What Questions Should You Ask About Endometrial Cancer Detection?
Gynecological cancer expert Dr. Nita Karnik Lee explains the importance of self-advocacy in endometrial cancer detection, including speaking up when you have concerns and seeking care early.
Dr. Nita Karnik Lee is a Gynecologic Oncologist at The University of Chicago Medicine. Learn more about Dr. Lee.
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How Does Biomarker Testing Impact Endometrial Cancer Screening and Detection? |
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Transcript:
Katherine Banwell:
What questions should patients be asking their doctor about detection?
Dr. Nita Karnik Lee:
For uterine cancer or endometrial cancer, detection is really based on symptoms. If there are any of those symptoms that are happening, they really should be asking, hey, I need to see a gynecologist. I need to do a biopsy. We do, unfortunately, see many patients who are sort of told, oh, it must be fibroids. But that shouldn’t happen in post-menopausal patients. I’ve heard everything. I’ve heard patients sort of self-reflect, and say, you know what, I was stressed that day, or I moved the couch that day. I’ve heard all the different things we think about, because none of us wants to feel like there could be something wrong. We often justify. It was probably nothing.
But the patients who do the best are the patients who have a spotting episode, they have a bleeding episode, they seek care right away. And then 80 percent of uterine cancers need only surgery, so that’s a good statistic compared to some of the other GYN cancers. I would say advocating for your symptoms, not being afraid of a symptom being worked up, because I think there’s a lot of fear with, if you report something, maybe it will be something.
And getting over that sensation of it may not be. It may be something completely different that’s benign. But I think the earlier that we can see a diagnosis and get people to treatment and/or hysterectomy, that tends to do the best in terms of survival and just getting over this episode.
How Does Biomarker Testing Impact Endometrial Cancer Screening and Detection?
How does biomarker testing impact endometrial cancer screening? Gynecologic expert Dr. Nita Karnik Lee reviews genetic mutations related to endometrial cancer and outlines key considerations for women with a family history of the disease.
Dr. Nita Karnik Lee is a Gynecologic Oncologist at The University of Chicago Medicine. Learn more about Dr. Lee.
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What Questions Should You Ask About Endometrial Cancer Detection? |
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Transcript:
Katherine Banwell:
What is the role of genetic and biomarker testing as screening tools?
Dr. Nita Karnik Lee:
Those two things are different in certain ways, and it’s actually really important to think about that as well because for genetic testing if you do have a strong family history, there may be times where you are going to see a cancer genetics person. They may say, hey, your mom had uterine cancer. Maybe they are diagnosed with a certain syndrome. Lynch syndrome is the most common one, which is caused by a mutation in some of the repair proteins that normally repair DNA. That’s something that can get diagnosed and predispose people to many cancers, the most common of which is colon or uterine cancer.
So, in those patients, some of those patients will actually undergo endometrial biopsies starting at a young age, even if they don’t have any irregular bleeding. Biomarkers are something also really important for somebody who is diagnosed already with endometrial cancer. So, if you get diagnosed with endometrial cancer, we actually use the biomarkers, which are an example of proteins the tumor has on its cell surface that can be turned on and off. And that profile of which biomarkers are on and off gives us an idea, and now can really help guide a little bit of treatment for some patients.
Katherine Banwell:
Okay. Should women with a family history of endometrial cancer take extra precautions?
Dr. Nita Karnik Lee:
I think they need to be really aware about the symptoms, and they need to be really thinking about whether or not there’s any role for genetic testing. Some patients, they have a family history. They’ve done genetic testing. It’s negative. There’s not anything else that we would do. But in those patients, if there’s any vaginal bleeding, spotting, anything irregular, that might really jump on the symptom diagnosis, or the symptoms leading to diagnosis, or sometimes people have other issues.
They have fibroids. They have other things going on, and maybe they need a surgery, and maybe having that family history in your background sways you a little bit more. Hey, maybe I will consider surgery. It’s probably not the only reason to do a hysterectomy, but it can contribute to the decision-making if that makes sense.
Advances in Endometrial Cancer Detection
How are patients currently screened for endometrial cancer? Gynecological cancer expert Dr. Nita Karnik Lee discusses tools for detection and diagnosis of endometrial cancer and factors that may impact risk.
