|Year : 2020 | Volume
| Issue : 3 | Page : 124-127
Radically treated breast cancer patient's perception about routine physical follow-up visit
Chaitali Manohar Waghmare, Vandana S Jain, Arya Bhanu, Padmini H Nirmal
Department of Radiation Oncology, RMC and PRH, PMTPIMS, Loni, Maharashtra, India
|Date of Submission||29-Jul-2020|
|Date of Decision||01-Oct-2020|
|Date of Acceptance||14-Oct-2020|
|Date of Web Publication||26-Nov-2020|
Chaitali Manohar Waghmare
Department of Radiation Oncology, RMC and PRH, PMTPIMS, Loni, Maharashtra - 413 736
Source of Support: None, Conflict of Interest: None
Aim: The study aimed to evaluate radically treated breast cancer patient's (RTBCP) perception about routine physical follow up visit (RPFUV). Materials and Methods: RTBCP who had completed treatment at least 1 year before and attended radiation oncology department for RPFUV from August 2018 to May 2019 were evaluated for the study. Patients of both sex and all age group who were declared disease free and ready to give informed written consent for the study were interviewed before and after briefing session. The briefing session included explanation of natural history of disease, long-term treatment side effects, alarming symptoms of disease recurrence, and coping up strategies. Data were collected, compiled, and analyzed using descriptive statistics. Results: One hundred and one radically treated eligible breast cancer patients were interviewed. The median age was 51 years. The female-to-male sex ratio was 100:1. Majority of the patients were Stage II (57.43%) and 67.33% of patients were from the middle socioeconomic group. The average investigation and travel cost per visit excluding food, stay, and care's cost per patient was Rs. 765(±343) and Rs. 483.7 (±400.67), respectively. Majority of the patients (63.37%) feel stressed when they plan for RPFUV. Before briefing sessions, 57.43% of patients agreed to follow-up with a local physician or telephonic follow-up. Whereas, after briefing sessions, 62.38% of patients agreed for the same. Conclusion: Routine physical follow-up visits cause psychological and financial burden on patients. There is a need to practice an alternative to routine physical follow-up visits in RTBCP along with patient's education to further improve posttreatment quality of life.
Keywords: Breast cancer, cost, psychology, routine physical follow-up visits
|How to cite this article:|
Waghmare CM, Jain VS, Bhanu A, Nirmal PH. Radically treated breast cancer patient's perception about routine physical follow-up visit. Oncol J India 2020;4:124-7
|How to cite this URL:|
Waghmare CM, Jain VS, Bhanu A, Nirmal PH. Radically treated breast cancer patient's perception about routine physical follow-up visit. Oncol J India [serial online] 2020 [cited 2021 Jan 20];4:124-7. Available from: https://www.ojionline.org/text.asp?2020/4/3/124/301583
| Introduction|| |
Breast cancer is the second most common cancer in the world and the most common cancer in females accounting for 1.67 million new cases per year. It is the most common cancer in India and in Indian females with an annual incidence of 162,468. Five-year disease-free survival and overall survival of early-stage breast cancer patients in India are reported as 70% and 78%, respectively. Usually, the patients are called for regular physical follow-up visits (RPFUV) after completion of radical treatment. The aim of the follow-up visit is to monitor and manage the side effects of treatment and to detect recurrences early.
It is documented in the literature that recurrences often present as an interval event and are not usually detected by clinical examination in asymptomatic patients. Furthermore, there is no advantage of increasing the number of follow-up visits in high-risk group due to the short lead time. Regular laboratory and radiological investigations do not improve survival and quality of life., Thus, the frequency of follow-up visits can be minimized without any detrimental effect on prognosis. However, the follow-up visits are said to provide psychological support to cancer survivors. To take care of the psychological issue, the ways suggested are telephonic follow-up, or follow-up with a local general practitioner.,
In resource-constraint and developing country like India where breast cancer is the most common malignancy and majority of the patients are living with compromised socioeconomic status, there is a need to evaluate radically treated breast cancer patient's (RTBCP) perception about RPFUV. The results of this study will guide us to formulate the follow-up strategies in RTBCPs in resource-limited countries like India which may indirectly improve patient's quality of life, especially economic and psychological aspects.
| Materials and Methods|| |
After getting approval from the institutional ethics committee, RTBCPs who had completed treatment (except hormonal therapy) at least 1 year before (treatment completed between year 2012 and 2017) and attended radiation oncology department for a routine physical follow-up visit from August 2018 to May 2019 were prospectively evaluated for the study. The patients of both sex and all age group who were declared disease free and ready to give informed written consent for the study were interviewed. The RPFUV was three monthly for first 2 years, six monthly for next 3 years, and yearly thereafter. It included complete physical examination of patient, chest radiograph, abdominal ultrasound, and/or mammography of normal and/or affected side along with other symptom-specific investigations.
