Reirradiation and lomustine in patients with relapsed high-grade gliomas

PURPOSE

The aim of this study was to evaluate the toxicity, response, and survival of patients with relapsed high-grade gliomas after radiation therapy (RT) combined with lomustine (CCNU).

METHODS AND MATERIALS

Thirty-one patients with relapsed gliomas at least 6 months after completion of RT were reirradiated. Twenty-four patients had a pathological diagnosis of high-grade gliomas, whereas 7 had a radiological diagnosis of relapsed malignant gliomas. The study focused on patients with high-grade relapsed gliomas. A total dose of 34.5 Gy was delivered in 23 fractions over 4.5 weeks. Oral administration of CCNU (130 mg/m2) was begun at the same time as RT, and was repeated every 6 weeks until disease progression, or up to 12 courses.

RESULTS

Twelve of 24 patients had surgery before RT plus CCNU treatment. Median interval between RT courses was 14 months (range 6-73). All patients received a complete course of RT, and 22 of 24 patients received at least one course of CCNU. Objective responses were seen in 14 evaluable patients: 3 with partial response, 5 with stable disease, and 6 with progressive disease. Duration of partial response was 20, 9, and 8 months. Median time to progression and overall survival from the onset of retreatment were 8.4 months (range 1-22) and 13.7 months (range 1-63+), respectively. One case of G4 thrombocytopenia was observed. Five patients had G1 or G2 leucopenia and 3 patients had G3 leucopenia. Moderate nausea and vomiting were reported in 4 patients. One patient, after one course of CCNU, refused further chemotherapy. No significant difference in survival from relapse was found between patients who underwent surgery before RT plus CCNU and those who received only RT plus CCNU (p = 0.74).

CONCLUSION

Overall, the acute toxicity was moderate, and patient compliance was good. Reirradiation of high-grade glioma was associated with modest subjective and objective response rates. It is remarkable that median overall survival from relapse was 13.7 months.

The epidemiology of lung cancer

Lung cancer is the most frequent cancer worldwide, accounting for about 12% of all new cancer diagnoses in the two sexes combined. During the 1950s and 1960s clear evidence emerged that smoking was the cause of striking lung cancer increases. Risk of lung cancer increases approximately with the fourth power of duration of smoking and the square of the number of cigarettes smoked daily. Between 1990 and 1994, lung cancer mortality rates showed first decreases in the US and several European countries, including Italy, in men although not in women. Marked shifts are, however, taking place in the incidence of different histologic types. Adenocarcinoma, which had always been the predominant type in women and non-smokers, is increasingly associated with tobacco smoking. Since the 1950s steady rises in the incidence of adenocarcinoma of the lung have been observed in many developed countries. Increases are similar in the two sexes and have followed a clear cohort pattern, paralleling changes in smoking habits and cigarette design more than diagnostic advances. Low-yield filter cigarettes tend to be inhaled more deeply than high-yield cigarettes in order to satisfy a craving for nicotine. The peripheral part of the lung, where most adenocarcinomas arise, is thus exposed to a disproportionately higher amount of smoke carcinogens. The hazards of light and ultra-light cigarettes tend to be underestimated, whereas the only safe cigarette is the non-smoked one.

Evaluation of the risk for metachronous colorectal neoplasms following intestinal polypectomy: a clinical, endoscopic and pathological study

BACKGROUND/AIMS

Surveillance programs are recommended for patients with previous intestinal polypectomy because of the high rate of adenomatous recurrences and risk of subsequent colorectal cancer. The parameters to identify patients at higher risk and the length and schedules of follow-up have not yet been established. We considered some clinical, endoscopic and pathological parameters in order to assess the probability of developing new colorectal neoplasms and eventually to schedule proper surveillance programs.

METHODOLOGY

Patients with removed adenomas were enrolled into a clinico-endoscopic follow-up, comprehensive of two colonoscopies the first at 1 year and the second at 3 years. We evaluated the risk of new neoplasms dividing the patients into four groups according to the number and size of the adenomas removed and the parameters considered.

RESULTS

Of 164 patients enrolled 156 completed the study. We had an overall 21.3% of adenomatous recurrences at 1 year and 12.8% at 3 years. Most of the adenomas removed were tubular and small in size (< 1 cm). The percentage of patients who had adenomas with advanced pathological features was 1.82% at 1 year and 0.64% at 3 years. The increase in number and size of the adenomas removed on the initial colonoscopic examination was the only one parameter statistically significant, X(2)1 (trend) 5.11; p<0.05 at the first follow-up and X(2)1 (trend) 4.87; p<0.05 at the second follow-up.

