Surgery is the Foundation of Endometrial Cancer Treatment at Every Stage – How it Helps Guide Future Care

As Dr. Jennifer Mueller, a gynecologic surgeon at Memorial Sloan Kettering Cancer Center in New York, explains it to SurvivorNet, one of the major goals for surgery is to determine how advanced the cancer is and where it has spread.

“Surgery is typically used for the purposes of treatment, to remove the cancer,” she says. “It’s also used for what we call staging — the true staging procedure is when you have surgery and everything that the surgeon removes is sent to pathology where everything’s looked at under the microscope and the report that the surgeon gets back and reviews with you is what we use to assign a stage.”

Dr. Mueller adds that gathering this information helps guide further treatment so  it can be specifically tailored to you and ensure that you get the best results.

When Do Doctors Recommend Surgery?

Doctors almost always recommend surgery as part of treatment for endometrial cancer at virtually every stage, from early to advanced disease.

There are two reasons surgery is such a large part of the treatment plan.

• To remove cancerous tissues
• To accurately assess (stage) the cancer

However, the type and extent of surgery your doctor will recommend depends on how advanced your cancer is at the time of diagnosis.

In early-stage endometrial cancer, surgery often involves the removal of the uterus (hysterectomy) and may sometimes also include the removal of ovaries and fallopian tubes. This can cure the disease because, when successful, it removes all of the cancer cells before they have a chance to grow and spread.

“The good news with endometrial cancer is that … the majority of people will be diagnosed when the cancer is caught quite early, and for a lot of folks, surgery is actually the treatment and, in many situations, may be all that someone needs,”​ Dr. Mueller says.

As the disease progresses to more advanced stages, surgery will be more involved and include the removal of nearby lymph nodes to help determine whether the cancer has spread. Testing the cancer is a critical way for doctors to understand more about the stage, type, and genetics of the cancer, which in turn guides the next steps.

For instance, if cancer is found in the lymph nodes, your doctor may recommend additional treatments such as radiation or chemotherapy to get rid of any remaining cancer cells and reduce the risk of it coming back.

“If you’ve been diagnosed with endometrial cancer — and sometimes it’s what we call advanced stage — where the cancer has had some spread outside of the uterus itself, that is a surgery we call debulking.”

Debulking typically involves taking out the uterus, cervix, tubes, ovaries, and any visible cancer spread, which could include areas beyond the reproductive organs, like lymph nodes or other parts of the abdomen, Dr. Mueller explains. The goal is to leave no visible cancer behind to improve outcomes and allow for more effective use of additional treatments, such as chemotherapy.

However, sometimes for a variety of reasons, doctors cannot perform surgery. If you have additional health problems, your tumor is too difficult to remove, or surgery is infeasible or too dangerous, doctors may recommend radiation, chemotherapy, or some other combinations of treatments instead.

Related: A New, Molecular Snapshot Could Lead to Better Treatment of Endometrial Cancer

What Are the Different Types of Surgery?

Before scheduling any type of surgery, Dr. Mueller says your doctor will do a complete work up.

“When I meet someone who I’m concerned that some of the symptoms she’s experiencing could be related to a diagnosis of endometrial cancer, the first thing that we do is take a thorough history to figure out what is going on for her and an examination,” she says.

The workup may include:

• Physical exam
• Medical history
• Biopsy, which involves taking a sample of the tumor and sending it to the lab for testing
• Blood tests
• Genetic testing of the cancer cells to for more personalized and effective treatment
• Imaging

“Often, people are having something like spotting, abnormal bleeding, or bleeding after menopause, and in situations like that, an ultrasound and an endometrial biopsy, or a biopsy that’s taken from the canal or the cavity of the uterus, is what we start with,” Dr. Mueller says.

The results of the workup will determine the type and extent of surgery you will have with the goal of removing the cancerous tissue while preserving as much normal function as possible.

Surgery in Early-Stage Endometrial Cancer

For early-stage endometrial cancer, where the cancer is confined to the uterus, doctors will usually perform a total hysterectomy which involves the removal of the uterus and cervix, effectively eliminating the primary site of cancer.

“This procedure is aimed both at treating the cancer by removing it and at determining the stage of the cancer through pathological examination of the removed tissues,” Dr, Mueller says. “The procedure is often performed using minimally invasive methods, such as laparoscopic surgery or robot-assisted laparoscopic surgery. This approach results in smaller incisions, which generally leads to a quicker recovery and less post-operative pain compared to traditional open surgery.”

In some cases, they will also do a bilateral salpingo-oophorectomy where they where they will also remove both ovaries and fallopian tubes to further reduce the risk of cancer spreading or coming back. The fallopian tubes and ovaries are part of the staging and if affected, may change therapy you are offered.

This is often the procedure of choice as a preventive measure for those at high risk for ovarian and breast cancers due to genetic factors.

“Removing the ovaries and fallopian tubes is crucial for both treatment and determining the extent of the disease’s spread. This information is vital for staging the cancer, which then informs the subsequent steps in the treatment plan, possibly including additional therapies,” Dr. Mueller says.

Either of these approaches is often sufficient for treating cancer at an early stage and preventing its spread.

Surgery in Advanced Endometrial Cancer

In advanced endometrial cancer, where the disease has spread beyond the uterus, surgery can be more extensive.

This process may begin with a radical hysterectomy, which involves the removal of the uterus, cervix, part of the vagina, and surrounding tissues.

It may possibly including a bilateral salpingo-oophorectomy, the removal of both ovaries and fallopian tubes.

Additionally, doctors may also opt for a lymphadenectomy, the removal of nearby lymph nodes, to assess if the cancer has spread into these areas.

