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Cancer Medicine :: Endometrial Cancer Treatment

Endometrial Cancer

Treatment

After all of the test results have been reviewed, your doctor will recommend one or more treatment options. Don't feel rushed about making a decision. If there is anything you do not understand, ask to have it explained again. The choice of treatment depends largely on the type of cancer and stage of the disease when it is found. Other factors could play a part in choosing the best treatment plan. These might include your age, your overall state of health, whether you plan to have children, and other personal considerations. Be sure you understand all the risks and side effects of the different treatment options before making a decision.

You may want to get a second opinion. This can provide more information and help you feel confident about the treatment plan you choose. Some insurance companies require a second opinion before they will pay for certain treatments, but a second opinion is usually not required for routine cancer treatments.

The four basic types of treatment for women with endometrial cancer are surgery, radiation therapy, hormonal therapy, and chemotherapy. Surgery is the main treatment for most women with this cancer. But in certain situations, a combination of these treatments may be used. The choice of treatment(s) will depend on the type and stage of your cancer and your overall medical condition as well as your desire to be able to have children in the future.

The next few sections describe the different types of treatment. This is followed by a section on the standard treatment options for each stage of the disease.

Surgery for endometrial cancer

Hysterectomy : The main treatment for endometrial cancer is an operation to remove the uterus and cervix (called a hysterectomy). When the uterus is removed through an incision in the abdomen, it is called a simple or total abdominal hysterectomy (TAH). If the uterus is removed through the vagina, it is known as a vaginal hysterectomy. Removing the ovaries and fallopian tubes, a bilateral salpingo-oophorectomy (BSO), is not actually part of a hysterectomy; it is a separate procedure that is often done during the same operation (see below). For endometrial cancer, removing the uterus but not the ovaries or fallopian tubes is seldom recommended. To decide what stage the cancer is in, lymph nodes in the pelvis and around the aorta will also need to be removed (see below). This can be done through the same incision as the abdominal hysterectomy. If a vaginal hysterectomy is done, lymph nodes can be removed by laparoscopy (this is discussed in detail below).

A radical hysterectomy is done when endometrial cancer has spread to the cervix or the area around the cervix (the parametrium). In this operation, the entire uterus, the tissues next to the uterus (parametrium and uterosacral ligaments), and the upper part of the vagina (next to the cervix) are all removed. For endometrial cancer, a BSO is done at the same time. This operation is most often done through an incision in the abdomen, but it can also be done going in through the vagina.

When a vaginal approach is used, laparoscopy is used to help safely remove all of the correct tissues. Laparoscopy is a technique that lets the surgeon look at the inside of the abdomen and pelvis through tubes inserted into very small incisions. Small surgical instruments can be controlled through the tubes, allowing the surgeon to operate without a large incision in the abdomen. This can shorten the time needed for recovery from surgery. Both a hysterectomy and a radical hysterectomy can also be done through the abdomen using laparoscopy.

Surgery for endometrial cancer using laparoscopy seems to be just as good as more traditional open procedures if done by a surgeon who has a lot of experience in laparoscopic cancer surgeries. The DaVinci ® robot is increasingly used to perform laparoscopic procedures.

For any of these surgeries, either general anesthesia or regional anesthesia will be used so the patient is asleep or sedated during these operations.

Bilateral salpingo-oophorectomy: This operation removes both fallopian tubes and both ovaries. This procedure is usually done at the same time the uterus is removed (either by simple hysterectomy or radical hysterectomy) to treat endometrial cancers. Removing both ovaries means that you will go into menopause if you have not done so already.

If you are younger than 45 when you get stage I endometrial cancer, you may discuss keeping your ovaries with your surgeon, because although women whose ovaries were removed had a lower chance of the cancer coming back, removing the ovaries didn’t seem to help them live longer.

