Cancers of the uterine body have their origin in the uterine lining (endometrium). The uterus is the hollow, pear-shaped pelvic organ where fetal development occurs. For this reason, cancer of the uterine body is also referred to as endometrial cancer. It is the most common cancer type of the female genital organs. Endometrial cancer is often detected at an early stage because it frequently produces abnormal vaginal bleeding. If endometrial cancer is discovered early, removing the uterus surgically often cures endometrial cancer.
Endometrial cancer is the second most common cancer of the female organs in Switzerland (breast cancer is the most common) and the fourth most common form of cancer in women. One in 50 women will develop uterine cancer in the course of their lives, one in 200 affected persons will eventually die of the disease. Due to this relatively good prognosis, the proportion of all cancer-related deaths is comparatively low at 2.9 percent. The relative five-year survival rate in uterine cancer is approximately 80 percent. The median age of onset is 69 years.
If endometrial cancer is suspected, the doctor can arrange the following examinations:
- Medical history and physical examination with a mirror (speculum) and tactile examination, Pap test
- Ultrasound examination (transvaginal sonography)
- uterine mirroring (hysteroscopy)
- separate scraping of the cervix and the lining of the uterus (fractional abrasion)
- blood tests
Sonography (transvaginal ultrasound examination). The ultrasound examination of the internal genital organs is carried out with an ultrasound probe that is inserted into the vagina (transvaginal sonography). With this method, the doctor can assess the endometrium and determine the thickness of the lining. The transvaginal ultrasound examination is always carried out when suspect of uterine cancer exists. It is painless and can be repeated a number of times since it does not expose the patient to radiation.
Hysteroscopy. During a hysteroscopy, a thin, flexible, lighted tube (hysteroscope), is pushed through the vagina and cervix into the uterine cavity. A lens on the hysteroscope provides a view of your uterus and endometrium. In case of suspicious areas, tissue samples are taken (biopsy) and examined under the microscope. The uterus examination is usually combined with scraping of cells from the lining.
Curettage (abrasion/scraping of the endometrium). Microscopic examination of the tissue sample from the cervix and endometrium is currently the safest way to detect changes in the uterine body. To obtain tissue samples, the uterus is usually carefully scraped out under the vagina. Parts of the mucous membrane of the cervix and uterine body are obtained and examined. The mucous membrane then gradually builds up again.
Blood tests. These provide information about the general condition of the patient. The test results are important with regard to an upcoming treatment. Some types of cancer occasionally produce tumor markers that can then be detected in the blood, for example CA-125. However, these tumor markers are not elevated in all patients and can also be above the normal range in healthy people. Tumor markers are particularly of interest for monitoring the course of the disease during chemotherapy and in the event of a relapse. In aftercare, tumor markers can be used as indicator of relapse. Tumor markers usually play an insignificant role in routine clinical practice except for clinical trials.
Surgery. The first choice for cancer of the uterine body is surgery which removes the uterus, fallopian tubes and ovaries. The operation aims to remove the tumor tissue and any affected lymph nodes in order to achieve curation. At the same time, the stage, the type of tumor and subsequent risk of relapse are determined by examining the removed tissue. The operation can be performed with an abdominal incision or, preferably in the early stages, by hysteroscopic surgery. The scope and technique of the operation depend on the type and extent of the cancer.
The operation is the equivalent of a complete removal of the uterus (hysterectomy). Because the ovaries produce estrogen, which favors the formation of tumors of the endometrium. Since these organs often carry metastases, it is recommended the ovaries and the fallopian tubes are removed as well. In addition, the lymph nodes in the area (in the small pelvis and along the aorta up to the level of the kidney vessels) are removed if the risks of metastasis are increased. In rare cases, neighboring organs such as the bladder and rectum are also removed if these organs have been affected. If the tumor is discovered at an early stage, surgery alone is usually sufficient. In that case, the prospects for permanent healing are very good. In advanced disease stages, surgery is often accompanied with radiation and / or chemotherapy in order to destroy any tumor cells that may remain in the body, reducing the risk of relapse.
