PEOPLE DIAGNOSED WITH early-stage cervical cancer have traditionally undergone radical hysterectomy, a procedure that, while effective in treating their cancer, carries the risk of bladder injuries and sexual dysfunction. However, some women may be eligible for a simple hysterectomy with a lower risk of complications.
Both surgeries remove the cervix and the uterus, but a radical hysterectomy also removes the parametrium—a layer of tissue on either side of the cervix—and a portion of the upper vagina. To extract this tissue, surgeons need to temporarily move the bladder, as well as the ureters, which are ducts that carry urine from the kidneys to the bladder.
A study presented at the 2023 American Society of Clinical Oncology Annual Meeting in June found simple hysterectomy is as effective as radical hysterectomy among stage I cervical cancer patients with small tumors. Patients who received the simple hysterectomy reported fewer surgical complications and long-term side effects compared with those who received the more extensive surgery.
Moving the bladder and ureters as part of a radical hysterectomy can sometimes cause bleeding and infection and can lead to increased urinary retention or incontinence, while removing part of the vagina can decrease vaginal function and negatively impact sexual health, according to Marie Plante, a gynecologic oncologist at Centre Hospitalier Universitaire de Québec in Quebec City, Canada, and the study’s lead author.
People who have a radical hysterectomy may also need follow-up surgeries, according to Evelyn A. Reynolds, a gynecologic oncologist at Mayo Clinic in Rochester, Minnesota, who was not involved in the study. “The more dissection, then the more potential for these risks to arise,” she says.
While radical hysterectomy has been the standard of care for people with early-stage cervical cancer for decades, Plante says oncologists have questioned whether the procedure is necessary in low-risk cases where the tumor has not extended into the parametrium. To see if a simple hysterectomy could yield similar outcomes, Plante led a phase III clinical trial involving 700 women with stage I cervical cancer whose tumors were 2 centimeters or smaller. Patients were divided into two groups to receive either simple or radical hysterectomy. Patients in both groups had lymph nodes in their pelvis removed, which is the current standard of care to accurately assess the stage of cancer. Researchers tracked recurrence and survival rates and administered quality-of-life assessments at various points following the procedure.
After three years, 11 women who had simple hysterectomy and 10 women who had radical hysterectomy experienced cancer recurrence in their pelvis, and 99% of women in both groups were alive. “We saw more bladder injury and three times more urethral injury” in participants who had radical hysterectomy, Plante says. Women who underwent the radical procedure had higher incidence of both urinary incontinence (11% vs. 4.7%) and urinary retention (9.9% vs. 0.6%) compared with simple hysterectomy patients, who recorded higher quality-of-life scores.
The results have the potential to change practice and make simple hysterectomy the new standard of care for treating women with low-risk cervical cancer, according to Reynolds. “We’re not losing anything oncologically, but we may be gaining as far as risks of the procedure, quality of life [and] sexual function afterwards,” she says.
For patients to be eligible for this surgery, their tumor cannot be deeply infiltrated into surrounding tissue and must be 2 centimeters or smaller, Plante stresses. The study analyzed patients who had cervical cancer caused by human papillomavirus (HPV), which is thought to cause more than 90% of cervical cancer cases in the U.S. Radical hysterectomy might be a better choice for non-HPV cervical cancer, which tends to be more aggressive, according to Plante.
This study is among a growing number of de-escalation trials that explore ways to limit the impact of cancer treatment on people’s lives, Plante says. “We used to think the only thing that matters was the outcome,” she says, noting oncologists now realize eliminating cancer is not enough if it leaves people with lifelong side effects.
“If we can get the same outcomes with less harm, we’re winning; it’s a no-brainer,” Reynolds says.
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