Diagnosis of Uterine Cancer
As with most conditions, diagnosis of uterine cancer starts with a thorough clinical history. A doctor will ask detailed questions about the symptoms, especially the abnormal vaginal bleeding. Other information that will be relevant includes menstrual history, number of pregnancies, medical history, family history, and other relevant information.
A physical examination is then, which includes a pelvic examination. If uterine cancer is suspected, the woman may be referred to a gynecologic oncologist (specialist in cancers of the female reproductive system).
Certain tests can help to confirm uterine cancer :
- Endometrial biopsy where a small piece of endometrial tissue is removed, which is then examined under the microscope to look for signs of abnormal cells that may be indicative of endometrial cancer. A biopsy is usually taken by introducing a thin flexible tube through the vagina and cervix to reach the endometrium. The results of an endometrial biopsy are usually conclusive.
- Dilation and Curettage (D&C) may be conducted if some doubts remain after an endometrial biopsy. This is usually done under general anesthesia as an outpatient procedure. An instrument (curette) is passed through the dilated cervix which scrapes a bit of tissue from the endometrium. The tissue is then examined under the microscope.
- Hysteroscopy is where a thin tube with a tiny camera and light source at its end (hysteroscope) assists with an endometrial biopsy or D&C . It affords good visualization of the inside of the uterus and allows endometrial tissue samples to be obtained with ease.
- Surgical staging is a post-operative diagnosis, where the tissue obtained after operation is examined for cancer. This is helpful in staging and grading of the cancer. Read more on uterine cancer grades and stages.
Other Uterine Cancer Tests
There are other tests which may be done, such as blood tests and imaging techniques, but none of these can conclusively confirm endometrial cancer. It may only be helpful in determining the extent of cancer in some cases and to assess if the patient is capable of undergoing treatment. These tests may also help in monitoring the efficacy of and response to treatment, as well as indicating cancer recurrence. Some of these tests include :
- Pap smear showing atypical endometrial cells may indicate the possibility of endometrial cancer but does not diagnose it conclusively.
- Routine blood tests, including cell count, liver and kidney function tests, and blood chemistry will be helpful in assessing the patient’s general health and ability to undergo surgery and other forms of therapy.
- Blood tests to check for the tumor marker CA 125, which is released into the blood stream by some ovarian and uterine tumors. This marker is non-specific for endometrial cancer, but a very high level may indicate the spread of cancer to other sites. By monitoring the level from time to time during treatment, the response to treatment may be assessed.
- Ultrasound may show the presence of tumor but the results are not always definitive. A transvaginal ultrasound or a hydroultrasound (saline solution used to expand the uterus for better visualization) may be done to look for abnormalities in the endometrium.
- CT scan or MRI may be done, especially for follow-up.
- Chest x-ray to look for lung metastasis.
- Bone scan in case of suspected metastasis to the bones.
Early Detection of Uterine Cancer
Early detection is only possible by being alert to the signs and symptoms suggestive of endometrial cancer, particularly in postmenopausal women. Finding atypical endometrial cells on routine pap smears may help to detect uterine cancer at an early stage.
Women at risk of hereditary nonpolyposis colon cancer (HNPCC) should undergo annual check-ups from the age of 35 onwards since they are at high risk of getting ovarian and uterine cancer. Hysterectomy with bilateral salpingo-oophorectomy (surgical removal of the uterus with removal of the fallopian tubes and ovaries on both sides) may be recommended for such high-risk women who no longer desire to get pregnant, to eliminate the chance of future cancer in these organs.
Treatment of Uterine Cancer
Various treatment options are available for uterine cancer, such as :
- Radiation therapy.
- Hormone therapy.
- A combination of therapies, such as surgery and radiation.
Although there are broad guidelines for treatment options of endometrial cancer, each case has to be evaluated on an individual basis. There are a host of variables that have to be taken into consideration before choosing any one option or a combination of therapies.
