Study Identifies Reasons for Delays in Surgery for Endometrial Cancer

Some patients with endometrial cancer experience a delay in surgical treatment as a result of risk factors including geographical location, ethnicity and health insurance status, says Emily M. Ko, M.D.

Survival analyses studied the demographics and socioeconomic status of patients with endometrial cancer who had a delay of undergoing surgery of more than 12 weeks from diagnosis. From the National Cancer Database, researchers studied factors of 88,256 patients with type 1 disease (defined as grade 1/2 endometroid histology) and 40,009 patients with type 2 disease (nonendometroid and grade 3 histology).

Findings showed that age, African-American and Hispanic ethnicity, lack of Medicaid coverage, stage 2/3 disease, comorbidities, low-case volume at treating hospital, and eventual lymphadenectomy were significantly associated with delayed surgery for both type 1 and type 2 cancers. The surgical delay was also associated with a significant survival disadvantage at five years for type 1 cancers (86.6 percent vs 77.9 percent) and type 2 cancers (67.9 percent vs 60.5 percent).

In an interview with CURE, Ko, an assistant professor of Obstetrics and Gynecology at the University of Pennsylvania, discusses the implications of these findings for patients with endometrial cancer.

Please provide an overview of the study examining risk factors for surgical treatment delay in endometrial cancer.

This was a study conducted in the National Cancer Database, and we wanted to look at patients with endometrial cancer, in particular. We do know that, or sometimes assume, that if patients have a delay of care, they perhaps might not do as well in the long run. Could we figure out or understand better who might have a delay of care? Additionally, what factors might be involved in that delay?

What were the reasons for delay of care?

That is a really good question. From the database, we took the information that was available and looked at where patients were treated, whether it was an academic center or community hospital setting. We looked at insurance status, basic demographics, racial differences, age, socioeconomic status and we also looked at their medical baseline conditions. Taking all those factors into account, it was a sorting out process to see what were the key factors.

It looks like we did have to separate our patients into what we consider lower-risk patients with endometrial cancer versus higher-risk patients. Without diving too much into that, the factors that came out seemed to be related to age, African-American and Hispanic ethnicity, and some socioeconomic factors, including insurance status and coverage.

With these findings, is there a way to better care for these patients?

There definitely seems to be more work that needs to be done. It is not just a matter of why, for example, should race be a disparity. From an insurance status, why would that make a difference? Is it a matter of enough hospitals being available? Is it the daily logistics of getting an appointment? There are various factors that are underlying.

I do think there is room for improvement. It certainly is a global health system issue at a certain level, and down to the individual provider availability, as well.

How would you describe the treatment landscape for endometrial cancer?

Endometrial cancer is, in general, a fairly uniformly treated condition. Most patients tend to have surgery upfront as the first step in their treatment; there is a small fraction of patients who have an alternative form of treatment first, such as chemotherapy or radiation therapy rather than surgery. From the standpoint of a cancer, surgery is usually first.

There are other factors to consider, of course. Who is a good surgical candidate versus who has many risk factors and may not be a good candidate or might be at high risk for complications. Because most patients do undergo surgery first, we want to make sure that the mechanism to get there is really the most efficient and effective.

For now, surgery is the best treatment because most uterine and endometrial cancers are confined to the uterus, for the most part. For that reason, if you can get rid of the disease upfront, patients do well. There are subsets of the endometrial patient population who present differently; they have what we call higher-risk or higher-grade tumors. They may already have metastatic disease outside of the uterus. For those situations, we always think carefully whether surgery would be the best first step versus a nonsurgical option.

Are there potentially nonsurgical options we should pursue? There are some treatments, such as hormonal medications, radiation therapy, or chemotherapy that we will do upfront. Usually, they are for very specific reasons. That might involve fertility-sparing issues if a patient is very young and develops endometrial cancer and we are trying to spare their fertility. In that case, then we might try one of these conservative treatment management strategies instead of surgery.

What are the important takeaways from this study?

When we looked at the data a little more closely, some of the patients who had surgery within one week or under two weeks — which occurred more frequently at a community center — more often did not have lymph node assessment as part of their surgical treatment. What was the reason they had to be treated surgically so quickly? If there was just a little more time taken, could they have gone to a gynecologic oncology center? Maybe. Could they have had a little more of a comprehensive assessment and potentially alter their treatment course? There is not an exact solution for this at this point. We are just noticing that there seems to be certain factors or practice patterns that are a little bit different, depending on geographic location, practice settings, and things like that.

We would like the community and all of our physician colleagues and healthcare providers to try and understand as much as they can about the endometrial treatment process. Certainly, hysterectomy seems very simple in itself, but there are a lot of caveats about the additional biopsies, staging procedures, testing, and follow-up treatments to consider within endometrial cancer care.

What can be done in the short-term?

If a treatment is delayed too long — which we found to be about eight weeks — then there could be potentially worse outcomes, such as a slightly higher [rate] of death at five years. It is hard to understand exactly why that happens. We don’t have all of the detail of status between surgery and five years down the road but we, as clinicians, could somehow think about how we can most efficiently get from new diagnosis to appropriate management, including surgery. If we can help expedite their insurance coverage, those are all things that we could potentially improve upon and to really insure that patients hopefully get the optimal care that they can.