Cervix

--Russell AH, Shingleton HM, Jones WB, Stewart AK, Fremgen AM, Winchester DP, Clive RE, Chmiel JS. Trends in the use of radiation and chemotherapy in the initial management of patients with carcinoma of the uterine cervix. Int J Radiat Oncol Biol Phys 1998; 40:605-13. (!)

Changes in the use of radiation therapy and surgical treatment of cervical cancer patients have been noted. This study suggests these changes may be due to the increasing surgical involvement of gynecologic oncologists in the management of early stage cervical cancer, rather than any significant alterations in the demographics of the disease. The empirical basis for this study come from a Commission on Cancer, American College of Surgeons Patient Care Evaluation Study which collected data on 11,721 cases from 703 hospital cancer registries in the United States. Patients were reported diagnosed in 1984 and 1990. Between the two study years, the use of radiation as all, or a component, of the initial course of therapy declined, coincident with an increase in the use of hysterectomy alone and a reduction in the use of radiation alone. The percentage of all patients receiving combined hysterectomy and radiation (preoperative or post-operative) remained virtually unchanged between 1984 and 1990. However, women who were treated by hysterectomy in 1990 were less likely to receive radiation as part of their treatment than patients treated by hysterectomy in 1984. Among patients treated by radiation without hysterectomy, the use of intracavitary brachytherapy techniques substantially exceeded interstitial brachytherapy techniques in both study years. Among patients treated by local radiation without hysterectomy, the frequency of adjunctive chemotherapy use increased markedly between 1984 and 1990, with chemotherapy and radiation increasingly administered concurrently rather than sequentially. Although differences based on age, histology, race/ethnicity, and insurance status were observed, these general management trends were seen in all groups. While brachytherapy is recognized as an important component of radiation treatment, some patients may not receive the potential benefit of this modality. Despite controversy concerning its efficacy, the use of adjuvant systemic chemotherapy to supplement local treatment modalities appears to be increasing rapidly.

--Jones WB, Shingleton HM, Russell A, Fremgen AM, Clive RE, Winchester DP, Chmiel JS. Cervical cancer and pregnancy: A national patterns of care study of the American College of Surgeons. Cancer 1996; 77:1479-1488. (*) (!)

Invasive cervical carcinoma was diagnosed in 161 patients who were pregnant at the time of diagnosis. A long term study of 78 patients diagnosed in 1984 was compared with a short term study of 83 patients diagnosed in 1990. The mean age of the patients was 31.8 years. Clinical stages were: IA (29%); IB (54%); IIA (6%); IIB (4%); IIIA (0%); IIIB (3%); IV (1%); and IVB (3%). Thirty-one percent of patients were diagnosed in the first trimester, 34% in the second, and 35% in the third. A tumor size of 4 cm or larger in diameter was found in 36% of the patients diagnosed in the first trimester, 40% of the patients diagnosed in the second, and 38% of the patients diagnosed in the third. Patients were treated with surgery alone (86), radiotherapy alone (30), or with combination therapy (45). The overall 5-year survival rate for patients diagnosed in 1984 was 82%. In this group, the 5- year survival rate for patients diagnosed in the first trimester was 94.6%, in the second, 76.9%, and in the third, 68.9%. Comparing the two time periods, surgical therapy was performed more often by gynecologic oncologists in 1990 (69% vs. 42%), and a greater percentage of patients were diagnosed with a tumor size of 4 cm or larger in diameter (43% vs. 26%) as well as with stage IIB-IVB disease (15% vs. 6.7%).

--Russell A, Shingleton HM, Jones WB, Fremgen AM, Winchester DP, Clive RE, Chmiel JS. Diagnostic assessments in patients with invasive cancer of the cervix: A national patterns of care study of the American College of Surgeons. Gynecol Oncol 1996; 63:159-165.

This retrospective survey includes data from 703 hospitals on 11,721 patients diagnosed with cervical cancer in 1984 and 1990. The purpose of the study was to quantitate the use of specific diagnostic tests and monitor their changing use during the two study years. Information concerning the initial use of diagnostic assessments was analyzed with respect to the potential influences of clinical stage, patient age, race/ethnicity, insurance status, and modalities of therapy employed. Judged by the number of procedures performed, the intensity of pretreatment assessment declined between 1984 and 1990. Increased use of the new body imaging modalities was balanced by a decline in the use of procedures historically important in staging and assessment. Race/ethnicity and insurance status had no discernible independent impact on the intensity of diagnostic evaluation. Periodic review of assessment strategies would seem prudent to avoid a widening discrepancy between sanctioned staging procedures and actual clinical practice.

