Endometrial Cancer

An overview of disease, diagnosis and treatment

Endometrial Cancer

The uterus is the pelvic, hollow, pear-shaped female reproductive organ, where fetal development occurs. In later stages of life, it is also the location of the most common gynaecological form of cancer. Cancer of the uterine body mainly originates in the internal uterine lining (endometrium), and is therefor also referred to as endometrial cancer. Endometrial cancer is often detected at an early stage, as it frequently causes abnormal and/or post-menopausal vaginal bleeding. If endometrial cancer is discovered early, surgical removal of the uterus can cure the disease.

Epidemiology

Women diagnosed with endometrial cancer are a median of 69 years, and most patients are postmenopausal.

High levels of estrogen in women predispose to development of endometrial cancer and include adipositas, PCOS, diabetes mellitus, tamoxifen (used in breast cancer treatment), and hormone replacement therapy (HRT).

The prognosis is good in stage 1 with more than 90 % being alive after 5 years. In stage 3 the 5 year survival rate is 40 %.

Diagnosis

Endometrial cancers tend to give symptoms early on. Patients may present  to their doctors with irregular vaginal discharge/bleeding (e.g. on/after hormone (estrogen) treatment), or with post-menopausal bleeding. Later on discomfort, pain and  urinary tract irritation/infection may arise.

Theses patients will be referred for specialized gynecological evaluation, where initially a gynaecological examination, vaginal ultrasound, and blood tests are performed.

Tumors may present as papillary (extending into the cavity), or more profound growing in the uterine wall. Tissue must be extracted from the tumor for histological examination to make a final diagnosis. This is done via a hysteroscopy or by endometrial fractional abrasion during gyneacological examination.

For staging of endometrial cancer an imaging examination must be performed to determine the extent of disease. The modality of imaging varies between locations between PET/CT, CT, and MRI.

Examinations

Transvaginal ultrasound

An ultrasound examination of the internal genital organs is carried out with an ultrasound probe inserted into the vagina (transvaginal sonography). It demonstrates pelvic structures well, but is insufficient to visualize cancerous lesions on e.g. bowel surfaces.

It is painless and can be repeated any number of times. It does not expose the patient to any radiation.

Hysteroscopy

During a hysteroscopy a thin, flexible, lighted tube (hysteroscope), is inserted through the vagina and cervical canal into the uterine cavity. With a lens on the hysteroscope the examiner can oversee the hollow internal cavity and lining of the uterus. In case of suspicious areas, tissue samples are taken and send to the pathologists for histological examination. The uterus examination is usually combined with scraping of cells from the lining (fractional abrasion).

Curettage (abrasion/scraping of the endometrium)

Obtaining tissue samples from suspicious areas in the endometrium is necessary to detect malignant lesions in the uterus, and thereby make a final histological diagnosis.

Tissue samples from the uterine and cervical canal membranes are carefully obtained by scraping, and the samples are collected for examination. It can cause minor discomfort and bleeding for a few days, but then the mucous membranes gradually rebuild again. 

Blood tests

These tests provide information on the general health condition of the patient. Doctors may examine blood tests for hemathological status, renal-,  and liverfunction as well as the ability to coagulate their blood during/after surgery.

No tumor marker is available for diagnosing/follow up on patients with endometrial cancer.  

Treatment Options

Surgery

The first choice of treatment for patients with endometrial cancer is surgery, if this is deemed feasible by the specialized oncological gynaecology team.

The uterine body is removed along with the fallopian tubes and ovaries. The operation aims to remove all tumor tissue and any cancerous lymph nodes in the pelvis and abdomen. If there are involvement/spread to neighboring organs (such as the bladder and rectum), theses may also be removed in selected cases. Many patients in lower stages (1-2) are cured by the surgical procedure alone.

The operation can be performed with an abdominal incision, or in early stages by hysteroscopic surgery.

All removed tissue is send for pathological examination for determination of final cancer type, grade, and stage of disease.

This information is essential for determining, if oncologic treatment is warranted also.

In certain cases with advanced stages, the surgical procedure is accompanied with radiation and/or chemotherapy. The aim is to destroy/kill any remaining cancer cells in the body, thereby reducing the risk of relapse of cancer.

Patients may experience complications or side effects after the surgery. In general the greater the procedure, the higher risk of complications such as e.g. hardened scar/fibrous tissue, lesion/dysfunction of nearby structures/organs, fluid gathering in the underlying tissue or legs (lymphoedema), sexual complaints etc. We recommend you discuss these issues with your doctor(s).

