Article Text

Radical hysterectomy in early cervical cancer in Europe: characteristics, outcomes and evaluation of ESGO quality indicators
  1. Felix Boria1,
  2. Luis Chiva2,
  3. Vanna Zanagnolo3,
  4. Denis Querleu4,
  5. Nerea Martin-Calvo5,
  6. Mihai Emil Căpîlna6,
  7. Anna Fagotti7,
  8. Ali Kucukmetin8,
  9. Constantijne Mom9,
  10. Galina Chakalova,10,
  11. Aliyev Shamistan11,
  12. Mario Malzoni12,
  13. Fabrice Narducci13,
  14. Octavio Arencibia14,
  15. Francesco Raspagliesi15,
  16. Tayfun Toptas16,
  17. David Cibula17,
  18. Dilyara Kaidarova18,
  19. Mehmet Mutlu Meydanli19,
  20. Mariana Tavares20,
  21. Dmytro Golub21,
  22. Anna Myriam Perrone22,
  23. Robert Poka23,
  24. Dimitrios Tsolakidis24,
  25. Goran Vujić25,
  26. Marcin A Jedryka26,
  27. Petra L M Zusterzeel27,
  28. Jogchum Jan Beltman28,
  29. Frederic Goffin29,
  30. Dimitrios Haidopoulos30,
  31. Herman Haller31,
  32. Robert Jach32,
  33. Iryna Yezhova33,
  34. Igor Berlev34,
  35. Margarida Bernardino35,
  36. Rasiah Bharathan36,
  37. Maximilian Lanner37,
  38. Minna M Maenpaa38,
  39. Vladyslav Sukhin39,40,
  40. Jean-Guillaume Feron41,
  41. Robert Fruscio42,43,
  42. Kersti Kukk44,
  43. Jordi Ponce45,
  44. María Alonso-Espías46,
  45. Jose Angel Minguez47,
  46. Daniel Vázquez-Vicente48,
  47. Nabil Manzour49,
  48. Matias Jurado47,
  49. Teresa Castellanos48,
  50. Enrique Chacon50 and
  51. Juan Luis Alcazar51
  1. 1Clinica Universidad de Navarra Departamento de Ginecologia y Obstetricia, Madrid, Spain
  2. 2Department of Obstetrics and Gynecology, Clinica Universidad de Navarra, Madrid, Spain
  3. 3Department of Gynecologic Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy
  4. 4Department of Surgery, Institut Bergonie, Bordeaux, France
  5. 5Department of Preventive Medicine and Public Health, Universidad de Navarra, Pamplona, Spain
  6. 6Emergency County Hospital Targu-Mures, Targu Mures, Romania
  7. 7Department of Woman, Child, and Public Health, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy
  8. 8Queen Elizabeth Hospital, Gateshead, Gateshead, UK
  9. 9Amsterdam University Medical Centres, Amsterdam, Noord-Holland, Netherlands
  10. 10University Oncologic Hospital, Sofia, Bulgaria
  11. 11National Center of Oncology, Baku, Azerbaijan
  12. 12Endoscopica Malzoni, Center for Advanced Endoscopic Gynecologic Surgery, Center for Advanced Endoscopic Gynecologic Surgery, Avellino, Italy
  13. 13Department of Gynecology, Centre Oscar Lambret, Lille, France
  14. 14University Maternal Hospital Canary Islands, Las Palma, Spain
  15. 15Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Lombardia, Italy
  16. 16Department of Gynecologic Oncology, Saglik Bilimleri University Antalya Research and Training Hospital, Antalya, Turkey
  17. 17Department of Obstetrics and Gynecology, University of Prague, Prague, Czech Republic
  18. 18Oncogynecology, Kazahskij Naucno-Issledovatel'skij Institut Onkologii i Radiologii, Almaty, Kazakhstan
  19. 19Department of Gynecologic Oncology, Zekai Tahir Burak Women's Health Education and Research Hospital, Ankara, Turkey
