Projecting the impact of implementation of WHO MPOWER measures on smoking prevalence and mortality in Japan

OBJECTIVE

This study aimed to quantify the long-term impact of implementing the WHO Framework Convention on Tobacco Control (FCTC) compliant tobacco control measures, MPOWER, on smoking prevalence and mortality in men and women aged ≥20 years in Japan.

DESIGN

A Stock-and-Flow simulation model was used to project smoking prevalence and mortality from 2018 to 2050 under eight different scenarios: (1) maintaining the 2018 status quo, (2) implementation of smoke-free policies, (3) tobacco use cessation programmes, (4-5) health warning about the dangers of tobacco (labels, mass media), (6) enforcement of tobacco advertising bans or (7) tobacco taxation at the highest recommended level and (8) all these interventions combined.

RESULTS

Under the status quo, the smoking prevalence in Japan will decrease from 29.6% to 15.5% in men and 8.3% to 4.7% in women by 2050. Full implementation of MPOWER will accelerate this trend, dropping the prevalence to 10.6% in men and 3.2% in women, and save nearly a quarter million deaths by 2050. This reduction implies that Japan will only attain the current national target of 12% overall smoking prevalence in 2033, 8 years earlier than it would with the status quo (in 2041), a significant delay from the national government's 2022 deadline.

CONCLUSIONS

To bring forward the elimination of tobacco smoking and substantially reduce smoking-related deaths, the government of Japan should fulfil its commitment to the FCTC and adopt stringent tobacco control measures delineated by MPOWER and beyond.

[Is "tobacco harm reduction" possible? Other countries' experiences and perspectives, and how they could inform tobacco control in Japan]

　"Tobacco harm reduction" is defined as a method to minimize harm and risk of death and disease without eliminating tobacco and nicotine use. In Japan, where heated tobacco products (HTPs) are prevalent, the tobacco industry is progressively endorsing the concept of "tobacco harm reduction." Therefore, stakeholders in tobacco control must urgently share perspectives and experiences surrounding this issue.　This discussion paper aimed to propose four requirements for effectively implementing "tobacco harm reduction" as a public health measure: (1) disease risk reduction, (2) cigarette smoking cessation, (3) no additional public health concerns, and (4) regulatory authorities held by health agencies, and compile information on them regarding nicotine-containing electronic cigarettes (e-cigarettes) and HTPs. Another aim was to summarize policies related to "tobacco harm reduction" adopted by an international organization (World Health Organization (WHO) and health authorities in foreign countries (the United States of America (USA), the United Kingdom (UK), Australia, Italy, and the Republic of Korea) to explore the implications of these requirements on Japan's approach. Regarding the first three requirements, scientific evidence indicated that e-cigarettes offers some level of risk reduction and can assist with cigarette smoking cessation. The potential uptake of e-cigarettes among youth and their possibility to serve as a gateway to combusted cigarette use is a concern, though a definitive causal link is yet to be established between the uptake of e-cigarette in youth and the subsequent use of different tobacco products. There is insufficient scientific evidence for any of the three requirements for HTPs. Regarding the official policies, WHO took the position that the same regulations should be applied to all tobacco products. Only the UK and USA officially established a health system based on the concept of "tobacco harm reduction"; even in Italy and the Republic of Korea, where HTPs are relatively widespread, health authorities denied any risk reduction by introducing HTPs. The UK officially adopted a smoking cessation policy with e-cigarettes. The USA established a modified risk tobacco product system under federal legislation enacted in 2009, whereas of June 2023, no HTP or e-cigarettes were recognized as explicitly reducing health risk. Regarding the fourth requirement, the UK and USA institutionalized "tobacco harm reduction" under health authorities' regulation independent of the tobacco industry. The introduction of a tobacco harm reduction policy in Japan should be considered only in line with health authorities' regulation and implementation of comprehensive tobacco control measures independent of the tobacco industry.

Exposure to pesticides and risk of Hodgkin lymphoma in an international consortium of agricultural cohorts (AGRICOH)

PURPOSE

Some pesticides may increase the risk of certain lymphoid malignancies, but few studies have examined Hodgkin lymphoma (HL). In this exploratory study, we examined associations between agricultural use of 22 individual active ingredients and 13 chemical groups and HL incidence.

METHODS

We used data from three agricultural cohorts participating in the AGRICOH consortium: the French Agriculture and Cancer Cohort (2005-2009), Cancer in the Norwegian Agricultural Population (1993-2011), and the US Agricultural Health Study (1993-2011). Lifetime pesticide use was estimated from crop-exposure matrices or self-report. Cohort-specific covariate-adjusted overall and age-specific (< 40 or ≥ 40 years) hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated using Cox regression and combined using random effects meta-analysis.

RESULTS

Among 316 270 farmers (75% male) accumulating 3 574 815 person-years at risk, 91 incident cases of HL occurred. We did not observe statistically significant associations for any of the active ingredients or chemical groups studied. The highest risks of HL overall were observed for the pyrethroids deltamethrin (meta-HR = 1.86, 95% CI 0.76-4.52) and esfenvalerate (1.86, 0.78-4.43), and inverse associations of similar magnitude were observed for parathion and glyphosate. Risk of HL at ≥ 40 years of age was highest for ever-use of dicamba (2.04, 0.93-4.50) and lowest for glyphosate (0.46, 0.20-1.07).

CONCLUSION

We report the largest prospective investigation of these associations. Nonetheless, low statistical power, a mixture of histological subtypes and a lack of information on tumour EBV status complicate the interpretability of the results. Most HL cases occurred at older ages, thus we could not explore associations with adolescent or young adult HL. Furthermore, estimates may be attenuated due to non-differential exposure misclassification. Future work should aim to extend follow-up and refine both exposure and outcome classification.

Analysis of the Breast Cancer Journey in Namibia

Importance

Breast cancer (BC) is the leading cancer among women in Namibia. Examining the BC journey in this multiracial country where inequalities remain large is needed to inform effective interventions to reduce BC mortality.

Objective

To describe the entire BC journey of Namibian women by race, utilizing the World Health Organization Global Breast Cancer Initiative (GBCI) framework.

Design, Setting, and Participants

This cohort study used the Namibian subset of the African Breast Cancer-Disparities in Outcomes prospective cohort. Participants were all Namibian residents with confirmed incident BC who presented at the main national public oncology center of the Windhoek Central Hospital (WCH). Follow-up started from recruitment (September 8, 2014, to October 5, 2016) and ended up to 3 years after diagnosis (December 13, 2014, to September 27, 2019). Data analysis was conducted from June 2022 to August 2023.

Exposures

Participants' self-reported ethnicities were aggregated into 3 population groups: Black, mixed ancestry, and White.

Main Outcomes and Measures

Three-year overall survival (OS) was examined using Cox models, and summary statistics were used to describe women's BC journey, including GBCI pillar key performance indicators: (1) early stage (TNM I or II) diagnosis (population benchmark ≥60%), (2) prompt diagnosis, ie, 60 days or less to first health care practitioner visit (population benchmark 100%), and (3) completion of recommended multimodal treatment (MT, ie, surgery plus chemotherapy) (population benchmark ≥80%).

Results

Of 405 women, there were 300 (74%) Black (mean [SD] age, 53 [15] years), 49 (12%) mixed ancestry (mean [SD] age, 53 [7] years), and 56 (14%) White (mean [SD] age, 59 [12] years) patients. Three-year OS was lowest in Black women (60% [95% CI, 54%-66%]; mixed ancestry: 80% [95% CI, 65%-89%]; White: 89% [95% CI, 77%-95%]), who had lower prevalence of early stage diagnosis (Black: 37% [95% CI, 31%-42%]; mixed ancestry and White: 75% [95% CI, 66%-83%]) and timely diagnosis (Black: 60% [95% CI, 54%-66%]; mixed ancestry and White: 77% [95% CI, 69%-85%]), while MT completion (Black: 53% [95% CI, 46%-59%]; mixed ancestry and White: 63% [95% CI, 50%-73%]) was low in all women.

Conclusions and Relevance

In this cohort study of 405 Namibian residents with BC, marked racial disparities in survival were paralleled by inequities all along the BC journey. To improve BC survival, interventions are needed to promote earlier diagnosis in Black Namibian women and to increase MT initiation and completion in all women.

Towards elimination of cervical cancer - human papillomavirus (HPV) vaccination and cervical cancer screening in Asian National Cancer Centers Alliance (ANCCA) member countries

About 95% of cervical cancers worldwide are caused by human papillomavirus (HPV). Cervical cancer is preventable and curable if it is detected and treated early. We reviewed the latest national cervical cancer indicators, and barriers to HPV vaccination and cervical cancer screening in 21 Asian National Cancer Centers Alliance (ANCCA) member countries. Half (n = 11, 52%) of the countries have introduced HPV vaccination for girls as part of their national vaccination programme, three countries reported coverage of over 90%. Most ANCCA member countries have cervical cancer screening programmes, only five countries reported screening uptake of over 50%. The barriers to HPV vaccination coverage and cervical cancer screening participation have been identified. Ensuring health service accessibility and affordability for women, addressing sociocultural barriers, and strengthening the healthcare system and continuum of care are essential to increase HPV vaccination and cervical cancer screening coverage.

