is to be able to clinically detect a recurrence. We want to use cost-effective practices. We want to decrease morbidity for our patients. And then most importantly, we want to impact their survival outcomes. And so we want to focus on surveillance activities that will increase the chance of picking up a recurrence that can be cured or appropriately palliated. So for most of this talk, these are the two articles that I referenced. The first one is the most recent. It's from 2017, and it's a white paper from the SGO. And I think it's a really good, concise paper on surveillance for GYN cancers. It includes a lot of the information that's embedded in a lot of the international guidelines as well. So first for endometrial cancer, most importantly, history and physical exam. And that physical exam is going to include doing a speculum exam to evaluate the vaginal vault and also the vaginal apex, doing a bimanual exam to feel for any nodularity at the upper vagina, and then performing a rectovaginal exam is also really important. I think the most interesting thing about this is that the detection rate for recurrence is greater than 80% with just history and physical exam. And then the most common symptom that patients will often present with is vaginal bleeding. And so very important, not just for us to be aware of the symptoms for possible recurrence, but educating patients on vaginal bleeding as well. And then importantly, as we talked about improving survival outcomes for patients is that these local recurrences can be salvaged with radiation therapy often. And so important to detect early. And so here's just a table that you'll see throughout the rest of the presentation. And it breaks down the follow-up that's recommended based on their risk of disease. So we look here in this first group, our lowest patients who are early stage patients or who have a grade one or grade two, they're gonna get followed up every six months for about the first year to two. And importantly, I noted in the box here is that they make a comment that these patients can also follow up with their primary gynecologist, which I know for us, we have patients who travel from far away and I'm sure that's true for most people who are practicing. And so either coordinating alternating visits or having those patients follow up. And the reason for that recommendation for the low risk patients are that the recurrences are typically going to occur within the two years, but they still need regular follow-up. For intermediate risk and high risk patients, so anywhere from our stage one B to stage fours in our high grade histology, much more frequent follow-up. So about every three months for high grade or high risk patients for the first two years and then every six months until five years of no recurrence. And they'll have annual follow-up after that. Here, I think a former practice used to be to perform cytology for these patients to try to detect for recurrence, but cytology is not indicated across the board as you can see. And the reason for that is, is there's only about a less than 10% rate of detection with cytology. So that's why that's no longer recommended. Similarly with tumor markers, unless a patient has a known elevation and tumor marker and it's something you can follow like with your high grade histologies, then it's not recommended routinely to get that. And then similarly for imaging studies, there is insufficient data to support routine imaging in the absence of symptoms. So that would just, that recommendations for patients who have no symptoms and come in should not get routine, a chest X-ray or a CAT scan or an MRI or a PET CT. And then certainly as you'll see with all of these patients, if a recurrence is suspected, then imaging is certainly warranted or with an elevated tumor marker. And then just briefly for uterine sarcomas, which are broken down into our stromal sarcomas, which the recommendation is not for routine imaging studies for these patients, but long-term follow-up is recommended since late recurrences are common. And then the undifferentiated uterine sarcomas and lyomar sarcomas are kind of grouped together in how we follow those up. And mainly because we know recurrences are very common for these patients, about 50%. And the recurrences can be in the pelvis, but can also be at distant sites. And so routine CT of the chest, the abdomen and the pelvis every six months, six to 12 months for the first couple of years or clinically indicated is what's recommended. And then for ovarian cancer, again, history and physical exam. The exam is, the components are the same, speculum exam, bimanual exam and rectivaginal exam. And then again here, you see that the detection rate for patients who present with symptoms of a recurrence are about 50% and then physical exam findings about 60%. The major issue for ovarian cancer with physical exam only is that it's very cost-effective, but the reproducibility is fairly low, which is very different than endometrial cancer and cervical cancer, which we'll talk about in a second. And so CA-125 is a pretty specific test for recurrence particularly in someone who has had an elevated CA-125. The specificity that's quoted in the studies is somewhere between 91 and 100%. The sensitivity is I think about 60 to 80%. However, retrospective studies, and that's all of the data that we have for most of the recommendations here, but patients who received treatment for their recurring ovarian cancer based on an elevated CA-125 alone versus having clinically relevant evidence of recurrence have really a similar difference, have a similar overall survival. And so that's where this recommendation in the chart comes from. So again, history, physical exam are gonna be the most important. Patients are following up much more frequently every three months for the first couple of years, and then after that begins to get spaced out. And then as we saw with endometrial cancer, pap smears are not recommended. And this note here of this being optional, I know that I've heard my attending say multiple times and how everyone kind of has a different way of counseling their patients about getting CA-125 is I think most patients want them because it gives them some level of scale to reassure them or to not reassure them. And so many patients decide to have the CA-125 drawn, but some don't. And then similarly, as we saw before, routine imaging. So this is again, in patients who are asymptomatic, so no symptoms, no physical exam findings, routine chest X-ray, PET scan, or CT are not recommended. With that being said, still the majority of patients do get routine imaging. And I think that that is, again, a part of kind of the patient provider conversation that happens. I think somewhere I saw