B Rachet

D Lister-Sharp

DH Brewster

DM Parkin

E Mitry

H Brenner

IJ Jacobs

M J Quinn

M P Coleman

M Sant

MJ Quinn

MP Coleman

N Cooper

NHS Centre for reviews and dissemination

S Lewis

English

PubMed

H C Kitchener

Crossref

Survival from cancer of the ovary in England and Wales up to 2001

Cooper, N

Quinn, MJ

Rachet, B

Mitry, E

Coleman, MP

LSHTM Research Online

Cooper, N; Quinn, MJ; Rachet, B; Mitry, E; Coleman, MP (2008)Survival from cancer of the ovary in England and Wales up to 2001.British journal of cancer, 99 Suppl 1. pp. 70-72. ISSN 0007-0920Downloaded from: http://researchonline.lshtm.ac.uk/6961/Usage GuidelinesPlease refer to usage guidelines at http://researchonline.lshtm.ac.uk/policies.html or alterna-tively contact researchonline@lshtm.ac.uk.Available under license: Creative Commons Attribution Non-commercial No Derivativeshttp://creativecommons.org/licenses/by-nc-nd/2.5/Survival AnalysisSurvival from cancer of the ovary in England and Walesup to 2001N Cooper1, MJ Quinn1, B Rachet2, E Mitry3 and MP Coleman*,21Social and Health Analysis and Reporting Division, Off ice for National Statistics (Room FG/114), 1 Myddelton Street, London EC1R 1UW, UK; 2CancerResearch UK Cancer Survival Group, Non-Communicable Disease Epidemiology Unit, Department of Epidemiology and Population Health, London Schoolof Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK; 3De´partement d’He´patogastroente´rologie et Oncologie Digestive, CentreHospitalo-Universitaire Ambroise-Pare´, 9 avenue Charles de Gaulle, F-92100 Boulogne, FranceBritish Journal of Cancer (2008) 99, S70 – S72. doi:10.1038/sj.bjc.6604593 www.bjcancer.comPublished online 23 September 2008& 2008 Cancer Research UKThe incidence of ovarian cancer varies widely around the world,with the highest rates in the developed countries of Europe andNorth America, and the lowest in Africa and Asia (Parkin et al,2002). In England and Wales, ovarian cancer is the most commongynaecological cancer, and the fourth most common after cancersof the breast, large bowel and lung, representing some 5% of allcancers in women. It is rare in premenopausal women, with lessthan 10% of cases arising under the age of 45.The pattern of incidence for ovarian cancer with age is similar tothat of breast and uterine cancers, and they share somereproductive risk factors. Late menarche, high parity, earlymenopause and long-term use of combined oral contraceptivesall confer a lower risk of ovarian cancer, probably by reducing thenumber of ovulatory cycles.Incidence in England and Wales has increased gradually sincethe early 1970s, especially in older women (Coleman et al, 1993),but the upward trend in younger women appears to have reached aplateau by the late 1990s (Quinn et al, 2001). Incidence is 5– 10%higher among women in more affluent groups than in the mostdeprived group, and it increased further in these groups during the1990s (data not shown). In the late 1990s, about 6000 women werediagnosed with ovarian cancer in England and Wales each year.Ovarian cancer accounts for 4000 deaths a year in England andWales, about 6% of all cancer deaths in women. In contrast to theincreasing trend in incidence, overall age-standardised mortalityhas fallen slightly over the last decade, but a 20– 30% fall inmortality among women under 65 years has been balanced by anincrease of about 10% in mortality among older women. Survivalfrom ovarian cancer is the lowest among the gynaecologicalcancers, because it is often at an advanced stage when diagnosed.Some 81 600 women were registered with an ovarian tumour inEngland and Wales during the 14-year period 1986–1999,but more than 6000 of these tumours were benign, of uncertainbehaviour, or metastatic to the ovary from a primary malignancyelsewhere. Of the 75 800 women resident in England and Waleswho were registered with a primary, malignant tumour of theovary, some 63 800 were included in the analyses (84% of thoseeligible). One percent of women were excluded because their vitalstatus was not known on 5 November 2002, when the data wereextracted for analysis and 10% because their recorded survivaltime was zero (mainly death certificate only (DCO) cases whosesurvival time was unknown). A further 3% were excluded becauseit was not the woman’s first primary, invasive cancer, a