Expert Point of View: Shitanshu Uppal, MD

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COMMENTING ON the study, invited discussant Shitanshu Uppal, MD, of the University of Michigan in Ann Arbor, called the data “provocative” but said he had progressed through the “five stages of grief” in reaction to the results. “I’ve gone through denial, I’ve gone through anger, I couldn’t bargain, and depression wasn’t an option, so I think I’m getting to acceptance,” he told the audience. 

Although he agreed with Dr. Ramirez that the results should be discussed with patients scheduled to undergo radical hysterectomy, he pointed out some of the major study limitations: early termination of the trial (631 patients vs the planned 740 patients) as well as unreported tumor size, grade, and invasion data in one-third of patients. “As more data are collected, controlling for these factors could change the results of this trial,” he said. He also noted the trial’s heavy leaning toward laparoscopic vs robotic-assisted procedures: 84% vs 16%. “These numbers are almost opposite in the United States,” he added. 

According to Dr. Uppal, surgeons should review the technique for minimally invasive radical hysterectomy. He suggested several potential starting points for explaining the increased risk of death associated with the modality in this study: the learning curve associated with minimally invasive surgery, exposure of the tumor to the peritoneal cavity, and the potential role of the uterine manipulator. He also stressed the importance of individual risk assessment (ie, an exophytic 2-cm tumor vs a 2-cm tumor on the cone with negative margins; young and healthy vs old/frail patients with multiple comorbidities). ■

DISCLOSURE: Dr. Uppal reported no conflicts of interest. 

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