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Roginski M, Sifaki-Pistolla D, Stomby A, Velivasaki G, Faresjö T, Lionis C, Faresjö Å. Paradoxes of breast cancer incidence and mortality in two corners of Europe. BMC Cancer 2022; 22:1123. [PMID: 36319987 PMCID: PMC9628067 DOI: 10.1186/s12885-022-10243-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 10/27/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Breast cancer incidence is rising globally, while mortality rates show a geographical heterogenous pattern. Early detection and treatment have been proven to have a profound impact on breast cancer prognosis. The aim of his study was to compare breast cancer incidence, mortality, and survival rates in two contrasting corners of Europe, Sweden and Crete, to better understand cancer determinants with focus on disease burden and sociocultural factors. METHODS Breast cancer data from Sweden and Crete was derived from registries. Incidence and mortality were expressed as Age-Standardized Incidence Rates (ASIR), Age-Standardized Mortality Rates (ASMR). FINDINGS Breast cancer incidence has for decades risen in Sweden and on Crete. In 2019, ASIR was 217.5 in Sweden and 58.9 on Crete, (p < 0.001). Mortality rates showed opposite trends. ASMR in Sweden was reduced from 25.5 to 16.8 (2005-2019) while on Crete, ASMR increased from 22.1 to 25.3. A successive rise in survival rate in Sweden with a 5-year survival rate of 92% since 2015, but a converse development on Crete with 85% 5-year survival rate the same year. INTERPRETATION The incidence of breast cancer is slowly rising in both studied regions, but mortality increases on Crete in contrast to Sweden with sinking mortality rates. The interpretation of these findings is that differences in health care systems and health policies including differences in early detection like screening programs and early treatment, as well as sociocultural factors in the two countries might play an important role on the differences found in breast cancer burden.
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Affiliation(s)
- Mikaela Roginski
- grid.5640.70000 0001 2162 9922Department of Health, Medicine and Caring Sciences, Linköping University, SE-581 83 Linköping, Sweden
| | - Dimitra Sifaki-Pistolla
- grid.8127.c0000 0004 0576 3437Clinic of Social and Family Medicine, Faculty of Medicine, University of Crete, Heraklion, Greece
| | - Andreas Stomby
- grid.5640.70000 0001 2162 9922Department of Health, Medicine and Caring Sciences, Linköping University, SE-581 83 Linköping, Sweden
| | - Georgia Velivasaki
- grid.8127.c0000 0004 0576 3437Clinic of Social and Family Medicine, Faculty of Medicine, University of Crete, Heraklion, Greece
| | - Tomas Faresjö
- grid.5640.70000 0001 2162 9922Department of Health, Medicine and Caring Sciences, Linköping University, SE-581 83 Linköping, Sweden
| | - Christos Lionis
- grid.5640.70000 0001 2162 9922Department of Health, Medicine and Caring Sciences, Linköping University, SE-581 83 Linköping, Sweden ,grid.8127.c0000 0004 0576 3437Clinic of Social and Family Medicine, Faculty of Medicine, University of Crete, Heraklion, Greece
| | - Åshild Faresjö
- grid.5640.70000 0001 2162 9922Department of Health, Medicine and Caring Sciences, Linköping University, SE-581 83 Linköping, Sweden
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Unanue-Arza S, Solís-Ibinagagoitia M, Díaz-Seoane M, Mosquera-Metcalfe I, Idigoras I, Bilbao I, Portillo I. Inequalities and risk factors related to non-participation in colorectal cancer screening programmes: a systematic review. Eur J Public Health 2021; 31:346-355. [PMID: 33313657 PMCID: PMC8071594 DOI: 10.1093/eurpub/ckaa203] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background Colorectal cancer (CRC) screening programmes require high levels of participation in order to reduce mortality. To improve participation rates, it is necessary to identify the health risk factors and social inequalities associated with non-participation. Methods A systematic review was conducted between June and September of 2019 in six databases: CINHAL, Medline, Scopus, Social Sciences Citation Index, Embase and PsycINFO. Studies assessing the relationship between health risk factors, participation in preventive activities and participation in CRC screening were included. Methodological assessment was carried out according to the Quality Assessment Tools of the National Heart, Lung and Blood Institute. Results A total of nine studies that analyze participation in both organized and opportunistic screening programmes using any type of screening method were finally selected. Data were mainly self-reported although in two studies medical records were also studied. We identified several variables: gender, body mass index, consultation with a doctor or a specialist, educational level, employment, health insurance, residence, ethnicity, age, marital status, income, other preventive activities, obesity, physical activity, smoking, family history of CRC and general health status. Conclusion The scarcity of studies linking risk factors, social inequalities and participation in preventive activities for participation in screening in the same study makes it difficult to reach definitive patterns related to non-participation in CRC screening programmes. Nevertheless, being under 60, obese, smoker and sedentary have shown an association with non-participation as well as not visiting a doctor.
