Review of guidance on recurrence risk management …postprint.nivel.nl/PPpp6620.pdfSpronk, I., Korevaar, J.C., Burgers, J.S., Albreht, T., Schellevis, F.G. Review of guidance on recurrence

Spronk, I., Korevaar, J.C., Burgers, J.S., Albreht, T., Schellevis, F.G. Review of guidance on recurrence risk management for general practitioners in breast cancer, colorectal cancer and melanoma guidelines. Family Practice: 2017, 34(2), 154-160

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DOI 10.1093/fampra/cmw140


Review of guidance on recurrence risk

management for general practitioners in breast

cancer, colorectal cancer and melanoma guidelines

INGE SPRONKA , JOKE C KOREVAAR

A , JAKO S BURGERS

BC , TIT ALBREHT

D, FRANÇOIS G

SCHELLEVISA

a NIVEL, Netherlands Institute for Health Services Research , Utrecht, The Netherlands

b Dutch College of General Practitioners , Utrecht , The Netherlands

c School CAPHRI, Department Family Medicine, Maastricht University , Maastricht , The Netherlands

d Centre for Health System Analyses, National Institute of Public Health , Ljubljana, Slovenia

ABSTRACT

Background.

General practitioners (GPs) will face cancer recurrences more frequently due to

the rising number of cancer survivors and greater involvement of GPs in the

follow-up care. Currently, GPs are uncertain about managing recurrence risks

and may need more guidance.

Objective.

To explore what guidance is available for GPs on managing recurrence risks for

breast cancer, colorectal cancer and melanoma, and to examine whether

recurrence risk management differs between these tumour types.

Methods.

Breast cancer, colorectal cancer and melanoma clinical practice guidelines were

identified via searches on internet and the literature, and experts were

approached to identify guidelines. Guidance on recurrence risk management that

was (potentially) relevant for GPs was extracted and summarized into topics.

Results.

We included 24 breast cancer, 21 colorectal cancer and 15 melanoma

guidelines. Identified topics on recurrence risk management were rather similar

among the three tumour types. The main issue in the guidelines was recurrence

detection through consecutive diagnostic testing. Guidelines agree on both

routine and nonroutine tests, but, recommended frequencies for follow-up are

inconsistent, except for mammography screening for breast cancer. Only six

guidelines provided targeted guidance for GPs.

Conclusion.

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This inventory shows that recurrence risk management has overlapping areas

between tumour types, making it more feasible for GPs to provide this care.

However, few guidance on recurrence risk management is specific for GPs.

Recommendations on time intervals of consecutive diagnostic tests are

inconsistent, making it difficult for GPs to manage recurrence risks and

illustrating the need for more guidance targeted for GPs.

INTRODUCTION

The number of cancer survivors is rising as a result of the increasing incidence of

cancer and the advances in treatment and early detection (1,2). In 2012, there were

almost 32.5 million cancer survivors worldwide (3). The World Cancer Research

Fund estimates that this number will grow to almost 70 million survivors in 2050 (4).

On completion of curative cancer treatment, patients usually receive follow-up care

in secondary care settings by medical specialists (5,6). Due to the rising number of

cancer survivors, the limited capacity of secondary care facilities to provide follow-

up care, and the increasing costs, general practitioners (GPs) are increasingly

involved in the follow-up care (7–9). An important component of follow-up care is

detecting recurrence (5).

Recurrences regularly occur between scheduled follow-up visits and are often

initially presented as symptoms to the GP (10–12). In addition, recurrences that

occur many years after the initial treatment are probably also first presented to the

GP.

It is expected that GPs will face cancer recurrences more frequently in particular, in

follow-up care of common tumour types with high survival rates and with

recurrences occurring many years after treatment, such as breast cancer, colorectal

cancer and melanoma (13–15). It is important that GPs are able to detect recurrence

and refer patients in time to secondary care for treatment.

