Keyhole surgery seemed like a no-brainer to Jeanine Andersson when she was diagnosed with cervical cancer last year.
A hysterectomy was her best option but the 45-year-old orthopedic surgeon had two choices: “Either the traditional, what they call open laparotomy, (in which they) kind of slice you vertically down the front, take everything out, and set you back up and it's a six to eight week recovery,” Andersson said.
The other was minimally invasive, robotic surgery. “Recovery was two, maybe three weeks. I would be back to work and to me it was a no-brainer,” Andersson told NBC News.
Her friends who specialized in gynecology urged her to go the minimally invasive route. “I chose minimally invasive thinking it was the best, latest and greatest and best thing to do,” Andersson said.
But a year and a half later, her cancer was back. And now two stunning new studies show that the common wisdom may have been wrong.
Keyhole surgery, which has become the standard for many different kinds of operations, may be more dangerous for women with cervical cancer.
Women who had minimally invasive hysterectomies, including those using robots such as the Da Vinci device, were more likely to have their cancer come back and kill them than women who had more invasive “open” surgery, the researchers found.
The results were so startling that the University of Texas MD Anderson Cancer Center has stopped offering minimally invasive surgery for most women with early stage cervical cancer, and several of the researchers at other institutions said they were advising their patients to opt for more invasive surgery.
“We are obviously all surprised about the findings,” Dr. Joe-Alejandro Rauh-Hain, a gynecologic cancer specialist at MD Anderson who worked on one of the studies, told NBC News.
The findings did not make sense to the researchers, who believed that women who got less invasive surgery should do better, not worse, than those who got more old-fashioned, invasive operations.
“When we designed the study we thought that we were going to see the same survival in women who had minimally invasive surgery and women who had open surgery,” Rauh-Hain said.
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Minimally invasive surgery involves making a small incision and using cameras and instruments called endoscopes to perform the operation. It usually leads to less bleeding, fewer infections and fewer complications. Patients usually get out of the hospital sooner, and there’s less scarring with the smaller incision.
Other studies have shown that these keyhole techniques are just as effective for early stage colorectal cancer, stomach cancer or cancer of the uterus. Even though there’s not much evidence to show whether it’s better than or equal to open surgery, minimally invasive surgery for cervical cancer has become the standard approach in the U.S.
Not any more.
“Given these two studies, we believe that we can no longer recommend minimally invasive radical hysterectomies for our patients with early stage cervical cancer,” Rauh-Hain said.
“Personally, I will not offer minimally invasive radical hysterectomy to patients who come to me for cervical cancer treatment until compelling new research demonstrates a minimally invasive approach that does not carry these risks,” agreed Dr. Alexander Melamed of Massachusetts General Hospital and Harvard Medical School, another member of the study team.
When the two teams first reported their findings earlier this year at a meeting of specialists, they were met with skepticism. They went back to check their numbers, to make sure that there wasn’t something different about the women who got open surgery compared to those who got robotic or laparascopic surgery.
Now both teams have reported their full results in the New England Journal of Medicine.
One study team looked at nearly 2,500 women with stage 1 cervical cancer in 2010-2013. Half got minimally invasive surgery and of those, 79 percent of them got robotic surgery.
Those who got the less invasive technique were more likely to die, they found.
“Over a median follow-up of 45 months, the four-year mortality was 9.1 percent among women who underwent minimally invasive surgery and 5.3 percent among those who underwent open surgery,” they wrote.
They said 94 women who got minimally invasive surgery died within four years compared to 70 who got open surgery. The women who got the minimally invasive surgery were 65 percent more likely to die over the next four years.
A second team did a more rigorous study, randomly assigning just over 600 women to get either minimally invasive or open surgery. They reported that 86 percent of those who got the minimally invasive surgery were still disease free 4.5 years later, compared to 95 percent of those who got more traditional, invasive surgery.
Andersson is upset that researchers had started their study comparing the two approaches when she got her surgery. And she was troubled that her follow-up after the surgery had not focused harder on making sure the tumor had not grown back.
“I was inwardly fuming. I was mad,” she said. She had traveled to MD Anderson from her home in Little Rock seeking the very best treatment available at the renowned Houston cancer center.
The tumor was large when it came back, and could not be removed surgically. So Andersson is being treated with radiation and chemotherapy.
The researchers don’t know why the risks are higher with the minimally invasive surgery. It’s possible minimally invasive surgery doesn’t quite get all the cancer out, or it’s possible the devices used to move tissue and organs around during the laparascopic surgery might someone spread tumor cells, they said.
“When we designed the study we thought that we were going to see the same survival in women who had minimally invasive surgery and women who had open surgery."
“With minimally invasive surgery the abdomen has to be inflated. So in other words we use gas, it's usually carbon dioxide gas, to inflate the abdomen so that we can see the surgical field,” said Dr. Pedro Ramirez, a professor in gynecologic oncology at MD Anderson who also worked on the study and who treated Andersson.
“And it has been thought that perhaps the carbon dioxide gas may have a role in causing a higher risk of cell implantation within the abdominal cavity,” Ramirez told NBC News.
Surgical skill may also be a factor, said Melamed.
“An alternative explanation is that U.S. surgeons could have been less experienced with the minimally invasive procedure than with open surgery during the study period,” he said.
The doctors involved agree their findings apply only to cervical cancer. “It is important to note these results are specific to cervical cancer, and minimally invasive surgery is still a great option for other surgeries and cancers,” said Dr. Shohreh Shahabi, chief of gynecological oncology atNorthwestern University Feinberg School of Medicine, who worked on one study team.