Cancer of the Uterus
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Cancer of the Uterus
Treatment for cancer of the uterus
Cancer of the uterus is often diagnosed early, before it has spread, and can be treated surgically. For many women, surgery will be the only treatment needed. If cancer has spread beyond the uterus, radiation therapy, chemotherapy or hormone therapy may also be used.
Cancer of the uterus is usually treated with an operation that removes the uterus and cervix (total hysterectomy), along with both fallopian tubes and ovaries (bilateral salpingo-oophorectomy). If the cancer has spread beyond the cervix, the surgeon may also remove a small part of the upper vagina and the ligaments supporting the cervix.
For more advanced or higher-grade tumours, the surgeon may suggest removing some nearby lymph nodes at the same time. This is called a pelvic lymphadenectomy, lymph node dissection or lymph node sampling and helps show whether cancer has spread outside the uterus.
Options for preserving fertility
If you have not yet been through menopause, the removal of the ovaries will bring it on. If your ovaries appear normal and you don’t have any risk factors, you may be able to keep your ovaries.
A small number of women with early uterine cancer choose to wait until after they have had children to have a hysterectomy. These women are offered hormone therapy instead. This is not standard treatment and they need to be monitored closely. If having children is important to you, talk to your doctor about your particular situation.
Total hysterectomy and bilateral salpingo-oophorectomy
Most women with uterine cancer will have this operation, which removes the uterus, cervix, fallopian tubes and ovaries. Sometimes one or more pelvic lymph nodes are also removed. A pathologist examines all removed tissue and fluids for cancer cells. The results will help confirm the type of uterine cancer you have, if it has spread (metastasised), and its stage and grade. The cancer may also be tested for particular gene changes.
The surgery will be performed under a general anaesthetic. It can be done in different ways, as shown in the diagrams below. The type of hysterectomy offered to you will depend on a number of factors, including:
- your age and build
- the size of your uterus
- the size of the tumour
- the surgeon’s specialty and experience.
Your surgeon will talk to you about the most appropriate surgery for you and explain the risks and benefits.
What to expect after the operation
When you wake up after the operation, you will be in a recovery room near the operating theatre. Once you are fully conscious, you will be transferred to the ward.
Tubes and drips − You will have an intravenous drip in your arm to give you medicines and fluid, and a tube in your bladder (catheter) to collect urine. These will usually be removed the day after the operation.
Pain − As with all major operations, you will have some discomfort or pain. For the first day or two, you may be given pain medicine. This may be delivered in different ways, such as:
- through a drip
- via a local anaesthetic injection into the abdomen (a transverse abdominis plane, or TAP, block)
- via a local anaesthetic injection into your back, either into spinal fluid (a spinal) or into the space around spinal nerves (an epidural)
- with a patient-controlled analgesia (PCA) system, a machine that allows you to press a button for a measured dose of pain relief.
Let your doctor or nurse know if you are in pain so they can adjust your medicines to make you as comfortable as possible. Do not wait until the pain is severe.
Wound care − You can expect some light vaginal bleeding after the surgery, which should stop within two weeks. Your treatment team will talk to you about how you can keep the wound/s clean to prevent infection once you go home.
Blood clot prevention − You will be given a daily injection of a blood thinner to reduce the risk of blood clots. Depending on your risk of clotting, you may be taught to give this injection to yourself, so you can continue it for a few weeks at home. You may also be advised to wear compression stockings for a couple of weeks to help the blood in your legs circulate.
Constipation − The medicines used during and after surgery can cause constipation (difficulty passing bowel motions). Talk to your treatment team about how to manage this – they may suggest a stool softener, fibre supplement, or another medicine. Once your surgeon says you can get out of bed, walking around can also help.
Length of stay − You will stay in hospital for about 1−4 days. The length of stay will depend on the type of surgery you have had and how quickly you recover.
Test results − Your doctor will have all the test results about a week after the operation. Whether further treatment is necessary will depend on the type, stage and grade of the disease, and the amount of any remaining cancer. If the cancer is at a very early stage, you may not need additional treatment.
