Author: By Lynda Williams, Senior medwireNews Reporter
medwireNews: Research shows that women undergoing radical hysterectomy for early-stage cervical cancer or adnexectomy for stage I epithelial ovarian cancer may have a higher risk of morbidity and mortality with minimally invasive surgery (MIS) versus open surgery.
“In the current issue of JAMA Oncology, 2 important studies add to the growing body of literature that suggest a worse outcome for patients with gynecologic cancers who are treated with MIS”, write Oliver Dorigo and Amer Karam, from Stanford University in California, USA, in an accompanying editorial.
While acknowledging MIS can have “considerable benefits” for gynaecological cancer patients, such as a reduced risk of complications and shorter hospital stays, the editorialists emphasize that “[t]he short-term advantages of MIS […] should be weighed against the risk of potentially worse long-term outcomes.”
The systematic review and meta-analysis, reported by Alexander Melamed, from Columbia University Vagelos College of Physicians and Surgeons in New York, USA, and colleagues, included 15 studies of 9499 patients who underwent radical hysterectomy for stage IA1–IIA cervical cancer before March 2020. Almost half (49%) of the patients underwent MIS, with 57% of these procedures robot-assisted.
Pooled analysis of 13 studies with 6109 patients revealed that MIS was associated with a significant 71% increased risk of disease recurrence or death than open surgery. And analysis of 8751 patients in 13 studies indicated that MIS conferred a 56% higher risk of death than open surgery.
Both these analyses had low to moderate heterogeneity, and use of robot-assisted surgery did not significantly alter the risk of recurrence or death associated with MIS versus open surgery, the researchers say.
“These results provide real-world evidence that may aid patients and clinicians engaged in shared decision-making about surgery for early-stage cervical cancer”, write Alexander Melamed et al.
The second study, published as a letter to the journal, focused on the risk of capsule rupture among 8850 women registered in the US National Cancer Database as having undergone adnexectomy for stage I ovarian cancer between 2010 and 2015.
Researcher Jason Wright, from Columbia University College of Physicians and Surgeons in New York, USA, and co-workers report that the use of MIS increased from 19.8% of procedures in 2010 to 34.9% in 2015.
Capsule rupture occurred in 22.5% of patients, and the rate increased from 20.2% in 2010 to 23.9% in 2015, with multivariable analysis indicating that use of MIS was an independent risk factor for capsule outcome, with a relative risk (RR) of 1.17 compared with open surgery.
Women were also more likely to experience capsule rupture if their tumours were larger, with an adjusted RR highest at 1.74 for a tumour sized 81–100 cm versus 0–20 cm.
Women with ruptured tumours were more likely to receive chemotherapy than those without ruptures, regardless of whether they had unilateral (67.0 vs 38.6%) or bilateral tumours (80.0 vs 58.9%).
After a median 39.4 months, the researchers found that women with ruptured tumours had significantly poorer 4-year overall survival than those without. The rates for women with ruptured tumours were 88.9% and 86.8% after MIS and open surgery, respectively, and corresponding values for non-ruptured tumours were 91.5% and 90.5%.
“We recognize a number of limitations of this study, including the inability to determine the timing of capsule rupture and whether or not the rupture was contained within a tissue extraction bag at the time of occurrence”, say Jason Wright and team.
But they emphasize: “Until more data become available, careful preoperative patient selection and intraoperative assessment prior to endoscopic oophorectomy should be performed to minimize the risk of tumor disruption and spillage.”
References
Nitecki R, Ramirez PT, Frumovitz M, et al. Survival after minimally invasive vs open radical hysterectomy for early-stage cervical cancer. A systematic review and meta-analysis. JAMA Oncol; Advance online publication 11 June 2020. doi:10.1001/jamaoncol.2020.1694
Matuso K, Huang Y, Matsuzaki S, et al. Minimally invasive surgery and risk of capsule rupture for women with early-stage ovarian cancer. JAMA Oncol; Advance online publication 11 June 2020. doi:10.1001/jamaoncol.2020.1702
Karam A, Dorigo O. Minimally invasive surgery for gynecologic cancers – a cautionary tale. JAMA Oncol; Advance online publication 11 June 2020. doi:10.1001/jamaoncol.2020.1617
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