Elsevier

Gynecologic Oncology

Volume 152, Issue 3, March 2019, Pages 439-444
Gynecologic Oncology

National trends, outcomes, and costs of radiation therapy in the management of low- and high-intermediate risk endometrial cancer

https://doi.org/10.1016/j.ygyno.2018.11.005Get rights and content

Highlights

  • Radiotherapy had no impact on survival in low-intermediate risk endometrial cancer.

  • Radiotherapy was associated with improved survival in high-intermediate risk endometrial cancer.

  • Adjuvant radiation had significantly increased costs and a higher morbidity risk.

Abstract

Objective

To assess treatment patterns, outcomes, and costs for women with low-(LIR) and high-intermediate risk endometrial cancer (HIR) who are treated with and without adjuvant radiotherapy.

Methods

All patients with stage I endometrioid endometrial cancer who underwent surgery from 2000 to 2011 were identified from the SEER-Medicare database. LIR was defined as G1–2 tumors with <50% myometrial invasion or G3 with no invasion. HIR was defined as G1–2 tumors with ≥50% or G3 with <50% invasion. Patients were categorized according to whether they received adjuvant radiotherapy (vaginal brachytherapy [VBT], external beam radiotherapy [EBRT], or both) or no radiotherapy. Outcomes were analyzed and compared (primary outcome was overall survival).

Results

10,842 patients met inclusion criteria. In the LIR group (n = 7609), there was no difference in 10-year overall survival between patients who received radiotherapy and those who did not (67% vs 65%, adjusted HR 0.95, 95% CI 0.81–1.11). In the HIR group (n = 3233), patients who underwent radiotherapy had a significant increase in survival (60% vs 47%, aHR 0.75, 95% CI 0.67–0.85). Radiotherapy was associated with increased costs compared to surgery alone ($26,585 vs $16,712, p < .001). Costs for patients receiving VBT, EBRT, and concurrent VBT/EBRT were $24,044, $27,512, and $31,564, respectively (p < .001). Radiotherapy was associated with an increased risk of gastrointestinal (7 vs 4%), genitourinary (2 vs 1%), and hematologic (16 vs 12%) complications (p < .001).

Conclusions

Radiotherapy was associated with improved survival in women with HIR, but not in LIR. It also had increased costs and a higher morbidity risk. Consideration of observation without radiotherapy in LIR may be reasonable.

Introduction

Endometrial carcinoma is the most common gynecologic malignancy in the United States, with an estimated 63,230 new cases in 2018 [1]. Although surgery at diagnosis is the cornerstone of management for women with suspected early-stage disease, the use of adjuvant radiation therapy is controversial [2]. Despite the fact that two randomized trials (Gynecologic Oncology Group 99 [GOG-99] and Post-Operative Radiation Therapy in Endometrial Carcinoma 1 [PORTEC-1]) have shown no overall survival advantage for adjuvant radiation in patients with Stage I cancer, evidence suggests a recurrence-free survival benefit for certain intermediate-risk subgroups [3,4].

In an effort to standardize management recommendations for radiotherapy, the American Society for Radiation Oncology (ASTRO) has developed treatment guidelines, which were endorsed by the American Society of Clinical Oncology (ASCO) with minor modifications [5,6]. Specifically, the guidelines recommended the following: 1) patients with early stage grade 1–2 tumors with <50% myometrial invasion (and features such as age > 60 and/or lymphovascular space invasion), or those with grade 3 tumors with no invasion ‘may be treated with or without’ vaginal brachytherapy (VBT); 2) patients with grade 1–2 tumors with ≥50% invasion (and features such as age > 60 and/or lymphovascular space invasion) ‘may benefit from’ external beam radiation therapy [EBRT] (ASTRO recommendation) or VBT (ASCO recommendation); and 3) patients with grade 3 tumors with <50% invasion ‘should be treated’ with VBT.

In 2016, national health expenditures comprised 17.9% of the gross domestic product (GDP) in the United States. Projections from the Center for Medicare and Medicaid Services suggest that medical costs will reach 20% of the GDP by 2026 [7]. As medical costs continue to rise, it is essential to scrutinize not only the benefit of different treatment approaches but also their costs. This is especially relevant in endometrial cancer, the incidence of which has been steadily increasing over the last few decades, likely related to the obesity epidemic [1]. Different medical societies have defined value in cancer care by emphasizing three critical elements: clinical benefit, complications, and cost [8]. The objective of our study was to assess treatment patterns, outcomes, and costs for women with low and high-intermediate risk histologic features who were treated with and without adjuvant radiation, using a national healthcare claims database.

Section snippets

Data source

We conducted a retrospective population-based cohort study of patients who underwent surgery for endometrioid endometrial cancer using the linked Surveillance, Epidemiology, and End Results registry (SEER)–Medicare database. The SEER registry of the National Cancer Institute contains approximately 97% of all incident cancer cases from tumor registries that cover 26% of the United States population. The Medicare claims database includes billed claims and services data on patients with Medicare

Results

We identified 10,842 women who underwent surgery for endometrial cancer and met our inclusion criteria during the study period. Of these patients, 7609 (70%) were LIR and 3233 (30%) were HIR. Nine percent (n = 660) of patients with LIR had radiation therapy, compared to 46% (n = 1478) of those with HIR. The use of adjuvant radiation in the entire cohort did not change over time (19.9% in 2000 to 19.5% in 2011). However, among all patients who underwent radiation, the following trends were noted

Discussion

In this study, we sought to assess treatment patterns, outcomes, and costs in patients with intermediate-risk endometrial cancer. Radiation therapy was associated with improved 10-year overall survival in women with HIR, but not in the LIR cohort. Adjuvant radiation also had significantly increased costs and a higher morbidity risk.

As the costs of cancer care continue to rise, it is paramount to assess the value and cost-effectiveness of different treatment strategies and not just their effect

Acknowledgement

This study used the linked SEER-Medicare database. The interpretation and reporting of these data are the sole responsibility of the authors. The authors acknowledge the efforts of the National Cancer Institute; the Office of Research, Development and Information, CMS; Information Management Services (IMS), Inc.; and the Surveillance, Epidemiology, and End Results (SEER) Program tumor registries in the creation of the SEER-Medicare database.

Conflict of interest statements

This research is supported in part by the Duncan Family Institute, and a National Cancer Institute grant (#P30 CA016672).

Rudy Suidan — Research support: National Institutes of Health T32 grant (#5T32 CA101642).

Larissa Meyer — Research support: Cancer Prevention and Research Institute of Texas grant (#RP140020); National Cancer Institute K award (#K07 CA201013).

Grace Smith — Research support: National Cancer Institute K award (#K07 CA211804).

Sharon Giordano — Research support: Cancer Prevention

Relevant financial activities outside the supported work

Larissa Meyer

  • Research support: AstraZeneca

  • Consultant: Clovis Oncology

Charlotte Sun:

  • Research support: AstraZeneca

The other authors declare that there are no conflicts of interest.

Author contribution section

Rudy Suidan and Larissa Meyer contributed towards the conception and design, collection and assembly of data, data analysis and interpretation, manuscript writing, and final approval of the manuscript.

Weiguo He, Charlotte Sun, and Hui Zhao contributed towards collection and assembly of data, data analysis and interpretation, manuscript writing, and final approval of the manuscript.

Grace Smith, Ann Klopp, Nicole Fleming, Karen Lu and Sharon Giordano contributed towards data analysis and

References (22)

  • Centers for Medicare and Medicaid Services

    CMS.gov

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