Optimizing follow-up after breast cancer treatment

Opportunities for personalised follow-up care among patients with breast cancer: A scoping review to identify preference-sensitive decisions

INTRODUCTION

Current follow-up arrangements for breast cancer do not optimally meet the needs of individual patients. We therefore reviewed the evidence on preferences and patient involvement in decisions about breast cancer follow-up to explore the potential for personalised care.

METHODS

Studies published between 2008 and 2017 were extracted from MEDLINE, PsycINFO and EMBASE. We then identified decision categories related to content and form of follow-up. Criteria for preference sensitiveness and patient involvement were compiled and applied to determine the extent to which decisions were sensitive to patient preferences and patients were involved.

RESULTS

Forty-one studies were included in the full-text analysis. Four decision categories were identified: "surveillance for recurrent/secondary breast cancer; consultations for physical and psychosocial effects; recurrence-risk reduction by anti-hormonal treatment; and improving quality of life after breast cancer." There was little evidence that physicians treated decisions about anti-hormonal treatment, menopausal symptoms, and follow-up consultations as sensitive to patient preferences. Decisions about breast reconstruction were considered as very sensitive to patient preferences, and patients were usually involved.

CONCLUSION

Patients are currently not involved in all decisions that affect them during follow-up, indicating a need for improvements. Personalised follow-up care could improve resource allocation and the value of care for patients.

Alberta CancerBridges development of a care plan evaluation measure

Background

No standardized measures specifically assess cancer survivors' and healthcare providers' experience of Survivor Care Plans (scps). We sought to develop two care plan evaluation (cpe) measures, one for survivors (cpe-s) and one for healthcare providers (cpe-p), examine initial psychometric qualities in Alberta, and assess generalizability in Manitoba, Canada.

Methods

We developed the initial measures using convenience samples of breast (n = 35) and head and neck (n = 18) survivors who received scps at the end of active cancer-centre treatment. After assessing Alberta's scp concordance with Institute of Medicine (iom) recommendations using a published coding scheme, we examined psychometric qualities for the cpe-s and cpe-p. We examined generalizability in Manitoba, Canada, with colorectal survivors discharged to primary care providers for follow-up (n = 75).

Results

We demonstrated acceptable internal consistency for the cpe-s and cpe-p subscales and total score after eliminating one item per subscale for cpe-s, two for cpe-p, resulting in revised scales with four 7-item and 6-item subscales, respectively. Subscale scores correlated highly indicating that for each measure the total score may be the most reliable and valid. We provide initial cpe-s discriminant, convergent, and predictive validity using the total score. Using the Manitoba sample, initial psychometrics similarly indicated good generalizability across differences in tumour groups, scp, and location.

Conclusions

We recommend the revised cpe-s and cpe-p for further use and development. Studies documenting the creation and standardization of scp evaluations are few, and we recommend further development of patient experience measures to improve both clinical practice and the specificity of research questions.

The prevalence of unmet needs in 625 women living beyond a diagnosis of early breast cancer

Background:

There are over half a million women with a previous breast cancer diagnosis living in the UK. It is important to establish their level of unmet physical and psychosocial needs, as many are not routinely seen for follow-up under current models of care.

Methods:

We conducted a retrospective analysis of early breast cancer survivors entering an Open Access Follow-Up (OAFU) programme in 2015. Unmet needs were assessed using the Holistic Needs Assessment (HNA) or extracted directly from the electronic patient record (EPR), when the HNA had not been completed.

Results:

Six hundred and twenty-five patients were eligible. Sixty-one per cent of the survivors had at least one unmet need and 18% had ⩾5 needs. Consistently higher levels of unmet needs were identified using the formal HNA checklist as opposed to extraction from EPR (P<0.001). Physical and emotional needs were the most frequently reported (55 and 24% respectively). Patients receiving endocrine therapy and those who had received chemotherapy were more likely to report unmet needs (both P<0.001).

Conclusions:

Unmet physical and emotional needs are common in breast cancer survivors. It is vital that the services are available for these patients as they transition from hospital-based follow-up to patient-led self-management models of care.

