What is endometrial cancer? What is uterine cancer?

Date: Sep-13-2013Endometrial cancer, also known as womb cancer or uterine cancer, is a type of cancer that begins in the uterus (womb), specifically in the layer of cells that form the lining of the uterus, called the endometrium. Endometrial cancer can also be called cancer of the womb or cancer of the uterus.

Nearly all uterine cancers are endometrial cancer. However, there is another much rarer type called uterine sarcoma, in which the malignancy starts in the muscles surrounding the womb. Endometrial cancer and uterine sarcoma are usually treated differently.

According to the National Cancer Institute, in the United States there are approximately 49,560 new cases of endometrial cancer and 8,190 deaths caused by the disease each year.

Most newly-diagnosed patients are over 55 years of age.
What is the uterus?

The uterus is a small, hollow, pear-shaped organ located in a woman's pelvis. It is part of a woman's reproductive system. The fetus develops in the uterus.

The uterus is divided into three parts:

The Fundus - the top part, shaped like a dome. The fallopian tubes extend from the top of the uterus to the ovaries.
The Corpus (body) - the middle part. The fetus grows in this part.
The Cervix - the bottom part. It is, in fact a canal that has an opening into the uterus and the vagina.

The uterine wall has two layers of tissue:

The Endometrium - the inner lining of the uterus. The lining of the uterus swells each month in preparation for pregnancy in women of reproductive age. If pregnancy does not occur, the swollen lining flows out of the body (menstrual period).
The Myometrium - the outer layer, which consists of muscle tissue.

The uterus is divided into three parts - The Fundus, Corpus and Cervix

The majority of endometrial cancers start off in cells that make and release mucus and other liquids - adenocarcinomas.
What are the signs and symptoms of endometrial cancer?

A symptom is something the patient feels and describes, such as pain, while a sign can be detected by others as well as, for example a skin rash.

The following are examples of signs and symptoms of endometrial cancer:

Vaginal bleeding between menstrual periods
Heavier-than-normal periods
Vaginal bleeding in post-menopausal women
Pain in the pelvic area (less common)
Pain during sexual intercourse (less common)
Abnormal vaginal discharge, usually watery or tinged with blood

The following symptoms are possible in the more advanced stages of the disease:

Pain in the legs and back
Pain in the pelvic area
Fatigue (tiredness)
Nausea

Some women also experience pain when urinating, while others have difficulties in emptying their bladder.

These signs and symptoms may be caused by endometrial cancer, or some other health problem. Post-menopausal vaginal bleeding does not necessarily mean it is cancer. Irregular bleeding could be caused by fibroids, endometriosis, endometrial hyperplasia or polyps in the womb lining.

According to the National Health Service, UK, "Only 1 in 10 cases of unusual vaginal bleeding after the menopause are caused by womb cancer, so it's unlikely your symptoms will be caused by this condition."
What are the risk factors linked to endometrial cancer?

A risk factor is something that increases the likelihood that something will happen, such as a disease. For example, smoking raises the risk of developing lung cancer. Therefore smoking is a risk factor for lung cancer.

The following are risk factors for endometrial cancer:

Endometrial hyperplasia - abnormal overgrowth of the endometrium. The lining of the uterus becomes abnormally thicker.

Obesity - women who gain weight during adulthood have a higher risk of endometrial cancer compared to those who maintain a stable body weight, researchers at the National Home Office of the American Cancer Society found.

Never having been pregnant.

When a woman had her last baby may impact on endometrial cancer risk - researchers at the University of Southern California found that women who last gave birth at age 40+ were 44% less likely to develop the disease compared to women who last gave birth under the age of 25.

Early menstruation - a woman who had her first menstrual period before twelve years of age.

Late menopause - women who experienced the menopause after 55 years of age.

Hormone replacement therapy (HRT) - estrogen only HRT should only be administered to women who have undergone a hysterectomy (had their uterus surgically removed). Combination HRT, where both estrogen and progesterone are used, is not associated with a higher risk of endometrial cancer.

Tamoxifen - a drug given to women to prevent or treat breast cancer. Women who took Tamoxifen are at higher risk of cancer of the uterus. However, doctors say the benefit provided by Tamoxifen in protecting from breast cancer outweighs the endometrial cancer risk.

Age - women over the age of 55 have a much higher risk of developing the disease than younger females.

Radiation therapy - women who have received radiation therapy to the pelvis.

A family history of uterine cancer - a woman whose mother, sister or daughter had/had uterine cancer is at a higher risk herself of developing the disease. Women who have Lynch syndrome, an inherited form of colorectal cancer are also at a higher risk.

