Temporal trends in the relative survival among patients diagnosed with ovarian cancer in Canada 1992–2005: A population-based study

Trends in survival of epithelial ovarian/tubal cancer by histology and socioeconomic status in Denmark 1996-2017

OBJECTIVES

To examine time trends in ovarian/tubal cancer relative survival, excess mortality, and all-cause mortality for different histological types and levels of socioeconomic position.

METHODS

Women with ovarian/tubal cancer diagnosed 1996-2017 were identified in the Danish Cancer Registry (n = 11,755). Age-standardized 5-year relative survival over time was estimated by histology, socioeconomic status, and stage. Furthermore, 5-year excess mortality rate ratios (EMRR) according to calendar time for all categories of histology and socioeconomic status were calculated using a Poisson regression model. Finally, all-cause mortality by histology and socioeconomic status was estimated in multivariate Cox proportional hazards regression models.

RESULTS

Statistically significant improvements in 5-year relative survival occurred for all histological types over time except mucinous tumors (5-year EMRR, localized: 0.92 (95% CI: 0.71-1.16); advanced: 0.96 (95% CI: 0.85-1.08). Increase in relative survival over time and corresponding decrease in excess mortality was observed for all categories of socioeconomic status except for women with localized disease in the lowest income group (5-year EMRR = 0.91 (95% CI:0.76-1.10)). The impact of histology and socioeconomic status on all-cause mortality depended on time since diagnosis. Among the socioeconomic factors, especially low educational level and living alone were associated with increased all-cause mortality, particularly in the first year after diagnosis.

CONCLUSIONS

Ovarian/tubal cancer survival generally increased over time across histological types and socioeconomic factors. However, the lack of improvement for mucinous tumors needs further research. Additionally, the results for women with low income and education shows that continued focus on social equality in survival is necessary.

Incidence and survival of epithelial ovarian, fallopian tube, peritoneal, and undesignated abdominal/pelvic cancers in Sweden 1960-2014: A population-based cohort study

Background

Despite improved surgical and oncological treatment, ovarian cancer continues to be the most lethal of the gynecologic malignancies. We aimed to analyze survival trends in epithelial ovarian cancer with regard to age, tumor site, and morphology in Sweden 1960 to 2014.

Methods

A nationwide population-based study was conducted using data from the Swedish Cancer Registry on 46,350 women aged 18 or older with a diagnosis of epithelial ovarian, fallopian tube, peritoneal, or undesignated abdominal/pelvic cancer 1960 to 2014. Analyses of age-standardized incidence and relative survival (RS) were performed and time trends modelled according to age, tumor site, and morphology.

Results

Overall incidence of ovarian, tubal, peritoneal, and undesignated abdominal/pelvic cancers declined since 1980. Median age at diagnosis increased. Serous carcinoma increased in incidence. RS at 1, 2 and 5 years from diagnosis improved since 1960, although not for the youngest and the oldest patients. Ten-year RS did not improve. The best RS was found for fallopian tube cancer and the worst RS for undesignated abdominal/pelvic cancer. Among the morphologic subgroups, endometrioid carcinoma had the best RS.

Conclusions

Survival in epithelial ovarian, tubal, peritoneal, and undesignated abdominal/pelvic cancers in Sweden has improved over the last six decades. Advances in epithelial ovarian cancer treatment have extended life for the first 5 years from diagnosis but 10-year survival remains poor.

Real-World Impact of Survival by Period of Diagnosis in Epithelial Ovarian Cancer Between 1990 and 2014

