Surgical treatment of stage IA2 cervical cancer

Background

Cervical cancer is the second most common cancer among women up to 65 years of age and is the most frequent cause of death from gynaecological cancers worldwide. Cervical cancer is staged (classified using a universally adopted system called International Federation of Gynecology and Obstetrics (FIGO) staging) according to how advanced the disease is and whether the cancer has spread beyond the cervix. Stage I cervical cancer is confined to the cervix. Stage I is divided into stage IA and IB. Stage IA is the earliest stage of cervical cancer where the cancer is so small it cannot be seen with the naked eye. Stage IA is subdivided further to stages IA1 and IA2. Stage IA2 means the cancer has grown between 3 and 5 mm into the cervical tissues, but it is still less than 7 mm wide.

It is well recognised that survival rates from the disease decrease as the stage at which the diagnosis is made increases. In women with stage IA2 cervical cancer it has been reported that between 95% and 98% survived five years after diagnosis with standard surgery.

For stage IA2 disease, surgery or radiotherapy have been the treatment of choice. Standard surgery is a radical hysterectomy and bilateral pelvic lymphadenectomy. It involves the removal of the womb, the cervix, the upper part of the vagina and the tissues around the cervix (parametrial tissue), as well as the lymph nodes (glands) in the pelvis (pelvic lymphadenectomy). Although this type of surgery has excellent results, it can result in side effects, such as organ injury (bladder, bowel, blood vessel, nerve) and long-term side effects, such as sexual or bladder dysfunction, pelvic cyst formation and lymphoedema (swelling) of the legs. One main disadvantage of radical hysterectomy is that it leaves the woman incapable of bearing children. As cervical cancer is common in women aged 25 to 35 years, this is an important consideration for many women.

The alternative surgical treatment is a radical trachelectomy and bilateral pelvic lymphadenectomy. Radical trachelectomy involves removing the cervix, the upper part of the vagina and the parametrial tissue and the pelvic lymph glands, but retaining the body of the womb. This treatment is well established and appears to be safe and effective in preserving fertility and has a high chance of conception. Late miscarriage and premature labour are the most serious side effects in pregnancies where the woman has had a trachelectomy.

Methods

This review aimed to assess less invasive types of surgery such as simple hysterectomy, conisation (removal of the central cervical tissue) with or without pelvic lymphadenectomy for women with stage IA2 disease. We searched the literature from 1966 to September 2013. We then checked 982 titles and abstracts, but found no relevant completed clinical trials that met the inclusion criteria only one on-going trial.

Findings

We identified one large ongoing, multicentre randomised controlled trial (RCT, a study in which women are allocated at random (by chance alone) to receive one of two treatments: standard versus less radical treatment) that looked at this subject. The results of this trial will be published in the future.

Currently there is absence of evidence that any form of surgical technique is better, equal or worse in prolonging survival, improving quality of life or are associated with fewer side effects. The review highlights the need to assess, once completed, the results of the ongoing RCT in order to compare different types of surgery.

Authors' conclusions: 

We found no evidence to inform decisions about different surgical techniques in women with stage IA2 cervical cancer. In the future, the results of one large ongoing RCT should allow comparison of different types of surgery.

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Background: 

Cervical cancer is the second most common cancer among women up to 65 years of age and is the most frequent cause of death from gynaecological cancers worldwide. Women with International Federation of Gynecology and Obstetrics (FIGO) stage IA2 cervical cancer have measured stromal invasion (when the cancer breaks through the basement membrane of the epithelium) of greater than 3 mm and no greater than 5 mm in depth with a horizontal surface extension of no more than 7 mm. For stage IA2 disease, radical hysterectomy with pelvic lymphadenectomy or radiotherapy is the standard treatment. In order to avoid complications of more radical surgical methods, less invasive options, such as simple hysterectomy, simple trachelectomy or conisation, with or without pelvic lymphadenectomy, may be feasible for stage IA2 disease, considering the relative low risk of local or distant metastatic disease. The evidence for less radical tumour excision and for the role of systematic lymphadenectomy in stage IA2 cervical cancer is not clear.

Objectives: 

To evaluate the effectiveness and safety of less radical surgery in stage IA2 cervical cancer.

Search strategy: 

We searched the Cochrane Gynaecological Cancer Group trials register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE up to September 2013. We also searched registers of clinical trials and abstracts of scientific meetings.

Selection criteria: 

We searched for randomised controlled trials (RCTs) that compared surgical techniques in women with stage IA2 cervical cancer.

Data collection and analysis: 

Two review authors independently assessed whether potentially relevant studies met the inclusion criteria. We found no trials and, therefore, no data were analysed.

Main results: 

The search strategy identified 982 unique references, which were all excluded on the basis of title and abstract because it was clear that they did not meet the inclusion criteria. We identified one relevant large ongoing trial, so it is anticipated that we will be able to add this evidence to this review in the future.

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