Variation in the use of chemotherapy in lung cancer

Factors influencing the use of chemotherapy for the initial (6 months) treatment of lung cancer in South East England were investigated. The variables explored as possibly influencing the use of chemotherapy were sex, age, the year of diagnosis, the type of lung cancer, the stage, the index of multiple deprivation and the cancer network of residence. χ² analysis and multivariate logistic regression models were used to examine the effect of each of the variables on the use of chemotherapy. The results showed a highly significant trend in use of chemotherapy over time; the adjusted proportion of patients receiving chemotherapy increasing from 13.6% in 1994 to 29.3% in 2003. However, age, cancer network and type of lung cancer had the strongest influence on the use of chemotherapy. This finding is important when we consider that the NHS Cancer Plan aims at improving inequalities in cancer care in the UK.

Efficacy and safety of patupilone in non-small cell lung cancer (NSCLC): A phase I/II trial

7104

Background: Based on its activity in a wide range of tumors including those that are taxane resistant, the novel microtubule stabilizer patupilone (EPO906; epothilone B) has the potential to treat NSCLC. Fifty patients were enrolled in phase I to evaluate safety, efficacy, and optimal dose. The phase II part of this study is investigating the antitumor activity of patupilone in 53 patients with stage IIIB/IV NSCLC. Methods: Patients with histologically or cytologically confirmed unresectable, locally advanced, or metastatic NSCLC documented before 1st-line therapy without symptomatic or uncontrolled brain metastases received patupilone at a starting dose of 10.0 mg/m2 q3wk by 20-minute IV infusion. Additional inclusion criteria: age ≥18 years; WHO performance status 0–1; prior treatment with a platinum-containing regimen. Primary objective of the phase II, single-arm, 2-stage, multicenter trial: to determine activity of patupilone q3wk (overall response using modified RECIST) in NSCLC. An additional cohort with recurrent brain metastases from NSCLC is being accrued to evaluate safety, pharmacokinetics, and activity. Results: In phase I, all patients received prior treatment with platinum therapy; 28% had received taxanes and 78% nontaxanes. Patupilone dose was escalated from 6.5 to 13.0 mg/m2 q3wk. Dose-limiting toxicities occurred in 4 patients: 1 with grade 3 asthenia and 3 with grade 3 diarrhea at various dose levels. The most frequent adverse events (AEs) were diarrhea (66%), nausea (40%), vomiting (34%), paraesthesia (32%), abdominal pain (30%), and fatigue (30%). The most frequent grade 3 AE was diarrhea (14%); a grade 4 AE (asthenia) occurred in 1 patient. Overall phase I response: 5 PR, 16 SD, and 26 PD. Based on risk-benefit analyses, 10.0 mg/m2 q3wk was recommended as the phase II dose. Phase II is ongoing: 25 of 53 patients (15 men and 6 women with NSCLC; 2 men and 2 women with brain metastases) have been enrolled. Conclusions: In phase I, patupilone q3wk was safe and well tolerated, with antitumor activity in patients with advanced pretreated NSCLC. Data from phase II will be available at time of presentation.

[Table: see text]

Pegylated liposomal doxorubicin (PLD) and gemcitabine (GEM) in combination in the salvage treatment of epithelial ovarian cancer (OC)—a Danish Gynaecologic Cancer Group (DGC) study

5094

Background: Ovarian cancer patients (pts) recurring with a short treatment-free interval (TFI) after prior chemotherapy (PCT) have a bad prognosis. DGC has conducted a phase II study of PLD-GEM in combination in OC pts recurring with a TFI of less than 12 months (mo). Methods: All pts must have received at least one platinum-paclitaxel containing regimen; no PCT with GEM or anthracyclines. Regimen: GEM 800mg/m2 day 1+8 and PLD 25mg/m2 day 1, q 21 days. GEM dose escalation to 1g/m2 day 1+8 from 2. cycle in the absence of grade 3–4 toxicity. Primary end point: OS, secondary: PFS, response and toxicity. Pts were grouped according to their response to PCT. Group 1: pts with CR on PCT and TFI 3–12 mo; group 2: pts with CR on PCT and TFI 0–3 mo; group 3: pts with PR/SD on PCT and TFI 0–12 mo. 35 pts with ≥2 prior number of treatments. Results: 82 pts were enrolled (May 2003-Aug 2005); the median age was 59 yrs (range 31 to 77 yrs); 15 pts were entered with rising CA125 only (GCIG criteria). Groups according to their response to PCT: group 1: 44 pts; group 2: 5 pts; group 3: 33 pts. TFI ≤ 6 mo 33 pts, TFI > 6 to ≤ 12 mo 49 pts. To date data on 330 cycles (mean 4.7 cycles) is available; 45 pts are evaluable for PFS and OS; 62 pts are evaluable for response and 71 pts for toxicity. Grade 3–4 toxicity: PPE 6/330 cycles; mucosites 8/330 cycles; febrile neutropenia 4%; treatment delay 9%. No dose reductions performed for PLD. GEM dose escalation to 1000 mg/m2 in 31 pts; dose reduction to 650 mg/m2 at any time in 21 pts; skipped dose day 8 in 44 cycles. Response (RESIST): CR 3 pts; PR 17 pts (CR+PR 32%); SD 39 pts; PD 2 pts. Median PFS 212 days, Median OS 234 days. Conclusions: PLD-GEM in combination in the salvage setting is well tolerated, with acceptable toxicity and clear activity.

