Is follow-up important for all patients?

Tagged Follow up, recurrence; Posted 9 years ago by Andreas Obermair

Sometimes I get asked by my patients who have been diagnosed with cancer why they need to come back to see me for follow up.

I usually say that while all the critical body parts were removed the bad and potentially dangerous issue about cancer is that it may recur. It may recur in the pelvis or in other distant parts of the body. For some patients, it would be important to diagnose a tumour recurrence early. 

Also and importantly, cancer treatment may leave adverse effects and they can become worse over time, especially if they are not recognised at an early stage. Follow up might recognise problems early when those problems may still be easily treatable.

I sympathise with patients who have to travel many hours to see me for a 15-minute consultation. I try to limit follow up examinations to the most reasonable extent as safely possible! 

For some patients it is possible and safe to reduce the frequency of follow up visits.  By contrast, for other patients follow up could be a lifesaver.

For many patients follow up is not necessary.

Many of my patients were diagnosed with endometrial cancer. Let’s assume, our patient had a successful laparoscopic hysterectomy and she recovered well without any problems. The tumour was completely removed. As doctors we also study the histopathology (how the cells look) of the tumour under a microscope and conclude that a number of variables give us the impression that the tumour is still very confined and the risk of recurrence is low.  

Lets assume that the risk of tumour recurrence is in the vicinity of 2% to 4%.

Our research suggests that 3 out of 4 patients with endometrial cancer recurrence present with symptoms, such as bleeding or pain. Hence, the likelihood that our patient benefits from seeing me regularly would be 1% or less. In cases such as this endometrial cancer patient, I often recommend not to attend follow up visits. However, if the tumour is of an aggressive nature I will be very much recommending regular follow up.

Follow up is often not necessary for patients with ovarian borderline tumours who were diagnosed at stage 1 where the disease is limited to the ovaries and who had optimal surgical treatment. The risk of these patients to develop a recurrence is remotely low.

I also don’t see the necessity to bring patients back to follow up consultations 5 years or 10 years after the diagnosis and treatment.

And finally, we need to be very careful to balance the stress and exhaustion of women who have difficulties getting around even close to home and would find the idea of driving to a faraway city unbearable.

By contrast, follow up is quite important for other patients.

For patients who carry a high risk of tumour recurrence, the early detection of tumour can be life saving.

The diagnostic tests that need to be completed before a follow up visit may differ from tumour to tumour.

For patients with high-risk uterine cancer no diagnostic tests are recommended. If my patient and I are concerned about recurrence, we will select the right test for her specific situation. Recently, we studied a new tumour marker HE4 and its value for the follow up of endometrial cancer. If HE4 was elevated prior to surgery, we would like to use it to monitor the disease.

Most patients who had treatment for ovarian cancer, would have had elevated tumour marker readings prior to surgery and/or chemotherapy. In this case, we assume that the CA-125 marker reading will allow us to monitor the disease. These patients should have a blood test approximately one week prior to the follow up visit. If we are concerned about recurrence, I will organise for a PET-CT scan, which is the most modern technology we have available for medical imaging. Conventional CT scanning comes with a resolution of 1 cm, whereas PET-CT scanning increases the resolution to 5 mm or less.

Follow up for cervical cancer requires a careful gynaecological examination at every visit. Sometimes PAP smears and HPV tests can assist.

Patients who required surgery for vulval cancer should have gynaecological examinations to exclude cancer recurrence on the vulval skin or the groin lymph nodes. Sometimes we arrange for groin ultrasounds prior to the examination to exclude a growth there.

Late effects of cancer treatment

In the early stages of follow up your surgeon would be keen to exclude any side effects resulting from your surgery. For example, swelling of the legs might indicate lymphoedema, which can be managed more successfully when diagnosed early. If diagnosed too late, skin damage may occur and might be irreversible.

We all understand that follow up will not protect from recurrence. However, it allows early detection of problems. If the risk of problems that could possibly develop is remotely low, I can safely release patients and ask them to contact me straight away if they develop any unusual symptoms.