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Evaluation of postmenopausal bleeding can lead to early detection of endometrial cancer

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August 6, 2018

Early detection strategies that focus on women with postmenopausal bleeding could catch as many as 90% of endometrial cancers, according to findings published in JAMA Internal Medicine.

Still, fewer than one in 10 women with postmenopausal bleeding had endometrial cancer.

“Unlike most cancers, the incidence of endometrial cancer and associated mortality rates have increased in recent years and are projected to rise during the next 10 years,” Megan A. Clarke, PhD, MHS, fellow at the NCI, and colleagues wrote. “Most endometrial cancers are diagnosed at a localized stage and are often curable with surgery, with a 5-year survival of approximately 95%. ... However, studies evaluating early detection strategies for endometrial cancer are lacking, and at present no recommendation for population-based screening exists.”

The researchers performed a systematic review and meta-analysis of observational studies published between 1977 and 2017 that reported data on the prevalence of postmenopausal bleeding in cases of endometrial cancer, as well as the risk for the disease among women who experienced postmenopausal bleeding. Two independent reviewers evaluated the bias risk in each study, as well as study quality, excluding articles that included highly selected populations, had 25 women or fewer, or lacked detailed inclusion criteria.

The analysis included 129 studies with 40,790 women; 34,432 unique patients had postmenopausal bleeding and 6,358 had endometrial cancer.

Among women who had endometrial cancer, the pooled prevalence of postmenopausal bleeding was 91% (95% CI, 87-93).

Women with postmenopausal bleeding had a 9% (95% CI, 8-11) pooled risk for endometrial cancer.

Risk estimates for endometrial cancer varied with the use of hormone therapy (range, 7% [95% CI, 6-9] to 12% [95% CI, 9-15]; P < .001 for heterogeneity), as well as geographic location (range, 5% [95% CI, 3-11] in North America to 13% [95% CI, 9-19] in Western Europe).

“As new markers are discovered or new clinical management strategies are evaluated, our results can aid in the assessment of their potential clinical value and will help to inform clinical and epidemiologic risk prediction models to support clinical decision-making,” the researchers wrote.

Often, cancers do not show symptoms until they reach advanced stages, Kristen A. Matteson, MD, MPH, associate professor at The Warren Alpert Medical School of Brown University and Women & Infants Hospital, and colleagues wrote in an accompanying editorial.

Endometrial cancer is quite different; nine out of 10 women with early-stage disease present with the symptom of postmenopausal bleeding,” Matteson and colleagues wrote. “Uterine bleeding in postmenopausal women prompts evaluation, evaluation can lead to early diagnosis of cancer, and early diagnosis means early treatment and increased survival. But not all women with postmenopausal bleeding have endometrial cancer, and risk needs to be appropriately communicated to patients.


“Overall, the results of this study will facilitate patient counseling and future projects assessing the effectiveness of novel strategies for evaluating women for endometrial cancer,” the researchers wrote. –by Andy Polhamus

Disclosures: The authors report no relevant financial disclosures. Matteson and the other editorial authors report no relevant financial disclosures.

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Unlike other gynecologic cancers, endometrial cancer will more often be diagnosed at an early stage and, thus, have a more favorable prognosis. In large part, this earlier detection of endometrial cancer is reflective of prompt evaluation of postmenopausal bleeding. The authors performed a systematic review of 129 studies which included more than 40,000 women and confirmed that 90% of patients with endometrial cancer experienced postmenopausal bleeding. Although recognizing that this symptom will lead to earlier diagnosis, the authors also concluded that only 9% of those with postmenopausal bleeding will be diagnosed with cancer and suggest a need to reevaluate current screening strategies to avoid unnecessary interventions among low-risk patients. 

Providers should use this study to educate patients on the need for prompt evaluation of postmenopausal bleeding, but also to discuss the value of current interventions such as transvaginal ultrasound and endometrial sampling. 

Gina M. Mantia-Smaldone, MD

Fox Chase Cancer Center

Disclosure:Mantia-Smaldone reports no relevant financial disclosures.