K Stålberg

Preoperative and intraoperative assessment of myometrial invasion in endometrial cancer—A Swedish Gynecologic Cancer Group (SweGCG) study

AbstractIntroductionDeep myometrial invasion (≥50%) is a prognostic factor for lymph node metastases and decreased survival in endometrial cancer. There is no consensus regarding which pre/intraoperative diagnostic method should be preferred. Our aim was to explore the pattern of diagnostic methods for myometrial invasion assessment in Sweden and to evaluate differences among magnetic resonance imaging (MRI), transvaginal sonography, frozen section, and gross examination in clinical practice.Material and methodsThis is a nationwide historical cohort study; women with endometrial cancer with data on assessment of myometrial invasion and FIGO stage I‐III registered in the Swedish Quality Registry for Gynecologic Cancer (SQRGC) between 2017 and 2019 were eligible. Data on age, histology, FIGO stage, method, and results of myometrial invasion assessment, pathology results, and hospital level were collected from the SQRGC. The final assessment by the pathologist was considered the reference standard.ResultsIn the study population of 1401 women, 32% (n = 448) had myometrial invasion of 50% of more. The methods reported for myometrial invasion assessment were transvaginal sonography in 59%, MRI in 28%, gross examination in 8% and frozen section in 5% of cases. Only minor differences were found for age and FIGO stage when comparing methods applied for myometrial invasion assessment. The sensitivity, specificity, and accuracy to find myometrial invasion of 50% or more with transvaginal sonography were 65.6%, 80.3%, and 75.8%, for MRI they were 76.9%, 71.9%, and 73.8%, for gross examination they were 71.9%, 93.6%, and 87.3%, and for frozen section they were 90.0%, 92.7%, and 92.0%, respectively.ConclusionsIn Sweden, the assessment of deep myometrial invasion is most often performed with transvaginal sonography, but the sensitivity is lower than for the other diagnostic methods. In clinical practice, the accuracy is moderate for transvaginal sonography and MRI.

Impact of lymphadenectomy and lymphoedema on health‐related quality of life 1 year after surgery for endometrial cancer. A prospective longitudinal multicentre study

ObjectiveTo assess the impact of lymphadenectomy and lymphoedema of the lower limbs (LLL) on health‐related quality of life (HRQoL) 1 year after surgery for endometrial cancer (EC).DesignProspective longitudinal cohort multicentre study.SettingDepartments of obstetrics and gynaecology at four university hospitals, six central hospitals and four county hospitals in Sweden.PopulationTwo‐hundred‐and‐thirty‐five women with early stage EC were included; 116 with high‐risk EC underwent surgery including lymphadenectomy (+LA), and 119 with low‐risk EC had surgery without lymphadenectomy (−LA).MethodsThe generic SF‐36 and EQ‐5D‐3L and the lymphoedema‐specific LYMQOL questionnaire were used to assess HRQoL. LLL was assessed by systematic circumferential measurements of the legs enabling volume estimation, clinical evaluation and patient‐reported perception of leg swelling. All assessments were carried out on four occasions; preoperatively, and 4–6 weeks, 6 months and 1 year postoperatively.Main outcome measureHRQoL scores.ResultsNo significant differences were seen in HRQoL between the +LA and –LA groups 1 year postoperatively. Irrespective of method of determining LLL, women with LLL were significantly more affected in the LYMQOL domains Function, Appearance/body image and Physical symptoms, but not in the domain Emotion/mood, than women without LLL. No such differences were seen in the generic HRQoL or in the LYMQOL global score between the groups with and without LLL.ConclusionsLymphadenectomy did not seem to affect generic HRQoL adversely. Irrespective of the method of measuring, LLL affected the lymphoedema‐specific HRQoL negatively, mainly in physical domains, but had no impact on the generic HRQoL.Tweetable abstractLymphoedema has impact on lymphoedema‐specific, but not on generic, HRQoL, 1 year after surgery for EC.

