What is Uterine Cancer?
Uterine cancer is the most common gynaecological cancer in Australia, with more than 3,000 women newly diagnosed every year. Most typically it is a disease of postmenopausal women.
Endometrial cancer (arising from the inner layer of the uterus) is the most common type. Endometrial hyperplasia (with cellular atypia) is a precancerous condition leading to cancer of the uterus if left untreated.
Types of Uterine Cancer
There are two main types of uterine cancer.
Type 1
Type 1 uterine cancer (endometroid cancer) is the most common form of uterine cancer.
It is most likely caused by metabolic syndrome (obesity, diabetes mellitus, high cholesterol). Type 1 cancers are likely to be slow growing and are less likely to spread to other parts of the body. They typically require less intensive treatment and patients normally can expect a good prognosis. Conservative treatment of endometrial cancer is possible for young patients with early stage endometrial cancer who wish to preserve fertility.
Type 2
Type 2 uterine cancer includes serous and clear cell types, sarcomas and other rather aggressive types of uterine cancer.
The causes of these cancer types are unknown. Aggressive treatment is required and includes surgery, often followed by radiotherapy, chemotherapy or a combination of both.
Sometimes cancer of the uterus can be inherited. See Lynch syndrome.
Uterine Cancer Symptoms
Symptoms of uterine cancer (endometrial cancer) include:
- Bloody, smelly or watery vaginal discharge
- Bleeding between periods (spotting)
- Unusually heavy periods
- Vaginal bleeding after menopause
- Discomfort or pain in the abdomen
- Difficulty or pain urinating
- Unexplained weight loss
- Pain during intercourse.
If you have one or more of these symptoms and they are persisting you should speak to a doctor as soon as possible. The most common symptom of endometrial cancer is abnormal vaginal bleeding, particularly any bleeding after menopause is a sign of a problem.
Endometrial Cancer Risk Factors
Obesity is the strongest risk factor linked to developing endometrial cancer.
Among all cancers, endometrial cancer has the highest association with obesity. Furthermore, women who had breast cancer are also at a higher risk of developing endometrial cancer. Another risk factor is a genetic predisposition, which is called Lynch syndrome.
Other risk factors for endometrial cancer include: early menarche, late menopause, polycystic ovary syndrome, infertility or failure to ovulate, family history, hypertension, type 2 diabetes, thyroid disease, or having never given birth. The risk of endometrial cancer also increases with age.
Uterine Cancer Diagnosis
Diagnosis of uterine cancer involves some or all of the following:
- Endometrial (Pipelle) Biopsy. The diagnosis of uterine cancer needs to be established by endometrial (Pipelle) biopsy. The procedure takes a small sample of tissue from the inner lining of the uterus. This procedure is performed in a gynaecologist’s office, without the use of general anaesthesia, then the sample of tissue is sent to a laboratory to test for cancer or other abnormal cells.
- Hysteroscopy, D&C. Another option is a hysteroscopy, which is a procedure to look inside the uterus. This procedure is a minor day surgery performed under general anaesthesia. The cervix is widened (dilated) and a thin telescope is inserted into the uterus to look inside. It is combined with a curettage, which samples the lining of the uterus to collect some tissue.
- Medical Imaging. Medical imaging (ultrasound and CT scans) and blood tests are also routinely taken.
Uterine Cancer Treatment
Treatment of uterine cancer involves surgery, with the possibility of radiotherapy or chemotherapy, or a combination of both.
Surgery
Surgery for uterine cancer will remove the uterus, fallopian tubes and the ovaries (total hysterectomy & salpingo-oophorectomy). The removal of lymph nodes has been performed for more than 35 years but evidence to support its clinical practice is poor. At present, I lead a research program to determine if removal of lymph nodes is of benefit to patients.
Two large previous studies found that patients with or without lymph node dissection had equal survival probabilities. However, this study was done using outdated technology.
By contrast, our ENDO3 trial uses sentinel lymph node dissection (SLND), a technique that utilises modern technology to remove local lymph nodes from the pelvis. According to the SLND concept, tumour cells spread first to one or two lymph nodes before involving other lymph nodes. Identification occurs via a small amount of dye injected into the uterine cervix and is transported via lymphatic channels towards the lymphatic basins in the pelvis. The first node the tracer reaches and highlights in the pelvis is called the “sentinel lymph node”. Only 6% to 10% of patients will have involved lymph glands.
After identifying the sentinel node and performing a SLND, the surgeon will proceed to a hysterectomy.
Patients with involved lymph nodes will need further postoperative treatment (radiotherapy, chemotherapy, or combinations of both). The ENDO3 trial will examine how useful the information from the lymph node removal is, to identify those patients who will benefit from postoperative treatment.
Before Surgery
Patients are required to fast at least 6 hours prior to surgery. Usually no bowel prep is required. We advise patients to stop smoking before the operation as it makes postoperative recovery much easier. Before surgery, all blood thinning medication should be stopped for two weeks prior.
