Randomized Trial of Long-Term Follow-Up for Early-Stage Breast Cancer: A Comparison of Family Physician Versus Specialist Care

Abstract

The article by Grunfeld et al in this issue of the Journal of Clinical Oncology is a landmark article for women with breast cancer and their health care providers. It shows conclusively that the health outcomes for women after primary treatment of breast cancer are the same if they are followed by their family physicians or cancer center specialists. Medical, psychosocial, and all other measured outcomes were the same. There really is no other conclusion that can be drawn. This is not one study; this relates to conclusions from years of research. Grunfeld et al previously showed that in Great Britain, follow-up by a generalist physician led to the same health outcomes as did follow-up by a specialist surgeon, with no change in quality of life, better patient satisfaction, and no change in health care expenditures. Another randomized trial in Great Britain showed that twice as many patients preferred simpler, less frequent follow-up by telephone. There is no a priori reason to expect that patients in the United States would choose differently, and Loprinzi et al demonstrated that the demand for medically inappropriate testing can be reduced by patient education about the specificity, sensitivity, and usefulness of the available tests. In fact, this conclusion corresponds with the American Society of Clinical Oncology (ASCO) guidelines for surveillance of breast cancer patients. Data suggest that current follow-up procedures could be improved. Lash and Silliman followed 303 stage I or II breast cancer patients aged 55 years or older diagnosed at five Boston hospitals, with patient interviews and medical record abstracts. Over 4 years, of the 303 women, 279 had some surveillance testing; the most common test was a mammogram (average, 3.9 in 4 years). Younger women, those treated at a breast cancer center with a unified patient chart, and women who worked, were more likely to complete surveillance; those 75 to 90 years old were less likely to complete guideline-approved surveillance. Mille et al at Centre Regional Leon Berard showed that implementation of clinical practice guidelines on follow-up of patients with localized breast cancer standardized care and a one-third decrease in cost per patient. Earle et al showed that patients followed up by a primary care physician and their oncologist were more likely to receive recommended preventive health services than those followed by their oncologists alone; with more and more survivors each year, this will become increasingly important. With all that evidence, why are we still uneasy with allocating surveillance care to primary care physicians, without oncology routine follow-up? There are substantial issues that have not yet been addressed. This study looked at the most important medical events, such as recurrence and new primary cancers. Are there data that show how frequently oncologists or primary care physicians inquire about some of the “softer” but important issues of body image, sexuality, sexual functioning, adaptation back to normal life, cognitive dysfunction, neuropathic pain, bone health, depression, menopause, or the myriad symptoms left after modern treatment? We know these issues are important, and we know we can fix some of them; we just don’t know in everyday practice how frequently they are addressed and controlled. A prospective study of a onepage follow-up check list would give the answers. Do patient outcomes for specific symptoms due to treatment, such as chronic breast pain, sexual function, menopause symptoms, depression, and so on vary between the two groups? The Hospital Anxiety and Depression Scale (HADS) and 36-item short form (SF-36) are good instruments for global function, but are not designed for breast cancer survivor symptoms. Are there data to suggest that any practitioner group is better? We do know that oncologists are not very good at assessing emotional health. For example, in a study of 204 patients and five oncologists, patients reported many more symptoms than their oncologists perceived, and the oncologists had better sensitivity and specificity for physical symptoms than psychosocial. The oncologists had sensitivity rates up to 80% for fatigue, nausea, vomiting, and hair loss, but recognized only 17% of the patients with anxiety and only 6% of those with clinical depression. Do patient outcomes for important issues such as genetic testing and secondary chemoprevention vary between the two groups? No data are provided. Are there data to suggest that oncologists provide good care in this regard? Data from our institution suggest underreferral of patients with potentially detectable genetic changes associated with breast and colorectal cancer for genetic consultation (personal communication, Joann N. Bodurtha, MD, MPH, October 23, 2005) compared with national recommendations, so there is work to be done. Are there data on the diffusion of new knowledge, such as adding letrozole after 5 years of primary treatment with tamoxifen, JOURNAL OF CLINICAL ONCOLOGY E D I T O R I A L VOLUME 24 NUMBER 6 FEBRUARY 2