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What Is Endometrial Cancer?

Endometrial cancer is a cancer that starts in the inner lining of the womb (uterus). This lining is called the endometrium .The uterus is a hollow organ, about the size and shape of a medium-sized pear. It has 2 main parts.

The cervix, (lower part), extends into the vagina
The corpus (upper part) is the body of the uterus
During a woman’s menstrual cycle the lining of the uterus changes.

In the early part of the cycle it thickens in order to nourish an embryo in case the woman becomes pregnant.
At the mid-point of the cycle, if pregnancy does not occur, the hormones change and the top layer of the lining begins to die.
By the end of the cycle, the dead tissue is shed from the uterus and becomes the menstrual flow.
This cycle repeats throughout a woman’s life until change of life (menopause).
Nearly all endometrial cancers are cancers of the glandular cells found in the lining of the uterus. Less common uterine cancers that do not come from glandular tissue of the endometrium are called uterine sarcomas and can involve the endometrium. Cancers of the cervix are different from cancers of the body of the uterus.

How Many Women Get Endometrial Cancer?

In this country, cancer of the endometrium is the most common cancer found in women’s reproductive organs. There will be about 41,200 new cases of cancer of the uterine body during 2006. More than 95% of these cancers are endometrial cancers. About 7,350 women in the United States will die from cancers of the uterine body during 2006.

What Causes Endometrial Cancer?

We do not yet know exactly what causes most cases of endometrial cancer, but we do know that certain risk factors are linked to this disease.

The ovaries (sex glands on either side of the uterus that produce eggs) normally make 2 main types of female hormones -

estrogen
progesterone.
The balance between these 2 hormones changes during a woman’s menstrual cycle each month. This results in a woman's monthly periods and keeps the endometrium healthy.

A shift in the balance of these hormones toward more estrogen increases a woman's risk for developing endometrial cancer. Many of the known risk factors for endometrial cancer such as

starting periods at an early age
late menopause
infertility
obesity
Most known risk factors for endometrial cancer are linked to the balance between estrogen and progesterone in the body.

Risk Factors for Endometrial Cancers

Early menarche: Starting monthly periods before age 12 increases the number of years that the uterus is exposed to estrogen and increases the risk of this cancer.

Late menopause: Having the change of life after age 50 increases the number of years the uterus is exposed to estrogen and has the same effect as starting periods early. Women with increased bleeding in the time just before menopause have a higher risk of endometrial cancer.

Total length of menstruation span: This may be a more important factor than the age at which periods started or ended. For example, starting periods early is less a risk factor for women with early menopause. Likewise, late menopause would not lead to a higher risk in women whose periods began later in their teens.

History of not being able to become pregnant or having never given birth: During pregnancy, the hormonal balance shifts toward more progesterone. Therefore, having many pregnancies reduces endometrial cancer risk. Women who have not been pregnant have a higher risk.

Obesity (very overweight): Although most of a woman's estrogen is made by her ovaries, fat tissue can change some other hormones into estrogens. Having more fat tissue can increase a woman's estrogen levels and therefore increase her endometrial cancer risk.

Tamoxifen: Tamoxifen is a drug that is used to treat women with breast cancer. It is also used to reduce the risk in women who are at a high risk of getting breast cancer. The drug acts like estrogen in the uterus. It can cause the uterine lining to grow and increase the risk of endometrial cancer in women who take this drug.

The relatively small risk of getting endometrial cancer (about 1 in 500) in women taking tamoxifen is more than balanced by the value of this drug in treating breast cancer and reducing the chances of the woman getting cancer in the other breast. However, this is an issue women may want to discuss with their doctors. If a woman decides to take tamoxifen, she should have yearly pelvic exams. And she should be sure and tell her doctor if she has any symptoms such as abnormal bleeding.

Estrogen replacement therapy (ERT): ERT is the use of female hormone estrogen to offset the effects of menopause. It once was common to prescribe estrogen alone (without progestins) to treat hot flashes and thinning of the bones. Doctors have found, however, that the use of estrogen alone increases a woman's risk of getting endometrial cancer. Studies now show that giving progesterone-type drugs along with the estrogens will help lower the risk. But recent studies also show that giving a combination of the drugs increases a woman’s chance of getting breast cancer and blood clots.

It is important to discuss the pros and cons of ERT with your doctor. If you choose to take them, you should have follow-up exams for cancer at least every year. Let your doctor know right away if you notice any abnormal bleeding or discharge.

Ovarian diseases: Certain ovarian tumors produce estrogen. Women who have these tumors have higher than normal estrogen levels and lower levels of progestins. The increase in estrogen compared to progestins can increase a woman’s chance of getting endometrial cancer.

