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Roman E, Kane E, Smith A, Howell D, Sheridan R, Simpson J, Bonaventure A, Kinsey S. Cohort profile: the United Kingdom Childhood Cancer Study (UKCCS) - a UK-wide population-based study examining the health of cancer survivors. BMJ Open 2023; 13:e073712. [PMID: 37977872 PMCID: PMC10660444 DOI: 10.1136/bmjopen-2023-073712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 10/25/2023] [Indexed: 11/19/2023] Open
Abstract
PURPOSE The United Kingdom Childhood Cancer Study's (UKCCS's) matched cohort was established to examine the longer term morbidity and mortality of individuals previously diagnosed with cancer before 15 years of age, comparing future healthcare patterns in 5-year cancer survivors to baseline activity seen in age- and sex-matched individuals from the general population. PARTICIPANTS Predicated on a national childhood cancer case-control study conducted in the early 1990s (4430 cases, 9753 controls) in England, Scotland and Wales, the case population comprises 3125 cancer survivors (>5 years), and the control population 7156 age- and sex-matched individuals from the general population who did not have cancer as a child. Participants are now being followed up via linkage to national administrative healthcare databases (deaths, cancers and secondary care hospital activity). FINDINGS TO DATE Enabling the creation of cohorts with minimal selection bias and loss to follow-up, the original case-control study registered all newly diagnosed cases of childhood cancer and their corresponding controls, regardless of their family's participation. Early findings based on the registered case population found marked survival variations with age and sex across subtypes and differences with deprivation among acute lymphoblastic leukaemia (ALL) survivors. More recently, comparing the health-activity patterns of the case and control populations revealed that survivors of childhood ALL experienced excess outpatient and inpatient activity across their teenage/young adult years. Adding to increased risks of cancer and death and involving most clinical specialties, excesses were not related to routine follow-up monitoring and showed no signs of diminishing over time. FUTURE PLANS With annual linkage updates, the UKCCS's maturing population-based matched cohorts provide the foundation for tracking the health of individuals through their lifetime. Comparing the experience of childhood cancer survivors to that of unaffected general-population counterparts, this will include examining subsequent morbidity and mortality, secondary care hospital activity and the impact of deprivation on longer term outcomes.
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Affiliation(s)
- Eve Roman
- Department of Health Sciences, University of York, York, North Yorkshire, UK
| | - Eleanor Kane
- Department of Health Sciences, University of York, York, North Yorkshire, UK
| | - Alexandra Smith
- Department of Health Sciences, University of York, York, North Yorkshire, UK
| | - Debra Howell
- Department of Health Sciences, University of York, York, North Yorkshire, UK
| | - Rebecca Sheridan
- Department of Health Sciences, University of York, York, North Yorkshire, UK
| | - Jill Simpson
- Department of Health Sciences, University of York, York, North Yorkshire, UK
| | - Audrey Bonaventure
- INSERM, Université Paris Cité and Université Sorbonne Paris Nord, Paris, Île-de-France, France
| | - Sally Kinsey
- Paediatric Haematology, Leeds Children's Hospital, Leeds, West Yorkshire, UK
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Dujon AM, Jeanjean J, Vincze O, Giraudeau M, Lemaître J, Pujol P, Ujvari B, Thomas F. Cancer hygiene hypothesis: A test from wild captive mammals. Ecol Evol 2023; 13:e10547. [PMID: 37745791 PMCID: PMC10515881 DOI: 10.1002/ece3.10547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 08/31/2023] [Accepted: 09/04/2023] [Indexed: 09/26/2023] Open
Abstract
The hygiene hypothesis, according to which the recent reduction of exposure to infectious agents in the human species would be the origin of various diseases, including autoimmune diseases and cancer, has often been proposed but not properly tested on animals. Here, we evaluated the relevance of this hypothesis to cancer risk in mammals in an original way, namely by using information on zoo mammals. We predicted that a higher richness of parasitic cohorts in the species' natural habitat would result in a greater occurrence of evolutionary mismatch due to the reduction of parasites in captive conditions. This, in turn, could contribute to an increased risk of developing lethal cancers. Using a comparative analysis of 112 mammalian species, we explored the potential relationship between cancer risk and parasite species richness using generalized phylogenetic least squares regressions to relate parasite species richness to cancer risk data. We found no strong evidence that parasite species richness increased cancer risk in zoo mammals for any of the parasite groups we tested. Without constituting definitive proof of the irrelevance of the hygienic hypothesis, our comparative study using zoo mammals does not support it, at least with respect to cancer risks.
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Affiliation(s)
- Antoine M. Dujon
- Geelong, School of Life and Environmental Sciences, Centre for Integrative EcologyDeakin UniversityWaurn PondsVictoriaAustralia
- CREEC/CANECEV (CREES), MIVEGEC, IRD 224–CNRS 5290–Université de MontpellierMontpellierFrance
| | - Jérémy Jeanjean
- CREEC/CANECEV (CREES), MIVEGEC, IRD 224–CNRS 5290–Université de MontpellierMontpellierFrance
| | - Orsolya Vincze
- Institute of Aquatic Ecology, Centre for Ecological ResearchDebrecenHungary
- Evolutionary Ecology Group, Hungarian Department of Biology and EcologyBabes‐Bolyai UniversityCluj‐NapocaRomania
- Littoral, Environnement et Sociétés (LIENSs), UMR 7266 CNRS‐La Rochelle UniversitéLa RochelleFrance
| | - Mathieu Giraudeau
- Littoral, Environnement et Sociétés (LIENSs), UMR 7266 CNRS‐La Rochelle UniversitéLa RochelleFrance
| | - Jean‐François Lemaître
- CNRS, UMR 5558, Laboratoire de Biométrie et Biologie EvolutiveUniversité de LyonVilleurbanneFrance
- Laboratory of Rare Human Circulating Cells (LCCRH)University Hospital of MontpellierMontpellierFrance
| | - Pascal Pujol
- CREEC/CANECEV (CREES), MIVEGEC, IRD 224–CNRS 5290–Université de MontpellierMontpellierFrance
- Centre Hospitalier Universitaire Arnaud de VilleneuveMontpellierFrance
| | - Beata Ujvari
- Geelong, School of Life and Environmental Sciences, Centre for Integrative EcologyDeakin UniversityWaurn PondsVictoriaAustralia
- CREEC/CANECEV (CREES), MIVEGEC, IRD 224–CNRS 5290–Université de MontpellierMontpellierFrance
| | - Frédéric Thomas
- CREEC/CANECEV (CREES), MIVEGEC, IRD 224–CNRS 5290–Université de MontpellierMontpellierFrance
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Bonaventure A, Kane E, Simpson J, Roman E. Maternal infections and medications in pregnancy: how does self-report compare to medical records in childhood cancer case-control studies? Int J Epidemiol 2023; 52:1187-1196. [PMID: 36847728 PMCID: PMC10396422 DOI: 10.1093/ije/dyad019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 02/14/2023] [Indexed: 03/01/2023] Open
Abstract
BACKGROUND Studies examining the potential impact of mothers' health during pregnancy on the health of their offspring often rely on self-reported information gathered several years later. To assess the validity of this approach, we analysed data from a national case-control study of childhood cancer (diagnosed <15 years) that collected health information from both interviews and medical records. METHODS Mothers' interview reports of infections and medications in pregnancy were compared with primary care records. Taking clinical diagnoses and prescriptions as the reference, sensitivity and specificity of maternal recall along with kappa coefficients of agreement were calculated. Differences in the odd ratios estimated using logistic regression for each information source were assessed using the proportional change in the odds ratio (OR). RESULTS Mothers of 1624 cases and 2524 controls were interviewed ∼6 years (range 0-18 years) after their child's birth. Most drugs and infections were underreported; in general practitioner records, antibiotic prescriptions were nearly three times higher and infections >40% higher. Decreasing with increasing time since pregnancy, sensitivity was ⩽40% for most infections and all drugs except 'anti-epileptics and barbiturates' (sensitivity 80% among controls). ORs associated with individual drug/disease categories that were based on self-reported data varied from 26% lower to 26% higher than those based on medical records; reporting differences between mothers of cases and controls were not systematically in the same direction. CONCLUSIONS The findings highlight the scale of under-reporting and poor validity of questionnaire-based studies conducted several years after pregnancy. Future research using prospectively collected data should be encouraged to minimize measurement errors.
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Affiliation(s)
- Audrey Bonaventure
- Université Paris Cité and Université Sorbonne Paris Nord, Inserm, INRAE, Center for Research in Epidemiology and StatisticS (CRESS), Paris, France
- Epidemiology and Cancer Statistics Group, Department of Health Sciences, University of York, York, UK
| | - Eleanor Kane
- Epidemiology and Cancer Statistics Group, Department of Health Sciences, University of York, York, UK
| | - Jill Simpson
- Epidemiology and Cancer Statistics Group, Department of Health Sciences, University of York, York, UK
| | - Eve Roman
- Epidemiology and Cancer Statistics Group, Department of Health Sciences, University of York, York, UK
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Infections and the development of childhood acute lymphoblastic leukemia: a population-based study. Eur J Cancer Prev 2021; 29:538-545. [PMID: 32032155 DOI: 10.1097/cej.0000000000000564] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
An infectious trigger for childhood acute lymphoblastic leukemia is hypothesized and we assessed the association between the rate, type, and critical exposure period for infections and the development of acute lymphoblastic leukemia. We conducted a matched case-control study using administrative databases to evaluate the association between the rate of infections and childhood acute lymphoblastic leukemia diagnosed between the ages of 2-14 years from Ontario, Canada and we used a validated approach to measure infections. In 1600 cases of acute lymphoblastic leukemia, and 16 000 matched cancer-free controls aged 2-14 years, having >2 infections/year increased the odds of childhood acute lymphoblastic leukemia by 43% (odds ratio = 1.43, 95% confidence interval 1.13-1.81) compared to children with ≤0.25 infections/year. Having >2 respiratory infections/year increased odds of acute lymphoblastic leukemia by 28% (odds ratio =1.28, 95% confidence interval 1.05-1.57) compared to children with ≤0.25 respiratory infections/year. Having an invasive infection increased the odds of acute lymphoblastic leukemia by 72% (odds ratio =1.72, 95% confidence interval 1.31-2.26). Having an infection between the age of 1-1.5 years increased the odds of acute lymphoblastic leukemia by 20% (odds ratio = 1.20, 95% confidence interval 1.04-1.39). Having more infections increased the odds of developing childhood acute lymphoblastic leukemia and having an infection between the ages of 1-1.5 years increased the odds of childhood acute lymphoblastic leukemia.
