De-escalating radical surgery for select FIGO Stage I cervical cancer

Four recent prospective trials demonstrated that de-escalation of radical surgery for select patients with apparent low-risk, FIGO Stage I cervical cancer does not compromise cancer-related survival but does improve quality of life and provide the opportunity to preserve fertility. We present a critical review of ConCerv, SHAPE, GOG-278, and LESSER, which have set the stage for de-escalation of surgery for low-risk, early-stage cervical cancer. ConCerv, a prospective phase II study evaluating the feasibility and oncologic outcomes of conization alone or simple hysterectomy in patients with early-stage cervical carcinoma, found a low recurrence rate of 2.4% in patients who underwent a cone biopsy with lymph node assessment and 0% in those who underwent simple hysterectomy with lymph node evaluation. SHAPE, a phase III trial assessing the safety of simple hysterectomy compared to radical hysterectomy in this patient population, showed no difference in pelvic recurrences between both groups. GOG-278, an international cohort study evaluating the efficacy of cone biopsy versus simple hysterectomy with pelvic nodal assessment, found a 3-year recurrence-free survival rate of 94.8% in the cone biopsy group, with no recurrences noted in the simple hysterectomy group. Finally, LESSER, a phase II proof-of-concept trial studying cancer and quality-of-life outcomes in patients who underwent either a simple or modified radical hysterectomy for early-stage cervical cancer, found no difference in the disease-free survival rate or overall survival between both groups. Rates of postoperative complications were also similar in both arms. Based on these trials, we propose the following set of criteria for which de-escalation of surgical intervention would be appropriate for select Stage I disease: tumors ≤2 cm on cone biopsy; magnetic resonance imaging showing <50% of cervical stromal invasion with no evidence of metastasis; and a histology of either squamous cell carcinoma of any grade or either grade 1 or 2 adenocarcinoma, with depth of invasion <10 mm and no lymphovascular invasion.