Endometrial cancer treatment after surgery

Endometrial cancer treatment after surgery

Authors
Steven C Plaxe, MD
Arno J Mundt, MD
Section Editor
Barbara Goff, MD
Deputy Editor
Don S Dizon, MD, FACP

Disclosures

INTRODUCTION — Endometrial cancer is a type of uterine cancer that involves the lining of the uterus (the endometrium). Treatment for endometrial cancer usually includes surgical removal of the uterus, cervix, ovaries, and fallopian tubes; it may also involve sampling or removal of the surrounding lymph nodes. There are two types of endometrial cancer, which are classified by their relationship to estrogen stimulation:

More information on the epidemiology, diagnosis, staging, and treatment of endometrial cancer is available by subscription. This topic will discuss the medical and radiation approaches for endometrial cancer following surgical treatment. (See “Patient information: Uterine cancer (The Basics)” and “Patient information: Endometrial cancer diagnosis and staging”.)

SURGICAL APPROACH TO ENDOMETRIAL CANCER — For women who are good candidates for surgery, hysterectomy, removal of both ovaries and both fallopian tubes (called a bilateral salpingo-oophorectomy, or BSO) and sampling or removal of surrounding lymph nodes is generally performed. The hysterectomy can be done through an incision in the lower abdomen (a total abdominal hysterectomy, or TAH), through the vagina with the help of a laparoscope (total laparoscopic hysterectomy (TLH)), or using a surgical robot (robot-assisted hysterectomy). The results at surgery will help your doctor determine if further treatment is necessary. (See “Patient information: Vaginal hysterectomy” and “Patient information: Abdominal hysterectomy”.)

DEFINING RISK IN ENDOMETRIAL CANCER — There are several recognized pathologic and clinical factors that can identify if you are at an increased risk of relapse after surgery, which can help your doctor determine an appropriate treatment pathway. These factors include: aggressively appearing cancer cells when viewed under the microscope (also called high grade); cancer that invades through the uterine muscle (invades the myometrium); tumor extending outside of the uterus (into the cervix, lower uterine segment, pelvis, or ovaries); papillary serous or clear cell histology (type of endometrial cancer); involvement of the lymphatic or blood vessels (lymphovascular invasion); and older age.

If your cancer is confined to the endometrium (subset of stage IA) it is considered to be low risk.
If the cancer has invaded the myometrium (subset of stage IA and all of stage IB) or has microscopic involvement of the cervix (subset of stage II), then it is considered to be of intermediate risk. Some doctors further refine this risk group to include the presence of other factors: lymphovascular invasion, outer-third myometrial invasion, and high tumor grade. However, women of any age with all three risk factors described above; women between 50 and 69 years with two of the risk factors; or women 70 years or older with one risk factor would be considered to have intermediate-high risk disease. Women without these risk factors are considered to have low-intermediate risk disease.
Your cancer is considered high risk if it has obvious involvement of the cervix at the time of surgery (a more advanced subset of stage II), has involvement of the pelvis (stage III), involves tissue outside the pelvis (stage IV), or is of papillary serous or clear cell type.
TREATMENT OPTIONS IN ENDOMETRIAL CANCER — Treatment for endometrial cancer depends on the risk for persistent or recurrent disease after surgical therapy:

Low-risk disease — The risk of relapse after surgery for low-risk endometrial cancer is very low with estimates placed at 5 percent or less. Given this, no further treatment is generally recommended.

Intermediate-risk disease — Women with low-intermediate risk disease can be observed without further treatment since their risk of relapse after surgery alone is low (5 percent or less). Women with high-intermediate risk endometrial cancer benefit from adjuvant therapy to help reduce the chances of the cancer coming back in the pelvis (also known as a local recurrence). For most women with intermediate-risk disease, adjuvant vaginal or external beam radiation therapy is given. Of the two ways to give radiation, vaginal brachytherapy seems to be as effective as external beam radiation therapy with fewer gastrointestinal side effects. These modes of radiation therapy are described below.

High-risk disease — Women with high risk endometrial cancer are treated with adjuvant chemotherapy, especially if the disease is located outside of the uterus. Some clinicians recommend adjuvant radiation with or without chemotherapy if high-risk disease is confined to the uterus.

TYPES OF ADJUVANT TREATMENT

Radiation therapy — Radiation therapy refers to the use of high-energy x-rays to slow or stop the growth of cancer cells. Exposure to x-rays damages cells. Unlike normal cells, cancer cells cannot repair the damage caused by exposure to x-rays over several days. This prevents the cancer cells from growing further and causes them to eventually die. For patients with endometrial cancer, adjuvant radiation is given to decrease the risk of the cancer coming back in the pelvis (this is called locoregional recurrence).

Radiation is usually given as external beam radiation, meaning that the radiation beam is generated by a machine that is outside the patient. Exposure to the beam typically takes only a few seconds (similar to having an x-ray). The main benefit of adjuvant radiation therapy for endometrial cancer is that it reduces the risk of a locoregional recurrence (ie, that the cancer will come back in the pelvis or vagina). There are two ways to deliver radiation therapy (RT): vaginal brachytherapy (VB) and external beam radiation therapy (EBRT).

