A population-based study of racial and ethnic differences in survival among women with invasive cervical cancer: analysis of Surveillance, Epidemiology, and End Results data

OBJECTIVE: The incidence of cervical cancer is higher in Hispanic than in non-Hispanic or African American women in the United States, but few studies have examined differences in survival between these groups. The objective of this study was to examine racial/ethnic differences in survival after diagnosis with invasive cervical cancer in a population-based sample of patients while adjusting for patient and tumor characteristics and treatment types. METHODS: We identified 7267 women (4431 non-Hispanic Caucasians, 1830 Hispanic Caucasians, and 1006 non-Hispanic African Americans) diagnosed with primary invasive cervical cancer from 1992 to 1996 (with follow-up through 2000) from the Surveillance, Epidemiology and End Results (SEER) Program. Kaplan-Meier and Cox proportional hazards survival methods were used to assess differences in survival by race/ethnicity. RESULTS: After adjusting for age at diagnosis, histology, stage, first course of cancer-directed treatment (surgery and radiation therapy), and SEER registry, Hispanic Caucasian women were at 26% decreased risk of death from any cause (hazard ratio (HR) = 0.74, 95% confidence interval (CI): 0.66-0.83) and non-Hispanic African American women were at 19% increased risk of death (HR = 1.19, 95% CI: 1.06-1.33) compared to non-Hispanic Caucasian women over the follow-up period. CONCLUSION: Analysis of population-based SEER data indicates significant survival differences by race/ethnicity for women with invasive cervical cancer. Hispanic Caucasian women in SEER had improved survival compared to non-Hispanic Caucasian or non-Hispanic African American women.     

Reproductive history and mortality after breast cancer diagnosis

OBJECTIVE: To assess whether reproductive factors are associated with mortality after breast cancer diagnosis. METHODS: We followed up 4,299 U.S. women enrolled between 1980 and 1982 at ages 20-54 years as incident breast cancer cases in a population-based, case-control study, the Cancer and Steroid Hormone Study. Vital status through 1997 for these cases was obtained by linking Cancer and Steroid Hormone Study data to Surveillance, Epidemiology, and End Results files. We estimated hazard ratios (HRs) and 95% confidence intervals (CIs) for death associated with selected reproductive factors using proportional hazards models. RESULTS: During a median follow-up of 14.5 years, 1,847 deaths occurred. Women aged 20-45 years whose last birth occurred 12 months or less (age-adjusted HR = 1.62, 95% CI 1.10-2.37) and 13-48 months before breast cancer diagnosis (age-adjusted HR = 1.35, 95% CI 1.05-1.75) were at an increased risk for death compared with nulliparous women. After adjusting for additional factors including tumor stage, women whose last birth occurred 12 months or less before diagnosis remained at an increased risk for death (HR = 1.51, 95% CI 1.02-2.23). Fifteen-year survival was 38%, 51%, and 60% among women aged 20-45 years whose last birth was 12 months or less, 13-48 months, and more than 48 months before diagnosis, respectively, compared with 65% among nulliparous women. Mortality risk was not associated with age at first birth, parity, or breastfeeding duration among women aged 20-45 years or among women aged 46-54 years. CONCLUSION: A recent birth may be an adverse prognostic indicator among women diagnosed with breast cancer at ages 20-45 years.     

Survival of women diagnosed with malignant, mixed mullerian tumors of the ovary (OMMMT)

OBJECTIVE: To analyze the survival of women with malignant, mixed mullerian tumors of the ovary (OMMMT) compared to women with epithelial ovarian cancer (EOC). METHODS: Data from the Surveillance, Epidemiology and End Results (SEER) Program on 14025 women diagnosed with primary invasive ovarian cancer between 1988 and 1997 were used for this analysis (382 had OMMMT). Differences in distribution of prognostic variables by histological type were compared using a chi-square test. Multivariable survival models were fit using Cox proportional hazards regression analysis to compare risk of death for OMMMT compared to EOC. Analyses were also performed using cases with OMMMT compared to high-grade EOC only. RESULTS: Women with OMMMT were older at diagnosis and were more likely to have primary surgery compared to women with EOC. The majority of women in either histological group had advanced-stage disease at diagnosis. Women with OMMMT had a significant increased risk of death from any cause whether being compared to all women with EOC (HR = 1.69, 95% CI = 1.50,1.90) or to women with high-grade EOC only (HR = 1.58, 95% CI = 1.40,1.79). Women with advanced-stage OMMMT were at a 60% increased risk of death compared to women with advanced-stage, high-grade EOC, after adjustment for other variables of interest (adjusted HR = 1.60, 95% CI = 1.40,1.84). There was no difference in risk of death for these two groups of women with early-stage disease. CONCLUSION: OMMMT is a rare malignancy compared to EOC and had a significantly worse prognosis compared to EOC.     

