What Are My Treatment Options?

Treatment for this cancer varies depending on the stage of the disease, the patient’s overall health, and other factors. Here’s an overview of the treatment options available for endometrial cancer.

Surgery

When the disease is localized, surgery is usually the first treatment considered and that alone may be all that’s required. More advanced stages often require a newer, more targeted treatment approach such as immunotherapy.

The most common surgical procedure is a hysterectomy, which involves removing the uterus. In some cases, the surgeon may also remove the cervix and the fallopian tubes and sometimes the ovaries. Surgery helps to remove the cancerous tissue and is often followed by additional treatments to ensure that all cancer cells are eradicated.

“So in my practice, probably 90% of patients get surgery first as their first treatment for their endometrial cancer. And that is if you have a stage one or a stage two or a stage three, sometimes even a stage four cancer surgery is usually typically the first step in your treatment,” explains Dr. Dana Chase, an associate professor of UCLA Obstetrics and Gynecology in Los Angeles.

Dr. Jennifer Mueller, a gynecologic surgeon at Memorial Sloan Kettering Cancer Center, explains how surgery can help determine treatment path. 

Radiation Therapy

Radiation therapy uses high-energy rays to stop cancer cells. It can be administered externally, where the radiation comes from a machine outside the body, or internally, where radioactive materials are placed inside the body near the cancer cells. Radiation therapy is often used after surgery to kill any remaining cancer cells and reduce the risk of recurrence.

“There are some features of the cancer that make you high risk for recurrence. And what that means essentially is the doctor could be scared that maybe even just a single cancer cell escape the uterus and could eventually grow back with time.,”Dr. Chase explains. “And if that’s the situation, your doctor might recommend radiation treatment.”

Chemotherapy

Chemotherapy involves using drugs to kill cancer cells. These drugs can be taken orally or injected into the bloodstream. Chemotherapy is often used in cases where the cancer has spread beyond the uterus or when there is a high risk of recurrence. It can be used alone or in combination with other treatments.

Chemotherapy is often given in conjunction with other therapies such as radiation or immunotherapy.

Dr. Marta Crispens, a professor and director of the division of gynologic oncology at Vanderbilt University Medical Center in Nashville, explains that when chemotherapy is given along side of other types of treatment it is even more effective. She points to studies that looked at combining standard chemotherapy with immunotherapy drugs that strengthen the immune system’s response for fighting cancer.

“If you gave the patient with advanced recurrent disease, endometrial cancer chemotherapy with standard chemotherapy for six treatments, which would be the standard combined with immunotherapy, followed by a maintenance period of immunotherapy, that patients had much better outcomes than if they were treated with chemotherapy alone,” Crispens says.

Hormone Therapy

Some endometrial cancers are hormone-sensitive, meaning they grow in response to hormones like estrogen. Hormone therapy involves taking medications that lower hormone levels in the body or block their effects on cancer cells. This type of therapy is often used for advanced or recurrent endometrial cancer.

“Hormonal therapy commonly works because most of endometrial cancers are estrogen receptor positive,” Dr. Michael Toboni, an assistant professor in the division of  gynologic oncology at the University of Alabama at Birmingham notes to SurvivorNet. “So if you give progesterone, it can counteract the estrogen feeding the cancer. This is commonly given with multiple anti-estrogen medications or an anti-estrogen medication in combination with another medication that inhibits a common pathway in endometrial cancer.”

Immunotherapy

Immunotherapy is a newer form of treatment that helps the body’s immune system fight cancer.

“For a long time, patients with early-stage endometrial cancer generally do very well with a combination of surgery, maybe some radiotherapy,” says Dr. Shannon Westin, a professor in the department of gynecologic oncology and reproductive medicine at the University of Texas, MD Anderson Cancer Center in Houston, TX.

“However, there’s a population of patients that are diagnosed at a later stage, stage three or four, or that have their cancer come back after initial therapy. And those patients have had a really hard time,” she adds.

