Does increased endometrial cancer incidence warrant more intensive screening?
Yes, the increased projected incidence of endometrial cancer certainly warrants more extensive screening.
Endometrial cancer has been increasing in frequency, as has the death rate from this disease, largely due to the obesity epidemic. As we expect the rates of obesity to continue to rise, we also would expect that the rates of endometrial cancer will rise alarmingly in parallel.
Abnormal uterine bleeding is the cardinal symptom of endometrial cancer, occurring among 75% to 90% of women diagnosed with this disease. Although endometrial cancer is most commonly diagnosed among postmenopausal women, incidence of endometrial cancer also is rising among premenopausal women — once again in alignment with the obesity epidemic. Up to 30% of cases are occurring among women aged younger than 50 years.
American College of Obstetricians and Gynecologists recommends that endometrial evaluation must be performed for postmenopausal women with any vaginal bleeding, spotting and/or staining; women aged 45 years through menopause with any abnormal uterine bleeding, such as more frequent, heavy or prolonged, or intermenstrual bleeding; obese women aged younger than 45 years with any abnormal uterine bleeding; and women aged younger than 45 years with abnormal uterine bleeding in the setting of unopposed estrogen exposure, failed medical management of the bleeding, or family history of Lynch or Cowden syndrome, both of which are associated with high risk for endometrial cancer.
Up to 20% of postmenopausal women with vaginal bleeding will have endometrial cancer. The rate is approximately 15% for women aged younger than 50 years with abnormal uterine bleeding, and 5% for women aged younger than 40 years.
Although adherence to the above recommendations certainly will aid in the early detection of endometrial cancer, more stringent guidelines need to be in place to ensure that endometrial cancer and its precursor lesion — endometrial hyperplasia — are detected early when treatment is effective as opposed to advanced stages, for which outcomes are poor.
Thus, obese women must be educated about the association between abnormal uterine bleeding/postmenopausal bleeding with endometrial cancer/hyperplasia, and they must be encouraged to report these symptoms as soon as possible to their health care providers. Most importantly, health care providers must screen obese women for these symptoms just as we screen obese women for diabetes, hypercholesterolemia and hypertension, all of which are obesity-related comorbidities. Until we can better control obesity, we must implement this screening practice for obese, at-risk women as our best weapon for continuing to diagnose endometrial cancer as early as possible, as well as preventing higher-stage and worse-outcome disease.
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Victoria Bae-Jump, MD, PhD, is associate professor in the division of gynecologic oncology at The University of North Carolina at Chapel Hill. She can be reached at firstname.lastname@example.org. Disclosure: Bae-Jump reports no relevant financial disclosures.
No, universal endometrial cancer screening is unnecessary.
There are absolutely no recommendations by any medical organization — such as American College of Obstetricians and Gynecologists, Society of Gynecologic Oncology or American Cancer Society — for either universal endometrial cancer screening of asymptomatic women, or for screening women at higher risk for developing endometrial cancer, such as those with Lynch syndrome or extreme obesity.
The vast majority of women with endometrial cancer present early in the disease process with complaints of abnormal vaginal bleeding, and they are diagnosed in early stages and have excellent survival rates following treatment. It remains unclear if screening asymptomatic women would, in any appreciable way, improve these outcomes.
In terms of methods available to screen for endometrial cancer, two potential modalities would be an endometrial biopsy or a transvaginal ultrasound to measure the endometrial stripe, which can only be employed for postmenopausal women. Screening tests must fulfill several attributes in order to be effective and merit universal adoption, and endometrial cancer misses on multiple criteria.
First, targeted disease must be sufficiently burdensome to the population that a screening program is warranted, and minor changes in relative risk should have substantial impact on the absolute population risk. Endometrial cancer represents 7% of cancers but is relatively less lethal, as it accounts for 4% of U.S. cancer deaths and lifetime risk is one in 35.
Second, targeted disease must have a well-understood natural history with a long preclinical latent period. Endometrial cancer precursors — such as endometrial intraepithelial neoplasia — exist, but they also frequently coexist with cancer (up to 43%) and both respond extremely well to surgical management.
Third, a screening method must have acceptable technical aspects. Screening with an endometrial biopsy is technically feasible, but it is unclear that there would be any survival benefit for detecting precursor lesions vs. an early-stage endometrial cancer.
Fourth, efficacious treatment for the target disease must be available. Efficacious treatments are available for both endometrial cancer and precancer, and it remains unclear if there would be any survival benefit if screening increased the proportion of precancer diagnoses compared with cancer diagnoses.
Finally, cost feasibility and acceptability of screening and early treatment should be established. Issues remain regarding financial cost of the endometrial biopsy or ultrasound, as well as their acceptability to patients in terms of willingness to undergo these procedures routinely.
Women with any symptoms concerning for endometrial cancer merit immediate diagnostic evaluation with endometrial biopsy and/or ultrasound, but universal screening is unnecessary and simply would add cost — as well as patient/physician burdens — without improving outcomes appreciably.
Modesitt SC. Cancer Screening in Women. In: Alvarez-Secord A and Gehrig P, eds. Gynecologic Oncology, 1st ed. Landes Bioscience;2009.
Siegel RL, et al. CA Cancer J Clin. 2018;doi:10.3322/caac.21442.
Susan C. Modesitt, MD, FACOG, FACS, is director of the gynecologic oncology division and the high-risk breast/ovarian cancer clinic at University of Virginia. She can be reached at email@example.com. Disclosure: Modesitt reports no relevant financial disclosures.