Cancer mortality in the United States by education level and race

Cancer mortality, state mean elevations, and other selected predictors

This ecological inquiry compares cancer mortality rates in the U.S. to the predictor of natural background radiation (via land elevation means) along with eight other predictors thought to be associated with cancer mortality. Age-adjusted cancer mortality in 2006 was compared to the predictors of mean land elevation, percent of smokers, educational attainment, percent of population without health insurance, income, obesity, health perception, physical activity, and diet. Among the six predictors considered appropriate for multiple linear regression, three were found to be statistically significant; from strongest to weakest, these three were: smoking, land elevation, and educational attainment. The predictors of smoking and educational attainment have long been considered associated with cancer mortality. The finding that the predictor of land elevation / natural background radiation is inversely related to cancer mortality is another piece of evidence supporting the theory of radiation hormesis. In this study, land elevation / natural background radiation ranked second in predictive strength regarding cancer mortality, behind smoking and ahead of educational attainment. Since this is an ecological inquiry, no causal inferences can be made.

Applicability of a video intervention to increase informed decision making for prostate-specific antigen testing

PURPOSE

To evaluate the applicability of an evidence-based video intervention to promote informed decision making for prostate cancer screening among African American men with different levels of health literacy.

METHODS

Forty nine African American men participated in interviewer-administered, pretest and posttest interviews between January and March 2008. Health literacy status was assessed with the Test of Functional Health Literacy in Adults. Repeated measures analysis of covariance (ANCOVA), McNemar or binomial distributions were computed to assess pretest and posttest differences in knowledge. Descriptive statistics were produced to describe participants' perceptions of the information presented in the video.

RESULTS

Results indicated that men with functional health literacy had higher mean levels of prostate cancer screening knowledge at baseline than men with inadequate health literacy. The between-group (F2,44= 4.84; p = .013) and within-group (F1,44 = 5.16; p = .028) test results from repeated-measures ANCOVA indicated that preexisting group differences in prostate cancer knowledge had lessened after intervention exposure. Nearly all men rated the information presented in the video as credible (98%), trustworthy (96%), interesting (100%), understandable (94%), and complete (96%).

CONCLUSIONS

Results from this exploratory study suggest that the video intervention is suitable for use with African American men with different health literacy characteristics in 2 counties in the greater Florida panhandle region. More research is recommended to evaluate the impact of the intervention on men's intentions to undergo screening and actual screening behavior.

The validity and reliability of the Socioeconomic Status Instrument for assessing prostate cancer patients

BACKGROUND

Because of the lack of consistency in the associations of the socioeconomic status (SES) of prostate cancer (PC) patients from diverse racial and ethnic backgrounds with PC health outcomes, I created the Socioeconomic Status Instrument (SESI) from the Demographic and Health Access components of the Behavioral Risk Factor Surveillance System 2004 Questionnaires and the socioeconomic indices of the subjects' residential counties to better assess the SES of PC patients.

METHODS

The SESI was tested on 220 consecutive subjects with pathologically confirmed PC at the Veterans Affairs Medical Center in Houston, TX. A team that included an epidemiologist, a validation statistician/health services research scientist, and PC survivors assessed the content validity of the SESI. The construct validity of the SESI was assessed with factor analysis by extracting and analyzing 5 principal components based on the subjects' individual responses on the assessment: county socioeconomic characteristics, individual socioeconomic characteristics, financial distress, increased domestic burden with limited earnings, and affluence. The internal consistency reliability of the SESI was assessed with Cronbach's alpha coefficients.

RESULTS

Based on the reviews of the SESI, all of the initial 10 items were retained. The correlations between individual responses on the SESI were similar to the results of previous studies. The 5 principal components that I assessed accounted for 71.5% of the variance. Factor loadings ranged from 0.66 to 0.98 and communalities ranged from 0.55 to 0.94. County socioeconomic characteristics accounted for 22.6% of the variance, whereas individual socioeconomic characteristics accounted for 14.6% of the variance. The overall Cronbach's alpha coefficient was 0.78.

CONCLUSIONS

The SESI is valid and reliable. Accurate measurements of the SES of PC patients would provide better guidance for future research and care deliveries.

Socioeconomic status and changing inequalities in colorectal cancer? A review of the associations with risk, treatment and outcome

BACKGROUND

Upcoming mass screening for colorectal cancer (CRC) makes a review of recent literature on the association with socioeconomic status (SES) relevant, because of marked and contradictory associations with risk, treatment and outcome.

METHODS

The Pubmed database using the MeSH terms 'Neoplasms' or 'Colorectal Neoplasms' and 'Socioeconomic Factors' for articles added between 1995 and 1st October 2009 led to 62 articles.

RESULTS

Low SES groups exhibited a higher incidence compared with high SES groups in the US and Canada (range risk ratio (RR) 1.0-1.5), but mostly lower in Europe (RR 0.3-0.9). Treatment, survival and mortality all showed less favourable results for people with a lower socioeconomic status: Patients with a low SES received less often (neo)adjuvant therapy (RR ranging from 0.4 to 0.99), had worse survival rates (hazard ratio (HR) 1.3-1.8) and exhibited generally the highest mortality rates up to 1.6 for colon cancer in Europe and up to 3.1 for rectal cancer.

CONCLUSIONS

A quite consistent trend was observed favouring individuals with a high SES compared to those with a low SES that still remains in terms of treatment, survival and thus also mortality. We did not find evidence that the low/high SES gradients for treatment chosen and outcome are decreasing. To meet increasing inequalities in mortality from CRC in Europe for people with a low SES and to make mass screening successful, a high participation rate needs to be realised of low SES people in the soon starting screening program.

Race, socioeconomic status, and health: complexities, ongoing challenges, and research opportunities

This paper provides an overview of racial variations in health and shows that differences in socioeconomic status (SES) across racial groups are a major contributor to racial disparities in health. However, race reflects multiple dimensions of social inequality and individual and household indicators of SES capture relevant but limited aspects of this phenomenon. Research is needed that will comprehensively characterize the critical pathogenic features of social environments and identify how they combine with each other to affect health over the life course. Migration history and status are also important predictors of health and research is needed that will enhance understanding of the complex ways in which race, SES, and immigrant status combine to affect health. Fully capturing the role of race in health also requires rigorous examination of the conditions under which medical care and genetic factors can contribute to racial and SES differences in health. The paper identifies research priorities in all of these areas.

Variations in gastric cancer care: a trend beyond racial disparities

BACKGROUND

Race is associated with patterns of presentation and survival outcomes of gastric cancer in the United States. However, the impact of race on the receipt of guideline-recommended care is not well characterized. By using current recommendations, the authors examined the association between race and guideline-recommended treatments and identified factors that are predictive of variations in gastric cancer care.

