Impact of surgical approach on oncologic outcomes in women undergoing radical hysterectomy for cervical cancer

Abstract

BACKGROUND: Recent studies demonstrating shorter survival among cervical cancer patients undergoing minimally invasive versus open radical hysterectomy could not account for surgeon volume and require confirmation in other jurisdictions with larger sample sizes, longer follow-up, and data on disease recurrence. OBJECTIVE: To determine if surgical approach is associated with oncologic outcomes in cervical cancer patients undergoing minimally invasive or open radical hysterectomy, while accounting for mechanistic factors including surgeon volume. STUDY DESIGN: We performed a population-based retrospective cohort study of cervical cancer patients undergoing primary radical hysterectomy by a gynecologic oncologist from 2006 to 2017 in Ontario, Canada. A multivariable marginal Cox proportional hazards model and cause-specific hazards model were used to evaluate the association of surgical approach with all-cause death and recurrence respectively, clustering at the surgeon level. We tested for interactions between surgical approach and either pathologic stage or surgeon volume. RESULTS: We identified 958 patients (minimally invasive 475; open 483) with mean age 45.9 and a median follow-up of 6 years. Of minimally invasive procedures, 89.6% were performed laparoscopically and 10.4% robotically. The unadjusted 5-year cumulative incidences of all-cause death (minimally invasive 12.5%; open 5.4%), cervical cancer death (minimally invasive 9.3%; open 3.3%), and recurrence (minimally invasive 16.2%; open 8.4%) were significantly increased for minimally invasive radical hysterectomy in patients with stage IB disease, but not the cohort overall. After adjusting for patient factors and surgeon volume, minimally invasive radical hysterectomy was associated with increased rates of death (hazard ratio [HR], 2.20; 95% confidence interval [CI], 1.15e4.19) and recurrence (HR, 1.97; 95% CI, 1.10e3.50) compared to open radical hysterectomy in patients with stage IB disease (n ¼ 534), but not IA disease (n ¼ 244; HR, 0.73; 95% CI, 0.13e4.01; HR, 0.34; 95% CI, 0.10e1.10). CONCLUSION: Minimally invasive radical hysterectomy is associated with increased rates of death and recurrence in patients with stage IB cervical cancer even after controlling for surgeon volume; open radical hysterectomy should be the recommended approach in this population.Although there may be a subset of patients with microscopic early-stage disease for whom minimally invasive radical hysterectomy remains safe, additional studies are required.

Comparison of laparoscopic and open radical hysterectomy in cervical cancer patients with tumor size ≤2 cm

“…Kim et al 15 studied 593 patients with early-stage cervical cancer and found that cervical cancer patients who underwent minimally invasive surgery had significantly worse progression-free survival than those in the open surgery group with tumor size >2 cm and ≤4 cm (p=0.044). In addition, Cusimano et al 14 reported that minimally invasive surgery was associated with a higher rate of recurrence and death compared with the open surgery group in cervical cancer with stage IB1, and that the harm associated with this approach may be independent of surgeon volume.…”

Rethinking a common surgery technique for early cervical cancer

“…They include the Laparoscopic Approach to Cervical Cancer (LACC) trial, a randomized controlled phase 3 trial helmed by Pedro Ramirez, MD, director of minimally invasive surgical research and education in the center's Department of Gynecologic Oncology and Reproductive Medicine, and an epidemiologic study led by J. Alejandro Rauh‐Hain, MD, MPH, an assistant professor of gynecologic oncology, reproductive medicine, and health services research. Since the findings were published, several studies in journals such as Gynecologic Oncology , the International Journal of Gynecological Cancer , and the American Journal of Obstetrics and Gynecology have corroborated the results.…”

Reply

“…Cervical cancer is a rare malignancy; surgeons in Ontario have performed a median of 8 radical hysterectomies (interquartile range, 4e12) for cervical cancer annually. 4 This is the reality for most regions in North America and Europe, thanks to screening and vaccination programs. It may take a decade for surgeons to achieve stated targets for proficiency in such settings, and heterogeneity in surgeon volume is inevitable.…”

“…That even some observational studies, which remain susceptible to confounding, have produced comparable results should indeed be cause for concern, in early-stage cervical cancer patients specifically. 4 Open radical hysterectomy must be the recommended approach outside of future randomized trials.…”

“…We should be open to the proposition that minimally invasive techniques may have drawbacks, including inferior survival or complications. However, the worldwide media interest 4 that preceded even the publication by Ramirez et al also indicates the far-reaching effects that studies can have that cause doubt or, worse still, fear in patients who undergo operations that in all other specialties have shown equivalence or superiority. If there is indeed an increased mortality and early disease recurrence with MH, then this is a profound and important finding.…”