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Affiliation(s)
- Saloa Unanue-Arza
- Department of Nursing I, Faculty of Medicine and Nursing, University of the Basque Country UPV/EHU, Bizkaia, Spain
- Correspondence: Saloa Unanue-Arza., Faculty of Medicine and Nursing, University of the Basque Country UPV/EHU, Barrio Sarriena s/n 48940 Leioa, Bizkaia, Spain, Tel: +34 946 01 5610, e-mail:
| | | | - Marta Díaz-Seoane
- Department of Preventive Medicine and Public Health, University Clinical Hospital of Valladolid, Valladolid, Spain
| | | | - Isabel Idigoras
- BioCruces-Bizkaia Health Research Institute, Barakaldo, Spain
- Basque Country Colorectal Cancer Screening Programme, Osakidetza, Basque Health Service, Bilbao, Spain
| | - Isabel Bilbao
- BioCruces-Bizkaia Health Research Institute, Barakaldo, Spain
- Basque Country Colorectal Cancer Screening Programme, Osakidetza, Basque Health Service, Bilbao, Spain
| | - Isabel Portillo
- BioCruces-Bizkaia Health Research Institute, Barakaldo, Spain
- Basque Country Colorectal Cancer Screening Programme, Osakidetza, Basque Health Service, Bilbao, Spain
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MOUMTZI THEOFANO, ATHANASOPOULOS ALEXANDROS. Assessment of the operation of a pilot program of preventive medicine for adults in three primary care centers of Athens and Piraeus: a cross-sectional study. JOURNAL OF PREVENTIVE MEDICINE AND HYGIENE 2021; 61:E621-E627. [PMID: 33628969 PMCID: PMC7888401 DOI: 10.15167/2421-4248/jpmh2020.61.4.1445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Accepted: 08/12/2020] [Indexed: 12/04/2022]
Abstract
OBJECTIVE To evaluate the operation of the pilot Program of Preventive Medicine for Adults (PPMA) from the provision of healthcare services in three primary health care centers of Athens and Piraeus (Greece). DESIGN An observational, cross-sectional study was undertaken. A structured questionnaire was used to collect data. SETTING Three public primary health centers of Athens, Greece. PARTICIPANTS 142 participants, 40-55 years of age, with no previously identified/diagnosed health issues (overall healthy) that should not have undergone any type of screening in the past 12 months. MEASURES AND RESULTS The majority of participants were female (75.4%), aged 40-45 years (43.7%), Greek nationals (88%), employed (62.7%) and high school graduates (52.8%). 68.3% of participants scheduled an appointment in the first two days and 58.9% waited up to 5 minutes in the waiting room. The paramedical personnel scored higher evaluation (4.94) than the doctor (4.61), but all health care centers received a very high general evaluation (4.87). Multiple linear regression showed significant association between the evaluation of the pilot PPMA, the evaluation of health visitor/nurse (B = .240) and the communication of results to participants (B = .245). CONCLUSIONS Findings show an extremely positive evaluation of the pilot PPMA, a result that can be used by healthcare managers for the expansion of the screening program to the general population.
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Affiliation(s)
- THEOFANO MOUMTZI
- Primary Health Care centre of Neos Kosmos, Machis Analatou, Neos Kosmos, Greece
| | - ALEXANDROS ATHANASOPOULOS
- Microbial Molecular Genetics Laboratory, Institute of Biosciences and Applications, NCSR Demokritos, Agia Paraskevi, Greece
- Correspondence: Alexandros Athanasopoulos, Microbial Molecular Genetics Laboratory, Institute of Biosciences and Applications, NCSR Demokritos, 15310, Agia Paraskevi, Greece - E-mail:
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Cardoso R, Guo F, Heisser T, Hoffmeister M, Brenner H. Utilisation of Colorectal Cancer Screening Tests in European Countries by Type of Screening Offer: Results from the European Health Interview Survey. Cancers (Basel) 2020; 12:cancers12061409. [PMID: 32486077 PMCID: PMC7352919 DOI: 10.3390/cancers12061409] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 05/22/2020] [Accepted: 05/27/2020] [Indexed: 12/24/2022] Open
Abstract
In the past two decades, an extensive rollout of colorectal cancer (CRC) screening programmes has been initiated in European countries with a large heterogeneity of screening offers. Using data from a population-based cross-sectional survey conducted between 2013 and 2016 in all European Union countries, we analysed the utilisation of faecal tests and colonoscopy among people aged 50–74 years and the factors associated with uptake by type of screening offer. We observed the highest utilisation of either test for countries with fully rolled out organised programmes with faecal tests (ranging from 29.7% in Croatia to 66.7% in the UK) and countries offering both faecal tests and colonoscopy (from 22.7% in Greece to 70.9% in Germany). Utilisation was very low for countries with no programme (from 6.3% in Romania to 30.5% in Norway). Younger age (50–54 years), longer time since last consultation with a doctor and a lifestyle score associated with increased CRC risk were significantly associated with lower test use, a pattern observed across all types of screening offers. Our results suggest that more countries should implement organised programmes with faecal immunochemical tests, in combination with alternative endoscopy offers where resources allow. Furthermore, there is a large potential for increasing screening use in Europe by better reaching the younger eligible individuals, those who have not been to the doctor recently and those at increased risk for CRC.
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Affiliation(s)
- Rafael Cardoso
- Division of Preventive Oncology, German Cancer Research Center (DKFZ) and National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany;
- Medical Faculty Heidelberg, University of Heidelberg, 69120 Heidelberg, Germany; (F.G.); (T.H.)
- Correspondence: ; Tel.: +49-6221-42-3033
| | - Feng Guo
- Medical Faculty Heidelberg, University of Heidelberg, 69120 Heidelberg, Germany; (F.G.); (T.H.)
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany;
| | - Thomas Heisser
- Medical Faculty Heidelberg, University of Heidelberg, 69120 Heidelberg, Germany; (F.G.); (T.H.)
