Despite lower costs, minimally invasive hysterectomy may reduce cervical cancer survival

CHICAGO — Minimally invasive laparoscopic or robotic hysterectomy appeared to be associated with decreased morbidity and costs among women stage IB1 cervical cancer, according to study results presented at ASCO Annual Meeting.

However, minimally invasive radical hysterectomy was associated with significantly decreased survival among women with tumors larger than 2 cm.

“These results are consistent with the recently presented randomized, international, phase 3 Laparoscopic Approach to Cervical Cancer trial. Our study adds to these data in a few distinct ways,” David J. Margul, MD, PhD, member of Shahabi Laboratory at Northwestern University Feinberg School of Medicine, said during his presentation. “First, our study is confirmatory in that it was completed independently with no knowledge of trial outcomes; second, our study confirms these findings in a general population; and, third, our study suggests minimally invasive surgery may still be acceptable in tumors smaller than 2 cm.”

More than 12,800 new cervical cancer cases occurred in 2017, according to Margul.

Treatment options consist of primary chemoradiation or primary surgery. Primary surgery includes a radical hysterectomy with can be open, robotic or laparoscopic. The latter two are considered minimally invasive.

“Several small retrospective studies, mostly at single institutions, have shown that minimally invasive radical hysterectomy is feasible and safe. As such, current National Comprehensive Cancer Network guidelines support both open and minimally invasive approaches,” Margul said. “In this study, we sought to compare open and minimally invasive radical hysterectomy for stage IB1 cervical cancer with regard to surgical complications and costs and OS.”

Investigators evaluated data from the Premiere Healthcare database between 2010 and 2015 using international classification of disease codes to identify specific complications, as well as billing and admission data to provide length of stay, readmission rates and surgical and admission costs of patients with cervical cancer.

Researchers identified more than 43,000 women with cervical cancer, 2,830 of whom underwent radical hysterectomy: 45% with an open procedure, 49% with a robotic surgery, and 6% with a laparoscopic surgery.

Open radical hysterectomy was associated with longer length of hospital stay (median, 3 days) than robotic radical hysterectomy (median, 1 day) and laparoscopic radical hysterectomy (median, 0 days; P < .001).

Additionally, open radical hysterectomy had an overall complication rate of 52.7%, compared with 24.9% for robotic radical hysterectomy and 23.7% for laparoscopic radical hysterectomy (P < .001). Complications associated with open radically hysterectomy included bowel injuries, infections, electrolyte or fluid disorders, transfusions and ileus (P .001 for all).

Thirty-day readmission rates were similar among the groups — 2.3% for open surgery, 1.4% for robotic surgery and 1.8% for laparoscopic surgery.

Total surgical hospitalization costs favored minimally invasive laparoscopic surgery with a median cost of $9,649 (interquartile range [IQR], $7,478- $13,010) compared with $12,080 for open surgery (IQR, $8,957-$16,052) and $11,562 for robotic surgery (IQR, $8,636-$14,600).

Researchers then evaluated data from the National Cancer Database to identify 1,661 women who underwent radically hysterectomy as primary treatment between 2010 and 2013. Researchers measured 5-year survival after open (n = 854) or minimally invasive (n = 807) radical hysterectomy.

Results of a multivariable Cox model showed open radical hysterectomy was associated with worse OS (HR = 1.92; 95% CI, 1.24-2.96).

When researchers evaluated data by tumor size, they observed no survival difference for those with a tumor small than 2 cm. However, patients with tumors 2 cm to 4 cm had significantly poorer survival with open radical hysterectomy (HR = 2.39; P = .004).

“This study suggests a need for further investigation into relationship between tumor size and surgical approach,” Margul said. – by Melinda Stevens

Reference:

Margul DJ, et al. Abstract 5502. Presented at: ASCO Annual Meeting; June 1-5, 2018; Chicago.

Disclosures: Margul reports no relevant financial disclosures. Please see the abstract for all other authors’ relevant financial disclosures.