LACC trial sparks surge in open abdominal hysterectomy for cervical cancer

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A recent study revealed a substantial rise in open abdominal hysterectomy following the Laparoscopic Approach to Cervical Cancer trial, impacting surgical approaches but not 30-day complications.

LACC trial sparks surge in open abdominal hysterectomy for cervical cancer | Image Credit: © ibreakstock - © ibreakstock - stock.adobe.com.

LACC trial sparks surge in open abdominal hysterectomy for cervical cancer | Image Credit: © ibreakstock - © ibreakstock - stock.adobe.com.

Publication of the Laparoscopic Approach to Cervical Cancer (LACC) trial led to an increase in the open abdominal approach for managing invasive surgical cancer, according to a recent study published in The American Journal of Obstetrics & Gynecology.

Takeaways

  1. The publication of the Laparoscopic Approach to Cervical Cancer (LACC) trial led to a significant increase in the use of open abdominal hysterectomy for managing invasive cervical cancer, as opposed to minimally invasive surgery.
  2. In 2020, there were 604,000 new cases and 342,000 deaths from cervical cancer, making it the fourth leading cause of cancer mortality in women. Radical hysterectomy with bilateral pelvic lymph node staging is a common treatment for early-stage cervical cancer.
  3. While the LACC trial indicated improved overall and disease-free survival with open abdominal radical hysterectomy, subsequent research on changes in cervical cancer surgical treatment following the trial's publication has conflicting results.
  4. To assess the impact of the LACC trial, investigators conducted a retrospective cohort study using data from the American College of Surgeons National Surgical Quality Improvement Program databases, covering over 700 US hospitals and medical centers.
  5. The study revealed a significant increase in the rate of open abdominal hysterectomy after the LACC trial, accompanied by a decline in minimally invasive hysterectomy. However, there was no significant change in the 30-day complication rates between the pre-LACC and post-LACC periods

In 2020, 604,000 new cases and 342,000 deaths from cervical cancer were reported. It is the fourth leading cause of cancer mortality in women and is treated in early stages using radical hysterectomy with bilateral pelvic lymph node staging.

Cervical cancer surgical treatment significantly changed following the publication of the LACC trial, which revealed open abdominal radical hysterectomy improved overall and disease-free survival over minimally invasive radical hysterectomy. However, research on changes in cervical cancer surgical treatment following the trial’s publication is conflicting.

To evaluate the impact of the publication of the LACC trial, investigators conducted a retrospective cohort study. Data was obtained from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) databases, which include over 700 US hospitals and medical center and were up to date through 2020 at the time of data collection. 

Data from January 2016 to December 2020 was included in the analysis to obtain data from before and after the LACC trial’s publication in 2019. International Classification of Diseases, Ninth and Tenth Revision codes were used to determine invasive cervical cancer presence. 

Exclusion criteria included receiving a supracervical hysterectomy or pregnancy-related hysterectomy, being aged under 18 years, carcinoma in situ, American Society of Anesthesiologists class 5, preoperative systemic inflammatory response syndrome, sepsis, septic shock, and emergency cases.

Participants were categorized based on treatment approach, which included open abdominal surgery and minimally invasive surgery. The change in surgical approach and 30-day complication rate before and after publication of the LACC trial were the primary outcomes of the analysis.

A pre-LACC period and post-LACC period were determined, from January 2016 to December 2017 and from January 2019 to December 2020, respectively. Data from 2018 was not included in the analysis.

Complications were categorized as major or minor. Major complications included wound disruption, sepsis, unplanned intubation, septic shock or systemic inflammatory respiratory syndrome, ventilator support for over 48 hours, deep incisional surgical site infection, acute renal failure, pneumonia, organ space surgical site infection, and progressive renal insufficiency.

Additional major complications included myocardial infarction, pulmonary embolism, stroke or cerebrovascular accident with neurological deficit, cardiac arrest needing cardiopulmonary resuscitation, deep vein thrombosis, and thrombophlebitis. Minor complications included superficial surgical site infection or urinary tract infection.

There were 3024 patients included in the final analysis, 50.1% from the pre-LACC period and 49.9% from the post-LACC period. Open abdominal hysterectomy was reported in 41.6% of patients and minimally invasive hysterectomy in 58.4%.

The rate of open abdominal hysterectomy rose significantly between the pre-LACC period and post-LACC period, from 24.4% to 58.9%. In comparison, minimally invasive hysterectomy significantly declined between the pre-LACC period and post-LACC period, from 75.6% to 41.1%.

A 30-day major complication was reported by 5.3% of patients, a 30-day minor complication in 7.4%, and an intra- or postoperative transfusionin 5.3%. Similar rates were reported across the pre-LACC and post-LACC groups, at 5.6% vs 4.9%, respectively, experiencing a 30-day major complication and 6.8% vs 8%, respectively, experiencing a 30-day minor complication.

Abdominal surgery was associated with significantly higher rates of 30-day major complications, at 6.4% vs 4.4% for minimal invasive surgery. A similar pattern was observed for 30-day minor complications, at 9.8% vs 5.7%, respectively.

These results indicated publication of the LACC trial impacted surgical approach, but not 30-day complications. A significant rate of minimally invasive approach use was still observed, indicating a need for further studies to fully evaluate the impact of the LACC trial with longer follow-up.

Reference

Schivardi G, Casarin J, Habermann EB, et al. Practice patterns and complications of hysterectomy for invasive cervical cancer after the Laparoscopic Approach to Cervical Cancer trial. Am J Obstet Gynecol. 2024;230:69.e1-10. doi:10.1016/j.ajog.2023.09.002

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