Can I still have children if I have endometrial cancer? Can it be cured?

Author: Zhang Jingfei, deputy chief physician, Beijing Century Altar Hospital, Capital Medical University

Zhao ZheAttending physician at Beijing Century Altar Hospital, Capital Medical University

Reviewer: Bai Wenpei, Chief Physician, Beijing Century Altar Hospital, Capital Medical University

Endometrial cancer ranks second in incidence among malignant tumors of the female reproductive system in my country, second only to cervical cancer. In recent years, the incidence of endometrial cancer has increased year by year, and in some areas, there is a trend of younger patients. Data show that in economically developed areas such as Beijing and Shanghai, the incidence of endometrial cancer has approached or even exceeded that of cervical cancer. This may be related to the aging of the population, the continued increase in the prevalence of metabolic syndrome, and changes in fertility patterns.

Many patients will have many questions, let’s talk about them today.

Can I retain my fertility if I have endometrial cancer?

In recent years, due to the increasing incidence of endometrial cancer in young women, some patients are diagnosed at around 40 years old or even earlier. Due to late marriage, not having children yet or planning to have a second child, they hope to retain their fertility. So what conditions meet the conditions for retaining fertility?

First, basic conditions: age less than 40 years old, no more than 45 years old; strong need to preserve fertility; no contraindications to pregnancy; no contraindications to drug treatment; high compliance. Second, clinical conditions: stage IA (lesions confined to the endometrium), imaging assessment shows no evidence of myometrial invasion, adnexal involvement, and distant metastasis. Third, pathological conditions: pathological type is well-differentiated endometrioid carcinoma. High-risk types such as serous carcinoma, clear cell carcinoma, and carcinosarcoma cannot be treated with fertility preservation due to their high degree of malignancy; immunohistochemistry tests are positive for ER and PR; in addition, patients with molecular classification of p53 mutations have a poor prognosis, and fertility preservation treatment is not recommended. Fourth, genetic conditions: Fertility preservation treatment is not recommended for patients with hereditary tumor syndromes such as Lynch syndrome.

In addition to meeting the above conditions, fertility-preserving treatment also involves multidisciplinary comprehensive management, such as evaluation, treatment and follow-up by gynecological oncologists, fertility assessment and assisted reproductive technology by reproductive doctors, weight and comorbidity management by endocrinologists, etc. At the same time, patients must also have good follow-up conditions and compliance, take oral hormones as prescribed by doctors and undergo regular check-ups, so that they can try to preserve fertility under strict monitoring.

Therefore, only a very small number of patients can retain their fertility, and patients need to be fully aware that retaining fertility is not a standard treatment method. Clinical guidelines usually recommend that patients with endometrial cancer undergo total hysterectomy and bilateral adnexectomy to reduce the risk of recurrence.

Figure 1 Original copyright image, no permission to reprint

Do both early and late stage endometrial cancer require surgical treatment?

Usually, 80% of patients are still in the early stages of the disease when they are diagnosed with endometrial cancer. What is the early stage? According to the international staging system, stage I and stage II are early stages, and stage III and stage IV are late stages.

For example, for patients with stage I endometrial cancer, the standard treatment is minimally invasive total hysterectomy + bilateral salpingo-oophorectomy + surgical staging. If there are high-risk factors, pelvic and para-aortic lymph node resection should be performed. Pelvic lymph nodes include external iliac lymph nodes, internal iliac lymph nodes, obturator lymph nodes, and common iliac lymph nodes. Special pathological types (such as serous carcinoma, undifferentiated carcinoma, carcinosarcoma) should undergo omental biopsy or resection.

Regarding the lymph node management strategy for patients with advanced stage, there are the following differences of opinion in the academic community: The basis for supporting systematic lymph node resection is: accurate staging guides postoperative treatment, potential therapeutic value (clearing micrometastases) and compliance with international guidelines. Opinions against extended lymph node resection include: increased risk of surgical complications, no significant improvement in overall survival, and modern imaging technology can assist in preoperative evaluation. However, current guidelines show that pelvic lymph node resection is correct and acceptable at all stages, especially for patients with advanced stage, systematic lymph node resection is more generally recognized. Lymph node management needs to balance staging accuracy and surgical safety.

For patients in the advanced stage, such as stage IVB, do they need surgery? The current view is to try to have surgery. You can shrink the tumor with neoadjuvant chemotherapy first, then have surgery; or you can shrink the tumor with radiotherapy first, then have a palliative surgery.

Figure 2 Original copyright image, no permission to reprint

By removing the uterus and the two adnexa and the primary lesion, the tumor burden can be reduced. In addition, removing the two adnexa can reduce the secretion of hormones; removing the uterus can reduce the heavy bleeding caused by the shedding of large cancer lesions in the uterine cavity.

Therefore, surgery remains the main treatment for endometrial cancer.

Can endometrial cancer be cured?

The treatment of patients with malignant tumors is not called radical cure. The term "clinical cure" is usually used, which means that the patient survives disease-free for five years. Compared with other tumors, the prognosis of endometrial cancer is relatively good.

For example, for patients in stage I and II, the five-year survival rate is relatively high, reaching 74%-91%. For patients with stage III endometrial cancer, the five-year survival rate can reach 57%-66%. For patients with stage IV endometrial cancer, the five-year survival rate is 20%-26%. Therefore, the prognosis of endometrial cancer is relatively good.

Of course, we still have some measures to deal with the recurrence of endometrial cancer.

The treatment of recurrent endometrial cancer is mainly comprehensive treatment, and the specific plan needs to be individualized according to the patient's specific situation. The most common treatment methods are chemotherapy, immunotherapy, radiotherapy, surgery, and endocrine therapy, targeted therapy, etc.

If the recurrence is isolated and localized, surgical resection can be considered; if the lesions are multiple or metastatic, systemic chemotherapy is usually recommended. If it is simply liver metastasis, hepatic artery chemoembolization, radiofrequency ablation, and other comprehensive treatments such as traditional Chinese medicine can be used.

In short, the choice of treatment plan needs to comprehensively consider factors such as the recurrence site, lesion range, patient's general condition and previous treatment history. It is recommended that patients receive standardized treatment under the guidance of a multidisciplinary diagnosis and treatment team to achieve the best therapeutic effect. During treatment, close follow-up should be conducted to monitor the treatment effect and adverse reactions, and the treatment plan should be adjusted in a timely manner.