The patient's demographic details were collected from the hospital case records. The socioeconomic status as per the Modified Prasad's scale and travel cost per hospital visit excluding the government's travel benefit for cancer patients was recorded during the patient's interview. The cost of hospital stay, food, and carer's travel was not included. The investigation cost was noted from hospital case records. The number of follow-up visits and cost of investigations per visit was noted.
Four close-ended questions were asked to the patients by a nononcological physician to avoid the investigator's bias. Three questions were asked before and one question was asked after the briefing session for the patient and carer. The briefing session was conducted by treating radiation oncologist which included education about the natural history of disease, alarming symptoms of disease recurrence, expected long-term treatment side effects, and ways to manage it, for example, regular physiotherapy to combat lymphedema and possible coping strategies for psychological and family issues. The four questions asked during an interview are given in [Table 1]. Question “C” and question “D” were addressing the same issue before and after the briefing session.
The data were collected, compiled, and analyzed using descriptive statistics.
| Results|| |
One hundred and one radically treated eligible breast cancer patients were interviewed. The median age was 51 years within the age range of 35–78 years. The female-to-male sex ratio was 100:1. Majority of the patients were Stage II (57.43%). Sixty-eight patients (67.33%) belonged to the middle socioeconomic class. Demographic details of the study group are given in [Table 2]. The average investigation cost per visit was Rs 765 ± 343 (mean ± standard deviation [SD]). The average travel cost excluding expenses for carer, food, stay, and government's travel benefit for cancer patients was Rs 483.7 ± 400.67 (mean ± SD).
Sixty-four (63.37%) patients experienced stress when they plan for follow-up visit either because of the cost (32 [50%]), disease fear (13 [20.31%]), or both (19 [29.69%]). Thus, follow-up visit cost was a reason for stress in 79.68% (51) of patients. For the question “B” (Do you feel the follow-up visit is costing you significantly?), 58 (57.43%) patients answered “Yes,” 18 (17.82%) patients answered “No,” while 25 (24.75%) patients said they cannot comment on this question. When given an alternative to RPFUV as to follow-up with a local physician or telephonic follow-up and then at primary oncology treatment center if needed (question “C”), 58 (57.43%) patients agreed for the same. Forty-three patients (42.57%) denied the alternative to RPFUV. After the briefing session, 63 (62.38%) patients agreed for an alternative method of follow-up. Three patients who have answered “Yes” for question C changed the answer as “No” to question “D” (the same question after briefing session) for unknown reasons. Eight patients changed the answer from “No” to “Yes” for an alternative to RPFUV after a briefing session. Thus, the answer for question “D” was “Yes” in 63 (62.38%) patients and it was “No” in 38 (37.62%) patients. When asked about hesitancy for alternative to RPFUV, the majority of the answers were directed to the training of local physicians in oncology care, belief/bonding with the primary treating physician, and disease anxiety.
| Discussion|| |
Posttreatment economic burden and psychological stress in RTBCP is a matter of concern. Usually, patients are kept on RPFUV along with regular laboratory and radiological investigations. Patients feel reassured when test results are normal. On the contrary, literature had shown that routine laboratory and radiological investigations do not improve survival or quality of life. Hence, it should not be recommended., Beaver et al. conducted a randomized controlled trial of telephonic versus physical follow-up visits. They concluded that hospital-based follow-up visits significantly increase the travel and productivity cost, and there was no difference in the cost of treating recurrences. Routine follow-up of women treated by mastectomy has limited value and majority (96.04%) of our patients were postmastectomy. Follow-up guidelines given by ICMR are as six-monthly visits for the first 5 years, annually up to 10 years, and two yearly thereafter. Reduced follow-up strategies for breast cancer have not yet been widely accepted in clinical practice.
We tried to evaluate an economic burden and psychological aspects associated with RPFUV from the patient's perspective. Socioeconomic status was noted as per the Modified Prasad's scale which in itself has many limitations. The logistics of travel to the primary treating hospital is again an important question mainly because of the availability of patient attendant to accompany at hospital, relatively old age, female sex, and loss of daily earning of the patient's carer. When asked about whether the follow-up visit is costing significantly, patients answered that they have to pay for RPFUV as it is meant for their benefit. This reflects their anxiety about the disease which further increases because of social taboo associated with cancer and the belief that they have to follow the physician's instructions. For question C, few patients who answered “Yes” said so from their past experience of physical examination and investigation results report which were normal all the time. After the briefing session which was conducted by treating radiation oncologist and which included education about the natural history of disease, alarming symptoms of disease recurrence, expected long-term treatment side effects, and ways to manage it along with possible coping strategies for psychological and family issues, 18.60% of patients (8 of 43 patients) who have answered “No” for question C agreed for an alternative method of follow-up evaluation. We observed that the educational status of patients and understanding had also affected the answers. Kimman et al. had suggested that improvements in psychosocial support and information to patients could lead to a better acceptance of reduced follow-up and improvement in the quality of life.
