Outcomes of Minimally Invasive Surgery vs Laparotomy for Stage II Endometrial Cancer
In this video, Christian Dagher, MD, discusses the results of his team's study comparing the oncologic outcomes associated with treatment of stage II endometrial cancer with minimally invasive surgery vs laparotomy. Dr Dagher presented this research at the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting in San Diego, CA.
Additional Resource:
- Dagher C, Mueller JJ, Sonoda Y, Broach V, Abu-Rustum NR, Leitao MM. Oncologic outcomes of minimally invasive surgery versus laparotomy for the treatment of 2009 FIGO stage II endometrial cancer. Poster presented at: The Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer; March 16-18, 2024; San Diego, CA. Accessed March 22, 2024. www.sgo.org/events/annual-meeting/
For more SGO 2024 coverage, visit the Newsroom.
TRANSCRIPTION:
Christian Dagher, MD: This is Christian Dagher, I'm a second-year research fellow at Memorial Sloan Kettering Cancer Center.
Consultant360: To begin, could you discuss what prompted this study?
Dr Dagher: Over the last decade, there has been an increasing adoption of minimally invasive surgery (MIS) in the setting of endometrial cancer. This was primarily fueled by a shorter recovery period, lower wound complications, and improved quality of life following surgery.
Both the LACC and Lab2 trials, which are two large clinical trials, have demonstrated the safety of minimally invasive surgery in endometrial cancer, but patients with stage 2 disease were excluded from these studies. Recently, in 2018, a randomized clinical trial comparing MIS, or minimally invasive surgery, with laparotomy for patients with early-stage cervical cancer, showed concerning data regarding the use of minimally invasive surgery. The trial had to be terminated early due to higher rates of recurrence and death in the minimally invasive surgery arm.
While the results of this study cannot be applied directly to an endometrial cancer owing to the differences in disease processes, it has prompted the research community to answer this question in endometrial cancer, giving the potential concern for achieving your radicality in minimally invasive surgery. So in 2020, a large national cancer database looking at 3000 patients with stage 2 endometrial cancer offered reassuring data regarding the use of MIS on endometrial cancer. However, giving these conflicting results, we sought to examine our own data using a well-annotated database of patients with endometrial cancer, including those with gross cervical involvement, that received treatment at our institution over the last 20 years, stemming from our belief that minimally invasive surgery is just a tool to aid the physician in achieving their goal.
C360: What are some of the patient specific factors that may influence whether a health care practitioner performs a MIS vs laparotomy on a patient with stage II endometrial cancer?
Dr Dagher:Thank you for highlighting this important issue. While our study didn't specifically examine what determines whether a patient undergoes minimally invasive surgery or laparotomy, we did, however, observe some notable differences in the characteristics of patients and tumors between the two groups.
Specifically, patients in the laparotomy group often had larger tumors, a higher incidence of cervical involvement, meaning the tumors and the cervix was visible or palpable during the exam. They had more frequent lymphovascular space invasion and more advanced tumor grades.
Traditionally, laparotomy has been the go-to for more extensive surgeries, which might explain these differences. Additionally, the LACC trial published in 2018 might have made surgeons hesitant to choose MIS for these patients. Yet, it's worthy mentioning me that with the advancement of robotic surgery, achieving the desired surgical resection is deemed possible with either method. And over time and with more data we might find these differences diminishing.
Interestingly, in our study, both groups had similar body sizes with an average BMI of 31 kg/m2. This might be surprising since a higher BMI is often thought to complicate minimally invasive procedures.
This similarity probably reflects our surgical team's skill and the benefit of modern technology, especially the frequent use of robotic MIS in our center, which occurred in about 82% of this subgroup.
Finally, we should be cautious with these results, especially because we haven't adjusted them for the year of surgery. Surgical methods and the popularity of MIS have changed a lot in the last 10 years, and the decision to use MIS or laparotomy depends on many factors, including the surgeon’s experience, the patient's wishes, and what resources the hospital has.
C360: Your study found that while the 3-year progression-free survival rates were similar between the MIS and laparotomy groups, the 3-year overall survival was lower in the laparotomy group (~81%) vs the MIS group (~92%). What is the significance of this finding?
Dr Dagher: Thank you for highlighting these statistics. Firstly, it's crucial to understand the key principle when it comes to reporting statistical data. Any figure derived from a sample group inherently carries a margin of error. This is because the sample is only a small representation of the entire population and therefore, the figures we represent are estimates that come with inherent uncertainty.
In this specific instance, we reported a 92% survival rate with a margin of error of +/- 4% for patients undergoing minimally invasive surgery, and an 81% survival rate with a margin of error of +/- 7% for patients undergoing laparotomy.
When we consider that standard error rate, we observe that the intervals for those two percentages overlap. And this overlap indicates that the apparent difference in the survival rates between the two groups might not be statistically significant. And in our case, the p-value coded for this percentage is 0.6. Therefore, based on this statistical analysis, we conclude that there is no discernible difference in survival rates between the MIS group and the laparotomy group.
C360: What are the next steps for research concerning MIS and laparotomy for the treatment of patients with stage II endometrial cancer?
Dr Dagher: I think the logical next step is to examine how the use of minimally invasive surgery has evolved following the outcomes of the LACC trial in 2018. Specifically, it would be insightful to compare the survival rates in centers that reduced their use of MIS post-trial to those that continued its use unchanged.
Another important consideration is to compare within the MIS group and the use of the robotic platform compared to the conventional laparoscopy.
C360: Is there anything else that you would like to add today?
Dr Dagher: I think one of the important things to address in studying diseases of rare occurrence is to do multicenter collaborations. And from my experience working on this project itself, we saw that the numbers are very limited in any kind of specialized center. And this is why our next step is gonna be doing a multicenter collaboration between our centers and others in order to assess one of the questions is whether robotics or MIS could have different differential outcomes and also to validate the findings of what we have found and maybe also look at the associations of these high-risk factors with the outcome that we saw.
Thank you so much, Leigh, for interviewing me and I look forward to interviewing you for other projects.