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Oncology Letters Feb 2021The benefit of adjuvant hysterectomy after definitive concurrent chemoradiotherapy (CCRT) for locally-advanced cervical cancer (LACC) is controversial. The purpose of...
The benefit of adjuvant hysterectomy after definitive concurrent chemoradiotherapy (CCRT) for locally-advanced cervical cancer (LACC) is controversial. The purpose of the present study was to systematically search the literature and perform a meta-analysis to compare overall survival (OS) and disease-free survival (DFS) between patients subjected to CCRT with hysterectomy and those who underwent CCRT alone. The PubMed, Scopus, Embase and Google scholar databases were searched. A meta-analysis to determine hazard ratios (HRs) and odds ratios (ORs) with meta-regression was performed for the following moderators: Disease stage, histology and proportion of radical hysterectomy. Data from 14 studies were included. The results indicated that patients who received CCRT with hysterectomy had significantly better OS (HR, 0.72; 95% CI, 0.56 to 0.91; I=19%; P=0.007) and DFS (HR, 0.72; 95% CI, 0.56 to 0.93; I=27%; P=0.01) than those treated with CCRT alone. However, in a subgroup analysis by study type, the results were significant only for retrospective studies but not for randomized controlled trials (RCTs). However, only 2 RCTs were included with small sample size, heterogeneity and low overall quality. Subgroup analyses based on the use of brachytherapy in the CCRT with hysterectomy group demonstrated no difference in OS and DFS between the two groups. Regarding the absolute numbers of death and recurrence events, no significant difference in mortality (OR, 0.91; 95% CI, 0.62 to 1.33; I=0%; P=0.64) was determined between the two groups, but a significantly reduced incidence of recurrence was observed in the CCRT with hysterectomy group (OR, 0.61; 95% CI, 0.47-0.79; I=29%; P=0.0002). The meta-regression results point to a significant influence of the proportion of stage II patients on OS. Despite the overall analysis indicating improved OS and DFS with the use of adjuvant hysterectomy after CCRT, subgroup analysis based on similar treatment protocols failed to demonstrate any significant benefit of hysterectomy in LACC. However, the results indicated that the recurrence rate may be higher in patients undergoing CCRT without hysterectomy. The limited quality of the studies included and selection bias from retrospective studies restrict the possibility to draw strong conclusions.
PubMed: 33552278
DOI: 10.3892/ol.2020.12421 -
International Journal of Gynecological... Jul 2021To investigate the oncologic outcomes of patients with early-stage cervical carcinoma and tumor size 2 cm who underwent open or minimally invasive radical hysterectomy. (Meta-Analysis)
Meta-Analysis
OBJECTIVE
To investigate the oncologic outcomes of patients with early-stage cervical carcinoma and tumor size 2 cm who underwent open or minimally invasive radical hysterectomy.
METHODS
The Pubmed/Medline, Embase, and Web-of-Science databases were queried from inception to January 2021 (PROSPERO CRD 42020207971). Observational studies reporting progression-free survival and/or overall survival for patients who had open or minimally invasive radical hysterectomy for early-stage cervical carcinoma and tumor size 2 cm were selected. Level of statistical heterogeneity was evaluated with the I statistic. A random-effects model was used to compare progression and overall survival between the two groups and HR with 95% confidence intervals were calculated with the Der Simonian and Laird approach. Risk of bias and quality of included studies was assessed with the Newcastle-Ottawa scale.
RESULTS
A total of 10 studies that met the inclusion criteria were included encompassing 4935 patients. Of these, 2394 (48.5%) patients had minimally invasive and 2541 (51.5%) patients had open radical hysterectomy; respectively. Patients who underwent minimally invasive hysterectomy had worse progression-free survival than those who had open surgery (HR 1.68, 95% CI 1.20, 2.36, I 26%). Based on five studies, patients who had minimally invasive (n=1808) hysterectomy had a trend towards worse overall survival than those who had open surgery (n=1853) (HR 1.64, 95% CI 1.00 to 2.68, I 15%).
