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Bentestuen M, Ladekarl M, Knudsen A, Zacho HD. Diagnostic accuracy and clinical value of [68Ga]Ga-FAPI-46 PET/CT for staging patients with ovarian cancer: study protocol for a prospective clinical trial. BMC Cancer 2024; 24:699. [PMID: 38849741 DOI: 10.1186/s12885-024-12461-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 05/31/2024] [Indexed: 06/09/2024] Open
Abstract
BACKGROUND [18F]Fluorodeoxyglucose ([18F]FDG) positron emission tomography (PET) is recommended during diagnostic work-up for ovarian cancer; however, [18F]FDG PET has several inherent limitations. The novel oncologic PET-tracer fibroblast activation protein inhibitor (FAPI) has demonstrated promising results in multiple cancer types, including ovarian cancer, and could overcome the limitations of [18F]FDG PET; however, high-quality clinical studies are lacking. The primary objective of the present study is to compare the diagnostic accuracy of [68Ga]Ga-FAPI-46 PET/CT and [18F]FDG PET/CT in ovarian cancer patients and to investigate how this potential difference impacts staging and patient management. METHODS AND DESIGN Fifty consecutive ovarian cancer patients will be recruited from Aalborg University Hospital, Denmark. This study will be a single-center, prospective, exploratory clinical trial that adheres to the standards for reporting diagnostic accuracy studies (STARD). This study will be conducted under continuous Good Clinical Practice monitoring. The eligibility criteria for patients are as follows: (1) biopsy verified newly diagnosed ovarian cancer or a high risk of ovarian cancer and referred for primary staging with [18F]FDG PET/CT; and (2) resectable disease, i.e., candidate for primary debulking surgery or neoadjuvant chemotherapy followed by interval debulking surgery. All recruited study subjects will undergo [68Ga]Ga-FAPI-46 PET/CT at primary staging, before primary debulking surgery or neoadjuvant chemotherapy (Group A + B), in addition to conventional imaging (including [18F]FDG PET/CT). Study subjects in Group B will undergo an additional [68Ga]Ga-FAPI-46 PET/CT following neoadjuvant chemotherapy prior to interval debulking surgery. The results of the study-related [68Ga]Ga-FAPI-46 PET/CTs will be blinded, and treatment allocation will be based on common clinical practice in accordance with current guidelines. The histopathology of surgical specimens will serve as a reference standard. A recruitment period of 2 years is estimated; the trial is currently recruiting. DISCUSSION To our knowledge, this trial represents the largest, most extensive, and most meticulous prospective FAPI PET study conducted in patients with ovarian cancer thus far. This study aims to obtain a reliable estimation of the diagnostic accuracy of [68Ga]Ga-FAPI-46 PET/CT, shed light on the clinical importance of [68Ga]Ga-FAPI-46 PET/CT, and examine the potential applicability of [68Ga]Ga-FAPI-46 PET/CT for evaluating chemotherapy response. TRIAL REGISTRATION clinicaltrials.gov: NCT05903807, 2nd June 2023; and euclinicaltrials.eu EU CT Number: 2023-505938-98-00, authorized 11th September 2023.
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Affiliation(s)
- Morten Bentestuen
- Department of Nuclear Medicine and Clinical Cancer Research Center, Aalborg University Hospital, Hobrovej 18- 22, Aalborg, DK-9000, Denmark.
- Department of Clinical Medicine, Aalborg University, Sdr. Skovvej 11, Aalborg, DK-9000, Denmark.
| | - Morten Ladekarl
- Department of Oncology and Clinical Cancer Research Center, Aalborg University Hospital, Hobrovej 18-22, Aalborg, DK- 9000, Denmark
- Department of Clinical Medicine, Aalborg University, Sdr. Skovvej 11, Aalborg, DK-9000, Denmark
| | - Aage Knudsen
- Department of Gynecology and Obstetrics, Aalborg University Hospital, Reberbansgade 15, Aalborg, DK-9000, Denmark
- Department of Clinical Medicine, Aalborg University, Sdr. Skovvej 11, Aalborg, DK-9000, Denmark
| | - Helle D Zacho
- Department of Nuclear Medicine and Clinical Cancer Research Center, Aalborg University Hospital, Hobrovej 18- 22, Aalborg, DK-9000, Denmark
- Department of Clinical Medicine, Aalborg University, Sdr. Skovvej 11, Aalborg, DK-9000, Denmark
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Wagner SK, Moon AS, Howitt BE, Renz M. SMARCA4 loss irrelevant for ARID1A mutated ovarian clear cell carcinoma: A case report. Gynecol Oncol Rep 2023; 50:101305. [PMID: 38033359 PMCID: PMC10685047 DOI: 10.1016/j.gore.2023.101305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 11/08/2023] [Accepted: 11/12/2023] [Indexed: 12/02/2023] Open
Abstract
Clear cell carcinomas are rare and relatively chemo-insensitive ovarian cancers with a characteristic molecular pathogenesis. Alterations in ARID1A, a component of the multiprotein chromatin remodeling complex SWI/SNF, are likely early events in the development of ovarian clear cancers arising from atypical endometriosis. Insight into additional driver events and particularly mutations in the same chromatin remodeling complex is limited. Isolated loss of SMARCA4, encoding the ATPase of the SWI/SNF complex, characterizes other aggressive gynecologic cancers including small cell carcinomas of the ovary hypercalcemic type (SCCOHT), undifferentiated endometrial carcinomas (UDEC), and uterine sarcomas (SDUS). The ovarian clear cell carcinoma of a 48-year-old showed in the initial surgical specimen a subclonal loss of SMARCA4 in addition to an ARID1A mutation, i.e., two alterations in the SWI/SNF heterochromatin remodeling complex. We anticipated that the SMARCA4 loss would worsen the disease course in analogy to SCCOHT, UDEC, and SDUS. However, the disease did not accelerate. Instead, the recurrent disease showed restored SMARCA4 expression while retaining the ARID1A mutation. Combinatorial redundancy, diversity and sequence in the SWI/SNF complex assembly as well as DNA- and tissue-specificity may explain the observed irrelevance of SMARCA4 loss in the presented ARID1A mutated ovarian clear cell carcinoma.
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Affiliation(s)
- Samantha Kay Wagner
- Department of Obstetrics & Gynecology, Stanford University, Stanford, CA, USA
| | - Ashley S. Moon
- Gynecologic Oncology Division, Department of Obstetrics & Gynecology, Stanford University, Stanford, CA, USA
| | - Brooke E. Howitt
- Department of Clinical Pathology, Stanford University, Stanford, CA, USA
| | - Malte Renz
- Gynecologic Oncology Division, Department of Obstetrics & Gynecology, Stanford University, Stanford, CA, USA
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Dilley J, Gentry-Maharaj A, Ryan A, Burnell M, Manchanda R, Kalsi J, Singh N, Woolas R, Sharma A, Williamson K, Mould T, Fallowfield L, Campbell S, Skates SJ, McGuire A, Parmar M, Jacobs I, Menon U. Ovarian cancer symptoms in pre-clinical invasive epithelial ovarian cancer - An exploratory analysis nested within the UK Collaborative Trial of Ovarian Cancer Screening (UKCTOCS). Gynecol Oncol 2023; 179:123-130. [PMID: 37980767 DOI: 10.1016/j.ygyno.2023.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 11/02/2023] [Accepted: 11/06/2023] [Indexed: 11/21/2023]
Abstract
OBJECTIVE UKCTOCS provides an opportunity to explore symptoms in preclinical invasive epithelial ovarian cancer (iEOC). We report on symptoms in women with pre-clinical (screen-detected) cancers (PC) compared to clinically diagnosed (CD) cancers. METHODS In UKCTOCS, 202638 postmenopausal women, aged 50-74 were randomly allocated (April 17, 2001-September 29, 2005) 2:1:1 to no screening or annual screening till Dec 31,2011, using a multimodal or ultrasound strategy. Follow-up was through national registries. An outcomes committee adjudicated on OC diagnosis, histotype, stage. Eligible women were those diagnosed with iEOC at primary censorship (Dec 31, 2014). Symptom details were extracted from trial clinical-assessment forms and medical records. Descriptive statistics were used to compare symptoms in PC versus CD women with early (I/II) and advanced (III/IV/unable to stage) stage high-grade-serous (HGSC) cancer. ISRCTN-22488978; ClinicalTrials.gov-NCT00058032. RESULTS 1133 (286PC; 847CD) women developed iEOC. Median age (years) at diagnosis was earlier in PC compared to CD (66.8PC, 68.7CD, p = 0.0001) group. In the PC group, 48% (112/234; 90%, 660/730CD) reported symptoms when questioned. Half PC (50%, 13/26PC; 36%, 29/80CD; p = 0.213) women with symptomatic HGSC had >1symptom, with abdominal symptoms most common, both in early (62%, 16/26, PC; 53% 42/80, CD; p = 0.421) and advanced (57%, 49/86, PC; 74%, 431/580, CD; p = 0.001) stages. In symptomatic early-stage HGSC, compared to CD, PC women reported more gastrointestinal (change in bowel habits and dyspepsia) (35%, 9/26PC; 9%, 7/80CD; p = 0.001) and systemic (mostly lethargy/tiredness) (27%, 7/26PC; 9%, 7/80CD; p = 0.017) symptoms. CONCLUSIONS Our findings, add to the growing evidence, that we should reconsider what constitutes alert symptoms for early tubo-ovarian cancer. We need a more nuanced complex of key symptoms which is then evaluated and refined in a prospective trial.
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Affiliation(s)
- James Dilley
- Department of Gynaecological Oncology, Barts Health NHS Trust, London, UK
| | - Aleksandra Gentry-Maharaj
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology, University College London, London, UK; Department of Women's Cancer, Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK
| | - Andy Ryan
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology, University College London, London, UK
| | - Matthew Burnell
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology, University College London, London, UK
| | - Ranjit Manchanda
- Department of Gynaecological Oncology, Barts Health NHS Trust, London, UK; Wolfson Institute of Population Health, CRUK Barts Cancer Centre, Queen Mary University of London, London, UK
| | - Jatinderpal Kalsi
- Department of Women's Cancer, Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK
| | - Naveena Singh
- Department of Cellular Pathology, Barts Health NHS Trust, London, UK
| | - Robert Woolas
- Department of Gynaecological Oncology, Queen Alexandra Hospital, Portsmouth, UK
| | - Aarti Sharma
- Department of Obstetrics and Gynaecology, University Hospital of Wales, Cardiff, UK
| | - Karin Williamson
- Department of Gynaecological Oncology, Nottingham University Hospitals, Nottingham, UK
| | - Tim Mould
- Department of Gynaecological Oncology, University College London Hospitals NHS Trust, London, UK
| | - Lesley Fallowfield
- Sussex Health Outcomes Research and Education in Cancer (SHORE-C), Brighton and Sussex Medical School, University of Sussex, Sussex, UK
| | | | - Steven J Skates
- Massachusetts General Hospital and Harvard Medical School, Harvard, MA, USA
| | | | - Mahesh Parmar
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology, University College London, London, UK
| | - Ian Jacobs
- Department of Women's Cancer, Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK
| | - Usha Menon
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology, University College London, London, UK.
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Wang T, Bin Y, Zhao L, Li Q. Positive Rate of Malignant Cells in Endometrial Cytology Samples of Ovarian Cancer, Fallopian Tube Cancer, and Primary Peritoneal Cancer Patients: A Systematic Review and Meta-Analysis. J Cytol 2023; 40:51-57. [PMID: 37388400 PMCID: PMC10305903 DOI: 10.4103/joc.joc_49_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 05/04/2022] [Accepted: 03/30/2023] [Indexed: 07/01/2023] Open
Abstract
To estimate the feasibility of diagnosing ovarian cancer, fallopian tube cancer, and primary peritoneal cancer through endometrial cytology, we performed a systematic review and meta-analysis to calculate the pooled positive rate of malignant cells in endometrial cytology samples. We queried PubMed, EMBASE, Medline, and Cochrane Central Register of Controlled Trails from inception to November 12, 2020 for studies estimating positive rates of malignant cells in endometrial cytology samples from patients with ovarian cancer, fallopian tube cancer, and primary peritoneal cancer. The positive rates of the included studies were calculated as pooled positive rate through meta-analyses of proportion. Subgroup analysis based on different sampling methods was conducted. Seven retrospective studies involving 975 patients were included. Pooled positive rate of malignant cells in endometrial cytology specimens of ovarian cancer, fallopian tube cancer, and primary peritoneal cancer patients was 23% (95% CI: 16% - 34%). Statistical heterogeneity between the included studies was considerable (I2 = 89%, P < 0.01). The pooled positive rates of the group of brushes and the group of aspiration smears were 13% (95% CI: 10% - 17%, I2 = 0, P = 0.45) and 33% (95% CI: 25% - 42%, I2 = 80%, P < 0.01), respectively. Although endometrial cytology is not an ideal diagnostic tool for ovarian cancer, fallopian tube cancer, and primary peritoneal cancer, it is a convenient, painless, and easy-to-implement adjunct to other tools. Sampling method is one of the factors that affect the detection rate.