Dr. Nita Karnik Lee is a Gynecologic Oncologist at The University of Chicago Medicine. Learn more about Dr. Lee.
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How Does Biomarker Testing Impact Endometrial Cancer Screening and Detection? |
What Questions Should You Ask About Endometrial Cancer Detection? |
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Transcript:
Katherine Banwell:
Dr. Lee, what are the screening tests for endometrial cancer?
Dr. Nita Karnik Lee:
That’s also a situation that we don’t actually have screening tests for uterine cancer. Again, PAP smears are usually normal in patients who have endometrial cancer because the PAP smear collects just the cells from the outside. Occasionally, sometimes cells that are in the endometrial lining can fall down into the cervix and get found on a PAP smear.
But that’s actually, usually, the exception and not the norm. So, most women I operate on who have endometrial cancer will have had normal PAP smears. But it’s really important to know what symptoms would really trigger the first diagnosis. So, any type of vaginal bleeding after menopause, vaginal spotting, brownish discharge, or anything that seems unusual, really warrants a biopsy. That is not exactly a screening test because screening tests are usually for patients who don’t have any symptoms, but it is really a very important diagnostic test for someone who has any of those symptoms.
Katherine Banwell:
Have there been advances in screening or screening technology that patients should know about?
Dr. Nita Karnik Lee:
Yeah, people are talking about that. We know that there are certain risk factors for uterine cancer, so there has always been a discussion about, what about maybe we don’t screen everyone. Maybe we don’t biopsy everyone, but maybe we should be biopsying some people. So, the issue of patients who have obesity is one of the risk factors, not all of them, because some patients who have obesity don’t have this, and vice versa.
Some patients are very thin and get endometrial cancer, because there are so many different types of endometrial cancer. But I think people have talked about the idea of people who have had a real cycle of irregular periods before menopause, and then may have some risk factors such as obesity, or metabolic syndrome, or diabetes, maybe they should get screened, but that has not been advocated at a public health level. Now, patients who do have a genetic mutation should get screening tests by the endometrial biopsy.
Katherine Banwell:
So, you mentioned some things to look for. How is endometrial cancer diagnosed?
Dr. Nita Karnik Lee:
It’s diagnosed when somebody usually comes in. Most of the people will be diagnosed because they have a symptom such as vaginal bleeding or vaginal discharge. Then they will have either an office-based biopsy, which is called an endometrial pipelle or endometrial biopsy.
Or they can have something that people have heard of before, called a D&C. That stands for dilation and curettage. That means opening up or dilating the cervix just a little bit to allow an instrument to come in and do a small scraping of the lining of the uterus. So, one of those two ways is going to be the way this is diagnosed.
How Does Biomarker Testing Impact Ovarian Cancer Screening and Detection?
What role does biomarker testing play in ovarian cancer detection? Dr. Nita Karnik Lee reviews genetic mutations related to ovarian cancer and discusses key steps women with a family history of the disease should consider.
Dr. Nita Karnik Lee is a Gynecologic Oncologist at The University of Chicago Medicine. Learn more about Dr. Lee.
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Transcript:
Katherine Banwell:
What is the role of genetic and biomarker testing as screening tools?
Dr. Nita Karnik Lee:
Genetic testing is very important. When we get, for example, and I’ll kind of back up a little bit to say if somebody gets diagnosed with ovarian cancer, that is actually everyone who has a diagnosis of ovarian, fallopian tube, or peritoneal, because those are all sort of the same cancer, should get genetic testing to see if there’s a hereditary predisposition in their genetics that are passed on.
That’s called germline testing. And those patients, and 20 percent of them, may actually have a hereditary condition that could be passed on. Then that’s where you can see how important it is. If I have somebody, and her children now know that the person has the BRCA gene, for example, then it’s really important for her children, men and women, to get screened, because then they may be able to do preventive measures, such as preventive surgery, preventive medications, or more frequent screening, to be able to prevent cancer from happening.
Katherine Banwell:
Okay. What genetic mutations are associated with ovarian cancer?
Dr. Nita Karnik Lee:
The ones that are most common that you hear about are something called BRCA, or B-R-C-A, 1 and 2. Those make up the majority of those mutations. There are some other less common ones such as Lynch syndrome, which is more associated with colon and endometrial cancer but can have about 10 percent to 12 percent of patients related to ovarian cancer as well.
