Minimally Invasive versus Open Radical Hysterectomy for Cervical Cancer: Which Results in Better Survival Outcomes?

Patients with early stage cervical cancer may have a greater survival risk if they undergo open radical hysterectomy compared to minimally invasive hysterectomy, according to a new report.

“It is important to keep in mind that there may be more differences between minimally invasive and open procedures besides the size of the incisions,” said lead study author, Alexander Melamed, MD, MPH, assistant professor of obstetrics and gynecology at Columbia University Vagelos College of Physicians and Surgeons and a member of Columbia’s Herbert Irving Comprehensive Cancer Center, in a press release. “In the case of radical hysterectomy, these are two different operations, albeit with the same goal. Subtle technical differences may affect the oncologic efficacy of these procedures. We just don’t know yet.”

Dr. Melamed and colleagues conducted a systematic review and meta-analysis by querying Ovid MEDLINE, Ovid Embase, PubMed, Scopus, and Web of Science databases from inception through March 26, 2020, for relevant studies. Observational studies using survival analyses to compare outcomes between patients who underwent minimally invasive versus open radical hysterectomy for early stage cervical cancer. The Newcastle-Ottawa Scale was used to determine study quality, and studies with scores of at least 7 points that controlled for tumor size or stage were included. The main outcomes were risk of recurrence or death, and risk of all-cause mortality.

A total of 49 studies were identified; 15 studies encompassing 9,499 radial hysterectomy patients were used for the meta-analysis. Of the total cohort, just under half (n=4,684; 49%) underwent minimally invasive surgery. Most of the minimally invasive patients (n=2,675; 57%) received robot-assisted laparoscopy. A total of 530 recurrences and 451 deaths occurred. Patients who underwent minimally invasive radial hysterectomy, compared to open surgery, had a pooled hazard of recurrence or death 71% higher (hazard ratio [HR], 1.71; 95% confidence interval [CI], 1.36 to 2.15; P<0.001) and hazard of death 56% higher (HR, 1.56; 95% CI, 1.16 to 2.11; P=0.004).

“No association was found between the prevalence of robot-assisted surgery and the magnitude of association between minimally invasive radical hysterectomy and hazard of recurrence or death (2.0% increase in the HR for each 10-percentage point increase in prevalence of robot-assisted surgery [95% CI, −3.4% to 7.7%]) or all-cause mortality (3.7% increase in the HR for each 10-percentage point increase in prevalence of robot-assisted surgery [95% CI, −4.5% to 12.6%]),” the authors further reported.

The results of the study were published in JAMA Oncology.

“Since the publication of the 2018 studies,” said Dr. Melamed, citing previous research that found an increased risk of mortality in minimally invasive versus open surgery cervical cancer patients, “there has been a lot of hand-wringing and debate. I hope that this new meta-analysis will help clinicians and patients understand that the available evidence strongly suggests that the harm of minimally invasive surgery for cervical cancer outweighs the benefits. A number of medical centers, in fact, no longer even offer the option of minimally invasive radical hysterectomy for early-stage cervical cancer.”

The key takeaway, Dr. Melamed said, ” is that we should never take the status quo for granted. Conventional wisdom and tradition need to be constantly revisited.”