The reason for not accepting the alternative follow-up method came out as concern on the competency of local physicians in diagnosis and management of cancer-related problems. Some patients were very much worried, rather tense about the disease that they do not wish to consult a physician other than primary treating physician/cancer specialist. Sensitizing local physicians about the importance and art of follow-up visits in RTBCP along with posttreatment patient's education will help to obviate this quandary. Telephonic follow-up may help to reduce the psychological stress with an equal outcome as RPFUV.,
There are few limitations of this study. The level of patient's satisfaction with physical follow-up was not studied. The standardized psychological scale was not used to assess the stress. Instead, it was noted as per the patient's perception as 'yes' or 'no'.
| Conclusion|| |
Routine physical follow-up visits cause psychological and economical burden on patients. Making patient's education a routine practice may help to reduce an anxiety and increase acceptance to alternative follow-up visit which is needed, especially in resource-constraint countries like India and this may help to further improve the patient's quality of life. Future studies with a large number of patients are needed to prove this proposition.
All procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional ethics committee under research cell. Institutional ethics committee approval was obtained before the start of the study.
Informed written consent was obtained from all individual participants included in the study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin 2018;68:394-424.
Badwe R, Hawaldar R, Parmar V, Nadkarni M, Seth T, Desai S, et al
. Single injection depot progesterone before surgery in women with operable breast cancer: A randomized control trial. Jr Clin Oncol 2011;29:2845-51.
Churn M, Kelly V. Outpatient follow-up after treatment for early breast cancer: Updated results after 5 years. Clin Oncol (R Coll Radiol) 2001;13:187-94.
Ritoe SC, Verbeek AL, Krabbe PF, Kaanders JH, van den Hoogen FJ, Marres HA. Screening for local and regional cancer recurrence in patients curatively treated for laryngeal cancer: Definition of a high-risk group and estimation of the lead time. Head Neck 2007;29:431-8.
Ghezzi P, Magnanini S, Rinaldini M, Berardi F, Biagio G, Testare F, et al
. 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. JAMA 1994;271:1587-92.
Rosselli Del Turco M, Palli D, Cariddi A, Ciatto S, Pacini P, Distante V. Intensive diagnostic follow-up after treatment of primary breast cancer. A randomized trial. National research council project on breast cancer follow-up. JAMA 1994;271:1593-7.
Dewar JA, Kerr GR. Value of routine follow up of women treated for early carcinoma of the breast. Br Med J (Clin Res Ed) 1985;291:1464-7.
Wertheimer MD. Against minimalism in breast cancer follow-up. JAMA 1991;265:396-7.
Beaver K, Tysver RD, Campbell M, Twomey M, Williams S, Hindley A, et al
. Comparing hospital and telephonic follow up after treatment for breast cancer: Randomized equivalence trial. BMJ 2009;338:a3147.
Mathew AS, Agarwal JP, Munshi A, Laskar SG, Pramesh CS, Karimundackal G, et al
. A prospective study of telephonic contact and subsequent physical follow-up of radically treated lung cancer patients. Indian J Cancer 2017;54:241-52.
] [Full text]
Donnelly J, Mack P, Donaldson LA. Follow-up of breast cancer: Time for a new approach? Int J Clin Pract 2001;55:431-3.
Grunfeld E, Mant D, Vessey MP, Fitzpatrick R. Specialist and general practice views on routine follow-up of breast cancer patients in general practice. Fam Pract 1995;12:60-5.
Pandey VK, Aggarwal P, Kakkar R. Modified B G Prasad's Socioeconomic classification-2018. The need for an update in present scenario. Indian J Community Health 2018;30:82-4.
Loprinzi CL. Follow up testing for curatively treated cancer survivors–What to do? JAMA 1995;273:1877-8.
Beaver K, Hollingworth W, McDonald R, Dunn G, Tysver-Robinson D, Thomson L, et al
. Economic evaluation of a randomized clinical trial of hospital versus telephone follow-up after treatment for breast cancer. Br J Surg 2009;96:1406-15.
Snee M. Routine follow-up of breast cancer patients. Clin Oncol (R Coll Radiol) 1994;6:154-6.
Kimman ML, Voogd AC, Dirksen Q, Falger P, Hupperets P, Keymeulen K, et al
. Improving the quality and efficiency of follow up after curative treatment of breast cancer-a rational and study design of MaCare trial. BMC Cancer 2007;7:1.
[Table 1], [Table 2]