Radical hysterectomy practice patterns for early-stage cervical cancer: a cross-sectional survey of gynecologic oncologists

Objectives: In this study, we evaluated current practice patterns related to radical hysterectomies for early stage cervical cancer and how they have changed since new literature was released in 2018. Methods: This study was a cross-sectional survey of current gynecologic oncologists. The primary outcome assessed was performance of primarily open radical hysterectomies for FIGO Stages IA1, IA2, IB1, and IB2 cervical carcinoma. A secondary outcome assessed was a change in surgical practice. Multivariable logistic regression analyses were completed to assess for associations of demographic and surgical experience predictors. Additional descriptive analyses were performed to evaluate reasons physicians would consider a minimally invasive radical hysterectomy, specific changes made to surgical technique, concerns regarding the 2018 NEJM trials, and beliefs about the role of future clinical trials. Results: Of 1309 SGO members invited to participate, 249 responded (19.0%) and 218 (87.6%) complete responses were analyzed. Performance of primarily open radical hysterectomies was reported in 61.6%, 80.2%, and 88.9% of Stage IA2, IB1, and IB2 cancers, respectively. For Stage IA2 cancer, the age group of 40-49 was associated with 73% lower odds of performing primarily open hysterectomies compared to the reference group of ages 30-39 (OR 0.27, p=0.01). Female gender was associated with greater odds of performing primarily open radical hysterectomies (OR 2.03, p=0.04 for IA2, OR 3.25, p=0.01 for IB1). For Stage IB2 cancers, no demographic or surgical experience factors were statistically associated with performance of open surgery. Change from minimally invasive to open surgery was reported in 52.3%, 68.4%, and 71.1% of Stage IA2, IB1, and IB2 cancers, respectively. Change in minimally invasive technique was reported in 5.5%, 6.42%, and 5.96% of Stage IA2, IB1, and IB2 cancers, respectively. For Stage IA2 cancer, each decrease of 1 year in practice (i.e. since fellowship graduation) was associated with 10% greater odds of changing surgical route or technique. Time since fellowship graduation was associated with 23% greater odds of a change for Stage IB2 cancers. For Stage IB1 cancer, each increase in case volume by 1 radical hysterectomy annually was associated with 6% lower odds of changing surgical route or technique. Most (66.7%) physicians reported they would consider a minimally invasive hysterectomy for one or more reasons. The majority of respondents (84.7%) reported believing there is a role for additional studies evaluating the topic of route of surgery for early stage cervical cancer. Download : Download high-res image (239KB) Download : Download full-size image Conclusions: Despite emerging research demonstrating worse oncologic outcomes for minimally invasive radical hysterectomies in early stage cervical cancer, our research shows that current practices remain heterogeneous. In this study, female surgeons had greater odds of performing open surgery compared to their male colleagues for Stage IA2 and IB1 cancers. The odds for performing open surgery were lower in middle age surgeons compared to younger physicians. More recent fellowship graduation was associated with greater odds of change, indicating that more senior surgeons reported being less likely to change practice. Many individuals reported feeling there is room for additional randomized clinical trials to inform evidence-based practices. Given the high rates of practice change reported, there will also be a role for future epidemiologic studies to evaluate oncologic outcomes in the current practice environment.