Cervical Cancer
Conditions
Brief summary
The reason this study is being done is to see if a simple hysterectomy is as good as a radical hysterectomy in preventing cancer of the cervix from returning, and whether, because less tissue surrounding the uterus is removed during surgery, there are fewer side-effects after the surgery and in the long-term.
Detailed description
At this time, it is not clear which of these approaches best balances the desire to prevent cancer of the cervix from returning with the risks of side effects after surgery and in the long-term.
Interventions
This procedure may be performed abdominally, laparoscopically, robotically or vaginally. The uterus, cervix, medial 1/3 of parametria, 2cm of the uterosacral ligaments and upper 1-2cm of the vagina are to be removed en bloc. The uterine artery is ligated laterally to the ureters and the ureters are unroofed to the ureterovesical junction.
PROCEDURESimple hysterectomy + pelvic lymph node dissection
This procedure may be performed abdominally, laparoscopically, robotically or vaginally. Extrafascial hysterectomy involves removal of the uterus with cervix without adjacent parametria. The uterine arteries are transected medial to the ureters at the level of the isthmus and the uterosacral ligaments are transected at the level of the cervix. Surgeons should pay special attention to make sure that the whole cervix is removed. As such, a maximum of 0.5 cm of vaginal cuff can be removed to ensure the complete removal of the cervix.
Sponsors
Canadian Cancer Trials Group
Gynecologic Cancer Intergroup (GCIG)
Canadian Institutes of Health Research (CIHR)
Korean Gynecologic Oncology Group
Dutch Gynaecological Oncology Group
Cancer Trials Ireland
Arbeitsgemeinschaft Gynaekologische Onkologie Austria
Belgian Gynaecological Oncology Group
ARCAGY/ GINECO GROUP
Institute of Cancer Research, United Kingdom
Shanghai Cancer Centre
P. Herzen Moscow Oncology Research Institute
Arbeitsgemeinschaft Gynaekologische Onkologie Studiengruppe Ovarialkarzinom Germany
Institut Universitaire du Cancer de Toulouse
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
NONE
Eligibility
Sex/Gender
FEMALE
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
* Histologically confirmed adenocarcinoma, squamous, or adenosquamous cancer of the cervix. Diagnosis has been made by LEEP, cone or cervical biopsy and has been reviewed and confirmed by the local reference gynecological pathologist. * Patient has been classified as low-risk early-stage cervical cancer. These patients include: • FIGO Stage IA2 \[FIGO Annual Report, 2009\], defined as: o evidence of disease by microscopy; * for patients who underwent a LEEP or cone: * histologic evidence of depth of stromal invasion \> 3.0 and ≤ 5.0 mm based on the local reference pathologist's measurement of the LEEP or cone specimen NB: the maximum depth of stromal invasion must be ≤ 10 mm. * histologic evidence of lateral extension that is ≤ 7.0 mm based on the local reference pathologist's measurement of the LEEP or cone specimen; and * negative margins (patients with positive margins are considered IB1, see below) * for patients who underwent a cervical biopsy only: * radiologic evidence of less than 50% stromal invasion based on pelvic MRI • FIGO Stage IB1 \[FIGO Annual Report, 2009\] with favorable (low risk) features, defined as: * measured stromal invasion and lateral extension that meet the criteria for IA2 (see above) but with positive margins; * evidence of disease by clinical exam; lesion must clinically measure ≤ 20 mm * evidence of disease by microscopy; * for patients who underwent a LEEP or cone: * histologic evidence of depth of stromal invasion between 5.1-10 mm and/or lateral extension between 7.1-20.0 mm based on the local reference pathologist's measurement of the LEEP or cone specimen * for patients who underwent a cervical biopsy only: * radiologic evidence of less than 50% stromal invasion based on pelvic MRI * lateral extension ≤ 20 mm based on clinical exam or radiologic imaging. In addition to above criteria on maximal stromal invasion of ≤ 10 mm, the lesion must be no larger than 20 