Survival of patients with ovarian cancer in central and northern Denmark, 1998-2009

The clinical and pathological characteristics and survival of patients with advanced ovarian cancer

Introduction: Ovarian cancer has the highest mortality rate of all gynaecologic malignancies. The aim of this study was the evaluation of the clinical pathological characteristics and survival analysis of primarily operated patients with advanced stages of malignant epithelial ovarian tumour. Methods: The research was conducted as a cohort study with 59 patients with FIGO stage III and IV, which were primarily operated between 1 January 2008 and 31 December 2010 (three years). Age, comorbidities, BMI, presence of ascites, the level of the marker CA-125, histopathology and FIGO stage were analysed. The survival rate was estimated at the level of 1, 3 and 5 years. Results: The median age was 53 years (range 29-86). The most common histopathological type was serous (66.1 %) and the most common FIGO stage was 3a (49.2 %). Optimal cytoreduction was performed in 35.5 % of patients, 84.7 % of patients survived for one year, 44.1 % three years and 37.3 % for five years. The median survival was 26.25 months (range 0-91). Chi-square test showed significant difference between the number of months of survival and: the value of CA125 (t = 2.004, p = 0.050), cytoreduction (p < 0.001) and FIGO stage (p < 0.01). Conclusion: According to the results of this study, optimal cytoreduction and FIGO stage significantly influence survival (p < 0.001). Optimal cytoreduction (< 2 cm of residual disease) had the highest prognostic value for survival. A total five-year survival in this study was 37.3 %.

Perioperative change in CA125 is an independent prognostic factor for improved clinical outcome in advanced ovarian cancer

OBJECTIVE

Despite being the most important prognostic factor for prolonged overall survival in epithelial ovarian cancer (EOC), the measurement of residual disease is hampered by its subjective character. Additional assessment tools are needed to establish the success of cytoreductive surgery in order to predict patients' prognosis more accurately. The aim of this study is to evaluate the independent prognostic value of perioperative CA125 change in advanced stage EOC patients.

STUDY DESIGN

We identified all patients who underwent primary cytoreductive surgery for advanced stage (FIGO IIB-IV) EOC between 2008 and 2015, from the Netherlands Cancer Registry. The relative perioperative change in CA125 was categorized into four groups; increase, <50% decline, 50-79% decline and ≥80% decline. Overall survival (OS) was analyzed using Kaplan-Meier survival curves and multivariable cox regression models.

RESULTS

We included 1232 eligible patients with known pre- and postoperative CA125 serum levels. Patients with a decline of ≥80% in CA125 levels experienced improved OS compared to those with a decline of <50% (univariable Hazard Ratio (HR) 0.45, 95%CI 0.36-0.57). The prognostic effect of perioperative CA125 change was independent of patient- and treatment characteristics, such as the extent of residual disease after cytoreductive surgery (multivariable HR_≥80% 0.52(0.41-0.66)).

CONCLUSIONS

This study shows that the perioperative change in CA125 is an independent prognostic factor for overall survival after primary surgery for EOC patients. This pleads for the use of a combined model, consisting of perioperative CA125 change and the outcome of residual disease, in order to predict the prognosis of EOC patients more accurately.

The prognostic values of the peroxiredoxins family in ovarian cancer

Purpose: Peroxiredoxins (PRDXs) are a family of antioxidant enzymes with six identified mammalian isoforms (PRDX1–6). PRDX expression is up-regulated in various types of solid tumors; however, individual PRDX expression, and its impact on prognostic value in ovarian cancer patients, remains unclear.

Methods: PRDXs family protein expression profiles in normal ovarian tissues and ovarian cancer tissues were examined using the Human Protein Atlas database. Then, the prognostic roles of PRDX family members in several sets of clinical data (histology, pathological grades, clinical stages, and applied chemotherapy) in ovarian cancer patients were investigated using the Kaplan–Meier plotter.

