After diagnosis and initial evaluation, the doctor considers treatment options that fit each woman's needs and discusses these options with her. The choice of treatment depends on the size of the tumor, the stage of the disease, whether female hormones affect tumor growth, and tumor grade. (The tumor grade tells how closely the cancer resembles normal cells and suggests how fast the cancer is likely to grow. Low-grade cancers are likely to grow and spread more slowly than high-grade cancers.) Other factors, including the woman's age and general health, are also considered when planning treatment. Women with uterine cancer may be treated by a team of specialists that may include a gynecologist, gynecologic oncologist (a doctor who specializes in treating cancer of the female reproductive tract), and a radiation oncologist.

Getting a Second Opinion

Before starting treatment, a woman may want a second specialist to confirm the diagnosis and review her treatment options. It may take a week or two to arrange for another opinion, but a short delay will not reduce the chance that treatment will be successful. Some insurance companies require a second opinion; many others cover a second opinion if the patient requests it.

There are a number of ways to find a doctor who can give a second opinion:

• The woman's doctor may be able to suggest specialists to consult.
  
• A woman can get the names of doctors from her local medical society, a nearby hospital, or a medical school.
  
• The Official ABMS Directory of Board Certified Medical Specialists lists doctors' names along with their specialty and their background. This resource is in most public libraries.

Preparing for Treatment

Many people with cancer want to learn all they can about their disease and their treatment choices so they can take an active part in decisions about their medical care. When a woman learns she has uterine cancer, shock and stress are natural reactions. These feelings may make it difficult for her to think of everything she may want to ask the doctor. Often, it helps to make a list of questions. To help remember what the doctor says, a woman may take notes or ask whether she may use a tape recorder. Some patients find it helpful to have a family member or friend with them when talking to the doctor to participate in the discussion, take notes, or just listen.

These are some questions a woman may want to ask the doctor:

• What kind of uterine cancer do I have?
  
• Is there any evidence the cancer has spread? What is the stage of the disease?
  
• What is the tumor grade?
  
• What are my treatment choices? Which do you recommend for me? Why?
  
• What are the expected benefits of each kind of treatment?
  
• What are the risks and possible side effects of each treatment?
  
• What is the treatment likely to cost?
• How will treatment affect my normal activities?
  
• How often should I have a checkup?
  
• Would a treatment study be appropriate for me?

Women do not need to ask all their questions or understand all the answers at once. They will have many chances to ask the doctor to explain things that are not clear and to ask for more information.

Methods of Treatment

Most women with uterine cancer are treated with surgery. Some have radiation therapy. A smaller number of women may be treated with hormone therapy or chemotherapy. Another treatment option for women with uterine cancer is to take part in treatment studies (clinical trial). Such studies are designed to improve cancer treatment.

The following sections describe types of uterine cancer treatment.
Surgery to remove the uterus (hysterectomy) and the fallopian tubes and ovaries (bilateral salpingo-oophorectomy) is the treatment recommended for most women with uterine cancer. Lymph nodes near the tumor may also be removed during surgery to see if they contain cancer. If cancer cells have reached the lymph nodes, it may mean that the disease has spread to other parts of the body. If cancer cells have not spread beyond the endometrium, the disease can usually be cured with surgery alone.

These are some questions a woman may want to ask the doctor before having surgery:

• What kind of operation will it be?
• How will I feel after the operation?
  
• If I have pain, how will you help?
  
• How long will I have to stay in the hospital?
  
• Will I have any long-term effects because of this operation?
  
• When will I be able to resume my normal activities?
  
• Will follow-up visits be necessary?

In radiation therapy (also called radiotherapy), high-energy rays are used to kill cancer cells. The rays may come from a small container of radioactive material, called an implant, which is placed directly into or near the tumor site (internal radiation). It may also come from a large machine outside the body (external radiation). Some patients with uterine cancer need both internal and external radiation therapy. Like surgery, radiation therapy is a local therapy. It affects cancer cells only in the treated area. Radiation therapy may be used in addition to surgery to treat women with certain stages of uterine cancer. Radiation may be used before surgery to shrink the tumor or after surgery to destroy any cancer cells that remain in the area. Also, for a small number of women who cannot have surgery, radiation treatment is sometimes used instead.

In internal radiation therapy, tiny tubes containing a radioactive substance are inserted through the vagina and left in place for a few days. The patient is hospitalized during this treatment. Patients may not be able to have visitors or may have visitors only for a short period of time while the implant is in place. Once the implant is removed, there is no radioactivity in the body. External radiation therapy is usually given on an outpatient basis in a hospital or clinic 5 days a week for several weeks. This schedule helps protect healthy cells and tissue by spreading out the total dose of radiation.