Endocrine Therapy

Anti-hormonal therapy (endocrine therapy) can be used for patients with recurrent/disseminated endometrial cancer, if metastases (daughter tumors) have spread to other locations or organs in the body. Endocrine therapy has significantly fewer side effects than chemotherapy. The effect of hormone therapy is slower in onset, than that of chemotherapy. Chemotherapy is usually given initially as treatment for metastatic disaese with signinficant/severe symptoms incl. shortness of breath due to spread to the lungs.

Fragile and/or elderly patients who may not be candidates for (further) chemotherapy do in many cases tolerate endocrine treatment well. Some patients derive benefit from the treatment for extended periods of time. 

Particularly aggressive, malignant tumors usually do not respond well or at all to endocrine therapy. 

Anti-hormone treatment can have side effects, such as weight gain, nausea, dry skin, and sleep-disturbances. The side effects disappear after the therapy stops, and are overall less disturbing, than those caused by chemotherapy or radiation treatment.

Chemotherapy

For patients who undergo primary surgery: Based on the stage, histological type, surgical findings and outcome, the recommendation/option of receiving post-surgical treatment with “adjuvant” chemotherapy will be discussed with you. It will be recommended to give adjuvant chemotherapy for a selected group of patients with high risk disease based upon stage and/or histological type and mutational status.

Chemotherapy are powerful pharmaceutical drugs used to kill fast-growing cells (e.g. cancer cells) throughout the body. The drugs work by inhibiting cell growth, thereby aiming to induce tumor regression.

The standard adjuvant chemotherapy for endometrial cancer is a combination therapy with two drugs (carboplatin and paclitaxel), which are given intravenously six times with 3 weeks apart.

Treatment with chemotherapy also affects normal tissue, which can cause side effects. Especially tissues which renew themselves quickly, are likely to be affected. These include the mucous membranes of the mouth, stomach and intestines, the hematopoietic system in the bone marrow, and the hair roots. Several side effects can be alleviated well with medication, and usually disappear/diminishes significantly, when chemotherapy is no longer administered.

Radiation Therapy

For more advanced cancers (at diagnosis), a combination of surgery with radiation and/or chemotherapy may be recommended.

The radiation therapy is given to a limited part of the pelvic area, and is effective and intended to reduce the risk of relapse (adjuvant radiation therapy).

Radiation therapy kills or destroys any remaining malignant cells after surgery. Radiation may be given from the outside (external), or through the vagina (internal). Ask your doctor about the recommendations for your specific case.

In several countries radiotherapy is not given routinely in combination with surgery and chemotherapy due to the risk of persistent side effects. There radiotherapy is reserved for selected high risk cases, and for patients with localized relapse in the pelvis. The treatment can still be curative in nature, if given to correctly selected cases.

The nature and extent of patients physical complaints (side effects), during or following radiotherapy, are often relative to the extent of pre-radiation surgery, and the size of the irradiated field. The more extensive the treatment, the sooner and the more extensive the side effects may be.

Radiation should only be used instead of surgery, if serious health issues are present, which makes surgery too great a risk for the patient.

Making decisions about your care

The choice of therapy for your cancer is an individual decision, and many factors are taken in to consideration, when your doctor(s) discuss the best option(s) with you. These include the type, size and location/spread of the tumor, as well as your age and general health status. 

We recommend, that you have a thorough discussion with your doctor(s) about the results upon your diagnosis, the treatment-plan and your chances of recovery (e.g. prognosis).

You are encouraged to include family and/or friends for participation in doctors appointments etc. for improving your/their understanding and remembrance of relevant information, as well as for emotional and physical support during appointments and treatments. 

Your doctor can give a detailed explanation of the various therapy options, and has knowledge of the possibility to participate in a clinical trial. Each patient is different and so is their wish upon information needed/wanted prior to making important decisions. 

Well designed and conducted clinical trials are essential to determine the effectiveness of a promising new drug or intervention. Many gynaecologic oncology departments have studies open for inclusion during the course of your cancer treatment. Talk to your doctor(s) about your thoughts regarding possible inclusion in a clinical trial now or in the future.

                                                                                                               (References; www.DGCG.DK, Kræft Klinik og sygepleje, FADL’s forlag 2019) 

Author: Kristine Madsen, MD, Deputy Medical Director NSGO-CTU

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Privacy Policy for NSGO

NSGO treats personal information and complies with the laws and principles of good data processing practices. Therefore, we have adopted this Privacy Policy, which briefly describes how we treat personal information, so legal and transparent processing is ensured.

We are responsible for processing your personal information:

NSGO is the data controller and you can always contact the organization’s data protection officer:

Mansoor Raza Mirza

Nordic Society of Gynecologic Oncology – Clinical Trial Unit
Copenhagen University Hospital
Department of Oncology, 9431
Blegdamsvej 60
DK-2100 Copenhagen
Office phone: +45 35 45 33 78
fax: +45 3545 2898
nsgo-dpo.rigshospitalet@regionh.dk

We treat the following personal information about members:

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For historical reasons and as your details might be saved in old attendance lists, email correspondence and minutes from meetings, we cannot promise that all personal information about you will be deleted, if you terminate your membership.