No significant financial relationships to disclose.

Review of thyroid cancer cases among patients with previous benign thyroid disorders

A previous register linkage study showed an increased risk of thyroid cancer among patients previously discharged from a hospital with a diagnosis of a benign thyroid disorder. In this study, we have reviewed all available medical records, first to validate the earlier result and second to describe the symptomatology of patients with a history of benign thyroid disorder prior to the cancer diagnosis. The previous study identified 189 patients with a benign and subsequent malignant thyroid disorder. Medical records were obtainable for 156 of these patients and were reviewed. For 104 patients, benign and malignant thyroid diseases were metachronous (a clearly separated disease history of the benign and malignant diseases), and for 48 patients synchronous. In 4 cases, thyroid cancer could not be confirmed. Among patients with metachronous thyroid disorders, all major benign thyroid disorders were represented including hot nodules, diffuse and multinodular toxic and nontoxic goiter. Symptoms preceding diagnosis of thyroid cancer included growth of goiter/nodules, globulus, stridor, hoarseness, and metastasis. No major differences were found among patients with metachronous and synchronous benign and malignant thyroid disorder, apart from the fact that all metastases were found among metachronous cases. This study confirmed the conclusion that patients with a previous history of goiter or nodules have an increased risk of thyroid cancer. However, thyroid cancer still occurs too infrequently to warrant screening in all patients with a previous history of goiter or nodules.

Cancer risk in individuals with benign thyroid disorders

The risk of cancer was examined in a cohort of 57,326 individuals who were discharged from a Danish hospital with a diagnosis of myxedema, thyrotoxicosis, or goiter. Although the general risk of cancer was only slightly increased, the risk of several sites was significantly above expected. The risk of thyroid cancer especially, was increased with standardized incidence ratios among women of 2.1 (myxedema), 2.5 (thyrotoxicosis), and 6.6 (nontoxic goiter). The increase in risk was present even many years after discharge, indicating that surveillance was not the only explanation. Furthermore, an increased risk was noted for cancer of the kidney in women discharged with myxedema (standardized incidence ratios [SIR] = 1.8) and thyrotoxicosis (SIR = 1.3), for cancer of the bladder in women discharged with myxedema (SIR = 1.5) and nontoxic goiter (SIR = 1.3), and for cancer of the hematopoetic system in women discharged with myxedema (SIR = 1.4) and nontoxic goiter (SIR = 1.4). The findings indicate that thyroid disorders may be related to cancer risk of several specific sites other than the thyroid.

[The role of diet for development of renal cell carcinoma]

Dietary risk factors for renal cell cancer were investigated in a population based case-control study of incident cases. A total of 351 cases and 340 controls matched for age and sex were interviewed about dietary habits as well as exposure to other known or suspected risk factors. An association was found between risk of renal cell cancer and energy intake, especially fats. There was no protective effect of fruits but a weak protective effect of cruceferous vegetables. The association with diet was present after adjusting for the effect of cigarette smoking, socioeconomic status and body mass index, all of which have been identified as risk factors for renal cell cancer.

[Marital status and survival in colorectal cancer]

We analysed marital status and survival from colorectal cancer among 9596 patients in a nationwide Danish study with complete follow-up of 22-26 years. After exclusion of 2294 patients with missing information, adjusted survival among married patients diagnosed with colon cancer was significantly longer (RR = 0.85; 95% CI: 0.78-0.93). We conclude that marital status does indeed prognosticate long-term survival from colon cancer. These results may have implications for psychosocial intervention after surgery for colorectal cancer.

Influence of marital status on survival from colon and rectal cancer in Denmark

Survival from colorectal cancer has been analysed in relation to marital status in a nationwide Danish study of 9596 patients with complete follow-up of 22-26 years. After exclusion of 2294 patients with missing information adjusted five-year survival among married patients was significantly longer (RR=0.85; 95% CI 0.78-0.93).