  20. 20Instituto Português de Oncologia do Porto Francisco Gentil, Porto, Portugal
  21. 21Department of Surgery, LISOD - Israeli Oncological Hospital, Kyiv region, Ukraine
  22. 22Azienda Ospedaliero-Universitaria di Bologna Policlinico SantOrsola-Malpighi, Bologna, Italy
  23. 23Obstetrics and Gynecology, Unit of Gynecologic Oncology, Institute of Obstetrics and Gynecology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
  24. 24General Hospital of Thessaloniki Papageorgiou, Thessaloniki, Central Macedonia, Greece
  25. 25Clinical Hospital Center, Zagreb, Croatia
  26. 26Department of Oncological Gynecology, Uniwersytet Medyczny im Piastów Śląskich we Wrocławiu (Wroclaw Medical University), Wroclaw, Poland
  27. 27Department of Gynecological Oncology, Radboudumc, Nijmegen, Netherlands
  28. 28Department of Gynaecology, LUMC, Leiden, Netherlands
  29. 29Department of Obstetrics and Gynecology, University of Liege, Liege, Belgium
  30. 30Division of Gynecologic Oncology, 1st Department of Obstetrics and Gynecology, Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece
  31. 31Clinical Hospital Center Rijeka, Rijeka, Croatia
  32. 32Department of Gynecology and Oncology, Jagiellonian University, Krakow, Poland
  33. 33Lviv Oncology Center, Lviv, Ukraine
  34. 34North-Western State Medical University. N.N. Petrov Research Institute of Oncology, Saint-Petersburg, Saint-Petersburg, Russian Federation
  35. 35Department of Gynecology, Instituto Português de Oncologia de Lisboa, Lisboa, Lisboa, Portugal
  36. 36University Hospitals of Leicester NHS Trust, Leicester, Leicester, UK
  37. 37Kardinal Schwarzenberg'sches Krankenhaus, Schwarzach, Steiermark, Austria
  38. 38Department of Obstetrics and Gynecology, Tampere University Hospital, Tampere, Finland
  39. 39Department of Oncology, Radiology and Radiation Medicine, V N Karazin Kharkiv National University, Harkiv, Ukraine
  40. 40Department of Oncogynecology, Grigoriev Institute for Medical Radiology NAMS of Ukraine, Harkiv, Ukraine
  41. 41Institut Curie, Paris, Île-de-France, France
  42. 42Department of Medicine and Surgery, University of Milan–Bicocca, Milano, Italy
  43. 43Clinic of Obstetrics and Gynecology, Hospital San Gerardo, Monza, Italy
  44. 44North Estonia Medical Centre, Tallinn, Estonia
  45. 45Bellvitge University Hospital, L'Hospitalet de Llobregat, Catalunya, Spain
  46. 46Department of Gynecologíc Oncology, Hospital Universitario La Paz, Madrid, Madrid, Spain
  47. 47Department of Gynecology, Clinica Universitaria de Navarra, Pamplona, Navarra, Spain
  48. 48Department of Gynecology, Clinica Universitaria de Navarra, Madrid, Spain
  49. 49Clinica Universidad de Navarra Departamento de Ginecologia y Obstetricia, Pamplona, Navarra, Spain
  50. 50Department of Gynecologic Oncology, Universidad de Navarra, Pamplona, Navarra, Spain
  51. 51Department of Obstetrics and Gynecology, School of Medicine; University of Navarra, Pamplona, Spain
  1. Correspondence to Dr Luis Chiva, Department of Obstetrics and Gynecology, Clinica Universidad de Navarra, Madrid, Spain; lchiva{at}unav.es

