Ovarian Conservation and Overall Survival in Young Women With Early-Stage Cervical Cancer

Abstract

Objective: To identify predictors of ovarian conservation at hysterectomy and to examine the association of ovarian conservation and survival of young women with early-stage cervical cancer.

Methods: This is a retrospective cohort study using the Surveillance, Epidemiology, and End Results Program to identify hysterectomy-based surgically treated patients with stage I cervical cancer diagnosed between 1983 and 2012 (N=16,511). Multivariable models were used to identify independent factors associated with ovarian conservation. Among the subgroup of 9,419 women younger than 50 years of age with stage I disease, survival outcomes and causes of death were examined for 3,908 (41.5%) women who underwent ovarian conservation at hysterectomy without radiotherapy.

Results: On multivariable analysis, age younger than 50 years, stage IA disease, and squamous histology were independent factors associated with ovarian conservation (all, P<.001). Among 5,526 women younger than 50 years of age with stage IA disease who underwent hysterectomy without radiotherapy, overall survival was significantly higher in patients undergoing ovarian conservation than in those undergoing oophorectomy (20-year rate, 93.5% compared with 86.8%, P<.001); cervical cancer-specific survival was similar between the patients who underwent ovarian conservation and those who underwent oophorectomy (98.8% compared with 97.8%, P=.12). On multivariable analysis, ovarian conservation remained an independent prognostic factor for improved overall survival (adjusted hazard ratio 0.63, 95% confidence interval [CI] 0.49-0.82, P=.001) and was independently associated with lower cumulative risks of death resulting from cardiovascular disease (20-year cumulative rate, 1.2% compared with 3.3%, adjusted hazard ratio 0.47, 95% CI 0.26-0.86, P=.014) and other chronic disease (0.5% compared with 1.4%, adjusted hazard ratio 0.24, 95% CI 0.09-0.65, P=.005) compared with oophorectomy. Both cervical cancer-specific survival (20-year rate, 93.1% compared with 92.0%, P=.37) and overall survival (86.7% compared with 84.6%, P=.12) were similar between ovarian conservation and oophorectomy among 3,893 women younger than 50 years of age with stage IB disease who underwent hysterectomy without radiotherapy.

Conclusion: Among young women with stage IA cervical cancer, ovarian conservation at hysterectomy is associated with decreased all-cause mortality including death resulting from cardiovascular disease and other chronic diseases.

Fig. 1.

Selection criteria. Stage I cervical cancer refers stage IA and IB disease.

Fig. 2.

Temporal and age-related trends in frequency of ovarian conservation. A. Age-specific frequency of ovarian conservation is shown for patients with stage I diseases (N = 16,511). Between ages 39 and 53 years, there was a significant decline in the use of ovarian conservation with each subsequent year of age (percent change per year 12.7, 95% confidence interval [CI] 10.3–15.0, P<.001). B. Annual frequency of ovarian conservation is shown for women younger than 50 years of age with stage IA cervical cancer (n=5,526) (red line). There was a significant increase in the frequency of ovarian conservation with each subsequent calendar year (annual percent change 0.6, 95% CI 0.14–1.09, P=.013). Annual frequency of ovarian conservation is shown for women younger than 50 years of age with stage IB cervical cancer (n=3,893) (blue line). Between 1983 and 1998, there was a significant increase in the frequency of ovarian conservation (annual percent change 14.6, 95% CI 10.5–18.9, P<.001).

Fig. 3.

Temporal trend in frequency of ovarian conservation based on histology subtypes in women younger than 50 years of age with stage I cervical cancer. Frequency of ovarian conservation per year at hysterectomy is shown for women younger than 50 years of age with stage I squamous cell carcinoma (n = 7,632) (red line). Between 1983 and 1999, there was a significant increase in the frequency of ovarian conservation with each subsequent year (annual percent change 4.4, 95% confidence interval [CI] 2.6–6.3, P<.001). Frequency of ovarian conservation per year at hysterectomy is shown for women younger than 50 years of age with stage I adenocarcinoma (n=2,726) (blue line). Between 1985 and 1999, there was a significant increase in the frequency of ovarian conservation with each subsequent year (annual percent change 10.0, 95% CI 6.2–13.9, P<.001).

Fig. 4.

Kaplan-Meier curves for women younger than 50 years of age with stage I cervical cancer. Log-rank test for P values. Y-axis was truncated to 50–100% for A–D and 0–50% for E–F. Survival curves were constructed for cervical cancer–specific survival (A), overall survival (B), and cumulative mortality risk from cardiovascular disease (C) and another chronic disease (D) for women younger than 50 years of age with stage IA cervical cancer with no radiotherapy; and cervical cancer–specific survival (E) and overall survival (F) for women younger than 50 years of age with stage IB cervical cancer with no radiotherapy.