Bowel obstruction in elderly ovarian cancer patients: A population-based study☆
Highlights
► Bowel obstruction in 17% of ovarian cancer patients in population based sample ► Post-obstruction survival 382 days for those with adhesions versus 93 days in others ► No increase in survival with surgery except for those with adhesions
Introduction
Death due to cancer can involve painful and care-intensive complications, demanding palliative treatments sensitive to patient needs. One such complication is bowel obstruction, wherein recurrent abdominal or pelvic cancer leads to a blocked intestinal tract, which in turn results in nausea, vomiting, and dehydration [1]. Obstruction usually requires inpatient hospitalization [2], [3] and may be the proximal cause of death [4], [5]. Bowel obstruction is particularly common in advanced ovarian cancer patients, with estimates of lifetime incidence ranging up to 35% [6], [7], [8].
Obstruction management options can be broadly categorized into surgical treatments, such as bypasses or colostomies, and non-surgical treatments, such as bowel rest with decompression, pharmacological management, or endoscopic placement of a stent at the obstruction site [9]. There exist no formal guidelines for treatment [3], in part because some studies have found surgery to be associated with improved survival [4], [7], [10] while others have found no survival benefit to surgery or attribute minor survival differences to patient selection [6], [11].
To date, most studies of bowel obstruction management and outcomes in the context of recurrent ovarian cancer have been hospital-based and had small sample sizes [4], [5], [6], [7], [8], [10], [11], [12], [13], [14], [15]. In this study, we estimate the incidence of obstruction in a population-based sample of ovarian cancer patients, using the Surveillance, Epidemiology and End Results (SEER) and Medicare claim linked databases [16]. We also investigate factors associated with bowel obstruction, treatment of bowel obstruction, and outcomes after a hospitalization for obstruction.
Section snippets
Data source
We analyzed data from the Surveillance, Epidemiology, and End Results (SEER)–Medicare database, which links SEER's detailed registry data with Medicare claims data [17]. The SEER database contains records of patients diagnosed with cancer in regions that contain approximately 14% of the US population; in 2000, this database was expanded to include approximately 26% of the US population [18].
Cohort selection
We selected women who had a pathologically confirmed first and primary diagnosis of stage IC, II, III,
Characteristics of surgical treatment for bowel obstruction
We considered a physician or hospital claim for gastroenterostomy, entero-enterostomy, bowel resection, enterostomy, and lysis of peritoneal adhesions (codes provided online in Appendix 1) to represent surgical therapy. We did not consider an isolated claim for laparotomy or laparoscopy to constitute surgical therapy in the absence of secondary procedure codes because it is unclear whether surgical correction of the obstruction was attempted.
Outcomes
We used hospital claim files to calculate length of stay and considered horizontal transfers to another acute care hospital part of the same hospitalization. For each patient who had died at the time of last follow-up, we calculated days of life remaining after first post-diagnosis obstruction. We examined all Medicare hospital claims that post-dated the initial claim for obstruction to assess hospital re-admission rates, post obstruction chemotherapy rates, and to compute a ratio of days in to
Statistical analysis
We used univariable Cox proportional hazards models to assess predictors of time to hospitalization for bowel obstruction and post-obstruction survival. We used Kaplan–Meier curves to compute survival times, median time to obstruction and length of hospital stay. Time-to-obstruction models used date of PTR or cancer diagnosis (if no PTR) as time 0, and treated both death and loss to follow-up as censoring events. The assumption of proportionality was assessed visually. All statistical tests
Results
We identified 8663 women ≥ 65 years old diagnosed with stages IC–IV ovarian carcinoma. We excluded 56 women who had a diagnosis of bowel obstruction prior to the cancer diagnosis. The final cohort was composed of 8607 women, 6966 (80.9%) of whom had died by the time of last follow-up. Of the final cohort, 1518 (17.6%) were hospitalized for bowel obstruction at least once between cancer diagnosis and end of follow-up, including 1357 (19.5%) of those who had died. Among the 1518 hospitalized for
Discussion
In this study of 8607 women diagnosed with ovarian cancer after age 65, 19.5% of those followed from diagnosis to death were hospitalized for bowel obstruction subsequent to their cancer diagnosis. Subsequent obstruction was associated with mucinous tumor histology, younger age, earlier year of diagnosis and history of obstruction at time of cancer diagnosis. About 1 in 4 obstructions were managed surgically, and the median survival after obstruction was poor unless the obstruction appeared to
Conflict of interest statement
The authors have no conflicts of interest to disclose.
Source of funding
This study was supported in part by a fellowship from NCI (R25 CA094061) to MW and a fellowship from NCI (T32 CA09529) to SJM.
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Data in this manuscript has not been presented previously.