Background: Fertility-sparing surgery (FSS) is a viable option for young women with early-stage cervical cancer (ECC); however, certain risk factors may necessitate additional treatments and impact fertility. This review examines the prevalence of these risk factors and available treatment options. Methods: A systematic search was conducted of studies including patients with ECC (IA1 with LVSI, IA2, IB1 (FIGO 2009)) who underwent FSS. Results: Sixty-four articles, comprising a total of 4118 women planned for FSS, were included. High- or intermediate-risk histologic features were found in 638 (15.5%) women: 5.1% had positive lymph node(s), 4.1% had positive resection margins, 0.3% had parametrial involvement, 1.0% had unspecified high-risk features, and 5.1% had intermediate-risk histology (primarily based on the Sedlis criteria). Adjuvant treatment impaired fertility in all women with adjuvant hysterectomy and/or (chemo)radiation (58.7%). Adjuvant chemotherapy was given to 1351 (32.8%) patients, which may reduce fertility. Conclusions: Fertility preservation could be achieved in most women; but high- or intermediate-risk factors necessitate more extensive surgery or radiotherapy leading to infertility. Adjuvant chemotherapy could be an alternative treatment option considering its effectiveness, safety and higher change in fertility preservation. The low incidence of parametrial involvement justifies waiving parametrectomy in tumors < 2 cm.

Background/Objectives: Fertility-sparing surgery (FSS) is a standard practice for managing early stage cervical cancer, yet significant variation exists in clinical approaches worldwide. Our objective was to ascertain current practices and preferences for cerclage use among expert centers globally regarding FSS in patients with early stage cervical cancer. Methods: We conducted a cross-sectional survey from May to July 2023 involving expert centers identified through their scientific contributions and participation in international workgroups and conferences.. The survey, comprising 27 questions, evaluated existing practices in FSS. Results: Out of the centers surveyed, 21 (36.2%) gynecologic oncologists responded. For tumors 2 cm, 47.6% utilized neoadjuvant chemotherapy before trachelectomy. Others did not offer FSS or performed an abdominal radical trachelectomy. Over time, there has been a shift towards less radical surgeries for tumors <2 cm and increased use of neoadjuvant chemotherapy for larger tumors. Some abandoned the minimally invasive surgical approach. Nearly all experts (90.5%) placed a cerclage immediately following trachelectomy. Conclusions: The majority of experts opt for radical trachelectomy in early stage cervical cancer, with immediate cerclage placement being a common practice. However, considerable international variations highlight the urgent need for standardized guidelines and further research to optimize treatment strategies, balancing oncological safety with fertility outcomes.

PURPOSE: The oncologic safety of fertility-sparing surgery in young women with early-stage cervical cancer is largely based on retrospective data from small series, highlighting the need for larger studies to validate its safety. METHODS: We performed a nation-wide retrospective matched cohort study of all patients age 18-45 years with Fédération Internationale de Gynécologie et d’Obstétrique (FIGO) 2018 stage IA1 to IB2 cervical cancer who underwent fertility-sparing surgery (FSS; cone biopsy, large loop excision of the transformation zone, or [radical] trachelectomy) between 2000 and 2022 in the Netherlands (fertility-sparing group). These patients were matched 1:2 with women who had a (radical) hysterectomy for early-stage cervical cancer (hysterectomy group). Patients were matched for pretreatment FIGO 2018 stage, histology, and lymph vascular space invasion. We compared data on recurrence-free survival, disease-free survival, and overall survival (OS) between the fertility-sparing group and the hysterectomy-group. RESULTS: In total, 1,446 patients were included: 482 treated with FSS and 964 with a (radical) hysterectomy; 57.5% had stage 1A1 or 1A2, and 42.5% had IB1 or IB2 cervical cancer. The median follow-up was 8.9 years (IQR, 4.4-13.7). During the study period, 4.8% of patients developed a recurrence: 7.1% in the fertility-sparing group and 3.6% in the hysterectomy group (hazard ratio [HR], 2.21 [95% CI, 1.38 to 3.56]).The OS in both groups did not differ (HR, 1.06 [95% CI, 0.62 to 1.80]). CONCLUSION: Women treated with FSS had a significantly higher recurrence rate than patients who had the uterus completely removed. However, since the increased recurrence rate did not affect OS, fertility-sparing surgery appears to be a potentially safe treatment option.

