Endometrial cancer is a cancer that has developed from the endometrium, which is the inner lining of the uterus (womb).
During a woman's menstrual cycle, the endometrium undergoes a sequence of changes. The level and mixture of hormones released by the ovaries trigger these changes. The menstrual flow is made up of the inner part of the endometrium. After the menstrual period, the deeper part of the endometrium grows to replace the part of the surface that had been lost. During pregnancy, the endometrium undergoes special changes to prepare for implantation of the developing embryo.
Nearly all endometrial cancers are adenocarcinomas (cancers of glandular cells). Over 75% are endometrioid adenocarcinomas. Although " endometrial " and " endometrioid " have similar spelling, the words are not identical. Endometrioid cancers are a specific type of endometrial cancers. From one-third to one-half of endometrioid cancers have glandular areas as well as areas formed by squamous cells (the type of cells found on the surface of the cervix and the skin). If the squamous cells look benign under a microscope, these tumors are adenoacanthomas. If the squamous areas look cancerous, these tumors are adenosquamous carcinomas.
Papillary serous carcinoma (about 10% of endometrial cancers) and clear cell carcinoma (less than 5%) are less common types of endometrial cancer which often grow and spread rapidly.
The above cancers of the endometrium form in the lining layer, or epithelium, of the uterus.
Three less common uterine cancers which are also called uterine sarcomas can involve the endometrium. These include (1) stromal sarcomas which develop in the stroma (supporting connective tissue) of the endometrium, (2) malignant mixed mesodermal tumors (MMMT, or carcinosarcomas) which may combine features of endometrial carcinoma and those of sarcomas, and (3) leiomyosarcomas which start in the muscular wall of the uterus. These three types of cancer are not discussed in this document because their treatment and prognosis (outlook) are different from the most common cancers of the endometrium. Information on these three types of uterine cancer is available from the American Cancer Society upon request.
WHAT ARE THE KEY STATISTICS ABOUT ENDOMETRIAL CANCER?
In the United States, cancer of the endometrium is the most common cancer of female reproductive organs.
The American Cancer Society estimates that 36,100 new cases of endometrial cancer will be diagnosed in the United States during 1998. The disease is 70% more common in whites than in African Americans.
It is estimated that about 6,300 women in the United States will die from endometrial cancer during 1998.
The 5-year relative survival rate is 96% if endometrial cancer is found at an early stage. This rate falls to 66% if the cancer has spread regionally at the time of diagnosis. Relative survival rates for whites exceed those for African Americans by at least 15% at every stage of the disease.
CAN ENDOMETRIAL CANCER BE PREVENTED?
Although not all cases of endometrial cancer can be prevented, there are certain things a woman can do to lower her risk of developing this disease.
Use of oral contraceptives can reduce endometrial cancer risk. The risk is lowest in women who take oral contraceptives for a long time, and this protection continues for at least 10 years after a woman stops taking them. However, endometrial cancer risk is not the only factor to be considered in choosing a contraceptive method. Women are advised to discuss advantages and disadvantages of different types of contraceptives with their health care provider.
Endometrial cancer risk can also be decreased by avoiding known risk factors whenever possible and by obtaining proper treatment of precancerous disorders of the endometrium.
Controlling obesity, high blood pressure, and diabetes may help reduce the risk of this disease. If you have any of these conditions, discuss them with your health care provider.
