CONDITIONS

Endometrial Cancer

What Is Endometrial Cancer

Endometrial cancer, also referred to as uterine cancer, starts in the endometrium, which is the inner lining of the uterus, or womb. The uterus is a hollow, muscular organ where a fetus grows. Most cancers of the uterus start in the endometrium; thus are called endometrial cancers. If the uterine cancer originates from the muscle or other supportive tissues it is referred to as a uterine sarcoma. Uterine sarcomas are rare and include the subtypes of leiomyosarcomas and endometrial stromal sarcomas.

Endometrial cancers are classified according to how they appear under a microscope. They are divided into the following subtypes:

  • Adenocarcinomas – most endometrial cancers are adenocarcinomas, which originate from cells that make mucous and other fluids. These cancers can be further subdivided into clear-cell carcinomas, mucinous adenocarcinomas, and papillary serous adenocarcinomas.
  • Carcinosarcoma
  • Squamous cell carcinoma
  • Undifferentiated carcinoma
  • Small cell carcinoma
  • Transitional carcinoma

In the United States, endometrial cancer is the most common cancer of the female reproductive organs. The American Cancer Society estimates that in 2015, nearly 55,000 new cases of uterine cancers will be diagnosed and more than 10,000 women will die from uterine cancers.

What Causes Endometrial Cancer

Doctors do not know what causes endometrial cancer, but there are certain risk factors associated with developing the disease that have been identified. These are outlined below in the Risk Factors section.

It is known that kidney cancer, as well as all other cancers, are a disease characterized uncontrolled cellular growth. Normally, specific genes within the DNA (genetic material) of cells have functions to regulate cell division. Genes involved in cell replication (or division), cellular growth, and cellular survival are called oncogenes, while those involved in limiting cell growth and division and induce cell death when necessary are called tumor suppressor genes (such as TP53 and RB1 genes).

When cell DNA is damaged, these genes may be altered and the oncogenes are turned on and the tumor suppressor genes are turned off. As a result, there is uncontrollable cell growth and possible cancer. While these changes to cellular DNA are caused by the environment, changes or mutations to DNA can also be inherited. If these mutations in the DNA correspond to genes that are involved with effective and correct cell replication, a person’s risk for developing kidney cancers and other cancers may be increased.

Risk Factors For Endometrial Cancer

Although the cause of endometrial cancer is still largely unknown, there are some known risk factors that may increase your likelihood of developing the disease.

Risk factors for endometrial cancer include:

  • Changes in the balance of female hormones in your body – the ovaries produce two hormones, which are estrogen and progesterone. Fluctuations in the production of these hormones can cause changes in the endometrium. Thus, a condition or disease that increases the amount of estrogen, but not progesterone will increase your chances of endometrial cancer. Examples of this process can occur with irregular ovulation patterns, which can result from polycystic ovarian disease (PCOD), obesity, and diabetes. Also, taking hormones with estrogen, but not progesterone, after menopause will increase your risk of endometrial cancer.
  • More years of menstruation – starting menstruation at an early age (before 12) and beginning menopause at an older age increases the time your endometrium is exposed to estrogen and increases the risk of endometrial cancer
  • Never being pregnant – women who have never had children have an increased risk compared to those to have had at least one pregnancy
  • Older age – the majority of endometrial cancers are diagnosed in older women who have already undergone menopause
  • Obesity – yet again, another reason to strive to maintain a healthy weight
  • Hormone therapy for breast cancer – women taking tamoxifen for breast cancer may have an increased risk of endometrial cancer. However, the improvement in breast cancer treatment may outweigh the risks of developing endometrial cancer. Please seek your doctor’s advice to discuss your personal health status and goals
  • An inherited colon cancer syndrome – hereditary nonpolyposis colorectal cancer (HNPCC) is a genetic disease that increases a person’s risk of colorectal cancer and other cancers, including endometrial cancer. If a family member has been diagnosed with HNPCC, please discuss your individual risks with your physician and inquire about what type of cancer screenings you should undergo.