Introduction: Although advances in surgical and chemotherapeutic approaches have improved management of epithelial ovarian cancer (EOC) in recent decades. The mortality of EOC over time remains controversial. The aim of this study was to assess the survival trends of EOC according to period of diagnosis using real-world data. Methods: Patients with EOC diagnosed from 1990 to 2014 were included from the Surveillance, Epidemiology, and End Results database. The Kaplan-Meier method and multivariate Cox regression models were used to evaluate the trends in survival over time. Results: We identified 59,763 patients diagnosed with EOC as follows: 6,586 (11.0%) in 1990-1994, 7,408 (12.4%) in 1995-1999, 15,348 (25.7%) in 2000-2004, 14,908 (24.9%) in 2005-2009, and 15,513 (26.0%) in 2010-2014. In the distant stage, the use of surgery decreased from 92.0% in 1990-1994 to 88.9% in 2010-2014. The use of chemotherapy increased from 67.4% in 1990-1994 to 75.0% in 2010-2014. The 5-year cause-specific survival (CSS) increased from 48.6% in 1990-1994 to 57.4% in 2010-2014 (P < 0.001). The 5-year overall survival (OS) increased from 42.7% in 1990-1994 to 51.7% in 2010-2014 (P < 0.001). The 5-year CSS and OS showed slight improvement in the localized stage (CSS, 91.9 vs. 93.1%; OS, 85.6 vs. 88.5%), and largely improved in the distant stage (CSS, 31.4 vs. 42.7%; OS, 26.7 vs. 37.4%) between 1990-1994 and 2010-2014. The multivariate analysis indicated that being diagnosed in the later years was related to better CSS and OS of EOC. Conclusion: The trends in survival of EOC have improved over time, but net survival remains poor overall in distant-stage EOC.

Targeted surgical prevention of epithelial ovarian cancer is cost effective and saves money in BRCA mutation carrying family members of women with epithelial ovarian cancer. A Canadian model

OBJECTIVE

Survival but not cure rates have improved for epithelial ovarian cancer (EOC), demonstrating the need for effective prevention. Targeted prevention in BRCA carriers by risk reducing surgery (RRS) prevents 80% of cases but incurs additional up-front costs, compensated for by the potential for long term savings from treatment avoidance. Does prevention represent value for money? In the absence of long-term data from prospective trials, determining the cost effectiveness of a prevention strategy requires economic modelling.

METHODS

A patient level simulation was developed comparing outcomes between two groups, using Canadian data. Group 1: no mutation testing with treatment if EOC developed. Group 2: cascade testing (index patient BRCA tested and the first and second-degree relatives tested if index patient or first-degree relative respectively were positive) with RRS in carriers. End points were Incremental Cost-Effectiveness Ratio (ICER) and budget impact.

RESULTS

2786 women with EOC (1 year incidence) had 766 first and 207 second-degree female relatives. BRCA mutations were present in 390 index cases, 366 first and 49 second-degree relatives. With 100% RRS uptake, 59 EOC were prevented and testing dominated no testing (more effective and less costly; ICER -$8919). The total cost saving over 50 years was $2,904,486 (cost saving of $9,660,381 in treatment costs versus increased cost from cascade testing/RRS of $6,755,895). At a threshold of $100,000 per QALY, prevention was cost effective in all modelled scenarios.

CONCLUSIONS

Targeted prevention in BRCA mutation carriers not only prevents EOC but is cost-effective compared to treating EOC if it develops.

No improvement in long-term survival for epithelial ovarian cancer patients: A population-based study between 1989 and 2014 in the Netherlands

AIM

This study investigates changes in therapy and long-term survival for patients with epithelial ovarian cancer (EOC) in the Netherlands.

METHODS

All patients with EOC, including peritoneal and fallopian tube carcinoma, diagnosed in the Netherlands between 1989 and 2014 were selected from the Netherlands Cancer Registry. Changes in therapy were studied and related to overall survival (OS) using multivariable Cox regression models.

RESULTS

A total of 32,540 patients were diagnosed with EOC of whom 22,047 (68%) had advanced stage disease. In early stage, lymph node dissection as part of surgical staging procedures increased over time from 4% in 1989-1993 to 62% in 2009-2014 (P < 0.001). In advanced stage, the number of patients receiving optimal treatment with surgery and chemotherapy increased from 55% in 1989-1993 to 67% in 2009-2014 (P < 0.001). Five-year survival rates improved in both early stage (74% versus 79%) and advanced stage (16% versus 24%) as well as in all patients combined (31% versus 34%). Ten-year survival rates, however, slightly improved in early stage (62% versus 67%) and advanced stage (10% versus 13%) but remained essentially unchanged at 24% for all patients combined.

CONCLUSION

Despite intensified treatment and staging procedures, long-term survival for women with EOC has not improved in the last 25 years. The observed improvements in 5-year OS reflect a more prolonged disease control rather than better chances for cure. Furthermore, the apparent better long-term outcome, when early and advanced stage patients are analysed separately, is largely due to improved staging procedures and the ensuing stage migration. These effects disappear in a combined analysis of all patients.

