Wait Times Do Not Affect Survival in Endometrial Cancer

Pam Harrison

January 15, 2015

Longer wait times between endometrial biopsy and surgical staging do not compromise prognosis in women with type I endometrial cancer, with the possible exception of those with more aggressive underlying disease.

This finding comes from a retrospective study published online January 7 in Obstetrics & Gynecology.

Endometrial cancer is the most common gynecologic malignancy in the United Sates, note lead investigator Koji Matsuo, MD, PhD, from the Los Angeles County Medical Center at the University of Southern California, and colleagues.

Because the majority of these cancers are characterized by low-grade tumors and early-stage disease, prognosis is generally good after hysterectomy-based surgical treatment.

"Many patients with endometrial cancer have comorbidities that require preoperative clearance, and that can be a lengthy process and lead to delays between diagnosis and time of surgery," Dr Matsuo told Medscape Medical News. In addition, women can face either socioeconomic or geographic challenges that impede timely referral to a specialist, he explained.

"Since delay for these reasons is relatively common, it is helpful to know whether such a delay has a prognostic impact," he said.

The review involved 435 patients with grade 1 and 2 endometrioid adenocarcinoma diagnosed by preoperative endometrial biopsy. All patients had undergone hysterectomy-based surgical staging from 2000 to 2013.

The wait time for surgical staging was defined as the time between endometrial biopsy and hysterectomy. Tumor grade was based on the International Federation of Gynecology and Obstetrics (FIGO) system for endometrial cancer.

The mean age at diagnosis was 52.2 years, and 70.6% of the patients were Hispanic. More than 70% of the cohort had a body mass index of at least 30 kg/m², and 87.1% had early-stage (I to II) disease.

"The median wait time for surgical staging was 57 days," the investigators note, but times ranged from 1 to 177 days. Approximately 17% of the cohort waited more than 85 days for surgical staging.

"Patients going to surgery in 1 to 14 days tended to be either emergent because of hemorrhage from the uterus or have advanced disease, both of which are negative prognostic factors," Dr Matsuo reported.

In fact, "as a group, those going to the operating room in 1 to 14 days had worse prognostic disease than the other groups," he explained.

Table. Five-year Survival Rates

Wait Time, Days Disease-free Survival, % Overall Survival, %
1–14 56.5 62.5
15–42 86.5 93.6
43–84 91.2 95.2
≥85 100.0 100.0

 

As expected, advanced-stage disease at the time of hysterectomy was associated with decreased disease-free and overall survival on multivariable analysis (P < .001 for both).

Change in Tumor Grade

The investigators also examined whether the time between biopsy and hysterectomy had any effect on changes in tumor grade.

They found 29.4% of the cohort experienced a change in tumor grade during the wait time.

Of the 4.7% of women who had a grade 1 tumor at biopsy and the 18.4% who had a grade 2 tumor, only 8.3% were upgraded to grade 3 at hysterectomy.

On multivariable analysis, both disease-free and overall survival at 5 years were significantly worse in women with tumors upgraded from grade 1 at biopsy to grade 3 at hysterectomy than in women with grade 1 tumors at hysterectomy (P < .001). The same was not true for women with tumors upgraded from grade 2 at biopsy to grade 3 at hysterectomy.

Asked about this apparent paradox, Dr Matsuo explained that the sample size for both of these subgroups was small and the differences might be due to error alone.

He added that there was no significant difference in survival between women with tumors upgraded from grade 1 to grade 3 and those upgraded from grade 2 to grade 3.

"Wait time for surgical staging was not associated with decreased survival outcome in patients with type I endometrial cancer," the investigators conclude. Although their findings are reassuring, they point out that if a patient has grade 1 disease but no risk factors for type I endometrial cancer (obesity, anovulation), or if there is evidence of advanced disease on CT, "there might be a negative prognostic impact from delay as these are patients who are more likely to have more aggressive underlying disease."

The authors have disclosed no relevant financial relationships.

Obstet Gynecol. Published online January 7, 2015. Abstract

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