Some of the factors that need to be taken into consideration before deciding on the type of treatment are :
- Age of the patient
- Health status of the patient at the time of cancer detection
- Extent and spread of cancer to distant sites
- Types of uterine cancer
- Desire for future pregnancy
- Women at high risk of endometrial cancer
- Whether the cancer is hormone dependent
Total abdominal hysterectomy (TAH), usually with bilateral salpingo-oophorectomy (BSO), is the favored treatment in case of early stage 1 endometrial cancer. The uterus and cervix, along with the fallopian tubes and ovaries on both sides are removed in this procedure. Abdominal hysterectomy is preferred over vaginal hysterectomy since the abdominal cavity can be visualized better during operation. Also, tissues for biopsy may be removed more easily and with precision.
A radical hysterectomy may be done when the cervix or the area around the cervix has been involved. The uterus, cervix, the tissues around the uterus, and the upper part of vagina are removed, along with BSO.
Lymph node surgery is where the lymph nodes of the pelvis (pelvic lymph nodes) and those along the aorta (para-aortic lymph nodes) may be removed during a hysterectomy if lymph node involvement is suspected. When all or most of the lymph nodes of a certain area are removed, it is known as lymph node dissection. If only some are removed, it is called lymph node sampling.
Pelvic washings may be obtained during surgery by washing the abdominal and pelvic cavity with saline and examining this fluid in the laboratory for cancer cells.
Complications of Surgery for Uterine Cancer
The main complications of hysterectomy, besides the complications that may occur with any major surgery, are the inability to fall pregnant since the uterus has been removed. This is more of a consequence rather than a complication but needs to be taken into consideration in women who desire to fall pregnant. With the onset of menopause due to removal of the ovaries, the symptoms of menopause may then appear which includes hot flashes, night sweats, and vaginal dryness. The psychological impact of a hysterectomy should also be considered.
Radiation therapy may be undertaken in any stage of endometrial cancer. It may be done where surgery is not possible. It may also be used before or after surgery.
In radiation therapy, high-energy radiation is used to kill the cancer cells. Internal radiation therapy or brachytherapy is given by means of radioactive materials placed inside the body near the tumor. External beam radiation therapy is delivered from outside the body. Sometimes, both internal and external radiation therapy may be administered.
Complications of radiation therapy includes nausea, diarrhea, fatigue, vaginal stenosis, temporary loss of pubic hair, vaginal discharge, urinary difficulty, and low blood count. The skin over the treated area may show redness, dryness or irritation. There may be symptoms of early menopause in premenopausal women.
The combination of surgery and radiation is often recommended for stage 1 endometrial cancer which has an increased chance of recurrence, has involved the lymph nodes or is a grade 2 or grade 3 cancer. Stage 2 cancer may also be treated by a combination of surgery and radiation. Where cancer has spread beyond the uterus to other tissues, a combination of radiation and chemotherapy may be recommended.
Chemotherapy is usually recommended for treatment of stage 3 and 4 endometrial cancers. It may be used following surgery where the tumor could not be removed totally, or if there is chance of recurrence. Anti-cancer drugs may be given intravenously or orally. Sometimes, a combination of drugs may need to be given for a better response. Drugs used in chemotherapy for endometrial cancer may include paclitaxel, carboplatin, doxorubicin, and cisplatin.
Complications of chemotherapy may include nausea, vomiting, tiredness, low blood cell count, loss of appetite, hair loss, mouth and vaginal sores. Side effects depend upon the drug used and in most cases are reversible once chemotherapy is stopped.
Endometrial tumors that are hormone-dependent may be treated with hormone therapy. Women with advanced uterine cancer and those with stage 1 cancer who wish to have children may benefit from hormone therapy. Certain hormones or anti-hormones are used in the treatment of endometrial cancer, such as progestins, tamoxifen, gonadotropin-releasing hormone (GnRH) agonists, and aromatase inhibitors.
Progestins such as medroxyprogesterone acetate and megestrol acetate are most often used in hormone therapy for endometrial cancer. It slows down the growth of endometrial cancer cells.
