Minimally invasive surgery less effective than open surgery for cervical cancer


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Early-stage cervical cancer patients who undergo a minimally invasive hysterectomy have a worse survival outlook than open surgery of the procedure, according to two studies published simultaneously.

Minimally invasive surgery less effective than open surgery for cervical cancer

Researchers "recommend on only using open surgery for cervical cancer" based on the results of the a epidemiologic study published Wednesday in the New England Journal of Medicine.

And researchers examining a phase 3 trial, published in the same issue of the New England Journal of Medicine also support only open surgery.

Researchers from Harvard Medical School, M.D. Anderson Cancer Center, University of Wisconsin School of Medicine and Public Health and the Herbert Irving Comprehensive Cancer Center at Columbia University participated in the studies.

"Do these studies signal the death knell for minimally invasive radical hysterectomy in cervical-cancer treatment? Not necessarily, but this approach has been dealt a great blow," Dr. Amanda N. Fader, a professor in the Department of Gynecology and Obstetrics at Johns Hopkins School of Medicine, wrote in an accompanying editorial in the journal. "Although the data are alarming, select patient subgroups may still benefit from a less invasive approach.

Cervical cancer is due to the abnormal growth of cells in the cervix that have the ability to invade or spread to other parts of the body.

It is the fourth most frequently diagnosed cancer and the fourth leading cause of cancer-related death in women worldwide. Around 13,240 women will be diagnosed with cervical cancer in the United States this year, according to the American Society of Clinical Oncology.

Current guidelines from the National Comprehensive Cancer Network and European Society of Gynaecological Oncology indicate that laparotomy, which is open surgery, or laparoscopy, which is minimally invasive surgery, is an acceptable approach to radical hysterectomy in patients with early-stage cervical cancer.

A hysterectomy is the removal of the uterus, cervix and other parts of the female reproductive system

Since 2006, minimally invasive radical hysterectomy first started to become popular. In 2010, just more than a third of radical hysterectomies were performed with minimally invasive surgery, but by 2013, nearly 60 percent were performed minimally invasively, researchers noted.

In minimally invasive surgery, the abdomen is inflated with gas and very small incisions are made using a camera and long instruments or a robot. Patients sometimes can go home the same day as the procedure, which is much shorter the open surgery.

In the more invasive surgery, there is large laparotomy incision in the middle of the abdomen.

In the epidemiologic study, the risk of death within four years was 9.1 percent among women undergoing minimally invasive surgery compared to 5.3 percent in the open surgery group. This means women who undergo minimally invasive surgery are about 1.65 times more likely to die over this timeframe than if they received open surgery.

"At this point, we would recommend only using open surgery to perform a radical hysterectomy for cervical cancer," co-senior author Dr. Shohreh Shahabi, chief of gynecologic oncology at Northwestern University Feinberg School of Medicine and a Northwestern Medicine physician, said in a press release on the study.

She noted the results are specific to cervical cancer "and minimally invasive surgery is still a great option for other surgeries and cancers."

"Although based on our analyses we cannot explain why minimally invasive surgery is associated with inferior overall survival, possible explanations include the potentially limited extent of tumor removal during minimally invasive surgery, or that tools used during minimally invasive hysterectomy may inadvertently disseminate tumor cells," Shahabi said.

The study examined data from patients in the National Cancer Database from 2010 to 2013, which includes 70 percent of all new cancer diagnoses in the United States.

A total of 2,461 patients had stage IA2 or IB1 cervical cancer who were treated with a radical hysterectomy. About half of these women had open surgery and half had minimally invasive surgery.

In the other study, 319 patients with a mean age of 46 were assigned to minimally invasive surgery and 312 to undergo open surgery from June 2008 through June 2017 at 33 centers. Among all patients, 91.9 percent, had stage IB1 disease.

Of the patients who underwent minimally invasive surgery, 84.4 percent underwent laparoscopy and 15.6 percent robot-assisted surgery. The rate of disease-free survival at 4.5 years was 86 percent with minimally invasive surgery and 96.5 percent with open surgery.

"The strengths of our trial include the fact that it is a prospective, randomized trial evaluating oncologic outcomes of minimally invasive radical hysterectomy," study leader Dr. Pedro T. Ramirez, a professor in the Department of Gynecologic Oncology and Reproductive Medicine at Mzd Anderson Cancer Center, wrote. "It included a large number of centers throughout the world, and all centers were required to demonstrate proficiency in minimally invasive surgery.

By Allen Cone

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