Survival outcomes after inadvertent surgery in low-risk early-stage cervical cancer

Recent randomized de-escalation trials have shown that planned simple hysterectomy with lymph node assessment provides outcomes comparable to radical hysterectomy in selected patients with early-stage cervical cancer (tumors ≤2 cm, limited stromal invasion). However, whether these favorable outcomes extend to patients who undergo inadvertent simple hysterectomy-performed without oncologic surgical planning due to diagnostic or treatment pathway failures-remains unknown.

To evaluate whether patients with early-stage cervical cancer (tumors ≤2 cm) who underwent inadvertent surgery have similar overall survival compared with those treated with planned oncologic surgery. We also assessed whether salvage adjuvant therapy in this setting shows a survival benefit over observation.

This cohort study used data from the U.S. National Cancer Database (2010-2020) to identify patients with early-stage cervical cancer (≤2 cm) who underwent either planned oncologic surgery or inadvertent surgery (simple hysterectomy without nodal staging), including women with an inadvertent diagnosis or those inadequately treated for previously known in situ or microinvasive disease. Missing data were handled through multiple imputations. Inverse probability of treatment weighting balanced covariates across groups. Overall survival was analyzed using inverse probability of treatment weighting-adjusted Kaplan-Meier curves and Cox proportional hazards models. Subgroup analyses assessed effect modification. Inverse probability of treatment weighting was reapplied within the inadvertent surgery cohort to compare overall survival by salvage adjuvant therapy receipt.

Among 5608 eligible patients, 688 (12.3%) underwent inadvertent surgery, including 258 with an inadvertent diagnosis and 430 with a known diagnosis but inadequate surgical treatment, while 4920 (87.7%) received planned oncologic surgery. After inverse probability of treatment weighting adjustment, patients in the inadvertent surgery cohort had significantly lower 5-year overall survival (91.5% vs 96.2%; HR, 1.89; 95% CI, 1.42 to 2.52; P<.001). Adjuvant (chemo) radiotherapy was more common after inadvertent surgery (29.1% vs 11.3%, P=0.035). Among these patients, salvage adjuvant (chemo) radiotherapy did not significantly improve overall survival when compared with observation (HR, 1.33; 95% CI, 0.59-3.00; P=.5).

In patients with low-risk, early-stage cervical cancer, inadvertent surgery was associated with a survival disadvantage. Salvage adjuvant (chemo) radiotherapy failed to overcome this disadvantage, underscoring the importance of appropriate oncologic surgical planning and referral.