|LETTER TO EDITOR
|Year : 2022 | Volume
| Issue : 1 | Page : 145-147
Problems associated with inadequate surgery in patients with cervical cancer: Can they be avoided?
Mrinalini Verma1, Kirti Srivastava1, Sanjay Singhal2, M L B Bhatt1
1 Department of Radiotherapy, KGMU, Lucknow, Uttar Pradesh, India
2 Department of Pulmonary Medicine, AIIMS, Rajkot, Gujarat, India
|Date of Submission||26-Jan-2022|
|Date of Decision||18-Feb-2022|
|Date of Acceptance||19-Feb-2022|
|Date of Web Publication||31-Mar-2022|
Assistant Professor, Department of Radiotherapy, KGMU, Lucknow - 226 003, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Verma M, Srivastava K, Singhal S, Bhatt M L. Problems associated with inadequate surgery in patients with cervical cancer: Can they be avoided?. Cancer Res Stat Treat 2022;5:145-7
|How to cite this URL:|
Verma M, Srivastava K, Singhal S, Bhatt M L. Problems associated with inadequate surgery in patients with cervical cancer: Can they be avoided?. Cancer Res Stat Treat [serial online] 2022 [cited 2022 May 28];5:145-7. Available from: https://www.crstonline.com/text.asp?2022/5/1/145/341280
Cervical cancer is the most prevalent cancer among women worldwide, and its incidence is rising steadily in developing countries., It is a major cause of mortality among women in India. India contributes to nearly one-third of the deaths due to cervical cancer even though early cervical cancers are curable. Periodic screening and regular follow-up can help in the early diagnosis of cervical cancer. The World Health Organization's (WHO) 90-70-90 strategy is a major initiative aimed at the elimination of cervical cancer by 2030. According to this strategy, 90% of adolescent girls should be given prophylactic human papillomavirus (HPV) vaccination, 70% of women should undergo cervical HPV testing at least twice during their lifetime, and 90% of women with cervical cancer should get evidence-based adequate treatment for the disease. Despite the documented benefits, screening for cervical cancer in developing countries, including India, remains an uphill task. Lack of periodic cancer screening, poor access to healthcare facilities, low socioeconomic status, and lack of awareness are some of the reasons why the majority of patients with carcinoma cervix present with locally advanced disease. We noted similar trends at our center, King George's Medical University, Lucknow. In 2019, we registered 5000 patients for radiation, either radical or adjuvant, with or without chemotherapy in our outpatient department. Of these, nearly 10% (580) had carcinoma of the uterine cervix, mostly diagnosed at the locally advanced stage.
Both definitive radiation therapy and radical hysterectomy with bilateral lymph node dissection are acceptable and appropriate treatment choices for early-stage cervical cancer. The two treatment modalities are comparable, resulting in a cure rate of 85%–90%. The choice of treatment modality depends mainly on the patient's health status and the availability of expertise at a given center.
Despite level I evidence, a sizeable proportion of patients with early-stage cervical cancer are subjected to inadequate surgery in the form of a simple hysterectomy. A German study revealed that approximately 15% of patients undergo inadequate surgery. In our center (one of the largest in North India), approximately 25% (148 out of 580) patients with advanced-stage disease had undergone inadequate surgeries at other community centers and were subsequently referred to us for radiotherapy after 3–6 months without any medical documentation of the previous treatment. A recent study attributed the findings of occult cancers in surgical specimens to inadequate preoperative workup (28.1%) and false-negative reports on pap smears (9%). Finding occult cancer in the surgical specimen used to be common (12.9%) a few decades ago, but in a study by Bai et al., it was only 1.9%.,,, This drastic change was brought about by improved screening methods and the growing awareness among patients and medical professionals about prevention strategies. In our patients as well, no preoperative work-up had been done.
A simple hysterectomy without lymph node dissection is not a curative option in patients with early-stage cervical cancer as the primary tumor is not adequately treated. Moreover, a false sense of cure in these patients leads to delayed reporting and progression of the disease to an advanced stage.
Besides being inadequate, it may also negatively impact the subsequent definitive treatment modality. Invasive cancers detected in surgical specimens after a simple hysterectomy need to be treated further with either radical parametrectomy and partial vaginectomy with pelvic lymph node dissection or adjuvant radiation therapy with or without systemic chemotherapy. Orr et al. recommend radical re-operation as a safe alternative to radiotherapy to avoid the risks associated with it, such as ovarian function loss, distortion of the vagina, sexual dysfunction, bowel or bladder-related morbidity, and carcinogenesis. At some centers, the preferred adjuvant treatment is radical parametrectomy with partial vaginectomy and pelvic lymph node dissection. The results of re-surgery largely depend on the experience and skill of the surgeon. However, currently in most centers, definitive postoperative radiotherapy is usually recommended as radical re-surgery is technically difficult due to the lack of supporting tissue. Therefore, for patients who have undergone inadequate surgeries, as per evidence, we attempt definitive treatment with concurrent chemoradiotherapy for disease cure. Delivering adequate doses of radiation to eliminate the disease has always been challenging because the removal of the uterus makes it difficult to deliver brachytherapy (intracavitary), resulting in inadequate irradiation of the lateral part of the tumor (parametrium), thus increasing the chances of residual disease and making treatment plans complicated and cumbersome.
