Local excision as the main alternative for fertility-sparing surgery (FSS) has been widely used in patients with early-stage cervical cancer to achieve fertility preservation, but its safety and practicability are still questioned. Therefore, we evaluated the current application of local excision in early-stage cervical cancer with this population-based study and compared its efficacy with hysterectomy.Women diagnosed with International Federation of Gynecology and Obstetrics (FIGO) stage I cervical cancer at childbearing age (18-49 y) recorded in the Surveillance, Epidemiology and End Results (SEER) database from 2000 to 2017 were included. Overall survival (OS) and disease-specific survival (DSS) rates were compared between local excision and hysterectomy.A total of 18,519 patients of reproductive age with cervical cancer were included, and 2,268 deaths were observed. 17.0% of patients underwent FSS via local excision, and 70.1% underwent hysterectomy. Among patients younger than 39 years, OS and DSS of local excision were comparable to those of hysterectomy, whereas, in patients older than 40 years, OS and DSS of local excision were significantly worse than those of hysterectomy. In addition, OS and DSS of local excision were similar to hysterectomy in patients with stage IA cervical cancer, but OS and DSS were inferior to hysterectomy in patients with stage IB cervical cancer who underwent local excision. Multivariate Cox analysis showed no substantial difference in OS between local excision and hysterectomy.For patients without fertility requirements, hysterectomy remains the best therapeutic option. However, for patients under 40 years of age diagnosed with stage IA cervical cancer, FSS via local excision is a viable option that can achieve a well-balanced outcome between tumor control and fertility preservation.Copyright © 2023 the Author(s). Published by Wolters Kluwer Health, Inc.