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Endometrial Cancer

Uterus cancer is the most common cancer that you will see in your gynecologic practice. It is the most common malignancy that we see in the pelvis and it’s only second to breast cancer. It’s estimated that there will be between 30,000 to 40,000 cases in the new millennium diagnosed of endometrial cancer in the United States. If you are unfortunately enough to get a female cancer, endometrial cancer tends to be one of the friendlier cancers, although it has the highest incidence of malignancy in the female pelvis, it also has one of the lowest death rates due to uterus cancer.

The median age of endometrial cancer is 61, the vast majority of cases occur between the ages of 50 and 59, this makes endometrial cancer a very easily detectable cancer because the vast majority of your women are postmenopausal. Indeed, 75% of patient’s diagnosed with endometrial cancer are post menopausal therefore they walk in with a big red flag.

Approximately 25% of women who are diagnosed with endometrial cancer unfortunately are not postmenopausal, and this group of patient’s is more difficult to diagnose, you really must listen to the patient’s history saying I am having increased menstrual bleeding during the month or I’m having heavier bleeding than I used to have and it takes an astute physician to say we really need to pursue this and get an endometrial biopsy. Approximately 5% of patient’s who develop endometrial cancer.

Everybody in this room is probably familiar with the risk factors of endometrial cancer, the number one risk factor would be obesity in the postmenopausal group, the reason for obesity being a risk factor is as androstene dione is peripherally converted to estrone in the adipose tissue, so the more adipose tissue you have, the potential for more estrone production you have, therefore more stimulation of your endometrial cavity. Nulliparity has always been a risk factor for endometrial cancer, it is unclear whether it’s because patient’s who do develop endometrial cancer may be anovulatory or they have no interruption.

If we look at late menopause again, this is a subjective symptom, sometimes you will have women who come in and say, well I have been bleeding and their 65 years old, well obviously they haven’t gotten with the program that they are having abnormal bleeding, they have gone through the change but they are having abnormal bleeding. Diabetes and hypertension is disease processes that are associated with the elderly and also associated with the obese.

In recent years, there has been a lot of use with tamoxifen therapy in breast cancer prevention and in patient’s who have breast cancer to prevent the other breast from receiving tamoxifen in order to be protective against receiving another breast cancer in the opposite breast. There has been a lot of controversy in the literature saying that if you are on tamoxifen, your risk of developing endometrial cancer is seven times that of normal, and indeed that is true. However, of all the patient’s if you take 1000 patient’s who are on tamoxifen therapy for breast cancer prevention, out of the thousand, only two will develop endometrial cancer, therefore, 998 patient’s who are on tamoxifen will not get endometrial cancer. The type of endometrial cancer that patient’s get while they are on tamoxifen is exactly identical to what they get if they are not on tamoxifen. The present with postmenopausal bleeding and therefore, have an early warning sign that allows you to sample them.

The history that is compatible with endometrial cancer is number one, postmenopausal bleeding. I think that is fairly obvious for most gynecologists who have a patient present in their office who say, I am bleeding. There are other causes for postmenopausal bleeding, but the first flag in your head should be, this may be coming from her uterus, therefore we should get an endometrial biopsy. Certainly, there are other sources of postmenopausal bleeding that can be coming from the bladder, the rectum, vagina.

Only 20% of patient’s who present with postmenopausal bleeding will ultimately have a malignancy, however, the older the patient that presents with postmenopausal bleeding, the more likely she is to have an endometrial cancer.

The last diagnosis of endometrial cancer is occasionally picked up on an asymptomatic woman which again is very rare to have a patient who has endometrial cancer who is asymptomatic, but it does occur, to pick it up on a Pap smear. If you have 100 patient’s that have endometrial cancer and you took Pap smears from those patient’s, only 20.

Now looking at the symptomatic and symptomatic, the big to do about this paper is that they are trying to point out that asymptomatic patient’s, there was no incidence of atypical hyperplasia, if they were asymptomatic and there was no incidence of cancer, and only a very small percentage who had thickened endometrial stripes, actually had atypical hyperplasia, in this study, they felt that simple hyperplasia was not a precursor to cancer. So because 70 to 80% of patient’s who had thickened endometrial stripes had insufficient tissue or normal endometrium as the study went on.

If the patient is not having postmenopausal bleeding, if she should get an ultrasound done by her internist that shows an endometrial stripe of 9 mm, she does not need to be sampled unless she becomes symptomatic, and I want to make one point here, that atypical hyperplasia and cancer, in many institutions, if you show a slide of atypical hyperplasia to 20 pathologists, 10 will report it out as well differentiated cancer and 10 will report it out as atypical hyperplasia, atypical hyperplasia.

So if we look at endometrial cancer again, the higher the stage, is usually associated with higher grade lesions. As a GYN oncologist, of course I see all spectrum and I see people who have well differentiated cancers who walk in the door with a stage III disease simply because they let their disease process go. I am briefly going to review the staging of endometrial cancer.