previousmalignancy having been registered for the same woman at sometime since 1971. The proportion of cases excluded from analysis asDCOs did not vary by year of diagnosis or by deprivation category.Tumours of the ovary have usually been grouped with those ofthe Fallopian tube, broad ligament and other uterine adnexa (ICD-9 183, ICD-10 C56– 57). Ovarian tumours were only assigned aseparate three-digit rubric in the International Classification ofDiseases with the introduction of the tenth revision in 1995 (ICD-9183.0; ICD-10 C56), but in any case almost 99% of the tumourswere coded to the ovary, with only about 1% to the Fallopian tube(183.2, C57.0); tumours coded to the broad ligament and otheradnexa were extremely rare. As is conventional, therefore, thesetumours were included with ovarian cancers in the survivalanalyses, for consistency in the interpretation of long-term trends.Adenocarcinomas accounted for most tumours that wereassigned to a specific morphology, with 39% coded to serous,papillary or mucinous cystadenocarcinoma and 34% to otherspecific types of adenocarcinoma; 20% were poorly specifiedcarcinomas.SURVIVAL TRENDSRelative survival at 1 year rose from 56% for women diagnosedduring 1986– 1990 to 66% for those diagnosed during 1996–1999.This represents a rapid and significant deprivation-adjustedincrease of about 5% every 5 years (Table 1). Five-year survivalrose from 30 to 38%, representing a statistically significantincrease of 3% every 5 years.Short-term predictions based on hybrid analysis (Brenner andRachet, 2004) of patients’ survival experience during 2000–2001suggest that the underlying increase in survival up to 5 years islikely to continue (Table 1, Figure 1).It is striking that relative survival at 10 years has remained low,around 26%, for women who were diagnosed in both the late 1980sand the early 1990s (Table 1, Figure 1). These estimates are basedon classical techniques of following up all or most of the women*Correspondence: Professor MP Coleman;E-mail: michel.coleman@lshtm.ac.ukBritish Journal of Cancer (2008) 99, S70 – S72& 2008 Cancer Research UK All rights reserved 0007 – 0920/08 $32.00www.bjcancer.comdiagnosed in those periods for up to 10 years, and no such estimatecan yet be made for women diagnosed during 1996–1999. Inthis case, however, hybrid analysis based on events during2000–2001 suggests that a substantial increase in 10-year survivalcan be expected within the next 5 years or so, to approximately 33%(Figure 1). This is because 5-year survival increased much morequickly between the early and late 1990s than over the previous5 years (Table 1, Figure 1), and the hybrid estimate of 10-year survivalincorporates this recent jump in medium-term survival.DEPRIVATIONWomen living in more deprived areas who were diagnosed withovarian cancer in the late 1980s had lower survival than moreaffluent women at both 1 and 5 years after diagnosis (Table 2). TheTable 1 Trends in relative survival (%) by time since diagnosis and calendar period of diagnosis: England and Wales, adults (15–99 years) diagnosedduring 1986–1999 and followed up to 2001Calendar period of diagnosisaAverage change (%) Predictionc for patients1986–1990 1991–1995 1996–1999 every 5 yearsb diagnosed during 2000–2001Time sincediagnosisSurvival(%) 95% CISurvival(%) 95% CISurvival(%) 95% CISurvival(%) 95% CISurvival(%) 95% CI1 year Women 56.0 (55.2, 56.6) 59.6 (59.0, 60.3) 65.8 (65.1, 66.5) 4.9** (3.6, 6.3) 66.6 (65.6, 67.5)5 years Women 29.8 (29.1, 30.4) 31.1 (30.4, 31.7) 38.1 (37.3, 38.9) 2.9** (1.5, 4.3) 38.6 (37.6, 39.6)10 years Women 25.6 (24.9, 26.2) 26.4 (25.7, 27.1) 0.3 (2.7, 2.2) 33.3 (32.2, 34.4)CI¼ confidence interval. aSurvival estimated with cohort or complete approach (see Rachet et al, 2008). bMean absolute change (%) in survival every 5 years, adjusted fordeprivation (see Rachet et al, 2008). cSurvival estimated with hybrid approach (see Rachet et al, 2008). **Po0.01.Table 2 Trends in the deprivation gap in relative survival (%) by time since diagnosis and calendar period of diagnosis: England and Wales, adults(15–99 years) diagnosed during 1986–1999 and followed up to 2001Calendar period of diagnosisaAverage change (%) Predictionc for patients1986–1990 1991–1995 1996–1999 every 5 yearsb diagnosed during 2000–2001Time sincediagnosisDeprivationgap (%) 