“Endometrial and Uterine Cancer” – with Dr. Gizelka David-West

Dr. Fox: Welcome to today’s episode of “Healthful Woman,” a podcast designed to explore topics in women’s health at all stages of life. I’m your host, Dr. Nathan Fox, an OBGYN and maternal fetal medicine specialist practicing in New York City. At “Healthful Woman,” I speak with leaders in the field to help you learn more about women’s health, pregnancy and wellness. 

 

All right, we have Gizelka David-West here with us. Dr. David-West is an assistant professor of OBGYN and GYN oncology at New York Medical College and practices at Westchester Medical Center and we’ve known each other a long time and, Gizelka, I’m really happy that you’re here. Thanks for coming on. 

 

Dr. David-West: Thank you, Dr. Fox. 

 

Dr. Fox: Dr. Fox? 

 

Dr. David-West: Absolutely. I know, I can’t help it. 

 

Dr. Fox: You can call me Natey on the podcast. It’s okay. My listeners know my name. 

 

Dr. David-West: It’s funny, you never kind of get over that and your attendings or with your attendings. I’m honored and very happy to be on your podcast this morning. 

 

Dr. Fox: Wonderful. Well, thanks for coming on. Thanks for taking time out of your busy schedule. All GYN oncologists are always busy. That’s what I, unfortunately, have learned over the years. So just so our listeners understand who you are, where are you from? How’d you get into medicine, gynecology, the whole thing? Start from the beginning. 

 

Dr. David-West: Sure, there’s a short and long version of everything. So I’ll give it like, an abridged. I’m an immigrant, I immigrated from Nigeria with my family, my Nigerian father and my Slovakian mother, and then my three siblings. So we came to New York City, the melting pot, in 1991. So I was about nine years old or so. And so basically, New York is considered hometown. We’ve been here for many, many years now, did move around quite a bit, lived in a variety of different states, ultimately ended up doing my medical school education at University of Miami. Miller School of Medicine, then went on to Mount Sinai in New York, where I got to learn under the infamous Natey Fox and other amazing attendings. So my internship and residency were completed there. And then fellowship was at NYU for GYN oncology. And I’ve been at Westchester Medical Center now for about five years. 

 

This is my first job out of fellowship and it’s really been amazing, very fulfilling. How I got into medicine, I think it’s an interesting story. I was totally enamored and excited about pathology, actually, forensic pathology, and had all these kind of plans on being a forensic scientist. And I think it was my dad who suggested, “Well, what about going the medicine route and you could be a physician in forensic pathology?” So I looked into that, I actually did a summer internship at the Medical Examiner’s Office in Albuquerque, New Mexico. 

 

Dr. Fox: Really? 

 

Dr. David-West: Yeah, when we were living out there. And that was quite fascinating. And after that, I was for sure that I was gonna do forensic pathology, and that was gonna be my lifelong career. I ended up in med school, then fell in love with women’s health and OBGYN and had an incredible mentor at the time who really helped me carve a path towards women’s health. And I was determined to go to Mount Sinai and I made it there for residency. And it was then at Mount Sinai when I really got a chance to really take care of some of our, the sickest of our sick oncology patients there. In our intern year, we had an incredible rotation in GYN oncology then, of course, as seniors, and I really just found myself connecting with them in a different way. And finding that I really could give all of myself to this patient population. And that’s what I wanted to do. And so I pursued fellowship, and here I am. 

 

Dr. Fox: It’s amazing. How does a kid get interested in forensic pathology? Is it like, were you watching old “Quincy” reruns? Like, how did you get into that? 

 

Dr. David-West: It’s funny, I think I’ve always enjoyed detective shows or even “Dateline” or all those kind of mystery novels. I did read a lot of mystery novels when I was younger. I think Ed McBain, I wanna say, is a mystery author from a long, long time ago, and so “Crime Scene Investigation,” all that kind of stuff. So, yeah, I was really into it, I still am. If you find me watching shows, I don’t watch medical shows at all. I’m like, I live that so I can’t possibly watch Netflix shows about medicine, but you will find me watching them on crime and that kind of genre, so it still piques my interest. 

