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Factors influencing treatment decision and guideline conformity in high-grade endometrial cancer patients: a population-based study

  • Gynecologic Oncology
  • Published:
Archives of Gynecology and Obstetrics Aims and scope Submit manuscript

Abstract

Purpose

Treatment according to guidelines has been demonstrated to improve survival in a number of different cancer entities. Deviations from guidelines depend on several factors, including the patient’s preferences, age and comorbidities. The aim of this study was to assess the adherence to guideline recommendations concerning surgical and adjuvant treatment in endometrial cancer. Furthermore, we sought to evaluate the reasons for non-adherence to guidelines by further examining the influence of comorbidities and age.

Methods

The influence of age, comorbidities, tumor stage and histological subtype on guideline adherence was evaluated by multivariable logistic regression in a cohort of 353 high-grade endometrial cancer patients. High-grade endometrial cancer was defined as carcinosarcoma, Type II (serous, clear cell, mixed cell carcinoma) and Type I G3 histology.

Results

Extensive surgical procedures, particularly systematic LNE, were less frequently applied in patients with comorbidities (p = 0.015) or higher age (p < 0.01). Guideline adherence was not affected by comorbidities (p = 0.563), but was significantly reduced with higher age (p < 0.01). In a multivariable model, higher age (p < 0.01), obesity (p = 0.011), higher FIGO Stage (p < 0.01) and histologic subtype (p < 0.01) significantly decreased OS. Surgery (p < 0.001), chemotherapy (p < 0.01) and systematic LNE (p = 0.011) were associated with higher OS.

Conclusion

Age seems to be the strongest independent factor leading to guideline deviation. Comorbidities were associated with less aggressive treatment, but not with deviations from guidelines.

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Data availability

The data sets generated and/or analysed during the current study are not publicly available due to preservation of privacy but are available from the corresponding author on reasonable request.

References

  1. Schwentner L, van Ewijk R, Kurzeder C et al (2013) Participation in adjuvant clinical breast cancer trials: does study participation improve survival compared to guideline adherent adjuvant treatment? A retrospective multi-centre cohort study of 9433 patients. Eur J Cancer 49(3):553–563. https://doi.org/10.1016/j.ejca.2012.08.011

    Article  CAS  PubMed  Google Scholar 

  2. Schwentner L, Wolters R, Koretz K et al (2012) Triple-negative breast cancer: the impact of guideline-adherent adjuvant treatment on survival—a retrospective multi-centre cohort study. Breast Cancer Res Treat 132(3):1073–1080. https://doi.org/10.1007/s10549-011-1935-y

    Article  CAS  PubMed  Google Scholar 

  3. Wöckel A, Varga D, Atassi Z et al (2010) Impact of guideline conformity on breast cancer therapy: results of a 13 year retrospective cohort study. Onkologie 33(1–2):9. https://doi.org/10.1159/000264617

    Article  Google Scholar 

  4. Wolters R, Wischhusen J, Stüber T et al (2015) Guidelines are advantageous, though not essential for improved survival among breast cancer patients. Breast Cancer Res Treat 152(2):357–366. https://doi.org/10.1007/s10549-015-3484-2

    Article  PubMed  Google Scholar 

  5. Dholakia J, Llamocca E, Quick A et al (2020) Guideline-concordant treatment is associated with improved survival among women with non-endometrioid endometrial cancer. Gynecol Oncol. https://doi.org/10.1016/j.ygyno.2020.03.016

    Article  PubMed  PubMed Central  Google Scholar 

  6. Battista MJ, Schmidt M, Rieks N et al (2015) Adjuvant treatment decisions for patients with endometrial cancer in Germany: results of the nationwide AGO pattern of care studies from the years 2013, 2009 and 2006. J Cancer Res Clin Oncol 141(3):555–562. https://doi.org/10.1007/s00432-014-1834-9

