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Access to Minimally Invasive Hysterectomies in Early Uterine Cancer Remains Persistently Limited

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Key Points

  • Researchers found the procedures occurred only 23.6% of the time in hospitals dubbed low-volume, which performed fewer than 10 hysterectomies for uterine cancer annually.
  • In addition, black and Hispanic women, and those with Medicaid or who were uninsured, were less likely to receive a minimally invasive surgery.
  • Patients treated at medium- and high-volume hospitals, defined as those performing between 10 to 30 hysterectomies and more than 30 hysterectomies for uterine cancer each year, respectively, were up to four times as likely as others to undergo a minimally invasive procedure.

A new study led by Johns Hopkins researchers shows wide racial and economic disparities in access to minimally invasive hysterectomies for early uterine cancer in the United States. This is despite years of accumulating evidence that the procedures to remove the uterus are linked to fewer postoperative complications, the researchers wrote. Their findings were published by Fader et al in Obstetrics and Gynecology.

Rates of Minimally Invasive Hysterectomy

Researchers analyzed data in the National Inpatient Sample database, representing more than 1,000 hospitals in 45 states, on 32,560 patients who underwent laparoscopic or robotic-assisted minimally invasive or open hysterectomy for nonmetastatic uterine cancer between 2007 and 2011.

During that time, 33.6% of the patients had minimally invasive surgery, either laparoscopic or robotic-assisted, for their cancer. That percentage rose from 22% in 2007 to 50.8% in 2011.

“We were encouraged to see that utilization of minimally invasive surgery for endometrial cancer rose significantly since 2007, but we still have a long way to go to provide most patients access to these procedures,” said Amanda Fader, MD, Director of the Johns Hopkins Kelly Gynecologic Oncology Service, Department of Gynecology and Obstetrics, and member of the Johns Hopkins Kimmel Cancer Center.

In the last decade, Dr. Fader said, several studies showed that minimally invasive procedures resulted in fewer complications, better quality of life, and equal rates of survival, compared with open procedures that call for making large surgical incisions into the abdomen. This past spring, panels of experts at the Society of Gynecologic Oncology and the American College of Surgeons' Commission on Cancer selected minimally invasive surgery as the standard of care for nonmetastatic uterine cancers.

Reasons for Lower Rates

The researchers' new study found the procedures occurred only 23.6% of the time in hospitals dubbed low-volume, which performed fewer than 10 hysterectomies for uterine cancer annually. In addition, black and Hispanic women, and those with Medicaid or who were uninsured, were less likely to receive a minimally invasive surgery. Patients treated at medium- and high-volume hospitals, defined as those performing between 10 to 30 hysterectomies and more than 30 hysterectomies for uterine cancer each year, respectively, were up to four times as likely as others to undergo a minimally invasive procedure.

Obesity is perceived by many physicians as a barrier to minimally invasive surgery, Dr. Fader said, but she noted that most women with endometrial cancer are obese, and that in most cases, they can be safely offered minimally invasive care. “Obese women often have comorbidities, such as diabetes, high blood pressure, and sleep apnea, that put them at high risk for surgical complications,” she said. “So these are the women who will most benefit from a less invasive approach to surgery.”

Dr. Fader and her team found that comorbidities, such as obesity, did not independently influence the data. They also found that open hysterectomies were more than twice as likely as minimally invasive surgeries to result in complications, such as surgical site infection, pneumonia, blood clots, major blood loss, and longer hospital stays.

“Our study found that while patients at larger academic or teaching hospitals may have more comorbidities, these hospitals still performed the minimally invasive procedures at a higher rate,” she said. “We believe this is evidence that in skilled centers, these operations can be far more widely offered.”

Cost of Procedures

The study also showed that robotic-assisted hysterectomies were more than $2,000 costlier up front than open or laparoscopic procedures, and that inpatient hospitalization costs for open and laparoscopic hysterectomies were similar—generally more than $10,000. Yet complications added another $7,000 to $8,000 on average to each type of surgery, and those complications occurred twice as often with open procedures.

Dr. Fader said that the proliferation of robotic surgical equipment in hospitals has helped to increase the use of minimally invasive surgeries, although her study did not track the prevalence of surgeons well trained in the technique. She placed less importance on whether a surgeon uses a robot or traditional laparoscopy for uterine cancer surgery. “The goal is to increase the overall rate of minimally invasive surgery for these patients, irrespective of the specific type of procedure offered,” said Dr. Fader. “Surgeon preference to perform minimally invasive surgery is highly variable in the U.S. and remains an important disparity in cancer care.”

The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.


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