BACKGROUND

Cervical cancer is a common cancer in women younger than 65 years and the most common cause of death from gynecological cancers worldwide. The introduction of screening programs has internationally contributed to early identification of cervical cancer in Europe and the United States. Tumors are being identified and staged at International Federation of Gynecology and Obstetrics (FIGO) IA1 and treated by removal of affected tissue using local cervical treatments or total hysterectomy. Tumors identified at FIGO stages IA2 to IB1 are commonly treated with radical hysterectomy with pelvic lymphadenectomy or chemoradiotherapy. In contrast, later stage cervical cancer, locally advanced FIGO stages IB2 to III, where there is significant likelihood of lymph node metastases, the consensus is to treat nonsurgically, using combination chemoradiotherapy.

This has implications in developing countries, such that (1) cervical cancer is often not discovered until it has progressed and has locally advanced because of inadequate screening and (2) treatment choices are limited, particularly by lack of access to radiotherapy. In this context, hysterectomy is frequently performed in combination with chemotherapy, although its effectiveness in reducing mortality is uncertain. In addition, chemotherapy, radiotherapy, and surgery are different in terms of risks and burdens associated with treatment in the short, medium, and long terms. For nurses discussing treatment options with patients, it would be valuable to have information about risks and benefits associated with each treatment and combination of these treatments. For these reasons, there is a need to assess the effectiveness of hysterectomy as a treatment for locally advanced cervical cancer in combination with other therapies for outcomes including survival, adverse events, and quality of life.

AIM

The aim of this review is to determine whether hysterectomy, in addition to standard treatment with radiation or chemotherapy or both, in women with locally advanced cervical cancer is safe and effective compared with standard treatment alone.1

METHODS

Rigorous and transparent methods were used in the conduct of this review. Multiple electronic databases were searched to identify the studies that met the following inclusion criteria:

* population-adult women (aged 18 years or older) with locally advanced (stage IB2 to III) cervical cancer;

* intervention-hysterectomy in combination with neoadjuvant, concurrent, or adjuvant therapy;

* comparator-nonsurgical interventions;

* outcome-the primary outcome was overall survival; secondary outcomes were progression or disease-free survival, quality of life, and adverse events; and

* study type-randomized controlled trials.

The data were extracted, and the quality was assessed using the Cochrane Risk of Bias tool. Appropriate data were pooled statistically using meta-analysis.

RESULTS

Seven studies (1217 participants) conducted in countries including Italy, Mexico, China, France, the United States, and Japan met the inclusion criteria for this review. A meta-analysis (571 participants) using the data from 3 studies of moderate quality found that hysterectomy (simple or radical) with neoadjuvant chemotherapy reduced the risk of death compared with radiotherapy (hazard ratio = 0.71; 95% confidence interval, 0.55-0.93). There was no evidence of a difference in the proportion of women with disease progression or recurrence.

Three further comparisons were identified where meta-analysis was not appropriate and no statistically significant evidence of effect was found in any individual analysis:

* hysterectomy with radiotherapy versus radiotherapy alone,

* hysterectomy with chemoradiotherapy versus chemoradiotherapy alone, and

* hysterectomy with chemoradiotherapy versus internal radiotherapy with chemoradiotherapy.

None of the included studies found evidence of a difference in the rate of adverse events. None of the included studies investigated the effect of interventions on quality of life.

CONCLUSION

There is insufficient evidence to reach firm conclusions on the additive effect of hysterectomy to various combinations of chemotherapy and radiotherapy on survival, adverse events, or quality of life. Where there is apparent evidence of a reduced risk of death associated with hysterectomy and neoadjuvant chemotherapy versus radiotherapy, it is unclear whether this effect results from intervention with hysterectomy, chemotherapy, the combination of both, or because an unknown number of the women included in the intervention arms also received radiotherapy.

IMPLICATION FOR PRACTICE

In areas where the treatment for locally advanced cervical cancer is based on the consensus view that chemoradiotherapy is the best treatment, as in Europe and the United States, the inconclusive results of this review will do little to change practice. In situations where treatment choices are limited such as in the developing countries, the decision is less clear, and the decision to offer adjuvant hysterectomy should be individualized or, when possible, offered as part of a clinical trial.

Reference