Conditional Relative Survival of Ovarian Cancer: A Korean National Cancer Registry Study

Prognostic value of HE4 in advanced-stage, high-grade serous ovarian cancer: Analysis of HE4 kinetics during NACT, predicting surgical outcome and recurrence in comparison to CA125

OBJECTIVES

To assess the prognostic value of human epididymis protein 4 (HE4) kinetics during and after neoadjuvant chemotherapy (NACT) cycles compared with cancer antigen 125 (CA-125), in predicting the surgical outcomes of interval debulking surgery (IDS) in patients with advanced-stage, high-grade serous ovarian cancer.

METHODS

This retrospective cohort study was conducted at Severance Hospital in Seoul, South Korea and involved 123 women with high-grade serous epithelial ovarian, fallopian tube, or primary peritoneal cancer who were diagnosed between April 2015 and July 2020. Three outcomes were considered: the chemotherapy response score (CRS) by omentum, residual disease after IDS, and recurrence. Other clinical, imaging, and biological parameters at baseline, during NACT cycles, and pre- and postoperative time were collected and analyzed.

RESULTS

We observed a substantial and gradual decrease in both CA-125 level (median from 1612 to 85.55 U/mL; p < 0.001) and HE4 level (514.7 to 87.7 pmol/L; p < 0.001) during NACT cycles, while pre-to-postoperative reduction was only significant for HE4 (median from 77.3 to 62.0 pmol/L (p < 0.001)). Of the total patients, 4.1% showed no response to NACT (chemoresistance) and 65.9% had a partial response. Residual disease was observed in 55 (44.7%) patients. Recurrence occurred in 90 patients (73.2%), with a median progression-free survival of 15.28 months. The percent reduction in CA-125 level- but not HE4 - during NACT was significantly associated with CRS (by omentum); the reduction in CA-125 during NACT cycles was higher when the CRS was found to be 3 and 2 (median = 96.4 [IQR = 8.3] and 93.7 [12.2] respectively) compared to score 1 (68.3 [34.1]), and the difference was statistically significant (p = 0.004). However, no significant association was observed between the percent reduction in CA-125 or HE4 levels during NACT and residual disease or recurrence. The normalization of HE4 - but not CA-125 - before surgery was predictive for surgery outcome; that is, an abnormal preop HE4 level was associated with a residual disease risk ratio of 2.72 (95% CI = 1.27-5.79).

CONCLUSION

Monitoring HE4 or CA-125 levels has low prognostic value in patients with advanced-stage, high-grade serous ovarian cancer who are treated with NACT followed by IDS. However, the preoperative level of the HE4 biomarker may be useful in identifying patients at higher risk for suboptimal cytoreductive surgery or who may require more extensive surgery. Further prospective studies are warranted to explore the prognostic utility of eventual combinations of clinical, radiological, and biological parameters, notably by using artificial intelligence-based models.

Prognosis and conditional survival among women with newly diagnosed ovarian cancer

OBJECTIVE

An important question in determining long-term prognosis for women with ovarian cancer is whether risk of death changes the longer a woman lives. Large real-world datasets permit assessment of conditional survival (CS) given both prior overall survival (OS) and real-world progression-free survival (rwPFS).

METHODS

Using a longitudinal dataset from US oncology centers, this study included 6778 women with ovarian cancer. We calculated CS rates as the Kaplan-Meier probability of surviving an additional 1 or 5 years, given no mortality (OS) or disease progression (rwPFS) event in the previous 0.5-5 years since first-line chemotherapy initiation, adjusted for factors associated with OS based on multivariable Cox regression.

RESULTS

Median study follow-up was 9 years (range, 1-44) from first-line initiation to data cutoff (17-Feb-2021). Median OS was 58.0 months (95% CI, 54.9-60.8); median rwPFS was 18.4 months (17.4-19.4). The adjusted 1-year CS rate (ie, rate of 1 year additional survival) did not vary based on time alive, whereas the adjusted 5-year CS rate increased from 48.5% (47.0%-50.1%) for women who had already survived 6 months to 66.4% (63.3%-69.6%) for those already surviving 5 years (thus surviving 10 years total). The adjusted 1-year CS rate increased from 90.4% (89.5%-91.4%) with no rwPFS event at 6 months to 97.6% (96.4%-98.8%) with no rwPFS event at 5 years; adjusted 5-year CS rate increased from 53.7% (52.0%-55.5%) to 85.0% (81.2%-88.9%), respectively.

