What is Uterine Cancer?
What is uterine cancer?
Cancer of the uterus (womb) is a malignant growth that forms in tissues of the uterus. It can be broadly divided into two groups, endometrial cancer (cancer that begins in cells lining the uterus), which is by far the most common womb cancer, and uterine sarcoma (a rare cancer that begins in muscle or other tissues in the uterus). A combination of these two types of cancer also occurs and is termed carcinosarcoma.The uterus (womb) is the pear shaped organ in the pelvis at the top of the vagina. A layer of tissue called endometrium lines the uterus and it is this lining that bleeds each month causing a menstrual period.
Cancer of the endometrium occurs when cancer (malignant) cells are found growing in the endometrium. This cancer is the most common gynaecological cancer in Australia. It occurs most commonly in women who have gone through menopause (postmenopausal status). The commonest age group for this disease is between 60 and 69 years of age, however, not infrequently cases are seen in younger women including women in their 30’s.
The following factors/conditions increase your chance of developing uterine cancer, they are known as risk factors:
- Obesity: Being overweight increases your risk two to four times. A higher level of fat tissue increases your level of oestrogen, which stimulates the lining of the uterus.
- Eating a diet high in saturated fat.
- Age: the vast majority of endometrial cancer patients are diagnosed after their menopause (change of life).
- Tamoxifen: this medication used to treat patients with breast cancer can stimulate the internal lining of the womb and cause endometrial cancer.
- Oestrogen replacement therapy without progesterone in women who have not had hysterectomy.
- Personal and/or family history of uterine, ovarian or bowel cancer. This may be a sign of Lynch syndrome (Hereditary Non-Polyposis Colorectal Cancer or HNPCC).
- Complex atypical endometrial hyperplasia: it is a pre cancerous condition that, if not treated, can lead to endometrial cancer.
- Diabetes Mellitus.
- No previous pregnancies.
- Early menarche (age you start having your periods) younger than 12 years old, and later menopause.
- Breast cancer.
Different from mammogram for breast cancer screening and Pap smear test for cervical cancer, there are no acceptable screening tests for endometrial cancer. However, you can help yourself if you:
- Pay attention to your body.
- Know the symptoms of uterine cancer and report any signs to your doctor.
- Lower your risk factors.
- Talk to your doctor about pelvic exams and Pap smear.
- Women diagnosed with Lynch syndrome (Hereditary Nonpolyposis Colorectal Cancer syndrome or HNPCC) should have endometrial biopsies every year beginning at age 35 or 5 years earlier than the age of a family member diagnosed with HNPCC.
Any of the following symptoms must be assessed:
- If you have gone through your menopause (change of life): any vaginal discharge or vaginal spotting / bleeding.
- If you have not gone through your menopause:
- Unusual bleeding, such as between periods or heavier flow.
- Abnormal vaginal discharge.
- Pelvic pain or pressure.
- Weight loss.
- Pain or difficulty when emptying the bladder.
- Pain during intercourse.
- Lower abdominal pain.
These symptoms do not always mean you have uterine cancer, but it must be excluded.
Diagnosis and Staging
Based on your symptoms, I will try to find out what is causing the problems. You will have a physical examination and may have blood tests.
Also, you may have one or more of the following tests:
Radiology test not involving radiation. For a better view of the uterus, the device may be inserted into the vagina (transvaginal ultrasound).
The removal of tissue to look for cancer cells under the microscope is named biopsy. A thin tube is inserted through the vagina into your uterus. Gentle scraping and suction are used to remove samples of tissue. This sometimes can be done in the consulting rooms (Pipelle biopsy) or as a day procedure in hospital (hysteroscopy and uterine curettage). A dedicated gynaecologic pathologist will have a look at it under the microscope to look for cancer cells. In most cases, a biopsy is the only way to tell whether cancer is present or not.
If uterine cancer is diagnosed, we need to know the extent (stage) of the disease to assist us in selecting the best treatment option. The stage is based on whether the cancer has invaded nearby tissues or spread to other parts of the body.
I may order one or more tests:
A Pap smear test can show whether cancer cells have spread from the womb (top of uterus) to the cervix, and blood tests can show how well the liver and kidneys are working. Also, I may order a blood test known as CA 125. Cancer may cause a high level of CA125.
Chest X-Ray or Chest CT Scan
This can show spread of disease to the lungs.
An x-ray machine linked to a computer takes a series of detailed pictures of your pelvis, abdomen, and sometimes your chest. You may receive an injection of contrast material so organs are shown in more detail in the pictures. A CT scan can show cancer in the uterus, lymph nodes, lungs, liver, or elsewhere.
Radiology test using used to make detailed pictures of your uterus and lymph glands. You may receive an injection of contrast material. MRI can show cancer in the uterus, lymph nodes, or other tissues in the abdomen.
In most cases, surgery is needed to determine the stage of uterine cancer. The uterus and ovaries are removed and I may take tissue samples from the pelvis and abdomen. After the uterus is removed, it is checked to see how deeply the tumour has grown though the uterine wall (muscle). Also, the other tissue samples are checked for cancer cells.
The Stages of Uterine Cancer
Stage IA: Cancer is found in the endometrium (uterine lining) or up to the inner half of the myometrium (uterine muscle wall).
Stage IB: Cancer has spread to outer half of the myometrium.
