Cost-effectiveness analysis of the treatment for intermediate risk endometrial cancer: postoperative brachytherapy vs. observation1

Impact of different adjuvant radiotherapy modalities on women with early-stage intermediate- to high-risk endometrial cancer

OBJECTIVE

Vaginal brachytherapy was recommended for patients with intermediate-risk endometrial cancer, however, optimal radiotherapy modalities for intermediate-high- or high-risk patients remains controversial. Previous studies have mainly focused on survival outcomes and have seldom taken cost issues into consideration, especially for high-risk patients. The purpose of this study is to compare the survival outcomes and costs associated with two adjuvant radiotherapy modalities in the management of patients with early-stage, intermediate- to high-risk endometrial cancer.

METHODS

According to ESMO-ESCO-ESTRO criteria, 238 patients with stage I/II, intermediate- to high-risk endometrial cancer who underwent radiotherapy from January 2003 to December 2015 at our institution were reviewed. The vaginal brachytherapy group and external beam radiation therapy combined with the vaginal brachytherapy group were propensity score-matched at a 1:1 ratio. The Kaplan-Meier method and Cox proportional hazards regression model were used.

RESULTS

A total of 361 patients met our inclusion criteria, the median age of the patients was 58 years (range, 28-85). All were diagnosed with stage I-II endometrial cancer (324 with stage I and 37 with stage II; 350 with endometrioid adenocarcinoma; and 10 with mucinous carcinoma). The median follow-up time was 60.5 months (range, 3-177). Among 119 matched pairs, no significant differences were found in overall (10.9% vs 8.4%, P=0.51), locoregional (4.2% vs 1.7%, P=0.45), or distant recurrence rates (6.7% vs 6.7%, P=1.0) between the two groups. There were also no differences in the 5-year overall (94.8% vs 93.9%, P=0.78) or progression-free survival (90.0% vs 84.4%, P=0.23) between the two groups. The rates of acute and late toxicity were significantly higher in the external beam radiation therapy combined with vaginal brachytherapy vs the vaginal brachytherapy group (all P<0.05), except for the acute hematological toxicity rate (17.6% vs 9.2%, P=0.06). External beam radiation therapy combined with vaginal brachytherapy had a higher median cost ($2759 vs $937, P<0.001) and longer median radiotherapy duration (41 days vs 17 days, P<0.001) than vaginal brachytherapy.

CONCLUSION

Vaginal brachytherapy was associated with similar local control and long-term survival outcomes relative to the combination of external beam radiotherapy and vaginal brachytherapy and it also minimizes radiation-related complications, reduces medical costs, and shortens radiotherapy duration. Vaginal brachytherapy may be the optimal radiation modality for patients with early-stage endometrial cancer at intermediate to high risk.

Cost-effectiveness of adjuvant intravaginal brachytherapy in high-intermediate risk endometrial carcinoma

PURPOSE

We assessed the cost-effectiveness of adjuvant intravaginal brachytherapy (IVBT) vs. observation after total hysterectomy and bilateral salpingo-oophorectomy (TH/BSO) for high-intermediate risk (HIR) endometrial carcinoma.

METHODS AND MATERIALS

A Markov model was used to assess the cost-effectiveness of IVBT by comparing average cumulative costs, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios (ICERs) between patients allocated to (1) 'observation' or (2) 'IVBT' after TH/BSO. We used a prototype Post-Operative Radiation Therapy in Endometrial Carcinoma (PORTEC)-defined HIR patient in the base case analysis. We calibrated the model to match the outcomes reported in the PORTEC-1 and PORTEC-2 trials. Utilities were obtained from published estimates, and costs were calculated based on Medicare reimbursement ($5445 for IVBT). The societal willingness-to-pay threshold was set at $100,000 per QALY. The time horizon was 5 years.

RESULTS

IVBT was associated with a net increase of 0.094 QALYs (4.512 vs. 4.418) as well as an increase in mean cost ($17,453 vs. $15,620) relative to observation. The ICER for IVBT was $19,500 per QALY. On one-way sensitivity analysis, IVBT remained cost-effective when its cost was less than $12,937. If the probability of vaginal recurrence in the observation arm was increased or decreased by 25%, the ICER became $1335 per QALY and $87,925 per QALY, respectively. Probabilistic sensitivity analysis revealed that IVBT was the preferred management option in 86% of simulations.