CONCLUSIONS

This analysis extends the concept of CS by also conditioning on time progression-free. Patients with longer rwPFS experience longer survival than patients with shorter rwPFS.

Mammographic Breast Density and Risk of Ovarian Cancer in Korean Women

BACKGROUND

This study aimed to investigate the potential association between mammographic breast density and ovarian cancer risk.

METHODS

This retrospective cohort study included women ≥40 years of age who underwent a mammography screening from 2009 to 2014. Breast density was assessed using the Breast Imaging-Reporting and Data System. The primary outcome was ovarian cancer development, and the cases were recorded until 2020. Cox proportional hazards regression was used to assess the association between breast density and ovarian cancer development. Subgroup analyses stratified by age, menopausal status, and body mass index (BMI) were conducted.

RESULTS

Of the 8,556,914 women included in this study, 9,246 ovarian cancer events were recorded during a median follow-up period of 10 years (interquartile range, 8.1-11.0 years). Compared with women with almost entirely fat density, those with scattered fibroglandular density, heterogeneous density, and extreme density had an increased risk of ovarian cancer with adjusted HRs of 1.08 [95% confidence interval (CI), 1.02-1.15], 1.16 (95% CI, 1.09-1.24), and 1.24 (95% CI, 1.15-1.34), respectively. The strongest association was observed in the ≥60 years age group; subgroup analysis indicated a significant increase in association between the higher-density category and ovarian cancer risk, regardless of BMI or menopausal status.

CONCLUSIONS

Higher levels of breast density are associated with an increased risk of ovarian cancer.

IMPACT

Breast density may have a relationship with ovarian cancer risk and could be used to assess future risk.

Use of Period Analysis to Timely Assess Five-Year Relative Survival for Patients with Ovarian Cancer from Taizhou, Eastern China

OBJECTIVE

Ovarian cancer is a deadly gynecologic malignancy with a poor prognosis. It is essential to evaluate the early detection and screening programs of ovarian cancer via timely assessment of long-time survival, particularly in China where those data are incredibly limited. Here, we aimed to provide timely and accurately assessment of long-term survival estimate of ovarian cancer patients from eastern China.

METHODS

Data of 770 ovarian cancer patients diagnosed between 2004-2018 were obtained from four cancer registries in Taizhou, eastern China, were included. We used period analysis to calculate five-year relative survival (RS) of aforementioned ovarian cancer patients for overall and the stratification by age at diagnosis and region.

RESULTS

Our findings demonstrated that the overall five-year RS for ovarian cancer patients in Taizhou between 2014 and 2018 was 69.2%, while urban areas were higher compared to rural areas (77.6% vs. 64.9%). We also observed a significant age gradient with the five-year RS decreasing from 79.6% for age group < 55 years to 66.9% for age group > 74 years. Furthermore, we identified a clear upward trend of five-year RS over the study period, both overall and stratified by region and age at diagnosis.

CONCLUSION

This is the first study in China using period analysis to provide the most up-to-date five-year RS for ovarian cancer patients from Taizhou, eastern China, which reaches 69.2% during 2014-2018. Our results provide valuable information for timely assessment of early detection and screening programs for ovarian cancer in eastern China.

Stratifying the risk of ovarian cancer incidence by histologic subtypes in the Korean Epithelial Ovarian Cancer Study (Ko-EVE)

INTRODUCTION

This study aimed to verify the association between ovarian cancer (OC) and reproductive- and lifestyle-related risk factors stratified by the subtype of OC.

METHODS

In this matched case-control study derived from the Korean epithelial ovarian cancer study (Ko-EVE), we calculated the risk of OC subtypes using odds ratios (ORs) and 95% confidence intervals (95% CIs) in a logistic regression model.