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Ballantine K, Gooder C, Ryan E, Macfarlane S. Listening to the experts: Parents' perspectives around infection risk and returning to education and social activities following their child's diagnosis of acute lymphoblastic leukemia. Cancer Rep (Hoboken) 2021; 5:e1424. [PMID: 33988314 PMCID: PMC9199503 DOI: 10.1002/cnr2.1424] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 04/14/2021] [Accepted: 05/04/2021] [Indexed: 01/30/2023] Open
Abstract
Background During a child's prolonged treatment for acute lymphoblastic leukemia (ALL), there is a need to balance their increased risk of developing infection‐related complications with meeting their educational and social needs. Aims To determine the safe timing of return to social activities for children undergoing treatment for ALL and to determine how parents perceive and act on advice related to infection risk while navigating their child's “return to normal.” Methods and results Medical and educational attendance records were reviewed for 47 children who were diagnosed with ALL and 24 semi‐structured qualitative interviews were conducted with a representative sample of their parents. The majority of children (69%) did not return to education prior to the start of maintenance therapy regardless of the advice that the families received from their healthcare team. Those who returned earlier were at no greater risk of major infection complications (mean = 0.5) than those who did not return until after commencing maintenance (mean = 0.4, P = .74). Parents spoke of the difficulty in obtaining practical, consistent, and timely advice and of balancing infection risk with a desire to return to normalcy. Inconsistent advice and constant vigilance placed a burden on parents which often profoundly affected their mental wellbeing. Overall, parents wanted to make their own decisions about how and when their child returned to education and social activities. They made these decisions based on many factors, of which infection risk was just one. Conclusion Following the study conclusion, a national working group was established—including parent representatives—to implement the study recommendations. This includes the development of a range of practical resources to better support families. Health professional guidelines provide quantitative data pertaining to infection risk, while emphasizing that the returning decisions ultimately rest with the families. This research demonstrates that listening to parents—who are the experts through their lived experiences—is a critical element in creating policies that are responsive, meaningful, and widely accepted.
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Affiliation(s)
- Kirsten Ballantine
- National Child Cancer Network, Auckland, New Zealand.,Children's Haematology Oncology Centre, Christchurch Hospital, Christchurch, New Zealand
| | - Claire Gooder
- National Child Cancer Network, Auckland, New Zealand.,Child Cancer Foundation, Auckland, New Zealand
| | | | - Scott Macfarlane
- National Child Cancer Network, Auckland, New Zealand.,Starship Blood and Cancer Centre, Starship Child Health, Auckland, New Zealand
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Garn H, Potaczek DP, Pfefferle PI. The Hygiene Hypothesis and New Perspectives-Current Challenges Meeting an Old Postulate. Front Immunol 2021; 12:637087. [PMID: 33815389 PMCID: PMC8012489 DOI: 10.3389/fimmu.2021.637087] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 03/04/2021] [Indexed: 01/11/2023] Open
Abstract
During its 30 years history, the Hygiene Hypothesis has shown itself to be adaptable whenever it has been challenged by new scientific developments and this is a still a continuously ongoing process. In this regard, the mini review aims to discuss some selected new developments in relation to their impact on further fine-tuning and expansion of the Hygiene Hypothesis. This will include the role of recently discovered classes of innate and adaptive immune cells that challenges the old Th1/Th2 paradigm, the applicability of the Hygiene Hypothesis to newly identified allergy/asthma phenotypes with diverse underlying pathomechanistic endotypes, and the increasing knowledge derived from epigenetic studies that leads to better understanding of mechanisms involved in the translation of environmental impacts on biological systems. Further, we discuss in brief the expansion of the Hygiene Hypothesis to other disease areas like psychiatric disorders and cancer and conclude that the continuously developing Hygiene Hypothesis may provide a more generalized explanation for health burden in highly industrialized countries also relation to global changes.
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Affiliation(s)
- Holger Garn
- Translational Inflammation Research Division & Core Facility for Single Cell Multiomics, Medical Faculty, Biochemical Pharmacological Center (BPC), Philipps University of Marburg, Marburg, Germany.,German Center for Lung Research (DZL), Marburg, Germany
| | - Daniel Piotr Potaczek
- Translational Inflammation Research Division & Core Facility for Single Cell Multiomics, Medical Faculty, Biochemical Pharmacological Center (BPC), Philipps University of Marburg, Marburg, Germany
| | - Petra Ina Pfefferle
- German Center for Lung Research (DZL), Marburg, Germany.,Comprehensive Biobank Marburg (CBBMR), Medical Faculty, Philipps University of Marburg, Marburg, Germany.,German Biobank Alliance (GBA), Marburg, Germany
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7
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Pelland-Marcotte MC, Pole JD, Nathan PC, Sutradhar R, Sung L. Severe infections following treatment for childhood cancer: a report from CYP-C. Leuk Lymphoma 2020; 61:2876-2884. [PMID: 32654563 DOI: 10.1080/10428194.2020.1789626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Little is known about infections occurring after childhood cancer treatment. We assessed the risk of severe infection postcancer therapy in survivors of leukemia compared to other cancer types. We performed a population-based cohort study of children <15 years of age diagnosed with cancer (2001-2016), alive and relapse-free 30 days after treatment completion. The risk of severe infection in both groups was estimated using subdistribution proportional hazard regression. We identified 6148 survivors (1960 with leukemia). The cumulative incidence (95% confidence interval) of severe infections at 3 years was 0.70% (0.40-1.2%) in leukemia and 0.51% (0.32-0.79%) in other cancers. The risk of severe infection was not statistically different in leukemia survivors compared to other cancer types in univariate and multivariate analysis (adjusted hazard ratio: 1.40, 95% CI: 0.69-2.85). No significant association was found between a history of leukemia and an increased risk of severe infection after treatment, compared to other cancer types.
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Affiliation(s)
- Marie-Claude Pelland-Marcotte
- Division of Hematology/Oncology, CHU de Québec - Centre Mère-Enfant Soleil, Quebec City, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Jason D Pole
- ICES, Toronto, Canada.,Centre for Health Services Research, University of Queensland, Woolloongabba, Australia
| | - Paul C Nathan
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Canada.,Program in Child Health Evaluative Sciences, The Hospital for Sick Children, Peter Gilgan Centre for Research and Learning, Toronto, Canada
| | | | - Lillian Sung
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Canada.,Program in Child Health Evaluative Sciences, The Hospital for Sick Children, Peter Gilgan Centre for Research and Learning, Toronto, Canada
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8
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Søegaard SH, Rostgaard K, Skogstrand K, Wiemels JL, Schmiegelow K, Hjalgrim H. Neonatal Inflammatory Markers Are Associated with Childhood B-cell Precursor Acute Lymphoblastic Leukemia. Cancer Res 2019; 78:5458-5463. [PMID: 30217873 DOI: 10.1158/0008-5472.can-18-0831] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 05/24/2018] [Accepted: 07/05/2018] [Indexed: 12/25/2022]
Abstract
It has been proposed that children with acute lymphoblastic leukemia (ALL) are born with a dysregulated immune function that together with postnatal environmental exposures causes childhood ALL. Despite its importance for the understanding of ALL etiology, this hypothesis has been inadequately explored. In a population-based case-control study, we measured the concentrations of 10 cytokines and other inflammatory markers on neonatal dried blood spots from 178 children who at ages 1 to 9 years were diagnosed with B-cell precursor ALL and 178 matched controls. Through linkage with Danish nationwide registers, we also assessed whether neonatal inflammatory markers were associated with previously demonstrated risk factors for childhood ALL. Children who developed B-cell precursor ALL had significantly lower neonatal concentrations of IL8, soluble IL6 receptor (sIL6R) α, TGFβ1, monocyte chemotactic protein (MCP)-1, and C-reactive protein (CRP) and higher concentrations of IL6, IL17, and IL18 compared with matched controls. Concentrations of IL10 were below the detection level for both patients and controls. Birth order (IL18 and CRP), gestational age (sIL6Rα, TGFβ1, and CRP), and sex (sIL6Rα, IL8, and CRP), but not maternal age, infections during pregnancy, birth weight nor mode of delivery were significantly associated with the neonatal concentrations of inflammatory markers. Our findings support the hypothesis that children who later develop B-cell precursor ALL are born with a dysregulated immune function.Significance: Children who develop acute lymphoblastic leukemia are immunologically distinct at birth and could potentially react abnormally to infections in early childhood. Cancer Res; 78(18); 5458-63. ©2018 AACR.
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Affiliation(s)
- Signe Holst Søegaard
- Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark.
| | - Klaus Rostgaard
- Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark
| | - Kristin Skogstrand
- Danish Centre for Neonatal Screening, Department for Congenital Disorders, Statens Serum Institut, Copenhagen, Denmark
| | - Joseph Leo Wiemels
- Department of Preventative Medicine, University of Southern California, Los Angeles
| | - Kjeld Schmiegelow
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark.,Institute of Clinical Medicine, Faculty of Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Henrik Hjalgrim
- Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark.,Department of Hematology, University Hospital Rigshospitalet, Copenhagen, Denmark
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9
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Pelland-Marcotte MC, Pole JD, Hwee J, Sutradhar R, Science M, Nathan PC, Sung L. Long-Term Risk of Infections After Treatment of Childhood Leukemia: A Population-Based Cohort Study Using Administrative Health Data. J Clin Oncol 2019; 37:2651-2660. [PMID: 31393747 DOI: 10.1200/jco.19.00570] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
PURPOSE Infections are a frequent complication during childhood leukemia treatment. Little is known about the infectious risk in survivors. We compared the relative rate (RR) of infections after treatment completion between pediatric leukemia survivors and the general population. METHODS We performed a retrospective, population-based cohort study of children diagnosed with leukemia between 1992 and 2015 in Ontario, Canada, who were alive and relapse free 30 days after treatment completion (index date). Leukemia survivors were matched 5:1 with the general population by year of birth, sex, and rural status and stratified by initial treatment, including and excluding hematopoietic stem-cell transplantation (HSCT). The primary outcome was time to infections, as identified using validated diagnostic codes from administrative databases. Individuals were censored at the earliest of death, first relapse, loss to follow-up, or end of study. RESULTS A total of 2,204 leukemia survivors were included and matched with 11,020 controls. The rate of infections was elevated after treatment completion compared with controls (RR, 1.51; 95% CI, 1.45 to 1.57) and at less than 1 year (RR, 1.77; 95% CI, 1.69 to 1.86); 1 to 4.99 years (RR, 1.66; 95% CI, 1.62 to 1.71), and 5 or more years (RR, 1.29; 95% CI, 1.22 to 1.36) from the index date. Among those whose initial treatment excluded HSCT, the rate remained elevated more than 5 years from the index date (RR, 1.29; 95% CI, 1.23 to 1.35). Infection-related death was significantly increased in leukemia survivors both among the entire cohort (hazard ratio, 149.3; 95% CI, 20.4 to 1,091.9) and among those without HSCT (hazard ratio, 92.7; 95% CI, 12.4 to 690.7). CONCLUSION A significant association was found between a history of leukemia therapy and an increased risk of infections. Additional study is needed to establish which exposures in patients with leukemia lead to late infections.
