Tobacco Smoking, Alcohol Drinking and Dietary Factors as Determinants of New Primaries among Male Laryngeal Cancer Patients: A Case-Cohort Study

Aims and Background

The paper examines the determinants associated with second primary occurrence in laryngeal cancer cases.

Methods

A series of 220 incident male laryngeal cancer cases was interviewed 10 years ago within the framework of a population-based, case-control study. The occurrence of other primaries among these patients was assessed by means of the Lombardy Cancer Registry, which covers their area of residence. The relationship between tobacco, alcohol, dietary factors and the risk of occurrence of new primaries was analyzed by means of a nested case-control study. Cases were defined as those subjects who developed a new primary, and controls as those without.

Results

New primaries occurred among 36 subjects during an 8-year follow-up; 147 control cancer patients were matched for age and length of follow-up. A twofold risk increase was associated with the highest tobacco consumption, as registered at time of first primary; a weaker relationship, i.e. risk of 1.2 for the highest tertile, was seen for alcohol drinking. The occurrence of new primaries was also influenced by dietary habits. In particular, those who had a high intake of monosaturated fatty acids had a one-third lower risk of developing a new primary.

Conclusions

Our results support the hypothesis that a healthy diet is protective among those who experience a laryngeal neoplasm and suggests that diet could be a potential preventive agent against the occurrence of new primaries among these patients.

Dietary Habits, Internal Migration and Social Class in a Sample of a Northern Italian Population

The study of migrants has generated interesting hypotheses on the etiology of different types of cancer. In particular, it has been suggested that both colon and breast cancer could be related to living conditions, including diet, in the country of immigration. Considerable internal migration occurred in Italy in the sixties. We studied a random sample of 1,400 subjects living in the city of Torino and the province of Varese. They were interviewed with a detailed questionnaire about their dietary habits, and the consumption of several nutrients was considered according to the area of birth and social class. The hypothesis we tested was whether, after controlling for social class, there were different dietary habits among the migrants and the native population, and whether such differences could help in the formulation of etiologic hypotheses on cancer. We found that the intake of saturated fatty acids and cholesterol was lower among the migrants from the south, whereas they consumed higher levels of vegetables than people born in the north. The different intake of saturated fatty acids and cholesterol seemed to be attributable mainly to the consumption of butter, for which the south/north ratio was as low as 0.47 in men and 0.56 in women. Important gradients by social class were also suggested for several nutrients.

Cancer Prevalence in the Elderly

Aims and Background

To describe the cancer prevalence in elderly Italian people and analyze the differences, if any, with the prevalence among younger subjects.

Methods & Study Design

The cancer prevalence among elderly patients (65 years and over), the three age classes encompassing elderly age (65-74 years, 75-84 years, 85 years and over) and younger patients (0-64 years) was computed using the PREVAL method on the basis of the incident cases over the period 1976-1992 followed up to 31 December 1992 (prevalence reference date). Data were collected by 11 Italian cancer registries.

Results

The observed prevalence figures for all cancers (except skin epitheliomas), both sexes combined and considering the whole elderly group, were 1,090 and 3,601 cases per 100,000 one and five years since diagnosis, respectively; the prevalence increased up to the 75-84 age group and showed a slight decrease after age 85. With regard to specific cancer sites, in men bladder and prostate had the highest prevalence 5 years from diagnosis (more than 800 cases per 100,000), followed by colon and lung (about 500 cases per 100,000) stomach and rectum (about 300 cases per 100,000); in women breast cancer ranked first (more than 1,000 cases per 100,000), followed by colon (about 350 cases per 100,000), corpus uteri, stomach and rectum cancers (between 150 and 200 cases per 100,000). For all malignancies and the two sexes combined the prevalence figures were about six times higher in the older than in the younger age group.

Conclusions

These figures confirm the important role of aging in determining the increase in cancer prevalence. The resulting prevalence figures clearly indicate the cancer burden placed on health care services; moreover, the figures will probably increase in the next decades due to a possible improvement in survival and to the dramatic aging of the population, assuming a stable trend for incidence rates. This picture will represent a major challenge for politicians and those dealing with health care planning and social policies in general, especially in the light of the reduction of the available financial resources and the specific features of medical and social needs in the elderly.

Incidence and Survival of Brain Tumors: A Population-Based Study

Since 1976 the Lombardy Cancer Registry (RTL) has recorded all malignant tumors and the benign tumors of the nervous system, bladder and liver occurring in the Varese province. The aims of this report are: to describe age-specific incidence rates of the different oncotypes of primary nervous system tumors (PNSTs) and to analyze the duration of survival of the patients according to the histotype of the neoplasm. From 1976 to 1981, the RTL recorded 498 PNST: 213 tumors of glial origin, 132 tumors of mesodermal tissues, 15 tumors of multipotential cell origin, 37 tumors of nerve roots, 8 of vascular origin, and 54 PNST in which the histotype was not specified. For tumors of glial origin, the 60–69 year age class showed the highest incidence rate: 16 per 100,000/year. The incidence rate of tumors of mesodermal tissues reached the maximum value of 7.9 per 100,000/year in the age group of 75 years and over. Tumors of multipotential cell origin had a maximum incidence of 2.2 in the 60–69 year age class. The probability of survival at 5 years after diagnosis was computed by the method of Kaplan and Meier (15), and the log rank procedure was used to test statistical differences among survivors. Tumors of glial origin, excluding ependymomas and papillomas of choroid plexus, had a 5-year survival probability of 14%. Age (categorized in ≤50 and > 50 years) and histologic grade (grades I+II and grades III+IV) were analyzed as prognostic factors for tumors of glial origin: a younger age was the most predictive prognostic factor in grade I+II tumors (probability of survival = 53% in the group ≤50 years vs 0 in the group > 50 years; p < 0.005). In the less differentiated tumors there were no differences between the two age groups. Patients with tumors of mesodermal tissues had a 5-year probability of survival of 83%. Subjects younger than 50 years had a probability of survival of 95%, whereas older patients had a probability of 79%. For the other oncotypes, the 5-year survival probability was: 50% for tumors of multipotential cell origin, 63% for ependymomas and papillomas of the choroid plexus, 64% for tumors of vascular derivation, and 21% for PNST with not specified histotype.

