- How is endometrial cancer treated?
- Surgery for endometrial cancer
- Radiation therapy for endometrial cancer
- Chemotherapy for endometrial cancer
- Hormone therapy for endometrial cancer
- Clinical trials for endometrial cancer
- Complementary and alternative therapies for endometrial cancer
- Treatment options for endometrial cancer by stage
- More treatment information about endometrial cancer
Treatment options for endometrial cancer by stage
Endometrial cancer is often diagnosed when a woman who is having symptoms has an endometrial biopsy or D&C. Tests, such as ultrasound and CT scan, may be done to look for signs that the cancer has spread to lymph nodes or tissues outside of the uterus. Even when these tests show no signs of cancer spread, surgery is needed to fully stage the cancer. This operation includes removing the uterus, fallopian tubes, and ovaries (total hysterectomy bilateral salpingo-oophorectomy -- TH/BSO). Lymph nodes from the pelvis and around the aorta are also removed (a pelvic and para-aortic lymph node dissection [LND] or sampling) and examined for cancer spread. Pelvic washings are obtained. If tests done before surgery show signs that the cancer has spread outside of the uterus, a different surgery may be planned.
An endometrial cancer is stage I if the cancer is limited to the body of the uterus and has not spread to lymph nodes or distant sites. If the tumor is endometrioid, standard treatment includes surgery to remove and stage the cancer (see above). The tissues removed at surgery are examined under a microscope in a lab to see how far the cancer has spread. This decides the stage of the cancer and what treatment is needed after surgery. Surgery and other treatment often differ for cancers that aren't endometrioid. These cancers are discussed separately in this section.
Treatment after complete staging for endometrioid cancers
In stage IA, the cancer has grown less than halfway into the myometrium. Many of these can be observed without further treatment after surgery. For high grade tumors, doctors are more likely to recommend radiation after surgery. Either vaginal brachytherapy (VB), pelvic radiation, or both can be used.
In stage IB, the cancer has grown more than halfway through the myometrium. After surgery the patient may be watched without further treatment or offered some form of radiation treatment. Either VB, pelvic radiation, or both can be used.
Treatment for high-grade cancers: These cancers, such as papillary serous carcinoma or clear cell carcinoma, are more likely to have spread outside of the uterus at the time of diagnosis. Patients with these types of tumors do not do as well as those with lower grade tumors. If the biopsy done before surgery showed a high-grade cancer, the surgery may be more extensive. In addition to the TH/BSO and the pelvic and para-aortic lymph node dissections, the omentum is often removed. After surgery, both chemotherapy (chemo) and radiation therapy are often given to help keep the cancer from coming back. The chemo usually includes the drugs carboplatin and paclitaxel (Taxol) and less frequently cisplatin and doxorubicin (Adriamycin).
Uterine carcinosarcoma: Someone with a uterine carcinosarcoma often has the same type of surgery that is used for high-grade endometrial carcinoma. After surgery, radiation, chemo, or both may be used. The chemo often includes the drugs carboplatin and paclitaxel, ifosfamide (Ifex) with paclitaxel, or less often ifosfamide and cisplatin.
Patients not staged with surgery
As stated above, standard treatment for endometrial cancer includes surgery to remove and stage the cancer. In some cases, however, the doctor may treat based on the clinical stage (see the section “How is endometrial cancer staged?” for more details) and radiologic testing.
If the cancer seen on endometrial biopsy or D&C is grade 1 and it looks like the cancer is only in the uterus, the cancer is said to be clinical stage I, grade 1. Because few of these cancers have already spread, some doctors do not feel that full surgical staging is always needed. Often a TH/BSO will be done first. As soon as the uterus is removed, it will be examined to see how deep and far the cancer may have spread. If the cancer is only in the upper two thirds of the body of the uterus and hasn't grown more than halfway through the muscle layer of the uterus, the chance that the cancer has spread is very low. In these cases, the surgeon may not do a LND but instead may remove only a few lymph nodes or none at all. Some studies have shown that this may be as good as a full LND. If any of the lymph nodes contains cancer it means that the cancer is stage IIIC and further treatment is needed (treatment of stage IIIC is discussed later). If no lymph nodes were removed (or if there were no cancer cells in the nodes that were removed), treatment after surgery could include observation without further treatment or radiation.