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Affiliation(s)
| | - Jason D Pole
- The Hospital for Sick Children, Toronto, Ontario, Canada.,Institute for Clinical Evaluative Services, Toronto, Ontario, Canada
| | - Jeremiah Hwee
- University of Toronto, Toronto, Ontario, Canada.,Institute for Clinical Evaluative Services, Toronto, Ontario, Canada.,Trillium Health Partners, Mississauga, Ontario, Canada
| | - Rinku Sutradhar
- University of Toronto, Toronto, Ontario, Canada.,Institute for Clinical Evaluative Services, Toronto, Ontario, Canada
| | | | - Paul C Nathan
- The Hospital for Sick Children, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Lillian Sung
- The Hospital for Sick Children, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
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10
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Precision medicine and health disparities: The case of pediatric acute lymphoblastic leukemia. Nurs Outlook 2019; 67:331-336. [PMID: 31279488 DOI: 10.1016/j.outlook.2019.05.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Revised: 05/07/2019] [Accepted: 05/12/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND Precision medicine has uncertain potential to address population health disparities. PURPOSE Case study of disparities in pediatric acute lymphoblastic leukemia (ALL). METHOD Literature-based evaluation of ALL in African American (AA) and European American (EA) children. FINDINGS AA children have a lower incidence of ALL than EA children, experience higher relapse rates, and are more likely to be diagnosed with poor prognostic indicators. Environmental risk exposures for ALL have small effect sizes; data are insufficient to determine their contribution to differences in incidence and prognosis. Differences in prevalence of gene variants associated with treatment response contribute to higher relapse rates in AA children. However, higher relapse rates were not seen in a care setting that eliminated out of pocket costs, used risk-directed therapy, and included rigorous case management. DISCUSSION Unequal access to effective treatment contributes to ALL disparities. Precision medicine can help to define effective treatment for diverse patient populations.
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11
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Abstract
In this Review, I present evidence supporting a multifactorial causation of childhood acute lymphoblastic leukaemia (ALL), a major subtype of paediatric cancer. ALL evolves in two discrete steps. First, in utero initiation by fusion gene formation or hyperdiploidy generates a covert, pre-leukaemic clone. Second, in a small fraction of these cases, the postnatal acquisition of secondary genetic changes (primarily V(D)J recombination-activating protein (RAG) and activation-induced cytidine deaminase (AID)-driven copy number alterations in the case of ETS translocation variant 6 (ETV6)-runt-related transcription factor 1 (RUNX1)+ ALL) drives conversion to overt leukaemia. Epidemiological and modelling studies endorse a dual role for common infections. Microbial exposures earlier in life are protective but, in their absence, later infections trigger the critical secondary mutations. Risk is further modified by inherited genetics, chance and, probably, diet. Childhood ALL can be viewed as a paradoxical consequence of progress in modern societies, where behavioural changes have restrained early microbial exposure. This engenders an evolutionary mismatch between historical adaptations of the immune system and contemporary lifestyles. Childhood ALL may be a preventable cancer.
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Affiliation(s)
- Mel Greaves
- Centre for Evolution and Cancer, The Institute of Cancer Research, London, UK.
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12
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Lupatsch JE, Bailey HD, Lacour B, Dufour C, Bertozzi AI, Leblond P, Faure-Conter C, Pellier I, Freycon C, Doz F, Puget S, Ducassou S, Orsi L, Clavel J. Childhood brain tumours, early infections and immune stimulation: A pooled analysis of the ESCALE and ESTELLE case-control studies (SFCE, France). Cancer Epidemiol 2017; 52:1-9. [PMID: 29128708 DOI: 10.1016/j.canep.2017.10.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Revised: 10/22/2017] [Accepted: 10/24/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Few studies have investigated whether early infections and factors potentially related to early immune stimulation might be involved in the aetiology of childhood brain tumours (CBT). In this study, we investigated the associations between CBT with early day-care attendance, history of early common infections, atopic conditions (asthma/wheezing, eczema, allergic rhinitis), early farm residence/visits and contact with animals. METHODS We pooled data from two nationwide French case-control studies, the ESCALE and ESTELLE studies. Children with a CBT diagnosed between 1 and 14 years of age were identified directly from the French National Registry of Childhood Cancers, while population controls were recruited from telephone subscribers. Odds-ratios (OR) and 95% confidence intervals (CI) were estimated using logistic regression adjusted for potential confounders. RESULTS The analyses included 469 cases and 2719 controls. We found no association between attending a day-care centre (OR: 0.9, 95%CI: 0.7-1.2) or having had repeated common infections (OR: 0.9, 95%CI: 0.7-1.2) in the first year of life and the risk of CBT. There was also no association with a history of asthma/wheezing (OR: 0.8, 95%CI: 0.56-1.1). Farm visits (OR: 0.6, 95%CI: 0.5-0.8) as well as contact with pets (OR: 0.8, 95%CI: 0.6-1.0) in the first year of life were inversely associated with CBT. CONCLUSIONS Our findings suggest a protective effect of early farm visits and contact with pets, but not with other markers of early immune stimulation. This might be related to immune stimulation but needs further investigation.
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Affiliation(s)
- Judith E Lupatsch
- UMRS 1153, INSERM, Université Paris-Descartes, Université Sorbonne-Paris-Cité, CRESS-EPICEA Epidémiologie des cancers de l'enfant et de l'adolescent, Paris, France; Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland.
| | - Helen D Bailey
- UMRS 1153, INSERM, Université Paris-Descartes, Université Sorbonne-Paris-Cité, CRESS-EPICEA Epidémiologie des cancers de l'enfant et de l'adolescent, Paris, France
| | - Brigitte Lacour
- UMRS 1153, INSERM, Université Paris-Descartes, Université Sorbonne-Paris-Cité, CRESS-EPICEA Epidémiologie des cancers de l'enfant et de l'adolescent, Paris, France; RNCE - National Registry of Childhood Cancers, Inserm, Villejuif and CHU de Nancy, France
| | - Christelle Dufour
- Gustave Roussy, Département de cancérologie de l'enfant et de l'adolescent, Villejuif, France
| | | | - Pierre Leblond
- Pediatric Oncology Unit, Oscar Lambret Comprehensive Cancer Center, Lille, France
| | - Cécile Faure-Conter
- Institut d'hématologie et d'oncologie pédiatrique, IHOPe, Centre Léon Bérard, Lyon, France
| | | | - Claire Freycon
- Clinique de pédiatrie, Hôpital Couple Enfant, CHU Grenoble-Alpes, Grenoble, France
| | - François Doz
- Oncology Center SIREDO (Care Innovation Research in Children, Adolescents and Young Adults Cancer), Institut Curie and Université Paris Descartes, Paris, France
| | - Stéphanie Puget
- Service de neurochirurgie pédiatrique, Hôpital Necker-Enfants malades, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Stéphane Ducassou
- Service d'onco-hématologie pédiatrique, Hôpital Pellegrin Tripode, Bordeaux, France
| | - Laurent Orsi
- UMRS 1153, INSERM, Université Paris-Descartes, Université Sorbonne-Paris-Cité, CRESS-EPICEA Epidémiologie des cancers de l'enfant et de l'adolescent, Paris, France
| | - Jacqueline Clavel
- UMRS 1153, INSERM, Université Paris-Descartes, Université Sorbonne-Paris-Cité, CRESS-EPICEA Epidémiologie des cancers de l'enfant et de l'adolescent, Paris, France; RNCE - National Registry of Childhood Cancers, Inserm, Villejuif and CHU de Nancy, France
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13
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Hwee J, Tait C, Sung L, Kwong JC, Sutradhar R, Pole JD. A systematic review and meta-analysis of the association between childhood infections and the risk of childhood acute lymphoblastic leukaemia. Br J Cancer 2017; 118:127-137. [PMID: 29065105 PMCID: PMC5765221 DOI: 10.1038/bjc.2017.360] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Revised: 09/19/2017] [Accepted: 09/21/2017] [Indexed: 01/02/2023] Open
Abstract
Background: To determine whether childhood infections were associated with the development of childhood acute lymphoblastic leukaemia (ALL). Methods: We included studies that assessed any infection in childhood prior to the diagnosis of ALL in children aged 0–19 years compared to children without cancer. The primary analysis synthesised any infection against the odds of ALL, and secondary analyses assessed the frequency, severity, timing of infections, and specific infectious agents against the odds of ALL. Subgroup analyses by data source were investigated. Results: In our primary analysis of 12 496 children with ALL and 2 356 288 children without ALL from 38 studies, we found that any infection was not associated with ALL (odds ratio (OR)=1.10, 95% CI: 0.95–1.28). Among studies with laboratory-confirmed infections, the presence of infections increased the odds of ALL by 2.4-fold (OR=2.42, 95% CI: 1.54–3.82). Frequency, severity, and timing of infection were not associated with ALL. Conclusions: The hypothesis put forward by Greaves and others about an infectious aetiology are neither confirmed nor refuted and the overall evidence remains inadequate for good judgement. The qualitative difference in the subgroup effects require further study, and future research will need to address the challenges in measuring infectious exposures.
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Affiliation(s)
- Jeremiah Hwee
- Dalla Lana School of Public Health, University of Toronto, Health Sciences Building, 155 College Street, Toronto, ON, Canada
| | - Christopher Tait
- Dalla Lana School of Public Health, University of Toronto, Health Sciences Building, 155 College Street, Toronto, ON, Canada
| | - Lillian Sung
- Division of Haematology/Oncology, Department of Pediatrics, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, Canada.,Program in Child Health Evaluative Sciences, The Hospital for Sick Children, Peter Gilgan Centre for Research and Learning, 686 Bay Street, Toronto, ON, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Health Sciences Building, 155 College Street, Toronto, ON, Canada
| | - Jeffrey C Kwong
- Dalla Lana School of Public Health, University of Toronto, Health Sciences Building, 155 College Street, Toronto, ON, Canada.,Institute for Clinical Evaluative Sciences, 2075 Bayview Avenue, Toronto, ON, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, ON Canada.,Public Health Ontario, Toronto, ON, Canada.,Toronto Western Family Health Team, University Health Network, Toronto, ON, Canada
| | - Rinku Sutradhar
- Dalla Lana School of Public Health, University of Toronto, Health Sciences Building, 155 College Street, Toronto, ON, Canada.,Institute for Clinical Evaluative Sciences, 2075 Bayview Avenue, Toronto, ON, Canada
| | - Jason D Pole
- Dalla Lana School of Public Health, University of Toronto, Health Sciences Building, 155 College Street, Toronto, ON, Canada.,Pediatric Oncology Group of Ontario, 480 University Avenue, Suite 1014, Toronto, ON, Canada
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14
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Pérez-Saldivar ML, Fajardo-Gutiérrez A, Sierra-Ramírez JA, Núñez-Villegas N, Pérez-Lorenzana H, Dorantes-Acosta EM, Román-Zepeda PF, Rodríguez-Zepeda MDC, González-Ulivarri JE, López-Santiago N, Martínez-Silva SI, Paredes-Aguilera R, Velázquez-Aviña MM, Flores-Lujano J, Jiménez-Hernández E, Núñez-Enríquez JC, Bekker-Méndez VC, Mejía-Aranguré JM. Parental Exposure to Workplace Carcinogens and the Risk of Development of Acute Leukemia in Infants. Case-Control Study. Arch Med Res 2017; 47:684-693. [PMID: 28476196 DOI: 10.1016/j.arcmed.2016.12.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 11/23/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND AIMS Occupational exposure of parents to carcinogens is of great interest in the etiology of leukemias. Evidence of the impact of such exposure on infants or small children is scarce. Here we estimated whether occupational exposure of parents to carcinogens could be a risk factor for leukemias in their children. METHODS Cases of acute leukemia (AL) in infants ≤24 months old diagnosed in Mexico City (1998-2013) were included in a population-based, case-control study. Each of the 195 cases was matched with at least one healthy child (n = 369). For each of four exposure windows studied, the degree of exposure to carcinogens was determined for both parents by using a validated occupational exposure index. An unconditional logistic regression was carried out. RESULTS Odds ratios (OR) and the 95% confidence intervals (CI) of the overall occupational exposure for parents during the four exposure windows indicated no association with risk of AL in their children. Pre-conception, the OR by the father 0.77 (0.49-1.21), by the mother 1.03 (0.50-2.11); during pregnancy, father 0.66 (0.38-1.15), mother 1.79 (0.46-6.90); during breastfeeding, father 0.75 (0.43-1.30), mother 0.96 (0.21-4.30); and after birth, father 0.74 (0.45-1.22), mother 0.90 (0.24-3.32). The statistical power of the sample size to identify an OR ≥2 and an exposure of ≥10% among controls was 78%. CONCLUSIONS These data support the idea that parents' occupational exposure during any of the periods studied was not a risk factor contributing to the etiology of AL in infants ≤24 months of age.
