Miss Jane Bridges MBChB FRCOG is a gynaecologist at Bupa Cromwell Hospital and Chelsea and Westminster Hospital.
Endometrial cancer is the most common gynaecological cancer in the developed world. In Great Britain the incidence is increasing in post-menopausal women and it is now the fourth most common cancer in women in the UK after breast, colon and lung.
Who gets the disease?
The majority of women developing endometrial cancer are post-menopausal (90%). Risk factors for the disease include factors which increase chronic exogenous or endogenous exposure to oestrogen. The rise in obesity levels has been attributed to the increase of this disease within the UK.
Symptoms at presentation and making the diagnosis
Symptoms in pre-menopausal women usually present as prolonged irregular or inter-menstrual bleeding. Post-menopausal bleeding, however, has always been the traditional symptom that raises suspicion of endometrial cancer, although it is estimated that of all women with PMB, only 5 to 10% will have any sinister pathology.
Post-menopausal bleeding should always be investigated and the first line investigation of choice after a clinical examination should be a transvaginal ultrasound. This allows visualisation of the endometrium so that the thickness can be measured and any other pathology, such as uterine polyps, can be detected. In those women with a single episode of bleeding, who have an endometrial thickness of less than 5 mm, and no other obvious pathology, it is safe to adopt a conservative approach. All other women should have an endometrial sample performed to obtain tissue for histology. This can be performed in an out-patient setting (pipelle biopsy +/- out-patient hysteroscopy) or as an in-patient (hysteroscopy dilation and curettage).
Pathology of endometrial cancer
The majority of women will have Type 1 tumours (80 to 90%), which are oestrogen dependent adenocarcinomas, generally of good prognosis. Type 2 tumours are more aggressive and have a much higher risk of presenting with metastatic disease at presentation and of subsequent relapse. These tumours are generally of clear cell or serous papillary type.
In those women who are diagnosed with endometrial hyperplasia, rather than a frank malignancy, the risk of a developing a subsequent endometrial cancer must be considered. Simple or complex hyperplasias have a relatively low risk of malignancy (1 to 3%) and hormonal therapy with progestogens may be appropriate. Those women with complex hyperplasia with atypia however have a 30 to 40% chance of a concurrent carcinoma at the time of presentation.
Treatment of endometrial cancer
The majority of women with endometrial cancer will present with Stage 1 disease, i.e. disease confined to the uterus. In these patients total hysterectomy with bilateral salpingoophorectomy is the treatment of choice. This can be performed both abdominally and via a laparoscopic approach, although most cancer centres within the UK now favour the latter as recovery time after surgery is much improved.
The use of staging MRI prior to surgery enables invasion of the myometrium, cervical or ovarian involvement and enlarged lymph nodes to be identified, which together with the grade of pathology at diagnosis, will influence the decision as to whether a pelvic and or para aortic lymphadenectomy should be performed. The role of lymphadenectomy has been much debated over the last few years with conflicting data from around the world. In general, however, the consensus is that with Grade 1 early stage tumours there is probably no role for lymphadenectomy, while in high risk patients it may help plan adjuvant therapy.
In those women with early stage, low-grade disease no adjuvant therapy is required, including hormonal manipulation, which was given in the past. In high-risk patients with deep involvement of the myometrium and/or cervical involvement, adjuvant therapy consisting of radiotherapy (brachytherapy +/- external beam) is the treatment of choice. Those women with nodal involvement or distant disease at the time of presentation will be offered chemotherapy, often followed up by radiotherapy to help local control. Although progestogens may have a role in metastatic disease, many high-risk tumours are receptor negative and are therefore unlikely to respond to this form of treatment.
The overall survival of women with endometrial cancer is approximately 80%. If we are to make improvements in survival rates then early presentation and diagnosis of women must be improved together with careful individualisation of patient treatment plans depending on the tumour type, stage and grade.