Surveillance For Endometrial Cancer Research Articles

Yield of annual endometrial cancer surveillance in women with PTEN Hamartoma Tumor Syndrome

ObjectiveExpert-opinion based guidelines state that endometrial cancer surveillance (ECS) might be considered for patients with PTEN Hamartoma Tumor Syndrome (PHTS) based on an elevated lifetime risk of endometrial cancer. We aimed to evaluate the yield of ECS by annual transvaginal ultrasound (TVUS) and endometrial biopsy (EMB) in PHTS patients. MethodsPHTS patients who visited our PHTS expert center between August 2012 and September 2020 and opted for annual ECS were included. Data on surveillance visits, diagnostics, reports of abnormal uterine bleeding and pathology results were retrospectively gathered and analyzed. ResultsSurveillance was initiated in 25 women with a total of 93 gynecological surveillance visits during 76 surveillance years. The median age at first visit was 39 years (range 31–60) with a median follow-up duration of 38 months (range 6–96). Hyperplasia with and without atypia was detected six and three times, respectively, in seven (28%) women. The median age at hyperplasia detection was 40 years (range 31–50). In six asymptomatic women hyperplasia was detected during annual surveillance visits, while in one patient hyperplasia with atypia was detected during an additional visit due to abnormal uterine bleeding. In seven out of nine hyperplasias detected with EMB, TVUS beforehand showed no abnormalities. No (interval) carcinomas occurred. ConclusionsECS in women with PHTS enables detection of a substantial number of asymptomatic premalignancies, such as hyperplasia with and without atypia, suggesting that ECS may be beneficial with regard to cancer prevention. The addition of EMB to TVUS likely improves the detection of premalignancies.

Is there a role for routine imaging in Type 2 endometrial cancer surveillance? A retrospective review of method of detection of recurrent disease (495)

<b>Objectives:</b> National Comprehensive Cancer Network guidelines recommend symptom and exam-based surveillance of all endometrial cancers after remission, regardless of the staging and histology of the carcinoma. Similarly, "Choosing Wisely" discourages routine imaging. Our primary objective was to identify the first method of detection of recurrence in the highest risk Type II endometrial cancers and, secondarily, to examine patterns of disease recurrence in this population. <b>Methods:</b> We conducted a retrospective chart review of all patients diagnosed with Type II endometrial cancer from January 2014 through March 2019 at a large academic institution. Type II endometrial cancers were classified by histology (grade 3 endometrioid, serous, clear cell, carcinosarcoma, and poorly differentiated) and pathologic stage. Patient characteristics and disease and treatment information were abstracted from the medical record. At our institution, standard surveillance consists of quarterly visits with exams, with some patients receiving routine imaging and CA-125 levels based on their elevated risk of recurrence. Among patients with recurrence, we identified the first method of detection of recurrence and sites of recurrence. All patients were followed for a minimum of two years. We calculated descriptive statistics, presenting data as percent, median (interquartile range), or mean (± standard deviation). <b>Results:</b> We identified 180 patients with Type II endometrial cancer, with 49 (22%) recurrences. The mean age at diagnosis was 68 years. The cohort was primarily White (68%) and African American (20%). Approximately 50% were stage I, 9% stage II, 28% stage III, and 12% stage IV at diagnosis. Patient characteristics and symptoms at presentation and surgery were similar between the total cohort and recurrence sub-population. The median time of follow-up for the entire cohort was 3.6 years (IQR: 2.2-4.8 years). Recurrence was first detected with routine imaging in 50%, followed by symptoms in 37%, while the minority of patients were diagnosed with CA-125 levels (10%) and routine physical exam (2%). The most common site of recurrence was in the lung (49%), followed by the peritoneum (28%). The median time from the initial diagnosis to recurrence was 1.4 years (IQR: 0.91-2.0 years). For patients with recurrences, 77% were identified within two years from initial diagnosis, while 10% were identified more than three years after recurrence. <b>Conclusions:</b> Recurrence of Type II endometrial cancer was most commonly first detected by routine imaging in approximately one- half of patients, followed by symptoms in 37%. CA-125 and routine physical exam detected the minority of recurrences. Further studies examining the role of imaging to surveil these high-risk, high-grade endometrial cancer patients are needed to evaluate if earlier detection with routine imaging translates into better cancer outcomes, particularly in light of newly approved systemic therapy options.

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

<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.

