Cancer Res Treat.  2021 Apr;53(2):549-557. 10.4143/crt.2020.802.

Nationwide Comparison of Surgical and Oncologic Outcomes in Endometrial Cancer Patients Undergoing Robotic, Laparoscopic, and Open Surgery: A Population-Based Cohort Study

• Eoh KJ
• Nam EJ
• Kim SW
• Shin M
• Kim SJH
• Kim JA
• Kim YT

• KMID: 2514935
• DOI: http://doi.org/10.4143/crt.2020.802

Abstract

Purpose
Population-based comparisons between minimally invasive surgery (MIS) (robotic surgery [RS] and laparoscopic surgery [LS]) and open surgery (OS) for managing endometrial cancer are lacking. This study aimed to compare surgical and oncologic outcomes between endometrial cancer patients who underwent surgical staging via MIS or OS.
Materials and Methods
A population-based retrospective cohort study was performed using claims data from the Korean National Health Insurance database from January 2012 to December 2016. All patients who underwent hysterectomy under diagnosis of endometrial cancer were identified. Patients were classified into RS, LS, and OS groups. Operative and oncologic outcomes were compared among the three groups after adjustments for age group, risk group (adjuvant therapy status), modified Charlson comorbidity index, income level, insurance type, and index year using propensity scores obtained via the inverse probability of treatment weighted method.
Results
After adjustment, 5,065 patients (RS, n=315; LS, n=3,248; OS, n=1,503) were analyzed. Patient demographics were comparable. Hospital stay, postoperative complications, and cost were more favorable in the RS and LS groups than in the OS group (all p < 0.001). Five-year overall survival was significantly longer in the RS and LS groups than in the OS group (94.8%, 91.9%, and 86.9%, respectively; p < 0.001). Moreover, the survival benefit of RS was shown in the subgroup analysis of low-risk endometrial cancer patients.
Conclusion
Our study provides further evidence for the RS being a safe surgical alternative to the LS and OS, especially in low-risk endometrial cancer patients, offering surgical and oncologic outcomes equivalent to other surgical approaches.

Keyword

Robot-assisted surgery; Endometrial neoplasms; Population-based cohort study

Figure

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  Fig. 1 Flow diagram of the study population. IPTW, inverse probability of treatment weighting; mCCI, modified Charlson comorbidity index.

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  Fig. 2 IPTW-adjusted progression-free survival (A) and overall survival (B) for patients with endometrial cancer. IPTW, inverse probability of treatment weighting.

Reference

References

1. Siegel RL, Miller KD, Jemal A. Cancer statistics, 2019. CA Cancer J Clin. 2019; 69:7–34.

2. Wright JD, Barrena Medel NI, Sehouli J, Fujiwara K, Herzog TJ. Contemporary management of endometrial cancer. Lancet. 2012; 379:1352–60.

3. Walker JL, Piedmonte MR, Spirtos NM, Eisenkop SM, Schlaerth JB, Mannel RS, et al. Recurrence and survival after random assignment to laparoscopy versus laparotomy for comprehensive surgical staging of uterine cancer: Gynecologic Oncology Group LAP2 Study. J Clin Oncol. 2012; 30:695–700.

4. Walker JL, Piedmonte MR, Spirtos NM, Eisenkop SM, Schlaerth JB, Mannel RS, et al. Laparoscopy compared with laparotomy for comprehensive surgical staging of uterine cancer: Gynecologic Oncology Group Study LAP2. J Clin Oncol. 2009; 27:5331–6.

5. Lau S, Vaknin Z, Ramana-Kumar AV, Halliday D, Franco EL, Gotlieb WH. Outcomes and cost comparisons after introducing a robotics program for endometrial cancer surgery. Obstet Gynecol. 2012; 119:717–24.

6. Chu LH, Chang WC, Sheu BC. Comparison of the laparoscopic versus conventional open method for surgical staging of endometrial carcinoma. Taiwan J Obstet Gynecol. 2016; 55:188–92.

7. Vuorinen RK, Maenpaa MM, Nieminen K, Tomas EI, Luukkaala TH, Auvinen A, et al. Costs of robotic-assisted versus traditional laparoscopy in endometrial cancer. Int J Gynecol Cancer. 2017; 27:1788–93.

8. Ran L, Jin J, Xu Y, Bu Y, Song F. Comparison of robotic surgery with laparoscopy and laparotomy for treatment of endometrial cancer: a meta-analysis. PLoS One. 2014; 9:e108361.

9. Jorgensen SL, Mogensen O, Wu CS, Korsholm M, Lund K, Jensen PT. Survival after a nationwide introduction of robotic surgery in women with early-stage endometrial cancer: a population-based prospective cohort study. Eur J Cancer. 2019; 109:1–11.