 

Dr. Fox: That’s so interesting. And then, what you’re saying about GYN oncology is really true, and the people who are drawn to GYN oncology, it’s a unique breed of person, because it’s really intense, and the women can be very sick. Obviously, they’re not always sick and, frequently, they do really well, but they can be, and when you’re doing OBGYN as a residency, let’s say half of it is obstetrics, pregnancy, half of it is gynecology, but most of the gynecology is general gynecology, well women, things of that sort. But then there’s oncology, which is like this other world where you’re, it’s like these really intense and very big operations. And there’s chemotherapy, and there’s all of this cancer care, which is almost its own world in OBGYN and the people who are drawn to it are just drawn to it. It’s just amazing. 

 

Dr. David-West: I think, yeah, you’re absolutely right. Once you’re kind of hit with that bug, it just lingers and you can’t shake it. I find myself really fulfilled taking care of my patients. And you’re right, they’re not all very sick. And we do have some really incredible stories and amazing outcomes. But then we’re also, we have the tools to help and care for those who do have the more unfortunate outcomes, and we really provide them with compassionate care through the entire course of their disease and at end-of-life. And I think it’s really incredible to be able to have that kind of continuity with a single patient population. 

 

Dr. Fox: Right, totally. And as a side note, you didn’t mention this, but you’re also a singer. 

 

Dr. David-West: Oh, yes. I am. That’s also another awesome part of being a GYN oncologist, because I essentially got recruited to be the new lead singer for the band, No Evidence of Disease. So last summer, they were looking for a new female lead singer. And so they reached out to me and, yeah, I got on their tour with them and it was an awesome experience. And we were looking forward to 2020 and doing more shows, and then COVID happened, but it is very exciting. So it’s a band of all GYN oncologists from all over the country, actually. And they’ve been around for over 10 years, they have a PBS documentary, about three albums already out. I’m not on any of those. But we’re hoping to put out a new one, one or two new albums in the next year or two, recordings with me in them. But it’s exciting. It’s really fun. It’s a great outlet. 

 

And the main premise for the band is really advocacy and awareness for women’s cancer. So we kind of go around the country promoting awareness and providing support for our patients and other women around the world or country with GYN cancer. 

 

Dr. Fox: Yeah, it’s really cool. So, I mean, the band is N.E.D., or No Evidence of Disease. N.E.D. is a medical acronym that’s well known to doctors, but as a band, and I think it’s great that you’re doing it. And also, you guys are really good, on top of that. 

 

Dr. David-West: Thanks. 

 

Dr. Fox: It’s not just, like, neat that you do it. But you guys actually sound good, which is a plus if I’m listening to music. I wanted to talk with you about uterine cancer or, as we’ll discuss mostly, endometrial cancer. And I think that this is probably one of those circumstances where most of the women who present with this type of cancer actually have good outcomes after treatment. And so this is, of all the cancers that you’re gonna be dealing with, probably one of the, I don’t wanna say “easier,” but in terms of what the expectations are, in terms of care, in terms of survival, they’re generally much better than for, say, ovarian cancer. 

 

Dr. David-West: Correct. Absolutely. I always tell my patients there’s no good cancer. But there are different, of course, variations and some that are obviously a lot easier to treat or curable whereas there are others that are more aggressive and higher risk and with not so favorable prognosis. Right. 

 

Dr. Fox: Right. And in the U.S., uterine cancer or endometrial cancer is actually the most common gynecological cancer, the most cancer for women, correct? 

 

Dr. David-West: Yes, it is absolutely the most common and, like you mentioned, endometrial of the uterine cancers is the most common. So uterine cancer, you have endometrial and then you have the very rare sarcomas. Those are extremely rare and don’t add to the cohort of most common when you’re talking about endometrial cancer. 

 

Dr. Fox: Right, and endometrial cancer, the endometrium is the inner lining of the uterus, right? 

