IVF impact on the risk of recurrence of endometrial adenocarcinoma after fertility-sparing management.

RESEARCH QUESTION: Do IVF treatments after conservative management of endometrial atypical hyperplasia or grade 1 endometrial adenocarcinoma (AH/EC) increase the risk of disease recurrence? DESIGN: This is a prospective cohort study from a national registry from January 2008 to July 2019. Sixty patients had an AH/EC and received progestin treatment using chlormadinone acetate for at least 3 months. After remission, 31 patients underwent IVF and 29 did not. The primary outcome was the recurrence rate at 24 months according to the use of IVF. The secondary outcome was the identification of risk factors for recurrence. RESULTS: The probability of 2-year recurrence was 37.7% (SD 10.41%) in the IVF group and 55.7% (SD 14.02%) in the no IVF group (P = 0.13). Obesity, nulliparity, polycystic ovary syndrome, age and tumoural characteristics were not associated with recurrence. Pregnancy was a protective factor for recurrence, with 2-year recurrence probabilities of 20.5% and 62.0% in the pregnancy and no pregnancy groups, respectively (P = 0.002, 95% CI 0.06-0.61). In contrast, the number of cycles, maximum serum oestradiol concentration during ovarian stimulation, ovarian stimulation protocol, total dose of gonadotrophin administered and thickness of the endometrium showed no significant differences in terms of the risk of recurrence in the IVF subgroup. CONCLUSION: IVF treatment after fertility-sparing management of AH/EC does not increase the risk of recurrence. Therefore, it is an acceptable strategy to decrease the time to pregnancy. Overall, the recurrence rate is high enough to justify close monitoring once remission occurs.

Impact of Sociodemographic Characteristics on the Quality of Care in the Surgical Management of Endometrial Cancer: An Analysis of a National Database in the United States.

INTRODUCTION: Quality of care is an emerging concern, notably in oncology. The aim of the present study was to identify the sociodemographic factors influencing the quality of care in the USA concerning the surgical management of endometrial cancer (EC) through the Surveillance Epidemiology and End Results (SEER) database using already published Belgian quality indicators (QI). METHODS: Using the SEER database 1988-2013, we identified 151,752 patients treated for EC. Six QI were extracted from a Belgian study on quality of care in EC because of their applicability to the SEER. These QI evaluated only the surgical management. We examined the association between sociodemographic characteristics and quality of care with a logistic regression model. We compared our results with those defined as theoretical target by the Belgian initiative and considered a QI to be accurately met if >80% of the population met the indicator, moderately met between 50 and 80%, and poorly met under 50%. RESULTS: Concerning the 6 surgical QIs, one was accurately met, 3 were moderately met, and 2 were poorly met. For example, 73% of the patients with a high-risk EC underwent a pelvic lymphadenectomy. Age over 75 years old, black ethnicity, lower-income group, without partner, and uninsured had a negative impact on adherence to QIs. CONCLUSION: Demographic discrepancies persist in the surgical management of EC, impacting evidence-based care.

Ovarian protection and fertility preservation in women with cancer: A French national registry analysis between 2005 and 2014.

OBJECTIVE: Ovarian failure is a common effect of treatment for cancer. The aim of this study was to describe the practices concerning ovarian protection and fertility preservation in young women treated for cancer. STUDY DESIGN: Women between 15 and 49 years old diagnosed with cancer between 2005 and 2014 were studied, abstracted from a representative French National Healthcare database. To assess practices concerning ovarian protection, gonadotropin-releasing hormone (GnRH) agonist consumption and ovarian transposition were analyzed. For fertility preservation, GnRH agonist consumption, ovarian cryopreservation and oocyte cryopreservation were analyzed. Explanatory variables were analyzed using a multilevel model. RESULTS: A total of 2447 women were identified. Among the 553 patients exposed to ovarian failure, 74 (13%) had ovarian protection (67 received GnRH agonists, 7 underwent ovarian transposition). Among the 227 women exposed to fertility alteration, 53 (23%) had fertility preservation (37 received GnRH agonists, 16 had ovarian or oocyte cryopreservation). Factors associated with ovarian protection were age under 40 years old (OR = 1.56 [1.5-1.62], p = 0.006) and diagnosis of breast cancer (OR = 1.15 [1.08-1.22], p < 0.001). The only factor associated with fertility preservation was breast cancer (OR = 1.17 [1.1-1.24], p < 0.001). The five-year probability of pregnancy was 3.8% and 9.8% (p = 0.26) for women with and without fertility preservation, respectively. CONCLUSION: Over the last decade, ovarian protection and fertility preservation concerned 13% and 23%, respectively, of young French women treated for cancer. Awareness about ovarian protection and fertility preservation remain insufficient and need to be extended to improve this major aspect of cancer management.