These are some questions a woman may want to ask the doctor before having radiation therapy:

• What is the goal of treatment?
  
• How will the radiation be given?
  
• When will the treatments begin? When will they end?
  
• How will I feel during therapy? Are there side effects?
  
• What can I do to take care of myself during therapy?
  
• How will we know if the radiation therapy is working?
  
• Will I be able to continue my normal activities during treatment?

Hormone therapy is the use of drugs, such as progesterone, that prevent cancer cells from getting or using the hormones they may need to grow. Hormone treatment is a systemic therapy. The drugs, which are usually taken by mouth, enter the bloodstream, travel through the body, and control cancer cells outside the uterus. Women who are unable to have surgery are sometimes treated with hormone therapy. Also, this form of treatment is often recommended for women who have metastatic or recurrent endometrial cancer.

These are some questions a woman may want to ask the doctor before having hormone therapy:

• Why do I need this treatment?
  
• What hormones will I be taking? What will they do?
  
• Will I have side effects? What can I do about them?
  
• How long will I be on this treatment?

Chemotherapy is the use of drugs to kill cancer cells. Anticancer drugs may be taken by mouth or given by injection into a blood vessel or a muscle. Like hormone therapy, chemotherapy is a systemic therapy; it can kill cancer cells throughout the body. Chemotherapy is being evaluated in treatment studies for patients with uterine cancer that has spread.

These are some questions a woman may want to ask the doctor before starting chemotherapy:

• What is the goal of this treatment?
  
• What drugs will I be taking?
  
• Will the drugs cause side effects? What can I do about them?
  
• How long will I need to take this treatment?
  
• How will we know if the drugs are working?

Treatment Studies

Doctors conduct treatment studies to learn about the effectiveness and side effects of new treatments. In some studies, all patients receive the new treatment. In other studies, doctors compare different therapies by giving the new treatment to one group of patients and the standard therapy to another group. Treatment studies are also designed to compare one standard treatment with another.

Women who take part in these studies have the first chance to benefit from treatments that have shown promise in earlier research. They also make an important contribution to medical science.

Doctors are studying new ways of giving radiation therapy and chemotherapy, new drugs and drug combinations, biological therapy", and new ways of combining various types of treatment. Some studies are designed to find ways to reduce the side effects of treatment and to improve the quality of women's lives.

Women who are interested in taking part in a study should talk with their doctor.

Side Effects of Cancer Treatment

In treating cancer, it is hard to limit the effects of treatment so that only cancer cells are removed or destroyed. Because treatment also damages healthy cells and tissues, it often causes side effects.

The side effects of cancer treatment depend on a variety of factors, including the type and extent of the treatment. Side effects may not be the same for each person, and they may even change from one treatment to the next. Doctors and nurses can explain possible side effects, and they can help relieve symptoms that may occur during and after treatment.

Surgery

After a hysterectomy, women usually have some pain and general fatigue. In some cases, patients may have nausea and vomiting following surgery, and some women may have problems returning to normal bladder and bowel function. The effects of anesthesia and discomfort may also temporarily limit physical activity. Diet is usually restricted to liquids at first and gradually increases to regular meals. The length of the hospital stay may vary from several days to a week.

Women who have had a hysterectomy no longer have menstrual periods. When the ovaries are removed, menopause occurs immediately. Hot flashes and other symptoms of menopause caused by surgery may be more severe than those caused by natural menopause. In the general population, estrogen replacement therapy (ERT) is often prescribed to relieve these problems. However, ERT is not commonly used for women who have had endometrial cancer. Because estrogens has been linked to the development of uterine cancer, many doctors are concerned that ERT may cause uterine cancer to recur. Other doctors point out that there is no scientific evidence that ERT increases the risk of recurrence. A large research study is being conducted to determine whether women who have had early stage endometrial cancer can safely take estrogen.

After surgery, normal activities usually can be resumed in 4 to 8 weeks. Sexual desire and sexual intercourse are not usually affected by hysterectomy. However, some women may experience feelings of loss that may make intimacy difficult. Counseling or support for both the patient and her partner may be helpful.

Radiation Therapy

Radiation therapy destroys the ability of cells to grow and divide. Both normal and diseased cells are affected, but most normal cells are able to recover. With radiation therapy, the side effects depend largely on the treatment dose and the part of the body that is treated. During radiation therapy, people are likely to become very tired, especially in the later weeks of treatment. Resting is important, but doctors usually advise patients to try to stay as active as they can.