METHODS

By using the National Cancer Database for 1998 through 2005, 106,002 patients with gastric adenocarcinoma were identified. Multivariate analysis techniques were used to examine the association between race, the receipt of guideline-recommended care, and survival after adjusting for covariates.

RESULTS

Although African-American and Hispanic patients were more likely to undergo adequate lymphadenectomy (> or =15 lymph nodes) and to receive care at comprehensive cancer centers and high-volume facilities (for all, P < or = .001), they were less likely to receive adjuvant multimodality therapy for American Joint Committee on Cancer stage IB through IV, lymph node-negative (M0) disease. Up to 60% of all patients who underwent gastrectomy failed to receive adequate lymphadenectomy and adjuvant multimodality therapy. The delivery of multimodality therapy varied significantly by stage and lymph node evaluation (P < or = .001). These findings persisted on our multivariate analyses, indicating that African-American and Hispanic patients received adequate lymph node evaluation (P < or = .001), whereas they were associated with receiving no adjuvant multimodality therapy (P < or = .025).

CONCLUSIONS

There were significant variations in treatment for gastric cancer among ethnic groups in the United States. It was noteworthy that, although nonwhite race was associated with improved surgical care, gastric cancer care remained suboptimal overall. Cancer programs need to identify procedures to maximize the delivery of adequate gastric cancer care to all patients.

Impact of socioeconomic status on extent of lymph node dissection for colon cancer

BACKGROUND

The pathologic identification of 12 or more lymph nodes (LN) after colectomy for colon cancer became a quality indicator for surgery in 2001. We investigated whether this new standard of care was differentially adopted across racial and socioeconomic lines.

METHODS

We identified 111,339 stage I to III colon cancer patients identified as black or white in the Surveillance, Epidemiology, and End Results database from 1988 to 2004 who underwent colectomy. We did multivariable logistic regression to investigate the influence of race, area socioeconomic status (SES), and other clinical and demographic characteristics on the number of LNs examined.

RESULTS

Between 1988 and 2004, white patients were more likely than black patients to have > or =12 LNs identified (odds ratio, 1.06; 95% confidence interval, 1.02-1.10) after adjustment for age, year of diagnosis, sex, marital status, tumor grade, stage, and subsite within the colon. After adjustment for SES, race was no longer significant (adjusted odds ratio, 1.00; 95% confidence interval, 0.96-1.04). There was, however, a significant positive trend between a patient's SES and having > or =12 LNs examined (P(trend) < 0.0001), with a 30% increased odds comparing the highest to the lowest quintiles of SES. We found that the association between SES and the dissection of > or =12 LNs was only present in individuals diagnosed after 1999.

CONCLUSIONS

The association between high SES and the examination of > or =12 LNs was only apparent from 2000 onward, and coincides with its dissemination and acceptance as a new standard of care. This suggests that the emergence of LN dissection as a quality indicator may have been more rapidly disseminated into higher SES groups.

Psychosocial determinants of mammography follow-up after receipt of abnormal mammography results in medically underserved women

This article targets the relationship between psychosocial determinants and abnormal screening mammography follow-up in a medically underserved population. Health belief scales were modified to refer to diagnostic follow-up versus annual screening. A retrospective cohort study design was used. Statistical analyses were performed examining relationships among sociodemographic factors, psychosocial determinants, and abnormal mammography follow-up. Women with lower mean internal health locus of control scores (3.14) were two times more likely than women with higher mean internal health locus of control scores (3.98) to have inadequate follow-up (OR=2.53, 95% CI=1.12-5.36). Women with less than a high school education had lower cancer fatalism scores than women who had completed high school (47.5 vs. 55.2, p-value=.02) and lower mean external health locus of control scores (3.0 vs. 5.3) (p-value<.01). These constructs have implications for understanding mammography follow-up among minority and medically underserved women. Further comprehensive study of these concepts is warranted.

Lung cancer diagnostic and treatment intervals in the United States: a health care disparity?

INTRODUCTION

Lung cancer diagnostic and treatment delays have been described for several patient populations. However, few studies have analyzed these intervals among patients treated in contemporary health care systems in the United States. We therefore studied the timing of lung cancer diagnosis and treatment at a U.S. medical center providing care to a diverse patient population within two different hospital systems.

METHODS

We performed a retrospective analysis of consecutive patients diagnosed with non-small cell lung cancer stage I to III from 2000 to 2005 at public and private hospitals affiliated with the University of Texas Southwestern Medical Center. We recorded patient and disease characteristics; dates of initial radiograph suspicious for lung cancer, diagnosis, and treatment; and overall survival. Associations between these factors were assessed using univariate analysis, multivariate logistic regression, and Kaplan-Meier survival analysis.

RESULTS

A total of 482 patients met criteria for analysis. In univariate analyses, the image-treatment interval was significantly associated with race, age, income, insurance type, and hospital type (76 days for public versus 45 days for private; p < 0.0001). In multivariate analysis, only hospital type remained significantly associated with the image-treatment interval; patients in the private hospital setting were more likely to receive timely treatment (hazard ratio 1.85; 95% confidence interval, 1.37-2.50; p < 0.001). In univariate analysis, the image-treatment interval was not associated with disease stage (p = 0.27) or with survival (p = 0.42).

CONCLUSION

Intervals between suspicion, diagnosis, and treatment of lung cancer vary widely among patients. Health care system factors, such as hospital type, largely account for these discrepancies. In this study, these intervals do not appear to be associated with clinical outcomes.

Prostate-specific antigen-based risk-adapted discontinuation of prostate cancer screening in elderly African American and Caucasian American men

OBJECTIVES

To evaluate the relationship between initial prostate-specific antigen (PSA) and prostate cancer (PCa) risk in elderly African American (AA) and Caucasian American (CA) men.

METHODS

A total of 408 AA and 1720 CA men whose initial PSA measurement was performed between 75 and 80 years of age were retrieved from Duke Prostate Center database. Patients were stratified by race and initial PSA value. The relative risk (RR) of PCa detection was estimated. The rates of high risk PCa, and death from PCa stratified by initial PSA groups were compared using the chi-square test.

RESULTS

The age-adjusted RR of PCa detection in CA men with PSA 3.0-5.9 ng/mL was 1.9-fold higher when compared with that of men with PSA 0.0-2.9 ng/mL (P < .001), but it did not change significantly in AA men (P = .270). PSA 6.0-9.9 ng/mL was associated with age-adjusted RR of PCa 9.3-fold in AA men and 4.1-fold in CA men (both P values < .001). A low rate of high-risk PCa and death from PCa was indicated with PSA < 6.0 ng/mL and < 3.0 ng/mL and follow-up of a maximum of 19.2 years and 17.6 years, respectively, in AA and CA men.

