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Introduction

  1. Top of page
  2. Introduction
  3. Methods
  4. Results
  5. Discussion
  6. Disclosures of interest
  7. Contribution to authorship
  8. Details of ethics approval
  9. Funding
  10. Acknowledgements
  11. References

A radical hysterectomy (RH), in combination with bilateral pelvic lymphadenectomy, is the standard therapy for a woman with stage 1b1 cervical cancer. This complex surgical procedure carries the risk of serious complications and therefore selecting women for and safely undertaking this operation has become the responsibility of subspecialist gynaecological oncologists.

The process by which this occurred evolved over the last two decades. The first step was the development of a gynaecological oncology subspecialty training syllabus by the Royal College of Obstetricians and Gynaecologists (RCOG). This was followed by the establishment of a number of training centres throughout the UK. The third step followed national organisational changes that classify hospitals as either cancer units or cancer centres and arrange them in a ‘hub and spoke’ pattern. Cancer units undertake diagnostic and simple surgical procedures whereas complex surgery has become the responsibility of cancer centres. As a result, RH caseloads achieved the critical mass that allowed not only the development of but also the maintenance of the skills and experience necessary to ensure quality care.

Informal discussions within the UK gynaecological oncology community suggest a growing level of disquiet about the emergence of a number of new obstacles to the maintenance of this critical mass. First, the number of RH being undertaken is falling because overall rates of cervical cancer are falling, fertility-sparing operations have been introduced, primary chemoradiotherapy has been shown to be a viable non-surgical option, simple hysterectomy for low volume stage 1b1 tumours is acceptable and there have been efforts to limit rates of adjuvant post-RH chemoradiotherapy.1–3 Second, subspecialty trainees are entering programmes with less surgical experience – which necessitates more time on the development of basic surgical skills in the early phases of training programmes thereby leaving less time for the development of radical surgical skills and experience. Third, the introduction of laparoscopic techniques has reduced the number of RH undertaken via the open route.4 As the skills to undertake this complex operation laparoscopically are ideally developed against a background of experience with open operations, trainees are being placed in the unfortunate quandary of having access to too few open operations to develop the skills to undertake these operations laparoscopically.

The aim of this study is to provoke formal discussions on this subject by presenting an analysis of the treatments offered to a cohort of women with newly diagnosed stage 1b1 cervical cancer managed in a moderate to large gynaecological cancer centre over a three-year period.

Methods

  1. Top of page
  2. Introduction
  3. Methods
  4. Results
  5. Discussion
  6. Disclosures of interest
  7. Contribution to authorship
  8. Details of ethics approval
  9. Funding
  10. Acknowledgements
  11. References

The Pan-Birmingham Gynaecological Cancer Network provides services to a population of 1.8 million and diagnoses about 560 new gynaecological cancers per year, of which about 100 are cervical.

Care is delivered according to the ‘hub and spoke’ model outlined above with five hospitals acting as cancer units and one as a cancer centre. All women with newly diagnosed stage 1b1 cervical cancers are discussed at a cancer centre multidisciplinary team (MDT) meeting. This meeting is attended by gynaecological oncology surgeons, clinical and medical oncologists, pathologists, radiologists with a special interest and gynaecological oncology clinical nurse specialists.

This MDT acknowledges that a minority of women undergoing cervical cancer surgery will have an unacceptably high risk of death from recurrence and recommends adjuvant chemoradiotherapy for women who have lymph node metastases, inadequate surgical margins and/or two of the following factors identified in the histopathological specimens that follow radical hysterectomy and bilateral pelvic lymphadenectomy– tumour size >4 cm, lymphovascular space invasion or deep cervical stromal invasion.5 Furthermore, because of the higher rates of treatment-related morbidity in this group, it strives to limit the administration of adjuvant therapy to <20% of such women.3 It therefore carefully scrutinises every woman with newly diagnosed but untreated stage 1b1 cervical cancer for the following – histopathological evidence of lymphovascular space involvement and cross-sectional imaging evidence of lymph node metastases, tumour size >4 cm and deep cervical stromal invasion. Women are not managed surgically if lymph node metastases seem likely or if two other factors are present.

Data, including MDT discussions and decisions for newly referred women, are prospectively recorded in a dedicated database. This was used to retrieve and collate data on all women with stage 1b1 cervical cancer who were discussed for the first time between 1 January 2006 and 31 December 2008. This group was then analysed for decisions regarding primary treatment.

