STEP 4: Treatment

Step 4 describes the optimal treatments for endometrial cancer, the training and experience required of the treating clinicians and the health service characteristics required for optimal cancer care.

All health services must have clinical governance systems that meet the following integral requirements:

  • identifying safety and quality measures
  • monitoring and reporting on performance and outcomes
  • identifying areas for improvement in safety and quality (ACSQHC 2020).

Step 4 outlines the treatment options for endometrial cancer. For detailed clinical information on treatment options refer to these resources:

The intent of treatment can be defined as one of the following:

  • curative
  • anti-cancer therapy to improve quality of life and/or longevity without expectation of cure
  • symptom palliation.

The treatment intent should be established in a multidisciplinary setting, documented in the patient’s medical record and conveyed to the patient and carer as appropriate.

The potential benefits need to be balanced against the morbidity and risks of treatment.

The lead clinician should discuss the advantages and disadvantages of each treatment and associated potential side effects with the patient and their carer or family before treatment consent is obtained and begins so the patient can make an informed decision. Supportive care services should also be considered during this decision-making process. Patients should be asked about their use of (current or intended) complementary therapies (see Appendix D).

Timeframes for starting treatment should be informed by evidence-based guidelines where they exist. The treatment team should recognise that shorter timeframes for appropriate consultations and treatment can promote a better experience for patients.

Initiate advance care planning discussions with patients before treatment begins (this could include appointing a substitute decision-maker and completing an advance care directive). Formally involving a palliative care team/service may benefit any patient, so it is important to know and respect each person’s preference (AHMAC 2011).

Immunohistochemistry (IHC) for Lynch syndrome should be performed on all cases of endometrial cancer. Non-endometroid cancers may benefit from other IHC testing and should be discussed at an MDM (if not already done). Any patient with abnormal IHC suggesting Lynch syndrome should be referred to a familial cancer service for discussions about germline testing.

For more information about genetic testing refer to eviQ’s Referral guidelines for endometrial cancer risk assessment and consideration of genetic testing.

Surgery is the primary treatment for endometrial cancer. The type of surgery offered will depend on several factors such as the extent and grade of disease, the patient’s age, medical comorbidities, performance status and desire to retain fertility.

For patients with early-stage endometrial cancer that is confined to the uterus, a hysterectomy and bilateral salpingo-oophorectomy (pelvic lymph node assessment including sentinel lymph node biopsy where appropriate) is the standard surgical approach, unless the patient opts for a fertility-sparing option (NCCN 2017).

Total abdominal hysterectomy (laparotomy) is used less frequently today in favour of laparoscopy or robotic surgery, a minimally invasive option providing equivalent results with fewer complications (Cancer Council Australia 2014; Colombo et al. 2016; ESMO 2013). Lymphadenectomy may be considered in select patients (Cancer Council Australia 2014).

For premenopausal patients, post-surgery assessment of the effects of surgical menopause must be ongoing.

Timeframe for starting treatment

Surgery should occur within four weeks of the MDM, provided the patient is medically fit.

Training and experience required of the surgeon

Gynaecological oncologist (FRANZCOG) with adequate training and experience in gynaecological cancer surgery and institutional cross-credentialing and agreed scope of practice within this area. In some cases, it may be appropriate for a specialist gynaecologist to perform the surgery, provided they are linked to a gynaecological cancer multidisciplinary team.

Documented evidence of the surgeon’s training and experience, including their specific (sub-specialty) experience with endometrial cancer and procedures to be undertaken, should be available.

Health service characteristics

To provide safe and quality care for patients having surgery, health services should have these features:

  • critical care support
  • 24-hour medical staff availability
  • appropriate nursing and theatre resources to manage complex surgery
  • 24-hour operating room access and intensive care unit
  • diagnostic imaging
  • pathology.

Following discussion at an MDM, adjuvant radiation therapy may be recommended.

The decision about the type of radiation therapy will be based on risk factors. For intermediate-risk patients, adjuvant vaginal vault brachytherapy may be recommended to improve local control. For high-risk patients, external pelvic beam radiotherapy with or without chemotherapy may be recommended to improve survival. There may be some situations where adjuvant vault brachytherapy to external beam radiation therapy may be considered.

In selected cases, where surgery is inappropriate, radiation therapy may be offered as part of primary treatment following discussion at an MDM.

Some patients may benefit from radiation therapy for symptomatic relief and palliation of metastatic or recurrent disease, following discussion at an MDM.

Timeframe for starting treatment

  • Radiation therapy as a primary treatment should begin within six weeks of the MDM.
  • Radiation therapy as an adjuvant treatment should begin within eight weeks following surgery.

Training and experience required of the appropriate specialists

Radiation oncologist (FRANZCR or equivalent) with adequate training and experience that enables institutional credentialing and agreed scope of practice within this area. The radiation oncologist must be part of a gynaecological oncology multidisciplinary team.

The training and experience of the radiation oncologist should be documented.

