Effect of fragmentation of surgery and adjuvant treatment in high-grade non-endometrioid endometrial cancer: a population-based cohort study.

Background: Fragmentation of cancer care (FC) occurs when patients receive treatment across several different hospitals. Regionalization of surgery for patients with high grade endometrial cancer means that patients must travel longer distances to receive care; these patients often require adjuvant treatment after surgery.

Objectives: To determine whether the fragmentation of surgery and adjuvant treatment impacts survival in patients with high grade non-endometrioid endometrial cancer.

Methods: This population-based retrospective cohort study included patients diagnosed between 2003-2017 with high-grade non-endometrioid endometrial cancer who received adjuvant treatment post-operatively. Non-fragmented care (NFC) was defined as receiving surgery and adjuvant treatment at the same institution. The primary outcome was overall survival (OS).

Results: We identified 1,795 patients, of whom 583 (32.5%) had FC. Patients with NFC were more likely to have had surgery by a Gynecologic Oncologist (92.4 vs 58.8%, p<0.001), surgical staging (66.6 vs 44.8%, p<0.001), and less travel for surgery (mean 30.8 km vs 93.7 km, p<0.001). They were less likely to receive chemotherapy (26.3 vs 30%, p<0.001) and chemoradiation (38.4 vs 41.3%, p<0.001). Median survival was 9 years. There was no significant difference in OS between patients who received FC and NFC. 92.4 and 93.5% of the patients in the FC and NFC groups were treated at a specialized gynecologic oncology center for at least part of their treatment (surgery, adjuvant treatment or both).

Conclusions: We have previously shown that regionalization of surgery in high-grade endometrial cancer is associated with improved survival. Fragmentation of surgery and adjuvant treatment in this population does not have an adverse effect on survival. After receiving surgical treatment with a Gynecologic Oncologist, these patients may receive adjuvant treatment closer to home to decrease financial and travel burden.