If you are experiencing menopause and are considering estrogen replacement therapy, ask your health care provider to assess your risk of endometrial cancer. There is evidence that the use of progestins can reduce the risk of endometrial cancer in women taking estrogen replacement therapy. If you have not had a hysterectomy (surgical removal of the uterus) and are taking estrogen replacement therapy, you will want to discuss this issue with your health care provider. Most endometrial cancers develop over a period of years. Many are known to follow and possibly develop from less serious abnormalities of the endometrium. Endometrial hyperplasia is an increased growth of the endometrium. Unlike a cancer, mild or simple hyperplasia can go away on its own or with hormonal treatment, and never invade the rest of the uterus or other parts of the body. The most common type of hyperplasia, simple hyperplasia, has a very small risk of becoming cancerous. However, simple atypical hyperplasia and complex atypical hyperplasia become cancerous in about 8% and up to 29% of cases if not treated. Treatment with progestins and a dilation and curettage (D & C) can prevent hyperplasia from becoming cancerous. D & C is described in the section on " How is Endometrial Cancer Diagnosed? " Because abnormal vaginal bleeding is the most common symptom of endometrial precancers and cancers, it needs to be reported and evaluated immediately.
HOW IS ENDOMETRIAL CANCER TREATED?
After the diagnostic tests are done, your cancer care team will recommend a treatment plan. Don't feel rushed about considering your options. If there is anything you do not understand, ask to have it explained again. 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 more 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.
You may want to get a second opinion. 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 treatments.
There are four basic types of treatment for women with endometrial cancer - surgery, radiation therapy, hormonal therapy and chemotherapy, or a combination of these. The choice of treatment(s) will depend on the type and stage of your cancer, and your overall medical condition.
Surgical treatment of endometrial cancer
Several operations are used to treat endometrial cancer. The medical vocabulary for these operations is based on the Greek or Latin medical names of the organs they remove. The medical name of an operation that removes something usually ends with " -ectomy." So, removing the uterus is a hysterectomy and removing lymph nodes is a lymphadenectomy (also called lymph node biopsy or dissection). Removing one ovary is a unilateral (one side) oophorectomy and removing both is a bilateral (two side) oophorectomy. Likewise, removing one or two fallopian tubes is a unilateral salpingectomy or bilateral salpingectomy. Often, an operation removes several organs. For example removal of both ovaries and fallopian tubes is called a bilateral salpingo-oophorectomy (often abbreviated as BSO). This partial list of the names of operations should help you understand information you may read about endometrial cancer and in discussing your cancer with your health care providers. Don't hesitate to ask your cancer care team to explain your condition and recommend treatments in simple, nonmedical terms.
The choice of what surgical procedures should be done to treat each woman's endometrial cancer is based mostly on the stage, type, and grade of her cancer. This decision is also influenced by a women's general state of health and her age. In some cases, a firm surgical plan is based on preoperative (before surgery) tests such as imaging studies, and results of the pelvic examination, endometrial biopsy and/or D & C. In other cases, the surgeon begins the operation with several options which were selected based on the preoperative examination and test results. A decision about which of these options to take depends on what the surgeon finds during the early parts of the operation.
- Simple Hysterectomy: This is surgical removal of the uterus (the body of the uterus and the cervix). The parametria and uterosacral ligaments (tissue next to the uterus) are not removed. The vagina remains intact, and pelvic lymph nodes are not removed. The operation may involve a surgical incision in the front of the abdomen or may be performed through the vagina. General anesthesia or regional anesthesia is used so the patient is asleep or sedated during the procedure. A hospital stay of about 5-7 days is usual. Complete recovery takes about 4-6 weeks. Hysterectomy results in infertility (inability to have children). Complications are unusual, but could include excessive bleeding, wound infection, or damage to the urinary or intestinal systems.
- Radical hysterectomy and pelvic lymph node dissection: Like a simple hysterectomy, this operation removes the entire uterus. However, the tissues next to the uterus (parametria and uterosacral ligaments), the upper part (about 1 inch) of the vagina next to the cervix, and lymph nodes (bean-shaped collections of immune system tissue that help the body in fighting infections and cancers) from the pelvis are also removed. As in simple hysterectomy, general or regional anesthesia and an abdominal surgical incision are usually used. However, a radical hysterectomy can be performed through the vagina in combination with a laparoscopic lymph node dissection. Laparoscopic lymph node sampling is discussed further in the section on " What's New in Endometrial Research and Treatment? " Since more tissue is removed by a radical hysterectomy than by a simple hysterectomy, the hospital stay is longer - about 7 days. The surgery results in infertility. Complications are unusual, but could include excessive bleeding, wound infection, and damage to the urinary system.