Health service unit characteristics

To provide safe and quality care for patients having radiation therapy, health services should have these features:

  • linear accelerator (LINAC) capable of image-guided radiation therapy (IGRT)
  • dedicated CT planning
  • brachytherapy service
  • access to MRI and PET imaging
  • automatic record-verify of all radiation treatments delivered
  • a treatment planning system
  • trained medical physicists, radiation therapists and nurses with radiation therapy experience and brachytherapy experience
  • coordination for combined therapy with systemic therapy, especially where facilities are not co-located
  • coordination for brachytherapy at an alternative centre if not available at a local centre
  • participation in Australian Clinical Dosimetry Service audits
  • an incident management system linked with a quality management system.

A number of patients may benefit from systemic therapy:

  • patients with adverse risk factors (systemic therapy may be offered in conjunction with adjuvant radiotherapy to improve local control and, in selected cases, survival)
  • as a primary treatment, where the patient is unsuitable for surgery
  • to manage recurrent/metastatic or residual disease following surgery (Cancer Council Australia 2014).

Timeframes for starting treatment

  • Systemic therapy as a primary treatment should begin within six weeks of
  • the MDM.
  • Systemic therapy as an adjuvant treatment should begin within eight weeks following surgery.

Training and experience required of the appropriate specialists

Medical oncologists must have training and experience of this standard:

  • Fellow of the Royal Australian College of Physicians (or equivalent)
  • adequate training and experience that enables institutional credentialing and agreed scope of practice within this area (ACSQHC 2015).

Cancer nurses should have accredited training in these areas:

  • anti-cancer treatment administration
  • specialised nursing care for patients undergoing cancer treatments, including side effects and symptom management
  • the handling and disposal of cytotoxic waste (ACSQHC 2020).

Systemic therapy should be prepared by a pharmacist whose background includes this experience:

  • adequate training in systemic therapy medication, including dosing calculations according to protocols, formulations and/or preparation.

In a setting where no medical oncologist is locally available (e.g. regional or remote areas), some components of less complex therapies may be delivered by a general practitioner or nurse with training and experience that enables credentialing and agreed scope of practice within this area. This should be in accordance with a detailed treatment plan or agreed protocol, and with communication as agreed with the medical oncologist or as clinically required.

The training and experience of the appropriate specialist should be documented.

Health service characteristics

To provide safe and quality care for patients having systemic therapy, health services should have these features:

  • a clearly defined path to emergency care and advice after hours
  • access to diagnostic pathology including basic haematology and biochemistry, and imaging
  • cytotoxic drugs prepared in a pharmacy with appropriate facilities
  • occupational health and safety guidelines regarding handling of cytotoxic drugs, including preparation, waste procedures and spill kits (eviQ 2019b)
  • guidelines and protocols to deliver treatment safely (including dealing with extravasation of drugs)
  • coordination for combined therapy with radiation therapy, especially where facilities are not co-located
  • appropriate molecular pathology access.

Hormonal therapy may be appropriate in the following scenarios:

  • fertility preservation in young patients under the guidance and ongoing management of a gynaecological oncology multidisciplinary team
  • intrauterine and/or high-dose oral progestins in well-differentiated early-stage disease for patients who are unfit for surgery
  • recurrent/metastatic disease – patients with progesterone-receptor-positive endometrial cancer recurrence may benefit from high-dose oral progesterone or other hormonal agents (NCI 2019).

The Therapeutic Goods Administration has recently provisionally approved targeted therapy for treating selected patients with advanced or recurrent endometrial cancer.

Endometrial cancer is a heterogenous disease and there is work being carried out to identify sub-groups that might impact future treatment selection.

Emerging therapies, based on genetic testing and biomarkers, show promise for treating endometrial cancer. These therapies include:

  • targeted therapies
  • immunotherapies
  • combined therapies (Charo & Plaxe 2019).

The key principle for precision medicine is prompt and clinically oriented communication and coordination with an accredited laboratory and pathologist. Tissue analysis is integral for access to emerging therapies and, as such, tissue specimens should be treated carefully to enable additional histopathological or molecular diagnostic tests in certain scenarios.

Early referral to palliative care can improve the quality of life for people with cancer and in some cases may be associated with survival benefits (Haines 2011; Temel at al. 2010; Zimmermann et al. 2014). This is particularly true for cancers with poor prognosis.

The lead clinician should ensure patients receive timely and appropriate referral to palliative care services. Referral should be based on need rather than prognosis. Emphasise the value of palliative care in improving symptom management and quality of life to patients and their carers.

The ‘Dying to Talk’ resource may help health professionals when initiating discussions with patients about future care needs (see ‘More information’). Ensure that carers and families receive information, support and guidance about their role in palliative care (Palliative Care Australia 2018).

Patients, with support from their family or carer and treating team, should be encouraged to consider appointing a substitute decision-maker and to complete an advance care directive.

Refer to Step 6 for a more detailed description of managing patients with recurrent, residual or metastatic disease.

More information

These online resources are useful:

The team should support the patient to participate in research or clinical trials where available and appropriate. Many emerging treatments are only available on clinical trials that may require referral to certain trial centres.

For more information visit the Cancer Australia website.

See validated screening tools mentioned in Principle 4 ‘Supportive care’.

