Survival Assessment of Modified Radical Hysterectomy for Stage IB2 Cervical Cancer

INTRODUCTION: The use of treatment de-escalation to reduce surgical radicality while maintaining oncologic outcomes continues to be actively explored in the management of malignancy. In invasive cervical cancer, radical hysterectomy (type C2) has been the mainstay of surgical treatment for patients with a grossly visible tumor confined to the uterine cervix with a size greater than 2 cm but no larger than 4 cm (clinical stage IB2). To date, the role of modified radical hysterectomy (type B) for clinical stage IB2 cervical cancer has not been fully evaluated. OBJECTIVE: To assess surgical–pathological factors and survival associated with modified radical hysterectomy for clinical stage IB2 cervical cancer. METHODS: This retrospective cohort study queried the Commission-on-Cancer’s National Cancer Database. The study population included 2,242 patients with clinical stage IB2 cervical cancer who had primary surgical therapy, including lymph node assessment from 2010 to 2022. Exposure was hysterectomy type, grouped as modified radical hysterectomy (n=446, 19.9%) or radical hysterectomy (n=1,796, 80.1%). Co-primary outcomes included (i) surgical–pathological factors, including surgical margin tumor involvement, lympho-vascular space invasion, regional lymph node metastasis, and parametrial involvement, and (ii) overall survival. Propensity score inverse probability of treatment weighting cohort was created to mitigate the preoperative background differences between the exposure groups, adjusting for surgical–pathological factors and adjuvant therapy. RESULTS: Between the modified radical hysterectomy and radical hysterectomy groups, the rates for surgical margin involvement (7.4% vs 5.8%, odds ratio [OR] 1.29, 95% confidence interval [CI] 0.87–1.93), lympho-vascular space invasion (39.6% vs 44.0%, OR 0.85, 95% CI 0.68–1.05), regional lymph node metastasis (18.2% vs 19.4%, OR 0.93, 95% CI 0.71–1.21), and parametrial involvement (6.0% vs 6.8%, 0.89, 95% CI 0.58–1.35) were similar. Likewise, postoperative radiotherapy (47.5% vs 45.8%, OR 1.07, 95% CI 0.87–1.32) and chemotherapy (30.0% vs 31.0%, OR 0.95, 95% CI 0.76–1.19) rates were similar between the two groups. At whole-cohort level, 5-year overall survival rate was 3.1 percentage-points lower for the modified radical hysterectomy group compared to the radical hysterectomy group (84.5% vs 87.6%); adjusted-hazard ratio (HR) of all-cause mortality for modified radical hysterectomy compared to radical hysterectomy was 1.34 (95% CI 1.03–1.75) (Fig. 1). In the exploratory assessment, among those aged 50 years or older with tumor size greater than 3 cm, modified radical hysterectomy was associated with a two-fold increased risk of surgical margin involvement (18.2% vs 8.2%, OR 2.50, 95% CI 1.16–5.41) and decreased overall survival (5-year rates, 66.2% vs 76.7%, adjusted-HR 1.63, 95% CI 1.03–2.58) compared to radical hysterectomy (Fig. 2A). In contrast, among those aged younger than 50 years with tumor size of 3 cm or smaller, modified radical hysterectomy and radical hysterectomy had comparable surgical margin involvement (3.4% vs 4.1%, OR 0.84, 95% CI 0.34–2.04) and overall survival (5-year rates, 91.3% vs 93.9%, adjusted-HR 1.34, 95% CI 0.78–2.32) (Fig. 2B). CONCLUSIONS: The results of this cohort study confirmed that radical hysterectomy remains the gold-standard surgical approach for clinical stage IB2 cervical cancer. However, there may be a subgroup of patients who qualify as possible candidates for treatment de-escalation with modified radical hysterectomy (e.g., younger patients with smaller tumor size). These hypothesis-generating findings warrant further investigation with prospective study.Figure 1Figure 2