Transcript PPT - David Geffen School of Medicine at UCLA

Cancer Survivorship
Endometrial Cancer Risks and Treatments:
Epidemiology and Late Effects
of Cancer Survival
Part A
All images in this module were obtained from
Berek, JS, Hacker, NF: Practical Gynecologic Oncology, 2nd Ed, 1994.
2004, David Geffen School
of Medicine at UCLA.
Cancer Survivorship Grant.
Goal of this Module





This is an interactive and self-directed learning module
intended to build a foundation of knowledge around the
epidemiology and late effects of cancer survival. This is
one of several educational modules you will complete
during your core clinical clerkships. Themes
emphasized in this, and other modules, are:
Epidemiology of survival
Late effects
Psychosocial concerns
Secondary prevention
Strategies for behavior change
Case #1
Ms. Johnson, an obese, 64 year-old, Caucasian woman,
gravida 1, para 1, comes to see you because she is
having post menopausal bleeding over the past
month (Causes of post menopausal bleeding). She
has no other symptoms. She has not been receiving
hormone replacement therapy with estrogen or
progesterone.
Next
Question #1
Of the following risk factors for developing
endometrial cancer, which are the most significant
in the patient’s history:
A.
B.
C.
D.
Amount of vaginal bleeding
Obesity
Patient age
Number of pregnancies
Incorrect. Question #1
A. Amount of vaginal bleeding

The amount of vaginal bleeding per se is not a risk
factor for the development of endometrial cancer. More
important is the relationship of the bleeding to the
menopausal status. Even relatively modest amount of
bleeding in women who are many years postmenopausal is associated with a very high rate
endometrial cancer. Very heavy and irregular menses
over many years in pre-menopausal women can be
associated with endometrial hyperplasia which is a
precursor for endometrial cancer.
Back to
Question 1
Correct. Question #1
B. Obesity

Women who are overweight get endometrial
cancer twice as often as do women who are not
overweight. Excessive weight can put a woman
at the highest relative risk of developing
endometrial cancer. Most young women who get
the disease are obese, although it is unusual to
get endometrial cancer under the age of 45.
Go to
Relative Risk
Continue
Module
Incorrect. Question #1
C. Patient Age

Patient age is an important risk factor because
most women who get endometrial cancer are
post-menopausal. However, the relative risk
associated with age is not as great as one other
variable.
Back to
Question 1
Incorrect. Question #1
D. Number of Pregnancies

Although women who have never been pregnant
have a higher chance of developing endometrial
cancer, it is not the variable with the highest risk.
It is thought that pregnancy protects against
endometrial cancer because ovulation is
suppressed.
Back to
Question 1
Question #2
Had this patient been taking oral post menopausal estrogen
therapy she would be at higher risk of developing
endometrial cancer. There is an indisputable link between
“unopposed” estrogen therapy and the risk of developing
endometrial cancer. Of the following variables of estrogen
usage, which has the significant impact of that risk?
A.
B.
C.
D.
Types of hormone
Dose of hormone
Duration of use (years)
Age of initiation of therapy
Incorrect. Question #2
A. Types of Hormone



The type of estrogen and progesterone is not as
important as whether or not the woman is taking
estrogen without progesterone to protect the
endometrium.
Risk is mediated through states that lead to an excess of
estrogen over progesterone.
Using a combination of estrogen and progesterone
decreases the risk linked to the use of estrogen alone.
Back to
Question 2
Incorrect. Question #2
B. Dose of hormone

Increase in estrogen dose increases the risk of
endometrial cancer, but decrease exposure to
estrogens or increase progesterone levels tend
to be protective.
Back to
Question 2
Correct. Question #2
C. Duration of use (years)

Increase in duration of use increases the risk of
endometrial cancer. The longer the use of
estrogen in the absence of progesterone, the
higher the probability of developing endometrial
cancer.
Continue
Module
Incorrect. Question #2
D. Age of initiation of therapy

Most women initiate therapy when they become
menopausal. The age of initiation of therapy is
not particularly relevant compared with the
duration of use of hormone therapy.
Back to
Question 2
Case #1 Continued
On physical exam, the patient is noted to
weigh 232 lbs and her height is 5’5”. On
pelvic exam it is difficult to assess the size of
her uterus, however it appears to be slightly
enlarged. You perform an endometrial biopsy
and submit it for pathological evaluation.
Next
Question #3
Based on this scenario, the most likely
histology is:
A.
B.
C.
D.
Clear cell
Endometrioid
Papillary Serous
Mixed histology
Incorrect. Question #3
A. Clear Cell

