Hysterectomy with a general gynecologist versus gynecologic-oncologist in the setting of complex atypical hyperplasia: a cost-effectiveness analysis

Objectives: The standard of care for patients with endometrial complex atypical hyperplasia (CAH) is a total hysterectomy. The underlying risk of finding endometrial cancer at the time of hysterectomy is as high as 43%. Both general gynecologists and gynecologic oncologists perform total hysterectomies. However, some patients with endometrial cancer found at the time of hysterectomy require a lymph node dissection (LND), a procedure typically done only by gynecologic oncologists. Patients who have a hysterectomy for CAH with a general gynecologist and are found to have cancer may require a second surgery with a gynecologic oncologist. In this study, we examined the cost-effectiveness of hysterectomy by general gynecologists versus gynecologic oncologists for CAH patients. Methods: We designed a decision-analytic model using TreeAge to compare outcomes between CAH patients who received hysterectomy by a general gynecologist versus a gynecologic oncologist. Our theoretical cohort contained 200,000 patients, the approximate number of patients with new CAH diagnoses per year in the United States. Our outcomes were costs, quality-adjusted life years (QALYs), LND, LND as a second surgery, surgical site infection, and perioperative mortality. We assumed that cancer-related care and outcomes were identical for both groups except for the morbidity and mortality directly related to a second surgery for LND. We applied a cost of frozen section to the gynecologic oncologist branch. Probabilities of perioperative mortality and surgical site infection were the same regardless of surgeon specialty and were applied twice for those who underwent two surgeries. We derived all values from the literature and discounted QALYs at a rate of 3%. To assess the robustness of our model, we performed univariate sensitivity analyses. Results: In our one-year theoretical cohort of 200,000 patients with CAH, the hysterectomy with a gynecologic-oncologist strategy was associated with a decrease in 10,744 second surgeries for LND, 546 surgical site infections, and 76 perioperative mortalities (Table 1). The hysterectomy with a general gynecologist strategy was associated with a decrease in 77 LNDs due to perioperative mortalities prior to subsequent LND. Hysterectomy with a gynecologic oncologist was the dominant, cost-effective strategy as it saved $210 million and increased QALYs by 1,138. In our sensitivity 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. Download : Download high-res image (96KB) Download : Download full-size image Conclusions: In our model, hysterectomy with a gynecologic oncologist for patients with CAH was associated with cost savings and increased QALYs. Our study suggests that patients undergoing hysterectomy for CAH should consider surgery with a gynecologic oncologist rather than a general gynecologist to reduce costs and outcomes associated with a second surgery.