Nowadays, when we do genetic testing, we do a panel, so there are like 35 genes that are tested. There are a whole lot of different genes that can have an association with ovarian cancer, but the BRCA genes are the ones that most people hear about.
Katherine Banwell:
Should women with a family history of ovarian cancer take extra precautions?
Dr. Nita Karnik Lee:
That’s a very good question. So, if you have a family history, it’s probably important to talk to your doctor and to maybe even see somebody in cancer genetics who can draw out a family tree for you to see how high is this risk? If people have an ovarian cancer patient, one – or a breast cancer patient – some of it also matters what was the age that that patient got diagnosed. Some genetic mutation syndromes, actually the patient gets diagnosed much younger than average.
The average age for ovarian cancer is about 60. Some patients will get it. For some genetic mutations, it’s still about that range. So, I think it’s important because even if you don’t have a genetic mutation, having a family member with ovarian cancer slightly increases your risk.
Knowing those symptoms, knowing that your history will help your doctor dictate how quickly are they thinking about something else is really important, ultrasound, but we know that ultrasound is not perfect.
How Is Ovarian Cancer Detected?
Dr. Nita Karnik Lee discusses how ovarian cancer is diagnosed, shares challenges in screening tests and procedures, and reviews ongoing research in the field. Dr. Lee also shares key questions to ask one’s healthcare team about ovarian cancer detection.
Dr. Nita Karnik Lee is a Gynecologic Oncologist at The University of Chicago Medicine. Learn more about Dr. Lee.
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How Does Biomarker Testing Impact Ovarian Cancer Screening and Detection? |
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Transcript:
Katherine Banwell:
Dr. Lee, what are the screening tests and procedures to detect ovarian cancer?
Dr. Nita Karnik Lee:
So, one of the important things to realize is that we do not actually have a screening test for ovarian cancer. That’s really important for the general public who maybe is at average risk. Patients who have a strong family history or a genetic, hereditary condition, sometimes we do use ultrasound and CA125, but that’s not considered a screening test for average-risk patients. We’re very limited in that sense for ovarian cancer. There’s a lot of research that’s being done about this.
Katherine Banwell:
Have there been advances in screening or screening technology that patients should know about?
Dr. Nita Karnik Lee:
I think the issue with screening and ovarian cancer is because we have not had any, and there have been really large studies that have been done both in the U.S. and in Europe, trying to see does ultrasound work every six months. Does CA125 and ultrasound work?
There’s some combination of blood tests that have started to become a little bit more researched in terms of going further along, but there’s really nothing that’s the perfect answer. One of the really important things that we talk about is knowing family history to see if there’s something that can be done to help patients who have a family history.
And then also being really aware of subtle symptoms of ovarian cancer that can trigger you going to your doctor and then really pushing and advocating for yourself and your family member to get a workup done, which can often include an exam, an ultrasound, and maybe even something like a CAT scan or CT scan if any of the symptoms are a little more worrisome.
Katherine Banwell:
What questions should patients ask their doctor about detection?
Dr. Nita Karnik Lee:
I think that when we’re thinking about detection, or if somebody has these symptoms coming up, definitely asking, like, hey, you know what? I’m seeing you as an internist, but I haven’t had a pelvic exam. So, making sure you’re seeing a gynecologist or an internist or family medicine doctor who can do a vaginal and a rectal exam is one important step. Perhaps getting an ultrasound or perhaps getting a CAT scan if the symptoms are more significant.
Unfortunately, we still see a lot of women who have these sort of vague symptoms, maybe they’re GI-related, and they get a workup for like six months on an EGD, or a colonoscopy, or they tried Pepcid. And all of those things are good, and they’re not unreasonable to do, but I think something else that can be done in addition would be a pelvic ultrasound, as an example.
I would say that if somebody doesn’t have any of those symptoms, but they have a family history, that’s why we’re in a little bit more of a bind as to know what the right thing to do is. We know that for patients who have a known BRCA mutation and are not ready for risk reduction surgery, we often will use ultrasound, but we know that ultrasound is not perfect.
How Do Biomarkers Impact Ovarian Cancer Treatment and Care?
How do biomarkers impact ovarian cancer care? Dr. Heidi Gray discusses how genetic biomarkers like BRCA-1, BRCA-2, and HRD inform treatment options, affect prognosis, and guide therapies like PARP inhibitors.
