Medicine for Africa - Medical Information Service

ANCER   of  the   TERUS

Definition:

Cancer of the uterus, also called uterine cancer or endometrial cancer (endometrium is the epithelium that lines the inside of the uterine cavity) is a malignant growth of the mucosal cells (epithelium), lining the uterus (womb).

Cancer of the uterus is the third most common cancer in women, and the most frequent malignant cancer in the pelvic area.  It usually develops after menopause (cessation of regular menstrual bleeding).

A long lasting, unopposed influence of estrogens increases the risk of developing endometrial carcinoma.  Cancer of the uterus usually develops between the ages of 55 and 65, i.e. following the menopause it rarely develops prior to age 40.

An increased risk is associated with obesity, in connection with diabetes mellitus and high blood pressure, as well as in infertile or childless women.  A very early onset of menstrual bleeding, as well as menopause at an advanced age, can also contribute to an increased cancer risk.  Also, a family history of cancer of the breast, ovaries, colon or uterus may increase the risk of developing endometrial cancer.

A sexually transmitted virus, the so-called human papillomavirus, HPV, has recently also been shown to be able to cause cancer of the uterus, in addition to its potential of causing cancer of the cervix among other benign and malignant tumors.

A diagnosis of ‘endometrial hyperplasia’ (abnormal and increased growth pattern of mucosal glands in the uterine cavity) can signal an increased potential to the development of endometrial cancer.

Occasionally, a somewhat increased tendency of developing endometrial cancer has been seen in women who receive Tamoxifen (hormone therapy) as treatment for breast cancer, although, in certain cases, the same drug is also used to treat endometrial carcinoma (see Treatment).

Another type of uterine cancer, the so-called sarcoma, is a very malignant carcinoma of the muscle cells of the uterus.  This type of cancer can occasionally arise from a benign type of muscle cell tumor, called fibroma or fibromyoma (leiomyoma) of the uterus, or develop de novo (from the beginning) as a malignant sarcoma (leiomyosarcoma).

Prognosis

If endometrial cancer is detected at an early stage, when the tumor has not yet invaded the muscle layers of the uterus, nor developed metastases, it has a very good chance to be successfully treated by surgery or radiation therapy.

In advanced stages, complications usually involve neighboring organs, which will become impeded in their own functions by the expanding tumor growth.  Metastases can also develop in the liver, the bones, or in the brain, and cause organ specific symptoms.

Following treatment, regular close control examinations are required, in order to assure that no relapse will occur, or, to be able to quickly respond in case of the development of new tumor growth.  Follow-up examinations usually consist only of a physical exam by the gynecologist, a blood test and occasional x-rays.

Symptoms:

An important symptom for the early detection of endometrial cancer is the sudden bleeding after menopause, i.e. after the woman does not experience any normal menstrual bleeding anymore.

In younger women, irregular menstrual bleeding patterns, bleeding between the normal menstruation, or especially heavy bleeding periods can be symptomatic.  However, these symptoms are not specific for cancer, and can also be caused by a variety of other diseases or hormonal imbalances.  In any case, it is necessary to consult a gynecologist or, at least, a family practitioner, in order to determine the exact cause of the bleeding disorder and to treat it accordingly.

Other symptoms include pain during or difficulty of urinating, pain during intercourse or general pelvic pain.  While these symptoms are not specific for endometrial cancer, they DO require a medical work-up in any case, because they are indicative of some kind of disease process that is going on, which needs to be diagnosed appropriately and treated accordingly.

In an advanced stage of cancer, symptoms originating from neighboring organs can become predominant, such as pressure upon the urinary bladder, increased urinary frequency, repeated urinary tract infections, or even kidney infections with radiating lower back pains, as well as constipation due to pressure on the intestinal tract.

Diagnosis:

After registering the pertinent symptoms and a general as well as a gynecological medical history, the physician will conduct a thorough physical examination, including a gynecological examination, during which the physician will carefully palpate all pelvic organs.  This will allow him/her to already diagnose an increase in size of the uterus, or major adhesions in the pelvic area. 
                   
A standard blood test may show low red blood cells due to anemia, secondary to persistent bleeding from the tumor site.  A blood test for CA 125, a specific so-called tumor marker for uterine cancer, can point to advanced tumor, if very high levels are detected; this tumor marker can also be used after surgery to evaluate the success of the treatment.

