Oncological And Obstetrical Outcomes With Fertility-sparing Therapy For Early-stage Cervical Cancer:a Meta-analysis

Background:The cervical cancer is the fourth most popular malignant neoplasm in female throughout the world. Recently, with the improvement of cervical cancer screening test, early onset age, and delay of childbearing, more reproductive age females are diagnosed with early cervical cancer before giving births. As reported,43%of the patients diagnosed cervical cancer aged under 45, and patients aged under 40 years account for 20-28%. While many young women have no babies yet, standard treatment for these patients is radical hysterectomy combined with pelvic lymphadenectomy or radiation, which results in the loss of childbearing ability. Since Dargent came up with radical vaginal trachelectomy(RVT) associated with laparoscopic lymphadenectomy for young females with early stage cervical cancer in 1994, thousands of eCC patients with strong willing for fertility sparing published undergone the conservative surgery, with a global pregnancy rate (total number of women who conceived of all who retained fertility) of 24%, and a relapse and death rate of 4.2%and 2.9%; respectively. And to overcome the unproficient aspects of RVT in treating eCC, surgeons offer alternative approaches such as abdominal radical trachelectomy or even robotic radical trachelectomy, which broadens the applied range of RT procedure. Although researches demonstrating that radical trachelectomy as a safe and feasible technique can bring excellent results similar with radical surgery for eCC in terms of overall survival and disease-free survival rate, high rates of first-, second-trimester and preterm births becomes the main problem. Considering the truth of low rate of parametrial metastasis, more conservative surgery mode is being developed such as simple conization with or without pelvic lymphadenectomy. However, sufficient evidence that conization is effective and safe for young patients with eCC is still scarce and further surveys need to be done.Objective:The objective of the study was to evaluate the relapse, death rate, pregnancy rate and pregnancy outcome of early-stage cervical cancer(eCC) with fertility-sparing treatments, conization and radical trachelectomy(RT) with or without pelvic lymphadenectomy by meta-analysis.Method:Glean researches on Cochrane Library, PubMed, Medline and Embase up to September 2015 about security and pregnant outcome of eCC patients operated by conization or RT. Screen through the assays and exclude those that don’t conform to the aim of our research and the ones with low quality. Use the Methodological Index for Non-Randomized Studies(MINORS) to assess the quality of the researches and make a meta-analysis by RevMan 5.3 of these articles focusing on the security, effectiveness and pregnancy results. Odds Ratio(OR) for recurrence rate, mortality and their corresponding 95%confidence intervals (CIs) are used to calculate the prognosis. The rates of pregnancy, miscarriage and preterm delivery with their corresponding 95%confidence intervals (CIs) are used to describe the pregnancy outcome.Results:60 observational studies with 2,854 patients were included, evaluating the relapse, death rates, and pregnancy outcome of eCC planned for conservative treatments of conization(CON group:17 studies) and RT(RT group:43 studies). We identified 375 cases in CON group and 2479 cases in RT group. In CON group, the ratio of different stages are IA1 46.9%, IA28.0%, IB144.5%, IB20.3%, IIA 0.3%; in RT group, they are IA16.0%, IA2 12.1%, IB179.9%, IB21.5%, IIA 0.5%. Conization for eCC achieved in 347(92.5%) cases to maintain fertility competence, bringing a pooled relapse rate of 3.8%, a pregnancy rate of 40.5%, an abortion rate of 21.9%and a preterm delivery rate of 16.0%. For RT group, 2273(91.7%) patients kept fertility competence with a pooled relapse rate of 5.7%, a pregnancy rate of 21.9%, an abortion rate of 30.6%and a preterm delivery rate of 35.1%. For subgroup analysis, the relapse rates of conization and RT in stage IA were 3.8%,7.4%, respectively; in stage IB were 5.7%and 7.4%.Conclusion:1. Fertility-sparing treatment of RT for eCC is feasible and an effective treatment to selected women which can satisfy their reproductive desires favorably, especially for patients under stage IB1.2. Compared with RT, conization seems to be easier to obtain better pregnancy outcome.3. Security of conization in stage IB1 still needs more high-qualified clinical trials or researches to prove further.