Two Surgeries at Once: Endometrial Cancer & Stress Incontinence

Pam Harrison

March 26, 2019

HONOLULU, Hawaii — Women who require surgery for endometrial cancer and who choose to also have surgery to treat concomitant stress urinary incontinence (SUI) are significantly more likely to enjoy a better quality of life (QoL) at 6 months than women with the same conditions who opt for cancer surgery alone, new research shows.

"One of the reasons these two surgeries have not been done together historically is because coordinating surgeons' time is never easy," Katina Robison, MD, research program director, Women and Infants Hospital, Brown University, Providence, Rhode Island, told Medscape Medical News.

"But we found that adding SUI surgery really did not change the amount of time surgeons spent in surgery, and it didn't seem to delay the cancer surgery either," she said.

"Also, while everybody's quality of life goes up after surgery because the cancer is gone, quality of life went up more among the concomitant surgery group, which I think shows how much SUI means to women," she added.

The study was presented here at the Society of Gynecologic Cancers (SGO) Annual Meeting 2019.

The multicenter prospective study was carried out in eight hospitals in the United States. It involved women with endometrial intraepithelial neoplasia or clinical stage I–II endometrial cancer and SUI.

"Those who screened positive [for SUI] were offered a preoperative referral to a urogynecologist and informed of all treatment options, including concomitant surgery," the researchers state.

Of the 1322 women screened, 53.1% were found to have SUI.

Of the women with endometrial cancer and SUI, 509 were evaluable. Of these, 21% chose to have concomitant surgery for endometrial cancer and SUI; 60% chose cancer surgery alone; and 19% chose a nonsurgical treatment for SUI, such as kegel exercises.

Women who chose to have their SUI treated surgically underwent the sling procedure. In that procedure, surgeons create a sling or hammock under the urethra or the bladder neck to support the structures and to help keep the urethra closed during coughing or sneezing.

QoL was measured using the Functional Assessment of Cancer Therapy–Endometrial at baseline, at 6 weeks, and at 6 months. Scores were compared at the end of the 6-month assessment.

After adjusting for demographics, clinical measures, and severity of SUI at baseline, the investigators found that QoL increased for all groups from baseline, at 6 weeks, and at 6 months after surgery (P < .0001 overall).

The mean difference in QoL (of 4.60) of the women who chose concomitant surgery compared to those who chose cancer surgery alone was statically significant (P = .008), Robison added.

The mean difference in QoL between women who chose concomitant surgery and those who chose a nonsurgical option for treatment of SUI was smaller, at 3.81. This difference did not quite reach statistical significance (P = .065), but it is likely to become significant with further follow-up, Robison suggested.

Women Decide Which Surgery to Opt For

Robison noted that the real goal of the study was to ensure that women had all the information they needed to make a decision about the SUI treatment that was right for them.

At the same time, the researchers needed to ascertain how feasible it was for two surgeons to work together on separate procedures in the same patient and how well scheduling of those procedures worked.

Sometimes it required that the urogynecologist on call in the operating room carry out a timely sling procedure, rather than the surgeon who had seen the patient in the office, Robison noted.

However, she and her colleagues found that all of the urogynecologists in the eight centers in the study were "very accommodating" and that "everything was done in the patient's best interest to keep her on schedule and make sure that they were able to have these surgeries seamlessly," Robison said.

Common Risk Factors

Endometrial cancer shares a number of common risk factors with SUI, including obesity and diabetes.

The prevalence rate of SUI among women with endometrial cancer is therefore higher than it would be in the general population, Robison noted.

"However, SUI is still more common than most women know about — and most do not seek care for it. They just wear pads and they suffer through it," she said.

Perhaps not surprisingly, the women in the study who chose concomitant surgery had more severe symptoms of SUI, and they were more motivated to undergo treatment of those symptoms than the women who chose to cope with symptoms as usual.

Concomitant Surgery Approach

Asked by Medscape Medical News to comment on the concomitant surgery approach, John Curtin, MD, professor of gynecologic oncology, Perlmutter Cancer Center, NYU Langone Health, New York City, observed that the study highlights the fact that, first and foremost, SUI is a common problem among women with endometrial cancer.

"SUI can be identified by asking a simple question during the initial history and physical evaluation of the patient," Curtin noted in an email.

Curtin pointed out that the success of the current approach depended on teamwork between gynecologic oncology surgeons and female pelvic medicine and reconstructive surgery specialists who were able to see and evaluate patients with SUI in a timely fashion.

"Overall, this represents an efficient model which allows for concomitant surgical treatment of the patient's endometrial cancer and SUI, presumably resulting in overall cost savings and demonstrable improvement in quality of life for patients," Curtin said.

Session co-discussant Barbara Goff, MD, chair of obstetrics and gynecology, University of Washington, Seattle, told Medscape Medical News that the main point of the study is that it is very feasible to perform both surgeries at the same time.

"There is a big need [for concomitant surgery], as many of these women have undiagnosed SUI, and doing the procedures at the same time didn't add on a lot of time to the procedure and didn't delay surgery for cancer," she reiterated.

"Treatment of SUI also improved QoL, and so [performing the surgeries together] is very reasonable to consider," she added.

"This information should prompt gynececologic oncologists and urogynecologists to work more closely together," Goff concluded.

Robison and Goff have disclosed no relevant financial relationships. Curtin has served as an expert witness on behalf of Quest Diagnostics.

Society of Gynecologic Cancers (SGO) Annual Meeting 2019: Abstract 31. Presented March 19, 2019.

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