What is cancer?
Endometrial (Uterine) Cancer
What is cancer?
The body is made up of hundreds of millions of living cells. Normal body cells grow, divide, and die in an orderly fashion. During the early years of a person's life, normal cells divide faster to allow the person to grow. After the person becomes an adult, most cells divide only to replace worn-out or dying cells or to repair injuries.
Cancer begins when cells in a part of the body start to grow out of control. There are many kinds of cancer, but they all start because of out-of-control growth of abnormal cells.
Cancer cell growth is different from normal cell growth. Instead of dying, cancer cells continue to grow and form new, abnormal cells. Cancer cells can also invade (grow into) other tissues, something that normal cells cannot do. Growing out of control and invading other tissues are what makes a cell a cancer cell.
Cells become cancer cells because of damage to DNA. DNA is in every cell and directs all its actions. In a normal cell, when DNA gets damaged the cell either repairs the damage or the cell dies. In cancer cells, the damaged DNA is not repaired, but the cell doesn’t die like it should. Instead, this cell goes on making new cells that the body does not need. These new cells will all have the same damaged DNA as the first cell does.
People can inherit damaged DNA, but most DNA damage is caused by mistakes that happen while the normal cell is reproducing or by something in our environment. Sometimes the cause of the DNA damage is something obvious, like cigarette smoking. But often no clear cause is found.
In most cases the cancer cells form a tumor. Some cancers, like leukemia, rarely form tumors. Instead, these cancer cells involve the blood and blood-forming organs and circulate through other tissues where they grow.
Cancer cells often travel to other parts of the body, where they begin to grow and form new tumors that replace normal tissue. This process is called metastasis. It happens when the cancer cells get into the bloodstream or lymph vessels of our body.
No matter where a cancer may spread, it is always named for the place where it started. For example, breast cancer that has spread to the liver is still called breast cancer, not liver cancer. Likewise, prostate cancer that has spread to the bone is metastatic prostate cancer, not bone cancer.
Different types of cancer can behave very differently. For example, lung cancer and breast cancer are very different diseases. They grow at different rates and respond to different treatments. That is why people with cancer need treatment that is aimed at their particular kind of cancer.
Not all tumors are cancerous. Tumors that aren't cancer are called benign. Benign tumors can cause problems -- they can grow very large and press on healthy organs and tissues. But they cannot grow into (invade) other tissues. Because they can’t invade, they also can't spread to other parts of the body (metastasize). These tumors are almost never life threatening.
What is endometrial cancer?
Endometrial cancer is a cancer that starts in the endometrium, the inner lining of the uterus (womb). The picture below shows where the uterus is located.
About the uterus and endometrium
The uterus is a hollow organ, about the size and shape of a medium-sized pear. The uterus is where a fetus grows and develops when a woman is pregnant. The uterus has 2 main parts (see picture above). The lower end of the uterus extends into the vagina and is called the cervix. The upper part of the uterus is called the body and is also known as the corpus. (Corpus is the Latin word for body.)
The body of the uterus has 2 layers. The inner layer or lining is called the endometrium. The outer layer of muscle is known as the myometrium. This thick layer of muscle is needed to push the baby out during birth. The tissue coating the outside of the uterus is the serosa.
Hormone changes during a woman's menstrual cycle cause the endometrium to change. During the early part of the cycle, before the ovaries release an egg (ovulation), the ovaries produce estrogens. The hormone called estrogen causes the endometrium to thicken so that it could nourish an embryo if pregnancy occurs. If there is no pregnancy, estrogen is produced in lower amounts and more of the hormone called progesterone is made after ovulation. This causes the innermost layer of the lining to prepare to shed. By the end of the cycle, the endometrial lining is shed from the uterus and becomes the menstrual flow (period). This cycle repeats throughout a woman's life until menopause (change of life).
Cancers of the uterus and endometrium
Nearly all cancers of the uterus start in the endometrium and are called endometrial carcinomas. Cancers can also start in the muscle layer or supporting connective tissue of the uterus. These cancers belong to the group of cancers called sarcomas.
Endometrial cancers start in the cells that line the uterus and belong to the group of cancers called carcinomas. Most endometrial carcinomas are cancers of the cells that form glands in the endometrium. These are called adenocarcinomas. The most common type of endometrial cancer is called endometrioid adenocarcinoma. Other rare types of endometrial carcinomas include squamous cell and undifferentiated.
Over 80% of endometrial cancers are typical adenocarcinomas -- also known as endometrioid. Endometrioid cancers are made up of cells in glands that look much like the normal uterine lining (endometrium). Some of these cancers contain squamous cells (squamous cells are flat, thin cells that can be found on the outer surface of the cervix), as well as glandular cells. A cancer with both types of cells is called an adenocarcinoma with squamous differentiation. If, under the microscope, the glandular cells look cancerous but the squamous cells don't, the tumor may be called an adenoacanthoma. If both the squamous cells and the glandular cells look malignant (cancerous), these tumors can be called adenosquamous carcinomas. There are other types of endometrioid cancers, such as secretory carcinoma, ciliated carcinoma, and mucinous adenocarcinoma.
The grade of an endometrioid cancer is based on how much the cancer forms glands that look similar to the glands found in normal, healthy endometrium. In lower-grade cancers, more of the cancerous tissue forms glands. In higher-grade cancers, more of the cancer cells are arranged in a haphazard or disorganized way and do not form glands.
- Grade 1 tumors have 95% or more of the cancerous tissue forming glands.
- Grade 2 tumors have between 50% and 94% of the cancerous tissue forming glands.
- Grade 3 tumors have less than half of the cancerous tissue forming glands. Grade 3 cancers are called "high-grade." They tend to be aggressive and have a poorer outlook than low grade cancers (grades 1 and 2).
Some less common forms of endometrial adenocarcinoma are clear-cell carcinoma, serous carcinoma (also called papillary serous carcinoma), and poorly differentiated carcinoma. These cancers are more aggressive than most endometrial cancers. They tend to grow quickly and often have spread outside the uterus at the time of diagnosis.
Uterine carcinosarcoma (CS) is another cancer that starts in the endometrium and is included in this document. When looked at under the microscope, this cancer has features of both endometrial carcinoma and sarcoma. In the past, CS was considered a type of uterine sarcoma, but many doctors now believe that CS may actually be a form of poorly differentiated carcinoma.
Endometrial carcinoma and uterine CS have many things in common. For example, they have similar risk factors. These cancers are also similar in how they spread and are treated. CSs are also known as malignant mixed mesodermal tumors or malignant mixed mullerian tumors (MMMTs). They make up about 4% of uterine cancers.
Doctors sometimes divide endometrial carcinoma into 2 types based on their outlook and underlying causes. "Type 1" cancers are thought to be caused by excess estrogen. They are usually not very aggressive and are slow to spread to other tissues. Grades 1 and 2 endometrioid cancers are "type 1" endometrial cancers. A small number of endometrial cancers are "type 2." Experts aren't sure what causes type 2 cancers, but they don't seem to be caused by too much estrogen. Serous carcinoma, clear-cell carcinoma, poorly differentiated carcinoma, and grade 3 endometrioid carcinoma are all type 2 cancers. These cancers don't look at all like normal endometrium and so are called "poorly differentiated" or "high-grade." Because type 2 cancers are more likely to grow and spread outside of the uterus, they have a poorer outlook (than type 1 cancers). Doctors tend to treat these cancers more aggressively.
Cancer can also start in the supporting connective tissue (stroma) and muscle cells of the uterus. These cancers are called uterine sarcomas. They are much less common than endometrial carcinoma. These include:
- Stromal sarcomas, which start in the supporting connective tissue of the endometrium
- Leiomyosarcomas, which start in the myometrium or muscular wall of the uterus
These cancers are not discussed in this document because their treatment and prognosis (outlook) are different from the most common cancers of the endometrium. These cancers are discussed in our document, Uterine Sarcoma.
Cancers of the cervix are different from cancers of the body of the uterus and are described in our document, Cervical Cancer.
What are the key statistics about endometrial cancer?
In the United States, cancer of the endometrium is the most common cancer of the female reproductive organs. The American Cancer Society most recent estimates for endometrial cancer in the United States are for 2010:
- About 43,470 new cases of cancer of the body of the uterus (uterine corpus) will be diagnosed.
- About 7,950 women will die from cancers of the uterine body.
These estimates include both endometrial cancers and uterine sarcomas. About 2% of uterine body cancers are sarcomas, so the actual numbers for endometrial cancer cases and deaths are slightly lower than these estimates.
Endometrial cancer is rare in women under the age of 40. Most cases are found in women aged 50 and over, with more than half of all endometrial cancer cases diagnosed in the 50 to 69 age group. The average chance of a woman being diagnosed with this cancer during her lifetime is about one in 40. There are over 500,000 women who are survivors of this cancer. This cancer is more common in white women, but black women are more likely to die from it.
When all cases of endometrial cancer are looked at together, the 5-year relative survival rate is about 83%. Most of these cancers are found at an early stage, which has a 5-year survival rate of over 96%. However, the outlook (prognosis) for any single woman depends on the stage of her cancer as well as several other factors.
Five-year rates are a standard way for doctors to discuss prognosis. The 5-year survival rate refers to the percentage of women who live at least five years after their cancer is diagnosed. But many of these women live much longer than five years after diagnosis. Relative survival rates compare the survival of people with the cancer to the survival for people without the cancer. Since some people will die of causes other than cancer, this is a way to look only at deaths from the cancer in question. The 5-year relative survival rate is a more accurate way to describe the outlook for patients with a particular type and stage of cancer.
But it is important to always remember that people are not statistics. Every person is different, and every person will have his/her own experience with cancer and its treatment. The statistics themselves are based on patients diagnosed and first treated more than five years ago. They do not take into account newer and more effective treatments that may mean a better outlook for recently diagnosed patients. To learn more about survival rates see the section, "How is endometrial cancer treated?"
What are the risk factors for endometrial cancer?
A risk factor is anything that changes your chance of getting a disease such as cancer. Different cancers have different risk factors. For example, unprotected exposure to strong sunlight is a risk factor for skin cancer. Smoking is a risk factor for many cancers.
There are different kinds of risk factors. Some, such as your age or race, can't be changed. Others are related to personal choices such as smoking, drinking, or diet. Some factors influence risk more than others. But risk factors don't tell us everything. Someone can have several risk factors and still not get a disease. Also, not having any risk factors doesn't mean that you won't get the disease.
A woman's hormone balance plays a part in the development of most endometrial cancers. Many of the risk factors for endometrial cancer affect estrogen levels. Before menopause, the ovaries are the main source of the 2 main types of female hormones -- estrogen and progesterone. The balance between these hormones changes during a woman's menstrual cycle each month. This produces a woman's monthly periods and keeps the endometrium healthy. A shift in the balance of these two hormones toward more estrogen increases a woman's risk for developing endometrial cancer. After menopause, the ovaries stop making these hormones, but a small amount of estrogen is still made naturally in fat tissue. This estrogen has a bigger impact after menopause than it does before menopause. Female hormones are also available to take (as a medicine) in birth control pills to prevent pregnancy and hormone therapy to treat symptoms of menopause.
