Screening
for Cancer in Women
Endometrial Cancer
Screening…?
Organized identification
High coverage of a target population
Continuous quality assessment.
Feasibility of treatment & follow up
Of a pre - clinical disease state
By a test that is repeated at a given interval
OR…
Screening can be defined as
The application of diagnostic tests or procedures
To asymptomatic people
For the purpose of dividing them into two
groups:
• those who have a condition that would benefit from
early intervention
• and those who do not.
Early diagnosis alone does not justify a screening
program. The only justification is early diagnosis that
leads to a measurable improvement in outcome.
The Number Needed to Screen(NNS) is the number of
asymptomatic women who must be enrolled in a
screening program over a given period of time to prevent
one death from the disease in question.
The NNS reflects both the prevalence of the disease and
the effectiveness of therapy, and has the advantage of
being easy to calculate and intuitively useful to clinicians
and patients.
An Ideal Screening Program…
Features of the disease
Significant impact on public health
Asymptomatic period during which detection is possible
Outcomes improved by treatment during asymptomatic period
Features of the test
Sufficiently sensitive to detect disease during asymptomatic period
Sufficiently specific to minimize false-positive test results
Acceptable to patients
Features of the screened population
Sufficiently high prevalence of the disease to justify screening
Relevant medical care is accessible
Patients willing to comply with further work-up and treatment
To screen or To screen not ?
Recommended Screening
Cervical Carcinoma
Not yet , for…
Ovarian Cancer
Bronchogenic Carcinoma
Breast Carcinoma
Skin cancer
Oral Cancer
Colorectal Carcinoma
Endometrial Cancer
Effective Screening Program
Should be tailored to suit the principles for national
cancer control programs. We Should NOT copy
other’s programs...
Otherwise…
Too much money & effort will be spent with
minimal impact on the incidence & mortality from
the disease.
Endometrial Cancer
Adenocarcinoma is the most common cancer of
the female reproductive tract.
2-3% of women will develop it in a lifetime.
75% occur in postmenopausal women.
Associated with the best overall survival of all
gynecologic malignancies.
Usually diagnosed as early stage disease.
Endometrial Hyperplasia (EMHP)
The majority of the simple and complex EMHPs
will regress spontaneously.
Atypical HP has a much greater tendency to
persist or progress if not specifically treated.
Lesions are classified as invasive or pre-invasive
according to the presence or absence of stromal
invasion.
EMHP - Tendency for Progression
Hyperplasia
Regression
Progression
Yrs.
Simple HP
80%
1%
Complex HP
78%
3%
8.3
Atypical HP *
58%
29%
4.1
* true cancer precursor
Risk Factors for Endometrial Cancer
•Unopposed estrogen exposure
•Median age at diagnosis: 59 years
•Menstrual cycle irregularities, specifically menorrhagia and
menometrorrhagia
•Postmenopausal bleeding
•Chronic anovulation
•Nulliparity
•Early menarche (before 12 years) / Late menopause (after 52 years)
•Infertility
•Tamoxifen (Nolvadex) use
•Granulosa and thecal cell tumors
•Ovarian dysfunction
•Obesity
•Diabetes mellitus
•Arterial hypertension with or without atherosclerotic heart disease
•History of breast or colon cancer
Risk factors: Unopposed Estrogen
May accelerate the progression from
Simple
Atypical
Cancer
Simple or atypical HP will regress if unopposed
estrogen is stopped.
Users of unopposed estrogen for at least 2 years
develop endometrial cancer 2 - 20 times more
frequently than nonusers.
Risk increases with higher doses and
longer use.
Risk factors: Unopposed Estrogen
After 10 years of use, the risk of developing
endometrial cancer = 10 per 1000 postmenopausal
women.
There is a residual risk that may persist for up to 15
years even after estrogen is stopped.
Tamoxifen use???
Risk factors: Prolonged Endogenous Estrogen
Primarily due to chronic anovulation.
Obesity.
Polycystic ovarian disease.
Infertility.
Late menopause.
Explains why smokers have a decreased risk
of endometrial cancer.
Endometrial Cancer
Vaginal bleeding is the most common presenting
symptom.
Gross and microscopic hemorrhage.
Most common histologic types are endometrial and
mucinous.
Most common prognostic factors:
Degree of histologic differentiation.
Depth of stromal invasion.
Methods of Detection:Endometrial Cancer
Endometrial cells on the Pap Smear
Endometrial cells
HP
Adenocarcinoma
Normal
13%
11%
Atypical
11%
20%
Of women with Malignant endometrial cells on a Pap
smear, 70% have deep myometrial invasion.
Do not ignore endometrial cells on a Pap smear !
Methods of Detection:Endometrial Cancer
Endometrial Aspiration
Office endometrial samplers are highly
sensitive ( 97.5 % or more ) for detection of
endometrial cancer.
• misses polyps and submucous fibroids.
May fail to adequately sample the atrophic
endometrium.
• insufficiency rate = 15 %.
• samples by “shear” rather than curettage.
Methods of Detection:Endometrial Cancer
Ultrasonography
The thicker the endometrial lining of postmenopausal women
on TVUS, the greater the risk of endometrial disease.
The negative predictive value for the diagnosis of cancer or HP is
100 % when the lining measures < 5 mm in thickness.
• Does not apply if EMBx has been previously performed.
Saline Contrast Sonography
Allows a better evaluation of the endometrium specially in case of
TAM therapy or if there is a ? Endometrial polyp or Fibroid
Methods of Detection:Endometrial Cancer
Hysteroscopy
The combination of Hysteroscopy and Guided Biopsy can
approach 100 % accuracy in the diagnosis of endometrial
cancer and HP.
Used to stage the tumor.
• Confined to uterine corpus ?
• Cervical involvement ?
– Errors in staging can occur 10-15% of the time with blind D&C .
Four Major Types of Pathologic Findings
on Endometrial Biopsy
•Proliferative, secretory, benign or atrophic endometrium
•Simple or complex (adenomatous) hyperplasia without atypia
•Simple or complex (adenomatous) hyperplasia with atypia
•Endometrial adenocarcinoma
Regardless of histologic type, the presence of atypia is
the major determinant of risk for endometrial cancer.
Management of Hyperplasia Without Atypia
6mm.
POLYP from the fundus
3-D ultrasound-Endometrial polyp
Screening…To whom it should be directed
All women with postmenopausal bleeding
(except in the first 6 months of HRT).
Perimenopausal women at high risk or with
persistent AUB despite hormonal therapy.
Women at any age at high risk for EMHP.
Obese women with AUB.
Women with DUB not responding to hormonal
therapy.
Women on tamoxifen therapy.