Low exposure to sunlight - a study carried out at the University of California, San Diego, found a clear association between deficiency in sunlight exposure and endometrial cancer risk. Specifically, low exposure to ultraviolet B.

Diabetes - diabetes causes an increase in insulin body levels, which in turn raises estrogen levels. Long-term high estrogen levels raise the probability of developing uterine cancer.

Polycystic ovarian syndrome (PCOS) - women with PCOS have higher estrogen levels, which raises the risk of endometrial cancer.

Other cancers - women who have or have had ovarian or breast cancer are at higher risk of endometrial cancer.

Scientists at Maastricht University in the Netherlands found that acrylamide is linked to a higher risk of endometrial and ovarian cancer in post-menopausal women. Acrylamide is a carcinogenic compound found in cooked, particularly burned, carbohydrate-rich food.
Diagnosing endometrial cancer

The doctor will ask questions about the symptoms, the patient's medical history, and whether there is a history of endometrial cancer in the family.

Pelvic examination - after carefully inspecting the vulva (outer portion of the woman's genitals), the doctor will insert two fingers of one hand into the vagina while pressing onto the abdomen with the other hand to feel the uterus and ovaries. A speculum - a device that opens the vagina - is inserted so that the doctor may look carefully at the vagina and cervix. The doctor will be looking out for any lumps or changes in shape or size.

Transvaginal ultrasound (TVU) scan - can determine the texture and thickness of the endometrium. This allows the doctor to rule out other conditions. A transducer, a wand-like device, is inserted into the vagina. Sound waves create a video image of the uterus on a monitor.

Blood test - some tumor markers can be detected in a blood test, which can help doctors in their diagnosis. However, the test is not very reliable, says the National Health Service. It is possible to have uterine cancer and not have the tumor markers show up in the blood test.

Biopsy - a biopsy is the removal of a sample of tissue or cells so that a pathologist can examine them, usually under a microscope for the presence of cancerous cells. A biopsy is usually recommended if the TVU detected changes in the thickness of the endometrium. There are several ways a biopsy can be carried out:

- hysteroscopy: the doctor uses a hysteroscope, a thin kind of telescope which is inserted through the vagina and into the uterus. With hysteroscopy the doctor can look at the lining of the uterus and take a tissue sample.

- aspiration biopsy: a small flexible tube (cannula) is inserted into the uterus and attached via tubing to a pump. The pump creates a vacuum, thus sucking up samples of cells from the lining of the uterus.

Grading the tumor

If cancer is detected, the pathologist will need to learn the "grade" of the tumor. This can determine how different the tumor tissue is from normal tissue in the uterus and can help suggest how fast it is likely to grow.

Higher grade tumors grow more rapidly than lower grade ones. A higher grade tumor is more likely to metastasize - to spread to other parts of the body.
Staging endometrial cancer

The "stage" of the cancer refers to the extend of the disease. Determining the stage, known as "staging", helps the doctor chose the best treatment.

Staging is based on whether the cancer is localized or has spread to nearby tissue, or beyond.

When endometrial cancer spreads from its original site to others parts of the body and a new tumor is formed, that new tumor has the same type of abnormal cells as the original endometrial cancer cells. Endometrial cancer that has spread to a lung is not lung cancer, it is metastasized endometrial cancer.

The doctor will want to find out whether the cancer has spread, and may order one or some of the following tests:

Pap test - to see whether the cancer has spread to the cervix.

Blood tests - to measure levels of CA-125, which rise in the presence of cancer. Blood tests can also show how well the kidneys and liver are functioning.

Chest x-ray - to determine whether the cancer has spread to the lung(s).

CT (computed tomography) scan - a medical imaging method that employs tomography, the process of generating a two-dimensional image of a slice or section through a 3-dimensional object (a tomogram), in this case of the pelvis, abdomen or chest.

The patient may have contrast material injected, to see whether the lymph nodes are affected. A CT scan can tell the doctor whether there is cancer in the uterus, lungs, lymph nodes and other parts of the body.

MRI (magnetic resonance imaging) scan - a large machine that uses a magnetic field and radio waves to create detailed images of the body, in this case the uterus and lymph nodes. Sometimes contrast material may be injected into the patient. MRI can reveal cancer in the uterus, lymph nodes and elsewhere.

