CANCER OF THE WOMB (UTERUS)

( By JASCAP )

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Treatment

Treatment for womb cancer

Types of treatment
Multidisciplinary team
Giving your consent
Benefits and disadvantages of treatment
Making decisions about treatment
Second opinion

Types of treatment

Most womb cancers are discovered at an early stage (when they have not spread beyond the womb) and may be cured by a hysterectomy (surgical removal of the womb). As this treatment is very successful for many women, further treatment is not normally necessary.

Radiotherapy may be given after the operation, if your surgeon feels that there is any risk of the cancer coming back. Radiotherapy may be used instead of surgery if the cancer cannot be removed surgically, or if you are not fit enough to have an operation. Radiotherapy may be used if the cancer comes back (recurs) in the pelvic area at a later date.

If the cancer has spread to other parts of the body, treatment with a female hormone called progesterone may be able to shrink the cancer and control symptoms. Chemotherapy is also used sometimes for people in this situation, and can help to shrink the cancer and control its growth for a time. Your treatment will depend on a number of factors, including:

your age
your general health
the type of tumour you have
the stage and the grade of the cancer.

Multidisciplinary team

If your tests show that you have womb cancer, you will be looked after by a multidisciplinary team. This is a team of staff who specialise in treating gynaecological cancer and in giving information and support. It will normally include:

gynaecological surgeons
specialist nurses who give information and support
oncologists – doctors who have experience in gynaecological cancer treatment using chemotherapy, radiotherapy and hormonal therapy
radiologists who help to analyse x-rays
pathologists who advise on the type and extent of the cancer.

Other staff will also be available to help you if necessary, such as:

physiotherapists
counsellors and psychologists
social workers
dietitians.

Giving your consent

Before you have any treatment, your doctor will explain its aims to you. They will usually ask you to sign a form saying that you give your permission (consent) for the hospital staff to give you the treatment. No medical treatment can be given without your consent, and before you are asked to sign the form you should have been given full information about:

the type and extent of the treatment that you are advised to have
the advantages and disadvantages of the treatment
any other treatments that may be available
any significant risks or side effects of the treatment.

If you do not understand what you have been told, let the staff know straight away so that they can explain again. Some cancer treatments are complex, so it is not unusual for people to need repeated explanations.

It is often a good idea to have a friend or relative with you when the treatment is explained, to help you remember the discussion more fully. You may also find it useful to write down a list of questions before you go to your appointment.

Patients often feel that the hospital staff are too busy to answer their questions, but it is important for you to be aware of how the treatment is likely to affect you. The staff should be willing to make time for you to ask questions.

You can always ask for more time to decide about the treatment if you feel that you can’t make a decision when it is first explained to you.

You are also free to choose not to have the treatment. The staff can explain what may happen if you do not have it. It is important to tell a doctor, or the nurse in charge, so that they can record your decision in your medical notes. You do not have to give a reason for not wanting to have treatment, but it can be helpful to let the staff know your concerns so that they can give you the best advice.

Benefits and disadvantages of treatment

Many people are frightened at the idea of having cancer treatments, because of the side effects that can occur. Some people ask what would happen if they did not have any treatment. Although treatments such as radiotherapy can cause side effects, these can usually be well controlled with medicines.

Treatment can be given for different reasons and the potential benefits will vary depending upon the individual situation.

Early-stage womb cancer

In women with early-stage endometrial cancer, surgery is usually done with the aim of curing the cancer and, in most cases, is successful. Sometimes additional treatments such as radiotherapy are given after the surgery to reduce the risks of the cancer coming back.

Advanced womb cancer

If the cancer is at a more advanced stage or has come back (recurred), treatment may only be able to control it, leading to an improvement in symptoms and a better quality of life. However, for some people in this situation, treatment will not have much effect upon the cancer and they will get the side effects with little benefit.

Making decisions about treatment

If you have early-stage cancer and have been offered treatment that aims to cure it, deciding whether or not to accept the treatment may not be difficult. However, if you have more advanced cancer and the treatment is being given to control the cancer for a period of time, it may be more difficult to decide whether to go ahead.

Making decisions about treatment in these circumstances is always difficult, and you may need to discuss in detail with your doctor whether you wish to have treatment. If you choose not to, you can still be given supportive (palliative) care, with medicines to control any symptoms.

