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Endometrial Cancer This disease effects mainly postmenopausal women with incidence peaking between ages 50 and 60. Less than 5% of cases occur among women less than 40 years old. As with all cancers, uterine cancer is curable if treated at the early stages. Fortunately, most patients with endometrial cancer are likely to have early stage disease. Women with known risk factors and those who are concerned about uterine cancer should talk with their doctor about the disease, the symptoms to watch for, and an appropriate schedule for checkups. The doctor's advice will be based on the women's age, medical history, and other factors.
Detection
and Prevention of Endometrial Cancer Abnormal vaginal bleeding, especially after menopause, is the most common symptom of uterine cancer. Bleeding may start as a watery, blood-streaked flow that gradually contains more blood. Although uterine cancer usually occurs after menopause, it sometimes occurs around the time that menopause begins. Irregular bleeding should not be considered simply part of menopause; it should always be checked by a doctor. The great majority of patients with endometrial cancer present with abnormal vaginal bleeding, predominantly postmenopausal bleeding. Although endometrial cancer is primarily a disease in women over 50 years old, perimenopausal and premenopausal women with irregular and/or heavy bleeding, especially if they have a history of irregular cycles and chronic anovulation, should see their physician. The only way to diagnose endometrial cancer is by taking a biopsy. A woman should see a doctor if she has any of the following symptoms:
These symptoms can be caused by cancer or other less serious conditions. Most often, they are not cancer, but only a doctor can tell for sure. If a woman has symptoms, her doctor asks about her medical history and conducts a physical exam. In addition to checking general signs of health, the doctor usually performs blood and urine tests and one or more of the following procedures:
Staging of Endometrial Cancer Once uterine cancer is diagnosed, the doctor needs to know the stage, or extent, of the disease in order to plan the best treatment. Staging procedures help the doctor find out whether the cancer has spread and, if so, what parts of the body are affected. For most women, staging procedures include blood and urine tests and chest x-rays. Doctors may also order a CT scan, MRI, sigmoidoscopy, colonoscopy, ultrasonography, or other x-rays. However, these tests are not commonly needed to evaluate a woman with endometrial cancer. Staging is based on histological differentiation (grade) of the tumor and findings during surgery, including depth of invasion, cervical involvement (glandular involvement versus stromal invasion), and extrauterine metastasis such as those to the adnezae, lymph nodes and peritoneal cavity. Surgical staging helps the doctor find out whether the cancer has spread and, if so, what parts of the body are affected. The stage of the disease affects the prognosis and further treatment. The most accurate tool for assessing prognosis is comprehensive surgical staging including removal of the pelvic and paraaortic lymph nodes. Surgical staging also allows for a proper or more logical use of postoperative treatment based on the true biologic nature of the disease and not an estimation of the risk of spread. Comprehensive surgical staging is more accurate than other modalities such as ultrasound, CT scan, MRI and other x-rays. Gynecologic oncologists perform complete surgical staging when indicated, have a working knowledge of the natural history of this disease and can accurately counsel the patient regarding the necessity of postoperative therapy. Prognosis is influenced by the tumor's histologic appearance and grading, the patient's age and metastatic spread (surgical stage). For patients with stage I disease, the reported 5 year survival rate is 70 to 95%. The five year survival rate for those with stage III or IV disease is 10 to 60%. Obviously, all patients and families are concerned regarding prognosis. Each patient is different and may have individual characteristics that affect their prognosis. Good or bad, assumptions should not be made until discussed in detail with the gynecologic oncologist.
Most women with uterine cancer are treated with surgery. Some have radiation therapy. A smaller number of women may be treated with hormone therapy or chemotherapy. Another treatment option for women with uterine cancer is to take part in clinical trials. Surgery to remove the uterus (hysterectomy) and the fallopian tubes and ovaries (bilateral salpingo-oophorectomy) is the treatment recommended for most women with uterine cancer. In most patients, lymph nodes near the tumor should also be removed during surgery to see if they contain cancer. If cancer cells have reached the lymph nodes, further therapy will be based on this information. The benefit of comprehensive surgical staging not only allows for identification of disease spread (which might only be seen under the microscope), but also to identify those patients that do not require postoperative treatment. If cancer cells have not spread beyond the endometrium, the disease can usually be cured with surgery alone. It has been recommended by the International Federation of Gynecology and Obstetrics (FIGO) that endometrial cancer be surgically staged since 1988. Complete surgical staging includes removal and histologic evaluation (microscopic) of pelvic and paraaortic lymph nodes and intraabdominal cytology. Comprehensive surgical staging will detect the presence of extrauterine disease (disease spread) in 28% of patients thought to have disease clinically confined to the uterus. The risk of disease spread is increased with specific high risk histologic subtypes. When cancer is confined to the uterus after comprehensive surgical staging, the cure rate is in excess of 85% and it is unlikely that the patient will obtain a survival benefit from adjuvant (additional) treatment. Also, patients with occult or visible extrauterine disease may benefit from additional therapy and can be cured. Unfortunately, if extrauterine disease is unrecognized at the time of surgery, the chance of cure is compromised. Cancer cure can be expected only when adequate therapy addresses all sites of disease spread. Gynecologic oncologists are well trained in the techniques in the complete surgical staging procedure for endometrial cancer including the translation of histologic and surgical findings into clinical care. In radiation therapy (also called radiotherapy), high-energy rays are used to kill cancer cells. The