Treatment of Endometrial Cancer
Treatment options for endometrial cancer (uterine lining) are dependent on many different factors. You and your doctor need to consider the type of endometrial cancer, the stage at diagnosis and the aggressiveness of the disease. A variety of options are available including surgery, radiotherapy (radiation), chemotherapy, and hormonal therapy. Each patient’s disease is unique and therefore, medical management should be personalized for each patient. Below is an explanation of treatment options that your doctor may recommend.
Treatment of endometrial cancer by stage:
Stage I endometrial cancer is limited to the uterus and has not spread to lymph nodes or other sites outside of the uterus. Treatment for this stage includes surgery to remove and stage the cancer. Radiation or chemotherapy may be considered based on surgical stage and tumor subtype and grade.
Stage II endometrial cancer has spread to the connective tissue of the cervix, but has not grown outside the uterus. Treatment at this stage would likely include surgery followed by radiation therapy. Chemotherapy may be considered based on surgical stage and tumor subtype and grade. The surgery may include a radical hysterectomy (the entire uterus, tissues next to the uterus/cervix, and upper part of the vagina are all removed), both fallopian tubes and ovaries (bilateral salpingo-oophorectomy or BSO) are likely removed, and pelvic and para-aortic lymph node dissection.
Stage III endometrial cancer has spread outside of the uterus. Treatment at this stage likely involves a hysterectomy and removal of both ovaries and fallopian tubes. Surgery may be followed by chemotherapy, radiation therapy or both.
Stage IV endometrial cancer has spread beyond the pelvis. The cancer may have grown into the bladder or bowel, to lymph nodes outside the pelvis or para-aortic area or spread to other parts of the body outside the pelvis. Treatment for this stage may include surgical cytoreduction (removal of as much tumor as possible). In addition to surgery, options include radiation therapy, hormone therapy, or a combination of chemotherapy drugs. Discuss with your doctor which option would be most appropriate for you.
Surgery is the most common type of treatment for endometrial cancer. Surgery is used to physically remove cancer from the body and determine the stage (how widespread the cancer may be). Nearly all women with endometrial cancer will be required to have some type of surgery in their treatment process.
Types of Endometrial Cancer Surgery
Total hysterectomy– Surgery to remove the uterus, including the cervix
- Vaginal hysterectomy- uterus and cervix are taken out through the vagina
- Total abdominal hysterectomy- uterus and cervix are taken out through a large incision in the abdomen
- Total laparoscopic hysterectomy- uterus and cervix are removed through the vagina or through a small incision in the abdomen using instruments and a laparoscope (thin, lighted tube)
Bilateral salpingo-oophorectomy– surgery to remove both ovaries and fallopian tubes
Radical hysterectomy– surgery to remove the uterus, cervix (and tissues around the cervix) and upper part of the vagina. The ovaries, fallopian tubes (BSO), or nearby lymph nodes may also be removed
Tumor surgical cytoreduction- Removes as much of the cancer as possible
Side Effects of Surgery:
- Infection, bleeding, blood clots, damage to the vital organs
- Any hysterectomy causes infertility
- For women who were premenopausal before surgery, removing the ovaries will cause surgical menopause. This can lead to symptoms such as hot flashes, night sweats, and vaginal dryness.
- Removal of the lymph nodes in the pelvis can very rarely lead to a build-up of fluid in the legs (lymphedema)
Endometrial Cancer Treatment. National Cancer Institute. Available at: http://www.cancer.gov/types/uterine/patient/endometrial-treatment-pdq. Accessed April 6, 2016.
