Montgomery, David A
Developing an evidence based approach to follow up in breast cancer.
MSc(R) thesis, University of Glasgow.
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After breast cancer, long term follow up is provided with a view to early detection of locoregional relapse, detection and amelioration of side effects of therapy and provision of psychosocial support to those requiring it. There is pressure within the United Kingdom from the National Institute for Clinical Excellence (NICE) to reduce the amount of follow up provided after breast cancer. There is reluctance on the part of clinicians to adopt the NICE guidelines as they are perceived to be based on limited evidence. At the same time, guidelines in other countries continue to advocate long term follow up, sometimes for life.
The evidence base for follow up is explored in the first section of this thesis. In chapter one, a systematic review of the literature is undertaken to establish what evidence exists from randomised controlled trials. The randomised controlled trial is the gold standard for comparing one intervention with another, and any evidence for the benefit of routine clinic visits from randomised trials would be of particular value. Trials which have compared differing frequencies of traditional follow up visits or have compared traditional clinic visits with a novel alternative are included. The impact of these different strategies on relapse detection, survival and quality of life is investigated.
In chapters 2 and 3, the pattern and timing of potentially treatable locoregional relapse and the contribution of regular clinical examination to detection of such relapse is explored. This information would help to establish the value of routine clinics in terms of detecting relapse, and whether there was a time after diagnosis and treatment that risk of relapse was low enough to allow safe discharge. In chapter 2, retrospective analyses of two local cohorts is undertaken to explore this issue. A systematic review of the literature is presented in chapter 3 incorporating both the data presented in chapter 2 as well as any other evidence available from previously published retrospective analyses.
In section 2 of this thesis, the options for alternative follow up are explored. Very little work has been done to establish what women expect from follow up, either in terms of the amount of follow up they expect to receive or their perceptions of the purpose of follow up. In chapter 4, the results of a survey of a cohort of women undertaken prior to attending for their first review visit after completion of therapy is presented.
In the final chapter of this thesis, a prospective cohort study into the acceptability and feasibility of an alternative method of follow up is presented. In this study, an automated computer telephone system was used to deliver a well validated quality of life questionnaire to women in their own homes with the aim of remotely identifying women who were having significant problems with either psychosocial concerns or side effects of treatment and therefore identify those with ongoing problems who required to come back to clinic. In this way, those patients with no ongoing problems would be spared a potentially stressful clinic visit and the number of patients coming back to clinic would be reduced, allowing more time to attend to the needs of the few women brought back with concerns.
Summary of Results
The analysis in chapter 1 reveals that there are only 5 randomised trials of alternative follow methods, and only 2 trials differing frequencies of visits. None is of sufficient size to establish whether routine clinic visits are necessary for relapse detection or overall survival. All suggest that clinic visits have limited impact on quality of life, and may even be less valuable that some alternative methods of follow up for diagnosing anxiety and depression in these women.
Potentially treatable relapse occurs at a constant rate to ten years and beyond. Very few relapses are diagnosed by routine clinical examination, the majority being diagnosed by mammography or symptoms. Mammography is of increasing importance. Patients with clinically detected relapse do no better than those relapses detected in other ways, and there is some evidence that, for some types of relapse, they may do worse.
Chapter 4 reveals that most women expect some follow up, but their expectations are that follow up will be more frequent but for a shorter duration than is currently provided in our unit. When informed of the inefficiency of routine follow up in terms of relapse detection, most women still choose to come back to routine follow up, but a large number state that they would be happy not to come back to clinic.
An alternative method of follow up is shown to be acceptable to a large proportion of women, and valuable in detecting psychological concerns among women after treatment for breast cancer.
The implications of all the findings presented in this thesis for the planning of follow up care in the future are discussed.
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