College Researchers Studying Breast Cancer Follow-Up Care

Last year more than 211,000 new cases of invasive breast cancer were diagnosed in the US, and nearly 40,000 women died from the disease. While research into cancer diagnosis and treatment is ongoing, not much is known about the follow-up care of cancer survivors. To this end, the Medical College of Wisconsin has received a $1.2 million grant from the National Cancer Institute to study breast cancer surveillance care.

Ken Schellhase, MD, MPH, Assistant Professor of Family and Community Medicine at the Medical College of Wisconsin, is one of the researchers on the Breast Cancer Surveillance grant, along with Ann Butler Nattinger, MD, MPH, Professor and Chief of the Division of General Internal Medicine, the grant's Principal Investigator.

"Breast cancer surveillance care is the routine cancer-related care provided to breast cancer survivors after they've completed their cancer treatment," Dr. Schellhase says. "Essentially, that means getting annual mammograms and regular office visits with a physician." Regarding the grant itself, Dr. Schellhase explains, "The grant is a 4-year study of a very large dataset, to look at the quality of follow-up care received by older breast cancer survivors."

Study Goals
Dr. Schellhase says the study has two primary goals: First, to find out who is providing the after-treatment care to breast cancer survivors. Dr. Schellhase asks, "How often is it a cancer-related specialist, and how often is it a primary care doctor, like a family medicine physician?"

The second goal is to determine what sort of care the survivors are actually receiving. Dr. Schellhase wants answers to questions such as, "Are they truly receiving annual mammograms? Are they receiving a lot of other tests on a routine basis, like bone scans and chest x-rays, despite these being not recommended for asymptomatic patients?"

To implement this study, Dr. Schellhase and Dr. Nattinger are using something called the SEER-Medicare database to analyze the care of thousands of breast cancer survivors. SEER stands for Surveillance, Epidemiology, and End Results. The dataset comes from combining a collection of state and regional cancer registries maintained by the National Cancer Institute, with billing data from Medicare. The women involved are age 65 and older, and roughly mirror the diversity of our population.

"The SEER-Medicare database contains very detailed data on tumor diagnoses and treatment from the SEER registries, and links that to the Medicare claims files for those cancer patients who are Medicare enrollees," says Dr. Schellhase. "The claims allow us to analyze the patterns of care delivered to these women; for example, what proportion of breast cancer survivors received an annual mammogram in the 2 years following their cancer treatment?"

"Over-Testing" at Issue
"Post-treatment care has been evaluated in two randomized controlled trials from the mid-1990s," Dr. Schellhase says. "Both trials found that women who received annual mammography and regular office visits had the same survival rates as those who received routine CT scans, liver function tests, ultrasounds, as well as routine mammography and office visits."

In other words, the extra testing did not have an impact on breast cancer survival rates. This is not to say that some women in the group receiving extensive routine testing might not have been diagnosed earlier with a cancer recurrence, compared to women in the low-intensity testing group, notes Dr. Schellhase; however, the earlier diagnosis of recurrence did not make any difference in terms of survival.

The conclusion reached from these trials was that routine follow-up of breast cancer survivors should consist of annual mammography and regular office visits to their physician. And it's not always necessary to see a cancer specialist for post-treatment care, Dr. Schellhase says. "In the follow-up phase, generalist physicians such as family physicians and general internists have the training to manage routine follow-up care needs just as well as a specialist; but if patients do present with complications of treatment, or manifestations of recurrence, specialists may be more experienced managing these things." He adds, "If there is concern for a recurrence, generalists will promptly seek consultation with a cancer specialist."

Results Could Lead to More Effective After-Care
The Medical College's breast cancer surveillance care study could lead to several changes in the post-treatment care of breast cancer survivors, Dr. Schellhase affirms. "Hopefully, it will lead to an awareness - and subsequent education of both physicians and patients - that a significant portion of this population at high risk for recurrent breast cancer may not be getting basic follow-up care."

The researchers in the study also plan to analyze whether a team approach to care leads to better quality of follow-up, he explains. This will help answer questions about the type of physicians patients see, and whether seeing both a generalist and a cancer specialist improves outcomes. And lastly, Dr. Schellhase says, "We will evaluate the extent to which over-testing occurs, which could lead to awareness and education among physicians that there is little to be gained by such testing."

Overall, Dr. Schellhase says, not enough is known about the post-treatment care of breast cancer (or other cancer) survivors. This study will bring important information to the field by evaluating the quality of routine follow-up care of older breast cancer survivors, and then identifying factors that seem to predict higher quality care. By determining how the quality of care for survivors can be improved and implementing changes based on the data, it is possible that survival rates for breast cancer could be increased.

This article includes information from the US Centers for Disease Control and Prevention.

P.J. Early
HealthLink Contributing Writer

MCW Health News presents up-to-date information on patient care and medical research by the physicians of the Medical College of Wisconsin.