Differences in cervical cancer mortality among black and white women.

OBJECTIVE: To determine whether stage of disease and treatment patterns account for mortality differences between black and white women with cervical cancer. METHODS: Using data obtained from the Surveillance, Epidemiology, and End Results (SEER) Program for 1988-1994, we determined the associations between race and stage, and race and treatment. Racial differences in survival for up to 7 years of follow-up were adjusted for age, marital status, SEER location, International Federation of Gynecology and Obstetrics (FIGO) stage of disease, lymph node status, grade, histology, and treatment. RESULTS: Cumulative mortality was 36% (366 deaths in 1029 women) for black women and 24% (1215 deaths in 5021 women) for white women; unadjusted hazard ratio was 1.60 (95% confidence interval [CI] 1.43, 1.80). Black women were more likely to present with advanced disease than white women (43.8% compared with 34.8%). In a model adjusting for demographics and FIGO stage, the hazard ratio for black women compared with white women decreased to 1.35 (95% CI 1.19, 1.54). Treatment varied by race, with black women receiving surgery less often (33.5% compared with 48.2%, respectively) and radiation therapy more often (35.3% and 25.2%, respectively) than white women. In a comprehensive model including demographic factors, FIGO stage, other tumor characteristics, and treatment, the adjusted hazard ratio for mortality remained high for black women at 1.30 (95% CI 1.14, 1.48). CONCLUSION: Race remains an independent predictor of cervical cancer survival after accounting for age, stage of disease, treatment patterns, and other factors. Future studies should assess racial differences in clinical severity of disease, comorbidity, and socioeconomic status.     

Prognostic factors in early-onset epithelial ovarian cancer: a population-based study

OBJECTIVE: To investigate the clinical prognostic factors that influence ovarian cancer survival in women with early-onset epithelial ovarian cancer using population-based data. METHODS: Subjects in the current study were from a population-based series of 197 patients with invasive ovarian cancer and 60 patients with ovarian cancer of low malignant potential who were identified from the Cancer and Steroid Hormone study. All subjects were between 20 and 54 years of age at diagnosis for ovarian cancer. Epidemiologic data were obtained from each participant. Immunohistochemical staining was performed to assess p53 expression in paraffin-embedded ovarian cancers. Univariate and multivariate analyses for survival were conducted using the proportional hazards model to test the prognostic significance of several clinicopathologic factors among subjects. RESULTS: Among women with invasive tumors, the proportional hazards model revealed that advanced stage at diagnosis [hazard ratio = 4.1, 95% confidence interval (CI) = 2.5, 6.6], age at diagnosis 46-54 (hazard ratio = 2.0, 95% CI = 1.3, 3.0), and overexpression of p53 (hazard ratio = 1.5, 95% CI = 1.1, 2.3) were significantly associated with decreased survival. CONCLUSION: These results provide evidence that stage, age, and p53 overexpression are independent predictors of decreased survival in women with invasive ovarian cancer diagnosed younger than age 55. Further investigation of the effect of age at diagnosis on the relationship between p53 overexpression and ovarian cancer survival is warranted.     

Adherence to recommendations for follow-up to abnormal Pap tests

OBJECTIVE: To evaluate whether timely adherence rates differ by race among women with abnormal Pap tests participating in a cost-free or reduced-cost program. METHODS: Eligible subjects included women aged 47-64 years who received a referral for follow-up care after an abnormal Pap test from 1999 to 2002 in South Carolina (n=330). Adherence was measured as days to receipt of follow-up care after an abnormal Pap test. Cox proportional hazards modeling was used to estimate risk factors associated with time to adherence within 60 and 365 days by race. RESULTS: African-American and non-Hispanic white women had similar adherence to follow-up. Among white women, those with high-grade lesions were less likely to adhere in a timely manner relative to those with low-grade lesions (hazard ratio 0.6, 95% confidence interval [CI] 0.4-1.0). For African-American women, rural residence (hazard ratio: 0.5, 95% CI 0.2-0.9) and history of abnormal Pap tests (hazard ratio 0.6, 95% CI 0.3-1.0) were associated with decreased adherence, whereas less education (hazard ratio 2.3, 95% CI 1.3-3.9) was associated with increased adherence. CONCLUSION: Adherence rates do not differ by race. However, risk factors for adherence within race are variable. Interventions tailored to the differential needs of racial and ethnic groups may prove effective toward increasing timely adherence rates. LEVEL OF EVIDENCE: II.     

