[Show abstract][Hide abstract] ABSTRACT: Better outcome of advanced ovarian cancer after centralized surgery has led to the recommendation for centralized surgery in a Norwegian health region. Whether the practice pattern has changed according to this recommendation has not been examined.
The objective of this study was to evaluate the referral practice and treatment of ovarian cancer in a Norwegian health region after the introduction of centralized surgery.
This was a retrospective, population-based study, including all women undergoing surgery for primary ovarian, tubal, and peritoneal cancer between 2000 and 2005, in Health Region IV of Norway. Clinical data and data regarding treatment and 5-year follow-up were analyzed.
In total, 279 cases of ovarian, peritoneal, and tubal cancer were included. Eighty-four percent underwent primary surgery at the teaching hospital and 16% at the nonteaching hospitals. After an immediate rise in the number of cases undergoing primary surgery at the teaching hospital after the introduction of centralization in 1995, the percentage distribution between the teaching and nonteaching hospitals was stable during the study period. The women who underwent surgery at the nonteaching hospitals had a higher percentage of early-stage disease and were at higher risk of reoperation for comprehensive staging.
Centralization of ovarian cancer surgery has been successfully accomplished in a health region in Norway. The referral practice of assumed advanced ovarian cancer cases shows satisfactory compliance with centralization at 10 years after the implementation of centralized surgery.
International Journal of Gynecological Cancer 11/2011; 22(2):226-31. DOI:10.1097/IGC.0b013e31823589ef · 1.95 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To study the results in cervical carcinoma after a combined treatment with surgery and radiotherapy with regard to survival and side effects.
A retrospective analysis of 71 patients who underwent radical hysterectomy and postoperative radiotherapy between January 1, 1987, and December 31, 2001, was performed.
Median follow-up periods were 162 months for surviving patients and 62 months for deceased patients. The 5-year overall survival and disease-specific survival for all stages were 80.3% and 82.7%, respectively. The 5-year actuarial incidence of late reactions for grade 1 + 2 was as follows: for upper gastrointestinal tract, 36%; for rectum, 37%; for urinary tract, 19%; for vagina, 26%; and for lymph edema, 19%. The 5-year actuarial incidence of late reactions for grade 3 + 4 was as follows: for upper gastrointestinal tract, 12%; and for rectum, 3%.
Careful pretreatment workup and well-defined criteria for postoperative radiotherapy are essential, and new treatment options such as intensity-modulated radiation therapy should be considered.
International Journal of Gynecological Cancer 12/2009; 19(9):1595-9. DOI:10.1111/IGC.0b013e3181bed288 · 1.95 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The aim of the study was to compare the histological outcome of the cone specimens with the diagnoses of the preoperative biopsies, to assess the distribution of histological features consistent with human papillomavirus (HPV) infection and, finally, to analyse the impact of cellular HPV features on classification of cervical intraepithelial neoplasia (CIN). The study comprised a population of 317 women treated for CIN by laser conization during the period 1983-85. A total of 634 cervical specimens (317 preoperative biopsies and their corresponding cones) were studied retrospectively for CIN classification and examined for morphological signs of HPV infection. For presentation of the results, we used a modified terminology for CIN. Low-grade (LG) CIN included borderline lesions and CIN I, while high-grade (HG) CIN included CIN II and CIN III. The blinded histopathological review revealed HG CIN both in the preoperative biopsies and the cones in 71% of the cases. LG CIN or benign lesions were found in the preoperative biopsies and their corresponding cone specimens in 6% of the study population. HPV features were present in 65% of the preoperative biopsies, and were most prevalent in women under 29 years of age (p<0.001). Thirteen percent of the total biopsy material was downgraded. The downgrading was most prevalent among original CIN II (p=0.009) and HPV-negative biopsies (p<0.001). This study demonstrates that CIN lesions are frequently associated with HPV features, which are significantly more prevalent in the youngest women. Concomitant HPV features do not influence the CIN classification.
[Show abstract][Hide abstract] ABSTRACT: To study the treatment of patients with cervical carcinoma with regard to side effects and survival. Materials and
A retrospective analysis of 107 patients with cervical carcinoma treated by radiotherapy with curative intent between January 1, 1987 and December 31, 2001.
