No reduced risk of overall, colorectal, lung, breast, and prostate cancer with metformin therapy in diabetic patients: database analyses from Germany and the UK

BACKGROUND

In observational studies, a lower cancer risk was reported for patients with diabetes using metformin. However, many of these studies had shortcomings like time-related biases. We aimed to compare the incidence rate of any cancer and some selected cancer sites in metformin, sulfonylurea, and insulin users and to reduce some major biases common in observational studies.

METHODS

In a retrospective database study, we used patient data from general practices throughout Germany and the UK. Eighty thousand two hundred and sixty-three patients aged 30-89 years at diagnosis of diabetes were observed for a mean follow-up of 4.8 years after the first antidiabetes medication. In Cox regression models adjusted for age, sex, country, metabolic factors, diabetes duration, medication, and comorbidity, patients who started using metformin were compared with those who started using sulfonylurea (or insulin) (intention-to-treat type analysis), and, additionally, patients with metformin monotherapy were compared with those with sulfonylurea (or insulin) monotherapy. The initial 12 months of follow-up after the first antidiabetes prescription were excluded.

RESULTS

Four thousand seven hundred seventy-nine (6.0%) incident cases of cancer were identified. Throughout all analyses, hazard ratios were close to the null for comparisons of metformin use with sulfonylurea and insulin use. For example, in intention-to-treat analyses comparing metformin with sulfonylurea use, hazard ratios were 1.05 (95%CI: 0.99-1.12) for any cancer, 1.05 (0.85-1.30) for colorectal, 1.04 (0.82-1.31) for lung, 1.03 (0.81-1.30) for breast, and 0.89 (0.73-1.08) for prostate cancer.

CONCLUSION

This study provides evidence that metformin has no protective effect on the incidence of cancer in persons with diabetes.

The researcher and the consultant: from testing to probability statements

In the first instalment of this series, Stang and Poole provided an overview of Fisher significance testing (ST), Neyman-Pearson null hypothesis testing (NHT), and their unfortunate and unintended offspring, null hypothesis significance testing. In addition to elucidating the distinction between the first two and the evolution of the third, the authors alluded to alternative models of statistical inference; namely, Bayesian statistics. Bayesian inference has experienced a revival in recent decades, with many researchers advocating for its use as both a complement and an alternative to NHT and ST. This article will continue in the direction of the first instalment, providing practicing researchers with an introduction to Bayesian inference. Our work will draw on the examples and discussion of the previous dialogue.

The regional myocardial infarction registry of Saxony-Anhalt (RHESA) in Germany - rational and study protocol

BACKGROUND

In 2012 the age-standardized acute myocardial infarction (AMI) mortality rate was in the federal state Saxony-Anhalt 67 deaths per 100.000 whereas in Germany the AMI-rate was 47 deaths per 100.000. The rate in Saxony-Anhalt was therefore 43 % above the national average. Many factors may explain this above-average AMI mortality rate: First, the prevalence of cardiovascular risk factors (e.g. arterial hypertension, diabetes mellitus, smoking) in Saxony-Anhalt is the highest among all the Federal States of Germany. Second, structural health care for patients with AMI is potentially deficient (e.g. insufficient number of percutaneous coronary intervention-centers or deficits in the pre-hospital logistics of care). Third, the pre- and in-hospital process quality of health care for patients with AMI is possibly insufficient (e.g. time to reperfusion therapy). In July 2013 we established the regional myocardial infarction registry of Saxony-Anhalt (Regionales Herzinfarktregister in Sachsen-Anhalt, RHESA). RHESA is a population-based registry in the eastern part of Germany. Aims of RHESA are to calculate the AMI morbidity and mortality rates. Furthermore we study the factors that may potentially influence these rates in Saxony-Anhalt.

METHODS

RHESA is a population-based registry of patients with fatal or non-fatal AMI that was established in July 2013. The registry population comprises inhabitants aged 25 years or more of the city of Halle (Saale) (n = 179.000) and inhabitants of the rural district Altmark (n = 165.000) in the federal state Saxony-Anhalt, Germany.