Treating the symptoms of menopause with estrogen is known as estrogen therapy or menopausal hormone therapy. Estrogen is available in many different forms to treat the symptoms of menopause, such as pills, skin patches, creams, and vaginal rings. Estrogen treatment can reduce hot flashes, improve vaginal dryness, and help prevent the weakening of the bones (osteoporosis) that can occur with menopause. Doctors have found, however, that using estrogen alone (without progesterone) can lead to endometrial cancer. Progesterone-like drugs must be given along with estrogen to avoid the increased risk of endometrial cancer. This approach is called combination hormone therapy. Studies have shown that estrogen therapy increases a woman's chance of developing serious blood clots.
Giving progesterone along with estrogen does not cause endometrial cancer, but it does still have risks. Studies have shown that this combination increases a woman's chance of developing breast cancer and also increases the risk of serious blood clots.
If you are taking (or plan to take) hormones after menopause, it is important for you to discuss the potential risks (including cancer, blood clots, heart attacks, and stroke) with your doctor. Like any other medicine, hormones should be used only at the lowest dose that is needed and for the shortest possible time to control symptoms. You should also have at least yearly follow-up checks for cancer. If you have any abnormal bleeding or discharge you should see your doctor or other health care provider right away.
Birth control pills
Using birth control pills (oral contraceptives) lowers the risk of endometrial cancer. The risk is lowest in women who take the pill for a long time, and this protection continues for at least ten years after a woman stops taking this form of birth control. However, it is important to look at all of the risks and benefits when choosing a contraceptive method -- endometrial cancer risk is only one factor to be considered. It's a good idea to discuss the pros and cons of different types of birth control with your doctor.
Total number of menstrual cycles
Having more menstrual cycles during a woman's lifetime raises her risk of endometrial cancer. Starting menstrual periods (menarche) before age 12 and/or going through menopause later in life raises the risk. Starting periods early is less a risk factor for women with early menopause. Likewise, late menopause may not lead to a higher risk in women whose periods began later in their teens.
The hormonal balance shifts toward more progesterone during pregnancy. So having many pregnancies protects against endometrial cancer. Women who have never been pregnant (nulliparity) have a higher risk, especially if they were also infertile (unable to become pregnant).
Most of a woman's estrogen is produced by her ovaries, but fat tissue can change some other hormones into estrogens. Having more fat tissue can increase a woman's estrogen levels, which increases her endometrial cancer risk. In comparison with women who maintain a healthy weight, endometrial cancer is twice as common in overweight women, and more than three times as common in obese women.
Tamoxifen is a drug that is used to prevent and treat breast cancer. Tamoxifen acts as an anti-estrogen in breast tissue, but it acts like an estrogen in the uterus. It can cause the uterine lining to grow, which increases the risk of endometrial cancer.
The risk of developing endometrial cancer from tamoxifen is small -- about 1 in 500. Women taking tamoxifen must balance this risk against the value of this drug in treating breast cancer and reducing the chance of cancer in the other breast. This is an issue women may want to discuss with their doctors. If you are taking tamoxifen, you should have yearly gynecologic exams and should be sure to report any abnormal bleeding, as this could be a sign of endometrial cancer.
A certain type of ovarian tumor, the granulosa-theca cell tumor, often makes estrogen. Estrogen release by one of these tumors is not controlled the way hormone release from the ovaries is, which can sometimes lead to high estrogen levels. The resulting hormone imbalance can stimulate the endometrium and even lead to endometrial cancer. In fact, sometimes vaginal bleeding from endometrial cancer is the first symptom of one of these tumors.
Polycystic ovarian syndrome
Women with a condition called polycystic ovarian syndrome (PCOS) have abnormal hormone levels, such as higher estrogen levels and lower levels of progesterone. The increase in estrogen relative to progesterone can increase a woman's chance of getting endometrial cancer.
Use of an intrauterine device
Women who used an intrauterine device (IUD) for birth control seem to have a lower risk of getting endometrial cancer. Information about this protective effect is limited to IUDs that do not contain hormones. Researchers have not yet studied whether newer types of IUDs that release hormones have any effect of endometrial cancer risk.
The risk of endometrial cancer increases as a woman gets older.
A high-fat diet can increase the risk of several cancers, including endometrial cancer. Because fatty foods are also high-calorie foods, a high fat diet can lead to obesity, which is a well-known endometrial cancer risk factor. Many scientists think this is the main way in which a high fat diet raises endometrial cancer risk. Some scientists think that fatty foods may also have a direct effect on estrogen metabolism, which increases endometrial cancer risk.
Endometrial cancer may be as much as 4 times more common in women with diabetes. Diabetes is more common in people who are overweight, but even diabetics who are not overweight have a higher risk of endometrial cancer.
Endometrial cancer tends to run in some families. Some of these families also have an inherited tendency to develop colon cancer -- this disorder is called hereditary nonpolyposis colon cancer (HNPCC). Another name for HNPCC is Lynch syndrome. In most cases, this disorder is caused by a defect in either the gene MLH1 or the gene MSH2. But at least 5 other genes can cause HNPCC: MLH3, MSH6, TGBR2, PMS1, and PMS2. An abnormal copy of any one of these genes reduces the body's ability to repair damage to its DNA. This results in a very high risk of colon cancer, as well as a high risk of endometrial cancer. Women with this syndrome have a 40% to 60% risk of developing endometrial cancer sometime during their lives. The risk of ovarian cancer is also increased.
If you have colon cancer or endometrial cancer in several family members, you might want to think about having genetic counseling and testing for HNPCC. Genetic testing can help determine if you or members of your family have a high risk of getting endometrial cancer. If you do, you will need to be watched carefully for endometrial cancer. American Cancer Society guidelines recommend that women with known or suspected (based on family history) HNPCC consider beginning endometrial sampling at age 35 and that their doctors offer this test to them and explain its benefits, risks, and limitations.
Another option for a woman who has (or may have) HNPCC is to have the uterus removed once she is finished having children.
There are some families that have a high rate of only endometrial cancer. These families may have a different genetic disorder that hasn't been discovered, yet.
Breast or ovarian cancer
Women who have had breast cancer or ovarian cancer may have an increased risk of developing endometrial cancer. Some of the dietary, hormonal, and reproductive risk factors for breast and ovarian cancer also increase endometrial cancer risk.
Prior pelvic radiation therapy
Radiation used to treat some other cancers can damage the DNA of cells, sometimes increasing the risk of a second type of cancer such as endometrial cancer.
Endometrial hyperplasia is an increased growth of the endometrium. Mild or simple hyperplasia -- the most common type -- has a very small risk of becoming cancerous. It may go away on its own or after treatment with hormone therapy. If the hyperplasia is called "atypical," it has a higher chance of becoming a cancer. Simple atypical hyperplasia turns into cancer in about 8% of cases if it is not treated. Complex atypical hyperplasia has a risk of becoming cancerous if not treated in up to 29% of cases.
Although these factors increase a woman's risk for developing endometrial cancer, they do not always cause the disease. Many women with one or more of these risk factors never develop endometrial cancer. Some women with endometrial cancer do not have any of these risk factors. Even if a woman with endometrial cancer has one or more risk factors, there is no way to know which, if any, of these factors was responsible for her cancer.
Do we know what causes endometrial cancer?
We do not yet know exactly what causes most cases of endometrial cancer, but we do know that there are certain risk factors, particularly hormone imbalance, for this type of cancer. A great deal of research is going on to learn more about the disease. We know that most endometrial cancer cells contain estrogen and/or progesterone receptors on their surfaces. Somehow, interaction of these receptors with their hormones leads to increased growth of the endometrium. This can mark the beginning of cancer. The increased growth can become more and more abnormal until it develops into a cancer.
As noted in the previous section about risk factors, many of the known endometrial cancer risk factors affect the balance between estrogen and progesterone in the body.
Scientists are learning more about changes in the DNA of certain genes that occur when normal endometrial cells become cancerous. Some of these are discussed in the section, "What's new in endometrial cancer research and treatment?"
Can endometrial cancer be prevented?
Most cases of endometrial cancer cannot be prevented, but there are some things that may lower your risk of developing this disease.
One way to lower endometrial cancer risk is to change risk factors whenever possible. For example, weight loss may reduce the risk of this type of cancer in those who are obese. Controlling diabetes may also help reduce the risk. If you have any of these conditions, discuss them with your doctor.
A healthy diet and exercise can also lower endometrial cancer risk. Women who exercise on a daily basis can cut their risk in half compared to women who don't exercise. As mentioned in the risk factor section, maintaining a healthy body weight can substantially reduce your risk for this cancer.
Estrogen to treat the symptoms of menopause is available in many different forms like pills, skin patches, creams, and vaginal rings. If you are thinking about using estrogen for menopausal symptoms, ask your doctor about how it will affect your risk of endometrial cancer. Progestins (progesterone-like drugs) can reduce the risk of endometrial cancer in women taking estrogen therapy, but this combination increases the risk of breast cancer. If you still have your uterus and are taking estrogen therapy, discuss this issue with your doctor.
Getting proper treatment of pre-cancerous disorders of the endometrium is another way to lower the risk of endometrial cancer. Most endometrial cancers develop over a period of years. Many are known to follow and possibly start from less serious abnormalities of the endometrium called endometrial hyperplasia (see the section, "What are the risk factors for endometrial cancer?"). Some cases of hyperplasia will go away without treatment. Sometimes hyperplasia needs to be treated with hormones or even surgery. Treatment with progestins and a dilation and curettage (D & C) or hysterectomy can prevent hyperplasia from becoming cancerous. (D & C is described in the section, "How is endometrial cancer diagnosed?") Abnormal vaginal bleeding is the most common symptom of endometrial pre-cancers and cancers, and it needs to be reported and evaluated right away.
Can endometrial cancer be found early?
In most cases, noticing any signs and symptoms of endometrial cancer, such as abnormal vaginal bleeding or discharge, and reporting them right away to your doctor allows the disease to be diagnosed at an early stage. Early detection improves the chances that your cancer will be treated successfully. But some endometrial cancers may reach an advanced stage before signs and symptoms can be noticed. More information about the signs and symptoms of endometrial cancer can be found in the section, "How is endometrial cancer diagnosed?"
Early detection tests
Early detection refers to testing to find a disease such as cancer in people who do not have symptoms of that disease.
Women at average endometrial cancer risk
At this time, there are no tests or exams that can find endometrial cancer early in women who are at average endometrial cancer risk and have no symptoms.
The American Cancer Society recommends that, at the time of menopause, all women should be told about the risks and symptoms of endometrial cancer and strongly encouraged to report any vaginal bleeding or spotting to their doctor.
Women should talk to their doctors about getting regular pelvic exams. A pelvic exam can find some cancers, including some advanced uterine cancers, but it is not very effective in finding early endometrial cancers.
