Contributing factors for menopausal symptoms after surgical staging for endometrial cancer

New Insights into the Assessment of Peri-Operative Risk in Women Undergoing Surgery for Gynecological Neoplasms: A Call for a New Tool

Existing tools for predicting postoperative complications in women undergoing surgery for gynecological neoplasms are evaluated in this narrative review. Although surgery is a very efficient therapy for gynecological tumors, it is not devoid of the possibility of negative postoperative outcomes. Widely used tools at present, such as the Surgical Apgar Score and the Modified Frailty Index, fail to consider the complex characteristics of gynecological malignancies and their related risk factors. A thorough search of the PubMed database was conducted for our review, specifically targeting studies that investigate several aspects impacting postoperative outcomes, including nutritional status, obesity, albumin levels, sodium levels, fluid management, and psychological well-being. Research has shown that both malnutrition and obesity have a substantial impact on postoperative mortality and morbidity. Diminished sodium and albumin levels together with compromised psychological well-being can serve as reliable indicators of negative consequences. The role of appropriate fluid management in enhancing patient recovery was also investigated. The evidence indicates that although current mechanisms are useful, they have limitations in terms of their range and do not thoroughly address these recently identified risk factors. Therefore, there is a need for a new, more comprehensive tool that combines these developing elements to more accurately forecast postoperative problems and enhance patient results in gynecological oncology. This paper highlights the need to create such a tool to improve clinical practice and the treatment of patients.

Prediction of high-risk factors for ovarian metastasis in patients with endometrial cancer: A large-sample retrospective case-control study

OBJECTIVE

To determine the high-risk factors of ovarian metastasis of endometrial cancer and their impact on prognosis.

METHODS

A retrospective case-control study was conducted on a large cohort of patients with endometrial cancer.

RESULTS

A total of 1240 patients with endometrial cancer were eligible for analysis, of whom 120 (9.7%) had ovarian metastasis. The patients with endometrial cancer with ovarian metastasis were more likely to have deep myometrial infiltration, lymph node metastasis, and elevated levels of CA125. The median survival was 39 months in patients with ovarian metastasis and 111 months in those without ovarian metastasis (P < 0.001). According to the stratified analysis, the progression-free survival (PFS) and overall survival in the low-risk group and PFS in the high-risk group of patients with endometrial cancer with ovarian metastasis were significantly shorter than those without ovarian metastasis (P < 0.0001, P = 0.0034, and P < 0.0001, respectively).

CONCLUSION

Deep myometrial invasion, lymph node metastasis, and elevated levels of CA125 may be independent high-risk factors for ovarian metastasis in patients with endometrial cancer. Ovarian metastasis has a greater impact on the prognosis of patients with low-risk endometrial cancer.

Ovarian conservation for young women with early-stage, low-grade endometrial cancer: a 2-step schema

In 2020, endometrial cancer continues to be the most common gynecologic malignancy in the United States. The majority of endometrial cancer is low grade, and nearly 1 of every 8 low-grade endometrial cancer diagnoses occurs in women younger than 50 years with early-stage disease. The incidence of early-stage, low-grade endometrial cancer is increasing particularly among women in their 30s. Women with early-stage, low-grade endometrial cancer generally have a favorable prognosis, and hysterectomy-based surgical treatment alone can often be curative. In young women with endometrial cancer, consideration of ovarian conservation is especially relevant to avoid both the short-term and long-term sequelae of surgical menopause including menopausal symptoms, cardiovascular disease, metabolic disease, and osteoporosis. Although disadvantages of ovarian conservation include failure to remove ovarian micrometastasis (0.4%-0.8%), gross ovarian metastatic disease (4.2%), or synchronous ovarian cancer (3%-5%) at the time of surgery and the risk of future potential metachronous ovarian cancer (1.2%), ovarian conservation is not negatively associated with endometrial cancer-related or all-cause mortality in young women with early-stage, low-grade endometrial cancer. Despite this, utilization of ovarian conservation for young women with early-stage, low-grade endometrial cancer remains modest with only a gradual increase in uptake in the United States. We propose a framework and strategic approach to identify young women with early-stage, low-grade endometrial cancer who may be candidates for ovarian conservation. This evidence-based schema consists of a 2-step assessment at both the preoperative and intraoperative stages that can be universally integrated into practice.

Patterns of utilization and outcome of ovarian conservation for young women with minimal-risk endometrial cancer

OBJECTIVE

To profile patient characteristics associated with and outcomes of ovarian conservation at the time of hysterectomy in young women with minimal-risk endometrial cancer.

METHODS

A population-based retrospective analysis of the Nationwide Inpatient Sample between 2007 and 2015 was performed. Women aged <50 with minimal-risk endometrial cancer who had ovarian conservation (n = 2314) were compared to those who had oophorectomy (n = 8191). A classification-tree model with recursive partitioning analysis was constructed to examine patterns of ovarian conservation. Propensity score matching was performed and length of stay and perioperative complications were compared. Two validation cohorts were also analyzed in a similar fashion (benign gynecologic disease and cervical cancer).

