title: Detection of recurrence in early stage endometrial cancer - the role of symptoms and routine follow-up.
abstract: BACKGROUND
  Considerable controversy remains as to the optimal organization of endometrial cancer follow-up.
  
  
  OBJECTIVE
  To evaluate the relationship between the way recurrence was detected and survival after treatment for endometrial cancer. Further, to identify characteristics associated with a pre-scheduled examination in women with symptomatic recurrence.
  
  
  METHODS
  All women with early stage endometrial cancer during 2005-2009 were included in a population-based historical cohort derived from the Danish Gynecological Cancer Database. Women diagnosed with recurrence within three years after primary surgery and the mode of recurrence detection were identified from hospital charts: asymptomatic recurrence detected at regular follow-up, symptomatic recurrence detected at regular follow-up or symptomatic recurrence detected in between follow-up. Survival of women with symptomatic and asymptomatic disease was compared. Furthermore, characteristics associated with self-referral as compared to presenting symptoms at regular follow-ups were identified using univariate analyses.
  
  
  RESULTS
  In total, 183 cases of recurrence (7%) were identified in the cohort of 2612 women. Of these, 65.5% were symptomatic with vaginal bleeding as the most prevalent symptom. Asymptomatic women had a significantly better three-year survival rate compared to symptomatic women (80.3% vs. 54.3%, p < 0.01). A total of 2.3% of the entire population had an asymptomatic recurrence. Women diagnosed at a pre-scheduled visit due to symptoms had a higher educational level (p = 0.03) and more often high-risk disease (p = 0.02) than symptomatic women diagnosed at regular follow-up.
  
  
  CONCLUSIONS
  Early stage endometrial cancer carries a low risk of recurrence. Survival appears to be superior in asymptomatic patients, but length-time bias, i.e. the effect of aggressive tumor biology in symptomatic recurrences, may bias results in non-randomized controlled trials. Well educated patients with symptoms of recurrence more often sought medical attendance compared to less educated counterparts. This should be considered if patient-initiated follow-up is the standard care.
authors.affiliation: a Department of Gynaecology and Obstetrics, Faculty of Health Sciences , Odense University Hospital, Clinical Institute, University of Southern Denmark , Odense , Denmark.
authors.forename: Mette Moustgaard
authors.initials: MM
authors.lastname: Jeppesen
authors.affiliation: b Department of Obstetrics and Gynaecology , Karolinska University Hospital, Sweden and Clinical Institute, University of Southern Denmark , Odense , Denmark.
authors.forename: Ole
authors.initials: O
authors.lastname: Mogensen
authors.affiliation: c The National Research Center of Cancer Rehabilitation, Research Unit of General Practice , University of Southern Denmark , Odense , Denmark.
authors.forename: Dorte Gilså
authors.initials: DG
authors.lastname: Hansen
authors.affiliation: d The Research Unit of Clinical Epidemiology , Institute of Clinical Research, University of Southern Denmark , Odense , Denmark.
authors.forename: Maria
authors.initials: M
authors.lastname: Iachina
authors.affiliation: a Department of Gynaecology and Obstetrics, Faculty of Health Sciences , Odense University Hospital, Clinical Institute, University of Southern Denmark , Odense , Denmark.
authors.forename: Malene
authors.initials: M
authors.lastname: Korsholm
authors.affiliation: a Department of Gynaecology and Obstetrics, Faculty of Health Sciences , Odense University Hospital, Clinical Institute, University of Southern Denmark , Odense , Denmark.
authors.forename: Pernille Tine
authors.initials: PT
authors.lastname: Jensen
mesh_terms: D000368:Aged; D016889:Endometrial Neoplasms / Q000175:diagnosis* / Q000401:mortality / Q000473:pathology; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local / Q000175:diagnosis*; D009367:Neoplasm Staging