Endometrial Cancer Treatment by Stage

Endometrial cancer starts in the lining of the uterus. NCI calls it the most common gynecologic cancer in the United States. It accounts for about 7 percent of all cancers in women.

For 2025 the American Cancer Society projected 69,120 new cancers of the uterine corpus in the United States, and 13,860 deaths. NCI's PDQ summary reprints both numbers. The uterine corpus is the body of the uterus. Most of those cancers are endometrial.

Most cases are found early. NCI says most are treatable with surgery alone. There are two exceptions. One is women whose pathology predicts a high relapse rate. The other is women whose cancer has already spread outside the uterus. Both groups relapse often, even with treatment added after surgery.

Where an operation is possible, endometrial cancer is surgically staged: the stage is set after surgery and a pathology review, rather than from imaging alone. The 2023 FIGO system also folds in the cell type and the molecular classification, so the final stage is not purely anatomical.

Imaging still changes decisions. Scans looking for spread to lymph nodes or distant organs can move the plan before a knife is picked up. And some women cannot safely have surgery, or have disease too advanced for it. They are given a clinical stage instead, based on examination, imaging and biopsy, and treated from that.

In early disease, NCI describes a standard operation. It is a total hysterectomy with removal of both tubes and ovaries. It is done through small cuts, by keyhole surgery. Extra steps depend on the cell type. Some women also have part of the fatty apron over the bowel removed. That step is called an infracolic omentectomy. It is done for serous and undifferentiated carcinoma, and for carcinosarcoma. The reason is that tiny spread to that tissue is common.

Lymph node staging is done in intermediate-high and high-risk disease. Sentinel lymph node biopsy is an adequate alternative to taking out all the nodes. A sentinel biopsy maps the first nodes the tumor drains into, and takes only those. It spares many women a wider dissection.

NCI says three things must be recorded at every stage. They are the grade, the histological type, and lymphovascular space invasion, or LVSI. LVSI means cancer cells were seen inside small vessels. Ask for all three by name.

The current FIGO staging system asks for molecular testing in all patients, where it can be done. It is used for risk grouping. It can also change what is offered after surgery.

There are four groups:

• POLEmut: a pathogenic change in the POLE gene.
• MMRd: mismatch repair deficient.
• NSMP: no specific molecular profile.
• p53abn: abnormal TP53.

Ask whether this testing was done. Ask which group your tumor falls into. It is a different question from the stage. Our page on biomarker testing explains how these reports work.

Grades 1 and 2 are considered low risk, unless the cells are serous or clear cell type.

NCI lists these treatment options for low-risk stage I disease:

• Surgery: hysterectomy with removal of both tubes and ovaries, with possible lymph node dissection.
• Vaginal brachytherapy after surgery, which places a radiation source inside the vagina.
• Radiation therapy alone.

NCI adds that most patients do well with surgery alone.

Stage II deserves its own caution. In the current FIGO system, stage II means the tumor has grown into the cervical stroma. NCI notes that almost all trials in early disease left these patients out. So there is little good data behind stage II decisions. For stage II disease, it is fair to ask what evidence the advice rests on.

High risk means a grade 3 tumor of any type, or any serous tumor, clear cell tumor or carcinosarcoma.

For these, NCI lists surgery, then chemotherapy after surgery, with or without radiation therapy.

The reason for harder treatment is relapse risk. A Gynecologic Oncology Group study looked at women with no spread outside the uterus. Grade 3 tumors and deep muscle invasion drove recurrence more than anything else.

NCI publishes the risk of node involvement in clinical stage I disease. The numbers explain why some women have nodes removed and others do not.

• Grade 1 tumors involving only the endometrium, with no spread inside the abdomen: under 5 percent risk of node involvement.
• Grade 2 or 3 tumors that invade less than half the muscle wall, with no spread inside the abdomen: 5 to 9 percent in pelvic nodes. Para-aortic nodes, 4 percent.
• Deep muscle invasion, high grade, or spread inside the abdomen: 20 to 60 percent in pelvic nodes. Para-aortic nodes, 10 to 30 percent.

The same study named the findings that raise the chance of recurrence sharply. They are positive pelvic nodes, spread to the ovary or tube, positive washings from the abdomen, cancer in capillary spaces, involvement of the isthmus or cervix, and positive para-aortic nodes.

NCI groups these together and sorts the options by whether surgery is possible.

• Operable disease: surgery followed by chemotherapy or radiation therapy.
• Inoperable disease: chemotherapy and radiation therapy.
• Inoperable disease where radiation is not an option: hormone therapy, or biological therapy.

NCI states this plainly. Women with regional and distant spread are rarely cured. The cancer does sometimes respond to standard hormone therapy.

Knowing where this cancer travels helps you read a scan report. Regional spread goes to pelvic and para-aortic nodes. Distant spread most often reaches the lungs, the groin and collarbone nodes, the liver, the bones, the brain and the vagina.

One randomized trial added pembrolizumab to chemotherapy in advanced or recurrent disease. Pembrolizumab is an immune checkpoint inhibitor. Patients were split by mismatch repair status. There were 222 with deficient repair, called dMMR. There were 588 with proficient repair, called pMMR.

In the dMMR group, progression-free survival at 1 year was 74 percent with pembrolizumab. It was 38 percent with placebo. The hazard ratio was 0.30.

In the pMMR group, median progression-free survival was 13.1 months with pembrolizumab. It was 8.7 months with placebo. The hazard ratio was 0.54.

Both groups gained. The size of the gain was very different. So it is worth knowing your MMR status before advanced treatment is chosen.

Progesterone drugs were tested after surgery in several randomized trials. A Cochrane review pooled them. It confirmed no clinical benefit in clinical stage I disease. If progesterone is proposed, ask what it is for. It is not supported as routine treatment after early-stage surgery.

NCI records a fact that rarely reaches patients. The most common cause of death in women with endometrial cancer is heart and blood vessel disease. It is driven by the same metabolic risk factors that raise the risk of this cancer.

That changes what follow-up is for. Blood pressure, blood sugar, cholesterol and weight are not side topics here. Ask who is managing them. Make sure someone is.

• What is my FIGO stage, my grade, my histological type, and was LVSI present?
• Was molecular classification done, and which of the four groups am I in?
• Were lymph nodes assessed, by sentinel biopsy or full dissection, and what did they show?
• What is the goal of the treatment being proposed after surgery?
• Who is watching my heart and metabolic health during follow-up?

• Call 911 or go to an emergency department if you have sudden shortness of breath, sharp chest pain, a racing heartbeat, or you cough up blood. Surgery and this cancer both raise the risk of a clot in the lung. Go straight there as well if you are on chemotherapy and your temperature reaches 100.4°F (38°C) or higher, or you get shaking chills. CDC treats a fever during chemotherapy as an emergency, because your white cells may be too low to hold an infection back for even a few hours.
• Call your care team the same day if one leg turns swollen, red, or painful, or a surgical wound opens, leaks, or turns red and hot.
• Call your care team within a day or two if vaginal bleeding or discharge starts again, pelvic pain is new or worse, or urinating becomes difficult or painful.

Our page on cancer staging explains what these systems measure. If a big decision feels uncertain, getting a second opinion covers how to set one up.

• NCI PDQ on endometrial cancer, for doctors
• NCI PDQ on endometrial cancer, for patients
• NCI — Infection and neutropenia during cancer treatment
• CDC — Watch out for fever during cancer treatment
• MedlinePlus — Pulmonary embolus