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Bønløkke S, Blaakær J, Steiniche T, Iachina M. Social factors and age play a significant role in cervical cancer and advanced-stage disease among Danish women. BMC Cancer 2024; 24:259. [PMID: 38395802 PMCID: PMC10893677 DOI: 10.1186/s12885-024-11994-4] [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: 02/01/2023] [Accepted: 02/11/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND For cervical cancer (CC), the implementation of preventive strategies has the potential to make cervical cancer occurrence and death largely avoidable. To better understand the factors possibly responsible for cervical cancer, we aimed to examine possible differences in age and social parameters as well as screening status between women with low- or high-stage cervical cancer and matched controls. METHODS Through the Danish Cancer Registry (DCR), women diagnosed with cervical cancer in Denmark between 1987 and 2016 were included. These were age- and residence-matched in a 1:5 ratio with controls from the general female population. The study population was sub grouped into a low-stage subpopulation with women with early-stage cervical cancer and matched controls and a high-stage subpopulation with women with late-stage cervical cancer and matched controls. Age and social parameters were compared within the subpopulations as well as between low- and high-stage cases. For part of the study population, screening attendance was examined to compare differences in adherence. RESULTS Overall, we found that the risk of cervical cancer is significantly increased in socially disadvantaged women and not least non-attenders in screening. Interestingly, the high-stage subpopulation was significantly older than the low-stage subpopulation (p < 0.001), and when examining the impact of age further, we found that for cervical cancer cases, the risk of having low-stage disease decreases significantly with increasing age, whereas the risk of having high-stage disease increases significantly with increasing age. In the screening cohort, significantly less cases than controls were attenders in screening with the most pronounced differences seen in the old subpopulation (women aged 50-64 years) and in the high-stage subpopulation (p-values all < 0.001). Interestingly, when examining the risk of CC for attenders and non-attenders, we demonstrated that many social parameters continue to influence the risk of cervical cancer, even in women attending screening. CONCLUSIONS Older women, socially disadvantaged women, and non-attenders in screening are particularly vulnerable in terms of developing cervical cancer, especially high-stage disease. Therefore, improvements in the participating rate in screening as well as a revision of the current screening guidelines are needed.
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Affiliation(s)
- Sara Bønløkke
- Department of Clinical Medicine - Department of Pathology, Aarhus University, Aarhus N, Denmark.
- Department of Pathology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, Aarhus N, 8200, Denmark.
| | - Jan Blaakær
- Department of Obstetrics and Gynaecology, Odense University Hospital, Odense C, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense M, Denmark
| | - Torben Steiniche
- Department of Clinical Medicine - Department of Pathology, Aarhus University, Aarhus N, Denmark
- Department of Pathology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, Aarhus N, 8200, Denmark
| | - Maria Iachina
- Department of Clinical Epidemiology, Odense University Hospital, Odense C, Denmark
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Neumeyer S, Tanaka LF, Liang LA, Klug SJ. Epidemiology of cervical cancer in elderly women: Analysis of incidence, treatment, and survival using German registry data. Cancer Med 2023; 12:17284-17295. [PMID: 37403686 PMCID: PMC10501271 DOI: 10.1002/cam4.6318] [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: 04/06/2023] [Revised: 06/21/2023] [Accepted: 06/25/2023] [Indexed: 07/06/2023] Open
Abstract
BACKGROUND Cervical cancer (CC) screening is generally recommended until age 65. The incidence of CC could be underestimated, particularly in older women, due to a lack of hysterectomy correction. Furthermore, elderly women (≥65 years) are more often diagnosed with late-stage disease and have worse outcomes than younger patients. This study aims to provide an in-depth overview of CC in Germany. METHODS Incidence rates of CC (ICD-10 C53) were determined using data from the German Centre of Cancer Registry data (ZfKD) of six federal state registries. Incidence was corrected by using hysterectomy prevalence values from a real-world study. The distribution of treatment modalities (surgery, chemotherapy, radiation therapy) was assessed. Relative survival was calculated using the period approach (2011-2015). Survival was stratified by tumor (T) stage and histological type. RESULTS In total, 14,528 CC cases were included, 27.6% of which occurred in elderly women. Cumulative (2001-2015) age-standardized incidence rates were 12.5 per 100,000 women without hysterectomy correction and 15.5 per 100,000 women after hysterectomy correction (+24% relative change). A lower proportion of elderly women were treated, especially in advanced tumor stages. Younger women (20-64 years) had a higher 5-year relative survival compared to elderly women: 76.7% versus 46.9%, respectively. Survival was worse with increasing stage and for glandular histological subgroups, particularly among elderly women. CONCLUSIONS CC incidence in elderly women is underestimated and survival is lower compared to younger women in Germany. Due to the high disease burden in elderly women, screening and treatment strategies need to be improved.
