Endometrial cancer originates from cell growth in the uterus, a hollow, pear-shaped organ in the pelvic area where fetal development occurs. This cancer develops from the endometrium, the cell layer lining the uterus, and is often referred to as uterine cancer. While there are other less common forms of cancer that can occur in the uterus, such as uterine sarcoma, endometrial cancer is the most prevalent.
The uterine walls are muscular, which usually slows the spread of cancerous cells beyond the uterus. Often detected in its early stages, endometrial cancer is typically treatable with a simple hysterectomy. The lifetime risk of developing endometrial cancer is about 1%, with the highest occurrence post-menopause, in the 50s and 60s. Awareness of signs and symptoms is particularly crucial for menopausal women. Factors like high body mass index (BMI), diabetes, and hypertension can also heighten the risk of this cancer type.
The exact cause of endometrial cancer remains unclear. However, it’s understood that the transformation of normal cells into cancerous ones in the uterus lining, or endometrium, plays a central role. In endometrial cancer, the endometrial cells undergo DNA alterations. DNA in a cell dictates its functions, and these changes prompt the cells to proliferate rapidly and survive beyond their typical life cycle, contrary to normal cells. This abnormal growth leads to an accumulation of excess cells, potentially forming a mass known as a tumor. These cancerous cells have the capability to invade and deteriorate healthy tissues and, over time, may detach and spread to different body parts.
Using combined Hormone Replacement Therapy (HRT) can actually serve as a protective measure against endometrial cancer. Women undergoing HRT experience a 30% reduction in the risk of developing endometrial cancer. This is primarily due to the progesterone in combined HRT counteracting the effects of both supplemental and naturally occurring estrogen in the body, thereby lowering the risk of this type of cancer.
Post-menopausal bleeding is a common initial sign of endometrial cancer, though such bleeding can also stem from various non-cancerous reasons like polyps or vaginal atrophy.
– Experiencing pain in the pelvic region.
– While endometrial cancer predominantly occurs post-menopause, it can sometimes develop before menopause. Any abnormal bleeding, such as bleeding between periods or changes in the duration and heaviness of periods, should be promptly and thoroughly investigated. It’s important to note that only about 5-6 out of every 100 women experiencing post-menopausal bleeding may have endometrial cancer. Nevertheless, as it stands as a significant cause of this type of abnormal bleeding, it warrants serious consideration and investigation.
There are three ways that cancer spreads in the body.
Cancer has the ability to propagate through various means including tissue, the lymphatic system, and the bloodstream:
– Tissue: Cancer expands from its original site by infiltrating adjacent areas.
– Lymphatic System: The cancer cells enter the lymphatic system and move through the lymph vessels to different body parts.
– Bloodstream: Cancer cells can also invade the bloodstream, spreading through blood vessels to distant body parts.
Cancer may spread from where it began to other parts of the body.
Cancer’s spread from its initial location to other body regions is known as metastasis. The process involves cancer cells detaching from the primary tumor and traveling via the lymphatic system or bloodstream to form new tumors (metastatic tumors) elsewhere.
These metastatic tumors retain the characteristics of the original cancer type. For instance, if endometrial cancer spreads to the lungs, the cancer cells in the lungs are still endometrial cancer cells, making it metastatic endometrial cancer, rather than lung cancer.
A significant cause of cancer fatalities is this metastatic spread, where cancer moves from the original tumor site to other organs and tissues. This process illustrates how cancer cells migrate from their initial formation site to various body parts.
Endometrial cancer is classified into different stages based on its progression:
Stage I
– In Stage I, the cancer is confined to the uterus. It’s further categorized into:
– Stage IA: Cancer is present only in the endometrium or extends less than halfway through the myometrium (the uterus’s muscle layer).
– Stage IB: The cancer has infiltrated halfway or further into the myometrium.
Stage II
– Stage II endometrial cancer indicates that the cancer has moved into the cervical connective tissue but hasn’t spread outside the uterus.
Stage III
– Stage III signifies that the cancer has extended beyond the uterus and cervix but is still within the pelvic region. It includes:
– Stage IIIA: Cancer has reached the outer layer of the uterus and/or to structures like the fallopian tubes, ovaries, and uterine ligaments.
– Stage IIIB: The cancer has invaded the vagina and/or the parametrium (the tissue and fat surrounding the uterus and cervix).
– Stage IIIC: The cancer has spread to lymph nodes in the pelvis or around the aorta (the body’s largest artery).
Stage IV
– At Stage IV, the cancer has progressed beyond the pelvic area. This stage is divided into:
– Stage IVA: The cancer has infiltrated the bladder and/or bowel wall.
– Stage IVB: The cancer has extended to areas outside the pelvis, such as the abdomen and/or lymph nodes in the groin.
Endometrial cancer may be grouped for treatment as follows
Endometrial cancer risk levels vary depending on the tumor grade
Low-Risk Endometrial Cancer
– Tumors classified as Grades 1 and 2 are typically deemed low-risk. Generally, these tumors do not metastasize to other body parts.
