Management of Endometrial Cancer Precursors in the Military Health System: A Survey-Based Study

Introduction: Endometrial intraepithelial neoplasia (EIN) and atypical endometrial hyperplasia (AEH) are precancerous pathologies which carry a 40-50% concurrent cancer incidence. National guidelines recommend an individualized approach to gynecologic oncologist (GO) referral for a new EIN-AEH diagnosis. With the risk of underlying carcinoma, exactly who should manage EIN-AEH is controversial. In the military health system, gynecologic specialists (GS) may be remote with significant barriers to GO consultation, presenting a complex medical and social burden with potential impact to mission readiness. To our knowledge, no study has evaluated EIN-AEH practice patterns in the military health system. As practice patterns may vary, we surveyed EIN-AEH management by active duty GS and GO. Materials and Methods: An observational, voluntary, tri-service, survey-based study was conducted (eIRB protocol #966986) using two web-based surveys designed by military GO: one completed by active duty GS, the other by active duty GO. Demographics examining influential factors were collected. Surveys examined attitudes and practice patterns regarding referral and management of EIN-AEH. Univariate analysis was performed. Results: Of eligible physicians, 72 of 269 GS (26.8%) and 18 of 19 GO (94.7%) responded. More than 80% of GS/GO completed military medical training (81.9% vs. 88.9%), 72.2% vs. 61.1% were specialty-specific board-certified, 72.2% vs. 88.9% had a CONUS assignment, and 52.8% vs. 100% were part of large gynecologic surgery and obstetrics (GS&O) departments, respectively. Most GS (61.1%) had access to a GO at their facility or within 60miles and 56.9% had no formal EIN-AEH policy. Half of GS (50%) were willing to manage EIN-AEH in an appropriately counseled and biopsied patient; however, less than a quarter (23.6%) felt comfortable with fertility-sparing management. Most GS (68%) were willing to perform EIN-AEH surgical management if GO back-up was available and 83.5% of GOs indicated willingness to provide virtual consultation. When offered co-management with GO virtual consultation, GS expressed a 3-fold increased comfort with hysterectomy surgical management, including those stationed overseas (OR=3.10; 95% CI=1.55-6.21, P<.0014; overseas P=NS), and an 8-fold increased comfort with fertility-sparing management (OR=7.86; 95% CI=3.73-16.4, P<.0001). Conclusions: Management and referral of EIN-AEH by military GS varies widely with no policy at most facilities. A solution is needed, particularly in remote and overseas locations, to reduce medical, health system and social burden, and to conserve the fighting strength.