A gynaecologist and robotic surgeon, Dr Olumide Ofinran, discusses endometrial cancer and the advantages of treating it with robotic surgery in this interview with ALEXANDER OKERE

What is endometrial cancer?

Endometrial cancer, also known as uterine cancer, is a cancer that starts from the endometrium, which is the lining of the uterus or the womb.

Is there a known cause?

There is no known or exact cause of endometrial cancer yet but we know there are changes in the DNA (called mutation) of the endometrium. These changes cause normal cells to become abnormal and grow out of control and can spread to nearby areas and distant organs in the body, if not caught early. One thing that is known, however, is that excess oestrogen can increase the chances of getting endometrial cancer.

How is it different from endometrial hyperplasia?

While endometrial cancer is the development of cancer cells in the lining of the womb, endometrial hyperplasia is a stage before endometrial cancer (precancerous stage) where there is excessive growth of the lining of the womb. This is also linked to high levels of the oestrogen.

What are the symptoms of endometrial cancer?

Endometrial cancer often produces symptoms at relatively early stages, so the disease is generally diagnosed early. The commonest symptom of endometrial cancer is abnormal bleeding or spotting from the vagina after menopause. This happens in over 90 per cent of cases and it could be an early sign. Such women who have gone through menopause are advised to contact their doctors immediately if they notice such symptoms.

Other symptoms are heavy, unusual vaginal bleeding, abnormal, persistent vaginal discharge, which could also be an early sign. Also included are vaginal bleeding during periods, blood in the urine, pain during sex or when urinating, pelvic pain, which is usually a symptom of advanced cancer, and unexplained weight loss, also in advanced cancer.

It is very important to state that the above symptoms are common and can be caused by various other conditions, so the presence of those symptoms does not mean one has endometrial cancer but it is important to note them and get checked up.

Do the symptoms include swelling in the knees or pain in the joints?

Not usually. Advanced cases of endometrial cancer can cause constant lower pain in addition to pelvic pain.

How common is endometrial cancer among women?

Endometrial cancer is the sixth commonest cancer in women worldwide and the 14th commonest cancer overall, with about 320,000 diagnosed in a year worldwide.

At what stage in a woman’s life is she most at risk of endometrial cancer?

Endometrial cancer is more common in women who have gone through menopause and it is less common in women under 45.

What are the other risk factors?

There is an increased chance of developing endometrial cancer with obesity, hypertension, early menses, use of some types of hormone replacement therapy, use of tamoxifen (a medication used in the treatment of breast cancer). There is also an increased risk if there’s a family history of bowel, ovarian or endometrial cancer. Finally, the presence of a rare genetic condition called Lynch Syndrome increases the risk of developing endometrial cancer.

Does this type of cancer occur in stages?

There are four main stages of endometrial cancer. These tell us how advanced and far spread the cancer is.

Stage one means that the cancer hasn’t spread past the uterus. Stage two means that the cancer has spread to the tissues of the neck of the uterus called the cervix, but it still hasn’t spread outside the uterus. Stage three means that the cancer has spread further to the ovaries, fallopian tubes, vagina or lymph nodes. Stage four means that the cancer is in the bladder, rectum, or organs far from the uterus, like the lungs.

How is endometrial cancer diagnosed?

The tests done to detect endometrial cancer depend on the symptoms and they include ultrasound of the pelvis to look at the uterus, especially the endometrium and measure its thickness and texture, and hysteroscopy,  a procedure where a thin, telescopic camera is passed through the vagina and cervix into the uterus to examine the inside of the uterus and the endometrium.

Another type of test is endometrial biopsy, which is where sample of cells from the lining of the uterus is removed for examination and testing in the laboratory. This can be done with or without doing a hysteroscopy.

There are special scans that can be done after a diagnosis of endometrial cancer to determine how far spread it is. These include CT scan, MRI scan, PETCT scan or even a chest X-ray.

What are the different treatment options and how affordable are they?

Endometrial can be easily treated when detected early. It includes a hysterectomy (removal of the uterus and cervix), chemotherapy or radiotherapy. Treatment depends on how far the cancer has spread (the stage), how quickly it’s growing (grade), the fitness of the patient and her wishes. In very early stage of slow growing endometrial cancer, a cure can be achieved with hysterectomy alone.

What are the chances of survival for each stage?

Stage one endometrial cancer has the best survival with over 95 per cent of women well beyond five years. In stage four, survival after five years is 15 to 20 per cent.

Is age a factor that determines the best treatment option?

The stage, grade, size of cancer and fitness of the patient determines the best treatment option, not forgetting the wishes of the patient and the availability of the treatment options.

Are there complications that could result from the treatment for endometrial cancer?

Each treatment option has its benefits and risks and these will be discussed extensively with the patient during their consultation.

Complication of surgery could include pain, chronic pain, bleeding, infection, accidental injury to nearby organs like the bowel, bladder, ureters and blood clots in the legs and lungs.

With radiotherapy and chemotherapy, side effects depend on the type, dose and duration of treatment, which depend on how advanced the cancer is and they include nausea, vomiting, hair loss, weakness, tiredness and diarrhoea.

What happens when this cancer is left untreated?

If not treated, endometrial cancer will spread. How quickly that happens depends on how aggressive it is. It can grow bigger, cause worse symptoms of bleeding, pain and eventually cause death.

What form of support do patients treated for endometrial cancer need to recover well?

Getting a diagnosis of endometrial cancer can be very distressing and overwhelming. It helps to have a support system. However, a group of specialists look after patients diagnosed with cancer. These also include specialist nurses with the necessary experience and training and they are usually your point of contact during and after your treatment.

Robotic surgery is fast gaining acceptance in medicine globally. What is responsible for that?

Robotic surgery or robotic assisted laparoscopic surgery is one of the most cutting-edge medical technologies of modern times. It has transformed laparoscopic surgery since it was first performed in 1997. Its benefits are gaining wider recognition and more procedures using the robot are being undertaken.

Robotic surgery is the use of small sophisticated, surgical instruments attached to robotic arms to perform laparoscopic surgery.  These instruments are totally under the control of the surgeon. The robot mimics and assists the surgeon’s movements; it does not perform the operation. This technique is now widely used because of its high degree of surgical accuracy, and because recovery is much faster than it is for open surgery.

Are there other areas robotic surgery could be applied?

Robotic surgery is used in gynaecological operations to perform hysterectomies in endometrial cancer, early stage cervical cancer and benign gynaecological conditions. It is also used in other areas such as urology (bladder, prostate), thoracics and bowel surgery.

What has been the rate of success in robotic surgeries?

The rate of robotic surgery has been increasing every year by more than 25 per cent. The benefits of advanced precision because of its high definition imaging and flexible instruments allow surgeons to better get to previously difficult areas. There’s also faster recovery, less pain, fewer complications and in cases of gynaecological cancer, more yield of specimen for testing and treatment.

How do they compare to human surgeries in terms of cost and efficiency?

Robot-assisted laparoscopic surgery comes at a high cost but can become cost-effective in centres where large a number of cases are performed. With more companies developing their technology and competing, there’s also potential that it’ll become more cost effective.