Lymph node surgery: Pelvic and para-aortic lymph node dissection: This operation removes lymph nodes from the pelvis and the area next to the aorta to see if they contain cancer cells that have spread from the endometrial tumor. It is called a lymph node dissection when most or all of the lymph nodes in a certain area are removed. This procedure is usually done at the same time as the operation to remove the uterus. If the patient is having an abdominal hysterectomy, the lymph nodes can be removed through the same incision. In women who have had a vaginal hysterectomy, these lymph nodes may be removed by laparoscopic surgery.

Laparoscopy is a technique that lets the surgeon look at the inside of the abdomen and pelvis through tubes inserted into very small incisions. Small surgical instruments can be controlled through the tubes, allowing the surgeon to remove lymph nodes. This approach avoids the need for a large incision in the abdomen and so can shorten the time needed for recovery from surgery. A recent study showed that laparoscopic surgery (including lymph node removal) works as well (at least in the short-term) as open abdominal surgery.

Lymph node sampling: When only a few of the lymph nodes in an area are removed, it is called lymph node sampling.

Depending on the grade, amount of cancer in the uterus and how deeply the cancer invades into the muscle of the uterus, lymph nodes may not need to be removed.

Pelvic washings: In this procedure, the surgeon “washes” the abdominal and pelvic cavities with salt water (saline) and sends the fluid to the lab to see if it contains cancer cells. This is also called peritoneal lavage.

Other procedures that may be used to look for cancer spread

Omentectomy: The omentum is a layer of fatty tissue that covers the abdominal contents like an apron. Cancer sometimes spreads to this tissue. When this tissue is removed, it is called an omentectomy. Sometimes the omentum is removed during a hysterectomy to see if cancer has spread there.

Peritoneal biopsies: The tissue lining the pelvis and abdomen is called the peritoneum. Peritoneal biopsies involve removing small pieces of this lining to check for cancer cells.

Tumor debulking : If cancer has spread throughout the abdomen, the surgeon may attempt to remove as much of the tumor as possible. This is called debulking. Debulking a cancer can help other treatments, like radiation or chemotherapy, work better. Tumor debulking is helpful for other types of cancer, and it may also be helpful in treating some types of endometrial cancer.

Recovery after surgery: For an abdominal hysterectomy the hospital stay is usually from 3 to 7 days. The average hospital stay after a radical hysterectomy is about 5 to 7 days. Complete recovery can take about 4 to 6 weeks. A laparoscopic procedure and vaginal hysterectomy usually require a hospital stay of 1 to 2 days and 2 to 3 weeks for recovery. Complications are unusual but could include excessive bleeding, wound infection, and damage to the urinary or intestinal systems.

Side effects: Any hysterectomy causes infertility (not being able to start or maintain a pregnancy). For those who were premenopausal before surgery, removing the ovaries will cause menopause. This can lead to symptoms such as hot flashes, night sweats, and vaginal dryness. Removing lymph nodes in the pelvis can lead to a build up of fluid in the legs, a condition called lymphedema. This occurs more often if radiation is given after surgery.

Radiation therapy for endometrial cancer

Radiation therapy is the use of high-energy radiation (such as x-rays) to kill cancer cells. Radiation therapy may be given by placing radioactive materials inside the body near the tumor. This is called internal radiation therapy or brachytherapy. Another option is to give radiation from a machine outside the body in a procedure that is much like having an x-ray. This is called external beam radiation therapy. In some cases, both brachytherapy and external beam radiation therapy are given. The stage and grade of the cancer help determine what areas need to be exposed to radiation therapy and which methods are used.

Brachytherapy: For vaginal brachytherapy, a cylinder containing a source of radiation is inserted into the vagina. The length of the cylinder (and the amount of the vagina treated) can vary, but the upper part of the vagina is always treated. With this method, the radiation mainly affects the area of the vagina in contact with the cylinder. Nearby structures such as the bladder and rectum get less radiation exposure. The most common side effect is changes to the lining of the vagina (discussed in more detail below).

