Since 2000, the incidence of cervical cancer in the United States has declined due to screening and preventive HPV vaccination [[1], [2], [3]]. With fewer cases of cervical cancer diagnosed, imaging resulting in findings of nodal metastasis at diagnosis, and the availability of curative primary chemoradiation for both bulky stage I and locally advanced disease, it is likely that primary surgical treatment with radical hysterectomy is decreasing over time. While national data on radical hysterectomy case volume are lacking, one high volume center reported a significant drop in radical hysterectomy case volume between 1999 and 2018 [4]. Radical hysterectomy case volume decreased by 26% from 2000 to 2017 in the U.S. tumor registry [5].

Despite these trends, radical hysterectomy remains a surgical cornerstone of gynecologic oncology training and practice [6]. Radical hysterectomy with lymphadenectomy is a standard of care treatment option for early stage cervical cancer (stages stage 1A1 with lymph vascular invasion, 1A2, 1B1, and 1B2), making it a mandatory skill that a gynecologic oncologist should be able to routinely perform [7,8]. Sufficient radical hysterectomy case volume is considered a key to successful gynecologic oncology fellowship training. However, one study in the United Kingdom found that gynecologic oncology fellows were performing fewer radical hysterectomies than required by the European Society of Gynecologic Oncology [8]. Additionally, low surgical case volume, defined as <1 case per month for gynecologic surgeons, has been associated with increased intra- and postoperative complication rates as well as higher patient mortality [9]. Thus, a decline in radical hysterectomy case volume has the potential to negatively impact the quality of training for gynecologic oncology fellows and contribute to poor patient outcomes at low volume institutions.

According to the Center for Disease Control (CDC), the COVID-19 pandemic caused an estimated 77–85% drop in screening for cervical cancer in the first 6 months of 2020, which likely impacted detection of early stage disease [10]. Diversion of non-emergent care and avoidance of healthcare centers due to fear of contracting COVID-19 could also have contributed to delays in diagnosis and treatment of cervical cancer during the pandemic. A recent systematic review demonstrated that fewer cases of cervical cancer were diagnosed after the outbreak of the pandemic across multiple countries, although the extent of this decline varied significantly among studies [11]. International studies have documented a shift to later stage of disease at time of diagnosis as well as a decline in the rate of surgical procedures for patients undergoing cervical cancer treatment [12,13]. Determining the extent to which these factors impacted cervical cancer care delivery in the United States is critically important, as it is well documented that advanced stage and delays in delivery of treatment can drastically impact patient outcomes [[14], [15], [16]].

Thus, we wished to evaluate trends in cervical cancer treatment, specifically radical hysterectomy case volume, in a longitudinal multicenter study covering the periods immediately preceding and following the outbreak of COVID-19. Additionally, we wished to study stage at diagnosis, treatment modality, and treatment timeliness. We hypothesized that the volume of radical hysterectomy declined at many institutions in the COVID-19 pandemic and recovery period and that the pandemic also adversely affected other aspects of cervical cancer treatment.