Kanbergs Alexa, Melamed Alexander, Viveros-Carreño David, Wu Chi-Fang, Wilke Roni Nitecki, Zamorano Abigail, Paladugu Kimeera, Havrilesky Laura, Rauh-Hain Jose Alejandro, Agusti Nuria
Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston.
Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston.
JAMA Netw Open. 2025 Jan 2;8(1):e2453604. doi: 10.1001/jamanetworkopen.2024.53604.
The goal of surgical deescalation is to minimize tissue damage, enhance patient outcomes, and reduce the adverse effects often associated with extensive or traditional surgical procedures. This shift toward less invasive techniques has the potential to revolutionize surgical practices, profoundly impacting the methods and training of future surgeons.
To evaluate adoption of surgical deescalation within the field of gynecologic oncology using The National Cancer Database.
DESIGN, SETTING, AND PARTICIPANTS: This cohort study used prospectively collected data from the National Cancer Database from January 2004 to December 2020. Eligible participants included women in the US who received a diagnosis of clinical stage I to IV endometrial, ovarian, cervical, or vulvar cancer within this time frame. Data were analyzed between January and June 2024.
Diagnosis of stage I to IV endometrial, ovarian, cervical, or vulvar cancer.
The primary outcome was surgical deescalation, which included evaluation of receipt of surgical intervention, the surgical approach, the type of lymph node assessment, and salvage interventions for disease-affected organs. A Poisson model was applied to estimate the average annual percentage change (AAPC) in the receipt of surgical treatment.
A total of 1 218 490 patients (mean [SD] age at diagnosis, 61.2 [13.7] years) were included. Over the study period, the percentage of patients undergoing surgery decreased from 47.4% to 39.9% for those with cervical cancer (AAPC, -1.3%; 95% CI, -1.6% to -1.1%), from 72.0% to 67.9% for those with ovarian cancer (AAPC, -0.5%; 95% CI, -0.6% to -0.4%), from 83.7% to 79.1% for those with endometrial cancer (AAPC, -0.5%; 95% CI, -0.7% to 11 -0.4%), and from 81.1% to 72.6% for those with vulvar cancer (AAPC, -1.3%; 95% CI, -1.6% to -0.9%). The use of minimally invasive surgery increased from 45.8% to 82.2% for those with endometrial cancer (AAPC, 4.6%; 95% CI, 4.5% to 4.8%) and from 13.3% to 37.0% for those with ovarian cancer (AAPC, 9.4%; 95% CI, 9.0% to 9.7%). Sentinel lymph node dissection increased from 0.7% to 39.6% for patients with endometrial cancer (AAPC, 51.8%; 95% CI, 50.5% to 53.2%), from 0.2% to 10.6% for patients with cervical cancer (AAPC, 44.0%; 95% CI, 39.3% to 48.9%), and from 12.3% to 36.9% for patients with vulvar cancer (AAPC, 10.7%; 95% CI, 8.0% to 13.5%) cancers, whereas the rate of complete lymphadenectomies decreased in all 3 groups. The rate of fertility-sparing surgery for patients with cervical cancer younger than 40 years rose from 17.8% to 28.1% (AAPC, 3.1%; 95% CI, 2.3%-3.9%).
These findings suggest that over the past 15 years, the field of gynecologic oncology has moved toward surgical deescalation through an overall reduction in the number of patients who undergo surgery, increased use of minimally invasive surgical techniques, and increased use of sentinel lymph node techniques. Future research should focus not only on understanding the impact of surgical escalation on patients (including disease outcomes, quality of life, and equitable access to these services), but also on surgical training.
手术降级的目标是将组织损伤降至最低，提高患者预后，并减少通常与广泛或传统手术相关的不良反应。这种向微创技术的转变有可能彻底改变手术实践，对未来外科医生的方法和培训产生深远影响。
利用国家癌症数据库评估妇科肿瘤领域手术降级的采用情况。
设计、设置和参与者：这项队列研究使用了2004年1月至2020年12月从国家癌症数据库前瞻性收集的数据。符合条件的参与者包括在此时间段内被诊断为临床I至IV期子宫内膜癌、卵巢癌、宫颈癌或外阴癌的美国女性。数据于2024年1月至6月进行分析。
I至IV期子宫内膜癌、卵巢癌、宫颈癌或外阴癌的诊断。
主要结局是手术降级，包括评估手术干预的接受情况、手术方式、淋巴结评估类型以及对受疾病影响器官的挽救性干预。应用泊松模型估计接受手术治疗的年均百分比变化（AAPC）。
共纳入1218490例患者（诊断时的平均[标准差]年龄为61.2[13.7]岁）。在研究期间，宫颈癌患者接受手术的比例从47.4%降至39.9%（AAPC，-1.3%；95%CI，-1.6%至-1.1%），卵巢癌患者从72.0%降至67.9%（AAPC，-0.5%；95%CI，-0.6%至-0.4%），子宫内膜癌患者从83.7%降至79.1%（AAPC，-0.5%；95%CI，-0.7%至-0.4%），外阴癌患者从81.1%降至72.6%（AAPC，-1.3%；95%CI，-1.6%至-0.9%）。子宫内膜癌患者使用微创手术的比例从45.8%增至82.2%（AAPC，4.6%；95%CI，4.5%至4.8%），卵巢癌患者从13.3%增至37.0%（AAPC，9.4%；95%CI，9.0%至9.7%）。子宫内膜癌患者前哨淋巴结清扫率从0.7%增至39.6%（AAPC，51.8%；95%CI，50.5%至53.2%），宫颈癌患者从0.2%增至10.6%（AAPC，44.0%；95%CI，39.3%至48.