 

Dr. David-West: Exactly. The inner lining is where the cancer originates, and most often will stay in that inner lining and not invade beyond. And so that’s what makes it a more favorable prognosis when diagnosed early and then treated early. 

 

Dr. Fox: Right. And then in other countries, cervical cancer tends to be more common. And that’s just because potentially those countries don’t have as robust a screening program for cervical cancer with pap smears and whatnot that we do here. 

 

Dr. David-West: Correct. So the screening and also vaccination, I have to throw in a plug for the Gardasil vaccine because it is absolutely critical in decreasing the rates of cervix cancer that we would potentially see, but yeah, the screening programs are much more robust here. And what drives the endometrial cancer numbers here in the United States is also the level of obesity in our country because that’s directly correlated to the type of endometrial cancer that is related to hormone levels. And so there’s a correlation with obesity and that particular type of endometrial cancer. 

 

Dr. Fox: Who’s most likely to get endometrial cancer? Meaning in what cohort of women? It’s typically older women, yes? 

 

Dr. David-West: Yes. So you’ll see in older women, it’s the postmenopausal, usually the obese or overweight, who have what we call the exogenous estrogen. So, when you’re in menopause, your ovaries stop producing your normal estrogen and progesterone levels. And those work to counteract each other, give you a nice equilibrium so things stay “normal” in the endometrium. When you’re in menopause, and let’s say now you’re overweight or obese, your fatty tissue has an ability to create estrogen. And so that estrogen now circulates throughout your body and is going to act on various organs and structures. It acts in a positive way on our heart, in a positive in our bones, but unfortunately acts in a negative way on that uterus that’s still inside your body, especially when there’s no progesterone to counteract it. 

 

And so then what we see is these higher levels of estrogen that are targeting this uterus, and that lining is stimulated by that estrogenic and grows kind of out of control, grows thicker and thicker over time. And with that growth, then you can start having cell populations that start mutating and behaving abnormally, and that’s where you can then develop precancers or cancers related to those high hormone levels. And that’s how you really get the most common types of endometrial cancer that we see. 

 

Dr. Fox: Right. The way I always remembered it when I was practicing as a gynecologist or when I was learning this was that during a regular menstrual cycle before menopause, right, there’s, estrogen sort of builds up the lining of the uterus, the inner lining, and that progesterone, sort of what we call your, stabilizes it or counteracts that, and then you get a period and it all sloughs off and then you start anew. And so for someone who’s getting regular periods, there’s estrogen building it up, progesterone sort of holding it back, you get your period, the chance of it becoming what we call atypical or unusual or cancerous is very, very low because it’s regenerating and it’s going away every month. And so the people who could develop cancer are either people who are after menopause when they’re not getting periods, but they are exposed to estrogen alone, right, without the progesterone or before menopause, the women who don’t get periods because, for whatever reason, their hormones are often, they just have a lot of estrogen and not enough progesterone. So they have, like, growth, growth, growth, but they don’t actually slough it off on a monthly basis. 

 

Dr. David-West: Exactly. And so you bring up a nice segue here where, so even though I mentioned we see it in postmenopausal women much primarily, we do have a small percentage of our patient population that we see that are premenopausal. We have young women who developed endometrial cancer, and it’s exactly that patient, as you said, their periods are irregular or they just don’t have the periods or there’s an hormone imbalance. And so we do see them present with endometrial cancer at the younger ages. Not as common, of course. 

 

Dr. Fox: But just to be clear, for people who aren’t getting their periods, if it’s because they’re pregnant, or they’re nursing, or they’re taking a type of contraceptive where you take it continuously, those you’re not at risk for getting it because you don’t have that unopposed estrogen in the same way. 

 

Dr. David-West: Absolutely correct, yes. 

 

Dr. Fox: Right. So it’s just women who sort of naturally don’t get periods because they have too much estrogen and not enough progesterone, and one of the risk factors of that is having fat tissue, so obesity. 

 

Dr. David-West: Exactly, right. Exactly. 

