Cancer of the Uterus (Uterine Cancer or Endometrial Cancer)

What is the uterus?

The uterus (from Latin "uterus" (womb, belly), plural uteruses or uteri) or womb is a major female hormone-responsive reproductive sex organ of most mammals including humans. One end, the cervix, opens into the vagina, while the other is connected to one or both fallopian tubes, depending on the species. It is within the uterus that the fetus develops during gestation, usually developing completely in placental mammals such as humans and partially in marsupials such as kangaroos and opossums. The uterus is part of a woman's reproductive system. It's a hollow organ in the pelvis.

The uterus has three parts:

• Top: The top (fundus) of your uterus is shaped like a dome. From the top of your uterus, the fallopian tubes extend to the ovaries.
• Middle: The middle part of your uterus is the body (corpus). This is where a baby grows.
• Bottom: The narrow, lower part of your uterus is the cervix. The cervix is a passageway to the vagina.

The wall of the uterus has two layers of tissue:

• Inner layer: The inner layer (lining) of the uterus is the endometrium. In women of childbearing age, the lining grows and thickens each month to prepare for pregnancy. If a woman does not become pregnant, the thick, bloody lining flows out of the body. This flow is a menstrual period.
• Outer layer: The outer layer of muscle tissue is the myometrium.

What is uterine cancer (endometrial cancer)?

Cancer begins in cells, the building blocks that make up tissues. Tissues make up the uterus and the other organs of the body. Normal cells grow and divide to form new cells as the body needs them. When normal cells grow old or get damaged, they die, and new cells take their place. Sometimes, this process goes wrong. New cells form when the body doesn't need them, and old or damaged cells don't die as they should. The buildup of extra cells often forms a mass of tissue called a growth or tumor. Tumors in the uterus can be benign (not cancer) or malignant (cancer). Benign tumors are not as harmful as malignant tumors:

• Malignant growths:
• may be a threat to life
• usually can be removed but can grow back
• can invade and damage nearby tissues and organs (such as the vagina)
• can spread to other parts of the body
• Benign tumors (such as a fibroid, a polyp, or endometriosis):
• are usually not a threat to life
• can be treated or removed and usually don't grow back
• don't invade the tissues around them
• don't spread to other parts of the body

Cancer cells can spread by breaking away from the uterine tumor. They can travel through lymph vessels to nearby lymph nodes. Also, cancer cells can spread through the blood vessels to the lung, liver, bone, or brain. After spreading, cancer cells may attach to other tissues and grow to form new tumors that may damage those tissues.

What causes uterine cancer? Who is at risk for uterine cancer?

When you get a diagnosis of uterine cancer, it's natural to wonder what may have caused the disease. Doctors usually can't explain why one woman gets uterine cancer and another doesn't. However, we do know that women with certain risk factors may be more likely than others to develop uterine cancer. A risk factor is something that may increase the chance of getting a disease.

The following risk factors for uterine cancer:

• Abnormal overgrowth of the endometrium (endometrial hyperplasia): An abnormal increase in the number of cells in the lining of the uterus is a risk factor for uterine cancer. Hyperplasia is not cancer, but sometimes it develops into cancer. Common symptoms of this condition are heavy menstrual periods, bleeding between periods, and bleeding after menopause. Hyperplasia is most common after age 40.

To prevent endometrial hyperplasia from developing into cancer, the doctor may recommend surgery to remove the uterus (hysterectomy) or hormone therapy with progesterone and regular follow-up exams.

• Obesity: Women who are obese have a greater chance of developing uterine cancer.
• Reproductive and menstrual history: Women are at increased risk of uterine cancer if at least one of the following reasons apply:
• Have never had children
• Had their first menstrual period before age 12
• Went through menopause after age 55
• History of taking estrogen alone: The risk of uterine cancer is higher among women who used estrogen alone (without progesterone) for menopausal hormone therapy for many years.
• History of taking tamoxifen: Women who took the drug tamoxifen to prevent or treat breast cancer are at increased risk of uterine cancer.
• History of having radiation therapy to the pelvis: Women who had radiation therapy to the pelvis are at increased risk of uterine cancer.
• Family health history: Women with a mother, sister, or daughter with uterine cancer are at increased risk of developing the disease. Also, women in families that have an inherited form of colorectal cancer (known as Lynch syndrome) are at increased risk of uterine cancer.

Many women who get uterine cancer have none of these risk factors, and many women who have known risk factors don't develop the disease.

