Revised November 2011

This information should not be used to self-diagnose, or be used in place of a qualified physician’s care.

• Cancers of the uterus are treated by members of the BC Cancer Agency’s Gynecology Tumour Group.
• For healthcare professional information on treating these cancers, please see our Cancer Management Guidelines.
• For newly diagnosed patients, we offer Taking it Step by Step: a guide for women diagnosed with gynecological cancer.  This BC guide was created by survivors and health care professionals of the BC Cancer Agency.  It covers all aspects of the patient journey.
• Cancer of the uterus is also called uterine cancer.
• Often the terms uterine cancer and endometrial cancer are used interchangeably because cancer that starts in the endometrium (lining of the uterus) occurs in the majority of cases. Cancers that start in the muscle or connective tissue in or near the uterus are much less common and are known as uterine sarcomas.
• The uterus or "womb" is part of the female reproductive system. It is the part of the body in which a baby grows and develops during pregnancy.
• The uterus is a hollow organ the size and shape of an upside-down pear. It lies in the pelvis between the bladder and rectum.
• The upper portion of the uterus is called the fundus.
• The central portion of the uterus is called the body or corpus.
• The lower or neck portion of the uterus is called the uterine cervix. It provides the connection between the corpus or body of the uterus and the vagina.
• The body of the uterus is made up of two layers of tissue: 
• The myometrium is the muscular, outer layer. It is needed to push a baby out during birth.
• The endometrium is the inner layer or lining. During a woman’s menstrual cycle, hormones cause the endometrium to change. Ovaries produce estrogens which cause the endometrium to thicken so that it could nourish an embryo if pregnancy occurs. If there is no pregnancy, a lower amount of estrogen is produced and more of the hormone progesterone is produced. This causes the thick, blood-rich lining of the endometrium to shed each month during a woman’s menstrual period.
• Cancers of the uterus are the most common cause of cancers of the female reproductive system.

What causes it and who gets it?
Listed below are some of the known risk factors for this cancer.  Not all of the risk factors below may cause this cancer, but they may be contributing factors.

• The longer the women’s body is exposed to the hormone estrogen, the greater her risk of developing cancer of the uterus.
• Estrogen is produced during a woman’s menstrual cycle.
• Women who have had more menstrual cycles are at higher risk for getting cancer of the uterus. For example, women who began to menstruate at a young age or who have continued periods after the age of 50.
• Pregnancy interrupts the menstrual cycle so that women who have never had children are more likely to get cancer of the uterus.
• Women who do not ovulate during menstrual cycles are at higher risk for getting cancer of the uterus.
• Cancer of the uterus usually occurs in post-menopausal women between the ages of 45 - 70.
• Estrogen therapy is used to control the symptoms of menopause. When estrogen is combined with progesterone the incidence of cancer of the uterus is lowered.
• Women who take birth control pills which contain a combination of estrogen and progesterone have a decreased risk of developing endometrial cancer.
• Obese women (especially those who have hypertension and diabetes) are at higher risk because some estrogen is produced in fatty tissue.
• White women are affected more commonly than black.
• Higher income groups are affected more often than low income groups.
• Statistics
• BC
• Canada

Can I help to prevent it?

• Do not take estrogen alone. The combination of estrogen and progesterone therapy can help prevent cancer of the uterus.
• The use of birth control pills lowers a women’s chance of developing cancer of the uterus.
• Maintain a healthy body weight because fatty tissue produces estrogen.

Screening for this cancer

• There is no simple, reliable, test for the detection of cancer of the uterus. 
• Although a routine Pap test occasionally detects patients with this disease, it will miss many of them because the pap smear scrape does not reach the uterine cavity. 
• In post-menopausal women who have not had any previous abnormality of the uterine cervix, the pap smear should include the microscopic examination of cells from the lining of the cervical canal or from vaginal wall secretions.
• Promptly talk to your doctor about abnormal vaginal bleeding (particularly post-menopausal bleeding and abnormal bleeding after the age of 40).

Signs and Symptoms

• The most common symptoms are:
• Unusual vaginal bleeding such as :
• Bleeding between periods
• Bleeding with sexual intercourse
• Heavy bleeding
• Irregular or heavy bleeding during menopause or any bleeding after menopause
• Unusual vaginal discharge
• Difficult or painful urination
• Pain in the abdomen or pelvic area
• Back pain
• Precancerous conditions that should be watched carefully are:
• Atypical hyperplasia (an overgrowth of the cells in the lining of the uterus)
• Polyps (small growths of endometrial tissue that are attached to the inner lining of the uterus. They may regress at any stage.)
• Endometriosis is a benign condition in which tissue resembling the uterine lining occurs inappropriately in various locations in the pelvic area.
• Attention to early symptoms generally leads to an early diagnosis with a successful treatment outcome.

Diagnosis
Below is a list of some or all of the tests used to diagnose this type of cancer. We have more information on other diagnostic tests for cancer. 

