Uterus Cancer: Regular Screening and Prevention
Endometrial cancer is a type of uterine cancer that involves the lining of the uterus (the endometrium). There are two types of endometrial cancer, which are classified by their relationship to oestrogen hormone stimulation. Endometrial cancer is the most common cancer of the organs of the female reproductive system. It usually occurs in women over the age of 50, and thus after menopause, but up to 25 per cent of cases may occur before the menopause. At diagnosis, about 75 per cent of women have a cancer confined to the uterus (stage I). For these women, the prognosis is very good.
Today, it is not clear why endometrial cancer occurs. Some risk factors have been identified. There are several recognised pathologic and clinical factors that can identify if you are at an increased risk of relapse after surgery, or treatments which can help your doctor determine an appropriate treatment pathway. There are even genetic-related endometrial cancers, which account for up to five per cent of cases.
Risk factors include:
Aging
Genes
Family history of endometrial cancer
Personal history of certain gynaecological diseases
Exposure to oestrogen
Overweight and obesity
Diabetes
Hypertension
Geographic factors
No pregnancy and total number of menstrual cycles
Taking contraceptive pills containing both oestrogen and progesterone lower the risk of developing endometrial cancer. Other factors have been suspected to be associated with an increased risk (alcohol consumption, lack of physical activity) or a decreased risk (consumption of phytoestrogens found in soya food, coffee and vegetables) of developing endometrial cancer, but the evidence is inconsistent.
Treatment for endometrial cancer depends on the risk for persistent or recurrent disease after surgical therapy:
Low-risk disease
The risk of relapse after surgery for low-risk endometrial cancer is very low, with estimates placed at five per cent or less. Given this, no further treatment is generally recommended.
Intermediate-risk disease
Women with low-intermediate risk disease can be observed without further treatment, since their risk of relapse after surgery alone is low (five per cent or less). Women with high-intermediate risk endometrial cancer benefit from adjuvant therapy to help reduce the chances of the cancer coming back in the pelvis (also known as a local recurrence). For most women with intermediate-risk disease, adjuvant vaginal or external beam radiation therapy is given. Of the two ways to give radiation, vaginal brachytherapy seems to be as effective as external beam radiation therapy, with fewer gastrointestinal side effects. These modes of radiation therapy are described below.
High-risk disease
Women with high-risk endometrial cancer are treated with adjuvant chemotherapy, especially if the disease is located outside of the uterus. Adjuvant radiation with or without chemotherapy is administered to decrease relapse, particularly if the disease is limited to the pelvis.
Doctors will need to consider many aspects of both the patient and the cancer in order to decide on the best treatment. The cornerstone of treatment is surgery. Radiotherapy and chemotherapy used after surgery are called adjuvant therapies, meaning that they are used in addition to surgery. Even a tailored and recommended surgery performed by a skilled gynaecological oncologist will impact the patient’s prognosis. Treatments have their benefits, their risks and their contraindications. It is recommended to ask doctors about the expected benefits and risks of every treatment in order to be informed of the consequences of the treatment. For some patients, several treatment possibilities are available and the choice should be discussed according to the balance between expected benefits and risks.
Regular check-ups and screening related to age are a very important milestone of early diagnostic and excellent prognosis of uterine cancer. Screening consists of performing an examination in order to detect cancer at an early stage, before any sign of the disease appears. A systematic screening is proposed if a safe and acceptable exam can be performed and if this exam is able to detect cancer in the majority of cases. It should also be proved that treating screened cancers is more effective than treating cancers diagnosed because signs of cancer were present. For example, this has been demonstrated for the Pap smear test used in cervical cancer screening.
Cancer surveillance
Experts recommend close follow-up after the completion of treatment for endometrial cancer, particularly in the first three years after diagnosis, when the risk of recurrence is highest. This usually includes a history and physical exam every three to six months for several years. Other tests, like Pap smears, blood tests and computed tomography (CT) scans or other radiology tests, should be done only as needed.
If the cancer does not come back after five years, women can usually stop seeing the oncologist and return to their primary care provider or women’s healthcare provider. Women should call their doctor if they develop any symptoms of vaginal bleeding, pain in the belly or pelvis, a cough that will not go away or unintentional weight loss. These could be signs that the cancer has come back.
Treating menopausal symptoms
Premenopausal women who have had their ovaries removed as part of treatment usually experience symptoms of menopause. This may include hot flashes, night sweats, and vaginal dryness. The most effective treatment for these symptoms is the female hormone oestrogen. Most experts think that oestrogen is a reasonable option for women with endometrial cancer. You should discuss the potential risks and benefits of oestrogen with your doctor. For women receiving adjuvant treatment, some experts recommend waiting six to 12 months after finishing treatment before beginning oestrogen therapy. Other non-hormonal treatments for menopausal symptoms are available; these are discussed separately.
Sexual issues after treatment
Changes in the vagina are common after endometrial cancer treatment. Pelvic or vaginal radiation can cause the vagina to shorten, narrow and feel dry. These changes can cause pain with sex (also called dyspareunia). Many of these problems are treatable: Ask your doctor or nurse about using vaginal dilators to prevent and treat narrowing of the vagina. Use a vaginal moisturiser or lubricant during sex to treat dryness. Women with endometrial cancer may be able to use a vaginal oestrogen (a cream, vaginal ring or pill) to treat dryness. Pelvic physical therapy and counselling for sexual or psychological difficulties can be helpful.
Patients should undergo follow-up visits every three to four months with physical and gynaecological examination for the first two years, and then with a six-month interval until five years. Further investigations can be performed, if clinically indicated.
It can be hard to live with the idea that the cancer can come back. From what is known today, no specific way of decreasing the risk of recurrence* after completion of the adjuvant* treatment can be recommended. As a consequence of the cancer itself and of the treatment, return to normal life may not be easy for some people. Questions related to body image, sexuality, fatigue, work, emotions or lifestyle may be of concern to you. Discussing these questions with relatives, friends or doctors may be helpful.
Dr Murat as an internationally known minimal invasive gynaecologist, gynaecological oncologist and breast surgeon, providing the fully equipped and standard-based diagnostic and treatments in Dr Murat Women’s Clinic. From genetic testing, to all kinds of imaging with surgical options included. At the same time Dr Murat is the director of the Gynaecological Oncology Unit of King Hamad University Hospital and is providing diagnostics and surgeries for female patients in Bahrain. He is at the same time a referral centre for female cancers in Bahrain.
