American Cancer Society: Endometrial cancer is a cancer that starts in the endometrium, the inner lining of the uterus (womb). The picture below shows where the uterus is located. The uterus is a hollow organ, about the size and shape of a medium-sized pear. The uterus is where a fetus grows and develops when a woman is pregnant. The uterus has 2 main parts (see picture above). The cervix is the lower end of the uterus that extends into the vagina. The upper part of the uterus is called the body or the corpus. (Corpus is the Latin word for body.) Although the cervix is technically part of the uterus, when people talk about the uterus, they usually mean the body, not the cervix.
The body of the uterus has 2 main layers. The inner layer or lining is called the endometrium. The outer layer of muscle is known as the myometrium. This thick layer of muscle is needed to push the baby out during birth. The tissue coating the outside of the uterus is the serosa.
Hormone changes during a woman's menstrual cycle cause the endometrium to change. During the early part of the cycle, before the ovaries release an egg (ovulation), the ovaries produce hormones called estrogens. Estrogen causes the endometrium to thicken so that it could nourish an embryo if pregnancy occurs. If there is no pregnancy, estrogen is produced in lower amounts and more of the hormone called progesterone is made after ovulation. This causes the innermost layer of the lining to prepare to shed. By the end of the cycle, the endometrial lining is shed from the uterus and becomes the menstrual flow (period). This cycle repeats throughout a woman's life until menopause (change of life).
Cancers of the uterus and endometrium
Nearly all cancers of the uterus start in the endometrium and are called endometrial carcinomas. Cancers can also start in the muscle layer or supporting connective tissue of the uterus. These cancers belong to the group of cancers called sarcomas.Carcinomas
Endometrial cancers start in the cells that line the uterus and belong to the group of cancers called carcinomas. Most endometrial carcinomas are cancers of the cells that form glands in the endometrium. These are called adenocarcinomas. The most common type of endometrial cancer is called endometrioid adenocarcinoma. Other less common types of endometrial carcinomas include squamous cell and undifferentiated.Over 80% of endometrial cancers are typical adenocarcinomas -- also known as endometrioid. Endometrioid cancers are made up of cells in glands that look much like the normal uterine lining (endometrium). Some of these cancers contain squamous cells (squamous cells are flat, thin cells that can be found on the outer surface of the cervix), as well as glandular cells. A cancer with both types of cells is called an adenocarcinoma with squamous differentiation. If, under the microscope, the glandular cells look cancerous but the squamous cells don't, the tumor may be called an adenoacanthoma. If both the squamous cells and the glandular cells look malignant (cancerous), these tumors can be called adenosquamous carcinomas. There are other types of endometrioid cancers, such as secretory carcinoma, ciliated carcinoma, and mucinous adenocarcinoma.
The grade of an endometrioid cancer is based on how much the cancer forms glands that look similar to the glands found in normal, healthy endometrium. In lower-grade cancers, more of the cancerous tissue forms glands. In higher-grade cancers, more of the cancer cells are arranged in a haphazard or disorganized way and do not form glands.
- Grade 1 tumors have 95% or more of the cancerous tissue forming glands.
- Grade 2 tumors have between 50% and 94% of the cancerous tissue forming glands.
- Grade 3 tumors have less than half of the cancerous tissue forming glands. Grade 3 cancers are called "high-grade." They tend to be aggressive and have a poorer outlook than lower grade cancers (grades 1 and 2).
Doctors sometimes divide endometrial carcinoma into 2 types based on their outlook and underlying causes. “Type 1” cancers are thought to be caused by excess estrogen. They are usually not very aggressive and are slow to spread to other tissues. Grades 1 and 2 endometrioid cancers are “type 1” endometrial cancers. A small number of endometrial cancers are “type 2.” Experts aren't sure what causes type 2 cancers, but they don't seem to be caused by too much estrogen. Serous carcinoma, clear-cell carcinoma, poorly differentiated carcinoma, and grade 3 endometrioid carcinoma are all type 2 cancers. These cancers don't look at all like normal endometrium and so are called "poorly differentiated" or “high-grade.” Because type 2 cancers are more likely to grow and spread outside of the uterus, they have a poorer outlook (than type 1 cancers). Doctors tend to treat these cancers more aggressively.
Uterine carcinosarcoma (CS) is another cancer that starts in the endometrium and is included in this document. When looked at under the microscope, this cancer has features of both endometrial carcinoma and sarcoma. In the past, CS was considered a type of uterine sarcoma, but many doctors now believe that CS may actually be a form of poorly differentiated carcinoma.
Uterine CS has many things in common with type 2 endometrial carcinoma. For example, they have similar risk factors. These cancers are also similar in how they spread and are treated. CSs are also known as malignant mixed mesodermal tumors or malignant mixed mullerian tumors (MMMTs). They make up about 4% of uterine cancers.
Uterine sarcomas
Cancer can also start in the supporting connective tissue (stroma) and muscle cells of the uterus. These cancers are called uterine sarcomas. They are much less common than endometrial carcinoma. These include:- Stromal sarcomas, which start in the supporting connective tissue of the endometrium
- Leiomyosarcomas, which start in the myometrium or muscular wall of the uterus
Cervical cancers
Cancers that start in the cervix and then spread to the body of the uterus are different from cancers that start in the body of the uterus; the former are described in our document Cervical Cancer.What are the key statistics about endometrial cancer?
In the United States, cancer of the
endometrium is the most common cancer of the female reproductive organs.
The American Cancer Society estimates for cancer of the uterus in the
United States for 2015 are:
- About 54,870 new cases of cancer of the body of the uterus (uterine body or corpus) will be diagnosed.
- About 10,170 women will die from cancers of the uterine body.
These estimates include both
endometrial cancers and uterine sarcomas. About 2% of uterine body
cancers are sarcomas, so the actual numbers for endometrial cancer cases
and deaths are slightly lower than these estimates.
Endometrial cancer is rare in women under
the age of 45. Most (about 3 out of 4) cases are found in women aged 55
and over The average chance of a woman being diagnosed with this cancer
during her lifetime is about 1 in 37. There are over 600,000 women who
are survivors of this cancer. This cancer is slightly more common in
white women, but black women are more likely to die from it.
risk factors
A risk factor is anything that changes your
chance of getting a disease such as cancer. Different cancers have
different risk factors. For example, unprotected exposure to strong
sunlight is a risk factor for skin cancer. Smoking is a risk factor for
many cancers.
There are different kinds of risk factors.
Some, such as your age or race, can't be changed. Others are related to
personal choices such as smoking, exercising, body weight, drinking, or
diet. Some factors influence risk more than others. Although certain
factors increase a woman's risk for developing endometrial cancer, they
do not always cause the disease. Many women with one or more risk
factors never develop endometrial cancer. Some women with endometrial
cancer do not have any known risk factors. Even if a woman with
endometrial cancer has one or more risk factors, there is no way to know
which, if any, of these factors was responsible for her cancer.
Hormone factors
A woman's hormone balance plays a part in
the development of most endometrial cancers. Many of the risk factors
for endometrial cancer affect estrogen levels. Before menopause, the
ovaries are the main source of the 2 main types of female hormones --
estrogen and progesterone. The balance between these hormones changes
during a woman's menstrual cycle each month. This produces a woman's
monthly periods and keeps the endometrium healthy. A shift in the
balance of these two hormones toward more estrogen increases a woman's
risk for developing endometrial cancer. After menopause, the ovaries
stop making these hormones, but a small amount of estrogen is still made
naturally in fat tissue. This estrogen has a bigger impact after
menopause than it does before menopause. Female hormones are also
available to take (as a medicine) in birth control pills to prevent
pregnancy and as hormone therapy to treat symptoms of menopause.
