Impact of follow-up testing on survival and health-related quality of life in breast cancer patients. A multicenter randomized controlled trial. The GIVIO Investigators. Intensive diagnostic follow-up after treatment of primary breast cancer. A randomized trial. National Research Council Project on Breast Cancer follow-up. Comparison of breast cancer patient satisfaction with follow-up in primary care versus specialist care: results from a randomized controlled trial. Routine follow up of breast cancer in primary care: randomised trial. Nurse-led follow-up on demand or by a physician after breast cancer surgery: a randomised study. Using an office system intervention to increase breast cancer screening. Nurse led follow up and conventional medical follow up in management of patients with lung cancer: randomised trial. Yearly colonoscopy, liver CT, and chest radiography do not influence 5-year survival of colorectal cancer patients. A clinic-based mammography intervention targeting inner-city women.
To assess prospectively the impact on survival and health-related quality of life of two follow-up protocols in patients with early breast cancer.
                Randomized controlled clinical trial.
                Multicenter study involving 26 general hospitals in Italy.
                A consecutive sample of 1320 women younger than 70 years with stage I, II, and III unilateral primary breast cancer.
                Patients were randomly assigned to an intensive surveillance, which included physician visits and performance of bone scan, liver echography, chest roentgenography, and laboratory tests at predefined intervals (n = 655), or to a control regimen (n = 665), in which patients were seen by their physicians at the same frequency but only clinically indicated tests were performed. Both groups received a yearly mammogram aimed at detecting contralateral breast cancer.
                Primary end points were overall survival and health-related quality of life.
                Compliance to the two follow-up protocols was more than 80%. At a median follow-up of 71 months, no difference was apparent in overall survival with 132 deaths (20%) in the intensive group and 122 deaths (18%) in the control group. No significant differences were apparent in time to detection of recurrence between the two groups. Measurements of health-related quality of life (ie, overall health and quality-of-life perception, emotional well-being, body image, social functioning, symptoms, and satisfaction with care) at 6, 12, 24, and 60 months of follow-up did not show differences by type of care received.
                Results of this trial support the view that a protocol of frequent laboratory tests and roentgenography after primary treatment for breast cancer does not improve survival or influence health-related quality of life. Routine use of these tests should be discouraged. To evaluate the effectiveness of early detection of intrathoracic and bone metastases in reducing mortality in breast cancer patients.
                Randomized clinical trial allocating breast cancer patients to two alternative follow-up protocols (intensive vs clinical) for at least 5 years.
                Twelve breast clinics (referral centers) in different areas in Italy.
                A total of 1243 consecutive patients (either premenopausal or postmenopausal) surgically treated for unilateral invasive breast carcinoma with no evidence of metastases. The two study groups were well balanced in terms of clinical and prognostic characteristics.
                Patients in both treatment groups had physical examination and mammography, while patients of the intensive follow-up group had, in addition, chest roentgenography and bone scan every 6 months.
                Vital status at 5 years was the main outcome; information was available for all except five patients (0.4%). Relapse-free survival was also analyzed.
                Overall, 393 recurrences (104 local and 289 distant) were observed during the study. Increased detection of isolated intrathoracic and bone metastases was evident in the intensive follow-up group compared with the clinical follow-up group (112 vs 71 cases), while no difference was observed for other sites and for local and/or regional recurrences. The 5-year relapse-free survival rate was significantly higher for the clinical follow-up group, with patients in the intensive follow-up group showing earlier detection of recurrences. No difference in 5-year overall mortality (18.6% vs 19.5%) was observed between the two follow-up groups.
                Periodic chest roentgenography and bone scan allow earlier detection of distant metastases, but anticipated diagnosis appears to be the only effect of intensive follow-up, and no impact on prognosis is evident after 5 years. Periodic intensive follow-up with chest roentgenography and bone scan should not be recommended as a routine policy. Routine follow-up of breast cancer patients in specialist clinics is standard practice in most countries. Follow-up involves regularly scheduled breast cancer check-ups during the disease-free period. The aims of follow-up are to detect breast cancer recurrence and to provide psychosocial support to the patient; however, little is known about patients' views on breast cancer follow-up.
                To assess the effect on patient satisfaction of transferring primary responsibility for follow-up of women with breast cancer in remission from hospital outpatient clinics to general practice.
                Randomized controlled trial with 18 months' follow-up in which women received routine follow-up either in hospital outpatient clinics or from their own general practitioner. Two hundred and ninety-six women with breast cancer in remission receiving regular follow-up care at two district general hospitals in England were included in the study. Patient satisfaction was measured by means of a self-administered questionnaire supplied three times during the 18-month study period.
