (false negative examination); conversely, some abnormal findings on examination may be benign but prompt invasive tests that may impact on the patient's quality of life (eg. biopsy of radiotherapy induced lung nodule causing pneumothorax or death).
Breast cancer is one of the most common cancers and due to high cure rates these patients make up a significant bulk of follow up clinics. A Cochrane review of breast cancer follow up demonstrated no benefit to invasive follow up investigations (bloods, CT, bone scan, liver ultrasound). There are randomised controlled trials demonstrating equivalent outcomes with GP versus specialist follow up. Regardless of who follows the patient up, over half of recurrences are detected by the patient anyway. The benefit of physical examination or mammogram is unproven but they are commonly done to detect salvageable recurrences or new primary lesions. The length of follow up is also unclear, as some tumour recurrences occur after 10 years.
Prostate cancer relapses are often silent until the disease has progressed to an incurable stage. Follow up after primary treatment is typically recommended with measurement of PSA levels. Early introduction of salvage therapy may improve survival as suggested by Stephenson.
In contrast to breast cancer, close follow up with bloods and imaging has proven effective at reducing mortality in colorectal cancer patients. This was shown in a meta-analysis of five randomised trials that alone did not have the power to prove a benefit. NHMRC guidelines state that patients should have:
- 3 monthly review for 2 years, then 6 monthly for 3 years, then annually
- History, physical examination including PR, and sigmoidoscopy if the tumour was rectal at each review
- Regular CEA and CT scans
Early detection of metastatic disease in lung cancer is often of no benefit and optimal follow up is not clear.
Most recurrences (90%) are detected by the patient themselves and therefore intensive follow up is rarely justified.
Germ Cell Tumours
Seminoma has an immensely high cure rate at early stages regardless of treatment choice. This is partly due to low risk of nodal metastases, sensitivity of these to radiation, and excellent response to systemic cytotoxic therapy. Standard follow up depends on treatment: active surveillance, chemotherapy or radiotherapy (and volume of radiotherapy):
- Active surveillance: 3 monthly history/examination/tumour markers and 6 monthly CT for 2 years. 6 monthly history/examination/tumour markers and annual CT for 3 years. Yearly history/examination/bloods for 5 years
- Chemotherapy: History/examination/bloods as for active surveillance. Annual CT for 3 years.
- Radiotherapy: History/examination/bloods as for active surveillance. CT can be omitted for patients w