referral association

hello, i'm helen zorbas. it's my pleasure to welcome youto the second program on gynaecological cancer, produced by cancer australia andthe rural health education foundation. we're delightedto have health professionals from rural and remote areas of australia joining us for this programon endometrial cancer. endometrial cancer is the most commoninvasive gynaecological cancer in australia,and its incidence is increasing.

each year,about 1,700 women are diagnosed, about a third of whomlive outside a metropolitan area. as rural health professionals,you have a vital role to play in the early detectionof endometrial cancer and the investigations that canlead to timely referral and diagnosis. we hope that through this broadcast,you gain a better understanding of those women who are at greater riskof developing endometrial cancer, as well as the importance of appropriateinvestigation of symptoms and referral for treatment.

thanks to helen zorbas.hello, i'm norman swan. welcome to this programon endometrial cancer. it's a programwhich is a joint initiative of the rural healtheducation foundation and the national centrefor gynaecological cancers, which is part of cancer australia. this is the second program in our serieson gynaecological cancer. endometrial cancer is the most commongynaecological cancer. it's on the rise in australiadue to an ageing population,

and increase in prevalence of obesityand diabetes in women. tonight we'll discuss risk factors,signs and symptoms, appropriate investigations,who should you refer to, all of which influence whether or notyou make a timely diagnosis and get your patient into treatment. you'll find a number of useful resourcesavailable for you on the rural health educationfoundation's website: and also on cancer australia's website: let's meet our panel.

jenny may is a rural generalpractitioner working in tamworth. - welcome, jenny.- thanks, norman. jenny is employed by the universitydepartment of rural health in tamworth and is a rural gp academic. jenny has a strong interest in makingsure rural people get the same standard of healthcare as thoseliving in the cities. pieter mourik is an obstetricianand gynaecologist working in albury wodonga. - welcome, pieter.- thanks, norman. good evening.

pieter has been working in that areasince 1979. he also travels widely workingas a gynaecologist throughout australia and teaches women's healthto medical students at the rural clinical schoolof the university of new south wales. kath nattress is a cancer-nursecoordinator for gynaecological cancer at the sydney cancer centre. - welcome, kath.- thanks. kath is also a clinical senior lecturerat the university of sydney, and her research interests focus onthe impact of disease and treatment

on women with gynaecological cancer. michael quinn is professor in thedepartment of obstetrics and gynaecology at the university of melbourne and is a consultantfor the oncology/dysplasia unit at the royal women's hospitalin melbourne. - welcome, michael.- good evening, norman. michael is also a memberof the advisory group of the national centrefor gynaecological cancer. i will do simultaneous translationfor kath and michael,

who speak the same language i do,but not necessarily where you do. jenny may is actually the onlyaustralian-born australian on the team, so have pity on her. welcome to you all. what i thought we'd do tonightis show you a video we've made in pieter mourik's hometown of wodonga about marjorie,who developed endometrial cancer. it creates a focus on the womanwho experiences endometrial cancer. i went to my gp for a routine pap smear.

i'd had no signs or symptomsor any worries at all. the pathology report of the pap smearcame back that there were someendometrial changes, probably benign. i can remember very clearly my gp saying that he was not happy withthe 'probably benign.' he didn't want to put it offfor 6 or 12 months. he referred me to a gynaecologistin wodonga, where i had an ultrasound, which showed some thickeningof the lining of the uterus.

he recommended i have a curette. the pathology report from the curettewas that there was endometrial cancer. living in albury, wodonga, i had to go to a cancer specialistin melbourne for treatment. that is quite overwhelming. when you leave the security of your homeand family and friends to go to an unknown place,you have to organise your home base so that it will workwhilst you're not there. because of some complicationswith surgery,

i was down in melbournefor about six, seven weeks. that caused another considerable stressfor my partner. even though i am well pasthaving babies, the fact that i had a hysterectomy and all of those parts that make mea woman have been removed, there is a sense of loss, same asa woman who has her breasts removed. there's an enormous sense of loss because it's part of your femininityand part of your womanhood. that's something thatyou have to think about

and come to terms with. having had the experience of cancer,it has made me very much more aware of my body and my health. i make sure thati keep up regular appointments with my specialistand general practitioner. - hello.- hi. i'm here to see dr mourik, please. if i find there is something worrying meabout the endometrial cancer, being able to go to my specialistand discuss the concern with him, i find that's very reassuring for me.

good to see you again, pieter. how have you beenin the last six months? - i've been very well indeed.- wonderful. it's two-and-a-half years since you wentto melbourne for the operation for endometrial cancer, is that correct? yes. my trip to melbourne wasa very big event in my life, a very dislocating one and a very scary timefor me and my family. you're very fortunatecompared to a lot of country women

in that we are ableto do your follow-ups. that can be quite an arduous round tripof 600km. to leave your hometo go to the city for treatment, you have to ask for helpfrom your family or friends, perhaps at your gp'sor specialist's rooms or your council. go to those places and ask for help. pieter: you've had a wonderful resultfrom the histology. the tumour was very early because you presentedbefore you had any symptoms.

