365Surveillance Recommendations

SURVEILLANCE GUIDELINES

•   At completion of primary surgery and/or initial adjuvant treatment, patients should be counseled regarding the purpose of follow-up.

•   History and physical examination should include a vaginal speculum examination, bimanual exam, and rectal examination. There is no evidence for the regular use of any imaging or laboratories; these should only be obtained guided by patient symptoms or physical exam findings. Pap smears of the vaginal cuff are not recommended in patients with a history of endometrial cancer. It is not recommended to perform colposcopy for low grade, or less, Pap tests in women with a history of cervical cancer (1).

•   Screening for significant anxiety and depression symptoms should be included and psychosocial support should be offered at each visit.

•   Referral for palliative care for women with advanced or relapsed gynecologic cancer is important for quality of life (QOL). Avoidance of unnecessary treatments at the end of life reduces patient and family discomfort.

•   In addition to cancer-specific follow-up, all women should have a primary care provider (PCP) who provides them with routine health care assessments to include hypertension (HTN), breast cancer screening, and bone density assessment. On discharge from oncologic care, women and their primary care physician should receive specific information on which symptoms to be aware of and to seek additional assessment for.

•   Cost of surveillance in ovarian cancer: an additional $26 million will be needed to identify the 5% of women with recurrence seen only on CT. 95% of patients had either elevated CA-125 or office visit findings at the time of recurrence. The surveillance cost for the U.S. ovarian cancer population for 2 years after diagnosis and surgery is $32.5 billion using National Comprehensive Cancer Network (NCCN) guidelines and $58 billion if one CT scan is obtained (2).

•   Rustin Guidelines: the EORTC 55955 reported that there was no evidence of a survival benefit with early treatment of relapse on the basis of a raised CA-125 concentration alone, and therefore the value of routine measurement of CA-125 in the survival care of patients with ovarian cancer who attain a complete response after first-line treatment is not proven. Thus, relevant therapy, not timing, is vital (3).

UTERINE CANCER

•   Low-risk disease (include: stage I, grades 1 to 2): surveillance should include a history, physical exam and pelvic exam with visual inspection of the vaginal cuff. The time interval is: every 6 months for 1–2 years, then annually. Pap smears are not recommended.

•   High-risk disease surveillence includes those with stage I grade 3 disease, stage II and higher—all grades. Surveillance should include a history, physical exam and pelvic exam with visual inspection of the vaginal cuff. Time interval is: every 3 months for 2 years, every 6 months up to year 5, then annually. Pap smears are not recommended.

OVARIAN AND TUBAL CANCER

•   Surveillance should include a history, physical exam and pelvic exam with visual inspection of the vaginal cuff. The time interval is: every 3 months for 2 years, every 6 months up to year 5, then annually.

•   Genetic testing should be performed on all high grade serous tubo-ovarian cancer patients for BRCA 1/2 and other identified high–risk-associated genes.

•   Women with germ cell tumors should have laboratory testing to include the tumor marker that was elevated at the time of presentation.

CERVICAL CANCER, VULVAR, AND VAGINAL CANCER

•   Surveillance should include a history, physical exam and pelvic exam with visual inspection of the vaginal cuff. The time interval is: every 3 months for 2 years, every 6 months up to year 5, then annually.

•   Vaginal screening with cytology alone should be done no more than once a year. Atypical squamous cells of undetermined significance (ASCUS) and low grade squamous intraepithelial lesions (LSIL) are low-risk results and should not be further assessed with colposcopy.

•   Well-woman care should include smoking cessation.

MELANOMA PATIENTS

Melanoma patients: the earlier recommendations do not apply and follow-up should be guided by the current literature associated with cytotoxic, biologic, and immunotherapies (4,5) (Tables 7.1 through 7.4).

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SURVIVORSHIP GUIDELINES

A patient is considered a cancer survivor from the time of diagnosis, through the rest of her life.

•   Care of the survivor should include the following: prevention and surveillance of new and recurrent cancers, and assessment of late psychosocial and physical effects. Intervention for consequences of cancer and treatment include late effects of treatment, medical comorbidities, psychologic distress, and financial or social concerns. Coordination of care between primary care providers and specialists is necessary to ensure that all of the survivor’s health needs are met.

        An annual periodic assessment is recommended to determine any needs and necessary interventions. This review is to include current disease status, performance status, medication review, medical comorbidity management, and potential reversible causes for any symptoms due to prior treatment.

        Symptom review should include assessment of the following:

             Cardiac toxicity: shortness of breath (SOB), chest pain, paroxysmal nocturnal dyspnea, especially if there is a history of anthracycline administration.

             Anxiety and depression: bothered more than half the day with little interest or pleasure in doing things, days feeling down, depressed, or hopelessness, or not being able to control or stop worrying.

             Cognitive function: is there difficulty multitasking or paying attention, difficulty remembering things, or is the thought process slower?