In order to provide optimal recurrence risk management, GPs need more applicable

guidance (16–22). GPs are especially uncertain about the type and, frequency of

tests, and the length of maintaining a test scheme during the follow-up (21). Besides,

GPs expect that providing this care increases their workload (23–25) and that they

need more expertise and formal training (16,23–27). A recent study on evidence-

based recommendations on care for breast cancer survivors in five recent evidence-

based guidelines showed that these guidelines are insufficiently helpful for GPs (28).

This stimulates the need of including guidelines not evidence based.

To uncover what guidance is available for GPs on managing recurrence risks in

patients with breast cancer, colorectal cancer and melanoma, and to examine whether

recurrence risk management differs between these tumour types, we made an

inventory of existing clinical practice guidelines originating from Australia, Canada,

European countries, New Zealand and USA and created an overview of presented

guidance.

METHODS

Two strategies were used to collect guidelines. As part of the European Union Joint

Action Cancer Control (CanCon; www.cancercontrol.eu), a Joint Action (29) which

aims to contribute to reducing the cancer burden in the European Union, an inventory

of existing clinical practice guidelines in European countries via national experts was




undertaken and in addition internet and scientific literature was searched to complete

the inventory of guidelines.

Inventory of guidelines via experts

In Autumn 2014, experts from the European Union Member States and four other

non-EU countries (Norway, Switzerland, Iceland and Turkey) were asked to supply

existing national and/or regional guidelines from their own country. Experts were

delegates from national primary care associations, nursing associations, universities

with a medical department and CanCon associated partners. At least three experts per

country were approached. In December 2014, also delegates were approached from

the Cancer and Primary Care Research International Network (CA-PRI), the

European Forum for Primary Care (EFPC), the European Society of General

Practice/Family Medicine (WONCA Europe) and CanCon collaborating partners

from nonresponding countries. Inclusion criteria were that guidelines needed to

contain guidance on care for adult cancer survivors, subsequent to curative treatment,

and that they were (potentially) relevant to GPs.

Internet and literature search

A bibliographical database search using the terms ‘guideline’, ‘breast cancer’,

‘colorectal cancer’, ‘colon cancer’, ‘rectum cancer’, ‘melanoma’ was conducted in

January 2015 to complete the inventory of clinical practice guidelines. Databases

included Embase and Medline. Also, the National Guideline Clearinghouse website,

the Guidelines International Network (G-I-N) website and cancer agency websites

were searched for relevant tumour-specific guidelines (see Supplementary Table 1

for all websites that were searched). Guidelines with a publication date from 2000 to

2015 were included and searches were conducted without any language restriction.

Guidelines were required to contain guidance on care for cancer survivors that was

(potentially) relevant to GPs, subsequent to curative treatment.

Guideline selection

Guidelines obtained from literature and internet searches were selected on basis of

title. Screening of guidelines was done by one researcher (IS). We included

guidelines focusing on adults and originating from western countries, as mentioned

above, and Australia, Canada, New Zealand and USA. We excluded older versions

of guidelines, duplicates, those that were specifically made for oncologists, and those

that only focussed on early detection, screening, treatment or palliative care,

advanced cancer or metastasis, or on specific patients groups, e.g. hereditary cancer

survivors and childhood cancer survivors.

Data extraction and content analysis

Data were extracted on the target audience of the guideline, the clinical content and

the supporting evidence. Evidence was defined as one or more references to

scientific, peer reviewed sources. Translations were used for data extraction from

guidelines written in other languages than English or Dutch. The data from Croatian,

Danish, Finnish, Norwegian and Polish guidelines were validated by the expert who

provided the guidelines. Translations of data from the French, German and Italian

guidelines were validated by researchers from the NIVEL institute who were native

speakers or who speak the specific language. Extracted data were categorized into

‘guidance on recurrence risk management’ and ‘other guidance’ by two researchers

independently (IS and JK). Subsequently, it was assessed whether the




recommendations were relevant for GPs; recommendations on diagnostic tests

performed in a secondary care setting were excluded.

Based on the relevant guidance, a clinical topic list for each tumour type was

composed. The topic lists were composed by one researcher (IS) and checked by a

second researcher (JK). Guidance was independently allocated to topics by two

researchers (IS and JK). If guidance did not fit into the predefined topics, a new topic

was created by discussion. Disagreements on categorization or allocation into topics

were resolved by discussion with a third researcher (FS).