rays may come from a small container of radioactive material, called an implant, which is placed directly into or near the tumor site (internal radiation). It may also come from a large machine outside the body (external radiation). Some patients with uterine cancer need both internal and external radiation therapy. Like surgery, radiation therapy is a local therapy. It affects cancer cells only in the treated area. Radiation therapy may be used in addition to surgery to treat women with certain stages of uterine cancer. Radiation therapy prior to surgery is usually not performed except in exceptional and individualized cases. It is a primary modality for treatment in patients that are found to have disease spread or have localized disease, but are at high risk for recurrence. Also, for a small number of women who cannot have surgery, radiation treatment is sometimes used instead. In internal radiation therapy, tiny tubes containing a radioactive substance are inserted through the vagina and left in place for a few days. The patient is hospitalized during this treatment. Patients may not be able to have visitors or may have visitors only for a short period of time while the implant is in place. Once the implant is removed, there is no radioactivity in the body. External radiation therapy is usually given on an outpatient basis in a hospital or clinic 5 days a week for several weeks. This schedule helps protect healthy cells and tissue by spreading out the total dose of radiation. Hormone therapy is the use of drugs, such as progesterone, that prevent cancer cells from getting or using the hormones they may need to grow. Hormone treatment is a systemic therapy. The drugs, which are usually taken by mouth, enter the bloodstream, travel through the body, and control cancer cells outside the uterus. Women who are unable to have surgery are sometimes treated with hormone therapy. Also, this form of treatment is often recommended for women who have metastatic or recurrent endometrial cancer. Chemotherapy is the use of drugs to kill cancer cells. Anticancer drugs may be taken by mouth or given by injection into a blood vessel or a muscle. Like hormone therapy, chemotherapy is a systemic therapy; it can kill cancer cells throughout the body. Chemotherapy is being evaluated in treatment studies for patients with uterine cancer that has spread.
WHAT ARE THE KEY STATISTICS ABOUT ENDOMETRIAL CANCER? The 5-year relative survival rate is 84% when all cases of endometrial cancer are considered together. However, the prognosis (outlook for survival) for any individual patient depends on the stage of her cancer as well as several other factors. WHAT ARE THE RISK FACTORS FOR ENDOMETRIAL CANCER? A risk factor is anything that increases a person's chance of getting a disease such as cancer. Different cancers have different risk factors. The ovaries normally produce two main types of female hormones - estrogen and progesterone. The balance between these two hormones changes each month, producing a woman's monthly periods and helping to keep the endometrium healthy. When the balance of these two hormones shifts toward relatively more estrogen, a woman's risk for developing endometrial cancer increases. Many, but not all of the known risk factors for endometrial cancer (such as early menarche, late menopause, infertility, and obesity) are believed to be related to changes in hormone balance. DO WE KNOW WHAT CAUSES ENDOMETRIAL CANCER? We do not yet know exactly what causes most cases of endometrial cancer, but we do know what certain risk factors are. A great deal of research is underway to learn more about the disease. Most known risk factors affect the balance between estrogen and progesterone in the body. Scientists have recently learned much about changes in the DNA of certain genes that occur when normal endometrial cells become cancerous. CAN ENDOMETRIAL CANCER BE FOUND EARLY? In most cases, being alert to any signs and symptoms of endometrial cancer and discussing them promptly with your health care provider permits diagnosis at an early stage. Unfortunately, some endometrial cancers may reach an advanced stage before recognizable signs and symptoms are present. Early detection improves the chances that your endometrial cancer will be treated successfully. Signs and symptoms of endometrial cancer include unusual bleeding, spotting or other discharge, and/or pelvic pain and/or mass and weight loss. HOW IS ENDOMETRIAL CANCER TREATED? The choice of treatment depends largely on the type of cancer and stage of the disease at discovery. Other factors might 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. Be sure you understand all the risks and side effects of the various therapies before making a decision about treatment. There are four basic types of treatment for women with endometrial cancer - surgery, radiation therapy, hormonal therapy and chemotherapy. A combination of these treatments may also be used. Most patients with endometrial cancer are treated by surgery alone. The choice of treatment(s) will depend on the type and stage of your cancer, and your overall medical condition. WHAT SHOULD YOU ASK YOUR PHYSICIAN ABOUT ENDOMETRIAL CANCER? It is important for you to have honest, open discussions with your physician. You should ask questions, no matter how trivial you may think they are. Some questions to consider:
WHAT'S NEW IN ENDOMETRIAL CANCER RESEARCH AND TREATMENT? Molecular pathology of endometrial cancer: Recent research has improved our understanding of how changes in certain molecules can cause normal endometrial cells to become cancerous. It has been known for several years that mutations (damage or defects) to DNA can alter important genes that regulate cell growth. If these genes are damaged, excess growth may result in cancer formation. Sometimes, endometrial cancer and colon cancer may seem to "run in a family." We now know that some of these families have a higher risk for these cancers because their members have inherited a defect in certain genes that normally help repair damage to DNA. Molecular analysis of endometrial cancer may provide a new avenue for detection, prevention, or new therapeutic strategies. Tumor markers: Molecules released by cancer cells can help detect recurrence of some types of cancer. Recent studies find that certain blood tests may also be helpful in detecting recurrent endometrial cancer, before tumor deposits are visible by imaging studies such as computed tomography (CT scans) or magnetic resonance imaging (MRI) scans. Chemotherapy: Newer anticancer drugs appear promising for treating metastatic endometrial cancer.
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