The role of bariatric and metabolic surgery in the development, diagnosis, and treatment of endometrial cancer

Global trends in the management of cancer through obesity reduction: a bibliometric based systematic literature review

Background

The escalating prevalence of obesity poses increased risk for public health, including an increasing incidence of cancer. The association between obesity and cancer has become an area of increasing concern and investigation. Literature on the treatment of obesity leading to a reduction in the incidence of cancer and as an adjunct to cancer-directed therapy is beginning to emerge. We conducted a bibliometric analysis to study the current trends in published literature.

Objectives

The aims of the study were to explore the evolving landscape of obesity-related cancer management and identify the current areas of active research in the field.

Methods

We searched the SCOPUS database on December 11, 2023, to identify the content and patterns of the literature published on the subject of 'treatment of obesity to prevent or treat cancers' using keywords, '(obesity OR overweight OR 'Body Mass Index' OR 'body weight') AND (cancer OR neoplasm) AND (prevention OR 'bariatric surgery' OR 'weight loss' OR 'weight reduction')' in the title, abstract or the author-supplied keywords. After removing non-English and non-journal articles, a manual search was carried out to ensure relevance to the research question. The 'bibliometric package' version R 4.3.2 binaries for macOS 11 (Big Sur) and higher, signed and notarised packages, were used to extract data.

Results

Over the study period, a total of 724 documents were published, 624 were subjected to manual screening and 95 were identified for analysis. An increase in the number of articles was seen from 2017 onward. 'Bradford's law' was applied, and 5 core journals published 33/95 (34.7%) of all articles and received 1,808/4,399 citations (41.1%). The vast majority of articles, reported on the use of bariatric surgery for weight reduction as a method for cancer prevention and as an adjunct to cancer-directed treatment.

Conclusion

The treatment of obesity seems to be emerging as a strategy for the prevention and treatment of cancer. The field is relatively new, publications have begun to emerge in the last 10 years, and there is a growing interest in bariatric surgery as a method to prevent obesity-related cancers.

Outcomes of Metabolic and Bariatric Surgery in Populations with Obesity and Their Risk of Developing Colorectal Cancer: Where Do We Stand? An Umbrella Review on Behalf of TROGSS-The Robotic Global Surgical Society

Introduction: Obesity is a chronic disease associated with increased risk for several cancers, including colorectal cancer (CRC), a leading cause of cancer-related mortality. The majority of CRC cases are associated with modifiable risk factors. Metabolic and bariatric surgery (MBS) is a proven, durable, and successful intervention for obesity. This study aimed to evaluate the impact of MBS on CRC risk through measures of association, such as relative risk (RR) and odds ratio (OR). Methods: A systematic search of PubMed, Scopus, Web of Science, ScienceDirect, and Embase was conducted to identify systematic reviews (SR) and meta-analyses examining the relationship between obesity treated with MBS and CRC incidence. The PICO framework guided inclusion criteria, and three independent reviewers screened articles using Rayyan software. Quality assessment was performed using AMSTAR2. Results: Of 1336 screened articles, 10 SR met inclusion criteria, encompassing 53,452,658 patients. Meta-analyses consistently showed a significant reduction in CRC risk following MBS in patients with severe obesity. Risk reductions were reported by Liu et al. (RR: 0.46, 95% CI: 0.32-0.67, p < 0.01), Chierici et al. (RR: 0.46, 95% CI: 0.28-0.75, p = 0.018), Wilson et al. (RR: 0.69, 95% CI: 0.53-0.88, p = 0.003), and Pararas et al. (RR: 0.56, 95% CI: 0.40-0.80, p < 0.001). Sensitivity analyses supported these findings. For colon cancer, Liu and Chierici both reported an RR of 0.75 (95% CI: 0.46-1.21, p = 0.2444) with significant heterogeneity (I2 = 89%). A trend towards reduced rectal cancer risk (RR: 0.74, 95% CI: 0.40-1.39, p = 0.3523) was noted but limited by fewer studies. Sex-specific analyses revealed protective effects in both sexes, with a more pronounced impact in females (RR: 0.54, 95% CI: 0.37-0.79, p = 0.0014). Conclusions: This umbrella review synthesizes current evidence on the impact of MBS on CRC risk, highlighting a consistent protective association. The findings also indicate a potential risk reduction for both colon and rectal cancer, with a more pronounced effect observed among females compared to males. Given the profound implications of MBS on cancer incidence, morbidity, and mortality, further high-quality, long-term studies are essential to deepen our understanding and optimize its role in cancer prevention and patient care.

