Key learning points:
- Understanding the diagnostic pathway
- The treatment principles
- How primary care can support patients during treatment
Cancer of the womb (also known as endometrial or uterine cancer) is the fourth most common cancer in women. According to Cancer Research UK2, about 23 women are diagnosed with womb cancer every day. Although incidence rates of womb cancer have increased 43% since the early 1990s in Great Britain, (3) more than three quarters of these women will survive their cancer (4). This ranks womb cancer sixth highest out of 20 common cancers in England and Wales for 10-year survival.
Types of womb cancer
Womb cancers develop from the endometrium, the glandular menstrual tissue that lines the inside of the womb. Malignant tumours of the womb muscle (myometrium) are sarcomas.
There are several types of womb cancer. The commonest (about 80%) is type 1 endometrial cancer, endometrioid adenocarcinoma. Less common type 2 womb cancers include carcinosarcomas (also known as mixed myesenchimal mullerian tumour MMMT), serous papillary and clear cell cancers; these have different causes, behave differently and are generally more aggressive, metastasise earlier and have poorer outcomes.
Endometrioid adenocarcinoma is associated with exposure to oestrogen without the inhibiting effects of progesterone. Unopposed oestrogen stimulates menstrual tissue to grow and thicken. This is endometrial hyperplasia and can indicate cancer or precursar to cancer.
It is this exposure to unopposed oestrogen that helps explain the main risk factors. Almost two thirds of womb cancers occur in women aged 55 to 75,2 i.e. after the menstrual cycle has ended. Oestrogen is synthesised in fat tissue so it follows that being overweight is a significant risk factor; obesity has been suggested as a cause of one third of the cases in the UK (1).
Exposure to Tamoxifen and oestrogen-only HRT as well as nuliparity are also risk factors. Women who carry the hereditary non-polyposis colorectal cancer (HNPCC) gene also are at risk (30-60% lifetime) of developing womb cancer. In younger women, polyctystic ovary syndrome – which causes progesterone deficiency – and obesity are risk factors.
These risk factors and a recognition that pre cancer and cancer can cause random bleeding should make every GP and practice nurse aware that inter-menstrual bleeding or post-menopausal bleeding can be due to cancer and this symptom must be investigated.
A woman with abnormal uterine bleeding and no obvious cause should be referred to the gynaecology abnormal or post menopausal bleeding clinic (PMB) under the two week wait cancer referral system. In addition to history taking she may be given a trans-vaginal ultrasound scan to measure her endometrial lining.
The endometrial thickness in the menopause should be less than 4mm. If abnormally thick (over 4mm) a sample of tissue (endometrial biopsy) may be taken by passing a fine straw into the uterus and sucking out some cells for laboratory analysis. A sampling instrument (e.g. Pipelle, Wallace, Accurette or Explora sampler) is passed through the cervix via a speculum examination. The majority of women find this tolerable, experiencing period type cramps during the procedure, wearing off within minutes. Light bleeding and mild period like discomfort may continue for a couple of days post procedure.
A hysteroscopy is more invasive, but can also be performed in the outpatient setting. This involves a fibrotic light source (hysteroscope) inserted through the vagina and cervix to visualise the endometrial cavity and lining and to take biopsies. Many women tolerate this with oral pain relief and local anaesthetic injected into the cervix. However, women should be offered the procedure under general anaesthetic if they find the procedure intolerable.
It generally takes a week to process the biopsies and the woman may be invited back to clinic to receive results. The majority of results are not linked to cancer.
The diagnosis of cancer requires additional investigations. A full holistic history is needed to assess psychological and family needs and a staging scan, usually a CT (computerised tomography) may be needed to assess the risk that the cancer has spread beyond the womb. The test results and case history will be discussed at the gynaecology cancer multi-disciplinary team (MDT) meeting.
The team comprises experts in gynaecology oncology to include surgeons, medical and clinical oncologists (chemotherapy and radiotherapy), radiologists, pathologists, research nurses and clinical nurse specialists.
The basic principle of uterine cancer surgery is to remove the womb cancer with curative intent. Therefore, the usual treatment is a hysterectomy if the clinical examination and radiology demonstrate that the cancer is confined to the womb. The ovaries are traditionally removed at the same time and some centres believe that lymph nodes should also be removed.
However, surgery to remove the womb will not be enough to cure if the cancer has spread beyond the womb. The MDT will consider the type of cancer and extent of spread of disease and will recommend surgery, radiotherapy or chemotherapy (or a combination) to treat the disease.
Radiotherapy and chemotherapy can be given after the hysterectomy. This is known as adjuvant therapy and is designed to reduce the risk of recurrence.
Primary care support during investigation and treatment
Many women describe the diagnostic process and subsequent treatment as “surreal”, as though it’s happening to someone else. Some describe the wait for test and the results as intolerably long. Others tell a story of “like being on a rollercoaster, fast and frightening, I couldn’t get off even if I wanted to”.
A fundamental part of modern cancer care for women and their families includes emotional support, communication with her cancer team, information provision on the patient’s treatment pathway and choices. This role usually falls to an identified key worker allocated to the patient at the point of their diagnosis. This is usually a clinical nurse specialist (CNS) although this role may be taken by the surgeon in the private system. The CNS will support the patient through her cancer journey, provide written information on tests and cancer treatment and remain in contact.
The CNS should inform the primary care team within 24 hours of a cancer diagnosis, giving contact details for enquiries on treatment planning, manage the uncertainties, fears and distress of a cancer diagnosis. Liaison between primary and secondary care teams helps to establish good working links, especially key as more post treatment care is being commissioned in the primary care sector.
For this reason the primary care nurse should have the cancer centre’s link numbers for any queries to include the CNS, chemotherapy nurses and acute oncology service
Nursing support from primary care during investigation and treatment can help to “normalise “ the cancer experience, keeping some support local, instead of all through the hospital. For example taking bloods pre operatively or pre chemotherapy (guided by the hospital) can provide a more convenient pathway for the woman.
Wound care in the expert hands of district or practice nurses can also offer a reassuring opportunity for women to talk about to return to normal of aspects such as bowel function.
Surveillance after treatment
Continued support after primary treatment involves screening for treatable recurrent disease, supporting the consequences of treatment (survivorship). This care package is variable depending on the patient and family’s needs.
It can range from “available but never needed” to supporting complex family dynamic, finances, grants, post traumatic stress, managing the toxicity from radiotherapy and the psychological distress of loss of perceived femininity, fertility or sexual function. The diagnosis of a recurrence begins the cycle again.
Click here to read a patient’s point of view
1. Cancer Research UK. Uterine cancer statistics. http://www.cancerresearchuk.org/cancer-info/cancerstats/types/uterus/uk-... (accessed 13 February 2015)
2. Outline of Uterine Cancer in the United Kingdom: Incidence, Mortality and Survival. Gynaecological Cancer SSCRG. National Cancer Intelligence Network. 2014
3. Cancer Research UK: Uterine cancer statistics http://www.cancerresearchuk.org/cancer-info/cancerstats/types/uterus/uk-... (accessed 13 February 2015)
4. NICE. Referral Guidelines for Suspected Cancer CG27 2005.
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