Low-Risk Gestational Trophoblastic Neoplasia in Manitoba: Experience With Alternating Methotrexate and Dactinomycin.

OBJECTIVES: The aim of this study was to review the treatment and outcomes of low-risk gestational trophoblastic neoplasia (GTN) in Manitoba over more than 3 decades, with a focus on those treated with alternating methotrexate and dactinomycin, a protocol that has only rarely been described. MATERIALS AND METHODS: We retrospectively reviewed all patients with GTN referred to CancerCare Manitoba from January 1977 to December 2012. Cases were classified as low risk as per the modified WHO-FIGO prognostic scoring system (score, ≤6). Demographic, treatment, and outcomes data were abstracted, and descriptive statistics and time-to-event analysis were performed. The low-risk protocol used at CancerCare Manitoba consists of alternating single-agent use of methotrexate and dactinomycin, each for 5 days, on a 14-day cycle. RESULTS: Sixty-seven cases of GTN were identified, of which 52 were low risk. Thirty-nine patients were initiated on alternating methotrexate and dactinomycin. Thirty-four (87.2%) achieved primary cure on this regimen, with a median of 4.4 cycles administered (range, 2-7). Median time to response was 56 days. One patient achieved cure after receiving a repeat course of methotrexate as their final cycle. Second-line multiagent chemotherapy was required by 4 patients. Two patients experienced grade 3 toxicities, and none greater than grade 3. There were no recurrences. CONCLUSIONS: Alternating methotrexate and dactinomycin is an effective treatment protocol for low-risk GTN, with high rates of primary cure and acceptable toxicity.

Rate of Appendiceal Metastasis with Non-Serous Epithelial Ovarian Cancer in Manitoba.

OBJECTIVE: This study sought to evaluate the rate of appendiceal involvement in non-serous mucinous and endometrioid-associated epithelial ovarian cancers. METHODS: The Manitoba Cancer Registry and CancerCare database were used to find all women with non-serous epithelial ovarian, fallopian tube, or primary peritoneal cancer between 1995 and 2011. All patients with an appendectomy were then identified, and their final pathology findings were reviewed. Women who did not receive treatment or lacked follow-up were excluded. RESULTS: We identified 338 patients from 1995-2011 with no prior appendectomy. Of these, 16.6% received an appendectomy, and 22.8% were clinically evaluated. Most cases within this cohort were mucinous (62%) and stage 1 (63%). Four appendiceal metastases were identified (7.2%), and one half appeared clinically normal at the time of surgery (3.6%). Within the mucinous histologic type, 32.7% of patients received an appendectomy, with a metastatic rate of 5.7%. Of the 127 endometrioid cases, only 10 patients received an appendectomy, and 2 were found to have metastases. No metastases were found in the 85 patients in the clear cell cohort, only 5 of whom received an appendectomy. CONCLUSION: Routine appendectomy or clinical assessment of the appendix is valuable for all non-serous ovarian cancers. The rate of involvement for endometriosis-associated ovarian cancers may be significantly higher than expected, and further studies need to be conducted.

Examining the Selection Criteria of Neoadjuvant Chemotherapy Patients.

OBJECTIVES: To identify predictors of neoadjuvant chemotherapy (NAC) and to examine toxicities, dose reduction, interruptions, and second-line chemotherapy MATERIALS AND METHODS: A retrospective chart review of 391 patients with late-stage ovarian cancer diagnosed between January 1, 2004 and December 31, 2010 was conducted. Logistic regression was used to predict chemotherapy type. Cumulative incidence of toxicities, dose reduction, and treatment interruption were calculated using the Kaplan-Meier method. Overall survival was analyzed using time-varying Cox regression models. A competing risk model was used to predict second-line chemotherapy with death as a competing risk. RESULTS: Older patients were less likely to receive primary debulking (OR 0.710; 95% CI 0.55-0.92, P = 0.0108), as were patients with longer diagnostic intervals. Clear-cell, endometrioid, and mucinous carcinoma were more likely to receive adjuvant treatment than unclassified epithelial (OR 6.964; 95% CI 2.02-24.03, P = 0.0021). Adjuvant patients experienced higher incidence of chemotherapy toxicities (P <0.0001) and treatment interruption (P = 0.016) at 3 months. There was no statistically significant difference in the incidence of chemotherapy dose reduction of >20% in the NAC and adjuvant populations (P = 0.142). Neoadjuvant patients were more likely to require more than one line of chemotherapy ([Subhazard Ratio] = 4.334; 95% CI 2.51-7.50, P <0.0001). CONCLUSION: Our study found that patients with shorter diagnostic intervals, more advanced age, and unclassified epithelial histotype were more likely to receive NAC. NAC patients did not experience a higher incidence of chemotherapy toxicities, treatment interruption, or dose reduction. There is treatment selection bias for sicker patients being treated with NAC.