 

Dr. Fox: We had a podcast about ovary cancer and how hard it is to screen for it. And then we had a podcast on pap smears and how great that is in screening for cervical cancer. How would someone screen for endometrial cancer? 

 

Dr. David-West: The screening per se is really advocated or recommended for women who have a known genetic mutation or they’re a part of the familial hereditary syndrome called Lynch syndrome. So in that patient population, they are very high risk for endometrial cancer and there is screening recommendation for endometrial biopsy in those patients, periodically. 

 

Dr. Fox: Oh, so they get a pair of biopsies, but for everyone else, it’s basically just, it’s just clinical, right? Meaning if you’re postmenopausal, the only time you really get screened is if you’re bleeding, right? 

 

Dr. David-West: Right. And that’s the major difference with ovarian cancer, for example, is the first sign or symptom is postmenopausal bleeding. Any kind of bleeding, a spot of blood, pink, brown, dark brown, bright red, any little spot of blood that has happened in your postmenopausal phase prompts a visit to your GYN and a screening for endometrial cancer and I stress that because that is the first telltale sign that something could be going wrong. And that’s how you’re, and if you have a prompt assessment and screening, you will be diagnosed much earlier and then can, of course, undergo curative treatment much earlier as well. 

 

Dr. Fox: What would that screen be? So someone, let’s say they’re menopausal. So they’re past the age of menopause, they normally don’t get periods anymore. And then they have a little bit of bleeding, and so you’re saying, okay, this requires evaluation. So number one, in that person, what is the likelihood it’s something cancerous or precancerous versus just nothing? And number two, how would you figure that out? 

 

Dr. David-West: Right. So the likelihood is all based on history and physical exam, you’re seeing your GYN, they’re getting a full history, assessing you, assessing risk factors, familial history, pelvic ultrasound, and endometrial biopsy. And endometrial biopsy is something that can be done in the office, a very minor, low-risk procedure that is quite high-yield. It can capture tissue from the lining of the uterus and endometrial lining, we’ve talked about, and can diagnose either something benign, precancerous, or malignant in that scenario. 

 

Dr. Fox: Right. If someone, let’s say, is not menopausal, right? They’re still getting regular periods. If someone’s getting regular periods, there really wouldn’t be any screening for them, again, unless they were in some very high-risk group, which they would know about. 

 

Dr. David-West: Exactly, and somebody who is menstruating regularly with regular periods, if there is a change in their pattern of bleeding, that would then prompt an evaluation or some form of screening, again, considering other factors, considering other risks that they may or may not have. 

 

Dr. Fox: The nice thing about this is that the screening tests are really very straightforward. It’s an ultrasound, you look at the lining of the uterus, it looks normal or abnormal, how thick is it, how thin is it, and plus/minus a biopsy, which, as you said, is a in-office procedure, you don’t have to take off of work for it. There’s no anesthesia for it. You have it, you can literally go back to work the second you’re done. There’s really not much risk and then you get all the information you’re gonna need in terms of, again, normal, precancerous, or cancerous. 

 

Dr. David-West: Yes, correct. 

 

Dr. Fox: And so this is something that’s actually diagnosed by biopsy, meaning it’s not diagnosed by an MRI or a CAT scan or an ultrasound, correct? 

 

Dr. David-West: Exactly. In oncology, we like to say, “Tissue is the issue.” 

 

Dr. Fox: Oh, I like that. 

 

Dr. David-West: So, you need that tissue to get that diagnosis. MRIs, CAT scans, ultrasounds are all great. They can give you a very good educated guess on what’s happening and predict the potential, but without that tissue, you really don’t have a 100% definitive diagnosis. 

 

Dr. Fox: Right. And also, I think it’s because, certainly nowadays, so much of the treatment and the prognosis is based on how abnormal the cancer cells are. This is true for all cancers, meaning it’s not like cancer, no cancer, it’s not binary. There is cancer that is highly unusual, which is worse. And there’s cancer that’s just slightly unusual, which is generally better prognosis, easier treatment. And so not only do you need it to make a diagnosis of cancer, but sort of, what I believe you guys called, you grade it, correct? 