Missed therapeutic and prevention opportunities in women with BRCA-mutated epithelial ovarian cancer and their families due to low referral rates for genetic counseling and BRCA testing: A review of the literature

Answer questions and earn CME/CNE Fifteen percent of women with epithelial ovarian cancer have inherited mutations in the BRCA breast cancer susceptibility genes. Knowledge of her BRCA status has value both for the woman and for her family. A therapeutic benefit exists for the woman with cancer, because a new family of oral drugs, the poly ADP-ribose polymerase (PARP) inhibitors, has recently been approved, and these drugs have the greatest efficacy in women who carry the mutation. For her family, there is the potential to prevent ovarian cancer in those carrying the mutation by using risk-reducing surgery. Such surgery significantly reduces the chance of developing this, for the most part, incurable cancer. Despite these potential benefits, referral rates for genetic counseling and subsequent BRCA testing are low, ranging from 10% to 30%, indicating that these therapeutic and prevention opportunities are being missed. The authors have reviewed the relevant available literature. Topics discussed are BRCA and its relation to ovarian cancer, the rates of referral for genetic counseling/BRCA testing, reasons for these low rates, potential strategies to improve on those rates, lack of effectiveness of current screening strategies, the pros and cons of risk-reducing surgery, other prevention options, and the role and value of PARP inhibitors. CA Cancer J Clin 2017;67:493-506. © 2017 American Cancer Society.

Epidemiology and treatment patterns of epithelial ovarian cancer

INTRODUCTION

While ovarian cancer (OC) is relatively rare, it remains one of the most fatal cancers. Lack of robust screening methods for eOC lead to detection of most cases at advanced stages, and most patients relapse following initial treatment. Areas covered: This review summarizes epidemiology and treatment patterns of epithelial ovarian cancer (eOC). MEDLINE, EMBASE, conference proceedings, and the Cochrane Library were searched using key terms and Medical Subject Headings for ovarian cancer, treatment patterns, and epidemiology to identify articles published from 2005-2015. Expert commentary: To improve early detection, future studies should focus on the identification of biomarkers that can detect asymptomatic disease. Following diagnosis and eventual relapse, response to first-line platinum appears to guide physicians' choice of subsequent therapies, but we do not understand what patients ultimately receive or its relationship to categories of response to first-line platinum. Improved understanding of later-line treatment patterns, by initial response to platinum, could correlate with overall outcomes among relapsed patients and promote development of more effective treatment guidelines. Novel treatment approaches, such as immunotherapies, would fulfill a need for an effective strategy against advanced stages of OC that results in fewer toxic side effects.

Characteristics of Long-Term Survivors of Epithelial Ovarian Cancer

OBJECTIVE

To identify characteristics associated with long-term survival for patients with epithelial ovarian cancer using the California Cancer Registry.

METHODS

A descriptive analysis of survival of all California residents diagnosed with epithelial ovarian cancer between 1994 and 2001 was conducted using patients identified through the cancer registry with follow-up through 2011. Characteristics of the patients who survived more than 10 years (long-term survivors) were compared with three other cohorts: patients who survived less than 2 years, those who survived at least 2 but no more than 5 years, and those who survived at least 5 but no more than 10 years.

RESULTS

A total of 3,582 out of 11,541 (31%, confidence interval 30.2-31.8%) of the patients survived more than 10 years. Younger age, early stage, low-grade, and nonserous histology were significant predictors of long-term survival, but long-term survivors also included women with high-risk cancer.

CONCLUSION

Long-term survival is not unusual in patients with epithelial ovarian cancer, even in those with high-risk disease. Many of the prognostic factors are well known, but it remains to be determined why some patients with advanced-stage high-grade cancers survive longer than others with the same histology. These findings are important for patient counseling.

LEVEL OF EVIDENCE

III.

Population-level trends in relative survival for cervical cancer

OBJECTIVE

While the last 3 decades have seen numerous advances in the treatment of cervical cancer, it remains unclear if population-level survival has improved. We examined relative survival, the ratio of survival in cervical cancer patients to matched controls over time.

