Disparities in the use of fertility-sparing surgery for early stage cervical cancer

Abstract

Women with early stage cervical cancer who are of reproductive age and wish to preserve fertility may be candidates for fertility-sparing surgery (FSS). The goal of this study was to examine the presence of disparities in the use of fertility-preserving surgery (FSS) and to investigate outcomes in this group. Retrospective cohort study. The National Cancer Database was used to identify patients aged <=35 years diagnosed with cervical cancer between 2004-2015. Those with stage IA2 or IB1 squamous cell carcinoma (SCC) or adenocarcinoma (AC) who underwent definitive treatment by hysterectomy (HYST) versus cone resection or trachelectomy (FSS) were identified. Univariate analysis was performed with chi-square and Mann-Whitney tests. Overall survival (OS) was evaluated for cases diagnosed between 2004-2014 after generation of Kaplan-Meier curves and compared with the log-rank test. A Cox model was constructed to control for confounders. A total of 2623 patients met the inclusion criteria. Median patient age at the time of diagnosis was 31 years (IQR:5). The majority had squamous cell carcinoma (62.4%) and stage IB1 disease (84.1%). The rate of FSS was 13.6%. Compared to patients who underwent HYST, those who received FSS were younger (median 30 vs 32 yrs, p<0.001), had fewer co-morbidities (3.6% vs 7.6%, p=0.007), were more likely to reside in large metropolitan areas (61.1% vs 49.5%, p<0.001), have private insurance (75.8% vs 62.9%, p<0.001), higher median income (p<0.001), present with stage IA2 disease (25.2% vs 14.4%, p<0.001) and adenocarcinoma (45.4% vs 36.3%, p=0.001). No differences were noted based on patient race (p=0.14). After controlling for clinical stage, histology, age, presence of co-morbidities, and area of residence, private insurance and higher income were associated with the receipt of FSS. There was no difference in OS between patients who received HYST (n=2036) and FSS (n=305), p=0.37; 5-yr OS rates were 93.5% and 94.5%, respectively. After controlling for age, clinical stage, histology, presence of medical comorbidities and performance of lymph node dissection, receipt of FSS was not associated with a worse survival (HR: 0.75, 95% CI: 0.42, 1.37). Socio-economic disparities exist in the utilization of FSS for early stage cervical cancer. For this selected population no difference in OS was found. This is critical information for patients referred for oncofertility consultation.