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Affiliation(s)
- María Luisa Pérez-Saldivar
- Unidad de Investigación Médica en Epidemiología Clínica, Unidad Médica de Alta Especialidad (UMAE) Hospital de Pediatría, Centro Médico Nacional (CMN) "Siglo XXI", Instituto Mexicano del Seguro Social (IMSS); Sección de Estudios de Posgrado, Escuela Superior de Medicina, Instituto Politécnico Nacional.
| | - Arturo Fajardo-Gutiérrez
- Unidad de Investigación Médica en Epidemiología Clínica, Unidad Médica de Alta Especialidad (UMAE) Hospital de Pediatría, Centro Médico Nacional (CMN) "Siglo XXI", Instituto Mexicano del Seguro Social (IMSS)
| | | | - Nancy Núñez-Villegas
- Servicio de Hematología Pediátrica, Hospital General "Gaudencio González Garza", CMN "La Raza", IMSS
| | - Héctor Pérez-Lorenzana
- Servicio de Cirugía Pediátrica, Hospital General "Gaudencio González Garza", CMN "La Raza", IMSS
| | | | - Pedro Francisco Román-Zepeda
- Servicio de Hematología Pediátrica, Hospital General Regional (HGR) No. 1 "Dr. Carlos Mac Gregor Sánchez Navarro" IMSS
| | | | | | | | | | | | | | - Janet Flores-Lujano
- Unidad de Investigación Médica en Epidemiología Clínica, Unidad Médica de Alta Especialidad (UMAE) Hospital de Pediatría, Centro Médico Nacional (CMN) "Siglo XXI", Instituto Mexicano del Seguro Social (IMSS)
| | - Elva Jiménez-Hernández
- Servicio de Hematología Pediátrica, Hospital General "Gaudencio González Garza", CMN "La Raza", IMSS
| | - Juan Carlos Núñez-Enríquez
- Unidad de Investigación Médica en Epidemiología Clínica, Unidad Médica de Alta Especialidad (UMAE) Hospital de Pediatría, Centro Médico Nacional (CMN) "Siglo XXI", Instituto Mexicano del Seguro Social (IMSS)
| | - Vilma Carolina Bekker-Méndez
- Unidad de Investigación Médica en Inmunología e Infectología, Hospital de Infectología "Dr. Daniel Méndez Hernández", CMN "La Raza", IMSS
| | - Juan Manuel Mejía-Aranguré
- Unidad de Investigación Médica en Epidemiología Clínica, Unidad Médica de Alta Especialidad (UMAE) Hospital de Pediatría, Centro Médico Nacional (CMN) "Siglo XXI", Instituto Mexicano del Seguro Social (IMSS); Laboratorio de Biología Molecular, UMAE, Hospital de Pediatría, CMN "Siglo XXI", IMSS; Coordinación de Investigación en Salud, CMN "Siglo XXI", IMSS.
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15
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Schüz J, Luta G, Erdmann F, Ferro G, Bautz A, Simony SB, Dalton SO, Lightfoot T, Winther JF. Birth order and risk of childhood cancer in the Danish birth cohort of 1973-2010. Cancer Causes Control 2015; 26:1575-82. [PMID: 26259524 DOI: 10.1007/s10552-015-0651-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2015] [Accepted: 08/04/2015] [Indexed: 01/04/2023]
Abstract
PURPOSE Many studies have investigated the possible association between birth order and risk of childhood cancer, although the evidence to date has been inconsistent. Birth order has been used as a marker for various in utero or childhood exposures and is relatively straightforward to assess. METHODS Data were obtained on all children born in Denmark between 1973 and 2010, involving almost 2.5 million births and about 5,700 newly diagnosed childhood cancers before the age of 20 years. Data were analyzed using Poisson regression models. RESULTS We failed to observe associations between birth order and risk of any childhood cancer subtype, including acute lymphoblastic leukemia; all rate ratios were close to one. Further analyses stratified by birth cohort (those born between 1973 and 1990, and those born between 1991 and 2010) also failed to show any associations. Considering stillbirths and/or controlling for birth weight and parental age in the analyses had no effect on the results. Analyses by years of birth (those born between 1973 and 1990, and those born between 1991 and 2010) did not show any changes in the overall pattern of no association. CONCLUSIONS In this large cohort of all children born in Denmark over an almost 40-year period, we did not observe an association between birth order and the risk of childhood cancer.
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Affiliation(s)
- Joachim Schüz
- Section of Environment and Radiation, International Agency for Research on Cancer (IARC), 150 Cours Albert Thomas, 69372, Lyon, France.
| | - George Luta
- Department of Biostatistics, Bioinformatics and Biomathematics, Georgetown University, Washington, DC, USA
| | - Friederike Erdmann
- Section of Environment and Radiation, International Agency for Research on Cancer (IARC), 150 Cours Albert Thomas, 69372, Lyon, France
| | - Gilles Ferro
- Section of Environment and Radiation, International Agency for Research on Cancer (IARC), 150 Cours Albert Thomas, 69372, Lyon, France
| | - Andrea Bautz
- Survivorship Unit, Childhood Cancer Survivorship Research Group, Danish Cancer Society Research Center, Copenhagen, Denmark
| | - Sofie Bay Simony
- Survivorship Unit, Social Inequality in Survivorship Group, Danish Cancer Society Research Center, Copenhagen, Denmark
| | - Susanne Oksbjerg Dalton
- Survivorship Unit, Social Inequality in Survivorship Group, Danish Cancer Society Research Center, Copenhagen, Denmark
| | - Tracy Lightfoot
- Section of Environment and Radiation, International Agency for Research on Cancer (IARC), 150 Cours Albert Thomas, 69372, Lyon, France
- Epidemiology and Cancer Statistics Group, Department of Health Sciences, University of York, York, UK
| | - Jeanette Falck Winther
- Survivorship Unit, Childhood Cancer Survivorship Research Group, Danish Cancer Society Research Center, Copenhagen, Denmark
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16
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Yan K, Xu X, Liu X, Wang X, Hua S, Wang C, Liu X. The associations between maternal factors during pregnancy and the risk of childhood acute lymphoblastic leukemia: A meta-analysis. Pediatr Blood Cancer 2015; 62:1162-70. [PMID: 25728190 DOI: 10.1002/pbc.25443] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Accepted: 12/26/2014] [Indexed: 01/25/2023]
Abstract
BACKGROUND Although genetic and environmental factors are considered to be the main causes of acute lymphoblastic leukemia, the associations between maternal factors during pregnancy and the childhood ALL is still unclear. PROCEDURE In this study, meta-analysis was used. Medline, PubMed, and Web of Science were searched. The result was assessed based on pooled odds ratios (ORs) with 95% confidence intervals (CIs). RESULTS The pooled ORs showed that there were associations between childhood ALL and the birth order (The first vs others, OR = 1.08, 95%CI = 1.00-1.16), the education of pregnant woman (>high school vs ≤ high school, OR = 0.82, 95%CI = 0.77-0.86), smoking (Ever vs never, OR = 1.10, 95%CI = 1.02-1.19). CONCLUSIONS Our meta-analysis showed that there were important associations between childhood ALL and the birth order, the education of pregnant woman, smoking.
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Affiliation(s)
- Kangkang Yan
- Epidemiology and Statistics, School of Public Health, Jilin University, Changchun, Jilin, China
| | - Xuejing Xu
- Epidemiology and Statistics, School of Public Health, Jilin University, Changchun, Jilin, China
| | - Xiaodong Liu
- Key Laboratory of Radiobiology (Ministry of Health), School of Public Health, Jilin University, Changchun, China
| | - Xikui Wang
- Department of Statistics, University of Manitoba, Winnipeg, Canada
| | - Shucheng Hua
- The First Hospital of Jilin University, Changchun, China
| | - Chunpeng Wang
- School of Mathematics and Statistics, Northeast Normal University, Changchun, Jilin, China
| | - Xin Liu
- Epidemiology and Statistics, School of Public Health, Jilin University, Changchun, Jilin, China
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17
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Gradel KO, Kaerlev L. Antibiotic use from conception to diagnosis of child leukaemia as compared to the background population: A nested case-control study. Pediatr Blood Cancer 2015; 62:1155-61. [PMID: 25790083 DOI: 10.1002/pbc.25477] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Accepted: 01/16/2015] [Indexed: 11/12/2022]
Abstract
BACKGROUND The role of infection in the aetiology of childhood leukaemia is unknown. We used prescriptions of antibiotics from Danish pharmacies as a proxy measure for the occurrence of infections. PROCEDURE We investigated the association between exposure to antibiotics, from conception to leukaemia diagnosis, and the risk of leukaemia. Incident cases of leukaemia among children in Denmark, 1995-2008, with mothers having their earliest conception date in 1995, were individually matched to population controls by age, sex and municipality. Conditional logistic regression analyses assessed antibiotic redemptions in different time periods from conception up to 6 months before the diagnoses of all leukaemia types, acute lymphoblastic leukaemia [ALL] and ALL in 2- to 5-year-old children, adjusting for several potential confounders. RESULTS A total of 120/360 (33.3%) leukaemia mothers and 1,081/3,509 (30.8%) control mothers redeemed antibiotics during pregnancy (P = 0.32). For children, the equivalent numbers were 276 (76.7%) and 2,665 (75.9%) (P = 0.76). Histograms of antibiotic redemptions showed no temporal differences between leukaemia mothers/children and controls, which was confirmed in adjusted regression analyses (OR [95% CI]: 1.02 [0.75-1.38]). Only antibiotics redeemed during the first year after birth differed from this (OR [95% CI] for ALL diagnosed in 2- to 5-year-old children: 0.46 [0.31-0.66]). CONCLUSIONS In this hypothesis generating study, the similar amount and pattern of antibiotic redemptions in children with and without leukaemia indicate that infections play a minor role in the aetiology of childhood leukaemia. However, less antibiotic redemptions during the first year of life conform to Greaves' 'delayed infection hypothesis'.
