Diagnosis and Management of Endometrial Cancer

 


FREE PREVIEW. AAFP members and paid subscribers: Log in to get free access. All others: Purchase online access.


FREE PREVIEW. Purchase online access to read the full version of this article.

Am Fam Physician. 2016 Mar 15;93(6):468-474.

  Patient information: See related handout on endometrial (uterine) cancer, written by the authors of this article.

Author disclosure: No relevant financial affiliations.

Endometrial cancer is the most common gynecologic malignancy. It is the fourth most common cancer in women in the United States after breast, lung, and colorectal cancers. Risk factors are related to excessive unopposed exposure of the endometrium to estrogen, including unopposed estrogen therapy, early menarche, late menopause, tamoxifen therapy, nulliparity, infertility or failure to ovulate, and polycystic ovary syndrome. Additional risk factors are increasing age, obesity, hypertension, diabetes mellitus, and hereditary nonpolyposis colorectal cancer. The most common presentation for endometrial cancer is postmenopausal bleeding. The American Cancer Society recommends that all women older than 65 years be informed of the risks and symptoms of endometrial cancer and advised to seek evaluation if symptoms occur. There is no evidence to support endometrial cancer screening in asymptomatic women. Evaluation of a patient with suspected disease should include a pregnancy test in women of childbearing age, complete blood count, and prothrombin time and partial thromboplastin time if bleeding is heavy. Most guidelines recommend either transvaginal ultrasonography or endometrial biopsy as the initial study. The mainstay of treatment for endometrial cancer is total hysterectomy with bilateral salpingo-oophorectomy. Radiation and chemotherapy can also play a role in treatment. Low- to medium-risk endometrial hyperplasia can be treated with nonsurgical options. Survival is generally defined by the stage of the disease and histology, with most patients at stage I and II having a favorable prognosis. Controlling risk factors such as obesity, diabetes, and hypertension could play a role in the prevention of endometrial cancer.

Endometrial cancer is the most common gynecologic malignancy. It is the fourth most common cancer in women after breast, lung, and colorectal cancers. Projections from the American Cancer Society (ACS) for 2015 estimated 54,870 new cases of endometrial cancer and 10,170 deaths from the disease.1 The death rate for endometrial cancer has increased more than 100% during the past 20 years, rising by 8% since 2008. The mean age of patients at the time of diagnosis is 63 years, with 90% of cases occurring in women older than 50 years. Only 20% of patients with endometrial cancer receive a diagnosis before menopause.2

WHAT IS NEW ON THIS TOPIC: ENDOMETRIAL CANCER

The 2009 update of the International Federation of Gynecology and Obstetrics tumor-node-metastasis staging system for endometrial cancer better predicts disease prognosis compared with the previous system (Table 1).

View/Print Table

BEST PRACTICES IN ONCOLOGY: RECOMMENDATIONS FROM THE CHOOSING WISELY CAMPAIGN

RecommendationSponsoring organization

Do not perform Papanicolaou tests for surveillance of women with a history of endometrial cancer.

Society of Gynecologic Oncology


Source: For more information on the Choosing Wisely Campaign, see http://www.choosingwisely.org. For supporting citations and to search Choosing Wisely recommendations relevant to primary care, see http://www.aafp.org/afp/recommendations/search.htm.

BEST PRACTICES IN ONCOLOGY: RECOMMENDATIONS FROM THE CHOOSING WISELY CAMPAIGN

RecommendationSponsoring organization

Do not perform Papanicolaou tests for surveillance of women with a history of endometrial cancer.

Society of Gynecologic Oncology


Source: For more information on the Choosing Wisely Campaign, see http://www.choosingwisely.org. For supporting citations and to search Choosing Wisely recommendations relevant to primary care, see http://www.aafp.org/afp/recommendations/search.htm.

View/Print Table

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferencesComments

Women older than 65 years should be informed of the risks and symptoms of endometrial cancer and advised to seek evaluation if symptoms occur.

C

4

Recommendation based on consensus guidelines

Women with abnormal uterine bleeding should be evaluated for endometrial cancer if they are older than 45 years or if they have a history of unopposed estrogen exposure.

C

2, 3, 19

Recommendation based on consensus guidelines

In postmenopausal women, the endometrial thickness on transvaginal ultrasonography should be less than 4 to 5 mm. With thickness above this level, biopsy should be considered to rule out endometrial hyperplasia or cancer.