95% CIDeprivationgap (%) 95% CIDeprivationgap (%) 95% CIDeprivationgap (%) 95% CIDeprivationgap (%) 95% CI1 year Women 5.1** (7.2, 3.1) 4.2** (6.1, 2.3) 4.6** (6.6, 2.7) 0.3 (1.2, 1.7) 5.1** (7.8, 2.3)5 years Women 1.9 (3.8, 0.1) 1.7 (3.5, 0.2) 1.0 (1.4, 3.5) 1.4 (0.2, 3.0) 1.2 (1.8, 4.2)10 years Women 1.1 (3.0, 0.8) 0.2 (1.8, 2.2) 1.3 (1.5, 4.1) 2.7 (0.4, 5.9)CI¼ confidence interval. aSurvival estimated with cohort or complete approach (see Rachet et al, 2008). bMean absolute change (%) in the deprivation gap in survival every5 years, adjusted for the underlying trend in survival (see Rachet et al, 2008). cSurvival estimated with hybrid approach (see Rachet et al, 2008). **Po0.01.0Relative survival (%)0 2 4 6 8 10Years since diagnosis2000–20011996–19991991–19951986–1990Women10080604020Figure 1 Relative survival (%) up to 10 years after diagnosis by calendarperiod of diagnosis: England and Wales, adults (15–99 years) diagnosedduring 1986–1999 and followed up to 2001. Survival estimated with cohortor complete approach (1986–1990, 1991–1995, 1996–1999) or hybridapproach (2000–2001) (see Rachet et al, 2008).105-year relative survival (%)AffluentDeprivation category2000–20011996–19991991–19951986–1990Women504030202 3 4 DeprivedFigure 2 Trends in the deprivation gap in 5-year relative survival (%) bycalendar period of diagnosis: England and Wales, adults (15–99 years)diagnosed during 1986–1999 and followed up to 2001.Survival from ovarian cancer in England and WalesN Cooper et alS71British Journal of Cancer (2008) 99(S1), S70 – S72& 2008 Cancer Research UKdeprivation gap in survival between the affluent and deprived wassignificantly wider at 1 year (5.1%) than at 5 years (1.9%).Survival rose slightly more for women in the deprived categoriesthan for the more affluent groups. The deprivation gap in 1-yearsurvival fell slightly to 4.6%, and the deprivation gap in 5-yearsurvival disappeared, becoming positive (1.0%). These changes aresmall, and not individually significant, but they appear systematic.It is notable that the larger increase in 5-year survival in the late1990s (Figure 1) is accompanied by a distinct flattening of thedeprivation gradient (Figure 2).Short-term predictions of the socioeconomic gradient in ovariancancer survival suggest little imminent change (Table 2), with asignificant deficit in 1-year survival of 5% for the least affluentwomen, but little difference in longer-term survival (Table 2).COMMENTThe more recent improvement in survival is probably due toprogress in treatment. Only a minority of women are diagnosedearly enough for radical hysterectomy and oophorectomy alone tobe successful, and many women are given adjuvant chemotherapy.Regimens combining taxanes (paclitaxel and docetaxel) withplatinum compounds are now generally recommended as first-linetreatment for women with advanced disease (Lister-Sharp et al,2000). Evidence of effectiveness suggests that survival is improvedwhen surgery is done by specialists in gynaecological oncology andwhen treatment is undertaken by expert multi-disciplinary teams(NHS Centre for reviews and dissemination, 1999).Survival at 1 year after diagnosis is lower for women living indeprived areas: these women tend to have more advanced diseaseat diagnosis (Brewster et al, 2001). However, the gradualdisappearance of the deprivation gap in 5-year survival by thelate 1990s – in contrast to the pattern for most other cancersin women – suggests that deprived women diagnosed during1996– 1999 generally obtained at least as good access to optimaltreatment as affluent women.Thus among the 17 different cancers in women examined inthese analyses, ovarian cancer was one of only five (with stomach,pancreas, kidney, and the different types of leukaemia) for whichsurvival for women living in the poorest one-fifth of electoralwards in England and Wales in the late 1990s was not lower thanfor women in the richest fifth of wards. The proportion of DCOcases was similar in each year and in each deprivation category(data not shown); therefore, estimates of trend in the deprivationgradient in survival are not likely to be biased as a result of theirexclusion from analysis. The deprivation-specific life tables used inthe analyses are the same as those used for all other cancers, formost of which the deprivation gap in survival