CONCLUSIONS

Patients with previous single adenoma showed few recurrences of extremely benign histological features. Since they do not require short-term endoscopic examination, it would be reasonable to defer the next colonoscopy for at least another 5 years. During follow-up, patients with multiple polyps had adenomas with advanced pathological features so it was useful to follow-up at 1 year. The tendency for advanced pathological features of removed polyps was not seen at 3 years, suggesting the importance of long-term follow-up, but with longer intervals.

Physical activity and bone mineral density in Italian middle-aged women

Osteoporosis is a major health issue in post-menopausal women on account of the association between low bone mineral density and fractures. A role of physical activity in the prevention and treatment of low bone mineral density is possible but still unclear. The relationship between low spine bone mineral density measured by means of dual photon absorptiometry at lumbar spines, and levels of past and recent physical activity has been assessed by means of a population-based screening study carried out on 1373 women (age 40-64 years) in the North-East of Italy. Physical activity at work and in leisure time was investigated for three specific periods of life: at age 12, between 15 and 19 years (during bone formative years), and in the recent years prior to the interview (30-39 or 50-59 years). Data were analysed comparing low versus high bone mineral density tertile (i.e., 458 and 461 women, respectively), after controlling for other known contributory factors in the development of osteoporosis. A positive association emerged with leisure time physical activity, with significant trends at age 15-19 (odds ratio (OR) for low versus high tertile of leisure time activity: 1.4, 95% confidence interval (CI): 0.8-2.4) and at most recent age (OR: 1.7, 95% CI: 1.1-2.6). Risk trends with occupational physical activity were less clear and non-statistically significant. The present Southern European cross-sectional study lends further support to the possibility that past and recent physical activity helps increasing bone mineral density in middle-aged women. Although the most beneficial type and intensity level of exercise has yet to be determined, the present results provide further evidence that participation in even moderate exercise programs should be encouraged.

High mortality rates from liver cancer in the urban area of Campania Region: prevalence of hepatitis and sociodemographic factors

The incidence of liver cancer appears lower in Europe and the USA and it is often looked upon as a problem in developing countries. Liver cancer has two main risk factors: the abuse of alcohol and the elevated prevalence of hepatitis B and C viruses. In Italy the first one is mainly present in the North and the second one in Southern less developed areas. Our study evaluates the relationship between living in urban and suburban zones in South of Italy in conditions of overcrowding, poor health services and high incidence of hepatitis and liver cancer.

High-Dose Epirubicin in Locally Advanced Operable Noninflammatory Breast Cancer: A Feasibility Trial

Aims and background

Anthracyclines are among the most active agents for the treatment of patients with locally advanced breast cancer. The aim of our study was to evaluate the feasibility and activity of a relatively high-dose regimen with 4-epirubicin plus normal doses of cyclophosphamide over a short period of time without the use of hematologic growth factors as adjuvant in resected locally advanced breast cancer.

Methods.

Between January 1990 and June 1992, 43 consecutive patients, premenopausal or postmenopausal «60 yrs, were surgically resected and then treated with epirubicin plus cyclophosphamide for at least 4 cycles (maximum 6). Electron beam (6–10 MeV energy) radiotherapy was delivered on the chest wall in patients with pathological skin infiltration (pT4b).

Results

Median age was 46 years (range, 27–59); 37 were premenopausal and 6 postmenopausal. The total number of administered cycles was 202 (6 in 15 patients and 4 in 28 patients); 195/202 (96.5%) were administered at full dose, and 7 (3.5%) were reduced to 75% of the planned dosage. The three-year disease-free survival was 67% for stage IlIa and 61% for stage IIIb patients. The three-year overall survival was 88% and 79%, respectively. Local relapse only was reported in one patient (2%), distant relapse in 11 patients (25%), and local and distant relapse in four patients (9%). Toxicity was acceptable and mainly hematologic.

Conclusions.

Our trial showed that the regimen is feasible without the use of hematologic growth factors. In this era of cost containment, the use of this short-term, high-dose induction course instead of repetitive courses of conventional dose regimens merits further evaluation, possibly in a large randomized trial.