The Pap test (or Pap smear) can find some early endometrial cancers, but it is not used to look for endometrial cancer because it is not a good screening test for this type of cancer. The Pap test is very effective in finding early cancers of the cervix (the lower part of the uterus). For this reason, the American Cancer Society recommends that:
- All women begin cervical cancer screening about 3 years after they begin having vaginal intercourse, but no later than when they are 21 years old. Screening should be done every year with the regular Pap test or every 2 years using the liquid-based Pap test.
- Beginning at age 30, women who have had three normal test results in a row may get screened every two to three years. Another reasonable option for women over 30 is to get tested every three years (but not more often) with either the regular Pap test or the liquid-based Pap test, plus the HPV DNA test. Women who have certain risk factors such as diethylstilbestrol (DES) exposure before birth, HIV infection, or a weakened immune system due to organ transplant, chemotherapy, or chronic steroid use should continue to be screened annually.
- Women 70 years of age or older who have had 3 or more normal Pap tests in a row and no abnormal Pap test results in the last ten years may choose to stop having cervical cancer screening. Women with a history of cervical cancer, DES exposure before birth, HIV infection, or a weakened immune system should continue to have screening as long as they are in good health.
- Women who have had a total hysterectomy (removal of the uterus and cervix) may also choose to stop having cervical cancer screening, unless the surgery was done as a treatment for cervical cancer or pre-cancer. Women who have had a hysterectomy without removal of the cervix should continue to follow the guidelines above.
Women at increased endometrial cancer risk
The American Cancer Society recommends that most women at increased risk should be informed of their risk and advised to see their doctor whenever there is any abnormal vaginal bleeding. This includes women whose risk of endometrial cancer is increased due to increasing age, late menopause, never giving birth, infertility, obesity, diabetes, high blood pressure, estrogen treatment, or tamoxifen therapy.
Women who have (or may have) hereditary nonpolyposis colon cancer (HNPCC) have a very high risk of endometrial cancer. These women should be offered yearly testing for endometrial cancer with endometrial biopsy beginning at age 35. This includes women known to carry HNPCC-linked gene mutations, women who are likely to carry such a mutation (those with a mutation known to be present in the family), and women from families with a tendency to get colon cancer where genetic testing has not been done.
Another option for a woman who has (or may have) HNPCC would be to have a hysterectomy once she is finished having children. One study found that none of 61 women who had prophylactic hysterectomies developed endometrial cancer, while 1/3 of the women who didn't have the surgery did get endometrial cancer.
How is endometrial cancer diagnosed?
There is no test recommended to find this cancer before symptoms develop (except for women at high risk). Routine pelvic exams rarely find this disease. Most women are diagnosed because they have symptoms.
Signs and symptoms of endometrial cancer
Unusual bleeding, spotting, or other discharge
About 90% of patients diagnosed with endometrial cancer have abnormal vaginal bleeding such as bleeding between periods or after menopause. This symptom can also occur with some non-cancerous conditions, but it is important to have a doctor look into any irregular bleeding right away. If you have gone through menopause, it is especially important to report any vaginal bleeding, spotting, or abnormal discharge to your doctor.
Non-bloody vaginal discharge may also be a sign of endometrial cancer. Even if you cannot see blood in the discharge, it does not mean there is no cancer. In about 10% of cases, the discharge associated with endometrial cancer is not bloody. Any abnormal discharge should be checked out by your doctor.
Pelvic pain and/or mass and weight loss
Pain in the pelvis, feeling a mass (tumor), and losing weight without trying can also be symptoms of endometrial cancer. These symptoms are more common in later stages of the disease. Still, any delay in seeking medical help may allow the disease to progress even further. This lowers the odds for successful treatment.
History and physical exam
If you have any of the symptoms of endometrial cancer described above, you should visit your doctor. The doctor will ask you about your symptoms, risk factors, and family medical history. The doctor will also perform a general physical exam and a pelvic exam.
Seeing a specialist
If the doctor thinks you might have endometrial cancer, you should be examined by a gynecologist, a doctor qualified to diagnose and treat diseases of the female reproductive system. Specialists in treating cancers of the endometrium and other female reproductive organs are called gynecologic oncologists.
Sampling endometrial tissue
To find out whether endometrial hyperplasia or endometrial cancer is present, the doctor must remove some tissue so that it can be looked at under a microscope. Endometrial tissue can be obtained by endometrial biopsy or by dilation and curettage (D & C) with or without a hysteroscopy. A specialist such as a gynecologist usually does these procedures, which are described below.
An endometrial biopsy is the most commonly performed test for endometrial cancer. It can be done in the doctor's office. In this procedure a very thin flexible tube is inserted into the uterus through the cervix. Then, using suction, a small amount of endometrium is removed through the tube. The suctioning takes about a minute or less. The discomfort is similar to menstrual cramps and can be helped by taking a nonsteroidal anti-inflammatory drug such as ibuprofen before the procedure.
Transvaginal ultrasound (see below) is often done before the biopsy. This helps the doctor locate any suspicious areas that should be biopsied.
For this technique doctors insert a tiny telescope (about 1/6 inch in diameter) into the uterus through the cervix. To get a better view of the inside of the uterus, the uterus is filled with salt water (saline). This lets the doctor see and biopsy anything abnormal, such as a cancer or a polyp. This is usually done with the patient awake, using a local anesthesia (numbing medicine). This is the most accurate way of looking for cancer.
Dilation and curettage (D & C)
If the endometrial biopsy sample doesn't provide enough tissue, or if the biopsy suggests cancer but the results are uncertain, a D & C must be done. In this outpatient procedure, the opening of the cervix is enlarged (dilated) and a special instrument is used to scrape tissue from inside the uterus. This may be done with or without a hysteroscopy.
The procedure takes about an hour and may require general anesthesia (where you are asleep) or conscious sedation (medicine given into a vein to make you drowsy). A D & C is usually done in an outpatient surgery area of a clinic or hospital. Most women have little discomfort after this procedure.
Testing of endometrial tissue
Endometrial tissue samples removed by biopsy or D & C are looked at under the microscope to see whether cancer is present. If cancer is found, it will be described. The lab report will state what type of endometrial cancer it is and what grade it is.
Endometrial cancer is graded based on how much it looks like normal endometrium. A cancer is called grade 1 if 95% or more of the cancer forms glands similar to those of normal endometrial tissue. Grade 2 tumors have between 50% and 94% gland formations. Cancers with less than half of the tissue forming glands are given a grade of 3. Women with lower grade cancers are less likely to have advanced disease or recurrences.
Imaging tests for endometrial cancer
Transvaginal ultrasound or sonography
Ultrasound tests use sound waves to take pictures of parts of the body. For a transvaginal ultrasound a probe that gives off sound waves is inserted into the vagina. The sound waves create images of the uterus and other pelvic organs. These images often help show whether a tumor is present and may be able to determine if it is growing into the muscle layer of the uterus (myometrium).
In order for the doctor to see the uterine lining more clearly, salt water (saline) may be put through a small tube into the uterus before the sonogram. This procedure is called a saline infusion sonogram or ultrahysterosonogram. Sonography may help doctors direct their biopsy if other procedures didn't detect a tumor.
Cystoscopy and proctoscopy
If a woman has problems that suggest the cancer has spread to the bladder or rectum, the inside of these organs can be looked at through a lighted tube. In cystoscopy the tube is placed into the bladder through the urethra. In proctoscopy the tube is placed in the rectum. These exams allow the doctor to look for possible cancers. Small tissue samples can also be removed during these procedures for pathologic (microscopic) testing. They can be done using a local anesthetic but some patients may require general anesthesia. Your doctor will let you know what to expect before and after the procedure. These procedures were used more often in the past, but now are rarely part of the work up for endometrial cancer.
Computed tomography (CT)
The CT scan is an x-ray procedure that creates detailed, cross-sectional images of your body. For a CT scan, you lie on a table while an X-ray takes pictures. Instead of taking one picture, like a standard x-ray, a CT scanner takes many pictures as the camera rotates around you. A computer then combines these pictures into an image of a slice of your body. The machine will take pictures of many slices of the part of your body that is being studied.
Before any pictures are taken, you may be asked to drink 1 to 2 pints of a liquid called "oral contrast." This helps outline the intestine so that certain areas are not mistaken for tumors. You may also receive an IV (intravenous) line through which a different kind of contrast dye (IV contrast) is injected. This helps better outline structures in your body.
The injection can cause some flushing (redness and warm feeling that may last hours to days). A few people are allergic to the dye and get hives. Rarely, more serious reactions like trouble breathing and low blood pressure can occur. Medicine can be given to prevent and treat allergic reactions. Be sure to tell the doctor if you have ever had a reaction to any contrast material used for x-rays.
CT scans are not used to diagnose endometrial cancer. However, they may be helpful to see if the cancer has spread to other organs and to see if the cancer has come back after treatment.
CT scans can also be used to precisely guide a biopsy needle into a suspected area of cancer spread. For this procedure, called a CT-guided needle biopsy, you remain on the CT scanning table while a doctor moves a biopsy needle toward the mass. CT scans are repeated until the doctor is sure that the needle is inside the mass. A fine needle biopsy sample (tiny fragment of tissue) or a core needle biopsy sample (a thin cylinder of tissue about ½ inch long and less than 1/8 inch in diameter) is removed and looked at under a microscope.
CT scans take longer than regular x-rays. You might feel a bit confined by the ring you lie within when the pictures are being taken.
Magnetic resonance imaging (MRI)
MRI scans use radio waves and strong magnets instead of x-rays. The energy from the radio waves is absorbed and then released in a pattern formed by the type of tissue and by certain diseases. A computer translates the pattern of radio waves given off by the tissues into a very detailed image of parts of the body. This creates cross sectional slices of the body like a CT scanner and it also produces slices that are parallel with the length of your body.
MRI scans are particularly helpful in looking at the brain and spinal cord. Some doctors also think MRI is a good way to tell whether, and how far, the endometrial cancer has grown into the body of the uterus. MRI scans may also help find enlarged lymph nodes with a new technique that uses very tiny particles of iron oxide. These are given into a vein and settle into lymph nodes where they can be spotted by MRI.
Sometimes a contrast material is injected into a vein -- just as with CT scans. The contrast used for MRI is different than the one used for CT. MRI scans are a little more uncomfortable than CT scans. First, they take longer -- often up to an hour. Also, you have to be placed inside a tube, which is confining and can upset people with fear of enclosed places. Newer, "open MRI" machines can help people with this fear. The machine also makes a thumping or buzzing noise that you may find disturbing. Many places will provide headphones with music to block this out.
Positron emission tomography (PET)
In this test radioactive glucose (sugar) is given to look for cancer cells. Because cancers use glucose (sugar) at a higher rate than normal tissues, the radioactivity will tend to concentrate in the cancer. A scanner can spot the radioactive deposits. This test can be helpful for spotting small collections of cancer cells. But PET scans are not routinely ordered, and their role in endometrial cancer is still being studied.
This test can show whether the cancer has spread to the lungs. It may also be used to look for serious lung or heart problems, especially before surgery.
