Recurrent uterine cancer is cancer that has returned after primary treatment. The following is a general overview of the treatment of recurrent 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.
For most women, recurrent uterine cancer is incurable with currently available standard therapies. If the recurrence follows primary treatment with surgery alone and is detected early, cure is still attainable with additional surgery and/or radiation therapy. Unfortunately, the removal of all cancer cannot typically be achieved for the majority of patients with recurrent disease. For these patients, treatment of recurrent uterine cancer is dictated by the site of metastatic cancer and symptoms related to the spread of cancer. The goal of treatment for women with recurrent uterine cancer is to reduce symptoms and prolong survival.
Women with Early Stage Cancer who Treatment with Fail Surgery Alone
Women who initially had stage I or IIB cancer and experienced a recurrence after treatment with surgery alone are frequently cured with further surgery and the addition of radiation therapy. Radiation therapy is usually given as brachytherapy (placement of a radioactive isotope near the cancer) and external beam radiation therapy. This therapy is often successful since stage I and IIB patients treated initially with surgery alone have frequent follow-up examinations, which allow for detection of a recurrence early, when it is curable. For patients with bulky pelvic disease, radiation therapy consisting of a combination of brachytherapy and external-beam radiation therapy is frequently used. Radiation therapy can decrease symptoms and improve survival for patients with inoperable uterine cancer.
Women who Fail Surgery and Radiation Therapy
Further radiation therapy in women who experience a recurrence following initial radiation is usually not possible. However, some women will fail treatment that only included brachytherapy and these women could be treated with external beam radiation therapy if they develop a recurrence in the pelvis away from the site of isotope placement. For more information, go to Radiation Therapy and Cancer of the Uterus.
Primary Hormone Therapy
Hormonal treatment of cancers that have estrogen or progesterone receptors can delay cancer progression and prolong survival, especially in patients with small amounts of cancer not involving the lung or liver. Estrogen and progesterone are female hormones produced mainly by the ovaries and are found circulating in the blood. Many organs in the body are composed of cells that respond to or are regulated by exposure to these hormones. Cells in the breast, uterus and other female organs have estrogen and progesterone receptors and when exposed to these hormones, are stimulated to grow. When cells that have these receptors become cancerous, the growth of these cancer cells can be increased by exposure to the female hormones.
The basis of hormonal therapy as a treatment for uterine cancer is to block or prevent the cancer cells from being exposed to estrogen and progesterone hormones. Removal of the ovaries, the organ chiefly responsible for producing these hormones, is one effective approach to eliminating hormone production and is commonly used in many countries. Another approach is to utilize drugs that can accomplish a similar effect without removing the ovaries.
Progestational agents have long been used in the treatment of advanced or recurrent uterine cancer because of the presence of receptors for these agents on the cancer cells. Well-differentiated cancers respond better to progestational agents than undifferentiated cancers. Progestational agents that have been used include hydroxyprogesterone, medroxyprogesterone and megestrol. These agents produce a partial or complete disappearance of cancer in 20-29% of women with advanced or recurrent uterine cancer. The combination of a progestional agent (megestrol) and tamoxifen (an anti-estrogen) may be better treatment than megestrol alone. In one study performed by the Gynecology Oncology Group, 61 patients with advanced or recurrent uterine cancer were treated with megestrol and tamoxifen. The complete response rate was 21% and 5.4% had a partial response. The average survival was 14 months. Toxicity was moderate and there were no treatment related deaths. Of those who responded, 50% sustained this response for an average of 20 months. It was noted that, overall, younger women had better responses to the treatment than older women. From these findings, the researchers concluded that megestrol and tamoxifen appears to be an active combination against advanced and recurrent endometrial cancers.
Chemotherapy is the use of chemicals (drugs or medications) to kill cancer cells. Numerous chemicals have been developed for this purpose and most act to injure the DNA of cells. When the DNA is injured, the cells cannot grow or survive. Successful chemotherapy depends on the cancer cells being at least somewhat more sensitive to the chemicals than the normal cells. Because the cells of the bone marrow, the intestinal tract, the skin, and hair follicles are also very sensitive to these chemicals, injury to these organs are common side effects of chemotherapy (i.e., mouth sores, diarrhea, rashes, and hair loss).