CONCLUSIONS

AA men with initial PSA < 6.0 ng/mL and CA men with initial PSA < 3.0 ng/mL between 75 and 80 years of age are unlikely to be diagnosed with high risk PCa or death from PCa. It may be safe to discontinue PSA screening in these men.

Access to hematopoietic cell transplantation in the United States

Hematopoietic cell transplantation (HCT) is a highly specialized and resource-intense medical procedure that can be associated with disparities in access to transplantation. Barriers to access to HCT are multifactorial, complex, and interrelated. Our current knowledge of specific barriers that prevent access to HCT is very limited. As the utilization of HCT increases, it is imperative that underserved populations receive the benefit of this life-saving procedure. We review the prevailing literature on access to HCT and describe research priorities for eliminating disparities in transplantation. Better understanding of these complex barriers will minimize inequities, inform health policy, guide development of interventions targeted to eliminate disparities, and continue the expansion of HCT in the future.

Addressing cancer disparities through community engagement: improving breast health among Haitian women

PURPOSE/OBJECTIVES

To describe processes for fostering community engagement among Haitian women to facilitate breast health education and outreach that are consonant with Haitians' cultural values, literacy, and linguistic skills.

DATA SOURCES

Existing breast cancer education and outreach efforts for Haitian immigrant communities were reviewed. Local community partners were the primary source of information and guided efforts to create a series of health-promoting activities. The resultant partnership continues to be linked to a larger communitywide effort to reduce cancer disparities led by the Tampa Bay Community Cancer Network.

DATA SYNTHESIS

A systematic framework known as the CLEAN (Culture, Literacy, Education, Assessment, and Networking) Look Checklist guided efforts for improved communications.

CONCLUSIONS

Community engagement forms the foundation for the development and adaptation of sustainable breast education and outreach. Understanding and considering aspects of Haitian culture are important to the provision of competent and meaningful care.

IMPLICATIONS FOR NURSING

Nurses should expand their skills, knowledge, and competencies to better address the changing demographics of their communities. Nurses also can play a critical role in the development of outreach programs that are relevant to the culture and literacy of Haitian women by forming mutually beneficial partnerships that can decrease health disparities in communities.

Socioeconomic status and prostate cancer incidence and mortality rates among the diverse population of California

BACKGROUND

The racial/ethnic disparities in prostate cancer rates are well documented, with the highest incidence and mortality rates observed among African-Americans followed by non-Hispanic Whites, Hispanics, and Asian/Pacific Islanders. Whether socioeconomic status (SES) can account for these differences in risk has been investigated in previous studies, but with conflicting results. Furthermore, previous studies have focused primarily on the differences between African-Americans and non-Hispanic Whites, and little is known for Hispanics and Asian/Pacific Islanders.

OBJECTIVE

To further investigate the relationship between SES and prostate cancer among African-Americans, non-Hispanic Whites, Hispanics, and Asian/Pacific Islanders, we conducted a large population-based cross-sectional study of 98,484 incident prostate cancer cases and 8,997 prostate cancer deaths from California.

METHODS

Data were abstracted from the California Cancer Registry, a population-based surveillance, epidemiology, and end results (SEER) registry. Each prostate cancer case and death was assigned a multidimensional neighborhood-SES index using the 2000 US Census data. SES quintile-specific prostate cancer incidence and mortality rates and rate ratios were estimated using SEER*Stat for each race/ethnicity categorized into 10-year age groups.

RESULTS

For prostate cancer incidence, we observed higher levels of SES to be significantly associated with increased risk of disease [SES Q1 vs. Q5: relative risk (RR) = 1.28; 95% confidence interval (CI): 1.25-1.30]. Among younger men (45-64 years), African-Americans had the highest incidence rates followed by non-Hispanic Whites, Hispanics, and Asian/Pacific Islanders for all SES levels. Yet, among older men (75-84 years) Hispanics, following African-Americans, displayed the second highest incidence rates of prostate cancer. For prostate cancer deaths, higher levels of SES were associated with lower mortality rates of prostate cancer deaths (SES Q1 vs. Q5: RR = 0.88; 95% CI: 0.92-0.94). African-Americans had a twofold to fivefold increased risk of prostate cancer deaths in comparison to non-Hispanic Whites across all levels of SES.

CONCLUSIONS

Our findings suggest that SES alone cannot account for the greater burden of prostate cancer among African-American men. In addition, incidence and mortality rates of prostate cancer display different age and racial/ethnic patterns across gradients of SES.

Pharmacologic rationale for early G-CSF prophylaxis in cancer patients and role of pharmacogenetics in treatment optimization

The use of recombinant human granulocyte colony stimulating factors (G-CSF) has become an integral part of supportive care during cytotoxic chemotherapy. Current guidelines recommend the use of G-CSF in patients with substantial risk of febrile neutropenia. However, little consensus exists about optimal timing and tailoring of this therapy. Based on the known effects of chemotherapy and G-CSF on bone marrow compartments, we propose a model that supports the prophylactic rather than therapeutic use of G-CSF therapy. In addition, several genetic alterations in G-CSF signalling pathway have been described. These genetic variants may predict the risk of febrile neutropenia and response to G-CSF. Thus, future pharmacogenetic/omics studies in this field are warranted. Through the identification of patients at risk and the knowledge of biological basis for optimal timing, hopefully we should soon be able to improve the application of the existing guidelines for G-CSF therapy and patient's prognosis.

Smoking and ischemic heart disease disparities between studies, genders, times, and socioeconomic strata

Large, unexplained, but possibly related disparities exist between heart disease risks observed in differing genders, educational levels, times, and studies. Such heart disease disparities might be related to cumulative tobacco smoke damage (smoke load) disparities that are overlooked in standard assessments of point smoking status. So, I reviewed possible relationships between smoke load and heart disease levels across genders, educational strata, years, and leading studies. Smoker heart disease risk assessments in the Nurses Health Study (Nurses), Cancer Prevention Study-II (CPS-II), and British Doctors studies were compared and related to their likely selection and misclassification biases. Relationships between smoke loads and United States (US) education- and gender-related heart disease mortality disparities were qualitatively assessed using lung cancer rates as a smoke load proxy. The high heart disease mortality risks observed in smoking Nurses in 1980–2004 and in less educated US women in 2001 were qualitatively associated with their higher smoke loads and lower selection and exposure misclassification biases than in the CPS-II and Doctors studies. Smoking-attributable heart disease death tolls and disparities extrapolated from mortality ratios from the CPS-II and Doctors studies may be substantial underestimates. Such studies appear to have compared convenience samples of light smokers to lighter smokers instead of comparing representative smokers to the unexposed. Further efforts to minimize smoke exposures and better quantify cumulative smoking-attributable burdens are needed.

