Anthropometric variables and risk of breast cancer

The role of anthropometric variables in the risk of breast cancer has been investigated using pooled data from 2 hospital-based case-control studies conducted in Italy for a total data-set of 3,247 cases and 3,263 controls. No association was observed in pre-menopausal women between breast cancer risk and height, weight, indices of body mass (W/H2; W/H1.5) and surface area. In post-menopausal women, the risk of breast cancer was inversely related to height, being 0.8 in taller women (greater than 165 cm) compared with women 155 cm tall or less; the trend in risk, although not constantly decreasing, was statistically significant (p trend = 0.03). A direct, statistically significant association emerged with weight and indices of body mass and post-menopausal breast cancer risk. Considering 2 indices of body weight (W/H2 and W/H1.5) and relative to thinner women, the respective estimated risks of post-menopausal breast cancer increased to 1.4 and 1.3 for grossly obese women, and the corresponding p values for trend were respectively 0.002 and 0.02. The role of overweight was more evident in women with early age at menopause, thus suggesting a duration-risk effect.

A centralised cytology screening programme for cervical cancer in Florence

STUDY OBJECTIVE

The aim of the study was to evaluate the effectiveness of a centralised population based cervical cytology screening programme.

DESIGN

The study was a case-control investigation.

SETTING

Cases and controls were confined to the province of Florence.

PARTICIPANTS

191 out of 208 cases of cervical cancer in women less than 75 years old at diagnosis in the period 1982-85 were interviewed. For each case three living controls were selected, strictly matched by year of birth and district of residence; in all 573 controls were eventually identified. Of these, 15 had had a hysterectomy (2.6%) and were excluded, and a further 18 (3.2%) did not take part for other reasons, leaving a total of 540 controls.

MEASUREMENT AND RESULTS

Screening history was taken from a computerised archive for both cases and controls. A mail questionnaire was used to collect information on several potential confounding variables. For women screened only once in comparison with those never screened, the reduction in risk was about 70% (odds ratio 0.29. 95% confidence limits 0.15-0.55), while the reduction was even greater for those screened twice or more. No trend of increasing risk with increasing interval since last test was shown: considering separately women who had only had one test and those who had had two or more tests, the risk estimates were stable across different time intervals since the last test.

CONCLUSIONS

There is a strong protective effect against developing invasive cervical cancer through participation in the screening programme.

A case-control study of gastric cancer and diet in Italy

A case-control study was conducted in high- and low-risk areas of Italy to evaluate reasons for the striking geographic variation in gastric cancer (GC) mortality within the country. Personal interviews with 1,016 histologically confirmed GC cases and 1,159 population controls of similar age and sex revealed that the patients were more often of lower social class and resident in rural areas and more frequently reported a familial history of gastric (but not other) cancer. After adjusting for these effects, case-control differences were found for several dietary variables, assessed by asking about the usual frequency of consumption of 146 food items and beverages. A significant trend of increasing GC risk was found with increasing consumption of traditional soups, meat, salted/dried fish and a combination of cold cuts and seasoned cheeses. The habit of adding salt and the preference for salty foods were associated with elevated GC risk, while more frequently storing foods in the refrigerator, the availability of a freezer and use of frozen foods lowered risk. Reduced GC risk were associated with increasing intake of raw vegetables, fresh fruit and citrus fruits. Lowered risk was also related to consumption of spices, olive oil and garlic. Neither cigarette smoking nor alcoholic beverage drinking were significantly related to GC risk. The case-control differences tended to be consistent across geographic areas, despite marked regional variations in intake levels of certain foods. The high-risk areas tended to show higher consumption of food associated with elevated risk (traditional soups, cold cuts) and lower consumption of foods associated with reduced risks (raw vegetables, citrus fruits, garlic). Our findings indicate that dietary factors contribute to the regional variation of stomach cancer occurrence in Italy, and offer clues for further etiologic and prevention research.

Time interval since last test in a breast cancer screening programme: a case-control study in Italy

STUDY OBJECTIVE

To evaluate a population based screening programme for breast cancer.

