There are two main types of uterine cancer: uterine sarcomas, which develop from the muscle or connective tissue of the uterus, and endometrial cancer, which starts in the inner lining of the uterus. Endometrial cancer is the most common type, and the information below mainly describes endometrial cancers.
Symptoms of endometrial cancer may include abnormal vaginal spotting, bleeding or discharge and pelvic pain or discomfort.
Tests that may be done to diagnose endometrial cancer include a pelvic examination, ultrasound, a hysteroscopy (which is a thin, telescope-like device inserted through the vagina to visualise the uterus) and a tissue sample (biopsy).
Types and staging of endometrial cancer
Like most cancers, endometrial cancers have different types, depending on how the cells look like under the microscopic (histologic types). The most common subtype is called endometrioid adenocarcinoma. Less common but more aggressive types include clear-cell carcinoma, serous adenocarcinoma, and carcinosarcoma.
The stage of any cancer describes how far the cancer has spread from the organ where it started. The stage determines how serious the cancer is and what the most appropriate treatment is. The stage can be 1, 2, 3 or 4. A lower number indicates that the cancer is present only in the uterus, whereas stage 4 cancer has spread outside the uterus to other parts of the body, such as the lung. If an endometrial cancer spreads to lung, it is still called endometrial cancer and not lung cancer, as any cancer that spread to other organs still looks like the original tissue where it had started.
Endometrial cancer is also described by another measure, called ‘grade’, which describes the degree to which the cancer cells are similar or different to non-cancerous cells. Grades 1 and 2 endometrial cancer are less aggressive and spread to other organs or tissues less often than high grade cancers (grade 3).
Treatment will depend on a number of factors, including the type, grade and stage of the cancer, as well as age, other health problems and patient preferences for treatment and expected side effects.
Most uterine cancers are treated with an operation to remove the uterus (hysterectomy), as well as the ovaries and fallopian tubes (bilateral salpingo-oophorectomy – BSO). There may also be removal or sampling of lymph nodes in the pelvis or near the aorta, to determine whether any cancer cells have spread to these areas, providing a more accurate stage to help decide on further treatments needed after surgery.
Once surgery has been performed and the type, grade and stage of the cancer is known, the treating team then typically meets to discuss these findings at a multi-disciplinary ‘Tumour Board’. The Tumour Board meeting ensures your case is presented and discussed by experts, including the surgeon (gynaecologic oncologist), radiation and medical oncologists, pathologists, radiologists and others. Depending on the risk of recurrence, a recommendation is made on whether any further treatment is needed to reduce the risk of the cancer coming back, which is called ‘adjuvant treatment’. Many patients with low risk endometrial cancers do not need any further treatment, while others are recommended to have adjuvant treatment that may include radiotherapy, chemotherapy, or both.
Radiotherapy uses high-energy ionising radiation (like x-rays or gamma rays) to kill cancer cells. It is used to kill any cancer cells in the pelvis remaining after surgery, or cancer cells within the lymph nodes that are in the pelvis or near the aorta.
There are two types of radiotherapy used after surgery for endometrial cancer. Vaginal brachytherapy and external radiotherapy. Vaginal brachytherapy is internal radiotherapy that is given by inserting radioactive seeds into the vagina to kill any cancer cells in the upper part of the vagina. External radiation is given by delivering radiotherapy beams externally, much like a normal x-ray. It is typically given 5 days a week for 4 to 6 weeks, although each treatment is very quick. The radiation plan is developed by a radiation oncologist, who is a cancer doctor that specialises in radiation treatment.
Side effects of radiotherapy will depend on which type of radiation will be given, but can include skin changes, fatigue and bowel disturbances such as diarrhea. Most of the side effects improve once treatment is completed, but some effects can persist for longer.
Chemotherapy are drugs used to fight cancer. In endometrial cancer, they are usually given through a needle in the vein, and often more than one drug is used. Chemotherapy is usually recommended for stage 3 or 4 uterine cancer, or when uterine cancer has recurred after prior treatment. Side effects include fatigue, hair loss and gut symptoms such as nausea. Most side effects related to chemotherapy can be managed with other supportive treatments or drugs and tend to improve once treatment is finished.
These are drugs that block hormones to fight or slow the growth of endometrial cancer. These drugs are sometimes used in early endometrial cancer, or in advanced or recurrent disease.
Clinical trials are a type of research studies that may be testing a new treatment approach or new drugs. They are the best way to develop new treatments to treat cancer, and often are comparing a new approach to current standard treatments or testing a new treatment when there is no current beneficial treatment. They also are one way of getting the newest treatment for cancer, especially when treatment options are not effective or stop working.
Other treatments may also be recommended to help prevent and/or control some of the symptoms of endometrial cancer and symptoms related to the treatments. These are referred to as Supportive Care.
Recurrent endometrial cancer
Although most endometrial cancers are cured after initial treatment, some cancers can recur months or years after initial treatment. Treatments for recurrent endometrial cancer depend on the location of recurrence, and what prior treatments have been given. There can be a role for more surgery, radiotherapy, or chemotherapy / hormone therapy, as well as consideration of suitable clinical trials of new treatments.