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Abstract
Objective
To evaluate the opinions of women who underwent surgery for cervical cancer (CC) and physicians who treat CC about the acceptability of increased oncological risk after less-radical surgery.
Methods
One hundred eighty-two women who underwent surgery for CC and 101 physicians participated in a structured survey in 3 tertiary cancer centers in Czech Republic and Turkey. Patients and physicians were asked whether they would accept any additional oncological risks, which would be attributable to the omission of parametrectomy (radical hysterectomy/ trachelectomy vs. simple hysterectomy/trachelectomy) or pelvic lymph node dissection (systematic resection vs. sentinel lymph node sampling).
Results
Although 52.2% of patients reported morbidity related to their previous treatment, the majority of patients would not accept less-radical surgical treatment if it was associated with any increased risk of recurrence (50%–55%, no risk; 17%–24%, risk <0.1%). Physicians tended to accept a significantly higher risk than patients in the Czech Republic, but not in Turkey. Patients with higher education levels, more advanced-stage of disease, or adverse events related to previous cancer treatment, and patients who received adjuvant therapy were significantly more likely to accept an increased oncological risk.
Conclusion
Patients, even if they suffered from morbidity related to previous CC treatment, do not want to choose between oncological safety and a better quality of life. Physicians tend to accept the higher oncological risk associated with less-radical surgical procedures, but attitudes differ regionally. Professionals should be aware of this tendency when counselling the patients before less-radical surgery.
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References
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 | Fig. 1.Visual comparison of the patients' and physicians' risk acceptance. The mean values of the subjective oncological risk acceptance are visualized. Hyst.=simple hysterectomy instead of RH; Lymph.=removal of SLNs only instead of pelvic lymphadenectomy; Trach.=simple trachelectomy instead of radical trachelectomy; Total=these three questions together. RH, radical hysterectomy; SLN, sentinel lymph node. |
Table 1.
Characteristics of patients
| Characteristics | Total (n=182) | Turkey (n=137) | Czech (n=45) | p value* |
|---|---|---|---|---|
| Age at diagnosis | 43; 40 | 41; 39 | 50; 49 | <0.001 |
| Age | 48; 46 | 47; 45 | 53; 52 | 0.015 |
| Parity | 2; 2 | 2; 2 | 2; 2 | 0.016 |
| Education level | <0.001 | |||
| Primary school + illiterate | 87 (47.8) | 80 (58.4) | 7 (15.6) | |
| Secondary school | 64 (35.2) | 35 (25.5) | 29 (64.4) | |
| University certificate | 31 (17.0) | 22 (16.1) | 9 (20.0) | |
| Social status | <0.001 | |||
| Employed | 49 (26.9) | 29 (21.2) | 20 (44.4) | |
| On sick leave | 8 (4.4) | 3 (2.2) | 5 (11.1) | |
| Unemployed | 12 (6.6) | 8 (5.8) | 4 (8.9) | |
| Retired | 28 (15.4) | 14 (10.2) | 14 (31.1) | |
| Housewife | 85 (46.7) | 83 (60.6) | 2 (4.4) | |
| RH/trachelectomy† | <0.001 | |||
| Yes | 166 (91.2) | 131 (95.6) | 35 (77.8) | |
| No | 16 (8.9) | 6 (4.4) | 10 (22.2) | |
| Pelvic lymphadenectomy | <0.001 | |||
| Yes | 169 (92.9) | 135 (98.5) | 34 (75.6) | |
| No | 13 (7.1) | 2 (1.5) | 11 (24.4) | |
| SLN ± pelvic lymphadenectomy | – | 2 (1.5) | 11 (24.4) | <0.001 |
| Surgery date | <0.001 | |||
| 1997–2010 | 70 (38.5) | 68 (49.6) | 2 (4.4) | |
| 2011–2016 | 112 (61.5) | 69 (50.4) | 43 (95.6) | |
| Years from surgery to 2016 | 6; 4 | 6; 5 | 3; 3 | <0.001 |
| Stage of the disease | 0.012 | |||
| IA | 29 (15.9) | 27 (19.7) | 2 (4.4) | |
| IB1 | 109 (59.9) | 79 (57.7) | 30 (66.7) | |
| IB2 | 30 (16.5) | 24 (17.5) | 6 (13.3) | |
| IIA1 | 3 (1.6) | 3 (2.1) | 0 | |
| IIA2 | 3 (1.6) | 1 (0.7) | 2 (4.4) | |
| IIB | 8 (4.4) | 3 (2.1) | 5 (11.1) | |
| Adjuvant therapy | 0.008 | |||
| Brachytherapy + EBRT | 19 (10.4) | 17 (12.4) | 2 (4.4) | |
| Concomitant RT + CT or CT | 53 (29.1) | 46 (33.6) | 7 (15.6) | |
| None CT or RT | 110 (60.4) | 74 (54.0) | 36 (80.0) |
RH, radical hysterectomy; SLN, sentinel lymph node mapping; EBRT, external beam radiation therapy; RT, radiotherapy; CT, chemotherapy.
