New Guideline for Surveillance of Gynecologic Cancers

Nick Mulcahy

June 02, 2011

June 2, 2011 — For the first time, the Society of Gynecologic Oncology (SGO) has issued expert recommendations for gynecologic cancer surveillance. The document was published in the June issue of the American Journal of Obstetrics & Gynecology.

The guidelines were created with primary care providers — internists, family practitioners, and gynecologists — especially in mind, said the lead study author, Ritu Salani, MD, MBA, assistant professor, Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus.

"This is for patients who completed treatment and are returning to their primary care provider," she told Medscape Medical News.

The guidelines, which review the most recent data on surveillance for gynecologic cancer recurrence in women who have had a complete response to therapy, hold some potentially practice-changing surprises, said Dr Salani.

"Before reviewing the literature, I was not aware of the low efficacy of Pap tests for gynecologic cancer surveillance," she said, offering an example of a potentially practice-changing insight in the new guidelines.

Papanicolaou (PAP) tests have "very low rates" of detection of recurrent disease for endometrial and cervical cancer but are "commonly" performed in these patients, said Dr Salani. The tests are also "unnecessarily" performed in ovarian cancer.

In the new guidelines, Pap tests are not indicated for surveillance in endometrial, cervical, or ovarian cancer patients. "I think that's going to be a practice change for a lot of physicians," she said.

What are recommended as surveillance techniques and monitoring intervals for endometrial, ovarian, nonepithelial ovarian, cervical, vulvar, and vaginal cancers?

For the most part, the recommended surveillance for all of the gynecologic cancers consists of a detailed review of symptoms and physical examination at office visits, the intervals of which vary depending on the cancer and years of survival. This method "results in the detection of most recurrences," write Dr Salani and her colleagues.

For example, the guidelines point out that for endometrial cancer, symptoms, as a method of recurrence detection, provide a detection rate of 41% to 83% of cases. And physical examination provides a detection rate of 35% to 68% for endometrial cancer. In contrast, cytologic evidence/Pap test (0%-7%), chest radiograph (0%-20%), and cancer antigen (CA) 125 level (15%) have much lower detection rates for endometrial cancer and are thus neither clinically effective nor cost-effective, say the study authors.

"The use of additional modalities has not been well-supported," they say about imaging, biomarker tests, and other methods. "Individualized treatment plans should be made with each patient," they write.

Dr Salani summarized the most important elements of surveillance. "Taking a thorough history, performing a thorough examination, and educating cancer survivors about concerning symptoms are the most effective methods for the detection of gynecologic cancer recurrences. There is very little evidence that routine cytologic procedures or imaging improves the ability to detect gynecologic cancer recurrence at a stage that will impact cure or response rates to salvage therapy," she said in a press statement.

One of the goals of the new guidelines is to help clinicians eliminate cost-ineffective testing, acknowledged Dr Salani.

"The goal of follow-up evaluation for the detection of recurrent disease requires both clinical and cost-effectiveness," she said.

The guideline authors say that surveillance should seek to maximize the chance of benefit with a minimum risk of harm — at an acceptable cost.

What About the NCCN?

The current guidelines of the National Comprehensive Cancer Network (NCCN) cover much of the same territory as the new SGO document, admitted Dr Salani. However, the new recommendations are "more comprehensive in the review of the literature," said Dr. Salani.

The guidelines also are issued at a time in which more and more women with gynecologic cancers are survivors. Although gynecologic cancers account for only 10% of all new cancer cases in women, these cancers account for 20% of all female cancer survivors, the study authors pointed out.

Because long-term survival is now more common, it is increasingly important to detect recurrence, say the study authors.

Thus, the Clinical Practice Committee of the SGO created its new clinical document outlining their expert recommendations for cancer surveillance.

"Prevention is a big part of our mission as a collective membership," said SGO president John Curtin in a press statement. "By sharing our best knowledge regarding surveillance of patients who have had a gynecologic malignancy with the medical team in the best position to detect a recurrence, we are helping our patients who do have a recurrence obtain appropriate care as soon as possible."

Am J Obstet Gynecol. 2011;6:466-478. Full text

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