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany;
| | - Michael Hoffmeister
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany;
| | - Hermann Brenner
- Division of Preventive Oncology, German Cancer Research Center (DKFZ) and National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany;
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany;
- German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
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Panteris V, Vasilakis N, Demonakou M, Kornarou E, Ktenas E, Rapti E, Spithakis G, Katopodi K, Horti M, Vgenopoulou S, Triantafyllidis J, Papalois A, Karantanos P. Alarming endoscopic data in young and older asymptomatic people: Results of an open access, unlimited age colonoscopic screening for colorectal cancer. Mol Clin Oncol 2020; 12:179-185. [PMID: 31929891 DOI: 10.3892/mco.2019.1967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 11/04/2019] [Indexed: 11/06/2022] Open
Abstract
There is a lack of a national organized screening program for colorectal cancer in Greece, and asymptomatic detection is usually the result of individual decisions. The collection of epidemiologic endoscopic data from a population of interest would therefore provide valuable information for future treatment guidance, especially during periods of economic austerity. The current cross-sectional study included 380 asymptomatic, average risk individuals undergoing screening colonoscopy for the first time, during the period of one year in a tertiary public hospital in Athens. Descriptive and analytic epidemiologic data were analyzed. The prevalence of adenomas and advanced lesions were compared between the younger and older cohort, and a regression model was applied for risk evaluation. The mean age of participants was 63 years, and 53% were male. A significant proportion of patients presented with polyps (51.5%) and 25% of them had lesions in the proximal colon. The prevalence of adenomas and advanced adenomas was 29.5 and 11.8%, respectively. Similar high prevalence rates of lesions were identified in the cohort of individuals <50 years of age and the older cohort (>50 years of age). Regression models identified age, number and size of polyps as the major risk factors for the detection of adenomas. The increase of advanced lesions in the older and younger cohort requires confirmation by larger studies. Overall, the results of the present study indicate the requirement for a well-organized screening colonoscopy program starting from as early as 40 years of age. This program may confer an additional endoscopic burden with socioeconomic consequences in a country with limited health resources.
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Affiliation(s)
- Vasileios Panteris
- Department of Gastroenterology, Sismanogleio-Amalia Flemig General Hospital, 15126 Athens, Greece
| | - Nikolaos Vasilakis
- Department of Gastroenterology, Sismanogleio-Amalia Flemig General Hospital, 15126 Athens, Greece
| | - Maria Demonakou
- Department of Histopathology, Sismanogleio-Amalia Flemig General Hospital, 15126 Athens, Greece
| | - Eleni Kornarou
- Department of Epidemiology and Biostatistics, National School of Public Health, 11521 Athens, Greece
| | - Eftyxios Ktenas
- Department of Epidemiology and Biostatistics, National School of Public Health, 11521 Athens, Greece
| | - Emanuella Rapti
- Department of Gastroenterology, Sismanogleio-Amalia Flemig General Hospital, 15126 Athens, Greece
| | - George Spithakis
- Department of Gastroenterology, Sismanogleio-Amalia Flemig General Hospital, 15126 Athens, Greece
| | - Konstantina Katopodi
- Department of Gastroenterology, Sismanogleio-Amalia Flemig General Hospital, 15126 Athens, Greece
| | - Maria Horti
- Department of Histopathology, Sismanogleio-Amalia Flemig General Hospital, 15126 Athens, Greece
| | - Stefani Vgenopoulou
- Department of Histopathology, Sismanogleio-Amalia Flemig General Hospital, 15126 Athens, Greece
| | - John Triantafyllidis
- Department of Gastroenterology, Metropolitan General, Hellenic Society of Gastrointestinal Oncology, 15562 Athens, Greece
| | - Apostolos Papalois
- Experimental, Educational and Research Center, ELPEN Laboratories, Hellenic Society of Gastrointestinal Oncology, 19009 Athens, Greece
| | - Panagiotis Karantanos
- Department of Gastroenterology, Sismanogleio-Amalia Flemig General Hospital, 15126 Athens, Greece
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Grimley CE, Kato PM, Grunfeld EA. Health and health belief factors associated with screening and help-seeking behaviours for breast cancer: A systematic review and meta-analysis of the European evidence. Br J Health Psychol 2019; 25:107-128. [PMID: 31876992 DOI: 10.1111/bjhp.12397] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 10/28/2019] [Indexed: 12/13/2022]
Abstract
PURPOSE The aim of this systematic review was to identify health or health belief factors associated with mammography attendance or with self-initiated medical help-seeking for breast cancer symptoms among women in Europe. METHODS Five databases were searched for articles published between 2005 and 2018. Meta-analyses were conducted for 13 factors related to screening attendance and two factors associated with help-seeking behaviour. Where there were too few studies to include in the meta-analysis, a narrative synthesis was undertaken. RESULTS Sixty-five studies were included. Never having had cervical screening (d = -.72, p < .001) and higher perceived barriers to mammography (d = -.40, p < .001) were associated with lower levels of screening attendance. Possessing health insurance (d = .49, p < .001), greater perceived benefits (d = .31, p < .001) and motivation (d = .36, p = .003) towards screening, and higher perceived seriousness (d = .24, p = .019) and susceptibility (d = .20, p = .024) towards breast cancer were associated with a higher level of screening attendance. Presenting with a non-lump symptom was associated with a longer time to presentation (d = .32, p < .001). The narrative synthesis revealed that previous benign breast disease was associated with a higher level of screening attendance but with a longer time to presentation. CONCLUSIONS The review identified key similarities in factors associated with screening and help-seeking behaviours which offer scope for combined interventions aimed at women that target both behaviours. Furthermore, the review highlighted that fewer studies have focused on help-seeking behaviour, despite two thirds of breast cancer cases being self-detected. Future research should further examine predictors of help-seeking behaviour including a focus on modifiable factors, such as BMI, and physical activity.