Dr. Heidi Gray is the Division Chief of Gynecologic Oncology and the Director of Gynecologic Oncology Clinical Trials at UW Medicine. Learn more about Dr. Gray.
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Transcript:
Katherine Banwell:
What are the most common biomarkers associated with ovarian cancer?
Dr. Heidi Gray:
So, the most common biomarkers, first of all, are the genetic mutations that are associated with higher risk. So, many folks are familiar with BRCA-1 and BRCA-2. There are a couple of lesser-known genetic mutations that fall into that family that also can put patients at an inherited risk.
Other biomarker testing that we do is for something called HRD, which is a test to look at a profile of the cancer that is similar to having the BRCA-1 and BRCA-2 mutations. It is a spectrum of different testing that may make those cancers more susceptible to PARP inhibitor therapy.
Katherine Banwell:
Are there biomarkers associated with prognosis?
Dr. Heidi Gray:
Let me back up a little bit. So, the biomarkers associated with prognosis – yes. So, in patients who have BRCA-1 or BRCA-2 mutations, they actually tend to have better prognosis longer term and better responsiveness to chemotherapy and other therapies.
Patients who also have HRD may also have a little improved responsiveness to some of the therapies as well.
Katherine Banwell:
How do these biomarkers impact ovarian cancer treatment options?
Dr. Heidi Gray:
Good question. So, the biomarker testing again, particularly for the BRCA-1, BRCA-2, and then the HRD spectrum, there have been several very large studies that have looked at using a variety of drugs that fall under this group called PARP inhibitors, P-A-R-P inhibitors.
These drugs specifically target cancers that have these mutations – or more susceptible to these mutations and interestingly have found that when we use these PARP inhibitors in a maintenance therapy, so after patients have completed their primary treatment, surgery, chemotherapy, and then go on maintenance therapy to prevent recurrence, they have very, very long improvement in survival and pushing out recurrence very far, significantly so, more than we’ve seen for anything in ovarian cancer in recent years.
So, it’s very, very exciting.
Katherine Banwell:
What question should patients ask about test results?
Dr. Heidi Gray:
It is interesting now because as many patients have experienced, they sometimes get their test results before their provider has had a chance to review them as part of the patient access program that has been in place. So, I find that many patients have had time to sit with their results or question or go on the Internet about them before they see me. So, some of it is helping direct, okay, where are you getting your information from and all of that, because I think that that is something newer now.
But I think it’s important for patients to be asking do I qualify for genetic testing, what are those results, what are the implications for myself and/or my family members? Then the molecular testing, as I said, is a very important next step that we do recommend for all, certainly advanced ovarian cancers or recurrent ovarian cancers, to help better guide therapy.
Essential Testing Following an Ovarian Cancer Diagnosis
What essential testing should follow an ovarian cancer diagnosis? Dr. Heidi Gray explains that patients should undergo both genetic testing, which identifies inherited risk factors, and molecular testing, which evaluates specific tumor mutations.
Dr. Heidi Gray is the Division Chief of Gynecologic Oncology and the Director of Gynecologic Oncology Clinical Trials at UW Medicine. Learn more about Dr. Gray.
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Transcript:
Katherine Banwell:
Dr. Gray, what essential testing should people with ovarian cancer have following diagnosis?
Dr. Heidi Gray:
That’s a great question. We’re learning more and more about this disease. Therefore, we also have a lot more variety of tools to look at to be able to match better therapies for patients. Historically, when patients were diagnosed with ovarian cancer, it was based on just the pathology at the time of surgery and some lab testing called the CA-125, which many patients with ovarian cancer are familiar with.
The next level of testing that we are doing for ovarian cancer is really to look at how aspects of either the patient themselves or of the cancer themselves that might better match therapies. So, the first line of testing we recommend for all women for ovarian cancer is genetic testing. Genetic testing is blood-based testing.
It is testing for if you have an inherited gene or a mutated gene, that’s being passed along through families that may have put you at risk of developing ovarian cancer and potentially breast cancer. That is recommended for all women and patients who have been diagnosed with ovarian cancer because we know about 15 percent to 20 percent of these cancers are due to a genetic cause.
