We appreciate the interest of Dr Basile and his colleagues in our work. Utilizing a large population-based database of patients with endometrial cancer treated from 1988 to 2006, we noted that those women who underwent lymphadenectomy were less likely to receive adjuvant external beam radiotherapy than those who did not undergo nodal evaluation. The association between lymphadenectomy and avoidance of radiation was strongest for women with intermediate risk tumors (Fédération Internationale de Gynécologie et d’Obstétrique 1988 stage IB grades 2 and 3 and stage IC grades 1 and 2).

Basile et al suggest that the proper question to ask is not whether lymphadenectomy influences the use of radiation but rather whether lymphadenectomy influences the natural history and survival of patients with endometrial cancer? In theory, we certainly agree with this point. Despite methodalologic issues that have been well discussed, 2 large randomized trials failed to show a survival benefit for lymphadenectomy. Likewise, the Post-Operative Radiation Therapy for Endometrial Carcinoma (PORTEC)-2 investigators noted that vaginal brachytherapy was not inferior to pelvic radiation for women with apparent early-stage endometrial cancer.

However, in clinical practice the issue is not as straightforward and clear-cut as to whether lymphadenectomy influences survival. Decisions regarding adjuvant therapy must be made and a fair question is whether lymphadenectomy helps to guide clinicians in these decisions. Much of the difficulty with these decisions arises from the lack of clear data defining optimal adjuvant therapy for endometrial cancer. The appropriate treatment for high-risk disease confined to the uterus as well as for patients with isolated nodal disease remains a subject of active debate. In the United States, patients with stage IIIC endometrial cancer are frequently treated with multimodality therapy including both chemotherapy and radiation. The purpose of the radiation is to sterilize nodal disease. Is chemoradiation superior to chemotherapy alone? If so, should we omit pelvic radiation in a patient with a grade 2 tumor invading 90% of the endometrium who did not undergo lymphadenectomy but has a nearly 20% risk of nodal disease? Although it is unclear what the correct answers are to these questions, these are decisions faced every day by oncologists.

A strength of population-based registry studies lies in the ability of these investigations to capture the way patients are actually treated in real world settings. We believe our findings clearly demonstrate that lymphadenectomy influenced treatment planning for endometrial cancer. We recognize that the publication of PORTEC-2 will likely decrease the magnitude of our findings in the coming years. However, in areas of clinical uncertainty, the data provided by lymphadenectomy have an important influence on management.