National trends, outcomes, and costs of radiation therapy in the management of low- and high-intermediate risk endometrial cancer

Gynecol Oncol. 2019 Mar;152(3):439-444. doi: 10.1016/j.ygyno.2018.11.005.


Objective: To assess treatment patterns, outcomes, and costs for women with low-(LIR) and high-intermediate risk endometrial cancer (HIR) who are treated with and without adjuvant radiotherapy.

Methods: All patients with stage I endometrioid endometrial cancer who underwent surgery from 2000 to 2011 were identified from the SEER-Medicare database. LIR was defined as G1-2 tumors with <50% myometrial invasion or G3 with no invasion. HIR was defined as G1-2 tumors with ≥50% or G3 with <50% invasion. Patients were categorized according to whether they received adjuvant radiotherapy (vaginal brachytherapy [VBT], external beam radiotherapy [EBRT], or both) or no radiotherapy. Outcomes were analyzed and compared (primary outcome was overall survival).

Results: 10,842 patients met inclusion criteria. In the LIR group (n = 7609), there was no difference in 10-year overall survival between patients who received radiotherapy and those who did not (67% vs 65%, adjusted HR 0.95, 95% CI 0.81-1.11). In the HIR group (n = 3233), patients who underwent radiotherapy had a significant increase in survival (60% vs 47%, aHR 0.75, 95% CI 0.67-0.85). Radiotherapy was associated with increased costs compared to surgery alone ($26,585 vs $16,712, p < .001). Costs for patients receiving VBT, EBRT, and concurrent VBT/EBRT were $24,044, $27,512, and $31,564, respectively (p < .001). Radiotherapy was associated with an increased risk of gastrointestinal (7 vs 4%), genitourinary (2 vs 1%), and hematologic (16 vs 12%) complications (p < .001).

Conclusions: Radiotherapy was associated with improved survival in women with HIR, but not in LIR. It also had increased costs and a higher morbidity risk. Consideration of observation without radiotherapy in LIR may be reasonable.

Keywords: Cost; Endometrial cancer; High-intermediate risk endometrial cancer; Low-intermediate risk endometrial cancer; Overall survival; Radiotherapy.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Aged, 80 and over
  • Cohort Studies
  • Endometrial Neoplasms / economics*
  • Endometrial Neoplasms / epidemiology
  • Endometrial Neoplasms / radiotherapy*
  • Endometrial Neoplasms / surgery
  • Female
  • Health Care Costs
  • Humans
  • Radiotherapy, Adjuvant / economics
  • Radiotherapy, Adjuvant / statistics & numerical data
  • Retrospective Studies
  • Risk Factors
  • SEER Program
  • United States / epidemiology