The effects of antineoplastic chemotherapy on HIV disease

Six patients with human immunodeficiency virus (HIV)-associated non-Hodgkin lymphoma receiving chemotherapy (CT) with cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) plus granulocyte colony-stimulating factor were sequentially monitored to study the effects of these treatments on their immunologic status (CD4 and CD8 cell counts) and on HIV plasma viremia. We show that mean CD4 cell counts declined significantly after the third cycle of CT (187 +/- 117/microliters before CT versus 92.4 +/- 60/microliters; p = 0.04) and remained significantly reduced 4 months after completion of CT. Modifications of CD8 cell counts were not statistically significant. The effects of CT on plasma viremia, as measured by a competitive polymerase chain reaction technique, were delayed until the fourth cycle, when an increase of viral load ranging from 0.6 to 2 logs (p = 0.027) was observed. After this point, viremia returned to baseline levels, with the exception of two patients who later developed opportunistic infections and one who underwent disease progression. These results suggest that, contrary to CD4 cell counts, plasma viremia could be a faithful surrogate marker for monitoring of HIV disease progression in patients undergoing CT.

Menopause, menstrual and reproductive history, and bone density in northern Italy

STUDY OBJECTIVE

To analyse the relationship between menstrual and reproductive factors and the risk of low bone mineral density (BMD).

DESIGN

This was a population based screening programme carried out between 1991 and 1993 among 1373 perimenopausal women in northern Italy by means of dual photon absorptiometry at the lumbar spine.

MAIN RESULTS

BMD was strongly related to the age at menopause. In comparison with women reporting menopause below 45 years of age, the odds ratios (OR) of being in the lowest compared with the highest BMD tertile were 0.7 (95% confidence interval (CI) 0.3,1.5) and 0.3 (95% CI 0.1,0.8), respectively, in those with menopause at age 45-49 and above 50 years: the trend in risk was significant. Likewise, the risk of being in the lowest tertile increased with years since the menopause. Compared with women who reported they had undergone the menopause less than two years before interview, the OR of being in the lowest BMD tertile were 2.1 (95% CI 1.1,4.3), 2.3 (95% CI 1.1, 5.0), and 5.7 (95% CI 2.5,12.9) respectively in women who reported menopause 2-5, 6-9, and > or = 10 years earlier. The protective effect on bone density of late age at menopause was observed in different strata of years since menopause. Likewise, the increasing risk of a low BMD with increasing years since the menopause was evident in strata of different age at menopause. No relationships were observed between BMD and the age at menarche, characteristics of menstrual cycles, and the duration of menses. Likewise, no association emerged between reproductive history, including parity and age at first pregnancy, and BMD.

CONCLUSIONS

In this Italian population the risk of being in the lowest BMD tertile decreased with increasing age at menopause and increased with years since menopause. No relationships emerged between BMD and other menstrual characteristics or reproductive factors.

The influence of body size, smoking, and diet on bone density in pre- and postmenopausal women

We studied the determinants of low bone mineral density, using data from a population-based screening program of osteoporosis carried out among 1,373 women (age 40-64 years) in the province of Pordenone, Italy, by means of dual photon absorptiometry of the lumbar spine. Menopause had a major effect on bone mineral density. Age had little influence before menopause. In multivariate linear regression analyses, weight was the strongest predictor of bone mineral density in pre- as well as postmenopausal women. After the inclusion in a single model of a term for current weight, weight at ages 12 and 30 years explained some additional variance, whereas high waist-to-hip ratio (an indicator of central adiposity) had no influence. Smoking 15 or more cigarettes per day entailed a small increased risk of osteoporosis, but this effect, independent of weight, appeared to be restricted to premenopausal women. No food or micronutrient that we examined was predictive of bone mineral density, nor was coffee or alcoholic beverage intake.

Immunohistochemical evaluation of multiple biological markers in ductal carcinoma in situ of the breast

