For women under 40 with early-stage endometrial cancer, fertility-preserving hormonal therapy offers comparable survival to hysterectomy, making it a viable option for those desiring pregnancy. However, women aged 40-49 face significantly increased mortality risk with hormonal therapy and should strongly consider hysterectomy as first-line treatment.
Study Design & Population
- Study Type: Retrospective cohort study using National Cancer Database data (2004-2020)
- Sample Size: 15,849 premenopausal women aged 18-49 years
- Population: Clinical stage I, grade 1-2 endometrioid endometrial cancer patients
- Treatment Groups: 14,662 (92.5%) primary hysterectomy vs 1,187 (7.5%) primary hormonal therapy
- Methodology: Propensity score matching to compare survival outcomes
Key Findings
- Overall 5-year survival: 98.5% (hysterectomy) vs 96.8% (hormonal therapy), HR = 1.84 (95% CI, 1.06-3.21)
- Age <40 years: No survival difference between treatments, HR = 1.00 (95% CI, 0.50-2.00)
- Age 40-49 years: Hormonal therapy associated with significantly increased death risk, HR = 4.94 (95% CI, 1.89-12.91)
- Treatment trends: Hormonal therapy use increased from 5.2% in 2004 to 13.8% in 2020 (P < .001)
Clinical Implications
- Women under 40 can safely pursue fertility-preserving hormonal therapy without compromising survival
- Women aged 40-49 should be counseled about the nearly 5-fold increased mortality risk with hormonal therapy
- Age-based treatment algorithms should guide clinical decision-making for fertility preservation discussions
- Rising utilization trends suggest growing acceptance of conservative management in appropriate candidates
Limitations
- Retrospective design with potential selection bias and unmeasured confounding variables
- Database limitations prevent assessment of fertility outcomes, pregnancy rates, or quality of life measures
- Lack of detailed information on hormonal therapy protocols, duration, or response monitoring
- Follow-up period may be insufficient to capture long-term recurrence patterns in hormonal therapy patients
Source: https://jamanetwork.com/journals/jamaoncology/article-abstract/2838069