Impact of the COVID-19 pandemic on mortality trends in Japan: a reversal in 2021? A descriptive analysis of national mortality data, 1995-2021

OBJECTIVE

The COVID-19 pandemic led to an increase in mortality in most countries in 2020, deviating from prior decreasing trends. In Japan, however, mortality was suggested to decrease in 2020. This study investigated long-term mortality trends and cause-specific contributions, focusing on the period of the COVID-19 pandemic in Japan.

DESIGN

We analysed Japanese age-standardised mortality rates (ASMRs) from 1995 to 2021 using vital statistics.

MAIN OUTCOME MEASURES

The cause-specific annual ASMR changes were calculated in comparison with the previous year over the abovementioned period.

RESULTS

There was a general downward trend in overall ASMR for both sexes until 2020 followed by a small increase in 2021. In men, the all-cause ASMR (per 100 000 persons) decreased from 1352.3 to 1328.8 in 2020 (-1.74% from 2019), and increased to 1356.3 in 2021 in men (+2.07% from 2020). In women, the all-cause ASMR decreased from 746.0 to 722.1 in 2020 (-3.20% from 2019), and increased to 737.9 (+2.19% from 2020) in 2021. ASMRs from malignant neoplasms, pneumonia, accidents and suicide (men only) continued to decrease during the COVID-19 pandemic while the trend of cardiovascular mortality increased in 2021. Analysis of ASMR changes revealed that COVID-19, senility, cardiovascular disease and 'other causes not classified as major causes' contributed to the all-cause mortality increase in 2021.

CONCLUSIONS

In Japan, the decreasing trend in overall mortality continued in 2020 despite the COVID-19 pandemic. However, approximately 2% mortality increase was observed in 2021, which was attributable to COVID-19, senility, cardiovascular disease and 'other causes'. The year 2021 was a turning point of mortality trends in Japan, although continued monitoring is warranted.

Prevalence of subclinical lung cancer detected at autopsy: a systematic review

BACKGROUND

Lung cancer screening in high-risk populations with low-dose computed tomography is supported by international associations and recommendations. Overdiagnosis is considered a risk of screening with associated harms. The aim of this paper is to determine the prevalence of subclinical lung cancer diagnosed post-mortem to better understand the reservoir of subclinical lung cancer.

METHODS

We searched EMBASE, PubMed, and MEDLINE databases from inception until March 2022 with no language restrictions. We considered all studies with ≥100 autopsies in adults. Two reviewers independently assessed eligibility of studies, extracted data, and assessed risk of bias of included studies. We performed a meta-analysis using a random-effects model for prevalence of subclinical lung cancer diagnosed post-mortem with sensitivity and subgroup analyses.

RESULTS

A total of 13 studies with 16 730 autopsies were included. Pooled prevalence was 0.4% (95% CI 0.20 to 0.82%, I2 = 84%, tau2 = 1.19, low certainty evidence,16 730 autopsies). We performed a sensitivity analysis excluding studies which did not specify exclusion of children in their cohort, with a pooled prevalence of subclinical lung cancer of 0.87% (95% CI 0.48 to 1.57%, I2 = 71%, tau2 = 0.38, 6998 autopsies, 8 studies).

CONCLUSIONS

This is the first published systematic review to evaluate the prevalence of post-mortem subclinical lung cancer. Compared to autopsy systematic reviews in breast, prostate and thyroid cancers, the pooled prevalence is lower in lung cancer for subclinical cancer. This result should be interpreted with caution due to the included studies risk of bias and heterogeneity, with further high-quality studies required in target screening populations.

Practical Implications of the Update to the 2015 Japan Standard Population: Mortality Archive From 1950 to 2020 in Japan

BACKGROUND

The 2015 Japan Standard Population (JSP) was established in response to changes in the age structure. However, the effects of major updates, especially the recategorization of older age groups, for interpreting various health metrics have not been clarified.

METHODS

Population data were collected and estimated for older age categories (85-89, 90-94, and ≥95 years). Data on the number of deaths were also collected from the Vital Statistics. We recalculated the all-cause and leading cause-specific age-standardized mortality rate (ASMR) using the 2015 JSP by the direct standardization method for data from 1950 to 2020. We compared ASMRs calculated using the 2015 JSP with those calculated using the 1985 JSP. Pearson's correlation coefficients were used to evaluate the consistency of mortality trends between the 2015 and 1985 JSPs.

RESULTS

The absolute all-cause ASMRs calculated using the 2015 JSP were 2.22-3.00 times higher than those calculated using the 1985 JSP. The ASMR ratios increased gradually over time. While trends in all-cause and cause-specific ASMRs calculated using the 2015 JSP and 1985 JSP were generally highly correlated (Pearson's correlation coefficient [r] = 0.993 for all-cause), correlations were relatively low for malignant neoplasms (r = 0.720 for men and r = 0.581 for women) and pneumonia/bronchitis (r = 0.543 for men and r = 0.559 for women) due to non-monotonous trends over time and fluctuations in earlier time periods.

CONCLUSION

The effect of introducing the new JSP for interpreting trends in all-cause mortality was considered minimal. However, caution is needed when interpreting trends in some cause-specific mortality rates.

[Geographic information in National Cancer Registry data: Overseas examples and challenges in Japan]

 Worldwide, research based on geographic information of official statistical data, including cancer registries, is utilized for cancer control and public health policies. The National Cancer Registry of Japan was launched in 2016, making it possible to use data on cancer incidence systematically. Given the nature of this comprehensive survey, the usefulness of the National Cancer Registry would be further enhanced when it is utilized at small-regional levels, such as in municipalities or even smaller geographical units. It is essential to maintain a balance between privacy protection and data usability. Currently, the national and prefectural councils determine the availability of the data from the National Cancer Registry at the small-regional level on an individual application basis. Under this framework, use of the data is often restricted or declined. This paper showcases three model countries where geographic information obtained from cancer registry data are widely utilized: the United States, Canada, and the United Kingdom. It further discusses measures to ensure that data are effectively used, without compromising data privacy. In the three countries, data-providing systems have been established to compile the necessary data from the cancer registry and other linked databases, in accordance with the purpose of use. The relationships between healthcare access and various outcomes are elaborately examined at the small-regional level. In Japan, similar utilization of data has not been fully implemented, and there remain many hurdles to the application of the data use. For the National Cancer Registry to promote research and further enhance cancer control, it is necessary to establish a system that enables effective and safe utilization of the data from the National Cancer Registry, including linkage with other data and on-site use.

Response to Toshihide Tsuda, Yumiko Miyano and Eiji Yamamoto [1]

BACKGROUND

Using a toolkit approach, Tsuda et al. critiqued work carried out by or in collaboration with the International Agency for Research on Cancer (IARC/WHO), including the IARC technical publication No. 46 on "Thyroid health monitoring after nuclear accidents" (TM-NUC), the project on nuclear emergency situations and improvement on medical and health surveillance (SHAMISEN), and the IARC-led work on global thyroid cancer incidence patterns as per IARC core mandate.

MAIN BODY

We respond on the criticism of the recommendations of the IARC technical publication No. 46, and of global thyroid cancer incidence evaluation.

CONCLUSION

After nuclear accidents, overdiagnosis can still happen and must be included in informed decision making when providing a system of optimal help for cases of radiation-induced thyroid cancer, to minimize harm to people by helping them avoid diagnostics and treatment they may not need.

Measurement of Intermediate Frequency Magnetic Fields Generated by Household Induction Cookers for Epidemiological Studies and Development of an Exposure Estimation Model

INTRODUCTION

Exposure assessment of intermediate frequency (IF) electromagnetic fields (EMFs) is difficult and epidemiological studies are limited. In the present study, we aimed to estimate the exposure of pregnant women to IF-EMFs generated by induction cookers in the household using a questionnaire and discussed its applicability to epidemiological studies.

METHOD

Two main home-visit surveys were conducted: a Phase 1 survey to develop an estimation model and a Phase 2 survey to validate the model. The estimation model included the following variables: wattage, cookware diameter, and distance from the hob center (center of the stove). Four models were constructed to determine the importance of each variable and the general applicability for epidemiological studies. In addition, estimated exposure values were calculated based on the Phase 2 survey questionnaire responses and compared with the actual measured values using the Spearman rank correlation coefficient.

RESULT

The average value of the magnetic field measured in the Phase 1 survey was 0.23 μT (variance: 0.13) at a horizontal distance of 30 cm at the height of the cooking table. The highest validity model was inputted distance from the hob center to the body surface that is variable (correlation coefficient = 0.54, 95% confidence interval: 0.22-0.75). No clear differences were identified in the correlation coefficients for each model (z-value: 0.09-0.18, p-value: 0.86-0.93).

