Life after LACC: a survey of practices and attitudes among gynecologic oncologists in the practice of sentinel lymph node mapping for early-stage cervical cancer

Abstract

Objectives: To determine practice patterns among gynecologic oncologists in sentinel lymph node mapping (SLNM) for early-stage cervical cancer after the Laparoscopic Approach to Cervical Cancer trial (LACC) Methods: An online survey was distributed to candidates and full members of the Society of Gynecologic Oncology (SGO) in September 2020. The survey assessed the incidence of SLNM in early-stage cervical cancer, practice patterns, perceived benefits, barriers to SLNM, and how practice may have changed after the LACC trial. Descriptive statistics and univariate analyses were performed. Results: Of the 1206 SGO members surveyed, 242 responses (20.1%) were received during a three-week period in September 2020. The majority of respondents, 86.8% (n=210), reported performing >50% of their radical surgeries for early-stage cervical cancer with an open surgical approach during the 12 months prior to the survey. Of those who used an open surgical approach, 45.7% (n=95) reported performing SLNM in the majority of their cases. Of those performing SLNM, laparotomy was the most commonly used approach to SLNM (74.7%), followed by robotic-assisted laparoscopy (13.7%), and laparoscopy (11.6%). The most common perceived benefits of SLNM included reduced surgical morbidity and reduced lymphedema (both 93.7%) followed by increased accuracy of identifying node positive disease and decreased operating room time (56.8% and 43.2%, respectively). Among the 54.3% (n=113) who did not perform SLNM, the most common concerns were regarding the lack of supporting data for use (51.3%), missing positive nodal disease (30.1%), and lack of access to technology (30.1%). Cost of equipment (32.8%) and operating room leadership priorities (32.4%) were the two largest barriers to SLNM technology. Over half (55.4%) of respondents performed SLNM prior to the LACC trial. Those who performed SLNM prior to the LACC trial were less likely to report an open surgical approach during the last 12 months compared to those who did not use SLNM prior (82.8% vs 91.7%; p=0.044). Of the 134 surgeons who reporting using SLNM before the LACC trial, 60.4% continue to use SLNM (n=81). Overall, 56.2% agree that the data supports the use of SLNM and 77.3% of those surveyed agree that gynecology oncology fellows should be trained in SLNM techniques for early-stage cervical cancer. Conclusions: Following the publication of the LACC trial, the majority of gynecologic oncologists report an open approach for radical surgeries for early-stage cervical cancer. However, SLNM is being used in less than half of these cases, which is decreased from prior to LACC trial publication. The most common reasons for not using SLNM technology include lack of supporting data for use, concern for missing positive nodal disease, and lack of access to technology. While data support the SLNM approach such that this technique is included in national guidelines, the oncologic safety and efficacy of the SLNM technique in early-stage cervical cancer is being addressed in an international trial (SENTICOL3). However, access to technology is an issue that deserves attention in the post-LACC era to ensure equitable delivery of care for patients eligible for this approach. To determine practice patterns among gynecologic oncologists in sentinel lymph node mapping (SLNM) for early-stage cervical cancer after the Laparoscopic Approach to Cervical Cancer trial (LACC) An online survey was distributed to candidates and full members of the Society of Gynecologic Oncology (SGO) in September 2020. The survey assessed the incidence of SLNM in early-stage cervical cancer, practice patterns, perceived benefits, barriers to SLNM, and how practice may have changed after the LACC trial. Descriptive statistics and univariate analyses were performed. Of the 1206 SGO members surveyed, 242 responses (20.1%) were received during a three-week period in September 2020. The majority of respondents, 86.8% (n=210), reported performing >50% of their radical surgeries for early-stage cervical cancer with an open surgical approach during the 12 months prior to the survey. Of those who used an open surgical approach, 45.7% (n=95) reported performing SLNM in the majority of their cases. Of those performing SLNM, laparotomy was the most commonly used approach to SLNM (74.7%), followed by robotic-assisted laparoscopy (13.7%), and laparoscopy (11.6%). The most common perceived benefits of SLNM included reduced surgical morbidity and reduced lymphedema (both 93.7%) followed by increased accuracy of identifying node positive disease and decreased operating room time (56.8% and 43.2%, respectively). Among the 54.3% (n=113) who did not perform SLNM, the most common concerns were regarding the lack of supporting data for use (51.3%), missing positive nodal disease (30.1%), and lack of access to technology (30.1%). Cost of equipment (32.8%) and operating room leadership priorities (32.4%) were the two largest barriers to SLNM technology. Over half (55.4%) of respondents performed SLNM prior to the LACC trial. Those who performed SLNM prior to the LACC trial were less likely to report an open surgical approach during the last 12 months compared to those who did not use SLNM prior (82.8% vs 91.7%; p=0.044). Of the 134 surgeons who reporting using SLNM before the LACC trial, 60.4% continue to use SLNM (n=81). Overall, 56.2% agree that the data supports the use of SLNM and 77.3% of those surveyed agree that gynecology oncology fellows should be trained in SLNM techniques for early-stage cervical cancer. Following the publication of the LACC trial, the majority of gynecologic oncologists report an open approach for radical surgeries for early-stage cervical cancer. However, SLNM is being used in less than half of these cases, which is decreased from prior to LACC trial publication. The most common reasons for not using SLNM technology include lack of supporting data for use, concern for missing positive nodal disease, and lack of access to technology. While data support the SLNM approach such that this technique is included in national guidelines, the oncologic safety and efficacy of the SLNM technique in early-stage cervical cancer is being addressed in an international trial (SENTICOL3). However, access to technology is an issue that deserves attention in the post-LACC era to ensure equitable delivery of care for patients eligible for this approach.