10. Kim YT, Kim SW, Hyung WJ, Lee SJ, Nam EJ, Lee WJ. Robotic radical hysterectomy with pelvic lymphadenectomy for cervical carcinoma: a pilot study. Gynecol Oncol. 2008; 108:312–6.

11. Kang HW, Yun SJ, Chung JI, Choi H, Kim JH, Yu HS, et al. National practice patterns and direct medical costs for prostate cancer in Korea across a 10 year period: a nationwide population-based study using a national health insurance database. BMC Health Serv Res. 2019; 19:408.

12. Mehrotra R, Kermah D, Fried L, Kalantar-Zadeh K, Khawar O, Norris K, et al. Chronic peritoneal dialysis in the United States: declining utilization despite improving outcomes. J Am Soc Nephrol. 2007; 18:2781–8.

13. Read WL, Tierney RM, Page NC, Costas I, Govindan R, Spitznagel EL, et al. Differential prognostic impact of comorbidity. J Clin Oncol. 2004; 22:3099–103.

14. Austin PC, Stuart EA. Moving towards best practice when using inverse probability of treatment weighting (IPTW) using the propensity score to estimate causal treatment effects in observational studies. Stat Med. 2015; 34:3661–79.

15. Salehi S, Avall-Lundqvist E, Legerstam B, Carlson JW, Falconer H. Robot-assisted laparoscopy versus laparotomy for infrarenal paraaortic lymphadenectomy in women with high-risk endometrial cancer: a randomised controlled trial. Eur J Cancer. 2017; 79:81–9.

16. Bergstrom J, Aloisi A, Armbruster S, Yen TT, Casarin J, Leitao M Jr, et al. Minimally invasive hysterectomy surgery rates for endometrial cancer performed at National Comprehensive Cancer Network (NCCN) Centers. Gynecol Oncol. 2018; 148:480–4.

17. Jorgensen SL, Mogensen O, Wu C, Lund K, Iachina M, Korsholm M, et al. Nationwide introduction of minimally invasive robotic surgery for early-stage endometrial cancer and its association with severe complications. JAMA Surg. 2019; 154:530–8.

18. Galaal K, Donkers H, Bryant A, Lopes AD. Laparoscopy versus laparotomy for the management of early stage endometrial cancer. Cochrane Database Syst Rev. 2018; 10:CD006655.

19. Siesto G, Uccella S, Ghezzi F, Cromi A, Zefiro F, Serati M, et al. Surgical and survival outcomes in older women with endometrial cancer treated by laparoscopy. Menopause. 2010; 17:539–44.

20. Corrado G, Cutillo G, Pomati G, Mancini E, Sperduti I, Patrizi L, et al. Surgical and oncological outcome of robotic surgery compared to laparoscopic and abdominal surgery in the management of endometrial cancer. Eur J Surg Oncol. 2015; 41:1074–81.

21. Cardenas-Goicoechea J, Shepherd A, Momeni M, Mandeli J, Chuang L, Gretz H, et al. Survival analysis of robotic versus traditional laparoscopic surgical staging for endometrial cancer. Am J Obstet Gynecol. 2014; 210:160.

22. Brudie LA, Backes FJ, Ahmad S, Zhu X, Finkler NJ, Bigsby GE 4th, et al. Analysis of disease recurrence and survival for women with uterine malignancies undergoing robotic surgery. Gynecol Oncol. 2013; 128:309–15.

23. Kilgore JE, Jackson AL, Ko EM, Soper JT, Van Le L, Gehrig PA, et al. Recurrence-free and 5-year survival following robotic-assisted surgical staging for endometrial carcinoma. Gynecol Oncol. 2013; 129:49–53.

24. Janda M, Gebski V, Davies LC, Forder P, Brand A, Hogg R, et al. Effect of total laparoscopic hysterectomy vs total abdominal hysterectomy on disease-free survival among women with stage I endometrial cancer: a randomized clinical trial. JAMA. 2017; 317:1224–33.

25. Booth CM, Tannock IF. Randomised controlled trials and population-based observational research: partners in the evolution of medical evidence. Br J Cancer. 2014; 110:551–5.

26. Safdieh J, Lee YC, Wong A, Lee A, Weiner JP, Schwartz D, et al. A comparison of outcomes between open hysterectomy and robotic-assisted hysterectomy for endometrial cancer using the National Cancer Database. Int J Gynecol Cancer. 2017; 27:1508–16.

27. Wright JD, Burke WM, Tergas AI, Hou JY, Huang Y, Hu JC, et al. Comparative effectiveness of minimally invasive hysterectomy for endometrial cancer. J Clin Oncol. 2016; 34:1087–96.