P13 Is there a role for routine imaging in Type 2 endometrial cancer surveillance? A retrospective review of method of detection of recurrent disease

P13 Is there a role for routine imaging in Type 2 endometrial cancer surveillance? A retrospective review of method of detection of recurrent disease

Prevalence of mutations in BRCA and MMR genes in patients affected with hereditary endometrial cancer

Endometrial cancer (EC) is the fifth most common cancer in women from developed countries, accounting for 4.8% of new cases and 2.1% of deaths. The genetic basis for the familial risk of endometrial cancer has not been completely defined. Mostly, hereditary EC is part of two syndromes as Lynch syndrome (LS) and Hereditary Breast and Ovarian Cancer syndrome (HBOC). LS is the prototypical hereditary cancer syndrome in EC and accounts for 2–6% of all endometrial cancers. This disease is caused by autosomal dominant mutations in DNA mismatch repair (MMR) genes. Patients carrying a germline mutation in one of the MMR genes have a cumulative lifetime risk to develop EC of 20–70%. HBOC is an autosomal dominantly inherited disease, which mostly predisposes to breast and ovarian cancers, but it can be also associated with other malignancies. HBOC results from germline mutations in BRCA1/2 genes. The aim of this study was to determine the mutational status of a cohort of 40 EC patients, 19 belonging to families with LS and 21 to HBOC. Mutation analysis of MLH1, MSH2, BRCA1 and BRCA2 genes showed pathogenic variants in 17/40 (42.5%) patients. Out of 19 patients belonging to LS families, 8 (42.1%) showed a pathogenic variant. Out of 21 patients belonging to HBOC families, 9 (42.8%) showed a pathogenic variant. 1/21 (4.8%) patient report 1 variant of unknown significance (UV), c.599 C > T (p.T200I), in BRCA2. Moreover, in 1/21 (4.8%) patient we identified a novel missense variant in BRCA2, c.9541A > T (p.Met3181Leu). Mutational analysis was extended to family members, both healthy and cancer affected, of mutated patients; all the tested relatives affected with cancer displayed the pathogenic variant. Our data suggest that patients with hereditary EC have a high percentage of mutations in the LS and HBOC main susceptibility genes; therefore, the surveillance for EC, already indicated in LS patients, should also be recommended for patients with HBOC.

Japan Society of Gynecologic Oncology 2018 guidelines for treatment of uterine body neoplasms.

The Fourth Edition of the Guidelines for Treatment of Uterine Body Neoplasm was published in 2018. These guidelines include 9 chapters: 1. Overview of the guidelines, 2. Initial treatment for endometrial cancer, 3. Postoperative adjuvant therapy for endometrial cancer, 4. Post-treatment surveillance for endometrial cancer, 5. Treatment for advanced or recurrent endometrial cancer, 6. Fertility-sparing therapy, 7. Treatment of uterine carcinosarcoma and uterine sarcoma, 8. Treatment of trophoblastic disease, 9. Document collection; and nine algorithms: 1-3. Initial treatment of endometrial cancer, 4. Postoperative adjuvant treatment for endometrial cancer, 5. Treatment of recurrent endometrial cancer, 6. Fertility-sparing therapy, 7. Treatment for uterine carcinosarcoma, 8. Treatment for uterine sarcoma, 9. Treatment for choriocarcinoma. Each chapter includes overviews and clinical questions, and recommendations, objectives, explanation, and references are provided for each clinical question. This revision has no major changes compared to the 3rd edition, but does have some differences: 1) an explanation of the recommendation decision process and conflict of interest considerations have been added in the overview, 2) nurses, pharmacists and patients participated in creation of the guidelines, in addition to physicians, 3) the approach to evidence collection is listed at the end of the guidelines, and 4) for clinical questions that lack evidence or clinical validation, the opinion of the Guidelines Committee is given as a “Recommendations for tomorrow”.

Utility of Vaginal Vault Cytology in Detection of Recurrent Endometrial Cancer in a Tertiary, Safety Net Health System: An Area for Quality Improvement and Cost Saving

Objectives: Current guidelines do not recommend vaginal vault cytology for routine surveillance in patients with endometrial cancer. However, in a tertiary, safety net health system, 67% of patients are uninsured and 11% have never received screening with cervical or vaginal vault cytology. Thus, many providers consider this patient population high risk and routinely perform vaginal vault cytology for endometrial cancer surveillance. Our objective was to determine the clinical utility and cost effectiveness of vaginal vault cytology for detecting recurrent endometrial cancer in women receiving care at a tertiary, safety net health system.

