A prospective regional audit of surgical management of endometrial cancer in the South and West of England

Should Endometrial Cancer Treatment Be Centralized?

Endometrial cancer (EC) is the most common malignancy of the female genital tract in Western and emerging countries. In 2012, new cancer cases numbered 319,605, and 76,160 cancer deaths were diagnosed worldwide. ECs are usually diagnosed after menopause; 70% of ECs are diagnosed at an early stage with a favorable prognosis and a 5-year overall survival rate of 77%. On the contrary, women with advanced or recurrent disease have extremely poor outcomes because they show a low response rate to conventional chemotherapy. EC is generally considered easy to treat, although it presents a 5-year mortality of 25%. Though the guidelines (GLs) recommend treatment in specialized centers by physicians specializing in gynecologic oncology, most women are managed by general gynecologists, resulting in differences and discrepancies in clinical management. In this paper we reviewed the literature with the aim of highlighting where the treatment of EC patients requires gynecologic oncologists, as suggested by the GLs. Moreover, we sought to identify the causes of the lack of GL adherence, suggesting useful changes to ensure adequate treatment for all EC patients.

The effect of rural vs. urban setting on the management and outcomes of surgery for endometrial cancer

INTRODUCTION

To evaluate the proportion of endometrial cancers surgically managed in rural centers, and to compare the surgical management and perioperative morbidity of hysterectomies for endometrial cancer performed in rural settings with those performed in urban settings.

MATERIALS AND METHODS

We conducted a retrospective cohort study using the Nationwide Inpatient Sample (NIS) database from 2003 to 2010. We included all patients diagnosed with endometrial cancer who underwent a hysterectomy and compared surgical approaches, lymph node dissection rates, perioperative complication rates, and lengths of stay according to location of care provided (rural versus urban centers), using multivariate logistic regression models.

RESULTS

Of the 52,299 women who underwent surgery for endometrial cancer, 6% were performed in rural centers-a proportion that trended down over the study period. A disparity in surgical management was noted between rural versus urban settings, with rural centers having lower rates of laparoscopy and robotics (6.9% vs. 18.5%; OR 0.35, CI 0.30-0.40), and lower rates of lymph node dissection both overall (39.4% vs. 67.0%; OR 0.32, CI 0.30-0.35) and for early (37.2% vs. 66.2%; OR 0.30, 95%CI 0.28-0.33) and advanced (57.7% vs. 71.7%; OR 0.56, 95% CI 0.44-0.70) stage disease. Perioperative morbidity was comparable in both settings, with lower rates of transfusion, sepsis, wound infection, ileus, and prolonged hospitalization in rural settings.

CONCLUSIONS

Although women obtaining care for endometrial cancer in rural centers receive differential surgical management than women cared for in urban centers, perioperative morbidity appears to be overall comparable.

Province wide clinical governance network for clinical audit for quality improvement in endometrial cancer management

BACKGROUND

According to the hub-and-spoke model introduced in the Provincial Healthcare System of Reggio Emilia, early endometrial cancer is treated in peripheral low-volume hospitals (spokes) by general gynecologist, whereas more complex cancers are treated by gynecological oncologists at the main hospital (hub).

OBJECTIVE

To guarantee a uniformly high standard of care to all patients with endometrial cancer treated in hub and spoke hospitals of Reggio Emilia Province.

METHODS

The specialists of the 5 hospitals of Reggio Emilia Province instituted an inter hospital and multidisciplinary oncology group to write common and shared guidelines based on evidence-based medicine through the use of clinical audit. They valued the process indicators before and after guidelines introduction identifying the site of improvement and verifying the standard achievement.

RESULTS

Diagnostic hysteroscopy use increased significantly from preguideline period, 53%, to postguideline period, 74%. Magnetic resonance use and accuracy increased significantly from preguideline to postguideline periods: 8.1% to 35.3% and 37.3% to 74.7%, respectively. Laparoscopy use increased from 1.6% (preguideline) to 18.6 (postguideline). Early surgical complications decreased from 16% (preguideline) to 9% (postguideline). Radiotherapy use increased from 14.% (preguideline) to 32.3% (postguideline).

CONCLUSION

It is possible for a provincial oncology group to build an oncology network providing an improvement in the assistance of patients with endometrial cancer through the use of clinical audit. Clinical audit made it possible to obtain the full attendance of specialists of various disciplines involved in the treatment of endometrial cancer to optimize response time schematizing process.

Surgical management of endometrial cancer in Slovak Republic

AIM

To evaluate the routine surgical treatment of endometrial cancer in Slovak Republic in relation to current international recommendations.

METHODS

A retrospective study based on a questionnaire was undertaken. Data on surgical and post-operative adjuvant therapy of endometrial cancer patients in Slovakia in 2001 were collected, assessed and validated for good clinical practice.

RESULTS

We presented data of 298 cases of endometrial adenocarcinoma from 48 of 66 Slovak gynecologic departments. Laparotomy with hysterectomy and bilateral salpingo-oophorectomy was performed in 280/298 patients. Peritoneal washings were examined in 41/298 cases. Lymphadenectomy (pelvic and/or para-aortic) was performed in 52/298 of the women. Malignancy remained undiagnosed in 29/298 of the cases until it was detected by histological investigation of extirpated uterus.

CONCLUSION

The study demonstrates that surgical management of endometrial cancer is far from optimal. It seems necessary to restrict treatment to the centres with gynecologic oncologists trained in pelvic surgery.