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Affiliation(s)
- Tiantian Wang
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Xi’an Jiaotong University, China
| | - Yadi Bin
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Xi’an Jiaotong University, China
| | - Lanbo Zhao
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Xi’an Jiaotong University, China
| | - Qiling Li
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Xi’an Jiaotong University, China
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Yap S, Vassallo A, Goldsbury D, O'Connell DL, Brand A, Emery J, DeFazio A, Canfell K, Steinberg J. Pathways to diagnosis of endometrial and ovarian cancer in the 45 and Up Study cohort. Cancer Causes Control 2023; 34:47-58. [PMID: 36209449 PMCID: PMC9816254 DOI: 10.1007/s10552-022-01634-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 09/19/2022] [Indexed: 01/11/2023]
Abstract
PURPOSE To determine pathways to endometrial or ovarian cancer diagnosis by comparing health service utilization between cancer cases and matched cancer-free controls, using linked health records. METHODS From cancer registry records, we identified 238 incident endometrial and 167 ovarian cancer cases diagnosed during 2006-2013 in the Australian 45 and Up Study cohort (142,973 female participants). Each case was matched to four cancer-free controls on birthdate, sex, place of residence, smoking status, and body mass index. The use of relevant health services during the 13-18-, 7-12-, 0-6-, and 0-1-months pre-diagnosis for cases and the corresponding dates for their matched controls was determined through linkage with subsidized medical services and hospital records. RESULTS Healthcare utilization diverged between women with cancer and controls in the 0-6-months, particularly 0-1 months, pre-diagnosis. In the 0-1 months, 74.8% of endometrial and 50.3% of ovarian cases visited a gynecologist/gynecological oncologist, 11.3% and 59.3% had a CA125 test, 5.5% and 48.5% an abdominal pelvic CT scan, and 34.5% and 30.5% a transvaginal pelvic ultrasound, respectively (versus ≤ 1% of matched controls). Moreover, 25.1% of ovarian cancer cases visited an emergency department in the 0-1-months pre-diagnosis (versus 1.3% of matched controls), and GP visits were significantly more common for cases than controls in this period. CONCLUSION Most women with endometrial or ovarian cancer accessed recommended specialists and tests in the 0-1-months pre-diagnosis, but a high proportion of women with ovarian cancer visited an emergency department. This reinforces the importance of timely specialist referral.
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Affiliation(s)
- Sarsha Yap
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, 153 Dowling St, Woolloomooloo, Sydney, NSW, 2011, Australia.
| | - Amy Vassallo
- Cancer Council NSW, Sydney, NSW, Australia
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
- Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - David Goldsbury
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, 153 Dowling St, Woolloomooloo, Sydney, NSW, 2011, Australia
| | - Dianne L O'Connell
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, 153 Dowling St, Woolloomooloo, Sydney, NSW, 2011, Australia
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
| | - Alison Brand
- Department of Gynaecological Oncology, Westmead Hospital, Sydney, NSW, Australia
- Westmead Clinical School, University of Sydney, Sydney, NSW, Australia
| | - Jon Emery
- Centre for Cancer Research and Department of General Practice, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia
| | - Anna DeFazio
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, 153 Dowling St, Woolloomooloo, Sydney, NSW, 2011, Australia
- Department of Gynaecological Oncology, Westmead Hospital, Sydney, NSW, Australia
- School of Medical Sciences, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- Centre for Cancer Research, The Westmead Institute for Medical Research, Sydney, NSW, Australia
| | - Karen Canfell
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, 153 Dowling St, Woolloomooloo, Sydney, NSW, 2011, Australia
| | - Julia Steinberg
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, 153 Dowling St, Woolloomooloo, Sydney, NSW, 2011, Australia
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Norbeck A, Asp M, Carlsson T, Kannisto P, Malander S. Age and Referral Route Impact the Access to Diagnosis for Women with Advanced Ovarian Cancer. J Multidiscip Healthc 2023; 16:1239-1248. [PMID: 37163196 PMCID: PMC10164381 DOI: 10.2147/jmdh.s401601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Accepted: 03/17/2023] [Indexed: 05/11/2023] Open
Abstract
Purpose The majority of women with ovarian cancer are diagnosed in late stages. Most women do have symptoms prior to diagnosis, sometimes several months before the diagnosis. The aim of this study was to evaluate the timeline from the first presentation of symptoms to a physician until there is a reasonable suspicion of cancer, among women diagnosed with advanced stage ovarian cancer. We wanted to investigate which symptoms were the most common and whether there are other factors affecting the time interval before the suspicion of cancer was confirmed. Patients and Methods This was a retrospective population-based cohort study of women diagnosed with advanced ovarian cancer between January 1, 2017 and December 31, 2019 who were referred to Skane University Hospital Lund, Sweden. Data were collected from electronic medical records at Skane University Hospital. The time interval was recorded as the time from first physician consultation with predefined symptoms to the date when there was a reasonable suspicion of ovarian cancer. Data processing and statistical analysis were performed with the statistical software R. Results Among the 249 patients included in this study, the median time interval from the first consultation to the reasonable suspicion of cancer was 24 days. The first consultation in specialized care had a 70% decrease in delay compared to primary care. Emergency consultations had a 52.2% decrease in time delay compared to planned consultations. Older age was associated with an increase in the geometric mean by 54.7%, comparing the first to the third quartile. The most common symptom was abdominal pain. Conclusion The length of time interval from first presentation with symptoms relating to ovarian cancer to reasonable suspicion of cancer was associated with whether the consultation was in primary or specialized care, emergency or planned visit and the patient's age.
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Affiliation(s)
- Anna Norbeck
- Department of Obstetrics and Gynecology, Skåne University Hospital, Lund, Sweden
- Department of Clinical Sciences, Division of Obstetrics and Gynecology, Lund University, Lund, Sweden
- Correspondence: Anna Norbeck, Kvinnoklinken Skånes Universitetessjukhus, Klinikgatan 12, Lund, 221 85, Sweden, Tel +4646172106, Email
| | - Mihaela Asp
- Department of Obstetrics and Gynecology, Skåne University Hospital, Lund, Sweden
- Department of Clinical Sciences, Division of Obstetrics and Gynecology, Lund University, Lund, Sweden
| | | | - Päivi Kannisto
- Department of Obstetrics and Gynecology, Skåne University Hospital, Lund, Sweden
- Department of Clinical Sciences, Division of Obstetrics and Gynecology, Lund University, Lund, Sweden
| | - Susanne Malander
- Department of Oncology, Skåne University Hospital, Lund, Sweden
- Department of Clinical Sciences, Division of Oncology, Lund University, Lund, Sweden
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Lawson-Michod KA, Watt MH, Grieshober L, Green SE, Karabegovic L, Derzon S, Owens M, McCarty RD, Doherty JA, Barnard ME. Pathways to ovarian cancer diagnosis: a qualitative study. BMC Womens Health 2022; 22:430. [PMCID: PMC9636716 DOI: 10.1186/s12905-022-02016-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 10/14/2022] [Indexed: 11/06/2022] Open
Abstract
Abstract
Background
Ovarian cancer is often diagnosed at a late stage, when survival is poor. Qualitative narratives of patients’ pathways to ovarian cancer diagnoses may identify opportunities for earlier cancer detection and, consequently, earlier stage at diagnosis.
Methods
We conducted semi-structured interviews of ovarian cancer patients and survivors (n = 14) and healthcare providers (n = 11) between 10/2019 and 10/2021. Interviews focused on the time leading up to an ovarian cancer diagnosis. Thematic analysis was conducted by two independent reviewers using a two-phase deductive and inductive coding approach. Deductive coding used a priori time intervals from the validated Model of Pathways to Treatment (MPT), including self-appraisal and management of symptoms, medical help-seeking, diagnosis, and pre-treatment. Inductive coding identified common themes within each stage of the MPT across patient and provider interviews.
Results
The median age at ovarian cancer diagnosis was 61.5 years (range, 29–78 years), and the majority of participants (11/14) were diagnosed with advanced-stage disease. The median time from first symptom to initiation of treatment was 2.8 months (range, 19 days to 4.7 years). The appraisal and help-seeking intervals contributed the greatest delays in time-to-diagnosis for ovarian cancer. Nonspecific symptoms, perceptions of health and aging, avoidant coping strategies, symptom embarrassment, and concerns about potential judgment from providers prolonged the appraisal and help-seeking intervals. Patients and providers also emphasized access to care, including financial access, as critical to a timely diagnosis.
Conclusion
Interventions are urgently needed to reduce ovarian cancer morbidity and mortality. Population-level screening remains unlikely to improve ovarian cancer survival, but findings from our study suggest that developing interventions to improve self-appraisal of symptoms and reduce barriers to help-seeking could reduce time-to-diagnosis for ovarian cancer. Affordability of care and insurance may be particularly important for ovarian cancer patients diagnosed in the United States.
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Huepenbecker SP, Sun CC, Fu S, Zhao H, Primm K, Rauh-Hain JA, Fleming ND, Giordano SH, Meyer LA. Association between time to diagnosis, time to treatment, and ovarian cancer survival in the United States. Int J Gynecol Cancer 2022; 32:1153-1163. [PMID: 36166208 PMCID: PMC10410715 DOI: 10.1136/ijgc-2022-003696] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE Evaluate the association between time to diagnosis and treatment of advanced ovarian cancer with overall and ovarian cancer specific mortality using a retrospective cross sectional study of a population based cancer registry database. METHODS The Surveillance, Epidemiology, and End Results-Medicare database was searched from 1992 to 2015 for women aged ≥66 years with epithelial ovarian cancer and abdominal/pelvic pain, bloating, difficulty eating, or urinary symptoms within 1 year of cancer diagnosis. Time from presentation to diagnosis and treatment were evaluated as outcomes and covariables. Cox regression models and adjusted Kaplan-Meier curves evaluated 5 year overall and cancer-specific survival. RESULTS Among 13 872 women, better survival was associated with longer time from presentation to diagnosis (overall survival hazard ratio (HR) 0.95, 95% confidence interval (CI) 0.94 to 0.95; cancer specific survival HR 0.95, 95% CI 0.94 to 0.96) and diagnosis to treatment (overall survival HR 0.94, 95% CI 0.92 to 0.96; cancer specific survival HR 0.93, 95% CI 0.91 to 0.96). There was longer time from presentation to diagnosis in Hispanic women (relative risk (RR) 1.21, 95% CI 1.12 to 1.32) and from diagnosis to treatment in non-Hispanic black women (RR 1.36, 95% CI 1.21 to 1.54), with lower likelihood of survival at 5 years after adjustment for time to diagnosis and treatment among non-Hispanic black women (HR 1.15, 95% CI 1.05 to 1.26) compared with non-Hispanic white women. Gynecologic oncology visit was associated with improved overall (p<0.001) and cancer specific (p<0.001) survival despite a longer time from presentation to treatment (p<0.001). CONCLUSION Longer time to diagnosis and treatment were associated with improved survival, suggesting that tumor specific features are more important prognostic factors than the time interval of workup and treatment. Significant sociodemographic disparities indicate social determinants of health influencing workup and care. Gynecologic oncologist visits were associated with improved survival, highlighting the importance of appropriate referral for suspected ovarian cancer.
