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.
Optimal treatment of patients with stage II uterine cancer often requires more than one therapeutic approach and includes both surgery and radiation. 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.
Surgery
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
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.
Adjuvant Systemic Therapy
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. Because patients with advanced uterine cancer do respond to treatment with hormonal agents and various combinations of chemotherapy clinical trials evaluating drug combinations for adjuvant therapy alone or in combination with radiation are ongoing.