Examining the Effects of Time to Diagnosis, Income, Symptoms, and Incidental Detection on Overall Survival in Epithelial Ovarian Cancer: Manitoba Ovarian Cancer Outcomes (MOCO) Study Group.

OBJECTIVE: The primary objectives of this study were to analyze data on time to diagnosis and correlate this with overall survival. We secondarily analyzed the effects of emergency room visits, symptoms, incidental findings, residence, socioeconomic status, and residual disease on overall survival. METHODS: This retrospective population-based descriptive cohort study examined all invasive ovarian cancer cases in Manitoba, Canada, between 2004 and 2010. Clinicopathologic, socioeconomic, and outcome data were collected. Analysis was performed with Cox and logistic regression stratified by early and late stage. RESULTS: Six hundred eighty-seven ovarian cancer patients were identified, with a final cohort of 601 patients: 210 with early-stage (1/2) and 391 with late-stage (3/4) disease. No presenting symptoms were associated with survival outcome. Poorer survival was associated with increasing age (P = 0.0016) and neoadjuvant chemotherapy (P = 0.0037). Higher income within the urban setting was also associated with a survival advantage (P = 0.0037), whereas initial presentation to the emergency room (P = 0.0399) was associated with decreased survival. Finally, for advanced-stage disease, incidental diagnosis had a significantly improved overall survival (hazard ratio, 0.424; 95% confidence interval, 0.27-0.67; P = 0.0003), even when accounting for confounding factors. Time from first presentation to diagnosis was associated with survival (P = 0.0309). CONCLUSIONS: This study found that time to diagnosis did not negatively impact overall survival, although there was an association. Age, morphology, treatment type, residual disease, medical comorbidities, and income were significant prognostic factors. This is the first study to show a survival advantage to incidentally finding an ovarian cancer. Further research is needed on the outcomes of pelvic examination.

Diagnostic and referral intervals for Manitoba women with epithelial ovarian cancer - the Manitoba Ovarian Cancer Outcomes (MOCO) study group: a retrospective cross-sectional study.

BACKGROUND: Epithelial ovarian cancer has the highest mortality of all gynecologic cancers. The poor survival rates are often attributed to the advanced stage at which most of these cancers are detected. We sought to examine the effects of patient demographics, comorbidities and presenting symptoms on diagnostic and referral intervals by location of first presentation (emergency department v. elsewhere) and to identify factors that affect these intervals. METHODS: We performed a retrospective analysis of chart and medical record data for ovarian cancers, with the exceptions of sex cord and germ cell tumours, diagnosed between 2004 and 2010 in Manitoba, Canada. Data were collected on baseline characteristics, time to diagnosis and referral, number and type of physician visits and emergency department visits. RESULTS: The final cohort consisted of 601 patients. Sixty-three percent of patients received their diagnosis within 60 days of initial presentation, and 75.2% had their cancer diagnosed within 2 physician encounters. The median diagnostic interval for all stages of patients presenting to the emergency department was 7 days, compared with 55 days for patients presenting elsewhere. Early stage patients not presenting to the emergency department had their diagnosis a median of 34.0 days later than patients with advanced disease (95% confidence interval [CI] 22.22 to 45.69, p < 0.0001). The presence of some symptoms was associated with shortened diagnostic intervals. Patients with serous, clear-cell or endometrioid histotypes were less likely to have first presentation beginning in the emergency department (odds ratio [OR] 0.40, 95% CI 0.24 to 0.64, p = 0.0001; OR 0.28, 95% CI 0.14 to 0.59, p = 0.007) than those with unclassified epithelial histotype. INTERPRETATION: For this group of patients, the main factor associated with diagnostic and referral intervals is presentation to the emergency department. These patients likely required more urgent attention for their more symptomatic disease, leading to quicker diagnosis and referral patterns, despite poorer prognosis.

Hormone Use After Nonserous Epithelial Ovarian Cancer: Overall and Disease-Free Survival.