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Affiliation(s)
- Sarah P Huepenbecker
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Charlotte C Sun
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Shuangshuang Fu
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
- Becton Dickinson and Company, Franklin Lakes, New Jersey, USA
| | - Hui Zhao
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Kristin Primm
- Department of Epidemiology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jose Alejandro Rauh-Hain
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Nicole D Fleming
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Sharon H Giordano
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Larissa A Meyer
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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9
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Menon U, Weller D, Falborg AZ, Jensen H, Butler J, Barisic A, Knudsen AK, Bergin RJ, Brewster DH, Cairnduff V, Fourkala EO, Gavin AT, Grunfeld E, Harland E, Kalsi J, Law RJ, Lin Y, Turner D, Neal RD, White V, Harrison S, Reguilon I, Lynch C, Vedsted P. Diagnostic routes and time intervals for ovarian cancer in nine international jurisdictions; findings from the International Cancer Benchmarking Partnership (ICBP). Br J Cancer 2022; 127:844-854. [PMID: 35618787 PMCID: PMC9427750 DOI: 10.1038/s41416-022-01844-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 01/21/2022] [Accepted: 05/04/2022] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND International Cancer Benchmarking Partnership Module 4 reports the first international comparison of ovarian cancer (OC) diagnosis routes and intervals (symptom onset to treatment start), which may inform previously reported variations in survival and stage. METHODS Data were collated from 1110 newly diagnosed OC patients aged >40 surveyed between 2013 and 2015 across five countries (51-272 per jurisdiction), their primary-care physicians (PCPs) and cancer treatment specialists, supplement by treatment records or clinical databases. Diagnosis routes and time interval differences using quantile regression with reference to Denmark (largest survey response) were calculated. RESULTS There were no significant jurisdictional differences in the proportion diagnosed with symptoms on the Goff Symptom Index (53%; P = 0.179) or National Institute for Health and Care Excellence NG12 guidelines (62%; P = 0.946). Though the main diagnosis route consistently involved primary-care presentation (63-86%; P = 0.068), onward urgent referral rates varied significantly (29-79%; P < 0.001). In most jurisdictions, diagnostic intervals were generally shorter and other intervals, in particular, treatment longer compared to Denmark. CONCLUSION This study highlights key intervals in the diagnostic pathway where improvements could be made. It provides the opportunity to consider the systems and approaches across different jurisdictions that might allow for more timely ovarian cancer diagnosis and treatment.
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Affiliation(s)
- Usha Menon
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology, University College London, London, UK.
| | - David Weller
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | | | - Henry Jensen
- Research Unit for General Practice, Aarhus, Denmark
| | - John Butler
- The Royal Marsden NHS Foundation Trust, London, UK
| | | | - Anne Kari Knudsen
- European Palliative Care Research Centre (PRC), Department of Oncology, Oslo, Norway
- University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Rebecca J Bergin
- Cancer Epidemiology Division, Cancer Council Victoria, Melbourne, VIC, Australia
- Department of General Practice, University of Melbourne, Melbourne, VIC, Australia
| | - David H Brewster
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
- Scottish Cancer Registry, Edinburgh, UK
| | - Victoria Cairnduff
- Northern Ireland Cancer Registry, Queen's University Belfast, Belfast, UK
| | - Evangelia Ourania Fourkala
- Gynaecological Cancer Research Centre, Women's Cancer, Institute for Women's Health, University College London, London, UK
| | - Anna T Gavin
- Northern Ireland Cancer Registry, Queen's University Belfast, Belfast, UK
| | - Eva Grunfeld
- Health Services Research Program, Ontario Institute for Cancer Research, Toronto, Ontario, Canada
| | - Elizabeth Harland
- Department of Epidemiology and Cancer Registry, CancerCare Manitoba, Winnipeg, Canada
| | - Jatinderpal Kalsi
- Gynaecological Cancer Research Centre, Women's Cancer, Institute for Women's Health, University College London, London, UK
| | - Rebecca-Jane Law
- North Wales Centre for Primary Care Research, Bangor University, Wrexham, UK
| | - Yulan Lin
- European Palliative Care Research Centre (PRC), Department of Oncology, Oslo, Norway
| | - Donna Turner
- Population Oncology, Cancer Care Manitoba, Winnipeg, Canada
| | - Richard D Neal
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Victoria White
- School of Psychology Deakin University, Geelong, VIC, Australia
- Centre for Behavioral Research in Cancer, Cancer Council Victoria, Melbourne, VIC, Australia
| | - Samantha Harrison
- International Cancer Benchmarking Partnership, Cancer Research UK, Stratford, UK
| | - Irene Reguilon
- International Cancer Benchmarking Partnership, Cancer Research UK, Stratford, UK
| | - Charlotte Lynch
- International Cancer Benchmarking Partnership, Cancer Research UK, Stratford, UK
| | - Peter Vedsted
- International Cancer Benchmarking Partnership, Cancer Research UK, Stratford, UK
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Vela-Vallespín C, Manchon-Walsh P, Aliste L, Borras JM, Marzo-Castillejo M. Prehospital care for ovarian cancer in Catalonia: could we do better in primary care? Retrospective cohort study. BMJ Open 2022; 12:e060499. [PMID: 35868821 PMCID: PMC9316044 DOI: 10.1136/bmjopen-2021-060499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
OBJECTIVE To assess the impact of prehospital factors (diagnostic pathways, first presentation to healthcare services, intervals, participation in primary care) on 1-year and 5-year survival in people with epithelial ovarian cancer (EOC). DESIGN Retrospective quasi-population-based cohort study. SETTING Catalan Integrated Public Healthcare System. PARTICIPANTS People with EOC who underwent surgery with a curative intent in public Catalan hospitals between 1 January 2013 and 31 December 2014. OUTCOME MEASURES Data from primary and secondary care clinical histories and care processes in the 18 months leading up to confirmation (signs and symptoms at presentation, diagnosis pathways, referrals, diagnosis interval) of the EOC diagnosis (stage, histology type, treatment). Diagnostic process intervals were based on the Aarhus statement. 1-year and 5-year survival analysis was undertaken. RESULTS Of the 513 patients included in the cohort, 67.2% initially consulted their family physician, while 36.4% were diagnosed through emergency services. In the Cox models, survival was influenced by advanced stage at 1 year (HR 3.84, 95% CI 1.23 to 12.02) and 5 years (HR 5.36, 95% CI 3.07 to 9.36), as was the type of treatment received, although this association was attenuated over follow-up. Age became significant at 5 years of follow-up. After adjusting for age, adjusted morbidity groups, stage at diagnosis and treatment, 5-year survival was better in patients presenting with gynaecological bleeding (HR 0.35, 95% CI 0.16 to 0.79). Survival was not associated with a starting point involving primary care (HR 1.39, 95% CI 0.93 to 2.09), diagnostic pathways involving referral to elective gynaecological care from non-general practitioners (HR 0.80, 95% CI 0.51 to 1.26), or self-presentation to emergency services (HR 0.82, 95% CI 0.52 to 1.31). CONCLUSIONS Survival in EOC is not associated with diagnostic pathways or prehospital healthcare, but it is influenced by stage at diagnosis, administration of primary cytoreduction plus chemotherapy and patient age.
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Affiliation(s)
- Carmen Vela-Vallespín
- Primary Health Care Center Riu Nord i Riu Sud, Catalan Institute of Health, Santa Coloma de Gramenet, Spain
- Research Support Unit Metropolitana Nord, University Institute for Primary Health Care Research (IDIAP) Jordi Gol, Catalan Health Institut, Mataró, Spain
| | - Paula Manchon-Walsh
- Catalonian Cancer Strategy, Department of Health, L'Hospitalet de Llobregat, Spain
| | - Luisa Aliste
- Catalonian Cancer Strategy, Department of Health, L'Hospitalet de Llobregat, Spain
| | - Josep M Borras
- Catalonian Cancer Strategy, Department of Health, L'Hospitalet de Llobregat, Spain
- Clinical Sciences, University of Barcelona, L'Hospitalet de Llobregat, Spain
| | - Mercè Marzo-Castillejo
- Research Support Unit Metropolitana Sud, University Institute for Primary Health Care Research (IDIAP) Jordi Gol, Catalan Health Institut, Cornellà de Llobregat, Spain
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11
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The Potential of Novel Lipid Agents for the Treatment of Chemotherapy-Resistant Human Epithelial Ovarian Cancer. Cancers (Basel) 2022; 14:cancers14143318. [PMID: 35884379 PMCID: PMC9322924 DOI: 10.3390/cancers14143318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 07/04/2022] [Accepted: 07/06/2022] [Indexed: 02/04/2023] Open
Abstract
Simple Summary Disease recurrence and chemotherapy resistance are the major causes of mortality for the majority of epithelial ovarian cancer (EOC) patients. Standard of care relies on cytotoxic drugs that induce a form of cell death called apoptosis. EOC cells can evolve to resist apoptosis. We developed drugs called glycosylated antitumor ether lipids (GAELs) that kill EOC cells by a mechanism that does not involve apoptosis. GAELs most likely induce cell death through a process called methuosis. Importantly, we showed that GAELs are effective at killing chemotherapy-resistant EOC cells in vitro and in vivo. Our work shows that the EOC community should begin to investigate methuosis-inducing agents as a novel therapeutic platform to treat chemotherapy-resistant EOC. Abstract Recurrent epithelial ovarian cancer (EOC) coincident with chemotherapy resistance remains the main contributor to patient mortality. There is an ongoing investigation to enhance patient progression-free and overall survival with novel chemotherapeutic delivery, such as the utilization of antiangiogenic medications, PARP inhibitors, or immune modulators. Our preclinical studies highlight a novel tool to combat chemotherapy-resistant human EOC. Glycosylated antitumor ether lipids (GAELs) are synthetic glycerolipids capable of killing established human epithelial cell lines from a wide variety of human cancers, including EOC cell lines representative of different EOC histotypes. Importantly, GAELs kill high-grade serous ovarian cancer (HGSOC) cells isolated from the ascites of chemotherapy-sensitive and chemotherapy-resistant patients grown as monolayers of spheroid cultures. In addition, GAELs were well tolerated by experimental animals (mice) and were capable of reducing tumor burden and blocking ascites formation in an OVCAR-3 xenograft model. Overall, GAELs show great promise as adjuvant therapy for EOC patients with or without chemotherapy resistance.
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12
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Berek JS, Renz M, Kehoe S, Kumar L, Friedlander M. Cancer of the ovary, fallopian tube, and peritoneum: 2021 update. Int J Gynaecol Obstet 2021; 155 Suppl 1:61-85. [PMID: 34669199 PMCID: PMC9298325 DOI: 10.1002/ijgo.13878] [Citation(s) in RCA: 120] [Impact Index Per Article: 40.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
In 2014, FIGO's Committee for Gynecologic Oncology revised the staging of ovarian cancer, incorporating ovarian, fallopian tube, and peritoneal cancer into the same system. Most of these malignancies are high-grade serous carcinomas (HGSC). Stage IC is now divided into three categories: IC1 (surgical spill); IC2 (capsule ruptured before surgery or tumor on ovarian or fallopian tube surface); and IC3 (malignant cells in the ascites or peritoneal washings). The updated staging includes a revision of Stage IIIC based on spread to the retroperitoneal lymph nodes alone without intraperitoneal dissemination. This category is now subdivided into IIIA1(i) (metastasis ≤10 mm in greatest dimension), and IIIA1(ii) (metastasis >10 mm in greatest dimension). Stage IIIA2 is now "microscopic extrapelvic peritoneal involvement with or without positive retroperitoneal lymph node" metastasis. This review summarizes the genetics, surgical management, chemotherapy, and targeted therapies for epithelial cancers, and the treatment of ovarian germ cell and stromal malignancies.