Risk factors for lymph ascites after surgery for endometrial cancer and impact on lymphedema of the legs. A prospective longitudinal Swedish multicenter study

AbstractIntroductionThe primary aim was to determine the occurrence of lymph ascites 4–6 weeks after surgery for endometrial cancer. Secondary aims were to assess risk factors for lymph ascites and the association with lymphedema of the legs.Material and MethodsThis was a post hoc analysis of an observational prospective multicenter study, performed in 14 Swedish hospitals that included 235 women undergoing surgery for early‐stage endometrial cancer between June 2014 and January 2018; 116 underwent surgery including pelvic and para‐aortic lymphadenectomy and 119 had surgery without lymphadenectomy. Lymph ascites (free intraabdominal fluid or encapsulated pelvic or para‐aortic fluid) was assessed by vaginal ultrasound 4–6 weeks postoperatively. Lymphedema was assessed using circumferential measurements of the legs preoperatively and 1 year postoperatively, enabling estimation of leg volume. A BMI‐standardized leg volume increase ≥10% was classified as lymphedema. Evaluation of risk factors was performed using multiple logistic regression.ResultsLymph ascites 4‐6‐weeks postoperatively occurred in 28.5% (67/235) of the women. The estimated volume of the lymph ascites in these women was mean 28 mL (standard deviation 48 mL) and median 14 mL (interquartile range 2–36 mL). Lymphadenectomy was a risk factor for lymph ascites (aOR 9.97; 95% CI 4.53–21.97) whereas the use of minimally invasive surgery (aOR 0.50; 95% CI 0.25–0.99) reduced the risk. Twenty‐two of 231 women (9.5%) developed lymphedema of the legs 1 year after surgery. The presence of lymph ascites was predictive of lymphedema (aOR 3.90; 95% CI 1.52–9.96).ConclusionsLymph ascites was common 4–6 weeks after surgery but in a low and clinically insignificant volume. Lymphadenectomy was a strong risk factor for lymph ascites and the use of minimally invasive surgery seemed to reduce the risk. Detection of lymph ascites at early postoperative follow‐up may be a means of selecting patients at high risk of developing lymphedema after treatment with endometrial cancer for preventive measures against lymphedema progression.

Validation of data quality in the Swedish quality register of gynecologic cancer for cervical cancer and vulvar cancer—a Swedish gynecologic cancer group (Swe‐GCG) study

AbstractIntroductionPopulation‐based registers provide an important source of real‐world data. The growing number of large cohort studies using data from cancer registers makes validation of such registers important. The Swedish Quality Register of Gynecologic Cancer (SQRGC) is a nationwide population‐based register containing data on patient and tumor characteristics, treatment, and follow‐up. To ensure that the results from research and quality assurance reports using SQRGC data are robust and reliable, the accuracy and completeness of the register need to be validated. The aim of this study was to evaluate the quality of data on cervical cancer and vulvar cancer in the SQRGC.Material and MethodsQuality of data in the SQRGC was investigated by evaluating completeness, timeliness, comparability, and validity in accordance with recommendations from the International Agency for Research on Cancer and the national Swedish guidelines on validation of cancer registers. Completeness was evaluated by coverage relative to the Swedish National Cancer Register, and timeliness as the time from diagnosis until entry into the SQRGC. We randomly selected 276 women diagnosed with cervical cancer (n = 138) and vulvar cancer (n = 138) between 2014 and 2019 for validation. An external monitor manually re‐abstracted data on 10 core variables per sub‐register from the patients' medical records. Comparability was assessed by reviewing the adherence to international standards regarding coding. Validity was evaluated by the agreement between re‐abstracted data and original data in the SQRGC. Correlations were estimated using Pearson's correlation coefficient and Cohen's kappa coefficient.ResultsFor cervical cancer, the completeness was 99% and the timeliness was 87.1% within 12 months. The corresponding figures for vulvar cancer were 100% and 87.9%, respectively. Adherence to international coding standards was satisfactory. The median degree of agreement between re‐abstracted data and data in the SQRGC was 90.8% (range 73.2%–100%) for cervical cancer, and 85.4% (range 59.6%–98.2%) for vulvar cancer.ConclusionsThe data on cervical and vulvar cancer in the SQRGC are of adequate quality and may well be used for research and clinical purposes.

