Perioperative cesarean delivery morbidity among HIV-infected women under highly active antiretroviral treatment: a case-control study

Objective

To compare post-cesarean complications between HIV-infected women on highly active antiretroviral therapy (HAART) and a matched group of non-HIV-infected women, and to evaluate predisposing risk factors for these complications in the HIV group.

Study design

We performed a retrospective study of 160 HIV-infected women and 320 non-infected women who underwent cesarean section in a single reference center from 1997 to 2007. All HIV patients were under high active antiretroviral therapy (HAART). The women were assessed for a large number of major and minor postoperative complications. Selected risk factors for perioperative morbidity were analyzed in the HIV-positive group and data were analyzed using logistic regression.

Result(s)

Overall postoperative complications did not differ significantly between the two groups (26.9% in HIV patients vs. 22.8% in controls; OR = 1.24; 95% confidence interval [CI] = 0.8-1.92). Anemia was the most frequent morbidity observed, affecting 17.5% of HIV-positive women and 11.8% of controls. Major complications were associated with a CD4+ cell count of <500 cell/ml (OR = 3.28, 95% CI = 1.04-10.31) and prematurity <34 weeks (OR = 9.76, 95% CI = 1.99-47.71).

Conclusion(s)

Post-cesarean complications were not significantly increased in HIV-infected women on HAART compared to non-HIV-infected women. Prematurity and low CD4+ cell count were risk factors for major complications.     

Endometrial cancer surgery in Arizona: a statewide analysis of access to care

Objectives

To investigate access to surgical care for endometrial cancer in Arizona.

Methods

The Arizona HealthQuery (AZHQ) data warehouse with claims information on over 7 million patients in Arizona was searched using the International Classification of Disease (ICD-9) codes and Current Procedural Terminology (CPT) codes for endometrial cancer surgery from 2005 to 2008. Coordinates were gathered for patients and hospital to determine the distance traveled, race, insurance and annual caseload per hospital/surgeon were collected. Distance traveled was local (< 50 miles) or distant (≥ 50 miles) and served as the primary independent variable. Secondary variables included age, race, insurance, surgeon annual volume, and hospital annual volume. Logistic regression for distance traveled was performed for insurance coverage, race, hospital volume, and surgeon volume and expressed as an odds ratio.

Results

There were 1532 endometrial cancer surgeries performed at 67 hospitals by 242 surgeons in 15 counties. Most (61%) were performed by high-volume surgeons. Approximately 1 in 5 (19%) of patients traveled greater than 50 miles. Medicare insured patients were twice (OR = 2.07, 95% CI = 1.38-3.13) and Medicaid patients were three times (OR = 3.41, 95% CI = 1.89-6.15) as likely to travel over 50 miles. No significant difference was found between uninsured and privately insured patients (OR = 0.87, 95% CI = 0.45-1.68). Patients were more likely to travel to a high volume facility (OR 2.39, 95% CI = 1.26-4.51). Hispanics (OR = 2.72, 95% CI = 1.72-4.32) and Native Americans (OR = 8.60, 95% CI = 3.43-21.52) were more likely to travel compared to Caucasians.

Conclusion

In Arizona significantly different patterns of care are seen for endometrial cancer surgery based upon insurance coverage, race, surgeon and hospital. Patients travel farther to a high-volume hospital and high-volume surgeon. Hispanics or Native Americans travel farther for care when compared with Caucasians. Patients on government funded insurance plans travel farther for care than patients covered by private insurance or those lacking insurance.     

Effect of socio-economic factors on delayed access to health care among Chinese cervical cancer patients with late rectal complications after radiotherapy

Objectives

To determine the effect of socio-economic status (SES) on delayed access to medical treatment by Chinese cervical cancer patients who suffered from late rectal sequelae (LRS) after external beam radiation therapy (EBRT) and intracavitary brachytherapy.

Methods

Patients diagnosed with LRS were interviewed for their SES, factors including age, residing district, religion, marital status, income, education, insurance and patient delay (the time interval from the onset of symptoms to the first medical consultation) and other factors such as weight, symptom duration and disease stage at diagnosis.

