A critical evaluation of follow-up of women treated for endometrial adenocarcinoma

How Do We Follow Up Patients With Endometrial Cancer?

PURPOSE OF REVIEW

In this review, we present the existing evidence regarding follow-up care after endometrial cancer, including content of follow-up and type of provider. We furthermore discuss the future perspectives for follow-up care and research in the field.

RECENT FINDINGS

Recently published randomized controlled trials show that nurse-led telephone follow-up and patient-initiated follow-up are feasible alternatives to routine hospital-based follow-up. No randomized or prospective study has evaluated the effect of routine follow-up on survival. Hence, current knowledge is derived from retrospective studies with the inherent risk of bias. The most important method for recurrence detection is a review of symptoms. There is no evidence to support a survival benefit from the use of routine physical examinations, additional tests, or imaging. One in three of the women attending hospital-based follow-up experience unmet needs, and alternative models for follow-up focused on survivorship care and empowerment should be tested.

Stratification of risk groups according to survival after recurrence in endometrial cancer patients

To identify prognostic factors for overall survival after recurrence (OSr) in endometrioid endometrial cancer (EC) patients and categorize patient subgroups that predict outcomes using these variables.Consecutive patients with recurrent endometrioid EC seen in our institution from 1989 to 2013 were retrospectively reviewed. Cox regression models were used to identify the clinicopathological factors associated with OSr. By summing scores proportionate to the hazard ratio (HR) for each significant variable, we stratified patients into 3 risk groups.Enrolled patients (n = 108) had a median time to recurrence of 15 (range, 3-163) months after initial treatment and a median OSr of 22 (range, 1-207) months. Twenty patients (18.5%) had locoregional recurrence, and 88 (81.5%) distant. One hundred three patients underwent salvage therapy; 51 (47.2%) received chemotherapy only, 22 (20.3%) received radiotherapy either alone or combined with chemotherapy, and 29 (26.9%) underwent salvage cytoreductive surgery. Multivariate regression analysis revealed that time to relapse after initial treatment, cancer antigen-125 level at recurrence, and the number of recurrent lesions were independent predictors of OSr. Incorporating these factors, we stratified patients into low-risk (n = 19), intermediate-risk (n = 43), and high-risk (n = 46) groups. The likelihood of cancer-specific death was higher in both the high-risk (HR = 8.948, 95% confidence interval [CI] = 3.498-22.893, P < .001) and the intermediate-risk (HR = 2.619, 95% CI = 1.002-6.850, P = .05) groups compared with the low-risk group.Incorporating 3 variables, recurrent endometrioid EC patients with a broad spectrum of outcome could be stratified according to OSr. This model may help predict outcomes in recurrent EC patients.

Detection of recurrence in early stage endometrial cancer - the role of symptoms and routine follow-up

BACKGROUND

Considerable controversy remains as to the optimal organization of endometrial cancer follow-up.

AIM

To evaluate the relationship between the way recurrence was detected and survival after treatment for endometrial cancer. Further, to identify characteristics associated with a pre-scheduled examination in women with symptomatic recurrence.

MATERIAL AND METHODS

All women with early stage endometrial cancer during 2005-2009 were included in a population-based historical cohort derived from the Danish Gynecological Cancer Database. Women diagnosed with recurrence within three years after primary surgery and the mode of recurrence detection were identified from hospital charts: asymptomatic recurrence detected at regular follow-up, symptomatic recurrence detected at regular follow-up or symptomatic recurrence detected in between follow-up. Survival of women with symptomatic and asymptomatic disease was compared. Furthermore, characteristics associated with self-referral as compared to presenting symptoms at regular follow-ups were identified using univariate analyses.

RESULTS

In total, 183 cases of recurrence (7%) were identified in the cohort of 2612 women. Of these, 65.5% were symptomatic with vaginal bleeding as the most prevalent symptom. Asymptomatic women had a significantly better three-year survival rate compared to symptomatic women (80.3% vs. 54.3%, p < 0.01). A total of 2.3% of the entire population had an asymptomatic recurrence. Women diagnosed at a pre-scheduled visit due to symptoms had a higher educational level (p = 0.03) and more often high-risk disease (p = 0.02) than symptomatic women diagnosed at regular follow-up.

