Slow Uptake of Minimally Invasive Surgery for Endometrial Cancer

Charles Bankhead

June 2016, Vol 7, No 5 - Gynecologic Cancer


More than 50% of women with early-stage endometrial cancer had open surgery, in contradiction to recommendations in clinical guidelines, according to a study reported at the 2016 Society of Gynecologic Oncology (SGO) annual meeting. Among 9800 patients with stage I to stage III endometrial cancer, 52% of the women had open surgery. The operations all occurred in the 2 years leading up to the publication of a clinical guideline recommending minimally invasive surgery for all women with stage I to stage III endometrial cancer.

Minimally Invasive Surgery Results in Less Complications

Open surgery is associated with a significantly higher complication rate than minimally invasive surgery, which can add millions of dollars to the healthcare costs. The minimally invasive surgery cohort “was older, had more lymphad­enectomies, and was equally obese compared to the open surgery cohort,” said Diana B. Mannschreck, a medical student, Kelly Gynecologic Oncology Service, Johns Hopkins Medicine, Baltimore, MD. Yet, this cohort “still had fewer perioperative complications. Women of black race or Hispanic ethnicity and women treated in rural settings were much less likely to receive standard-of-care surgery.” “Open surgery may no longer be justified for most patients in this setting,” Ms Mannschreck added. A previous study demonstrated that minimally invasive surgery for early-stage endometrial cancer resulted in significantly fewer complications and achieved similar survival compared with open surgery. In 2014, the SGO/American Cancer Society guideline confirmed minimally invasive surgery as the approach of choice for women with stage I to stage III endometrial cancer.

Minimally Invasive Surgery Is Underused, Saves Costs

A new study showed a steady increase in the adoption of minimally invasive surgery for early endometrial cancer from 2007 to 2011 (Fader AN, et al. Obstet Gynecol. 2016;127:91-100). However, the analysis of 32,560 cases showed that it still accounted for <50% of surgeries at the end of the study. Ms Mannschreck reported the findings from an analysis of the Healthcare Cost and Utilization Project/National Inpatient Sample database for 2012 to 2013. The objectives were to obtain a contemporary estimate of minimally invasive surgery uptake for endometrial cancer and to identify the patient- and hospital-related factors that are associated with the choice of surgical approach, complication rates, and costs. Limited to patients with stage I to stage III nonmetastatic disease, the data showed that open surgery accounted for 52% of the 9799 procedures performed during the study period. The patients undergoing minimally invasive surgery were slightly older and more often had lymphadenectomies. Minimally invasive surgery was performed more frequently in the Northeast and the West, whereas open surgery predominated in the Midwest and the South. Open surgery was performed significantly less often in higher-volume hospitals. Open surgery occurred significantly more often in government hospitals than in private hospitals and in rural areas than in urban areas. Patient race or ethnicity other than white significantly increased the odds for open surgery. In a matched-propensity cohort of 7388 patients, the likelihood of any complication was almost 3 times higher with open surgery than with minimally invasive surgery. Surgical complications, major blood loss, and length of stay exceeding 2 days also occurred significantly more often with open surgery than with minimally invasive surgery. Overall, minimally invasive surgery costs significantly less than open surgery per case—$13,469 versus $14,712, respectively. The cost of a procedure without complications was similar between the 2 groups, as was the average added cost per complication. “We estimate that utilizing [minimally invasive surgery] for 80% of the patients would have averted 2733 complications and saved $19 million for 2012 to 2013,” Ms Mannschreck said.