September 11, 2013 | by Roberta Nichols
Unlike ovarian cancer, dubbed the "silent killer" because it can stealthily grow for months, endometrial cancer loudly announces its presence through hard-to-miss clues: vaginal bleeding or discharges in between periods and, particularly after menopause, difficult or painful urination as well as pain during intercourse.
Women experiencing these symptoms should immediately consult a gynecologist, said Robert Morgan, M.D., co-director of the Gynecological Oncology/Peritoneal Malignancy Program at City of Hope.
And if the doctor suggests "watchful waiting" instead of immediate treatment?
"Get a second opinion," advised Morgan.
"Endometrial [or uterine] cancer is the most common gynecologic cancer, but it’s very treatable if it’s diagnosed in time," said Ernest Han, M.D., Ph.D., an assistant professor and surgeon in the Division of Gynecologic Oncology at City of Hope.
Endometrial cancer develops in the endometrium, the lining of the uterus. About 49,560 new cases will be diagnosed this year in the U.S., and an estimated 8,190 women will die from the disease. (These American Cancer Society estimates include the decidedly more rare uterine sarcomas, which account for only about 2 percent of cases.)
Most often affecting women over 50, endometrial cancer has been linked to a hormonal imbalance triggered by a number of factors, including obesity. Fat cells produce excess estrogen but, after menopause, women no longer produce extra progesterone to balance out this disparity.
This imbalance also is traced to "unopposed estrogen exposure," such as Premarin given sometimes for hot flashes or menopausal symptoms, Morgan said.
"The primary familial risk factor for uterine cancer is due to the syndrome denoted HNPCC [hereditary nonpolyposis colon cancer], which also predisposes to other cancers including ovarian, gastric and small bowel, pancreatic, urothelial or brain cancers," he continued.
Risks for developing endometrial cancer also rise if a woman has polycystic ovary syndrome, diabetes and/or hypertension, takes tamoxifen (for breast cancer treatment), began her period before she was 12 (or menopause after 55), and if she never became pregnant, had a full-term pregnancy or breast-fed.
Following diagnosis, surgeons usually perform a hysterectomy, in which they remove the uterus, cervix, ovaries and fallopian tubes (salpingo-oophorectomy). They generally also remove lymph nodes in the pelvis and abdomen to ensure the disease has not spread.
Just as breast cancer patients can develop lymphedema (ongoing swelling in their arms following surgical removal of lymph nodes under their arms), endometrial cancer patients also can develop this condition when their pelvic lymph nodes are removed. To counteract these side effects, including swelling in patients’ legs and, occasionally, nerve damage, some surgeons are beginning to perform sentinel lymph node biopsies (in the nodes closest to the primary tumor site).
Improvements in treatment
Gynecologic oncologists are becoming more adept at staging gynecologic cancers thanks to the less-invasive da Vinci robot now used in some surgeries. Robot surgery patients generally have less pain and blood loss, shorter hospital stays, and faster recoveries than traditional surgery patients, doctors say.
Further advances to the robotic technology include the creation of a special attachment called a "firefly" that can help surgeons detect a fluorescent dye injected into patients. This can assist in identifying sentinel lymph nodes, helping to stage the cancer and determine whether the disease has spread.
"Removing only the affected nodes would potentially reduce lymphedema and other complications," Han said, noting that more studies are required before determining whether this evolving technology should become the standard of care.
In an important new quality-of-life study, City of Hope recently opened a clinical trial documenting the experiences of women who are undergoing lymph node dissections for vulvar, uterine and cervical cancer. Part of a national cooperative study by the Gynecologic Oncology Group, the trial is being carried out at City of Hope by principal investigator Thanh Dellinger, M.D., assistant professor in the Division of Gynecologic Oncology at City of Hope.
Patients will be examined before and after surgery to assess the frequency and severity of swelling in their legs. "The results eventually will inform oncologists on the incidence and natural history of postoperative lymphedema, and possible future treatments in gynecological cancer patients," said Dellinger.
As for diagnosing the illness, however, reliable screening tests are still lacking.
Han is intrigued by a pilot study of the PapGene test developed by Johns Hopkins Kimmel Cancer Center researchers and documented in Science Translational Medicine (Jan. 9, 2013). In that study, researchers evaluated DNA from cervical fluid in Pap tests to detect endometrial and ovarian cancers. The test accurately detected 100 percent (24 of 24) of endometrial cancers and 41 percent (9 of 22) of ovarian cancers, but will need to be studied in a larger group of patients before it is adopted, said Han.
As scientists continue searching for the definitive diagnostic test, "women have to be attuned to their bodies and pay attention to early symptoms – such as bleeding, discharge and pelvic pain," Han said. "If they had their last period over one year ago and now they’re having another period – most women know something isn’t right, and will call their doctor and get a biopsy and workup.
"Even if you’re not scheduled for a pap test doesn’t mean you shouldn’t see your gynecologist [at least once a year] to make sure things are normal," Han said.
"My fear is that women will say, ‘I don’t need a Pap smear for three years’ and equate that with ‘I don’t need to see a gynecologist for three years’ – and in the meantime – something develops."