Some younger women with early endometrial cancer may have the uterus removed without removing the ovaries. Although this does increase the chance that the cancer will come back, it doesn’t make it more likely that you will die from your cancer. This may be something that you want to discuss with your doctor.
Women who cannot have surgery because of other medical problems or who are frail due to age are often treated with radiation alone.
In place of surgery to remove the uterus, progestin therapy is sometimes used to treat stage IA, grade 1 endometrial cancer in young women who still want to have children. Progestin treatment can cause the cancer to shrink or even go away for some time, giving the woman a chance to get pregnant. It can be given as a pill, injection, or as a progestin containing intrauterine device. This approach is experimental and can be risky if the patient isn't watched closely. In many cases, it does not work. Sometimes the cancer keeps growing. Sometimes the tumor gets smaller or goes away for a while, but then comes back again. Not having surgery right away may give the cancer time to spread outside the uterus. A second opinion from a gynecologic oncologist and pathologist (to confirm the grade of the cancer) before starting progestin therapy is important. Patients need to understand that this is not a standard treatment and may increase risk.
Doctors are more likely to remove some lymph nodes when the biopsy shows that the cancer is a higher grade (2 or 3). If the cancer has spread deeper than half the thickness of the wall of the uterus, then the pelvic and para-aortic lymph nodes are usually sampled.
If the cancer comes back after surgery, it usually does so in the vagina. Many doctors recommend VB to prevent this from happening. Others recommend external beam radiation to the whole pelvic area. Certain features make it more likely that the cancer will come back after surgery, such as higher grade, spread to the lower third or outer half of the uterus, growth into lymph or blood vessels, larger tumor size, and patient age over 60.
Radiation therapy is often given to reduce the risk of cancer coming back in the vagina or pelvis for cancers with one or more of these features. In patients without these risk factors, the chance that the cancer will come back is small and radiation may not be given after surgery. Giving radiation right after surgery reduces the chance of the cancer growing back in the pelvis, but it does not help women live longer than if the radiation is only given when the cancer comes back. There may be less worry if the radiation is given right away, but fewer women will receive radiation (and experience its side effects) if they wait until the cancer returns.
When a cancer is stage II, it has spread to the connective tissue of the cervix but still has not grown outside of the uterus. One treatment option is to have surgery first, possibly followed by radiation therapy. The surgery would include a radical hysterectomy (discussed in the “Surgery for endometrial cancer” section), bilateral salpingo-oophorectomy (BSO), and pelvic and para-aortic lymph node dissection (LND) or sampling. Radiation therapy, often including both vaginal brachytherapy and external pelvic radiation may be given after the patient has recovered from surgery. The other option is to give the radiation therapy first, followed by a simple hysterectomy, BSO, and possible LND or lymph node sampling.
The lymph nodes that have been removed are checked for cancer cells. If lymph nodes show cancer, then the cancer is not really a stage II - it is a stage IIIC.
In some cases, a woman with early stage endometrial cancer might be too frail or ill from other diseases to safely have surgery. These women are treated with radiation therapy alone.
For women with high-grade cancers, such as papillary serous carcinoma or clear cell carcinoma, the surgery may include omentectomy and peritoneal biopsies in addition to the TH/BSO, pelvic and para-aortic lymph node dissections, and pelvic washings. After surgery, chemo, radiation therapy, or both may be given to help keep the cancer from coming back. The chemo usually includes the drugs carboplatin and paclitaxel or possibly cisplatin and doxorubicin.
Someone with a Stage II uterine carcinosarcoma often has the same type of surgery that is used for a high-grade cancer. After surgery, radiation, chemo, or both may be used. The chemo often includes paclitaxel and carboplatin but may instead include ifosfamide, along with paclitaxel or cisplatin.
Stage III cancers have spread outside of the uterus.
If the surgeon thinks that all visible cancer can be removed, a hysterectomy with bilateral salpingo-oophorectomy (BSO) is done. Sometimes patients with stage III cancers require a radical hysterectomy. A pelvic and para-aortic lymph node dissection may also be done. Pelvic washings will be obtained and the omentum may be removed. Some doctors will try to remove any remaining cancer (debulking), but it isn’t clear that this will help patients live longer.