International renal-cell-cancer study. VI. the role of medical and family history

A number of medical conditions have been linked with renal-cell cancer, although the evidence is not consistent in every case. In a large international case-control study of renal-cell cancer, we examined, among other hypotheses, associations with a personal history of certain medical conditions and a family history of cancer of the kidney or thyroid. Relative risks (RR), adjusted for the effects of age, gender, body-mass index, tobacco smoking and study centre, were significantly increased by a history of kidney stones or thyroid or kidney disease. The RR were not altered by additional adjustment for hypertension, or when diagnoses were restricted to those made at least 5 or 10 years before 1987 (the usual "cut-off" date). The link with kidney injury is particularly likely to be affected by recall bias. Increased RR of borderline significance were found for kidney infection (RR, 1.2) and diabetes (RR, 1.4). Having one first-degree relative with kidney cancer was associated with a significantly increased risk of renal-cell cancer (RR, 1.6; 95% Cl, 1.1-2.4). Seven cases reported 2 first-degree relatives with kidney cancer. No controls had first-degree relatives with kidney cancer. None of our participants reported having von Hippel-Lindau disease. The data suggests that a few conditions of the kidney are strongly associated with renal-cell cancer and that heredity plays a role in a small proportion of cases.

International renal-cell-cancer study. VI. the role of medical and family history

A number of medical conditions have been linked with renal-cell cancer, although the evidence is not consistent in every case. In a large international case-control study of renal-cell cancer, we examined, among other hypotheses, associations with a personal history of certain medical conditions and a family history of cancer of the kidney or thyroid. Relative risks (RR), adjusted for the effects of age, gender, body-mass index, tobacco smoking and study centre, were significantly increased by a history of kidney stones or thyroid or kidney disease. The RR were not altered by additional adjustment for hypertension, or when diagnoses were restricted to those made at least 5 or 10 years before 1987 (the usual "cut-off" date). The link with kidney injury is particularly likely to be affected by recall bias. Increased RR of borderline significance were found for kidney infection (RR, 1.2) and diabetes (RR, 1.4). Having one first-degree relative with kidney cancer was associated with a significantly increased risk of renal-cell cancer (RR, 1.6; 95% Cl, 1.1-2.4). Seven cases reported 2 first-degree relatives with kidney cancer. No controls had first-degree relatives with kidney cancer. None of our participants reported having von Hippel-Lindau disease. The data suggests that a few conditions of the kidney are strongly associated with renal-cell cancer and that heredity plays a role in a small proportion of cases.

Dietary risk factors for renal cell carcinoma in Denmark

The role of diet in the aetiology of renal cell carcinoma was investigated in a population-based case-control study in Denmark. Cases were 20-79 years old, with a histologically verified diagnosis of renal cell carcinoma. Controls were sampled from the general population and were frequency-matched on age and sex. A total of 351 cases (73% of the eligible) and 340 controls (68% of the eligible) were included in the study. Dietary information was obtained in a self-administered food frequency questionnaire and the information was confirmed in a subsequent interview performed by trained interviewers who also elicited information on other suspected risk factors such as smoking, occupation, medical history, education and reproductive history. Logistic regression models were used to calculate the odds ratios, and, both frequency of consumption of various food stuffs and computed nutrients were examined. A positive association was observed between risk of renal cell carcinoma and total energy intake (odds ratio, OR, for highest quartile compared to lowest: 1.7 (95% confidence interval, CI, 1.0-3.0) for men, and 3.5 (95% CI 1.6-6.5) for women), fat intake (OR for highest quartile compared to lowest: 1.9 (95% CI 1.1-3.5) for men, and 3.3 (95% CI 1.6-6.9) for women). For women, an effect was also seen for intake of carbohydrates (OR for highest quartile compared to lowest: 3.2 (95% CI 1.5-6.8), while no protective effect was seen for vegetables or fruit. Dairy products may be associated with risk of renal cell cancer (OR for women using thickly spread butter compared to thinly spread: 11.4 (95% CI 2.8-45), OR for women who drank more than one glass of milk with 3.5% fat content compared to never drink milk: 3.7 (95% CI 1.2-11). As expected, total energy intake, intake of fat, protein and carbohydrates were closely correlated making it difficult to identify one of the energy sources as more closely associated with risk of renal cell cancer than the other. Several energy sources have been identified as possible risk factors for renal cell carcinoma. It is possible that a high energy intake as such rather than the individual sources are responsible for the increased risk. Furthermore, dairy fats may be associated with renal cell carcinoma risk. The observed associations appeared stronger in women, and did not explain the association with obesity and low socio-economic status previously found in Denmark.

