|Year : 2018 | Volume
| Issue : 2 | Page : 37-41
Epidemiology of ovarian tumours in Northern India - A tertiary hospital based study
Sonia Puri1, Veenal Chadha2, AK Pandey3
1 Assistant Professor, Dept Of Community Medicine GMCH-32, Chandigarh, India
2 Demonstrator, Dept Of Community Medicine GMCH-32, Chandigarh, India
3 Prof and Head, Dept Of Community Medicine GMCH-32, Chandigarh, India
|Date of Submission||20-Oct-2018|
|Date of Acceptance||31-Dec-2018|
|Date of Web Publication||4-Feb-2019|
Assistant Professor, Deptt Of Community Medicine GMCH-32, Chandigarh
Source of Support: None, Conflict of Interest: None
Introduction: Ovarian cancer is the leading cause of mortality of female gynaecological cancers and ranks seventh as the most common cancer worldwide. The increasing life expectancy has led to increase in its burden exponentially now even in developing countries but limited knowledge is there about the pattern of ovarian tumours. Objective: To determine the burden and describe the pattern of ovarian tumours in patients visiting GMCH. Material and methods: This epidemiological study is retrospective, descriptive hospital based study over five years. The data so collected was analysed using SPSS software. Results: Maximum number i.e 74(24.4%) of cases were in the age group of 50 to 59 years followed by 40 to 49 years. It is also seen that maximum number of cases i.e total of 65 registries were in the year 2013. Maximum number of cases were from the state of Haryana contributing to nearly 41% of total cases. Most of the cases could not be classified into four stages i.e they were categorized as unknown. Chemotherapy is the most commonly used treatment modality. Epithelial adenocarcinoma was the commonest histology subtype. Conclusion: Research should be aimed to find tools for screening and early diagnosis so that better therapeutic approaches can be designed to decrease the burden.
Keywords: Ovarian cancer, Chemotherapy, Epidemiology
|How to cite this article:|
Puri S, Chadha V, Pandey A K. Epidemiology of ovarian tumours in Northern India - A tertiary hospital based study. Indian J Community Fam Med 2018;4:37-41
|How to cite this URL:|
Puri S, Chadha V, Pandey A K. Epidemiology of ovarian tumours in Northern India - A tertiary hospital based study. Indian J Community Fam Med [serial online] 2018 [cited 2019 Aug 20];4:37-41. Available from: http://www.ijcfm.org/text.asp?2018/4/2/37/251437
| Introduction|| |
Ovarian cancer is the seventh most common cancer worldwide (Age standardized mortality rate being 4.0/100,000). In USA, it accounts for just 2.5% of all female cancer cases, but leads to 5% of cancer deaths. This explains the low survival of the disease. In India, too female cancer cases, especially ovarian cancer figures are escalating. India shows dangerous data of having 3rd highest number of cancer cases among women after China and USA. Infact, India has the 2nd highest incidence of ovarian cancer globally. The increase in longevity has led to an increase in its incidence that accounts for the fact that 90% of cases of it are seen in postmenopausal age group i.e 55-64 years. However, these figures are just the tip of the iceberg, as they depict the registered cases only. And many cases are usually underdiagnosed and unreported. The World Health Organization histological classification ovarian tumors separate ovarian neoplasms according to the most probable tissue of origin; surface epithelial (65%), germ cell (15%), sex cord-stromal (10%), metastasis (5%), miscellaneous. Surface epithelial tumors are further classified by cell type (serous, mucinous, endometroid etc) and atypia (benign, borderline [ atypical proliferation, low malignant potential ] or malignant; malignant may be invasive or non-invasive) most malignant tumors are surface epithelial (90%).
Though risk factors are evident but most ovarian cancer patients (60%) are diagnosed with distant-stage disease, for which 5-year survival is just 29%. The major risk factor is the family history. Studies corroborate that risk of ovarian cancer is increased by about fourfold among women with a first-degree relative with a history of the disease and by about twofold for those with an affected second-degree relative. Approximately 20% of ovarian cancer cases, particularly high-grade serous tumors, are estimated to be due to inherited mutations that confer elevated risk, the majority from BRCA1 and BRCA2.
The International Agency for Research on Cancer recently also concluded that excess body weight modestly increases the risk of developing epithelial ovarian cancer. Height is associated with elevated risk by about 7% for each additional 5 centimeters of adult height. This may be related to genetic and environmental factors including growth hormone exposure during early life. Cigarette smoking increases risk of mucinous ovarian cancer by about 80% Physical inactivity is associated with about a 30% higher risk of epithelial ovarian cancer.,, The International Agency for Research on Cancer has found that perineal use of talc-based body powder increases the risk of ovarian cancer but evidence is limited.