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Affiliation(s)
| | - Pamela M Kato
- P. M. Kato Consulting, Mountain View, California, USA
| | - Elizabeth A Grunfeld
- Department of Psychological Sciences, Birkbeck College, University of London, UK
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Arli SK, Bakan AB. Effects of the Training About Prostate Cancer and Screening Methods on Knowledge Level. Nurs Sci Q 2019; 32:333-339. [PMID: 31514615 DOI: 10.1177/0894318419864345] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This quasi-experimental study aims to identify the effects of the training about prostate cancer and screening methods given to men aged 40 and over on their knowledge level. It was found that there were no differences between the experimental and control groups in terms of the perceived susceptibility, perceived seriousness, health motivation, perceived barriers, and perceived benefits subscale mean scores, but the posttest data revealed that the perceived susceptibility, health motivation, and perceived benefits subscale mean scores of the experimental group were higher and their perceived barriers mean score was lower; the differences between the mean scores were statistically significant (p < .05, p < .01, p < .001). An analysis of the Health Belief Model after the training about prostate cancer and screening methods showed that the training was effective. Actually, the authors recommended that especially male nurses can play an effective role in training about prostate cancer and screening methods for men in Turkey.
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Affiliation(s)
- Senay Karadag Arli
- Assistant Professor, Department of Nursing, Agri Ibrahim Cecen University School of Health, Agri, Turkey
| | - Ayse Berivan Bakan
- Assistant Professor, Department of Nursing, Agri Ibrahim Cecen University School of Health, Agri, Turkey
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Carmona-Torres JM, Cobo-Cuenca AI, Martín-Espinosa NM, Piriz-Campos RM, Laredo-Aguilera JA, Rodríguez-Borrego MA. [Prevalence in the performance of mammographies in Spain: Analysis by Communities 2006-2014 and influencing factors]. Aten Primaria 2018; 50:228-237. [PMID: 28732722 PMCID: PMC6836949 DOI: 10.1016/j.aprim.2017.03.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Revised: 02/27/2017] [Accepted: 03/08/2017] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE To determine the frequency of the performance of mammography with preventive purpose of the screening of breast cancer in Spanish women, the evolution between the years 2006-2014, the sociodemographic profile of the women who undergo the mammography and to analyze the factors that influence in their adhesion. DESIGN Transversal study. SITES Spain. PARTICIPANTS A total of 53.628 women over 15 years old that are surveyed in the National Health Survey in Spain 2006 and 2011/12 and the European Health Survey in Spain 2009 and 2014. MEASUREMENTS The following variables were used: mammography, frequency of mammography performance and the reason for the realization, as well as sociodemographic variables. Social class was obtained from the last occupation of the main family supporter. A logistic regression analysis was performed with sociodemographic variables. RESULTS The prevalence of mammography has been increasing from 2006 to 2014, and also for the reason that the participants had received a letter, they were telephoned or offered in their Health Center to undergo this test. There are significant differences in the performance of mammography in the different autonomous communities. CONCLUSIONS Performing mammography has increased significantly from 2006 to 2014, although there are still differences between autonomous communities, with Ceuta and Melilla being the least percentage of performed mammography. The factors that are related to greater performed mammography are: higher educational level, higher social class, married civil status, Spanish nationality and age.
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Affiliation(s)
- Juan Manuel Carmona-Torres
- Universidad de Castilla-La Mancha (UCLM), E.U. Enfermería y Fisioterapia de Toledo, Toledo, España; Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Córdoba, España
| | - Ana Isabel Cobo-Cuenca
- Universidad de Castilla-La Mancha (UCLM), E.U. Enfermería y Fisioterapia de Toledo, Toledo, España; Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Córdoba, España.
| | | | - Rosa María Piriz-Campos
- Universidad de Castilla-La Mancha (UCLM), E.U. Enfermería y Fisioterapia de Toledo, Toledo, España
| | | | - María Aurora Rodríguez-Borrego
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Córdoba, España; Universidad de Córdoba, Córdoba, España; Hospital Universitario Reina Sofía, Córdoba, España
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Ferrando J, Palència L, Gotsens M, Puig-Barrachina V, Marí-Dell'Olmo M, Rodríguez-Sanz M, Bartoll X, Borrell C. Trends in cancer mortality in Spain: the influence of the financial crisis. GACETA SANITARIA 2018; 33:229-234. [PMID: 29452751 DOI: 10.1016/j.gaceta.2017.11.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Revised: 11/07/2017] [Accepted: 11/08/2017] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To determine if the onset of the economic crisis in Spain affected cancer mortality and mortality trends. METHOD We conducted a longitudinal ecological study based on all cancer-related deaths and on specific types of cancer (lung, colon, breast and prostate) in Spain between 2000 and 2013. We computed age-standardised mortality rates in men and women, and fit mixed Poisson models to analyse the effect of the crisis on cancer mortality and trends therein. RESULTS After the onset of the economic crisis, cancer mortality continued to decline, but with a significant slowing of the yearly rate of decline (men: RR = 0.987, 95%CI = 0.985-0.990, before the crisis, and RR = 0.993, 95%CI = 0.991-0.996, afterwards; women: RR = 0.990, 95%CI = 0.988-0.993, before, and RR = 1.002, 95%CI = 0.998-1.006, afterwards). In men, lung cancer mortality was reduced, continuing the trend observed in the pre-crisis period; the trend in colon cancer mortality did not change significantly and continued to increase; and the yearly decline in prostate cancer mortality slowed significantly. In women, lung cancer mortality continued to increase each year, as before the crisis; colon cancer continued to decease; and the previous yearly downward trend in breast cancer mortality slowed down following the onset of the crisis. CONCLUSIONS Since the onset of the economic crisis in Spain the rate of decline in cancer mortality has slowed significantly, and this situation could be exacerbated by the current austerity measures in healthcare.
