'Smoke like a man, die like a man'?: a review of the relationship between gender, sex and lung cancer

25 year trends in cancer incidence and mortality among adults aged 35-69 years in the UK, 1993-2018: retrospective secondary analysis

OBJECTIVE

To examine and interpret trends in UK cancer incidence and mortality for all cancers combined and for the most common cancer sites in adults aged 35-69 years.

DESIGN

Retrospective secondary data analysis.

DATA SOURCES

Cancer registration data, cancer mortality and national population data from the Office for National Statistics, Public Health Wales, Public Health Scotland, Northern Ireland Cancer Registry, NHS England, and the General Register Office for Northern Ireland.

SETTING

23 cancer sites were included in the analysis in the UK.

PARTICIPANTS

Men and women aged 35-69 years diagnosed with or who died from cancer between 1993 to 2018.

MAIN OUTCOME MEASURES

Change in cancer incidence and mortality age standardised rates over time.

RESULTS

The number of cancer cases in this age range rose by 57% for men (from 55 014 cases registered in 1993 to 86 297 in 2018) and by 48% for women (60 187 to 88 970) with age standardised rates showing average annual increases of 0.8% in both sexes. The increase in incidence was predominantly driven by increases in prostate (male) and breast (female) cancers. Without these two sites, all cancer trends in age standardised incidence rates were relatively stable. Trends for a small number of less common cancers showed concerning increases in incidence rates, for example, in melanoma skin, liver, oral, and kidney cancers. The number of cancer deaths decreased over the 25 year period, by 20% in men (from 32 878 to 26 322) and 17% in women (28 516 to 23 719); age standardised mortality rates reduced for all cancers combined by 37% in men (-2.0% per year) and 33% in women (-1.6% per year). The largest decreases in mortality were noted for stomach, mesothelioma, and bladder cancers in men and stomach and cervical cancers and non-Hodgkin lymphoma in women. Most incidence and mortality changes were statistically significant even when the size of change was relatively small.

CONCLUSIONS

Cancer mortality had a substantial reduction during the past 25 years in both men and women aged 35-69 years. This decline is likely a reflection of the successes in cancer prevention (eg, smoking prevention policies and cessation programmes), earlier detection (eg, screening programmes) and improved diagnostic tests, and more effective treatment. By contrast, increased prevalence of non-smoking risk factors are the likely cause of the observed increased incidence for a small number of specific cancers. This analysis also provides a benchmark for the following decade, which will include the impact of covid-19 on cancer incidence and outcomes.

Trends in Health Behavior of Polish Women in 1986-2021: The Importance of Socioeconomic Status

In the last 35 years Poland has undergone a series of fundamental economic, social, and biological transformations. With the transition from a centrally planned to a free-market economy, a period of economic and social transformation, Poland's accession to the European Union, and the COVID-19 coronavirus pandemic, living conditions in the country have seen dramatic changes. The aim of this study was to assess whether there were changes in the basic health behaviors of Polish women, and if so, in what directions and with what strength, and whether there were differences in these changes depending on the socioeconomic status. Information on basic lifestyle factors (drinking alcohol, smoking, coffee drinking, and physical activity) and socioeconomic status (level of education, Gini coefficient, Gender Inequality Index, women total employment, employed women being in managerial positions, women among scientists) of 5806 women aged 40-50 years were analyzed. During the 1986-2021 period, based on the same methodology, team of technicians and research tools, six birth cohorts of women were examined in 1986, 1991, 1996, 2006, 2019 and 2021. Highly statistically significant changes were found in the frequencies of declared health behaviors from 1986-2021, according to the order of significance in coffee and alcohol consumption, physical activity levels, and smoking and smoking intensity. In subsequent cohorts, there were fewer and fewer women who did not drink coffee and alcohol, while more drank more than two cups of coffee a day and drank alcohol more often than 2× a week. Furthermore, they were more likely to be physically active, and slightly fewer were smokers. The lifestyles of the women were less likely to depend on their socio-economic status than the cohorts. In 1991 and 1996, there was a marked intensification of unhealthy behavior. Changes in the analyzed health behaviors may have been caused by adaptation to the high level of psychosocial stress observed during the transition of the 1986-2021 period and may result in changes in the biological condition and quality and length of life of Polish women. Research on social differences in health behavior provides an opportunity to analyze the biological effects of changes in the living environment.

Sociodemographic Survival Disparities for Lung Cancer in the United States, 2000-2016

BACKGROUND

Understanding the impact of patient and tumor characteristics on lung cancer survival can help build personalized prognostic models and identify health disparities.

METHODS

We identified 557 555 patients aged 25 years and older diagnosed with lung or bronchus carcinoma from the Surveillance, Epidemiology, and End Results database, 2000-2016. We estimated hazard ratios (HR) for demographic (sex, age, race and ethnicity), tumor (stage, histology, year of diagnosis), and geographic characteristics (census tract-level urbanicity, socioeconomic status [SES]), as well as selected interactions, on the rate of lung cancer-specific death using multivariable proportional hazards models.

RESULTS

Women had a higher survival (lower hazard) of lung cancer-specific death than men (HR = 0.83, 95% confidence interval [CI] = 0.82 to 0.83). Hazards differed by race and ethnicity. Regional (HR = 2.41, 95% CI = 2.37 to 2.44) and distant (HR = 6.61, 95% CI = 6.53 to 6.69) tumors were associated with a lower survival (higher hazard) than localized tumors. Small cell tumors were associated with a lower survival (HR = 1.19, 95% CI = 1.18 to 1.20) than non-small cell tumors. Patients diagnosed after 2009 had lower hazards (HR = 0.86, 95% CI = 085 to 0.86) than those diagnosed 2000-2009. Lung cancer-specific survival did not depend on urbanicity after adjusting for census tract-level SES, but survival decreased with decreasing census tract-level SES. Differences in survival between non-Hispanic Black and White patients were greater for younger patients and localized tumors and increased with census tract-level SES. Differences by sex were greatest for young patients and localized tumors.

CONCLUSIONS

Disparities in survival after lung cancer diagnosis remain, with intersectional patterns suggesting differential access to and quality of care. Efforts are needed to ensure that high-risk groups receive guideline-concordant treatment.