 

Dr. David-West: You’re absolutely correct. It’s really on how abnormal the cells are. And the most common type of endometrial cancer we see is your low-grade, or some people will see on their reports a grade one, or a well-differentiated endometrioid, endometrial cancer. So this is the terminology that we use, but it’s the low-grade type, these are the most common. These are the ones that will stay in that lining, unlikely to invade beyond that lining, and are cured with surgical intervention. Ninety percent, 95% chance of cure rates without chance of recurrence. 

 

Dr. Fox: So let’s just go through the options, someone is evaluated for this, either they’re premenopausal or postmenopausal, whatever it is, they prompt some sort of evaluation, they have a biopsy. Now obviously, if the biopsy comes back normal, then, okay, it’s a gynecologic problem, why are they bleeding? It’s maybe concerning, maybe annoying, whatever it is, but that’s sort of one set. Let’s say they get back that precancerous diagnosis, which is called hyperplasia, so the cells are growing more than they should, but it’s before the pathologist would call it cancer. How is that managed? And is it different based on who the person is? 

 

Dr. David-West: Hyperplasia, there is, again, different grades or different levels of severity of hyperplasia. You have your simple, meaning these cells are very, very close to normal, they’ve barely started mutating, or you have your complex, which they’re starting to look more abnormal. And then you have your group that has atypia or no atypia. And again, this is just, as we discussed, how irregular, how abnormal are these cells, and whenever I talk with my patients about this, I usually draw a little diagram, it’s a spectrum of disease. I put on one end of the paper normal and the other end is cancer. And then I do little tick marks all along the middle… 

 

Dr. Fox: Getting closer to cancer. 

 

Dr. David-West: …from normal to cancer, getting closer to cancer. And so basically, simple hyperplasia, no atypia is the closest to normal, whereas complex hyperplasia with atypia is the closest to cancer. 

 

So, depending on which one you have determines the type of treatment and, again, how old you are, too. So somebody who is premenopausal with simple hyperplasia, this is something we can correct with hormone therapy, we just need to get their hormone balance back in check, give them a little bit more progesterone, a little less estrogen, clears it right up, and they’re good to go. They may need what we call a dilation and curettage to scrape the linings and clean it out, give some hormone therapy, and then they’re fine. And it’s resolved, it’s a resolved issue. They would need follow-up to just monitor their bleeding pattern. And if they developed irregular bleeding again, you would then resample to see, “Oh, is this hyperplasia coming back?” But that usually does not need definitive surgical intervention with hysterectomy, which I know we’re gonna talk about later, versus now your patient who has complex atypical hyperplasia, young or older, this requires a little bit more thought and more decision-making about kind of which direction you wanna go. 

 

If they’re younger and pursuing fertility, you can still do that dilation and curettage, do some hormone therapy, help them clear that because it can clear. There is about 50%, 60% regression rate with the appropriate therapies and they can then go on to pursuing fertility once they have a cleared lining without hyperplasia anymore. If you have your older patient who’s postmenopausal that doesn’t need to retain their uterus, this is a patient that if they can undergo a definitive surgical management, you highly recommend that because complex atypical hyperplasia has the highest rate of progression to cancer, about a 25% chance to progress to cancer. And we have seen on these final hysterectomy specimens that about 40% to 50% of those hysterectomies that, initially, the biopsy said complex atypical hyperplasia now actually have concurrent cancer. 

 

Dr. Fox: Because a biopsy is only a small portion, whereas if you… 

 

Dr. David-West: Exactly. Right. 

 

Dr. Fox: …look through the whole uterus, you’ll find small areas of cancer potentially. 

 

Dr. David-West: You can have, for small areas, and again, this will be a low-grade type of cancer, because that’s the progression of the disease. It goes from that complex atypical to the low-grade, it doesn’t jump from the complex atypical to something high-grade or very aggressive. 