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Affiliation(s)
| | - Laia Palència
- Agència de Salut Pública de Barcelona, Barcelona, Spain; CIBER de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain; Institut d'Investigació Biomèdica IIB Sant Pau, Barcelona, Spain
| | - Mercè Gotsens
- Agència de Salut Pública de Barcelona, Barcelona, Spain; CIBER de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain; Institut d'Investigació Biomèdica IIB Sant Pau, Barcelona, Spain.
| | | | - Marc Marí-Dell'Olmo
- Agència de Salut Pública de Barcelona, Barcelona, Spain; CIBER de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain; Institut d'Investigació Biomèdica IIB Sant Pau, Barcelona, Spain
| | - Maica Rodríguez-Sanz
- Agència de Salut Pública de Barcelona, Barcelona, Spain; CIBER de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain; Institut d'Investigació Biomèdica IIB Sant Pau, Barcelona, Spain; Departamento de Ciencias Experimentales y de la Salud, Facultad de Ciencias de la Salud y de la Vida, Universitat Pompeu Fabra, Barcelona, Spain
| | - Xavier Bartoll
- Agència de Salut Pública de Barcelona, Barcelona, Spain; Institut d'Investigació Biomèdica IIB Sant Pau, Barcelona, Spain
| | - Carme Borrell
- Agència de Salut Pública de Barcelona, Barcelona, Spain; CIBER de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain; Institut d'Investigació Biomèdica IIB Sant Pau, Barcelona, Spain; Departamento de Ciencias Experimentales y de la Salud, Facultad de Ciencias de la Salud y de la Vida, Universitat Pompeu Fabra, Barcelona, Spain
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10
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Guessous I, Cullati S, Fedewa SA, Burton-Jeangros C, Courvoisier DS, Manor O, Bouchardy C. Prostate cancer screening in Switzerland: 20-year trends and socioeconomic disparities. Prev Med 2016; 82:83-91. [PMID: 26582208 DOI: 10.1016/j.ypmed.2015.11.009] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Revised: 11/03/2015] [Accepted: 11/05/2015] [Indexed: 12/29/2022]
Abstract
BACKGROUND Despite important controversy in its efficacy, prostate cancer (PCa) screening has become widespread. Important socioeconomic screening disparities have been reported. However, trends in PCa screening and social disparities have not been investigated in Switzerland, a high risk country for PCa. We used data from five waves (from 1992-2012) of the population-based Swiss Health Interview Survey to evaluate trends in PCa screening and its association with socioeconomic indicators. METHODS We used multivariable Poisson regression to estimate prevalence ratios (PR) and 95% Confidence Intervals (CI) adjusting for demographics, health status, and use of healthcare. RESULTS The study included 12,034 men aged ≥50 years (mean age: 63.9). Between 1992 and 2012, ever use of PCa screening increased from 55.3% to 70.0% and its use within the last two years from 32.6% to 42.4% (p-value <0.05). Income, education, and occupational class were independently associated with PCa screening. PCa screening within the last two years was greater in men with the highest (>$6,000/month) vs. lowest income (≤$2,000) (46.5% vs. 38.7% in 2012, PR for overall period =1.29, 95%CI: 1.13-1.48). These socioeconomic disparities did not significantly change over time. CONCLUSIONS This study shows that about half of Swiss men had performed at least one PCa screening. Men belonging to high socioeconomic status are clearly more frequently screened than those less favored. Given the uncertainty of the usefulness of PCa screening, men, including those with high socioeconomic status, should be clearly informed about benefits and harms of PCa screening, in particular, the adverse effect of over-diagnosis and of associated over-treatment.
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Affiliation(s)
- Idris Guessous
- Unit of population epidemiology, Department of Community Medicine, Primary Care and Emergency Medicine, University Hospitals of Geneva, Geneva, Switzerland; Emory University, Department of Epidemiology, Atlanta, GA, USA; Division of chronic diseases, Institute of Social and Preventive Medicine, Lausanne University Hospital, Lausanne, Switzerland.