Gender and tobacco epidemic in South Korea: implications from age-period-cohort analysis and the DPSEEA framework

OBJECTIVES

To understand a 20-year trend of gender-specific smoking prevalence among adults in South Korea.

DESIGN

Age-period-cohort analysis using the intrinsic estimator method was applied to examine the separate contribution of age, period and cohort effect on smoking prevalence. The Driving Force-Pressure-State-Exposure-Effect-Action (DPSEEA) framework was used to explain the observed smoking trends by mapping potential determinants and to address policy implications.

SETTING

General adult population in South Korea.

PARTICIPANTS

34 828 men and 43 632 women who aged 19-78 years, were not currently pregnant and were without a prior diagnosis of cardiovascular disease or cancer.

OUTCOME MEASURES

Gender-specific current smoking prevalence using the 1998-2017 Korea National Health and Nutrition Examination Survey.

RESULTS

Our results showed gender-specific age and birth cohort effects. More specifically, the smoking prevalence peaked at their mid-20s (prevalence rate ratio (PRR): 1.54, 95% CI: 1.49 to 1.59) and cohort born in 1959-1963 (PRR: 1.63, 95% CI: 1.57 to 1.70) and then decreased in men. On the other hand, in women, the smoking prevalence consistently increased until their mid-40s (PRR: 1.53, 95% CI: 1.27 to 1.84) and in recent birth cohort groups (PRR in 1994-1998 cohort: 1.55, 95% CI: 1.13 to 2.13). The period effects declined from 1998-2002 to 2003-2007, following increasing fluctuations in both genders. The smoking-DPSEEA framework showed the absence of policy actions to target female smokers and emphasised a proactive approach that tackles the upstream causes for smoking in women.

CONCLUSIONS

Men and women are clearly in different phases of the smoking epidemic in Korean population, and gender-tailored policies should be implemented.

Sex differences in lung cancer treatment and outcomes at a large hybrid academic-community practice

Introduction

Methods

Results

Conclusions

Lung Cancer in Women

BACKGROUND

Lung cancer is the leading cause of cancer-related death for women in the United States. Clinical characteristics, histology, epidemiology, and treatment responses are unique for women with lung cancer.

METHODS

Literature search of MEDLINE publications from 1989 to 2021 was conducted for lung cancer in women. Subsequent narrative review focused on identified differences in risk factors, diagnosis, and treatment of importance to the surgical care of these patients.

RESULTS

Studies investigating lung cancer, in which sex-differences are explored, demonstrated differences in risk factors, histology, and treatment response among women, with a significant post-surgical survival advantage over men (41.8 months vs 26.8 months, p=0.007) and greater clinical benefit from anti-PD1 combined with chemotherapy (HR=0.44, 95% CI: 0.25-0.76) compared with men (HR=0.76, 95% CI: 0.64-0.91). Smoking remains a dominant risk factor and multiple clinical trials suggest lung cancer screening provides greater benefit for women. However, young non-smoking patients with lung cancer are 2-fold more likely to be female, advocating for broader sex-based screening criteria. Potential roles of genetic mutations, estrogen signaling, and infectious elements in sex-based differences in presentation, histology, prognosis and treatment response are explored.

CONCLUSIONS

Overall, much remains unknown regarding how sex influences lung cancer risk, treatment decisions and outcomes. However, evidence of specific differences in presentation, environmental risk, molecular drivers, and mutational burden support the need to better leverage these sex-associated differences to further improve detection, diagnosis, surgical outcomes and systemic regimens in order to advance the overall care strategy for women with lung cancer.

An application of machine learning based on real-world data: Mining features of fibrinogen in clinical stages of lung cancer between sexes

Background

Lung cancer is the most threatening malignant tumor to human health and life. Using a variety of machine learning algorithms and statistical analyses, this paper explores, discovers and demonstrates new indicators for the early diagnosis of lung cancer and their diagnostic performance from large samples of clinical data in the real world.

Methods

By applying machine learning methods, including minimum description length (MDL), naive Bayesian (NB), K-means (KM), nonnegative matrix factorization (NMF), and decision tree (DT), based on large sample data of 2,502 patients, we built a classification model and systematically explored differences in fibrinogen levels in different clinical stages of lung cancer between the sexes. We also validated the reliability of the model by testing it on a validation cohort of 447 patients. This report adheres to the “Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis” (TRIPOD) statement for the reporting of prediction models.

Results

The analysis revealed significant differences in fibrinogen levels, pleural effusion, chlorine levels, A-G ratio, glutamic-oxaloacetic transaminase and alkaline phosphatase levels as well as in sex composition between the early-stage lung cancer group and the middle-late-stage lung cancer group. The classification model created by the combination of fibrinogen, alkaline phosphatase and sex demonstrated good performance with an AUC of 73.5%. In addition, in males, a fibrinogen level of 2.94 g/L could initially serve as the upper limit for determining the early-stage lung cancer group, but a level of 3.91 g/L could be preliminarily used as a reference threshold for the lower limit for middle- to late-stage lung cancer. This latter level could also serve as the upper limit of the critical value for early-stage lung cancer in females.

Conclusions

An integrated application based on supervised and unsupervised machine learning algorithms could effectively explore the potential links contained in the clinical data and reveal the differences in fibrinogen levels in different clinical stages of lung cancer between the sexes, which could provide a new reference basis for lung cancer staging.

The impact of sex differences on genomic research

Sex and gender differences affect all dimensions of human health ranging from the biological basis of disease to therapeutic access, choice and response. Genomics research has long ignored the role of sex differences as potential modulators and the concept is gaining more attention only recently. In the present review we summarize the current knowledge of the impact of sex differences on genomic and epigenomic research, the potential interaction of genomics and gender and the role of these differences in disease etiopathogenesis. Sex differences can emerge from differences in the sex chromosomes themselves, from their interaction with the genome and from the influence of hormones on genomic processes. The impact of these processes on the incidence of autoimmune and oncologic disease is well documented. The growing field of systems biology, which aims at integrating information from different networks of the human body, could also greatly benefit from this approach. In the present review we summarize the current knowledge and provide recommendations for the future performance of sex-sensitive genomics research.