International renal cell cancer study. VII. Role of diet

We investigated the role of diet in the etiology of renal cell cancer (RCC) in a multi-center, population-based case-control study conducted in Australia, Denmark, Sweden and the United States, using a shared protocol. A total of 1,185 incident histopathologically confirmed cases (698 men, 487 women) and 1,526 controls (915 men, 611 women) frequency-matched to cases by sex and age were included in the analyses. The association between RCC and diet was estimated by relative risks (RR) and 95% confidence intervals (CI) adjusted for age, sex, study center, body mass index and smoking. A statistically significant positive association was observed for total energy intake (RR = 1.7, 95% CI = 1.4-2.2 for the highest vs. lowest quartile, p value for trend < 0.00001), while the hypothesis that protein and fat are risk factors independent of energy was not supported. Fried meats were associated with increased RCC risk, while vegetables and fruits were protective, with the strongest effect observed for the highest quartile of consumption of orange/dark green vegetables but not vitamin C or beta carotene. Increased risk was associated with low intake (lowest decile) of vitamin E and magnesium. We observed an apparent protective effect of alcohol confined to women and probably due to chance. Our findings indicate an important role of nutrition in the development of RCC. The apparent positive association of energy intake with risk of RCC needs further investigation in a prospective cohort study to exclude the possible impact of differences in recall between cases and controls.

International renal-cell cancer study. VIII. Role of diuretics, other anti-hypertensive medications and hypertension

Risk of renal-cell cancer in relation to use of diuretics, other anti-hypertensive medications and hypertension was assessed in a multi-center, population-based, case-control study conducted in Australia, Denmark, Germany, Sweden and the United States, using a shared protocol and questionnaire. A total of 1,732 histologically confirmed cases and 2,309 controls, frequency-matched to cases by age and sex, were interviewed. The association between renal-cell cancer and the drugs was estimated by relative risks (RRs) and 95% confidence intervals (CIs). Risks were increased among users of diuretics and other anti-hypertensive medications. After adjustment for hypertension, risk for diuretics was reduced to unity, except among long-term (15+ years) users. Risk for use of non-diuretic anti-hypertensive drugs remained significantly elevated and increased further with duration of use. Overall risk was not enhanced when both classes of medications were used. Excess risk was not restricted to any specific type of diuretic or anti-hypertensive drug and no trend was observed with estimated lifetime consumption of any particular type of product. The RR for hypertension after adjustment for diuretics and other anti-hypertensive medications was 1.4 (95% CI = 1.2-1.7), although among non-users of any anti-hypertensive medications, there was little excess risk associated with a history of hypertension. Exclusion of drug use that first occurred within 5 years of cancer diagnosis or interview did not alter the associations. Our findings suggest small effects on renal-cell cancer risk associated with hypertension and use of diuretics and other anti-hypertensive medications. However, because of potential misclassifications of these highly correlated variables, it is difficult to distinguish the effect of treatment from its indication, hypertension.

International renal-cell cancer study. IV. Occupation

The relationship between renal-cell cancer (RCC) and occupation was investigated in an international multicenter population-based case-control study. Study centers in Australia, Denmark, Germany, Sweden and the United States interviewed 1732 incident RCC cases and 2309 controls. Significant associations were found with employment in the blast-furnace or the coke-oven industry [relative risk (RR), 1.7; 95% confidence interval (CI), 1.1-2.7], the iron and steel industry (RR, 1.6; 95% CI, 1.2-2.2) and exposure to asbestos (RR, 1.4; 95% CI, 1.1-1.8), cadmium (RR, 2.0; 95% CI, 1.0-3.9), dry-cleaning solvents (RR, 1.4; 95% CI, 1.1-1.7), gasoline (RR, 1.6; 95% CI, 1.2-2.0) and other petroleum products (RR, 1.6; 95% CI, 1.3-2.1). Asbestos, petroleum products and dry-cleaning solvents appear to merit further investigation, in view of the relationship between risk and duration of employment or exposure and after adjustment for confounding. There was a negative association between RCC and education, but it was not consistent across all centers. Overall, the results of our multicenter case-control study suggest that occupation may be more important in the etiology of RCC than indicated by earlier studies.

International renal-cell cancer study. V. Reproductive factors, gynecologic operations and exogenous hormones

The relationships between reproductive factors, exogenous hormones and renal-cell cancer were examined in an international, multicenter, population-based, case-control study undertaken in 1989-1991. Data from 5 centers situated in Australia, Denmark, Germany, Sweden and the United States included for analysis 608 women with renal-cell cancer and 766 female controls. A significant trend in risk (p = 0.002) was associated with number of births, with an 80% excess risk for 6 or more births [RR = 1.8, 95% confidence interval (CI) = 1.1 to 2.9] compared with one birth. A decreasing risk was seen for increasing age at first birth, although this was confounded by body-mass index and number of births. A suggestive reduction of risk was also seen for increasing age at menarche. Age at menopause was unrelated to risk of renal-cell cancer. An increased risk was observed for women having had both a hysterectomy and an oophorectomy. Use of oral contraceptives in non-smoking women reduced the risk of renal-cell cancer (RR = 0.5, 95% CI = 0.4 to 0.8); this reduction increased with longer duration of use. No association was observed for estrogen replacement therapy. Our results indicate that certain hormonal and reproductive variables may be related to risk of renal-cell cancer and deserve further investigation, both epidemiologically and experimentally.