Tamoxifen is an anti-estrogen drug commonly used in the treatment of breast cancer. It acts by opposing the action of circulating estrogen which helps in the growth of cancer cells. Tamoxifen is used mainly in treatment of advanced or recurrent endometrial cancer.
Gonadotroping-releasing hormone (GnRH), such as goserelin and leuprolide act by lowering estrogen levels and thus slowing growth of cancer cells.
Aromatase inhibitors, such as letrozole, anastrozole and exemestane are drugs used in treating breast cancer but are under research for use in the treatment of endometrial cancer.
Complications of hormone therapy depend upon the hormone used. Common complications are hot flashes, night sweats, weight gain, increased blood sugar level (hyperglycemia) in diabetic women, vaginal dryness, increased risk of thrombosis, and osteoporosis.
Treatment of Uterine Cancer according to Stage
- In Stage 1 and Stage 2 endometrial cancer, hysterectomy may result in complete cure of the cancer. In premenopausal women wishing to have children, hormone therapy with progestins may be used but hysterectomy is ultimately advised once further pregnancy is no longer desired.
- In some Stage 2 endometrial cancers, such as type 2 endometrial cancer which is known to be more aggressive, radiation therapy or chemotherapy may be advisable to prevent recurrence of cancer.
- In Stage 3 endometrial cancer, hysterectomy with removal of the affected lymph nodes, may result in a cure. Radiation therapy or chemotherapy may be recommended after surgery.
- In Stage 4 endometrial cancer, a cure may not be possible at this late stage but slowing the progress of the disease and alleviation of symptoms may be done by means of chemotherapy, radiation therapy and hormone therapy.
Complications of Uterine Cancer
As a rule, the earlier the cancer is detected and treatment started, the lower the chance of complications. The patient’s health status prior to commencing treatment is also a consideration in the development of complications.
Due to Direct Spread to Neighboring Tissues
Cancer cells can invade and damage nearby tissues and organs, such as the bladder in front, the rectum behind, or the vagina lower down, resulting in
- Urinary obstruction.
- Bowel obstruction.
- Bleeding from the vagina, bladder or rectum.
It can spread to the deeper layers of connective tissue around the uterus and the pelvic lymph nodes.
Due to Metastasis
Complications of uterine cancer can also develop due to spread of the cancer (metastasis) to distant tissues and organs. This may occur when the cancer cells detachfrom the uterine tumor and reach other organs either through the lymph vessels or through blood vessels to reach the lungs, liver, brain, or bones. Once at these sites these cells replicate to form new tumors.
These tumors have the same kind of abnormal cells as the primary tumor. For instance, cancer that has metastasized to the lungs from the uterus will contain uterine cancer cells and are known as metastatic uterine cancer. The cancer can grow and metastasize rapidly if treatment is not commenced at an early stage. The most common sites for metastasis of endometrial cancer are the vagina, lungs and abdominal cavity, leading to complications such as :
- Ascites – fluid collection in the abdomen.
- Dyspnea – difficulty breathing.
- Persistent cough.
As a Result of Treatment
Complications following :
- Surgical removal of the uterus (hysterectomy), along with removal of the cervix, fallopian tubes and ovaries may produce various complications such as early menopause and prevent premenopausal women from having children.
- There are various other complications of surgery in general and the psychological effects of a hysterectomy on younger women also needs to be considered.
- Thromboembolism is a possible and potentially serious post-operative complication.
- Lymphadenectomy or removal of the pelvic lymph nodes can cause lymphedema.
- Radiation Therapy
- Some of the symptoms associated with radiotherapy include nausea, diarrhea, fatigue, vaginal discharge, pain while passing urine, and temporary loss of pubic hair.
- Radiotherapy may lead to early menopause in women who have not reached menopause.
- Chemotherapy may cause nausea, vomiting, tiredness, hair loss, and increased susceptibility to infections.
- Hormone therapy with progesterone may lead to nausea, weight gain, cramps.