Radical surgery or radiotherapy for stage Ib-lla cervical cancer

There is wide agreement that surgery and radiotherapy give equivalent cure rates in the treatment of stage Ib-IIa squamous-cell carcinoma of the cervix. Adenocarcinoma is commonly said to be better treated by surgery. Thus the choice of treatment is dictated by the different types of morbidity associated with the treatment. Surgery is generally recommended for younger women because coital function is better preserved and the ovaries can be conserved. Radiotherapy is recommended for older women because they tolerate surgery less well. However, until this week, there had been only one prospective randomised trial comparing radical surgery and radiotherapy in 119 women with clinically detectable stage I cervical cancer.[1] Since then both radiotherapy and surgical techniques have improved.

The paper from Fabio Landoni and colleagues in today's Lancet describes a larger study, in which 343 women with stage Ib-IIa were randomised to surgery or radiotherapy. It confirms that surgery gives superior survival rates in women with adenocarcinoma but there was no difference between surgery and radiotherapy in survival in those with squamous-cell carcinoma. However, 64% of the surgical group received postoperative radiotherapy--a surprisingly high proportion in view of the scant evidence of survival benefit[2-4] and high risk of complications.[3,5] Furthermore, women under 30 years of age were excluded from this trial, so the mean age of the women in this study was over 50 years, a factor that has to be taken into account when considering the complications reported.

In the absence of any difference in survival rates, morbidity becomes an important issue. The authors describe a 28% incidence of major morbidity associated with surgery and 12% with radiotherapy. This complication rate after surgery is substantially higher than is usually reported,[5,6]] and it seems to be due mainly to "chronic neurogenic bladder", a problem that rarely persists beyond 8 weeks in my experience, and to lymphoedema and radiation cystitis, which occurred only in the women who received postoperative radiotherapy. Unfortunately, no mention is made of coital problems, which are usually far more common after radiotherapy.

If major complications are defined as death, urinary fistulae or bowel perforations, hydroureter requiring treatment, severe proctitis or radiation cystitis, or lymphoedema, the 61 women treated with surgery alone had 6 (10%) major complications, the 108 treated with surgery and postoperative radiotherapy had 25 (23%), and the 158 women treated with radiotherapy alone had 28 (18%). Most of the serious, long-term complications occurred in those who received radiotherapy. Unlike the early morbidity after surgery, such complications are usually very difficult or impossible to treat satisfactorily.[5]

Since there is no evidence that two treatments are more effective than one, it would seem sensible to formulate a protocol that will expose women to only one of the options. This protocol may be best achieved by modifying the criteria for postoperative radiotherapy to include only those at very high risk of central, pelvic recurrence, and by using criteria for surgery that select those most likely to benefit from the preservation of sexual function and who are unlikely to qualify for postoperative radiotherapy by these new criteria. One possible exception to these general principles could be women with bulky central disease who might benefit from neoadjuvant chemotherapy followed by radical surgery. The results of the Italian trial of this approach will be of considerable interest. A second group who might be managed differently are those women with bulky lymph-node disease, for whom retroperitoneal surgical debulking followed by radical radiotherapy may offer an improved prognosis.[7]

1 Newton M. Radical hysterectomy or radiotherapy for stage I cervical cancer: a prospective comparison with 5 and 10 year follow up. Am J Obstet Gynecol 1975; 123: 535-42

• 2 Fuller AF, Elliott N, Kosloff C, Lewis JL. Lymph node metastases from carcinoma of the cervix, stages Ib and IIa: implications for prognosis and treatment. Gynaecol Oncol 1982; 13: 165-74.
• 3 Himmelmann A, Holmberg E, Jansson I, Oden A, Skogsberg K. The effect of postoperative external radiotherapy on cervical carcinoma stage Ib and IIa. Gynaecol Oncol 1985; 22: 73-84.
• 4 Remy JC, di Maio T, Fruchter RG, et al. Adjunctive radiotherapy after radical hysterectomy in stage Ib squamous cell carcinoma of the cervix. Gynaecol Oncol 1990; 38: 161-65.
• 5 Kjorstad KE, Martimbeau PW, Iveren T. Stage Ib carcinoma of the cervix, the Norwegian Radium Hospital: results and complications. Gynaecol Oncol 1983; 15: 42-47.
• 6 Bissett D, Lamont DW, Nwabinelli NJ, Brodie MM, Symonds RP. The treatment of stage I carcinoma of the cervix in the West of Scotland 1980-87. Br J Obstet Gynaecol 1994; 101: 615-20.
• 7 Hacker NF, Wain GV, Nicklin JL. Resection of bulky positive lymph nodes in patients with cervical carcinoma. Int J Gynecol Cancer 1995; 5: 250-56.