Table 2.
Characteristics of physicians
| Characteristics | Total (n=101) | Turkey (n=47) | Czech (n=54) | p value* |
|---|---|---|---|---|
| Age | 45; 45 | 49; 49 | 41; 39 | <0.001 |
| Type of hospital | 0.424 | |||
| University or teaching hospital | 60 (59.4) | 30 (63.8) | 30 (55.6) | |
| General hospital | 41 (40.6) | 17 (36.2) | 24 (44.4) | |
| Years of experience in gynecologic oncology | 10; 10 | 13; 12 | 7; 4 | <0.001 |
| Formal specialization | <0.001 | |||
| Gynecology and obstetrics | 49 (48.5) | 9 (19.1) | 40 (74.1) | |
| Gynecologic oncology | 52 (51.5) | 38 (80.9) | 14 (25.9) | |
| Annual number of patients with invasive CC | 37; 20 | 28; 20 | 45; 16 | 0.218 |
| Average number of RHs per year | 9; 8 | 14; 10 | 4; 10 | <0.001 |
| Average number of fertility-sparing procedures in CC performed per year | 1; 0 | 1; 1 | 1; 0 | 0.037 |
Table 3.
Subjective oncological risk acceptance of patients
| Variables imple hysterectomy instead of RH* | Total (n=182) | Turkey (n=137) | Czech (n=45) |
|---|---|---|---|
| No, never (0%) | 101 (55.5) | 76 (55.5) | 25 (55.6) |
| Yes, if the maximum additional risk of treatment failure is 1 in 1,000 (0.1%) | 31 (17.0) | 22 (16.1) | 9 (20.0) |
| Yes, if the maximum additional risk of treatment failure is 1 in 100 (1%) | 27 (14.8) | 18 (13.1) | 9 (20.0) |
| Yes, if the maximum additional risk of treatment failure is 5 in 100 (5%) | 12 (6.6) | 11 (8.0) | 1 (2.2) |
| Yes, if the maximum additional risk of treatment failure is 10 in 100 (10%) | 11 (6.0) | 10 (7.3) | 1 (2.2) |
| Removal of sentinel lymph nodes only instead of pelvic lymphadenectomy† | |||
| No, never (0%) | 100 (54.9) | 75 (54.7) | 25 (55.6) |
| Yes, if the maximum additional risk of treatment failure is 1 in 1,000 (0.1%) | 44 (24.2) | 34 (24.8) | 10 (22.2) |
| Yes, if the maximum additional risk of treatment failure is 1 in 100 (1%) | 26 (14.3) | 18 (13.1) | 8 (17.8) |
| Yes, if the maximum additional risk of treatment failure is 5 in 100 (5%) | 5 (2.7) | 4 (2.9) | 1 (2.2) |
| Yes, if the maximum additional risk of treatment failure is 10 in 100 (10%) | 7 (3.8) | 6 (4.4) | 1 (2.2) |
| Simple trachelectomy instead of radical trachelectomy‡ | |||
| No, never (0%) | 95 (52.2) | 69 (50.4) | 26 (57.8) |
| Yes, if the maximum additional risk of treatment failure is 1 in 1,000 (0.1%) | 39 (21.4) | 30 (21.9) | 9 (20.0) |
| Yes, if the maximum additional risk of treatment failure is 1 in 100 (1%) | 21 (11.5) | 13 (9.5) | 8 (17.8) |
| Yes, if the maximum additional risk of treatment failure is 5 in 100 (5%) | 6 (3.3) | 5 (3.6) | 1 (2.2) |
| Yes, if the maximum additional risk of treatment failure is 10 in 100 (10%) | 21 (11.5) | 20 (14.6) | 1 (2.2) |
alues are presented as number (%). H, radical hysterectomy; SLN, sentinel lymph node. he entire text of the question:
* Would you recommend to your relatives a simple hysterectomy instead of RH, if it significantly reduces the risk of postoperative omplications such as voiding difficulties, defecation difficulties, and sexual problems, but at the same time, it may be associated with a higher risk of the reatment failure?;
† Would you recommend to your relatives a removal of SLNs only instead of complete pelvic lymphadenectomy, if it significantly reduces the sk of postoperative complications such as swelling of lower extremities, but at the same, it may be associated with a higher risk of the treatment failure?;
‡ If our relatives are diagnosed with a cervical cancer at a young age and they still plan future pregnancy, would you recommend to them a simple trachelectomy ess radical procedure aiming at partial removal of the cervix) instead of radical trachelectomy (radical procedure aiming at partial removal of the cervix ogether with the surrounding tissue), if it significantly reduces the risk of postoperative complications such as voiding difficulties, defecation difficulties, and exual problems, but at the same, it may be associated with a higher risk of the treatment failure?
