Seeking early medical attention after vaginal bleeding will not assure mild disease in postmenopausal endometrial carcinoma

Reasons for diagnostic delay in gynecological malignancies

INTRODUCTION

To describe the different delay types in women with gynecological cancer and to analyze the relationship between diagnostic delay and a number of characteristics for patients, cancers, and the health care system.

METHOD

Data were obtained from 4 different questionnaires, the Electronic Patient Journal (EPJ), and the Danish Gynecological Cancer Database (DGCD). A total of 161 women with ovarian cancer (63), endometrial cancer (50), cervical cancer (34), and vulvar cancer (14) were included. Outcome measures were different delay types counted in days and 4 clinically important variables' impact on the diagnostic delay: presence of alarm symptoms, age (divided into 2 groups: ≤60 or >60 years), performance of gynecological examination by the general practitioner (GP), and notification of cancer suspicion on first referral from GP.

RESULTS

Across cancer types, median total delay was 101 days. Some 10% of women experienced the longest delay with a total delay of 436 days or more. Vulva cancer had the longest delay, whereas women with ovarian cancer had the shortest delay. More than one third (39%) of the women consulted their GP for reasons other than the predefined alarm symptoms. Gynecological examination by the GP was less likely to be performed if the woman did not present with vaginal bleeding. The length of the delay was shortened by performance of a gynecological examination by the GP and a primary referral from the GP raising the receiver's suspicion of cancer.

CONCLUSION

Reducing diagnostic delays should be achievable, particularly for those most delayed, and interventions aimed at reducing delays need to be developed. Creation of new valid instruments for measuring delay is essential in future research.

Endometrial endometrioid carcinoma: a glimpse at the natural course

OBJECTIVE

This study was undertaken to assess the natural course of endometrial endometrioid carcinoma by identifying untreated patients and those with a prolonged (>6 months) treatment delay.

STUDY DESIGN

A chart review of 252 patients with histologically confirmed endometrial endometrioid carcinoma was conducted and clinical data of untreated patients and those with a prolonged treatment delay were abstracted.

RESULTS

Seven patients (3 untreated and 4 with prolonged treatment delay) were identified. Five had clinical stage I and 5 had well-differentiated tumors. The survival of the untreated patients ranged from 5 to 59 months. Of the patients with prolonged treatment delay, 2 died more than 5 years after diagnosis and 2 are alive more than 5 years after diagnosis.

CONCLUSION

The lengthy survival of our patients seems to indicate that the natural progression course, even in untreated patients, may be very slow in endometrial endometrioid carcinoma with favorable prognostic factors.

Ultrasonographic detection of asymptomatic endometrial cancer in postmenopausal patients offers no prognostic advantage over symptomatic disease discovered by uterine bleeding

The aim of this study was to investigate whether endometrial carcinoma (EC) screening by transvaginal sonography (TVS) has a prognostic advantage over symptomatic EC. In a retrospective study, 190 postmenopausal patients with symptomatic EC and 123 asymptomatic patients with suspicious endometrium detected by TVS were analysed regarding clinical, socio-economic and histopathological findings. Total bleeding time and the International Federation of Gynecology and Obstetrics (FIGO) tumour stage were evaluated with respect to their effect on survival. In 123 asymptomatic patients with suspicious endometrium, 16 (13%) EC, 61 (50%) polyps, 21 (17%) hyperplasias, 23 (19%) atrophias, 1 (0.8%) myoma and 1 (0.8%) metastasis were found. TVS findings in asymptomatic patients resulted in unnecessary operations, which were associated with considerable costs totalling at least 116256. Compared with screened asymptomatic patients, symptomatic patients were significantly (P<0.05) older, more frequently obese, and hypertensive, had a larger proportion of cases living in rural areas and visited their gynaecologists rarely. The bleeding time of symptomatic patients strongly correlated with the tumour stage (P<0.0001). Depending on the bleeding time, the 5-year disease-free survival and overall survival rates were 77% and 86% (no bleeding), 83% and 98% (<8 weeks), 74% and 90% (8-16 weeks), and 62% and 69% (>16 weeks), respectively. The corresponding tumour stage-related data for disease-free and overall survival were 100% (Ia; both rates), 87% and 95% (Ib), 66% and 93% (Ic), 63% and 78% (II) and 36% (III/IV; both rates), respectively. Postmenopausal vaginal bleeding represents an early symptom of EC, but it is not always perceived as problematic by the patients. There is no prognostic advantage for screened compared with symptomatic patients, who had bleeding of shorter than 8 weeks. Moreover, patients who are at a high risk for EC tend to avoid TVS screening. Finally, endometrial screening often results in unnecessary operations, which are associated with increased morbidity and costs.

Diagnosis and treatment delay in gynecological malignancies. Does it affect outcome?

Delay of diagnosis and treatment of malignant tumors is perceived as unfavorably affecting outcome. However, tumor behavior may be determined early in the histogenesis process and the outcome may be more a function of the biologic properties of the tumor than of our ability to make an early diagnosis. The objective of the present review is to evaluate data concerning the effect of diagnosis and treatment delay on outcome in gynecological malignancies. A medline search including the terms diagnosis delay, treatment delay, outcome, vulvar carcinoma, cervical carcinoma, endometrial carcinoma and ovarian carcinoma was conducted and all pertinent articles in the English language were included. Relatively few investigations deal with the effect of diagnosis and treatment delay on prognostic factors and on outcome in invasive gynecological malignancies. The reviewed data do not seem to indicate an unequivocal deleterious effect of a delay of several weeks or even several months in patients with some gynecological malignancies. Intentional delay of diagnosis or treatment of gynecologic malignancies is unjustified; however, the data presented should encourage a closer scrutiny and possibly a revision of the concept of "early" diagnosis and of the notion that delay of any duration has a definite, unfavorable effect on outcome.

Endometrial adenocarcinoma--lack of correlation between treatment delay and tumor stage

OBJECTIVE

The objective was to examine why a proportion of patients with endometrioid adenocarcinoma (EMC) presents with advanced stage disease and whether the duration of bleeding prior to hysterectomy (treatment delay) is predictive of stage.

STUDY DESIGN

A retrospective clinicopathologic study of 182 patients treated for EMC at Columbia-Presbyterian Medical Center in New York City between 1988 and 1996 was performed.

RESULTS

Ninety percent of patients with EMC presented with abnormal uterine bleeding. The median time interval from onset of bleeding to biopsy diagnosis was 2.5 months (range, 2 weeks to 60 months) and 3 weeks from biopsy to hysterectomy. No correlation between the duration of symptoms and tumor stage was found (P = 0.87). There was, however, significant correlation between poor tumor differentiation and the advanced stage of the disease (P = 0.0001).

CONCLUSIONS

Stage at presentation in patients with EMC correlates with tumor differentiation but not with time interval from bleeding to definitive therapy.

The effect of diagnosis and treatment delay on prognostic factors and survival in endometrial carcinoma

OBJECTIVE

The aim of this study was to assess the association of diagnosis and treatment delay with established prognostic factors and survival.

STUDY DESIGN

The study group comprised 181 consecutive patients with endometrial carcinoma diagnosed between 1970 and 1986, whose records contained details with regard to diagnosis delay; 174 of them also contained details with regard to treatment delay.

RESULTS

The significant prognostic factors that we found, namely, age, clinical stage, grade, depth of myometrial invasion, and histologic type, are in line with those of other studies. However, no significant correlation was found between the duration of delay and these prognostic factors or with survival.

CONCLUSION

We conclude that delay of diagnosis (< 1 year) and of treatment of < 4 months do not compromise survival of patients with endometrial cancer.