RESULTS

Included guidelines

Twelve countries indicated that there were no tumour-specific guidelines containing

information on care for cancer survivors (potentially) relevant for GPs. From other

countries, we received at least one tumour-specific guideline on breast cancer (n =

16), colorectal cancer (n = 17) or melanoma (n = 13). Thirty of these guidelines were

considered eligible and were included. Excluded guidelines were duplicates (n = 3),

translated versions of included guidelines (n = 3) and guidelines specifically

targeting oncologists (n = 10) (Fig. 1).

[FIGURE 1.]

The database search yielded 639 results, the National Guideline Clearinghouse

website 547 results and the G-I-N website 246. In total, in the databases and on the

cancer agency websites, 30 additional relevant guidelines were found. Overall, 60

guidelines were deemed eligible, including 24 breast cancer guidelines, 21 colorectal

cancer guidelines and 15 melanoma guidelines (Supplementary Table 2). The colon

cancer and rectal cancer guideline from the United States included the same

guidance, therefore only the colon cancer guideline was used. Included guidelines

were published between 2003 and 2015 and originated from Europe (n = 45), Canada

(n = 7), United States (n = 5) and Australia and New Zealand (n = 3). Twenty-eight

guidelines were not published in English: five were published in Dutch, five in

German, three in Danish, three in Finnish, three in French, three in Polish, two in

Croatian, two in Italian and two in Norwegian. Three guidelines were specifically

made for GPs (30,31) and three guidelines provided a summarized guide explicitly

for GPs (32–34). Furthermore, 23 other guidelines mentioned the GP explicitly as

part of their target audience.

Identification of topics

Eight topics were identified in the breast cancer and melanoma guidelines (Fig. 2). In

colorectal guidelines, seven of these topics were covered; self-examination was not

mentioned. For all tumour types, most attention was given to recurrence detection by

recommendations on diagnostic testing. Physical examination was recommended for

each of the three tumour types. Self-examination by patients was recommended in

87% of the melanoma and in 29% of the breast cancer guidelines. Additional,

diagnostic imaging (mammography) for breast cancer and laboratory diagnostic

testing [carcinoembryonic antigen testing (CEA)] for colorectal cancer was

recommended. Another topic that was often highlighted was awareness of cancer

recurrence; it was mentioned in 67% of the breast cancer, 73% of the melanoma and




80% of the colorectal cancer guidelines. In contrast, specific signs and symptoms of

recurrence received limited attention; these were reported in 15% of the colorectal

cancer, 21% of the breast cancer and 33% of the melanoma guidelines. Differences

in coverage of topics between guidelines from the tumour types were also observed.

Risk of recurrence/second cancer was pointed out in most breast cancer (67%) and

melanoma guidelines (73%), but in less colorectal cancer guidelines (40%).

Recommendations on organization of care were provided in 67% of the breast cancer

guidelines, in 50% of the colorectal cancer guidelines and in 33% of the melanoma

guidelines.

[FIGURE 2.]

Recommendations on frequency of diagnostic testing

Breast cancer

Recommendations on the frequency of physical examination were provided in 20 out

of 24 guidelines and all 24 guidelines reported a recommended frequency of

mammography (Table 1). Broad consensus existed on annual mammography.

Additionally, 10 guidelines stated that the first mammogram after breast conserving

therapy should take place after at least 6 months. Less agreement was observed on

the frequency of physical examination ranging from one to four times a year in the

first 3 years after treatment. In the 3 subsequent years, most guidelines recommended

(semi-)annually examinations. Guidelines agreed on an annual examination after 3

years.

[TABLE 1.]

Colorectal cancer

Eighteen out of 20 guidelines contained recommendations on time intervals between

consecutive physical examinations and nineteen on time intervals between

consecutive CEA testing. Eleven guidelines recommended the same frequency for

both tests. Overall, there was some agreement among guidelines on the time intervals

between consecutive tests. Recommended time intervals were 3- to 6-monthly in the

first 3 years and 6- to 12-monthly in the 4th and 5th year (Table 2). All, except one

guideline, agreed that there is no need for diagnostic testing after 5 years.

