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Survival and prognostic factors for cervical cancer: a hospital based study in Mysuru, India

Cervical cancer continues to have a major impact on women worldwide, particularly women in developing countries. Cervical cancer has been the most important cancer among women in India, over the past two decades. 1 One in every five women in the world suffering from cervical cancer belongs to India which has the largest burden of cervical cancer patients in the world. 2 It is predicted that if conditions remain the same in India, by 2020, the number of women newly diagnosed with cervical cancer will be 1,82,027 and over a lakh (1,01,362) will succumb to the disease each year. 3

Survival refers to the life of a person after diagnosis of the disease. Survival studies measure the overall performance of a group of patients in terms of quality and quantity of life after diagnosis or treatment. It gives an overview of differences among populations pertaining to age, ethnicity, socio economic status, stage of diagnosis, treatment etc. Besides incidence and clinical stage at presentation, knowledge of survival is essential to monitor and evaluate cancer control programme. The lower survival rates in developing countries reflect lack of awareness, inadequate screening facilities, the advanced stages of disease at presentation and inadequate treatment due to poor patient compliance, financial constraints and inadequate treatment facilities.
This study was conducted to determine the survival rates and prognostic factors in cervical cancer patients. The observations from the present study will provide useful inputs for policy makers so that efforts can be directed towards universalization of cervical cancer detection and treatment.

METHODS
This combined prospective and retrospective study was conducted for a period of one year during January 2012 -December 2012 in a tertiary care cancer hospital at Mysuru. Institutional Ethics Committee approval and required permission from hospital authorities were obtained prior to the start of the study. The study subjects were 380 newly diagnosed cervical cancer patients during the period 1st January 2006-31st December 2007. Patients who were registered prior to the study period and already on treatment were excluded from the study. Survival status of the patient at five years was assessed by follow up either through telephone, house visits and review of follow up details in the hospital registry taking feasibility factor into account.
A pre tested structured questionnaire was used to collect data regarding socio-demographic profile, details of reproductive factors, clinical features, diagnosis, treatment details and survival status of the patients. The socio demographic profile consisted of name, age, residential address, locality, religion, marital status, education and socio economic status. The modified B.G. Prasad's Classification was used to assess the socio economic status. 4 Reproductive factors included age at marriage, age at first sexual intercourse, age at first pregnancy, parity and age at menopause. Symptoms of cervical cancer and its duration, performance status at presentation, history of reproductive tract and sexually transmitted infections were obtained. Diagnosis details included date and method of diagnosis, histology and International Federation of Gynaecology and Obstetrics (FIGO) staging. 5 The survival status of the patient was assessed at the end of five years after diagnosis.
Data thus obtained was coded and entered into Microsoft Excel worksheet. This was analyzed using SPSS version 18. Survival analysis was done using the Kaplan Meier method. The Log rank test and Breslow test were used to test the statistical significance. Cox proportional hazards regression model was used to find the prognostic factors associated with cervical cancer.

RESULTS
In the present study consisting of 380 cervical cancer patients, 183 (48.1%) were alive, 147 (38.7%) were dead and 50 (13.2%) were lost to follow up by the end of 5 years. To find out the association of various factors influencing survival in cervical cancer patients, 330 patients were included since 50 were lost to follow up. Loss to follow up was due to migration of the patients, inability to trace the address and change in telephone numbers.
The survival rate was 53.8% among patients aged < 35 years when followed up for five years. 65.8% and 56.8% of the patients survived in the 35-49 and 50-64 years age group. Whereas among patients aged more than 65 years the survival was only 30.9%. The median survival time (14 months) was the highest among patients in the age group of 50-64 years. Patients aged < 35 years as well as patients aged > 65 years had a median survival time of 6 months (Table1), (Figure 1).
Nulliparous women had a median survival time of 18 months whereas women who had given birth to >4 children had a median survival time of 12 months. Patients who had the habit of chewing tobacco had a median survival time of 8 months compared to 12 months in non chewers (Table 1).
Patients who were active at the time of presentation to the hospital had a median survival time of 14 months. The median survival time was only 3 months among the bedridden patients (Table 1), (Figure 2). Patients who were diagnosed at an early stage had a better survival compared to those patients who were diagnosed at a later stage. The survival was 84%, 80%, 71.7%, 58.8%, 45.7% and 8.1% among patients belonging to stage I, IIA, IIB, IIIA, IIIB and stage IV respectively. Patients in stage I had a median survival of 35 months and patients in stage IV survived only for 4 months (Table 1)    Performance status: 1: Active; 2: Bedridden.  duration in weeks (hazard ratio = 1.96, p < 0.01) were the independent predictors of survival (Table 2).

DISCUSSION
Cervical cancer is an important cause of morbidity and mortality among women. Survival studies indicate the overall performance of a group of patients after diagnosis or treatment. The present study was undertaken to determine the survival rates and prognostic factors for cervical cancer in Mysuru.

CONCLUSION
The 5 year survival rate for cervical cancer was 48.1%. Age at diagnosis, performance status at presentation, staging and duration of treatment were the prognostic factors for cervical cancer. Emphasis should be on creating awareness regarding cervical cancer from the adolescent age group through school health programmes; providing screening facilities; accessible and affordable diagnostic and treatment facilities form the level of primary health care.