Background
Methods
Systematic review on the evidence of effects of intensive follow-up on breast cancer outcomes
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Population: breast cancer patients, treated with curative intent;
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Intervention: intensive follow-up schedule;
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Comparison: non-intensive follow-up;
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Outcomes: 5- and 10-year mortality due to breast cancer; 5 and 10-year breast cancer recurrences (loco-regional and distant separately); 5- and 10-year breast cancer specific survival; quality of life at 2 and 5 years after diagnosis; women’s satisfaction with follow-up (measured by reassurance of women with the intensive follow-up and convenience by the women of intensive follow-up).
Inclusion and exclusion criteria
Search strategy
Data extraction
Risk of bias
Effect measures
Quality of the evidence evaluation
Data analysis
Review on women’s values and preferences
Inclusion and exclusion criteria
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examining women’s preferences for follow-up strategies after breast cancer treatment;
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evaluating how women value the main outcomes associated with follow-up strategies after breast cancer treatment;
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examining the choices women make when informed about the desirable and undesirable effects associated with follow-up strategies after breast cancer treatment.
Search strategy
Data extraction
Quality of the evidence evaluation
Review on economic evidence
Inclusion and exclusion criteria
Search strategy
Data extraction
Quality of evidence
Results
Evidence of effects of intensive follow-up on breast cancer outcomes
Study | Participants | Intervention | Comparator | Outcome | Risk of bias |
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Oltra 2007 RCT | Spain, hospital setting, 58 cases and 63 controls | Intensive follow-up: Outpatient appointments (following ASCO guidelines in frequency) had: anamnesis and physical examination, biochemistry, blood count, and the markers carcinoembryonic antigen (CEA) and CA15–3. Annual check-up included: mammography, hepatic echography, chest X-ray, and bone scan. | Standard follow up: Outpatient appointments (following ASCO guidelines in frequency) had anamnesis and physical examination; no complementary tests in absence of clinical symptoms. Annual check-up included mammography. | Cost-benefit evaluation (intensive vs. standard follow-up) in the early detection of breast cancer relapses. | - Random sequence generation: unclear - Allocation concealment: unclear - Blinding of participants and personnel: high risk - Blinding of outcome assessment: high risk - Incomplete outcome data: low risk - Selective reporting: low risk |
Kokko 2003 Kokko 2005 RCT | Finland, hospital setting, 243 cases and 229 controls | Patient-initiated follow-up: Chest X-rays and other diagnostic tests taken only when clinically indicated. Moreover, patients were further randomised into: - outpatient appointments every 3 months (group A); - outpatient appointments every 6 months (group C). | Standard follow-up: Chest X-rays and other diagnostic tests taken routinely every 6 months. Moreover, patients were further randomised into: - outpatient appointments every 3 months (group B); - outpatient appointments every 6 months (group D). | Main study: recurrences, free disease survival, overall survival. Cost-benefit study: evaluation of the early detection of breast cancer relapses (appointments every 3 vs. 6 months, and routine vs. clinically-requested exams). | - Random sequence generation: unclear - Allocation concealment: unclear - Blinding of participants and personnel: high risk - Blinding of outcome assessment: high risk - Incomplete outcome data: low risk - Selective reporting: low risk |
Brown 2002 Multicentre RCT | England, hospital setting (4 clinics), 31 cases and 30 controls | Patient-initiated follow-up: Patients received written information on the signs and symptoms of recurrence, and the invitation to contact the nurses by telephone in case of any problem. They did not attend routine clinic appointments. Annual check-up with mammography. | Standard follow-up: Outpatient appointments as standard clinic follow-up: anamnesis, physical examination, and possibility to ask questions. Annual check-up with mammography. | Quality of life. Psychological morbidity. Satisfaction with follow-up. | - Random sequence generation: low risk - Allocation concealment: unclear - Blinding of participants and personnel: high risk - Blinding of outcome assessment: high risk - Incomplete outcome data: low risk - Selective reporting: low risk |
