You’ve been treated for uterine cancer. Now what? With surveillance strategies varying from doctor to doctor, it can be hard to know which advice you should follow. Dr. Jennifer Mueller, Head of the Endometrial Cancer Section, Gynecologic Oncology Service at Memorial Sloan Kettering Cancer Center, delves into surveillance guidelines, which tests to consider, and how to keep an eye out for any symptoms which could indicate recurrence. 

1. MSK Confidential — do not distribute
Moving forward after
uterine cancer treatment
Jennifer Mueller, MD
March 2024
Surveillance strategies, testing, and watching for
recurrence

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MSK Confidential — do not distribute
I have no disclosures

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Outline for this talk
• Define basic terms used in cancer care (surveillance, remission, recurrence, cure)
• Review the different risk of recurrence profiles
• Early versus advanced stage
• High-risk versus low-risk
• Review the current guidelines for endometrial cancer surveillance
• Discuss sites of potential recurrence and how risk differs across patient groups
• Frequently Asked Questions
• Side effects from treatment and supportive strategies
• Future directions for endometrial cancer surveillance

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National Cancer Institute Dictionary of Cancer Terms and
American Cancer Society cancer.org/cancer/understanding-cancer/can-cancer-be-cured
What do these words even mean?
• Surveillance – closely watching a patient’s condition but not giving any treatment unless there are changes
in test results that show the condition is getting worse. During surveillance certain exams, tests and
biopsies can be done to monitor the condition.
• Remission – all signs and symptoms of cancer have disappeared, although cancer may still be in the body
• Recurrence – cancer that has come back, after a period of time which the cancer could not be detected.
Can come back to the same place or another place in the body.
• Cure – cancer has gone away, no more treatment is needed and the cancer is not expected to come back.
• Cure alternate definition – to heal or restore health

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Matei D et al. N Engl J Med 2019;380:2317-2326
Seer.cancer.gov/statfacts
Siegenthaler F et al. Gyn Oncol. 2022;165:230-238
What is my risk of the cancer coming back?
• Approximately 1:5 (~20%) patients will experience recurrence
• Most occur within 2 years of completing treatment
• Recurrence risk is not the same for all patients
• Some factors that matter:
• Stage
• Cell type (‘high grade’ or ‘low grade’)
• Age
• Treatment after surgery

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https://www.mypathologyreport.ca/pathology-dictionary/definition-lymphovascular-invasion/
https://foundationforwomenscancer.org/resources/survivorship/
What is my risk of the cancer coming back?
Low grade tumors
Endometrioid (Grades 1,2)
High grade tumors
Endometrioid (Grade 3)
Serous
Clear Cell
Carcinosarcoma
De/Undifferentiated

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https://foundationforwomenscancer.org/resources/survivorship/
What is my risk of the cancer coming back?

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Cytology not indicated (low yield)
CA125 can be checked IF ELEVATED AT DIAGNOSIS
Current surveillance guidelines
80% of recurrences are detected with exam + symptom review
MSKCC
Low risk
– Every 6 mos year 1
– Annually til year 2-5
– Pelvic exam, symptom review, imaging
if indicated
Intermediate risk
– Every 3 mos year 1
– Every 6 mos year 2
– Annually til years 3-5
– Pelvic exam, symptom review, imaging
if indicated
High risk
– Every 3 mos year 1-2
– Every 6 mos years 3-5
– Pelvic exam, symptom review, imaging
if indicated
Society of Gynecologic Oncology (SGO) NCCN

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https://www.mayoclinic.org/tests-procedures/pelvic-exam/about/pac-20385135
What do we mean ‘symptom review’ and ‘imaging when
indicated’?
Common symptoms (new/persistent)
• Vaginal or rectal bleeding
• Pain
• Coughing
• Weight loss, headaches
• Lethargy (constant low-level fatigue)
• Bumps in neck, groin
Indications for imaging
• New or concerning symptom
• Exam finding (lesion in vagina, bump/mass)
• Type of imaging can vary (MRI, CT, PET, US)

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Francesco Legge et al. Int J Gynecol Cancer 2020;30:193-200
Potential areas of recurrence
local versus distant
• Local recurrence (vagina)
• Belly cavity (peritoneum)
• Lymph nodes
• Liver
• Lung
• Bone
• Brain
• Genital area

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Francesco Legge et al. Int J Gynecol Cancer 2020;30:193-200
Potential areas of recurrence
local versus distant
• Local recurrence (vagina)
• Belly cavity (peritoneum)
• Lymph nodes
• Liver
• Lung
• Bone
• Brain
• Genital area
Imaging
Exam

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Google images
FAQs
Should I have pap test?
Answer:
Not for endometrial cancer
surveillance.
If you had abnormal paps before
surgery an annual pap is
indicated for that reason.
Reason: No evidence that pap
tests increase or enhance
detection of endometrial cancer
recurrence

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Google images
FAQs
Are there any blood tests I
should be getting?
Answer:
Not routinely for most people.
If you had a CA125 elevated
before surgery/treatment it may
be a useful test after completing
treatment.
Reason: We don’t have any
evidence-based blood tests that
are approved for routine
screening for endometrial cancer
recurrence.