Laparoscopic bariatric surgery with hysterectomy for endometrial cancer to improve long-term outcomes: A review article

Endometrial cancer is the most common gynecologic malignant disease in Canada, and women with an elevated body mass index carry an increased lifetime risk of developing this disease. As rates of obesity have risen, the rates of endometrial cancer have seen a similar rise. Given this association, women diagnosed with endometrial cancer often suffer from several obesity-related co-morbidities, including type 2 diabetes, hypertension, and cardiovascular disease. Studies have suggested that women with early-stage endometrial cancer have a higher potential to die of obesity-related complications than recurrence and that weight reduction would be beneficial for these patients to improve quality-of-life and long-term obesity-related morbidity and mortality. Bariatric surgery is currently the only treatment modality to result in sustained long-term weight loss for this cohort of patients. Early evidence has suggested that combining bariatric surgery with total laparoscopic hysterectomy may improve the underlying metabolic disease, the patients' quality of life, and the long-term obesity-related morbidity and mortality. Additionally, the inclusion of bariatric surgery in treatment of patients with obesity and endometrial cancer may decrease the projected lifetime health care cost when compared to hysterectomy alone. This narrative review aims to examine the evidence surrounding endometrial cancer and its link to obesity. Further, we hope to explore current treatments for the aforementioned conditions and the possible benefits and feasibility of a combined intervention of vertical sleeve gastrectomy and total laparoscopic hysterectomy for patients with obesity and endometrial cancer.

Combined robotic surgery for concomitant treatment of endometrial cancer and obesity

BACKGROUND

Endometrial Cancer (EC) is strongly linked to obesity. Bariatric surgery is recognized as a long-term solution for weight loss in severely obese patients. This pilot study investigates the feasibility, intraoperative and 30-day morbidity outcomes of integrating gynecological surgical staging and bariatric robotic surgery in class II and III obese patients affected by early EC or Endometrial Intraepithelial Neoplasia (EIN).

METHODS

Patients aged over 18 years old with early EC or EIN and class II and III obesity (Body mass index (BMI) ≥ 35 kg/m2) who are surgical and anesthesiologic candidates. Standard robotic surgery for early EC staging performed alone (THBSO group) or in conjunction with sleeve gastrectomy (THBSO + SG group) for obesity management was proposed.

RESULTS

Of the 13 patients who met the inclusion criteria, 5 (38.46%) opted for combined surgery. The groups showed a significant difference in preoperative BMI (49.68 kg/m2 vs. 40.24 kg/m2 p = 0.017 with and without SG), preoperative weight (143.92 kg vs. 105.62 kg p = 0.004 with and without SG), preoperative (p = 0.01) and postoperative (p = 0.005) aspartate transaminase (AST). The THBSO + SG group had higher anesthesia induction end-tidal carbon dioxide (ETCO2) (p = 0.05), final Partial pressure of carbon dioxide (PaCO2) (p = 0.044), anesthesia induction lactate (p = 0.001) and final lactate (p = 0.011) without a significant difference in final pH (p = 0.31). Operative time was longer in the THBSO + SG group (p < 0.001), but this did not result in longer ICU (p = 0.351), total hospital stays (p = 0.208), nor increased blood loss and transfusion. The simultaneous combined approach had an 80% success rate. At 6 months, the THBSO + SG group achieved significantly greater weight loss than the THBSO group (ΔBMI - 11.81 kg/m2 vs - 1.72 kg/m2, p = 0.003, with and without SG).

CONCLUSION

Integrating robotic EC staging with SG in obese women with early EC increased the operative time without increasing intraoperative risks, early and 30 days post-surgery complication and offering a promising approach to simultaneously treating both conditions.

High prevalence of dysfunctional uterine bleeding in candidates for metabolic/bariatric surgery: increased endometrial cancer risk?

BACKGROUND

Endometrial cancer (EC) is the strongest obesity-associated malignancy and the fastest-growing cancer in young women. Early identification of EC and other endometrial pathology (malignant and nonmalignant) in women with severe obesity may improve treatment options and uterine preservation. Screening for endometrial pathology using abnormal or postmenopausal uterine bleeding (APUB) as a surrogate in women pursuing metabolic/bariatric surgery may be clinically beneficial, but data supporting this effort are limited.

OBJECTIVE

To develop and institute a screening program for APUB as a surrogate for endometrial pathology in bariatric surgery candidates.