Modality of Lung Cancer Treatment in an Unselected Population

The modality of lung cancer treatment was retrospectively evaluated in an unselected population. All the lung cancer cases diagnosed among the residents in a Local Sanitary Unit of Lombardy during four years (1974–1979), were identified. The clinical records of the 235 collected patients were reviewed and on this basis the anatomical extent of disease was retrospectively classified in stages according to the TNM of UICC (1978). The relative frequency of clinical stages resulted 29 % for stage I, 17 % II, 20 % III and 32 % IV. Only 57 % of all the subjects had been treated; 11 % by resection, 22 % by radiotherapy and 24 % by chemotherapy. For the stages I and II the operability rates were 35 % and 26 % respectively, while the resectability rates were 29 % and 17 %. An objective reason of exclusion from surgery was found in no more than a quarter of stage I and II lung cancers, while the remaining (40 %) had probably been excluded from exploration owing to a subjective prognostic evaluation. If compared with similar reports from other countries, these data show a striking defect in the choice of curative treatment for a high proportion of the examined cases.

Cancer Prevalence in Italian Cancer Registry Areas: The Itapreval Study

Aim

To present data on cancer prevalence for the areas covered by Italian cancer registries, by using a standardized set of data collection and elaboration criteria, and a single method of data analysis.

Subjects and Methods

Data on over 250,000 patients with cancer, diagnosed between 1978 and 1992, from 11 Italian cancer registries covering about 12% of the Italian population were collected, validated and analyzed according to the unified protocol of the ITAPREVAL project. The method implemented in the PREVAL computer program was used to provide prevalence estimates for the period covered by cancer registration. The total prevalence for each registry and for the pool of all registries was then estimated by correcting for incomplete observations due to the period in which the registration was not yet activated. All prevalence estimates were for 1992.

Results

Prevalence figures are presented by cancer site, age, sex, years from diagnosis and registry area. For all malignancies combined, total prevalence ranged from 1,350 per 100,000 inhabitants in Ragusa to 3,650 per 100,000 inhabitants in Romagna, the ratio between these two extremes being 2.7. For the pool of the areas covered by registration cancer prevalence was 3,100 per 100,000 females and 2,250 per 100,000 males. About a third of the total female cases and about half the male cases were diagnosed in the previous five years. Among those aged over 75 years, total prevalence was higher for males than for females: 11,300 versus 8,900 per 100,000 respectively.

Conclusions

This is the first large-scale estimate of the burden of cancer in Italy. It is also one of the first studies in the world which was aimed to study cancer prevalence in detail. These data are necessary for predicting health service needs and help in the evaluation of differences in health service demand by sex, age and Italian regions.

Incident Lung Cancer Survival. Long-Term Follow-Up of a Population-Based Study in Italy

The long-term survival of an incident lung cancer population was evaluated in relation to clinical stage, treatment modalities and other prognostic factors. The survey was carried out among the residents in the Local Sanitary Unit of Saronno, a highly industrialized area of northern Italy, where all the lung cancer cases diagnosed during the years 1976-79 had been identified and clinically studied. The overall survival of the 222 cases included in the analysis was 32% at 1 year, 10% at 3 years and 5% at 5 years; median survival was 7 months. A significantly better prognosis was associated with surgical resection (32% at 5 years; median, 42 mo), clinical stage I (16% at 5 years; median, 15 mo), and squamous cell carcinoma (13% at 5 years; median, 11 mo). Other factors such as age, sex, social class or cancer symptoms did not affect survival when treatment was taken into account. Our data show that surgical resection is the major determinant of survival, and suggest that suboptimal access to curative treatment, particularly in patients aged 60 to 75 with limited disease, might have compromised the overall survival.

Prognostic Value of Histochemical Evaluation of Steroid Binding Sites in Breast Tumors

Frozen tumor sections and/or cytological smears and aspirates from 614 pateints were studied utilizing the fluorescent estrogen binding technique of Lee. Survival analyses of the results indicated that women less than 55 years of age and with positive tumors had a statistically better disease-free interval and survived significantly longer than older patients. The method is thus an independent predictor of survival and disease-free interval in this siubgroup of breast cancer patients.

Overhead Electricity Power Lines and Childhood Leukemia: A Registry-Based, Case-Control Study

AIMS AND BACKGROUND

To evaluate the role of exposure to low-frequency electromagnetic fields generated by overhead power lines on the risk of childhood leukemia, we carried out a case-control study in the area (Varese province) covered by the Lombardy Cancer Registry.

METHODS AND STUDY DESIGN

Exposure to magnetic fields was estimated using line load data and the distance between subjects' homes and the nearest power line. A total of 101 cases and 412 controls were investigated.

RESULTS

Twenty subjects (9 cases and 11 controls) were considered exposed. A significant fourfold increase in risk for leukemia in exposed subjects and a dose-response relationship were found. The risk was higher than that reported by other studies. Potential biases related to the representativity of controls and validity of exposure assessment do not seem to have influenced the risk estimates.

