ENDOMETRIAL CANCER TREATMENT GUIDELINES

The American College of Obstetricians and Gynecologists and the Society of Gynecologic Oncology have issued new guidance for endometrial cancer. The practice bulletin was published in the April issue of Obstetrics & Gynecology.

"A thorough understanding of the epidemiology, pathophysiology, and diagnostic and management strategies for this type of cancer allows the obstetrician–gynecologist to identify women at increased risk, contribute toward risk reduction, and facilitate early diagnosis," the bulletin states.

The practice bulletin reviews current knowledge about endometrial cancer and offers recommendations for diagnosis and management.

Endometrial cancer, the most common gynecologic malignancy, will affect about 54,870 US women in 2015, and 10,170 will die from it, the authors note. At diagnosis, more than 70% of women have stage I disease, which has a 5-year survival rate of 90%. Although white women have a slightly higher lifetime risk of being diagnosed with endometrial cancer, black women are more likely than white women to have higher-grade, more advanced disease at diagnosis.

Type 1 endometrial cancer, or endometrioid adenocarcinoma, causes about three quarters of cases. At diagnosis, most are low-grade and limited to the uterus. With conservative treatment, the precursor lesion (endometrial intraepithelial neoplasia) has a 19-year cumulative risk for progression of 27.5% (95% confidence interval, 8.6% - 42.5%). The precursor lesion coexists with undiagnosed endometrioid carcinoma in 30% to 50% of cases.

Type 2 has clear cell and papillary serous histologies. It carries a worse prognosis than type 1, with high-grade lesions and significant risk for extrauterine disease. Although uterine papillary carcinoma causes about 10% of uterine cancer cases, it accounts for 40% of deaths resulting from the disease. Endometrial intraepithelial carcinoma usually precedes type 2 uterine cancer.

Risk factors include prolonged exposure to unopposed estrogen, obesity, type 2 diabetes, hypertension, older age, nulliparity, infertility, tamoxifen use, early age at menarche, late age at menopause, smoking (increased risk for type 2, decreased risk for type 1), and genetic predisposition with Lynch syndrome and Cowden disease.

The recommendations address the following issues: diagnosis; metastatic evaluation in new diagnoses; the role of the gynecologic oncologist in initial management; comprehensive staging; initial surgical management; adjuvant therapy; cytoreduction, chemotherapy, and hormone therapy in advanced-stage or recurrent disease; fertility-sparing treatment and ovarian preservation; management of incidentally diagnosed endometrial cancer after hysterectomy for another indication; follow-up; and estrogen therapy for the management of menopausal symptoms in survivors.

The practice bulletin offers recommendations based on level A evidence ("good and consistent scientific evidence"), level B evidence ("limited or inconsistent evidence"), and level C evidence ("primarily consensus or expert opinion").

Recommendations based on level A evidence include:

• Outpatient endometrial sampling with disposable devices: Method of choice for histological evaluation; usually reliable and accurate.
• Hysteroscopy: Not required, although it is recommended along with directed dilation and curettage to include discrete lesions and background endometrium; it is the best way to confirm endometrial premalignancy and exclude associated endometrial carcinoma.
• Routine preoperative imaging: Not necessary for evaluation of metastasis.
• Initial management: Comprehensive staging (total hysterectomy, bilateral salpingo-oophorectomy, pelvic and para-aortic lymphadenectomy, and collection of pelvic washings). Exceptions only in consultation with a specialist in endometrial cancer.
• Minimally invasive surgery: Standard surgical approach for comprehensive staging. Do not use power morcellation in women with known or strongly suspected uterine cancer.
• Adjuvant radiation: Can decrease local recurrence rate in certain stage I or stage II tumors, but does not affect survival.
• Adjuvant treatment of choice: Vaginal brachytherapy, preferred over pelvic whole irradiation in some patients with high-intermediate risk for recurrence.
• Chemotherapy: Improves outcomes in advanced disease.
• Estrogen therapy: Consider for menopausal symptoms in early-stage survivors, but only after comprehensive counselling about risks and benefits.

The article also includes a list of selection criteria for women who may be candidates for conservative treatment.

The Practice Bulletin was developed by the American College of Obstetricians and Gynecologists Committee on Practice Bulletins–Gynecology and the Society of Gynecologic Oncology's Clinical Practice Committee.

Obstet Gynecol. 2015;125:1006-1026. Abstract