Introduction
In Europe in 2006, it is estimated that there were over three million new cases of cancer. 145,000 of these were cancer of the body of the uterus or endometrium. The endometrium is the lining of the uterus.
Endometrial cancer is the fifth most common cancer in women in Europe. It particularly affects women aged between 50 and 70 who have been through the menopause, and it is more common in women who have never been pregnant. It rarely affects women under 40 years of age.
Cancer of the cervix or neck of the uterus is a separate disease – for more information on this see the section on cervical cancer.
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The Uterus
The uterus or womb is a pear-shaped organ, made up mainly of muscle and capable of increasing dramatically in size during pregnancy to allow the baby to develop. The uterus lies in the pelvis, behind the bladder, and in front of the rectum. The lower portion of the uterus (the neck of the uterus) is the cervix. The broader, upper part is the body of the uterus, made up of two layers of muscle and connective tissue, the myometrium and lined by the endometrum. The myometrium, which is lined by the endometrium, contracts during labour at the end of the pregnancy to deliver the baby.
Each month after the start of the menstrual cycle, the inner layer of the uterus (the endometrium), grows and thickens in preparation to receive a fertilised egg. If no egg embeds itself in the endometrium, the lining is lost in the menstrual period.
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Cancer of the Uterus
All cancers are uncontrolled growths of cells. In uterine cancer, this uncontrolled growth happens mainly in the cells lining the uterus – the endometrium.
About 95% of endometrial cancers of the uterus develop from cells in glands and so are called adenocarcinomas. Endometrial cancer can be divided into three types:
There are two other rare malignant tumours that can occur in the uterus:
- Carcinosarcomas that develop in the endometrium
- Leiomyosarcomas that develop in the muscular wall of the uterus
Both are sarcomas. More information on sarcomas can be found in the section on sarcomas.
One of the characteristics of cancer is that it can spread to other parts of the body either by direct invasion of neighbouring areas or because cancer cells travel through the blood or lymphatic systems to other parts of the body. Uterine cancer may spread to surrounding structures in the pelvis such as the cervix, the ovaries, bladder and rectum as well as through the bloodstream to the liver and bones.
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Uterine Cancer Risk Factors
Uterine cancer occurs most commonly in women between the ages of 50 and 70 – generally, after the menopause when menstruation stops. It rarely affects women under 40 years old.
There are differing trends in the number of new cases reported across Europe. In many countries in Northern and Western Europe, endometrial cancer appears to be becoming less common in postmenopausal women. But in some Southern and Eastern European countries, particularly Slovakia and Slovenia, the numbers are increasing.
Uterine cancer is more common in women who have never been pregnant.
Obesity is an important risk factor for many cancers including uterine cancer, with the risk increasing the more overweight someone is.
Oestrogen-only HRT (Hormone Replacement Therapy) taken for a long time results in an increased risk of developing uterine cancer. Consequently, combined oestrogen and progesterone HRT is recommended for patients who have not had their uterus removed. But taking combined oestrogen and progesterone HRT for more than 5 years does slightly increase the risk of developing uterine cancer.
Rarely, a gene fault HNPCC (Lynch syndrome/Hereditary non-polyposis colorectal cancer) can raise the risk of developing bowel or uterine cancer.
Cowden syndrome or polycystic ovary syndrome may increase the chance of developing uterine cancer.
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Preventing Uterine Cancer
There is no way of completely eliminating the risk of developing uterine cancer, but there are things which can be done to reduce the risk.
As obesity is such a major factor in uterine cancer, in up to 40% of all cases, reducing weight by having a healthy low fat diet, combined with regular exercise, makes sense.
Women who are still menstruating and who take the contraceptive pill are believed to have a lower risk of developing cancer of the uterus.
Preventative removal of the uterus and ovaries is a radical step for any woman but removes the risk of ovarian and endometrial cancer in women with Lynch syndrome, (Hereditary Non-Polyposis Colorectal Cancer - HNPCC) who have a 40-60% lifetime risk of endometrial cancer and a 10-12% lifetime risk of ovarian cancer.
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Symptoms of Uterine Cancer
The commonest symptoms of uterine cancer are:
- vaginal bleeding after the menopause (postmenopausal bleeding)
- bleeding between menstrual periods (intermenstrual bleeding)
- heavier menstrual periods (menorrhagia)
- an abnormal vaginal discharge
Other more general symptoms of uterine cancer can include pain in the lower abdomen, back or legs and discomfort during sexual intercourse (dyspareunia).
These symptoms may be due to a variety of conditions, only one of which is cancer of the uterus, but women over the age of 50 with any of these symptoms should seek medical advice immediately.
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Staging Uterine Cancer
The treatment recommended for any patient with uterine cancer will depend on a number of factors unique to them, including their own preferences. In uterine cancer, one important factor in deciding on the most suitable treatment is the stage the tumour has reached.
Stage 1 - the cancer is confined to the uterus.
There are three sub-categories of Stage 1:
- Stage 1A - the cancer is only in the inner lining (endometrium) of the womb
- Stage 1B - the cancer has grown into the muscle wall, but no more than halfway
- Stage 1C - the cancer has grown more than halfway into the muscle wall
Stage 2 - the cancer has spread to the cervix.
There are two sub-categories of Stage 2:
- Stage 2A - the cancer has grown into the glands covering the cervix
- Stage 2B - the cancer has grown into the muscle of the cervix
Stage 3 - the cancer has spread to other parts of the pelvis.