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Affiliation(s)
- Jonathan S. Berek
- Stanford Women’s Cancer CenterStanford Cancer InstituteStanford University School of MedicineStanfordCaliforniaUSA
| | - Malte Renz
- Stanford Women’s Cancer CenterStanford Cancer InstituteStanford University School of MedicineStanfordCaliforniaUSA
| | - Sean Kehoe
- Oxford Gynecological Cancer CenterChurchill HospitalOxfordUK
- St Peter’s CollegeOxfordUK
| | - Lalit Kumar
- Department of Medical OncologyAll India Institute of Medical SciencesNew DelhiIndia
| | - Michael Friedlander
- Royal Hospital for WomenSydneyAustralia
- Prince of Wales Clinical SchoolUniversity of New South WalesSydneyAustralia
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13
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Medina-Lara A, Grigore B, Lewis R, Peters J, Price S, Landa P, Robinson S, Neal R, Hamilton W, Spencer AE. Cancer diagnostic tools to aid decision-making in primary care: mixed-methods systematic reviews and cost-effectiveness analysis. Health Technol Assess 2021; 24:1-332. [PMID: 33252328 DOI: 10.3310/hta24660] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Tools based on diagnostic prediction models are available to help general practitioners diagnose cancer. It is unclear whether or not tools expedite diagnosis or affect patient quality of life and/or survival. OBJECTIVES The objectives were to evaluate the evidence on the validation, clinical effectiveness, cost-effectiveness, and availability and use of cancer diagnostic tools in primary care. METHODS Two systematic reviews were conducted to examine the clinical effectiveness (review 1) and the development, validation and accuracy (review 2) of diagnostic prediction models for aiding general practitioners in cancer diagnosis. Bibliographic searches were conducted on MEDLINE, MEDLINE In-Process, EMBASE, Cochrane Library and Web of Science) in May 2017, with updated searches conducted in November 2018. A decision-analytic model explored the tools' clinical effectiveness and cost-effectiveness in colorectal cancer. The model compared patient outcomes and costs between strategies that included the use of the tools and those that did not, using the NHS perspective. We surveyed 4600 general practitioners in randomly selected UK practices to determine the proportions of general practices and general practitioners with access to, and using, cancer decision support tools. Association between access to these tools and practice-level cancer diagnostic indicators was explored. RESULTS Systematic review 1 - five studies, of different design and quality, reporting on three diagnostic tools, were included. We found no evidence that using the tools was associated with better outcomes. Systematic review 2 - 43 studies were included, reporting on prediction models, in various stages of development, for 14 cancer sites (including multiple cancers). Most studies relate to QCancer® (ClinRisk Ltd, Leeds, UK) and risk assessment tools. DECISION MODEL In the absence of studies reporting their clinical outcomes, QCancer and risk assessment tools were evaluated against faecal immunochemical testing. A linked data approach was used, which translates diagnostic accuracy into time to diagnosis and treatment, and stage at diagnosis. Given the current lack of evidence, the model showed that the cost-effectiveness of diagnostic tools in colorectal cancer relies on demonstrating patient survival benefits. Sensitivity of faecal immunochemical testing and specificity of QCancer and risk assessment tools in a low-risk population were the key uncertain parameters. SURVEY Practitioner- and practice-level response rates were 10.3% (476/4600) and 23.3% (227/975), respectively. Cancer decision support tools were available in 83 out of 227 practices (36.6%, 95% confidence interval 30.3% to 43.1%), and were likely to be used in 38 out of 227 practices (16.7%, 95% confidence interval 12.1% to 22.2%). The mean 2-week-wait referral rate did not differ between practices that do and practices that do not have access to QCancer or risk assessment tools (mean difference of 1.8 referrals per 100,000 referrals, 95% confidence interval -6.7 to 10.3 referrals per 100,000 referrals). LIMITATIONS There is little good-quality evidence on the clinical effectiveness and cost-effectiveness of diagnostic tools. Many diagnostic prediction models are limited by a lack of external validation. There are limited data on current UK practice and clinical outcomes of diagnostic strategies, and there is no evidence on the quality-of-life outcomes of diagnostic results. The survey was limited by low response rates. CONCLUSION The evidence base on the tools is limited. Research on how general practitioners interact with the tools may help to identify barriers to implementation and uptake, and the potential for clinical effectiveness. FUTURE WORK Continued model validation is recommended, especially for risk assessment tools. Assessment of the tools' impact on time to diagnosis and treatment, stage at diagnosis, and health outcomes is also recommended, as is further work to understand how tools are used in general practitioner consultations. STUDY REGISTRATION This study is registered as PROSPERO CRD42017068373 and CRD42017068375. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology programme and will be published in full in Health Technology Assessment; Vol. 24, No. 66. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Antonieta Medina-Lara
- Health Economics Group, College of Medicine and Health, University of Exeter Medical School, Exeter, UK
| | - Bogdan Grigore
- Exeter Test Group, College of Medicine and Health, University of Exeter Medical School, Exeter, UK
| | - Ruth Lewis
- North Wales Centre for Primary Care Research, Bangor University, Bangor, UK
| | - Jaime Peters
- Exeter Test Group, College of Medicine and Health, University of Exeter Medical School, Exeter, UK
| | - Sarah Price
- Primary Care Diagnostics, College of Medicine and Health, University of Exeter Medical School, Exeter, UK
| | - Paolo Landa
- Health Economics Group, College of Medicine and Health, University of Exeter Medical School, Exeter, UK
| | - Sophie Robinson
- Peninsula Technology Assessment Group, College of Medicine and Health, University of Exeter Medical School, Exeter, UK
| | - Richard Neal
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - William Hamilton
- Primary Care Diagnostics, College of Medicine and Health, University of Exeter Medical School, Exeter, UK
| | - Anne E Spencer
- Health Economics Group, College of Medicine and Health, University of Exeter Medical School, Exeter, UK
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14
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Huepenbecker SP, Sun CC, Fu S, Zhao H, Primm K, Giordano SH, Meyer LA. Factors impacting the time to ovarian cancer diagnosis based on classic symptom presentation in the United States. Cancer 2021; 127:4151-4160. [PMID: 34347287 DOI: 10.1002/cncr.33829] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 07/02/2021] [Accepted: 07/07/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND Patients with ovarian cancer often present with late-stage disease and nonspecific symptoms, but little is known about factors affecting the time to diagnosis (TTD) in the United States. METHODS A retrospective, population-based study of the Surveillance, Epidemiology, and End Results-Medicare database was conducted. It included women 66 years old or older with stage II to IV epithelial ovarian cancer with at least 1 code for abdominal/pelvic pain, bloating, difficulty eating, or urinary symptoms within 1 year of the cancer diagnosis. TTD was defined from the first claim with a prespecified symptom to the ovarian cancer diagnosis. Kruskal-Wallis tests were used to assess for differences in TTD by group medians. Univariate and generalized linear models with a log-link function evaluated TTD by covariables. RESULTS For the 13,872 women analyzed, the mean and median times to diagnosis were 2.9 and 1.1 months, respectively. The median TTD differed significantly by first symptom (P < .001), number of symptoms (P < .001), and first physician specialty seen (P < .001). In a multivariable analysis, TTD differed significantly according to race/ethnicity (P < .001), geographic region (P = .001), urban-rural location (P = .031), emergency room presentation (P < .001), and number of specialties seen (P < .001). A shorter TTD was associated with a diagnosis in 2006-2010 (relative risk [RR], 0.92; 95% confidence interval [CI], 0.87-0.98) or 2011-2015 (RR, 0.87; 95% CI, 0.81-0.93) in comparison with 1992-1999. CONCLUSIONS The time from a symptomatic presentation to care to a diagnosis of ovarian cancer is influenced by clinical and demographic variables. This study's findings reinforce the importance of educating all physicians on ovarian cancer symptoms to aid in diagnosis. LAY SUMMARY Ovarian cancer is often diagnosed once disease has spread because the classic symptoms of ovarian cancer-abdominal or pelvic pain, bloating, difficulty eating, and urinary issues-can be mistaken for other problems. This study examined the time between when women with classic ovarian cancer symptoms went to a physician and when they received a cancer diagnosis in a large database population. The authors found that the time to diagnosis differed according to the type and number of symptoms and what type of physician a woman saw as well as factors such as race, geographic location, and year of diagnosis.
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Affiliation(s)
- Sarah P Huepenbecker
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Charlotte C Sun
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Shuangshuang Fu
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Hui Zhao
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Kristin Primm
- Department of Epidemiology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sharon H Giordano
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Larissa A Meyer
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
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15
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Falzone L, Scandurra G, Lombardo V, Gattuso G, Lavoro A, Distefano AB, Scibilia G, Scollo P. A multidisciplinary approach remains the best strategy to improve and strengthen the management of ovarian cancer (Review). Int J Oncol 2021; 59:53. [PMID: 34132354 PMCID: PMC8208622 DOI: 10.3892/ijo.2021.5233] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 03/31/2021] [Indexed: 02/07/2023] Open
Abstract
Ovarian cancer represents one of the most aggressive female tumors worldwide. Over the decades, the therapeutic options for the treatment of ovarian cancer have been improved significantly through the advancement of surgical techniques as well as the availability of novel effective drugs able to extend the life expectancy of patients. However, due to its clinical, biological and molecular complexity, ovarian cancer is still considered one of the most difficult tumors to manage. In this context, several studies have highlighted how a multidisciplinary approach to this pathology improves the prognosis and survival of patients with ovarian cancer. On these bases, the aim of the present review is to present recent advantages in the diagnosis, staging and treatment of ovarian cancer highlighting the benefits of a patient‑centered care approach and on the importance of a multidisciplinary team for the management of ovarian cancer.
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Affiliation(s)
- Luca Falzone
- Epidemiology and Biostatistics Unit, National Cancer Institute‑IRCCS Fondazione G. Pascale, I‑80131 Naples, Italy
| | | | | | - Giuseppe Gattuso
- Department of Biomedical and Biotechnological Sciences, University of Catania, I‑95123 Catania, Italy
| | - Alessandro Lavoro
- Department of Biomedical and Biotechnological Sciences, University of Catania, I‑95123 Catania, Italy
| | | | - Giuseppe Scibilia
- Unit of Obstetrics and Gynecology, Cannizzaro Hospital, I‑95126 Catania, Italy
| | - Paolo Scollo
- Unit of Obstetrics and Gynecology, Cannizzaro Hospital, I‑95126 Catania, Italy
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16
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Funston G, Hamilton W, Abel G, Crosbie EJ, Rous B, Walter FM. The diagnostic performance of CA125 for the detection of ovarian and non-ovarian cancer in primary care: A population-based cohort study. PLoS Med 2020; 17:e1003295. [PMID: 33112854 PMCID: PMC7592785 DOI: 10.1371/journal.pmed.1003295] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 09/11/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND The serum biomarker cancer antigen 125 (CA125) is widely used as an investigation for possible ovarian cancer in symptomatic women presenting to primary care. However, its diagnostic performance in this setting is unknown. We evaluated the performance of CA125 in primary care for the detection of ovarian and non-ovarian cancers. METHODS AND FINDINGS We studied women in the United Kingdom Clinical Practice Research Datalink with a CA125 test performed between 1 May 2011-31 December 2014. Ovarian and non-ovarian cancers diagnosed in the year following CA125 testing were identified from the cancer registry. Women were categorized by age: <50 years and ≥50 years. Conventional measures of test diagnostic accuracy, including sensitivity, specificity, and positive predictive value, were calculated for the standard CA125 cut-off (≥35 U/ml). The probability of a woman having cancer at each CA125 level between 1-1,000 U/ml was estimated using logistic regression. Cancer probability was also estimated on the basis of CA125 level and age in years using logistic regression. We identified CA125 levels equating to a 3% estimated cancer probability: the "risk threshold" at which the UK National Institute for Health and Care Excellence advocates urgent specialist cancer investigation. A total of 50,780 women underwent CA125 testing; 456 (0.9%) were diagnosed with ovarian cancer and 1,321 (2.6%) with non-ovarian cancer. Of women with a CA125 level ≥35 U/ml, 3.4% aged <50 years and 15.2% aged ≥50 years had ovarian cancer. Of women with a CA125 level ≥35 U/ml who were aged ≥50 years and who did not have ovarian cancer, 20.4% were diagnosed with a non-ovarian cancer. A CA125 value of 53 U/ml equated to a 3% probability of ovarian cancer overall. This varied by age, with a value of 104 U/ml in 40-year-old women and 32 U/ml in 70-year-old women equating to a 3% probability. The main limitations of our study were that we were unable to determine why CA125 tests were performed and that our findings are based solely on UK primary care data, so caution is need in extrapolating them to other healthcare settings. CONCLUSIONS CA125 is a useful test for ovarian cancer detection in primary care, particularly in women ≥50 years old. Clinicians should also consider non-ovarian cancers in women with high CA125 levels, especially if ovarian cancer has been excluded, in order to prevent diagnostic delay. Our results enable clinicians and patients to determine the estimated probability of ovarian cancer and all cancers at any CA125 level and age, which can be used to guide individual decisions on the need for further investigation or referral.
