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2004, David Geffen School of Medicine at UCLA. Cancer Survivorship Grant. Cancer Survivorship Endometrial Cancer Risks and Treatments: Epidemiology and.

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Presentation on theme: "2004, David Geffen School of Medicine at UCLA. Cancer Survivorship Grant. Cancer Survivorship Endometrial Cancer Risks and Treatments: Epidemiology and."— Presentation transcript:

1 2004, David Geffen School of Medicine at UCLA. Cancer Survivorship Grant. Cancer Survivorship Endometrial Cancer Risks and Treatments: Epidemiology and Late Effects of Cancer Survival All images in this module were obtained from Berek, JS, Hacker, NF: Practical Gynecologic Oncology, 2 nd Ed, 1994.

2 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

3 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.Causes of post menopausal bleeding Next

4 Question #1 Of the following risk factors for developing endometrial cancer, which are the most significant in the patients history:risk factors endometrial cancer A.Amount of vaginal bleedingAmount of vaginal bleeding B.ObesityObesity C.Patient agePatient age D.Number of pregnanciesNumber of pregnancies

5 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 post- menopausal 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.heavy and irregular mensesendometrial hyperplasia Back to Question 1

6 Correct. Question #1 B. ObesityObesity 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. Continue Module Go to Relative Risk

7 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. Patient age Back to Question 1

8 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.pregnancy Back to Question 1

9 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?estrogen therapy A.Types of hormoneTypes of hormone B.Dose of hormoneDose of hormone C.Duration of use (years)Duration of use (years) D.Age of initiation of therapyAge of initiation of therapy

10 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

11 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

12 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

13 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

14 Case #1 Continued On physical exam, the patient is noted to weigh 232 lbs and her height is 55. 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

15 Question #3 Based on this scenario, the most likely histology is: A.Clear cellClear cell B.EndometrioidEndometrioid C.Papillary SerousPapillary Serous D.Mixed histologyMixed histology

16 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.clear cell Back to Question 3

17 Correct. Question #3 B. Endometrioid (See image)See image This is the most common type of endometrial cancer (See table). It is called endometrioid because it looks like endometrial glands.See table Continue Module

18 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).See microscopic imageSee hysterectomy specimen Back to Question 3

19 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

20 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.grade 2 Next

21 Question #4 The recommended surgery for this condition is exploratory laparotomy, total abdominal hysterectomy and bilateral salpingo- oophorectomy (TAH & BSO) and: A.No other biopsiesNo other biopsies B.Pelvic lymphadenectomyPelvic lymphadenectomy C.Para-aortic lymphadenectomyPara-aortic lymphadenectomy D.Pelvic and para-aortic lymphadenectomyPelvic and para-aortic lymphadenectomy

22 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. uterineFIGO staging Back to Question 4

23 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

24 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

25 Correct. Question #4 D.Pelvic and para-aortic lymphadenectomy In order to perform a thorough surgical staging for endometrial cancer, both pelvic and para- aortic lymphadenectomy should be performed unless there is a medical contraindication, e.g., morbid obesity or severe cardiovascular disease. Continue Module

26 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

27 Question #5 Based on these findings, her stage is: A.Stage IStage I B.Stage IIStage II C.Stage IIIStage III D.Stage IVStage IV

28 Correct. Question #5 A.Stage I The patients disease is confined to the uterus (See image) and there is no evidence of metastatic disease (FIGO Stage I).See imageFIGO Stage I Continue Module

29 Incorrect. Question #5 B.Stage II Stage II disease means the tumor has extended from the endometrium to the cervix (FIGO Stage II).FIGO Stage II Back to Question 5

30 Incorrect. Question #5 C.Stage III FIGO Stage III means the disease has spread to the pelvic or para-aortic lymph nodes. FIGO Stage III Back to Question 5

31 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). FIGO Stage IV See X-ray image Back to Question 5

32 Case #1 Continued Based on these finding this patient was recommended and received pelvic radiation therapy.

33 Question #6 Based on her stage and treatment, the probability of her five-year disease-free survival: A.85%85% B.70%70% C.50%50% D.30%30%

34 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).Stage IBSee table Next

35 Incorrect. Question #6 B.70% Patient with Stage IB, grade 2 tumor and has a better 5 year survival based on surgical staging.Stage IB Back to Question 6

36 Incorrect. Question #6 C.50% Patient with Stage IB, grade 2 tumor and has a better 5 year survival based on surgical staging.Stage IB Back to Question 6

37 Incorrect. Question #6 D.30% Patient with Stage IB, grade 2 tumor and has a better 5 year survival based on surgical staging.Stage IB Back to Question 6

38 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.5%5% B.10%10% C.15%15% D.25%25%

39 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

40 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

41 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

42 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

43 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.HysterectomyHysterectomy B.Radiation therapyRadiation therapy C.Hysterectomy plus radiation therapyHysterectomy plus radiation therapy D.ChemotherapyChemotherapy

44 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

45 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

46 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

47 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.clear cell papillary serous carcinoma Back to Question 8

48 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.Recurrent endometrial cancerRecurrent endometrial cancer B.Cervical cancerCervical cancer C.Breast cancerBreast cancer D.Colon cancerColon cancer

49 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

50 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

51 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

52 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.HNPCC syndrome Back to Question 9

53 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.AbrogatedAbrogated B.DecreasedDecreased C.UnchangedUnchanged D.IncreasedIncreased