DISCUSSION AND CONCLUSIONS

No differences were found in the validity of the four models. This could be due to the biased wattage of the validation population, and for versatility it would be preferable to use three variables (distance, wattage, and estimation using the diameter of the cookware) whenever possible. To our knowledge, this is the first systematic measurement of magnetic fields generated by more than 70 induction cookers in a real household environment. This study will contribute to finding dose-response relationships in epidemiological studies of intermediate-frequency exposure without the use of instrumentation. One of the limitations of this study is it estimates instantaneous exposure in place during cooking only.

Parental occupational exposures in wood-related jobs and risk of testicular germ cell tumours in offspring in NORD-TEST a registry-based case-control study in Finland, Norway, and Sweden

OBJECTIVE

We assessed the association between parental prenatal exposures in wood-related jobs and risk of testicular germ cell tumours (TGCT) in offspring.

METHODS

NORD-TEST, a registry-based case-control study in Sweden, Finland and Norway, included 8112 TGCT cases diagnosed at ages 14-49 years between 1978 and 2012 with no history of prior cancer, and up to four controls matched to each case on year and country of birth. Parents of cases and controls were identified via linkages with the population registries and their occupational information was retrieved from censuses. The Nordic Occupational Cancer Study Job-Exposure Matrix was used to assign occupational exposures to each parent. Logistic regression models were used to estimate odds ratios (OR) and 95% confidence intervals (CI).

RESULTS

Maternal wood-related job was not associated with the risk of TGCT in offspring (OR 1.08, CI 0.55-2.14), while paternal wood-related job was associated with a decreased risk of TGCT in offspring (OR 0.85, CI 0.75-0.96). None of the specific wood-related jobs, such as upholsterers, sawyers, or construction carpenters, were significantly associated with a risk of TGCT. Only exception was observed in a sensitivity analysis which showed an increased risk in the small group of sons of fathers working as 'cabinetmakers and joiners' the year before conception (OR of 2.06, CI 1.00-4.25).

CONCLUSION

This large-scale NORD-TEST analysis provided no evidence of an association between parental prenatal exposures in wood-related jobs and TGCT in sons.

Cancer incidence in agricultural workers: Findings from an international consortium of agricultural cohort studies (AGRICOH)

BACKGROUND

Agricultural work can expose workers to potentially hazardous agents including known and suspected carcinogens. This study aimed to evaluate cancer incidence in male and female agricultural workers in an international consortium, AGRICOH, relative to their respective general populations.

METHODS

The analysis included eight cohorts that were linked to their respective cancer registries: France (AGRICAN: n = 128,101), the US (AHS: n = 51,165, MESA: n = 2,177), Norway (CNAP: n = 43,834), Australia (2 cohorts combined, Australian Pesticide Exposed Workers: n = 12,215 and Victorian Grain Farmers: n = 919), Republic of Korea (KMCC: n = 8,432), and Denmark (SUS: n = 1,899). For various cancer sites and all cancers combined, standardized incidence ratios (SIR) and 95% confidence intervals (CIs) were calculated for each cohort using national or regional rates as reference rates and were combined by random-effects meta-analysis.

RESULTS

During nearly 2,800,000 person-years, a total of 23,188 cancers were observed. Elevated risks were observed for melanoma of the skin (number of cohorts = 3, meta-SIR = 1.18, CI: 1.01-1.38) and multiple myeloma (n = 4, meta-SIR = 1.27, CI: 1.04-1.54) in women and prostate cancer (n = 6, meta-SIR = 1.06, CI: 1.01-1.12), compared to the general population. In contrast, a deficit was observed for the incidence of several cancers, including cancers of the bladder, breast (female), colorectum, esophagus, larynx, lung, and pancreas and all cancers combined (n = 7, meta-SIR for all cancers combined = 0.83, 95% CI: 0.77-0.90). The direction of risk was largely consistent across cohorts although we observed large between-cohort variations in SIR for cancers of the liver and lung in men and women, and stomach, colorectum, and skin in men.

CONCLUSION

The results suggest that agricultural workers have a lower risk of various cancers and an elevated risk of prostate cancer, multiple myeloma (female), and melanoma of skin (female) compared to the general population. Those differences and the between-cohort variations may be due to underlying differences in risk factors and warrant further investigation of agricultural exposures.

Self-reported symptoms of arm lymphedema and health-related quality of life among female breast cancer survivors

We examined cross-sectional associations between arm lymphedema symptoms and health-related quality of life (HRQoL) in the Health, Eating, Activity and Lifestyle (HEAL) Study. 499 women diagnosed with localized or regional breast cancer at ages 35-64 years completed a survey, on average 40 months after diagnosis, querying presence of lymphedema, nine lymphedema-related symptoms, e.g., tension, burning pain, mobility loss, and warmth/redness, and HRQoL. Analysis of covariance models were used to assess HRQoL scores in relation to presence of lymphedema and lymphedema-related symptoms. Lymphedema was self-reported by 137 women, of whom 98 were experiencing lymphedema at the time of the assessment. The most common symptoms were heaviness (52%), numbness (47%), and tightness (45%). Perceived physical health was worse for women reporting past or current lymphedema than those reporting no lymphedema (P-value < 0.0001). No difference was observed for perceived mental health (P-value = 0.31). Perceived physical health, stress, and lymphedema-specific HRQoL scores worsened as number of symptoms increased (P-values ≤ 0.01). Women reporting tension in the arm had lower physical health (P-value = 0.01), and those experiencing burning pain, tension, heaviness, or warmth/redness in the arm had lower lymphedema-specific HRQoL (P-values < 0.05). Treatment targeting specific lymphedema-related symptoms in addition to size/volume reduction may improve some aspects of HRQoL among affected women.

Geospatial barriers to healthcare access for breast cancer diagnosis in sub-Saharan African settings: The African Breast Cancer-Disparities in Outcomes Cohort Study

We examined the geospatial dimension of delays to diagnosis of breast cancer in a prospective study of 1541 women newly diagnosed in the African Breast Cancer-Disparities in Outcomes (ABC-DO) Study. Women were recruited at cancer treatment facilities in Namibia, Nigeria, Uganda and Zambia. The baseline interview included information used to generate the geospatial features: urban/rural residence, travel mode to treatment facility and straight-line distances from home to first-care provider and to diagnostic/treatment facility, categorized into country/ethnicity (population)-specific quartiles. These factors were investigated in relation to delay in diagnosis (≥3 months since first symptom) and late stage at diagnosis (TNM: III, IV) using logistic regression, adjusted for population group and sociodemographic characteristics. The median (interquartile range) distances to first provider and diagnostic and treatment facilities were 5 (1-37), 17 (3-105) and 62 (5-289) km, respectively. The majority had a delay in diagnosis (74%) and diagnosis at late stage (64%). Distance to first provider was not associated with delay in diagnosis or late stage at diagnosis. Rural residence was associated with delay, but the association did not persist after adjustment for sociodemographic characteristics. Distance to the diagnostic/treatment facility was associated with delay (highest vs lowest quartile: odds ratio (OR) = 1.56, 95% confidence interval (CI) = 1.08-2.27) and late stage (overall: OR = 1.47, CI = 1.05-2.06; without Nigerian hospitals where mostly local residents were treated: OR = 1.73, CI = 1.18-2.54). These findings underscore the need for measures addressing the geospatial barriers to early diagnosis in sub-Saharan African settings, including providing transport or travel allowance and decentralizing diagnostic services.

Cancer Incidence and Mortality among Petroleum Industry Workers and Residents Living in Oil Producing Communities: A Systematic Review and Meta-Analysis

Petroleum extraction and refining are major sources of various occupational exposures and of air pollution and may therefore contribute to the global cancer burden. This systematic review and meta-analysis is aimed at evaluating the cancer risk in petroleum-exposed workers and in residents living near petroleum facilities. Relevant studies were identified and retrieved through PubMed and Web of Science databases. Summary effect size (ES) and 95% confidence intervals (CI) were analysed using random effect models, and heterogeneity across studies was assessed (I2). Overall, petroleum industry work was associated with an increased risk of mesothelioma (ES = 2.09, CI: 1.58-2.76), skin melanoma (ES = 1.34, CI: 1.06-1.70 multiple myeloma (ES =1.81, CI: 1.28-2.55), and cancers of the prostate (ES = 1.13, Cl: 1.05-1.22) and urinary bladder (ES = 1.25, CI: 1.09-1.43) and a decreased risk of cancers of the esophagus, stomach, colon, rectum, and pancreas. Offshore petroleum work was associated with an increased risk of lung cancer (ES = 1.20; 95% CI: 1.03-1.39) and leukemia (ES = 1.47; 95% CI: 1.12-1.92) in stratified analysis. Residential proximity to petroleum facilities was associated with childhood leukemia (ES = 1.90, CI: 1.34-2.70). Very few studies examined specific exposures among petroleum industry workers or residents living in oil producing communities. The present review warrants further studies on specific exposure levels and pathways among petroleum-exposed workers and residents living near petroleum facilities.

