Summary
The updated FIGO 2023 staging system for endometrial cancer, incorporating molecular alterations, lymphovascular invasion, and tumor type and grade, has faced challenges in implementation. While the system aims to personalize treatment, its reliance on molecular testing, which not all laboratories can perform, and the variability in assessing lymphovascular invasion, have led to concerns about practicality and potential inconsistencies in staging. Despite these challenges, the new system addresses limitations of the previous FIGO 2009 system, which relied solely on anatomic site and extent of disease.
Karen Titus
April 2025—Seen through the lens of metaphor, cancer staging is traffic control. Identify the biological crash, so to speak, and its severity; direct and redirect therapy; and try, ultimately, to unsnarl persistently risky crossings.
That’s the sunny ideal. But efforts to improve traffic flow can also give rise to strong reactions, usually in words (if not a chorus of honking horns).
Such is the case with the updated International Federation of Gynecology and Obstetrics staging system for endometrial cancer. FIGO 2023, by nearly all accounts, differs sharply from what had come before, incorporating molecular alterations, lymphovascular invasion, and tumor type and grade. Nearly two years later, it has yet to merge seamlessly into practice.
“It definitely is controversial,” says Ekene Okoye, MD, associate professor of clinical pathology and genomic medicine, Department of Pathology and Genomic Medicine, Houston Methodist Hospital and Weill Cornell Medical College. “It has caused a lot of angst, not only with gyn pathologists but with general surgical pathologists. I have not met a gyn pathologist who has said, ‘Oh, wow, this is so great!’”
“It’s tough on everyone,” says Anne Mills, MD, associate professor of pathology, Department of Pathology, University of Virginia School of Medicine, noting that laboratories are juggling whether and how to report elements from earlier FIGO classifications as well as those from FIGO 2023 and the American Joint Committee on Cancer staging. “It’s a lot.”
Even though the new system is nearly two years old, the answer to the question of how physicians are adjusting to it is just as likely to be, “They’re not,” says UVA’s Marilyn Huang, MD, with a laugh. Dr. Huang holds the Richard and Louise Crockett Endowed Professorship and is professor and director, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Virginia Comprehensive Cancer Center.