Intravenous pyelogram (IVP)
This is an x-ray of the urinary system that is taken after injecting a special dye into a vein. This dye is removed from the bloodstream by the kidneys and passes through the ureters into the bladder (the ureters are the tubes that connect the kidneys to the bladder). This test is useful in finding abnormalities of the urinary tract, such as changes caused by spread of cancer to the pelvic lymph nodes, which may compress or block a ureter. IVP is rarely used in the initial evaluation of patients with endometrial cancer. You will not usually need an IVP if you have already had a CT or MRI.
Complete blood count
The complete blood count (CBC) is a test that measures the different cells in the blood, such as the red blood cells, the white blood cells, and the platelets. Many times women with a lot of blood loss from the uterus will have low red blood cell counts (anemia).
CA 125 blood test
CA 125 is a substance released into the bloodstream by many, but not all, endometrial and ovarian cancers. Very high blood CA 125 levels suggest that an endometrial cancer has probably spread beyond the uterus. Some doctors will use this in deciding whether surgery should be done by a gynecologic oncologist. If CA 125 levels are high before surgery, some doctors use follow-up measurements to find out how well the treatment is working (levels will drop after surgery if treatment is effective) and to see if the cancer has come back after initially successful treatment.
How is endometrial cancer staged?
Staging is the process of looking at all of the information the doctors have learned about your tumor to tell how much the cancer may have spread. The stage of an endometrial cancer is the most important factor in choosing a treatment plan. Ask your doctor to explain the stage of your cancer so that you can make fully informed choices about your treatment.
Doctors use a staging system to describe how far a patient's cancer has spread. The 2 systems used for staging endometrial cancer, the FIGO (International Federation of Gynecology and Obstetrics) system and the American Joint Committee on Cancer TNM staging system, are very similar. They both classify this cancer on the basis of 3 factors: the extent of the tumor (T), whether the cancer has spread to lymph nodes (N) and whether it has spread to distant sites (M). The system described below is the most recent AJCC system, which went into effect January 2010. Any differences between the AJCC system and the FIGO system are explained in the text.
Endometrial cancer is staged based on examination of tissue removed during an operation. This, known as surgical staging, means that doctors can't tell for sure what stage the cancer is in until after surgery is done (in most cases). Both staging systems classify the cancer in stages I through IV (1 through 4), with some of these stages being further divided (for example, stages IIIA and IIIB).
A doctor may order tests before surgery, such as ultrasound, MRI, or CT scan, to look for signs that a cancer has spread. Although it is not as good as the surgical stage, this information can be helpful in planning surgery and other treatment. These tests may result in the need to refer a patient to a gynecologic oncologist
The staging system looks at how far the cancer has spread. It can spread locally to other parts of the uterus. It can also spread regionally to nearby lymph nodes (bean-sized organs that are part of the immune system). The regional lymph nodes are found in the pelvis and farther away along the aorta (the main artery that runs from the heart down along the back of the abdomen and pelvis). The lymph nodes along the aorta are called para-aortic nodes. Finally, the cancer can spread (metastasize) to distant lymph nodes or organs such as lung, liver, bone, brain, and others.
Tumor extent (T)
T0: No signs of a tumor in the uterus
Tis: Pre-invasive cancer (also called carcinoma in-situ). Cancer cells are only found in the surface layer of cells of the endometrium, without growing into the layers of cells below.
T1: The cancer is only growing in the body of the uterus. It may also be growing into the glands of the cervix, but is not growing into the supporting connective tissue of the cervix.
T1a: The cancer is in the endometrium (inner lining of the uterus) and may have grown from the endometrium less than halfway through the underlying muscle layer of the uterus (the myometrium).
T1b: The cancer has grown from the endometrium into the myometrium, growing more than halfway through the myometrium. The cancer has not spread beyond the body of the uterus.
T2: The cancer has spread from the body of the uterus and is growing into the supporting connective tissue of the cervix (called the cervical stroma). The cancer has not spread outside of the uterus.
T3: The cancer has spread outside of the uterus, but has not spread to the inner lining of the rectum or urinary bladder.
T3a: The cancer has spread to the outer surface of the uterus (called the serosa) and/or to the fallopian tubes or ovaries (the adnexa)
T3b: The cancer has spread to the vagina or to the tissues around the uterus (the parametrium).
T4: The cancer has spread to the inner lining of the rectum or urinary bladder (called the mucosa)
Lymph node spread (N)
NX: spread to nearby lymph nodes cannot be assessed
N0: no spread to nearby lymph nodes
N1: cancer has spread to lymph nodes in the pelvis
N2: cancer has spread to lymph nodes along the aorta (peri-aortic lymph nodes)
Distant spread (M)
M0: The cancer has not spread to distant lymph nodes, organs, or tissues
M1: The cancer has spread to distant organs (such as the lungs or liver)
Information about the tumor, lymph nodes, and any cancer spread is then combined to assign the stage of disease. This process is called stage grouping. The stages are described using the number 0 and Roman numerals from I to IV. Some stages are divided into sub-stages indicated by letters and numbers.
Stage 0 (Tis, N0, M0): This stage is also known as carcinoma in-situ. Cancer cells are only found in the surface layer of cells of the endometrium, without growing into the layers of cells below. The cancer has not spread to nearby lymph nodes or distant sites. This stage is not included in the FIGO staging system.
Stage I (T1, N0, M0): The cancer is only growing in the body of the uterus. It may also be growing into the glands of the cervix, but is not growing into the supporting connective tissue of the cervix. The cancer has not spread to lymph nodes or distant sites.
Stage IA (T1a, N0, M0): In this earliest form of stage I, the cancer is in the endometrium (inner lining of the uterus) and may have grown from the endometrium less than halfway through the underlying muscle layer of the uterus (the myometrium). It has not spread to lymph nodes or distant sites.
Stage IB (T1b, N0, M0): The cancer has grown from the endometrium into the myometrium, growing more than halfway through the myometrium. The cancer has not spread beyond the body of the uterus.
Stage II (T2, N0, M0): The cancer has spread from the body of the uterus and is growing into the supporting connective tissue of the cervix (called the cervical stroma). The cancer has not spread outside of the uterus. The cancer has not spread to lymph nodes or distant sites.
Stage III (T3, N0, M0): Either the cancer has spread outside of the uterus into nearby tissues in the pelvic area.
Stage IIIA (T3a, N0, M0): The cancer has spread to the outer surface of the uterus (called the serosa) and/or to the fallopian tubes or ovaries (the adnexa). The cancer has not spread to lymph nodes or distant sites.
Stage IIIB (T3b, N0, M0): The cancer has spread to the vagina or to the tissues around the uterus (the parametrium). The cancer has not spread to lymph nodes or distant sites.
Stage IIIC1 (T1 to T3, N1, M0): The cancer is growing in the body of the uterus. It may have spread to some nearby tissues, but is not growing into the inside of the bladder or rectum. The cancer has spread to pelvic lymph nodes but not to lymph nodes around the aorta or distant sites.
Stage IIIC2 (T1 to T3, N2, M0): The cancer is growing in the body of the uterus. It may have spread to some nearby tissues, but is not growing into the inside of the bladder or rectum. The cancer has spread to lymph nodes around the aorta (peri-aortic lymph nodes) but not to distant sites.
Stage IV: The cancer has spread to the inner surface of the urinary bladder or the rectum (lower part of the large intestine), to lymph nodes in the groin, and/or to distant organs, such as the bones or lungs.
Stage IVA (T4, any N, M0): The cancer has spread to the inner lining of the rectum or urinary bladder (called the mucosa). It may or may not have spread to lymph nodes but has not spread to distant sites.
Stage IVB (any T, any N, M1): The cancer has spread to organs away from the uterus, such as the bones or lungs. The cancer can be any size and it may or may not have spread to lymph nodes.
Survival by stage
Survival rates are often used by doctors as a standard way of discussing a person's prognosis (outlook). Some patients with cancer may want to know the survival statistics for people in similar situations, while others may not find the numbers helpful, or may even not want to know them. Whether or not you want to read about the survival statistics below for endometrial cancer is up to you.
The 5-year survival rate refers to the percentage of patients who live at least 5 years after their cancer is diagnosed. Of course, many people live much longer than 5 years (and many are cured).
In order to get 5-year survival rates, doctors have to look at people who were treated at least 5 years ago. Improvements in treatment since then may result in a more favorable outlook for people now being diagnosed with endometrial cancer.
Survival rates are often based on previous outcomes of large numbers of people who had the disease, but they cannot predict what will happen in any particular person's case. Many other factors may affect a person's outlook, such as their general health and how well the cancer responds to treatment. Your doctor can tell you how the numbers below may apply to you, as he or she is familiar with the aspects of your particular situation.
The numbers below come from the National Cancer Data Base, and are based on people diagnosed between 2000 and 2002.
Relative 5-year survival rates by stage for endometrial adenocarcinoma are:
Stage 0: 90%
Stage IIIB: 50%
Stage IIIC: 47%
Stage IVB: 15%
The statistics below for uterine carcinosarcoma are different from those given for endometrial adenocarcinoma in some important ways. First of all, the numbers given are for 5-year relative survival. These rates assume that some people will die of other causes and compare the observed survival with that expected for people without the cancer. This can better show the impact of a particular type and stage of cancer on survival. In addition, these numbers come from a different source -- the SEER program from the National Cancer Institute. Lastly, the stages listed are based on an older version of staging. In the most recent staging system, some of the cancers that were stage III might actually be considered stage I or II. These differences in staging may make it more difficult to apply these numbers to your own situation.
Relative 5-year survival rates for uterine carcinosarcoma are:
Stage I: 70%
Stage II: 45%
Stage III: 30%
Stage IV: 15%
How is endometrial cancer treated?
General treatment information
After all of the test results have been reviewed, your doctor will recommend one or more treatment options. Don't feel rushed about making a decision. 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 when it is found. Other factors could 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 different treatment options before making a decision.
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 certain treatments, but a second opinion is usually not required for routine cancer treatments.
There are four basic types of treatment for women with endometrial cancer -- surgery, radiation therapy, hormonal therapy, and chemotherapy. Surgery is the main treatment for most women with this cancer. But in certain situations, a combination of these treatments may be used. The choice of treatment(s) will depend on the type and stage of your cancer, and your overall medical condition.
The next few sections describe the different types of treatment. This is followed by a section on the standard treatment options for each stage of the disease.
The main treatment for endometrial cancer is an operation to remove the uterus and cervix (called a hysterectomy). When the uterus is removed through an incision in the abdomen, it is called a simple or total abdominal hysterectomy (TAH). If the uterus is removed through the vagina, it is known as a vaginal hysterectomy. Removing the ovaries and fallopian tubes is not actually part of a hysterectomy -- it is a separate procedure known as a bilateral salpingo-oophorectomy (BSO). The BSO is often done along with a hysterectomy in the same operation (see below). For endometrial cancer, removing the uterus but not the ovaries or fallopian tubes is seldom recommended. To decide what stage the cancer is in, lymph nodes in the pelvis and around the aorta will also need to be removed (see below). This can be done through the same incision as the abdominal hysterectomy. If a vaginal hysterectomy is done, lymph nodes can be removed by laparoscopy (this is discussed in detail below).
