What is the recommended follow‑up schedule and surveillance strategy for a postmenopausal woman after total hysterectomy with bilateral salpingo‑oophorectomy (with or without lymphadenectomy) for endometrial cancer?

Endometrial Cancer Follow-Up After Hysterectomy

For postmenopausal women after total hysterectomy with bilateral salpingo-oophorectomy for endometrial cancer, follow-up should consist of clinical visits every 3-4 months for the first 3 years, then every 6 months for years 4-5, with history and physical/vaginal examination only—routine imaging, vaginal cytology, and laboratory tests are not recommended as they do not improve survival or detection of curable recurrences. 1

Recommended Surveillance Schedule

Years 1-3 (High-Risk Period)

• Clinical visits every 3-4 months 1
• History and physical examination with vaginal examination at each visit 1
• This intensive schedule is justified because approximately 70% of all recurrences occur within the first 3 years 1, 2

Years 4-5

• Clinical visits every 6 months 1
• Continue history and physical examination with vaginal examination 1

After Year 5

• Annual visits 1
• Maintain focus on clinical examination 1

What to Include at Each Visit

Essential Components

• Detailed history focusing on symptoms of recurrence: vaginal bleeding, pelvic/abdominal/back pain, decreased appetite, weight loss, cough, shortness of breath, leg swelling 1
• Physical examination including pelvic and vaginal examination 1
• The clinical examination is the most effective method for detecting potentially curable vaginal or pelvic recurrences 3

What NOT to Routinely Include

• Vaginal cytology/Pap smears: Not recommended—detected zero recurrences in multiple studies and provides no survival benefit 1, 3, 4
• Routine imaging (CT, MRI): Only order if clinically indicated by symptoms or examination findings 1
• CA-125 levels: Optional at best, not routinely recommended 1
• Chest radiography: May be performed annually but is category 2B evidence (lower quality) 1

Critical Patient Education

Provide both verbal and written instructions on recurrence symptoms 1:

• Vaginal, bladder, or rectal bleeding 1
• Pelvic, abdominal, hip, or back pain 1
• Decreased appetite or weight loss 1
• Cough or shortness of breath 1
• Abdominal or leg swelling 1

Patients should seek immediate evaluation if symptoms develop rather than waiting for scheduled appointments 1, as 75-90% of recurrences are symptomatic at detection 4, 2, 5.

Evidence Supporting This Approach

Why Intensive Testing Doesn't Help

• Only 1 asymptomatic recurrence was detected per 206-653 routine follow-up visits in research studies 4, 6
• No survival difference exists between patients with symptomatic versus asymptomatic recurrence detection 4, 2
• Routine follow-up protocols do not improve detection of recurrences or survival compared to symptom-based evaluation 4

Focus on Curable Recurrences

• The primary goal is early detection of isolated vaginal or pelvic recurrences that may be amenable to curative treatment 1, 3
• Vaginal recurrences treated with radiation therapy have reported survival rates of 40-50% 1
• Clinical examination remains the cornerstone for detecting these potentially curable local recurrences 3

Additional Surveillance Considerations

Screen for Secondary Malignancies

• Increased risk of breast, ovarian, and colon cancers in endometrial cancer survivors 1
• Consider genetic counseling if significant family history suggests hereditary cancer syndrome 1

Health Maintenance

• Blood pressure monitoring 1
• Breast examination and mammography as clinically indicated 1
• Stool guaiac testing 1
• Address other health problems common in this population 1

Common Pitfalls to Avoid

• Over-reliance on vaginal cytology: This test has proven worthless for detecting endometrial cancer recurrence 3, 4
• Ordering routine imaging in asymptomatic patients: This increases cost without improving outcomes 1, 2
• Inadequate patient education about symptoms: Most recurrences are symptomatic, so patient awareness is critical 1, 2
• Failure to maintain the recommended schedule during years 1-3: This is when recurrence risk is highest 3, 2
• Neglecting thorough vaginal examination: This remains the most effective detection method for curable local recurrences 3