“For most patients, a staging procedure includes a lymph node assessment. This is a critical part of the surgery because it helps determine the extent of the cancer’s spread beyond the uterus,” Dr. Mueller says.

The method most commonly used for lymph node evaluation is called a sentinel lymph node evaluation. Dr. Mueller adds. This technique involves injecting a dye into the cervix during surgery to identify the first lymph node(s) or “sentinel” lymph node(s) that drain from the tumor area. These lymph nodes are then removed and examined for the presence of cancer cells.

Dr. Mueller explains that the removal of sentinel lymph nodes allows the surgical team to determine if the cancer has spread to the lymphatic system, which is a crucial factor in staging the disease and planning further treatment.

Such extensive surgery aims not only to eliminate as much of the cancerous tissue as possible but also to gather detailed insights into the disease’s spread, to help guide further treatments like chemotherapy or radiation.

Different surgical approaches

Surgeons can approach any of these procedures in multiple ways:

• Traditional (Open) Surgery: The surgeon makes a larger cut called an incision in the abdomen to directly access the uterus. This is the method most surgeons take in advanced or complex cases where they need the most complete view or access to the affected area. Open surgery can be very precise and allow for the removal of the uterus, possibly along with ovaries, fallopian tubes, lymph nodes, and affected surrounding tissues.
• Laparoscopic Surgery: This is a minimally invasive technique where the surgeon makes small incisions in the abdomen to insert a laparoscope—a thin, lighted tube with a camera—and other surgical instruments. This method reduces recovery time, pain, and scarring compared to open surgery. It’s suitable for performing a hysterectomy, bilateral salpingo-oophorectomy, and lymph node biopsy with less stress on the patient’s body.
• Robotic Surgery: This approach uses similar techniques to laparoscopic but the surgeon uses robotic arms to perform the procedure. This technology provides better precision, flexibility, and control, potentially offering advantages in complex procedures. The outcomes are similar to laparoscopic surgery.

Each surgical approach has merits for use depending on the cancer stage, patient health, and specific anatomical and medical considerations. In general laparoscopic and robotic hysterectomies lead to less pain, bleeding, and infection. They can shorten the time spent in the hospital after surgery.

“After a minimally invasive surgery, patients can often go home the same day or the next morning,” Dr. Mueller says. “Recovery is active, with patients encouraged to walk and gradually resume normal activities while avoiding heavy lifting and strenuous exercise for about six to eight weeks to allow the internal and external incisions to heal properly.”

However, sometimes minimally invasive techniques aren’t a good choice if the tumor is too large or in a hard to reach location.

Related: Exciting New Combination Therapy Gives Hope To Women With Advanced Endometrial Cancer

Will I Need Treatment After Surgery?

Mueller says that once the surgeon removes the cancer, they send it to a lab where the tissue will be examined under a microscope. Information from your lab results and your initial workup help determine if you will need additional treatment after the surgery. If you do need more treatment your doctor will recommend one or more of the following:

• Observation: If you have a very low risk of of the cancer coming back your treatment plan will focus on regular follow-ups to detect any signs of the cancer returning.
• Brachytherapy: A radiation technique that targets the specific area to destroy any remaining cancer to minimize the risk of recurrence.
• External Beam Radiation Therapy (EBRT): For more advanced disease or when there’s a higher risk of cancer spreading outside the uterus, doctors will use EBRT to kill any remaining cancer cells in the pelvic region.
• Chemotherapy: Post-surgical chemotherapy may be used for endometrial cancer that has spread beyond the uterus or is at high risk for recurrence.

“Even when the immediate post-surgical period is over and any additional treatments are completed, patients will continue to have regular follow-ups with their healthcare team to monitor for any signs of cancer recurrence and manage any long-term side effects of the treatment,” Dr. Mueller says.

What Can I Expect After Surgery?

Following surgery some side effects are common, including:

• Pain at the incision sites
• Effects from the anesthesia (nausea and drowsiness)

You will typically spend between one and four days at the hospital after having vaginal and laparoscopic hysterectomies and up to five days for abdominal hysterectomies.

During your hospital stay, your care team may place an IV in your arm, dressings on your incisions, a catheter to help with urination, and drainage tubes that remove excess fluid (which are removed after a few days) around incisions.

If you had a vaginal hysterectomy, there can also be dressing inserted in your vagina.

Most patients take four to six weeks to fully recover from a laparoscopic or vaginal hysterectomy and even longer after an abdominal hysterectomy.

During this time it is not uncommon to have bladder and bowel changes. You may also have vaginal discharge.

Many care centers now use advanced tools such as wearable devices to track heart rate, oxygen levels, and wound healing to help speed up recovery and reduce hospital stays. Some even have smart beds to monitor sleep quality and movement, offering a comprehensive view of a patient’s recovery progress.

Additionally, many care centers now incorporate integrative medicine practices, such as nutrition planning, physical therapy, and psychological support, as part of the recovery process to improve overall well-being and outcomes.

“Patients may experience fatigue, soreness around the incisions, and possibly shoulder pain due to residual gas used during the surgery. It’s normal for these symptoms to improve significantly within a week or two, but full internal healing takes longer,” Dr. Mueller says.

Discuss any potential symptoms with your healthcare provider. In many cases, they will have strategies to help ease these aftereffects.

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Questions to Ask Your Doctor

• What stage is my endometrial cancer, and how does that affect my surgical options?
• Can you explain the specific type of surgery you recommend for me and why?
• What are the potential risks and benefits of the recommended surgery?
• How will this surgery help in determining the next steps in my treatment plan?
• What can I expect during recovery, and how can I best prepare for it?
• What’s covered by insurance and what can I expect to pay out of pocket?

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