The labour market, psychosocial outcomes and health conditions in cancer survivors: protocol for a nationwide longitudinal survey 2 and 5 years after cancer diagnosis (the VICAN survey)

INTRODUCTION

Today, a growing need exists for greater research into cancer survivorship, focusing on different spheres of the day-to-day life of diagnosed patients. This article describes the design and implementation of VICAN (VIe après le CANcer), a national survey on French cancer survivors.

METHOD AND ANALYSIS

The target population included patients aged 18-82, diagnosed with cancer between January and June 2010, and registered in one of the three main French Health Insurance Schemes. It was restricted to 12 tumour sites. Sampling was stratified using a non-proportional allocation, based on age at diagnosis (18-52 and 53-82) and tumour site. Data were collected from telephone interviews with patients 2 and 5 years after diagnosis, a medical survey completed by the physician who initiated cancer treatment, and information from the national medicoadministrative database on reimbursement data and hospital discharge records. First data collection, 2 years after diagnosis, occurred between March and December 2012. Second data collection, 5 years after diagnosis, will be conducted in 2015. Analyses will be conducted on various outcomes: quality of life, health status and psychosocial conditions, with a particular focus on the impact of cancer diagnosis on the labour market. The variety of measurements included in the survey will enable us to control a wide range of factors.

ETHICS AND DISSEMINATION

The methodology of the VICAN survey was approved by three national ethics commissions. Results of the study will be disseminated through national and international research conferences, and in articles published in international peer-reviewed journals.

Patients' preferences for post-treatment breast cancer follow-up in primary care vs. secondary care: a qualitative study

OBJECTIVE

To explore patients' preferences for follow-up in primary care vs. secondary care.

METHODS

A cross-sectional design was employed, involving semi-structured interviews with 70 female patients with a history of early-stage breast cancer. Using descriptive content analysis, interview transcripts were analysed independently and thematically by two researchers.

FINDINGS

Patients expressed the strongest preference for annual visits (31/68), a schedule with a decreasing frequency over time (27/68), and follow-up > 10 years, including lifelong follow-up (20/64). The majority (56/61) preferred to receive follow-up care from the same care provider over time, for reasons related to a personal doctor-patient relationship and the physician's knowledge of the patient's history. About 75% (43/56) preferred specialist follow-up to other follow-up models. However, primary care-based follow-up would be accepted by 57% (39/68) provided that there is good communication between GPs and specialists, and sufficient knowledge among GPs about follow-up. Perceived benefits of primary care-based follow-up referred to the personal nature of the GP-patient relationship and the easy access to primary care. Perceived barriers included limited oncology knowledge and skills, time available, motivation among GPs to provide follow-up care and patients' confidence with the present specialist follow-up.

CONCLUSIONS

More than half of the patients were open to primary care-based follow-up. Patients' confidence with this follow-up model may increase by using survivorship care plans to facilitate communication across the primary/secondary interface and with patients. Training GPs to improve their oncology knowledge and skills might also increase patients' confidence.

Qualitative evaluation of care plans for Canadian breast and head-and-neck cancer survivors

BACKGROUND

Survivorship care plans (scps) have been recommended as a way to ease the transition from active cancer treatment to follow-up care, to reduce uncertainty for survivors in the management of their ongoing health, and to improve continuity of care. The objective of the demonstration project reported here was to assess the value of scps for cancer survivors in western Canada.

METHODS

The Alberta CancerBridges team developed, implemented, and evaluated scps for 36 breast and 21 head-and-neck cancer survivors. For the evaluation, we interviewed 12 of the survivors, 9 nurses who delivered the scps, and 3 family physicians who received the scps (n = 24 in total). We asked about satisfaction, usefulness, emotional impact, and communication value. We collected written feedback from the three groups about positive aspects of the scps and possible improvements (n = 85). We analyzed the combined data using qualitative thematic analysis.