The other level of testing that we have incorporated is what we call molecular testing. Other terms for it are “tumor-based testing” – I think you use the term “biomarker testing.” Some people use the term “precision medicine,” and that is a little different. That is testing that is actually testing the tumor itself. It’s looking at a variety of different factors but particularly looking at mutations in the cancer itself, in the tumor itself, so different than the genetic, which is an inherited thing. This is in the tumor itself. There is some overlap of that.
But it has an expanded profile of different targets that we can match therapies to.
Katherine Banwell:
Would you define biomarker testing for us?
Dr. Heidi Gray:
Yeah. So, biomarker testing is just that. It is more expanded testing, particularly tumor testing is one aspect of it. There can also be some blood testing, genetic testing. Then there is a new realm also of looking at cell-free DNA or ct or tumor DNA in the blood as well too that is gaining a lot of interest.
Ultrasound Pictures of Ovarian Cancer
During the process of diagnosing ovarian cancer, doctors will use several tests to learn more about the tumor. The first test that doctors usually recommend is an ultrasound. This painless imaging test helps doctors see what the inside of the abdomen looks like. Doctors can use ultrasounds to detect various problems with the ovaries and nearby organs.
How Do Ultrasounds Work?
An ultrasound machine uses a small handheld tool called a transducer to send sound waves into the body. These sound waves are painless and are so high-pitched that humans can’t hear them. Echoes of the sound waves bounce back to the transducer, and the machine converts the sound waves into an image. The result is a sonogram — a picture of the tissues and organs within a particular part of the body.
There are a couple of types of ultrasound. When diagnosing potential cases of ovarian cancer, doctors often use a transvaginal ultrasound, in which a probe is placed into the vagina. Doctors may also perform a pelvic ultrasound, in which the transducer is placed on the skin of the lower part of the abdomen. Both of these approaches can capture pictures of the ovaries and uterus.
What Does the Ovary Look Like on an Ultrasound?
Sonograms from an ultrasound test can show several features of the ovary. They allow doctors to see the size and shape of the ovary. A sonogram can also look at the texture of the outer surface of the ovary. Additionally, ultrasound imaging can detect abnormalities or masses on the ovary, which may or may not be cancerous.
The Normal Ovary on an Ultrasound
In general, the ovaries appear as almond-shaped structures on either side of the uterus. In individuals who have given birth multiple times, the ovaries may have moved slightly from their original position. The ovaries also shrink after menopause, so an ultrasound may not be able to detect them in older people.
For individuals who have not yet gone through menopause and are still getting their period, their ovary will contain follicles. Ovarian follicles are small sacs. Each one contains an egg cell. Follicles develop and grow larger throughout the beginning phase of the menstrual cycle. Then, a single follicle will continue to grow until it releases an egg, called ovulation.
On an ultrasound, the follicles may appear as small, dark, round shapes around the edge of the ovary. Follicles may be different sizes depending on where a person is within their menstrual cycle.
Cysts on an Ultrasound
Sometimes, an ultrasound may detect other more unusual features within an ovary. Most of these findings are not cancerous, and many are not harmful
A common ultrasound finding is a cyst (a fluid-filled sac). About 8 percent to 18 percent of women have cysts on their ovaries. Occasionally, ovarian cancer may appear as a cyst. However, ovarian cysts are usually benign (noncancerous). Often, cysts develop when a follicle fails to release an egg or fails to disappear after ovulation. These cysts usually go away over time. Occasionally, cysts are caused when blood or tissue from the uterus attaches to the ovary, called endometriomas. Cysts can also be teratomas — masses that form when an egg cell begins growing within the follicle.
Like follicles, cysts usually appear round and black on an ultrasound. They often have thin walls and don’t look like they contain anything inside. However, they are often larger than normal follicles.
Cysts don’t usually need any treatment and are often not a cause for concern. In some cases, doctors may recommend a follow-up ultrasound a few months later to see if the cyst has grown.
