Examining the Effects of Time to Diagnosis, Income, Symptoms, and Incidental Detection on Overall Survival in Epithelial Ovarian Cancer: Manitoba Ovarian Cancer Outcomes (MOCO) Study Group

Time to Diagnosis and Treatment for Ovarian Cancer and Associations with Outcomes: A Systematic Review

Background: Ovarian cancer is commonly diagnosed symptomatically at an advanced stage. Better survival for early disease suggests improving diagnostic pathways may increase survival. This study examines literature assessing diagnostic intervals and their association with clinical and psychological outcomes. Methods: Medline, EMBASE, and EmCare databases were searched for studies including quantitative measures of at least one interval, published between January 1, 2000 and August 9, 2022. Interval measures and associations (interval, outcomes, analytic strategy) were synthesized. Risk of bias of association studies was assessed using the Aarhus Checklist and ROBINS-E tool. Results: In total, 65 papers (20 association studies) were included and 26 unique intervals were identified. Interval estimates varied widely and were impacted by summary statistic used (mean or median) and group focused on. Of Aarhus-defined intervals, patient (symptom to presentation, n = 23; range [median]: 7-168 days) and diagnostic (presentation to diagnosis, n = 22; range [median]: 7-270 days) were most common. Nineteen association studies examined survival or stage outcomes with most, including five low risk-of-bias studies, finding no association. Conclusions: Studies reporting intervals for ovarian cancer diagnosis are limited by inconsistent definitions and reporting. Greater utilization of the Aarhus statement to define intervals and appropriate analytic methods is needed to strengthen findings from future studies.

Ovarian cancer symptoms in pre-clinical invasive epithelial ovarian cancer - An exploratory analysis nested within the UK Collaborative Trial of Ovarian Cancer Screening (UKCTOCS)

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.

Pathways to diagnosis of endometrial and ovarian cancer in the 45 and Up Study cohort

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.

Age and Referral Route Impact the Access to Diagnosis for Women with Advanced Ovarian Cancer

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.

GD2 and GD3 gangliosides as diagnostic biomarkers for all stages and subtypes of epithelial ovarian cancer

Background

Ovarian cancer (OC) is the deadliest gynecological cancer, often diagnosed at advanced stages. A fast and accurate diagnostic method for early-stage OC is needed. The tumor marker gangliosides, GD2 and GD3, exhibit properties that make them ideal potential diagnostic biomarkers, but they have never before been quantified in OC. We investigated the diagnostic utility of GD2 and GD3 for diagnosis of all subtypes and stages of OC.

Methods

This retrospective study evaluated GD2 and GD3 expression in biobanked tissue and serum samples from patients with invasive epithelial OC, healthy donors, non-malignant gynecological conditions, and other cancers. GD2 and GD3 levels were evaluated in tissue samples by immunohistochemistry (n=299) and in two cohorts of serum samples by quantitative ELISA. A discovery cohort (n=379) showed feasibility of GD2 and GD3 quantitative ELISA for diagnosing OC, and a subsequent model cohort (n=200) was used to train and cross-validate a diagnostic model.

Results

GD2 and GD3 were expressed in tissues of all OC subtypes and FIGO stages but not in surrounding healthy tissue or other controls. In serum, GD2 and GD3 were elevated in patients with OC. A diagnostic model that included serum levels of GD2+GD3+age was superior to the standard of care (CA125, p<0.001) in diagnosing OC and early-stage (I/II) OC.

Conclusion

GD2 and GD3 expression was associated with high rates of selectivity and specificity for OC. A diagnostic model combining GD2 and GD3 quantification in serum had diagnostic power for all subtypes and all stages of OC, including early stage. Further research exploring the utility of GD2 and GD3 for diagnosis of OC is warranted.

