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A Review of Treatment and Outcomes
Cancer of the uterus is the most common gynecologic malignancy. According to the American Cancer Society (ACS), it is the 4th most common cancer in women and the 8th in terms of causing cancer-related death. About 47,000 cases were diagnosed in the USA in 2011. Uterine cancer is more common in women who are after the menopause. The American College of Surgeons- National Cancer Data Base (ACoS-NCDB) statistics show that 83% of cases nationally occur in women over age 50 and 31% occur in women older than 70 years. The Cancer Registry data at Community Hospital (CH) show the identical age distributions.
The most common symptom of uterine cancer is painless bleeding. This symptom often occurs early in the disease and can lead to the cancer being diagnosed in an early stage in many women. Nationally, 65 percent of women are diagnosed in Stage 1. At Community Hospital, 69 percent are diagnosed in Stage 1 and through the rest of Indiana, 68 percent are diagnosed in Stage 1. Stage 2 uterine cancer is diagnosed in 9 percent of our patients with the national rate being percent. Stage III uterine cancer is diagnosed in 10-11 percent of patients and this rate is the same between national, Indiana and Community Hospital ACoS-NCDB statistics (Fig 1).
Once the diagnosis is made, surgery is the preferred method of treatment for Stage 1 to 3 uterine cancers. Hysterectomy with removal of the ovaries is the procedure of choice. In patients with high risk Stage 1 disease (aggressive acting tumors) and Stage 2/3 disease, lymph node removal is typically done as well. At CH, 90 percent of patients receive this surgery. Nationally and in the rest of Indiana, 92 – 93 percent of patients are treated with this operation.
After surgery, some patients benefit from additional treatment. At CH, 54 percent of patients are treated with surgery alone. This compares to a rate of 58 percent at University Hospitals and 62 percent overall nationally. The main additional treatment used is radiation therapy and 26 percent of CH patients are treated with radiation. Alternatively, 8 percent of patients at CH are treated with chemotherapy or chemo-radiation therapy after surgery. Overall, 34 percent of patients at CH are treated with some form of additional therapy while 31 percent of patients in Indiana, 33 percent of University hospital patients and 30 percent of patients nationally receive additional treatment after surgery. The relatively higher use of additional therapy at CH reflects our higher percentage of Stage 2 patients (9 percent CH, 6 percent Indiana and 7 percent nationally) and of high risk Stage 1 patients (Fig 2).
As mentioned, radiation therapy is the most commonly used follow-up treatment after surgery. The radiation can take the form of external radiation (EBRT) to the pelvic area, internal radiation (brachytherapy) to the vaginal area or both. The most common area of disease relapse is in the vagina, which is the reason for using internal radiation to this area. At CH, 10 percent of patients are treated with EBRT alone and 24 percent received vaginal brachytherapy +/- EBRT. Nationally, 12 percent of patients are treated with EBRT alone (10 percent in Indiana). Vaginal brachytherapy +/- EBRT is used in 14 percent of patients nationally and in 19 percent of patients overall in Indiana (Fig 3). The higher use of brachytherapy at CH and in Indiana in general reflects our institutional and regional preferences that stress the importance of the vaginal therapy.
With the majority of patients diagnosed in Stage I, survival results for uterine cancer are generally good. According to the ACoS-NCDB, 5 year survival (all stages) is 78 percent nationally. For Stage I, it is 87 percent. At CH, our 5 year overall survival is 74 percent and 5 year survival for our Stage I patients is 84 percent.