Abstract

Introduction Comprehensive updated information on cervical cancer surgical treatment in Europe is scarce.

Objective To evaluate baseline characteristics of women with early cervical cancer and to analyze the outcomes of the ESGO quality indicators after radical hysterectomy in the SUCCOR database.

Methods The SUCCOR database consisted of 1272 patients who underwent radical hysterectomy for stage IB1 cervical cancer (FIGO 2009) between January 2013 and December 2014. After exclusion criteria, the final sample included 1156 patients. This study first described the clinical, surgical, pathological, and follow-up variables of this population and then analyzed the outcomes (disease-free survival and overall survival) after radical hysterectomy. Surgical-related ESGO quality indicators were assessed and the accomplishment of the stated recommendations was verified.

Results The mean age of the patients was 47.1 years (SD 10.8), with a mean body mass index of 25.4 kg/m2 (SD 4.9). A total of 423 (36.6%) patients had a previous cone biopsy. Tumor size (clinical examination) <2 cm was observed in 667 (57.7%) patients. The most frequent histology type was squamous carcinoma (794 (68.7%) patients), and positive lymph nodes were found in 143 (12.4%) patients. A total of 633 (54.8%) patients were operated by open abdominal surgery. Intra-operative complications occurred in 108 (9.3%) patients, and post-operative complications during the first month occurred in 249 (21.5%) patients, with bladder dysfunction as the most frequent event (119 (10.3%) patients). Clavien-Dindo grade III or higher complication occurred in 56 (4.8%) patients. A total of 510 (44.1%) patients received adjuvant therapy. After a median follow-up of 58 months (range 0–84), the 5-year disease-free survival was 88.3%, and the overall survival was 94.9%. In our population, 10 of the 11 surgical-related quality indicators currently recommended by ESGO were fully fulfilled 5 years before its implementation.

Conclusions In this European cohort, the rate of adjuvant therapy after radical hysterectomy is higher than for most similar patients reported in the literature. The majority of centers were already following the European recommendations even 5 years prior to the ESGO quality indicator implementations.

  • cervical cancer
  • postoperative complications
  • radiation
  • SLN and lympadenectomy
  • hysterectomy

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information. Data will be available upon the requirement of the reviewers at any time.

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HIGHLIGHTS

  • In this European cohort, including 1156 cases from 126 institutions belonging to 29 European countries, the 5-year disease-free survival rate was 88.3%, and the overall survival rate at 5 years was 94.9%.

  • Up to 44% of the patients received some type of adjuvant therapy treatment after radical hysterectomy (33.7% received either standard external radiation or concurrent chemoradiotherapy).

  • In 2013 and 2014, 5 years before the publication of the ESGO quality indicators for surgical treatment of cervical cancer, 91% of them were accomplished in this cohort.

INTRODUCTION

In 2018, approximately 5 70 000 cases and 311 000 deaths from cervical cancer occurred worldwide. In the same year in Europe, 66 000 new patients with cervical cancer were diagnosed, and 26 000 patients died.1 To date, we have no data about the annual rate of radical hysterectomies performed in Europe. Historically, radical hysterectomy has been the primary treatment for early cervical cancer. The technical achievements in this procedure have been growing along with the development of new surgical improvements. For years, this operation was carried out by open or vaginal approaches,2 3 and more recently, since 1992,4 by minimally invasive surgery, either by laparoscopy or robotic surgery. In 2018, a prospective randomized trial conducted by Ramirez et al (LACC trial),5 revealed higher rates of recurrence and deaths in patients who underwent minimally invasive surgery. Moreover, several recent retrospective studies6–13 and a meta-analysis14 confirmed these findings.

The SUCCOR study was a multicenter, retrospective cohort study aiming to determine the difference between the two surgical approaches in Europe for disease-free survival of patients undergoing radical hysterectomy. Our primary analyses showed that minimally invasive surgery in patients with IB1 cervical cancer was associated with a higher risk of relapse and death. Nevertheless, we also found as secondary objectives that avoiding the uterine manipulator and implementing protective maneuvers were associated with higher rates of disease-free survival and overall survival in patients who underwent minimally invasive surgery, leading to similar results as for those in patients who underwent open surgery.15

The European Society of Gynaecological Oncology (ESGO) aims to improve clinical practice in the treatment of patients with gynaecologic malignancies. In 2020, the ESGO quality indicators for surgical treatment of cervical cancer were published.16 The main objective of this study was to describe the characteristics of women with early cervical cancer and to analyze the outcomes after radical hysterectomy in the SUCCOR database. Second, we evaluated the accomplishment of the surgical-related ESGO quality indicators 5 years before its implementation.

METHODS

Accrual and Data Source

All ESGO members were invited to participate in the SUCCOR database. Researchers from 126 institutions in 29 European countries were registered and contributed to the project. After obtaining ethical consent from our central institutional review board, we required a Certificate of Approval or a Letter of Exemption by the investigators’ local ethics committees.