Results

One hundred and twenty nine patients were interviewed. Seventy-one patients (55%) sought medical treatment within three months after the first symptom being recognized and fifty-eight patients (45%) delayed their medical treatment over 3 months. The study shows that age ≥ 55 (OR = 12.1; 95% CI: 3.3-43.9), lower education (OR = 4.6; 95% CI: 2.0-10.4 for women with primary school education or illiterate), low annual household income (OR = 2.3; 95% CI: 1.2-5.1) and widow/divorce (OR = 0.1; 95% CI: 0.01-0.07) were the high risk factors for delayed reporting. Patients with bleeding or bleeding plus other symptoms (61.2%) were more likely to seek treatment within three months, compared to patients with other symptoms only (38.8%) (p = 0.002). Additionally, delayed reporting was found to be significantly associated with the late stage of late rectal sequelae (LRS) (p = 0.000) and the patients with 55 years or older (p = 0.000).

Conclusions

Delayed reporting and late-stage presentation of late rectal sequelae are more prevalent among Chinese cervical cancer patients with 55 years or older, low education, poor marital status, or poor financial status. Effective social support and educational programs should be implemented to encourage these patients to seek medical treatment as soon as possible.     

Surgical staging for endometrial cancer in the elderly - is there a role for lymphadenectomy?

Objectives

We sought to evaluate the effect of systematic lymphadenectomy (LND) on endometrial cancer-specific survival in an elderly population.

Methods

Data were obtained from the Surveillance, Epidemiology, and End Results (SEER) program from 1988 to 2006. Women who underwent primary hysterectomy for non-serous, non-clear cell endometrial carcinoma were included. Women were stratified by age (< 70, 70-79, and ≥ 80) and disease-specific survival (DSS) was analyzed via the Kaplan-Meier method and stratified by postoperative grade. Cohorts were compared using the log-rank test. In a simulated population, the disease-specific survival of women with pre-operative grade 1 endometrial carcinoma was calculated using a weighted average survival accounting for those upgraded at final pathology.

Results

Endometrial cancer was identified in 5759 women ≥ 80 years old. Disease specific survival at 5 years for the LND and no LND groups was 93.4% and 94.5% (p = 0.36) for grade 1, 84.4% and 85% (p = 0.97) for grade 2, and 65.9% and 60.9% (p = 0.002) for grade 3. In the simulated pre-operative grade 1 group, 5 year disease-specific survival (DSS) was 91% in the LND group and 92% in the no LND group.

Conclusion

In women older than 80, systematic lymphadenectomy is associated with improved DSS for high grade, but similar DSS for low grade endometrial cancer, consistent with what is seen with younger women. As there is no clear survival benefit to lymphadenectomy in elderly women presenting with low grade disease, the surgeon should carefully weigh the surgical risks and benefits in this patient population, which may be at higher risk for morbidity.     

Racial disparities and patterns of ovarian cancer surgical care in California

Objective

To investigate disparities in the frequency of ovarian cancer-related surgical procedures and access to high-volume surgical providers among women undergoing initial surgery for ovarian cancer according to race.

Methods

The California Office of Statewide Health Planning and Development database was accessed for women undergoing a surgical procedure that included oophorectomy for a malignant ovarian neoplasm between 1/1/06 and 12/31/10. Multivariate logistic regression analyses were used to evaluate differences in the odds of selected surgical procedures and access to high-volume centers (hospitals ≥ 20 cases/year) according to racial classification.

Results

A total of 7933 patients were identified: White = 5095 (64.2%), Black = 290 (3.7%), Hispanic/Latino =1400 (17.7%), Asian/Pacific Islander = 836 (10.5%) and other = 312 (3.9%). White patients served as reference for all comparisons. All minority groups were significantly younger (Black mean age 57.7 years, Hispanic 53.2 years, Asian 54.5 years vs. 61.1 years, p < 0.01). Hispanic patients had lower odds of obtaining care at a high-volume center (adjusted OR (adj. OR) = 0.72, 95% CI = 0.64–0.82, p < 0.01) and a lower likelihood of lymphadenectomy (adj. OR = 0.80, 95% CI = 0.70–0.91, p < 0.01), bowel resection (adj. OR = 0.80, 95% CI = 0.71–0.91, p < 0.01), and peritoneal biopsy/omentectomy (adj. OR = 0.69, 95% CI = 0.58–0.82, p < 0.01). Black racial classification was associated with a lower likelihood of lymphadenectomy (adj. OR = 0.76, 95% CI = 0.59–0.97, p = 0.03).

