National University Cancer Institute, Singapore A Member of the Cochrane Nursing Care Field (CNCF)
This is a summary of a Cochrane Review. The full citation and the names of the researchers who conducted the review are listed in the Reference section.
The author have no funding or conflicts of interest to disclose.
Correspondence: Tan Yi Siew, RN, DipNursing, National University Cancer Institute, 5, Lower Kent Ridge Rd, Singapore 119074 (email@example.com).
The incidence of patients having endometrial cancer is on the rise. Traditionally, laparotomy is used to remove the cancer. The emergence in new technologies such as laparoscopy has offered patients alternative choices in their treatment plan, as the overall survival is comparable to laparotomy. In addition, the laparoscopic approach also reduces postoperative complications including infection, blood loss, and ileus. Nurses play a vital role in supporting patients’ decision regarding their treatment options in the management of early-stage endometrial cancer; therefore, they should be aware of the best available evidence regarding treatment options.
The objective of the review was to compare the overall survival and disease-free survival for laparoscopic surgery versus laparotomy in woman with presumed early-stage endometrial cancer.
This summary is based on the results of a Cochrane Systematic Review1 containing 8 randomized controlled trials (3644 participants). The inclusion criteria required adult women diagnosed with early endometrial cancer undergoing surgery as primary treatment. Interventions of interest were laparotomy (such as total abdominal hysterectomy) in comparison with laparoscopy (namely, laparoscopically assisted vaginal hysterectomy or total laparoscopic hysterectomy). The primary outcomes of interest were overall survival and recurrence-free survival. The secondary outcomes were perioperative death rate, estimated blood loss, severe postoperative adverse events, operative duration, and quality-of-life (QoL) data. The duration of follow-up varied across the trials, ranging from 2 to 96 months.
Overall, the methodological quality of the evidence was moderate as 6 of the 8 trials performed random-sequence generation and allocation concealment. Five trials were at moderate risk of bias as they satisfied 3 criteria used by the reviewers to assess bias. One trial was at moderate to high risk of bias, and 2 trials were at high risk of bias. Six trials reported the method of randomization. In all trials (except 3 where data were unclear), at least 80% of women who were enrolled were assessed at end point. In 1 trial, there may be additional bias because outcome definitions varied between the 3 different publications of the same trial. Three trials used validated tools to measure QoL, but only one of the trials used an adequate follow-up period of 4 years. Meta-analysis was undertaken where possible.
Results were as follows:
• Meta-analysis of 3 trials (n = 359) found no statistically significant difference in the risk of death between the women who underwent laparotomy versus laparoscopy.
• No statistically significant differences were found for the risk of disease recurrence in 4 trials (n = 2975) across the intervention and control groups.
• Five trials showed no significant difference in the perioperative death rate (within 30 days to 6 weeks) between those undergoing laparotomy versus laparoscopy.
• Meta-analysis of 3 randomized controlled trials (n = 313) indicated that laparoscopy was associated with a statistically significant reduction in blood loss compared with laparotomy (mean difference, −106.82; 95% confidence interval, −141.59 to −72.06).
• Two trials (n = 2923) demonstrated that the rate of severe postoperative adverse events was significantly lower in the laparoscopy group (relative risk, 0.58; 95% confidence interval, 0.37–0.91) compared with the laparotomy group.
• Three trials reported conflicting data on the QoL between the laparotomy and laparoscopy groups over varying time periods.
Currently, there is no evidence to support the role of laparoscopy in increasing overall survival and disease-free survival for the management of early endometrial cancer compared with laparotomy. However, evidence does suggest that laparoscopy can significantly reduce blood loss during the operation as compared with laparotomy.
Implications for Practice
Nurses updated with the best available evidence are able to inform women with early-stage endometrial cancer about the differences between laparotomy versus laparoscopy, which consists of both mortality and morbidity data. As a result, patients are able to make a more informed choice regarding their treatment plan.
1. Galaal K, Bryant A, Fisher AD, Al-Khaduri M, Kew F, Lopes AD. Laparoscopy versus laparotomy for the management of early stage endometrial cancer. Cochrane Database Syst Rev.
2012;(9): article no. CD006655. DOI: 10.1002/14651858.CD006655.pub2.