DISCUSSION

The main objectives of RHESA are to provide detailed estimates of the burden of AMI in Saxony-Anhalt which is the federal state with the highest AMI mortality rate in Germany and to investigate factors that influence morbidity and mortality rates due to AMI. Data collected in RHESA enable us to assess different levels of quality of health care of patients with AMI (structural, process and outcome). RHESA provides for the first time estimates of the burden of AMI in Saxony-Anhalt, and therefore contributes considerably to an improvement of the German Health Monitoring that strives for a more valid extrapolation of the nationwide morbidity and mortality rates of AMI.

Mortality of Testicular Cancer in East and West Germany 20 Years after Reunification: A Gap Not Closed Yet

BACKGROUND

The decline of testicular cancer mortality in East Germany began in the 1980s, about 10 years later than that recorded in West Germany. We aimed at providing up-to-date time trends of testicular cancer mortality rates in Germany.

MATERIAL AND METHODS

Mortality data from East Germany (1971-2010) and West Germany (1954-2010) were provided by the Federal Bureau of Statistics. We estimated age-specific and age-standardized mortality rates using the World Standard Population.

RESULTS

Despite the declining trend in the 2000s, the mortality rates of testicular cancer remained higher in East than in West Germany. These rates were 5.5 and 2.6 per million person-years in 2010, respectively. Age-specific mortality trends by period and birth cohort showed that the mortality decline was larger among younger (15-44 years) than elderly men.

CONCLUSION

The mortality of testicular cancer is still higher in East than West Germany. Despite very similar densities of hospital beds, urologists and oncologist per million male population in both parts of Germany, we hypothesized that a paucity of centers of expertise for treating testicular cancers in the East could account for this particular pattern.

An inter-state comparison of cardiovascular risk factors in Germany: towards an explanation of high ischemic heart disease mortality in Saxony-Anhalt

BACKGROUND

For years, the state of Saxony-Anhalt has had one of the highest mortality rates from ischemic heart disease among all federal states in Germany. In this article, we provide an overview of the prevalence of known risk factors for ischemic heart disease across the German states and discuss possible artefacts in mortality statistics.

METHODS

On the basis of data from a selective literature review and from official statistics, we compare, if available, age-standardized prevalences of diabetes, obesity, increased waist circumference, metabolic syndrome, and cigarette smoking across the German states. We also present statistics on completion of schooling, dropping out of school, and unemployment.

RESULTS

Saxony-Anhalt was in first or second place among German states for all of the risk factors considered. It was also among the leaders in the percentage of school dropouts (14.1%), and, in 2011, it had the lowest percentage of persons educated to matriculation level (19.2%). The unemployment rate in Saxony-Anhalt was 11.5% in 2012, one of the highest rates in Germany. Even after unclear and unknown causes of death are taken into account, the high mortality from ischemic heart disease in Saxony-Anhalt (153.3 per 100 000 person years cannot be attributed completely to an artefact.

CONCLUSION

The high prevalence of risk factors and the unfavorable profile of social factors are consistent with the observed high mortality from ischemic heart disease in Saxony-Anhalt. There is an urgent need for lasting prevention strategies on all levels—societal, behavioral, and clinical.

A survey of etiologic hypotheses among testicular cancer researchers

Basic research results can provide new ideas and hypotheses to be examined in epidemiological studies. We conducted a survey among testicular cancer researchers on hypotheses concerning the etiology of this malignancy. All researchers on the mailing list of Copenhagen Testis Cancer Workshops and corresponding authors of PubMed-indexed articles identified by the search term 'testicular cancer' and published within 10 years (in total 2750 recipients) were invited to respond to an e-mail-based survey. Participants of the 8th Copenhagen Testis Cancer Workshop in May 2014 were subsequently asked to rate the plausibility of the suggested etiologic hypotheses on a scale of 1 (very implausible) to 10 (very plausible). This report describes the methodology of the survey, the score distributions by individual hypotheses, hypothesis group, and the participants' major research fields, and discuss the hypotheses that scored as most plausible. We also present plans for improving the survey that may be repeated at a next international meeting of experts in testicular cancer. Overall 52 of 99 (53%) registered participants of the 8th Copenhagen Testis Cancer Workshop submitted the plausibility rating form. Fourteen of 27 hypotheses were related to exposures during pregnancy. Hypotheses with the highest mean plausibility ratings were either related to pre-natal exposures or exposures that might have an effect during pregnancy and in post-natal life. The results of the survey may be helpful for triggering more specific etiologic hypotheses that include factors related to endocrine disruption, DNA damage, inflammation, and nutrition during pregnancy. The survey results may stimulate a multidisciplinary discussion about new etiologic hypotheses of testicular cancer.