that means the prognosis, the chance of having any tumourcome back is exceptionally small, probably 1% or 2% in your case. but we still have to do the follow-upslike you're doing today. it's important to keep an eye on you. at the end of our interview today,i'll do a letter and i'll send a copyto the melbourne oncologist, so that he can keep tabs on you as well. marj: i've often wonderedwhether a specialist or a gp

would benefit froma patient's personal experience. i've often thought, could i ask that practitioner to putthemselves in my shoes for a moment to understand that that patientreally needs a lot of reassurance after your treatment. you can be very anxious. every pain and ache can bethe worst possible diagnosis. marjorie,i've got really good news for you. the examination was perfectly clear.

i will have a result of the pap smearin a week's time. marj: with the encouragementof my gynaecologist here and the general practitioner, they reassured me and gave me as muchinformation as i wanted to know. that was very helpful to me, and helped me to get the diagnosisof cancer into perspective. i was very happy about thatcommunication i was able to have with both of those doctors. pieter: i'll see youin six months' time.

marjorie's story, from wodonga. she's a lucky woman who had a good gpwho picked it up on the pap smear. a very good gp. she just had a routine pap smearand the abnormalities were picked up and they were equivocal. he wasn't too sure. he said to her,'i don't do i'm not sure. i'll send you to the local specialist.' a typical story for womenin that ambivalent situation

of stay at home, get referred tothe major centre, jenny? often the story. people often like to stay local, or like to know a lot aboutwhere they're going. and kath, that typical story of people not expecting herto still be a sexual person even at 72. definitely. she comments on that. even having a hysterectomy at that age still has associations for many womenof femininity and sexuality.

how often do we address it as we should? did she talk to you about that, pieter? she has talked to me about that. i've known marjorie for 30 years,which is a lifetime, really. we have discussed that. boundary issues when you've knownsomebody that long are hard. yes. i was just reflecting on thatas pieter said it. sometimes it's easier to talk to someonewho's actually a bit more anonymous about some of those things as well.

to what extent, kath,in your experience in new south wales, does the multidisciplinary team carethat you get in the major centre translate back to the country town? because obviously somebody like marjoriecontinues to need it in some form. there are very good linksthat we should be making, particularly with the gp, when a womangoes back to a country town. within the new south wales, we haveregional cancer-nurse coordinators who are cancer-generic,not cancer-specific. so if a woman is going back, say,to dubbo,

i would speak tothe cancer-nurse coordinator there and we will liaise between us. she may well call me on more specificgynaecological cancer-related things. when that woman is home,you're still on the end of a telephone. a great deal of things can be doneover the phone. it doesn't actually need to beface-to-face. just becauseshe's however many miles away doesn't meanshe's not getting that support. the commonest gynaecological cancer?that surprised me.

by far. much more than any other cancer. we've got almost 2,000coming up in australia annually. ovary cancer is about 1,400, and cervix cancer,we're now less than 700. this is three timesas common as cervix cancer, but most women are more preoccupied withhaving pap smears than worrying about the risk factorsfor endometrial cancer. what are the risk factors? over and above everything else,it's estrogen-related.

obesity is the number-one factor. that's why we have a worldwide epidemic of this disease. about 30,000 american women every year get cancer of the endometrium and about 6,500 of those women are going to die. it's a very common cancer. it's a cancer that will unfortunately

kill about 25% - 30% of those women. it's a real issue in australia as our population is getting more obese, as diabetes is getting more prevalent,and as our population is ageing. it's a big relative risk for obesity? it's enormous. it's the single most important thingthat contributes. norman: and that's estrogen? it's the same asbeing on unopposed estrogen,

and of course, we don't giveunopposed estrogen anymore. diabetes, is that insulin growth factor? you're absolutely right. it's an insulin-related phenomenondue to aberrant growth factors within probably the ovary, causing stromal hyperplasiaand estrogen production, even in the postmenopausal ovary. we've got a web question from marissapillar, who's from north queensland acknowledging that this type of canceris on the increase

due to us getting fatterand more diabetes. the question is, should we beroutinely screening, in some sense, for endometrial cancer,particularly amongst indigenous women? it's a terrific question. the answer is no, we don't have a screening test availablefor endometrial cancer. ultrasound has been shownnot to be cost-effective in reducing the death ratefrom this cancer. there's no blood test available.

currently we have nothingthat we can recommend for screening. the only situationwhere it might be of value would be in the very high-risk patient. that would be a womanwho carries a genetic mutation for what's calleda mismatch repair gene. these are womenwho have hereditary bowel cancer. norman: this is lynch families. they've got 50% chance of bowel cancer,50% chance of endometrial cancer. we currently recommend that those womenshould have at least an ultrasound,

perhaps an endometrial sample doneevery year to see what's going on at uterine level. but there's no evidence to showthat reduces a woman's risk of dying. you're talking abouttransvaginal ultrasound. there are different types,type 1 and type 2, and they've got different prognoses. we now know thatthe estrogen-driven cancers are, if you like, the good cancers. about 80% of all endometrial cancers

fall into this group. if a woman has this estrogen-driven cancer, she's got about a 90% chance she's going to be cured of her cancer. in comparison is the type-2 cancer. it's much more aggressive. it's usually a grade 3 or a serious tumour.

they're non-estrogen-driven. the woman doesn't have risk factors that she would have for the type-1 cancer. these women have about a 50% - 60% risk of dying from the disease, so it's a very bad cancer to get. norman: and the risk factors for type 2? michael: none that we know of.

