Adoption strategies of fertility-sparing surgery for early-stage cervical cancer patients based on clinicopathological characteristics: a large retrospective cohort study

Abstract

Background: The demand for fertility-sparing surgery (FSS) is increasing among patients with early-stage cervical cancer (CC). This study aimed to evaluate the feasibility of local excision as an alternative to hysterectomy in stage I CC patients aged 15-39 years-commonly referred to as adolescents and young adults (AYAs)-with varying clinicopathological characteristics.

Methods: Using the Surveillance, Epidemiology, and End Results (SEER) database, we identified patients diagnosed between 2000 and 2020. We examined treatment interventions across different age groups, degrees of histological types, tumor differentiation, and tumor stages. The effect of local excision vs. hysterectomy was assessed by comparing overall survival (OS) and disease-specific survival (DSS) rates.

Results: A total of 10,629 stage I AYA cervical cancer patients were included in this study. Among these patients, 24.5% underwent local excision for fertility preservation, while 67.3% underwent radical hysterectomy. For patients with cervical squamous cell carcinoma (SCC), long-term outcomes favored local excision over hysterectomy, and a similar trend was observed in those with adenosquamous cell carcinoma (ASCC). However, the prognosis was comparable among patients with cervical adenocarcinoma (AC). In patients with well- and moderate- differentiated tumors, local excision demonstrated superior OS compared to hysterectomy. No significant differences in prognosis were found between the two surgical interventions for patients with poorly differentiated and undifferentiated tumors. In stage IA patients, local excision was considered a viable alternative to hysterectomy. In stage IB1-IB2, FSS yielded prognostic outcomes comparable to those of hysterectomy. Conversely, patients with stage IB3 exhibited significantly shorter 5-year OS and DSS following local excision than those who underwent hysterectomy.

Conclusion: In stage IA-IB2 (diameter ≤4 cm) AYA patients, local excision may serve as a viable option for fertility preservation. The histological type of SCC, AC, and ASCC, along with differentiation, should not serve as restrictive factors in determining fertility preservation strategies for these patients. Patients with early-stage, well- or moderately-differentiated SCC may benefit from local excision surgery, even when fertility preservation is not the primary objective.

Keywords: early-stage cervical cancer; fertility preservation; hysterectomy; local excision; prognosis.

Figure 1

Screening flowchart.

Figure 2

Prognosis of AYA stage I patients undergoing different types of surgical interventions. (A) The rate at which patients underwent local excision or hysterectomy; (B,C) OS and DSS of AYA stage I patients receiving local excision or hysterectomy.

Figure 3

Prognosis of AYA stage I patients with different pathologic types receiving different types of surgical interventions. (A,D,G) Rates of patients with SCC, AC, ASCC receiving local excision or hysterectomy; (B,C) OS and DSS of stage I SCC patients undergoing local excision or hysterectomy; (E,F) OS and DSS of stage I AC patients undergoing local excision or hysterectomy; (H,I) OS and DSS of patients with stage I ASCC undergoing local excision or hysterectomy.

Figure 4

Prognosis in patients with different pathologic differentiations undergoing different types of surgical interventions. (A,D) The rate of Grade 1–2 (A) and Grade 3–4 (D) differentiated patients receiving local excision or hysterectomy; (B,C,E,F) OS and DSS of Grade1-2 (B,C) and Grade3-4 (E,F) differentiated patients undergoing local excision or hysterectomy.

Figure 5

Prognosis in AYA stage IA and IB patients undergoing different types of surgical interventions. (A,D) The rate of stage IA (A) and stage IB (D) patients receiving local excision or hysterectomy; (B,C,E,F) OS and DSS of stage IA (B,C) and stage IB (E,F) patients undergoing local excision or hysterectomy.

Figure 6

Prognosis of stage IB1-IB3 AYA patients undergoing different types of surgical interventions. (A,D,G) Rates of patients at stage IB1, IB2, IB3 receiving local excision or hysterectomy; (B,C) OS and DSS of stage IB1 patients undergoing local excision or hysterectomy; (E,F) OS and DSS of stage IB2 patients undergoing local excision or hysterectomy; (H,I) OS and DSS of patients with stage IB3 undergoing local excision or hysterectomy.

Figure 7

CMR among AYA stage I patients undergoing different types of surgical interventions. (A) CMR due to cancer-related diseases; (B) CMR due to infectious diseases; (C) CMR due to diseases of the heart and brain; (D) CMR due to respiratory diseases; (E) CMR due to gastrointestinal diseases; (F) CMR due to breast diseases; (G) CMR due to external injury; (H) CMR due to other causes of death.