Stage II Uterine Cancer
Stage II uterine cancer involves the main body of the uterus and the cervix. Stage IIA cancer involves the uterus and only the surface lining of the cervix. Stage IIB cancer involves the uterus and extends into deep layers of the cervix.
A variety of factors ultimately influence a patient’s decision to receive treatment of cancer. The purpose of receiving cancer treatment may be to improve symptoms through local control of the cancer, increase a patient’s chance of cure, or prolong a patient’s survival. The potential benefits of receiving cancer treatment must be carefully balanced with the potential risks of receiving cancer treatment.
The following is a general overview of the treatment of stage II uterine cancer. Circumstances unique to your situation and prognostic factors of your cancer may ultimately influence how these general treatment principles are applied. The information on this Web site is intended to help educate you about your treatment options and to facilitate a mutual or shared decision-making process with your treating cancer physician.
Most new treatments are developed in clinical trials. Clinical trials are studies that evaluate the effectiveness of new drugs or treatment strategies. The development of more effective cancer treatments requires that new and innovative therapies be evaluated with cancer patients. Participation in a clinical trial may offer access to better treatments and advance the existing knowledge about treatment of this cancer. Clinical trials are available for most stages of cancer. Patients who are interested in participating in a clinical trial should discuss the risks and benefits of clinical trials with their physician. To ensure that you are receiving the optimal treatment of your cancer, it is important to stay informed and follow the cancer news in order to learn about new treatments and the results of clinical trials.
Optimal treatment of patients with stage II uterine cancer often requires more than one therapeutic approach. Thus, it is important for patients to be treated at a medical center that can offer multi-modality treatment involving gynecologic oncologists and radiation oncologists.
Most women with stage II uterine cancer are treated with surgery and radiation therapy. Surgery consists of hysterectomy (removal of the uterus and cervix) and bilateral salpingo-oophorectomy (removal of both ovaries) and removal of the pelvic lymph nodes with biopsy or removal of the para-aortic lymph nodes. Surgery alone can be used to treat some patients with stage IIA disease; however, most patients with stage IIA, and all patients with stage IIB cancer, will be offered adjuvant radiation therapy.
Following standard treatment for stage II uterine cancer with a hysterectomy, 20-40% of patients will experience recurrence of their cancer. This is because some patients with stage II cancer have microscopic cancer cells (micrometastases) that have spread outside the uterus and therefore were not removed by surgery. These cancer cells cannot be detected with any of the currently available tests. The presence of these micrometastases causes recurrence following treatment with surgery alone. Following surgery, patients may benefit from additional treatment (adjuvant therapy) to decrease the risk of cancer recurrence. There is a progressive increase in local and distant cancer recurrences in patients with stage IIA and IIB disease and in patients with well, moderately and poorly differentiated cancers following treatment with surgery alone. To learn more about surgery, go to Surgery & Uterine Cancer.
Adjuvant therapy is the delivery of cancer treatment following local treatment with surgery and may include chemotherapy, radiation therapy, hormonal therapy and/or biologic therapy. The objective of adjuvant radiation therapy is to kill cancer cells that were not removed by surgery for a maximum probability of a cure with a minimum of side effects. Radiation therapy, unlike chemotherapy, is considered a local treatment. Cancer cells can only be killed where the actual radiation is delivered to the body. If cancer exists outside the radiation field, the cancer cells are not destroyed by the radiation. Radiation therapy can either be delivered externally via a linear accelerator (external beam radiation therapy) or can be delivered internally by implanting radioactive isotopes directly into the cancer (brachytherapy). Treatment of stage II uterine cancer with surgery followed by adjuvant brachytherapy and external beam radiation therapy has been reported to cure 60-80% of patients. Post-operative radiation therapy consists of external beam radiation to the pelvis, brachytherapy or both external beam radiation therapy and brachytherapy.
Despite adjuvant radiation therapy, 20-40% of patients will experience a cancer recurrence. Recurrences occur outside the pelvis in 25% of women, primarily those with cancer deep in the uterus and those with less differentiated cancers. Further treatment with systemic hormonal and/or chemotherapy, in addition to radiation therapy, may be required to prevent recurrences in the 25% who fail treatment outside the pelvis.