Estrogen therapy
Treating the symptoms of menopause with estrogen is known as estrogen therapy or menopausal hormone therapy.
Estrogen is available in many different forms such as pills, skin
patches, creams, shots, and vaginal rings to treat the symptoms of
menopause. Estrogen treatment can reduce hot flashes, improve vaginal
dryness, and help prevent the weakening of the bones (osteoporosis) that
can occur with menopause. Doctors have found, however, that using
estrogen alone (without progesterone) can lead to endometrial cancer in
women who still have a uterus. Progesterone-like drugs must be given
along with estrogen to reduce the increased risk of endometrial cancer.
This approach is called combination hormone therapy.
Giving progesterone along with estrogen does
not cause endometrial cancer, but it does still have risks. Studies
have shown that this combination increases a woman's chance of
developing breast cancer and also increases the risk of serious blood
clots.
Studies have shown that estrogen therapy
increases a woman's chance of developing serious blood clots and heart
disease. If you are taking (or plan to take) hormones after menopause,
it is important for you to discuss the potential risks (including
cancer, blood clots, heart attacks, and stroke) with your doctor. Like
any other medicine, hormones should be used only at the lowest dose that
is needed and for the shortest possible time to control symptoms. You
should also have yearly follow-up pelvic exams. If you have any abnormal
bleeding or discharge from the vagina you should see your doctor or
other health care provider right away.
Birth control pills
Using birth control pills (oral
contraceptives) lowers the risk of endometrial cancer. The risk is
lowest in women who take the pill for a long time, and this protection
continues for at least ten years after a woman stops taking this form of
birth control. However, it is important to look at all of the risks and
benefits when choosing a contraceptive method; endometrial cancer risk
is only one factor to be considered. It's a good idea to discuss the
pros and cons of different types of birth control with your doctor.
Total number of menstrual cycles
Having more menstrual cycles during a
woman's lifetime raises her risk of endometrial cancer. Starting
menstrual periods (menarche) before age 12 and/or going through
menopause later in life raises the risk. Starting periods early is less a
risk factor for women with early menopause. Likewise, late menopause
may not lead to a higher risk in women whose periods began later in
their teens.
Pregnancy
The hormonal balance shifts toward more
progesterone during pregnancy. So having many pregnancies protects
against endometrial cancer. Women who have never been pregnant have a
higher risk, especially if they were also infertile (unable to become
pregnant).
Obesity
Most of a woman's estrogen is produced by
her ovaries, but fat tissue can change some other hormones into
estrogens. Having more fat tissue can increase a woman's estrogen
levels, which increases her endometrial cancer risk. In comparison with
women who maintain a healthy weight, endometrial cancer is twice as
common in overweight women, and more than three times as common in obese
women.
Tamoxifen
Tamoxifen is a drug that is used to prevent and treat breast cancer.
Tamoxifen acts as an anti-estrogen in breast tissue, but it acts like
an estrogen in the uterus. In women who have gone through menopause, it
can cause the uterine lining to grow, which increases the risk of
endometrial cancer.
The risk of developing endometrial cancer
from tamoxifen is low (less than 1% per year). Women taking tamoxifen
must balance this risk against the value of this drug in treating and
preventing breast cancer. This is an issue women should discuss with
their doctors. If you are taking tamoxifen, you should have yearly
gynecologic exams and should be sure to report any abnormal bleeding, as
this could be a sign of endometrial cancer.
Ovarian tumors
A certain type of ovarian tumor, the granulosa-theca cell tumor,
often makes estrogen. Estrogen release by one of these tumors is not
controlled the way hormone release from the ovaries is, which can
sometimes lead to high estrogen levels. The resulting hormone imbalance
can stimulate the endometrium and even lead to endometrial cancer. In
fact, sometimes vaginal bleeding from endometrial cancer is the first
symptom of one of these tumors.
Polycystic ovarian syndrome
Women with a condition called polycystic
ovarian syndrome (PCOS) have abnormal hormone levels, such as higher
androgen (male hormones) and estrogen levels and lower levels of
progesterone. The increase in estrogen relative to progesterone can
increase a woman's chance of getting endometrial cancer.
Use of an intrauterine device
Women who used an intrauterine device (IUD)
for birth control seem to have a lower risk of getting endometrial
cancer. Information about this protective effect is limited to IUDs that
do not contain hormones. Researchers have not yet studied whether newer
types of IUDs that release progesterone have any effect of endometrial
cancer risk. However, these IUDs are sometimes used to treat pre-cancers
and early endometrial cancers in women who wish to preserve
child-bearing ability.
Age
The risk of endometrial cancer increases as a woman gets older.
Diet and exercise
A high-fat diet can increase the risk of
several cancers, including endometrial cancer. Because fatty foods are
also high-calorie foods, a high fat diet can lead to obesity, which is a
well-known endometrial cancer risk factor. Many scientists think this
is the main way in which a high fat diet raises endometrial cancer risk.
Some scientists think that fatty foods may also have a direct effect on
estrogen metabolism, which increases endometrial cancer risk.
Physical activity protects against
endometrial cancer. Several studies found that women who exercised more
had a lower risk of this cancer, while in one study women who spent more
time sitting had a higher risk. To learn more, you can read the American Cancer Society Guidelines on Nutrition and Physical Activity for Cancer Prevention.
Diabetes
Endometrial cancer may be as much as 4 times
more common in women with diabetes. Diabetes is more common in people
who are overweight, but even people with diabetes who are not overweight
have a higher risk of endometrial cancer.
Family history
Endometrial cancer tends to run in some families. Some of these families also have an inherited tendency to develop colon cancer. This disorder is called hereditary nonpolyposis colon cancer (HNPCC). Another name for HNPCC is Lynch syndrome. In most cases, this disorder is caused by a defect in either the gene MLH1 or the gene MSH2. But at least 5 other genes can cause HNPCC: MLH3, MSH6, TGBR2, PMS1, and PMS2.
An abnormal copy of any one of these genes reduces the body's ability
to repair damage to its DNA. This results in a very high risk of colon
cancer, as well as a high risk of endometrial cancer. Women with this
syndrome have a 40% to 60% risk of developing endometrial cancer
sometime during their lives. The risk of ovarian cancer is also
increased. General information about inherited cancer syndromes can be
found in our document Family Cancer Syndromes.
There are some families that have a high
rate of only endometrial cancer. These families may have a different
genetic disorder that hasn't been discovered yet.
Breast or ovarian cancer
Women who have had breast cancer or ovarian cancer
may have an increased risk of developing endometrial cancer. Some of
the dietary, hormonal, and reproductive risk factors for breast and
ovarian cancer also increase endometrial cancer risk.
Prior pelvic radiation therapy
Radiation used to treat some other cancers
can damage the DNA of cells, sometimes increasing the risk of a second
type of cancer such as endometrial cancer.
Endometrial hyperplasia
Endometrial hyperplasia is an increased
growth of the endometrium. Mild or simple hyperplasia, the most common
type, has a very small risk of becoming cancerous. It may go away on its
own or after treatment with hormone therapy. If the hyperplasia is
called “atypical,” it has a higher chance of becoming a cancer. Simple
atypical hyperplasia turns into cancer in about 8% of cases if it is not
treated. Complex atypical hyperplasia (CAH) has a risk of becoming
cancerous if not treated in up to 29% of cases. For this reason, CAH is
usually treated.
Prevention
Most cases of endometrial cancer cannot be
prevented, but there are some things that may lower your risk of
developing this disease.