The survival rate with residual disease even after adjuvant radiotherapy is 23%–40%.,, Many factors, including time-lag between surgery and radiotherapy, postoperative fibrosis, and uterus removal, preclude the delivery of an optimal radiation dose, especially during brachytherapy, which may be the reason for poor survival.
Besides the negative impact on treatment delivery, there is a negative impact on the patients' quality of life. Removal of the uterus results in the displacement of the bowel loops in the pelvic cavity, which move into the irradiation field, resulting in higher chances of late sequelae such as perforations, fistulae, and adhesions leading to obstruction, in addition to acute toxicity. Serious late complications after postoperative radiotherapy in occult invasive cervical cancer after incomplete surgery occurred in 27% of patients, as reported in the study by Bai et al.; complications included frozen pelvis, radiation cystitis, intestinal obstruction, radiation proctitis, and rectovaginal fistula. Besides the treatment- and quality of life-related issues, there is an added burden of financial toxicity for the patients and their caregivers.
As a radiation oncologist, I believe that it is essential to not only prevent inadequate surgery but also to provide prompt evidence-based treatment without significant financial burden. In most cases, inadequate surgeries can be avoided (especially in patients with gross residual disease) by adhering to established cervical cancer detection guidelines and precise preoperative staging workup.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Franco EL, Schlecht NF, Saslow D. The epidemiology of cervical cancer. Cancer J 2003;9:348-59.
Wilson CM, Tobin S, Young RC. The exploding worldwide cancer burden: The impact of cancer on women. Int J Gynecol Cancer 2004;14:1-11.
Shetty R, Mathew RT, Vijayakumar M. Incidence and pattern of distribution of cancer in India: A secondary data analysis from six population-.based cancer registries. Cancer Res Stat Treat 2020;3:678-82. [Full text]
Monica, Mishra R. An epidemiological study of cervical and breast screening in India: District-level analysis. BMC Womens Health 2020;20:225.
Davies-Oliveira JC, Smith MA, Grover S, Canfell K, Crosbie EJ. Eliminating cervical cancer: Progress and challenges for high income countries. Clin Oncol (R Coll Radiol) 2021;33:550-9.
Vora KS, Saiyed S. Cervical cancer screening in India: Need of the hour. Cancer Res Stat Treat 2020;3:796-7. [Full text]
Vidhubala E, Shewade HD, Niraimathi K, Dongre AR, Gomathi R, Ramkumar S, et al
. Loss to follow-up after initial screening for cervical cancer: A qualitative exploration of barriers in Southern India. Cancer Res Stat Treat 2020;3:700-7. [Full text]
Lataifeh I, Jaradat I, Seoud M, Youssef B, Barahmeh S, Geara F. Survival outcome after radiation therapy for patients with early cervical carcinoma undergoing inadequate primary surgery. Int J Gynecol Cancer 2014;24:124-9.
Münstedt K, von Georgi R, Zygmunt M, Misselwitz B, Stillger R, Künzel W. Shortcomings and deficits in surgical treatment of gynecological cancers: A German problem only? Gynecol Oncol 2002;86:337-43.
Bai H, Cao D, Yuan F, Wang H, Chen J, Wang Y, et al
. Occult invasive cervical cancer after simple hysterectomy: A multi-center retrospective study of 89 cases. BMC Cancer 2016;16:507.
Leath CA 3rd
, Straughn JM, Bhoola SM, Partridge EE, Kilgore LC, Alvarez RD. The role of radical parametrectomy in the treatment of occult cervical carcinoma after extrafascial hysterectomy. Gynecol Oncol 2004;92:215-9.
Park JY, Kim DY, Kim JH, Kim YM, Kim YT, Nam JH. Management of occult invasive cervical cancer found after simple hysterectomy. Ann Oncol 2010;21:994-1000.
Suh DH, Chung HH, Kim JW, Park NH, Song YS, Kang SB. An occult invasive cervical cancer found after a simple hysterectomy: A 10-year experience in a single institution. Int J Gynecol Cancer 2011;21:1646-53.
Orr JW Jr, Ball GC, Soong SJ, Hatch KD, Partridge EE, Austin JM. Surgical treatment of women found to have invasive cervix cancer at the time of total hysterectomy. Obstet Gynecol 1986;68:353-6.
Choi DH, Huh SJ, Nam KH. Radiation therapy results for patients undergoing inappropriate surgery in the presence of invasive cervical carcinoma. Gynecol Oncol 1997;65:506-11.
Andras EJ, Fletcher GH, Rutledge F. Radiotherapy of carcinoma of the cervix following simple hysterectomy. Am J Obstet Gynecol 1973;115:647-55.
Hopkins MP, Peters WA 3rd
, Andersen W, Morley GW. Invasive cervical cancer treated initially by standard hysterectomy. Gynecol Oncol 1990;36:7-12.
Roman LD, Morris M, Mitchell MF, Eifel PJ, Burke TW, Atkinson EN. Prognostic factors for patients undergoing simple hysterectomy in the presence of invasive cancer of the cervix. Gynecol Oncol 1993;50:179-84.