Hysterectomy with medical management for cervical cancer that has spread to nearby tissues only
Cancer of the neck of the womb (cervical cancer) is the commonest cancer among women up to 65 years of age. A high proportion of women in developing countries are diagnosed with locally advanced disease (spread to nearby tissues, but no obvious distant spread). They are usually treated with radiotherapy, with or without chemotherapy (medical treatment). Hysterectomy (surgery to remove the womb and the cervix) with medical treatment is also used, especially in developing countries where access to radiotherapy is limited.
The aim of the review
Is hysterectomy with medical treatment more beneficial compared to medical treatment alone in locally advanced cervical cancer?
How was the review conducted?
A literature search from 1966 to February 2014 identified seven trials at moderate to high risk of bias. These included 1217 women and compared: hysterectomy with radiotherapy versus radiotherapy alone; hysterectomy with chemoradiotherapy versus chemoradiotherapy alone; hysterectomy with chemoradiotherapy versus internal radiotherapy (brachytherapy) with chemoradiotherapy; and hysterectomywith upfront (neoadjuvant) chemotherapy versus radiotherapy alone.
What are the main findings?
Two studies, including 374 women, compared preoperative radiotherapy andhysterectomy versus radiotherapy alone, but only one trial reported overall survival, with no difference between the groups. These studies found no difference in therisk of disease progression (or death) or five-year tumour-free survival.
One study, including 61 women, reported no difference in overall and recurrence-free survival between chemotherapy and hysterectomy versus chemoradiotherapy alone.
Another study comparing internal radiotherapy (brachytherapy) versushysterectomy in 211 women who received chemoradiotherapy found no difference in the risk of death or disease progression.
By combining results from three of the independent studies that assessed 571 women, we found that fewer women who received neoadjuvant chemotherapy plushysterectomy died than those who received radiotherapy alone. However, many women in the first group also had radiotherapy. There was no difference in the number of women who were disease-free after treatment.
Adverse events were incompletely reported. Results of single trials showed no differences in severe adverse events between the two groups in any comparison. Limited data suggested that the interventions appeared to be reasonably well tolerated, although more evidence is needed.
Quality of life measures were not reported.
What are the conclusions?
We found insufficient evidence that hysterectomy added to radiation and chemoradiation improved survival, quality of life or adverse events in locally advanced cervical cancer compared with medical treatment alone. Overall, the quality of the evidence was variable and was universally downgraded due to concerns about risk of bias. The quality of the evidence for neoadjuvant chemotherapy and radical hysterectomy versus radiotherapy alone for survival outcomes was moderate, with evidence from other comparisons being of low quality. Further data from carefully planned trials assessing medical management with and without hysterectomy are likely to impact on how confident we are about these findings.