Does the FIGO 2018 cervical cancer staging system need revision? Insights from a global survey.

Abstract

e17513 Background: FIGO 2018 incorporated imaging and nodal status into cervical cancer staging; however, concerns remain regarding prognostic discrimination, imaging-related pitfalls, and global feasibility. We conducted a global multidisciplinary survey to identify key limitations of FIGO 2018 and priorities for future revision. Methods: A structured, web-based survey (20 items across 6 domains) was distributed internationally to gynecologic oncologists, radiation oncologists, radiologists, and pathologists. Domains included parametrial laterality, nodal site and burden, extranodal extension (ENE), imaging pitfalls, feasibility in low- and middle-income countries (LMICs), and comparison with AJCC/UICC TNM 9th edition. Descriptive statistics were reported as frequencies and percentages. Associations between categorical variables were assessed using chi-square or Fisher’s exact tests as appropriate. Ordinal Likert-scale responses were analyzed using trend analysis and collapsed agreement categories. Statistical significance was defined as p <0.05. Results: A total of 228 complete responses were analyzed. FIGO 2018 was considered inadequate for differentiating unilateral versus bilateral parametrial involvement by 80.3%. MRI overstaging of bilateral parametrial disease due to inflammatory changes was reported by 82.5% and was significantly associated with dissatisfaction regarding parametrial stratification ( p <0.001). Failure to distinguish micro- versus macrometastases was identified as a major limitation by 88.6%, while 79.4% supported incorporation of pelvic nodal burden into staging. Inguinal lymph nodes were variably classified, most commonly as distant metastases (56.6%), suggesting a lack of consensus. ENE was considered inadequately addressed by 84.6%, with 68.9% supporting automatic upstaging. Imaging-based nodal overstaging due to reactive nodes was reported by 76.8%, and 69.3% cited significant inter-observer MRI variability. Implementation challenges included limited imaging availability (41.2%) and pathology infrastructure (27.6%). Resource-stratified staging was supported by 89.5%. TNM 9th edition was perceived as providing superior nodal and prognostic stratification by 58.8%, with 87.7% favoring a complementary role. Conclusions: Global expert consensus indicates that FIGO 2018 is clinically practical but prognostically oversimplified. Revision incorporating nodal burden, ENE, imaging reliability, and resource-stratified frameworks is strongly supported. Domain Result Parametrial laterality Inadequate 80.3% (χ² p<0.001) MRI parametrial overstaging 82.5% No micro/macro nodal split 88.6% (χ² p<0.001) Nodal number ignored 79.4% (χ² p<0.01) ENE not addressed 84.6% (χ² p<0.001) Resource stratification needed 89.5% Global survey shows strong statistical support for FIGO 2018 revision.