                The general practice group selected responses indicating greater satisfaction than did the hospital group on virtually every question. Furthermore, in the general practice group there was a significant increase in satisfaction over baseline; a similar significant increase in satisfaction over baseline was not found in the hospital group.
                Patients with breast cancer were more satisfied with follow-up in general practice than in hospital outpatient departments. When discussing follow-up with breast cancer patients, they should be provided with complete and accurate information about the goals, expectations, and limitations of the follow-up programme so that they can make an informed choice. To assess the effect on time to diagnosis of recurrence and on quality of life of transferring primary responsibility for follow up of women with breast cancer in remission from hospital to general practice.
                Randomised controlled trial with 18 month follow up in which women received routine follow up either in hospital or in general practice.
                296 women with breast cancer in remission receiving regular follow up care at district general hospitals in England.
                Time between first presentation of symptoms to confirmation of recurrence; quality of life measured by specific dimensions of the SF-36 schedule, the EORTC symptom scale, and hospital anxiety and depression scale.
                Most recurrences (18/26, 69%) presented as interval events, and almost half (7/16, 44%) of the recurrences in the hospital group presented first to general practice. The median time to hospital confirmation of recurrence was 21 days in the hospital group (range 1-376 days) and 22 days in the general practice group (range 4-64). The differences between groups in the change in SF-36 mean scores from baseline were small: -1.8 (95% confidence interval -7.2 to 3.5) for social functioning, 0.5 (-4.1 to 5.1) for mental health, and 0.6 (-3.6 to 4.8) for general health perception. The change from baseline in the mean depression score was higher in the general practice group at the mid-trial assessment (difference 0.6, 0.1 to 1.2) but there was no significant difference between groups in the anxiety score or the EORTC scales.
                General practice follow up of women with breast cancer in remission is not associated with increase in time to diagnosis, increase in anxiety, or deterioration in health related quality of life. Most recurrences are detected by women as interval events and present to the general practitioner, irrespective of continuing hospital follow up. The value of routine follow-up with frequent visits to a breast cancer specialist-both in terms of detection of recurrence and patient satisfaction-has been questioned. The aim of this study was to compare nurse-led follow-up on demand versus physician follow-up after breast cancer treatment with regards to patients' well-being, satisfaction, access to medical care and medical safety. Two hundred and sixty-four consecutively selected women with newly diagnosed breast cancer, classified as UICC stage I or stage II, were randomised to follow-up at two hospitals in Sweden, either by routine medical follow-up, the physician group (PG, n=131), or on demand by a specialist nurse, the nurse group (NG, n=133). Measures were done at baseline and twice a year over a period of 5 years by means of a questionnaire containing the Hospital Anxiety and Depression Scale (HAD), and the Satisfaction and Accessibility (SaaC) scale. Number of contacts with the health care services, number of diagnostic procedures, and time to recurrence or death were monitored. The ratings of HAD and SaaC did not show any statistically significant differences between the groups. The levels of anxiety and depression were generally low and levels of patient satisfaction high. There were no differences between the groups concerning time to recurrence or death. This study indicates that women with breast cancer in stages I to II can be followed up by a specialist nurse with high patient satisfaction and good medical safety. To evaluate an innovative approach to continuing medical education, an outreach intervention designed to improve performance rates of breast cancer screening through implementation of office systems in community primary care practices.
                Randomized, controlled trial with primary care practices assigned to either the intervention group or control group, with the practice as the unit of analysis.
                Twenty mostly rural counties in North Carolina.
                Physicians and staff of 62 randomly selected family medicine and general internal medicine practices, primarily fee-for-service, half group practices and half solo practitioners.
                Physician investigators and facilitators met with practice physicians and staff over a period of 12 to 18 months to provide feedback on breast cancer screening performance, and to assist these primary care practices in developing office systems tailored to increase breast cancer screening.
                Physician questionnaires were obtained at baseline and follow-up to assess the presence of five indicators of an office system. Three of the five indicators of office systems increased significantly more in intervention practices than in control practices, but the mean number of indicators in intervention practices at followup was only 2.8 out of 5. Cross-sectional reviews of randomly chosen medical records of eligible women patients aged 50 years and over were done at baseline (n = 2,887) and follow-up (n = 2,874) to determine whether clinical breast examinations and mammography, were performed. Results for mammography were recorded in two ways, mention of the test in the visit note and actual report of the test in the medical record. These reviews showed an increase from 39% to 51% in mention of mammography in intervention practices, compared with an increase from 41% to 44% in control practices (p = .01). There was no significant difference, however, between the two groups in change in mammograms reported (intervention group increased from 28% to 32.7%; control group increased from 30.6% to 34.0%, p = .56). There was a nonsignificant trend (p = .06) toward a greater increase in performance of clinical breast examination in intervention versus control practices.