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Affiliation(s)
- Kim Oren Gradel
- Research Unit of Clinical Epidemiology, Institute of Clinical Research, University of Southern Denmark, Odense, Denmark.,Center for Clinical Epidemiology, Odense University Hospital, Odense, Denmark
| | - Linda Kaerlev
- Research Unit of Clinical Epidemiology, Institute of Clinical Research, University of Southern Denmark, Odense, Denmark.,Center for Clinical Epidemiology, Odense University Hospital, Odense, Denmark
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18
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Rudant J, Lightfoot T, Urayama KY, Petridou E, Dockerty JD, Magnani C, Milne E, Spector LG, Ashton LJ, Dessypris N, Kang AY, Miller M, Rondelli R, Simpson J, Stiakaki E, Orsi L, Roman E, Metayer C, Infante-Rivard C, Clavel J. Childhood acute lymphoblastic leukemia and indicators of early immune stimulation: a Childhood Leukemia International Consortium study. Am J Epidemiol 2015; 181:549-62. [PMID: 25731888 DOI: 10.1093/aje/kwu298] [Citation(s) in RCA: 76] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Accepted: 09/29/2014] [Indexed: 01/04/2023] Open
Abstract
The associations between childhood acute lymphoblastic leukemia (ALL) and several proxies of early stimulation of the immune system, that is, day-care center attendance, birth order, maternally reported common infections in infancy, and breastfeeding, were investigated by using data from 11 case-control studies participating in the Childhood Leukemia International Consortium (enrollment period: 1980-2010). The sample included 7,399 ALL cases and 11,181 controls aged 2-14 years. The data were collected by questionnaires administered to the parents. Pooled odds ratios and 95% confidence intervals were estimated by unconditional logistic regression adjusted for age, sex, study, maternal education, and maternal age. Day-care center attendance in the first year of life was associated with a reduced risk of ALL (odds ratio = 0.77, 95% confidence interval: 0.71, 0.84), with a marked inverse trend with earlier age at start (P < 0.0001). An inverse association was also observed with breastfeeding duration of 6 months or more (odds ratio = 0.86, 95% confidence interval: 0.79, 0.94). No significant relationship with a history of common infections in infancy was observed even though the odds ratio was less than 1 for more than 3 infections. The findings of this large pooled analysis reinforce the hypothesis that day-care center attendance in infancy and prolonged breastfeeding are associated with a decreased risk of ALL.
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19
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Rudant J, Orsi L, Bonaventure A, Goujon-Bellec S, Baruchel A, Petit A, Bertrand Y, Nelken B, Pasquet M, Michel G, Saumet L, Chastagner P, Ducassou S, Réguerre Y, Hémon D, Clavel J. ARID5B, IKZF1 and non-genetic factors in the etiology of childhood acute lymphoblastic leukemia: the ESCALE study. PLoS One 2015; 10:e0121348. [PMID: 25806972 PMCID: PMC4373901 DOI: 10.1371/journal.pone.0121348] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Accepted: 01/30/2015] [Indexed: 01/18/2023] Open
Abstract
Genome-wide association studies (GWAS) have identified that frequent polymorphisms in ARID5B and IKZF1, two genes involved in lymphoid differentiation, increase the risk of childhood acute lymphoblastic leukemia (ALL). These findings markedly modified the current field of research on the etiology of ALL. In this new context, the present exploratory study investigated the possible interactions between these at-risk alleles and the non-genetic suspected ALL risk factors that were of sufficient prevalence in the French ESCALE study: maternal use of home insecticides during pregnancy, preconception paternal smoking, and some proxies for early immune modulation, i.e. breastfeeding, history of common infections before age one year, and birth order. The analyses were based on 434 ALL cases and 442 controls of European origin, drawn from the nationwide population-based case-control study ESCALE. Information on non-genetic factors was obtained by standardized telephone interview. Interactions between rs10740055 in ARID5B or rs4132601 in IKZF1 and each of the suspected non-genetic factors were tested, with the SNPs coded as counts of minor alleles (trend variable). Statistical interactions were observed between rs4132601 and maternal insecticide use (p = 0.012), breastfeeding p = 0.017) and repeated early common infections (p = 0.0070), with allelic odds ratios (OR) which were only increased among the children not exposed to insecticides (OR = 1.8, 95%CI: 1.3, 2.4), those who had been breastfed (OR = 1.8, 95%CI: 1.3, 2.5) and those who had had repeated early common infections (OR = 2.4, 95%CI: 1.5, 3.8). The allelic ORs were close to one among children exposed to insecticides, who had not been breastfed and who had had no or few common infections. Repeated early common infections interacted with rs10740055 (p = 0.018) in the case-only design. Further studies are needed to evaluate whether these observations of a modification of the effect of the at-risk alleles by non-genetic factors are chance findings or reflect true underlying mechanisms.
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Affiliation(s)
- Jérémie Rudant
- Institut national de la santé et de la recherche médicale (INSERM) U1153, Epidemiology and Biostatistics Sorbonne Paris Cité Center (CRESS), Epidemiology of childhood and adolescent cancers team (EPICEA), Villejuif, France
- Paris-Descartes University, UMRS-1153, Epidemiology and Biostatistics Sorbonne Paris Cité Center (CRESS), Paris, France
- French National Registry of Childhood Hematopoietic Malignancies (RNHE), Villejuif, France
- * E-mail:
| | - Laurent Orsi
- Institut national de la santé et de la recherche médicale (INSERM) U1153, Epidemiology and Biostatistics Sorbonne Paris Cité Center (CRESS), Epidemiology of childhood and adolescent cancers team (EPICEA), Villejuif, France
- Paris-Descartes University, UMRS-1153, Epidemiology and Biostatistics Sorbonne Paris Cité Center (CRESS), Paris, France
| | - Audrey Bonaventure
- Institut national de la santé et de la recherche médicale (INSERM) U1153, Epidemiology and Biostatistics Sorbonne Paris Cité Center (CRESS), Epidemiology of childhood and adolescent cancers team (EPICEA), Villejuif, France
- Paris-Descartes University, UMRS-1153, Epidemiology and Biostatistics Sorbonne Paris Cité Center (CRESS), Paris, France
| | - Stéphanie Goujon-Bellec
- Institut national de la santé et de la recherche médicale (INSERM) U1153, Epidemiology and Biostatistics Sorbonne Paris Cité Center (CRESS), Epidemiology of childhood and adolescent cancers team (EPICEA), Villejuif, France
- Paris-Descartes University, UMRS-1153, Epidemiology and Biostatistics Sorbonne Paris Cité Center (CRESS), Paris, France
- French National Registry of Childhood Hematopoietic Malignancies (RNHE), Villejuif, France
| | - André Baruchel
- Assistance Publique-Hôpitaux de Paris, Hôpital Robert Debré, Paris, France
- Université Paris Diderot-Paris 7, Sorbonne Paris Cité, Paris, France
| | - Arnaud Petit
- Assistance Publique-Hôpitaux de Paris, HUEP, Hôpital Trousseau, Paris, France
- Sorbonne Universités, UPMC Univ Paris 06, UMR S_938, Paris, France
| | - Yves Bertrand
- Institut d’Hémato-Oncologie Pédiatrique, Lyon, France
- Université Claude Bernard Lyon 1, Lyon, France
| | - Brigitte Nelken
- Pôle Enfant, CHRU, Lille, France
- Université Lille Nord de France, Lille, France
| | - Marlène Pasquet
- Hématologie pédiatrique, CHU Toulouse, INSERM U1037, Equipe 16, CRCT, Oncopôle, Toulouse, France
| | - Gérard Michel
- Department of Pediatric Hematology and Oncology, Timone Enfants Hospital, Marseille, France
- Aix-Marseille University, Marseille, France
| | - Laure Saumet
- Hôpital Arnaud de Villeneuve, Montpellier, France
| | | | | | | | - Denis Hémon
- Institut national de la santé et de la recherche médicale (INSERM) U1153, Epidemiology and Biostatistics Sorbonne Paris Cité Center (CRESS), Epidemiology of childhood and adolescent cancers team (EPICEA), Villejuif, France
- Paris-Descartes University, UMRS-1153, Epidemiology and Biostatistics Sorbonne Paris Cité Center (CRESS), Paris, France
| | - Jacqueline Clavel
- Institut national de la santé et de la recherche médicale (INSERM) U1153, Epidemiology and Biostatistics Sorbonne Paris Cité Center (CRESS), Epidemiology of childhood and adolescent cancers team (EPICEA), Villejuif, France
- Paris-Descartes University, UMRS-1153, Epidemiology and Biostatistics Sorbonne Paris Cité Center (CRESS), Paris, France
- French National Registry of Childhood Hematopoietic Malignancies (RNHE), Villejuif, France
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20
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Ajrouche R, Rudant J, Orsi L, Petit A, Baruchel A, Lambilliotte A, Gambart M, Michel G, Bertrand Y, Ducassou S, Gandemer V, Paillard C, Saumet L, Blin N, Hémon D, Clavel J. Childhood acute lymphoblastic leukaemia and indicators of early immune stimulation: the Estelle study (SFCE). Br J Cancer 2015; 112:1017-26. [PMID: 25675150 PMCID: PMC4366894 DOI: 10.1038/bjc.2015.53] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Revised: 01/04/2015] [Accepted: 01/12/2015] [Indexed: 11/29/2022] Open
Abstract
Background: Factors related to early stimulation of the immune system (breastfeeding, proxies for exposure to infectious agents, normal delivery, and exposure to animals in early life) have been suggested to decrease the risk of childhood acute lymphoblastic leukaemia (ALL). Methods: The national registry-based case–control study, ESTELLE, was carried out in France in 2010–2011. Population controls were frequency matched with cases on age and gender. The participation rates were 93% for cases and 86% for controls. Data were obtained from structured telephone questionnaires administered to mothers. Odds ratios (OR) were estimated using unconditional regression models adjusted for age, gender, and potential confounders. Results: In all, 617 ALL and 1225 controls aged ⩾1 year were included. Inverse associations between ALL and early common infections (OR=0.8, 95% confidence interval (CI): 0.6, 1.0), non-first born (⩾3 vs 1; OR=0.7, 95% CI: 0.5, 1.0), attendance of a day-care centre before age 1 year (OR=0.7, 95% CI: 0.5, 1.0), breastfeeding (OR=0.8, 95% CI: 0.7, 1.0), and regular contact with pets (OR=0.8, 95% CI: 0.7, 1.0) in infancy were observed. Conclusions: The results support the hypothesis that conditions promoting the maturation of the immune system in infancy have a protective role with respect to ALL.