Conclusions

Among women undergoing initial surgery for ovarian cancer, Hispanic patients are significantly less likely to be operated on at a high-volume center, and both Black and Hispanic patients are significantly less likely to undergo important ovarian cancer-specific surgical procedures compared to White patients.     

Clinical/pathologic features and patient outcome in early onset endometrial carcinoma: a population based analysis and an institutional perspective from the Detroit metropolitan area, Michigan

Objective

Analyze tumor characteristics and outcomes in patients with endometrial carcinoma (EC) < 40 years of age and compare them to the characteristics of patients ≥ 40 years of age.

Methods

10,700 patients (305 patients < 40 years of age) diagnosed between 1988 and 2007 with EC from the Metropolitan Detroit Cancer Surveillance System (MDCSS), and 884 patients (42 patients < 40 years of age) diagnosed between 1996 and 2008 with EC from our institutional database were identified. Differences in clinical and demographic variables by age (< 40 vs. ≥ 40) were assessed for statistical significance by chi-square tests. Cox proportional hazards models were used to calculate adjusted hazard ratios (HR) and their 95% confidence intervals (95% CI) to assess the risk of death from all causes.

Results

MDCSS based analysis: Patients < 40 were more likely to present with low grade tumors (p < 0.0001) and endometroid histology (p = 0.0004) but less likely to undergo surgery (p = 0.0007) or radiotherapy (p = 0.0007). A multivariate analysis confirmed the significance of age, grade, and stage in all patients, and that of histologic type, surgery, and race in patients ≥ 40 as independent prognostic factors for overall survival. Institution based analysis: Patients < 40 had a higher proportion of patients with BMI ≥ 30 (p = 0.04), and presented with a higher frequency of well differentiated (p = 0.04) endometrioid tumors (p = 0.004) that are less prone to have deep myometrial invasion (p = 0.008).

Conclusion

This study supports the hypothesis of a disease that is biologically and genetically heterogeneous among women of different ages and ethnicities.     

Recurrent versus isolated pre-eclampsia and risk of feto-infant morbidity outcomes: racial/ethnic disparity

Objective

We examined the association between recurrent versus isolated pre-eclampsia and feto-infant morbidity outcomes.

Study design

This is a population-based retrospective study on Florida hospital discharge data linked to the birth cohort files from 1998 through 2007. The study population comprised women with singleton first and second births who experienced pre-eclampsia in both pregnancies, and a comparison group consisting of women who were normotensive during their first pregnancy but developed pre-eclampsia in their second pregnancy. Feto-infant morbidities (low birth weight, very low birth weight, preterm, very preterm and small for gestational age) were the outcome of interest. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for the association between recurrent pre-eclampsia and feto-infant morbidity outcomes were obtained from logistic regression models.

Result

Women who experienced recurrent pre-eclampsia were at elevated risk for low birth weight, very low birth weight, preterm and very preterm. The risk was most pronounced for preterm infants (OR = 1.58 CL = 1.42-1.76). Subgroup analysis demonstrated that infants born to black mothers with recurrent pre-eclampsia experienced the most elevated risk across all the racial/ethnic subgroups and this was most pronounced for very low birth weight and very preterm with a more than three-fold increase in risk (OR = 3.77, 95% CI = 2.77-5.13 and OR = 3.66, 95% CI = 2.66-5.03, respectively) as compared to the referent category (white mothers who were normotensive in first pregnancy but developed pre-eclampsia in their second pregnancy).

Conclusion

Pre-eclampsia is very severe when it recurs and black women are affected more than white or Hispanic women.     

Endometrial cancer and genetic variation in PTEN, PIK3CA, AKT1, MLH1, and MSH2 within a population-based case-control study

Objective

We assessed whether common genetic variation in PTEN, PIK3CA, AKT1, MLH1, and MSH2—genes that reportedly are frequently altered in endometrial cancer—was associated with risk of endometrial cancer.

Methods

Using data from a population-based case-control study in Poland (PECS) of 417 cases and 407 matched controls, we genotyped 76 tagging single nucleotide polymorphisms (tagSNPs; located in or within 10 kb upstream or 5 kb downstream of the gene of interest, minor allele frequency >=5% among various ethnic groups, and not already represented by another tagSNP at a LD of r² >=0.80) on an Illumina Custom Infinium iSelect assay that included over 29,000 SNPs in 1316 genes. For individual SNPs, we used unconditional logistic regression models, adjusted for age and site, to generate odds ratios (ORs) and 95% confidence intervals (CIs). To replicate the one statistically significant association in PECS, we independently genotyped that tagSNP among 1141 endometrial cancer cases and 2275 controls from the SEARCH study in the UK. We assessed haplotypes via extended haplotype blocks and the sequential haplotype scan method.

