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ORIGINAL RESEARCH |
From the Department of Family Medicine, Division of Gynecologic Oncology, Obstetrics, and Gynecology, and the Department of Preventive Medicine, Comprehensive Cancer Center, University of Wisconsin School of Medicine, Madison, Wisconsin.
Address reprint requests to: Kathleen A. Oriel, MD Department of Family Medicine University of Wisconsin Medical School 777 South Mills Street Madison, WI 53715
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Abstract |
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Methods: The mortality data of the Centers for Disease Control and Prevention were accessed using the Wide-ranging ONline Data for Epidemiologic Research (WONDER). We selected all deaths among women with International Classification of Diseases, Ninth Revision (ICD-9) code 183.0 (ovarian malignant neoplasm). Mortality data for the years 1979–1995 were age-adjusted to the United States 1990 female population, and mortality rates for each year were calculated for females of all ages by age category, by race, and by geographic location. Trends were obtained for the periods 1979–1983 to 1991–1995, and the impact on the number of ovarian cancer deaths was calculated.
Results: Age-adjusted ovarian cancer mortality rates have changed little in the United States from 1979 to 1995, but rates are increasing in older women (65 years and older) and decreasing in younger women. Age-adjusted mortality rates are higher among whites than in blacks. Ovarian cancer mortality rates are higher in northern compared with southern states.
Conclusion: The trends in ovarian cancer mortality among younger and older women parallel published changes in incidence and may be due to changes in risk factors, such as the use of oral contraceptives. The reasons for the higher ovarian cancer death rates in northern states are unknown. Better understanding of how modifiable risk factors and treatment methods affect ovarian cancer mortality trends is needed.
Ovarian cancer is the fourth leading cause of cancer death among women, with one in 70 women developing this disease during her lifetime.1 Known risk factors for ovarian cancer include advanced age, family history, nulliparity, early menarche and late menopause, white race, higher socioeconomic status, and residence in North America and northern Europe.2 Unlike cervical and breast cancer, there is no effective method of screening for ovarian cancer, and screening techniques for high-risk women remain controversial.3
Treatment advances over the last 20 years include platinum-based chemotherapy and paclitaxel, emphasis on aggressive pelvic surgical tumor debulking, novel strategies for drug delivery such as intraperitoneal infusion, and investigation of biologic response modifiers.4 Relative survival rates have improved over time,5 with improvement paralleling more aggressive surgical management and effective chemotherapy.6
This study describes trends in United States ovarian cancer mortality over time from 1979 to 1995 in all ages and by age, race, and geographic location. This information can be used to understand ovarian cancer trends over time in an aging United States population.
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Materials and Methods |
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AbstractMaterials and MethodsResultsDiscussionReferences |
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Trends for the periods 1979–1983 to 1991–1995 were obtained overall and by age and race. To assess the impact of changing rates on the number of ovarian cancer deaths, we subtracted the death rate during 1991–1995 from the death rate during 1979–1983 for each age category. This rate difference was then multiplied by the 1995 population in each age group.
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Results |
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). For younger women, mortality rates decreased for the periods 1979–1983 to 1991–1993, resulting in 808 fewer deaths in 1991–1995 than would have occurred if the rates had persisted at the previous levels (Table 2). Half of these deaths avoided were among women 45–54 years of age. In contrast, ovarian cancer mortality rates increased among women 65 years of age and older, representing 1201 more deaths in 1991–1995 than would have occurred if the rates had persisted at 1979–1983 levels. Almost half of these excess deaths were among women 75–84 years of age. Because older women experienced a greater increase in death rates, there were 403 more deaths from ovarian cancer among women of all ages in 1991–1995 than would have occurred had mortality continued at the 1979–1983 rates.
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Age-adjusted mortality rates were higher in the northern United States than in southern states (Figure 2). This geographic trend was similar for younger and older women and was similar during the earlier and later periods studied (data not shown).
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Discussion |
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Changes in the use of oral contraceptives (OCs) might explain the decreasing incidence and mortality rates among younger women in the United States. Two analyses of ovarian cancer in England and Wales9,10 and one Swedish study7 showed that cohorts with increased exposure to OCs had marked decreases in the incidence of ovarian cancer. Authors have also reported that ovarian cancer risk increased for earlier cohorts of women as family size decreased.10,11 In addition to a decreasing incidence of ovarian cancer in younger women, improved treatment of germ cell malignancies, which are more common in younger women, may contribute slightly to the decreased mortality in women younger than 65 years.12,13
It is not clear what might explain the increasing mortality rates among older women. Younger women with ovarian cancer tend to have earlier stages of disease than older women, but even when matched by stage, survival is poorer in older women. This poorer survival has been attributed to less aggressive treatment with surgery and chemotherapy in older women.14 Unless the tendency to undertreat older women has worsened over time, however, this cannot explain the increasing mortality in this cross-section of older women.
