In the case of cervical cancer, minimally invasive surgery exposes you to a higher risk of death and cancer recurrence than conventional surgery. Objectified in 2 studies on real-life databases and demonstrated in a randomized clinical trial, these excess risks call into question minimally invasive surgery in this indication.
For women with early-stage cervical cancer, doctors sometimes recommend removal of the uterus and cervix. Called radical hysterectomy, this operation can be performed conventionally, by opening the belly (laparotomy), but also in “minimally invasive” laparoscopic surgery, possibly with robotic assistance.
Less invasive and allowing faster recovery, this technique consists of operating through very small incisions and tubes, using a camera and robotic instruments, rather than performing a complete opening of the belly (abdominal incision). Implemented in 1992 and generalized since 2006, it is widely acclaimed by patients: 60% of women operated on in the United States in 2013 opted for minimally invasive surgery.
Yet this minimally invasive surgery would not be the safer of the two options. Two new studies published at the beginning of November in The New England Journal of Medicine conclude that, compared to abdominal surgery, the minimally invasive approach is likely to cause more cancer recurrences and death of the patient.
A lower survival rate
In the first study, based on data (epidemiological study), the researchers analyzed information from the American cancer database, which covers about 70% of newly diagnosed cancer cases in more than 1,500 American hospitals. Of the 2,461 patients who underwent radical hysterectomy for early-stage cervical cancer between 2010 and 2013, about half had minimally invasive surgery and a similar proportion had undergone an open procedure.
Of the patients in the minimally invasive group, 94 died from any cause within four years of surgery, compared to 70 patients in the conventional surgery group. These figures reflect a 9.1% risk of death in the minimally invasive group and a 5.3% risk in the open surgery group. The authors specify that there were no differences between the groups in terms of initial tumor pathology or the use of radiotherapy or chemotherapy in addition to surgery.
Less survival in another register
Since the files available in the National Cancer Database only date back to 2004, the researchers also analyzed information from the Surveillance, Epidemiology and Final Outcomes (SEER) database for patients treated from 2000 to 2010. The results are final. Prior to 2006, when minimally invasive radical hysterectomy began to be widely adopted for the treatment of early-stage cervical cancer, they show a stable 4-year survival rate. After 2006, survival rates drop steadily by 0.8% per year.
“It is important to note that our study does not explain why mortality is higher in women who have minimally invasive surgery,” insists Alexander Melamed, researcher 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 to long-term survival. Another explanation is that American surgeons may have had less experience with the minimally invasive technique than with open surgery during the study period,” he said.
A progression of the disease multiplied by 3
The randomized trial, also published in The New England Medicine Journal, formally confirms and demonstrates the existence of the same risks associated with minimally invasive surgery. To compare it to open radical hysterectomy, researchers randomly assigned 740 women with early-stage cervical cancer to one of two procedures. Four and a half years after its start, the trial was finally stopped in 2017 with 631 patients analyzed. The researchers found that minimally invasive radical hysterectomy was associated with a three-fold increase in disease progression compared to open radical hysterectomy.
In addition, the disease-free survival rate at 4.5 years was 86% with minimally invasive surgery versus 96.5% with open surgery. Finally, the overall survival rate after the operation was 91.2% in the minimally invasive group, compared to 97.1% in the group operated using the conventional technique.
Questioning minimally invasive surgery
“Our study highlights the need for more randomized clinical trials in the field of surgery,” said Pedro T. Ramirez, who led the trial. “Too often, the success of a new surgery is measured by retrospective data. We must always test and measure our procedures to determine what works best for our patients.” In this case, the data from the clinical trial go further than the retrospective study.
A point of view shared by Dr. Alexander Melamed. “While we need to learn more about the reasons for these findings, surgeons wishing to offer minimally invasive radical hysterectomy to cervical cancer patients should be sure to properly inform them of these findings. risks.”
“I personally will not offer minimally invasive radical hysterectomy to patients who come to me for cervical cancer treatment until compelling new research demonstrates that a minimally invasive approach does not involve these risks.
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