The utility of follow-up testing after curative cancer therapy - A critical review and economic analysis

OBJECTIVE: To review (1) basic principles of follow-up in patients who are in complete remission following curative therapy for cancer; (2) evaluate the available data on follow-up strategies for testicular cancer, Hodgkin's disease, non-Hodgkin's lymphoma, breast cancer, colorectal cancer, small cell and non-small cell lung cancer, and prostate cancer; and (3) analyze the cost of follow-up strategies. METHODS: The English language Literature was reviewed utilizing MEDLINE headings for the specific malignancies and the text word ''follow-up.'' Bibliographies of relevant articles also were reviewed. Emphasis was placed on prospective, randomized trials or large retrospective studies in which all patients who potentially could have been evaluated were accounted. The costs of various testing strategies were analyzed utilizing data from the Health Care Finance Administration. DATA SYNTHESIS: Proper follow-up strategies should take into account patterns and time course of recurrence and should be obtained if detection of recurrence would allow meaningful therapeutic intervention. Testing also should be directed at early detection of malignant and nonmalignant complications known to be associated with the primary disease. Testicular cancer is a ''model'' malignancy in that sensitive tests for recurrence are available and early detection of recurrence allows for potentially curative therapy. CONCLUSIONS: According to the currently available literature, repetitive follow-up laboratory and radiologic testing, except for nonseminomatous germ cell tumors, does not detect the vast majority of cancer relapses, nor does it result in a greater chance of cure or prolonged survival. The majority of recurrences at all disease sites will first be recognized as symptomatic changes in the patient's condition or alterations in the physical examination. A limited panel of blood tests and radiographic studies to detect recurrences, metachronous disease, and complications of therapy (malignant and nonmalignant), will suffice for most cancers. Though data are limited, this more restrictive policy of follow-up testing does not appear to adversely impact patient quality of life and results in dramatic cost of savings to the health care system.