Effect of the surgical approach on survival outcomes in patients undergoing radical hysterectomy for cervical cancer: A real-world multicenter study of a large Chinese cohort from 2006 to 2017

Abstract

Objective: To compare survival outcomes of minimally invasive surgery (MIS) and laparotomy in early-stage cervical cancer (CC) patients.

Methods: A multicenter retrospective cohort study was conducted with International Federation of Gynecology and Obstetrics (FIGO, 2009) stage IA1 (lymphovascular invasion)-IIA1 CC patients undergoing MIS or laparotomy at four tertiary hospitals from 2006 to 2017. Propensity score matching and weighting and multivariate Cox regression analyses were performed. Survival was compared in various matched cohorts and subgroups.

Results: Three thousand two hundred and fifty-two patients (2439 MIS and 813 laparotomy) were included after matching. (1) The 2- and 5-year recurrence-free survival (RFS) (2-year, hazard ratio [HR], 1.81;95% confidence interval [CI], 1.09-3.0; 5-year, HR, 2.17; 95% CI, 1.21-3.89) or overall survival (OS) (2-year, HR, 1.87; 95% CI, 1.03-3.40; 5-year, HR, 2.57; 95% CI, 1.29-5.10) were significantly worse for MIS in patients with stage I B1, but not the cohort overall (2-year RFS, HR, 1.04; 95% CI, 0.76-1.42; 2-year OS, HR, 0.99; 95% CI, 0.70-1.41; 5-year RFS, HR, 1.12; 95% CI, 0.76-1.65; 5-year OS, HR, 1.20; 95% CI, 0.79-1.83) or other stages (2) In a subgroup analysis, MIS exhibited poorer survival in many population subsets, even in patients with less risk factors, such as patients with squamous cell carcinoma, negative for parametrial involvement, with negative surgical margins, negative for lymph node metastasis, and deep stromal invasion < 2/3. (3) In the cohort treated with (2172, 54%) or without adjuvant treatment (1814, 46%), MIS showed worse RFS than laparotomy in patients treated without adjuvant treatment, whereas no differences in RFS and OS were observed in adjuvant-treatment cohort. (4) Inadequate surgeon proficiency strongly correlated with poor RFS and OS in patients receiving MIS compared with laparotomy.

Conclusions: MIS exhibited poorer survival outcomes than laparotomy group in many population subsets, even in low-risk subgroups. Therefore, laparotomy should be the recommended approach for CC patients.

Keywords: cervical cancer; laparotomy; matching; minimally invasive surgery; radical hysterectomy; survival outcome.