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Affiliation(s)
- Garth Funston
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | | | - Gary Abel
- University of Exeter, Exeter, United Kingdom
| | - Emma J. Crosbie
- Gynaecological Oncology Research Group, Division of Cancer Sciences, University of Manchester, Manchester, United Kingdom
- Department of Obstetrics and Gynaecology, Manchester University NHS Foundation Trust, Manchester Academic Health Sciences Centre, Manchester, United Kingdom
| | - Brian Rous
- National Cancer Registration and Analysis Service, Public Health England, Cambridge, United Kingdom
| | - Fiona M. Walter
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
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17
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Dilley J, Burnell M, Gentry-Maharaj A, Ryan A, Neophytou C, Apostolidou S, Karpinskyj C, Kalsi J, Mould T, Woolas R, Singh N, Widschwendter M, Fallowfield L, Campbell S, Skates SJ, McGuire A, Parmar M, Jacobs I, Menon U. Ovarian cancer symptoms, routes to diagnosis and survival - Population cohort study in the 'no screen' arm of the UK Collaborative Trial of Ovarian Cancer Screening (UKCTOCS). Gynecol Oncol 2020; 158:316-322. [PMID: 32561125 PMCID: PMC7453382 DOI: 10.1016/j.ygyno.2020.05.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Accepted: 05/03/2020] [Indexed: 01/21/2023]
Abstract
OBJECTIVE There are widespread efforts to increase symptom awareness of 'pelvic/abdominal pain, increased abdominal size/bloating, difficulty eating/feeling full and urinary frequency/urgency' in an attempt to diagnose ovarian cancer earlier. Long-term survival of women with these symptoms adjusted for known prognostic factors is yet to be determined. This study explored the association of symptoms, routes and interval to diagnosis and long-term survival in a population-based cohort of postmenopausal women diagnosed with invasive epithelial tubo-ovarian cancer (iEOC) in the 'no screen' (control) UKCTOCS arm. METHODS Of 101,299 women in the control arm, 574 were confirmed on outcome review to have iEOC between randomisation (2001-2005) and 31 December 2014. Data was extracted from medical notes and electronic records. A multivariable model was fitted for individual symptoms, time interval from symptom onset to diagnosis, route to diagnosis, speciality, morphological Type, age at diagnosis, year of diagnosis (period effect), stage, primary treatment, and residual disease. RESULTS Women presenting with symptoms listed in the NICE guidelines (HR1.48, 95%CI1.16-1.89, p = 0.001) or the modified Goff Index (HR1·68, 95%CI1·32-2.13, p < 0.0001) had significantly worse survival than those who did not. Each additional presenting symptom decreased survival (HR1·20, 95%CI1·12-1·28, p < 0.0001). In multivariable analysis, in addition to advanced stage, increasing residual disease and inadequate primary treatment, abdominal pain and loss of appetite/feeling full were significantly associated with increased mortality. CONCLUSIONS The ovarian cancer symptom indices identify postmenopausal women with a poorer prognosis. This study however cannot exclude the possibility of better outcomes in those who are aware and act on their symptoms.
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Affiliation(s)
- James Dilley
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology, University College London, UK
| | - Matthew Burnell
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology, University College London, UK
| | - Aleksandra Gentry-Maharaj
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology, University College London, UK
| | - Andy Ryan
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology, University College London, UK
| | - Christina Neophytou
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology, University College London, UK
| | - Sophia Apostolidou
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology, University College London, UK
| | - Chloe Karpinskyj
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology, University College London, UK
| | | | - Tim Mould
- University College London Hospital, UK
| | | | | | | | - Lesley Fallowfield
- Sussex Health Outcomes Research and Education in Cancer (SHORE-C), Brighton and Sussex Medical School, University of Sussex, UK
| | | | - Steven J Skates
- Massachusetts General Hospital and Harvard Medical School, USA
| | | | - Mahesh Parmar
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology, University College London, UK
| | - Ian Jacobs
- University of New South Wales, Australia
| | - Usha Menon
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology, University College London, UK.
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18
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Socioeconomic Status and Ovarian Cancer Stage at Diagnosis: A Study Nested Within UKCTOCS. Diagnostics (Basel) 2020; 10:diagnostics10020089. [PMID: 32046189 PMCID: PMC7168054 DOI: 10.3390/diagnostics10020089] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 01/29/2020] [Accepted: 01/31/2020] [Indexed: 11/16/2022] Open
Abstract
Background: Tubo-ovarian cancer (OC) continues to be the most lethal of all gynaecological cancers. Over half of women are diagnosed with late stage (III/IV) disease, which has a five-year survival rate of 11%. Socioeconomic status (SES) has been shown to have an impact on outcomes of several cancer types, including OC. This study aims to investigate any potential association between SES and stage at diagnosis of OC. Methods: Women from the non-screening arm of the United Kingdom Collaborative Trial of Ovarian Cancer Screening (UKCTOCS) with a confirmed diagnosis of OC prior to 01 January 2015 and an English index of multiple deprivation (IMD) score were eligible for the study. The association between IMD and OC stage (FIGO) was analysed using an ordinal logistic regression model adjusted for age at diagnosis and BMI. Results: Four-hundred and fifty seven women were eligible for inclusion in the primary analysis. The odds of being diagnosed with the higher dichotomization of stage (I vs. II/III/IV; I/II vs. III/IV; I/II/III vs. IV) was 1.29 (p = 0.017; 95% CI: 1.048–1.592) per unit SD (standard deviation) increase in IMD. This translates to a 29% increase in odds of being diagnosed at the higher stage per each unit SD increase in IMD. Conclusion: Increased deprivation is consistently associated with a higher probability of being diagnosed with later stage OC.
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Baun MLL, Jensen H, Falborg AZ, Heje HN, Petersen LK, Vedsted P. Ovarian cancer suspicion, urgent referral and time to diagnosis in Danish general practice: a population-based study. Fam Pract 2019; 36:751-757. [PMID: 31046091 DOI: 10.1093/fampra/cmz013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Ovarian cancer (OC) survival rates are lower in Denmark than in countries with similar health care. Prolonged time to diagnosis could be a contributing factor. The Danish cancer patient pathway (CPP) for OC was introduced in 2009. It provides GPs with fast access to diagnostic work-up. OBJECTIVE To investigate cancer suspicion and pathway use among GPs and to explore the association between these factors and the diagnostic intervals (DIs). METHODS We conducted a national population-based cohort study using questionnaires and national registers. RESULTS Of the 313 women with participating GPs, 91% presented with symptoms within 1 year of diagnosis, 61% presented vague non-specific symptoms and 62% were diagnosed with late-stage disease. Cancer was suspected in 39%, and 36% were referred to a CPP. Comorbidity [prevalence ratio (PR): 0.53, 95% confidence interval (CI): 0.29-0.98] and no cancer suspicion (PR: 0.35, 95% CI: 0.20-0.60) were associated with no referral to a CPP. The median DI was 36 days. Long DIs were associated with no cancer suspicion (median DI: 59 versus 20 days) and no referral to a CPP (median DI: 42 versus 23 days). CONCLUSIONS Nine in ten patients attended general practice with symptoms before diagnosis. Two-thirds initially presented with vague non-specific symptoms were less likely to be referred to a CPP and had longer DIs than women suspected of cancer. These findings underline the importance of supplementing the CPP with additional accelerated diagnostic routes.
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Affiliation(s)
- Marie-Louise L Baun
- Research Centre for Cancer Diagnosis in Primary Care (CaP), Research Unit for General Practice, Aarhus C, Denmark.,Department of Public Health, Aarhus University, Aarhus C, Denmark
| | - Henry Jensen
- Research Centre for Cancer Diagnosis in Primary Care (CaP), Research Unit for General Practice, Aarhus C, Denmark
| | - Alina Z Falborg
- Research Centre for Cancer Diagnosis in Primary Care (CaP), Research Unit for General Practice, Aarhus C, Denmark
| | - Hanne N Heje
- Research Centre for Cancer Diagnosis in Primary Care (CaP), Research Unit for General Practice, Aarhus C, Denmark
| | - Lone K Petersen
- Department of Gynaecology, Odense University Hospital, Odense, Denmark
| | - Peter Vedsted
- Research Centre for Cancer Diagnosis in Primary Care (CaP), Research Unit for General Practice, Aarhus C, Denmark
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Funston G, Van Melle M, Baun MLL, Jensen H, Helsper C, Emery J, Crosbie EJ, Thompson M, Hamilton W, Walter FM. Variation in the initial assessment and investigation for ovarian cancer in symptomatic women: a systematic review of international guidelines. BMC Cancer 2019; 19:1028. [PMID: 31676000 PMCID: PMC6823968 DOI: 10.1186/s12885-019-6211-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Accepted: 09/26/2019] [Indexed: 11/25/2022] Open
Abstract
Background Women with ovarian cancer can present with a variety of symptoms and signs, and an increasing range of tests are available for their investigation. A number of international guidelines provide advice for the initial assessment of possible ovarian cancer in symptomatic women. We systematically identified and reviewed the consistency and quality of these documents. Methods MEDLINE, Embase, guideline-specific databases and professional organisation websites were searched in March 2018 for relevant clinical guidelines, consensus statements and clinical pathways, produced by professional or governmental bodies. Two reviewers independently extracted data and appraised documents using the Appraisal for Guidelines and Research Evaluation 2 (AGREEII) tool. Results Eighteen documents from 11 countries in six languages met selection criteria. Methodological quality varied with two guidance documents achieving an AGREEII score ≥ 50% in all six domains and 10 documents scoring ≥50% for “Rigour of development” (range: 7–96%). All guidance documents provided advice on possible symptoms of ovarian cancer, although the number of symptoms included in documents ranged from four to 14 with only one symptom (bloating/abdominal distension/increased abdominal size) appearing in all documents. Fourteen documents provided advice on physical examinations but varied in both the examinations they recommended and the physical signs they included. Fifteen documents provided recommendations on initial investigations. Transabdominal/transvaginal ultrasound and the serum biomarker CA125 were the most widely advocated initial tests. Five distinct testing strategies were identified based on the number of tests and the order of testing advocated: ‘single test’, ‘dual testing’, ‘sequential testing’, ‘multiple testing options’ and ‘no testing’. Conclusions Recommendations on the initial assessment and investigation for ovarian cancer in symptomatic women vary considerably between international guidance documents. This variation could contribute to differences in the way symptomatic women are assessed and investigated between countries. Greater research is needed to evaluate the assessment and testing approaches advocated by different guidelines and their impact on ovarian cancer detection.
