Abstract
BackgroundLittle is known about the impact of comorbidity on cervical cancer survival in Australian women, including whether Indigenous women’s higher prevalence of comorbidity contributes to their lower survival compared to non-Indigenous women.MethodsData for cervical cancers diagnosed in 2003–2012 were extracted from six Australian state-based cancer registries and linked to hospital inpatient records to identify comorbidity diagnoses. Five-year cause-specific and all-cause survival probabilities were estimated using the Kaplan-Meier method. Flexible parametric models were used to estimate excess cause-specific mortality by Charlson comorbidity index score (0,1,2+), for Indigenous women compared to non-Indigenous women.ResultsOf 4,467 women, Indigenous women (4.4%) compared to non-Indigenous women had more comorbidity at diagnosis (score ≥1: 24.2% vs. 10.0%) and lower five-year cause-specific survival (60.2% vs. 76.6%). Comorbidity was associated with increased cervical cancer mortality for non-Indigenous women, but there was no evidence of such a relationship for Indigenous women. There was an 18% reduction in the Indigenous: non-Indigenous hazard ratio (excess mortality) when comorbidity was included in the model, yet this reduction was not statistically significant. The excess mortality for Indigenous women was only evident among those without comorbidity (Indigenous: non-Indigenous HR 2.5, 95%CI 1.9–3.4), indicating that factors other than those measured in this study are contributing to the differential. In a subgroup of New South Wales women, comorbidity was associated with advanced-stage cancer, which in turn was associated with elevated cervical cancer mortality.ConclusionsSurvival was lowest for women with comorbidity. However, there wasn’t a clear comorbidity-survival gradient for Indigenous women. Further investigation of potential drivers of the cervical cancer survival differentials is warranted.ImpactThe results highlight the need for cancer care guidelines and multidisciplinary care that can meet the needs of complex patients. Also, primary and acute care services may need to pay more attention to Indigenous Australian women who may not obviously need it (i.e. those without comorbidity).
Highlights
Comorbidity was associated with increased cervical cancer mortality for non-Indigenous women, but there was no evidence of such a relationship for Indigenous women
There was an 18% reduction in the Indigenous: non-Indigenous hazard ratio when comorbidity was included in the model, yet this reduction was not statistically significant
The results highlight the need for cancer care guidelines and multidisciplinary care that can meet the needs of complex patients
Summary
Cancer patients commonly have comorbidities.[1, 2] There is evidence that higher comorbidity burden is associated with worse survival for cancer patients.[3,4,5] The prevalence of comorbidity varies between population groups and may contribute to cancer survival disparities, for different ethnic groups.[6,7,8,9,10,11]Evidence regarding the effect of comorbidity on survival for cervical cancer is limited and inconsistent: comorbidity was not associated with higher mortality for Italian[12] or Mexican [13] women with cervical cancer; it was associated with higher all-cause mortality but not cancer-specific mortality for women in the United States;[14, 15] and it was associated with both all-cause and cancer-specific mortality for New Zealand (NZ) women.[11]In Australia, cervical cancer incidence and mortality have fallen by approximately 50% since the introduction of the National Cervical Screening Program in 1991.[16, 17] Five-year survival improved during the 1990s and has remained steady at about 72% since .[18]. Cancer patients commonly have comorbidities.[1, 2] There is evidence that higher comorbidity burden is associated with worse survival for cancer patients.[3,4,5] The prevalence of comorbidity varies between population groups and may contribute to cancer survival disparities, for different ethnic groups.[6,7,8,9,10,11]. Little is known about the impact of comorbidity on cervical cancer survival in Australian women, including whether Indigenous women’s higher prevalence of comorbidity contributes to their lower survival compared to non-Indigenous women
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