Survival among U.S. women with invasive epithelial ovarian cancer

OBJECTIVE: Invasive epithelial ovarian cancer is a highly fatal disease, diagnosed at advanced stages when survival is poor. Relatively little is known about the variation in survival across U.S. women of different race/ethnicities. To investigate this issue, we evaluated pathological characteristics and death rates due to invasive epithelial ovarian cancer in a population-based sample of patients from six racial/ethnic groups. METHODS: The analysis included 38,012 women diagnosed with primary invasive epithelial ovarian cancer between 1973 and 1997 in the Surveillance, Epidemiology and End Results Program of the National Cancer Institute. RESULTS: Filipina patients were younger at diagnosis, more likely to have localized disease, and had more mucinous cancers than whites. African-Americans were more likely than whites to be diagnosed at older ages, with distant disease and with undifferentiated/unclassified cancers. After adjusting for age at diagnosis, stage of disease at diagnosis, and cancer histology, we found that, compared to whites, death rates were significantly elevated among African-Americans and significantly reduced among Hispanics and Filipina. We also found that death rates declined significantly with time since diagnosis among women with advanced disease. CONCLUSION: The declining death rates in women with advanced disease suggest the presence of considerable prognostic heterogeneity among these women, which could reflect differences in quality of care. This issue, as well as the survival disadvantage for African-American women and survival advantages for Hispanic and Filipina women, needs investigation.     

Racial differences in breast cancer survival: The interaction of socioeconomic status and tumor biology

OBJECTIVE: Our purpose was to evaluate the effect of sociodemographic and clinical variables on survival rates of African-American and white women with breast cancer.STUDY DESIGN: Between 1988 and 1992 the Metropolitan Detroit Cancer Surveillance System identified 10,502 women (82% white and 18% African-American) in whom invasive breast cancer was diagnosed. Cox proportional hazards regression was used to estimate the relative risk of death for African-Americans compared with whites after controlling for variables believed to influence survival.RESULTS: African-American women were more likely than white women to have tumors that were of a more advanced stage, a higher grade, and hormone receptor–negative. After controlling for age, tumor size, stage, histologic grade, census-derived socioeconomic status, and the presence of a residency training program at the treatment hospital, the relative risk of dying for African-Americans compared with whites was 1.68 (95% confidence interval, 1.27-2.23) for women less than 50 years of age, and 1.33 (95% confidence interval, 1.13-1.56) for women older than 50 years of age.CONCLUSIONS: Known factors that predict survival differences between African-Americans and whites are more prevalent among women less than 50 years of age, emphasizing the need to focus more attention on public health efforts directed toward younger women. (Am J Obstet Gynecol 1997;176:S233-9.)     

Cervical adenocarcinoma survival among Hispanic and white women: a multicenter cohort study

OBJECTIVE: We compared the clinical outcome of cervical adenocarcinoma in Hispanic and white women to determine whether race was an independent predictor of survival. STUDY DESIGN: All women who were diagnosed with cervical adenocarcinoma at three institutions between 1982 and 2000 were identified. Medical records were reviewed retrospectively. Hispanic and white cohorts were matched 1:2 for age, stage of disease, date of diagnosis, tumor size, histologic subtype, grade, and invasive depth. RESULTS: The 65 Hispanic patients were more likely to be treated at the public hospital (71% vs 14%; P <.001) than the 122 matched white patients. Most Hispanic patients (72%) and white patients (76%) presented with early (stage IA-IIA), not advanced (IIB-IVB), disease. Early (81% vs 81%, P =.65), advanced (37% vs 26%, P =.21), and overall 5-year survival rates (67% vs 68%, P =.57) were similar among Hispanic and white patients, respectively. The relative risk of race on recurrence was 1.22 (95% CI, 0.56-2.42) and on survival was 0.72 (95% CI, 0.36-1.44). CONCLUSION: Hispanic race is not an independent predictor of survival in cervical adenocarcinoma.     