Gulliford 1997 Multicentre RCT | England, hospital setting (2 clinics), 97 cases and 96 controls | Patient-initiated follow-up: Outpatient visits only after mammography: yearly (lumpectomies done less than 5 years before; mastectomies performed less than 1 year before) or every other year (lumpectomies done more than 5 years before; mastectomies performed more than 1 year before). Patient-initiated phone contact in case of symptoms. | Standard follow-up: Outpatient visits according to conventional schedule: every 3 months if the surgery took place less than one year before; every four months if the surgery was between one and two years before; every six months if the surgery was between two and five years before; and annually if the surgery was more than five years before. Mammography as the other arm. Phone contact as the other arm. | Interim use of telephone and general practitioner. Satisfaction with allocation to follow-up. | - Random sequence generation: unclear - Allocation concealment: unclear - Blinding of participants and personnel: high risk - Blinding of outcome assessment: high risk - Incomplete outcome data: low risk - Selective reporting: low risk |
Rosselli del Turco 1994 Palli 1999 Multicentre RCT | Italy, hospital setting (12 clinics), 622 cases and 621 controls | Intensive follow-up: Physical examination performed every 3 months in the first 2 years and every 6 months in the following 3 years; 2-view chest X-rays and bone scan performed every 6 months; mammography performed every year. | Standard follow-up: Physical examination performed every 3 months in the first 2 years and every 6 months in the following 3 years; mammography performed every year during the study (5 years). Other diagnostic tests performed only in presence of symptoms. | Overall survival. Relapse-free survival. Distant metastases. Death. Event-free survival (distant metastases or death). | - Random sequence generation: unclear - Allocation concealment: low risk - Blinding of participants and personnel: high risk - Blinding of outcome assessment: high risk - Incomplete outcome data: low risk - Selective reporting: low risk |
GIVIO 1994 Multicentre RCT | Italy, hospital setting (26 clinics), 655 cases and 665 controls | Intensive follow-up: Physical exam every 3 months for 2 years and then every 6 months for 3 years; blood test every visit (ALP, gammaGT); chest X-rays every 6 months; annual radionuclide bone scan; annual liver echography; annual contralateral mammography. | Standard follow-up: Physical exam every 3 months for 2 years and then every 6 months for 3 years; annual contralateral mammography. | Mortality/overall survival. Recurrence (type of recurrence, time to detection of recurrence). Symptomatic status at diagnosis of metastases. Health-related quality of life. | - Random sequence generation: low risk - Allocation concealment: low risk - Blinding of participants and personnel: high risk - Blinding of outcome assessment: high risk - Incomplete outcome data: low risk - Selective reporting: low risk |
Quality assessment | No. of patients | Effect | Quality | Importance | ||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|
No. of studies | Study design | Risk of bias | Inconsistency | Indirectness | Imprecision | Other considerations | Intensive follow-up | Non-intensive follow-up | Relative (95% CI) | Absolute (95% CI) | ||
10-year overall mortality in women with breast cancer | ||||||||||||
1 | RCT | not serious | not serious | not serious | not serious | none | 222/622 (35.7%) | 212/621 (34.1%) |
RR 1.05
|
17 more per 1000
| ⨁⨁⨁⨁ | CRITICAL |
Palli 1999 | (0.90 to 1.22) | (from 34 fewer to 75 more) | HIGH | |||||||||
5-year overall mortality in women with breast cancer | ||||||||||||
3 | RCT | not serious | not serious | not serious | not serious | none | 277/1520 (18.2%) | 277/1515 (18.3%) |
RR 1.00
|
0 fewer per 1000
| ⨁⨁⨁⨁ | CRITICAL |
Rosselli del Turco 1994 | (0.86 to 1.16) | (from 26 fewer to 29 more) | HIGH | |||||||||
GIVIO 1994 | ||||||||||||
Kokko 2003 | ||||||||||||
5-year recurrence of breast cancer | ||||||||||||
3 | RCT | serious1
| not serious | not serious | not serious | none | 460/1520 (30.3%) | 414/1515 (27.3%) |
RR 1.08
|
22 more per 1000
| ⨁⨁⨁ ◯ | CRITICAL |