CONCLUSIONS

We suggest that measures to remedy residential exposure should be taken wherever practicable.

The EpiLink Record Linkage Software

Objectives: Record linkage, the process of bringing together separately compiled but related records from different databases, is essential in many areas of biomedical research. We developed a record linkage program (EpiLink), which employs a simple mathematical approach. We describe the program and present results obtained testing it in a linkage task.

Methods: EpiLink was designed to be flexible with user-friendly settings to tailor linkage and operating parameters to specific linkage tasks, and employ deterministic, probabilistic or sequential deterministic-probabilistic linkage strategies as required. The user can also standardize data format, examine linkage results and accept or discard them. We used EpiLink to link a subset of cases of the Lombardy Cancer Registry (20,724 records) with the Social Security file of the population (1,021,846 records) covered by the registry. The linkage strategy was deterministic, followed by several probabilistic linkage steps.

Results: Manual inspection of the results showed that EpiLink achieved 98.8% specificity and 96.5% sensitivity.

Conclusions: EpiLink is a practical and accurate means of linking records from different databases that can be used by non-statisticians and is efficient in terms of human and financial resources.

Estimates of cancer burden in Italy

Aims and background

This paper presents updated estimates of the incidence, prevalence and mortality of stomach, colorectal, lung, breast, uterine cervix and prostate cancer and skin melanoma in the Italian population. In particular, point estimates for 2012 and time trends from 1970 to 2015 will be provided.

Methods

The presented figures were obtained by summing up the regional epidemiological indicator estimates presented in the other papers of this monographic issue, which were derived by applying the MIAMOD statistical back-calculation method to cancer registries survival data and official mortality rates.

Results

Our findings indicate that breast, colon-rectum and prostate will be the cancer sites with the highest incidence rates in the forthcoming years. The incidence rates still tend to increase for breast, male colorectal cancer and female lung cancer as well as for skin melanoma. By contrast, the incidence of stomach cancer, cervical cancer and male lung cancer, by far the most common tumor sites up to the early 1990s, will continue to decrease. The mortality estimates showed a decreasing trend for all considered cancers with the only exception of lung cancer in women.

Conclusion

These results point to the need to reinforce prevention activities by developing more effective preventive measures for population groups at risk. There is also a need to support timely and continuous cancer surveillance in the Italian population through cancer registries in order to monitor the spread of the cancer risk and to evaluate the impact of prevention policies and therapeutic advances.

Towards the eradication of HPV infection through universal specific vaccination

BACKGROUND

The Human Papillomavirus (HPV) is generally recognized to be the direct cause of cervical cancer. The development of effective anti-HPV vaccines, included in the portfolio of recommended vaccinations for any given community, led to the consolidation in many countries of immunization programs to prevent HPV-related cervical cancers. In recent years, increasing evidence in epidemiology and molecular biology have supported the oncogenic role of HPV in the development of other neoplasm including condylomas and penile, anal, vulvar, vaginal, and oro-pharyngeal cancers. Men play a key role in the paradigm of HPV infection: both as patients and as part of the mechanisms of transmission. Data show they are affected almost as often as women. Moreover, no screening procedures for HPV-related disease prevention are applied in men, who fail to undergo routine medical testing by any medical specialist at all. They also do not benefit from government prevention strategies.

DISCUSSION

A panel of experts convened to focus on scientific, medical, and economic studies, and on the achievements from health organizations' intervention programs on the matter. One of the goals was to discuss on the critical issues emerging from the ongoing global implementation of HPV vaccination. A second goal was to identify contributions which could overcome the barriers that impede or delay effective vaccination programs whose purpose is to eradicate the HPV infection both in women and men.

SUMMARY

The reviewed studies on the natural history of HPV infection and related diseases in women and men, the increasing experience of HPV vaccination in women, the analysis of clinical effectiveness vs economic efficacy of HPV vaccination, are even more supportive of the economic sustainability of vaccination programs both in women and men. Those achievements address increasing and needed attention to the issue of social equity in healthcare for both genders.

[Study of lung cancer risk in the electroplating industry in Lombardy based on the OCCAM method]

BACKGROUND

The OCCAM method consists of case-control studies aimed at estimating occupational risks by cancer site, by area and by economic sector, using available archives to identify cases and controls; for exposure definition each subject is assigned to the category code of the economic sector or company where he/she worked the longest, obtained by automatic link with the Social Security Institute (INPS) files. The reference category (unexposed) consists of service industry workers. The economic sector is given by the ATECO category that INPS assigns to each firm.

OBJECTIVES

In the Lombardy Region, lung cancer risk evaluated for the "metal treatment" industry as a whole was 1.32 (90% CI 1.33-3.10, 67 cases) for males and 1.33 (90% CI 0.51-3.59, 10 cases) for females. The aim of the study was to estimate lung cancer risk among metal electroplating workers only.

METHODS

The metal electroplating firms were identified according to the detailed description of production, data which was also contained in INPS files, instead of using the "metal treatment" ATECO code. Lung cancer risk was evaluated using 2001-2008 incident cases identified from hospital discharge records of residents in the Lombardy Region. Controls were a sample from National Health Service files.

RESULTS

For the group of firms identified as metal electroplating industries the risk was 2.03 (90% CI 1.69-8.32, 18 cases) for males and 3.75 (90% CI 1.38-9.03, 4 cases) for females.

