SGO member update: Emerging data on the surgical approach for radical hysterectomy in the treatment of women with cervical cancer

SGO member update: Emerging data on the surgical approach for radical hysterectomy in the treatment of women with cervical cancer

CHICAGO, IL (Sept. 11, 2019)— Gynecologic oncologists should be aware of the continued emerging data on minimally invasive surgery (MIS) for cervical cancer so that a thorough discussion can be undertaken with patients and shared decision making used when choosing the surgical approach for radical hysterectomy. We provide the following updated statement from the SGO Clinical Practice Committee and approved by the SGO Executive Committee.

The recently published prospective randomized Phase 3 Laparoscopic Approach to Cervical Cancer (LACC) trial and the National Cancer Institute Surveillance, Epidemiology, and End Results (SEER) database study in the New England Journal of Medicine both noted inferior overall survival outcomes for patients with Stage IA2 and IB1 cervical cancer treated with MIS in early-stage cervical cancer. Since the publication of these important studies, a number of large, population-based and single-institution, retrospective analyses have been performed in several countries, including the United States, Canada, United Kingdom and South Korea (Table). These studies collectively demonstrate similar adverse survival trends for MIS compared to open radical hysterectomy as the LACC trial and the analysis by Melamed et al. Additionally, the National Comprehensive Cancer Network now states that open radical hysterectomy is “the historical and standard approach” to treatment of early-stage cervical cancer.

While the reasons for these outcomes remain unclear, the preponderance of the contemporary published literature suggests poorer survival outcomes for women undergoing radical hysterectomy for cervical cancer treated with MIS compared to open radical hysterectomy. Gynecologic oncologists are encouraged to consider all available data as they counsel individual patients to determine the most appropriate surgical approach.

Table: Contemporary Data Regarding the Survival Impact of Minimally Invasive Compared with Open Radical Hysterectomy

Study # of Pts Type of Study Recurrence Rates PFS* OS**
Ramirez et al LACC Trial 2018

International

Stage IA2/IB1

631 Phase III Trial N/A 3 year PFS: 91.2% MIS~ Hyst@ vs. 97.1% Open Hyst (HR#: 3.74, 95% CI##, 1.63 to 8.58) 3 year OS: 93.9% MIS Hyst vs.

99% Open Hyst (HR: 6.00)

Melamed et al

2018

U.S.

Stage IA2/IB1

2461 Retrospective SEER database study N/A N/A 4 year mortality: 9.1% MIS Hyst vs

5.3% Open Hyst p=.002

Kim et al

2019

Korea

Stage IB1

565 Retrospective, two-institution cohort study   3-year PFS: 85.4% MIS Hyst vs. 91.8% Open Hyst; p = 0.03 No significant difference
NCRAS^ Study

2019

UK

Stage IA2/IB1

929 Population-based, retrospective national registry study N/A N/A 4.5 year survival 97.5% Open Hyst

93.1% MIS Hyst p=.007

Cusimano et al

2019

Canada

Stage IA2/IB1

958 Population-based, retrospective cohort study IA: No significant difference

IB: Higher risk of recurrence in MIS Hyst: HR, 1.97; 95% CI, 1.10-3.50)

  IA: No significant difference

IB: Increased risk of death in MIS Hyst: HR: 2.20; 95% CI 1.15-4.19

Doo et al

2019

U.S.

Stage IA2/IB1

105  

Retrospective, single institution comparing Robotic vs. Open Hyst

All study subjects: 24% MIS vs 14% Open Hyst

>2 cm tumors:

30% MIS vs. 8% Open Hyst p=.006

≥2 cm tumors: Shorter PFS in the Robotic cohort (HR 0.31, p = 0.04)

 

 

 

N/A

Uppal

2019

Stage IA2/IB1

700 Retrospective, multi-institution; propensity matched cohort 14.1% MIS Hyst

6.1% Open Hyst

P=0.027

HR 2.93 (95% CI 1.22-7.1) favoring the Open Hyst arm No significant difference

*PFS = progression-free survival, **OS = overall survival. ~MIS = Minimally invasive surgery, @Hyst = Hysterectomy, #HR = Hazard ratio, ##CI = Confidence interval, ^NCRAS = National Cancer Registration and Analysis Service

References

  1. Ramirez PT, Frumovitz M, Pareja, R, et al. Minimally invasive versus abdominal radial hysterectomy for cervical cancer. New Engl J Med, 2018 Nov 15;379(20):1895-1904. 
  2. Melamed A, Margul D, Ching D, et al. Minimally Invasive Radical Hysterectomy for Early-Stage Cervical Cancer, New Engl J Med, 2018 Nov 15; 379(20):1905-1914.
  3. Doo DW, Kirkland CT, Griswold LH, McGwin G, Huh WK, Leath CA 3rd et al. Comparative outcomes between robotic and abdominal radical hysterectomy for IB1 cervical cancer: Results from a single high volume institution. Gynecol Oncol. 2019 May; 153(2):242-247.
  4. National Cancer Registration and Analysis Service (NCRAS) cervical cancer surgery analysis May 2019
  5. Kim SI, Lee M, Lee S, Suh DH, Kim HS, Kim K. Impact of laparoscopic radical hysterectomy on survival outcome in patients with FIGO stage IB cervical cancer: A matching study of two institutional hospitals in Korea. Gynecol Oncol. 2019 Aug 2 [Epub ahead of print]
  6. CusimanoMC, Baxter NN, Gien LT, Moineddin R, Liu N, Dossa F, Willows K, Ferguson SE. Impact of surgical approach on oncologic outcomes in women undergoing radical hysterectomy for cervical cancer. Am J Obstet Gynecol. 2019 Jul 6. [Epub ahead of print]
  7. Uppal S, Gehrig P, Vetter, M, Davidson B, Lees B, Brunette L et al. et al. Recurrence rates in cervical cancer patients treated with abdominal versus minimally invasive radical hysterectomy: A multi-institutional analysis of 700 cases. J Clin Oncol 37, 2019 (suppl; abstr 5504).
  8. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology Cervical Cancer (version I.2019) [Internet]. Available from: https://www.nccn.org/professionals/physician_gls/pdf/cervical.pdf