--Shingleton HM, Jones WB, Russell AR, Fremgen AM, Chmiel JS, Zuber-Ocwieja KE, Winchester DP, Clive RE. Hysterectomy in invasive cervical cancer: A national patterns of care study of the American College of Surgeons. J Am Coll Surg 1996; 183:393-400. (!)

Cancer registrars at 703 hospitals submitted anonymous data on 11,721 patients with carcinoma of the cervix who were diagnosed or treated, or both, in 1984 and 1990. Fifty- six percent of the patients had major operations. An operation with curative intent, either total hysterectomy (TAH) or radical type II or III hysterectomy with pelvic node dissection P.D. (RHPND), was carried out in 43.6% of the patients, constituting 38.9% of the patients in 1984, and 48.2% of the patients in 1990. The type of operation performed was judged appropriate in 95.6% of the patients who underwent RHPND, but in only 80.0% of the patients who underwent TAH. Gynecologic oncologists performed 46.8% of the hysterectomies in 1984, and 63.8% in 1990. Recurrence and long-term survival data are available for the 1984 patients; 5-year survival rates for women who underwent TAH (n=1,013) and RHPND (n=1,279) were 89 and 85%, respectively. A RHPND with negative nodes resulted in a 90% 5-year survival rate (n=916) as compared to 70% in those with positive nodes (n=194).

--Shingleton HM, Jones WB, Russell AR, Fremgen A. Patterns of care for invasive cervical cancer. In: Rubin SC, Hoskins WJ: eds. Cervical cancer and preinvasive neoplasia. Philadelphia,
Lippincott-Raven, 1996. (!)

Data were received from 684 hospitals on 5,904 patients diagnosed in 1984 and from 700 hospitals on 5,817 patients diagnosed in 1990. Of the patients, 58.3% were between age 30 and 39, and one-third of the patients were above age 60. Almost 74% were white. About 80% of the women had squamous cell carcinomas, and 15.8% had adenocarcinomas or subgroups thereof. The study comprised approximately 45% of the invasive cervical cancer seen in the U.S. during the study years and indicate that invasive cervical cancer is highly curable when diagnosed early. However, a significant number of patients continue to be diagnosed with advanced disease. There was a substantially increased use of newer body imaging modalities such as CT and MRI and a decline in the use of historically important diagnostic procedures (cystoscopy, proctoscopy, barium enema, bone scans, etc.). Use of extended hysterectomy as definitive therapy for early-stage cervical cancer increased considerably between 1984 and 1990 and was associated with the low complication rates and high 5-year survival. It was observed that hysterectomies were also being performed in clinical stage III and IV of the disease, which suggests that guidelines should be developed for the appropriate use of hysterectomy. Survival of pregnant women with invasive cervical cancer was comparable to that reported for non-pregnant patients. The significant number of patients diagnosed in the second or third trimester and the frequent finding of large tumors in all trimesters emphasizes the need for physician and patient education with regard to early prenatal evaluation. The large numbers of individuals with adenocarcinoma (1,849) presented an opportunity to study this tissue type. Significantly poorer survival was observed in stage II disease where squamous cell carcinoma patients fared much better than patients with adenocarcinoma or adenosquamous tumors. Pure adenocarcinoma and adenosquamous carcinoma patients did not have higher rates of nodal metastases compared to squamous cell carcinoma patients, yet adenocarcinoma patients with positive nodes had a significantly worse 5-year survival rate than did those with the other two tissue types.

--Jones WB, Shingleton HM, Russell AR, Chmiel JS, Fremgen AM, Clive RE, Zuber-Ocwieja KE, Winchester DP. Patterns of care for invasive cervical cancer: Results of a national survey of 1984 and 1990. Cancer 1995; 76:1934-47. (*) (!)