We found that overall ovarian cancer mortality has changed little from 1979 to 1995. The National Cancer Institute5 reported that age-adjusted ovarian cancer mortality rates declined 9% over the last 16 years, yet our analysis showed a slight increase. The National Cancer Institute and other investigators use a 1970 United States standard million in age-adjusting mortality rates. This method gives greater weight to the younger population of 1970 compared with the current female census. Giving greater weight to younger women leads to decreasing overall mortality rates because rates are declining among younger women. Age-adjusting to the 1990 United States female population, as in this analysis, more accurately reflects the current population. This adjustment gives greater weight to older women, who are experiencing increasing mortality, resulting in the slight rise in ovarian cancer deaths demonstrated here. This reflects what is happening over time: Our population is aging and the number of ovarian cancer deaths is increasing.
The CDC database contains the underlying cause of death for all death certificates, so reporting bias is unlikely to account for the demonstrated trends. If physicians have become better over time at recognizing ovarian cancer as a cause of death, this could theoretically result in greater numbers of deaths being attributed to ovarian cancer, but we believe that this is unlikely.
White women experience higher ovarian cancer mortality than women of other races. Higher mortality parallels a higher ovarian cancer incidence among white women. Our analysis demonstrates that the increase in mortality rates over time was greater among women of other races than among white women. These racial differences are most likely due to yearly variation. The number of deaths was relatively small among nonwhite women, so a change of relatively few deaths (115 deaths for black women and 50 for "other" women) resulted in a large percentage change in death rates. Data from the Surveillance, Epidemiology, and End Results study5 suggested no major differences between whites and blacks in ovarian cancer 5-year relative survival rates, survival by stage, and stage at diagnosis. These racial trends must be followed over time to determine whether important differences exist in detection or survival.
Our finding of higher mortality rates in northern than in southern states has been reported previously but not explained. Several factors could account for the geographic variation in ovarian cancer mortality, including higher proportions of northern European descendants, differences in OC use, different fertility patterns, variations in medical services, or other environmental factors. Reporting bias is unlikely to contribute to this geographic distribution because similar geographic trends are not seen with other gynecologic malignancies. Further study of the higher ovarian cancer mortality in northern states may show variations in predisposing or protective exposures, or it may lead to clues about the etiology of this elusive disease.
We need to understand the reasons for the declining rates of ovarian cancer mortality among younger women and the increasing rates among older women in the United States. As the cohort of women at highest risk of ovarian cancer (decreasing fertility and no exposure to OCs) ages, the age at which mortality increases in cross-sectional studies should also rise. This trend must be followed to see whether anticipated decreases in mortality actually occur.
A comprehensive approach to disease control includes prevention, early detection, and treatment. We need a better understanding of the modifiable risk factors for ovarian cancer. We need to identify better methods for early detection, to find the disease while it is still early and when chances for cure are greater. Finally, we need to increase the effectiveness of treatments, especially among older women.
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Footnotes |
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Received March 16, 1998. Received in revised form July 13, 1998. Accepted July 24, 1998.
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References |
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2. Tortolero-Luna G, Mitchell MF, Rhodes-Morris HE. Epidemiology and screening of ovarian cancer. Obstet Gynecol Clin North Am 1994;21:1–23.[Medline]
3. NIH Consensus Development Panel on Ovarian Cancer. Ovarian cancer: Screening, treatment, and follow-up. JAMA 1996;273:491–7.
4. Qazi F, McGuire WP. Treatment of epithelial ovarian cancer. CA Cancer J Clin 1995;45:88–101.[Abstract]
5. Ries LAG, Kosary CL, Hankey BF, Miller BA, Harras A, Edwards BK, eds. SEER cancer statistics review: 1973–1994, National Cancer Institute. NIH publication no. 97-2789. Bethesda, Maryland: NIH, 1997.
6. Averette HE, Janicek MF, Menck HR. The national cancer data base report on ovarian cancer. Cancer 1995;76:1096–103.[Medline]
7. Adami HO, Bergstrom R, Persson I, Sparen P. The incidence of ovarian cancer in Sweden, 1960–1984. Am J Epidemiol 1990;132: 446–52.
8. Hanai A. Trends and differentials in ovarian cancer: Incidence, mortality, and survival experience. APMIS 1990;12:1–20.
9. Villard-Mackintosh L, Vessey MP, Jones L. The effects of oral contraceptives and parity on ovarian cancer trends in women under 55 years of age. Br J Obstet Gynaecol 1989;96:783–8.[Medline]
10. Silva IS, Swerdlow AJ. Recent trends in incidence of and mortality from breast, ovarian and endometrial cancer in England and Wales and their relation to changing fertility and oral contraceptive use. Br J Cancer 1995;72:485–92.[Medline]
11. Ewertz M, Kjaer SK. Ovarian cancer incidence and mortality in Denmark, 1943–1982. Int J Cancer 1988;42:690–6.[Medline]
12. Williams S, Blessing JA, Liao SY, Ball H, Hanjani P. Adjuvant therapy of ovarian germ cell tumors with cisplatin, etoposide, and bleomycin: A trial of the Gynecologic Oncology Group. J Clin Oncol 1994;12:701–6.[Abstract]
13. Gershenson DM. Management of early ovarian cancer: Germ cell and sex cordstromal tumors. Gynecol Oncol 1994;55:S62–72.[Medline]
14. Ries LAG. Ovarian cancer: Survival and treatment difference by age. Cancer 1993;71(2 Suppl):524–9.[Medline]
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