Results

The rs2677764 tagSNP in PIK3CA was statistically significantly associated with endometrial cancer in PECS (OR = 1.42, 95% CI, 1.03-1.95; P = 0.03) but not SEARCH (OR = 0.98, 95% CI = 0.82-1.17). Of the 25 haplotypes observed in at least 5% of cases and controls in PECS, only 1, in PIK3CA, was statistically significantly associated with endometrial cancer (OR = 1.39, 95% CI, 1.00-1.93). All haplotype global p-values were null.

Conclusion

Common genetic variation in PTEN, PIK3CA, AKT1, MLH1, or MSH2 was not statistically significantly associated with endometrial cancer.     

The prevalence of fecal incontinence and urinary incontinence in primiparous postpartum Chinese women

Objective

This study investigated the prevalence of fecal incontinence (FI) and urinary incontinence (UI) in primiparous postpartum Chinese women.

Study design

Questionnaires about FI and UI symptoms were completed via telephone interviews conducted within 6 months postpartum.

Results

A total of 1889 primiparous postpartum women were asked to participate in this investigation. Only 13 (0.69%) of them had FI within 6 months after parturition, including loss of flatus in six women (0.32%), loss of solid stool in one (0.05%), loss of liquid stool in two (0.11%) and fecal urgency in four (0.21%). Bivariate logistic regression analysis showed that FI was significantly associated with forceps delivery OR = 37.91 (95% CI 4.20-342.18, P = 0.001) and medio-lateral episiotomy OR = 11.79 (95% CI 1.47-94.46, P = 0.02). The prevalence of UI, stress urinary incontinence (SUI), urge urinary incontinence (UUI) and mixed urinary incontinence (MUI) was 9.9% (186), 8.0% (151), 1.0% (18) and 0.9% (17), respectively. Multinomial logistic regression analysis found that SUI prevalence was related to age OR = 1.08 (95% CI 1.04-1.12, P = 0.000), maternal weight OR = 1.04 (95% CI 1.02-1.06, P = 0.001), neonate head circumference OR = 1.17 (95% CI 1.01-1.36, P = 0.043), spontaneous labor OR = 5.42 (95% CI 2.60-11.32, P = 0.000), forceps delivery OR = 7.0 (95% CI 2.40-20.41, P = 0.000), and medio-lateral episiotomy OR = 5.24 (95% CI 3.15-8.72, P = 0.000).

Conclusions

1. FI and UI prevalence was lower in our department than reported in previous studies in other areas. 2. Vaginal delivery has a risk impact on women's FI and UI, especially forceps delivery and medio-lateral episiotomy. 3. Maternal age, weight, newborn head circumference, spontaneous vaginal delivery, forceps delivery, and medio-lateral episiotomy increase the risk of UI.     

Defining the limits of radical cytoreductive surgery for ovarian cancer

Objective

Despite significant morbidity, surgical cytoreduction is the standard of care for ovarian cancer. We examined the outcomes of cytoreductive surgery to determine if there are groups of patients in which the morbidity is so substantial that alternate treatment strategies are warranted.

Methods

The Nationwide Inpatient Sample was used to identify women who underwent surgery for ovarian cancer from 1998 to 2007. The effect of age, number of radical procedures performed, and clinical characteristics on morbidity and mortality were examined.

Results

A total of 28,651 women were identified. The complication rates increased with age from 17.1% in those < 50 years of age to 29.7% in women age 70-79 and to 31.5% in those ≥ 80 (p < 0.05). The number of extended procedures performed was also a predictor of morbidity; complications increased from 20.4% for women with 0 procedures to 34.0% for 1 and 44.0% for ≥ 2 procedures (p < 0.0001). In multivariable analysis age, comorbidity, and the number of procedures performed were the strongest predictors of outcome. The morbidity associated with additional procedures was greatest in the elderly. Medical complications in women < 50 years of age occurred in 10.2% of those who underwent 0 radical procedures vs. 23.7% in those who underwent 2 or more procedures. For women ≥ 80 years, complications were noted in 18.3% for 0 procedures, and 33.3% for 2 or more procedures.

