Follow-Up of Patients with Curable Lymphomas Ouside of Clinical Trials: A National Survey of Practice Patterns.

With increasingly effective therapy for patients with aggressive histology non-Hodgkin’s Lymphoma and Hodgkin’s Lymphoma, more patients are attaining complete remission and are eligible for follow-up monitoring. Such monitoring offers the potential for early detection of relapse and surveillance for late effects of treatment, but is resource-intensive and may lead to unnecessary investigation of false relapses and cumulative radiation exposure. A number of Practice Guidelines (PG) provide recommendations on follow-up of patients with lymphoma, but provide conflicting recommendations particularly relating to the use of imaging. The PG of the American College of Radiology (ACR) and the National Comprehensive Cancer Network (NCCN) recommend routine use of imaging in follow-up, while those of the Canadian Association of Radiologists (CAR) and Cancer Care Ontario (CCO) recommend limiting imaging to patients suspected of relapse and those at higher risk of recurrence. We conducted a survey of practicing hematologists across Canada to document follow-up practice of patients outside of clinical trials. A 12-question survey was mailed to 244 Hematologists identified from the database of the Royal College of Physicians and Surgeons of Canada. The Dillman method was used to administer the questionnaire with a second mailing sent at 4 weeks to non-respondents. The target response rate was 50%. 127 responded (52%) after the second mailing. 93% indicated that they routinely follow-up patients in remission following curative treatment. 41% reported following patients indefinitely, 39% followed patients for up to 5 years, and 22% tailored the duration to the risk of relapse (generally 2–5 years). The median visit interval in years 1–2 was 3 months, years 3–5 6 months, and beyond 5 years 12 months. 41% used imaging (generally CT scans) routinely in all patients, while 31% used scans only in patients in partial remission and 21% in patients felt to be high risk at presentation. The majority of respondents performed CBC and LDH blood testing routinely in all patients and performed serum TSH levels in patients following mediastinal radiation. Serum electrolytes, liver function testing and blood films were ordered routinely only by a minority of respondents. 27% of practitioners reported utilizing printed educational material for patients and/or primary care practitioners regarding follow-up. 25% indicated an intent to change their follow-up practice in the near future, generally citing a plan to limit the duration of follow-up and to decrease reliance on CT scanning.

Conclusion: This national survey indicates that the majority of Canadian hematologists routinely follow patients with lymphoma after curative treatment. The use of imaging in follow-up is variable, but is more consistent with the recommendations of the CAR and CCO than the ACR and NCCN.