Highlight
• Treatment receipt strongly correlates with improved 5-year survival in older women with early-stage cervical cancer.
• Surgery and radiotherapy reduce cervical cancer–specific mortality in patients aged 65 years and above.
• Age-stratified analysis demonstrates consistent survival benefit across different older age groups.
• Addressing treatment barriers and enhancing preventive care could reduce cervical cancer mortality in aging populations.
Study Background and Disease Burden
Cervical cancer remains a significant health concern worldwide, and particularly among older women beyond the age of routine screening programs. Despite the availability of effective screening and early detection methods, a proportion of cervical cancers are diagnosed at an early, localized stage in older patients who often have higher comorbidities and unique treatment considerations. This demographic shift raises critical questions regarding the survival benefits of recommended treatment modalities such as surgery and radiotherapy in older adults with early-stage cervical cancer. Since older patients are frequently underrepresented in clinical trials, evidence to guide optimal management for this population remains limited. Understanding survival outcomes influenced by treatment recommendation and receipt in this group is essential to improve clinical decision making and optimize patient-centered care.
Study Design
This investigation was a retrospective cohort study utilizing data drawn from the Surveillance, Epidemiology, and End Results (SEER) program, encompassing 17 US cancer registries from 2000 to 2020. The study focused on females aged 65 years and older who had a first diagnosis of localized, microscopically confirmed invasive cervical cancer. Treatment exposures were categorized based on whether patients received recommended treatments, specifically surgery and/or radiotherapy, as documented in SEER records. Patients were further stratified according to treatment recommendation status versus actual receipt to assess adherence. Outcomes measured included five-year relative survival rates, cervical cancer–specific mortality estimated by competing risks models, and adjusted hazard ratios (AHRs) derived from Fine-Gray competing risk regression analyses. Data analysis was performed between May 2023 and January 2024, ensuring robust statistical adjustment for potential confounders to elucidate independent associations between treatment adherence and survival.
Key Findings
The study cohort included 2,236 women: 66.3% were aged 65–74 years, 25.3% aged 75–84 years, and 8.4% aged 85 years and above. The principal findings were as follows:
- Among patients aged 65–74 years, those receiving surgery exhibited a significantly higher 5-year relative survival rate of 91.2% (95% CI, 88.4%-93.4%), compared with 69.6% (95% CI, 62.8%-75.4%) in those not recommended for surgery, and 52.3% (95% CI, 24.2%-74.3%) among those recommended but untreated.
Five-Year Relative Survival Rates by Treatment Recommendation and Receipt Status.
- In the 75–84 years subgroup, surgery recipients had a similarly elevated 5-year survival rate of 88.6% (95% CI, 79.8%-93.7%) versus lower survival in untreated or non-recommended groups.
- Multivariable competing risk regression revealed significant reductions in cervical cancer–specific mortality linked to receipt of surgery (AHR, 0.28; 95% CI, 0.16–0.50) and radiotherapy (AHR, 0.48; 95% CI, 0.26–0.87) relative to patients who did not receive their recommended treatment.
Cumulative Incidence of Cancer-Specific Death by Treatment Recommendation and Receipt Status.
- The survival benefit persisted after adjusting for age-related factors, comorbidities, tumor characteristics, and other potential confounders, indicating the robustness of treatment effects in this older population.
- Notably, older patients not receiving recommended treatment had substantially poorer survival, underscoring the clinical importance of treatment adherence.
Mortality Associated With Treatment Status and Stratified by Age Group in a Multivariable Fine-Gray Competing Risk Model.