The prevalence of estrogen receptor-negative breast cancer in Ethiopia

Background

In contrast with breast cancers (BCs) in other parts of the world, most previous studies reported that the majority of BCs in sub-Saharan Africa are estrogen-receptor (ER) negative. However, a recent study using the US SEER database showed that the proportion of ER-negative BC is comparable between US-born blacks and West-African born blacks but substantially lower in East African-born blacks, with over 74% of patients Ethiopians or Eritreans. In this paper, we provide the first report on the proportion of ER-negative BC in Ethiopia, and the relation to progesterone-receptor (PgR) status.

Methods

We analysed 352 female patients with ER results available out of 1208 consecutive female BC patients treated at Addis Ababa-University Hospital, Ethiopia, from June 2005 through December 2010. The influences of age, stage, and histology on the probability of ER-negative tumours were assessed by a log-linear regression model.

Results

Of the 352 patients, only 35% were ER-negative. The proportion of ER-negative tumours decreased with advancing age at diagnosis and was not affected by histology or stage. For age, the proportion decreased by 6% for each additional 5 years (stage-adjusted prevalence ratio PR = 0.94, 95% CI: 0.89–1.00). About 31% were ER- and PgR-negative, and 69% were ER- and/or PgR-positive.

Conclusions

Contrary to most previous reports in other parts of sub-Saharan Africa, the majority of patients in Ethiopia are ER-positive rather than ER-negative. These findings are in line with low proportions of ER-negative BCs from East African immigrants within the SEER database, and they have clinical implications for management of BC patients in Ethiopia and other parts of sub-Saharan Africa where ER-status is not ascertained as part of routine management of the disease. Since the majority of patients showed ER-positive BC, Tamoxifen-therapy should be given to all patients even with unknown ER status.

Nationwide shoulder arthroplasty rates and revision burden in Germany: analysis of the national hospitalization data 2005 to 2006

BACKGROUND

The aim of this study was to provide nationwide shoulder arthroplasty rates in Germany based on the national hospitalization file and to estimate the revision burden for shoulder arthroplasty and its determinants.

METHODS

We analyzed the nationwide, population-based, German diagnosis-related groups data from the years 2005 and 2006. Procedure codes and diagnosis were analyzed for each hospitalization. Overall, 16,488 primary shoulder arthroplasties and 1302 revisions were performed during the study period. Age-standardized rates, age-specific rates, rates by indication, and revision burden were calculated.

RESULTS

The age-standardized hemiarthroplasty (HA) rates were 3.6 per 100,000 person-years (standard error [SE], 0.1) for men and 9.3 per 100,000 person-years (SE, 0.1) for women and clearly exceeded the age-standardized total shoulder arthroplasty (TSA) rates of 1.7 per 100,000 person years (SE, 0.1) for men and 3.7 per 100,000 person-years (SE, 0.1) for women. The revision burden was 4.7% for HA and 15.0% for TSA. Multivariable-adjusted analysis showed increasing age was associated with a lower relative burden of revision, and an increased Charlson comorbidity index and male gender were associated with a higher relative burden of revision. The adjusted relative burden of revision was considerably higher for TSA than for HA (adjusted relative burden of revision, 2.89; 95% confidence interval, 2.60-3.22).

CONCLUSION

We found more than 2-fold higher primary rates for HA than for TSA and up to 3-fold higher shoulder arthroplasty rates for women than for men. TSA had a 3-fold higher relative burden of revision than HA.

Risk of contralateral second primary breast cancer according to hormone receptor status in Germany

INTRODUCTION

Hormone receptor (HR) status has become an established target in treatment strategies of breast cancer. Population-based estimates of contralateral breast cancer (CBC) incidence by HR subtype in particular are limited. The aim of this study was to provide detailed data on CBC incidence for Germany.

METHODS

Invasive breast cancer data were extracted on 49,804 women yielding 594 second primaries from the cancer registries of the Federal States of Brandenburg and Saarland and the area of Munich for the period from 1998 to 2007. Multiple imputation was used on missing values for HR status. We estimated standardized incidence ratios (SIRs) with 95% confidence intervals (95%CIs).