RESULTS

Survivors, nurses, and family physicians agreed that scps could ease the transition to survivorship partly by enhancing communication between survivors and care providers. Survivors appreciated the individualized attention and the comprehensiveness of the plans. They described positive emotional impacts, but wanted a way to ensure that their physicians received the scps. Nurses and physicians responded positively, but expressed concern about the time required to implement the plans. Suggestions for streamlining the process included providing survivors with scp templates in advance, auto-populating the templates for the nurses, and creating summary pages for physicians.

CONCLUSIONS

The results suggest ways in which scps could help to improve the transition to cancer survivorship and provide starting points for larger feasibility studies.

Active approach for breast cancer genetic counseling during radiotherapy: long-term psychosocial and medical impact

Genetic counseling and DNA testing (GCT) for breast cancer is increasingly being actively offered to newly diagnosed patients. Little is known about the consequences of such an approach. Therefore, the long-term psychosocial and medical impact of referring breast cancer patients for GCT during an early phase of treatment was studied. A group of 112 breast cancer patients who had been actively offered GCT during adjuvant radiotherapy 7-14 years earlier, returned a self-report questionnaire. We compared their experiences with a group of 127 breast cancer patients who had not met the criteria for GCT. In total, 239 women participated in this long-term follow-up study (72% response rate). Nearly 75% of them had received regular mammography surveillance in the past 3 years. Preventive surgery was reported more often in the counseling group (specifically in the BRCA1/2 mutation carriers). Like the comparative group, only a minority of patients who had received GCT were experiencing high levels of depression (5%) or psychological distress (14%). Breast cancer patients can be actively approached and referred for GCT at the beginning of their radiotherapy without a threat to psychological functioning in the long term.

Attending the breast screening programme after breast cancer treatment: a population-based study

INTRODUCTION

In the Netherlands, breast cancer patients are treated and followed at least 5 years after diagnosis. Furthermore, all women aged 50-74 are invited biennially for mammography by the nationwide screening programme. The relation between the outpatient follow-up (follow-up visits in the outpatient clinic for 5 years after treatment) and the screening programme is not well established and attending the screening programme as well as outpatient follow-up is considered undesirable. This study evaluates potential factors influencing women to attend the screening programme during their outpatient follow-up (overlap) and the (re-)attendance to the screening programme after 5 years of outpatient follow-up.

METHODS

Data of breast cancer patients aged 50-74 years, treated for primary breast cancer between 1996 and 2007 were selected from the Netherlands Cancer Registry and linked to the National Breast Cancer Screening Programme in the Northern region. Cox regression analyses were used to study women (re-)attending the screening programme over time, possible overlap with the outpatient follow-up and factors influencing this.

RESULTS

In total 11227 breast cancer patients were included, of whom 19% attended the screening programme after breast cancer treatment, 4.4% within 5 years and 15.4% after more than 5 years. Factors that independently influenced attendance within 5 years as well as more than 5 years after treatment were: interval tumours (HR 0.77; 95%CI 0.61-0.97 and HR 0.69; 95%CI 0.53-0.88, ref: screen-detected tumours), receiving adjuvant radiotherapy (HR 0.65; 95%CI 0.47-0.90 and HR 0.66; 95%CI 0.47-0.93; ref: none) and diagnosis of in situ tumours (HR 1.67; 95%CI 1.25-2.23 and HR 1.39; 95%CI 1.05-1.85; ref: stage I tumours). Non-screen related tumours (HR 0.41; 95%CI 0.29-0.58) and recent diagnosis (HR 0.89 per year; 95%CI 0.86-0.92) were only associated with attendance within 5 years after treatment.

CONCLUSION

The interrelation between outpatient follow-up and screening should be improved to avoid overlap and low attendance to the screening programme after outpatient follow-up. Breast cancer patients should be informed that attending the screening programme during the outpatient follow-up is not necessary.

Prognostic factors of young women (≤ 35 years) with node positive breast cancer: possible influence on post-therapeutic follow-up

PURPOSE

Although young age at diagnosis is an independent prognostic factor of poor survival; no specific recommendation are provided concerning the timing and modalities of follow-up for this population. These patients are followed similarly to older women during post-therapeutic surveillance. The objective of this study is to examine patterns of recurrence in a large series of positive lymph node breast cancer women aged 35 years or below and treated within adjuvant chemotherapy trials.