RESULTS

As a result of matching, 531 cases and 2,124 controls were selected. Smoking had positive association with high-grade serous (HGS) OC (OR = 2.69, 95% CI = 1.15-6.30), whereas alcohol consumption had positive association with mucinous type (MUC) (OR = 3.63, 95% CI = 1.39-9.49). Obesity (≥30 kg/m² ) was associated with clear cell type (CLC) (OR = 4.57, 95% CI = 1.06-19.77). Spontaneous abortion was negatively associated with CLC (OR = 0.34, 95% CI = 0.13-0.90), in contrast to HGS (OR = 1.43, 95% CI = 0.96-2.15). Tubal ligation, hysterectomy, and oophorectomy were associated with decreased risk of HGS (OR = 0.14, 95% CI = 0.05-0.39; OR = 0.23, 95% CI = 0.07-0.73; OR = 0.28, 95% CI = 0.08-0.97, respectively). Early menarche was strongly associated with increased risk of CLC, but not MUC (OR = 6.11, 95% CI = 1.53-24.42; OR = 3.23, 95% CI = 0.98-10.86). Further, childbirth (≥2 times) was negatively associated with endometrioid type OC and CLC (OR = 0.11, 95% CI = 0.04-0.35; OR = 0.12, 95% CI = 0.02-0.37, respectively). Oral contraceptives and hormone replacement therapy were negatively associated with OC (OR = 0.61, 95% CI = 0.40-0.93; OR = 0.51, 95% CI = 0.32-0.80, respectively), and similar negative associations were also observed in HGS (OR = 0.69; OR = 0.60, respectively). Associations between family history of breast cancer and OC, regular exercise (≥5/week), and artificial abortion and OC were similar across all subtypes (OR = 3.92; OR = 0.41; OR = 0.72, respectively).

CONCLUSION

A heterogeneous association between some risk factors and the incidence of each subtype of epithelial OC was observed, suggesting that the carcinogenic mechanisms of each subtype may be partly different.

Contrasting clinical characteristics and treatment patterns in women with newly diagnosed advanced-stage epithelial ovarian cancer in Australia, South Korea and Taiwan

OBJECTIVE

The real-world INFORM study analyzed sociodemographics, treatment patterns and clinical outcomes for patients with newly diagnosed advanced epithelial ovarian cancer (EOC) in Australia, South Korea (S.Korea) and Taiwan preceding incorporation of poly(ADP-ribose) polymerase inhibitors into clinical practice.

METHODS

Retrospective data from patients diagnosed with EOC (high-grade serous EOC for Taiwan) between January 2014 and December 2018 with ≥12 months follow-up from diagnosis were analyzed descriptively. Survival was evaluated by Kaplan-Meier with two-sided 95% confidence interval (CI).

RESULTS

Of the 987 patients (Australia, 223; S.Korea, 513; Taiwan, 251), 98% received platinum-based chemotherapy (CT). In S.Korea and Taiwan 76.0% and 78.9% respectively underwent primary cytoreductive surgery; in Australia, 56.5% had interval debulking surgery. Bevacizumab was included in primary/maintenance therapy for 22.4%, 14.6% and 6.8% of patients in Australia, S.Korea and Taiwan, respectively. Patients receiving bevacizumab were high-risk (reimbursement policy) and achieved similar real-world progression-free survival (PFS) compared with CT only. Overall, the median real-world PFS (months; 95% CI) was similar across Australia (16.0 [14.63-18.08]), S.Korea (17.7 [16.18-19.27]) and Taiwan (19.1 [17.56-22.29]).

CONCLUSION

This study reveals poor prognosis despite differences in demographics and treatment patterns for patients with EOC across Asia-Pacific suggesting the need for biomarker-driven novel therapies to improve outcomes.

Projection of Cancer Incidence and Mortality From 2020 to 2035 in the Korean Population Aged 20 Years and Older

OBJECTIVES

This study aimed to identify the current patterns of cancer incidence and estimate the projected cancer incidence and mortality between 2020 and 2035 in Korea.

METHODS

Data on cancer incidence cases were extracted from the Korean Statistical Information Service from 2000 to 2017, and data on cancer-related deaths were extracted from the National Cancer Center from 2000 to 2018. Cancer cases and deaths were classified according to the International Classification of Diseases, 10th edition. For the current patterns of cancer incidence, age-standardized incidence rates (ASIRs) and age-standardized mortality rates were investigated using the 2000 mid-year estimated population aged over 20 years and older. A joinpoint regression model was used to determine the 2020 to 2035 trends in cancer.

