Uterine cancer – incubating the wrong cells

 Dr Mia Hugo educates us on the risk of developing uterine cancer and the treatment options that are available.

You can listen to this article below, or by using your favourite podcast player at pod.link/oncologybuddies

What is uterine cancer?

It’s a general term that describes cancer in your uterus, with two main subtypes being endometrial cancer and uterine sarcoma. Endometrial cancer develops in the lining of the uterus (endometrium) and accounts for around 95% of all cases. The other 5% of cases are rare, more aggressive and comprises uterine sarcoma which is a cancer that develops in themuscle wall of the uterus (myometrium).¹

Raising the risk

Uterine cancer is the fourth most common cancer diagnosed in females in SA (excluding non-melanoma skin cancer), and the 11^th cause of cancer-related deaths in females in SA.²  

These factors may raise the risk of developing uterine cancer:³

• Age: The average age at diagnosis is 60, very uncommon under age 45.
• Obesity: Fatty tissue if you’re overweight produces additional oestrogen. This risk increases with a rise in body mass index (BMI). About 70% of cases are linked to obesity.
• Ethnicity: White women are more likely to develop it, but black women have a higher chance of being diagnosed with advanced uterine cancer.
• Genetics: Uterine cancer may run in families where colon cancer is hereditary; families with Lynch syndrome, also called hereditary non-polyposis colorectal cancer (HNPCC), have a higher risk. About 2-5% of women with endometrial cancer have Lynch syndrome. If you’ve had breast-, colon- or ovarian cancer, you may also have an increased risk.
• Type 2 diabetes: You may have an increased risk if you have Type 2 diabetes, which is often associated with obesity. 
• Tamoxifen: If you’re taking tamoxifen to reduce the risk of breast cancer recurrence, you have an increased risk. The benefits of tamoxifen usually outweigh the risk of developing uterine cancer, but it’s vital that women taking tamoxifen have a yearly gynaecological check-up with an ultrasound, measuring the endometrial thickness to screen for endometrial cancer.
• Radiation: Previous radiation for another cancer in the pelvic area may have an increased risk.
• Diet/nutrition: If you eat foods high in animal fat, you may have an increased risk.
• Oestrogen: Extended exposure to oestrogen and/or   an imbalance of oestrogen. 

For example: early age onset of menstrual cycle or late menopause; hormone replacement therapy (HRT) after menopause, especially taking oestrogen alone (risk is lower if taken with progesterone); and never having been pregnant.³

Nipping it in the bud 

Thankfully, there are ways to reduce the risk:

• Screening: Regular ultrasound screening of the uterus in women with a genetic risk factor or taking tamoxifen for breast cancer prevention. 
• Reducing overgrowth of the uterine lining: Birth control pills have a combination of oestrogen and progesterone that produce a monthly menstrual period or using a progestin-secreting intrauterine device (IUD), which is a form of birth control.
• HRT: Considering the risks and benefits of HRT, especially oestrogen alone.
• Maintaining a healthy weight: Ideally a body mass index (BMI) less than 25.
• Diabetic management: Regularly monitoring blood glucose levels and careful management of diabetes can help lower the risk.³

How to spot the trouble brewing

Spotting/abnormal vaginal bleeding is the most common early symptom of endometrial cancer. This includes vaginal bleeding after menopause; spotting between menstrual periods, or periods that are irregular, heavy or longer than normal. About 1 to 14% of women with vaginal bleeding after menopause have endometrial cancer. Postmenopausal women who have vaginal bleeding should see a doctor promptly, even if there is only a small amount of blood or pink, red, or brown staining.

Women with sarcoma usually also have abnormal vaginal bleeding and it may cause pain or pressure in the pelvis or abdomen.⁴

Diagnosis

Uterine cancer is usually suspected on an ultrasound in response to the complaint of abnormal vaginal bleeding. Most often a transvaginal ultrasound done by the gynaecologist that shows a thickened endometrial lining or an abnormal muscle layer. The diagnosis is confirmed by biopsy which may be done in the rooms or by dilation and curettage (D&C) in theatre. If confirmed then further tests may be performed, such as blood tests, CT or MRI, to determine if it has spread beyond the uterus and to assess your fitness for surgery. 

Better out than in

Hysterectomy (surgical removal of uterus) is the mainstay of treatment for uterine cancer. Treatment of endometrial cancer that has spread to the cervix, vagina, parametria or lymph nodes requires more radical surgery and then depending on the surgery findings, may be followed by radiation, sometimes with chemotherapy, post-operatively.  Uterine sarcoma is more aggressive and treatment usually entails surgery followed by chemotherapy and/or radiation.⁴

For more advanced cancer that can’t be removed surgically, for women not medically fit for surgery or cases with distant metastatic spread, radiation, chemotherapy and/or hormone therapy may all be treatment options.⁴ 

References:

1. Cleveland Clinic. [Online] [Cited: 25 June 2023.] https://my.clevelandclinic.org/health/diseases/16409-uterine-cancer.
2. Stats SA. Cancer in South Africa 2008-2019. Stats SA. [Online] 23 March 2023. [Cited: 25 June 2023.] https://www.statssa.gov.za/publications/03-08-00/03-08-002023.pdf.
3. ASCO. Cancer.Net. [Online] 12 2021. [Cited: 25 June 2023.] https://www.cancer.net/cancer-types/uterine-cancer/risk-factors-and-prevention.
4. Pedro T. Ramirez, Gloria Salvo. MSD Manual. [Online] Sep 2022. [Cited: 25 June 2023.] https://www.msdmanuals.com/home/women-s-health-issues/cancers-of-the-female-reproductive-system/cancer-of-the-uterus.

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