Cancer incidence in men with Klinefelter syndrome

Many case reports have suggested an association between Klinefelter syndrome (KS) and cancer, but studies of the cancer incidence in larger groups of men with KS are lacking. A cohort of 696 men with KS was established from the Danish Cytogenetic Register. Information on the cancer incidence in the cohort was obtained from the Danish Cancer Registry and compared with the expected number calculated from the age, period and site specific cancer rates for Danish men. A total of 39 neoplasms were diagnosed (relative risk = 1.1). Four mediastinal tumours were observed (relative risk = 67); all four were malignant germ cell tumours. No cases of breast cancer or testis cancer were observed. One case of prostate cancer occurred within a previously irradiated field. No excess of leukaemia or lymphoma was found. An increased risk of cancer occurred in the age group 15-30 years (relative risk = 2.7). All six tumours in this group were germ cell tumours or sarcomas. The overall cancer incidence is not increased and no routine cancer screening seems to be justified. A considerably elevated risk of mediastinal germ cell tumours occurs in the period from early adolescence until the age of 30.

International renal-cell cancer study. II. Analgesics

There has been concern about the role of analgesics in the development of renal-cell cancer, although a few studies have reported moderately elevated risks with regular or long-term use. In a large international case-control study of renal-cell cancer we examined, among other hypotheses, the effect of phenacetin-containing and of other types of analgesics: paracetamol (acetaminophen), salicylates (mainly aspirin) and pyrazolones (e.g., antipyrine or phenazone). Relative risks, adjusted for the effects of age, sex, body-mass index, tobacco smoking and study centre, were not significantly increased with intake of phenacetin, either when lifetime consumption was categorized at the level of > or = 0.1 kg or when subjects were subdivided further by amount. Nor were paracetamol, salicylates or pyrazolones linked with renal-cell cancer. No consistently increasing risks with consumption level was found. The lack of association was not altered by restricting analgesic use to that which occurred 5 or 10 years before the defined "cut-off" date or when analysis was restricted to exclusive users of a particular type of analgesic. Neither was the risk influenced by the rate of consumption or whether the consumption had occurred at a young age. Our study provides clear evidence that aspirin is unrelated to renal-cell cancer risk, and our findings do not support the hypothesis that analgesics containing phenacetin or paracetamol increase the risk, although the number of "regular" users and the amount of these types of analgesic consumed were too small to confidently rule out a minor carcinogenic effect of phenacetin and paracetamol.

International renal-cell cancer study. III. Role of weight, height, physical activity, and use of amphetamines

Although numerous studies have identified obesity or high relative weight as a risk factor for renal-cell cancer in women, the degree to which this effect is present in men remains unclear. A multicenter population-based case-control study concerning incident cases of histologically verified renal-cell cancer (n = 1,732) and age- and sex-matched controls (n = 2,309) was conducted in Australia, Denmark, Germany (2 centers), Sweden and the United States. Relative weight was estimated by the body mass index, and the association between this factor and other factors, such as height, physical activity and use of amphetamines, was measured by the relative risk estimated in logistic regression models. Body mass index was found to be a risk factor among women and, to a lesser extent, among men. A 3-fold increased risk (RR = 3.6, 95% CI = 2.3-5.7) was observed for women with a relative weight in the top 5% compared with those in the lowest quartile. Rate of weight change (estimated as weight change per annum in kilograms) appeared to be an independent risk factor among women but not among men. Physical activity and height were unrelated to risk of renal-cell cancer regardless of level of BMI, while use of amphetamines was associated with an increased risk among men, although no dose or duration effect was seen. Our findings verify the link between high relative weight and risk of renal-cell cancer, particularly among women. The mechanism that underlies this association is, however, still unclear, although the rate of weight change may play a role.

International renal-cell cancer study. I. Tobacco use

The relationship between renal-cell cancer (RCC) and tobacco use was investigated in an international, multicenter, population-based case-control study. Coordinated studies were conducted in Australia, Denmark, Germany, Sweden and the United States using a shared protocol and questionnaire. A total of 1,732 cases (1,050 men, 682 women) and 2,309 controls (1,429 men, 880 women) were interviewed for the study. No association was observed between risk and use of cigars, pipes or smokeless tobacco. A statistically significant association was observed for cigarette smoking, with current smokers having a 40% increase in risk [relative risk (RR) = 1.4, 95% confidence interval (CI) 1.2-1.7]. Risk increased with intensity (number of cigarettes) and duration (years smoked). Among current smokers the RR for pack-years rose from 1.1 (95% CI 0.8-1.5) for < 15.9 pack years to 2.0 (95% CI 1.6-2.7) for > 42 pack years (p for trend < 0.001). Long-term quitters (> 15 years) experienced a reduction in risk of about 15-25% relative to current smokers. Those who started smoking late (> 24 years of age) had about two-thirds the risk of those who started young (< or = 12 years of age). Overall, the findings of this pooled analysis confirm that cigarette smoking is a causal factor in the etiology of RCC.

