Change in Surgery Trend for Early-Stage Cervical Cancer

This year, more than 14,000 new cases of cervical cancer will be diagnosed. Surgery is the most common treatment for this type of cancer when it’s found early, but a patient’s surgical options seem to have changed in recent years.

Results from a new study reveal surgeons are performing fewer minimally invasive procedures to treat early-stage cervical cancer.

The treatment shift comes after a previous study, known as the LACC trial, found that women with early-stage cervical cancer who underwent less-invasive procedures had worse outcomes.

“Our work revealed that the use of minimally invasive surgery decreased after this study was published, which is encouraging,” says Patrick Lewicki, MD, the coauthor of the study and a resident physician in the department of urology at NewYork-Presbyterian Hospital Weill Cornell Medicine in New York City.

What Did the Earlier LACC Trial Find?

The LACC trial results were published in the New England Journal of Medicine in 2018. In this study, researchers compared 312 women who had a traditional, “open” radical hysterectomy (a surgery to remove the uterus) to 319 women who had a “minimally invasive” radical hysterectomy, including robotic and laparoscopic procedures.

The authors concluded that “[m]inimally invasive radical hysterectomy was associated with lower rates of disease-free survival and overall survival than open abdominal radical hysterectomy among women with early-stage cervical cancer.”

Specifically, the women who had the minimally invasive procedure were more likely to have their cancer return and less likely to be alive three years later than those who had open surgery.

As a result of this study and others that showed similar results, many medical organizations in the United States and Europe updated their guidelines to recommend open surgery, also called a “laparotomy,” as the standard choice for patients with early-stage cervical cancer.

New Study Suggests That Surgeons Took Note

The new data imply that surgeons around the country have taken the LACC trial results to heart.

In this recent study, which appeared in the New England Journal of Medicine in April 2021, researchers looked at statistics on nearly 2,500 women with early-stage cervical cancer from a robust database that included about 25 percent of the hospitals in the United States.

They found the percentage of women who had a minimally invasive radical hysterectomy decreased from 58 percent to 43 percent in the 18 months after the LACC results were published.

“The observed decrease was larger in magnitude among academic centers, compared with non-academic centers,” says Dr. Lewicki.

For example, results showed that the use of minimally invasive surgery decreased by 73 percent in academic centers and by 19 percent in nonacademic centers.

Lewicki says these findings suggest that “variations in cancer care quality are an important area of further study.”

Why Might Open Surgery Be a Better Option?

Though the LACC trial, along with other studies, showed significantly worse outcomes for minimally invasive surgical approaches, they didn’t explain why.

“We don’t really know,” says Lewicki. “No correlation has been demonstrated between specific components of minimally invasive surgery and the observed inferior outcomes with this technique.”

One theory is that devices called uterine manipulators, which are sometimes used during minimally invasive surgeries, may lead to worse outcomes. These gadgets, which help surgeons access and visualize the uterus, may cause disruption to the uterus, and this could trigger cancer cells to dislodge and spill over into nearby areas.

Another possible reason could be a lack of surgeon proficiency. Minimally invasive techniques can be more challenging to perform.

But Lewicki says that “none of these has been specifically proven to impact outcomes in cervical cancer.”

Limitations of the Research

While the idea that open radical hysterectomies are superior to minimally invasive approaches is generally well accepted in the medical community, some say the evidence isn’t completely clear-cut.

According to an article published in May 2021 by the National Cancer Institute, one problem with the LACC trial is that 84 percent of the minimally invasive procedures studied were performed with traditional laparoscopic surgery techniques, rather than robotic approaches. Some experts say the lack of data on robotic surgeries doesn’t paint a true picture, as robotic surgeries are more common and offer advantages, such as a lower risk of complications.

A study conducted in Sweden and published in the European Journal of Cancer in July 2019 seems to support this notion. Researchers found that robotic radical hysterectomies were not linked to a higher risk of death or cancer recurrence when compared with open procedures in those with early-stage cervical cancer.

But another large research study, published in the New England Journal of Medicine in November 2018, backed the results of the LACC trial, finding that individuals who had robotic radical hysterectomies did in fact have a worse survival rate.

The Bottom Line: What Do These Results Mean for Patients With Cervical Cancer?

The April 2021 study suggests more and more doctors are turning to an open-surgery approach to treat this type of cancer.

While further investigation may be needed to determine the exact reasons why minimally invasive surgeries aren’t as successful, they appear to be waning in popularity, which is a trend that many doctors and researchers applaud.

“Still, some hospitals perform minimally invasive surgery. This means that there is room to improve the overall treatment of early-stage cervical cancer in the U.S.,” Lewicki says.

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