II. Epidemiology
- Onset age over 50 years in 90% of cases (mean age is 63 years)
- Premenopausal diagnosis of Endometrial Cancer occurs in 20% of cases
- Most common gynecologic tract cancer
- Incidence 1.5 times more common than Ovarian Cancer
- Incidence 3 times more common than Cervical Cancer
- U.S. Statistics from 2015 (increasing Incidence, doubling in the last 20 years)
- Incidence: 54, 870 new cases per year
- Mortality: 10,170 deaths per year
- ACS Cancer facts and figures
III. Risk Factors
- See Endometrial Cancer Risk Factors (also includes protective factors)
-
Hereditary Nonpolyposis Colorectal Cancer (HNPCC, Lynch Syndrome) are at high risk of Endometrial Cancer
- Offer annual Endometrial Biopsy starting at age 35 years
- Paradoxically, Tobacco use is associated with a lower Incidence of Uterine Cancer
IV. Types
- Type I - Endometrioid (70 to 75% of cases)
- Typically associated with Unopposed Estrogen with Endometrial Hyperplasia as a precursor
- Type II - Non-Endometrioid (10%)
- Not associated with Unopposed Estrogen, Endometrial Hyperplasia or other typical Endometrial Cancer Risks
- Includes serous, papillary, clear cell, mucinous, squamous, an adenosquamous types
- Onset at older age, more advanced stage and with worse prognosis (accounts for 40% of mortality)
- Most common in black women over age 50 years old
- Familial Tumors (10%)
- Most associated with Lynch Syndrome (Hereditary Nonpolyposis Colorectal Cancer, HNPCC)
- HNPCC confers a 22-50% lifetime risk of Endometrial Cancer
V. Pathophysiology
- See Endometrial Hyperplasia (precursor of Type I, endometrioid cancers)
VI. Symptoms: Presentation (90% of cases)
- Abnormal Uterine Bleeding (most common symptom)
- Abnormal Vaginal Discharge
VII. Exam
- Evaluate for other sources of bleeding (e.g. vagina, Cervix)
- Bimanual exam
VIII. Evaluation
- See Endometrial Cancer Screening
- Covers Indications (includes Endometrial Hyperplasia)
- Includes evaluation with Trasvaginal Ultrasound and Endometrial Biopsy
- See Dysfunctional Uterine Bleeding
IX. Imaging
- See Endometrial Cancer Screening for Transvaginal Ultrasound recommendations
- At time of Endometrial Cancer diagnosis
- Chest XRay
- Trasvaginal Ultrasound (if not already performed)
- Consider Pelvic MRI
X. Labs
- Urine Pregnancy Test
-
Pap Smear (if due)
- AGUS on Pap Smear may suggest Endometrial Hyperplasia or Endometrial Cancer
XI. Staging
XII. Management
- Precautions
- Biopsy may under-grade Endometrial Cancer (e.g. Grade I is really a Grade 3)
- Surgery
- Total Hysterectomy with bilateral salpingoophorectomy
- First-line management in Stages I-III
- Tumor debulking in Stage IV Endometrial Cancer
- Vaginal Hysterectomy is not recommended
- Does not allow for abdominal evaluation or lymphadenectomy
- Peritoneal washings (pelvic washings)
- Indicated in Stages I-III
- Para-aortic or pelvic Lymph Node dissection may be needed depending on staging
- Indicated in Stages I-III
- Total Hysterectomy with bilateral salpingoophorectomy
-
Radiation Therapy
- Indicated in Stages II, III
- Systemic therapy (indicated in Stages III, IV)
- Post-treatment surveillance (Cancer Survivor Care)
- History and exam every 3-6 months for 2-3 years, then every 6-12 months up to year 5, then yearly
- Cancer Antigen 125 monitoring if initially elevated (per oncology)
- Imaging as indicated for findings suggestive of recurrence
- Carek (2024) Am Fam Physician 110(1): 37-44 [PubMed]
XIII. Prognosis
XIV. Prevention
- Manage Unopposed Estrogen states (e.g. OCP, weight loss)
- Consider prophylactic Hysterectomy at age 40 years old for women with Lynch Syndrome