mm in any dimension by any assessment method (MRI, clinical or histological exam). To ensure patients meet this criterion, investigators may need to sum the lesion measurements from biopsy and other methods that evaluate it in the same plane. Patients are eligible irrespective of the presence or absence of lymph-vascular space involvement (LVSI). * Physical examination, recto-vaginal examination and visualization of the cervix by speculum or colposcopic examination have been done after the initial diagnostic procedure (LEEP, cone or biopsy) and prior to randomization. * Chest x-ray or CT scan of chest AND pelvic MRI\* done after initial diagnostic procedure (LEEP, cone or biopsy) and prior to randomization. The CT should be a 16 slice (or higher) helical scanner. Oral and intravenous contrasts are preferred (unless there is a contraindication to the use of contrast) with scan obtained in the portal phase at a slice thickness of 5mm or lower Pelvic MRI should be performed on a 1.5 or 3 Tesla magnet with pelvic phased-array coils. The MR pulse sequences will consist of T1 gradient echo in the axial plane at 5 mm slice thickness and fast spin echo in the axial, sagittal, and coronal planes at 4 mm slice thickness. The short axis (perpendicular to the tumour's long axis) with a 3 mm slice thickness is required in the best plane to show the maximum thickness of stromal invasion. Use of an anti-peristaltic agent is mandatory while intravenous use of gadolinium or diffusion-weighted imaging (DWI) is optional. \* Note: pelvic MRI is optional if the patient has stage IA2 disease and underwent a LEEP or cone. * After consideration of a patient's medical history, physical examination and laboratory testing, patients must be suitable candidates for surgery as defined by the attending physician / investigator. * Patients must have no desire to preserve fertility. * Patients fluent in English or French must be willing to complete the Quality of Life Questionnaire. The baseline assessments must be completed within 6 weeks prior to randomization. Inability (illiteracy in English or French, loss of sight, or other equivalent reason) to complete the questionnaires will not make the patient ineligible for the study. However, ability but unwillingness to complete the questionnaires will make the patient ineligible. As additional GCIG groups join the study, more translations of some of the questionnaires may be added. Patients fluent in English or French who reside in Canada and the United Kingdom must agree to participate in the economic evaluation component of this trial and complete the Health Economics Questionnaire. Similarly, patients fluent in English or French accrued from other GCIG groups who are participating in the economic evaluation must be willing to complete the Health Economics Questionnaires. * Patient consent must be appropriately obtained in accordance with applicable local and regulatory requirements. Each patient must sign a consent form prior to enrolment in the trial to document their willingness to participate. * Patients must be accessible for treatment and follow-up. Investigators must assure themselves the patients randomized on this trial will be available for complete documentation of the treatment, adverse events, and follow-up. * Surgery is to be done within 20 weeks of initial diagnosis (NO EXCEPTIONS). The 20-week period includes time required for diagnosis, referral, diagnostic staging, randomization and scheduling of the surgical procedure. * Patients must be ≥ 18 years old.
Exclusion criteria
* Patients with FIGO 1A1 disease \[FIGO Annual Report, 2009\]. * History of other malignancies, except: adequately treated non-melanoma skin cancer, curatively treated in-situ cancer of the cervix, or other solid tumours, Hodgkin's lymphoma or non-Hodgkin's lymphoma curatively treated with no evidence of disease for \> 5 years. * Patients with evidence of lymph node metastasis on preoperative imaging or histology. * Patients who have had or will receive neoadjuvant chemotherapy. * Patients who are pregnant. * Patients for whom adjuvant radiation and/or chemotherapy is planned.