we can't target high-risk population, unfortunately, to try and reduce the death rate. how similar is it to breast cancer?a lot of risk factors are the same. certainly for type-1 cancer, we knowobesity is one of the risk factors for breast canceras it is for endometrial cancer. interestingly, obesity has been shownin a very big australian study to be a risk factor for mucinous cancerof the ovary. so obesity, no matter which wayyou look at it in general practice,

it's the number-one disease of our time. does treatment change according to type? if you pick up histologythat it's type-2, do you go for things more aggressively? type-1 cancers tend to bethe well-differentiated cancers. they're the type that are less likelyto spread in comparison to the type 2s. they're more likely to go to the cervix,the tubes and ovaries, the lymph nodes or the omentum. those are the ones we concentrate on.

we spend more time staging the cancer,if you like, as opposed to the type 1. how much of a risk is tamoxifen?there are a lot of women on tamoxifen. a lot of family doctors ask methis question - should we be screening womenon tamoxifen? the answer is no. the recommendation is that the riskwould be about twice that of the general population risk. when you look at obesity as a riskfactor, it's up to nine or ten times.

so obesity really isthe number-one thing. the way i explain it to women is, your risk of getting endometrial canceron tamoxifen is the same as gettingan increased risk of breast cancer having one or two alcoholic drinksa day. that's what it amounts to. - the pill is a protective factor.- terrific. the pill is a great drug for stoppingcancer and lots of other things too. the pill does reduce the riskof endometrial cancer - anything up to 50%for ten continuous years of use,

and of course it reduces the riskof ovarian cancer as well. the pill is very goodfor the female genital-tract cancers. presenting features -jenny, what do you know as a gp about the presenting features?what raises the alarm bells for you? the most common presenting featurefrom my point of view is bleeding. bloody vaginal discharge is the normalway we think about it presenting, certainly in postmenopausal women, and an abnormal bleeding patternin perimenopausal women. a bleeding pattern that doesn't fitwith their hrt usage,

for instance if they're using itperimenopausally, or prolonged or persistent bleedingthat doesn't follow a pattern that you could identify. we'll come back to presenting featuresin a moment. alan from finley medical practice asks, 'why does marjorie go to melbournefor an oncologist? was there a special reason? were the albury wodonga oncologistsnot appropriate? i'm 150km away from albury

and my endometrial cancer patientsare followed up at wodonga. pieter? she wasn't my patient. my colleague referred her to melbournefor his own reasons. but he suspected that it might betechnically quite difficult because she was plump,is the polite word, and it can be a challenging operationwhen you have limited resources. but with the aidof the retrospectoscope, she may have been betterto have been managed locally

because she had a superficial lesion, no penetration at all, and she hada horrendous post-op complication. of course, in the country,we wouldn't expect to see that. absolutely. no complications everfrom surgeons in the country. but you might not know thatbefore you go in, that she has a nice superficial lesion. no. the most difficult part isto know what you're dealing with. except if you've gota well-differentiated type-1 tumour in someone who is asymptomatic,

you can suspect thatthey're not going to be grossly invaded. from your point of view,what's the most difficult thing that gps often talk to you about,pieter, in terms of wondering whether or notthis is a woman with endometrial cancer? probably the most difficult thing,as everyone knows, is the shortage of gynaecologistsin rural areas. they're fully booked, and can be booked for three or fourmonths for routine appointments. i would like gps to be aware

that this is a problemthat needs a phone call and a personal communicationwith the specialist, not just to say to the lady,'you need to see a specialist.' because when she rings up, she might betold by the lady on the desk, who has no idea of the significanceof postmenopausal bleeding, that she has a six-month appointment. i think that's unacceptable. what about symptoms? what gives you the most heartburn?

as i said, vaginal bleeding isthe symptom par excellence that i've got my sonar out for. it's relatively easyin postmenopausal women, but if she's not through the menopauseand you're not sure, that's difficult. very difficult. and if she is,as many women are, on hrt, it often makes the decisioneven more difficult, because you're trying to work out,is this a progesterone-withdrawal bleed, as you would expect,or is it something else? michael, what about other things?bleeding is the hallmark.

do you often find endometrial cancerwith no symptoms at all? very rarely. this woman has beenextraordinarily lucky. getting endometrial cancer picked upin a smear test is most unusual. it accounts for less than 1%of the total patient load that we carry. as pieter says, that's going to be a very early cancerunder those circumstances before it's even caused bleeding. she's been very fortunate.

unusual. in ovarian cancer, we're not sure early detectionmakes a difference to the outcome. do we know thatwith endometrial cancer? we don't have that information either. norman: it's an act of faith?- it is. the thing about it is, as jenny says,that it's the bleeding. bleeding is that trigger. it's a lovely symptom to follow.

as soon as a woman who's postmenopausalgets bleeding, she usually goes to her family doctor. she plucks up courageand recognises that this is abnormal. norman: what about overlap of symptomsof ovarian cancer with abdominal symptoms? very few. certainly in my experience,most women with endometrial cancer present with either irregular bleedingif they're premenopausal - and remember, 25% of these patientsare going to be premenopausal -

or postmenopausal bleedingor as you say, jenny, a watery vaginal discharge that isblood-stained. that's not uncommon. norman: so, premenopausal. that would be inspiring fearin the hearts of gps watching. absolutely. it's a tough one. when we looked at the data, a third of those womenwith premenopausal endometrial cancer presented with heavy periods. it's such a common symptomin general practice.

most general practitionersexamine a woman and say, 'i'll put you on the pill.that will sort it.' - mirena.- that will sort it out for you. it raises that spectre of,am i undertreating this patient? but probably not. premenopausal women,more often than not, will have the irregular bleeding,as you say quite rightly. it's not the infrequent bleeding,it's the more frequent bleeding. that raises alarm bells.

