Recurrent patterns after postoperative radiotherapy for early stage endometrial cancer: A competing risk analysis model

Kang Ren, Wenhui Wang, Shuai Sun, Xiaorong Hou, Ke Hu, Fuquan Zhang, Kang Ren, Wenhui Wang, Shuai Sun, Xiaorong Hou, Ke Hu, Fuquan Zhang

Abstract

Objective: The study aimed to evaluate site-specific recurrent patterns via competing risks analysis and hazard function to provide evidence for adjuvant treatment and follow-up for early staged endometrial cancer (EC).

Methods: A total of 858 patients with International Federation of Gynecology and Obstetrics stage I-II EC who received adjuvant radiotherapy at our institution (2000-2017) were included. The radiotherapy modality comprised external beam radiotherapy (EBRT) with or without vaginal brachytherapy (VBT) or VBT alone. Competing risks analysis and hazard rate function were employed to evaluate the recurrence rate according to the ESMO-ESGO-ESTRO risk classification.

Results: The 5-year overall survival rates of the low-risk (LR), intermediate-risk (IR), high-intermediate risk (HIR), and high-risk (HR) groups were 96.1%, 95%, 93%, and 89.7%, respectively (p = 0.018). Sixty-eight patients developed recurrence. The 5-year incidence of distant recurrence was the highest in the HR group (14.87%), followed by the HIR (7.71%), IR (5.27%), and LR (1.26%) groups (Gray's test, p < 0.001). The LR and IR groups showed late metastasis behaviors for distant metastasis. The HR group presented a large magnitude of distant metastasis with an early peak that increased beyond 3 years. Subgroup analysis revealed that EBRT±VBT tended to reduce the locoregional relapse rate compared with VBT in the HIR-HR group (2.36% vs. 7.73%, Gray's test, p = 0.08).

Conclusion: The established competing risk modeling demonstrated different recurrence patterns across the risk groups and radiotherapy modes. A better understanding of the change in site-specific recurrence behavior allows more targeted adjuvant treatment and surveillance regimens.

Keywords: adjuvant radiotherapy; competing risk model; endometrial cancer; recurrence pattern.

Conflict of interest statement

The authors have no potential conflict of interest to report.

© 2021 The Authors. Cancer Medicine published by John Wiley & Sons Ltd.

Figures

FIGURE 1
FIGURE 1
Kaplan–Meier survival curves: (A) the 5‐year overall survival stratified by risk groups; (B) the 5‐year overall survival stratified by radiotherapy modalities; (C) patients with and without recurrence; and (D) patients with different recurrent patterns
FIGURE 2
FIGURE 2
Hazard function plots representing failure sites over follow‐up time according to the risk groups: (A) vaginal recurrence; (B) regional recurrence; and (C) distant metastasis
FIGURE 3
FIGURE 3
Multistate plots for risk occupation probabilities: (A) multistate based on the risk groups; (B) multistate based on the radiotherapy modes in the LR–IR groups; and (C) multistate based on the radiotherapy modes in the HIR–HR groups. HIR, high–intermediate risk; HR, high‐risk; IR, intermediate‐risk; LR, low‐risk

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