Cancer of the Uterus(Endometrial Cancer)

Cancer of the uterus develops in the lining of the uterus (endometrium) and is thus also called endometrial cancer.

• Endometrial cancer usually affects women after menopause.
• It sometimes causes abnormal vaginal bleeding.
• To diagnosis this cancer, doctors remove a sample of tissue from the endometrium to be analyzed (biopsy).
• Usually, the uterus and fallopian tubes are removed, often followed by radiation therapy and sometimes by chemotherapy.

Cancer of the uterus begins in the lining of the uterus (endometrium) and is more precisely termed endometrial cancer (carcinoma). In the United States, it is the most common gynecologic cancer and the fourth most common cancer among women. One in 50 women gets endometrial cancer. This cancer usually develops after menopause, most often in women aged 50 to 65.

More than 80% of endometrial cancers are adenocarcinomas, which develop from gland cells. Fewer than 5% of cancers in the uterus are sarcomas. These cancers develop from connective tissue and tend to be more aggressive.

Causes

Endometrial cancer is more common in developed countries where the diet is high in fat.

The most important risk factors for endometrial cancer are

• Obesity
• Diabetes
• Hypertension

Other factors increase risk because they result in a high level of estrogen but not progesterone Some Trade Names
CRINONEENDOMETRIN
. They include the following:

• Having an early start of menstrual periods (menarche ), menopause after age 52, or both
• Having menstrual problems (such as excessive bleeding, spotting between menstrual periods, or long intervals without periods)
• Not having any children
• Having tumors that produce estrogen
• Taking high doses of drugs that contain estrogen, such as estrogen therapy without a progestin (synthetic drugs similar to the hormone progesterone Some Trade Names
  CRINONEENDOMETRIN
  ), after menopause
• Using tamoxifen for more than 5 years

Estrogen promotes the growth of tissue and rapid cell division in the lining of the uterus (endometrium). Progesterone Some Trade Names
CRINONEENDOMETRIN
helps balance the effects of estrogen. Levels of estrogen are high during part of the menstrual cycle. Thus, having more menstrual periods during a lifetime may increase the risk of endometrial cancer. Tamoxifen, a drug used to treat breast cancer, blocks the effects of estrogen in the breast, but it has the same effects as estrogen in the uterus. Thus, this drug may increase the risk of endometrial cancer. Taking oral contraceptives that contain estrogen and a progestin appears to reduce the risk of endometrial cancer.

Other risk factors include the following:

• Having had or having a family member who has had cancer of the breast, ovaries, or possibly the large intestine (colon) or lining of the uterus
• Having had radiation therapy directed at the pelvis

Symptoms

Abnormal bleeding from the vagina is the most common early symptom. Abnormal bleeding includes

• Bleeding after menopause
• Bleeding between menstrual periods
• Periods that are irregular, heavy, or longer than normal

One of three women with vaginal bleeding after menopause has endometrial cancer. Women who have vaginal bleeding after menopause should see a doctor promptly. A watery, blood-tinged discharge may also occur. Postmenopausal women may have a vaginal discharge for several weeks or months, followed by vaginal bleeding.

Diagnosis

Doctors may suspect endometrial cancer if women have typical symptoms or if results of a Papanicolaou (Pap) test, usually done as part of a routine examination, are abnormal. If cancer is suspected, doctors take a sample of tissue from the endometrium (endometrial biopsy) in their office and send it to a laboratory for analysis. This test accurately detects endometrial cancer more than 90% of the time. If the diagnosis is still uncertain, doctors scrape tissue from the uterine lining for analysis—a procedure called dilation and curettage (D and C—see Symptoms and Diagnosis of Gynecologic Disorders: Dilation and Curettage). At the same time, doctors may view the interior of the uterus using a thin, flexible viewing tube inserted through the vagina and cervix into the uterus in a procedure called hysteroscopy. Alternatively, an ultrasound device may be inserted through the vagina into the uterus (transvaginal ultrasonography) to evaluate abnormalities.

If endometrial cancer is diagnosed, some or all of the following procedures may be done to determine whether the cancer has spread beyond the uterus: blood tests, kidney and liver function tests, and a chest x-ray. If results of the physical examination or other tests suggest that the cancer has spread beyond the uterus, computed tomography (CT) or magnetic resonance imaging (MRI) is done. Other procedures are sometimes required. Staging is based on information obtained from these procedures and during surgery to remove the cancer.

