Follow-up care for breast cancer patients costs less if it is conducted by nurses rather than physicians, yet there is no difference in the patients' anxiety, depression, satisfaction or outcome, according to research presented today (Friday) at the 6th European Breast Cancer Conference (EBCC-6) in Berlin.
The study found that over a five-year period the cost of follow-up care was €630 per person per year for patients who saw a physician and €495 per person per year for those who saw specialist cancer nurses. Over a five-year period this made a difference of €866 per patient - a modest saving per patient, but one that would enable substantial savings to be made in a country's health budget as breast cancer is the most prevalent tumour worldwide.
Dr IngaLill Koinberg, who is both a nurse and medical doctor at the Department of Research and Development, Hospital Varberg and Kristianstad University, Sweden, said: "These results showed that follow-up led by specialist nurses, with check-ups on demand, were 20% less expensive than routine follow-up visits to the physician. The main difference in cost between physician-led follow-up and nurse-led follow-up was explained by the number of visits to the physician. There were 21% more contacts with the physician in the physician group than in the nurse group."
Dr Koinberg and her colleagues randomised 264 breast cancer patients to two different follow-up groups in a prospective trial. Women in the physician group had routine medical follow-ups by a physician, involving four visits per year in the first two years, then examinations twice a year for up to five years, and annually thereafter. In the nurse group, patients saw a specialist nurse three months after the initial visit to the physician following radiotherapy. They were told how to recognise recurrence in the breast, skin, axillary nodes and scar tissue, and to telephone the nurse if they had any questions or symptoms of cancer recurrence. In addition, they had an annual mammography, and after three years they were referred back to the routine mammography screening programme.
The researchers found that the women in the two groups did not differ in terms of anxiety, depression, their satisfaction with care, how accessible they found the medical centre, or in medical outcomes measured by rates of cancer recurrence or death.
"The difference in cost per year and per patient between the physician and nurse groups is modest, but transforms to nearly €900 per patient and five-year period, offering a substantial opportunity for reallocating resources since breast cancer is the most prevalent tumour worldwide" said Dr Koinberg. "Follow-up for breast cancer - and cancer follow-up in general - is an important area for developing new, less costly alternatives, so that scarce resources can be used more effectively. Our study indicates that follow-up after primary cancer treatment is an area where economic evaluation can be worthwhile."
She gave an example of the difference nurse-led follow-up could make in Sweden. "If we estimate that 50% of the 60,000 women with prevalent breast cancer in Sweden are under active follow-up, the savings for Sweden alone would amount to €4.1 million per year if the findings of this study were applied."
Dr Koinberg concluded that individual countries needed to have coherent discussions about how they organised the follow-up of cancer patients. "The majority of women treated within the last five years attend a follow-up programme. Thus, in total, these follow-up programmes consume large resources, even if the individual patient consultation entails only limited expense. Since there is no generally accepted strategy for a follow-up programme, these vary in their design from region to region and centre to centre. Recent research* has indicated that more intensive follow-up does not increase medical safety. Furthermore, there are indications that good quality programmes can be run with trained nurses. Despite the high total amount of resources spent on follow-up programmes and the indications that several alternative approaches could be used effectively, there is no coherent discussion about costs and/or cost-effectiveness of follow-up programmes."