- a pattern of increasing intensity?jenny: yes. you do the same investigations. if she's got irregular bleeding, it's exactly the same as if she hadpostmenopausal bleeding. a question from deena casefrom queensland. 'is there an association between endometrial polypsand endometrial cancer? if an asymptomatic postmenopausal womanhas a visible polyp of the cervix, should she have a vaginal ultrasoundto measure endometrial thickness?'

no. norman: so this is a cervical polyp? there's no link between ectocervicalpolyps and endometrial polyps. norman: there is betweenendometrial polyps and cancer. yes.so, if you have an endometrial polyp and this is picked up as an incidental and you're being screenedfor some other situation, the risk of that being malignant is 1%. it's very low, but it's there.

we're jumping ahead,but i'll ask the question - albert vermeulen from northwest healthasks, 'premenopausal women with symptomsand endometrial hyperplasia - would you prescribe hrt if she insists,and how would you follow up?' - one of your hobbyhorses.- it is. the management of hyperplasiain australia is not handled well. it's becausewe've changed the terminology. our brother and sister pathologists haveintroduced the term complex hyperplasia. as soon as complex has comeonto the scene, people have panicked.

but they don't need to panic. the most important thingin hyperplasia is whether there are atypical cells thereor not. if you have just complex hyperplasia, the chances of you, in the nextten years, getting a malignancy is 1%. whereas if you've gotatypical hyperplasia, you've got a 20% - 40% of already havingan underlying cancer. that's the most important thing. if it's simple hyperplasia,another great indication for a mirena.

jenny? norman: for an iud?- absolutely. a progesterone-lined iud, yeah. let's go to our next case study, who's mary,a postmenopausal woman of 54. she comes to you, jenny, complainingof blood-stained vaginal discharge. she's got a bmi of 33, a sedentary job. she's got type-2 diabetesand is on metformin. she's married with no children.

- your patient.jenny: thanks, norman. the first thing in general practice isa good history. that's the way i would start. i'd want to know particularlyabout that bleeding - when did it occur?was it related to intercourse? was it somethingshe'd noticed regularly? was there any pattern to it? also what we were mentioning,other symptoms - did she have any pain on intercourseor is there any abdominal pain?

and when was she menopausal? is this bleeding that could be relatedto her perimenopause or is this bleeding that has comea significant time after menopause? she tells you she's been spotting a bit. she's never really been free of bleedingthrough the menopause, but not had a regular periodfor quite some time. well, that doesn't help us much. one of things we need to inquire intois medications, at this point. has she been started on any hrt,either cyclical or continuous?

also, has she been availing herself ofany other estrogens? i'm thinking here, natural estrogens. a number of my patients havesourced natural estrogens thinking that they had no impact onestrogenization at all in the way i think about it. and in fact, that has been a problem. michael,that's something you're seeing also, that bioidentical estrogensare not considered by the patient as estrogen or medication.

but from the point of viewof their being unopposed estrogen, there's a big issue.norman: they're just as potent. it's not just the patient. the complimentary-health practitionerwho's prescribing it actually believes thatthey don't have the same potency. part of the problem is,we don't know what the potency is. these are unregulated, so we don't knowwhat the real concentration and what the real contentof these medications are. but they certainly can causean increased risk of endometrial cancer.

we've seen many cases. norman: you're taking the history.what else? i need to know about her family history. we've heard already that lynch familiesare at high risk, so i need to know about that. i also need to know a little bit abouther menopause and her menarche. and did she have no children by choice, or was it thatshe couldn't have children? in that case, had she had pcos or beenanovulatory for a considerable period.

all those things are going tobe important to paint a pictureof whether this is significant. if she told youshe'd had endometriosis in the past? is there any relationship betweenendometriosis and endometrial cancer? - not that i'm aware of.- no. norman: what are you going to do next? she had an unclewho died of bowel cancer at 45. ok. well that's... norman: maybe.- that might be helpful.

i'm going to prop her up on the couch. she's not going to leave the consultwithout being examined presenting withthis bloody vaginal discharge. so up on the couch, and i'm going to doa speculum examination and a pap smear. norman: you're looking forlocal causes of bleeding? yeah. i'm looking to identifyif i can see an obvious bleeding source. is there pathology on the cervix?is there pathology in the vagina? then i'll do a bimanual examinationand have a good feel around and see if i can feel anything inher adnexae, or try and feel her uterus.

i have to admit that in a personmore than 100kg, i have considerable difficultyin identifying anything. if i can find anything or feel anything,i would suspect that that's abnormal. norman: i suspect experiencedgynaecologists would find the same? very much so. it's a great problem. especially if the woman hashad no children, she's going to be more difficultto examine. she'll have a cervixthat's very difficult to expose. it can be quite a challenge.

