The premise that early diagnosis of certain types of malignancies
improves outcome and survival is a cornerstone of modern medicine.
Routine use of the Pap smear has been associated with reduced
mortality from cervical cancer. Randomized trials have demonstrated a
survival benefit for screening mammography for women aged 50 to 70
years. Similarly, data have emerged to support screening for
Use of prostate-specific antigen (PSA) screening for prostate cancer
has also been endorsed, although evidence supporting this practice
has been derived from nonrandomized trials. All of these practices
are predicated on the tenet that early diagnosis of certain cancers
As a consequence of the success of screening practices, there is an
understandable belief by both patients and physicians that early
diagnosis of recurrent diseasewhen it is presumably more
amenable to treatmentwill also yield a clinical benefit.
Frequently, this translates into regular, intensive testing of
asymptomatic survivors of early-stage cancers in the hope that early
detection of metatastic disease will improve survival and/or quality
Lack of Benefit From Screening
Unfortunately, this belief has not been borne out. Indeed, as Drs.
Schwartz, Billingsley, and Wallner discuss, existing data show that
rigorous testing of survivors of early-stage breast, prostate, or
colorectal cancer has little impact on their ultimate outcome.
Further, such testing is quite costly and places a substantial burden
on the health-care system, especially since these three malignancies
are diagnosed in over 400,000 Americans each year.
Evidence against routine screening for metastatic breast cancer has
been most thoroughly established. Two large randomized trials that
included more than 2,500 patients have demonstrated that more
intensive follow-up may detect recurrent disease sooner. However,
both studies failed to show that earlier detection translates into
improved survival or a delay in cancer-related deaths.[1,2] Further,
the GIVIO (Interdisciplinary Group for Cancer Care Evaluation [Gruppo
Interdisciplinare Valutazione Interventi Oncologia]) trial showed
that patient-assessed quality of life was similar in the intensive
and nonintensive groups.
Importantly, 70% of recurrences were detected by patients between
visits.[1,2] Proponents of regular, intensive screening point out
that neither of these trials examined the use of newer tests, such as
tumor markers or computed tomography. Further, these trials were
conducted before certain newer salvage therapies, such as the
taxanes, aromatase inhibitors, or trastuzumab (Herceptin), became available.
However, it seems unlikely that these interventions would result in
substantially different findings, particularly in an era where
adjuvant systemic therapy is widely used. Given the results of these
two trials and other data cited by Schwartz et al, recent
evidence-based guidelines from the American Society of Clinical
Oncology (ASCO) and an Italian consensus panel appropriately
recommend only regular office visits, with testing limited to a
targeted evaluation of symptoms or physical abnormalities that are
suggestive of metastatic disease.[3,4]
The only exception is mammography. By extrapolation from screening
studies, mammography to detect ipsilateral breast recurrence or a
contralateral breast primary is the only suggested routine follow-up
test in early breast cancer survivors, since treatment of these two
entities is likely to be associated with improved long-term survival.
High Price of Follow-up Screening
The range and costs of follow-up for colorectal cancer vary even more
widely than those for breast cancer. In addition, randomized data
addressing the value of screening of colorectal cancer survivors are
considerably more limited, involving about 500 patients enrolled in
three trials.[5-7] However, these trials involve several diagnostic
modalities, including computed tomography and colonoscopy.
These and other available data were reviewed by ASCO last year; their
evidence-based guidelines center on office visits every 3 to 6 months
for the first 3 years, and annually thereafter. Monitoring of
carcinoembryonic antigen is warranted only in stage II or III
patients in whom hepatic metastectomy would be considered.
Surveillance for local recurrence by sigmoidoscopy is recommended for
patients with rectal cancer who do not receive radiation therapy.
Even less information is available about the value of follow-up after
treatment of early prostate cancer. No randomized evaluation of
follow-up testing has been performed. This is somewhat surprising,
since a rather sensitive and specific test existsPSA. Here,
expert opinion appears to support PSA monitoring to identify the
fraction of patients who develop local recurrence that might be
amenable to salvage surgery or radiotherapy. Neither digital rectal
examination nor routine imaging studies appear to offer value in
asymptomatic individuals or in the absence of a rising PSA. Thus, PSA
testing and office visits to elicit symptoms of disease recurrence or
therapy complications should also be the focus of prostate cancer
follow-up at this time.[9,10]
For some time, cancer specialists have realized that more
is not always better. This appears to be the case for follow-up
testing, since prospective trials have not demonstrated advantages
for intensive or sophisticated testing of breast and colorectal
survivors, and a paucity of information exists for the follow-up of
prostate cancer survivors.
As the cost of health care continues to escalate, it is imperative
that we as physicians employ evidence-based medicine, rather than
intuition in our daily practice. In the case of follow-up testing,
this means shifting our priorities to regular patient assessment and
selective laboratory testing. Adherence to this lower-cost strategy
does not appear to endanger patient outcome; rather, it should help
optimize the allocation of health-care dollars and ensure that funds
are available to develop and provide better strategies for cancer
screening, prevention, and treatment.
1. Del Turco MR, Palli D, Cariddi A, et al: Intensive diagnostic
follow-up after treatment of primary breast cancer: A randomized
trial. National Research Council Project on Breast Cancer Follow-up.
JAMA 271:1594-1597, 1994.
2. The GIVIO Investigators: Impact of follow-up testing on survival
and health-related quality of life in breast cancer patients: A
multicenter, randomized, controlled trial. JAMA 271:1587-1592, 1994.
3. Consensus Conference on Follow-up of Breast Cancer Patients. Ann
Oncol 6(suppl 2):69-70, 1995.
4. Smith TJ, Davidson NE, Schapira DV, et al: American Society of
Clinical Oncology 1998 update of recommended breast cancer
surveillance guidelines. J Clin Oncol 17:1080-1082, 1999.
5. Schoemaker D, Black R, Giles L, et al: Yearly colonoscopy, liver
CT, and chest radiograph do not influence 5-year survival of
colorectal cancer patients. Gastroenterology 114:7-14, 1998.
6. Ohlsson B, Breland U, Ekberg H, et al: Follow-up after curative
surgery for colorectal carcinoma. Dis Colon Rectum 38:619-626, 1995.
7. Makela JT, Laitinen SO, Kairaluoma MI: Five-year follow-up after
radical surgery for colorectal cancer: Results of a prospective,
randomized trial. Arch Surg 130:1062-1067, 1995.
8. Desch CE, Benson AB, Smith TJ, et al: Recommended colorectal
cancer surveillance guidelines by the American Society of Clinical
Oncology. J Clin Oncol 17:1312-1321, 1999.
9. Oh J, Colberg JW, Ornstein DK, et al: Current follow-up strategies
after radical prostatectomy: A survey of American Urological
Association urologists. J Urol 161:520-523, 1999.
10. Pound CR, Partin AW, Eisenberger MA, et al: Natural history of
progression after PSA elevation following radical prostatectomy. JAMA