OBJECTIVE: To evaluate whether hormone therapy (HT) after nonserous epithelial ovarian cancer is associated with a decrease in overall and disease-free survival. METHODS: We conducted a retrospective cohort study. The Manitoba Cancer Registry and Drug Programs Information Network were searched to find all women with known nonserous epithelial ovarian, fallopian tube, or primary peritoneal cancer between 1995 and 2010 who had used HT after treatment. Women who did not receive treatment or had no follow-up were excluded. RESULTS: Three hundred ninety-one patients met the inclusion criteria. Seventeen patients were excluded because the patients did not receive treatment for cancer, and 17 were excluded for lack of follow-up. A total of 94 women received HT after treatment, and 263 women did not. The average age was 57.8 years. In HT users younger than 55 years of age, disease-free survival is improved according to both the multivariable landmark analysis (n=68/145, adjusted hazard ratio 0.354, 95% confidence interval [CI] 0.17-0.74, P=.006) and the time-varying Cox regression analysis (n=42/158, adjusted hazard ratio 0.212, 95% CI 0.07-0.60, P=.004) when adjusting for International Federation of Gynecology and Obstetrics stage and need for chemotherapy. There is no statistical difference in overall survival in this age group. No associations between HT use and overall survival or disease-free survival were found among women aged 55 years and older. CONCLUSION: After treatment for nonserous epithelial ovarian cancer, hormone therapy is not associated with decreased disease-free or overall survival.

Effect of changes in treatment practice on survival for cervical cancer: results from a population-based study in Manitoba, Canada.

BACKGROUND: Results from clinical trials in the 1990s led to changes in the recommended treatment for the standard therapy for stage IIB-IVA cervical cancer from radiotherapy alone to chemo-radiotherapy. We conducted the first population-based study in Canada to investigate temporal treatment patterns for cervical cancer and long-term survival in relation to these changes in the treatment guidelines. METHODS: Detailed information on stage and treatment for 1085 patients diagnosed with cervical cancer in 1984-2008 and identified from the population-based Manitoba Cancer Registry (MCR) in Canada was obtained from clinical chart review and the MCR. Factors associated with receiving guideline treatment were identified using logistic regression. All cause and cervical cancer specific survival were compared in patients who were and were not treated as recommended in the guidelines, using Cox proportional hazards models. RESULTS: The median follow-up time was 6.4 years (range: 0.05-26.5 years). The proportion of women who received guideline treatment was 79 % (95 % confidence interval [CI]: 76-81 %). However, the likelihood of being treated according to the guidelines over time was modified by age (p < 0.0001) and tumour stage at diagnosis (p = 0.002). Women who were treated according to the guidelines after the change in recommended clinical practice (1999-2008) had a significantly lower risk of death from all causes and from cervical cancer. This was driven by lower mortality rates in cases with stage IIB-IVA tumours (all causes of death: hazard ratio [HR] = 0.60, 95 % CI: 0.43-0.82, p = 0.002; cervical cancer related death: HR = 0.64, 95 % CI: 0.44-0.93, p = 0.02). CONCLUSIONS: The management of cervical cancer patients in Manitoba, Canada was in good agreement with treatment guidelines although reasons for departure from the guideline recommendations could not be examined further due to lack of data. Treatment of stage IIB-IVA cervical cancers with recommended concurrent chemo-radiotherapy, which is now standard practice, was associated with substantially increased survival, although the effect of changes in clinical practice including maintenance of haemoglobin levels on improved survival cannot be ruled out as a contributing factor.

Pure Immature Teratoma of the Ovary in Adults: Thirty-Year Experience of a Single Tertiary Care Center.