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Affiliation(s)
- Garth Funston
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK.
| | - Marije Van Melle
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Marie-Louise Ladegaard Baun
- Research Centre for Cancer Diagnosis in Primary Care, Research Unit for General Practice, Aarhus University, Aarhus, Denmark
| | - Henry Jensen
- Research Centre for Cancer Diagnosis in Primary Care, Research Unit for General Practice, Aarhus University, Aarhus, Denmark
| | - Charles Helsper
- Julius Centre for Health Sciences and Primary Care, Utrecht University, Utrecht, Netherlands
| | - Jon Emery
- Centre for Cancer Research and Department of General Practice, University of Melbourne, Melbourne, Australia
| | - Emma J Crosbie
- Gynaecological Oncology Research Group, Division of Cancer Sciences, University of Manchester, Manchester, UK
| | - Matthew Thompson
- Department of Family Medicine, University of Washington, Seattle, USA
| | - Willie Hamilton
- University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Fiona M Walter
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
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Tørring ML, Falborg AZ, Jensen H, Neal RD, Weller D, Reguilon I, Menon U, Vedsted P, Almberg SS, Anandan C, Barisic A, Boylan J, Cairnduff V, Donnelly C, Fourkala EO, Gavin A, Grunfeld E, Hammersley V, Hawryluk B, Kearney T, Kelly J, Knudsen AK, Lambe M, Law R, Lin Y, Malmberg M, Moore K, Turner D, White V. Advanced‐stage cancer and time to diagnosis: An International Cancer Benchmarking Partnership (ICBP) cross‐sectional study. Eur J Cancer Care (Engl) 2019; 28:e13100. [DOI: 10.1111/ecc.13100] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 04/17/2019] [Accepted: 05/01/2019] [Indexed: 12/01/2022]
Affiliation(s)
- Marie L. Tørring
- Department of Anthropology, School of Culture and Society Aarhus University Højbjerg Denmark
| | - Alina Z. Falborg
- Research Unit for General Practice Research Centre for Cancer Diagnosis in Primary Care Aarhus C Denmark
| | - Henry Jensen
- Research Unit for General Practice Research Centre for Cancer Diagnosis in Primary Care Aarhus C Denmark
| | - Richard D. Neal
- Academic Unit of Primary Care, Leeds Institute of Health Sciences University of Leeds Leeds UK
| | - David Weller
- Centre for Population Health Sciences University of Edinburgh Edinburgh UK
| | | | - Usha Menon
- Gynaecological Cancer Research Centre, Institute for Women's Health University College London London UK
| | - Peter Vedsted
- Research Unit for General Practice Research Centre for Cancer Diagnosis in Primary Care Aarhus C Denmark
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Berek JS, Kehoe ST, Kumar L, Friedlander M. Cancer of the ovary, fallopian tube, and peritoneum. Int J Gynaecol Obstet 2018; 143 Suppl 2:59-78. [PMID: 30306591 DOI: 10.1002/ijgo.12614] [Citation(s) in RCA: 175] [Impact Index Per Article: 29.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The Gynecologic Oncology Committee of FIGO in 2014 revised the staging of ovarian cancer, incorporating ovarian, fallopian tube, and peritoneal cancer into the same system. Most of these malignancies are high-grade serous carcinomas (HGSC). Stage IC is now divided into three categories: IC1 (surgical spill); IC2 (capsule ruptured before surgery or tumor on ovarian or fallopian tube surface); and IC3 (malignant cells in the ascites or peritoneal washings). The updated staging includes a revision of Stage IIIC based on spread to the retroperitoneal lymph nodes alone without intraperitoneal dissemination. This category is now subdivided into IIIA1(i) (metastasis ≤10 mm in greatest dimension), and IIIA1(ii) (metastasis >10 mm in greatest dimension). Stage IIIA2 is now "microscopic extrapelvic peritoneal involvement with or without positive retroperitoneal lymph node" metastasis. This review summarizes the genetics, surgical management, chemotherapy, and targeted therapies for epithelial cancers, and the treatment of ovarian germ cell and stromal malignancies.
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Affiliation(s)
- Jonathan S Berek
- Stanford Women's Cancer Center, Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA, USA
| | - Sean T Kehoe
- Institute of Cancer and Genomics, University of Birmingham, Birmingham, UK
| | - Lalit Kumar
- Department of Medical Oncology, All India Institute of Medical Sciences, New Delhi, India
| | - Michael Friedlander
- Royal Hospital for Women, Randwick, Sydney, NSW, Australia.,University of New South Wales Clinical School, Sydney, NSW, Australia
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Examining the Effects of Time to Diagnosis, Income, Symptoms, and Incidental Detection on Overall Survival in Epithelial Ovarian Cancer. Int J Gynecol Cancer 2017; 27:1637-1644. [DOI: 10.1097/igc.0000000000001074] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
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Mahyuddin AP, Liu L, Zhao C, Kothandaraman N, Salto-Tellez M, Pang BNK, Lim DGS, Annalamai L, Chan JKY, Lim TYK, Biswas A, Rice G, Razvi K, Choolani M. Diagnostic accuracy of haptoglobin within ovarian cyst fluid as a potential point-of-care test for epithelial ovarian cancer: an observational study. BJOG 2017; 125:421-431. [DOI: 10.1111/1471-0528.14835] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/16/2017] [Indexed: 01/05/2023]
Affiliation(s)
- AP Mahyuddin
- Department of Obstetrics & Gynaecology; National University of Singapore; Singapore Singapore
| | - L Liu
- Murdoch Childrens Research Institute; Royal Children's Hospital; Parkville Vic. Australia
| | - C Zhao
- Boehringer Ingelheim (S) Pte Ltd; Singapore Singapore
| | - N Kothandaraman
- Department of Obstetrics & Gynaecology; National University of Singapore; Singapore Singapore
| | - M Salto-Tellez
- Centre for Cancer Research and Cell Biology; Queen's University; Belfast UK
| | - BNK Pang
- Department of Pathology; National University Hospital; Singapore Singapore
| | - DGS Lim
- Department of Pathology; National University Hospital; Singapore Singapore
| | - L Annalamai
- Department of Obstetrics & Gynaecology; National University of Singapore; Singapore Singapore
| | - JKY Chan
- Department of Reproductive Medicine; KK Women's and Children's Hospital; Singapore Singapore
| | - TYK Lim
- Department of Gynaecological Oncology; KK Women's and Children's Hospital; Singapore Singapore
| | - A Biswas
- Department of Obstetrics & Gynaecology; National University of Singapore; Singapore Singapore
| | - G Rice
- University of Queensland Centre for Clinical Research; Royal Brisbane & Women's Hospital Campus; The University of Queensland; Herston Qld Australia
| | - K Razvi
- Department of Obstetrics & Gynaecology; Southend University Hospital NHS Foundation Trust; Westcliff-on-Sea UK
| | - M Choolani
- Department of Obstetrics & Gynaecology; National University of Singapore; Singapore Singapore
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Ovarian Cancer and Comorbidity: Is Poor Survival Explained by Choice of Primary Treatment or System Delay? Int J Gynecol Cancer 2017; 27:1123-1133. [DOI: 10.1097/igc.0000000000001001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
ObjectivesComorbidity influences survival in ovarian cancer, but the causal relations between prognosis and comorbidity are not well characterized. The aim of this study was to investigate the associations between comorbidity, system delay, the choice of primary treatment, and survival in Danish ovarian cancer patients.MethodsThis population-based study was conducted on data from 5317 ovarian cancer patients registered in the Danish Gynecological Cancer Database. Comorbidity was classified according to the Charlson Comorbidity Index and the Ovarian Cancer Comorbidity Index. Pearson χ2 test and multivariate logistic regression analyses were used to investigate the association between comorbidity and primary outcome measures: primary treatment (“primary debulking surgery” vs “no primary surgery”) and system delay (more vs less than required by the National Cancer Patient Pathways [NCPPs]). Cox regression analyses, including hypothesized mediators stepwise, were used to investigate if the impact of comorbidity on overall survival is mediated by the choice of treatment or system delay.ResultsA total of 3945 patients (74.2%) underwent primary debulking surgery, whereas 1160 (21.8%) received neoadjuvant chemotherapy. When adjusting for confounders, comorbidity was not significantly associated to the choice of treatment. Surgically treated patients with moderate/severe comorbidity were more often experiencing system delay longer than required by the NCPP. No association between comorbidity and system delay was observed for patients treated with neoadjuvant chemotherapy. Survival analyses demonstrated that system delay longer than NCPP requirement positively impacts survival (hazard ratio, 0.90 [95% confidence interval, 0.82–0.98]), whereas primary treatment modality has no significant impact on survival.ConclusionsPatients with moderate/severe comorbidity experience often a longer system delay than patients with no or mild comorbidity. Age, stage, and comorbidity are factors influencing the choice of treatment, with stage being the most important factor and comorbidity of lesser importance. The impact of comorbidity on survival does not seem to be mediated by the choice of treatment or system delay.
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Love AJ, Lambert P, Turner D, Lotocki R, Dean E, Popowich S, Altman AD, Nachtigal MW. Diagnostic and referral intervals for Manitoba women with epithelial ovarian cancer - the Manitoba Ovarian Cancer Outcomes (MOCO) study group: a retrospective cross-sectional study. CMAJ Open 2017; 5:E116-E122. [PMID: 28401127 PMCID: PMC5378539 DOI: 10.9778/cmajo.20160100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Epithelial ovarian cancer has the highest mortality of all gynecologic cancers. The poor survival rates are often attributed to the advanced stage at which most of these cancers are detected. We sought to examine the effects of patient demographics, comorbidities and presenting symptoms on diagnostic and referral intervals by location of first presentation (emergency department v. elsewhere) and to identify factors that affect these intervals. METHODS We performed a retrospective analysis of chart and medical record data for ovarian cancers, with the exceptions of sex cord and germ cell tumours, diagnosed between 2004 and 2010 in Manitoba, Canada. Data were collected on baseline characteristics, time to diagnosis and referral, number and type of physician visits and emergency department visits. RESULTS The final cohort consisted of 601 patients. Sixty-three percent of patients received their diagnosis within 60 days of initial presentation, and 75.2% had their cancer diagnosed within 2 physician encounters. The median diagnostic interval for all stages of patients presenting to the emergency department was 7 days, compared with 55 days for patients presenting elsewhere. Early stage patients not presenting to the emergency department had their diagnosis a median of 34.0 days later than patients with advanced disease (95% confidence interval [CI] 22.22 to 45.69, p < 0.0001). The presence of some symptoms was associated with shortened diagnostic intervals. Patients with serous, clear-cell or endometrioid histotypes were less likely to have first presentation beginning in the emergency department (odds ratio [OR] 0.40, 95% CI 0.24 to 0.64, p = 0.0001; OR 0.28, 95% CI 0.14 to 0.59, p = 0.007) than those with unclassified epithelial histotype. INTERPRETATION For this group of patients, the main factor associated with diagnostic and referral intervals is presentation to the emergency department. These patients likely required more urgent attention for their more symptomatic disease, leading to quicker diagnosis and referral patterns, despite poorer prognosis.