The lesions of clear cell carcinoma are similar
to those seen in the ovary. An association with
DES has not been demonstrated with the
endometrial lesion. The lesions are uncommon,
accounting for 2-3% of all adenocarcinomas of
the endometrium and tend to have a poor
prognosis.
Back to
Question 3
Correct. Question #3
B. Endometrioid (See image)

This is the most common type of endometrial
cancer (See table). It is called endometrioid
because it looks like endometrial glands.
Continue
Module
Incorrect. Question #3
C. Papillary Serous

Similar to a papillary serous lesion of the ovary.
The complex papillae are lined with cuboidal or
low columnar cells with severe nuclear anaplasia,
prominent nucleoli, and high mitotic activity (See
microscopic image). An aggressive behavior
with peritoneal spread can occur with minimal
myometrial invasion, presumably through
transtubal spread (See hysterectomy specimen).
Back to
Question 3
Incorrect. Question #3
D. Mixed histology

One can have combinations of endometrioid,
clear cell, and papillary serous carcinomas, but
these are less common.
Back to
Question 3
Case #1 Continued
The results of the biopsy showed an
endometrioid adenocarcinoma, moderately
differentiated (grade 2). Based on this result,
you recommend that the patient have surgery.
Next
Question #4
The recommended surgery for this condition is
exploratory laparotomy, total abdominal
hysterectomy and bilateral salpingooophorectomy (TAH & BSO) and:
A.
B.
C.
D.
No other biopsies
Pelvic lymphadenectomy
Para-aortic lymphadenectomy
Pelvic and para-aortic lymphadenectomy
Incorrect. Question #4
A. No other biopsies

A “staging” laparotomy must be perform in
order to determine the true extensive disease
even if there is a preoperative scan showing a
uterine tumor. The FIGO staging requires a
surgical procedure. The staging laparotomy
typically includes the performance of peritoneal
cytology and biopsies including lymph node
biopsies.
Back to
Question 4
Incorrect. Question #4
B. Pelvic lymphadenectomy

In most circumstances in order to do a thorough
staging operation a paraortic lymphadenectomy
must be performed. This is important because
patients with metastatic disease to the paraortic
lymph nodes require additional therapy.
Back to
Question 4
Incorrect. Question #4
C. Para-aortic lymphadenectomy

While it is important to perform a para-aortic
lymphadenectomy, a pelvic lymphadenectomy
is also included in the staging laparotomy.
Back to
Question 4
Correct. Question #4
D. Pelvic and para-aortic lymphadenectomy

In order to perform a thorough surgical staging
for endometrial cancer, both pelvic and paraaortic lymphadenectomy should be performed
unless there is a medical contraindication, e.g.,
morbid obesity or severe cardiovascular
disease.
Continue
Module
Case #1 Continued
Patient undergoes a hysterectomy and
staging. The tumor is grade 2 and invades
one half of the muscle wall. There are no
metastasis to the pelvic or para-aortic lymph
nodes.
Next
Question #5
Based on these findings, her stage is:
A.
B.
C.
D.
Stage I
Stage II
Stage III
Stage IV
Correct. Question #5
A. Stage I

The patient’s disease is confined to the uterus
(See image) and there is no evidence of
metastatic disease (FIGO Stage I).
Continue
Module
Incorrect. Question #5
B. Stage II

Stage II disease means the tumor has extended
from the endometrium to the cervix (FIGO
Stage II).
Back to
Question 5
Incorrect. Question #5
C. Stage III

FIGO Stage III means the disease has spread to
the pelvic or para-aortic lymph nodes.
Back to
Question 5
Incorrect. Question #5
D. Stage IV

FIGO Stage IV means the disease has
metatasized to distant organs. e.g., the liver or
the lung parenchyma (See X-ray image).
Back to
Question 5
Case #1 Continued
Based on these finding this patient was
recommended and received pelvic radiation
therapy.
Question #6
Based on her stage and treatment, the
probability of her five-year disease-free
survival:
A.
B.
C.
D.
85%
70%
50%
30%
Correct. Question #6
A. 85%

Patient with Stage IB, grade 2 has
approximately 85%, 5 yr survival based on
surgical staging. Within Stage IB, the
prognosis depends on additional variables (See
table).
Next
Incorrect. Question #6
B. 70%