Table 4.
Subjective oncological risk acceptance of physicians
| Variables | Total (n=101) | Turkey (n=47) | Czech (n=54) |
|---|---|---|---|
| Simple hysterectomy instead of RH* | |||
| No, never (0%) | 37 (36.6) | 24 (51.1) | 13 (24.1) |
| Yes, if the maximum additional risk of treatment failure is 1 in 1,000 (0.1%) | 20 (19.8) | 11 (23.4) | 9 (16.7) |
| Yes, if the maximum additional risk of treatment failure is 1 in 100 (1%) | 33 (32.7) | 10 (21.3) | 23 (42.6) |
| Yes, if the maximum additional risk of treatment failure is 5 in 100 (5%) | 9 (8.9) | 1 (2.1) | 8 (14.8) |
| Yes, if the maximum additional risk of treatment failure is 10 in 100 (10%) | 2 (2.0) | 1 (2.1) | 1 (1.9) |
| Removal of sentinel lymph nodes only instead of pelvic lymphadenectomy† | |||
| No, never (0%) | 26 (25.7) | 17 (36.2) | 9 (16.7) |
| Yes, if the maximum additional risk of treatment failure is 1 in 1,000 (0.1%) | 24 (23.8) | 14 (29.8) | 10 (18.5) |
| Yes, if the maximum additional risk of treatment failure is 1 in 100 (1%) | 36 (35.6) | 13 (27.7) | 23 (42.6) |
| Yes, if the maximum additional risk of treatment failure is 5 in 100 (5%) | 13 (12.9) | 3 (6.4) | 10 (18.5) |
| Yes, if the maximum additional risk of treatment failure is 10 in 100 (10%) | 2 (2.0) | 0 | 2 (3.7) |
| Simple trachelectomy instead of radical trachelectomy‡ | |||
| No, never (0%) | 27 (26.7) | 16 (34.0) | 11 (20.4) |
| Yes, if the maximum additional risk of treatment failure is 1 in 1,000 (0.1%) | 23 (22.8) | 14 (29.8) | 9 (16.7) |
| Yes, if the maximum additional risk of treatment failure is 1 in 100 (1%) | 33 (32.7) | 13 (27.7) | 20 (37.0) |
| Yes, if the maximum additional risk of treatment failure is 5 in 100 (5%) | 15 (14.9) | 4 (8.5) | 11 (20.4) |
| Yes, if the maximum additional risk of treatment failure is 10 in 100 (10%) | 3 (3.0) | 0 | 3 (5.6) |
* Would you recommend to your relatives a simple hysterectomy instead of RH, if it significantly reduces the risk of postoperative complications such as voiding difficulties, defecation difficulties, and sexual problems, but at the same time, it may be associated with a higher risk of the treatment failure?;
† Would you recommend to your relatives a removal of SLNs only instead of complete pelvic lymphadenectomy, if it significantly reduces the risk of postoperative complications such as swelling of lower extremities, but at the same, it may be associated with a higher risk of the treatment failure?;
‡ If your relatives are diagnosed with a cervical cancer at a young age and they still plan future pregnancy, would you recommend to them a simple trachelectomy (less radical procedure aiming at partial removal of the cervix) instead of radical trachelectomy (radical procedure aiming at partial removal of the cervix together with the surrounding tissue), if it significantly reduces the risk of postoperative complications such as voiding difficulties, defecation difficulties, and sexual problems, but at the same, it may be associated with a higher risk of the treatment failure?
Table 5.
Comparison of risk acceptance between patients and physicians
Table 6.
