Trends in Survival from Cancer of the Corpus uteri in Switzerland

Introduction Swiss incidences as well as mortality rates for cancer of the corpus uteri have decreased slightly over the last 20 years [1]. In the recent past (2006-2010), about 16 in 100’000 women were diagnosed each year with endometrial cancer, while 3 in 100’000 died of their disease. The most common type of cancer is adenocarcinoma of the endometrial lining, which is the most common malignancy of the female genital tract in the Western world. There are no simple and reliable ways to screen for uterine cancer, but due to symptoms at early stages of the disease, most diagnoses occure early enough that surgery alone may be adequate for cure. Diagnostic symptoms can be postmenopausal bleeding, pyometra or abnormal endometrial cells identified on Pap smear (25%) [2]. It is important to consider the diagnosis of endometrial cancer also in perimenopausal women with abnormal, intermenstrual or increasingly heavy periods [3]. In such patients also a history of anovulation due to obesity or polycystic ovaries should be seen as risk factor. The etiology of abnormal bleeding in endometrial cancer patients can be due to exogenous hormone intake (10-30%), atrophic endometritis/vaginitis (30%), endometrial cancers (15%), cervical/ endometrial polyps (10-30%) and endometrial hyperplasia (5%). Less often, it can be due to cervical cancers, uterine sarcomas, urethral caruncles or trauma (10%). Endometrial cancers are classified into type I (80%) and type II (20%) [4]. The most common type I is estrogenrelated, low grade endometrioid, associated with atypical endometrial hyperplasia and is generally expressing estrogen and/or progesterone receptors (ER/PR positive). Risk factors are therefore either endogenous (obesity, anovulatory cycles, estrogen secreting tumors) or exogeneous estrogen exposure (unopposed hormone replacement therapy, Tamoxifen). Other risk factors include diabetes, hypertension, age above 60 years and certain genetic mutations. Type II cancers are completely unrelated to estrogen or endometrial hyperplasia, are ER/PR negative and present as high grade or poor prognostic cell types such as serous, clear cell and mucinous tumors. Patients are often multiparous and have a family history of breast cancer. Preoperative diagnosis can be best performed via Pipelle de Cornier, which has shown a sensitivity of 99.6% in postmenopausal and 91% in premenopausal patients, with a false negative rate of only 10% [5]. Nevertheless, hysteroscopy and dilatation and curettage remains the gold standard, although the tumor grade is often underestimated. Transvaginal ultrasonography enables the visualization of the endometrial thickness, with endometrial cancers showing an endometrial thickness of 18.2 +/6.2 mm [6]. All cancers (100%) and 95% of patients with hyperplasia demonstrated an endometrial thickness of over 5 mm, so that the main rule needs to be: persistent postmenopausal bleeding in the setting of normal sonographic findings requires endometrial sampling [7, 8]. In premenopausal women with polypoid intrauterine lesions it might be helpful to use sonohysterography before hysteroscopic resection. The diagnostic gold standard, however, is still hysteroscopy and fractional curettings. It is important that endocervical curettings (ECC) are always performed first in order to exclude endometrial contamination and to rule out endocervical cancer involvement. However, false positive ECC are found in stage II cancers in 40 to 50%. If the diagnosis is expanded and the ECC are negative, a wedge or cone biopsy might be helpful. Surgical treatment in endometrial cancer has improved during the past decade due to the development of minimally invasive techniques. Studies have shown that not only is a the total laparoscopic hysterectomy equally effective as the open surgical procedure [9], it is also associated with a significantly decreased risk of major surgical adverse events [10], improved quality of life [11] and cost-effectiveness [12]. In the present descriptive study, epidemiological information from tumour registries of several Swiss cantons have been combined to examine the development in survival pattern of patients diagnosed with primary endometrial cancer during the last 30 years.