Cancer Of The Uterus
What You Need To Know About Cancer of the Uterus
The National Cancer Institute (NCI) has prepared this booklet to help patients and their families better understand and deal with cancer of the uterus. We also hope that it will encourage all readers to learn more about this type of cancer. The information presented here on the symptoms, diagnosis, and treatment of cancer of the uterus and on living with the disease is intended to add to talks with doctors, nurses, and other members of the medical team.
Our knowledge about uterine cancer is increasing rapidly. Research sponsored by the NCI and by other groups is aimed at developing tests to detect uterine cancer in an early stage when the chances for cure are high. Scientists also are working to find more effective treatment methods.
The uterus (womb) is a hollow, pear-shaped organ located in a woman’s lower abdomen between the bladder and the rectum. The narrow, lower portion of the uterus is the cervix the broader, upper part is the corpus. The corpus is made up of two layers of tissue.
In women of childbearing age, the inner layer of the uterus (endometrium) goes through a series of monthly changes known as the menstrual cycle. Each month, endo-metrial tissue grows and thickens in preparation to receive a fertilized egg. Menstruation occurs when this tissue is not used and passes out through the vagina. The outer layer of the corpus (myometrium) is a muscle that expands during pregnancy to hold the growing fetus. Because most uterine cancer develops in the endometrium, cancer of the uterus also is called endometrial cancer.
What is Cancer?
Cancer is a group of more than 100 diseases. Although each disease differs from the others in many ways, every cancer is a disease of some of the body’s cells.
Healthy cells that make up the body’s tissues grow, divide, and replace themselves in an orderly manner. This process keeps the body in good repair. Sometimes, however, certain cells lose the ability to limit and direct their growth. They divide too rapidly and grow without any order. Too much tissue is produced, and tumors begin to form. Tumors can be benign or malignant.
Benign tumors are not cancer. They do not spread to other parts of the body and are seldom a threat to life. Several types of benign tumors occur in the uterus. In some cases, these growths do not need to be treated. Sometimes, however, benign tumors must be removed by surgery. Once removed, these tumors are not likely to return.
Fibroids are benign tumors in the uterus that are found most often in women over 35 years of age. While single fibroid tumors occur, multiple tumors are more common. Symptoms of fibroids depend on the size and location of the tumors and may include irregular bleeding, vaginal discharge, and frequent urination. When fibroids press against nearby organs and cause pain, surgery may be recommended. Often, however, fibroids do not cause symptoms and do not need to be treated, although they should be checked often. When a woman stops having menstrual periods (menopause), fibroids may become smaller, and sometimes they disappear. Another benign condition of the uterus is endometriosis. In this condition, tissue that looks and acts like endometrial tissue begins to grow in unusual places, such as on the surface of the ovaries, on the outside of the uterus, and in other tissues in the abdomen. Endometriosis is most com-mon in women in their thirties and forties. This condition causes painful menstrual periods and abnormal bleeding; sometimes, it can cause infertility. Some patients with endometriosis are treated with medication, and some are treated by surgery.
Hyperplasia is an increase in the number of normal cells lining the uterus. Although this condition is not cancer, it may develop into cancer in some women. The most common symptoms of hyperplasia are heavy menstrual periods and bleeding between periods. Treatment depends on the extent of the condition (mild, moderate, or severe) and on the age of the patient. Young women usually are treated with female hormones, and the endometrial tissue is checked often. Hyperplasia in women near or after menopause may be treated with hormones if the condition is not severe. Surgery to remove the uterus is the usual treatment for severe cases.
Malignant tumors are cancer. They invade and destroy nearby healthy tissues and organs. Cancer cells also can metastasize, or spread, to other parts of the body and form new tumors. When cancer of the uterus spreads, it may travel through the bloodstream or lymphatic system. Cancer cells can be carried along by blood or lymph, an almost colorless fluid discharged by tissues into the lymphatic system. Lymph nodes scattered along this system filter bacteria and abnormal substances such as cancer cells. For this reason, surgeons often remove pelvic lymph nodes to learn whether they contain cancer cells.
Because uterine cancer can spread, it is important for the doctor to find out as early as possible if a tumor is present and whether it is benign or malignant. As soon as a diagnosis is made, the doctor can begin treatment.
Abnormal bleeding after menopause is the most common symptom of cancer of the uterus. Bleeding may begin as a watery, blood-streaked discharge. Later, the discharge may contain more blood.
Cancer of the uterus does not often occur before menopause, but it does occur around the time menopause begins. The reappearance of bleeding should not be considered simply part of menopause; it should always be checked by a doctor.
Abnormal bleeding is not always a sign of cancer. It is important for a woman to see her doctor, however, because that is the only way to find out what the problem is. Any illness should be diagnosed and treated as soon as possible, but early diagnosis is especially important for cancer of the uterus.