Taking care of yourself at home after a hysterectomy
Your recovery time will depend on your age, general health and the type of surgery that you had. Most women feel better within 1–2 weeks and should be able to fully return to usual activities after 4–8 weeks. In general, women do not need specific help to recover, but if you think you may need home nursing care, ask hospital staff about services in your area.
Rest – When you get home from hospital, you will need to take things easy for the first week. Ask family or friends to help you with chores so you can rest.
Lifting – Avoid heavy lifting (more than 3–4 kg) for 2−3 months, depending on the advice of your surgeon. This will depend on the method of the surgery.
Work – Depending on the nature of your job, you will probably need 4–6 weeks leave from work.
Driving – You will need to avoid driving for about a month after the surgery. Check with your car insurer for any exclusions regarding major surgery and driving.
Bowel problems – It is important to avoid straining when passing bowel motions. Continue to manage constipation as advised by your treatment team.
Nutrition – Focus on eating a balanced diet (including proteins such as lean meats and poultry, fish, eggs, milk, yoghurt, nuts, seeds and legumes/ beans) to help your body recover from surgery.
Sex – Sexual intercourse should be avoided for up to 8 weeks after surgery. Ask your doctor when you can resume sexual intercourse, and explore other ways you and your partner can be intimate, such as massage.
Bathing – Take showers instead of baths for 4–6 weeks after surgery.
Exercise – Your health care team will probably encourage you to walk the day after the surgery. Exercise has been shown to help people manage some side effects of treatment, speed up a return to usual activities, and improve overall quality of life. Start with a short walk and then go a little
further each day. Speak to your doctor if you would like to try more vigorous exercise.
Side effects after surgery
Menopause – If you had a bilateral salpingo-oophorectomy and had not been through menopause before the operation, the removal of your ovaries will cause menopause.
Vaginal vault prolapse – After a hysterectomy, the top of the vagina can drop towards the vaginal opening because the structures that support it have weakened. To help avoid a prolapse, it is important to do pelvic floor exercises several times a day. Most women can start these exercises 1−2 weeks after surgery. Your treatment team may explain how to do these exercises. You can also consult a women’s health physiotherapist – you may be able to see one at the hospital or you can ask your GP for a referral.
Impact on sexuality – The changes you experience after surgery may affect how you feel about sex and how you respond sexually.
Lymphoedema – The removal of lymph nodes from the pelvis can stop lymph fluid from draining normally, causing swelling in the legs known as lymphoedema. The risk of developing lymphoedema is low following most operations for cancer of the uterus in Australia, but it is higher in women who had a lymphadenectomy followed by external beam radiation therapy. Symptoms appear gradually, sometimes years after the treatment. Your treatment team will explain how to reduce your risk.
Also known as radiotherapy, radiation therapy is the use of targeted radiation to kill or damage cancer cells so they cannot grow, multiply or spread. The radiation is usually in the form of x-ray beams. Treatment is carefully planned to limit damage to the surrounding healthy tissues.
For cancer of the uterus, radiation therapy is commonly used as an additional treatment after surgery to reduce the chance of the disease coming back. This is called adjuvant therapy. In some cases, radiation therapy may be recommended as the main treatment if other health conditions mean you are not well enough for a major operation.
There are two main ways of delivering radiation therapy: internally or externally. Some women are treated with both types of radiation therapy. Your radiation oncologist will recommend the course of treatment most suitable for you.
Internal radiation therapy (brachytherapy)
Internal radiation therapy may be used after a hysterectomy to deliver radiation directly to the top of the vagina (vaginal vault) from inside your body. This is known as vaginal vault brachytherapy.
During each treatment session, a plastic cylinder (the applicator) is inserted into the vagina. The applicator is connected by plastic tubes to a machine that contains radioactive material in the form of a small metal seed. Next, this seed is moved from the machine through the tubes into your body. After a few minutes, the seed is returned to the machine. The applicator is taken out after each session.
Brachytherapy does not need any anaesthetic, and each treatment session usually takes only 20−30 minutes. You are likely to have 3–6 treatment sessions as an outpatient over 1−2 weeks.
If a hysterectomy has not been done and radiation is given as the main treatment, the internal radiation therapy may involve an applicator being placed inside the uterus. This is done under general anaesthetic or sedation, and may require a short hospital stay.
