Learning to manage with less
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Among the lessons we are learning due to the COVID-19 pandemic, perhaps one of the most significant has been the degree to which we have had to adjust to a less intensive, more hands-off approach to taking care of our patients.
The most extreme manifestation of that has been those patients who “voted with their feet” and decided to delay their appointments at the beginning of the pandemic. At our center, many of those patients who are, of course, predominantly not on active treatment, are now beginning to return to care. The vast majority do not appear to have been adversely affected by the delay.
The next degree of separation involves those who are not coming to the center for an in-person visit but are instead relying on telehealth for their treatment-monitoring or follow-up visits. Six months ago, few of us would have been comfortable with this model of care, not just because of the lack of face-to-face interaction with our patients, but also because of the lack of data available to us from our physical exam.
Again, 5 months after the start of the crisis, it turns out that for many patients, we can provide good care in some clinical contexts without access to all the information we tend to think we need.
Change to follow-up protocols
Even in the context of our clinical research protocols, we and trial sponsors have had to make some compromises over the intensity of follow-up and evaluation of patients, abandoning some of the required physical assessments and laboratory and imaging evaluations.
It doesn’t come as much of a surprise to find out that it’s possible to get by in many cases without multiple EKGs, lab draws and scans without undermining the key endpoints of clinical trials. It turns out that we don’t have to deny patients access to these studies and to potentially helpful therapy because they are too remote from our centers or unable to travel.
It will be many months, and possibly years, before we will know whether the approaches — which some might regard as shortcuts — taken during the pandemic will have any effect on patient outcomes. That said, we can take comfort from existing literature that shows some of the routine practices that have been embedded our follow-up protocols for years waste time and money, add stress and expense for our patients, and can be safely discarded with no adverse effect on outcomes.
In the follow-up of patients with Hodgkin lymphoma and aggressive non-Hodgkin lymphoma, there is now extensive literature on the value of routine surveillance imaging and laboratory data.
Long story short, for those patients in complete remission at the end of therapy and who are free of symptoms at follow-up, routine imaging with CT or CT/PET and/or the use of routine surveillance laboratory data have very limited value in detecting relapse. Most relapses are detected by patients who are symptomatic or, much less frequently, by a routine physical exam. The additional yield from routine testing in the absence of symptoms in patients with a normal physical exam is almost zero.
Further, in addition to unnecessary cost, anticipation of the results is often a source of significant and unnecessary anxiety for our patients. Most importantly, routine surveillance tests have no influence on lymphoma survival in the population under follow-up.
In the spirit of full disclosure, although I have had no problem in abandoning routine surveillance imaging for these patients, I still obtain follow-up labs, for reasons I’m not entirely sure. Even though I know the literature on this subject, I still cling to the idea that I, and my patients, get some kind of reassurance knowing the complete blood count (CBC), chemistry and lactate dehydrogenase (LDH) are normal, although I know at the intellectual level that they have no real value.
A step toward value improvement
In the setting of indolent lymphomas, I have held onto the belief that there is still a role for intermittent imaging and laboratory follow-up.
My rationale has been that given the low-grade nature of these diseases, lymphadenopathy in the abdomen, for example, or slowly progressive marrow involvement might go undetected. By the time the disease is sufficiently advanced to cause organ compromise, therapy may be more complicated or less successful.
Data from a recent study suggest that, as with aggressive lymphomas, routine follow-up labs (and, although not a primary objective of the study, imaging) may be of little or no value.
The study — conducted at two large lymphoma treatment centers in Australia — included 183 patients aged 16 years and older with indolent lymphomas — mostly grade 1 to grade 3A follicular lymphoma, with a small number with marginal zone lymphomas.
In a retrospective analysis, the researchers evaluated 1,757 clinic visits that occurred between 2008 and 2017. Around 20% of the visits were for patients initially managed by observation only, with no initial therapy, the remainder being for patients with varying numbers and modalities of prior therapy. The analyses specifically focused on the utility of routine CBCs, beta-2 microglobulin and LDH. Researchers obtained routine laboratory data in just over 80% of visits.
Overall, researchers detected 74 progression events in 62 patients, only two of which were found based on the results of routine lab work in the absence of symptoms or an abnormal physical exam. In these two patients — both untreated patients on initial observation — symptoms had developed within 3 weeks of the clinic visit.
Although not a primary objective of the study, it was interesting that routine surveillance imaging, not performed in asymptomatic patients, detected only 9% of relapse events.
Of course, this is a relatively small, retrospective analysis with potential biases as a result, but it is consistent with previous findings in more aggressive lymphomas and, if confirmed, represents an opportunity for us to reduce unnecessary testing, cost, time and anxiety for our patients, with no effect on outcome — an incremental step toward value improvement in this patient population.
Whether we can reduce the test burden for these patients will depend on the results of further studies and the adaptation of current guidelines to reflect these results.
It will also depend on our ability to convince ourselves and manage the expectations of our patients about the lack of benefit of follow-up testing. Some of the data we need may eventually emerge from follow-up of those patients under surveillance during the pandemic.
Reference:
Piercey OA, et al. JCO Oncol Pract. 2020;doi:10.1200/JOP.19.00771.
For more information:
John Sweetenham, MD, FRCP, FACP, is HemOnc Today’s Chief Medical Editor for Hematology. He also is associate director for clinical affairs at Harold C. Simmons Comprehensive Cancer Center at UT Southwestern Medical Center. He can be reached at john.sweetenham@utsouthwestern.edu.
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