Underuse of long-term routine hospital follow-up care in patients with a history of breast cancer?

Breast cancer is the commonest incident form of malignancy among women in Europe[1]. Advances in the early diagnosis and treatment of breast cancer increase the number of breast cancer survivors[2]. Nowadays, it is estimated that more than 80% of the patients with a history of breast cancer will survive longer than 5 years and more than 60% of these patients will survive longer than 10 years[3, 4]. After primary treatment, these patients are offered routine hospital follow-up. One of the main aims is to early detect loco-regional recurrences and second primary tumours. Approximately 40% of the isolated locoregional recurrences are diagnosed during routine visits and routine tests in asymptomatic patients treated for early-stage invasive breast cancer [5]. In a recently published meta-analysis it was shown that the detection of isolated loco-regional or contra-lateral breast cancer recurrences in patients without symptoms has beneficial impact on survival of breast cancer patients when compared to late symptomatic detection, indicating that regular hospital follow-up might be beneficial for some patients [6]. Although recommendations vary to some extent with regards to timing, routine hospital follow-up visits include history taking, physical examination and mammography are part of the schedule. Health care utilization after primary treatment for women with a history of breast cancer represents a major public health issue with increasing importance [7, 8].

Routine hospital follow-up care is a major portion of health care use of breast cancer survivors [8]. There is a limited number of studies examining the health care use of long-term follow up care of breast cancer survivors including hospital visits (history taking and clinical examination) and mammography[9, 10]. Data on utilization of long-term follow-up care beyond five years of breast cancer patients are relatively rare as well as on factors associated with the utilization of long-term follow-up care [7, 11]. The aim of the current study was to assess the use of long-term routine hospital follow-up care, to describe the reasons of stopping this follow-up care, and to assess the determinants of the use of this routine hospital follow-up care. For that we derived information from hospital documents of 662 patients treated for breast cancer.

This study evaluated utilization of hospital follow-up in a cohort of 662 patients with a median follow-up time of 9.0 years (range: 0.1-18.2). At fifth and tenth year after diagnosis, 16.1% and 33.5% of the patients were under using hospital follow-up care, respectively, where of the patients in hospital follow-up, 33.1% and 40.4% of the patients were under using mammography, respectively. Underuse of yearly mammography was found in older patients (age > 70; OR: 2.10; 95%CI: 1.62-2.74), patients with comorbidity (OR: 1.26; 95%CI: 1.05-1.52) and patients with hormonal therapy (OR: 1.51; 95%CI: 1.01-2.25).

Routine hospital follow-up care was ended for 37.3% (n = 247) recurrence-free patients. For one-third of these patients (n = 90; 36.4%) the time of stopping their hospital follow-up was earlier than it should have been based on the guidelines. According to the guidelines, women with a history of breast cancer should be advised to be followed-up until age of 75 either in hospital or being transferred to the National Breast Cancer Screening Program. Only one-third of the patients who were at age of between 50 and 75 at the time of ending follow-up were indeed transferred to the National Breast Cancer Screening Program. Patients between the age of 50 and 75, ending their routine hospital follow-up program should be well actively referred to the National Breast Cancer Screening Program. Recently this was added to the Dutch national guideline for breast cancer screening [http://www.oncoline.nl/index.php?pagina=/richtlijn/item/pagina.php&richtlijn_id=593].

Patients who received radiation therapy for their primary tumours and women with positive lymph node at the first tumour were less likely to underuse the routine hospital follow-up. This might be a reflection of more concern about the risk of breast cancer recurrences and the more consequent recall policy of the radiation oncologist.

Compared to first five years after primary treatment, women were more likely underuse the hospital follow up in the sixth to the tenth year from the primary treatment of first tumour (OR: 2.86, 95%-CI: 2.26-3.62). This finding is consistent with another research and the decreasing concern about the risk of breast cancer over time may be a possible explanation for declining routine hospital follow-up visits [14].

In this study, the utilization of mammography was evaluated in women who were followed up in hospital. For patients who stopped their hospital follow-up, the utilization of mammography was not evaluated. Mammography is the only recommended imaging test for the routine follow-up of women with a history of breast cancer and is recommended by most guidelines [15]. Underutilization of mammography was still found in 30-40% patients during the routine hospital follow-up phase in this study. Several studies reported that elderly patients are less likely to receive routine mammography [14, 16] which is also the case in this study, patients over 70 had a lower chance to receive yearly mammography. An explanation might be that among elderly, there is a decreasing concern about the risk of breast cancer recurrences [16]. Lower use among the elderly could be related to competing medical needs and/or perceived diminishing benefit from regular mammography with advancing age also. Patients who had comorbidity and patient who received radiation therapy had fewer mammograms than advised. These findings may reflect potentially appropriate decisions by patients or their physicians for less intensive care as a result of competing comorbid illness causing that follow-up mammography became a lower priority in these patients[14, 16, 17]. The finding that the patients who received hormonal therapy had less frequent mammography than advised might be a reflection of the awareness of the decreasing efficiency of mammography in follow-up after recalculating the incidence of local recurrences which is reduced by hormonal therapy. The patients with a first tumour diagnosed after 1994 were more likely to have yearly mammography probably due to the increasing awareness of the benefit of mammography and the publications of guideline on follow-up of breast cancer which addressed the importance of mammography[18–20].

As well as the use of routine hospital follow-up, the use of yearly mammography decreased gradually over years. It may be an effective and safe choice to transfer women with a history of breast cancer to their general practitioner to keep the continuity of care at an appropriate time[21]. This may reflect tailored follow-up schedules, where the estimated risk of recurrence influences the choice to adhere to the follow-up schedule as in the national guidelines or to decrease the number of follow-up visits and examinations. Because the recurrence rate in the study population cannot be assessed reliable from the present data, this hypothesis cannot be tested.

Caution is needed when generalizing study results and conclusions to other population and settings. Our study cohort consists of patients with metachronous contra-lateral breast cancers and random group stratified on hospital of diagnosis, age and duration of follow-up. This cohort is representative of breast cancer survivors at a greater risk of secondary breast cancer who are expected to be under close surveillance. The other limitation of present study is we only reviewed the utilization of hospital follow-up. It is still unclear whether patients who stop their hospital follow-up were followed up in the National Breast Screening Program or in general practice routinely or not. From other research it became clear that patients who continued to see cancer specialists after their initial cancer treatment were more likely than other patients to undergo routine follow-up mammography [22, 23]. The utilization of follow-up care elsewhere such as the National Breast Screening Program or in general practice for long term survivors deserves further research. The consequence of underuse of hospital follow-up is not clear due to the lack of conclusive evidence in the literature about the benefit of regular hospital follow-up visits, either in terms of early detection of recurrences or in relation to psychological well-being.

Most patients with a history of breast cancer use hospital follow-up care according to the guidelines. In older patients, patients with comorbidity and patients receiving hormonal therapy we should be careful to ensure the use of yearly mammography.