Factors influencing risk acceptance of patients
| Predictor | Reference category | Tested category | Total (Y/N: 250/296) | Turkey (Y/N: 191/220) | Czech (Y/N: 59/76) |
|---|---|---|---|---|---|
| Oncological risk acceptance | |||||
| Age at diagnosis | — | 0.985 (0.970–1.000) | 0.989 (0.967–1.010) | 0.979 (0.955–1.005) | |
| Age | — | 0.968 (0.953–0.983) | 0.960 (0.941–0.980) | 0.979 (0.954–1.004) | |
| Parity | — | 0.713 (0.612–0.829) | 0.789 (0.675–0.923) | 0.308 (0.189–0.500) | |
| Education level | Primary school | Secondary school | 1.156 (0.792–1.686) | 0.892 (0.560–1.420) | 38.376 (2.254–653.546)* |
| + illiterate | University certificate | 2.832 (1.728–4.642) | 2.404 (1.364–4.237) | 83.737 (4.557–1 538.676)* | |
| Social status | Employed | Housewife | 0.808 (0.537–1.215) | 0.565 (0.345–0.926) | 1.857 (0.344–10.024) |
| Other | 1.100 (0.695–1.742) | 0.755 (0.406–1.404) | 1.912 (0.940–3.889) | ||
| RH | No | Yes | 1.126 (0.629–2.014) | 1.089 (0.421–2.818) | 1.071 (0.485–2.369) |
| Pelvic lymphadenectomy | No | Yes | 0.503 (0.258–0.981) | 0.065 (0.004–1.156)* | 0.560 (0.254–1.236) |
| Surgery date | 2011–2016 | 1997–2010 | 0.683 (0.481–0.968) | 0.581 (0.393–0.859) | 1.304 (0.253–6.705) |
| Years from surgery to 2016 | — | 0.911 (0.870–0.954) | 0.889 (0.844–0.936) | 0.961 (0.718–1.285) | |
| Stage of the disease | IB1 | IA | 1.141 (0.709–1.837) | 1.023 (0.616–1.700) | 1.812 (0.345–9.509) |
| IB2 | 1.678 (1.050–2.684) | 1.599 (0.940–2.718) | 1.812 (0.654–5.025) | ||
| II+ | 2.282 (1.179–4.418) | 1.407 (0.575–3.439) | 4.531 (1.601–12.826) | ||
| Adjuvant therapy | No | Yes | 2.149 (1.517–3.044) | 2.381 (1.601–3.542) | 1.508 (0.647–3.514) |
| Quality of life after surgery† | |||||
| Swelling of lower extremities | No | Yes | 1.555 (1.106–2.185) | 1.545 (1.044–2.286) | 1.586 (0.798–3.153) |
| Voiding difficulties | No | Yes | 2.680 (1.830–3.923) | 3.355 (2.154–5.228) | 1.354 (0.633–2.894) |
| Defecation difficulties | No | Yes | 1.217 (0.868–1.706) | 1.064 (0.718–1.576) | 2.050 (1.004–4.187) |
| Sexual problems | No | Yes | 2.292 (1.617–3.248) | 2.765 (1.830–4.180) | 1.303 (0.641–2.648) |
Statistical evaluation was done with logistic regression and values are presented as OR (95% CI). The answers on subjective oncological risk acceptance were recoded as yes or no.
Y/N, Yes/No; —, used when the predictor is continuous, without reference and tested category; RH, radical hysterectomy; OR, odds ratio; CI, confidence interval.
Table 7.
Factors influencing risk acceptance of physicians
| Predictor | Reference category | Tested category | Total (Y/N: 213/90) | Turkey (Y/N: 84/57) | Czech (Y/N: 129/33) |
|---|---|---|---|---|---|
| Oncological risk acceptance | |||||
| Age | — | 0.957 (0.929–0.985) | 0.901 (0.845–0.959) | 1.009 (0.967–1.053) | |
| Type of hospital | University or teaching hospital | General hospital | 1.106 (0.668–1.831) | 3.250 (1.508–7.003) | 0.266 (0.117–0.607) |
| Years of experience in gynecologic oncology | — | 0.993 (0.963–1.023) | 0.919 (0.862–0.979) | 1.121 (1.037–1.212) | |
| Formal specialization | Gynecology and obstetrics | Gynecologic oncology | 0.845 (0.515–1.385) | 0.559 (0.226–1.381) | 32.543 (1.947–544.011)* |
| Annual number of patients with invasive CC | — | 1.016 (1.006–1.025) | 1.007 (0.987–1.028) | 1.022 (1.006–1.038) | |
| Average number of RHs per year | — | 0.989 (0.963–1.016) | 0.992 (0.956–1.029) | p<0.001† | |
| Average number of fertility-sparing procedures in CC perform per year | — | 1.116 (0.985–1.264) | 1.014 (0.826–1.245) | p=0.003† |
Statistical evaluation was done with logistic regression and values are presented as OR (95% CI). The answers on subjective oncological risk acceptance were recoded as yes or no.
Y/N, Yes/No; —, used when the predictor is continuous, without reference and tested category; CC, cervical cancer; RH, radical hysterectomy; OR, odds ratio; CI, confidence interval.
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