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Relationship of age to survival rate in carcinoma of the cervix
Relationship of age to survival rate in carcinoma of the cervix J. R. DODDS, M.D. J.P. A. LATOUR, M.D. Montreal, Quebec
T H E statement is frequently made that the prognosis of cervical carcinoma in young individuals is poorer than in women of the older age groups. We undertook this study because we were uncertain as to the validity of this claim and because if it could be supported by our own findings it might have some influence in the management of these patients. A review of the literature reveals two large series in which the statistics were analyzed and the subject carefully considered. Truelsen 8 in his very comprehensive study of carcinoma of the cervix in 1949 found widely divergent statements on the question. He relates that authors such as Heyman felt that it has not been proved that young women have a poorer prognosis than their older counterparts; Voltz, on the other hand, felt that younger women had poorer cure rates in all stages than the entire group, while Dietel and Doderlein found the results to be actually better in the younger age group. Truelsen analyzed 2,450 cases treated between the years 1922 and 1937 and found that the number of patients surviving 5 years was practically constant in all age groups up to 65. When he further divided the various age groups into stages, he found the difference in the
survival rate to be only slight and not always in the same direction. The second large series was reported by Lindell5 in 1952 and consisted of 5,258 patients treated by radiotherapy in the Radiumhemmet between 1910 and 1944. He noted that 4.03 per cent or 207 patients were under 31 years of age, and he analyzed these further. True!sen had found 68 patients, or 2.8 per cent, under 30 years of age and did not feel that the number was of sufficient magnitude to be statistically significant. Lindell's tables showed that the 5 year survival rate was 10 to 12 per cent lower in Stages I and II for patients under 31 years of age than it was for the patients of the same stages in the succeeding three decades where they were approximately the same. In Stage III the 5 year survival rate was 8.2 per cent in 49 patients under 31 and was 12.8, 19.5, and 24.2 per cent in the succeeding three decades, respectively. Lindell also noted that the cancer death rate was greatest in the first 2 years after treatment in young women while in women of 50 years and over it was evenly distributed over the 5 years. Decker, Fricke, and Pratt3 of Rochester, reporting on the cases seen in the Mayo Clinic from 1940 to 1949, found 149 of 1,451 patients to be under the age of 35. Following an analysis of these cases they concluded that there was no essential differ· ence in the end results of treatment between
From the Department of Obstetrics and Gynaecology, Royal Victoria Hospital and McGill University. Presented at the Sixteenth Annual Meetint< of the Society of Obstetricians and Gynecologists of Canada, Jasper, Alberta, june 8-10, 1960.
vvomen under the age of 35 and those over
the age of 35. A substantial number of the
33
34
Dodds and Latour
Am .
Material and methods
600
f:3
~
4 00
u
~
g
July, 1961 & Gy ncc.
J. Obst.
200
0
2
4
3
STAGE
Fig. 1. In cid ence of ca rcinoma of cervi x, Roya l Vi c tori a M ontreal M a t ern ity H ospital, by stage. Stippled p ortion represen ts precli nical cases.
p a tients in Stage I were treated surgically a nd it was not recorded whether or n ot there we re a ny p reclinical lesions included . StrobeF in 1956 reported on 127 p a tien ts under the age of 30, which was 2.54 per cent of the series. The 5 year surviva l rate in Stage I was 54.5 per cent, in Stage II 27 per cent, and in Stage III 7.2 per cent. Bottger and Beric 2 in 1958, reporting a series of 1,808 cases, found tha t 4.1 p er cent or 75 pa tients were under the age of 30 years. T en of the cases were concomitan t with a pregnancy. Nineteen p a tients or 25 per cent survived 5 years.
The present study is based on the case records of 1,418 consecutive cases of prima ry carcinoma of the cervix seen in the R oyal V ictoria H ospital b etween 1926 a nd 1959, inclusive. The Interna tional C lassifica tion was used in staging. It was noted tha t since 1949 the widespread use of cytological screening h as m arked ly increased the number in Stage 0 and h as altered the composition of Stage I by the inclusion of invasive but clinically una ppreciable tumors. This preclinical segm ent of Stage I will be identified in the sta tistical presenta tion . In age-stage studies 5 year increm ents were used . In the age-stage su rvival stu dies 10 year increments were used as the series did not appear la rge enough to permit significant conclusions with the sm a ller figure. As a basis of "cu re" it was decided to u se "5 year survivors." This m ethod of a nalysis renders unnecessary the often ve ry difficult task of ascertaining tha t a p a tient alive a t 5 years is or is not free of tumor. Pa tients living less than 5 yea rs but dying of other causes even though considered free of tumo r are n ot considered as 5 year survivors. All pa tients lost to fo llow-up a re considered
200
150
16 20
21 25
26 30
41 40
46
51
45 50 55 AGE G\OUP
56 60
Fig. 2. D istribution of carcinoma of cervix by age.