Global patterns and trends in incidence and mortality of thyroid cancer in children and adolescents: a population-based study

BACKGROUND

There has been a considerable increase in thyroid cancer incidence among adults in several countries in the past three decades, attributed primarily to overdiagnosis. We aimed to assess global patterns and trends in incidence and mortality of thyroid cancer in children and adolescents, in view of the increased incidence among adults.

METHODS

We did a population-based study of the observed incidence (in 49 countries and territories) and mortality (in 27 countries) of thyroid cancer in children and adolescents aged 0-19 years using data from the International Incidence of Childhood Cancer Volume 3 study database, the WHO mortality database, and the cancer incidence in five continents database (CI5plus; for adult data [age 20-74 years]). We analysed temporal trends in incidence rates, including absolute changes in rates, and the strength of the correlation between incidence rates in children and adolescents and in adults. We calculated the average annual number of thyroid cancer deaths and the age-standardised mortality rates for children and adolescents.

FINDINGS

Age-standardised incidence rates of thyroid cancer among children and adolescents aged 0-19 years ranged from 0·4 (in Uganda and Kenya) to 13·4 (in Belarus) cancers per 1 million person-years in 2008-12. The variability in the incidence rates was mostly accounted for by the papillary tumour subtype. Incidence rates were almost always higher in girls than in boys and increased with age in both sexes. Rapid increases in incidence between 1998-2002 and 2008-12 were observed in almost all countries. Country-specific incidence rates in children and adolescents were strongly correlated (r>0·8) with rates in adults, as were the temporal changes in the respective incidence rates (r>0·6). Thyroid cancer deaths in those aged younger than 20 years were less than 0·1 per 10 million person-years in each country.

INTERPRETATION

The pattern of thyroid cancer incidence in children and adolescents mirrors the pattern seen in adults, suggesting a major role for overdiagnosis, which, in turn, can lead to overtreatment, lifelong medical care, and side effects that can negatively affect quality of life. We suggest that the existing recommendation against screening for thyroid cancer in the asymptomatic adult population who are free from specific risk factors should be extended to explicitly recommend against screening for thyroid cancer in similar populations of children and adolescents.

FUNDING

International Agency for Research on Cancer and the Union for International Cancer Control; French Institut National du Cancer; Italian Association of Cancer Research; and Italian Ministry of Health.

Breast cancer survival and survival gap apportionment in sub-Saharan Africa (ABC-DO): a prospective cohort study

BACKGROUND

Breast cancer is the second leading cause of death from cancer in women in sub-Saharan Africa, yet there are few well characterised large-scale survival studies with complete follow-up data. We aimed to provide robust survival estimates in women in this setting and apportion the survival gaps.

METHODS

The African Breast Cancer-Disparities in Outcomes (ABC-DO) prospective cohort study was done at eight hospitals across five sub-Saharan African countries (Namibia, Nigeria, South Africa, Uganda, and Zambia). We prospectively recruited women (aged ≥18 years) who attended these hospitals with suspected breast cancer. Women were actively followed up by use of a telephone call once every 3 months, and a mobile health application was used to keep a dynamic record of follow-up calls due. We collected detailed sociodemographic, clinical, and treatment data. The primary outcome was 3-year overall survival, analysed by use of flexible proportional mortality models, and we predicted survival under scenarios of modified distributions of risk factors.

FINDINGS

Between Sept 8, 2014, and Dec 31, 2017, 2313 women were recruited from these eight hospitals, of whom 85 did not have breast cancer. Of the remaining 2228 women with breast cancer, 58 women with previous treatment or recurrence, and 14 women from small racial groups (white and Asian women in South Africa), were excluded. Of the 2156 women analysed, 1840 (85%) were histologically confirmed, 129 (6%) were cytologically confirmed, and 187 (9%) were clinically confirmed to have breast cancer. 2156 (97%) women were followed up for up to 3 years or up to Jan 1, 2019, whichever was earlier. Up to this date, 879 (41%) of these women had died, 1118 (52%) were alive, and 159 (7%) were censored early. 3-year overall survival was 50% (95% CI 48-53), but we observed variations in 3-year survival between different races in Namibia (from 90% in white women to 56% in Black women) and in South Africa (from 76% in mixed-race women to 59% in Black women), and between different countries (44-47% in Uganda and Zambia vs 36% in Nigeria). 215 (10%) of all women had died within 6 months of diagnosis, but 3-year overall survival remained low in women who survived to this timepoint (58%). Among survival determinants, improvements in early diagnosis and treatment were predicted to contribute to the largest increases in survival, with a combined absolute increase in survival of up to 22% in Nigeria, Zambia, and Uganda, when compared with the contributions of other factors (such as HIV or aggressive subtypes).

INTERPRETATION

Large variations in breast cancer survival in sub-Saharan African countries indicate that improvements are possible. At least a third of the projected 416 000 breast cancer deaths that will occur in this region in the next decade could be prevented through achievable downstaging and improvements in treatment. Improving survival in socially disadvantaged women warrants special attention.

FUNDING

Susan G Komen and the International Agency for Research on Cancer.

Parental occupational exposure to solvents and heavy metals and risk of developing testicular germ cell tumors in sons (NORD-TEST Denmark)

Objective The present study aims to assess if parental occupational exposure to solvents or heavy metals is associated with risk of testicular germ cell tumors (TGCT) in sons in Denmark. Methods The NORD-TEST Denmark included 3421 cases diagnosed with TGCT at ages 14-49 years in Denmark between 1981 and 2014. Controls (N=14 024) selected from the central population registry were matched to cases on birth year. The Danish Supplementary Pension Fund provided parental occupational information. A job-exposure matrix was used to assign exposures, and conditional logistic regression models were used to estimate odds ratios (OR) and 95% confidence intervals (CI). Results The overall analyses showed no significant associations except for paternal exposure to a sub-group of "heavy metal(s) and solvent(s)" (OR 1.50, 95% CI 1.01-2.24). Most fathers in this category had worked in wood related jobs and were assigned exposure to chromium VI and toluene. Other sub-group analyses suggested that maternal exposure to aromatic hydrocarbon were associated with TGCT risk, in sons born in 1970-1979, and to heavy metals (chromium, iron and nickel) in sons born in 1980-1998. Conclusion NORD-TEST Denmark provides no strong support for an association between parental exposures to solvents or heavy metals and TGCT in sons, and only weak support for an association between paternal exposure to chromium and toluene and TGCT risk in sons.

Abstract C78: Pre-diagnostic journey of women with breast cancer and disparities in stage at diagnosis in Namibia: The African Breast Cancer–Disparities in Outcomes (ABC-DO) Cohort Study

Purpose: Breast cancer survival rates in sub-Saharan Africa (SSA) are low and the reasons therefor partly involve advanced disease at diagnosis. Within the African Breast Cancer – Disparities in Outcomes (ABC-DO) Study, a prospective study of breast cancer survival in multiple SSA settings, we examined spatiotemporal barriers to early presentation and diagnosis related to pre-diagnostic journey of women with breast cancer in the vast Southern African country of Namibia.

Methods: 503 newly diagnosed breast cancer patients who presented at the Windhoek Central Hospital (WCH) in Namibia completed face-to-face interviews between September 2014 and October 2016. Participants were asked about sociodemographic factors, locations of residential home and health care providers, dates of visits to health care providers, and mode of transport. The straight-line distances from home to the first health care provider and the cancer care facility (WCH) were calculated. Clinical data including disease stage were extracted from medical records. Logistic regression models were used to estimate the odds ratios (OR) and corresponding 95% confidence intervals (CI) for late stage disease (stage III or IV) associated with the pre-diagnostic journey of women.

Results: The analytical sample included 498 women, the majority of whom were black (79%), were diagnosed with a late-stage disease (stage III, 41%; stage IV, 15%), and resided outside Windhoek (within Namibia, 70%; outside Namibia, 10%). The mean age at diagnosis was 54 years (standard deviation, 14.7; range, 24–98). The distance from home to the WCH ranged from 0 to 1,643 km (median, 308 km). In unadjusted analyses, a longer distance from home to the WCH was associated with late stage (per 100 km increment: OR, 1.09; 95% CI, 1.04–1.15); however, distance to the first care provider was not statistically significantly associated with disease stage (OR per 100-km increment, 1.06; 95% CI, 0.97–1.17). Unadjusted analyses also showed that being black (vs. non-black: OR, 5.38. 95% CI, 3.30–8.78), longer time taken to travel to the WCH (OR per one-hour increment, 1.06; 95% CI, 1.02–1.10), and travelling by a transport service provided by a cancer association or a hospital (vs. travelling by private cars: OR, 2.71; 95% CI, 1.78–4.11) were associated with late stage whereas age, time interval between the first contact with a health care provider and the first visit to the WCH, and number of health care providers seen before referral to the WCH were not associated with disease stage. In the analysis that adjusted for race/ethnicity, neither travel distance/time from home to the WCH nor transport mode was statistically significantly associated with disease stage.