Diagnosing Cancer of the Uterus
When symptoms suggest uterine cancer, the doctor will ask a woman about her medical history and will conduct a thorough exam. In addition to checking general signs of health (temperature, pulse, blood pressure, and so on), the doctor usually performs one of the following exams:
• Pelvic exam. The doctor thoroughly examines the uterus, vagina, ovaries, bladder, and rectum (pelvic exam). The doctor feels these organs for any abnormality in their shape or size. A speculum is used to widen the opening of the vagina so that the doctor can look at the upper portion of the vagina and the cervix.
• Biopsy. For a biopsy, the doctor surgically removes a small amount of suspicious looking uterine tissue, which is examined under a microscope by a pathologist.
• D and C. In a D and C, the doctor dilates (widens) the cervix and inserts a curette (a small spoon-shaped instrument) to remove pieces of the lining of the uterus. A sample of the uterine lining also can be removed by applying suction through a slender tube (called suction curettage). The tissue is examined for evidence of cancer.
• Pap test. The Pap test is often used to detect cancer of the cervix. While it is sometimes done for cancer of the uterus, it is not a reliable test for uterine cancer because it cannot always detect abnormal cells from the endometrium.
If cancer cells are found, doctors use other tests to find out whether the disease has spread from the uterus to other parts of the body. These procedures include blood tests and a chest x-ray. For some pa-tients, special x-rays are needed. For example, computed tomography (also called CT or CAT scan), is used to take a series of x-rays of various sections of the abdomen. Doctors may also use ultrasound to view organs inside the body. In this procedure, high-frequency sound waves are bounced off internal organs, and the echoes can be seen on a screen that resembles a television. Patients also may have special exams of the bladder, colon, and rectum.
Treating Cancer of the Uterus
The doctor considers a number of factors to determine the best treatment for cancer of the uterus. Among these factors are the stage of the disease, the growth rate of the cancer, and the age and general health of the woman.
The doctor develops a treatment plan to fit a woman’s individual needs. Before starting treatment, a woman might want a second doctor to review the diagnosis and treatment plan. If so, there are a number of ways to get a second opinion:
• The doctor can discuss the patient’s case with other physicians who treat cancer of the uterus.
Methods of Treating Uterine Cancer
Surgery, radiation therapy, hormone therapy, or chemotherapy may be used to treat uterine cancer. Radiation therapy (also called x-ray therapy, radiotherapy, or irra-diation) uses high-energy rays to kill cancer cells. Radiation may be given from a machine located outside the body (external radiation therapy), or radioactive material may be placed inside the body (internal radiation therapy). In hormone therapy, female hormones are used to stop the growth of cancer cells. Chemotherapy is the use of drugs to treat cancer. Often, a combination of these methods is used. In some cases, the patient is referred to specialists in the different kinds of cancer treatment.
In its early stages, cancer of the uterus usually is treated with surgery. The uterus and cervix are removed (hysterectomy), as well as the ovaries and fallopian tubes (salpingo-oophorectomy). Some doctors recommend radiation therapy before surgery to shrink the cancer. Others prefer to evaluate the patient carefully during surgery and recommend radiation therapy after surgery for patients whose tumors appear likely to recur. A combination of external and internal radiation therapy often is used. If the cancer has spread extensively or has recurred after treatment, the doctor may recommend a female hormone (progesterone) or chemotherapy.
Side Effects of Treatment
The treatments used against uterine cancer must be very powerful. It is rarely possible to limit the effects of cancer treatment so that only cancer cells are destroyed. Normal, healthy cells may be damaged at the same time. That’s why the treatment often causes side effects.
Hysterectomy is major surgery. After the operation, the hospital stay usually lasts about 1 week. For several days after surgery, patients may have problems emptying their bladder and having normal bowel movements. The lower abdomen will be sore. Normal activities, including sexual intercourse, usually can be resumed in 4 to 8 weeks.
Women who have their uterus removed no longer have menstrual periods. When the ovaries are not removed, women do not have symptoms of menopause (change of life) because their ovaries still produce hormones. If the ovaries are removed or damaged by radiation therapy, menopause will occur. Hot flashes or other symptoms of menopause caused by treatment may be more severe than those from a natural menopause.
Sexual desire and the ability to have intercourse usually are not affected by hysterectomy. However, many women have an emotionally difficult time after a hysterectomy. They may have feelings of deep emotional loss because they are no longer able to become pregnant.
Radiation therapy destroys the ability of cells to grow and divide. Both normal and diseased cells are affected, but most normal cells are able to recover quickly. Patients usually receive external radiation therapy as an outpatient. Treatments are given 5 days a week for several weeks. This schedule helps to protect healthy tissues by spreading out the total dose of radiation. Weekend rest breaks allow the normal cells to repair themselves.
Internal radiation therapy puts the radiation as close as possible to the site of the cancer, while sparing most of the healthy tissues around it. This type of radiation therapy requires a short hospital stay. A radiation implant, a capsule containing radioactive material, is inserted through the vagina into the uterus. The implant usually is left in place 2 or 3 days.
