Virtual Exams for Routine Surveillance After Ovarian Cancer

Roxanne Nelson, RN, BSN

February 15, 2022

Among patients with ovarian cancer who have achieved remission, routine surveillance with virtual appointments, along with tumor marker monitoring and imaging, may offer an alternative to the currently mandated frequent in-person visits.

The suggestion comes from Jacqueline Feinberg, MD, gynecologic oncology fellow at Memorial Sloan Kettering Cancer Center (MSKCC), New York City, and colleagues, who conducted a retrospective review of 147 patients who experienced ovarian cancer recurrence within 2 years of their first clinical remission, and found that none of these recurrences were detected by physical examination alone.

About one third of these patients had a recurrence that was first detected by tumor marker, over half by imaging, and the rest by the presentation of new symptoms and biopsies taken during non-oncologic surgery.

"This finding suggests that virtual visits, which have quickly gained acceptance during the COVID-19 pandemic, combined with a surveillance protocol for tumor marker testing and imaging, may be sufficient to identify ovarian cancer recurrence,"  the team concludes. The study was published in the February issue of the International Journal of Gynecologic Cancer.

The COVID-19 pandemic has accelerated the use of telemedicine, with new international guidelines recommending minimizing in-person contact, note the authors.

They wondered how this would work in patients who have achieved remission from ovarian cancer.  

At MSKCC, the usual surveillance protocol for the first 2 years after ovarian cancer remission includes an in-person physical examination every 3 months, along with CA-125 testing and imaging of the chest, abdomen, and pelvis. For year 3, the time between surveillance testing is extended to every 3-6 months, for the fourth and fifth year, to every 6 months. Beyond 5 years, physical examination and testing for the protein CA-125 are performed annually, and imaging is optional.

However, there is no strong evidence to support this current surveillance regimen, the authors point out. They sought to determine if  it was possible to do virtual visits instead, along with tumor marker monitoring and imaging.

Evidence for Virtual Exams

To answer that question, Feinberg and colleagues from MSKCC conducted a retrospective study that included patients who were initially seen from January 2015 to December 2017, and who had achieved clinical remission and then  experienced ovarian cancer recurrence with 2 years of remission.

A total of 147 patients were included in the final analysis. None of these patients had their recurrence detected on routine physical exam, including pelvic exam, as the primary method of detection. More than half of patients (n = 81, 55%) had their recurrence detected on radiographic scan, whereas for 46 patients (31%), it was by tumor marker. Among the remaining patients, 17 (12%) experienced new symptoms and for 3 (2%), it was by biopsy during a non-oncologic surgery.

By the time treatment was initiated for recurrence, 111 patients (75%) had multiple positive findings; 48 (33%) had symptoms, 21 (14%) had physical exam findings, 106 (72%) had increases in their tumor markers, and 141 (96%) had changes on their imaging.

In addition, 131 (89%) had baseline increases in CA-125, and of 16 remaining patients, 12 experienced a CA-125 increase during recurrence.

There were 21 patients who had positive physical exam findings following their recurrence, which had already been detected. Within this subset, 19 had concurrent symptoms, and for 6 of them, symptom onset had been the primary method of detection. For the 2 patients without symptoms, recurrence was initially detected by a rise in CA-125 on routine check in one patient, by surveillance imaging in the other.

The authors are now planning a pilot virtual intensive surveillance program, where they will evaluate patient-reported outcomes

The study was funded in part through the NIH/NCI Cancer Center Support Grant P30 CA008748. Study author Dennis Chi, MD, reports personal fees from Bovie Medical Co. (now Apyx Medical), Verthermia, C Surgeries, and Biom'Up, and is also a former stockholder of Intuitive Surgical and TransEnterix. The other authors have disclosed no relevant financial relationships.

Int J Gynecol Cancer. Published online February 7, 2022. Full text

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