A diet high in animal fat: 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 confirmed endometrial cancer risk factor. Some doctors think that fatty foods may also have a direct effect on endometrial cancer risk.

Diabetes: Diabetes is more common in people who are overweight. This could be why diabetes is a risk factor for endometrial cancer. But some studies suggest that diabetes by itself could be a risk factor.

Age: As a woman gets older, her chance of getting endometrial cancer goes up. More than 95% of endometrial cancers occur in women age 40 or older. The average age at diagnosis is 63.

Family history: This cancer appears to run in some families who also tend to get a certain type of colon cancer. A small number of endometrial cancers may be due to this inherited factor. Women who have had several family members with colon cancer or endometrial cancer might think about having genetic counseling and testing. This kind of testing can help show if you or members of your family are at high risk.

Breast or ovarian cancer: Women who have had breast cancer or ovarian cancer may have a higher risk of getting endometrial cancer. Some of the risk factors for breast and ovarian cancer also increase endometrial cancer risk.

Earlier pelvic radiation therapy: Radiation used to treat some other cancers can damage the DNA of cells. This could increase the risk of getting a second type of cancer such as endometrial cancer.

It is important to remember that although these factors may increase a woman's risk for getting endometrial cancer, they do not always cause the disease. Many women with one or more of these risk factors never get endometrial cancer, and some women with endometrial cancer do not have any of these risk factors.

How Is Endometrial Cancer Found?

In most cases, being alert to any signs and symptoms of this cancer and talking to your doctor right away allows the disease to be found at an early stage. Finding it early improves the chances that the cancer will be treated successfully. Sometimes, though, this cancer can reach an advanced stage before any symptoms appear.

Except for a small number of women at high risk for endometrial cancer, there are no special tests to find this cancer early. Pelvic exams may help to spot other female problems.

Women should talk to their doctors about getting regular pelvic exams, including Pap tests. Although the Pap test can find some female cancers early, most cases of endometrial cancer are not found by this test. But the Pap test is very good at finding early cancer of the cervix (the lower part of the uterus).
At the time of menopause, all women should be told about the risks and symptoms of endometrial cancer and urged to report any vaginal bleeding or spotting to their doctor.

Women at high risk should know about early detection testing. Women who have (or are at risk for) a certain type of colon cancer (hereditary nonpolyposis colon cancer, or HNPCC), should be offered yearly testing with an endometrial biopsy beginning at age 35.

Signs and Symptoms of Endometrial Cancer

Unusual bleeding, spotting, or other discharge: If you have gone through menopause it is very important to report unusual bleeding or spotting to your doctor. About 9 out of 10 women diagnosed with endometrial cancer have some type of abnormal vaginal bleeding. Although this symptom also can occur with hyperplasia and some other conditions, it should be checked by your doctor. The discharge might be bloody or it might be white.

Pelvic pain and/or mass and weight loss: These symptoms usually occur in the later stages of the disease. But delays in seeking medical help may allow the disease to progress even further, which lowers the chance for successful treatment.

In most cases, being alert for any symptoms and talking to your doctor right away allows the disease to be found at an early stage. Finding the cancer early improves the chances that it can be treated successfully. But sometimes the cancer is at an advanced stage before symptoms appear.

What Tests will be Done If Cancer Is Suspected ?

If a woman has any of the symptoms described earlier, she should visit her doctor. The doctor will ask about her symptoms, risk factors, and family medical history. The doctor will also do a physical and a pelvic exam.

If endometrial cancer is suspected, the woman should be seen by a doctor with special training in diseases of the female reproductive system, a gynecologist.

To find out if endometrial hyperplasia or endometrial cancer is present, the doctor must remove some tissue so that it can be looked at under the microscope. Tissue can be obtained by endometrial biopsy or by a D & C (dil ation and curettage).

Endometrial biopsy: This kind of biopsy can be done in a doctor’s office.

A sample of tissue is obtained through a very thin flexible tube placed into the uterus through the cervix.
The tube is used to remove a small amount of endometrium using suction.
The suction takes about a minute or less.
The discomfort is something like severe menstrual cramps and can be helped by taking a drug such as ibuprofen an hour or so before the test.

Dilation and curettage (D & C): If the biopsy sample doesn’t provide enough tissue, or if the doctor can’t tell for sure whether it is cancer or not, a D & C must be done.

