Two new studies out this week in The New England Journal of Medicine conclude that patients who have non-invasive surgery for cervical cancer are more likely to die than those who opt for conventional open surgery. Dr. Alex Melamed worked on one of the studies. He's a gynecologic oncologist at Massachusetts General Hospital in Boston. Melamed spoke with WGBH All Things Considered anchor Barbara Howard about the study. The following transcript has been edited for clarity.
Barbara Howard: Minimally invasive surgery involves small slits, while conventional surgery involves a big incision. So talk about the outcomes in these studies for women who have had minimally invasive versus open-incision surgery.
Dr. Alex Melamed: Minimally invasive surgery has been shown to be safe and effective for many other kinds of cancers, like uterine cancer and colorectal cancer. That's why folks really expected that it would have similar outcomes in cervical cancer. However, what both these studies show is that women who have surgery through a laparotomy — that is an incision on the abdomen — have lower rates of recurrence, and indeed have a lower risk of dying than women who have minimally invasive surgery.
Howard: Have you been able to figure out why?
Dr. Melamed: I think one of the things about these two studies that is a little bit unsatisfying is they don't point to a reason why. And we really don't know why. People have proposed lots of different hypotheses, but we really don't have evidence from either of these studies to explain why this might be in this particular cancer.
Howard: I understand that some hospitals are already changing their practices on this. Is that so?
Dr. Melamed: Yes, absolutely. At a minimum, given these results, anyone who is offering minimally invasive surgery for cervical cancer really needs to discuss the risks and benefits with their patients. But a lot of folks that I have talked to have said "look, until there is evidence that shows that there is some safe way of doing these procedures through a minimally invasive approach, we're just going to do them the old-fashioned way and do open surgery."
For example at MGH, the providers have taken it on a one-by-one basis. I know that folks have been discussing these results with their patients even before these New England Journal articles were published. And certainly MGH, while we haven't crafted a formal policy yet about it, I think that one by one the providers I work with here are really doing these procedures now mostly through an open approach. Again, just for cervical cancer.
Howard: The American Cancer Society is estimating about 13,000 new cases of cervical cancer will be diagnosed this year nationwide, and over 4,000 women will die from cervical cancer. Now if you had a woman in front of you, a patient with cervical cancer, who is faced with a choice of minimally invasive surgery or conventional open surgery, Dr. Melamed, what would you advise her to do?
Dr. Melamed: For a woman that was sitting in front of me I would say right now, the evidence is pretty convincing that minimally invasive radical hysterectomy is associated with a higher risk of cancer coming back, and a higher risk of dying. So, I personally wouldn't offer minimally invasive surgery at this point to anyone with cervical cancer. And therefore I would not advise minimally invasive surgery.
Howard: You’d go for a conventional open surgery?
Dr. Melamed: Absolutely.
Howard: Has this shift in your thinking spread beyond Boston to other hospital centers nationwide?
Dr. Melamed: Some of the places that I've talked to have drafted formal policies where they're not going to do these procedures at all, minimally invasive, whereas other places I've talked to have said look, there may still be some patients who these procedures are safe in, and we are going to make these decisions on a one-by-one basis and obviously discuss these data with patients, but will let patients make their own decisions. It's a hot topic of debate right now. These studies came out yesterday, and I think people are still digesting them. This is very surprising information for our field. Nobody expected it, and when that kind of information comes up, it takes people time to digest it.
Howard: The word is out though. It sounds like the word is out.
Dr. Melamed: I think the word getting out. Our phones here are ringing off the hook. And one of the problems with this is people who have uterine cancer, which is much, much more common, are calling and saying I want to have my procedure through an open incision.
Howard: But this isn't for uterine cancer, this is for cervical cancer only.
Dr. Melamed: Exactly. So, I think it's really important to be clear that these studies in no way condemn minimally invasive surgery in a general way. It's really just for cervical cancer.
Howard: That's Dr. Alex Melamed. He's a gynecologic oncologist at Massachusetts General Hospital. He contributed to studies out this week on cervical cancer. The studies found that patients who have open surgery for the cancer are more likely to survive than those who have non-invasive procedures. This is WGBH’s All Things Considered.