Quiz questions for cancer endometrium screening
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I now have rich textbook content from Berek & Novak's Gynecology. Let me compile 15 specialist-level MCQs.
Endometrial Cancer Screening — 15 MCQs (Consultant Level)
Q1. Which of the following is the MOST accurate statement regarding routine population-based screening for endometrial cancer?
- A) Transvaginal ultrasound (TVU) is recommended annually after menopause
- B) Pap smear is an adequate screening tool for endometrial pathology
- C) No routine screening is currently recommended due to lack of a cost-effective test that reduces mortality
- D) Endometrial cytology is a sensitive and specific screening method
- E) Annual CA-125 is recommended for all postmenopausal women
✅ Answer: C
Rationale: Routine screening for endometrial cancer is not undertaken because there is no appropriate, cost-effective, and acceptable test that reduces mortality. Pap testing is inadequate, and endometrial cytologic assessment is too insensitive and nonspecific. TVU and endometrial biopsy are too expensive for population-level screening. — Berek & Novak's Gynecology, p. 2147
Q2. A 52-year-old woman with breast cancer is on adjuvant tamoxifen therapy. What is the recommended screening approach for endometrial cancer in this patient?
- A) Annual endometrial biopsy
- B) Biannual transvaginal ultrasound
- C) No routine screening with TVU or endometrial biopsy; report any abnormal bleeding promptly
- D) Annual TVU with Doppler
- E) Annual Pap smear with endocervical sampling
✅ Answer: C
Rationale: Women taking tamoxifen receive no benefit from routine screening with transvaginal ultrasonography or endometrial biopsy. Any abnormal uterine bleeding, however, should be investigated promptly. — Berek & Novak's Gynecology, p. 2147
Q3. A woman with Lynch II (HNPCC) syndrome asks about endometrial cancer surveillance. According to the Mallorca group recommendations, the correct surveillance strategy is:
- A) Annual TVU and biopsy starting at age 50
- B) Annual pelvic examination, TVU, and endometrial biopsy starting at age 35–40
- C) Biannual TVU starting at age 30
- D) Annual Pap smear and endometrial aspiration starting at age 45
- E) No surveillance; prophylactic hysterectomy immediately at diagnosis
✅ Answer: B
Rationale: The Mallorca group recommended annual pelvic examination, transvaginal ultrasound, and endometrial biopsy beginning at 35–40 years of age for Lynch II syndrome patients, though this is based on expert opinion only. — Berek & Novak's Gynecology, p. 2149
Q4. What is the lifetime risk of endometrial cancer in women with Lynch II syndrome?
- A) 5–10%
- B) 15–25%
- C) 32–60%
- D) 65–80%
- E) Greater than 90%
✅ Answer: C
Rationale: The lifetime risk of endometrial cancer in women with Lynch II syndrome is 32% to 60% — exceeding the lifetime risk of colorectal cancer in women with the same syndrome. — Berek & Novak's Gynecology, p. 2149
Q5. Lynch II syndrome is caused by mutations in mismatch repair (MMR) genes. Which gene, when its protein product is lost by immunohistochemistry, is most commonly due to somatic hypermethylation rather than a true germline mutation?
- A) MSH2
- B) MSH6
- C) PMS2
- D) MLH1
- E) PMS1
✅ Answer: D
Rationale: Loss of MLH1 expression on immunohistochemistry is most often caused by promoter hypermethylation (somatic), not a germline mutation. Further analysis for methylation is necessary to appropriately triage patients to germline testing. — Berek & Novak's Gynecology, p. 2149
Q6. Universal molecular tumor testing for Lynch syndrome in newly diagnosed endometrial cancer patients has been shown to be more cost-effective than clinical criteria-based testing (SGO criteria). The primary reason is:
- A) Germline testing is cheap and widely available
- B) Prevention of colorectal cancer in index patients and their relatives
- C) Endometrial cancer treatment differs significantly in Lynch patients
- D) Lynch patients have better chemotherapy responses
- E) Universal testing prevents ovarian cancer recurrence
✅ Answer: B
Rationale: Goverde et al. found universal testing in endometrial cancer patients under age 70 was cost-effective (£6,668/life-year gained) primarily due to prevention of colorectal cancer in index patients and their relatives. — Berek & Novak's Gynecology, p. 2149
Q7. Which of the following is NOT a recognised indication for endometrial biopsy in a woman under 45 years of age with abnormal uterine bleeding?
- A) Obesity with irregular cycles
- B) Failure to ovulate (PCOS)
- C) Nulliparity
- D) Intact hymen with no prior sexual activity
- E) Unopposed estrogen exposure
✅ Answer: D
Rationale: Endometrial biopsy is indicated in women under 45 with risk factors for endometrial cancer such as obesity, anovulation (PCOS), and unopposed estrogen. An intact hymen alone is not an indication — it is a technical barrier, not a risk factor per se, and does not itself warrant biopsy. — Sabiston Surgery
Q8. A 38-year-old with atypical complex hyperplasia desires fertility preservation. She is started on megestrol acetate. What is the minimum recommended duration of therapy before endometrial biopsy to assess response?
