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Which Surgical Techniques Yield The Best Outcomes For Early Endometrial Cancer?
Photo Credit: Mohammed Haneefa Nizamudeen
Researchers compared surgical outcomes among patients with early endometrial cancer who underwent laparoscopic, robotic-assisted, or open surgery.
Minimally invasive surgery employing robotic-assisted or laparoscopic techniques appears to be safer and more effective than open surgery for the early treatment of endometrial cancer (EC), according to the authors of a review published in Cancers.
EC is currently the sixth most common cancer among women and the fifteenth most common cancer overall, with more than 417,000 new cases diagnosed in 2020.
Early symptoms most commonly include postmenopausal bleeding but can also include persistent intermenstrual and heavy vaginal bleeding associated with features of anovulation. Diagnosis involves a histological evaluation of an endometrial sample.
Based on evidence from randomized controlled trials (RCTs) demonstrating low post-operative morbidity with comparable oncological outcomes, current guidelines recommend minimally invasive surgery as the preferred route for early-stage EC. Purushothaman Natarajan and colleagues noted existing RCTs may report limited risks and outcomes and may not include a complete picture of different surgical approaches.
To better understand the benefits, complications, and outcomes associated with minimally invasive surgical options, the researchers conducted a systematic review and network meta-analysis, incorporating evidence from randomized and nonrandomized studies. The final sample included 99 studies, comprising 181,716 women and 14 different outcomes.
Primary outcomes included the duration of the operation, the length of stay in the hospital, blood loss, blood transfusions, postoperative complications, complications of uncertain timing, total complications, total intraoperative and postoperative complications, and oncologic outcomes, including disease-free survival and recurrence.
"The network meta-analysis, a random-effect model, was expanded with a Bayesian method that allowed the inclusion of direct and indirect comparisons of the surgical techniques used, allowing for a better understanding of the data," the authors wrote.
Comparing Surgical Methods"Compared with open surgery, laparoscopic and robotic-assisted surgery demonstrated reduced blood loss and length of hospital stay but increased operating time," Natarajan and colleagues wrote.
Laparoscopic and robot-assisted methods demonstrated significant differences in blood loss, −226.9 mL (95% CI, −298.4 to −155.9) and −257.2 mL (95% CI, −351.2 to −163.8), respectively, compared with open surgery. The difference between the two techniques was not statistically significant.
Both laparoscopic and robot-assisted options also demonstrated significant reductions in length of hospital stay, with mean differences of −3.54 days (95% CI, −4.22 to −2.87) and −3.79 days (95% CI, −4.79 to −2.79), respectively. Reduced hospital stays also correlated with reduced healthcare costs.
When compared with open surgery, robotic-assisted surgery was associated with a significant reduction in ileus (OR, 0.40; 95% CI, 0.17-0.87) and total intra-operative complications (OR, 0.38; 95% CI, 0.17-0.75), as well as a higher disease-free survival (OR, 2.45; 95% CI, 1.04-6.34).
The duration of operating time is one area where open surgery surpassed minimally invasive options, with an increase of 18.95 minutes (95% CI, 7.68–30.20) in laparoscopic and an added 29 minutes (95% CI, 13.66–44.23) in robot-assisted surgeries.
"Although the duration of surgery was slightly longer," the authors noted, "minimally invasive surgery was associated with significantly lower rates of complications during and after surgery, in conjunction with a possible superiority in oncological outcomes, compared with those who underwent open surgery."
Techniques Depend on Multiple FactorsThe study authors conducted a ranking analysis and determined that open surgery is often the best technique, considering the duration of the operation or total lymph nodes. Laparoscopic techniques may be preferred in cases of infections, venous thromboembolism, and recurrence.
Meanwhile, robot-assisted surgeries stood out as the best choice regarding blood loss, length of stay, disease-free survival, incidences of blood transfusion, fever, ileus, total complications, total intra-operative complications, and total postoperative complications.
"The main strength of this study is the inclusion of all relevant published data from both RCTs and cohort studies," Natarajan and colleagues concluded. "By including data from cohort studies that were excluded by previous systematic reviews, our study represents, to our knowledge, the most comprehensive summary to date of peri- and post-operative and oncological outcomes associated with surgical treatment for early EC."
