Uterine cancer: treatments
Many years of treating cancer patients and testing treatments in clinical trials has helped doctors know what is likely to work for a particular type and stage of cancer. Your doctor will advise you on the best treatment for your cancer. This will depend on the results of your tests, where the cancer is and if it has spread, your age and general health, and what you want.
Cancer of the uterus is often diagnosed early, before it has spread. This means that many women will not need treatment other than surgery. The major side effect of the surgery is that women cannot have children. The surgery also causes menopause.
If the cancer has spread beyond the uterus, then radiotherapy, hormone treatment or chemotherapy may be used in addition to surgery.
Treatment for cancer of the uterus has a very high cure rate.
Research into the causes of cancer of the uterus is underway in many parts of the world. This research usually involves testing to see which genes are involved. If you are interested, ask your doctor for information about clinical trials of treatments in Australia and other parts of the world.
Cancer of the uterus is usually treated by removing the uterus. The operation is called a hysterectomy. The operation also allows the doctors to find out which type of cancer of the uterus you have and see if it has spread.
The cut is made along the pubic hair line or from the pubic area to the belly button. Once the abdomen is open, the surgeon washes out the area with a fluid, which is sent to a pathologist, who checks the fluid for cancer cells.
The surgeon checks all the organs in the abdomen, looking for signs of cancer spread (metastasis). This part of the operation is called a laparotomy.
The surgeon then removes the uterus (hysterectomy). Your Fallopian tubes and ovaries will also be removed. This is called a bilateral salpingo oophorectomy. Sometimes the operation can be done through keyhole surgery, where four or five small holes are made in the abdomen. The surgeon uses a small camera to see inside the abdomen.
The pathologist will look at the uterus to establish the type of cancer and whether the cancer has spread to the muscle wall of the uterus. A frozen section is done during the operation. If the cancer is only on the surface or is in a very early stage, you may not need to have any more treatment.
If the cancer has spread into the muscle wall of the uterus, this increases the risk of spread to the abdominal lymph nodes. Removal of lymph nodes is called a lymphadenectomy. If you have cancer in the lymph nodes you may benefit from additional therapy.
If the cancer has spread to the cervix, a small part of the upper vagina and the ligaments supporting the cervix are also removed. If this is necessary, the operation will be longer.
After the operation
When you wake up from the operation, you will have several tubes in place. An intravenous drip will give you fluid as well as medication. There may also be one or two tubes in your abdomen to drain away fluid from the operation site. There will be a catheter in your bladder to drain away urine. As you recover from the operation, these tubes will be removed, usually within three to five days.
As with all major operations, you will have discomfort or some pain. You will have pain relievers through an intravenous drip or through an epidural into your spine. This epidural pain relief is similar to that given to women during childbirth. It is best to let your nurse know when you are starting to feel uncomfortable-don't wait until the pain becomes severe. Some patients are comfortable using patient controlled analgesic (PCA). PCA is delivered through a drip and allows you to choose when you receive a dose of pain-relieving medication.
A few days after your operation, your doctor will have all the test results and will discuss any further treatment with you. Further treatment will depend on the type of cancer, the stage of the disease and if there is any remaining cancer.
Side effects of surgery
This is major surgery so you may be in hospital for up to seven days. Your recovery time will depend on different factors. Don't expect to get back to your normal activities too quickly. For some women it may take six weeks or longer. During this time, avoid heavy work and lifting at work or around the house and garden. Standing for stretches of time can be tiring, too. Some women may need six to 12 months before they feel completely well.
After surgery, some women develop internal scar tissue called adhesions. This scar tissue can glue together internal body surfaces. Sometimes this can be painful and may affect the working of the bowel and the bladder. Adhesions to the bowel or bladder may need to be treated with surgery.
If you have not been through menopause, the removal of your ovaries will cause menopause. This may cause strong symptoms such as hot flushes. These may be more severe than a ‘normal' menopause, where the reduction of hormones happens more slowly. If you have been through menopause, there may be a recurrence of hot flushes.
You may want to discuss with your gynaecological oncologist whether hormone replacement therapy (HRT) is suitable for you. Because cancer of the uterus can be hormone-sensitive, HRT may not be suitable for some women.
If surgery has induced an early menopause you will not be able to get pregnant or have children.
Physical and emotional changes may affect how you feel about sex and how you respond sexually.
Radiotherapy treats cancer by using radiation to destroy cancer cells. The radiation can be targeted to cancer sites in your body. Treatment is carefully planned to do as little harm as possible to your normal body tissues.
Radiotherapy may be advised if you are not well enough for a major operation. Radiotherapy may also be advised as an additional therapy. Additional therapies are often called adjuvant therapies.
Radiotherapy can be given internally and externally. Since internal radiotherapy and external radiotherapy have slightly different purposes, it is possible that you could have both forms of radiotherapy.
Women who have radiotherapy to the pelvis may be advised to use a vaginal cylinder to prevent adhesions in the vagina or narrowing of the vagina.
Brachytherapy (internal radiotherapy)
Internal radiotherapy is also called brachytherapy. It is a type of radiotherapy where the radiation source is placed close to the cancer. If you need to have radiotherapy for cancer of the uterus, you may need to have this type of treatment.
If there is any risk of cancer developing in the scar at the top of the vagina following surgery, adjuvant internal radiotherapy may be advised.
There are different forms of the implant that is used for internal radiotherapy. Your gynaecological oncologist and radiation oncologist will advise the best form of treatment, based on your cancer and medical history. The implant is inserted through the vagina or the tissues around the vagina using special applicators.
