Chemotherapy uses drugs to destroy cancer cells anywhere in the body. Chemotherapy may be recommended for treating advanced or recurrent endometrial cancer that has spread beyond the uterus. It is also used when cancer has metastasized (spread) into other organs or tissue.

You may receive chemotherapy drugs by pill (orally) or through your veins (intravenously). These drugs enter your bloodstream and then travel through your body, killing cancer cells. Chemotherapy is sometimes recommended by itself or with radiotherapy after surgery if there's an increased risk that the cancer might return. It can also be used before surgery to shrink the cancer so that it's more likely to be removed completely during surgery.

Hormone therapy involves taking medications to lower the hormone levels in the body. In response, cancer cells that rely on hormones to help them grow might die. Hormone therapy [progesterone therapy] may be an option if you have advanced endometrial cancer that has spread beyond the uterus. It is usually given in a palliative setting or for very early cancers managed conservatively. It is in the form of coil inserted in the womb or tablets.

Targeted drug treatments focus on specific weaknesses present within cancer cells. By blocking these weaknesses, targeted drug treatments can cause cancer cells to die. Targeted drug therapy is usually combined with chemotherapy for treating advanced endometrial cancer.

Immunotherapy is a drug treatment that helps your immune system to fight cancer. Your body's disease-fighting immune system might not attack cancer because the cancer cells produce proteins that blind the immune system cells. Immunotherapy works by interfering with that process. For endometrial cancer, immunotherapy might be considered if the cancer is advanced and other treatments haven't helped. These are under trials.

Most women will have surgery for womb cancer. Find out about surgery, including what to expect before and after your operation.

Minimally invasive (Laparoscopic/ Robotic) Hysterectomy for Endometrial Cancer

Women with cancer of the lining of the womb (uterus) need an operation to remove their womb, fallopian tubes and ovaries. This operation may be carried out using key-hole surgery.

There are two minimally invasive approaches: laparoscopic and robotic-assisted surgery, possibly with da Vinci technology. Surgeons perform minimally invasive laparoscopic or robotic-assisted surgeries through a few small incisions. In laparoscopic surgery, surgeons use special long-handled tools while viewing magnified images from the laparoscope (camera) on a video screen.

Surgeons can perform Robotic hysterectomies for cancer using da Vinci technology. With da Vinci, your surgeon sits at a console next to you and operates using tiny, fully wristed instruments.

A camera provides a high-definition, 3D magnified view inside your body. Every hand movement your surgeon makes is translated by the da Vinci system in real-time to bend and rotate the instruments with precision.

Compared to patients who had an open procedure, patients who had a hysterectomy with da Vinci experienced fewer complications and stayed in the hospital for less time. Compared to patients who had a laparoscopic procedure, patients who had a hysterectomy with da Vinci had fewer, or similar, complications and stayed in the hospital for the same, or less, time.

The womb (uterus) along with the cervix (neck of the womb), fallopian tubes and ovaries are removed (bilateral salpingo-oophorectomy). Sometimes it is necessary to remove some lymph nodes in the pelvis. Your surgeon will discuss this with you before your operation.

The operation aims to remove all of cancer. If there is any evidence that cancer has spread, or if the results of the operation suggest that you may be at increased risk of recurrence of cancer (your cancer returning), you may be offered further treatment such as radiotherapy and/ or chemotherapy. This will be discussed with you when all of your results are available. If there is an advanced disease (cancer spread to other organs) at the time of having a look with the telescope your surgeon may abandon the procedure and you have chemotherapy upfront and have surgery at a later date or the surgeon might perform an operation removes all cancer(debulking) either by minimally invasive procedure or by giving a cut (laparotomy). Having an MIS instead of through a large cut on your abdomen (tummy) should result in a shorter hospital stay, less scarring on your tummy and a quicker recovery.

The advantages of using a robot or laparoscope include Shorter hospital stay, less pain, less risk of wound infection, less blood loss reducing the need for a blood transfusion, less scarring, faster recovery, quicker return to normal activities such as driving.

When treating gynecological cancers, the aim of modern radiotherapy techniques is to ensure that the tumor bed and the pelvic lymph node bearing region receive the correct dose. An additional and equally important aim is to ensure that the normal organs in the vicinity i.e., the urinary bladder, rectum, small and large bowel, and bone marrow, receive the least possible dose. This is done to ensure that the toxicity of radiation is kept at the minimum possible.