you've taken a pap smear.there's nothing much to find. it was very hard to examine her. i'll talk to mary.it sounds to me like this is a symptom that i'm going to investigateimmediately. i haven't seen anythinggrossly on her cervix that makes me think thatit's cervical pathology. i'll talk to her about organisinga transvaginal ultrasound. certainly that would be my next step. that could be a surprise for herif you don't warn her about it.

it's my bitter experience thati've had patients come back and be cross that i didn't warn them. norman: because it's not a little probe. it's quite a significant probe,and it is a vaginal probe. unless they're warned about that,obviously that could feel quite invasive and quite disarming for them. i talk to them about this probe that is going to looka bit like a condom and is going to be quite uncomfortable,potentially, to get a decent picture.

your tamworth interventional radiologistdoes that? indeed,or probably our local gynaecologist. what are you looking for in a tvus,a transvaginal ultrasound? purely the endometrium. that's the number-one thing in a womanwith postmenopausal bleeding. you're looking hopefully fora thin endometrium. anything less than 5mm,you're going to be happy that the likelihood of malignancyis going to be low. - this is generalised thickness?- yeah.

you can have a carcinomatosis? no, just a uniform thickeningof the endometrial lining. it's very difficult to seeif there's an underlying cancer if there is myometrial penetrationon ultrasound. it's even quite difficult on mri. that's somethingwe'll probably talk about later. there's a question herefrom effie parakilas. 'can you comment on the diagnosticaccuracy of a pipelle endometrial sample under local, compared to an endometrialsample collected via hysteroscopy?

when is it appropriateto do a pipelle endometrial biopsy, and when is it appropriateto refer for a d and c, bearing in mind waiting times are longer at public gynaecologyoutpatient clinics?' i might ask you first, pieter,then i'll go to michael on this. it's a procedure thatmost specialists do. i'm not sure whether many gpswould be able to do it, unless they're comfortable doing mirenasthemselves and doing their own curettes, and they have the facilities.

it is quite a simple technique. the correlation is quite good,in that if it's an endometrial cancer, it usually fills up the whole cavity and you get a sample which isvery clearly malignant on histology. - it's simply a suction technique?- it's a suction catheter. 5mm diameter, it slides into the uterusand aspirates the menstrual lining. however, if it comes back negative,there are false negatives. that would mean they probably needreferral for an anaesthetic and a hysteroscopy.

norman: coming back negativedoesn't mean you can relax? definitely not. what's the relationshipbetween a transvaginal ultrasound and a pipelle? there's a good relationship. norman: can you do both?- if you're doing both, you can see where the pipelle is goinginside the uterus. but you don't need an ultrasoundto do a pipelle. most gynaecologists are very happy,particularly in a multiparous woman,

in doing a pipelle. in nulliparous women - and a nulliparouswoman is more likely to get an endometrial cancer -it's more difficult. then your transvaginal ultrasound says,if you've got 5mm or more, you have to do a hysteroscopyand curette under those circumstances. the best thing is to do a pipelle samplein your office first up, and if there's tissue,you've got your diagnosis. a question also from effie is, 'i have a 75-year-old womanwith postmenopausal bleed.

transvaginal ultrasoundshows a normal 4mm lining with a 2mm cystic space at the fundus. is it reasonable to do a pipelleor should she have a hysteroscopy?' great question,and a common ultrasound finding. the answer is, do a pipelle.if you get a tissue, fine. if you don't get a tissue,then you do your hysteroscopy. norman: right.- ok, effie? i'm not sure. another question herefrom albert vermeulen asking,

'is pcos a risk factorfor endometrial cancer, or is it just the fact thatyou're overweight with pcos?' pcos means you're not ovulating, and you have unopposedestrogen production. for some reason that is, we know,associated with obesity. we're seeing younger women now,in their late 20s, early 30s, with obesity and pcos together. these women are developingendometrial cancers. they're the ones to have children,

so that poses a therapeutic dilemmafor us. on the request formfor a transvaginal ultrasound, is there anything thatyour radiologist asks for? they need to know whether they're post-,peri- or premenopausal, and whether they're symptomatic,i suspect. most ultrasound people,when they get that form, will look at the ovaries, make sure there's notan estrogen-secreting tumour, or in younger women, cystic ovaries.

it's really sophisticated now.fantastic, to be honest. - pieter?- i'd like to respond to that one. one of our endometrial cancer patientsis 120kg. when we told her the relationship, she said, 'i must speak to my twodaughters, because they're large.' we should go backto that previous question on waiting listsat public gynaecology clinics. this is something that you, as a gp,don't accept - the waiting lists. you've got to get her seen straightaway,no questions asked.