METHODS

Data of 200 patients (≤ 35 years) included in three UNICANCER adjuvant trials for node positive breast cancer were used. Competing risks methodology was used to identify prognostic factors associated with time to first failure according to type of event.

RESULTS

After a median follow-up of 52.4 months, 84 pts had disease related events (17 loco-regional, five contralateral, and 62 distant metastasis). Variables associated with an increased rate of first event were the number of involved lymph nodes and the type of surgery. In univariate analysis, prognostic factors associated with high potential curative recurrence were number of positive lymph nodes and vascular invasion. Only number of positive lymph node remained significant in multivariate analysis. Concerning distant metastasis, only the number of lymph node involved was associated to an increased risk of metastasis.

CONCLUSION

Using the number of positive nodes as important prognostic factors, it should be possible to identify patients at a higher risk of locoregional relapse or contralateral breast cancer, in order to propose more individualized follow-up.

Provider perceptions and expectations of breast cancer posttreatment care: a University of California Athena Breast Health Network project

PURPOSE

The Athena Breast Health Network collaboration is a University of California system-wide project initiated with the intent to drive innovation in breast cancer prevention, screening, and treatment. This qualitative research examines provider perceptions and expectations of posttreatment breast cancer care across five network sites with the goal of better understanding provider behavior during the posttreatment phase of the cancer care trajectory.

METHODS

Investigators at each site conducted semi-structured interviews with oncology specialists and primary care providers (PCPs). Interviews used case study examples and open- and closed-ended questions on the delivery of posttreatment breast cancer care. Informant responses were manually recorded by the interviewer, compiled in a database, then coded and analyzed using NVivo 9 software.

RESULTS

There were 39 key informants across the sites: 14 medical oncologists, 7 radiation oncologists, 11 surgeons, 3 oncology nurses, and 4 PCPs. Care coordination was a major unprompted theme identified in the interviews. There was a perceived need for greater care coordination across institutions in order to improve delivery of posttreatment health care services and a need for greater care coordination within oncology, particularly to help avoid duplication of follow-up care and services. Participants expect frequent follow-up visits and to use biomarker tests and advanced imaging services as part of routine surveillance care. Implementing survivorship care programs was perceived as a way to improve care delivery.

CONCLUSIONS

These results identify a need for increased focus on care coordination during the posttreatment phase of breast cancer care within the University of California system and the potential for system and provider-level interventions that could help increase coordination of posttreatment care.

IMPLICATIONS FOR CANCER SURVIVORS

Breast cancer survivors do not always receive evidence-based care. This research helps to better understand what motivates provider behavior during the posttreatment phase and lays a foundation for targeted interventions to increase adherence to evidence-based recommendations.

Discharge of breast cancer patients to primary care at the end of hospital follow-up: a cross-sectional survey

AIM

The present study explored (a) the discharge of breast cancer patients to primary care by specialists, at the end of hospital follow-up and (b) the experiences and views of general practitioners (GPs) regarding transfer of follow-up to the primary care setting.

METHODS

A cross-sectional survey was performed by sending a self-administered questionnaire to 960 GPs working in the three northern provinces of the Netherlands. Data were analysed using descriptive statistics.

RESULTS

Of 949 eligible questionnaires, 502 were returned, providing an adjusted response rate of 53%. In the year before the survey took place, one or more patients aged >60 years, and 5 years after breast-conserving therapy, were discharged to 22% of GPs (n=112) for follow-up. According to 56% of these GPs, transfer of follow-up was communicated by the hospital. The initiative to arrange follow-up visits and mammography appointments was mainly taken by patients. In this survey, 40% of GPs (n=200) were willing to accept exclusive responsibility for follow-up earlier than 5 years after completion of active treatment. Perceived barriers in current and future primary care-based follow-up included: communication with breast cancer specialists, patients' preference for specialist follow-up, GPs' oncology knowledge and skills and the organisation of follow-up in general practice.

CONCLUSIONS

Primary care-based follow-up might be improved if breast cancer specialists discharge patients more actively to their GPs. Survivorship care plans are needed to facilitate communication across the primary/secondary interface and with patients. Training of GPs and developing administrative tools may be helpful in arranging follow-up care and using guidelines in general practice.

