Fertility-sparing surgery matches standard surgery in cervical cancer survival

Fertility-sparing surgery and standard surgery lead to similar survival outcomes among cervical cancer patients with tumors of 4 cm or smaller, according to a recent study published in the American Journal of Obstetrics & Gynecology.¹

An increase in cervical cancer incidence has been reported among premenopausal women, with cervical cancer ranking in the top 3 cancers in 80% of countries for women aged under 45 years. To improve patient decision making, it is vital to understand when fertility-sparing treatment can be used without compromising oncologic outcomes.

The current global age at death from cervical cancer is 59 years, with the condition diagnosed at an average age of 53 years.² In 2018, there were approximately 570,000 cases of cervical cancer and 311,000 deaths reported.

Currently, the National Comprehensive Cancer Network recommend fertility-sparing treatment in patients with tumor sizes of 2 cm or less but warn against the procedure in patients with tumors of 2 to 4 cm because of reduced validation.¹ However, this cutoff has not been rigorously compared to alternative options.

Investigators conducted a retrospective cohort study to determine the association between tumor size and the safety of fertility-sparing surgery among patients with stage 1 cervical cancer. Data was obtained from the National Cancer Database, which included hospital registry data from over 1500 facilities.¹

Participants included patients aged 45 years or younger diagnosed with cervical cancer between 2006 and 2018 receiving either fertility-sparing surgery or standard surgery for stage 1 cancer. The stage of cancer was determined using the American Joint Commission on Cancer staging system.

Exclusion criteria included a previous cancer diagnosis, primary radiation therapy, primary or unknown chemotherapy status, tumors above 4 cm or of unknown size, and only receiving a loop electrocautery excision procedure or biopsy.

The type of surgery and tumor size were the primary exposures of the analysis. Fertility-sparing surgery included conization or trachelectomy, while hysterectomy was considered standard surgery. The difference in life expectancy within 5 years of diagnosis between these methods was calculated as the primary outcome.¹

Secondary outcomes included the odds of receiving adjuvant radiotherapy after fertility-sparing surgery. Life expectancy was calculated using restricted mean survival time, which estimates the area under a survival curve between origin time and 5 years following the diagnosis. Tumor, patients, and treatment center characteristics were included as covariates.

There were 11,946 patients included in the final analysis, 7.6% of whom received fertility-sparing surgery. Of patients receiving fertility-sparing surgery, 44.3% underwent trachelectomy and 55.6% a cone procedure. Patients receiving fertility-sparing surgery were often younger, with smaller tumors, and with less comorbidities.¹

After matching patients with fertility-sparing surgery 1:1 to those with standard surgery, there were no differences in overall survival between groups. The difference in 5-year survival between groups ranged from -0.19 months to 0.19 months, indicating no significant association between fertility-sparing surgery and 5-year life expectancy.

The difference in 5-year life expectancy was reduced for smaller tumor sizes vs larger ones. The decrease in 5-year life expectancy was no more than 0.67 months in a patient with a 1-cm tumor, while a decrease up to 3.79 months was reported in a patient with a 4-cm tumor. An association was also reported between increased tumor size and the odds of receiving radiation, with 5.6% odds for a 1-cm tumor vs 37% for a 4-cm tumor.¹

These results indicated there may be opportunities to provide fertility-sparing treatment to patients with tumor sizes above 2 cm. However, investigators noted that since few patients with tumor sizes above 2 cm underwent the procedure, “a clinically important survival difference could not be excluded in this population.”¹

Reference

1. Jorgensen KA, Agusti N, Wu C-F, et al. Fertility-sparing surgery vs standard surgery for early-stage cervical cancer: difference in 5-year life expectancy by tumor size. Am J Obstet Gynecol. 2024;230:663.e1-13. doi:10.1016/j.ajog.2024.02.012
2. Arbyn M, Weiderpass E, Bruni L, et al. Estimates of incidence and mortality of cervical cancer in 2018: a worldwide analysis. Lancet Glob Health. 2020;8(2):e191-e203. doi:10.1016/S2214-109X(19)30482-6