RESULTS

Overall, cancer cases were predicted to increase from 265 299 in 2020 to 474 085 in 2035 (growth rate: 1.8%). The greatest increase in the ASIR was projected for prostate cancer among male (7.84 vs. 189.53 per 100 000 people) and breast cancer among female (34.17 vs. 238.45 per 100 000 people) from 2000 to 2035. Overall cancer deaths were projected to increase from 81 717 in 2020 to 95 845 in 2035 (average annual growth rate: 1.2%). Although most cancer mortality rates were projected to decrease, those of breast, pancreatic, and ovarian cancer among female were projected to increase until 2035.

CONCLUSIONS

These up-to-date projections of cancer incidence and mortality in the Korean population may be a significant resource for implementing cancer-related regulations or developing cancer treatments.

Trends in the Incidence and Survival Rates of Primary Ovarian Clear Cell Carcinoma Compared to Ovarian Serous Carcinoma in Korea

Objective

To compare the incidence and survival rates of primary ovarian clear cell carcinoma (OCCC) and ovarian serous carcinoma (OSC) from a nationwide collected database.

Methods

We extracted information of patients with primary OCCC and OSC from the Korea Central Cancer Registry recorded between 1999 and 2018, including age at diagnosis and the Surveillance, Epidemiology, and End Results summary stage. Age-standardized incidence rates (ASRs) and annual percent changes (APCs) were calculated. Baseline characteristics and overall survival (OS) were compared between the OCCC and OSC groups.

Results

Overall, the incidence rate of primary OCCC increased markedly from 1999 (ASR, 0.16/100,000) to 2018 (0.76/100,000) (APC, 7.85%; P<0.0001). Patients with OCCC were significantly younger and had early-stage disease more frequently than those with OSC. Patients diagnosed with OCCC before the age of 50 showed better OS than those diagnosed after the age of 50 (P=0.0048). The 5-year OS of the OCCC group did not differ by study period [73.5% (1999–2008) vs. 75.4% (2009–2018), P=0.3187], whereas the 5-year OS of the OSC group improved from 54.4% to 58% (P=0.0003).

Conclusions

Our nationwide registry-based study demonstrated that the incidence of OCCC in Korea increased significantly from 1999 to 2018. Early-stage OCCC had a relatively good prognosis, but advanced-stage OCCC had a worse OS than advanced-stage OSC. Therefore, the development of optimal treatment strategies for OCCC is warranted.

Conditional relative survival of patients with endometrial cancer: a Korean National Cancer Registry study

Objective

The purpose of this study was to estimate 5-year conditional relative survival (5Y CRS) rates of endometrial cancer (EC) in Korea accounting for time already survived. Subgroup-specific estimates stratified by various patient characteristics were also presented.

Methods

Using the data from the Korean Central Cancer Registry, 5Y CRS rates were calculated in patients who were diagnosed with EC between 1998 and 2017. The CRS rates were presented by year of diagnosis, age at diagnosis, histology, cancer stage, and treatment received.

Results

The 5-year relative survival rate at the time of diagnosis was 89.0% for all cases. The probability of surviving an additional 5 years (i.e., 5Y CRS), if the patient survived 1, 2, 3, 4, and 5 years after diagnosis was 91.8%, 94.1%, 95.6%, 96.5%, and 97.3%, respectively. Patients with poor initial prognoses, i.e., those who were older, had non-endometrioid histology, and high stage, showed the largest improvements in 5Y CRS, reaching >90% for most subgroups, except those with serous histology (88.4%) and distant stage (77.7%). Patients aged ≥70 years had the highest probability of death in the 1st and 2nd years after diagnosis (13.8 and 11.0%), but the conditional probability of death in the 3rd, 4th, and 5th years declined rapidly to 7.3%, 4.5%, and 3.7%, respectively.

Conclusion

The CRS rates for patients with EC improved with increased time elapsed from diagnosis. The greatest improvements in 5Y CRS were observed among patients who were older, those with non-endometrioid histology, and those with more advanced disease.

There is paucity of research which estimated the conditional relative survival (CRS) rates for patients with endometrial cancer, and the Asian population is underrepresented in these studies, despite that Asian patients have different age and histologic distribution. CRS rates were presented by year of diagnosis, age at diagnosis, histology, cancer stage, and treatment received. Such estimates based on patient's evolving risk profile will provide updated prognostic information useful for both patients and healthcare providers.