Rosselli del Turco 1994 | (0.89 to 1.30) | (from 30 fewer to 82 more) | MODERATE | |||||||||
GIVIO 1994 | ||||||||||||
Kokko 2003 | ||||||||||||
Any time recurrence of breast cancer (follow up: range 1 to 5 years) | ||||||||||||
5 | RCT | serious1
| not serious | not serious | not serious | none | 475/1609 (29.5%) | 427/1608 (26.6%) |
RR 1.10
|
27 more per 1000
| ⨁⨁⨁ ◯ | CRITICAL |
Rosselli del Turco 1994 | (0.95 to 1.27) | (from 13 fewer to 72 more) | MODERATE | |||||||||
GIVIO 1994 | ||||||||||||
Brown 2002 | ||||||||||||
Kokko 2003 | ||||||||||||
Oltra 2007 | ||||||||||||
Satisfaction of women with the type of follow-up - Reassurance (follow-up: range 1 to 3 years) | ||||||||||||
2 | RCT | serious1
| very serious2
| not serious | not serious | none | 92/127 (72.4%) | 72/127 (56.7%) |
RR 1.28
|
159 more per 1000
| ⨁ ◯◯◯ | IMPORTANT |
Brown 2002 | (1.07 to 1.54) | (from 40 more to 306 more) | VERY LOW | |||||||||
Gulliford 1997 | ||||||||||||
Satisfaction of women with the type of follow-up - Convenience (follow-up: mean 1 year) | ||||||||||||
1 | RCT | serious1
| not serious | not serious | not serious | none | 1/31 (3.2%) | 22/30 (73.3%) | RR 0.04 | 704 fewer per 1000 | ⨁ ⨁◯◯ | IMPORTANT |
Brown 2002 | (0.01 to 0.31) | (from 506 fewer to 726 fewer) | LOW |
Women’s values and preferences
Study | Participants | Intervention | Results | Risk of bias |
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Gulliford 1997 RCT | 96 patients in conventional follow-up and 95 patients in non-conventional follow-up | Comparison of conventional follow-up (clinic visits, every three, four, six or 12 months, based on the time distance from the surgery) with non-conventional follow-up (clinical visits every 12 or 24 months). Mammography in both groups every 12 or 24 months. | Twice as many patients in both groups expressed a preference for reducing rather than increasing follow-up visits. No increased use of local practitioner services or telephone triage was recorded in the group with less-intensive follow-up. | Low risk of bias |
Stemmler 2008 Questionnaire in the context of a surveillance study | 801 (30.1%) of 2658 eligible patients | Survey aimed to evaluate patients’ views on surveillance after breast cancer. | The majority of women confirmed the need for surveillance (95%), and 47.8% of the patients in the self-help group answered that there was a need for more intensive diagnostic effort during follow-up. The main expectation from an intensified follow-up was the increased sense of security (80%). | High risk of bias |
Kimman 2010 Multicentre discrete-choice experiment survey | 5 hospitals, 331 (59%) of 557 eligible patients | Survey aimed to assess: - preferred professional/s involved in follow-up; - preferred type of follow-up (in person vs telephone); - preferred follow-up schedule | The most preferred person to perform follow-up was the medical specialist, but a combination of the medical specialist and breast care nurse was also acceptable to patients. Face-to-face contact was strongly preferred over telephone contact. Follow-up visits every three months were preferred over visits every four, six, or 12 months. | Moderate risk of bias |
Economic evidence
Should women be followed intensively after breast cancer treatment? | |||
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Problem: | Women treated for breast cancer are followed-up for monitoring treatment effectiveness and for detecting recurrences at an early stage, but the frequency of follow-up is under discussion. | Background: | Women treated for breast cancer are followed up for monitoring treatment effectiveness and for detecting recurrences at an early stage. Follow-up includes clinical and test examinations like routine haematological and liver function tests, tumour markers, chest X-ray, mammography, bone and liver scans. There is variability in the frequency of medical visits and the tests performed. |
Option: | Intensive follow-up. | ||
Comparison: | Non-intensive follow-up. | ||
Main outcomes: | 1. 10-year mortality due to breast cancer. 2. 5-year mortality due to breast cancer. 3. 5 (or 10)-year breast cancer specific survival. 4. 10-year breast cancer recurrences (loco-regional and distant separately). 5. 5-year breast cancer recurrences (logo-regional and distant separately). 6. Quality of life of breast cancer patients 2 (or 5) years after diagnosis. 7. Patient satisfaction with follow-up. | ||
Setting: | Breast cancer centres/other healthcare services. | ||
Perspective: | Population. |
Domain | Judgement | Research evidence | Additional considerations |
