It’s a well-known fact that obesity makes individuals more susceptible to conditions such as hypertension, heart disease and diabetes. Unfortunately, very few American women understand the crucial connection between weight and certain cancers, namely endometrial cancer. Women who are obese have an almost three-fold risk of developing endometrial cancer. And, as obesity rates continue to climb, endometrial cancer is becoming increasingly prevalent: In 2014, it’s estimated that there will be 50,000 new cases of endometrial cancer in the United States, and more than 8,000 women will die from it.
Dr. Andrea Hagemann, assistant professor of obstetrics and gynecology in the Division of Gynecologic Oncology at Washington University School of Medicine in St. Louis, says women have a 2.5 to 3 percent lifetime risk of developing endometrial cancer. “It is the most common gynecological cancer treated in the United States,” she says.
“I didn’t know anything about it,” says 59-year-old Marsha Coplon of St. Louis, who was diagnosed with Stage 1B Grade 1 endometrial cancer last year. “I learned about it in the deep end. It’s amazing how little people know about it.”
When Coplon started having periods in January 2013, she immediately knew something was amiss. “I knew that was not a good thing,” said Coplon, who had already gone through menopause. That March, she went to her gynecologist, Dr. Cathleen Faris at Women To Women Healthcare in St. Louis, who performed a biopsy.
Coplon was in Virginia visiting family when she got the phone call that it was cancer. “I immediately kicked into practical mode,” says Coplon. “You can choose to be devastated and sit in a corner and suck your thumb, or you can deal with it.” Looking back on it, Coplon realizes that all of the warning signs were there. She had many of the risk factors of endometrial cancer, including not having children, early onset of her menstrual cycle and early onset of menopause.
Endometrial cancer is most commonly diagnosed in post-menopausal women over the age of 60. But Dr. Pamela Soliman, assistant professor in the Department of Gynecologic Oncology at M. D. Anderson Cancer Center in Houston, is starting to see more patients diagnosed with endometrial cancer as early as their 20s and 30s, largely due to obesity. “Twenty-five percent of endometrial cancers are diagnosed in pre-menopausal women,” she says. Controlling obesity can reduce the number of new cases diagnosed annually, she adds.
Endometrial cancer occurs in the cells that form the lining of the uterus, the endometrium. Endometrial cancers are caused by high levels of unopposed estrogen, a condition in which a woman has excess estrogen in her body. In obese women, excess fat stimulates the overproduction of estrogen, which causes the endometrial lining to thicken and grow out of control.
“No doctor had ever told me that being obese was a risk factor for endometrial cancer,” says Deborah Brougher, a 59-year-old endometrial cancer survivor from Houston. “I feel like all my doctors failed me.”
Brougher, who was diagnosed with Stage 1 Grade 1 endometrioid adenocarcinoma cancer in February 2013, weighed 350 pounds at her heaviest. “Nobody wants to talk about fat people,” says Brougher. “I was eating myself to death. It was a sickness.”
Her periods stopped when she turned 40. “I wasn’t one to go to the gynecologist,” says Brougher. “I hadn’t been to the gyno in over 20 years. But then, I started spotting.”
The most common sign or symptom of endometrial cancer is abnormal vaginal bleeding. When a woman is postmenopausal, any vaginal bleeding should be evaluated, Dr. Hagemann says.
Brougher scheduled an appointment with Dr. Susan Shi at Texas Children’s Hospital Pavilion for Women in Houston. “Dr. Shi said it was probably nothing to worry about, but it needed to be checked out,” says Brougher. She had an endometrial biopsy and was diagnosed with complex hyperplasia with atypia, a precursor to endometrial cancer.
“I was taken aback,” says Brougher. “I’d never had any gynecological problems. It never entered my mind I might have cancer.”
Brougher underwent a hysterectomy in June. During the hysterectomy, the doctor injected radioactive dye into her cervix and removed the first lymph node on each side—a procedure called sentinel lymph node mapping—for further testing. The pathology came back clean.
“I’ve been cancer free since June 2013,” says Brougher. “I plan to be cancer free for a long time.”
She walks three miles a day and works out with her trainer. “I’m still 60 to 70 pounds overweight,” said Brougher. “I succeeded at weight loss when a lot of women don’t. I wish I could tell women it’s so much better to lose weight. I feel like a different person. I’m very fortunate.”
Coplon had a different outcome. “My doctor caught my cancer just in time,” she says. By that point, the cancer had just begun spread throughout her uterus and into the uterine wall. “As far as I knew, I just started getting symptoms in January. It was so close to not being controlled.”
She underwent six weeks of vaginal cuff brachytherapy radiation, a procedure in which an applicator that resembles a large plastic tampon is inserted into the vagina and radiation is delivered directly to the top of the vaginal canal. If endometrial cancer reoccurs, 80 percent come back at the top of the vaginal canal. Coplon’s last radiation treatment was on September 5, 2013.
“You never want to hear the words you have cancer,” says Coplon. “I was lucky.” She sees her doctor every three months for follow-up. “I don’t consciously live with the fear that it will come back,” she says. “I’m not tired anymore and I’m better shape. I feel like an ex-cancer patient.”
New hope on the horizon
Dr. David Mutch, chief of the Division of Gynecologic Oncology at the Siteman Cancer Center in St. Louis, and a team of investigators are looking at new approaches for identifying and treating endometrial cancer. The Siteman Cancer Center and Washington University School of Medicine received a Specialized Program of Research Excellence (SPORE) grant from the National Cancer Institute.
“We are focusing on the mutation drivers of endometrial cancer,” says Dr. Mutch. “We look for driver mutations that are targetable, identify the specific characteristics of the mutations and target tailor made treatments to the specific abnormality.” His research interest in molecular mismatch events dates back 25 years to his early collaborative efforts with Dr. Paul Goodfellow.
“Every cancer is different,” says Dr. Mutch. His work focuses on identifying endometrial cancer patients with Lynch syndrome, an inherited cancer susceptibility that can be passed down from one generation to the next and is caused by a mutation in the DNA mismatch repair gene. His team has identified the six genes responsible for Lynch syndrome and the four genes where the mutation typically occurs. His team is targeting specific genes in an attempt to alter the course of the disease.
Dr. Karen Basen-Engquist, director of the M. D. Anderson Center for Energy Balance in Cancer Prevention and Survivorship and professor of behavior science in the Division of Cancer Prevention and Population Science, is currently overseeing a study that looks at strategies to prevent endometrial cancer. She is looking at the effects of metformin—an anti-diabetic drug that helps control blood sugar in patients with type 2 diabetes—and lifestyle intervention individually and in combination.
“Lifestyle intervention has an impact,” says Dr. Basen-Engquist. She points to the results of the Diabetes Prevention Trial, which found patients taking metformin reduced their risk of developing diabetes but lifestyle interventions drastically reduced their chances of developing diabetes.
Luckily, with the proper behavioral change, endometrial cancer is highly preventable. Dr. Basen-Engquist recommends people consume a plant-based diet and exercise for 30 minutes a day and strength train twice a week. “The process isn’t easy,” she says. “People need people around them to encourage them.” When individuals see others like them making changes, it gives them the confidence that they can do it too.
Half of all Americans don’t know there is a link between obesity and cancer. “The word needs to get out there,” says Dr. Basen-Engquist.