What’s the current value of a pelvic exam? Methods of recurrence detection for endometrial cancer in the era of telemedicine (112)

Abstract

<b>Objectives:</b> To determine the detection method for initial endometrial cancer recurrences at a tertiary-care, academic, referral center in the era of telemedicine. <b>Methods:</b> The institutional enterprise data warehouse (EDW) was queried for all endometrial cancer patients seen between January 1, 2010, and December 31, 2019. The electronic health record for each patient was reviewed to identify the number of patients who experienced an initial recurrence within the period, the method of recurrence detection, patient demographics, and cancer characteristics. <b>Results:</b> Over the 10-year period, 234 initial recurrences were identified. The mean age was 68.5 years. Among the cases, 95.3% were White and lived an average of 50.2 miles from our institution. Endometrioid histology was most common at 64.5% (<i>n</i>=151), followed by serous at 22.2% (<i>n</i>=52), carcinosarcoma at 9.0% (<i>n</i>=21) and clear cell at 4.3% (<i>n</i>=10). The stage breakdown was 55.5% stage I (<i>n</i>=130), 3.8% stage II (<i>n</i>=9), 23.9% stage III (<i>n</i>=56), and 16.7% stage IV (<i>n</i>=39). Of the endometrioid cancer recurrences identified, 50.3% were grade 1 (<i>n</i>=76), 34.4% grade 2 (<i>n</i>=52), and 15.2% grade 3 (<i>n</i>=23). Of the 234 initial recurrences detected, 8.5% (<i>n</i>=20) were diagnosed by asymptomatic pelvic exam during a surveillance visit. The most common factor leading to recurrence detection was patient-reported symptoms in 67.9% (<i>n</i>=159) of patients, followed by surveillance imaging in 11.1% (<i>n</i>=26), surveillance biomarker elevation in 9.0% (<i>n</i>=21), and incidental finding on imaging for other indications in 3.4% (<i>n</i>=8). For the low-risk subset of patients with stage I/II, grade1/2 endometrioid histology (<i>n</i>=99), factors leading to recurrence detection were 78.8% patient-reported symptoms (<i>n</i>=78), 2.0% surveillance imaging (<i>n</i>=2), 2.0% surveillance biomarkers (<i>n</i>=2), 14.1% asymptomatic pelvic exam (<i>n</i>=14), and 3.0% incidental (<i>n</i>=3). For the high-risk subset (stage III/ IV or any stage G3EC, UPSC, CS, CCC; <i>n</i>=135), the factors leading to recurrence detection were 60.0% patient-reported symptoms (<i>n</i>=81), 17.8% surveillance imaging (<i>n</i>=24), 14.1% surveillance biomarkers (<i>n</i>=19), 4.4% asymptomatic exam (<i>n</i>=6), and 3.7% incidental (<i>n</i>=5). The low-risk subset was more likely to have recurrence detected by patient-reported symptoms (78.8% vs 60.0%) and asymptomatic exams (14.1% vs 4.4%) than the high-risk subset. The high-risk subset was more likely to have recurrence detected by surveillance imaging (17.8% vs 2.0%) and biomarkers (14.1% vs 2.0%) than the low-risk subset (Chi-square = 31.3, p<0.001). <b>Conclusions:</b> Current guidelines for endometrial cancer surveillance include evaluation of symptoms and examinations at regular intervals. These 10-year data from a high-volume referral center demonstrate a lower rate of recurrence detection by asymptomatic pelvic exams (8.5%), especially in a high-risk subgroup (4.4%), than previously reported. These data can be used for patient counseling regarding the low risk of missing an endometrial cancer recurrence in an era of telemedicine.