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BRIEF RESEARCH ARTICLE
Year : 2017  |  Volume : 61  |  Issue : 1  |  Page : 43-46  

Factors associated with survival and lost to follow-up of cervical cancer patients in a tertiary cancer centre in rural Kerala


1 Lecturer in Biostatistics, Department of Cancer Registry and Epidemiology, Malabar Cancer Centre, Thalassery, Kerala, India
2 HOD Department of Cancer Registry and Epidemiology, Malabar Cancer Centre, Thalassery, Kerala, India
3 Director, Malabar Cancer Centre, Thalassery, Kerala, India

Date of Web Publication16-Feb-2017

Correspondence Address:
T Bindu
Department of Cancer Registry and Epidemiology, Malabar Cancer Centre, Moozhikkara (P.O.), Thalassery, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-557X.200254

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   Abstract 

Cancer cervix is the second common cause of cancer death in India. It is the most curable form of any human cancer if detected at the precancerous stage. Although several factors determine the survival of the disease, the clinical stage at presentation is the single most important predictor of long-term survival. The present study aimed to describe the performance and follow-up status and 5-year survival experience of the cervical cancer patients registered between 2010 and 2011 by the hospital registry of Malabar Cancer Centre, Kerala, and factors affecting lost to follow-up and survival among them. The case sheets of 227 patients retrospectively scrutinized during May–July 2014. The mean age of patients was 58.8 years (standard deviation = 11.67 years). The majority of the patients completed the initially planned treatment, but a low proportion of patients were likely to be on regular follow-up. This study revealed that most of the patients registered at the hospital only at an advanced stage. Using Kaplan–Meier method, the estimated 5 years survival rate was found to be 66.8%. It was noted that performance status before treatment and Federation of Gynecology and Obstetrics staging were significantly associated with lost to follow-up and survival rate majority of the cervical cancer patients are observed to be highly noncomplaint to complete treatment and on follow-up. Thus, these findings stress the importance of counseling family members regarding the importance of follow-up and formulating public health policies aimed at increasing the awareness and implementation of cervical cancer screening programs in North Malabar.

Keywords: Cervical cancer, lost to follow-up, risk factors, survival rate


How to cite this article:
Bindu T, Kumar SS, Ratheesan K, Balasubramanian S. Factors associated with survival and lost to follow-up of cervical cancer patients in a tertiary cancer centre in rural Kerala. Indian J Public Health 2017;61:43-6

How to cite this URL:
Bindu T, Kumar SS, Ratheesan K, Balasubramanian S. Factors associated with survival and lost to follow-up of cervical cancer patients in a tertiary cancer centre in rural Kerala. Indian J Public Health [serial online] 2017 [cited 2017 Mar 24];61:43-6. Available from: http://www.ijph.in/text.asp?2017/61/1/43/200254

Cancer of the cervix uteri is the third most common cancer among women worldwide, with an estimated 83,195 new cases and 35,673 deaths in 2012.[1] In 2013, more than 12,000 women in the United States were diagnosed with invasive cervical cancer and most of them were younger than 55.[2] Cervical cancer is not only the most common cancer among women in many developing countries but the most common cause of cancer death as well.[3] It is perhaps the most curable form of any human cancer if detected at the precancerous stage.[4] It was reported that 67,477 new cervical cancer deaths occur annually in India, with the same ranking second in the country and its women aged 15–44 years.[5] It was reported that Underweight patients (body mass index [BMI] <18.5 kg/m 2) with locally advanced cervical cancer had diminished overall survival and more complications than normal-weight and obese patients.[6],[7] The chances of developing cervical cancer who had a family history are 2–3 times higher than who had no family history of carcinoma.[8] WHO/ICO information center 2010, estimated that number of new cervical cancer cases and deaths to increase by the year 2025-203,757 and 115,171 respectively.[9] However, the clinical stage of the disease at presentation is the single most important predictor of long-term survival.[10] It is also reported that recurrence after treatment beyond 5 years are extremely rare and hence 5-year survival is a good indicator of a cure and when treated appropriately, 5-year survival exceeds 80% for patients with stage I disease, exceeds 70% for patients with stage II A disease, while it is approximately 40%–50% for patients with stage IIB and stage III disease and < 10% in those with stage IV disease.[11],[12] It has been reported that late stage at diagnosis is correlated with lower survival rates in cervical cancer patients.[13] In the hospital-based cancer registries, cervix is the leading site of cancer in Bengaluru and Chennai, followed by Mumbai and Trivandrum.[13] The present study aimed to describe the performance status, follow-up status, and 5 years survival experience of the cervical cancer patients registered during 2010 and 2011 by the hospital registry of Malabar Cancer Centre, Kerala and factors affecting lost to follow-up and survival among them.

