Ingvild Vistad

Pregnancy outcome after cervical cone excision: a case-control study.

Background. To investigate the effect of cervical laser conisation (CLC) or loop electrosurgical excision procedure (LEEP) on the outcome of subsequent pregnancies. Methods. Multi‐centre, retrospective, case‐control study, which included a cohort of 742 women, who, after treatment with LEEP or CLC, gave birth or suffered second trimester miscarriage. Control women (n = 742) were extracted from the respective hospital birth registries and matched by age and parity. Outcome measures were perinatal mortality, length of gestation, birth weight and preterm premature rupture of membranes (pPROM). Results. There was no significant difference in perinatal mortality among women treated with LCL or LEEP compared to controls, 6/742 versus 2/742: odds ratio (OR) = 3.1 (95% CI: 0.6–15.2). Excluding second trimester miscarriages, ORs for giving birth before week 37, 32 and 28 after conisation compared to the controls were 3.4 (95% CI: 2.3–5.1), 4.6 (95% CI: 1.7–12.5), and 12.4 (95% CI: 1.6–96.1), respectively, after adjusting for smoking habits during pregnancy, marital status and educational level. Adjusted ORs of birth weight <2,500, <1,500 and <1,000 g after conisation compared to controls were 3.9 (95% CI: 2.4–6.3), 4.4 (95% CI: 1.5–13.6), and 10.4 (95% CI: 1.3–82.2), respectively. The adjusted OR for pPROM was 10.5 (95% CI: 3.7–29.5). Conclusion. Treatment by CLC and LEEP increases the risk of preterm delivery, low birth weight and pPROM in subsequent pregnancies.

Postradiotherapy Morbidity in Long-Term Survivors After Locally Advanced Cervical Cancer: How Well Do Physicians' Assessments Agree With Those of Their Patients?

PURPOSE Descriptions of late morbidity after radiotherapy in cervical cancer survivors (CCSs) are usually based on observations made by physicians, and rarely by patients themselves. We describe and compare physician-assessed morbidity with patient-rated symptoms more than 5 years after pelvic radiotherapy. METHODS AND MATERIALS In 147 CCSs treated between 1994 and 1999 at The Norwegian Radiumhospital, morbidity data were regularly documented by physicians at least for 5 years after radiotherapy. Information on patient-rated symptoms was collected by a questionnaire from 91 (62%) of the 147 survivors after a median follow-up time of 96 months (65-131 months). The results were compared with physician-assessed morbidity scores recorded at 5 years, and to selected normative data using descriptive statistics. Physician-assessed morbidity data were modeled using Kaplan-Meier method. Agreement between physician data and patient data was expressed using weighted kappa statistics. RESULTS The 5-year Kaplan-Meier estimates of physician-assessed intestinal, bladder, and vaginal morbidity Grade 3-4 were 15%, 13%, and 23%, respectively. The prevalence of patient-rated severe symptoms from these organs was much higher (intestines 45%, bladder 23%, and 58% vaginal discomfort among sexually active CCSs). Poor agreement was confirmed by low values of kappa: For bladder the concordance was slight (kappa = 0.16) and for intestine it was fair (kappa = 0.27). Stress incontinence, diarrhea, nausea, and sexual problems were significantly (p < 0.001) more prevalent when compared with a control sample from the general female population. CONCLUSIONS Morbidity is common after pelvic radiotherapy. However, our data indicate that physicians underreport patients symptoms. It is important to incorporate patient-reported outcomes in the evaluation of treatment-related morbidity.

Chronic fatigue and its correlates in long-term survivors of cervical cancer treated with radiotherapy.

Objective  To describe the prevalence of chronic fatigue (CF) and associated variables in locoregional cervical cancer survivors (CCSs) surveyed >5 years after radiotherapy. Demographic, clinical and psychological characteristics of the CCSs were compared with normative data.

Palliative pelvic radiotherapy of symptomatic incurable rectal cancer - a systematic review

Abstract Background. Locally advanced and recurrent rectal cancers frequently cause pelvic morbidity including pain, bleeding and mass effect. Palliative pelvic radiotherapy is used to relieve these symptoms and delay local progression. There is no established optimal radiotherapy regimen and clinical practices vary. Our aim was to review the efficacy and toxicity of palliative pelvic radiotherapy of symptomatic rectal cancer and to evaluate different fractionation schedules, based on published literature. Material and methods. Systematic literature searches of Medline, Embase and Cochrane databases were performed through 2011. Studies reporting symptomatic response or quality of life (QOL) after palliative radiotherapy for rectal or rectosigmoid cancer were eligible. Results. Twenty-seven studies were included, of which 23 were retrospective reviews. There were no patient-reported outcomes or QOL assessments. There were large variations in applied radiotherapy regimens. Pooled overall symptom response rate was 75% and positive responses were reported for pain (78%), bleeding and discharge (81%), mass effect (71%) and other pelvic symptoms (72%). Toxicity results were not evaluable. Conclusion. Palliative pelvic radiotherapy for symptomatic rectal cancer appears to provide relief of a variety of pelvic symptoms, although there is no documented optimal radiotherapy regimen in this context. There is inadequate evidence regarding onset, duration and degree of symptom palliation, QOL and associated toxicity with this treatment and prospective studies are therefore needed.

