Running head: CASE STUDY - ENDOMETRIAL CANCER

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Endometrial Cancer
Alysia Bang
Argosy University/Twin Cities
Case Study
Clinical Training, Radiation Therapy - RTH291
Julie Yasgar
11/20/15

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CASE STUDY - ENDOMETRIAL CANCER

Introduction
This paper provides a discussion on a woman with endometrial cancer, what is known
about endometrial cancer, and the current treatments available for endometrial cancer. It starts
with a consult report and goes through a womans simulation, treatment, and follow-up. It also
discusses the regular patterns, epidemiology, etiology, treatment options, and diagnostic tools for
current endometrial cancers. This patient was followed from the day of her consult to the day of
her follow up after treatment. This paper also includes an analysis of the comparison of the
common research for endometrial cancers to the specific case discussed in the case study portion
of this paper.
Case Study
Consult
Mrs. Marvin* is a 60-year-old African American female with a T1bN0M0, stage IB,
grade 1 endometrial adenocarcinoma. She had her radiation consult with Dr. Donald* on June
29, 2015. She had a radical hysterectomy with Dr. Lola* and was referred to Dr. Donald for
radiation therapy. She originally went in due to postmenopausal vaginal bleeding. She reported
that it was occurring for approximately one year. She had a pelvic ultrasound which found a large
lobular and heterogenous uterus with a thickened endometrium. She then had an endometrial
biopsy on March 24, 2015. It was positive for grade 1 endometrial adenocarcinoma. She was sent
to Dr. Lola after the biopsy where she underwent a modified radical hysterectomy, bilateral
salpingo-oophorectomy, and bilateral pelvic lymph node dissection. She had the hysterectomy on
May 11, 2015. According to the operative report, the surgery went well. No other organs in area
of interest showed any signs of disease. Lymph nodes showed no sign of disease. The surgical

CASE STUDY - ENDOMETRIAL CANCER

pathology was conclusive of a 4.9 cm well-differentiated endometrioid adenocarcinoma. It

involved the anterior and posterior endometrial areas. There was myometrial invasion at 1.2 cm
into the myometrial surface totaling 2.4 cm. Twelve lymph nodes were negative for metastatic
disease. There were eight negative right pelvic nodes and four negative left pelvic nodes.
As far as medical and family medical history, she stated she has mild abdominal
tenderness and slight edema in the lower left extremity. She had an ultrasound before coming
here and it was negative for thrombosis. She reported being slightly constipated and had nocturia
two times. She was taking a laxative every four days to control her constipation. She is currently
working at Walmart as a greeter. She is married and her husband is accompanying her today
along with one of her daughters. She has hypertension, cataracts, and deep vein thrombosis. She
has had five children, all spontaneous vaginal deliveries. She has never been on hormone
replacement. She experienced menarche at age 12 and menopause in her late 50s. As of the
consult she was overdue for a mammogram. She had a sigmoidoscopy done in 2003 for anemia.
She was taking Amlodipine, Losartan, and Vitamin D at the time of her radiation conuslt. Her
family history includes colorectal cancer in her brother which was diagnosed at the age of 67 and
lung cancer in her father.
Dr. Donald assessed the patient while at the consult today. She denied fever, chills, night
sweats, weight loss, vertigo, change in hearing, hoarseness, difficulty swallowing, and diplopia.
She denied shortness of breath, chest pain, chest pressure, chest tightness, palpitations, has slight
edema in lower left extremity. She denied shortness of breath coughing, wheezing, sputum,
hemoptysis, memory loss, weakness, headaches, loss of consciousness, has slight abdominal
pain, denied vomiting, diarrhea, has slight constipation, denied hematochezia, and melena. She

