Treatments for Uterine Cancer

Surgery is the most common treatment for uterine cancer. Usually, it involves removal of the uterus (hysterectomy) and sometimes evaluation of the lymph nodes (lymphadenectomy).

• Hysterectomy is performed in most women with uterine cancer and can be done through a single large abdominal incision (open procedure) or several small incisions (minimally invasive approach). Minimally invasive hysterectomy is often called laparoscopic hysterectomy and referred to as robotic-assisted hysterectomy when it is performed with the help of robotic technology. Although the fallopian tubes and ovaries are usually removed as well, ovaries may be spared in younger women.

• Lymph node dissection (or lymphadenectomy)is a surgical procedure to remove lymph nodes in the pelvic area to check the tissue for signs of cancer spread. Sometimes, the surgeon removes only the lymph node(s) most likely to be affected by cancer, a procedure known as sentinel lymph node biopsy. Sentinel lymph node mapping is an imaging technique that helps target nodes for removal.

Radiation therapy is a cancer treatment that uses high-energy X-rays and other types of radiation to kill cancer cells or keep them from growing. Radiation therapy is often given after surgery, with or without chemotherapy, to decrease the risk that the cancer comes back (recurs). There are two types of radiation therapy and sometimes they are used together:

• External radiation therapy uses a machine outside the body to send radiation toward the cancer. The treatment is usually given every day for about six weeks. You can be treated at a clinic, hospital, or radiation oncology office.

• Internal radiation therapy involves placing a small cylinder of radioactive material inside the vagina for a few minutes. This procedure can be performed on an inpatient or outpatient basis, depending on the recommendation of your treatment team. This type of radiation is referred to as brachytherapy.

Chemotherapy (chemo) is the use of drugs that kill cancer cells. Some are given into a vein while others are taken by mouth as pills. These drugs are systemic, meaning they go into the bloodstream and reach throughout the body. Because of this, chemo is often part of the treatment plan for women with metastatic, recurrent, or high-risk disease. Chemotherapy is sometimes used as initial treatment but more commonly given after surgery, with or without radiation.

In most cases, a combination of chemo drugs is used. Combination chemotherapy tends to work better than one drug alone. Chemo is often given in cycles: a period of treatment, followed by a rest period. The drugs may be given on one or more days in each cycle. These may include:

• Paclitaxel (Taxol®)
• Carboplatin (Paraplatin®)
• Doxorubicin (Adriamycin®) or liposomal doxorubicin (Doxil®)
• Cisplatin (Platinol®)
• Docetaxel (Taxotere®)

Hormone therapy involves taking medications to block the growth of uterine cancer. Hormone therapy may be an option if you have advanced endometrial cancer or a certain type of uterine sarcoma that has spread beyond the uterus. Hormone therapy is also sometimes used in selected young women who have not completed childbearing. Like chemotherapy, hormone therapy is a systemic treatment. The types of hormone therapies used most often for uterine cancer include:

• Progestins: Man-made versions of the hormone progesterone. Progestins help slow down the growth of endometrial cancer cells. The most common are medroxyprogesterone acetate (Provera®) and megestrol acetate (Megace®).

• Tamoxifen: Prevents estrogen in your body from stimulating the growth of the cancer cells.

• Aromatase inhibitors: Drugs that can stop estrogen from being made by fatty tissue in the body. They work to lower the overall amount of estrogen in the body. Examples include, letrozole (Femara®), anastrozole (Arimidex®), and exemestane (Aromasin®).

• GnRH (gonadotropin-releasing hormone) Agonists: Work by lowering estrogen in women who still have their ovaries. Examples are goserelin (Zoladex®) and leuprolide (Lupron®).

Targeted drug treatments focus on specific weaknesses or mutations present within cancer cells. By blocking these weaknesses, targeted drug treatments can cause cancer cells to die while leaving most healthy cells alone. Targeted drug therapy may be combined with chemotherapy and can be used for treating advanced and recurrent endometrial cancers. Like some chemotherapy, targeted therapies are given by infusion.

Targeted therapies for endometrial cancer include bevacizumab (Avastin®) and trastuzumab (Herceptin®). Entrectinib (Rozlytrek®) and larotrectinib (Vitrakvi®) are targeted therapies that may be used for endometrial cancers and uterine sarcomas with a certain marker (NTRK fusion) when other treatments have failed.

Immunotherapy helps your own immune system fight against cancer cells. Some cancer cells produce proteins that signal to immune cells at certain checkpoints, telling them that they are normal cells to avoid attack. Immunotherapy interferes with this mechanism, allowing the immune system to recognize and kill cancer cells. Immunotherapy may be considered for endometrial cancer if the cancer is advanced and other treatments have not helped.

The main immunotherapy drug used for endometrial cancer is pembrolizumab (Keytruda®). Pembrolizumab can be used for cancers that come back after treatment with chemotherapy or if your tumor tested positive for MMR deficiency (dMMR) or is high MSI (MSI-H). Pembrolizumab can be used with lenvatinib (Lenvima®) targeted therapy to treat advanced endometrial carcinoma, a type of uterine cancer, that is not MSI-H or dMMR, and that has progressed after treatment with anti-cancer medicine, and that cannot be treated with surgery or radiation.

Endometrial cancer can usually be cured because it is generally caught at an early stage. However, the cancer comes back in about 13% of cases. If your doctor suspects the cancer has returned, he or she will likely order imaging tests. The test may include:

• CT scan of your abdomen, pelvis, and/or chest
• PET/CT of your whole body
• MRI of your pelvis ( for women who will still have their uterus)

Cancer that returns may be treated with:

• Chemotherapy to destroy the cancer and slow the tumor’s growth. Chemotherapy is the most common treatment for recurrent uterine cancer.

• Radiation that can be given as brachytherapy (internal radiation) or external beam radiation therapy (EBRT).

• Surgery to remove the new cancer growths if they are in a specific area.

• Hormone therapy to slow the growth of certain types of uterine cancer cells that have receptors for estrogen on their surface.

• Targeted therapy against specific genes, proteins, or the tissue environment that helps the cancer survive, grow, and spread. This type of treatment limits the damage to healthy cells.

• Immunotherapy that boosts the body’s natural defenses to fight the cancer. It works to destroy the cancer’s ability to mimic healthy cells and avoid attack by the immune system.

• Clinical Trials – Talk to your doctor to learn about clinical trials that may be appropriate for your situation. Find more information at https://www.sharecancersupport.org/uterine-cancer/clinical-trial-matching-service/

People with recurrent cancer often experience a wide range of emotions. These can include disbelief, anger, anxiety, depression, or fear. If you experience any of these feelings, please talk with your healthcare team about resources for cancer support and counseling.