RESULTS

SIR estimates of CBC among women diagnosed with an invasive first primary breast cancer (FBC) of any HR subtype ranged from 1.0 to 1.5 in the three registries. Pooling three registries' data, the SIR of HR-positive CBC was 0.7 (95%CI: 0.6 to 0.8) among women with HR-positive FBC. For those women with HR-negative FBC, the SIR of HR-negative CBC was 8.9 (95%CI: 7.1 to 11.1). Among women with FBC diagnosed before the age of 50 years, incidence of CBC was increased, especially for HR-negative FBC (SIR: 9.2; 95%CI: 7.1 to 11.9).

CONCLUSIONS

HR status of the first primary and age at first diagnosis is relevant for predicting risk of CBC. Particularly, patients with HR-negative FBC had elevated risks.

Renal surgery for kidney cancer in Germany 2005-2006: length of stay, risk of postoperative complications and in-hospital death

Background

Representative statistics of surgical care among patients with kidney cancer are scant. With the introduction of the diagnosis related group system in Germany, it is now possible to provide nationwide statistics on surgical care. We studied in-hospital mortality risk in relation to comorbidity and complications, length of hospital stay in relation to surgical approach and comorbidity, and risk of complications in relation to surgical approach among kidney cancer patients undergoing nephrectomy.

Methods

We analyzed the nationwide hospitalization file of the years 2005 and 2006 including 23,753 hospitalizations with a diagnosis of renal cancer and partial or complete nephrectomy and classified comorbidity (Charlson comorbidity index) and complications. Length of stay, risk of in-hospital complications and in-hospital death were analyzed by linear regression and log-linear regression (relative risks (RR) and 95% confidence intervals (95% CI)).

Results

The overall in-hospital mortality was 1.4%. Per one unit increase of the Charlson comorbidity index, the adjusted risk of in-hospital mortality increased by 53% (95% CI 47-59%). The risks of bleeding or acute posthaemorrhagic anemia, respiratory, urological and gastrointestinal complications and infections ranged between 1.1% and 2.7% with the exception of bleeding or acute posthaemorrhagic anemia with 18.4%. Complications were associated with an increased adjusted in-hospital mortality risk. Highest adjusted mortality risk ratios were observed for gastrointestinal (RR = 3.61, 95% CI 2.32-5.63) and urological complications (RR = 3.62, 95% CI 2.62-5.00). The risk of haemorrhage or acute posthaemorrhagic anemia was lower for total laparoscopic nephrectomies than total open nephrectomies. The adjusted risk of gastrointestinal complications was lower for partial open compared to total open nephrectomy (adjusted RR = 0.66, 95% CI 0.45-0.97). Total laparoscopic nephrectomy was associated with shorter length of stay (−3.3 days; 95% CI 2.9-3.7 days) compared to total open nephrectomy. The estimated age-adjusted increase of length of stay per one unit increase of the Charlson comorbidity index was 1.3 days (95% CI 1.2-1.4 days).

Conclusions

In this representative population-based analysis, we found that the surgical approach is associated with the risk of complications and length of hospital stay. Furthermore, in the era of ageing populations, renal cancer patients with comorbidities should be counseled about their increased in-hospital mortality risk.

GNB3 gene 825 TT variant predicts hard coronary events in the population-based Heinz Nixdorf Recall study

OBJECTIVE

The C825T polymorphism of the gene encoding the human G protein beta-3 subunit (GNB3) is associated with hypertension and obesity. Moreover, genotypes of the GNB3 polymorphism have been associated with development of coronary artery disease, and the 825T allele is thought to influence the process of atherosclerosis. However, the potential of the C825T polymorphism to predict coronary events has been poorly explored in a longitudinal setting at the population level.

METHODS

In 4159 Caucasian subjects from the Heinz Nixdorf Recall study cohort (age: 45-75 years, 48% male), genotypes of the GNB3 C825T polymorphism (rs5443) were determined and associated with fatal and non-fatal myocardial infarction (hard coronary events). Established cardiovascular risk factors were used to adjust for confounders.