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Affiliation(s)
- Sonja Neumeyer
- Chair of Epidemiology, Department of Sport and Health SciencesTechnical University of MunichMunichGermany
| | - Luana Fiengo Tanaka
- Chair of Epidemiology, Department of Sport and Health SciencesTechnical University of MunichMunichGermany
| | - Linda A. Liang
- Chair of Epidemiology, Department of Sport and Health SciencesTechnical University of MunichMunichGermany
| | - Stefanie J. Klug
- Chair of Epidemiology, Department of Sport and Health SciencesTechnical University of MunichMunichGermany
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Lycke KD, Kahlert J, Damgaard R, Mogensen O, Hammer A. Trends in Hysterectomy Incidence Rates During 2000-2015 in Denmark: Shifting from Abdominal to Minimally Invasive Surgical Procedures. Clin Epidemiol 2021; 13:407-416. [PMID: 34103999 PMCID: PMC8180274 DOI: 10.2147/clep.s300394] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 04/17/2021] [Indexed: 12/16/2022] Open
Abstract
Background Hysterectomy (removal of the uterus) is a common surgical procedure in gynecology. Although minimally invasive surgical procedures have been introduced, hysterectomy is still associated with risk of short- and long-term complications. Given that hysterectomized women are no longer at risk of either hysterectomy or being diagnosed with endometrial or cervical cancer, it is important to describe trends in hysterectomy rates. Objective To describe trends in hysterectomy incidence rates overall and stratified by age, indication, and procedure. Methods Nationwide population-based cohort study using Danish national registries, 2000–2015, was conducted. We calculated the overall hysterectomy-corrected and age-standardized incidence rates of hysterectomy among women ≥20 years old. Incidence rates were stratified by age group, indication, and surgical procedure. We performed trend analyses using Joinpoint regression, thereby estimating the average annual percentage change (AAPC). Results A total of 98,484 women had a hysterectomy during the study period, corresponding to an overall age-standardized, hysterectomy-corrected hysterectomy incidence rate (SIR) of 351.1 per 100,000 person-years (95% CI 348.9;353.3). SIR of hysterectomy declined over time (AAPC −1.4; 95% CI −1.9;-1.0), which was driven by a decline in rates of benign hysterectomy (AAPC −2.1; 95% CI −2.7;-1.6). Irrespective of indication, rates of abdominal hysterectomy declined substantially during the study period and were surpassed by rates of minimally invasive procedures (ie, laparoscopy and robot-assisted laparoscopy) in 2013. Conclusion Hysterectomy-corrected incidence rates of benign hysterectomy declined over time. Irrespective of indication, we observed a shift in surgical procedure over time, from abdominal hysterectomy to minimally invasive surgical procedures.
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Affiliation(s)
- Kathrine Dyhr Lycke
- Department of Obstetrics and Gynecology, NIDO
- Denmark, Gødstrup Hospital, Herning, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Johnny Kahlert
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Rikke Damgaard
- Department of Obstetrics and Gynecology, NIDO
- Denmark, Gødstrup Hospital, Herning, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Ole Mogensen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark
| | - Anne Hammer
- Department of Obstetrics and Gynecology, NIDO
- Denmark, Gødstrup Hospital, Herning, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark
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Age at last screening and remaining lifetime risk of cervical cancer in older, unvaccinated women: a modelling study. Lancet Oncol 2018; 19:1569-1578. [DOI: 10.1016/s1470-2045(18)30536-9] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 07/12/2018] [Accepted: 07/13/2018] [Indexed: 11/21/2022]
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Hysterectomy-corrected rates of endometrial cancer among women younger than age 50 in the United States. Cancer Causes Control 2018; 29:427-433. [DOI: 10.1007/s10552-018-1018-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Accepted: 02/23/2018] [Indexed: 02/02/2023]
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Lynge E, Lönnberg S, Törnberg S. Cervical cancer incidence in elderly women-biology or screening history? Eur J Cancer 2017; 74:82-88. [PMID: 28335890 DOI: 10.1016/j.ejca.2016.12.021] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Revised: 11/24/2016] [Accepted: 12/08/2016] [Indexed: 11/27/2022]
Abstract
AIM In many countries, the age-specific pattern of cervical cancer incidence is currently bipolar with peaks at for instance 45 and 65 years of age. Consequently, a large proportion of cervical cancer cases are presently diagnosed in women above the screening age. The purpose of the study was to determine whether this bipolar pattern in age-specific incidence of cervical cancer reflects underlying biology or can be explained by the fact that the data come from birth cohorts with different screening histories. METHODS Combination of historical data on cervical screening and population-based cancer incidence data from Denmark 1943-2013, Finland and Norway 1953-2013, and Sweden 1958-2013. RESULTS Since the implementation of screening, the incidence of cervical cancer has decreased for each successive birth cohort. All birth cohorts showed a unipolar age-specific pattern. In unscreened women in Denmark and Sweden, the incidence peaked around the age of 50; the peak was less marked in Finland; while peak age for unscreened women could not be determined for Norway due to widespread opportunistic screening. The current old-age peak in the incidence of cervical cancer represents residuals from unscreened or underscreened birth cohorts. CONCLUSION The current bipolar pattern in age-specific incidence of cervical cancer can largely be explained by the different screening histories of successive birth cohorts. While it is reasonable to offer screening to elderly women today, birth cohort trends in disease burden should be carefully monitored to justify permanent changes in upper screening age.