Conclusions: In the Namibian subset of the ABC-DO Study, the association between a longer travel distance or time to the WCH and late stage of breast cancer at diagnosis appeared to be driven by the association between race/ethnicity and disease stage. The greater odds of late-stage diagnosis associated with the use of patient transport service likely reflect a response to urgent medical needs. The ongoing analysis will further investigate other potential barriers that explain disparities in stage at diagnosis among women in Namibia and other SSA settings.

Citation Format: Kayo Togawa, Fiona McKenzie, Annelle Zietsman, Isabel dos Santos Silva, Valerie McCormack. Pre-diagnostic journey of women with breast cancer and disparities in stage at diagnosis in Namibia: The African Breast Cancer–Disparities in Outcomes (ABC-DO) Cohort Study [abstract]. In: Proceedings of the Tenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2017 Sep 25-28; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2018;27(7 Suppl):Abstract nr C78.

Body mass index at age 18 years and recent body mass index in relation to risk of breast cancer overall and ER/PR/HER2-defined subtypes in white women and African-American women: a pooled analysis

BACKGROUND

Although it has been well-documented that obesity is associated with decreased risk of premenopausal breast cancer and increased risk of postmenopausal breast cancer, it is unclear whether these associations differ among breast cancer subtypes defined by the tumor protein expression status of estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2).

METHODS

We evaluated the associations of body mass index (BMI) at age 18 years and recent BMI in relation to risk of breast cancer overall and ER/PR/HER2-defined subtypes, in 6320 women (3934 case-patient participants, 2386 control participants) aged 35-64 years, who participated in one of three population-based case-control studies. We estimated multivariable-adjusted odd ratios (ORs) and corresponding 95% confidence intervals (CIs) using polychotomous unconditional logistic regression methods for case-control comparisons in premenopausal women and postmenopausal women.

RESULTS

BMI at age 18 years was inversely associated with risk of breast cancer, particularly among premenopausal women (≥ 25 vs. < 20 kg/m2, OR = 0.72, 95% CI = 0.53-0.96; per 5 kg/m2 increase, OR = 0.83, 95% CI = 0.73-0.95). This inverse association did not differ across ER/PR/HER2-defined subtypes or by race (white women, African-American women). Recent BMI was not associated with risk of premenopausal breast cancer after adjustment for BMI at age 18 years; nevertheless, the analysis for the joint effects of BMI at age 18 years and recent BMI showed that premenopausal women in the highest categories of the two BMI measures (≥ 25 kg/m2 at age 18 years and ≥ 30 kg/m2 for recent BMI) had 46% lower risk of breast cancer than premenopausal women in the lowest categories of the two BMI measures (< 20 kg/m2 at age 18 years and < 25 kg/m2 for recent BMI; OR = 0.54, 95% CI = 0.38-0.78). Neither measure of BMI was statistically significantly associated with risk of postmenopausal breast cancer.

CONCLUSION

Our findings indicate that high BMI near the end of adolescence decreases risk of all ER/PR/HER2-defined subtypes of premenopausal breast cancer and also suggest that this benefit could be maximized among premenopausal women who consistently have high BMI during their premenopausal years.

Parental Occupational Exposure to Organic Solvents and Testicular Germ Cell Tumors in their Offspring: NORD-TEST Study

BACKGROUND

Testicular germ cell tumors (TGCT) were suggested to have a prenatal environmentally related origin. The potential endocrine disrupting properties of certain solvents may interfere with the male genital development in utero.

OBJECTIVES

We aimed to assess the association between maternal and paternal occupational exposures to organic solvents during the prenatal period and TGCT risk in their offspring.

METHODS

This registry-based case control study included TGCT cases aged 14–49 y (n=8,112) diagnosed from 1978 to 2012 in Finland, Norway, and Sweden. Controls (n=26,264) were randomly selected from the central population registries and were individually matched to cases on year and country of birth. Occupational histories of parents prior to the child’s birth were extracted from the national censuses. Job codes were converted into solvent exposure using the Nordic job-Nordic Occupational Cancer Study Job-Exposure Matrix. Conditional logistic regression was used to estimate odds ratios (OR) and 95% confidence intervals (CI).

RESULTS

Overall, no association was found between prenatal maternal exposure to solvents and TGCT risk. In subset analyses using only mothers for whom occupational information was available in the year of or in the year prior to the child’s birth, there was an association with maternal exposure to aromatic hydrocarbon solvents (ARHC) (OR=1.53; CI: 1.08, 2.17), driven by exposure to toluene (OR=1.67; CI: 1.02, 2.73). No association was seen for any paternal occupational exposure to solvents with the exception of exposure to perchloroethylene in Finland (OR=2.42; CI: 1.32, 4.41).

CONCLUSIONS

This study suggests a modest increase in TGCT risk associated with maternal prenatal exposure to ARHC. https://doi.org/10.1289/EHP864.

Reproductive factors and the risk of triple-negative breast cancer in white women and African-American women: a pooled analysis

BACKGROUND

Early age at menarche, nulliparity, late age at first completed pregnancy, and never having breastfed, are established breast cancer risk factors. However, among breast cancer subtypes, it remains unclear whether all of these are risk factors for triple-negative breast cancer (TNBC).

METHODS

We evaluated the associations of these reproductive factors with TNBC, in 2658 patients with breast cancer (including 554 with TNBC) and 2448 controls aged 20-64 years, who participated in one of the three population-based case-control studies: the Women's Contraceptive and Reproductive Experiences Study, the Women's Breast Carcinoma in situ Study, or the Women's Learning the Influence of Family and Environment Study. We used multivariable polychotomous unconditional logistic regression methods to conduct case-control comparisons among breast cancer subtypes defined by estrogen receptor, progesterone receptor, and human epidermal growth factor receptor-2 expression status.

RESULTS

TNBC risk decreased with increasing duration of breastfeeding (P trend = 0.006), but age at menarche, age at first completed pregnancy, and nulliparity were not associated with risk of TNBC. Parous women who breastfed for at least one year had a 31% lower risk of TNBC than parous women who had never breastfed (odds ratio, OR = 0.69; 95% confidence interval, CI = 0.50-0.96). The association between breastfeeding and risk of TNBC was modified by age and race. Parous African-American women aged 20-44 years who breastfed for 6 months or longer had an 82% lower risk of TNBC than their counterparts who had never breastfed (OR = 0.18, 95% CI = 0.07-0.46).

CONCLUSIONS

Our data indicate that breastfeeding decreases the risk of TNBC, especially for younger African-American women.

Parental Occupational Exposure to Heavy Metals and Welding Fumes and Risk of Testicular Germ Cell Tumors in Offspring: A Registry-Based Case-Control Study

BACKGROUND

Data are scarce on the association between prenatal/preconception environmental exposure and testicular germ cell tumor (TGCT) in offspring. We examined parental occupational exposures to heavy metals and welding fumes in relation to TGCT in offspring in a registry-based case-control study (NORD-TEST Study).

METHODS

We identified TGCT cases diagnosed at ages 14-49 years in Finland (1988-2012), Norway (1978-2010), and Sweden (1979-2011) through nationwide cancer registries. These cases were individually matched by country and year of birth to controls selected from population registries. Information on parental occupations was retrieved from censuses. From this, we estimated prenatal/preconception exposures of chromium, iron, nickel, lead, and welding fumes (all three countries), and cadmium (Finland only) for each parent using job-exposure matrices specifying prevalence (P) and mean exposure level (L). Exposure indices were calculated as a product of P and L (P × L), and exposure categories were based on P × L or different combinations of P and L.

RESULTS

The study comprised 8,112 cases and 26,264 controls. We observed no statistically significant TGCT risk associated with presence of heavy metals/welding fumes (P × L > 0) and no dose-response relationship (Ptrend ≥ 0.32). A statistically significant elevated TGCT risk was found in paternal exposure category where both P and L of chromium were high (vs. no chromium; OR = 1.37, 95% confidence interval; 1.05-1.79).

CONCLUSIONS

Our study provides little evidence of associations between parental exposures to heavy metals/welding fumes and TGCT in offspring with the potential exception of high paternal chromium exposure.

IMPACT

Further research on paternal chromium exposure is warranted. Cancer Epidemiol Biomarkers Prev; 25(10); 1426-34. ©2016 AACR.

Recreational physical activity and risk of triple negative breast cancer in the California Teachers Study

BACKGROUND

Evidence has accumulated showing that recreational physical activity reduces breast cancer risk. However, it is unclear whether risk reduction pertains to specific receptor-defined subtypes. Moreover, few studies have examined whether changes in the amount of recreational physical activity during adulthood influence breast cancer risk.