If tests done before surgery reveal that the cancer has spread too far to be removed completely, radiation therapy may rarely be given before any surgery. The radiation may shrink the tumor enough to make surgery an option.
Stage IIIA: A cancer is considered stage IIIA when it has spread to the tissue covering the uterus (the serosa) or to other tissues in the pelvis like the fallopian tubes or the ovaries (the adnexa). For these cancers, treatment after surgery may include chemo, radiation, or a combination of both. Radiation is given to the pelvis or to both the abdomen and the pelvis. Sometimes vaginal brachytherapy is used as well.
Stage IIIB: In this stage, the cancer has spread to the vagina. After surgery, stage IIIB may be treated with chemo and/or radiation.
Stage IIIC: This includes cancers that have spread to the lymph nodes in the pelvis (stage IIIC1) and those that have spread to the lymph nodes around the aorta (stage IIIC2). Treatment includes surgery, followed by chemo and/or radiation.
For women with high-grade cancers, such as papillary serous carcinoma or clear cell carcinoma, the surgery may include omentectomy and peritoneal biopsies in addition to the TH/BSO, pelvic and para-aortic lymph node dissections, and pelvic washings. After surgery, chemo, radiation therapy, or both may be given to help keep the cancer from coming back. The chemo usually includes the drugs carboplatin and paclitaxel or cisplatin and doxorubicin.
Women with stage III uterine carcinosarcoma often have the same type of surgery that is used for a high-grade cancer. After surgery, radiation, chemo, or both may be used. The chemo often includes the drug paclitaxel and carboplatin, but ifosfamide, along with paclitaxel or cisplatin may be used.
Stage IVA: These cancers have grown inside the bladder or bowel.
Stage IVB: These cancers have spread to lymph nodes outside of the pelvis or para-aortic area. This stage also includes cancers that have spread to the liver, lungs, omentum or other organs.
Some endometrial cancers are stage IV because they have spread to lymph nodes in the abdomen (and not just the pelvis and para-aortic area), but the cancers have not spread to any other areas. Women with this kind of cancer spread may have the best chance if all the cancer that is seen can be removed and biopsies of other areas in the abdomen do not show cancer cells.
However, in most cases of stage IV endometrial cancer, the cancer has spread too far for it all to be removed with surgery and a surgical cure is not possible. A hysterectomy and bilateral salpingo-oophorectomy may still be done to prevent excessive bleeding. Radiation therapy may also be used for this reason. When the cancer has spread to other parts of the body, hormone therapy may be used. Drugs used for hormone therapy include progestins and tamoxifen. Aromatase inhibitors may also be useful and are being studied. High-grade cancers and those without detectable progesterone receptors are not likely to respond to hormone therapy.
Combinations of chemo drugs may help some women with advanced endometrial cancer for a time. The drugs used most often are paclitaxel, doxorubicin, and either carboplatin or cisplatin. These drugs are often used together in combination. Stage IV carcinosarcoma is often treated with similar chemo. Cisplatin, ifosfamide, and paclitaxel may also be combined. Women with stage IV endometrial cancer should consider taking part in clinical trials of chemotherapy or other new treatments.
Recurrent endometrial cancer
Cancer is called recurrent when it come backs after treatment. Recurrence can be local (in or near the same place it started) or distant (spread to organs such as the lungs or bone). Treatment depends on the amount and location of the cancer.
For local recurrences, such as in the pelvis, surgery (sometimes followed with radiation therapy may provide a cure. For women who have other medical conditions that make them unable to have surgery, radiation therapy alone or combined with hormone therapy is generally used.
For a distant recurrence, surgery and/or focused radiation therapy may also be used when the cancer is only in a few small spots (like in the lungs or bones). Women with more extensive recurrences (widespread cancer) are treated like those with stage IV endometrial cancer. Either hormone therapy or chemo is recommended. Low-grade cancers containing progesterone receptors are more likely to respond well to hormone therapy. Higher-grade cancers and those without detectable receptors are unlikely to shrink during hormone therapy but may respond to chemo. Clinical trials of new treatments are another option.
Last Medical Review: 11/04/2013
Last Revised: 02/03/2014