Conclusion

The morbidity of cytoreduction is greatest in elderly women where the effects of age and the number of radical procedures performed have an additive effect on complication rates.     

Changing demographics of cervical cancer in the United States (1973-2008)

Objective

To describe changes in the cervical cancer population.

Methods

The SEER database 9 registries from 1973 to 2008 were queried to perform a retrospective cohort study of women with invasive cervical cancer. Estimated annual percent change (EAPC) in incidence rates and 95% confidence intervals (CI) over the entire study period were compared according to age, stage, race, and cell type (squamous [SCC] and adenocarcinoma [ACA]). Proportions and odds ratios (OR) were calculated for patients diagnosed during the second half (1990-2008) compared to first half (1973-89) of the study period.

Results

40,363 women with cervical cancer were entered into SEER. The EAPC are falling fastest among those with localized disease (− 2.5%; 95% CI − 2.8 to − 2.1), age ≥ 50 (− 3.0%; 95% CI = − 3.2 to − 2.8), and black women (− 3.8%; 95% CI = − 4.1 to − 3.6). The odds of a newly diagnosed cervical cancer patient having advanced disease are 10% higher, being less than age 50 are 37% higher, and being Asian or Pacific Islander are 68% higher in the second time period as compared to the first.

Conclusions

In the US, the population with cervical cancer is changing. Patients are presently significantly more likely to be pre-menopausal, Asian or Pacific Islander, and more frequently have non-squamous histology than previously. These progressive and cumulative changes could be due to the disparate impact of current population based screening and prevention strategies. Understanding the implications of these evolving population characteristics may facilitate planning targeted studies and interventions for cervical cancer prevention, screening and treatment in the future.     

Factors predicting the outcome of conservatively treated adenocarcinoma in situ of the uterine cervix: an analysis of 166 cases

Objective

The present study assessed the clinical outcome of patients conservatively treated for cervical adenocarcinoma in situ (AIS) and their predictive factors using univariate and multivariate population averaged (PA) generalized estimating equation (GEE) model in a longitudinal setting.

Methods

A series of 166 consecutive women (mean age 39.8 yrs; range 23-63 yrs) underwent conservative treatment of AIS as the primary treatment and were followed-up (mean 40.9 mo) using colposcopy, PAP-smear, biopsy and HPV-testing with Hybrid Capture 2.

Results

Hysterectomy was performed as part of the primary management in 47 patients, who were excluded from the follow-up (FU) analysis. Out of 119 women closely followed-up, additional therapeutic procedures were performed in 69. At study conclusion, 7 patients (5.9%) showed persistent disease, while 8 (6.7%) had progressed to invasive adenocarcinoma (AC). Positive HR-HPV test was the only independent predictor of disease recurrence (adjusted OR = 2.72; 95%CI 1.08-6.87), and together with free cone margins (OR = 0.20; 95%CI 0.04-0.92), HR-HPV positivity was also the single most powerful predictor of disease progression to AC, with OR = 3.74; 95%CI 1.84-7.61 (p = 0.0001) in multivariate PA-GEE.

Conclusions

These results suggest that testing HR-HPV positive at any time point during FU is the most significant independent predictor of progressive disease, while showing free margins in cone has a significant protective effect against progression to AC. Furthermore, because 4.3% women with persistent, recurrent or progressive disease experienced a late (5th and 6th FU) diagnosis of HG-CGIN or microinvasive AC, a close surveillance should be scheduled for at least three years in conservatively treated AIS patients.     

Effect of age and comorbidity on the treatment and survival of older patients with vulvar cancer

Objective

To determine the disease characteristics and comorbidities predictive of vulvar cancer specific mortality and five year overall survival among older women, ages 65 and above.

Methods

A retrospective analysis was conducted of women diagnosed with vulvar cancer at a single regional cancer center from 1989 to 2003, with a follow up to 2009. Treatment records were extracted for: demographics and treatment information, Eastern Cooperative Oncology Group (ECOG) performance status and Charlson comorbidity index score. Probability of death from vulvar cancer was estimated using cumulative incidence, treating death by other known and unknown causes as competing risks. Predictors of overall survival were determined using multivariate Cox regression analyses.