OBJECTIVE: The aim of this study was to evaluate clinicopathologic characteristics, treatment outcome, and reproductive function in women diagnosed with ovarian immature teratoma (IT). Our standard chemotherapy regime is currently etoposide/cisplatin (EP), creating a unique opportunity to evaluate this protocol in ovarian ITs. MATERIALS AND METHODS: This study is a retrospective analysis. Twenty-seven women older than 18 years with ovarian IT stages IA to IIIC were identified and included in this study. Patients were treated at 1 institution, Health Sciences Center, Women's Hospital, Winnipeg, Manitoba, Canada, between 1983 and 2013. RESULTS: The median age at diagnosis was 27.0 years (range, 18-36 years). Twenty-two (82%) presented with an International Federation of Gynecology and Obstetrics stage I disease, 3 (11%) had stage II, and 2 patients (7%) had stage III disease. The histologic grade distribution was grade I in 9 patients (33%), grade II in 3 patients (11%), and grade III in 15 patients (56%). Initial management was surgical for all patients: 3 (11%) hysterectomy and bilateral salpingo-oophorectomy, 1 (4%) cystectomy only, and 23 (85%) unilateral salpingo-oophorectomy. Twenty-one patients (78%) received adjuvant therapy. The median follow-up was 60 months (range, 36-72 months). One patient recurred (histological grade III) 6 months after surgery and had a complete clinical response to 4 cycles of EP chemotherapy. Twelve patients reported an attempt to conceive resulting in 10 pregnancies (8 after chemotherapy). CONCLUSIONS: Ovarian IT is a curable disease. Fertility-sparing surgery should be offered. Adjuvant treatment with cisplatinum-based chemotherapy, typically with bleomycin, etoposide, and cisplatin, is still considered the standard in stages greater than stage IA grade I. Etoposide/cisplatin as a primary chemotherapy regime for early- or advanced-stage disease is an effective treatment with minimal adverse effects and high tolerability. This is the first published study examining EP as a primary treatment modality for IT. Further studies are needed to strengthen these findings.

Optimal uptake rates for initial treatments for cervical cancer in concordance with guidelines in Australia and Canada: Results from two large cancer facilities.

BACKGROUND: Prior work estimating optimal treatment utilisation rates for cervical cancer has focused on radiotherapy or chemotherapy, using proportions of patients with clinical indications for specific treatment strategies which were obtained from the published literature. OBJECTIVES: To estimate optimal uptake rates for surgery, radiotherapy, chemotherapy and chemo-radiotherapy for cervical cancer treatment in Australia and Canada, and to quantify the differences in the optimal and the observed treatment utilisation rates in a large cancer facility from each country. METHODS: A decision tree was constructed to reflect treatments according to guidelines and current practice (in 1999-2008) in each setting. Detailed patterns of care data from a large cancer facility in each country were obtained, and the observed stage distribution and proportions of patients with each clinical indication were used as inputs. RESULTS: The estimated overall optimal treatment rates for cervical cancer in Australia and Canada differed, largely due to the difference in the stage distribution at diagnosis in the two settings; 72% vs 54% with FIGO IA-IIA disease, respectively. The estimated optimal rates for surgery, radiotherapy, chemotherapy and chemo-radiotherapy in Australia were 63% (95% credible interval: 61-64%), 52% (53-56%), 36% (35-38%) and 36% (35-38%), respectively. The corresponding rates in Canada were 38% (36-39%), 68% (68-71%), 51% (49-52%) and 50% (49-51%), respectively. The absolute differences between the optimal and the observed rates were similar between the two settings; the absolute differences for chemotherapy and chemo-radiotherapy uptake were more pronounced (9-15% less than optimal) than those for surgery and radiotherapy uptake (within 5% of optimal). CONCLUSIONS: This is the first study to use detailed patterns of care data in multiple settings to compare optimal and observed rates for all cervical cancer treatment modalities. We found optimal treatment rates were largely dependent on the overall stage distribution. In Australia and Canada, observed surgery rates, as measured in the two large cancer facilities, were similar to the estimated optimal rates, whereas radiotherapy, chemotherapy and chemo-radiotherapy appeared to be under-utilised.

Performance measures related to colposcopy for canadian cervical cancer screening programs: identifying areas for improvement.

OBJECTIVE: To describe performance measures related to colposcopic examinations in Canadian cervical cancer screening programs; specifically, time to colposcopy, histological investigation rate, and agreement between cytology and histology. METHODS: As part of a national report on the performance of cervical cancer screening, aggregate provincial cervical cancer screening data provided by provinces to the Pan-Canadian Cervical Screening Network were used to evaluate colposcopy program performance measures for women 20 to 69 years of age who had a Pap test in 2009 and 2010. RESULTS: A total of 37 523 women had a high-grade or more severe Pap test result. The proportion of women who had a colposcopy ≤ 90 days after their Pap test ranged from 30.9% to 51.5%. Fewer women 60 to 69 years of age had a colposcopy than women in younger age groups. The proportion of women who had a high-grade or more severe Pap test result and colposcopy who had a biopsy within 12 months ranged from 82.1% to 96.5%. The proportion of biopsy results that agreed with the Pap test result ranged from 59.5% to 82.1%. CONCLUSION: The time from having a high-grade Pap test result to undergoing colposcopy must be reduced to lower the risk of adverse outcomes and the stress associated with delayed follow-up. The agreement between screening cytology and histology meets the national target of ≥ 65%. Although six of 13 provinces and territories provided data for colposcopy-related performance measures, more information is needed to assess colposcopy services accurately at the national level.

