Trachelectomy in decline: national trends, outcomes, and academic output across 3 major databases.
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BACKGROUND: In 2021, the ConCerv study provided the first prospective evidence that fertility-sparing surgery, including conization or simple hysterectomy, was safe in low-risk cervical cancer, and recurrence rates remained low, although oncologic outcomes were not the primary endpoint. OBJECTIVE: This study aimed to examine temporal trends in 2 fertility-sparing procedures for cervical cancer (trachelectomy and conization) along with associated oncologic outcomes and patterns of academic productivity via 3 separate datasets. STUDY DESIGN: This was a retrospective study of 3 separate database, integrating clinical data from the National Cancer Database (2004-2022; for oncologic outcomes and surgical trends), perioperative outcomes from the American College of Surgeons National Surgical Quality Improvement Program Participant Use Data Files (2012-2022; for postoperative complications), and scholarly output from the Web of Science Core Collection (2000-2025; for bibliometric analysis). In the National Cancer Database, we identified two cohorts of patients aged 18 to 45 years with cervical cancer, irrespective of histologic subtype, who were managed with conservative surgery and nodal staging: the first cohort underwent trachelectomy (radicality not specified), whereas the second cohort underwent conization. Temporal trends were examined using annual procedure counts, proportional utilization, and annual percentage change. Clinicopathologic characteristics were descriptively summarized and compared using appropriate parametric or nonparametric tests and chi-squared tests, with Bonferroni correction for multiple comparisons. Overall survival was analyzed in node-negative cases using Kaplan-Meier and log-rank methods, and treatment effects were evaluated with multivariate Cox regression adjusted for stage, histology, surgical margins, and tumor size, reporting hazard ratios with 95% confidence intervals. RESULTS: A total of 1841 patients underwent conservative surgery with lymph node assessment, including 911 trachelectomies (49.5%) and 930 conizations (50.5%). Patients who underwent trachelectomy were younger than those who underwent conization (median: 31 vs 33 years, respectively; P<.001). The number of lymph nodes examined was significantly greater in the trachelectomy cohort than in the conization cohort (15 vs 10, respectively; P<.001). Trachelectomy had a lower proportion of squamous cell carcinoma (465/911 [51.0%]) than conizations (570/930 [61.3%]), and adenocarcinoma was more common among patients who underwent trachelectomy (371/911 [40.7%]) than those who underwent conization (327/930 [35.2%]) (P<.001). In absolute numbers, trachelectomy use increased from 2004 to the mid-2010s, peaking in 2016, but subsequently demonstrated a steady and sustained decline through 2022. Among the whole cohort, the proportion of patients treated with trachelectomy declined from 64.0% in 2011 to 33.3% in 2022 (P<.001). The 10-year overall survival was similar between the groups (93.4% vs 92.3%; log-rank P=.39). In Cox regression, trachelectomy was not associated with overall survival (hazard ratio, 1.02 [95% confidence interval, 0.56-1.86]). Bibliometric analysis identified 1585 trachelectomy-related publications, which peaked in 2021 (n=128) and declined thereafter. Original research comprised 58.0% and reviews 15.6% of publications. CONCLUSION: Trachelectomy use has decreased significantly in recent years, and overall survival was high in both cohorts. This alignment of excellent overall survival with changing practice patterns underscores an ongoing transition toward less radical surgery.