CASE STUDY - ENDOMETRIAL CANCER

denied urinary frequency, urgency, dysuria, hematuria, and incontinence. She denied gait
disturbances, arthralgias, myalgias, fatigue, weight change, hot and cold intolerance, mood
disorders, anxiety, depression, easy bruising, bleeding, palpable adenopathy, rashes, and lesions.
Her scar from her hysterectomy had healed well. Physical examination proved no abnormalities.
Pelvic examination demonstrated normal appearing external genitalia. The vaginal cuff was wellhealed, there was no nodularity or irregularities. According to the doctor palpation of the vaginal
mucosa was smooth without thickening, no pain or tenderness during exam.
Dr. Donald explained to her and her family that there is a potential for recurrence, which
is why she was sent here today. He discussed with them vaginal brachytherapy and external
beam radiation therapy to the pelvis with vaginal brachytherapy. He explained that the potential
risks outweigh the potential benefits. After deciding the best treatment would be vaginal
brachytherapy, he discussed the possible acute and late side effects. The side effects can be
cystitis and proctitis. He explained the side effects usually diminish after one to two weeks and
might not appear until after treatment is complete. The side effects to the vagina can include
dryness, narrowing, stricturing, and the potential need for a vaginal dilator after completing
treatment. There is a very small risk for fistulas and that was also discussed at the consult. Mrs.
Marvin and her husband were encouraged to ask questions throughout the consult. It sounded
like their main concern was whether or not theyd be able to continue to have intercourse. Dr.
Donald explained the chances of dryness and the need for a vaginal dilator potentially. He also
explained that he thought the chances for these complications was low. Mrs. Marvin, her
daughter, and her husband understood the potential complications and benefits and she consented
to the treatment.

CASE STUDY - ENDOMETRIAL CANCER

Simulation
Mrs. Marvin came in for her simulation and administration of her first vaginal
brachytherapy treatment on July 10, 2015. She was brought to an exam room where she waited
for Dr. Donald. The first thing that was done was a pelvic exam. During the pelvic exam, she was
measured for the correct size cylinder to be used. It was selected that she would need the 3 cm
vaginal cylinder. She was then taken to the CT Simulator room. On the table, the cylinder was
inserted with the tip of the cylinder abutting against the vaginal cuff. The perineum stabilizer,
attached to the shaft of the cylinder, was used to keep the device in a stable position. CT was
then taken with the device inside Mrs. Marvin. The area to be imaged was selected and then
axial, 2.5 mm slice thickness images were obtained. The images were reviewed by Dr. Donald
and sent to Oncentra, the brachytherapy planning system at this site. The vaginal cylinder was
then removed and she was sent back to the exam room to wait for the planning to be done so she
could receive her first treatment.
Treatment
It was decided by Dr. Donald that Mrs. Marvin would receive 21 Gy over three
treatments with a 3 cm vaginal cylinder at 7 Gy per treatment. The radioactive source to be used
to give the treatments was iridium-192. The depth of the treatment was prescribed to 0-5 mm
from the vaginal surface. The treatments would be one treatment per week for three weeks. The
bladder and rectum were both contoured before the doctor drew his target volumes. The target
distance was selected for a distance of 15 mm. Eleven source positions were selected. The doctor
drew the treatment volume. The physicists, physician, and dosimetrists confirmed the plan and
transferred it to the Nucletron treatment console. At the treatment console, the dwelling times

CASE STUDY - ENDOMETRIAL CANCER

and source positions were reviewed by the physicist and physician. Mrs. Marvin, on July 10,
2015, was brought to the treatment room where she was placed supine on the stretcher. The
vaginal cylinder was placed with the tip abutting against the vaginal cuff. The perineal stabilizer
was utilized to keep the cylinder in place. The cylinder was connected to the treatment unit with
the #3 transfer tube. The treatment was delivered, totaling 7 Gy at the 100% isodose line. After
treatment was completed, the source was confirmed back into the HDR vault. The patient and
room were surveyed and both were negative for residual radioactivity. Mrs. Marvin tolerated the
treatment well. For her second and third treatments, a CT scan was no longer required. The plan
for cylinder treatments remains the same for all treatments so no imaging is required after the
first day. The only thing that changes between treatments is the length of treatment due to the
decay of the source. For both the second and third treatments, Mrs. Marvin was brought to the
treatment room, the cylinder was inserted and secured with the perineal stabilizer, and the
cylinder was connected to the HDR unit with the #3 transfer tube. For both treatments, the source
position and dwelling times were both checked by the physicist and physician before starting the
treatment. Both treatments received 7 Gy to the 100% isodose line. After each treatment both the
patient and room were surveyed for radioactivity. Both the patient and the room were negative
for residual radioactivity. After both the second and third treatments, the source was confirmed
back in the HDR vault. Mrs. Marvin tolerated all three treatments very well.
During Mrs. Marvins course of treatment, the radioactive source was decaying slightly
each week. Due to the concept of half life, calculations needed to be done before each treatment
in order to compensate for the decay of the source. The first treatment the activity was 6.635 Ci,
the total seconds to be treated with was 524.74. The second treatment the activity was 6.213 Ci,