Patients receiving radiation for uterine cancer commonly have side effects that include dry, reddened skin and hair loss in the treated area, loss of appetite, and fatigue. Radiation therapy also may cause a decrease in the number of white blood cells that help protect the body against infection. Treatment may also cause diarrhea or frequent and uncomfortable urination. Some women have dryness, itching, tightening, and burning in the vagina. Women may be advised not to have intercourse during treatment; however, most can resume sexual activity within a few weeks after treatment ends. Women may be taught how to use a dilator, as well as a water-soluble lubricant to help minimize these problems.

Hormone Therapy

Hormone therapy can cause a number of side effects. Women taking progesterone may experience fatigue and changes in appetite and weight, and they may retain fluid. Premenopausal women may have changes in their menstrual periods. Women may wish to discuss the side effects of hormone therapy with their doctor.

Chemotherapy

The side effects of chemotherapy depend mainly on the drugs and the doses received. In addition, as with other types of treatment, side effects vary for each individual. Generally, anticancer drugs affect cells that divide rapidly. These include blood cells, which fight infection, help the blood to clot, or carry oxygen to all parts of the body. When blood cells are affected by anticancer drugs, patients are more likely to get infections, may bruise or bleed easily, and may have less energy. Cells in hair roots and cells that line the digestive tract also divide rapidly. As a result, patients may lose their hair and may have other side effects, such as poor appetite, nausea and vomiting, or mouth sores. Usually, these side effects go away gradually during the recovery periods between treatments or after treatment is over.

Prevention

Possible Causes and Prevention

Scientists at hospitals and medical centers all across the country are studying uterine cancer. They are trying to learn more about what causes the disease and how to prevent it.

At this time, we do not know exactly what causes uterine cancer, and doctors can seldom explain why one woman gets this disease and another does not. It is clear, however, that uterine cancer is not caused by an injury, and is not contagious; no one can "catch" uterine cancer from another person.
By studying patterns of cancer in the population, researchers have found certain factors that are more common in women who get uterine cancer than in those who don't get this disease. It is important to know that most women with these risk factors do not get cancer, and many who do get uterine cancer have none of these factors.

The following are some of the known risk factors for this disease:

• Age. Cancer of the uterus is most common in women over age 50.
• Endometrial hyperplasia. Women who have endometrial hyperplasia have a higher risk of developing uterine cancer.
  
• Estrogen replacement therapy. Women who use estrogen replacement therapy to control symptoms associated with menopause, to prevent osteoporosis (thinning of the bones), or to reduce the risk of heart disease or stroke may have an increased risk of uterine cancer. Long-term treatment and large doses seem to increase this risk. Using a combination of estrogen and progesterone decreases the risk linked to the use of estrogen alone. The progesterone protects the endometrium from the cancer-causing effect of estrogen. A woman considering hormone replacement therapy should discuss the benefits and risks with her doctor. Regular follow-up visits with a health professional while taking estrogen replacement therapy may improve the chances of detecting and treating uterine cancer in the early stages should it develop.
  
• Overweight. Scientists believe that too much estrogen may be the reason why overweight women are more than twice as likely to develop uterine cancer as women of normal weight. Because fat converts certain hormones into a form of estrogen, women with excess fat produce higher levels of estrogen.
  
• Diabetes and high blood pressure. Some studies suggest that diabetes and high blood pressure increase the risk of uterine cancer. Because these conditions often occur in overweight people, researchers cannot be certain whether the conditions themselves or the relationship between body fat and estrogen levels increases uterine cancer risk.
  
• Other cancers. Women with a history of colon cancer, rectal cancer, or breast cancer have a slightly higher risk of developing uterine cancer than do most other women. Women who have had uterine cancer also have an increased risk of developing certain other cancers.
  
• Tamoxifen. An increased risk of developing uterine cancer has been found in women taking the drug tamoxifen for the treatment of breast cancer. This risk may be related to the estrogen-like effect of this drug on the uterus. Women taking tamoxifen should be closely monitored by the doctor for possible signs or symptoms of uterine cancer. Doctors emphasize that the benefits of tamoxifen as a treatment for breast cancer are firmly established and far outweigh the potential risk of other cancers.
• Race. White women have a greater chance of developing uterine cancer than black women.
  Other risk factors for uterine cancer are also related to estrogen, including having few or no children or entering menopause late in life. Some studies of women who have used oral contraceptives that combine estrogen and progesterone show that these women have a lower than average risk of uterine cancer.

Women with known risk factors and those who are concerned about uterine cancer should talk with their doctor about the disease, the symptoms to watch for, and an appropriate schedule for checkups. The doctor's advice will be based on the woman's age, medical history, and other factors.

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