One way to lower endometrial cancer risk is to change risk factors
whenever possible. For example, women who are overweight or obese have
up to 3½ times the risk of getting endometrial cancer as compared to
women with a healthy weight. Getting to and maintaining a healthy weight is one way to lower the risk of this cancer.
Studies have also linked higher levels of
physical activity to lower risks of endometrial cancer, so engaging in
regular physical activity (exercise) may also be a way to help lower
endometrial cancer risk. An active lifestyle can help you maintain a
healthy weight, as well as lowering the risk of high blood pressure and
diabetes (other risk factors for endometrial cancer.
Estrogen to treat the symptoms of menopause
is available in many different forms like pills, skin patches, shots,
creams, and vaginal rings. If you are thinking about using estrogen for
menopausal symptoms, ask your doctor about how it will affect your risk
of endometrial cancer. Progestins (progesterone-like drugs) can reduce
the risk of endometrial cancer in women taking estrogen therapy, but
this combination increases the risk of breast cancer. If you still have
your uterus and are taking estrogen therapy, discuss this issue with
your doctor.
Getting proper treatment of pre-cancerous
disorders of the endometrium is another way to lower the risk of
endometrial cancer. Most endometrial cancers develop over a period of
years. Many are known to follow and possibly start from less serious
abnormalities of the endometrium called endometrial hyperplasia.
Some cases of hyperplasia will go away without treatment, but it
sometimes needs to be treated with hormones or even surgery. Treatment
with progestins
and a dilation and curettage (D&C) or hysterectomy can prevent
hyperplasia from becoming cancerous. Abnormal vaginal bleeding is the most common symptom of endometrial pre-cancers and cancers, and it needs to be reported and evaluated right away.
Women with hereditary nonpolyposis colon
cancer (HNPCC, Lynch syndrome) have a very high risk of endometrial
cancer. A woman with HNPCC may choose to have her uterus removed (a
hysterectomy) after she has finished having children to prevent
endometrial cancer. One study found that none of 61 women with HNPCC who
had prophylactic (preventative) hysterectomies was later found to have
endometrial cancer, while 1/3 of the women who didn't have the surgery
did go on to be diagnosed with endometrial cancer over the next 7 years.
Can endometrial cancer be found early?
In most cases, noticing any signs and
symptoms of endometrial cancer, such as abnormal vaginal bleeding or
discharge (that is increasing in amount, occurring between periods, or
occurring after menopause), and reporting them right away to your doctor
allows the disease to be diagnosed at an early stage.
Early detection improves the chances that your cancer will be treated
successfully. But some endometrial cancers may reach an advanced stage
before signs and symptoms can be noticed.
Early detection tests
Early detection (also called screening)
refers to the use of tests to find a disease such as cancer in people
who do not have symptoms of that disease.
Women at average endometrial cancer risk
At this time, there are no screening tests
or exams to find endometrial cancer early in women who are at average
endometrial cancer risk and have no symptoms.
The American Cancer Society recommends that,
at the time of menopause, all women should be told about the risks and
symptoms of endometrial cancer and strongly encouraged to report any
vaginal bleeding, discharge, or spotting to their doctor.
Women should talk to their doctors about
getting regular pelvic exams. A pelvic exam can find some cancers,
including some advanced uterine cancers, but it is not very effective in finding early endometrial cancers.
The Pap test (or Pap smear), which screens for cervical cancer,
can occasionally find some early endometrial cancers, but it is not a
good test for this type of cancer. The Pap test is very effective in
finding early cancers of the cervix (the lower part of the uterus).
Women at increased endometrial cancer risk
The American Cancer Society recommends that
most women at increased risk should be informed of their risk and be
advised to see their doctor whenever there is any abnormal vaginal
bleeding. This includes women whose risk of endometrial cancer is
increased due to increasing age, late menopause, never giving birth,
infertility, obesity, diabetes, high blood pressure, estrogen treatment,
or tamoxifen therapy.
Women who have (or may have) hereditary nonpolyposis colon cancer
(HNPCC, Lynch syndrome) have a very high risk of endometrial cancer. If
colon or endometrial cancer has occurred in several family members, you
might want to think about having genetic counseling to learn about your
family’s risk of having HNPCC. If you (or a close relative) have
genetic testing and are found to have a mutation in one of the genes for
HNPCC, you have a high risk of getting endometrial cancer.
The American Cancer Society recommends that
women who have (or may have) HNPCC be offered yearly testing for
endometrial cancer with endometrial biopsy beginning at age 35. Their
doctors should discuss this test with them, including its risks,
benefits, and limitations. This applies to women known to carry
HNPCC-linked gene mutations, women who are likely to carry such a
mutation (those with a mutation known to be present in the family), and
women from families with a tendency to get colon cancer where genetic
testing has not been done.
Another option for a woman who has (or may
have) HNPCC would be to have a hysterectomy once she is finished having
children.
Signs and symptoms of endometrial cancer
There are a few symptoms that may point to endometrial cancer, but some are more common as this cancer becomes advanced.
Unusual vaginal bleeding, spotting, or other discharge
About 90% of patients diagnosed with
endometrial cancer have abnormal vaginal bleeding, such as a change in
their periods or bleeding between periods or after menopause. This
symptom can also occur with some non-cancerous conditions, but it is
important to have a doctor look into any irregular bleeding right away.
If you have gone through menopause, it is especially important to report
any vaginal bleeding, spotting, or abnormal discharge to your doctor.
Non-bloody vaginal discharge may also be a
sign of endometrial cancer. Even if you cannot see blood in the
discharge, it does not mean there is no cancer. In about 10% of cases,
the discharge associated with endometrial cancer is not bloody. Any
abnormal discharge should be checked out by your doctor.
Pelvic pain and/or mass and weight loss
Pain in the pelvis, feeling a mass (tumor),
and losing weight without trying can also be symptoms of endometrial
cancer. These symptoms are more common in later stages of the disease.
Still, any delay in seeking medical help may allow the disease to
progress even further. This lowers the odds for successful treatment.
Although any of these can be caused by things other than cancer, it is important to have them checked out by a doctor.
How is endometrial cancer diagnosed?
Most women are not screened for endometrial cancer, so it is most often diagnosed after a woman sees her doctor because she has symptoms.
History and physical exam
If you have any of the symptoms of endometrial cancer , you should visit your doctor. The doctor will ask you about your symptoms, risk factors, and family medical history. The doctor will also perform a general physical exam and a pelvic exam.
Seeing a specialist
If the doctor thinks you might have
endometrial cancer, you should be examined by a gynecologist, a doctor
qualified to diagnose and treat diseases of the female reproductive
system. Gynecologists can diagnose endometrial cancer, as well as treat
some early cases. Specialists in treating cancers of the endometrium and
other female reproductive organs are called gynecologic oncologists.
These doctors treat both early and advanced cases of endometrial cancer.
Sampling endometrial tissue
To find out whether endometrial hyperplasia
or endometrial cancer is present, the doctor must remove some tissue so
that it can be looked at under a microscope. Endometrial tissue can be
obtained by endometrial biopsy or by dilation and curettage (D&C)
with or without a hysteroscopy. A specialist such as a gynecologist
usually does these procedures, which are described below.
Endometrial biopsy
An endometrial biopsy is the most commonly
performed test for endometrial cancer and is very accurate in
postmenopausal women. It can be done in the doctor's office. In this
procedure a very thin flexible tube is inserted into the uterus through
the cervix. Then, using suction, a small amount of endometrium is
removed through the tube. The suctioning takes about a minute or less.
