Survivorship and MDT working — structured SAQ (15 marks)

(a) Survivorship care plan contents and delivery (3 marks)

One mark for listing components (at least four named), one for naming follow-up/late-effect content, one for the delivery principle. ^[1]

• Diagnosis and staging, treatments received (surgery extent, radiotherapy site/dose/brachytherapy, chemotherapy agents and cumulative doses), the surveillance schedule, the late and long-term effects to monitor, psychosocial resources, the named follow-up provider and shared-care arrangements, and health promotion (exercise, weight, smoking, bone health).^[1]
• Delivery matters: a written copy goes to the patient and her general practitioner, with a named pathway back into specialist care — a plan that lives only in the oncology file has failed.^[1]

(b) Sexual dysfunction — assessment and the restorative ladder (5 marks)

One mark for permission-giving assessment (FSFI), one for non-hormonal first-line, one for topical vaginal oestrogen, one for dilator with adherence, one for physiotherapy/sex therapy referral. ^[2]

• Assess first with permission-giving language ("Many women notice changes after this treatment…"), because dysfunction is prevalent but under-reported unless invited; objectify with the Female Sexual Function Index if needed. Mechanism is radiotherapy-induced epithelial atrophy and fibrosis producing stenosis, shortening and loss of lubrication.^[2]
• Non-hormonal first: vaginal moisturiser for atrophy, lubricant for activity.^[2]
• Topical vaginal oestrogen for atrophy and as part of prevention regimens (studied in the Martins randomised clinical trial of dilator and topical agents for stenosis prevention after cervical radiotherapy).^[3]
• Vaginal dilator therapy to prevent and treat stenosis, started during or soon after radiotherapy, used regularly (several times weekly) and long-term — adherence is the rate-limiting step (Law prospective study).^[4]
• Pelvic floor physiotherapy for hypertonicity and pain, and psychological/sex therapy referral — do not abandon the patient once the physical prescription is written.^[2][4]

(c) Evidence-based surveillance and the limits of the pelvic exam (4 marks)

One mark for the purpose of surveillance, one for symptom/marker/imaging as detection, one for the ovarian-cancer pelvic-exam finding, one for patient-initiated follow-up in endometrial cancer. ^[5]

• Surveillance exists to detect treatable recurrence early, to reassure, and to manage late effects — in tension, because over-surveillance has harms (false positives, cumulative radiation, anxiety).^[5]
• Most recurrences are detected by symptoms, tumour markers and imaging, not the ritual pelvic examination alone.^[5]
• In ovarian cancer, a retrospective series (Holtzman) found most patients were asymptomatic at the time recurrence was detected, and the pelvic examination was not the primary means of detection — the authors conclude the utility of routine surveillance visits and the pelvic exam should be re-examined.^[5]
• In early-stage endometrial cancer, a randomised trial (Jeppesen, BJOG 2018) showed patient-initiated follow-up was feasible and potentially cost-reducing, though hospital-based follow-up alleviated fear of recurrence to a slightly greater degree — so low-risk survivors can be managed with patient-initiated pathways supported by clear re-presentation advice.^[6]

(d) Fear of cancer recurrence and distress (3 marks)

One mark for naming fear of recurrence as the driver, one for the distress thermometer screen, one for the management plan. ^[7]

• Name it: fear of cancer recurrence is near-universal and is the single biggest driver of surveillance demand — no number of normal scans will treat the underlying fear.^[6]
• Screen with the Distress Thermometer (paired with the Impact Thermometer in Akizuki's work), repeated at visits; a positive screen triggers structured psychological assessment.^[7]
• Manage by acknowledging and normalising the fear, giving a specific written re-presentation plan ("if you develop new bleeding, constant pelvic pain, blood in your urine or a swollen leg, contact the clinic — don't wait"), offering structured psychological therapies for entrenched fear, and treating comorbid anxiety or depression.^[6]