Survivorship, MDT working and the generalist's role — structured SAQ (15 marks)

(a) Surveillance schedule and the evidence principle (3 marks)

One mark for the intervals, one for the role of routine testing, one for the principle. ^[1]

• Endometrial cancer surveillance: review every 3 to 6 months for 2 to 3 years, then 6 to 12 monthly to 5 years.
• Routine vault cytology and imaging add no survival benefit in the asymptomatic woman — the SGO recommendations (Salani 2017) are explicit. Surveillance is by history and examination.
• The principle: surveillance is symptom-driven, not test-driven — thorough history and examination detect most recurrences; routine testing detects them earlier but not well enough to change survival.^[1]

(b) The swollen leg — differential and workup (3 marks)

One mark for the differential, one for excluding recurrence, one for the lymphoedema workup and management. ^[2]

• Differential: recurrent disease versus treatment-induced lymphoedema (after lymphadenectomy or radiotherapy) versus DVT.
• Exclude recurrence first: targeted imaging of the leg and pelvis (MRI preferred) to exclude nodal recurrence or disease involving the iliac vessels; biopsy where a mass or node is identified.
• Lymphoedema management (once recurrence excluded): limb circumference measurement, complete decongestive therapy (manual lymphatic drainage, compression bandaging then garments, exercise, skin care), and referral to a lymphoedema service. Treat any cellulitis early and aggressively.^[2]

(c) Sexual dysfunction and genitourinary symptoms (3 marks)

One mark for screening, one for the specific interventions, one for the referral pathway. ^[4]

• Screen: ask directly — sexual dysfunction affects over 60 per cent of gynae-cancer survivors and is rarely volunteered. Normalise the question.
• Manage the reversible contributors: vaginal dilators for stenosis (graded schedule with lubricants); topical vaginal oestrogen for genitourinary syndrome of menopause where safe; systemic HRT where appropriate for her treatment-induced menopause.
• Refer to a sexual health counsellor or psycho-oncology for body-image, relationship and psychosexual work; address partner involvement where appropriate.^[4]

(d) Adjustment versus clinically significant fear of recurrence (3 marks)

One mark for the distinction, one for the screening, one for the evidence-based management. ^[3]

• Expected adjustment: grief, anxiety and low mood in early survivorship that are time-limited and resolve with support. Intrusive daily thoughts that stop sleep and impair function are not normal adjustment.
• Clinically significant FCR: intrusive, persistent, disabling fear — avoidance of follow-up, hypervigilance to bodily sensations, impaired functioning. Screen with the single-item question or the FCRI.
• Evidence-based management: validation and normalisation first; for clinically significant FCR, structured cognitive-existential group therapy — the FORT randomised controlled trial (Maheu 2023) showed reduced fear-of-recurrence scores. Refer severe cases to psycho-oncology.^[3]

(e) The written survivorship care plan (3 marks)

One mark for the components, one for the shared-care model, one for why its absence is a failure. ^[5]

• Components: cancer history (type, stage, date); treatments received (surgery, radiotherapy field, chemotherapy regimen); surveillance schedule; late-effect monitoring (DEXA for premature menopause, lipids, colorectal after pelvic radiotherapy); GP and generalist responsibilities; red flags for re-presentation.
• The shared-care model: planned transfer of primary oncological responsibility from the specialist MDT to the GP and generalist O&G with a written plan and a clear point of re-contact.
• Why its absence is a failure: a verbal handover leaves the woman unsure of her schedule, the GP unsure of what to watch for, and the late-effect monitoring (bone density, cardiovascular) never happening. The plan closes every gap.^[5]