Outcome of uterine clear cell carcinomas compared to endometrioid carcinomas and poorly-differentiated endometrioid carcinomas

OBJECTIVES: Our aim was to compare the survival between patients with clear cell carcinoma (CC) and patients with endometrioid carcinoma (EC). METHODS: Through the population-based Geneva Cancer Registry, we identified 1,380 resident women diagnosed with uterine cancer between 1970 and 2000. We excluded those with papillary serous endometrial carcinoma and uterine sarcomas. We categorized patients as CC (n = 32, 2.8%) or EC (n = 1,145, 97.2%). Uterine cancer-specific survival rates were calculated by Kaplan-Meier analysis. We used Cox proportional hazards analysis to compare uterine cancer mortality risks between groups, and adjusted these risks for other prognostic factors. RESULTS: CC patients presented with a more advanced stage at diagnosis than EC patients (p = 0.002). Compared to women with EC, women with CC had a significantly greater risk of dying from their disease (hazard ratio [HR] 2.9, 95% confidence interval (95% CI) 1.7-4.9). After adjustment for age, stage and adjuvant chemotherapy, the risk of dying from uterine cancer was still significantly higher for CC patients (HR 2.0, 95% CI 1.2-3.4). By univariate analysis, the risk of dying of endometrial cancer was not significantly higher in CC patients than in patients with poorly-differentiated EC (HR 1.3, 95% CI 0.7-2.3). CONCLUSION: This population-based investigation shows that patients with CC have a poorer outcome than those with EC. Studies to determine the role of adjuvant treatment in CC patients are needed.     

Epithelial ovarian carcinoma in younger vs older women: is age an independent prognostic factor? The Hellenic Oncology Cooperative Group experience

We retrospectively investigated the outcome of epithelial ovarian cancer (EOC) in women less than 45 years and over 70 years treated with cisplatin-based chemotherapy. We also investigated the impact of various factors on patients' survival. The tumor registry of the Hellenic Cooperative Oncology Group was used to identify women less than 45 years and over 70 years with EOC diagnosed between 1979 and 2004. Survival was calculated by the Kaplan-Meier method, and Cox proportional hazard models were used to determine the independent effect of each variable on survival. Of 1748 EOC patients, 200 were 45 or younger and 282 were over 70 years old. In the univariate analysis, younger age (P < 0.001), better performance status (PS) (P < 0.001), early stage (P < 0.001), 0-2 cm residual disease (P < 0.001), and well or moderate differentiation grade (P= 0.004) were significant prognostic factors for improved survival. In the multivariate analysis, older age (hazard ratio [HR]: 1.88, 95% CI: 1.27-2.77, P= 0.002), advanced stage (HR: 2.87, 95% CI: 1.49-5.52, P= 0.002), PS >1 (HR: 1.91, 95% CI: 1.18-3.08, P= 0.008), and residual disease (HR: 1.46, 95% CI: 1.01-2.13, P= 0.046) were independently associated with inferior survival. With a median follow-up of 45 months (range 0.1-197 months), median survival (118.5 months) of younger patients differed significantly compared to that of older patients (33 months) (P < 0.001). In conclusion, younger women with EOC have significantly improved survival compared to older patients. Age, PS, stage of the disease at diagnosis, and residual disease are important independent predictors for survival.     

Do risk factors for epithelial ovarian cancer have an impact on prognosis? Focus on previous pelvic surgery and reproductive variables

OBJECTIVES: The prognostic impact of risk factors for ovarian cancer development is sparsely explored, but previous sterilisation has been shown to have a negative impact on survival. METHODS: Ovarian cancer cases were from the Danish MALOVA study. Information on previous pelvic surgery as well as reproductive variables was obtained from a personal interview conducted closely after primary surgery. Cox regression models were used to estimate adjusted hazard ratios (HR) and 95% confidence intervals (95% CI) for ovarian cancer specific death in relation to previous pelvic surgery and reproductive variables including lifetime number of ovulation years. RESULTS: A total of 295 women with Stage III ovarian carcinomas were identified and followed to death or for a median of 7.3 years (range 5.4-9.5 years). Previously sterilised or hysterectomised women seemed to have a slightly decreased risk of ovarian cancer death (HR = 0.62; 95% CI: 0.36-1.08 and HR = 0.82; 95% CI: 0.55-1.21), although none of these associations reached statistical significance. The prognostic impacts of the individual reproductive variables followed the same pattern as the impact of the variables on ovarian cancer development, although significance was only reached for age at menarche (HR = 0.91 per year; 95% CI: 0.84-0.99). By accumulation of the possible minor effects of the reproductive variables in calculation of the total lifetime number of ovulation years, we found that survival decreased significantly with increasing number of ovulations (HR = 1.53 per 10 years; 95% CI: 1.09-2.14). CONCLUSION: Increasing lifetime number of ovulations was a negative prognostic factor for ovarian cancer specific survival. Previous sterilisation or hysterectomy seemed to be associated with improved survival.     