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Affiliation(s)
- R Ajrouche
- 1] Epidemiology of childhood and adolescent cancers, CRESS, INSERM U1153, Villejuif, France [2] Paris-Sud University, Le Kremlin Bicêtre, France
| | - J Rudant
- 1] Epidemiology of childhood and adolescent cancers, CRESS, INSERM U1153, Villejuif, France [2] Paris-Descartes University, Paris, France [3] RNHE-National Registry of Childhood Hematopoietic Malignancies, Villejuif, France
| | - L Orsi
- 1] Epidemiology of childhood and adolescent cancers, CRESS, INSERM U1153, Villejuif, France [2] Paris-Descartes University, Paris, France
| | - A Petit
- 1] AP-HP, Hôpital Armand Trousseau, Paris, France [2] Université Paris 6 Pierre et Marie Curie, Paris, France
| | - A Baruchel
- 1] AP-HP, Hôpital Robert Debré, Paris, France [2] Université Paris 7, Paris, France
| | | | - M Gambart
- Hôpital des Enfants, Toulouse, France
| | - G Michel
- AP-HM, Hôpital la Timone, Marseille, France
| | - Y Bertrand
- Institut d'Hématologie et d'Oncologie Pédiatrique, Lyon, France
| | - S Ducassou
- Hôpital Pellegrin Tripode, Bordeaux, France
| | | | - C Paillard
- Hôpital de Hautepierre, Strasbourg, France
| | - L Saumet
- Hôpital Arnaud de Villeneuve, Montpellier, France
| | - N Blin
- Hôpital Mère-Enfant, CHU-Nantes, Nantes, France
| | - D Hémon
- 1] Epidemiology of childhood and adolescent cancers, CRESS, INSERM U1153, Villejuif, France [2] Paris-Descartes University, Paris, France
| | - J Clavel
- 1] Epidemiology of childhood and adolescent cancers, CRESS, INSERM U1153, Villejuif, France [2] Paris-Descartes University, Paris, France [3] RNHE-National Registry of Childhood Hematopoietic Malignancies, Villejuif, France
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21
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Maia RDRP, Wünsch Filho V. Infection and childhood leukemia: review of evidence. Rev Saude Publica 2014; 47:1172-85. [PMID: 24626555 PMCID: PMC4206105 DOI: 10.1590/s0034-8910.2013047004753] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2013] [Accepted: 07/09/2013] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To analyze studies that evaluated the role of infections as well as indirect
measures of exposure to infection in the risk of childhood leukemia,
particularly acute lymphoblastic leukemia. METHODS A search in Medline, Lilacs, and SciELO scientific publication databases
initially using the descriptors "childhood leukemia" and "infection" and
later searching for the words "childhood leukemia" and "maternal infection
or disease" or "breastfeeding" or "daycare attendance" or "vaccination"
resulted in 62 publications that met the following inclusion criteria:
subject aged ≤ 15 years; specific analysis of cases diagnosed with acute
lymphoblastic leukemia or total leukemia; exposure assessment of mothers' or
infants' to infections (or proxy of infection), and risk of leukemia. RESULTS Overall, 23 studies that assessed infections in children support the
hypothesis that occurrence of infection during early childhood reduces the
risk of leukemia, but there are disagreements within and between studies.
The evaluation of exposure to infection by indirect measures showed evidence
of reduced risk of leukemia associated mainly with daycare attendance. More
than 50.0% of the 16 studies that assessed maternal exposure to infection
observed increased risk of leukemia associated with episodes of influenza,
pneumonia, chickenpox, herpes zoster, lower genital tract infection, skin
disease, sexually transmitted diseases, Epstein-Barr virus, and
Helicobacter pylori. CONCLUSIONS Although no specific infectious agent has been identified, scientific
evidence suggests that exposure to infections has some effect on childhood
leukemia etiology.
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22
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van Laar M, Stark DP, McKinney P, Parslow RC, Kinsey SE, Picton SV, Feltbower RG. Population mixing for leukaemia, lymphoma and CNS tumours in teenagers and young adults in England, 1996-2005. BMC Cancer 2014; 14:698. [PMID: 25248916 PMCID: PMC4180542 DOI: 10.1186/1471-2407-14-698] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Accepted: 09/17/2014] [Indexed: 01/12/2023] Open
Abstract
Background Little aetiological epidemiological research has been undertaken for major cancers occurring in teenagers and young adults (TYA). Population mixing, as a possible proxy for infectious exposure, has been well researched for childhood malignancies. We aimed to investigate effects of population mixing in this older age group using an English national cancer dataset. Methods Cases of leukaemia, lymphoma and central nervous system (CNS) tumours amongst 15–24 year olds in England (diagnosed 1996–2005) were included in the study. Data were obtained by ward of diagnosis and linked to 1991 census variables including population mixing (Shannon index); data on person-weighted population density and deprivation (Townsend score) were also used and considered as explanatory variables. Associations between TYA cancer incidence and census variables were investigated using negative binomial regression, and results presented as incidence rate ratios (IRR) with 95% confidence intervals (CI). Results A total of 6251 cases of leukaemia (21%), lymphoma (49%) and CNS tumours (30%) were analysed. Higher levels of population mixing were associated with a significant decrease in the incidence of CNS tumours (IRR = 0.83, 95% CI = 0.75-0.91), accounted for by astrocytomas and ‘other CNS tumours’; however, there was no association with leukaemia or lymphoma. Incidence of CNS tumours and lymphoma was 3% lower in more deprived areas (IRR = 0.97, 95% CI = 0.96-0.99 and IRR = 0.97, 95% CI =0.96-0.98 respectively). Population density was not associated with the incidence of leukaemia, lymphoma or CNS tumours. Conclusions Our results suggest a possible role for environmental risk factors with population correlates in the aetiology of CNS tumours amongst TYAs. Unlike studies of childhood cancer, associations between population mixing and the incidence of leukaemia and lymphoma were not observed.
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Affiliation(s)
| | | | | | | | | | | | - Richard G Feltbower
- Division of Epidemiology and Biostatistics, School of Medicine, Worsley Building, Clarendon Way, University of Leeds, Leeds LS2 9JT, UK.
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23
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Linabery AM, Erhardt EB, Fonstad RK, Ambinder RF, Bunin GR, Ross JA, Spector LG, Grufferman S. Infectious, autoimmune and allergic diseases and risk of Hodgkin lymphoma in children and adolescents: a Children's Oncology Group study. Int J Cancer 2014; 135:1454-69. [PMID: 24523151 DOI: 10.1002/ijc.28785] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2013] [Revised: 01/07/2014] [Accepted: 01/14/2014] [Indexed: 12/19/2022]
Abstract
An infectious origin for pediatric Hodgkin lymphoma (HL) has long been suspected and Epstein-Barr virus (EBV) has been implicated in a subset of cases. Increased HL incidence in children with congenital and acquired immunodeficiencies, consistent associations between autoimmune diseases and adult HL and genome-wide association and other genetic studies together suggest immune dysregulation is involved in lymphomagenesis. Here, healthy control children identified by random digit dialing were matched on sex, race/ethnicity and age to HL diagnosed in 1989-2003 at 0-14 years at Children's Oncology Group institutions. Parents of 517 cases and 784 controls completed telephone interviews, including items regarding medical histories. Tumor EBV status was determined for 355 cases. Using conditional logistic regression, we calculated odds ratios (ORs) and 95% confidence intervals (CIs) for risk of HL. Cases were more likely to have had an infection>1 year prior to HL diagnosis (OR=1.69, 95% CI: 0.98-2.91); case siblings were also more likely to have had a prior infection (OR=2.04, 95% CI: 1.01-4.14). Parental history of autoimmunity associated with increased EBV+ HL risk (OR=2.97, 95% CI: 1.34-6.58), while having a parent (OR=1.47, 95% CI: 1.01-2.14) or sibling (OR=1.62, 95% CI: 1.11-2.36) with an allergy was associated with EBV - HL. These results may indicate true increased risk for infections and increased risk with family history of autoimmune and allergic conditions that varies by tumor EBV status, or they may be attributable to inaccurate recall. In addition to employing biomarkers to confirm the role of immune-modulating conditions in pediatric HL, future studies should focus on family based designs.
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Affiliation(s)
- Amy M Linabery
- Division of Pediatric Epidemiology and Clinical Research, Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota; University of Minnesota Masonic Cancer Center, Minneapolis, Minnesota
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24
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Vestergaard TR, Rostgaard K, Grau K, Schmiegelow K, Hjalgrim H. Hospitalisation for infection prior to diagnosis of acute lymphoblastic leukaemia in children. Pediatr Blood Cancer 2013; 60:428-32. [PMID: 22915267 DOI: 10.1002/pbc.24286] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2012] [Accepted: 07/16/2012] [Indexed: 01/27/2023]
Abstract
BACKGROUND It has been proposed that infections in infancy and early childhood are associated with a reduced risk of childhood acute lymphoblastic leukaemia (ALL). We tested this hypothesis in a register-based study of hospitalisations for infectious diseases prior to diagnosis of childhood ALL. PROCEDURE A nation-wide cohort encompassing all Danish children aged 0-14 years and born between 1977 and 2008 (N = 1,778,129) was established and followed for hospitalisations for infectious diseases and risk of childhood ALL. The exposure was lagged 1 year to limit reverse causality. In the statistical analyses exposure was defined as (time dependent) number of early or late (before 2 or at/after 2 years of age) hospitalisations to further explore possible age-dependent associations. RESULTS A total of 815 children were diagnosed with ALL during follow-up. Risk of ALL was associated neither with hospitalisations for infectious diseases before (incidence rate ratio = 0.92, 95% confidence interval 0.78-1.07) nor at/after 2 years of age (incidence rate ratio = 1.04, 95% confidence interval 0.81-1.32). This also applied to subsets of ALL supposedly initiated prenatally. CONCLUSION The absence of association between hospitalisation for infections and risk of childhood ALL directs future investigations of the role of infections in development of childhood ALL towards exploration of less severe infections.
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25
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Chang JS, Tsai YW, Tsai CR, Wiemels JL. Allergy and risk of childhood acute lymphoblastic leukemia: a population-based and record-based study. Am J Epidemiol 2012; 176:970-8. [PMID: 23171876 DOI: 10.1093/aje/kws263] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
A deficit of normal immune stimulation in early childhood is a suspected risk factor for both childhood acute lymphoblastic leukemia (ALL) and allergies. The present study utilized a population-based case-control design using medical claims data from the National Health Insurance Research Database of Taiwan to evaluate the association between allergy and childhood leukemia. Eight hundred forty-six childhood ALL patients who were newly diagnosed during 2000 to 2008 and were older than 1 but less than 10 years of age were individually matched with 3,374 controls based on sex, birth date, and time of diagnosis (reference date for the controls). Conditional logistic regression was performed to assess the association between childhood ALL and allergies. An increased risk of ALL was observed with having an allergy less than 1 year before the case's ALL diagnosis (odds ratio (OR) = 1.7, 95% confidence interval (CI): 1.5, 2.0), more than 1 year before the case's diagnosis (OR = 1.3, 95% CI: 1.1, 1.5), and before the age of 1 year (OR = 1.4, 95% CI: 1.1, 1.7). These results suggest that the pathogenesis of childhood ALL and allergy share a common biologic mechanism.
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Affiliation(s)
- Jeffrey S Chang
- National Institute of Cancer Research, National Health Research Institutes, Tainan, Taiwan.
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26
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NQO1 rs1800566 (C609T), PON1 rs662 (Q192R), and PON1 rs854560 (L55M) polymorphisms segregate the risk of childhood acute leukemias according to age range distribution. Cancer Causes Control 2012; 23:1811-9. [DOI: 10.1007/s10552-012-0060-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2012] [Accepted: 08/28/2012] [Indexed: 12/17/2022]
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27
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Crouch S, Lightfoot T, Simpson J, Smith A, Ansell P, Roman E. Infectious illness in children subsequently diagnosed with acute lymphoblastic leukemia: modeling the trends from birth to diagnosis. Am J Epidemiol 2012; 176:402-8. [PMID: 22899827 DOI: 10.1093/aje/kws180] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Although there is increasing evidence that immune dysregulation in children who develop acute lymphoblastic leukemia (ALL) is detectable from birth, debate about the role of infectious exposures in infancy continues. With the aim of quantifying children's infectious exposures, investigators have used a number of infection exposure proxies, but there is a lack of consistency in findings, with some markers indicating increased ALL risks and others decreased risks, the disparity being evident both within and between studies. Accordingly, the authors conducted an in-depth analysis of key infection exposure proxies used in the United Kingdom Childhood Cancer Study, a national population-based case-control study conducted over the period 1991-1996, which combined data from medical records, parental interview, and population census. This longitudinal approach revealed the marked deterioration in immune response that emerged around 5 months prior to ALL diagnosis and confirmed that infectious diagnoses in the first year of life were significantly increased (P < 0.05) in children who developed leukemia between 2 and 14 years of age, as well as in those who had birth orders >1, were not breastfed, lived in deprived areas, or were diagnosed with eczema. By contrast, no association between infectious illness and preschool activity was detected, the lower infection levels among controls whose mothers reported attendance contributing to a significantly reduced ALL odds ratio.