Second opinion

Some women find it reassuring to have another medical opinion to help them decide about their treatment. Most doctors will be pleased to refer you to another specialist for a second opinion, if you feel this will be helpful. However, a second medical opinion may take some time to arrange and may delay the start of your treatment, so you need to be sure that it will be helpful to you.

Surgery for womb cancer

The surgical treatment for womb cancer is the removal of the womb (hysterectomy) and is carried out by a gynaecological surgeon. Usually, the fallopian tubes and both ovaries will also be removed. This operation is called a total hysterectomy with bilateral salpingo-oophorectomy. Sometimes the lymph nodes close to the womb will also be removed. The reason for this extra surgery is to remove as much of the cancer as possible and to enable the pathologist to see if there are any cancer cells in the lymph glands.

Often it is possible for the gynaecologist to remove all the cancer at this operation so that no further treatment is necessary. However, if the cancer cannot be completely removed your surgeon may recommend you have radiotherapy treatment after the operation. Even if the whole tumour has been removed, radiotherapy is sometimes given to reduce the chance of the cancer coming back. If radiotherapy is necessary, your surgeon will refer you to a clinical oncologist (a doctor who specialises in radiotherapy treatment).

Drips and drains
Moving around
Pain
Going home
Sex
Physical activity
Support

Drips and drains

When you get back to the ward you will have a drip (intravenous infusion) in a vein in your arm until you are able to eat and drink normally. You may have drainage tubes in the wound to stop any excess fluid collecting. These are taken out within a few days. Usually a small tube (catheter) is put into your bladder and urine is drained into a collecting bag.

Moving around

You will be encouraged to start moving about as soon as possible. This is an essential part of your recovery, and even if you have to stay in bed the nurses will encourage you to do regular leg movements to prevent blood clots in your legs. You will also be shown how to do deep-breathing exercises to prevent chest infections. A physiotherapist will help you to do these exercises.

Pain

After your operation you may need regular painkillers, which are very effective at controlling any pain. If you still have pain it is important to let your nurses know as soon as possible, so that your painkillers can be changed to find a type and dose that is more effective for you.

Going home
Most women are ready to go home about four to six days after their operation. If you think you might have problems when you go home – for example, if you live alone or have several flights of stairs to climb – let the ward nurses, or social worker, know as soon as possible so that help can be arranged.

Sex

Although you will no longer have your monthly periods or be able to become pregnant (see our booklet on fertility), you will, when you are ready, be able to be sexually active again. Your surgeon will probably advise you not to have sexual intercourse for at least six weeks after your operation, to allow the wound to heal properly. Many women need more time before they are ready to have a sexual relationship. If you have any questions about these issues, don’t be afraid to discuss them with your GP, surgeon, specialist nurse or one of our nurses.

Our booklet on sexuality and cancer discusses ways of dealing with the physical and emotional changes that cancer treatment can cause.

Physical activity

After a hysterectomy it can take time for the abdominal (tummy) muscle and skin to heal. Because of this you will need to avoid strenuous physical activity, or heavy lifting, for about two months. Some women also find it uncomfortable to drive after their operation. It is a good idea to wait a few weeks before you start driving again.

Support

Before you leave hospital, you will be given an appointment to attend an outpatient clinic for your post-operative check-up. This will be a good time to discuss any problems that you may have had since your operation. Some women take longer than others to recover from their operation.

If you find you are having problems, it may be helpful to talk to someone who is not directly associated with your illness. Some women find it very helpful to see a counsellor, and we can give you contact details for counselling services around the country.

Radiotherapy for womb cancer

Radiotherapy treats cancer by using high-energy rays which destroy the cancer cells while doing as little harm as possible to normal cells.

When it is given
External radiotherapy
Planning your treatment
Treatment sessions
Skin care
Internal (intracavity) radiotherapy
Side effects
Possible long-term side effects

When it is given

Radiotherapy may be given after surgery, if your doctor feels that there is a risk of the cancer coming back. Radiotherapy may be used instead of surgery if you are not fit enough to have surgery or if the cancer has spread to the area surrounding the womb. It can also be used if the cancer comes back in the pelvic area at a later date. Radiotherapy for womb cancer can be given externally or internally, and often as a combination of the two.

