FACTORS ASSOCIATED WITH TREATMENT RECEIVED FOR OVARIAN CANCER

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FACTORS ASSOCIATED WITH TREATMENT RECEIVED FOR
OVARIAN CANCER
AR Kahn, MJ Schymura, K Bauer, R Cress, S Neloms,
C OMalley, S Stewart, JM Wike Ovarian Cancer
Treatment Patterns and Outcomes (OCTPO)
Study California Cancer Registry Maryland
Cancer Registry New York State Cancer
Registry National Program of Cancer Registries
NAACCR Annual Conference Detroit, Michigan June
5, 2007
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Overview of Presentation

• Ovarian Cancer Background
• Statistics
• Course of Disease
• Treatment
• Methods of OCTPO Study
• Results

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Ovarian Cancer Facts

• Eighth most common cancer among females in the
  U.S. (approx. 20,000/year)
• Behind Breast, Lung, CR, Uterine, NHL, Melanoma,
  and Thyroid
• Fifth most common cause of cancer death among
  U.S. females (approx. 15,000/year)
• Most common gynecological cancer cause of death
• Lifetime Risk in U.S. women 1 in 67 (1.5 risk)
• All stage, 5-year relative survival 45
• Survival of cases with distant spread 30
• Survival of localized cases 92
• Percent diagnosed with localized disease 19

American Cancer Society. Cancer Facts and
Figures 2007. Atlanta American Cancer Society
2007. Ries LAG, Melbert D, Krapcho M, Mariotto
A, Miller BA, Feuer EJ, Clegg L, Horner MJ,
Howlader N, Eisner MP, Reichman M, Edwards BK
(eds). SEER Cancer Statistics Review, 1975-2004,
National Cancer Institute. Bethesda, MD,
http//seer.cancer.gov/csr/1975_2004/, based on
November 2006 SEER data submission, posted to the
SEER web site, 2007.
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OVARIAN CANCER INCIDENCE AND MORTALITY, U.S. CA,
MD, AND N.Y. 2000
Suggested Web citation U.S. Cancer Statistics
Working Group. United States Cancer Statistics
19992002 Incidence and Mortality Web-based
Report. Atlanta U.S. Department of Health and
Human Services, Centers for Disease Control and
Prevention and National Cancer Institute 2005.
Available at www.cdc.gov/cancer/npcr/uscs.
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Risk Factors (Most women with Ovarian Cancer have
no known risk factors)

• Genetics
• Family history of early breast, ovarian, or CR
  cancer
• BRCA1 and/or BRCA2 (assoc. with 9 of cases)
• Hormones
• Early Menarche, Late Menopause
• Polycystic Ovaries (increased hormonal
  environment)
• Infertility (use of ovulation-stimulating agents)
• Estrogen replacement therapy for ten or more
  years
• Also associated with increased gonadal hormones
  and epidermal growth factor

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Protective Factors

• Oral contraceptive use (30-60 reduced risk)
• Prolonged breast-feeding
• Tubal ligation and hysterectomy
• Diet high in vegetables
• Currently No Good Screening Method

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Ovarian Cancer Characteristics

• Approximately 90 are epithelial tumors,
  originating on ovarian surface.
• Tumor cells exfoliate into the peritoneal fluid
  also spread through lymphatics.
• Multiple peritoneal implants are common.

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Standard of Care
Standard of care is a Platinum Alkylating Agent
Plus a Taxane Minimum surgery for stage 2 or 3
is bilateral salpingo-oophorectomy with
hysterectomy
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Methods Study Population

• Study Population
• Original Goal 1500 cases per state - Final data
  set 4010 cases
• California Registries All women diagnosed with
  first primary ovarian carcinomas (not low
  malignant potential) diagnosed in 1998-2000
• Maryland Cancer Registry Same selection
  criteria as CA, but 1997-2000 diagnoses
• New York State Cancer Registry Random sample of
  patients diagnosed in 1998-2000

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Methods Record Review

• Hospital medical records were reviewed, and
  managing physicians were contacted to provide
  additional information
• Certified Tumor Registrars reabstracted the study
  variables, including AJCC clinical and pathologic
  staging elements.
• Current Presentation (3727 epithelial cancers
  - 3369 with complete stage and tx information)