| | - Stéphane Cullati
- Unit of population epidemiology, Department of Community Medicine, Primary Care and Emergency Medicine, University Hospitals of Geneva, Geneva, Switzerland
| | - Stacey A Fedewa
- Emory University, Department of Epidemiology, Atlanta, GA, USA; American Cancer Society, Atlanta, GA, USA
| | | | | | - Orly Manor
- School of Public Health and Community Medicine, Hebrew University-Hadassah, Jerusalem, Israel
| | - Christine Bouchardy
- Geneva Cancer Registry, Global Health Institute, University of Geneva, Geneva, Switzerland
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11
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Colorectal cancer screening in Korean workers: using a stage model approach to examine the ecological predictors of behavior. Cancer Nurs 2015; 37:278-91. [PMID: 23842525 DOI: 10.1097/ncc.0b013e31829bc913] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Early detection is important for reducing mortality by colorectal cancer. Workplaces have access to a large number of people, approximately half of the Korean population. For cancer prevention, it is necessary to approach cancer screening through the workplace. OBJECTIVE In this cross-sectional study, we aimed to identify colorectal cancer screening (CRCS) stages and to predict factors that affect the respective stages. METHODS Data were collected from 314 manual workers at 32 medium-sized and small workplaces located in Korea. The dependent variable was the stage of CRCS, and independent variables were intrapersonal, interpersonal, and organizational levels. RESULTS At the intrapersonal level, workers who increased work hours per week or who felt stress were less likely to be in the acting/maintenance stage than in the decided to act stage of CRCS. At the organizational level, workers in medium-sized workplaces, those whose administrators secured health checkup and cancer screening budget for their workplace, and those considering health checkup and cancer screening were more likely to be in the acting/maintenance stage, compared with the decided to act stage. CONCLUSIONS Our findings suggest that the respective stages are affected by different intrapersonal, interpersonal, and organizational factors. IMPLICATION FOR PRACTICE The workplace environment and organizational predictors before the implementation of CRCS promotion programs may produce better results.
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Camp EA, Prehn AW, Shen J, Herbst AL, Strohsnitter WC, Hobday CD, Robboy SJ, Adam E. Factors associated with a lack of pap smear utilization in women exposed in utero to diethylstilbestrol. J Womens Health (Larchmt) 2015; 24:308-15. [PMID: 25768943 DOI: 10.1089/jwh.2014.4930] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Women in the 1940s-1960s were prescribed diethylstilbestrol (DES), a nonsteroidal estrogen, to prevent miscarriages, but the practice was terminated after it was discovered that the daughters so exposed in utero were at increased risk for developing clear cell adenocarcinoma (CCA) of the vagina or cervix at early ages. Pap smear screening is one of the principal methods used to identify tumor development and is necessary in this group of women to maintain their health. Currently, little is known about the factors associated with nonutilization of this screening tool in this high-risk population of women. METHODS National cohort data from the National Cancer Institute (NCI) DES Combined Cohort Follow-up Study during 1994, 1997, 2001, and 2006 were used to determine which factors were associated with Pap smear screening nonutilization in 2006 among DES-exposed and unexposed women. Self-reported questionnaire data from 2,861 DES-exposed and 1,027 unexposed women were analyzed using binary logistic regression models. RESULTS DES exposure, not having a previous gynecologic dysplasia diagnosis, lack of insurance, originating cohort, increasing age, and previous screening behavior were all factors associated with not reporting a Pap smear examination in the 2006 questionnaire, although college education reduced nonutilization. CONCLUSIONS Understanding which factors are associated with not acquiring a screening exam can help clinicians better identify which DES-exposed women are at risk for nonutilization and possibly tailor their standard of care to aid in the early detection of cervical and vaginal adenocarcinomas in this high-risk group.
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Affiliation(s)
- Elizabeth A Camp
- 1 School of Health Sciences, Walden University , Minneapolis, Minnesota
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13
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Vrachnis N, Vlachadis N, Salakos N, Vlachadi M, Iliodromiti Z. Cancer mortality in Greece during the financial crisis. Acta Oncol 2015; 54:287-8. [PMID: 25238281 DOI: 10.3109/0284186x.2014.958785] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Nikolaos Vrachnis
- National and Kapodistrian University of Athens, School of Medicine, Aretaieio hospital , Athens , Greece
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14
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Domeyer PJ, Sergentanis TN, Katsari V, Souliotis K, Mariolis A, Zagouri F, Zografos GC. Screening in the era of economic crisis: misperceptions and misuse from a longitudinal study on Greek women undergoing benign vacuum-assisted breast biopsy. Asian Pac J Cancer Prev 2014; 14:5023-9. [PMID: 24175770 DOI: 10.7314/apjcp.2013.14.9.5023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To evaluate knowledge about screening tests and tests without proven screening value in a Greek Breast Unit population undergoing benign vacuum-assisted breast biopsy (VABB). MATERIALS AND METHODS This study included 81 patients. Three knowledge-oriented items (recommended or not, screening frequency, age of onset) were assessed. Regarding screening tests two levels of knowledge were evaluated: i). crude knowledge (CK), i.e. knowledge that the test is recommended and ii). advanced knowledge (AK), i.e. correct response to all three knowledge-oriented items. Solely CK was evaluated for tests without proven screening value. Risk factors for lack of knowledge were assessed with multivariate logistic regression. A second questionnaire was administered 18 months after VABB to assess its impact on the performance of tests. RESULTS Concerning screening tests considerable lack of AK was noted (mammogram, 60.5%; Pap smear, 59.3%; fecal occult blood testing, 93.8%; sigmoidoscopy, 95.1%). Similarly lack of CK was documented regarding tests without proven screening value (breast self-examination, 92.6%; breast MRI, 60.5%; abdominal ultrasound, 71.6%; barium meal, 48.1%; urine analysis, 90.1%; chest X-Ray, 69.1%; electrocardiogram, 74.1%; cardiac ultrasound, 75.3%). Risk factors for lack of AK were: place of residence (mammogram), age (Pap smear), personal income (sigmoidoscopy); risk factors for lack of CK included number of offspring (breast MRI, chest X-Ray), BMI (abdominal ultrasound), marital status (urine analysis), current smoking status (electrocardiogram). VABB's only effect was improvement in mammogram rates. CONCLUSIONS A considerable lack of knowledge concerning screening tests and misperceptions regarding those without proven value was documented.