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Google images
FAQs
What imaging should I get,
and how often?
Answer:
No routine imaging is indicated
for endometrial cancer
surveillance.
Reason: No evidence that routine
imaging in patients with normal
exams and no symptoms will
improve disease detection or
prolong survival.

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Google images
FAQs
What imaging should I get,
and how often?
In practice:
Patients with advanced stage or
high risk endometrial cancer will
typically have once or twice a
year imaging for the first 2-3
years.
Patients with ovary sparing
treatment will typically have
imaging of ovaries (US or MRI)
for the first 2-3 years.

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The potential costs of endometrial cancer treatment
• Post-surgical pain
• Fatigue
• Lymphedema (swelling in the legs)
• Numbness/tingling/pain in the feet and hands
• Weight gain
• Menopause
• Pain with sexual activity
• Vaginal dryness
• Depression
• Anxiety

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https://www.mskcc.org/cancer-care/patient-education/vaginal-health
Vulvovaginal
health
Moisturizers
Hydrating moisturizers
• HYALO GYN
• Revaree
• Replens
• Good Clean Love BioNourish
Natural Oils
• Vitamin E
• Coconut
• Carlson Key-E suppositories
Never use petroleum products
(increases risk of infection)

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https://www.mskcc.org/cancer-care/patient-education/vaginal-health
Vulvovaginal
health
Lubricants
Water-based
• Aloe Cadabra
• Luvena
• AH! YES
• Good Clean Love
Natural Oils
• Almond
Silicone-based
• Pjur
• PINK

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https://www.mskcc.org/cancer-care/patient-education/vaginal-health
Vaginal dilator use
• Can improve health and elasticity (stretch)
• Can make pelvic exams easier
• Can decrease pain with penetration
• Water-based lubricant helpful
• Increase size of dilator slowly over time
• Goal to use 3-4 times per week
• Avoid daily use (irritation, pain)
• Kegel exercises before dilators can be helpful

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Pelvic floor
health
Pelvic physical therapy can be
helpful for multiple symptoms
• Pain
• Incontinence
• Constipation
Professional pelvic PT is now
common in many communities
Goal is to improve movement,
mobility, reduce pain

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https://www.mayoclinic.org/diseases-conditions/hot-flashes/diagnosis-treatment/drc-20352795
https://www.mskcc.org/news/5-myths-about-cancer-related-early-menopause
Menopause
Average age 51 years (but varies)
• No menses for 12 months
• Surgical removal of the ovaries (abrupt)
Common symptoms
• Hot flashes
• Vaginal dryness
• Mood changes
• Sleep disturbance
• Bladder dysfunction
Non-hormonal options for hot flash management
• Gabapentin (Neurontin) or Pregabalin (Lyrica)
• Paroxetine (Brisdelle) FDA approved

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MSK Confidential — do not distribute
Google images
Physical health and
nutrition
Recommendations
• 2.5 hours per week of
moderate aerobic activity
• 2 days per week of muscle
strengthening activity
• 7-9 hours of sleep per night
(National Sleep Foundation)
• Daily calcium and vitamin D
supplementation
• 1200mg Calcium
• 600-800 IU Vitamin D

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https://www.cancer.gov/news-events/cancer-currents-blog/2020/cancer-survivors-managing-
anxiety-distress
Our emotional and psychological well-being

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https://www.cinj.org/managing-mental-health-during-holiday-season
Our emotional and psychological well-being
• Exercise, nutrition, rest
• Mental health professionals
• Support groups
• Stress management
• Social engagement
• Financial stress management

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General health matters too!
• See your primary care provider at least once a year
• Annual flu vaccine
Recommended screening tests (when off treatment)
• Colon cancer: Colonoscopy starting age 45
• Lung cancer: Annual low dose CT starting age 50 (former smokers)
• Breast cancer: Annual mammogram starting age 40
• Osteoporosis: Bone Mineral Density age 65 (earlier if at increased risk)

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Future directions for
endometrial cancer
surveillance

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Future directions for endometrial cancer surveillance

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Future directions for endometrial cancer surveillance

29. Images adapted and modified: https://www.bcgsc.ca/news/genome-sequencing-helps-prioritize-
cancer-treatment-options & https://www.diacarta.com/products/direct-cfdna-test
Circulating tumor DNA is shed into peripheral circulation

30. Ashley et al, Clin Canc Res 2023
cfDNA analysis for disease monitoring in endometrial cancer
Newly diagnosed endometrial cancer patients
Plasma derived cfDNA
MSK ACCESS (Analysis of Circulating cfDNA to Examine Somatic Status)

31. Nature. 2013;497(7447):67-73
The Cancer Genome Atlas (TCGA)

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NCCN Guidelines. Version 1.2024-September 20, 2023. Uterine Neoplasms
NCCN Guidelines® (V1.2024) Biomarker Testing
Recommendations for Endometrial Carcinoma
CN-L is also known as NSMP

33. TABLE 2. Proposed 5-Year Endometrial Cancer Surveillance Protocol
Published in: Anna L. Beavis; Amanda N. Fader; Journal of Clinical Oncology 2022 403790-3795.
DOI: 10.1200/JCO.22.01551
Copyright © 2022 American Society of Clinical Oncology