Cervical cancer survival worse after common keyhole surgery, studies warn

Procedure blacklisted after studies associate it with 'three-fold increase' in cervical cancer progression

Keyhole surgery using precision robotic instruments have helped to cut recovery times but might mean cancer cells are missed or spread (Rex)

Cervical cancer patients who have their tumour removed by common keyhole surgery which drastically cuts recovery times, are more likely to die early and have their cancer come back, a pair of studies has found.

US researchers looking at survival rates in early-stage cervical cancer, found 65 per cent more women who had the “minimally invasive” procedure died within four years.

The keyhole (laparoscopic) operation uses long instruments or a “robotic surgeon” to perform the radical hysterectomy, removing the cervix, uterus and surrounding tissue where cancer might have spread via a small incision in the abdomen.

It has become well established in gynaecological cancer surgery in the past decade because most patients are able to go home the same day, compared to days of recovery and extra risk of infection with open surgery.

Currently around 60 per cent of early-stage cervical cancer use this minimally invasive approach in the US. However, a pair of studies published in the New England Journal of Medicine on Wednesday, suggest that these women may have had worse outcomes and several hospitals or surgeons have blacklisted the procedure as a result.

“Given these two studies, we believe that we can no longer recommend minimally invasive radical hysterectomies for our patients with early-stage cervical cancer,” said Dr Alejandro Rauh-Hain, a gynaecological oncology specialist at the University of Texas MD Anderson Cancer Centre.

The first piece of research was an international trial across 33 cancer centres which recruited 631 women with stage one cervical cancer and randomly assigned them to receive either non-invasive or open treatment between 2008 and 2017.

It had intended to recruit 740 women but was stopped early on ethical grounds because the additional risks were already apparent.

Minimally invasive surgery was linked to a three-fold increase in disease progression and just 86 per cent of women disease free after 4.5 years, compared to 96.5 per cent who had open surgery, the study found.

Just 91.2 per cent of women were alive after three years in the minimally invasive group, compared to 97.1 per cent of the open surgery arm.

The second study, led by Dr Rauh-Hain’s group, in collaboration with Harvard, Columbia and Northwestern Universities, reviewed historical records of women who had undergone this procedure.

Of the 2,461 patients in the US National Cancer Database who had a radical hysterectomy for early stage cervical cancer between 2010 and 2013, 9.1 per cent of women who had the minimally invasive procedure died compared to 5.3 per cent in the open surgery group – a 65 per cent increase.

“Minimally invasive surgery was adopted as an alternative to open radical hysterectomy before high-quality evidence regarding its impact on survival was available,” Dr Rauh-Hain said.

“[We] were surprised to find that in our respective studies, surgical approach negatively affected oncologic outcomes for women with early-stage cervical cancer.

“Our research also found that compared with open surgery, minimally invasive surgery increased the risk of death among women who underwent radical hysterectomy for early-stage cervical cancer”.

Cervical cancer surgery in the NHS

In England annual cervical screening means many cases are picked up before they become cancerous – while radiotherapy is used in later stages. But there were still 291 of the operations last year and 72 per cent used the minimally invasive approach (18 per cent robotically assisted), according to the British and Irish Association of Robotic Gynaecological Surgeons.

Mr Thomas Ind, a consultant gynaecological surgeon and president of BIARGS told The Independent that the latest findings are subject to intense debate in their field. 

Chiefly the trial found an unexpectedly low rate of cancer recurrence in open surgery and he argues that those who had the minimally invasive procedure may not have had high quality surgery because “the number of cases that the surgeons did in this study was probably not enough to keep their skills up”. 

“This study has really resulted in more questions than answers and should not change surgical practice at present. However, it does result in more uncertainty for patients – regrettably.

“Discussions would need to be had with patients prior to surgery. It is indeed possible that patients might need to choose between one set of outcomes and another (e.g. survival and complications) in the future.”

Dr Shohreh Shahabi, who co-authored the latter paper, from Northwestern University, stressed that their findings cannot say what was causing this effect but it could be tumour cells being missed or spread by equipment.

“Possible explanations include the potentially limited extent of tumour removal during minimally invasive surgery, or that tools used during minimally invasive hysterectomy may inadvertently disseminate [spread] tumour cells,” Dr Shahabi said.

“It is important to note these results are specific to cervical cancer, and minimally invasive surgery is still a great option for other surgeries and cancers,” he added.