The cervix is opened (dilated) and a special instrument is used to scrape tissue from inside the uterus.
The test takes about an hour, and you may need general anesthesia or medicine to make you drowsy.
It is most often done in an outpatient surgery area of a clinic or hospital.
Most women have little discomfort after this procedure.

Testing the tissue: The tissue that has been removed is looked at under a microscope to see whether cancer cells are present. If cancer is found, the cells will be studied to learn more about the exact features of the cancer. The lab will also assign a grade to the cancer.

If most of the cancer looks like normal tissue, it’s given a grade 1.
If more than half of the cells look very different from normal cells, it’s given a grade of 3.
Grade 2 tumors fall somewhere in between.
The grade is important because women with lower grade cancers are less likely to have advanced disease or to have the cancer come back after treatment.
Other Tests

For most patients, these tests are rarely needed before surgery. Sometimes the cancer may appear to be more advanced and the doctor will order one of them. They may also be done if the cancer comes back after surgery.

Ultrasound: For this test, a probe is placed into the vagina. It gives off sound waves that echo off tissue of the pelvic organs to create a picture on a video screen. This test can be used to see if there is a tumor and whether it extends into the myometrium. Saltwater (saline) might be put into the uterus before the test to give a clearer picture.

Cystoscopy and proctoscopy: If a woman has signs that suggest the cancer may have spread, the doctor can use a lighted tube to look at the inside of the bladder (cystoscopy) or rectum (proctoscopy). Your doctor can tell you what to expect if you will have either of these tests.

CT scan: This is a special type of x-ray that creates detailed pictures of the inside of the body. CT scans are rarely used to find endometrial cancer. But they may be helpful if it looks as if the cancer has come back or has spread into the liver or other organs. CT scans can also be used to guide a biopsy needle into the mass.

CT scans take longer than regular x-rays. You will need to lie still on a table while the scans are done. You may also have an IV (intravenous) line through which a contrast "dye" is injected.

MRI scan (magnetic resonance imaging): Like a CT scan, MRI displays a cross-section of the body. However, MRI scans use radio waves and strong magnets instead of radiation. MRI scans are helpful in looking at the brain and spinal cord. They take longer than CT scans and you may have to be placed inside a tube. This can feel confining and upset people with a fear of closed spaces. A contrast dye might be injected just as with CT scans, but is used less often.

PET scan (positron emission tomography): In this test, a type of radioactive sugar is injected into the blood. The cancer cells absorb high amounts of the sugar. A special camera can detect where it goes in the body. PET is sometimes useful in finding a cancer and seeing how far it has spread. But PET is not often used for endometrial cancer.

Chest x-ray: This can show if the cancer has spread to the lungs. It may also be used to see if there is any serious lung or heart disease.

IVP (intravenous pyelogram): An IVP may be done if the doctor thinks the cancer might have spread around the tubes that connect the kidneys to the bladder. An IVP is an x-ray that outlines the urinary system. But CT scans are used more often than IVP.

If the doctor finds out that cancer is present, the next step is surgery to remove the uterus. First, though, some further tests are needed.

Complete blood count: This will be done to make sure you are able to have surgery safely. Many times women who have lost blood from the uterus will have low red blood cell counts.

CA 125 blood test: CA 125 is a substance released into the bloodstream by many endometrial and ovarian cancers. Very high blood CA 125 levels suggest that the cancer has probably spread beyond the uterus.

Staging

Staging is the process of finding out how widespread the cancer is and whether it has spread to other parts of the body. The stage of the cancer is an important factor in making treatment choices.

The system used to stage endometrial cancer is called the FIGO system of staging .

This is a surgical staging system, which means that it is based on an examination of tissue removed during an operation.
Stages are labeled using Roman numerals I through IV (1-4).
Some of these stages are further divided (for example, IIA, IIB).
As a rule, the lower the number, the less the cancer has spread.
A higher number, such as stage IV (4), means a more serious cancer.
After looking at your test results, the doctor will tell you the stage of your cancer. .

How Is Endometrial Cancer Treated?

After your test results have been reviewed, your doctor will recommend one or more treatment options.The choice of treatment depends largely on the type of cancer and stage of the disease when it is found. Other factors 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 treatments before making a decision.

There are 4 basic types of treatment for women with endometrial cancer:

surgery
radiation therapy
hormonal therapy
chemotherapy
Surgery is the main treatment for most women with endometrial cancer. But sometimes one or more of these treatments is combined. The choice of treatment will depend on the type and stage of your cancer, and your general health.

Surgery :Several operations are used to treat endometrial cancer.