Patient with Stage IB, grade 2 tumor and has a
better 5 year survival based on surgical staging.
Back to
Question 6
Incorrect. Question #6
C. 50%

Patient with Stage IB, grade 2 tumor and has a
better 5 year survival based on surgical staging.
Back to
Question 6
Incorrect. Question #6
D. 30%
•
Patient with Stage IB, grade 2 tumor and has a
better 5 year survival based on surgical staging.
Back to
Question 6
Question #7
In women with endometrial cancer, the likelihood
of cure is lower in African-American women
compared with Caucasian women in the U.S. What
is the difference in survival at 5 years?
A.
B.
C.
D.
5%
10%
15%
25%
Incorrect. Question #7
A. 5%

Unfortunately, there is an even greater disparity
in 5 year survival rates between African
American and Caucasian women in the United
States.
Back to
Question 7
Incorrect. Question #7
B. 10%

Unfortunately, there is an even greater disparity
in 5 year survival rates between African
American and Caucasian women in the United
States.
Back to
Question 7
Incorrect. Question #7
C. 15%

Unfortunately, there is an even greater disparity
in 5 year survival rates between African
American and Caucasian women in the United
States.
Back to
Question 7
Correct. Question #7
D. 25%

Unfortunately, there is this large disparity in 5
year survival rates between African American
and Caucasian women in the United States.
Next
Question
Question #8
The treatment of endometrial cancer has an impact on
subsequent sexual functioning. The most
significant decrease in the frequency of the sexual
activity is found after which of the following
treatments for stage I disease?
A.
B.
C.
D.
Hysterectomy
Radiation therapy
Hysterectomy plus radiation therapy
Chemotherapy
Incorrect. Question #8
A. Hysterectomy

In women who undergo a hysterectomy for this disease
and do not require adjuvant treatment, there should be
no significant impact on sexual function. However, in
women who are premenopausal who require removal of
their ovaries, the lower levels of estrogen may be
associated with changes in sexual function.
Back to
Question 8
Incorrect. Question #8
B. Radiation therapy

Radiation therapy can produce vaginal changes that can
make intercourse more difficult and in some cases
painful, adjuvant radiation is generally used after the
performance of a hysterectomy.
Back to
Question 8
Correct. Question #8
C. Hysterectomy plus radiation therapy

In some women who receive adjuvant radiation therapy
after hysterectomy, intercourse becomes more difficult
or even painful because of the development of
radiation vaginitis or stenosis.
Next
Question
Incorrect. Question #8
D. Chemotherapy

Most patients who receive adjuvant treatment for
endometrial cancer after hysterectomy require radiation
therapy. While chemotherapy is occasionally used in
selected patients with certain types of histologies, (clear
cell or papillary serous carcinoma), this usually does
not interfere with long term sexual function.
Back to
Question 8
Question #9
Following the treatment of stage I endometrial cancer
with a hysterectomy in an obese woman, the
patient should be counseled to lose weight,
because obesity increase the subsequent risk of:
A.
B.
C.
D.
Recurrent endometrial cancer
Cervical cancer
Breast cancer
Colon cancer
Incorrect. Question #9
A. Recurrent endometrial cancer

There is no evidence that obesity increases the
rate of recurrence of endometrial cancer.
Obesity does predispose the development of
endometrial cancer, however.
Back to
Question 9
Incorrect. Question #9
B. Cervical cancer

Patients who have been treated for endometrial
cancer should have undergone a complete
hysterectomy, including the surgical removal of
the cervix.
Back to
Question 9
Correct. Question #9
C. Breast cancer

Even though this patient may have been treated
for her endometrial cancer, obesity still
predisposes to the development of breast
cancer.
Next
Question
Incorrect. Question #9
D. Colon cancer

Unless the patient falls into a family cancer
syndrome which predisposes to both the
development of colon and endometrial cancer
(HNPCC syndrome), her risk of subsequent
colon cancer is not increased.
Back to
Question 9
Question #10
Conservative treatment (use of hormonal therapy with
preservation of the uterus) is used for selected
young patients (<35 years of age) with well
differentiated stage I endometrial cancer.
Compared to a woman who does not have the
disease, fertility in these women is significantly:
A.
B.
C.
D.
Abrogated
Decreased
Unchanged
Increased
Incorrect. Question #10
A. Abrogated