A radical hysterectomy is done when endometrial cancer has spread to the cervix or the area around the cervix (the parametrium). In this operation, the entire uterus, the tissues next to the uterus (parametrium and uterosacral ligaments), and the upper part of the vagina (next to the cervix) are all removed. For endometrial cancer, a BSO is done at the same time. This operation is most often done through an incision in the abdomen, but it can also be done going in through the vagina. When a vaginal approach is used, laparoscopy is used to help safely remove all of the correct tissues. Laparoscopy is a technique that lets the surgeon look at the inside of the abdomen and pelvis through tubes inserted into very small incisions. Small surgical instruments can be controlled through the tubes, allowing the surgeon to operate without a large incision in the abdomen. This can shorten the time needed for recovery from surgery. Both a hysterectomy and a radical hysterectomy can also be done through the abdomen using laparoscopy. Surgery for endometrial cancer using laparoscopy seems t be just as good as more traditional open procedures if done by a surgeon who has a lot of experience in laparoscopic cancer surgeries.
For any of these surgeries, either general anesthesia or regional anesthesia will be used so the patient is asleep or sedated during these operations.
This operation removes both fallopian tubes and both ovaries. This procedure is usually done at the same time the uterus is removed (either by simple hysterectomy or radical hysterectomy) to treat endometrial cancers. Removing both ovaries means that you will go into menopause if you have not done so already.
Lymph node surgery
Pelvic and para-aortic lymph node dissection: This operation removes lymph nodes from the pelvis and the area next to the aorta to see if they contain cancer cells that have spread from the endometrial tumor. This procedure is usually done at the same time as the operation to remove the uterus. If the patient is having an abdominal hysterectomy, the lymph nodes can be removed through the same incision. In women who have had a vaginal hysterectomy, these lymph nodes may be removed by laparoscopic surgery. In a lymph node dissection, most or all of the lymph nodes in a certain area are removed. When only a few of the lymph nodes in an area are removed, it is called lymph node sampling.
Laparoscopic lymph node sampling: The usual surgery for endometrial cancer is abdominal hysterectomy with lymph node sampling done at the same time. Laparoscopy is a technique that lets the surgeon look at the inside of the abdomen and pelvis through tubes inserted into very small incisions. Small surgical instruments can be controlled through the tubes, allowing the surgeon to remove lymph nodes. This approach avoids the need for a large incision in the abdomen, and so can shorten the time needed for recovery from surgery. A recent study showed that laparoscopic surgery (including lymph node removal) works as well (at least in the short-term) as open abdominal surgery.
In this procedure, the surgeon "washes" the abdominal and pelvic cavities with salt water (saline) and sends the fluid to the lab to see if it contains cancer cells.
Other procedures that may be used for staging
- Omentectomy: The omentum is a layer of fatty tissue that covers the abdominal contents like an apron. Cancer sometimes spreads to this tissue. When this tissue is removed, it is called an omentectomy. Sometimes the omentum is removed during a hysterectomy to see if cancer has spread there.
- Peritoneal biopsies: The tissue lining the pelvis and abdomen is called the peritoneum. Peritoneal biopsies involve removing small pieces of this lining to check for cancer cells.
If cancer has spread throughout the abdomen, the surgeon may attempt to remove as much of the tumor as possible. This is called debulking. Debulking a cancer can help other treatments, like radiation or chemotherapy, work better. Tumor debulking is helpful for other types of cancer, but it isn't clear yet if it will help patients with endometrial cancer live longer.
Recovery after surgery
For an abdominal hysterectomy the hospital stay is usually from 3 to 7 days. The average hospital stay after a radical hysterectomy is about 5 to 7 days. Complete recovery can take about 4 to 6 weeks. A laparoscopic procedure and vaginal hysterectomy usually require a hospital stay of 1 to 2 days and 2 to 3 weeks for recovery. Complications are unusual but could include excessive bleeding, wound infection, and damage to the urinary or intestinal systems.
Any hysterectomy causes infertility (not being able to start or maintain a pregnancy). For those who were premenopausal before surgery, removing the ovaries will cause menopause. This can lead to symptoms such as hot flashes, night sweats, and vaginal dryness.
Radiation therapy is the use of high-energy radiation (such as x-rays) to kill cancer cells. Radiation therapy may be given by placing radioactive materials inside the body near the tumor. This is called internal radiation therapy or brachytherapy. Another option is to give radiation from a machine outside the body in a procedure that is much like having an x-ray. This is called external beam radiation therapy. In some cases, both brachytherapy and external beam radiation therapy are given. The stage and grade of the cancer help determine what areas need to be exposed to radiation therapy and which methods are used.
For vaginal brachytherapy, a cylinder containing a source of radiation is inserted into the vagina. With this method, the radiation mainly affects the area in contact with the cylinder, such as the vaginal cuff (the upper third of the vagina). Nearby structures such as the bladder and rectum get less radiation exposure than the area in contact with the cylinder.
This procedure is done in the radiation suite of the hospital or care center. About 4 to 6 weeks after the hysterectomy, the surgeon or radiation oncologist inserts a special applicator into the woman's vagina, and pellets of radioactive material are inserted into the applicator. There are 2 types of brachytherapy used for endometrial cancer, low-dose rate (LDR) and high-dose rate (HDR).
In LDR brachytherapy, the pellets are usually left in place for about a day at a time. The patient needs to stay immobile to keep the pellets from moving during treatment, and so she is usually kept in the hospital overnight. Several treatments may be necessary.
In HDR brachytherapy, the radiation is more intense. Each dose takes a very short period of time (usually less than an hour), and the patient can return home the same day. For endometrial cancer, HDR brachytherapy is often given weekly or even daily for at least 3 doses.
External beam radiation therapy
In this type of treatment the radiation is delivered from a source outside of the body.
External beam radiation therapy is often given 5-days-a-week for 4 to 6 weeks. The skin covering the treatment area is carefully marked with permanent ink or injected dye similar to a tattoo. A special mold of the pelvis and lower back is custom made to ensure that the woman is placed in the exact same position for each treatment. Each treatment takes less than a half-hour, but the daily visits to the radiation center may be tiring and inconvenient.
Side effects of radiation therapy
Common side effects of radiation therapy include tiredness, upset stomach, or loose bowels. Serious fatigue, which may not occur until about 2 weeks after treatment begins, is a common side effect. Diarrhea is common, but can usually be controlled with over-the-counter medicines. Nausea and vomiting may also occur, but can be treated with medication. Side effects tend to be worse when chemotherapy is given with radiation.
Skin changes are also common, with the skin in the treated area looking and feeling sunburned. As the radiation passes through the skin to the cancer, it may damage the skin cells. This can cause irritation ranging from mild temporary redness to permanent discoloration. The skin may release fluid, which can lead to infection, so care must be taken to clean and protect the area exposed to radiation.
Radiation can irritate the bladder and problems with urination may occur. Irritation to the bladder, called radiation cystitis, can result in discomfort and an urge to urinate often.
Radiation can also lead to low blood counts, causing anemia (low red blood cells) and leukopenia (low white blood cells). The blood counts usually return to normal within a few weeks after radiation is stopped.
Pelvic radiation therapy may cause scar tissue to form in the vagina. The scar tissue can make the vagina shorter or more narrow (called vaginal stenosis), which can make sex (vaginal intercourse) painful. A woman can help prevent this problem by stretching the walls of her vagina several times a week. This can be done by having sexual intercourse 3 to 4 times per week or by using a vaginal dilator (a plastic or rubber tube used to stretch out the vagina). Still, vaginal dryness and pain with intercourse can be long-term side effects from radiation. Pelvic radiation can damage the ovaries, resulting in premature menopause. However, this is not an issue for most women who are being treated for endometrial cancer, because they have already gone through menopause, either naturally or as a result of surgery to treat the cancer (hysterectomy and removal of the ovaries).
Pelvic radiation therapy can also lead to a blockage of the fluid draining from the leg. This can lead to severe swelling, known as lymphedema. Lymphedema is a long-term side effect - it doesn't go away after radiation is stopped. In fact it may not appear for several months after treatment ends. This side effect is more common if pelvic lymph nodes were removed during surgery to remove the cancer.
Radiation to the pelvis can also weaken the bones, leading to fractures of the hips or pelvic bones. It is important that women who have had endometrial cancer contact their doctor right away if they have pelvic pain. Such pain might be caused by a fracture, recurrent cancer, or other serious conditions.
If you are having side effects from radiation, discuss them with your doctor. There are things you can do to get relief from these symptoms or to prevent them from happening.
Chemotherapy (often called "chemo") is the use of cancer-fighting drugs 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 sometimes works better than one drug alone in treating cancer.
Drugs used in treating endometrial cancer may include paclitaxel (Taxol®), carboplatin, doxorubicin (Adriamycin®), cisplatin. Most often, 2 or more drugs are combined for treatment. The most common combinations include carboplatin and paclitaxel, and less commonly used regimens include: cisplatin and doxorubicin, paclitaxel and doxorubicin, and cisplatin/paclitaxel/doxorubicin. For carcinosarcoma, the chemo drug ifosfamide, either alone or in combination with either carboplatin,cisplatin or paclitaxel, is often used. However, the combination of carboplatin and paclitaxel is also often being used for carcinosarcoma.
These drugs kill cancer cells but can also damage some normal cells, which in turn can cause side effects. Side effects of chemotherapy depend on the specific drugs, the amount taken, and the length of time you are treated. Common side effects include:
- Nausea and vomiting
- Loss of appetite
- Mouth and vaginal sores
- Hair loss
Also, most chemotherapy drugs can damage the blood-producing cells of the bone marrow. This can result in low blood cell counts, such as:
- Low white blood cells which increases the risk of infection
- Low platelet counts which can cause bleeding or bruising after minor cuts or injuries,
- Low red blood cells (anemia) which can cause problems like fatigue and shortness of breath
Most of the side effects of chemotherapy stop when the treatment is over, but some can last a long time. Different drugs can cause different side effects. For example, the drug doxorubicin can damage the heart muscle over time. The chance of heart damage goes up as the total dose of the drug goes up, so doctors place a limit on how much doxorubicin is given. Cisplatin can cause kidney damage. Giving large amounts of fluid before and after chemotherapy can help protect the kidneys. Both cisplatin and paclitaxel can cause nerve damage (called neuropathy). This can lead to numbness, tingling, or even pain in the hands and feet. Ifosfamide can injure the lining of the bladder, causing it to bleed (called hemorrhagic cystitis). This can be prevented by giving large amounts of fluid and a drug called mesna along with the chemo. Before starting chemotherapy, be sure to discuss the drugs and their possible side effects with your health care team.