According to Westin, the latest treatments combine immunotherapy with standard chemotherapy plus a drug that prevents cancer cells from fixing their own DNA.

What is Immunotherapy?

The immune system uses its white blood cells to attack cells in the body that are abnormal or foreign. Cancerous cells have the ability to prevent the immune system from doing its job. The cancer produces certain proteins to protect the tumor from white blood cells. As a result, the body does not recognize the tumor as abnormal.

Immunotherapy drugs stop this from happening and ensure the white blood cells recognize the cancer cell properly and attack it. The cancer cells themselves are not necessarily difficult to fight. However, they continue to divide rapidly. So, immunotherapy drugs help a patient’s immune system control their cancer on its own before it can spread.

“We’re not just treating cancer, we’re outsmarting it by targeting its vulnerabilities. This approach marks a significant departure from one-size-fits-all treatments, offering a beacon of hope for those with advanced stages of endometrial cancer,” says Dr. Westin.

What Causes Endometrial Cancer? Understanding Risk

Endometrial cancer is linked to changes in the balance of hormones in the body, particularly estrogen and progesterone. These hormones play a role in regulating the growth of the endometrial lining. When there is an imbalance, such as too much estrogen without enough progesterone, the endometrium can grow too much and become thicker, which can lead to the development of cancerous cells.

There are several risk factors that might increase a woman’s likelihood of developing endometrial cancer. According to the National Cancer Institute, these include:

• Taking estrogen-only hormone replacement therapy (HRT) after menopause
• Taking tamoxifen (hormone therapy drug known by the brand name Soltamox) to prevent or treat breast cancer
• Obesity
• Having metabolic syndrome, a group of conditions that raise the risk of heart disease, stroke, and diabetes
• Having type 2 diabetes
• Exposure of endometrial tissue to estrogen made by the body, sometimes a result of never having given birth
• Menstruating at an early age (Menstruation typically begins between 10 and 16)
• Starting menopause at a later age (Menopause typically begins between 45 and 55)
• Having polycystic ovarian syndrome (PCOS)
• Having a family history of endometrial cancer in a first-degree relative (mother, sister, or daughter).
• Having certain genetic conditions, such as Lynch syndrome
• Having endometrial hyperplasia

Having one or more risk factors does not mean a woman will definitely develop endometrial cancer, but it does mean you should pay attention to your health.

“As with disease in general, whether it be diabetes or endometrial cancer or even dementia, it’s important to find the disease at an early stage because potentially with treatment you can stop the disease from progressing,” Dr Chase says.

Regular gynecological exams and discussing any unusual symptoms with a healthcare provider can help in early detection and management.

Signs and Symptoms

The most common symptom of endometrial cancer is unusual bleeding from the vagina.

If you are still having periods, abnormal bleeding might mean bleeding between periods or having very heavy periods.

If you have gone through menopause and stopped having periods, any amount of vaginal bleeding is considered unusual. This is even more important if you are not taking hormone therapy for menopause symptoms. It’s normal for people who are taking hormone therapy for menopause to experience some bleeding in the first few months of treatment.

“It’s very, very important to spread the word that if you have irregular bleeding, even a pink discharge, it doesn’t have to be bright red blood, even a pink discharge, don’t hesitate or don’t be afraid to get that checked out,” Dr. Chase advises.

In addition to irregular bleeding, symptoms of endometrial cancer may include:

• Pelvic pain
• Pain during intercourse
• Unusual vaginal discharge (watery or blood-tinged)
• Unexplained weight loss
• Urinary problems (difficulty or pain when urinating)

How is Endometrial Cancer Diagnosed?

Women might be familiar with a certain test they get from their primary doctor or gynecologist, called a Pap test, or Pap smear. This procedure, in which a small brush is used to gently scrape cells from the surface of the cervix, only checks for cervical cancer. So other procedures are needed to help diagnose 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,” Dr. Mueller says.

