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Minimally invasive surgery linked to poorer survival in early-stage cervical cancer

Christina Lau
14 Nov 2018

Minimally invasive radical hysterectomy is associated with poorer survival than open surgery in patients with early-stage cervical cancer, data from two large US databases and a randomized trial have shown.

Using data from the US National Cancer Database as well as the Surveillance, Epidemiology, and End Results (SEER) database, researchers identified 2,461 patients diagnosed with stage IA2 or IB1 cervical cancer in 2010–2013 who underwent radical hysterectomy as primary treatment. Within this group, minimally invasive surgery was associated with a 65 percent higher risk of all-cause mortality compared with open surgery after a median follow-up of 45 months (hazard ratio [HR], 1.65; 95 percent confidence interval [CI], 1.22 to 2.22; p=0.002). [N Engl J Med 2018, doi: 10.1056/NEJMoa1804923]

Among the 1,225 patients treated with minimally invasive surgery, the risk of death within 4 years after diagnosis was 9.1 percent. In comparison, the 4-year mortality rate was 5.3 percent among 1,236 patients treated with open surgery.

The two groups were similar in terms of histopathological variables and rates of use of adjuvant radiotherapy or adjuvant chemotherapy. However, patients who underwent minimally invasive surgery had higher socioeconomic status and lower tumour grade.

All-cause mortality remained higher in the minimally invasive vs open surgery group after adjustment for adjuvant treatment (HR, 1.62; 95 percent CI, 1.20 to 2.19). Furthermore, the association between minimally invasive surgery and shorter overall survival (OS) was apparent regardless of the laparoscopic approach (robot-assisted [HR, 1.61 vs open surgery; 95 percent CI, 1.18 to 2.21] or traditional [HR, 1.50; 95 percent CI, 0.97 to 2.31]), tumour size, or histologic type.

“Before the adoption of minimally invasive radical hysterectomy [ie, in the 2000–2006 period], the 4-year relative survival rate among patients who underwent radical hysterectomy for cervical cancer remained stable, with an annual percentage change of 0.3 percent [95 percent CI, -0.1 to 0.6],” the investigators reported.

“The adoption of minimally invasive surgery coincided with a decline in 4-year relative survival rate of 0.8 percent [95 percent CI, 0.3 to 1.4] per year after 2006 [p=0.01 for change of trend],” they noted.

In a randomized trial that included 319 patients with stage IA1, IA2 or IB1 cervical cancer, the primary outcome of disease-free survival (DFS) rate at 4.5 years was 86 percent in the minimally invasive surgery group vs 96.5 percent in the open surgery group. [N Engl J Med 2018, doi: 10.1056/NEJMoa1806395]

The two groups were also similar in terms of histologic subtypes, rate of lymphovascular invasion, rates of parametrial and lymph node involvement, tumour size, tumour grade, and rate of use of adjuvant therapy.

The association between minimally invasive surgery and poorer DFS remained apparent after adjustment for age, body mass index, stage of disease, lymphovascular invasion, and lymph node involvement (3-year DFS rate, 91.2 percent for minimally invasive surgery vs 97.1 percent for open surgery; HR, 3.74; 95 percent CI, 1.63 to 8.58).

Furthermore, minimally invasive surgery was associated with a lower rate of 3-year OS vs open surgery (93.8 percent vs 99 percent; HR, 6.00; 95 percent CI, 1.77 to 20.30).

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