Study protocol: fit for delivery - can a lifestyle intervention in pregnancy result in measurable health benefits for mothers and newborns? A randomized controlled trial

BackgroundThe global obesity epidemic has led to increased attention on pregnancy, a period when women are at risk of gaining excessive weight. Excessive gestational weight gain is associated with numerous complications, for both mother and child. Though the problem is widespread, few studies have examined the effect of a lifestyle intervention in pregnancy designed to limit maternal weight gain. The Fit for Delivery study will explore the effectiveness of nutritional counseling coupled with exercise classes compared with standard prenatal care. The aims of the study are to examine the effect of the intervention on maternal weight gain, newborn birth weight, glucose regulation, complications of pregnancy and delivery, and maternal weight retention up to 12 months postpartum.Methods/designFit for Delivery is a randomized controlled trial that will include 600 women expecting their first child. To be eligible, women must be 18 years of age or older, of less than 20 weeks gestational age, with a singleton pregnancy, and have a Body Mass Index (BMI) ≥ 19 kg/m2. The women will be randomly allocated to either an intervention group or a control group. The control group will receive standard prenatal care. The intervention group will, in addition, receive nutritional counseling by phone, access to twice-weekly exercise sessions, and information on healthy eating and physical activity provided in pamphlets, evening meetings and an interactive website. Both groups will be monitored by weighing (including bioimpedance measurements of percent body fat), blood tests, self-report questionnaires and hospital record review.DiscussionWeight gained in pregnancy affects the health of both the mother and her unborn child, and simple models for efficient intervention are in high demand. The Fit for Delivery intervention provides concrete advice on limiting energy intake and practical training in increasing physical activity. This lifestyle intervention is simple, reproducible, and inexpensive. The design of the study reflects the realities of clinical practice, where patients are free to choose whether or not they respond to health initiatives. If we find measurable health benefits associated with the intervention, it may be an easily adopted supplement to routine prenatal care, in the prevention of obesity.Trial registrationClinicalTrial.gov, NCT01001689

Follow‐up routines in gynecological cancer – time for a change?

Objective. To determine current practice of follow‐up of Norwegian gynecological cancer patients, and to review available randomized controlled trials (RCTs) in gynecologic, breast and colorectal cancer patients in order to discuss whether such studies are feasible in gynecological cancer patients. Design. A combined questionnaire study and a systematic review of RCTs in follow‐up of gynecological, breast, and colorectal cancers. Population. Gynecological, breast, and colorectal cancer patients. Methods. A questionnaire regarding follow‐up routines was mailed to 31 gynecological departments in Norway. A systematic search on MEDLINE, EMBASE, and the Cochrane Library databases was conducted to identify RCTs in follow‐up of breast, colorectal, and gynecological cancers. Results. The questionnaire study showed that the number of controls varied from eight to 16 during the first five years’ post‐treatment. Routine investigations such as chest X‐ray and cytology were frequently used in endometrial and cervical cancer. All departments used CA‐125 in follow‐up of ovarian cancer patients. Reviewing the literature, 19 RCTs of varying methodological quality were identified for colorectal and breast cancers, and none for gynecologic cancer. Different follow‐up models were compared, and most studies concluded that there were no significant differences in the detection of recurrence, overall survival, and quality of life between the studied groups. Conclusions. Follow‐up routines after gynecological cancer vary in Norway. The optimal approach is unknown and RCTs comparing follow‐up protocols are missing. Studies of breast and colorectal cancer patients show that studies on follow‐up strategies are feasible but sufficient sample size and observation time are important.

The Fit for Delivery study: rationale for the recommendations and test-retest reliability of a dietary score measuring adherence to 10 specific recommendations for prevention of excessive weight gain during pregnancy

Aiming at preventing excessive weight gain during pregnancy, 10 specific dietary recommendations are given to pregnant women in the intervention arm of the Norwegian Fit for Delivery (FFD) study. This paper presents the rationale and test-retest reliability of the food frequency questionnaire (FFQ) and a dietary score measuring adherence to the recommendations. The study is part of the ongoing FFD study, a randomised, controlled, intervention study in nulliparous pregnant women. A 43-item FFQ was developed for the FFD study. A dietary score was constructed from 10 subscales corresponding to the 10 dietary recommendations. Adding the subscales yielded a score from 0 to 10 with increasing score indicating healthier dietary behaviour. The score was divided into tertiles, grouping participants into low, medium and high adherence to the dietary recommendations. Pregnant women attending ultrasound screening at about week 19 of pregnancy were asked to complete the FFQ twice, 2 weeks apart. Of 154 pregnant women completing the first questionnaire, 106 (69%) completed the form on both occasions and was included in the study. The test-retest correlations of the score and subscales were r = 0.68 and r = 0.56-0.84, respectively (both P ≤ 0.001). There was 68% test-retest correct classification of the score and 70-87% of the subscales. In conclusion, acceptable test-retest reliability of the FFQ and the dietary score was found. The score will be used in the FFD study to measure adherence to the dietary recommendations throughout pregnancy and in the following year post-partum.

