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Simple hysterectomy led to better sexual health outcomes compared with radical hysterectomy in patients with low-risk, early-stage cervical cancer, according to updated findings from the phase III SHAPE (Simple Hysterectomy and Pelvic Node Assessment) trial.

Reporting the results in the , Sarah E. Ferguson, MD, of Princess Margaret Cancer Centre, University Health Network, in Toronto, Ontario, and colleagues noted that treating cervical cancer with various modalities (i.e., surgery, radiation therapy, and chemotherapy) can lead to significant sexual morbidity secondary to the direct effects on sexual organs, autonomic nerves, and estrogen production. In addition, changes in sexual health and the psychosocial impact of those changes can cause distress after cervical cancer.

The researchers concluded that the findings support use of less extensive surgery for early-stage cervical cancer where appropriate.

The following Q&A includes additional details about the study. (The authors were not available for comment, and the answers here are from the text of the report.)

What does the study add to the literature?

in Feb. 2024 found that simple hysterectomy was non-inferior to radical hysterectomy for the treatment of women with low-risk early-stage cervical cancer, with a 3-year pelvic recurrence rate difference of only 0.35%.

In this population with very high recurrence-free survival (more than 96%) and overall survival it is important to evaluate other outcomes, such as sexual health, that may be improved with surgical de-escalation.

Our new study is the first surgical trial assessing sexual health as an important clinical outcome. We found the secondary sexual health and quality-of-life outcomes in patients with low-risk early-stage cervical cancer treated with simple hysterectomy compared favorably with radical hysterectomy.

What do you consider the highlights?

Using validated patient-reported outcome measures, we found that patients undergoing simple hysterectomy experienced less sexual dysfunction and distress as compared with radical hysterectomy. Although there was no impact on orgasm or sexual satisfaction between surgical groups, there were short-term adverse effects on arousal and desire for patients undergoing radical hysterectomy.

The most striking impact of radical surgery was the adverse effect on sexual vaginal functioning, with a clinically meaningful difference. Although between-group differences decreased over time, they persisted for 2 years, and neither surgical group returned to their baseline sexual vaginal functioning.

There was consistency between sexual health measures when assessing vaginal health with worse vaginal pain and lubrication for up to 1 year, thereby increasing the validity of these results. These changes resulted in more sexual worry, decreased sexual enjoyment, and less sexual activity (up to 3 years) in those treated with radical hysterectomy.

In light of the non-inferiority of simple compared with radical hysterectomy for oncologic outcomes, these results have become increasingly relevant when discussing surgical treatment in a young patient population, who have a very small chance of recurrence and a high overall survival rate.

Why has it been difficult to determine the effects of radical hysterectomy on sexual health in cervical cancer patients?

Early-stage cervical cancer is commonly diagnosed in young women and is managed surgically with radical hysterectomy and pelvic lymph node assessment that results in a cancer-specific survival rate of over 90%.

The impact of radical hysterectomy on sexual health has been difficult to determine in patients with cervical cancer since most studies are small, retrospective, and report on heterogeneous cohorts with varied stages and treatments. There has been controversy over the impact of radical hysterectomy alone on sexual health, with some studies reporting no difference in sexual functioning and others reporting both short-term and long-term negative effects of radical hysterectomy compared with healthy controls.

Considering the excellent oncologic outcomes for patients with surgically managed early-stage cervical cancer and the growing number of survivors, there is now a need for high-quality studies that aim to improve outcomes related to sexual health and quality of life.

How do your results support de-escalation of surgical treatment of low-risk early-stage cervical cancer?

The primary results of the SHAPE trial reported similar pelvic recurrence rates after simple and radical hysterectomy at 3 years, combined with worse short-term and long-term sexual and bladder function for patients undergoing radical hysterectomy.

The knowledge of the significant adverse sexual health outcomes with radical surgery has implications for patients with higher-risk early-stage (stages IB2 and IB3) disease who still require radical hysterectomy. Preoperative counseling and informed decision making are necessary to ensure that all surgical morbidity, including sexual health, is discussed, with reassurance that sexual health will improve over time.

There is an opportunity to intervene early to address these sexual health symptoms and potentially shorten their duration.

How can a woman who has had hysterectomy improve sexual function?

A reported improvement of sexual function with pelvic floor physiotherapy after gynecologic cancer treatment, including patients with cervical cancer treated with surgery alone. may include estrogen replacement therapy, both local and systemic, vaginal moisturizers and lubricants, and psychosexual counseling.

What is your main message to practicing oncologists?

The combination of non-inferiority of simple hysterectomy for oncologic outcomes, as well as improved urologic and sexual health outcomes, supports simple hysterectomy as the new standard of care for women with low-risk early-stage cervical cancer.

Read the study here.