Intensive care.

Top Line: Does intensive post-treatment surveillance improve survival in women treated for endometrial cancer?

The Study: In the TOTEM trial, 1847 women with FIGO I-IV endometrial cancer treated with surgery and indicated adjuvant therapy at 42 centers in France and Italy were randomized to an intensive versus minimalist surveillance schedule. Two thirds had surgery alone and the remaining third had surgery and adjuvant therapy. Importantly, a baseline CT chest, abdomen, pelvic was performed prior to randomization. At randomization, a 5-year follow-up schedule was generated that specified all visits, examination, and tests. It is important to note that both the intensive and minimalist follow up schedules were tailored to risk. Most patients (60.2%) were low risk (FIGO IA, grade 1-2). For those patients, minimalist follow up consisted of 11 visits with physical exams over 5 years–no other tests, cytology, or imaging. Low risk intensive follow up consisted of 13 visits/exams, annual vaginal cytology, and annual chest, abdomen, pelvis imaging. For those with high to intermediate risk, minimalist follow up consisted of 13 visits/exams and annual imaging for 2 years while intensive follow up consisted of 14 visits/exams with a CA-125 at each visit, an ultrasound of the abdomen and pelvis every 6 months for 3 years and then annually, annual cytology, and annual CT imaging. Even though it’s been hard to show improved survival with adjuvant therapy for endometrial cancer, TOTEM had the ambitious goal of improving OS by 5% with follow up alone. At 5 years, there was no difference in survival with intensive surveillance (90.6% v 91.9%). Even among the high risk group, intensive surveillance did not improve survival (85.3% v 84.7%). In interpreting the findings, it is important to note that 60.2% had low risk disease and 89.3% had stage I disease. In other words, the highest risk patients had relatively low representation. Finally, it’s important to remember that even minimalist follow up was tailored to risk and included baseline imaging and annual imaging for those at high intermediate risk.

TBL: In the TOTEM trial, intensive follow up for (mostly) stage I, low risk endometrial cancer did not improve overall survival compared to a less intensive, but risk-tailored follow up schedule. | Zola, J Clin Oncol 2022