The discomfort is similar to menstrual cramps and can be helped by
taking a nonsteroidal anti-inflammatory drug such as ibuprofen before
the procedure. Sometimes numbing medicine (local anesthetic) is injected
into the cervix just before the procedure to help reduce the pain.
Hysteroscopy
For this technique doctors insert a tiny telescope (about 1/6
inch in diameter) into the uterus through the cervix. To get a better
view of the inside of the uterus, the uterus is filled with salt water
(saline). This lets the doctor see and biopsy anything abnormal, such as
a cancer or a polyp. This is usually done with the patient awake, using
a local anesthesia (numbing medicine).
Dilation and curettage (D&C)
If the endometrial biopsy sample doesn't
provide enough tissue, or if the biopsy suggests cancer but the results
are uncertain, a D&C must be done. In this outpatient procedure, the
opening of the cervix is enlarged (dilated) and a special instrument is
used to scrape tissue from inside the uterus. This may be done with or
without a hysteroscopy.
The procedure takes about an hour and may
require general anesthesia (where you are asleep) or conscious sedation
(medicine given into a vein to make you drowsy) either with local
anesthesia injected into the cervix or a spinal (or epidural). A D&C
is usually done in an outpatient surgery area of a clinic or hospital.
Most women have little discomfort after this procedure.
Testing of endometrial tissue
Endometrial tissue samples removed by biopsy
or D&C are looked at under the microscope to see whether cancer is
present. If cancer is found, the lab report will state what type of
endometrial cancer it is (like endometrioid or clear cell) and what
grade it is.
Endometrial cancer is graded on a scale of 1
to 3 based on how much it looks like normal endometrium. Women with lower grade cancers are less likely to have advanced disease or recurrences.
If the doctor suspects hereditary nonpolyposis colon cancer
(HNPCC) as an underlying cause of the endometrial cancer, the tumor
tissue can be tested for protein changes (such as having fewer mismatch
repair proteins) or DNA changes (called microsatellite instability, or
MSI) that can happen when one of the genes that causes HNPCC is faulty.
If these protein or DNA changes are present, the doctor may recommend
that you see a genetic counselor to consider genetic testing for the
genes that cause HNPCC. Testing for low mismatch repair protein levels
or for MSI is most often ordered in women diagnosed with endometrial
cancer at an earlier than usual age or who have a family history of
endometrial or colon cancer.
Imaging tests for endometrial cancer
Transvaginal ultrasound or sonography
Ultrasound tests use sound waves to take pictures of parts of the body. For a transvaginal ultrasound a
probe that gives off sound waves is inserted into the vagina. The sound
waves create images of the uterus and other pelvic organs. These images
often help show whether the endometrium is thicker than usual, which
can be a sign of endometrial cancer. It may also help see if a cancer is
growing into the muscle layer of the uterus (myometrium).
In order for the doctor to see the uterine
lining more clearly, salt water (saline) may be put through a small tube
into the uterus before the sonogram. This procedure is called a saline infusion sonogram or hysterosonogram. Sonography may help doctors direct their biopsy if other procedures didn't detect a tumor.
Cystoscopy and proctoscopy
If a woman has problems that suggest the
cancer has spread to the bladder or rectum, the inside of these organs
can be looked at through a lighted tube. In cystoscopy the tube is placed into the bladder through the urethra. In proctoscopy
the tube is placed in the rectum. These exams allow the doctor to look
for possible cancers. Small tissue samples can also be removed during
these procedures for pathologic (microscopic) testing. They can be done
using a local anesthetic but some patients may require general
anesthesia. Your doctor will let you know what to expect before and
after the procedure. These procedures were used more often in the past,
but now are rarely part of the work up for endometrial cancer.
Computed tomography (CT)
The CT scan is an x-ray procedure that
creates detailed, cross-sectional images of your body. For a CT scan,
you lie on a table while an X-ray takes pictures. Instead of taking one
picture, like a standard x-ray, a CT scanner takes many pictures as the
camera rotates around you. A computer then combines these pictures into
an image of a slice of your body. The machine will take pictures of many
slices of the part of your body that is being studied.
Before any pictures are taken, you may be
asked to drink 1 to 2 pints of a liquid called oral contrast. This helps
outline the intestine so that certain areas are not mistaken for
tumors. You may also receive an IV (intravenous) line through which a
different kind of contrast dye (IV contrast) is injected. This helps
better outline structures in your body.
The injection can cause some flushing
(redness and warm feeling that may last hours to days). A few people are
allergic to the dye and get hives. Rarely, more serious reactions like
trouble breathing and low blood pressure can occur. Medicine can be
given to prevent and treat allergic reactions. Be sure to tell the
doctor if you have ever had a reaction to any contrast material used for
x-rays.
CT scans are not used to diagnose
endometrial cancer. However, they may be helpful to see whether the
cancer has spread to other organs and to see if the cancer has come back
after treatment.
CT scans can also be used to precisely guide
a biopsy needle into a suspected area of cancer spread. For this
procedure, called a CT-guided needle biopsy, you remain on the CT
scanning table while a doctor moves a biopsy needle toward the mass. CT
scans are repeated until the doctor is sure that the needle is inside
the mass. A fine needle biopsy sample (tiny fragment of tissue) or a
core needle biopsy sample (a thin cylinder of tissue about ½ inch long
and less than 1/8 inch in diameter) is removed and looked at under a microscope.
CT scans take longer than regular x-rays.
You might feel a bit confined by the ring you lie within when the
pictures are being taken.
Magnetic resonance imaging (MRI)
MRI scans use radio waves and strong magnets
instead of x-rays. The energy from the radio waves is absorbed and then
released in a pattern formed by the type of tissue and by certain
diseases. A computer translates the pattern of radio waves given off by
the tissues into a very detailed image of parts of the body. This
creates cross sectional slices of the body like a CT scanner and it also
produces slices that are parallel with the length of your body.
MRI scans are particularly helpful in
looking at the brain and spinal cord. Some doctors also think MRI is a
good way to tell whether, and how far, the endometrial cancer has grown
into the body of the uterus. MRI scans may also help find enlarged lymph
nodes with a special technique that uses very tiny particles of iron
oxide. These are given into a vein and settle into lymph nodes where
they can be spotted by MRI.
Sometimes a contrast material is injected
into a vein, just as with CT scans. The contrast used for MRI is
different than the one used for CT, so being allergic to one doesn’t
mean you are allergic to the other. MRI scans are a little more
uncomfortable than CT scans. First, they take longer, often up to an
hour. Also, you have to be placed inside a tube, which is confining and
can upset people with fear of enclosed places. Special, “open” MRI
machines can help with this if needed, however the drawback is that the
images may not be as good. The machine also makes a thumping or buzzing
noise that you may find disturbing. Many places will provide headphones
with music to block this out.
Positron emission tomography (PET)
In this test radioactive glucose (sugar) is
given to look for cancer cells. Because cancers use glucose (sugar) at a
higher rate than normal tissues, the radioactivity will tend to
concentrate in the cancer. A scanner can spot the radioactive deposits.
This test can be helpful for spotting small collections of cancer cells.
Special scanners combine a PET scan with a CT to more precisely locate
areas of cancer spread. PET scans are not a routine part of the work-up
of early endometrial cancer, but may be used for more advanced cases.
Chest x-ray
This test can show whether the cancer has
spread to the lungs. It may also be used to look for serious lung or
heart problems, especially before surgery.
Blood tests
Complete blood count
The complete blood count (CBC) is a test
that measures the different cells in the blood, such as the red blood
cells, the white blood cells, and the platelets. Many times women with a
lot of blood loss from the uterus will have low red blood cell counts
(anemia).
