Main findings
Translating the main findings of this DCE with women suffering from DE
and bowel involvement towards the clinical setting we can conclude that
1) In the general ranking, osteoporosis is ranked as least important
attribute, while in the DCE, a lower chance of osteoporosis is one of
the most important drivers for making a choice in the conservative
treatment. 2) Osteoporosis, fatigue symptoms, pain symptoms, pregnancy
rates and the presence of endometriosis nodules all have a significant
impact on the preference for conservative treatment. The three most
important drivers for conservative treatment are lower chance of
developing osteoporosis (gonadotropin-releasing hormone (GnRH)
analogues), higher chance of improving fatigue symptoms and higher
chance of reducing pain symptoms. For surgery, the attributes with a
significant impact are getting intestinal symptoms (LARS), pain
symptoms, fatigue symptoms, pregnancy rates and getting a temporary
stoma. The three most important drivers for surgery are lower chance of
getting bowel symptoms (LARS), higher chance of reducing pain symptoms
and higher chance of improving fatigue symptoms.
3) The chance of getting a
temporary stoma plays a less important role in the context of this study
compared to pain reduction and the risk of LARS. 4) Women with a future
child wish put pain reduction above possible improvement of fertility
chances. 5) Women with previous surgery have significant lower fear for
surgery compared to women without a surgical history (DE surgery).
Comparing the results of the direct ranking method and those of the
relative importance of the DCE shows discrepancy between both methods.
In particular the attribute chance of osteoporosis is considered least
important in the ranking exercise while one of the most important
attributes when choosing conservative treatment in the DCE. However, as
described by Louviere and Islam (29), explicit context like in this case
information about the type of treatment, the description of the
attributes and the associated levels might explain the difference
between the methods. For the ranking exercise, no levels were provided
and thus, in contrast with the discrete choice experiment, a trade-off
between levels of different attributes when making a choice for
conservative treatment or surgery was not required. We believe that the
DCE in this study provides more detailed and reliable outcomes, but also
requires more intellectual effort from the participants and therefore
more challenging to make. Solely ranking attributes is easy, but it
should be kept in mind that no considerations about the levels are taken
into account.
The risk of permanent intestinal symptoms being almost equally important
as pain reduction is an important finding, since the debate about
radical DE bowel surgery (resection) versus conservative surgery
(shaving/discoid) is ongoing and still undecided. Believers of radical
surgery have an approach (radical as possible) almost similar to
oncological surgical approaches (30) (31) and aim to reduce pain,
prevent recurrence and perhaps even cure women with DE. The potential
price they have to pay for this approach is theoretically more severe
complications and the risk of permanent intestinal symptoms (LARS) (32).
Surgeons who believe in a more reluctant approach aim to reduce pain
symptoms and accept possible recurrence/incomplete removal of
endometriosis, but try to reduce severe complications and prevent
possible permanent bowel symptoms (LARS) (33) (34) (35). However,
regarding the good results from the more reluctant surgical approach
from Donnez it has to be noted that these patients were treated with
progesterone afterwards and only followed up for one year. Long term
effects and patients without progesterone should be studied as well to
support the more reluctant surgical DE approach.