DESIGN

This was a case-control study of women dying of breast cancer between 1977 and 1987 who had been invited to take part in a screening programme.

SETTING

Community based study of women aged between 40 and 70 years (total population about 35,000 at 1981 census), living in 23 small towns near Florence, Italy.

PARTICIPANTS

103 cases were identified from death certification, and 515 living controls (five per case) selected for year of birth and town of residence.

MEASUREMENTS AND MAIN RESULTS

Screening history was obtained from computer archive. Sociodemographic information was obtained from town registry offices and directly from relatives of the deceased and from the controls by postal questionnaire, and if necessary telephone or personal interview. Analysis was carried out on two age groups--40-49 years and 50+ years at diagnosis--and considered the number of screening tests and the time interval since the last test, separately and together. In the older age group, women with at least one screening test in the previous 2 1/2 years showed a 50% reduction in risk (odds ratio 0.49, 95% confidence interval [CI] 0.25-0.95). If they had also had another previous negative screen the risk was reduced to one third (odds ratio 0.35, 95% CI 0.14-0.85). There was a significant trend of decreasing risk with increasing number of screens in older women. No clear evidence of a similar protective effect was shown for women in the 40-49 year age group.

CONCLUSIONS

A significant protective effect of the screening programme is evident in older women but not in younger ones. The data do not allow an assessment of optimal screening interval because of the small number of previously screened cases.

Gastric cancer in a high-risk area in Italy. Histopathologic patterns according to Lauren's classification

Two thousand five hundred forty cases (1628 males and 912 females) of primary gastric cancer (GC) histologically diagnosed in gastroscopic biopsy or resected specimens, occurring from 1973 to 1982 in a high risk area in Italy (Florence), were reviewed. According to Lauren's criteria, 1587 (62.5%) were classified as intestinal type, 624 (24.6%) as diffuse type and 329 (12.9%) as mixed unclassified. The intestinal type is more frequent in males and increases in both sexes with advancing age; conversely for the diffuse type. In the two 5-year periods (1973-1977 and 1978-1982) the intestinal type shows a reduction over time more evident in females than in males, in contrast to the increasing trend for the diffuse type. In males, the distribution of Lauren's histologic types is stable over time for resected specimens, whereas there is a significant reduction of intestinal type for biopsy specimens. In females, both for resected and biopsy specimens there is a reduction of the intestinal type and an increase of the diffuse type from the first to the second period. For a subgroup of 297 subjects two different specimens were available (gastroscopic biopsy and surgical); sensitivity and positive predictive value, for biopsy specimen as compared with the resected one, in the diagnosis for Lauren's histologic types were calculated. An excess of diagnoses in the mixed/unclassified category for biopsy material was evident (positive predictive value = 44.3%). However, for the two main histologic types, the biopsy appears a quite reliable indicator of the final diagnosis on surgical material (intestinal: ppv = 88.6%; Diffuse: ppv = 87.0%). The study supports the hypothesis that the reduction in GC mortality in the Province of Florence in recent years may be associated with a moderate reduction in the frequency of the intestinal type.

Plasma and Tissue Cea and Tpa Markers in Operable Breast Cancer. Preliminary Results

CEA and TPA were studied in sera and in histologic specimens of 200 patients with benign (77) or malignant (123) breast pathology. The frequency and expression of the two markers was different in benign and in cancer tissues. Histologic positivity and high levels of circulating markers were observed more frequently in cancer patients than in patients with benign disease. Tissue positivity for the two tumor markers did not always correlate with elevated levels of circulating markers. Positive CEA and TPA incidence was higher in tissue samples than in serum samples. In the breast cancer group, among 33 patients with histologic positivity for CEA, only 5 cases had circulating CEA levels higher than 5 ng/ml; among 91 patients with histologic positivity for TPA, only 45 cases showed circulating levels for TPA higher than 95 U/l. These findings confirm that tumor size, secretory characteristics and vascular supply are factors affecting the achievement of high circulating marker levels. Combined marker measurement in serum and tissues can provide more information about the presence of a given tumor marker. A limited evaluation of the prognostic meaning of the study of combined CEA and TPA in sera and in tissues was carried out during the follow-up of 60 evaluable patients. Only 5 patients had cancer relapses in the first 12 months from surgery; in 2 of 5 patients TPA was positive initially and at the time of recurrence, in serum as well as in tissues. Circulating CEA gave negative findings in all relapsed patients; 2 of them showed weak positivity only in the histologic staining at the time of presentation.