Ovarian Cancer on an Ultrasound
In rare cases, ovarian cysts or solid masses may be malignant (cancerous). The ultrasound doesn’t show for sure whether an abnormality is cancer, but it can provide clues. Malignant cysts and masses usually look a little different on an ultrasound. They may:
- Be very large
- Have papillary structures (bulges) on their outer or inner surface
- Be divided into multiple segments called loculations
- Contain blood or other material inside them, making them not look solid black all the way through
Some cases of ovarian cancer begin in the fallopian tubes (the tubes that connect the ovaries to the uterus). Fallopian tubes are usually invisible on an ultrasound. However, if there is a problem with the fallopian tube, it may appear as a long, thin mass. This may happen when the fallopian tube grows larger or fills with fluid due to conditions like a blockage, pelvic inflammatory disease, or cancer.
Doctors consider other information when deciding how likely it is that a cyst or mass is malignant. Risk factors that help indicate whether an abnormality is malignant include:
- Your age
- Whether you have gone through menopause
- Levels of CA-125 (a protein that can serve as a sign of ovarian cancer)
- How big the mass is
- How much solid tissue is inside of the mass, as opposed to fluid
- How many bulges or projections a mass contains
- How many masses are present
- Whether you have ascites (fluid in your abdomen)
If these factors indicate that you may have a malignancy, your doctor may recommend additional diagnostic tests or surgery to get a better look.
What Don’t Ultrasounds Tell You?
Although ultrasounds have several very useful purposes, they also have limitations. Doctors rely on additional diagnostic tests to gather more information about problems with the ovaries.
Whether You Have Cancer
Ultrasounds can detect abnormalities, and they can provide a clue as to whether an ovarian mass or cyst might be cancerous. However, biopsies are the only way to tell for sure whether a mass contains cancer cells.
For people with ovarian cancer, a biopsy is usually taken during surgery. Biopsies of the ovary are not usually performed before surgery because a needle biopsy of the ovary might potentially release cancer cells that were otherwise contained. The surgeon will send pieces of the mass to a laboratory where the cells will be studied under a microscope to determine whether they are cancerous. Biopsies also help determine the type of ovarian cancer.
Whether Ovarian Cancer Has Spread
The later the ovarian cancer stage is, the farther cancer cells have metastasized (spread within the body). Determining cancer’s stage is important for determining the prognosis (outlook) and knowing which treatment plan may be best.
Doctors don’t use ultrasounds to tell how far ovarian cancer cells have spread. Ultrasounds can’t distinguish whether cells are cancerous or not, and they are only used to look at one part of the body at a time. In order to determine cancer stage and locate metastases, doctors use other imaging tests or procedures. These other tests, which are often better at detecting cancer cells and show larger areas of the body, include:
- Magnetic resonance imaging (MRI)
- Computed tomography (CT) scan
- Positron emission tomography (PET) scan
- Surgery
Ultrasounds and Cancer Screening
Ultrasounds can be used to detect potential ovarian tumors. Does this mean that this test can help screen people for ovarian cancer?
Researchers have studied whether a transvaginal ultrasound helps detect ovarian cancer during its early stages. They have also studied whether adding blood tests to measure CA-125 levels helps improve ultrasound screening. However, the results were not promising. These tests often pick up benign, noncancerous conditions, which means that individuals who use these screening methods often undergo additional and sometimes unnecessary tests and surgeries. Additionally, ultrasound and CA-125 screenings don’t seem to reduce the overall number of people who die from ovarian cancer.
Experts say that individuals who have an average risk of developing ovarian cancer should not be screened using the currently available methods. However, some doctors recommend regular screening for those with a high risk of ovarian cancer. This includes women who have many family members who have had ovarian or breast cancer or women with genetic mutations in high-risk genes such as BRCA1 or BRCA2.
Talk With Others Who Understand
MyOvarianCancerTeam is the social network for people with ovarian cancer. More than 3,000 members come together to ask questions, give advice, and share their stories with others who understand life with ovarian cancer.
Are you living with ovarian cancer? Have you had to get an ultrasound test? Start a conversation by posting on MyOvarianCancerTeam.
The Foundation for Women’s Cancer Educational Series
The Foundation for Women’s Cancer (FWC) offers a comprehensive set of free educational courses designed to support patients and caregivers that answers the question, “What do I need to know?” for a cancer journey. From the basics of “what is cancer?” to understanding treatments, clinical trials and how genetics play a role, to lifestyle discussions on sexual health and nutrition, these courses meet you where you are to answer the questions you might have. Available in a variety of self-study and live webinar formats, these courses are available for you when you need them. Additional downloadable resources are a part of each course.