According to the National Cancer Institute, in the majority of cases the uterus is removed so that staging can be done. The pathologist checks to see how deeply the tumor has grown and whether other tissue samples from the uterus have cancer cells.
Endometrial cancer has five stages

Stage 0 - referred to by doctors as carcinoma in situ, i.e. the cancerous cells remain in the place where they first formed, on the surface of the inner lining of the uterus.

Stage I - the cancer has spread through the inner lining of the uterus to the endometrium. There is a possibility the myometrium may have been invaded too.

Stage II - the tumor has spread to the cervix.

Stage III - the tumor has spread through the uterus to nearby tissue, including the vagina or a lymph node.

Stage IV - the cancer has spread to the bladder or intestine, and possibly to other parts of the body, such as bones, liver, or lungs.

The National Cancer Institute says there are five stages. Some places, such as The Mayo Clinic and Cancer Research UK say there are only 4 stages (I, II, III, and IV).
What are the treatment options for endometrial cancer?

Treatment options depend on several factors, including the patient's age and general health, the grade of the tumor, whether it has invaded the muscle layer of the uterus, spread to tissues outside the uterus, or reached other parts of the body.

For patients with uterine cancer the current treatment options include surgery, radiation therapy, chemotherapy, and hormone therapy.

A multidisciplinary team - usually there will be a team of specialist health care professionals helping to plan the patient's treatment. The doctor may refer the patient to a specialist, who may be a gynecologist, gynecologic oncologist, medical oncologist and radiation oncologist. The team may also include a registered dietitian and oncology nurse.

The patient will be told what treatment choices there are, and the expected results for each one, plus their possible side effects. Although the aim of cancer therapy is to destroy cancer cells, often healthy cells and tissues are also damaged.

It is important to ask your health care team about any possible side effects and how treatment may impact on your normal everyday activities. It is important that the team and patient work together to make sure the treatment plan takes into account the patient's needs.
Surgery

Most doctors will recommend that women with endometrial cancer have their uterus surgically removed (hysterectomy). The fallopian tubes and ovaries will usually be removed as well (salpingo-oophorectomy).

Jason D. Wright, MD, wrote in the Journal of Clinical Oncology wrote that women aged 45 years or younger with endometrial cancer can safely keep their ovaries and avoid early menopause.

During the surgical procedure, the surgeon will look carefully around the uterus for signs of cancer. Lymph nodes may also be removed and sent to the laboratory for testing. Removing lymph nodes helps in the staging of the cancer.

Most women spend a couple of days in hospital after a hysterectomy before going home, but some may go home on the day of the operation. It takes from 4 to 8 weeks to be able to return to normal activities.

The doctor and patient should ideally discuss a plan for pain relief before the operation. Medicine can help control pain and discomfort, which is usually present for a few days.

It is not uncommon to feel weak and tired for a few days, and also to experience nausea and vomiting. Temporary loss of bladder control and constipation is also possible.

If the patient is premenopausal, she will stop having periods after the operation and will not be able to get pregnant. There may be symptoms of menopause, such as hot flashes, night sweats and vaginal dryness.

Lymphedema, swelling in one of both legs, is possible after lymph nodes have been removed.
Radiation therapy

Radiation therapy (UK: radiotherapy) works by damaging the cancer cell's DNA, thus destroying their ability to multiply. Radiation therapy also kills cancer cells. This type of therapy uses powerful energy beams, such as x-rays.

Two types of radiation therapy are used in the treatment of endometrial cancer:

External radiation therapy - the patient lies on a table and a large machine directs radiation at the pelvis and other areas with cancer. Treatment may occur for several weeks, with up to 5 sessions each week. A session lasts a few minutes.

Brachytherapy - internal radiation therapy. Small devices filled with radiation, such as wires, a cylinder or small seeds are placed inside the vagina for a few minutes, after which the patient goes home. The therapy is repeated two or more times over a period of several weeks. The radiation is gone from the patient's body as soon as the devices are removed.

Neo-adjuvant radiotherapy (before surgery) - the doctor may recommend radiation to shrink the tumor, making it easier to remove.

Adjuvant radiotherapy (after surgery) - the aim is to eliminate any cancer cells that may have remained.

For some patients who may not be healthy enough for surgery, radiation therapy only is an option.

In more advanced endometrial cancer, radiation therapy may be used to alleviate symptoms of pain.

Side effects - the skin in the treated area can become sore and red, there may be hair loss. The bowel may be affected, causing sickness and diarrhea. During the radiation therapy course the patient may feel progressively tired. When the treatment is finished these side-effects will usually go away. According to the National Health Service, approximately 5% of patients carry on with long-term treatment effects, including rectal bleeding and diarrhea.
Chemotherapy

Chemotherapy involves the use of medication to destroy cancer cells.

