Cancer from A to Z

Although uterine cancer is the most common cancer of the female reproductive system, the good news is that many risk factors can be modified to help prevent this disease:

• See a physician immediately if you experience any post-menopausal bleeding or irregular bleeding
• Maintain a healthy weight
• If using hormone replacement therapy (HRT), it should include progesterone if you still have a uterus
• Talk to your physician about ways to regulate irregular menses

Additionally, the use of combination oral contraceptives by pre-menopausal women appears to decrease the risk of developing uterine cancer.

Risk Factors
 

Most uterine cancers are endometrial cancer, which develops in the lining of the uterus (the endometrium). Factors that may increase the risk of developing endometrial cancer include:

• Obesity
• Age: more than 95% of endometrial cancers occur in women age 40 and older
• Tamoxifen: this breast cancer drug can cause the uterine lining to grow
• Estrogen replacement therapy (ERT): estrogen hormonal therapywithout progesterone increases risk
• Personal/family history of endometrial, ovarian or colon cancer may indicate Lynch syndrome (hereditary non-polyposis colorectal cancer), a significant risk factor. For more information on hereditary cancers, visit the Clinical Cancer Genetics web site
• Ovarian diseases: certain ovarian tumors can cause an increase in estrogen levels
• Complex atypical endometrial hyperplasia: a precancerous condition that may become cancerous if left untreated. Simple hyperplasia rarely becomes cancerous.
• Diabetes

Uterine Sarcoma is a rare type of cancer that occurs in the muscle of the uterus. The main risk factor for developing a uterine sarcoma is a history of high-dose radiation therapy in the pelvic area.

Screening
 

Screening for uterine cancer is not recommended for most women because the chance of disease is quite low. But for women with Lynch syndrome (hereditary nonpolyposis colorectal cancer syndrome), an annual endometrial biopsy is recommended beginning at age 35. Women at normal risk for uterine cancer should pay attention to their bodies, know the symptoms, and learn how to decrease the chances of developing certain gynecological cancers.

An endometrial biopsy should be performed if a woman is experiencing any symptoms of uterine cancer. A thin, flexible tube is inserted through the cervix and into the uterus. Using suction, a small amount of endometrial tissue is removed through the tube. A pathologist views the tissue under a microscope to look for abnormal cells and confirms the diagnosis of endometrial cancer. 

If the endometrial biopsy does not provide enough tissue or if a cancer diagnosis is not definite, a dilation and curettage (D&C) may be performed. This surgical procedure involves dilating the cervix with a series of increasingly larger metal rods, and then inserting an instrument (curette) to scrape cells from the uterine wall. D&C takes about an hour and is usually done as an outpatient procedure under general anesthesia.

Hysteroscopy is a diagnostic test used to help locate adhesions, abnormal growths and other problems inside the uterus. A thin, telescope-like device with a light (hysteroscope) is inserted into the uterus through the vagina, allowing the doctor to view the inside of the uterus and the openings to the fallopian tubes. 

When hysteroscopy is used as part of a surgical procedure, tiny instruments will be inserted through the hysteroscope. Hysteroscopy can be done along with a D&C. The procedure may be done with local, regional or general anesthesia depending upon whether other procedures are being done at the same time.

Staging
 

Staging is used to determine how far advanced the cancer is and to measure progress of the disease. Certain procedures are used in the staging process. A hysterectomy with bilateral salpingo-oophorectomy (removal of the uterus, ovaries and fallopian tubes) and pelvic lymph node dissection will usually be done to determine how far the cancer has spread. After reviewing test results, your doctor will tell you the stage of your cancer and discuss the best treatment options.

Endometrial cancers are staged as follows:

Stage I tumors have a five-year survival rate of 90-95%:

Stage IA: Tumor limited to the endometrium (uterine lining)
Stage IB: Invades the inner half of the myometrium (muscle wall of uterus)
Stage IC: Spreads to outer half of the myometrium
Stage II tumors have a five-year survival rate of 75%:

Stage IIA: Involvement of the cervical glands only
Stage IIB: Tumor invades cervical connective tissue 
Stage III tumors have a five-year survival rate of 60%:

Stage IIIA: Tumor spreads to outermost layer of uterus, tissue just beyond the uterus and/or the peritoneum (membrane lining the abdominal cavity)
Stage IIIB: Spreads to vagina
Stage IIIC: Spreads to lymph nodes near the uterus
Stage IV tumors have a five-year survival rate of 15-26%:

Stage IVA: Tumor invades the bladder and/or bowel wall
Stage IVB: Spreads beyond the pelvis, including lymph nodes in the abdomen or groin

Surgery
 

The primary surgery for uterine cancer is a total hysterectomy with bilateral salpingo-oophorectomy. The uterus is removed along with both ovaries and fallopian tubes and sometimes the pelvic lymph nodes. In a radical hysterectomy, the uterus, cervix, surrounding tissue, upper vagina and usually the pelvic lymph nodes are removed. A hysterectomy can be done either through the abdomen or the vagina, depending on a patient's medical history and overall health.

Some uterine cancer patients may undergo a lymphadenectomy, or lymph node dissection. Lymph nodes are removed from the pelvic area and examined for the presence of cancerous cells, helping doctors determine the exact stage and grade of the cancer. This surgery may be done as a part of a hysterectomy. The procedure can be done through an abdominal incision or by laparoscope.

Radiation Therapy
 

Radiation therapy may be used to treat uterine cancer after a hysterectomy or as the primary treatment when surgery is not an option. Depending on the stage and grade of the cancer, radiation therapy may also be used at different points of treatment. 

There are two types of radiation therapy and in some uterine cancercases, both types are given.

External beam radiation involves a series of radioactive beams precisely aimed at the tumor from outside the body. Intensity-modulated radiation therapy and proton therapy are examples of external beam radiation. Patients generally undergo daily outpatient treatments five days a week for four to six weeks, depending on the treatment plan.

Brachytherapy involves tiny radioactive seeds that are inserted through the vagina into the uterus wherever cancer cells are located. The seeds remain in place for two to three days and then removed. Depending on your cancer, several treatments may be needed. Because brachytherapydelivers radiation to a localized area, there is little effect on nearby structures such as the bladder or rectum.

Hormone Therapy
 

The presence of some hormones can cause certain cancers to grow. If tests show that the cancer cells have receptors where hormones can attach, drugs can be used to reduce the production of hormones or block them from working. In hormone therapy, progesterone-like drugs known as progestins are used to slow the growth of cancer cells.

Clinical Trials
 

New treatments are always being tested in clinical trials and some women with endometrial cancer may want to consider participating in one of these research studies. These studies are meant to help improve current cancer treatments or obtain information on new treatments. Search MD Anderson's clinical trials database for a current listing of our endometrial cancer clinical trials.