Uterine cancer: diagnosis
The latter two studies have received tremendous notoriety. They are the National Surgical Adjuvant Breast Project study and the Stockholm study. A total of 42 corpus cancers were reported in these two studies. Approximately 5,000 patients taking tamoxifen for various periods and at different doses were compared with patients not taking tamoxifen. The number dropped to 14 using a very conservative latency period of 2 years, as well as elimination of non-adenocarcinoma malignancies, those who were randomized to take tamoxifen but never did, and the patient who was said to have endometrial cancer but on evaluative histology was thought not to. Many of the patients had the diagnosis of corpus cancer made within a very short time of taking tamoxifen (2 months). Obviously, the endometrial cancer was not caused by tamoxifen. Over the last 10 years in the world’s literature, 250 endometrial cancers were identified. During that time, it has been estimated that about 3 million women took tamoxifen for some 7 million woman-years of use. In the United States during this time frame there have been approximately 365,000 women with corpus cancer. All patients who may have had tamoxifen-associated endometrial cancer have not been reported in the literature; however, these numbers would suggest that if tamoxifen is associated with endometrial cancer, that relationship is very minimal. It should also be remembered that women who have breast cancer are also at an increased risk for endometrial cancer (at least twofold to threefold increase). Women with breast cancer should have annual gynecologic examinations, including Pap tests and bimanual and rectovaginal examinations. Although any abnormality should be evaluated, data do not support routine annual biopsies for women taking tamoxifen.
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Diagnosis
The cost of screening for adenocarcinoma and its precursors in the total population would be prohibitive. The most common symptom of corpus cancer is uterine bleeding. Of all endometrial cancers, 75% occur in the postmenopausal patient, although only 20% of postmenopausal women will have a genital malignancy. As the patient’s age increases after menopause, there is a greater probability that the postmenopausal bleeding is due to a malignancy.
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Irregular bleeding during the perimenopause may be interpreted by both the patient and physician as “going through the menopause.” The menstrual bleeding should become lighter and less frequent as a women goes through this time. Any other bleeding should be evaluated as if she were having postmenopausal bleeding. In the premenopausal patient, the high index of suspicion should be maintained if a diagnosis of endometrial cancer is made. Prolonged heavy menstrual periods or intermenstrual spotting may suggest further evaluation. Many premenopausal patients with adenocarcinoma of the endometrium are obese and anovulatory.
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An in-office endometrial biopsy is probably the simplest and easiest way to rule out endometrial cancer. Adequate specimens should be obtained for proper evaluation. If cancer is not present, then further evaluation is probably not needed unless the patient continues to be symptomatic. A formal dilation and curettage, which used to be routine for postmenopausal bleeding evaluation, is no longer justified as the first diagnostic procedure. Many clinicians advocate dilation and curettage for women who have atypical hyperplasia because a considerable number of these women will have a coexistent, well-differentiated adenocarcinoma of the endometrium. Although vaginal ultrasonography may accurately identify endometrial thickness, there is no agreement regarding the thickness of endometrium that should cause concern. Some researchers have suggested 3 mm, others 5 mm or even 8 mm. In the patient not taking tamoxifen, 10 mm or more should prompt an endometrial biopsy. In patients who have been taking tamoxifen, very thick endometriums (eg, 20, 30, or 40 mm) have been described. It now appears that a thick endometrium is a false-positive indicator, because ultrasonography of the uterine cavity after saline instillation (sonohysterogram) has shown that this thickness may be due to large polyps or thickened proximal myometrium falsely identified as endometrium. Hysteroscopy has also been suggested as an accurate way of identifying significant endometrial pathology. Hysteroscopy can be performed easily in the office; however, the accuracy depends upon operator skill. If lesions are seen, biopsies are then taken. The endometrial biopsy may be the best diagnostic procedure, with ultrasonography and hysteroscopy reserved if further evaluation if needed.