[Colorectal cancer in Denmark 1943-1988]

Nation-wide incidence rates are presented of colorectal cancer in Denmark from 1943 to 1988. In Denmark notification of malignant and related diseases is mandatory. The percentage of histologically confirmed tumours is now 95. The annual incidence rate of colon cancer in Denmark has been increasing among men and women combined from 684 cases in 1943-1947 to 2020 cases in 1988. In the same period the incidence of rectal cancer has increased from 762 cases in 1943-1947 to 1108 cases in 1988. We analyzed the effects of age, calender time, and birth cohort with multiplicative Poisson models. We did not find consistent period effects in the models. We suggest an etiologic distinction between carcinoma of the rectum, the left colon and the right colon.

Risk factors for renal cell carcinoma in Denmark: role of medication and medical history

BACKGROUND

Several recent studies of risk factors for renal cell carcinoma have indicated that use of diuretics may increase risk of this cancer. It has also been suggested that use of weak analgesics, which are known to increase risk of cancer of the renal pelvis and ureter, may also be associated with an increased risk of renal cell carcinoma--the most frequent type of kidney cancer.

METHODS

A population-based case-control study was undertaken to investigate the role of diuretics, other anti-hypertensive drugs, analgesics, and medical history in the aetiology of renal cell carcinoma. The study base was the total Danish population, and 368 histologically verified cases and 396 sex- and age-matched controls who were interviewed from February 1989 to May 1992.

RESULTS

Response rates were 76% among cases and 79% among controls. We found no general increase in risk among users of diuretics or analgesics, although women taking loop diuretics and heavy users of acetyl salicylic acid had slightly increased risks. The use of nondiuretic anti-hypertensive medications was associated with decreased risk in women. We found non-significantly increased risks for history of hypertension and other cardiovascular disorders. We also observed elevated risks for urological disorders in both sexes which may be a result of recall bias.

CONCLUSION

This study provides only limited support for the suggested association between risk of renal cell carcinoma and use of diuretics and analgesics. The coexistence of renal cell carcinoma and cardiovascular diseases could be caused by risk factors that are common to these conditions.

Risk of kidney cancer and other second solid malignancies in patients with chronic lymphocytic leukemia

Patients with chronic lymphocytic leukemia (CLL) are known to to have an increased incidence of secondary cancers. We investigated the occurrence of secondary cancers in 7391 patients with CLL diagnosed between 1955 and 1988. The observed number of cancer cases was compared with the expected number of cancers calculated from national cancer incidence rates. The overall risk of cancer was significantly increased among persons with CLL. The standardized incidence ratios (ratio between the observed and the expected numbers) were 2.0 for men and 1.2 for women. Increased risks were found for cancer of the lung and prostate in men (RR = 2.0 and 1.5 respectively), renal parenchyma in both sexes (RR = 2.8 for men, RR = 3.6 for women) non-melanoma skin cancer in both sexes (RR = 4.7 for men, RR = 2.4 for women) and sarcomas (RR = 3.3 for men, RR = 2.8 for women). Although an increased risk of cancer is to be expected solely because individuals with CLL are being physically examined frequently, it appears that the risk is significantly increased for a number of cancer sites in persons with CLL.

Occupational risk factors for renal-cell carcinoma in Denmark

OBJECTIVES

Risk factors for renal-cell carcinoma, the most frequent type of kidney cancer, remains enigmatic. Time trends in incidence and changes in the regional distribution of this cancer are suggestive of environmental risk factors. This study reports on occupational risk factors for renal-cell carcinoma in Denmark.

METHODS

In a population-based study, 365 persons with histologically verified renal-cell carcinoma and 396 referents were interviewed. Information was collected on occupation, education, and occupational exposure to a number of suspected substances, including hydrocarbons, asbestos, and radiation.

RESULTS

Risk of renal-cell carcinoma was found to be associated with employment as a truck driver, exposure to gasoline, other hydrocarbons, and insecticides and herbicides. The risk of renal-cell carcinoma was higher in the lower socioeconomic strata for both the men and the women. Nonsignificantly elevated risks were observed for employment in oil refineries, gasoline stations, and the iron and steel industry. No association was found for exposure to radiation or for employment in industries such as leather manufacturing and health care, which have previously been linked to an increased risk of renal-cell carcinoma.

