Chelsea Anderson

Fertility preservation and in vitro fertilization (IVF) success rates after cancer

Abstract Background Evidence of the success of in vitro fertilization (IVF) procedures is critical for informed decision making before and after cancer treatment. We compared IVF outcomes between women with and without cancer. Methods Using data from a national IVF database—the Society for Assisted Reproductive Clinic Outcomes Reporting System, linked to statewide cancer registries and birth certificates in 9 states—we identified women who initiated IVF after a cancer diagnosis. Fertility preservation was defined as oocyte retrieval ≤90 days after cancer diagnosis, and IVF after cancer treatment as retrieval >90 days postdiagnosis. Number of oocytes retrieved and conception and livebirth rates were compared between these groups and a comparison group of women without cancer in couples with male factor infertility only. Results Compared with retrievals for male factor infertility only (n = 81 370), the number of oocytes retrieved was not significantly different for women who underwent retrieval for fertility preservation (n = 2941) but was significantly lower for women who underwent retrievals after cancer treatment (n = 2479) (mean difference = −2.99, 95% confidence interval [CI] = −3.40 to 2.59). Rate of conception as a function of transfer attempts and likelihood of livebirth after conception also did not significantly differ for fertility preservation (n = 291) compared with male factor infertility only (n = 34 410). Women with IVF after cancer treatment (n = 672) had a lower rate of conception (hazard ratio = 0.70, 95% CI = 0.61 to 0.79) but a similar overall likelihood of a livebirth after conception, relative to the group with male factor infertility only. Conclusion IVF outcomes may be maximized when ovarian retrieval is initiated before cancer treatment.

Claims-Based Measures of Care Coordination and Long-Term Health Among Older Women With Endometrial Cancer

Background: Coordination of care between providers may help ensure that cancer survivors receive the appropriate health care services to improve their long-term health. We examined associations between a claims-based measure of care coordination and several health outcomes among older endometrial cancer survivors. Methods: Using SEER-Medicare data, we identified women with endometrial cancer at ages 66+ during 2009–2015 (N=13,696). Medicare claims during years 1–3 postdiagnosis were used to calculate care density, a measure of care coordination, as the ratio of the number of patients shared among a woman’s outpatient providers to the number of provider pairs seen by that patient. We estimated associations between care density tertile and hospitalizations, emergency room (ER) visits, and all-cause mortality from 3 years postdiagnosis on, and adherence to guideline-recommended follow-up during years 3–5 postdiagnosis. Results: No clear trends were observed for risk of all-cause mortality, hospitalizations or ER visits according to care density category. However, for hospitalizations (HR=0.93; 95% CI: 0.87–0.99) and ER visits (HR=0.93; 95% CI: 0.88–0.98), there was a slightly lower risk in the highest care density tertile compared with the lowest. Women in the middle (OR=1.67; 95% CI: 1.40–2.00) and highest care density tertiles (OR=1.63; 95% CI: 1.36–1.96) were more likely to be adherent to follow-up recommendations than those in the lowest tertile. Conclusions: Greater care coordination during the early survivorship period may be associated with a slightly lower risk of hospitalization and ER visits and better adherence to surveillance recommendations after endometrial cancer.