CONCLUSIONS

IVBT is cost-effective compared with observation after TH/BSO for HIR endometrial carcinoma by commonly accepted willingness-to-pay thresholds.

Vaginal cuff brachytherapy in endometrial cancer - a technically easy treatment?

Endometrial cancer (EC) is one of the most common gynecological cancers among women in the developed countries. Vaginal cuff is the main location of relapses after a curative surgical procedure and postoperative radiation therapy have proven to diminish it. Nevertheless, these results have not translated into better survival results. The preeminent place of vaginal cuff brachytherapy (VCB) in the postoperative treatment of high- to intermediate-risk EC was given by the PORTEC-2 trial, which demonstrated a similar reduction in relapses with VCB than with external beam radiotherapy (EBRT), but VCB induced less late toxicity. As a result of this trial, the use of VCB has increased in clinical practice at the expense of EBRT. A majority of the clinical reviews of VCB usually address the risk categories and patient selection but pay little attention to technical aspects of the VCB procedure. Our review aimed to address both aspects. First of all, we described the risk groups, which guide patient selection for VCB in clinical practice. Then, we depicted several technical aspects that might influence dose deposition and toxicity. Bladder distension and rectal distension as well as applicator position or patient position are some of those variables that we reviewed.

Long-Term Secondary Care Costs of Endometrial Cancer: A Prospective Cohort Study Nested within the United Kingdom Collaborative Trial of Ovarian Cancer Screening (UKCTOCS)

BACKGROUND

There is limited evidence on the costs of Endometrial Cancer (EC) by stage of disease. We estimated the long-term secondary care costs of EC according to stage at diagnosis in an English population-based cohort.

METHODS

Women participating in UKCTOCS and diagnosed with EC following enrolment (2001-2005) and prior to 31st Dec 2009 were identified to have EC through multiple sources. Survival was calculated through data linkage to death registry. Costs estimates were derived from hospital records accessed from Hospital Episode Statistics (HES) with additional patient level covariates derived from case notes and patient questionnaires. Missing and censored data was imputed using Multiple Imputation. Regression analysis of cost and survival was undertaken.

RESULTS

491 of 641 women with EC were included. Five year total costs were strongly dependent on stage, ranging from £9,475 (diagnosis at stage IA/IB) to £26,080 (diagnosis at stage III). Stage, grade and BMI were the strongest predictors of costs. The majority of costs for stage I/II EC were incurred in the first six months after diagnosis while for stage III / IV considerable costs accrued after the first six months.

CONCLUSIONS

In addition to survival advantages, there are significant cost savings if patients with EC are detected earlier.

Salvage Versus Adjuvant Radiation Treatment for Women With Early-Stage Endometrial Carcinoma: A Matched Analysis

OBJECTIVES

Adjuvant radiation treatment (ART) has been shown to reduce local recurrences in early-stage endometrial carcinoma (EC); however, this has not translated into improved overall survival (OS) benefit. As a result, some physicians forgo ART, citing successful salvage rates in cases of recurrence. Survival end points were compared between women treated with salvage RT (SRT) for locoregional recurrence and similarly matched women treated upfront with ART.

MATERIALS AND METHODS

We identified 40 patients with stage I to II type 1 EC who underwent hysterectomy and received no adjuvant RT but later developed locoregional recurrence and subsequently received SRT. An additional 374 patients who underwent hysterectomy followed by ART during the same period were identified. Patients in the SRT group were matched to those in the ART group based on FIGO (International Federation of Gynecology and Obstetrics) stage and tumor grade in a 1:3 ratio. Disease-specific survival (DSS) and OS were calculated.

RESULTS

A total of 156 women were matched (39:117). Median follow-up was 56 months. The 2 groups were generally well balanced. With regard to the site of tumor recurrence, it was commonly vaginal in the SRT group (74.3% vs 28.6%, P = 0.01). More SRT patients received a combination of pelvic external-beam RT with vaginal brachytherapy (94.8% vs 35%, P < 0.001). The ART group had significantly better 5-year DSS (95% vs 77%, P < 0.001) and 5-year OS (79% vs 72%, P = 0.005) compared with those of the SRT group.

