A woman undergoing radiation treatment needs to stretch the vagina frequently to maintain the opening, both for ease of sexual intercourse and for maintaining the ability to undergo pelvic examinations without excessive pain. Narrowing of the vagina, also known as vaginal stenosis, is a common side effect of radiation. If possible, sexual intercourse three times a week can help prevent vaginal stenosis. As an alternative, doctors can prescribe special dilators to be inserted into the vagina for 10 to 15 minutes three times a week.
All women with cancer should take special care to attend to their emotional needs and maintain a healthy lifestyle. A diagnosis of cancer is always a difficult experience, and most women find it helpful to reach out to friends and family for support. Organized support groups through the hospital are also usually available.
Adopting and maintaining a healthy lifestyle is also important for enhancing one’s physical and mental well-being. If you are a smoker, ask your doctor for help in stopping. Limit alcohol to one to two drinks each day, and eat a healthy diet low in animal fat and with plenty of fresh fruits, vegetables, and whole grains. If you do not exercise regularly, ask your doctor about starting an exercise program.
Your doctor is the best source of information on the drug treatment choices available to you.
Radiation to the pelvis is used in addition to surgery for many patients. Depending on the stage and grade of the disease, surgery may be all the treatment required. For others, radiation in addition to surgery has been shown to improve survival.
Radiation is used instead of surgery only in unusual circumstances. Radiation may be used instead of surgery when a woman’s general health is too poor to allow her to undergo surgery, of if cancer has spread so extensively that surgery may not be a valid option.
Radiation therapy can be delivered in different ways. External beam radiation is a common method. For external beam radiation, a beam of radiation is delivered to the body from a machine. Each treatment takes less than half an hour, and is required for four to six weeks, five days a week.
Radiation typically causes fatigue, and can damage the skin as well as other structures in the area being radiated. Many women experience pelvic discomfort and the frequent urge to urinate, a condition called “radiation cystitis”. Radiation can also irritate the intestines, especially the rectosigmoid colon, producing “radiation proctitis”. Narrowing of the vagina (vaginal stenosis) from scar formation can occur. Pelvic bones may be weakened, making a woman vulnerable to hip or pelvis fracture.
If the cancer remaining after surgery is confined to a small area, pellets of radiation can be implanted directly to the site. Applying radiation directly to the vagina is called brachytherapy. It can be used to treat the upper vagina when it is believed that there is a risk that cancer can grow back after surgery. This is done when the tumor has grown to involve the lower part of the uterus (the cervix), for example. In most instances, this procedure can be done with a “vaginal cylinder”, which has radioactive material that is placed in the vagina for very brief periods of time. Indeed, there is now a technique of “high dose rate” brachytherapy, that is delivered in the outpatient setting over a period of just a few hours.
The side effects of this treatment may include vaginal discharge, irritation, and vaginal narrowing.
A hysterectomy is performed for endometrial cancer in almost all cases. For some patients, it may be all the treatment required. A hysterectomy involves removing the uterus and cervix. In most women, the ovaries and fallopian tubes are also removed. For cancer caught in the earliest stage, only a hysterectomy may be necessary. The uterus may be removed through an incision in the abdomen, or brought out through the vagina.
Typically during a hysterectomy, selected lymph nodes in the pelvis and the area around the aorta (the major artery that travels down the body) are removed and examined for cancer cells. If the surgery was done through the vagina, the lymph nodes can be removed through small incisions made in the abdomen.
A hysterectomy is an inpatient procedure requiring general or regional anesthesia. The hospital stay is typically three to four days for an abdominal procedure, and two to three days for a vaginal procedure. Complete recovery can be expected in four to six weeks.
Fallopian tubes and ovaries are also frequently removed to avoid the future possibility of cancer to the ovaries. This surgery is known as a bilateral salpingo-oophorectomy (BSO), and is often performed at the same time as a simple or radical hysterectomy. Removal of the ovaries induces menopause in premenopausal women.