Adverse Urinary System Diagnoses among Older Women with Endometrial Cancer

Abstract Background: Endometrial cancer and its treatment may impact urinary system function, but few large-scale studies have examined urinary diagnoses among endometrial cancer survivors. We investigated the risk of several urinary outcomes among older women with endometrial cancer compared with similar women without a cancer history. Methods: Women aged 66+ years with an endometrial cancer diagnosis during 2004–2017 (N = 44,386) and women without a cancer history (N = 221,219) matched 1:5 on exact age, race/ethnicity, and state were identified in the Surveillance, Epidemiology, and End Results-Medicare linked data. ICD-9 and -10 diagnosis codes were used to define urinary outcomes in the Medicare claims. HRs for urinary outcomes were estimated using multivariable Cox proportional hazards regression models. Results: Relative to women without cancer, endometrial cancer survivors were at an increased risk of several urinary system diagnoses, including lower urinary tract infection [HR, 2.36; 95% confidence interval (CI), 2.32–2.40], urinary calculus (HR, 2.22; 95% CI, 2.13–2.31), renal failure (HR, 2.28; 95% CI, 2.23–2.33), and chronic kidney disease (HR, 1.85; 95% CI, 1.81–1.90). Similar associations were observed in sensitivity analyses limited to 1+ and 5+ years after endometrial cancer diagnosis. Black race, higher comorbidity index, higher stage or grade cancer, non-endometrioid histology, and treatment with chemotherapy and/or radiation were often significant predictors of urinary outcomes among endometrial cancer survivors. Conclusions: Our results suggest that, among older women, the risk of urinary outcomes is elevated after endometrial cancer. Impact: Monitoring for urinary diseases may be a critical part of long-term survivorship care for older women with an endometrial cancer history.

Falls, walking or balance problems, and limitations in activities of daily living (ADLs) among older endometrial cancer survivors

Functional status deficits are important quality of life concerns for older cancer survivors. We examined the prevalence of falls, walking/balance problems, and limitations in activities of daily living (ADLs) among older women with a history of endometrial cancer. Cancer registry records from the Surveillance, Epidemiology, and End Results (SEER) program linked with Medicare Health Outcomes Survey (MHOS) data were used to identify endometrial cancer survivors aged ≥ 65 years who completed a survey ≥ 1 year after their cancer diagnosis (N = 3766), as well as an age- and race-matched group of women without a cancer history (N = 3766). We estimated prevalence ratios (PRs) to compare the prevalence of falls, walking or balance problems, and limitations in ADLs (bathing, dressing, eating, getting in/out of chairs, walking, using the toilet) between groups. Difficulty with walking or balance was more common among survivors than the noncancer group (43% vs 36%; PR = 1.19; 95% CI: 1.10-1.27). Fall prevalence was similar between groups (endometrial cancer: 25%; noncancer: 26%; PR = 0.98; 95% CI: 0.89-1.08). Nearly half of endometrial cancer survivors (47%) reported at least one ADL limitation, with several activities (getting in/out of a chair, walking, bathing, using the toilet) more often limited among survivors than among women without cancer. Functional impairments, especially problems with walking and/or balance, are common among older endometrial cancer survivors. Our results highlight the importance of addressing functional problems during the ongoing survivorship care of women with a history of endometrial cancer, with referral to rehabilitation or other relevant services when indicated.

Long-term Patterns of Excess Mortality among Endometrial Cancer Survivors

Abstract Background: We investigated excess mortality after endometrial cancer using conditional relative survival estimates and standardized mortality ratios (SMR). Methods: Women diagnosed with endometrial cancer during 2000–2017 (N = 183,153) were identified in the Surveillance Epidemiology and End Results database. SMRs were calculated as observed deaths among endometrial cancer survivors over expected deaths among demographically similar women in the general U.S. population. Five-year relative survival was estimated at diagnosis and each additional year survived up to 12 years post-diagnosis, conditional on survival up to that year. Results: For the full cohort, 5-year relative survival was 87.7%, 96.2%, and 97.1% at 1, 5, and 10 years post-diagnosis, respectively. Conditional 5-year relative survival first exceeded 95%, reflecting minimal excess mortality compared with the general population, at 4 years post-diagnosis overall. However, in subgroup analyses, conditional relative survival remained lower for Black women (vs. White) and for those with regional/distant stage disease (vs. localized) throughout the study period. The overall SMR for all-cause mortality decreased from 5.90 [95% confidence interval (CI), 5.81–5.99] in the first year after diagnosis to 1.16 (95% CI, 1.13–1.19) at 10+ years; SMRs were consistently higher for non-White women and for those with higher stage or grade disease. Conclusions: Overall, endometrial cancer survivors had only a small survival deficit beyond 4 years post-diagnosis. However, excess mortality was greater in magnitude and persisted longer into survivorship for Black women and for those with more advanced disease. Impact: Strategies to mitigate disparities in mortality after endometrial cancer will be needed as the number of survivors continues to increase.