Parity is associated with better prognosis in ovarian germ cell tumors, but not in other ovarian cancer subtypes

AbstractOvarian cancer is influenced by reproductive factors, with a reduced risk of epithelial ovarian cancer in parous women. Nonepithelial ovarian cancer frequently affects young women and often precedes or occurs during the childbearing years. However, the impact of reproductive factors on ovarian cancer survival remains unclear: in epithelial ovarian cancer, data are conflicting, and subtype‐specific associations have not been examined, and in nonepithelial ovarian cancer, it has not been studied. Using Swedish registers, we evaluated associations between women's reproductive history and cancer‐specific mortality by subtype of epithelial and nonepithelial ovarian cancer in 3791 women born 1953 and later, diagnosed from 1990 to 2018. Hazard ratios (HRs) with 95% confidence intervals (95% CIs) were calculated using Cox‐proportional hazard models. Parity was associated with a 78% decreased risk of cause‐specific mortality in 243 women with germ cell tumors (GCTs) (parous vs nulliparous, adjusted for age at diagnosis: HR: 0.22 [95% CI 0.07‐0.62]), with a decreased risk with increasing number of births (per birth: HR: 0.60 [95% CI 0.38‐0.95]). We found no evidence of associations between parity and cause‐specific mortality among the 334 patients with sex‐cord stromal tumors, nor among the 3214 patients with epithelial ovarian cancer; neither overall, nor by subtype. In conclusion, in our large, population‐based study, parity was associated with a clearly better prognosis in GCTs but not in the other ovarian cancer subtypes. Future research on how hormone exposure impacts GCT development may lead to a better understanding of mechanisms affecting survival.

Advanced gynecological cancer: Quality of life one year after diagnosis

Objective Gynaecological cancer treatment impacts women’s physical and psychological health. Our objective was to examine quality of life (QoL) in women with advanced gynaecological cancer at diagnosis and one year later, and to identify sociodemographic and clinical characteristics associated with QoL. Methods Women with endometrial, ovarian or cervical cancer treated in Uppsala, Sweden 2012–2019 were included. FIGO stage ≥II was considered advanced gynaecological cancer, whereas women in FIGO stage I were used as a control group. QoL was assessed with SF-36. We obtained information on sociodemographic and clinical characteristics from medical records and health questionnaires. Differences in QoL domains were tested with t-tests, a mixed model ANOVA and multiple linear regression analyses. Results The study population (n = 372) included 150 (40.3%) women with advanced gynaecological cancer. At diagnosis, women with advanced cancer reported lower physical (71.6 vs 81.8 (mean) p<0.05) and role functioning/physical scores (62.6 vs 77.2 (mean) p<0.05) than women in FIGO stage I. One year later, women with advanced cancer reported higher scores in the mental health domain (78.3 vs 73.2 (mean) p<0.05) than women in FIGO stage I. However, no difference was found in the QoL scores of women with advanced disease one year after diagnoses when stratified by diagnosis. Women with a history of psychiatric illness and higher BMI reported poorer physical and mental QoL at follow-up, while advanced stage, level of education and smoking were not associated with QoL. Conclusion Women with advanced gynaecological cancer have equally good QoL one year after diagnosis as women with limited disease. Women with previous psychiatric illness and high BMI, are at risk of impaired physical and mental health.

Polycystic ovary syndrome and the risk of ovarian tumours.

To explore the risk of ovarian cancer (OC) and its subtypes among women with PCOS. This is a retrospective cohort study with a follow-up of 25 years. The study included 479,759 participants, of which 80,131 were diagnosed with PCOS and 399,628 were matched controls (1:5 ratio). The data were obtained from Swedish registers, primarily the National Patient Registry and the Swedish National Cancer Registry. We used Cox regression to calculate hazard ratios, both crude and adjusted, and 95 % confidence intervals (95 % CI). During the study period, 450 individuals were diagnosed with OC or borderline tumour of the ovary (BOT). Following adjustment for obesity, country of birth and education, women with PCOS did not have an increased risk of epithelial ovarian cancer (EOC), aHR: 1.00 (95 % CI 0.64-1.55). However, the risks of developing BOT and non-EOC were higher in women with PCOS, aHR: 1.61 (95 % CI 1.16-2.23) and aHR: 4.26 (95 % CI 2.50-7.03), respectively. When further subgrouping non-EOC, stromal tumours stood out with a seventh-fold increased risk among women with PCOS. Women with PCOS are at higher risk of developing non-EOC and BOT than women without PCOS. Although the risk estimate is high, non-EOC is a rare diagnosis. Thus, the findings of this study may provide insights into the underlying mechanisms of PCOS and ovarian cancer, primarily non-EOC. However, they do not indicate any necessity for screening or alterations in the follow-up of women with PCOS.