RESULTS

There were nine distinct patterns of patient characteristics identified, and ovarian conservation rates ranged from 11.7% (women aged 40-49 who underwent abdominal hysterectomy at an urban teaching hospital) to 60.5% (non-obese women aged <40 with median household income ≥$63,000) (absolute difference, 48.8%, 95% confidence interval 39.9-57.7; P < 0.001). After propensity score matching, ovarian conservation was significantly associated with a decreased likelihood of hospitalization >2 days (relative risk reduction, 16.7%, P < 0.001). Rates of surgical complications were not different between the two groups (8.2% versus 8.3%, P = 0.91). In the benign gynecologic disease and cervical cancer cohorts, ovarian conservation was also associated with decreased length of hospitalization (all, P < 0.05).

CONCLUSION

There is substantial variability in the utilization of ovarian conservation in young women with minimal-risk endometrial cancer based on patient, surgical, and hospital factors. Our study suggests that guidelines for ovarian conservation in this population would be helpful for improving patient selection and rates of ovarian conservation.

Increased risk for depression persists for years among women treated for gynecological cancers - a register-based cohort study with up to 19 years of follow-up

OBJECTIVE

Little is known about long-term risk of depression in women treated for gynecological cancers. We aim to investigate risk for depression among these women compared to women without a history of cancer.

METHODS

We followed 16,833 women diagnosed with gynecological cancers between 1998 and 2013 and 138,888 reference women in nationwide registers for up to 19 years. Women with a history of severe psychiatric disorders, and those who had redeemed a prescription for antidepressants three years before study entry were excluded from analyses. Regression analyses were applied to compare the risk for antidepressant use among patients compared to reference women, and to investigate associations between socio-demographic as well as clinical risk factors and use of antidepressants.

RESULTS

We found an increased risk for antidepressant use among women treated for ovarian (HR 4.14, 95% CI 3.74-4.59), endometrial (HR 2.19, 95% CI 1.97-2.45), and cervical cancer (HR 3.14, 95% CI 2.74-3.61) one year after diagnosis. This increased risk persisted years after diagnosis in all three groups, with the longest (up to eight years) found for ovarian cancer. Advanced disease was strongly associated with antidepressant use followed by short education, and comorbidity.

CONCLUSIONS

Women diagnosed with gynecological cancer have an increased risk for depression compared to reference women. The risk remains increased for years after diagnosis throughout and beyond standard oncological follow-up care. Advanced disease, short education, and comorbidity are factors associated with antidepressant use in this patient group.

Association between body mass index and surgical menopausal symptoms in patients with early stage endometrial cancer

OBJECTIVES

Premenopausal women may undergo surgical menopause after staging for their endometrial cancer. Our aim was to determine the association between body mass index (BMI) and surgical menopausal symptoms.

METHODS

We report a retrospective review of endometrial cancer patients whom underwent menopause secondary to their surgical staging procedure. Symptoms were classified as severe if treatment was prescribed, or mild if treatment was offered, but declined. Univariate analysis was performed with ANOVA and Chi-square tests as appropriate. Relative risks (RR) were generated from Poisson regression models.

RESULTS

We identified 166 patients in whom the BMI (kg/m²) distribution was as follows: 33 (19.9%) had BMI <30, 49 (29.5%) had BMI 30-39.9, 50 (30.1%) had BMI 40-49.9, and 34 (20.5%) had BMI ≥50. There were no differences in race, age, or adjuvant treatment among the groups. Overall, 65 (39.2%) women reported symptoms of surgical menopause, including 19 (11.4%) mild and 46 (27.7%) severe. Symptom type did not differ by BMI; however, the prevalence of severe menopausal symptoms decreased with increasing BMI: <30 (45.5%), 30-39.9 (30.6%), 40-49.9 (22%), and ≥ 50 (14.7%); P = 0.002. Multivariate analysis confirmed that symptom prevalence decreased with increasing BMI. Compared to women with a BMI of <30, those with a BMI 40-49.9 (RR = 0.39, 95% CI: 0.17-0.87) or ≥ 50 (RR = 0.24, 95% CI: 0.08-0.70) were significantly less likely to experience menopausal symptoms.

CONCLUSIONS

Women younger than 50 with BMI >40 and stage I endometrial cancer are significantly less likely than women with BMI <30 to experience menopausal symptoms after oophorectomy. This information may assist in peri-operative counseling.

Risk of Subsequent Ovarian Cancer After Ovarian Conservation in Young Women With Stage I Endometrioid Endometrial Cancer

OBJECTIVE

To examine the cumulative incidence of subsequent ovarian cancer among young women with stage I endometrioid endometrial cancer who had ovarian conservation at surgical treatment.

METHODS

This retrospective study examined the Surveillance, Epidemiology, and End Results Program to identify women aged younger than 50 years who underwent hysterectomy with ovarian conservation for stage I endometrioid endometrial cancer between 1983 and 2013. Time-dependent risk of ovarian cancer diagnosed during the follow-up after endometrial cancer diagnosis was examined.