A five-year breast cancer-specific survival disadvantage of African American women

Racial/ethnic disparities in female breast cancer survival continue to persist in United States. However, disparities comparing African Americans (AA), Asians and Caucasians remain to be assessed. We aimed to assess multiracial/ethnic disparities in breast cancer survival, and to examine the factors that may explain the variability. A total of 6,951 women diagnosed with breast cancer between 1992 and 1998 were identified from surveillance, epidemiology, and end results tumor registries. The effect of race/ethnicity and the prognostic factors on survival was assessed using Cox proportional hazard model. AA demonstrated a survival disadvantage. Compared to Asians, Caucasians had 74% increased risk of dying (HR = 1.74, 95% CI = 1.31-2.33), while AA were almost three times as likely as Asians to die, (HR = 2.78, 95% CI 2.02-3.86). After adjustment for the relevant covariates the survival disadvantage of AA persisted. Relative to Asians, Caucasians were 45% more likely to die (HR = 1.45, 95% CI 1.10-1.93), while AA were more than two times as likely to die (HR = 2.57, 95% CI 1.86-3.55). There were substantial racial/ethnic disparities in breast cancer survival among United States women. AA demonstrated survival disadvantage compared with either Caucasia ns or Asians, which persisted even after controlling factors known to influence breast cancer survival.     

Insurance status and racial differences in uterine cancer survival: a study of patients in the National Cancer Database

Objective.

To examine the impact of race and insurance on survival among a large cohort of uterine cancer patients from the National Cancer Database (NCDB).

Methods.

Women diagnosed with stages I-III uterine cancer between 2000 and 2001 were selected from the NCDB. Kaplan-Meier (KM) and multivariate Cox proportional hazards were used to estimate 4 year survival rates and hazard ratios (HR) and 95% confidence intervals (CIs), respectively.

Results.

Among the 39,510 evaluable patients, African Americans had a higher risk of death compared to whites (HR = 1.43 95% CI 1.31-1.56) after adjusting for age, clinical and facility factors and zip code level education. After additional adjustment for treatment, the risk death decreased among African Americans (HR = 1.33 95%CI 1.21-1.46) and subsequent adjustment for insurance further reduced the hazard of death (HR = 1.28 95% CI 1.17-1.40). Patients with insurance other than private had an increased risk of death (uninsured HR = 1.44 95% CI 1.20-1.72, Medicaid HR = 1.70, 95% CI 1.46-1.99, Medicare among patients aged 18-64 HR = 2.49, 95% CI 2.10-2.95, Medicare among patients aged 65-99 HR = 1.22, 95% 1.11-1.34).

Conclusions.

The largest contributors to African American/white survival disparities in this study were clinical factors, including stage at diagnosis, grade and histopathology. Patients without private health insurance had worse uterine cancer survival that may be improved through future health care reform aimed at improving access to preventive services and adequate treatment.     

Breast cancer in premenopausal women: recurrence and survival rates and relationship to hormone replacement therapy.

OBJECTIVES: To determine any association between hormonal replacement therapy (HRT) usage and breast cancer recurrence and survival rates in women who were premenopausal at the time of diagnosis of breast cancer. METHODS: The study group comprised 524 women who were diagnosed with breast cancer when they were premenopausal. Of these, 277 women reached menopause before recurrence of the disease, being lost to follow-up, or reaching the end of the study. In this group, 119 women took HRT to control menopausal symptoms. The majority took combined continuous estrogen-progestin treatment. Times from diagnosis to cancer recurrence or new breast cancer, to death from all causes, and to death from primary tumor were compared between HRT users and non-users. RESULTS: Women who used HRT after their menopause had an adjusted relative risk of recurrence or new breast cancer of 0.75 (95% confidence interval (CI), 0.29-1.95) compared to that of non-users. The relative risk of death from all causes was 0.36 (95% CI, 0.11-1.16) and that of death from primary tumor was 0.24 (95% CI, 0.05-1.14). CONCLUSION: HRT use in women who were premenopausal at the diagnosis of primary invasive breast cancer is not associated with worse outcomes in terms of breast cancer recurrence or mortality.     