Results

One hundred forty-six women were identified, with a median age at diagnosis of 79 years (range 65-95). Median follow up was 5.0 years (range 0.1-16.7 years). The cumulative incidence of vulvar cancer-specific mortality was 13% (95% CI: 0.08-0.19) at year one, 24% (95% CI: 0.17-0.31) at year three and 26% (95% CI: 0.19-0.33) at year five. Use of adjuvant therapy or surgical procedure performed did not differ by age at diagnosis (p = 0.807 and 0.663) according to age group (65-74, 74-84 and 85+). Increasing age, Charlson comorbidity index score, lymph node involvement and type of surgery performed were associated with increased risk of death from any cause (all p < 0.05).

Conclusion

Among women aged ≥ 65, vulvar cancer specific mortality was most significant in the first three years after diagnosis. Conversely other causes of mortality which can be attributed to comorbid conditions steadily increased with time.     

Outcome of stage IVA cervical cancer patients with disease limited to the pelvis in the era of chemoradiation: a Gynecologic Oncology Group study

Objectives

To evaluate the outcome of stage IVA cervical cancer treated with radiation and concurrent cisplatin-based chemotherapy.

Methods

We conducted a retrospective study of stage IVA cervical cancer patients from four trials (Gynecologic Oncology Group protocols 56, 85, 120, and 165) treated with radiotherapy with or without concurrent cisplatin-based chemotherapy. Patient records were reviewed for demographic and tumor features, treatment, and progression-free survival (PFS) and overall survival (OS). Stage IVA patients were compared to stage IIIB patients from these same studies.

Results

Among the 51 stage IVA patients studied, 92% were stage IVA on the basis of bladder involvement. The median PFS was 10.1 months (95% CI = 6.3-14.5 months) and median OS was 21.2 months (95% CI = 13.3-30.5 months). The 3 year survival was 32%. On univariate analysis, only advanced age was associated with OS (p = 0.0115) but age had only marginal effect on PFS (p = 0.083). Pathologic proven pelvic nodal metastasis was of marginal significance for both PFS and OS, p = 0.059 and 0.064, respectively. Despite similar patient characteristics, the use of cisplatin-based chemotherapy had no impact on PFS or OS but was underpowered to address this question. When compared to stage IIIB patients, stage IVA patients had a poorer performance status (p = 0.0231), larger tumor size (p = 0.0302), and more frequent bilateral parametrial involvement (0.0063).

Conclusion

Patients with stage IVA disease had poor median survival of only 21 months with only 32% 3 year survival. Stage IVA patients have larger tumor size, more bilateral parametrial involvement, and poorer survival when compared to stage IIIB patients.     

Body mass index, recreational physical activity and female urinary incontinence in Gansu, China

Objective

To elucidate the influence of recreational physical activity, body mass index (BMI), and waist circumference on the risk of specific types of urinary incontinence.

Study design

We conducted a population-based cross-sectional survey in Gansu, China among 2603 women aged 20 years or older.

Results

The study found that BMI was positively associated with urinary incontinence (P for trend = 0.008) and the association was mainly observed for stress urinary incontinence (OR = 1.4, 95% CI: 1.1, 1.9 for BMI = 24.0-27.9 kg/m²; OR = 2.3, 95% CI: 1.5, 3.6 for BMI ≥ 28.0 kg/m²; P for trend = 0.0005). A positive association between stress incontinence (OR = 1.7, 95% CI: 1.2, 2.5) and waist circumference was observed for women who had waist circumference between 70 cm and 75 cm compared to waist circumference less than 70 cm. Recreational physical activity was inversely associated with overall and mixed urinary incontinence (P for trend <0.0001 for both). A significant interaction between physical activity and waist circumference was found for overall (P = 0.0007) and stress incontinence (P = 0.001).

Conclusions

The findings that physical activity inversely associated with urinary incontinence and its interaction with waist circumference warrant further investigation, particularly in prospective studies.     

Pre-eclampsia in the first pregnancy and subsequent risk of stillbirth in black and white gravidas

Objective

To examine the association between prior pre-eclampsia and subsequent stillbirth in black women and white women.