Endometrial cancer surveillance adherence reduces utilization and subsequent costs

ObjectivesIn June 2011, the SGO recommended that physical exam and symptoms be the primary surveillance methods in patients with endometrial cancer. We sought to evaluate adherence to these guidelines by comparing the use of CT scans, paps and serum CA125 ordered for endometrial cancer surveillance before and after publication of these guidelines. MethodsA retrospective review was performed for all patients undergoing surveillance for endometrial cancer at a single institution between June 2009 and June 2013. We assessed the number of patients without symptoms or abnormal physical exam findings who underwent surveillance CT scans, paps and/or CA125 during the 2years pre- and 2years post-SGO guidelines. Results92 patients (n=48 pre-6/2011, n=44 post-6/2011) were identified. Mean patient age was 58years. No significant difference in age, ethnicity, body mass index, or disease grade or stage was noted. There was a significant decline in surveillance CT scans (n=13, 27% vs. n=4, 9%, p=0.03), CA125 (n=14, 29% vs. 5, 11%, p=0.035) and paps (n=34, 71% vs. n=8 vs. 18%, p<0.001). There was no significant difference in disease status at the last follow-up. Institutional cost of surveillance also declined ($14,102.46 2years pre-guidelines, $3,054.99 2years post-guidelines). ConclusionsIn a single urban academic public hospital, after only 2years, clinical adherence to the 2011 SGO endometrial cancer surveillance guidelines resulted in a significant decline in the use of CT scans, CA125 and paps. This reduction does not appear to affect patient outcomes and led to an appreciable decrease in surveillance costs.

Endometrial Biopsy: American College of Nurse-Midwives.

Endometrial biopsy can be used to diagnose endometrial hyperplasia, endometrial cancer, and uterine infections. This cost-effective procedure has minimal side effects, and complications are rare. The purpose of this clinical bulletin is to provide clinicians with guidance about endometrial biopsy including the procedure's advantages and disadvantages, indications and contraindications, and side effects. In addition, step-by-step instructions for performing endometrial biopsy, the equipment required, selection of sampling devices, and care before and after the procedure are discussed.

Endometrial cancer surveillance adherence: Before and after June 2011 SGO position statement

Endometrial cancer surveillance adherence: Before and after June 2011 SGO position statement

Elevated risks of subsequent endometrial cancer development among breast cancer survivors with different hormone receptor status: a SEER analysis.

Estrogen receptor (ER)-positive breast cancer patients treated with tamoxifen are known to have an elevated risk of subsequent endometrial cancer. However, it is unclear if ER-negative patients also have a higher risk of endometrial cancer. This population-based study aims to evaluate whether breast cancer patients with distinctive ER and PR status possess differential risks in developing delayed endometrial malignancy. Data were obtained from the Surveillance, Epidemiology, and End Results program (1992-2009). Standardized incidence ratio (SIR) was calculated as the observed cases of endometrial cancers among breast cancer survivors compared with the expected cases in the general population. Data were stratified by latency periods, race, age, and calendar year of breast cancer diagnosis. We identified 2044 patients who developed a second primary endometrial cancer among 289,933 breast cancer survivors. The overall SIRs for subsequent endometrial cancers were increased in all of the four subtypes (ER+PR+, ER+PR-, ER-PR+, and ER-PR-) of breast cancer. SIR was increased for all latency periods except for the initial 6-11 months after breast cancer diagnosis. Stratifying by age of diagnosis, elevated SIRs in all ER/PR groups were statistically significant among patients diagnosed with breast cancer after the age of 40. Demographically, non-Hispanic whites had increased SIRs in all subtypes of breast cancer, while Hispanic whites had no statistically elevated SIRs. Here we showed that patients with invasive breast cancer have a higher risk of developing subsequent endometrial cancer regardless of ER or PR status. The increased risk among hormone receptor-negative breast cancer survivors raises concerns whether common etiological factors among these breast cancer subtypes increase the susceptibility to develop endometrial cancer. Lower threshold for routine endometrial cancer surveillance may be warranted.

