Before deciding on a treatment plan, a pathologist looks at the cancer tissue under a microscope to understand its type, how aggressive it is, and how far it has spread. They also do molecular tests, like checking for certain proteins or changes in the DNA. This information helps doctors understand:

• How likely surgery alone will be enough to treat the cancer
• Whether additional treatments are needed
• The risk of the cancer spreading or coming back

This information was developed in consultation with leading Canadian gynecologic oncologists and reviewed by Alicia Tone, PhD.

Does endometrial cancer spread?

Staging

Surgical staging usually includes removing the uterus, fallopian tubes, and ovaries, checking nearby lymph nodes, and taking small tissue samples (biopsies). After surgery, a pathologist examines the tissue to determine the stage of the cancer, which ranges from stage I (cancer is only in the uterus) to stage IV (cancer has spread to other parts of the body). Sub-stages give more detail about how far the cancer has spread, your team may discuss this with your further.

The Stages of Endometrial Cancer

• Stage I – Cancer is only found in the uterus. Sub-stages (IA, IB) describe how deeply it has grown into the wall of the uterus.
• Stage II – Cancer is still in the uterus but has also spread to the cervix (the lower part of the uterus).
• Stage III – The cancer has grown beyond the inside of the uterus and cervix but is still within the pelvic area or in lymph nodes in the pelvis or abdominal area. It may have reached the outer surface of the uterus, the ovaries, fallopian tubes, vagina, or nearby lymph nodes.
• Stage IV – The cancer has moved into nearby organs like the bladder or bowel, or to distant organs such as the lungs or liver.

What are the types of endometrial cancer?

Histotype, Grade and Molecular Classification

Histotype

• Endometrioid: This is the most common type of endometrial cancers (over 70% of cases) and can be grade 1, 2 or 3.
• Other types: Serous, clear cell, carcinosarcoma, dedifferentiated/undifferentiated, mesonephric-like, and gastric-type cancers. These are all less common and are usually high grade (grade 3).

Grade

The more the cancer cells look like a normal cell, the more they will behave like a normal cell and are likely to grow slowly.

The grades of endometrial cancer

• Grade 1 (low grade): Cells look fairly normal and are only slightly crowded. These cancers usually grow slowly and have a lower risk of spreading.
• Grade 2 (intermediate grade): Cells are more crowded and look a bit more abnormal, but often still behave like low-grade tumors.
• Grade 3 (high grade): Cells look very abnormal and look more like sheets of tumour. These cancers are more likely to spread or come back after treatment.

Molecular classification

Knowing the subtype helps doctors predict how likely the cancer is to come back (known as recurrence) and can help them choose the most effective treatment. The four molecular subtypes are:

How is endometrial cancer treated?

Overall treatment plans are based on:

• The stage of the cancer
• The grade of the cancer
• The histotype and/or molecular subtype of the cancer
• Your age and general health
• Your future fertility goals, if any

Surgery is often the main treatment, with other options like radiation, chemotherapy, hormone therapy, targeted therapies, or immunotherapies used in combination, depending on the specific characteristics of the cancer and the individual’s circumstances.

Surgery for endometrial cancer

Surgery is often the first step in treating most endometrial cancers. Surgical options can sometimes be adjusted based on age, health, and personal wishes:

• For some younger patients with precancer or early-stage cancer, the ovaries may be left in place to prevent early menopause. This can slightly increase the chance of the cancer returning.
• For people who still wish to have children, surgery may be postponed, and other treatments may be used first e.g., hormonal therapy (progesterone), to treat the cancer.
• If surgery isn’t safe because of other health conditions, treatments such as radiation or hormone treatment may be recommended instead.

Is Radiation Used to Treat Endometrial Cancer?

Radiation therapy may be used to treat endometrial cancer following surgery. It uses a very high localized dose of radiation to destroy cancer cells and damage the DNA of the cancer cells so that it can no longer divide and grow (this is a different approach to chemotherapy which destroys cancer cells throughout the body).

How is radiation given to treat endometrial cancer?

Radiation is given in two main ways:

• Internal radiation (brachytherapy): A small amount of radioactive material is placed inside the body, close to where the cancer is.

• External beam radiation therapy: A machine outside the body aims radiation at the tumor, similar to getting an X-ray.

Sometimes both types are used. In most of these cases, external beam radiation is given first, followed by brachytherapy.