Results

  1. Top of page
  2. Introduction
  3. Methods
  4. Results
  5. Discussion
  6. Disclosures of interest
  7. Contribution to authorship
  8. Details of ethics approval
  9. Funding
  10. Acknowledgements
  11. References

Sixty women with stage 1b1 cervical cancer were discussed at the MDT meetings between 2006 and 2008. The treatments undertaken are listed in Table 1.

Table 1.   Treatments for stage 1b1 cervical cancer
TherapyNumber of women
Primary chemoradiotherapy3
Fertility-sparing surgery5
Simple hysterectomy6
Radical hysterectomy with bilateral pelvic lymphadenectomy46
Total60

Three women undergoing RH were considered unsuitable for training – two had body mass indices of 45 and one had a hypervascularised pelvis. As a consequence, there were 43 women undergoing RH who might have provided suitable training opportunities. Following the introduction of the laparoscopic approach in January 2008, 12 of 22 RH procedures (55%) have been undertaken in this manner.

Discussion

  1. Top of page
  2. Introduction
  3. Methods
  4. Results
  5. Discussion
  6. Disclosures of interest
  7. Contribution to authorship
  8. Details of ethics approval
  9. Funding
  10. Acknowledgements
  11. References

The gynaecological oncology surgical team in Birmingham currently consists of six consultants and two trainees. If all surgery was performed by the open route, there would be seven annual training opportunities for each trainee and a consultant caseload of 2.3 per year. Given the learning curve that is inherent in the evolution of laparoscopic skills, the paucity of training and skill maintenance opportunities is even more severe. If an earlier version of the RCOG syllabus for gynaecological oncology training – which required a trainee to participate in 20 radical cervical resections in a two-year programme – was still in place, this cancer centre would not retain its training status.

As a group of health-care professionals, the wider gynaecological oncology community can feel justifiably proud of the manner in which the therapy of stage 1b1 cervical cancer has evolved for the benefit of women – there is now a portfolio of options rather than something one-dimensional. However, this gain for women has brought new challenges and this review of experience in an average to large UK cancer network confirms the need for a re-evaluation of the organisation of care for women with stage 1b1 cervical cancer so that quality of training and maintenance of skills is upheld.

The recognition of the weak relationship between ‘number of training opportunities’ and ‘surgical competence’ has led to a recent modification of the national syllabus for gynaecological oncology subspecialty training and trainees can be accredited without achieving the original ‘target of 20’. Nevertheless, we feel that the current caseload does not reach a critical mass and that evidence of both competency developed and competency maintained is going to prove hard to provide without innovative thinking.

The Pan-Birmingham Gynaecological Cancer Centre provides its two trainees with exposure to more than 500 major surgical procedures per annum and although only 8% of these are for cervical cancer, we are confident of providing these trainees with the competencies necessary to undertake RH procedures. In response to the challenges we face, the following changes to working and training practise have been made:

  • • 
    Two consultants have withdrawn from the surgical management of women with stage 1b1 cervical cancer.
  • • 
    The training methods concentrate on the components of an RH rather than the operation as a whole – dissection of the ureteric tunnels, mobilisation of the bladder and rectum and cross-clamping/transection/ligation of the parametrial pedicles.
  • • 
    The first and second components outlined above are generic to other gynaecological oncology operations and can be learnt in and recorded for other non-cervical situations.
  • • 
    Every open RH involves two trainees and each ‘does a side’– the ureteric tunnel dissections in particular.
  • • 
    We ensure that the opportunity for trainees to participate in RH procedures takes precedence over all other activities.
  • • 
    We provide trainees with the opportunity to attend an anatomy course.
  • • 
    We encourage trainees to opt for three-year rather than two-year programmes.

Ongoing audit and feedback from RCOG review of trainees will be crucial to the assessment of these changes. There may also be a case for RH for cervical cancer being performed in supraregional centres and trainees being seconded to such units for intensive surgical training over short periods of time.

Caution is required in the interpretation of data that reflect the result of practise in one network. After all, local practise is influenced by local interpretation of the literature on the subject of treating stage 1b1 cervical cancer and several questions need to be answered. Will the recently opened phase 3 randomised trial prove the superiority of laparoscopic over open RH with bilateral pelvic lymphadenectomy?6 How safe is it to omit parametrectomy in low-volume stage 1b1 disease? Although primary chemoradiotherapy achieves equivalent rates of survival, it carries the risk of different – some would say worse – morbidities. Does the entire gynaecological oncology community concur with the 20% rate of double treatment as the ideal standard? Are networks with fewer consultants and trainees better placed to achieve the critical mass necessary for the development and maintenance of RH skills?