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Pelvic Recurrence Rate at 3 Years | 3 years | Pelvic recurrence rate at 3 years was estimated by 1-the Kaplan-Meier estimate for the probability of pelvic relapse free survival (PRFS) at 3 years. PRFS was defined as the time from randomization to the time when a recurrence within the pelvic field was first documented. Patients who had a relapse outside of the pelvic field documented or died before the documentation of a pelvic relapse were censored at the time of first documented extra-pelvic relapse or death. The pelvic relapse free survival of patients who were alive without any relapse at the time of final analysis was censored at the last known alive. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Pelvic Relapse-free Survival | 3 years | It was defined as the time from randomization to the time when a recurrence within the pelvic field was first documented. Patients who had a relapse outside of the pelvic field documented or died before the documentation of a pelvic relapse were censored at the time of first documented extra-pelvic relapse or death. The pelvic relapse free survival of patients who were alive without any relapse at the time of final analysis was censored at the last known alive. 3 year pelvic relapse-free survival was estimated by Kaplan-Meier method. |
| Extra-pelvic Relapse-free Survival | 3 years | It was defined as the time from randomization to the documented reappearance of disease provided that this recurrence is outside of pelvic. Patients who relapsed in pelvic field were censored at the time of first documented pelvic relapse. Patients who died before any relapse or alive without recurrence were censored at the date of death or last known alive date. 3 year extra-pelvic relapse-free survival was estimated by Kaplan-Meier method. |
| Relapse-free Survival | 3 years | It was defined as the time from randomization to the first time when either a pelvic or extra-pelvic recurrence was documented. Patients who died before any recurrence or alive without recurrence were censored at the date of death or last known alive date. 3 year relapse-free survival was estimated by Kaplan-Meier method. |
| Overall Survival | 3 years | It was defined as the time from randomization until death from any cause. The living patients were censored at the date of last known alive. 3 year overall survival was estimated by Kaplan-Meier method. |
Countries
Austria, Belgium, Canada, China, France, Germany, Ireland, Netherlands, Norway, Russia, United Kingdom
Participant flow
Participants by arm
| Arm | Count |
|---|---|
| Radical Hysterectomy Radical Hysterectomy + pelvic lymph node dissection: This procedure may be performed abdominally, laparoscopically, robotically or vaginally. The uterus, cervix, medial 1/3 of parametria, 2cm of the uterosacral ligaments and upper 1-2cm of the vagina are to be removed en bloc. The uterine artery is ligated laterally to the ureters and the ureters are unroofed to the ureterovesical junction. | 350 |
| Simple Hysterectomy Simple hysterectomy + pelvic lymph node dissection: This procedure may be performed abdominally, laparoscopically, robotically or vaginally. Extrafascial hysterectomy involves removal of the uterus with cervix without adjacent parametria. The uterine arteries are transected medial to the ureters at the level of the isthmus and the uterosacral ligaments are transected at the level of the cervix. Surgeons should pay special attention to make sure that the whole cervix is removed. As such, a maximum of 0.5 cm of vaginal cuff can be removed to ensure the complete removal of the cervix. | 350 |
| Total | 700 |
Baseline characteristics
| Characteristic | Simple Hysterectomy | Total | Radical Hysterectomy |
|---|---|---|---|
| Age, Continuous | 42 years | 44 years | 45 years |
| Race (NIH/OMB) American Indian or Alaska Native | 2 Participants | 3 Participants | 1 Participants |
| Race (NIH/OMB) Asian | 22 Participants | 41 Participants | 19 Participants |
| Race (NIH/OMB) Black or African American | 3 Participants | 8 Participants | 5 Participants |
| Race (NIH/OMB) More than one race | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Native Hawaiian or Other Pacific Islander | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Unknown or Not Reported | 59 Participants | 123 Participants | 64 Participants |
| Race (NIH/OMB) White | 264 Participants | 525 Participants | 261 Participants |
| Region of Enrollment Austria | 13 participants | 28 participants | 15 participants |
| Region of Enrollment Belgium | 20 participants | 40 participants | 20 participants |
| Region of Enrollment Canada | 94 participants | 186 participants | 92 participants |
| Region of Enrollment China | 2 participants | 2 participants | 0 participants |
| Region of Enrollment France | 58 participants | 122 participants | 64 participants |