Median follow-up: 139 months for surviving patients and 23 months for deceased patients. Five-year overall and disease-specific survival for all stages was 36% and 45%, respectively. Corresponding figures for each stage were, Stage I: 54% and 80%, Stage II: 41% and 56%, Stage III: 33% and 36% and Stage IV: < 1%. Five-year actuarial incidence of late reactions, all grades were: vagina 77%, rectum 41%, urinary tract 28%, and gastrointestinal tract 37%.
a great variation of treatment techniques resulted in an overall survival somewhat inferior to that in other comparable series. Over time, an increasing tendency to include brachytherapy and external tumour boost was observed.
European journal of gynaecological oncology 02/2009; 30(1):20-4. · 0.61 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Inherited ovarian cancer carries a serious prognosis. Prophylactic oophorectomy has been advocated. The degree to which inherited ovarian cancer is restricted to BRCA mutation carriers is not fully known. We wanted to determine the prevalence of BRCA mutation carriers in women at high risk from ovarian cancer.
Healthy women who were found to be at increased risk judged by family history were followed prospectively. Full BRCA1/2 mutation analysis was conducted on all patients who contracted pelvic cancer.
We identified 1,582 women at risk during 5,674 person-years. Forty infiltrating epithelial ovarian cancers, six peritoneal cancers, and one fallopian tube cancer were diagnosed. All but one of these patients (98%) had a BRCA mutation, a frequency that was significantly higher than for the 3 patients with borderline ovarian cancers, who were all mutation negative (P = 0.0002). Eighty-two percent of the detected mutations belonged to one of the 10 Norwegian founder mutations previously reported. At prophylactic bilateral salpingo-oophorectomy, cancer was found in 18 of 345 (5.2%) of mutation carriers compared with none in the 446 mutation negative (P = 0.0000).
In healthy women with a family history of ovarian cancer, high risk for ovarian cancer was restricted to BRCA1/2 mutation carriers. A woman at risk for ovarian cancer according to her family history should have access to full BRCA1/2 mutation testing before deciding on prophylactic bilateral salpingo-oophorectomy.
Clinical Cancer Research 12/2008; 14(22):7569-73. DOI:10.1158/1078-0432.CCR-08-0112 · 8.72 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The population of gynaecological cancer survivors is growing. However, there is little knowledge of the long-term quality of life among these former patients. The aim of this study was to investigate the long-term quality of life in women treated successfully for gynaecological cancer and a control group of representative women selected from the general population.
The study comprised women aged 30-75 years residing in the central part of Norway. Cases were 319 gynaecological cancer survivors treated at St Olav's Hospital Trondheim, Norway, between 1987 and 1996, whereas 1276 age-matched women selected at random from the general population served as controls. The study population was identified and the respondents were invited to answer a postal questionnaire. After one reminder, the response rate was 55% (176/319) and 41% (521/1276) for cases and controls, respectively. Sixteen cases and 28 controls had incomplete responses to most questions and were excluded from the analyses. Eligible for the final analyses were 160 cases and 493 controls. Ferrans & Powers' Quality of Life Index (QLI) was used. All analyses were performed in SPSS version 13.0 with chi-square (categorical variables) and Mann-Whitney (continuous variables) tests. p <or= 0.05 is the level of statistical significance.
Cases had on an average, a complete recurrence-free period of 12 years (range 7-18). No differences were detected between cases and controls in the global quality of life or in any of the four sub-dimensions of QLI. Furthermore, no difference was found in co-morbidity, but cases consulted more often hospital physicians than controls did.
Long-term gynaecological cancer survivors enjoy the same quality of life as women in the general population.
[Show abstract][Hide abstract] ABSTRACT: To study urinary incontinence among long-term survivors of gynecological cancer.
In a population-based, cross-sectional design, we identified 319 recurrence-free survivors of gynecological cancer, and 1,276 controls without a history of gynecological cancer. All participants were addressed with a 16-pages questionnaire covering issues of quality of life, general health, daily living conditions, natural functions and co-morbidities. Following 1 reminder, the response rates were 55 and 41% for cases and controls, respectively. Urinary incontinence (total, stress, urge and mixed) was in agreement with definitions of the International Continence Society.