METHODS

A total of 108,907 women, ages 22 to 79 years with no history of breast cancer when joining the California Teachers Study in 1995-1996, completed a baseline questionnaire and were eligible for the study. Through 2012, 5882 women were diagnosed with invasive breast cancer. Breast cancer subtypes were defined by the expression status of estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2). Multivariable Cox proportional hazards models provided adjusted hazard ratios (HRs) and 95 % confidence intervals (CIs) for breast cancer overall and ER/PR/HER2-defined subtypes associated with long-term (from high school through age 54 or age at cohort entry, whichever was younger) and baseline (during 3 years prior to baseline) recreational physical activity. Among women who also completed a follow-up questionnaire at 10 years after baseline in 2005-2008 (54,686 women, 1406 with invasive breast cancer), risk associated with changes in the amount of recreational physical activity from baseline to the 10-year follow-up (during 3 years prior to the 10-year follow-up) was determined.

RESULTS

Both long-term and baseline strenuous recreational physical activity were inversely associated with risk of invasive breast cancer (P trend ≤0.03). The observed associations were mainly confined to women with triple negative breast cancer (TNBC, ER-/PR-/HER2-, P trend ≤0.02) or luminal A-like subtype (ER+ or PR+ plus HER2-) who were former users of menopausal hormone therapy at baseline (P trend = 0.02, P homogeneity of trends ≤0.03). Moreover, women who consistently engaged in the highest level (≥3.51 h/wk/y) of strenuous recreational physical activity between baseline and 10-year follow-up had the lowest risk of breast cancer (HR = 0.71, 95 % CI = 0.52-0.98) when compared to those who were consistently low (≤0.50 h/wk/y).

CONCLUSIONS

Strenuous recreational physical activity is associated with lower breast cancer risk, especially TNBC. The benefit may be maximized by consistently engaging in high-intensity recreational physical activity during adulthood.

Abstract 872: Long-term and recent recreational physical activity reduces risk of triple negative and other subtypes of invasive breast cancer in the California Teachers Study

Background. Evidence has accumulated showing that physical activity reduces breast cancer risk. Whether risk reduction pertains to all breast cancer or specific receptor-defined subtypes is unclear. Moreover, few studies have examined whether changes in the amount of physical activity during adulthood influence breast cancer risk.

Methods. Among 108,907 women, ages 22 to 79 years with no history of breast cancer when they joined the California Teachers Study in 1995-1996 (baseline), 5,578 women were diagnosed with invasive breast cancer during follow-up through December, 2011. Subtypes were defined by the expression status of estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2). Cox proportional hazards models were fit to data to estimate adjusted hazard rate ratios (HRs) and 95% confidence intervals (CIs) associated with long-term and recent (within 3 years of baseline) recreational physical activity. Among 54,690 women who provided updated information on physical activity in 2005-2008, we also assessed whether changes in the level of physical activity since baseline influenced breast cancer risk (654 cases diagnosed during follow-up).

Results. Long-term and recent recreational physical activity were inversely associated with risk of triple negative breast cancer (TNBC, both Ptrend ≤ 0.05), but not other subtypes (all Ptrend ≥ 0.07). The reduced risk of TNBC was limited to strenuous physical activity. A 50% (HR = 0.50, 95% CI = 0.29-0.86) lower risk of TNBC was observed among women in the highest (≥5.01 h/wk) versus lowest category (≤0.50 h/wk) of long-term strenuous recreational physical activity; this was not modified by baseline body mass index (&lt;25 kg/m2 vs. ≥25 kg/m2), menopausal hormone therapy (MHT) use (never vs. ever), or the cessation of MHT use (former vs. recent). An inverse association between strenuous recreational physical activity and risk of luminal A-like (ER+ or PR+ plus HER2-) breast cancer was observed only among former MHT users (Ptrend: 0.02 for both long-term and baseline strenuous physical activity). Women who increased their level of recent recreational physical activity from ≤0.50 h/wk at baseline to ≥4.51 h/wk in 2005-2008 had a 32% (HR = 0.68, 95% CI = 0.47-0.99) lower risk of breast cancer overall than those who stayed at the lowest level.

Conclusions. This study suggests that long-term strenuous physical activity is associated with lower risk of TNBC. Further, it shows that substantially increasing the amount of total recreational physical activity in adulthood decreases the risk of breast cancer.

Citation Format: Huiyan Ma, Jessica Clague, Xinxin Xu, Yani Lu, Kayo Togawa, Sophia S. Wang, Christina A. Clarke, Eunjung Lee, Hannah L. Park, Jane Sullivan-Halley, Susan Neuhausen, Leslie Bernstein. Long-term and recent recreational physical activity reduces risk of triple negative and other subtypes of invasive breast cancer in the California Teachers Study. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 872. doi:10.1158/1538-7445.AM2015-872

Risk factors for self-reported arm lymphedema among female breast cancer survivors: a prospective cohort study

INTRODUCTION

Lymphedema is a potentially debilitating condition that occurs among breast cancer survivors. This study examines the incidence of self-reported lymphedema, timing of lymphedema onset, and associations between sociodemographic, clinical and lifestyle factors and lymphedema risk across racial-ethnic groups using data from a multicenter, multiethnic prospective cohort study of breast cancer survivors, the Health, Eating, Activity and Lifestyle Study.

METHODS

A total of 666 women diagnosed with breast cancer staged as in situ, localized or regional disease at ages 35 to 64 years were recruited through the Surveillance, Epidemiology, and End Results registries in New Mexico (non-Hispanic white and Hispanic white), Los Angeles County (black), and Western Washington (non-Hispanic white) and followed for a median of 10.2 years. We evaluated sociodemographic factors, breast cancer- and treatment-related factors, comorbidities, body mass index (BMI), hormonal factors, and lifestyle factors in relation to self-reported lymphedema by fitting Cox proportional hazards models, estimating hazard ratios (HR) and 95% confidence intervals (CI).

RESULTS

Over the follow-up period, 190 women (29%) reported lymphedema. The median time from breast cancer diagnosis to onset of lymphedema was 10.5 months (range: 0.5 to 134.9 months). Factors independently associated with lymphedema were total/modified radical mastectomy (versus partial/less than total mastectomy; HR = 1.37, 95% CI: 1.01 to 1.85), chemotherapy (versus no chemotherapy; HR = 1.48, 95% CI: 1.09 to 2.02), no lymph nodes removed (versus ≥10 lymph nodes removed; HR = 0.17, 95% CI: 0.08 to 0.33), pre-diagnostic BMI ≥30 kg/m2 (versus BMI <25 kg/m2; HR = 1.59, 95% CI: 1.09 to 2.31), and hypertension (versus no hypertension; HR = 1.49, 95% CI: 1.06 to 2.10). After adjusting for demographics and breast cancer- and treatment-related factors, no significant difference in lymphedema risk was observed across racial/ethnic groups. Analyses stratified by race/ethnicity showed that hypertension and chemotherapy were lymphedema risk factors only for black women.

CONCLUSIONS

Breast cancer patients who have undergone extensive surgery or extensive lymph node dissection, or who have a higher BMI should be closely monitored for detection and treatment of lymphedema. Further studies are needed to understand the roles of chemotherapy and hypertension in the development of lymphedema.

Toxicity of bevacizumab in combination with chemotherapy in older patients

BACKGROUND

Bevacizumab leads to improved survival for patients with metastatic colorectal cancer (CRC) or non-small cell lung cancer (NSCLC) when added to chemotherapy. Little is known about factors associated with receipt of bevacizumab, or whether bevacizamab is associated with increased toxicity when added to chemotherapy.

PATIENTS AND METHODS

We conducted a prospective study of patients aged ≥65 years, which evaluated the association between geriatric assessment (GA) metrics and chemotherapy toxicity. We examined differences in characteristics and outcomes of patients with CRC and NSCLC cancers who received bevacizumab with chemotherapy versus chemotherapy alone.

RESULTS

From a total of 207 patients, 27 (13%) received bevacizumab plus chemotherapy and 180 (87%) received chemotherapy alone. Groups were similar in sociodemographic and cancer characteristics. There were no baseline differences in GA domains except that patients with heart disease were less likely to receive bevacizumab (4% vs. 26%, p = .01). Seventy-eight percent of patients who had bevacizumab had grade 3-5 toxicity compared to only 57% who received chemotherapy alone (p = .06). Patients receiving bevacizumab were more likely to develop grade 3 hypertension than those who received chemotherapy alone (15% vs. 2%, p < .01). In multivariable analysis, factors associated with grade 3 or more toxicity included: bevacizumab (OR: 2.86, p = .04), CRC (OR: 2.54, p < .01), and baseline anemia (OR: 2.58, p = .03).

CONCLUSION

Heart disease was more common in those who did not receive bevacizumab. Older patients who receive bevacizumab with chemotherapy have a higher odds of developing a grade 3-5 toxicity compared with those who receive chemotherapy alone.