Adult cancer survivors discuss follow-up in primary care: 'not what i want, but maybe what i need'

BACKGROUND Nearly one-third of office visits for cancer are handled by primary care physicians. Yet, few studies examine patient perspectives on these physicians' roles in their cancer follow-up care or their care preferences. METHODS We explored survivor preferences through qualitative, semistructured, in-depth interviews drawing on patients recruited from 2 National Cancer Institute-designated comprehensive cancer centers and 6 community hospitals. We recruited a purposive sample of early-stage breast and prostate cancer survivors aged 47 to 80 years, stratified by age, race, and length of time from and location of cancer treatment. Survivors were at least 2 years beyond completion of their active cancer treatment RESULTS Forty-two survivors participated in the study. Most participants expressed strong preferences to receive follow-up care from their cancer specialists (52%). They described the following barriers to the primary care physician's engagement in follow-up care: (1) lack of cancer expertise, (2) limited or no involvement with original cancer care, and (3) lack of care continuity. Only one-third of participants (38%) believed there was a role for primary care in cancer follow-up care and suggested the following opportunities: (1) performing routine cancer-screening tests, (2) supplementing cancer and cancer-related specialist care, and (3) providing follow-up medical care when "enough time has passed" or the survivors felt that they could reintegrate into the noncancer population. CONCLUSION Survivors have concerns about seeing their primary care physician for cancer-related follow-up care. Research interventions to address these issues are necessary to enhance the quality of care received by cancer survivors.

Safety and cost-effectiveness of shortening hospital follow-up after breast cancer treatment

BACKGROUND

In the Netherlands, the first 5 years of follow-up after treatment for breast cancer are carried out in hospital with yearly mammography. After this, for patients aged over 60 years who have undergone mastectomy, there is a shift of care to the National Screening Programme (NSP) for mammography every 2 years. After breast-conserving therapy follow-up is perfomed by the general practitioner (GP), with mammography every second year and physical examination annually. The aim of this study was to evaluate the clinical effects and costs of four different strategies for follow-up after breast cancer treatment.

METHODS

An extended and validated simulation model for breast cancer follow-up was used. The current guidelines for follow-up (baseline strategy) and three less intensive follow-up strategies were evaluated. The main outcome measure was the detection rate of small tumours (2 cm or smaller) and associated costs for each strategy.

RESULTS

Shortening the follow-up time in hospital by shifting care to the NSP or GP after 2 years instead of 5 years of hospital follow-up, lowering the age of referral to the NSP or GP from 60 to 50 years, and termination of annual physical examination by the GP after hospital follow-up did not decrease the detection of small tumours. In addition, a substantial decrease in costs was observed with simplified follow-up.

CONCLUSION

Decreasing hospital follow-up time, lowering the age of referral to the NSP or GP, and termination of annual physical examinations would lead to a substantial reduction in costs while maintaining the possibility of detecting small breast cancers.

Failure event types and prognostic factors after node-positive breast cancer in patients treated by adjuvant chemotherapy: impact on follow-up

PURPOSE

The role of post-therapeutic follow-up for breast cancer patients (pts) is open to debate. The aim of this study was to identify prognostic factors associated with the type of first event.

METHODS

Data of 2,820 pts included in three adjuvant trials for node-positive breast cancer were used. Competing risk methodology was used to identify prognostic factors associated with time to first failure according to type of event.

RESULTS

After a median follow-up of 53 months, 732 pts had disease-related events (114 locoregional, 58 contralateral, and 560 distant metastasis). The prognostic factors associated with high locoregional recurrence were young age, number of positive lymph nodes and grade III. In multivariate analysis, the type of first event influenced post-relapse survival. Nottingham Prognostic Index identified three groups of pts at different risk of relapse.

CONCLUSION

Early relapse is rare in the first year after surgery and is associated with more aggressive disease. Using the Nottingham Prognostic Index, it is possible to identify pts at lower risks of relapse for whom it seems reasonable to limit the frequency of routine follow-up during the first years. For pts at higher risk of locoregional recurrence, regular follow-up should be maintained in order to detect potential curative events.