What are uterine cancer symptoms and signs?

The most common symptom of uterine cancer is abnormal vaginal bleeding. It may start as a watery, blood-streaked flow that gradually contains more blood. After menopause, any vaginal bleeding is abnormal.

These are common symptoms of uterine cancer:

• Abnormal vaginal bleeding, spotting, or discharge
• Pain or difficulty when emptying the bladder
• Pain during sex
• Pain in the pelvic area

These symptoms may be caused by uterine cancer or by other health problems. Women with these symptoms should tell their doctor so that any problem can be diagnosed and treated as early as possible.

How is a diagnosis of uterine cancer determined?

If you have symptoms that suggest uterine cancer, your doctor will try to find out what's causing the problems. You may have a physical exam and blood tests. Also, you may have one or more of the following tests:

• Biopsy: The removal of tissue to look for cancer cells is a biopsy. A thin tube is inserted through the vagina into your uterus. Your doctor uses gentle scraping and suction to remove samples of tissue. A pathologist examines the tissue under a microscope to check for cancer cells. In most cases, a biopsy is the only sure way to tell whether cancer is present.
• Pelvic exam: Your doctor can check your uterus, vagina, and nearby tissues for any lumps or changes in shape or size.
• Ultrasound: An ultrasound device uses sound waves that can't be heard by humans. The sound waves make a pattern of echoes as they bounce off organs inside the pelvis. The echoes create a picture of your uterus and nearby tissues. The picture can show a uterine tumor. For a better view of the uterus, the device may be inserted into the vagina (trans-vaginal ultrasound).

Grade

If cancer is found, the pathologist studies tissue samples from the uterus under a microscope to learn the grade of the tumor. The grade tells how much the tumor tissue differs from normal uterine tissue. It may suggest how fast the tumor is likely to grow. Tumors with higher grades tend to grow faster than those with lower grades. Tumors with higher grades are also more likely to spread. Doctors use tumor grade along with other factors to suggest treatment options.

How is the stage determined for uterine cancer?

If uterine cancer is diagnosed, your doctor needs to learn the extent (stage) of the disease to help you choose the best treatment. The stage is based on whether the cancer has invaded nearby tissues or spread to other parts of the body. When cancer spreads from its original place to another part of the body, the new tumor has the same kind of abnormal cells and the same name as the primary (original) tumor. For example, if uterine cancer spreads to the lung, the cancer cells in the lung are actually uterine cancer cells. The disease is metastatic uterine cancer, not lung cancer. It's treated as uterine cancer, not as lung cancer. Sometimes Doctors call the new tumor "distant" disease. To learn whether uterine cancer has spread, your doctor may order one or more tests:

• CT scan: An x-ray machine linked to a computer takes a series of detailed pictures of your pelvis, abdomen, or chest. You may receive an injection of contrast material so your lymph nodes and other tissues show up clearly in the pictures. A CT scan can show cancer in the uterus, lymph nodes, lungs, or elsewhere.
• Lab tests: A Pap test can show whether cancer cells have spread to the cervix, and blood tests can show how well the liver and kidneys are working. Also, doctor may order a blood test for a substance known as CA-125. Cancer may cause a high level of CA-125.
• Chest x-ray: An x-ray of the chest can show a tumor in the lung.
• MRI: A large machine with a strong magnet linked to a computer is used to make detailed pictures of your uterus and lymph nodes. You may receive an injection of contrast material. MRI can show cancer in the uterus, lymph nodes or other tissues in the abdomen.

In most cases, surgery is needed to learn the stage of uterine cancer. The surgeon removes the uterus and may take tissue samples from the pelvis and abdomen. After the uterus is removed, it is checked to see how deeply the tumor has grown. Also, the other tissue samples are checked for cancer cells. These are the stages of uterine cancer:

• Stage 0: The abnormal cells are found only on the surface of the inner lining of the uterus. The doctor may call this carcinoma in situ.
• Stage I: The tumor has grown through the inner lining of the uterus to the endometrium. It may have invaded the myometrium.
• Stage II: The tumor has invaded the cervix.
• Stage III: The tumor has grown through the uterus to reach nearby tissues, such as the vagina or a lymph node.
• Stage IV: The tumor has invaded the bladder or intestine. Or, cancer cells have spread to parts of the body far away from the uterus, such as the liver, lungs, or bones.

What are treatment options for uterine cancer?

