Study of Rate of Hysterectomy in Patients with Cervical Cancer Referring to Radiotherapy and Oncology Ward of Ahvaz Golestan Hospital in

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1 International Journal of Advanced Biotechnology and Research (IJBR) ISSN , Online ISSN X, Vol-7, Special Issue-Number5-July, 2016, pp Research Article Study of Rate of Hysterectomy in Patients with Cervical Cancer Referring to Radiotherapy and Oncology Ward of Ahvaz Golestan Hospital in Hodjatollah Shahbazian *1, Sholeh Arvandi 1 and Younes Joonaki 2 1 Department of Radiotherapy and Oncology, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran 2 School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran *Corresponding author hjshahbazian@yahoo.com ABSTRACT Background and Objective: Cervical cancer is one the common genital cancer in females, and it is the third cancer in women. We can improve the life time and life style of patients with treatment. In early stages the first treatment options are hysterectomy or radiotherapy, while in the progressive stages is chemoradiotherapy. This study aimed to investigate the rate of hysterectomy in patients with cervical cancer. Materials and Methods: This was a retrospective study conducted on the medical records of patients with cervical cancer referring to radiotherapy and oncology ward of Ahvaz Golestan Hospital, Iran during 1995 to Data included age, type of treatment, disease stage, and time of admission and were analyzed with SPSS version 16. Results: Out of 430 patients, 16 patients were in metastatic stage and received palliative chemoradiotherapy and radiotherapy. Of 414 non-metastatic patients, 161 patients (39%) went under hysterectomy. Of the hysterectomy cases, 32% received adjuvant chemoradiotherapy, whereas the 7% underwent other treatments. Conclusion: Rate of hysterectomy in this study was 39% that was similar to some other studies. The trend has not significantly changed during the study period, 1995 to It seems that the surgeons desire to perform hysterectomy or chemoradiotherapy has not changed over the time. Keywords: Cervical cancer, Hysterectomy, Chemoradiotherapy INTRODUCTION Cervical cancer is one of the common genital tract cancers, and in terms of prevalence is the third cancer in women (1) and treatment not only extends the life, but also increases the quality of life. Thus, recognizing its outbreak is of great importance, and it is of few cancers that can be detected in pre-emergence stage (2). Annually, half a million women worldwide are diagnosed with cervical cancer. Twenty-five percent of deaths in women are caused by malignant tumors, 18% of them are cervical cancer, and its prevalence in Iran is 6.64 % (3). Cervical cancer is one of the most prevalent cancers in developing countries. Factors such as sexual ones and reproduction, sex at an early age, low economic and social class, smoking, long-term use of contraceptives are known as risk factors (4). Moreover, human papillomavirus has been detected in 99.7% of patients with cervical cancer (5). Dysplasia of cervical indicates disorder in its growth that is identified with appearance of cancerous and pre-cancerous cells at cervical. Cervical dysplasia often does not have any symptoms, but in 5% of cases, it can advance to cervical cancer. Early detection of these lesions by Pap smear has greatly prevented the progress towards cancer (6). The average age of cervical cancer in the United States is 47 years of age and the peak age is between the ages of 35 to 39 and 60 to 64 (7). Moreover, by screening that was

2 conducted in some countries over 50 years, its prevalence and incidence could be reduced. This is while in most parts of the world, this cancer is the second or third most common cancer in women (8). Treatment of cervical cancer includes simple hysterectomy in stage IA1, radical hysterectomy and pelvic lymphadenectomy in stage IA2, radical hysterectomy and pelvic lymphadenectomy or pelvic radiotherapy along with brachytherapy in stage IB2, radiotherapy along with chemotherapy in IIA-IVA and IB2 stages, and chemotherapy along with palliative radiotherapy in stage IVB (9). Hysterectomy means removal of the uterus and can include the removal of all or part of it, such as fundus, cervix, or its body (10). In this study, by determining the extent of hysterectomy and chemoradiotherapy as the main treatment for cervical cancer, probable changes of surgeons' tend to hysterectomy (primarily in early stage of the disease) were assessed in 15 years. The findings of this study will be effective in educational planning and treatment for the disease and improving the quality of treatment. Materials and Methods This was a retrospective study conducted on the medical records of patients with cervical cancer referring to radiotherapy and oncology ward of Ahvaz Golestan Hospital, Iran during a 15 year period (1995 to 2010). Total of 430 patients were studied in this study. Inclusion criteria included all patients with cervical cancer referring to the radiotherapy and oncology wards of Golestan Hospital, and exclusion criteria included incomplete records of patient. The medical records were studied separately for each year, and hysterectomy and chemoradiotherapy cases performed on patients with cervical cancer each year were examined separately and their processes were checked. Data included age, type of treatment, disease stage, and time of admission and were classified according to inclusion and exclusion criteria. Since the beginning of the study, the patients with cervical cancer were divided into two groups: the first group consisted of patients who had undergone curative treatment (hysterectomy with or without adjuvant chemoradiotherapy and Definitive chemoradiotherapy) and the second group was (metastatic) that had received palliative treatment. The main objective of the study was to study the first group. In this study, the clinical information of patients from the records were extracted and studied without mentioning personal characteristics or their names and no intervention took place for the patient. In recording patient data, the name and individual properties of the patients were not included and during the research, for classification of data, some codes were used instead of their names. It was also tried to practice all religious rules and legal ethics at all stages of the project. Results were statistically analyzed using SPSS 16 statistical software. RESULTS The study was conducted for 15 years from 1995 to 2010 on patients with cervical cancer referring to the Radiotherapy and Oncology wards of Golestan Hospital. About 10 cases due to defects were excluded. Out of the 430 cases 16 patients had been treated with metastatic, and out of 161 remaining patients hysterectomized patients were 39% and non-hysterectomized ones were 61%, which are given separately according to table 1. The hysterectomy in 2009 with 47% was the highest and in 2002 was the lowest with 25%. The hysterectomy during the study years showed no significant change (P-value= 0.097). Table 1. The frequency of hysterectomy in cervical cancer patients separately for each year Hysterectomized Non-hysterectomized Year 33% 3 67% % 5 59% % 4 67% % 4 67% Hojatollah Shahbazian, et al. 946