Results: PRDXs family protein expression in ovarian cancer tissues was elevated compared with normal ovarian tissues. Meanwhile, elevated expression of PRDX3, PRDX5, and PRDX6 mRNAs showed poorer overall survival (OS); PRDX5 and PRDX6 also predicted poor progression-free survival (PFS) for ovarian cancer patients. Furthermore, PRDX3 played significant prognostic roles, particularly in poor differentiation and late-stage serous ovarian cancer patients. Additionally, PRDX5 predicted a lower PFS in all ovarian cancer patients treated with Platin, Taxol, and Taxol+Platin chemotherapy. PRDX3 and PRDX6 also showed poor PFS in patients treated with Platin chemotherapy. Furthermore, PRDX3 and PRDX5 indicated lower OS in patients treated with these three chemotherapeutic agents. PRDX6 predicted a poorer OS in patients treated with Taxol and Taxol+Platin chemotherapy.

Conclusion: These results suggest that there are distinct prognostic values of PRDX family members in patients with ovarian cancer, and that the expression of PRDX3, PRDX5, and PRDX6 mRNAs are a useful prognostic indicator in the effect of chemotherapy in ovarian cancer patients.

The Danish Gynecological Cancer Nursing Database: Creating Evidence for Quality Improvements in Preoperative and Postoperative Cancer Care

Objective

Quality of preoperative and postoperative care is crucial to improve postoperative outcome of cancer surgery and to ensure that neither complications nor a poor general condition delays any subsequent radiochemotherapy or recovery. On this background, the Danish Gynecological Cancer Database (DGCD) established a nursing database in 2011. The aim of DGCD Nursing is to monitor the quality of preoperative and postoperative care and to generate data for research.

Material and Methods

In accordance with the current data protection legislation, real-time data are entered by clinical nurses at all national cancer centers. The DGCD Nursing includes data of preoperative and postoperative care, and nurses are independently represented in the steering committee. The aim of the present article is to present the first results from DGCD Nursing and the national care improvements that have followed.

Results

With national coverage of an average of 94%, 5726 patients have been registered since 2011. In patients undergoing surgery for ovarian, endometrial, and cervical cancer, 436 different variables monitor central preoperative and postoperative care elements within mobilization, nutritional status, pain score, vital functions, and psychosocial support.

Conclusions

At national level, DGCD offers a comprehensive overview of the total patient pathway within gynecological cancer surgery. The DGCD Nursing has added to the quality and implementation of evidence-based preoperative and postoperative care and in addition supported formation of professional networks. With a continued validation of data, DGCD Nursing now constitutes a sound and unique basis for research within the field of preoperative and postoperative cancer care.

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.

CREB5 promotes tumor cell invasion and correlates with poor prognosis in epithelial ovarian cancer

CAMP responsive element binding protein 5 (CREB5) has crucial roles in regulating cell growth, proliferation, differentiation and cell cycle regulation. CREB5 has been identified to be overexpressed in several types of human cancer. However, the expression characteristics of CREB5 in epithelial ovarian cancer remains unknown, and its potential clinical prognostic significance has not yet been elucidated. In the present study, quantitative polymerase chain reaction (qPCR) and western blot analysis were performed to detect CREB5 mRNA and protein expression levels in 10 fresh tissue and cell lines epithelial ovarian cancer. Furthermore, CREB5 expression was analyzed using immunohistochemical analysis in 125 clinicopathologically characterized ovarian cancers: Stage I+II (n=31), stage III (n=70), stage IV (n=24). The patient survival rate was evaluated using Kaplan-Meier analysis. CREB5 was significantly overexpressed at both the mRNA and protein levels in epithelial ovarian cancer cells. There was a significant positive correlation between high CREB5 expression and increasing the International Federation of Gynecology and Obstetrics (FIGO) stage and pelvic lymph node metastasis (P<0.05). Patients with high CREB5 expression had a shorter overall survival, whereas patients with low CREB5 expression had longer survival. In addition, patients with high CREB5 expression had shorter relapse-free survival whereas patients with low CREB5 expression had longer relapse-free survival. Univariate logistic regression analysis and stepwise multivariate analysis all revealed that the FIGO stage and high CREB5 expression were significant risk factors for epithelial ovarian cancer (P<0.001), which suggested that CREB5 upregulation may be associated with a poor prognosis; therefore, it may be an independent prognostic indicator of epithelial ovarian cancer and may serve as a tumor-aggressive gene.