C

17, 18

Recommendation based on consensus guidelines


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferencesComments

Women older than 65 years should be informed of the risks and symptoms of endometrial cancer and advised to seek evaluation if symptoms occur.

C

4

Recommendation based on consensus guidelines

Women with

The Authors

show all author info

MICHAEL M. BRAUN, DO, FAAFP, is associate residency director of the Family Medicine Residency at Madigan Army Medical Center, Tacoma, Wash., and clinical faculty of family medicine at the University of Washington, Seattle....

ERIKA A. OVERBEEK-WAGER, DO, is a staff family physician at Evans Army Community Hospital, Fort Carson, Colo.

ROBERT J. GRUMBO, MD, FAAFP, is adjunct faculty in the Family Medicine Residency at Madigan Army Medical Center.

Address correspondence to Michael M. Braun, DO, Madigan Army Medical Center, 9040 Fitzsimmons Dr., Tacoma, WA 98431 (e-mail: patchmb2@hotmail.com). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

REFERENCES

show all references

1. American Cancer Society. Cancer Facts and Figures 2014. http://www.cancer.org/acs/groups/content/@research/documents/webcontent/acspc-042151.pdf. Accessed October 27, 2014....

2. Sorosky JI. Endometrial cancer. Obstet Gynecol. 2012;120(2 pt 1):383–397.

3. Practice Bulletin No. 149: Endometrial cancer. Obstet Gynecol. 2015;125(4):1006–1026.

4. Smith RA, et al.; ACS Prostate Cancer Advisory Committee, ACS Colorectal Cancer Advisory Committee, ACS Endometrial Cancer Advisory Committee. American Cancer Society guidelines for the early detection of cancer: update of early detection guidelines for prostate, colorectal, and endometrial cancers [published correction appears in CA Cancer J Clin. 2001;51(3):150]. CA Cancer J Clin. 2001;51(1):38–75.

5. Buchanan EM, et al. Endometrial cancer. Am Fam Physician. 2009;80(10):1075–1080.

6. Saso S, et al. Endometrial cancer. BMJ. 2011;343:d3954.

7. Courneya KS, et al. Associations among exercise, body weight, and quality of life in a population-based sample of endometrial cancer survivors. Gynecol Oncol. 2005;97(2):422–430.

8. Calle EE, et al. Overweight, obesity, and mortality from cancer in a prospectively studied cohort of U.S. adults. N Engl J Med. 2003;348(17):1625–1638.

9. Fisher B, et al. Tamoxifen for prevention of breast cancer: report of the National Surgical Adjuvant Breast and Bowel Project P-1 Study. J Natl Cancer Inst. 1998;90(18):1371–1388.

10. Davies C, et al.; Adjuvant Tamoxifen: Longer Against Shorter (ATLAS) Collaborative Group. Long-term effects of continuing adjuvant tamoxifen to 10 years versus stopping at 5 years after diagnosis of oestrogen receptor-positive breast cancer: ATLAS, a randomised trial [published correction appears in Lancet. 2013;381(9869):804]. Lancet. 2013;381(9869):805–816.

11. Nelson HD, et al. Systematic review: comparative effectiveness of medications to reduce risk for primary breast cancer. Ann Intern Med. 2009;151(10):703–715, W-226–W-235.

12. Lindor NM, et al. Recommendations for the care of individuals with an inherited predisposition to Lynch syndrome: a systematic review. JAMA. 2006;296(12):1507–1517.

13. Vasen HF, et al.; Mallorca group. Revised guidelines for the clinical management of Lynch syndrome (HNPCC): recommendations by a group of European experts. Gut. 2013;62(6):812–823.

14. Schmeler KM, et al. Prophylactic surgery to reduce the risk of gynecologic cancers in the Lynch syndrome. N Engl J Med. 2006;354(3):261–269.

15. Chin J, et al. Levonorgestrel intrauterine system for endometrial protection in women with breast cancer on adjuvant tamoxifen. Cochrane Database Syst Rev. 2009;(4):CD007245.

16. Grady D, et al. Hormone replacement therapy and endometrial cancer risk: a meta-analysis. Obstet Gynecol. 1995;85(2):304–313.

17. Khati NJ, et al; Expert Panel on Women's Imaging. ACR Appropriateness Criteria: abnormal vaginal bleeding. Reston, Va.: American College of Radiology; 2014:1–13. http://www.guideline.gov/content.aspx?id=48294. Accessed February 27, 2015.