 

Dr. Fox: Right. So for people with the hyperplasia, again, just to summarize, based on sort of how close it is to cancer, that’ll change how likely it’s gonna work to treat with just hormones and a D and C, dilation and curettage. And that decision, again, is based on, does she wanna have more children or not, how averse is she to having a bigger operation like a hysterectomy? Or maybe, some people are a higher risk to do an operation on them because they have other medical problems and maybe more dangerous to do an operation versus wait. So those decisions, and that’s what you, I assume there must be some people who have even the less amount of hyperplasia who choose to just say, like, “I’m done. Do a hysterectomy, I don’t wanna deal with this anymore,” correct? 

 

Dr. David-West: Yes, absolutely. And that’s usually a scenario where they’ve tried the hormone therapy, they’ve done a dilation and curettage and they kind of just kind of have this persistent or recurrent hyperplasia. It’s still simple, but it just kind of lingers and it’s just not going away. And then yes, you can kind of throw in the towel at that point and say, “All right, we’ve tried conservative approach and you’re healthy enough to undergo a more major surgical operation, let’s then proceed with that.” 

 

Dr. Fox: And I think for a lot of women who might not realize is having a hysterectomy does not necessarily mean they’re gonna have a huge operation where if they stay in the hospital for three days and a two-month recovery, if the operation is done, a vaginal hysterectomy or a laparoscopic hysterectomy, these are typically in and out of the hospital within a day, right? 

 

Dr. David-West: Yes, absolutely. So, the beauty of minimally invasive surgery is, yes, some patients go home the same day or usually the next day, like a 23-hour stay in the hospital. But it’s a pretty quick recovery thereafter as well. 

 

Dr. Fox: Right. I mean, the times when you’d have to do a big incision to do a hysterectomy is really, if you think, they currently have advanced cancer, that’s the exception nowadays. Most people who have a simple, we call a simple “hysterectomy,” it’s either done vaginally or laparoscopically which both are what surgeons refer to as minimally invasive, although the people having the surgery don’t think it’s so minimal, but whatever, compared to the alternative. 

 

Dr. David-West: Yeah, exactly. Compared to maximally invasive, I guess. 

 

Dr. Fox: Yeah, that’s what someone once told me when I was a resident. The difference between invasive and minimally invasive surgery is minimally invasive surgery is what I’m doing to you and invasive is what anyone’s doing to me. 

 

Dr. David-West: Yeah. 

 

Dr. Fox: With all that in context, it is true that these operations are much less invasive and with a shorter recovery, easier recovery compared to sort of those, what we used to call a trans-abdominal hysterectomy, which is the big incision and the whole, that whole recovery. And so what about if someone gets back a diagnose, actually, of cancer? It’s usually what we call stage one, correct? 

 

Dr. David-West: Yeah, the staging is done once you have your final pathology, but clinically, you can stage them based on their exam. And so if ultrasound imaging or let’s say you do have an MRI or CAT scan shows, really, there’s no evidence of any thing that suggests cancer beyond the uterus, no enlarged lymph nodes, no other masses on the ovaries or beyond the pelvis in the abdomen. And all you’ve seen is this thickened lining and a biopsy that says endometrial cancer, you can safely say this is a clinical stage one and you take them to surgery, you’d get your final pathology and most likely, the final pathology will also correlate with a stage one disease. 

 

Dr. Fox: And then the treatment for stage one is what, just a hysterectomy? 

 

Dr. David-West: Right. For early-stage endometrial cancer, the recommended surgical intervention is hysterectomy, with removal of the tubes and ovaries, so I wanna just put in a plug for some kind of misnomers here. So when people hear “hysterectomy,” they automatically think it means taking everything out, the uterus, cervix, tubes and ovaries all equals hysterectomy. But really, hysterectomy, the term is just taking the uterus and cervix. You then have to clarify are the tubes and ovaries coming out as well. Standard surgery for endometrial cancer is that, yes, the uterus, cervix, tubes and ovaries are all coming out. 

