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.