The hindrances for not diagnosing this tumor early are late presentation and ineffective screening modalities. The screening tests related to estimation of Ca-125 and TVS are nonspecific. Hence the disease is diagnosed in late stage with more chances of high mortality. These characteristics make this tumor a public health issue. Hence an understanding of epidemiologic factors is important for managing this menace. The present study is an effort to learn the burden, pattern and characteristics of ovarian carcinoma.
| Material and methods|| |
The present hospital based epidemiological study was carried out in a Government Tertiary Care Hospital of India.
Sample size: All the patients suspected of suffering from ovarian cancer, who were registered in hospital based cancer registry of GMCH in the study time period were enrolled.
Time Period: Four years (2011-2015)
Study type: Retrospective Descriptive Hospital Based Study.
All the patients so registered in GMCH were screened in different departments for their ailment and those found suspected of suffering from symptoms of cancer were sent for diagnostics to pathology department. After being diagnosed for any benign or malignant cancer, patients were referred to Radiotherapy department for treatment and further management. And those suffering from ovarian tumour were further sent to gynaecology (cervical, ovarian, uterine) department for management. The histology pattern report of these patients was collected from pathology department. The patients with ovarian tumours comprised our study sample. As per WHO standardized guidelines on patient information for Hospital based cancer registry, detailed information was taken. Information on sociodemographic profile, medical history, family history and previous treatment, if any, was obtained from the patient. But if the patient couldn’t be contacted then information was retrieved from pathology, radiotherapy or medical records department of the hospital.
Ethical consideration: Subjects were explained the purpose of study and those who gave consent to participate in the study were interviewed to collect the desired information on the WHO (World Health Organization) designed cancer information leaflet. In case of respondents below 18 years of age, consent was taken from parents. Confidentiality of responses was assured as per Ethical guidelines of Helsinki.
Statistical analysis: The data was collected, compiled and analyzed using percentages, mean and median using SPSS.
| Results|| |
There were 7177 total malignancies from the year 2011 to 2015. Out of the total, 3370 and 3870 males and females respectively suffered from cancer. There were 1174 gynaecological malignancies encompassing 304 ovarian and 870 cervical along with endometroid carcinoma during the four year period.
[Table 1] shows age group wise distribution of ovarian cancer patients from the year 2011 to 2015. Maximum number i.e 74 (24.4%) of cases were in the age group of 50 to 59 years followed by 40 to 49 years 73(24.0%). It is also seen that maximum number of cases i.e total of 65 registries were in the year 2013. This table also shows state wise distribution of ovarian cancer patients from the year 2011 to 2015. Maximum number of cases were from the state of Haryana 123(40.5%). Also there was increase in the number of cases with every passing year. Second highest number of cases were from Punjab 97(31.9%) followed by Union territory (UT) Chandigarh36(11.8%). Least number of ovarian cancer cases were from the states of Madhya Pradesh and Delhi.
|Table 1: Age and Statewise distribution of ovarian cancer cases from 2011-2015|
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[Table 2] shows stage wise distribution of ovarian cancer patients from the year 2011 to 2015 as per hospital based cancer registry data at GMCH, Chandigarh. FIGO stage of ovarian malignancy, histopathological type and management were studied. Most of the cases could not be classified into four stages hence were categorized as unknown 120(39.5%). Second most common stage of this cancer was Stage III 74 (24.3 %). Among the treatment modalities chemotherapy was the most commonly used 156(51.3%). Only few patients were put to surgical treatment and surgical treatment along with chemotherapy 3(0.9%). Epithelial adenocarcinoma was commonest histology subtype and was seen in 135 cases (44.4%) followed by others 97 (31.9%), serous carcinoma 49 (16.1%), mucinous carcinoma 18(5.9%) and clear cell carcinoma 5 (1.6%). Patient’s mean age at diagnosis of ovarian malignancy was 52.1±8.96 years (median=52 years). The mean age at diagnosis for Stage I was 44.51 years (median=47 years), for Stage II 52.36 years (median= 52.5 years), 51.09 years (median=51 years) for Stage III, and 48.72 years (median=50 years) for Stage IV.
|Table 2: Stage and treatment wise distribution of ovarian cancer cases from 2011-2015|
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| Discussion|| |
In our study, the proportion of ovarian malignancy cases was 26% of all gynaecological malignancies during four year period. The proportion of epithelial ovarian carcinoma (EOC) among all ovarian cancer types comprised 44%. Se Ik Kim et al reported histologic subtype in 90% cases as EOC. Basu et al reported 80% EOC among all ovarian malignancies while in study by Yogambal et al epithelial tumors were seen in 71.6% cases., Mondal et al reported EOC in 60.9% cases.