- Bilateral salpingo-oophorectomy: This operation removes both fallopian tubes, and both ovaries. In treating endometrial cancer, this operation is done at the same time the uterus is removed by simple hysterectomy or radical hysterectomy. Removal of both ovaries means that you will go into menopause if you have not done so already. Many symptoms associated with menopause (such as hot flashes, night sweats, vaginal dryness) can be relieved by estrogen replacement therapy (ERT). This therapy also lowers a woman's risk of osteoporosis (softening of the bones) and heart disease. However, use of ERT is controversial in women with endometrial cancer, because of the potential of increasing the risk of recurrent disease or increasing the risk of other hormonally related cancers, such as breast cancer. Therefore, decisions about ERT in endometrial cancer survivors must balance the risk (recurrent or other hormonally related cancers) and benefits (relief of symptoms and protection against some other diseases). Most experts in this field would either entirely avoid ERT in endometrial cancer survivors, or prescribe ERT only when the stage and grade of the cancer indicate a very low risk of recurrence. There are nonhormonal alternative treatments for symptoms and prevention of heart disease and osteoporosis. Ask your doctor about these.
- Radiation therapy for endometrial cancer Radiation therapy uses high-energy radiation (such as x-rays) to kill cancer cells. These treatments may be given externally in a procedure that is much like having a diagnostic x-ray. This is called external beam radiation therapy. It also may be given as an implant of radioactive materials near the tumor. This is called brachytherapy.
The skin in the treated area may look and feel sunburned, but this gradually fades into a tanned look, and returns to a normal appearance in six to 12 months. Many women also notice tiredness, upset stomach, or loose bowels. Pelvic radiation therapy may cause vaginal stenosis (narrowing of the vagina by scar tissue), which might make intercourse painful. Premature menopause and problems with urination may also occur. If you are having side effects from radiation, discuss them with your cancer care team. There are things you can do to obtain relief from these symptoms or prevent their occurrence, such as using vaginal dilators to maintain vaginal function.
- Chemotherapy for endometrial cancer
Chemotherapy uses anticancer drugs that are given into a vein or by mouth. These drugs enter the bloodstream and reach all areas of 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 is sometimes more effective in treating cancer than one drug alone. Drugs used in treating endometrial cancer may include doxorubicin, cisplatin, and paclitaxel. These drugs kill cancer cells but can also damage some normal cells. Therefore, careful attention is given to avoiding or minimizing side effects.
Side effects of chemotherapy depend on the type of drugs, the amount taken, and the length of time you are treated. They might include:
- Upset stomach and vomiting (new medications given together with the chemotherapy can prevent these unpleasant side effects)
- Loss or increase of appetite
- Temporary loss of hair
- Mouth or vaginal sores
- Increased chance of infections, bleeding, or anemia (low red blood cell count)
- Changes in the menstrual cycle
- Premature menopause
- Infertility (inability to become pregnant) Note: Most patients with endometrial cancer are infertile before chemotherapy because their uterus was already removed.
Most of these side effects of chemotherapy (except premature menopause and infertility) stop when the treatment is over. If you are taking chemotherapy and have side effects, remember that there are remedies for many of them. Be sure to talk with your cancer care team about any side effects you are experiencing.
- Hormone therapy for endometrial cancer
Typically, hormone therapy uses drugs such as progesterone to slow the growth of endometrial cancer cells. The drugs are usually taken as pills. Tamoxifen may also be used in the treatment of advanced or recurrent disease.