A systematic review and meta-analysis of prognostic factors for remission in fertility-sparing management of endometrial atypical hyperplasia and adenocarcinoma.

BACKGROUND: Endometrial cancer and atypical hyperplasia are rare in young women but create a dilemma between desire for pregnancy and oncologic outcomes. OBJECTIVE: To identify remission rates and associated prognostic factors in patients undergoing fertility-sparing management for endometrial cancer and atypical hyperplasia. SEARCH STRATEGY: MEDLINE was searched for studies published between January 1, 1950 and July 31, 2017 using various search terms. SELECTION CRITERIA: Studies evaluating fertility-sparing management in patients aged between 19 and 44 years with atypical hyperplasia or stage I endometrial cancer. DATA COLLECTION AND ANALYSIS: Use of PRISMA guidelines to conduct a meta-analysis of the proportion of patients in remission and meta-regression analysis to test the effect of possible prognostic factors for remission. MAIN RESULTS: A total of 3673 studies were screened; 65 studies including 1604 patients met the inclusion criteria. The remission rate was 0.75 (95% CI, 0.73-0.77). Operative hysteroscopy for endometrial sampling was associated with higher remission rates (OR 2.31; 95% CI, 1.10-4.84; P=0.03). Studies with higher ratios of infertile women were associated with higher remission rates (OR 4.21; 95% CI, 1.44-12.33; P<0.01). CONCLUSION: Operative hysteroscopy is the preferred endometrial sampling method for patients with atypical hyperplasia or endometrial cancer undergoing fertility-sparing management.

Adherence to Guidelines During Follow-up of Endometrial Cancer: Analysis of French Health Insurance Database.

BACKGROUND/AIM: Recommendations for endometrial cancer (EC) follow-up after treatment include regular clinical examinations without further systematic investigation. The objectives of our study were to examine adherence to follow-up guidelines in patients who underwent surgery for EC and identify associated variables. PATIENTS AND METHODS: Patients who underwent surgery for EC between 2005 and 2014 were identified among the Echantillon Généraliste des Bénéficiaires. The adherence to guidelines was defined by fewer than two investigations performed, including vaginal smear, CA 125 evaluation and imaging during two postoperative years. RESULTS: Among the 314 women identified, a gap between recommendations and practices was observed in 48.1%. This gap was more frequently observed in patients who underwent surgery before 2011, in private institutions and in institutions performing less than 20 hysterectomies for EC per year and who had Long Duration Disease declaration for EC. CONCLUSION: A gap between recommendations and practices for the follow-up was observed in almost half of the patients with EC. Updating the recommendations in 2010 may have improved compliance with the recommendations.

Evaluation and Selection of Quality Indicators for the Management of Endometrial Cancer.