There are three sub-categories of Stage 3:
- Stage 3A - the cancer has spread to the ovaries
- Stage 3B - the cancer has spread down into the vagina
- Stage 3C - the cancer has spread to lymph glands in the pelvis
Stage 4 - the cancer has spread to other parts of the body.
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Diagnosing Uterine Cancer
If your symptoms might be due to cancer of the uterus, you will need to go to hospital for further tests. Any delay in diagnosis means that treatments have to be more extensive and may be less effective.
The only way to be sure about the diagnosis is to take an endometrial biopsy – a sample of the cells inside the uterus. This can be done in a number of ways. The cells are sent to the laboratory for examination under a microscope, and checked to see if they are cancerous cells.
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Treatment for Uterine Cancer
Treatment for cancer of the uterus is either surgery, radiotherapy or a combination of the two.
Surgery
Surgery is the first line and most common treatment for endometrial cancer. The aim is to remove the cancer entirely. Usually this involves taking out the uterus, fallopian tubes and ovaries (a total abdominal hysterectomy and bilateral salpingo-oophorectomy). This is done through a cut in the abdomen between the umbilicus and the pelvic bone. Lymph nodes in the pelvis may also be taken out as sometimes uterine cancers can spread to these nodes.
Sometimes it is recommended that part of the vagina is removed with the cervix, uterus, fallopian tubes and ovaries as well as the lymph nodes in the pelvis. This is often referred to as a radical hysterectomy.
Both radiotherapy and chemotherapy are used in combination with surgery to improve the results of treatment.
Radiotherapy
Radiotherapy can be given either before or after surgery. Sometimes, radiotherapy is given as an alternative to surgery. This would usually involve attending a radiotherapy department on a daily basis for up to 6 weeks with rests at the weekends. The treatment will be planned to suit the individual patient.
Radiation damages all cells, including cancer cells. Radiotherapy uses radiation from a range of different sources delivered in a variety of ways to maximise the killing effect of radiation on cancer cells whilst protecting, as far as possible, the normal cells. Radiation works by damaging the genetic material in the cell nucleus making it impossible for the cell to grow and divide, so shrinking the tumour as a whole.
Radiotherapy – Brachytherapy
The source of radiation may be inside the body (a technique known as brachytherapy) where a radioactive pellet or pellets are planted inside the tumour for a period of time.
External Beam Radiotherapy
A linear accelerator (LINAC) is the most common way to deliver external beam radiation treatment to patients. The linear accelerator delivers a uniform dose of high-energy X-ray to the region of the cancer. These X-rays can destroy the cancer cells while sparing the surrounding normal tissue.
Side Effects of Radiotherapy
Radiotherapy does cause a number of side effects, particularly on the bowel and bladder. Inflammation of the bowel causes diarrhoea, and so it is helpful to have a low-residue diet during, and for two weeks after, treatment. Inflammation of the bladder can cause symptoms like cystitis and so drinking plenty of fluids will help. These symptoms usually disappear 10 days after finishing treatment. General effects such as feeling sick and tired also stop soon after the treatment.
Chemotherapy
Chemotherapy, i.e. treatment with drugs, is not routinely used in uterine cancer. It might be recommended to kill more cancer cells if it is not possible to remove the entire tumour, if the cancer may have spread to other parts of the body, or to reduce the chances of the cancer returning after surgery.
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Looking after Yourself
Radiotherapy for uterine cancer, as the sole treatment or in combination with surgery is highly effective in many cases but can cause a number of side effects. Some patients will not experience any side effects, whilst others may find several troublesome. Fortunately, many of these side effects disappear soon after the treatment ends and the symptoms can usually be treated, so if you do experience any problems it is important to mention them to your doctor or nurse, so they can give you the treatment you need.
Diarrhoea may occur during radiotherapy, and can be treated with medication if necessary. Many clinicians suggest that a low residue diet is helpful but not everyone agrees with this approach. Diarrhoea quickly clears up once treatment is finished.
Cystitis, due to the radiation treatment, is also common, which is having to pass urine more frequently, sometimes with discomfort or a stinging pain. In most cases this will be helped by drinking plenty of fluids, but many doctors will check to make sure that there is no infection present. If there is an infection, antibiotics will be prescribed.
Skin irritation between the buttocks and between the legs usually responds well to treatment with hydrocortisone cream or ointment.
Whatever the problem, do not assume that nothing can be done about it – ask your doctor or nurse: do not just grin and bear it.
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Questions for your Doctor
Before making up your mind about the best treatment option for you, you will need information about your cancer, the treatments available in your area and what this will involve, what to expect from the treatment, what side effects you might experience and how these may change over time as well as what your doctors believe would be most effective in combating your cancer.
For different patients the answers will be different, so it is important to discuss all these issues with your doctor so that you make the right choice for you.
You will have your own questions but some issues you might want to raise are:
- What does the treatment involve?
- What are the benefits that I might get?
- How good are my chances of getting those benefits?
- Could having treatment make me feel worse? If so, in what way?
- Are there alternative treatments?
- What are the risks of the treatment?
- Are the risks minor or serious? How likely are they to happen?
- What care will I need after treatment?
- What happens if something goes wrong?
- What may happen if I don’t have the treatment?
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Conclusion
Discovering that you have any form of cancer is devastating, but with modern treatments the results are good particularly for patients who are diagnosed early in their disease.
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