widened during the1990s. Narrowing of the deprivation gap in survival from ovariancancer thus seems unlikely to be an artefact either of the data or ofour analytic approach.Advanced stage at diagnosis frequently limits the potentialfor radical treatment. Evidence from a large randomised controlledtrial indicates that earlier detection by screening does reducemortality (Jacobs et al, 1999). Mass screening for ovarian canceris being evaluated in the United Kingdom Collaborative Trialof Ovarian Cancer Screening (UKCTOCS) (Lewis and Menon,2003). This trial will compare two types of screening test (serumCA125 and transvaginal ultrasound) with no test at all; it is due toend in 2010.Compared with many other common cancers, survivalfrom ovarian cancer did not improve greatly during the1980s (Coleman et al, 1999). For women diagnosed in England andWales during the early 1990s, 5-year survival from ovarian cancer wasstill 5–8% below the age-standardised European average relativesurvival of 37% (Sant et al, 2003). It remains to be seen whether theimprovement in survival during the late 1990s will have narrowedthe gap with the European average survival.REFERENCESBrenner H, Rachet B (2004) Hybrid analysis for up-to-date long-termsurvival rates in cancer registries with delayed recording of incidentcases. Eur J Cancer 40: 2494 – 2501Brewster DH, Thomson CS, Hole DJ, Black RJ, Stroner PL, Gillis CR(2001) Relation between socioeconomic status and tumourstage in patients with breast, colorectal, ovarian, and lung cancer:results from four national, population based studies. Br Med J 322:830 – 831Coleman MP, Babb P, Damiecki P, Grosclaude PC, Honjo S, Jones J,Knerer G, Pitard A, Quinn MJ, Sloggett A, De Stavola BL (1999) CancerSurvival Trends in England and Wales 1971 – 1995: Deprivation and NHSRegion. Studies on Medical and Population Subjects No. 61. TheStationery Office: LondonColeman MP, Este`ve J, Damiecki P, Arslan A, Renard H (1993) Trends inCancer Incidence and Mortality (IARC Scientific Publications No. 121).International Agency for Research on Cancer: LyonJacobs IJ, Skates SJ, MacDonald N, Menon U, Rosenthal AN, Prys Davies A,Woolas R, Jeyarajah AR, Sibley K, Lowe DG, Oram DH (1999) Screeningfor ovarian cancer: a pilot randomised controlled trial. Lancet 353:1207 – 1210Lewis S, Menon U (2003) Screening for ovarian cancer. Exp Rev AntiCancerTher 3: 55 – 62Lister-Sharp D, McDonaugh MS, Khan KS, Kleijnen J (2000) A rapid andsystematic review of the effectiveness and cost-effectiveness of thetaxanes used in the treatment of advanced breast and ovarian cancer.Health Technol Assess 4: 1 – 113NHS Centre for reviews and dissemination (1999) Management ofgynaecological cancers. Eff Health Care 5: 1 – 12Parkin DM, Whelan SL, Ferlay J, Teppo L, Thomas DB (eds) (2002) CancerIncidence in Five Continents, Volume VIII (IARC Scientific PublicationsNo. 155). International Agency for Research on Cancer: LyonQuinn MJ, Babb P, Brock A, Kirby L, Jones J (2001) Cancer Trends inEngland and Wales 1950 – 1999. Studies on Medical and PopulationSubjects No. 66. Office for National Statistics: LondonRachet B, Woods LM, Mitry E, Riga M, Cooper N, Quinn MJ, Steward J,Brenner H, Este`ve J, Sullivan R, Coleman MP (2008) Cancer survivalin England and Wales at the end of the 20th century. Br J Cancer99(Suppl 1): S2 – S10Sant M, Aareleid T, Berrino F, Bielska Lasota M, Carli P-M, Faivre J,Grosclaude PC, He´delin G, Matsuda T, Møller H, Moller T, Verdecchia A,Capocaccia R, Gatta G, Micheli A, Santaquilani M, Roazzi P, Lisi D,EUROCARE Working Group (2003) EUROCARE-3: survival of cancerpatients diagnosed 1990 – 94 – results and commentary. Ann Oncol14(Suppl 5): 61 – 118Survival from ovarian cancer in England and WalesN Cooper et alS72British Journal of Cancer (2008) 99(S1), S70 – S72 & 2008 Cancer Research UK

Assess 4: 1–113 NHS Centre for reviews and dissemination

Hybrid analysis for up-to-date long-term survival rates in cancer registries with delayed recording of incident cases.

Screening for ovarian cancer: a pilot randomised controlled trial.

Survival from cancer of the ovary in England and Wales up to 2001.

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2557529

Survival from cancer of the ovary in England and Wales up to 2001

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