GYNECOLOGIC
ONCOLOGY
46,
273-274 (1992)
EDITORIAL The Gyn Oncologist as Primary Care Physician “Clinical Surveillance of Gynecologic Cancer Patients” ledge’s definition in 1972. The cross-discipline training in authored by Barnhill and his co-workers represents a gynecological, gastrointestinal, and genitourinary surgery timely and valuable addition to understanding the needs as well as chemotherapy, radiation therapy, and nutrition associated with follow-up of patients with invasive gyne- attests to the skill of the gynecological oncologist in the cological neoplasms. The study design is based on a survey treatment of the patient with gynecological malignancy. of 94 responses of selected gyn oncologists, with proven It provides the patient a single physician for treatment clinical experience and a background in academic teaching of their cancer, complications, and allied diseases. Patients naturally fall into high-risk and low-risk groups institutions, utilizing 15 questions concerning follow-up visits of women after completing therapy for gynecologic according to histological grade, depth of invasion, extent malignancy in an outpatient setting. The results are sub- of tumor, other prognostic factors, etc. High-risk patients jective and in general do not represent objective and are followed differently than low-risk patients. For instance, in our clinic, a patient with a FIG0 Stage IB points. The survey validates a consistent pattern of follow-up squamous cell carcinoma of the cervix with positive pelvic examinations by gyn oncologists every 3 months the first and para-aortic nodes will be followed every l-2 months 2 years, every 6 months the next 3 years, and annually during the first 2 years, as opposed to every 3 months as after 5 years. One hundred percent of the gynecologic proposed by the authors. With poor prognostic disease, oncologists surveyed performed a pelvic exam, 97% an recurrences are likely to occur earlier during the first labdominal exam, 69% a breast exam, 84% a pap smear, 2 years after treatment and in patients with a good progand 51% a stool guaiac with every rectovaginal exami- nosis many of these patients will pass 3 years following treatment and go on to survive without further recurrence nation at each follow-up visit. or treatment. The role and responsibility of the gyn oncologist in Unfortunately, we do not have quantifiable data to set patient follow-up is a key question brought to the surface by this survey. The survey indicates that 97% of these guidelines for suggesting optimal intervals between clinic patients are followed by gynecologic oncologists, with the visits for low- and high-risk patients. And particularly, assistance of other non-subspeciality physicians. In 65%) when asymptomatic, the lack of guidelines as to the frethe gyn oncologist represented the only source of gyne- quency of follow-up, chest X ray, serum markers, and cologic care for the patient. After treatment of their can- CAT scans makes it difficult to determine the timing of cer, it is fair to assume that some of these patients also these evaluations. This study has recycled the age-old receive primary care from their gynecologic oncologist. need for a prospective longitudinal study of essential labThe gyn oncologist was involved in ordering a serum oratory studies in patients with invasive gynecological cholesterol in 30%, prescribed daily vitamins in 26%, malignancies. prescribed daily calcium supplementation in 60% (most The role of the gynecologic oncologist as a primary common dose 1000 mg/day in 29%), checked a smoking care physician is controversial and not recommended, at history in 29%, and ordered regular sigmoidoscopy in least not in the conventional sense as a gatekeeper and 28%. Ninety-one percent of the respondents believe that provider of comprehensive care, for his/her patient with the gynecologic oncologist should be responsible for a primary medical problem. Every effort is made to return breast cancer screening and 65% believe in colon cancer the patient to her primary care physician. Pragmatically, screening for their patients. however, gynecologic oncologists sometimes have to adThe definition of a gynecologic oncologist has pro- dress first-line care because their patients request it. To gressively expanded and undergone refinement since Rut- maintain a professional and supportive relationship with 273 WO-8258192 $4.00 Copyright 0 1992 by Academic Press, Inc. All rights of reproduction in any form reserved.
274
EDITORIAL
these patients, the gynecologic oncologist can get caught in a catch-22 situation and needs to respond to their patients in a responsible manner. In the symptomatic patient, the problem is easily identified and the patient can be triaged to the appropriate physician without difficulty. What about the patient who is asymptomatic and doing well following treatment of her gynecological cancer? The author believes that, in this instance, the gynecologic oncologist has the responsibility to ensure that his/her patient receives good medical care. The primary focus in this instance should be on screening patients for followup of nongynecological disease. The recommendations of the American College of Obstetricians and Gynecologists (ACOG), American Cancer Society (ACS), and the American Heart Association are useful in this regard. Since a higher association of some malignant neoplasms exists between some cancers, such as adenocarcinoma of the endometrium and cancer of the breast and the colon, consideration should be given to these specific associations. The role of estrogen-replacement therapy following treatment of gynecological cancer was not included in this survey. The author believes that this is a crucial issue in
all of our patients. Unfortunately, the dictum “if there is a potential risk don’t use it” makes it difficult to prescribe exogenous estrogens in many cancers which the gynecologic oncologist treats. Because of the ethical issues involved, data relating estrogen replacement therapy and gynecologic cancer may never be forthcoming. The article by Barnhill and his coauthors is provocative and sets the stage for serious scientific inquiry into the timing and selection of tests in low-risk and high-risk disease and the role of the gynecologic oncologist screening in cardiovascular, metabolic, and extragenital neoplastic diseases in the period following successful treatment of gynecological cancer. REFERENCES 1. Rutledge, F. N. The gynecologic oncologist, his responsibilities and training, Obsret. Gynecol. 40, 749-754 (1972).
