The authors report no financial relationships relevant to this article.
Postmenopausal bleeding is a symptom evaluated often by general gynecologists. It necessitates assessment of the endometrium, most often by tissue sampling. When endometrial cancer is confirmed by biopsy, management becomes complex. Should the patient be referred to a gynecologic oncologist? What kind of surgery does she need? What kind of adjuvant treatment will be offered? Could the diagnosis be part of a genetic cancer syndrome?
Recent studies have yielded new information:
- Preoperative, intraoperative, and postoperative care by a gynecologic oncologist significantly lowers the cost of health care
- Lymphadenectomy for endometrial cancer remains controversial, and may be unnecessary in low-risk patients
- Chemotherapy plays an expanding role in the treatment of endometrial cancer. Adjuvant therapy with doxorubicin, cisplatin, and paclitaxel is the treatment of choice for patients who have advanced-stage disease
- Nine percent of women who are given a diagnosis of endometrial cancer before 50 years of age have a germ-line Lynch syndrome-associated mutation, which demonstrates that heredity is an important aspect of endometrial cancer and should be considered at all times.
It’s good economics to refer patients to gyn oncology sooner, not later
Hoekstra A, Singh DK, Garb M, Arekapudi S, Rademaker A, Lurain JR. Participation of the general gynecologist in the surgical staging of endometrial cancer: analysis of cost and perioperative outcomes. Gynecol Oncol. 2006;103:897–901.
Early-stage endometrial cancer is often curable with surgery alone because a full 88% of endometrial cancers present as clinical stage I.1 The role of the general gynecologist in surgical management of these cases is controversial; at some institutions, the practice is to call in the gynecologic oncologist for lymph-node sampling or when gross disease is identified; at others, the standard is to refer the patient to gynecologic oncology as soon as malignancy is diagnosed by endometrial biopsy. Hoekstra and colleagues have attempted to shed light on this issue with a retrospective chart review of 121 patients who were treated at one institution from 1998 to 2000.
Costs of early treatment by a gynecologic oncologist were lower than without referral
The authors performed a retrospective analysis of a group of women with clinical stage-I endometrial cancer who were treated surgically at Prentice Women’s Hospital in Chicago.
The cohort was divided in two:
- Group 1 comprised patients who underwent surgery with a general gynecologist, who consulted a gynecologic oncologist intraoperatively
- Group 2 comprised patients who were referred to a gynecologic oncologist before surgery and underwent the procedure with a gynecologic oncologist.
Overall, subjects in both groups were similar in age, distribution of surgical stage, need for lymphadenectomy, and length of follow-up.
Group 2 had a significantly shorter operative time overall, and shorter total time in the operating room. Cost per procedure was also significantly lower in this group, in terms of cost to the payer and the physician’s charge. Perioperative costs were also lower in Group 2.
No difference was observed in postoperative outcome. Total hospital costs and lengths of stay were also similar.
Recommendation for practice
With health-care costs rising, be aware of referral strategies that promote cost containment. Women who have endometrial cancer may benefit from the early involvement of a gynecologic oncologist.
Mariani A, Dowdy S, Cliby W, et al. Prospective assessment of lymphatic dissemination in endometrial cancer: a paradigm shift in surgical staging. Gynecol Oncol. 2008;109:11–18.
The need for surgical staging of endometrial cancer has been recognized since surgical staging criteria were adopted by the International Federation of Gynecology and Obstetrics (FIGO) in 1988. Staging includes hysterectomy, bilateral salpingo-oophorectomy, and biopsy of any gross disease. Clear guidelines on the assessment of lymphatic dissemination and the anatomic extent of this assessment are, however, still lacking.
Proponents of systematic pelvic and para-aortic lymph-node dissection for patients with endometrial cancer cite:
- the 15% risk of lymph-node metastasis in women who have tumors 2 cm or larger in diameter2
- poor correlation between frozen-section grade and myometrial invasion with final pathology3
- the potential therapeutic benefit of the procedure.4
Opponents of such lymph-node dissection argue that women who have grade-1, stage-I disease will be overtreated if standardized lymphadenectomy is adopted.
Several retrospective studies have explored this question, with varying results. A large, prospective, randomized trial evaluating lymphadenectomy in clinical stage-I patients (ASTEC trial) has been completed, but is yet to be published.