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Affiliation(s)
- Philip John Domeyer
- Breast Unit, Department of Propaedeutic Surgery, Hippokrateio Hospital, Medical School, University of Athens, Korinthos, Greece E-mail :
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15
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Affiliation(s)
- Andreas Tsounis
- Centers for the Prevention of Addictions and Promoting Psychosocial Health of Municipality of Thessaloniki-OKANA, Thessaloniki, Greece
| | - Pavlos Sarafis
- Department of Nursing, Technological Educational Institute of Lamia, 35100 Lamia, Greece.
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16
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Moudatsou MM, Kritsotakis G, Alegakis AK, Koutis A, Philalithis AE. Social capital and adherence to cervical and breast cancer screening guidelines: a cross-sectional study in rural Crete. HEALTH & SOCIAL CARE IN THE COMMUNITY 2014; 22:395-404. [PMID: 24450830 DOI: 10.1111/hsc.12096] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/06/2013] [Indexed: 06/03/2023]
Abstract
Breast and cervical cancers are among the leading causes of female mortality. The reasons that make women adhere, or not, to screening guidelines are not only related to individual and health characteristics but are also placed in a wider social and cultural context. Social capital might facilitate the dissemination of relevant knowledge of and the adherence to cancer screening guidelines. This cross-sectional study explored the associations of individual-level social capital with breast and cervical cancer screening and the knowledge for the existence of relevant screening tests (Pap test and mammography) in the municipality of Gorgolaini, a rural area in Crete, Greece. A random sample of 131 of the 592 women of the 2001 electoral register were invited to participate in the study and 125 completed the Social Capital Questionnaire and two questions on self-reported health knowledge and behaviour (participation rate 95.4%). Women were eligible to participate if they were aged 35-75, had lived in the area for the last 10 years and were of Greek origin. Multiple logistic regressions were performed to establish associations among each social capital factor (total, participation in the community, value of life, tolerance for diversity, feelings of safety, family/friends connections) and knowledge of and adherence to breast and cervical cancer screening guidelines after adjustment for confounders. Our results suggest that early detection of breast and cervical cancers may be facilitated when taking into account the social context of the population.
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Affiliation(s)
- Maria M Moudatsou
- Department of Medicine, Faculty of Social Medicine, University of Crete, Heraklion, Greece
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17
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Altobelli E, Lattanzi A, Paduano R, Varassi G, di Orio F. Colorectal cancer prevention in Europe: burden of disease and status of screening programs. Prev Med 2014; 62:132-41. [PMID: 24530610 DOI: 10.1016/j.ypmed.2014.02.010] [Citation(s) in RCA: 123] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2013] [Revised: 12/26/2013] [Accepted: 02/02/2014] [Indexed: 12/12/2022]
Abstract
Colorectal cancer is a major public health challenge worldwide. In Europe it is the first malignancy in terms of incidence and the second in terms of mortality in both genders. Despite evidence indicating that removal of premalignant and early-stage cancer lesion scan greatly reduce mortality, remarkable differences are still found among countries both in terms of organized screening programs and of the tests used. In 2003 the European Council recommended that priority be given to activation of organized cancer screening programs, and various states have been making significant efforts to adopt effective prevention programs with international quality standards and centralizing screening organization and result evaluation. After a 2008 European Union report on the state of screening program, activation highlighted that little more than 50% (12/22) of Member States had colorectal cancer screening programs, Screening programs have been adopted or earlier pilot projects have been extended nationwide. This paper examines the state of activation and the screening strategies of colorectal cancer screening programs in EU States as of July 2013.
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Affiliation(s)
- E Altobelli
- Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy; Epidemiologic and Social Marketing Unit, AUSL 4 Teramo, Italy.
| | - A Lattanzi
- Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy.
| | - R Paduano
- Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy.
| | | | - F di Orio
- Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy.
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18
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Adonis L, Basu D, Luiz J. Predictors of adherence to screening guidelines for chronic diseases of lifestyle, cancers, and HIV in a health-insured population in South Africa. Glob Health Action 2014; 7:23807. [PMID: 24647130 PMCID: PMC3957800 DOI: 10.3402/gha.v7.23807] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2014] [Revised: 02/20/2014] [Accepted: 02/22/2014] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Adherence to screening guidelines has been widely accepted to reduce morbidity, mortality, and cost outcomes. The aim of this study was to identify predictors of adherence to screening guidelines for chronic diseases of lifestyle (CDL), cancers, and HIV in a health-insured population in South Africa, some of whom voluntarily opt into a wellness program that incentivizes screening. METHOD A cross-sectional study for the period 2007-2011 was conducted using a random sample of 170,471 health insurance members from a single insurer. Adherence to screening guidelines was calculated from medical claims data. RESULTS Adherence to screening guidelines ranged from 1.1% for colorectal cancer to 40.9% for cholesterol screening. Members of the wellness program were up to three times more likely to screen for diseases (odds ratio [OR] = 3.2 for HIV screening, confidence interval [CI] = 2.75-3.73). Plan type (full comprehensive plan) was most strongly associated with cholesterol screening (OR = 3.53, CI = 3.27-3.80), and most negatively associated (hospital-only core plan) with cervical cancer screening (OR = 0.44, CI = 0.28-0.70). Gender was a negative predictor for glucose screening (OR = 0.88, CI = 0.82-0.96). Provincial residence was most strongly associated with cervical cancer screening (OR = 1.89, CI = 0.65-5.54). CONCLUSION Adherence to screening recommendations was <50%. Plan type, gender, provincial residence, and belonging to an incentivized wellness program were associated with disproportionate utilization of screening services, even with equal payment access.
