Survivorship, MDT working and the generalist's role — structured oral station (12 minutes)

Opening prompt — "What is the surveillance schedule for her endometrial cancer, and what is the principle behind it?"

Model response — state the intervals and the principle: [1]

• "For endometrial cancer, the SGO schedule is review every 3 to 6 months for 2 to 3 years, then 6 to 12 monthly to 5 years."
• "The principle is that surveillance is symptom-driven, not test-driven — thorough history and examination detect most recurrences. Routine vault cytology and imaging add no survival benefit in the asymptomatic woman."
• "The SGO recommendations (Salani 2017) are explicit on this. The woman is her own screening test."[1]

Probe 1 — "She has a swollen right leg. How do you approach this?"

• "My differential is recurrent disease, treatment-induced lymphoedema, and DVT — and I exclude recurrence before I settle on lymphoedema." [2]
• "I would order targeted imaging — MRI of the pelvis and leg — to exclude nodal recurrence or disease compressing the iliac vessels, and biopsy any mass or node identified."
• "Once recurrence is excluded, I would measure the limb, stage the lymphoedema, and start complete decongestive therapy: manual lymphatic drainage, compression bandaging then garments, exercise, and skin care, with referral to a lymphoedema service. I would treat any cellulitis early and aggressively."[2]

Probe 2 — "She has dyspareunia, vaginal dryness, and hot flushes. What is going on and what do you do?"

• "She has three overlapping late effects: sexual dysfunction with vaginal stenosis and atrophy after her surgery, genitourinary syndrome of menopause, and treatment-induced premature ovarian insufficiency." [4]
• "Sexual dysfunction affects over 60 per cent of gynae-cancer survivors and is rarely volunteered — I raise it at every visit. I would start vaginal dilators for stenosis with a graded schedule and lubricants, topical vaginal oestrogen for the genitourinary syndrome where safe, and systemic HRT until the typical age of natural menopause for her POI — the calculus is different from HRT for the naturally menopausal woman."[4]

Probe 3 — "She describes intrusive daily thoughts about recurrence that stop her sleeping and working. Is this normal?"

• "No — this is clinically significant fear of cancer recurrence, not expected adjustment. Expected adjustment is time-limited grief and anxiety that resolves with support; intrusive, persistent, disabling fear that impairs function is a clinical disorder." [3]
• "I would screen with the single-item question — how concerned are you about your cancer coming back — or the Fear of Cancer Recurrence Inventory, and validate and normalise her fear first."
• "For clinically significant FCR, the evidence-based intervention is structured cognitive-existential group therapy — the FORT randomised controlled trial (Maheu 2023) showed reduced fear-of-recurrence scores in breast and gynaecological cancer survivors. I would refer her to psycho-oncology."[3]

Probe 4 — Communication: "She asks whether her GP can manage all of this. What do you say?"

This is a scored communication domain — demonstrate it out loud: [1]

• "I would sit at her eye level and say: 'Yes — most of this is exactly what your GP and I will manage together, and you should not need to come back to the oncology clinic unless something changes. I am going to give you and your GP a written care plan today — it has your cancer history, the treatments you had, the schedule for your check-ups, what to watch for, and the symptoms that mean you should contact us urgently. Your leg, your comfort, and your sleep are all things we can help with right now, and you are not on your own with any of it.'"[1]

Probe 5 — "What is in the survivorship care plan, and why does it matter?"

• "The plan has six components: cancer history (type, stage, date); treatments received (surgery, radiotherapy field, chemotherapy regimen); the surveillance schedule; late-effect monitoring (DEXA for her premature menopause, lipids, colorectal surveillance if she had pelvic radiotherapy); GP and generalist responsibilities; and red flags for re-presentation." [2]
• "It matters because the shared-care model only works if the transfer is explicit and written. Without it, the woman is unsure of her schedule, the GP does not know what to watch for, and the bone-density and cardiovascular monitoring never happens. A verbal handover is the classic survivorship failure."[2]