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by Maggie Fox
Keyhole surgery seemed like a no-brainer to Jeanine Andersson when she was diagnosed with cervical cancer last year.
A hysterectomy was her best option but the 45-year-old orthopedic surgeon had two choices: "Either the traditional, what they call open laparotomy, (in which they) kind of slice you vertically down the front, take everything out, and set you back up and it's six to eight week recovery, "Andersson said.
The other was minimally invasive, robotic surgery. "Recovery was two, maybe three weeks. I would have been a no-brainer, "Andersson told NBC News.
Her friends who specialized in gynecology urged her to go to the minimally invasive route. "I minimally invasive thing thinking it was the best, and greatest thing to do," Andersson said.
But a year and a half later, her cancer was back. And now two new studies show that the common wisdom may have been wrong.
Keyhole surgery, which has become the standard for many different types of surgery, may be more dangerous for women with cervical cancer.
Women who had minimally invasive hysterectomies, including those using such machines as the Da Vinci device, were more likely to have their cancer come back and kill them than more invasive "open" surgery, the researchers found.
The results were so small that the University of Texas MD Anderson Cancer Center has been awarded a lower rate of invasive surgery for cervical cancer, and several of the researchers stated that they were advising their patients to opt for more invasive surgery.
"Dr. Joe-Alejandro Rauh-Hain, a Gynecologic Cancer Specialist at MD Anderson, who was working on one of the studies, told NBC News.
The findings did not make sense to the researchers, who believed that women who had less invasive surgery should do better, not worse, than those who got more old-fashioned, invasive operations.
"When we conceived the study we thought we were going to see the same survival in women who had minimally invasive surgery and women who had open surgery," Rauh-Hain said.
Minimally invasive surgery involves making a small incision and using cameras and instruments called endoscopes to perform the operation. It usually leads to less bleeding, fewer infections and fewer complications. Patients usually get out of the hospital sooner, and there's less scarring with the smaller incision.
Other studies have shown that these keyhole techniques are just as effective for early stage colorectal cancer, stomach cancer or cancer of the uterus. Even though there is no greater evidence to show it is better than or equal to open surgery, minimally invasive surgery for cervical cancer has become standard approach in the U.S.
Not any more.
"Given these two studies, we believe that minimally invasive radical hysterectomies for our patients with early stage cervical cancer," Rauh-Hain said.
"Personally, I will not offer minimally invasive radical hysterectomy to patients who will come to me for cervical cancer treatment." Dr. Alexander Melamed of Massachusetts General Hospital and Harvard Medical School, another member of the study team.
When the two teams first reported their findings to a meeting of specialists, they were met with skepticism. They went back to check their numbers, to make sure that they got their surgery done.
Now both teams report their full results in the New England Journal of Medicine.
One study team looked at nearly 2,500 women with stage 1 cervical cancer in 2010-2013. Half got minimally invasive surgery and of those, 79 percent of them got robotic surgery.
Those who got the less invasive technique were more likely to die, they found.
"Over a median follow-up of 45 months, the four-year mortality was 9.1 percent among women who underwent minimally invasive surgery and 5.3 percent among those who underwent open surgery," they wrote.
They said 94 women who got minimally invasive surgery died within four years compared to 70 who got open surgery. The women who got the minimally invasive surgery were 65 percent more likely to die over the next four years.
A second team did a more rigorous study, randomly assigning just over 600 women to get minimally invasive or open surgery. They reported that 86 percent of those who had the lowest invasive surgery were still suffering from the disease.
Andersson was upset that researchers had started their study comparing the two approaches when she got her surgery. And she was troubled that her follow-up after the surgery had not been focused on making sure the tumor had not grown back.
"I was inwardly fuming. I was mad, "she said. She has traveled to MD Anderson from her home in Little Rock seeking the best Houston cancer center.
The tumor was wide when it came back, and could not be removed surgically. So Andersson is being treated with radiation and chemotherapy.
The researchers do not know why the risks are higher than the minimally invasive surgery. It is possible to have a minimally invasive surgery, but it is possible that the devices used to move tissues and organs around the laparascopic surgery may be spreading tumor cells, they said.
"When we conceived the study we thought we were going to see the same survival in women who had minimally invasive surgery and women who had open surgery."
"With minimally invasive surgery the abdomen has to be inflated. "Dr. Pedro Ramirez," said Dr. Pedro Ramirez, "a professor in gynecology oncology at MD Anderson who also worked on the study and who treated Andersson.
"And it has been thought that carbon dioxide gas may have a role in causing cancer in the abdominal cavity," Ramirez told NBC News.
Surgical skill may also be a factor, said Melamed.
"An alternative explanation is that U.S. surgeons could have been less experienced with the minimally invasive procedure than with open surgery during the study period," he said.
The doctors involved agree their findings apply only to cervical cancer. "It is important to note these results are specific to cervical cancer, and minimally invasive surgery is still a great option for other surgeries and cancers," said Dr. Shohreh Shahabi, chief of gynecological oncology at Northwestern University Feinberg School of Medicine, who worked on one study team.
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