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Patient education: Endometrial cancer treatment after surgery (Beyond the Basics)

Patient education: Endometrial cancer treatment after surgery (Beyond the Basics)
Literature review current through: Jan 2024.
This topic last updated: Nov 20, 2023.

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 education: Uterine cancer (The Basics)" and "Patient education: Endometrial cancer diagnosis, staging, and surgical treatment (Beyond the Basics)".)

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 [BSO]), and evaluation of surrounding lymph nodes is generally performed. The hysterectomy can be done through an incision in the lower abdomen (a total abdominal hysterectomy [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 education: Vaginal hysterectomy (Beyond the Basics)" and "Patient education: Abdominal hysterectomy (Beyond the Basics)".)

RISK STRATIFICATION AND APPROACH TO ADJUVANT TREATMENT — There are several factors that can identify if you are at an increased risk of relapse after surgery. This can help your doctor determine an appropriate plan for "adjuvant" (additional) treatment. These 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), serous or clear cell histology (type of endometrial cancer), involvement of the lymphatic or blood vessels (lymphovascular invasion), and older age.

Low-risk disease — Low-risk endometrial cancer is defined as having all the following characteristics:

Cancer that is endometrioid or nongastrointestinal mucinous type, and

Histologic grade 1 or 2, and

Limited to the endometrium, or invading less than one-half of the myometrium, with no lymphovascular space invasion.

The overall probability of recurrence in these groups is very low following surgical treatment alone and adjuvant treatment is typically not indicated.

Intermediate-risk disease — Intermediate-risk endometrial cancer is defined as disease that has the following characteristics:

Cancer that is endometrioid or nongastrointestinal mucinous type and is any of the following:

Histologic grade 1 or 2 and invading less than one-half of the myometrium, with lymphovascular invasion; or

Histologic grade 1 or 2 and invading more than one-half of the myometrium or demonstrating occult cervical stromal invasion; or

Histologic grade 3 cancer and invading less than one-half of the myometrium. Note that we consider grade 3 endometrioid carcinoma that invades more than one-half of the myometrium to be high risk.

Among intermediate-risk cancers, some are classified as low-intermediate and others are classified as high-intermediate. People with low-intermediate endometrial cancer are typically not treated with adjuvant therapy. By contrast, people with high-intermediate endometrial cancer benefit from postoperative radiation therapy (RT), given via vaginal brachytherapy, for optimal local control (although no survival benefit has been demonstrated). Some clinicians may offer adjuvant chemotherapy (with or without RT) to people with high-intermediate endometrial cancer.

High-risk disease — High-risk endometrial cancer includes people with any of the following:

Serous carcinoma, clear cell carcinoma, or carcinosarcoma (any stage), or

Grade 3, deeply invasive endometrioid carcinoma, or

Stage III or IV endometrial cancer (table 1), any histology.

People with high-risk endometrial cancer have a poor prognosis and should be offered adjuvant chemotherapy.

TYPES OF ADJUVANT TREATMENT

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.

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 (RT), 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 everyone who gets 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)

Radiation therapy — Radiation therapy (RT) 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 people with endometrial cancer, adjuvant radiation is given to decrease the risk of the cancer coming back in the pelvis (this is called locoregional recurrence).

Vaginal brachytherapy — Vaginal brachytherapy (VB) 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 VB: 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:

Increased frequency of urination

Irregular bowel movements

Narrowing, scarring, and dryness of the vagina

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 RT.

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 'Risk stratification and approach to adjuvant treatment' 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.

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 a history and physical exam every three to six months for several years. Other tests, like Pap smears, blood tests, and computed tomography (CT) scans or other radiology tests, should be done only as needed.

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 women 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 education: Non-estrogen treatments for menopausal symptoms (Beyond the Basics)".)

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 education: Vaginal dryness (Beyond the Basics)".)

Pelvic physical therapy and counseling for sexual or psychological difficulties can be helpful. (See "Patient education: Sexual problems in females (Beyond the Basics)".)

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/

www.clinicaltrials.gov/

Videos addressing common questions about clinical trials are available from the American Society of Clinical Oncology (www.cancer.net/pre-act).

WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our web site (www.uptodate.com/patients). 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 — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient education: Uterine cancer (The Basics)
Patient education: Preserving fertility after cancer treatment in women (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient education: Endometrial cancer diagnosis, staging, and surgical treatment (Beyond the Basics)
Patient education: Vaginal hysterectomy (Beyond the Basics)
Patient education: Abdominal hysterectomy (Beyond the Basics)
Patient education: Non-estrogen treatments for menopausal symptoms (Beyond the Basics)
Patient education: Vaginal dryness (Beyond the Basics)
Patient education: Sexual problems in females (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Overview of resectable endometrial carcinoma
Overview of approach to endometrial cancer survivors
Management of locoregional recurrence of endometrial cancer

The following organizations also provide reliable health information:

American Society of Clinical Oncology

     (www.cancer.net/portal/site/patient)

Gynecologic Oncology Group

     (www.gog.org)

National Cancer Institute

     1-800-4-CANCER

     (www.cancer.gov)

Society of Gynecologic Oncologists

(www.sgo.org)

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Disclaimer: This generalized information is a limited summary of diagnosis, treatment, and/or medication information. It is not meant to be comprehensive and should be used as a tool to help the user understand and/or assess potential diagnostic and treatment options. It does NOT include all information about conditions, treatments, medications, side effects, or risks that may apply to a specific patient. It is not intended to be medical advice or a substitute for the medical advice, diagnosis, or treatment of a health care provider based on the health care provider's examination and assessment of a patient's specific and unique circumstances. Patients must speak with a health care provider for complete information about their health, medical questions, and treatment options, including any risks or benefits regarding use of medications. This information does not endorse any treatments or medications as safe, effective, or approved for treating a specific patient. UpToDate, Inc. and its affiliates disclaim any warranty or liability relating to this information or the use thereof. The use of this information is governed by the Terms of Use, available at https://www.wolterskluwer.com/en/know/clinical-effectiveness-terms. 2024© UpToDate, Inc. and its affiliates and/or licensors. All rights reserved.
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