MDNews - Cleveland-Akron-Canton

+++++++++++++++++++++++++++++++++++++++++++ + + +++++++++++++++++++++++++++++++++++++++++++ SPECIAL SECTION: WOMEN’S HEALTH  +++ +++ CLINICAL OPTIONS FOR OBESITY PATIENTS WITH ENDOMETRIAL CANCER By Stephen J. Andrews, MD women, representing 6% of all cancers. The development of EC is predomi- E nantly related to estrogen excess. Risk factors for development include obesity, nulliparity, late menopause, unexposed estrogen ingestion, tamoxifen use, high dietary fat intake, diabetes, hypertension and prior pelvic radiation therapy. Of all the risk factors, obesity has the highest associated relative risk (RR). Low physi- cal activity also was significantly associated with an increased RR of EC. According to the Centers for Disease Control (CDC), there has been a dra- matic rise in the incidence of obesity in the US over the past 20 years. In Ohio, the CDC reported in 2009 that 29.6 % of adults were obese (BMI greater than 30). The relationship between obesity and development of EC is well established. Obesity in women also has been associ- ated with increased rates of breast, gallbladder, colon and ovarian cancer. For the obese woman with EC, the clinical effects of obesity on EC have been evaluated. In a Gynecologic Oncology Group (GOG) study of EC in 380 patients of whom 24% were over- weight (BMI 25 – 29.9), 41% were obese (BMI 30 – 39.9) and 12% were morbidly obese (BMI > 40). The recurrence rate between groups did not differ. However, NDOMETRIAL CANCER (EC) is the most common of the gyneco- logic malignancies. It is the fourth most common cancer in those women who were morbidly obese had a higher mortality than those who were overweight or obese. During follow- up, almost 70% of the deaths in the morbidly obese group were from non- cancerous causes. The diagnosis of EC is usually made by a sampling of the endometrium through either an offi ce biopsy or a dila- tation and curettage. Once a histologic diagnosis of EC is made, patients would be referred to a gynecologic oncologist for counseling. The best treatment for EC is surgical with hysterectomy, bilat- eral salpingo-oopherectomy and lymph node sampling. In patients who are not candidates for surgery, options include radiotherapy, cytotoxic or hor- monal chemotherapy. EC is staged surgically which allows identification of patients at risk for recurrence who may require adjuvant therapy. Hysterectomy in the obese patient represents a challenge for the healthcare team. They will often har- bor other co-morbidities related to obesity such as diabetes, hypertension, sleep apnea and cardiovascular disease. In addition, obese patients are at risk of peri-operative complications such as wound infection and deep venous thrombosis. Hysterectomy can be performed using a traditional open approach via laparot- omy or by use of a minimally invasive technique such as laparocosopic or robotic surgery. Robotic surgery has 38 | Cleveland-Akron-Canton MD NEWS  MDNEWS.COM  JULY-AUGUST 2011 quickly become the technique of choice for obese women with EC. Multiple studies have shown advantages of robotic hysterectomy, bilateral saplingo-oopherec- tomy and lymph node sampling compared to traditional laparoscopic or open approach in terms of less blood loss, shorter hospital stays, less pain and less peri-operative c o m p l i c a t i o n s . S t u d i e s in the gynecologic literature have also shown that high volume surgeons have lower resource ut i l izat ion and lower complications. Therefore, referral of women with EC should be made to high volume gynecologic oncologists with robotic surgical expertise. Obese women with EC are known to be at increased of risk of mortality from non-cancerous causes. The study previously cited indicated women treated for EC are highly unlikely to make any changes in their lifestyle after diagnosis. A prospective study showed that six months a f ter diagnosis of EC, obese women did not change their sedentary lifestyles or their nutrit ional input. This study underscored the need for extensive counseling and continued coaching for EC survivors to follow the ACS guidelines. In summary, obesity is a known and powerful risk factor for the development of EC. Women with EC who are mor- bidly obese at are increased risk of death versus women with EC who are not obese, with most of the deaths related to non-cancerous causes. Surgical treatment and staging utilizing a mini- mally invasive approach with the robot is the preferred method of treatment. Dr. Andrews is a gynecological oncologist with Summa Physicians Inc. He received his medical degree from Case Western Reserve School of Medicine and completed his resi- dency training at Tripler Army Medical Center. He is fellowship trained in gyneco- logic oncology from the University of Kentucky Cancer Center and is board certi- fi ed in bothobstetrics and gynecology as well as gynecologic oncology. n

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