Open Surgery Safer than Minimally Invasive Approach for Early-Stage Cervical Cancer
Each year, about 13,000 women in the U.S. are diagnosed with cervical cancer. Most women with early-stage disease are treated with radical hysterectomy, which was largely performed until 2006, when some surgeons began adopting minimally invasive laparoscopic and robotic surgery.
“There was a good rationale for this trend,” says Jason D. Wright, MD, Chief of Gynecologic Oncology at NewYork-Presbyterian/Columbia University Irving Medical Center, and Associate Professor of Obstetrics and Gynecology at Columbia University Vagelos College of Physicians and Surgeons. “Studies had shown that for most cancers, outcomes with less invasive surgery are comparable to open surgery, with the added benefit of fewer short-term postoperative complications.”
But Dr. Wright and his colleagues began to suspect that minimally invasive radical hysterectomies might not be as safe as open surgery. In an analysis of data from throughout the United States, they noted that survival for women undergoing radical hysterectomy for cervical cancer remained relatively constant until about 2006. “Survival began to decrease after that – exactly the same time that some surgeons began performing minimally invasive hysterectomies,” he says.
Now, a study by Dr. Wright and his colleagues has shown that women with early-stage cervical cancer who underwent minimally invasive hysterectomy had a 65 percent higher risk of death compared to those who had open surgery. The study, which belies the general assumption that minimally invasive surgery is safer than conventional open surgery, was published in the November 15, 2018 issue of The New England Journal of Medicine.
“We suspected that there might be a difference in survival between the two approaches, but the extent of the difference was surprising,” says Dr. Wright, who served as Co-Principal Investigator of the study. “Our findings suggest that minimally invasive surgery may not be appropriate for many patients with early-stage cervical cancer.”
The researchers analyzed data from the National Cancer Database of 2,461 women with early cervical cancer who underwent radical hysterectomy between 2010 and 2013. Half of the women had minimally invasive surgery. Within four years after surgery, 9.1 percent of the minimally invasive surgery group had died versus 5.3 percent in the open-surgery group, translating into a statistically significant 65 percent higher risk of death for the former, when the difference over four years is considered.
The study did not investigate why minimally invasive hysterectomy might result in a higher mortality rate. One possible explanation is that uterine manipulators, which are used to retract and visualize the pelvic area during minimally invasive hysterectomy, may inadvertently spread microscopic tumor cells. Another possibility is that minimally invasive surgery is not inherently inferior to open surgery, but the surgeons who performed minimally invasive surgery on patients in this study may have been more experienced with open surgery.
“We recommend that patients talk to their doctor about the available surgical options,” says Dr. Wright. “Although minimally invasive surgery was associated with higher mortality, some patients may be willing to accept that risk, especially if they have very early cancers.”
For patients with early cervical cancer who already had minimally invasive hysterectomy, Dr. Wright says they don’t necessarily need more checkups or more screening. “The overall prognosis for women with early cervical cancer after minimally invasive or open hysterectomy is excellent,” he adds. “In either case, they should get periodic checkups, and if they experience any symptoms, such as pain or changes in vaginal bleeding, they should consult their gynecologic oncologist.”
Melamed A, Margul DJ, Chen L, Keating NL, Del Carmen MG, Yang J, Seagle BL, Alexander A, Barber EL, Rice LW, Wright JD, Kocherginsky M, Shahabi S, Rauh-Hain JA. Survival after minimally invasive radical hysterectomy for early-stage cervical cancer. The New England Journal of Medicine. 2018 Nov 15;379(20):1905-14.