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GYN
CMECNE

Endometrial Cancer: Beyond The Basics

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Learning Objectives and CME/Disclosure Information

This activity is intended for healthcare providers delivering care to women and their families.

After completing this activity, the participant should be better able to:

1. Summarize the two types of endometrial cancer and how they differ
2. Differentiate between the evaluation of a pre- and post-menopausal woman with abnormal bleeding

Estimated time to complete activity: 0.25 hours

Faculty:

Susan J. Gross, MD, FRCSC, FACOG, FACMG President and CEO, The ObG Project

Disclosure of Conflicts of Interest

Postgraduate Institute for Medicine (PIM) requires faculty, planners, and others in control of educational content to disclose all their financial relationships with ineligible companies. All identified conflicts of interest (COI) are thoroughly vetted and mitigated according to PIM policy. PIM is committed to providing its learners with high quality accredited continuing education activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of an ineligible company.


The PIM planners and others have nothing to disclose. The OBG Project planners and others have nothing to disclose.

Faculty: Susan J. Gross, MD, receives consulting fees from Cradle Genomics, and has financial interest in The ObG Project, Inc.

Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.

Method of Participation and Request for Credit

Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from Jan 25 2022 through Jan 25 2024, participants must read the learning objectives and faculty disclosures and study the educational activity.

If you wish to receive acknowledgment for completing this activity, please complete the test and evaluation. Upon registering and successfully completing the test with a score of 100% and the activity evaluation, your certificate will be made available immediately.

Joint Accreditation Statement

In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Physician Continuing Medical Education

Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Continuing Nursing Education

The maximum number of hours awarded for this Continuing Nursing Education activity is 0.2 contact hours.

Read Disclaimer & Fine Print

SUMMARY:

Endometrial cancer is the most common gynecologic malignancy in the US and accounts for 7% of all cancers in women. Most cases are diagnosed early and can be treated with surgery alone.  with surgery alone. However, there are certain cell types and clinical features (such as extrauterine spread) that are associated with a high rate of relapse following surgical and medical therapy. There are two types of endometrial cancer that vary in epidemiology, genetics, treatment, and prognosis.

Types of Endometrial Cancer

Type 1 (more common): Endometrioid

  • Precursor is atypical endometrial hyperplasia (or endometrial intraepithelial neoplasia)
  • Most cases are low grade
  • Generally results from unopposed, prolonged estrogen stimulation
  • Risk Factors
    • Unopposed estrogen |Age| Obesity | Metabolic syndrome | Nulliparity | Infertility | Late menopause | Tamoxifen use | Type 2 diabetes | Hypertension | Lynch syndrome

Note: Tamoxifen risk may be related to age and is significant in women ≥50 years of age (NSABP prevention trial in high risk women)

Type 2: Papillary serous | Clear cell| Carcinosarcoma (Mixed Mullerian Tumor [MMT])

  • Type 2 more common in older, nonwhite, multiparous women and current smokers
  • Papillary serous on 10% of uterine malignancies, but accounts for 40% of deaths
    • Precursor thought to be endometrial intraepithelial carcinoma
    • High grade, risk of extrauterine disease at time of diagnosis
  • Clear cell
    • Also poorer prognosis
    • Increased risk in smokers
  • MMT is a rare but aggressive tumor

Uterine Cancer Symptoms

  • Abnormal uterine bleeding (AUB) or postmenopausal bleeding
  • Advanced disease
    • Abdominal pain
    • Distention
    • Bloating
    • Early satiety
    • Change in bowel/bladder function

KEY POINTS:

Evaluation of Premenopausal Patient

  • Routine screening of asymptomatic patients using transvaginal ultrasound or endometrial sampling is not recommended
  • Evaluate if patient symptomatic with AUB
    • Thorough medical history, exam, imaging and consideration of age-based risk
  • Diagnosis is by endometrial sampling with dilation and curettage or endometrial biopsy
    • Endometrial biopsy should be performed in all women >45 or
    • Any age with risk factors for endometrial hyperplasia or malignancy (exclude pregnancy first) including failed medical management, and persistent abnormal AUB
  • Ultrasound measurement of endometrial thickness has no diagnostic value
  • ACOG recommends that “The decision to histologically evaluate the endometrium should be based on symptomatology and clinical presentation”

