Cost-effectiveness of routine vaginal cytology for endometrial cancer surveillance
Introduction
Endometrial cancer is the most common gynecologic malignancy in the United States, with an estimated 41,200 new cases and 7350 disease-related deaths anticipated in 2006 [1]. The overall 5-year survival rate in the U.S. for all patients with endometrial cancer is 84.4% [1]. Endometrial cancer is confined to the uterine corpus in over 70% of cases, and for this group of patients the 5-year survival rate is 96.1% [1], [2]. The risk of disease recurrence varies according to well defined risk factors but ranges from 13% to 17% in large reported series [3], [4]. As with most gynecologic cancers, intensive surveillance protocols to detect recurrent disease have traditionally been prescribed for women undergoing definitive treatment of endometrial cancer. In a 1992 study surveying gynecologic oncologists, Barnhill et al. reported that 100% of respondents recommended follow-up exams every 3 months for the first year of surveillance, 98% recommended follow-up every 4 months in the second year, and more than 85% of respondents recommended follow-up at least every 6 months thereafter until 5 years of surveillance had been completed [5]. More contemporary studies indicate that such intensive surveillance regimens are still commonly practiced in many centers [6], [7], [8], [9]. The rationale for intensive surveillance of patients definitively treated for endometrial cancer is based on the premise that early detection of an asymptomatic recurrence will translate into improved survival outcomes. Although this is a widely held belief, a number of studies have failed to demonstrate a significant survival advantage for patients whose recurrences are detected during routine follow-up visits compared to symptomatic patients presenting for interval evaluation [10], [11], [12], [13]. The current climate of escalating health care expenditures calls for a critical evaluation of the clinical and financial resources consumed by routine surveillance practices. The purpose of this study was to examine the cost-effectiveness of routine vaginal cytology for detecting asymptomatic isolated vaginal recurrence during post-treatment endometrial cancer surveillance.
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Methods
Approval to conduct this study was obtained from the Johns Hopkins Medical Institutions (JHMI) Clinical Research Committee and Joint Committee on Clinical Investigation. All patients undergoing clinical management for endometrial cancer between July 1, 1997 and June 30, 2005 were identified from a search of the JHMI tumor registry database. Patients were included if they had histologically confirmed endometrial cancer on hysterectomy specimen procured at JHMI. Patients undergoing hysterectomy
Results
Three hundred and seventy-seven patients who met study inclusion criteria were identified from the JHMI tumor registry database. Three hundred and twenty-six cases underwent hysterectomy at JHMI, and 51 cases underwent hysterectomy at an outside institution but received surveillance care at JHMI. The distribution of patients according to FIGO stage of disease was: Stage I = 63.7%, Stage II = 10.1%, Stage III = 18.8%, Stage IV = 7.4%. Atypical histologic subtypes (serous, clear cell) accounted for 11.1%
Discussion
Following definitive treatment for endometrial cancer, approximately 5% of patients will experience a local recurrence of disease confined to the vagina and central pelvis [4]. Of this subgroup, 73% to 89% of patients will have symptoms of vaginal bleeding and/or have a clinically apparent lesion in the vagina [7], [11], [14]. Taken together, these data indicate that roughly 1% of all endometrial cancer patients will be diagnosed with an asymptomatic vaginal recurrence. Despite this low
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2017, Gynecologic OncologyCitation Excerpt :Because most recurrences occur at the vaginal cuff, the use of vaginal cytology has been advocated; however, many gynecologic oncologists have challenged this recommendation [9,10–15,21]. Although studies have reported that cytologic evaluation detected 25% of all recurrences; the use of cytology alone in these studies detected only 3 of the 44 (7%) recurrences [10–15]. Additionally, in a study of women with early stage disease with a low recurrence risk, Salani et al. detected all recurrences based on symptoms/clinical findings and noted that cytology did not add any clinical benefit [17].