REGULAR ARTICLESurveillance for Recurrent Endometrial Carcinoma: Development of a Follow-up Scheme
Abstract
We examined the method of diagnosis for a group of women who developed recurrent endometrial carcinoma after being rendered clinically disease-free by primary therapy. We then used this information to develop a follow-up protocol that maximizes the chances for detecting recurrence while minimizing surveillance costs. In brief, we evaluated all women with clinical stage I endometrial carcinoma who were treated with curative intent during a 7-year period. Medical records were examined to identify patients who had tumor recurrence diagnosed during follow-up in our clinic. Clinical presentation, time to diagnosis, method of diagnosis, and subsequent outcome were analyzed. This information was used to design a surveillance protocol for further clinical testing. Ninety-six percent of 412 women treated between 1985 and 1992 were clinically disease-free after primary surgery with or without adjuvant treatment. Median follow-up is 64 months. Overall, 44 patients (11%) developed recurrent cancer after a median interval of 14.8 months. Complete follow-up data were available for the 39 patients who had their recurrence diagnosed in our clinic. The cumulative percentages of diagnosed recurrences were 51, 82, and 95% at 12, 24, and 36 months, respectively. Sixteen women (41%) had symptoms that led to the identification of recurrent disease. Recurrences in the 23 asymptomatic women (59%) were diagnosed by physical examination in 13, chest radiograph in 1, serum CA-125 level in 6, vaginal cytology in 1, and computed tomography in 2. Only 1 patient with a grade 1 adenocarcinoma had treatment failure. At the time of analysis, 30 patients with recurrent cancer had died of disease, 6 were alive with disease, and 3 were free of disease. A surveillance scheme consisting of an examination, vaginal cytology, and serum CA-125, combined with immediate evaluation of symptomatic women, could be expected to identify 95% of recurrences. Such an approach, performed at 6- to 12-month intervals for 3 years, could be limited to patients with grade 2–3 adenocarcinomas or variant cell types. However, given the high failure rate of salvage therapy, the prompt detection of recurrence may not convey a survival advantage.
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Can a symptom checklist improve the triage of patients following successful endometrial cancer treatment?
2020, Gynecologic Oncology ReportsEndometrial cancer (EC) is the fifth most common cancer in women in developed countries. Clinical practice guidelines recommend patients should be followed-up every 3–6 months after primary treatment of EC. Evidence suggests that 40% to 80% of patients develop symptoms prior to being diagnosed with EC recurrence, however which symptoms are key remains unclear. We previously conducted a comprehensive literature review and developed a questionnaire on patient-reported symptoms associated with EC recurrence.
This is a brief communication on a pilot prospective cohort study among 120 Australian patients who completed primary treatment for EC in the past three years. The study showed 47 of the 120 patients (39.2%) self-reported at least one symptom, four of whom (3.3%) were diagnosed with a recurrence. Back or lumbar pain (P = 0.012), vaginal bleeding (P < 0.001), and lethargy, fatigue, exhaustion or tiredness (P = 0.002) were significantly associated with the development of EC recurrence.
The checklist will be further validated as part of a randomized controlled clinical trial to confirm the observed relationship between symptoms and the development of EC recurrence.
Change in hazard rates of recurrence over time following diagnosis of endometrial cancer: An age stratified multicentre study from the FRANCOGYN group
2018, European Journal of Surgical OncologyPredicting the pattern of recurrence can aid in the development of targeted surveillance and treatment strategies. The objectives of this study were to identify patterns of recurrence in women with operable endometrial cancer (EC) and to identify high-risk periods for recurrence in function of age.
The data of 1153 women who received primary surgical treatment for stage I-III EC between January 2001 and December 2013 were abstracted from a prospectively maintained multicentre database. The time to first recurrence was calculated from the date of diagnosis, and the associated hazard function was examined to determine the peak risk period of recurrence. We categorized age at diagnosis as <65 and ≥ 65 years old and analysed the hazard rate (HR) by stratifying age groups.
Women with EC aged ≥65 years maintain a significant recurrence rate during follow-up whatever the stratification (locoregional recurrence, distant recurrence, ESMO/ESGO/ESTRO subgroup). Multivariable Cox proportional hazard regression showed that the increased risk of recurrence of EC was associated with advanced age, advanced disease ESMO/ESGO/ESTRO subgroup but not with initial treatment received.
The annual HR of recurrence is not uniformly distributed over time but is dynamic and markedly determined by prognostic factors at diagnosis.
The future for follow-up of gynaecological cancer in Europe. Summary of available data and overview of ongoing trials
2017, European Journal of Obstetrics and Gynecology and Reproductive BiologyAfter completing treatment, most patients follow a pre-determined schedule of regular hospital outpatient appointments, which includes clinical examinations, consultations and routine tests. After several years of surveillance, patients are transferred back to primary care. However, there is limited evidence to support the effectiveness and efficiency of this approach.
This paper examines the current rationale and evidence base for hospital-based follow-up after treatment for gynaecological cancer. We investigate what alternative models of care have been formally evaluated and what research is currently in progress in Europe, in order to make tentative recommendations for a model of follow-up.
