Three Opportunities in Uterine Cancer Research
Many people would have heard about endometriosis, but what is endometrial or uterine cancer?
Despite 417,000 new diagnoses globally in 2020 and being the sixth most common cancer in women in Australia, public awareness of endometrial cancer is largely lacking. Over the next 10 years, predictions estimate that more than 74,000 Australian women will be diagnosed with uterine cancer (95% of those with endometrial cancer, occurring when abnormal cells grow in the endometrium lining of the uterus).
Risk factors for endometrial cancer include postmenopausal, obesity and diabetes. While survival rates are improving due to early detection and women-focused treatment options, Australia is growing rapidly, and with it so too are our rates of obesity and an ageing population, ultimately driving an increase in incidence. Luckily our referral processes for patients diagnosed with endometrial cancer are very much streamlined. Endometrial cancer care is also very centralised, which means that the majority of patients will receive up-to-date care in tertiary referral centres.
For all these reasons, Australia is uniquely positioned to lead globally in endometrial cancer research.
Our high incidence of endometrial cancer and streamlined referral pathways, together with our existing research infrastructure offer fantastic opportunities for major progress. Yet there are key areas we can improve on, locally and nationally, to see progress made to help our mothers, daughters, sisters and friends.
In many ways, we stand at a crossroads. The evidence base is emerging. What’s missing is a coordinated, courageous response that connects disciplines, tackles hard truths and commits to real-world impact. But first we must attack prevention, access to care and surgical quality assurance.
Prevention: The elephant in the room
Endometrial cancer is a lifestyle cancer; 70% of cases are attributed to obesity.
This is no longer a matter of speculation but settled science. Yet we tiptoe around the issue. Weight loss, though often idealised, is rarely sustained. While I am not dismissing individual approaches to weight loss, such as bariatric surgery or medication, I call out to governments to invest in structural interventions: urban planning, active transport systems and disincentivising access to ultra-processed food. There is compelling evidence that ultra-processed foods drive weight gain even when calorie counts are matched. I believe that the biggest gains in prevention will come from looking beyond the clinic and into communities, streetscapes and food environments.
The prevention agenda must become cross-sectoral. Heart disease, stroke, diabetes and endometrial cancer are different faces of the same condition. A national research effort, backed by groups like the Australian and New Zealand Gynaecological Oncology Group, the Heart Foundation, and Diabetes Australia, could generate Australia-wide impact. But this work requires a public health lens, long-term investment and the courage to tackle politically charged issues like obesity without falling into stigma.
Access to Care: A postcode lottery
One of the most unsettling findings of our research is the profound variation in surgical and postoperative treatment of patients with uterine cancer.
One patient might be recommended external beam radiation to the whole pelvis, whereas the same patient with the same tumour profile might get recommended vaginal brachytherapy in another hospital down the road. Yet in another hospital in another city or State, the same patient may be recommended to hold off with any postoperative treatment.
This variation in postoperative treatment is well known, poorly documented and is certainly not evidence-based; it is cultural and geographical. This is, frankly, a national failure. And one that cries out for implementation research. We have the data, yet we lack standardisation. Australia urgently needs consensus guidelines and a commitment to equitable care. We can and must do better.
Equally troubling is the stark divide in survivorship care.
Surviving cancer does not necessarily mean thriving. Women are often left enduring treatment-related conditions for the rest of their life such as osteoporosis, lymphoedema and obesity. Recovery support is lacking, with an onus on women to manage her own post-treatment needs, creating disparity due to sociodemographic challenges.
Our funding models don't support holistic care. The science tells us women with access to recovery support have a better and sustainable quality of life after cancer. We need to support women after cancer and ensure women across all backgrounds can access it.
Lastly, a note on collaboration between rural/remote communities and urban areas.
Women with uterine cancer almost always will be referred to gynaecological oncologists in capital cities. But occasionally rural and remote patients need to be managed by general gynaecologists, because they are too frail to travel to the city. Sometimes, patients who are not fit to travel risk suboptimal treatment and lower survival. When lives are at stake, expertise matters.
However, a significant, if not the majority, of care that our patients require can be safely provided in the community. While complex surgical procedures must be performed in a “big hub” so that we maintain excellent patient outcomes, some services can indeed be provided in the community. Policy makers can better map out guidelines so that patients can have both, centralisation and community care.
Surgical Quality Assurance: Because everyone can improve
Our research team is currently leading the ENDO-3 trial, Australia’s landmark surgical trial in uterine cancer, which aims to refine and define the optimal extent of surgery.
But our work has also revealed sobering gaps in surgical quality. The surgeons joining our study undergo a rigorous quality assurance accreditation process to ensure consistency across our national and international sites. However, before surgeons get accredited, we are often seeing major differences in execution, resulting in massive differences in surgical outcomes, even among experienced surgeons.
These variations are concerning. To avoid offering patients substandard care, we need to evaluate novel surgical procedures for their safety and effectiveness. There are gaps in government funding for clinical trials. Studies which focus on improving and standardising surgical practices in Australia should be funded. We owe it to our patients.
We have before us an opportunity for bold leadership. We must reject siloed thinking and rally around a common goal: to prevent disease where we can and guarantee that every woman, no matter her postcode, gets care of the highest standard.