What is the recommended surveillance plan for a patient with stage 1A, grade 1 (G1) endometrioid endometrial carcinoma?

Surveillance for Stage 1A Grade 1 Endometrioid Endometrial Carcinoma

For stage 1A grade 1 endometrioid endometrial carcinoma, perform physical examination every 3-6 months for the first 2 years, then every 6 months through year 5, and annually thereafter. 1

Core Surveillance Schedule

Years 1-2: Intensive Monitoring Phase

• Physical examination (including pelvic-rectal examination) every 3-6 months 1
• Vaginal cytology every 6 months 1
• This intensive schedule is justified because 70-100% of recurrences occur within the first 3 years after primary treatment 1, 2

Years 3-5: Intermediate Monitoring Phase

• Physical examination every 6 months 1, 3
• Vaginal cytology annually 1

Year 5 Onward: Long-term Monitoring

• Physical examination annually 1, 3
• Vaginal cytology annually 1

What NOT to Do Routinely

Imaging Studies

• Do not perform routine CT scans, chest X-rays, or PET scans in asymptomatic patients 1
• Imaging has poor detection rates (0-20% for CT, 0-20% for chest X-ray) in asymptomatic endometrial cancer patients 1

Tumor Markers

• Do not routinely measure CA-125 levels in low-risk disease like stage 1A grade 1 endometrioid carcinoma 1
• CA-125 has negligible utility for detecting recurrence in low-risk disease, accounting for only 15% of detections overall and even less in low-risk patients 1

Progestational Agents

• Do not administer adjuvant progestational agents (such as medroxyprogesterone acetate) as they do not increase survival in low-stage endometrial cancer 1, 3

Understanding Your Patient's Excellent Prognosis

• Stage 1A grade 1 endometrioid endometrial carcinoma has a 5-year disease-free survival of approximately 94% 3, 4
• The recurrence rate for this low-risk group is only 2-10% 1, 2, 4
• No adjuvant therapy is recommended after complete surgical staging for this low-risk disease 1, 5, 3

Critical Symptom Education

Counsel patients to immediately report these symptoms, as 41-83% of recurrences are detected symptomatically rather than by surveillance testing: 1

• Vaginal bleeding (most important—indicates potentially curable local recurrence) 1
• Abdominal or pelvic pain 1
• Unexplained weight loss 1
• Persistent cough or headaches (suggesting distant metastasis) 1

Important Clinical Nuances

The Surveillance Paradox

Despite intensive surveillance protocols, most recurrences are detected based on symptoms rather than routine testing 1, 6. Physical examination has a detection rate of only 35-68%, and vaginal cytology detects only 0-7% of recurrences 1. However, some evidence suggests that asymptomatic detection may improve survival (20 months vs 7 months in one series), though other studies show no survival difference 1, 4.

Why Physical Examination Still Matters

Physical examination remains the cornerstone of surveillance because it can detect vaginal vault recurrences, which are often asymptomatic and potentially curable 6. This is particularly relevant since local recurrences respond well to salvage therapy 1.

Timing Considerations

The median time to recurrence is approximately 17.5 months, with most occurring within 3 years 4, 6. Patients who recur after 17.5 months have better survival than those with earlier recurrence 4.

Common Pitfalls to Avoid

• Do not order routine imaging in the absence of symptoms or examination findings—this increases costs without improving survival 1, 6
• Do not rely solely on vaginal cytology—it has extremely poor sensitivity (0-7%) for detecting recurrence 1
• Do not extend surveillance intervals too early—maintain the intensive 3-6 month schedule for the full 2 years given the temporal pattern of recurrence 1, 2