Uterine Cancer

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Uterine Cancer

Uterine Cancer

Overview

 

Cancer of the inner lining of the uterus, called the endometrium, is the most common cancer of the female reproductive tract. According to the American Cancer Society, an estimated 47,130 new cases of cancer of the uterine body, most of which are endometrial cancers, will be detected in the United States in 2012, resulting in about 8,010 deaths. The good news is that the prognosis is excellent if the cancer is detected and treated early.

The vast majority of women diagnosed with endometrial cancer are postmenopausal; more than half of cases occur in women ages 50 to 69. Younger women who develop the condition tend to be obese or have a genetic predisposition. A woman has about a one in 40 chance of developing endometrial cancer during her lifetime.

Unlike ovarian cancer, endometrial cancer has a major, identifiable symptom in its early stages: abnormal vaginal bleeding or postmenopausal bleeding. This symptom occurs in 90 percent of endometrial cancer cases. Other symptoms include pelvic pressure, a pelvic mass, abnormal discharge that doesn’t look like blood, difficulty and pain during urination and pain during intercourse.

The greatest risk factors for developing endometrial cancer are obesity and abnormal precancerous changes of the uterus. Other risks include using estrogen alone,diabetes and a strong family history of colon cancer, particularly a type of colon cancer known as hereditary nonpolyposis colon cancer, or HNPCC. Additional risks include never having had children, starting having menstrual periods at a young age and having a late menopause. Together, these risks can lead to continued estrogen stimulation of the endometrial tissue. In other words, the tissue continues to grow without a break, which increases the risk of cells growing out of control, leading to precancerous and cancerous lesion of the uterus.

Although endometrial cancer is more common in Caucasian women than African-American women, more African-American women die from the disease. This is due to many factors including the fact that African-American women often have more advanced disease and more aggressive types of the disease when they are diagnosed.

A much less common form of uterine cancer is sarcoma of the uterus, which is extremely aggressive. In this rare form of uterine cancer, cancer cells originate from the muscles or other supporting tissues of the uterus. Women who have received therapy with high-dose X-rays to their pelvis have a high risk for some types of uterine sarcomas.

Many sarcomas of the uterus begin after menopause. The prognosis and choice of treatment depend on the stage of the sarcoma, how fast the cancer cells grow and the woman’s general health.

 

Diagnosis

 

The primary symptom of uterine cancer is abnormal vaginal bleeding, especially after menopause. Bleeding may be so light that it’s only a pink discharge or drainage from the vagina.

Although irregular menstrual periods are common as you get closer to menopause, when hormone levels rise and fall unpredictably, they can also be a symptom of uterine abnormalities or uterine cancer. If your periods stop for several months and then start again, discuss your symptoms with your health care professional and ask for an examination. Also, be sure to mention any menstrual irregularities during regular checkups.

If you are postmenopausal, any vaginal bleeding is abnormal and you should contact your health care professional immediately. The earlier uterine cancer is diagnosed, the better the prognosis.

Whether you are pre- or postmenopausal, the absence of visible blood with any unusual vaginal discharge doesn’t mean you don’t have uterine cancer. If you experience any abnormal discharge, discuss it with your health care professional.

Also, if you have a family history or have been diagnosed with hereditary nonpolyposis colon cancer (HNPCC), you should be screened for uterine cancer every year beginning at age 35.

Diagnostic tests for uterine cancer include:

  • Endometrial biopsy. During this procedure, your doctor inserts a small instrument through your vagina and cervix and uses suction to take a small tissue sample of the uterine lining. The procedure is performed in the doctor’s office and, while uncomfortable, is not significantly painful. You may have cramps or pain for a short time afterward. Your doctor will usually recommend taking ibuprofen or other over-the-counter pain relievers before and after the procedure.
  • Hysteroscopy. A hysteroscopy allows your health care professional to look inside your uterus. It is usually performed if the endometrial biopsy is inconclusive or symptoms persist. During a hysteroscopy, a tiny telescope is inserted into the uterus through the cervix. The uterus is expanded with saline, allowing the doctor to view and biopsy any abnormalities.
  • Dilation and curettage (D&C). If your endometrial biopsy is inconclusive (i.e., if not enough tissue was retrieved), your health care professional may recommend a D&C to remove pieces of the lining of the uterus. During a D&C, the opening of the cervix is dilated and the walls of the uterus are gently scraped to remove any growths. The tissue is then checked for abnormal cells. The procedure is typically performed on an outpatient basis and takes about an hour. It may require general anesthesia or conscious sedation (medication that makes you drowsy, but still awake).

