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

Abstract

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][2006][2007][2008][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 ¼ 0.03) and more often high-risk disease (p ¼ 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.

Time from incident primary cancer until recurrence or second primary cancer: Risk factors and impact in general practice

“…However, thorough patient education in symptoms of CR, and how to respond to symptoms, is evidently a necessity to ensure timely detection of CR (Francken et al, 2007). Patients diagnosed with CR as interval events due to symptom presentation are found to have higher educational level (Jeppesen et al, 2017). Patients diagnosed with CR as interval events due to symptom presentation are found to have higher educational level (Jeppesen et al, 2017).…”

Patient‐initiated follow up affects fear of recurrence and healthcare use: a randomised trial in early‐stage endometrial cancer

“…It is unknown whether some women in the intervention group experienced symptoms to which they did not react, although we have no reason to suspect this. In a previous study, we concluded that women diagnosed with recurrence at an interval visit because of symptoms were more likely to have high‐risk disease and a higher educational level. Other studies have identified risk factors for delayed presentation of symptoms, including older age, lower socio‐economic status, atypical symptom types, comorbidity and lack of symptom awareness.…”

“…Hence, the majority of these women would never experience recurrence and it is estimated that only two in 1000 would potentially benefit from follow up . In addition, routine follow up could delay recurrence diagnosis, because patients postpone seeking help until the next scheduled visit …”

Re: Patient‐initiated follow up affects fear of recurrence and healthcare use: a randomised trial in early‐stage endometrial cancer

“…Second, the authors do not mention the fact that in women with asymptomatic recurrences only 39% had extravaginal recurrences, as stated in their earlier article, Jeppesen et al Morice et al., who included 390 women in their study, found that three out of five women with asymptomatic recurrences had a vaginal recurrence …”