CONCLUSIONS

Our study suggests that women who receive SRT for their locoregional recurrence have worse DSS and OS compared with those matched patients who received ART. Further studies are warranted to develop a high-quality cost-effectiveness analysis as well as accurate predictive models of tumor recurrence. Until then, ART should at least be considered in the management of early-stage EC patients with adverse prognostic factors.

Adjuvant therapy in early-stage endometrial cancer: a systematic review of the evidence, guidelines, and clinical practice in the U.S

Endometrial cancer is the most common gynecologic malignancy in the U.S., with an increasing incidence likely secondary to the obesity epidemic. Surgery is usually the primary treatment for early stage endometrial cancer, followed by adjuvant therapy in selected cases. This includes radiation therapy [RT] with or without chemotherapy, based on stratification of patients into categories dependent on their future recurrence risk. Several prospective trials (PORTEC-1, GOG#99, and PORTEC-2) have shown that the use of adjuvant RT in the intermediate risk (IR) and the high-intermediate risk (HIR) groups decreases locoregional recurrence (LRR) but has no effect on overall survival. The ad hoc analyses from these studies have shown that an even larger LRR risk reduction was seen within the HIR group compared with the IR group. Vaginal brachytherapy is as good as external beam radiotherapy in controlling vaginal relapse where the majority of recurrence occur, and with less toxicity. In the high-risk group, multimodality therapy (chemotherapy and RT) may play a significant role. Although adjuvant RT has been evaluated in many cost-effectiveness studies, high-quality data in this area are still lacking. The uptake of the above prospective trial results in the U.S. has not been promising. Factors that are driving current practices and defining quality-of-care measures for patients with early-stage disease are what future studies need to address.

The role of frozen section in surgical staging of low risk endometrial cancer

BACKGROUND

The role of frozen section (FS) in intraoperative decision making for surgical staging of endometrial cancer is controversial. Objective of this study is to assess the agreement rate between the FS and paraffin section (PS); and the potential impact of the role of FS in the intra-operative decision making for the complete surgical staging in low risk endometrial cancer.

METHODS

This is a retrospective analysis of patients diagnosed with intra-operative FS stage I, grade I or II endometrial cancer from 1995-2004. FS results were compared with final pathology results with regard to tumor grade, depth of myometrial invasion, cervical involvement, lymphovascular invasion, and lymph node involvement. Agreement statistic with kappa was calculated using SPSS statistical software. Categorical variables were tested using chi-square test with p value of ≤0.05 being statistically significant.

RESULTS

Of the 457 patients with endometrial cancer, 146 were evaluated by intra-operative FS and met inclusion criteria. FS results were in disagreement with permanent section in 35% for the grade (kappa 0.58, p = 0.003), 28% for depth of myometrial invasion (kappa 0.61, p<0.0001), 13% for cervical involvement (kappa 0.78, p = 0.002), and 32% for lymphovascular invasion (kappa 0.6, p = 0.01). Permanent pathology upstaged 31.9% & 23.2% of FS stage IA, & IB specimen respectively. Lymph node dissection was done in 56.8%. Lymph node metastasis was identified in 8.4%. Use of intraoperative FS would have resulted in suboptimal surgical treatment in 13% stage IA and 6.6% of stage IB patients respectively by foregoing lymphadenectomy.

CONCLUSION

A significant number of patients with low risk endometrial cancer by FS were upstaged and upgraded on final pathology. Before placing absolute reliance on intraoperative FS to undertake complete surgical staging, the inherent limitation of the same in predicting final stage and grade highlighted by our data need to be carefully considered.

Transvaginal application of a laparoscopic bipolar cutting forceps to assist vaginal hysterectomy in extremely obese endometrial cancer patients

INTRODUCTION

The purpose of this report is to evaluate our experience with transvaginal application of a laparoscopic bipolar cutting forceps to assist vaginal hysterectomy in extremely obese women with endometrial cancer in whom obesity precluded LAVH/BSO and lymphadenectomy and vaginal obesity limited visualization and exposure.