CA 125 blood test
CA 125 is a substance released into the
bloodstream by many, but not all, endometrial and ovarian cancers. In
someone with endometrial cancer, a very high blood CA 125 level suggests
that the cancer has probably spread beyond the uterus. If CA 125 levels
are high before surgery, some doctors check follow-up levels to find
out how well the treatment is working (levels will drop after surgery if
treatment is effective) and to see if the cancer has come back after
initially successful treatment.
How is endometrial cancer staged?
Staging is the process of looking at
all of the information the doctors have learned about your tumor to tell
how much the cancer may have spread. The stage of an endometrial cancer
is the most important factor in choosing a treatment plan. Ask your
doctor to explain the stage of your cancer so that you can make fully
informed choices about your treatment.
Doctors use a staging system to describe how
far a patient's cancer has spread. The 2 systems used for staging
endometrial cancer, the FIGO (International Federation of
Gynecology and Obstetrics) system and the American Joint Committee on
Cancer TNM staging system are basically the same. They both classify
this cancer on the basis of 3 factors: the extent of the tumor (T),
whether the cancer has spread to lymph nodes (N) and whether it has
spread to distant sites (M). The system described below is the most
recent AJCC system, which went into effect January 2010. The difference
between the AJCC system and the FIGO system is that the FIGO system
doesn’t include stage 0.
Endometrial cancer is staged based on examination of tissue removed during an operation. This is known as surgical staging, and means that doctors often can't tell for sure what stage the cancer is in until after surgery is done.
A doctor may order tests before surgery,
such as ultrasound, MRI, or CT scan, to look for signs that a cancer has
spread. Although it is not as good as the surgical stage, this
information can be helpful in planning surgery and other treatments. If
these tests show that the cancer may have spread outside the uterus, you
may be referred to a gynecologic oncologist (if you are not already
seeing one).
The staging system looks at how far the cancer has spread:
- It can spread locally to the cervix and other parts of the uterus.
- It can also spread regionally to nearby lymph nodes (bean-sized organs that are part of the immune system). The regional lymph nodes are found in the pelvis and farther away along the aorta (the main artery that runs from the heart down along the back of the abdomen and pelvis). The lymph nodes along the aorta are called para-aortic nodes.
- Finally, the cancer can spread (metastasize) to distant lymph nodes, the upper abdomen, the omentum (a large fatty sheet of tissue in the abdomen that drapes like an apron over the stomach, intestines, and other organs), or other organs such as lung, liver, bone, and brain.
Tumor extent (T)
T0: No signs of a tumor in the uterus
Tis: Pre-invasive cancer (also called carcinoma in-situ). Cancer cells are only found in the surface layer of cells of the endometrium, without growing into the layers of cells below.
T1: The cancer is only growing in the
body of the uterus. It may also be growing into the glands of the
cervix, but is not growing into the supporting connective tissue of the
cervix.
- T1a: The cancer is in the endometrium (inner lining of the uterus) and may have grown from the endometrium less than halfway through the underlying muscle layer of the uterus (the myometrium).
- T1b: The cancer has grown from the endometrium into the myometrium, growing more than halfway through the myometrium. The cancer has not spread beyond the body of the uterus.
T2: The cancer has spread from
the body of the uterus and is growing into the supporting connective
tissue of the cervix (called the cervical stroma). The cancer has not
spread outside of the uterus.
T3: The cancer has spread outside of the uterus, but has not spread to the inner lining of the rectum or urinary bladder.
- T3a: The cancer has spread to the outer surface of the uterus (called the serosa) and/or to the fallopian tubes or ovaries (the adnexa)
- T3b: The cancer has spread to the vagina or to the tissues around the uterus (the parametrium).
T4: The cancer has spread to the inner lining of the rectum or urinary bladder (called the mucosa)
Lymph node spread (N)
NX: spread to nearby lymph nodes cannot be assessed
N0: no spread to nearby lymph nodes
N1: cancer has spread to lymph nodes in the pelvis
N2: cancer has spread to lymph nodes along the aorta (peri-aortic lymph nodes)
Distant spread (M)
M0: The cancer has not spread to distant lymph nodes, organs, or tissues
M1: The cancer has spread to distant lymph nodes, the upper abdomen, the omentum, or other organs (such as the lungs or liver)
AJCC stage grouping and FIGO stages
Information about the tumor, lymph nodes,
and any cancer spread is then combined to assign the stage of disease.
This process is called stage grouping. The stages are described
using the number 0 and Roman numerals from I to IV. Some stages are
divided into sub-stages indicated by letters and numbers.
Stage 0
Tis, N0, M0: This stage is also known as carcinoma in-situ.
Cancer cells are only found in the surface layer of cells of the
endometrium, without growing into the layers of cells below. The cancer
has not spread to nearby lymph nodes or distant sites. This is a
pre-cancerous lesion. This stage is not included in the FIGO staging
system.
Stage I
T1, N0, M0: The cancer is only
growing in the body of the uterus. It may also be growing into the
glands of the cervix, but is not growing into the supporting connective
tissue of the cervix. The cancer has not spread to lymph nodes or distant sites.
- Stage IA (T1a, N0, M0): In this earliest form of stage I, the cancer is in the endometrium (inner lining of the uterus) and may have grown from the endometrium less than halfway through the underlying muscle layer of the uterus (the myometrium). It has not spread to lymph nodes or distant sites.
- Stage IB (T1b, N0, M0): The cancer has grown from the endometrium into the myometrium, growing more than halfway through the myometrium. The cancer has not spread beyond the body of the uterus.
Stage II
T2, N0, M0: The cancer has spread
from the body of the uterus and is growing into the supporting
connective tissue of the cervix (called the cervical stroma). The cancer
has not spread outside of the uterus. The cancer has not spread to
lymph nodes or distant sites.
Stage III
T3, N0, M0: Either the cancer has spread outside of the uterus or into nearby tissues in the pelvic area.
- Stage IIIA (T3a, N0, M0): The cancer has spread to the outer surface of the uterus (called the serosa) and/or to the fallopian tubes or ovaries (the adnexa). The cancer has not spread to lymph nodes or distant sites.
- Stage IIIB (T3b, N0, M0): The cancer has spread to the vagina or to the tissues around the uterus (the parametrium). The cancer has not spread to lymph nodes or distant sites.
- Stage IIIC1 (T1 to T3, N1, M0): The cancer is growing in the body of the uterus. It may have spread to some nearby tissues, but is not growing into the inside of the bladder or rectum. The cancer has spread to pelvic lymph nodes but not to lymph nodes around the aorta or distant sites.
- Stage IIIC2 (T1 to T3, N2, M0): The cancer is growing in the body of the uterus. It may have spread to some nearby tissues, but is not growing into the inside of the bladder or rectum. The cancer has spread to lymph nodes around the aorta (peri-aortic lymph nodes) but not to distant sites.
Stage IV
The cancer has spread to the inner surface
of the urinary bladder or the rectum (lower part of the large
intestine), to lymph nodes in the groin, and/or to distant organs, such
as the bones, omentum or lungs.
- Stage IVA (T4, any N, M0): The cancer has spread to the inner lining of the rectum or urinary bladder (called the mucosa). It may or may not have spread to nearby lymph nodes but has not spread to distant sites.
- Stage IVB (any T, any N, M1): The cancer has spread to distant lymph nodes, the upper abdomen, the omentum, or to organs away from the uterus, such as the bones, omentum, or lungs. The cancer can be any size and it may or may not have spread to lymph nodes.