This procedure is done in the radiation suite of the hospital or care center. About 4 to 6 weeks after the hysterectomy, the radiation oncologist inserts a special applicator into the woman's vagina, and pellets of radioactive material are inserted into the applicator. There are 2 types of brachytherapy used for endometrial cancer, low-dose rate (LDR) and high-dose rate (HDR).

In LDR brachytherapy, the radiation devices are usually left in place for about 1 to 4 days. The patient needs to stay immobile to keep the radiation sources from moving during treatment, and so she is usually kept in the hospital overnight. Several treatments may be necessary. Because the patient has to stay immobile, this form of brachytherapy carries a risk of serious blood clots in the legs (called deep venous thrombosis or DVT). LDR is less commonly used now in this country.

In HDR brachytherapy, the radiation is more intense. Each dose takes a very short period of time (usually less than an hour), and the patient can return home the same day. For endometrial cancer, HDR brachytherapy is often given weekly or even daily for at least 3 doses.

External beam radiation therapy: In this type of treatment the radiation is delivered from a source outside of the body.

External beam radiation therapy is often given 5-days-a-week for 4 to 6 weeks. The skin covering the treatment area is carefully marked with permanent ink or injected dye similar to a tattoo. A special mold of the pelvis and lower back is custom made to ensure that the woman is placed in the exact same position for each treatment. Each treatment takes less than a half-hour, but the daily visits to the radiation center may be tiring and inconvenient.

Side effects of radiation therapy

Short-term side effects: Common side effects of radiation therapy include tiredness, upset stomach, or loose bowels. Serious fatigue, which may not occur until about 2 weeks after treatment begins, is a common side effect. Diarrhea is common, but can usually be controlled with over-the-counter medicines. Nausea and vomiting may also occur, but can be treated with medication. These side effects are more common with pelvic radiation than with vaginal brachytherapy. Side effects tend to be worse when chemotherapy is given with radiation.

Skin changes are also common, with the skin in the treated area looking and feeling sunburned. As the radiation passes through the skin to the cancer, it may damage the skin cells. This can cause irritation ranging from mild temporary redness to permanent discoloration. The skin may release fluid, which can lead to infection, so care must be taken to clean and protect the area exposed to radiation.

Radiation can irritate the bladder, and problems with urination may occur. Irritation to the bladder, called radiation cystitis, can result in discomfort, blood in the urine, and an urge to urinate often.

Radiation can also cause similar changes in the intestine. When there is rectal irritation or bleeding, it is called radiation proctitis. This is sometimes treated with enemas that contain a steroid (like hydrocortisone) or suppositories that contain an anti-inflammatory.

Radiation can irritate the vagina, leading to discomfort and drainage (a discharge). If this, called radiation vaginitis, occurs, your radiation doctor may recommend douching with a dilute solution of hydrogen peroxide. When the irritation is severe, open sores can develop in the vagina, which may need to be treated with an estrogen cream.

Radiation can also lead to low blood counts, causing anemia (low red blood cells) and leukopenia (low white blood cells). The blood counts usually return to normal within a few weeks after radiation is stopped.

Long-term side effects: Radiation therapy may cause changes to the lining of the vagina leading to vaginal dryness. This is more common after vaginal brachytherapy than after pelvic radiation therapy. In some cases scar tissue can form in the vagina. The scar tissue can make the vagina shorter or more narrow (called vaginal stenosis), which can make sex (vaginal intercourse) painful. A woman can help prevent this problem by stretching the walls of her vagina several times a week. This can be done by having sexual intercourse 3 to 4 times per week or by using a vaginal dilator (a plastic or rubber tube used to stretch out the vagina). Still, vaginal dryness and pain with intercourse can be long-term side effects from radiation. Some centers have physical therapists who specialize in pelvic floor therapy which can help to treat these vaginal symptoms and sometimes improve sexual function. You should ask your physician about this if you are bothered by these problems.

