Cancer of the womb

WHAT IS CANCER?

The organs and tissues of the body are made up of tiny building blocks called cells.  Cancer is a disease of these cells.  It is important to realise that cancer is not a single disease with a single cause and a single type of treatment.  There are more than 200 different kinds of cancer, each with it’s own name and treatment.

Although cells in different parts of the body may look and work differently, most repair and reproduce themselves I the same way.  Normally, this division of cells takes place in an orderly and controlled manner.  If for some reason the process gets out of control, the cells will continue to divide, developing a lump which is called a tumour.  Tumours can either be benign or malignant.  Doctors can tell whether a tumour is begnin or malignant by examining a small sample of cells under a microscope.  This is called a biopsy.

In a benign tumour the cells do not spread to other parts of the body and so are not cancerous.  However, they may continue to grow at the original site, and may cause a problem by pressing on surrounding organs.

A malignant tumour consists of cancer cells that have the ability to spread beyond the original site.  If the tumour is left untreated, it may invade and destroy surrounding tissue.  Sometimes cells break away from the original (primary) cancer and spread to other organs in the body through the bloodstream or lymphatic system.

The lymphatic system is part of the immune system, the body’s natural defence against infection and disease.  It is a complex system made up of organs such as bone marrow, the thymus and the spleen, and the lymph nodes throughout the body that are connected by a network of tiny lymphatic vessels.  When the cancer cells reach a new site they may go on dividing and form a new tumour, often refereed to as a secondary or a metastasis.

THE WOMB

The womb, or uterus, is a muscular, pear shaped organ at the top of the vagina.  The lining of the womb is called the endomertruim and is shed each month, giving rise to bleeding called a period.  These periods stop temporarily during pregnancy and will normally continue until a woman has the menopause.

If cancer starts in the womb lining it is called endometrial cancer.  Approximately 5,000 women in the UK develop endometrial cancer each year.

Close to the womb are collections of lymph nodes.  These are small glands, about the size of a bean.  The lymph nodes are part of the lymphatic system.  This is a network of glands throughout the body, linked by fine ducts through which a colourless fluid, the lymph, passes and acts as a defence against disease.

CAUSES OF CANCER OF THE WOMB

The exact cause of cancer of the womb is not yet known.

Women who are still having periods and who take the contraceptive pill are believed to have a lower risk of developing cancer of the womb.  Women who have had their menopause and who take oestrogen – only HRT (hormone replacement therapy) for a long time may have a slightly increased risk of developing the disease.  Women who have not had their womb removed and are taking HRT should make sure that they are taking a combination of the hormones oestrogen and progesterone, rather than oestrogen on its own.  Taking combined oestrogen and progesterone HRT for up to five years causes no increase in the risk of developing cancer of the womb, but if it is taken for more than five years the risk may slightly be increased.

The use of Tamoxifen (a hormonal therapy sometimes taken to treat breast cancer) over a long period of time also slightly increases the risk of developing cancer of the womb.  However, this is so slight that the benefits of taking Tamoxifen to treat breast cancer are considered to outweigh the risk.

Cancer of the womb most commonly occurs in between the ages of 50 and 64.  It rarely affects women under 50.

Womb cancer, like other cancers, is not infectious and cannot be passed onto other people.  Cancer of the womb is not caused by genetic changes that can be passed down through families, so it is not inherited.

WHAT ARE THE SYMTOMS?

The most usual early symptom of cancer of the womb is abnormal vaginal bleeding.  This may occur as bleeding between periods, or heavier periods than normal (in pre-menopausal women), or bleeding which starts after menopause (in post – menopausal women).  Abnormal vaginal bleeding may due to many causes other than cancer, but you should always see you GP about it.

Some women notice pain in the lower abdomen (tummy) or pain or discomfort during sexual intercourse.

HOW IS IT DIAGNOSED

Usually you begin by seeing your GP who will examine you and arrange for any tests or x- rays that may be necessary.  Your GP may need to refer you to hospital for these tests and for specialist gynaecological advice and treatment.

HYSTEROSCOPY

A tiny telescope may be used to look inside the uterus.  This helps the gynaecologist to take accurate tissue samples.  After a hysteroscopy most women have period type pains for a day or so, which can be controlled by painkillers.

BIOPSY

A small sample of cells may be taken from the lining of the uterus by a gynaecologist.  This will be carried out in the outpatients department and does not need an anaesthetic.  A fine tube is passed into the uterus, and gentle suction is used to remove a sample of the lining.  The sample is sent to the laboratory for examination under microscope.

