What are the treatments for endometrial cancer ?
Cancer treatment is becoming increasingly personalized: for each patient, it will depend on the various factors gathered during the diagnosis and pre-therapy assessment of the disease :
- the nature of the cancer cells and their grade,
- the MSI status of the cancer cells,
- the location, and the stage of the disease.
When an endometrial cancer diagnosis is made, the treating physician or gynecologist, who often makes the diagnosis, will refer the patient to an oncologist specialized in the treatment of these cancers.
The oncologist will not decide alone on the most suitable treatment for the patient and her disease because each patient is unique. In practice, each case is discussed during a Multidisciplinary Consultation Meeting (MCM). This meeting involves at least an oncologist, a radiotherapist, and a surgeon. An anatomical pathologist or molecular biologist may also be present to provide their opinion on specific cases.
Once a treatment has been chosen during the MCM, the doctor who will initially manage the disease, whether an oncologist, surgeon, or radiotherapist, will explain the treatment in detail or, more precisely, the proposed therapeutic pathway during a specific consultation called the "announcement consultation".
Therapeutic pathway is indeed an appropriate term because the patient will be offered a sometimes-long journey, marked by several stages. During these stages, one or more of the five available treatments for endometrial cancer will be used: two of these treatments are locoregional (surgery or radiotherapy), while three others are systemic treatments, chemotherapy, hormone therapy (or immunotherapy).
Surgery is often the initial treatment for endometrial cancer. This surgery is often performed laparoscopically. It has become the reference technique, especially for low-risk or intermediate-risk tumors.
Laparoscopy and robotic laparoscopy
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Laparoscopy involves making a small incision in the abdomen to insert an endoscope , a thin tube that allows the surgeon to view the organs in two dimensions (2D) and remove the targeted organs.
This laparoscopy can also be performed with a robot ( robotic laparoscopy ). The robot controls four operating arms placed above the patient. The surgeon views the organs in high definition (HD) and in three dimensions (3D) and manipulates the operating arms with great precision to remove the targeted organs. Robotic surgery provides the same results as non-robotic laparoscopy and shortens the length of the hospital stay.
Surgery involves removing the uterus, cervix, ovaries, fallopian tubes, and sentinel lymph nodes. In pre-menopausal patients with early-stage cancer, ovarian preservation may be considered.
Sentinel lymph nodes
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Lymph nodes are organs of the immune system located throughout the body. They are connected to each other by lymphatic vessels . Sentinel lymph nodes are considered to be the first nodes affected when there is an invasion of the lymph nodes by cancer cells. They are identified after the injection of a radioactive or fluorescent substance at the level of the cervix.
If a sentinel lymph node is found to be invaded, the surgeon will remove the lymph nodes in the pelvic region and along the aorta (lymph node dissection), and the pathologist will determine if any lymph nodes have been infiltrated by cancer cells.
Traditional surgical techniques can also be used, either through an abdominal or vaginal approach. The vaginal approach uses natural passages and does not require an incision. This approach is the preferred method for early-stage disease (stage 1) or for frail patients.
After the surgical intervention, the risk of cancer recurrence is determined for each patient, and adjuvant treatment may be proposed if this risk is confirmed. This decision is based on various factors, such as age, the nature and grade of the tumor cells, the extent of cancer cell invasion in the uterus, and the presence or absence of lymph node involvement by tumor cells.
One of the adjuvant treatments is radiotherapy. This treatment uses radiation to destroy cancer cells and prevent them from multiplying. The frequency and duration of treatment are determined by a radiotherapist, a specialist in radiotherapy. For endometrial cancer, two types of radiotherapy may be used.
External beam radiotherapy uses an external source to deliver radiation to the pelvic area. Brachytherapy uses a radioactive source placed inside a cavity near the tumor, specifically in the vagina. Vaginal brachytherapy is currently the most commonly used technique, particularly for intermediate prognosis diseases. Brachytherapy alone may also be an alternative to surgery for low-grade tumors.
Chemotherapy is rarely used in early-stage disease. However, it may be prescribed after surgery (adjuvant treatment) in cases of high-grade tumors or lymph node involvement.
Chemotherapies
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Chemotherapy aims to kill cancer cells, regardless of their location in the body. It works by targeting all rapidly dividing cells, which include cancer cells.
However, some normal cells also divide rapidly, such as blood cells, hair follicle cells that produce hair, and cells lining the digestive tract. Damage to these normal cells can lead to the side effects associated with certain chemotherapy treatments.
Before chemotherapy, laboratory tests will be conducted to ensure that the levels of red blood cells (responsible for transporting oxygen to various tissues), white blood cells (responsible for immune defense), and platelets (responsible for blood clotting) are normal. One or more of these levels may decrease during chemotherapy, and they will be monitored throughout the treatment. The absence of infection, particularly dental infections, will also be checked.
Chemotherapy is often administered as a combination of several medications. In practice, these drugs are given through an intravenous infusion that lasts approximately three hours. To facilitate these infusions, a port is often implanted under the patient's skin, just below the collarbone. This port is a small reservoir connected to a thin, flexible tube ( catheter ) that goes into a large vein. Medications are injected directly into the port, which is more comfortable for the patient than infusions performed in a peripheral vein.
To treat endometrial cancer with chemotherapy, the standard protocol combines a platinum salt, carboplatin, with paclitaxel (Taxolâ„¢ and generics). It consists of 4 to 6 treatment cycles, each spaced with three-week rest periods.
Certain female hormones (estrone) are produced after menopause. The levels of these hormones are particularly high in obese women. These hormones are involved in the development of endometrial cancer. Therefore, hormone therapy aimed at counteracting the action of these hormones may be used in some patients, particularly older women or those with advanced or recurrent disease. Anti-estrogen treatments, such as fulvestrant, are among the hormone therapies prescribed for these patients.
Immunotherapy with checkpoint inhibitors is a new treatment approach for patients with endometrial cancer presenting microsatellite instability (see above).
Immunotherapy with checkpoint inhibitors
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The treatment of cancers with immunotherapy using checkpoint inhibitors is a true revolution in the treatment of certain cancers, including kidney cancer.
These treatments are based on three key discoveries :
- the first is the identification of specific molecules, called checkpoints , that can accelerate or slow down the functioning of the immune system ;
- the second discovery is that cancer cells can exploit checkpoints that slow down the immune system’s function to evade it. In particular, they use a checkpoint known as PD-L1 , which is present on the surface of cancer cells. This molecule binds to another molecule called PD-1 , which is present on the surface of white blood cells, specifically cytotoxic T lymphocytes , immune cells responsible for eliminating cancer cells. The binding of PD-L1 to PD-1 prevents the lymphocytes from performing their role and eliminating the tumor cells ;
- the third discovery is that drugs that block the PD-1 or PD-L1 checkpoints allow the immune system to be reactivated to eliminate tumor cells. These drugs are considered immunotherapies because they do not directly eliminate cancer cells like chemotherapy does; instead, they stimulate the immune system to remove cancer cells. These immunotherapies are often more effective if the cancer cells have numerous PD-L1 molecules on their surface.
Two immunotherapies that block the PD-1 checkpoint may be prescribed, either alone or in combination with another drug (Lenvatinib), for patients who have already been treated with platinum-based chemotherapy and have advanced or recurrent endometrial cancer.
Finally, many advances have been made in recent years in the treatment of endometrial cancer. However, numerous clinical trials exploring new therapeutic pathways are being conducted in France and elsewhere to continue optimizing the management of patients with endometrial cancer.
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Article updated on Jan 24, 2025
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