Treatment options for people with uterine cancer are surgery, radiation therapy, chemotherapy, and hormone therapy. You may receive more than one type of treatment.

The treatment that's suit for you depends mainly on the following:

• Whether the tumor has invaded the muscle layer of the uterus
• Whether the tumor has invaded tissues outside the uterus
• Whether the tumor has spread to other parts of the body
• The grade of the tumor
• Your age and general health

Specialists who treat uterine cancer include gynecologists, gynecologic oncologists (doctors who specialize in treating female cancers), medical oncologists, and radiation oncologists. Your health care team may also include an oncology nurse and a registered dietitian. Your health care team can describe your treatment choices, the expected results of each, and the possible side effects. Because cancer therapy often damages healthy cells and tissues, side effects are common. Before treatment starts, ask your health care team about possible side effects and how treatment may change your normal activities. You and your health care team can work together to develop a treatment plan that meets your needs.

What about surgery for the treatment of endometrial cancer?

Surgery is the most common treatment for women with uterine cancer. You and your surgeon can talk about the types of surgery (hysterectomy) and which may be right for you.

The surgeon usually removes the uterus, cervix, and nearby tissues. The nearby tissues may include:

• Fallopian tubes
• Ovaries
• Part of the vagina
• Nearby lymph nodes

The time it takes to heal after surgery is different for each woman. After a hysterectomy, most women go home in a couple of days, but some women leave the hospital the same day. You'll probably return to your normal activities within 4 to 8 weeks after surgery. You may have pain or discomfort for the first few days. Medicine can help control your pain. Before surgery, you should discuss the plan for pain relief with your doctor or nurse. After surgery, your doctor can adjust the plan if you need more pain control. It's common to feel tired or weak for a while. You may have nausea and vomiting. Some women are constipated after surgery or lose control of their bladder. These effects are usually temporary.

If you haven't gone through menopause yet, you'll stop having menstrual periods after surgery, and you won't be able to become pregnant. Also, you may have hot flashes, vaginal dryness, and night sweats. These symptoms are caused by the sudden loss of female hormones. Talk with your doctor or nurse about your symptoms so that you can develop a treatment plan together. There are drugs and lifestyle changes that can help, and most symptoms go away or lessen with time. Surgery to remove lymph nodes may cause lymphedema (swelling) in one or both legs. Your health care team can tell you how to prevent or relieve lymphedema. For some women, a hysterectomy can affect sexual intimacy. You may have feelings of loss that make intimacy difficult. Sharing these feelings with your partner may be helpful.

What about radiation therapy for the treatment of uterine cancer?

Radiation therapy is an option for women with all stages of uterine cancer. It may be used before or after surgery. For women who can't have surgery for other medical reasons, radiation therapy may be used instead to destroy cancer cells in the uterus. Women with cancer that invades tissue beyond the uterus may have radiation therapy and chemotherapy. Radiation therapy uses high-energy rays to kill cancer cells. It affects cells in the treated area only.

Doctors use two types of radiation therapy to treat uterine cancer. Some women receive both types:

• External radiation therapy: A large machine directs radiation at your pelvis or other areas with cancer. The treatment is usually given in a hospital or clinic. You may receive external radiation 5 days a week for several weeks. Each session takes only a few minutes.
• Internal radiation therapy (also called brachytherapy): A narrow cylinder is placed inside your vagina, and a radioactive substance is loaded into the cylinder. Usually, a treatment session lasts only a few minutes and you can go home afterward. This common method of brachytherapy may be repeated two or more times over several weeks. Once the radioactive substance is removed, no radioactivity is left in the body.

Side effects depend mainly on which type of radiation therapy is used, how much radiation is given, and which part of your body is treated. External radiation to the abdomen and pelvis may cause nausea, vomiting, diarrhea, or urinary problems. You may lose hair in your genital area. Also, your skin in the treated area may become red, dry, and tender. You are likely to become tired during external radiation therapy, especially in the later weeks of treatment. Resting is important, but doctors usually advise patients to try to stay as active as they can.

For women who have not had surgery to remove the ovaries, external radiation aimed at the pelvic area can harm the ovaries. Menstrual periods usually stop, and women may have hot flashes and other symptoms of menopause. Menstrual periods are more likely to return for younger women. After either type of radiation therapy, you may have dryness, itching, or burning in your vagina. Your doctor may advise you to wait to have sex until a few weeks after radiation therapy ends. Also, radiation therapy may make the vagina narrower. A narrow vagina can make sex or follow-up exams difficult. There are ways to prevent this problem. If it does occur, however, your health care team can tell you about ways to expand the vagina. Although the side effects of radiation therapy can be upsetting, they can usually be treated or controlled. Talk with your doctor or nurse about ways to relieve discomfort.