Pharmacological therapy – administered by Gynecologic Oncologist or Medical Oncologist
Chemotherapy treatment is the use of cytotoxic drugs to destroy cancer cells. Chemo for endometrial cancer is often a combination of 2 or more drugs given on a cycle (a period of treatment, followed by a rest period). (www.cancer.org)
Common chemotherapy drugs:
- Cisplatin (brand name: Platinol®)
- Carboplatin (brand name: Paraplatin®)
- Paclitaxel (brand name: Taxol®)
- Doxorubicin (brand name: Adriamycin®)
- Liposomal doxorubicin (brand name: Doxil®)
Common side effects:
- Nausea and vomiting
- Loss of appetite
- Loss of hair
- Mouth and vaginal sores
- Low blood cell counts
Radiation therapy (RT), or radiotherapy, is the use of high energy radiation to eliminate tumors by damaging the DNA of the cancer cells causing these cells to die. External beam radiation therapy is the most common form of radiotherapy. High-energy x-ray machines are used to focus radiation specifically to the tumor.
External radiation therapy- radiation is delivered from a source outside of the body
- This is often administered 5-days-a-week for 4 to 6 weeks
- A special mold of the pelvis and lower back is made to ensure that the woman is in the exact same position for each treatment
- Each treatment takes less than a half-hour
Internal radiation therapy (Brachytherapy)- Patients who have had their uterus (and cervix) removed may have the upper part of the vagina treated with brachytherapy. This is called vaginal brachytherapy. With this method of radiation, the vagina is mainly affected, but the bladder and rectum will get less radiation exposure. The most common side effect is narrowing of the vagina.
LDR brachytherapy- The radiation devices are left in place for 1 to 4 days. The patient needs to stay immobile in a hospital bed to keep the radiation sources from moving throughout the treatment. Several treatments may be necessary and because the patient is required to remain immobile, there is an increased risk for deep venous thrombosis in the legs. LDR is uncommonly used.
HDR brachytherapy- This form of radiation is much more intense. Each dose usually takes less than an hour and the patient is able to return home in the same day. For endometrial cancer, HDR brachytherapy is often given weekly or even daily for at least 3 doses.
Common side effects of Radiation Therapy:
- Mild skin reactions
Hormone therapy interferes with hormone production or blocks hormonal actions. The types of hormones used to treat endometrial cancer are those that typically affect menstruation or ovulation.
Types of hormone therapy:
Progestins – main hormone treatment used
Lutenizing hormone releasing hormone agonists
Researchers have been able to develop newer drugs that specifically target the gene and protein changes in cancer cells which work differently than standard chemotherapy drugs. Some of the targeted therapies that are being studied to treat endometrial cancer include:
Common targeted therapy drugs:
Temsirolimus (Torisel®)- An intravenous chemotherapeutic agent approved by the US Food and Drug Administration in May 2007 for the treatment of advanced renal cell carcinoma in adults. Current NCCN guidelines as of 2014 list temsirolimus for endometrioid carcinoma or serous or clear cell endometrial carcinoma as adjuvant therapy as a single agent with or without vaginal brachytherapy for stage 1A disease with no myometrial invasion or sequential tumor-directed radiation therapy for stage 1A disease with myometrial invasion or stage IB-IV disease (http://www.aetna.com/cpb/medical/data/800_899/0873.html)
Temsirolimus (Torisel). Temsirolimus (Torisel). Available at http://www.aetna.com/cpb/medical/data/800_899/0873.html. Accessed April 6, 2016.
Bevacizumab (Avastin®)- Adding bevacizumab to carboplatin/paclitaxel chemotherapy significantly increases progression-free survival in patients with advanced/recurrent endometrial cancer. This has been demonstrated in phase II trials as both a single agent and in conjunction with carboplatin and paclitaxel. (http://www.cancernetwork.com/asco-2015/adding-bevacizumab-chemotherapy-improves-pfs-endometrial-cancer)
Adding Bevacizumab to Chemotherapy Improves PFS in Endometrial Cancer. Adding Bevacizumab to Chemotherapy Improves PFS in Endometrial Cancer. Available at: http://www.cancernetwork.com/asco-2015/adding-bevacizumab-chemotherapy-improves-pfs-endometrial-cancer. Accessed April 6, 2016.