Risk factors for breast cancer: pooled results from three Italian case-control studies

The role of menstrual and reproductive factors, family history, and body weight in the epidemiology of breast cancer has been reassessed in a meta-analysis of three large case-control studies of breast cancer from several Italian regions, for a total data set of 4,072 cases and 4,099 controls. Multiple logistic regression equations were used to obtain relative risks adjusted for study, center, age, and various combinations of risk factors considered. Relative to women with menarche at age 15 or over, those with earlier menarche had a 20-30% higher breast cancer risk. However, there was no tendency for the risk to increase with lower age at menarche, and the association with menarche was stronger at younger age. The risk of breast cancer was directly related to age at menopause (relative risk (RR) = 0.7 for less than 45 years vs. greater than or equal to 50 years), age at first live birth (RR = 1.8 for greater than or equal to 28 years vs. less than 22 years), and family history of breast cancer in first-degree relatives (RR = 2.0). The effect of these factors was similar in various age strata. After allowance for age at first live birth, the risk of breast cancer did not differ among women with one to four live births, but it was significantly below unity (RR = 0.6) for those with five or more live births. Furthermore, there was a clear modifying effect of age at diagnosis on parity-related risk, since parous women had elevated breast cancer risk below age 35 and reduced risk above age 40.(ABSTRACT TRUNCATED AT 250 WORDS)

Gastric cancer in a high-risk area in Italy. Histopathologic patterns according to Lauren's classification

Two thousand five hundred forty cases (1628 males and 912 females) of primary gastric cancer (GC) histologically diagnosed in gastroscopic biopsy or resected specimens, occurring from 1973 to 1982 in a high risk area in Italy (Florence), were reviewed. According to Lauren's criteria, 1587 (62.5%) were classified as intestinal type, 624 (24.6%) as diffuse type and 329 (12.9%) as mixed unclassified. The intestinal type is more frequent in males and increases in both sexes with advancing age; conversely for the diffuse type. In the two 5-year periods (1973-1977 and 1978-1982) the intestinal type shows a reduction over time more evident in females than in males, in contrast to the increasing trend for the diffuse type. In males, the distribution of Lauren's histologic types is stable over time for resected specimens, whereas there is a significant reduction of intestinal type for biopsy specimens. In females, both for resected and biopsy specimens there is a reduction of the intestinal type and an increase of the diffuse type from the first to the second period. For a subgroup of 297 subjects two different specimens were available (gastroscopic biopsy and surgical); sensitivity and positive predictive value, for biopsy specimen as compared with the resected one, in the diagnosis for Lauren's histologic types were calculated. An excess of diagnoses in the mixed/unclassified category for biopsy material was evident (positive predictive value = 44.3%). However, for the two main histologic types, the biopsy appears a quite reliable indicator of the final diagnosis on surgical material (intestinal: ppv = 88.6%; Diffuse: ppv = 87.0%). The study supports the hypothesis that the reduction in GC mortality in the Province of Florence in recent years may be associated with a moderate reduction in the frequency of the intestinal type.

Short term increase in risk of breast cancer after full term pregnancy

To determine whether there is a short term increase in the risk of breast cancer after a full term birth data from two hospital based, case-control studies in Italy were pooled. Analysis was restricted to women aged under 50 with two or more children (573 women with cancer and 570 controls). A relative risk for breast cancer of 2.66 was seen in women who had given birth during the three years preceding the interview compared with women whose last birth had occurred 10 or more years before, after adjustment for age, age at first birth, and parity. The relative risk slowly decreased for women who had last given birth three to 10 years before. Multivariate analyses confirmed the protective effect of an early age at first birth and the age dependent effect of parity on the risk of breast cancer--that is, a direct relation below age 40 and an inverse one in older women. These data provide epidemiological evidence that a full term birth is followed by a transient increase in the risk of breast cancer, which for some time contrasts with and overcomes the long term protection of pregnancy at an early age. They therefore confirm predictions from animal studies and theoretical models that pregnancy prevents the early stages of breast carcinogenesis but promotes the late stages of the process.