Recommendations for research priorities in breast cancer by the Coalition of Cancer Cooperative Groups Scientific Leadership Council: systemic therapy and therapeutic individualization

Over 9,000 women with breast cancer are enrolled annually on clinical trials sponsored by the National Cancer Institute (NCI), accounting for about one-third of all patients enrolled on NCI-sponsored trials. Thousands are also enrolled on pharmaceutical-sponsored studies. Although breast cancer mortality rates have recently declined for the first time in part due to systemic therapeutic advances, coordinated efforts will be necessary to maintain this trend. The Coalition of Cancer Cooperative Groups convened the Scientific Leadership Council in breast cancer (BC), an expert panel, to identify priorities for future research and current trials with greatest practice-changing potential. Panelists formed a consensus on research priorities for chemoprevention, development and application of molecular markers for predicting therapeutic benefit and toxicity, intermediate markers predictive of therapeutic effect, pathogenesis-based therapeutic approaches, utilization of adaptive designs requiring fewer patients to achieve objectives, special and minority populations, and effects of BC and treatment on patients and families. Panelists identified 13 ongoing studies as High Priority and identified gaps in the current trial portfolio. We propose priorities for current and future clinical breast cancer research evaluating systemic therapies that may serve to improve the efficiency of clinical trials, identify individuals most likely to derive therapeutic benefit, and prioritize therapeutic strategies.

Reactive oxygen species up-regulate p53 and Puma; a possible mechanism for apoptosis during combined treatment with TRAIL and wogonin

BACKGROUND AND PURPOSE

Tumour necrosis factor-related apoptosis-inducing ligand (TRAIL) triggers apoptotic death in a variety of cancer cells without marked toxicity to most normal cells. We previously reported that wogonin, a potent anticancer agent from a Chinese herb, up-regulates p53 in prostate cancer cells. In this study, the effects of combinations of TRAIL and wogonin on a human prostate cancer cell line LNCaP, resistant to TRAIL, was evaluated for evidence of synergy in triggering apoptosis.

EXPERIMENTAL APPROACH

Western blot assay and the 'comet' assay were used to study the underlying mechanisms of cell death and search for any mechanisms of enhancement of TRAIL-induced apoptosis in the presence of wogonin.

KEY RESULTS

During combined treatment with wogonin and TRAIL, cytotoxicity, poly(ADP-ribose) polymerase cleavage and caspase activation were associated with up-regulation of p53 through DNA damage and reactive oxygen species (ROS) generation. N-acetylcysteine (NAC), an antioxidant, inhibited ROS generation and synergistic interaction between TRAIL and wogonin. Experimental results in human colon cancer HCT116 cells demonstrated that p53-dependent Puma up-regulation played an important role; deficiency in either p53 or Puma prevented wogonin-enhanced TRAIL-induced apoptosis.

CONCLUSIONS AND IMPLICATIONS

The present studies suggest that wogonin enhances TRAIL-induced cytotoxicity through up-regulation of p53 and Puma, mediated by ROS.

Statins and the risk of colorectal carcinoma: a nested case-control study in veterans with diabetes

OBJECTIVES

Experimental data indicate a possible preventive effect for statins in colorectal cancer (CRC). However, the available epidemiological data are conflicting.

METHODS

We conducted a nested case-control study of veterans with diabetes in national databases of the Department of Veterans Affairs (VA) and Medicare-linked files. Cases were defined as incident CRC during January 2001-December 2002, sampled on incidence density. VA pharmacy benefits management (PBM) files were used to identify filled prescriptions for statins. Multivariable conditional logistic regression models were used to estimate odds ratios (ORs) after adjusting for potential confounding variables. Stratified analyses were conducted for potential effect modifiers.

RESULTS

A total of 6,080 cases and 24,320 controls were examined. The mean age was 74 years, and the majority of patients were Caucasian (88%) and male (99%). Filled prescriptions of statins were recorded less frequently in cases (49%) than in controls (52%; OR: 0.88; 95% confidence interval (95% CI): 0.83-0.93). This inverse association remained significant after adjusting for inflammatory bowel disease, diabetes severity, cholecystectomy, liver disease, filled prescriptions for sulfonylurea, aspirin or NSAID use, or colorectal evaluation. Simvastatin comprised the majority (87%) of statin-filled prescriptions, and the association with risk of CRC with simvastatin was very similar to that of any statin. No significant associations were observed between the risk of CRC and nonstatin cholesterol (OR: 1.02; 95% CI 0.88-1.18) or triglyceride-lowering medications (OR: 0.96; 95% CI: 0.87-1.05). The significant inverse association was limited to Caucasians, patients without history of polyps, patients aged 65 years and older, and patients with colon cancer (excluding rectum).

CONCLUSIONS

The use of statins was associated with a small reduction in the risk of colon cancer in patients with diabetes. However, the causal link is not clear.

Muscular strength and adiposity as predictors of adulthood cancer mortality in men

BACKGROUND

We examined the associations between muscular strength, markers of overall and central adiposity, and cancer mortality in men.

METHODS

A prospective cohort study including 8,677 men ages 20 to 82 years followed from 1980 to 2003. Participants were enrolled in The Aerobics Centre Longitudinal Study, the Cooper Institute in Dallas, Texas. Muscular strength was quantified by combining 1-repetition maximal measures for leg and bench presses. Adiposity was assessed by body mass index (BMI), percent body fat, and waist circumference.

RESULTS

Cancer death rates per 10,000 person-years adjusted for age and examination year were 17.5, 11.0, and 10.3 across incremental thirds of muscular strength (P = 0.001); 10.9, 13.4, and 20.1 across BMI groups of 18.5-24.9, 25.0-29.9, and > or =30 kg/m(2), respectively (P = 0.008); 11.6 and 17.5 for normal (<25%) and high percent body fat (> or =25%), respectively (P = 0.006); and 12.2 and 16.7 for normal (< or =102 cm) and high waist circumference (>102 cm), respectively (P = 0.06). After adjusting for additional potential confounders, hazard ratios (95% confidence intervals) were 1.00 (reference), 0.65 (0.47-0.90), and 0.61 (0.44-0.85) across incremental thirds of muscular strength, respectively (P = 0.003 for linear trend). Further adjustment for BMI, percent body fat, waist circumference, or cardiorespiratory fitness had little effect on the association. The associations of BMI, percent body fat, or waist circumference with cancer mortality did not persist after further adjusting for muscular strength (all P > or = 0.1).

CONCLUSIONS

Higher levels of muscular strength are associated with lower cancer mortality risk in men, independent of clinically established measures of overall and central adiposity, and other potential confounders.