Extraovarian peritoneal serous papillary carcinoma: a phase II trial of cisplatin and cyclophosphamide with comparison to a cohort with papillary serous ovarian carcinoma-a Gynecologic Oncology Group Study

OBJECTIVES: The goals of this study were first, to assess the clinical effectiveness of cisplatin and cyclophosphamide in a phase II study involving a well-defined group of women with extraovarian peritoneal serous papillary carcinoma (EPSPC); and second, to compare these results with those of a group of patients with papillary serous ovarian carcinoma (PSOC) who received identical therapy. METHODS: After primary surgery, patients were treated with cisplatin 75 mg/m(2) and cyclophosphamide 750 mg/m(2) every 21 days for six cycles. Patient demographics, tumor characteristics, clinical and surgical response to treatment, progression-free survival, and overall survival were evaluated. These patients were then compared with patients with PSOC who received identical treatment on a separate protocol. RESULTS: Women with a diagnosis of tended to be older that those with EPSPC PSOC (median age: 65.8 years vs 60.3 years, P = 0.04). The estimated probability of clinical response (complete and partial) to the treatment regimen for EPSPC was 65% (95% confidence interval [CI]: 41-85%) compared with 59% (95% CI: 47-71%) for women with PSOC. Surgical complete responses were similar (20% vs 19%) in the two patient groups. Additionally, the death rates did not significantly differ between the two groups (hazard ratio: 1.25, 95% CI: 0.834-1.88). CONCLUSION: Women with EPSPC and PSOC exhibit a similar probability of response to cisplatin and cyclophosphamide and a similar overall survival. Based on these findings and the fact that results of ovarian cancer trials are frequently extrapolated to patients with EPSPC, it is reasonable to include EPSPC patients in future large-scale treatment trials involving patients with advanced ovarian cancer.     

Venous thromboembolism in ovarian cancer

OBJECTIVE: To determine the incidence, time-course, and risk factors associated with the development of thromboembolism (VTE) in a population-based study of women with ovarian cancer. METHODS: Using the California Cancer Registry, cases diagnosed with ovarian cancer for a 6-year period were identified. These cases were linked with the California Patient Discharge Data Set to determine the incidence of VTE. Proportional hazards modeling was performed to analyze the strength of specified risk factors to predict development of VTE or death within 2 years. RESULTS: Among 13,031 cases with ovarian cancer, 5.2% were diagnosed with a VTE event within 24 months after diagnosis. The cumulative incidence varied from 1.4% among women with local stage disease to 6.7% among women with advanced disease. The person-time incidence rate of VTE decreased over time, with the highest rate noted during the first 3 months. In a multivariate model, significant risk factors for VTE included advancing age, increasing number of chronic comorbid conditions, more advanced cancer stage, invasive histology, and absence of any major surgery. For all stages of cancer, development of VTE within 2 years was a significant risk factor for decreased survival, and the magnitude of the risk was greatest among the cases diagnosed with localized disease (HR 4.7, 95% CI: 2.3-9.5). CONCLUSIONS: VTE occurred in a significant proportion of ovarian cancer patients and adversely impacted survival, particularly among cases with local or regional stage cancer.     

In vitro fertilization,endometriosis, nulliparity and ovarian cancer risk

ObjectivesTo examine the risk of invasive epithelial ovarian cancer in a cohort of women seeking treatment for infertility.MethodsUsing whole-population linked hospital and registry data, we conducted a cohort study of 21,646 women commencing hospital investigation and treatment for infertility in Western Australia in the years 1982–2002. We examined the effects of IVF treatment, endometriosis and parity on risk of ovarian cancer and explored potential confounding by tubal ligation, hysterectomy and unilateral oophorectomy/salpingo-oophorectomy (USO).ResultsParous women undergoing IVF had no observable increase in the rate of ovarian cancer (hazard ratio [HR] 1.01; 95% confidence interval [CI] 0.35–2.90); the HR in women who had IVF and remained nulliparous was 1.76 (95% CI 0.74–4.16). Women diagnosed with endometriosis who remained nulliparous had a three-fold increase in the rate of ovarian cancer (HR 3.11; 95% CI 1.13–8.57); the HR in parous women was 1.52 (95% CI 0.34–6.75). In separate analyses, women who had a USO without hysterectomy had a four-fold increase in the rate of ovarian cancer (HR 4.23; 95% CI 1.30–13.77). Hysterectomy with or without USO appeared protective.ConclusionsThere is no evidence of an increased risk of ovarian cancer following IVF in women who give birth. There is some uncertainty regarding the effect of IVF in women who remain nulliparous. Parous women diagnosed with endometriosis may have a slightly increased risk of ovarian cancer; nulliparous women have a marked increase in risk.     