STUDY DESIGN

Patients with cervical cancer diagnosed from 1983 through 2009 and recorded in the Surveillance, Epidemiology, and End Results database were examined. Survival models were adjusted for age, race, stage, year of diagnosis, and time since diagnosis. Changes in stage-specific relative survival for patients with cervical cancer compared to the general population matched by age, race, and calendar year were examined over time.

RESULTS

A total of 46,932 patients were identified. For women with stage I tumors, the excess hazard ratio for women diagnosed in 2009 was 0.91 (95% confidence interval [CI], 0.86-0.95) compared to 2000, 0.81 (95% CI, 0.73-0.91) compared to 1990, and 0.75 (95% CI, 0.64-0.88) compared to 1983. For patients with stage III tumors, the excess hazard ratios for patients diagnosed in 2009 (relative to those diagnosed in 2000, 1990, and 1983) were 0.83 (95% CI, 0.80-0.87), 0.68 (95% CI, 0.62-0.75), and 0.59 (95% CI, 0.52-0.68). Similar trends in improved survival over time were noted for women with stage II tumors. There were no statistically significant improvements in relative survival over time for women with stage IV tumors.

CONCLUSION

Relative survival has improved over time for women with stage I-III cervical cancer, but has changed little for those with metastatic disease.

Characteristics of Long-Term Survivors of Epithelial Ovarian Cancer

OBJECTIVE

To identify characteristics associated with long-term survival for patients with epithelial ovarian cancer using the California Cancer Registry.

METHODS

A descriptive analysis of survival of all California residents diagnosed with epithelial ovarian cancer between 1994 and 2001 was conducted using patients identified through the cancer registry with follow-up through 2011. Characteristics of the patients who survived more than 10 years (long-term survivors) were compared with three other cohorts: patients who survived less than 2 years, those who survived at least 2 but no more than 5 years, and those who survived at least 5 but no more than 10 years.

RESULTS

A total of 3,582 out of 11,541 (31%, confidence interval 30.2-31.8%) of the patients survived more than 10 years. Younger age, early stage, low-grade, and nonserous histology were significant predictors of long-term survival, but long-term survivors also included women with high-risk cancer.

CONCLUSION

Long-term survival is not unusual in patients with epithelial ovarian cancer, even in those with high-risk disease. Many of the prognostic factors are well known, but it remains to be determined why some patients with advanced-stage high-grade cancers survive longer than others with the same histology. These findings are important for patient counseling.

LEVEL OF EVIDENCE

III.

Trends in relative survival for ovarian cancer from 1975 to 2011

OBJECTIVE

To examine relative survival (a metric that incorporates changes in survival within a population) in women with ovarian cancer from 1975 to 2011.

METHODS

Women diagnosed with ovarian cancer from 1975 to 2011 and recorded in the National Cancer Institute's Surveillance, Epidemiology, and End Results database were examined. Relative survival, estimated as the ratio of the observed survival of cancer patients (all-cause mortality) to the expected survival of a comparable group from the general population, was matched to the patients with the main factors that are considered to affect patient survival such as age, calendar time, and race. Hazard ratios were adjusted for age, race, year of diagnosis, time since diagnosis, and the interaction of age and years since diagnosis (except for stage II).

RESULTS

A total of 49,932 women were identified. For stage I ovarian cancer, the adjusted excess hazard ratio for death in 2006 was 0.51 (95% confidence interval [CI] 0.41-0.63) compared with those diagnosed in 1975. The reduction in excess mortality remained significant when compared with 1980 and 1985. For women with stage III-IV tumors, the excess hazard of mortality was lower in 2006 compared with all other years of study ranging from 0.49 (95% CI 0.44-0.55) compared with 1975 to 0.93 (95% CI 0.87-0.99) relative to 2000. For women aged 50-59 years, 10-year relative survival was 0.85 (99% CI 0.61-0.95) for stage I disease and 0.18 (99% CI 0.10-0.27) for stage III-IV tumors. For women aged 60-69 years, the corresponding 10-year relative survival estimates were 0.89 (99% CI 0.58-0.98) and 0.15 (99% CI 0.09-0.21).

CONCLUSION

Relative survival has improved for all stages of ovarian cancer from 1975 to 2011.

LEVEL OF EVIDENCE

II.