Abstract A10: Risk factors for self-reported arm lymphedema among female breast cancer survivors in Health, Eating, Activity, and Lifestyle (HEAL) Study

Background: With increasing breast cancer survival, more women are experiencing complications from breast cancer therapy. Arm lymphedema (ALE), one of the most common post-treatment conditions, is associated with both physical and psychological challenges. As there is no definitive cure for ALE, preventive measures are desired; more research is needed to study modifiable factors. Although previous studies investigated ALE, data from long-term prospective cohort studies are sparse. This study aims to assess timing of ALE onset and to identify epidemiological characteristics associated with developing the condition using long-term follow-up data.

Methods: Data were collected from 672 female breast cancer survivors aged 35-64 at diagnosis participating in the HEAL Study, a population-based, multi-center, multi-ethnic prospective cohort study. Women diagnosed with in situ, localized or regional breast cancer were recruited into the HEAL Study through SEER registries in New Mexico (Non-Hispanic Whites and Latinas), Los Angeles County (Blacks), and Western Washington (Non-Hispanic Whites). Participants provided information on sociodemographic factors, anthropometric factors, hormone use, and lifestyle factors at, on average, 6.2 months after diagnosis. Clinical information was abstracted from SEER registry records and hospital medical records. Women reported presence of ALE and date of first occurrence of ALE at two subsequent questionnaires that occurred, on average, 3.3 years (T1) and 10.2 years (T2) after diagnosis. Time to onset of ALE was calculated as the time from diagnosis until self-reported onset date. Cox proportional hazards models were fit and provided estimates of the hazard ratios (HR) for ALE and its 95% confidence interval (CI) using time since diagnosis as the time scale. Women who died or were lost to follow-up before T2 were censored at T1 because their ALE status after T1 was unknown.

Results: During follow-up, 192 women (29%) experienced ALE; 34 (18%) of these women developed ALE more than three years after diagnosis. The median time to onset of ALE was 11 months (range; 0.5-135). Approximately 58% of women who reported ALE at T1 and completed T2 (n=109) had ALE at T2 (persistent ALE). In a multivariable model, receiving total/modified radical mastectomy (vs. partial/less than total mastectomy; HR=1.43, 95% CI=1.06-1.94), receiving chemotherapy (HR=1.58, 95% CI=1.15-2.17), having 10 or more lymph nodes (LN) removed (vs. no LN removed; HR=3.05, 95% CI=1.81-5.11), having body mass index (BMI)≥30 kg/m2 (vs. BMI&lt;25 kg/m2; HR=1.59, 95% CI=1.09-2.32), and having hypertension (HR=1.47, 95% CI=1.04-2.07) all increased ALE risk. Stratifying by race, hypertension was a risk factor only for black women (HR=2.77, 95% CI=1.67-4.58). Contrary to findings from previous studies, we did not find that radiation therapy increased ALE risk (HR=1.18, 95% CI=0.87-1.58).

Conclusions: This study suggests that ALE can occur years after the initial diagnosis and the majority of ALE persists for a long time. In addition to established risk factors, hypertension was a risk factor, particularly in black women. It is important to increase awareness that ALE can develop later in the survival trajectory and to investigate further the role of hypertension in ALE after breast cancer.

Citation Format: Kayo Togawa, Jane Sullivan-Halley, Yani Lu, Ashley Wilder Smith, Catherine Alfano, Ikuyo Imayama, Anne McTiernan, Marian L. Neuhouser, Huiyan Ma, Rachel Ballard-Barbash, Leslie Bernstein. Risk factors for self-reported arm lymphedema among female breast cancer survivors in Health, Eating, Activity, and Lifestyle (HEAL) Study. [abstract]. In: Proceedings of the Eleventh Annual AACR International Conference on Frontiers in Cancer Prevention Research; 2012 Oct 16-19; Anaheim, CA. Philadelphia (PA): AACR; Cancer Prev Res 2012;5(11 Suppl):Abstract nr A10.

Use of complementary medications among older adults with cancer

BACKGROUND

Little is known about complementary medication use among older adults with cancer, particularly those who are receiving chemotherapy. The objective of this study was to evaluate the prevalence of complementary medication use and to identify the factors associated with its use among older adults with cancer.

METHODS

The prevalence of complementary medication use (defined as herbal agents, minerals, or other dietary supplements, excluding vitamins) was evaluated in a cohort of adults aged ≥65 years who were about to start chemotherapy for their cancer. The associations between complementary medication use and patient characteristics (sociodemographics; comorbidities; and functional, nutritional, psychological, and cognitive status), medication use (number of medications and concurrent vitamin use), and cancer characteristics (type and stage) were analyzed.

RESULTS

The cohort included 545 patients (mean age, 73 years; range, 65-91 years; 52% women) with cancer (61% stage IV). Seventeen percent of these patients (N = 93) reported using ≥1 complementary medication; the mean number of complementary medications among users was 2 (range, 1-10 medications). Complementary medication use was associated with 1) earlier cancer stage (29% had stage I-II disease vs 17% with stage III-IV disease; odds ratio [OR], 2.05; 95% confidence interval [CI], 1.21-3.49) and 2) less impairment with instrumental activities of daily living (OR, 1.39; 95% CI, 1.12-1.73).

CONCLUSIONS

Complementary medication use was reported by 17% of older adults with cancer and was more common among those who had less advanced disease (i.e., those receiving adjuvant, potentially curative treatment) and higher functional status. Further studies are needed to determine the association between complementary medication use and cancer outcomes among older adults.

Predicting chemotherapy toxicity in older adults with cancer: a prospective multicenter study

PURPOSE

Older adults are vulnerable to chemotherapy toxicity; however, there are limited data to identify those at risk. The goals of this study are to identify risk factors for chemotherapy toxicity in older adults and develop a risk stratification schema for chemotherapy toxicity.

PATIENTS AND METHODS

Patients age ≥ 65 years with cancer from seven institutions completed a prechemotherapy assessment that captured sociodemographics, tumor/treatment variables, laboratory test results, and geriatric assessment variables (function, comorbidity, cognition, psychological state, social activity/support, and nutritional status). Patients were followed through the chemotherapy course to capture grade 3 (severe), grade 4 (life-threatening or disabling), and grade 5 (death) as defined by the National Cancer Institute Common Terminology Criteria for Adverse Events.

RESULTS

In total, 500 patients with a mean age of 73 years (range, 65 to 91 years) with stage I to IV lung (29%), GI (27%), gynecologic (17%), breast (11%), genitourinary (10%), or other (6%) cancer joined this prospective study. Grade 3 to 5 toxicity occurred in 53% of the patients (39% grade 3, 12% grade 4, 2% grade 5). A predictive model for grade 3 to 5 toxicity was developed that consisted of geriatric assessment variables, laboratory test values, and patient, tumor, and treatment characteristics. A scoring system in which the median risk score was 7 (range, 0 to 19) and risk stratification schema (risk score: percent incidence of grade 3 to 5 toxicity) identified older adults at low (0 to 5 points; 30%), intermediate (6 to 9 points; 52%), or high risk (10 to 19 points; 83%) of chemotherapy toxicity (P < .001).

CONCLUSION

A risk stratification schema can establish the risk of chemotherapy toxicity in older adults. Geriatric assessment variables independently predicted the risk of toxicity.

Survival of metastatic gastric cancer: Significance of age, sex and race/ethnicity

BACKGROUND

Despite the success of modern chemotherapy in the treatment of large bowel cancers, patients with metastatic gastric cancer continue to have a dismal outcome. Identifying predictive and prognostic markers is an important step to improving current treatment approaches and extending survival.

METHODS

Extracting data from the US NCI's Surveillance, Epidemiology, and End Results (SEER) registries, we compared overall survival for patients with metastatic gastric cancer by gender, age, and ethnicity using Cox proportional hazards models. 13,840 patients (≥ 18 years) were identified from 1988-2004. Males and females were categorized by age grouping and ethnicity.

RESULTS

19% of Hispanic patients were diagnosed < 45 years of age as compared to 5.5% of Caucasians. Caucasian patients and men were more likely to be diagnosed with tumors in the gastric cardia (P<0.001). In our survival analysis, we found that women had a lower risk of dying as compared to men (P<0.001). Overall survival diminished with age (P<0.001). The median overall survival was 6 months in patients of ≤ 44 years old as compared to 3 months in patients 75 years and older. Gender differences in overall survival significantly varied by race and tumor grade/differentiation (P for interaction = 0.003 and 0.005, respectively).

CONCLUSION

This is the largest study of metastatic gastric cancer patients from the SEER registry to show that age, gender, and tumor location are significant independent prognostic factors for overall survival in patients with metastatic gastric cancer.

Implementing a geriatric assessment in cooperative group clinical cancer trials: CALGB 360401

PURPOSE

Factors captured in a geriatric assessment can predict morbidity and mortality in older adults, but are not routinely measured in cancer clinical trials. This study evaluated the implementation of a geriatric assessment tool in the cooperative group setting.