To assess whether international centres share similar concerns, the opinion of several colleagues in Europe and North America was solicited. The feedback was as follows.

Dr A Covens, Torontothe number of RHs performed at our centre has decreased due to the reduced incidence of cervical cancer and the evolution of fertility-sparing procedures. We perform about 60–70% of the RHs that were done ten years ago. We do not differentiate an open from a laparoscopic RHthe principles, spaces and planes are the same. To some extent this procedure is offset by our more complex pelvic operations on women with ovarian cancer, such that the necessary procedures are still taught to and learned by the trainees. One significant issue is the fact that we have eliminated routine pelvic lymphadenectomy in early-stage cervical cancer, and replaced it with sentinel lymph node biopsy only (sentinel node negative on frozen). However, our trainees have ample experience at pelvic lymphadenectomies with endometrial and ovarian cancers.

Professor I Vergote, Leuventhere is now a growing concern about both the training and maintenance of RH skills. This is a consequence of the decreasing incidence of cervical cancer, the use of robotics and other laparoscopic techniques which often are still in the development phase, making teaching even more difficult. Leuven is better placed to deliver effective training because it undertakes about 50 RHs annually (for two trainees). However smaller centres are adversely affected by this problem and further centralisation is certainly needed in our region.

Professor Koonings, San Diego (California)the United States faces similar challenges. With the improvements in cervical screening along with the restriction in work hours, the exposure to RH is limited. Therefore the opportunities to perform this operation along with its components need to be maximised. At the San Diego Kaiser Permanente facility we serve 250 000 women with two gynaecological oncologists and do approximately one open RH per month. To optimise the trainees’ experience, patients are place in lithotomy to facilitate the participation of three surgeons. Furthermore, the trainees assist each other with instruction from a consultant who is positioned between the patient’s legs. Moreover, during benign open hysterectomies, the ureter’s course is traced through the pelvis and during surgery for endometrial cancer of aggressive histopathological type, the pararectal and paravesical pelvic spaces are developed as part of lymphadenectomy. Surgery for advanced ovarian cancer presents another opportunity for trainees to learn to dissect out the ureteric tunnel. Cross-training with colorectal surgeons and urologists also provides opportunities for a trainee to gain familiarity with the pelvis, its structures and operative techniques. The realities of better screening, increasing laparoscopic technology and restricted training hours will all challenge the manner in which the next generation of gynaecological oncologists is trained. Fewer centres and computer simulations may provide some answers.

In conclusion, this audit confirms that the gynaecological oncology community has been correct in its perception of growing pressures on training opportunities and the skills maintenance of existing accredited consultants. We hope that this publication will trigger less informal and more public debate and discussion about an issue that reaches the core identity of surgical gynaecological oncologists.

Contribution to authorship

  1. Top of page
  2. Introduction
  3. Methods
  4. Results
  5. Discussion
  6. Disclosures of interest
  7. Contribution to authorship
  8. Details of ethics approval
  9. Funding
  10. Acknowledgements
  11. References

All authors participated in the design of this study and the preparation of the manuscript.

Acknowledgements

  1. Top of page
  2. Introduction
  3. Methods
  4. Results
  5. Discussion
  6. Disclosures of interest
  7. Contribution to authorship
  8. Details of ethics approval
  9. Funding
  10. Acknowledgements
  11. References

We are grateful to Dr Covens, Professor Vergote and Professor Koonings for sharing their experience.

References

  1. Top of page
  2. Introduction
  3. Methods
  4. Results
  5. Discussion
  6. Disclosures of interest
  7. Contribution to authorship
  8. Details of ethics approval
  9. Funding
  10. Acknowledgements
  11. References
  • 1
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    Naik R, Cross P, Nayar A, Mayadevi S, Lopes A, Godfrey K, et al. Conservative surgical management of small-volume stage IB1 cervical cancer. BJOG 2007;114:95863.
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    Morris M. Early cervical carcinoma: are two treatments better than one? Gynecol Oncol 1994;54:13.
  • 4
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  • 5
    Rotman M, Sedlis A, Piedmonte MR, Bundy B, Lentz SS, Muderspach LI, et al. A phase III randomized trial of postoperative pelvic irradiation in Stage IB cervical carcinoma with poor prognostic features: follow-up of a gynecologic oncology group study. Int J Radiat Oncol Biol Phys 2006;65:16976.
  • 6
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