DILATION AND CURETTAGE (D&C)

You may have the above procedure, which is carried out under general anaesthetic.  The cervix is stretched so that the gynaecologist can insert an instrument to remove samples of tissue from the inner lining of the uterus.  These samples can be examined under a microscope.  After a D&C most women have period – type pains for a day or so, which can be controlled by painkillers.

VAGINAL ULTRASOUND

In this test, sound waves are used to make up a picture of the inside of the uterus.  It will be done in the hospital-scanning department.

A small device is put into your vagina.  The device produces sound waves, which are then converted into a picture by a computer.  This may be uncomfortable but should not be painful.

FURTHER TEST

If the test show that you have cancer of the womb, your gynaecologist or surgeon will probably want to do some further test to see if there is a spread of the disease.  This helps the doctor to decide on the best type of treatment for you.  The tests may include any of those listed below.

BLOOD TESTS

Samples of your blood will be taken to check your general health, the number of cells in your blood (blood count) and to see how well your kidneys are working.

CHEST X-RAYS

This is to check your heart and lungs are healthy.

CT (COMPUTERISED TOMGRAPHY) SCAN

A CT scanner takes a series of x-rays which builds up a three dimensional picture of the inside of the body.  The scan is painless but takes longer than an x-ray (from 10-30 mins).  It may be used to identify the exact site of the tumour, or to check for any spread of the disease.  Most people who have a CT scan are given a drink or injection to allow the areas to be seen more clearly.  For a few minutes this may make you feel hot all over.  If you are allergic to iodine or have asthma, it is important to tell your doctor and the person doing the tests before you have the injection or drink.

It is still usually possible to have the injection, provided you receive steroid treatment on the day before and the day of the injection.

You will probably go home as soon as the scan is over.

MRI (MAGNETIC RESONANCE IMAGING) SCAN

This test is similar to a CT scan but uses magnetism instead of x-rays to build up a cross sectional picture of your body.  Some people are given an injection of dye into a vein in the arm to improve the image.

During the test you will be asked to lie very still on a couch inside a long chamber for up to an hour.  This can be unpleasant if you do not like enclosed spaces.  If so it may help to mention this to the radiographer.  The MRI scanning process is also very noisy, but you will be given earplugs or headphones to wear and many hospitals will play music for you during the scan.  You can take in your favourite tape or CD, you can usually take someone with you in the room to keep you company.

The chamber is a very powerful magnet, so before entering the room you have to remove any metal items you may be wearing.  People who have heart monitors, heart pace makers or certain types of surgical clips cannot have MRI scans because of the magnetic fields.

It may take several days for the results of the test to be ready, this may be an anxious time for you, and it may help if you have a friend or close family member that you can talk to.

STAGES OF GRADING CANCER OF THE WOMB

The stage of the cancer is a term used to describe the size and whether the cancer spread beyond its original site.  Knowing the extent of the cancer and the grade helps your specialist to decide on the most appropriate treatment for you.

The stages of endometrial cancer are:

STAGE 1 The tumour is contained within the endometrium (womb lining) or the muscle layers of the womb.

STAGE 2 The tumour has spread to the cervix.

STAGE 3 The tumour has spread into nearby tissues such as the supporting membranes in the pelvic area, the vagina, or nearby lymph nodes.

STAGE 4 The tumour has spread beyond the womb into surrounding organs, such as the bladder or the bowel, or to other parts of the body.  If the cancer has spread to other parts of the body this is secondary (or metastasis) womb cancer.

RECURRENT ENDOMETRIAL CANCER is when the cancer comes back after initial treatment.

GRADING OF CANCER OF THE WOMB

Grading refers to the appearance of the cancer cells under the microscope.  The grade gives an idea of how quickly the cancer may develop.  There are 3 grades: grade 1 (low grade), grade 2 (moderate grade) and grade 3 (high grade).  Low-grade means that the cancer cells look very like normal endometrial cells.  They are usually slow growing and less likely to spread.  In high-grade tumours the cells look very abnormal.  They are likely to grow more quickly and are more likely to spread.

TREATMENT

Most cancer of the womb is discovered at an early stage (when they have not spread beyond the womb) and are cured by a hysterectomy (surgical removal of the womb).  As this treatment is very successful for many women, further treatment is not normally necessary.

Radiotherapy may be given after the operation if your surgeon feels that there is a risk of the cancer coming back.  Radiotherapy may be used instead of surgery if the cancer cannot be removed surgically, or if you are not fit enough to have an operation.  Radiotherapy may be used to shrink a tumour down before surgery and may also be used if the cancer comes back (recurs) in the pelvic area at a later date.

