Association between hysterectomy wait-time and all-cause mortality for micro-invasive cervical cancer: treatment implications during the coronavirus pandemic

Abstract

In 2021, a global pandemic caused by a novel coronavirus (COVID-19) continues to be a major health threat. In the United States, nearly 33.5 million people have tested positive for COVID-19 and over 602,400 patients have died from complications related to COVID-19 as of early July 2021 [1]. The pandemic crisis is stressing the healthcare systems creating unprecedented challenges in providing timely oncologic care. Multiple studies have demonstrated that COVID19 has resulted in delayed cancer care [2, 3]. A recent high-quality meta-analysis concluded that cancer treatment delay is associated with increased mortality in various malignancies, but valid data on cervical cancer remain scant [4]. Given that the majority of women with early-stage cervical cancer are treated surgically with hysterectomy, we examined the association between hysterectomy wait-time and oncologic outcomes for women with microinvasive cervical cancer. This retrospective observational study examined women with stage IA squamous, adenocarcinoma, and adenosquamous carcinomas of the uterine cervix diagnosed from 2004 to 2015 in the National Cancer Database. All women underwent primary hysterectomy. Cases with no wait-time were excluded due to the assumption of occult malignancy. Associations between surgical wait-time, defined as time interval from cancer diagnosis to hysterectomy, and oncologic outcomes including surgical-pathological factors (pathological parametrical invasion, nodal metastasis, and lympho-vascular space invasion) and all-cause mortality were examined [5]. A generalized linear regression model was used to assess the association between wait-time and pathologic characteristics. Binary logistic regression and Cox proportional hazards regression models with restricted cubic spline transformation of surgery wait-time were used to assess the nonlinear associations between outcome measures, adjusting for other patient and tumor characteristics. The Columbia University Institutional Review Board deemed exempted this study due to the use of publicly available data. A total of 2732 women were examined. The median age was 43 (IQR 36–52) years. Squamous histology (n = 1792, 65.5%) and stage IA1 disease (n = 1185, 43.4%) were the most frequent tumor characteristics. The median hysterectomy wait-time was 6 (IQR 4–9) weeks. Non-Hispanic Black and Hispanic patients, and uninsured and Medicaid insurance were independently associated with longer hysterectomy wait-time in multivariable analysis (all, P < 0.001; Table 1). Longer hysterectomy wait-time was not associated with increased risks of pathological parametrial involvement, regional lymph node metastasis, or lympho-vascular space invasion (Fig. 1A–C). The median follow-up was 4.5 (IQR 2.2–7.2) years, and 136 (5.0%) deaths occurred. Longer hysterectomy wait-time was not associated with allcause mortality risk (P = 0.431; Fig. 1D). The observed result with absence of association between hysterectomy wait-time and mortality risk is somehow reassuring. Notably, our results for micro-invasive cervical * Jason D. Wright [email protected]