Rapid review of existing literature on the cost-effectiveness of follow-up strategies after cancer treatment

Introduction: A rapid review has been conducted to explore the cost-effectiveness of follow up strategies of patients previously treated for cancer. The aim of the review was to assess whether existing literature could be useful in informing UK policy in these areas.

Methods: A systematic literature was undertaken. All papers that were considered to be economic evaluations in the subject areas described above were extracted. Data extracted included details of condition (type of cancer) examined, study design, findings (including incremental cost-effectiveness ratios (ICERs), assessment of uncertainty) and quality assessment. In order to maximise the usefulness of this report, papers deemed of high quality and high relevance have been considered as the priority for discussion. However, data extracted from all papers meeting the inclusion criteria are presented in an Appendix. Further appendices describe the search strategy methods, results and individual abstracts. Subsequently, interventions/strategies were assessed for their relevance to UK policy and decision making by a group of clinical experts in the relevant fields

Results: The search identified 1,637 references. After excluding papers that were duplicates, non-English, not economic evaluations, not focussed on cancer or not related to follow-up of patients previously treated for cancer, 78 papers were identified as potentially relevant and these articles were ordered or retrieved from the web. After full text assessment, a total of 34 articles were included in the analysis. Results are presented separately for each cancer

Conclusions: Colorectal cancer was the most common (n=9) cancer type considered. Breast (n=7), lung (n=4), bladder (n=3), cervical (n=2), skin (n=2), gastro-oesophageal (n=1), ovarian (n=1), renal (n=1), seminoma (n=1), Hodgkins (n=1), uterine (n=1) and general cancer (n=1) were also studied. The higher quality studies and expert opinion suggested the following:

Colorectal

• An intensive follow-up strategy for patients who had received curative resection for colorectal cancer appears a cost-effective strategy compared to minimal follow-up.

• The optimal follow-up time with an intensive programme for this patient population is likely to be between 2 and 4 years.

• Nurse-led follow-up appears a cost-effective option. Similarly, follow-up in primary care is likely to be less costly and similarly effective as follow-up at hospital by surgeons.

• Expert input suggested that the method of follow-up (eg remotely) is a potential method of reducing costs without impacting on patient outcomes.

Breast

• In general, intensive follow-up programmes do not appear a cost-effective option for women with previously treated breast cancer.

• A move to open access after a certain follow-up period (5 years) is popular with patients and clinicians, and is likely to reduce costs with no impact on outcomes.

Lung

• Follow-up programmes involving nurses or GPs rather than follow-up at hospital clinics might represent efficient strategies for patients previously treated for lung cancer. However, clinical input suggests that it is important to conduct the follow-up in the same place as imaging (hospital), though there is potential for nurse specialists to be involved.

Cervical

• PET-CT does not appear a cost-effective option in addition to standard imaging in the UK for follow-up of women treated for cervical cancer.

The suggestions described above should be interpreted with caution. Some of the studies were not UK based, several were dated and there was limited evidence that all relevant data had been synthesised or considered. In addition, the relevance of the comparators included may be questioned. In order to identify the most relevant studies for UK decision makers, an expert panel of clinicians has been assembled to provide advice. The following review combines evidence from the published literature with the opinion of clinical experts to highlight relevant studies of acceptable quality.