Endometrial (Uterine) Cancer: Staging and Treatment

What is staging for cancer?

Staging is the process of learning how much cancer is in your body and where it is. For endometrial cancer, tests like ultrasound, biopsy, dilation and curettage (D&C), X-Ray, CT scan, MRI, PET scan, cystoscopy, and proctoscopy may be used to help stage your cancer. Blood tests, like a complete blood count (CBC) and tumor marker tests (such as CA-125) may also be done to help stage your cancer. Your providers need to know about your cancer and your health so that they can plan the best treatment for you.

Staging looks at the size of the tumor and where it is, and if it has spread to other organs (called metastasis). There are two staging systems used for endometrial cancer. The first system is called the FIGO (International Federation of Gynecology and Obstetrics) system. The second system is called the “TNM system" from the American Joint Committee on Cancer. Both systems stage endometrial cancer based on:

• T- Describes the size/location/extent of the "primary" tumor in the endometrium.
• N- Describes if the cancer has spread to the lymph nodes.
• M- Describes if the cancer has spread to other organs (metastases).

Your provider will use the results of the tests you had to figure out your FIGO and TNM result and combine these to get a stage from I (one) to IV (four).

How is endometrial cancer staged?

Staging may be done at different times during your treatment.

The staging system is very complex. Below is a summary of FIGO and AJCC staging. Talk to your provider about the stage of your cancer.

Stage I (T1, N0, M0): The cancer is growing inside the uterus, and it may be growing in the ovary (T1). It has not spread to nearby lymph nodes (N0) or to distant sites (M0).

Stage IA (T1a, N0, M0): The cancer is in the endometrium (inner lining of the uterus) and may have grown less than halfway through the muscle layer of the uterus (the myometrium) OR, the tumor is growing in the uterus and ovary (T1a). It has not spread to nearby lymph nodes (N0) or to distant sites (M0).

Stage IB (T1b, N0, M0): The cancer has grown from the endometrium into the myometrium. It has grown more than halfway through the myometrium but has not spread past the uterus (T1b). It has not spread to nearby lymph nodes (N0) or to distant sites (M0).

Stage II (T2, N0, M0): The cancer has spread from  the uterus and is growing into the connective tissue of the cervix (called the cervical stroma). But it has not spread outside the uterus, OR the tumor has spread to your lymphovascular space (blood vessels), OR it has spread to the myometrium (T2). It has not spread to nearby lymph nodes (N0) or to distant sites (M0).

Stage III (T3, N0, M0): The cancer has spread outside the uterus but has not spread to the inner lining of the rectum or urinary bladder (T3). It has not spread to nearby lymph nodes (N0) or to distant sites (M0).

Stage IIIA (T3a, N0, M0): The cancer has spread to the outer surface of the uterus (the serosa) and/or to the fallopian tubes or ovaries (T3a). It has not spread to nearby lymph nodes (N0) or to distant sites (M0).

Stage IIIB (T3b, N0, M0): The cancer has spread to the vagina or to the tissues around the uterus (T3b). It has not spread to nearby lymph nodes (N0) or to distant sites (M0).

Stage IIIC1 (T1-T3, N1/N1mi/N1a, M0): The cancer is growing in the uterus. It may have spread to some nearby tissue but is not growing into the inside of the bladder or rectum (T1 to T3). It has also spread to pelvic lymph nodes (N1, N1mi, or N1a), but not to lymph nodes around the aorta or distant sites (M0).

Stage IIIC2 (T1-T3, N2/N2mi/N2a, M0): The cancer is growing into the uterus. It may have spread to some nearby tissues but is not growing into the inside of the bladder or rectum (T1 to T3). It has also spread to lymph nodes around the aorta (N2, N2mi, or N2a), but not to distant sites (M0).

Stage IVA (T4, Any N, M0): The cancer has spread to the inner lining of the rectum or urinary bladder (T4). It may or may not have spread to nearby lymph nodes (Any N) but has not spread to distant sites (M0).

Stage IVB (Any T, Any N, M1): The cancer is in the inner lining of your abdomen (belly)  and pelvis (any T). It may or may not have spread to nearby lymph nodes (any N). The cancer has spread to inguinal (groin) lymph nodes, the upper abdomen, the omentum (fatty tissue near your stomach and bowels), or to organs away from the uterus, such as the lungs, liver, or bones (M1).

