Åsa Hallqvist Everhov

Hormone therapy after uterine cervical cancer treatment: a Swedish population-based study.

ObjectiveThis study aims to assess use of hormone therapy (HT) after cervical cancer treatment in women of premenopause age. MethodsWe identified 837 women aged 45 years or younger at diagnosis of cervical cancer in the Swedish Cancer Register from January 1, 2005 to September 30, 2009 with a minimal follow-up of 1.5 years. Information on cancer treatment (surgical operation, radiotherapy, and/or chemotherapy) was obtained through the National Patient Register. Use of HT was estimated through HT dispensing during follow-up as recorded in the Prescribed Drug Register. Percentage of recommended dose was assessed by frequency of HT dispensing at half-year intervals up to April 1, 2011 or a maximal age of 50 years. ResultsA total of 257 women (31%) received acute estrogen deprivation due to bilateral salpingo-oophorectomy and/or radiotherapy. Among these women, 171 (67%) of 257 had at least one dispensing of HT during the period 0.5 to 1 year after diagnosis, and 118 (46%) of 257 were dispensed 75% or more of the recommended dose. Proportion users decreased to 39% at 4.5 to 5 years after diagnosis (21% with ≥75% of the recommended dose). Women younger than 40 years had a higher prevalence of HT use at 0.5 to 1 year (79%), decreasing to 45% after 4.5 to 5 years. The results did not vary by cancer histology. ConclusionsFewer than half of cervical cancer survivors with therapy-induced early menopause used HT at or close to the recommended dose, and the use decreased during follow-up. Increased awareness of the health benefits of HT for this patient group is needed among professionals and women.

Editorial: importance of definition of inflammatory bowel disease and an increased incidence in children

review with meta-analysis: the impact of Clostridium difficile infection on the short and long-term risks of colectomy in inflammatory bowel disease. Aliment Pharmacol Ther 2017; 45: 1011–20. 3. Ananthakrishnan AN, McGinley EL, Binion DG. Excess hospitalisation burden associated with Clostridium difficile in patients with inflammatory bowel disease. Gut 2008; 57: 205–10. 4. Clayton EM, Rea MC, Shanahan F, et al. The vexed relationship between Clostridium difficile and inflammatory bowel disease: an assessment of carriage in an outpatient setting among patients in remission. Am J Gastroenterol 2009; 104: 1162–9. 5. Razik R, Rumman A, Bahreini Z, McGeer A, Nguyen GC. Recurrence of Clostridium difficile in Patients with Inflammatory Bowel Disease. Am J Gastroenterol 2016; 111: 1141–6. 6. Chen Y, Furuya-Kanamori L, Doi SA, Ananthakrishnan AN, Kirk M. Clostridium difficile infection and risk of colectomy in patients with inflammatory bowel disease: a bias-adjusted meta-analysis. Inflamm Bowel Dis 2017; 23: 200–7. 7. Khanna S, Shin A, Kelly CP. Management of Clostridium difficile infection in inflammatory bowel disease: expert review from the Clinical Practice Updates Committee of the AGA Institute. Clin Gastroenterol Hepatol 2017; 15: 166–74. 8. Newman KM, Rank KM, Vaughn BP, Khoruts A. Treatment of recurrent Clostridium difficile infection using faecal microbiota transplantation in patients with inflammatory bowel disease. Gut Microbes 2017; doi: 10.1080/19490976.2017.1279377 [Epub ahead of print].

Surgical Treatment in Childhood-onset Inflammatory Bowel Disease–A Nationwide Register-based Study of 4695 Incident Patients in Sweden 2002-2014

Background and Aims The incidence of childhood-onset [< 18 years] inflammatory bowel disease [IBD] is increasing worldwide, and some studies suggest that it represents a more severe disease phenotype. Few nationwide, population-based studies have evaluated the surgical burden in patients with childhood-onset IBD, and whether the improved medical treatment has influenced the need for gastrointestinal surgery. The aim was to examine whether the surgical treatment at any age of patients with childhood-onset IBD has changed over time. Methods In a nationwide cohort study we identified 4695 children [< 18 years] diagnosed with incident IBD in 2002-2014 through the Swedish Patient Register [ulcerative colitis: n = 2295; Crohns disease: n = 2174; inflammatory bowel disease-unclassified: n = 226]. Abdominal [intestinal resections and colectomies] and perianal surgeries were identified through the Swedish Patient Register. The cumulative incidences of surgeries were calculated using the Kaplan-Meier method. Results In the cohort, 44% were females and 56% males. The median age at inflammatory bowel disease diagnosis was 15 years and the maximum age at end of follow-up was 31 years. The 3-year cumulative incidence of intestinal surgery was 5% in patients with ulcerative colitis and 7% in patients with Crohns disease, and lower in children aged < 6 years at inflammatory bowel disease diagnosis [3%] than in those aged 15-17 years at diagnosis [7%]. Calendar period of inflammatory bowel disease diagnosis was not associated with risk of surgery. Conclusion Over the past 13 years, the risk of surgery in childhood-onset inflammatory bowel disease has remained unchanged.