3 36% 5 64% % 7 63% % 10 60% % 7 74% % 9 68% % 15 66% % 12 64% % 14 61% % 16 53% % 15 57% % 17 53% % 18 56% Out of all non-metastatic cases studied, 61% received (camo) definitive radiotherapy and from hysterectomized patients, 32% of patients with non-metastatic, 85% received (camo) Adjuvant radiotherapy and 15% did not receive (camo) Adjuvant radiotherapy (Figure 1). Figure 1. Percentage of Patients with Cervical Cancer hysterectomized (with or without radiotherapy Adjuvant) and non-hysterectomized Definitive Chemoradiotherapy treatment was done in about 61% of patients and was examined separately for each year. The treatment had the highest rate in 2002 with 74% and the lowest in 2009 had the lowest rate. Definitive Chemoradiotherapy showed no significant changes during the studied years (P-value= 0.05). Table 2. Absolute frequency and the frequency of Definitive Chemoradiotherapy treatment in patients with cervical cancer Absolute Frequency percent Year frequency Hojatollah Shahbazian, et al. 947

4 Total years From among the patients, 61% received Definitive treatment and among them, most of the patients were at Stage IIb and the fewest patients were at Stage Ib (Figure 2). Frequency percent Figure 2. Relative frequency of the disease stages of the patients treated by Definitive Chemoradiotherapy Chemoradiotherapy Adjuvant Treatment was generally carried out for about 32% of patients (85% of hysterectomy patients) and had the highest frequency in 2007 with 44 percent and the lowest was in 2003 with 22% of all patients (Table 3). Table 3. Absolute frequency and frequency percentage of patients treated by Adjuvant Chemoradiation each year Frequency Absolute percent frequency Year Total years The frequency perecentage of the patients who underwent Palliative Chemoradiation due to high stage and being metastatic without hysterectomy was overall 16 patients out of 430 patients studied. The relative frequency percent of Palliative treatment to all therapies was 3.7 percent, and had the highest frequency in 1995 with 10% and the lowest in 2008 and 2009 with zero percent (Table 4). Table 4. Relative frequency of Palliative treatment to all patients separately for years Frequency percent Year Hojatollah Shahbazian, et al. 948

5 Total DISCUSSION According to the results of this study, approximately 39% of patients (254 patients) had undergone hysterectomy. The figure compared with the results of previous studies results that we had showed no significant difference. For example, in a study by Hashemi et al. (11) in Tehran, of 346 patients with cervical cancer, 44 percent underwent hysterectomy, which is roughly consistent to the results obtained in this research. Moreover, in another study by Macintosh et al. (12) conducted in New Zealand, 42% hysterectomy in patients with cervical cancer was obtained that compared with our results showed little difference. The results were more similar in others, for example, in a study by Michael et al. (13), 35.2% of women underwent hysterectomy. Another study conducted in the United States showed that 37% of women with this disease before the age of 70 received hysterectomy. In another study by Gianfranco et al. (14), hysterectomy performed by women gynecological surgeons was 33.3 percent. However, our findings showed some differences with the findings of some previous similar studies. In the study by Coughlan et al. (15) on 210 patients with cervical cancer, 58% hysterectomy was reported and this difference may be due to different methods of incomplete hysterectomy or difference in guidelines relevant in the past years. In a study by Kamura et al. (16), 77% of women with cervical cancer underwent hysterectomy. These differences may be due to stages of patients and surgeons' preferences. CONCLUSION The choice of treatment depends on several other factors in addition to treatment guidelines. As the methods of cervical cancer screening in the area are more prevalent or start at younger ages, the disease of the person will be diagnosed at lower stages. Considering the fact that hysterectomy happens mostly in primary and lower stages, it can be done much more in these areas. Moreover, other factors such as the level of public awareness, the number of hospitals, physician gender, greater availability, more willingness to do surgery, socioeconomic status of patients, and the number of hospital beds are the important factors determining the rate of hysterectomies carried out in any area. The difference in data obtained in our study compared to other studies is probably because of these points. REFERENCES 1. Taherian AAFAS, B. The effective factors in cervical cancer: a case-control study in Isfahan. University of Medical Sciences. 1996;1: Tabeshian A F, F.. Studying the effect of health education on the prevention of cervical cancer in teachers of Isfahan. Islamic Azad University, Tehran University of Medical Sciences. 2009;19: Mobaraki AM, F, Mohebi, Z. Knowledge,. Attitude and Practice of Female Employees in the field of Yasouj hospitals Pap test. Journal of Nursing and Midwifery, Gorgan. 2008;5: Nabaei B B, A.. Tehran University of Medical Sciences Journal. Risk factors in the development of invasive cervical cancer: a case-control study. 2001;59(2): Walboomers JM, Jacobs MV, Manos MM, Bosch FX, Kummer JA, Shah KV, et al. Human papillomavirus is a necessary cause of invasive cervical cancer worldwide. The Journal of pathology. 1999;189(1): Ehdaei Vand FN, M.T. Amini Sani F, Chinifurush, M.. Pap smear for cervical dysplasia study in 5000 in the city of Ardabil. 2005;5(1): Jemal A, Siegel R, Ward E, Murray T, Xu J, Thun MJ. Cancer statistics, CA: a cancer journal for clinicians. 2007;57(1): Hojatollah Shahbazian, et al. 949

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