If the uterus responds to hormonal treatment and is
preserved, it is still possible for these patients to
become pregnant, although it often requires ovulation
induction and timed insemination.
Back to
Question 10
Correct Question #10
B. Decreased

Although these women retain the uterus and the
potential for fertility, their ability to conceive is
considerably reduced compared to women who do not
have this condition.
Complete
Post Test
Incorrect. Question #10
C. Unchanged

These women retain the uterus and the potential for
fertility, however, their ability to conceive is different
than women who do not have this condition.
Back to
Question 10
Incorrect. Question #10
D. Increased

These women retain the uterus and the potential
for fertility, however, their ability to conceive is
different than women who do not have this
condition.
Back to
Question 10
Endometrial Cancer Risk Factors
Certain factors can make one woman more likely to
get endometrial cancer than another. These are
called risk factors. However, a woman who has one
or more risk factors will not necessarily get
endometrial cancer. In fact, a woman can have all
the risk factors and still not get endometrial cancer,
or she can have no known risk factors and still get
the disease.
Back to
Question 1
What is Endometrial Cancer?
Endometrial cancer begins in the uterus, or womb.
The uterus is part of the female reproductive
system. It protects the growing fetus during
pregnancy, and is involved in menstruation and
menopause. The most common form of endometrial
cancer develops in the lining of the uterus, which is
known as the endometrium. Endometrial cancer is
the most common cancer of the female reproductive
system and is usually curable when detected early.
Back to
Question 1
Anatomy of the Uterus
Cross Section of the Female Reproductive System
(Courtesy of Jones and Bartlett Publishers)
Back to
Explanation
The Female Reproductive System
Back to
Explanation
Relative Risk Matrix
Age ( > 50 years)
1.5
Endometrial hyperplasia
2-10
Estrogen (unopposed)
2-6
Obesity
2-10
Other cancers (breast and ovary)
2-3
Pregnancy (nulligravida vs. gravida)
.5-.75
Race (African American vs. Caucasian)
1.25
Tamoxifen
2-7
Irregular menstrual periods
1.1-1.5
Hypertension
1.1-1.5
Diabetes
1.1-1.5
Late menopause
1.25-1.5
Back to
Question 1
Relative Risk Matrix
Age ( > 50 years)
1.5
Endometrial hyperplasia
2-10
Estrogen (unopposed)
2-6
Obesity
2-10
Other cancers (breast and ovary)
2-3
Pregnancy (nulligravida vs. gravida)
.5-.75
Race (African American vs. Caucasian)
1.25
Tamoxifen
2-7
Irregular menstrual periods
1.1-1.5
Hypertension
1.1-1.5
Diabetes
1.1-1.5
Late menopause
1.25-1.5
Back to
Question 1
Continue
Module
Endometrial Cancer Risk Factors
 Age. Most women who get endometrial
cancer are over age 50. A woman is at higher
risk if she is post-menopausal and over age
50.
Back to
Explanation
Go to
Relative Risk
Endometrial Cancer Risk Factors
 Age. Most women who get endometrial
cancer are over age 50. A woman is at higher
risk if she is post-menopausal and over age
50.
Go to
Relative Risk
Endometrial Cancer Risk Factors
 Age. Most women who get endometrial
cancer are over age 50. A woman is at higher
risk if she is post-menopausal and over age
50.
Go to
Relative Risk
Endometrial Cancer Risk Factors
 Endometrial hyperplasia. Women who
have endometrial hyperplasia (See image)
have a higher risk of developing endometrial
cancer.
Back to
Explanation
Go to
Relative Risk
Endometrial Cancer Risk Factors
 Endometrial hyperplasia. Women who
have endometrial hyperplasia (See image)
have a higher risk of developing endometrial
cancer.
Go to
Relative Risk
Endometrial Cancer Risk Factors
 Endometrial hyperplasia. Women who
have endometrial hyperplasia (See image)
have a higher risk of developing endometrial
cancer.
Go to
Relative Risk
Endometrial Cancer Risk Factors
 Estrogen (unopposed). Women who use estrogen
replacement therapy without progesterone have a
higher chance of developing endometrial cancer. If
a woman needs estrogen replacement therapy, she
should discuss using a combination of estrogen and
progesterone with her doctor. This protects the
uterus from developing cancer.
Go to
Relative Risk
Endometrial Cancer Risk Factors
 Estrogen (unopposed). Women who use estrogen
replacement therapy without progesterone have a
higher chance of developing endometrial cancer. If
a woman needs estrogen replacement therapy, she
should discuss using a combination of estrogen and
progesterone with her doctor. This protects the
uterus from developing cancer.
Go to
Relative Risk
Endometrial Cancer Risk Factors
 Obesity. Women who are overweight get
