Commentary

Early detection of endometrial cancer doesn't do much good unless treatment follows...and more


 

References


IS POPULATION-BASED SCREENING FOR ENDOMETRIAL CANCER FEASIBLE?
ANDREW M. KAUNITZ, MD (EXAMINING THE EVIDENCE; APRIL 2011)

In endometrial cancer, timely treatment is as vital as early detection

Dr. Kaunitz’s commentary reminded us how vital early detection of endometrial cancer is, especially recurrent cancer. We had a 54-year-old postmenopausal African-American patient (G2P2002) come to our medical school clinic complaining of severe abnormal bleeding, with clots, of 2 months’ duration. Pelvic ultrasonography (US) revealed an endometrial thickness of 1.1 cm, and a biopsy detected complex atypical hyperplasia with areas of invasive adenocarcinoma. We referred the patient to a gynecologic oncologist, who performed total abdominal hysterectomy, bilateral salpingo-oophorectomy, pelvic lymphadenectomy, and peritoneal washings. The final pathology report revealed stage 1c grade II adenocarcinoma. Because of the deep myometrial invasion and grade II lesion, adjuvant radiation therapy was recommended, but the patient declined it and failed to follow up with regular examinations.

Five years later, the patient was back, saying, “Doctor, my cancer has recurred.” She said she could feel a mass in her vagina—a mass she had noticed 18 months earlier! Now that she was symptomatic, with rectal pressure, vaginal bleeding, and pain, she was seeking medical attention.

On examination, a crowning 8-cm mass distended the vagina. The mass was tender and hemorrhagic and obliterated the vagina. A biopsy revealed grade II endometrioid adenocarcinoma, consistent with the previous endometrial adenocarcinoma. Because the mass was not resectable, the patient was referred for radiation therapy and chemotherapy.

Twenty percent of women who have endometrial cancer experience recurrent disease, usually within 24 to 36 months.1,2 Recurrence is the detection of disease more than 3 months after successful extirpative therapy.3 When disease is detected before 3 months, it is considered persistence of the original disease. Recurrence usually portends a poor prognosis if the disease is disseminated.3 The most common site of recurrence is the vaginal cuff.2,4 Postoperative radiotherapy can reduce this risk.4

In 1994, Rose and colleagues found an elevated CA 125 level in as many as 87% of women who had recurrent disease.5 In fact, CA 125 was elevated in women even before a recurrence could be identified, regardless of stage.5 Approximately 94% of women who had an elevated CA 125 level at recurrence had an initial preoperative CA 125 that was elevated.5 Therefore, CA 125 may be useful in predicting which patients are at risk of recurrence.5

In this case, the patient is still alive and receiving chemotherapy.

With an early diagnosis and treatment and appropriate follow-up, endometrial cancer can be a curable disease.

Daniel M. Avery Jr, MD
Marion D. Reed, MD
J. Michael Straughn Jr, MD
University of Alabama School of Medicine
Tuscaloosa, Ala

HOW TO IMPROVE OUTCOMES IN GESTATIONAL DIABETES—FOR MOTHER AND BABY
E. ALBERT REECE, MD, PHD, MBA (MARCH 2011)

Management of GDM isn’t always straightforward

I have several questions regarding some points in Dr. Reece’s article:

A 1-hour postprandial fingerstick glucose level of 130 mg/dL was mentioned as the cutoff for initiation of treatment. Is that cutoff the more widespread and accurate limit (rather than 140 mg/dL at 1 hour)? Do we have trials supporting this change?

I did not notice any mention of hemoglobin A1c (HbA1c) in the article. Most clinicians use an HbA1c level of 6% and below as the goal for gestational diabetes mellitus (GDM). However, I had a patient whose HbA1cconsistently remained below 5%, but her fingerstick glucose exceeded 140 mg/dL at 1 hour more than 50% of the time, so I treated that hyperglycemia.

Do we have guidelines or data addressing the question of whether it is postprandial high glucose levels that are responsible for the morbidities of GDM rather than the average level, i.e., HbA1c? Before HbA1ccame into use, I think that most of us treated the glucose level determined by fingerstick, even if the 3-hour test was negative, if the history and suspicion of GDM suggested that we should.

I hope that Dr. Reece can enlighten us on these points.

Dennis Fito, MD
Liberal, Kan

Dr. Reece responds

Traditionally, a 1-hour postprandial blood glucose level ≥140 mg/dL has been used as the cut-off for the diagnosis of GDM. However, the ongoing management of a woman given a diagnosis of GDM is a different issue. In the typical management scheme, to which I believe Dr. Fito is referring, if a patient is able to maintain her blood glucose level below 130 mg/dL on diet alone, then no further medical intervention is necessary other than third-trimester measurement of fetal abdominal circumference.

However, if a woman with previously diagnosed GDM has a fasting plasma glucose level ≥95 mg/dL or a 1-hour postprandial glucose level ≥130 mg/dL, after attempts have been made to control her blood sugar using dietary management, then insulin or another type of antihyperglycemic therapy should be initiated.

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