- A) 1 month
- B) 2 months
- C) 3–6 months
- D) 9 months
- E) 12 months
✅ Answer: C
Rationale: Progestin therapy should be continued for at least 3 to 6 months, after which endometrial biopsy should be performed to assess response. Periodic biopsy or TVU is essential given the 25%+ undiagnosed cancer rate in atypical hyperplasia. — Berek & Novak's Gynecology, p. 2147
Q9. The most effective primary prevention strategy for endometrial and ovarian cancer in Lynch II syndrome carriers who have completed childbearing is:
- A) Annual TVU and endometrial biopsy
- B) Long-term oral contraceptive use
- C) Prophylactic hysterectomy with bilateral salpingo-oophorectomy
- D) Progestin-releasing IUD
- E) Metformin therapy
✅ Answer: C
Rationale: A multi-institutional matched case-control study found that prophylactic hysterectomy with BSO is an effective primary prevention strategy in Lynch II patients — no woman who had the procedure developed endometrial, ovarian, or peritoneal carcinoma during follow-up, versus 33% developing endometrial cancer in the non-surgical group. — Berek & Novak's Gynecology, p. 2149
Q10. Approximately what percentage of endometrial cancers are attributable to Lynch syndrome (hereditary)?
- A) <1%
- B) 3–5%
- C) 10–15%
- D) 20–25%
- E) >30%
✅ Answer: B
Rationale: Approximately 3% to 5% of endometrial cancers can be attributed to Lynch syndrome, though at least 10% of all endometrial cancers have some hereditary basis. A new diagnosis of endometrial cancer therefore represents an opportunity to identify germline mutation carriers. — Berek & Novak's Gynecology, p. 2149
Q11. The SGO clinical criteria for Lynch syndrome testing in endometrial cancer patients were found to have which key limitation?
- A) They over-diagnose Lynch syndrome, leading to unnecessary testing
- B) They are too expensive for routine clinical use
- C) Poor sensitivity (approximately 33%), missing the majority of Lynch II patients
- D) They only apply to patients over age 60
- E) They cannot be applied to patients without a family history
✅ Answer: C
Rationale: Bruegl et al. validated the SGO guidelines in an unselected endometrial cancer cohort and found poor sensitivity of 32.6% (95% CI 19.2%–48.5%), meaning the majority of Lynch II patients were missed using this criteria. Universal screening proved more cost-effective. — Berek & Novak's Gynecology, p. 2149
Q12. Which of the following correctly ranks the prognostic variables in endometrial cancer from most to least important (per published data)?
- A) Tumor size > histologic grade > myometrial invasion
- B) Advanced age, non-endometrioid/grade 3 histology, deep myometrial invasion, LVSI, large tumor size, cervical extension, lymph node metastasis
- C) LVSI > peritoneal cytology > DNA ploidy
- D) Lymph node metastasis > hormone receptor status > histologic type
- E) Stage > hormone receptor status > age
✅ Answer: B
Rationale: The most important adverse prognostic variables in endometrial cancer, in order, are: advanced patient age, non-endometrioid or grade 3 histology, deep myometrial invasion, lymph-vascular invasion, large tumor size, cervical extension, lymph node metastasis, and intraperitoneal spread. — Berek & Novak's Gynecology, p. 2142
Q13. Which endometrial cancer histological subtypes, though representing less than 10% of cases, account for more than half of all endometrial cancer deaths?
- A) Endometrioid and mucinous
- B) Mucinous and squamous
- C) Serous and clear cell
- D) Clear cell and endometrioid
- E) Serous and mucinous
✅ Answer: C
Rationale: Serous and clear cell endometrial carcinomas make up less than 10% of endometrial cancers yet account for more than one-half of all endometrial cancer deaths due to their aggressive biology and propensity for extrauterine spread. — Berek & Novak's Gynecology, p. 2142
Q14. In women with Lynch II syndrome, what is the cumulative incidence of endometrial cancer by age 70, as reported in the Finnish Cancer Registry study of 1,763 patients?
- A) 20%
- B) 35%
- C) 44%
- D) 60%
- E) 75%
✅ Answer: D
Rationale: In a study of 1,763 patients from 50 Lynch II syndrome families in the Finnish Cancer Registry, the cumulative incidence of endometrial cancer in women was 60% by age 70, actually exceeding the 54% cumulative incidence of colorectal cancer in the same population. — Berek & Novak's Gynecology, p. 2149
Q15. Which of the following patient groups should NOT be routinely screened for endometrial cancer according to current evidence?
- A) Women with Lynch II syndrome aged 38
- B) Women with newly diagnosed endometrial cancer (for Lynch testing)
- C) Postmenopausal women with late menopause, obesity, or diabetes
- D) Women with atypical endometrial hyperplasia on progestin therapy
- E) Women aged 35 or older with unexplained abnormal uterine bleeding
✅ Answer: C
Rationale: There is insufficient evidence to recommend routine screening for endometrial cancer in women based solely on a history of unopposed estrogen therapy, late menopause, nulliparity, infertility, anovulation, obesity, diabetes, or hypertension. These are risk factors, not indications for screening programmes. — Berek & Novak's Gynecology, p. 2147
Summary Table
| Q | Topic | Answer |
|---|---|---|
| 1 | Population screening rationale | C |
| 2 | Tamoxifen users | C |
| 3 | Lynch II surveillance protocol | B |
| 4 | Lifetime EC risk in Lynch II | C |
| 5 | MLH1 hypermethylation | D |
| 6 | Universal Lynch testing rationale | B |
| 7 | Biopsy indications under 45 | D |
| 8 | Progestin therapy duration | C |
| 9 | Prevention in Lynch II post-childbearing | C |
| 10 | Hereditary EC proportion | B |
| 11 | SGO criteria limitation | C |
| 12 | Prognostic variable ranking | B |
| 13 | High-mortality histotypes | C |
| 14 | Finnish Registry EC incidence | D |
| 15 | Groups NOT requiring screening | C |
All questions sourced from Berek & Novak's Gynecology (Specialist Gynecology Oncology chapter).
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