B-QuiCK: Endometrial cancer

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B-QuiCK: Endometrial cancer – early detection and referral

Early detection

  • Endometrial cancer accounts for the majority of uterine cancer diagnoses. Excessive exposure to endogenous or exogenous oestrogen unopposed by progesterone is the primary cause, e.g. increasing age, obesity.
  • There are no screening programmes available or recommended for the early detection of endometrial cancer, so diagnosis relies on recognising and investigating suspicious symptoms:
    • Symptoms may include abnormal uterine bleeding (particularly post-menopausal, but also inter-menstrual or post-coital), abnormal vaginal discharge, unexplained weight loss, pelvic pain, abdominal pain or distention and urinary or bowel dysfunction
    • Incorporate education about the key symptoms of endometrial cancer during relevant discussions, e.g. about menopause or menopausal hormone therapy, to minimise delayed presentation and improve the likelihood of early detection

Some genetic conditions increase the risk of endometrial cancer; check local HealthPathways to assess eligibility criteria for referral to genetic services. Refer patients with Lynch syndrome to a gynaecologist for discussion about ongoing surveillance or risk-reducing strategies for endometrial cancer.

Patients with suspicion of endometrial cancer

  • Take a focused history, considering relevant risk factors (e.g. family history, Lynch syndrome, ethnicity) or factors that would result in excessive exposure to unopposed oestrogen (e.g. obesity, tamoxifen use, oestrogen-only menopausal hormone therapy)
  • If abnormal uterine bleeding is reported, determine the nature of the bleeding, including frequency, duration, quantity and precipitating factors, and ask about any associated symptoms such as pain or discomfort, fever, changes in bladder or bowel function
    • Consider potential causes, e.g. polycystic ovary syndrome, hypothyroidism, medicines such as anticoagulants, antidepressants, hormonal contraceptives
  • Perform a physical examination, including palpation of relevant lymph nodes and bimanual and speculum examinations. Offer cervical screening if due and swabs for sexually transmitted infections, e.g. chlamydia, gonorrhoea, if indicated.
  • Request laboratory tests depending on individual factors, to assess other aspects of the patient’s health and to identify a potential underlying cause of the symptoms, e.g. hypothyroidism
    • Tests may include: full blood count, ferritin, liver function tests, coagulation tests, thyroid stimulating hormone, HbA1c, urine pregnancy test or serum hCG (if appropriate)
  • Organise an endometrial biopsy (pipelle), ideally performed in primary care, and referral for a pelvic ultrasound for patients with suspected endometrial cancer
    • Discuss with patients prior to the referral that pelvic ultrasound usually includes transvaginal ultrasound so that they know what to expect
  • Request an urgent pelvic ultrasound for patients with post-menopausal bleeding. If post-menopausal bleeding is persistent or recurrent (i.e. a new episode of bleeding after several months of no bleeding) also arrange referral to gynaecology irrespective of the ultrasound results.

  • If a patient is taking tamoxifen and reports post-menopausal bleeding, organise a pipelle biopsy and request gynaecology referral for consideration of a hysteroscopy (or request hysteroscopy directly, if available) – annotate referral with “high suspicion of cancer”

Results from pelvic ultrasound and pipelle biopsy inform management decisions

N.B. Guidance may differ between regions; check local HealthPathways for specific advice.

  • Initiate treatment for atrophic vaginitis if endometrial thickness is < 8 mm and pipelle biopsy results are normal. Place a recall for review within two months; if bleeding persists, refer to a gynaecologist for further assessment.
  • Referral to a gynaecologist is generally indicated if:
    • The pelvic/transvaginal ultrasound shows significant uterine enlargement or cavity distortion, endometrial polyp(s), high-risk features or other abnormalities such as cystic spaces
    • Endometrial thickness is:
      • < 5 mm and bleeding is persistent despite treatment for atrophia
      • 5 – 8 mm and pipelle biopsy sample is inadequate
      • > 8 mm irrespective of pipelle biopsy results
    • Pipelle biopsy:
      • Is indicated but cannot be performed in primary care
      • Is inadequate, insufficient or limited
      • Shows hyperplasia without atypia
  • Urgently refer patients to a gynaecologist if the results show hyperplasia with atypia or endometrial carcinoma. Annotate referral with “high suspicion of cancer”.

International guidelines recommend that people diagnosed with endometrial cancer should be tested for Lynch syndrome. This test is performed by pathologists in New Zealand on the tumour using mismatch repair (MMR) immunohistochemistry. Referral for formal genetic (germline) testing is usually organised after abnormal immunohistochemistry results, e.g. MMR deficiency, or a significant family history of endometrial or colorectal cancer. Further information about genetic testing, including details about the referral process and cancer assessments is available through Genetic Health Service New Zealand, or some local HealthPathways.

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