- Clinical Trials
Clinical trials are scientific studies of promising new treatments. Ask your cancer care team if you qualify for any clinical trials. You can obtain a current list of these trials from the National Cancer Institute's Cancer Information Service by calling 1-800-4-CANCER
Treatment of endometrial cancer by stage
- Stage I: If the cancer seen on endometrial biopsy or D&C is grade 1, the extent of surgery will depend on findings of the staging surgery. A simple hysterectomy and a bilateral salpingo-oophorectomy (BSO) will be done. As soon as the uterus is removed, it is examined to see how deep and far the cancer has spread. This may simply involve a close look at the uterus after it has been cut in half. Sometimes a pathologist will look at a piece of the uterus under a microscope to determine the exact extent of the cancer. If the cancer involves the upper 2/3 of the body of the uterus and extends one third to less than halfway through the thickness of the uterus, the surgeon may not remove any lymph nodes or may remove selected pelvic and paraaortic nodes. If these nodes are not involved by cancer and if washings of the cavity near the uterus do not contain any cancer cells, postoperative (after surgery) radiation treatment is usually not done.
If the cancer seen on endometrial biopsy or D&C is grade 2 or 3, or if cancer has spread deeper than half the thickness of the wall of the uterus, then the pelvic lymph nodes (near the uterus) and the paraaortic lymph nodes (further from the uterus) are sampled. Biopsies of the omentum (fatty tissue from the abdomen) may also be taken, especially in certain types of endometrial cancer (uterine papillary serous cancer).
Even if cancer has not spread to pelvic lymph nodes, radiation therapy is usually given to reduce the risk of cancer recurring in the vagina or pelvis in patients with G2/G3 deep myometrial invasion. The 5-year survival rate for patients with stage I endometrial cancer is about 40%-90%, depending on grade and myometrial invasion. Overall, 5-year survival is about 75%. Within this range, those with grade 1 cancers have a higher survival rate. The rate is lower with grade 3 cancers.
- Stage II: Standard treatment is simple hysterectomy and bilateral salpingo-oophorectomy (BSO) with pelvic and paraaortic lymph node sampling. If the cervix is visibly invaded with tumor, a radical hysterectomy with bilateral salpingo-oophorectomy and pelvic and paraaortic lymph node sampling is performed. Radiation therapy is usually given after surgery. Internal and external radiation are used. Most studies report 5-year survival rates of about 56%.
- Stage III: If the surgeon thinks that all visible cancer can be removed, a radical hysterectomy and bilateral salpingo-oophorectomy (BSO) with or without pelvic and paraaortic lymph node sampling is done. These patients will usually receive radiation therapy after surgery. If paraaortic nodes are involved by the cancer, additional radiation will be aimed to cover this area. If the surgeon feels that it is not possible to remove all visible cancer, radiation therapy may be given without removing the uterus. Consultation with a gynecologic oncologist is advised. Patients with stage III endometrial cancer should consider participation in clinical trials of chemotherapy or other new systemic treatments. The 5-year survival rate is in the range of 31.5%.
- Stage IV: Because the extent of cancer spread makes a cure by surgery impossible, a hysterectomy and bilateral salpingo-oophorectomy may be done to prevent hemorrhage (bleeding). Radiation therapy may be used as an alternative. When distant metastases are present, hormonal therapy is often used. High-grade cancers and those without detectable progesterone receptors are less likely to respond to hormonal therapy. Patients with stage IV endometrial cancer should consider participation in clinical trials of chemotherapy or other new systemic treatments.
The 5-year survival rate is in the range of 10.5%.
Recurrent endometrial cancer: If the recurrent cancer is only in the pelvis, radiation therapy may provide a cure. With more extensive recurrences, hormonal therapy or chemotherapy is recommended. Low-grade cancers containing progesterone receptors are more likely to respond well to hormonal therapy. Higher-grade cancers and those without detectable receptors are less likely to shrink during hormonal therapy, but are more likely to respond to chemotherapy. The overall 5-year survival rate is in the range of 0%-35%.
Patients with other serious medical conditions: If patients have other medical conditions that make them unable to have surgery, radiation therapy alone or in combination with hormonal therapy is generally used. The outlook for these patients is not as good as those able to have surgery.