• Investigations of abnormal vaginal bleeding may include :
• Physical examination of the pelvic area
• Endometrial biopsy – removal of a small piece of tissue from the uterine lining or endometrium to check for signs of cancer
• D and C (dilation and curettage) is a procedure used to collect tissue samples from the uterine lining or endometrium. In this procedure, the opening of the cervix is enlarged (dilated) and a special instrument is used to sample the tissue on the inside of the uterus
• A hysterectomy (the surgical removal of the uterus) and surgical staging (removal of the ovariea, fallopian tubes, and lymph nodes that drain the uterus) to check if there is any spread of the cancer

Types & Stages
Staging describes the extent of a cancer. The TNM classification system is used as the standard around the world.  In general a lower number in each category means a better prognosis. The stage of the cancer is used to plan the treatment.

• T describes the site and size of the main tumour (primary);
• N describes involvement of lymph nodes;
• M relates to whether the cancer has spread (presence or absence of distant metastases).

Types

Endometrial cancer (adenocarcinoma or carcinoma)

• This cancer develops in the glands of the endometrium.

Subtypes

Endometrioid endometrial cancer

• Endometrioid is the most common subtype of endometrial cancer. It occurs in 70-80% of cases.
• It is confined to the uterus in approximately 85 % of cases (i.e.,stage I with no distant spread).
• Following surgical staging the majority of patients need no additional therapy.
• The cure rate is very high.

Serous and clear cell endometrial cancers

• Serous and clear cell endometrial cancers are rare, more aggressive subtypes of endometrial cancer.
• They usually require additional therapy following surgical staging

Adenocarcinomas

• Adenocarcinoma is a common sub-type of endometrial cancer.
• It is usually discovered in early stages.
• If the cancer is found in stage 1, the cure rate is very high.

Uterine Sarcomas

• Sarcomas are tumours that start in the muscle or connective tissue that support the uterus.
• This is an uncommon type of uterine cancer.
• Sarcomas can be fast growing. Patterns of spread depend on the subtype.

Subtypes of uterine sarcomas include:

Leiomyosarcoma

• Leiomyosarcoma accounts for about one third of all uterine sarcomas.
• Leiomyosarcomas develop in the myometrium or muscular wall of the uterus.
• Spread can be distant (for example, to the lungs).

Endometrial stromal sarcoma (ESS)

• This is a rare subtype which can be low or high grade.
• Low grade ESS often does not require any additional therapy or can be managed with hormones only.

Malignant Mixed Mullerian Tumour (MMMT or carcinosarcoma)

• Contain both glandular cells from the endometrial lining (carcinoma component) and appear to contain muscle-derived cells (sarcoma component). 
• Usually treated as an aggressive form of endometrial carcinoma, using the same surgical, chemotherapy and radiation guidelines.

Trophoblastic Tumours

• Trophoblastic tumours are uncommon malignant tumours of the tissues that become the placenta.
• The tumours may start during pregnancy, causing a miscarriage, or may start after delivery.
• The tumours can grow very quickly and may spread to the lungs.
• There is a high incidence in China, Mexico and the Philippines.
• Protein deficiency, malnutrition and multiple pregnancies are risk factors.
• These cancers are usually curable.
• Subtypes: Hydatidiform mole and choriocarcinoma

Staging

• Cancer that is discovered before it has spread outside the uterus has the greatest chance of cure.

Surgery

• For stage I cancers, potentially curative surgery removes the uterus and cervix. The procedure is called total abdominal hysterectomy.
• Bilateral salpingo oophorectomy (BSO) is surgery in which the uterus, cervix, ovaries and fallopian tubes are removed.

Radiation Therapy

• Radiation can be used pre-operatively to shrink tumours and make them more suitable for surgery.
• Radiation can also be used post-operatively to try to reduce the risk of recurrence in patients with very advanced tumours.

Chemotherapy

• Chemotherapy may be recommended for advanced cancer or for certain rare subtypes (papillary serious, small cell) or for cancers that have spread to distant sites.

Hormone Therapy

• Hormone therapy may be given when surgery is not feasible.
• It may be used in advanced or recurrent cancer.

Followup after Treatment

• Guidelines for followup after treatment has ended have been developed by the BC Cancer Agency and are listed on our website. 
• You will be returned to the care of your family doctor or your specialist for regular followup.
• Followup testing is based on your type of cancer and your individual circumstances.

Coping with Cancer

• BC Cancer Agency staff can help with quality of life issues for those living with or affected by cancer. This includes the physical, emotional, psychological and practical aspects of care. Each cancer experience is different, but in one way or another, many cancer patients share the same needs.
• The effects of cancer and its treatment can present unique challenges: from practical concerns like money and housing, to emotional concerns like anxiety and grief. If you need support with the practical and emotional impacts of cancer, or in managing symptoms and side effects you can use the information in Coping with Cancer to connect to these resources.

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Recommended websites 
The following websites have been selected and evaluated by the BC Cancer Agency.

1. NCI  http://www.cancer.gov/
2. CCS http://www.cancer.ca/ 
3. ASCO http://www.cancer.net/
4. BC Cancer Agency Recommended Links

Can I help with research at BCCA?
BCCA cancer patients are very helpful when it comes to the fight against cancer.  Here are a few ways that you can help.

• Clinical Trials – join our treatment-based research.  Ask your oncologist if you qualify for a clinical trial.
• What are the pros and cons of joining a clinical trial?
• Tumour Tissue Bank – support our research by donating some of your cancer tissue.
• BC Cancer Foundation – support our research with a donation of money.

This information has been reviewed and approved by a member of the Gynecology Tumour Group.