Kopelman Zachary A, Winkler Stuart S, Penick Emily R, Darcy Kathleen M, Hope Erica R
Gynecologic Cancer Center of Excellence, Department of Gynecologic Surgery & Obstetrics, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA.
Murtha Cancer Center Research Program, Department of Surgery, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA.
Mil Med. 2025 Sep 1;190(9-10):e2110-e2119. doi: 10.1093/milmed/usaf094.
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.
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.
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 60 miles 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).
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.
子宫内膜上皮内瘤变（EIN）和非典型子宫内膜增生（AEH）是癌前病变，同时合并癌症的发生率为40%-50%。国家指南建议，对于新诊断的EIN-AEH，应采用个体化方法转诊至妇科肿瘤学家（GO）处。鉴于存在潜在癌的风险，究竟应由谁来管理EIN-AEH存在争议。在军事卫生系统中，妇科专科医生（GS）可能地处偏远，向GO咨询存在重大障碍，这带来了复杂的医疗和社会负担，可能对任务准备状态产生影响。据我们所知，尚无研究评估军事卫生系统中EIN-AEH的诊疗模式。由于诊疗模式可能存在差异，我们对现役GS和GO管理EIN-AEH的情况进行了调查。
开展了一项基于网络调查的观察性、自愿性、三军联合研究（电子机构审查委员会协议编号#966986），使用由军事GO设计的两份网络调查问卷：一份由现役GS填写，另一份由现役GO填写。收集了考察影响因素的人口统计学数据。调查问卷考察了关于EIN-AEH转诊和管理的态度及诊疗模式。进行了单因素分析。
在符合条件的医生中，269名GS中有72名（26.8%）回复，19名GO中有18名（94.7%）回复。超过80%的GS/GO完成了军事医学培训（81.9%对88.9%），72.2%对61.1%获得了专科特定的委员会认证，72.2%对88.9%有美国本土驻防任务，分别有52.8%和100%是大型妇科手术和产科（GS&O）科室的成员。大多数GS（61.1%）在其所在机构或60英里范围内能够接触到GO，56.9%没有正式的EIN-AEH管理政策。一半的GS（50%）愿意在对患者进行适当咨询和活检后管理EIN-AEH；然而，不到四分之一（23.6%）的人对保留生育功能的管理感到放心。大多数GS（68%）愿意在有GO后备支持的情况下进行EIN-AEH的手术管理，83.5%的GO表示愿意提供远程会诊。当提供与GO远程会诊的联合管理时，GS对子宫切除手术管理的放心程度提高了3倍，包括那些驻扎在海外的GS（比值比=3.10；95%置信区间=1.55-6.21，P<.0014；海外P值无统计学意义），对保留生育功能管理的放心程度提高了8倍（比值比=7.86；95%置信区间=3.73-16.4，P<.0001）。
军事GS对EIN-AEH的管理和转诊差异很大，大多数机构没有相关政策。需要找到一个解决方案，特别是在偏远和海外地区，以减轻医疗、卫生系统和社会负担，并保持战斗力。