If the cancer has spread to other arts of the body, treatment with a female hormone called progesterone may be able to shrink the cancer and control symptoms.  Chemotherapy is also being tried in this situation but its effectiveness has not yet been established.

Your treatment will depend on a number of factors including your age, general health, the type of tumour you have, and the stage and the grade of the cancer.  A team of doctors working together and following national treatment guidelines will decide the treatment.

GIVING CONSENT

Before you have any treatment your doctor will explain the aims of the treatment to you and you will be usually asked to sign a form saying you give permission (consent) for the hospital staff to give you the treatment.  No medical treatment can be given without your consent, and before you sign the form you should have been given the full information about;

  • · The type and extent of your treatment
  • · The advantages and disadvantages of the treatment
  • · Any possible alternative treatments that may be available
  • · Any significant risks or side effects of the treatment.

If you do not understand what you have been told, let the staff know straight away so they can explain again.  Some cancer treatments are complex, so it is not unusual for patients to need repeated explanations.

It is often a good idea to have a friend or a relative with you when the treatment is explained, to help remember the discussion more fully.  You may also find it useful to write down a list of questions before you go for your appointments.  You can also ask the doctor if you can tape record the conversation.

Patients often feel that the hospital staff are too busy to answer their questions, but is important for you to be aware of how the treatment is likely to affect you and the staff should be willing to make time to answer your questions.

You are also free to choose not to have the treatment, and the staff can explain what may happen to you if you do not have it.  It is essential to tell a nurse or a doctor immediately so that he or she can record your decision in your medical notes.  You do not have to give reason for not wanting to have treatment, but it can be helpful to let staff know your concerns so that they can give you the best advice.

THE BENEFITS AND DISADVANTAGES OF TREATMENT

Many people are frightened at the idea of having cancer treatments, particularly because of the side effects that can occur.  Some ask what would happen if they did not go ahead with the treatment offered to them.

Treatments such as radiotherapy can cause side effects, treatment can be given for different reasons and the benefits may depend on the individual situation.  In women with early stage endometrial cancer surgery is usually done with the aim of curing the cancer and in most cases does this.  Sometimes additional treatments such as radiotherapy are given after surgery to reduce the risks of the cancer coming back.

If the cancer is at a more advanced stage or it has come back, treatment may only be available to control it, leading to an improvement in symptoms and a better quality of life.  However, for some people in this situation treatment will have no effect upon the cancer and they will get side effects without any benefit.

SURGERY

The surgical treatment for cancer of the womb is the removal of the womb. This operation is called a hysterectomy.  In most cases the gynaecologist will also remove both ovaries and the fallopian tubes.  Sometimes the lymph nodes close to the womb will also be removed.  This is known as a Wertheim’s hysterectomy.  The reason for this extra surgery is to remove as much of the cancer as possible and to enable the pathologist to see whether there are any cancer cells in the lymph glands.  Often it is possible for gynaecologist to remove all the cancer at this operation so that no further treatment is necessary.

However, if the cancer cannot be completely removed your surgeon may recommend radiotherapy treatment to be given after the operation. If radiotherapy is necessary your surgeon will refer you to a clinical oncologist (a doctor who specialises in radiotherapy treatment).

AFTER YOUR OPERATION

When you get back to the ward you will have an intravenous infusion (drip) into a vein in your arm until you are able to eat and drink normally.  You will probably have drainage tubes from the wound to stop any excess fluid collecting,  these are removed within a few days.

Usually a small tube (catheter) is put into the bladder and the urine is drained into a collecting bag.

You will be encouraged to start moving about as soon as possible.  This is an essential part of your recovery, and even if you have to stay in bed the nurses will encourage you to do regular leg movements to prevent blood clots in your legs.  You will also be shown how to do deep breathing exercises to prevent chest infections.

After your operation you may need regular painkilling drugs, which are very effective in controlling pain.

Most women are ready to go home about 6-8 days after their operation, once their stitches or clips have been removed.  If you think you may have a problem when you go home for example , if you live alone let the ward nurse know when you are admitted to the ward, so help can be arranged.

Although you will no longer have monthly periods you will be able to resume your usual sexual activities when you are ready, your surgeon will advice , though that normally is six weeks after your operation.

After a hysterectomy you will need to avoid strenuous physical activity or heavy lifting for about two months.  Some women even find it uncomfortable after the operation to drive, so wait a few weeks before you resume driving.

