Question: My 67-year-old grandmother had vaginal bleeding, and they are concerned she has cancer of her uterus. Is this common at her age?
Answer: Endometrial cancer, EC, is the name for cancer that begins in cells lining the uterus. Overall, about 2% to 3% of women will be diagnosed with EC in their lifetimes, peak age of diagnosis is between 60 and 70 years old. Over three-quarters of women diagnosed with this cancer are postmenopausal.
Risk factors for developing EC include obesity, never having been pregnant, late onset of menopause, having received “unopposed estrogen” — estrogen replacement without concomitant progestogen, or endogenously produced estrogen such as from polycystic ovarian disease or other conditions — cigarette smoking, having had certain other cancers — for example colon, breast or ovarian cancers — certain genetic conditions — such as Lynch syndrome — a family history of the disease and certain other conditions.
The most common symptom of EC is postmenopausal bleeding, and this raises suspicion of the condition in these patients. However, only about one in five women with postmenopausal bleeding are diagnosed with EC, the other 80% are found to have other causes of their bleeding — such as polyps, endometrial hyperplasia, endometrial atrophy, certain medications, other causes.
In premenopausal women, EC may be suspected based on abnormal/irregular vaginal bleeding, incidentally seeing an abnormality on a pelvic image done for some other reason, identifying EC cells an abnormal PAP smear — even though PAP smears screen for cervical cancer and not EC — seen on examination of the women’s uterus after a hysterectomy is done for some other condition, or for other reasons.
If EC is suspected, an ultrasound to visualize the uterus is indicated and endometrial tissue sampling biopsy — once pregnancy has been ruled out, there are several different methods to obtain these tissue samples — is taken to confirm the diagnosis.
Once EC is diagnosed, the extent of the disease, the stage of the cancer, is assessed. Staging depends on whether the cancer is confined to the uterus, and further by how deeply it invades the uterus, whether it has spread to nearby lymph nodes, or whether it has spread to other structures — such as bladder, bowel, abdominal cavity or more distant lymph nodes like those in the groin. The specific characteristics of the tumor cells are also evaluated — “graded.” All this information helps inform the overall prognosis and the treatment recommendations.
Treatment of EC usually includes removal of the uterus — hysterectomy, although more limited surgery may be possible in certain young women still wanting to conceive — sometimes with other organs/tissues removed as well — for example the woman’s ovaries and indicated lymph nodes may also be removed. Evaluation for spread of the cancer may include evaluation of cells obtained in “washings” of the woman’s abdomen, evaluation of her lymph nodes, etc. Depending on the stage of disease and the specific characteristics of the disease and the patient, other treatments, possibly including radiation therapy and/or chemotherapy may be indicated.
The prognosis for a woman with EC depends on the stage of her disease, as well as certain other factors. The overall 5-year survival rate for women with EC is over 80%. If the cancer is localized to just the uterus on diagnosis, two-thirds of cases, the five-year survival rate is over 95%. Women with regional spread of disease to local lymph nodes, about 20%t of cases, have a 65% to 70% five-year survival and those with metastatic disease, just under 10% of cases, have about a 50% five-year survival.
Jeff Hersh, Ph.D., M.D., can be reached at DrHersh@juno.com.