Inclusion and Exclusion Criteria

Patients were eligible if they had undergone radical hysterectomy for stage IB1 cervical cancer (FIGO 2009) in a European institution between January 1, 2013, and December 31, 2014. From May 15 to November 15, 2019, a total of 1272 patients were evaluated; however, 116 patients did not meet the inclusion criteria. The inclusion criteria were as follows: (1) age ≥18 years and (2) histologic type: squamous cell carcinoma, adenocarcinoma, or adenosquamous carcinoma. Pelvic MRI confirming a tumor diameter ≤4 cm with no parametrial invasion and a pre-operative CT scan, MRI, or positron emission tomography (PET) CT demonstrating no extracervical metastatic disease were mandatory. The operative report had to describe type B–C radical hysterectomy with bilateral pelvic lymphadenectomy by either minimally invasive surgery (laparoscopic or robotic) or open surgery, including at least 10 pelvic nodes. Women who underwent only sentinel lymph node mapping were included in the study, but data regarding tumor size, margins, and nodal status were required. Patients with any other histological type of cancer were excluded. Other exclusion criteria were as follows: (1) tumor size >4 cm, (2) final tumor stage IA, (3) history of any invasive tumor other than cervical cancer, (4) previous chemotherapy or radiation, and (5) conversion from minimally invasive surgery to open laparotomy (as it was stated in the SUCCOR database). It is important to note that unlike the SUCCOR study, patients who underwent cone biopsy for a suspected FIGO 2009 stage IB1 tumor were included (Online Supplemental Material 1).

Supplemental material

Outcomes

Disease-free survival was defined as the time, in months, between the date of radical hysterectomy and the date of relapse or the date of last contact, whichever came first. Overall survival was calculated, in months, as the difference between the radical hysterectomy date and the date of death from cervical cancer or last contact, whichever came first.

Process and outcomes quality indicators (11 items in total) were calculated in our cohort and compared with the recommendations stated by the ESGO. All the required elements in surgical reports and in pathology reports recommended by the ESGO were previously included in our database.

Statistical Analysis

Quantitative variables are described with a mean (SD). Quantitative variables were compared using the Student t-test. Categorical variables are defined with frequencies or percentages. We described disease-free survival and overall survival using the Kaplan-Meier method. The analyses were performed with SPSS v26.0.

RESULTS

Baseline Characteristics

The final cohort was composed of 1156 patients. The mean age was 47.1 years (range 18–82) and the mean body mass index (BMI) was 25.44 kg/m2 (range 15–68), and 1022 (88.3%) patients were considered to have an optimal performance status (ECOG PS 0). A total of 423 (36.6%) patients had undergone a cone biopsy before radical hysterectomy. The mean pre-operative maximum tumor diameter measured by MRI was 19.6 mm (SD 12.6) (Table 1).

Table 1

Baseline characteristics and complications

Surgical Procedure and Pathologic Findings

A senior surgeon with more than 10 years of experience was the first surgeon in 881 (76.2%) procedures. A total of 633 (55%) radical hysterectomies were performed by laparotomy, and 523 (45%) by minimally invasive surgery. Among patients who underwent minimally invasive surgery, 377 (72%) had a laparoscopic approach, 139 (27%) had robotic surgery, and only 7 (1.3%) underwent a vaginal-assisted laparoscopy. The surgical procedure was described as type III or type C radical hysterectomy in 789 (68.2%) cases. The nerve-sparing technique was performed in 558 (48.3%) cases. Sentinel lymph node biopsy was performed in 224 (19.4%) patients with a bilateral detection rate of 81.2%.

The median duration of surgery was 210 min (range 80–720). The average length of stay in hospital was 6.7 days (SD 4.2). The mean length of stay in hospital for the minimally invasive surgery group was lower than in the open surgery group (4.8 vs 8.4 days, p<0.001) (Table 1).

The most common histologic tumor type was squamous carcinoma (794 (68.7%)). Lymphovascular space invasion was present in 437 (37.8%) tumors. Parametrial invasion was observed only in 33 (2.9%) patients. A total of 143 (12.4%) patients had nodal metastasis. All pathology analysis is shown in Table 2. Patients were reclassified following the new 2018 FIGO staging. A total of 163 (14.1%) cases were upstaged, based on pathology report.

