Why Is Surgery Still Done after Concurrent Chemoradiotherapy in Locally Advanced Cervical Cancer in Romania?

Simple Summary Romania ranks second in Europe in both mortality and incidence rates for cervical cancer, and the majority of cases are diagnosed in locally advanced stages. Therapeutic guidelines indicate concomitant chemoradiotherapy as the proper treatment (total dose 85-90 Gy at point A). Yet, in Romania, as a result of poor radiotherapy infrastructure, deficient patient access to radiotherapy, and specific socio-psychologic factors, concurrent chemoradiotherapy is usually suboptimal (total dose 60-65 Gy at point A) and often followed by radical surgery aimed at better local control. Our retrospective cohort study of 351 patients with histopathological confirmed locally advanced cervical cancer proved that complete pathologic response is present in less than half of patients previously treated by concurrent chemoradiotherapy, thus demonstrating the rationale behind radical surgery-better local control, especially in unfavorable aggressive histological types like adenocarcinoma and adenosquamous carcinoma or tumors that have progressed under concurrent chemoradiotherapy. We discuss several possible causes for the over-usage of surgery in Romania for treating locally advanced cervical cancer.Abstract The incidence and mortality of cervical cancer are high in Romania compared to other European countries, particularly for locally advanced cervical cancer cases, which are predominant at the time of diagnosis. Widely accepted therapeutic guidelines indicate that the treatment for locally advanced cervical cancer consists of concurrent chemoradiotherapy (total dose 85-90 Gy at point A), with surgery not being necessary as it does not lead to improved survival and results in significant additional morbidity. In Romania, the treatment for locally advanced cervical cancer differs, involving lower-dose chemoradiotherapy (total dose 60-65 Gy at point A), followed by surgery, which, under these circumstances, ensures better local control. In this regard, we attempted to evaluate the role and necessity of surgery in Romania, considering that in our study, residual lesions were found in 55.84% of cases on resected specimens, especially in cases with unfavorable histology (adenocarcinoma and adenosquamous carcinoma). This type of surgery was associated with significant morbidity (28.22%) in our study. The recurrence rate was 24.21% for operated-on patients compared to 62% for non-operated-on patients receiving suboptimal concurrent chemotherapy alone. In conclusion, in Romania, surgery will continue to play a predominant role until radiotherapy achieves the desired effectiveness for local control.