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Problem | Is the problem a priority? | With over 458,000 new cases and 131,000 deaths per year, breast cancer is one of the main killers in Europe, and its diagnosis, treatment and follow-up represent major public health priorities. Despite the doubts that intensive follow-up care could improve survival in patients after breast cancer, intensive follow-up is quite common in clinical practice and represents a significant workload for radiotherapy, surgical and oncologic departments (Loprinzi 1994), and it is also costly. | |
○ No | |||
○ Probably no | |||
● Probably yes | |||
○ Yes | |||
○ Varies | |||
○ Don’t know | |||
Desirable effects | How substantial are the desirable anticipated effects? | The evidence showed uncertain differences in overall mortality at 5 and 10-year follow-up (high quality evidence), and uncertain differences in recurrences at 5 years of follow-up (moderate quality evidence). The evidence showed significant differences in reassurance of women in favour of intensive follow-up (very low quality evidence), and convenience in favour of non-intensive follow-up (low quality evidence). There was missing research evidence in respect to the outcomes: 5 and 10-year breast cancer specific survival, 10-year breast cancer recurrences and quality of life of breast cancer patients 2 or 5 years after diagnosis. | |
● Trivial | |||
○ Small | |||
○ Moderate | |||
○ Large | |||
○ Varies | |||
○ Don’t know | |||
Undesirable Effects | How substantial are the undesirable anticipated effects? | Undesirable health effects are related to mental health (stress for false positive, false reassurance for false negative). | |
○ Large | |||
○ Moderate | |||
○ Small | |||
● Trivial | |||
○ Varies | |||
○ Don’t know | |||
Certainty of evidence | What is the overall certainty of the evidence of effects? | The evidence on 5- and 10- year overall mortality was of high quality, and did not favour intensive versus standard follow-up. The evidence on 5-year cancer recurrences was of moderate quality, and there were uncertain differences between intensive and standard follo-up; similar conclusions apply to cancer recurrences at any time. The evidence of women satisfaction was of very low quality (reassurance domain) and of moderate quality (convenience domain). The evidence on values for women was of low quality (inconsistency among studies). The evidence on economic evaluations was of high quality, and favoured non-intensive follow-up. | |
○ Very low | |||
○ Low | |||
● Moderate | |||
○ High | |||
○ No included studies | |||
Values | Is there important uncertainty about or variability in how much people value the main outcomes? | Important variability was present among studies and within studies regarding women preferences for the intensity of follow-up (moderate confidence) (Gulliford 1997, Stemmler 2008, Kimman 2010). | |
○ Important uncertainty or variability | |||
● Possibly important uncertainty or variability | |||
○ Probably no important uncertainty or variability | |||
○ No important uncertainty or variability | |||
○ No known undesirable outcomes | |||
Balance of effects | Does the balance between desirable and undesirable effects favour the intervention or the comparison? | The evidence on health outcomes favours the comparison. The evidence on values for women is unclear: reassurance seems to favour the intervention (very low quality evidence), while convenience seems to favour the comparison (moderate quality evidence).The evidence on health outcomes favours the comparison. | |
○ Favours the comparison | |||
● Probably favours the comparison | |||
o Does not favour either the intervention or the comparison | |||
○ Probably favours the intervention | |||
○ Favours the intervention | |||
○ Varies | |||
○ Don’t know | |||
Resources required | How large are the resource requirements (costs)? | Moderate costs for the annual mammography option. Large costs could result for more intensive follow-up schedules that could include more than one mammography per year, clinical examinations, or MRI, or bone scans or others. Moderate costs for the annual mammography option. | |
○ Large costs | |||
○ Moderate costs | |||
○ Negligible costs and savings | |||
○ Moderate savings | |||
○ Large savings | |||
● Varies | |||
○ Don’t know | |||
Certainty of evidence of required resources | What is the certainty of the evidence of resource requirements (costs)? | Evidence comes from a good quality cost-utility analysis study from the UK (Robertson 2011). | |
