Whereas systematic postoperative surveillance has been extensively studied with regard to cure and survival, the possible benefit of surveillance with regard to better outcome of palliative care and/or quality of life has been less widely documented. It has been shown that follow-up programmes can lead to psychological stress . Kjeldsen concluded that patients receiving frequent follow-ups had greater confidence in the check-ups, but the improvement in the health-related quality of life was only marginally improved. The study concludes that the minor improvement in health-related quality of life does not justify an expensive and frequent follow-up schedule . Kievit published a meta-analysis in 2002 arguing for an increased focus on quality assessment and patient support in a follow-up programme, as improved survival is realized in only a few patients . According to this study, there is no need for routine follow-up to be performed by a surgeon. Patients with asymptomatic but incurable disease (9% in Korners study) , raise serious ethical concerns. Even with today's chemotherapy regimens with significant effects in terms of response rate and overall survival, cure is rarely seen when patients are beyond salvage curative surgery . A meta-analysis of six randomized trials demonstrated that intensive follow-up in colorectal cancer was associated with an absolute reduction in all-cause 5-year mortality of 10%; however, only two percent was attributable to cure from salvage re-operations. Renehan et al postulate that other factors, such as increased psychological well-being and/or altered lifestyle, and/or improved treatment of coincidental disease may contribute to the remaining lives saved .
The geography of Norway makes the costs of travelling a significant burden. In North Norway in particular, the population is scattered throughout a large geographic area, making the cost of travel to a specialist examination considerable. The specialists are mainly located in a few main cities. New regulations requiring each hospital to cover travel expenses have resulted in a stronger focus on these costs in recent years. At present, 5% of the total budget of the Regional Health Authority of North Norway is spent on travelling/transportation. The cost of travelling was earlier funded by the Norwegian Insurance Administration. If a follow-up programme (i.e. clinical examination and medical history) can be run by the patient's GP, there are obvious reasons to believe that the total costs of such a programme could be reduced.
Whereas there is evidence of survival gain related to intensive follow-up programmes, the burden of cost to the health care service is considerable [26–28]. Renehan et al. published a study in 2004 arguing that intensive follow-up after curative resection for colorectal cancer is economically justified and should be standard practice . However, a Danish study concludes the opposite, stating that follow-up after colorectal cancer surgery is not cost-effective compared to several other procedures, including screening for CRC . The cost-effectiveness of the Norwegian guidelines was documented cost-effective in a prior study when applied in a model-based study implementing data from the literature. The basic cost of the NGICG recommended programme was GBP£ 1,232 per patient. Including extended investigation due to suspected relapse in 45% of cases, the figure rose to £ 1,943 per patient . However, Korner et al  argue against this study. The total programme cost in this study was Euro € 228,117 (US 280,994 dollars), translating into € 20,530 (US 25,289 dollars) for one surviving patient after salvage surgery. This cost is less than the one calculated by Norum, but the costs are calculated at different times and in different settings, making a direct comparison useless. Costs are hard to compare with publications from other countries because of different reimbursement policies. Finally, they  argue whether the continuing implementation of such a program and costs are justified should be further debated.
The setting of follow-up may have an impact on patients' well-being and satisfaction with care. A recently published study showed that there were no differences in score for quality of life among patients with colon cancer, randomized to follow-up by GPs or specialists . However, this study is based upon follow-up procedures that differ from those used in Norway (e.g. no regular radiological procedures), and there is no cost-effectiveness analysis. To our knowledge this is the first study addressing this problem. According to a Cochrane review, further research is needed . Studies addressing follow-up of other cancer types by GPs have been performed, indicating for example that breast cancer patients can be safely followed up by their family physician without any concerns related to clinical outcome or health-related quality of life . Recent studies have indicated that the GP has a place in the follow-up of many patients with cancer, also in the initial phase after treatment . Patients trust their GP to provide competent care, especially when they have more complex health care needs on top of their cancer [34–36].