Lymph vascular space invasion (LVSI) is important in the management of early-stage cervical cancer. This study evaluated whether preoperative LVSI predicts final LVSI status and lymph node metastases (LNM), and the impact of LVSI discordance on overall survival (OS). In this nationwide retrospective cohort study, patients diagnosed between 2000 and 2024 with FIGO 2018 stages IA1-IB2 squamous, adeno-, or adenosquamous cervical carcinoma were included. Patients were classified into a biopsy-group (biopsy only prior to definitive surgery) or an excision-group (Large Loop Excision of the Transformation Zone (LLETZ) and/or conization (with or without biopsy first)) prior to surgery. In total, 2136 patients were included in the biopsy-group and 547 in the excision-group. In the biopsy-group, 40.3% of patients with preoperative LVSI-negative status was LVSI-positive on final pathology, yielding an Negative Predictive Value (NPV) of 55.8%, compared with 24.8% in the excision-group (NPV 71.0%). Among patients with FIGO 2018 stage IA1-IA2 disease, the risk of LNM was low (2.3%), including those with discordant LVSI status (1.7%). Five-year OS rates exceeded 94% across all LVSI categories for both IA1 and IA2 stages. Preoperative LVSI assessment has limited reliability in predicting final LVSI status, particularly when based on biopsy alone. Nevertheless, patients with FIGO IA1-IA2 cervical cancer and preoperative LVSI-negative status demonstrate low risks of LNM and excellent survival outcomes. Preoperative excision by LLETZ or conization improves diagnostic accuracy, informs FIGO staging and supports more informed surgical decision-making.

Fertility-sparing surgery offers the opportunity to preserve fertility but comes with higher oncologic and obstetric risks. This study aims to identify key factors influencing decision-making of women with early-stage cervical cancer. We conducted a vignette-based study involving former patients and gynecologic oncologists in the Netherlands. Eligible patients were aged 25-42 years at the time of surgery and underwent radical trachelectomy or radical hysterectomy for early-stage cervical cancer between 2014 and 2024. All Dutch gynecologic oncologists were invited. Four vignette attributes were selected based on literature and patients' and experts' opinions. Different risk percentages for these attributes were varied in 16 scenarios. Participants rated their preference on a 5-point Likert scale, where 1 indicated a strong preference for hysterectomy and 5 a strong preference for fertility-sparing surgery. Preferences were analyzed using linear mixed-effects models. A total of 58 out of 205 patients (28.3%) and 33 of 55 gynecologic oncologists (60%) participated. The mean preference for fertility-sparing surgery across all scenarios was 3.48 (95% confidence interval (CI) 3.22 to 3.74) for patients and 3.16 (95% CI 2.95 to 3.36) for gynecologic oncologists. All four attributes played significant roles in decision-making. For patients, the likelihood of achieving pregnancy was the most influential factor, increasing the preference score by 1.07 (scale 1 to 5) for an 85% chance of conception. For gynecologic oncologists, an increased risk of cancer-related death was the most decisive factor, resulting in a 1.84 decrease (scale 1 to 5) for a 10% additional risk of death. Patients and gynecologic oncologists showed a modest preference for fertility-sparing surgery over hysterectomy. Patients appeared to place relatively greater weight on likelihood of pregnancy and were less deterred than clinicians by hypothetical increases in cancer-related mortality risk. This underscores the importance of thoroughly involving patients in the decision-making process.