Follow-up after endometrial cancer
CMAJ 1998;158:587-8
See response from: O. Agboola
As radiation oncologists at the BC Cancer Agency, we frequently see patients with endometrial cancer — 221 in 1996 alone. As such, we eagerly read the article "Costs and benefits of routine follow-up after curative treatment for endometrial cancer" (CMAJ 1997;157[7]:879-86 [abstract/résumé]), by Dr. Olu O. Agboola and colleagues.
We congratulate the authors on a clearly written paper, but we also have a few concerns that were not addressed there.
When considering follow-up, physicians should give thought to the goals of such follow-up and the selection of an appropriate population. The risk of recurrence and the chance of potential curative treatment depend on the tumour and individual patient factors. Treatment recommendations are therefore based on these factors. For example, grade and stage are significant prognostic factors in endometrial cancer and can be used to predict recurrence. The risk of pelvic recurrence is affected by whether or not the patient has received adjuvant treatment. Karnofsky performance status is also a factor in patients with recurrent disease.
If treatment recommendations depend on these factors, then it seems reasonable that follow-up should also, to some extent, be based on the same factors, as well as those related to fiscal responsibility.
In the cohort of patients described by Agboola and colleagues, 62% of recurrent lesions were at distant sites. Such lesions are conventionally thought to be incurable, so their early detection has little effect on overall survival. In contrast, isolated local recurrence is thought to be treatable, and in the CMAJ study most local recurrent cases were picked up during routine follow-up. From this perspective, routine follow-up with pelvic examination was important.
Follow-up is also important for assessing the toxic effects of treatment. Many times we are not only assessing disease status but also the morbidity associated with radiation therapy, surgery or chemotherapy. Knowledge of toxic effects and survival is important for critical assessment of current treatment policies and consideration of newer treatment regimens.
We believe that follow-up is an important part of oncologic clinical care and that tailoring follow-up regimens allows us to optimize our resources. What is evident from the article by Agboola and colleagues is that the cost of detecting a treatable recurrence and preventing another cancer death is considerable.
Christina Aquino-Parsons, MD
Peter Lim, MD
Radiation Oncologists
BC Cancer Agency
Vancouver Cancer Centre
Vancouver, BC
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