Is More Really Better? Evolution of Surgery for Cervical Cancer

September is Cervical Cancer Awareness Month. Cervical Cancer remains the fourth most common cancer among women worldwide, despite increased access to screening.¹ Radical hysterectomy has long been the standard treatment for early-stage cervical cancer, but recent evidence suggests that less aggressive surgery may offer similar outcomes with fewer complications. This year’s SHAPE trial (Simple Hysterectomy and Pelvic Node Assessment) provides strong evidence that for women with low-risk, early-stage cervical cancer, simple hysterectomy is a safe and effective alternative to radical hysterectomy.²

Radical hysterectomy, first performed by Ernst Wertheim in 1898, involves the removal of the uterus, cervix, part of the vagina, and surrounding tissues, including lymph nodes.³ While this approach significantly improved survival rates, it also results in high surgical morbidity and long-term complications, such as bladder, bowel, and sexual dysfunction.^4-6

Retrospective data demonstrating a low (<1%) probability of parametrial infiltration in FIGO 2009 stage IB1 disease called into question the need for such extensive tissue removal.^7-9 In light of those data, the ConCerv trial – a prospective, single arm study – followed oncologic outcomes of cold knife cone or simple hysterectomy for early stage, low risk disease. ConCerv demonstrated acceptably low rates of disease recurrence with 3 recurrences over a median follow-up of 36.3 months for a 2-year cumulative incidence of 3.5%.¹⁰

The SHAPE trial was a multicenter, randomized, non-inferiority trial that compared simple hysterectomy to radical hysterectomy in patients with low-risk, early-stage cervical cancer. The trial included patients with FIGO 2009 stage IA1 (with lymphovascular space invasion), IA2, or IB1 cervical cancer with lesions ≤2 cm. The primary outcome was the rate of cancer recurrence in the pelvic area within 3 years. The results showed that simple hysterectomy was non-inferior to radical hysterectomy, with a 3-year pelvic recurrence rate of 2.52% in the simple hysterectomy group compared to 2.17% in the radical hysterectomy group. Additionally, patients who underwent simple hysterectomy experienced fewer complications, such as urinary incontinence and retention.²

Interestingly, neither ConCerv nor SHAPE trial specified whether simple hysterectomies were performed using minimally invasive techniques or traditional open surgery. This omission leaves room for further research, particularly in light of the LACC (Laparoscopic Approach to Cervical Cancer) trial, which found minimally invasive surgery to be associated with worse outcomes compared to open surgery for radical hysterectomy.¹¹ Future studies could specifically compare the outcomes of minimally invasive simple hysterectomy to open surgery in a similar cohort of patients as those studied in SHAPE. This research could help clarify the best surgical approach for managing early-stage cervical cancer, potentially reinstating the use of minimally invasive techniques where appropriate.

References

1. Cancer Facts for Women. American Cancer Society. Last revised 31 October 2023. https://www.cancer.org/cancer/risk-prevention/understanding-cancer-risk/cancer-facts/cancer-facts-for-women.html
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3. Marin F, Plesca M, Bordea CI, Moga MA, Blidaru A. Types of radical hysterectomies: From Thoma Ionescu and Wertheim to present day. J Med Life. 2014 Jun 15;7(2):172-6. Epub 2014 Jun 25. PMID: 25408722; PMCID: PMC4197497.
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8. Frumovitz M, Sun CC, Schmeler KM, Deavers MT, Dos Reis R, Levenback CF, Ramirez PT. Parametrial involvement in radical hysterectomy specimens for women with early-stage cervical cancer. Obstet Gynecol. 2009 Jul;114(1):93-99. doi: 10.1097/AOG.0b013e3181ab474d. PMID: 19546764.
9. Covens A, Rosen B, Murphy J, Laframboise S, DePetrillo AD, Lickrish G, Colgan T, Chapman W, Shaw P. How important is removal of the parametrium at surgery for carcinoma of the cervix? Gynecol Oncol. 2002 Jan;84(1):145-9. doi: 10.1006/gyno.2001.6493. PMID: 11748991.
10. Schmeler KM, Pareja R, Lopez Blanco A, Humberto Fregnani J, Lopes A, Perrotta M, Tsunoda AT, Cantú-de-León DF, Ramondetta LM, Manchana T, Crotzer DR, McNally OM, Riege M, Scambia G, Carvajal JM, Di Guilmi J, Rendon GJ, Ramalingam P, Fellman BM, Coleman RL, Frumovitz M, Ramirez PT. ConCerv: a prospective trial of conservative surgery for low-risk early-stage cervical cancer. Int J Gynecol Cancer. 2021 Oct;31(10):1317-1325. doi: 10.1136/ijgc-2021-002921. Epub 2021 Sep 7. PMID: 34493587.
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