endometrial cancer twice as often as do women
who are not overweight. Excessive weight can put
a woman at the highest risk of developing
endometrial cancer. Most young women who get
the disease are obese, although it is unusual to get
endometrial cancer under the age of 45. The
relative risk of endometrial cancer in obese
women is 2-7.
Back to
Explanation
Go to
Relative Risk
Endometrial Cancer Risk Factors
 Obesity. Women who are overweight get
endometrial cancer twice as often as do women
who are not overweight. Excessive weight can put
a woman at the highest risk of developing
endometrial cancer. Most young women who get
the disease are obese, although it is unusual to get
endometrial cancer under the age of 45. The
relative risk of endometrial cancer in obese
women is 2-7.
Go to
Relative Risk
Endometrial Cancer Risk Factors
 Obesity. Women who are overweight get
endometrial cancer twice as often as do women
who are not overweight. Excessive weight can put
a woman at the highest risk of developing
endometrial cancer. Most young women who get
the disease are obese, although it is unusual to get
endometrial cancer under the age of 45. The
relative risk of endometrial cancer in obese
women is 2-7.
Go to
Relative Risk
Endometrial Cancer Risk Factors
 Other cancers. Women who have had colon,
rectal, or breast cancer have a higher chance
of developing endometrial cancer
Go to
Relative Risk
Endometrial Cancer Risk Factors
 Other cancers. Women who have had colon,
rectal, or breast cancer have a higher chance
of developing endometrial cancer
Go to
Relative Risk
Endometrial Cancer Risk Factors
 Pregnancy. Women who have never been
pregnant have a higher chance of developing
endometrial cancer. It is thought that
pregnancy protects against endometrial
cancer because high levels of progestins are
produced during pregnancy.
Back to
Explanation
Go to
Relative Risk
Endometrial Cancer Risk Factors
 Pregnancy. Women who have never been
pregnant have a higher chance of developing
endometrial cancer. It is thought that
pregnancy protects against endometrial
cancer because high levels of progestins are
produced during pregnancy.
Go to
Relative Risk
Endometrial Cancer Risk Factors
 Pregnancy. Women who have never been
pregnant have a higher chance of developing
endometrial cancer. It is thought that
pregnancy protects against endometrial
cancer because high levels of progestins are
produced during pregnancy.
Go to
Relative Risk
Endometrial Cancer Risk Factors
 Race. Women who are white have a higher
chance of developing endometrial cancer
than do non-white women. For reasons that
are not entirely clear, cancer is approximately
twice as common in whites as it is in
African-Americans and other non-whites.
Go to
Relative Risk
Endometrial Cancer Risk Factors
 Race. Women who are white have a higher
chance of developing endometrial cancer
than do non-white women. For reasons that
are not entirely clear, cancer is approximately
twice as common in whites as it is in
African-Americans and other non-whites.
Go to
Relative Risk
Endometrial Cancer Risk Factors
 Tamoxifen. Tamoxifen is a drug that is sometimes used to treat
women with breast cancer. Studies have found that some
women who take tamoxifen for 5 years or more have a higher
risk of developing endometrial cancer. However, while several
studies have shown that tamoxifen can significantly increase a
woman's risk of endometrial polyps and cancer, it is believed
that its ability to lower the incidence of breast cancer deaths
outweighs the risk of developing endometrial cancer. A woman
who has been receiving tamoxifen, does not need routine x-rays
or biopsies, but she should be examined by her gynecologist at
least once a year or right away if irregular bleeding occurs.
Go to
Relative Risk
Endometrial Cancer Risk Factors
 Tamoxifen. Tamoxifen is a drug that is sometimes used to treat
women with breast cancer. Studies have found that some
women who take tamoxifen for 5 years or more have a higher
risk of developing endometrial cancer. However, while several
studies have shown that tamoxifen can significantly increase a
woman's risk of endometrial polyps and cancer, it is believed
that its ability to lower the incidence of breast cancer deaths
outweighs the risk of developing endometrial cancer. A woman
who has been receiving tamoxifen, does not need routine x-rays
or biopsies, but she should be examined by her gynecologist at
least once a year or right away if irregular bleeding occurs.
Go to
Relative Risk
Endometrial Cancer Risk Factors
 Irregular menstrual periods. Some women
may not ovulate regularly during the
