Expert Commentary

Is a minimally invasive approach to hysterectomy for Gyn cancer utilized equally in all racial and income groups?

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No. Although a minimally invasive approach was used in 50% of uterine, 43% of cervical, and 8.5% of ovarian cancer cases overall, black women were significantly less likely to undergo minimally invasive surgery (MIS) for uterine or cervical cancer, and women without insurance or on Medicaid were significantly less likely to undergo minimally invasive hysterectomy for uterine cancer, according to this cross-sectional analysis.

Esselen KM, Vitonis AS, Einarsson J, Muto, MG, Cohen S. Health care disparities in hysterectomy for gynecologic cancers: data from the 2012 National Inpatient Sample. Obstet Gynecol. 2015;126(5):1029–1039.



The minimally invasive approach to hysterectomy (laparoscopic, robot-assisted, or vaginal) is associated with less blood loss, a shorter length of stay, and quicker recovery than the abdominal approach (laparotomy). In this study, Esselen and colleagues drew from the 2012 National Inpatient Sample, the largest national all-payer database of hospital discharges, which samples some 20% of hospital discharges. Of an estimated 28,160 hysterectomies performed in 2012 for endometrial cancer, 50% were abdominal and 50% involved MIS (38% robot-assisted, 11% laparoscopic, and 1% vaginal).

MIS was used less often for black women (adjusted odds ratio [OR], 0.50) and Native American women (0.56), compared with white women. Similarly, Medicaid patients were less likely to undergo MIS (adjusted OR, 0.58) than those who were covered by commercial medical insurance.

MIS was used 3.68 times more often in women cared for in urban teaching hospitals, compared with women undergoing hysterectomy for endometrial cancer in rural hospitals (P<.04 for all comparisons).

Length of stay was substantially longer and total costs were higher for women undergoing abdominal hysterectomy.

Study did not control for stage of cancer at presentation
These striking findings parallel higher cancer-specific mortality and other disparities faced by minority patients. Esselen and colleagues point out that higher stage at presentation sometimes mandates use of an abdominal approach for hysterectomy and that minority and low-income women often present with higher-stage disease; accordingly, their inability to control for stage represents an important limitation.

This report indicates that, for US women of different ethnic and socioeconomic status, important differences are present with respect to access to MIS for gynecologic malignancy.
— Andrew M. Kaunitz, MD

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