Fertility-sparing trachelectomy for early-stage cervical cancer: A proposal of an ideal candidate

Abstract

Objective: To propose an ideal patient candidate with early-stage cervical cancer for undergoing fertility-sparing trachelectomy.

Methods: This nationwide, multicenter, retrospective study was conducted by the Japan Society of Obstetrics and Gynecology involving women aged <45 years with clinical stage I-II cervical cancer who had planned fertility-sparing trachelectomy and pelvic lymphadenectomy between 2009 and 2013 (n = 393). Ideal candidates were defined to have a tumor size of ≤2 cm, no lymph node metastasis, no deep stromal invasion, and no high-risk histology (n = 284, 69.6%). Less-ideal candidates were defined to have any one of these four characteristics (n = 109, 30.4%). Propensity score inverse probability of treatment weighting was used to assess survival outcomes.

Results: Less-ideal candidates were more likely to undergo hysterectomy conversion (22.9% versus 3.2%), receive postoperative radiotherapy (11.9% versus 0.4%), or chemotherapy (32.1% versus 3.2%) compared with ideal candidates (all, P < 0.05). The weighted model revealed that among those who underwent trachelectomy (ideal candidates, n = 275 and less-ideal candidates, n = 84), less-ideal candidates had significantly decreased disease-free survival (5-year rates: 85.5% versus 95.5%; HR 3.93, 95% CI 1.99-7.74; P < 0.001) and cause-specific survival (92.5% versus 98.6%; HR 5.47, 95% CI 1.68-17.8, P = 0.001) compared with ideal candidates. Similarly, less-ideal candidates were significantly associated with decreased disease-free survival compared with ideal candidates among those who were young age, had small tumors or squamous histology, and underwent surgery alone (all, P < 0.05).

Conclusion: Less-ideal candidates had approximately four-fold higher recurrence risk and cancer mortality compared with ideal candidates. Ideal candidates for fertility-sparing trachelectomy for early-stage cervical cancer proposed in our study may be useful as the future framework for developing guidelines for fertility-sparing trachelectomy in Japan.

Keywords: Cervical cancer; Deep stromal invasion; Lymph node metastasis; Survival; Trachelectomy; Tumor size.

Fig. 1.

Schema for patient selection.

Fig. 2.

Survival curves: ideal candidates versus less-ideal candidates. P values were derived from IPTW-adjusted log-rank test. A) disease-free survival and B) cause-specific survival are shown between the ideal and less-ideal candidate groups. Y-axis was truncated to 50–100%. Risk-stratified survival curves are shown for C) disease-free survival and D) cause-specific survival between the ideal versus less-ideal candidate groups.

Fig. 3.

Forest plots for HR for disease-free survival (IPTW models). Cox proportional hazard regression models for analysis. In each subgroup analysis, IPTW was fitted to compare the ideal and less-ideal candidate groups. HR represents the less-ideal candidate group versus the ideal candidate group. In all the subgroups, the less-ideal group had significantly decreased disease-free survival compared with that of the ideal group. X-axis was transformed to log₁₀ scale. Circles represent IPTW-HR, and bars represent 95% confidence intervals. Abbreviations: HR, hazard ratio; IPTW, inverse probability of treatment weighting; SCC, squamous cell carcinoma. *Trachelectomy alone without neoadjuvant chemotherapy or postoperative treatment.