The effect of neighborhood-level socioeconomic status on racial differences in ovarian cancer treatment in a population-based analysis in Chicago

BACKGROUND

Less than half of women with ovarian cancer and blacks specifically receive therapy adherent to National Comprehensive Cancer Network (NCCN) guidelines. The purpose is to assess the effect of neighborhood-level socioeconomic status (SES) on black-white treatment differences in a population-based analysis in a highly-segregated community.

METHODS

Illinois State Cancer Registry data for invasive epithelial ovarian cancer cases diagnosed in Cook County, IL in non-Hispanic white (NHW) or black (NHB) women from 1998 to 2009 was analyzed. As few women receive NCCN-adherent care, variables were constructed to assess extent of treatment, including receipt of: 1) debulking surgery; 2) any surgery; 3) multi-agent chemotherapy; and 4) any chemotherapy. Two measures (concentrated affluence and disadvantage) were used to estimate neighborhood-level SES. Multivariable logistic regression was used to compute odds ratios (OR) and 95% confidence intervals (95% CI), with generalized linear mixed models to account for hierarchical data.

RESULTS

2766 (81.0%) NHW and 647 (19.0%) NHB women were diagnosed. Adjusting for covariates, NHB were less likely to receive debulking surgery (OR: 0.39; 95% CI: 0.30-0.50), any surgery (OR: 0.38; 95%CI: 0.29-0.49), multi-agent chemotherapy (OR: 0.56; 95% CI: 0.45-0.71) and any chemotherapy (OR: 0.58; 95% CI: 0.45-0.74). Concentrated affluence but not disadvantage was significant in final models for multi-agent and any chemotherapy, but not debulking or any surgery.

CONCLUSIONS

Results identify black-white differences consistent across treatments that persist despite adjustment for neighborhood-level SES.

IMPACT

Results advance inequality awareness beyond "ideal" NCCN-adherent care, indicating inequality exists in delivery of even the most basic oncologic care.

(E)-2,4-Bis(p-hydroxyphenyl)-2-butenal enhanced TRAIL-induced apoptosis in ovarian cancer cells through downregulation of NF-κB/STAT3 pathway

Ovarian cancer is a cancerous growth arising from the ovary and with poor prognosis that usually have resistant to all currently available treatments. Whether (E)-2,4-bis(p-hydroxyphenyl)-2-butenal (butenal) synthesized by Maillard reaction from fructose-tyrosine, has potential therapeutic activity against human ovarian cancer was investigated using two ovarian cancer cell lines (PA-1, SK-OV-3). We found that butenal could inhibit NF-κB/STAT3 activity, thereby inducing apoptotic cell death of ovarian cancer cells. We treated with several concentration of butenal each cell line differently (PA-1; 5, 10 and 15 μg/ml, SK-OV-3; 10, 20 and 30 μg/ml). First, ovarian cancer cell lines exhibited constitutively active NF-κB, and treatment with butenal abolished this activation as indicated by DNA binding activity. Second, butenal suppressed activation of signal transducer and activator of transcription-3 as indicated by decreased phosphorylation and inhibition of Janus kinase-2 phosphorylation. Third, butenal induced expression of pro-apoptotic proteins such as proteolytic cleavage of PARP, Bax and activation of caspase-3, -8 and -9. Lastly, combination of butenal and TRAIL causes enhanced induction of apoptosis. Overall, our results indicate that butenal mediates its anti-proliferative and apoptotic effects through activation of multiple cell signaling pathways and enhances the TRAIL-induced apoptosis. These data suggested that butenal may be a potential anti-cancer agent in ovarian cancer.

