Share this article on:

Three Lymphadenectomy Strategies in Low-Risk Endometrial Carcinoma: A Cost-Effectiveness Analysis

Suidan, Rudy, S., MD, MS; Sun, Charlotte, C., DrPH; Cantor, Scott, B., PhD; Mariani, Andrea, MD; Soliman, Pamela, T., MD, MPH; Westin, Shannon, N., MD, MPH; Lu, Karen, H., MD; Giordano, Sharon, H., MD, MPH; Meyer, Larissa, A., MD, MPH

doi: 10.1097/AOG.0000000000002677
Gynecologic Oncology: Original Research: PDF Only

OBJECTIVE: To evaluate the cost-utility of three lymphadenectomy strategies in the management of low-risk endometrial carcinoma.

METHODS: A decision analysis model compared three lymphadenectomy strategies in women undergoing minimally invasive surgery for low-risk endometrial carcinoma: 1) routine lymphadenectomy in all patients, 2) selective lymphadenectomy based on intraoperative frozen section criteria, and 3) sentinel lymph node mapping. Costs and outcomes were obtained from published literature and Medicare reimbursement rates. Costs categories consisted of hospital, physician, operating room, pathology, and lymphedema treatment. Effectiveness was defined as 3-year disease-specific survival adjusted for the effect of lymphedema (utility=0.8) on quality of life. A cost-utility analysis was performed comparing the different strategies. Multiple deterministic sensitivity analyses were done.

RESULTS: In the base-case scenario, routine lymphadenectomy had a cost of $18,041 and an effectiveness of 2.79 quality-adjusted life-years (QALYs). Selective lymphadenectomy had a cost of $17,036 and an effectiveness of 2.81 QALYs, whereas sentinel lymph node mapping had a cost of $16,401 and an effectiveness of 2.87 QALYs. With a difference of $1,005 and 0.02 QALYs, selective lymphadenectomy was both less costly and more effective than routine lymphadenectomy, dominating it. However, with the lowest cost and highest effectiveness, sentinel lymph node mapping dominated the other modalities and was the most cost-effective strategy. These findings were robust to multiple sensitivity analyses varying the rates of lymphedema and lymphadenectomy, surgical approach (open or minimally invasive surgery), lymphedema utility, and costs. For the estimated 40,000 women undergoing surgery for low-risk endometrial carcinoma each year in the United States, the annual cost of routine lymphadenectomy, selective lymphadenectomy, and sentinel lymph node mapping would be $722 million, $681 million, and $656 million, respectively.

CONCLUSION: Compared with routine and selective lymphadenectomy, sentinel lymph node mapping had the lowest costs and highest quality-adjusted survival, making it the most cost-effective strategy in the management of low-risk endometrial carcinoma.

Sentinel lymph node mapping is the most cost-effective lymphadenectomy strategy in the management of low-risk endometrial cancer.

Division of Surgery, Department of Gynecologic Oncology and Reproductive Medicine, and the Department of Health Services Research, the University of Texas MD Anderson Cancer Center, Houston, Texas; and the Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota.

Corresponding author: Larissa A. Meyer, MD, MPH, Division of Surgery, Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, 1155 Herman Pressler, CPB 6.3271, Unit 1362, Houston, TX 77030; email: lmeyer@mdanderson.org.

Rudy S. Suidan is supported by a National Institutes of Health (NIH) T32 grant (#5T32 CA101642). Larissa A. Meyer is supported by a National Cancer Institute (NCI) K award (#K07 CA201013). Sharon H. Giordano is supported in part by a NCI MD Anderson Cancer Center Support Grant (#P30 CA016672) and a Cancer Prevention and Research Institute of Texas (CPRIT) grant (#RP160674). Shannon N. Westin is supported by the Andrew Sabin Family Fellowship, a NIH Specialized Program of Research Excellence (SPORE) in Uterine Cancer (#2P50 CA098258-06), and a NIH MD Anderson Cancer Center Support Grant (#P30CA016672).

Financial Disclosure Dr. Sun has received research support from AstraZeneca for unrelated research. Dr. Cantor has received research support from Intuitive Surgical and Hitachi. Dr. Soliman has received research support from Novartis and has been a consultant for Janssen Oncology. Dr. Westin has been a consultant for AstraZeneca, BioAscend, Medscape Oncology, Vaniam Group LLC, Genentech, Ovation, Vermillion, Clovis Oncology, Tesaro, and Medivation. She has received research support from AstraZeneca, Novartis, Critical Outcomes Technologies Inc, Tesaro, and Bayer. Dr. Meyer has received research support from AstraZeneca for unrelated research, and she participated in an advisory board Clovis Oncology in October of 2016. The other authors did not report any potential conflicts of interest.

Presented at the Society of Gynecologic Oncology’s Annual Meeting on Women's Cancer, National Harbor, Maryland, March 12–15, 2017; and at the American Society of Clinical Oncology’s Quality Care Symposium, Orlando, Florida, March 3–4, 2017.

Each author has indicated that he or she has met the journal's requirements for authorship.

Received January 25, 2018. Received in revised form March 23, 2018. Accepted March 29, 2018.

© 2018 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.