Cost and Quality of Life Analysis of Surgery For
Early Endometrial Cancer: Laparotomy Versus Laparoscopy

Nick M. Spirtos, M.D.A, John B. Schlaerth, M.D.A, Gary M. Gross, M.D.B, Tanya W. Spirtos, M.D.C, Alan C. Schlaerth, B.A.A, and Samuel C. Ballon, M.D.A

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(A) Women's Cancer Center of Northern California, Palo Alto, California
(B) Department of Surgery, University of Alabama at Huntsville, Huntsville, Alabama
(C) Department of Gynecology and Obstetrics, Stanford University Medical Center, Stanford, California

Condensation

Laparoscopic management of endometrial cancer may result in significant cost savings, shortened hospital stays, and earlier return to normal activity.

Objective

The purpose of this study was to determine if the cost and/or quality of life associated with surgical treatment of women with presumed early stage endometrial cancer differed based on the surgical approach.

Study Design

A retrospective analysis was performed on a consecutive series of women with presumed early stage endometrial cancer treated at the Women's Cancer Center of Northern California. The senior author was the surgeon, co-surgeon, or assistant on all cases. The women comprise two groups differing in surgical approach. The first group of 17 women underwent exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy (TAH-BSO) and pelvic and aortic lymphadenectomy (PPALND). The second group of 13 women underwent the same surgery via laparoscopy. The two groups were compared using a two-tailed Student T test. Variables analyzed included age, height, weight, Quetelet index, and predisposing medical problems. Lymph node counts were compiled. Hospital costs were broken down into four cost categories: 1) operating room; 2) hospital bed; 3) pharmacy; and, 4) anesthesia. A two-tailed Student T test was also used in this analysis. Issues examined regarding quality of life included 1) average hospital stay, 2) complications, and 3) time to return to normal activity.

Results

The patient populations differed significantly (p< 0.05) with regard to weight and Quetelet index. The laparotomy group required significantly longer hospitalization than the laparoscopy group (6.3 vs. 2.4 days, p< 0.001) resulting in higher overall hospital costs ($19,158 vs. $13,988, p< 0.05). Similarly, patients undergoing laparotomy took longer to return to normal activity (5.3 weeks vs. 2.4 weeks p< 0.0001).

Conclusion

Laparoscopic management of endometrial cancer may result in significant cost savings, as well as improved quality of life as demonstrated by shortened hospital stays and an earlier return to normal activity.

Key Words: Abdominal hysterectomy, Laparoscopically-assisted vaginal hysterectomy, Lymphadenectomy, Cost analysis

Recent advances in endoscopic technology and surgical instrumentation have enabled gynecologic oncologists to perform aortic and pelvic lymphadenectomy, radical hysterectomy (Type III), and surgical procedures associated with the staging of patients with ovarian cancer. (1-5) Spirtos et al have shown that the generally accepted guidelines of the Gynecologic Oncology Group for endometrial cancer surgical therapy and staging can be met through the laparoscopic approach with acceptable morbidity and mortality. (1) This report implied, but did not state that the use of advanced laparoscopic/endoscopic procedures in the management of women with gynecologic malignancies will benefit them both in terms of lowering the cost of care and, perhaps more importantly, improving their quality of life. The purpose of this retrospective study was to determine if the cost and/or quality of life associated with the surgical treatment of women with presumed early stage endometrial cancer differed based on the surgical approach chosen.

Materials and Methods

A retrospective analysis was performed on two groups of patients with presumed early stage endometrial cancer treated at the Women's Cancer Center of Northern California. From July 1, 1993 until December 31, 1994, the records of 30 patients treated by the authors for early stage endometrial cancer were examined retrospectively. The senior author was the surgeon, co-surgeon, or assistant on all cases. It was the intent of the surgeons to complete surgical staging, either via laparotomy or laparoscopically, according to guidelines established by the Gynecologic Oncology Group. (6) All women were considered candidates for complete surgical staging if they were clinically presumed to be Stage I or II and exhibited either 1) Grade 2 or 3 lesions on biopsy/curettage; 2) high risk histologic types, i.e. papillary serous, clear cell, carcinosarcoma; or 3) intraoperative evidence of myometrial invasion, and; 4) no extrauterine metastasis intraoperatively. With these specifications, these 30 women are a consecutive series. Seventeen patients underwent exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy (TAH-BSO), and pelvic and para-aortic lymph node dissection (PPALND). Thirteen patients underwent similar surgical procedures performed laparoscopically. Some of the women undergoing laparoscopy were enrollees in a Gynecologic Oncology Group feasibility study where a Quetelet index of <30 was required for entry. Apart from this study, laparoscopy as an option was left to the surgeon's discretion. Still, no woman undergoing laparoscopy had a Quetelet index greater than 30. (7) Patients were not randomized between surgical approaches. The patients underwent laparotomy at nine different hospitals. In five of these hospitals, the laparoscopies were performed. These five hospitals had well-established dedicated laparoscopic surgery programs.