Neoadjuvant Radiation Therapy
Neoadjuvant therapy is treatment given before surgery. Neoadjuvant radiation therapy is an accepted treatment for women with stage IIB uterine cancer although there is very little published information on outcomes of this treatment approach. The goal of neoadjuvant therapy is to reduce the extent of cancer before surgery with the hope that this approach will allow the surgeon to remove all of the cancer. Many combinations of intra-cavitary (radioactive isotopes placed in the upper vagina) and external-beam radiation therapy have been used to treat stage II uterine cancer before surgery.
Strategies to Improve Treatment
The progress that has been made in the treatment of stage II uterine cancer has resulted from the development of multi-modality treatments and doctor and patient participation in clinical trials. Future progress in the treatment of stage II uterine cancer will result from continued participation in appropriate clinical trials. Currently, there are several areas of active exploration aimed at improving the treatment of uterine cancer.
Supportive Care: Supportive care refers to treatments designed to prevent and control the side effects of cancer and its treatment. Side effects not only cause patients discomfort, but also may prevent the optimal delivery of therapy at its planned dose and schedule. In order to achieve optimal outcomes from treatment and improve quality of life, it is imperative that side effects resulting from cancer and its treatment are appropriately managed. For more information, go to Supportive Care.
Adjuvant Chemotherapy: Because patients treated with surgery and radiation develop cancer recurrence outside the pelvis, adjuvant therapy that can reach and destroy these cancer cells may improve treatment. There have been no meaningful comparative studies of adjuvant chemotherapy for the prevention of recurrences in patients with stage II uterine cancer. Patients with advanced uterine cancer do respond to hormonal agents and to various combinations of chemotherapy including drugs such as doxorubicin, Platinol® and paclitaxel. Clinical trials evaluating drug combinations of Platinol® and paclitaxel or doxorubicin and Platinol® for adjuvant therapy alone or in combination with radiation are ongoing.
Adjuvant Hormonal Therapy: Progestational agents have long been used in the treatment of advanced or recurrent uterine cancer because some cancer cells respond to treatment. Well-differentiated cancers respond better to progestational agents than undifferentiated cancers. Adjuvant progestational agents have also been evaluated after surgery without documentation of an improvement in survival.
The combination of a progestational agent (megestrol) and Nolvadex® (an antiestrogen) has been found to be better than megestrol alone in the treatment of uterine cancer. In one study performed by the Gynecology Oncology Group, 61 patients with advanced or recurrent endometrial cancer were treated with megestrol and tamoxifen. The complete response rate was 21% and 5.4% had a partial response. Overall survival was 14 months. Toxicity was moderate and there were no treatment related deaths. Clinical trials are ongoing to evaluate the efficacy of megestrol and tamoxifen administered alone or in combination with chemotherapy, surgery and/or radiation therapy.
Improved Staging: Undetected spread of cancer can lead to under-treatment of uterine cancer. One method for detecting the spread of cancer is examination of cells floating free in the peritoneum (pelvis). This is done by injecting a salt solution into the abdomen, allowing it to mix thoroughly and then removing it for examination under the microscope. However, it is sometimes difficult to distinguish normal cells from cancer cells when using this method.
Monoclonal antibodies are proteins that can locate cancer cells and bind to them, thereby enabling the pathologist to better distinguish cancer cells from normal cells. The use of monoclonal antibodies to identify cancer cells in the peritoneum may improve the accuracy of staging and help identify patients requiring more aggressive treatment.
Gene Therapy: Currently, there are no gene therapies approved for the treatment of uterine cancer. Gene therapy is defined as the transfer of new genetic material into a cell for therapeutic benefit. This can be accomplished by replacing or inactivating a dysfunction gene or replacing or adding a functional gene into a cell to make it function normally. Gene therapy has been directed towards the control of rapid growth of cancer cells, control of cancer death or efforts to make the immune system kill cancer cells. A few gene therapy studies may be carried out in women with advanced or recurrent uterine cancer.