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Affiliation(s)
- Elsebeth Lynge
- Department of Public Health, University of Copenhagen, Denmark.
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Hammer A, Kahlert J, Rositch A, Pedersen L, Gravitt P, Blaakaer J, Soegaard M. The temporal and age-dependent patterns of hysterectomy-corrected cervical cancer incidence rates in Denmark: a population-based cohort study. Acta Obstet Gynecol Scand 2016; 96:150-157. [DOI: 10.1111/aogs.13057] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Accepted: 11/06/2016] [Indexed: 11/29/2022]
Affiliation(s)
- Anne Hammer
- Department of Obstetrics and Gynecology; Aarhus University Hospital; Aarhus Denmark
- Department of Clinical Medicine; Aarhus University; Aarhus Denmark
| | - Johnny Kahlert
- Department of Clinical Medicine; Aarhus University; Aarhus Denmark
- Department of Clinical Epidemiology; Aarhus University Hospital; Aarhus Denmark
| | - Anne Rositch
- Department of Epidemiology; Johns Hopkins Bloomberg School of Public Health; Baltimore MD USA
| | - Lars Pedersen
- Department of Clinical Medicine; Aarhus University; Aarhus Denmark
- Department of Clinical Epidemiology; Aarhus University Hospital; Aarhus Denmark
| | - Patti Gravitt
- Department of Global Health; George Washington University; Washington DC USA
| | - Jan Blaakaer
- Department of Obstetrics and Gynecology; Aarhus University Hospital; Aarhus Denmark
- Department of Clinical Medicine; Aarhus University; Aarhus Denmark
| | - Mette Soegaard
- Department of Clinical Medicine; Aarhus University; Aarhus Denmark
- Department of Clinical Epidemiology; Aarhus University Hospital; Aarhus Denmark
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Temkin SM, Minasian L, Noone AM. The End of the Hysterectomy Epidemic and Endometrial Cancer Incidence: What Are the Unintended Consequences of Declining Hysterectomy Rates? Front Oncol 2016; 6:89. [PMID: 27148481 PMCID: PMC4830827 DOI: 10.3389/fonc.2016.00089] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Accepted: 03/29/2016] [Indexed: 12/12/2022] Open
Abstract
Population-level cancer incidence rates are one measure to estimate the cancer burden. The goal is to provide information on trends to measure progress against cancer at the population level and identify emerging patterns signifying increased risk for additional research and intervention. Endometrial cancer is the most common of the gynecologic malignancies but capturing the incidence of disease among women at risk (i.e., women with a uterus) is challenging and not routinely published. Decreasing rates of hysterectomy increase the number of women at risk for disease, which should be reflected in the denominator of the incidence rate calculation. Furthermore, hysterectomy rates vary within the United States by multiple factors including geographic location, race, and ethnicity. Changing rates of hysterectomy are important to consider when looking at endometrial cancer trends. By correcting for hysterectomy when calculating incidence rates of cancers of the uterine corpus, many of the disparities that have been assumed for this disease are diminished.