The determinants of lung cancer after detecting a solitary pulmonary nodule are different in men and women, for both chest radiograph and CT

Objectives

To determine the factors associated with lung cancer diagnosis and mortality after detecting a solitary pulmonary nodule (SPN) in routine clinical practice, in men and in women for both chest radiograph and CT.

Materials and methods

A 5-year follow-up of a retrospective cohort of of 25,422 (12,594 men, 12,827 women) patients aged ≥35 years referred for chest radiograph or CT in two hospitals in Spain (2010–2011). SPN were detected in 893 (546 men, 347 women) patients. We estimated the cumulative incidence of lung cancer at 5-years, the association of patient and nodule characteristics with SPN malignancy using Poisson logistic regression, stratifying by sex and type of imaging test. We calculated lung cancer specific mortality rate by sex and SPN detection and hazard rates by cox regression.

Results

133 (14.9%) out of 893 patients with an SPN and 505 (2.06%) of the 24,529 patients without SPN were diagnosed with lung cancer. Median diameter of SPN in women who developed cancer was larger than in men. Men who had a chest radiograph were more likely to develop a lung cancer if the nodule was in the upper-lobes, which was not the case for women. In patients with an SPN, smoking increased the risk of lung cancer among men (chest radiograph: RR = 11.3, 95%CI 1.5–83.3; CT: RR = 7.5, 95%CI 2.2, 26.0) but smoking was not significantly associated with lung cancer diagnosis or mortality among women with an SPN. The relative risk of lung cancer diagnosis in women with SPN versus those without was much higher compared to men (13.7; 95%CI 9.2, 20.4 versus 6.2; 95%CI 4.9,7.9).

Conclusion

The factors associated with SPN malignancy and 5-year lung cancer mortality were different among men and women, especially regarding smoking history and SPN characteristics, where we observed a relatively high rate of lung cancer diagnosis among female non-smokers.

The smoking epidemic across generations, genders, and educational groups: A matter of diffusion of innovations

This study determines whether the temporal variations in smoking habits across generations and genders and among groups with differing levels of education fit the pattern proposed by the theory of the diffusion of innovations (TDI) (Rogers, 2003). We focus on the Italian case and employ a pseudo-panel derived from repeated cross-sections of the annual household survey, "Aspects of Daily Life," that was part of the Multipurpose Survey carried out by the Italian National Statistical Office (ISTAT) for the period 1997 to 2012. The results confirm Rogers' TDI and show that smoking prevalence has declined over time and across age cohorts: Younger men of all educational levels and women with higher education are less likely to smoke than are those in other cohorts, while less-educated women who entered the smoking-diffusion process later than others are more likely to smoke. Hence, socio-economic differences in smoking continue to persist, especially for women. According to Rogers' TDI, smoking prevalence is expected to continue to decline, particularly among little-educated women.

Dysregulation of lipid metabolism induced by airway exposure to polycyclic aromatic hydrocarbons in C57BL/6 mice

Polycyclic aromatic hydrocarbons (PAHs), originated from cigarette smoke and fine particle matter (PM2.5), are important inducers of lung cancer. Lipid metabolic disorder is an important biological feature in the progression of lung cancer. However, the dysregulation of lipid metabolism induced by airway exposure to PAHs remains unknown. In this study, an untargeted lipidomics approach was performed to characterize the effects of airway exposure to benzo[a]pyrene (BaP) on lipid metabolism of C57BL/6 mice. Lipidome of serum samples were analyzed with an ultra-performance liquid chromatography coupled with quadrupole-orbitrap mass spectrometer. Lipid profiling and multivariate statistical analysis results demonstrated that airway exposure to BaP mainly disturbed glycerophospholipid metabolism of mice. Moreover, sex-dependent and time-dependent effects of BaP exposure on lipids profile of mice were observed. Several phosphatidylcholines (PCs), Lysophosphatidylcholines (LysoPCs), phosphatidylethanolamines (PEs), Lysophosphatidylethanolamines (LysoPEs) and phosphatidylinositols (PIs) were significantly down-regulated in mice serum after BaP exposure. Meanwhile, these altered lipids showed different susceptibility and change trends in male and female mice. Our results are corresponding with the lipid metabolic alterations induced by cigarette smoke and PM2.5 in animals or human. Compared with the dysregulation of lipid metabolism in patients with lung cancer, these results indicated that the lipid metabolism response to PAHs airway exposure may contribute to the lung cancer progression.

Method and design of drug treatment research of subjective premature ejaculation in men differs from that of lifelong premature ejaculation in males: proposal for a new objective measure (part 1)

As lifelong premature ejaculation (PE) and subjective PE are two different PE subtypes, the measurement of their characteristic features requires different objective measures. In this article, we address the differences between lifelong PE and subjective PE, in terms of the extent of variation of sexual performance and propose a new objective measure for research of subjective PE. By considering lifelong PE as a mainly "male" sex disorder and subjective PE as a mainly "man" sex disorder, we show that stopwatch-mediated intravaginal ejaculation latency time (IELT) measurement is most adequate for research of lifelong PE, but inadequate for research of subjective PE. Subjective PE needs another objective measure to capture its key characteristics. Arguments are provided to show that the characteristics of subjective PE are different from the key features of lifelong PE. The core issue in lifelong PE is the very short IELT with a very small variation in sexual performance. Subjective PE is characterized by a higher variation of sexual performance. Stopwatch-mediated IELT measurement is essential in case of small variation of sexual performance. In contrast, measurement of various parameters of penile intravaginal thrusting is suggested to be more appropriate in case of high variation of sexual performance observed in subjective PE. In conclusion, research of lifelong PE should be performed by stopwatch measurement of the IELT whereas research of subjective PE should be performed by movement tracker devices, designed to be bound to the males body and/or inserted into the women's vagina with robust software to measure intravaginal thrusting variation performance. Future studies are warranted to provide scientific data to support this hypothesis.

[Barriers and facilitators for the development of sex/gender sensitive clinical practice guidelines: A qualitative interview study]

INTRODUCTION

Sex and gender health research evaluates biological and psychosocial differences between women and men which can influence the development, progress and experience of diseases. However, despite the increasing body of evidence about relevant differences between women and men regarding healthcare, the prevention, management and treatment of many common diseases do not yet reflect the knowledge of sex/gender characteristics. Furthermore, in the development of clinical practice guidelines, which are a valuable tool for knowledge transfer between scientific evidence and healthcare, sex/gender factors are only rarely explicitly and systematically considered. The goal of the current study therefore is to identify barriers and facilitators for the consideration and integration of sex/gender differences into guidelines, to create a basis for potential solutions and tools to increase the development of sex/gender sensitive guidelines in the future.