CASE STUDY - ENDOMETRIAL CANCER

the total seconds to be treated with was 560.38. The third and final treatment, the activity read
5.818 Ci. The total seconds for the third and final treatment was 598.44. The source at calibration
read 10.049 Ci. These items are calculated with the use of a decay factor. In the case of the
iridium-192, the decay factor was .660 and the total number of days that elapsed during
treatment was 14 days.
Follow-Up
Mrs. Marvin received a radical hysterectomy followed by vaginal brachytherapy totaling
21 Gy in three fractions. She completed her treatment on July 24, 2015. At her follow-up visit,
today August 21, 2015, she is feeling well. Her husband was with her for this visit. She stated
shes had painful urination several times after treatment but that it is improving. She is no longer
needing a laxative to control her constipation. She is still taking the current medication and there
are no new medical diagnoses or medications. The pelvic exam did not take place at the visit due
to her having a pelvic exam three days prior with another doctor. She is feeling well and has
appeared to have tolerated the treatment well according to Dr. Donald. At her follow-up she was
provided with a vaginal dilator and was instructed on how to use it. She has a follow-up in six
months.
Research - Endometrial Cancers
Anatomy
The female pelvis consists of bony anatomy such as the ilium, sacrum, acetabulum,
coccyx, ischium, ischial tuberosity, and the pubic symphysis (Kelley & Petersen, 2013). The
internal female pelvis consists of the bladder, rectum, ovaries, uterus, cervix, vagina, anus,
urethra, clitoris, labia minor and majora, uterine tubes, sphincter, and the suspensory ligaments

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for the ovaries (Kelley & Petersen, 2013). The uterus is where the endometrium is located. The
uterus is broken into the body, the funds, and the cervix (Kelley & Petersen, 2013). The wall of
the uterus has three layers, the endometrium, myometrium, and perimetrium. The perimetrium is
the outer most layer (Kelley & Petersen, 2013). It covers the funds and the posterior surface of
the uterus. The myometrium is the middle layer and is composed of muscular tissue. The
myometrium is the thickest layer of the uterus (Kelley & Petersen, 2013). The endometrium is
the inner most layer of the uterus. The endometrium is a glandular tissue (Kelley & Petersen,
2013). It is lined by a mucous membrane that flows through the uterus to the inner lining of the
vagina and uterine tubes (Kelley & Petersen, 2013). The uterus itself has the function of
protecting the fetus during development. The uterus is held in place or stabilized by pairs of
suspensory ligaments which are formed by the peritoneum (Kelley & Petersen, 2013). There are
several different lymph nodes associated with the female pelvis. There are the common iliac
nodes, internal iliac nodes, external iliac nodes sacral nodes, paraortic nodes, obturator nodes,
and inguinal nodes (Kelley & Petersen, 2013). There are many different muscles in the pelvis.
Some of the muscles in the pelvis are the rectus abdomens muscles, the psoas muscles, external
and internal oblique muscles, gluteus muscles, piriformis muscle, obturator interns muscle,
obturator externs muscle, iliac us muscle, iliopsoas muscle, legator ahi muscles, and the
coccygeus muscles (Kelley & Petersen, 2013). There is a lot of vasculature structures in the
pelvis. Some of the vasculature structures in the pelvis are the median sacral artery, common
iliac arteries, internal iliac artery, femoral artery, interior epigastric artery, deep circumflex iliac
artery, internal iliac veins, superior rectal veins, and the median sacral veins (Kelley & Petersen,
2013).

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Epidemiology and Etiology

There are many different factors that increase the risk for endometrial cancers. Some of
the factors include the usage of intrauterine devices, age, diet, exercise, diabetes, family history
of endometrial or colorectal cancers, having been diagnosed with breast or ovarian cancer in the
past, having been diagnosed with endometrial hyperplasia in the past, treatment of the pelvis
with radiation therapy previously, pregnancy, obesity, the use birth control pills, estrogen after
menopause, number of menstrual cycles in the lifetime, and the use of tamoxifen (American
Cancer Society, 2015).
There is no certain cause for endometrial cancer at this point (ACS, 2015). There is a lot
of research about what causes endometrial cancer because it is so prevalent. What is known is
that hormone imbalance plays a large role in developing endometrial cancers (ACS, 2015). It is
also known that most endometrial cells have estrogen receptors, progesterone receptors, or both
estrogen and progesterone receptors (ACS, 2015). Interaction with those receptors can lead to the
endometrium growing, which can also be the beginning of cancer (ACS, 2015). The growing
becomes abnormal in cases and thats what develops into cancer (ACS, 2015).
Endometrial cancer cannot be prevented. Knowing the risk factors and trying to avoid
some of the risk factors can lead to a less of a chance of developing endometrial cancer. Being
obese can cause a woman to have three and a half times the normal risk for endometrial cancer
(ACS, 2015). Its also important to inform doctors about any abnormal discharge and to get
regular pelvic exams. Endometrial cancers arent typically detected by a pap smear (Washington
& Leaver, 2010). The most common presenting symptom is postmenopausal bleeding. About
70% of endometrial cancers are caught in stage I because of this (Washington & Leaver, 2010).