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Affiliation(s)
- Sarah M Temkin
- Division of Cancer Prevention, National Cancer Institute , Bethesda, MD , USA
| | - Lori Minasian
- Division of Cancer Prevention, National Cancer Institute , Bethesda, MD , USA
| | - Anne-Michelle Noone
- Division of Cancer Control and Population Sciences, National Cancer Institute , Bethesda, MD , USA
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Evidence of disrupted high-risk human papillomavirus DNA in morphologically normal cervices of older women. Sci Rep 2016; 6:20847. [PMID: 26875676 PMCID: PMC4753489 DOI: 10.1038/srep20847] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Accepted: 01/12/2016] [Indexed: 12/31/2022] Open
Abstract
High-risk human papillomavirus (HR-HPV) causes nearly 100% of cervical carcinoma. However, it remains unclear whether HPV can establish a latent infection, one which may be responsible for the second peak in incidence of cervical carcinoma seen in older women. Therefore, using Ventana in situ hybridisation (ISH), quantitative PCR assays and biomarkers of productive and transforming viral infection, we set out to provide the first robust estimate of the prevalence and characteristics of HPV genomes in FFPE tissue from the cervices of 99 women undergoing hysterectomy for reasons unrelated to epithelial abnormality. Our ISH assay detected HR-HPV in 42% of our study population. The majority of ISH positive samples also tested HPV16 positive using sensitive PCR based assays and were more likely to have a history of preceding cytological abnormality. Analysis of subsets of this population revealed HR-HPV to be transcriptionally inactive as there was no evidence of a productive or transforming infection. Critically, the E2 gene was always disrupted in those HPV16 positive cases which were assessed. These findings point to a reservoir of transcriptionally silent, disrupted HPV16 DNA in morphologically normal cervices, re-expression of which could explain the increase in incidence of cervical cancer observed in later life.
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Hammer A, Rositch AF, Kahlert J, Gravitt PE, Blaakaer J, Søgaard M. Global epidemiology of hysterectomy: possible impact on gynecological cancer rates. Am J Obstet Gynecol 2015; 213:23-29. [PMID: 25724402 DOI: 10.1016/j.ajog.2015.02.019] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2014] [Revised: 02/03/2015] [Accepted: 02/19/2015] [Indexed: 11/26/2022]
Abstract
Despite the fact that hysterectomy is the most common surgical procedure worldwide in gynecology, national reporting of the incidence rate of gynecological cancers rarely removes the proportion no longer at risk of the disease from the population-at-risk-denominator (ie, women who have had a hysterectomy). The incidence rate of gynecological cancers is thus likely underestimated. Because hysterectomy, as well as oophorectomy, incidence varies across countries, age, and over time, meaningful comparison of gynecological cancer incidence rates may be compromised. Without accurate estimates of gynecological cancer incidence rates, performed via removing the proportion of hysterectomized or oophorectomized women from the population-at-risk-denominator, the impact of prevention strategies may be masked or misinterpreted. Furthermore, because national cervical cancer screening guidelines are at least in part based on the national reporting of cervical cancer incidence, it is important that the incidence rate reflects the true population at risk.
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Lam JUH, Lynge E, Njor SH, Rebolj M. Hysterectomy and its impact on the calculated incidence of cervical cancer and screening coverage in Denmark. Acta Oncol 2015; 54:1136-43. [PMID: 25800858 DOI: 10.3109/0284186x.2015.1016625] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND The incidence rates of cervical cancer and the coverage in cervical cancer screening are usually reported by including in the denominator all women from the general population. However, after hysterectomy women are not at risk anymore of developing cervical cancer. Therefore, it makes sense to determine the indicators also for the true at-risk populations. We described the frequency of total hysterectomy in Denmark and its impact on the calculated incidence of cervical cancer and the screening coverage. MATERIAL AND METHODS With data from five Danish population-based registries, the incidence rate of cervical cancer and the screening coverage for women aged 23-64 years on 31 December 2010 were calculated with and without adjustments for hysterectomies undertaken for reasons other than cervical cancer. They were calculated as the number of cases divided by 1) the total number of woman-years from the general population; and 2) the at-risk population after exclusion of post-hysterectomy woman-years. Cases were defined as women with cervical cancer (incidence), or as women screened in the recommended interval, with or without adjustment for hysterectomies (coverage). RESULTS AND CONCLUSIONS In 2010, the all-age prevalence of hysterectomy was estimated at 6%, and ≥ 16% at age ≥ 65. This translated into an overall 6% increase in the incidence rate of cervical cancer, from 12.8 (unadjusted) to 13.5 (adjusted) per 100,000 woman-years. The screening coverage increased from 76% (unadjusted) to 79% (adjusted). In Denmark, hysterectomies do not have a large overall impact on the calculated cancer incidence and screening coverage. Nevertheless, at ≥ 65 years adjusted rates would increase by almost 20% compared to unadjusted rates. This suggests that calculating disease risks per organ-years may have a role in understanding the true burden of the disease in a population at risk of developing that disease.
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Affiliation(s)
- Janni Uyen Hoa Lam
- a Department of Public Health , University of Copenhagen , Copenhagen , Denmark
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Stang A, Hawk H, Knowlton R, Gershman ST, Kuss O. Hysterectomy-corrected incidence rates of cervical and uterine cancers in Massachusetts, 1995 to 2010. Ann Epidemiol 2014; 24:849-54. [DOI: 10.1016/j.annepidem.2014.07.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2014] [Revised: 05/14/2014] [Accepted: 07/07/2014] [Indexed: 10/24/2022]
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