Referral, Genetic Counselling, and BRCA Testing in the Manitoba High-Grade Serous Ovarian Cancer Population, 2004-2019

(1) Background: The primary objective of this study was to examine the rate of genetic referral, BRCA testing, and BRCA positivity amongst all patients with high-grade serous ovarian cancers (HGSOC) from 2004-2019. The secondary objective was to analyze secondary factors that may affect the rates of referral and testing. (2) Methods: This population-based cohort study included all women diagnosed with HGSOC using the Manitoba Cancer Registry, CervixCheck registry, Medical Claims database at Manitoba Health, the Hospital Discharge abstract, the Population Registry, and Winnipeg Regional Health Authority genetics data. Data were examined for three different time cohorts (2004-2013, 2014-2016; 2017-2019) correlating to practice pattern changes. (3) Results: A total of 944 patients were diagnosed with HGSOC. The rate of genetic referrals changed over the three timeframes (20.0% → 56.7% → 36.6%) and rate of genetic testing increased over the entire timeframe. Factors found to increase rates of referral and testing included age, histology, history of oral contraceptive use, and family history of ovarian cancer. Prior health care utilization indicators did not affect genetic referral or testing. (4) Conclusion: The rate of genetic referral (2004-2016) and BRCA1/2 testing (2004-2019) for patients with a diagnosis of HGSOC increased over time. A minority of patients received a consultation for genetics counselling, and even fewer received testing for a BRCA1/2. Without a genetic result, it is difficult for clinicians to inform treatment decisions. Additional efforts are needed to increase genetics consultation and testing for Manitoban patients with HGSOC. Effects of routine tumour testing on rates of genetic referral will have to be examined in future studies.

Association between time to diagnosis, time to treatment, and ovarian cancer survival in the United States

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.

Diagnostic routes and time intervals for ovarian cancer in nine international jurisdictions; findings from the International Cancer Benchmarking Partnership (ICBP)

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.

Prehospital care for ovarian cancer in Catalonia: could we do better in primary care? Retrospective cohort study

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.

The Potential of Novel Lipid Agents for the Treatment of Chemotherapy-Resistant Human Epithelial Ovarian Cancer

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.

Understanding the Experience of Canadian Women Living with Ovarian Cancer through the Every Woman StudyTM

The Every Woman StudyTM: Canadian Edition is the most comprehensive study to date exploring patient-reported experiences of ovarian cancer (OC) on a national scale. An online survey conducted in Fall 2020 included individuals diagnosed with OC in Canada, reporting responses from 557 women from 11 Canadian provinces/territories. Median age at diagnosis was 54 (11−80), 61% were diagnosed between 2016−2020, 59% were stage III/IV and all subtypes of OC were represented. Overall, 23% had a family history of OC, 75% had genetic testing and 19% reported having a BRCA1/2 mutation. Most (87%) had symptoms prior to diagnosis. A timely diagnosis of OC (≤3 months from first presentation with symptoms) was predicted by age (>50) or abdominal pain/persistent bloating as the primary symptom. Predictors of an acute diagnosis (<1 month) included region, ER/urgent care doctor as first healthcare provider or stage III/IV disease. Regional differences in genetic testing, treatments and clinical trial participation were also noted. Respondents cited substantial physical, emotional, practical and financial impacts of an OC diagnosis. Our national survey has revealed differences in the pathway to diagnosis and post-diagnostic care among Canadian women with OC, with region, initial healthcare provider, specific symptoms and age playing key roles. We have identified many opportunities to improve both clinical and supportive care of OC patients across the country.

Factors impacting the time to ovarian cancer diagnosis based on classic symptom presentation in the United States

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.

Cancer diagnostic tools to aid decision-making in primary care: mixed-methods systematic reviews and cost-effectiveness analysis

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.

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)

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.

Racial/ethnic differences in survival for patients with gliosarcoma: an analysis of the National cancer database

PURPOSE

Gliosarcoma is characterized by the World Health Organization as a Grade IV malignant neoplasm and a variant of glioblastoma. The association of race and ethnicity with survival has been established for numerous CNS malignancies, however, no epidemiological studies have reported these findings for patients with gliosarcoma. The aim of this study was to examine differences by race and ethnicity in overall survival, 30-day mortality, 90-day mortality, and 30-day readmission.

METHODS

Data were obtained by query of the National Cancer Database (NCDB) for years 2004-2014. Patients with gliosarcoma were identified by International Classification of Diseases for Oncology, Third Edition (ICD-O-3)-Oncology morphologic code 9442/3 and topographical codes C71.0-C71.9. Differences in survival by race/ethnicity were examined using univariable and multivariable Cox proportional hazards models. Readmission and mortality outcomes were examined with univariable and multivariable logistic regression.