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Approximately 78,490 patients will develop a gynecologic cancer in the United States,
alone, a year. This number gets divided into percentages with endometrial being at 50% of the
diagnoses (Washington & Leaver, 2010). For these cancers, endometrial has a death rate at 19%,
which is significantly lower than ovarian and cervical cancers (Washington & Leaver, 2010).
Endometrial cancer has a rate that has increased due to the increase in aging population,
increasing fat diets, increasing caloric diets, and the use of estrogen in the 1960s and 1970s
(Washington & Leaver, 2010). There are approximately 600,000 survivors of endometrial
cancers (ACS, 2015). The most typical stage at time of diagnosis is stage I due to the early rate at
which endometrial cancers are caught (Washington & Leaver, 2010).
Diagnosis
Early detection is very important with endometrial cancers. Most women are diagnosed
in an early stage due to the common symptom being abnormal bleeding (Washington & Leaver,
2010). If a woman experiences abnormal bleeding and reports to a doctor right away it can be
caught in a very early stage (ACS, 2015). Its not a very rapidly growing cancer. There is no
early screening for those at higher risk for endometrial cancers. It is recommended that at the
time of menopause, endometrial cancer should be discussed. Patients are told that if there is any
abnormal bleeding or discharge, they should contact a doctor right away (ACS, 2015). Women
should get yearly pelvic exams although those exams cannot detect endometrial cancer (ACS,
2015).
The first step in getting an endometrial cancer diagnosed is when a patient goes in due to
symptoms. The doctor will perform a physical exam, a pelvic exam, and get a complete medical
history (ACS, 2015). If endometrial cancer is suspected, the patient will be sent to a

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gynecologist. The next steps could all be used or several could be used. The diagnosis is a
combination of the following techniques. An ultrasound is performed frequently in cases of
gynecological cancers. Three different types of ultrasounds may be performed, a pelvic
ultrasound, a transvaginal ultrasound, or a saline infusion sonogram or hysterosonogram. A
pelvic ultrasound is where the transducer is placed on the lower abdomen to see the uterus,
ovaries, and fallopian tubes (ACS, 2015). During this procedure a woman must have a full
bladder (ACS, 2015). A transvaginal ultrasound utilizes a probe in order to look at the uterus
inside the body (ACS, 2015). The transvaginal ultrasound is good for spotting endometrial
cancers. A saline infusion sonogram is where a small tube inserted into the uterus allows the
doctor to fill the uterus with salt water to help in locating the area to be biopsied (ACS, 2015).
Next would be to sample the endometrial tissue. In order to get a sample of the tissue a biopsy
can be performed, a hysteroscopy can be performed, or a dilation and curettage can be
performed. A biopsy uses a small tube that is inserted into the uterus, a small amount of tissue is
removed, it can be slightly painful (ACS, 2015). A hysteroscopy uses a saline solution in the
uterus and a small telescope, this allows the doctor to see and biopsy (ACS, 2015). Dilation and
curettage is used when a biopsy doesnt provide the right amount of tissue needed (ACS, 2015).
In order to perform this procedure, anesthesia or conscious sedation could be needed (ACS,
2015). Local anesthesia is also used. During the procedure the cervix is dilated and the area
needed to be biopsied is scraped to extract tissue to analyze (ACS, 2015).
If cancer is thought to have spread, a computed tomography, magnetic resonance
imaging, or positron emission tomography may be required. Occasionally the cancer can spread
to the bladder or rectum because they are in close proximity to the uterus. If this is suspected, a

