COMMENTARY

'Shocking' Results With Minimally Invasive Hysterectomy

Maurie Markman, MD

Disclosures

November 15, 2018

Hello. I'm Dr Maurie Markman from Cancer Treatment Centers of America in Philadelphia. I want to briefly discuss two very important, but also concerning, papers that recently appeared in the New England Journal of Medicine (NEJM). Many of you are probably aware of these papers because they have had tremendous discussion in the lay press. One was a prospective randomized trial[1] and the second was a retrospective analysis[2] of patients treated with either standard radical hysterectomy (one might call it a more invasive radical hysterectomy) or minimally invasive radical hysterectomy.

Minimally invasive radical hysterectomy is a widely used approach for management of early-stage cervical cancer. The technologies used are either laparoscopic surgery or robotic surgery; gynecologic cancer surgeons and other surgeons have been using this strategy for over a decade. Rather surprisingly, and some would say shockingly, both studies showed a significant inferior survival associated with the use of the minimally invasive procedures.

Of course, the idea was that minimally invasive procedures would hopefully reduce hospital stay, potentially reduce morbidity associated with the procedure, and result in smaller incisions, quicker recovery time, and improved patient satisfaction. But the one impact to be concerned about is survival because we are talking about cancer. And the studies have shown rather convincingly—and, I would say, definitively—that these minimally invasive procedures should not be performed except under perhaps extraordinary circumstances where there is a serious risk for the patient associated with the standard approach.

These studies also raise a very important question that needs to be discussed among cancer specialists and regulators: When should an innovative strategy—one that sounds good on paper and can demonstrate success in terms of, for example, reducing hospital stay—be used as a standard of care, knowing that we are not going to interfere with a major cancer-associated outcome? (In this case, survival.) From my perspective, minimally invasive radical hysterectomy should not be considered a standard of care for this strategy. I encourage you to read and discuss these very important papers in NEJM. Thank you for your attention.

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