Follow-Up of Breast Cancer Survivors

Abstract

important study of the follow-up preferences of breast cancer survivors. However, I was struck by the marked disconnect between the study’s findings and the authors’ conclusions. In this survey of the self-perceived impact of follow-up by different types of providers, the 218 breast cancer survivors who completed the questionnaire overwhelmingly preferred follow-up with a medical oncologist to follow-up with a primary care physician (PCP) or nurse practitioner (NP). The odds ratios for the belief that medical oncologist follow-up relative to PCP follow-up would decrease breast cancer worry, and increase the chance of surviving cancer, were 36 (95% CI, 21 to 62) and 42 (95% CI, 24 to 74), respectively. Confidence in follow-up by an NP was nonsignificantly lower than that for a PCP. Nevertheless, the authors concluded that “Breast cancer survivors are comfortable with both PCPs and NPs providing follow-up care . . . the NP-led survivorship clinic model, with increased guidance for PCPs, offers a promising route for improving quality of and satisfaction with survivor care.” 1(p158) Breast cancer worry and fear of recurrence are high among breast cancer survivors, and often correlate poorly with objective prognosis. For example, in one study of 136 patients treated with curative intent, more than 50% had moderate to high levels of fear of recurrence. 2 It is inconceivable that a follow-up model that would exacerbate such fears would improve patient satisfaction. Shifting follow-up care from the oncologist to a PCP or NP could have more subtle detrimental effects on patient care, particularly for future medical oncology graduates, who would see far fewer follow-up patients during their training, and would never acquire the experience of monitoring large numbers of patients treated with adjuvant systemic therapy over several years. How will they be able to have balanced discussions with patients for whom the indication for chemotherapy is borderline if they have never seen the 40-year-old ICU nurse who can no longer work because of “chemo brain,” or the mother of six children who develops a cardiomyopathyrelated stroke? Nor will their perspective be balanced if they are asked to see only the patients with complications in the NP-led follow-up clinic next door. Even if patient care could somehow be unaffected, medical oncologists would have much to lose in terms of job satisfaction if we handed most, if not all, of our patients over to other health care professionals for follow-up. Undoubtedly most of us would prefer to see another patient responding to neoadjuvant chemotherapy than a whining but otherwise well survivor. But, more important, a clinic with several women in their thirties dying of metastatic disease is only bearable if, in the same clinic, there is also a patient, expected to have died 15 years ago of locally advanced disease, proudly showing pictures of her son’s wedding or daughter’s graduation. Referring patients with breast cancer who have completed active treatment to their PCP or a NP for follow-up is appropriate and optimal in many cases. Most patients, who greatly prefer medical oncologist follow-up initially, will gladly “graduate” back to their PCP after several years. However, the decision and timing should be made jointly by the patient and medical oncologist, taking into account factors such as patient preference and tumor prognosis. A health care system that allows both traditional and alternative follow-up models will maximize patient satisfaction, maintain the quality of oncology care, and avoid oncologist burn-out.