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Methods - Linkages

• SES Indicators Derived from 2000 Census
• Working class 66 of population
• Under-educated 25 of adults with less than H.S.
• Poverty 20 of households with incomes below
  poverty level
• Co-morbidities (CA and NY only) Statewide
  Hospital Discharge Files
• ICD-9-CM codes - categorized based on Charlson
  Index
• Vital Status obtained from linkage to state vital
  statistics files and the National Death Index

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Software

• Abstract Plus was used for reabstraction.
  Registry Plus was also used for record
  consolidation. SAS version 9.1 was used for
  analysis.

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Overall Percentage of Women Receiving the
Standard of Care based on Grade and Stage
70.9 Objective Identify Factors Associated
with NOT Receiving the Standard Treatment
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Co-Variates Considered

• Age
• lt50
• 50-64
• 65-79
• 80
• Stage
• Ever treated by Gynocologic Oncologist
• Insurance Coverage
• Private
• Medicaid
• Medicare with Supplement
• Medicare
• No Insurance
• Charlson Index
• 0
• 1-4
• State of Residency

• Race_Ethnicity
• White, Non-Hispanic
• Black, Non-Hispanic
• Other, Non-Hispanic
• Hispanic
• Urban/Rural
• 100 Urban
• 100 Rural
• Any combination
• Poverty
• lt20 of block group
• 20 of block group
• Education
• lt25 less than high school
• 25 less than high school
• Working Class
• lt66 working class
• 66 working class

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Percent Standard
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Distribution of Surgical Procedures by Ever Being
Treated by a Gynecologic Oncologist
N3727
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Distribution of Chemotherapies by Ever Being
Treated by a Gynecologic Oncologist, for Women
with Stage gt1 or Grade gt2
N2816
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Percent
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Distribution of Chemotherapies by Age, for Women
with Stage gt1 or Grade gt2
N2816
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Percent Standard
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Distribution of Age Group and TNM Stage
Percent
Based on cases with known stage and treatment
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Percent Standard
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Percent Standard
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PERCENT SEEN BY GYNECOLOGIC ONCOLOGIST BY PAYER
Not necessarily seen first Statistically
significant
N3720
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Percent Standard
N2334
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Percent Standard
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Age at Dx by Race_Ethnicity
Percent
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Stage at Dx by Race_Ethnicity
Percent
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Distribution of Chemotherapies by Race and
Ethnicity, for Women with Stage gt1 or Grade gt2
N2816
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Percent Standard
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Percent Standard
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Percent Standard
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Reason Given for No ChemotherapyFor Women with
Stage 2-4 or Grade gt2
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SUMMARYFactors Associated with NOT Receiving the
Standard Care

• Medical
• Stage 2, 3, or 4
• Having Co-morbidity
• Socio-Demographic
• Age older than 64 at diagnosis especially 80 or
  older
• Black Race
• Living in a Census Block Group with Low Education
• Living in a 100 urban area
• Combination Medical and Socio-Demographic
• Not being treated by a Gynecologic Oncologist
• Not having Health Insurance

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Future Plans

• Analyze factors related to specific deviations
  from the standard treatment (e.g., type of
  chemotherapy and surgery)
• Introduce hospital-specific information for the
  subset of women for whom the information can be
  obtained
• Continue to link the study cases to death records
  for annual vital status updates to see any
  correlation between receiving the standard care
  and survival

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THIS IS A COLLABORATIVE PROJECT INVOLVING THE
FOLLOWING MEMBERS OF THE OCTPO STUDY GROUP

• California
• Katrina Bauer
• Rosemary Cress
• Barbara Noble
• Cynthia OMalley
• Maryland
• Stacey Neloms
• NPCR
• Sherri Stewart
• Jen Wike
• (Irene Hall)

• New York
• Beth Bernard
• Patricia Brooks
• Paul Buckley
• Mary Ellen Hanley
• Amy Kahn
• Suzanne Solghan
• Maria Schymura

This project was supported by cooperative
agreement U58/CCU220322 from the CDC
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THANK YOU
Amy Kahn ark02_at_health.state.ny.us
518-474-2255