Cost-effectiveness and quality of life in surgeon versus general practitioner-organised colon cancer surveillance: a randomised controlled trial

Abstract

Objective: To assess whether colon cancer follow-up can be organised by general practitioners (GPs) without a decline in the patient's quality of life (QoL) and increase in cost or time to cancer diagnoses, compared to hospital follow-up.

Design: Randomised controlled trial.

Setting: Northern Norway Health Authority Trust, 4 trusts, 11 hospitals and 88 local communities.

Participants: Patients surgically treated for colon cancer, hospital surgeons and community GPs.

Intervention: 24-month follow-up according to national guidelines at the community GP office. To ensure a high follow-up guideline adherence, a decision support tool for patients and GPs were used.

Main outcome measures: Primary outcomes were QoL, measured by the global health scales of the European Organisation for Research and Treatment of Cancer QoL Questionnaire (EORTC QLQ C-30) and EuroQol-5D (EQ-5D). Secondary outcomes were cost-effectiveness and time to cancer diagnoses.

Results: 110 patients were randomised to intervention (n=55) or control (n=55), and followed by 78 GPs (942 follow-up months) and 70 surgeons (942 follow-up months), respectively. Compared to baseline, there was a significant improvement in postoperative QoL (p=0.003), but no differences between groups were revealed (mean difference at 1, 3, 6, 9, 12, 15, 18, 21 and 24-month follow-up appointments): Global Health; Δ-2.23, p=0.20; EQ-5D index; Δ-0.10, p=0.48, EQ-5D VAS; Δ-1.1, p=0.44. There were no differences in time to recurrent cancer diagnosis (GP 35 days vs surgeon 45 days, p=0.46); 14 recurrences were detected (GP 6 vs surgeon 8) and 7 metastases surgeries performed (GP 3 vs surgeon 4). The follow-up programme initiated 1186 healthcare contacts (GP 678 vs surgeon 508), 1105 diagnostic tests (GP 592 vs surgeon 513) and 778 hospital travels (GP 250 vs surgeon 528). GP organised follow-up was associated with societal cost savings (£8233 vs £9889, p<0.001).

Conclusions: GP-organised follow-up was associated with no decline in QoL, no increase in time to recurrent cancer diagnosis and cost savings.

Trial registration: ClinicalTrials.gov identifier NCT00572143.

Figure 1

Flow of participants. Patients were enrolled in the 2007 NGICG (Norwegian Gastrointestinal Cancer Group, table 1) follow-up programmes in both trial arms. The programmes are divided in 3-month cycles, that is, clinical examination at 1 (baseline), 3, 6, 9, 12, 15, 18, 21 and 24 months, carcinoembryonic antigen (CEA) measurement at 3-month intervals, chest x-ray and contrast-enhanced liver ultrasound every 6 months and colonoscopy once during 24 months (table 1).

Figure 2

A–C. Health-related quality of life 1–24 postoperative months. European Organisation for Research and Treatment of Cancer QoL Questionnaire (EORTC QLQ C-30) Global Health, EuroQol-5D (EQ-5D) index score and EQ-5D visual analogue scale.

Figure 3

Health care cost of follow-up per 3 month follow-up cycle.

Figure 4

Sensitivity analyses of cost-driving elements in surveillance. Societal cost per patient (£) for a 24-month colon cancer follow-up. Most critical variable in terms of impact is listed at the top of the graph, and the rest ranked according to their impact thereafter. As unit cost from the UK, like cost for GP consultation and diagnostic testing, has been reported to be 30–40% higher than units cost applied in this trial, relevant cost elements were increased accordingly. Cost values for serious clinical events, metastases surgeries and sick leave were adjusted for baseline characteristics.