Health related quality of life and symptoms after pelvic lymphadenectomy or radiotherapy vs. no adjuvant regional treatment in early-stage endometrial carcinoma: A large population-based study☆
Highlights
►742 stage I–II endometrial cancer survivors completed questionnaires. ►Distinct symptom patterns were observed after routine lymphadenectomy or radiotherapy. ►No differences in health related quality of life were found between treatment groups.
Introduction
Endometrial carcinoma is the most frequent gynecological cancer in the Western world with an incidence of 15–25 per 100,000 women per year [1], [2]. More than 75% of the endometrial cancers are diagnosed at an early stage, resulting in overall good prognosis, with a 5-year overall survival rate of 80% in the US and The Netherlands [1], [2]. On January 1, 2008, in the United States there were approximately 573,300 women alive with a history of cancer of the uterine corpus, compared to 18,000 on January 1, 2010 in The Netherlands [2].
The role and degree of lymphadenectomy and the use of postoperative external beam radiotherapy in early stage endometrial cancer are among the most controversial issues in gynecologic oncology [3]. The results of two randomized trials comparing systematic pelvic lymphadenectomy to no lymphadenectomy in early stage endometrial cancer [4], [5], as well as a meta-analysis [6], showed that routine lymphadenectomy improved surgical staging but did not result in improved survival. However, these studies are limited by the fact that HRQL was not measured [6]. Other than survival, lymphadenectomy may contribute in the selection of patients that could be withheld additional radiotherapy and hence prevent unnecessary over-treatment or inappropriate under-treatment [3]. This is important as one of the major concerns of adjuvant treatments is the risk of morbidity, and it is known that external beam radiotherapy (EBRT) can impact QoL up to years after diagnosis [7], [8], [9]. Unfortunately, information is poor regarding morbidity and HRQL after lymphadenectomy, and mostly based on chart review [10], or clinical reports [4], [5].
In order to compare the treatment strategy of routine lymphadenectomy without EBRT in the absence of lymph node metastasis with the treatment strategy of no lymphadenectomy and the application of EBRT in the presence of risk factors we performed a cross-sectional, population-based study of HRQL and symptoms of early stage endometrial cancer survivors.
Based on the low prevalence of lymphedema morbidity [4], [5], [10] and the well known long term effects of EBRT [7], [8], [9], we hypothesized that women undergoing pelvic lymphadenectomy would overall report a better HRQL compared to women who did not, but were administered EBRT in the presence of risk factors [11]. If our hypothesis is found to be true, the role of lymphadenectomy as a diagnostic tool would be important in low-risk cases, if only to prevent over-treatment, and consequently result in a better HRQL and fewer symptoms.
Section snippets
Setting and participants
The Comprehensive Cancer Center South comprises 10 hospitals in the southern part of The Netherlands. One hospital did not participate in this study. Since 1998, five hospitals in the West region recommend routine pelvic lymphadenectomy in women with apparently early stage endometrial cancer [12]. When pelvic lymphadenectomy was performed, external beam radiotherapy (EBRT) was administered only to patients with lymph-node metastases. The other four hospitals (East) did not perform routine
Results
The 5-year overall survival rate of all 1478 women diagnosed and registered with stage I or II endometrial cancer between Jan 1, 1999 and October 1, 2007 in the region of the Eindhoven Cancer Registry was 92% among women who underwent LA vs. 88% among women who did not (p = 0.004). One hospital, that did not perform routine pelvic lymphadenectomy, declined participation in this study (N = 108 patients). Among the other 9 hospitals, response rate was high, with 742 (76.9%) of the endometrial cancer
Discussion
This population-based analysis revealed distinct symptom patterns in early stage endometrial cancer survivors who received different treatment strategies: routine pelvic lymphadenectomy without RT in the presence of risk factors compared to no lymphadenectomy and adjuvant radiotherapy according to the PROTEC criteria. However, these differences did not result in clinically relevant differences in HRQL between the different groups. Our hypothesis that women undergoing pelvic lymphadenectomy – to
Author contributions
Study concept and design: van de Poll-Franse, Pijnenborg, Kruitwagen.
Acquisition of data: van de Poll-Franse, Pijnenborg, Boll, Vos, van den Berg, Lybeert, de Winter, Kruitwagen.
Analysis and interpretation of data: van de Poll-Franse, Pijnenborg, Kruitwagen.
Drafting of the manuscript: van de Poll-Franse.
Critical revision of the manuscript for important intellectual content: van de Poll-Franse, Pijnenborg, Boll, Vos, van den Berg, Lybeert, de Winter, and Kruitwagen.
Statistical analysis: van de
Conflict of interest statement
None.
Financial support
The data collection of this study was funded by the Comprehensive Cancer Centre South, Eindhoven, The Netherlands; Dr. Lonneke van de Poll-Franse is supported by a Cancer Research Award from the Dutch Cancer Society (#UVT-2009-4349).
Acknowledgment
We would like to thank all patients and their doctors for their participation in the study. Special thanks go to Dr. M. van Bommel, who was willing to function as an independent advisor and to answer questions of patients. In addition, we want to thank the following hospitals for their cooperation: Amphia Hospital, Breda; Catharina Hospital, Eindhoven; Elkerliek Hospital, Helmond and Deurne; Jeroen Bosch Hospital, 's Hertogenbosch; Maxima Medical Centre, Eindhoven and Veldhoven; Sint Anna
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The manuscript has been prepared in accordance with the style of the journal, and all authors have approved its contents. This manuscript is not being considered for publication elsewhere and the findings of this manuscript have not been previously published. Preliminary results were presented at the European Society of Gynecological Oncology Meeting in Belgrade, 2009 and the International Gynecologic Society Meeting in Prague, 2010. There is no conflict of interest.