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FERTILITY SPARING TREATMENTS IN ENDOMETRIAL CANCER

DR. SARA NASSER MRCOG

CHARITE COMPREHENSIVE CANCER CENTER

BERLIN, GERMANY

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WHY THINK ABOUT FERTILITY

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WHY THINK ABOUT FERTILITY

Fertility is a quality of life indicator

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WHY THINK ABOUT FERTILITY

Increase in average age of first pregnancy from early 20s to early 30s.

Average age from 25 in 2019 to 31 in 2022

(Eurostat)

Fertility is a quality of life indicator

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WHY THINK ABOUT FERTILITY

14% of EC are diagnosed in premenopausal women

Increase in average age of first pregnancy from early 20s to early 30s.

Average age from 25 in 2019 to 31 in 2022

(Eurostat)

Fertility is a quality of life indicator

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WHY THINK ABOUT FERTILITY

14% of EC are diagnosed in premenopausal women

4% of those are diagnosed under the age of 40 years

Increase in average age of first pregnancy from early 20s to early 30s.

Average age from 25 in 2019 to 31 in 2022

(Eurostat)

Fertility is a quality of life indicator

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WHEN TO THINK ABOUT FERTILITY

  • Women of reproductive age who wish to preserve their fertility ( appropriate counselling)

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  • LOW RISK EC/AEH (Balance between oncological safety and fertility preservation)

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WHEN TO THINK ABOUT FERTILITY

  • Women of reproductive age who wish to preserve their fertility ( appropriate counselling)

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  • LOW RISK EC/EH (Balance between oncological safety and fertility preservation)- IA, G1-2 endometrioid, dMMR, NSMP

A TH + BSO in a IA, G1-2 endometrioid, dMMR, NSMP EC leads to a 5-year survival rate of 99%

Requirements:

  1. Understanding of risks-deviation of SoC
  2. IA, G1, endometrioid- adequately staged ( MRI, Biopsy)
  3. Compliant with active surveillance and HT

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WHEN TO THINK ABOUT FERTILITY

  • Reproductive Outcomes
  • Oncological Outcomes

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WHEN TO THINK ABOUT FERTILITY

  • Reproductive Outcomes
  • Oncological Outcomes

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WHEN TO THINK ABOUT FERTILITY

  • Reproductive Outcomes
  • Oncological Outcomes

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WHEN TO THINK ABOUT FERTILITY

  • Reproductive Outcomes
  • Oncological Outcomes

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WHEN TO THINK ABOUT FERTILITY

  • Reproductive Outcomes
  • Oncological Outcomes

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WHEN TO THINK ABOUT FERTILITY

  • Reproductive Outcomes
  • Oncological Outcomes

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WHAT OPTIONS ARE AVAILABLE

  • Hormone Therapy:
    • Progestin- No consensus regarding the ideal progestin agent
    • Local- LNG-IUD
    • Systemic: MPA (Medroxyprogesterone acetat), MA (Megesterol acetate)
    • Metformin (decrease recurrence rate)
  • Remission rates:
    • 75% CR ( across literature)
    • Chung et al reported CR rate of 44% in patients with dMMR EC ( small study of 57 patients)

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TREATMENT ALGORITHM

Diagnosis of EC

Counselling/ Assessment I:

Age, risk factors ( BMI, DM, HTN)

Fertility wish

Staging:

MRI

Hysteroscopy and Bx

Counselling II:

Oncological safety

Pregnancy plan

Surveillance plan

Hysteroscopy and Bx in 6 Months

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TREATMENT ALGORITHM

Persistence or Progression

Continue HT

Complete Remission

Pregnancy

Hysteroscopy and Biopsy in 6 Months

Total hysterectomy

Reproductive Specialist

Interval 4-6 months, re-counselling

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VISIONS FOR THE FUTURE

  • Molecular Profiling as a predictor for success of conservative management
  • Office Hysteroscopic procedures for easier surveillance
  • Tight window for fertility sparing treatment in EC as early stage is highly curable
  • Many patients undergoing fertility sparing treatment choose not to achieve pregnancy- more insights into family planning behaviour

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