Comorbidity and survival of Danish ovarian cancer patients from 2000-2011: a population-based cohort study

OBJECTIVE

To examine the prevalence of comorbidity among patients diagnosed with epithelial ovarian cancer in the Central Denmark Region and to study the impact of comorbidity on cancer survival over time.

METHODS

We included women recorded with a first-time diagnosis of epithelial ovarian cancer in the Danish National Registry of Patients in the Central Denmark region between 2000 and 2011. We followed their survival through the Danish Civil Registration System. We estimated 1- and 5-year survival overall and stratified by Charlson Comorbidity Index score. We used Cox proportional hazard regression analyses to compute adjusted mortality rate ratios (MRRs) within different calendar time periods overall and by comorbidity level.

RESULTS

We identified 1,540 patients. In 2000-2002, 25% of the newly diagnosed ovarian cancer patients had a comorbidity diagnosis compared with 35% in 2009-2011. Median age increased from 61 to 66 years. One-year overall survival changed from 73% (95% confidence interval [CI]: 69-78) in 2000-2002 to 69% (95% CI: 63-73) in 2009-2011, corresponding to an age- and comorbidity-adjusted MRR of 1.03 (95% CI: 0.79-1.36). Five-year survival changed only slightly during the study period, from 37% (95% CI: 32-42) in 2000-2002 to 39% (95% CI: 34-44) in 2009-2011. In patients with Charlson score ≥3, 1-year survival changed from 63% (95% CI: 35-81) in 2000-2002 to 41% (95% CI: 24-57) in 2003-2005 and thereafter stabilized. One-year survival changed from 56% (95% CI: 44-66) to 64% (95% CI: 53-74) in patients with Charlson score 1-2. Compared with Charlson score 0, adjusted 1-year MRRs for Charlson score ≥3 were 1.44 (95% CI: 0.62-3.36) in 2000-2002 and 2.11 (95% CI: 1.27-3.51) in 2009-2011, whereas adjusted 1-year MRRs for Charlson score 1-2 changed from 2.04 (95% CI: 1.33-3.14) in 2000-2002 to 1.09 (95% CI: 0.69-1.71) in 2009-2011.

CONCLUSION

Comorbidity increased among ovarian cancer patients over time and was associated with poor survival. One- and 5-year overall survivals changed only little and an expected decrease in survival, following increased prevalence of comorbidity and increasing age of patients, may have been counteracted by more aggressive surgery.

Is serum human epididymis protein 4 ready for prime time?

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.

Ovarian cancer surgery: health and coping during the perioperative period

PURPOSE

The study objective was to survey general health and coping in women undergoing ovarian cancer surgery, and subsequently to develop and test a supportive care intervention.

METHODS/MATERIALS

Women who underwent surgery on the suspicion of ovarian cancer participated in a follow-up questionnaire study in which the Short Form-36 Questionnaire was used to survey general health twice during the perioperative period and the Life Orientation Questionnaire (SOC) was used once to define the postoperative coping capacity. An evidence-based, preoperative supportive care programme was subsequently developed and tested. This consisted of lean methodology applied to clinical pathways, preoperative optimisation, and psychosocial care and support.

RESULTS

From 294 women allocated to three study groups, a total of 546 Short Form-36 questionnaires and 253 SOC questionnaires were available for analysis. The overall response rate was 86 %. The presence of ascites, a pelvic mass, and a Risk of Malignancy Index >200 proved to be appropriate clinical markers for intensified preoperative care. Concerning physical health, levels were low throughout the perioperative period; the majority however stayed within standard levels. Concerning mental health, levels were below standard during the entire period, but did improve with time, also in women in whom the potential cancer diagnosis was refuted. The preoperative differences between these groups leveled out postoperatively in terms of physical health. At the end of the perioperative period, the coping capacity was close to normal.

CONCLUSIONS

A need for supportive care during the perioperative period was identified. This should be adjusted to the nature of the disease and the extent of the treatment. Participation in a preoperative supportive programme supported physical health during the perioperative period; however, further support of mental health seemed required.