The results of gynecologic surveillance in families with hereditary nonpolyposis colorectal cancer

ObjectiveWe aimed to estimate the incidence rate of endometrial cancer (EC) and to evaluate the results of EC-surveillance in hereditary nonpolyposis colorectal cancer (HNPCC) families. MethodsAll at-risk women recommended for EC-surveillance by the HNPCC-register—2959 women (19,334women years)—were included. Data on EC-surveillance were available for 871 women (6894women years), who had performed 1945 surveillance visits. The average surveillance period was 7.9 (range 0.1−21.7) years and 46% of the women had had less than 3years between their visits. ResultsDuring 19,334women years, 60 women with gynecological malignancies or premalignancies were diagnosed. Thirty-nine women had EC. Of these, 31 were from families with identified MMR gene mutations with the median age at diagnosis of 54 (39–83) years (Incidence Rate, IR=0.63 per 100women years) and four women from each Amsterdam (AMS)-positive and AMS-like families (median age 64 (55–73) years, IR=0.06 and 0.05 per 100women years, respectively, p<.0001).Among the 871 surveilled women, 13 EC were found: 7/13 cases were diagnosed by surveillance examination—two as prevalent cancers, diagnosed at the first visit—and 6/13 based on symptoms. In addition, five complex atypical hyperplasias and four ovarian cancers (OCs) were diagnosed. All these women were MMR mutation carriers. ConclusionBased on 19,334women years of EC-surveillance, our analysis provides a thorough estimation of the EC risk in women with an MMR mutation, or suspected of having Lynch syndrome. We conclude that EC surveillance should only be targeted at MMR-mutation carriers.

Awareness of Endometrial Cancer Risk and Compliance With Screening in Hereditary Nonpolyposis Colorectal Cancer

Women with hereditary nonpolyposis colorectal cancer (HNPCC) have a 40-60% lifetime risk for endometrial cancer. Guidelines in Denmark recommend gynecologic screening for female members of families with HNPCC. We estimated the knowledge of endometrial cancer risk and identified possible predictors of compliance with the screening among women from families with HNPCC. A questionnaire exploring the knowledge of endometrial cancer risk and compliance with screening was sent to 707 women from families with HNPCC who had been recommended endometrial cancer surveillance. The response rate after one reminder was 86% (606 of 707). Data were analyzed by simple and multivariable logistic regression models. Four hundred seventy-one women were included in the final analyses; 65% reported being aware of the increased risk of endometrial cancer. The awareness was significantly greater among women with high educational level (81%; P<.001), women who had received genetic counseling (75%; P<.001), women with family history of gynecologic cancer (76%; P<.001), and those with high perceived endometrial cancer risk (77%; P<.001). Overall, 67% had participated in gynecologic screening. No significant differences were found in compliance regarding women's educational level or their family risk classification. Analyses of data in a multivariable logistic regression model showed that knowledge of endometrial cancer risk was the most important predictor for positive compliance with the gynecologic screening (odds ratio 4.86, 95% confidence interval 3.05-7.74). Women's awareness of endometrial cancer risk is the most important predictor of their compliance with gynecologic screening in families with HNPCC. II.

Could Different Follow-Up Modalities Play a Role in the Diagnosis of Asymptomatic Endometrial Cancer Relapses?: An Italian Multicentric Retrospective Analysis

To determine current practice and to assess the value of routine follow-up procedures for endometrial cancer surveillance. To discuss whether such procedures are feasible and effective to identify asymptomatic recurrences and describe the pattern of relapse detected by procedures. The records of 282 consecutive women with recurrent endometrial cancer treated from 1986 to 2005 were retrospectively collected in 8 Italian institutions. Primary disease, clinical history, and recurrence features and data were analyzed. Thirty-five (12.4%) of 282 patients had recurrence in vaginal vault, 51 patients (18.0%) had recurrence in central pelvis, 14 patients (4.9%) had recurrence in pelvic wall, and 39 patients (13.8%) had recurrence in lymph nodes. One-hundred twenty-eight patients (45.3%) showed a distant relapse, whereas 15 patients (5.3%) developed both distant relapse and local relapse. The site of relapse influenced survival because the patients with vaginal vault recurrences lived significantly longer than the patients with recurrences in other sites. Eighty (28.4%) of the 282 patients became symptomatic and anticipated the scheduled visit, 37 (13.1 %) of the patients reported their symptoms during the follow-up meeting, and 165 (58.5 %) of the patients were asymptomatic and the diagnostic path was introduced by a planned visit or examination. Among the asymptomatic patients, the first procedure that led to further examinations was clinical visit alone for 60 (36.4%) of 165 patients, imaging for 103 patients (62.4%), and cytologic examination for 2 patients (1.2%). Symptoms at recurrence can predict survival: patients with an asymptomatic recurrence had a median survival time from relapse of 35 months versus 13 months if they had a symptomatic repetition (P = 0.0001). Follow-up after endometrial cancer treatment varies in Italy. In this retrospective study, women with asymptomatic recurrence have shown a better clinical outcome compared with those with symptomatic relapse. The optimal approach is actually unknown, and guidelines comparing follow-up protocols have not been established. Prospective cost-effectiveness studies are needed.