    Article  CAS  PubMed  Google Scholar 

  7. Battista MJ, Schmidt M, Rieks N et al (2014) Nationwide analysis on surgical procedures for patients with endometrial cancer in Germany: results of the AGO pattern of care studies from the years 2013, 2009, and 2006. J Cancer Res Clin Oncol 140(12):2087–2093. https://doi.org/10.1007/s00432-014-1755-7

    Article  PubMed  Google Scholar 

  8. Eggink FA, Mom CH, Boll D et al (2017) Compliance with adjuvant treatment guidelines in endometrial cancer: room for improvement in high risk patients. Gynecol Oncol 146(2):380–385. https://doi.org/10.1016/j.ygyno.2017.05.025

    Article  CAS  PubMed  Google Scholar 

  9. Boll D, Verhoeven RHA, van der Aa MA et al (2011) Adherence to national guidelines for treatment and outcome of endometrial cancer stage I in relation to co-morbidity in southern Netherlands 1995–2008. Eur J Cancer 47(10):1504–1510. https://doi.org/10.1016/j.ejca.2011.03.023

    Article  CAS  PubMed  Google Scholar 

  10. Du Bois A, Strutas D, Buhrmann C et al (2009) Impact of treatment guidelines and implementation of a quality assurance program on quality of care in endometrial cancer. Onkologie 32(8–9):493–498. https://doi.org/10.1159/000226146

    Article  PubMed  Google Scholar 

  11. Wollschläger D, Meng X, Wöckel A et al (2018) Comorbidity-dependent adherence to guidelines and survival in breast cancer-Is there a role for guideline adherence in comorbid breast cancer patients?: a retrospective cohort study with 2137 patients. Breast J 24(2):120–127. https://doi.org/10.1111/tbj.12855

    Article  CAS  PubMed  Google Scholar 

  12. Pursche T, Hedderich M, Heinrichs A et al (2014) Guideline conformity treatment in young women with early-onset breast cancer in Germany. Breast Care 9(5):1. https://doi.org/10.1159/000366435

    Article  Google Scholar 

  13. Austin SR, Wong Y-N, Uzzo RG et al (2015) Why summary comorbidity measures such as the Charlson comorbidity index and Elixhauser score work. Med Care 53(9):e65-72. https://doi.org/10.1097/MLR.0b013e318297429c

    Article  PubMed  PubMed Central  Google Scholar 

  14. Mehta HB, Dimou F, Adhikari D et al (2016) Comparison of comorbidity scores in predicting surgical outcomes. Med Care 54(2):180–187. https://doi.org/10.1097/MLR.0000000000000465

    Article  PubMed  PubMed Central  Google Scholar 

  15. Sundararajan V, Henderson T, Perry C et al (2004) New ICD-10 version of the Charlson comorbidity index predicted in-hospital mortality. J Clin Epidemiol 57(12):1288–1294. https://doi.org/10.1016/j.jclinepi.2004.03.012

    Article  PubMed  Google Scholar 

  16. Tominaga T, Nonaka T, Takeshita H et al (2018) The Charlson comorbidity index as an independent prognostic factor in older colorectal cancer patients. Indian J Surg 80(1):54–60. https://doi.org/10.1007/s12262-016-1544-4

    Article  PubMed  Google Scholar 

  17. Uemura M, Imataki O, Kawachi Y et al (2016) Charlson comorbidity index predicts poor outcome in CML patients treated with tyrosine kinase inhibitor. Int J Hematol 104(5):621–627. https://doi.org/10.1007/s12185-016-2074-3

    Article  CAS  PubMed  Google Scholar 

  18. Takemura K, Takenaka Y, Ashida N et al (2017) Age-adjusted Charlson comorbidity index predicts prognosis of laryngopharyngeal cancer treated with radiation therapy. Acta Otolaryngol 137(12):1307–1312. https://doi.org/10.1080/00016489.2017.1362112

    Article  PubMed  Google Scholar 

  19. Wu C-C, Hsu T-W, Chang C-M et al (2015) Age-adjusted Charlson comorbidity index scores as predictor of survival in colorectal cancer patients who underwent surgical resection and chemoradiation. Medicine (Baltimore) 94(2):e431. https://doi.org/10.1097/MD.0000000000000431

