ESGO 2013

Treatment guidelines for endometrial cancer and increased rates of incidence

Prof John Green – University of Liverpool, UK

John Green, endometrial cancer, I understand it has been a bit neglected but things are happening and there are curious facts about it emerging at the moment.

Well, if you just look at the UK data, the incidence of endometrial cancer has gone up 25% in the last ten years. Now, there are a number of factors to do with that, possibly the increasing sedentary lifestyle that many people have and the increasing incidence of obesity which is a problem affecting all Western societies. So it’s becoming commoner, many of the cases of endometrial cancer do actually very well and many may not need additional treatment beyond surgery. We’ve found ways in trials that have been presented recently that we can treat with additional radiotherapy in some if the intermediate risk patients and the high risk patients by giving a more localised form of radiation therapy which may give just as good outcomes without the same side effects. The third point is that we are looking at some of the high risk groups to see whether the addition of chemotherapy may be useful, either in the adjuvant situation after removal of the tumour, or certainly for the treatment of the small proportion of cases that present with advanced disease or when some of the more aggressive ones come back.

I know you have a session focussing on endometrial cancer here in Liverpool at the conference, what are the key points that doctors need to bear in mind? For instance, what’s the general approach to endometrial cancer right now?

It’s a combination of surgery, radiation therapy and chemotherapy. And I think it’s fair to say there are still debates, quite constructive debates, about the exact extent of surgery that you should do in some of these different risk categories. We are trying to refine these risk categories to divide patients into high risk, intermediate risk and low risk, perhaps incorporating biomarkers, blood tests or biopsy tests to get molecular characterisation of the different types of endometrial cancers. That, we hope, will help us better define the correct treatments.

So what should doctors be doing, bearing in mind the fact that the incidence is changing at the moment?

That’s getting on to separate issues about health promotion and education which is, again, why we need the link to these patient groups. I don’t think it’s enough just to sit in your particular category of doctor and say, ‘Well my responsibility is to treat disease in a certain stage or a certain category.’ We do work increasingly in multidisciplinary teams when we discuss each individual case and work out the optimum management of individual patients. That’s very much how cancer is managed these days. We need to support clinical trials, either of the major types of treatment like surgery or radiation therapy or, and these are now often phase II randomised trials, of the introduction of new anti-cancer agents into the clinic.

And the treatment of endometrial cancer hasn’t been eagerly researched recently but would you make out a case for it being more earnestly researched and what needs to be done?

I think we are very keen to encourage patients and doctors and nurses and all those who advise patients to take part in clinical trials. One of the difficulties is that there are a fairly small number of patient organisations specifically orientated at endometrial cancer. There are ovarian cancer advocacy groups and there are some cervical cancer ones, particularly in Eastern countries where cervical cancer is particularly common, but there are remarkably few endometrial or womb cancer patient organisations. And we get the impression, and I used the word Cinderella in an earlier conversation with you, that the existence of these tumours and the problems need to be presented both to our professional leaders but also to governments and those who fund both the health services and the research organisations to make them recognise that this is a real problem. Once we get the molecular characterisation sorted out, and we’re not quite as advanced as they are, for example, in breast, lung or ovarian cancer, but once these categories get clarified and there’s a general consensus of what the different groups are, that’s the key to making progress.

And a bottom line message for doctors coming out of the latest research on endometrial cancer?

On endometrial cancer, I think just steady progress without earth-shattering advances. It’s a balance between looking at the long-term outcome without exposing patients to adverse side effects of the treatment, whether that’s surgical treatment or radiation therapy or whether it’s some of the new anti-cancer drugs. Because some of these patients are often at the elderly range of the spectrum and some of them have other diseases such as cardiovascular disease or diabetes. So it’s not an easy disease to treat or to give a one line answer to how to manage it but we are getting there.

Well you’ve done very well at giving those words. John, thank you very much.

Thank you.