             Fatigue: is there persistent fatigue despite a good night’s sleep and does the fatigue interfere with usual activities?

             Pain: is there any pain score that should be documented?

             Sexual function: are there any concerns regarding sexual function or activity in the patient or with the partner, and are these concerns causing distress personally or within the relationship?

             Sleep: are there problems falling asleep or staying asleep? Is there excessive sleepiness? Is snoring a problem? Does the partner notice sleep apnea?

             Healthy lifestyle: is regular physical activity worked into each day? Is a healthful diet eaten each day?

             Vaccination: seasonal flu vaccine and other indicated vaccinations.

•   Secondary malignancies may occur in survivors due to: genetic predisposition, environmental exposures, prior oncologic therapy (radiation therapy [XRT], alkaloid cytotoxic therapy). Screening for secondary malignancies should be shared between the PCP and the oncology providers.

•   Specific toxicities:

        Cardiac:

             Causes: often due to anthracycline, can be induced by receptor-targeted therapies (Herceptin), chest irradiation (left-sided breast or mantle XRT), and can take up to 10 years to become evident

             There are four stages:

                  Stage A:

                   –   Cardiac risk factors are present but no structural heart disease. Risk factors are: HTN, dyslipidemia, family history of cardiomyopathy, age greater than 65, smoking, obesity, alcoholism, comorbid cardiac diseases (atrial fibrillation, coronary artery disease [CAD], baseline structural heart disease, and personal history of rheumatic fever), and diabetes.

                   –   Pre-treatment Workup: thorough clinical screening for heart failure should occur within 1 year of completion of anthracycline therapy. A cardiac ECHO should be obtained.

                   –   Treatment: primary prevention with early detection is suggested. Diet, exercise, blood pressure control, cholesterol lowering medications, and consideration of cardiac remodeling/cardio protective agents.

                  Stage B:

                   –   Structural heart disease present but no signs or symptoms of heart failure: patients may have left ventricular hypertrophy (LVH), left ventricular diastolic dysfunction, asymptomatic valvular disease, or had a previous myocardial infarction.

                   –   Pre-treatment Workup: as in stage A with referral to cardiologist for further diagnosis and management.

                  Stage C:

                   –   Signs and symptoms of heart failure are present with underlying structural heart disease.

                   –   Management: refer to cardiologist for further diagnosis and management.

                  372Stage D:

                   –   Signs and symptoms: advanced structural heart disease with significant symptoms of heart failure are present at rest despite maximal medical therapy and interventions.

                   –   Management: refer to cardiologist for further diagnosis and management.

        Pain:

             Pre-treatment Workup: quantify, qualify, and determine the etiology and pathophysiology of the pain. It is important to discuss with the patient goals for comfort and function, and determine if it is a specific cancer pain syndrome.

             Pain types: neuropathic from neuromas, or nerve transection. Postsurgical pains from amputation, neck dissection, mastectomy, and thoracotomy. Musculoskeletal pain: myalgias, arthralgias, bone pain, and myofascial pain. Gastrointestinal (GI) discomfort: small bowel obstruction (SBO), partial small bowel obstruction (PSBO), chronic diarrhea, or constipation. Pelvic pain or urinary pain from surgery, XRT, hydronephrosis, or infection.

             Management is with physical therapy, pelvic floor exercise, dorsal column stimulation for chronic cystitis or pelvic pain. Neuromodulating selective serotonin reuptake inhibitors (SSRIs)/serotonin and norepinephrine reuptake inhibitors (SNRIs), or gabapentin, can be used in addition to biofeedback, and a bowel regimen to include stool softners. Massage therapy may be an additional resource. Additional means of pain modification can be use of nonsteroidal anti-inflammatory drugs (NSAIDs), narcotics, bowel regimen, a low roughage low residue diet, and hydration. Surgical options, when appropriate, are to bypass, stent, or divert bowel obstructions.

             It is important to ensure there is no recurrent tumor with imaging and biopsy.

        Lymphedema: the etiology is usually from lymph node dissection (LND) but may be from XRT, scarring, or tumor obstruction. Referral to a lymphedema specialist is indicated with assistance from compression garments, progressive resistance training, physical therapy with range of motion exercises, and manual lymphatic drainage. Temsirolimus has been shown to assist in guiding postoperative lymphatic drainage.

        Anxiety and depression:

             General anxiety disorder or adjustment disorder with anxious mood:

                  Symptoms are excessive anxiety that is difficult to control involving: sleep disturbances, restlessness, muscle tension, irritability, difficulty concentrating, and easy fatigue.

                  Management: refer for counseling for consideration of medical management.

             Panic disorder: acute onset of ≥4 of the following:

                  Palpations, sweating, chills or hot flashes, trembling or shaking, sensation of SOB, chest pain or discomfort, nausea, dizziness, out of body experience/being detached from self, fear of dying, fear of losing control, and paraesthesias.

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