Brazilian Society of Surgical Oncology guidelines for surgical treatment of endometrial cancer in regions with limited resources

Management of endometrial cancer in Latin America: raising the standard of care and optimizing outcomes

Molecular characterization of endometrial cancer is allowing for increased understanding of the natural history of tumors and paving a more solid pathway for novel therapies. It is becoming increasingly apparent that molecular classification is superior to histological classification in terms of reproducibility and prognostic discrimination. In particular, the Proactive Molecular Risk Classifier for Endometrial Cancer allows classification of endometrial cancer into groups very close to those determined by the Cancer Genome Atlas Research Network-that is, DNA polymerase epsilon-mutated, mismatch repair-deficient, p53 abnormal, and non-specific molecular profile tumors. The transition from the chemotherapy era to the age of targeted agents and immunotherapy, which started later in endometrial cancer than in many other tumor types, requires widespread availability of specialized pathology and access to novel agents. Likewise, surgical expertise and state-of-the-art radiotherapy modalities are required to ensure adequate care. Nevertheless, Latin American countries still face considerable barriers to implementation of international guidelines. As we witness the dawn of precision medicine as applied to endometrial cancer, we must make continued efforts towards improving the quality of care in this region. The current article discusses some of these challenges and possible solutions.

Management of patients with recurrent/metastatic endometrial cancer: Consensus recommendations from an expert panel from Brazil

Background

Endometrial cancer is of increasing concern in several countries, including Brazil, in part because of an ageing population, declines in fertility, and the increasing prevalence of obesity. Although endometrial tumors had lagged behind other cancer types in terms of treatment improvements, molecular characterization of these tumors is paving the way for novel therapies and an expansion of the therapeutic arsenal. We aimed to help medical oncologists who manage patients with recurrent or metastatic endometrial cancer in the Brazilian healthcare setting.

Methods

The panel, composed of 20 medical oncologists, convened in November 2021 to address 50 multiple-choice questions on molecular testing and treatment choices. We classified the level of agreement among panelists as (1) consensus (≥75% choosing the same answer), (2) majority vote (50% to <75%), or (3) less than majority vote (<50%).

Results

Consensus was present for 25 of the 50 questions, whereas majority vote was present for an additional 23 questions. Key recommendations include molecular testing for every patient with recurrent/metastatic endometrial cancer; choice of first-line treatment according to microsatellite instability and HER2, with the addition of programmed death ligand 1 (PD-L1) and hormone receptors (HRs) for second-line therapy; carboplatin and paclitaxel as the preferred option in first-line treatment of HER2-negative disease, with the addition of trastuzumab in HER2-positive disease; pembrolizumab plus lenvatinib as a key option in second line, regardless of HER2, PD-L1 or HRs; and various recommendations regarding treatment choice for patients with distinct comorbidities.

Conclusion

Despite the existing gaps in the current literature, the vast majority of issues addressed by the panel provided a level of agreement sufficient to inform clinical practice in Brazil and in other countries with similar healthcare environments.

Survival after laparoscopy versus laparotomy for apparent early-stage uterine clear cell carcinoma: Results of a large multicenter cohort study

Objective

To compare the long-term survival between laparoscopic surgery and open surgery in patients with apparent early-stage uterine clear cell carcinoma (UCCC).

Patients and methods

254 patients with apparent early-stage UCCC were reviewed. Comparisons were made between patients who underwent laparoscopic surgery versus those who underwent open surgery. Baseline data, clinicopathological data, and oncological outcomes were analyzed. 5-year disease-free survival (DFS) rate and 5-year overall survival (OS) rate were estimated and compared using the Kaplan-Meier method and the Log-rank test. The Cox proportional hazard regression model was employed to control the confounding factors.

Results

147 patients underwent laparoscopic surgery, and 107 patients were managed by open surgery. No differences in terms of recurrence rate (laparoscopy versus laparotomy: 10.9% versus 12.9%, P=0.842) and recurrence pattern were observed. For patients who underwent open surgery and patients who underwent laparoscopic surgery, the 5-year DFS rates and 5-year OS rate were 75.8% (95% CI: 65.8%-83.2%) and 69.1% (95% CI: 58.8%-77.4%), 66.0% (95% CI: 57.1%-73.5%) and 60.8% (95% CI: 52.0%-68.5%), respectively. The Cox proportional hazards regression model shown that for apparent early-stage UCCC, the approach of surgical staging was not an independent predictor for survival (laparoscopy versus laparotomy: for DFS, aHR=1.06, 95% CI=0.64-1.75, P=0.826; for OS, aHR=1.10, 95% CI=0.72-1.68, P=0.671).

Conclusion

For apparent early-stage UCCC, in terms of oncological survival, laparoscopic surgery was as safe as open surgery.

Assessment of diagnostics capacity in hospitals providing surgical care in two Latin American states

BACKGROUND

Diagnostic services are an essential component of high-quality surgical, anesthesia and obstetric (SAO) care. Efforts to scale up SAO care in Latin America have often overlooked diagnostics capacity. This study aims to analyze the capacity of diagnostic services, including radiology, pathology, and laboratory medicine, in hospitals providing SAO care in the states of Chiapas, Mexico and Amazonas, Brazil.

METHODS

A stratified cross-sectional evaluation of diagnostic capacity in hospitals performing surgery in Chiapas and Amazonas was performed using the Surgical Assessment Tool (SAT). National data sources were queried for indicators of diagnostics capacity in terms of workforce, infrastructure and diagnosis utilization. Fisher's exact tests and chi-square tests were used to compare categorical variables between the private and public sector in Chiapas while descriptive statistics are used to compare Amazonas and Chiapas.

FINDINGS

In Chiapas, 53% (n = 17) of public and 34% (n = 20) of private hospitals providing SAO care were assessed. More private hospitals than public hospitals could always provide x-rays (35% vs 23.5%) and ultrasound (85% vs 47.1%). However neither sector could consistently perform basic laboratory testing such as complete blood counts (70.6% public, 65% private). In Amazonas, 30% (n = 18) of rural hospitals were surveyed. Most had functioning x-ray machine (77.8%) and ultrasound (55.6%). The majority of hospitals could provide complete blood count (66.7%) but only one hospital (5.6%) could always perform an infectious panel. Both Chiapas and Amazonas had dramatically fewer diagnostic practitioners per capita in each state compared to the national average capacity.

INTERPRETATION

Facilities providing SAO care in low-resource states in Mexico and Brazil often lack functioning diagnostics services and workforce. Scale-up of diagnostic services is essential to improve SAO care and should occur with emphasis on equitable and adequate resource allocation.