If you have side effects while on chemotherapy, remember that there are ways to prevent or treat many of them. For example, modern anti-nausea drugs can prevent or reduce nausea and vomiting. Be sure to talk with your doctor or nurse about any side effects you are having.
Hormone therapy is the use of hormones or hormone blocking drugs to fight cancer. This type of hormone therapy is not the same as hormones given to treat the symptoms of menopause (menopausal hormone therapy).
The main hormone treatment for endometrial cancer uses progesterone-like drugs called progestins. The 2 most commonly used progestins are medroxyprogesterone acetate (Provera®, which can be given as an injection or as a pill) and megestrol acetate (Megace®, which is given as a pill). These drugs work by slowing the growth of endometrial cancer cells. Side effects can include increased blood sugar levels in patients with diabetes. Hot flashes, night sweats, and weight gain (from fluid retention and an increased appetite) also occur. Rarely, serious blood clots are seen in patients on progestins.
Tamoxifen, an anti-estrogen drug often used to treat breast cancer, may also be used to treat advanced or recurrent endometrial cancer. The goal of tamoxifen therapy is to prevent any estrogens circulating in the woman's body from stimulating growth of the cancer cells. Even though tamoxifen may prevent estrogen from nourishing the cancer cells, it acts like a weak estrogen in other areas of the body. It does not cause bone loss, but can cause hot flashes and vaginal dryness. People taking tamoxifen also have an increased risk of serious blood clots in the leg.
Gonadotropin-releasing hormone agonists
Most women with endometrial cancer have had their ovaries removed as a part of treatment. In others, radiation treatments have made their ovaries inactive. This reduces the production of estrogen and may also slow the growth of the cancer. Gonadotropin-releasing hormone (GNRH) agonists are another way to lower estrogen levels. These drugs switch off estrogen production by the ovaries in women who are premenopausal. Examples of GNRH agonists include goserelin (Zoladex) and leuprolide (Lupron). These drugs are injected every 1 to 3 months. Side effects can include any of the symptoms of menopause, such as hot flashes and vaginal dryness. If they are taken for a long time (years), these drugs can weaken bones (sometimes leading to osteoporosis).
After the ovaries are removed (or are not functioning), estrogen is still made in fat tissue. This becomes the body's main source of estrogen. Drugs called aromatase inhibitors can stop this estrogen from being formed and lower estrogen levels even further. Examples of aromatase inhibitors include letrozole (Femara), anastrozole (Arimidex), and exemestane (Aromasin). These drugs are most often used to treat breast cancer, but may be helpful in the treatment of endometrial cancer. Side effects can include joint and muscle pain as well as hot flashes. If they are taken for a long time (years), these drugs can weaken bones (sometimes leading to osteoporosis). These drugs are still being studied for use in treating endometrial cancer.
You may have had to make a lot of decisions since you've been told you have cancer. One of the most important decisions you will make is choosing which treatment is best for you. You may have heard about clinical trials being done for your type of cancer. Or maybe someone on your health care team has mentioned a clinical trial to you.
Clinical trials are carefully controlled research studies that are done with patients who volunteer for them. They are done to get a closer look at promising new treatments or procedures.
If you would like to take part in a clinical trial, you should start by asking your doctor if your clinic or hospital conducts clinical trials. You can also call our clinical trials matching service for a list of clinical trials that meet your medical needs. You can reach this service at 1-800-303-5691 or on our Web site at http://clinicaltrials.cancer.org. You can also get a list of current clinical trials by calling the National Cancer Institute's Cancer Information Service toll-free at 1-800-4-CANCER (1-800-422-6237) or by visiting the NCI clinical trials Web site at www.cancer.gov/clinicaltrials.
There are requirements you must meet to take part in any clinical trial. If you do qualify for a clinical trial, it is up to you whether or not to enter (enroll in) it.
Clinical trials are one way to get state-of-the art cancer treatment. They are the only way for doctors to learn better methods to treat cancer. Still, they are not right for everyone.
You can get a lot more information on clinical trials in our document called Clinical Trials: What You Need to Know. You can read it on our Web site or call our toll-free number (1-800-227-2345) and have it sent to you.
Complementary and alternative therapies
When you have cancer you are likely to hear about ways to treat your cancer or relieve symptoms that your doctor hasn't mentioned. Everyone from friends and family to Internet groups and Web sites offer ideas for what might help you. These methods can include vitamins, herbs, and special diets, or other methods such as acupuncture or massage, to name a few.
What exactly are complementary and alternative therapies?
Not everyone uses these terms the same way, and they are used to refer to many different methods, so it can be confusing. We use complementary to refer to treatments that are used along with your regular medical care. Alternative treatments are used instead of a doctor's medical treatment.
Complementary methods: Most complementary treatment methods are not offered as cures for cancer. Mainly, they are used to help you feel better. Some methods that are used along with regular treatment are meditation to reduce stress, acupuncture to help relieve pain, or peppermint tea to relieve nausea. Some complementary methods are known to help, while others have not been tested. Some have been proven not be helpful, and a few have even been found harmful.
Alternative treatments: Alternative treatments may be offered as cancer cures. These treatments have not been proven safe and effective in clinical trials. Some of these methods may pose danger, or have life-threatening side effects. But the biggest danger in most cases is that you may lose the chance to be helped by standard medical treatment. Delays or interruptions in your medical treatments may give the cancer more time to grow and make it less likely that treatment will help.
Finding out more
It is easy to see why people with cancer think about alternative methods. You want to do all you can to fight the cancer, and the idea of a treatment with no side effects sounds great. Sometimes medical treatments like chemotherapy can be hard to take, or they may no longer be working. But the truth is that most of these alternative methods have not been tested and proven to work in treating cancer.
As you consider your options, here are 3 important steps you can take:
- Look for "red flags" that suggest fraud. Does the method promise to cure all or most cancers? Are you told not to have regular medical treatments? Is the treatment a "secret" that requires you to visit certain providers or travel to another country?
- Talk to your doctor or nurse about any method you are thinking about using.
- Contact us at 1-800-227-2345 to learn more about complementary and alternative methods in general and to find out about the specific methods you are looking at.
The choice is yours
Decisions about how to treat or manage your cancer are always yours to make. If you want to use a non-standard treatment, learn all you can about the method and talk to your doctor about it. With good information and the support of your health care team, you may be able to safely use the methods that can help you while avoiding those that could be harmful.
Treatment options for endometrial cancer by stage
Endometrial cancer is often diagnosed when a woman who is having symptoms has an endometrial biopsy or D&C. Tests, such as ultrasound and CT scan, may be done to look for signs that the cancer has spread to lymph nodes or tissues outside of the uterus. Even when these tests show no signs of cancer spread, surgery is needed to fully stage the cancer. This operation includes removing the uterus, fallopian tubes, and ovaries (total hysterectomy bilateral salpingo-oophorectomy -- TH/BSO). Lymph nodes from the pelvis and around the aorta are also removed (a pelvic and para-aortic lymph node dissection [LND] or sampling) and examined for cancer spread. Pelvic washings are obtained. If tests done before surgery show signs that the cancer has spread outside of the uterus, a different surgery may be planned.
An endometrial cancer is stage I if the cancer is limited to the body of the uterus and has not spread to lymph nodes or distant sites. If the tumor is endometrioid, standard treatment includes surgery to remove and stage the cancer (see above). The tissues removed at surgery are examined under a microscope in a lab to see how far the cancer has spread. This decides what stage the cancer is in and what treatment is needed after surgery. Surgery and other treatment often differ for cancers that aren't endometrioid - this will be discussed later in this section.
Treatment after complete staging for endometrioid cancers
In stage IA, the cancer has grown less than halfway into the myometrium. Many of these can be observed without further treatment after surgery. For high grade tumors, doctors are more likely to recommend radiation after surgery. Either vaginal brachytherapy (VB), pelvic radiation, or both can be used.
In stage IB, the cancer has grown more than halfway through the myometrium. After surgery the patient may be watched without further treatment or offered some form of radiation treatment. Either VB, pelvic radiation, or both can be used.
Treatment for high-grade cancers: These cancers, such as papillary serous carcinoma or clear cell carcinoma, are more likely to have spread outside of the uterus at the time of diagnosis. Patients with these types of tumors do not do as well as those with lower grade tumors. If the biopsy done before surgery showed a high-grade cancer, the surgery may be more extensive. In addition to the TH/BSO and the pelvic and para-aortic lymph node dissections, the omentum is often removed and peritoneal biopsies may be obtained. After surgery, both chemotherapy and radiation therapy are often given to help keep the cancer from coming back. The chemotherapy usually includes the drugs carboplatin and paclitaxel and less frequently cisplatin and doxorubicin.
Uterine carcinosarcoma: Someone with a uterine carcinosarcoma often has the same type of surgery that is used for high-grade endometrial carcinoma. After surgery, radiation, chemotherapy, or both may be used. The chemotherapy often includes the drug carboplatin and paclitaxel, ifosfamide with paclitaxel, or less often ifosfamide and cisplatin.
Patients not staged with surgery
As stated above, standard treatment for endometrial cancer includes surgery to remove and stage the cancer. In some cases, however, the doctor may treat based on the clinical stage (see the section about staging for more details) and radiologic testing.
If the cancer seen on endometrial biopsy or D&C is grade 1 and it looks like the cancer is only in the uterus, the cancer is said to be clinical stage I, grade 1. Because few of these cancers have already spread, some doctors do not feel that full surgical staging is always needed. Often a TH/BSO will be done first. As soon as the uterus is removed, it will be examined to see how deep and far the cancer may have spread. If the cancer is only in the upper two thirds of the body of the uterus and hasn't grown more than halfway through the muscle layer of the uterus, the chance that the cancer has spread is very low. In these cases, the surgeon may not do a LND but instead may remove only a few lymph nodes or none at all. Recent studies have shown that this may be as good as a full LND. If any of the lymph nodes contains cancer it means that the cancer is stage IIIC and further treatment is needed (treatment of stage IIIC is discussed later). If no lymph nodes were removed (or if there were no cancer cells in the nodes that were removed), treatment after surgery could include observation without further treatment or radiation.
Women who cannot have surgery because of other medical problems are often treated with radiation alone.
In place of surgery to remove the uterus, progestin therapy is sometimes used to treat stage I, grade 1 EC in young women with who still want to have children. Progestin treatment can cause the cancer to shrink or even go away for some time, giving the woman a chance to get pregnant. This approach is experimental and can be risky. In some cases, it does not work and the cancer keeps growing. Sometimes the tumor gets smaller or goes away for a while, but then comes back again. Not having surgery right away may give the cancer time to spread outside the uterus. A second opinion from a gynecologic oncologist and pathologist (to confirm the grade of the cancer) before starting progestin therapy is important. Patients need to understand that this is not a standard treatment and may increase risk.
Doctors are more likely to remove some lymph nodes when the biopsy shows that the cancer is a higher grade (2 or 3). If the cancer has spread deeper than half the thickness of the wall of the uterus, then the pelvic and para-aortic lymph nodes are usually sampled.