this is about patient advocacy. this is about the fact that,particularly in postmenopausal women, that a bloody discharge equalsendometrial cancer until it's defined that it isn't. access to ultrasound is either directlyor through gynaecology services. it's certainly important thatyou stay on that patient's case and get them seen if your clinical suspicion suggests thatthat's the most likely diagnosis. kath, at this stage for this woman,where she's not diagnosed,

is there any role for someone like you, or is this too early,before she's got the diagnosis? if there is access to someone like me,i think there is a role for this. she is probably convinced she has canceruntil proven otherwise. she's going to be in a state of limboand probably has questions - what will this mean if this is cancer? and has a lot of unresolved fearswhile she waits for that diagnosis. it's a really uncertain time at which point there often isn'ta great deal of support

because she's not fallen intothe cancer pathway at that time. let's say she hasa transvaginal ultrasound, michael, and it's just on the marginsin terms of thickness. michael: 5mm. norman: and the bleeding stops. and you've got no tissueon your pipelle sample. you don't go any further,but say to the woman categorically, 'if you have another episodeof bleeding, contact me.' if you can get that message home,that's very important.

but having made contactwith the family doctor, she's plucked up enough courage,and i'm sure she would do that. what's the process for diagnosis? let's say the pipellecomes back positive. we head for hysterectomy,or do you do a d and c? no, you don't have to do a d and c. once you've got a histological sampleconfirming there's endometrial cancer, you're hot to trot. you sit down with the woman

and tell the woman what the likelyimplications of that diagnosis are, and what further investigationswill be undertaken, and what's the likelysurgical approach. in the vast majority of cases, women aretreated surgically for this disease. how important is surgical staging? surgical staging is extremely important,particularly with high-risk tumours. the problem is that we don't knowlow-risk tumours are low-risk until we surgically stage them. it's a catch-22 position.

you'll see on the screen that even women we think have got early disease, up to a third of those women will actually have disease that we categorise as high-risk. by that we mean, more likely to spread to pelvic and para-aortic lymph nodes. we feel that surgical staging is important prognostically,

so the woman knows how advanced her cancer is. secondly, it dictates her treatment. for instance, if we remove pelvic lymph nodes and they're not involved, we don't have to give women full pelvic irradiation, which takes five or six weeks. but if they're positive, then we know

she'll benefit from pelvic irradiation. so staging helps us in management, it gives the patient information and i think probably is the benchmark,in 2011, in the management of womenwith endometrial malignancies. is there value tothe multidisciplinary team here, kath? it's sometimes hard to reconstructin a country town. there's valuein a multidisciplinary team, but that doesn't have to besitting there in one spot.

a lot can be done by phone. as long as the liaison process is there and people know who to go if theyhaven't got that level of information. it doesn't need to bea physical team meeting there, it can be a virtual-realitymultidisciplinary team. we often see that happening. pieter, this issueabout where somebody goes, it's clearer with a womanwith ovarian cancer. but if surgical staging is so important,

do you think general gynaecologistsin country towns can do that? it depends on the individual. there are some very talentedgynaecologists in the country. the best person to assess thatis the local gp, who may have had many yearsof working with that person. he'll know whether he has an interestin this work. he may have done extra trainingin oncology and is able to do the node samplingthat michael is talking about. michael is talking about an ideal world,

where everybody is managedat this level. i don't believethere's any hard evidence to say that that improves the outcomes for theamazing cost of disrupting that woman and sending her a long wayto people that they don't know. occasionally, they're managedin a city hospital by a trainee, rather than someone who may have30 years of operative experience. (does tarzan yell) no, i don't think that's ever happened. i don't think anyone is ever managed bya trainee.

my view is thatthese cancers are life-threatening. when we ask patients,what's the number-one thing you want when you're being treated for cancer,the number-one thing they want is to be sure they are gettingwhat they describe as cutting-edge care. they want to know they're gettingthe very best of modern care. the occasional surgeondoing occasional lymph node sampling is not in that patient's best interests. the surgery is important,but it's not just surgery. cancer care is multidisciplinary.

it's the comprehensive careof the patient. marjorie spoke eloquentlyabout the dislocation. but every patient who gets a cancerhas a crisis. they get dislocated from their families whether they're in the middle of sydneyor tamworth. they have to go somewhere that they'reuncomfortable with, threatened by. they meet people they don't really know, because not everyone knowsthe local gynaecologist that well. it's very threatening, no matter what.

the analogy is,if you've got coronary artery disease, your chances of living at five yearsare higher than if you get an endometrial cancerand treat it, even in a major centre. you wouldn'tgo to your local gynaecologist to have your coronary arteries done,would you? even although he was able to do them,or she. - jenny?- i feel very vexed about this. i hear both michael and pieter. my problem is,a lot of these patients are elderly.

a lot of these patients are, i'd like to say,not skilled at managing going to a city but that sounds patronising,and i don't mean to be. but with increasing prevalenceof regional cancer centres, which are based around bunkers,so you've got radiotherapy, increasingly, it's only the surgeryand diagnosis they can have, and they can come homefor their regional... indeed. my ideal world is somethingbetween the two extremes. i would like to see thatcomparative best-practice care

can be deliveredin regional cancer centres with the supportof the highly skilled surgeons, clinicians and multidisciplinaryteam members. but it grieves me that the only placeto go for cancer therapy is a metro centre. we're talking about the staging processso you know what the woman has. yes.and i agree that's the ideal scenario. if we had regional cancer centres withvisiting gynaecological oncologists and the whole other set-up, fantastic.that's the solution.