Before you leave the hospital you will be given an appointment to attend an outpatient clinic for your post-operative check up.  This is a good time to discuss any problems that you may have had since your operation, but remember you can ring your hospital doctor or ward nurse at any time.

RADIOTHERAPY

Radiotherapy treats cancer by using high-energy rays, which destroy the cancer cells while doing little harm as possible to normal cells.

Radiotherapy may be given after surgery if your doctor feels that there is a risk of the cancer coming back.  It may be used instead of surgery if the cancer has spread to the area surrounding the womb.  Sometimes it is given to shrink a tumour before an operation.  It may also be used if the cancer comes back in the pelvic area at a later date.  Radiotherapy for cancer of the womb can be given externally or internally, and often as a combination of the two.

SIDE EFFECTS

It is not unusual to have slight bleeding or discharge once the radiotherapy treatment has been completed.  If it continues or becomes heavy let your clinical oncologist or specialist nurse know.

Radiotherapy to the pelvic area can cause side effects such as tiredness, diarrhoea and a burning sensation when passing urine.  These side effects can be mild or more troublesome, depending on the strength of the radiotherapy dose and the length of the treatment.

Most of these side effects can be treated quite easily with tablets and your radiotherapist will be able to help you.  Any side effects should gradually disappear a few weeks after your treatment is over.

It is important to drink plenty of fluids and maintain a healthy diet during your treatment.  You may feel slightly sick but this is not uncommon.  During your treatment it is helpful to get as much rest as you can, especially if you have to travel a long way each day.

Sometimes radiotherapy causes narrowing of the vagina, which can make sexual intercourse uncomfortable.  Some women become less interested in sex and notice that their vagina is dry.

POSSIBLE LONG TERM EFFECT

Radiotherapy to the pelvic area can sometimes cause long-term side effects.

In a small number of people, the bowel or bladder may be permanently affected by the radiotherapy.

The blood vessels in the bowel and bladder can become more fragile after radiotherapy treatment and this can cause blood to appear in the urine or bowel movements.  This can take many months or years to occur.  If you notice any bleeding let your doctor know so that tests can be carried out and appropriate treatment given.

HORMONAL TREATMENT

In some situations, if your surgeon feels that there is a risk of the cancer coming back or if it comes back after surgery, he or she may recommend hormonal treatment.  This treatment may shrink the cancer and control symptoms.  Hormonal treatment may also be used for endometrial cancers that have already spread to other parts of the body when they are diagnosed.  Cancer of the womb is sometimes sensitive to hormones such as progesterone.

PROGESTERONE

Progesterone is a hormone that occurs naturally in women.  It can stop or slow the growth of endometrial cancer cells for some women.  Artificial progesterone is available as tablets or by injection and can be given by your GP.

CHEMOTHERAPY

Chemotherapy may be used if the cancer comes back or has spread to other parts of the body and does not respond to hormonal treatment.  In some people chemotherapy may help to shrink the cancer and relieve the symptoms. Chemotherapy is the use of ant-cancer (cytotoxic) drugs to destroy the cancer cells.

The drugs are sometimes given as tablets or capsules or, more usually, by injection into the vein (intravenously).  They tend to temporarily reduce the number of normal cells in the blood.  When your blood count is low you are more likely to get an infection and may tire easily.  During chemotherapy your blood will be tested regularly and, if necessary, you will be given antibiotics to treat infection.  Blood transfusions may be given if you are anaemic.

Other side effects may include tiredness, feeling sick (nausea), vomiting and hair loss, although nausea and vomiting are now much less of a problem than they used to be due to effective ant-sickness drugs.  Some chemotherapy drugs also make the mouth sore and cause small ulcers.  If you do not feel like eating meals, you can supplement your diet with nutritious drinks or soups.  A wide range of these drinks is available from most chemists

Occasionally women may have an allergic reaction to a chemotherapy drug, which can be frightening.  Tell your doctor or nurse if you notice skin rashes, itching, high temperature, shivering, and redness of the face, a feeling of dizziness, headache, shortness of breath, anxiety and a need to pass urine.  Treatment can be given to reduce allergic reactions.

Although these side effects may be hard to bear at the time, they do disappear once your treatment is over.  Some people do not have many side effects.

FOLLOW UP

After your treatment has been completed your cancer specialist will see you at the hospital for regular check-ups and possibly x rays.  These will often continue for several years.  If you have any problems or notice new symptoms in between these times, let your doctor know as soon as possible.

