A minimalist policy for breast cancer surveillance

Article Abstract:

Breast cancer patients (stage I or II cancer) are usually followed-up to detect tumor recurrence, with the idea that such surveillance improves survival. Surveillance programs usually include a physical examination (with mammogram) and blood tests, including measurement of factors known to be associated with malignancy. Evidence exists, however, that shows such surveillance does not improve survival. This evidence is reviewed and evaluated. At least three quarters of all cases of breast cancer recurrence are discovered by patients themselves between follow-up visits; in one study, physicians found abnormalities in only 15 percent of the cases. Bone scans to detect metastases (cancer spread) have a high rate of false-positive results; only one in nine patients with abnormal results actually have bone metastases. Chest X-rays were not useful in detecting recurrence: one study showed that recurrence was detected by this method in only 2 percent of patients. Finally, evaluation of blood chemistry to diagnose liver function rarely show recurrence in patients who did not already have symptoms of metastasis, and some test results were elevated in women without metastasis. The cost of a minimal, rather than the current intensive, surveillance strategy was examined. A model was developed to calculate and compare costs using the two approaches. The per-case costs for intensive surveillance during the five-year period are $5,735 (in 1990 dollars); for minimal surveillance, $1,025 (18 percent of the higher figure). When multiplied by the projected number of eligible cancer cases, the savings for 1990 would be $636 million; by the year 2000, more than $1 billion could be saved. Physicians need not fear additional malpractice suits if minimal surveillance were adopted; intensive surveillance does not ensure survival. Other articles concerning the treatment of breast cancer appear in the January 16, 1991 issue of The Journal of the American Medical Association. (Consumer Summary produced by Reliance Medical Information, Inc.)

Diagnosis, Metastasis, Cancer metastasis

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Against minimalism in breast cancer follow-up

Article Abstract:

Although steps have been taken to improve methods of early detection and treatment of breast cancer, the disease remains the most common female cancer and a leading cause of death. Financial limits threaten to reduce the diagnostic and therapeutic gains that have been made, as funds for mammography and research become increasingly restricted. An article in the January 16, 1991 issue of The Journal of the American Medical Association maintains the position that follow-up of patients with Stage I or II breast cancer is expensive and unlikely to lead to improved survival. Several points made in this article are questionable. In contrast with the recommendations in this report, surveillance should be maintained for its potential to improve survival and the quality of life of patients. Patients' psychological adjustment to their disease can be monitored at follow-up, as well as their overall health and the possible development of additional primary tumors. Survival advantages have been shown when asymptomatic breast cancer recurrences have been detected, and although 60 percent of metastases (spread to other organs) are discovered by patients, the rest are detected at follow-up examination. Early treatment of very small metastases is more effective than treatment of larger tumors, and usually employs approaches that are less damaging to other organ systems. Follow-up appointments with the cancer physician play an important role in the patient's life; such appointments are rarely missed. Another argument expressed in the report that cannot be supported is how money saved on follow-up might be spent (on more mammographic screening). The US health care system does not rationally set priorities or shift resources: money saved is not money more wisely spent. Better posttreatment tests are needed, but cancer patients deserve and should receive intensive physician attention. (Consumer Summary produced by Reliance Medical Information, Inc.)

editorial

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Intensive care, survival, and expense of treating critically ill cancer patients

Article Abstract:

Treatment of terminal cancer patients in a hospital's intensive care unit (ICU) increases the cost of their medical care markedly without prolonging their life significantly. Among 147 patients admitted to the ICU of a university medical center over a two-year period, 83 had different types of solid tumors and 64 were suffering from lymphoma. Forty-one percent of the patients with solid tumors and 50% of those with lymphoma died in the ICU. Almost 80% of the patients in both groups died less than six months after admission to the ICU. The only treatment in the ICU that increased survival significantly was mechanically assisted ventilation for patients with lymphoma. Admittance to the ICU increased the cost of treatment per year of life gained by $82,845 for patients with solid tumors and by $189,339 for patients with lymphoma. Other types of treatment cost considerably less per year of life gained.

Usage, Cancer patients, Intensive care units, Critically ill

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