MATERIALS AND METHODS

We performed a retrospective review and identified 6 consecutive cases. No cases were excluded. A laparoscopic 33-cm Plasma Kinctic (PK) cutting forceps with a 5-mm diameter was applied transvaginally to coagulate and cut the uterosacral and cardinal ligaments, uterine vasculature, and ovarian ligaments. The uterus was delivered vaginally. Staging lymphadenectomy was not performed.

RESULTS

Median age was 51 years, median weight was 405 lbs, and median BMI was 66 kg/m². Five of 6 cases were successfully performed vaginally (83%). Median operative time was 1 hour 10 minutes, median blood loss was 500 mL, and pain was only discomforting. All patients were discharged the day after surgery. There were no complications. At median follow-up of 1 year, all patients were alive with no evidence of disease.

CONCLUSION

It is our opinion that the transvaginal application of a laparoscopic bipolar cutting forceps can successfully assist vaginal hysterectomy in extremely obese endometrial cancer patients who cannot tolerate LAVH/BSO and lymphadenectomy and vaginal obesity limits visualization and exposure.

Laparoscopy compared with laparotomy for comprehensive surgical staging of uterine cancer: Gynecologic Oncology Group Study LAP2

PURPOSE

The objective was to compare laparoscopy versus laparotomy for comprehensive surgical staging of uterine cancer.

PATIENTS AND METHODS

Patients with clinical stage I to IIA uterine cancer were randomly assigned to laparoscopy (n = 1,696) or open laparotomy (n = 920), including hysterectomy, salpingo-oophorectomy, pelvic cytology, and pelvic and para-aortic lymphadenectomy. The main study end points were 6-week morbidity and mortality, hospital length of stay, conversion from laparoscopy to laparotomy, recurrence-free survival, site of recurrence, and patient-reported quality-of-life outcomes.

RESULTS

Laparoscopy was initiated in 1,682 patients and completed without conversion in 1,248 patients (74.2%). Conversion from laparoscopy to laparotomy was secondary to poor visibility in 246 patients (14.6%), metastatic cancer in 69 patients (4.1%), bleeding in 49 patients (2.9%), and other cause in 70 patients (4.2%). Laparoscopy had fewer moderate to severe postoperative adverse events than laparotomy (14% v 21%, respectively; P < .0001) but similar rates of intraoperative complications, despite having a significantly longer operative time (median, 204 v 130 minutes, respectively; P < .001). Hospitalization of more than 2 days was significantly lower in laparoscopy versus laparotomy patients (52% v 94%, respectively; P < .0001). Pelvic and para-aortic nodes were not removed in 8% of laparoscopy patients and 4% of laparotomy patients (P < .0001). No difference in overall detection of advanced stage (stage IIIA, IIIC, or IVB) was seen (17% of laparoscopy patients v 17% of laparotomy patients; P = .841).

CONCLUSION

Laparoscopic surgical staging for uterine cancer is feasible and safe in terms of short-term outcomes and results in fewer complications and shorter hospital stay. Follow-up of these patients will determine whether surgical technique impacts pattern of recurrence or disease-free survival.

The role of comprehensive surgical staging in patients with endometrial cancer

BACKGROUND

The cornerstone of the management of patients with endometrial cancer is hysterectomy. Since 1988, the role of lymphadenectomy for patients with endometrial cancer has been debated. Patients who undergo pelvic and para-aortic lymphadenectomy are more likely to be accurately staged and are less likely to receive adjuvant radiation therapy.

METHODS

The authors perform a narrative review of the recent literature. Overall survival, utilization of radiation therapy, impact on quality of life, and alternative approaches to surgical staging are discussed.

RESULTS

Although a survival benefit from comprehensive surgical staging has not been clearly demonstrated in patients diagnosed with endometrial cancer, surgical staging allows one to determine the need for adjuvant therapy. Preoperative and intraoperative assessment of lymph node metastasis and tumor grade lacks accuracy. Unstaged patients are more likely to receive postoperative radiation therapy.

CONCLUSIONS

Comprehensive surgical staging with lymphadenectomy allows patients to be classified accurately into risk categories. Risk status can be definitively determined only with final pathology. Surgically staged patients are more likely to receive appropriate adjuvant therapy or observation when warranted.

