Survival with open surgery vs. minimally invasive radical hysterectomy

Originally Published By 2 Minute Medicine®. Reused on MPR with permission.

1. A retrospective cohort study noted that minimally invasive surgery was associated with a higher risk of death compared to open surgery among women who underwent radical hysterectomy for early stage cervical cancer.

2. The advent of minimally invasive surgical techniques in 2006 was associated with a decline in 4-year relative survival rates among women undergoing radical hysterectomy for early stage cervical cancer

Evidence Rating Level: 2 (Good)

Study Rundown: Current standard treatment for early cervical cancer most commonly involves radical hysterectomy, either via open abdominal surgery or minimally invasive techniques. Minimally invasive surgery for cervical cancer was widely adopted as a treatment for cervical cancer in 2006, and as a result, long-term comparative survival outcomes have not been well outlined to date. In this analysis, the authors sought to determine the comparative survival outcomes of minimally invasive radical hysterectomy versus open radical hysterectomy using two weighted national cancer databases. Overall, they found that there was an overall lower survival rate among women who underwent minimally invasive surgery versus open surgery. They also noted that survival rates for women who had cervical cancer and underwent radical hysterectomy did show significantly declining trends after minimally invasive surgery was adopted as a treatment modality. These findings require additional analysis, however do conflict with earlier retrospective studies that noted the safety of minimally invasive surgery in patients with early stage cervical cancer.

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Strengths of this study include its use of multiple national databases and inclusion of many patient cases. Limitations include lack of an explanatory mechanism for decreased survival rates for minimally invasive surgical techniques and limited quality of data obtained from a large national database.

Click to read the study in NEJM

Relevant Reading: Robotic Radical Hysterectomy for Cervical Cancer: A Population – Based Study of Adoption and Immediate Postoperative Outcomes in the United States

In-Depth [retrospective cohort]: This retrospective study used the Surveillance, Epidemiology, and End Results program database to assess survival outcomes for 2461 patients who underwent either open radical hysterectomy (n= 1236) or minimally invasive surgery (n=1225) for stage IA2 or IB1 cervical cancer between 2010-2013. The primary outcome of this analysis was all-cause mortality following either surgical procedure. Secondary outcomes included 4-year survival rates, death rates within 3 months of surgery, number of lymph nodes studied, the frequency of positive lymph nodes, amount of parametrial involvement, and presence of positive surgical margins. Demographic data showed that patients who underwent minimally invasive surgery were more likely to be white, have private insurance, reside in zip codes with higher incomes, receive treatment at nonacademic facilities, and receive diagnoses later on in the study period. The 4-year all-cause mortality was 9.1% in the minimally invasive group and 5.3% in the open surgery group. (hazard ratio [HR], 1.65; 95% confidence interval [CI], 1.22 to 2.22; P=0.002). All-cause mortality remained higher in the minimally invasive group after sensitivity analyses adjusted for adjuvant treatment (HR 1.62; 95% CI, 1.20 to 2.19). Researchers also compared survival rates before and after minimally invasive surgery was widely adopted as a treatment option for women with cervical cancer by using data from the Surveillance, Epidemiology and End Results program database (SEER). They noted that there was a significant decline in 4-year relative survival after minimally invasive treatment options were adopted (4-year decline 0.8%, 95% CI, 0.3 to 1.4; P-trend= 0.01).

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