Comparison of Oncologic Outcomes between Radical Hysterectomy and Primary Concurrent Chemoradiotherapy in Women with Bulky IB and IIA Cervical Cancer under Risk Stratification

SIMPLE SUMMARY: Bulky IB and IIA cervical cancer portends a worse prognosis than smaller tumors. Although treatment modalities include surgery or radiation (RT)-based treatment, there is no optimal treatment choice for these patients that is indicated by recurrence risk. The aim of our study was to compare the oncologic outcome between radical hysterectomy (RH) and concurrent chemoradiation (CCRT) under risk stratification according to tumor markers and histology. We defined patients with squamous cell carcinoma (SCC) with elevated carcinoembryonic antigen (CEA) ≥ 10 ng/mL, adenocarcinoma, or adenosquamous carcinoma as the high-risk group. We found that RH provided better locoregional control and relapse-free survival in the high-risk group. Meanwhile, there was a similar oncologic outcome regardless of treatment modality in patients without these risk factors. We suggest that surgery should be considered first for patients with these high-risk features of poor RT response. ABSTRACT: Purpose: To stratify patients according to tumor marker and histology and compare the survival outcome between radical hysterectomy (RH) and primary concurrent chemoradiotherapy (CCRT) in bulky IB and IIA cervical cancer. Methods: A total of 442 patients with cervical cancer were enrolled in the Chang Gung Research Database from January 2002 to December 2017. Patients with squamous cell carcinoma (SCC) and carcinoembryonic antigen (CEA) ≥10 ng/mL, adenocarcinoma (AC), or adenosquamous carcinoma (ASC) were stratified into the high-risk (HR) group. The others were classified into the low-risk (LR) group. We compared oncology outcomes between RH and CCRT in each group. Results: In the LR group, 5-year overall survival (OS) and recurrence-free survival (RFS) were 85.9% vs. 85.4% (p = 0.315) and 83.6% vs. 82.5% (p = 0.558) in women treated with RH (n = 99) vs. CCRT (n = 179), respectively. In the HR group, the 5-year OS and RFS were 83.2% vs. 73.3% (p = 0.164) and 75.2% vs. 59.6% (p < 0.036) in patients treated with RH (n = 128) vs. CCRT (n = 36), respectively. Regarding recurrence, locoregional recurrence (LRR) (8.1% vs. 8.6%, p = 0.812) and distant metastases (DM) (17.8% vs. 21%, p = 0.609) were similar between RH and CCRT in the LR group. However, lower LRR (11.6% vs. 26.3%, p = 0.023) but equivalent DM (17.8% vs. 21%, p = 0.609) were found for women undergoing RH compared with CCRT in the HR group. Conclusions: There were similar survival and recurrence rates between both treatment modalities in low-risk patients. Meanwhile, primary surgery with or without adjuvant radiation provides better RFS and local control in women with high-risk features. Further prospective studies are needed to confirm these findings.