Mean relapse-free follow-up time after treatment was 12 years (range: 8-17 years) for cases. The prevalence of total, stress, urge and mixed urinary incontinence were 34.3, 24, 0.8 and 9.5%, respectively. Previous gynecological cancer treatment was not associated with any outcomes of urinary incontinence. Obesity, previous and current use of HRT were associated with total, stress and mixed urinary incontinence, whereas increasing parity order was associated with total and stress urinary incontinence. In comparison with single factor analyses, the combination of obesity and parity 2+ had a multiplicative effect on total, stress and mixed incontinence.
Recurrence-free long-term survivors of gynecological cancer are not at increased risk for urinary incontinence.
[Show abstract][Hide abstract] ABSTRACT: The Norwegian coordinated cervical cancer screening program invites women from 25 to 69 years of age to have a cytological smear from the cervix uteri analysed every third year. The aim of this study was to identify the volume of smears collected and to evaluate the consequences of having or not having this done for 24-year-old and younger women not included in the screening program and to compare the results with those for other age groups.
Data were obtained from the following Norwegian Cancer Registry sources: the Cancer Registry for incident cases of cancer cervix uteri (1995-2004), the Cytology Registry for volume of cervical specimen collection (1992-2005) and outcome of smears (2004), the CIN-treatment database for the number of incident cases of cervical intraepithelial neoplasia grade 2 or 3 (2004) and the Cervix Histology Registry for histological outcome of cervical biopsies (2004). Data were displayed by age (< or = 24, 25-29, 30-69 and 70 years or older). No statistical testing was done.
Cancer in the cervix uteri is extremely rare among 24 year-old and younger women (0-3 cases per year). The volume of cervix smears taken from young women has decreased over the past 10 years; in 2005 approximately 35,000 out of 440,000 smears came from young women. More smears from young women were inconclusive and more lesions were of low grade than in older women; repeat testing was therefore required more frequently in young women. More young than older women were diagnosed with grade 1 or grade 2 lesions.
Most lesions in young women regress spontaneously. By not collecting smears from young women, many lesions that would anyway regress spontaneously, would not be discovered and follow-up could be avoided. Prospective follow-up studies of viral processes and oncogeneses indicate that it takes many years for normal cervix cells in the uterus to develop into cancer. For most young women it makes no difference whether low grade lesions or lesions that require treatment are diagnosed at age 23, 24 or shortly after 25. With reference to data from the Norwegian Cancer Registry and international literature, we conclude that analysis of cytological cervix smears from young women is more harmful than beneficial.
Tidsskrift for den Norske laegeforening 07/2007; 127(13):1782-5.
[Show abstract][Hide abstract] ABSTRACT: Patients with epithelial ovarian cancer are often diagnosed with advanced disease; hence they have a generally poor survival rate. The main objective was to assess the clinical effectiveness of the four main treatment options in the primary treatment of epithelial ovarian cancer: i) adjuvant chemotherapy and/or adjuvant radiotherapy, ii) cytoreductive surgery, iii) neoadjuvant chemotherapy in advanced disease, and iv) postoperative chemotherapy in advanced disease.
The scientific literature was identified by searches in Medline, Embase and Cochrane CCTR and by additional manual searches. Using criteria defined by protocol, two reviewers assessed each study according to relevance, quality and validity. Among 2227 publications identified, 635 were read as full-text articles, and 90 studies were critically assessed as relevant publications. All included studies were systematised in three subgroups according to the quality of the study design in question and the validity of the results: high, moderate, or low. A total of 45 studies of high or moderate quality form the documentary basis for this review.
Current data are inconclusive regarding the effect of adjuvant chemotherapy. Retrospective data show a survival advantage for patients who have had maximum cytoreductive surgery. The effect of neoadjuvant chemotherapy is uncertain. Several questions remain unanswered despite wide acceptance of paclitaxel-carboplatin as the current standard in first-line treatment.
This systematic review demonstrates the need for more clinical studies.
Tidsskrift for den Norske laegeforening 03/2005; 125(3):278-81.
[Show abstract][Hide abstract] ABSTRACT: Cervical intraepithelial neoplasia (CIN) is an established precursor of invasive cervical cancer. Excision procedures such as cold-knife conization, electrodiathermy or laser conization of the cervix are major surgical treatment modalities of CIN.