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cystoscopy or a proctoscopy may be required (ACS, 2015). A complete blood count may be
requested in order to check the blood levels. Endometrial cancer has the ability to cause
bleeding, therefore the complete blood count may be necessary (ACS, 2015). CA 125 levels can
be checked with blood testing. The CA 125 levels can suggest that the cancer has spread beyond
the uterus but doesnt always (ACS, 2015).
Staging and Pathology
The most common type of endometrial cancer is adenocarcinoma of the lining of the
endometrium. Adenocarcinoma of the endometrium totals 50% of all endometrial cancers.
Second most common type, coming in at about 20%, is adenocarcinoma with squamous
differentiation (Washington & Leaver, 2010). There is also papillary serous adenocarcinoma.
This is a rapidly spreading form of endometrial cancer and has a very poor prognosis
(Washington & Leaver, 2010). Clear cell adenocarcinoma has approximately the same behavior
of papillary serous adenocarcinoma (Washington & Leaver, 2010). The last type of endometrial
cancer is a sarcoma and it has a very poor outcome, as well. Sarcomas usually require an
aggressive multimodal treatment approach (Washington & Leaver, 2010).
The staging for gynecological cancers utilizes the FIGO staging system. That is the
International Federation of Gynecology and Obstetrics system (ACS, 2015). For endometrial
cancers, stage IA is where the tumor is limited to just the endometrium (Washington & Leaver,
2010). For stage IB, the tumor invades less than half the full volume of the myometrium
(Washington & Leaver, 2010). For Stage IC, the tumor invades one half or more than one half of
the full volume of the myometrium (Washington & Leaver, 2010). For stage IIA, the tumor
shows no connective tissue involvement but does have involvement into the glandular epithelium

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of the endocervix (Washington & Leaver, 2010). Stage IIB, has invasion of the stromal
connective tissues in the cervix (Washington & Leaver, 2010). Stage IIIA, the tumor invades the
serosa and/or the anexa (Washington & Leaver, 2010). This stage can also have cancer cells in
peritoneal washings or ascites. Stage IIIB has vaginal involvement. Stage IIIC has involvement
in the pelvis and/or the paraortic lymph nodes (Washington & Leaver, 2010). Stage IVA is where
the tumor invades the bowel, bladder, or both (Washington & Leaver, 2010). The five year
survival rates, by stage, for endometrial cancers are as follows: stage 0 is 90%, stage IA is 88%,
stage IB is 75%, stage II is 69%, stage IIIA is 58%, stage IIIB is 50%, stage IIIC is 47%, stage
IVA is 17%, and stage IVB is 15% (ACS, 2015).
Treatment Options
There are four main types of treatment for cancers. The four main types are
chemotherapy, radiation therapy, hormonal therapy, and surgery. For a lot of cancers, a
multimodal approach is utilized for best results. This is when a combination of the four types of
treatments are used in sequence or conjunctively. Each case is very different, no two endometrial
cancers are exactly alike. This can mean a different treatment for each one. It will be up to the
doctor based on the patient, stage, and status of the patient.
Most commonly, endometrial cancer patients are seen after surgery. There is a high
recurrence rate in most cases and that is why they tend to receive some sort of radiation in
conjunction with their surgery. For stage IB grades 1 and 2 and for stage IA grade 2,
brachytherapy will typically be used after surgery to reduce the risk for recurrence (Washington
& Leaver, 2010). High-dose-rate brachytherapy will typically be treated at 5-7 Gy in 3-5
fractions (Washington & Leaver, 2010). For stages IC and higher, there is a higher risk for nodal

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involvement and external beam radiation with or without brachytherapy may be prescribed
(Washington & Leaver, 2010). If external beam is going to be prescribed with brachytherapy,
there will typically be a midline block utilized to not overdose any structures being treated with
the brachytherapy device. If there is nodal involvement, external beam radiation may be
prescribed at about 40-50 Gy and can get a boost up to 65 Gy (Washington & Leaver, 2015). The
actual uterus may receive 75-90 Gy with combined external beam radiation and brachytherapy
(Washington & Leaver, 2015). The critical structures that need dose limits would be the bladder
and rectum for endometrial fields.
Surgeries that can be utilized for endometrial cancers include bilateral salpingooophorectomy, lymph node dissection, pelvic washing, tumor debulking, and hysterectomy
(ACS, 2015). A hysterectomy is the removal of the uterus and cervix. If the uterus is removed
through the abdomen, it can be a simple hysterectomy or a total abdominal hysterectomy (ACS,
2015). If the uterus is removed through the vagina it is called a vaginal hysterectomy (ACS,
2015). A bilateral salpingo-oophorectomy is the removal of the fallopian tubes and the ovaries
(ACS, 2015). The salpingo-oophorectomy would be done at the same time as the hysterectomy.
Lymph node dissection is done to check to see if the cancer has spread to the lymph nodes. Its a
sampling or removal. Pelvic washings are done to check for cancer. A surgeon will wash the area
of interest and send the fluid back to a lab to check for cancer cells (ACS, 2015). Debulking is
done for many different cancers. Its done when there are particularly large tumors that need to
be made smaller for other types of treatment.
Chemotherapy agents that can be utilized for endometrial cancers include Paclitaxel
(Taxol), carboplatin, doxorubicin (Adiramycin), and cisplatin (ACS, 2015). Chemotherapy is

