Surgical trends, outcomes and disparities in minimal invasive surgery for patients with endometrial cancer in England: a retrospective cohort study

Abstract

ObjectiveTo examine surgical outcomes and trends in the implementation of minimally invasive surgery (MIS) use for endometrial cancer (EC).DesignRetrospective cohort study.SettingEnglish National Health Service hospitals 2011–2017/2018.Population35 304 patients having a hysterectomy for EC identified from Hospital Episode Statistics.MethodsUnivariate and multivariate analyses compared MIS to open hysterectomy (OH) by assessing the association between demographic, clinical and hospital characteristics by using logistic regression. A propensity score was created, to control for confounding factors including demographics, clinical and hospital characteristics, from a logistic regression which enabled the inverse probability weighting of treatment to be applied in order to compare outcomes of treatment.Main outcome measuresThe association between route of surgery on perioperative morbidity and mortality.ResultsThe MIS rate rose from 40.3% in 2011 to 68.7% in 2017/2018, however, there was significant geographical variation (p<0.001). The overall 90-day mortality was significantly higher with OH versus MIS (OR 0.34, 95% CI 0.18 to 0.62, p=0.0002). MIS rates were significantly lower in patients from the lowest socioeconomic group (LSEG) compared with patients from the highest group (HSEG) (55.4% vs 59.9%, p<0.01), and in the black population as compared with white and Asian populations (40.4% vs 58.6% and 56.0%, p<0.0001). When patients from LSEG and black patients were treated in hospitals with high MIS rates, the MIS rate increased close to that of the HSEG and white patients (81.0% and 74.1% vs 83.2% and 82.6%).ConclusionsFurther investigation is needed to understand the barriers to MIS and improve access so that as many patients as possible can benefit from the reduced morbidity/mortality associated with MIS.

Economic evaluation of different routes of surgery for the management of endometrial cancer: a retrospective cohort study

“…There will always be a proportion of cases that have to be performed OH due to contraindications/complications with MIS, which will inevitably attract higher costs due to their complexity, but this can be reduced to low levels. 17 The significantly higher complication/readmission rate with OH has been reported previously 8 and in this study we have shown that even in the HC groups, the complication rate was higher with OH (71.5%) as compared with RH (55.6%) and LH (61.0%). A longer recovery time may impact on patient and employment costs, with greater loss of earnings and longer return to work or contribution to society activities as compared with MIS.…”

“…As previously described, there was a significant difference in the social/ethnic characteristics of the patients undergoing MIS as compared with OH within this cohort of patients. 8 The characteristics of the RH population differed to patients undergoing LH; with a significantly higher percentage of RH patients having any comorbidity from our defined list than LH (68.2% vs 64.0%, p<0.001), more specifically the comorbidities of diabetes, hypertension and obesity all being higher proportion in RH cohort than LH cohort.…”

“…Due to the low numbers, the VH cases were not included in any of the subsequent analyses. The cohort selection for the study has been described in more detail previously 8 and the list of specific diagnosis (ICD-10) and procedure (OPCS-4.7) codes can be found in the online supplemental table A1 .…”

“…[5][6][7] Widespread adoption of RH is limited in England, although the number of EC cases having RH is increasing year on year. 8 In light of the capital and consumable costs of RH, as compared with OH or LH, the use of RH in EC is therefore being called into question. 6 Reports from institutions with well-established robotic programmes however have contested this view with no significant difference, 9 or cost improvements reported as compared with LH.…”

“…As we had a number of years of the HES Database, we could analyse any potential trends across surgical approaches and the year. As we have previously described, 8 the HES Database does have limitations, primarily it only covers NHS-funded care, the reliability of coding and lacks oncological details of stage/histology. A limitation of the CCI calculated using the HES data is that people with no hospital attendance 12 months prior to intervention are classified as having no comorbidities instead of missing; but as the NHS is free at the point of contact, the HES Database is extensive at capturing all hospital-reported comorbidities in England.…”