Palliative pelvic radiotherapy of symptomatic incurable prostate cancer – A systematic review

BACKGROUND AND PURPOSE Patients with prostate cancer (PC) and a symptomatic pelvic tumor may be treated with palliative pelvic radiotherapy for symptom relief or to delay symptom progression. Radiotherapy dose and fractionation regimens vary. We aimed to provide an overview of the literature and to evaluate palliative pelvic radiotherapy of PC focusing on symptomatic effect, quality of life (QOL), and toxicity, and to determine the optimal radiotherapy schedule. MATERIAL AND METHODS Systematic literature searches of Medline, Embase and Cochrane databases were performed through 2011. Studies reporting symptom and QOL responses were eligible. RESULTS Nine studies were included, all retrospective chart reviews. There were large variations in radiotherapy dose and fractionation. Overall symptom response rate was 75% and positive responses were reported for hemorrhage (73%), pain (80%), bladder outlet obstruction (63%), rectal symptoms (78%) and ureteric obstruction (62%). Toxicity results were not evaluable. CONCLUSIONS Despite limitations in the review process and the included studies, we conclude that pelvic radiotherapy for symptomatic PC appears to provide effective palliation of a variety of symptoms. There is currently no valid documentation regarding onset or duration of palliation. No recommendations can be provided regarding target dose or fractionation schedule in this context.

Patient factors and quality of life outcomes differ among four subgroups of oncology patients based on symptom occurrence

Abstract Context: Reviews of the literature on symptoms in oncology patients undergoing curative treatment, as well as patients receiving palliative care, suggest that they experience multiple, co-occurring symptoms and side effects. Objectives: The purposes of this study were to determine if subgroups of oncology patients could be identified based on symptom occurrence rates and if these subgroups differed on a number of demographic and clinical characteristics, as well as on quality of life (QoL) outcomes. Methods: Latent class analysis (LCA) was used to identify subgroups (i.e. latent classes) of patients with distinct symptom experiences based on the occurrence rates for the 13 most common symptoms from the Memorial Symptom Assessment Scale. Results: In total, 534 patients with breast, head and neck, colorectal, or ovarian cancer participated. Four latent classes of patients were identified based on probability of symptom occurrence: all low class [i.e. low probability for all symptoms (n = 152)], all high class (n = 149), high psychological class (n = 121), and low psychological class (n = 112). Patients in the all high class were significantly younger compared with patients in the all low class. Furthermore, compared to the other three classes, patients in the all high class had lower functional status and higher comorbidity scores, and reported poorer QoL scores. Patients in the high and low psychological classes had a moderate probability of reporting physical symptoms. Patients in the low psychological class reported a higher number of symptoms, a lower functional status, and poorer physical and total QoL scores. Conclusion: Distinct subgroups of oncology patients can be identified based on symptom occurrence rates. Patient characteristics that are associated with these subgroups can be used to identify patients who are at greater risk for multiple co-occurring symptoms and diminished QoL, so that these patients can be offered appropriate symptom management interventions.

Intestinal Malabsorption in Long-Term Survivors of Cervical Cancer Treated With Radiotherapy

PURPOSE The aim of this cross-sectional study is to investigate the associations between pelvic radiotherapy (RT) and markers of intestinal absorption in cervical cancer survivors (CCSs). We compared patient data with normative data from a reference population and explored the associations between cobalamin status and clinically significant diarrhea and depression. METHODS AND MATERIALS Fifty-five CCSs treated with RT in 1994-1999 were included in 2005 in a follow-up questionnaire study exploring physical and psychological symptoms. Blood tests, including serum (S)-vitamin B(12,) S-methylmalonic acid, S-folate, erythrocyte-folate, and plasma homocysteine, were analyzed. Differences in median values between CCSs and reference populations were evaluated by using Wilcoxon tests. Associations between variables were examined by means of multiple regression analyses. RESULTS Median S-vitamin B(12) level was significantly lower and median S-methylmalonic acid level was significantly higher in CCSs compared with the reference population (p < 0.001). Correction for renal function verified a likely cobalamin deficiency in 20% of CCSs (11 of 55). Diarrhea or depression was not significantly related to any of the mentioned markers of cobalamin or folate status. Fifteen percent of CCSs (8 of 55) had subnormal S-calcium values. CONCLUSIONS Significant cobalamin deficiency was observed in 11 (20%) and low calcium level was observed in 8 CCSs (15%) 6-12 years after pelvic RT. Neither diarrhea nor depression was associated with this deficiency. Routine monitoring of S-vitamin B(12) level is recommended, and regular intake of cobalamin should be considered in CCSs treated with RT.