    Article  CAS  PubMed Central  Google Scholar 

  20. Scharl S, Papathemelis T, Kronberger K et al (2018) Does post-operative radiochemotherapy improve survival in high-grade endometrial cancer patients? Results of a population-based cohort analysis of a cancer registry. Arch Gynecol Obstet 297(5):1245–1253. https://doi.org/10.1007/s00404-018-4708-6

    Article  PubMed  Google Scholar 

  21. Creasman W (2009) Revised FIGO staging for carcinoma of the endometrium. Int J Gynaecol Obstet 105(2):109. https://doi.org/10.1016/j.ijgo.2009.02.010

    Article  PubMed  Google Scholar 

  22. Charlson ME, Pompei P, Ales KL et al (1987) A new method of classifying prognostic comorbidity in longitudinalstudies: Development and validation. J Chronic Dis 40(5):373–383. https://doi.org/10.1016/0021-9681(87)90171-8

    Article  CAS  Google Scholar 

  23. Quan H, Sundararajan V, Halfon P et al (2005) Coding algorithms for defining comorbidities in ICD-9-CM and ICD-10 administrative data. Med Care 43(11):1130–1139. https://doi.org/10.1097/01.mlr.0000182534.19832.83

    Article  Google Scholar 

  24. Deutsche Krebsgesellschaft, Deutsche Krebshilfe, AWMF Diagnostik (2020) Therapie und Nachsorge der Patientinnen mit Endometriumkarzinom. Langversion1.0, 2018, AWMF Registernummer: 032/034-OL. http://www.leitlinienprogramm-onkologie.de/leitlinien/endometriumkarzinom/. Accessed 15 Feb 2020

  25. Kommission Uterus der Arbeitsgemeinschaft Gynäkologische Onkologie e.V. in der Deutschen Gesellschaft für Gynäkologie und Geburtshilfe e.V. sowie in der Deutschen Krebsgesellschaft e. V. (2010) Interdisziplinäre S2k-Leitlinie für die Diagnostik und Therapie des Endometriumkarzinoms. https://www.awmf.org/uploads/tx_szleitlinien/032-034l_S2k_Endometriumkarzinom_01.pdf. Accessed 18 Apr 2020

  26. DGGG Diagnostik und Therapie des Endometriumkarzinoms (2020). https://www.dggg.de/leitlinien-stellungnahmen/leitlinien/leitlinie/diagnostik-und-therapie-des-endometriumkarzinoms-239/. Accessed 13 Dec 2020

  27. Kim HS, Suh DH, Kim M-K et al (2012) Systematic lymphadenectomy for survival in patients with endometrial cancer: a meta-analysis. Jpn J Clin Oncol 42(5):405–412. https://doi.org/10.1093/jjco/hys019

    Article  PubMed  Google Scholar 

  28. Piccirillo JF, Vlahiotis A, Barrett LB et al (2008) The changing prevalence of comorbidity across the age spectrum. Crit Rev Oncol Hematol 67(2):124–132. https://doi.org/10.1016/j.critrevonc.2008.01.013

    Article  PubMed  PubMed Central  Google Scholar 

  29. van Leersum NJ, Janssen-Heijnen MLG, Wouters MWJM et al (2013) Increasing prevalence of comorbidity in patients with colorectal cancer in the South of the Netherlands 1995–2010. Int J Cancer 132(9):2157–2163. https://doi.org/10.1002/ijc.27871

    Article  CAS  PubMed  Google Scholar 

  30. Nout RA, Smit V, Putter H et al (2010) Vaginal brachytherapy versus pelvic external beam radiotherapy for patients with endometrial cancer of high-intermediate risk (PORTEC-2): an open-label, non-inferiority, randomised trial. Lancet 375(9717):816–823. https://doi.org/10.1016/S0140-6736(09)62163-2