Women who were treated for CIN 2/3 or suspected invasive cancer with cold-knife conization between 1977 and 1980 (n=212) were compared with women treated with laser conization between 1987 and 1990 (n=439). Outcome parameters were method of anaesthesia, duration of hospital stay, treatment efficacy and postoperative complications such as bleeding, infection or cervical stenosis.
General anaesthesia was used in 88 % of women treated with cold-knife conization, while paracervical block anaesthesia was used in 97 % of women treated with laser conization. Mean hospital stay was 7.6 days after cold-knife conization, while laser conization was performed as an outpatient procedure. The overall complication rate was 36.8 % after cold-knife conization and 8.4 % after laser conization. Significantly higher rates of postoperative bleeding (21.1 % v. 5.0 %), infections (2.6 % v. 0.5 %) and cervical stenosis (11.8 % v. 1.6 %) were found after cold-knife conization compared to laser conization. Treatment efficacy was equally high (98 %) with both methods.
Laser conization was found to be a significantly less resource consuming procedure and with fewer postoperative complications compared to cold-knife conization.
Tidsskrift for den Norske laegeforening 02/2005; 125(2):167-9.
[Show abstract][Hide abstract] ABSTRACT: To examine the effect of centralized surgery on overall survival in patients with ovarian cancer and, in particular, patients with advanced disease (stage III/IV).
In a historical prospective study design, patients referred from community hospitals to a teaching hospital for primary surgery during the 2-year period, 1995-1997, were included as cases. For each referred case, two controls, matched for International Federation of Gynecology and Obstetrics (FIGO) stage and age, were selected among patients who had had primary surgery at the referral hospitals (nonteaching) in the years, 1992-1995. Kaplan-Meier survival curves were computed and tested statistically by the log rank test. Cox proportional hazard model was applied for estimation of prognostic factors of survival.
There was no difference in postoperative mortality for stage I/II patients by level of care (community hospitals versus teaching hospital). However, for advanced stage disease (III + IV), the controls had significantly shorter crude survival than patients who had been operated on at the teaching hospital (5-year survival: 4% versus 26%; median survival: 12 months versus 21 months) (P=.01). Multivariable analyses showed that completed chemotherapy and size of residual tumor after primary surgery were independent prognostic factors of survival. Patients optimally operated on at the teaching hospital had significantly lower risk of death compared with all other groups, independently of chemotherapy. This indicates that the extent of cytoreductive surgery and the overall management undertaken in the teaching hospital are significant predictors of improved survival.
Centralization of primary ovarian cancer surgery in one health region in Norway has improved survival for patients with advanced disease. Patients with apparent advanced ovarian cancer should be referred to a subspecialty unit for primary surgery, and every effort should be made to attain as complete cytoreduction as possible.
Obstetrics and Gynecology 10/2003; 102(3):499-505. DOI:10.1016/S0029-7844(03)00579-9 · 5.18 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To assess incidence during a 10-year study period and to identify and discuss clinical relevance for prognostic factors of survival within a cohort of Norwegian ovarian cancer patients.
Incidence and prognostic factors of survival within a population-based cohort of ovarian cancer patients from one health region in Norway were examined over the 10-year period 1987 through 1996. A total of 571 histologically verified cases of primary ovarian cancer originally registered either in the Cancer Registry of Norway or in the hospital's discharge registers were included in the study. Pearson chi(2) test was used in univariate analyses of cofactors by 5-year survival, and Kaplan-Meier survival curves were computed and tested statistically by the log rank test. A multivariable proportional hazard model (Cox) was applied to assess the prognostic significance of the different covariates.
The incidence and crude 5-year survival remained stable over the 10-year study period. The standardized incidence rate for the time periods 1987-1991 and 1992-1996 was 11.9/100,000 and 12.5/100,000, respectively. The crude 5-year survival rate for the cohort was 39%, whereas median survival was 32 months. Cox multivariable regression analysis showed that the only independent significant prognostic factors were International Federation of Gynecology and Obstetrics stage (P <.001), size of residual tumor at the end of primary surgery (P <.001), and age at diagnosis (P <.01). Variables such as time period, histologic type and grade, treating hospital, comorbidity, or CA 125 were insignificant in predicting 5-year survival.