CONCLUSIONS

The risk of renal-cell carcinoma is increased in lower socioeconomic strata, and previously identified or suspected risk factors do not explain the excess in risk. This study adds additional support to the hypothesis of a link between renal-cell carcinoma and hydrocarbons and also demonstrates the need for further studies on occupational risk factors for renal-cell carcinoma.

Risk factors for renal cell carcinoma in Denmark. I. Role of socioeconomic status, tobacco use, beverages, and family history

Risk factors for renal cell carcinoma were examined in a population based case-control study in Denmark. A total of 368 cases and 396 age- and gender-matched controls were interviewed in their homes. Increased risk was associated with low socioeconomic status. For men, an increasing risk with decreasing socioeconomic status was seen (odds ratio [OR] = 2.2, 95 percent confidence interval [CI] = 1.0-4.6 for men in the lowest socioeconomic stratum cf the highest). For women, the risk was lower in the highest socioeconomic stratum compared with the rest (OR = 2.4, CI = 0.9-5.9 for the lowest strata cf the highest). Cigarette smoking was a risk factor in men with an OR = 2.3 (CI = 1.1-5.1) for cigarette smokers with a total consumption of more than 40 pack-years compared with nonsmokers. Family history of kidney cancer was associated with an increased risk in both genders (for men, OR = 4.1, CI = 1.1-14.9; for women, OR = 4.8, CI = 1.0-23). Observations were inconsistent regarding coffee and alcohol consumption, and we found no association with tea drinking. The association with socioeconomic status remained after adjustment for other factors.

[Increased incidence of sarcoma in patients treated for seminoma]

In a nationwide cancer registry analysis of second primary malignancies in 6187 men with testicular cancer in the period 1943-1987, 13 sarcomas were found, yielding a 4-fold increase of the relative risk (RR). The majority of sarcomas occurred in men with seminoma, and the increased incidence was seen irrespective of time since the diagnosis of testicular cancer. The interval between the testicular cancer and the sarcoma varied from five to 34 years. After investigation of the hospital records and re-examination of the histological specimens, three patients were excluded. In spite of this, the RR was still considerably increased (at least three-fold). Seven of the 10 sarcomas were found to be located within the field of the radiation treatment administered and three at the periphery. The histological type of sarcomas varied, with leiomyosarcoma as the most frequent (three cases), followed by malignant fibrous histiocytoma (two cases) and fibrosarcoma (two cases). Since none of these patients had received chemotherapy and did not harbour sarcomatous components within the primary testis cancer, the sarcomas were probably caused by the radiation treatment. The absolute number of these secondary sarcomas is low, but the risk of developing such neoplasms and other malignancies should, even so, be kept in mind in the follow-up of testicular cancer patients.

Risk factors for renal-cell carcinoma in Denmark. III. Role of weight, physical activity and reproductive factors

A population-based case-control study of risk factors for renal-cell carcinoma was conducted in Denmark from 1989 to 1992. A total of 368 histologically verified cases and 396 controls were included. Information on weight, height, physical activity and reproductive factors were collected in a structured interview, along with information on other suspected risk factors. A significant increase in risk was seen for obese women but not obese men. Although there was no clear gradient, the risk was highest among women with a relative weight in the upper 5% (OR 6.1; 95% CI, 2.3 to 16.1). The increased risk was most evident for high relative weight in ages 30 to 50. No association was observed for height or physical activity. Use of amphetamines was associated with increased risk but, because of the close link with obesity, we were unable to provide evidence that amphetamines are an independent risk factor. We found some evidence for an association with reproductive variables, including decreased risk for women with late menarche and first pregnancy and birth. We observed no association with number of pregnancies or age at menopause, or use of estrogen-containing medication.

Obesity and cancer risk: a Danish record-linkage study

A cohort of 43,965 obese persons was accrued on the basis of discharge registrations from Danish hospitals, and incidence of cancer in the cohort was compared to that in the Danish population as a whole using indirect standardisation for age and period. Increased incidence was observed for cancer of the uterine corpus independently of age [114 cases, relative risk (RR) = 2.0, confidence interval 1.6-2.4], and for breast cancer in women above the age of 70 (133 cases, RR = 1.2). These findings are consistent with previous studies. In younger women, breast cancer occurred less frequently and ovarian cancer occurred more frequently than expected. Increased incidence was observed for cancers of the oesophagus (26 cases, RR = 1.9) and the liver (58 cases, RR = 1.9), probably reflecting an increased prevalence of excessive alcohol consumption in the cohort. Increased incidence was furthermore observed for cancers of the pancreas (101 cases, RR = 1.7), the prostate (96 cases, RR = 1.3) and the colon (195 cases, RR = 1.2), which may indicate the existence of risk factors which are common to obesity and to these cancers, for example, dietary habits. Kidney cancer was increased in women only. Overall, the incidence of cancer was increased by 16% in the cohort. The results were essentially unchanged by restriction to the subcohort of 8207 persons in whom obesity was the primary discharge diagnosis, and were also similar in the first year of follow-up after hospital discharge. Selection bias is, therefore, not likely to have influenced the results.