Other tests may include routine blood tests, a urine test and a chest X-ray. If the biopsy or D&C is positive, further evaluation and treatment will be required to remove the cancer and properly assess the extent of disease. In some cases, you may have an ultrasound, a CT scan or other scans before surgery.

In addition, some physicians will order a blood test to check for levels of CA-125, a substance released into the bloodstream by many (but not all) cancers of the endometrium and ovary. Some physicians will use a CA-125 test to decide whether surgery should be done by a gynecologic oncologist or, if CA-125 levels were high before surgery, as a follow-up to see how well treatment is working. This level can also be used after treatment to follow the cancer growth.

Early diagnosis and treatment of uterine cancer is critical. This type of gynecologic cancer often can be successfully treated in its early stages. Before beginning any treatment, however, you may want to consult with a gynecologic oncologist, a physician who specializes in treating cancers of the reproductive tract. These doctors have the most experience in diagnosing and treating such conditions.

Staging Endometrial Cancer

After a diagnosis, your health care professional will “stage” the disease to determine if the disease has spread. The stage of the cancer provides information about treatment options and survival rates.

  • Stage I: Cancer is found only in the main part of the uterus. It has not spread to the lymph nodes or distant sites.
  • Stage II: Cancer cells have spread to the cervix, but not to the lymph nodes or distant sites.
  • Stage III: Cancer cells have spread outside the uterus, such as the lymph nodes, fallopian tubes, ovaries or vagina.
  • Stage IV: Cancer cells have spread beyond the pelvis, to other body parts, into the lining of the bladder or rectum and/or have spread to lymph nodes in the groin. Stage IV endometrial cancer may also have spread to organs farther away from the uterus, such as the lungs, liver or bones.
  • Recurrent: Recurrent disease means the cancer has come back (recurred) after it has been treated.

 

Treatment

 

During surgery to remove the uterus, the surgeon will determine the stage of the cancer. The most common treatment is a total or radical hysterectomy, in which the uterus, fallopian tubes, ovaries and lymph nodes in which the tumor commonly spreads are all removed. Other therapies—radiation, chemotherapy and hormone therapy—may also be used to treat this form of the disease. Ask your health care provider about the possibility of participating in a clinical trial.