SETTING

Two, academic metabolic/bariatric surgery programs in Louisiana, United States.

METHODS

The Modified SAMANTA is a 10-item questionnaire that was implemented to identify patients with APUB, specifically combining tools designed to identify anovulatory/postmenopausal and heavy menstrual bleeding. Demographic (age, race), body mass index, and questionnaire data were analyzed with respect to positive screening using data from March 2021 through May 2023.

RESULTS

Of 1371 eligible women presenting for surgical evaluation, 664 (48.4%) positive screens were identified and referred for gynecologic evaluation to rule out endometrial hyperplasia/cancer or other endometrial pathology. The likelihood of positive screening for APUB was associated with increasing BMI (P = .001) and Black/African American race (P = .003), as well as increasing SAMANTA score (P < .001). In contrast, risk of positive screening was negatively associated with increasing age (P < .001).

CONCLUSIONS

Women presenting for metabolic/bariatric surgery have a high prevalence of APUB and, given this dysfunctional bleeding and concurrent obesity, are at greater risk for underlying EC. Potential risk factors for APUB, given their associations with screening positive, include increased body mass index, younger age, and Black/African American race. Standardized screening with appropriate gynecologic referral should be a routine part of the overall evaluation for women with severe obesity.

Uterine-Conserving Treatment Options for Atypical Endometrial Hyperplasia and Early Endometrial Cancer

PURPOSE OF REVIEW

This review aims to synthesize available literature on uterine-conserving treatment options for atypical endometrial hyperplasia and grade 1 endometrial carcinoma while highlighting remaining unanswered questions.

RECENT FINDINGS

The need for uterine-conserving treatment options for atypical endometrial hyperplasia and grade 1 endometrial carcinoma is growing with the increasing number of cases in younger patients or those who cannot undergo surgery. We reviewed the oncological and reproductive outcomes associated with endocrine therapies used for atypical endometrial hyperplasia and grade 1 endometrial carcinoma. The rising prevalence of delayed childbearing, obesity, and diabetes in reproductive-age individuals and of medical comorbidities associated with high surgical risk continues to amplify the demand for uterine-conserving therapies. Appropriate patient selection for such therapies is imperative to maximize likelihood of treatment response. The ideal candidates are patients with atypical endometrial hyperplasia or early-stage, low-grade endometrial cancer with no evidence of myometrial invasion or extrauterine disease. The most accepted conservative therapeutic approach is hormonal therapy with close surveillance, with or without eventual hysterectomy following childbearing or failure of treatment. Further prospective and randomized trials are needed to address optimal patient and treatment selection, as well as the use of molecular profiling for treatment individualization and prognostication.

Metabolic Syndrome and Survival Outcomes in Endometrial Cancer

Menopause, through attributable estrogen level decline and the corresponding increase in circulating androgens, significantly elevates a woman's risk for cardiometabolic diseases, including metabolic syndrome (MetS), type 2 diabetes, and cardiovascular disease. Metabolic syndrome itself is a cluster of interconnected risk factors, and among them, central obesity is a well-established factor for the development of endometrial cancer (EC), the most common gynecologic malignancy. This research investigates the impact of metabolic syndrome on survival rates among patients with endometrial cancer. The goal is to assess whether having metabolic syndrome or its individual components influences disease-free survival (DFS), overall survival (OS), cancer-specific survival, and recurrence rates. Understanding this link is crucial for determining risk levels and could help tailor treatment approaches for better long-term outcomes in endometrial cancer care.

Hysteroscopy and weight loss in treatment of endometrial cancer: case report and literature review

Fertility-sparing treatments have become important for young women with atypical endometrial hyperplasia (AEH) or endometrial carcinoma (EC) who wish to preserve their reproductive potential. Evidence indicates a strong relationship between weight and EC and the effect of weight loss on reducing the risk of EC. We report the case of a young obese woman with a body mass index (BMI) of 46.6 kg/m2, diagnosed with grade 2 endometrial endometrioid adenocarcinoma, who underwent a combined fertility-sparing treatment with hysteroscopic resection followed by insertion of a levonorgestrel intrauterine system. After twelve months of failure to achieve a complete response, bariatric surgery was proposed to lose weight and improve the response to treatment. Histologic regression was achieved three months after surgery, with a weight loss of 30 kg and fifteen months after combined treatment of endometrial cancer. We reviewed the literature to summarize the evidence on the role of bariatric surgery and weight loss in modifying the oncologic and reproductive outcomes of women undergoing fertility-sparing treatment for atypical endometrial lesions.

