Risk Specific Follow-up for Endometrial Carcinoma Patients
Abstract & Commentary
Synopsis: Patients at low risk of recurrence after primary treatment for endometrial cancer do not benefit from routine follow-up.
Source: Shumsky AG, et al. Gynecol Oncol 1997; 65:379-382.
Shumsky and colleagues conducted a retrospective review of endometrial cancer patients to identify risk factors for recurrence. Based on a profile of risk factors, women were classified as either low- or high-risk for recurrence (median follow-up time, 70 months). The classification system was then validated on a subsequent cohort. The purpose of the study was to propose a risk-specific follow-up protocol for endometrial cancer patients. Surgical stage, histologic grade, and histologic type were found to be significant predictors of recurrence (P = 0.001). In the original cohort, patients with stage 1A, grade 1 or 2, or stage 1B, grade 1 adenocarcinoma, had a recurrence rate of 4/98 (4.1%). The remaining high-risk patients had a recurrence rate of 37/158 (23.4%). When these criteria were applied to the subsequent cohort, the rates were similar: low-risk 3/113 (2.7%) and high-risk 30/140 (21.4%). Seventy-five percent of recurrences occurred within three years of diagnosis, and the majority were heralded by site-specific symptoms. Shumsky et al conclude that women with endometrial cancer could be successfully classified for low- or high-risk of recurrence. They proposed that low-risk patients not be maintained on routine follow-up and that a tailored schedule of follow-up be used for high-risk patients. They felt that these changes would serve patients more appropriately and use health care resources more efficiently.
COMMENT BY DAVID M. GERSHENSON, MD
Managed health care has caused all of us to re-examine our mode of practice and the rationale for each decision as never before. In areas where managed care plans are mandating bad medical practices to reduce cost, it is incumbent on us as physicians to challenge such mandates. There are a growing number of examples of such, including legislative changes in the minimum number of post partum, inpatient days. On the other hand, surveillance of oncology patients after completion of primary therapy is an area that required close scrutiny. Historically, justification for the frequency of follow-up visits and the type of tests ordered has been lacking and largely empiric. In the area of surveillance, evidence-based information can be obtained and used to formulate appropriate guidelines for follow-up for each type of malignancy. Data such as time and location of recurrence, presence or absence of symptoms, method of diagnosis, and ultimate outcome are important in developing these guidelines. Of course, post-treatment surveillance serves purposes other than simply detecting and treating recurrent disease. It also serves to diagnose and treat complications of therapy, to provide psychological support, and to provide routine health maintenance such as weight and blood pressure check, annual mammography, and vaginal cytology. We also have to realize that this study was conducted in Canada, where the health care system is somewhat different. Who should perform the recommended follow-upnurse practitioners, family practice physicians, gynecologists, or gyncologic oncologists? These issues remain unresolved and may differ from one area or region to the next. The rationale and goals for a study such as this one are appropriate, but more study is necessary to resolve many of these issues. Similar issues will be examined for virtually every major cancer.
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