Six hundred eighty-four hospitals submitted data on 5,904 patients diagnosed in 1984 and 700 hospitals submitted data on 5,817 patients diagnosed in 1990. Of the 11,721 patients reported, 59.4% were diagnosed and treated at the reporting institution in 1984 and 54.8% in 1990. The remaining patients were referred for treatment elsewhere after diagnosis. Diagnosis was established by cervical biopsy (69.8%), conization alone (9.3%), and by both procedures (11.8%). The histopathologic diagnoses were squamous cell carcinoma (79.8%), adenocarcinoma (15.8%), and other (4.4%). The stage distributions were as follows: IA, 15.9%; IB, 36.8%; IIA, 8.2%; IIB, 15.5%; IIIA, 2.5%; IIIB, 13.3%; IVA, 2.6%; and IVB, 5.2%. The stage was listed as unknown for 20.3% of patients. Patients were treated with surgery alone (29.2%), radiation alone (40.7%), chemotherapy alone (0.7%), or combination therapy (21.5%). Almost 8% received no treatment at the reporting institution. Overall survival for patients diagnosed in 1984 was 68.3%. Survival by stage was as follows: IA, 93.7%; IB, 80.0%; IIA, 67.2%; IIB, 64.7%; III, 37.9%; IV, 11.3%.

--Shingleton HW, Bell MC, Fremgen AM, Chmiel JS, Russell AR, Jones WB, Winchester DP, Clive RE. Is there really a difference in survival of women with squamous cell carcinoma, adenocarcinoma and adenosquamous cell carcinoma of the cervix? Cancer 1995; 76:1948-55. (*) (!)

Seven hundred three hospitals submitted data on 11,157 patients with cervical cancer diagnosed and/or treated in 1984 and 1990. Among these patients, 83.8% had SCC, 12.6% had Ad/CA, and 3.5% had Ad/SC cancers. A multi-variate analysis of patients with clinical IB disease showed that tumor size, nodal metastases, and treatments other than surgery alone were independent prognostic factors; however, histologic type had no significant effect on survival. No significant differences were found in 5-year survival among the 3 tissue types in any clinical stage except AJCC stage II. Two-thirds of women with early clinical stage disease had hysterectomy as all or part of their primary therapy. Surgery was found to be the treatment of choice for patients with Stage I SCC or Ad/CA, as judged by better survival rates. However, for patients with Ad/SC tumors, combined surgery and radiation seemed to result in higher rates of cure. Patients with Ad/CA with positive nodes had a significantly reduced 5-year survival rate (33.3%), compared with 76.1 % and 85.7% for patients with SCC and Ad/SC tumors, respectively.

--Shingleton HM, Menck HR, Clive RE. AJCC staging of cervical cancer. A study of variables and stage of disease at first diagnosis. The (NCRA) Abstract 1994; January:19-20.

A total of 1,334 hospitals submitted data for cervical cancer patients diagnosed in 1985/86 and/or 1991. During 1985-1986, a total of 19,534 cervix cases were reported. In 1991, the total was 21,836. From 1985-1986, 70.5% of cases were unstaged according to AJCC staging. In 1991, 52.2% of the cases were unstaged, showing a decrease in the percent of undocumented cases. Cases reported for 1985-1986 included relatively more advanced disease than those for 1991. Because the NCDB is a convenience sample of U.S. cancer patients, it cannot be determined whether these changes reflect the total U.S. experience. However, these data are consistent with a theory of improved stage of disease at first diagnosis over time, and may reflect improved screening and other early detection efforts.

--Mettlin CJ, Natarajan N, Priore R, Smart CR, Murphy GP. Treatment and follow-up study of squamous cell carcinoma in situ of the cervix. Surg Gynecol Obstet 1982; 155:481-488. (*)

In order to provide a representative view of the management of patients with squamous cell carcinoma in situ of the cervix, data was collected from a total of 392 hospitals reporting 9,468 patients diagnosed and treated prior to December 31, 1970. Sixty-four percent of these patients had been observed for at least 9 years. Treatment ranged from no treatment to hysterectomy and radiation. The most commonly used definitive treatment was hysterectomy. Recurrences were observed after hysterectomy, conization, and radiation therapy. There were significantly more recurrences in the group treated by conization compared with those treated by hysterectomy. The highest rate of second primary cancer to the vagina, vulva, uterus, or ovaries was among patients who received no treatment. The cancer specific, 10-year survival rate for those with no treatment was 96.6%, and for those treated by conization or by hysterectomy, the rates were 99.4% and 99.8%, respectively.

 

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