Fertility-sparing surgery vs standard surgery for early-stage cervical cancer: difference in 5-year life expectancy by tumor size

Background Cervical cancer incidence in premenopausal women is rising, and fertility-sparing surgery offers an important option in this young population. There is a lack of evidence about what tumor size cutoff should be used to define candidacy for fertility-sparing surgery. Objectives We sought to describe how the association between fertility-sparing surgery (compared with standard surgery) and life expectancy varies by tumor size among patients with cervical cancers measuring ≤ 4 cm in largest diameter. Our secondary objective was to quantify the probability of undergoing adjuvant radiotherapy among patients who underwent fertility-sparing surgery as a function of tumor size. Study design We identified patients in the National Cancer Database aged ≤45 years, diagnosed with stage I cervical cancer with tumors ≤4 cm between 2006 and 2018, who received no preoperative radiation or chemotherapy and underwent either fertility-sparing surgery (cone or trachelectomy, either simple or radical) or standard surgery (simple or radical hysterectomy) as their primary treatment. Propensity-score matching was performed to compare patients who underwent fertility-sparing surgery with those who received standard surgery. A flexible parametric model was employed to quantify the difference in life expectancy within 5 years of diagnosis (restricted mean survival time; RMST) based on tumor size for patients who underwent fertility-sparing versus standard surgery. Additionally, among those who underwent fertility-sparing surgery, a logistic regression model was used to explore the relationship between tumor size and the probability of receiving adjuvant radiation. Results A total of 11,946 patients met the inclusion criteria, of whom 904 (7.6%) underwent fertility-sparing surgery. After propensity-score matching, 897 patients who underwent fertility-sparing surgery were matched 1:1 with those who underwent standard surgery. While 5-year life expectancy was similar among patients who had fertility sparing or standard surgery regardless of tumor sizes, estimates of life-expectancy differences associated with fertility-sparing surgery were more precise among patients with smaller tumors (1-cm tumor: RMST difference, -0.10 months; 95% CI, -0.67 to 0.47) compared with those with larger tumors (4-cm tumor: RMST difference, -0.11 months; 95% CI, -3.79 to 3.57). The probability of receiving adjuvant radiation increased with tumor size, ranging from 5.6% (95% CI, 3.9-7.9%) for a 1-cm tumor to 37% (95% CI, 24.3-51.8%) for a 4-cm tumor. Conclusion Within 5 years of diagnosis, young patients with stage I cancers measuring ≤4 cm had similar survival outcomes following either fertility-sparing or standard surgery. However, because few patients with tumors >2 cm underwent fertility-sparing surgery, a clinically important survival difference could not be excluded in this population. Cervical cancer incidence in premenopausal women is rising, and fertility-sparing surgery offers an important option in this young population. There is a lack of evidence about what tumor size cutoff should be used to define candidacy for fertility-sparing surgery. We sought to describe how the association between fertility-sparing surgery (compared with standard surgery) and life expectancy varies by tumor size among patients with cervical cancers measuring ≤ 4 cm in largest diameter. Our secondary objective was to quantify the probability of undergoing adjuvant radiotherapy among patients who underwent fertility-sparing surgery as a function of tumor size. We identified patients in the National Cancer Database aged ≤45 years, diagnosed with stage I cervical cancer with tumors ≤4 cm between 2006 and 2018, who received no preoperative radiation or chemotherapy and underwent either fertility-sparing surgery (cone or trachelectomy, either simple or radical) or standard surgery (simple or radical hysterectomy) as their primary treatment. Propensity-score matching was performed to compare patients who underwent fertility-sparing surgery with those who received standard surgery. A flexible parametric model was employed to quantify the difference in life expectancy within 5 years of diagnosis (restricted mean survival time; RMST) based on tumor size for patients who underwent fertility-sparing versus standard surgery. Additionally, among those who underwent fertility-sparing surgery, a logistic regression model was used to explore the relationship between tumor size and the probability of receiving adjuvant radiation. A total of 11,946 patients met the inclusion criteria, of whom 904 (7.6%) underwent fertility-sparing surgery. After propensity-score matching, 897 patients who underwent fertility-sparing surgery were matched 1:1 with those who underwent standard surgery. While 5-year life expectancy was similar among patients who had fertility sparing or standard surgery regardless of tumor sizes, estimates of life-expectancy differences associated with fertility-sparing surgery were more precise among patients with smaller tumors (1-cm tumor: RMST difference, -0.10 months; 95% CI, -0.67 to 0.47) compared with those with larger tumors (4-cm tumor: RMST difference, -0.11 months; 95% CI, -3.79 to 3.57). The probability of receiving adjuvant radiation increased with tumor size, ranging from 5.6% (95% CI, 3.9-7.9%) for a 1-cm tumor to 37% (95% CI, 24.3-51.8%) for a 4-cm tumor. Within 5 years of diagnosis, young patients with stage I cancers measuring ≤4 cm had similar survival outcomes following either fertility-sparing or standard surgery. However, because few patients with tumors >2 cm underwent fertility-sparing surgery, a clinically important survival difference could not be excluded in this population.