Endometrial cancer management guidelines updated: assorting the uncertainties! -----1

The first joint European Society for Medical Oncology (ESMO), European SocieTy for Radiotherapy & Oncology (ESTRO) and European Society of Gynaecological Oncology (ESGO) consensus conference on endometrial cancer was held on 11–13 December 2014 in Milan, Italy.

The multidisciplinary panel consists of 40 leading experts on endometrial cancer.

The experts were asked to prepare 3 clinically relevant questions on four basic areas related to the cancer: prevention and screening, surgery, adjuvant treatment and advanced and recurrent disease. They developed these extremely relevant guidelines after going through the literature methodically.

There was more than 90% agreement was reached for all the guidelines except one for or performance of staging lymphadenectomy in patients who have deeply invasive grade 3 cancers( agreement 73%).

These guidelines provide an invaluable framework for clinical decision making especially in an area fraught with uncertainties.   

These guidelines were published in an article by Colombo N et al in January issue of Annals of Oncology.

For each of four basic subject areas, three relevant clinical questions were identified, giving a total of 12 categories on which the guidelines were developed.

The first question is: Which surveillance should be used for asymptomatic women?

Women with average risk for endometrial cancer

Recommendation 1.1: There is no evidence for endometrial cancer screening in the general population. Evidence: II, strength of recommendation :A.

Women at increased risk for endometrial cancer

Recommendation 1.2: Unopposed oestrogen treatment should not be started or should be discontinued in women with a uterus in situ? Evidence: III, strength of recommendation A.

Recommendation 1.3: Routine surveillance in asymptomatic women with obesity, PCOS, diabetes mellitus, infertility, nulliparity or late menopause is not recommended. Evidence: III, strength of recommendation: B.

Recommendation 1.4: For women with adult granulosa cell tumour, if hysterectomy has not been performed, endometrial sampling is recommended. If this shows no evidence of (pre)malignancy, no further screening for endometrial malignancies is required. Evidence: IV, strength of recommendation:B.

Recommendation 1.5: In patients with epithelial ovarian cancer undergoing fertility-sparing treatment, endometrial sampling is recommended at the time of diagnosis. Evidence: IV, strength of recommendation: B.

Recommendation 1.6: Routine screening for endometrial cancer in asymptomatic tamoxifen users is not recommended. Evidence: III, strength of recommendation: B.

Women with high risk for endometrial cancer

Recommendation 1.7: Surveillance of the endometrium by gynaecological examination, transvaginal ultrasound and aspiration biopsy starting from the age of 35 years (annually until hysterectomy) should be offered to all Lynch Syndrome (LS) mutation carriers

Evidence: IV,Strength of recommendation: B.

Recommendation 1.8: Prophylactic surgery (hysterectomy and bilateral salpingo-oophorectomy), preferably using a minimally invasive approach, should be discussed at the age of 40 as an option for Lynch Syndrome(LS)  mutation carriers to prevent endometrial and ovarian cancer. All pros and cons of prophylactic surgery must be discussed

Level of evidence: IV,Strength of recommendation: B.

To be continued------------ 

References: 

Colombo N,Creutzberg CL, Amant F et al. ESMO-ESGO-ESTRO consensus conference on endometrial cancer: diagnosis, treatment and follow-up. Ann Oncol 2016; 27: 16–41.