Treatment Choices for Endometrial Cancer, by Stage
This operation includes removing the uterus, fallopian tubes, and ovaries (total hysterectomy bilateral salpingo-oophorectomy or TH/BSO). Lymph nodes from the pelvis and around the aorta may also be removed (a pelvic and para-aortic lymph node dissection [LND] or sampling) and examined for cancer spread. Pelvic washings may be done, too. The tissues removed at surgery are examined under a microscope to see how far the cancer has spread (the stage). Depending on the stage of the cancer, other treatments, such as radiation and/or chemotherapy may be recommended.
For some women who still want to be able to get pregnant, surgery may be put off for a time and other treatments tried instead.
If the cancer has spread outside the uterus, a different surgery may be planned. If the cancer has spread to the inside of the liver, the lungs, or other organs, surgery may not be helpful, and so chemotherapy or other treatments may be used instead.
Stage I cancers
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. Surgery and other treatment often differ for cancers that aren't endometrioid. These cancers are discussed separately in this section.
Stage I cancers that have been staged with surgery may not need any further treatment. For some patients, especially those with higher grade tumors, doctors are more likely to recommend radiation after surgery. Either vaginal brachytherapy (VB), pelvic radiation, or both can be used.
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.
Fertility-sparing treatment for stage IA grade 1 cancers: In young women who still want to have children, surgery may be postponed for a time while progestin therapy is used to treat the cancer. Progestin treatment, as a pill, injection, or as a progestin-containing intrauterine device, can cause the cancer to shrink or even go away for some time, giving the woman a chance to get pregnant. This approach is experimental and can be risky if the patient isn't watched closely.
Often, this does not work and the cancer doesn’t get better or keeps growing. Putting off surgery can give the cancer time to spread outside the uterus. If the cancer doesn’t go away, surgery to remove and stage the cancer is recommended (including a hysterectomy and removal of both fallopian tubes and ovaries).
Sometimes the tumor gets smaller or goes away for a while following treatment with progestins, but then comes back again. Because the cancer often comes back again, doctors recommend surgery to remove the uterus, fallopian tubes, and ovaries after childbearing is complete.
A second opinion from a gynecologic oncologist and pathologist (to confirm the grade of the cancer) before starting progestin therapy is important. Women need to understand that this is not a standard treatment and may increase risk.
Other endometrial cancers
Cancers such as papillary serous carcinoma, clear cell carcinoma, or carcinosarcoma are more likely to have already spread outside the uterus when diagnosed. Women 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 total hysterectomy, removal of both fallopian tubes and ovaries, 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), but other combinations can also be used.
Stage II cancers
When an endometrial cancer is stage II, it has spread to the connective tissue of the cervix but still has not grown outside the uterus.
One treatment option is to have surgery first, possibly followed by radiation therapy. The surgery would include a radical hysterectomy (the entire uterus, the tissues next to the uterus, and the upper part of the vagina are all removed), removal of both fallopian tubes and ovaries (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’s 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 total hysterectomy, removal of both fallopian tubes and ovaries, 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’s 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
Stage III endometrial cancers have spread outside of the uterus.
If the surgeon thinks that all visible cancer can be removed, a hysterectomy is done and both ovaries and fallopian tubes are removed. Sometimes women with stage III cancers need a radical hysterectomy. A pelvic and para-aortic lymph node dissection may also be done. Pelvic washings will be done 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 total hysterectomy, removal of both ovaries and fallopian tubes, 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’s 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 IV cancers
Stage IVA: These endometrial cancers have grown inside the bladder or bowel.
Stage IVB: These endometrial cancers have spread to lymph nodes outside 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’s seen can be removed (debulked) 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 removal of both fallopian tubes and ovaries 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 and estrogen 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: February 10, 2016 Last Revised: February 29, 2016