In our study in almost all the years similar number of cases were found to be reported. This was in contrast to various studies in that reported increasing trends in ovarian cancer over the years.,,, Murthy et al reported mean annual percent increase of ovarian cancer in India ranging from 0.7-2.4% in different age groups. This increasing trend may reflect increased exposure to risk factors or due to increased awareness and increase in proportion of elderly women.
Age has a strong corelation to ovarian cancer risk and 80% cases are diagnosed after 50 years of age. Advancing age increased the possibility of malignant transformation. Murthi et al reported that the disease increases from 35 years of age and reaches a peak between the ages 55-64 years. In their study, the mean age at diagnosis reported varied between 52.2 to 59.5 years. Saini et al in their study reported median age as 55years with mean age of 55.98±9.24 years. Basu et al reported mean age as 48.8±11.2 years. Another study in India by Mondal et al reported median age of 48 years at diagnosis and maximum incidence of 44.3% in age group of 41-50 years. Doufekas K reported mean age at diagnosis to be 63 years in UK. An epidemiologic risk prediction model By K li reported median age of EOC in various countries as 52.4 years. In our study too the mean age at diagnosis was 52.1±8.96 years (median=52). It was also found that the mean age increased in relation to stage of EOC at diagnosis from 44±9.53 years in stage1 to 55.35±9.74 years in stage IV. Similar findings were evident in a study by Saini et al with mean age of 52.67±8.04 in stage1 to 58.30±8.48 years in stage 4.
In a limited resource setting, ovarian malignancy screening program may be restricted to age group above 45 years, being at high risk. The disease is diagnosed in late stages as there is delay between onset of symptoms and diagnosis. Doufekas and Olaitan reported that 60% cases were diagnosed in stage III and IV. In our study, 24% patients were in stage III and 20% were in stage IV. In study by Saini et al 20.8% cases were in stage II, 47.85% in stage III and 16.56% in stage IV. Mondal et al also reported 20% cases in stage II and 60% in stage III while Basu et al reported 80% patients in stage III/IV at diagnosis.,,
Determination of histology pattern is useful in diagnosis, treatment and prognosis in EOC., Endometroid carcinoma is identified at early stage and being chemosensitive is associated with better prognosis. Clear cell carcinoma when identified at early stage has good prognosis but in later stage has worse prognosis in comparison to serous carcinoma as it is less sensitive to platinum based chemotherapy. There is increase in clear cell carcinoma which is related to increased incidence of endometriosis while mucinous carcinoma is related to cigarette smoking. Doufekas K et al reported serous subtype in one third cases. Its malignant potential is highest, spread is faster but response to chemotherapy is good. In our study 16.1% cases were serous carcinoma. Histopathological grading is also related to patient survival. Basu et al reported tumors to be well differentiated in 27%, moderately differentiated in 48% and poor differentiation in 25% cases while in our study only 7% were well differentiated, 42% had moderate differentiation and 51% poor differentiation.
The standard management of ovarian tumor consists of surgical staging with optimal cytoreduction followed by a platinum based chemotherapy as per stage of tumor. In present study, 1.3% patients were treated with surgery i.e. Total Abdominal Hysterectomy (TAH) with Bilateral Salpingo Oophrectomy (BSO) with infracolic omentectomy, followed by chemotherapy. 20% patients were given Neo adjuvant chemotherapy (NACT), surgery and postoperative chemotherapy. 51% cases received palliative chemotherapy. There is improvement in survival rates in early stage disease due to advancement in chemotherapy and surgery but unfortunately majority of the patients report in late stage. According to Basu et al optimal debulking could be done in only 20.3% cases due to advanced disease stage. Stage IV patients were not treated with surgery in his study.
| Conclusion and Recommendations|| |
Epithelial ovarian cancer has emerged as one of the commonest malignancy affecting women in India. A steady increase has been observed in the incidence of ovarian cancer in several registries. EOC is disease of fifth decade and above age group. Its diagnosis is done in advanced stage with poor survival. Efforts should be made to detect the disease at early stage through population education with respect to epidemiological factors. Currently, a major goal of ovarian cancer research is to develop an effective test that can detect the disease at its earliest stages, which would ultimately result in decreased mortality. Increased knowledge of ovarian cancer etiology and pathogenesis would greatly enhance the development of this tool.
