Featured Review: Follow-up strategies after completion of primary cancer treatment

Interview with review author Beverley Lim Høeg, from the Danish Cancer Society Research Center

What is the aim of this review?
More and more people are surviving cancer and receiving follow-up care. The aim of this review was to compare the effectiveness of different types of follow-up care after completion of cancer treatment on the outcomes of survival, detection of recurrence, health-related quality of life, anxiety, depression and cost.

There are now more than 44 million cancer survivors worldwide and thanks to better screening and treatment, these numbers will continue to grow. Thus, healthcare systems are being challenged to optimise follow-up in a way that meets the cancer survivor’s long-term physical and psychological needs, while remaining economically viable. This review provides an overview of the current scientific evidence of the effects of different types of follow-up on the outcomes that are most important for patients, so policy-makers can make informed decisions.

What was studied in the review?
After being treated for cancer, most patients receive long-term follow-up care to look for signs of a recurrence. If the cancer returns, it is thought to be better to detect it earlier, as it allows earlier treatment, which is expected to improve survival.  

Traditional follow-up usually involves fixed visits to a cancer specialist in a hospital setting for examinations and tests, but this is expensive for healthcare systems, may be burdensome for the patient and many survivors also report unmet psychosocial needs. Thus, newer follow-up strategies involving non-specialist care providers, different intensity of examinations, or the addition of survivorship care plans have been developed and tested but their effectiveness remains unclear.

In this review, we searched for all the relevant studies testing different types of follow-up care and analysed 53 studies, involving 20,832 participants with 12 types of cancer in 15 different countries, mainly in Europe, North America and Australia. All the studies were carried out in either a hospital or general practice setting.


What would you like patients and those treating cancer patients to know?
As there were many types of cancer follow-up being tested in the included studies, we grouped them into three main categories. Here are our main findings:

  • When cancer survivors receive aftercare led by non-specialists, such as GPs and nurses we are uncertain if overall survival is affected or if cancer recurrence is detected earlier. This was because there were either too few studies evaluating the outcome or the studies reported their results in a way that we could not summarise. However, we found that it probably makes little or no difference to health-related quality of life and anxiety and it makes no difference for depression at 12 months of follow-up. So patients can be reassured that receiving follow-up care from their GP or nurse will not worsen their well-being.
  • When cancer survivors receive less intensive aftercare, such as fewer examinations and tests, it may make little or no difference to overall survival, but it probably delays detection of recurrence. However, we need different types of studies, which were outside the scope of this review, before we can make conclusions about how a delay in detection of recurrence may or may not affect survival. Finally, we are uncertain if this type of care makes a difference to health-related quality of life and anxiety, as there were too few studies to summarise, and none of the studies assessed depression.
  • When cancer survivors receive aftercare with additional education about their symptoms or survivorship care plans, we are uncertain how this type of aftercare affects health-related quality of life, anxiety or depression at 12 months of follow-up. We also did not find any studies that assessed overall survival or if cancer recurrence is detected earlier. As this is a relatively new type of aftercare, we expect the current ongoing studies to provide more evidence for this follow-up in the future.

For all three types of follow-up, we could not summarise the results for cost, as the results were calculated and reported differently in the studies that evaluated this outcome. Also, only two studies reported economic evaluations using quality-adjusted life years (QALY), which takes into account good health and survival in assessing the value for money of an intervention. However, less intensive follow-up was generally reported to be cheaper than more intensive follow-up from the perspective of the healthcare system and the patient.

What sort of studies would be useful now?
Our review identified several knowledge gaps. We need studies that evaluate the effect of non-specialist-led follow-up on survival and detection of recurrence and we need studies that evaluate the effect of intensity of follow-up on the patient’s well-being. For the final type of follow-up care, we need studies that include survival and recurrence as their outcomes, as well as a follow-up time of at least 12 months using measures that can be pooled in a meta-analysis, so we can calculate the long-term effects on patient well-being.

Did you find any of results or findings surprising?
Many trials of cancer follow-up have been carried out over the years, so I was surprised that the evidence available was of so poor certainty, or lacking entirely, for quite a few outcomes. Researchers of follow-up care need to remember to include both prognostic outcomes and well-being outcomes when testing the effects of interventions and funders must be willing to provide the necessary resources to do so, as this knowledge is important for optimal patient care.