In order to obtain prognostic clinicopathological information, 49 cases of pure ductal carcinoma in situ of the breast (DCIS), were evaluated for the immunohistochemical expression of potential predictor markers including c-erbB-2 oncogene product, p53 protein, oestrogen (ER) and progesterone (PR) receptors, oestrogen-regulated proteins pS2 and cathepsin-D (cath-D), CD44 protein and 67-kDa laminin receptor (MLuC5). Immunohistochemical findings were compared with conventional pathological parameters, clinical findings, and the clinical outcome of the patients. When markers were matched to each other, statistical analyses provided a significant positive correlation between c-erbB-2 overexpression and p53 positivity (P < 0.01) and between ER and PR (P < 0.01), ER, PR and pS2 (P < 0.01), pS2 and MLuC5 (P < 0.05). Significant negative correlations between c-erbB-2 overexpression and ER (P < 0.05), PR (P < 0.01) and pS2 (P < 0.01) positivity was also observed. Data on the relationship between marker status and pathological findings revealed a significant positive trend between c-erbB-2, p53, and increased grade values (P < 0.05) and opposite results with PR receptor expression (P < 0.01). c-erbB-2 overexpression was further significantly associated with comedotype carcinoma (P < 0.05) and distribution of disease in confluent neoplastic ducts (P < 0.01). Although no statistically significant correlation among biological markers expression, clinical findings and outcome was demonstrated, overall this study indicates that tumour cells from a subset of DCIS, which includes comedotype carcinoma, express significantly unfavourable prognostic factors.

Differences in Cancer Mortality Trends between Four Neighboring North-Eastern Areas and Italy, 1970-1990

Aims and background

The present report combines descriptive statistics (partly never published) on four neighboring areas of north-eastern (NE) Italy [Friuli-Venezia Giulia (1970-89) and Veneto (1970-87) regions and the provinces of Trento (1970-89) and Bolzano (1971-90)], and all Italy (1970-89). The aim was to highlight potential differences in mortality trends and promote a more systematic sharing of data and methodologies.

Methods

Death certificates stratified by cause, sex, age and residence were obtained from official publications of the Italian Central Institute of Statistics. Absolute numbers of deaths from different causes, age-standardized rates (on the basis of the European standard population) and percentage of change over the examined period for both sexes were computed for each geographic area.

Results

Unfavorable trends were seen for neoplasms of the upper aerodigestive tract, lung, breast, colorectum, bladder, kidney and pancreas and cutaneous malignant melanoma. Increases in most of these neoplasms were more marked in the 4 NE areas than in Italy, especially with respect to cancers of the upper aerodigestive tract in both sexes and cancer of the lung and ovary in women. In Bolzano, rates of neoplasms associated with tobacco and alcohol consumption were lower and less steeply increasing than in the other NE areas, most notably Trento, therefore, contributing to produce the lowest overall cancer mortality rates of NE areas. Cancers of the stomach, uterus, and testis and Hodgkin's disease presented consistent downward trends in all examined areas.

Conclusions

The analysis of mortality trends across areas is consistent with elevated and still increasing cancer rates in the 4 NE areas considered, especially for tobacco and alcohol-related neoplasms and skin melanoma. Preventive strategies, based on epidemiologic knowledge, especially against tobacco and heavy alcohol consumption, and intense intermittent sun exposure, seem to be priorities and may benefit from systematic sharing of information, expertise and intervention tools in NE Italy. At least part of the lack of cancer deaths in Bolzano must be attributable to the deaths of Bolzano residents abroad (especially in Austria) and/or to differences in coding practices. This should be elucidated in future studies.

Il carcinoma uroteliale della vescica pT1G3. Studio clinico-patologico e morfometrico di 26 casi trattati con BCG: Urothelial bladder carcinoma pT1G3. Clinico-pathological and morphometric study of 26 cases treated with BCG

From 1987 to 1993, 26 patients with superficial urothelial bladder carcinoma pT1G3 were observed consecutively at the Dept. of Urology of Pordenone City Hospital and the Division of Pathology of the Centro di Riferimento Oncologico di Aviano (Italy). All patients were treated with TUR and then with a course of BCG-intravesical instillations. The complete immunoprophylaxis treatment consisted of a weekly instillation of BCG for 6 weeks; then cystoscopy and urinary cytologies or random biopsies were performed. An additional 1-monthly BCG treatment for 3 months was administered to 10 disease-free patients. In 6 cases of pT1G3 recurrences, a new complete cycle of BCG was performed whereas in 10 patients with local progression, defined as muscular infiltration, a cystoprostatectomy or RT therapy was advised. Follow-up examinations, planned every 3 months for 2 years and then every 6 months for 3 years, included cystoscopy and urinary cytologies in 19 patients and cystoscopy with randomized biopsies and washing in the remaining 7 patients. Ten patients were disease-free at a mean of 34 months follow-up (range 13-65 months); 6 patients experienced recurrence at a mean of 7 months follow-up (range 3-40 months) and 10 patients local progression at a mean of 13 months follow-up (range 3-44 months). The morphometric study demonstrated that cases with average nuclear area, in the deepest part of the histological section, more or equal to 40 μm2 have a threefold progression rate, compared to cases with average nuclear area less than 40 μm2 (p = 0.10). Our results would indicate the possible role of morphometric evaluation of prognostically important parameters, in the clinical management of patients with pT1G3 tumours.

