Introduction: Post-treatment surveillance for potentially curable malignancies

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RECEIVING A DIAGNOSIS of cancer comes with unimaginable anxiety, even for malignancies that are potentially curable. Patients, families, friends, and physicians expend immeasurable energy in implementing treatment plans and supportive care. Unfortunately, nothing prepares the patient for the anxiety that often comes with completion of therapy. More importantly, physicians are not properly equipped with controlled data defining appropriate post-treatment surveillance with which they can educate patients to allay their fears. These two factors lead patients and physicians to rely on surveillance studies, which may result in a false sense of security when tests are normal or anxiety when tests are abnormal.

Through an enormous research effort over the past five decades, the treatment of cancer is more effective and more patients are cured. Development of new drugs currently requires close monitoring of patients on research trials to carefully define the activity of the drug and the duration of its effectiveness. Often, these studies are phase II trials in patients with relapsed disease, and the majority of the situations are not curative. This need to perform frequent testing often finds its way into phase III trials and clinical practice, despite a lack of data suggesting the utility of such an approach.

The current medical business climate requires that patients on clinical trials be followed in a similar fashion to patients receiving standard cancer treatments, or that the research trial bears the costs of the increased surveillance. Excessive utilization of laboratory tests or imaging studies increases the cost of medical care, regardless of the treatment approach. Patients and physicians are caught in the middle between third-party payers and clinical trial sponsors, and which entity should pay for such “extra” examinations. Clearly, the cost of research must be covered, or further progress in the care of patients with cancer will be stifled. Follow-up studies need to be not only effective, but also cost-effective.

The real question regarding the utility and approach to post-treatment follow-up is: Does early detection of relapse enhance subsequent potential for cure? While the theoretical answer may be “yes,” the established answer is often “we really don’t know.” Cancer medicine is replete with situations where common belief was disproved by a randomized, controlled trial, such as third-generation chemotherapy programs for aggressive lymphoma or high-dose chemotherapy with stem cell rescue for breast cancer. Post-treatment surveillance is no different, and because randomized trials are difficult to conduct in this area, we must rely on observational studies, consensus panels, and expert opinion. These opinions should relate to the care of patients receiving standard or research therapies.

The focus of this issue of Seminars in Oncology is to compile the latest information on post-treatment surveillance of potentially curable cancers into a single, useful reference for practicing clinicians and researchers alike. We have assembled an outstanding group of physicians with both clinical and research experience, and many of them have served on consensus panels or published on this topic as it relates to their respective area of expertise. We believe these contributions can serve as the basis for enhanced clinical care through appropriate testing and patient education. Furthermore, we hope this issue serves as an impetus for researchers to incorporate accepted follow-up guidelines into research studies or, better yet, incorporate surveillance questions into the design of future clinical research trials.