reproductive years. This can upset the
delicate balance between estrogenic
hormones that encourage the development of
cancer and the progestigenic hormones that
protect against cancer.
Back to
Explanation
Go to
Relative Risk
Endometrial Cancer Risk Factors
 Irregular menstrual periods. Some women
may not ovulate regularly during the
reproductive years. This can upset the
delicate balance between estrogenic
hormones that encourage the development of
cancer and the progestigenic hormones that
protect against cancer.
Back to
Question #4
Endometrial Cancer Risk Factors
 Irregular menstrual periods. Some women
may not ovulate regularly during the
reproductive years. This can upset the
delicate balance between estrogenic
hormones that encourage the development of
cancer and the progestigenic hormones that
protect against cancer.
Go to
Relative Risk
Endometrial Cancer Risk Factors
 Hypertension. Hypertension (high blood
pressure) has been associated with
endometrial cancer, but not as strongly as
some of the other risk factors.
Go to
Relative Risk
Endometrial Cancer Risk Factors
 Hypertension. Hypertension (high blood
pressure) has been associated with
endometrial cancer, but not as strongly as
some of the other risk factors.
Go to
Relative Risk
Endometrial Cancer Risk Factors
 Diabetes. Women with diabetes have twice
the risk of endometrial cancer as women who
do not have diabetes. Similar to
hypertension, many women with diabetes are
also overweight. It is not entirely clear how
much of the increased risk in women with
diabetes is due to the diabetic condition as
opposed to being overweight.
Go to
Relative Risk
Endometrial Cancer Risk Factors
 Diabetes. Women with diabetes have twice
the risk of endometrial cancer as women who
do not have diabetes. Similar to
hypertension, many women with diabetes are
also overweight. It is not entirely clear how
much of the increased risk in women with
diabetes is due to the diabetic condition as
opposed to being overweight.
Go to
Relative Risk
Endometrial Cancer Risk Factors
 Late menopause. Women who have a later
menopause have a slightly increased risk of
developing endometrial cancer
Go to
Relative Risk
Endometrial Cancer Risk Factors
 Late menopause. Women who have a later
menopause have a slightly increased risk of
developing endometrial cancer
Go to
Relative Risk
Relative Risk Matrix
Age ( > 50 years)
1.5
Endometrial hyperplasia
2-10
Estrogen (unopposed)
2-6
Obesity
2-10
Other cancers (breast and ovary)
2-3
Pregnancy (nulligravida vs. gravida)
.5-.75
Race (African American vs. Caucasian)
1.25
Tamoxifen
2-7
Irregular menstrual periods
1.1-1.5
Hypertension
1.1-1.5
Diabetes
1.1-1.5
Late menopause
1.25-1.5
Go to
Question 2
Endometrial Cancer Risk Factors
 Age. Most women who get endometrial
cancer are over age 50. A woman is at higher
risk if she is post-menopausal and over age
50.
Go to
Relative Risk
Endometrial Cancer Risk Factors
 Endometrial hyperplasia. Women who
have endometrial hyperplasia have a higher
risk of developing endometrial cancer.
Go to
Relative Risk
Endometrial Cancer Risk Factors
 Estrogen (unopposed). Women who use estrogen
replacement therapy without progesterone have a
higher chance of developing endometrial cancer. If
a woman needs estrogen replacement therapy, she
should discuss using a combination of estrogen and
progesterone with her doctor. This protects the
uterus from developing cancer.
Back to
Question 2
Go to
Relative Risk
Endometrial Cancer Risk Factors
 Estrogen (unopposed). Women who use estrogen
replacement therapy without progesterone have a
higher chance of developing endometrial cancer. If
a woman needs estrogen replacement therapy, she
should discuss using a combination of estrogen and
progesterone with her doctor. This protects the
uterus from developing cancer.
Go to
Relative Risk
Endometrial Cancer Risk Factors
 Obesity. Women who are overweight get
endometrial cancer twice as often as do women
who are not overweight. Excessive weight can put
a woman at the highest risk of developing
endometrial cancer. Most young women who get
the disease are obese, although it is unusual to get
endometrial cancer under the age of 45. The
relative risk of endometrial cancer in obese
women is 2-7.
Go to
Relative Risk
Endometrial Cancer Risk Factors
 Other cancers. Women who have had colon,
rectal, or breast cancer have a higher chance
of developing endometrial cancer
Go to
Relative Risk
Endometrial Cancer Risk Factors
 Pregnancy. Women who have never been
pregnant have a higher chance of developing
endometrial cancer. It is thought that
pregnancy protects against endometrial
