Simple Hysterectomy Increasingly Used for Early-Stage Cervical Cancer

By Will Boggs MD

November 17, 2019

NEW YORK (Reuters Health) - The rates of simple hysterectomy for women with early-stage cervical cancer increased significantly in the U.S. between 2004 and 2014, with different associations between hysterectomy extent and mortality rate in women with stage-IA2 and stage-IB1 cancers, according to new findings.

"Despite the fact that prognosis is favorable for women with early-stage cervical cancer and that there is a strong rationale that less-radical surgery should be safe, data supporting the safety of less-radical surgery remains limited," Dr. Jason D. Wright of Columbia University College of Physicians and Surgeons, in New York, told Reuters Health by email. "Use of less-radical surgery, particularly for women with stage-IB1 cancers, should be approached cautiously."

Dr. Wright and colleagues used National Cancer Database data to investigate trends in simple-hysterectomy rates and to compare survival in women with stage-IA2 tumors (which include microscopic carcinomas with a depth of invasion between 3 mm and 5 mm) and stage-IB1 tumors (which include macroscopic carcinomas limited to the uterus measuring under 2 cm in diameter) who underwent radical versus simple hysterectomy.

Among women with stage-IA2 cancers, 44.6% underwent simple hysterectomy, a rate that increased from 37.8% in 2004 to a peak of 52.7% in 2014, the researchers report in Obstetrics and Gynecology, online November 4.

Fewer women with stage-IB1 cancers underwent simple hysterectomy (35.3%), but this rate also increased from 29.7% in 2004 to a peak of 43.8% in 2013.

Simple-hysterectomy rates for women with stage-IA2 tumors were more common among those 40-49 and 50-59 years of age than among those under 40 and were more common among those treated at community cancer centers than among those treated at academic centers.

For women with stage-IB1 tumors, simple hysterectomy was also more common among those treated at community cancer centers, and black women were 21% more likely than white women to undergo simple hysterectomy.

There was no significant association between the extent of hysterectomy and survival for women with stage-IA2 cancers (five-year survival, 97.6% after simple hysterectomy versus 95.1% after radical hysterectomy). But among women with stage-IB1 cancers, simple hysterectomy was associated with a 55% higher risk of death than radical hysterectomy, a significant increase, with five-year survivals of 92.4% and 95.3%, respectively.

"Radical hysterectomy remains the standard of care for women with stage IA2-IB1 cervical cancer who undergo hysterectomy," Dr. Wright said. "Performance of less radical surgery clearly warrants further study. Women considering less radical surgery should be carefully counseled regarding the potential risks and benefits."

Dr. Allan Covens of Sunnybrook Health Sciences Center, University of Toronto, Canada, who co-authored an accompanying editorial, told Reuters Health by email that he was surprised at "the sheer number of patients managed this way outside of a clinical trial. I think people need to be very cautious with selection criteria if not done within the context of a clinical trial."

"While these are small cancers with excellent care rates, if managed inappropriately, cure can be compromised, so don't be complacent," he said.

Simple hysterectomy should be done within the context of a clinical trial, Dr. Covens said. "If not, be very conservative with the selection criteria. At the minimum, use the criteria outlined in 1 of the 3 ongoing trials."

Dr. Kathleen M. Schmeler, a gynecologic oncologist at The University of Texas MD Anderson Cancer Center, in Houston, told Reuters Health by email, "The current study provides interesting and exciting results regarding less-radical surgery for women with early-stage cervical cancer. However, the standard of care for women with stage IA2 and IB1 cervical cancer remains radical hysterectomy or radical trachelectomy (fertility-sparing) with lymph node assessment."

"Although it is reassuring and exciting that women with stage IA2 disease who underwent simple hysterectomy did not have different outcomes from those undergoing radical hysterectomy, prospective data are needed to inform a change in clinical practice (and will be available shortly from the ConCerv, SHAPE, and GOG trials)," she said.

"Similarly, for stage-IB1 disease, we need these prospective data to determine if conservative surgery is safe and has similar oncologic outcomes to radical hysterectomy," Dr. Schmeler said. "The preliminary data from the three ongoing prospective studies show that it may be safe, but only in carefully selected patients with proper preoperative workup and risk stratification based on pathologic and radiologic findings (these data could not be obtained from the current study given the nature of the study)."

She added, "Women diagnosed with invasive cervical cancer (as well as women with a suspicion of invasive cervical cancer) should be referred to a gynecologic oncologist so that they can receive adequate surgery that won't compromise their cancer outcomes and survival. Referral to a gynecologic oncologist will also allow them access to clinical trials that are safely and carefully evaluating more conservative and innovative approaches to the management of their disease."


Obstet Gynecol 2019.