番茄社区

Use of a minimally invasive approach to hysterectomy for early cervical cancer decreased substantially after a clinical trial showed the procedure may actually cause harm, researchers found.

Following publication of the Laparoscopic Approach to Cervical Cancer ( trial -- which showed worse outcomes for women who received minimally invasive versus open radical hysterectomies -- use of minimally invasive surgery dropped 59% (OR 0.41, 95% CI 0.29-0.59), reported Patrick Lewicki, MD, of NewYork-Presbyterian Hospital and Weill Cornell Medicine in New York City, and colleagues.

But rates of minimally invasive surgery (either laparoscopic or robotic) decreased more dramatically in academic centers compared to nonacademic settings, they wrote in a letter in the .

"The use of this approach among nonacademic providers suggests an opportunity to improve outcomes," they stated.

Amer Karam, MD, a clinical professor of ob/gyn at Stanford University in California, said that he expected to see an overall decrease in minimally invasive procedures since the publication of the LACC trial, but he was surprised by how many providers were still performing them.

"Despite the fact that outcomes are worse, close to 50% of practitioners are still doing minimally invasive surgery for cervical cancer," Karam, who was not involved in the study, told 番茄社区.

He added that the uptake of new guidance is typically slower at nonacademic versus academic facilities, and that stronger statements from professional organizations are needed to determine which procedures should be the standard of care, and also which are potentially harmful.

In patients with invasive cervical cancer, a minimally invasive approach is hard to justify, Karam said, adding that "We could potentially be harming patients by continuing this practice."

Lewicki's group noted that minimally invasive surgery has been widely adopted for the treatment of cervical cancer, but there are few randomized, controlled trials to assess outcomes.

Results from the LACC trial published in 2018 showed that early-stage cervical cancer patients who underwent minimally invasive surgery had worse disease-free and overall survival outcomes versus those who had open surgery. Since these findings came out, guidance from medical societies, including the , have stated that gynecologic oncologists should consider all data before counseling patients on their chosen surgical approach.

Lewicki and colleagues assessed the use of minimally invasive versus open radical hysterectomy for cervical cancer. The researchers calculated the number of hysterectomies performed with a minimally invasive approach each month, comparing data before and after LACC trial results were published. They evaluated data from the Premier Healthcare Database, a large, national sample of healthcare providers.

The study included more than 2,400 patients, all of whom received care at one of nearly 300 centers between November 2015 and March 2020. Around 60% of the patients went to an academic center for care, while the remaining 40% went to a nonacademic setting.

Prior to the publication LACC results, a minimally invasive approach was used in 58% of hysterectomies. However after the trial, overall use declined to around 43%.

At academic healthcare centers, the odds of performing minimally invasive surgery went down more than 70% (OR 0.27, 95% CI 0.17-0.43). But at nonacademic settings, the reduction in use of this approach was much lower (OR 0.81, 95% CI 0.45-1.47). There were no significant changes in the use of minimally invasive surgery based on hospital census region, patient race, or insurance status.

Lewicki's group noted that the study relied on billing codes, which may have limited the results, and that clinicopathological information was lacking.

However, they noted that "Our study builds on previous data suggesting changes in practice patterns," specifically a that looked at real-world rates of minimally invasive radical hysterectomy pre- and post-LACC.

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