Recently there have been changes in the equipment and treatment options available so you will need to talk with your specialists about the options that are best for you and available to you.
You will have internal radiotherapy as two to five short treatments. You may be treated as an outpatient or you may need to stay in hospital as an inpatient.
You will need to make between four to eight visits to the treatment centre as an outpatient. If you are an inpatient, two treatments will be done in one day. The actual treatment time for each high dose rate radiation treatment can be as little as five to 10 minutes.
Your choice of treatment may be shaped by how easy or difficult it is for you to make several treatment visits. This may be a particular issue for women who live in the country.
In external radiotherapy, x-rays from a large machine are directed at the part of the body needing treatment. For cancer of the uterus, the lower abdominal area and pelvis are treated but if the cancer has spread this can be extended to include other areas.
You usually have external radiotherapy as an outpatient, five days a week for four to six weeks. The actual treatment takes a few minutes each time. However, the waiting and preparation time is longer.
This sort of radiotherapy involves careful measurement and planning so the x-ray treatment is delivered just to the necessary areas. Radiotherapy does not cause pain or discomfort as it is being given.
Side effects of radiotherapy
Radiotherapy may cause a number of side effects which are temporary and can be controlled. These may include tiredness, loss of appetite, diarrhoea, pain when passing urine and frequent urination. There may also be skin problems, and the skin between your buttocks may look and feel as if it has been sunburnt. Sometimes this effect occurs after radiotherapy has finished. Special creams can be used to relieve this burning feeling.
There may be some hair loss in the area where radiotherapy has been targeted. This means that your pubic hair may become thinner. It will grow back after the treatment is finished; this could take a number of months.
Internal radiotherapy can also narrow the vagina. This can be prevented by using a vaginal cylinder or vibrator and an oestrogen vaginal cream or lubricating jelly. Discuss any concerns about vaginal narrowing, adhesions and oestrogen vaginal cream with your doctor and nurse.
Sometimes, side effects do not occur for some time after the end of treatment. These late side effects can be long term and for some women they will be permanent. The effects can include inflammation of the rectum and perhaps the bowel and the bladder. Bladder inflammation is called radiation cystitis. Speak to your doctor or nurse about how to manage any side effects.
Some cancers of the uterus depend on hormones for growth. Women's ovaries are removed during surgery for two reasons:
- because the cancer may have spread to the ovaries
- because they produce oestrogen, which may help the cancer to grow.
Tissue removed during your operation will be tested to see if your cancer can be treated by hormones. Drugs such as provera block the body's use of oestrogen. Provera is a form of the female hormone progesterone. Tamoxifen, an anti-oestrogen drug, is also commonly used.
Hormone treatment can work very well for advanced or recurrent cancer of the uterus. It can also be used to treat early stage cancer of the uterus if other medical problems prevent surgery or radiotherapy.
Hormone treatment is taken orally.
Side effects of hormone treatment
Side effects of provera include breast tenderness, nausea and fluid retention. In high doses, it may increase your appetite and cause some weight gain. Tamoxifen can cause hot flushes, headaches and fluid retention.
You may have some or none of these side effects. Discuss any problems or concerns with your doctors.
Chemotherapy is the treatment of cancer using anti-cancer drugs. The aim is to destroy cancer cells while causing the least possible damage to normal cells. The drugs kill cancer cells by stopping them from multiplying.
Chemotherapy may be offered with radiation therapy and is usually given to women who have a very high risk of the cancer returning, to try to prevent recurrence. It may also be recommended for women whose cancer is quite advanced when they are first diagnosed, to try to shrink the cancer or to relieve symptoms caused by the cancer. If cancer returns after surgery or radiotherapy, chemotherapy may be used to control the growth of the cancer and to help relieve symptoms. It is also used if the cancer does not respond to hormone treatment. Your medical oncologist will explain to you why chemotherapy may be helpful.
Chemotherapy is usually given through a needle inserted into a vein, by specialised nurses and under the guidance of a medical oncologist. You may need to stay in hospital overnight or you may be treated as a day patient. This depends on the drugs you have and how you are feeling.
You may have a number of chemotherapy treatments, usually six, every three to four weeks over several months. You will be closely monitored during this time. You may have tests to check that the chemotherapy is working for you. The length of treatment will depend on the actual disease and what other treatment is being used. Before each treatment, you will have blood tests to make sure your body's normal cells have had time to recover.
Side effects of chemotherapy
The side effects of chemotherapy vary according to the particular drugs used. Your doctor will talk to you about these side effects and how to manage them.
Side effects may include feeling sick, vomiting, feeling off-colour and tired, and some thinning or loss of your body and head hair. Most side effects are temporary and steps can often be taken to either prevent or reduce them.
When cancer can't be cured
If your cancer has spread and it is not possible to cure it by surgery, your doctor may still recommend treatment. In this case, treatment may help relieve any symptoms, can make you feel better and may allow you to live longer.
Whether or not you choose to have anti-cancer treatment, symptoms can still be controlled. For example, if you have pain, there are effective treatments for this.
General practitioners, specialists and palliative care teams in hospitals all play important roles in helping people with cancer. For further information, contact the Cancer Council Helpline on 13 11 20 or Palliative Care Victoria on 9662 9644.
Most women with early cancer of the uterus will be cured of their disease. For women with more advanced disease, a cure may still be possible. For other women, treatment can keep the disease under control for long periods of time.
You will need to talk with your gynaecological oncologist about your own prognosis. Your medical history is unique, so you will need to discuss with someone who knows your medical history what you can expect and the treatment options best for you.