RESULTS

The median follow-up time was 9.9 years (1st/3rd quartiles 9.5/10.2). 148 subjects (3.6%) experienced a hard coronary event. The 10-year event-free survival rate was CC, 96.1%; CT 96.9%, TT, 93.7% (p = 0.018). Multivariable analysis showed that the TT genotype is a significant risk factor for hard coronary events (hazard ratio (HR) = 1.9 (95% confidence interval (CI) 1.2-2.9); p = 0.008) after adjustment for age, sex, diabetes, systolic blood pressure, body mass index, high-density lipoprotein, and coronary artery calcification as determined by electron beam computed tomography at baseline. While prognosis in females was independent of GNB3 genotypes, analysis in males even elevated the HR for TT versus C-allele to 2.6 (95% CI 1.6-4.2; p < 0.001).

CONCLUSION

The GNB3 825 TT genotype is a significant and independent risk factor for hard coronary events independent of other established cardiovascular risk factors at a population level in males.

Progression of coronary artery calcification seems to be inevitable, but predictable - results of the Heinz Nixdorf Recall (HNR) study

Aim

Coronary artery calcification (CAC), as a sign of atherosclerosis, can be detected and progression quantified using computed tomography (CT). We develop a tool for predicting CAC progression.

Methods and results

In 3481 participants (45–74 years, 53.1% women) CAC percentiles at baseline (CAC_b) and after five years (CAC_5y) were evaluated, demonstrating progression along gender-specific percentiles, which showed exponentially shaped age-dependence. Using quantile regression on the log-scale (log(CAC_b+1)) we developed a tool to individually predict CAC_5y, and compared to observed CAC_5y. The difference between observed and predicted CAC_5y (log-scale, mean±SD) was 0.08±1.11 and 0.06±1.29 in men and women. Agreement reached a kappa-value of 0.746 (95% confidence interval: 0.732–0.760) and concordance correlation (log-scale) of 0.886 (0.879–0.893). Explained variance of observed by predicted log(CAC_5y+1) was 80.1% and 72.0% in men and women, and 81.0 and 73.6% including baseline risk factors. Evaluating the tool in 1940 individuals with CAC_b>0 and CAC_b<400 at baseline, of whom 242 (12.5%) developed CAC_5y>400, yielded a sensitivity of 59.5%, specificity 96.1%, (+) and (−) predictive values of 68.3% and 94.3%. A pre-defined acceptance range around predicted CAC_5y contained 68.1% of observed CAC_5y; only 20% were expected by chance. Age, blood pressure, lipid-lowering medication, diabetes, and smoking contributed to progression above the acceptance range in men and, excepting age, in women.

Conclusion

CAC nearly inevitably progresses with limited influence of cardiovascular risk factors. This allowed the development of a mathematical tool for prediction of individual CAC progression, enabling anticipation of the age when CAC thresholds of high risk are reached.

A novel approach for estimating the nationwide incidence of renal cancer

BACKGROUND

The aim of this study was to provide a novel approach for estimating the incidence of renal cancer in Germany by using hospitalization data from the years 2005-2006 and to compare these estimates with incidence rates from cancer registries. We used nationwide hospitalization data from the years 2005-2006 including 34.2 million hospitalizations. We used three definitions of potential incident renal cancer cases: 1) a main or secondary diagnosis of renal cancer and a partial or total nephrectomy; 2) a main diagnosis of renal cancer and a partial or total nephrectomy; and 3) a main diagnosis of renal cancer (without a secondary diagnosis of renal pelvis cancer) and a partial or total nephrectomy. In addition, we used cancer registry data for comparison of rates.

RESULTS

Hospitalization data to which definition 2 applied provided incidence rate estimates nearly identical to those provided by the cancer registries (when the cases registered from death certificates only were excluded). Age-standardized (European standard population) incidence rates based on hospitalization data and cancer registry data were 15.6 per 100 000 and 15.7 per 100 000 among men and 8.0 per 100 000 and 7.6 per 100 000 among women respectively. Cancer registry-based incidence rates were lower especially among those federal states with an estimated completeness of registration below 90% (Berlin and Saxony-Anhalt).

CONCLUSIONS

Representative hospitalization data can be used to estimate incidence rates of renal cancer. We propose that incidence rates can be estimated by hospitalization data if 1) the primary treatment is performed during an in-hospital stay and 2) nearly all patients undergo a defined surgical procedure that is not repeated for the treatment of the same cancer. Our results may be useful for countries with no or incomplete cancer registration or for countries that use hospitalization data to provide a representative incidence of renal cancer.