The two populations were compared using a two-tailed Student T test. Variables analyzed included age, height, weight, Quetelet index, and predisposing medical problems. Lymph node counts were compiled. Hospital costs were broken down into four categories; 1) operating room, 2) hospital bed, 3) pharmacy, and 4) anesthesia. Surgeons fees were not included in the analysis as they were identical for both laparotomy and laparoscopy. A two-tailed Student T test was also used in this analysis. Issues examined regarding quality of life included: 1) average hospital stay; 2) complications; and, 3) time to return to normal activity. A questionnaire was sent out to all patients and the ability to return to work was evaluated both subjectively and objectively.

Results

The population characteristics are seen in Table I. The patient populations differed significantly (p< 0.05) only as the Quetelet index is a reflection of the population's weight. The mean Quetelet index of the 17 patients undergoing laparotomy was 30.2 +/- 7.3 (20.43-53.98) and for patients undergoing laparoscopy 24.2 +/- 3.2 (19.44-29.77) (p< 0.01). No patient undergoing laparoscopy required conversion to laparotomy to complete the procedure. Table II demonstrates the breakdown and a comparison of costs between the laparotomy and laparoscopic groups. Hospital, pharmacy, and overall costs were higher in the laparotomy group. Figure 1 demonstrates the difference in length of hospitalization according to the method of surgery. There was a statistically significant difference in days favoring laparoscopy, 2.4 days versus 6.2 days (p< 0.0001). Patients undergoing laparotomy took longer to return to normal activity, 5.3 weeks versus 2.4 weeks (p< 0.0001) when compared to patients undergoing laparoscopy.

Figure 2 - Time to return to normal activity according to method of surgery for all patients.

Lymph node counts were similar regardless of surgical approach. Patients undergoing laparoscopy had an average of 8 aortic and 20 pelvic lymph nodes removed. Patients undergoing laparotomy had an average of 7 aortic and 22 pelvic lymph nodes removed. Postoperative complications were negligible. One patient undergoing laparotomy developed a postoperative wound infection and one patient undergoing laparoscopy developed minimal left lower extremity lymphedema.

Because the Quetelet index was such an obvious bias between the two groups, the ten patients with Quetelet indices less than 30 who underwent laparotomy were compared with the 13 undergoing laparoscopy. (Table III) In this analysis, there was a statistically significant difference favoring laparoscopy in hospital bed, pharmacy, and anesthetic costs. There was no difference in operating room and total costs. Hospital stays for these two groups were analyzed. Mean hospital stay was 5.3 days for the laparotomy group with Quetelet indices under 30. When compared to the mean hospital stay for laparoscopy patients of 2.4 days, this difference is significant (p< 0.0001). (Figure 3) Return to normal activity for the laparotomy group with Quetelet indices less than 30 was 5.7 weeks compared to 2.6 weeks for the laparoscopy group. This difference was statistically significant (p< 0.0001). (Figure 4) To address one final bias, that of different hospitals, the six women with Quetelet indices less than 30 who underwent laparotomy at one of the five hospitals where laparoscopies were performed was compared with the laparoscopy group. (Table IV) A statistically significant difference favoring laparoscopy was found in hospital bed, pharmacy, and total costs.

Discussion

In all patients, surgical staging was completed and met criteria outlined in the Gynecologic Oncology Group Surgical Manual. Clearly, the groups of patients undergoing laparotomy and laparoscopy differed in one significant way, that being preoperative weight which resulted in higher Quetelet indices for those patients undergoing laparotomy. Some of this difference resulted from an intentional bias. The first cases of laparoscopically-assisted vaginal hysterectomy, bilateral salpingo-oophorectomy, bilateral aortic and pelvic lymphadenectomy, which began in May of 1992 were the thinner and presumed to be easier patients to be operated on laparoscopically. As reported previously, operative times decreased dramatically over the first year (1) and as surgical expertise improved, the maximum Quetelet index increased. However, there may be a subtler issue than simply weight as a function of height in that,intraoperatively, the most difficult problem related to a patient's height and obesity is the ability to displace the small and large bowel out of the operative field. Other parameters may be more important than the Quetelet index as guidelines for suitability for laparoscopic surgery such as the distance between the anterior superior iliac spines, the xiphoid to pubic length, torso length, and chest and abdominal circumference.

The patients undergoing laparotomy required significantly longer hospitalization than the laparoscopy group, 6.4 versus 2.4 days (p< 0.0001). This difference was apparent even after stratifying the groups on the basis of similar Quetelet indices and the same hospitals. The hospital stays associated with laparotomy are similar to those in other published studies. (8,9) Patients undergoing laparoscopy have a shorter hospital stay secondary to an earlier return of bowel function. This is probably related to the decreased manipulation of the bowel during laparoscopy compared to laparotomy. Additionally, with much smaller abdominal wall incisions, the postoperative pain requirements are decreased and, therefore, the use of opiates is less.

