How Endometrial Cancer Is Treated

In the United States, endometrial cancer is the most common cancer of the female reproductive system. The upside is that most women are diagnosed when the cancer is at an early stage. This means that for many women, endometrial cancer can be cured with surgery alone.

While surgery is the first-line treatment for endometrial cancer, some women will need to undergo additional therapies like radiation therapy or chemotherapy based on their risk of cancer recurrence after treatment.

This risk of recurrence—defined as low, intermediate, or high—is designated by a woman's cancer healthcare provider (called a gynecological oncologist) and is based largely on the following three factors:

• The stage of cancer (how far the cancer has spread)
• How aggressive the cancer is, based on an examination of the cancer tissue (called the tumor grade)
• The type of cells that make up the cancer (called histological type)

To provide two examples, a woman with low-risk endometrial cancer will likely only undergo surgery for her treatment (without radiation therapy or chemotherapy). On the other hand, a woman with high-risk endometrial cancer may be treated with surgery, radiation, and chemotherapy.

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Surgery

Surgery is the treatment of choice for most endometrial cancers, often consisting of a hysterectomy (removal of the uterus) along with the removal of the fallopian tubes and ovaries (called a bilateral salpingo-oophorectomy).

Total Abdominal Hysterectomy

A total abdominal hysterectomy, which refers to the removal of the uterus through the abdomen, can be accomplished through laparoscopy or laparotomy, depending on a woman's situation and her surgeon's preference.

With a laparoscopy, multiple small incisions are made in a woman's abdomen. Then, using a thin instrument with a camera and light at the end, the surgeon will remove the uterus (and the ovaries and fallopian tubes). With a laparotomy, a larger skin incision is made in the abdomen in order to remove the above organs.

Vaginal Hysterectomy

Besides a total abdominal hysterectomy, the uterus can also be removed through the vagina (called a vaginal hysterectomy). Again, the type of surgery decided upon takes into account many factors and requires careful thought.

Lymph Node Removal

In addition to surgical removal of the uterus, ovaries, and fallopian tubes, your surgeon will also likely remove pelvic and para-aortic lymph nodes. This is because while cancer begins in the uterus, it can spread to the lymph nodes (and other organs, like the cervix) if left untreated.

Lymph node removal can be done at the same time as the total abdominal hysterectomy. However, with a vaginal hysterectomy, lymph node removal will need to be performed laparoscopically.

Radical Hysterectomy

If the cancer has spread to the cervix, a radical hysterectomy is performed. This type of surgery entails removing the uterus, cervix, upper part of the vagina, and some tissue located next to the uterus. Of course, as with many hysterectomies, the fallopian tubes and ovaries are also removed.

Side Effects and Risks

A hysterectomy and bilateral salpingo-oophorectomy is a surgery performed in an operating room under general anesthesia. After surgery, a woman will have to recover in the hospital for up to one week, depending on the type of surgery performed.

As with any surgery, there are risks involved, which should be discussed carefully with your healthcare provider.

Some of these risks include:

• Infection
• Bleeding
• Damage to the nerves that control the bladder (from a radical hysterectomy)
• Swelling of the legs from lymph node removal (called lymphedema)

Keep in mind, for premenopausal women, by removing the uterus (and/or ovaries and fallopian tubes), a woman becomes infertile. If the ovaries are removed, a woman will also enter menopause (if she is premenopausal before going into surgery) because there is no more estrogen being released by the ovaries.

Radiation

Radiation therapy is administered by a healthcare provider called a radiation oncologist and involves using a type of high-energy X-ray to slow or halt the growth of cancer cells. Most commonly, radiation is given after surgery to kill any remaining cancer cells and prevent a recurrence.

However, for some early-stage endometrial cancers, radiation therapy may be used alone. In less common situations, surgery may not be possible, potentially due to a woman's older age, or if she has multiple other medical problems that make surgery too risky. In this case, radiation therapy with or without chemotherapy may be the treatment of choice.

Vaginal Brachytherapy

With vaginal brachytherapy (VBT), pellets of radioactive material are placed into a device which is then temporarily placed inside a woman's vagina. Typically, a woman will undergo a radiation session (which lasts less than an hour) once weekly or daily at least three times.

External Beam Radiation Therapy:

With external beam radiation therapy (EBRT), a machine located outside the body focuses radiation beams on the cancer. This type of radiation is given daily, five days per week, for five to six weeks. A typical session is fairly quick, lasting less than thirty minutes or so.

Side Effects and Risks

Common short-term side effects of radiation include:

• Fatigue
• Diarrhea
• Nausea and vomiting
• Skin rash
• Frequent urination, along with bladder discomfort
• Loose stools and feeling the need to have a bowel movement frequently
• Vaginal inflammation causing discharge and sores

There are also potential long-term side effects of radiation therapy. For example, extreme vaginal dryness along with vaginal scarring and narrowing can make sex painful.