CONCLUSIONS

Focusing on the true electroplating firms increased the risk estimates. Even though these risk were due to past exposures, case histories and recent acute effects indicate that, at least in some factories, a carcinogenic hazard still exists.

[Italian national register of low etiological fraction occupational cancer pursuant to art. 244 of legislative decree n. 81/2008]

Legislative decree No. 81/2008 in the article n. 244 states that ISPESL, now INAIL, realizes a register of occupational cancers with low etiological fraction by means of a data collection method based exclusively on voluntary reports by GPs, healthcare and social security agencies (ReNaLOC) and a surveillance cancer monitoring system (OCCAM) based on linkage of routinely available data (cancer registries, hospital discharge records, Italian Social Security archives). ReNaLOC has produced a partial picture of the situation, it includes 1.584 cases as of June 2011. With OCCAM many situations of known risks were identified and others are worthy to be deepen.

The 'incessant menstruation' hypothesis: a mechanistic ovarian cancer model with implications for prevention

Serous, endometrioid, clear cell and mucinous histotypes are the most common epithelial ovarian cancer. Most serous cancers appear to originate from precursor lesions at the fimbriated tubal end, whereas most endometrioid and clear cell cancers seem to derive from atypical endometriosis. Data regarding hormonal factors and associated gynaecologic conditions were critically analysed with the objective of defining a carcinogenic model for sporadic epithelial ovarian cancer complying with epidemiologic and pathologic findings. Oral contraceptives and tubal ligation substantially reduce the risk of serous, endometrioid and clear cell subgroups, but have no significant effect on mucinous tumours, which probably follow a different oncogenic pathway. We hypothesize that serous, endometrioid and clear cell cancers share a common pathogenic mechanism, i.e. iron-induced oxidative stress derived from retrograde menstruation. Fimbriae floating in bloody peritoneal fluid are exposed to the action of catalytic iron and to the genotoxic effect of reactive oxygen species, generated from haemolysis of erythrocytes by pelvic macrophages. This would explain the distal site of tubal intraepithelial neoplasia. Collection of blood inside endometriomas would lead to the same type of genotoxic insult on gonadal endometrial implants. This would explain why endometriosis-associated cancers develop much more frequently in the ovary than at extragonadal sites. In women not seeking conception, bilateral salpingectomy could be advised whenever planning surgery for independent indications, thus possibly reducing cancer risk, while preserving ovarian function. The use of oral contraceptives should be favoured for prolonged periods of time, especially in women with endometriosis, a population at doubled risk of gonadal malignancy.

[Confounding and confusion: recognition of causative relation and identification of victims of occupational carcinogens]

The recognition of occupational cancers is often hampered by the confusion between the individual determinants of the disease and the effect at the group exposure. Here we propose an approach based on the evaluation of the attributable risk at group level aimed to quantify the respective role of multiple causes, and the individual rebounds of it.

[In-progress matrix for occupational cancer recognition]

BACKGROUND

In Italy only a small proportion of all cancers is reported to the national labour insurance board and recognized as having an occupational origin. Cancers with a lower etiological fraction such as lung or bladder cancer have a lower rate of recognition than mesotheliomas or sino-nasal tumours either because of a lack of information obtained via specific occupational anamnesis or because knowledge concerning occupational carcinogens is still uncertain.

OBJECTIVES

To interpret findings and advance new working hypotheses, within the framework of an occupational monitoring survey project (OCCAM) we performed an extensive bibliographical search in the scientific literature on occupational cancer.

METHODS AND RESULTS

We built an on-line "literature matrix" (www.occam.it) containing positive" results from 685 cohort, case-control and cross-sectional epidemiological studies on occupational cancer, from which 1870 citations were obtained describing risk increases by type of cancer and industry. Production cycles or type of industry (iron foundry, leather and shoe manufacturing, etc.) constitute one axis of the matrix and the other consists of type of cancer by site.

CONCLUSIONS

This tool is not only useful for interpretation of evidence arising from occupational cancer surveys but was also intended to be a fast and easy-to-use working tool for occupational physicians, general practitioners and many other specialists to investigate and ascertain the possible occupational origin of a cancer case.

[Active search of work related tumours: preliminary findings]

The OCCAM (Occupational Cancer Monitoring) project enabled the active detection of occupational cancer cases in Lombardy Region.

METHODS

OCCAM is based on a record linkage with social security files to obtain occupational histories for all subjects having worked in private firms, since 1974. It provides risks by area, site and job.

RESULTS

271 incident cancer cases obtained by hospital discharge record in the period 2001-2002 where investigate to assess eventually their occupational origin. Approximately 38% where considered to be occupational cancers.

CONCLUSIONS

OCCAM provides name of the firms and their economic activity completed by information coming from OCCAM risks ascertainment and deeper knowledge on productive cycle retained by local occupational health services. Thus this system can lead to detection of many cancer cases of occupational origin suitable for compensation and determine strategies for the improvement of the work environment.

Genetic susceptibility according to three metabolic pathways in cancers of the lung and bladder and in myeloid leukemias in nonsmokers

BACKGROUND

We chose a set of candidate single nucleotide polymorphisms (SNPs) to investigate gene-environment interactions in three types of cancer that have been related to air pollution (lung, bladder and myeloid leukemia).

PATIENTS AND METHODS

The study has been conducted as a nested case-control study within the European Prospective Investigation into Cancer and Nutrition cohort (409 cancer cases and 757 matched controls). We included never and ex-smokers. SNPs were in genes involved in oxidative stress, phase I metabolizing genes, phase II metabolizing genes and methylenetetrahydrofolate reductase (MTHFR).