If the cancer comes back after surgery, it usually does so in the vagina. Many doctors recommend vaginal brachytherapy to prevent this from happening. Others recommend external beam radiation to the whole pelvic area. Certain features make it more likely that the cancer will come back after surgery, such as higher grade, spread to the lower third or outer half of the uterus, growth into lymph or blood vessels, larger tumor size, and patient age over 60. Radiation therapy is often given to reduce the risk of cancer coming back in the vagina or pelvis for cancers with one or more of these features. In patients without these risk factors the chance that the cancer will come back is small and radiation may not be given after surgery. Giving radiation right after surgery reduces the chance of the cancer growing back in the pelvis, but it does not help women live longer than if the radiation is only given when the cancer comes back. There may be less worry if the radiation is given right away, but fewer women will receive radiation if they wait until the cancer returns.
When a cancer is stage II, it has spread to the connective tissue of the cervix but still has not grown outside of the uterus.
One treatment option is to have surgery first, possibly followed by radiation therapy. The surgery would include a radical hysterectomy (discussed in the section about treatment), bilateral salpingo-oophorectomy (BSO), and pelvic and para-aortic lymph node dissection (LND) or sampling. Radiation therapy, often including both vaginal brachytherapy and external pelvic radiation may be given after the patient has recovered from surgery. The other option is to give the radiation therapy first, followed by a simple hysterectomy, BSO, and possible LND or lymph node sampling.
The lymph nodes that have been removed are checked for cancer cells. If lymph nodes show cancer, then the cancer is not really a stage II - it is a stage IIIC.
In some cases, a woman with early stage endometrial cancer might be too frail or ill from other diseases to safely have surgery. These women are treated with radiation therapy alone.
For women with high-grade cancers, such as papillary serous carcinoma or clear cell carcinoma, the surgery may include omenetectomy and peritoneal biopsies in addition to the TH/BSO, pelvic and para-aortic lymph node dissections, and pelvic washings. After surgery, chemotherapy, radiation therapy, or both may be given to help keep the cancer from coming back. The chemotherapy usually includes the drugs carboplatin and paclitaxel or possibly cisplatin and doxorubicin.
Someone with a Stage II uterine carcinosarcoma often has the same type of surgery that is used for a high-grade cancer. After surgery, radiation, chemotherapy, or both may be used. The chemotherapy often includes paclitaxel and carboplatin but may instead include ifosfamide, along with paclitaxel or cisplatin.
Stage III cancers have spread outside of the uterus.
If the surgeon thinks that all visible cancer can be removed, a hysterectomy with bilateral salpingo-oophorectomy (BSO) is done. Sometimes patients with stage III cancers require a radical hysterectomy. A pelvic and para-aortic lymph node dissection may also occur. Pelvic washings will be obtained and the omentum may be removed. Some doctors will try to remove any remaining cancer (debulking), but doing this hasn't been proven to help patients live longer.
If tests done before surgery reveal that the cancer has spread too far to be removed completely, radiation therapy may rarely be given before any surgery. The radiation may shrink the tumor enough to make surgery an option.
A cancer is considered stage IIIA when it has spread to the tissue covering the uterus (the serosa) or to other tissues in the pelvis like the fallopian tubes or the ovaries (the adnexa). When this occurs, treatment after surgery may include chemotherapy, radiation, or a combination of both. Radiation is given to the pelvis or to both the abdomen and the pelvis. Sometimes vaginal brachytherapy is used as well.
Stage IIIB: In this stage, the cancer has spread to the vagina. After surgery, stage IIIB may be treated with radiation, with or without chemotherapy.
Stage IIIC: This includes cancers that have spread to the lymph nodes in the pelvis (stage IIIC1) and those that have spread to the lymph nodes around the aorta (stage IIIC2). Treatment includes surgery, followed by chemotherapy and radiation.
For women with high-grade cancers, such as papillary serous carcinoma or clear cell carcinoma, the surgery may include omenetectomy and peritoneal biopsies in addition to the TH/BSO, pelvic and para-aortic lymph node dissections, and pelvic washings. After surgery, chemotherapy, radiation therapy, or both may be given to help keep the cancer from coming back. The chemotherapy usually includes the drugs carboplatin and paclitaxel and less commonly cisplatin and doxorubicin.
Someone with a Stage III uterine carcinosarcoma often has the same type of surgery that is used for a high-grade cancer. After surgery, radiation, chemotherapy, or both may be used. The chemotherapy often includes the drug paclitaxel and carboplatin, but ifosfamide, along with paclitaxel or cisplatin may be used.
Stage IVA: These cancers have grown into the bladder or bowel.
Stage IVB: These cancers have spread to lymph nodes outside of the pelvis or para-aortic area. This stage also includes cancers that have spread to the liver, lungs, or other organs.
The patient may have the best chance if all the cancer that is seen can be removed and biopsies of the abdomen do not show cancer cells. This may be possible if the cancer has only spread to lymph nodes in the abdomen and pelvis. In most cases of stage IV endometrial cancer, the cancer has spread too far for it all to be removed with surgery, meaning that a surgical cure is not possible. A hysterectomy and bilateral salpingo-oophorectomy may still be done to prevent excessive bleeding. Radiation therapy may also be used for this reason. When the cancer has spread to other parts of the body, hormone therapy may be used. Drugs used for hormone therapy include progestins and tamoxifen. Aromatase inhibitors may also be useful and are being studied. High-grade cancers and those without detectable progesterone receptors are not likely to respond to hormone therapy.
Combinations of chemotherapy drugs may help for a time in some women with advanced endometrial cancer. The drugs used most often are paclitaxel (Taxol) doxorubicin (Adriamycin), and either carboplatin or cisplatin. These drugs are often used together in combination. Stage IV carcinosarcoma is often treated with similar chemotherapy. Cisplatin, ifosfamide, and paclitaxel may also be combined. Women with stage IV endometrial cancer should consider taking part in clinical trials of chemotherapy or other new treatments.
Recurrent endometrial cancer
Cancer is called recurrent when it come backs after treatment. Recurrence can be local (in or near the same place it started) or distant (spread to organs such as the lungs or bone). Treatment depends on the amount and location of the cancer. If the recurrent cancer is only in the pelvis, radiation therapy may provide a cure. Women with more extensive recurrences are treated like those with stage IV endometrial cancer. Either hormone therapy or chemotherapy is recommended. Low-grade cancers containing progesterone receptors are more likely to respond well to hormone therapy. Higher-grade cancers and those without detectable receptors are unlikely to shrink during hormone therapy, but may respond to chemotherapy. Clinical trials of new treatments are another option.
If patients have other medical conditions that make them unable to have surgery, radiation therapy alone or combined with hormonal therapy is generally used. The outlook for these patients is not as good as those who are able to have surgery.
More treatment information
For more details on treatment options -- including some that may not be addressed in this document -- the National Comprehensive Cancer Network (NCCN) and the National Cancer Institute (NCI) are good sources of information.
The NCCN, made up of experts from many of the nation's leading cancer centers, develops cancer treatment guidelines for doctors to use when treating patients. Those are available on the NCCN Web site (www.nccn.org).
The NCI provides treatment guidelines via its telephone information center (1-800-4-CANCER) and its Web site (www.cancer.gov). Detailed guidelines intended for use by cancer care professionals are also available on www.cancer.gov.
What should you ask your doctor about endometrial cancer?
As you cope with cancer, we encourage you to have honest, open talks with your doctor. Feel free to ask any question that's on your mind, no matter how small it might seem. Here are some questions you might want to ask. Be sure to add your own questions as you think of them. Nurses, social workers, and other members of the treatment team may also be able to answer many of your questions.
- 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 might be right for me? What do you recommend? Why?
- What is the goal of this treatment?
- 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?
- How will I feel during treatment?
- When can I resume my usual activities at work and/or around the house?
In addition to these sample questions, be sure to write down some of your own. For instance, you may need specific information about how long it might take you to recover so you can plan your work schedule. You may also want to ask about second opinions or about clinical trials that might be right for you.
What will happen after treatment for endometrial cancer?
Completing treatment can be both stressful and exciting. You will be relieved to finish treatment, yet it is hard not to worry about cancer coming back. (When cancer returns, it is called recurrence.) This is a very common concern among those who have had cancer.
It may take a while before your confidence in your own recovery begins to feel real and your fears are somewhat relieved. Even with no recurrences, people who have had cancer learn to live with uncertainty. You can learn more about what to look for and how to learn to live with the possibility of cancer coming back in our document, Living With Uncertainty: The Fear of Cancer Recurrence, available at 1-800-227-2345.
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, further treatment is needed. During the first 3 years after treatment, follow-up visits are usually scheduled for every 3 to 6 months. About 75% of endometrial cancer recurrences are found within the first 3 years of follow-up. Later on, recurrence is less likely and follow-up visits are scheduled less often, usually twice yearly.
During each follow-up visit, the doctor will do a pelvic exam and look for any enlarged lymph nodes in the groin area. A Pap test may also be done to look for cancer cells in the upper part of the vagina, near the area where the uterus used to be. The doctor will also ask about any symptoms that might point to cancer recurrence or side effects of treatment. It is very important that you tell your doctor exactly how you are feeling.
If your symptoms or the physical exam results suggest the cancer may have come back, imaging tests (such as CT scans or ultrasound studies), a CA 125 blood test, and/or biopsies may be done. Studies of many women with endometrial cancer show that if no symptoms or physical exam abnormalities are present, routine blood tests and imaging tests are not needed.
It is also important to keep medical insurance. Even though no one wants to think of their cancer coming back, it is always a possibility. If it happens, the last thing you want is to have to worry about paying for treatment. Should your cancer come back our document, When Your Cancer Comes Back: Cancer Recurrence gives you information on how to manage and cope with this phase of your treatment. You can get this document by calling 1-800-227-2345.
Seeing a new doctor
At some point after your cancer diagnosis and treatment, you may find yourself in the office of a new doctor. Your original doctor may have moved or retired, or you may have moved or changed doctors for some reason. It is important that you be able to give your new doctor the exact details of your diagnosis and treatment. Make sure you have the following information handy:
- A copy of your pathology report from any biopsy or surgery
- If you had surgery, a copy of your operative report
- If you were hospitalized, a copy of the discharge summary that every doctor must prepare when patients are sent home from the hospital
- If you were treated with radiation, a summary of your radiation therapy
- Finally, since some cancer treatment drugs can have long-term side effects, a list of your drugs, drug doses, and when you took them
Lifestyle changes to consider during and after treatment
Having cancer and dealing with treatment can be time-consuming and emotionally draining, but it can also be a time to look at your life in new ways. Maybe you are thinking about how to improve your health over the long term. Some people even begin this process during cancer treatment.
Make healthier choices
Think about your life before you learned you had cancer. Were there things you did that might have made you less healthy? Maybe you drank too much alcohol, or ate more than you needed, or smoked, or didn’t exercise very often. Emotionally, maybe you kept your feelings bottled up, or maybe you let stressful situations go on too long.