Vaginal brachytherapy — Brachytherapy delivers radiation from a device that is temporarily placed inside the vagina. This device delivers a high dose of radiation directly to the area where cancer cells are most likely to be found, and this helps to minimize the effects of radiation on healthy tissues. There are two types of vaginal brachytherapy: low-dose rate and high-dose rate.

Low-dose rate brachytherapy uses a device that delivers radiation through the vagina continuously for two or three days, 24 hours per day. Patients stay in the hospital during this treatment.
High-dose rate brachytherapy also uses a device that delivers radiation through the vagina. However, the device is placed in the vagina for only a few minutes at a time once a day, and treatment is generally repeated three to five times. This treatment is generally given as an outpatient, and women who get high-dose rate brachytherapy do not have to stay in the hospital overnight. They can usually continue their normal daily activities during treatment.
External beam radiation therapy — With external beam radiation therapy (EBRT), the source of the radiation is outside the body, and the area to be treated (referred to as the radiation “field”) is designed carefully to limit the amount of radiation directed at healthy tissue. During EBRT, your body is positioned beneath the X-ray machine in the same way every day, and the radiation field is exposed to the radiation beam for a few seconds (similar to having an X-ray) once per day, five days per week, for five to six weeks. This is done as an outpatient, and you can usually continue your normal daily activities during treatment.

Side effects of radiation therapy — Radiation can cause both short-term and long term side effects. The short term side effects may include:

Feeling tired
Needing to empty your bladder frequently
Discomfort with urination
Loose stools and feeling the need to have a bowel movement frequently
Temporary loss of pubic hair
In addition to the short-term side effects, which usually resolve after treatment is completed, there are long-term side effects that may not appear until months after treatment is completed and they may become more chronic problems. These include:

Urine leakage
Pain or bleeding with bowel movements
Narrowing or scarring of the vagina
Chemotherapy — Chemotherapy is a treatment given to stop the growth of cancer cells. It aims to destroy any remaining cancer cells to increase the chance of cure. This type of chemotherapy is called “adjuvant”, which means that it is given after surgery with curative intent. For women with high-risk endometrial cancer, a combination of agents (called a regimen) is usually recommended. This typically consists of two drugs, carboplatin and paclitaxel. However, some clinicians may prescribe the three-drug combination of cisplatin, doxorubicin, and paclitaxel (TAP).

How is chemotherapy given? — Chemotherapy is not given every day but instead is given in cycles. A cycle of chemotherapy (which is typically 21 or 28 days) refers to the time it takes to give the treatment and then allow the body to recover from the side effects of the medicines. This treatment usually involves a combination of several chemotherapy drugs (called regimens). Following surgery, it is usually started within four to six weeks postoperatively, and precedes radiation therapy, if this too has been recommended. Since different combinations of chemotherapy can be used, your doctor will describe which specific chemotherapy drugs will be needed, how long treatment will last, and what side effects are expected from your treatment.

Side effects of chemotherapy — It is important to understand that while chemotherapy can cause side effects, some of which can be quite serious, not all patients who are getting chemotherapy will develop all of these side effects. The most common side effects of chemotherapy include:

Feeling tired
Temporary hair loss
Nausea and vomiting
Diarrhea
Low blood counts
Menopausal symptoms, like hot flashes, night sweats, and vaginal dryness
Numbness and tingling of the fingers and toes (this is called neuropathy)
SPECIAL CONSIDERATIONS FOR WOMEN WITH NEWLY DIAGNOSED ENDOMETRIAL CANCER — While most women with newly diagnosed endometrial cancer should undergo surgical treatment and adjuvant treatment tailored to risk, there are several situations in which the above discussion may not necessarily apply. These include the following scenarios:

Endometrial cancer in the young woman — Young premenopausal women are sometimes diagnosed with endometrial cancer at a time when they are considering or desire to have children. For young women with a low risk of relapse, surgery (hysterectomy) may be delayed. This is not an option for women with intermediate- or high-risk endometrial cancer. However, women should know of options to preserve fertility and alternate means of becoming a parent before beginning any form of treatment. If surgical treatment is delayed, progestin treatment is used to suppress the growth of the endometrial cancer. Women who are able to delay immediate surgery for family planning still require definitive surgical treatment. Without surgery there is a significant risk that the cancer will come back later.

Cancer in the obese patient or medically inoperable woman — For women who are obese or who have other serious medical problems, surgery with nodal sampling or removal may not be a treatment option. For these women, treatment options may include a more limited surgical procedure to remove the uterus or non-surgical treatment such as the use of radiation therapy.

Incompletely staged patients — As described above, the treatment of endometrial cancer requires information on the tumor and whether lymph nodes are involved. However, for some women, surgery may not have included comprehensive staging (ie, evaluation of nodes). Most clinicians will not give adjuvant therapy to women with low-risk endometrial cancer who have not had lymph node sampling. However, options for women with intermediate- or high- risk disease, include further surgical evaluation or the use of adjuvant chemotherapy or radiation. Your doctor can help you decide which of these options may be best for you. (See ‘Defining risk in endometrial cancer’ above.)

