CRITICAL APPRAISAL ON AN ARTICLE ABOUT PROGNOSIS

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CLINICAL QUESTION

• What is the recurrence of malignancy in patients who underwent total laparoscopic hysterectomy for endometrial cancer?

• Population: Patients with endometrial cancer• Intervention: Total laparoscopic hysterectomy• Outcome: Recurrence• Method: Retrospective Cohort

• Search terms: recurrence, endometrial cancer, total laparoscopic hysterectomy

RELEVANCE

• Is the objective of the article on prognosis similar to your clinical dilemma?– YES– The objective of the article was to evaluate the

effect of the laparoscopic approach on patterns of recurrence, disease-free survival (DFS), and overall survival (OS) in patients with endometrial cancer.

VALIDITY GUIDES

• Was there a representative sample of patients without the outcome at the start of observation?– YES– In the study, there were 600 patients who underwent

primary surgery for endometrial cancer. Patients with concurrent malignancy (n=77) and patients who had vaginal hysterectomy were excluded from the series. Analysis is based on 510 patients (Paragraph 2, page 2). The surgical intent was laparoscopy in 226 patients and laparotomy in 284 patients (Paragraph 4, page 2).

VALIDITY GUIDES

• Was follow-up sufficiently long and complete?– YES– The median observation period post-op was 29.4

months. Of the 510 patients, only 3.1% were lost to follow-up. (Paragraph 2, page 3)

VALIDITY GUIDES

• Were the criteria for determining the prognostic factor and outcome explicit and credible?– YES– Cases were identified from the West Australian Gynecologic

Cancer Service database and cross-checked with the clinical coding database of the medical records departments and the database of histopathologic diagnoses from the Department of Pathology. Staging and grading were determined according to the 1988 FIGO criteria. Preoperatively, patients were scored according to the criteria of the American Society of Anaesthesiologists. (Paragraph 2, page 2)

VALIDITY GUIDES

• Was there adjustment for other prognostic factors?– NO.

OVERALL, IS THE STUDY VALID?

• Since the validity questions were fulfilled, the study can be considered valid.

WHAT ARE THE RESULTS?

• How large is the likelihood of outcome to occur in those with the prognostic factor in a specified period of time? Was it statistically significant?– The study stated that 46 patients (9%) developed

recurrent disease. 9 of the 226 patients (4.0%) in the laparoscopy group developed recurrence while 37 of the 284 patients (13.0%) in the laparotomy group develop recurrence. Computed relative risk was 0.31 indicating good prognosis and the risk of recurrence is less in laparoscopy. However, no port-site recurrence was detected in the laparoscopy group. (Paragraph 2, page 3)

CAN THE RESULTS HELP ME IN CARING FOR MY PATIENTS?

• Are the study patients similar to my own?– The subjects in the study were women with

endometrial cancer who underwent laparoscopy as the definitive treatment. The subjects were similar to the case.

CAN THE RESULTS HELP ME IN CARING FOR MY PATIENTS?

• Can I use the results to decide on the intervention or reassure my patient?– YES– Laparoscopic hysterectomy compared to the standard

laparotomy procedure has better prognosis. In terms of recurrence, the laparoscopic procedure resulted to a small number of recurrence (4%) compared to laparotomy (13.0%). Also, port-site recurrence was not detected in the laparoscopic approach. This makes laparoscopic hysterectomy a better treatment alternative than the standard.

RESOLUTION OF THE PROBLEM IN THE SCENARIO

• Based on the study, we would advise the patient to undergo laparoscopic hysterectomy because it has a better prognosis in terms of a decreased risk of recurrence of malignancy, as compared to the standard approach.