Fertility-Sparing Surgery May Be Safe Despite Recurrence in Cervical Cancer

Patients with early-stage cervical cancer treated with fertility-sparing surgery (FSS) had a significantly higher rate of recurrence compared with patients who had their uterus completely removed, although the increased rate of recurrence did not affect survival, according to results from a retrospective cohort study published in JCO Oncology Practice.

With a median follow-up of 8.9 years for both groups, a total of 4.8% of patients developed a recurrence, with 7.1% of the FSS group and 3.6% of the hysterectomy group experiencing a recurrence (HR, 2.21; 95% CI, 1.38-3.56). The 5-year recurrence-free survival (RFS) rate was 92% in the FSS group vs 96.4% in the hysterectomy group.

Considering all FIGO stages, recurrences were more frequent after FSS than hysterectomy, with the only difference of significance observed in the FIGO IB1 group (HR, 4.76; 95% CI, 1.92-11.83).

The median time of recurrence occurrence was 24.4 months, with 10 of the patients in the FSS group developing recurrence in the remaining cervix; 7 of them received additional surgical treatment, and 2 developed a vaginal recurrence.

Of the 198 patients in the pretreatment FIGO IB2 stage, 66 patients and 132 patients were in the FSS group and the hysterectomy group, respectively. A total of 28 patients developed a recurrence, and no significant difference was observed between the groups (HR, 0.82; 95% CI, 0.32-2.11).

In the FSS group, 47.1% of patients with a recurrence died during follow-up vs 62.9% of patients in the hysterectomy group (HR, 0.54; 95% CI, 0.26-1.15). No difference was observed for overall survival (OS; HR, 1.06; 95% CI, 0.62-1.80). The 5-year OS rate was 96.6% in the FSS group and 97.4% in the hysterectomy group. Notably, although patients in the FSS group with FIGO stage IB1 had a higher recurrence rate vs the hysterectomy group, there was no difference for OS (HR, 2.22; 95% CI, 0.88-5.59).

Two separate sensitivity analyses were conducted, one of which was to identify the impact of survival data, and the other was to exclude fertility-sparing patients who received neoadjuvant chemotherapy and their controls. Neither analysis identified differences for OS.

“In conclusion, we did not demonstrate a difference in OS for patients with FIGO 2018 stage 1A1 to 1B2 cervical cancer, treated with FSS compared with patients treated with (radical) hysterectomy despite a higher risk of recurrence in fertility-sparing patients,” wrote lead study author Janneke T. Wolswinkel, MD, of the Department of Obstetrics and Gynecology at Radboud University Medical Centre in Nijmegen, the Netherlands, and coauthors. “We therefore consider FSS as a potentially safe option for patients wishing to preserve fertility. For patients with [tumors greater than] 2 cm, larger series are needed to properly assess safety.”

A total of 1446 patients with early-stage cervical cancer who underwent either FSS or radical hysterectomy between 2000 and 2022 were included in the final analysis, with 482 in the FSS group and 964 in the hysterectomy group. Eligible patients were also between 18 and 45 years old.

Exclusion criteria included being pregnant at the time of diagnosis; having a histologic type other than squamous cell carcinoma, adenocarcinoma, and adenosquamous carcinoma; or having a tumor size greater than 40 mm post-operation.

Patient data were collected from the Netherlands Cancer Registry and Dutch Nationwide Pathology Databank in April 2023, with a follow-up period of at least 15 months.

The median age of patients in the FSS group and radical hysterectomy group were 30 years (range, 29-34) and 39 years (range, 35-42), respectively. Patients had pretreatment FIGO 2018 stage IA2 disease (30.7% each), squamous cell carcinoma (69.3% each), and grade 2 tumors (37.8% and 36.6%). In the FSS group, primary treatment was radical trachelectomy (79.9%), cone biopsy/large loop excision of the transformation zone (17.2%), and trachelectomy without parametrectomy (2.9%). In the hysterectomy group, primary treatment was radical hysterectomy (90.5%) and hysterectomy (9.5%).

The outcome measures were RFS and OS.

Reference

Wolswinkel JT, Zusterzeel PLM, Smits A, et al. Survival after fertility-sparing surgery for early-stage cervical cancer compared with nonsparing surgery: a nationwide comparative study. JCO Oncol Pract. Published online September 23, 2025. doi:10.1200/OP-25-00131