pieter: it would be the ideal solution. the local gynaecologist would be willingto operate with someone like michael. and provide appropriate follow-up. tell me what you do with womenwith endometrial cancer, kath. prior to treatment.just give me the spiel. prior to treatment, i would see themin a pre-admission clinic to go through with themwhat they can expect in terms of their surgery,their recovery process and how things will followonce we get results.

giving them a time line so they're awarewe will not have results immediately, that they may have gone homebefore they have those results. if this is a woman from the country, and frequently it's another tripto the city for them, but making sure as well thatwe are doing all we can to facilitate that trip to the city, that there is support for the familywho are coming down with them, that we've completed things likeiptaas forms, so that there's financial support.

because the whole cost of transitioningto the city, even if it's for a week, and your partner is staying in a motelwhile you have your surgery... norman: is quite crippling?- is considerably crippling. a lot is preparing with information, then taking things very much aswe find their pathology to looking at the next step. as we see them for the first time, we often don't know what that next stepis going to be. so, establishing that relationship.

talk about the rangeof therapy treatments available. there's surgery. is it always radical? no, it's not. our management of these patientsincludes pre-operative imaging. we've got a reasonable ideabefore we go in there that they don't have metastatic diseaseto their liver or lungs. norman: this is pet? no, we usually do an mri or a ct scanof the abdomen and chest. we want to exclude metastatic disease.

we're also interested inobviously enlarged lymph nodes in the para-aortic and pelvic area. if they are node-enlarged and we go in,it depends then on what sort of cancer. is this a high-risk cancer? how muchinvasion is there into the myometrium? is there invasion down to the cervix? is there spread to the tubesand ovaries? that's done with a frozen section. we do the hysterectomy,we send it to a pathologist, then we look at each other lovinglyacross the table

while it takes 20 minutes for thepathologist to phone us with the result. it's not a lymph-node sampling,it's a full pelvic lymphadenectomy. we remove all the pelvic nodesand the para-aortic nodes if required. norman: this is if a sentinel nodeshows up as positive? no, we don't do sentinel nodes. under investigations at the moment, whether a sentinel node willbe of value, no-one really knows. who gets the bilateral lymphadenectomy? a patient who has eithera grade-3 tumour, a serious tumour,

a clear-cell tumour, any tumour morethan halfway through the myometrium, any tumour involving the cervix and any tumour that involves the tubesor ovaries. round about 40% of patients overallend up with the much larger operation with the attendant morbidity,particularly in obese women, which is not an easy operation. and lymphoedema is a risk there too? kath: particularly if they arefollowed up with radiotherapy. what about adjuvant therapy?

if the woman has positive lymph nodes,she's usually treated with radiation. she may go on to a trial. australia is part of a largeinternational trial called portec-3. that's using chemo-irradiationfollowed by four cycles of chemotherapy to see if that reduces the riskof recurrence. she would either go on that trialor get full pelvic irradiation or radiation to the para-aortic areaif that was involved. norman: some people aretrying brachytherapy. brachytherapy is given...

that's radioactive seeds, essentially. no, brachytherapy is given in thissituation through a cylinder. it's given as a cylinderto the top of the vagina, and that is after-loaded. so no anaesthetic is needed. the patient is in a quarantined room,the cylinder is put into the vagina, then a machine automatically,and from a distance, loads the top. it's like a large vibrator. norman: it's high-rate?- high-rate brachytherapy.

that's given to patientswhose lymph nodes are negative, but who are at higher risk of havinga recurrence at the top of the vagina. norman: does hormone treatment work? we don't use hormone treatmentin an adjuvant setting anymore. but hormone treatment including provera- medroxyprogesterone - and tamoxifen are usedin advanced disease. so, post-operatively, kath and jenny, when you see these women,and i'll start with jenny. they could have hadfairly radical treatment.

this would have enormouspsychosexual effects on them. absolutely. this is huge surgery. it's huge surgery in physical terms, and it's huge surgeryin emotional terms. as i'm sure kath will attest,these women take a long time to recover. as marjorie told us,they need enormous support to get through what isan extremely challenging time, both in terms of mortalityand sense of self-identity. norman: what practical advicedo you give people?

it varies very much on the woman. we have to have a detailed discussionwith them to find out what their concerns areand what they're worried about. as we've said, lymphoedema canbe an issue for these women. we know that there are thingswomen can do to reduce their riskof developing lymphoedema, but also if they do develop it, that they have very quick referralto a lymphoedema therapist, which will manage the problem.

it's individualising what that womanneeds, so giving practical advice, discussing with them, relating to how their sexual functionhas been before the operation. for quite a few womenwho are sexually active, the whole factof having postmenopausal bleeding is going to be something thathas affected sexual function before it's even diagnosed. they may have concernsand misconceptions. we need to be dealing with thoseappropriately,

but not making any assumptionsthat are often made because these are postmenopausal women. or people think, she's very large,i'm sure she wouldn't have sex. we don't neglect thiswhen discussing things with them. the national centrefor gynaecological cancers is in the process of developingclinical-practice guidelines for endometrial cancerwith cancer council australia. there's a working groupchaired by alison brand. let's go to our last case study.

mrs mills, she's 86, livesin a residential aged-care facility in your country town, jenny. she has limited mobilityand severe cognitive impairment. staff report that she hasblood-stained vaginal discharge. her daughter rings you up, jenny,to have a look at her mother and comes with her. this is a really tricky situation,and one i encountered last week. the important thing isto see this patient's bleeding in the contextof their health in general.

