Early, Late Treatment May Increase Mortality Risk in Uterine Cancer

Delaying surgery is known to increase the risk of mortality from uterine cancer, but new findings suggest that undergoing the procedure early could increase the risk as well.

The investigators found that patients undergoing surgery, typically a hysterectomy, within the first 2 weeks after receiving a uterine cancer diagnosis, had an increased risk of death within 5 years compared with patients who waited 3 to 4 weeks, according to a study published by the American Journal of Obstetrics and Gynecology.

In the United States, more than 60,000 patients will be diagnosed with endometrial cancer each year, with the number of cases increasing due to growing obesity rates. Endometrial cancer is a type of uterine cancer that generally occurs in post-menopausal women, and has been linked to obesity.

Included in the study were more than 200,000 patients with uterine cancer, with 140,078 classified as low-risk cancers. Of patients with low-risk cancer, patients who underwent surgery within the first or second week after diagnosis had a 14% increased mortality risk compared with those who underwent surgery within the following 2 weeks.

Of the 68,360 patients with high-risk cancer, patients who underwent early surgery had a 20% increased risk of death compared with those who underwent surgery at a later time. The investigators believe that their findings may reflect the delivery of care rather than the disease, according to the study.

However, patients undergoing early surgery were more likely to die within 30 days of the treatment, regardless of the risk factor. The researchers found that these patients were more likely to be black, have advanced disease, be uninsured or have Medicaid insurance, and receive care at hospitals with few patients.

Factors such as access to care, insurance, and other existing conditions could cause surgical delay.

"We suspect that physicians diagnosing endometrial cancer may believe, not unreasonably, that the best thing they can do for those patients is to operate as soon as possible, because if they wait too long the cancer could progress, resulting in a worse outcome," said senior author David I. Shalowitz, MD. "But, the results of our study suggest that pre-surgical care and referring patients to a gynecologic oncologist may be more important."

The researchers also found higher mortality rates among patients with low-risk cancer if they underwent surgery 8 weeks or more after initial diagnosis. Approximately 84.5% of patients underwent surgery at 8 weeks. Poor survival outcomes related to treatment delays were found in in breast, rectal, and bladder cancers, but previous studies showed a variety of results related to endometrial cancer.

Past 8 weeks, survival rates continued to worsen. Survival plummeted from 82.1% at 11 weeks to 78.6 at 15 weeks, according to the study.

For patients with high-risk cancer, there was no increased mortality risk for those who underwent surgery after week 3. This finding suggests that the disease stage contributes more to outcomes than disease progression during the time to treatment, the study reported.

The researchers recommend that physicians aim to treat patients within 8 weeks, especially for patients with low-risk cancers, and to not initiate treatment too early.

They also suggest that gynecologic oncologists and policymakers use these results to inform practice standards for uterine cancer treatment, the study concluded.

"Knowledge is power," Dr Halowitz said. "The primary goal is to make sure that there is a mechanism in place so that women who have a cancer diagnosis can see a specialist in the appropriate time period, that they are able to physically get to a high-volume treatment center, and that the process of referral and medical optimization for surgery can be done expediently."