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Managing Endometrial Cancer, From Symptoms to Treatment

March 11, 2022

With 66,570 new cases estimated in 2021 in the United States, endometrial cancer is the fourth-most common cancer in women, and the most common gynecologic malignancy. The incidence has been rising due to women living longer, and the increased rates of obesity.  As most women with endometrial cancer will fortunately survive their initial diagnosis, this is the largest group of gynecologic malignancy survivors. It should be noted that endometrial cancer is responsible for one of the largest racial disparities among cancers in the U.S., largely related to delays in diagnosis. Management of endometrial cancer typically will include surgery with removal of the uterus, fallopian tubes and ovaries (often minimally invasive), often with sampling of lymph nodes. Women with low-risk cancers during childbearing years may have options for fertility sparing treatment. Recommendations for additional treatments are based on assessment of various levels of risk determined by microscopic characteristics (such as microscopic appearance of cancer cell aggressiveness-grade, cancer cell type-histology), stage (extent of whether/where the cancer has spread) and other tumor-related factors. Additional treatments may include observation alone, vaginal brachytherapy (3-5 short radiation treatments directed to the vagina using an applicator holding a radioactive seed), external beam radiation therapy (often given five days a week for 4-6 weeks, directed to the pelvis) or chemotherapy (most commonly six intravenous infusions three weeks apart; in rare cases, a maintenance infusion may be continued beyond these treatments indefinitely). The term “survivor” can be defined as someone who completed initial treatment for cancer and who is without evidence of disease. Often this is simply determined after successful completion of surgery. In some circumstances, imaging will be completed at the end of additional treatments to confirm no evidence of disease. Post-treatment surveillance occurs every 3-6 months for two years, then every 6-12 months, and is aimed at the early detection of recurrent disease. This consists of monitoring for symptoms and physical examinations, with varying practices and indications for additional bloodwork and imaging. While detection of early recurrences is important, an important component of surveillance includes identification and management of the physical and psychosocial effects of a cancer diagnosis and therapies; some of which, but not all, will be discussed here.

Menopausal Symptoms

Twenty-five percent of endometrial cancers occur in premenopausal women. Most of these women will experience an early and abrupt menopause related to surgery. Symptoms may include hot flashes (vasomotor symptoms), vaginal dryness and mood changes. There are non-hormonal and, in certain cases, hormonal therapies that may be safely used in endometrial cancer survivors, along with non-medical interventions such as yoga, hypnosis and acupuncture.

Sexual Dysfunction and/or Pelvic Pain

Sexual dysfunction and/or pelvic pain are common, complex and multifactorial in women who have completed treatment for endometrial cancer. This is an appropriate topic to discuss with gynecologic oncology providers before, during and after treatment, and should be a routine part of surveillance. Approaches to treatment include management of menopause or radiation related vaginal dryness with non-hormonal or hormonal lubricants or therapies, referral to pelvic floor physical therapy, vaginal dilator use and referral to a women’s health psychologist who specializes in post-cancer pelvic pain, sexual dysfunction and sexual relationship strain (among other relevant stressors). These are services our Hartford HealthCare gynecologic oncology team can help coordinate:

Lymphedema

Lymphedema, which is swelling in an extremity due to poor lymphatic drainage, used to be more common in endometrial cancer survivors. Surgical practice has changed to allow for a more limited lymph node sampling (called “sentinel lymph node dissection”), which has significantly decreased the rate of lower extremity lymphedema. Radiation therapy is another risk factor. It can present as swelling in one or both lower extremities, though can also cause feelings of heaviness, discomfort, or pain in the lower extremities. Early identification is important to allow for early referral to physical therapy for lymphatic massage, custom compression stockings and exercises.

Chemotherapy-Related Toxicities

Although chemotherapy agents for high risk endometrial cancer tend to be relatively well tolerated, there can be some lingering toxicities after treatment has ended. Most commonly, these are neuropathy (numbness or pain in the hands/feet) and fatigue. Neuropathy will improve in one-half of patients over 4-6 months, though severe neuropathy can persist. Unfortunately, there is a lack of effective preventive therapies. Some data suggest a regular exercise routine during treatment may reduce the risk, especially in older patients. There are various options for management of neuropathy related pain. Duloxetine is recommended as first line treatment of chemotherapy induced neuropathy. Other less well proven but low-risk interventions include exercise and acupuncture. Fatigue can persist after therapy is complete, and is multifactorial, often caused by the chemotherapy itself as well as other side effects such as premature menopause, anemia, pain, emotional distress, poor nutrition, and sleep disruption. Assessment and management of potential treatable causes (such as sleep hygiene and stress reduction for sleep disorders, antidepressants for mood disorders and treatment of anemia) is important. Cognitive behavioral interventions (support groups, counseling, relaxation training, or formal cognitive behavioral therapy) may help, as well as yoga, and moderate aerobic exercise. Rarely are medications indicated or prescribed.

Radiation-Related Toxicities

Known long-term radiation side effects can include bowel dysfunction (such as chronic diarrhea), bladder dysfunction (urinary incontinence or retention), sexual dysfunction (vaginal dryness/scarring). Fortunately, advancements in delivery of radiation therapy are more commonly used, which spare the gastrointestinal tract, reducing the risk of GI toxicity with equivalent treatment effect, making GI effects less common. Management of radiation related effects target the specific symptoms, including dietary modifications and the use of antidiarrheal agents, scheduled voiding or recognition of dietary or pharmacologic bladder triggers, and use of vaginal dilators and moisturizers/lubricants. At Hartford HealthCare Cancer Institute, we offer a designated survivorship visit to all of our patients who have completed treatment for Stage I-III cancer within one year. This is completed with the survivorship APRN in our New Britain office and is intended to help patients move forward in their cancer journey, with review of their individual survivorship care plan. This care plan includes a summary of the patient’s cancer care and covers the physical, psychosocial, practical and economic issues of cancer beyond the diagnosis and treatment phases. Part of the plan will address the new normal, follow-up medical care, late side effect awareness and management, coping issues, practical life issues and sexuality.