Stage II: Cancer has spread to uterine cervix (neck of the womb).
Stage IIIA: Cancer has spread to:
- The outer layer of uterus.
- Other pelvic organs including the fallopian tubes or ovaries.
Stage IIIB: Cancer has spread to the vagina.Stage IIIC: Cancer has spread to lymph nodes near the uterus.
Stage IVA: Cancer has spread to the bladder and/or bowel wall.
Stage IVB: Cancer has spread beyond the pelvis, including lymph nodes in the abdomen or groin(s).
The cancer was treated, but has returned after a period of time during which it could not be detected. The cancer may show up again in the top of vagina, pelvic organs or in other parts of the body.
Treatment options for women diagnosed with uterine cancer are surgery, radiation therapy, chemotherapy, and hormone therapy. Sometimes there is a need for combination treatment and you may be offered a combination of the above.
The best treatment option for you depends mainly on the following:
- Whether the tumour has invaded the muscle layer of the uterus.
- Whether the tumour has invaded tissues outside the uterus.
- Whether the tumour has spread to other parts of the body.
- The grade of the tumour.
- Your age and general health.
Surgery is the most common treatment for women with uterine cancer. There different types of hysterectomies and I will discuss in detail which one is the most appropriate considering your situation. Usually the uterus, cervix, ovaries, and fallopian tubes are removed. In addition, there may be a need to remove pelvic and lower abdominal lymph glands.
The entire operation can be done via laparoscopic surgery (keyhole surgery) in most of women. It will depend on a few factors including extent of disease.
The time it takes to heal after surgery is different for each woman. After a laparoscopic hysterectomy for example, most women go home in a couple days, but some women leave the hospital on day one after surgery. You will probably return to your normal activities within 2 to 4 weeks after surgery if done laparoscopically, and 4 to 6 weeks if done open (cut through muscle operation).
Radiation therapy is an option for women with nearly all stages of uterine cancer. It is usually used after surgery (adjuvant radiation therapy). For women who can’t have surgery for other medical reasons, radiation therapy may be used instead to treat cancer cells in the uterus. Women with cancer that invades tissue beyond the uterus may have a combination of radiation and chemotherapy.
Radiation therapy uses high-energy X-ray to kill cancer cells. It affects cells in the treated area only.
There are two types of radiation therapy to treat uterine cancer. Some women receive both types:
External Beam Radiation Therapy (EBRT)
A large machine directs radiation at your pelvis or other areas with cancer. The treatment is given in a hospital. You may receive external radiation 5 days a week for 4 to 5 weeks. Each session takes only a few minutes.
Internal Radiation Therapy (Brachytherapy)
A narrow cylinder is placed inside your vagina, and a radioactive substance is loaded into the cylinder. Usually, a treatment session lasts only a few minutes and you can go home afterward. This common method of brachytherapy may be repeated two or more times over a few weeks. Once the radioactive substance is removed, no radioactivity is left in the body.
For women who have not had surgery to remove the ovaries, external radiation aimed at the pelvic area can harm the ovaries. Menstrual periods usually stop, and women may have hot flashes and other symptoms of menopause. Menstrual periods are more likely to return for younger women.
Chemotherapy uses drugs to kill cancer cells. It may be used after surgery to treat uterine cancer that has an increased risk of returning after treatment. For example, uterine cancer that is a high grade or is Stage II, III, or IV may be more likely to return. Also, chemotherapy may be given to women whose uterine cancer can’t be completely removed by surgery.
For advanced cancer, it may be used alone or with radiation therapy. Chemotherapy for uterine cancer is usually given by vein (intravenous). It’s usually given in cycles. Each cycle has a treatment period followed by a rest period.You may have your treatment in an outpatient part of the hospital, or at a dedicated chemotherapy clinic. The vast majority of women do not have to stay in hospital to have their chemotherapy treatment.
Some uterine tumours have positive hormone receptors meaning they need hormones to grow e.g. oestrogen, progesterone, or both. If laboratory tests (immunohistochemistry tests) show that the uterine cancer contains these receptors, then hormone therapy may be a treatment option.
Hormone therapy may be used for women with advanced uterine cancer. Also, women with Stage I uterine cancer (early stage disease) that want to preserve their fertility may be offered hormone therapy instead of surgery. The most common drugs used for hormone therapy are a progesterone tablet or a levonorgestrel (progesterone type hormone) intrauterine system.
The usual follow-up for patients who have been treated for endometrial cancer is as follows:
For the first two years: Every three months.
For the next three years: Every six months.
From five years onwards: Every year.
At the follow-up visit a short history is taken covering the time since the last visit. This is followed by physical examination covering lymph node areas, abdomen and pelvis. You may have a Pap smear test type done, but this is not common due to the lack of evidence supporting Pap tests during follow up for endometrial cancer. I will discuss all the above with you.
Dr Marcelo Nascimento
MD MSc FRANZCOG CGO
I am a clinical specialist in the treatment of gynaecological pre-cancers, cancers and complex non-cancer gynaecological conditions. I am dedicated to improving the quality of life for women with gynaecological conditions providing the highest quality of diagnosis, treatment and recovery pathways in a caring and supporting environment. I work with fertility-preserving surgery whenever possible which allows women more options for treatment without compromising oncologic outcomes.