Objectif : Décrire les mesures de rendement associées aux examens colposcopiques au sein des programmes canadiens de dépistage du cancer du col utérin (plus particulièrement : le délai avant le recours à la colposcopie, le taux d'exploration histologique et le taux de concordance des résultats cytologiques et histologiques). Méthodes : Dans le cadre d'un rapport national sur le rendement du dépistage du cancer du col utérin, les données agrégées provinciales sur ce dépistage qu'ont fournies les provinces à l'Initiative pancanadienne sur le dépistage du cancer du col de l'utérus ont été utilisées pour évaluer les mesures du rendement des programmes de colposcopie chez les femmes de 20 à 69 ans qui avaient subi un test de Pap en 2009 et en 2010. Résultats : En tout, 37 523 femmes avaient obtenu des résultats de test de Pap indiquant la présence d'une anomalie de haut grade histologique ou d'une anomalie plus grave. La proportion des femmes qui ont subi une colposcopie ≤ 90 jours à la suite de leur test de Pap se situait entre 30,9 % et 51,5 %. Moins de femmes du groupe d'âge des 60 à 69 ans ont subi une colposcopie, par comparaison avec les femmes des groupes d'âge plus jeunes. La proportion des femmes qui avaient obtenu des résultats de test de Pap indiquant la présence d'une anomalie de haut grade histologique ou d'une anomalie plus grave, qui ont subi une colposcopie et qui ont subi une biopsie dans un délai de 12 mois se situait entre 82,1 % et 96,5 %. La proportion des résultats de biopsie qui concordaient avec les résultats de test de Pap se situait entre 59,5 % et 82,1 %. Conclusion : Le délai entre l'obtention de résultats de test de Pap indiquant la présence d'une anomalie de haut grade histologique et la tenue d'une colposcopie se doit d'être réduit pour que l'on puisse abaisser le risque d'issues indésirables et le stress qui sont associés au report du suivi. Le taux de concordance des résultats cytologiques et histologiques atteint la cible nationale de ≥ 65 %. Bien que six des 13 provinces et territoires aient fourni des données sur les mesures de rendement associées à la colposcopie, plus de renseignements s'avèrent requis pour que l'on puisse évaluer avec précision les services de colposcopie au niveau national.

Comparative models of cervical cancer screening in Manitoba.

The laboratory system in Manitoba for routine cervical screening is outdated and costly. We developed a costing framework for the implementation of new cervical cancer screening technology models. The direct healthcare costs in the baseline model, the conventional Papanicolaou smear test, were compared with estimates of two newer technology platforms, liquid-based cytology and human papillomavirus (HPV) testing. The findings revealed that HPV testing as a primary screening model for women aged 30 years and older represented the least-cost strategy. Liquid-based cytology would be used for routine screening of women under 30 years of age and to triage women 30 years and older whose results were HPV positive.

Quality of pathology reports for advanced ovarian cancer: are we missing essential information? An audit of 479 pathology reports from the EORTC-GCG 55971/NCIC-CTG OV13 neoadjuvant trial.

OBJECTIVE: To assess the quality of surgical pathology reports of advanced stage ovarian, fallopian tube and primary peritoneal cancer. This quality assurance project was performed within the EORTC-GCG 55971/NCIC-CTG OV13 study comparing primary debulking surgery followed by chemotherapy with neoadjuvant chemotherapy and interval debulking surgery. METHODS: Four hundred and seventy nine pathology reports from 40 institutions in 11 different countries were checked for the following quality indicators: macroscopic description of all specimens, measuring and weighing of major specimens, description of tumour origin and differentiation. RESULTS: All specimens were macroscopically described in 92.3% of the reports. All major samples were measured and weighed in 59.9% of the reports. A description of the origin of the tumour was missing in 20.5% of reports of the primary debulking group and in 23.4% of the interval debulking group. Assessment of tumour differentiation was missing in 10% of the reports after primary debulking and in 20.8% of the reports after interval debulking. Completeness of reports is positively correlated with accrual volume and adversely with hospital volume or type of hospital (academic versus non-academic). Quality of reports differs significantly by country. CONCLUSION: This audit of ovarian cancer pathology reports reveals that in a substantial number of reports basic pathologic data are missing, with possible adverse consequences for the quality of cancer care. Specialisation by pathologists and the use of standardised synoptic reports can lead to improved quality of reporting. Further research is needed to better define pre- and post-operative diagnostic criteria for ovarian cancer treated with neoadjuvant chemotherapy.