Postmenopausal Patient

  • Prompt evaluation recommended for the following
    • Vaginal bleeding | Presenting symptom is 91% of women with endometrial cancer
    • Endometrial cells on pap smear cytology
  • Initial assessment can be either endometrial biopsy or transvaginal ultrasound
    • Biopsy is not required if endometrial thickness is ≤4 mm
    • Biopsy is required if endometrial thickness cannot be evaluated or is >4 mm
  • Persistent or recurrent bleeding requires biopsy regardless of endometrial thickness

Note: If biopsy has been performed and is benign, yet bleeding persists, dilation and curettage plus hysteroscopy is needed

Evaluation of Asymptomatic Patients with Incidental Findings

  • In an asymptomatic patient, incidental finding of endometrial thickness of >4 mm is not an accurate predictor of an endometrial cancer diagnosis
  • Endometrial thickness of >11 mm in asymptomatic patient has a similar risk of endometrial cancer as a symptomatic patient with >4 mm endometrial thickness
  • Polyps can be managed expectantly or surgically, depending on patient symptoms/risk factors
    • Low prevalence of malignancy in polyps (<5%)

Cervical Cytology Findings Requiring Evaluation (ASCCP)

Postmenopausal Women

  • Evaluate if endometrial cells present on cytology

Asymptomatic Premenopausal Women

  • Endometrial cells
    • Do not evaluate
  • All categories of atypical glandular cells or adenocarcinoma in situ
    • Endometrial sampling in conjunction with colposcopy and endocervical sampling in nonpregnant patients ≥35 years
    • <35 years old if risk factors for endometrial neoplasia are present
  • Atypical endometrial cells
    • Endometrial and endocervical sampling alone is preferred
    • Colposcopy is acceptable as part of the initial evaluation

Endometrial Sampling

  • Office-based endometrial sampling is minimally invasive and cost-effective for evaluation of endometrial cancer
    • Pipelle catheter Detection rates for endometrial cancer
      • Postmenopausal: 99.6%
      • Premenopausal: 91%
      • Posttest probability of endometrial cancer with a negative biopsy <1%
  • If AUB is persistent
    • Further evaluation is required
    • SGO recommends hysteroscopic-guided biopsy

Referral to Gyn Oncology

  • Metastases may be found in approximately 20% of presumed early-stage endometrial cancer at surgery
  • ACOG recommends referral to gyn oncology subspecialist for patients with diagnosis of endometrial cancer

Patient outcomes are improved when high-volume surgeons in high-volume institutions render care, and this outcomes model typically is reproduced by standard gynecologic oncology practice

Learn More – Primary Sources:

ACOG/ SGO Practice Bulletin 149: Endometrial Cancer

NCI: Endometrial Cancer – Health Professional Version

Executive Summary of the Uterine Cancer Evidence Review Conference

Locate a GYN Oncology Specialist:

Gyn Oncology Locator – SGO

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Related ObG Topics:

Endometrial Hyperplasia – Current Nomenclature and Treatment
Ovarian or Endometrial Cancer? Consider Lynch Syndrome
Endometrial Polyps – Do They Always Need To Be Removed?
Transvaginal Ultrasound in the Evaluation of Postmenopausal Bleeding

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Computer System Requirements

OBG Project CME requires a modern web browser (Internet Explorer 10+, Mozilla Firefox, Apple Safari, Google Chrome, Microsoft Edge). Certain educational activities may require additional software to view multimedia, presentation, or printable versions of their content. These activities will be marked as such and will provide links to the required software. That software may be: Adobe Flash, Apple QuickTime, Adobe Acrobat, Microsoft PowerPoint, Windows Media Player, or Real Networks Real One Player.

Disclosure of Unlabeled Use

This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.

The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.

Disclaimer

Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information
presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.

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