Study design

This is a population-based retrospective study of Missouri maternally linked birth cohort files from 1989 to 2005. We analyzed singleton first and second births to mothers in the state of Missouri. The study population comprised women who experienced pre-eclampsia in their first pregnancy and a comparison group consisting of women who did not. The two groups were followed to their second pregnancy to document stillbirth occurrence. Adjusted odds ratios (OR) and 95% confidence intervals (CI) for the association between prior pre-eclampsia and subsequent stillbirth were obtained from logistic regression models.

Results

Women who experienced prior pre-eclampsia had a 43% increased risk of subsequent stillbirth [OR = 1.43; 95% CI = 1.08–1.89]. Whereas women with a history of late-onset pre-eclampsia had no elevated risk for subsequent stillbirth, those whose first pregnancy resulted in early-onset pre-eclampsia had a more than 4-fold increased risk of stillbirth in their second pregnancy [OR = 4.07; 95% CI = 2.32–7.14]. When sub-analysis was performed on the two main racial groups in the State, we found that elevated risk for subsequent stillbirth in a second pregnancy was observed among black women with prior early-onset pre-eclampsia (OR = 8.21; 95% CI = 4.03–16.70) but not in whites (OR = 1.95; 95% CI = 0.72–5.26).

Conclusion

Initiation of pregnancy with pre-eclampsia elevates the risk for subsequent stillbirth. The risk elevation is most pronounced in black women with early-onset pre-eclampsia in their first pregnancy. This information is valuable for inter-pregnancy counseling of affected women.     

Significance of age and comorbidity on treatment modality, treatment adherence, and prognosis in elderly ovarian cancer patients

Background

Age is associated with poor prognosis in ovarian cancer patients. Reasons could be increased comorbidity, more advanced stage, or nonoptimal surgery or chemotherapy. Objectives of this study were to evaluate the significance of comorbidity and age ≥ 70 years on receiving cytoreductive surgery, standard combination chemotherapy (TC), adherence to TC treatment, and prognosis.

Methods

A retrospective cohort study of all women registered in a nation-wide database with ovarian or peritoneal cancer in 2005-2006. Logistic regression was employed for determining the predictive value of age and comorbidity (ASA score) on receiving cytoreductive surgery and TC, and on adhering to TC. Kaplan-Meier method and Cox proportional hazards analysis were employed for survival analyses.

Results

Of 961 patients, 348 (36.2%) were elderly. Age ≥ 70 years was independently predictive of not receiving surgery, OR 0.2(95% CI 0.1-0.5) and TC treatment, OR 0.03 (95% CI 0.01-0.1). Comorbidity was also independently predictive of not receiving standard treatment: OR for receiving surgery with ASA score of ≥ 3 was 0.2 (95% CI 0.1-0.5), and for receiving TC it was 0.03 (95% CI 0.01-0.1). Overall, age ≥ 70 was a poor prognostic factor in OS and PFS, but the effect of age ceased after 16 months. Comorbidity was a poor prognostic factor throughout the study period but with time-varying effect. For patients treated with TC, age was not a prognostic factor, whereas ASA score ≥ 3 was.

Conclusion

Elderly patients and patients with comorbidity less often receive optimal surgical and medical treatment. For those receiving optimal treatment, age ≥ 70 is not an independent poor prognostic factor, whereas severe comorbidity is.     

Morbidly obese women with and without endometrial cancer: are there differences in measured physical fitness, body composition, or hormones?

Objective

Exercise is potentially protective against cancer for obese women. The objectives were to examine differences in activity, body composition, and hormones in overweight/obese women with and without endometrial cancer.

Methods

Women ≥ 50 years old with a body mass index (BMI) ≥ 25 kg/m² scheduled for abdominal hysterectomy were enrolled. Demographics, physical activity, and quality of life (QOL) data were collected. Body composition/fitness was evaluated using Air Displacement Plethysmography (BodPod) and a standardized treadmill. Adiponectin, androstenedione, leptin, estradiol, estrone, progesterone, sex hormone binding globulin, insulin and glucose were measured.

Results

Thirty-eight women enrolled in this pilot study; 22 had endometrial cancer. Mean age was 58.3 years, mean BMI, fat weight and percent body fat were 41.3 kg/m², 55 kg and 51% respectively. Fitness levels were poor; 90% of women had peak oxygen uptakes below the 10th percentile of population normals yet 80% still rated their fitness level as equivalent to other women. Women with and without cancer did not differ in age, BMI, co-morbidities, energy expenditures, body composition, hormones or QOL although glucose levels were higher in women with cancer (119.5 vs. 90.7 mg/dl; p = 0.049). Cancer subjects scored worse on every fitness measurement, reaching statistical significance for VO_2peak (15.0 vs. 17.9 ml/kg/min; p = 0.033). Current exercisers had a lower BMI (p = 0.039), decreased fat weight (p = 0.024), decreased waist circumference (p = 0.05) and improved vitality compared to non-exercisers.

