title: The impact of comorbidity and stage on ovarian cancer mortality: a nationwide Danish cohort study.
abstract: BACKGROUND
  The incidence of ovarian cancer increases sharply with age, and many elderly patients have coexisting diseases. If patients with comorbidities are diagnosed with advanced stages, this would explain the poor survival observed among ovarian cancer patients with severe comorbidity. Our aims were to examine the prevalence of comorbidity according to stage of cancer at diagnosis, to estimate the impact of comorbidity on survival, and to examine whether the impact of comorbidity on survival varies by stage.
  
  
  METHODS
  From the Danish Cancer Registry we identified 5,213 patients (> 15 years old) with ovarian cancer diagnosed from 1995 to 2003. We obtained information on comorbidities from the Danish National Hospital Discharge Registry. Vital status was determined through linkage to the Civil Registration System. We estimated the prevalence of comorbidity by stage and computed absolute survival and relative mortality rate ratios (MRRs) by comorbidity level (Charlson Index score 0, 1-2, 3+), using patients with Charlson Index score 0 as the reference group. We then stratified by stage and computed the absolute survival and MRRs according to comorbidity level, using patients with Charlson score 0 and localized tumour/FIGO I as the reference group. We adjusted for age and calendar time.
  
  
  RESULTS
  Comorbidity was more common among patients with an advanced stage of cancer. One- and five-year survival was higher in patients without comorbidity than in patients with registered comorbidity. After adjustment for age and calendar time, one-year MRRs declined from 1.8 to 1.4 and from 2.7 to 2.0, for patients with Charlson scores 1-2 and 3+, respectively. After adjustment for stage, the MRRs further declined to 1.3 and 1.8, respectively. Five-year MRRs declined similarly after adjustment for age, calendar time, and stage. The impact of severe comorbidity on mortality varied by stage, particularly among patients with tumours with regional spread/FIGO-stages II and III.
  
  
  CONCLUSIONS
  The presence of severe comorbidity was associated with an advanced stage of ovarian cancer. Mortality was higher among patients with comorbidities and the impact of comorbidity varied by stage.
authors.affiliation: Department of Clinical Epidemiology, Aarhus University Hospital, 8000 Aarhus, Denmark. mst@rn.dk
authors.forename: Mette S
authors.initials: MS
authors.lastname: Tetsche
authors.forename: Claus
authors.initials: C
authors.lastname: Dethlefsen
authors.forename: Lars
authors.initials: L
authors.lastname: Pedersen
authors.forename: Henrik T
authors.initials: HT
authors.lastname: Sorensen
authors.forename: Mette
authors.initials: M
authors.lastname: Norgaard
mesh_terms: D017677:Age Distribution; D000368:Aged; D002423:Cause of Death; D015331:Cohort Studies; D015897:Comorbidity / Q000639:trends*; D003718:Denmark / Q000453:epidemiology; D005260:Female; D006801:Humans; D015994:Incidence; D008875:Middle Aged; D009361:Neoplasm Invasiveness / Q000473:pathology*; D009367:Neoplasm Staging; D010051:Ovarian Neoplasms / Q000453:epidemiology* / Q000473:pathology* / Q000628:therapy; D011336:Probability; D011379:Prognosis; D016016:Proportional Hazards Models; D012042:Registries; D018570:Risk Assessment; D017678:Sex Distribution; D016019:Survival Analysis