許多因素與陰道癌死亡風險增加有關


  June 9, 2009 — 根據5月份婦產科期刊的研究結果,腫瘤分期、腫瘤大小、組織特徵以及治療方法都與陰道癌死亡率風險增加有關。
  
  華盛頓大學的Chirag A. Shah醫師等人寫道,已知會增加婦女陰道癌的終身風險因素,包括初次性行為年紀輕、性伴侶多、抽菸、胚胎時期暴露在乙烯雌酚、人類乳突病毒(HPV)感染。引起陰道癌的原因與子宮頸癌密切相關,HPV感染似乎是多數案例的共同必要因素。
  
  研究目標在評估人口統計學因素、腫瘤病理特徵、選擇的陰道癌治療方式等的死亡率關聯。研究者在1990至2004年間研究了2,149名診斷有原發性陰道癌的婦女,使用參與「監測、流行病學及最終結果計畫」的17個族群基礎癌症登記資料庫。使用Cox正比例風險模式以確認各種人口統計學因素、腫瘤病理特徵、選擇的陰道癌治療方式等之間的關係。
  
  診斷時的平均年紀為65.7 ± 14.3歲,約有三分之二是非西班牙裔白人。不過,非洲裔美國婦女的陰道癌發生率最高(每100,000人-年有1.24例)。疾病分期越高則5年特定疾病存活者越少,第1期有84%、第2期有75%、第3/4期有57%。多變項校正模式中,腫瘤大小超過4公分者的死亡風險增加(風險比[HR]為1.71)、末期疾病風險也增加(HR,4.67)。
  
  陰道黑色素瘤婦女的死亡率風險是鱗狀細胞癌婦女的1.51倍(95%信心區間:1.07 - 2.41)。治療方法中,單純手術者的死亡率風險最低。相較於1990至1994年間診斷的婦女,於2000年之後診斷的婦女死亡風險降低17%,研究認為死亡率風險隨著時間降低。
  
  研究作者寫道,腫瘤分期、腫瘤大小、組織學、治療方法等顯著影響陰道癌婦女的死亡風險。隨著化學放射療法的出現,似乎有存活上的幫助。
  
  研究限制包括屬於觀察性設計,使用現有的資料,半數以上案例缺乏腫瘤大小的資料,缺乏化療的資料,可能有其他未探討的可能干擾因素。
  
  研究作者結論表示,當可能是早期疾病時,手術似乎可以有存活利益。依舊必須依照病患的狀況決定治療方式,因為不可能進行前溯試驗來解答這個問題。未來,我們將觀察現代的治療進步是否會有死亡率繼續下降的趨勢;但是目前,陰道癌婦女使用化學放射療法似乎與持續降低的死亡率風險有關。
  
  國家健康研究中心(NIH)腫瘤訓練資金、Fred Hutchinson癌症研究中心、華盛頓大學NIH K30 臨床研究訓練計畫支持本研究。研究作者宣告沒有相關財務關係。
  

Several Factors Linked to Increased Risk for Mortality From Vaginal Cancer

By Laurie Barclay, MD
Medscape Medical News

June 9, 2009 — Stage, tumor size, histologic features, and treatment modality are associated with an increased risk for mortality from vaginal cancer, according to the results of a study reported in the May issue of Obstetrics & Gynecology.

"Recognized factors that increase a woman's lifetime risk of vaginal cancer include younger age at coitarche, greater number of lifetime sexual partners, smoking, in utero diethylstilbestrol exposure, and human papillomavirus (HPV) infection," write Chirag A. Shah, MD, MPH, from the University of Washington in Seattle, and colleagues. "The cause of vaginal cancer is closely linked to cervical cancer, and HPV infection seems to be a necessary cofactor in most cases."

The goal of this study was to assess the current effect on mortality of demographic factors, pathologic characteristics of the tumor, and choice of treatment in women with vaginal cancer. The investigators identified 2149 women diagnosed with primary vaginal cancer between 1990 and 2004, using data from 17 population-based cancer registries participating in the Surveillance, Epidemiology, and End Results program. Cox proportional hazards modeling was used to determine the association between various demographic factors, tumor characteristics, and treatments and risk for vaginal cancer mortality.

At diagnosis, mean age was 65.7 ± 14.3 years, and approximately two thirds were non-Hispanic whites. However, African American women had the highest incidence of vaginal cancer (1.24 per 100,000 person-years). Higher stage predicted lower 5-year disease-specific survival duration, which was 84% for stage I, 75% for stage II, and 57% for stage III/IV. The risks for mortality were increased for tumor size greater than 4 cm (hazard ratio [HR], 1.71) and for advanced disease (HR, 4.67), as determined in a multivariate adjusted model.

Women with vaginal melanoma had a 1.51-fold increased risk for mortality vs those who had squamous cell carcinomas (95% confidence interval, 1.07 - 2.41). In treatment modality, surgery alone had the lowest risk for mortality. Compared with women diagnosed from 1990 to 1994, those diagnosed after 2000 had an adjusted 17% decrease in their risk for death, suggesting a decrease in risk of mortality with time.

"Stage, tumor size, histology, and treatment modality significantly affect a woman's risk of mortality from vaginal cancer," the study authors write. "There seems to be a survival advantage that is temporally related to the advent of chemoradiation."

Limitations of this study include observational design, use of data that had already been collected, missing data on tumor size for more than half of cases, lack of data on chemotherapy, and possible residual confounding by unmeasured predictors.

"When possible in early stage disease, surgery seems to confer a survival advantage," the study authors conclude. "The decision on treatment modality must still be made in the context of the individual patient, because it is unlikely that prospective trials will be undertaken to answer this specific question. In the future we may be able to see if the trend of decreased mortality with modern treatment continues; but presently, it seems there may be an ongoing reduction in the risk of mortality associated with the use of chemoradiation in women with vaginal cancer."

A National Institutes of Health (NIH) Oncology Training Grant, the Fred Hutchinson Cancer Research Center, and the NIH K30 Clinical Research Training Program at the University of Washington in Seattle supported this study. The study authors have disclosed no relevant financial relationships.

Obstet Gynecol. 2009;113:1038-1045.

    
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