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Simple hysterectomy SHAPE-ing up to be the treatment of choice for early cervical cancer under 2 cm
Anouk Benseler,Allan Covens 대한부인종양학회 2024 Journal of Gynecologic Oncology Vol.35 No.2
Cer vical cancer is the fourth most common cancer in women [1]. While we hope globalhuman papillomavirus vaccination efforts will change this reality, as a result of screeningprograms 42% of women in North America present with localized disease [2]. Radicalhysterectomy has been recommended for most patients, presenting with stage IA2 to 4 cmIB3 cancers [3]. Overall sur vival is excellent, however there are significant adverse effectsassociated with parametrial and vaginal resection [4]. We congratulate Plante et al. on completing this randomized non-inferiority trial of 700patients with stage 1A2 and 1B1 cer vical cancer comparing simple hysterectomy and pelvicnode dissection to radical hysterectomy and pelvic node dissection (recently published inthe New England Journal of Medicine) [5]. The primar y endpoint was designed to detect non-inferiority of pelvic-relapse free sur vival at 3 years, with secondar y outcomes including overallsur vival, parametrial involvement, quality of life and treatment-related toxicity. The 3-yearpelvic-recurrence rate was 2.5% in the simple hysterectomy group and 2.2% in the radicalhysterectomy group per intention to treat analysis (2.8% and 2.3% per protocol analysis) andthe upper 95% confidence limit did not meet the pre-defined threshold of inferiority. The3-year extra pelvic relapse-free sur vival and overall sur vival were 98.1% vs. 99.7% and 99.1%vs. 99.4%, respectively. Surgical margins were similar (2.4% SH vs. 2.7% RH). Patient reported outcomes of sexual health were measured by the Female Sexual FunctionIndex and the Female Sexual Distress Scale-Revised, and bowel, bladder and non-sexualvaginal symptoms were measured by EORTC QLQ-C30 with QLQ-CX24. Simple hysterectomywas associated with decreased pain experience and favorable sexual health. Patients whounder went simple hysterectomy reported less sexual worr ying and increased sexual enjoymentat 3 months, less sexual pain and improved sexual lubrication for the first 12 months, andimproved sexual vaginal functioning for the first 24 months. Overall better body image andincreased sexual activity was reported for up to 36 months. Decreased urinar y retentionand incontinence also favored simple hysterectomy (0.6% vs. 9.9% and 4.7% vs. 11%,respectively). These findings of decreased sexual health and increased bladder symptoms inpatients undergoing radical hysterectomy are consistent with the literature [6-9]. The ConCer v trial prospectively evaluated patients with cer vical cancer up to 2 cm, treatedwith conization or simple hysterectomy, and concluded conser vative surger y may be offeredbased on a cumulative recurrence of 3.5% over a median follow up of 36.3 months [10].A systematic review of the literature including 2,662 women demonstrated no significantassociation between mortality and simple vs. radical hysterectomy in patients withmicroscopic disease, and the recent SCCAN retrospective trial of 1,257 patients comparingtype B, C1 and C2 radical hysterectomy techniques found no sur vival difference for tumors upto 2 cm with increased radicality of surger y [11,12]. What can we conclude from all this? The evidence from these studies is congruent; nonradical surger y for small cer vical cancers is safe, not associated with increased relapse rates,and improves quality of life, measured through patient reported outcomes. Rarely do wefind a therapy, that relative to standard of care, is as effective yet less complex, less costly andbetter tolerated by patients. While it is unlikely this study will be replicated, these findingsstimulate additional questions. With no reason to suspect other wise, will the 5-year overallsur vival be consistent with these 3-year findings? Given that the majority of patients inthe ConCer v trial (96%) and the SHAPE trial (75%) under went minimally invasive surger yfor their hysterectomy, what is the optimal surgical approach for these patients [10,13]?Can sentinel node biopsy replace full pelvic lymphad...
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