  • Hysterectomy is major surgery requiring one to three days in the hospital. Depending on the stage of your cancer, you may have a total hysterectomy, which involves removal of the whole uterus, cervix ovaries and fallopian tubes or a radical hysterectomy, which involves removal of tissue surrounding the uterus, in addition to removing the uterus and cervix. It can be done through the abdomen or using a more minimally invasive procedure (robotic or laparoscopic).For several days after surgery, you may have problems emptying your bladder and having normal bowel movements. Normal activities, including sex, can be resumed in about four to six weeks.After a hysterectomy, you no longer have menstrual periods. If your ovaries are removed before menopause, you will immediately enter menopause and usually experience significant menopausal symptoms, including hot flashes, moodiness and vaginal dryness. Talk to your health care professionl about whether you can take medications to help reduce any symptoms.�
  • Radiation therapy involves the use of high-dose X-rays to kill cancer cells and shrink tumors. Radiation may come from a machine outside the body (called external radiation) or from implanting materials that produce radiation (radioisotopes) through thin plastic tubes into the cancerous area (called internal radiation or brachytherapy). Radiation is sometimes used after surgery depending on the extent of the cancer. If you’re unable to have surgery, or the disease is too advanced for surgery, radiation may be the only treatment offered. Radiation therapy also may be offered before surgery to decrease the extent of disease.During radiation therapy, you may notice a number of side effects. These include skin reactions (redness or dryness) in the area being treated, tiredness, diarrhea, nausea and frequent and uncomfortable urination and/or defecation. Treatment can also cause dryness, itching and burning in the vagina. Sex may be painful, and some women are advised not to have sexual relations during treatment. All symptoms should disappear once treatment ends, and most women can resume sexual activity within a few weeks.�
  • Chemotherapy uses drugs to kill cancer cells. The drugs are typically infused through your veins and travel throughout your body. They’re designed to kill all rapidly growing cells, both cancer cells and healthy cells. Chemotherapy is used in the treatment of endometrial cancer, particularly if it’s spread beyond the endometrium or if it is a very aggressive type. If chemotherapy is part of your treatment, you will likely be given a combination of drugs, because combination chemotherapy is often more effective than one drug alone. The most common chemotherapy combinations include carboplatin (Paraplatin) with paclitaxel (Taxol) and cisplatin (Platinol-AQ) with doxorubicin (Adriamycin). Your provider may also recommend a clinical trial.Loss of appetite can be a serious problem for women receiving radiation therapy or chemotherapy. Yet nutrition is important because it helps you withstand the side effects of treatment. Eating well means getting enough calories to prevent weight loss and having enough protein in the diet to build and repair skin, hair, muscles and organs. If you have trouble eating right during your treatment, try several small meals throughout the day instead of three large meals, in addition to nutritional supplements.The side effects of cancer therapies vary from person to person and from one treatment to the next. Your health care professional will plan your treatment to minimize side effects. Also remember that most side effects are temporary. Still, it’s important to tell your health care professional about any reactions and side effects because he or she may be able to adjust treatments and/or prescribe other options to help you feel better.�
  • Hormone therapy involves the use of female hormones, typically progesterone-like drugs called progestins, to slow the growth of endometrial cancer cells. The two most commonly used progestins for treating endometrial cancer are medroxyprogesterone (Provera) and megestrol acetate (Megace). Side effects of progestins include nausea, vomiting, mild shortness of breath, weakness, hot flashes, menstrual bleeding, headache, insomnia, decreased sex drive and blood clots.The anti-estrogen drug Tamoxifen, which is most often used to treat breast cancer, may also be used to treat advanced-stage or recurrent endometrial cancer. Tamoxifen works to prevent estrogens circulating in your body from stimulating the growth of cancer cells. Side effects of Tamoxifen include blood clots, endometriosis, stroke, fertility issues and thinning of hair and nails.Hormones called gonadotropin-releasing hormone agonists, which switch off estrogen production by the ovaries in premenopausal women, may also be used to reduce estrogen levels in women with endometrial cancer who still have their ovaries. By lowering estrogen levels, these drugs, which include goserelin (Zoladex) and leuprolide (Lupron), work to slow the growth of the cancer. Gonadotropin-releasing hormone agonists are injected every one to three months. Side effects include hot flashes, vaginal dryness and other symptoms of menopause. However, most women with endometrial cancer have their ovaries removed as part of treatment or their ovaries destroyed with radiation, which reduces estrogen production and may slow the growth of the cancer.

Regular follow-up exams are very important for any woman who has been treated for cancer of the uterus. Your health care professional will want to watch you closely for several years to be sure that the cancer has not returned. Most follow-up examinations include a pelvic exam and a chest X-ray, possibly a CA-125 test.

When uterine cancer is caught early, the treatment is quite effective and chances of recurrence are small. The likelihood of recurrence goes up relative to the stage of the cancer.

If uterine cancer does recur, it’s likely to happen in the first three years after the initial treatment. The best chance of a cure is if the disease recurs in the vagina or is seen during a pelvic exam. That’s why you will likely have a pelvic exam every three to four months for the first two years after hysterectomy, then annually; a Pap test every six months for two years, then annually; and a CA-125 test at each visit if your levels were initially elevated. Talk to your health care provider about what’s right for you.

Recurrence can also occur in an organ distant from the uterus.

Treatment for recurrent uterine cancer depends on the amount and the location of the cancer. If it is only in the pelvis, radiation therapy alone may be enough. More extensive recurrences may require hormonal therapy or chemotherapy.

Low-grade cancers that contain progesterone receptors are more likely to respond well to hormone therapy than higher grade cancers, which respond better to chemotherapy. If you are diagnosed with recurrent uterine cancer, you may also want to consider participating in clinical trials of new treatments.

 

Prevention

 

Some uterine cancer can be prevented by maintaining a normal weight, preventing diabetes and in some cases preventive surgery. Knowing your risk factors for this gynecologic cancer can help you be more aware of it, as well as try to find ways to avoid continual estrogen stimulation of the uterine lining, also called “unopposed estrogen.”