Table 2

Final pathology results

Complications and Long-Term Sequelae

One hundred and eight (9.3%) patients experienced at least one intra-operative complication. Intra-operative bleeding (7.2%), bladder injury (4.1%), and vascular injury (3.0%) were the most common complications. Two hundred and forty-nine (21.5%) patients had at least one post-operative complication during the first month after surgery. Bladder dysfunction (10.3%), urinary infection (6.1%), and fever (6.7%) were the most common complications. Clavien-Dindo grade III or higher complications occurred in 56 (4.8%) patients. At last contact, 97 (8.4%) patients complained of chronic sequelae, with leg lymphedema and bladder dysfunction being the most common (37.4% and 16.2%, respectively) (Table 1).

Adjuvant Therapy

Five hundred and ten (44.1%) patients received adjuvant therapy (Table 3). A total of 390 (33.7%) patients received either standard external radiation or concurrent chemoradiotherapy. Standard external radiation and brachytherapy were the most frequently used modalities of adjuvant treatment (215 (18.6%) and 251 patients (21.7%), respectively), while concomitant chemoradiation was used in 174 (15.1%) of cases. A total of 366 of these 510 patients (71.8%) had positive pelvic lymph nodes, parametrial extension, positive surgical margins, and/or were considered patients at intermediate risk by Sedlis criteria.17 In the remaining 144 (28.2%) patients the indications for adjuvant treatment were depth of invasion (41.7%), lymphovascular space invasion (20.8%), histological grade (56.3%), and tumor size (52.1%).

Table 3

Adjuvant therapy

Oncologic Outcomes

After a median follow-up of 58 months (range 0–84), 1019 (88.1%) patients remained free of disease, 37 (3.2%) were alive with disease, and 5.6% (n=65) had died. The 5-year disease-free survival rate was 88.3%, and the cervical cancer overall survival rate at 5 years was 94.9%. The 5-year disease-free survival and overall survival rate in the open surgery group were respectively 92.2% and 95.2%, respectively, and 86.2% and 92.1% in the minimally invasive surgery group. A total of 126 (10.9%) of the 1156 patients in the study relapsed. The median time to relapse was 19 months (range 2–72). Pelvic recurrence was the most frequent form of relapse (54.8%), while distant metastases without local relapse were diagnosed in 27.o% of cases (Table 4). Among the 126 patients who relapsed, the median time of post-recurrence survival was 33.8 months (range 2–66), with a median follow-up after recurrence of 19.8 months (range 1–66) Online Supplemental Material 1.

Table 4

Follow up

Surgical ESGO Quality Indicators

Accomplishment of the process and outcomes ESGO quality indicators was achieved in 10 of the 11 items assessed. The required pre-operative investigation, surgical report, minimum elements in the pathology report defined by the ESGO-ESTRO-ESP guidelines18–20 were achieved in 100% of the patients (recommended 100%).

Structured prospective reporting of the follow-up and 30-day post-operative morbidity using a validated surgical complication scoring system was conducted in 100% of the cases (recommended 100%). Urological fistula rate within 30 post-operative days after a radical parametrectomy was 1.5% (recommended ≤3%). Proportion of patients after primary surgical treatment who had clear vaginal (invasive disease) and parametrial margins was 98.6% (recommended ≥97%). Proportion of patients with a stage T1b disease T-upstaged after surgery was 4.1% (recommended <10%). T-upstaging refers to detection of any involvement of parametria or vagina found on pathology which was unknown before surgery, or a stage shift from T1b1 to T1b2 or higher, from pre-operative assessment to post-operative pathology. Detection of positive lymph nodes is not included.

Recurrence rate at 2 years in patients with a stage pT1b1 with negative lymph nodes after primary surgical treatment was 5.6% (recommended <10%). Proportion of patients with a stage T1 disease treated by primary surgery who have undergone lymph node staging according to the ESGO-ESTRO-ESP Guidelines was 100% (recommended ≥98%).

Surgery was performed or supervised by a certified gynecologic oncologist or a trained surgeon dedicated to gynecological cancer in 99.1% of cases (recommended 100%). Proportion of patients receiving adjuvant chemoradiotherapy after a primary surgical treatment for a stage pT1b1 pN0 disease was 7.7% (recommended <15%). It is important to notice that in this section evaluating the quality indicator we are only looking at the 510 patients who are stage IB1 in the final pathology and have negative nodal status. However, of 1013 patients with pT1b1 (FIGO 2009) with negative nodal status, up to 193 patients (19.1%) received standard external radiotherapy without chemotherapy (Table 5).