Irradiation of these of the above-mentioned structures leads to short term and long term consequences such as inflammation of the bladder, diarrhea, narrowing of the gut, bleeding in the urine and stool and risk of insufficiency fractures.

The side effects can be minimized by reducing the doors to all these structures.

At Apollo Proton Cancer Centre, the options for delivering safe and accurate radiotherapy are the Radixact helical tomotherapy Unit and Proteus Plus proton therapy unit.

The Radixact helical tomotherapy machine is a sophisticated linear accelerator that has inbuilt features that ensure that patient undergoes imaging I,e a CT scan before delivery of treatment every day. The radiation is delivered in successive narrow segments as the patient moves through the machine which allows the treating team to spare normal organs very effectively.

Proton therapy has a unique characteristic in that proton, which are positively charged particles, deposit their entire energy at a predefined target and tissues distal to the target receive no radiation. This allows better sparing of the normal organs. In endometrial cancer patients, this results in smaller doses to the small bowel, large bowel, bone marrow and urinary bladder. The expected outcome of this is a reduction in the risk of diarrhoea, narrowing of the bowel and inflammation of the bladder. Also, since the pelvic bone marrow is being spared, there is better tolerance of treatment delivered along with or after chemotherapy. This is especially relevant in the elderly. In young patients, there is an additional benefit of reduction in the risk of radiation-induced second cancers because of a decrease in low dose radiation being received by normal structures.

All patients receive treatment with diligent attention to ensuring the least possible dose to normal organs by following daily bladder filling protocols; a filled urinary bladder displaces bowel for the region being treated, thus protecting it.

At present, Vaginal brachytherapy services are not available at Apollo Proton Cancer Centre.

What happens at a follow up appointment after womb cancer treatment – the team will explain to you depending on what stage and treatment you had.

There are different modes of treatments aimed to control symptoms when womb cancer is advanced

Surgery to remove your womb

Your surgeon removes your womb and cervix. This is called a total hysterectomy. They usually remove both fallopian tubes and ovaries at the same time. This is called a bilateral salpingo oophorectomy (BSO).

This operation is called a radical hysterectomy. Some women with stage 3 womb cancer also have this type of hysterectomy, depending on how far the cancer has spread.

Your surgeon may also remove the sheet of fatty tissue in your abdomen (the omentum). This is called an Omentectomy. They are more likely to do this for serous carcinomas.

In younger women, removing both ovaries will bring about the menopause. Menopausal symptoms include hot flushes and night sweats. In the longer term it can cause bone thinning (osteoporosis). So in some cases, your surgeon may consider leaving one or both of your ovaries in place.

Checking for cancer outside the womb

During the operation, your surgeon usually takes samples of areas where the cancer could have spread. This information helps them to make decisions about treatment after surgery.

Your surgeon may take biopsies from the lining of your abdomen and pelvis. They may also put fluid into your abdomen and then remove it. They send the fluid to the lab to check for cancer cells. This is called peritoneal washing.

Your surgeon may also remove some or all the lymph nodes around your womb and at the back of the abdomen to check for cancer cells.

Keyhole surgery

The surgeon may use a special machine (robot) to help with laparoscopic surgery. This is called assisted robotic surgery or da Vinci surgery.

During the surgery, a robotic machine is beside you. It has 4 arms. One arm holds a camera and the others hold the surgical instruments. The surgeon carries out the operation by using a machine that controls the robotic arms. The surgeon has a 3D magnified view of the operating area.

Treatment after surgery

Most women only need surgery to treat their endometrial cancer. You might need other treatment if you have high grade or advanced cancer.

Treatment after surgery helps to reduce the chance of the cancer coming back. You might have chemotherapy or radiotherapy or a combination of both.

Surgery for advanced womb cancer

If your cancer has already spread to another part of your body at diagnosis, you don’t normally have surgery. But in some cases of advanced cancer your specialist may suggest removing as much of the cancer as possible, if they think this will slow down its growth and help with symptoms. This is called debulking surgery.

Having surgery will depend on:

• your general health
• how fast the cancer is likely to grow
• how far the cancer has spread

After surgery, you may have chemotherapy, radiotherapy or hormone therapy, or a combination of treatments.