[TABLE 2.]

Melanoma

Guidance on time intervals between consecutive physical examinations was provided

by 12 out of 15 melanoma guidelines, two other guidelines stated that the frequency

and the duration of follow-up should be tailored to each individual patient.

Recommended time intervals in eight guidelines were dependent on the stage of the

melanoma as the risk of recurrence/second cancer is related to the primary tumour

thickness (35). Recommendations were inconsistent on the time intervals between

consecutive tests for both stage I and stages II and III, ranging from one to four times

a year in the first 5 years after treatment (Table 3). Most guidelines (67%) stressed




that the more advanced the disease the shorter the time intervals should be in the first

2 years. Most guidelines (83%) agreed on continuing testing during 5 to 10 years

after the initial treatment. After 10 years, there was disagreement whether to stop or

continue testing.

[TABLE 3.]

Evidence regarding recurrence risk management

Eighteen out of 59 reviewed guidelines did not include any references to scientific

evidence related to cancer recurrence risk management. Among the guidelines that

included references, the range in the number of references was one to 54. Only few

guidelines provided evidence-based recommendations on time intervals; five on

physical examination and ten on mammography for breast cancer, three on both

physical examination and CEA testing for colorectal cancer and five on physical

examination for melanoma. Evidence-based recommendations showed the same

discrepancies in preferred time intervals as the recommendations were not evidence

based (data not shown).

DISCUSSION

This is the first inventory evaluating guidance on recurrence risk management

available in existing breast cancer, colorectal cancer and melanoma guidelines that is

(potentially) relevant to GPs. It demonstrates that the topics on recurrence risk

management were rather similar among the three tumour types and that few guidance

on recurrence risk management is targeted to GPs. Most attention was given to

recurrence detection often by highlighting the importance of the diagnostic tests. For

each tumour type, there is consensus among the guidelines about the preferred type

of diagnostic tests, but, recommended frequencies for follow-up are inconsistent,

except for mammography screening for breast cancer, reflecting the lack of evidence

in this field.

The guidance on recurrence risk management of three tumour types could be

summarized into identical topics with similar components. This facilitates GPs to

provide follow-up care because the same pattern applies for different tumour types.

However, GPs still need more knowledge on details, like on diagnostic tests, which

are specific per tumour type.

Overall, the main focus in the guidelines is recurrence detection through consecutive

diagnostic testing. Guidelines agree on both routine and nonroutine tests, but, except

for mammography screening for breast cancer, recommendations on time intervals

are inconsistent. This diversity reflects the lack of high quality evidence available;

recommendations are mainly based on expert opinion. Although, the evidence-based

recommendations showed the same discrepancies in preferred time interval. Thus the

lack of agreement not only arises from expert opinions. The discrepancies in

recommended time intervals make it difficult for GPs to determine the frequency of

follow-up. This problem was confirmed by a study investigating the views of GPs on

follow-up care (21). Most common problems among GPs were uncertainty about the

type and frequency of diagnostic tests and duration of follow-up. Even when

guidance is univocal and evidence based, its implementation is crucial to improve the

quality of care and, subsequently, the survival of cancer. Further research is needed

to examine the facilitators and barriers of implementing the guidance on recurrence




risk management in daily practice and whether this leads to better cancer survival in

respective countries.

Awareness of cancer recurrence is also often mentioned in the guidelines. However,

specific signs and symptoms that may indicate recurrence are reported by few

guidelines and only one guideline provided EB guidance on signs of recurrence (33).

Signs of recurrence also receive little attention in the scientific literature as there is a

paucity of research in this field, especially in the primary care setting. Until now,

only one study examined the signs of recurrence in primary care (36). This study

showed that the symptoms of recurrence in primary care were very different from

those reported by secondary care, reflecting the need for specific guidance on signs

of recurrence for primary care. More research in primary care is needed to fill the

knowledge gap.