    Article  CAS  PubMed  Google Scholar 

  31. Wortman BG, Creutzberg CL, Putter H et al (2018) Ten-year results of the PORTEC-2 trial for high-intermediate risk endometrial carcinoma: improving patient selection for adjuvant therapy. Br J Cancer 119(9):1067–1074. https://doi.org/10.1038/s41416-018-0310-8

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  32. de Boer SM, Powell ME, Mileshkin L et al (2018) Adjuvant chemoradiotherapy versus radiotherapy alone for women with high-risk endometrial cancer (PORTEC-3): final results of an international, open-label, multicentre, randomised, phase 3 trial. Lancet Oncol 19(3):295–309. https://doi.org/10.1016/S1470-2045(18)30079-2

    Article  PubMed  PubMed Central  Google Scholar 

  33. Wallwiener CW, Hartkopf AD, Grabe E et al (2016) Adjuvant chemotherapy in elderly patients with primary breast cancer: are women ≥65 undertreated? J Cancer Res Clin Oncol 142(8):1847–1853. https://doi.org/10.1007/s00432-016-2194-4

    Article  CAS  PubMed  Google Scholar 

  34. Scholten AN, Smit VTHBM, Beerman H et al (2004) Prognostic significance and interobserver variability of histologic grading systems for endometrial carcinoma. Cancer 100(4):764–772. https://doi.org/10.1002/cncr.20040

    Article  PubMed  Google Scholar 

  35. Han G, Sidhu D, Duggan MA et al (2013) Reproducibility of histological cell type in high-grade endometrial carcinoma. Mod Pathol 26(12):1594–1604. https://doi.org/10.1038/modpathol.2013.102

    Article  CAS  PubMed  Google Scholar 

  36. Gilks CB, Oliva E, Soslow RA (2013) Poor interobserver reproducibility in the diagnosis of high-grade endometrial carcinoma. Am J Surg Pathol 37(6):874–881. https://doi.org/10.1097/PAS.0b013e31827f576a

    Article  PubMed  Google Scholar 

  37. Suarez AA, Felix AS, Cohn DE (2017) Bokhman Redux: endometrial cancer “types” in the 21st century. Gynecol Oncol 144(2):243–249. https://doi.org/10.1016/j.ygyno.2016.12.010

    Article  PubMed  Google Scholar 

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Authors and Affiliations

Authors

Contributions

S.S, A.S., M.K., O.K. and T.P. conceived of the presented idea. T.S. and M.G. collected the data and performed the computations. The manuscript was drafted by S.S. The manuscript was revised by E.I., O.O., A.I., A.S. and O.K. All authors discussed the results and contributed to the final manuscript.

Corresponding author

Correspondence to Sophia Scharl.

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The authors declare that they have no conflict of interest.

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Due to the analysis of data from a clinical cancer registry no ethics approval was necessary.

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Not applicable, due to the analysis of data from a clinical cancer registry.

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Supplementary Information

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404_2021_6140_MOESM1_ESM.pptx

Supplementary file1 (PPTX 271 KB) Figure S1: Treatment scheme for high-grade endometrial cancer derived from the German DGGG Guideline 1998. Figure S2: Treatment scheme for high-grade endometrial cancer derived from the German DGGG Guideline 1999. Figure S3: Treatment scheme for high-grade endometrial cancer derived from the German DGGG Guideline 2004. Figure S4: Treatment scheme for high-grade endometrial cancer derived from the German DGGG Guideline 2006. Figure S5: Treatment scheme for high-grade endometrial cancer derived from the German S2k-Guideline 2008.

Supplementary file2 (DOCX 49 KB)

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Scharl, S., Sprötge, T., Gerken, M. et al. Factors influencing treatment decision and guideline conformity in high-grade endometrial cancer patients: a population-based study. Arch Gynecol Obstet 305, 203–213 (2022). https://doi.org/10.1007/s00404-021-06140-5

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  • DOI: https://doi.org/10.1007/s00404-021-06140-5

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