In overall cancer treatment, chemotherapy can be used for the following goals:

Total remission - to cure the patient. In some cases chemotherapy can achieve this.

Combination therapy - alongside radiation therapy or surgery. For example, if the tumor cannot be completely removed during surgery. In more advanced cancer chemotherapy may be used in combination with radiation therapy.

Prevent/delay recurrence - when used to prevent cancer recurrences it is used after surgery to remove a tumor.

Slow down cancer progression - for patients with advanced cancer.

Symptom relief - for more advanced cancers.

Chemotherapy used for endometrial cancer is usually administered intravenously and in cycles. Each treatment cycle is followed by a rest period.

Side effects - chemotherapy, while killing fast-growing cancer cells, also harms some rapidly dividing healthy cells. The following side effects are possible:

Lower levels of healthy blood cells - resulting in easier bruising and bleeding, as well as fatigue. Patients who have these symptoms must tell the medical team immediately. The dosage may have to be altered, or the treatment stopped for a while. There are drugs that help the body make new blood cells.

Hair loss - cells in the hair roots are affected, resulting in possible hair loss. After the treatment is over the hair grows back, but its texture may be permanently different.

Gastrointestinal problems - including nausea, vomiting, diarrhea and poor appetite. Some patients also report lip and mouth sores. These problems typically go away after treatment is completed.

Less commonly, some patients may experience swollen legs and feet, joint pain, balance problems, hearing difficulties, numbness and tingling in the hands and feet, and skin rash.
Hormone therapy

Hormone therapy is the use of hormones in medical treatment. Hormone therapy may be recommended for patients with advanced endometrial cancer that has metastasized.

Some women in the early stages of cancer who wish to get pregnant may opt for hormone therapy rather than surgery.

There are two main types of hormone therapy for people with endometrial cancer:

Progesterone tablets - progestin can help shrink the tumor and control symtpoms.

Hormone therapy to reduce estrogen levels - endometrial cancer cells need estrogen to thrive. Hormone therapy medications to help reduce estrogen levels in the body or make it harder for the estrogen to be used make it more difficult for the cancer cells to survive.

Side effects may include weight gain, mild muscle cramps, and mild nausea.
What are the complications of endometrial cancer?

If the endometrial cancer is not detected early or is left untreated it can metastasize - spread to other parts of the body, most commonly to the lungs.
What is the outlook (prognosis) for endometrial cancer?

The 5-year survival rate, when all endometrial cancer cases are looked at together, is approximately 69%, according to the American Cancer Society.

For patients whose endometrial cancer is diagnosed at an early stage, the 5-year survival rate is more than 91%.

The earlier the cancer is detected and treated, the better the survival rate.
The American Cancer Society emphasizes "These numbers give you an overall picture, but keep in mind that every woman's situation is unique and the statistics can't predict exactly what will happen in your case. Talk with your cancer care team if you have questions about your personal chances of a cure, or how long you might survive your cancer. They know your situation best."

Removing both lymph nodes improves survival - Professor Noriaki Sakuragi and Dr Yukiharu Todo, at the Hokkaido University Graduate School of Medicine in Japan reported that the complete removal of both pelvic lymph nodes and the para-aortic lymph nodes results in better survival rates compared to just removing the pelvic lymph nodes.
Prevention of endometrial cancer

Diet, exercise and coffee - a study carried out by the American Cancer Society found that endometrial cancer risk can be reduced with physical exercise, following a healthy and balanced diet, and drinking coffee.

The researchers said that doing 30 minutes of exercise each day and maintaining a healthy body weight can reduce the risk of developing endometrial cancer by almost 60%.
According to co-researcher, Elisa V. Bandera, drinking coffee regularly is linked to "an estimated 7% reduction in risk for every cup of coffee consumed, based on eight studies." Bandera added that this applies to both caffeinated and decaffeinated coffee.

In another study, a team at the Harvard School of Public Health also found that coffee protects from endometrial cancer.

Hannah Arem, a doctoral student at Yale School of Public Health, reported that regardless of bodyweight, women who exercised for at least 150 minutes a week had a reduced risk of endometrial cancer.

Contraception - long-term use of the combined contraceptive pill has been associated with a lower risk of developing endometrial cancer, as have contraceptive implants and the IUD (intrauterine device).
Video - Uterine Cancer

This video talks about two types of uterine cancer: 1. Endometrial cancer. 2. Uterine sarcoma.

Written by Christian Nordqvist

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