Background
Cancer is a leading cause of death worldwide. Gynaecological cancers (i.e. cancers affecting the ovaries, uterus, cervix, vulva and vagina) are among the most common cancers in women, with a higher incidence in developing countries. Globally, a woman's risk of developing cancer of the cervix, ovaries or uterus by the age of 65 is 2.2%; cancers of the vulva and vagina are less common. The biology of recurrent ovarian cancer differs from that of other gynaecological cancers; it is often responsive to chemotherapy and is not included in this review.
Review question
Unfortunately, in some women with gynaecological cancer, the disease will return (recur) or progress after initial treatment. Cancer recurrence is defined as the return of cancer after treatment and after a period during which the cancer is undetectable. Although the surgical management of early cancers is relatively straightforward, with lower associated morbidity and mortality, the surgical management of advanced and recurrent cancer is significantly more complicated, often requiring very extensive operations. Pelvic exenterative surgery involves removal of some or all of the pelvic organs, including lower bowel (rectum with or without the sigmoid colon and sometimes the anal canal), bladder, reproductive organs (including womb, fallopian tubes, ovaries, vagina and vulva), pelvic peritoneum (the membrane that lines the pelvis and pelvic organs) and sometimes the perineum (external area around the vagina and anus), with reconstruction. The intent of exenterative surgery should be resection of all tumour with clear histological margins with the aim of cure. It is radical, often mutilating, surgery that is associated with significant postoperative side effects (morbidity) and risk of death (mortality), and it is a major undertaking for both patient and surgeon. However, it may be the only potentially curative treatment option for women with recurrent cancer.
Quality of the evidence
Although two review authors independently checked 1311 articles identified by searching, we found no relevant studies that were suitable for inclusion in the review. Therefore, no evidence is currently available from which to determine whether exenterative surgery is better than, equivalent to or worse than non-surgical treatment in terms of prolonged survival, treatment-related complications and impact on quality of life. This review highlights the need for good-quality studies comparing exenterative surgery versus non-surgical treatment in women with recurrent gynaecological cancer.
We found no evidence to inform decisions about exenterative surgery for women with recurrent cervical, endometrial, vaginal or vulvar malignancies. Ideally, a large RCT or, at the very least, well-designed non-randomised studies that use multivariate analysis to adjust for baseline imbalances are needed to compare exenterative surgery versus medical management, including palliative care.
Cancer is a leading cause of death worldwide. Gynaecological cancers (i.e. cancers affecting the ovaries, uterus, cervix, vulva and vagina) are among the most common cancers in women. Unfortunately, given the nature of the disease, cancer can recur or progress in some patients. Although the management of early-stage cancers is relatively straightforward, with lower associated morbidity and mortality, the surgical management of advanced and recurrent cancers (including persistent or progressive cancers) is significantly more complicated, often requiring very extensive procedures. Pelvic exenterative surgery involves removal of some or all of the pelvic organs. Exenterative surgery for persistent or recurrent cancer after initial treatment is difficult and is usually associated with significant perioperative morbidity and mortality. However, it provides women with a chance of cure that otherwise may not be possible. In carefully selected patients, it may also have a place in palliation of symptoms. The biology of recurrent ovarian cancer differs from that of other gynaecological cancers; it is often responsive to chemotherapy and is not included in this review.
To evaluate the effectiveness and safety of exenterative surgery versus other treatment modalities for women with recurrent gynaecological cancer, excluding recurrent ovarian cancer (this is covered in a separate review).
We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE up to February 2013. We also searched registers of clinical trials, abstracts of scientific meetings and reference lists of clinical guidelines and review articles and contacted experts in the field.
Randomised controlled trials (RCTs) or non-randomised studies with concurrent comparison groups that included multivariate analyses of exenterative surgery versus medical management in women with recurrent gynaecological malignancies.
Two review authors independently assessed whether potentially relevant studies met the inclusion criteria. No studies were found; therefore no data were analysed.
The search strategy identified 1311 unique references, of which seven were retrieved in full, as they appeared to be potentially relevant on the basis of title and abstract. However, all were excluded, as they did not meet the inclusion criteria of the review.