Role of complete lymphadenectomy in endometrioid uterine cancer

Although surgical pathological staging is the standard of care for uterine carcinoma, the benefits of a complete lymphadenectomy remain controversial. Evidence suggests that this procedure provides prognostic information and directs the use of appropriate adjuvant treatment in patients who are node-positive. Furthermore, it eliminates the need for adjuvant treatment in low-risk patients with negative nodes and no extrauterine spread of disease. Although the complications associated with this procedure raise the question as to whether all low-risk patients need a complete lymphadenectomy, the limitations of preoperative and intraoperative pathological analyses mean that lymphadenectomy in low-risk patients might still have merit. Future advances are warranted to enhance preoperative radiological and intraoperative pathological assessment to establish the risk of nodal disease. In this review, we assess the evidence on the prognostic and therapeutic benefits of a complete versus selective lymphadenectomy. Moreover, we discuss the complications associated with lymphadenectomy and identify subsets of low-risk patients who might not need to undergo this procedure.

Survival and recurrent disease after postoperative radiotherapy for early endometrial cancer: systematic review and meta-analysis

OBJECTIVE

To clarify the effect of postoperative (adjuvant) external-beam pelvic radiotherapy (EBRT) for different grades of early endometrial cancer.

SEARCH STRATEGY

Meta-analysis of data from randomised trials stratified by histological risk factors supported by cohort studies.

SELECTION CRITERIA

Cochrane methodology.

DATA

Seven randomised trials were identified. Five were eligible for meta-analysis. Homogeneity was confirmed (I2 < 25%).

MAIN OUTCOME MEASURES

Survival, site of recurrence and added complications.

MAIN RESULTS

EBRT after hysterectomy for low-risk disease increases the odds of death (OR for overall survival 0.71; 95% CI 0.52-0.96). EBRT does not appear to alter survival for intermediate-risk cancers (stage ICG1/2 and IBG3) (OR 0.97; 95% CI 0.69-1.35). In contrast, EBRT offers a significant disease-free survival advantage for high-risk cancer (OR 1.76; 95% CI 1.07-2.89). The survival advantage benefits one in ten women. The definition of high risk is variable across studies but focuses on ICG3 (deeply invasive, poorly differentiated) tumours. Pelvic EBRT reduces the risk of pelvic recurrent disease in all types of invasive endometrial cancer (OR 0.27; 95% CI 0.16-0.44), but local recurrence may respond to salvage treatment. The risk of distant metastasis appears to be increased significantly by prophylactic EBRT (OR 1.58; 95% CI 1.07-2.35), but this might be because pelvic relapse in untreated women alters reporting of metastatic disease.

AUTHORS' CONCLUSIONS

Adjuvant EBRT should not be used for low- (IA, IBG1) or intermediate-risk (IBG2) cancer, but it is associated with a 10% survival advantage for high-risk (stage ICG3) endometrial cancer. This challenges the role of a staging lymphadenectomy.

Cost-effectiveness analysis of treatment strategies for Stage I and II endometrial cancer

OBJECTIVE

Practice patterns vary across Canada with respect to indications for surgical staging and adjuvant radiotherapy in early endometrial cancer. We evaluated the cost-effectiveness of two common strategies for managing early endometrial cancer as part of an Ontario population-based study.

METHODS

A decision-analytic model (DATA 4.5) was developed for Stage I and II endometrioid-type cancer using empiric data from Ontario. On the basis of preoperative biopsy grade, one of two surgical procedures was selected: (1) hysterectomy and bilateral salpingo-oophorectomy (HBSO) or (2) surgical staging (HBSO and pelvic +/- para-aortic lymphadenectomy). Adjuvant radiotherapy (RT) was administered according to final grade and stage. After HBSO, pelvic RT was indicated for Grades 1 and 2 if Stage IC, IIA with > 50% myometrial invasion (MI), or IIB, and for Grade 3 if Stage IB, IC, IIA, or IIB. After staging, pelvic RT was indicated for Grades 1 and 2 if Stage IIB, and for Grade 3 if Stage IC, IIA with > 50% MI, or IIB. Main outcome measures were quality-adjusted life-years (QALY) and incremental cost-effectiveness ratios (ICER). Sensitivity analyses were used to evaluate uncertainty around various parameters.

