Endometrial (Uterine) Cancer: Symptoms, Diagnosis and Treatment

What is endometrial cancer?

Endometrial cancer develops from the inner lining of the uterus and is the most common gynaecological cancer in developed countries. Because most patients notice an early symptom such as bleeding after menopause, it can often be diagnosed at an early stage. In recent years the molecular features of the tumour (POLE, MMR/MSI, p53) have become increasingly important in treatment planning [1][2].

Risk factors

Obesity, diabetes, unopposed oestrogen exposure, polycystic ovary syndrome, never having given birth, late menopause, tamoxifen use and Lynch syndrome are the main risk factors [2][3].

What are the symptoms?

The most important symptom is any vaginal bleeding after menopause. Before menopause, irregular or heavy bleeding, pelvic pain and discharge should also be assessed. Every woman with bleeding after menopause is advised to have a gynaecological assessment [1][3].

Most of these complaints can also be caused by other conditions; complaints that persist or get worse need to be assessed by a doctor.

How is it diagnosed?

Diagnosis is made by transvaginal ultrasound and endometrial biopsy (or curettage/hysteroscopy). Pelvic MRI and chest-abdomen CT are used to assess spread. In pathology, besides histological type and grade, POLE mutation, MMR proteins (MSI), p53 and hormone receptors are assessed; HER2 is important in the serous type [1][4].

Staging

Staging follows the FIGO system; the 2023 FIGO update incorporated molecular classification into staging. Surgical findings (myometrial invasion, lymph node status, lymphovascular invasion) determine the stage and risk group [1][4].

Treatment options

• Surgery: The main treatment is total hysterectomy, bilateral salpingo-oophorectomy and, in suitable patients, sentinel lymph node assessment.
• Treatment after surgery: Depending on the risk group, observation, vaginal brachytherapy, pelvic radiotherapy and/or chemotherapy may be used.
• Advanced or recurrent disease: Guidelines recommend adding immunotherapies such as dostarlimab, pembrolizumab or durvalumab to carboplatin + paclitaxel chemotherapy, especially in mismatch repair-deficient (dMMR/MSI-H) tumours. Lenvatinib + pembrolizumab is a later-line option. Hormone therapy may be used in low-grade, hormone receptor-positive tumours; trastuzumab may be added in HER2-positive serous carcinoma [4][5].
• Fertility-sparing approach: In young, selected patients with very early, low-grade tumours, progestin therapy with close monitoring may be considered in specialised centres.

Treatment is planned individually, taking into account the stage, tumour characteristics, general condition and the patient’s preferences. Not every option listed here is suitable for every patient.

Recent developments

The inclusion of molecular classification in staging and treatment decisions, and the addition of immunotherapy to first-line treatment, are the most important developments of recent years. MMR testing is recommended for all patients with regard to Lynch syndrome [4][5].

Support and follow-up during treatment

During treatment, not only the anti-cancer drugs but also the patient’s general condition is monitored. Nausea, fatigue, loss of appetite, pain, infection risk and changes in mood are asked about at every visit; when needed, preventive medication, nutritional support, physiotherapy and psychosocial support are planned. In situations such as fever, shortness of breath, uncontrollable diarrhoea or vomiting, or new severe pain, it is advisable to contact the treatment team without waiting for the scheduled visit. Herbal products and supplements can interact with some cancer drugs, so the treatment team should be consulted before using them.

Examinations are carried out every 3–6 months in the first 2–3 years and every 6–12 months thereafter; imaging is planned according to symptoms or risk.