Surgical management of cervical cancer by laparoscopy or laparotomy?

Abstract

The cervical cancer management in the twenty first century has been determined by the GOG/NRG Oncology (Leath & Monk, 2018). Solely due to the GOG clinical trials the treatment has changed dramatically leading to an increased survival. In their closing remarks Leath III and Monk state that “Clinical trial work from the GOG is changing the standard of care for all clinical scenarios” (Leath & Monk, 2018). I strongly agree and for this reason I would like to open the discussion on surgery in cervical cancer based upon the recently presented Laparoscopic Approach to Cervical Cancer (LACC) trial of the Global Gynecologic Oncology Consortium (G-GOC) (LACC/G-GOC-1001 trial; ClinicalTrials.gov Identifier: NCT00614211) (Ramirez et al., 2018; LACC Trials, n.d.) This randomized phase 3 trial tested the non-inferiority of minimal invasive radical hysterectomy versus abdominal radical hysterectomy in women with early-stage cervical cancer. The conclusions were that minimal invasive surgery was associated with significant higher recurrence rates and a significant worse overall survival. Changing from minimal invasive surgery to open surgery would reduce the number of recurrences by 6 and the number of deaths by 5 per 100. You can have a debate about the study and do a SWOT analysis, but at the end of the day it is still level 1 evidence (Tjalma, 2018). The historical perspective paper mentions the increased use of minimal invasive survival techniques in early stage cervical tumors (Leath & Monk, 2018). This is approach is based on the fact that the survival was assumed to be equal between the procedures and the fact that non-randomized controlled trials showed that there was a significant advantages of minimal invasive surgery regarding a reduction in blood loss, lower transfusion rates, lesser bladder and wound infections, shorter hospital stay and decreased morbidity (Tjalma, 2018). There are several possible explanations why a minimal invasive procedure could have a higher risk of causing metastases (Tjalma, 2018). Further research is needed to explore these suggestions and look for other reasons. Until then we have more questions than answers. I agree with Charles Leath III and Bradley Monk that survivorship and special populations are top priorities. According to the new preliminary data there is a survival advantage for open surgery, but at a price in morbidity. Is there a balance between survival and morbidity? It will be interesting to see the final analysis of the LACC trial together with the long-term treatment related morbidity and follow-up. Will the outcome still be the same? At present, during the informed consent we have to explain the new data to the patients. There are several ways to inform the patients. One snow drop doesn t mean a blizzard. Our guidelines and recommendation should incorporate the new data, together with a clear statement how patients and their families should be informed.