Ethnicity, socioeconomic status, and attainment of clinical practice guideline standards in dialysis patients in the United kingdom

BACKGROUND AND OBJECTIVES

The role of socioeconomic status (SES) and its contribution to ethnic differences in standards attainment among dialysis patients is not known.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We examined associations between area- level SES (Townsend index) and ethnicity (white, black, South Asian) and standards attainment in 14,117 incident dialysis patients (1997-2004) in the UK.

RESULTS

Deprived patients were less likely to achieve hemoglobin (Hb) > or = 10 g/dl (trend P < 0.001) but not after controlling for patient and center characteristics (trend P = 0.1). There was no association with hemodialysis dose and parathyroid hormone (PTH) standard but deprived patients had better attainment of phosphate (PO4) <5.6 mg/dl, calcium (Ca) and Calcium-phosphate (CaPO4) standard (e.g., most deprived versus least deprived adjusted odds ratio [OR] 1.25, 95% confidence intervals [CI] 1.12, 1.38). There was no association with SES using a lower limit for PO4 (3.5 - 5.5 mg/dl). Compared with Whites, Blacks had lower attainment of Hb (adjusted OR 0.57, 95% CI 0.45, 0.71) and PTH standards (adjusted OR 0.27, 95% CI 0.22, 0.33) but better attainment of PO4 and CaPO4, while South Asians experienced better or comparable outcomes for most standards except Ca and PTH.

CONCLUSIONS

There was no evidence of socioeconomic inequity in standards attainment or a consistent pattern of inequity by ethnic group. The lower attainment of some standards in ethnic minorities may reflect biologic differences rather than ethnicity-related inequity of care.

Quantification of phase I/II metabolizing enzyme gene expression and polycyclic aromatic hydrocarbon-DNA adduct levels in human prostate

BACKGROUND

Studies of migrant populations suggest that dietary and/or environmental factors play a crucial role in the etiology of prostatic adenocarcinoma (CaP). The human prostate consists of the peripheral zone (PZ), transition zone (TZ), and central zone (CZ); CaP occurs most often in the PZ.

METHODS

To investigate the notion that an underlying differential expression of phase I/II genes, and/or the presence of polycyclic aromatic hydrocarbon (PAH)-DNA adducts might explain the elevated PZ susceptibility, we examined prostate tissues (matched tissue sets consisting of PZ and TZ) from men undergoing radical retropubic prostatectomy for CaP (n = 26) or cystoprostatectomy (n = 1). Quantitative gene expression analysis was employed for cytochrome P450 (CYP) isoforms CYP1A1, CYP1B1, and CYP1A2, as well as N-acetyltransferase 1 and 2 (NAT1 and NAT2) and catechol-O-methyl transferase (COMT).

RESULTS

CYP1B1, NAT1, and COMT were expressed in all tissue sets; levels of CYP1B1 and NAT1 were consistently higher in the PZ compared to TZ. Immunohistochemistry confirmed the presence of CYP1B1 (nuclear-associated and primarily in basal epithelial cells) and NAT1. Normal tissue from 23 of these aforementioned 27 matched tissue sets was analyzed for PAH-DNA adduct levels using antiserum elicited against DNA modified with r7,t8-dihydroxy-t-9,10-oxy-7,8,9,10-tetrahydro-benzo[a]pyrene (BPDE). PAH-DNA adduct levels were highest in glandular epithelial cells, but a comparison of PZ and TZ showed no significant differences.

CONCLUSION

Although expression of activating and/or detoxifying enzymes may be higher in the PZ, PAH-DNA adduct levels appear to be similar in both zones. Therefore, factors other than PAH-DNA adducts may be responsible for promotion of tumor formation in the human prostate.

Butanol fraction containing berberine or related compound from nexrutine inhibits NFkappaB signaling and induces apoptosis in prostate cancer cells

BACKGROUND

Epidemiological and laboratory studies support the hypothesis that several plant components influence prostate carcinogenesis and holds promise for disease prevention. Previously we reported that Nexrutine (bark extract from Phellodendron amurense) inhibits proliferation of prostate cancer cells and prostate tumor development in the transgenic adenocarcinoma of mouse prostate (TRAMP) model through modulation of Akt signaling pathway. In the present investigation we conducted studies to further define the mechanism of action of Nexrutine and to identify the active component associated with its biological activity.

METHODS

Androgen-responsive, androgen-independent human prostate cancer cell lines and tissues from TRAMP mice fed Nexrutine(R) were used in these studies. Activity guided fractionation identified butanol fraction recapitulating the activities of Nexrutine assessed by proliferation assays, apoptotic assays (DAPI and TUNEL staining), transient transfections, gel shift assays and Western blotting. In addition ultra-performance liquid chromatography (UPLC) of butanol fraction was used to identify active component of Nexrutine.

RESULTS

Butanol fraction recapitulated the activities of Nexrutine in (i) inhibiting proliferation; (ii) inducing apoptosis; and (iii) modulating transcriptional activity of NFkappaB in prostate cancer cells. Our data also indicates that both Nexrutine and butanol fraction modulates NFkappaB transcriptional activity by inhibiting IkappaBalpha phosphorylation. Expression of p65 and phosphorylated IkappaBalpha are high in tumors from TRAMP mice. In contrast dietary administration of Nexrutine reduced expression of p65 and phosphorylated IkappaBalpha in prostate from TRAMP mice. In addition using UPLC, we have identified berberine or closely related compound in the butanol fraction.

CONCLUSION

The results suggest that berberine or closely related component of butanol fraction may be responsible for the observed biological activities and induce apoptosis in prostate cancer cells by targeting critical cell survival signaling pathways both in vitro and in vivo.

Trends in area-socioeconomic and race-ethnic disparities in breast cancer incidence, stage at diagnosis, screening, mortality, and survival among women ages 50 years and over (1987-2005)

BACKGROUND

Breast cancer is the most commonly diagnosed cancer and the second leading cause of cancer death among women in the United States and varies systematically by race-ethnicity and socioeconomic status. Previous research has often focused on disparities between particular groups, but few studies have summarized disparities across multiple subgroups defined by race-ethnic and socioeconomic position.

METHODS

Data on breast cancer incidence, stage, mortality, and 5-year cause-specific probability of death (100 - survival) were obtained from the Surveillance, Epidemiology, and End Results program and data on mammography screening from the National Health Interview Survey from 1987 to 2005. We used four area-socioeconomic groups based on the percentage of poverty in the county of residence (<10, 10-15, 15-20, +20%) and five race-ethnic groups (White, Black, Asian, American Indian, and Hispanic). We used summary measures of disparity based on both rate differences and rate ratios.