Use of high technology imaging for surveillance of early stage breast cancer

Guidelines do not support utilization of high technology radiologic imaging (HTRI) for surveillance after curative treatment for early stage breast cancer. Surveillance, Epidemiology, and End Results (SEER)-Medicare linked data were used to identify 25,555 women diagnosed with stage I-II breast cancer between 1998 and 2003 who survived ≥ 48 months from diagnosis without evidence of second primary or recurrent cancer in this interval. HTRI utilization (computerized tomography scanning (CT), bone scan (BS), breast magnetic resonance imaging, and positron emission tomography scans) was measured in months 13-48 post-diagnosis. Cases were individually matched to 75,669 female Medicare enrollees without cancer. Factors associated with HTRI utilization were evaluated. Forty percent of women with stage I-II breast cancer and 25% of controls had ≥ 1 HTRI during the surveillance interval (P < 0.001). High utilization rates were observed for CT (30%) and BSs (19%). The proportion of women who had a CT during the surveillance period increased in both cancer survivors and controls. Among breast cancer cases age <80, higher comorbidity index, stage II disease, and more recent diagnosis were independently associated with receipt of HTRI. Paralleling patterns observed in controls, HTRI utilization for surveillance following diagnosis of early stage breast cancer has steadily increased among Medicare beneficiaries. Strategies to foster judicious utilization of HTRI should be a priority.

Patients' needs and preferences in routine follow-up for early breast cancer; an evaluation of the changing role of the nurse practitioner

BACKGROUND

In evaluating follow-up of early breast cancer, patients' views on care are important. The aim of this study was to evaluate the effect of the introduction of nurse practitioners (NPs) in a breast cancer unit on patients' informational needs, preferences and attitude towards follow-up.

PATIENTS AND METHODS

A cross-sectional survey was performed among two groups in 2005. Group A (n = 89) consisted of patients operated before, and group B (n = 100) after the introduction of a breast cancer unit (respectively in 1998-1999 and 2001-2004).

RESULTS

Response was 72% in group A and 84% in group B. Median follow-up was 69 (54-86) and 33 (0-57) months, respectively. Aspects highly appreciated by patients in both groups were lifetime follow-up, information about prognosis, life style and additional investigations. Important discussion subjects were fatigue, pain, genetic factors, prevention and arm function/lymph-oedema. Less valued aspects were information about peers, conversations with psychologists or social workers, breast reconstruction, and acceptation by family members. The informational needs and preferences did not differ statistically significantly between both groups. In group B, communication with the caregiver was valued higher and more patients indicated that the caregiver took the time needed. More patients in group B indicated that follow-up could be performed by the NP. Duration of follow-up correlated with preferred frequency, not with informational needs in follow-up, only young age increased these needs.

CONCLUSION

Despite the limitations of this retrospective study, we conclude that while expectations and informational needs did not change with the introduction of a NP to the standard care, patient satisfaction increased and communication and time taken were appreciated more.

Models of care for early-stage breast cancer in Canada

There is growing evidence that follow-up for patients with early breast cancer (ebc) can be effectively carried out by the primary health care provider if a plan is in place. Here, we present data from a recent survey conducted in Ontario indicating that a shared-care model could work if communication between all health professionals involved in the care of ebc patients were to be improved. Patients and primary care providers benefit when the specialist provides written information about what their roles are and what to expect. Primary care providers need to have easy access to the specialist to discuss areas of concern. Patients also need to share responsibility for their care, ensuring that they attend follow-up visits on a regular basis and that they discuss areas of concern with their primary health care provider. A shared-care model has the potential to provide the best care for the least cost to the health system.

Barriers to rehabilitative care for young breast cancer survivors: a qualitative understanding

PURPOSE

The goal of this study was to assess the rehabilitation needs of young women breast cancer survivors under the age of 50 and to identify factors that may impact or prevent cancer rehabilitation utilization.

METHODS

Utilizing a grounded theory methodology, 35 young breast cancer survivors were interviewed twice in four Atlantic Canadian provinces.