                A moderately intensive outreach intervention to increase rates of breast cancer screening through the development of office systems was modestly successful in increasing indicators of office systems and in documenting mention of mammography, but had little impact on actual performance of breast cancer screening. At follow-up, few practices had a complete office system for breast cancer screening. Outreach approaches to assist primary care practices implement office systems are promising but need further development. To assess the effectiveness of nurse led follow up in the management of patients with lung cancer.
                Randomised controlled trial.
                Specialist cancer hospital and three cancer units in southeastern England.
                203 patients with lung cancer who had completed their initial treatment and were expected to survive for at least 3 months.
                Nurse led follow up of outpatients compared with conventional medical follow up. Outcome measures: Quality of life, patients' satisfaction, general practitioners' satisfaction, survival, symptom-free survival, progression-free survival, use of resources, and comparison of costs.
                Patient acceptability of nurse led follow up was high: 75% (203/271) of eligible patients consented to participate. Patients who received the intervention had less severe dyspnoea at 3 months (P=0.03) and had better scores for emotional functioning (P=0.03) and less peripheral neuropathy (P=0.05) at 12 months. Intervention group patients scored significantly better in most satisfaction subscales at 3, 6, and 12 months (P<0.01 for all subscales at 3 months). No significant differences in general practitioners' overall satisfaction were seen between the two groups. No differences were seen in survival or rates of objective progression, although nurses recorded progression of symptoms sooner than doctors (P=0.01). Intervention patients were more likely to die at home rather than in a hospital or hospice (P=0.04), attended fewer consultations with a hospital doctor during the first 3 months (P=0.004), had fewer radiographs during the first 6 months (P=0.04), and had more radiotherapy within the first 3 months (P=0.01). No other differences were seen between the two groups in terms of the use of resources.
                Nurse led follow up was acceptable to lung cancer patients and general practitioners and led to positive outcomes. Guidelines on the type and frequency of follow-up of patients after curative surgery for colorectal cancer are unclear. The aim of this study was to determine the survival benefit of a planned follow-up program.
                Three hundred twenty-five patients who underwent curative resection of colorectal cancer were prospectively randomized to either intensive or standard follow-up. After stratification according to Dukes' stage and site in the colon or rectum, patients were randomized to intensive follow-up of yearly colonoscopy, computerized tomography (CT) of the liver, and chest radiography and clinical review and simple screening vs. structured clinical review and simple screening tests only.
                On completion of 5-year follow-up, there was no significant difference in survival between the two groups. Yearly colonoscopy failed to detect any asymptomatic local recurrences. Only one asymptomatic curable metachronous colon tumor was detected. Liver CT resulted in earlier detection of hepatic metastases but did not increase the number of curative hepatectomies. Only 1 patient had an asymptomatic CT-detected liver metastasis, and another had an asymptomatic chest radiography-detected lung metastasis. Both had curative resections.
                Yearly colonoscopy, liver CT, and chest radiography will not improve survival from colorectal cancer when added to symptom and simple screening review. The objective was to evaluate the effect of a clinic-based intervention program on mammography use by inner-city women.
                A randomized controlled trial employing firm system methodology was conducted.
                The study setting was a general internal medicine clinic in the university-affiliated county hospital serving metropolitan Seattle.
                Women aged 50 to 74 years with at least one routine clinic appointment (when they were due for mammography) during the study period were enrolled in the trial (n = 314).
                The intervention program emphasized nursing involvement and included physician education, provider prompts, use of audiovisual and printed patient education materials, transportation assistance in the form of bus passes, preappointment telephone or postcard reminders, and rescheduling assistance. Control firm women received usual care.
                Mammography completion within 8 weeks of clinic visits was significantly higher among intervention (49%) than control (22%) firm women (p < .001). These effects persisted after adjustment for potential confounding by age, race, medical insurance coverage, and previous mammography experience at the hospital (odds ratio 3.5; 95% confidence interval 1.9, 6.5). The intervention effect was modified by type of insurance coverage as well as prior mammography history. Process evaluation indicated that bus passes and rescheduling efforts did not contribute to the observed increases in screening participation.
                A clinic-based program incorporating physician education, provider prompts, patient education materials, and appointment reminders and emphasizing nursing involvement can facilitate adherence to breast cancer screening guidelines among inner-city women.
This updated review of RCTs conducted almost 20 years ago suggest that follow-up programs based on regular physical examinations and yearly mammography alone are as effective as more intensive approaches based on regular performance of laboratory and instrumental tests in terms of timeliness of recurrence detection, overall survival and quality of life. 
In one RCT, follow-up care performed by trained general practitioners working in an organized practice setting had comparable effectiveness to that delivered by hospital-based specialists in terms of quality of life and time to detection of distant metastases.