61
66
71
76
81
65
io
15
00
85
Volume 82 N umber 1
Survival rate
1n
carcinoma of cerv1 x
STAGE
35
00
4
3
2
0
4"5 50 M:£. GROUP
Fig. 3. Incidence of carcinoma of cervix, broken down by age a nd stage.
dead of tumor. There were only 8 such cases.
Results Fig. 1 shows the entire series broken down into the 5 International Classification stages with the stippled portion of Stage I representing the preclinical cases. The clinical staging of any series of cervical cancer is subj ect to two important limitations. The first is the huma n varia tion in the evaluation of the examination. The second is the va rying degree of the use of screening techniques by any one clinic. A wide varia tion in staging by variou s authors is noted in the last volume of the Annual R ejJort on the R esu lts of Treatment of Carcinoma of the U terus. 1 Compa red to this series there seems to be a tendency to increase the number of cases in Stage II a t the expense of Stage I. Fig. 2 is a breakclown of the series into 5 year age groups which in essence is a popula tion distribution cu rve . Looking at the two extremes in age grouping one notes tha t there are only 24 p a tients of 25 years a nd under, a nd 45 p a tients of 70 years and over. The greatest number of cases is concentra ted about
equally in the four divisions of the twentyyear period from age 36 to age 55. There are 102 p a tients under the age of 31. Six tyeight of these pa tients h ave preclinical disease and of the rem aining 34 only 26 h ave been followed for 5 years. The 34 cases represen t 3 per cent of the clinical lesion s. T able I shows "5 year survivals" in the va rious Interna tional stages. It is realized th a t now onl y cases up to the year 1954· may be included . The high survival ra te in Stage 0 and the low ra te in Stage IV are obviou s. Act ually the one patient who was not a survivor in Stage 0 died of oth er causes. Stage I includes 88 preclinical cases. Fig. 3 shows an individu al age-stage correla tion which indicates a di stinctive trend
Table I. Five-year surviva l ra tes according to stage 5 y ea r sur vival Sta ge
0 I II III IV
N o. cases
N o.
51 407 333 210 60
50 291 134 38 1
% 98.0 71.5 40.2 18. 1 1.1
36
july, 196 1 Am. J. Obst. & Gyncc.
Dodds and Latour
eo 60
40
20
31
AGE
I
~I
~ !li:>io
STAGE
31
I
~I
4oj5CJ6c 2
31 41 51
~
51:>.0 3
Fig. 4. P ercentage 5 year survival by age and stage.
