Treatment Choices for Endometrial Cancer, by Stage

The stage (extent) of endometrial cancer is the most important factor in choosing treatment. But other factors can also affect your treatment options, including the type of cancer, your age and overall health, and whether you want to be able to have children. Tests done on the cancer cells are also used to find out if certain treatments, like hormone and targeted therapy, might work.

Surgery is the first treatment for almost all women with endometrial cancer. The operation includes removing the uterus, fallopian tubes, and ovaries. (This is called a 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 tested for cancer spread. Pelvic washings may be done, too. The tissues removed at surgery are tested 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 a woman isn't well enough to have surgery, other treatments, like radiation, will be used.

Stage I cancers

Stage I is only in the uterus. It has not spread to lymph nodes or distant sites.

Stage I endometrioid cancers

Standard treatment includes surgery to remove and stage the cancer (see above). Sometimes this is the only treatment needed. The patient is then closely watched for signs that the cancer has come back (recurred).

For women with higher grade tumors, radiation will likely be recommended after surgery. Vaginal brachytherapy (VB), pelvic radiation, or both can be used.

Some younger women with early endometrial cancer may have their uterus removed without removing the ovaries. This prevents menopause and the issues that can come with it. This also increases the chance that the cancer will come back, but it doesn’t make it more likely that you will die from the 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 just radiation (external radiation and/or vaginal brachytherapy).

Fertility-sparing treatment for stage IA grade 1 endometrioid cancers: For young women who still want to have children, surgery may be postponed while progestin therapy is used to treat the cancer. Progestin treatment can cause the cancer to shrink or even go away for some time, giving the woman a chance to get pregnant. Still, this is experimental and can be risky if the patient isn't watched closely. An endometrial biopsy or a D&C should be done every 3 to 6 months. If there's still no cancer after 6 months, the woman can try to become pregnant. She will continue to be checked for cancer every 6 months. Because the cancer often comes back again, doctors recommend TH/BSO after childbearing is complete.

Many times, progestin treatment doesn't 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 it doesn’t go away in 6 to 12 months , surgery to remove and stage the cancer is recommended (hysterectomy and removal of both fallopian tubes and ovaries).

A second opinion from a gynecologic oncologist and pathologist (to confirm the grade of the cancer) before starting progestin therapy is important. Seeing a fertility expert is also a good idea. It's important to understand that this isn't a standard treatment and may increase risk of cancer growth and spread.

Other types of stage I 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 don't do as well as those with lower grade tumors. If the biopsy done before surgery shows a high-grade cancer, the surgery may be more extensive. Along with the total hysterectomy and removal of both fallopian tubes and ovaries, the pelvic and para-aortic lymph node will be removed, and the omentum is often removed, too.

After surgery, chemotherapy (chemo) with or without radiation therapy are given to help keep the cancer from coming back. The chemo usually includes the drugs carboplatin and paclitaxel, but other drugs can also be used.

If the cancer can't be removed with surgery, both chemotherapy (chemo) with or without and radiation are used. Sometimes, the tumor then shrinks so that surgery can then be done to remove it.

Stage II cancers

When an endometrial cancer is stage II, it has spread to the connective tissue of the cervix. But it still hasn't grown outside the uterus.

One treatment option is to have surgery first, followed by radiation therapy. The surgery includes a radical hysterectomy (the entire uterus, the tissues next to the uterus, and the upper part of the vagina are removed), removal of both fallopian tubes and ovaries (BSO), and pelvic and para-aortic lymph node dissection (LND) or sampling. Radiation therapy, often both vaginal brachytherapy and external pelvic radiation, may be given after the patient has recovered from surgery. Another option is to give the radiation therapy first, and then do a simple hysterectomy, BSO, and possible LND or lymph node sampling.

The lymph nodes that have been removed are checked for cancer cells. If there's cancer in them, the cancer isn't 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 external radiation and brachytherapy.

For women with high-grade cancers, like papillary serous carcinoma or clear cell carcinoma, the surgery may include omentectomy and peritoneal biopsies along with the total hysterectomy, removal of both fallopian tubes and ovaries, pelvic and para-aortic lymph node dissections, and pelvic washings. After surgery, radiation therapy, chemo, 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 (called debulking), but it isn’t clear that this helps patients live longer.

If tests done before surgery show that the cancer has spread too far to be removed completely, in rare cases, radiation therapy may be given before any surgery. It might shrink the tumor enough to make surgery an option. For advanced endometrial cancers that cannot be treated with surgery or radiation, treatment with the immunotherapy drug, pembrolizumab might be an option.

Stage IIIA: A cancer stage IIIA 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 both. Radiation is given to the pelvis or to both the abdomen (belly) and pelvis. Vaginal brachytherapy is often used, too.

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 along with 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. Targeted and/or immunotherapy may also be options for some women.

Stage IV cancers

Stage IVA: These endometrial cancers have grown into 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 they haven't spread to any other areas. Women with this kind of cancer spread may have better outcomes if all the cancer that’s seen can be removed (debulked) and biopsies of other areas in the abdomen do not show cancer cells.

In most cases of stage IV endometrial cancer, the cancer has spread too far for it all to be removed with surgery. 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. But high-grade cancers and those without detectable progesterone and estrogen receptors on the cancer cells are not likely to respond to hormone therapy.

Combinations of chemo drugs may help some women 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 much the same chemo. Cisplatin, ifosfamide, and paclitaxel may also be combined.

Targeted drugs and/or immunotherapy drugs may also be options for some women with advanced endometrial cancer.

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 of cancer and where it is, as well as the kind of treatment was used the first time.

For local recurrences, such as in the pelvis, surgery (sometimes followed with radiation therapy) is used. For women who have other medical conditions that make them unable to have surgery, radiation therapy alone or combined with hormone therapy tends to be used.

For a distant recurrence, surgery and/or focused radiation therapy may 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. Targeted therapy and immunotherapy may be used in some cases. Clinical trials of new treatments are another good option.