Diagnosing Endometrial Cancer

A diagnosis of endometrial cancer will likely start with a visit to your primary care physician, who will obtain a thorough medical history and then perform a physical examination. In addition, he or she will then utilize any of the following tools to arrive at a diagnosis:

A pelvic exam may be the first more directed physical exam performed for a patient. During this procedure, you will be asked to lie on your back, place your legs in a stirrup-type device and then slide to the end of a table. Then, the physician will examine the appearance of the vagina. Afterwards, he or she will insert a device called a speculum into the vagina to allow visualization of the inner walls of the vagina and the cervix.

A Pap smear, or Pap test, will also be done. During a Pap smear, the physician will use a brush-like tool to collect cells from the surface of the cervix. The collected cells will then be analyzed under a microscope to ensure there are no cancerous changes on the cervix, which may suggest cervical cancer.

In addition, a bi-manual exam will may be performed, which entails placing two fingers inside the vagina and then using the other hand to feel, or palpate, for masses or tenderness in the lower abdomen and pelvis. Finally, your physician may elect to do a rectovaginal exam, which involves placing a finger in the anus and vagina to feel for masses or any other abnormalities, which may involve the back, or posterior, part of the uterus and rectum.

A pelvic ultrasound may also be used to assess the uterine cavity and look for any abnormalities. During this procedure, a probe called the transducer is placed on the lower abdomen and then sound waves are used to generate images on a screen and to help identify masses or injuries to organs. It utilizes no radiation, unlike many other imaging modalities, like x-rays or CT scans. A transvaginal ultrasound, or TVUS, requires the probe be placed inside the vagina and yields more accurate images of the inside of the uterus.

If any of the above exams are abnormal, your physician may elect to perform an endometrial biopsy. An endometrial biopsy is the most commonly performed test for women with endometrial cancer. It is most often performed in the doctor’s office and is only slightly uncomfortable (many women compare the pain to menstrual cramping). Ibuprofen or non-steroidal anti-inflammatories (NSAIDs) can further reduce pain if taken prior to the biopsy. During this procedure, a small, narrow tube is inserted through the cervix and then used to suction small amounts of endometrial tissue, which is then assessed under the microscope. A pathologist will then study the biopsy to determine if the mass is benign or malignant and will then identify the exact type of malignancy.

Your physician may also perform a hysteroscopy, which utilizes a small camera to visualize the inside of the uterus. After a small amount of local anesthesia is placed in the cervix, the camera is inserted through the cervix and into the uterus. Then, saline is used to fill the uterus, which helps to provide a clear image and assess for the presence of abnormal tissue or masses.

If the endometrial biopsy does not provide adequate tissue or a diagnosis is uncertain, your physician may elect to do a dilation and curettage, or D&C. During this procedure, you are either under general anesthesia, conscious sedation, and/or with local anesthesia in an outpatient surgical center. Once comfortable, the physician will dilate the cervix and then use a small instrument to remove endometrial tissue, which can then be assessed for abnormal or cancerous cells and hopefully allow a certain diagnosis.

If it is suspected that the cancer has spread beyond the uterus or the physician desires a sharper image of the uterus, he or she may order a CT scan, which uses x-rays to generate an image. It will show the precise location, shape, and size of masses. In order to obtain even sharper images, some patients are asked to drink or receive IV contrast. This contrast makes some tissues appear brighter, which makes the images and the structures more apparent and easier to discern. Allergies to contrast medium may cause hives, flushing, shortness of breath, and low blood pressure. If you have had a reaction to contrast before, you should inform your physician. In addition to masses (such as cancers), it can show enlarged lymph nodes, which may have cancer cells. Many patients will have CT scans of the chest, as well as the abdomen to look for cancer spread, which may involve the liver, adrenal glands, or other internal organs. The CT scan may also involve the brain to look for cancer metastasis. A CT scan may also be used to obtain biopsies of masses or cancers what lie deep within or nearby other vital structures, which is termed CT guided needle biopsy.