RESULTS

The most notable findings are: GSTM1 deletion and bladder cancer risk [odds ratio (OR) = 1.60; 95% confidence interval 1.00-2.56]; CYP1A1 and leukemia (2.22, 1.33-3.70; heterozygotes); CYP1B1 and leukemia (0.47, 0.27-0.84; homozygotes); MnSOD and leukemia (1.91, 1.08-3.38; homozygotes) and NQO1 and lung cancer (8.03, 1.73-37.3; homozygotes). Other statistically significant associations were found in subgroups defined by smoking habits (never or ex-smokers), environmental tobacco smoke or gender, with no obvious pattern. When gene variants were organized according to the three main pathways, the emerging picture was of a strong involvement of combined phase I enzymes in leukemia, with an OR of 5 (1.63-15.4) for those having three or more variant alleles. The association was considerably stronger for leukemias arising before the age of 55.

Alcohol consumption and risk of Hodgkin's lymphoma and multiple myeloma: a multicentre case-control study

BACKGROUND

Few studies have analysed the association between alcohol intake and Hodgkin's lymphoma (HL) or multiple myeloma (MM) risks.

MATERIALS AND METHODS

A multicentre population-based case-control study of 363 HL, 270 MM cases, and 1771 controls offered the opportunity to evaluate the relationship between alcohol and HL/MM risks. Unconditional logistic regression was carried out to estimate odds ratios (ORs) and 95% confidence intervals (CIs), associated with alcohol intake (servings per week, grams per day of ethanol intake) or duration of exposure (year).

RESULTS

For HL, considering nonsmokers only, ever drinkers had a significantly decreased risk than never drinkers (OR=0.46). Significantly lower risks in all levels of total alcohol intake were also detected, considering servings per week (OR for one to four servings per week=0.51, 95% CI 0.32-0.82; OR for five to nine servings per week=0.39, 95% CI 0.21-0.73; OR for 10-19 servings per week=0.26, 95% CI 0.12-0.54; OR for >or=20 servings per week=0.34, 95% CI 0.15-0.79) and grams per day of ethanol intake (OR for 0.1-9.0 g/day=0.45, 95% CI 0.27-0.74; OR for 9.1-17.9 g/day=0.52, 95% CI 0.30-0.90; OR for 18.0-31.7 g/day=0.27, 95% CI 0.13-0.57; OR for >31.7 g/day=0.35, 95% CI 0.15-0.79). In the analysis for ever-smoking HL cases and controls, ever drinkers had the same risk as never drinkers. For MM, ever drinkers had a non-significantly decreased risk than non-drinkers (OR=0.74), and ORs in almost all consumption levels were not significant (OR for 0.1-9.0 g/day=0.93; OR for 9.1-17.9 g/day=0.82; OR for 18.0-31.7 g/day=0.47; 95% CI 0.28-0.81; OR for >31.7 g/day=0.68). For HL and MM, the beverage type did not affect the risk significantly, and no consistent dose-response relationships were found, considering intensity or duration of alcohol consumption.

CONCLUSIONS

Our study indicates a protective effect of alcohol consumption for nonsmoking HL cases.

Cigarette smoking and alcohol consumption as determinants of survival in non-Hodgkin's lymphoma: a population-based study

BACKGROUND

The risk of non-Hodgkin's lymphoma (NHL) seems to be enhanced by cigarette smoking and lowered by alcohol drinking.

PATIENTS AND METHODS

To assess whether cigarette smoking and alcohol drinking affect NHL survival, a population-based prospective study on 1138 Italian patients, diagnosed in 1991-1993, followed-up until 2002, was carried out. At diagnosis, clinical and socio-demographic data were recorded and lifestyle habits were assessed through a validated questionnaire. Survival analysis was performed with Kaplan-Meier methods. Hazard ratios (HR) were estimated by Cox regression.

RESULTS

The mean follow-up was 6.6 years (standard deviation (SD) 4.3). The mean survival time was 7.56 years (SD 0.155). At both univariate and multivariate analysis heavy cigarette smoking and alcohol drinking were associated with poor survival. Compared with those with a lower cumulative exposure to tobacco smoking, those who had smoked>31 pack-years had a worse survival (HR=1.60, 95%CI=1.18-2.18). Drinkers had a higher risk of death compared with non-drinkers (HR=1.41, 95%CI=1.10-1.81). Considering only those who had NHL as cause of death, the HR for the higher category of pack-years smoked, compared with the lowest, was 1.63 (95% CI=1.15-2.33) and for drinkers, compared with non-drinkers, it was 1.33 (95% CI=1.01-1.80).

CONCLUSIONS

cigarette smoking and alcohol drinking may influence NHL survival.

Advances in the management of endometriosis: an update for clinicians

Endometriosis is a chronic and recurrent disease characterized by the presence and proliferation of endometrial tissue outside the uterine cavity, which occurs in approximately 10% of women of reproductive age. In this estrogen-dependent disorder, lesions become inactive and gradually undergo regression during states of ovarian down-regulation, such as amenorrhoea or menopause. The impact of endometriosis includes impaired fertility potential, as well as symptoms of dysmenorrhoea, dyspareunia and chronic non-menstrual pain, all of which adversely affect quality of life. Management of endometriosis focuses on pain relief and includes medical and surgical treatment. Pharmacologic therapies currently in use include combination oral contraceptives (COCs), danazol, GnRH analogues and progestins. Although some agents show efficacy in relieving pain, all differ in their side effects, making it difficult to achieve a balance between efficacy and safety. Efficacy has been demonstrated with danazol or GnRH analogues; however, treatment is limited to 6 months because of significant metabolic side effects. Alternatives for longer-term management of symptoms include add-back therapy with GnRH analogues, COCs or progestins. Newer options for treatment of endometriosis include depot medroxyprogesterone acetate subcutaneous injection, as well as several agents under investigation that may prove to have therapeutic potential.