A number of specific challenges and needs may arise for patients at this time:

  • assistance for dealing with emotional and psychological issues, including body image concerns, fatigue, quitting smoking, traumatic experiences, existential anxiety, treatment phobias, anxiety/depression, interpersonal problems and sexuality concerns
  • potential isolation from normal support networks, particularly for rural patients who are staying away from home for treatment
  • management of physical symptoms such as pain and fatigue
  • symptom management – postoperative oestrogen replacement therapy (ERT) may be recommended (after discussion of its risks and benefits), if quality of life is affected or for vaginal symptoms (Angioli et al. 2018)
  • loss of fertility, surgically or chemically induced menopause, and sexual dysfunction (e.g. vaginal dryness, bleeding, stenosis, dyspareunia, atrophic vaginitis and pain) requires sensitive discussion and possible referral to a clinician with skills in the relevant area (Harris 2019) (sexual dysfunction may persist for several years after surgery)
  • lower limb lymphoedema, which is a common side effect in women after complete pelvic lymphadenectomy and/or radiation therapy – referral to a physiotherapist trained in managing lymphoedema or a trained lymphoedema massage specialist may be appropriate
  • bowel dysfunction, gastrointestinal or abdominal symptoms – these may require monitoring and assessment (patients may benefit from discussing these symptoms with a specialist nurse such as a stomal therapist or continence nurse, or referred to a gastroenterologist
  • nausea and vomiting – managing both is important for improving quality of life
  • managing comorbidities, especially weight
  • presenting with unintentional weight loss
  • malnutrition/undernutrition as identified using a validated malnutrition screening tool
  • obesity – many patients with a high BMI may be malnourished
  • appropriate bariatric resources
  • decline in mobility or functional status as a result of treatment
  • assistance with beginning or resuming regular exercise with referral to an exercise physiologist or physiotherapist (COSA 2018; Hayes et al. 2019).

Early involvement of general practitioners may lead to improved cancer survivorship care following acute treatment. General practitioners can address many supportive care needs through good communication and clear guidance from the specialist team (Emery 2014).

Patients, carers and families may have these additional issues and needs:

  • financial issues related to loss of income (through reduced capacity to work or loss of work) and additional expenses as a result of illness or treatment
  • advance care planning, which may involve appointing a substitute decision-maker and completing an advance care directive
  • legal issues (completing a will, care of dependent children) or making an insurance, superannuation or social security claim on the basis of terminal illness or permanent disability.

Cancer Council’s 13 11 20 information and support line can assist with information and referral to local support services.

For more information on supportive care and needs that may arise for different population groups, see Appendices A and B, and special population groups.

Rehabilitation may be required at any point of the care pathway. If it is required before treatment, it is referred to as prehabilitation (see section 3.6.1).

All members of the multidisciplinary team have an important role in promoting rehabilitation. Team members may include occupational therapists, speech pathologists, dietitians, social workers, psychologists, physiotherapists, exercise physiologists and rehabilitation specialists.

To maximise the safety and therapeutic effect of exercise for people with cancer, all team members should recommend that people with cancer work towards achieving, and then maintaining, recommended levels of exercise and physical activity as per relevant guidelines. Exercise should be prescribed and delivered under the direction of an accredited exercise physiologist or physiotherapist with experience in cancer care (Vardy et al. 2019). The focus of intervention from these health professionals is tailoring evidence-based exercise recommendations to the individual patient’s needs and abilities, with a focus on the patient transitioning to ongoing self-managed exercise.

Other issues that may need to be dealt with include managing cancer-related fatigue, improving physical endurance, achieving independence in daily tasks, optimising nutritional intake, returning to work and ongoing adjustment to cancer and its sequels. Referrals to dietitians, psychosocial support, return-to-work programs and community support organisations can help in managing these issues.

The lead or nominated clinician should take responsibility for these tasks:

  • discussing treatment options with patients and carers, including the treatment intent and expected outcomes, and providing a written version of the plan and any referrals
  • providing patients and carers with information about the possible side effects of treatment, managing symptoms between active treatments, how to access care, self-management strategies and emergency contacts
  • encouraging patients to use question prompt lists and audio recordings, and to have a support person present to aid informed decision making
  • initiating a discussion about advance care planning and involving carers or family if the patient wishes.

The general practitioner plays an important role in coordinating care for patients, including helping to manage side effects and other comorbidities, and offering support when patients have questions or worries. For most patients, simultaneous care provided by their general practitioner is very important.

Patients with low-risk endometrial cancer may be appropriately referred back to a general practitioner as per Cancer Australia’s (2020c) guidelines.

The lead clinician, in discussion with the patient’s general practitioner, should consider these points:

  • the general practitioner’s role in symptom management, supportive care and referral to local services
  • using a chronic disease management plan and mental health care management plan
  • how to ensure regular and timely two-way communication about:
    • the treatment plan, including intent and potential side effects
    • supportive and palliative care requirements
    • the patient’s prognosis and their understanding of this
    • enrolment in research or clinical trials
    • changes in treatment or medications
    • the presence of an advance care directive or appointment of a substitute decision-maker
    • recommendations from the multidisciplinary team.
More information

Refer to Principle 6 ‘Communication’ for communication skills training programs and resources.