What about chemotherapy for the treatment of endometrial cancer?

Chemotherapy uses drugs to kill cancer cells. It may be used after surgery to treat uterine cancer that has an increased risk of returning after treatment. For example, uterine cancer that is a high grade or is Stage II, III, or IV may be more likely to return. Also, chemotherapy may be given to women whose uterine cancer can't be completely removed by surgery. For advanced cancer, it may be used alone or with radiation therapy. Chemotherapy for uterine cancer is usually given by vein (intravenous). It's usually given in cycles. Each cycle has a treatment period followed by a rest period. You may have your treatment in an outpatient part of the hospital, at the doctor's office, or at home. Some women may need to stay in the hospital during treatment.

The side effects depend mainly on which drugs are given and how much. Chemotherapy kills fast-growing cancer cells, but the drugs can also harm normal cells that divide rapidly.

• Blood cells: When drugs lower the levels of healthy blood cells, you're more likely to get infections, bruise or bleed easily, and feel very weak and tired. Your health care team will check for low levels of blood cells. If your levels are low, your health care team may stop the chemotherapy for a while or reduce the dose of the drug. There are also medicines that can help your body make new blood cells.
• Cells in hair roots: Chemotherapy may cause hair loss. If you lose your hair, it will grow back after treatment, but the color and texture may be changed.
• Cells that line the digestive system: Chemotherapy can cause a poor appetite, nausea and vomiting, diarrhea, or mouth and lip sores. Your health care team can give you medicines and suggest other ways to help with these problems. They usually go away when treatment ends.

Other possible side effects include skin rash, tingling or numbness in your hands and feet, hearing problems, loss of balance, joint pain, or swollen legs and feet. Your health care team can suggest ways to control many of these problems. Most go away when treatment ends.

What about hormone therapy for the treatment of uterine cancer?

Some uterine tumors need hormones to grow. These tumors have hormone receptors for the hormones estrogen, progesterone, or both. If lab tests show that the tumor in your uterus has these receptors, then hormone therapy may be an option. Hormone therapy may be used for women with advanced uterine cancer. Also, some women with Stage I uterine cancers who want to get pregnant and have children choose hormone therapy instead of surgery.

The most common drug used for hormone therapy is progesterone tablets. Possible side effects include:

• weight gain,
• swelling, and
• breast tenderness

NutritionIt's important for you to take very good care of yourself before, during, and after cancer treatment. Taking care of yourself includes eating well so that you get the right amount of calories to maintain a good weight. You also need enough protein to keep up your strength. Eating well may help you feel better and have more energy. Sometimes, especially during or soon after treatment, you may not feel like eating. You may be uncomfortable or tired. You may find that foods don't taste as good as they used to. In addition, the side effects of treatment (such as poor appetite, nausea, vomiting, or mouth blisters) can make it hard to eat well. Your doctor, a registered dietitian, or another health care provider can suggest ways to help you meet your nutrition needs.

What sort of follow-up treatment is needed during and after uterine cancer treatment?

You'll need regular checkups (such as every 3 to 6 months) after treatment for uterine cancer. Checkups help ensure that any changes in your health are noted and treated if needed.

You should contact your doctor if you have any of the following health problems between checkups:

• Bleeding from your vagina, bladder, or rectum
• Bloated abdomen or swollen legs
• Pain in the abdomen or pelvis
• Shortness of breath or cough
• Loss of appetite or weight for unknown reason

Uterine cancer may come back after treatment. Your doctor will check for return of cancer. Checkups may include a pelvic exam, lab tests (such as for CA-125), a chest x-ray, a CT scan, or an MRI.

Uterine Cancer (Cancer of the Uterus, Endometrial Cancer) At a Glance

• Cancer of the uterus occurs most often in women between the ages of 55 and 70 years.
• Risk factors (factors that increase chances of developing the disease) have been identified.
• Abnormal bleeding after menopause is the most common symptom of cancer of the uterus.
• Cancer of the uterus is diagnosed based on the results of the pelvic examination, Pap smear, biopsy of the uterus, and D and C procedure.
• Treatment of cancer of the uterus depends on the stage of the disease, the growth rate of the cancer, as well as the age and health of the woman.