Although most cases of endometrial cancer are diagnosed at an early stage, delays in recognizing symptoms and seeking care may prevent patients from receiving timely treatment. Alexander B. Olawaiye, MD, FRCOG, FACOG, FACS, discusses the importance of improving awareness of postmenopausal bleeding, reducing barriers to diagnosis, and leveraging emerging diagnostic and biomarker-driven approaches, as shared at the recent 2026 ASCO Annual Meeting, to help optimize outcomes for patients with endometrial cancer.

Following this presentation, featured expert Alexander B. Olawaiye, MD, FRCOG, FACOG, FACS, was interviewed by Conference Reporter Medical Director Noreen Iftikhar, MD. Clinical perspectives from Dr Olawaiye on these findings are presented here.

Timely diagnosis is important in all cancers because the earlier cancer is diagnosed, the more treatment opportunities exist and the more we are able to positively influence the outcome. One cancer for which early diagnosis is very critical is endometrial cancer, and the opportunity exists to diagnose endometrial cancer early.

The median age of patients at the time of initial endometrial cancer diagnosis is 63 years, when most women are postmenopausal and no longer have routine normal menstrual cycles, and there is no good reason for them to experience bleeding. Most endometrial cancers present with postmenopausal bleeding. Endometrial cancer can be diagnosed early in most cases when patients who experience postmenopausal bleeding are examined expediently. The reasons for considerable delays in diagnosing endometrial cancer early are not well understood; some are patient driven, and some are provider or system driven. However, fortunately, 75% of endometrial cancers are still diagnosed early (ie, at stage I). And when patients are diagnosed at stage I, overall survival exceeds 95%, which is excellent. So, the opportunity for early diagnosis is one that we cannot miss.

In addition to early diagnosis being important in the management of endometrial cancer, biomarker testing is also very important, given the current array of treatment options and new agents coming to the market. Examples include ICIs, which are highly effective in treating deficient mismatch repair endometrial cancer. For recurrent endometrial cancer, we now have ADCs such as trastuzumab deruxtecan on the market. Trastuzumab deruxtecan is US Food and Drug Administration (FDA) approved for patients with endometrial cancers that express HER2 in high proportion (ie, immunohistochemistry 2+ or 3+). In addition to the treatments that are already FDA approved, we have a host of ongoing clinical trials targeting specific biomarkers that a patient’s cancer must express for them to participate.

At ASCO 2026, Jamie Nadine Bakkum-Gamez, MD, presented a poster on the development of an endometrial cancer test from a vaginal swab (abstract 5624). Now, I think anything that is effective will be clinically useful, although not necessarily applicable to every health care system. I am aware that investigations such as endometrial biopsy in the clinic or diagnostic hysteroscopy with dilation and curettage are not widely available in all regions of the world outside of Western countries. And in those places, I think that noninvasive methods of diagnosing endometrial cancer, such as using a vaginal swab–based test, would be helpful.

In the United States, I think that a more important concern regarding delayed diagnosis is the lack of patient awareness. I have seen many times in clinic how patients with postmenopausal bleeding have various ways of explaining it away, such as, “I just thought that my period had returned” or “My friend told me that it was okay to have a little bleeding as long as it goes away and is not too heavy.”

It turns out that in cases of postmenopausal bleeding, the extent of the bleeding does not necessarily correlate with the grade of the underlying cancer. Sometimes high-grade endometrial cancer will be associated with very minimal bleeding or maybe even just brownish vaginal discharge. Therefore, we counsel patients to assume that any postmenopausal bleeding, including brownish vaginal discharge that may not be overtly bloody, should be investigated. In the United States, the investigation is straightforward. All that is required is for the patient to see a gynecologist, who will obtain a tissue sample through an endometrial biopsy, sometimes after a pelvic ultrasound.

I am sincerely concerned about the lack of awareness of the importance of bleeding in the postmenopausal years or disorganized bleeding around the perimenopausal years. With expedient presentation and investigation, we have an opportunity to diagnose nearly 90% of endometrial cancers at stage I. If that happens, most of these cancers are curable with surgery alone and do not require systemic therapy. I do not think that we can overemphasize how critical it is for people to present the minute they see postmenopausal bleeding. I joke with my patients to tell their loved ones that once a person goes through menopause, bleeding is not allowed. If it happens, do not explain it. Just go to a physician and get evaluated because we do not want to lose an opportunity to diagnose a cancer at stage I and be in the situation where, by the time we know that this is what we are dealing with, it is at stage III or IV.