RESULTS

Among 1,322 women in the study cohort, 16 women developed subsequent ovarian cancer with 5- and 10-year cumulative incidences of 1.0% and 1.3%, respectively. Median time to develop subsequent ovarian cancer was 2.4 years, and the majority of subsequent ovarian cancer was diagnosed within the first 3 years from the diagnosis of endometrial cancer (68.8%). The majority of subsequent ovarian cancer was endometrioid type (81.3%) and stage I disease (75.0%). With a median follow-up time of 11.6 years, there were no ovarian cancer deaths. Younger age at endometrial cancer diagnosis was significantly associated with increased risk of subsequent ovarian cancer (10-year cumulative incidences: age younger than 40 compared with 40-49 years, 2.6% compared with 0.4%, hazard ratio 5.00, 95% confidence interval [CI] 1.60-15.7, P=.002).

CONCLUSION

Young women with stage I endometrioid endometrial cancer have an approximately 1% risk of developing subsequent ovarian cancer after ovarian conservation at the time of hysterectomy that was associated with favorable tumor factors resulting in good ovarian cancer-specific survival. Our results endorse the importance of genetic testing and close follow-up when counseling about this procedure, especially for those who are younger than 40 years.

Ovarian Conservation and Overall Survival in Young Women With Early-Stage Low-Grade Endometrial Cancer

OBJECTIVE

To characterize contributing factors for ovarian conservation during surgical treatment for endometrial cancer and to examine the association of ovarian conservation on survival of young women with early-stage, low-grade tumors.

METHODS

This was a population-based study using the Surveillance, Epidemiology, and End Results program to identify surgically treated stage I type I (grade 1-2 endometrioid histology) endometrial cancer cases diagnosed between 1983 and 2012 (N=86,005). Multivariable models were used to identify independent factors for ovarian conservation. Survival outcomes and cause of death were examined for women aged younger than 50 with stage I type I endometrial cancer who underwent ovarian conservation (1,242 among 12,860 women [9.7%]).

RESULTS

On multivariable analysis, age younger than 50 years, grade 1 endometrioid histology, and tumor size 2.0 cm or less were noted to be independent factors for ovarian conservation (all, P<.001). For 9,110 women aged younger than 50 years with stage I grade 1 tumors, cause-specific survival was similar between ovarian conservation and oophorectomy cases (20-year rates 98.9% compared with 97.7%, P=.31), whereas overall survival was significantly higher in ovarian conservation cases than oophorectomy cases (88.8% compared with 82.0%, P=.011). On multivariable analysis, ovarian conservation remained an independent prognostic factor for improved overall survival (adjusted hazard ratio 0.73, 95% confidence interval [CI] 0.54-0.98, P=.036) and was independently associated with a lower cumulative risk of death resulting from cardiovascular disease compared with oophorectomy (20-year rates, 2.3% compared with 3.7%, adjusted hazard ratio 0.40, 95% CI 0.17-0.91, P=.029). Contrary, cause-specific survival (20-year rates 94.6% compared with 96.1%, P=.68) and overall survival (81.0% compared with 80.6%, P=.91) were similar between ovarian conservation and oophorectomy among 3,750 women aged younger than 50 years with stage I grade 2 tumors.

CONCLUSION

Ovarian conservation is performed in less than 10% of young women with stage I type I endometrial cancer. Ovarian conservation is associated with decreased mortality in young women with stage I grade 1 tumors.

Endometrial cancer arising in adenomyosis versus endometrial cancer coexisting with adenomyosis: are these two different entities?

PURPOSE

While adenomyosis is one of the most common benign histologic findings in hysterectomy specimens of endometrial cancer, demographics of endometrial cancer arising in adenomyosis (EC-AIA) has not been well elucidated. The aim of this study is to evaluate histopathological findings and disease-free survival (DFS) of EC-AIA in comparison to endometrial cancer coexisting with adenomyosis (EC-A).

METHODS

EC-AIA cases were identified via a systematic literature search (n = 46). EC-A cases were identified from a historical cohort that underwent hysterectomy-based surgical staging in two institutions (n = 350). Statistical comparisons of the two groups were based on univariate and multivariate analyses.

RESULTS

The EC-AIA group was significantly older than the EC-A group (58.9 versus 53.8, p = 0.002). As to tumor characteristics, 63.6% of EC-AIA cases reported tumor within the myometrium without endometrial extension. The EC-AIA group was significantly associated with more non-endometrioid histology (23.9 versus 14.8%; p = 0.002) and deep myometrial tumor invasion (51.6 versus 19.4%; p < 0.001) than EC-A. Tumor grade, stage, and nodal metastasis risk were similar (all, p > 0.05). In a univariate analysis, the EC-AIA group had a significantly decreased DFS compared to EC-A (5-year rates, 72.2 versus 85.5%, p = 0.001). After controlling for age, histology, tumor grade, and stage, EC-AIA remained an independent prognostic factor associated with decreased DFS compared to EC-A (adjusted-hazard ratio 2.87, 95% confidence interval 1.44-5.70, p = 0.031).

CONCLUSION

Our study demonstrated that EC-AIA has distinct tumor characteristics and a poorer survival outcome compared to EC-A. This suggests a benefit of recognition of this unique entity as an aggressive variant of endometrial cancer.