A minimally invasive, robotic surgery commonly used for performing hysterectomies in women with early stage cervical cancer actually boosts the risk of a woman dying, researchers warned on Wednesday.
A pair of studies published in the New England Journal of Medicine sound the alarm about a surgery that has quickly become the go-to option for many women, even before its outcome was thoroughly studied.
“At this point, we would recommend only using open surgery to perform a radical hysterectomy for cervical cancer,” said co-senior author Shohreh Shahabi, chief of gynecologic oncology at Northwestern University Feinberg School of Medicine.
When a woman is diagnosed with cervical cancer, she often gets her uterus and cervix removed, an operation known as a radical hysterectomy.
Minimally invasive radical hysterectomy using either laparoscopic or robot-assisted procedures have been around since 1992, but ballooned in popularity in the last decade.
More than 60 percent of hysterectomies performed on women with early stage cervical cancer in 2013 were done in a minimally invasive way, allowing women to go home the same day.
The procedure involves inflating the abdomen with gas and operating through small incisions, using a camera and a robotic instrument.
In comparison, a traditional, open hysterectomy requires a long incision through the center of the abdomen and several days of hospitalization.
While robotic surgeries are gaining popularity fast, and are generally seen as less risky in terms of surgical complications, researchers wanted to understand which method was better from a cancer-survival standpoint.
A randomized clinical trial was conducted to compare the two methods in terms of how many women were free of disease 4.5 years later.
The trial was halted early, in 2017, when researchers realized there was a 10 percent difference in survival between the two groups.
Eighty-six percent of women who had the robotic surgery were alive and disease-free after 4.5 years, compared to 96.5 percent in the open surgery group.
Minimally invasive surgery was also associated with a lower overall survival rate after three years – 93 percent in the minimally invasive group were alive compared to 99 percent in the traditional surgery group.
A second study analyzed 2,461 patients in the National Cancer Database who had radical hysterectomies for early-stage cervical cancer from 2010 through 2013, half by robotic surgery and half via open surgery.
There, too, researchers found that women who underwent the minimally invasive surgery had higher rates of cancer recurrence and death than those who had a traditional surgery.
There was a 9.1 percent risk of death in the minimally invasive group and a 5.3 percent risk in the open surgery group.
But the research does not explain why.
According to Shahabi, it’s possible that tumor tissue is not completely removed in some robotic procedures, or that somehow the tools used encourage tumor tissue to spread.
“It’s important to note that our study doesn’t explain why mortality is higher among women who have minimally invasive surgery,” said the lead author of the larger study, Alexander Melamed, a clinical fellow in Obstetrics, Gynecology and Reproductive Biology at Harvard Medical School.
“One possible explanation is that there could be something technical about minimally invasive radical hysterectomy that is different from the open procedure and makes a difference for long-term survival,” he added.
“An alternative explanation is that US surgeons could have been less experienced with the minimally invasive procedure than with open surgery during the study period.”
The study spanned 33 medical centers in 13 countries, and all the cancer recurrences were clustered in 14 of those sites.
More work is needed to understand the factors that led to poorer survival in the robotic surgery group, wrote doctor Amanda Fader of Johns Hopkins University in an accompanying editorial in the New England Journal of Medicine.
“Do these studies signal the death knell for minimally invasive radical hysterectomy in cervical cancer patients?
“Not necessarily, but this approach has been dealt a great blow,” Fader said.
Cervical cancer is the fourth leading cause of cancer death in women worldwide, and affects more than 13,000 women in the United States each year.
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