The Manitoba human papillomavirus vaccine surveillance and evaluation system.

BACKGROUND: With the recent introduction of a human papillomavirus (HPV) vaccine in Canada, it is important to establish surveillance and evaluation programs that not only track the uptake of the vaccine, but also assess its safety and its impact on: distribution of HPV type, cervical cancer screening programs, the incidence of anogenital warts, precancerous lesions and various cancers, and sexual behaviour. DATA SOURCES AND METHODS: Administrative databases, registries and questionnaire information are being linked to identify people receiving the HPV vaccine and to develop an evaluation system. INTERPRETATION: The availability of extensive linkable databases in Manitoba allows for the development of a comprehensive HPV vaccine surveillance and evaluation system that can address many of the questions related to the HPV vaccine. Aspects of the Manitoba surveillance and evaluation system could be implemented in other provinces that have similar databases.

Initial evaluation and referral guidelines for management of pelvic/ovarian masses.

OBJECTIVES: To optimize the management of adnexal masses and to assist primary care physicians and gynaecologists determine which patients presenting with an ovarian mass with a significant risk of malignancy should be considered for gynaecologic oncology referral and management. OPTIONS: Laparoscopic evaluation, comprehensive surgical staging for early ovarian cancer, or tumour debulking for advanced stage ovarian cancer. OUTCOMES: To optimize conservative versus operative management of women with possible ovarian malignancy and to optimize the involvement of gynaecologic oncologists in planning and delivery of treatment. EVIDENCE: Published literature was retrieved through searches of PubMed or MEDLINE, CINAHL, and the Cochrane Library, using appropriate controlled vocabulary and key words. Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. Grey (unpublished) literature was identified by searching the web sites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. RECOMMENDATIONS: 1. Primary care physicians and gynaecologists should always consider the possibility of an underlying ovarian cancer in patients in any age group who present with an adnexal or ovarian mass. (II-2B) 2. Appropriate workup of a perimenopausal or postmenopausal woman presenting with an adnexal mass should include evaluation of symptoms and signs suggestive of malignancy, such as persistent pelvic/abdominal pain, urinary urgency/frequency, increased abdominal size/bloating, and difficulty eating. In addition, CA125 measurement should be considered. (II-2B) 3. Transvaginal or transabdominal ultrasound examination is recommended as part of the initial workup of a complex adnexal/ovarian mass. (II-2B) 4. Ultrasound reports should be standardized to include size and unilateral/bilateral location of the adnexal mass and its possible origin, thickness of septations, presence of excrescences and internal solid components, vascular flow distribution pattern, and presence or absence of ascites. This information is essential for calculating the risk of malignancy index II score to identify pelvic mass with high malignant potential. (IIIC) 5. Patients deemed to have a high risk of an underlying malignancy should be reviewed in consultation with a gynaecologic oncologist for assessment and optimal surgical management. (II-2B).

Twenty-year trends in the incidence and prevalence of diagnosed anogenital warts in Canada.

BACKGROUND: A vaccine has recently been licensed in many countries that protects against the human papillomavirus types 6, 11, 16, and 18. Types 6 and 11 account for approximately 90% of anogenital warts (AGWs). We describe the 20-year trends in the incidence and prevalence of AGWs in Manitoba, Canada. METHODS: We used linked population-based hospital and physician databases for Manitoba for 1984 to 2004. Cases were identified using tariff (billing) and ICD codes. A case was considered to be incident if it was preceded by a 12-month interval free period of AGWs care. Otherwise, it was deemed to be prevalent. An episode was considered over once a 12-month interval had elapsed without an AGW claim. RESULTS: Approximately 25,000 Manitobans were diagnosed with AGWs between 1985 and 2004. The annual age-standardized incidence rates peaked in 1992 (men, 149.9/100,000; women 170.8/100,000). In recent years, the rates have been increasing again, particularly for men. The male:female incidence rate ratio increased from 0.76 in 1985 to 1.25 in 2004. The highest incidence rate tended to be in those aged 20 to 24 years. Trends in prevalence were similar. Prevalence in 2004 was 165.2/100,000 for men and 128.4/100,000 for women. CONCLUSIONS: These population-based findings suggest that AGWs are a substantial burden to Manitobans and that their pattern has changed over time, with incidence and prevalence becoming higher in men than women. Monitoring the future trends in AGWs will provide an early marker of the effectiveness and duration of protection of human papillomavirus vaccination at a population level.