Lymph nodes are removed to determine if the cancer has spread to them and to determine the stage of the cancer. During the hysterectomy, lymph nodes in the pelvis and around the aorta are sampled for cancer. If present, a lymph node “dissection” is performed, in which most or all of the nodes in the region are taken out.
A radical or modified radical hysterectomy may be necessary if the cancer has spread to the cervix. A radical hysterectomy (or modified radical hysterectomy) involves removing the uterus as well as the upper part of the vagina and the connective tissue adjacent to the cervix (parametrium), if necessary. A typical hospital stay is four or five days.
Premenopausal women with endometrial cancer undergo menopause after being treated with a hysterectomy and ovary removal. For women who have not yet entered menopause, the standard surgical treatment for endometrial cancer causes them to do so. Symptoms of menopause, including hot flashes, mood swings, and vaginal dryness, are typically more severe than for women who go through menopause more slowly and naturally.
Hormone replacement therapy can help to alleviate these symptoms. However, current guidelines state that estrogen alone (unopposed estrogen) can increase uterine cancer risk. Estrogen and progesterone combined have not been shown to increase this risk. Over-the-counter lubricants can also be used to alleviate vaginal dryness.
Surgery is not only essential for treatment, but also provides important information about the stage and prognosis of the disease, and guides further treatment decisions Table 01. Surgery allows doctors to stage the disease; that is, determine the cancer’s localized growth in the uterus and surrounding area, and discover whether there is evidence that it has spread. The doctors will:
- visually explore the female organs, the bladder, and the rectum
- cut open the uterus after it has been removed and determine how far into the muscle the cancer has spread
- remove lymph nodes from the pelvis and near the aorta
- sample fluid from the abdomen and pelvis
- remove other sites where the diseasehas spread if they are found
Table 1. Simplified Staging System for Endometrial Cancer
Stage Characteristic Stage I Cancer is present only in the uterus. Stage II Cancer has spread to the cervix. Stage III Cancer has spread beyond the uterus, but is still confined to the pelvic area. Metastases may be present in the vagina and lymph nodes in the pelvis. Stage IV Cancer has spread to the bladder or rectum. Metastases may be present in distant lymph nodes, bones or lungs
Patients with stage III or IV disease or recurrent cancer may wish to consider joining a clinical trial to test new treatments for endometrial cancer. Clinical trials can give cancer patients access to potentially helpful new treatments. New medications are tested because it is believed that they may be better than standard treatment for the disease. For information about clinical trials, talk with your doctor and contact the Cancer Information Service at (800)-4-CANCER, or visit http://www.centerwatch.com/ and http://www.clinicaltrials.gov on the Internet.
Most women can be cured of endometrial cancer. The stage of the disease is the most important factor in determining prognosis. Fortunately, most cases of endometrial cancer are caught in the early stages of the disease when cure rates are high. Five-year survival rates for stage I disease are 70% to 95%. A five-year time period is used as a standard for statistical purposes, and most women can expect to be cured at that point and live a normal life span.
For stage III or IV, survival rates are 10% to 60%. Rates vary widely depending on individual circumstances.
The disease grade is another important factor. Grade of the disease is a measure of how abnormal the cancer cells appear under the microscope. Like stage, a lower grade has a better prognosis.
Younger women tend to have a better prognosis.
Endometrial cancers of cell types; e.g., serous carcinomas, tend to be more aggressive and carry a worse prognosis.
It is essential to set a schedule of follow-up visits during diagnosis, treatment, and recovery. Women should be seen frequently by their doctors while endometrial cancer is being diagnosed and treated, on a schedule determined by their individual circumstances. After treatment, women typically follow up with their doctors every three to six months, when the chance of recurrence is highest. After three years with no evidence of a recurrence, women typically follow up with their doctors every six months. Visits may include:
- a pelvic exam
- a Pap test
- a physical exam, with special attention feeling lymph nodes where cancer might spread
- a CA 125 blood test
- imaging tests such as CT scan or ultrasound
Women should report any pelvic pain following cancer treatment. Persistent pelvic pain could indicate a recurrence of the cancer or a fracture of a pelvic bone, particularly if a woman has had radiation therapy.
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