THE EMOTIONAL EFFECTS OF CANCER

A diagnosis of cancer is a devastating experience for most people.  When you are first told you have cancer you may feel shocked, numb and unable to believe what is happening or to feel any emotion.  Some people feel as though the situation is happening to someone else, you may feel as if your life will never be the same.

The diagnosis may cause you to feel a range of strong emotions such as fear, anger, sadness or depression.  These emotions can be very frightening and difficult to deal with.

When you have been diagnosed with cancer, it is natural to worry about what will happen.  Sometimes the worry can be very intense, and more like a fear or anxiety.  Fear and anxiety are normal reactions to stressful situations, such as those caused by cancer or its treatment, and can be very uncomfortable.

The fear and anxiety aroused by cancer may be present all of the time or may come and go.  Sometimes the feelings can be very intense and difficult to cope with.  You may find that you cannot concentrate, and tire easily.

Fear and anxiety can also cause physical effects on the body including:

  • Over breathing (hyperventilating)
  • Shaking
  • Tense Muscles
  • Breathlessness
  • Palpitations (a sensation of your heart beating too fast)
  • Dizziness
  • Sweating
  • · A dry mouth
  • · Nausea
  • · Diarrhoea
  • · Chest pain
  • · A lump in the throat
  • · Pins and needles
  • · Flushing (redness) of the skin.

If you are very anxious you may have a “panic attack”, in which the fear and anxiety is almost overwhelming and you may feel very breathless, have a pounding heart, sweating and shaking.  This can be very frightening and if you feel that you need help consult your GP or a counsellor who can help you with ways of coping with it.

Your distress may lead to feeling of anger and irritable moods, you may feel resentful that you have cancer whilst other people are well.

It is normal to feel sad after cancer has been diagnosed.  The sadness may come and go, or may be present a lot of the time.  You may feel grief at the loss of your good health, or your ability to enjoy your life to the full.

There may be times when you want to be left alone to come to terms with your illness, but if this is ongoing and you want to be alone for long periods of time this may be a sign that you may be depressed.

Depression can develop slowly, making it very difficult for either you or your family to recognise when it started.  You may find it helpful to talk to a close family member or a close friend about your illness and how you feel, they may help you not only come to terms with what is happening to you but to give you ongoing support throughout these worrying times.

SYMPTOMS OF DEPRESSION

Very low mood most of the time

Not feeling your usual self

Not able to be lifted out of your low mood by yourself or others

Loss of interest or enjoyment in favourite activities

Feeling worse in a morning

Disturbed sleep pattern-problems getting off to sleep or waking early

Poor concentration or forgetfulness

Feelings of guilt/burden/blame

Feeling helpless or hopeless

Feeling close to tears

Irritability

 

TALK THINGS THROUGH

Try not to bottle things up.  Acknowledge the emotions you are feeling.  Often one of the hardest things to cope with is the feeling that the cancer has taken over your life and that you have lost control.  This is a common feeling and is partly true, but over time people usually find things they can do which will help them to cope.

There may be times when you feel too tired and helpless even to think about what could help.  It is not unusual to feel like this when you have cancer.  You’ll have good days and bad days, and it’s important for you and your family to realise this.

For some people it is important to try to live life as normally as possible.  Keeping up with friends and trying to continue with your usual activities can reassure you that life has not changed too much.

An experience of cancer may help some people decide on new priorities in their lives. This may mean spending more time with family members, taking the holiday you have long dreamed of or taking up a new hobby.

Some people may decide to improve their general health by eating a more healthy diet or by getting fitter.  Finding a complementary therapy, which helps you to relax, can be a very positive way of becoming involved in your illness.

 

FINANCIAL HELP AND BENEFITS

If you are employed and unable to work your employer can pay you statutory sick pay (SSP) for a maximum of 28 weeks.

If you are still unable to work after this period, you may be able to claim incapacity benefit.  There are three rates of Incapacity benefit: a short term lower rate, a short-term higher rate and a long-term rate.

You can claim the short-term higher rate of benefit from the benefits agency, if you have paid the correct level of National Insurance contributions.  If you are still unable to work after one year, you can claim long term Incapacity Benefit.

People who are not eligible for incapacity benefit because they have not paid the relevant National Insurance contributions can apply to see if they qualify for Income Support.

You may qualify for disability Living Allowance (if you are under 65) or for Attendance Allowance (if you are over 65). Ask your local social security office for claim forms.  People who are claiming under ‘special rules’ need to get their doctor to complete a form for either benefit.