Major organizations currently recommend screening for endometrial cancer (EC) only for women with an inherited mismatch repair defect, commonly known as HNPCC (hereditary non-polyposis colorectal cancer) and Lynch syndrome. For women with HNPCC—which typically is identified after diagnosis of EC—endometrial biopsy is recommended annually or less frequently, starting at age 35. The precise definition and diagnostic criteria for Lynch and HNPCC syndromes vary. Genetic proof of these inherited disorders is not always available. In these circumstances, clinical criteria such as Amsterdam Criteria or a high index of suspicion should be sufficient to consider EC screening at some arbitrary interval and starting age.1
The homogeneity of opinions about EC screening, however, may be ending. The Centers for Disease Control and Prevention (CDC) publicly announced that it is looking into EC screening, an initiative spurred by an unrelated, highly publicized case of morcellation.2 An incidentally discovered sarcoma is being used by at least one legislator to justify a request to the CDC to examine mandating endometrial biopsy before all hysterectomies. Many surgeons already perform biopsies before all hysterectomies and ovarian surgeries in at-risk women. In essence, these practitioners are screening for EC in an at-risk population: women about to undergo pelvic surgery.
Routine screening for EC was studied during the initial experience with selective estrogen receptor modulators (SERMS).3 The attention was due to an increase in EC in patients with breast cancer who use SERMS to prevent recurrence. The conclusion of most opinions at that time was that screening was not warranted due to a low incidence and positive predictive value of the then-favored screening modality, ultrasonography. Only ultrasonography was considered because of a perceived increased risk of office endometrial biopsy. Based on these assumptions, screening was not adopted by most practitioners because of the poor specificity of ultrasonography and the low prevalence of EC. In retrospect, that decision still seems appropriate, given the information available at that time.4
Data on complications of endometrial biopsy (perforation, bleeding, pain, infection) are derived from reports of a population with a strong indication for sampling (i.e., symptoms and presumed cancer until proven otherwise). In triage of this patient group, sampling attempts persist until successful, thus adding additional risks to the overall goal of sampling the endometrium.5,6
On the other hand, sampling asymptomatic patients, or screening, would exclude women at increased risk of complications from the procedure. In other words, patients at increased risk of complications from a screening biopsy would not be put through additional invasive procedures or attempts. For instance, a woman considered for screening who has cervical stenosis or severe comorbidities would not be subjected to dilatation and curettage in the operating room. Instead such as a patient could be triaged to serial pelvic ultrasonography or other safer office maneuvers, such as cervical “ripening,” before biopsy.7 Thus, risk associated with biopsy for EC screening could be adjusted and lower than previously reported for endometrial sampling for other indications. In general, in-office sampling for screening should have little to no risk, as there are alternatives for difficult patients and procedures.8,9
The authors report no potential conflicts of interest with regard to this article.
- Del Priore G. Endometrial Sampling Procedures. In: UpToDate, Post, TW (Ed), UpToDate, Waltham, MA, 2019.
- Levitz J, McKay B. CDC eyes review of gynecological cancer screens. Wall Street Journal. May 2, 2018. Available at https://www.wsj.com/articles/cdc-eyes-review-of-gynecological-cancer-scr... Accessed June 7, 2019.
- van Leeuwen FE, Benraadt J, Coebergh JW, et al. Risk of endometrial cancer after tamoxifen treatment of breast cancer. Lancet. 1994 Feb 19;343(8895):448-452.
- Del Priore G. Sonographic Follow-up in tamoxifen patients. Gynecol Oncol. 2000;76:423.
- Gordon SJ, Westgate J. The incidence and management of failed Pipelle sampling in a general outpatient clinic. Aust N Z J Obstet Gynaecol. 1999; 39:115.
- Elsandabesee D, Greenwood P. The performance of Pipelle endometrial sampling in a dedicated postmenopausal bleeding clinic. J Obstet Gynaecol. 2005;25:32.
- Güney M, Oral B, Mungan T. Intrauterine lidocaine plus buccal misoprostol in the endometrial biopsy. Int J Gynaecol Obstet. 2007; 97:125.
- de Leon MC, Wu HH, Lennon AE, Del Priore G. Novel approach to outpatient endometrial biopsy to detect endometrial cancer. J Reprod Med. 2016 May-Jun;61(5-6):243-248.
- Sierecki AR, Gudipudi DK, Montomarano N, Del Priore G. Comparison of endometrial aspiration biopsy techniques: specimen adequacy. J Repro Med. 2008;53(10):760-764.
- Timoteo-Liaina I Khozaim K Buenconsejo-Lum LE, Del Priore G. Screening for endometrial cancer should be considered in special population. Available at https://www.sgo.org/wp-content/uploads/2017/03/Saturday-March-11-2017-SGO-Annual-Meeting-International-Session-Abstracts.pdf Accessed on April 1, 2019.
- Scott OW, Tin Tin S, Bigby SM, Elwood JM. Rapid increase in endometrial cancer incidence and ethnic differences in New Zealand. Cancer Causes Control. 2019 Feb;30(2):121-127.
- Arthur R, Brasky TM, Crane TE, Felix AS, et al. Associations of a healthy lifestyle index with the risks of endometrial and ovarian cancer among women in the Women’s Health Initiative Study. Am J Epidemiol. 2019 Feb 1;188(2):261-273.
- Luo J, Chlebowski RT, Hendryx M, et al. Intentional weight loss and endometrial cancer risk. J Clin Oncol. 2017 Apr 10;35(11):1189-1193.
- Del Priore G, MD, Hamed KK, Chen, YJ, Timoteo-Liaina I, Matthews RPW, Buenconsejo-Lum, L. Is screening for uterine cancers an opportunity to reduce cancer’s burden among populations with disparities? Obstet Gynecol. May 2019; 133: 84S