Prognostic significance of estrogen receptor determination in primary breast cancer

The authors report on 767 consecutive primary Stage I-II breast cancer cases followed-up from 3 to 8 years. The estrogen receptor (ER) content was determined in all cases and did not influence the treatment choice. A correlation was attempted between ER and menstrual or pathological nodal status (N) or the 5-year disease-free survival (DFS). ER was correlated with menopausal status ER+ cases being more frequent in postmenopausal patients, whereas no correlation was observed between ER and nodal status. In absence of nodal involvement (N-) the prognosis was not influenced by the ER status. A significantly better DFS was evident for ER+ respect to ER- patients in the N+ series but such a correlation is questionable as the adjuvant treatment (hormone or chemotherapy) given to such patients may have influenced the DFS according to the ER status. According to the present study, ER determination should not be used as a discriminant in the performance of adjuvant postoperative treatment based on a prognostic judgment.

Diagnostic and prognostic role of infrared thermography

A series of 469 breast cancer studied by physical examination (PE), mammography (M) and infrared thermography (TH) is discussed. Follow-up was performed up to 5 years later. The poor diagnostic role of TH is proven for the low sensitivity in the total series (0.47) and, particularly, in T1 cancers (0.26). TH does not increase significantly the cumulative sensitivity (0.98 vs. 0.97 in the total series). Its limited advantage is offset by the great number of useless biopsies due to TH false positive. A correlation between TH pattern and prognosis is evident only when TH is considered independently from other reliable prognostic indicators such as the T or N categories. If survival curves are stratified by T or N or if a multivariate analysis based on TH, T and N variables is performed, all correlations between TH pattern and prognosis disappear; for this reason the use of TH as a prognostic indicator in the clinical practice is disregarded.

A case-control study of the efficacy of a non-randomized breast cancer screening program in Florence (Italy)

In a rural area near Florence a population-based screening program for breast cancer was started in 1970, offering a mammography test every 2.5 years to all women between 40 and 70 years of age. In order to evaluate the efficacy of this program a case-control study has been carried out comparing the screening history of all women who died from breast cancer in this area in the years 1977-1984, and who had been diagnosed after the start of the program, with that of a matched group of living controls. The case-control study showed that the overall O.R. of dying from breast cancer in the study period for "screened" versus "never-screened" women was 0.53 (95% C.I. = 0.29-0.95). After evaluation of other variables as potential confounders the adjusted O.R. estimates were respectively 0.57 (95% C.I. = 0.35-0.92) and 0.32 (95% C.I. = 0.20-0.52) for women screened only once or at least twice. No significant protective effect was shown for women below the age of 50 years.

Cervical intraepithelial neoplasia III. An estimate of screening error rates and optimal screening interval

The detection rates of grade III cervical intraepithelial neoplasia (CIN III) in women at the initial and subsequent screenings were studied in Florence for the period 1979 to 1982 to assess the optimal interval between tests and the sensitivity of the screening (cytology plus advised colposcopy in cases with slightly abnormal Papanicolaou tests). The protective interval was calculated to be about three years. No differences in the risk of developing CIN III were observed between women with only an initial screening and women rescreened within the three-year interval. Screening sensitivity was calculated according to two different models: (1) when assumed to be a constant, the sensitivity of our cytologic-colposcopic screening was 0.71, with 0.64 for cytology alone; (2) when assumed to decrease in subsequent screening rounds, the sensitivity was calculated at 0.60 (0.50 in subsequent rounds), with 0.52 for cytology alone. The benefit of an early cytologic rescreening is discussed and compared to a wider use of colposcopy, which, with lower costs, permits a good sensitivity utilizing only one round of screening.