| Region of Enrollment Germany | 27 participants | 56 participants | 29 participants |
| Region of Enrollment Ireland | 7 participants | 14 participants | 7 participants |
| Region of Enrollment Netherlands | 57 participants | 110 participants | 53 participants |
| Region of Enrollment Norway | 9 participants | 20 participants | 11 participants |
| Region of Enrollment Russia | 1 participants | 2 participants | 1 participants |
| Region of Enrollment South Korea | 9 participants | 18 participants | 9 participants |
| Region of Enrollment United Kingdom | 53 participants | 102 participants | 49 participants |
| Sex: Female, Male Female | 350 Participants | 700 Participants | 350 Participants |
| Sex: Female, Male Male | 0 Participants | 0 Participants | 0 Participants |
Adverse events
| Event type | EG000 affected / at risk | EG001 affected / at risk |
|---|---|---|
| deaths Total, all-cause mortality | 7 / 344 | 7 / 338 |
| other Total, other adverse events | 208 / 344 | 181 / 338 |
| serious Total, serious adverse events | 0 / 344 | 0 / 338 |
Outcome results
Primary
Pelvic Recurrence Rate at 3 Years
Pelvic recurrence rate at 3 years was estimated by 1-the Kaplan-Meier estimate for the probability of pelvic relapse free survival (PRFS) at 3 years. PRFS was defined as the time from randomization to the time when a recurrence within the pelvic field was first documented. Patients who had a relapse outside of the pelvic field documented or died before the documentation of a pelvic relapse were censored at the time of first documented extra-pelvic relapse or death. The pelvic relapse free survival of patients who were alive without any relapse at the time of final analysis was censored at the last known alive.
Time frame: 3 years
Population: All patients randomized.
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Radical Hysterectomy | Pelvic Recurrence Rate at 3 Years | 2.17 percentage of participants |
| Simple Hysterectomy | Pelvic Recurrence Rate at 3 Years | 2.52 percentage of participants |
90% CI: [-0.0162, 0.0232]
Secondary
Extra-pelvic Relapse-free Survival
It was defined as the time from randomization to the documented reappearance of disease provided that this recurrence is outside of pelvic. Patients who relapsed in pelvic field were censored at the time of first documented pelvic relapse. Patients who died before any relapse or alive without recurrence were censored at the date of death or last known alive date. 3 year extra-pelvic relapse-free survival was estimated by Kaplan-Meier method.
Time frame: 3 years
Population: All patients randomized.
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Radical Hysterectomy | Extra-pelvic Relapse-free Survival | 99.7 percentage of participants |
| Simple Hysterectomy | Extra-pelvic Relapse-free Survival | 98.1 percentage of participants |
95% CI: [0.79, 18.4]
Secondary
Overall Survival
It was defined as the time from randomization until death from any cause. The living patients were censored at the date of last known alive. 3 year overall survival was estimated by Kaplan-Meier method.
Time frame: 3 years
Population: All patients randomized.
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Radical Hysterectomy | Overall Survival | 99.4 percentage of participants |
| Simple Hysterectomy | Overall Survival | 99.1 percentage of participants |
95% CI: [0.38, 3.14]
Secondary
Pelvic Relapse-free Survival
It was defined as the time from randomization to the time when a recurrence within the pelvic field was first documented. Patients who had a relapse outside of the pelvic field documented or died before the documentation of a pelvic relapse were censored at the time of first documented extra-pelvic relapse or death. The pelvic relapse free survival of patients who were alive without any relapse at the time of final analysis was censored at the last known alive. 3 year pelvic relapse-free survival was estimated by Kaplan-Meier method.
Time frame: 3 years
Population: All patients randomized.
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Radical Hysterectomy | Pelvic Relapse-free Survival | 97.5 percentage of participants |
| Simple Hysterectomy | Pelvic Relapse-free Survival | 97.8 percentage of participants |
95% CI: [0.47, 2.67]
Secondary
Relapse-free Survival
It was defined as the time from randomization to the first time when either a pelvic or extra-pelvic recurrence was documented. Patients who died before any recurrence or alive without recurrence were censored at the date of death or last known alive date. 3 year relapse-free survival was estimated by Kaplan-Meier method.
Time frame: 3 years
Population: All patients randomized.
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Radical Hysterectomy | Relapse-free Survival | 97.8 percentage of participants |
| Simple Hysterectomy | Relapse-free Survival | 96.3 percentage of participants |
95% CI: [0.69, 3.45]