CONCLUSION

Early stage endometrial cancer carries a low risk of recurrence. Survival appears to be superior in asymptomatic patients, but length-time bias, i.e. the effect of aggressive tumor biology in symptomatic recurrences, may bias results in non-randomized controlled trials. Well educated patients with symptoms of recurrence more often sought medical attendance compared to less educated counterparts. This should be considered if patient-initiated follow-up is the standard care.

Survival Outcomes Improved in Contemporary Cohort of Patients With Pelvic or Abdominal Recurrence After Treatment for Stage I/II Endometrial Carcinoma

OBJECTIVES

Pelvic and abdominal recurrences in stage I/II endometrial carcinoma are associated with poor outcomes, yet prognostic factors for survival after recurrence are not well described. Herein, we identify patients with pelvic or abdominal recurrence after surgery for stage I/II endometrial carcinoma and describe symptoms at presentation, prognostic factors, and salvage treatment toxicity.

MATERIALS AND METHODS

This is a retrospective cohort of 20 consecutively treated patients with recurrence after treatment for stage I/II endometrial carcinoma followed by our Institution's Radiation Oncology Department from 1998 to 2015.

RESULTS

The median time to pelvic or abdominal recurrence was 18.1 months (range, 4.2 to 59.6 mo), with 50% of recurrences at extranodal locations. Two-year progression-free survival (PFS) was 44% and 2-year overall survival (OS) was 82%. Salvage treatments varied widely, including chemotherapy and radiotherapy (RT) (7), surgery and RT (3), and surgery, chemotherapy, and RT (3). On univariate analysis of PFS, symptoms at recurrence (P=0.04) and extranodal recurrences (P<0.01) were found to be statistically significant negative prognosticators for PFS. On univariate analysis of OS, increasing age at recurrence and presence of symptoms were found to have a trend toward statistically significant association with negative OS outcomes (P=0.08 and P=0.10, respectively).

CONCLUSIONS

Our study demonstrates that long-term survival for pelvic or abdominal recurrences is possible with curative salvage therapy. The presence of symptoms is a negative prognostic factor in treatment outcome, and imaging may be effective for diagnosis in symptomatic and asymptomatic patients. Larger studies need to be performed to confirm these findings.

An overview of uterine cancer and its management

Endometrial cancer is increasingly common in affluent Western countries, largely owing to the growing obesity of those populations. There are two recognized types of endometrial cancer: Type I is more common and is associated with obese postmenopausal women and comprises approximately 80% of all endometrial cancers; Type II describes a woman who is often younger and thinner with a more aggressive histologic type that is nonestrogen dependent, of either serous or clear cell histology, and consists of a more aggressive clinical course and results in poorer prognosis. As the majority of patients with endometrial cancer present with symptoms and have early disease, screening is unlikely to be cost effective or reduce the mortality rate. However, surveillance of high-risk populations is a different proposition. Patients who may benefit from routine surveillance include those with a family history of endometrial cancer, a history of hormone replacement therapy with less than 12-14 days of progestogens, long-term use of tamoxifen, hereditary nonpolyposis colorectal cancer family syndrome, Cowden's syndrome, Peutz-Jeghers syndrome, a history of breast cancer and obesity. Most patients with endometrial cancer are offered surgery as first-line therapy. The standard surgical procedure should be an extrafascial total hysterectomy with bilateral salpingo-oophorectomy. Adnexal removal is also recommended, even if the adnexa appear normal, as they may contain micrometastases. The safety of a laparoscopic approach in the surgical management of uterine cancer has not yet been demonstrated in prospective randomized trials, therefore, the field awaits the Gynaecologic Oncology Group's prospective Lap-2 study. While post-treatment follow-up guidelines vary between institutions and countries, in general, patients at high risk of recurrence are followed closely every 3-4 months for the first year or two, then every 6 months to complete 5 years of follow-up.