METHODS

Barriers and facilitators for the development of sex/gender sensitive guidelines were identified by conducting semi-structured interviews with twelve experts in national and international guideline development (guideline authors and coordinators), as well as gender experts (female: n=8). The selection of experts followed a purposeful sampling strategy and the interview data was analyzed using the qualitative content analysis according to Mayring.

RESULTS

The views on barriers and facilitators were allocated to and summarized in five categories with ten subcategories. The identified barriers mainly addressed the increasing complexity of guidelines, the lack of availability and quality of sex/gender sensitive evidence, and the shortage of resources. In addition, barriers were identified in an individual/professional context, such as deficiencies in awareness/knowledge about relevant sex/gender differences. The results of facilitating factors showed that experts see political policies and standards from guideline organizations as support for the consideration of sex/gender factors in guideline development.

CONCLUSION

The perspective of experts illustrates that besides organizational and political inventions, individual and social factors should also be addressed in order to achieve behavioral change.

Survival based radiographic-grouping for esophageal squamous cell carcinoma may impact clinical T stage

Most patients diagnosed with thoracic esophageal squamous cell carcinoma (ESCC) have progressed beyond surgical resection as a therapeutic option. Difficulties in the proper assessment of tumor invasion depth before treatment complicate determination of the type and extent of therapy. Therefore, accurate tumor clinical staging is a necessity for identifying treatment options and aiding in patient prognosis. We investigated radiographic factors as prognostic indicators for survival in ESCC. Between July 2006 - July 2010, 324 thoracic ESCC patients who underwent surgery were selected. All patients received contrast enhanced preoperative chest CT scans and esophageal barium swallow examinations. Measurement of maximal lesion cross-sectional area, the largest long diameter, largest short diameter, CT-indicated lesion length, barium-indicated lesion length and the length of pericardial fat reduction were performed. Relationships between these indicators and post-surgical survival time and the cutoff values of related factors were analyzed. Maximum long diameter, maximum lesion area and lesion length, as measured by CT imaging, were correlated with survival. Survival effects were clearly associated with group intervals, calculated by a genetic algorithm, and tumor stages. Risk-stratification intervals of esophageal lesions from radiographic imaging included: maximum long diameter < 28.7, 28.7-34.6mm, 34.6-41.4mm and >41.4mm; maximum lesion area < 355.8mm², 355.8-568.0mm², 568.0-907.3mm² and >907.3mm²; and CT-indicated lesion length <30.9mm, 30.9-57.3mm, 57.3-70.6mm and > 70.6mm. The reasonable stratification of maximum esophageal lesion area, largest long diameter and lesion length measured in CT is valuable for clinical T staging of ESCC. Radiographic parameters may have prognostic clinical value in the staging of esophageal carcinoma.

Sex and Gender: The Challenges for Epidemiologists

Gender issues are now receiving more attention on global and national health agendas. However, the evidence base for policy and practice in this area remains limited and conceptual confusion is still common. This article reviews the challenges facing epidemiologists and other researchers who aim to make their work more “gender sensitive.” It begins by exploring the concepts of biological “sex” and social “gender” and assesses their implications for the health of both women and men. It then reviews a range of strategies for mainstreaming sex and gender into health research. The article concludes with brief comments on the links between gender equity and wider equality concerns.

Diabetes mellitus as an independent risk factor for lung cancer: a meta-analysis of observational studies

BACKGROUND

Epidemiologic studies have demonstrated inconsistent associations between diabetes mellitus and the risk of lung cancer. To determine whether diabetes mellitus is associated with an increased risk of lung cancer, we performed a meta-analysis of observational studies.

METHODS

PubMed, EMBASE and the Cochrane Library were searched for observational studies conducted prior to September 2012. We included prospective cohort studies that reported relative risks and case-control studies that showed odds ratios in the analysis. The pooled relative risk (RR) with 95% confidence intervals (CIs) was calculated with a random effects model. Sensitivity analysis was performed with studies which controlled for smoking status. Associations were assessed in several subgroups representing different participant and study characteristics.

RESULTS

A total of 34 studies from 24 manuscripts (10 case-control studies and 24 cohort studies) were included in the analyses. Diabetes was significantly associated with the increased risk of lung cancer compared with non-diabetic controls when limiting the analysis to studies adjusting for smoking status (RR, 1.11; 95% CI, 1.02-1.20; I(2)=46.1%). By contrast, this association disappeared when the analysis was restricted to studies not adjusting for smoking status (RR, 0.99; 95% CI, 0.88-1.11; I(2)=96.7%). When stratifying by sex, an increased risk of lung cancer was prominent in diabetic women (RR, 1.14; 95% CI, 1.09-1.20; I(2)=0%), while there was no association in diabetic men (RR, 1.07; 95% CI, 0.89-1.28; I(2)=96.6%). Among diabetic women, significantly increased risks of lung cancer were found in the following subgroups: cohort studies (RR, 1.14; 95% CI, 1.08-1.20; I(2)=0%), studies controlling for major confounding variables such as age, smoking and alcohol (RR, 1.19; 95% CI, 1.00-1.43; I(2)=23.1%), studies with long-term follow-up (RR, 1.14; 95% CI, 1.08-1.20; I(2)=0%), and high-quality studies assessed by the Newcastle-Ottawa Scale (RR, 1.14; 95% CI, 1.08-1.20; I(2)=0%).

INTERPRETATION

Preexisting diabetes mellitus may increase the risk of lung cancer, especially among female diabetic patients. Further large-scale prospective studies are needed to test specifically the effect of diabetes mellitus on lung cancer risk.

Applying anthropology to eliminate tobacco-related health disparities

INTRODUCTION

Disparities in tobacco's harm persist. Declines in smoking among the general population have not been experienced to the same extent by vulnerable populations. Innovative strategies are required to diminish disparities in tobacco's harm. As novel tools, anthropological concepts and methods may be applied to improve the design and outcomes of tobacco cessation interventions.