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Affiliation(s)
- Allison J Love
- University of Manitoba (Love), Max Rady College of Medicine; Department of Epidemiology (Lambert, Turner), CancerCare Manitoba; Department of Obstetrics Gynecology and Reproductive Sciences (Lotocki, Dean, Popowich, Altman, Nachtigal) University of Manitoba; Division of Gynecologic Oncology (Lotocki, Dean, Popowich, Altman) CancerCare Manitoba; Department of Biochemistry and Medical Genetics (Nachtigal), University of Manitoba; Research Institute in Oncology and Hematology (Nachtigal), CancerCare Manitoba, Winnipeg, Man
| | - Pascal Lambert
- University of Manitoba (Love), Max Rady College of Medicine; Department of Epidemiology (Lambert, Turner), CancerCare Manitoba; Department of Obstetrics Gynecology and Reproductive Sciences (Lotocki, Dean, Popowich, Altman, Nachtigal) University of Manitoba; Division of Gynecologic Oncology (Lotocki, Dean, Popowich, Altman) CancerCare Manitoba; Department of Biochemistry and Medical Genetics (Nachtigal), University of Manitoba; Research Institute in Oncology and Hematology (Nachtigal), CancerCare Manitoba, Winnipeg, Man
| | - Donna Turner
- University of Manitoba (Love), Max Rady College of Medicine; Department of Epidemiology (Lambert, Turner), CancerCare Manitoba; Department of Obstetrics Gynecology and Reproductive Sciences (Lotocki, Dean, Popowich, Altman, Nachtigal) University of Manitoba; Division of Gynecologic Oncology (Lotocki, Dean, Popowich, Altman) CancerCare Manitoba; Department of Biochemistry and Medical Genetics (Nachtigal), University of Manitoba; Research Institute in Oncology and Hematology (Nachtigal), CancerCare Manitoba, Winnipeg, Man
| | - Robert Lotocki
- University of Manitoba (Love), Max Rady College of Medicine; Department of Epidemiology (Lambert, Turner), CancerCare Manitoba; Department of Obstetrics Gynecology and Reproductive Sciences (Lotocki, Dean, Popowich, Altman, Nachtigal) University of Manitoba; Division of Gynecologic Oncology (Lotocki, Dean, Popowich, Altman) CancerCare Manitoba; Department of Biochemistry and Medical Genetics (Nachtigal), University of Manitoba; Research Institute in Oncology and Hematology (Nachtigal), CancerCare Manitoba, Winnipeg, Man
| | - Erin Dean
- University of Manitoba (Love), Max Rady College of Medicine; Department of Epidemiology (Lambert, Turner), CancerCare Manitoba; Department of Obstetrics Gynecology and Reproductive Sciences (Lotocki, Dean, Popowich, Altman, Nachtigal) University of Manitoba; Division of Gynecologic Oncology (Lotocki, Dean, Popowich, Altman) CancerCare Manitoba; Department of Biochemistry and Medical Genetics (Nachtigal), University of Manitoba; Research Institute in Oncology and Hematology (Nachtigal), CancerCare Manitoba, Winnipeg, Man
| | - Shaundra Popowich
- University of Manitoba (Love), Max Rady College of Medicine; Department of Epidemiology (Lambert, Turner), CancerCare Manitoba; Department of Obstetrics Gynecology and Reproductive Sciences (Lotocki, Dean, Popowich, Altman, Nachtigal) University of Manitoba; Division of Gynecologic Oncology (Lotocki, Dean, Popowich, Altman) CancerCare Manitoba; Department of Biochemistry and Medical Genetics (Nachtigal), University of Manitoba; Research Institute in Oncology and Hematology (Nachtigal), CancerCare Manitoba, Winnipeg, Man
| | - Alon D Altman
- University of Manitoba (Love), Max Rady College of Medicine; Department of Epidemiology (Lambert, Turner), CancerCare Manitoba; Department of Obstetrics Gynecology and Reproductive Sciences (Lotocki, Dean, Popowich, Altman, Nachtigal) University of Manitoba; Division of Gynecologic Oncology (Lotocki, Dean, Popowich, Altman) CancerCare Manitoba; Department of Biochemistry and Medical Genetics (Nachtigal), University of Manitoba; Research Institute in Oncology and Hematology (Nachtigal), CancerCare Manitoba, Winnipeg, Man
| | - Mark W Nachtigal
- University of Manitoba (Love), Max Rady College of Medicine; Department of Epidemiology (Lambert, Turner), CancerCare Manitoba; Department of Obstetrics Gynecology and Reproductive Sciences (Lotocki, Dean, Popowich, Altman, Nachtigal) University of Manitoba; Division of Gynecologic Oncology (Lotocki, Dean, Popowich, Altman) CancerCare Manitoba; Department of Biochemistry and Medical Genetics (Nachtigal), University of Manitoba; Research Institute in Oncology and Hematology (Nachtigal), CancerCare Manitoba, Winnipeg, Man
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Lim AWW, Mesher D, Gentry‐Maharaj A, Balogun N, Widschwendter M, Jacobs I, Sasieni P, Menon U. Time to diagnosis of Type I or II invasive epithelial ovarian cancers: a multicentre observational study using patient questionnaire and primary care records. BJOG 2016; 123:1012-20. [PMID: 26032603 PMCID: PMC4855631 DOI: 10.1111/1471-0528.13447] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/26/2015] [Indexed: 01/25/2023]
Abstract
OBJECTIVE To compare time to diagnosis of the typically slow-growing Type I (low-grade serous, low-grade endometrioid, mucinous, clear cell) and the more aggressive Type II (high-grade serous, high-grade endometrioid, undifferentiated, carcinosarcoma) invasive epithelial ovarian cancer (iEOC). DESIGN Multicentre observational study. SETTING Ten UK gynaecological oncology centres. POPULATION Women diagnosed with primary EOC between 2006 and 2008. METHODS Symptom data were collected before diagnosis using patient questionnaire and primary-care records. We estimated patient interval (first symptom to presentation) using questionnaire data and diagnostic interval (presentation to diagnosis) using primary-care records. We considered the impact of first symptom, referral and stage on intervals for Type I and Type II iEOC. MAIN OUTCOME MEASURES Patient and diagnostic intervals. RESULTS In all, 78% of 60 Type I and 21% of 134 Type II iEOC were early-stage. Intervals were comparable and independent of stage [e.g. median patient interval for Type I: early-stage 0.3 months (interquartile range 0.3-3.0) versus late-stage 0.3 months (interquartile range 0.3-4.5), P = 0.8]. Twenty-seven percent of women with Type I and Type II had diagnostic intervals of at least 9 months. First symptom (questionnaire) was also similar, except for the infrequent abnormal bleeding (Type I 15% versus Type II 4%, P = 0.01). More women with Type I disease (57% versus 41%, P = 0.04) had been referred for suspected gynaecological cancer. Median time from referral to diagnosis was 1.4 months for women with iEOC referred via a 2-week cancer referral to any specialty compared with 2.6 months (interquartile range 2.0-3.7) for women who were referred routinely to gynaecology. CONCLUSION Overall, shorter diagnostic delays were seen when a cancer was suspected, even if the primary tumour site was not recognised to be ovarian. Despite differences in carcinogenesis and stage for Type I and Type II iEOC, time to diagnosis and symptoms were similar. Referral patterns were different, implying subtle symptom differences. If symptom-based interventions are to impact on ovarian cancer survival, it is likely to be through reduced volume rather than stage-shift. Further research on histological subtypes is needed. TWEETABLE ABSTRACT No difference in time to diagnosis for Type I versus Type II invasive epithelial ovarian cancers.
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Affiliation(s)
- AWW Lim
- Centre for Cancer PreventionWolfson Institute of Preventive MedicineQueen Mary University of LondonBarts & The London School of Medicine and DentistryLondonUK
| | - D Mesher
- Centre for Cancer PreventionWolfson Institute of Preventive MedicineQueen Mary University of LondonBarts & The London School of Medicine and DentistryLondonUK
| | - A Gentry‐Maharaj
- Gynaecological Cancer Research CentreWomen's CancerInstitute for Women's HealthUniversity College LondonLondonUK
| | - N Balogun
- Gynaecological Cancer Research CentreWomen's CancerInstitute for Women's HealthUniversity College LondonLondonUK
| | - M Widschwendter
- Gynaecological Cancer Research CentreWomen's CancerInstitute for Women's HealthUniversity College LondonLondonUK
| | - I Jacobs
- Gynaecological Cancer Research CentreWomen's CancerInstitute for Women's HealthUniversity College LondonLondonUK
- Faculty of Medical and Human SciencesUniversity of ManchesterManchesterUK
| | - P Sasieni
- Centre for Cancer PreventionWolfson Institute of Preventive MedicineQueen Mary University of LondonBarts & The London School of Medicine and DentistryLondonUK
| | - U Menon
- Gynaecological Cancer Research CentreWomen's CancerInstitute for Women's HealthUniversity College LondonLondonUK
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Affiliation(s)
- René H M Verheijen
- Department of Gynaecological Oncology, Division of Surgical Oncology, UMC Utrecht Cancer Center, 3584 CX Utrecht, Netherlands.
| | - Ronald P Zweemer
- Department of Gynaecological Oncology, Division of Surgical Oncology, UMC Utrecht Cancer Center, 3584 CX Utrecht, Netherlands
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Why have ovarian cancer mortality rates declined? Part I. Incidence. Gynecol Oncol 2015; 138:741-9. [PMID: 26080287 DOI: 10.1016/j.ygyno.2015.06.017] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2015] [Revised: 06/09/2015] [Accepted: 06/12/2015] [Indexed: 12/20/2022]
Abstract
The age-adjusted mortality rate from ovarian cancer in the United States has declined over the past several decades. The decline in mortality might be the consequence of a reduced number of cases (incidence) or a reduction in the proportion of patients who die from their cancer (case-fatality). In part I of this three-part series, we examine rates of ovarian cancer incidence and mortality from the Surveillance Epidemiology and End Results (SEER) registry database and we explore to what extent the observed decline in mortality can be explained by a downward shift in the stage distribution of ovarian cancer (i.e. due to early detection) or by fewer cases of ovarian cancer (i.e. due to a change in risk factors). The proportion of localized ovarian cancers did not increase, suggesting that a stage-shift did not contribute to the decline in mortality. The observed decline in mortality paralleled a decline in incidence. The trends in ovarian cancer incidence coincided with temporal changes in the exposure of women from different birth cohorts to various reproductive risk factors, in particular, to changes in the use of the oral contraceptive pill and to declining parity. Based on recent changes in risk factor propensity, we predict that the trend of the declining age-adjusted incidence rate of ovarian cancer in the United States will reverse and rates will increase in coming years.
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Time interval between endometrial biopsy and surgical staging for type I endometrial cancer: association between tumor characteristics and survival outcome. Obstet Gynecol 2015; 125:424-433. [PMID: 25569000 DOI: 10.1097/aog.0000000000000636] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To examine whether wait time between endometrial biopsy and surgical staging correlates with tumor characteristics and affects survival outcomes in patients with type I endometrial cancer. METHODS A retrospective study was conducted to examine patients with grade 1 and 2 endometrioid adenocarcinoma diagnosed by preoperative endometrial biopsy who subsequently underwent hysterectomy-based surgical staging between 2000 and 2013. Patients who received neoadjuvant chemotherapy or hormonal treatment were excluded. Time interval and grade change between endometrial biopsy and hysterectomy were correlated to demographics and survival outcomes. RESULTS Median wait time was 57 days (range 1-177 days) among 435 patients. Upgrading of the tumor to grade 3 in the hysterectomy specimen was seen in 4.7% of 321 tumors classified as grade 1 and 18.4% of 114 tumors classified as grade 2 on the endometrial biopsy, respectively. Wait time was not associated with grade change (P>.05). Controlling for age, ethnicity, body habitus, medical comorbidities, CA 125 level, and stage, multivariable analysis revealed that wait time was not associated with survival outcomes (5-year overall survival rates, wait time 1-14, 15-42, 43-84, and 85 days or more; 62.5%, 93.6%, 95.2%, and 100%, respectively, P>.05); however, grade 1 to 3 on the hysterectomy specimen remained as an independent prognosticator associated with decreased survival (5-year overall survival rates, grade 1 to 3 compared with grade change 1 to 1, 82.1% compared with 98.5%, P=.01). Among grade 1 preoperative biopsies, grade 1 to 3 was significantly associated with nonobesity (P=.039) and advanced stage (P=.019). CONCLUSION Wait time for surgical staging was not associated with decreased survival outcome in patients with type I endometrial cancer.
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Neal RD, Tharmanathan P, France B, Din NU, Cotton S, Fallon-Ferguson J, Hamilton W, Hendry A, Hendry M, Lewis R, Macleod U, Mitchell ED, Pickett M, Rai T, Shaw K, Stuart N, Tørring ML, Wilkinson C, Williams B, Williams N, Emery J. Is increased time to diagnosis and treatment in symptomatic cancer associated with poorer outcomes? Systematic review. Br J Cancer 2015; 112 Suppl 1:S92-107. [PMID: 25734382 PMCID: PMC4385982 DOI: 10.1038/bjc.2015.48] [Citation(s) in RCA: 614] [Impact Index Per Article: 68.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND It is unclear whether more timely cancer diagnosis brings favourable outcomes, with much of the previous evidence, in some cancers, being equivocal. We set out to determine whether there is an association between time to diagnosis, treatment and clinical outcomes, across all cancers for symptomatic presentations. METHODS Systematic review of the literature and narrative synthesis. RESULTS We included 177 articles reporting 209 studies. These studies varied in study design, the time intervals assessed and the outcomes reported. Study quality was variable, with a small number of higher-quality studies. Heterogeneity precluded definitive findings. The cancers with more reports of an association between shorter times to diagnosis and more favourable outcomes were breast, colorectal, head and neck, testicular and melanoma. CONCLUSIONS This is the first review encompassing many cancer types, and we have demonstrated those cancers in which more evidence of an association between shorter times to diagnosis and more favourable outcomes exists, and where it is lacking. We believe that it is reasonable to assume that efforts to expedite the diagnosis of symptomatic cancer are likely to have benefits for patients in terms of improved survival, earlier-stage diagnosis and improved quality of life, although these benefits vary between cancers.