RESULTS

A considerable number of barriers exist to receiving rehabilitative care post-treatment for young breast cancer survivors. The systemic barriers include the lack of availability of services, travel issues, cost of services, and the lack of support to address the unique needs for this age group. However, the most complicated barriers to accessing rehabilitative care were personal barriers which related more to choice and circumstances, such as the lack of time due to family responsibilities and appointment fatigue. Many of these personal barriers were rooted in the complex set of gender roles of young women as patients, mothers, workers, and caregivers.

CONCLUSIONS

The contexts of young women's lives can have a substantial impact on their decisions to seek and receive rehabilitative care after breast cancer treatment. The systemic barriers can be reduced by introducing more services or financial assistance; however, the personal barriers to rehabilitation services are difficult to ameliorate due to the complex set of roles within and outside the family for this group of young breast cancer survivors. Health care providers need to take into consideration the multiple contexts of women's lives when developing and promoting breast cancer rehabilitation services and programs.

Early breast cancer in the older woman

BACKGROUND

Women aged ≥65 are generally underrepresented in early breast cancer studies. Therefore, the optimal management of this group of women remains less certain.

METHODS

A literature review of recently published trials, reviews, and practice guidelines outlining the surgical and adjuvant management of early breast cancer in older women was performed.

RESULTS

Surgery remains as the cornerstone treatment for early breast cancer in the elderly. Adjuvant radiation is generally considered if the projected lifespan is >5 years. Hormone receptor-positive disease is best treated with adjuvant endocrine treatment; aromatase inhibitors and tamoxifen are both options. Evidence for the use of adjuvant chemotherapy and trastuzumab for high-risk disease in the elderly is more limited. Polychemotherapy is still preferred in fit older women. Certain toxicities from systemic treatments can be more pronounced and should be carefully managed. Treatment with systemic agents should be individualized, with consideration of patient preference, performance status, comorbidities, and projected lifespan. Molecular tumor signatures may help better select patients for treatment in the future.

CONCLUSIONS

Age in itself should not be an absolute contraindication to any breast cancer therapy. Comprehensive, multidisciplinary assessment of elderly patients is imperative in evaluating eligibility for beneficial therapies.

Economic evaluation of four follow-up strategies after curative treatment for breast cancer: results of an RCT

BACKGROUND

An economic evaluation was performed alongside a randomised controlled trial (ISRCTN 74071417) investigating the cost-effectiveness of nurse-led telephone follow-up instead of hospital visits, and of a short educational group programme (EGP) in the first year after breast cancer treatment.

METHOD

This economic evaluation (n = 299) compared the one-year costs and the effects of four follow-up strategies: (1) hospital follow-up; (2) nurse-led telephone follow-up; (3) hospital follow-up plus EGP; and (4) nurse-led telephone follow-up plus EGP. Costs were measured using cost diaries and hospital registrations. Quality-adjusted life years (QALYs) were measured using the EQ-5D. Outcomes were expressed in incremental cost-effectiveness ratios (ICERs) and cost-effectiveness acceptability curves.

RESULTS

Hospital follow-up plus EGP yielded most QALYs (0.776), but also incurred the highest mean annual costs (€4914). The ICER of this strategy versus the next best alternative, nurse-led telephone follow-up plus EGP (0.772 QALYs and €3971), amounted to €235.750/QALY. Hospital and telephone follow-up without EGP both incurred higher costs and less QALYs than telephone follow-up plus EGP and were judged inferior. Hospital follow-up plus EGP was not considered cost-effective, therefore, telephone follow-up plus EGP was the preferred strategy. The probability of telephone follow-up plus EGP being cost-effective ranged from 49% to 62% for different QALY threshold values. Secondary and sensitivity analyses showed that results were robust.

CONCLUSION

Nurse-led telephone follow-up plus EGP seems an appropriate and cost-effective alternative to hospital follow-up for breast cancer patients during their first year after treatment.