Papanicolaou test utilization and frequency of screening opportunities among women diagnosed with cervical cancer.

BACKGROUND: Although the importance of Papanicolaou (Pap) smear test screening in reducing the incidence of cervical cancer is well established, in 1994-95 one in 4 women in Manitoba aged 18 to 69 years reported never having had a Pap test or not having had a Pap test in the last 3 years. The objectives of this study were to examine the screening history of women in Manitoba diagnosed with invasive cervical cancer and to explore whether opportunities for screening were missed. METHODS: In this case-control study women aged 18 years and older who resided in Manitoba and were diagnosed with invasive cervical cancer between 1989 and 2001 were each matched by age and area of residence to 5 controls, (N = 4009). Conditional logistic regression analyses were used to examine the association between Pap test utilization and the likelihood of diagnosis with invasive cervical cancer. Generalized linear models using the negative binomial distribution were used to assess the association between cancer status and rates of prior Pap testing and of opportunities to be screened. Logistic generalized estimating equation models were used for the analysis of physician characteristics. RESULTS: Forty-six percent of women in Manitoba diagnosed with invasive cervical cancer and 67% of the control group had received a Pap test in the 5 years before the case's diagnosis. After adjustment for age, income and residence, the rate of Pap testing was significantly higher in the control group (rate ratio [RR] = 1.57, 95% confidence interval [CI] 1.44-1.73). Conversely, when cervical cancer was the outcome, women who had not had Pap tests were more likely to be diagnosed with invasive cervical cancer (odds ratio [OR] = 2.77, 95% CI 2.30-3.30) than women who did have a Pap test. Although women diagnosed with invasive cervical cancer had fewer Pap tests, they had had as many opportunities to be screened as controls (RR = 1.04, 95% CI 0.96-1.12). Compared with urban family physicians, rural family physicians were less likely to provide Pap tests (OR = 0.68, 95% CI 0.58-0.80) and specialists were more likely to provide Pap tests (OR = 1.70, 95% CI 1.30-2.22). CONCLUSIONS: Women who were diagnosed with invasive cervical cancer in the province of Manitoba, Canada, had fewer Pap tests but the same frequency of opportunities to be screened as matched controls. These results reinforce the need to educate women about cervical cancer screening and the importance of receiving Pap tests.

Cervical cancer in the province of Manitoba: a 30-year experience.

OBJECTIVES: This study was undertaken to analyze trends in cervical cancer incidence by histological type and to track the survival rate in the province of Manitoba over a 30-year period. METHODS: Data from the Manitoba Cancer Registry (MCR) relating to all cases of cervical cancer that occurred between 1970 and 1999 in the province of Manitoba were analyzed to calculate incidence and survival rates according to histological subtype. RESULTS: Over this 30-year span, invasive cervical cancer was diagnosed in 1927 women, and carcinoma in situ was diagnosed in 10 006 women. Cervical cancer was the fifth most frequent cancer diagnosis for women in 1970, and by 1999 it had become the eleventh most frequent. The incidence rate for cervical cancer decreased from 21.6/100 000 women in 1970 to 8.8/100 000 women in 1999. The mortality rate for women with cervical cancer fell from 7.3/100 000 women in 1970 to 2.8 /100 000 women in 1999. Squamous cell carcinoma (SCC) was the most frequently diagnosed histologic subtype, but its incidence decreased from 1970 to 1999; the proportion of women with adenocarcinoma increased gradually over the same time from 7% to 22%. Survival rates were comparable in women with SCC and adenocarcinoma. In 1999, the incidence of cervical cancer in Manitoba was comparable to the Canadian rate. However, the mortality rate from cervical cancer was higher in Manitoba than in Canada overall. CONCLUSION: The incidence of cervical cancer and the incidence of cervical cancer-related deaths in Manitoba both dropped between 1970 and 1999. However, the incidence of cervical carcinoma in situ has increased steadily during the same period. These observations may reflect the effect of screening programs on the detection and treatment of cervical cancer precursors. Squamous cell carcinoma is still the most frequently diagnosed subtype of invasive cervical cancer, but the proportion of women with adenocarcinoma has increased. Deaths from cervical cancer showed a non-significant reduction over the study period.