Effect of bariatric surgery on endometrial cancer regression as part of fertility sparing treatment

INTRODUCTION

Obesity is a major risk factor in the development of endometrial cancer (EC) in young patients of reproductive age. Fertility sparing treatment is a viable option for a select group of patients with early EC, and involves systemic and intra-uterine hormonal therapy. Weight loss has been associated with improved outcomes in this group. Bariatric surgery (BS) has been shown to be the most efficient and durable method of weight loss in obese patients. However, there is a paucity of data studying the benefit of BS as part of fertility sparing treatment.

METHODS

We present a retrospective case series of five patients who are undergoing fertility sparing treatment for early EC, who also underwent BS for treatment of obesity and related comorbidities. We aim to show early regression of EC for all the patients and also report on the other health benefits of BS.

RESULTS

All five patients in the series achieved regression of EC within 6 months of undergoing BS. They also achieved significant weight loss consistent with previous studies, and three patients who had comorbidities related to obesity had remission of these conditions. One of the patients with EC regression also managed to conceive with IVF (In-vitro Fertilisation).

CONCLUSION

Patients on fertility sparing treatment for early EC who underwent BS was associated with early regression within 6 months, significant weight loss and resolution of comorbidities. BS could be a promising component of fertility sparing treatment. Long term, prospective studies are required to confirm the benefits reported in this case series.

Gynecologic counseling for patients undergoing bariatric surgery: a scoping review

PURPOSE OF REVIEW

Obesity is associated with several gynecologic conditions. While bariatric surgery is regarded as the most effective treatment option for obesity, gynecologic counseling for patients planning bariatric surgery is limited and often focused on fertility. The goal of this scoping review is to investigate the current recommendations for gynecologic counseling prior to bariatric surgery.

RECENT FINDINGS

A comprehensive search was conducted to find peer reviewed studies written in English discussing a gynecologic issue of patients who were planning or previously had bariatric surgery. All the included studies identified a gap in preoperative gynecologic counseling. The majority of the articles made specific recommendations for a multidisciplinary approach to preoperative gynecologic counseling with a call to involve gynecologists or primary care providers.

SUMMARY

Patients deserve to receive appropriate counseling about how obesity and bariatric surgery impact their overall gynecologic health. We advocate that the scope of gynecologic counseling includes more than pregnancy and contraception counseling. We propose a gynecologic counseling checklist for female patients undergoing bariatric surgery. Offering patients a referral to a gynecologist from the patient's first entry to a bariatric clinic is imperative to facilitate appropriate counseling.

Immunometabolism at the crossroads of obesity and cancer-a Keystone Symposia report

Immunometabolism considers the relationship between metabolism and immunity. Typically, researchers focus on either the metabolic pathways within immune cells that affect their function or the impact of immune cells on systemic metabolism. A more holistic approach that considers both these viewpoints is needed. On September 5-8, 2022, experts in the field of immunometabolism met for the Keystone symposium "Immunometabolism at the Crossroads of Obesity and Cancer" to present recent research across the field of immunometabolism, with the setting of obesity and cancer as an ideal example of the complex interplay between metabolism, immunity, and cancer. Speakers highlighted new insights on the metabolic links between tumor cells and immune cells, with a focus on leveraging unique metabolic vulnerabilities of different cell types in the tumor microenvironment as therapeutic targets and demonstrated the effects of diet, the microbiome, and obesity on immune system function and cancer pathogenesis and therapy. Finally, speakers presented new technologies to interrogate the immune system and uncover novel metabolic pathways important for immunity.

Endometrial Cancer in Reproductive Age: Fertility-Sparing Approach and Reproductive Outcomes

Endometrial cancer is the most common gynecologic malignancy in developed countries and approximately 7% of the women with endometrial cancer are below the age of 45. Management of endometrial cancer in young women who desire to maintain fertility presents a unique set of challenges since the standard surgical treatment based on hysterectomy and salpingo-oophorectomy is often not compatible with the patient's goals. A fertility-preserving approach can be considered in selected patients with early stage and low-grade endometrial cancer. An increasing amount of data suggest that oncologic outcomes are not compromised if a conservative approach is utilized with close monitoring until childbearing is completed. If a fertility-preserving approach is not possible, assisted reproductive technologies can assist patients in achieving their fertility goals.