OBJECTIVE: The aim of this study was to evaluate 36 quality indicators (QIs) for monitoring the quality of care of uterine cancer to be implemented in the EFFECT (effectiveness of endometrial cancer treatment) project. METHODS: The 36 QIs were evaluated in the first 10 patients diagnosed with endometrial cancer and managed in 14 French hospitals in 2011. To assess the status of each QI, a questionnaire detailing the 36 QIs was sent to each hospital, and the information was cross-checked with information from the multidisciplinary staff meeting, surgical reports, and pathological reports. The QIs were evaluated in terms of measurability and improvability. The remaining QIs were evaluated with a multiple correspondence analysis to highlight the interrelationships between qualitative variables describing a population. RESULTS: Thirteen of the 14 institutions responded to the survey for a total of 130 patients. Twenty-five of the 36 QIs affected less than 80% of the patients. Thirteen QIs were found not to be improvable because they reached more than 95% of the theoretical target. Finally, 5 QIs concerning more than 80% of the patients were found to be improvable. The multiple correspondence analysis finally identified 3 dimensions-outcome, safety, and perioperative management-that included the 5 QIs. CONCLUSIONS: In the present study, 5 of the 36 QIs suggested by the EFFECT project seem to be sufficient to report on the quality of endometrial cancer management. Further studies are needed to correlate the information provided by those 5 questions and the relevant outcomes reflecting quality of care in endometrial cancer.

Preoperative diagnosis of tumor grade and type in endometrial cancer by pipelle sampling and hysteroscopy: Results of a French study.

BACKGROUND: No data are available to establish whether operative hysteroscopy is superior to standard pipelle sampling to determine histological and grade status in endometrial cancer (EC). The aim of this study was to evaluate whether pipelle device sampling or operative hysteroscopy had an impact on preoperative determination of histological and grade status in EC and consequently on surgical management. METHODS: Data of 224 women with EC receiving primary surgical treatment between 2002 and 2014 were abstracted from a single institution with maintained database. Women were staged on the basis of preoperative and final pathological findings according to the 2009 International FIGO classification. Discrepancies in pathological analysis were assessed between pipelle sampling or operative hysteroscopy and final histology. Values of p < 0.05 were considered to denote significant differences. RESULTS: 149 women underwent preoperative pipelle sampling and 75 operative hysteroscopy. Global discrepancies between pre-operative and post-operative analysis was 20.8% versus 20.0% in the pipelle device and operative hysteroscopy group, respectively, with no significant difference considering type 1 grade 1 or 2 versus type 1 grade 3 versus type 2 EC. Discrepancies in histological type between preoperative and final histology were found in 25 (16.8%) and 11 (14.7%) women in the pipelle device and operative hysteroscopy groups, respectively (p = 0.85). Discrepancies in histological grade between preoperative and final histology were found in 6 (5.8%) vs. 4 (7.0%) of the women in the pipelle device and operative hysteroscopy groups, respectively (p = 1). CONCLUSION: This study suggests that both pipelle sampling and operative hysteroscopy are of limited value in determining definitive histological type and grade. Additional investigations should be evaluated to better characterize the risk groups.

Impact of Radical Hysterectomy on Survival in Patients with Stage 2 Type1 Endometrial Carcinoma: A Matched Cohort Study.

BACKGROUND: In cases of stage 2 endometrial cancers (ECs), a radical hysterectomy is recommended; however, its benefits are poorly documented. OBJECTIVE: The aim of this study was to determine whether a primary radical hysterectomy improves specific and overall survival compared with a simple hysterectomy in stage 2 EC. METHODS: Data from all women with type 1 EC and International Federation of Gynecology and Obstetrics (FIGO) 2009 stage 2 who underwent surgical treatment between January 1998 and December 2012 were extracted from the Surveillance, Epidemiology, and End Results (SEER) database. Women treated with radical hysterectomy were matched with women treated with simple hysterectomy according to demographic and tumoral criteria. The primary endpoint was cancer-related survival. RESULTS: One-to-two matching enabled a comparison of 273 patients who underwent a radical hysterectomy for stage 2 EC (case group) with 546 patients who received a simple hysterectomy (control group). The probability of cancer-related survival was not significantly different in the case group compared with the control group (p = 0.08), and the 3-year cancer-related survivals in the radical and simple hysterectomy groups were 88.7 and 94.1 %, respectively. Following adjustment for radiation, survival analysis indicated there was no survival difference between the two groups with regard to cancer-related survival or overall survival. CONCLUSION: The present study indicates that for patients with stromal cervical invasion and type 1 EC, the type of hysterectomy does not impact cancer-related or overall survival, even after adjustment for adjuvant radiation. This finding suggests that additional, randomized clinical studies are required.