Many centers continue a policy of intensive surveillance of women treated for endometrial cancer on the assumption that detecting asymptomatic recurrent disease will improve survival. Numerous studies have, however, failed to confirm significantly improved survival despite routine follow-up visits, compared to interval assessment of symptomatic patients.
The goal of this retrospective study was to determine whether routine vaginal cytology is a cost-effective means of detecting isolated asymptomatic vaginal recurrences following surgery for endometrial cancer. Participants were 377 women undergoing hysterectomy in the years 1997–2005 who had completed primary treatment and who initially had no evidence of disease. The median follow-up interval was 30 months. Surveillance consisted of a pelvic exam and a vaginal cytology Pap test every 3 months for the first year, every 3 to 4 months in the second year, and then every 6 months for a total of 5 years. Chest radiography and CT were done at the physician’s discretion.
Endometrial cancer recurred in 16.2% of patients. In 10% of cases, distant disease was present at the time of recurrence. Eleven patients (2.9%) had regional recurrences, and the same number had a local recurrence involving only the vagina. Nine of the latter patients were symptomatic or had clinically evident vaginal disease. Six of the 11 patients with vaginal recurrences were successfully treated. Four died of endometrial cancer, and 1 of intercurrent illness. Two asymptomatic vaginal recurrences were detected solely by routine vaginal cytologic Pap testing. These two women represented 0.5% of the study population. On average, patients had 5.8 Pap tests, and the total number of tests was 2134. Detecting each of the asymptomatic vaginal recurrences required 1067 Pap tests whose cumulative cost, adjusted using the consumer price index, was $44,049.
The investigators conclude that routine vaginal cytology testing is a costly and inefficient means of surveillance for recurrent endometrial cancer in surgically treated women. Less than 1% of patients can be expected to benefit from this policy. A prospective study aimed at finding the most cost-effective evidence-based means of surveillance would be appropriate in view of increasing health care costs.