Gestational Trophoblastic Disease: Treatment Options

This section has been reviewed and approved by the Cancer.Net Editorial Board, 07/2014

ON THIS PAGE: You will learn about the different ways doctors use to treat women with GTD. To see other pages, use the menu on the side of your screen.

This section outlines treatments that are the standard of care (best proven treatments available) for this specific type of tumor. When making treatment plan decisions, patients are also encouraged to consider clinical trials as an option. A clinical trial is a research study to test a new approach to treatment to evaluate whether it is safe, effective, and possibly better than the standard treatment. Clinical trials may test such approaches as a new drug, a new combination of standard treatments, or new doses of current therapies. Your doctor can help you review all treatment options. For more information, see the Clinical Trials and Latest Research sections.

Treatment overview

For GTD, different types of doctors often work together to create a patient’s overall treatment plan that combines different types of treatments. This is called a multidisciplinary team. For GTD, this often includes the woman’s gynecologist, who is a doctor that treats problems of a woman’s reproductive system, as well as a gynecologic oncologist, who specializes in specifically treating cancer of the female reproductive system. Other specialists may include a medical oncologist, surgeon, and radiation oncologist, described below.

GTD is typically curable, especially when found early. Descriptions of the most common treatment options for GTD are listed below. Surgery and/or chemotherapy may be used to treat a woman with GTD. Treatment options and recommendations depend on several factors, including the type, stage, and risk grouping of GTD, and the patient’s preferences and overall health.

Your care plan may also include treatment for symptoms and side effects, an important part of medical care. Women diagnosed with GTD may have concerns about how treatment will affect their fertility (ability to become pregnant in the future) and sexual health, and patients are encouraged to talk about these concerns with their health care team before treatment begins. Take time to learn about all of your treatment options and be sure to ask questions about things that are unclear. Also, talk about the goals of each treatment with your doctor and what you can expect while receiving the treatment. Learn more about making treatment decisions.

Surgery

Surgery is the removal of the tumor and surrounding tissue during an operation. It is often the first treatment used for an HM and may be the only treatment necessary. A surgical oncologist is a doctor who specializes in treating cancer using surgery.

For GTD, the extent of surgery depends on the stage of the tumor. Two common surgical options are described below:

Suction dilation and curettage (D&C). A D&C is when the doctor removes a tumor within the uterus using a small vacuum-like device. After that, the walls of the uterus are scraped to remove any molar tissue that remains. The patient may receive a drug called oxytocin that helps remove the uterine tissue. A D&C is used for an HM and allows for preservation of a woman’s fertility. Side effects may include some vaginal bleeding, infection, scarring, cramping, and blood clots. Talk with your health care team about what to expect before a D&C.

Hysterectomy. A hysterectomy is the removal of the woman’s uterus and cervix. It is usually recommended to reduce risk of recurrence, treat a later-stage tumor, or a tumor type of PSTT and ETT. Hysterectomy can be either a simple hysterectomy, which is the removal of the uterus and cervix, or a radical hysterectomy which is the removal of the uterus, cervix, upper vagina, and the tissue around the cervix. There are different techniques to perform a hysterectomy, including a traditional incision in the stomach or a technique that use several, smaller incisions called a laparoscopic hysterectomy. Side effects of a hysterectomy include infertility. Other side effects include pain, bleeding, and infection. Talk with your doctor and other members of your health care team about possible side effects and how they can be relieved.

Following GTD surgery, the woman’s beta hCG level (see Diagnosis) will be monitored with blood tests to make sure it falls into normal levels. If the beta hCG level remains high or increases after an initial drop, it may mean that tumor cells are still present, either in a portion of the original tumor -- called a persistent or invasive mole -- and/or the cancer has spread to another area. If this occurs, additional treatment such as chemotherapy will be recommended. If the GTD surgery shows the presence of choriocarcinoma, chemotherapy (described below) is started immediately.  Choriocarcinoma is malignant and always needs chemotherapy.  Learn more about cancer surgery and coping with gynecologic surgery that can affect sexual health.

Chemotherapy

Chemotherapy is the use of drugs to destroy tumor cells, usually by stopping those cells’ ability to grow and divide. Chemotherapy is given by a gynecologic oncologist or medical oncologist, a doctor who specializes in treating a tumor with medication. Chemotherapy is usually very effective in treating an HM and some types of GTN, but it is not as effective with PSTT and ETT. Sometimes, chemotherapy is used as a single treatment, and in other cases, it may be combined with surgery.

Systemic chemotherapy is delivered through the bloodstream to reach tumor cells throughout the body. Common ways to give chemotherapy include an intramuscular (IM) injection (or shot), intravenous (IV) tube placed into a vein using a needle, or in a pill or capsule that is swallowed (orally). A chemotherapy regimen (schedule) usually consists of a specific number of cycles given over a set period of time. A patient may receive one drug at a time or combinations of different drugs at the same time. Common drugs used in chemotherapy for GTD include:

  • methotrexate (multiple brand names)
  • dactinomycin (Actinomycin-D, Cosmegen)
  • etoposide (VePesid, VP-16, Toposar)
  • cyclophosphamide (Cytoxan, Neosar)
  • vincristine (Oncovin, Vincasar)
  • cisplatin (Platinol, CDDP)

Similar to surgery, the type of chemotherapy depends on the stage grouping of GTD, including whether the tumor is low risk or high risk. A low-risk invasive mole or metastatic disease often can be treated successfully with methotrexate either alone or in combination with leucovorin (folinic acid, Wellcovorin). Another drug that can be used is dactinomycin, especially if the patient’s liver is not fully healthy. Approximately 15% of women with low-risk disease will need treatment with a second drug for treatment.

