•Endometrial Cancer

Screening for Cancer in

Women

Screening…?

Organized identification

High coverage of a target population

Continuous quality assessment.

Feasibility of treatment & follow up

Of a pre - clinical disease state

By a test that is repeated at a given interval

OR…

Screening can be defined as

The application of diagnostic tests or

procedures

To asymptomatic people

For the purpose of dividing them into two

groups:

• those who have a condition that would benefit from

early intervention

• and those who do not.

Early diagnosis alone does not justify a screening program. The only justification is early diagnosis that leads to a measurable improvement in outcome.

The Number Needed to Screen(NNS) is the number of asymptomatic women who must be enrolled in a screening program over a given period of time to prevent one death from the disease in question.

The NNS reflects both the prevalence of the disease and the effectiveness of therapy, and has the advantage of being easy to calculate and intuitively useful to clinicians and patients.

An Ideal Screening Program…Features of the disease

Significant impact on public health

Asymptomatic period during which detection is possible

Outcomes improved by treatment during asymptomatic period

Features of the test

Sufficiently sensitive to detect disease during asymptomatic period

Sufficiently specific to minimize false-positive test results

Acceptable to patients

Features of the screened population

Sufficiently high prevalence of the disease to justify screening

Relevant medical care is accessible

Patients willing to comply with further work-up and treatment

To screen or To screen not ?

Recommended Screening

Cervical Carcinoma

Breast Carcinoma

Colorectal Carcinoma

Not yet , for…

Ovarian Cancer

Bronchogenic Carcinoma

Skin cancer

Oral Cancer

Endometrial Cancer

Effective Screening Program

Should be tailored to suit the principles for national cancer control programs. We Should NOT copy other’s programs...

Otherwise… Too much money & effort will be spent with

minimal impact on the incidence & mortality from the disease.

Endometrial Cancer

Adenocarcinoma is the most common

cancer of the female reproductive tract.

2-3% of women will develop it in a lifetime.

75% occur in postmenopausal women.

Associated with the best overall survival of

all gynecologic malignancies.

Usually diagnosed as early stage disease.

Endometrial Hyperplasia (EMHP)

The majority of the simple and complex

EMHPs will regress spontaneously.

Atypical HP has a much greater tendency to

persist or progress if not specifically

treated.

Lesions are classified as invasive or pre-

invasive according to the presence or

absence of stromal invasion.

Hyperplasia Regression Progression Yrs.

Simple HP 80% 1%

Complex HP 78% 3% 8.3

Atypical HP * 58% 29% 4.1

* true cancer precursor

EMHP - Tendency for Progression

Risk Factors for Endometrial Cancer

•Unopposed estrogen exposure •Median age at diagnosis: 59 years •Menstrual cycle irregularities, specifically menorrhagia and menometrorrhagia•Postmenopausal bleeding •Chronic anovulation •Nulliparity •Early menarche (before 12 years) / Late menopause (after 52 years) •Infertility •Tamoxifen (Nolvadex) use •Granulosa and thecal cell tumors •Ovarian dysfunction •Obesity •Diabetes mellitus •Arterial hypertension with or without atherosclerotic heart disease •History of breast or colon cancer

Risk factors: Unopposed Estrogen

May accelerate the progression from

Simple or atypical HP will regress if unopposed estrogen is stopped.

Users of unopposed estrogen for at least 2 years develop endometrial cancer 2 - 20 times more frequently than nonusers.

Risk increases with higher doses and longer use.

Simple Atypical Cancer

Risk factors: Unopposed Estrogen

After 10 years of use, the risk of developing

endometrial cancer = 10 per 1000

postmenopausal women.

There is a residual risk that may persist for up

to 15 years even after estrogen is stopped.

Tamoxifen use???

Risk factors: Prolonged Endogenous Estrogen

Primarily due to chronic anovulation.

Obesity.

Polycystic ovarian disease.

Infertility.

Late menopause.

Explains why smokers have a

decreased risk of endometrial cancer.

Endometrial Cancer

Vaginal bleeding is the most common presenting symptom.

Gross and microscopic hemorrhage.

Most common histologic types are endometrial and mucinous.

Most common prognostic factors:

Degree of histologic differentiation.

Depth of stromal invasion.

Endometrial cells on the Pap Smear

Endometrial cells HP Adenocarcinoma

Normal 13% 11%

Atypical 11% 20%

Of women with Malignant endometrial cells on a Pap smear, 70% have deep myometrial invasion.

Do not ignore endometrial cells on a Pap smear !

Methods of Detection:Endometrial Cancer

Methods of Detection:Endometrial Cancer

Endometrial Aspiration

Office endometrial samplers are highly sensitive ( 97.5 % or more ) for detection of

endometrial cancer.• misses polyps and submucous fibroids.

May fail to adequately sample the atrophic endometrium.

• insufficiency rate = 15 %.

• samples by “shear” rather than curettage.

Ultrasonography

The thicker the endometrial lining of postmenopausal

women on TVUS, the greater the risk of endometrial disease.

The negative predictive value for the diagnosis of cancer or

HP is 100 % when the lining measures < 5 mm in thickness.

• Does not apply if EMBx has been previously performed.

Saline Contrast Sonography

Allows a better evaluation of the endometrium specially in

case of TAM therapy or if there is a ? Endometrial polyp

or Fibroid

Methods of Detection:Endometrial Cancer

Hysteroscopy

The combination of Hysteroscopy and Guided

Biopsy can approach 100 % accuracy in the

diagnosis of endometrial cancer and HP.

Used to stage the tumor.

• Confined to uterine corpus ?

• Cervical involvement ?

– Errors in staging can occur 10-15% of the time with blind

D&C .

Methods of Detection:Endometrial Cancer

Four Major Types of Pathologic Findings on Endometrial Biopsy

•Proliferative, secretory, benign or atrophic endometrium•Simple or complex (adenomatous) hyperplasia without atypia•Simple or complex (adenomatous) hyperplasia with atypia•Endometrial adenocarcinoma

Regardless of histologic type, the presence of atypia is the major determinant of risk for

endometrial cancer.

Management of Hyperplasia Without Atypia

6mm.

POLYP from the fundus

3-D ultrasound-Endometrial polyp

Screening…To whom it should be directed

All women with postmenopausal bleeding (except in the first 6 months of HRT).

Perimenopausal women at high risk or with persistent AUB despite hormonal therapy.Women at any age at high risk for EMHP.Obese women with AUB.Women with DUB not responding to hormonal therapy.Women on tamoxifen therapy.