toward a higher stage with advancing age. This may be explained partly by the tendency of younger women to seek screening procedures and by older women to disregard symptoms. It is noted that the highest incidence of carcinoma in situ is in the 31 to 40 age group whereas for Stage I it is in the 41 to 50 group . If Stage I is divided into preclinical and clinical lesions then the age group of highest incidence of carcinoma in situ is 31 to 35, that for preclinical Stage I is 35 to 40, and that for Stage I clinical is 46 to 50. These figures correspond closely with those in reports by Wheeler and H ertig 9 in 1955, by L atour and Brown·• in 1957, and by Stern6 in 1959. Fig. 4 shows th e percentage age-stage survival rate of the three major decades of the series. The number of cases at either end of the age scale is relatively very small and these cases have been excluded. All the preclinical cases have been removed and the series is now reduced to 773. The cure rate
REFERENCES
1. American Cancer Society et al.: Annual R eport on the R esults of Treatm ent in Carcinom a of the Uterus, Stockholm , 1958, vol. 11. 2. Bottger, H ., and Beric, B. : Gynaecologia 146: 36 1, 1958 . 3. D ecker, D. G., Fricke, R. E ., and Pra tt, J. H .: J. A. M. A. 158: 1417, 1955. 4. L a tour, J. P . A., Brown, L. B., and Turnbull,
in Stage IV is so small that to all intents and purposes this stage might as well not be considered . Th e difference in the percentage survival rate in Stages I , II, and III for the three age groups is very small, the actual figures being 62.2, 70.5, and 67 per cent for Stage I , 38.3, 36. 1, and 45 .1 per cen t fo r Stage II, and 15.4, 20, and 18.9 per cent for Stage III. However, the slight difference seems to indi cate a poorer prognosis for the younger woma n. Lindell' s" tables showed percentages of 65.5, 67 .9, and 67 per cen t for Stage I, 49, 40, and 48 . l per cent for Stage II, and 12.8, 19.5, and 24.2 per cent for Stage III . Corresponding fi gm es [rom Truelsen's8 tables show 59.3, 61.7, and 70. t per cent fo r Stage I , 37. 2, 39.5, and 44.8 per cent for Stage II, and 13.2, 22 .8, and 22 .4 per cent for StaO'e III. Truelsen reported 59 patients under the age of 30 in Stages I , II, and III. The survival was 59. 1, 38.9, and 15.8 per cent, respec tively. Lindell , with a much larger series, reported corresponding figures of 54·.3, 40.3, and 8.2 per cent. In thi s series there were only 26 pati ents under the age of 30. Summ a ry and conclu sions
1. This material shows a distinct bias in the direction of more advanced stages with increasing age. Th e most obvious findin g in this regard is that p reclinical cancers an teela te the clinical cancers by some 10 years . 2. The age-stage survival analysis docs not permit firm conclusions. If th ere is any difference it is in the direction of the younge r women having a poorer pro
L. A .: AM. J. Ou sT. & GvNEC. 74: 354, 1957. 5. Lindell , A.: Acta radiol. (suppl. 92) , 1952 . 6. Stern, E.: Cancer 12: 933, 1959. 7. Strobel, E., a nd Strobel-Treuter, S.: K rebsarzt 11 : 197, 1956 . 8. Truelsen, F.: Cancer of the Uterine Cervix, Copenhagen, 1949 , R osenkild e and Bagge r. 9. Wheeler, J. D., and H erti g, A. T .: Am. J. Clin. Pa th . 25: 345, 1955.
T H E statement is frequently made that the prognosis of cervical carcinoma in young individuals is poorer than in women of the older age groups. We undertook this study because we were uncertain as to the validity of this claim and because if it could be supported by our own findings it might have some influence in the management of these patients. A review of the literature reveals two large series in which the statistics were analyzed and the subject carefully considered. Truelsen 8 in his very comprehensive study of carcinoma of the cervix in 1949 found widely divergent statements on the question. He relates that authors such as Heyman felt that it has not been proved that young women have a poorer prognosis than their older counterparts; Voltz, on the other hand, felt that younger women had poorer cure rates in all stages than the entire group, while Dietel and Doderlein found the results to be actually better in the younger age group. Truelsen analyzed 2,450 cases treated between the years 1922 and 1937 and found that the number of patients surviving 5 years was practically constant in all age groups up to 65. When he further divided the various age groups into stages, he found the difference in the
survival rate to be only slight and not always in the same direction. The second large series was reported by Lindell5 in 1952 and consisted of 5,258 patients treated by radiotherapy in the Radiumhemmet between 1910 and 1944. He noted that 4.03 per cent or 207 patients were under 31 years of age, and he analyzed these further. True!sen had found 68 patients, or 2.8 per cent, under 30 years of age and did not feel that the number was of sufficient magnitude to be statistically significant. Lindell's tables showed that the 5 year survival rate was 10 to 12 per cent lower in Stages I and II for patients under 31 years of age than it was for the patients of the same stages in the succeeding three decades where they were approximately the same. In Stage III the 5 year survival rate was 8.2 per cent in 49 patients under 31 and was 12.8, 19.5, and 24.2 per cent in the succeeding three decades, respectively. Lindell also noted that the cancer death rate was greatest in the first 2 years after treatment in young women while in women of 50 years and over it was evenly distributed over the 5 years. Decker, Fricke, and Pratt3 of Rochester, reporting on the cases seen in the Mayo Clinic from 1940 to 1949, found 149 of 1,451 patients to be under the age of 35. Following an analysis of these cases they concluded that there was no essential differ· ence in the end results of treatment between
From the Department of Obstetrics and Gynaecology, Royal Victoria Hospital and McGill University. Presented at the Sixteenth Annual Meetint< of the Society of Obstetricians and Gynecologists of Canada, Jasper, Alberta, june 8-10, 1960.
vvomen under the age of 35 and those over
the age of 35. A substantial number of the
33
34
Dodds and Latour
Am .