The type of radiation – and the areas to be treated – will be based on stage (how far the cancer has spread) and grade (how the cancer cells look under a microscope).

What are the side effects of radiation treatment?

Side effects of radiation treatment may include:

• Fatigue
• Mild redness/skin sensitivities
• Loss of appetite
• Hair loss in the pelvic region
• Nausea and vomiting
• Diarrhea or constipation
• Gas
• Bladder problems (frequent urination, discomfort, bleeding)
• Treatment-induced menopause
• Vaginal irritation
• Low blood counts
• Sexual changes

These side effects will fade once radiation therapy ends.

Chemotherapy for Endometrial Cancer

Chemotherapy is often used as a treatment for endometrial cancer, most commonly given after surgery but sometimes can be given before surgery. Chemotherapy, sometimes referred to as systemic therapy refers to intravenous or oral administration of cancer treatment to the whole body (as compared to radiation therapy which is usually to a specific anatomic area). There are many different types of chemotherapy protocols for endometrial cancer.

When is chemotherapy used to treat endometrial cancer?

• Chemotherapy is used as a treatment for high stage or aggressive endometrial cancer, most commonly given after surgery.
• Chemotherapy given after surgery (‘adjuvant’), is used to destroy any remaining cancer cells and is often accompanied by radiation therapy.
• Chemotherapy given before surgery (‘neoadjuvant’), reduces the size of the tumour and treats any accompanying fluid (ascites), making it easier to remove the cancer during surgery or to treat with radiation.

Which chemotherapy drugs are used to treat endometrial cancer?

Chemotherapy to treat endometrial cancer typically includes a combination of two different chemotherapy drugs; carboplatin and paclitaxel. These are administered intravenously (IV) so that they can circulate through the bloodstream.

Other Treatments for endometrial cancer

Hormone therapy is used to treat some endometrial cancer. It is believed to be most effective for endometrial cancers belonging to the NSMP molecular subtype and that have strong estrogen receptor expression (ER positive). The most common hormone therapy consists of a progesterone, either given by mouth or in an intra-uterine device (IUD). It is given most commonly in these situations:

• For younger patients who wish to preserve fertility and keep their uterus
• For advanced cancer (stage III or IV)
• If the cancer has come back after treatment (recurrence)
• For people with early-stage cancer who cannot have surgery for health reasons

Immunotherapy and Targeted Therapy: These are newer types of treatments for endometrial cancer. Most of these treatments are intravenous but some are oral. They work by focusing on specific features of the cancer. Whether these treatments are recommended depends on the molecular classification of the cancer.

Is endometrial cancer curable?

Remission and recurrence

After treatment is completed, patients may experience feelings of insecurity, loneliness, and fear of recurrence. They may also feel a heightened sense of responsibility for their own health. For those experiencing worry or stress, there are resources and support services available to help.

What Happens After Endometrial Cancer Treatment?

Follow-up tests and treatments will vary once treatment is complete. Patients will have scheduled visits with their doctor to:

• monitor their response to treatment
• recognize and immediately deal with any treatment-related complications
• monitor for a recurrence of the cancer

The frequency of visits will vary according to a patient’s specific situation, although a general guideline is:

• year 1-2: every 3-5 months
• years 3-5: every 6 months
• years 5+: annually

What Happens If Endometrial Cancer Comes Back?

Patients with endometrial cancer can experience a recurrence or multiple recurrences. For those who have experienced a recurrence, it may be helpful to think of endometrial cancer as a chronic disease that will need to be managed.

Treatment options for recurrence may include:

• use of chemotherapy drugs
• use of other drugs like immunotherapy
• surgery
• radiation (if localized)

Some considerations regarding treatment of recurrence include:

• Length of time from the finish of the first treatment series to recurrence (also called progression-free survival).
• Patient factors- overall health, personal values and choices
• Consideration of side effects, such as neuropathy, also needs to be given to the choice of chemotherapy drugs.
• Availability of clinical trials may be an option to be explored.
• Availability and/or cost of treatments offered
• Surgery for recurrent endometrial cancer may be an option if it has been a long time since completing chemotherapy and the new disease is only in one (or limited) area.

Support and education

Understanding the complex experiences women face when navigating their healthcare is what we do best.  As someone facing endometrial cancer or uterine sarcoma, you are welcome in our community. Find resources, information, and opportunities to connect with others who understand what you’re going through.