During Surgery
The procedure usually takes 2 to 3 hours and is routinely carried out laparoscopically (“keyhole hysterectomy”). The procedure requires general anaesthesia.
After Surgery
When you wake up from general anaesthesia you will have a drip to give you the necessary fluids and a urinary catheter will drain the urine from your bladder. An oxygen mask will supply oxygen to the respiratory system. These will be removed once I am happy that your body functions have returned to normal, which is usually after a few hours.
You will need to stay in hospital for one or two days. I recommend you give yourself a good break for the couple of weeks following surgery. Whenever possible we will mobilise patients on the day or the day after a hysterectomy with the help of experienced physiotherapy staff.
Important tips to consider after surgery:
- Take your painkillers regularly, even if you are not in pain. If you develop pain, it may intensify rapidly and you may require admission to hospital, including blood and medical imaging tests.
- Avoid intercourse, vaginal tampons, full baths and any straining (ie- pilates, yoga) for 6 weeks and other factors that could disrupt wound healing or facilitate an infection.
- Use laxatives for the first couple of weeks because some of the anaesthetic medication and pain killers may cause severe constipation.
Other DOs and DON'Ts after surgery are described separately. Recovery from surgery is difficult to predict. All going well, a patient should be able to go back to work after two weeks.
Please notify me immediately if your condition becomes worse after you have been discharged from hospital.
The final histopathological report may take a few days. It forms the basis for the decision if any further treatment (e.g., chemotherapy) is required. If further treatment is required I will refer you to a medical oncologist to administer this treatment.
Surgical risks
Surgery always carries risks. I do everything possible to minimise these risks.
Risks may include:
- Laparoscopic surgery may need to be converted to open surgery through the opening of the abdomen (approximate 3%). The vast majority (97%) of all laparoscopic procedures will be completed laparoscopically.
- Medical and anaesthetic risks associated with general anaesthetic may occur.
- A risk of injury to pelvic organs, such as the bowel, bladder, ureters, blood vessels and nerves (~1.5%). Should this occur, these injuries usually are repaired during surgery. However, in an exceedingly small proportion of patients these injuries can unfortunately escape to be recognised during surgery or injuries may even develop after surgery. Should this occur, further surgery is required to repair those injuries. Injury to large blood vessels may result in the need of a blood transfusion. Injury of nerves is common in patients who require removal of lymph nodes in the pelvis. In this case, patients will experience some numbness of the skin around the upper thigh.
- The risk of a bleed to the vagina is approximately 4%. A bleed can be triggered by an infection and may develop into a haematoma. In the majority of patients, a course of antibiotics will resolve this problem.
- Lymphoedema: Lymphatic fluid usually drains from the legs via the lymph glands in the pelvis and the aorta back into the blood circulation. When lymph glands have to be removed, some fluid may accumulate in the legs (lymphoedema). The risk of lymph oedema is around 20% in patients who had to have a lymph node dissection. Patients with lymphoedema require lymph drainage.
- In young women, oophorectomy (ovary removal) may be necessary for cancer treatment and will lead to instant surgical menopause. Estrogen Replacement Therapy (ERT) may be required to alleviate menopausal symptoms. ERT is far easier to manage than combined Estrogen + Progestin replacement.
Possible complications after hysterectomy
- Infections to the bladder, the abdominal wound, the lungs with resulting temperatures and septicaemia. I prescribe antibiotics before the skin incision in order to avoid skin and other infections.
- Thromboembolic complications (formation of blood clots) in the legs that can travel to the lungs and cause life-threatening emboli. This risk is very small (less than 1%) because of our efforts to minimise them. Prior to and after surgery patients are asked to wear calf compression stockings in order to prevent the formation of blood clots in the legs.
- Shoulder tip pain is common after laparoscopic surgery. It is caused by the CO2 gas that is needed for the surgery. It normally lasts only for a day, but unfortunately painkillers are not effective.
- After hysterectomy a vaginal discharge that can even be blood-stained is very common for up to 6 weeks.
- Changes in bowel habits are not uncommon for a couple of months after surgery. I recommend regulation of the bowels with natural substances such as yoghurt, prune juice and natural fibre.
Follow-up
After surgery, patients with uterine cancer (except those with very low risk of recurrence) should be seen regularly for follow-up for 3 to 5 years.
These examinations include pelvic examinations. I will discuss with my patients if any other tests (vault smears, medical imaging, blood tests) are required. After several years, the risk of a recurrence becomes very low. Should you experience any bleeding or pain, please contact my office as soon as possible.
Uterine Cancer Outcomes
Cancers of all types and stages may recur. Recurrence may be local (vagina), in the pelvis or distant (abdomen, lungs). Treatment of recurrent cancer is more challenging than treatment of primary cancer.
Survival rates for Type 1 uterine cancer are generally very good (85% survival rate at 5 years from surgery across all stages).