A magnetic resonance imaging (MRI) study also provides detailed soft tissue “pictures.” As opposed to CT scans, which utilizes x-rays, MRIs use magnetic radio waves to generate images. MRIs are particularly useful for imaging the brain and spinal cord. Gadolinium, a contrast, is often used to produce even better MRI images.

PET scans, also known as positron emission tomography, are especially useful to look for cancer spread. This study involves injecting a special radioactive sugar (flourodeoxyglucose, or FDP) into the vein. The amount of radioactivity is very low and will not cause you harm. After the injection, a special scanner will pickup areas in your body where the sugar has accumulated. As cancer cells are very active and require a great amount of energy (sugar), the FDP will concentrate in these areas. The PET scan does not produce extremely detailed images, but rather indicates spread of cancer throughout the body.

Bone scans can also be performed to detect spread of cancer to bones. During this procedure, a radioactive dye is injected in the vein, where is it transported to areas of bone with abundant activity, which may occur in cancerous and non-cancerous states.

A simple chest x-ray or radiograph will usually be performed, as it is convenient, cheap, and will reveal if the cancer has progressed to the lungs.

Possible lab tests used to diagnosis endometrial cancer include a CBC, or complete blood count. As bleeding is a common symptom, a low red blood cell count may be found. Also, a CA-125 level may be ordered. This is a substance often times found elevated in endometrial or ovarian cancers. As this test is not required for a diagnosis of endometrial cancer, it is not ordered on all patients.

Symptoms of Endometrial Cancer

The most common symptom of endometrial cancer is irregular bleeding from the vagina, often times after the onset of menopause, or bleeding in between periods.

Other common signs and symptoms include:

  • An abnormal watery or blood-tinged discharge from the vagina
  • Pelvic pain
  • Pain during intercourse
  • Weight loss
  • Fatigue

 

Prognosis

Prognosis refers to the likely course of a disease or ailment. To determine the prognosis of endometrial cancer, many factors must be considered. For example, the age of the patient and his or her functional status, or level of functioning, also plays a vital role in prognosis. Generally, younger and higher functioning patients will do best. Further, the amount of tumor able to be removed, also known as resected, impacts prognosis. If the entire tumor is removed, prognosis improves, while if only part of the tumor is removed, prognosis will likely deteriorate. If the tumor recurs, or comes back after removal, the prognosis is worse.

Also very important for prognosis is staging and grading of the cancer. Staging of a cancer is the process of classifying how far a cancer has spread, while grading determines the makeup and characteristics of the cancer’s cells. In addition to prognostic value, staging and grading can help predict what therapy is ideal and the effectiveness of the therapy. The American Joint Committee on Cancer (AJCC) has standardized staging system that employs:

 

  • Size of the tumor (T)
  • Number of involved lymph nodes (N)
  • Presence of metastasis (M).

 

Thus, it is referred to as the TNM staging system. The more advanced each of these categories, i.e. tumor size, the higher the number that follows the letter. The size of the tumor ranges from 0-4, while the staging of involved lymph nodes varies from 0-2 and the presence of metastases is determined with 0 or 1. A combination of these three variables and numbers then determines the stage of the cancer.

The grade of a cancer cell describes how similar or dissimilar the cell looks compared to a healthy cell observed under a microscope. Healthy tissue will have many different types of cells grouped together. If the tumor has many different types of cells and appears similar to healthy tissue, it is termed differentiated, or a low-grade tumor. Conversely, if the tumor appears very different from the healthy tissue, it is termed poorly differentiated, or a high-grade tumor. In general, the lower the grade of tumor, the better chance of treatment, survival, and prognosis.

As with most cancers, the prognosis of the disease depends on the type of cancer as well as the individual patients and the response to treatments. According to the National Cancer Database as published in the AJCC Staging Manual in 2010, the 5-year survival rate for those with endometrial adenocarcinoma varies from 90% for those patients with very early disease (stage 0) to 15% for those with distant metastases, or spread (stage IV) disease.

Living With Endometrial Cancer

People with cancer not only face physical challenges, but also mental and emotional challenges. It is important to understand your illness and treatment as it can make you feel more in control. Taking care of your emotional health is also vital. Family and friends can be an important source of support for you during this challenging time.