Analysis of the p53 gene in relation to tobacco and alcohol in cancers of the upper aero-digestive tract

To elucidate the relationship, if any, of p53 gene expression according to smoking and drinking habits, 135 subjects with cancer of the upper aero-digestive tract were sampled from a case-control investigation conducted in Pordenone province, Northeast Italy, between 1986 and 1991. Adequate pathological material for immunohistochemical analysis was available for 83 subjects. Level of p53 expression was classified according to intensity on immunoreaction and percentage of p53-positive cells. Mutations were analyzed by means of single-strand conformation polymorphism and sequencing in 8 p53-positive life-long non-smokers exposed to various levels of alcohol intake. The association between p53 expression and smoking status and alcohol intake was evaluated by means of odds ratios, and 95% confidence intervals. Significantly, more men (39/65) than women (6/18) had elevated p53 expression. No significant trend of increasing percentage of p53-positive cancers with increasing smoking and drinking level was detected, especially after allowance for gender. With respect to specific mutation pattern, in 8 life-long non smokers who drank alcohol, 6 mutations involved G:C base pairs. G-to-A transitions were identified in 4 cases. The present study does not support an association between elevated p53 expression and tobacco smoking or alcohol intake. It provides an example of a molecular biology study in the framework of a large epidemiological investigation.

Tomatoes and risk of digestive-tract cancers

In view of the persisting uncertainty concerning possible mechanisms by which high vegetable and fruit intake decreases cancer risk, foods with divergent values for potentially important micronutrients are a priority for investigation. Tomatoes are low in beta-carotene, but high in lycopene, an active antioxidative agent. In order to assess the effect of tomatoes on risk of cancers of the digestive tract, data were analyzed from an integrated series of case-control studies conducted between 1985 and 1991 in northern Italy, where tomato intake is high but, also, heterogeneous. The overall dataset included the following histologically confirmed cancer cases: oral cavity and pharynx, 314; esophagus, 85; stomach, 723; colon, 955; and rectum, 629; and a total of 2,879 controls admitted to hospital for acute non-neoplastic or non-digestive conditions, unrelated to long-term dietary modifications. Multivariate odds ratios (OR) and 95% confidence interval (CI) for subsequent quartiles of intake of raw tomatoes were derived, after allowance for age, sex, study center, education, smoking and drinking level, and tertile of total caloric intake. There was a consistent pattern of protection for all sites (OR in the upper quartile ranging between 0.4 and 0.7), most notably for gastrointestinal neoplasms. All trends in risk were highly significant. The beneficial effect of raw tomatoes in this population may be partly due to the fact that they constitute perhaps the most specific feature of the Mediterranean diet. However, if it is true that tomatoes protect against digestive-tract cancers, this is of interest from both a scientific and a public health viewpoint.

Primary gastric non-Hodgkin's lymphoma--does surgery still play any role?

36 patients with primary gastric non-Hodgkin's lymphoma (PGL) (stage Ie and IIe) were treated at the Comprehensive Cancer Center of Aviano (PN) Italy. The median follow-up time of the patients was 59 months (range 10 to 117). The pre-operative diagnosis of PGL was established by using endoscopy in 70% of the patients. There was understaging in non-invasive methods of diagnosis in comparison to laparotomy. Prognostic factors such as: stage, grade according to the Working Formulation, size, depth of penetration of the gastric wall and resectability of the tumor, were taken into consideration in the treatment plan. This consisted of surgical resection of the gastric lymphoma where feasible and according to the bad prognostic factors escalating adjuvant treatment was included: group I (n = 6) patients were treated only by surgery (S), II (n = 8) by S+radiotherapy (RT) (n = 5) or S+chemotherapy (CT) (n = 3), III (n = 17) by S+RT+CT and IV (n = 5) by non-resectable S+RT+CT. There were no statistically significant differences in the survival rate, calculated by Kaplan-Meier method, between the first three groups of patients. Only stage of disease (P = 0.048) and resectability of the lesion (P = 0.003) had a significant influence on survival. There were no serious complications observed in either S, RT or CT treatment. The estimated 5-year survival rate after management was 100%, 75% and 88%, respectively for stage Ie (n = 21), stage IIe (n = 15) and all together.