Your clinical oncologist, who plans your treatment, will be able to help you with any problems or concerns you may have.

Our booklet on radiotherapy provides detailed information about this treatment and its side effects.

External radiotherapy

This is given by directing high-energy rays at the area of the cancer. It is usually done at a hospital outpatient clinic each weekday, with a rest at the weekend. The type and length of your treatment will depend on the size and position of the cancer, but it may last a few weeks.

Planning your treatment

To make the radiotherapy as effective as possible, it has to be carefully planned. On your first few visits to the radiotherapy department you will be asked to lie under a large machine called a simulator, which takes CT scans of the area to be treated.

Planning may take a few visits. Marks will be made on your skin to show the radiographer, who gives you your treatment, where the rays are to be directed. Sometimes a few permanent marks may be made on the skin instead of pen marks. These marks are tiny and will be made only with your permission.

Treatment sessions
Before each session of radiotherapy, the radiographer will position you carefully on the couch and make sure you are comfortable. During your treatment, which only takes a few minutes, you will be left alone in the room but you will be able to talk to the radiographer, who will be watching you carefully from the next room.


A radiographer watches on a monitor while treatment is given. You can talk to them by intercom

Radiotherapy is not painful but you do have to be still for a few minutes while your treatment is being given. The treatment will not make you radioactive and it is perfectly safe for you to be with other people, including children, after your treatment.

Skin care

Your skin may become sore in the area being treated. Perfumed soaps, creams or deodorants may irritate the skin and should not be used during the treatment. Your radiographer or nurse can advise you on skin care during this time.

Internal (intracavity) radiotherapy

Internal radiotherapy (often called brachytherapy) gives radiation directly to the womb and the area close by. It can be used after surgery if there is a chance that the cancer may come back. For those few women who can’t have surgery it may be used as an alternative treatment. Internal radiotherapy can be used on its own or combined with external radiotherapy.

With this treatment, applicators (hollow plastic or metal tubes) are placed into the top of the vagina. These tubes are usually put in position without anaesthetic or under light sedation. But if you still have your womb you may need a general anaesthetic.

Internal radiotherapy gives a high dose of radiation to the area close to the applicator, but only a low dose to tissues and organs more than a few centimetres away. The treatment is given by a machine that delivers radioactive sources (small radioactive metal balls) into the applicators.

This treatment can be given at two different speeds – depending on the machine being used. If the machine is a ‘low dose-rate’ machine, treatment will be given once over several hours or even days as an inpatient. This machine may be called a Selectron®, but other names are used sometimes. If the machine is a ‘high dose-rate’ machine, then the treatment is delivered in a few minutes as an outpatient but may have to be repeated more than once. Both low dose-rate and high dose-rate treatments seem to be equally effective.

If a low dose-rate machine is used, you will probably need to be in a separate room, set apart from the main ward and often behind lead shields. You will be asked to stay in bed while the applicator is in place, to make sure that it stays in the correct position. For the same reason, you will have a small tube (catheter) placed into your bladder to drain your urine. If a high dose-rate machine is used, a catheter is not usually needed as the treatment only takes a few minutes.

Visitors may only be allowed to stay for a short time, during which the machine is switched off and the radioactive sources go back into the machine. This is to keep the dose of radioactivity to visitors and hospital staff as low as possible. Children and pregnant women are not encouraged to visit.

You may feel isolated, frightened and possibly depressed at a time when you might want people around you. If you feel like this, you can let the staff looking after you know. It might also be helpful to take in plenty of reading material, a radio and other things to keep you occupied. The isolation only lasts while the applicators are in place. Once they are removed, the radioactivity disappears and it is perfectly safe for you to be with other people.

The applicator will be removed by one of the doctors or nurses on the ward. This can be uncomfortable. You will be given painkillers and occasionally sedation or gas and air (entonox) before the tubes are removed to make the removal easier for you.

Side effects

It is not unusual to have slight discharge once radiotherapy treatment has finished. If it continues or becomes heavy, let your clinical oncologist or specialist nurse know.

Radiotherapy to the pelvic area can cause side effects such as tiredness, diarrhoea and a burning sensation when passing urine. These side effects can be mild or more troublesome, depending on the strength of the radiotherapy dose and the length of your treatment. Your clinical oncologist, or specialist nurse, will be able to tell you what to expect.

