Cervical cancer practice patterns and appropriateness of therapy

Effect of changes in treatment practice on survival for cervical cancer: results from a population-based study in Manitoba, Canada

BACKGROUND

Results from clinical trials in the 1990s led to changes in the recommended treatment for the standard therapy for stage IIB-IVA cervical cancer from radiotherapy alone to chemo-radiotherapy. We conducted the first population-based study in Canada to investigate temporal treatment patterns for cervical cancer and long-term survival in relation to these changes in the treatment guidelines.

METHODS

Detailed information on stage and treatment for 1085 patients diagnosed with cervical cancer in 1984-2008 and identified from the population-based Manitoba Cancer Registry (MCR) in Canada was obtained from clinical chart review and the MCR. Factors associated with receiving guideline treatment were identified using logistic regression. All cause and cervical cancer specific survival were compared in patients who were and were not treated as recommended in the guidelines, using Cox proportional hazards models.

RESULTS

The median follow-up time was 6.4 years (range: 0.05-26.5 years). The proportion of women who received guideline treatment was 79 % (95 % confidence interval [CI]: 76-81 %). However, the likelihood of being treated according to the guidelines over time was modified by age (p < 0.0001) and tumour stage at diagnosis (p = 0.002). Women who were treated according to the guidelines after the change in recommended clinical practice (1999-2008) had a significantly lower risk of death from all causes and from cervical cancer. This was driven by lower mortality rates in cases with stage IIB-IVA tumours (all causes of death: hazard ratio [HR] = 0.60, 95 % CI: 0.43-0.82, p = 0.002; cervical cancer related death: HR = 0.64, 95 % CI: 0.44-0.93, p = 0.02).

CONCLUSIONS

The management of cervical cancer patients in Manitoba, Canada was in good agreement with treatment guidelines although reasons for departure from the guideline recommendations could not be examined further due to lack of data. Treatment of stage IIB-IVA cervical cancers with recommended concurrent chemo-radiotherapy, which is now standard practice, was associated with substantially increased survival, although the effect of changes in clinical practice including maintenance of haemoglobin levels on improved survival cannot be ruled out as a contributing factor.

Changes in prevalence and clinical characteristics of cervical cancer in the People's Republic of China: a study of 10,012 cases from a nationwide working group

PURPOSE

About one-third of the world's total annual new cervical cancer cases are found in the People's Republic of China. We investigate the prevalence and clinical characteristics of cervical cancer cases in the People's Republic of China over the past decade.

METHOD

A total of 10,012 hospitalized patients with cervical cancer from regions nationwide were enrolled from 2000 to 2009. Demographic and clinical characteristics, therapeutic strategies, and outcomes were analyzed.

RESULTS

The mean age at diagnosis of all cervical cancer patients was 44.7 ± 9.5 years, which is 5-10 years younger than mean ages reported before 2000 in the People's Republic of China. The age distribution showed 16.0% of patients were ≤35 years old, 41.7% were 35-45 years old, and 41.7% were >45 years old. Early stage diagnoses were most prevalent: 57.3% were stage I, 33.9% were stage II, and 4.3% were stage III or IV. Most patients (83.9%) were treated with surgery, and only 9.5% had radiotherapy alone. Among 8,405 patients treated with surgery, 68.6% received adjuvant treatments, including chemotherapy (20.9%), radiotherapy (26.0%), and chemoradiotherapy (21.9%). Among stage IA patients, 16.0% were treated with corpus uteri preservation. The proportion of ovarian preservation was 42.0%.

CONCLUSIONS

Cervical cancer cases in the People's Republic of China show increasing prevalence in young patients and at early stages. In the past 10 years, surgery has become the dominant treatment and is increasingly combined with adjuvant chemotherapy for patients with stages I and II. Conservative surgical approaches are reasonable options for genital organ preservation in selected patients.

Geographic disparities in cervical cancer mortality: what are the roles of risk factor prevalence, screening, and use of recommended treatment?

CONTEXT

Despite advances in early detection and prevention of cervical cancer, women living in rural areas, and particularly in Appalachia, the rural South, the Texas/Mexico border, and the central valley of California, have had consistently higher rates of cervical cancer mortality than their counterparts in other areas during the past several decades.

METHODS

This paper reviews the published literature from 1966 to July 2002 to assess three potential pathways underlying this excess mortality--high human papilloma virus (HPV) prevalence, lack of or infrequent screening and advanced disease at diagnosis, and under-use of recommended treatment and shorter survival.

FINDINGS

Living in rural areas may impose barriers to cervical cancer control, including lack of transportation and medical care infrastructures. Population characteristics that place women at greater risk for developing and dying from cervical cancer, such as low income, lack of health insurance, and physician availability, are concentrated in rural areas. Published data, however, are insufficient to identify the key reasons for the observed mortality patterns.

CONCLUSIONS

At this time, given the lack of definitive evidence in the published literature, decisions about priorities in areas with high rates of cervical cancer mortality will depend on knowledge of current levels of screening, incidence, and stage distribution; and service delivery infrastructures, resources, and acceptability of interventions to the target population.

Age-specific differences in treatment and survival of patients with cervical cancer in the southeast of The Netherlands, 1986-1996

Age at diagnosis has been proven to be an important determinant of the choice of initial treatment for several sites of cancer. Elderly patients are more likely to receive no treatment or less intensive treatment modalities. This study analysed the influence of age on treatment choice and survival in patients diagnosed with cervical cancer. This population-based study used data on 1176 new cases of invasive cervical cancer diagnosed in the period of 1986-1996 from three regional cancer registries in the Netherlands. All available information on treatment and survival (on 1 January 1998) was recorded. Relative survival rates were calculated according to the Hakulinen method. Relative risks (RR) for excess mortality due to the diagnosis of cervical cancer were calculated with a regression model for relative survival rates. Only 5% of the patients aged 70 years and older (n=224) were diagnosed with stage IA disease, compared with 11 and 30% of the patients aged 50-69 years and 49 years and younger, respectively. Almost 50% of the 70+ patients with stage IB-IIA were treated with radiotherapy as a single treatment modality, whereas 64% of the patients aged < or =49 years were treated with surgery alone. In all age groups, treatment for advanced stage disease (stage > or =IIB) was radiotherapy alone. No treatment was given to 10% of the patients aged 70 years and older, 5% of those aged 50-69 years and 1% of those aged 49 years and younger. Five-year relative survival was 69% (95% Confidence Interval (CI): 66-72%) and differed significantly (P=0.001) with age (70+ years: 49%; 50-69 years 58%; < or =49 years: 81%). Multivariate analyses on a subset of patients showed that age was not an independent prognostic factor, whereas stage and treatment modality were very important prognostic factors. Although elderly cancer patients were sometimes treated differently from younger patients, this was in accordance with the guidelines. Relative survival rates differed significantly by age. The multivariate analyses on the subset of patients also revealed that excess mortality increased with age. However, when adjustment was made for stage and treatment, this difference disappeared. The influence of treatment on survival is likely to be due to the selection of patients based on other characteristics, such as tumour volume, comorbidity and performance status.