If a tumor is suspected, further examinations could include an ultrasound of the pelvis, although a definite diagnosis can only be rendered upon the examination of tissue.  Tissue samples will be harvested through a so-called ‘dilation and curettage’ (D&C), in which the cervix will be dilated, and mucosal tissue scraped from the uterine cavity.  This tissue will then be examined by a pathologist, who will diagnose the cells as showing benign or malignant changes.

Following the diagnosis of malignancy, further tests will follow, to evaluate the extent of the tumor growth and the presence of metastases (satellite tumor growths in other organs), with special consideration of local lymph nodes, the urinary bladder and intestinal tract.

Magnetic Resonance Imaging (MRI) is a special photography in levels by radio waves, or a Computer Tomography (CT-scan), a special kind of x-ray procedure, are often used, in order to evaluate the extent of metastases.

Recently, DNA tests are performed, in order to identify high risk women early and thus, to allow for close medical controls.   

Once the diagnosis of endometrial cancer has been established, the extent of the tumor growth will be determined by ‘staging’ the cancer.  The main system that is used for staging endometrial cancer is called the FIGO (International Federation of Gynecology and Obstetrics) system.  This system, which resembles the so-called TNM (T-tumor, N-lymph nodes; M-metastases, see article ‘Lung Cancer’) system for other cancer classifications, divides the cancer into four major stages as follows:

• Stage I – The cancer is limited to the body of the uterus;
• Stage II – The cancer has spread from the body of the uterus to the cervix;
• Stage III – The cancer has spread beyond the uterus itself, but is still present only in the pelvic area;
• Stage IV – The cancer has spread and invaded the urinary bladder or the rectum, as well as to lymph nodes in the groin and/or distant organs, such as the lungs or bones.

Each stage is further divided into sub-stages A, B, with stages I and III also having a ‘C’ sub-category, for a more detailed description of the tumor’s growth pattern.

The relative 5-year survival rate depends on the stage of the endometrial carcinoma, and decreases as the stage increases.  While in stage I, the relative survival rate is more than 95%, in stage IV it is only about 30%.    

 
Treatment:

Surgery is the primary method of therapy for endometrial carcinoma.  The operation is called a ‘hysterectomy’, and includes the removal of the body of the uterus, as well as the cervix; a ‘total hysterectomy’ also includes the fallopian tubes and ovaries.

Surgery is usually followed by local radiation therapy, which is occasionally given even before surgery, in order to shrink the tumor pre-operatively.  In this procedure, high energy x-rays are aimed at the area of tumor.  There are two ways of applying this radiation therapy, one is applied from outside the body to the area in question, the other one consists of a radiation ball or stick, which is inserted into the vagina close to the tumor area, in order to specifically treat the vicinity of the tumor.  Both kinds of treatment have to be repeated several times over a relatively short period of time.

Chemotherapy is a ‘systemic’ treatment, meaning that the drugs are dispersed throughout the body via the blood circulation, in order to kill the largest amount of cancer cells.  Chemotherapy can also follow surgery, or, at times, is given in lieu of an operation.  However, this kind of treatment is still in a research phase, since no satisfactorily effective drugs for endometrial cancer have yet been discovered.

Recently, treating physicians have begun to test endometrial cancer tissue for its hormone expression, which is performed by the examining pathologist at the time of the tissue diagnosis.  Hormone therapy is given to those tumors that show sensitivity to hormones and may include progesterone-like drugs, called progestins, anti-estrogen drugs such as Tamoxifen, which is also used for treating certain hormone-positive breast cancers, and other, less frequently used drugs such as gonadotropin-releasing hormone agonists or aromatase inhibitors, both of which are used to lower estrogen levels in women whose ovaries have been removed during surgery.

The success of treatment for endometrial cancer is largely dependent on the size of the tumor and the extent of its growth at the time of surgery.  Therefore, it is of utmost importance to discover the tumor at the earliest time possible, when it can still be treated relatively easily.  

Prevention:

The most important preventive measure is the regular visit to your gynecologist, as well as an immediate consultation in case of abnormal bleeding patterns, especially if there is vaginal bleeding after menopause or in-between the regular menstrual periods.

You should ask your gynecologist about your specific risk factors and the necessity for regular screening examinations as they apply to you.

Following surgery for an endometrial cancer, there is no physiologically caused basis for a decrease in sexual desire, nor in the ability of experiencing an orgasm.  However, many women develop psychological problems, which may interfere with their ability to desire and to enjoy sex.

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