Table 5

Evaluation of quality indicators

DISCUSSION

Summary of Main Results

In 2013 and 2014, 1156 women were operated in this European cohort as part of their treatment for cervical cancer FIGO stage IB1 (2009). The 5-year disease-free survival rate was 88.3%, and the overall survival rate at 5 years was 94.9%. In addition, we noted that 5 years before the publication of the ESGO quality indicators for surgical treatment of cervical cancer, the vast majority of centers participating in our study were already following the stated recommendations. However, 44% of patients received adjuvant therapy after radical hysterectomy and, in addition, a total of 144 (12.5%) patients received adjuvant therapy without meeting routine criteria for such treatment.

Results in the Context of Published Literature

In our study, patients underwent a higher rate of adjuvant treatment than described previously in the literature. In a prospective study, the LACC trial,5 adjuvant therapy was administered to 28% of the patients and chemoradiation was indicated in 18%. In retrospective studies adjuvant treatment varied from 18% to 33%.8 12 13 21–23 All these studies included tumors with FIGO stage IA, which could imply lower rates of adjuvant therapy. In our study, as a descriptive retrospective study, the selection criteria for adjuvant therapy were applied individually at each center. After these findings, we reviewed all our data searching for indications for adjuvant treatment. After excluding standard indications of adjuvant therapy (positive nodal status, positive surgical margins, parametrial infiltration, or intermediate risk in Sedlis criteria), we identified 144 patients who did not fulfill any of the standard criteria, representing 28.2% of the patients who received adjuvant therapy and 12.5% of the entire cohort. Out of the 126 patients that recurred, 63 (50%) patients have had adjuvant therapy after surgery. Further investigation is needed to estimate if we are overtreating our patients in Europe.

Sentinel lymph node biopsy was performed in 224 (19.4%) patients, with a bilateral identification of 81.2%. The SENTIX trial found a higher bilateral identification rate of sentinel lymph node of 91%.24 In that trial, previous experience with sentinel lymph node biopsy was needed to participate, which might explain the different results and highlights the importance of surgical training in complex techniques, such as sentinel lymph node biopsy. The ABRAX trial recently showed that surgery must be abandoned if a positive node is found at frozen section.25 In 25.5% of the patients of our cohort, lymph nodes (with or without sentinel lymph node biopsy) were sent for frozen section, with a positive rate of 8.4%. However, no procedure was abandoned due to nodal positivity.

In our study, which included a time before publication of the LACC trial, over half of the patients (54%) underwent open surgery for radical hysterectomy. Among the patients who underwent a minimally invasive approach, only 26% (n=139) underwent robotic surgery, which highlights the infrequent use of this approach across Europe. Melamed et al recently published a cohort study13 of women who underwent radical hysterectomy for stage IA2 or IB1 cervical cancer in the 2010–2013 period at US Commission on Cancer-accredited hospitals. With 2461 patients followed up for a median of 45 months, they found an overall survival of 94.4%. These results are similar to those obtained in our study.

The mean length of stay in our cohort was 4.8 days for the minimally invasive group and 8.4 for the open group. This represents a longer length of stay than other series reported previously, such as the LACC trial (3 and 5 days, respectively).5 However, the length of stay reported for radical hysterectomy varies considerably depending on the region where the study is done. As an example, in this Korean series length of stay reported for radical hysterectomy was 12 days in the minimally invasive group and 20 days in the open group.22

This could be influenced by cultural and sociodemographic differences affecting the different healthcare services.

Study Limitations

Our study has several weaknesses, including the fact that there was no formal auditing of the data. To account for these limitations, we provided the participating sites with a strict list of inclusion and exclusion criteria, and all investigators declared that the reported information adhered to the data in the reviewed charts. In addition, there is no information regarding indications for surgical approach. Similarly, indications for adjuvant treatment were at the discretion of the physicians in each center and such indications might have varied from one institution to another. Lastly, there are no data on the regimen used for surveillance or information as to whether recurrences were documented by clinical suspicion, imaging studies, or pathologic confirmation.