Squamous cell carcinoma of the vulva in Brazil: prognostic importance of host and viral variables.

BACKGROUND: Certain clinicopathologic features of vulvar squamous cell carcinoma have been correlated with adverse prognosis. However, few large-scale studies have addressed their role in patient survival. This study examined the relationship between multiple variables and prognosis in a large group of vulvar cancers in Brazil. METHODS: One hundred eighty-four Brazilian women with vulvar carcinoma were studied and the following variables recorded: age, pathologic TNM stage, survival, histologic grade, tumor histologic pattern, invasion pattern, tumor thickness, and tissue stromal and inflammatory response. Human papillomavirus (HPV) was detected by polymerase chain reaction amplification of extracted archival DNA. Data were analyzed using Cox proportional hazards modeling. RESULTS: After controlling for age, the probability of cancer survival decreased with increasing age, stage, grade, and tumor thickness, a fibromyxoid stromal response, infiltrative growth pattern, and basaloid histologic pattern. With the exception of fibromyxoid stromal response, each of these variables remained prognostically significant after adjustment for several other predictors in a multivariate model. Women whose tumors displayed a basaloid pattern were 3.5 times as likely to die from cancer than those with keratinizing tumors [hazard ratio (HR) = 3.5, 95% CI(1.3-9.2)]. An infiltrative invasion pattern strongly increased the probability of cancer death [HR = 4.6, 95% CI(1.9,11.4)]. HPV status did not influence survival, despite its association with basaloid histology. CONCLUSIONS: Previously reported associations of negative HPV status and fibromyxoid response with adverse prognosis in vulvar cancer were not confirmed by multivariate analysis. Basaloid variants, and particularly diffusely infiltrative tumors, carry an adverse prognosis.     

Uterine carcinosarcomas and grade 3 endometrioid cancers: evidence for distinct tumor behavior

OBJECTIVE: To compare the clinical behavior and outcome of uterine carcinosarcomas and grade 3 endometrioid carcinomas. METHODS: Data on patients with grade 3 endometrioid adenocarcinomas and uterine carcinosarcomas, from 1988 to 2004, was obtained from the Surveillance, Epidemiology, and End Results database. Mortality was analyzed using Cox proportional hazards models. Survival analysis was performed with the Kaplan-Meier method and log rank test. RESULTS: The cohort included 8,986 women with 5,024 (56%) grade 3 endometrioid carcinomas and 3,962 (44%) uterine carcinosarcomas. Women with uterine carcinosarcomas were older (aged 70 years compared with 66 years; P<.001) and more often nonwhite (23% compared with 15%; P<.001). These women presented with more advanced disease (stage III/IV 41% compared with 31%; P<.001). Multivariable analysis demonstrated that uterine carcinosarcoma histology, advanced age, nonwhite race, and advanced stage were independent predictors of poor survival. Cancer-specific mortality was 45% lower in women with grade 3 endometrioid carcinomas (hazard ratio 0.55; 95% confidence interval [CI] 0.5-0.6). The 5-year cancer-specific survival was lower for women with uterine carcinosarcoma for each disease stage. Survival for stage IC was 38% (95% CI 33-45%) for uterine carcinosarcoma compared with 68% (95% CI 63-73%) for grade 3 endometrioid carcinoma. For stage III, survival was 22% (95% CI 19-26%) for uterine carcinosarcoma compared with 45% (95% CI 41-49%) for grade 3 endometrioid carcinoma. CONCLUSION: Carcinosarcomas present at more advanced stage and have worse survival than grade 3 endometrioid carcinomas. Carcinosarcomas may represent a distinct biologic entity. LEVEL OF EVIDENCE: II.