Doxorubicin was the standard chemotherapy treatment for women with advanced or recurrent uterine cancer for over a decade. When doxorubicin is administered as a single agent, it reduces the amount of cancer in about 25% of women with advanced or recurrent uterine cancer. Doxorubicin is now being administered in combination with other chemotherapy agents. A comparison of doxorubicin administered alone to doxorubicin plus Platinol® in women with uterine cancer showed that the combination reduced the amount of cancer in 45% of women, compared to only 27% for doxorubicin alone. Thus, doxorubicin and Platinol® became the standard chemotherapy drug combination for treatment of women with advanced or recurrent uterine cancer.
Recently, the Gynecologic Oncology Group compared the standard doxorubicin and Platinol® treatment regimen to doxorubicin and paclitaxel. This study randomly allocated 314 women with advanced or recurrent uterine cancer to receive doxorubicin combined with either Platinol® or paclitaxel. Paclitaxel was given with Neupogen® to hasten recovery of blood counts. Side effects were similar between both treatments. The response rate following doxorubicin and Platinol® was 40% and 15% of these were complete responses. The response rate following doxorubicin and paclitaxel was 43% and 17% of these were complete responses. Longer follow-up is required to determine whether either treatment prolonged survival.
Chemotherapy and Hormonal Therapy
Chemotherapy and hormonal therapy prevent cancer cells from growing by different methods. Combining chemotherapy with hormonal therapy may reduce cancer cell growth more than either treatment administered alone. Researchers in Greece have evaluated a four-drug combination of Paraplatin®, methotrexate, fluorouracil and medroxyprogesterone. These physicians treated 23 patients with advanced or recurrent uterine cancer. None of the patients had received prior chemotherapy or hormonal therapy and 10 had received prior radiation therapy. Responses were observed in 74% of women, with two long-lasting complete remissions. The average duration of response was over 10 months and the average survival was over 16 months. This regimen was administered on an outpatient basis and was well tolerated. These doctors concluded that this was an active treatment regimen for women with advanced or recurrent uterine cancer.
Strategies to Improve Treatment
The progress that has been made in the treatment of recurrent uterine cancer has resulted from improved hormonal treatments, chemotherapy treatments and doctor and patient participation in clinical studies. Future progress in the treatment of recurrent uterine cancer will result from continued participation in appropriate studies. Currently, there are several areas of active exploration aimed at improving the treatment of recurrent 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.
New Hormonal Agents: Researchers are continuing to design new agents that take advantage of the hormone sensitivity of some uterine cancers. SERM LY353381 binds to the estrogen receptor and has been shown to prevent growth of uterine cancer. A novel agent, SERM LY353381, was evaluated in 35 women with progesterone sensitive uterine cancer. Most patients in this study had failed surgery and radiation therapy. Twenty-two percent of patients experienced a partial disappearance of cancer following treatment. The major side effects were hot flashes, swelling and sweating. The importance of this study is that a new hormonal agent with a different mechanism of action is now available for further evaluation in patients with advanced or recurrent uterine cancer.
New Chemotherapy Regimens: Development of new multi-drug chemotherapy treatment regimens that incorporate new or additional anti-cancer therapies for use as treatment is an active area of clinical research carried out in phase II clinical trials. These studies are performed in patients with stage IV or recurrent uterine cancer. One drug combination currently under investigation is Platinol® and Hycamtin®.
Phase I Trials: New chemotherapy drugs continue to be developed and evaluated in phase I clinical trials. The purpose of phase I trials is to evaluate new drugs in order to determine the best way of administering the drug and to determine whether the drug has any anti-cancer activity in patients with uterine cancer.
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. Gene therapy studies will be carried out in patients with recurrent uterine cancer.
Miller DS, Fleming G, Randall ME. Chemo- and radiotherapy in adjuvant management of optimally debulked endometrial cancer. Journal of the National Comprehensive Cancer Network. 2009;7:535-541.
Randall ME, Filiaci VL, Muss H et al. Randomized phase III trial of whole-abdominal irradiation versus doxorubicin and cisplatin chemotherapy in advanced endometrial carcinoma: A Gynecologic Oncology Group study. Journal of Clinical Oncology. 2006;24:36-44.
Maggi R, Lissoni A, Spina F et al. Adjuvant chemotherapy vs radiotherapy in high-risk endometrial carcinoma: results of a randomized trial. British Journal of Cancer. 2006;95:266-271.
Hogberg T, Rosenberg P, Kristensen G et al. A randomized phase-III study on adjuvant treatment with radiation (RT) ± chemotherapy (CT) in early-stage high-risk endometrial cancer (NSGO-EC-9501/EORTC 55991). Presented at the 2007 annual meeting of the American Society of Clinical Oncology. Abstract 5503.