Endometrial Cancer Recurrent

Recurrent endometrial cancer occurs when cancer returns after successful treatment, often within the first three years. While this diagnosis can be challenging, understanding what to expect and the available treatment options can help you work with your healthcare team to manage your condition.

Table of contents

• What Is Recurrent Endometrial Cancer?
• How Common Is Recurrence?
• Risk Factors for Recurrence
• Symptoms to Watch For
• Treatment Options
• Follow-Up Care and Monitoring

What Is Recurrent Endometrial Cancer?

Endometrial cancer is a type of cancer that starts in the lining of the uterus, called the endometrium (the inner tissue layer of the uterus). It is the most common form of gynecologic cancer in the United States.^[1] Recurrent endometrial cancer means the cancer has come back after you have been in remission (a period when there are no signs of cancer in your body).^[2]

Endometrial cancer can recur in two main ways. A local recurrence is when the cancer comes back in or near the place where it started. The most common locations are the pelvis or vagina. The cancer can recur at the vaginal cuff, which is the top of the vagina.^[1] A distant recurrence is when the cancer comes back in a different part of the body, like the lungs or bone.^[1]

Some distant recurrences affect only a few sites with no evidence of cancer anywhere else in the body. This is called isolated metastases (when cancer spreads to a limited number of locations). When distant recurrence occurs in many places throughout the body, it is called disseminated disease.^[5]

How Common Is Recurrence?

After treatment, 15% to 20% of people with early-stage (stage I or II) endometrial cancer will have a recurrence. Among those who experience recurrence, around 50% have a local recurrence, 25% have a distant recurrence, and 25% have both local and distant recurrences.^[1] Studies show your cancer is more likely to return within three years of your first treatment.^[2] Most recurrences happen within three years after treatment.^[1]

Hysterectomy (surgery to remove the uterus and cervix, which is the bottom of the uterus that connects to the vagina) is the main treatment for endometrial cancer. The cancer can come back even after you have your uterus removed. About 15% to 20% of people with endometrial cancer have a recurrence after a hysterectomy.^[1]

The likelihood of endometrial cancer returning depends on several factors related to the disease and to the person’s overall health. The stage at which endometrial cancer is diagnosed greatly affects the chances of recurrence. For stage 1, the recurrence rate is 4.8 percent. For stage 2, it is 17.6 percent. For stage 3, it ranges from 20 percent to 50 percent. For stage 4, the recurrence rate is 66.7 percent.^[2]

Risk Factors for Recurrence

Certain things increase the risk of an endometrial cancer recurrence. It is more likely to return if you have a late-stage cancer or if your cancer has spread to lymph nodes (small organs that are part of your immune system).^[1]

Tumor size affects recurrence risk. Tumors larger than 2 centimeters (about the size of a grape) have a higher chance of recurring.^[2] If you have a large tumor or waited six months or more after the biopsy to have a hysterectomy, the risk increases.^[1]

Myometrial invasion means cancer has spread into the middle layer of your uterus, called the myometrium (the muscular wall of the uterus). Cancer that invades deeper into the myometrium is more likely to come back, especially if the cancer cells are more aggressive. Researchers have found that the risk of recurrence becomes about twice as high when cancer spreads deeply into this area.^[2]

If you had a hysterectomy but the surgeon did not remove your fallopian tubes, cervix, and ovaries in a procedure called bilateral salpingo-oophorectomy (surgical removal of both fallopian tubes and ovaries), your risk may be higher.^[1]

Tumor grade describes how cancer cells look under a microscope. Low-grade tumors resemble normal cells and are less likely to spread. High-grade tumors look more abnormal, are more aggressive, and are more likely to come back after treatment.^[2] If the cancer has a gene mutation like TP53 that makes it more aggressive, recurrence risk increases.^[1]

Endometrial cancer can also be classified into two types. Type 1 endometrial cancers are linked to high levels of the hormone estrogen. These cancers tend to be less aggressive, and studies show that around 20 percent of cases recur. Type 2 cancers, including clear cell and serous carcinomas (specific aggressive types of endometrial cancer), do not rely on estrogen, tend to grow faster, and are more aggressive. Around half of type 2 endometrial cancer cases recur.^[2]

Not everyone with these risk factors will have a recurrence. Other things are involved in determining the risk. And even if you do not have any of these risks, your cancer might come back.^[1]