METHODS

We reviewed over 60 articles published in peer-reviewed journals since 1995 for content on anthropology and smoking cessation. The specific questions framing the review were: (a) "How can lessons learned from anthropological studies of smoking improve the design and effectiveness of smoking cessation interventions?" (b) How can anthropology be applied to diminish disparities in smoking cessation? and (c) How can qualitative methods be used most effectively in smoking cessation intervention research?

RESULTS

Three specific disciplinary tools were identified and examined: (a) culture, (b) reflexivity, and (c) qualitative methods. Examining culture as a dynamic influence and understanding the utilities of smoking in a particular group is a precursor to promoting cessation. Reflexivity enables a deeper understanding of how smokers perceive quitting and smoking beyond addiction and individual health consequences. Qualitative methods may be used to elicit in-depth perspectives on quitting, insights to inform existing community-based strategies for making behavior changes, and detailed preferences for cessation treatment or programs.

CONCLUSIONS

Anthropological tools can be used to improve the effectiveness of intervention research studies targeting individuals from vulnerable groups. Synthesized applications of anthropological concepts can be used to facilitate translation of findings into clinical practice for providers addressing tobacco cessation in vulnerable populations.

The role of gender in a smoking cessation intervention: a cluster randomized clinical trial

BACKGROUND

The prevalence of smoking in Spain is high in both men and women. The aim of our study was to evaluate the role of gender in the effectiveness of a specific smoking cessation intervention conducted in Spain.

METHODS

This study was a secondary analysis of a cluster randomized clinical trial in which the randomization unit was the Basic Care Unit (family physician and nurse who care for the same group of patients). The intervention consisted of a six-month period of implementing the recommendations of a Clinical Practice Guideline. A total of 2,937 current smokers at 82 Primary Care Centers in 13 different regions of Spain were included (2003-2005). The success rate was measured by a six-month continued abstinence rate at the one-year follow-up. A logistic mixed-effects regression model, taking Basic Care Units as random-effect parameter, was performed in order to analyze gender as a predictor of smoking cessation.

RESULTS

At the one-year follow-up, the six-month continuous abstinence quit rate was 9.4% in men and 8.5% in women (p = 0.400). The logistic mixed-effects regression model showed that women did not have a higher odds of being an ex-smoker than men after the analysis was adjusted for confounders (OR adjusted = 0.9, 95% CI = 0.7-1.2).

CONCLUSIONS

Gender does not appear to be a predictor of smoking cessation at the one-year follow-up in individuals presenting at Primary Care Centers. CLINICALTRIALS.GOV IDENTIFIER: NCT00125905.

Evaluating the effects of genetic variants of DNA repair genes using cytogenetic mutagen sensitivity approaches

Mutagen sensitivity, measured in short-term cultures of peripheral blood lymphocytes by cytogenetic endpoints, is an indirect measure for DNA repair capacity and has been used for many years as a biomarker for intrinsic susceptibility for cancer. In this article, we briefly give an overview of the different cytogenetic mutagen sensitivity approaches that have been used successfully to evaluate the biological effects of polymorphisms in DNA repair genes based on a current review of the literature and based on the need for biomarkers that would allow the characterization of the biological and functional significance of such polymorphisms. We also address some of the future challenges facing this emerging area of research.

[Study KBP-2010-CPHG: inclusion of new cases of primary lung cancer diagnosed in general hospital pneumology departments between 1st January and 31 December 2010]

INTRODUCTION

The College of General Hospital Respiratory Physicians (CPHG) is following up the KBP-2000-CPHG study, performed ten years ago, with a new observational epidemiological study of primary lung cancer.

PATIENTS AND METHODS

The study includes all new cases of primary lung cancer diagnosed on histology or cytology between 1 January and 31 December 2010 and managed by one of the general hospital pneumology departments participating in the study. The primary objective is to estimate five-year mortality and to analyze risk factors. Secondary objectives are to describe the characteristics of this patient population and their management, and to estimate one, four and five-year survival rates. These data will be compared to those of the KBP-2000-CPHG study. The four-year prognosis score developed in 2000 will also be assessed in the new study. Data are collected by standardized questionnaire with exhaustiveness control.

EXPECTED RESULTS

One hundred and eight investigating centers have agreed to participate; 4000 to 5000 new cases of primary lung cancer should be collected and analyzed.

CONCLUSION

The study will describe the characteristics of patients presenting with primary lung cancer in the participating pneumology departments during the year 2010, and their diagnostic and therapeutic management, and assess changes over the last ten years.

Creating the "desired mindset": Philip Morris's efforts to improve its corporate image among women

Through analysis of tobacco company documents, we explored how and why Philip Morris sought to enhance its corporate image among American women. Philip Morris regarded women as an influential political group. To improve its image among women, while keeping tobacco off their organizational agendas, the company sponsored women's groups and programs. It also sought to appeal to women it defined as "active moms" by advertising its commitment to domestic violence victims. It was more successful in securing women's organizations as allies than active moms. Increasing tobacco's visibility as a global women's health issue may require addressing industry influence.

[Gender sensitive health promotion and prevention]

Numerous gender differences in health-related behaviour are relevant in the planning of health promotion and prevention. More men than women consume amounts of alcohol that are a risk to their health. Tobacco consumption has fallen slightly among men but has risen among women. Women eat more healthy food. Man behave risky in leisure time and traffic, thus their mortality rates due to accidents are much higher, especially in young age groups. The epidemiological data lead to the conclusion that gender sensitive health promotion and prevention is necessary. Gender mainstreaming is declared as the main strategy to enhance gender equity in health. The paper focuses on the public health action cycle and demonstrates that at each step gender mainstreaming improves the quality of intervention. To implement gender mainstreaming in health promotion and prevention, a process of sensitization has to be initialized. An instrument is presented that supports this process at the foundation "Health Promotion Switzerland". A short description of some examples of gender adequate interventions is given at the end of the paper.