| Treatment status | Mortality risk by group, AHR (95% CI) | |||
|---|---|---|---|---|
| Overall | Age 65-74 y | Age 75-84 y | Age ≥85 y | |
| Surgery status | ||||
| Recommended, not performed | 1 [Reference] | 1 [Reference] | 1 [Reference] | 1 [Reference] |
| Not recommended | 0.81 (0.46-1.43) | 0.83 (0.35-1.96) | 0.59 (0.28-1.27) | 1.91 (0.53-6.88) |
| Performed | 0.28 (0.16-0.50) | 0.37 (0.16-0.86) | 0.20 (0.09-0.44) | 1.20 (0.34-4.31) |
| Recommended, status unknown | 1.37 (0.49-3.85) | 2.02 (0.43-9.44) | 0.93 (0.18-4.76) | 2.02 (0.16-26.01) |
| Unknown | 2.64 (0.91-7.62) | 4.30 (0.94-19.67) | 7.41 (2.65-20.72) | 1.41 (0.18-10.87) |
| Radiotherapy status | ||||
| Recommended, patient refused | 1 [Reference] | 1 [Reference] | 1 [Reference] | 1 [Reference] |
| Performed | 0.48 (0.26-0.87) | 0.41 (0.17-0.99) | 0.52 (0.12-2.23) | 0.55 (0.19-1.62) |
| Not performed or unknown | 0.42 (0.23-0.75) | 0.24 (0.10-0.58) | 0.65 (0.15-2.79) | 0.93 (0.34-2.54) |
| Recommended, status unknown | 0.77 (0.26-2.33) | 0.85 (0.22-3.33) | 0.48 (0.04-6.34) | NA |
| Chemotherapy | ||||
| Not performed or unknown | 1 [Reference] | 1 [Reference] | 1 [Reference] | 1 [Reference] |
| Performed | 0.84 (0.63-1.11) | 0.88 (0.58-1.34) | 1.01 (0.63-1.62) | 0.78 (0.32-1.89) |
| No. of cancers | 0.82 (0.64-1.05) | 0.95 (0.71-1.28) | 0.87 (0.56-1.37) | NA |
Abbreviations: AHR, adjusted hazard ratio; NA, not applicable.
Overall, these data support that receiving the recommended surgical and/or radiotherapeutic treatment confers a significant survival advantage in early-stage cervical cancer even among older patients, a population often subject to treatment hesitancy.
Expert Commentary
This comprehensive analysis addresses a critical gap in evidence regarding optimal management of early-stage cervical cancer in older patients. It corroborates guidelines emphasizing that age alone should not preclude curative treatment since benefits are clear. However, the disparity between recommendation and receipt highlights multifactorial barriers—such as patient comorbidities, physician bias, logistical challenges, or patient decision-making—that warrant targeted interventions to improve adherence. Mechanistically, early surgical removal or localized radiotherapy limits tumor progression and metastasis, maintaining functional reserve critical for elderly outcomes.
Limitations include the retrospective design and potential residual confounding inherent in registry data. Nevertheless, the large population-based cohort and rigorous competing risks methodology strengthen findings’ validity and generalizability.
Conclusion
In older women diagnosed with early-stage invasive cervical cancer, receipt of guideline-recommended surgery and/or radiotherapy is associated with significantly improved survival outcomes. These findings underscore the necessity to encourage treatment adherence and implement enhanced early detection and preventive strategies tailored to this aging demographic. Addressing barriers to treatment uptake can substantially impact population health by reducing cervical cancer mortality among older women, a group that continues to be clinically underserved and under-screened.
References
1. Suk R, Lin YY, Dilley S, Chandler R, Xiao R, Shao H, Wells J. Survival by Treatment Recommendation and Receipt Among Older Patients With Early-Stage Cervical Cancer. JAMA Netw Open. 2025 Sep 2;8(9):e2532206. doi: 10.1001/jamanetworkopen.2025.32206 IF: 9.7 Q1 . PMID: 40956576 IF: 9.7 Q1 ; PMCID: PMC12441871 IF: 9.7 Q1 .2. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: Cervical Cancer. Version 1.2024.3. Tewari KS, Monk BJ. Management of early stage cervical cancer: balancing recurrence risk with treatment morbidity. Gynecol Oncol. 2017 Oct;147(1):139-146. doi: 10.1016/j.ygyno.2017.08.005 IF: 4.1 Q1 .4. Lin YG et al. Age-related disparities in treatment and survival outcomes of cervical cancer: Evidence from SEER database. Gynecol Oncol. 2023 Jan;168(1):120-128.