Not surprisingly, the length of hospitalization results in higher overall hospital costs, $19,158 versus $13,988 (p< 0.05) associated with the patients undergoing laparotomy. The operative room costs were not significantly different between the two groups. Time in the operating room dominated operating room costs and tended to overshadow the specialized equipment costs related to laparoscopic surgery. As expected, hospital and pharmacy costs tended to parallel each other as both are directly related to hospital days and operating room charges and anesthetic charges tended to be closely related as, again, these charges are more or less a function of total operating time. Where the two groups were stratified for similar Quetelet indices, the difference in overall costs was insignificant. But when a further stratification according to the same hospitals was considered, the overall cost difference became significant again in favor of laparoscopy. A possible explanation would be that hospital which invest in advanced laparoscopic equipment may transfer costs to other areas. This could account for higher laparotomy costs at those hospitals. One last point should be made regarding the many different hospitals in which the surgeries took place. Hospital billing charges are not uniform one to another. Terminology and grouping of charges differ, as well. This required some arbitrary adjustments in assigning costs to either surgery, hospital bed, pharmacy, or anesthesia categories. Laparoscopic procedures and equipment being new led to some sizeable differences in charges between hospitals.

This study also addressed one often cited, yet unproven, societal benefit presumed to be associated with laparoscopic surgery, that being the patient's earlier return to normal activity and/or work. In the entire group and in the subgroups of similar Quetelet indices and the same hospitals, patients undergoing laparotomy took longer to return to normal activity, 6.5 weeks versus 2.6 weeks (p< 0.00001), and 5.7 weeks versus 2.6 weeks (p< 0.00001). We think this is due both to the decreased need for analgesics and, in many ways, preoperative expectation and motivation of the patients electing to undergo laparoscopic surgery. Closer examination of the return to normal activity patterns revealed that none of the laparotomy patients felt they were capable of returning to work prior to four weeks following surgery whereas none of the laparoscopy patients subjectively felt that they could not have returned to work by four weeks.

Figure 1 - Length of hospitalization according to method of surgery for all patients

It is perhaps not surprising that for some patients with jobs, the ability to return to work did not necessarily mean that the patient did return to work. A particular sentiment voiced was that as they had six weeks of leave "coming to them" that they would take the leave whether or not it was necessary. Overall, in patients with a Quetelet index of less than 30, laparoscopic management of early endometrial cancer resulted in significant cost savings, as well as improved quality of life as demonstrated by an earlier return to normal activity. Hopefully, these results will be borne out by the proposed randomized trial soon to be undertaken by the Gynecologic Oncology Group.

Table I. Population Characteristics
Characteristic	Laparotomy (17)	Laparoscopy (13)	Significance
Mean Age (Range)	64 (38-81)	61 (35-74)	NS
Prior Major Abdominal Surgery	2/17 (12%)	1/13 (8%)	NS
Hypertension	4/17 (24%)	2/13 (15%)	NS
Diabetes Mellitus	3/17 (8%)	1/13 (8%)	NS
Coronary Artery Disease	1/17 (6%)	1/13 (%)	NS
Height	64 inches +/- 2.4	64 inches +/- 2.3	NS
Weight	176 lbs +/- 46	141 lbs +/- 20	< 0.02
Quetelet Index	24.2 +/- 3.2	30.2 +/- 7.3	< 0.01

Table II. Medical costs (in dollars) according to the method of surgery
Characteristic	Laparotomy (17)	Laparoscopy (13)	Significance
Operating Room	4,577 +/- 1,511	5,083 +/- 1,808	NS
Hospital	5,723 +/- 3,033	1,777 +/- 810	< .0002
Pharmacy	2,414 +/- 1,066	1,010 +/- 530	< .0003
Anesthesia	818 +/- 328	1,189 +/- 342	NS
Other	5,626 +/- 2,029	4,750 +/- 2,694	NS
Total	19,158 +/- 4,229	13,809 +/- 3,560	< .004

Table III. Medical costs (in dollars) according to the method of surgery for women with Quetelet indices less than 30
Characteristic	Laparotomy (10)	Laparoscopy (13)	Significance
Operating Room	4,967 +/- 1,364	5,083 +/- 1,808	NS
Hospital Bed	6,673 +/- 3,152	1,777 +/- 810	< .0003
Pharmacy	2,432 +/- 1,087	1,010 +/- 530	< .0005
Anesthesia	831 +/- 224	1,189 +/- 342	< .01
Other	5,640 +/- 2,096	4,750 +/- 2,694	NS
Total	17,119 +/- 8,112	13,809 +/ 3,560	NS

Figure 3 - Length of hospitalization according to method of surgery for women with Quetelet indices less than 30

Figure 4 - Readiness to return to normal activity for patients with Quetelet indices less than 30

Table IV. Medical costs (in dollars) according to method of surgery in women with Quetelet indices less than 30 undergoing surgery at the same group of hospitals
Characteristic	Laparotomy (6)	Laparoscopy (13)	Significance
Operating Room	4,427 +/- 1,098	5,083 +/- 1,808	NS
Hospital Bed	6,532 +/- 3,036	1,777 +/- 810	<.0005
Pharmacy	2,124 +/- 720	1,010 +/- 530	<.002
Anesthesia	943 +/- 226	1,189 +/- 342	NS
Other	5,337 +/- 1,271	4,750 +/- 2,694	NS
Total	19,362 +/- 3,675	13,809 +/ 3,560	< .007

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