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Impact of surgical approach on oncologic outcomes in women undergoing radical hysterectomy for cervical cancer.
Am J Obstet Gynecol. 2019 12; 221(6):619.e1-619.e24.AJ

Abstract

BACKGROUND

Recent studies demonstrating shorter survival among cervical cancer patients undergoing minimally invasive versus open radical hysterectomy could not account for surgeon volume and require confirmation in other jurisdictions with larger sample sizes, longer follow-up, and data on disease recurrence.

OBJECTIVE

To determine if surgical approach is associated with oncologic outcomes in cervical cancer patients undergoing minimally invasive or open radical hysterectomy, while accounting for mechanistic factors including surgeon volume.

STUDY DESIGN

We performed a population-based retrospective cohort study of cervical cancer patients undergoing primary radical hysterectomy by a gynecologic oncologist from 2006 to 2017 in Ontario, Canada. A multivariable marginal Cox proportional hazards model and cause-specific hazards model were used to evaluate the association of surgical approach with all-cause death and recurrence respectively, clustering at the surgeon level. We tested for interactions between surgical approach and either pathologic stage or surgeon volume.

RESULTS

We identified 958 patients (minimally invasive 475; open 483) with mean age 45.9 and a median follow-up of 6 years. Of minimally invasive procedures, 89.6% were performed laparoscopically and 10.4% robotically. The unadjusted 5-year cumulative incidences of all-cause death (minimally invasive 12.5%; open 5.4%), cervical cancer death (minimally invasive 9.3%; open 3.3%), and recurrence (minimally invasive 16.2%; open 8.4%) were significantly increased for minimally invasive radical hysterectomy in patients with stage IB disease, but not the cohort overall. After adjusting for patient factors and surgeon volume, minimally invasive radical hysterectomy was associated with increased rates of death (hazard ratio [HR], 2.20; 95% confidence interval [CI], 1.15-4.19) and recurrence (HR, 1.97; 95% CI, 1.10-3.50) compared to open radical hysterectomy in patients with stage IB disease (n = 534), but not IA disease (n = 244; HR, 0.73; 95% CI, 0.13-4.01; HR, 0.34; 95% CI, 0.10-1.10).

CONCLUSION

Minimally invasive radical hysterectomy is associated with increased rates of death and recurrence in patients with stage IB cervical cancer even after controlling for surgeon volume; open radical hysterectomy should be the recommended approach in this population. Although there may be a subset of patients with microscopic early-stage disease for whom minimally invasive radical hysterectomy remains safe, additional studies are required.

Authors+Show Affiliations

Department of Obstetrics & Gynecology, University of Toronto, Toronto, ON, Canada.Department of Surgery, University of Toronto, Toronto, ON, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada; Department of Surgery and Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada; Institute for Clinical Evaluative Sciences, Toronto, ON, Canada.Department of Obstetrics & Gynecology, University of Toronto, Toronto, ON, Canada; Institute for Clinical Evaluative Sciences, Toronto, ON, Canada; Division of Gynecologic Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada; Institute for Clinical Evaluative Sciences, Toronto, ON, Canada.Institute for Clinical Evaluative Sciences, Toronto, ON, Canada.Department of Surgery, University of Toronto, Toronto, ON, Canada.Department of Obstetrics & Gynecology, University of Toronto, Toronto, ON, Canada.Department of Obstetrics & Gynecology, University of Toronto, Toronto, ON, Canada; Division of Gynecologic Oncology, Princess Margaret Cancer Centre, Toronto, ON, Canada. Electronic address: sarah.ferguson@uhn.ca.

Pub Type(s)

