Survival after Minimally Invasive Radical Hysterectomy for Early-Stage Cervical Cancer

Abstract

Background: Minimally invasive surgery was adopted as an alternative to laparotomy (open surgery) for radical hysterectomy in patients with early-stage cervical cancer before high-quality evidence regarding its effect on survival was available. We sought to determine the effect of minimally invasive surgery on all-cause mortality among women undergoing radical hysterectomy for cervical cancer.

Methods: We performed a cohort study involving women who underwent radical hysterectomy for stage IA2 or IB1 cervical cancer during the 2010-2013 period at Commission on Cancer-accredited hospitals in the United States. The study used inverse probability of treatment propensity-score weighting. We also conducted an interrupted time-series analysis involving women who underwent radical hysterectomy for cervical cancer during the 2000-2010 period, using the Surveillance, Epidemiology, and End Results program database.

Results: In the primary analysis, 1225 of 2461 women (49.8%) underwent minimally invasive surgery. Women treated with minimally invasive surgery were more often white, privately insured, and from ZIP Codes with higher socioeconomic status, had smaller, lower-grade tumors, and were more likely to have received a diagnosis later in the study period than women who underwent open surgery. Over a median follow-up of 45 months, the 4-year mortality was 9.1% among women who underwent minimally invasive surgery and 5.3% among those who underwent open surgery (hazard ratio, 1.65; 95% confidence interval [CI], 1.22 to 2.22; P=0.002 by the log-rank test). Before the adoption of minimally invasive radical hysterectomy (i.e., in the 2000-2006 period), the 4-year relative survival rate among women who underwent radical hysterectomy for cervical cancer remained stable (annual percentage change, 0.3%; 95% CI, -0.1 to 0.6). The adoption of minimally invasive surgery coincided with a decline in the 4-year relative survival rate of 0.8% (95% CI, 0.3 to 1.4) per year after 2006 (P=0.01 for change of trend).

Conclusions: In an epidemiologic study, minimally invasive radical hysterectomy was associated with shorter overall survival than open surgery among women with stage IA2 or IB1 cervical carcinoma. (Funded by the National Cancer Institute and others.).

Figure 1.. Study Population.

Figure 2.. Inverse Probability of Treatment–Weighted Survival Curves among Women with Stage IA2 or IB1 Cervical Cancer, According to Type of Surgery.

Shaded bands represent the 95% confidence interval. Women who underwent minimally invasive surgery had shorter overall survival than those who underwent open surgery (P = 0.002 by the log-rank test). The at-risk table shows the actual number of patients at risk. The inset shows the same data on an enlarged y axis.

Figure 3.. Subgroup Analyses.

Subgroup analyses show the associations between minimally invasive radical hysterectomy and all-cause mortality according to mode of minimally invasive surgery (laparoscopic approach vs. robot-assisted approach), histologic type (squamous-cell carcinoma vs. adenocarcinoma), and tumor size in the greatest dimension (<2 cm vs. ≥2 cm). Diamonds represent point estimates for the hazard ratio as compared with open surgery, and horizontal lines indicate the associated 95% confidence intervals. Separate propensity-score models were fitted to predict the probability of minimally invasive surgery for each subgroup, and hazard ratios were estimated with the use of inverse probability of treatment–weighted Cox proportional-hazards models.

Figure 4.. Interrupted Time-Series Evaluation of the Effect of Adoption of Minimally Invasive Radical Hysterectomy on 4-Year Relative Survival Rate.

Shown are the 4-year relative survival rates among women who underwent radical hysterectomy for cervical cancer by any surgical approach (diamonds) with 95% confidence intervals (error bars) and the percentages of radical hysterectomies that were undertaken with the use of a minimally invasive approach (circles). The adoption of minimally invasive radical hysterectomy in 2006 was associated with a significant change of temporal trend (as indicated by the dotted blue line) (P=0.01) and a declining 4-year relative survival rate after 2006 (yellow line) (annual percentage change, 0.8%; 95% CI, 0.3 to 1.4).