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Affiliation(s)
- Leegale Adonis
- School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| | - Debashis Basu
- School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| | - John Luiz
- Graduate School of Business, University of Cape Town, Cape Town, South Africa
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19
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Griva F, Anagnostopoulos F, Potamianos G. Time perspective and perceived risk as related to mammography screening. Women Health 2013; 53:761-76. [PMID: 24215271 DOI: 10.1080/03630242.2013.836140] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
The present study explored the relation of time perspective to perceived risk for breast cancer and mammography screening. Women free from breast cancer (N = 194), eligible for mammography screening in terms of age, completed the Zimbardo Time Perspective Inventory (Zimbardo & Boyd, 1999) and measures of perceived risk, attitude toward performing mammography screening, intention to get a mammogram, and mammography screening behavior. Hierarchical multiple regression analysis revealed that perceived risk of breast cancer (β= .18, p < .01) and intention to be screened (β = .35, p < .01) were significantly associated with mammography screening, after controlling for the effects of sociodemographic (e.g., age, education, and economic level) and health-related variables (e.g., family history of breast cancer and previous benign breast disease). Path analyses including the main psychological variables indicated that perceived risk was indirectly related to intention via attitude (β = .17, p < .01), and to mammography screening through attitude and intention (β = .06, p < .01). Attitude was indirectly related to mammography screening via intention (β = .20, p < .01). Also, a significant indirect association was observed between future orientation and mammography screening, via perceived risk (β = .10, p < .01). Theoretical implications of study findings and suggestions for future research on use of mammography are presented.
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Affiliation(s)
- Fay Griva
- a Department of Psychology , Panteion University of Social and Political Sciences , Athens , Greece
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20
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Kaltsa A, Holloway A, Cox K. Factors that influence mammography screening behaviour: A qualitative study of Greek women's experiences. Eur J Oncol Nurs 2013; 17:292-301. [DOI: 10.1016/j.ejon.2012.08.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2012] [Revised: 07/19/2012] [Accepted: 08/03/2012] [Indexed: 11/29/2022]
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21
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Anagnostopoulos F, Dimitrakaki C, Niakas D, Tountas Y. Validity and reliability assessment of health belief scales for mammography screening in Greek asymptomatic women. Psychooncology 2012; 22:1912-7. [PMID: 23080526 DOI: 10.1002/pon.3212] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2011] [Revised: 08/13/2012] [Accepted: 09/25/2012] [Indexed: 12/17/2022]
Abstract
OBJECTIVE The purpose was to assess the validity and reliability of health belief model variables (perceived benefits, perceived barriers, and self-efficacy beliefs) that are often the target of mammography screening interventions. METHODS Based on Champion's health belief model scales, questionnaire data were obtained from a nationally representative sample of 408 Greek women, 40 years of age or older and with no personal history of cancer. RESULTS Using confirmatory factor analysis, we found all items to load significantly on their respective factors. Standardized factor loadings ranged from 0.55 to 0.88. An analysis of localized areas of respecification of a three-factor model revealed that measurement error correlations between a few items existed. Known-groups and criterion-related validity was supported for all scales, while internal consistency reliability of the scales was satisfactory, with Cronbach's alpha ranging from 0.71 to 0.88. CONCLUSIONS The Greek version of the scales measuring perceived benefits, perceived barriers, and self-efficacy beliefs is a reliable and valid tool when used to assess health beliefs for mammography screening among women. Implications for intervention strategies aimed at increasing the likelihood of mammography utilization are considered.
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Affiliation(s)
- Fotios Anagnostopoulos
- Department of Psychology, Panteion University of Social and Political Sciences, Athens, Greece.
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22
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Health Beliefs and Illness Perceptions as Related to Mammography Uptake in Randomly Selected Women in Greece. J Clin Psychol Med Settings 2011; 19:147-64. [DOI: 10.1007/s10880-011-9272-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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van der Aalst CM, van Klaveren RJ, de Koning HJ. Does participation to screening unintentionally influence lifestyle behaviour and thus lifestyle-related morbidity? Best Pract Res Clin Gastroenterol 2010; 24:465-78. [PMID: 20833350 DOI: 10.1016/j.bpg.2010.06.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2010] [Revised: 04/20/2010] [Accepted: 06/18/2010] [Indexed: 01/31/2023]
Abstract
Cancer is a leading cause of death worldwide and the burden could be reduced by evidence-based strategies for the primary prevention of cancer, the early detection of malignancies and more adequate treatment of cancer patients. Previous research has shown that lifestyle factors are associated with common cancers and that several cancer screening programmes are cost-effective in reducing cancer-specific mortality. But, some recent studies reported that participants of screening programs might unintentionally change their lifestyle. Cancer screening might be a teachable moment or, on the other hand, have a false health certificate effect. Despite that the evidence is scarce, cancer screening might have opportunities for lifestyle improvements, although a possible health certificate effect still remains. Integrated approaches to combine primary and secondary prevention have the potential to optimise the efforts to improve cancer prevention and survival. More research is warranted to investigate evidence-based approaches.
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Affiliation(s)
- C M van der Aalst
- Department of Public Health, Erasmus MC, University Medical Centre Rotterdam, Dr. Molewaterplein 50, 3015 GE Rotterdam, The Netherlands.
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