RESULTS

From 1987 to 2004, area-socioeconomic disparities declined by 20% to 30% for incidence, stage at diagnosis, and 5-year cause-specific probability of death, and by roughly 100% for mortality, whether measured on the absolute or relative scale. In contrast, relative area-socioeconomic disparities in mammography use increased by 161%. Absolute race-ethnic disparities declined across all outcomes, with the largest reduction for mammography (56% decline). Relative race-ethnic disparities for mortality and 5-year cause-specific probability of death increased by 24% and 17%, respectively.

CONCLUSIONS

Our analysis suggests progress towards race-ethnic and area-socioeconomic disparity goals for breast cancer, especially when measured on the absolute scale. However, greater progress is needed to address increasing relative socioeconomic disparities in mammography and race-ethnic disparities in mortality and 5-year cause-specific probability of death.

Neighborhood composition and cancer among Hispanics: tumor stage and size at time of diagnosis

BACKGROUND

We have previously reported that cancer incidence for lung, female breast, and colon and rectum for Hispanics decreases with increasing percentage of Hispanics at the census tract. In contrast, cervical cancer incidence increases with increasing percentage of Hispanics at the census tract.

METHODS

In this study, we investigate the hypothesis that Hispanics living in census tracts with high percentages of Hispanics are diagnosed with more advanced cancer, with respect to tumor size and stage of diagnosis. Data from the Surveillance, Epidemiology, and End Results registry and the U.S. Census Bureau were used to estimate the odds of diagnosis at a "late" stage (II, III, IV) versus "early" stage (I) and breast cancer tumor size among Hispanics as a function of census tract percent Hispanic. Hispanic ethnicity in the Surveillance, Epidemiology, and End Results registry was identified by medical record review and Hispanic surname lists. The study also used income of Hispanics living in the census tract and controlled for age at diagnosis and gender.

RESULTS

We found that Hispanics living in neighborhoods with higher density of Hispanic populations were more likely to be diagnosed with late-stage breast, cervical, or colorectal cancer, and to have a larger tumor size of breast cancer.

CONCLUSIONS

Our findings suggest that the benefits of lower cancer incidence in high tract percent Hispanics are partially offset by poorer access and reduced use of screening in conjunction with lower income, poorer health insurance coverage, and language barriers typical of these communities.

Effects of selenite and genistein on G2/M cell cycle arrest and apoptosis in human prostate cancer cells

Combination of chemopreventive agents with distinct molecular mechanisms is considered to offer a potential for enhancing cancer prevention efficacy while minimizing toxicity. Here we report two chemopreventive agents, selenite and genistein, that have synergistic effects on apoptosis, cell cycle arrest, and associated signaling pathways in p53-expressing LNCaP and p53-null PC3 prostate cancer cells. We show that selenite induced apoptosis only, whereas genistein induced both apoptosis and G2/M cell cycle arrest. Combination of these two agents exhibited enhanced effects, which were slightly greater in LNCaP than PC3 cells. Selenite or genistein alone upregulated protein levels of p53 in LNCaP cells only and p21(waf1) and Bax in both cell lines. Additionally, genistein inhibited AKT phosphorylation. Downregulation of AKT by siRNA caused apoptosis and G2/M cell cycle arrest and masked the effects of genistein. Treatment with insulin-like growth factor I (IGF-I) elevated levels of total and phosphorylated AKT and suppressed the effects of genistein. Neither downregulation of AKT nor IGF-I treatment altered the cellular effects of selenite. Our study demonstrates that selenium and genistein act via different molecular mechanisms and exhibit enhanced anticancer effects, suggesting that a combination of selenium and genistein may offer better efficacy and reduction of toxicity in prostate cancer prevention.

[Reflections on the relation between education and disease]

The relation between education in the context of the socioeconomic construct and health has not yet been fully elucidated, despite numerous findings that have accumulated in about 150 years. Rather, the growing knowledge of the complex interaction of various domains, which are important for health, comes to the fore. Miscellaneous biological, social, medical, behavioural and environmental parameters play a role, whereas primary medicine may have a direct protective influence on almost all population-based indicators of health. The translation of these factors into individual reality is modulated by additional circumstances like the physician-patient relationship, influences that strongly frame the normal course of life such as working conditions, and the increasingly overburdening by an overflow of information as well as health care deficiencies. Education alone does not guarantee improved health; instead it is part of a widespread continuous contest with negative aspects of a global nature which increasingly limit the quality of life and the natural habitat.

Education and risk of cancer in a large cohort of men and women in the United States

BACKGROUND

Education inequalities in cancer incidence have long been noted. It is not clear, however, whether such inequalities persist in the United States, especially for less common malignancies and after adjustment for individual risk factors.

METHODOLOGY/PRINCIPAL FINDINGS

Within the NIH-AARP Diet and Health Study, we examined the association between education and the risk of developing cancers in a prospective cohort of 498,455 participants who were 50-71 year old and without cancer at enrollment in 1995/96. During a maximum 8.2 years of follow-up we identified 40,443 cancers in men and 18,367 in women. In age-adjusted models, the least educated men (

CONCLUSIONS/SIGNIFICANCE

We found a higher risk of malignant disease, particularly smoking- related cancers, among those in the lowest educational attainment category. Only some of the educational gradient is attributable to smoking. The persistence of substantial education inequalities in cancer incidence poses a challenge for etiologic research and public health policy.

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MESH Headings

• Aged
• Animals
• Educational Status
• Female
• Humans
• Male
• Middle Aged
• Neoplasms/epidemiology
• Prospective Studies
• Risk Factors
• Smoking
• United States/epidemiology

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Grants

• Intramural NIH HHS

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Affiliation(s)

Traci Mouw Division of Epidemiology, Public Health & Primary Care, Faculty of Medicine, Imperial College London, London, United Kingdom
Annemarie Koster Laboratory of Epidemiology, Demography, and Biometry, National Institute on Aging, National Institutes of Health, Bethesda, Maryland, United States of America Faculty of Health, Medicine and Life Sciences, Universiteit Maastricht, Maastricht, The Netherlands
Margaret E. Wright Department of Pathology, University of Illinois at Chicago, Chicago, Illinois, United States of America
Madeleine M. Blank Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, United States of America
Steven C. Moore Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, United States of America
Albert Hollenbeck AARP, Washington, D. C., United States of America
Arthur Schatzkin Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, United States of America

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Recent trends in Black-White disparities in cancer mortality

Despite decreases in overall cancer death rates across all racial and ethnic groups since the early 1990s, racial disparities in cancer mortality persist. We examined temporal trends in Black-White disparities in cancer mortality from all sites combined, smoking-related cancers (lung and a group including oral cavity, pharynx, larynx, esophagus, pancreas, bladder, and kidney), and sites affected, or potentially affected by screening and treatment (breast, prostate, colon/rectum). Death rates, rate differences, and rate ratios comparing Blacks to Whites from 1975 through 2004 were based on mortality data from the National Center for Health Statistics. The Black-White disparity in overall cancer death rates narrowed from the early 1990s through 2004, especially in men. This reduction was driven predominantly by more rapid decreases in mortality from tobacco-related cancers in Black men than White men. In contrast, racial disparities in mortality from cancers potentially affected by screening and treatment increased over most of the interval since 1975. Coordinated efforts to improve early detection and treatment for all segments of the population are essential to eliminate racial disparities in cancer mortality.

Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment

CONTEXT

Talking about death can be difficult. Without evidence that end-of-life discussions improve patient outcomes, physicians must balance their desire to honor patient autonomy against a concern of inflicting psychological harm.

OBJECTIVE

To determine whether end-of-life discussions with physicians are associated with fewer aggressive interventions.

DESIGN, SETTING, AND PARTICIPANTS

A US multisite, prospective, longitudinal cohort study of patients with advanced cancer and their informal caregivers (n = 332 dyads), September 2002-February 2008. Patients were followed up from enrollment to death, a median of 4.4 months later. Bereaved caregivers' psychiatric illness and quality of life was assessed a median of 6.5 months later.

MAIN OUTCOME MEASURES

Aggressive medical care (eg, ventilation, resuscitation) and hospice in the final week of life. Secondary outcomes included patients' mental health and caregivers' bereavement adjustment.

RESULTS

One hundred twenty-three of 332 (37.0%) patients reported having end-of-life discussions before baseline. Such discussions were not associated with higher rates of major depressive disorder (8.3% vs 5.8%; adjusted odds ratio [OR], 1.33; 95% confidence interval [CI], 0.54-3.32), or more worry (mean McGill score, 6.5 vs 7.0; P = .19). After propensity-score weighted adjustment, end-of-life discussions were associated with lower rates of ventilation (1.6% vs 11.0%; adjusted OR, 0.26; 95% CI, 0.08-0.83), resuscitation (0.8% vs 6.7%; adjusted OR, 0.16; 95% CI, 0.03-0.80), ICU admission (4.1% vs 12.4%; adjusted OR, 0.35; 95% CI, 0.14-0.90), and earlier hospice enrollment (65.6% vs 44.5%; adjusted OR, 1.65;95% CI, 1.04-2.63). In adjusted analyses, more aggressive medical care was associated with worse patient quality of life (6.4 vs 4.6; F = 3.61, P = .01) and higher risk of major depressive disorder in bereaved caregivers (adjusted OR, 3.37; 95% CI, 1.12-10.13), whereas longer hospice stays were associated with better patient quality of life (mean score, 5.6 vs 6.9; F = 3.70, P = .01). Better patient quality of life was associated with better caregiver quality of life at follow-up (beta = .20; P = .001).

CONCLUSIONS

End-of-life discussions are associated with less aggressive medical care near death and earlier hospice referrals. Aggressive care is associated with worse patient quality of life and worse bereavement adjustment.

Suppression of NFkappaB and its regulated gene products by oral administration of green tea polyphenols in an autochthonous mouse prostate cancer model

PURPOSE

This study examines the role of cell survival/apoptosis related proteins involved in NFkappaB signaling pathways and its associated events in GTP-induced chemoprevention of prostate cancer in TRAMP mice.

METHODS

Mice were given 0.1% GTP as drinking fluid. Western blot and immunohistochemical analysis performed to examine NFkappaB and its regulated pathway in response to GTP.

RESULTS

Our data demonstrated increased expression of NFkappaB, IKKalpha, IKKbeta, RANK, NIK and STAT-3 in dorso-lateral prostate of TRAMP mice as a function of age and tumor growth and continuous GTP infusion for 32 weeks resulted in substantial reduction in these proteins. The levels of transcription factor osteopontin, a non-collagenous extracellular matrix protein, were also downregulated. Inhibition of NFkappaB signaling is known to activate apoptotic and inhibit anti-apoptotic proteins. Therefore, we analyzed Bax and Bcl2 levels in the dorsolateral prostate of TRAMP mice fed GTP and observed a shift in balance between Bax and Bcl2 favoring apoptosis.

CONCLUSIONS

Based on the data we suggest that oral consumption of GTP might inhibit osteopontin and NFkappaB signaling that may contribute to induction of apoptosis observed in GTP fed TRAMP mice.

Changes in cancer incidence and mortality in England and Wales and a comparison of cancer deaths in the major developed countries by age and sex 1979-2002 in context of GDP expenditure on health

Background:

The successful treatment of cancer is a major health and political issue for England and Wales and the major developed countries (MDCs). All malignancy deaths by age and sex are analysed to determine how successful the MDCs were in reducing cancer mortality between the end points of 1979–81 and 2000–2, and whether there was any association between each nations ‘gross domestic product expenditure on health’ (GDPEH) and the reduction in their cancer deaths.

Method:

Incidence of cancer in England and Wales was examined for 1979–80 to 2003–4 to highlight the extent of the problem. The cancer mortality rates for England and Wales were compared with each MDC by age and sex, using ‘WHO all malignancies mortality rates’ for the periods of 1979–81 and 2000–2, and tests of significance were made. The GDPEH for each MDC was examined for 1980–2002, and Spearman rank-order correlations calculated to explore any association between declining cancer deaths and the GDPEH of each MDC.

Results:

Conclusions:

The rising incidence in cancer-related deaths poses a problem for every MDC, and the poorer women’s results should be a matter of concern for most MDCs. The reduction in cancer deaths reflects well on frontline services, and the significant association between reduced cancer mortality and increased GDPEH is encouraging, but still a challenge for governments, especially if the incidence continues to rise.

Secular trends in mortality from common cancers in the United States by educational attainment, 1993-2001

Background

Death rates for the four major cancer sites (lung, breast, prostate, and colon and rectum) have declined steadily in the United States among persons aged 25–64 years since the early 1990s. We used national data to examine these trends in relation to educational attainment.

Methods

We calculated age-standardized death rates for each of the four cancers by level of education among 25- to 64-year-old non-Hispanic white and non-Hispanic black men and women for 1993 through 2001 using data on approximately 86% of US deaths from the National Center for Health Statistics, education level as recorded on the death certificate, and population data from the US Bureau of Census Current Population Survey. Annual percent changes in age-adjusted death rates were estimated using weighted log-linear regression models. All statistical tests were two-sided.