Most melanoma and breast cancer guidelines report the risk of recurrence and state

which patients have an increased risk of recurrence, but only few colorectal cancer

guidelines discuss this, although the risk of recurrence is not significantly lower in

colorectal cancer (37–40). In addition to detection of recurrence by health care

providers, recurrences are also detected by the patients themselves (41,42). Almost

all melanoma guidelines provide instructions on self-examination to patients,

whereas only 29% of the breast cancer guidelines recommend this. This is in

accordance with the current literature; regular self-examination does not reduce

breast cancer morbidity or mortality and it is associated with an increased number of

physician visits and high rates of benign biopsies (43–45). For melanoma, self-

examination is promoted (46,47) as evidence suggests that self-examination is

associated with reduced mortality (48) and the vast majority of melanomas and

melanoma recurrences are found by patients themselves (41,49,50). Besides,

melanomas found by self-examination have been shown to be thinner than those

found incidentally (51).

A previous study from our group focussing just on evidence-based recommendations

on care for cancer survivors in five recent evidence-based breast cancer guidelines

showed that these guidelines are not helpful to GPs (28). We used the same method

as in the current study and restricted the inclusion to evidence-based guidelines and

identified the same topics, except for signs of recurrence. Signs of recurrence were

never covered by the evidence-based recommendations. Recommendations on the

frequency of mammography screening were the same as in the current study, but, in

contrast to the lack of agreement on the recommended frequency of physical

examination in the current study, the evidence-based recommendations agreed on the

frequency of physical examination. However, a limitation was that only two

guidelines provided a recommendation on physical examination and three on

mammography. This limited number of evidence-based guidelines stimulated the

need to include guidelines not evidence-based as is done in the current study.

All guidelines in our study included both evidence-based recommendations as well

as opinion based recommendations. The lack of clear and uniform data to support

recommendations calls for expert opinions, which could explain differences between

the guidelines. However, we also found discrepancies between evidence-based

recommendations, showing the influence of interpretation of research findings is not

always straightforward.

Our study showed limited applicability of cancer guidelines for GPs, which was also

highlighted by an earlier study focussing on breast cancer, colorectal cancer and




prostate cancer guidelines (19). Another recent publication focussing on the role of

the GP in aftercare, also found that recommendations in guidelines are often not

targeted toward GPs (52). Involvement of GPs in the development of guidelines

could raise the number and relevance of recommendations to GPs (19). However, it

may be argued whether this is sufficient. Due to the limited applicability of current

guidelines for GPs, it seems the right time to develop GP specific guidelines. These

could address specific topics that are relevant in the GP care setting, where care is

more holistic and includes personalised care for patients’ comorbidities. A first

example that a GP guideline is feasible, is a recent guideline on care for breast cancer

survivors as developed in the United Stated (53). This guideline is, where possible,

based on research in primary care.

A strength of this inventory is the input of 45 experts from all 32 approached

countries. We gained information from all European Union countries and collected

additional information from other Western countries. Therefore, we were able to

create a fairly complete overview of guidance on recurrence risk management for

GPs.

A limitation of present study is the inclusion of guidelines older than 5 years. It is has

been demonstrated that almost half of the guidelines are outdated after 5 years (54).

Although, no differences were seen in both included topics and guidance between the

older and newer guidelines. This might indicate a low availability of new evidence

on recurrence risk management in the recent years.

Conclusion

This inventory represents the guidance on recurrence risk management (potentially)

relevant for GPs provided in breast cancer, colorectal cancer and melanoma

guidelines. It shows that care on recurrence risk management has overlapping areas

between tumour types, making it more feasible for GPs to provide this care.

However, only little guidance on recurrence risk management is specific for GPs and

recommendations between time intervals of consecutive diagnostic tests are

inconsistent, making it hard for GPs to know how to manage recurrence risks and

illustrating the need for more guidance targeted for GPs. Besides, all guidelines to

some extent provided recommendations that were opinion based, reflecting the need

of more high quality studies on cancer recurrence risk management.

SUPPLEMENTARY MATERIAL

Supplementary data are available at Family Practice online.