RESULTS

The most cost-effective (dominant) strategies were determined for each preoperative grade. For Grade 1, HBSO strongly dominated surgical staging. For Grade 2, neither strategy was dominant; surgical staging had an ICER of $5216 per QALY. For Grade 3, surgical staging strongly dominated HBSO. These results were stable over a wide range of estimates for costs and utilities (i.e., patient preferences for a particular health state).

CONCLUSION

The most cost-effective treatment strategies for early endometrial cancer in Ontario differ according to preoperative grade.

Cost-Effectiveness Analysis of Strategies for the Surgical Management of Grade 1 Endometrial Adenocarcinoma

OBJECTIVE

To estimate the costs and outcomes of various strategies used for the management of grade 1 endometrial cancer.

METHODS

A cost-effectiveness analysis compared three strategies for the management of grade 1 endometrial cancer: 1) surgical staging in all patients (including hysterectomy and lymphadenectomy); 2) frozen section following hysterectomy with surgical staging based on the results of tumor grade and depth of myometrial invasion; and 3) hysterectomy without surgical staging (no staging). Surgical probabilities and recurrence rates were estimated from published data. Actual payer costs of surgery, radiation therapy, and chemotherapy were estimated for each strategy. Cost-effectiveness ratios were estimated for each strategy. Sensitivity analyses evaluated the costs of radiation and survival estimates used in the model.

RESULTS

For the estimated 10,000 women diagnosed annually with grade 1 endometrial cancer in the United States, the annual cost of surgical staging is $240.4 million, compared with $252.4 million for frozen section and $255.8 million for no staging. Five-year disease-free survival for surgical staging is 87.9%, compared with 87.3% for frozen section and 86.7% for no staging. This translates into a lower cost-effectiveness ratio for surgical staging ($27,337) compared with frozen section ($28,913) or no staging ($29,513). Surgical staging yielded 64 additional disease-free patients per 10,000 patients compared with frozen section and 126 additional disease-free patients compared with no staging. Use of adjuvant radiation therapy was the lowest in the surgical staging strategy (13%).

CONCLUSION

Surgical staging of all patients with grade 1 endometrial cancer is the most cost-effective strategy and decreases the use of radiation therapy without negatively impacting survival.

Cost-effectiveness analysis of the treatment of large leiomyomas: laparoscopic assisted vaginal hysterectomy versus abdominal hysterectomy

OBJECTIVE

The purpose of this study was to perform a cost-effectiveness analysis comparing the treatment of large leiomyomas by laparoscopic assisted vaginal hysterectomy (LAVH) versus abdominal hysterectomy (AH).

STUDY DESIGN

Twenty consecutive LAVH were compared to 20 consecutive AH for leiomyoma > or = 250 g. Hospital costs were obtained through Healthcare cost accounting system. The 6 principles of cost-effectiveness analysis were used.

RESULTS

The groups were similar in respect to age, weight, race, medical comorbidities, blood loss, and operative time. Median uterine weight (513 g) was approximately 20% > for LAVH. Length of stay and pain was significantly less for LAVH. Total hospital cost for AH was approximately 12% less expensive ($4394 vs $5023, P = .18).

CONCLUSION

Because of multiple benefits of LAVH versus AH and no significant difference in cost, we believe LAVH is an acceptable treatment for large leiomyoma.

Participation of the general gynecologist in surgical staging of endometrial cancer: analysis of cost and perioperative outcomes

OBJECTIVE

To compare the cost and perioperative outcomes of endometrial cancer staging when the procedure is performed by a gynecologic oncologist alone or when a general gynecologist participates in the procedure.

METHODS

A retrospective analysis was performed on a series of women with clinical stage I endometrial cancer treated at a single institution between 1/98 and 12/00. The patients were grouped according to the participation of a general gynecologist in their surgery. The 48 patients in Group 1 underwent surgery with a general gynecologist who consulted a gynecologic oncologist intraoperatively. Group 2 included 77 patients whose procedure was performed completely by a gynecologic oncologist. The two groups were compared with the chi-square, Fisher's exact, and Wilcoxon rank sum tests. Cost analysis included total hospital costs (room, pharmacy, and ancillary services) and total surgical costs (anesthesia, operating room, procedure, and perioperative physician evaluation costs).

