Impact of surgical approach on oncologic outcomes in women undergoing radical hysterectomy for cervical cancer
Cusimano MC, Baxter NN, Gien LT, Moineddin R, Liu N, Dossa F, Willows K, Ferguson SE. Am J Obstet Gynecol. 2019; 221(6):619.e1-24. Epub 2019 Jul 6. DOI: https://doi.org/10.1016/j.ajog.2019.07.009.
Background — Recent studies demonstrating shorter survival among cervical cancer patients undergoing minimally invasive (MH) versus open radical hysterectomy (OH) 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 (MH) or open radical hysterectomy (OH), 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 2006-2017 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 (MH 475; OH 483) with mean age 45.9 (SD 11.2) and a median follow-up of 6 years. Of MH procedures, 89.6% were performed laparoscopically and 10.4% robotically. The unadjusted 5-year cumulative incidences of all-cause death (MH 12.5%; OH 5.4%), cervical cancer death (MH 9.3%; OH 3.3%), and recurrence (MH 16.2%; OH 8.4%) were significantly increased for MH in patients with stage IB disease, but not the cohort overall. After adjusting for patient factors and surgeon volume, MH was associated with increased rates of death (HR 2.20, 95% CI 1.15-4.19) and recurrence (HR 1.97, 95% CI 1.10-3.50) compared to OH in patients with stage IB disease (n=534), but not IA disease (n=244; HR 0.73, 95% CI 0.13-4.01; HR 0.34, 95% CI 0.10-1.10).
Conclusion — MH is associated with increased rates of death and recurrence in patients with stage IB cervical cancer even after controlling for surgeon volume; OH should be the recommended approach in this population. Although there may be a subset of patients with microscopic early-stage disease for whom MH remains safe, additional studies are required.
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