Survival by stage of endometrial cancer
Survival rates are often used by doctors as a
standard way of discussing a person's prognosis (outlook). Some
patients with cancer may want to know the survival statistics for people
in similar situations, while others may not find the numbers helpful,
or may even not want to know them.
The 5-year survival rate refers to the
percentage of patients who live at least 5 years after their cancer is
diagnosed. Of course, many people live much longer than 5 years (and
many are cured). Also, although some people die of their cancer, others
die from something else. These are observed survival rates, and include deaths from all causes, not just from cancer.
In order to get 5-year survival rates,
doctors have to look at people who were treated at least 5 years ago.
Improvements in treatment since then may result in a more favorable
outlook for people now being diagnosed with endometrial cancer.
Survival rates are often based on previous
outcomes of large numbers of people who had the disease, but they cannot
predict what will happen in any particular person's case. Many other
factors may affect a person's outlook, such as their general health and
how well the cancer responds to treatment. Your doctor can tell you how
the numbers below may apply to you, as he or she is familiar with the
aspects of your particular situation.
The numbers below come from the National
Cancer Data Base as published in the AJCC Staging Manual in 2010, and
are based on people diagnosed between 2000 and 2002.
Endometrial adenocarcinoma
Stage
|
5-year survival
|
Stage 0
|
90%
|
Stage IA
|
88%
|
Stage IB
|
75%
|
Stage II
|
69%
|
Stage IIIA
|
58%
|
Stage IIIB
|
50%
|
Stage IIIC
|
47%
|
Stage IVA
|
17%
|
Stage IVB
|
15%
|
The statistics below for uterine
carcinosarcoma are different from those given for endometrial
adenocarcinoma in some important ways.
- The numbers given are for 5-year relative survival. These rates assume that some people will die of other causes and compare the observed survival with that expected for people without the cancer. This can better show the impact of a particular type and stage of cancer on survival.
- These numbers come from a different source -- the SEER program from the National Cancer Institute.
- The stages listed are based on an older version of staging. In the most recent staging system, some of the cancers that were stage III might actually be considered stage I or II.
These differences in staging may make it more difficult to apply these numbers to your own situation.
Uterine carcinosarcoma
Stage
|
5-year relative survival
|
Stage I
|
70%
|
Stage II
|
45%
|
Stage III
|
30%
|
Stage IV
|
15%
|
How is endometrial cancer treated?
This information
represents the views of the doctors and nurses serving on the American
Cancer Society's Cancer Information Database Editorial Board. These
views are based on their interpretation of studies published in medical
journals, as well as their own professional experience.
The
treatment information in this document is not official policy of the
Society and is not intended as medical advice to replace the expertise
and judgment of your cancer care team. It is intended to help you and
your family make informed decisions, together with your doctor.
Your
doctor may have reasons for suggesting a treatment plan different from
these general treatment options. Don't hesitate to ask him or her
questions about your treatment options.
General treatment information
After all of the test results have been
reviewed, your doctor will recommend one or more treatment options. The
four basic types of treatment for women with endometrial cancer are:
- Surgery
- Radiation therapy
- Hormonal therapy
- Chemotherapy
Surgery is the main treatment for most
women with this cancer. But in certain situations, a combination of
these treatments may be used. The choice of treatment depends largely on
the type of cancer and stage
of the disease when it is found. Other factors could play a part in
choosing the best treatment plan. These might include your age, your
overall state of health, whether you plan to have children, and other
personal considerations.
It is important to discuss all of your
treatment options with your doctors to help make the decision that best
fits your needs.
Be sure you understand all the risks and side effects of the different
treatment options before making a decision. If there is anything you do
not understand, ask to have it explained again.
When considering your treatment options it
is often a good idea to seek a second opinion, if possible. This can
provide more information and help you feel confident about the treatment
plan you choose. Some insurance companies require a second opinion
before they will pay for certain treatments, but a second opinion is
usually not required for routine cancer treatments.
The next few sections describe the different types of treatment. This is followed by a section on the standard treatment options for each stage of endometrial cancer.
Surgery for endometrial cancer
Hysterectomy
The main treatment for endometrial cancer is
an operation to remove the uterus and cervix (called a hysterectomy).
When the uterus is removed through an incision in the abdomen, it is
called a simple or total abdominal hysterectomy (TAH). If the uterus is
removed through the vagina, it is known as a vaginal hysterectomy.
Removing the ovaries and fallopian tubes, a bilateral salpingo-oophorectomy
(BSO), is not actually part of a hysterectomy; it is a separate
procedure that is often done during the same operation (see below). For
endometrial cancer, removing the uterus but not the ovaries or fallopian
tubes is seldom recommended, but it may be considered in women who are
premenopausal. To decide what stage
the cancer is in, lymph nodes in the pelvis and around the aorta will
also need to be removed (see below). This can be done through the same
incision as the abdominal hysterectomy. If a vaginal hysterectomy is
done, lymph nodes can be removed by laparoscopy (this is discussed in
detail below).
A radical hysterectomy is done when endometrial cancer has spread to the cervix or the area around the cervix (called the parametrium).
In this operation, the entire uterus, the tissues next to the uterus
(parametrium and uterosacral ligaments), and the upper part of the
vagina (next to the cervix) are all removed. For endometrial cancer, a
BSO is done at the same time. This operation is most often done through
an incision in the abdomen, but it can also be done going in through the
vagina.
When a vaginal approach is used, laparoscopy
is used to help safely remove all of the correct tissues. Laparoscopy
is a technique that lets the surgeon look at the inside of the abdomen
and pelvis through tubes inserted into very small incisions. Small
surgical instruments can be controlled through the tubes, allowing the
surgeon to operate without a large incision in the abdomen. This can
shorten the time needed for recovery from surgery. Both a hysterectomy
and a radical hysterectomy can also be done through the abdomen using
laparoscopy.
Surgery for endometrial cancer using
laparoscopy seems to be just as good as more traditional open procedures
if done by a surgeon who has a lot of experience in laparoscopic cancer
surgeries. The DaVinci® robot is increasingly used to perform laparoscopic procedures.
For any of these surgeries, either general
anesthesia or regional anesthesia will be used so the patient is asleep
or sedated during these operations.
Bilateral salpingo-oophorectomy
This operation removes both fallopian tubes
and both ovaries. This procedure is usually done at the same time the
uterus is removed (either by simple hysterectomy or radical
hysterectomy) to treat endometrial cancers. Removing both ovaries means
that you will go into menopause if you have not done so already.
If you are younger than 45 when you get
stage I endometrial cancer, you may discuss keeping your ovaries with
your surgeon, because although women whose ovaries were removed had a
lower chance of the cancer coming back, removing the ovaries didn’t seem
to help them live longer.
Lymph node surgery
Pelvic and para-aortic lymph node dissection:
This operation removes lymph nodes from the pelvis and the area next to
the aorta to see if they contain cancer cells that have spread from the
endometrial tumor. It is called a lymph node dissection when
most or all of the lymph nodes in a certain area are removed. This
procedure is usually done at the same time as the operation to remove
the uterus. If you are having an abdominal hysterectomy, the lymph nodes
can be removed through the same incision. In women who have had a
vaginal hysterectomy, these lymph nodes may be removed by laparoscopic
surgery.
Laparoscopy is a technique that lets the
surgeon look at the inside of the abdomen and pelvis through tubes
inserted into very small incisions. Small surgical instruments can be
controlled through the tubes, allowing the surgeon to remove lymph
nodes. This approach avoids the need for a large incision in the abdomen
so the recovery time is often shorter. A recent study showed that
laparoscopic surgery (including lymph node removal) works as well (at
least in the short-term) as open abdominal surgery.
