Balancing fertility potential and oncologic and obstetric risks: a vignette study on decision-making in...

Fertility-sparing surgery offers the opportunity to preserve fertility but comes with higher oncologic and obstetric risks. This study aims to identify key factors influencing decision-making of women with early-stage cervical cancer.

We conducted a vignette-based study involving former patients and gynecologic oncologists in the Netherlands. Eligible patients were aged 25-42 years at the time of surgery and underwent radical trachelectomy or radical hysterectomy for early-stage cervical cancer between 2014 and 2024. All Dutch gynecologic oncologists were invited. Four vignette attributes were selected based on literature and patients' and experts' opinions. Different risk percentages for these attributes were varied in 16 scenarios. Participants rated their preference on a 5-point Likert scale, where 1 indicated a strong preference for hysterectomy and 5 a strong preference for fertility-sparing surgery. Preferences were analyzed using linear mixed-effects models.

A total of 58 out of 205 patients (28.3%) and 33 of 55 gynecologic oncologists (60%) participated. The mean preference for fertility-sparing surgery across all scenarios was 3.48 (95% confidence interval (CI) 3.22 to 3.74) for patients and 3.16 (95% CI 2.95 to 3.36) for gynecologic oncologists. All four attributes played significant roles in decision-making. For patients, the likelihood of achieving pregnancy was the most influential factor, increasing the preference score by 1.07 (scale 1 to 5) for an 85% chance of conception. For gynecologic oncologists, an increased risk of cancer-related death was the most decisive factor, resulting in a 1.84 decrease (scale 1 to 5) for a 10% additional risk of death.

Patients and gynecologic oncologists showed a modest preference for fertility-sparing surgery over hysterectomy. Patients appeared to place relatively greater weight on likelihood of pregnancy and were less deterred than clinicians by hypothetical increases in cancer-related mortality risk. This underscores the importance of thoroughly involving patients in the decision-making process.