Studies suggest minimally invasive surgery for early-stage cervical cancer results in lower 4-year survival rates
Women undergoing minimally invasive radical hysterectomy for early-stage cervical cancer have lower rates of disease-free survival and overall survival compared with those who have open abdominal radical hysterectomy, studies with 4 years of follow-up have found. [58] [59] A commentary on the two studies described the findings as "a great blow” to minimally invasive surgery for cervical cancer. [60] Updated guidelines from the US National Comprehensive Cancer Network state that these new findings of worse outcomes from minimally invasive techniques compared with open laparotomy should prompt clinicians to counsel women carefully about the risks and benefits of the different surgical approaches. [55]
In the randomised non-inferiority LACC (Laparoscopic Approach to Cervical Cancer) trial of 631 patients with FIGO stage IA1 to IB1 disease (92% had stage IB1 disease), disease-free survival at 4.5 years was 86.0% in the minimally invasive surgery group versus 96.5% in the open surgery group (-10.6% difference; 95% CI -16.4 to -4.7). [58] Minimally invasive surgery was associated with significantly lower overall survival (3-year rate, 93.8% vs. 99.0%). The trial closed early due to the higher rate of recurrence and death in the minimally invasive surgery group.
The second study (a retrospective cohort study) of nearly 2500 US women with stage IA2 or IB1 disease reported a 4-year mortality rate of 9.1% in the minimally invasive surgery group and 5.3% in the open surgery group (hazard ratio: 1.65; 95% CI 1.22 to 2.22). [59]
Open surgery is the standard approach for radical hysterectomy. [55] However, use of minimally invasive surgery (laparoscopic or robotic) has been increasing, [60] supported by evidence from observational studies with short follow-up time showing similar survival rates and reduced morbidity versus open surgery. [61] [62]
See Management: approach See Management: treatment algorithmSummary
Definition
History and exam
Key diagnostic factors
- presence of risk factors
- abnormal vaginal bleeding
- postcoital bleeding
- pelvic pain, dyspareunia
- cervical mass
- cervical bleeding
Other diagnostic factors
- mucoid or purulent vaginal discharge
- bladder, renal, or bowel obstruction
- bone pain
Risk factors
- human papillomavirus (HPV) infection
- age group
- HIV
- early onset of sexual activity (younger than 18)
- multiple sexual partners
- cigarette smoking
- immunosuppression
- all other STDs
- oral contraceptive pill use
- high parity
- uncircumcised male partner
- micronutrient malnutrition
- low serum folate
- low vitamin C and E levels
- alcohol abuse
- low socioeconomic status
Diagnostic investigations
1st investigations to order
- vaginal or speculum examination
- colposcopy
- biopsy
- human papillomavirus (HPV) testing
Investigations to consider
- FBC
- renal function testing
- liver function tests
- CXR
- intravenous pyelogram
- renal ultrasound
- barium enema
- proctoscopy
- cystoscopy
- MRI pelvis
- PET whole body
- PET/CT whole body
- CT of chest/abdomen/pelvis with intravenous/oral contrast
Treatment algorithm
Contributors
Authors VIEW ALL
Clinical Director
Medical Gynecologic Oncology
Division of Hematology Oncology
Massachusetts General Hospital
Boston
MA
Disclosures
RTP is a paid participant in scientific advisory boards for Genentech/Roche. RTP is an author of a number of references cited in this topic.
Assistant Professor
Department of Radiation Oncology
Brigham and Women’s Hospital
Boston
MA
Disclosures
LJL declares that she has no competing interests.
Dr Richard T. Penson and Dr Larissa J. Lee would like to gratefully acknowledge Dr Neil S. Horowitz and Dr Anthony H. Russell, previous contributors to this topic.
Peer reviewers VIEW ALL
Fellow
Minimally Invasive Gynecologic Surgery
Magee Women's Hospital
University of Pittsburgh Medical Center
PA
Disclosures
LY declares that she has no competing interests.
Consultant in Obstetrics & Gynaecology
Lead Clinician in Colposcopy
Imperial College Healthcare NHS Trust
London
UK
Disclosures
DL declares that she has no competing interests.
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