 

Dr. Fox: For cancer but not for hyperplasia? 

 

Dr. David-West: For cancer. Not for hyperplasia. And I will say in some early-stage, stage one endometrial cancers in women who are premenopausal and let’s say you’re a 45-year-old or under, ovaries can be retained. We have some good data, good literature that supports maintaining the ovaries in those women because they reap so many benefits from those ovaries, there’s extremely low risk for recurrence to the ovaries or metastases to those ovaries once the uterus has been removed. So, can retain them in certain situations with cancer. Definitely can be retained in the hyperplasia cases. Menopausal women, postmenopausal women, the recommendation is that the ovaries and the tubes come out with the uterus, again, because those ovaries do not have that hormone function anymore as there’s really no benefit to having them in. 

 

Dr. Fox: And again, that’s just a decision in terms of sort of retaining them whether they have benefit from hormones or not. But in terms of the actual operation done, it doesn’t change the route that you would have to do it. I mean, having the tubes, are we staying or come out, no one would know in their postoperative phase which one it was. 

 

Dr. David-West: Yeah, exactly. And then in addition to the hysterectomy, with tubes and everything removed, there’s the lymph node, pelvic lymph node assessment. And currently for the early-stage, low-grade disease, we advocate for a sentinel lymph node biopsy, which is less morbid than the full lymph node dissection that used to be done in the past for these early-stage, low-grade endometrial cancers. 

 

Dr. Fox: And that’s just to verify that it has not spread beyond the uterus, really. 

 

Dr. David-West: Correct. Exactly. So you wanna have a sampling of the pelvic lymph nodes, because cancer spreads, this type of cancer, particularly, it spreads through the lymphatic system. And so assessing those lymph nodes then can confirm that it is stage one if those are negative, and that dictates the type of treatment they may or may not need after surgery. 

 

Dr. Fox: Right. And so if someone does have stage one, and they have the right operation, and it’s confirmed to be stage one, do they need anything afterwards like chemotherapy or radiation or anything? 

 

Dr. David-West: So this is where the pathologic factors come into play. So there is a variety of factors we look at on the final pathologic specimen that then determine the need for any treatment after surgery. Majority of patients will not need any radiation or any chemotherapy and the majority are gonna have a grade one or that low grade that is not invasive that has negative lymph nodes. They will be somebody who, surgery has cured them and they have an exceedingly low risk of any kind of recurrence. Once we see now, we start seeing a very deep invasion beyond that lining of the uterus, or we see higher grade lesions of that type of cancer, or let’s say now, lymph nodes are positive, those patients are gonna need additional therapies after surgery. 

 

Dr. Fox: Right. But those, again, those are the exception, the ones who have a higher stage or a higher grade or something that would require more treatment, that’s the exception. Are those usually people who are just sort of, like, unlucky, they came and they had their first sign of bleeding and they had the workup and they were at advanced stage or is it usually people who maybe had symptoms for a much longer time and didn’t realize it was a problem? 

 

Dr. David-West: It’s a combination of both, but I will say it’s primarily those that had symptoms for a longer time and just didn’t address them or didn’t think anything of it. And next thing they knew, it was something more than just the early stage. 

 

Dr. Fox: Right. So again, I think that one of the messages here about uterine cancer, endometrial cancer is even though it’s very common, it’s something that is typically noticeable, meaning if you’re postmenopausal, you would have bleeding. And if you’re premenopausal, everyone would know that your cycles are irregular, and there’s a risk for this, the evaluation is pretty straightforward. And then the treatment is, again, it is either hormones or an operation. But the operation tends to be low morbidity, pretty easy recovery, and a very high cure rate. And that’s the vast majority of people that we’re talking about here. 

 

Dr. David-West: Yes. Absolutely. Really, truly the vast majority. And that’s what we do see, and I can’t stress enough, that first sign of irregular bleeding in somebody who is premenopausal, and that one spot of blood in the postmenopausal, and really, there’s a wide differential for that postmenopausal woman with the one or two spots of blood. There’s many benign reasons, non-cancer reasons for that, but it prompts an evaluation, and it should be evaluated. And then you can be pleasantly surprised it’s benign and go on with your life, or you’ve now diagnosed an early endometrial cancer, and then you can get that taken care of and then move on with your life. 