Material and methods
600
f:3
~
4 00
u
~
g
July, 1961 & Gy ncc.
J. Obst.
200
0
2
4
3
STAGE
Fig. 1. In cid ence of ca rcinoma of cervi x, Roya l Vi c tori a M ontreal M a t ern ity H ospital, by stage. Stippled p ortion represen ts precli nical cases.
p a tients in Stage I were treated surgically a nd it was not recorded whether or n ot there we re a ny p reclinical lesions included . StrobeF in 1956 reported on 127 p a tien ts under the age of 30, which was 2.54 per cent of the series. The 5 year surviva l rate in Stage I was 54.5 per cent, in Stage II 27 per cent, and in Stage III 7.2 per cent. Bottger and Beric 2 in 1958, reporting a series of 1,808 cases, found tha t 4.1 p er cent or 75 pa tients were under the age of 30 years. T en of the cases were concomitan t with a pregnancy. Nineteen p a tients or 25 per cent survived 5 years.
The present study is based on the case records of 1,418 consecutive cases of prima ry carcinoma of the cervix seen in the R oyal V ictoria H ospital b etween 1926 a nd 1959, inclusive. The Interna tional C lassifica tion was used in staging. It was noted tha t since 1949 the widespread use of cytological screening h as m arked ly increased the number in Stage 0 and h as altered the composition of Stage I by the inclusion of invasive but clinically una ppreciable tumors. This preclinical segm ent of Stage I will be identified in the sta tistical presenta tion . In age-stage studies 5 year increm ents were used . In the age-stage su rvival stu dies 10 year increments were used as the series did not appear la rge enough to permit significant conclusions with the sm a ller figure. As a basis of "cu re" it was decided to u se "5 year survivors." This m ethod of a nalysis renders unnecessary the often ve ry difficult task of ascertaining tha t a p a tient alive a t 5 years is or is not free of tumor. Pa tients living less than 5 yea rs but dying of other causes even though considered free of tumo r are n ot considered as 5 year survivors. All pa tients lost to fo llow-up a re considered
200
150
16 20
21 25
26 30
41 40
46
51
45 50 55 AGE G\OUP
56 60
Fig. 2. D istribution of carcinoma of cervix by age.
61
66
71
76
81
65
io
15
00
85
Volume 82 N umber 1
Survival rate
1n
carcinoma of cerv1 x
STAGE
35
00
4
3
2
0
4"5 50 M:£. GROUP
Fig. 3. Incidence of carcinoma of cervix, broken down by age a nd stage.
dead of tumor. There were only 8 such cases.
Results Fig. 1 shows the entire series broken down into the 5 International Classification stages with the stippled portion of Stage I representing the preclinical cases. The clinical staging of any series of cervical cancer is subj ect to two important limitations. The first is the huma n varia tion in the evaluation of the examination. The second is the va rying degree of the use of screening techniques by any one clinic. A wide varia tion in staging by variou s authors is noted in the last volume of the Annual R ejJort on the R esu lts of Treatment of Carcinoma of the U terus. 1 Compa red to this series there seems to be a tendency to increase the number of cases in Stage II a t the expense of Stage I. Fig. 2 is a breakclown of the series into 5 year age groups which in essence is a popula tion distribution cu rve . Looking at the two extremes in age grouping one notes tha t there are only 24 p a tients of 25 years a nd under, a nd 45 p a tients of 70 years and over. The greatest number of cases is concentra ted about
equally in the four divisions of the twentyyear period from age 36 to age 55. There are 102 p a tients under the age of 31. Six tyeight of these pa tients h ave preclinical disease and of the rem aining 34 only 26 h ave been followed for 5 years. The 34 cases represen t 3 per cent of the clinical lesion s. T able I shows "5 year survivals" in the va rious Interna tional stages. It is realized th a t now onl y cases up to the year 1954· may be included . The high survival ra te in Stage 0 and the low ra te in Stage IV are obviou s. Act ually the one patient who was not a survivor in Stage 0 died of oth er causes. Stage I includes 88 preclinical cases. Fig. 3 shows an individu al age-stage correla tion which indicates a di stinctive trend
Table I. Five-year surviva l ra tes according to stage 5 y ea r sur vival Sta ge
0 I II III IV
N o. cases
N o.
