Cancer Res Treat.  2021 Jan;53(1):243-251. 10.4143/crt.2020.063.

Impact of the Learning Curve on the Survival of Abdominal or Minimally Invasive Radical Hysterectomy for Early-Stage Cervical Cancer

• Li LY
• Wen LY
• Park SH
• Nam EJ
• Lee JY
• Kim S
• Kim YT
• Kim SW

• KMID: 2510666
• DOI: http://doi.org/10.4143/crt.2020.063

Abstract

Purpose
The objective of this study was to define the learning curve required to attain satisfactory oncologic outcomes of cervical cancer patients who were undergoing open or minimally invasive surgery for radical hysterectomy, and to analyze the correlation between the learning curve and tumor size.
Materials and Methods
Cervical cancer patients (stage IA-IIA) who underwent open radical hysterectomy (n=280) or minimal invasive radical hysterectomy (n=282) were retrospectively reviewed. The learning curve was evaluated using cumulative sum of 5-year recurrence rates. Survival outcomes were analyzed based on the operation period (“learning period,” P1 vs. “skilled period,” P2), operation mode, and tumor size.
Results
The 5-year disease-free and overall survival rates between open and minimally invasive groups were 91.8% and 89.0% (p=0.098) and 96.1% and 97.2% (p=0.944), respectively. The number of surgeries for learning period was 30 and 60 in open and minimally invasive group, respectively. P2 had better 5-year disease-free survival than P1 after adjusting for risk factors (hazard ratio, 0.392; 95% confidence interval, 0.210 to 0.734; p=0.003). All patients with tumors < 2 cm had similar 5-year disease-free survival regardless of operation mode or learning curve. Minimally invasive group presented lower survival rates than open group when tumors ≥ 2 cm in P2. Preoperative conization improved disease-free survival in patients with tumors ≥ 2 cm, especially in minimally invasive group.
Conclusion
Minimally invasive radical hysterectomy required more cases than open group to achieve acceptable 5-year disease-free survival. When tumors ≥ 2 cm, the surgeon’s proficiency affected survival outcomes in both groups.

Keyword

Uterine cervical neoplasms; Minimally invasive surgical procedures; Learning curve

Figure

• 

  Fig. 1 Kaplan-Meier estimates of overall survival (A, D) and disease-free survival (B, C, E, F) for cervical cancer patients treated with open radical hysterectomy (ORH) and minimally invasive surgery-radical hysterectomy (MIS-RH). (A) The 5-year overall survival of open and minimally invasive groups were 96.1% (269/280) and 97.2% (274/282), respectively, p=0.944. (B) The 5-year disease-free survival of open and minimally invasive groups were 91.8% (257/280) and 89.0% (251/282), respectively, p=0.098. (C, D) P1 phase presented significantly worse survival rates than P2 phase in the open group (disease-free survival: 85.4% vs. 94.4%, p=0.011; overall survival: 84.1% vs. 97.5%, p=0.001). However, the minimally invasive group did not show statistically significant difference in survival rates of P1 and P2 phase (disease-free survival: 86.0% vs. 92.7%, p=0.233; overall survival: 94.8% vs. 99.1%, p=0.194). Also, there was no significant difference in survival rates between the two groups either in the P1 phase or P2. (E) In the subgroup of patients with tumors < 2 cm, operation period or mode had little effect on disease-free survival. (F) In the subgroup of patient with ≥ 2 cm, P1 phase presented significantly worse disease-free survival than P2 phase in the open group (74.4% [32/43] vs. 91.1% [112/123], p=0.003). The minimally invasive group showed the same tendency but it was not significant (77.4% [65/84] vs. 86.2% [50/58], p=0.193).

• 

  Fig. 2 Learning curve analysis with regard to 5-year recurrence number. Cumulative sum for 5-year recurrence number of every 10 cases was plotted. The 5-year recurrence number decreased after 30 cases in open group, and after 60 cases in the minimally invasive group. LRH, laparoscopic radical hysterectomy; MIS-RH, minimally invasive surgery-radical hysterectomy; ORH, open radical hysterectomy; RRH, robotically assisted radical hysterectomy.

Reference

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