Endometrial Cancer Surgery: comparing treatment methods

3 Feb 2016

Minimally invasive hysterectomy does not appear to compromise long-term survival for women with endometrial cancer, analysis of the SEER-Medicare database has shown.

Minimally invasive hysterectomy: nonsignificant difference in perioperative mortality

In the study, the SEER-Medicare database was used to identify 6,304 women with stage I-III uterine cancer who underwent hysterectomy from 2006 to 2011. A total of 4,139 patients who underwent abdominal hysterectomy were compared with 2,165 who underwent either laparoscopic or robot-assisted hysterectomy.

When compared with women who underwent abdominal hysterectomy, minimally invasive hysterectomy was associated with a lower overall complication rate, and a nonsignificant difference in perioperative mortality. However, the study also showed that these women were more likely to receive adjuvant pelvic radiotherapy and brachytherapy.

Linking treatment allocation with socioeconomic status

The reasons for the increased use of adjuvant therapy after minimally invasive hysterectomy remain unclear, particularly since many of these patients had more favorable tumor prognostic factors, said Jason D. Wright, MD of Columbia University College of Physicians and Surgeons in New York City and colleagues. "Particularly for women with large uteri, manipulation at the time of surgery or disruption or spillage of tumor from the uterine cavity may prompt use of radiation. This phenomenon warrants further investigation and careful monitoring."

A higher perioperative morbidity rate seen with robotically assisted surgery was due to postoperative medical complications, including higher rates of respiratory and renal failure and bacteremia, said the researchers. Prior studies have reported substantially longer operative times with robot-assisted surgery, they noted, and this may partially explain morbidity.

There were a number of discrepancies in treatment allocation, a finding in keeping with prior study reports. The analysis showed that minimally invasive hysterectomy was more commonly used in patients with higher socioeconomic status and in larger hospitals, reported Wright and colleagues. "This is in accord with other studies of hysterectomy for both benign and oncologic indications that have shown significant disparities in the use of newer procedures. Not surprisingly, women with higher stage tumors and more aggressive histologic subtypes were less likely to undergo a minimally invasive operation."

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“These surgical approaches should be available to all patients

There was no association between the use of minimally invasive hysterectomy and either overall or cancer-specific mortality, according to researchers. However, robotically assisted hysterectomy was associated with a small, but statistically significant, increased risk of complications when compared with laparoscopic hysterectomy.

"Encouragingly, we found no difference in survival between laparotomy and minimally invasive surgery for endometrial cancer," Wright and colleagues reported.

"The laparoscopic approach to treatment of endometrial cancer provides similar survival outcomes to exploratory laparotomy but with decreased perioperative mortality and morbidity rates and improved quality of life in the perioperative period," commented Celestine S. Tung, MD, MPH, of Baylor College of Medicine in Houston, Texas. "We should consider minimally invasive surgical approaches when possible for patients who are diagnosed with endometrial cancer," said Tung, who was not involved in the study. "These surgical approaches should be available to all patients regardless of insurance or socioeconomic status," she added.

Study limitations

The study had several important limitations, noted the authors, including the use of claims data, which under-captures complications. For this reason, they included only major perioperative complications. "Although any under-capture of complications should be balanced across the groups, we recognize that we cannot measure minor complications with the current study design," said Wright and colleagues.

In addition, the analysis may not be generalizable to all women since it was limited to elderly Medicare beneficiaries, said the investigators. What's more, survival is favorable for early-stage endometrial cancer but the analysis was not powered to detect small differences in survival between groups. "This is an intrinsic limitation of studies of endometrial cancer and highlights the importance of including other outcomes metrics, such as complications and patient-reported outcomes in comparative effectiveness studies," suggested the authors. They also noted that they could not capture individual patient and physician preferences that "undoubtedly influenced treatment decision making."

To further improve outcomes, patients need to understand that any postmenopausal bleeding is unusual and should be evaluated, Tung commented. Other risk factors for endometrial cancer, such as obesity, need to be factored in, she said, noting that obesity is associated with increased surgical risk and increased perioperative morbidity.

Source: MedPage Today
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