Now is not the time to feel guilty or to blame yourself. However, you can start making changes today that can have positive effects for the rest of your life. Not only will you feel better but you will also be healthier. What better time than now to take advantage of the motivation you have as a result of going through a life-changing experience like having cancer?
You can start by working on those things that you feel most concerned about. Get help with those that are harder for you. For instance, if you are thinking about quitting smoking and need help, call the American Cancer Society at 1-800-227-2345.
Diet and nutrition
Eating right can be a challenge for anyone, but it can get even tougher during and after cancer treatment. For instance, chemotherapy may change your sense of taste. Nausea can be a problem. You may lose your appetite for a while and lose weight when you don't want to. On the other hand, some people gain weight even without eating more. This can be frustrating, too.
If you are losing weight or have taste problems during treatment, do the best you can with eating and remember that these problems usually improve over time. You may want to ask your cancer team for a referral to a dietitian, an expert in nutrition who can give you ideas on how to fight some of the side effects of your treatment. You may also find it helps to eat small portions every 2 to 3 hours until you feel better and can go back to a more normal schedule.
One of the best things you can do after treatment is to put healthy eating habits into place. You will be surprised at the long-term benefits of some simple changes, like increasing the variety of healthy foods you eat. Try to eat five or more servings of vegetables and fruits each day. Choose whole grain foods instead of white flour and sugars. Try to limit meats that are high in fat. Cut back on processed meats like hot dogs, bologna, and bacon. Get rid of them altogether if you can. If you drink alcohol, limit yourself to one or two drinks a day at the most. And don't forget to get some type of regular exercise. The combination of a good diet and regular exercise will help you maintain a healthy weight and keep you feeling more energetic.
Rest, fatigue, work, and exercise
Fatigue is a very common symptom in people being treated for cancer. This is often not an ordinary type of tiredness but a “bone-weary” exhaustion that doesn’t get better with rest. For some, this fatigue lasts a long time after treatment, and can discourage them from physical activity.
However, exercise can actually help you reduce fatigue. Studies have shown that patients who follow an exercise program tailored to their personal needs feel physically and emotionally improved and can cope better.
If you are ill and need to be on bed rest during treatment, it is normal to expect your fitness, endurance, and muscle strength to decline some. Physical therapy can help you maintain strength and range of motion in your muscles, which can help fight fatigue and the sense of depression that sometimes comes with feeling so tired.
Any program of physical activity should fit your own situation. An older person who has never exercised will not be able to take on the same amount of exercise as a 20-year-old who plays tennis three times a week. If you haven’t exercised in a few years but can still get around, you may want to think about taking short walks.
Talk with your health care team before starting, and get their opinion about your exercise plans. Then, try to get an exercise buddy so that you’re not doing it alone. Having family or friends involved when starting a new exercise program can give you that extra boost of support to keep you going when the push just isn’t there.
If you are very tired, though, you will need to balance activity with rest. It is okay to rest when you need to. It is really hard for some people to allow themselves to do that when they are used to working all day or taking care of a household. (For more information about fatigue, please see our document, Fatigue in People With Cancer)
Exercise can improve your physical and emotional health.
- It improves your cardiovascular (heart and circulation) fitness.
- It strengthens your muscles.
- It reduces fatigue.
- It lowers anxiety and depression.
- It makes you feel generally happier.
- It helps you feel better about yourself.
And long term, we know that exercise plays a role in preventing some cancers. The American Cancer Society, in its guidelines on physical activity for cancer prevention, recommends that adults take part in at least one physical activity for 30 minutes or more on 5 days or more of the week. Children and teens are encouraged to try for at least 60 minutes a day of energetic physical activity on at least 5 days a week.
How about your emotional health?
Once your treatment ends, you may find yourself overwhelmed by emotions. This happens to a lot of people. You may have been going through so much during treatment that you could only focus on getting through your treatment.
Now you may find that you think about the potential of your own death, or the effect of your cancer on your family, friends, and career. You may also begin to re-evaluate your relationship with your spouse or partner. Unexpected issues may also cause concern -- for instance, as you become healthier and have fewer doctor visits, you will see your health care team less often. That can be a source of anxiety for some.
This is an ideal time to seek out emotional and social support. You need people you can turn to for strength and comfort. Support can come in many forms: family, friends, cancer support groups, church or spiritual groups, online support communities, or individual counselors.
Almost everyone who has been through cancer can benefit from getting some type of support. What's best for you depends on your situation and personality. Some people feel safe in peer-support groups or education groups. Others would rather talk in an informal setting, such as church. Others may feel more at ease talking one-on-one with a trusted friend or counselor. Whatever your source of strength or comfort, make sure you have a place to go with your concerns.
The cancer journey can feel very lonely. It is not necessary or realistic to go it all by yourself. And your friends and family may feel shut out if you decide not include them. Let them in -- and let in anyone else who you feel may help. If you aren’t sure who can help, call your American Cancer Society at 1-800-227-2345 and we can put you in touch with an appropriate group or resource.
You can't change the fact that you have had cancer. What you can change is how you live the rest of your life -- making healthy choices and feeling as well as possible, physically and emotionally.
What happens if treatment is no longer working?
If cancer continues to grow after one kind of treatment, or if it returns, it is often possible to try another treatment plan that might still cure the cancer, or at least shrink the tumors enough to help you live longer and feel better. On the other hand, when a person has received several different medical treatments and the cancer has not been cured, over time the cancer tends to become resistant to all treatment. At this time it's important to weigh the possible limited benefit of a new treatment against the possible downsides, including continued doctor visits and treatment side effects.
Everyone has his or her own way of looking at this. Some people may want to focus on remaining comfortable during their limited time left.
This is likely to be the most difficult time in your battle with cancer -- when you have tried everything medically within reason and it's just not working anymore. Although your doctor may offer you new treatment, you need to consider that at some point, continuing treatment is not likely to improve your health or change your prognosis or survival.
If you want to continue treatment to fight your cancer as long as you can, you still need to consider the odds of more treatment having any benefit. In many cases, your doctor can estimate the response rate for the treatment you are considering. Some people are tempted to try more chemotherapy or radiation, for example, even when their doctors say that the odds of benefit are less than 1%. In this situation, you need to think about and understand your reasons for choosing this plan.
No matter what you decide to do, it is important that you be as comfortable as possible. Make sure you are asking for and getting treatment for any symptoms you might have, such as pain. this type of treatment is called palliative treatment.
Palliative treatment helps relieve these symptoms, but is not expected to cure the disease; its main purpose is to improve your quality of life. Sometimes, the treatments you get to control your symptoms are similar to the treatments used to treat cancer. For example, radiation therapy might be given to help relieve bone pain from bone metastasis. Or chemotherapy might be given to help shrink a tumor and keep it from causing a bowel obstruction. But this is not the same as receiving treatment to try to cure the cancer.
At some point, you may benefit from hospice care. Most of the time, this is given at home. Your cancer may be causing symptoms or problems that need attention, and hospice focuses on your comfort. You should know that receiving hospice care doesn't mean you can't have treatment for the problems caused by your cancer or other health conditions. It just means that the focus of your care is on living life as fully as possible and feeling as well as you can at this difficult stage of your cancer.
Remember also that maintaining hope is important. Your hope for a cure may not be as bright, but there is still hope for good times with family and friends -- times that are filled with happiness and meaning. In a way, pausing at this time in your cancer treatment is an opportunity to refocus on the most important things in your life. This is the time to do some things you’ve always wanted to do and to stop doing the things you no longer want to do.
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 damaged or defective DNA (called mutations) can alter important genes that regulate cell growth. If these genes are damaged, out-of-control growth may result in cancer.
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 they have an inherited defect in certain genes that normally help repair damage to DNA. If these repair enzymes are not working properly, damage to DNA is more likely to persist and cause cancer, Similar DNA repair defects have also been found in endometrial cancer cells from some patients without an inherited tendency to develop this disease. One of the normal genes responsible for suppressing tumor growth, called PTEN, is often abnormal in endometrial cancers.
Tests for this and other DNA changes may someday help find endometrial cancers early. Endometrial cancers without other tumor suppressor genes (or with inactive ones), such as the retinoblastoma (Rb) gene and the p53 gene, tend to be more likely to come back after initial treatment. Tests for these and other DNA changes may someday be used to help predict how aggressive the cancer might be and to select the best treatment for each woman with this disease. The long-range goal of this field of research is gene therapy that can correct the DNA abnormalities that caused the endometrial cells to become cancerous.
Molecules released by cancer cells can help detect recurrence of some types of cancer. For example, CA 125 is a useful marker in finding recurrent ovarian cancer. Recent studies find that blood tests for CA 125 may also be helpful in finding recurrent endometrial cancer, before tumor deposits are visible by CT or MRI scans. Measuring CA 125 levels in some patients before surgery may also be helpful if it appears the cancer may have spread. This may be useful in deciding which patients will benefit from surgical staging and which patients might be safely treated by hysterectomy without lymph node sampling.
Researchers are examining new drugs, combinations of drugs and "targeted therapies" in patients with advanced endometrial cancer. The use of adjuvant chemotherapy, with or without radiation is also under investigation.
Another way to see if cancer has spread to the lymph nodes in the pelvis is to identify and remove the lymph nodes that most likely are draining the cancer. This is called sentinel lymph node biopsy. In this procedure, radioactive tracer and/or blue dye is injected into the area with the cancer. The lymph nodes that turn blue (from the dye) or that become radioactive (from the tracer) are removed at surgery. These lymph nodes are examined closely to see if they contain any cancer cells. This technique is commonly used for some other tumors, such as breast cancer, but it is still new in the treatment of endometrial cancer. It is not known if sentinel lymph node biopsy is as good as lymph node dissection for staging and treatment of endometrial cancer. This is why it is not part of the standard surgery for this cancer.
More information from your American Cancer Society
The following related information may also be helpful to you. These materials may be ordered from our toll-free number, 1-800-227-2345.
After Diagnosis: A Guide for Patients and Families (also available in Spanish)
Cancer Facts for Women (also available in Spanish)
Sexuality for the Woman With Cancer (also available in Spanish)
Understanding Chemotherapy: A Guide for Patients and Families (also available in Spanish)
Understanding Radiation Therapy: A Guide for Patients and Families (also available in Spanish)
The following book is available from the American Cancer Society. Call us at 1-800-227-2345 to ask about costs or to place your order.
Caregiving: A Step-By-Step Resource for Caring for the Person With Cancer at Home
National organizations and Web sites*
In addition to the American Cancer Society, other sources of patient information and support include:
Gynecologic Cancer Foundation
Toll-free number: 1-800-444-4441
Web site: www.thegcf.org
National Cancer Institute
Telephone: 1-800-422-6237 (1-800-4-CANCER)
Web site: www.cancer.gov
*Inclusion on this list does not imply endorsement by the American Cancer Society.
No matter who you are, we can help. Contact us anytime, day or night, for information and support. Call us at 1-800-227-2345 or visit www.cancer.org.
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Last Medical Review: 10/22/2009
Last Revised: 08/09/2010