Results

Death rates for each cancer decreased statistically significantly from 1993 to 2001 in people with at least 16 years of education in every sex and race stratum except lung cancer in black women, for whom death rates were stable. For example, colorectal cancer death rates among white men, black men, white women, and black women with at least 16 years of education decreased by 2.4% (P < .001), 4.8% (P = .011), 3.0% (P < .001), and 2.6% (P = .030) annually, respectively. By contrast, among people with less than 12 years of education, a statistically significant decrease in death rates from 1993 through 2001 was seen only for breast cancer in white women (1.4% per year; P = .029). Death rates among persons with less than 12 years of education over the same time interval increased for lung cancer in white women (2.4% per year; P < .001) and for colon cancer in black men (2.7% per year; P < .001) and were stable for the remaining race/sex/site strata. Temporal trends generally followed an educational gradient in which the slopes of the decreases in death rate became steeper with higher educational attainment.

Conclusion

The recent declines in death rates from major cancers in the United States mainly reflect declines in more highly educated individuals.

COX-2/EGFR expression and survival among women with adenocarcinoma of the lung

Previous studies suggest that cyclooxygenase-2 (COX-2) expression may predict survival among patients with non-small cell lung cancer. COX-2 may interact with epidermal growth factor receptor (EGFR), suggesting that combined COX-2/EGFR expression may provide predictive value. The extent to which their independent or combined expression is associated with prognosis in women with adenocarcinoma of the lung is unknown. In the present study, we examined relationships between COX-2 expression (n = 238), EGFR expression (n = 158) and dual COX-2/EGFR expression (n = 157) and survival among women with adenocarcinoma of the lung. Overall survival was estimated by constructing Cox proportional hazards models adjusting for other significant variables and stratifying by stage at diagnosis and race. Clinical or demographic parameters were not associated with either COX-2 or EGFR expression. Patients with COX-2-positive tumors tended to have poorer prognosis than did patients with COX-2-negative tumors [hazard ratio (HR) 1.67, 95% confidence interval (CI) 1.01-2.78]. African-Americans with COX-2-positive tumors had a statistically non-significant higher risk of death than African-Americans with COX-2-negative tumors (HR 5.58, 95% CI 0.64-48.37). No association between COX-2 expression and survival was observed among Caucasians (HR 1.29, 95% CI 0.72-2.30). EGFR expression was associated with a 44% reduction in the risk of death (HR 0.56, 95% CI 0.32-0.98). COX-2-/EGFR+ tumor expression, but not COX-2+/EGFR+ tumor expression, was associated with survival when compared with other combined expression results. In conclusion, COX-2 and EGFR expression, but not combined COX-2+/EGFR+ expression, independently predict survival of women with adenocarcinoma of the lung.

Cardiorespiratory fitness as a predictor of cancer mortality among men with pre-diabetes and diabetes

OBJECTIVE

The purpose of this article was to examine the risk of cancer mortality across levels of fitness and to examine the fitness-mortality relation for site-specific cancers in men with pre-diabetes and diabetes.

RESEARCH DESIGN AND METHODS

We examined the fitness-mortality relation for all-cause and site-specific cancer mortality among 18,858 men with pre-diabetes and 2,805 men with diabetes (aged 46.3 +/- 9.7 years [mean +/- SD]) from the Aerobics Center Longitudinal Study. We identified 719 cancer deaths during 354,558 person-years of risk. The duration of follow-up was 16.4 +/- 7.8 years (range <1-30.0 years).

RESULTS

In men with pre-diabetes, moderate (hazard ratio 0.71 [95% CI 0.57-0.88]) and high fitness (0.76 [0.60-0.96]) were associated with lower risks of cancer mortality compared with the low-fit group in a model adjusted for age, examination year, smoking, alcohol use, fasting glucose concentration, previous cancer, and BMI. Similarly, for individuals with diabetes, moderate (0.53 [0.35-0.82]) and high fitness (0.44 [0.26-0.73]) were associated with lower risks of cancer mortality compared with the low-fit group. Among all men, being fit was associated with a lower risk of mortality from gastrointestinal (0.55 [0.39-0.77]), colorectal (0.53 [0.30-0.96]), liver (0.22 [0.07-0.71]), and lung cancer (0.43 [0.30-0.60]).

CONCLUSIONS

In men with pre-diabetes and diabetes, higher levels of cardiorespiratory fitness were associated with lower risk of cancer mortality, particularly as a result of cancers of the gastrointestinal tract, compared with those who had low levels of fitness.

Lung cancer mortality is elevated in coal-mining areas of Appalachia

Previous research has documented increased lung cancer incidence and mortality in Appalachia. The current study tests whether residence in coal-mining areas of Appalachia is a contributing factor. We conducted a national county-level analysis to identify contributions of smoking rates, socioeconomic variables, coal-mining intensity and other variables to age-adjusted lung cancer mortality. Results demonstrate that lung cancer mortality for the years 2000-2004 is higher in areas of heavy Appalachian coal mining after adjustments for smoking, poverty, education, age, sex, race and other covariates. Higher mortality may be the result of exposure to environmental contaminates associated with the coal-mining industry, although smoking and poverty are also contributing factors. The knowledge of the geographic areas within Appalachia where lung cancer mortality is higher can be used to target programmatic and policy interventions. The set of socioeconomic and health inequalities characteristic of coal-mining areas of Appalachia highlights the need to develop more diverse, alternative local economies.

Cancer assessment methodology in a native Hawaiian community

BACKGROUND

Limited data have been collected on cancer in Native Hawaiian communities, although Native Hawaiians tend to have higher cancer mortality rates than other ethnic groups in Hawaii.

OBJECTIVES

We sought to describe the community-based participatory research (CBPR) process used to deliver a culturally tailored protocol, combining traditional Native Hawaiian practices and random sampling methods, to determine cancer screening practices and program preferences of residents of a Hawaiian Homes (HH) community.

METHODS

Following a culturally tailored protocol, we attempted to survey half of the 644 households in the Waimanalo Hawaiian Homes Community (WHHC). Pairs of Native Hawaiian college students performed the majority of data collection; a community member joined them if available. Visits to the selected homes were tracked and participation rates estimated. Additional information on this methodology emerged from discussions between researchers and community members.

RESULTS

Of the 449 households accessed, 187 (42%) completed the survey, with an average of two visits per household. Individuals at 63 (14%) households refused outright. The remaining 199 (44%) homes were visited up to five times, but produced no response. Although some homes were vacant, often it appeared that residents were home but unresponsive. Our sampling procedure (targeting every other house and requiring accrual of 75 individuals in each of four age-gender groups) reduced participation.

CONCLUSIONS

The use of CBPR built capacity for all partners by engaging them in all levels of research. The results, however, suggest the need for a more inclusive sampling strategy and the continued use of CBPR.