Reduce radiation use in uterine cancer

Assessment of lymph node cuts costs

A new study suggests that physicians are routinely assessing the extent of malignancies while patients are in endometrial cancer surgery.1

If your center isn’t routinely doing this, you should consider it because it reduces the cost of treating endometrial cancer by as much as $5,000 and reduces patient recovery time to a month. It’s a medical practice that bodes well for patients and third-party payers.

Called "surgical staging," this procedure enables surgeons to determine how far the cancer has spread and whether treatment will involve surgery alone or whether the patient must undergo irradiation therapy.

Avoid overtreating patients

Irradiation therapy involves longer recovery time and thousands of extra medical care dollars.

"Our goal is to fight the cancer without overtreating the patient," says the study’s lead author, Herbert F. Gretz III, MD, assistant professor of obstetrics and gynecology in the division of gynecologic oncology at New York Hospital-Cornell Medical College in New York City.

Overtreating was a possibility with the earlier, less precise methods of "clinical staging" that were widely used before 1976, explains Frank Major, MD, of the Colorado Gynecologic Oncology Group in Denver. The diagnostic methods used for clinical staging included physical examination of the uterus and cervix, lab analysis of uterine tissue samples, and CT scans.

Surgical staging is an important advancement, Major says, "because we can use the findings to tailor postoperative radiation therapy to fit the malignancy."

Gretz explains that surgical staging is particularly important for patients in the "gray area," meaning patients whose tumors are early stage (stage I: grades 1, 2, and 3) with various degrees of lymph node involvement. While the patient is in surgery, the surgeon performs lymphadenectomy, removal of lymph node sample tissue, followed by lab examination to determine the extent of malignant growth into the lymph nodes. The study’s findings show that surgical staging results in reductions of 16% to 23% in recommendations for follow-up radiation therapy.

With tumors that are confined to the uterus (grade 1), the lymph node sampling takes place 10% of the time, Major says, adding that the cure rate for such early cases of endometrial cancer is 90%. Additional factors influence the course a physician takes in determining when lymphadenectomy is the procedure of choice.

Lymphadenectomy takes more time, Gretz says. The removal and lab analysis of lymph node tissue requires an extra half-hour on the operating table, so the patient’s general health determines whether she’s up to it.

If the patient has a heart problem, diabetes, or high blood pressure, the doctor should weigh the risks of the extra time under anesthesia against the benefits of possibly avoiding post-surgical radiation, Gretz says. In addition, obesity may reduce the chances of obtaining an accurate assessment from lymphadenectomy, he says.

Staging cuts costs, speeds recovery time

In terms of tangible and intangible savings, there are many reasons to regard surgical staging as an important assessment tool in determining the treatment of early endometrial cancer. Major pegs radiation therapy costs at $5,000. Gretz says the figures can run as high as $10,000, depending on the geographic regions.

"With lymphadenectomy, we’re looking at extra operating room time with extra surgical, lab, and anesthesia fees," he says. "We have to take that trade-off into account when we figure the overall savings."

Brenda Gordon, RN, MS, administrative director of the St. Joseph Cancer Institute in Tampa, FL, raises a different cautionary note regarding overall savings. "If there is some involvement regionally, we have to look at the long range: Is it less costly to take care of it at once or have a recurrence and have to treat it again later?" Gordon asks.

Any patient who has undergone radiation therapy would agree that the savings of time and illness are definitely worthwhile whenever there’s an effective alternative to radiation. Major says recovery time after surgical treatment is typically four days in the hospital followed by four to six weeks at home before the patient is able to get back to her normal routine.

Radiation therapy is an altogether different story. Linda Schoales, RNC, ACCE, manager of the gynecological unit of women’s and children’s services at Morton Plant Mease Healthcare in Clearwater, FL, explains that the surgical wounds have to heal before radiation commences. That normally takes two weeks. Then, Major says, outpatient treatments of 30 minutes each, Monday through Friday, last five weeks. "It takes most women two months to regain their full energy after the last treatment," he says.

Since Gretz’s study determined that surgical staging is a widespread practice among gynecologic oncologists, there are valuable implications for your patients who are newly diagnosed with endometrial cancer and are weighing their treatment options.

You should ensure your physicians are up-to-date on surgical staging to determine the extent of malignancy and the course of post-surgical treatment.

Reference

1. Gretz III HF, Economos K, Husain A, et al. The practice of surgical staging and its impact on adjuvant treatment recommendations in patients with stage 1 endometrial carcinoma. J Gynecologic Oncology 1996; 61:409-415.