DECLARATION

Funding: Joint Action CanCon as part of the Health Programme of the European

Union.

Ethical approval: none.

Conflict of interest: IS, JCK, JSB, TA and FGS declare that they have no conflict of

interest.

ACKNOWLEDGEMENTS

We gratefully acknowledge Anne-Vicky Carlier, Marianne Heins, Pekka Honkanen,

Anne Kari Knudsen, Roar Maagaard, Mario Sekerija and Elzbièta Senkus-Konefka




for validating our translations. We would also like to acknowledge all experts who

provided us response.

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54 Shekelle PG Ortiz E Rhodes S et al Validity of the Agency for Healthcare Research and Quality clinical practice guidelines: how quickly do guidelines become outdated? JAMA 2001 ; 286 : 1461 – 7

TABLES AND FIGURES











Supplementary table 1. Literature and internet searches

Literature search

EMBASE (2000 to 2015) Search 1

1. 'breast cancer':ti

2. guideline:ti

3. [humans]/lim

4. [2000-2015]/py

5. 1 AND 2 AND 3 AND 4

Search 2

1. 'melanoma':ti

2. guideline:ti

3. [humans]/lim

4. [2000-2015]/py


Search 3

1. 'colorectal cancer':ti

2. guideline:ti

3. [humans]/lim

4. [2000-2015]/py


Search 4

1. 'rectal cancer':ti

2. guideline:ti

3. [humans]/lim

4. [2000-2015]/py


Search 5

1. 'colon cancer':ti

2. guideline:ti

3. [humans]/lim

4. [2000-2015]/py


Medline (2000 to 2015) Search 1

1. breast cancer[Title] 2. limit to guideline 3. limit to publication date from 2000/01/01

Search 2 1. melanoma[Title] 2. limit to guideline 3. limit to publication date from 2000/01/01

Search 3 1. colorectal cancer[Title] 2. limit to guideline 3. limit to publication date from 2000/01/01

Search 4 1. rectal cancer[Title] 2. limit to guideline 3. limit to publication date from 2000/01/01

Search 5 1. colon cancer[Title] 2. limit to guideline 3. limit to publication date from 2000/01/01

Internet search

National guideline clearinghouse (January 2015) http://www.guideline.gov/search/search.aspx?term=melanoma http://www.guideline.gov/search/search.aspx?term=breast+cancer http://www.guideline.gov/search/search.aspx?term=colorectal+cancer http://www.guideline.gov/search/search.aspx?term=rectal+cancer http://www.guideline.gov/search/search.aspx?term=colon+cancer Guidelines International Network (G-I-N) (January 2015) http://www.g-i-n.net/library/international-guidelines-library/@@guideline_search_results?type=basic&basic-searchable-text=breast+cancer http://www.g-i-n.net/library/international-guidelines-library/@@guideline_search_results?type=basic&basic-searchable-text=melanoma http://www.g-i-n.net/library/international-guidelines-library/@@guideline_search_results?type=basic&basic-searchable-text=colorectal+cancer http://www.g-i-n.net/library/international-guidelines-library/@@guideline_search_results?type=basic&basic-searchable-text=rectal+cancer http://www.g-i-n.net/library/international-guidelines-library/@@guideline_search_results?type=basic&basic-searchable-text=colon+cancer Cancer agency websites (January 2015) Alberta Health Services (http://www.albertahealthservices.ca/) American Cancer Society (http://www.cancer.org/) American Society for Clinical Oncology (ASCO) (http://www.asco.org/) British Colombia Cancer Agency (BCCA) (http://www.bccancer.bc.ca/) Cancer Care Ontario (https://www.cancercare.on.ca/) Cancer Council Australia (http://www.cancer.org.au/health-professionals/clinical-guidelines/) Comprehensive Cancer Centre the Netherlands (IKNL) (http://www.oncoline.nl/) European Society for Medical Oncology (ESMO) (http://www.esmo.org/) Haute Autorité de Santé (http://www.has-sante.fr) National Comprehensive Cancer Network (NCCN) (http://www.nccn.org/) National Institute for Health and Clinical excellence (NICE) (https://www.nice.org.uk/) New Zealand Guidelines Group (NZGG) (http://www.health.govt.nz/about-ministry/ministry-health-websites/new-zealand-guidelines-group) Saskatchewan Cancer Agency (http://www.saskcancer.ca/) Scottish Intercollegiate Guidelines Network (SIGN) (http://www.sign.ac.uk/) Sociedad Espanola de Oncologia Medica (SEOM) (http://www.seom.org/)

