Resource Use for Patients Undergoing Hysterectomy with or without Lymph Node Dissection for Endometrial Cancer

Abstract & Commentary

Synopsis: Age and racial/ethnic differences in comorbid illness, complications, and resource use exist for patients undergoing hysterectomy for endometrial cancer. Quantification of the complexity of care is of utmost importance for allocation of sufficient resources.

Source: Brooks SE, et al. Gynecol Oncol. 2002;85: 242-249.

Brooks and colleagues conducted a population-based analysis of patients undergoing hysterectomy for endometrial cancer in Maryland from 1994 to 1996. Of 1281 women undergoing hysterectomy, 91% had total abdominal hysterectomy, 6% underwent vaginal hysterectomy, 2.5% underwent radical hysterectomy, and 0.3% underwent laparoscopically assisted vaginal hysterectomy. Lymph node dissection was performed in 32% of the cohort. Neither age, nor race, nor comorbid illness influenced admission to teaching hospitals. Comorbidity was documented in 56% of cases. African Americans were more likely to have one (P = .002) or > 1 comorbid illness (P = .045) than Caucasians. The most common complications were anemia (13.6%), infection/fever (12%), cardiac (9.4%), pneumonia (8%), ileus (5%), and bowel obstruction (5%). These complications occurred with higher frequency in teaching hospitals (P = .0001), in large hospitals (P = .0001), and in African American patients compared to Caucasians (P = .028). Multivariate regression analysis revealed that older age, admission to teaching or large hospitals, lymph node dissection, heart disease, and African American race were associated with significantly higher resource use. Brooks et al concluded that age and racial/ethnic differences in comorbid illness, complications, and resource use exist for patients undergoing hysterectomy for endometrial cancer. The differences in resource use for teaching hospitals may be reflective of the severity of complications, which are indirectly determined by length of stay. Given the higher costs and skills required to care for elderly women with comorbid disease and complications, quantification of the complexity of care is of utmost importance for allocation of sufficient resources for the care of women with endometrial cancer.

Comment by David M. Gershenson, MD

The study findings reported herein are important, in that they detail that advanced age and ethnicity are associated with differences in comorbid illness, complications, and resource use for women with endometrial cancer undergoing surgery in Maryland. Previous studies have documented that African American women with endometrial cancer have a significantly decreased survival rate compared with Caucasian women. This study drills down to some of the reasons for this disparity—comorbid illnesses and complication rates. Of course, this population-based study did not include those women whose comorbidity precluded surgery; such women might be treated with radiotherapy alone, hormonal therapy, or no treatment at all. As Brooks et al also point out, the African American patients in their study were more likely to be uninsured or insured by Medicaid, suggesting that survival may be linked to income level. It is not surprising that teaching hospitals had higher rates of complications and longer lengths of stay, but the precise reasons for this finding remain elusive. There apparently was no difference in the rate of comorbidity between patients admitted to teaching hospitals vs. other types of hospitals. One wonders if more advanced disease resulting in more complicated treatment played a role in this observation. This study addresses resource use in a common cancer for women and underscores the need for further study in this area.

Dr. Gershenson is Professor and Chairman, Department of Gynecology, M.D. Anderson Cancer Center, Houston.