Robert D. Hilgers, M.D. Department of Obstetrics and Gynecology Southern Illinois University School of Medicine Springfield, Illinois 62794-9230
ONCOLOGY
46,
273-274 (1992)
EDITORIAL The Gyn Oncologist as Primary Care Physician “Clinical Surveillance of Gynecologic Cancer Patients” ledge’s definition in 1972. The cross-discipline training in authored by Barnhill and his co-workers represents a gynecological, gastrointestinal, and genitourinary surgery timely and valuable addition to understanding the needs as well as chemotherapy, radiation therapy, and nutrition associated with follow-up of patients with invasive gyne- attests to the skill of the gynecological oncologist in the cological neoplasms. The study design is based on a survey treatment of the patient with gynecological malignancy. of 94 responses of selected gyn oncologists, with proven It provides the patient a single physician for treatment clinical experience and a background in academic teaching of their cancer, complications, and allied diseases. Patients naturally fall into high-risk and low-risk groups institutions, utilizing 15 questions concerning follow-up visits of women after completing therapy for gynecologic according to histological grade, depth of invasion, extent malignancy in an outpatient setting. The results are sub- of tumor, other prognostic factors, etc. High-risk patients jective and in general do not represent objective and are followed differently than low-risk patients. For instance, in our clinic, a patient with a FIG0 Stage IB points. The survey validates a consistent pattern of follow-up squamous cell carcinoma of the cervix with positive pelvic examinations by gyn oncologists every 3 months the first and para-aortic nodes will be followed every l-2 months 2 years, every 6 months the next 3 years, and annually during the first 2 years, as opposed to every 3 months as after 5 years. One hundred percent of the gynecologic proposed by the authors. With poor prognostic disease, oncologists surveyed performed a pelvic exam, 97% an recurrences are likely to occur earlier during the first labdominal exam, 69% a breast exam, 84% a pap smear, 2 years after treatment and in patients with a good progand 51% a stool guaiac with every rectovaginal exami- nosis many of these patients will pass 3 years following treatment and go on to survive without further recurrence nation at each follow-up visit. or treatment. The role and responsibility of the gyn oncologist in Unfortunately, we do not have quantifiable data to set patient follow-up is a key question brought to the surface by this survey. The survey indicates that 97% of these guidelines for suggesting optimal intervals between clinic patients are followed by gynecologic oncologists, with the visits for low- and high-risk patients. And particularly, assistance of other non-subspeciality physicians. In 65%) when asymptomatic, the lack of guidelines as to the frethe gyn oncologist represented the only source of gyne- quency of follow-up, chest X ray, serum markers, and cologic care for the patient. After treatment of their can- CAT scans makes it difficult to determine the timing of cer, it is fair to assume that some of these patients also these evaluations. This study has recycled the age-old receive primary care from their gynecologic oncologist. need for a prospective longitudinal study of essential labThe gyn oncologist was involved in ordering a serum oratory studies in patients with invasive gynecological cholesterol in 30%, prescribed daily vitamins in 26%, malignancies. prescribed daily calcium supplementation in 60% (most The role of the gynecologic oncologist as a primary common dose 1000 mg/day in 29%), checked a smoking care physician is controversial and not recommended, at history in 29%, and ordered regular sigmoidoscopy in least not in the conventional sense as a gatekeeper and 28%. Ninety-one percent of the respondents believe that provider of comprehensive care, for his/her patient with the gynecologic oncologist should be responsible for a primary medical problem. Every effort is made to return breast cancer screening and 65% believe in colon cancer the patient to her primary care physician. Pragmatically, screening for their patients. however, gynecologic oncologists sometimes have to adThe definition of a gynecologic oncologist has pro- dress first-line care because their patients request it. To gressively expanded and undergone refinement since Rut- maintain a professional and supportive relationship with 273 WO-8258192 $4.00 Copyright 0 1992 by Academic Press, Inc. All rights of reproduction in any form reserved.
274
EDITORIAL
these patients, the gynecologic oncologist can get caught in a catch-22 situation and needs to respond to their patients in a responsible manner. In the symptomatic patient, the problem is easily identified and the patient can be triaged to the appropriate physician without difficulty. What about the patient who is asymptomatic and doing well following treatment of her gynecological cancer? The author believes that, in this instance, the gynecologic oncologist has the responsibility to ensure that his/her patient receives good medical care. The primary focus in this instance should be on screening patients for followup of nongynecological disease. The recommendations of the American College of Obstetricians and Gynecologists (ACOG), American Cancer Society (ACS), and the American Heart Association are useful in this regard. Since a higher association of some malignant neoplasms exists between some cancers, such as adenocarcinoma of the endometrium and cancer of the breast and the colon, consideration should be given to these specific associations. The role of estrogen-replacement therapy following treatment of gynecological cancer was not included in this survey. The author believes that this is a crucial issue in
all of our patients. Unfortunately, the dictum “if there is a potential risk don’t use it” makes it difficult to prescribe exogenous estrogens in many cancers which the gynecologic oncologist treats. Because of the ethical issues involved, data relating estrogen replacement therapy and gynecologic cancer may never be forthcoming. The article by Barnhill and his coauthors is provocative and sets the stage for serious scientific inquiry into the timing and selection of tests in low-risk and high-risk disease and the role of the gynecologic oncologist screening in cardiovascular, metabolic, and extragenital neoplastic diseases in the period following successful treatment of gynecological cancer. REFERENCES 1. Rutledge, F. N. The gynecologic oncologist, his responsibilities and training, Obsret. Gynecol. 40, 749-754 (1972).
Robert D. Hilgers, M.D. Department of Obstetrics and Gynecology Southern Illinois University School of Medicine Springfield, Illinois 62794-9230