http://www.guideline.gov/search/search.aspx?term=melanoma

http://www.guideline.gov/search/search.aspx?term=breast+cancer

http://www.guideline.gov/search/search.aspx?term=colorectal+cancer

http://www.guideline.gov/search/search.aspx?term=rectal+cancer

http://www.guideline.gov/search/search.aspx?term=colon+cancer

http://www.g-i-n.net/library/international-guidelines-library/@@guideline_search_results?type=basic&basic-searchable-text=breast+cancer

http://www.g-i-n.net/library/international-guidelines-library/@@guideline_search_results?type=basic&basic-searchable-text=breast+cancer

http://www.g-i-n.net/library/international-guidelines-library/@@guideline_search_results?type=basic&basic-searchable-text=melanoma

http://www.g-i-n.net/library/international-guidelines-library/@@guideline_search_results?type=basic&basic-searchable-text=melanoma

http://www.g-i-n.net/library/international-guidelines-library/@@guideline_search_results?type=basic&basic-searchable-text=colorectal+cancer

http://www.g-i-n.net/library/international-guidelines-library/@@guideline_search_results?type=basic&basic-searchable-text=colorectal+cancer

http://www.g-i-n.net/library/international-guidelines-library/@@guideline_search_results?type=basic&basic-searchable-text=rectal+cancer

http://www.g-i-n.net/library/international-guidelines-library/@@guideline_search_results?type=basic&basic-searchable-text=rectal+cancer

http://www.g-i-n.net/library/international-guidelines-library/@@guideline_search_results?type=basic&basic-searchable-text=colon+cancer

http://www.g-i-n.net/library/international-guidelines-library/@@guideline_search_results?type=basic&basic-searchable-text=colon+cancer

http://www.albertahealthservices.ca/

http://www.cancer.org/

http://www.asco.org/

http://www.bccancer.bc.ca/

https://www.cancercare.on.ca/

http://www.cancer.org.au/health-professionals/clinical-guidelines/

http://www.oncoline.nl/

http://www.esmo.org/

http://www.has-sante.fr/

http://www.nccn.org/

https://www.nice.org.uk/

http://www.health.govt.nz/about-ministry/ministry-health-websites/new-zealand-guidelines-group

http://www.health.govt.nz/about-ministry/ministry-health-websites/new-zealand-guidelines-group

http://www.saskcancer.ca/

http://www.sign.ac.uk/

http://www.seom.org/

Supplementary table 2. Included guidelines

Table 1. Included guidelines

Country Year Title

Breast cancer (n=24)

Australia 2010 Recommendations for follow-up of women with early breast cancer*

Austria 2007 Tumour aftercare in general practice†

Belgium 2013 Breast cancer in women: diagnosis, treatment and follow-up Canada 2005 Clinical practice guidelines for the care and treatment of breast cancer: 9.

Follow-up after treatment for breast cancer (2005 update) Canada – Alberta 2013 Follow-up care for early-stage breast cancer Canada – British Columbia

2013 Breast Cancer: Management and Follow-Up

Canada - Saskatchewan 2012 Breast Cancer Treatment Guidelines Croatia 2012 Clinical guideline for the diagnosis, treatment and monitoring of patients with

non-invasive breast cancer Denmark 2012 Breast cancer guideline Europa 2013 Primary breast cancer: ESMO Clinical Practice Guidelines for diagnosis,

treatment and follow-up Finland 2014 Breast cancer France 2010 Breast cancer Germany 2012 Interdisciplinary S3 guideline for the diagnosis, treatment and aftercare of

breast cancer Ireland 2013 Follow-up care plan after treatment for breast cancer - A guide for General