High-Risk Endometrial Cancer
– Grade 3 tumors are categorized as high-risk due to their tendency to spread to other body regions. Specific subtypes like uterine papillary serous, clear cell, and carcinosarcoma fall under the grade 3 classification.
Post-treatment, there is a possibility of endometrial cancer recurrence. It may reappear in the uterus, pelvic area, abdominal lymph nodes, or other body parts.
Several factors can heighten the likelihood of developing endometrial cancer, such as:
– Utilizing estrogen-only hormone replacement therapy (HRT) post-menopause.
– Presence of metabolic syndrome.
– Being diagnosed with type 2 diabetes.
– Exposure to estrogen produced by the body, which can result from:
– Never having given birth.
– Early onset of menstruation.
– Entering menopause at an older age.
– Having polycystic ovarian syndrome (PCOS).
– A family history of endometrial cancer among immediate relatives like a mother, sister, or daughter.
– The presence of endometrial hyperplasia.
– Hormonal imbalances, particularly alterations in estrogen and progesterone levels, can influence the endometrium.
Conditions or diseases that raise estrogen levels without a corresponding increase in progesterone can elevate endometrial cancer risk. For example, obesity, diabetes, and irregular ovulation patterns (as seen in PCOS). Taking post-menopausal hormone therapy with estrogen but no progestin also raises this risk.
A less common cause is estrogen-producing ovarian tumors.
– Age is a factor; the risk of endometrial cancer grows with age, particularly post-menopause.
– Obesity can increase the risk due to changes in hormonal balances caused by excess body fat.
– Hormone therapy for breast cancer, such as tamoxifen, can heighten the risk of endometrial cancer. It’s important to discuss this risk with healthcare providers. Generally, the benefits of tamoxifen outweigh the risk of endometrial cancer.
– Genetic factors like Lynch syndrome, which increases the likelihood of colon and other cancers, including endometrial cancer. This genetic change is inheritable, so if there’s a family history of Lynch syndrome, it’s advisable to discuss the risk and necessary screenings with healthcare professionals.
Because endometrial cancer begins inside the uterus, it does not usually show up in the results of a Pap test. For this reason, a sample of endometrial tissue must be removed and checked under a microscope to look for cancer cells. One of the following procedures may be used:
• A pelvic examination is necessary to look for causes such as cervical polyp or atrophic changes in the vagina. A pelvic ultrasound scan is often the first investigation to assess the lining of the uterus and also look for other abnormalities. The endometrial lining is thin after menopause and usually measures below 4mm. An endoscopic examination of the uterine cavity and biopsy of the uterine lining is the definitive gold standard test to rule out or sometimes confirm the diagnosis.
• Endometrial biopsy: The removal of tissue from the endometrium (inner lining of the uterus) by inserting a thin, flexible tube through the cervix and into the uterus. The tube is used to gently scrape a small amount of tissue from the endometrium and then remove the tissue samples. A pathologist views the tissue under a microscope to look for cancer cells.
• Dilatation and curettage: A procedure to remove samples of tissue from the inner lining of the uterus. The cervix is dilated and a curette (spoon-shaped instrument) is inserted into the uterus to remove tissue. The tissue samples are checked under a microscope for signs of disease. This procedure is also called a D&C.
• Hysteroscopy: A procedure to look inside the uterus for abnormal areas. A hysteroscope is inserted through the vagina and cervix into the uterus. A hysteroscope is a thin, tube-like instrument with a light and a lens for viewing. It may also have a tool to remove tissue samples, which are checked under a microscope for signs of cancer.
Other tests and procedures used to diagnose endometrial cancer include the following:
• Physical exam and health history: An exam of the body to check general signs of health, including checking for signs of disease, such as lumps or anything else that seems unusual. A history of the patient’s health habits and past illnesses and treatments will also be taken.
• Transvaginal ultrasound exam: A procedure used to examine the vagina, uterus, fallopian tubes, and bladder. An ultrasound transducer (probe) is inserted into the vagina and used to bounce high-energy sound waves (ultrasound) off internal tissues or organs and make echoes. The echoes form a picture of body tissues called a sonogram. The doctor can identify tumors by looking at the sonogram.
Since endometrial cancer originates inside the uterus, it’s not typically detectable through a Pap test. Therefore, to check for cancer cells, a sample of endometrial tissue needs to be extracted and examined microscopically. The following methods are commonly employed for this purpose:
– A pelvic examination is crucial for identifying potential causes such as cervical polyps or vaginal atrophy. An initial step often involves a pelvic ultrasound scan to evaluate the uterine lining and identify any irregularities. Post-menopause, the endometrial lining usually measures less than 4mm in thickness. An endoscopic examination of the uterine cavity, coupled with a biopsy of the lining, is the definitive procedure for diagnosing or excluding endometrial cancer.