CONCLUSION
Based on a systematic review of the literature and meta-analysis of studies that control for confounders, for patients with cervical cancer and tumor size 2 cm, minimally invasive radical hysterectomy was associated with worse progression-free survival than laparotomy.
Topics: Female; Humans; Hysterectomy; Minimally Invasive Surgical Procedures; Neoplasm Staging; Progression-Free Survival; Treatment Outcome; Uterine Cervical Neoplasms
PubMed: 34016701
DOI: 10.1136/ijgc-2021-002505 -
European Journal of Surgical Oncology :... Apr 2024Minimally invasive surgery on treatment of early-stage cervical cancer is debatable. Traditional approaches of colpotomy are considered responsible for an inferior... (Meta-Analysis)
Meta-Analysis Review
Minimally invasive surgery on treatment of early-stage cervical cancer is debatable. Traditional approaches of colpotomy are considered responsible for an inferior oncological outcome. Evidence on whether protective colpotomy could optimize minimally invasive technique and improve prognoses of women with early-stage cervical cancer remains limited. We produced a systematic review and meta-analysis to compare oncological outcomes of the patients treated by minimally invasive radical hysterectomy with protective colpotomy to those treated by open surgery according to existing literature. We explored PubMed, Embase, the Cochrane Library, and ClinicalTrials.gov from inception to December 2022. Inclusion criteria were: (1) randomized controlled trials or observational studies published in English, (2) studies comparing minimally invasive radical hysterectomy with protective colpotomy to abdominal radical hysterectomy in early-stage cervical cancer, and (3) studies comparing survival outcomes. Two reviewers performed the screening, data extraction, and quality assessment independently. A total of 8 retrospective cohort studies with 2020 women were included in the study, 821 of whom were in the minimally invasive surgery group, and 1199 of whom were in the open surgery group. The recurrence-free survival and overall survival in the minimally invasive surgery group were both similar to that in the open surgery group (pooled hazard ratio, 0.88 and 0.78, respectively; 95% confidence interval, 0.56-1.38 and 0.42-1.44, respectively). Minimally invasive radical hysterectomy with protective colpotomy on treatment of early-stage cervical cancer had similar recurrence-free survival and overall survival compared to abdominal radical hysterectomy. Protective colpotomy could be a guaranteed approach to modifying minimally invasive technique.
Topics: Humans; Female; Pregnancy; Colpotomy; Uterine Cervical Neoplasms; Retrospective Studies; Hysterectomy; Proportional Hazards Models; Laparoscopy; Minimally Invasive Surgical Procedures; Neoplasm Staging
PubMed: 38457858
DOI: 10.1016/j.ejso.2024.108240 -
European Journal of Surgical Oncology :... Jun 2017This study aimed to evaluate the surgical safety and clinical effectiveness of RH versus LH and laparotomy for cervical cancer. (Meta-Analysis)
Meta-Analysis Review
Surgical and clinical safety and effectiveness of robot-assisted laparoscopic hysterectomy compared to conventional laparoscopy and laparotomy for cervical cancer: A systematic review and meta-analysis.
AIM
This study aimed to evaluate the surgical safety and clinical effectiveness of RH versus LH and laparotomy for cervical cancer.
METHODS
We searched Ovid-Medline, Ovid-EMBASE, and the Cochrane library through May 2015, and checked references of relevant studies. We selected the comparative studies reported the surgical safety (overall; peri-operative; and post-operative complications; death within 30 days; and specific morbidities), and clinical effectiveness (survival; recurrence; length of stay [LOS]; estimated blood loss [EBL]; operative time [OT]) and patient-reported outcomes.
RESULTS
Fifteen studies comparing RH with OH and 11 comparing RH with LH were identified. No significant differences were found in survival outcomes. The LOS was shorter and transfusion rate was lower with RH compared to OH or LH. EBL was significantly reduced with RH compared to OH. Compared to OH, overall complications, urinary infection, wound infection, and fever were significantly less frequent with RH. The overall, peri-operative, and post-operative complications were similar in other comparisons. Several patient-reported outcomes were improved with RH, though each outcome was reported in only one study.