51 407 333 210 60
50 291 134 38 1
% 98.0 71.5 40.2 18. 1 1.1
36
july, 196 1 Am. J. Obst. & Gyncc.
Dodds and Latour
eo 60
40
20
31
AGE
I
~I
~ !li:>io
STAGE
31
I
~I
4oj5CJ6c 2
31 41 51
~
51:>.0 3
Fig. 4. P ercentage 5 year survival by age and stage.
toward a higher stage with advancing age. This may be explained partly by the tendency of younger women to seek screening procedures and by older women to disregard symptoms. It is noted that the highest incidence of carcinoma in situ is in the 31 to 40 age group whereas for Stage I it is in the 41 to 50 group . If Stage I is divided into preclinical and clinical lesions then the age group of highest incidence of carcinoma in situ is 31 to 35, that for preclinical Stage I is 35 to 40, and that for Stage I clinical is 46 to 50. These figures correspond closely with those in reports by Wheeler and H ertig 9 in 1955, by L atour and Brown·• in 1957, and by Stern6 in 1959. Fig. 4 shows th e percentage age-stage survival rate of the three major decades of the series. The number of cases at either end of the age scale is relatively very small and these cases have been excluded. All the preclinical cases have been removed and the series is now reduced to 773. The cure rate
REFERENCES
1. American Cancer Society et al.: Annual R eport on the R esults of Treatm ent in Carcinom a of the Uterus, Stockholm , 1958, vol. 11. 2. Bottger, H ., and Beric, B. : Gynaecologia 146: 36 1, 1958 . 3. D ecker, D. G., Fricke, R. E ., and Pra tt, J. H .: J. A. M. A. 158: 1417, 1955. 4. L a tour, J. P . A., Brown, L. B., and Turnbull,
in Stage IV is so small that to all intents and purposes this stage might as well not be considered . Th e difference in the percentage survival rate in Stages I , II, and III for the three age groups is very small, the actual figures being 62.2, 70.5, and 67 per cent for Stage I , 38.3, 36. 1, and 45 .1 per cen t fo r Stage II, and 15.4, 20, and 18.9 per cent for Stage III. However, the slight difference seems to indi cate a poorer prognosis for the younger woma n. Lindell' s" tables showed percentages of 65.5, 67 .9, and 67 per cen t for Stage I, 49, 40, and 48 . l per cent for Stage II, and 12.8, 19.5, and 24.2 per cent for Stage III . Corresponding fi gm es [rom Truelsen's8 tables show 59.3, 61.7, and 70. t per cent fo r Stage I , 37. 2, 39.5, and 44.8 per cent for Stage II, and 13.2, 22 .8, and 22 .4 per cent for StaO'e III. Truelsen reported 59 patients under the age of 30 in Stages I , II, and III. The survival was 59. 1, 38.9, and 15.8 per cent, respec tively. Lindell , with a much larger series, reported corresponding figures of 54·.3, 40.3, and 8.2 per cent. In thi s series there were only 26 pati ents under the age of 30. Summ a ry and conclu sions
1. This material shows a distinct bias in the direction of more advanced stages with increasing age. Th e most obvious findin g in this regard is that p reclinical cancers an teela te the clinical cancers by some 10 years . 2. The age-stage survival analysis docs not permit firm conclusions. If th ere is any difference it is in the direction of the younge r women having a poorer pro
L. A .: AM. J. Ou sT. & GvNEC. 74: 354, 1957. 5. Lindell , A.: Acta radiol. (suppl. 92) , 1952 . 6. Stern, E.: Cancer 12: 933, 1959. 7. Strobel, E., a nd Strobel-Treuter, S.: K rebsarzt 11 : 197, 1956 . 8. Truelsen, F.: Cancer of the Uterine Cervix, Copenhagen, 1949 , R osenkild e and Bagge r. 9. Wheeler, J. D., and H erti g, A. T .: Am. J. Clin. Pa th . 25: 345, 1955.