A common treatment for cervical cancer in its early stages (when a small tumor is confined to the cervix) is a hysterectomy, often performed using a minimally invasive procedure called laparoscopic radical hysterectomy. The procedure, which came into widespread use in 2006, involves only a few small surgical incisions, offering women the promise of shorter hospital stays and fewer complications. Yet two recent studies question whether this minimalist approach leads to comparable survival rates compared with more invasive open surgery.
Open vs. laparoscopic surgery
During open surgery, or abdominal radical hysterectomy, the surgeon makes one large lower-abdominal incision. He or she removes the uterus, cervix, neighboring uterine tissues, and top of the vagina through the incision. Pelvic lymph nodes are often removed and tested for cancer. Potential complications include excessive blood loss, infection, and damage to surrounding organs. Recovery takes about four to six weeks after three to five days in the hospital.
During a laparoscopic radical hysterectomy, the surgeon makes tiny incisions in the abdomen to insert surgical instruments and a tube with a tiny camera on its tip, which allows the surgeon to see inside thepelvic area via a TV monitor. The procedure can also be done using robotic arms that the surgeon moves using a control panel a few feet away. In both cases, the uterus and the surrounding structures are removed through the vagina.
Minimally invasive surgery is sometimes preferred over open surgery because it involves less blood loss, pain, and recovery time due to smaller incisions. A one- to two-day hospital stay is followed by about two to three weeks of recovery. As with open surgery, there’s a risk of injury to surrounding organs as well as the urinary tract.
Treatment guidelines recommend either procedure for performing a radical hysterectomy for early-stage cervical cancer. The question has been whether one type leads to better survival odds and lower relapse rates than the other. A few studies have shown no difference in survival rates, but most were done retrospectively—meaning that researchers looked back at the results of surgeries performed in the past when treatment recommendations were different. Earlier studies were also small, and they tracked patients for only a brief time.
A new look at both procedures
The first of two studies published in the November 15, 2018, New England Journal of Medicine compared survival and disease recurrence rates between the two procedures at the MD Anderson Cancer Center in Houston and 32 other facilities worldwide. The clinical trial was funded by MD Anderson and Medtronic, the manufacturer of devices used during laparoscopy.
The authors randomly assigned 631 women (average age, 46) with early-stage cervical cancer to receive either open radical hysterectomy (312) or laparoscopic or robot-assisted laparoscopic hysterectomy (319), all performed by highly experienced surgeons. Some women received chemotherapy, radiation, or both after surgery.
Two and a half years later, the differences in cancer recurrences and deaths were striking. The odds of cancer returning in the laparoscopic/robotic group (27 recurrences) was four times that of the open surgery group (7 recurrences). Nineteen women in the minimally invasive group died (14 from cancer), compared with three in the open-surgery group (2 from cancer).
After four and a half years, the disease-free survival rate was 86 percent (274 of 319 women) with laparoscopy, compared with 96.5 percent (301 of 312 women) with open surgery. The differences were so significant that the trial was closed to new patients, and MD Anderson has since stopped offering laparoscopic surgery for cervical cancer.
In the second study, also in The New England Journal of Medicine, researchers from MD Anderson, Harvard Medical School, and other institutions looked back at data from two large U.S. cancer registries to compare survival rates between the two procedures among more than 2,400 women. Nearly four years after their procedures, 94 women who had laparoscopy/robotic surgery had died, compared to 70 women who underwent open surgery, although the data analyzed didn’t specify cause of death.
The authors of these studies couldn’t offer a precise reason for the survival advantages with open surgery, but one hypothesis is that the surgeons remove less tissue with the minimally invasive approach, which could leave some tumor cells behind.
What you can do
If you’ve been diagnosed with early-stage cervical cancer and your surgeon recommends a radical hysterectomy, discuss the pros and cons of each procedure carefully and consider getting a second opinion. If you opt for a laparoscopic radical hysterectomy, use a surgeon who has had plenty of experience performing the procedure.
If you’ve previously had a laparoscopic radical hysterectomy for cervical cancer, be sure to adhere to the screening schedule recommended by your doctor.
This article first appeared in the April 2019 issue of UC Berkeley Health After 50.
Also see Racial Gap in Cervical Cancer Deaths.