– Endometrial Biopsy: This involves collecting tissue from the endometrium (the uterus’s inner lining) using a slender, flexible instrument inserted through the cervix. This tool gently scrapes off a small tissue sample for analysis. A pathologist then examines the tissue under a microscope to detect cancer cells.
– Dilatation and Curettage (D&C): This procedure involves dilating the cervix and using a curette (a spoon-shaped tool) to extract tissue samples from the uterus’s inner lining. These samples are then microscopically examined for signs of cancer.
– Hysteroscopy: This technique allows for direct observation inside the uterus for any abnormalities. A hysteroscope, a slender instrument with a light and viewing lens, is passed through the vagina and cervix into the uterus. It can also be equipped to collect tissue samples for cancer examination.
Additional diagnostic methods for endometrial cancer include:
– A comprehensive physical examination and health history assessment, checking for overall health indicators and any unusual signs like lumps. This also includes a review of the patient’s lifestyle, previous health issues, and treatments.
– Transvaginal Ultrasound Exam: This procedure is conducted to inspect the vagina, uterus, fallopian tubes, and bladder. A transducer (probe) is inserted into the vagina, emitting high-energy sound waves to create echoes that form a sonogram or image, allowing doctors to detect tumors.
An MRI scan is essential to confirm that cancer cells are confined to the uterine cavity. This imaging technique can evaluate the extent of cell invasion into the uterine walls and assess the status of lymph nodes.
Endometrial cancer treatment encompasses five primary methods:
Surgery
– The most prevalent treatment for endometrial cancer involves surgical removal of the cancer. The surgeries employed include:
– Total hysterectomy: This involves removing the uterus and cervix. It can be performed as a vaginal hysterectomy (through the vagina), a total abdominal hysterectomy (via a large abdominal incision), or a total laparoscopic hysterectomy (using a small abdominal incision and a laparoscope).
– Bilateral salpingo-oophorectomy: Involves removing both ovaries and fallopian tubes.
– Radical hysterectomy: Removes the uterus, cervix, and a part of the vagina. This surgery may also entail the removal of ovaries, fallopian tubes, or nearby lymph nodes.
– Lymph node dissection: Involves the removal of lymph nodes from the pelvis to check for cancer signs, also known as lymphadenectomy.
Post-surgery, some patients might receive radiation or hormone therapy to eliminate any remaining cancer cells, a process known as adjuvant therapy.
Radiation Therapy
– This therapy uses high-energy X-rays or other radiation types to destroy or halt the growth of cancer cells. It includes:
– External radiation therapy, directing radiation from a machine outside the body.
– Internal radiation therapy, placing radioactive material inside or near the cancer.
The treatment method depends on the cancer’s type and stage and can also be used palliatively.
Chemotherapy
– Chemotherapy employs drugs to stop cancer cells from multiplying, either by killing the cells or inhibiting their division. It can be systemic (throughout the body) or regional (directed to specific areas).
Hormone Therapy
– This treatment removes or blocks hormones to prevent cancer cell growth. If cancer cells have hormone receptors, drugs, surgery, or radiation therapy may be used to reduce or inhibit hormone production.
Targeted Therapy
– Targeted therapy uses substances to specifically attack cancer cells with minimal harm to normal cells. It includes:
– Monoclonal antibody therapy, where lab-made antibodies target cancer cells, sometimes delivering drugs or toxins directly to them. Bevacizumab is one such drug used for advanced stages of endometrial cancer.
– mTOR inhibitor therapy, blocking the mTOR protein to prevent cancer cell growth and new blood vessel formation. Everolimus and ridaforolimus are examples used for advanced stages.
– Signal transduction inhibitor therapy, blocking cell signals to kill cancer cells, with Metformin being researched for advanced stages.
Since the majority of endometrial cancer cases are identified in their initial stages, the outlook for patients is often very positive. Hence, promptly consulting a doctor if you experience any unusual bleeding symptoms is crucial.
It’s advisable to schedule a Well- examination at the age of 50, which can be organized through your GP or our services. To lower your chances of developing endometrial cancer, consider the following:
– Discuss the implications of post-menopausal hormone therapy with your healthcare provider. If you’re contemplating hormone replacement therapy to manage menopause symptoms, inquire about its risks and benefits. For those who haven’t undergone a hysterectomy, estrogen replacement alone might heighten the risk of endometrial cancer. Combining estrogen with progestin in hormone therapy can mitigate this risk. However, hormone therapy has other risks, so it’s important to balance these against the benefits with your healthcare team.
– Evaluate the option of using birth control pills. Long-term use (at least a year) of oral contraceptives can decrease the risk of endometrial cancer, and this protective effect may persist for several years after discontinuing their use. While birth control pills offer benefits, they also come with side effects, so it’s crucial to discuss both aspects with your healthcare team.
– Aim for a healthy weight. Since obesity is a known risk factor for endometrial cancer, strive for and maintain a healthy weight. If weight loss is needed, consider increasing your physical activity and reducing daily calorie intake.