For some cancers the majority of patients will have an appropriate target for a specific targeted therapy. For other cancers, patients must receive a blood test or tumor tissue test to determine eligibility for a targeted therapy. If a patient displays specific gene mutations that are targets for targeted therapy they would be a candidate of targeted therapy. (cancer.org)
Although targeted therapy doesn’t affect the body the same way that standard chemotherapy does patients still may experience side effects. There is a large variety of targeted therapy drugs and the side effect of each varies depending on what each drug targets. Some drugs target substances that are found more prevalently on cancer cells, but are also found on healthy cells. Side effects occur when targeted therapy drugs affect healthy cells.
Some targeted therapy drugs cause more side effects than others. When drugs attack more than one target there is a greater chance of experiencing side effects. Not every person will get every side effect. Some patients get few side effects if any. Talk with your doctor about which side effects are associated with your specific treatment regimen.
Common Side effects:
- Skin problems
- High blood pressure
- Problems with bleeding or blood clotting
- Problems with wound healing
- Heart damage
- Autoimmune reactions
Other side effects may include:
- Nausea and vomiting
- Diarrhea or constipation
- Mouth sores
- Shortness of breath or trouble breathing
- Feeling tired all the time
- Swelling in the hands and feet
- Damage to organs such as the thyroid gland, liver, or kidneys
- Allergic reactions
- Increased risks of certain infections
A caregiver is anyone who provides physical, emotional, spiritual, financial, or logistical support to anyone suffering from a disabling or life threatening illness. Caring for a loved one with cancer is the role of caregivers but it is also important that caregivers take care of themselves. Finding a balance between helping your loved one and helping yourself is imperative for all caregivers.
Every caregiver is at a different point in their journey. Understanding the important role caregivers hold helps them be effective at embracing their new life. Caregivers may face many obstacles while adapting to their new role, but there are resources to help them along the way. Some online resources include the American Cancer Society (cancer.org), the National Cancer Institute (cancer.gov), Cancer Support Community (cancersupportcommunity.org), OncoLink (oncolink.com), and Breastcancer.org.
Some tips that may help include:
Find support from others in similar positions: Communicating with other caregivers may help you relieve stress and become a better caregiver.
Educate yourself on their specific situation: Learning about what your loved one is going through will enable you to help them in many different ways.
Embrace new life changes: It is normal to feel like things are different and that they may never be how they once were. It is important to embrace your new situation and learn to adapt to the changes in life. Learning to balance what you have control of and what is out of your control may help remove some of the stress from your life.
Take time outs: It is ok to take time for yourself. Rejuvenating yourself is imperative to becoming the best caregiver you can be.
Remain connected with community, friends, and family: Becoming a caregiver should not involve you abandoning your old life. Being around people that love and care about you can recharge you and uplift your spirit. The level of involvement you have with friends and family may vary, but keeping them close can help give you strength and a positive attitude.
Allow help from others: Accepting help from others will take strain off of you and allow others to feel a part of caring for someone in need. People around you may want to help but don’t know how. If they ask to help, learn to say yes.
Maintain yourself physically, mentally, and emotionally: Taking care of yourself allows you to be a better resource to those in need. It is easy to overlook your personal wellbeing while taking on the role of a caregiver, but allowing time to keep yourself healthy will make you a more effective helper.
Find ways to relieve stress: It is important to plan stress relieving activities into busy schedules. Learning different ways that allow your body to relax can enhance the way your mind and body function.
Understand your limits: You can’t do everything, and that is ok. It is easy to get caught up feeling like you need to take care of every single responsibility. Ask for help when you need it, take a break when it’s hard, and try not to overwork yourself.
(10 tips for caregivers: www.cancersupportcommunity.org)
Sources: Cancer.org, radiologyinfo.org, NCCN guidelines, FDA.gov, cancer.gov, cancerresearchuk.org, oncolink.com, cancernetwork.com, cancersupportcommunity.org
Platinol, Paraplatin, Taxol, Adriamycin, Doxil, Torisel, and Avastin are either trademarks or registered trademarks of their respective owners.