Endometriosis and cancer: When a "breakthrough" may not be all that

There is an interesting new study that was just published online at the Lancet Oncology. It is a pooled analysis of a bunch of case-control studies to explore the association between endometriosis and certain types of ovarian cancer. Here is the abstract:

Background

Endometriosis is a risk factor for epithelial ovarian cancer; however, whether this risk extends to all invasive histological subtypes or borderline tumours is not clear. We undertook an international collaborative study to assess the association between endometriosis and histological subtypes of ovarian cancer.

Methods

Data from 13 ovarian cancer case—control studies, which were part of the Ovarian Cancer Association Consortium, were pooled and logistic regression analyses were undertaken to assess the association between self-reported endometriosis and risk of ovarian cancer. Analyses of invasive cases were done with respect to histological subtypes, grade, and stage, and analyses of borderline tumours by histological subtype. Age, ethnic origin, study site, parity, and duration of oral contraceptive use were included in all analytical models.

Findings

13 226 controls and 7911 women with invasive ovarian cancer were included in this analysis. 818 and 738, respectively, reported a history of endometriosis. 1907 women with borderline ovarian cancer were also included in the analysis, and 168 of these reported a history of endometriosis. Self-reported endometriosis was associated with a significantly increased risk of clear-cell (136 [20·2%] of 674 cases vs 818 [6·2%] of 13 226 controls, odds ratio 3·05, 95% CI 2·43—3·84, p<0·0001), low-grade serous (31 [9·2%] of 336 cases, 2·11, 1·39—3·20, p<0·0001), and endometrioid invasive ovarian cancers (169 [13·9%] of 1220 cases, 2·04, 1·67—2·48, p<0·0001). No association was noted between endometriosis and risk of mucinous (31 [6·0%] of 516 cases, 1·02, 0·69—1·50, p=0·93) or high-grade serous invasive ovarian cancer (261 [7·1%] of 3659 cases, 1·13, 0·97—1·32, p=0·13), or borderline tumours of either subtype (serous 103 [9·0%] of 1140 cases, 1·20, 0·95—1·52, p=0·12, and mucinous 65 [8·5%] of 767 cases, 1·12, 0·84—1·48, p=0·45).

Interpretation

Clinicians should be aware of the increased risk of specific subtypes of ovarian cancer in women with endometriosis. Future efforts should focus on understanding the mechanisms that might lead to malignant transformation of endometriosis so as to help identify subsets of women at increased risk of ovarian cancer.

Funding

Ovarian Cancer Research Fund, National Institutes of Health, California Cancer Research Program, California Department of Health Services, Lon V Smith Foundation, European Community's Seventh Framework Programme, German Federal Ministry of Education and Research of Germany, Programme of Clinical Biomedical Research, German Cancer Research Centre, Eve Appeal, Oak Foundation, UK National Institute of Health Research, National Health and Medical Research Council of Australia, US Army Medical Research and Materiel Command, Cancer Council Tasmania, Cancer Foundation of Western Australia, Mermaid 1, Danish Cancer Society, and Roswell Park Alliance Foundation.

Alas, I do not have access to the full article (paywall), so cannot go though it in a detailed way. Nevertheless, we can try to put these findings in perspective. So, briefly, the investigators put together data from many case-control studies and discovered that the risk of some, though not all, ovarian cancers was 2-3 times higher in the presence of endometriosis than in its absence, and concluded that clinicians should be aware of this increase in risk. Fair? But you know I am going to deconstruct it, right? Here we go.

By now we all understand what a case-control study is, right? It is a study where cases (those patients with the disease of interest) are compared to controls (subjects who are in all ways the same as the cases with the exception that they do not harbor the disease in question). So the study identifies subjects with an outcome, and follows them backward to the exposure that is of interest vis-a-vis this outcome. These studies are notoriously difficult to do well, particularly when it comes to the choice of a control, and very few do it well in my experience. I cannot comment on the current conglomeration of 13 of them, so will not venture a guess on whether some or how many of them may lead us astray. Though these studies are difficult, for various reasons they are the way to go when examining an uncommon outcome. So the choice of the design is legit.

No, let's examine the risk for misclassification for both the disease and the exposure. I think you will agree that a case of ovarian cancer is difficult to misclassify, so I will not pick on this as a potentially major threat to the validity. But what about endometriosis? This is a chameleonic condition that is probably way under-recognized. Its symptoms and signs are varied and, unless the studies required a look "inside," which I sincerely doubt they did -- note, the abstract states that this exposure was self-reported -- there is a very real and grave threat to validity here. Ever heard of recollection bias? If such exists, then more women with cancer are likely to report symptoms that may be indicative of endometriosis than those without cancer. So, the observed increase in the risk of ovarian CA in the presence of endometriosis may be due to just that -- a recollection bias.

These limitations notwithstanding, the authors felt that the study was a breakthrough (emphasis mine):

"This breakthrough could lead to better identification of women at increased risk of ovarian cancer and could provide a basis for increased cancer surveillance of the relevant population, allowing better individualization of prevention and early detection approaches such as risk-reduction surgery and screening,” lead author Celeste Leigh Pearce, at the University of Southern California, Los Angeles, said in a journal news release. 

What does Dr. Pearce mean by "increased cancer surveillance?" Is she talking about screening women with endometriosis because of this possibly heightened risk? And if so, is this really wise? Let's simulate some of these numbers.

Let us suppose that endometriosis does indeed increase the risk of ovarian cancer 2-3-fold. This means that the incidence now goes from 13 per 100,000 women up to 39 per 100,000. Let us now also assume that there is a test that is 99% sensitive (able to identify ovarian CA when it is present) and 99% specific (able to demonstrate that no ovarian CA is present when it is not present). Recall that at the population incidence of ovarian CA, the USPSTF does not recommend screening due to a very high risk of a false positive. The question is does this 3-fold elevation in risk change the positive predictive value of screening substantially enough for it now to be recommended? I think I know the answer, but let's go through the exercise anyway, just to be explicit.

	Disease present	Disease absent	Total
Test+	39	1,000	1,038
Test-	0	98,961	98,962
Total	39	99,961	100,000

So, the corresponding positive predictive value is... drum roll, please... 3.7%. This means that out of 100 women who have tested positive, fully 96 have a false positive result and are now likely to be subjected to invasive procedures. If we imagine that a test can have near-perfect specificity of 99.99% (no test that I know of can come close to this in any consistent way), still 20% of all positive results are false positives. So, is this indeed food for screening thought? I really don't think so, particularly given that the current risk calculation is likely a gross over-estimate.

So, there you have it. I don't think I am engaging in hyperbole when I say that "breakthrough" is very likely an overstatement.