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You have a number of rights via the General Data Protection Regulation (GDPR):

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You can file a complaint with the supervisory authorities – The Danish ‘Datatilsynet’ – About processing your personal information (www.datatilsynet.dk).

Revision of Privacy Policy:

We reserve the right to change the organization’s privacy policy. When we change privacy policy, we also change the date and version number at the bottom of this document. In case of significant changes, you will receive a notification.

The current privacy policy is always available on our website.

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Privacy Policy for NSGO-CTU

NSGO-CTU treats personal information and complies with the laws and principles of good data
processing practices. Therefore, we have adopted this Privacy Policy, which briefly describes how we treat personal information, so legal and transparent processing is ensured.

We are responsible for processing your personal information:

NSGO-CTU is the data controller and you can contact the organization’s data protection officer:

Mansoor Raza Mirza

Nordic Society of Gynecologic Oncology – Clinical Trial Unit
Copenhagen University Hospital
Department of Oncology, 9431
Blegdamsvej 60
DK-2100 Copenhagen
Office phone: +45 35 45 33 78
fax: +45 3545 2898
nsgo-dpo.rigshospitalet@regionh.dk

We treat the following personal information about personnel participating in NSGO-CTU trials:
• General personal information: For example; contact information such as name, work
address, work phone number, date of birth, email address, country, work title, date of start
of participation and termination in a trial and, if applicable, CV, GCP certificates, records of
training and other qualification data.
• If applicable, financial disclosure forms and/or Bank account number for reimbursement
purposes.

We collect personal information from:
• We will ask you to provide us the information yourself, when you in decide to take part
in NSGO-CTU trials.
The organization’s legal basis to process personal information:
• That we as an organization have a (legitimate) interest in processing your information, for
example to secure your qualifications in handling the care of the participants in a trial.
• That it is necessary for us to fulfill an agreement with your employer
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conducted according to the principals governing clinical research as set out in the
Declaration of Helsinki and with the acceptance of all involved Regulatory Health
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• Communicate regarding studies.
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• To comply with legislation.
• To deliver services, in the form of the possibility to participate in the Annual Meeting,
Investigator Meeting.
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your employer where terms and conditions are described, or if you put your name on the
Delegation Log of a trial, you agree to the information described in this Privacy Policy.
However, it may happen that we judge it necessary to obtain your written consent for other
purposes. In that case you will have the opportunity to voluntarily agree, and you may withdraw it
at any time by notifying us.
Be aware that there are legal bases for certain forms of processing of your data for the abovementioned purposes and that your consent is the only legal basis for other forms of processing.

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also if a less severe data protection law should exist.
We do not disclose information about you to anyone outside the organization without the above
consent, however, it should be noted, that if you e.g. accept an invitation to a meeting, your
personal information might be forwarded to the meeting location or the meeting organizer. Only
personal information relevant for the 3rd party will be disclosed in these circumstances.
Furthermore, your data can be transmitted to public databases for registration, as well as
publication of a trial and your data can be stored and published in those databases.
Storing and deleting your personal information:
For historical reasons and as your details might be saved in old attendance lists, email
correspondence and minutes from meetings, we cannot promise that all personal information
about you will be deleted, when you end your participation in a study. In general, all information
about a trial is deleted at least 20 years after end of study.

Your rights:
You have a number of rights via the General Data Protection Regulation (GDPR):
• The Right to Information (to be informed what information we process about you)
• The Right of Access (to get a print of the information we process about you)
• The Right to Rectification (to have false information about you corrected)
• The Right to Erasure (to delete information we process about you, however, information
already received cannot be deleted)
• The Right to Restriction of processing (under certain conditions, to have the processing of
your data restricted)
• The Right to Object (to object to your information being used for wrong purposes)

You may make use of your rights by contacting us, however, the legality of the processing carried out
prior to e.g., a withdrawal will not be affected. If you submit a request to have your personal
information corrected or deleted, we will investigate whether the conditions are met and, in that
case, make changes or deletions as soon as possible and, if applicable, also notify our data
processors to do so.

If you do not believe that NSGO-CTU handles your data correctly, you can file a complaint with the
supervisory authorities – The Danish ‘Datatilsynet’ – About processing your personal information
(www.datatilsynet.dk).

Revision of Privacy Policy:
We reserve the right to change the organization’s privacy policy. When we change privacy policy,
we also change the date and version number at the bottom of this document. In case of significant
changes, you will receive a notification.

The current privacy policy for NSGO-CTU is always available on our website.

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