Response to "surgical management of cervical cancer by laparoscopy or laparotomy".

We appreciate the kind comments from Professor Tjalma from the University of Antwerp in regards to our recent review on the impact of studies from the Gynecologic Oncology Group and NRG Oncology on cervical cancer management over the last two decades (Leath 3rd and Monk, 2018). While many of the developments for contemporary cervical cancer management have resulted from a series of clinical trials performed via sponsorship by the United States National Cancer Institute through the cooperative group mechanism, increasingly multinational cooperation is helping to address unresolved questions for cervical cancer patients. At present, the benefit of chemoradiation therapy in intermediate risk cervical cancer following radical hysterectomy is being addressed in strong collaboration with the Korean Gynecologic Oncology Group (KGOG) in GOG 263 (NCT 01101451). Likewise, the GOG partnered with the Australia New Zealand Gynecologic Oncology Group (ANZGOG) in evaluating the role of adjuvant chemotherapy following chemoradiation in the Outback Trial, GOG 274 (NCT 01414608), which accrued over 900 patients worldwide.

The recent presentation by Ramirez and colleagues of data from the Laparoscopic Approach to Cervical Cancer (LACC) trial at the Society of Gynecologic Oncology Annual Meeting on Women's Cancer® in March 2018 was quite provocative and should give us all pause regarding the potential clinical implications of these results (Ramirez et al., 2018). Importantly, the initial scientific presentation of LACC is just the first step in evaluating and considering this data and its impact on clinical practice, with the planned publication not yet available through the peer review process. In his cogent and comprehensive letter in the European Journal of Obstetrics & Gynecology and Reproductive Biology, Professor Tjalma elucidated the issues germane to the current debate raised by the LACC trial, in regards to the future optimization of care for women with cervical cancer. Specifically, he questions the potential balance between surgical morbidity, which is generally accepted as more favorable for patients undergoing laparoscopy, and survival which now perhaps is worse in this same group undergoing less morbid procedures (Tjalma, 2018).

Surgical management and potential refinement of surgical techniques in cervical cancer is important. The question of the utility of minimally invasive surgery (MIS) for patients with a gynecologic cancer is not unique or without precedent having been previously addressed in endometrial cancer. The GOG performed a sentinel surgical trial for the management of early stage endometrial cancer, GOG LAP-2, which noted that minimally invasive surgery, as compared to traditional abdominal hysterectomy with surgical staging, appeared to be associated with similar oncologic outcomes with an overall survival of nearly 90% at 5-years for patients in both arms and uniformly less morbidity for women underdoing MIS (Walker et al., 2012; Walker et al., 2009).

Ramirez and colleagues are to be congratulated for taking the first step to address an extremely important question in women with cervical cancer. At present it remains to be seen if the accepted paradigm of MIS use in, or abandonment for, early stage cervical cancer will occur. We look forward to working to determine the ideal surgical management of women with early stage cervical cancer and call on the gynecologic cancer community to participate.

Conflicts of interest

The authors affirm they have no conflicts of interest for the current manuscript.