it was about 75% of patients are still getting routine imaging. And then if a recurrence is suspected, obviously imaging is warranted, usually with a CT scan. And so those were our epithelial ovarian cancers. So for our non-epithelial ovarian cancers, so oftentimes our younger patients, same thing as we talked about before, a history and physical exam is gonna be our best tool that we have. For patients who had a low malignant potential tumor and had fertility preservation, those patients should be considered for pelvic ultrasound every six months or so just to follow for recurrence. If they had an initially elevated CA-125 when tumor markers were collected, then certainly checking that every three to six months is reasonable. And just remembering that patients who with low malignant potential tumors specifically have an increased risk of recurrence if they had only a unilateral removal of an ovary or they just had a cystectomy and just had the mass removed without the entire ovary. If they're older or if they had distant disease, they definitely have a higher risk of recurrence and they might need to be seen more frequently because of that. The chart here that you've been used to seeing by now breaks down the follow-up for germ cell tumors and sex cord stromal tumors. So history and physical is still again recommended. For germ cell tumors, the recommendation here for frequent follow-up up until this two-year mark is that most of these recurrences happen within the two years. And so they feel confident in making a recommendation to space out the follow-up to yearly visits, but those should continue to be with a gynecologic oncologist preferably. And then for the sex cord stromal tumors, which can have later recurrences, the follow-up is similar for the first two years and then every six months thereafter. And then with tumor markers, which is a little bit different than that optional recommendation for the epithelial ovarian cancers, germ cell tumors, again, this two-year recommendation here is because most of the recurrences will be diagnosed in the two years. So evaluating those every two to four months, so at the routine follow-up visits. And then for sex cord stromal tumors, again, following up those tumor markers if they were initially elevated for patients. And then for germ cell tumors, I just want to point out the unique thing here for imaging studies is unless the patient did not have an elevated tumor marker to follow, there is no recommendation for imaging studies. So said differently, if the patient doesn't have a tumor marker to follow, then imaging would be indicated in those first two years of follow-up for our germ cell tumor patients. And for cervical cancer, again, history and physical exam is going to be really important. Some of the different symptoms are new pain for patients, new lymphedema or worsening lymphedema if they had it from prior therapy, vaginal bleeding or new vaginal discharge, new urinary symptoms that are continuing to be bothersome, cough, which could indicate lung metastases or lung recurrences, weight loss. And so patients often present with symptoms if they have recurrent cervical cancer. So it's very common and very important to pick up on those things when patients bring them up during visits. And then physical exam is the same as we've discussed for all of our other malignancies. And again, the detection rate is pretty high, up to 75% of recurrences can be diagnosed on history and physical exam alone, which is really important. I'll talk about the pap smear in a second. So for our low-risk patients, so early-stage patients who didn't require adjuvant therapy, the recommendation is for them to follow up every six months for two years, and then, excuse me, annually thereafter. And again, there's this little note here that it can be with their primary gynecologist or with their GYN oncologist. And then high-risk patients, as expected, are gonna follow up more frequently with their GYN oncologist. And then here, there is a yearly note here about pap testing. And many people still continue to perform cytology at the top of the vagina, but the recommendation is for no treatment for patients with an ASCIS pap or a low-grade pap smear. And the reason for that is, is you can get a very high number of those pap smears just from radiation changes. And so if people are performing them, to hopefully not act on those results and only act on a high-grade cytology result. And then lastly, vaginal and vulvar cancer. Again, some different symptoms that are presented on history. So burning, itching, new lumps or ulcerations on the vulva or skin changes. Even if the patient had radiation, they might notice some new skin changes in an area, either where they had their prior cancer or opposite of that. Lymphedema, so new or worsening lymphedema or swelling elsewhere. And then really important for patients with a history of vulvar cancer in particular, is to look and biopsy any concerning lesions. And still do a bimanual exam and then make sure to palpate their groin nodes or their inguinal lymph nodes to evaluate for enlargement. And so we know that most of the vulvar cancers are in cervical cancers or are HPV related. So for these patients, just making sure that if they need to continue to have pap smears, that they're following the guidelines for pap smears. And make sure that the cervix is evaluated if they still have one to evaluate the vagina as well as the perianal region, which can all be affected by HPV. So this chart is very similar to the, it's the exact same one we just saw. And so low risk patients are followed up every six months until two years and then yearly thereafter. And then high risk patients every three months till two years and then every six months until five years where they're followed annually. So this last slide is just kind of a reminder of the sensitivity of our history and physical exam. I think for the majority of the cancers that we take care of. So for endometrial cancer, you can see huge ability to detect a recurrence based on history and physical exam. Ovarian cancer, we kind of add in this tumor marker for this blood test that helps us determine if we need to get additional imaging and increases our sensitivity of detecting a recurrence. And then for cervical cancer, again, history and physical exam is going to be really important. And the last thing I'll put here, I'll just leave it up. This is from the 2017 article and it just has symptoms of recurrence for all of the cancers with local findings and distant findings and symptoms as well. All right, thank you again for having me. I appreciate the opportunity.

surveillance activities

recurrent gynecologic cancers

history and physical exams

routine imaging

pap smears