cancer because high levels of progestins are
produced during pregnancy.
Go to
Relative Risk
Endometrial Cancer Risk Factors
 Race. Women who are white have a higher
chance of developing endometrial cancer
than do non-white women. For reasons that
are not entirely clear, cancer is approximately
twice as common in whites as it is in
African-Americans and other non-whites.
Go to
Relative Risk
Endometrial Cancer Risk Factors
 Tamoxifen. Tamoxifen is a drug that is sometimes used to treat
women with breast cancer. Studies have found that some
women who take tamoxifen for 5 years or more have a higher
risk of developing endometrial cancer. However, while several
studies have shown that tamoxifen can significantly increase a
woman's risk of endometrial polyps and cancer, it is believed
that its ability to lower the incidence of breast cancer deaths
outweighs the risk of developing endometrial cancer. A woman
who has been receiving tamoxifen, does not need routine x-rays
or biopsies, but she should be examined by her gynecologist at
least once a year or right away if irregular bleeding occurs.
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Relative Risk
Endometrial Cancer Risk Factors
 Irregular menstrual periods. Some women
may not ovulate regularly during the
reproductive years. This can upset the
delicate balance between estrogenic
hormones that encourage the development of
cancer and the progestigenic hormones that
protect against cancer.
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Relative Risk
Endometrial Cancer Risk Factors
 Hypertension. Hypertension (high blood
pressure) has been associated with
endometrial cancer, but not as strongly as
some of the other risk factors.
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Relative Risk
Endometrial Cancer Risk Factors
 Diabetes. Women with diabetes have twice
the risk of endometrial cancer as women who
do not have diabetes. Similar to
hypertension, many women with diabetes are
also overweight. It is not entirely clear how
much of the increased risk in women with
diabetes is due to the diabetic condition as
opposed to being overweight.
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Relative Risk
Endometrial Cancer Risk Factors
 Late menopause. Women who have a later
menopause have a slightly increased risk of
developing endometrial cancer
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Relative Risk
Causes of Postmenopausal
bleeding
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Case 1
Endometrial Hyperplasia
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Explanation
Endometrial Hyperplasia
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Explanation
Endometrial Hyperplasia
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Explanation
Histology Table
Subtype
Adenoacanthoma
Adenocarcinoma
Papillary serous
Adenosquamous
Clear cell
Sarcoma
Alive (%)
87.5
79.8
69.7
53.1
44.2
31.2
DOD (%)
6.3
6.2
21.2
32.7
51.2
64.3
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Explanation
Uterus
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Explanation
Tamoxifen
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Explanation
Tamoxifen
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Explanation
Tamoxifen
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Explanation
Clear Cell
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Explanation
Clear Cell
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Explanation
Endometrioid
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Explanation
Normal vs. Abnormal Uterine
Normal Uterus
Endometrial CA
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Explanation
Papillary Serous Carcinoma
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Explanation
Papillary Serous Carcinoma
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Explanation
Lung X-ray
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Explanation
Sarcoma
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Histology
Table
Papillary Serous
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Explanation
Prognostic Variables
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Explanation
Histologic Grade of Endometrioid
Adenocarcinoma
 Graded by the architecture alone (GOG) or a
combination of architecture and nuclear features
(FIGO and WHO):
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
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Well-differentiated (grade 1) lesions contain 98% or
more glandular or papillary formations.
Moderately differentiated (grade 2) tumors have 2-50%
solid areas.
Poorly differentiated (grade 3) neoplasms have more