The data of cervical cancer patients registered between 2010 and 2011 were retrospectively collected for this study which was conducted during May–July 2014. In this study, the demographic and diagnostic details, clinical stage and treatment, follow-up details and the current status of patients were considered. The sociodemographic variables included age, marital status, education, number of children and BMI. The variables in relation to clinical stage and treatment were clinical extent of disease classified according to Federation of Gynecology and Obstetrics (FIGO) system (stage I, stage II, stage III, stage IV, and unknown) performance status (WHO) before treatment classified as active, not active and bedridden (WHO performance status 4). The patients who completed the prescribed initial treatment was termed as “completed initial planned treatment” and the patients who did not complete were included in the category “drop out.” The follow-up status was categorized as “lost to follow up” and the “regular follow up.” Among those with completed initial treatment who did not come for follow up was termed as “lost to follow up” and who were in regular follow up were considered as “regular follow up.” The follow-up information and current status of the patients for this study were obtained by scrutinizing the case records and contacting them through telephone interview to those for whom only incomplete information was available in the case records. This study was approved by the Institutional Scientific Review committee after declaring there are no ethical issues.

Chi-square test at 5% significance is used to find out the association, Kaplan–Meier method and the log-rank test were used to compare the survival rates. Statistical software IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp. was used for statistical analysis.

During the year 2010 and 2011, a total of 227 cervical cancer patients registered at MCC. Patients' age ranged from 32 to 99 years while maximum number of patients were in the age group 45–49 years. Among the patients, only 32.6% had normal BMI (18.5–24.9) while 67% of them had more than 2 children. According to FIGO staging, 6.2% of patients had stage I, 46.7% had stage II, 14.1% had stage III, and 22% had stage IV. Staging information was not available for 10.57% of patients. The 78% of the patients had performance status before treatment as Active. Among the 227 cervical cancer patients 216 (95.2%) of the patients completed the initial planned treatment and among them only 30.4% had regular follow up while the rest 69.6% were lost to follow-up.

The Chi-square test at 5% significance level revealed that there was a significant relation between age group and lost to follow-up (P = 0.04). The performance status (P = 0.0001) and staging (P = 0.0001) at the time of registration were also associated with lost to follow-up. Poorer performance status of the patients before treatment increased the loss to follow-up. Patients in advanced stages such as stage III and stage IV were more likely to be lost to follow-up when compared to patients with early stage [Table 1].
Table 1: Factors related to lost to follow-up for study subjects who completed the initial planned treatment (n=216)

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The overall estimated survival rate was 66.8% [Figure 1]. The observed survival rates were significantly related to the factors such as performance status before treatment (P = 0.0001) and FIGO staging at the time of registration (P = 0.0001) [Table 2]. When the patient registered in an early stage, the 5-year survival rate was found to be 92.1% but when the patients registered in the advanced stage the survival rate was decreased to 28.1%. Similarly, the performance status at registration also had some critical role in survival rate. The 5-year survival rate was found to be 73.4% for active and 54.3% for nonactive patients.
Figure 1: Observed survival rate by Federation of Gynecology and Obstetrics staging.

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Table 2: Factors related to survival in cervical cancer patients

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The patients who had registered at an advanced stage had poorer survival rate than the patients who had registered early [Figure 1]. Similarly, the performance status before treatment was also a significant factor for predicting the survival rate of cancer patients. The [Figure 2] shows that the patients who had poorer performance status before treatment had the poorer survival rate.
Figure 2: Observed survival rate by performance status.

