Follow-Up

Tagged Follow up; Comments 1 ; Posted 11 years ago

Most gynaecologists see patients at 6 weeks from surgery. By contrast, most postoperative issues actually arise in the early postoperative period. Urinary tract and other infections, vault haematomas, or bowel irregularities, such as diarrhoea mostly develop in the first week or two.

Hence, I see my patients at 1 to 2 weeks postop not only to capture those events for quality assessment and self-audit but also for being able to sort those issues out. I agree that surgical adverse events can develop up to the six-week mark. Therefore my practice doctor will give all my patients a call at 6 weeks from surgery to cover those events also that we would have missed otherwise.

Around this time we normally also send out our patient satisfaction survey, yielding enormous response rates of up to 80%.  We receive most valuable feedback that we then use to improve the service of the practice.

Cancer patients are traditionally seen every 3 months for a couple of years; and then 6-monthly and yearly from year 5. Consistent with tradition, guidelines, such as the one recently published in the American Journal of Obstetrics and Gynaecology, also recommend seeing patients regularly after their gynaecological cancer diagnosis.

By contrast, no study ever proved a measurable patient benefit through follow up. The greater concept behind follow up is to diagnose recurrence at an early stage, when it is amenable to treatment. While the concept has merit it has never been proven.

Patients have a love-hate relationship with follow up. They love it because patients do believe it prevents recurrence. The patient expectation is that if she sees the doctor regularly, nothing bad will happen. These expectations are well documented. For the clear mind it is obvious though that these expectations are neither logical nor realistic.

Patients also hate to attend follow up visits and are quite anxious about outcomes, blood test and cytology results. Patents dislike the travel. Some women have to be driven by family over long distances, or go even on a flight for a couple of hours to be seen for 10 minutes.

Doctors’ expectations are quite different. We wish to see patients because we want to be the first ones approached if things go wrong. I want to know about if a patient develops symptoms suggestive of recurrence or if she develops symptoms and signs suggestive of a treatment complication.

Let’s have a look at endometrial cancer, which is the most common of all gynaecological cancers:

According to every study published so far, three of four patients present with symptoms, such as bleeding or pain and those symptoms trigger investigations, which confirm a recurrence. Only one in four patients who suffer a local relapse will be diagnosed primarily on a speculum examination. I don’t even expect that an internal examination will detect early cancer recurrence. That might be the case but only in the minority of patients.

A couple of years ago, we developed an iPhone App (Uterine Cancer Relapse Prediction Calculator), which is an endometrial cancer recurrence risk calculator. It can be downloaded for free as an iPhone or Android app and calculates the risk of a local recurrence or a distant relapse based on seven patient and tumour characteristics. The app is based on a study published in Gynecologic Oncology in 2012.

I was quite surprised how many patients have a very low risk of relapse. If the risk of relapse is 4 in 100 patients, I can expect that a vaginal examination will only be of value to one of these 4 patients. The other three patients will contact me in between follow up visits to discuss their symptoms.

Let’s assume I operate on 100 patients with endometrial cancer a year. Of those, 20 patients will have a risk of relapse of 4% or less. If we apply the above, I will need to follow up on 500 patients to diagnose one recurrence by vaginal speculum examination alone. I would need to work for 5 years to provide value to one patient.

The cost of providing value to one patient is that I ask 100 low-risk patients to come and see me four times a year.

I discussed these issues with some of my colleagues. One was concerned that declining to see patients for follow up would put strain on the relationship between the referrer and the gynaecological oncologist. He was concerned that I could be frowned upon if I withdraw from offering to see patients regularly.

Therefore, here is my question to you, esteemed readers:

From a doctor-doctor relationship point of view –

• Would you like me to continue seeing patients as per traditional “guidelines” every 3 months.
• Or do you believe we should be more open with patients, discuss the pros and cons and explain to selected patients that their benefit from follow up is only 1%.
• Or do you believe follow up should not be offered to patients with a very low risk of recurrence because we waste different kinds of resources to achieve minimal (or non-measurable) benefit.

I am curious to learn about your expectations and anxiously awaiting your thoughts. Any comments are fine.

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