CONCLUSIONS
RH appears to have a positive effect in reducing overall complications, individual adverse events including wound infection, fever, urinary tract infection, transfusion, LOS, EBL, and time to diet than OH for cervical cancer patients. Compared to LH, the current evidence is not enough to clearly determine its clinical safety and effectiveness. Further rigorous prospective studies with long-term follow-up that overcome the many limitations of the current evidence are needed.
Topics: Adenocarcinoma; Blood Loss, Surgical; Carcinoma, Squamous Cell; Female; Humans; Hysterectomy; Laparoscopy; Laparotomy; Length of Stay; Neoplasm Recurrence, Local; Operative Time; Postoperative Complications; Robotic Surgical Procedures; Survival Rate; Treatment Outcome; Uterine Cervical Neoplasms
PubMed: 27546015
DOI: 10.1016/j.ejso.2016.07.017 -
Oncotarget Jul 2017The objectives of this study were to evaluate the rates of recurrence, survival and pregnancy, and characterize pregnancy outcomes of early-stage cervical cancer(eCC)... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
The objectives of this study were to evaluate the rates of recurrence, survival and pregnancy, and characterize pregnancy outcomes of early-stage cervical cancer(eCC) treated with fertility-sparing methods such as cervical conization (CON) and radical trachelectomy(RT) with or without pelvic lymphadenectomy.
STUDY DESIGN
This was a meta-analysis of observational studies analyzed by a random-effects model and a meta-regression to assess heterogeneity.
RESULTS
Sixty observational studies encompassing 2,854 patients were included; 17 of which evaluated CON and 43 RT. Three hundred and seventy-five patients were included in the CON group: 176(46.9%) stage IA1 and 167(44.5%) stage IB1. In the RT group, 2479 cases were included: 143(6.0%) stage IA1, 299(12.1%) stage IA2, 1987(79.9%) stage IB1. CON was performed in 347(92.5%) cases, resulting in a recurrence rate of 0.4%(95%CI: 0.0%-1.4%), a death rate of 0%(0%-0%), a pregnancy rate of 36.1%(26.4%-46.2%), a spontaneous abortion rate of 14.8%(9.3%-21.2%) and a preterm delivery rate of 6.8%(1.5%-15.5%). For the RT group, 2273(91.7%) underwent successful surgeries with a recurrence rate of 2.3%(1.3%-3.4%),a death rate of 0.7%(0.3%-1.1%), a pregnancy rate of 20.5%(16.8%-24.5%), a spontaneous abortion rate of 24.0%(18.8%-29.6%) and a preterm delivery rate of 26.6%(19.6%-34.2%). From a subgroup analysis, the recurrence rates for stage IA tumors treated with CON and RT were 0.4%(0.0%-1.9%) and 0.7%(0.0%-2.3%), respectively; and for stage IB were 0.6%(0.0%-2.7%) and 2.3%(0.9%-4.1%).
CONCLUSION
Fertility-sparing treatment including CON or RT for eCC is feasible and carefully selected women can preserve fertility and achieve pregnancy resulting in live births. CON seems to result in better pregnancy outcomes than RT with similar rates of recurrence and mortality.
Topics: Combined Modality Therapy; Conization; Female; Fertility; Humans; Neoplasm Staging; Organ Sparing Treatments; Pregnancy; Pregnancy Outcome; Prognosis; Radiotherapy; Trachelectomy; Treatment Outcome; Uterine Cervical Neoplasms
PubMed: 28418849
DOI: 10.18632/oncotarget.16233 -
The Cochrane Database of Systematic... Oct 2018Cervical cancer is the fourth most common cancer in women, with 528,000 estimated new cases globally in 2012. A large majority (around 85%) of the disease burden occurs... (Review)
Review
BACKGROUND
Cervical cancer is the fourth most common cancer in women, with 528,000 estimated new cases globally in 2012. A large majority (around 85%) of the disease burden occurs in low- and middle-income countries (LMICs), where it accounts for almost 12% of all female cancers. Treatment of stage IB2 cervical cancers, which sit between early and advanced disease, is controversial. Some centres prefer to treat these cancers by radical hysterectomy, with chemoradiotherapy reserved for those at high risk of recurrence. In the UK, we treat stage IB2 cervical cancers mainly with chemoradiotherapy, based on the rationale that a high percentage will have risk factors necessitating chemoradiotherapy postsurgery. There has been no systematic review to determine the best possible evidence in managing these cancers.