Cervical cancer in Ethiopia: survival of 1,059 patients who received oncologic therapy

BACKGROUND

Almost 500,000 women are newly diagnosed with cervical cancer (CC) every year, the majority from developing countries. There is little information on the survival of these patients. Our primary objective was to evaluate consecutive CC patients presenting over 4 years at the only radiotherapy center in Ethiopia.

METHODS

All patients with CC from September 2008 to September 2012 who received radiotherapy and/or surgery were included (without brachytherapy). Vital status was obtained through telephone contact or patient cards.

RESULTS

Of 2,300 CC patients, 1,059 patients with standardized treatment were included. At the end of the study, 249 patients had died; surviving patients had a median follow-up of 16.5 months; the 10% and 90% percentiles were 3.0 and 32.7 months, respectively. Mean age was 49 years (21-91 years). The majority of patients presented with International Federation of Gynecology and Obstetrics stage IIb-IIIa (46.7%). Because of progression during the waiting time (median 3.8 months), this proportion declined to 19.3% at the beginning of radiotherapy. The 1- and 2-year overall survival probabilities were 90.4% and 73.6%. If assuming a worst-case scenario (i.e., if all patients not available for follow-up after 6 months had died), the 2-year survival probability would be 45.4%.

CONCLUSION

This study gives a thorough 4-year overview of treated patients with CC in Ethiopia. Given the limited treatment availability, a relatively high proportion of patients survived 2 years. More prevention and early detection at all levels of the health care system are needed. Increasing the capacity for external-beam radiation as well as options for brachytherapy would facilitate treatment with curative intention.

Agreement of different methods for assessing sleep characteristics: a comparison of two actigraphs, wrist and hip placement, and self-report with polysomnography

OBJECTIVE

To assess the agreement of sleep parameters measured by two actigraphs (SOMNOwatch plus, ActiGraph GT3X+) at two different placements (wrist, hip) and of self-reported sleep with polysomnography (PSG).

METHODS

We estimated agreement with PSG for total sleep time (TST), sleep onset latency (SOL), wake after sleep onset (WASO), number of awakenings after sleep onset (NASO), and sleep efficiency (SE%) for 100 participants of the general population, aged 18-75 years by judging mean differences to PSG and intervals of agreement using Bland-Altman plots.

RESULTS

Mean difference to PSG for TST was 8.3 min (95% confidence intervals [CI] -7.4; 24.1) for SOMNOwatch plus (wrist), 39.8 min (95% CI 24.3; 55.3) for self-report, -79.0 min (95% CI -89.0; -68.9) for SOMNOwatch plus (hip), and -81.1 min (95% CI -91.9; -70.4) for GT3X+ (hip), respectively. The width of intervals of agreement differed with the placement of the devices. Mean differences to PSG were higher for hip-based measurements compared with wrist placement for most parameters.

CONCLUSIONS

Agreement of sleep parameters assessed by actigraphy with PSG differs with the placement of the device and is limited for hip-based measurements. Agreement of self-report with PSG is comparable to that of actigraphy for some parameters.

Having children, social characteristics, smoking and the risk of uveal melanoma: a case-control study

PURPOSE

We analyzed data from the Risk Factors for Uveal Melanoma (RIFA) study to evaluate possible associations between uveal melanoma risk and having children, socioeconomic level and smoking.

METHODS

The RIFA study was a German case-control study conducted from September 2002 to March 2005. The study population consisted of 455 incident uveal melanoma patients (20-74 years of age) and 827 matched (age, sex, region of residence) population controls. Odds ratios (OR) and 95% confidence intervals (CI) were estimated using conditional logistic regression.

RESULTS

Women with children showed an increased OR (1.59, 95% CI 0.95-2.66) for uveal melanoma development compared to women without children. We estimated decreased ORs for subjects with higher socioeconomic level compared to the lowest status (upper secondary school leaving certificate: OR 0.68, 95% CI 0.49-0.94; higher education: OR 0.60, 95% CI 0.38-0.96). Ever smokers showed an OR of 1.19 (95% CI 0.92-1.55) compared to never smokers.

CONCLUSION

The observed association between lower socioeconomic level and increased odds for uveal melanoma possibly represents a higher occupational uveal melanoma risk for occupational categories that are usually associated with lower socioeconomic status. Concerning having children and uveal melanoma development, we hypothesize that the observed association is mediated through alpha-melanocyte-stimulating hormone, a hormone that increases during pregnancy and is linked to pigmentation alterations in pregnant women.