FOLLOW-UP AFTER ENDOMETRIAL CANCER TREATMENT — Most women and families affected by endometrial cancer worry about their short-term and long-term health and the risk of the cancer coming back. It is important for women to talk openly and honestly with their family and healthcare team. Many women benefit from bringing a family member or friend to visits with their doctor; this person can help you to understand your options, ask important questions, take notes, and provide emotional support.

A variety of support options are available both during and after treatment, including individual counseling, support groups, and Internet-based discussion groups. A list of reputable groups is available as well. (See ‘Patient support’ below.)

Cancer surveillance — Experts recommend close follow-up after the completion of treatment for endometrial cancer, particularly in the first three years after diagnosis when the risk of recurrence is highest. This usually includes an exam and Pap smear every three to six months for several years. Other tests, like blood tests and computed tomography (CT) scans or other radiology tests should be done only if a recurrence is suspected.

If the cancer does not come back after five years, women can usually stop seeing the oncologist and return to their primary care provider or women’s healthcare provider. Women should call their doctor if they develop any symptoms of vaginal bleeding, pain in the belly or pelvis, a cough that will not go away, or unintentional weight loss. These could be signs that the cancer has come back.

Treating menopausal symptoms — Premenopausal woman who have had their ovaries removed as part of treatment usually experience symptoms of menopause. This may include hot flashes, night sweats, and vaginal dryness. The most effective treatment for these symptoms is the female hormone estrogen. Most experts think that estrogen is a reasonable option for women with endometrial cancer. You should discuss the potential risks and benefits of estrogen with your doctor. For women receiving adjuvant treatment (eg, radiation therapy or chemotherapy), some experts recommend waiting 6 to 12 months after finishing treatment before beginning estrogen therapy. Other non-hormonal treatments for menopausal symptoms are available; these are discussed separately. (See “Patient information: Nonhormonal treatments for menopausal symptoms”.)

Sexual issues after treatment — Changes in the vagina are common after endometrial cancer treatment. Pelvic or vaginal radiation can cause the vagina to shorten, narrow, and feel dry. These changes can cause pain with sex (also called dyspareunia). Many of these problems are treatable:

Ask your doctor or nurse about using vaginal dilators to prevent and treat narrowing of the vagina.
Use a vaginal moisturizer or lubricant during sex to treat dryness.
Women with endometrial cancer may be able to use a vaginal estrogen (a cream, vaginal ring, or pill) to treat dryness. More information about vaginal estrogen is available in a separate article. (See “Patient information: Vaginal dryness”.)
Pelvic physical therapy and counseling for sexual or psychological difficulties can be helpful. (See “Patient information: Sexual problems in women”.)
CLINICAL TRIALS — Progress in treating cancer requires that better treatments be identified through clinical trials, which are conducted all over the world. A clinical trial is a carefully controlled way to study the effectiveness of new treatments or new combinations of known therapies. Ask for more information about clinical trials, or read about clinical trials at:

www.cancer.gov/clinicaltrials/learning/
www.cancer.gov/clinicaltrials/
file://clinicaltrials.gov/
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem.

 

Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

Patient Level Information:

Patient information: Endometrial cancer diagnosis and staging
Patient information: Vaginal hysterectomy
Patient information: Abdominal hysterectomy
Patient information: Nonhormonal treatments for menopausal symptoms
Patient information: Vaginal dryness
Patient information: Sexual problems in women

Professional Level Information:

Endometrial cancer: Pretreatment evaluation, staging and surgical treatment, and posttreatment surveillance
Endometrial cancer: Epidemiology, risk factors, clinical features, diagnosis, and screening
Histopathology and pathogenesis of endometrial cancer
Treatment of advanced or recurrent endometrial cancer

The following organizations also provide reliable health information:

American Society of Clinical Oncology
(www.cancer.net/portal/site/patient)

National Comprehensive Cancer Network
(www.nccn.com)

Gynecologic Oncology Group
(www.gog.org/gynecologiccancerinformation.html)

National Cancer Institute
1-800-4-CANCER
(www.cancer.gov)

Patient support — There are a number of online forums where patients can find information and support from other people with similar conditions.

About.com Cancer Forum
(file://cancer.about.com/forum)

REFERENCES
National Comprehensive Cancer Network (NCCN) guidelines. Available at: www.nccn.org (Accessed on October 13, 2011).
Randall ME, Filiaci VL, Muss H, et al. Randomized phase III trial of whole-abdominal irradiation versus doxorubicin and cisplatin chemotherapy in advanced endometrial carcinoma: a Gynecologic Oncology Group Study. J Clin Oncol 2006; 24:36.
Nag S, Erickson B, Parikh S, et al. The American Brachytherapy Society recommendations for high-dose-rate brachytherapy for carcinoma of the endometrium. Int J Radiat Oncol Biol Phys 2000; 48:779.