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According to Hospital Based Cancer Registry report 2010 and 2011 cervical cancer is the second most common cancer among females and considering all cancers, this is the in the fourth and second sixth position, respectively.[14] Majority of the patients completed the initial planned treatment, but only a low proportion (30.4%) underwent regular follow-up. This may be due to the lack of support from the family members or due to the unawareness about the importance of follow-up for cancer treatment. Thus, this study recommended that the counseling about the importance of the follow-up is required for the family members. Similarly, the disease-related factors like performance status before treatment and the FIGO staging at presentation affected the follow-up status. This study revealed that the staging and performance status of the patient before treatment had a significant role on the survival rate of cervical cancer patients. Thus, the early detection improves the survival rate of cervical cancer. Thus, these findings stress the importance of formulating public health policies aimed at increasing the awareness and implementation of cervical cancer screening programs in North Malabar.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
GLOBOCAN, International Agency for Research on Cancer, France; 2012. Available from: http://www.globocan.iarcfr/pages/fact_sheets_apx. [Last accessed on Last accessed on 2015 Jan 16].  Back to cited text no. 1
    
2.
National Cancer Institute. What do You Need to Know about Cervix Cancer. Available from: http://www.cancer.gov/publication/patient-education/wynk-vervical-cancer. [Last accessed on 2014 Jul 10].  Back to cited text no. 2
    
3.
Cervical Cancer Action Report Card 2011. Progress in Cervical Cancer Prevention. Available from: http://www.cervicalcanceraction.org/pubs/CCA__reportcard_low_res.pdf. [Last accessed on 2014 Dec 10].  Back to cited text no. 3
    
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Devi BC, Tang TS, Corbex M. Reducing by half the percentage of late-stage presentation for breast and cervix cancer over 4 years: A pilot study of clinical downstaging in Sarawak, Malaysia. Ann Oncol 2007;18:1172-6.  Back to cited text no. 4
    
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Human Papillomavirus and Related Diseases Report INDIA © ICO Information Centre on HPV and Cancer (HPV Information Centre); 2014. Available from: http://www.hpvcentre.net/statistics/reports/Ind.pdf. [Last accessed on 2014 Aug 12].  Back to cited text no. 5
    
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Kizer NT, Thaker PH, Gao F, Zighelboim I, Powell MA, Rader JS, et al. The effects of body mass index on complications and survival outcomes in patients with cervical carcinoma undergoing curative chemoradiation therapy. Cancer 2011;117:948-56.  Back to cited text no. 6
    
7.
Prabhakar AK, Menon GR. Age at marriage and cervical cancer incidence. Indian J Cancer 1995;32:63-8.  Back to cited text no. 7
    
8.
American Cancer Society. What are the Risk Factors of Cervical Cancer. Available from: http://www.cancer.org/cancer/cervicalcancer/detailedguide/cervical-cancer-risk-factors. [Last accessed on 2015 Mar 11].  Back to cited text no. 8
    
9.
WHO/ICO Information Centre on HPV and Cervical Cancer- HPV and Cervical Cancer Statistics in India; 2010. Available from: http://www.hpvcentre.net/statistics/reports/XWX.pdf. [Last accessed on 2015 Feb 04].  Back to cited text no. 9
    
10.
Monograph on Human Papilloma Viruses. Vol. 90. Lyon, France: WHO, International Agency for Research on Cancer; 2007. Aavailable from: https://monographs.iarc.fr/ENG/Monographs/vol90/mono90.pdf. [Last accessed on 2015 Mar 10].  Back to cited text no. 10
    
11.
Sankaranarayanan R, Black RJ, Parkin DM, editors. Cancer Survival in Developing Countries. (IARC Scientific Publications No. 145). Lyon: IARC Press; 1998a.  Back to cited text no. 11
    
12.
Waggoner SE. Cervical cancer. Lancet 2003;361:2217-25.  Back to cited text no. 12
    
13.
Nandakumar A. National Cancer Registry Programme Consolidated Report of the Population Based Cancer Registry 1990-1996 Incidence and Distribution of Cancer; 1990-1996.  Back to cited text no. 13
    
14.
HBCR. Hospital Based Cancer Registry Report-2010, Malabar Cancer Centre, Thalassery, Kerala; 2010, 2011.  Back to cited text no. 14
    


    Figures

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