title: Effect of changes in treatment practice on survival for cervical cancer: results from a population-based study in Manitoba, Canada.
abstract: BACKGROUND
  Results from clinical trials in the 1990s led to changes in the recommended treatment for the standard therapy for stage IIB-IVA cervical cancer from radiotherapy alone to chemo-radiotherapy. We conducted the first population-based study in Canada to investigate temporal treatment patterns for cervical cancer and long-term survival in relation to these changes in the treatment guidelines.
  
  
  METHODS
  Detailed information on stage and treatment for 1085 patients diagnosed with cervical cancer in 1984-2008 and identified from the population-based Manitoba Cancer Registry (MCR) in Canada was obtained from clinical chart review and the MCR. Factors associated with receiving guideline treatment were identified using logistic regression. All cause and cervical cancer specific survival were compared in patients who were and were not treated as recommended in the guidelines, using Cox proportional hazards models.
  
  
  RESULTS
  The median follow-up time was 6.4 years (range: 0.05-26.5 years). The proportion of women who received guideline treatment was 79 % (95 % confidence interval [CI]: 76-81 %). However, the likelihood of being treated according to the guidelines over time was modified by age (p < 0.0001) and tumour stage at diagnosis (p = 0.002). Women who were treated according to the guidelines after the change in recommended clinical practice (1999-2008) had a significantly lower risk of death from all causes and from cervical cancer. This was driven by lower mortality rates in cases with stage IIB-IVA tumours (all causes of death: hazard ratio [HR] = 0.60, 95 % CI: 0.43-0.82, p = 0.002; cervical cancer related death: HR = 0.64, 95 % CI: 0.44-0.93, p = 0.02).
  
  
  CONCLUSIONS
  The management of cervical cancer patients in Manitoba, Canada was in good agreement with treatment guidelines although reasons for departure from the guideline recommendations could not be examined further due to lack of data. Treatment of stage IIB-IVA cervical cancers with recommended concurrent chemo-radiotherapy, which is now standard practice, was associated with substantially increased survival, although the effect of changes in clinical practice including maintenance of haemoglobin levels on improved survival cannot be ruled out as a contributing factor.
authors.affiliation: Prince of Wales Clinical School, the University of New South Wales, Sydney, NSW, Australia. yoonjung.kang@nswcc.org.au.|Cancer Research Division, Cancer Council NSW, 153 Dowling Street, Woolloomooloo, NSW, Australia. yoonjung.kang@nswcc.org.au.
authors.forename: Yoon-Jung
authors.initials: YJ
authors.lastname: Kang
authors.affiliation: Cancer Research Division, Cancer Council NSW, 153 Dowling Street, Woolloomooloo, NSW, Australia. dianneo@nswcc.org.au.
authors.forename: Dianne L
authors.initials: DL
authors.lastname: O'Connell
authors.affiliation: Division of Gynecologic Oncology, CancerCare Manitoba, Winnipeg, MB, Canada. rlotocki@mymts.net.|Community Health Sciences, University of Manitoba, Winnipeg, MB, Canada. rlotocki@mymts.net.
authors.forename: Robert
authors.initials: R
authors.lastname: Lotocki
authors.affiliation: Epidemiology and Cancer Registry, CancerCare Manitoba, Winnipeg, MB, Canada. Erich.Kliewer@cancercare.mb.ca.|Community Health Sciences, University of Manitoba, Winnipeg, MB, Canada. Erich.Kliewer@cancercare.mb.ca.
authors.forename: Erich V
authors.initials: EV
authors.lastname: Kliewer
authors.affiliation: Cancer Research Division, Cancer Council NSW, 153 Dowling Street, Woolloomooloo, NSW, Australia. davidg@nswcc.org.au.
authors.forename: David E
authors.initials: DE
authors.lastname: Goldsbury
authors.affiliation: Epidemiology and Cancer Registry, CancerCare Manitoba, Winnipeg, MB, Canada. alain.demers@phac-aspc.gc.ca.|Community Health Sciences, University of Manitoba, Winnipeg, MB, Canada. alain.demers@phac-aspc.gc.ca.
authors.forename: Alain A
authors.initials: AA
authors.lastname: Demers
authors.affiliation: Prince of Wales Clinical School, the University of New South Wales, Sydney, NSW, Australia. karen.canfell@nswcc.org.au.|Cancer Research Division, Cancer Council NSW, 153 Dowling Street, Woolloomooloo, NSW, Australia. karen.canfell@nswcc.org.au.
authors.forename: Karen
authors.initials: K
authors.lastname: Canfell
mesh_terms: D000328:Adult; D000368:Aged; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000008:administration & dosage*; D002170:Canada; D017024:Chemotherapy, Adjuvant; D002945:Cisplatin / Q000008:administration & dosage; D005260:Female; D006801:Humans; D008875:Middle Aged; D009367:Neoplasm Staging; D016016:Proportional Hazards Models; D018714:Radiotherapy, Adjuvant; D002583:Uterine Cervical Neoplasms / Q000188:drug therapy* / Q000401:mortality / Q000473:pathology / Q000532:radiotherapy
chemical_list: D002945:Cisplatin