OBJECTIVES
To determine if primary surgery for stage IB2 cervical cancer (type II or type III radical hysterectomy with lymphadenectomy) improves survival compared to primary chemoradiotherapy.To determine if primary surgery combined with postoperative adjuvant chemoradiotherapy, for stage IB2 cervical cancer increases patient morbidity in the management of stage IB2 cervical cancer compared to primary chemoradiotherapy.
SEARCH METHODS
We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 3), MEDLINE via Ovid (1946 to April week 2, 2018) and Embase via Ovid (1980 to 2018 week 16). We also searched registers of clinical trials, abstracts of scientific meetings and reference lists of included studies up to April 2018.
SELECTION CRITERIA
We searched for randomised controlled trials (RCTs), quasi-RCTs or non-randomised studies (NRSs) comparing surgery to chemoradiotherapy in stage IB2 cervical cancers.
DATA COLLECTION AND ANALYSIS
Two review authors independently assessed whether potentially relevant studies met the inclusion criteria, abstracted data, assessed risk of bias and analysed data using standard methodological procedures expected by Cochrane.
MAIN RESULTS
We identified 4968 records from the literature searches, but we did not identify any RCTs that compared primary surgery with chemoradiotherapy in stage IB2 cervical cancer.We found one NRS comparing surgery to chemoradiotherapy in IB2 and IIA2 cervical cancers which met the inclusion criteria. However, we were unable to obtain data for stage IB2 cancers only and considered the findings very uncertain due to a high risk of selection bias.
AUTHORS' CONCLUSIONS
There is an absence of high-certainty evidence on the relative benefits and harms of primary radical hysterectomy versus primary chemoradiotherapy for stage IB2 cervical cancer. More research is needed on the different treatment options in stage IB2 cervical cancer, particularly with respect to survival, adverse effects, and quality of life to facilitate informed decision-making and individualised care.
Topics: Chemoradiotherapy; Female; Humans; Hysterectomy; Neoplasm Staging; Non-Randomized Controlled Trials as Topic; Uterine Cervical Neoplasms
PubMed: 30311942
DOI: 10.1002/14651858.CD011478.pub2 -
European Radiology Feb 2018To review the diagnostic performance of MRI for detection of parametrial invasion (PMI) in cervical cancer patients. (Meta-Analysis)
Meta-Analysis Review
Magnetic resonance imaging for detection of parametrial invasion in cervical cancer: An updated systematic review and meta-analysis of the literature between 2012 and 2016.
OBJECTIVE
To review the diagnostic performance of MRI for detection of parametrial invasion (PMI) in cervical cancer patients.
METHODS
MEDLINE and EMBASE databases were searched for studies providing diagnostic performance of MRI for detecting PMI in patients with cervical cancer. Studies published between 2012 and 2016 using surgico-pathological results as reference standard were included. Study quality was evaluated using QUADAS-2. Sensitivity and specificity of all studies were calculated. Results were pooled and plotted in a hierarchical summary receiver operating characteristic plot. Meta-regression and subgroup analyses were performed.
RESULTS
Fourteen studies (1,028 patients) were included. Study quality was generally moderate. Pooled sensitivity was 0.76 (95% CI 0.67-0.84) and specificity was 0.94 (95% CI 0.91-0.95). The possibility of heterogeneity was considered low: Cochran's Q-test (p = 0.471), Tau (0.240), Higgins I (0%). With meta-regression analysis, magnet strength, use of DWI, and antispasmodic drugs were significant factors affecting heterogeneity (p < 0.01). Subgroup analysis for studies solely using radical hysterectomy as reference standard yielded pooled sensitivity and specificity of 0.73 (95% CI 0.60-0.83) and 0.93 (95% CI 0.90-0.95), respectively.