Conclusion

Physical fitness levels were abysmal in these morbidly obese subjects and worse for cancer patients. Exercise correlated with improved body composition and vitality.     

Incidence of metastasis in circumflex iliac nodes distal to the external iliac nodes in intermediate- and high-risk endometrial cancer

Objective

The aim of this study was to elucidate the incidence of metastasis in circumflex iliac nodes distal to the external iliac nodes (CINDEIN), which are also called suprainguinal nodes, in intermediate- and high-risk endometrial cancer. Removal of these nodes needs to be discussed from the viewpoint of patient's quality of life because removal of CINDEIN is strongly related to lower extremity lymphedema.

Methods

A retrospective chart review was carried out for 508 patients with intermediate- and high-risk endometrial cancer who were included in this study. We identified patients with lymph node metastasis. Lymph node sites were classified into four groups: (1) CINDEIN, (2) external iliac nodes, (3) Group A consisting of circumflex iliac nodes to the distal obturator nodes, internal iliac nodes, obturator nodes, cardinal ligament nodes (including deep obturator nodes), and sacral nodes, and (4) Group B consisting of common iliac nodes and para-aortic nodes. Logistic regression analysis was used to select risk factors for CINDEIN metastasis.

Results

In an analysis of 508 patients with intermediate- and high-risk disease, CINDEIN metastasis was found in fourteen (2.8%) of the patients. Multivariate analysis confirmed that high-risk histology (OR = 5.7, 95% CI = 1.2-16.1) and Group A node metastasis (OR = 9.7, 95% CI = 2.9-31.4) were independent risk factors for CINDEIN metastasis. None of the patients with G1 endometrioid adenocarcinoma had CINDEIN metastasis. Three (2.5%) of the patients with G2 endometrioid adenocarcinoma had CINDEIN metastasis and all of these three patients had other pelvic node metastasis.

Conclusion

Removal of CINDEIN can be eliminated in patients with G1 endometrial cancer and patients with G2 endometrial cancer who have no pelvic node metastasis.     

Polymorphisms in the CASP8 gene and the risk of epithelial ovarian cancer

Objective

The CASP8 gene plays a central role in the apoptotic pathway and is therefore a plausible cancer susceptibility gene. However, the precise role of the CASP8 gene in epithelial ovarian cancer carcinogenesis is unclear. Therefore, we analyzed the correlation between single nucleotide polymorphisms (SNPs) and haplotypes in CASP8 and the risk and clinical characteristics of epithelial ovarian cancer (EOC) in the Chinese population.

Subjects and methods

Eight tag SNPs were identified using the MassARRAY system to genotype 37 genetic polymorphisms around and in the CASP8 gene in 100 unrelated, healthy females. Then, a case-control study of 218 EOC patients and 285 controls who were matched on residence, age and race was conducted using these 8 tag SNPs.

Results

The risk of developing EOC was significantly decreased in association with CASP8 rs3834129 ins > del (odds ratio (OR)_del/del = 0.129, 95% confidence interval (95% CI): 0.038-0.439; OR_ins/del = 0.769, 95% CI, 0.534-1.108), rs3769827 T > C (OR_C/C = 0.187, 95% CI: 0.070-0.500; OR_T/C = 0.729, 95% CI: 0.505-1.052), rs6704688 C > T (OR_T/T = 0.344, 95% CI, 0.168-0.707; OR_C/T = 0.802, 95% CI, 0.552-1.166), and with the del-C-T haplotype of these 3 SNPs (OR = 0.615, 95% CI: 0.453-0.8363). Moreover, a notably later onset was significantly associated with the rs3834129 ins/del + del/del and the rs3769827 T/C + C/C genotypes (p < 0.0001).

Conclusions

Genetic variants of the CASP8 gene protect against EOC carcinogenesis and delay the age of EOC onset. Furthermore, these protective effects may be due to the dysfunctional expression of caspase-8 caused by the − 652 6 N del variant in the promoter.