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Hysterectomy with a General Gynecologist vs. Gynecologic Oncologist in the Setting of Endometrial Intraepithelial Neoplasia: A Cost-Effectiveness Analysis

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      Abstract:

      Background

      Standard treatment for patients with endometrial intraepithelial neoplasia (EIN) is a hysterectomy, which has a 43% risk of concomitant endometrial cancer on final pathology. General gynecologists and gynecologic oncologists perform hysterectomies; however, patients who have a hysterectomy for EIN with a general gynecologist and are found to have cancer may require a second surgery by a gynecologic oncologist to complete staging. There is current ongoing discussion regarding whether patients with EIN should be provided the option to receive the initial hysterectomy with a gynecologic oncologist.

      Objective

      To better understand if patients with EIN should be initially referred to a gynecologic oncologist for treatment, we examined the cost-effectiveness of hysterectomy by general gynecologists versus gynecologic oncologists for patients with EIN.

      Study Design

      We created a decision-analytic model using TreeAge Pro software to compare outcomes between patients with EIN undergoing hysterectomy by a general gynecologist versus a gynecologic oncologist. Our theoretical cohort contained 200,000 patients, an estimate of the number of individuals diagnosed with EIN each year in the United States. Outcomes included costs, quality-adjusted life years (QALYs), primary lymph node dissection (LND), secondary LND, surgical site infection, and perioperative mortality. We assumed that surgical morbidity and mortality were the same under generalist and specialist care and applied costs of travel and lost work for those seeing a gynecologic oncologist. We performed univariable sensitivity analyses as well as multivariable probabilistic sensitivity analysis to assess the model’s robustness given the uncertainty of model inputs.

      Results

      In our theoretical cohort of 200,000 patients with EIN, hysterectomy with a gynecologic oncologist was associated with a decrease in 10,811 second surgeries for LND, 87 surgical site infections, and 9 perioperative mortalities. When hysterectomy was performed by a general gynecologist, 9 fewer patients had a LND due to perioperative mortalities that occurred prior to LND with a gynecologic oncologist. Hysterectomy with a gynecologic oncologist was the dominant, cost-effective strategy as it saved $116 million and increased QALYs by 180. In our univariable analyses, hysterectomy with a gynecologic oncologist was cost-saving and increased QALYs over a wide range of probabilities and costs for LND, surgical site infection, and perioperative mortality. However, hysterectomy with a gynecologic oncologist is only a cost-effective and cost-saving saving strategy in just over 50% of multivariable simulations, demonstrating that that there is significant uncertainty in the model’s cost-effectiveness.

      Conclusions

      In our model, hysterectomy with a gynecologic oncologist for patients with EIN was associated with cost savings and increased QALYs. Our study supports that patients undergoing hysterectomy for EIN at institutions using Mayo criteria to determine need for lymphadenectomy may benefit from surgery with a gynecologic oncologist rather than a general gynecologist to reduce costs and adverse events associated with a second surgery.

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