Could Different Follow-Up Modalities Play a Role in the Diagnosis of Asymptomatic Endometrial Cancer Relapses?: An Italian Multicentric Retrospective Analysis

Objective

To determine current practice and to assess the value of routine follow-up procedures for endometrial cancer surveillance. To discuss whether such procedures are feasible and effective to identify asymptomatic recurrences and describe the pattern of relapse detected by procedures.

Methods

The records of 282 consecutive women with recurrent endometrial cancer treated from 1986 to 2005 were retrospectively collected in 8 Italian institutions. Primary disease, clinical history, and recurrence features and data were analyzed.

Results

Thirty-five (12.4%) of 282 patients had recurrence in vaginal vault, 51 patients (18.0%) had recurrence in central pelvis, 14 patients (4.9%) had recurrence in pelvic wall, and 39 patients (13.8%) had recurrence in lymph nodes. One-hundred twenty-eight patients (45.3%) showed a distant relapse, whereas 15 patients (5.3%) developed both distant relapse and local relapse. The site of relapse influenced survival because the patients with vaginal vault recurrences lived significantly longer than the patients with recurrences in other sites. Eighty (28.4%) of the 282 patients became symptomatic and anticipated the scheduled visit, 37 (13.1 %) of the patients reported their symptoms during the follow-up meeting, and 165 (58.5 %) of the patients were asymptomatic and the diagnostic path was introduced by a planned visit or examination. Among the asymptomatic patients, the first procedure that led to further examinations was clinical visit alone for 60 (36.4%) of 165 patients, imaging for 103 patients (62.4%), and cytologic examination for 2 patients (1.2%). Symptoms at recurrence can predict survival: patients with an asymptomatic recurrence had a median survival time from relapse of 35 months versus 13 months if they had a symptomatic repetition (P = 0.0001).

Conclusions

Follow-up after endometrial cancer treatment varies in Italy. In this retrospective study, women with asymptomatic recurrence have shown a better clinical outcome compared with those with symptomatic relapse. The optimal approach is actually unknown, and guidelines comparing follow-up protocols have not been established. Prospective cost-effectiveness studies are needed.

Follow-up routines in gynecological cancer - time for a change?

OBJECTIVE

To determine current practice of follow-up of Norwegian gynecological cancer patients, and to review available randomized controlled trials (RCTs) in gynecologic, breast and colorectal cancer patients in order to discuss whether such studies are feasible in gynecological cancer patients.

DESIGN

A combined questionnaire study and a systematic review of RCTs in follow-up of gynecological, breast, and colorectal cancers.

POPULATION

Gynecological, breast, and colorectal cancer patients.

METHODS

A questionnaire regarding follow-up routines was mailed to 31 gynecological departments in Norway. A systematic search on MEDLINE, EMBASE, and the Cochrane Library databases was conducted to identify RCTs in follow-up of breast, colorectal, and gynecological cancers.

RESULTS

The questionnaire study showed that the number of controls varied from eight to 16 during the first five years' post-treatment. Routine investigations such as chest X-ray and cytology were frequently used in endometrial and cervical cancer. All departments used CA-125 in follow-up of ovarian cancer patients. Reviewing the literature, 19 RCTs of varying methodological quality were identified for colorectal and breast cancers, and none for gynecologic cancer. Different follow-up models were compared, and most studies concluded that there were no significant differences in the detection of recurrence, overall survival, and quality of life between the studied groups.

CONCLUSIONS

Follow-up routines after gynecological cancer vary in Norway. The optimal approach is unknown and RCTs comparing follow-up protocols are missing. Studies of breast and colorectal cancer patients show that studies on follow-up strategies are feasible but sufficient sample size and observation time are important.

Surveillance procedures for patients treated for endometrial cancer: a review of the literature

OBJECTIVES

The aim of this review was to analyze the role of follow-up in patients treated for endometrial cancer and to provide some compelling issues that may contribute to improve daily practice while waiting for evidence-based guidelines.

METHODS/MATERIALS

A literature search has been conducted in MEDLINE database using key words "endometrial neoplasms" and "follow up".