54 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

55 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

56 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

57 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

58 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

59 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.uterusfemale reproductive system Back to Question 1

60 Anatomy of the Uterus Cross Section of the Female Reproductive System (Courtesy of Jones and Bartlett Publishers) Back to Explanation

61 The Female Reproductive System Back to Explanation

62 Relative Risk Matrix Age Age ( > 50 years)1.5 Endometrial hyperplasia2-10 EstrogenEstrogen (unopposed)2-6 Obesity2-10 Other cancersOther cancers (breast and ovary)2-3 PregnancyPregnancy (nulligravida vs. gravida) RaceRace (African American vs. Caucasian)1.25 Tamoxifen2-7 Irregular menstrual periods Hypertension Diabetes Late menopause Back to Question 1

63 Age Age ( > 50 years)1.5 Endometrial hyperplasia2-10 EstrogenEstrogen (unopposed)2-6 Obesity2-10 Other cancers Other cancers (breast and ovary)2-3 PregnancyPregnancy (nulligravida vs. gravida) RaceRace (African American vs. Caucasian)1.25 Tamoxifen2-7 Irregular menstrual periods Hypertension Diabetes Late menopause Back to Question 1 Continue Module Relative Risk Matrix

64 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 Back to Explanation

65 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

66 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

67 Endometrial Cancer Risk Factors Endometrial hyperplasia. Women who have endometrial hyperplasia (See image) have a higher risk of developing endometrial cancer.See image Go to Relative Risk Back to Explanation

68 Endometrial Cancer Risk Factors Endometrial hyperplasia. Women who have endometrial hyperplasia (See image) have a higher risk of developing endometrial cancer.See image Go to Relative Risk

69 Endometrial Cancer Risk Factors Endometrial hyperplasia. Women who have endometrial hyperplasia (See image) have a higher risk of developing endometrial cancer.See image Go to Relative Risk

70 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. Endometrial Cancer Risk Factors Go to Relative Risk

71 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. Endometrial Cancer Risk Factors Go to Relative Risk

72 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 Back to Explanation

73 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

74 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

75 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

76 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

77 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 Back to Explanation

78 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

79 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

80 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

81 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

82 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.endometrial polyps and cancer Go to Relative Risk

83 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.endometrial polyps and cancer Go to Relative Risk

84 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 Back to Explanation

85 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

86 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

87 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

88 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

89 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

90 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

91 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

92 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

93 Relative Risk Matrix AgeAge ( > 50 years)1.5 Endometrial hyperplasia2-10 Estrogen Estrogen (unopposed)2-6 Obesity2-10 Other cancers Other cancers (breast and ovary)2-3 Pregnancy Pregnancy (nulligravida vs. gravida) Race Race (African American vs. Caucasian)1.25 Tamoxifen2-7 Irregular menstrual periods Hypertension Diabetes Late menopause Go to Question 2

94 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

95 Endometrial Cancer Risk Factors Endometrial hyperplasia. Women who have endometrial hyperplasia have a higher risk of developing endometrial cancer. Go to Relative Risk

96 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. Endometrial Cancer Risk Factors Back to Question 2 Go to Relative Risk

97 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. Endometrial Cancer Risk Factors Go to Relative Risk

98 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

99 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

100 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

101 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

102 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.endometrial polyps and cancer Go to Relative Risk

103 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

104 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

105 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

106 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

107 Causes of Postmenopausal bleeding Back to Case 1

108 Endometrial Hyperplasia Back to Explanation

109 Endometrial Hyperplasia Back to Explanation

110 Endometrial Hyperplasia Back to Explanation

111 Histology Table SubtypeAlive (%)DOD (%) Adenoacanthoma Adenocarcinoma Papillary serous Adenosquamous Clear cell Sarcoma Back to Explanation

112 Uterus Back to Explanation

113 Tamoxifen Back to Explanation

114 Tamoxifen Back to Explanation

115 Tamoxifen Back to Explanation

116 Clear Cell Back to Explanation

117 Clear Cell Back to Explanation

118 Endometrioid Back to Explanation

119 Normal vs. Abnormal Uterine Normal Uterus Endometrial CA Back to Explanation

120 Papillary Serous Carcinoma Back to Explanation

121 Papillary Serous Carcinoma Back to Explanation

122 Lung X-ray Back to Explanation

123 Sarcoma Back to Histology Table

124 Papillary Serous Back to Explanation

125 Prognostic Variables Back to Explanation

126 Histologic Grade of Endometrioid Adenocarcinoma Graded by the architecture alone (GOG) or a combination of architecture and nuclear features (FIGO and WHO): 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. Back to Case #1

127 FIGO* Staging of Endometrial Cancer 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 Back to Question 5

128 FIGO* Staging of Endometrial Cancer 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

129 Actuarial 5-year survival by Histologic Grade and Stage Stage IStage II IAIBICIIAIIB Grade%%% Not Graded Back to Explanation

130 Actuarial 5-year survival by Histologic Grade and Stage Stage IStage II IAIBICIIAIIB Grade%%% Not Graded Back to Explanation

131 Actuarial 5-year survival by Histologic Grade and Stage Stage IStage II IAIBICIIAIIB Grade%%% Not Graded Back to Explanation

132 Actuarial 5-year survival by Histologic Grade and Stage Stage IStage II IAIBICIIAIIB Grade%%% Not Graded Back to Explanation

133 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. Back to Explanation

134 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


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