Another approach that can improve diagnosis of epithelial ovarian cancer is to educate primary care physician about ovarian cancer and to include it in differential diagnosis in the specific patient population. Further studies are needed to elicit the causative factors responsible for the increase in the incidence of the disease and also their mechanism of action. Most ovarian cancers are environmental in origin and therefore in principle preventable. It is suggested that in low resource settings like India, an epidemiological study should be done to find effect of screening programs using relatively easy available imaging modality (USG) on diagnosis in ovarian cancer risk age group patients with vague gastric symptoms. Research should be aimed to find tools for screening and early diagnosis so that better therapeutic approaches can be designed to decrease the burden.
Source of Funding: Nil
Conflict of Interest : Nil
| References|| |
SEER*Stat Database: NAACCR Incidence Data - CiNA AnalyticFile, 1995-2014, for Expanded Races, Custom File With County, ACS Facts and Figures projection Project December 2016.
Howlader N, Noone AM, Krapcho M, Miller D, Bishop K, Kosary CL. SEER Cancer Statistics Review, 1975-2014, National Cancer Institute. Bethesda, MD. Available from https://seer.cancer.gov/csr/1975_2014.
[Last accessed on May 3,2018]
Whittemore AS, Harris R, Itnyre J. Characteristics relating to ovarian cancer risk: studies. II. Invasive epithelial ovarian cancers in white women. Collaborative Ovarian Cancer Group. Am J Epidemiol. 1992;136: 1184-1203.
Collaborative Group on Epidemiological Studies of OvarianCancer, Beral V, Gaitskell K, et al.
Ovarian cancer and smoking:individual participant meta-analysis including 28,114 women with ovarian cancer from 51 epidemiological studies. Lancet Oncol.2012;13: 946-956.
Crane TE, Khulpateea BR, Alberts DS, Basen-Engquist K, Thomson CA. Dietary intake and ovarian cancer risk: a systematic review. Cancer Epidemiol Biomarkers Prev. 2014;23: 255-273.
Cannioto R, LaMonte MJ, Risch HA, et al.
Chronic recreational physical inactivity and epithelial ovarian cancer risk: evidence from the Ovarian Cancer Association Consortium. Cancer Epidemiol Biomarkers Prev. 2016;25: 1114-1124.
Houghton SC, Reeves KW, Hankinson SE, et al.
Perineal powder use and risk of ovarian cancer. J Natl Cancer Inst. 2014;106.
Kim SI, Lim MC, Lim J, Won YJ, Soo S, Kang SS, et al.
Incidence of epithelial ovarian cancer according tohistologic subtypes in Korea. 1999 to 2012. J Gynecol Oncol. 2016;27(1):5.
Basu P, De P, Mandal S, Ray K, Biswas J. Study of ‘patterns of care’ of ovarian cancer patients in a specialized cancer institute in Kolkata, eastern India. Indian J Cancer. 2009;46:28-33.
Yogambal M, Arunalatha P, Chandramouleeswari K, Palaniappan V. Ovarian tumours-Incidence anddistribution in a tertiary referral center in south India.IOSR. 2014;13(2):74-80.
Mondal SK, Banyopadhyay R, Nag DR, Roychowdhury S, Mondal PK, Sinha SK. Histologic pattern, bilaterality and clinical evaluation of 957ovarian neoplasms: A 10-year study in a tertiary hospital of eastern India. J Can Res Ther. 2011;7:4337.
Murthy NS, Shalini S, Suman G, Pruthvish S, MathewA. Changing Trends in Incidence of Ovarian Cancer the Indian Scenario. Asian Pacific J Cancer Prev2009;10:1025-30.
Doufekas K, Olaitan A. Clinical epidemiology ofepithelial ovarian cancer in the UK. InternationalJournal of Women’s Health 2014:6 537-45.
Li K, Husing A, Fortner R, Tj0nneland A, Hansen L, Dossus L, et al.
An epidemiologic risk prediction model for ovarian cancer in Europe: the EPIC study. British J Cancer. 2015;112:1257-65.
McLemore M R, Miaskowski C, Bradley E. Chen L M, Dodd M J. Epidemiologic and Genetic Factors Associatedwith Ovarian Cancer Cancer Nurs. 2009; 32(4):28190.
Saini SK, Shrivastava S, Singh Y, Dixit AK, Prasad SN. Epidemiology of epithelial ovarian cancer, a single institution based study in India. Clin Cancer Investig J. 2016;5:20-4.
[Table 1], [Table 2]