Simple Hysterectomy May Be Effective in Low-Risk Cervical Cancer

The differences between simple and radical hysterectomies were defined by an expert.

For patients with early-stage, low-risk cervical cancer, research has shown simple hysterectomy to not be inferior to radical hysterectomy regarding the three-year incidence of pelvic recurrence and associated with a lower risk of urinary incontinence or retention, according to findings published in the New England Journal of Medicine.

“For patients who have what we call low-risk disease, that means very early cancer, our results showed that a simple hysterectomy seems to be just as effective in terms of cure rates and control of disease as the traditional or standard radical hysterectomy, which is a much more elaborate, complicated procedure,” said Dr. Marie Plante, a professor in the Department of Obstetrics and Gynecology at Laval University in Quebec City, Canada, and head of the oncology-gynecology department and in charge of clinical research at l’Hôtel-Dieu de Québec, as well as a co-author of the study.

A potential shift for some patients towards a less-radical surgery, with potentially fewer side effects and complications, “is interesting from a patient perspective,” Plante said. “And there is a trend towards de-escalating radicality of treatment not just for cervical cancer, but in other kinds of diseases to see, once we've achieved good results with a certain procedure, can we sort of de-escalate that procedure and still maintain the good results that we look for in terms of cancer-curing, cancer results, while reducing the side effects and complications caused by the treatment?”

Among the 700 patients in the study, 350 each underwent simple hysterectomy and radical hysterectomy. Researchers reported that 91.7% of patients had tumors that were stage 1B, 61.7% had squamous-cell histologic features and 59.3% were grade 1 or 2.

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At a median follow-up of 4.5 years, the incidence of three-year pelvic recurrence was 2.17% among patients treated with radical hysterectomy and 2.52% among patients who underwent simple hysterectomy.

Within four weeks after surgery, there was a 2.4% incidence of urinary incontinence in the simple hysterectomy group and 5.5% in the radical hysterectomy group, with those rates extending to 4.7% and 11% beyond four weeks, researchers reported.

Urinary retention incidence was 0.6% and 11% in the simple and radical hysterectomy groups within four weeks after surgery, and 0.6% and 9.9% beyond four weeks, according to the study findings.

Differences in Simple Versus Radical Hysterectomies

Both simple and radical hysterectomies, Plante said, involve removal of the uterus and the cervix. However, radical hysterectomy also removes the parametrium, or the tissue surrounding the cervix, and in order to do so the ureters, which are tubes connecting the kidney to the bladder, need to be mobilized or identified, she said.

“So the first difficulty is the surgeon needs to be able to do a good ureteral mobilization, and then we also need to move the bladder down a lot more than with a simple hysterectomy because we remove a slice of the vagina in addition, and then we take what we call the ureteral sacral ligaments which are behind your uterus, we need to take them down lower,” Plante said. “So, all of this explains why a radical surgery or radical hysterectomy is more elaborate. … There is more risk of damaging or injuring the ureters, more risk of damaging the bladder. And of course, if you remove more vagina, then you potentially also impact sexual life and quality of life from the sexual vaginal functioning perspective.”

While current surgical techniques have resulted in the postoperative recovery following radical hysterectomy significantly improving over time, there is still a difference in patients’ postsurgical quality of life between the two procedures, Plante said.

“Considering that a fairly high proportion of women with very early disease tend to be younger, because we do better screening and so on, if you impact their quality of life or sexual health they can live with that for a long time,” Plante said. “So that's something to keep in mind as well: What's the aftermath? Or, what's the quality of life?”

To be eligible for a simple hysterectomy, Plante noted, patients’ cancer has to measure less than two centimeters, have the usual histology and be superficial. A lymph node assessment will also have to be performed, she said.

“Even though we're dealing with small lesions, there's still about a 5% risk of having lymph node metastasis despite [the fact] that these are small lesions,” Plante said. “So, I just wanted the message to be to not underestimate cervical cancer even though it looks small and not very aggressive. One needs to always be very careful because it can play tricks.”

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