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From Cancer Patient to Cancer Survivor: Lost in Transition
The depth of coverage on survivorship issues varies markedly among guidelines, with some CPGs including both guidance on follow-up and extensive coverage of specific issues such as lymphedema and hormone replacement therapy (e.g., National Breast Cancer Center of Australia, British Columbia Cancer Agency, Steering Committee on Clinical Practice Guidelines for the Care and Treatment of Breast Cancer of Canada). Others cover only one or two topics, with little detail. Some guidelines describe potential late effects of treatment, but have little information on how to manage symptoms.
Only one guideline, from the National Breast Cancer Center of Australia, touches on all of the topics reviewed, although it does not cover each of them with equal depth. The Steering Committee on Clinical Practice Guidelines for the Care and Treatment of Breast Cancer covers nearly all of the topics; however, the lymphedema and hormone replacement therapy guidelines are published separately from the general breast cancer follow-up guideline. The clinician seeking comprehensive recommendations would be able to find them if multiple sources were searched, however, some of the guidelines are not easily identified. Of note, some major guidelines such as the Australian National Breast Cancer Center guidelines and those of the National Comprehensive Cancer Network were not included in the National Guideline Clearinghouse (NGC) that can be searched at the website of the U.S. Department of Health and Human Services (AHRQ, 2004b).25
All guidelines that address the issue of testing for recurrence advise against routine imaging, and blood and marker testing. The contraindication for such testing comes from randomized trials demonstrating no benefit from these procedures (Rosselli Del Turco et al., 1994; GIVIO, 1994; Liberati, 1995; Palli et al., 1999; Rojas et al., 2005). In terms of frequency of follow-up visits, all guidelines advise that visits occur on more than an annual basis, although one randomized trial assessing visit frequency showed no difference in outcomes or satisfaction for women seen on an annual or more frequent basis (Gulliford et al., 1997). The frequencies of visits in the CPGs reviewed varied within narrow limits from every 3 to 4 months to every 6 months in the first 2 years, and every 6 or 12 months in subsequent years.
Most of the guidelines offer similar schedules for follow-up visits, but recommendations for the content of follow-up visits varies. All reviewed guidelines that address surveillance recommend follow-up mammography. The strength of the mammography recommendations vary markedly, as shown in Table 3-5. Thus, depending on the guideline used, the clinician
These guidelines may not have been submitted for inclusion in the NGC or they may not have met Agency for Healthcare Research and Quality criteria for inclusion (AHRQ, 1998).