The main treatment for endometrial cancer is an abdominal hysterectomy and bilateral salpingo-oophorectomy to remove the entire uterus (along with the cervix, ovaries, and fallopian tubes). This is usually done through an incision in the abdomen.
If the uterus, cervix, upper part of the vagina, and other tissues next to the uterus are removed, the operation is a radical hysterectomy.
If only the uterus and cervix (an approach that is not often used) are removed, it’s called a simple/total hysterectomy.
The surgery can also be done through the vagina (vaginal hysterectomy), but it’s harder for the doctor to see whether the cancer has spread with this approach.
If the doctor wants to take out some lymph nodes, this can be done through the same incision as the abdominal hysterectomy. Or, if the vaginal approach was used, the nodes can be removed with a laparoscope

Pelvic lymph node dissection: In this operation, some lymph nodes from the pelvis and the area next to the main artery that carries blood from the heart (the aorta) are removed. They are looked at to see if they contain cancer cells. This can be done through the same incision used in the above operations.
Laparoscopic lymph node sampling: This procedure is sometimes used along with vaginal hysterectomy. Thin tubes are placed into the abdomen through very small incisions. Small tools can be controlled through the tubes and the doctor can remove some lymph nodes. Studies are going on to find out whether this method is as good as the usual one for treating endometrial cancer.
For an abdominal hysterectomy, the hospital stay is usually 3 to 5 days. Complete recovery takes about 4 to 6 weeks. Vaginal hysterectomy with laparoscopic lymph node sampling usually means a hospital stay of 1 to 2 days and 2 to 3 weeks for full recovery.

Radiation Therapy

Radiation therapy is treatment with high energy rays (such as x-rays) to kill or shrink cancer cells. The radiation may come from outside the body (external radiation) or from radioactive materials placed near the tumor. This is called brachytherapy . In some cases, both types of radiation therapy are given.

How much of the pelvis needs to be exposed to radiation treatment depends on how far the cancer has spread.

Brachytherapy: In cases where only the upper third of the vagina needs to be treated after surgery, radioactive pellets can be put into place for a short time through the vagina. Several treatments may be needed. With this approach, there is little effect on nearby structures such as the bladder or rectum.
If cancer cells are found in the fluid tested during surgery, a radioactive liquid might be placed into the abdominal and pelvic cavities after surgery. This type of treatment should not be combined with external radiation treatment.

External radiation is like a regular x-ray but it takes longer. It is given for 4 or 5 weeks, 5 days per week. The treatment itself takes less than a half-hour, but the daily trips may be tiring and inconvenient.
Listed below are some of the side effects that can happen from external radiation. If you have any of these, be sure to tell your doctor or nurse as there are often ways to help.

tiredness
skin changes (redness, other changes in color)
diarrhea
problems with urinating
narrowing of the vagina, causing pain during sex
menopause
weakened bones in the pelvis
Chemotherapy

Chemotherapy refers to the use of drugs to kill cancer cells. Usually the drugs are given into a vein or by mouth. Once the drugs enter the bloodstream they spread throughout the body. Chemotherapy is useful in treating cancer that has spread. One or more drugs may be used.

Chemotherapy can have some side effects. These side effects will depend on the type of drugs given, the amount taken, and how long treatment lasts. Side effects could include the following:

nausea and vomiting
loss of appetite
hair loss
mouth sores
vaginal sores
a higher chance of infection (from low white blood cell counts)
bleeding or bruising after minor cuts or injuries (from a shortage of blood platelets)
shortness of breath or tiredness (from low red blood cell counts)
Most side effects go away after treatment ends. If you have problems with side effects, talk with your doctor or nurse, as there are often ways to help.
Hormone Therapy

In hormone therapy, progesterone-like drugs are used to slow the growth of cancer cells. The drugs are usually taken as pills or injections. Tamoxifen, a drug often used to treat breast cancer, may also be used to treat advanced endometrial cancer or cancer that has returned.

Most women with endometrial cancer have their ovaries removed as a treatment measure, or their ovaries stop working after radiation. This lowers the amount of estrogen produced and slows the growth of the cancer.

Endometrial Cancer Survival by Stage

The 5-year relative survival rate is the percentage of patients who have not died from endometrial cancer at least 5 years after the cancer is found. Those who die of other causes are not counted. Of course, patients might live more than 5 years after diagnosis.
Stage Survival Rate
I 90% to 95%
II 75%
III 60%
IV 15% to 26%

These numbers provide an overall picture, but keep in mind that every woman’s situation is unique and the statistics can’t predict exactly what will happen in your case. Talk with your cancer care team if you have questions about your personal chances of a cure, or how long you might survive your cancer. They know your situation best.