Ultrasound Screening Often Misses Endometrial Cancer In Black Females
A new report found that a common screening technique used to assess the risk of endometrial cancer (EC) may be less effective in Black people.
The study, published in JAMA Oncology in June, discovered that pelvic transvaginal ultrasonography (TVUS) led to false negatives in a portion of Black females who actually had EC.
TVUS, which uses sound waves to produce a picture of the inside of the pelvis, is routinely recommended to females experiencing postmenopausal bleeding, which is a symptom of EC.
If the TVUS reveals that the individual has a thicker endometrial thickness (ET), they should also get a tissue biopsy to screen for EC.
Some Black females with EC have a relatively thin endometrial thickness — as a result, they don't get a biopsy, and the cancer is missed.
With EC, early detection is crucial.
"Since we know that ultrasound assessment is not always accurate in Black women, other screening modalities are essential for early cancer detection, including symptom awareness and advocacy," Elena Ratner, MD, MBA, a gynecologic oncologist at Yale Cancer Center and Smilow Cancer Hospital, told Healthline.
The report evaluated the health data of 1,494 Black individuals who underwent pelvic ultrasonography with an ET measurement before a hysterectomy.
Of the group, 210 had EC. In addition, 78% had fibroids, 71% had vaginal bleeding, and 57% had pelvic pain.
Of the 210 who had EC, about 11% had an ET that was below the diagnostic threshold for detection (4 mm).
The study found that roughly 9.5% of cancers detected in Black females were detected below the threshold of 4 mm, and 3.8% were in people who had an ET less than 3 mm.
An estimated 11.5% of the cancers would have been missed because the people had a relatively thin ET.
The findings suggest the most accurate way to identify EC in Black females is through a tissue biopsy.
Diana Pearre, MD, a board certified gynecologic oncologist at The Roy and Patricia Disney Family Cancer Center at Providence Saint Joseph Medical Center in Burbank, CA, says that the lead researcher of the study, Dr. Kemi Doll, has significantly added to the scant research that's been done surrounding health inequities in the diagnosis and treatment of endometrial cancer.
"The main takeaway I believe she wants us to understand is that we cannot rely simply on the image we see on an ultrasound report to determine whether to biopsy a patient with postmenopausal bleeding," Pearre said.
In many patient populations, TVUS is an effective way to measure ET and provide a risk assessment for EC.
"It is often used to determine whether patients should get a biopsy of the internal lining of the uterus and make sure there are no cancerous or precancerous changes in the lining," Amer Karam, MD, a gynecologic surgeon with Stanford Medicine, says.
However, the procedure doesn't appear to be as reliable in Black females.
Prior research has shown that Black females with postmenopausal bleeding are less likely to get an endometrial biopsy.
A study published in 2019 revealed that Black females are more likely to get false negative transvaginal ultrasounds compared to white females.
"In publications, ultrasound findings of being below a certain endometrial thickness threshold rule out the possibility of endometrial cancer. In Black women, that does not appear to be the case," Ratner said.
According to Karam, the majority of studies examining the accuracy of TVUS have been conducted in mostly white patients.
The researchers of the new report suspect that the decreased visibility of the cancers in Black females and the increased prevalence of fibroids may make the cancer harder to detect via TVUS alone.
"One other factor not examined in the current study is the higher prevalence of aggressive types of endometrial cancer that present with thinner linings among Black patients," Karam said.
Pearre suspects that many physicians will be surprised to see these new findings.
"I hope they take this study into account and refer patients to gynecologists when they report bleeding regardless of how thick the inner lining of their uterus is," Pearre said.
The researchers suggest that a tissue biopsy should always be done to provide an accurate diagnosis of EC.
According to Pearre, endometrial sampling is the cornerstone of EC diagnosis.
"If a patient reports bleeding after menopause or even heavy bleeding prior to menopause, endometrial sampling is probably the next best strategy in their workup," Pearre said.
A new report found that a common screening technique used to detect endometrial cancer risk may be less effective in Black people.
Pelvic transvaginal ultrasonography misses a significant percentage of cancer risk cases in Black females.
The most accurate way to detect endometrial cancer in Black females is through a tissue biopsy.
Diagnosis Of Neoplasia In Endometrial Biopsies
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