Letter: phenotype and natural history of elderly onset inflammatory bowel disease

EDITORS, In Ma~ nosa and colleagues’ recent study comparing 1374 cases of elderly (≥60 years) onset inflammatory bowel disease (IBD) with a similar number of younger onset (18-40 years) controls matched for sex, disease subtype and calendar year, they conclude that elderly onset IBD is a less aggressive phenotype. The milder clinical course in elderly IBD has been noted in previous studies, based on a lower frequency of treatment with immunosuppressants, fewer extraintestinal manifestations, but similar surgery rates. However, more recent studies have described a more aggressive disease in elderly onset ulcerative colitis, and higher rates of IBD-associated surgery in the elderly, compared to younger age groups. In the Spanish hospital-based study, published in the journal, the researchers found a lower use of immunomodulators and anti-TNF agents in elderly onset IBD patients, in line with data from our group and others. Ma~ nosa et al also report similar surgery rates in elderly as in younger patients with Crohn’s disease (36% vs 29% after 5 years) but significantly higher rates in elderly vs younger patients with ulcerative colitis (11% vs 5%). In our recent Swedish nationwide study, the cumulative 5-year incidence of intestinal surgery was higher in the elderly IBD patients (13%), than in adults (1859 years, 10%), or children with IBD (9%). The differences between adult and elderly onset IBD patients regarding pharmaceutical treatment noted in this Spanish and other studies may reflect true differences in phenotype, but in our study the treatment differences across age groups were also present in analyses stratified by disease phenotypes. Differences could also be due to a cautious attitude among clinicians regarding treatment of the elderly patient, because of the increased potential for adverse effects in older, multimorbid individuals already exposed to many potent drugs. Finally, differences could be due to suboptimal use of medical therapies in the elderly. Ma~ nosa et al report more thiopurine-related adverse events in the elderly, and suggest anti-TNF monotherapy in those elderly patients in whom immunosuppression is indicated. Similarly, increased surgery rates in the elderly can reflect treatment failure, but just as well a conscious choice from the treating physician, since timely surgery can reduce the risk of severe complications, induce remission and allow physicians to refrain from future medical therapy. Ma~ nosa et al argue that in elderly onset ulcerative colitis, surgery should be considered as a real alternative to immunosuppression. The prevalence of elderly onset IBD is likely to increase, due to an ageing population and the overall increase in IBD worldwide. In the study by Ma~ nosa et al, the elderly represented 11% of all incident IBD cases. In our recent nationwide Swedish study, 23% of incident IBD cases 2006-2013 were 60 years or older. The elderly patient with IBD represents a treatment challenge, and the risk-benefit of different treatment algorithms in elderly IBD needs to be assessed, preferably by means of randomized controlled studies.

Anti‐Müllerian hormone in premenopausal women following treatment of uterine cervical cancer

In this longitudinal study we prospectively enrolled 32 premenopausal women (ages 23–44 years) with stage I–III uterine cervical cancer undergoing surgery and/or chemoradiation. Serum levels of anti‐Müllerian hormone, follicle‐stimulating hormone and estradiol were examined at baseline and 1 year after treatment. As expected, serum anti‐Müllerian hormone was undetectable after salpingo‐oophorectomy or chemoradiation. After radical hysterectomy and pelvic lymphadenectomy with ovarian preservation serum anti‐Müllerian hormone declined from a mean value of 2.0 ± 1.4 μg/L to 1.1 ± 0.8 μg/L (p = 0.01), representing a 45% reduction, whereas there was no significant change in serum levels of follicle‐stimulating hormone and estradiol. This implies that ovarian function may be affected not only by castrating treatment but also by radical hysterectomy with ovarian preservation. The risk of premature menopause and the potential need of hormone replacement therapy among these women may be overlooked since they no longer menstruate.

Sick Leave and Disability Pension in Prevalent Patients With Crohn’s Disease

Background and Aims Crohns disease may affect the ability to work and lead to permanent disability. We aimed to investigate work loss in prevalent patients. Methods We identified patients with Crohns disease and general population comparators matched by sex, birth year, healthcare region and education. We assessed days of sick leave and disability pension retrieved from the Swedish Social Insurance Agency and estimated the absolute and relative risk of receiving disability pension [minimum 25% work impairment]. Results In 2014, the 20638 Crohns disease patients [median age 44 years] had more than twice as many mean lost workdays [disability pension: 44; sick leave: 19] as the 102038 comparators [disability pension: 20; sick leave: 8], mean difference 35 days [95% confidence interval 33-37]. However, the majority had no lost workdays [68% of patients and 85% of comparators]. The proportion of patients receiving disability pension was 15% (6.5% in the comparators, risk ratio 2.34 [2.25-2.43]) and was higher in all subgroups, especially in female patients [28% vs 13% in the comparators], in those with ≤9 years of education [41% vs 23%] and in ages 60-64 years [46% vs 25%]. The relative risk of disability pension within the patient cohort [adjusted for age, sex, region and education] was higher in patients with complicated disease behaviour, extraintestinal manifestations, need of surgery or treatment with biologics. The differences between patients and comparators remained when comparing other calendar years [2006-2013]. Conclusion Work loss was found in approximately one-third of patients. The mean number of lost workdays was twice as high as in the comparators.