Stage IVC: The cancer has spread to inguinal (groin) lymph nodes, the upper abdomen (belly), the omentum (fatty tissue near your stomach and bowels), or to organs away from the uterus, such as the lungs, liver, or bones. The cancer can be any size and it may or may not have spread to other lymph nodes outside your abdomen or above your kidneys.

How is endometrial cancer treated?

Treatment for endometrial cancer depends on things like your cancer stage, age, overall health, and testing results. Your treatment may include:

• Surgery.
• Radiation Therapy.
• Chemotherapy.
• Hormone Therapy.
• Targeted Therapy.
• Immunotherapy.
• Clinical Trials.

Surgery

The most common surgery used to treat endometrial cancer is a hysterectomy. During a hysterectomy, your uterus is removed. Your cervix, ovaries, fallopian tubes, and/or other nearby organs may also be removed. There are a few types of hysterectomy:

• Total hysterectomy: Your uterus and cervix are removed.
• Subtotal hysterectomy: Only your uterus is removed.
• Total hysterectomy with bilateral salpingo-oophorectomy: Your uterus, cervix, fallopian tubes (salpingectomy), and ovaries (oophorectomy) are removed.
• Radical hysterectomy: Your uterus and nearby tissues are removed, including the fallopian tubes, part of your vagina, ovaries, lymph glands, and fatty tissue.

There are 3 ways to do a hysterectomy:

• Laparoscopic: Small incisions (surgical cuts) are made in your abdomen (belly) and one in your vagina. Your uterus is removed through your vagina.
• Vaginal: Your uterus is removed through an incision at the top of your vagina.
• Abdominal: Your uterus is removed through an incision in the lower abdomen.

Radiation Therapy

Radiation is the use of high-energy x-rays to kill cancer cells. Endometrial cancer is often treated with radiation therapy after surgery. Radiation is used to lower the chances that the cancer will come back (recurrence).

The most common types of radiation therapy used for endometrial cancer are:

• External beam radiation therapy (EBRT): The radiation is delivered from the outside of your body and focused on your endometrium and nearby areas.
• Brachytherapy (internal radiation therapy): A radioactive source is placed inside your vagina.

Radiation can also be given with chemotherapy, called chemoradiation.

Chemotherapy

Chemotherapy is often used in stage III or stage IV endometrial cancer. In most cases, more than one chemotherapy will be used for your treatment. Chemotherapy medications used to treat endometrial cancer are paclitaxel, carboplatin, doxorubicin, liposomal doxorubicin, cisplatin, docetaxel, and ifosfamide.

Hormone Therapy

Some cancers need hormones to grow. Blocking these hormones might stop the cancer from growing. Hormone therapy is often given along with chemotherapy. Some hormone therapy medications used to treat endometrial cancer are medroxyprogesterone acetate, megestrol acetate, tamoxifen, goserelin acetate, leuprolide, letrozole, anastrozole, and exemestane.

Targeted Therapy

Targeted therapy are medications that target something specific to the cancer cells, stopping them from growing and dividing. Some types of targeted therapy used for endometrial cancer are lenvatinib, bevacizumab, everolimus, temsirolimus, larotrectinib, entrectinib, cabozantinib, and fam-trastuzumab deruxtecan.

Immunotherapy

Immunotherapy is the use of medication to help your immune system fight cancer. Examples of immunotherapy medications used to treat endometrial cancer are pembrolizumab, nivolumab, and dostarlimab. Both of these medications are immune checkpoint inhibitor medications that block a protein called PD-1. By blocking PD-1, these medications help your immune system decrease tumor size or slow down cancer cell division.

Clinical Trials

You may be offered a clinical trial as part of your treatment plan. To find out more about current clinical trials, visit the OncoLink Clinical Trials Matching Service.

Making Treatment Decisions

Your care team will make sure you are included in choosing your treatment plan. This can be overwhelming as you may be given a few options to choose from. It feels like an emergency, but you can take a few weeks to meet with different providers and think about your options and what is best for you. This is a personal decision. Friends and family can help you talk through the options and the pros and cons of each, but they cannot make the decision for you. You need to be comfortable with your decision – this will help you move on to the next steps. If you ever have any questions or concerns, be sure to call your team.

You can learn more about endometrial cancer at OncoLink.org.