Elsevier

Gynecologic Oncology

Volume 103, Issue 2, November 2006, Pages 709-713
Gynecologic Oncology

Cost-effectiveness of routine vaginal cytology for endometrial cancer surveillance

https://doi.org/10.1016/j.ygyno.2006.05.013Get rights and content

Abstract

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 2134 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 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.

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.

Section snippets

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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