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Affiliation(s)
- Simon Crouch
- Epidemiology & Cancer Statistics Group, Department of Health Sciences, University of York, Heslington, York, United Kingdom.
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28
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Chang JS, Tsai CR, Tsai YW, Wiemels JL. Medically diagnosed infections and risk of childhood leukaemia: a population-based case-control study. Int J Epidemiol 2012; 41:1050-9. [PMID: 22836110 DOI: 10.1093/ije/dys113] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Previous studies on the association between childhood infections and childhood leukaemia have produced inconsistent results, likely due to the recall error/bias of infection data reported by the parents. The current study used a population-based and record-based case-control design to evaluate the association between childhood leukaemia and infections using the National Health Insurance Research Database of Taiwan. METHODS In all, 846 childhood acute lymphoblastic leukaemia (ALL) and 193 acute myeloid leukaemia (AML) patients newly diagnosed between 2000 and 2008, aged >1 and <10 years, were included. Up to four controls (3374 for ALL and 766 for AML) individually matched to each case on sex, birth date and time of diagnosis (reference date for the controls) were identified. Conditional logistic regression was performed to assess the association between childhood leukaemia and infections. RESULTS Having any infection before 1 year of age was associated with an increased risk for both childhood ALL (odds ratio = 3.2, 95% confidence interval 2.2-4.7) and AML (odds ratio = 6.0, 95% confidence interval 2.0-17.8), with a stronger risk associated with more episodes of infections. Similar results were observed for infections occurring >1 year before the cases' diagnosis of childhood leukaemia. CONCLUSIONS Children with leukaemia may have a dysregulated immune function present at an early age, resulting in more episodes of symptomatic infections compared with healthy controls. However, confounding by other infectious measures such as birth order and day care attendance could not be ruled out. Finally, the results are only relevant to the medically diagnosed infections.
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Affiliation(s)
- Jeffrey S Chang
- National Institute of Cancer Research, National Health Research Institutes, Tainan, Taiwan, ROC.
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29
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Wiemels J. Perspectives on the causes of childhood leukemia. Chem Biol Interact 2012; 196:59-67. [PMID: 22326931 PMCID: PMC3839796 DOI: 10.1016/j.cbi.2012.01.007] [Citation(s) in RCA: 158] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2011] [Revised: 01/05/2012] [Accepted: 01/24/2012] [Indexed: 12/22/2022]
Abstract
Acute leukemia is the most common cancer in children but the causes of the disease in the majority of cases are not known. About 80% are precursor-B cell in origin (CD19+, CD10+), and this immunophenotype has increased in incidence over the past several decades in the Western world. Part of this increase may be due to the introduction of new chemical exposures into the child's environment including parental smoking, pesticides, traffic fumes, paint and household chemicals. However, much of the increase in leukemia rates is likely linked to altered patterns of infection during early childhood development, mirroring causal pathways responsible for a similarly increased incidence of other childhood-diagnosed immune-related illnesses including allergy, asthma, and type 1 diabetes. Factors linked to childhood leukemia that are likely surrogates for immune stimulation include exposure to childcare settings, parity status and birth order, vaccination history, and population mixing. In case-control studies, acute lymphoblastic leukemia (ALL) is consistently inversely associated with greater exposure to infections, via daycare and later birth order. New evidence suggests also that children who contract leukemia may harbor a congenital defect in immune responder status, as indicated by lower levels of the immunosuppressive cytokine IL-10 at birth in children who grow up to contract leukemia, as well as higher need for clinical care for infections within the first year of life despite having lower levels of exposure to infections. One manifestation of this phenomenon may be leukemia clusters which tend to appear as a leukemia "outbreak" among populations with low herd immunity to a new infection. Critical answers to the etiology of childhood leukemia will require incorporating new tools into traditional epidemiologic approaches - including the classification of leukemia at a molecular scale, better exposure assessments at all points in a child's life, a comprehensive understanding of genetic risk factors, and an appraisal of the interplay between infectious exposures and the status of immune response in individuals.
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Affiliation(s)
- Joseph Wiemels
- Department of Epidemiology and Biostatistics, University of California San Francisco, Helen Diller Cancer Center Research Building, 1450 3rd Street, HD274, San Francisco, CA 94158, United States.
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30
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Chang JS, Zhou M, Buffler PA, Chokkalingam AP, Metayer C, Wiemels JL. Profound deficit of IL10 at birth in children who develop childhood acute lymphoblastic leukemia. Cancer Epidemiol Biomarkers Prev 2011; 20:1736-40. [PMID: 21653647 DOI: 10.1158/1055-9965.epi-11-0162] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Childhood acute lymphoblastic leukemia (ALL) may originate via abnormal immune responses to infectious agents. It is unknown whether prenatal immune development may differ in children who develop the disease. The current study examines the association between neonatal cytokine profiles, a proxy measure for a child's prenatal immune development, and childhood ALL. METHODS Neonatal blood spots of 116 childhood ALL cases and 116 controls living in California were ascertained. Eleven cytokines associated with Th1, Th2, and Th17 lymphocytes were measured using a multiplex bead-based assay. Unconditional logistic regression was done to estimate the odds ratio (OR) by measuring the association between neonatal cytokines and ALL adjusted for age, sex, race/ethnicity, and household income. RESULTS Of the 11 cytokines measured, 5 [interleukin (IL)4, IL6, IL10, IL12, and IL13] were detectable. Except for IL12, the other 4 cytokines were all significantly lower among cases than controls. In a multivariable model including the 5 cytokines, only IL10 remained independently associated with childhood ALL with an OR = 0.04, 95% CI: 0.01 to 0.18, comparing the highest tertile to the lowest tertile. CONCLUSIONS A child's neonatal level of IL10, a key regulator for modulating the intensity and duration of immune responses, is associated with his/her subsequent risk of developing ALL. IMPACT The current analysis shows that children with ALL may have a dysregulated immune function present at birth.
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Affiliation(s)
- Jeffrey S Chang
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA 94143-0520, USA.
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31
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Rudant J, Orsi L, Monnereau A, Patte C, Pacquement H, Landman-Parker J, Bergeron C, Robert A, Michel G, Lambilliotte A, Aladjidi N, Gandemer V, Lutz P, Margueritte G, Plantaz D, Méchinaud F, Hémon D, Clavel J. Childhood Hodgkin's lymphoma, non-Hodgkin's lymphoma and factors related to the immune system: the Escale Study (SFCE). Int J Cancer 2011; 129:2236-47. [PMID: 21170962 DOI: 10.1002/ijc.25862] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2010] [Accepted: 11/17/2010] [Indexed: 11/07/2022]
Abstract
The study investigated the role of factors considered related to the early stimulation of the immune system in the aetiology of childhood lymphoma. The national registry-based case-control study, Escale, was carried out in France over the period 2003-2004. Population controls were frequency matched with the cases on age and gender. Data were obtained from structured telephone questionnaires administered to mothers. Odds ratios (ORs) were estimated using unconditional regression models adjusted for potential confounders. Data from 128 cases of Hodgkin's lymphoma (HL) aged 5-14 years, 164 cases of non-Hodgkin's lymphoma (NHL) aged 2-14 years and 1,312 controls were analyzed. Negative associations were observed between HL and day care attendance [OR = 0.5 (0.2-1.2)] and between HL and repeated early common infections among non-breastfed children [OR = 0.3 (.2-0.7), p = 0.003] [OR for breastfed children: 1.0 (.5-2.1)], but not for the other factors investigated. Negative associations were observed between NHL and birth order 3 or more [OR = 0.7 (0.4-1.1)], prolonged breastfeeding [OR = 0.5 (0.3-1.0)], regular contact with farm animals [OR = 0.5 (0.3-1.0)], frequent farm visits in early life [OR = 0.6 (0.4-1.1)] and history of asthma [OR = 0.6 (0.3-1.1)]. In conclusion, the results partly support the hypothesis that an abnormal maturation of the immune system may play a role in childhood HL or NHL, and call for further investigations.
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Affiliation(s)
- Jérémie Rudant
- Inserm UMRS1018, CESP, Université Paris Sud, Villejuif, France
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32
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Urayama KY, Ma X, Selvin S, Metayer C, Chokkalingam AP, Wiemels JL, Does M, Chang J, Wong A, Trachtenberg E, Buffler PA. Early life exposure to infections and risk of childhood acute lymphoblastic leukemia. Int J Cancer 2010; 128:1632-43. [PMID: 21280034 DOI: 10.1002/ijc.25752] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2010] [Accepted: 10/12/2010] [Indexed: 11/06/2022]
Abstract
Evidence from a growing number of studies indicates that exposure to common infections early in life may be protective against childhood acute lymphoblastic leukemia (ALL). We examined the relationship between three measures of early life exposure to infections-daycare attendance, birth order and common childhood infections in infancy-with the risk of ALL in non-Hispanic white and Hispanic children, two ethnicities that show sociodemographic differences. The analysis included 669 ALL cases (284 non-Hispanic whites and 385 Hispanics) and 977 controls (458 non-Hispanic whites and 519 Hispanics) ages 1-14 years enrolled in the Northern California Childhood Leukemia Study (NCCLS). When the three measures were evaluated separately, daycare attendance by the age of 6 months (odds ratio [OR] for each thousand child-hours of exposure = 0.90, 95% confidence interval [CI]: 0.82-1.00) and birth order (OR for having an older sibling = 0.68, 95% CI: 0.50-0.92) were associated with a reduced risk of ALL among non-Hispanic white children but not Hispanic children, whereas ear infection before age 6 months was protective in both ethnic groups. When the three measures were assessed simultaneously, the influence of daycare attendance (OR = 0.83, 95% CI: 0.73-0.94) and having an older sibling (OR = 0.59, 95% CI: 0.43-0.83) became stronger for non-Hispanic white children. In Hispanic children, a strong reduction in risk associated with ear infections persisted (OR = 0.45, 95% CI: 0.25-0.79). Evidence of a protective role for infection-related exposures early in life is supported by findings in both the non-Hispanic white and Hispanic populations within the NCCLS.
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Affiliation(s)
- Kevin Y Urayama
- School of Public Health, University of California, Berkeley, CA, USA.
