Special Feature
Why American Women Are Not Receiving State-of-the-Art Care for Endometrial Cancer
By David M. Gershenson, MD
Endometrial cancer is the most common gynecologic malignancy. In 1988, the International Federation of Gynecology and Obstetrics (FIGO) changed the staging system from a clinical to a surgicopathologic staging.1 Primary treatment consists of hysterectomy and bilateral salpingo-oophorectomy, and a thorough investigation to establish the presence or absence of extrauterine disease. Surgical staging includes peritoneal cytology and bilateral pelvic and paraaortic lymphadnectomy. When the cancer is confined to the uterus, as documented by comprehensive surgical staging, the cure rate exceeds 85%.2-4 Patients who have extrauterine disease may benefit from postoperative treatment and can become long-term survivors.5,6 If extrauterine disease is not recognized at primary surgery, the patient will eventually develop clinically recurrent tumor, and the probability of cure in that setting is dismal.
Patients with low-grade and/or minimally invasive endometrial cancer may not require lymphadenectomy since less than 5% may have nodal metastases; however, this decision is best made intraoperatively. Ideally, after removal of the uterus, the pathologist should determine the grade and depth of myometrial invasion by frozen section analysis. Therefore, predicting the extent of surgical staging preoperatively is not very reliable. In addition, patients with extensive extrauterine disease may benefit from cytoreductive surgery, a procedure best performed by a gynecologic oncologist.7,8
Resection of retroperitoneal lymph nodes may be therapeutic in a significant proportion of endometrial cancer patients.9,10 When performed by surgeons who are appropriately trained, morbidity associated with comprehensive surgical staging is acceptable.11,12 Failure to adequately stage endometrial cancer surgically may significantly compromise decision making about adjuvant treatment and thus lead to either overtreatment (additional surgery, unnecessary radiotherapy, etc) or undertreatment. Overtreatment may result in unacceptable morbidity or mortality, and undertreatment may lead to preventable relapse and death.
In a Patient Care Evaluation Study of the National Cancer Database of the American College of Surgeons, 713 hospitals submitted data on 9954 cases of endometrial cancer.13 Only 2937 (30%) of the patients had pathological lymph node evaluation. Thirty-three percent of the patients had a gynecologic oncologist as the primary surgeon, and 11% as the assistant surgeon. Sixty-one percent of patients had nodal evaluation if the primary surgeon was a gynecologic oncologist, compared with only 24% if an obstetrician-gynecologist.
Therefore, in an ideal world, a gynecologic-oncologist should perform surgery on every woman with endometrial cancer. An alternative would be to have the gynecologic oncologist on standby call if comprehensive surgical staging is required. However, most gynecologic oncologists feel that this latter practice is detrimental and should be discouraged.14 Another obvious alternative would be development of an algorithm by which low-risk patients would be operated on by obstetrician-gynecologists and high-risk patients would be referred to gynecologic oncologists, but the unpredictability of intraoperative findings makes this option somewhat unattractive.
The issue of the value of adjuvant treatment—principally radiotherapy—for high-risk or incompletely staged patients remains a topic of debate. Adjuvant radiotherapy studies are difficult to conduct because of the relatively low frequency of events and the large number of patients required to adequately power such trials. In general, the evidence suggests that the use of adjuvant radiotherapy reduces the risk of local recurrence but has no appreciable effect on overall survival.15 There is a palpable trend toward avoiding radiotherapy in an increasingly larger proportion of patients, but this direction is influenced only slightly, in my view, by turf battles. In my judgment, the cooperative groups—the Gynecologic Oncology Group and the Radiation Therapy Oncology Group—could combine their efforts in a more efficient manner to resolve many of the issues surrounding adjuvant radiotherapy. The major issue is that American women are, in many instances, not receiving optimal care for endometrial cancer.
The reasons for the current status are myriad and include the following: 1) the unregulated nature of the American health care system; 2) a failure of professional education with regard to surgical expertise and/or referral algorithms; 3) conflicts of interest between physicians and patients or disincentives to refer patients to appropriate specialists; and 4) lack of optimal clinical trials by academic institutions and cooperative groups.
The quality of gynecologic cancer care for American women must be the overarching principle. Recommendations to improve care for patients with endometrial cancer include enhanced public education, promotion of practice guidelines and referral guidelines, improved monitoring systems for adherence, continued outcomes studies, and establishment of centers of excellence. In addition, the American health care system requires radical change. Among the initiatives should be support of subspecialty care by the American College of Obstetricians and Gynecologists and state and federal legislation to ensure optimal gynecologic cancer care for American women.
References
1. Mikuta JJ. Cancer. 1993;71:1460-1463.
2. Orr JW. Am J Obstet Gynecol. 1997;176:777-789.
3. Larson DM, et al. Obstet Gynecol. 1998;91:355-359.
4. Fanning J, et al. Obstet Gynecol. 1996;87:1041-1044.
5. Rose PG, et al. Int J Radiat Oncol Biol Phys. 1992;24:229-233.
6. Onda T, et al. Br J Can. 1997;75:1836-1841.
7. Chi DS, et al. Gynecol Oncol. 1997;67:56-60.
8. Bristow R, et al. Gynecol Oncol. 2000;76:240.
9. Kilgore LC, et al. Gynecol. 1995;56:29-33.
10. Mariani A, et al. Gynecol Oncol. 2000;76:348-356.
11. Homesley HD, et al. Am J Obstet Gynecol. 1992;167: 1225-1230.
12. Larson DM, et al. Obstet Gynecol. 1992;29:998-1001.
13. Partridge EE, et al. Gynecol Oncol. 1999;72:445.
14. Messing MJ. Gynecol Oncol. 2001;80:298.
15. Roberts JA, et al. Gynecol Oncol. 1998;68:135.
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