Most of these side effects can be treated quite easily with tablets which your clinical oncologist can prescribe. Any side effects should gradually disappear a few weeks after your treatment is over.

It is important to drink plenty of fluids and maintain a healthy diet during your treatment. You may feel slightly sick but this is not common. If you don’t feel like eating you can replace meals with nutritious, high-calorie drinks, which are available from most chemists and can be prescribed by your GP. Our booklet on eating well has some helpful hints on how to eat well when you are feeling ill.

During your treatment it is helpful to get as much rest as you can, especially if you have to travel a long way each day. Our coping with fatigue booklet, has helpful tips on dealing with tiredness.

Sometimes radiotherapy causes a narrowing of the vagina, which can make sexual intercourse uncomfortable. Some women become less interested in sex and notice that their vagina is dry.

See the section on the effects on your sex life and fertility. Our information about the possible side effects of pelvic radiotherapy during treatment may also be useful.

Possible long-term side effects

Radiotherapy to the pelvic area can sometimes cause long-term side effects. However, improved planning and treatment techniques have made these long-term effects much less likely.

A small number of people, the bowel or bladder may be permanently affected by the radiotherapy. If this happens, the increased bowel motions and diarrhoea may continue, or you may need to pass urine more often than before. The blood vessels in the bowel and bladder can become more fragile after radiotherapy treatment and this can make blood appear in the urine or bowel movements. This can take many months or years to happen. If you notice any bleeding, let your doctor know so that tests can be carried out and appropriate treatment given.

Some people also find that the radiotherapy affects the lymph glands in the pelvic area and can cause swelling of the legs. This is known as lymphoedema and is an uncommon side effect.

There is more information about possible long-term side effects in our booklet on pelvic radiotherapy in women.

Hormonal treatment for womb cancer

If you have advanced womb cancer your doctor may recommend hormonal treatment with progesterone. This may shrink the cancer and control symptoms the cancer may be causing.

Progesterone is a hormone that occurs naturally in women. Artificial progesterone is available as tablets or by injection and can be given by your GP. The most common types are medroxyprogesterone acetate (Provera®) and megestrol (Megace®).

Side effects
Progesterone has very few side effects. Although some women may feel slightly sick, most women find that their appetite increases. This may make them put on some weight. Some women also notice slight muscle cramps.

Chemotherapy for womb cancer

Chemotherapy may be used if the cancer comes back, or has spread to other parts of the body, and does not respond to hormonal treatment. In some people, chemotherapy may help to shrink the cancer and relieve symptoms.

Chemotherapy is the use of anti-cancer (cytotoxic) drugs to destroy cancer cells. Some of the chemotherapy drugs that may be used to treat womb cancer are carboplatin, cisplatin, doxorubicin and paclitaxel (Taxol®).

How chemotherapy is given
Side effects

How chemotherapy is given

These chemotherapy drugs are given by injection into a vein (intravenously).

Side effects

Chemotherapy drugs tend to temporarily reduce the number of normal cells in the blood. When your blood count is low you are more likely to get an infection and may tire easily. During chemotherapy your blood will be tested regularly and, if necessary, you will be given antibiotics to treat infection. Blood transfusions may be given if you are anaemic.

Other side effects may include tiredness, feeling sick (nausea), vomiting and hair loss. Nausea and vomiting can now be well controlled with anti-sickness medicines. Some chemotherapy drugs also make the mouth sore and cause small ulcers. Regular mouthwashes are important and the nurses will explain how to use these properly. If you don’t feel like eating meals, you can supplement your diet with nutritious drinks or soups. A wide range of these drinks are available and you can buy them at most chemists.

Occasionally, women may have an allergic reaction to a chemotherapy drug, which can be very frightening. Tell your doctor or nurse if you notice any skin rashes and itching, a high temperature, shivering, redness of the face, dizziness, headache, breathlessness, or anxiety and a need to pass urine. Treatment can be given to reduce allergic reactions.

Although these side effects may be hard to bear at the time, they disappear once your treatment is over and your hair will grow back within a few months of finishing chemotherapy. Our booklet on coping with hair loss describes the different options for head coverings.

Some people do not have many side effects. Your doctor will tell you what problems to expect from your treatment.

Our chemotherapy booklet discusses the treatment and its side effects in more detail.

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