The evidence base for traditional hospital based follow-up is limited. Alternative models have been reported for other cancer types but there are few evaluations of alternative approaches for gynaecological cancers. We identified five ongoing European studies; four were focused on endometrial cancer patients and one feasibility study included all gynaecological cancers. Only one study had reached the reporting stage. Alternative models included nurse-led telephone follow-up and comparisons of more intensive versus less intensive regimes. Outcomes included survival, quality of life, psychological morbidity, patient satisfaction and cost effectiveness of service.
More work is needed on alternative strategies for all gynaecological cancer types. New models will be likely to include risk stratification with early discharge from secondary care for early stage disease with fast track access to specialist services for suspected cancer recurrence or other problems.
Patterns and utility of routine surveillance in high grade endometrial cancer
2015, Gynecologic OncologyTo evaluate surveillance methods and their utility in detecting recurrence of disease in a high grade endometrial cancer population.
We performed a multi-institutional retrospective chart review of women diagnosed with high grade endometrial cancer between the years 2000 and 2011. Surveillance data was abstracted and analyzed. Surveillance method leading to detection of recurrence was identified and compared by stage of disease and site of recurrence.
Two hundred and fifty-four patients met the criteria for inclusion. Vaginal cytology was performed in the majority of early stage patients, but was utilized less in advanced stage patients. CA-125 and CT imaging were used more frequently in advanced stage patients compared to early stage. Thirty-six percent of patients experienced a recurrence and the majority of initial recurrences (76%) had a distant component. Modalities that detected cancer recurrences were: symptoms (56%), physical exam (18%), surveillance CT (15%), CA-125 (10%), and vaginal cytology (1%). All local recurrences were detected by symptoms or physical exam findings. While the majority of loco-regional and distant recurrences (68%) were detected by symptoms or physical exam, 28% were detected by surveillance CT scan or CA 125. One loco-regional recurrence was identified by vaginal cytology but no recurrences with a distant component detected by this modality.
Symptoms and physical examination identify the majority of high grade endometrial cancer recurrences, while vaginal cytology is the least likely surveillance modality to identify a recurrence. The role of CT and CA-125 surveillance outside of a clinical trial needs to be further reviewed
Follow-up of endometrial cancer
2014, Bulletin du CancerPeu de choses ont évolué concernant la surveillance du cancer de l’endomètre en l’absence d’études prospectives bien menées. La plupart des récidives surviennent dans les trois ans suivant le traitement et sont symptomatiques. Aucun examen complémentaire n’est préconisé à titre systématique en dehors de symptômes. En cas de suspicion de récidive, le TEP scanner semble être l’examen le plus sensible et le plus spécifique. Curieusement, aucune donnée n’existe concernant l’IRM. Les preuves sont insuffisantes pour conclure sur la pertinence et l’impact sur la survie de la fréquence des visites de suivi. Un suivi adapté au risque considéré de récidive nécessite d’être discuté. L’information et la sensibilisation des patientes aux symptômes justifiant un avis spécialisé doivent être un objectif majeur de la surveillance.
Available data on appropriate follow-up in endometrial cancer highlight the need of well-conducted studies. Most recurrences tend to occur within three years and involve symptoms. Routine tests are not advocated without symptoms. In case of suspicious recurrence, TEP/CT seems to be the most sensitive and specific method. There is limited evidence to decide whether follow-up schedules with multiple visits result in survival benefits. An appropriate follow-up should be discussed based upon the risk of recurrence. Counselling on the potential symptoms of recurrence should be a major aim.
Post treatment surveillance of type II endometrial cancer patients
2013, Gynecologic OncologyCitation Excerpt :The site of relapse was the most important predictor of survival in their study. Other studies have similarly questioned the value of early recurrence detection and have validated the high failure rate of salvage therapy in endometrial cancer recurrence of all subtypes [11,17,18]. This raises the question of whether surveillance for endometrial cancer, at least for low-risk endometrial cancer, should be relinquished altogether.
There are few studies analyzing surveillance for Type II endometrial cancer recurrence. Our objective was to determine the types of post treatment surveillance tests performed in our institution and the efficacy of these tests in detecting recurrence in type II endometrial cancer patients.
One hundred and thirty six cases of type II endometrial cancers at Cedars-Sinai Medical Center from January of 2000 to August of 2011 were identified and 106 patients met inclusion criteria. Medical charts were reviewed for surveillance methods and number of follow up visits. For patients who underwent a recurrence of disease, the surveillance method utilized for detection was documented.
Forty-seven of the 106 (44%) patients developed recurrence with a mean progression free interval of 11 months. All patients had a history and physical at each surveillance visit, 78% had Pap testing, 57% had CA-125 levels drawn, 59% had CT (computed tomography) scans done, 6% had PET (positron emission tomography) scans done for surveillance. In our cohort, recurrence was detected by symptoms in 16, by CA-125 in 11, by physical exam in 7, by CT scan in 12, and by PET scan in one patient. No patients had recurrence detected by vaginal cytology.
Although performed in the majority of patients, Pap testing did not detect any recurrences within this cohort. History and physical exam detected the most recurrences. These findings suggest that educating patients about relevant symptoms and performing thorough follow-up exams may be the most important aspects of detecting type II endometrial cancer recurrence.