# GUIDELINE OBJECTIVE
This guideline was written to provide guidance on the most appropriate follow-up strategy for patients with cervical cancer who are clinically disease-free after receiving primary treatment. This guideline is an update of a previous version, which was published in 2009. The update was initiated when the members of the Program in Evidence-Based Care (PEBC) Gynecologic Cancer Disease Site Group become aware of new publications related to follow-up for the target population. The Disease Site Group members wanted to determine whether this new evidence would result in modifications to the existing recommendations.

# TARGET POPULATION
This practice guideline applies to women who are clinically disease free and asymptomatic after receiving potentially curative primary treatment for cervical cancer. This guideline does not apply to the follow-up of women who have been treated for cervical precancer.

# INTENDED USERS
This practice guideline is for clinicians involved in the care and follow-up of women who have received treatment for cervical cancer.
Note: the content of these recommendations has not changed since the 2009 version of this guideline, however the evidence-base has been updated and now includes studies published up to 2014.
- Follow-up care after primary treatment should be conducted and coordinated by a physician experienced in the surveillance of patients with cancer. Continuity of care and dialogue between the healthcare professional and patient about symptoms of recurrence may enhance and facilitate early cancer recurrence detection because the majority of women who develop a recurrence have symptoms and signs that occur outside scheduled follow-up visits.

# Follow-up to Five Years
- A reasonable follow-up strategy involves visits at the following intervals: o every three to four months within the first two years, o every six to 12 months from years 3 to 5. - At a minimum, follow-up visits should include a patient history and a complete physical examination. o Symptoms elicited during the patient history should include general performance status, lower back pain (especially if it radiates down one leg), vaginal bleeding, or unexplained weight loss. Focused imaging or testing appropriate to findings is warranted. o A physical examination should attempt to identify abnormal findings related to general health and/or those that suggest vaginal, pelvic sidewall, or distant recurrence.
Because central pelvic recurrences are potentially curable, the physical examination should include a speculum examination with bimanual and pelvic/rectal examination. Focused imaging or testing appropriate to findings is warranted. o If vaginal vault cytology examination is used to detect new precancerous conditions of the vagina it should be performed no more frequently than once a year. An abnormal cytology result that suggests the possibility of neoplasia warrants colposcopic evaluation and directed biopsy for histological confirmation.
- Because their role has not been evaluated in a definitive manner, the following investigations are not advocated: o Positron emission tomography (PET) with computed tomography (PET-CT), o Other imaging or biomarker tests in asymptomatic patients.
- Although there is evidence showing that HPV DNA testing has promise as a method of detection of recurrence after radiotherapy, data are preliminary and need verification in higher quality studies with larger sample sizes, and HPV DNA testing is currently unfunded at this time in the province of Ontario.

# Follow-up Beyond Five Years
- After five years of recurrence-free follow-up: o Patients may return to annual assessment with a history, general physical, including pelvic examination with cervical/vaginal cytology performed by the primary care physician that is consistent with standards for well-woman care; however, some patients with treatment complications such as those related to radiotherapy may require more prolonged follow-up at the cancer centre. o Routine lower genital tract screening to identify new pre-invasive disease according to population-based guidelines is recommended for patients who have undergone surgical treatment. Cytological follow-up is not recommended for patients who have been treated with radiotherapy.