Women with high-risk, metastatic disease generally receive more than one drug, called combination chemotherapy. Common combinations include:

  • EMA-CO: etoposide, methotrexate, dactinomycin, cyclophosphamide, and vincristine
  • EMA-EP: etoposide, methotrexate, dactinomycin, etoposide, and cisplatin

Treatment results are measured by testing the woman’s beta hCG levels. Usually chemotherapy is continued until beta hCG levels are normal, and for additional cycles of treatment.

The side effects of chemotherapy depend on the individual and the dose used, but they can include fatigue, risk of infection, nausea and vomiting, mouth sores, hair loss, loss of appetite, neuropathy (numbness and tingling in the fingers and toes) and oto-toxicity, which is loss of high-frequency hearing and/or ringing in the ears. These side effects usually go away once treatment is finished. Talk with your doctor beforehand about the possible side effects from the specific drug(s) given and how side effects may be relieved or reduced.

Learn more about chemotherapy and preparing for treatment. The medications used to treat GTD are continually being evaluated. Talking with your doctor is often the best way to learn about the medications prescribed for you, their purpose, and their potential side effects or interactions with other medications. Learn more about your prescriptions by using searchable drug databases.

Getting care for symptoms and side effects

GTD and its treatment often cause side effects. In addition to treatment to slow, stop, or eliminate the tumor, an important part of medical care is relieving a person’s symptoms and side effects. This approach is called palliative or supportive care, and it includes supporting the patient with her physical, emotional, and social needs.

Palliative care can help a person at any stage of illness. People often receive treatment for the tumor and treatment to ease side effects at the same time. In fact, patients who receive both often have less severe symptoms, better quality of life, and report they are more satisfied with treatment.

Palliative treatments vary widely and often include medication, nutritional changes, relaxation techniques, and other therapies. You may also receive palliative treatments similar to those meant to eliminate the tumor, such as chemotherapy and surgery. Talk with your doctor about the goals of each treatment in your treatment plan.

Before treatment begins, talk with your health care team about the possible side effects of your specific treatment plan and supportive care options. And during and after treatment, be sure to tell your doctor or another health care team member if you are experiencing a problem so it is addressed as quickly as possible. Learn more about palliative care.  

Remission and the chance of recurrence

A remission is when the tumor cannot be detected in the body and there are no symptoms. This may also be called “no evidence of disease” or NED.

A remission can be temporary or permanent. This uncertainty leads to many survivors feeling worried or anxious that the tumor will come back. While many remissions of GTD are permanent, it’s important to talk with your doctor about the possibility of the tumor returning. The risk of recurrence for GTD overall is low, but it may be as high as 10% to 15% for women with a high-risk tumor. Understanding the risk of recurrence and the treatment options may help you feel more prepared if the tumor does return. Learn more about coping with the fear of recurrence

If GTD does return after the original treatment, it is called recurrent. It may come back in the uterus (called a local recurrence), nearby (regional recurrence), or in another place (distant recurrence).

When this occurs, a cycle of testing will begin again to learn as much as possible about the recurrence, including whether the GTD stage and risk group has changed. After testing is done, you and your doctor will talk about your treatment options. Often the treatment plan will include the therapies described above such as surgery or chemotherapy but they may be used in a different combination or given at a different pace. Your doctor may also suggest clinical trials that are studying new ways to treat this type of recurrent tumor. Treatment is often effective for a recurrent GTD.

People with recurrent GTD often experience emotions such as disbelief or fear. Patients are encouraged to talk with their health care team about these feelings and ask about support services to help them cope. Learn more about dealing with cancer recurrence.

If treatment fails

GTD is often curable. However, recovery is not always possible. If treatment is not successful, the disease may be called advanced or terminal.

This diagnosis is stressful, and this is difficult to discuss for many people. However, it is important to have open and honest conversations with your doctor and health care team to express your feelings, preferences, and concerns. The health care team is there to help, and many team members have special skills, experience, and knowledge to support patients and their families. Making sure a person is physically comfortable and free from pain is extremely important.

Patients who have advanced disease and who are expected to live less than six months may want to consider a type of palliative care called hospice care. Hospice care is designed to provide the best possible quality of life for people who are near the end of life. You and your family are encouraged to think about where you would be most comfortable: at home, in the hospital, or in a hospice environment. Nursing care and special equipment can make staying at home a workable alternative for many families. Learn more about advanced cancer care planning.

After the death of a loved one, many people need support to help them cope with the loss. Learn more about grief and loss.

The next section helps explain clinical trials, which are research studies. Use the menu on the side of your screen to select About Clinical Trials, or you can select another section, to continue reading this guide.