“Often people are having something like spotting abnormal bleeding or bleeding after menopause and in situations like that and 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,” she adds.

Dr. Mueller also says that doctors sometimes order blood tests or imaging to pin down the diagnosis, but often a definitive diagnosis comes after surgery when a mass has been removed and sent to the lab for testing. If the surgeon does find cancer, lab tests will determine the exact type and staging to see if further treatment is needed. For cases caught early, surgery may effectively lead to a cure.

If you have unusual bleeding, your doctor might suggest tests to check for endometrial cancer. The most common tests are: transvaginal ultrasound and a hysteroscopy with endometrial biopsy.

Ultrasound

An ultrasound is often one of the first tests done to check the uterus, ovaries, and fallopian tubes if there are possible problems related to a woman’s reproductive system. It uses sound waves to create images of the inside of the body. During the test, a small device called a transducer or probe sends out sound waves and catches the echoes that bounce back from the organs. These echoes are then turned into pictures by a computer.

For a pelvic ultrasound, the transducer is moved over the skin on the lower part of the belly. To get clear images of the uterus, ovaries, and fallopian tubes, it’s often necessary for the bladder to be full, so women are usually asked to drink a lot of water before the test.

A transvaginal ultrasound (TVUS) is often a better way to look at the uterus. In this test, a similar probe is inserted into the vagina. The TVUS can show if there is a mass (like a tumor) in the uterus or if the lining of the uterus is thicker than normal, which might indicate endometrial cancer. It can also help see if the cancer has spread into the muscle layer of the uterus.

Hysteroscopy

A hysteroscopy is a medical procedure used to examine the inside of the uterus. It involves using a thin, lighted tube called a hysteroscope, which is inserted through the vagina and cervix into the uterus.

The hysteroscope has a camera that allows the doctor to view the uterine lining and the openings of the fallopian tubes on a screen. The procedure can be done in a doctor’s office or a hospital, and it usually takes less than 30 minutes. Patients may receive local, regional, or general anesthesia, depending on the specific situation and the extent of the procedure.

If any suspicious areas are found, the doctor can pass small instruments through the hysteroscope to take a biopsy (a small sample of tissue) from the endometrial lining. Recovery time is typically short, with most patients able to return to their normal activities within a day or two.

Staging Endometrial Cancer

Endometrial cancer staging is a way to describe how advanced the cancer is and how far it has spread in the body.

This information is crucial because it helps doctors decide on the best treatment plan for you and gives an idea of your prognosis, which is the likely outcome or course of the disease.

There are four main stages of endometrial cancer:

• Stage 1: The cancer is only in the uterus.
• Stage 2: The cancer has not spread beyond the uterus, but has been found in the connective tissue of the cervix.
• Stage 3: The cancer has spread beyond the uterus and cervix, such as to the outer layer of the uterus, the fallopian tubes, the ovaries, ligaments or vagina.
• Stage 4: The disease has spread beyond the pelvis, to areas such as to the bladder, bowel wall, abdomen, or groin lymph nodes.

Each stage can be further divided into sub-stages, depending on specific details like the size of the tumor or the exact extent of the spread.

Staging is important for several reasons:

• Treatment Planning: Different stages of cancer may require different treatments. For example, early-stage cancer might be treated with surgery alone, while more advanced stages might need a combination of surgery, radiation therapy, and chemotherapy.
• Prognosis: Generally, the earlier the stage of cancer, the better the chances of successful treatment and long-term survival.
• Research and Comparisons: Staging allows doctors and researchers to compare the effectiveness of treatments for different stages of cancer and to develop new treatments.

Staging is usually done after a diagnosis is confirmed.

“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 that report that the surgeon gets back and reviews with you is what we use to assign a stage,” Dr. Mueller says.

Remember, each person’s cancer is unique, and your doctor will consider many factors, including the stage, to recommend the best treatment plan for you.