In addition, it is helpful to consider the following:

  • Explore all treatment options. Educate yourself on potential treatment methods and ask your doctor questions. Be sure to seek out reliable sources both online and in print. See the resources section for sources of information on brain cancer.
  • Weigh the benefits and risks of each treatment options. Ask yourself what the aim of your treatment should be, and what you wish to accomplish as you live with the disease.
  • Consider palliative care, a type of medical care specialized to help patients with terminal illnesses remain comfortable while living out their disease.
  • Live out your dreams and goals to help you be as happy as possible. Don’t let prognosis or statistics discourage you from accomplishing want you want to accomplish.

Screening

Screening is not recommended for endometrial cancer, unless you have a condition with known risk factors for the cancer, such as HNPCC.

Prevention

Unfortunately, there is no guaranteed preventative method to stop endometrial cancer from developing.  However, cases of endometrial cancer that are diagnosed early are less likely to progress and to carry worse a worse prognosis than cases that are diagnosed at later stages.

If you experience any of the symptoms described above for endometrial cancer, contact your physician immediately.

Medication And Treatment

The treatment options for your endometrial cancer will depend on the stage of the cancer, your general health status, and your preferences. Potential treatment options include:

  • Surgery to remove the uterus (hysterectomy) is recommended for most women with endometrial cancer. Often times, the fallopian tubes and ovaries are removed as well, which is termed salpingo-oophorectomy. A hysterectomy makes it impossible for you to have children in the future. And, if your ovaries are removed, you will experience menopause, if you had not yet previously. During these surgeries, the physician will also inspect the areas near the uterus for areas of cancer spread, which includes lymph nodes as the presence of cancer in lymph nodes will help determine the stage of the cancer.
  • Radiation – this treatment involves high energy x-rays focused on a specific site to kill cancer cells. For those not healthy enough to undergo surgery or those who simply decide to decline surgery, radiation can help with symptoms control and the cancer related pain. The efficacy of radiation is cumulative; so multiple sessions of radiation are necessary for optimal treatment. Furthermore, a small device with radiation may be placed inside the vagina to allow more targeted delivery of the treatment to the cancer in a procedure known as brachytherapy. Side effects of radiation include fatigue, skin damage, and necrosis of nearby structures to the cancer.
  • Hormone therapy – this may prove very useful, as endometrial cancer is often the result of too much estrogen and a relative lack of progesterone. As a result, a patient may respond well to synthetic progestin, a similar substance to progesterone. In addition, medications aimed at reducing the amount of estrogen in your body may prove helpful, such as aromatase inhibitors, which prevent a vital enzyme from working to make estrogen.
  • Chemotherapy – uses medication via oral or intravenous routes to kill rapidly diving cells (which is characteristic of cancer cells, but other cells in the body divide quickly as well and may be killed by the chemotherapy, such as hair cells leading to baldness during chemotherapy). High-grade tumors may respond well to chemotherapy and shrink the tumor prior to a possible surgery, which makes resection easier for the surgeon. Besides the aforementioned baldness, chemotherapy may also cause loss of appetite, nausea, vomiting, weight loss, lethargy, and an increased risk of infection.

Complementary and Alternative Treatment

As the definitive treatment for endometrial cancer remains chemotherapy, radiation, and surgery, alternative treatments for this condition should only be considered after traditional interventions have been initiated or completed.

Complementary medicine, which refers to interventions performed in addition to traditional or standard treatment, are numerous and may provide additional symptom relief and improved quality of life for many patients. According to the National Center for Complementary and Integrative Health, these include:

Acupuncture – is particularly effective in alleviating treatment-related nausea and vomiting in cancer patients. It may even help control cancer pain. Although complications from acupuncture are rare, it is important to ensure that the needles are properly sterilized. Many cancer patients have weakened immune systems and more prone to infections.

Ginger – may help to control nausea secondary to cancer chemotherapy, especially when used along with standard anti-nausea medications.