Symptoms to Watch For

Between visits to your oncologist, call your doctor if you have any of these symptoms of recurrent endometrial cancer:^[1]

• Bleeding from your vagina
• Changes in your bladder or bowel habits
• Belly or back pain
• Tiredness
• Bloating
• Shortness of breath
• Nausea or vomiting

Treatment Options

The treatment for recurrent endometrial cancer depends on where the cancer is, how much cancer there is, the cancer subtype, and what treatment you had before.^[1] Your oncologist will work with you to create a new treatment plan. Your treatment options depend on many factors, including where your cancer is located and your previous treatment history.^[2]

The treatment of recurrent endometrial cancer can be curative or palliative depending on the site of recurrence and previous therapy. Due to the complexity of the cases, it is recommended to discuss individual cases in a multidisciplinary tumor board.^[3]

Surgery

You may be offered surgery for recurrent endometrial cancer, depending on how much cancer there is and where it has spread. In cases of locally recurrent cancer, a pelvic exenteration (extensive surgery to remove multiple pelvic organs) may be used to remove organs and tissues not removed during previous surgeries for endometrial cancer. This can include fallopian tubes, ovaries, lymph nodes in the pelvis and around the aorta, parts of the peritoneum, the bladder, the rectum, the vagina, and the vulva.^[5]

A pelvic exenteration surgery is usually only done if the cancer has not responded to treatment with other therapies. It is a type of salvage therapy (treatment given after other treatments have failed). When cancer is more widespread throughout the pelvis, tumor debulking (surgery to remove as much of the tumor as possible) may be done instead. This surgery helps relieve pain and symptoms caused by the tumor.^[5]

In cases of distant recurrence, surgery may be used to try to remove the cancer when it has only spread to a few sites and there is no evidence of cancer anywhere else in the body. Surgery for recurrent endometrial cancer is followed by another type of treatment, such as radiation therapy or chemotherapy. This is called adjuvant therapy (treatment given after the main treatment to lower the risk that cancer will come back).^[5]

Radiation Therapy

Radiation therapy uses high-energy rays or particles to destroy cancer cells. Radiation therapy is often given for recurrent endometrial cancer. The type of radiation therapy you have depends on where the cancer came back and the type of radiation therapy you previously had for endometrial cancer.^[5]

For a local recurrence, if you did not have radiation therapy or only previously had brachytherapy (internal radiation therapy) for endometrial cancer, you may be offered external radiation therapy as an adjuvant therapy after surgery for locally recurrent endometrial cancer. When you cannot have surgery, you will likely have radiation as the primary treatment. External radiation therapy can be given alone or together with brachytherapy, or hormone therapy, or both.^[5]

If you previously had external radiation therapy for endometrial cancer, palliative external radiation therapy may be offered. It is given with surgery or systemic therapy. When cancer comes back only in the vagina or tissues around the vagina, you may be offered brachytherapy to relieve pain and other symptoms.^[5]

Other Treatment Options

If you have recurrent endometrial cancer, your doctor will talk to you about your treatment options, including radiation, chemotherapy (drugs that kill cancer cells), immunotherapy (treatment that uses your immune system to fight cancer), or sometimes surgery.^[1]

The available treatment options increase with the development of novel radiotherapy techniques and new systemic therapies. Newly emerging medical treatments, such as immunotherapy, might be of benefit in selected patients. Moreover, combinations of different treatments can lead to a better outcome. Recent insights on oligometastatic disease (cancer that has spread to a limited number of sites) lead us to expect that ablative or radical local treatment for distant metastasis will be of benefit in selected patients.^[3]

Follow-Up Care and Monitoring

Your oncologist will check you every three to six months for the first three years after treatment. These visits are to make sure that if your cancer does return, it is caught early.^[1] Once you finish endometrial cancer treatment, your oncologist will recommend follow-ups and regular testing to look for any remaining cancer.^[2]

After completing treatment for endometrial cancer, it is crucial to stay vigilant for any signs of recurrence. Regular check-ups may involve physical exams and imaging tests to detect any signs of cancer recurrence or treatment side effects. It is important to attend all follow-up appointments and communicate any changes or concerns with your cancer care team. Depending on your cancer stage and type, the frequency of exams and imaging tests will vary to ensure comprehensive monitoring of your health status.^[16]