During radiation therapy, patients may notice a number of side effects, which usually disappear when treatment is completed. Patients may have skin reactions (redness or dryness) in the area being treated, and they may be unusually tired. Some may have diarrhea and frequent and uncomfortable urination. Treatment can also cause dryness, itching, and burning in the vagina. Intercourse may be painful, and some women are advised not to have intercourse at this time. Most women can resume sexual activity within a few weeks after treatment ends.
Hormones occur naturally in the body; their purpose is to regulate the growth of specific cells or organs. In cancer treatment, hormones are sometimes used to stop the growth of cancer cells. Hormones travel through the bloodstream to all parts of the body, affecting cancer cells far from the original tumor. Hormone therapy causes few side effects.
Anticancer drugs also travel through the bloodstream to almost every area of the body. Drugs used to treat cancer may be given in different ways: some are given by mouth; others are injected into a muscle, a vein, or an artery. Chemotherapy is most often given in cycles—a treatment period, followed by a rest period, then another treatment period, and so on.
Depending on the drugs that the doctor orders, the patient may need to stay in the hospital for a few days so that the effects of the drugs can be watched. Often, the patient receives treatment as an outpatient at the hospital, at a clinic, at the doctor’s office, or at home.
The side effects of chemotherapy depend on the drugs given and the individual response of the patient. Chemotherapy commonly affects hair cells, blood-forming cells, and cells lining the digestive tract. As a result, patients may have side effects such as hair loss, lowered blood counts, nausea, or vomiting. Most side effects end after treatment is stopped.
Loss of appetite can be a serious problem for patients receiving radiation therapy or chemotherapy. Researchers are learning that patients who eat well are better able to withstand the side effects of treatment. Therefore, nutrition is an important part of the treatment plan. Eating well means getting enough calories to prevent weight loss and having enough protein in the diet to build and repair skin, hair, muscles, and organs. Many patients find that eating several small meals throughout the day is easier than eating three large meals.
The side effects that patients have during cancer therapy vary from person to person and may even be different from one treatment to the next. Doctors try to plan treatment to keep problems to a minimum, and fortunately, most side effects are temporary. Doctors, nurses, and dieticians can explain the side effects of cancer treatment and suggest ways to deal with them.
Follow up Care
Regular followup exams are very important for any woman who has been treated for cancer of the uterus. The doctor will want to watch the patient closely for several years to be sure that the cancer has not returned. In general, followup examinations include a regular pelvic exam, a chest x-ray, and other laboratory tests.
Adjusting to the Disease
When people have cancer, life can change for them and for the people who care about them. These changes in daily life can be difficult to handle. When a woman finds out she has uterine cancer, a number of different and sometimes con-fusing emotions may appear.
At times, patients and family members may feel depressed, angry, or frightened. At other times, feelings may vary from hope to despair or from courage to fear. Patients usually are better able to cope with their emotions if they can talk openly about their illness and their feelings with family members and friends.
Concerns about the future, as well as about medical tests, treatment, a hospital stay, and medical bills, often arise. Talking to doctors, nurses, or other members of the health care team may help to ease fear and confusion. Patients can ask questions about their disease and its treatment and can take an active part in decisions about their medical care. Patients and family members often find it helpful to write down questions for the doctor as they think of them. Taking notes during visits to the doctor also can help patients remember what was said.
Patients should ask the doctor to repeat or explain more fully anything that is not clear. Patients have many important questions to ask about cancer, and their doctor is the best person to provide answers. Most people ask what kind of cancer they have, how it can be treated, and how successful the treatment is likely to be. The following are some other questions that patients might want to ask the doctor:
• What are the benefits of treatment?
• What are the risks and side effects of treatment?
• Will changes in my normal activities be required?
• Is it possible to keep working?
• How often are checkups needed?
Many women become concerned, especially after surgery and radiation therapy, that the changes to their bodies will affect how other people feel about them. They may worry about working, caring for their family, or about how cancer and its treatment will affect their sex life. Usually, as the patient recovers, the changes to her body become more accepted. With love and support, patients gradually feel reassured that they are just as appreciated as before.
The patient’s doctor is the best person to give advice about working or limiting other activities, but it may be hard to talk to the doctor about feelings and other very personal matters. Many patients find it helpful to talk with others who are facing similar problems. This kind of help is available through cancer-related support groups, such as those described in the next section. If the emotional problems of the patient or family become too hard to handle, a mental health counselor may be able to help.
Living with any serious disease is a difficult challenge.
Support for Cancer Patients
Adapting to the changes brought about by having cancer is easier for both patients and their families when they get helpful information and support services. Often, the hospital can suggest local agencies that will help with rehabilitation, emotional support, financial aid, transportation, or home care.
Adapted from NCI (National Cancer Institute) – NIH publication No 88-1562