18. American College of Obstetricians and Gynecologists. The role of transvaginal ultrasonography in the evaluation of postmenopausal bleeding. ACOG Committee Opinion No. 440, August 2009. Obstet Gynecol. 2009;114:409–411.

19. American College of Obstetricians and Gynecologists. Management of acute abnormal uterine bleeding in non-pregnant reproductive-aged women. ACOG Committee Opinion No. 557, April 2013. Obstet Gynecol. 2013;121(4):891–896.

20. Smith-Bindman R, et al. Endovaginal ultrasound to exclude endometrial cancer and other endometrial abnormalities. JAMA. 1998;280(17):1510–1517.

21. Gupta JK, et al. Ultrasonographic endometrial thickness for diagnosing endometrial pathology in women with postmenopausal bleeding: a meta-analysis. Acta Obstet Gynecol Scand. 2002;81(9):799–816.

22. Elsandabesee D, et al. The performance of Pipelle endometrial sampling in a dedicated postmenopausal bleeding clinic. J Obstet Gynaecol. 2005;25(1):32–34.

23. Clark TJ, et al. Accuracy of hysteroscopy in the diagnosis of endometrial cancer and hyperplasia: a systematic quantitative review. JAMA. 2002;288(13):1610–1621.

24. Lewin SN, et al. Comparative performance of the 2009 International Federation of Gynecology and Obstetrics' staging system for uterine corpus cancer. Obstet Gynecol. 2010;116(5):1141–1149.

25. Edge SB; American Joint Committee on Cancer. AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer; 2010.

26. Pecorelli S. Revised FIGO staging for carcinoma of the vulva, cervix, and endometrium [published correction appears in Int J Gynaecol Obstet. 2010;108(2):176]. Int J Gynaecol Obstet. 2009;105(2):103–104.

27. Trimble CL, et al.; Society of Gynecologic Oncology Clinical Practice Committee. Management of endometrial precancers. Obstet Gynecol. 2012;120(5):1160–1175.

28. American College of Obstetricians and Gynecologists. Supracervical hysterectomy. ACOG Committee Opinion No. 388, November 2007. Obstet Gynecol. 2007;110(5):1215–1217.

29. Ghezzi F, et al. Postoperative pain after laparoscopic and vaginal hysterectomy for benign gynecologic disease: a randomized trial. Am J Obstet Gynecol. 2010;203(2):118.e1–8.

30. Orbo A, et al. Levonorgestrel-impregnated intrauterine device as treatment for endometrial hyperplasia: a national multicentre randomised trial. BJOG. 2014;121(4):477–486.

31. Aalders JG, et al. Endometrial cancer—revisiting the importance of pelvic and para aortic lymph nodes. Gynecol Oncol. 2007;104(1):222–231.

32. Kong A, et al. Adjuvant radiotherapy for stage I endometrial cancer. Cochrane Database Syst Rev. 2012;(3):CD003916.

33. Podzielinski I, et al. Primary radiation therapy for medically inoperable patients with clinical stage I and II endometrial carcinoma. Gynecol Oncol. 2012;124(1):36–41.

34. Barlin JN, et al. Cytoreductive surgery for advanced or recurrent endometrial cancer: a meta-analysis. Gynecol Oncol. 2010;118(1):14–18.

35. Martin-Hirsch PP, et al. Adjuvant progestagens for endometrial cancer. Cochrane Database Syst Rev. 2011;(6):CD001040.

36. Gunderson CC, et al. Oncologic and reproductive outcomes with progestin therapy in women with endometrial hyperplasia and grade 1 adenocarcinoma: a systematic review. Gynecol Oncol. 2012;125(2):477–482.

37. Eltabbakh GH, et al. Surgical stage, final grade, and survival of women with endometrial carcinoma whose preoperative endometrial biopsy shows well-differentiated tumors. Gynecol Oncol. 2005;99(2):309–312.



 

Copyright © 2016 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions

CME Quiz

More in AFP


Editor's Collections


Related Content


More in Pubmed

MOST RECENT ISSUE


Sep 15, 2016

Access the latest issue of American Family Physician

Read the Issue


Email Alerts

Don't miss a single issue. Sign up for the free AFP email table of contents.

Sign Up Now

Navigate this Article