Uterine Cancer Treatment: Approaches by Stage

The approach to treating uterine cancer varies significantly depending on several factors, with the most important determinant being the stage of cancer. Other considerations include age, pre-existing medical conditions as well as the desire to have children. Different types of uterine cancer may warrant distinct approaches to treatment, depending on the aggressiveness and severity of the disease.

Uterine cancer commonly spreads outside of the uterus through the lymphatic system. Lymph node assessment is performed to complete the staging, often with sentinel lymph node mapping.

The main approach taken in treating uterine cancer involves surgery. Hysterectomy is a surgical procedure in which the uterus is removed. In most cases, a total hysterectomy is performed to treat uterine cancer. This involves the removal of the entire uterus, along with the cervix. Additionally, depending on the severity and spread of the cancer, surgery may be required to remove the surrounding structures as well. A bilateral salpingo-oophorectomy is often performed to remove the ovaries and fallopian tubes.

The tissue removed from surgery is further examined by the pathologist to evaluate the extent of spread (stage) and severity of the cancer. This provides a more accurate diagnosis and helps guide further treatment. Additional processing for HER2/neu and mismatch repair mutations are also often done to help guide therapy.

For patients who cannot undergo surgery, other forms of treatment, such as radiation therapy and hormone therapy, are used to manage their condition.

Stage 1 (I) uterine cancer refers to cancer that is confined within the uterus. Surgery is often the only treatment required for uterine cancer at this stage. Following which, the patient is monitored for any signs of recurrence.

If the cancer is assessed to have a higher risk of recurrence, adjuvant therapy may be required. Adjuvant therapy refers to follow-up treatment given after surgery to kill off any remaining cancer cells. The need for adjuvant therapy is assessed based on factors such as the grade of the tumor, degree of myometrial involvement and cell type. This helps to determine whether the patient is at a higher risk for recurrence with stage 1 uterine cancer. At this stage, radiation therapy is commonly used to treat higher risk endometrial cancers.

Fertility-sparing treatment

For patients with stage 1 low grade endometrial cancer who are still looking to have their own biological children, hormone therapy may be used as their primary form of treatment. In particular, progestin therapy is used to treat uterine cancer in these patients. Progestin therapy refers to the use of progestins and other hormone-blocking drugs to treat cancer. Patients undergoing this treatment have to be monitored closely to check for the presence or spread of the cancer.

Progestin therapy may be able to reduce the size of the tumor or allow the patient to be in remission for a short period of time. This allows for potential pregnancies to happen. However, it is not a reliable form of treatment and may not work depending on the patient. Nonetheless, for these patients, surgery is still eventually required to treat their condition. Hence, it is important to discuss with your healthcare provider to see if this approach is suitable for you.

Stage 2 (II) uterine cancer refers to cancer that has spread beyond the uterus to the cervix. Surgery remains the primary mode of treatment for uterine cancer at this stage. However, the risk for nodal spread is higher and additional treatment is always required.

Post-surgery, patients usually have to undergo radiation therapy as well. Both vaginal brachytherapy and external pelvic radiation may be performed. Vaginal brachytherapy refers to the internal delivery of radiation directly to the tumor site. On the other hand, external pelvic radiation uses an external radioactive source to target cancer cells in the pelvic region. For patients with higher risk tumors, chemotherapy may be required on top of surgery and radiation therapy.

Stage 3 (III) uterine cancer refers to cancer that has spread locally within the pelvis or to the lymph nodes. At this stage, surgery is usually performed with the objective to remove all visible tumor. Depending on the extent of cancer spread, the amount of surgery may differ for each patient.

Postoperative therapy will be recommended after surgery. This typically involves radiation therapy and chemotherapy, but immunotherapy may be used as well. In rare cases where the cancer has spread extensively in the pelvis, radiation therapy may be performed first to shrink the tumor until surgery becomes an option.

Stage 4 (IV) uterine cancer refers to cancer that has spread beyond the pelvic region, often to the upper abdomen or chest. At this point, surgery may no longer be a viable option if the cancer has spread too far. However, it may still be performed to relieve symptoms, such as excessive bleeding or to reduce overall tumor volume.

At this stage, the primary mode of treatment becomes chemotherapy, radiation therapy, hormone therapy and/or immunotherapy. Depending on the type of uterine cancer, different combinations of treatment may be required. For instance, hormone therapy is the most effective when there are progesterone and estrogen receptors on the cancer cells. As such, the types of uterine cancer which do not express many of these receptors may not respond well to hormone therapy. Therefore, it is important to consult your healthcare provider to determine the most appropriate and effective treatment option for you.

Moreover, at this stage, the effectiveness of these treatment methods may vary significantly among different patients. However, there are many ongoing clinical trials that assess the safety, effectiveness and potential advantages of new treatments. These trials have the potential to introduce breakthrough therapies or refine existing approaches for uterine cancer. Participating in these trials can also give patients access to promising new therapies. Discuss with your healthcare provider to assess if any of these trials might benefit you.

After completion of the initial treatment of cancer, your doctor will advise you to return regularly for cancer surveillance to monitor for any signs of recurrence. All stages and types of uterine cancer will have some degree of recurrence risk. Depending on the level of risk, follow-up procedures may include clinical pelvic exam and symptom assessment, radiologic imaging by computed tomography (CT) scan, positron emission tomography-computed tomography (PET-CT) scan or magnetic resonance imaging (MRI). If the patient has a suspicious lesion upon examination or imaging, a biopsy may be required to confirm the presence of recurrent cancer.

Recurrent cancer refers to cancer that returns after treatment has ended. The recurrence may be local, whereby the cancer returns in the same place that it originated from. It can also be distant, in which the cancer returns in other parts of the body.

Treatment of recurrent uterine cancer depends on the extent of recurrence as well as the treatment given after the first diagnosis. If surgery was not performed, it may be considered for local recurrent uterine cancer. For all other cases, a combination of chemotherapy, radiation therapy, hormone therapy and immunotherapy is used. It is crucial to work with your healthcare provider to choose the treatment that best meets your needs and goals.