In Reply:

In Reply: We thank the authors of the correspondence for their thoughtful review of our article in the January 2025 issue.1 In response to their concerns, we acknowledge the inherent limitations of using large databases such as the National Cancer Database. Although these databases may not offer the granularity of data available in randomized trials, they provide comprehensive data that allow for robust and meaningful analysis.2 The National Cancer Database classifies simple hysterectomy procedures as code 30 (total hysterectomy without removal of tubes and ovaries) or code 40 (total hysterectomy with removal of tubes or ovaries or both). These codes refer to procedures that remove the uterine corpus cervix and, when performed, a limited portion of the vaginal cuff. Radical hysterectomy procedures are grouped as code 50, encompassing modified radical, radical, and extended radical hysterectomy. Any procedure involving deviations from a strict definition of simple hysterectomy, such as limited parametrial resection, should be categorized as radical hysterectomy. This approach aims to enhance the reliability of the data set. Regarding positive surgical margins, we anticipated a low incidence due to the small lesion sizes in this cohort, aligning with findings from the SHAPE (Simple Hysterectomy and Pelvic Node Assessment) trial,3 which demonstrated that margin status was low in this population (less than 3%). For transparency, we provided additional data on surgical margins for our study, which were available for more than 98% of patients. Positive margins were observed in 32 patients (2.1%) undergoing radical hysterectomy and 39 patients (2.6%) undergoing simple hysterectomy (P=.107). These findings suggest that margin status may not significantly influence outcomes in our study. However, we acknowledge the limitation of the database in not capturing the reasons behind the selection of adjuvant treatments. Minimally invasive surgery was the predominant approach across all groups, with a higher proportion of minimally invasive surgery in the simple hysterectomy group. Although the LACC (Laparoscopic Approach to Cervical Cancer) trial4 was not specifically powered to analyze outcomes by tumor size, we included surgical approach as a variable in propensity score matching to mitigate potential biases. Minimally invasive surgery use was appropriately balanced between groups, and subgroup analyses showed no significant differences in outcomes. Thus, any potential negative minimally invasive surgery–related effects probably should not have influenced our results. We appreciate the opportunity to enhance the broader discussion on treatment strategies for low-risk early-stage cervical cancer.