Association of surgical approach with oncologic outcomes in low-risk cervical cancer

BACKGROUND: Recent randomized evidence suggesting that simple hysterectomy is non-inferior to radical hysterectomy in cervical cancer patients with low-risk disease has invigorated questions about the safety of a minimally invasive approach in this population. OBJECTIVE: To determine whether the association between surgical approach and oncologic outcomes varied by disease risk group. STUDY DESIGN: Population-based retrospective cohort study of cervical cancer patients undergoing primary radical hysterectomy by a gynecologic oncologist from 2006 to 2017 in Ontario, Canada. Analyses were stratified by disease risk group, with patients classified as low-risk (depth of invasion 20 mm) according to pathologic Canadian Cancer Trials Group CX.5 Simple Hysterectomy and Pelvic Node Assessment (SHAPE) criteria. Overlap propensity score‑weighted survival models were used to examine the association between surgical approach and oncologic outcomes, adjusting for demographic, clinical, and pathologic factors. RESULTS: We identified 903 patients with median age 44 years (interquartile range, 38-53) and follow-up 10 years (interquartile range, 7-13). In low-risk patients (N=621), minimally invasive radical hysterectomy was not associated with all-cause death (hazard ratio [HR], 0.88; 95% confidence interval [CI], 0.39-2.01; P=.76), cervical cancer death (HR, 1.15; 95% CI, 0.27-4.87; P=.85), or recurrence (HR, 0.88; 95% CI, 0.4-1.91; P=.74) compared to open radical hysterectomy. In high-risk patients (N=282), minimally invasive radical hysterectomy was associated with significantly increased all-cause death (HR, 3.22; 95% CI, 1.37-7.58; P=.008), cervical cancer death (HR, 4.88; 95% CI, 1.50-15.83; P=.008), and recurrence (HR, 2.32; 95% CI, 1.01-5.34; P=.048) compared to open radical hysterectomy. CONCLUSION: The relationship between surgical approach and oncologic outcomes appeared to vary by disease risk group. Minimally invasive radical hysterectomy may not be associated with adverse oncologic outcomes in patients with low-risk disease, but recurrence and death were uncommon in this subgroup. Additional studies are needed to confirm whether minimally invasive surgery remains safe in a low-risk population defined by strict SHAPE criteria.