Medical experts call for a rethink on using minimally invasive surgery in cervical cancer

For many years, surgeons chose minimally invasive surgery (MIS) over open surgery when treating cervical cancer, due to factors such as lower blood loss, fewer complications and shorter recovery times.

However, that changed in 2018, when results from the Laparoscopic Approach to Cervical Cancer (LACC) trial were released. This international, randomised phase III trial of women with early-stage cervical cancer compared the survival outcomes of various surgical approaches. It found that patients who underwent an  abdominal radical hysterectomy had higher progression-free survival rates than those who underwent a minimally invasive radical hysterectomy. The trail also found that the MIS group had lower rates of overall survival.

Based on these results, the National Comprehensive Cancer Network (NCCN) guidelines were changed to recommend open surgery as the standard approach.

During a virtual symposium on MIS for cervical cancer, organised by the International Society of Gynecological Endoscopy (ISGE) and Peking University (PKU) in China, the results of the LACC trail were put under the microscope by an international group of researchers. They agreed that a change in practice should not have been based on the results of one randomised clinical trial alone. They also proposed a series of steps to revaluate, and potentially reintroduce the use of MIS in cervical cancer. Their recommendations have been published in the KeAi journal Gynecology and Obstetrics Clinical Medicine, and include:

• Introducing a sub-specialised training in gynaecologic oncology for surgeons who perform MIS for cervical cancer.
• Staging a new randomised trial that features a single pathologist review, preoperative MRI, parametrical measurements, and quality indicators of radical hysterectomy performed on sufficient patients.
• Appointing well-trained, certified gynaecologic oncologists to conduct the trial.
• Offering MIS to low-risk, early-stage patients, e.g., those with tumours less than 2cm in diameter, where the depth of invasion is less than 1 cm, without lymph node metastasis, or lymph vascular space invasion, and a well-differentiated pathologic type.
• The introduction of pre-counselling and consultation for patients who receive MIS.

Dr. Jianliu Wang, President of the symposium, who also co-moderated the meeting, explains: “Increasingly, researchers are seeking new evidence to verify the feasibility of MIS, and find a way to reestablish its use in cervical cancer patients. Literature has reported no significant differences in survival between different surgical approaches in early cervical cancer patients without risk factors. Additionally, surgeons are improving their techniques; for example, they are avoiding using manipulators, which may raise risk of tumour spread, and they are performing transvaginal closures or vaginal cerclage of the cervix, isolating the tumour.”

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Contact the corresponding author: Jianliu Wang, wangjianliu1203@163.com