Prognosis

If endometrial cancer is detected early, nearly 70 to 95% of women who have it survive at least 5 years, and most are cured. The prognosis is better for women whose cancer has not spread beyond the uterus. If the cancer grows relatively slowly, the prognosis is also better. Less than one third of women who have this cancer die of it.

Treatment

Hysterectomy, surgical removal of the uterus, is the mainstay of treatment for women who have endometrial cancer. If the cancer has not spread beyond the uterus, removal of the uterus plus removal of the fallopian tubes and ovaries (salpingo-oophorectomy) almost always cures the cancer. Unless the cancer is very advanced, hysterectomy improves the prognosis. Nearby lymph nodes are usually removed at the same time. These tissues are examined by a pathologist to determine whether the cancer has spread and, if so, how far it has spread. With this information, doctors can determine whether additional treatment (chemotherapy, radiation therapy, or a progestin) is needed after surgery.

For very advanced cancer, treatment varies but usually involves a combination of surgery, radiation therapy, chemotherapy, and occasionally synthetic hormones.

Radiation therapy may be given after surgery in case some undetected cancer cells remain. More than half of women with cancer limited to the uterus do not need radiation therapy. However, if the cancer has spread to the cervix or beyond the uterus, radiation therapy is usually recommended after surgery.

If the cancer has spread beyond the uterus and cervix or recurs, chemotherapy drugs (such as carboplatin Some Trade Names
PARAPLATIN
, cisplatin Some Trade Names
PLATINOL
, cyclophosphamide Some Trade Names
LYOPHILIZED CYTOXAN
, doxorubicin Some Trade Names
DOXIL
, and paclitaxel Some Trade Names
ABRAXANETAXOL
) may be used instead of or sometimes with radiation therapy. These drugs reduce the cancer's size and control its spread in more than half of women treated. However, these drugs are toxic and have many side effects.

If the cancer does not respond to chemotherapy, progestins (synthetic drugs similar to the hormone progesterone Some Trade Names
CRINONEENDOMETRIN
) may be used. These drugs are much less toxic than chemotherapy drugs. In 20 to 25% of women who have cancer that has spread or recurred, a progestin may reduce the cancer's size and control its spread for 2 to 3 years. Treatment is continued as long as the cancer responds to it.

If menopausal symptoms such as hot flashes and vaginal dryness become bothersome after the uterus is removed, hormones such as estrogen, a progestin, or both can taken to relieve them. This treatment is safe and does not increase the risk of developing cancer again.

Understanding Hysterectomy A hysterectomy is the removal of the uterus. Usually, the uterus is removed through an incision in the lower abdomen. Sometimes the uterus can be removed through the vagina. Either method usually takes about 1 to 2 hours and requires a general anesthetic. Afterward, vaginal bleeding and pain may occur. The hospital stay is usually 2 to 3 days, and recovery may take up to 6 weeks. When the uterus is removed through the vagina, less bleeding occurs, recovery is faster, and there is no visible scar. Because of advances in technology, hysterectomy may be done using laparoscopy or robotic surgery. Then, the hospital stay is only 1 day. Women usually have less pain after surgery and can return more quickly to normal activities. In addition to treating certain gynecologic cancers, a hysterectomy may be used to treat prolapse of the uterus, endometriosis, or fibroids (if causing severe symptoms). Sometimes it is done as part of the treatment for cancer of the colon, rectum, or bladder. There are several types of hysterectomy. The type used depends on the disorder being treated. Subtotal (supracervical) hysterectomy: Only the upper part of the uterus is removed, but the cervix is not. The fallopian tubes and ovaries may or may not be removed. Total hysterectomy: The entire uterus including the cervix is removed. Radical hysterectomy: The entire uterus plus the surrounding tissues, ligaments, and lymph nodes are removed. Both fallopian tubes and ovaries are usually also removed in women older than 45. After a hysterectomy, menstruation stops. However, a hysterectomy does not cause menopause unless the ovaries are removed also. Removal of the ovaries has the same effects as menopause, so hormone therapy may be recommended. (see Menopause: Hormone Therapy) Many women anticipate feeling depressed or losing interest in sex after a hysterectomy. However, hysterectomy rarely has these effects unless the ovaries are also removed.