The results underline the importance of improved surgical management of ovarian cancer, as residual tumor is the only prognostic factor achievable.
[Show abstract][Hide abstract] ABSTRACT: Completeness of reporting and accuracy of the diagnosis of ovarian cancer from one health region in Norway to the Cancer Registry were examined. Data kept by the Cancer Registry were evaluated against discharge diagnosis data from all 8 hospitals in the health region during the period of 1987-1996. The assessment of the accuracy of the diagnosis recorded in the Cancer Registry was based on review of all medical records in the hospital setting and on slide review of all histologic diagnoses. The overall completeness of reporting ovarian cancer to the Cancer Registry was 99.6%. The organ specific completeness of registration of histologic verified ovarian cancer within the Cancer Registry was 95.3%; 0.9% was erroneously coded and 3.5% had their diagnosis changed to ovarian cancer at re-evaluation. Of all ovarian cancer cases registered at the Cancer Registry, 91% had a primary histologic diagnosis. Among 591 cases identified with a histologic diagnosis in the Cancer Registry, the accuracy of the diagnosis was estimated at 92%. Coding errors were found in 2% of these cases, while in 6% of the cases it was not possible to reproduce the original diagnosis of ovarian cancer at re-evaluation. In order to provide data of high quality for cancer surveillance a cancer registry needs several data providers, such as histopathologic laboratory reports and clinical reports. In addition, assessment of reported data through stringent quality assurance procedures within the registry are necessary for reaching a nearly 100% completeness of registration as found for ovarian cancer in the Cancer Registry of Norway.
International Journal of Cancer 05/2002; 98(6):907-11. DOI:10.1002/ijc.10254 · 5.09 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Familial breast-ovarian cancer has been demonstrated to be frequent but unevenly distributed in Norway. This was assumed to be caused by the reduced population size created by the medieval Bubonic plagues 25 generations ago, and by the following rapid expansion. We have previously reported that four mutations account for 68% of the BRCA1 mutation carriers. Subsequent analysis has resulted in a total of 100 separate families carrying one of these founder mutations. The four mutations occurred on one specific BRCA1 haplotype each. The 1675delA, 816delGT and 3347delAG families originated from the South-West coast of Norway with a few families in the north, while the traceable ancestors of the 1135insA families clustered along the historical inland road from the South-East to mid-Norway. The carriers of each of the four mutations today are descendants of one or a few individuals surviving the plagues. We may identify the majority of BRCA1 mutation carriers in Norway by screening for local founder mutations.
European Journal of Cancer 01/2002; 37(18):2428-34. DOI:10.1016/S0959-8049(01)00299-4 · 5.42 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Cervical cancer is the third most frequent cancer among women worldwide. Human papillomavirus (HPV) infection is a necessary risk factor and the first step in cervical carcinogenesis.
This article reviews the current literature concerning the possibility of preventing cervical cancer by HPV testing and vaccination.
HPV testing cannot replace cytology, but will reduce false negative cytology and may improve the screening programme for cervical neoplasia. It has not yet been incorporated in any national cervical cancer screening program, but trials are ongoing in Scandinavia and in the Netherlands. The cost-effectiveness of HPV testing in screening has to be proven and whether it can affect the recommended screening-intervals. Therapeutic and prophylactic vaccines for HPV associated disease are in progress. Evaluating the clinical trials that are ongoing will take several years. Several anti-HPV vaccines are now in clinical trials; Norway will also participate. Therapeutic vaccines against cervical cancer have so far not been successful, but anogenital dysplasias and condylomas may be more susceptible. Prophylactic vaccines against HPV 6, 11, 16 and 18 have been evaluated in clinical phase I and II trials, and phase III trials are in progress.
HPV testing improves the specificity and sensitivity of cervical cytology and it can be used to clarify cases with atypical cells of undetermined significance (ASCUS) and low-grade intraepithelial neoplasia. In the near future it may also be included in the cervical cancer screening programme for women above the age of 30. The first results in clinical vaccine trials are encouraging, and final conclusions about the effectiveness of these vaccines may be achieved in five years' time.
Tidsskrift for Den norske legeforening 11/2001; 121(25):2947-51.