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August 6, 2009 – Vol. 3 • No. 12
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Uterine cancer:
Obesity a key risk factor

Dorthula Anderson is not the typical 76-year-old woman.

She started skiing in her 60s and has an award to show for her remarkable progress. In one season, she proudly explains, she went from a non-skier to the intermediate level.

And there are the whitewater rafting expeditions that she has gone on in her early 70s.

To say the least, Anderson is exuberant about life. So when she was diagnosed with uterine cancer — commonly referred to as endometrial cancer — last year, she handled it with bold determination.

No time for tears or worry. “I just wanted to know what could be done about it,” she said. “It was going to be whatever it was to be.”

Anderson readily admits that she was not familiar with uterine cancer, nor did she know its warning signs.

“It was puzzling,” she said.

Quiet as it’s kept, uterine cancer is the fourth most common cancer in women, trailing breast, lung and colon cancers. The American Cancer Society estimates that over 42,000 new cases of uterine cancer will be diagnosed this year and there will be almost 8,000 deaths.

It is the most common gynecological cancer. Its incidence is almost twice as high as ovarian cancer and three times as high as cervical cancer.

Although it is more frequent in whites, the death rate from uterine cancer in blacks is more than 80 percent higher than in whites, according to the latest data from the Surveillance Epidemiology and End Results program of the National Cancer Institute.

Furthermore, the death rate in blacks is more than twice that in Hispanics and almost triple that in Asians.

A gynecologic oncologist at Massachusetts General Hospital, Dr. Marcela del Carmen explained that the racial disparities do not appear to be biological.

“The likely theory is that minorities lack access to the type of care they need,” she said.

That wasn’t the case with Anderson.

She knew something was wrong when she noticed a small amount of vaginal bleeding. A few days later, the bleeding became heavier and darker. As a post-menopausal woman, she couldn’t think of any explanation.

Fortunately, she already had a scheduled appointment with her doctor. When her doctor was unable to confirm a diagnosis, Anderson was referred to a gynecologist who performed a dilation and curettage (D&C) procedure.

When those results returned, the doctor immediately called her into the office — Anderson had a high grade stage 1 uterine cancer.

It wasn’t great news, but it could have been much worse. Uterine cancers are sometimes divided into two types based on their prognosis and underlying cause.

“Type 1 uterine cancer is a low grade estrogen-related cancer and has the most favorable outcome,” del Carmen explained. Type 1 cancers are usually not very aggressive and are slow to spread to other parts of the body.

“Type 2, on the other hand, is not estrogen related and is more aggressive and harder to treat,” she added. This type of cancer occurs more frequently in older people.

Endometrial cancer gets its name from the endometrium, the inner lining of the upper part of the uterus. The cervix is the lower narrow part of the uterus. The endometrium is the site of 95 percent of all uterine cancers. The remaining 5 percent are called sarcomas, which grow in the muscle of the uterus.

One of the most significant risk factors for uterine cancer is age. The median age of diagnosis is 62, but younger women are not exempt. Fran Drescher, the star of “The Nanny,” was diagnosed at the age of 42. Almost 57 percent of the cases occur in women under the age of 65, and 43 percent in those 65 and older.

Hormones are another risk factor. Uterine cancer is fuelled by estrogen. Women with prolonged exposure to estrogen — those who started their periods early or stopped late, or those who have not had children — may have increased risk.

It’s been found that women who take hormone replacement therapy of estrogen without progesterone have a higher incidence. The risk decreases when estrogen and progesterone are used together.

Heredity plays a role as well. Uterine cancer tends to run in families, especially those with an inherited tendency to develop colon cancer. The risk of ovarian cancer is also increased in these women.

Two common illnesses — diabetes and high blood pressure — are strong risk factors. According to the American Cancer Society, uterine cancer can be up to four times more common in women who have diabetes.

But the most controllable risk factor is obesity. Fat tissue and ovaries are sources of estrogen.

In the July issue of Obstetrics and Gynecology, researchers found that women who completed menopause before the age of 45 and had a body mass index (BMI) greater than 35 had a 22 times higher risk of uterine cancer than women of normal weight.

The BMI is a measure of body fat based on a person’s height and weight. A person with a BMI of 30 and above is considered obese.

The study went on to show that women of all ages, regardless of their status of menopause, had an increased risk of uterine cancer if their BMI exceeded 25, the upper limit of normal.

“Why don’t people tell you that?” an incredulous Sadie B. King wondered aloud.

King, a 62-year-old retired school teacher, knew all too well about what she described as her “few extra pounds.”

She also knew that she couldn’t escape the fact that “French fries and fried chicken just taste so good.”

But King, like Anderson, admits that she knew little about uterine cancer and even less about the correlation between that type of cancer and obesity.

All that changed when she was diagnosed with stage 1 uterine cancer. She quickly learned as much as she could and couldn’t wait to fire off questions during a meeting with her surgeon.

“Am I going to have a bikini cut?” she asked, referring to a common incision used to remove the uterus.

The surgeon had other plans. Because of her relative good health and “strong abdominal muscles,” the surgeon recommended robotic surgery.

The minimally invasive method can be used instead of open surgery and is known for its quicker recovery, fewer complications and shorter hospital stay.

As to King’s bikini cut question, the surgeon answered “no” and explained that she would have a few “poke holes,” the small incisions used for the robotic procedure.

Her surgery took place on a Friday and she was discharged the following Monday. She also had four treatments of radiation “to make sure they got all of it,” she said.

King has addressed the issue of obesity as well. She’s at the gym five days a week and has traded in her fried foods for fruits and vegetables.

Fortunately for King, they found the cancer early. Although there is no screening test for uterine cancer, the symptoms are distinctive and easily recognized.

For postmenopausal women, a gynecologist should evaluate spotting or bleeding or an unusual discharge right away. For younger, pre-menopausal women, unusual bleeding, such as bleeding between periods or excessively heavy periods, should also be examined. These symptoms can occur with noncancerous conditions, such as uterine fibroids, but should still be checked out by a doctor. Other symptoms may include pelvic pain or pain during intercourse.

The gold standard treatment for uterine cancer is hysterectomy.

The surgery includes removal of the uterus, ovaries and Fallopian tubes, and sampling of lymph nodes, and can be performed through an abdominal incision — the “bikini cut” — or less invasive techniques, such as laparoscopy or robotic surgery.

Some cases may require chemotherapy, radiation or hormone therapy.

Quite naturally, Anderson, a daredevil at heart, had few reservations about having a complete hysterectomy. Nor did she complain about the six additional treatments of radiation and chemotherapy.

On the day after her abdominal surgery, she was up and walking. She needed little medication for pain or nausea after the chemotherapy.

And as Anderson tells it, so far so good.

“When I woke up [from the surgery] … I knew I was OK,” she said.

Sadie B. King, who was treated for uterine cancer last year, participates in a clinical trial called SUCCEED — Survivors of Uterine Cancer Empowered by Exercise and Healthy Diet — to examine the impact of healthy lifestyle on the quality of life of obese women in remission from stage I or II uterine cancer.

Marcela del Carmen, M.D.
Gynecologic Oncologist
Massachusetts General Hospital

Dorthula Anderson (right) accepts every challenge head-on. She learned how to ski at the age of 61 and overcame uterine cancer last year at the age of 75.

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