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33
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Rudant J, Orsi L, Menegaux F, Petit A, Baruchel A, Bertrand Y, Lambilliotte A, Robert A, Michel G, Margueritte G, Tandonnet J, Mechinaud F, Bordigoni P, Hémon D, Clavel J. Childhood acute leukemia, early common infections, and allergy: The ESCALE Study. Am J Epidemiol 2010; 172:1015-27. [PMID: 20807738 DOI: 10.1093/aje/kwq233] [Citation(s) in RCA: 91] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
This study investigated the role of factors considered related to early stimulation of the immune system in the etiology of childhood acute leukemia. The national registry-based case-control study ESCALE was carried out in France in 2003-2004. Population controls were frequency matched to cases on age and gender. Data were obtained from structured telephone questionnaires administered to mothers. Odds ratios were estimated using unconditional regression models adjusted for potential confounders. Included were 634 acute lymphoblastic leukemia cases, 86 acute myeloblastic leukemia cases, and 1,494 controls aged ≥1 year. Negative associations were observed between acute lymphoblastic leukemia and birth order (P for trend < 0.0001), attendance at a day-care center before age 1 year (odds ratio (OR) = 0.8, 95% confidence interval (CI): 0.6, 1.1), prolonged breastfeeding (OR = 0.7, 95% CI: 0.5, 1.0), repeated early common infections (OR = 0.7, 95% CI: 0.6, 0.9), regular contact with farm animals (OR = 0.6, 95% CI: 0.5, 0.8), frequent farm visits in early life (OR = 0.4, 95% CI: 0.3, 0.6), and history of asthma (OR = 0.7, 95% CI: 0.4, 1.0) or eczema (OR = 0.7, 95% CI: 0.6, 0.9). Results support the hypothesis that repeated early infections and asthma may play a role against childhood acute leukemia.
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Affiliation(s)
- Jérémie Rudant
- CESP Centre for Research in Epidemiology and Population Health, INSERM, Villejuif, France
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Early life patterns of common infection: a latent class analysis. Eur J Epidemiol 2010; 25:875-83. [PMID: 20976529 PMCID: PMC3898516 DOI: 10.1007/s10654-010-9518-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2010] [Accepted: 10/12/2010] [Indexed: 01/07/2023]
Abstract
Early life infection has been implicated in the aetiology of many chronic diseases, most often through proxy measures. Data on ten infectious symptoms were collected by parental questionnaire when children were 6 months old as part of the Avon Longitudinal Study of Parents and Children, United Kingdom. A latent class analysis was used to identify patterns of infection and their relationship to five factors commonly used as proxies: sex, other children in the home, maternal smoking, breastfeeding and maternal education. A total of 10,032 singleton children were included in the analysis. Five classes were identified with differing infectious disease patterns and children were assigned to the class for which they had a highest probability of membership based on their infectious symptom profile: ‘general infection’ (n = 1,252, 12.5%), ‘gastrointestinal’ (n = 1,902, 19.0%), ‘mild respiratory’ (n = 3,560, 35.5%), ‘colds/ear ache’ (n = 462, 4.6%) and ‘healthy’ (n = 2,856, 28.5%). Females had a reduced risk of being in all infectious classes, other children in the home were associated with an increased risk of being in the ‘general infection’, ‘mild respiratory’ or ‘colds/ear ache’ class. Breastfeeding reduced the risk of being in the ‘general infection’ and ‘gastrointestinal’ classes whereas maternal smoking increased the risk of membership. Higher maternal education was associated with an increased risk of being in the ‘mild respiratory’ group. Other children in the home had the greatest association with infectious class membership. Latent class analysis provided a flexible method of investigating the relationship between multiple symptoms and demographic and lifestyle factors.
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35
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Crouch S, Simpson J, Ansell P, Kane E, Howell D, Smith A, Newton R, Jack A, Roman E. Illness patterns prior to diagnosis of lymphoma: analysis of UK medical records. Cancer Epidemiol 2010; 35:145-50. [PMID: 20832384 DOI: 10.1016/j.canep.2010.08.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2010] [Revised: 07/20/2010] [Accepted: 08/06/2010] [Indexed: 12/20/2022]
Abstract
BACKGROUND Increased understanding of the relationship between lymphomas and co-morbidities is likely to provide valuable insights into the natural history of these disorders. METHODS 761 cases with lymphoma (310 diffuse large B-cell [DLBCL]; 226 follicular [FL]; and 225 Hodgkin [HL]) and 761 unaffected age and sex matched controls were recruited and their histories of infection and non-infection diagnoses in primary care records were compared using negative binomial regression. RESULTS No differences were observed between the infectious illness patterns of DLBCL and FL cases and their matched controls over the 15 years preceding lymphoma diagnosis. A marked excess of infectious illness episodes was recorded for HL cases compared to their controls; evident at least a decade prior to HL diagnosis. For non-infectious consultations an excess of case over control visits emerged 4-6 years before DLBCL and FL diagnosis; no specific co-morbidity associations were found. No case-control differences for non-infectious conditions were apparent for HL. CONCLUSION There are substantial variations in patterns of illness prior to diagnosis of the three lymphoma subtypes examined. The excess of infectious diagnoses prior to HL may point to underlying immune abnormality, but there was no suggestion of this for DLBCL and FL where a generalized excess of non-infectious conditions was evident.
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Affiliation(s)
- Simon Crouch
- Epidemiology and Genetics Unit, Department of Health Sciences, University of York, Heslington, York, UK.
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Urayama KY, Buffler PA, Gallagher ER, Ayoob JM, Ma X. A meta-analysis of the association between day-care attendance and childhood acute lymphoblastic leukaemia. Int J Epidemiol 2010; 39:718-32. [PMID: 20110276 PMCID: PMC2878455 DOI: 10.1093/ije/dyp378] [Citation(s) in RCA: 103] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background Childhood acute lymphoblastic leukaemia (ALL) may be the result of a rare response to common infection(s) acquired by personal contact with infected individuals. A meta-analysis was conducted to examine the relationship between day-care attendance and risk of childhood ALL, specifically to address whether early-life exposure to infection is protective against ALL. Methods Searches of the PubMed database and bibliographies of publications on childhood leukaemia and infections were conducted. Observational studies of any size or location and published in English resulted in the inclusion of 14 case–control studies. Results The combined odds ratio (OR) based on the random effects model indicated that day-care attendance is associated with a reduced risk of ALL [OR = 0.76, 95% confidence interval (CI): 0.67, 0.87]. In subgroup analyses evaluating the influence of timing of exposure, a similarly reduced effect was observed for both day-care attendance occurring early in life (≤2 years of age) (OR = 0.79, 95% CI: 0.65, 0.95) and day-care attendance with unspecified timing (anytime prior to diagnosis) (OR = 0.81, 95% CI: 0.70, 0.94). Similar findings were observed with seven studies in which common ALL were analysed separately. The reduced risk estimates persisted in sensitivity analyses that examined the sources of study heterogeneity. Conclusions This analysis provides strong support for an association between exposure to common infections in early childhood and a reduced risk of ALL. Implications of a ‘hygiene’-related aetiology suggest that some form of prophylactic intervention in infancy may be possible.
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Affiliation(s)
- Kevin Y Urayama
- School of Public Health, University of California, Berkeley, CA 94720, USA.
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Infectious proxies and childhood leukaemia: Findings from the United Kingdom Childhood Cancer Study (UKCCS). Blood Cells Mol Dis 2009; 42:126-8. [DOI: 10.1016/j.bcmd.2008.10.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2008] [Accepted: 10/18/2008] [Indexed: 11/20/2022]
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Law GR. Host, family and community proxies for infections potentially associated with leukaemia. RADIATION PROTECTION DOSIMETRY 2008; 132:267-272. [PMID: 18945723 DOI: 10.1093/rpd/ncn263] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Three hypotheses have proposed the involvement of infections in the aetiology of childhood leukaemia, suggesting either a specific leukaemogenic infection or a series of common infections that lead to a dysregulation of the immune system. Much of the evidence for the link with infections has been based on epidemiological observations, often using proxy measures of infection. Proxy measures include population mixing, parental occupation, age distribution of incidence, spatial and space-time clustering of cases, birth order and day care during infancy. This paper discusses the proxies used and examines to what extent a commonly used proxy measure, birth order, is a fair representation of either specific infections or general infectious load. It is clear that although leukaemia, and other diseases, may be linked with infections, one needs to (1) measure specific and general infections with more accuracy and (2) understand how proxy measures relate to real infections in the population.
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Affiliation(s)
- Graham Richard Law
- Biostatistics Unit, Centre for Epidemiology and Biostatistics, Room 8.01, Worsley Building, University of Leeds, Leeds LS2 9LN, UK.
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Infections in early life and childhood leukaemia risk: a UK case-control study of general practitioner records. Br J Cancer 2008; 99:1529-33. [PMID: 18827817 PMCID: PMC2579698 DOI: 10.1038/sj.bjc.6604696] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
We investigated infections in early life (diagnosed in general practice) and subsequent risk of childhood leukaemia in the UK General Practice Research Database (GPRD). All children born at GPRD practices and subsequently diagnosed with leukaemia were identified as cases and were individually matched (on year of birth, sex and practice) to up to 20 controls. The final analysis included 162 leukaemia cases and 2215 matched controls. Conditional logistic regression demonstrated no evidence that children with one or more recorded infection in the first year of life had a reduced risk of leukaemia (OR=1.05, 95%CI 0.69, 1.59; P=0.83) or acute lymphoblastic leukaemia (ALL; OR=1.05, 95%CI 0.64–1.74; P=0.84). Our study provides no support for the Greaves hypothesis, which proposes that reduced or delayed exposure to infections in early life increases the risk of childhood ALL.
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Current Awareness in Hematological Oncology. Hematol Oncol 2008. [DOI: 10.1002/hon.832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Newton R, Crouch S, Ansell P, Simpson J, Willett EV, Smith A, Burton C, Jack A, Roman E. Hodgkin's lymphoma and infection: findings from a UK case-control study. Br J Cancer 2007; 97:1310-4. [PMID: 17895891 PMCID: PMC2360469 DOI: 10.1038/sj.bjc.6603999] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2007] [Revised: 08/22/2007] [Accepted: 08/29/2007] [Indexed: 11/17/2022] Open
Abstract
Between 1998 and 2003, 214 people with Hodgkin's lymphoma and 214 controls randomly selected from population registers in the north of England (after matching for age and sex) were recruited and their primary care medical records examined for details of clinical diagnoses due to infectious and non-infectious conditions in the preceding 15 years. In the year before diagnosis of Hodgkin's lymphoma, almost all cases (99%) visited their general practitioner (GP) at least once. In comparison with controls, the excess was evident both for visits with an infection (odd's ratio (OR)=2.1; 95% confidence interval (CI) 1.4-3.2) and for visits with non-infectious problems (OR=17.2; 95% CI 6.7-43.9). During the rest of the 15-year period prior to diagnosis, the proportion of people visiting their GP with a non-infectious condition did not differ between cases and controls. In contrast, compared to controls, there was an excess of cases visiting the GP with an infection, a finding that was evident for at least a decade prior to diagnosis and increased linearly with time (P=0.02). This excess was not due to a specific infection(s) and may reflect underlying immune abnormality. Alternatively, infection may cause B-cell proliferation from which a malignant clone may evolve.
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Affiliation(s)
- R Newton
- Department of Health Sciences, Epidemiology and Genetics Unit, University of York, Area 3 Seebohm Rowntree Building, Heslington, York YO10 5DD, UK.
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