Calcific myonecrosis as a late complication of an open fracture

In June 2011, the SGO recommended that physical exam and symptoms be the primary surveillance methods in patients with endometrial cancer. We sought to evaluate adherence to these guidelines by comparing the use of CT scans, paps and serum CA125 ordered for endometrial cancer surveillance before and after publication of these guidelines.A retrospective review was performed for all patients undergoing surveillance for endometrial cancer at a single institution between June 2009 and June 2013. We assessed the number of patients without symptoms or abnormal physical exam findings who underwent surveillance CT scans, paps and/or CA125 during the 2 years pre- and 2 years post-SGO guidelines.92 patients (n = 48 pre-6/2011, n = 44 post-6/2011) were identified. Mean patient age was 58 years. No significant difference in age, ethnicity, body mass index, or disease grade or stage was noted. There was a significant decline in surveillance CT scans (n = 13, 27% vs. n = 4, 9%, p = 0.03), CA125 (n = 14, 29% vs. 5, 11%, p = 0.035) and paps (n = 34, 71% vs. n = 8 vs. 18%, p < 0.001). There was no significant difference in disease status at the last follow-up. Institutional cost of surveillance also declined ($14,102.46 2 years pre-guidelines, $3,054.99 2 years post-guidelines).In a single urban academic public hospital, after only 2 years, clinical adherence to the 2011 SGO endometrial cancer surveillance guidelines resulted in a significant decline in the use of CT scans, CA125 and paps. This reduction does not appear to affect patient outcomes and led to an appreciable decrease in surveillance costs.

Surveillance for Endometrial Cancer in Women on Tamoxifen: The Role of Liquid-Based Endometrial Cytology–Cytohistological Correlation in a Population of 168 Women

Tamoxifen has for some time been standard adjuvant therapy in women with endocrine-responsive breast cancer. It does lower the recurrence rate and prolongs disease-free survival, but also appears to entail an increased risk of endometrial cancer. The best means of surveillance for women on long-term tamoxifen therapy has not been established, but 1 option is liquid-based cytology, which is able to reduce obscuring factors including inflammatory cells and blood and which provides a thin-layer endometrial sample. This study compared the diagnostic accuracy of liquid-based cytology with the histological diagnosis in 168 women on tamoxifen therapy who were scheduled for hysteroscopy. Hysteroscopy was followed sequentially by endometrial cytology and biopsy. All procedures were done in an outpatient setting without analgesia, using the Endoflower device for cytological sampling. Endometrial biopsy alone was inadequate in 67% of patients, and both biopsy and cytology in 11%. Endometrial cytology alone was inadequate in only 4 instances (2% of patients). In 20% of the study group, both endometrial biopsy and cytology were adequate. In all, endometrial biopsy proved inadequate in 78% of patients and endometrial cytology in 14%. Cytology provided enough material to reach a diagnosis more often than did endometrial biopsy. When both endometrial cytology and biopsy were adequate, there was complete correlation between the results. Among 28 women with inadequate biopsy and adequate cytology who had further histological assessment was 1 with endometrial adenocarcinoma that was detected only by endometrial cytology. The cytologic diagnosis subsequently was confirmed by endometrial curettage. Liquid-based endometrial cytology appears to be a useful means of endometrial surveillance in women taking tamoxifen. It may be used by itself or in conjunction with transvaginal ultrasonography.

