Cancer of the lining of the womb, also known as endometrial cancer, is the most common gynaecological cancer in New Zealand with around 380 new cases per year.
Fortunately, the disease can be detected early because of abnormal vaginal bleeding or discharge, and can be completely cured in about 80% of the cases. Factors that increase the risk of developing womb cancer include obesity, having a late menopause, polycystic ovarian syndrome and not having any children (type1 endometrial cancer).
There can be some more aggressive forms of endometrial cancer (serous, clear cell) that we as yet do not know the cause for (type 2 endometrial cancer). In addition, genetic predisposition such as Lynch syndrome (also known as hereditary non-polyposis colorectal cancer) can significantly increase risk of developing this cancer (type 3). In such cases, it may be advisable to undergo a prophylactic hysterectomy once the patient has completed her family.
Patients with womb cancer usually present with abnormal vaginal bleeding such as heavy or irregular periods in younger pre-menopausal women or, more commonly, post-menopausal bleeding. However, having post-menopausal bleeding does not necessarily mean that a cancer is present. Only 10% to 20% of those with post-menopausal bleeding will actually have a cancer as there are many other reasons for the bleeding.
Diagnosis of is usually confirmed by an endometrial biopsy, which is a sample of the tissue lining the uterus. This is a simple procedure that can normally be done in our rooms. The tissue is then sent to the pathologist to obtain a diagnosis.
In some cases, additional investigation might be necessary – either a hysteroscopy (where a tiny camera is inserted through the cervix or neck of the womb to look inside the womb) and / or a curettage (where the uterine lining is more extensively sampled using an instrument called a curette, and the tissue tested by a pathologist). These will be done as a day surgery case under a short general anaesthesia.
The results of these investigations will be discussed at the Multidisciplinary Team Meeting.
Depending on the results, further imaging with a CT scan or MRI (abdomen and pelvis) and blood tests may be organized in order to obtain information on whether the cancer has spread and, if so, how far it has spread from the womb.
All treatment decisions will be individualized
Treatment and Surgery
The usual treatment for endometrial cancer is a form of surgery called ‘total hysterectomy’ where the entire uterus is removed. Both ovaries and any other visible signs of tumour in the surrounding tissues will be removed.
Further information can found under ‘Your Surgery’ (provide link once content is defined)
Pelvic lymph node removal / Sentinel lymph node mapping
One of the first places that endometrial cancers spreads to are the pelvic lymph nodes, but removing them can lead to increased complications. However, removing these lymph nodes and assessing them helps determine whether it is necessary to have additional treatment such as chemotherapy or radiation therapy after the surgery. Therefore, the decision on whether or not to remove them will only be made after evaluation of all factors (at Multidisciplinary meeting).
Sentinel lymph node (SLN) mapping may be used in early-stage endometrial cancer if imaging tests don’t clearly show signs that cancer has spread to the lymph nodes in your pelvis. To do this, a green dye is injected into the area with the cancer, near the cervix. The surgeon then looks for the lymph nodes that turn green (from the dye). These lymph nodes are the ones that the cancer would first drain into (the sentinel nodes). They’re removed and tested to see if there are cancer cells in them. This procedure is usually done at the same time as surgery to remove the uterus (hysterectomy). Your doctor will talk with you about whether SLN mapping is an option for you.
Chemotherapy and / or Radiation Therapy
In some cases, further treatment with other modalities is required after surgery. The need for chemotherapy and radiation therapy will be based on the decision made following discussions between our expert panel at the Auckland Multidisciplinary Meeting.
Radiation therapy is usually used to treat endometrial cancers in more advanced or “high-risk” cases. The treatment is delivered into the vagina using special applicators, which is less invasive and has fewer side effects. In some cases, external beam radiation may be required (like having an Xray).
Chemotherapy is usually recommended only for certain types of endometrial cancers or if the cancer has spread.
Note: Sometimes there are research trials comparing the effectiveness of different treatments in the fight against gynaecological cancers. Patient enrolment in these trials is very valuable and plays a key role in improving our understanding of cancer and its response to various treatments. You may be invited to participate.
Dr. Tan will discuss the best follow-up regime that is tailored to suit each individual patient. For patients living outside Auckland, arrangements can be made for on-going follow-up with your GP or Gynaecologist.
At follow up, expect a pelvic examination, but other tests will only be done if required. After five years, the risk of a recurrence becomes very low. Endometrial cancer is completely cured in the majority of cases; however, it is normal for patients to have regular follow-ups after treatment. It is particularly important to be alert of any new symptoms rather than just relying on follow-up visits. If the cancer recurs it usually does so in the first 2 years and almost always presents with symptoms (e.g. vaginal bleeding), so it is usually detected early which allows for fast, effective treatment of the recurrence.
New Zealand Gynaecological cancer follow-up guidelines.
Hormone Replacement Therapy (HRT)
Patients may be worried about the use of HRT after endometrial cancer as the endometrial cells normally grow in response to estrogen and similar hormones. However, there has been no evidence from research to show that HRT increases the chance of this cancer recurring.
If HRT is indicated because of intolerable post-menopausal side effects (e.g. hot flushes), then HRT can be safely used without concern with the exception of patients who are at high risk of developing breast cancer or who have a history of breast cancer. There are also certain types of rare uterine cancers like endometrial stromal sarcomas where HRT should not be prescribed. A referral to an endocrinologist who specializes in dealing with HRT in cancer can be arranged.