[Gender in epidemiology. State of discussion and perspectives]

Against the background of sex-specific and sex-comparative approaches in health research, this article aims to clarify to what extent the category sex/gender with its biological dimensions (sex) and social dimensions (gender) has systematically and conceptually been consider ed in epidemiology and which methods have been developed. Epidemiologic research has been criticized for routinely controlling statistically for age and sex but often ignoring aspects of gender. Inadequate consideration of sex/gender may result in systematic errors (gender bias), on the one hand, if sex/gender is ignored as an important variable, and, on the other hand, if differences between men and women are assumed when there are actually similarities. There are examples of adequate consideration of gender in exposure assessment, analysis of social position or modelling of interactions in current articles of scientific journals. How ever, epidemiologic reference books and textbooks as well as university training in epidemiology show that the category sex/gender has not been integrated with both dimensions sex and gender into the currently predominating thought style of epidemiology. For the further development of valid epidemiologic research clarification of terms, generation of unambiguous concepts and sophisticated statistical tools are necessary. This is the only way to succeed in analysing the complex interactions between sex-linked biology and gender relations.

What makes a man a man? The lived experience of male breast cancer

Male breast cancer is a rare condition with scant research into its psychosocial impact. This phenomenologic study sought to elicit its lived experience. Following analysis of interview data, 4 key themes emerged: Living with male breast cancer, concealment as a strategy for managing the diagnosis, a contested masculinity, interacting with health services. Male breast cancer constitutes a unique lived experience for men that is unparalleled in other disease profiles. The idea of living with a feminized illness was very distressing and stigmatizing for some men. Furthermore, treatment resulted in a profound change to the concept of their embodied selves and constituted a significant change to body image and sexuality. This was reinforced in participants who experienced erectile dysfunction related to tamoxifen therapy. Sadly, some health professionals were unable to offer specific psychosocial support, and participants felt marginalized from the potential benefits of the treatment environment. However, participants adapted to the illness by reasserting and renegotiating masculinity and finding ways to accommodate life with a stigmatizing condition and an altered body image.

Influence of glutathione S-transferase polymorphisms on genotoxic effects induced by tobacco smoke

Genotoxicity of tobacco smoke has long been investigated and tobacco smoke is considered to be one of the principal human carcinogens. Although its role in DNA-damage induction and cancer development has been documented, the mechanisms by which this happens are not well understood. Many chemical constituents of tobacco smoke are enzymatically metabolized by phase-I and phase-II enzymes, but modifications in coding and regulating sequences of these genes could influence their ability to detoxify these compounds. In this work, we studied several enzymes involved in the metabolism of xenobiotics, viz. the glutathione S-transferases (GST) M1, T1, P1 and A1, with respect to their influence on the genotoxic effects induced by cigarette smoking. We assessed the genotoxic effects of tobacco smoke on peripheral blood lymphocytes of 72 healthy caucasians by use of the chromosomal aberration (CA) assay and the micronucleus (MN) test. Genotypes of GST M1, T1, P1 and A1 were determined by means of the polymerase chain reaction and methods based on restriction fragment length polymorphism (RFLP). We found that smoke and gender are the two variables that most influence the DNA damage. In particular, we observed that female smokers seem to be more sensitive than male smokers, having a significantly higher frequency of CAs. Moreover, a significant increase in frequency of micronuclei in bi-nucleated cells (BNMN) was found in smokers, but not in non-smokers. This increase seems to be influenced not only by age and gender, but also by genetic constitution. Subjects carrying GSTM1-null genotype seemed to have an higher susceptibility to DNA damage induced by tobacco smoke than GSTM1-positive ones. When considering a combination of GST genotypes, we found a lower BNMN frequency in subjects with GSTP1 variant allele plus GSTM1-positive genotypes, while the most damaged cells are found in subjects bearing GSTM1-null plus GSTP1-wild type. Our results suggest that investigation of the association between several gene polymorphisms and important endpoints of DNA damage could contribute to better understanding the role of gene-gene interaction.

'You think that I'm smoking and they're not': why mothers still smoke in the home

Past research into smoking and motherhood has explained how smoking enables mothers to care in conditions of hardship and poverty. However, much of this research was conducted before the risks to the health of non-smokers of inhaling tobacco smoke were widely known, and so mothers' attitudes towards passive smoking and caring remain under explored. Children living with smokers are at risk of developing serious acute and chronic conditions during childhood and later life. Despite increased awareness of health messages among parents, young children are still exposed to environmental tobacco smoke (ETS) in the home, with maternal smoking identified as the primary source of exposure. In this paper, we present the findings from a project set up to explore the changing social and environmental context of smoking and motherhood. Using focus groups, 54 mothers of children aged under five years from the Merseyside area of England, who smoked, discussed their beliefs about smoking, passive smoking and the health of their children. Although mothers were aware of the messages linking ETS exposure to childhood illnesses they appeared to rely more on their own explanations for any ill health experienced by their children, discounting smoking as a primary cause and preferring alternative explanations including 'genetics' and 'pollution'. These alternative explanations were common both within and between groups, suggesting that they form part of a wider resistant dialogue constructed within families and communities, where information about smoking and child health is received, challenged, and reconciled with existing knowledge, before being either accepted or rejected. Crucially, this alternative dialogue supports the mothers' continued smoking, and is inevitably linked to their personal need to smoke while caring. These findings have implications for the development of future strategies for promoting the health of children with mothers who are reluctant, or feel unable, to accept that smoking can affect the health of their children.

A genetic mouse model for metastatic lung cancer with gender differences in survival

Lung cancer is a devastating disease with poor prognosis. The design of better therapies for lung cancer patients would be greatly aided by good mouse models that closely resemble the human disease. Unfortunately, current models for lung adenocarcinoma are inadequate due to the absence of metastases. In this study, we incorporated both K-ras and p53 missense mutations into the mouse genome and established a more faithful genetic model for human lung adenocarcinoma, the most common type of lung cancer. Mice with both mutations developed advanced lung adenocarcinomas that were highly aggressive and metastasized to multiple intrathoracic and extrathoracic sites in a pattern similar to that of human lung cancer. These mice also showed a gender difference in cancer-related death. Additionally, the presence of both mutations induced pleural mesotheliomas in 23% of these mice. This mouse model recapitulates the metastatic nature of human lung cancer and will be invaluable to further probe the molecular basis of metastatic lung cancer and for translational studies.

