GYNECOLOGIC ONCOLOGY 46, 273-274 (1992)

EDITORIAL The Gyn Oncologist as Primary Care Physician

“Clinical Surveillance of Gynecologic Cancer Patients” authored by Barnhill and his co-workers represents a timely and valuable addition to understanding the needs associated with follow-up of patients with invasive gyne- cological neoplasms. The study design is based on a survey of 94 responses of selected gyn oncologists, with proven clinical experience and a background in academic teaching institutions, utilizing 15 questions concerning follow-up visits of women after completing therapy for gynecologic malignancy in an outpatient setting. The results are sub- jective and in general do not represent objective and points.

The survey validates a consistent pattern of follow-up examinations by gyn oncologists every 3 months the first 2 years, every 6 months the next 3 years, and annually after 5 years. One hundred percent of the gynecologic oncologists surveyed performed a pelvic exam, 97% an abdominal exam, 69% a breast exam, 84% a pap smear, and 51% a stool guaiac with every rectovaginal exami- nation at each follow-up visit.

The role and responsibility of the gyn oncologist in patient follow-up is a key question brought to the surface by this survey. The survey indicates that 97% of these patients are followed by gynecologic oncologists, with the assistance of other non-subspeciality physicians. In 65%) the gyn oncologist represented the only source of gyne- cologic care for the patient. After treatment of their can- cer, it is fair to assume that some of these patients also receive primary care from their gynecologic oncologist. The gyn oncologist was involved in ordering a serum cholesterol in 30%, prescribed daily vitamins in 26%, prescribed daily calcium supplementation in 60% (most common dose 1000 mg/day in 29%), checked a smoking history in 29%, and ordered regular sigmoidoscopy in 28%. Ninety-one percent of the respondents believe that the gynecologic oncologist should be responsible for breast cancer screening and 65% believe in colon cancer screening for their patients.

The definition of a gynecologic oncologist has pro- gressively expanded and undergone refinement since Rut-

ledge’s definition in 1972. The cross-discipline training in gynecological, gastrointestinal, and genitourinary surgery as well as chemotherapy, radiation therapy, and nutrition attests to the skill of the gynecological oncologist in the treatment of the patient with gynecological malignancy. It provides the patient a single physician for treatment of their cancer, complications, and allied diseases.

Patients naturally fall into high-risk and low-risk groups according to histological grade, depth of invasion, extent of tumor, other prognostic factors, etc. High-risk patients are followed differently than low-risk patients. For in- stance, in our clinic, a patient with a FIG0 Stage IB squamous cell carcinoma of the cervix with positive pelvic and para-aortic nodes will be followed every l-2 months during the first 2 years, as opposed to every 3 months as proposed by the authors. With poor prognostic disease, recurrences are likely to occur earlier during the first l- 2 years after treatment and in patients with a good prog- nosis many of these patients will pass 3 years following treatment and go on to survive without further recurrence or treatment.

Unfortunately, we do not have quantifiable data to set guidelines for suggesting optimal intervals between clinic visits for low- and high-risk patients. And particularly, when asymptomatic, the lack of guidelines as to the fre- quency of follow-up, chest X ray, serum markers, and CAT scans makes it difficult to determine the timing of these evaluations. This study has recycled the age-old need for a prospective longitudinal study of essential lab- oratory studies in patients with invasive gynecological malignancies.

The role of the gynecologic oncologist as a primary care physician is controversial and not recommended, at least not in the conventional sense as a gatekeeper and provider of comprehensive care, for his/her patient with a primary medical problem. Every effort is made to return the patient to her primary care physician. Pragmatically, however, gynecologic oncologists sometimes have to ad- dress first-line care because their patients request it. To 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 pa- tients in a responsible manner. In the symptomatic pa- tient, 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 on- cologist has the responsibility to ensure that his/her pa- tient receives good medical care. The primary focus in this instance should be on screening patients for follow- up 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 pre- scribe 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 screen- ing in cardiovascular, metabolic, and extragenital neo- plastic diseases in the period following successful treat- ment 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