than 50% solid areas.
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Case #1
FIGO* Staging of Endometrial
Cancer
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Stage I: The cancer is only in the body of the uterus.
Stage IA: The cancer is only in the endometrium.
Stage IB: The cancer has spread less than halfway through the myometrium.
Stage IC: The cancer has spread halfway through the myometrium.
Stage II: The cancer has spread from the uterus to the cervix.
Stage IIA: The cancer is in the body of the uterus and the endocervical glands.
Stage IIB: The cancer is in the body of the uterus and the cervical stroma.
Stage III: The cancer has spread outside the body of the uterus, but has not left the pelvic area.
Stage IIIA: The cancer has spread to the serosa of the uterus, or the adnexa, or there are no
cancer cells in peritoneal fluid.
Stage IIIB: The cancer has spread to the vagina.
Stage IIIC: The cancer has spread to the lymph nodes near the uterus.
Stage IV: The cancer has spread to the mucosa of the bladder or the rectum and/or has spread to
the lymph nodes in the groin, and/or has spread to other organs, such as the lungs or the bones.
Stage IVA: The cancer has spread to the mucosa or inner lining of the rectum or bladder.
Stage IVB: The cancer has spread to the lymph nodes in the groin area and/or has spread to
other organs, such as the lungs or bones.
*FIGO: International Federation of Obstetrics and Gynecology
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Question 5
FIGO* Staging of Endometrial
Cancer
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Stage I: The cancer is only in the body of the uterus.
Stage IA: The cancer is only in the endometrium.
Stage IB: The cancer has spread less than halfway through the myometrium.
Stage IC: The cancer has spread halfway through the myometrium.
Stage II: The cancer has spread from the uterus to the cervix.
Stage IIA: The cancer is in the body of the uterus and the endocervical glands.
Stage IIB: The cancer is in the body of the uterus and the cervical stroma.
Stage III: The cancer has spread outside the body of the uterus, but has not left the pelvic area.
Stage IIIA: The cancer has spread to the serosa of the uterus, or the adnexa, or there are no
cancer cells in peritoneal fluid.
Stage IIIB: The cancer has spread to the vagina.
Stage IIIC: The cancer has spread to the lymph nodes near the uterus.
Stage IV: The cancer has spread to the mucosa of the bladder or the rectum and/or has spread to
the lymph nodes in the groin, and/or has spread to other organs, such as the lungs or the bones.
Stage IVA: The cancer has spread to the mucosa or inner lining of the rectum or bladder.
Stage IVB: The cancer has spread to the lymph nodes in the groin area and/or has spread to
other organs, such as the lungs or bones.
*FIGO: International Federation of Obstetrics and Gynecology
Next
Question
Actuarial 5-year survival by
Histologic Grade and Stage
Stage I
IA
IB
IC
Stage II
IIA
IIB
Grade
%
%
%
%
%
1
92.3
94.1
83.2
86.1
72.7
2
89.7
84.9
79.8
71.8
71.1
3
81.5
76.3
68.3
65.9
49
Not Graded
85.9
84.8
68.8
80
59.6
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Explanation
Actuarial 5-year survival by
Histologic Grade and Stage
Stage I
IA
IB
IC
Stage II
IIA
IIB
Grade
%
%
%
%
%
1
92.3
94.1
83.2
86.1
72.7
2
89.7
84.9
79.8
71.8
71.1
3
81.5
76.3
68.3
65.9
49
Not Graded
85.9
84.8
68.8
80
59.6
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Explanation
Actuarial 5-year survival by
Histologic Grade and Stage
Stage I
IA
IB
IC
Stage II
IIA
IIB
Grade
%
%
%
%
%
1
92.3
94.1
83.2
86.1
72.7
2
89.7
84.9
79.8
71.8
71.1
3
81.5
76.3
68.3
65.9
49
Not Graded
85.9
84.8
68.8
80
59.6
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Explanation
Actuarial 5-year survival by
Histologic Grade and Stage
Stage I
IA
IB
IC
Stage II
IIA
IIB
Grade
%
%
%
%
%
1
92.3
94.1
83.2
86.1
72.7
2
89.7
84.9
79.8
71.8
71.1
3
81.5
76.3
68.3
65.9
49
Not Graded
85.9
84.8
68.8
80
59.6
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Explanation
Endometrial Cancer Genetics
 The most common type of hereditary
endometrial cancer syndrome is the Hereditary
Non-Polyposis Colorectal Cancer (HNPCC or
Lynch Syndrome II). In this syndrome, multiple
family members can develop cancers arising
from the colon, uterus, small intestine, kidney
system, or the ovaries.
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Explanation
Post Test
 Please complete the post test included on this
CD. Just click on the button below to access
the post test. Turn in a completed post test and
this CD to your clerkship director.
Post Test