1. The Danish Cancer Diagnostic Pathways – Reliable in diagnosing endometrial Cancer?
Helle Kirkegaard1, Kresten R. Petersen1, Ole Mogensen2
1Odense University Hospital, Department of Obstetrics and Gynaecology, Sdr. Boulevard 29, 5000 Odense C, Denmark
2Karolinska University Hospital, Department of Obstetrics and Gynaecology, Stockholm, Sweden
Conclusion
Objective
Results
Endometrial Cancer in women with Postmenopausal Bleeding was lower than expected. This also accounts for cervical cancer
The criteria for entering a cancer pathway for Endometrial Cancer may be differentiated accordingly to risk factors.
Repeated vaginal Bleeding in Postmenopausal Women should always cause careful re-examination
To evaluate the frequency of uterine cancer i women referred to the Endometrial Cancer (EC) pathway because of Postmenopausal Bleeding (PMB)
To determine the risk factors for EC in this population
After initial examination following national guidelines 6,6% (44 women) were diagnosed with malignancies: 5,53% with EC, 0,45% with Cervical cancer, 0,30% with uterine sarcoma, 0,15% with vulva carcinoma and 0,15% with metastatic Urethral adenocarcinoma.
Age > 60 years, menopausal age > 5 years, diabetes and hypertension was associated with increased risk of EC (p<0,05).
Former use of Oral Contraceptives reduced the risk of EC (p<0,05)
After a benign diagnosis at first evaluation, 6 women were diagnosed with EC and 1 with Cervical Cancer after repeated PMB during the observational period.
Introduction
National integrated cancer pathways were introduced in Denmark in 2009 as standards for the diagnostics and treatment of gynaecological cancer. 1 Women with PMB are included in the National Cancer pathway for EC because of a reported incidence of EC of 10-15%2-3
According to national guidelines a histological diagnosis should be obtained in women with PMB having an endometrial thickness of > 4 mm by transvaginal ultrasound. Women with a thinned endometrium should be evaluated for cervical malignancy-4-6.
n=3
0,45%
n=37
5,53%
n=4
0,60%
Figure 1:
Distribution of diagnoses in the 669 Women.
* Endometriosis, Fibroma, Pyometra, Inflamation, insufficient endometrial proliferation.
Risk factors OR
95% CI
P-value
Age ≥ 60 år
5,65
2,17-14,69
<0,0001
≥ 5 years since menopause
8,09
1,93-34,00
0,0003
Hypertension
2,03
1,02-4,03
0,040
Diabtes
2,98
1,28-6,93
0,008
Former oral contraceptive use
0,34
0,16-0,76
0,006
Nulliparity
1,32
0,45-3,91
0,545
Postmenopausal Hormonal Substitution
0,86
0,38-1,93
0,707
Smoking*
0,56
0,27-1,16
0,116
Alkohol consumption**
1,03
0,35-3,04
0,960
Method
A retrospective study of 717 women referred to Cancer Diagnostic Pathway for EC in a tertiary care unit because of PMB in 2013 and 2014
48 patients were not postmenopausal or were hysterectomized, leaving 669 for evaluation
During chart reviews, the incidence of cancer after initial evaluation was recorded as well as the incidence of cancer developing in an observational period, starting after the initial evaluation, and ending at Dec 31, 2015
Table 1: Odd-ratios and 95% confidence intervals for factors associated with risk of endometrial cancer. Univariate analysis. * Former and current
** >7 drinks pr week
AUTHOR FOR CORRESPONDANCE:
Helle Kirkegaard, MD,
Odense University Hospital
Department of Obstetrics and Gynecology
REFERENCES:
Burbos N, Musonda P et al: Predicting the risk of endometrial cancer in postmenopausal women presenting with vaginal bleeding: the Norwich DEFAB risk assessment tool. Br J Cancer 2010 Apr 13;102(8):1201-6
Salman MC, Bozdag G el al: Role of postmenopausal bleeding pattern and women's age in the prediction of endometrial cancer, Aust N Z Obst Gynaecol 2013 Oct;52(5):484-8
Epstein E, Jamei B, Lindqvist PG. High risk of cervical pathology among women with postmenopausal bleeding and endometrium <or=4.4 mm: long-term follow-up results. Acta Obstet Gynecol Scand. 2006;85(11):
Gredmark T, Kvint S, Havel G, Mattsson LA. Histopathological findings in women with postmenopausal bleeding. Br J Obstet Gynaecol Feb;102(2):
Karlsson B, Granberg S, Wikland M, Torvid K, Marsal K, Valentin L. Transvaginal ultrasonography of the endometrium in women with postmenopausal bleeding- a Nordic multicenter study. Am J obstet Gynecol 1995;172: