Should an adult woman in complete remission after chemoradiation (combined chemotherapy and radiation therapy) for endometrial carcinoma, with normal PET (positron emission tomography) scans at 3 months and 1 year, undergo any further routine PET imaging or CA‑125 (cancer antigen 125) testing for surveillance?

Surveillance After Complete Remission of Endometrial Carcinoma

Routine PET imaging and CA-125 testing are NOT recommended for surveillance in asymptomatic patients with endometrial carcinoma in complete remission after chemoradiation. 1

Evidence-Based Surveillance Approach

What Guidelines Recommend

The NCCN guidelines for endometrial cancer explicitly state that intensive surveillance has not been demonstrated to provide value in this disease, and therefore ancillary testing is not recommended 1. This is reinforced by the ACR Appropriateness Criteria, which clearly specify that radiologic evaluation such as CT scan or PET/CT scan should only be used to investigate suspicion of recurrent disease and not for routine surveillance after treatment 1.

Standard Surveillance Protocol

For patients in complete remission, the recommended approach includes 1:

• Clinical visits every 3-6 months for the first few years (when recurrence risk is highest)
• History and physical examination at each visit, focusing on symptoms of recurrence
• No routine imaging (PET, CT, or MRI) in asymptomatic patients
• No routine CA-125 testing in asymptomatic patients

Why This Approach?

Most recurrences are symptomatic (50-70% of patients with recurrence present with symptoms), making aggressive surveillance imaging of limited value 1. The recurrence rate for clinical stage I and II endometrial cancer is approximately 15%, with most occurring within 3 years of initial treatment 1.

Critical Symptoms to Monitor

Patients should be educated to seek immediate evaluation (not wait for scheduled appointments) if they experience 1:

• Vaginal, bladder, or rectal bleeding
• Decreased appetite or weight loss
• Pelvic, abdominal, hip, or back pain
• Cough or shortness of breath
• Abdominal or leg swelling

Role of CA-125 in Endometrial Cancer

Limited Utility in Routine Surveillance

While CA-125 can be elevated in some endometrial cancer patients, its role in routine surveillance is not established 1. The evidence shows:

• More than half of patients with advanced-stage or high-grade endometrial cancer have elevated pretreatment CA-125 levels 2
• CA-125 accounts for only 15% of asymptomatic recurrence detection in select endometrial cancer patients 2
• False elevations can occur after radiation therapy, which is particularly relevant for this patient 3, 4

When CA-125 Might Be Considered

CA-125 testing may be considered in highly select circumstances 2:

• Patients with advanced disease at diagnosis
• Serous histology (which has higher recurrence risk)
• Elevated pretreatment CA-125 levels

However, even in these cases, routine testing is not standard practice 1.

PET Imaging: Not for Routine Surveillance

Clear Guideline Recommendations

The ACR explicitly states that PET/CT should only be used to investigate suspicion of recurrent disease, not for routine surveillance 1. This is consistent across multiple gynecologic cancer guidelines.

When PET Might Be Appropriate

PET imaging should be reserved for 1:

• Symptomatic patients with concern for recurrence
• Investigation of abnormal findings on physical examination
• Evaluation of rising tumor markers (if they were being followed)

Pitfalls of Routine PET Surveillance

• False positives from post-radiation inflammation can lead to unnecessary biopsies and surgeries 1
• No survival benefit has been demonstrated from early detection via routine imaging in asymptomatic patients
• Increased cost and patient anxiety without proven clinical benefit

Quality of Life Considerations

Observation with symptom-directed evaluation provides psychosocial reassurance without the burden of intensive testing 1. Evidence from ovarian cancer surveillance (which has been more extensively studied) suggests that treating recurrences early based solely on asymptomatic detection does not improve survival and may decrease quality of life 1, 5.

Practical Management Algorithm

For this patient with normal PET scans at 3 months and 1 year post-chemoradiation:

1. Continue clinical surveillance every 3-6 months for years 1-2, then every 6 months for years 3-5 1
2. Perform thorough history and physical examination at each visit, including pelvic examination 1
3. Educate patient about warning symptoms requiring immediate evaluation 1
4. Do NOT order routine PET scans 1
5. Do NOT order routine CA-125 testing unless it was markedly elevated at diagnosis and patient had high-risk features 1, 2
6. Order imaging only if symptoms develop or physical examination findings are concerning 1

Common Pitfalls to Avoid

• Do not confuse ovarian cancer surveillance with endometrial cancer surveillance - the evidence base differs significantly 1
• Do not order PET scans based on patient anxiety alone - counsel patients about lack of benefit and potential harms 1
• Be aware that radiation therapy can cause false CA-125 elevations if testing is performed 3, 4
• Remember that vaginal cytology is no longer recommended for asymptomatic endometrial cancer patients 1