Urine leakage and pain or bleeding with bowel movements may also occur, due to radiation-induced inflammation of the bladder and bowel, respectively.

Lastly, lymphedema (impaired lymph fluid drainage leading to leg swelling) is another long-term side effect and occurs as a result of EBRT to the pelvis.

Chemotherapy

Chemotherapy refers to drugs that kill rapidly duplicating cells in the body, which happens to be cancer cells, along with some normal cells, such as those in the bone marrow or digestive tract (this is where the side effects of chemotherapy come into play).

A typical chemotherapy regimen for endometrial cancer includes the two drugs carboplatin and Taxol (paclitaxel), although some healthcare providers use a three-drug regimen that consists of cisplatin, Adriamycin (doxorubicin), and Taxol (paclitaxel).

Chemotherapy is often given about four to six weeks after surgery and before radiation therapy is given (if radiation is part of the plan).

Side Effects and Risks

Depending on the chemo drugs used to treat your endometrial cancer, there are various potential side effects. That said, some of the more common ones include:

• Nausea and vomiting
• Mouth sores
• Temporary hair loss
• Excessive tiredness
• Low blood counts
• Numbness and tingling of the fingers and toes (called neuropathy)
  

Hormone Therapy

According to the American Cancer Society, there are four types of hormone therapy that may be used to treat endometrial cancer, with progestin being the primary one.

Hormone therapy is generally reserved for women who have advanced endometrial cancer who cannot undergo surgery or radiation therapy. Progestin may be given to certain premenopausal women with low-risk endometrial cancer who still want to have children.

Progestin

Progestins, like Provera (medroxyprogesterone acetate) or Megace (megestrol acetate) can help slow the growth of endometrial cancer cells.

Tamoxifen

Used traditionally to treat breast cancer, tamoxifen may be used to treat advanced endometrial cancer or endometrial cancer that has returned after treatment (called a recurrence).

Gonadotropin-Releasing Hormone (GnRH) Agonists

GnRH agonists like Zoladex (goserelin) or Lupron (leuprolide) turn off the production of estrogen by the ovaries in women who are premenopausal. By decreasing estrogen in the body, the growth of endometrial cancer may be slowed.

Aromatase Inhibitors

While most estrogen is produced in a woman's ovaries, some estrogen is produced in the body's fatty tissue (called adipose tissue). The aromatase inhibitors Femara (letrozole), Arimidex (anastrozole), and Aromasin (exemestane) reduce the formation of estrogen from adipose tissue. These drugs are still being investigated for their use in treating endometrial cancer.

Immune Checkpoint Inhibitors

The immune system turns “checkpoint” immune cell proteins on (or off) to start an immune response. Immune checkpoint inhibitor drugs can be used to treat some endometrial cancers by targeting these checkpoints.

Keytruda (pembrolizumab) and Jemperli (dostarlimab) boost the body’s immune response against cancer cells, which can shrink some tumors or slow their growth.

Keytruda

Keytruda has been approved in combination with lenvatinib (Lenvima, Eisai) for people with certain advanced endometrial carcinomas, typically after at least one other drug treatment has been tried and curative surgery or radiation isn’t possible. Keytruda can also be used alone to treat advanced endometrial cancers, typically after other treatments have been tried, and if the cancer cells have certain testable characteristics.

Jemperli

Jemperli has been approved for certain recurrent advanced endometrial cancers that have progressed on or following prior treatment.

Side Effects and Risks

Side effects can include:

• Feeling weak or tired
• Fever
• Cough
• Nausea
• Itching
• Skin rash
• Loss of appetite
• Muscle or joint pain
• Shortness of breath
• Constipation or diarrhea

Other, more serious side effects are possible:

Infusion reactions: Which include fever, chills, flushing of the face, rash, itchy skin, feeling dizzy, wheezing, and trouble breathing.

Autoimmune reactions: The immune system may attack other parts of the body, which can cause serious or even life-threatening problems in the lungs, intestines, liver, hormone-making glands, kidneys, skin, or other organs.

It’s very important to tell your healthcare provider right away about any side effects you experience—either during or after treatment.

Complementary Medicine

According to a study in the International Journal of Gynecological Cancer, the most commonly utilized complementary medicine practices used by women with gynecological cancer include:

• Vitamin and mineral use
• Herbal supplements
• Prayer
• Deep breathing relaxation exercises

While several types of complementary therapies may provide benefits (for example, easing pain or stress), many have not been rigorously studied to confirm their overall safety or effectiveness.

In the end, implementing complementary medicine into your traditional endometrial cancer care is certainly possible and a reasonable goal. Be sure, though, to do so only under the guidance of your oncologist. This way you can be certain of their safety and avoid any undesirable side effects or interactions.