PATIENTS AND METHODS

Patients age ≥ 65 with cancer, who enrolled on cooperative group cancer trials, were eligible to enroll on Cancer and Leukemia Group B (CALGB) 360401. They completed a geriatric assessment tool before initiation of protocol therapy, consisting of valid and reliable geriatric assessment measures which are primarily self-administered and require minimal resources and time by healthcare providers. The assessment measures functional status, comorbidity, cognitive function, psychological state, social support, and nutritional status. The protocol specified criteria for incorporation of the tool in future cooperative group trials was based on the time to completion and percent of patients who could complete their portion without assistance. Patient satisfaction with the tool was captured.

RESULTS

Of the 93 patients who enrolled in this study, five (5%) met criteria for cognitive impairment and three did not complete the cognitive screen, leaving 85 assessable patients (median age, 72 years). The median time to complete the geriatric assessment tool was 22 minutes, 87% of patients (n = 74) completed their portion without assistance, 92% (n = 78) were satisfied with the questionnaire length, 95% (n = 81) reported no difficult questions, and 96% (n = 82) reported no upsetting questions. One hundred percent of health care professionals completed their portion.

CONCLUSION

This brief, primarily self-administered geriatric assessment tool met the protocol specified criteria for inclusion in future cooperative group clinical trials.

Long-term recovery after hematopoietic cell transplantation: predictors of quality-of-life concerns

This prospective longitudinal study examined the quality of life (QOL) after hematopoietic cell transplantation (HCT) and identified risk factors of poor QOL in 312 adult autologous and allogeneic HCT patients. Physical, psychological, social, and spiritual well-being was assessed before HCT, 6 months, and 1, 2, and 3 years after HCT. For all HCT patients, physical QOL was stable from before to after HCT (P > .05); psychologic (P < .001), social (P < .001), and spiritual (P = .03) QOL improved at 6 months. Study noncompleters (because of illness or death) had worse QOL. Allogeneic patients reported worse physical and psychologic well-being (P < .05). Older patients reported worse physical but better social well-being regardless of HCT type (P < .05). Two or more domains were affected by race/ethnicity, household income, and education in autologous patients, and by body mass index (BMI), decline in BMI, primary diagnosis, and chronic graft-versus-host disease (GVHD) in allogeneic patients (P < .05). At 3 years, 74% of HCT patients were employed full or part time. Older autologous patients with lower pre-HCT income were less likely to work (P < .05); allogeneic patients with chronic GVHD were less likely to work (P = .002). Multidisciplinary efforts to identify and support vulnerable subgroups after HCT need to be developed.

Geriatric assessment of older adults with cancer: Baseline data from a 500 patient multicenter study

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Background: As the cancer population ages, a brief, comprehensive measure is needed to characterize the “functional age” of a patient, in order to optimize treatment decisions and evaluate outcomes based on factors other than chronological age. A geriatric assessment (GA) evaluates factors other than age that predict morbidity and mortality in older adults. The goals of this study are to describe the results of a GA performed in 500 older adults with cancer from 7 participating institutions and to evaluate the feasibility of completing this assessment in oncology practice. Methods: The GA is comprised of validated measures of functional status, comorbidity, cognition, psychological status, social functioning and support, and nutritional status (Hurria et al, Cancer 2005). The GA was completed prior to the start of a new chemotherapy regimen in patients age ≥ 65 with a solid tumor or lymphoma. Results: 500 patients (mean age 73; range 65–91) completed the GA. The most common tumor types were lung (29%), GI (29%) and breast/gyn (22%) cancer; 57% had stage IV disease. The GA revealed that 41% of patients needed assistance with instrumental activities of daily living despite a mean physician-reported KPS of 85 (range 50–100), 92% had ≥1 comorbid medical conditions (mean 2.5; range 0–9), 95% took ≥ 1 medications (mean 5; range 0–23), 16% had ≥ 1 falls in the past 6 months, 6% had gross cognitive impairment on the Blessed Orientation-Memory-Concentration Test, and 39% had > 5% weight loss in the past 6 months. The mean time to complete the GA was 27 minutes (range 10–80); 94% were satisfied with the GA length and 70% were able to complete the GA without assistance. Multivariate logistic regression identified the following sociodemiographic and disease variables predict the need for assistance with completion of the GA: age ≥ 80 (p=0.02), high school education or less (p<0.01), non-white race (p<0.01), and the presence of metastatic disease (p=0.01). Conclusions: This brief GA is largely self-administered, can be completed by the majority of older patients without assistance, and identifies important deficits and problems that may impact morbidity and mortality. Prospective data are being acquired to identify factors in the GA that predict chemotherapy toxicity in older adults with cancer.

No significant financial relationships to disclose.

The influence of sleep position and obesity on sleep apnea

The influence of sleep position and the degree of obesity were examined in 257 subjects with sleep apnea. Subjects were divided into three groups according to obesity: normal weight (body mass index (BMI) under 24.0 kg/m2), mild obese (BMI 24.0-26.4 kg/m2) and obese group (BMI 26.4 kg/m2 and heavier). The apnea + hypopnea index (AHI), the intraesophageal pressure and the lowest oxygen saturation became significantly worse according to the degree of obesity. The subjects were also divided into two groups according to the reduction in the AHI by lateral position: good responders showed 50% or more reduction of AHI in lateral position and poor responders indicated less than 50% reduction. The percentage of good responders to sleep position change was 90.9% in normal weight group, 74.0% in mild obese group and 57.4% in the obese group. The ratio of the subjects who had indicated two or more obstructive sites in normal weight group was 36.0% in good responders and 40.0% in poor responders. The ratio in the mild obese group was 51.8% in good responders and 66.7% in poor responders. In the obese group, the ratio was 59.4% in good responders and 78.9% in poor responders.

Influence of alcohol on respiratory disturbance during sleep

Oxygen saturation was measured in 37 patients with sleep-related breathing disorders over 2 nights: after alcohol intake and under control conditions. Both the number of 3% oxygen desaturation per hour (ODI3) and the lowest saturation (LSAT) were significantly aggravated after alcohol ingestion. Oxygen saturation was degraded in 28 cases after alcohol intake. In 69% of the cases in which ODI3 increased after alcohol ingestion, the aggravation during the alcohol metabolism time was noted. No correlation was found between the quantity of alcohol and oxygen desaturation following alcohol ingestion. Our study revealed that alcohol aggravates sleep-related breathing disorders.

Membrane enzyme systems responsible for the Ca(2+)-dependent phosphorylation of Ser(27), the independent phosphorylation of Tyr(10) and Tyr(7), and the dephosphorylation of these phosphorylated residues in the alpha-chain of H/K-ATPase

H/K-ATPase preparations (the G1 membrane) from pig stomach contain both kinases and phosphatases and show reversible phosphorylation of Tyr(7), Tyr(10), and Ser(27) residues of the alpha-chain of H/K-ATPase. The Tyr-kinase is sensitive to genistein and quercetin and recognized by anti-c-Src antibody. The Ser-kinase is dependent on Ca(2)(+) (K(0.5) = 0.9 microM), sensitive to a PKC inhibitor, and recognized by antibodies against PKCalpha and PKCbetaII. The addition of 3-[(3-cholamidopropyl)dimethylammonio]-1-propane-sulfonic acid (CHAPS) caused a dramatic increase in the phosphorylation of added synthetic copolymer substrates and permitted the phosphorylation of maltose-binding proteins fused with the N-terminal domain of alpha-chains. The phosphotyrosine phosphatase was inhibited by vanadate. The phosphoserine phosphatase was inhibited by okadaic acid and by inhibitor-2. The presence of protein phosphatase-1 was immunologically detected. Column chromatographic separation of CHAPS-solubilized G1 membrane and others indicate the apparent molecular weight of the Src-kinase to be approximately 60 kDa, the PKCalpha and/or PKCbII to be approximately 80 kDa, the Tyr-phosphatase to be 200 kDa, and PP-1 to be approximately 35 kDa. These data show that these membrane-bound enzyme systems are in sufficiently close proximity to be responsible for reversible phosphorylation of Tyr(7), Tyr(10), and Ser(27) of the catalytic subunit of membrane H/K-ATPase in parietal cells, the physiological role of which is unknown.

Intestinal cell kinase (ICK) localizes to the crypt region and requires a dual phosphorylation site found in map kinases

Identification of key regulatory kinases in the intestinal epithelium are useful to understand the molecular mechanisms that underlie proliferation and differentiation in cells found in this compartment. We used the polymerase chain reaction (PCR) to amplify the catalytic kinase domain of serine-threonine kinases by employing degenerate primers and then screened an intestinal crypt cDNA library to clone and sequence the open reading frame of a novel serine-threonine kinase. This was then further characterized by Northern blot analysis and RNA in situ hybridization. This kinase, designated intestinal cell kinase, harbors a dual phosphorylation site found in mitogen-activating protein (MAP) kinases that is important for kinase activity.