Outcomes of Endometrial Cancer Patients Undergoing Surgery With Gynecologic Oncology Involvement
Abstract & Commentary
Synopsis: Involvement of a gynecologic oncologist at the time of primary surgery for endometrial cancer was associated with comparable outcomes in both the university and community hospital setting.
Source: Pearl ML, et al. Obstet Gynecol. 2002;100: 724-729.
Pearl and associates undertook this study to compare the outcomes of patients with endometrial cancer who had primary surgery with gynecologic oncology involvement at university or community hospitals. The patients were divided into 2 groups based on whether their surgery was performed at a university or community hospital. There were no significant differences between the 2 groups with regard to Quetelet index; intervals between biopsy and consultation, consultation and surgery, and biopsy and surgery; estimated blood loss; incidence of operative or hospital complications; frequency of appropriate surgical staging; stage distribution; histology or grade; and hospital stay. Patients at a university hospital were significantly older, had a higher severity index, and were more likely to have had a vaginal hysterectomy and participate in a research protocol. Both the Quetelet index and the severity index were significantly higher for patients who had vaginal hysterectomy than for those who had either laparoscopically assisted vaginal hysterectomy or total abdominal hysterectomy. When analyzed by surgical approach, the frequencies of pelvic and para-aortic lymph node sampling were comparable between the groups. Both the Quetelet and severity indices were significantly higher for patients who did not have lymph node sampling. Pearl and colleagues conclude that involvement of a gynecologic oncologist at the time of primary surgery for endometrial cancer was associated with comparable outcomes in both the university and community hospital setting.
Comment by David M. Gershenson, MD
In recent commentaries on endometrial cancer, I have raised some issues related to adequacy of surgical staging comparing generalists with gynecologic oncologists. Because most general obstetrician gynecologists are not trained to perform lymph node sampling, they typically take one of 3 approaches: 1) involve a gynecologic oncologist; 2) involve another type of surgeon—general surgeon, urologist, etc; or 3) do not perform lymph node sampling. This article is focused on yet another important question: Do endometrial cancer patients have comparable outcomes, regardless of the setting—community-based vs university-based institutions? The simple answer is yes, in this case. One university-based gynecologic oncology group, operating in 2 university hospitals and 5 community hospitals, was able to deliver the same quality of care in these 2 distinct settings. Not surprisingly, university-based patients were older and had a significantly higher preoperative severity index, reflecting the fact that elderly and sicker patients are referred to a university setting more frequently. Of course, these were the same gynecologic oncologists operating in both settings. We don’t really know how far we can extrapolate these findings; for instance, would similar findings be achieved if one compared a university-based group with a community-based group? Although I would predict that the answer is yes, we don’t know this from the present study. In addition, I would underscore one other point not emphasized by Pearl et al: community-based patients were enrolled in clinical trials significantly less frequently than university-based patients—10% vs 26% (P = .004). We need to develop the infrastructures to make clinical trials more accessible to community-based patients. The pediatric oncology community has been very successful in this area, but the same is not true for adult cancer patients and their physicians.
Dr. Gershenson is Professor and Chairman, Department of Gynecology, M.D. Anderson Cancer Center, Houston, Tex.