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given in cycles with rest periods to recuperate. The most common method is to receive more than
one chemotherapy drug at the same time. When chemotherapy is used during radiation therapy,
the chemotherapy agents act to protect tissues or make tissues more vulnerable to the radiation
treatments.
Hormonal therapy agents used for endometrial cancers include Progestins, Tamoxifen,
Lutenizing hormone releasing hormone agonists, and Aromatase inhibitors (ACS, 2015).
Progestins are hormones that slow the growth of the cancer cells in the endometrium (ACS,
2015). Tamoxifen is a hormone that works to stop the estrogen in the body from letting the
cancer cells grow (ACS, 2015). Luteinizing hormone-releasing hormone agonists are another
way to lower estrogen in the body of those who still have functioning ovaries (ACS, 2015).
Aromatase inhibitors work to stop estrogen production to lower estrogen levels in the body
(ACS, 2015).
Analysis
According to the research conducted from several different sources, the current course of
treatment that Mrs. Marvin received was what would typically be prescribed to treat early stage
endometrial cancers. Different treatment types are chosen for different stages and for each
individual case based on the patient. Given Mrs. Marvins healthy status and her early stage and
grade cancer, the treatment course conducted was what is currently recommended for that stage
and grade of endometrial cancer. The current recommendations are to receive surgery followed
by internal or external brachytherapy based on the stage and grade. Mrs. Marvin had a stage IB,
grade 1 endometrial adenocarcinoma. As discussed earlier, adenocarcinoma of the endometrium
has a relatively good prognosis if caught at an early stage. Mrs. Marvins cancer was caught at a

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stage I and grade 1 (Washington & Leaver, 2010). The recommended course of treatment for this
stage would be surgery with or without radiation (Washington & Leaver, 2010). In the case of
endometrial cancers, radiation is used to prevent recurrence and also to kill off any cancer cells
that might have been left behind or seeded during the surgery (Washington & Leaver, 2010).
With the use of radiation and surgery together the recurrence rate can be reduced to 3%
(Washington & Leaver, 2010). With surgery alone the recurrence rate is at about 12%
(Washington & Leaver, 2010). For a stage IA cancer, surgery alone would be recommended. For
a stage IB cancer, surgery followed by brachytherapy would be recommended. Mrs. Marvins
case followed the recommendations for current treatment of endometrial cancer based on her
hysterectomy followed by brachytherapy.
Conclusion
I think that the course of treatment chosen for this patient follows what is recommended
by several different sources. I feel that Mrs. Marvin tolerated the treatment very well. She was
not having complications at her follow-up which is what we hope for. I really wanted to utilize a
brachytherapy patient for my Case Study because I really enjoy learning about brachytherapy.
Its so readily available and is utilized so much at the clinic Im at that it seemed like the right
course. Mrs. Marvin was an excellent patient to observe. She was very compliant and handled
the entire situation very well. I enjoyed seeing someone throughout their entire course of
treatment including the follow-up. I also enjoyed participating in her brachytherapy treatments. It
was an enlightening experience having to do so much research on one particular cancer and
being able to compare it with a case Dr. Donald did.
*Names have been changed for confidentiality reasons.

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References
American Cancer Society (ACM). (March 17, 2015). What is Endometrial Cancer. Retrieved
from http://www.cancer.org/cancer/endometrialcancer/detailedguide/endometrial-uterinecancer-key-statistics
Kelley, Lorrie L., Petersen, Connie M.. (2013). Sectional anatomy for imaging professionals (3rd
ed.). Mosby, Inc., an affiliate of Elsevier Inc.
Washington, Charles M., Leaver, Dennis. (2010). Principles and practice of radiation therapy
(3rd ed.). Mosby, Inc., an affiliate of Elsevier Inc.

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