Alcohol and cancers of the upper aerodigestive tract in men and women

In order to explore the potential differences in the effect of alcohol in men and women we took advantage of a case-control study of upper aerodigestive tract tumors conducted between 1986 and 1991 in Northern Italy Five hundred forty-six incidence cases of cancer of the oral cavity and pharynx (of whom 81 were women), 410 of cancer of the esophagus (of whom 67 were women), and 388 with cancer of the larynx, (of whom 19 were women) were interviewed. The control group included 2263 inpatients (of whom 557 were women) with acute conditions unrelated to alcohol and tobacco consumption. Among alcohol drinkers, similar odds ratios were detected in men and women. In the highest, well comparable intake category (i.e., > or = 42 drinks/week in women and 42-55 drinks/week in men), odds ratios were 4.5 and 3.8 for cancer of the oral cavity and pharynx, 3.0 and 4.7 for cancer of the esophagus, and 2.6 and 2.0 for cancer of the larynx in women and men, respectively, as compared to light drinkers. However, for all cancer sites a reduced risk was found among abstaining women but not in abstaining men, when compared with light-to-moderate drinkers. The present study, therefore, does not support the hypothesis that women may be substantially more vulnerable than men to alcohol carcinogenesis, at least at the level of the upper aerodigestive tract.(ABSTRACT TRUNCATED AT 250 WORDS)

Occupation and bladder cancer in Pordenone (north-east Italy): a case-control study

This case-control study evaluated the relationship between bladder cancer and occupational factors in an area of North-east Italy. The study included 273 bladder cancer cases and 573 controls identified through the services of local hospitals. Information on socio-demographic characteristics, past medical history, lifestyle factors, employment in certain industries and occupational exposures was obtained by interviewing study subjects. Elevated relative risks (RR), albeit not statistically significant, were found among males ever employed in the general chemical (RR = 2.8), dye (RR = 6.9) and painting (RR = 3.1) industries. When results related to the general chemical and specialty chemical industries were combined the RR was 3.1 (95% confidence interval [CI]: 1.2-8.5). The RR increased with increasing duration and decreasing age at starting and years since quitting employment. The risk was significantly decreased for subjects ever employed in agriculture (RR = 0.6 for males, 0.5 for females), livestock farming (RR = 0.5 for males, 0.4 for females) and furniture manufacturing (RR = 0.5 for males), whereas an elevated risk was found among white collar workers (RR and 95% CI: 1.5, 1.1-2.4 and 2.7, 1.1-6.6 for males and females, respectively). These results confirm a well-known risk among subjects employed in various sectors of the chemical industry, and indicate that bladder cancer is associated with urbanization indicators. Because lifestyle factors (i.e. smoking, coffee consumption, etc.) did not totally explain the results for white collar workers, it is possible that other still undefined aspects of the urban environment play a role in bladder carcinogenesis.

Refined-sugar intake and the risk of colorectal cancer in humans

The relationship between sugar added to coffee and other hot beverages--as an indicator of taste for sugar and sugar intake outside main meals--and the risk of colorectal cancer was investigated using data from a case-control study conducted in Northern Italy on 953 cases of histologically confirmed colon cancer, 633 of rectal cancer and 2845 controls admitted to hospital for acute, non-neoplastic, non-digestive tract disorders. Compared with subjects who reported adding no sugar to their beverages, the multivariate relative risks (RR) of colon cancer were 1.4 for those adding one spoonful of sugar, 1.6 for those adding 2 spoonful, and 2.0 for those adding 3 or more. The corresponding RRs for rectal cancer were 1.3, 1.5 and 1.4. For combination of colorectal cancer the RRs were 1.4, 1.5 and 1.8. All the trends in risk were significant, and the results were consistent across strata of study centre, sex and age, and were not appreciably modified by allowance for a number of major identified potential distorting factors, including an estimate of total calorie intake. These findings, if confirmed, would suggest that taste for sugar is a relevant indicator of colorectal cancer risk, and could be interpreted either in terms of a role of sugar in colorectal carcinogens, or of a specific influence of even limited amounts of sugar taken outside meals, which may stimulate the proliferation of the bowel epithelium, and hence enhance colorectal carcinogenesis.