Practitioners†

Italy 2014 Breast cancer guideline Netherlands 2012 Breast cancer. National guideline version 2.0

§

New Zealand 2009 Management of Early Breast Cancer Norway 2014 National action program with guidelines for diagnosis, treatment and

monitoring of patients with breast cancer Poland 2014 Control tests after treatment in the most common solid tumours in adults Spain 2013 SEOM Clinical Guidelines for the systemic treatment of early breast cancer

2013 Spain - Catalonia 2009 Breast Cancer Guideline United Kingdom 2009 Early and locally advanced breast cancer: diagnosis and treatment United States 2013 Breast Cancer Follow-Up and Management After Primary Treatment: American

Society of Clinical Oncology Clinical Practice Guideline Update United States 2014 Breast Cancer

Colorectal cancer (n=21)

Austria 2007 Tumour aftercare in general practice*

Belgium 2014 Colon Cancer Belgium 2004 Rectum Cancer Canada - British Columbia

2013 Follow-up of Colorectal Polyps or Cancer

Canada - Ontario 2012 Follow-up Care, Surveillance Protocol, and Secondary Prevention Measures for Survivors of Colorectal Cancer

Canada – Saskatchewan

2011 Provincial Colorectal Cancer Treatment Guidelines

Croatia Clinical guideline for the diagnosis, treatment and monitoring of patients with colorectal cancer

Denmark 2012 Colorectal cancer guideline Europe 2013 Early colon cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment

and follow-up Finland 2013 Colorectal cancer France 2012 Colorectal cancer and adenocarcinoma Germany 2014 S3 guideline colorectal cancer

Italy 2014 Colorectal cancer guideline Netherlands 2014 Colorectal cancer. National guidelines version 3.0 Poland 2014 Control tests after treatment in the most common solid tumours in adults Spain - Catalonia 2009 Colorectal Cancer guideline Switzerland 2007 Revised consensus recommendations for aftercare

after colonoscopy and after curative surgery for colorectal cancer United Kingdom 2011 Colorectal cancer

The diagnosis and management of colorectal cancer USA 2015 Colon Cancer USA 2015 Rectal Cancer

Melanoma (n=15)

Australia and New Zealand

2008 Clinical Practice Guidelines for the Management of Melanoma in Australia and New Zealand

*

Belgium 2007 National guidelines for clinical practice: Melanoma Denmark 2012 Melanoma guideline Europe 2012 Cutaneous melanoma: ESMO Clinical Practice Guidelines for diagnosis,

treatment and follow-up Europe 2012 Diagnosis and treatment of melanoma. European consensus-based

interdisciplinary guideline – Update 2012 Finland 2012 Melanoma France 2012 Cutaneous melanoma Germany 2013 Malignant Melanoma S3 guideline "Diagnosis, treatment and aftercare of

melanoma" Netherlands 2012 Melanoma. National guideline version 2.0 Norway 2013 National action program with guidelines for diagnosis, treatment and follow-up

of malignant melanomas Poland 2014 Control tests after treatment in the most common solid tumours in adults Scotland 2003 Cutaneous Melanoma - A national clinical guideline Switzerland 2011 Updated Swiss guidelines for the treatment and follow-up of cutaneous

melanoma United Kingdom 2011 Improving outcomes for people with skin tumours including melanoma:

Evidence Update October 2011 United States 2015 Melanoma *This clinical guideline provided a guide for general practitioners. This guide refers to the clinical guideline for more

information. Therefore, the clinical guideline is included.

†This guideline

was specifically made for general practitioners.

§A part of the information reported in the multidisciplinary guideline is copied to the general practitioners guide ‘diagnosis

of breast cancer’. This guide refers to the multidisciplinary guideline. Therefore, the multidisciplinary guideline is included.

Documents

Review of guidance on recurrence risk management …postprint.nivel.nl/PPpp6620.pdfSpronk, I., Korevaar, J.C., Burgers, J.S., Albreht, T., Schellevis, F.G. Review of guidance on recurrence