Lymph node sampling: When only a few of the lymph nodes in an area are removed, it is called lymph node sampling.
Depending on the grade, the amount of cancer
in the uterus and how deeply the cancer invades into the muscle of the
uterus, lymph nodes may not need to be removed.
Pelvic washings
In this procedure, the surgeon “washes” the
abdominal and pelvic cavities with salt water (saline) and sends the
fluid to the lab to see if it contains cancer cells. This is also called
peritoneal lavage.
Other procedures that may be used to look for cancer spread
- Omentectomy: The omentum is a layer of fatty tissue that covers the abdominal contents like an apron. Cancer sometimes spreads to this tissue. When this tissue is removed, it is called an omentectomy. This may be done at the time of a hysterectomy if cancer has spread there or to check for cancer spread.
- Peritoneal biopsies: The tissue lining the pelvis and abdomen is called the peritoneum. Peritoneal biopsies involve removing small pieces of this lining to check for cancer cells.
Tumor debulking
If cancer has spread throughout the abdomen, the surgeon may attempt to remove as much of the tumor as possible. This is called debulking. Debulking a cancer can help other treatments, like radiation or chemotherapy,
work better. Tumor debulking is helpful for other types of cancer, and
it may also be helpful in treating some types of endometrial cancer.
Recovery after surgery
For an abdominal hysterectomy the hospital
stay is usually from 3 to 7 days. The average hospital stay after a
radical hysterectomy is about 5 to 7 days. Complete recovery can take
about 4 to 6 weeks. A laparoscopic procedure and vaginal hysterectomy
usually require a hospital stay of 1 to 2 days and 2 to 3 weeks for
recovery. Complications are unusual but could include excessive
bleeding, wound infection, and damage to the urinary or intestinal
systems.
A radical hysterectomy affects the nerves
that control the bladder, so a catheter is used to drain urine and is
kept in place for at least a few days after surgery. If the bladder
hasn’t recovered completely when it is removed, it may be replaced for a
time or you may be shown how to insert a catheter yourself several
times a day to empty your bladder until bladder function returns.
Side effects
Any hysterectomy causes infertility (not
being able to start or maintain a pregnancy). For those who were
premenopausal before surgery, removing the ovaries will cause menopause.
This can lead to symptoms such as hot flashes, night sweats, and
vaginal dryness. Removing lymph nodes in the pelvis can lead to a build
up of fluid in the legs, a condition called lymphedema. This happens more often if radiation is given after surgery.
Surgery and menopausal symptoms can also affect your sex life.
Radiation therapy for endometrial cancer
Radiation therapy uses high-energy radiation (such as x-rays) to kill cancer cells. It can be given in two ways:
- By placing radioactive materials inside the body near the tumor. This is called internal radiation therapy or brachytherapy.
- By using a machine that focuses a beam of radiation at the tumor, much like having an x-ray. This is called external beam radiation therapy.
In some cases, both brachytherapy and
external beam radiation therapy are given. When that is done, usually
the external beam radiation is given first, followed by the
brachytherapy. The stage and grade of the cancer help determine what areas need to be exposed to radiation therapy and which methods are used.
If your treatment plan includes radiation to be given after surgery, you will be given time to heal from the operation before starting radiation. Often, at least 4 to 6 weeks is needed.
Brachytherapy
For vaginal brachytherapy, a cylinder
containing a source of radiation is inserted into the vagina. The length
of the cylinder (and how much of the vagina is treated) can vary, but
the upper part of the vagina is always treated. With this method, the
radiation mainly affects the area of the vagina in contact with the
cylinder. Nearby structures such as the bladder and rectum get less
radiation exposure. The most common side effect is changes to the lining
of the vagina (discussed in more detail below).
This procedure is done in the radiation
suite of the hospital or care center. The radiation oncologist inserts a
special applicator into the woman's vagina, and pellets of radioactive
material are inserted into the applicator. There are 2 types of
brachytherapy used for endometrial cancer, low-dose rate (LDR) and
high-dose rate (HDR).
In LDR brachytherapy, the radiation devices
are usually left in place for about 1 to 4 days. The patient needs to
stay immobile to keep the radiation sources from moving during
treatment, and so she is usually kept in the hospital overnight. Several
treatments may be necessary. Because the patient has to stay immobile,
this form of brachytherapy carries a risk of serious blood clots in the
legs (called deep venous thrombosis or DVT). LDR is less commonly used
now in this country.
In HDR brachytherapy, the radiation is more
intense. Each dose takes a very short period of time (usually less than
an hour), and the patient can return home the same day. For endometrial
cancer, HDR brachytherapy is often given weekly or even daily for at
least 3 doses.
External beam radiation therapy
In this type of treatment the radiation is delivered from a source outside of the body.
External beam radiation therapy is often
given 5-days-a-week for 4 to 6 weeks. The skin covering the treatment
area is carefully marked with permanent ink or injected dye similar to a
tattoo. A special mold of the pelvis and lower back is custom made to
ensure that the woman is placed in the exact same position for each
treatment. Each treatment takes less than a half-hour, but the daily
visits to the radiation center may be tiring and inconvenient.
Side effects of radiation therapy
Short-term side effects: Common side effects of radiation therapy include tiredness, upset stomach, or loose bowels. Serious fatigue,
which may not occur until about 2 weeks after treatment begins, is a
common side effect. Diarrhea is common, but can usually be controlled
with over-the-counter medicines. Nausea and vomiting
may also occur, but can be treated with medication. These side effects
are more common with pelvic radiation than with vaginal brachytherapy.
Side effects tend to be worse when chemotherapy is given with radiation.
Skin changes are also common, which can
range from mild redness to peeling and blistering. The skin may release
fluid, which can lead to infection, so care must be taken to clean and
protect the area exposed to radiation. Sometimes, as it heals, the skin
in the treated area becomes darker or less flexible (harder).
Radiation can irritate the bladder, and problems with urination may occur. Irritation to the bladder, called radiation cystitis, can result in discomfort, blood in the urine, and an urge to urinate often.
Radiation can also cause similar changes in the intestine. When there is rectal irritation or bleeding, it is called radiation proctitis.
This is sometimes treated with enemas that contain a steroid (like
hydrocortisone) or suppositories that contain an anti-inflammatory.
Radiation can irritate the vagina, leading to discomfort and drainage (a discharge). If this, called radiation vaginitis,
occurs, your radiation doctor may recommend douching with a dilute
solution of hydrogen peroxide. When the irritation is severe, open sores
can develop in the vagina, which may need to be treated with an
estrogen cream.
Radiation can also lead to low blood counts,
causing anemia (low red blood cells) and leukopenia (low white blood
cells). The blood counts usually return to normal within a few weeks
after radiation is stopped.
Long-term side effects: Radiation
therapy may cause changes to the lining of the vagina leading to vaginal
dryness. This is more common after vaginal brachytherapy than after
pelvic radiation therapy. In some cases scar tissue can form in the
vagina. The scar tissue can make the vagina shorter or more narrow
(called vaginal stenosis), which can make sex (vaginal
intercourse) painful. A woman can help prevent this problem by
stretching the walls of her vagina several times a week. This can be
done by having sexual intercourse 3 to 4 times per week or by using a
vaginal dilator (a plastic or rubber tube used to stretch out the
vagina). Still, vaginal dryness and pain with intercourse can be
long-term side effects from radiation. Some centers have physical
therapists who specialize in pelvic floor therapy which can help to
treat these vaginal symptoms and sometimes improve sexual function. You
should ask your physician about this if you are bothered by these
problems.
