Prognostic factors in endometrial cancer

Most patients with endometrial carcinoma present with stage I disease and it is this group of patients in which prognostic factors have been studied, so that therapy can be tailored to the risks for recurrence. The papillary serous endometrial cancer and clear cell cancers have a poor prognosis but these comprise only a small proportion of endometrial cancer patients. The current surgical staging system for endometrial cancer is based on previously identified intra and extra-uterine factors that influence the prognosis. However, much of the information regarding prognosis, such as histologic type and grade, evidence of disease beyond the uterus and receptor-status can be gleaned from careful preoperative assessment of these patients. Information regarding ploidy and receptor status is available from curettage specimens and, with increasing use of hysteroscopy and/or vaginal ultrasound a more precise assessment of the extent of the disease in the uterine cavity and involvement of the cervix may be possible, although the uterine extent of the disease does not play the prognostic role that was anticipated formerly. A major concern regarding surgical staging has been the fact that many of these patients are elderly and obese with significant medical problems. There is the imminent risk that the pelvic and para-aortic node dissection (rather than sampling) may increase morbidity. More studies have shown that this might not be a factor with sampling. But does it suffice? Similarly, concerns have been expressed regarding those patients who may require postoperative radiation which may be compromised by postoperative adhesions, bladder, intestine and ureteral problems. It is yet to be demonstrated that in diseases extending outside the pelvis, the currently available treatment affects survival. Undoubtedly, recurrence patterns will be affected but clear demonstration of survival advantage is not available, eventually will never be. The concepts of treatment of advanced disease with spread outside the pelvis should undergo rethinking in the way that control of the existing disease rather than eradicating it by all means might offer better chances for life quality, life expectancy albeit limited, in cancer patients.