Pelvic radiation can damage the ovaries, resulting in premature menopause. However, this is not an issue for most women who are being treated for endometrial cancer because they have already gone through menopause, either naturally or as a result of surgery to treat the cancer (hysterectomy and removal of the ovaries).

Pelvic radiation therapy can also lead to a blockage of the fluid draining from the leg. This can lead to severe swelling, known as lymphedema. Lymphedema is a long-term side effect; it doesn't go away after radiation is stopped. In fact it may not appear for several months after treatment ends. This side effect is more common if pelvic lymph nodes were removed during surgery to remove the cancer. There are specialized physical therapists who can help treat this. It is important to begin treatment early if you develop it.

Radiation to the pelvis can also weaken the bones, leading to fractures of the hips or pelvic bones. It is important that women who have had endometrial cancer contact their doctor right away if they have pelvic pain. Such pain might be caused by a fracture, recurrent cancer, or other serious conditions.

Pelvic radiation can also lead to long-term problems with the bladder (radiation cystitis) or bowel (radiation proctitis). Rarely, radiation damage to the bowel can cause a blockage (called obstruction) or for an abnormal connection to form between the bowel and the vagina or outside skin (called a fistula). These conditions may need to be treated with surgery.

If you are having side effects from radiation, discuss them with your doctor. There are things you can do to get relief from these symptoms or to prevent them from happening.

Chemotherapy for endometrial cancer

Chemotherapy (often called “chemo”) is the use of cancer-fighting drugs given into a vein or by mouth. These drugs enter the bloodstream and reach throughout the body, making this treatment potentially useful for cancer that has spread beyond the endometrium. If this treatment is chosen, you may receive a combination of drugs. Combination chemotherapy sometimes works better than one drug alone in treating cancer.

Drugs used in treating endometrial cancer may include: Paclitaxel (Taxol®), Carboplatin, Doxorubicin (Adriamycin®), Cisplatin

Most often, 2 or more drugs are combined for treatment. The most common combinations include carboplatin with paclitaxel and cisplatin with doxorubicin. Less often, paclitaxel and doxorubicin and cisplatin/paclitaxel/doxorubicin may be used.

For carcinosarcoma, the chemo drug ifosfamide, either alone or in combination with either carboplatin, cisplatin or paclitaxel, is often used. However, the combination of carboplatin and paclitaxel is also often being used for carcinosarcoma.

Side effects of chemotherapy

These drugs kill cancer cells but can also damage some normal cells, which in turn can cause side effects. Side effects of chemotherapy depend on the specific drugs, the amount taken, and the length of time you are treated. Common side effects include: Nausea and vomiting, Loss of appetite, Mouth and vaginal sores, Hair loss

Also, most chemotherapy drugs can damage the blood-producing cells of the bone marrow. This can result in low blood cell counts, such as:

Low white blood cells which increases the risk of infection

Low platelet counts which can cause bleeding or bruising after minor cuts or injuries

Low red blood cells (anemia) which can cause problems like fatigue and shortness of breath

Most of the side effects of chemotherapy stop when the treatment is over, but some can last a long time. Different drugs can cause different side effects. For example, the drug doxorubicin can damage the heart muscle over time. The chance of heart damage goes up as the total dose of the drug goes up, so doctors place a limit on how much doxorubicin is given. Cisplatin can cause kidney damage. Giving large amounts of fluid before and after chemotherapy can help protect the kidneys. Both cisplatin and paclitaxel can cause nerve damage (called neuropathy). This can lead to numbness, tingling, or even pain in the hands and feet. Ifosfamide can injure the lining of the bladder, causing it to bleed (called hemorrhagic cystitis). This can be prevented by giving large amounts of fluid and a drug called mesna along with the chemo. Before starting chemotherapy, be sure to discuss the drugs and their possible side effects with your health care team.

If you have side effects while on chemotherapy, remember that there are ways to prevent or treat many of them. For example, modern anti-nausea drugs can prevent or reduce nausea and vomiting. Be sure to talk with your doctor or nurse about any side effects you are having.