External beam radiation therapy
External beam radiation therapy (EBRT) directs the radiation at the cancer and surrounding tissue from outside the body. For cancer of the uterus, the lower abdominal area and pelvis are treated, but if the cancer has spread (metastasised), other areas may also be treated. You will lie on a treatment table under a large machine known as a linear accelerator, which delivers the radiation.
The actual treatment takes only a few minutes each time and is painless (like having an x-ray). However, the planning may involve a number of visits to your doctor to have more tests, such as blood tests and scans.
You will probably have EBRT sessions from Monday to Friday for 4–6 weeks. You usually receive this treatment as an outpatient and won’t need to stay in hospital. It’s very important that you attend all of your scheduled sessions to ensure you receive enough radiation to kill the cancer cells or relieve symptoms.
Side effects of radiation therapy
The side effects you experience will vary depending on the type of radiation, the dose of radiation and the areas treated. Brachytherapy tends to have fewer side effects than EBRT. Side effects often get worse during treatment and just after the course of treatment has ended. They usually get better within weeks, through some may continue for longer. Some side effects may not show up until many months or years after treatment. These are called late effects.
Short-term side effects
Fatigue – Your body uses a lot of energy to recover, and travelling to treatment can also be tiring. The fatigue may last for weeks after treatment ends. Exercise can help manage fatigue.
Bowel and bladder problems – Radiation therapy can cause inflammation and swelling of the bowel (radiation proctitis) and bladder (radiation cystitis). Bowel motions may be more frequent, urgent or loose (diarrhoea), or you may pass more wind than normal. Less commonly, there may be blood in the stools. You may also pass urine more often or with more urgency, or with a burning sensation. Your treatment team will prescribe medicines to reduce these side effects.
Nausea and vomiting – Because the radiation therapy is directed near your abdomen, you may feel sick (nauseous), with or without vomiting, for several hours after each treatment. Your doctor may prescribe anti-nausea medicine to help prevent this.
Vaginal discharge – Radiation therapy may cause or increase vaginal discharge. Let your treatment team know if it smells bad or has blood in it. Do not wash inside the vagina with douches as this may cause infection.
Skin redness, soreness and swelling – The vulva and the skin in the groin area may become sore and swollen. It may start by being pink or red and feeling itchy, and then peel, blister or weep. Your treatment team will recommend creams and pain relief to use. Wash the vulva with lukewarm water or weak salt baths, avoid perfumed products, and wear cotton underwear.
Long-term or late effects
Hair loss – You may lose your pubic hair. For some women, this can be permanent. Radiation therapy to the pelvis will not affect the hair on your head or other parts of your body.
Bowel and bladder changes – Bowel changes, such as diarrhoea, wind or constipation, and bladder changes, such as frequent or painful urination, can also be late effects, appearing months or years after treatment. Bleeding from the bowel or bladder can also occur. In rare cases, women experience loss of bowel control (faecal incontinence) or blockage of the bowel. It is important to let your doctor know if you have any bleeding or if you have pain in the abdomen and cannot open your bowels.
Lymphoedema – Radiation can scar the lymph nodes and vessels and stop them draining lymph fluid properly from the legs, making the legs swollen. This can occur months or years after radiation therapy. Lymphoedema is easier to treat if recognised early.
Narrowing of the vagina – The vagina can become drier, shorter and narrower (vaginal stenosis), which may make sex and pelvic examinations uncomfortable or difficult. Your treatment team will suggest strategies to prevent this, such as the use of vaginal dilators.
Menopause – In premenopausal women, radiation therapy to the pelvis can stop the ovaries producing hormones, and this causes early menopause. Your periods will stop, you will no longer be able to become pregnant and you may have menopausal symptoms. Talk to your radiation oncologist about these issues. You may be able to visit a menopause clinic.
Chemotherapy uses drugs to kill or slow the growth of cancer cells. The aim is to destroy cancer cells while causing the least possible damage to healthy cells.