RESULTS

The groups did not differ in age, type of surgeries performed, distribution of surgical stage, proportion of patients undergoing lymph node sampling (LNS), and length of follow-up. When LNS was performed, Group 2 had a significantly shorter median operative time (170 vs. 180 min; P=0.05) and shorter total time in the operating room (204 vs. 224 min; P=0.02). This group had a lower procedure cost when considered both in terms of payor's cost ($1,414 vs. $2,134; P<0.0001) and physician charge ($7,106 vs. $11,116; P<0.0001). Perioperative physician evaluation was reduced by almost half ($685 vs. $424; P<0.0001) in Group 2. Group 2 had a savings in total surgical cost by payor's cost ($9,142 vs. 10,294; P=0.005) or physician's charge ($14,546 vs. $19,276; P<0.0001), and in combined hospital and surgical cost by payor's cost ($15,664 vs. $17,346; P=0.004) or physician charge ($21,311 vs. $26,328; P<0.0001). Total hospital costs, however, did not differ between groups.

CONCLUSION

Operative time and costs increase when general gynecologists participate in the surgical procedure of patients with clinical stage I endometrial cancer. Although perioperative outcomes are similar, the involvement of two surgeons increases the length of the procedure as well as the cost of operating room time and physician reimbursement. The efficient use of limited health care resources must be considered as we plan the surgical approach to endometrial cancer.

Adjuvant Radiotherapy in Endometrial Carcinoma

Endometrial cancer is a common female malignancy, affecting approximately 40,000 women per year. Despite the publication of several prospective randomized trials, there continues to be controversy regarding the use of adjuvant radiation therapy in endometrial cancer management. It is clear that most women with early-stage, low-risk disease will do well without adjuvant therapy. Intermediate-risk patients are at risk for local-regional relapse, and radiotherapy has been shown to effectively reduce this risk without significantly impacting overall survival. The absence of a clear impact on survival has resulted in a lack of consensus regarding the use of radiotherapy in intermediate-risk patients. At the same time, the patterns of failure in intermediate-risk patients have resulted in differing recommendations regarding appropriate radiotherapy targets. High-risk patients are at risk for both local and distant failure, and chemotherapy has been shown to improve outcome in these patients. High-risk patients are also at risk for local failure, and targeted radiotherapy may be appropriate. In this article, we discuss the controversies surrounding the use of adjuvant radiotherapy in endometrial cancer using an evidence-based approach.

Surgical Staging for Patients Presenting With Grade 1 Endometrial Carcinoma

OBJECTIVE

To examine the impact of surgical staging of patients presenting with grade 1 endometrial cancer.

METHODS

The charts of all patients who presented for surgery for endometrial cancer between March 1997 and July 2003 were analyzed for demographic data, final tumor histology, grade, stage, and complications.

RESULTS

A total of 349 patients underwent surgical management for endometrial cancer. Preoperatively, 181 (52%) were identified with grade 1 disease, with a mean age of 61 years (range 27-89). Surgical staging (pelvic +/- para-aortic lymphadenectomy) was performed in 82% of cases and was omitted only in cases when disease was apparently confined to the endometrium and surgical risk was high. In staged patients, 3.2% had severe surgical complications. There were 2 perioperative mortalities (1 pulmonary emboli and 1 myocardial infarct). In comparison of pre- and postoperative histology, 19% of patients were upgraded, with 15% grade 2, 0.5% grade 3, 2.5% serous or clear cell, and 1% mixed mesodermal tumor. Lymph node metastases were found in 3.9% of patients presenting with grade 1 endometrial cancer, and 10.5% had extrauterine spread (> IIb). High-risk uterine features, including myometrial invasion more than 1/2, grade 3 lesions, high-risk histologic variants, and/or cervical involvement, were found in 26% of the patients. No patients with stage Ia-IIb endometrioid cancer received adjuvant teletherapy or chemotherapy. Four patients with low-risk uterine features were found to have extrauterine disease. Twelve percent of patients received adjuvant therapy, and 17% avoided teletherapy and/or chemotherapy based on surgical staging.

CONCLUSION

Surgical staging in patients presenting with grade 1 endometrial cancer significantly impacted postoperative treatment decisions in 29% of patients. Omitting lymphadenectomy in patients presenting with grade 1 endometrial cancer may lead to inappropriate postoperative management.