○ Very low | |||
○ Low | |||
● Moderate | |||
○ High | |||
○ No included studies | |||
Cost effectiveness | Does the cost-effectiveness of the intervention favour the intervention or the comparison? | In the base-case scenario of a cost-utility analysis of different follow-up strategies carried out in the UK, the strategy with the highest net benefit, and most likely to be considered cost-effective, was surveillance mammography alone every 12 months at a societal willingness to pay for a quality-adjusted life year of either £20,000 or £30,000. The incremental cost-effectiveness ratio for surveillance mammography alone every 12 months compared with no surveillance was € 6051 (2008 value) (Robertson 2011). | Even though different countries use different cost per QALY thresholds for deciding which interventions will be funded by public health services, € 6051 is far below the threshold used in most European countries. |
● Favours the comparison | |||
○ Probably favours the comparison | |||
○ Does not favour either the intervention or the comparison | |||
○ Probably favours the intervention | |||
○ Favours the intervention | |||
○ Varies | |||
○ No included studies | |||
Equity | What would be the impact on health equity? | With less intensive follow-up strategies, resources could be mobilised to other aspects of breast cancer care or other areas of health care that could increase equity. | |
○ Reduced | |||
○ Probably reduced | |||
○ Probably no impact | |||
● Probably increased | |||
○ Increased | |||
○ Varies | |||
○ Don’t know | |||
Acceptability | Is the intervention acceptable to key stakeholders? | Some patients, relatives and health professionals might find it unacceptable to reduce the number of visits and tests performed. | |
○ No | |||
○ Probably no | |||
○ Probably yes | |||
○ Yes | |||
● Varies | |||
○ Don’t know | |||
Feasibility | Is the intervention feasible to implement? | Settings with more intensive follow-up strategies will need to consider what is the impact of implementing less intensive strategies (e.g. relocate healthcare professionals or equipment). | |
○ No | |||
○ Probably no | |||
● Probably yes | |||
○ Yes | |||
○ Varies | |||
○ Don’t know |
Should women be followed intensively after breast cancer treatment? | |||||
---|---|---|---|---|---|
Type of recommendation | Strong recommendation against the option | Conditional recommendation against the option | Conditional recommendation for either the option or the comparison | Conditional recommendation for the option | Strong recommendation for the option |
○ | ● | ○ | ○ | ○ | |
Recommendation | We suggest that women with breast cancer are followed-up once a year with a mammography (as opposed to other regimens) (provisional and conditional recommendation). | ||||
Justification | There is moderate certainty of evidence that intensive follow-up compared with less intensive follow-up (more frequent diagnostic tests or visits) does not reduce 5–10-year overall mortality and recurrences in women with breast cancer. The cost of different regimens of follow-up is variable, with more intensive regimens being more expensive and cost-effectiveness favouring less intensive regimens. Resources could be mobilised to other aspects of breast cancer care, or other areas of healthcare, potentially increasing equity. This recommendation is provisional because of the uncertainty about the net benefit of the interventions. This recommendation is conditional because it might be different depending on the feasibility of the setting of the intensive follow-up policy. | ||||
Subgroup considerations | Not applicable (no specific subgroup of women were considered). | ||||
Implementation considerations | Women should be informed in detail at baseline about different types of follow-up and their related impacts, to increase their satisfaction and reassurance with a less intensive follow-up. Resources could be mobilised to other aspects of breast cancer care, or other areas of health care, potentially increasing equity. | ||||
Monitoring and evaluation | Health outcomes related to less intensive follow-up should be periodically assessed (we suggest every 5 years). | ||||
Research priorities | Patient-centred endpoints should be explored, and the relationship between follow-up intensity and technical and psychological support to continue endocrine treatment should be further studied. Similarly, organisational aspects related to the coordination of follow-up activities should be addressed. |