Trends and clinical predictors in ovarian preservation in patients with low-risk endometrial cancer
For premenopausal patients with early-stage endometrial cancer, iatrogenic menopause raises concerns regarding cardiovascular risk, cognitive decline, and loss of future fertility. Although previous studies have demonstrated the safety of ovarian preservation in selected patients with low-risk endometrial cancer, and national guidelines support its use in selected cases, contemporary ovarian preservation practices and potential sociodemographic disparities in care delivery remain poorly characterized. This study aimed to assess national trends in ovarian preservation and identify clinical and sociodemographic factors associated with ovarian preservation among premenopausal women. We conducted a retrospective cohort study using the National Cancer Database, including women aged less than 45 years diagnosed with stage IA, grade 1 or 2 endometrioid endometrial cancer between January 1, 2004 and December 31, 2021. A subanalysis was performed among patients who also underwent lymph node assessment as proxy for patients with preoperative oncologic planning. Time trends were evaluated using the Cochran-Armitage trend test, and average annual percent change was estimated using a Poisson model. Group differences were assessed using Chi-squared or Fisher's exact tests, and logistic regression was used to evaluate associations between ovarian preservation and clinical and sociodemographic variables. A total of 4343 women met the inclusion criteria. Between 2004 and 2021, ovarian preservation rates declined from 16.7% to 3.7% (average annual percent change, -8.6%; 95% confidence interval, -10.4% to 6.6%; P<.0001). On multivariable logistic regression analysis, older age (odds ratio, 0.94; 95% confidence interval, 0.92-0.96; P<.001), grade 2 disease (odds ratio, 0.47; 95% confidence interval, 0.34-0.63; P<.0001), and treatment at academic/research facilities (odds ratio, 0.74; 95% confidence interval, 0.60-0.91; P=.006) were associated with lower odds of ovarian preservation. Race/ethnicity, insurance status, income, urban/rural residence, and distance to the diagnosing facility were not significantly associated with ovarian preservation. Among patients who underwent lymph node assessment, ovarian preservation similarly declined, from 5.6% in 2004 to 2.8% in 2021 (average annual percent change, -4.8%; 95% confidence interval, -8.9% to 0.62%; P=.03). In this cohort, older age at diagnosis (odds ratio, 0.92; 95% confidence interval, 0.89-0.96; P<.001) was associated with decreased odds of ovarian preservation and Asian/American Indian race/ethnicity (odds ratio, 3.43; 95% confidence interval, 1.97-6.04; P<.001) were associated with higher odds of ovarian preservation. Ovarian preservation remains underused in premenopausal patients with low-risk endometrial cancer despite guideline support and evidence highlighting its long-term health benefits. Older age, higher tumor grade, and treatment at academic centers influence practice, highlighting missed opportunities for evidence-based, patient-centered care. Further research is needed to better understand the drivers of these patterns and support more consistent, individualized surgical decision-making.