What are the consequences of the operation? Physical complaints that may occur after the operation depend largely on the extent to which the operation was carried out. In general, the larger the operation, the higher the chance of complications and/or therapy related complaints.
Radiation therapy. If the disease is already more advanced at the time of diagnosis a combination of surgery with radiation and/or chemotherapy is most likely. In this case the radiation therapy is intended to reduce the risk of relapse (adjuvant radiation therapy). Radiation should only be used instead of surgery if, for serious health reasons, surgery is not possible or undesirable. However, the chances of a cure are significantly poorer with radiation therapy alone. The aim of radiation therapy is to destroy the malignant cells. To achieve this, radiation is usually given from the inside (via the vagina) and outside (from the abdominal wall). With the so-called short-distance radiation, a radiation source is inserted into the vaginal vault or - if no surgery has been done - into the uterine cavity and left there for a short time until the desired radiation dose is reached. The radiation remains locally limited and thus protects the neighboring organs. Internal radiation is used in most patients to prevent relapses in the vaginal area.
In addition, the entire pelvic area on the large blood vessels can also be treated with high-energy rays from the outside (external or percutaneous radiation). This is particularly the case if many lymph nodes are affected or if the tumor is well advanced.
What are the side-effects of radiation therapy?
Physical complaints that arise after the radiation treatment depend on the extent of the pretreatment (surgery) and the radiation therapy. The more extensive the treatment, the sooner complaints can arise.
Chemotherapy. Chemotherapy is a drug treatment that uses powerful chemicals to kill fast-growing cells throughout the body by inhibiting cell growth, aiming specifically for rapidly growing cells, like tumor cells. At certain stages, adjuvant chemotherapy in the curable situation can be an alternative or a supplement to adjuvant radiation therapy. Chemotherapy is also used to treat metastases and to relieve symptoms of advanced illness (palliative treatment). It is used in particular when the disease progresses under hormone therapy (endocrine therapy) or when the tumor has no binding sites (receptors) for hormones. However, since palliative chemotherapy also has side effects, the benefits and risks must be carefully outweighed against each other in individual cases.
What are the side effects of chemotherapy?
Treatment with chemotherapy also affects normal tissues that renew themselves relatively quickly. This primarily affects the mucous membranes of the stomach and intestines, the hematopoietic system in the bone marrow and the hair roots. Most of the side effects can be alleviated well with medication and usually disappear again when chemotherapy is no longer administered.
Endocrine Therapy. Hormone therapy (endocrine therapy) is used for uterine cancer when so-called metastases (daughter tumors) have spread to other organs. In that case, progestogen is administered in high doses. As an antagonist of estrogen, this hormone inhibits the growth of tumors that originate from the endometrium. If the therapy responds well, long-term therapy can be carried out for non-aggressive tumors. Endocrine therapy has significantly fewer side effects than chemotherapy. However, the effect of hormone therapy is slower than that of chemotherapy. Therefore, chemotherapy is first carried out for metastases that cause severe symptoms (e.g. shortness of breath). Particularly aggressive, malignant tumors usually do not respond to endocrine therapy.
Side effects of endocrine therapy
Hormone treatment can have undesirable side effects, such as weight gain and nausea being the most common. These side effects disappear after the therapy has ended and are overall less stressful than the ones observed with alternative treatment methods.
Making decisions about your care
Which therapy is carried out in individual cases depends in particular on the location and size of the tumor(s), your age and general health status. It is important that you talk to your doctor in detail about the findings and the chances of recovery (prognosis) of your illness. Get a detailed explanation of the various therapy options and find out the possibilities of participating in a clinical trial. Well-designed, well-conducted clinical trials are the only way to determine the actual effectiveness of a promising new drug or intervention that is being studied.
The tremendous advances in the treatment of childhood cancer are a direct result of their participation in clinical trials. As more than 60 percent of children with cancer participate in clinical trials, whereas only 3% of adults with cancer do. The success of cancer therapy in children relates directly to this participation rate. For this reason, we recommend, if possible, participation in a clinical trial.
Should participation in clinical trials be the NEW standard of care for women with endometrial cancer?