Journal Article
Research Support, Non-U.S. Gov't

Language

eng

PubMed ID

31288006

Citation

Cusimano, Maria C., et al. "Impact of Surgical Approach On Oncologic Outcomes in Women Undergoing Radical Hysterectomy for Cervical Cancer." American Journal of Obstetrics and Gynecology, vol. 221, no. 6, 2019, pp. 619.e1-619.e24.
Cusimano MC, Baxter NN, Gien LT, et al. Impact of surgical approach on oncologic outcomes in women undergoing radical hysterectomy for cervical cancer. Am J Obstet Gynecol. 2019;221(6):619.e1-619.e24.
Cusimano, M. C., Baxter, N. N., Gien, L. T., Moineddin, R., Liu, N., Dossa, F., Willows, K., & Ferguson, S. E. (2019). Impact of surgical approach on oncologic outcomes in women undergoing radical hysterectomy for cervical cancer. American Journal of Obstetrics and Gynecology, 221(6), e1-e24. https://doi.org/10.1016/j.ajog.2019.07.009
Cusimano MC, et al. Impact of Surgical Approach On Oncologic Outcomes in Women Undergoing Radical Hysterectomy for Cervical Cancer. Am J Obstet Gynecol. 2019;221(6):619.e1-619.e24. PubMed PMID: 31288006.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Impact of surgical approach on oncologic outcomes in women undergoing radical hysterectomy for cervical cancer. AU - Cusimano,Maria C, AU - Baxter,Nancy N, AU - Gien,Lilian T, AU - Moineddin,Rahim, AU - Liu,Ning, AU - Dossa,Fahima, AU - Willows,Karla, AU - Ferguson,Sarah E, Y1 - 2019/07/06/ PY - 2019/05/15/received PY - 2019/06/30/revised PY - 2019/07/02/accepted PY - 2019/7/10/pubmed PY - 2020/3/19/medline PY - 2019/7/10/entrez KW - cervical cancer KW - hysterectomy KW - laparoscopy KW - laparotomy KW - minimally invasive surgical procedures KW - robotic surgical procedures KW - uterine cervical neoplasms SP - 619.e1 EP - 619.e24 JF - American journal of obstetrics and gynecology JO - Am. J. Obstet. Gynecol. VL - 221 IS - 6 N2 - BACKGROUND: Recent studies demonstrating shorter survival among cervical cancer patients undergoing minimally invasive versus open radical hysterectomy could not account for surgeon volume and require confirmation in other jurisdictions with larger sample sizes, longer follow-up, and data on disease recurrence. OBJECTIVE: To determine if surgical approach is associated with oncologic outcomes in cervical cancer patients undergoing minimally invasive or open radical hysterectomy, while accounting for mechanistic factors including surgeon volume. STUDY DESIGN: We performed a population-based retrospective cohort study of cervical cancer patients undergoing primary radical hysterectomy by a gynecologic oncologist from 2006 to 2017 in Ontario, Canada. A multivariable marginal Cox proportional hazards model and cause-specific hazards model were used to evaluate the association of surgical approach with all-cause death and recurrence respectively, clustering at the surgeon level. We tested for interactions between surgical approach and either pathologic stage or surgeon volume. RESULTS: We identified 958 patients (minimally invasive 475; open 483) with mean age 45.9 and a median follow-up of 6 years. Of minimally invasive procedures, 89.6% were performed laparoscopically and 10.4% robotically. The unadjusted 5-year cumulative incidences of all-cause death (minimally invasive 12.5%; open 5.4%), cervical cancer death (minimally invasive 9.3%; open 3.3%), and recurrence (minimally invasive 16.2%; open 8.4%) were significantly increased for minimally invasive radical hysterectomy in patients with stage IB disease, but not the cohort overall. After adjusting for patient factors and surgeon volume, minimally invasive radical hysterectomy was associated with increased rates of death (hazard ratio [HR], 2.20; 95% confidence interval [CI], 1.15-4.19) and recurrence (HR, 1.97; 95% CI, 1.10-3.50) compared to open radical hysterectomy in patients with stage IB disease (n = 534), but not IA disease (n = 244; HR, 0.73; 95% CI, 0.13-4.01; HR, 0.34; 95% CI, 0.10-1.10). CONCLUSION: Minimally invasive radical hysterectomy is associated with increased rates of death and recurrence in patients with stage IB cervical cancer even after controlling for surgeon volume; open radical hysterectomy should be the recommended approach in this population. Although there may be a subset of patients with microscopic early-stage disease for whom minimally invasive radical hysterectomy remains safe, additional studies are required. SN - 1097-6868 UR - https://www.unboundmedicine.com/medline/citation/31288006/Impact_of_surgical_approach_on_oncologic_outcomes_in_women_undergoing_radical_hysterectomy_for_cervical_cancer_ L2 - https://linkinghub.elsevier.com/retrieve/pii/S0002-9378(19)30893-2 DB - PRIME DP - Unbound Medicine ER -