Detecting endometrial cancer

Abstract

Endometrial cancer (EC) is the most common gynaecological cancer in the UK. Ninety percent of women with EC present with postmenopausal bleeding (PMB), but less than 10% of women with PMB have a sinister underlying cause. National Institute for Health and Care Excellence guidance advises that symptomatic postmenopausal women undergo urgent investigation; however, guidance is unclear for premenopausal women. Current investigations for PMB, including transvaginal ultrasound scan, endometrial biopsy and/or outpatient hysteroscopy, have advantages and disadvantages. Novel detection tools are in development, which combine minimally invasive sampling with genomic, proteomic and single cell technologies. Learning objectivesTo understand who is at risk of EC and who should be referred for urgent investigations.To understand the evidence underpinning the current diagnostic pathway for EC. To highlight unique and promising perspectives for EC detection and their potential to transform clinical care. Ethical issuesCurrent diagnostics for EC are invasive and often painful. There is an urgent need for high-quality randomised controlled trials to inform effective pain relief options. Premenopausal women with suspected EC do not fit criteria for urgent investigations. How can we identify those at highest risk to ensure they are fast-tracked appropriately? Novel diagnostic tools hold promise, but they must be robustly validated before being introduced into clinical practice.

DEveloping Tests for Endometrial Cancer deTection (DETECT): protocol for a diagnostic accuracy study of urine and vaginal samples for the detection of endometrial cancer by cytology in women with postmenopausal bleeding

“…Women will be investigated by TVS, outpatient hysteroscopy and/or endometrial biopsy according to local clinical diagnostic pathways for the investigation of PMB ( figure 2 ). 3 All women will have their endometrium measured by TVS. Those with an endometrial thickness <4 mm will be considered at low risk of endometrial cancer and alternative diagnoses explored.…”

“… 2 A woman with PMB is referred by her general practitioner (GP) on the urgent ‘suspected cancer’ pathway to a rapid access gynaecology clinic, where she is offered a series of invasive, unpleasant and often painful tests to rule out endometrial cancer. 3 These include transvaginal sonography (TVS), outpatient hysteroscopy and endometrial biopsy. 4 Together, these tests cost the National Health Service (NHS) around £750/woman.…”

HE4 as a Biomarker for Endometrial Cancer

“…Currently, in the UK, all women presenting to their General Practitioner (GP) with suspected EC are referred to secondary care for further investigations. Presentation to the gynaecology clinic with post-menopausal bleeding is extremely common, but only around 5% have an underlying endometrial malignancy, leading to unnecessary discomfort, pain and anxiety in the majority of those investigated, and additional costs to the healthcare service [ 6 ]. Women undergo a TVUS to assess endometrial thickness, the sensitivity of which is 98%, 95% and 90% at cut-offs of 3 mm, 4 mm and 5 mm, respectively.…”

“…Investigations include transvaginal ultrasound (TVUS), endometrial biopsy and in some cases outpatient hysteroscopy. These investigations have a good sensitivity for the diagnosis of EC but are limited by poor specificity, as is the case with TVUS, or are invasive and painful [ 6 ]. Overall, EC has an excellent five-year survival of 84%, since two-thirds of cases present at an early, curable stage [ 1 ].…”

Re: Detecting endometrial cancer

“…We read with interest the article by Jones et al 1 that addressed the diagnosis of endometrial cancer and the role of hysteroscopy, as well as outpatient endometrial biopsy. We are, however, concerned at the combined average failure rate and inadequate sample rate quoted by the authors, which is 42% and may suggest to the reader that outpatient endometrial biopsy devices are not fit for use in clinical practice.…”