my first port of call isto try and make a diagnosis and try and establishwhat's causing the bleeding. i will examine mrs mills as best i can,and sometimes that's quite tricky on a soft bedin the residential aged-care facility. my bent here would beto try and establish a diagnosis in terms of wherethe bleeding is coming from. norman: why? it's important,in talking to the daughter about what to doabout mrs mills' problem,

to give some ideaof what the diagnosis is. - then i can give her a prognosis.norman: do you agree, pieter? i do, yes. especially if it's a benigncondition, they can be reassured. if it's a malignant condition, they needto have the discussion about treatments which are perhaps not invasivelike surgery, such as progesterone treatment,mirena treatment. something to stop the bleeding. what would you doafter you've done the examination? it's going to be hard to doa transvaginal ultrasound on her.

it is. this is a situation wherethe pipette, the endometrial biopsy, would be hugely useful. if that was possible, for meto get the patient to the gynaecologist or access someone to do it,that's obviously a great outcome. if we can get the diagnosiswith the pipette, we're in a position to discusswith the daughter what the low-stress options areas well as the high-stress options, given this lady's comorbidities. and if the family saysthey want everything done, michael?

you've got to respect that. it's a joint decision. it's the family and the family doctorinvolved, the local gynaecologist. everyone is involved. there are no easy answers to this. it's people sitting down as a group and trying to work out what's bestfor this woman. there's no algorithm we can writeto say, this is what you need to do. every situation like this is dealt within a different way

from patient to patient. it's respecting the family's wishes,and also respecting the woman herself, even though she's demented. so what you're saying, pieter, isyou could put in a progesterone iud? if the bleeding is what is making herupset, if she's aware of that bleeding, it can be reduced for some monthsjust by inserting a mirena, which is something that can be doneunder very light anaesthetic in a patient like that. some people give a quick blastof external beam.

if this was an endometrial cancer, a single or two fractionsof radiation treatment would be enough to control bleeding, because that's whatyou're trying to do - make her symptom-freefor whatever life she's got left. what sort of death is it? endometrial cancercan be an awful death. that's why it's such an importantdisease to be talking about. it can recur locallyand go into the bladder or rectum,

and that causes fistulisation, which is the worst possible wayfor anyone to live their life, or it can metastasise, usuallyto the lungs or to the common site. but under those circumstances,progesterones are pretty good. two last questions on our webcast. we've dealt with this before,but we'll come back to it, adina case from queensland health asks, 'in young women with oligomenorrheaand polycystic ovarian syndrome, is there any benefit in screeningultrasounds for endometrial thickness,

and if so, how often?' the answer is no, not screening. it's a fabulous question. we need to sit down with these youngwomen and say that they are at risk of developing endometrial abnormalities,and they can protect themselves. they can do that with cyclicalprogesterone, a mirena or just the pill. they need to know, so they don't end upwith an unexpected endometrial cancer in their 30s or early 40swhen they're trying to have children. - did you want to add to that, pieter?- no, i quite agree.

and a comment from effie parakilas,who asked a couple questions before. 'we must refer to our localgynaecology outpatient department who then liaise with the visitinggynaecological oncologist from sydney', which is that partnershipyou were talking about earlier. what are your take-home messagesfor people watching, jenny? the really key one is,don't ignore bleeding. bleeding isa potentially troubling symptom. we will shortly have some guidelinesthat we'll be able to refer to. norman: this is the cancer australia?

from cancer australia,which have some helpful algorithms both for menopausal women, and alsoperi- and premenopausal women. that just underlines that bleeding is a symptomwe need to take seriously. norman: pieter? having travelled around australiaover the last few years, i think the gp must take responsibilityto expedite the referral, not just give the patient a letterto say, make an appointment, because when she rings up,

with the shortage of gynaecologistsin the country, she may have a six-month waiting list. i'm sure that's not going to beto her advantage. the gp should make surethat woman is seen within the week. norman: not slip between the cracks.- no. that we shouldn't underestimate theimpact of endometrial cancer on women, often because they're postmenopausal. because the majority are treatedand cured with surgery alone, we sometimes see it asa relatively minor cancer.

they still have psychological andphysical disease and treatment matters to cope with for many years after, and we need to be able to address thoseappropriately. norman: beat your breast,professor quinn. i think the take-home message is, more women die from this diseasethan cervix cancer. we've got the opportunityto talk to women in family practice, to warn them about the effectsof obesity and diabetes, and get them to try and institutesome intervention to reduce the risk.

thank you all very much.i've learned a lot. great program. i hope you've got a lot too fromthis program on endometrial cancer. this program and the first in our serieson gynaecological cancer, on psychosexual care,can both be ordered free from the rural education foundation. our thanks to the national centre for gynaecological cancers for making the program possible. i'm sure when that guideline isavailable,

it will come up on their website. also thanks to you for taking the timeto attend and contribute. let us know what you thought about itby filling in an evaluation form, and if you're watching the webcast, bysubmitting a comment in the text box on your computer screen. if you're interested inobtaining more information about issues raised in the program,there are resources available on the rural education foundationwebsite: and the cancer australia website, at:

i'm norman swan. see you next time