Pelvic radiation can damage the ovaries,
resulting in premature menopause. However, this is not an issue for most
women who are being treated for endometrial cancer because they have
already gone through menopause, either naturally or as a result of
surgery to treat the cancer (hysterectomy and removal of the ovaries).
Pelvic radiation therapy can also lead to a
blockage of the fluid draining from the leg. This can lead to severe
swelling, known as lymphedema. Lymphedema is a long-term side
effect; it doesn't go away after radiation is stopped. In fact it may
not appear for several months after treatment ends. This side effect is
more common if pelvic lymph nodes were removed during surgery to remove
the cancer. There are specialized physical therapists who can help treat
this. It is important to begin treatment early if you develop it.
Radiation to the pelvis can also weaken the
bones, leading to fractures of the hips or pelvic bones. It is important
that women who have had endometrial cancer contact their doctor right
away if they have pelvic pain. Such pain might be caused by a fracture,
recurrent cancer, or other serious conditions.
Pelvic radiation can also lead to long-term
problems with the bladder (radiation cystitis) or bowel (radiation
proctitis). Rarely, radiation damage to the bowel can cause a blockage
(called obstruction) or for an abnormal connection to form between the bowel and the vagina or outside skin (called a fistula). These conditions may need to be treated with surgery.
If you are having side effects from
radiation, discuss them with your doctor. There are things you can do to
get relief from these symptoms or to prevent them from happening.
Chemotherapy for endometrial cancer
Chemotherapy (often called “chemo”) is the
use of cancer-fighting drugs given into a vein or by mouth. These drugs
enter the bloodstream and reach throughout the body, making this
treatment potentially useful for cancer that has spread beyond the
endometrium. If this treatment is chosen, you may receive a combination
of drugs. Combination chemotherapy sometimes works better than one drug
alone in treating cancer.
Chemo is often given in cycles, in which a
period of treatment is followed by a rest period. The chemo drugs may be
given on one or more days in each cycle.
Drugs used in treating endometrial cancer may include:
- Paclitaxel (Taxol®)
- Carboplatin
- Doxorubicin (Adriamycin®) or liposomal doxorubicin (Doxil®)
- Cisplatin
Most often, 2 or more drugs are
combined for treatment. The most common combinations include carboplatin
with paclitaxel and cisplatin with doxorubicin. Less often, paclitaxel
and doxorubicin and cisplatin/paclitaxel/doxorubicin may be used.
For carcinosarcoma, the chemo drug ifosfamide (Ifex®),
either alone or in combination with either carboplatin, cisplatin or
paclitaxel, is often used. However, the combination of carboplatin and
paclitaxel is also often being used for carcinosarcoma.
Sometimes chemo is given for a few cycles, followed by radiation. Then chemo is given again. This is called sandwich therapy and is sometimes used for endometrial papillary serous cancer and uterine carcinosarcoma.
Side effects of chemotherapy
These drugs kill cancer cells but can also
damage some normal cells, which in turn can cause side effects. Side
effects of chemotherapy depend on the specific drugs, the amount taken,
and the length of time you are treated. Common side effects include:
- Nausea and vomiting
- Loss of appetite
- Mouth and vaginal sores
- Hair loss
Also, most chemotherapy drugs can
damage the blood-producing cells of the bone marrow. This can result in
low blood cell counts, such as:
- Low white blood cells which increases the risk of infection
- Low platelet counts which can cause bleeding or bruising after minor cuts or injuries
- Low red blood cells (anemia) which can cause problems like fatigue and shortness of breath
Most of the side effects of
chemotherapy stop when the treatment is over, but some can last a long
time. Different drugs can cause different side effects. For example, the
drug doxorubicin can damage the heart muscle over time. The chance of
heart damage goes up as the total dose of the drug goes up, so doctors
place a limit on how much doxorubicin is given. Cisplatin can cause
kidney damage, so you will be given large amounts of IV fluids before
and after chemotherapy to help protect the kidneys. Both cisplatin and
paclitaxel can cause nerve damage (called neuropathy). This can
lead to numbness, tingling, or even pain in the hands and feet.
Ifosfamide can injure the lining of the bladder, causing it to bleed
(called hemorrhagic cystitis). To prevent this, you might be given large amounts of IV fluids and a drug called mesna
along with the chemo. Before starting chemotherapy, be sure to discuss
the drugs and their possible side effects with your health care team.
If you have side effects while on
chemotherapy, remember that there are ways to prevent or treat many of
them. For example, modern anti-nausea drugs can prevent or reduce nausea
and vomiting. Be sure to talk with your doctor or nurse about any side
effects you are having.
Hormone therapy for endometrial cancer
Hormone therapy is the use of hormones or
hormone blocking drugs to fight cancer. This type of hormone therapy is
not the same as hormones given to treat the symptoms of menopause
(menopausal hormone therapy).
Progestins
The main hormone treatment for endometrial
cancer uses progesterone-like drugs called progestins. The 2 most
commonly used progestins are medroxyprogesterone acetate (Provera®, which can be given as an injection or as a pill) and megestrol acetate (Megace®,
which is given as a pill). These drugs work by slowing the growth of
endometrial cancer cells. Side effects can include hot flashes, night
sweats, and weight gain (from fluid retention and an increased
appetite), For women with diabetes, progestins can cause increased blood
sugar levels. Rarely, serious blood clots can happen.
Sometimes endometrial hyperplasia and early
endometrial cancers can be treated with an intrauterine device that
contains levonorgestrel, a progestin. This may be combined with another
hormone drug, such as medroxyprogesterone acetate or a
gonadotropin-releasing hormone agonist (see below).
Tamoxifen
Tamoxifen, an anti-estrogen drug often used to treat breast cancer,
may also be used to treat advanced or recurrent endometrial cancer. The
goal of tamoxifen therapy is to prevent any estrogens circulating in
the woman's body from stimulating growth of the cancer cells. Even
though tamoxifen may prevent estrogen from nourishing the cancer cells,
it acts like a weak estrogen in other areas of the body. It does not
cause bone loss, but it can cause hot flashes and vaginal dryness.
People taking tamoxifen also have an increased risk of serious blood
clots in the leg.
Gonadotropin-releasing hormone agonists
Most women with endometrial cancer have had their ovaries removed as a part of treatment. In others, radiation treatments
have made their ovaries inactive. This reduces the production of
estrogen and may also slow the growth of the cancer.
Gonadotropin-releasing hormone (GNRH) agonists are a way to lower
estrogen levels in women who still have functioning ovaries. These drugs
switch off estrogen production by the ovaries in women who are
premenopausal. Examples of GNRH agonists include goserelin (Zoladex®) and leuprolide (Lupron®).
These drugs are injected every 1 to 3 months. Side effects can include
any of the symptoms of menopause, such as hot flashes and vaginal
dryness. If they are taken for a long time (years), these drugs can
weaken bones (sometimes leading to osteoporosis).
Aromatase inhibitors
Even after the ovaries are removed (or are
not functioning), estrogen is still made in fat tissue. This becomes the
body's main source of estrogen. Drugs called aromatase inhibitors can
stop this estrogen from being formed and lower estrogen levels even
further. Examples of aromatase inhibitors include letrozole (Femara®), anastrozole (Arimidex®), and exemestane (Aromasin®).
These drugs are most often used to treat breast cancer, but may be
helpful in the treatment of endometrial cancer. Side effects can include
joint and muscle pain as well as hot flashes. If they are taken for a
long time (years), these drugs can weaken bones (sometimes leading to
osteoporosis). These drugs are still being studied for use in treating
endometrial cancer.