RESULTS

Endometrial cancer represents the most common gynecologic malignancy after breast cancer. The overall recurrence rate is 13% and correlates with prognostic factors of the primary tumor. The anatomic sites of endometrial cancer relapse are mostly equivalently distributed between local (pelvic) and distant (abdominal and chest). Most endometrial cancer recurrences are symptomatic, even if vaginal vault relapses represent a particular setting of a more frequently asymptomatic disease. Most of endometrial cancer recurrences occur within 3 years since diagnosis of primary tumor. Long-term surveillance programs are mainly addressed to the early detection of recurrence, the rationale of follow-up being that an earlier diagnosis of relapse correlates with lower morbidity and mortality rates. Adjunctive objectives of routine follow-up are identification of treatment complications and detection of possible second tumors associated with endometrial cancer.

CONCLUSIONS

No rationale (examination sensitivity/sensibility, cost-effectiveness, or patient's survival benefit) is available today for any particular follow-up protocol; follow-up procedures should probably be tailored according to different prognostic factors; only physical examination, including pelvic-rectal examination, showed some utility in detecting recurrence. In this uncertain setting, follow-up interval should be defined with the consideration of the patient's will.

Pattern of failure and value of follow-up procedures in endometrial and cervical cancer patients

OBJECTIVE

The aim of this study was to evaluate the outcome benefit of follow-up protocols for patients with recurrent endometrial and cervical cancer.

METHODS

A retrospective review on patients primarily treated at the Division of Gynecologic Oncology, University of Brescia, was performed. We focused our attention on recurrent patients and we evaluated the pattern of relapse and the presence of symptoms or signs of disease at recurrence and evidence of disease on routine follow-up test or visits.

RESULTS

The vast majority of recurrences occurred within the first 3 years after primary treatment (78% and 87% in endometrial and cervical cancers, respectively). A better overall survival from relapse was observed when vaginal relapse was compared to other sites in endometrial cancer patients and when pelvic recurrence was compared to distant sites in cervical cancer cases. Recurrent endometrial and cervical cancer patients were symptomatic in 52% and 65% of cases, respectively. Among asymptomatic recurrent endometrial cancer cases, pelvic examination, abdominal or pelvic ultrasound and CT could detect 92% of relapses, while the vast majority of cervical cancer relapses could be diagnosed by pelvic examination and/or CT (85%).

CONCLUSION

Endometrial cancer patients showed a significantly better prognosis when the recurrence was detected during follow-up visits, thus supporting the real advantage of our surveillance programs, while no statistically significant differences were found in survival of cervical cancer patients between the symptomatic and the asymptomatic group.

Professionals’ and patients’ views of routine follow-up: a questionnaire survey

Traditionally, women who have been treated for a gynecological cancer have undergone long-term follow-up by hospital doctors. Recently, there has been interest in alternative models of follow-up, including nurse-based review. The project compares patients' and professionals' views of follow-up. A questionnaire was completed by 96 women attending routine follow-up clinics and by 32 professionals involved in delivering follow-up. A large majority of women (82/96, 92%) and professionals (25/34, 73%) thought that follow-up should be provided by a hospital doctor. However, professionals were more likely to think that specialist nurses and general practitioners should be involved in the provision of follow-up (P < 0.01). Professionals thought that the most important part of the follow-up visit was the consultation, whereas women thought it was the examination (P < 0.001). Women thought that detection of recurrence was the most important reason for continuing surveillance, whereas professionals regarded addressing patients' concerns as the primary reason for follow-up (P < 0.001). We conclude that the views of women undergoing follow-up after gynecological cancer differ significantly from the professionals providing follow-up care. These views must be considered when developing alternative follow-up strategies.

Cost-effectiveness of routine vaginal cytology for endometrial cancer surveillance

OBJECTIVE

To examine the cost-effectiveness of routine vaginal cytology in detecting asymptomatic isolated vaginal recurrence during post-treatment endometrial cancer surveillance.