WHAT WILL HAPPEN AFTER TREATMENT FOR ENDOMETRIAL CANCER?
Each type of treatment for endometrial cancer could have side effects that may last from a few months to many years. A woman may be able to hasten her recovery by being aware of those side effects before treatment begins and by taking steps to minimize them and shorten their duration where possible after treatment.
From the start, keep in mind that you must deal with your own individual physical and emotional factors. In the process of deciding what kind of treatment to have, for instance, you will find it helpful to discuss options with your family and friends, as well as with your primary care physician and nurse. At every step of the way in pre-treatment, treatment, and recovery, you should talk with your cancer care team about side effects, ways to make them easier to endure, and the general outlook, or prognosis, for your case. They want to answer your questions, so ask them!
Your body is as unique as your personality and your fingerprints. Scientists can determine certain facts about tumors and drugs, and doctors can use a variety of treatments to eliminate the cancer. But no one can say precisely how you will respond to cancer or its treatment.
You may have special strengths such as a healthy immune system, a history of excellent nutrition, a strong family support system, a deep faith. All of these can make a difference in how you respond to cancer. In fact, behavioral scientists have recently found that women who took advantage of a social support system, such as a cancer support group, survived with a better quality of life.
An important part of your treatment plan is a specific schedule of follow-up visits after surgery, chemotherapy, or radiation therapy to be sure what, if any, additional treatment is necessary .
Follow-up may involve procedures such as x-rays, CT scans, ultrasound studies, or magnetic resonance imaging. There also may be biopsies to check tissue samples under the microscope, blood tests, and other examinations.
You can help in your own recovery from cancer by making healthy lifestyle choices.
If you use tobacco, stop now. Quitting will improve your overall health and the full return of the sense of smell may help you enjoy a healthy diet during recovery.
If you use alcohol, limit how much you drink. Have no more than one or two drinks per day.
Good nutrition can help you get better after treatment. Eat a nutritious diet. Researchers are also finding increasing evidence of the importance of nutrition in the prevention of cancer. Eat more fruits, vegetables, whole grains, and high-fiber foods. Eat less fats, especially animal fat. If you have had pelvic radiation, you may not be able to tolerate a high-fiber diet because of diarrhea, bloating, and cramping. Discuss diet with your health care team.
Exercise once you are well.
If you are in treatment for cancer, be aware of the battle that is going on in your body. Radiation therapy and chemotherapy add to the fatigue caused by the disease itself. Give your body all the rest it needs so that you will feel better as time goes on.
A cancer diagnosis and its treatment is a major life challenge, with an impact on you and everyone who cares for you. Before you get to the point where you feel overwhelmed, consider attending a meeting of a local support group. If you need individual assistance in other ways, contact your hospital's social service department or your local Division of the American Cancer Society for help in contacting counselors or other services.
Finally, your cancer care team is always ready to help you understand your disease and treatment and to answer your questions about what you can do to improve your outlook for the future.
WHAT SHOULD YOU ASK YOUR PHYSICIAN ABOUT ENDOMETRIAL CANCER?
It is important for you to have frank, open discussions with your cancer care team. You should ask questions, no matter how trivial you may think they are.
Some questions to consider:
- What type and grade of endometrial cancer do I have?
- Has my cancer spread beyond the uterus?
- What is the stage of my cancer and what does that mean in my case?
- What treatments are appropriate for me? What do you recommend? Why?
- What should I do to be ready for treatment?
- What risks or side effects should I expect?
- What are the chances of recurrence of my cancer with the treatment programs we have discussed?
- Should I follow a special diet?
- Will I be able to have children after my treatment?
- What is my expected prognosis, based on my cancer as you view it?
- Does this cancer prevent me from considering estrogen replacement therapy?
In addition to these sample questions, be sure to write down some of your own. For instance, you may need specific information about anticipated recovery times so you can plan your work schedule. Or, you may want to ask about second opinions or about experimental programs or clinical trials for which you may qualify.