Stage II endometrial carcinoma: limiting post-operative radiotherapy to the vaginal vault in node-negative tumors.

OBJECTIVE: To evaluate the outcomes of patients with node-negative stage II endometrial cancer who received vault brachytherapy without external beam pelvic radiotherapy (EBRT). METHODS: A retrospective review of all stage II endometrioid type endometrial cancer patients referred to Cancer Care Manitoba was undertaken between October 1995 and March 2001. Forty-nine patients were identified with disease confined to the uterus, but not all patients received extended surgical staging (ESS) with pelvic lymphadenectomy. These patients were evaluated for recurrence and morbidity data. RESULTS: Twenty node-negative stage II cancers were identified. Three were treated without adjuvant treatment, 12 received vault brachytherapy and 5 received more conventional treatment with EBRT and vault brachytherapy. No recurrences or deaths occurred in these patients. Mean follow-up was 40 months. No surgical complications were encountered in this group and no morbidity from radiotherapy was observed. CONCLUSIONS: Limiting adjuvant treatment to vault brachytherapy for node-negative stage II endometrial cancer results in less morbidity and excellent survival and is worthy of further investigation.

Report of the 2003 pan-Canadian forum on cervical cancer prevention and control.

OBJECTIVE: To develop evidence-based consensus recommendations on the delivery of cervical cancer screening, human papillomavirus (HPV) education, HPV testing, and the optimal tool for cervical cytology within the Canadian health system. PARTICIPANTS: Leading up to a forum held in Ottawa on November 21 and 22, 2003, 254 registrants reviewed position papers through a Web-based discussion group. Experts in program management, clinical practice, epidemiology, public health, economics, and women's health, representing 48 organizations, then participated in the 2-day forum to develop consensus recommendations. EVIDENCE: Writing groups prepared position papers on optimal methods for cervical cytology; education concerning HPV; HPV testing in primary screening; HPV testing as a triage tool in cytopathology; and delivery mechanisms for cervical screening. Systematic reviews were the primary source of evidence supplemented by literature searches. CONSENSUS PROCESS: Feedback from Web-based discussions was incorporated into consecutive drafts of position papers. At the forum, recommendations and supporting evidence were presented, further debated in small-group sessions, and discussed in a plenary session. Despite divergent professional mandates and opinions, consensus was achieved on 15 recommendations across all areas. Final recommendations were posted to the Web for further input and circulated for written consensus by participants. CONCLUSIONS: The recommendations cover the use of new evidence and technologies in cervical cancer prevention in Canada and provide a framework for provision of HPV education, planning the implementation of new cervical screening technologies in Canada, the development of evaluation plans, and new research areas.

High-risk surgical stage 1 endometrial cancer: outcomes with vault brachytherapy alone.

OBJECTIVE: Prior to 1995, in our center, patients with surgically staged endometrial cancer with greater than 50% myoinvasion (FIGO 1C) were treated with vault brachytherapy and whole pelvis (WP) radiotherapy despite negative nodes. After October 1, 1995, these patients were treated with vault brachytherapy alone. The aim of this study was to ensure that the survival and recurrence rate had not changed. METHODS: A retrospective review of Cancer Care Manitoba charts was undertaken. All patients diagnosed with endometrioid adenocarcinoma between October 1, 1995, and March 1, 2001, were reviewed. Data for all FIGO surgical stage 1 patients, and a subset of stage 1C patients, were analyzed and compared with those of a historical control group, composed of patient data previously collected in our center (1978 to 1990) [Gynecol. Oncol. 55 (1994), 51]. RESULTS: A total of 172 patients had negative selective pelvic lymphadenectomy and FIGO stage 1 disease. Fifty-three stage 1C patients were spared WP radiotherapy. Median follow-up was 32 months. Recurrence rate in FIGO stage 1 disease was 2.3% (4/172) and for the subset 1C was 5.7% (3/53). The recurrence rate was not statistically significantly different from that of the historical control group, 3.6% for stage 1 (P = 0.562) and 7.2% for stage 1C (P = 0.51). Two- and five-year survival rates for stage 1 patients in this study were 97 and 95%, respectively. In the historical group, 2- and 5-year survival rates were 97 and 94%. CONCLUSION: Whole pelvis radiotherapy can be safely omitted in patients with FIGO stage 1C endometrial cancer if nodal status is known.