Massage therapy – may help to alleviate symptoms experienced by many cancer patients, such as pain, nausea, anxiety, and depression. However, the massage therapist should be careful to avoid deep or too rigorous massage prior to physician approval, especially directly over a tumor or around sensitive skin, which is common following radiation treatments.

Mindfulness-based Stress Reduction – as a type of meditation, mindfulness-based stress reduction can help cancer patients by relieving anxiety, stress, fatigue, and general mood and sleep disturbances. As a result, this can lead to an overall improvement in quality of life.

Yoga – preliminary studies suggest that yoga may improve anxiety, depression, and stress in patients with cancer. It may also alleviate fatigue in breast cancer patients. However, additional studies need to be completed for better evidence and conclusions.

Hypnosis, relaxation therapies, and biofeedback – various studies are currently assessing the benefits of these activities in cancer patients.

Herbal supplements – a 2008 review of research regarding herbal supplements and cancer concluded that the scientific evidence is limited and many clinical trials were not well designed. Furthermore, there are specific concerns regarding some herbal supplements in terms of medication interactions. Thus, any use of herbal medications should be discussed thoroughly with your physician.

When To Contact A Doctor

If you are experiencing any of the signs or symptoms of endometrial cancer (see above), you should seek medical attention as soon as possible. The earlier a diagnosis can be made, the earlier treatment can begin, which generally leads to improved outcomes and better prognosis.

Unless the symptoms are life threatening, you can make an appointment within a reasonable time period and do not need to visit the emergency department.

 

Find a Doctor

Your medical team may consist of several healthcare professionals, including your primary care physician, OB/GYN, oncologist, and an oncologic surgeon.

The National Cancer Institute offers a Web site where you can find a cancer center near you at http://www.cancer.gov/researchandfunding/extramural/cancercenters/find-a-cancer-center

 

Resources

Other useful resources to help you learn about endometrial cancer can be found at:

The National Cancer Institute: http://www.cancer.gov/types/uterine

The American Cancer Society: http:/www.cancer.org/cancer

References

  1. The American Cancer Society. Endometrial cancer. http://www.cancer.org/cancer/%20endometrialcancer/index
  2. The National Cancer Institute. Uterine cancer. http://www.cancer.gov/types/uterine
  3. The Mayo Clinic. Endometrial cancer – causes. http://www.mayoclinic.org/diseases-conditions/endometrial-cancer/basics/causes/con-20033696
  4. The Mayo Clinic. Endometrial cancer – risk factors. http://www.mayoclinic.org/diseases-conditions/endometrial-cancer/basics/risk-factors/con-20033696
  5. Foundation for Women’s Cancer. Medical evaluation. http://www.foundationforwomenscancer.org/types-of-gynecologic-cancers/uterine/medical-evaluation/
  6. The Mayo Clinic. Endometrial cancer – symptoms. http://www.mayoclinic.org/diseases-conditions/endometrial-cancer/basics/symptoms/con-20033696
  7. The American Cancer Society. Survival by stage of endometrial cancer. http://www.cancer.org/cancer/endometrialcancer/detailedguide/endometrial-uterine-cancer-survival-rates
  8. The Mayo Clinic. Endometrial cancer – treatment and drugs. http://www.mayoclinic.org/diseases-conditions/endometrial-cancer/basics/treatment/con-20033696

 

Questions For Your Doctor

Your medical team may consist of several healthcare professionals, including your primary care physician, OB/GYN, oncologist, and an oncologic surgeon.

The National Cancer Institute offers a Web site where you can find a cancer center near you.

Questions For A Doctor

When you go to see your doctor, it’s good to have a list of the questions you’d like to have answered. Take a moment to write down some of the things you want to know. Your questions for your doctor might include some of these:

 

  • How far advanced is my cancer?
  • What are my options for treatment?
  • What is my prognosis?
  • What treatment would you recommend, and why?
  • What are the possible side effects?
  • Does my insurance cover these treatments?
  • What changes will I need to make in my day-to-day life?
  • Is there anything else I should know about my cancer?

Resources

Other useful resources to help you learn about endometrial cancer can be found at:

The National Cancer Institute

The American Cancer Society