Trends in the incidence of cancer of the kidney, pelvis, ureter and bladder in Denmark 1943-88

Temporal trends in the incidence of cancer of the renal parenchyma, renal pelvis, ureter, bladder, urethra and Wilm's tumor in the period 1943-88 were described. Log-linear Poisson models were used to estimate the changes over time and the geographical variations. We have found a steep increase in the incidence of pelvis and ureter cancer; and to some extent also for bladder cancer in men. The incidence of cancer of the renal parenchyma has increased more moderately while the rates of Wilm's tumor have been virtually stable throughout the period. These findings suggest that tumors in the urinary system differ with respect to risk factors and should be grouped by their histological origin as well as topographical site.

Risk of kidney cancer among patients using analgesics and diuretics: a population-based cohort study

The aim of this study was to determine the risk of kidney cancer in 2 cohorts defined on the basis of hospital discharge diagnoses associated with analgesic or diuretic use during the period 1965 to 1983. Patients were followed up through 1984 for cancer incidence. After excluding cancers in the first year of observation, 161 kidney cancers were observed vs. 138 expected among 54,662 patients in the analgesics cohort. The relative risk was higher for women than for men. When examined by sub-site within the kidney, risk for cancer of the renal pelvis was similar in magnitude to that for the renal parenchyma. Among 115,616 patients in the diuretics cohort, 278 kidney cancers occurred vs. 209 expected. The risk for women was higher than for men. This elevation in risk was confined to cancer of the renal parenchyma, with no significantly increased risk seen for cancer of the renal pelvis. Although we observed little excess risk among members of the analgesics cohort, the significantly elevated risk among patients using diuretics supports a number of recent studies, but inability to adjust for confounding factors such as obesity preclude drawing any conclusion regarding diuretics. Further research is warranted to assess in detail the relationship between diuretic use and cancer of the renal parenchyma.

[Unrecognized Hodgkin's disease as cause of death. A review of 27 cases diagnosed post mortem]

The purpose of the study was to examine the incidence of unrecognised Hodgkin's disease (HD) as cause of death and to search for clinical features that could have ensured a correct pre-mortem diagnosis. A review of cases of HD reported to the Danish Cancer Registry from 1976 through 1987 in patients younger than 70 years old disclosed 27 where HD was the primary cause of death and the diagnosis was unrecognised at the time of death. The majority of the patients had no concurrent diseases and may have benefitted from a correct diagnosis and a potentially curative treatment. Most of the patients had persistent unexplained fever and weight loss. Pancytopenia, hepatic involvement, bone marrow involvement, advanced stage disease, and lymphocytic depletion histology were also frequent findings. Peripheral or retroperitoneal lymphadenopathy was noted in nine patients without biopsy. The many uncommon features of HD together with the frequent findings of falsely negative chest X-ray, bone marrow examination, liver biopsy, and abdominal ultrasound contributed to the difficulty in diagnosis. However, in about 1/3 of the patients clinical findings suggestive of lymphoma did not result in relevant diagnostic procedures.

Bone-marrow hemosiderin iron and serum iron status markers in small-cell carcinoma of the lung

Bone marrow haemosiderin iron grade and serum (S-) iron status markers (haemoglobin (Hb), S-iron, S-transferrin, transferrin saturation, S-ferritin) were measured in 31 patients with newly discovered small cell cancer of the lung (SCCL), and compared to the values in 53 healthy control subjects. Among SCCL patients, 2 had grade 0 (absent), 5 grade (1+) (trace), 8 grade 1+ (normal), and 16 grade 2+ (increased) marrow haemosiderin iron. Median S-ferritin values in the respective groups were 38 mug/l, 243 mug/l, 384 mug/l and 433 mug/l. There was no correlation between Hb, S-iron, S-transferrin or transferrin saturation and marrow iron grade. S-ferritin displayed a correlation with marrow iron grade (r(s) = 0.40, p <0.05) but there was marked overlap between the groups. Among the controls, 5 had grade 0, 11 grade (1+), and 37 grade 1+ marrow iron. Median S-ferritin values in the respective groups were 14 mug/l, 26 mug/l and 57 mug/l. Hb, S-iron, S-transferrin, transferrin saturation and S-ferritin were all significantly correlated to marrow iron grade; S-ferritin, r(s) = 0.64, p <0.0001. In conclusion, SCCL patients have inappropriately high S-ferritin values. In SCCL, serum iron status markers, including S-ferritin, are poor indicators of marrow haemosiderin iron and thus body iron stores. Therefore, estimation of marrow haemosiderin iron or histochemical/chemical liver iron content remains the only reliable way of assessing iron stores in SCCL.