Endometrial cancer — structured oral station (12 minutes)

Opening prompt — "Walk me through your diagnostic approach to this woman."

Model response — the pathway: ^[2]

• "Any postmenopausal bleeding is endometrial cancer until proven otherwise. I arrange transvaginal ultrasound and an endometrial biopsy — there is no role for watch-and-wait. Her risk profile (obesity, type 2 diabetes, nulliparity-equivalent low parity, late menopause) makes the pre-test probability high."
• "On TVUS, an endometrial thickness of 4 to 5 mm or more in a postmenopausal woman not on HRT mandates biopsy — sensitivity and negative predictive value over 95 per cent below this threshold. I confirm the bleeding is uterine and exclude cervical, vaginal and atrophic causes on speculum exam."^[2]

Probe 1 — "Pipelle returns grade 1 endometrioid carcinoma. What is your surgical plan?"

• "The cornerstone is total hysterectomy with bilateral salpingo-oophorectomy, laparoscopic or robotic preferred for apparent stage I disease — shorter stay, less blood loss, equivalent oncological outcomes. I add peritoneal washings on opening."^[2]
• "For lymph nodes I use sentinel lymph node biopsy with indocyanine green and cervical injection. The FIRES trial (Rossi 2017) showed it detects nodal metastases with high sensitivity and negative predictive value, with far less morbidity than full lymphadenectomy. I reserve systematic lymphadenectomy for high-risk disease — grade 3, deep invasion, serous or clear cell, or suspected nodes."^[5]

Probe 2 — "Final histology: stage IA grade 2, under 50 per cent invasion, no LVSI, sentinel nodes negative, but the molecular class is p53-abnormal. How does that change your answer?"

• "This is where FIGO 2023 changes the answer. The anatomic stage is IA2, but the p53abn molecular class up-stages the tumour — recorded as IAmp53abn (with the 'm' subscript indicating molecular class). p53abn tumours behave aggressively and are managed as high-risk despite the anatomic stage."^[1]
• "I favour chemoradiotherapy — pelvic external beam radiotherapy plus chemotherapy (the PORTEC-3 regimen: cisplatin concurrent with EBRT, then carboplatin and paclitaxel). The PORTEC-3 molecular analysis (Leon-Castillo 2020) showed 5-year recurrence-free survival was 59 per cent with chemoradiotherapy versus 36 per cent with radiotherapy alone for p53abn tumours — the subgroup that benefits most."^[3][4]
• "The polarity: POLEmut stage IA-IB is down-staged (IAmPOLEmut) and may avoid adjuvant therapy — the opposite end of the molecular spectrum."^[1]

Probe 3 — "Name the four molecular subgroups and what each means for adjuvant therapy."

• "POLEmut — excellent prognosis, 5-year RFS around 98 per cent, de-escalate. MMRd — intermediate, Lynch-enriched, immunotherapy candidate in advanced disease. NSMP — intermediate, the largest group, standard risk-stratified therapy. p53abn — worst, 5-year RFS around 48 per cent, escalate to chemoradiotherapy."^[3]
• "The classifier is ProMisE — POLE sequencing plus MMR IHC plus p53 IHC, applied to every endometrial cancer. And every tumour also gets universal MMR IHC for Lynch screening — endometrial cancer is frequently the sentinel cancer in Lynch syndrome."^[2]

Probe 4 — "She asks whether her 34-year-old niece with the same tumour could keep her fertility. What do you say?"

• "For a selected young woman with grade 1 endometrioid cancer confined to the endometrium on MRI, no myometrial invasion, no LVSI and MMR-proficient status, high-dose oral progestin or the levonorgestrel intrauterine system with 3-monthly sampling is the fertility-sparing option. Response rates are 60 to 75 per cent; recurrence is 25 to 40 per cent after regression, so definitive hysterectomy is recommended once childbearing is complete. This is a multidisciplinary decision with careful counselling."^[2]

Probe 5 — Communication probe: "She is frightened this means she will die. What do you say?"

This is a scored communication domain — demonstrate it out loud: ^[2]

• Move to her eye level, use her name, acknowledge the fear: "Endometrial cancer is one of the most treatable cancers when caught early — yours was found at stage I, which carries an 85 to 95 per cent five-year survival. The molecular result tells us exactly how to tailor your treatment, so we are not guessing. There is a clear surgical plan, a clear plan for any additional therapy, and a team behind you. I am not going to send you away to face this alone."^[2]