[A monitoring system for occupational cancer]

INTRODUCTION

The Italian Occupation and Safety Act (d.lgs 626/94) provided for the establishment of a nationwide occupational cancer registry, under the National Institute for Occupational Health and Safety (ISPESL), with the aim of detecting cancer cases of occupational origin and estimating the influence of occupation in cancer causation.

METHODS

Information on cancer cases, drawn from six Italian population-based cancer registries (CRs of Friuli Venezia Giulia Region, Genoa Town and Genoa Province, Macerata Town, Umbria Region, Varese Town, Veneto Region), and on a random sample of population controls selected in each CRs area were linked with data on subjects employed in private enterprises that have been available in electronic form since 1974 at the National Institute for Social Security (INPS). In this way, both for cases and controls, the occupational histories of past employment were collected. A population-based case-control study covering the period 1990-1998 was carried out with the aim of estimating occupational cancer risk in the private sector by site and economic category in each area. Since one of the major drawbacks of this approach is the difficulty in distinguishing true occupational hazards from incidental findings derived from multiple comparisons, an extensive research of occupational literature was carried out, independently of the study results, to compare our results with existing knowledge on occupational risks.

RESULTS

Pooled analysis of the most recent incidence data based on 36,379 cases and 29,572 controls was performed; 34 "statistically significant" associations were found for 11 economic categories. Using our literature review, 10 associations were supported by more than 5 publishedpapers, 14 by a number of papers between 1 and 5, and 10 associations had not been previously reported.

CONCLUSIONS

This system appears suitable for assessing existing occupational cancer risks and can eventually lead to detecting occupational hazards in many areas of Italy. The system can also provide a list of cases suitable for in-depth search for past occupational exposures.

The EpiLink record linkage software: presentation and results of linkage test on cancer registry files

OBJECTIVES

Record linkage, the process of bringing together separately compiled but related records from different databases, is essential in many areas of biomedical research. We developed a record linkage program (EpiLink), which employs a simple mathematical approach. We describe the program and present results obtained testing it in a linkage task.

METHODS

EpiLink was designed to be flexible with user-friendly settings to tailor linkage and operating parameters to specific linkage tasks, and employ deterministic, probabilistic or sequential deterministic-probabilistic linkage strategies as required. The user can also standardize data format, examine linkage results and accept or discard them. We used EpiLink to link a subset of cases of the Lombardy Cancer Registry (20,724 records) with the Social Security file of the population (1,021,846 records) covered by the registry. The linkage strategy was deterministic, followed by several probabilistic linkage steps.

RESULTS

Manual inspection of the results showed that EpiLink achieved 98.8% specificity and 96.5% sensitivity.

CONCLUSIONS

EpiLink is a practical and accurate means of linking records from different databases that can be used by non-statisticians and is efficient in terms of human and financial resources.

[Use of pension records for occupational health surveillance: example of record-linkage with hospital discharge records to study the association between work and the incidence of leukaemias, lung and bladder cancer, and miscarriage]

BACKGROUND

Epidemiologic surveillance of occupational health based on routinely collected data allows groups of workers to be studied, whose type of work (e.g. small enterprises, self-employed workers, artisans) makes it difficult to use a traditional cohort study design.

OBJECTIVE

To evaluate the validity of a study design based on the record-linkage between hospital discharge records and INPS social security records (National Institute for Social Security), in order to investigate the association between past employment in an economic sector and occurrence of diseases with a low fraction attributable to occupation and a high frequency in the population, where it is too costly to perform retrospective interviews to gather data from each recruited subject.

METHODS

A case-control study design was used in which hospital discharge records from 1995 in the Piedmont Region represented the source of subjects enrolled. Four series of cases were identified: males aged 40-75 years, with first hospital admission for leukaemia, lung or bladder cancer; and women aged 18-39 years, admitted for miscarriage. The controls were a random sample of patients admitted in the same year and matched by sex and age. The exposure variable was the prevalent economic sector in the occupational history of the subjects enrolled, as inferred from INPS social security records.

RESULTS

No economic sector examined showed a significant excess of incidence of bladder cancer or leukaemia. There was a significant excess of lung cancer in subjects with longest employment in the building industry, in metal working, and in the "foundries, heat pressing, forging, and rolling mills" sector. A significant excess of miscarriages was present only in women working in commerce.

DISCUSSION

The results demonstrated overall a low consistency compared with those obtained via other surveillance systems of occupational morbidity and mortality, as well as by means of analytical studies. The results appear more plausible for the sectors characterized by a low number of job tasks, or by a more homogenous exposure to risk factors among workers in different jobs. Among the limitations of this study the lack of a complete occupational history, the absence of information on potential confounders like smoking and alcohol consumption, and the probable non-differential misclassification of the longest held job need to be stressed

[Epidemiologic surveillance in occupational carcinogenesis]

Research on occupational cancer epidemiology has been an important area of occupational health in Italy. While according to epidemiological estimates the proportion of all cancers attributable to occupational factor is about 4%, the number of compensated occupational cancers in Italy is remarkably lower. Re.Na.M., OCCAM and ISOD projects are example of epidemiological surveillance and can serve as basis for ad hoc studies.