Feasibility and economic impact of a clinical pathway for pap test utilization in Gynecologic Oncology practice

Objective To evaluate the feasibility and impact on cost to the U.S. healthcare system of implementing a clinical pathway for Pap test utilization in screening and surveillance of gynecologic cancers in a university-based gynecologic oncology practice. Methods Baseline data were collected for Pap test utilization between 1/1/04 and 6/30/05 and prospectively compared to Pap test utilization following the implementation of a clinical pathway (7/1/05 to 5/30/06). The clinical pathway: 1) employed ACOG guidelines for asymptomatic screening of non-cancer patients, 2) allowed testing at 4 months intervals for cervical/vaginal cancer surveillance, 3) limited testing for endometrial cancer surveillance to 2 tests/60 months, and 4) eliminated testing as part of ovarian cancer surveillance. Relevant costs were calculated using Medicare charge-to-cost ratios and adjusted to 2006 USD. For statistical analysis, differences in Pap test utilization and cost were evaluated using student's t-test. Results During the baseline period, 1725 Pap tests were collected from 5605 ambulatory encounters, for a Pap test rate of 30.8% and an annualized cost of $93,759. After implementation of the clinical pathway, 4209 ambulatory encounters yielded an annual Pap test rate of 11% and an annual cost of $35,728 ( p < 0.0001), a savings of $58,031. In addition, clinical pathway implementation also registered an opportunity cost savings of 180.3 nursing personnel work hours ($4,162). Conclusions Reduction in the unnecessary use of Pap testing for asymptomatic screening and surveillance for gynecologic cancers through a straightforward clinical pathway is feasible and offers an opportunity for significant cost savings in gynecologic oncology healthcare expenditure.

Surveillance for Endometrial Cancer in Women on Tamoxifen: The Role of Liquid-Based Endometrial Cytology – Cytohistological Correlation in a Population of 168 Women

Aims: The aim of this study was to evaluate the utility of liquid-based cytology for endometrial surveillance in patients receiving tamoxifen. Methods: One hundred and sixty-eight women scheduled for hysteroscopy were enrolled in the study. The women sequentially underwent hysteroscopy, endometrial cytology and biopsy. Results: Endometrial biopsy only was inadequate in 112 (67%) patients, both endometrial biopsy and cytology were inadequate in 19 (11%) patients, endometrial cytology only was inadequate in 4 (2%) patients, and both endometrial biopsy and cytology were adequate in 33 (20%) patients. Overall, endometrial biopsy was inadequate in 131 (78%) patients and endometrial cytology in 23 (14%) patients. Endometrial cytology provided sufficient material for diagnosis more often than endometrial biopsy (p < 0.05). In the series of 33 patients (20%) in whom both endometrial cytology and biopsy were adequate, there was a 100% correlation between the endometrial cytology and biopsy results. Conclusions: For the first time, this study shows the diagnostic efficacy of liquid-based endometrial cytology in the follow-up of women receiving tamoxifen. It could be applied solely or in conjunction with ultrasonography.

Surveillance for endometrial cancer in hereditary nonpolyposis colorectal cancer syndrome

The estimated lifetime risk for endometrial carcinoma (EC) in hereditary nonpolyposis colorectal cancer syndrome (HNPCC) is 32-60%, thus supporting surveillance. The survival rate of EC patients is, however, favourable questioning the need for surveillance. Yet, the effectiveness of gynecological surveillance remains to be shown. The 2 previously published studies were based on transvaginal ultrasound (TVUS) alone. Intrauterine biopsy has not been tested in surveillance for EC in HNPCC families. The effect of gynecological surveillance was evaluated among 175 Finnish mutation carriers. During 759 person years at risk, there were 503 surveillance visits including TVUS and intrauterine biopsy of endometrium at 94% and 74% of the visits, respectively. EC occurred in 14 cases, 11 of which were diagnosed by surveillance, 8 by intrauterine biopsies. TVUS indicated only 4 EC patients but missed 6 other cases. Intrauterine sampling detected 14 additional cases of potentially premalignant hyperplasia. The stage distribution and survival tended to be more favorable in the 14 EC cases of the surveilled group (no deaths) than in the group of 83 symptomatic mutation carriers of whom 6 died of EC, but with no statistical significance. Four cases of ovarian cancer occurred but none was detected by surveillance in TVUS examinations. In conclusion, EC surveillance in HNPCC seems more effective with endometrial biopsies than with TVUS alone. A definite improvement in survival remains to be shown. The detection of early cancer stages and premalignant lesions offers the opportunity to avoid extensive adjuvant treatment.

Cost-effectiveness of routine vaginal cytology for endometrial cancer surveillance

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.