Peter Kovacs, MD, PhD
Progestogen Treatment Options for Early Endometrial Cancer
Cade TJ, Quinn MA, Rome RM, Neesham D
Cancer therapy has improved significantly in recent years, and the concept of care has changed as well. Whereas in the past, cancer therapy was radical and definite, now new, more conservative surgical options, more focused radiation therapy, and chemotherapy with improved side effect profiles have been introduced.
Cancer is typically associated with older age, but certain types of cancers occur predominantly in childhood or in young adults (eg, hematologic). Other types of cancers that are more frequent later in life can occur in young adults as well (eg, cancer of the female genital tract).
Endometrial cancer is the most common cancer of the female gynecologic-pelvic organs. The age-adjusted incidence rate was 23.5 per 100,000 women per year between 2003 and 2007. The average age at diagnosis was 62 years, and 8% of cases were diagnosed in patients younger than 45 years of age.
The endometrium undergoes cyclic changes. During the follicular phase, under the influence of estrogen, it proliferates, whereas after ovulation, under the influence of progesterone, the endometrium undergoes secretory changes. If pregnancy does not occur at the end of the cycle, once the support of the corpus luteum subsides, menstruation follows and a new cycle begins. If this cyclic function is disrupted, abnormal changes in the endometrium may follow. When the endometrium is exposed to unopposed estrogen, it continues to proliferate, and hyperplasia with cellular atypia may develop. If left untreated, this condition may give rise to endometrial cancer.
Standard therapy for endometrial cancer is hysterectomy with adequate staging, and if needed, adjuvant therapy. For women who wish to maintain fertility or who are an unusually high surgical risk, hysterectomy may not be acceptable. High dose progesterone therapy may be an alternative in these cases. The article by Cade and colleagues summarizes the investigators’ experience with high dose progesterone therapy for the care of early stage, well-differentiated endometrial cancer.
This report is a case series that describes 16 patients with endometrial cancer who were managed conservatively with high dose oral (400 mg medroxyprogesterone acetate) or local (levonorgestrel intrauterine system) progesterone, or a combination of the 2 formulations. Magnetic resonance imaging was used to assess myometrial invasion, and only patients who had no invasion were eligible for the study. Patients were closely monitored with regular curretage, and if persistent disease was noted on histology, definitive surgery was recommended.