Delayed infection, late tonsillectomy or adenoidectomy and adult leukaemia: a case-control study

In a population-based case-control study among adults in Italy, of 261 lymphoid and 313 myeloid leukaemias and 1718 controls, a later age at adenoidectomy and tonsillectomy (after age 10 years) increased considerably the risk of lymphocytic (but not myeloid) leukaemia (odds ratio 4.2, 95% confidence interval 1.1-16.2). We propose that late infection is a proliferative stimulus for B-cells.

Assessment of the QoL in Italian menopausal women: comparison between HRT users and non-users

OBJECTIVES

The aim of this cross-sectional study was to describe QoL in a large sample of women attending menopause centres and compare untreated postmenopausal women and matched HRT users by employing the Women's Health Questionnaire (WHQ) and two generic instruments, the SF-36 and the EQ-5D.

METHODS

Overall, 2906 women were recruited by 64 menopause centres throughout Italy, of whom 2160 filled in the questionnaire (1093 on HRT and 1067 not on HRT; response rate: 74%).

RESULTS

HRT users tended to be younger, healthier and with shorter menopause duration as opposed to non users, while no major socio-economic differences were present. At multivariate analysis, the presence of chronic diseases, low socio-economic status and living in Southern Italy represented the most important predictors of poor QoL. Furthermore, HRT users showed a lower probability of reporting problems in usual activities and pain/discomfort (EQ-5D), role limitations due to emotional problems (SF-36) and anxiety/fears (WHQ). HRT users also showed highly significant better outcomes in those areas that are more directly attributable to hormonal changes of mid age, namely vasomotor symptoms and sexual problems.

CONCLUSIONS

Although QoL is mainly influenced by socio-economic and cultural factors, HRT has the potential for improving not only symptoms, but also more general aspects of physical and psychological well-being of symptomatic postmenopausal women.

Selection criteria, methods of analysis and results presentation issues

In this paper we presented materials and methods used for analysing survival of cancer patients recorded by the Italian cancer registries. First, we included first primary malignant tumours and excluded skin carcinomas, and cases identified by death certificate only, or by autopsy. Observed survival has been computed with the life-table method, with one month time lags. We corrected survival rates by the overall mortality effect (relative survival) with the Hakulinen method. The relative survival was age and sex adjusted with the EUROCARE method. Finally we discussed the results presentation issues.

Validation of Italian version of the Women's Health Questionnaire: assessment of quality of life of women from the general population and those attending menopause centers

OBJECTIVES

The Women's Health Questionnaire has been developed and validated in Anglo-Saxon and Swedish populations. The purpose of this study was to evaluate the Italian version of the questionnaire to determine whether cross-cultural differences exist in the perception of quality of life, and to use it to compare the quality of life in women attending menopause centers with that of women in the general population.

METHODS

An Italian version of the Women's Health Questionnaire (WHQ) was produced, using the forward-backward translation method to ensure conceptual equivalence, and approved by the originator. Women were recruited by random selection from the general population and from menopause centers, those taking hormone replacement therapy being ineligible. The questionnaire was completed anonymously at home and mailed to the co-ordinating center. Psychometric evaluation included tests of item convergent and discriminant validity, internal-consistency reliability, test-retest reliability, construct validity and the discriminative properties of the questionnaire.

RESULTS

The completeness of the data was good, with missing-value rates consistently low for most items. Item-scale correlations, used to evaluate internal consistency, were also good and the scaling success rate, used to measure item discriminant validity, was high for all scales. Scale scores were reliable for seven out of nine scales and test-retest reliability was excellent. There were few significant differences between the two populations of women in most of the WHQ areas. A comparison of Italian data with published data on English women showed great similarity.

CONCLUSION

The Italian version of the WHO is valid and reproducible. The subjective perception of the menopause and its related problems is similar in geographically and culturally different populations.

Smoking and hematolymphopoietic malignancies

OBJECTIVE

Tobacco use is the most prominent cause of respiratory cancers. Little is known, however, about the influence of smoking on hematolymphopoietic malignancies. To evaluate this relation, a population-based case-control study was carried out in 12 areas of Italy.

METHODS

Detailed interviews on tobacco smoking habits were administered to 1450 non-Hodgkin's lymphoma (NHL), 365 Hodgkin's disease (HD), 270 multiple myeloma (MM), and 649 leukemia (LEU) patients occurring from 1990 to 1993, and 1779 population controls.

RESULTS

We found a slightly increased risk for NHL in smokers (odds ratio 1.2, 95% confidence interval 1.0-1.4 for ever smokers), but a consistent positive association was shown only for follicular NHL. In this subtype, a significant excess risk was observed for ever versus never smokers, after adjustment for gender, age, geographic residence, education, and respondent (OR = 1.8, 95%, CI 1.3-2.7), with a positive exposure-response gradient for smoking duration (p < 0.01). The risk for follicular NHL was significantly elevated only among women, with ever smokers showing OR = 2.3 (CI 1.4-3.8), while for men we found OR = 1.3 (CI 0.69-2.3). No major differences were shown according to age. Female subjects also showed significant positive exposure-response trends for duration.

CONCLUSION

Cigarette smoking could be a risk factor for follicular NHL among women. For HD, MM, or LEU, no clear association was observed.