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.

Stage I: 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 and radiation therapy are often given to help keep the cancer from coming back. The chemotherapy 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, chemotherapy, or both may be used. The chemotherapy 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  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. Recent 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 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 vaginal brachytherapy 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.

Stage II : 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, chemotherapy, radiation therapy, or both may be given to help keep the cancer from coming back. The chemotherapy 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, chemotherapy, or both may be used. The chemotherapy often includes paclitaxel and carboplatin but may instead include ifosfamide, along with paclitaxel or cisplatin.

Stage III: 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 occur. Pelvic washings will be obtained and the omentum may be removed. Some doctors will try to remove any remaining cancer (debulking), but doing this hasn't been proven to 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). When this occurs, treatment after surgery may include chemotherapy, 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 chemotherapy 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 chemotherapy 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, chemotherapy, radiation therapy, or both may be given to help keep the cancer from coming back. The chemotherapy usually includes the drugs carboplatin and paclitaxel or cisplatin and doxorubicin.

Someone with a Stage III uterine carcinosarcoma often has the same type of surgery that is used for a high-grade cancer. After surgery, radiation, chemotherapy, or both may be used. The chemotherapy often includes the drug paclitaxel and carboplatin, but ifosfamide, along with paclitaxel or cisplatin may be used.

Stage IV: 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.

The patient may have the best chance if all the cancer that is seen can be removed and biopsies of the abdomen do not show cancer cells. This may be possible if the cancer has only spread to lymph nodes in the abdomen and pelvis. In most cases of stage IV endometrial cancer, the cancer has spread too far for it all to be removed with surgery, meaning that 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 chemotherapy drugs may help for a time in some women with advanced endometrial cancer. The drugs used most often are paclitaxel (Taxol®) doxorubicin (Adriamycin®), and either carboplatin or cisplatin. These drugs are often used together in combination. Stage IV carcinosarcoma is often treated with similar chemotherapy. 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. If patients have other medical conditions that make them unable to have surgery, radiation therapy alone or combined with hormonal 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 chemotherapy 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 chemotherapy. Clinical trials of new treatments are another option.

What will happen after treatment for endometrial cancer?

For many women with endometrial cancer, treatment may remove or destroy the cancer. Completing treatment can be both stressful and exciting. You may be relieved to finish treatment, but find it hard not to worry about cancer coming back. (When cancer comes back after treatment, it is called recurrence.) This is a very common concern in people who have had cancer.

It may take a while before your fears lessen. But it may help to know that many cancer survivors have learned to live with this uncertainty and are living full lives.

For other women with this cancer, the cancer may never go away completely. They may get regular treatments with chemotherapy, radiation therapy, or other therapies to try to help keep the cancer in check. Learning to live with cancer that does not go away can be difficult and very stressful. It has its own type of uncertainty. 

Follow-up care: When treatment ends, your doctors will still want to watch you closely. It is very important to go to all of your follow-up appointments. During these visits, your doctors will ask questions about any problems you may have and may do exams and lab tests or x-rays and scans to look for signs of cancer or treatment side effects. Almost any cancer treatment can have side effects. Some may last for a few weeks to months, but others can last the rest of your life. This is the time for you to talk to your cancer care team about any changes or problems you notice and any questions or concerns you have.

An important part of your treatment plan is a specific schedule of follow-up visits after treatment to see if the cancer has come back. How often you need to be seen depends mostly on what stage your cancer was.

Women who had low grade endometrioid cancers (grades 1 and 2) that were stage IA may be seen every 6 months for the first year after treatment, and then yearly after that. If the cancer was stage IB or II, follow-up visits are more frequent – every 3 months for the first year, then every 6 months for the next 4 years, and then once a year.

For women with higher stage or grade cancers (stages III or IV, or cancers that were grade III, including papillary serous, clear cell, or carcinosarcomas), follow-up visits may occur even more often. Experts recommend visits every 3 months for the first 2 years, every 6 months for the next 3 years, and then yearly after that. Most endometrial cancer recurrences are found within the first few years of follow-up.