CONCLUSIONS
MRI shows good performance for detection of PMI in cervical cancer. Using 3-T scanners and DWI may improve diagnostic performance.
KEY POINTS
• MRI shows good performance for detection of parametrial invasion in cervical cancer. • Subgroup of studies using only radical hysterectomy showed consistent results. • Using 3-Tesla scanners and diffusion-weighted imaging may improve diagnostic performance.
Topics: Female; Humans; Magnetic Resonance Imaging; Neoplasm Invasiveness; Peritoneal Neoplasms; Peritoneum; Uterine Cervical Neoplasms
PubMed: 28726120
DOI: 10.1007/s00330-017-4958-x -
European Journal of Surgical Oncology :... Sep 2016This study aimed to evaluate the surgical safety and clinical effectiveness of RH compared to OH and LH for endometrial cancer. (Comparative Study)
Comparative Study Meta-Analysis Review
Comparative safety and effectiveness of robot-assisted laparoscopic hysterectomy versus conventional laparoscopy and laparotomy for endometrial cancer: A systematic review and meta-analysis.
AIM
This study aimed to evaluate the surgical safety and clinical effectiveness of RH compared to OH and LH for endometrial cancer.
METHODS
We searched Ovid-Medline, Ovid-EMBASE, and the Cochrane library for studies published through May 2015. The outcomes of interest included safety (overall; peri-operative and post-operative complications; death within 30-days; and specific morbidities), effectiveness (survival, recurrence, length of stay [LOS], estimated blood loss [EBL], and operative time [OT]), and patient-reported outcomes (pain score, pain medication use, length of pain medication use, and time to return to work). Two independent reviewers extracted data and assessed the risk of bias.
RESULTS
Twenty-four studies comparing RH to OH and 24 comparing RH to LH were identified. No significant differences were found in survival outcomes. The LOS was shorter, there was less EBL, and the rates of complications, readmission, and transfusion were lower with RH compared to OH. However, RH showed a longer OT and a higher incidence of vaginal cuff dehiscence compared to those for OH. Compared to LH, the LOS was shorter, there was less EBL, and the rates of conversion to laparotomy, intra-operative complications, urinary tract injuries, and cystotomy were lower in RH. Several patient-reported outcomes showed a significant benefit of RH, but each outcome was reported in only one study.
CONCLUSIONS
RH may be a generally safer and better option than OH and LH for patients with endometrial cancer. Further prospective studies with long-term follow-up are required.
Topics: Adenocarcinoma, Clear Cell; Analgesics; Blood Loss, Surgical; Carcinoma, Endometrioid; Conversion to Open Surgery; Disease-Free Survival; Endometrial Neoplasms; Female; Humans; Hysterectomy; Laparoscopy; Laparotomy; Length of Stay; Neoplasms, Cystic, Mucinous, and Serous; Pain, Postoperative; Patient Readmission; Patient Reported Outcome Measures; Postoperative Complications; Robotic Surgical Procedures; Time Factors; Treatment Outcome
PubMed: 27439723
DOI: 10.1016/j.ejso.2016.06.400 -
Surgical Endoscopy Apr 2020A meta-analysis was performed to assess risks of intraoperative and postoperative urologic complications in laparoscopic radical hysterectomy (LRH) and abdominal radical... (Comparative Study)
Comparative Study Meta-Analysis
OBJECTIVE
A meta-analysis was performed to assess risks of intraoperative and postoperative urologic complications in laparoscopic radical hysterectomy (LRH) and abdominal radical hysterectomy (ARH).
METHODS
We searched Pubmed, EMBASE, and Cochrane library for studies published up to December, 2018. Manual searches of related articles and relevant bibliographies of published studies were also performed. Two researchers independently performed data extraction. Inclusion criteria of studies were: (1) had information of perioperative complications, and (2) had at least ten patients per group.