METHODS

All patients treated for endometrial cancer between 7/1/97 and 6/30/2005 were retrospectively identified from the tumor registry database. Clinico-pathologic characteristics and surveillance testing data were abstracted from medical records. The total number of Pap tests performed during surveillance or until the time of recurrence was calculated and charges associated with detecting asymptomatic isolated vaginal recurrence assigned based on 2005 Pap test costs adjusted retroactively using the consumer price index.

RESULTS

Three hundred seventy-seven patients met inclusion criteria: FIGO Stage I=63.7%, Stage II=10.1%, Stage III=18.8%, Stage IV=7.4%. The median follow-up time was 30.4 months. A total of 2,134 Pap tests were collected during the study interval (median 5, mean 5.76 samples/patient). Endometrial cancer recurred in 61 patients (16.2%); 11 patients (2.9%) had an isolated vaginal recurrence. Seven isolated vaginal recurrences were detected by physical examination alone, and 2 were detected by interval computed tomography. An asymptomatic isolated vaginal recurrence was detected by routine vaginal cytology in 2 of 377 patients (0.5%). Detection of each asymptomatic vaginal recurrence required 1067 Pap tests, generating 44,049 US dollar in cumulative charges.

CONCLUSIONS

As a surveillance test for endometrial cancer recurrence, routine vaginal cytology is costly, inefficient, and benefits less than 1% of patients. Elimination or reduction in the use of vaginal cytology for this purpose offers an opportunity for significant cost savings in gynecologic oncology health care expenditure.

Follow-up after primary therapy for endometrial cancer: a systematic review

OBJECTIVE

To determine the optimum follow-up of women who are clinically disease-free following potentially curative treatment for endometrial cancer.

METHODS

A systematic search of MEDLINE, EMBASE and the Cochrane Library databases (1980 to October 2005) was conducted. Data were pooled across trials to determine overall estimates of recurrence patterns.

RESULTS

Sixteen non-comparative retrospective studies were identified. The overall risk of recurrence was 13% for all patients and 3% or less for patients at low risk. Approximately 70% of all recurrences were symptomatic, and 68% to 100% of recurrences occurred within approximately the first 3 years of follow-up. No reliable differences in survival were detected between patients with symptomatic or asymptomatic recurrences nor were differences in patient outcomes reported by type of follow-up strategy employed. Detection of asymptomatic recurrences ranged from 5% to 33% of patients with physical examination, 0% to 4% with vaginal vault cytology, 0% to 14% with chest X-ray, 4% to 13% with abdominal ultrasound, 5% to 21% with abdominal/pelvic CT scan, and 15% in selected patients with CA 125.

CONCLUSIONS

There is limited evidence to inform whether intensive follow-up schedules with multiple routine diagnostic interventions result in survival benefits any more or less than non-intensive follow-up schedules without multiple routine diagnostic interventions. Routine testing seems to be of limited benefit for patients at low risk of disease. Most recurrences tend to occur in high risk patients within 3 years, and most recurrences involve symptoms. The most appropriate follow-up strategy is likely one based upon the risk of recurrence and the natural history of the disease. Counseling on the potential symptoms of recurrence is extremely important because the majority of patients with recurrences were symptomatic. A proposed routine follow-up schedule is offered.

The role of routine follow-up after gynecological malignancy

The objective of this article was to determine the evidence base for routine follow-up after gynecological malignancy. Only articles with a survival analysis were included. Relevant articles were identified by a comprehensive literature search of the main biomedical databases, hand searching of references of selected articles, and expert spotting of relevant journals and proceedings of international meetings. A two-stage extraction of data was undertaken. No prospective trials were identified. Twenty-nine retrospective case series analyses and one poster presentation met the inclusion criteria. Eight articles and one letter on endometrial cancer, six articles and one poster presentation on cervical cancer, and two articles in vulval cancer were reviewed. Only one article in endometrial cancer showed any survival benefit from routine follow-up, but it was of very poor methodologic quality. Two articles found a survival benefit from routine follow-up after cervical cancer. The two articles on vulval cancer did not find any survival benefit from routine review. There is no prospective research on the benefits of routine follow-up after gynecological cancer. Retrospective evidence calls in to question the benefit of universal follow-up. Prospective research is urgently needed.