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Affiliation(s)
- R D Neal
- North Wales Centre for Primary Care Research, Bangor University, Bangor LL13 7YP, UK
| | - P Tharmanathan
- Department of Health Sciences, University of York, York, YO10 5DD, UK
| | - B France
- North Wales Centre for Primary Care Research, Bangor University, Bangor LL13 7YP, UK
| | - N U Din
- North Wales Centre for Primary Care Research, Bangor University, Bangor LL13 7YP, UK
| | - S Cotton
- Betsi Cadwaladr University Health Board, Wrexham Maelor Hospital, Wrexham LL13 7TD, UK
| | - J Fallon-Ferguson
- Primary Care Collaborative Cancer Clinical Trials Group, School of Primary, Aboriginal, and Rural Healthcare, University of Western Australia, M706, 35 Stirling Highway, Crawley, Western Australia 6009, Australia
| | - W Hamilton
- University of Exeter Medical School, Exeter EX1 2LU, UK
| | - A Hendry
- North Wales Centre for Primary Care Research, Bangor University, Bangor LL13 7YP, UK
| | - M Hendry
- North Wales Centre for Primary Care Research, Bangor University, Bangor LL13 7YP, UK
| | - R Lewis
- Department of Health Sciences, University of York, York, YO10 5DD, UK
| | - U Macleod
- Centre for Health and Population studies, Hull York Medical School, University of Hull, Hull HU6 7RX, UK
| | - E D Mitchell
- Leeds Institute of Health Sciences, University of Leeds, Leeds LS2 9LJ, UK
| | - M Pickett
- Betsi Cadwaladr University Health Board, Wrexham Maelor Hospital, Wrexham LL13 7TD, UK
| | - T Rai
- North Wales Organisation for Randomised Trials in Health, Bangor University, Bangor LL57 2PZ, UK
| | - K Shaw
- Primary Care Collaborative Cancer Clinical Trials Group, School of Primary, Aboriginal, and Rural Healthcare, University of Western Australia, M706, 35 Stirling Highway, Crawley, Western Australia 6009, Australia
| | - N Stuart
- School of Medical Sciences, Bangor University, Bangor, LL57 2AS UK
| | - M L Tørring
- Research Unit for General Practice, Aarhus University, Bartholins Alle 2, Aarhus DK-8000, Denmark
| | - C Wilkinson
- North Wales Centre for Primary Care Research, Bangor University, Bangor LL13 7YP, UK
| | - B Williams
- Primary Care Collaborative Cancer Clinical Trials Group, School of Primary, Aboriginal, and Rural Healthcare, University of Western Australia, M706, 35 Stirling Highway, Crawley, Western Australia 6009, Australia
| | - N Williams
- North Wales Centre for Primary Care Research, Bangor University, Bangor LL13 7YP, UK
- North Wales Organisation for Randomised Trials in Health, Bangor University, Bangor LL57 2PZ, UK
| | - J Emery
- Primary Care Collaborative Cancer Clinical Trials Group, School of Primary, Aboriginal, and Rural Healthcare, University of Western Australia, M706, 35 Stirling Highway, Crawley, Western Australia 6009, Australia
- General Practice & Primary Care Academic Centre, University of Melbourne, 200 Berkeley Street, Melbourne, Victoria 3053, Australia
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Abstract
The National Institute for Health and Clinical Excellence (NICE) guidelines have sparked hot debate regarding the role of carbohydrate antigen 125 (CA-125) for ovarian cancer (OC) detection. Recent literature and evidence calls into question the use of CA-125 in diagnostic algorithms, given the better performance of human epididymis protein 4 (HE4) vs. CA-125 to rule OC. This is an important consideration since combined measurements are not cost-effective. The quality of this evidence is, however, threatened by important gaps related to study design, enrolled populations and analytical issues. For instance, despite the clinical need to prioritize the evaluation of biomarker performance in early stage tumours, sound evidence on this cannot be provided. In addition, results should be cautiously interpreted due to wide differences in the type of employed assays and in adopted diagnostic thresholds for HE4. Comparability among results obtained by different commercially available HE4 assays, together with an objective establishment of analytical goals is essential for the optimal clinical application of this marker.
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Affiliation(s)
- Simona Ferraro
- Cattedra di Biochimica Clinica e Biologia Molecolare Clinica, Dipartimento di Scienze Biomediche e Cliniche "Luigi Sacco", Università degli Studi, Milano, Italy
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Kondalsamy-Chennakesavan S, Hackethal A, Bowtell D, Obermair A. Differentiating stage 1 epithelial ovarian cancer from benign ovarian tumours using a combination of tumour markers HE4, CA125, and CEA and patient's age. Gynecol Oncol 2013; 129:467-71. [PMID: 23500084 DOI: 10.1016/j.ygyno.2013.03.001] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2012] [Revised: 02/27/2013] [Accepted: 03/01/2013] [Indexed: 10/27/2022]
Abstract
OBJECTIVE Evaluating the presence of possible malignant disease in women with ovarian masses relies on medical imaging and serum marker findings. This study considers the role of serum Human Epididymal Protein 4 (HE4) antigen in combination with other serum markers to more effectively estimate the risk of malignancy in patients with isolated pelvic masses. METHODS We used prospectively collected biospecimens held by the Australian Ovarian Cancer Study (AOCS). Serum samples of patients with FIGO stage 1 epithelial ovarian cancer or with a benign condition were analysed for levels of circulating HE4 antigen, CA 125, and CEA, and test results were used to predict the presence of malignancy and to differentiate benign from malignant pelvic masses. RESULTS HE4 levels were significantly elevated amongst postmenopausal women and amongst patients with malignancy compared to premenopausal women and those with benign disease (p<0.001 for both). The combination of CA125 and age, achieved an area under the ROC curve of 0.677 (95% CI: 0.584 to 0.770, p=0.778), whilst HE4+CA125+CEA in combination with patient's age showed significantly higher AUC of 0.797 (95% CI: 0.721 to 0.874, p=0.0052). By adjusting the ROMA cut-off values the percentage of correctly classified premenopausal patients into low and high risk groups increased from 36.99% to 69.86%. CONCLUSIONS In patients with isolated pelvic masses, the combination of HE4, CA 125 and age with or without CEA provides higher diagnostic value compared to CA125 and age alone. It may therefore be considered for continuous evaluation in patients with adnexal masses.
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Tørring ML, Frydenberg M, Hansen RP, Olesen F, Vedsted P. Evidence of increasing mortality with longer diagnostic intervals for five common cancers: a cohort study in primary care. Eur J Cancer 2013; 49:2187-98. [PMID: 23453935 DOI: 10.1016/j.ejca.2013.01.025] [Citation(s) in RCA: 170] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2012] [Revised: 01/22/2013] [Accepted: 01/24/2013] [Indexed: 10/27/2022]
Abstract
BACKGROUND Early diagnosis is considered a key factor in improving the outcomes in cancer therapy; it remains unclear, however, whether long pre-diagnostic patient pathways influence clinical outcomes negatively. The aim of this study was to assess the association between the length of the diagnostic interval and the five-year mortality for the five most common cancers in Denmark while addressing known biases. METHODS A total of 1128 patients with colorectal, lung, melanoma skin, breast or prostate cancer were included in a prospective, population-based study in a Danish county. The diagnostic interval was defined as the time from the first presentation of symptoms in primary care till the date of diagnosis. Each type of cancer was analysed separately and combined, and all analyses were stratified according to the general practitioner's (GP's) interpretation of the presenting symptoms. We used conditional logistic regression to estimate five-year mortality odds ratios as a function of the diagnostic interval using restricted cubic splines and adjusting for comorbidity, age, sex and type of cancer. RESULTS We found increasing mortality with longer diagnostic intervals among the approximately 40% of the patients who presented in primary care with symptoms suggestive of cancer or any other serious illness. In the same group, very short diagnostic intervals were also associated with increased mortality. Patients presenting with vague symptoms not directly related to cancer or any other serious illness had longer diagnostic intervals and the same survival probability as those who presented with cancer suspicious/serious symptoms. For the former, we found no statistically significant association between the length of the diagnostic interval and mortality. CONCLUSION In full coherence with clinical logic, the healthcare system instigates prompt investigation of seriously ill patients. This likely explains the counter-intuitive findings of high mortality with short diagnostic intervals; but it does not explain the increasing mortality with longer diagnostic intervals. Thus, the study provides further evidence for the hypothesis that the length of the diagnostic interval affects mortality negatively.
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Affiliation(s)
- Marie Louise Tørring
- The Research Unit for General Practice, Research Centre for Cancer Diagnosis in Primary Care, Aarhus University, Denmark; Department of Public Health - Section for General Medical Practice, Aarhus University, Denmark; Department of Culture and Society - Section for Anthropology, Aarhus University, Denmark.
| | - Morten Frydenberg
- Department of Public Health - Section for Biostatistics, Aarhus University, Denmark
| | - Rikke P Hansen
- The Research Unit for General Practice, Research Centre for Cancer Diagnosis in Primary Care, Aarhus University, Denmark
| | - Frede Olesen
- The Research Unit for General Practice, Research Centre for Cancer Diagnosis in Primary Care, Aarhus University, Denmark
| | - Peter Vedsted
- The Research Unit for General Practice, Research Centre for Cancer Diagnosis in Primary Care, Aarhus University, Denmark
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Berek JS, Crum C, Friedlander M. Cancer of the ovary, fallopian tube, and peritoneum. Int J Gynaecol Obstet 2012; 119 Suppl 2:S118-29. [DOI: 10.1016/s0020-7292(12)60025-3] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Maringe C, Walters S, Butler J, Coleman MP, Hacker N, Hanna L, Mosgaard BJ, Nordin A, Rosen B, Engholm G, Gjerstorff ML, Hatcher J, Johannesen TB, McGahan CE, Meechan D, Middleton R, Tracey E, Turner D, Richards MA, Rachet B. Stage at diagnosis and ovarian cancer survival: evidence from the International Cancer Benchmarking Partnership. Gynecol Oncol 2012; 127:75-82. [PMID: 22750127 DOI: 10.1016/j.ygyno.2012.06.033] [Citation(s) in RCA: 125] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2012] [Revised: 06/15/2012] [Accepted: 06/20/2012] [Indexed: 10/28/2022]
Abstract
OBJECTIVE We investigate what role stage at diagnosis bears in international differences in ovarian cancer survival. METHODS Data from population-based cancer registries in Australia, Canada, Denmark, Norway, and the UK were analysed for 20,073 women diagnosed with ovarian cancer during 2004-07. We compare the stage distribution between countries and estimate stage-specific one-year net survival and the excess hazard up to 18 months after diagnosis, using flexible parametric models on the log cumulative excess hazard scale. RESULTS One-year survival was 69% in the UK, 72% in Denmark and 74-75% elsewhere. In Denmark, 74% of patients were diagnosed with FIGO stages III-IV disease, compared to 60-70% elsewhere. International differences in survival were evident at each stage of disease; women in the UK had lower survival than in the other four countries for patients with FIGO stages III-IV disease (61.4% vs. 65.8-74.4%). International differences were widest for older women and for those with advanced stage or with no stage data. CONCLUSION Differences in stage at diagnosis partly explain international variation in ovarian cancer survival, and a more adverse stage distribution contributes to comparatively low survival in Denmark. This could arise because of differences in tumour biology, staging procedures or diagnostic delay. Differences in survival also exist within each stage, as illustrated by lower survival for advanced disease in the UK, suggesting unequal access to optimal treatment. Population-based data on cancer survival by stage are vital for cancer surveillance, and global consensus is needed to make stage data in cancer registries more consistent.
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Affiliation(s)
- Camille Maringe
- Cancer Research UK Cancer Survival Group, Department of Non Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, and St. Bartholomew's Hospital, London, UK.
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Markman M. Ovarian cancer in 2011: Mutations and non-inferiority analyses show a way forward. Nat Rev Clin Oncol 2011; 9:69-70. [PMID: 22182970 DOI: 10.1038/nrclinonc.2011.200] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Highly clinically relevant ovarian cancer clinical research in 2011 focused on an increased understanding of the biology of the malignancy, limitations of strategies for early detection and screening, and the provocative reports of alternative primary and second-line management strategies.
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Affiliation(s)
- Maurie Markman
- Cancer Treatment Centers of America, Eastern Regional Medical Center, 1331 East Wyoming Avenue, Philadelphia, PA 19124, USA.
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