Chemotherapy for uterine cancer may be used:
- for certain types of uterine cancer
- when cancer comes back after surgery or radiation therapy to try to control the cancer and to relieve symptoms
- if the cancer does not respond to hormone therapy
- if the cancer has spread beyond the pelvis when first diagnosed
- during radiation therapy (chemoradiation) and/or after radiation therapy.
Chemotherapy is usually given by injecting the drugs into a vein (intravenously). You may be treated as an outpatient or, very rarely, you may need to stay in hospital overnight. You will have a number of treatments, sometimes up to six, every 3–4 weeks over several months. Talk to your doctor about how long your treatment will last.
Side effects of chemotherapy
The side effects of chemotherapy vary greatly for each woman and depend on the drugs you receive, how often you have the treatment, and your general fitness and health. Side effects may include feeling sick (nausea), vomiting, fatigue, some thinning and loss of body and head hair, and numbness and tingling in the hands and feet (peripheral neuropathy). Most side effects are temporary and steps can often be taken to prevent or reduce their severity.
Hormones such as oestrogen and progesterone are substances that are produced naturally in the body. They help control the growth and activity of cells. Some cancers of the uterus depend on oestrogen and/or progesterone to grow. These are known as hormone-dependent or hormone-sensitive cancers and can sometimes be treated with hormone therapy.
Hormone therapy may be recommended for uterine cancer that has spread or come back (recurred), particularly if it is a low-grade cancer. It is also sometimes offered as the first treatment if surgery has not been done (e.g. when a young woman with early, low-grade uterine cancer chooses not to have a hysterectomy because she wants to have children, or if a woman is too unwell for surgery).
The main hormone therapy for women with hormone-dependent cancer of the uterus is progesterone that has been produced in a laboratory. Progesterone is available in tablet form (usually either medroxyprogesterone or megestrol); as an injection given by your GP or nurse; or through a hormone-releasing intrauterine device (IUD) called a Mirena, which is fitted into the uterus by your doctor (if you have not had a hysterectomy). Talk to your doctor about the risks and benefits of the different methods.
Side effects of hormone therapy
The common side effects of progesterone treatment include breast tenderness, headaches, tiredness, nausea, menstrual changes, and bloating. In high doses, progesterone may increase appetite and cause weight gain. If you have an IUD, it may move out of place and need to be refitted by your doctor.
Targeted therapy is a drug treatment that attacks specific features of cancer cells to stop the cancer growing and spreading. Your oncologist may discuss additional testing of the tumour to see whether any of these drugs might be an option, particularly for cancer that has returned. Targeted therapy drugs are not yet standard treatment for cancer of the uterus, but you can ask your oncologist whether you may be able to access them through a clinical trial.
Palliative treatment helps to improve people’s quality of life by managing symptoms of cancer without trying to cure the disease. Many people think that palliative treatment is for people at the end of their life, but it can help at any stage of advanced uterine cancer. It is about living as long as possible in the most satisfying way you can.
As well as slowing the spread of cancer, palliative treatment can relieve any pain and help manage other symptoms. Treatment may include radiation therapy, chemotherapy or hormone therapy. Palliative treatment is one aspect of palliative care, in which a team of health professionals aim to meet your physical, practical, emotional, spiritual and social needs. The team also supports families and carers.
This information is reviewed by
This information was last reviewed March 2019 by the following expert content reviewers: A/Prof Alison Brand, Director, Gynaecological Oncology, Westmead Hospital, NSW; Kate Barber, 13 11 20 Consultant, Cancer Council Victoria; Prof Jonathan Carter, Director, Gynaecological Oncology, Chris O’Brien Lifehouse, NSW; Dr Robyn Cheuk, Senior Radiation Oncologist, Royal Brisbane and Women’s Hospital, QLD; Dr Alison Davis, Medical Oncologist, Canberra Region Cancer Centre, The Canberra Hospital, ACT; Kim Hobbs, Clinical Specialist Social Worker, Westmead Hospital, NSW; Nicole Kinnane, Nurse Coordinator, Gynaecology Oncology, Peter MacCallum Cancer Centre, VIC; Jennifer Loveridge, Consumer; Pauline Tanner, Gynaecology Cancer Nurse Coordinator, WA Cancer & Palliative Care Network, North Metropolitan Health Service, WA.