RESULTS
A total of 38 eligible clinical trials were collected. Intraoperative and postoperative urologic complications were reported by 34 studies and 35 studies, respectively. When all studies were pooled, odd ratios (OR) of LRH for the risk of intraoperative urologic complications compared to abdominal radical hysterectomy (ARH) was 1.40 [95% confidence interval (CI) 1.05-1.87]. The OR of LRH for postoperative complication risk compared to ARH was 1.35 [95% CI 1.01-1.80]. However, significant adverse effects of intraoperative urologic complications in LRH were not observed among articles published after 2012 (OR 1.12, 95% CI 0.77-1.62) in cumulative meta-analysis or subgroup analysis. The incidence of bladder injury was statistically higher than that of ureter injury (p = 0.001). In subgroup analysis, obesity and laparoscopic type (laparoscopic assisted vaginal radical hysterectomy) were associated with intraoperative urologic complications.
CONCLUSION
LRH is associated with significantly higher risk of intraoperative and postoperative urologic complications than abdominal radical hysterectomy.
Topics: Abdomen; Adult; Female; Humans; Hysterectomy; Intraoperative Complications; Laparoscopy; Middle Aged; Postoperative Complications; Treatment Outcome; Urinary Bladder; Urologic Diseases
PubMed: 31953731
DOI: 10.1007/s00464-020-07366-1 -
Applied Health Economics and Health... Oct 2015Robot assisted laparoscopic (RAL) surgery developed to overcome the limitations of laparoscopy to assist in surgical procedures, has high capital and operating costs.... (Comparative Study)
Comparative Study Review
BACKGROUND
Robot assisted laparoscopic (RAL) surgery developed to overcome the limitations of laparoscopy to assist in surgical procedures, has high capital and operating costs. Systematically assembled evidence demonstrating its clinical and cost effectiveness would be helpful for its adoption by decision makers.
OBJECTIVE
To summarise the evidence on the cost-effectiveness of robot-assisted laparoscopic (RAL) surgery compared with relevant alternatives. Methods and results of identified studies were assessed to identify the deficiencies in evidence and areas for further research.
METHODS
Studies reporting both costs and outcomes for comparisons of RAL with laparoscopy and/or open surgery were systematically identified. Searches were conducted in February 2015 on MEDLINE, EMBASE and NHS EED. Quality of the included studies was assessed against a standard checklist for economic analyses. Length of hospital stay and operating time (determinants of cost), cost of intervention, quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratio (ICER) were extracted. To aid comparison, costs were converted into a common currency and price year (2014 US dollars).
RESULTS
Forty-seven eligible studies were identified (full economic evaluation n = 6 and cost analysis n = 41). Economic models were used in 11 (23%) studies. Only three studies used a model considered representative of the disease and clinical pathway with a time-horizon allowing capture of relevant differences in outcomes across strategies. The cost of RAL varied substantially between uses, ranging from US$7011 for hysterectomy to over US$30,000 for radical cystectomy. The majority of estimates were between US$15,000 and US$25,000 per person. In part this difference is explained by the difference between studies in which costs were included. It was also identified to have higher costs than the alternatives it was compared against. Incremental cost per QALY for RAL radical prostatectomy was US$28,801-$31,763 over a 10-year period assuming 200 cases per annum.
CONCLUSION
The clinical evidence available for RAL overall and used within included studies is limited. RAL surgery costs were consistently higher than open and laparoscopic surgery. Therefore, in adopting the robotic technology decision makers need to take into account the cost effectiveness within their own systems. Economic models generated and published for radical prostatectomy and hysterectomy may be adapted to other health systems if the care pathway is similar to provide locally relevant data.
Topics: Acetazolamide; Costs and Cost Analysis; Humans; Laparoscopy; Robotic Surgical Procedures
PubMed: 26239361
DOI: 10.1007/s40258-015-0185-2