RESULTS

A total of 1988 patients diagnosed with gliosarcoma were identified (White Non-Hispanic n = 1,682, Black Non-Hispanic n = 165, Asian n = 40, Hispanic n = 101). There were no differences in overall survival, 30- and 90-day mortality, or 30-day readmission between the races and ethnicities examined. Median survival was 10.4 months for White Non-Hispanics (95% CI 9.8, 11.2), 10.2 months for Black Non-Hispanics (95% CI 8.6, 13.1), 9.0 months for Asian Non-Hispanics (95% CI 5.1, 18.2), and 10.6 months for Hispanics (95% CI 8.3,16.2). 7.3% of all patients examined had an unplanned readmission within 30 days.

CONCLUSION

Race/ethnicity are not associated with differences in overall survival, 30-day mortality, 90-day mortality, or 30-day readmission following surgical intervention for gliosarcoma.

Being treated in higher volume hospitals leads to longer progression-free survival for epithelial ovarian carcinoma patients in the Rhone-Alpes region of France

BACKGROUND

To investigate the relationship between hospital volume activities and the survival for Epithelial Ovarian Carcinoma (EOC) patients in France.

METHODS

This retrospective study using prospectively implemented databases was conducted on an exhaustive cohort of 267 patients undergoing first-line therapy during 2012 in the Rhone-Alpes Region of France. We compared Progression-Free Survival for Epithelial Ovarian Carcinoma patients receiving first-line therapy in high- (i.e. ≥ 12 cases/year) vs. low-volume hospitals. To control for selection bias, multivariate analysis and propensity scores were used. An adjusted Kaplan-Meier estimator and a univariate Cox model weighted by the propensity score were applied.

RESULTS

Patients treated in the low-volume hospitals had a probability of relapse (including death) that was almost two times (i.e. 1.94) higher than for patients treated in the high-volume hospitals (p < 0.001).

CONCLUSION

To our knowledge, this is the first study conducted in this setting in France. As reported in other countries, there was a significant positive association between greater volume of hospital care for EOC and patient survival. Other factors may also be important such as the quality of the surgical resection.

Examining the Selection Criteria of Neoadjuvant Chemotherapy Patients

OBJECTIVES

To identify predictors of neoadjuvant chemotherapy (NAC) and to examine toxicities, dose reduction, interruptions, and second-line chemotherapy MATERIALS AND METHODS: A retrospective chart review of 391 patients with late-stage ovarian cancer diagnosed between January 1, 2004 and December 31, 2010 was conducted. Logistic regression was used to predict chemotherapy type. Cumulative incidence of toxicities, dose reduction, and treatment interruption were calculated using the Kaplan-Meier method. Overall survival was analyzed using time-varying Cox regression models. A competing risk model was used to predict second-line chemotherapy with death as a competing risk.

RESULTS

Older patients were less likely to receive primary debulking (OR 0.710; 95% CI 0.55-0.92, P = 0.0108), as were patients with longer diagnostic intervals. Clear-cell, endometrioid, and mucinous carcinoma were more likely to receive adjuvant treatment than unclassified epithelial (OR 6.964; 95% CI 2.02-24.03, P = 0.0021). Adjuvant patients experienced higher incidence of chemotherapy toxicities (P <0.0001) and treatment interruption (P = 0.016) at 3 months. There was no statistically significant difference in the incidence of chemotherapy dose reduction of >20% in the NAC and adjuvant populations (P = 0.142). Neoadjuvant patients were more likely to require more than one line of chemotherapy ([Subhazard Ratio] = 4.334; 95% CI 2.51-7.50, P <0.0001).

CONCLUSION

Our study found that patients with shorter diagnostic intervals, more advanced age, and unclassified epithelial histotype were more likely to receive NAC. NAC patients did not experience a higher incidence of chemotherapy toxicities, treatment interruption, or dose reduction. There is treatment selection bias for sicker patients being treated with NAC.