Gender differences in genetic damage induced by the tobacco-specific nitrosamine NNK and the influence of the Thr241Met polymorphism in the XRCC3 gene

The rapid increase in adenocarcinoma of the lung and mortality amongst women strongly suggests that gender differences exist in sensitivity to certain tobacco carcinogens. In the current study, we performed the mutagen-sensitivity assay, with the tobacco-specific nitrosamine 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK), to test the hypothesis that women are more sensitive to the genotoxic effects of NNK than men. Chromosome aberration (CA) frequencies in peripheral blood lymphocytes (PBLs) from 99 patients were evaluated before and after in vitro exposure to NNK. Because the Thr241Met polymorphism in the DNA-repair gene XRCC3 is associated with increased risk of tobacco-related cancers, especially among women, we also tested the hypothesis that individuals who inherit the homozygous variant 241Met allele are more sensitive to the genotoxic effects of NNK. CA frequency was significantly higher 1 hr after NNK treatment in women, compared with men (P = 0.02). When smoking and gender were considered together, a significant interaction was observed. PBLs from female smokers had significantly higher frequencies of NNK-induced CA, compared with female nonsmokers 1 hr after treatment (P = 0.02). We observed no overall effect of the Thr241Met polymorphism on NNK-induced CA in men, women, smokers, or nonsmokers. Overall, our data indicate that women are more sensitive to the genotoxic effects of NNK than men. Because in past years smoking among women has increased, and in view of the close correlation between NNK exposure and adenocarcinoma of the lung, our data provide a plausible explanation for the recent increase in the incidence of this cancer among women.

Lung cancer mortality and serum levels of carotenoids, retinol, tocopherols, and folic acid in men and women: a case-control study nested in the JACC Study

BACKGROUND

Lung cancer mortality is inversely associated with high serum carotenoid levels and high intake of vegetables and fruits rich in carotenoids. The Japan Collaborative Cohort (JACC) Study was conducted to investigate whether serum levels of carotenoids, retinol, tocopherols, and folic acid were associated with risk for lung cancer death with follow-up through 1997. To examine the association by sex, we extended the follow-up and analyzed additional serum samples.

METHODS

In the JACC Study, 39,242 subjects provided serum samples at baseline between 1988 and 1990. We identified 211 cases (163 men and 48 women) of death from lung cancer during about 10-year follow-up ending in 1999. Of the subjects who survived to the end of that follow-up, 487 controls (375 men and 112 women) were selected, and were matched to each case of lung cancer death for sex, age and participating institution. We measured serum levels of antioxidants in cases of lung cancer death and controls. Odds ratio (OR) for lung cancer death was estimated using conditional logistic models by sex.

RESULTS

For men, the risk of lung cancer death was significantly lower for the highest quartile of serum alpha- and beta-carotenes, lycopene, and beta-cryptoxanthin than for the lowest quartile: the OR adjusted for smoking and other covariates were 0.41, 0.28, 0.46, and 0.39, respectively. For women, serum levels of alpha-carotene and zeaxanthin/lutein were inversely associated with risk of lung cancer, but the association was not significant. No association between lung cancer and serum levels of beta-carotene, beta-cryptoxanthin, and retinol was appeared among women. There was a suggestion that association between lung cancer and high serum levels of these components might differ between men and women.

CONCLUSIONS

Higher serum levels of carotenoids appear to play a role in preventing death from lung cancer among Japanese men. Relationships between lung cancer and serum levels of some carotenoids appear to differ between sexes. However, further study with a large number of women cases needs to clarify the discrepancy between sexes.

Lung cancer in women

Lung cancer is one of the most important avoidable causes of death around the world, it is the most widespread carcinoma with a very poor prognosis, and is the leading cause of cancer death in both developed and developing countries. At present more men than women die each year from lung cancer, but in recent years a rapid increase in lung cancer mortality has been observed among women in developed countries, contrasting with a levelling off or decrease among men. The rising trend in female lung cancer mortality has been observed to parallel with the past and current prevalence of cigarette smoking among women in the United States and elsewhere. An important role of other factors acting either as independent risk factors or interacting with the effect of smoking has been suggested by some studies among women, among them genetic, biologic and hormonal factors, and probably some factors related to the environment and lifestyle. There is a controversy concerning the claim that women have a different susceptibility to tobacco carcinogens, which might or might not be greater than men do. Since tobacco is far and away the strongest epidemiological risk factor for the development of lung cancer, comprehensive smoking control efforts are the priority in the prevention of lung cancer among women.

[Gender differences in premature mortality and avoidable deaths]

OBJECTIVE

This paper aims to describe and to analyse disparities between men and women for "premature" mortality rates (deaths before 65 year-old). The study is particularly focused on "avoidable" causes of death. These types of deaths are greatly related to risk behaviours such as alcohol abuse, tobacco abuse or dangerous driving. Taking account of these indicators ("premature" and "avoidable" mortality) enables to study health status discrepancies by gender and to characterize specific public health issues in France including high rates of "premature" mortality and risk behaviours.

METHODS

The analysis is based on exhaustive mortality data from 1980 to 1999 supplied by the Centre for epidemiology of medical causes of death (CepiDc-INSERM). Specific causes of death closely related to risk behaviours are classified as "avoidable": lung and upper airways cancers, cirrhosis, alcoholic psychosis, traffic accidents, aids and suicide. The contribution of these categories in the global male overmortality was assessed according to different demographic and geographic characteristics.

RESULTS

Within "premature" mortality, males experience greater burden of "avoidable" mortality (sex-ratio: 4 versus 2). The gender differences are mainly due to injuries and suicides in the younger age groups and to tobacco and alcohol-related cancers (lung and upper airways) in the 45-64 years age group. The recent decline in "premature" mortality sex-ratio is explained by an increase of these two cancers for females. Among european countries, the French male overmortality is especially marked and mainly attributable to "avoidable" causes of death.

CONCLUSION

"Avoidable" and "premature" mortality provide useful tools for the follow-up of health status in France particularly because of high risk behaviours and prevention inadequacy. Reducing gender discrepancies will depend mainly on public health policies in terms of primary prevention.

Duration of smoking abstinence as a predictor for non-small-cell lung cancer survival in women

BACKGROUND

Previous studies have attempted to investigate the impact of smoking cessation on lung cancer survival but have been limited by small numbers of former smokers and incomplete data.