For example, women with a family history of early onset colorectal cancer or other reproductive cancers may have an increased risk for uterine cancer. The cancers in these families may be caused by a genetic predisposition to cancer called hereditary nonpolyposis colon cancer, or HNPCC. Up to 60 percent of women with HNPCC will develop endometrial cancer at some point in their lives. Genetic counseling is recommended for women with a family history of early onset (before age 50) colon, breast, ovary or other cancer caused by a genetic mutation.

The following may help you reduce your risk of developing uterine cancer or identify it early:

  • Control your weight and your risk of diabetes by eating healthy foods and exercising. Women who are slim can cut their risk of endometrial cancer by 75 percent compared to obese women.
  • If you still have your uterus, don’t take supplemental estrogen without also taking progestin or progesterone.
  • Report abnormal bleeding promptly to your health care professional and ask for an examination.
  • Know your family history.

 

Facts to Know

 

  1. Cancer of the lining of the uterus, the endometrium, is the most common gynecologic cancer and ranks as one of the most treatable when identified in its earliest stages.
  2. An estimated 47,130 new cases of cancer of the uterine body are expected to be detected in the United States in 2012, according to the American Cancer Society.
  3. More than half of endometrial cancers are diagnosed in women between the ages of 50 and 69, although endometrial cancer can strike women in their childbearing years.
  4. The majority of uterine cancers develop in the glandular cells, or endometrium, lining the inside of the uterine cavity. This is the same tissue that is shed each month during a normal menstrual period.
  5. A small number of uterine cancers (about 2 percent) are sarcomas, which can originate in the endometrium or in the muscular and connective tissues of the uterus.
  6. There is evidence that use of oral contraceptives can reduce uterine cancer risk, particularly in women who take oral contraceptives for several years. The protection continues for at least 10 years after you stop taking the pills. You should not take birth control pills just to prevent uterine cancer, however, since they carry their own risks.
  7. Obesity, precancerous lesions of the uterus and a family history of colon cancer are the strongest risk factors for uterine cancer. Other risk factors include late menopause and never having children.
  8. Uterine cancer is more common in Caucasians than in African Americans and other non-Caucasian women. On the other hand, African-American women who get this type of cancer are twice as likely to die of the disease.
  9. Women who have been diagnosed with a genetic condition known as hereditary nonpolyposis colon cancer (HNPCC) have an increased risk of endometrial cancer and should begin screening for the condition at 35.
  10. Uterine cancer can be treated with surgery, radiation, chemotherapy, and/or hormonal therapy, depending on the stage and cell type of the disease.

 

Key Q&A

 

  1. I am 40 years old and have abnormal bleeding. What are the chances that it’s uterine cancer?Abnormal uterine bleeding has many causes. Thyroid and adrenal gland conditions, for example, can cause hormonal imbalances that affect menstrual periods. Fibroids, polyps, scar tissue, infection, trauma, atrophy and precancerous conditions also can cause irregular menstrual bleeding. You may also find that you are just beginning to experience the menstrual irregularities common to the years just prior to menopause, when hormone levels fluctuate unpredictably. However, your symptoms could be something more serious. Discuss your symptoms as soon as possible with your health care professional.
  2. My health care professional said she suspects that I could have uterine cancer. What kind of test will tell for sure?If cancer is suspected, a tissue sample must be taken from inside your uterus. This procedure is called an endometrial biopsy and can usually be done in the health care professional’s office with minimal discomfort. Narrow instruments and suction tools are used to take the sample. You may have cramps or pain for a short time after the procedure.
  3. I have uterine cancer and have been told I need a hysterectomy. Does that mean my sex life is over?Absolutely not. In fact, your interest in and enjoyment of sex may increase. Ask your health care professional when you may begin sexual activity after surgery. Because your vagina may be shorter, you and your partner may want to experiment with different positions to find one that is comfortable. Foreplay may enable the vagina to lengthen before intercourse.If your ovaries are also removed during your hysterectomy (called oophorectomy) and you are premenopausal, you will go through sudden menopause and experience menopausal symptoms that can interfere with your sex life, such as hot flashes, vaginal dryness, moodiness, insomnia and night sweats. Beginning therapy soon after hysterectomy and oophorectomy can reduce or alleviate these symptoms, and there are other options. Discuss the risks and benefits associated with hormone therapy with your health care professional.
  4. What are my chances of survival after surgery?With early diagnosis and treatment, up to 90 percent of women with endometrial cancer survive for five years.
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