During each follow-up visit, the doctor will do a pelvic exam (using a speculum) and check for any enlarged lymph nodes in the groin area. A Pap test may also be done to look for cancer cells in the upper part of the vagina, near the area where the uterus used to be, but it is no longer recommended as a matter of routine due to the low chance of detecting a recurrence. Sometimes a CA 125 blood test is done as a part of follow-up, but this is also not needed in all patients. The doctor will also ask about any symptoms that might point to cancer recurrence or side effects of treatment. Most endometrial cancer recurrences are found based on symptoms, so it is very important that you tell your doctor exactly how you are feeling.

If your symptoms or the physical exam results suggest the cancer may have come back, imaging tests (such as CT scans or ultrasound studies), a CA 125 blood test, and/or biopsies may be done. Studies of many women with endometrial cancer show that if no symptoms or physical exam abnormalities are present, routine blood tests and imaging tests are not needed.

It is important to keep health insurance. Tests and doctor visits cost a lot, and even though no one wants to think of their cancer coming back, this could happen.

What`s new in endometrial cancer research and treatment?

Molecular pathology of endometrial cancer

Recent research has improved our understanding of how changes in certain molecules can cause normal endometrial cells to become cancerous. It has been known for several years that damaged or defective DNA (called mutations) can alter important genes that regulate cell growth. If these genes are damaged, out-of-control growth may result in cancer.

Sometimes, endometrial cancer and colon cancer may seem to “run in a family.” We now know that some of these families have a higher risk for these cancers because they have an inherited defect in certain genes that normally help repair damage to DNA. If these repair enzymes are not working properly, damage to DNA is more likely to persist and cause cancer. Similar DNA repair defects have also been found in endometrial cancer cells from some patients without an inherited tendency to develop this disease. One of the normal genes responsible for suppressing tumor growth, called PTEN, is often abnormal in endometrial cancers.

Tests for this and other DNA changes may someday help find endometrial cancers early. Endometrial cancers without other tumor suppressor genes (or with inactive ones), such as the retinoblastoma (Rb) gene and the p53 gene, tend to be more likely to come back after initial treatment. Tests for these and other DNA changes may someday be used to help predict how aggressive the cancer might be and to select the best treatment for each woman with this disease. The long-range goal of this field of research is gene therapy that can correct the DNA abnormalities that caused the endometrial cells to become cancerous.

Tumor markers: Molecules released by cancer cells can help detect recurrence of some types of cancer. For example, CA 125 is a useful marker in finding recurrent ovarian cancer. Recent studies find that blood tests for CA 125 may also be helpful in finding recurrent endometrial cancer, before tumor deposits are visible by CT or MRI scans. Measuring CA 125 levels in some patients before surgery may also be helpful if it appears the cancer may have spread. This may be useful in deciding which patients will benefit from surgical staging and which patients might be safely treated by hysterectomy without lymph node sampling.

New treatments: Researchers are examining new drugs, combinations of drugs and “targeted therapies” in patients with advanced endometrial cancer. The use of adjuvant chemotherapy, with or without radiation is also under investigation.

Surgery: Another way to see if cancer has spread to the lymph nodes in the pelvis is to identify and remove the lymph nodes that most likely are draining the cancer. This is called sentinel lymph node biopsy. In this procedure, radioactive tracer and/or blue dye is injected into the area with the cancer. The lymph nodes that turn blue (from the dye) or that become radioactive (from the tracer) are removed at surgery. These lymph nodes are examined closely to see if they contain any cancer cells. This technique is commonly used for some other tumors, such as breast cancer, but it is still new in the treatment of endometrial cancer. It is not known if sentinel lymph node biopsy is as good as lymph node dissection for staging and treatment of endometrial cancer. This is why it is not part of the standard surgery for this cancer.

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