METHODS

Over a six-year period, 5229 patients with non-small-cell lung cancer (NSCLC) and small-cell lung cancer (SCLC) were enrolled in a prospective cohort of whom 2052 were former smokers. Patient's characteristics were obtained from medical records and a baseline interview. Vital status was determined through multiple sources. Cox proportional hazards models were used to estimate the effect of smoking abstinence on post-diagnosis mortality.

RESULTS

For all patients with NSCLC, the median survival among never, former, and current smokers was 1.4 years, 1.3 years, and 1.1 years, respectively (P < 0.01). Female NSCLC patients had a significantly lower risk of mortality with a longer duration of smoking abstinence (RR per 10 years of smoking abstinence = 0.85; 95% CI: 0.75, 0.97). No effect of smoking abstinence on mortality was observed for women with SCLC or for men with either histologic group.

CONCLUSIONS

The identification of smoking history as a prognostic factor in lung cancer survival supports previous research suggesting a direct biologic effect of smoking on survival. However, this effect may vary by sex and type of lung cancer.

Influence of Sex on Toxicity and Treatment Outcome in Small-Cell Lung Cancer

Purpose

Female sex has been shown consistently to be a favorable prognostic factor in small-cell lung cancer (SCLC). Studies have shown that women with other tumor types experience greater treatment toxicity, but there have been few studies of sex-related toxicity in SCLC.

Patients and Methods

This was a sex-based retrospective analysis of four SCLC trials conducted by the National Cancer Institute of Canada Clinical Trials Group between 1987 and 1999. The 1,006 patients (648 males and 358 females) received similar chemotherapy consisting of cyclophosphamide-doxorubicin-vincristine and etoposide-cisplatin. Toxicities examined included myelosuppression, stomatitis, vomiting, and infection. Other end points included dose reductions and omissions, response, and survival.

Results

Women experienced significantly more hematologic toxicity than men (grade 3 and 4 anemia, 16.3% v 7.6%, respectively, P < .001; grade 3 and 4 leukopenia, 80.4% v 69.2%, respectively, P = .0001). However, toxic death rates were similar for men and women (1.5% v 1.1%, respectively, P = .58). Women also had significantly more stomatitis and vomiting of all grades. Despite increased toxicity, 76% of females versus 73.4% of males received all six treatment cycles (P = .38), but 52% of females versus 43.4% of males had treatment delayed for 2 weeks or more (P = .022). Only 31.8% of females and 28.2% of males had at least one cycle of chemotherapy dose reduction (P = .23). The overall response rate was 80.3% for females and 66.9% for males (P < .0001), and the median survival time was 1.31 years for females compared with only 0.91 year for males (P < .0001).

Conclusion

Women experience more chemotherapy-related toxicity in the treatment of SCLC, but they also have increased response rates and survival.

Is the urban excess in lung cancer in Scotland explained by patterns of smoking?

Numerous studies have shown that lung cancer rates are higher in urban than rural areas, controlling for differences in age and sex profiles. One explanation is that smoking rates are higher in urban areas, although it is not clear whether the variations in smoking behaviour fully account for the observed urban/rural gradient in lung cancer incidence. Indeed, some studies have demonstrated an excess of cases in urban areas, even controlling for smoking behaviour. However, previous studies have been hampered by the lack of small-area smoking estimates which are required if urban/rural variations are to be examined reliably. This paper considers whether there is an urban excess in lung cancer incidence in Scotland, a country with particularly high rates of the disease, for the period 1988-1991. First, we examine whether an urban excess exists in Scotland using Poisson probabilities and a cluster detection technique. Second, regression analysis was then used to test whether any urban excess in lung cancer incidence remained once smoking behaviour was controlled for, using smoking estimates calculated for small areas throughout Scotland. The results demonstrate that the rates of lung cancer were higher in urban areas and that all the significant clusters of cases of lung cancer were located in the large urban centres of Scotland. Smoking behaviour did account for much of this urban excess in lung cancer, although it did not explain the entire effect. These results suggest that there are urban effects that influence the incidence of lung cancer that are not explained entirely by smoking behaviour. Possible explanations include the variations in exposure to air pollution, occupational differences and the legacy of selective migration between urban and rural areas.

Gender differences in patients' written narratives about being diagnosed with cancer

The medical field has shown a growing interest in gender and gender differences. In psychosocial oncology, for example, some studies suggest that men and women cope differently with cancer; e.g. women express their emotions more readily than men do, and men rely more on their healthy spouse. Using a qualitative perspective, this study examines 83 narratives written by male and female cancer patients who were asked to write down how they experienced receiving their cancer diagnosis. The narratives were analyzed both as to structure and content. The women wrote longer, more personally, and more emotionally than the men, and to a greater extent they included family members and other relatives in their stories. When the men mentioned relatives, they mainly referred to their spouse. Men and women commented differently as to their experiences of 'reception'; i.e. how their psychological needs were addressed and 'connection'; i.e. whether they felt in sufficient contact with medical staff. Although the women described good reception, they complained a lot about bad connection. Among the men, it was just as common to report about positive as negative experiences in both categories. There are reasons to be cautious when evaluating these findings. The found differences may be due to different ways of reacting to similar situations or different willingness and ways of commenting on similar situations, but also to different reception and connection for men and women. Further research should focus on the basic question: Are men and women without medical reasons being treated differently during their oncological treatment?

Lung cancer among women in France

As the incidence of primary lung cancer in women seems to be increasing in parallel with that of smoking, we conducted an exhaustive epidemiological study in 137 hospitals in 2000. We identified 904 women with proven primary lung cancer (mean age 63.9 years), many of whom have never smoked (32.3%), particularly in cases of adenocarcinoma (43.4%). Small cell cancer accounted for 16.1% of cases. Adenocarcinomas were the most frequent (45.3%) of the non-small cell lung cancer (NSCLC), followed by squamous cell (23.4%), large cell (11.6%) and bronchoalveolar (1.9%) carcinomas. About one third (32.2%) of NSCLC were stage III and 48.1% were stage IV. Over half of all adenocarcinomas were stage IV. According to multivariate analysis, adenocarcinoma is related to less smoking and younger age. In conclusion, many women affected by lung cancer have never smoked. Adenocarcinoma appears to be the most frequent form and more often at a metastatic stage.