Implications for Practice and Future Research

The current study has demonstrated that in Europe, patients with early cervical cancer are undergoing adjuvant therapy after radical hysterectomy at a higher rate than those published in the literature. Further research is needed to investigate the indications for adjuvant treatment and if such high rates of adjuvant treatment are indicated. Our study also provides valuable information, in that it provides updated survival outcomes to be set as the expected benchmark for overall survival outcomes.

CONCLUSIONS

In summary, in this European cohort, we found that 5-year disease-free survival and overall survival were 88.3% and 94.9%; respectively. We also noted a higher proportion of patients receiving adjuvant treatment in comparison with those previously reported in the literature. In 2013 and 2014, 5 years before the publication of the ESGO quality indicators for surgical treatment of cervical cancer, 91% of the indicators were accomplished in this cohort.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information. Data will be available upon the requirement of the reviewers at any time.

Ethics statements

Patient consent for publication

Acknowledgments

We thank our colleagues, Dr Antonio Gil and Dr Antonio Gonzalez-Martin, for their invaluable support when designing this project. A special recognition to the medical editor of the International Journal of Gynecological Cancer for his continuous assistance in improving this manuscript. We thank the ESGO Council for the diffusion of the SUCCOR study among our members.

References

Supplementary materials

  • Supplementary Data

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Footnotes

  • Twitter @BoriaFelix, @r.bolatbekova@gmail.com, @RasiahBharathan, @Quique_ChC, @Juan_L_Alcazar

  • Correction notice This article has been corrected since it was first published. The third affiliation has been updated to include 'IRCCS'.

  • Collaborators On behalf of the SUCCOR study Group: Nabil Abdalla, Özgür Akbayir, Sedat Akgöl, Elif Aksahin, Shamistan Aliyev, Maria Alonso-Espias, Igor Aluloski, Claudia Andrade, Nikola Badzakov, Rosa Barrachina, Giorgio Bogani, Eduard-Aexandru Bonci, Hélène Bonsang-Kitzis, Cosima Brucker, Laura Cárdenas, Andrea Casajuana, Pere Cavalle, Jorge Cea, Benito Chiofalo, Gloria Cordeiro, Pluvio Coronado, Maria Cuadra, Javier Díez, Teresa Diniz da Costa, Santiago Domingo, Lukas Dostalek, Fuat Demirkiran, Diego Erasun, Mathias Fehr, Sergi Fernandez-Gonzalez, Annamaria Ferrero, Soledad Fidalgo, Gabriel Fiol, Khadra Galaal, José García, Gerhard Gebauer, Fabio Ghezzi,Juan Gilabert, Nana Gomes, Elisabete Gonçalves, Virginia Gonzalez, Frederic Grandjean, Miriam Guijarro, Frédéric Guyon, Jolien Haesen, Gines Hernandez- Cortes, Sofía Herrero, Imre Pete, Ioannis Kalogiannidis, Erbil Karaman, Andreas Kavallaris, Lukasz Klasa, Ioannis Kotsopoulos, Stefan Kovachev, Meelis Leht, Arantxa Lekuona, Mathieu Luyckx, Michael Mallmann, Gemma Mancebo, Aljosa Mandic, Tiermes Marina, Victor Martin, María Belén Martín- Salamanca, Alejandra Martinez, Gesine Meili, Gustavo Mendinhos, Liliana Mereu, Milena Mitrovic, Sara Morales, Enrique Moratalla, Bibiana Morillas, Eva Myriokefalitaki, Maja PakižImre, Stamatios Petousis, Laurentiu Pirtea, Natalia Povolotskaya, Sonia Prader, Alfonso Quesada, Mikuláš Redecha, Fernando Roldan, Philip Rolland, Reeli Saaron, Cosmin-Paul Sarac, Jens-Peter Scharf, Špela Smrkolj, Rita Sousa, Artem Stepanyan, Vladimír Študent, Carmen Tauste, Hans Trum, Taner Turan, Manuela Undurraga, Arno Uppin, Alicia Vázquez, Ignace Vergote, George Vorgias, and Ignacio Zapardiel.

  • Contributors All authors contributed meaningfully to the conception or design of the work or the acquisition, analysis, or interpretation of data for the study. The authors confirm the completeness and accuracy of the data and analyses,the fidelity of the study to the protocol, and the final approval of the version to be published.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.