<p>Endometrial cancer poses unique challenges for women of reproductive age who hope to have children, as the standard of care is surgery. However, fertility-sparing treatment has emerged as a viable alternative for some patients with early-stage disease.</p>

We sometimes see patients who are diagnosed with endometrial cancer as early as their late 20s or early 30s. The first thing I do when any woman of reproductive age is diagnosed with endometrial cancer is have a conversation with them, about not only their diagnosis and its implications but also their desire for children and whether they have completed childbearing. Generally speaking, women with grade 1, and sometimes grade 2, endometrial cancer, particularly those with a background of hyperplasia, may have the option of using fertility-sparing treatment. In patients who have a noninvasive grade 1 tumor or hyperplasia, conservative treatment with hormonal therapy is associated with excellent response rates.

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The standard of care for endometrial cancer is typically surgery involving a hysterectomy, but, if the patient has a lot of medical comorbidities or desires future fertility, there may be options for fertility-sparing treatment, depending on their tumor histology. I usually do a complete workup with dilation and curettage to know the full extent of the tumor, and I also order a pelvic magnetic resonance imaging scan to make sure that there is no myometrial invasion.

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If a woman with grade 1 endometrial adenocarcinoma or hyperplasia bordering on grade 1 wants to remain fertile, I usually refer them to a reproductive endocrinologist to assess their likelihood of becoming pregnant and successfully carrying a pregnancy to term. This can help with the decision making, particularly in women who are in their mid-40s who have never been able to become pregnant.

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Even if their likelihood of pregnancy is extremely low, sometimes patients do not want to undergo a hysterectomy because they still want to preserve their fertility. As long as the patient is not being harmed by a more conservative treatment, this approach is okay. Conversely, I also often see patients who have grade 2 endometrial cancer or a higher-risk cancer who do not want surgery, but, in these situations, conservative therapy may not be the best option. I think that our job is to help people understand the risks and benefits of treatments so that they can make the best decision for themselves.

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I would like to remind the physicians who are reading this that we need to take into account a patient’s age and fertility. Today, there is a greater awareness of fertility-sparing options than there was 10 or 15 years ago, when we generally thought that everyone needed surgery for endometrial cancer. However, I think that we need to do a better job educating patients with endometrial cancer about their potential treatment options, including fertility-sparing treatment.