The belief that an earlier detection of recurrence leads to a higher likelihood of disease control, complete remission, or at least extended survival has led to intensive routine surveillance programs. It now appears that such ardent follow-up screening (chest x-ray and bone scan) for asymptomatic women is a costly measure that has wide acceptance but limited value. Usefulness is a judgment measured by the criteria of quality of life and sur: vival benefit. The early detection of distant metastases has shown no survival advantage. Chest x-rays have not been particularly useful in detecting recurrence, nor has bone-scan surveillance been fruitful in asymptomatic patients.43 After a review of several studies, the following conclusion was reached by Roselli Del Turco et al⁴⁴: "Periodic intensive follow-up with chest [x-rayJ and bone scan should not be recommended as routine policy."

Chest x-rays were instituted as a public-health protection against tuberculosis: their routine use is considered an expensive and outmoded practice by many. On the other hand, follou-up with a physical exam twice a year and a yearly mammogram are both sensible and cost effective. According to Charles Loprinzi⁴⁵ of the Mayo Clinic, "retrospective studies ... do not suggest that patients who had routine follow-up testing did any better than those patients who did not.... A history and physical examination are clearly the best methods for obtaining evidence of recurrent breast cancer. Several studies have reported that 75% to 85% of recurrences are detected this way (even when frequent additional tests are performed)."

Every time Lyra, a 52-year-old woman who had a mastectomy 4 years ago, feels an ache in her calves, she worries. She anticipates bone scans every few months with equal parts dread and hopeful expectation. The usefulness of this intensive surveillance ritual is more than questionable. Metastatic bone disease rarely remains asymptomatic for more than 3 months. If Lyra's bone scan is negative, it simply means that the part of the bone scanned did not show evidence of disease. If it is positive, there is little advantage in knowing this before actual symptoms of the disease arise. Most bone metastases will become symptomatic within 90 days. Greater power is attributed to diagnostic instruments than is often warranted--scans are imperfect devices that offer relatively crude measurement. Technology has advanced more rapidly than our understanding of how to derive benefit from it.

A savings of $636 million in the United States for the year 1990 was projected for the minimalist surveillance protocol (history, physical exam, mammogram) over the more intensive series (physical exam, blood cell count and chemistry, antigen level. mammogram, chest x-ray, bone scan) currently in routine use.⁴⁶ By the year 2000, the cost savings is estimated to be S1 billion. Again, science can only dubiously cater to the best hopes of patients and doctors. Researchers comment: "In conclusion, although the patient and physician may have an intuition that intensive surveillance will detect recurrence earlier and prolong survival compared with minimal surveillance, this feeling is not borne out...."⁴³ In 1990 breast cancer consumed $6.5 billion--more healthcare dollars than any other cancer. After an exhaustive assessment, Herman Kattlove et al^37(p142) concluded. "Regrettably, it is easier to estimate the expense of medical care than to project the benefit."