Nurse-led telephone follow-up and an educational group programme after breast cancer treatment: results of a 2 × 2 randomised controlled trial

OBJECTIVE

To investigate whether frequent hospital follow-up in the first year after breast cancer treatment might partly be replaced by nurse-led telephone follow-up without deteriorating health-related quality of life (HRQoL), and whether a short educational group programme (EGP) would enhance HRQoL.

PATIENTS AND METHODS

A multicentre pragmatic randomised controlled trial (RCT) with a 2×2 factorial design was performed among 320 breast cancer patients who were treated with curative intent. Participants were randomised to follow-up care as usual (3-monthly outpatient clinic visits), nurse-led telephone follow-up, or the former strategies combined with an educational group programme. The primary outcome for both interventions was HRQoL, measured by EORTC QLQ-C30. Secondary outcomes were role and emotional functioning and feelings of control and anxiety.

RESULTS

Data of 299 patients were available for evaluation. There was no significant difference in HRQoL between nurse-led telephone and hospital follow-up at 12 months after treatment (p = 0.42; 95% confidence interval (CI) for difference: -1.93-4.64) and neither between follow-up with or without EGP (p = 0.86; 95% CI for difference: -3.59-3.00). Furthermore, no differences between the intervention groups and their corresponding control groups were found in role and emotional functioning, and feelings of control and anxiety (all p-values > 0.05).

CONCLUSION

Replacement of most hospital follow-up visits in the first year after breast cancer treatment by nurse-led telephone follow-up does not impede patient outcomes. Hence, nurse-led telephone follow-up seems an appropriate way to reduce clinic visits and represents an accepted alternative strategy. An EGP does not unequivocally affect positive HRQoL outcomes.

The role of a clinician-led reflective interview on improving self-efficacy in breast cancer survivors: a pilot study

Breast cancer survivors experience a wide range of survivorship issues that are not always adequately addressed. This study is an assessment of the Survivorship Consult (SC), a one-to-one clinician-led reflective interview used to capture a comprehensive summary of the survivor experience, to determine its impact on self-efficacy and the perceived likelihood that it initiates behavior change. Using a pre-test/post-test design, data were collected from participants (N = 40) using validated instruments and opened-ended questions to evaluate the SC. Participants found the SC to be a useful tool for planning and goal setting and improved self-efficacy as measured by the Cancer Behavior Inventory with an increase of 2.0 (p = 0.03). The SC demonstrates promise in improving the ability and confidence of breast cancer survivors to manage their care, but further research is required to understand the optimal implementation of this intervention and its impact on the delivery of survivorship services.

Follow-up after treatment for breast cancer: one strategy fits all? An investigation of patient preferences using a discrete choice experiment

Clinical guidelines for the follow-up after breast cancer recommend frequent outpatient clinic visits to be examined for a possible recurrence or a second primary breast tumour, and to receive information and psychosocial support. However, needs and preferences for follow-up may differ between patients, raising the question whether the current 'one size fits all' approach is appropriate. This study explored patients' preferences for follow-up. Patients and methods. A discrete choice experiment survey with 16 choice tasks was filled out by 331 breast cancer patients. Each choice task consisted of two hypothetical follow-up scenarios for the first year after treatment, described by levels of the following characteristics; attendance at an educational group programme, frequency of visits, waiting time, contact mode, and type of healthcare provider. Results. The healthcare provider and contact mode were the most important characteristics of follow-up to patients. The medical specialist was the most preferred to perform the follow-up, but a combination of the medical specialist and breast care nurse alternating was also acceptable to patients. Face-to-face contact was strongly preferred to telephone contact. Follow-up visits every three months were preferred over visits every four, six, or 12 months. Heterogeneity in preference between patients was strong, especially for the healthcare provider and attendance at an educational group programme. Age, education, and previous experience with follow-up characteristics influenced preferences, but treatment modality did not. Conclusion. The results of this study show that overall patient satisfaction would not differ significantly if patients have follow-up by medical specialist and breast care nurse alternating compared to follow-up by a medical specialist only. Furthermore, we found heterogeneity in preferences for most attributes, indicating that one strategy does not fit all. Individualised follow-up seems to offer the potential for significant increases in patient satisfaction.