 

Dr. Fox: Right. It’s so interesting, because it’s literally the mirror image of ovary cancer where in ovary cancer, it’s the exception or the surprise where you get to pick it up early and have that sort of simpler treatment and high cure rate and endometrial, it’s the surprise when you don’t pick it up early. And that’s why these are so, they’re so different from each other in that sense, even though they’re both gynecologic cancers, and that’s really just, because if you think about it, it’s just that women are sort of fortunate that they would have postmenopausal bleeding with this type of cancer that they have that sign, it’s early because there is no sign for that in ovary cancer. That’s really the difference. 

 

And then we mentioned just in the beginning that the other type of cancer of the uterus, which is the cancer of the actual wall of the uterus, the muscle uterus, the sarcoma. How is that different from endometrial cancer? 

 

Dr. David-West: It is much more rare. It grows from the muscle, like you’d mentioned, it’s farly more aggressive. In these scenarios, you may have a patient who has a history of, let’s say, fibroids. Fibroids, a lot of people know as benign growths of the uterus. But these can have a malignant potential. Anyone in 1,000, depending what you read, can transform to a sarcoma or to the malignant version of that muscular overgrowth of tissue. And so you may have somebody who kind of had these fibroids, you know, they now kind of went into menopause and still kind of had issues with them. Now they’re growing and causing discomfort, but maybe didn’t really think too much of it. And the next thing we know, there’s a workup done, a biopsy to confirm, now, the sarcoma that’s a more advanced, aggressive form of this cancer. That’s one scenario versus where these can come up de novo, meaning just spontaneously, again, overgrowth mutation within that muscular lining of the uterus, and we can see them at early stages. Because they’re so highly aggressive, they tend to metastasize and then are found at the more advanced stages. 

 

Dr. Fox: Right? I mean, sarcoma’s tough because the cancer itself is a more aggressive cancer, and sort of like ovary cancer, it’s harder to find until they’re big. That cancer, fortunately, is rare because the prognosis is much worse. 

 

Dr. David-West: It is exceedingly rare. We do see it from time to time and we have, of course, surgical intervention, radiation, chemotherapy, the prognosis is not as good as your endometrial variety. 

 

Dr. Fox: Got it. Wow. Gizelka, this was so helpful. Thank you for coming on and clarifying and explaining everything and the importance of recognizing potential symptoms of endometrial cancer and the fact that the prognosis, again, is typically really, really good with proper care and with proper follow up. 

 

Dr. David-West: Absolutely. Thank you so much for having me. I am a big advocate for patient education and promoting disseminating of knowledge to our general population because it’s just only gonna help people and help us take care of our patients if they’re well-educated. 

 

Dr. Fox: Yeah, and I’m gonna try to get every single person from your residency class onto this podcast. So, I got you, I’ve got…Melka has been on, like, 46 times, of course. 

 

Dr. David-West: I know. 

 

Dr. Fox: And Gylynthia was on, we had the whole crew. 

 

Dr. David-West: Yeah, definitely. This is wonderful. Thanks again. I really enjoyed it and I do hope that I shared some valuable information to the people listening. 

 

Dr. Fox: Thank you for listening to the “Healthful Woman Podcast.” To learn more about our podcast, please visit our website at www.healthfulwoman.com. That’s healthfulwoman.com. If you have any questions about this podcast or any other topic you would like us to address, please feel free to email us at hw@healthfulwoman.com. Have a great day. 

 

The information discussed in “Healthful Woman” is intended for educational uses only. It does not replace medical care from your physician. “Healthful Woman” is meant to expand your knowledge of women’s health and does not replace ongoing care from your regular physician or gynecologist. We encourage you to speak with your doctor about specific diagnoses and treatment options for an effective treatment plan.