A multicenter case-control study in Italy on hematolymphopoietic neoplasms and occupation

We conducted a population-based, case-control study on hematolymphopoietic malignancies in 12 areas in Italy to investigate associations between different hematolymphopoietic malignancies and exposure to solvents and pesticides. We collected all incident cases 20-74 years of age from 12 areas, with a combined population of approximately 7 million residents. The control group was formed by a random sample of the study population. Data presented in this paper refer to 2,737 interviewed cases of 3,357 eligible cases and to 1,779 of 2,391 eligible controls. We analyzed risks associated with occupation using job-title information to evaluate disease pattern according to job category. An earlier publication presented results for women; here, we report the findings for men and discuss the overall patterns in both genders. The most consistent overall finding was an approximate doubling in relative risk for all four types of malignancies among male managers and related occupations. Several additional occupations were associated with elevated risk of one or more malignancies among men. These included cooks, waiters, and bartenders, and building caretakers and cleaners, for non-Hodgkin's lymphoma; textile workers and machinery fitters for Hodgkin's lymphoma; metal processors, material handlers, rubber workers, and painters for leukemia; and hairdressers, metal processors, tailors, electrical workers, and plumbers for multiple myeloma. The finding of increased risk of non-Hodgkin's lymphoma among both male and female cooks, waiters, and bartenders has not been previously reported; nor has the elevated risk of leukemia among material handlers. Among people engaged in agriculture, those employed as tractor drivers and as "orchard, vineyard, and related tree and shrub workers" appeared to be at increased risk for hematolymphopoietic malignancies.

Reliability of ovulation tests in infertile women

OBJECTIVE

To assess the reliability of the most widely used clinical methods for predicting or confirming ovulation.

METHODS

We monitored spontaneous cycles in 101 infertile women using basal body temperature (BBT), transvaginal ultrasound, a urinary stick system for LH surge, and three serum progesterone measurements in the midluteal phase. Transvaginal ultrasound monitoring was standard for ovulation detection and sensitivity. We calculated specificity and accuracy of each method compared with that standard.

RESULTS

Follicular development and ultrasound evidence of ovulation were confirmed in 97 of 101 cycles (96%). Urinary LH surge preceded follicular rupture assessed by ultrasonography in all cycles and showed concordance with ultrasound-evidenced ovulation in 98 of 101 cases. The timing of BBT nadir had wide variability, and BBT and ultrasonography agreed in a similar percentage of cases (74%). Midluteal serum progesterone assessments showed ovulatory values in 93 subjects, and ovulation was concordant with ultrasonography in 90 subjects.

CONCLUSION

Urinary LH was accurate in predicting ovulation with ultrasonography as the standard for detection, but time varied widely. The nadir of BBT predicted ovulation poorly. The BBT chart was less accurate for confirming ovulation, whereas a single serum progesterone assessment in midluteal phase seemed as effective as repeated serum progesterone measures.

Delayed infection, family size and malignant lymphomas

BACKGROUND

The annual incidence of non-Hodgkin's lymphomas (NHL) is increasing by 3%-4% in different parts of the developed world. Excesses of NHL have been observed in populations exposed to immunosuppressants and to HIV, but these causes do not explain the increasing trends. It is suggested that delayed infection could explain NHL trends, through an impairment of the Th1/Th2 lymphocyte patterns.

METHODS

In a population-based study on 1388 patients with NHL, 354 with Hodgkin's disease (HD) and 1718 healthy controls, the age of first occurrence of bacterial and viral diseases was investigated. Clinical records were perused in one centre to check the anamnestic data.

FINDINGS

The age of occurrence of bacterial and viral diseases was significantly higher among NHL patients than in the controls. The association between later age at first bacterial or viral disease was limited to small families (OR= 1.95; 95% confidence intervals 1.26, 3.00, for age 4-8 at first infection; OR=1.91; 1.19, 3.06, for age 9+, compared with less than 4). The association was more obvious for bacterial diseases (possibly for the lower degree of misclassification). High grade lymphomas showed the strongest association. The later age of occurrence of bacterial or viral diseases in NHL patients is consistent with a higher incidence of lymphomas observed in higher social groups. No clear association was found between HD and age at first bacterial or viral diseases.

INTERPRETATION

It is proposed that delayed infection could explain the increasing NHL trends, through an impairment of the Th1/Th2 lymphocyte patterns. The model of delayed infection has been proposed also to explain increasing prevalence rates of asthma.

Haematopoietic cancer and medical history: a multicentre case control study

BACKGROUND

Viruses (such as Epstein-Barr virus) and pathological conditions (mainly involving immunosuppression) have been shown to increase the risk of haematolymphopoietic malignancies. Other associations (diabetes, tonsillectomy, autoimmune diseases) have been inconsistently reported.

METHODS

The association between different haematolymphopoietic malignancies (lymphomas, myelomas and leukaemias) and the previous medical history has been studied in a population-based case-control investigation conducted in Italy, based on face to face interviews to 2669 cases and 1718 population controls (refusal rates 10% and 19%, respectively). Controls were a random sample of the general population.

RESULTS

Previous findings were confirmed concerning the association between non-Hodgkin's lymphoma (NHL) and lupus erythematosus (odds ratio, OR=8.4; 95% CI 1. 6, 45), tuberculosis (OR=1.6; 1.05, 2.5) and hepatitis (1.8; 1.4, 2. 3). An association was found also between NHL and maternal (OR=2.8; 1.1, 6.9) or paternal tuberculosis (OR=1.7; 0.7, 3.9). Odds ratios of 4.0 (1.4, 11.8) and 4.4 (1.1, 6.6) were detected for the association between NHL and Hodgkin's disease, respectively, and previous infectious mononucleosis, but recall bias cannot be ruled out. No association was found with diabetes, tonsillectomy and adenoidectomy. An association with malaria at young age and "low grade" lymphatic malignancies is suggested. One interesting finding was the observation of four cases of poliomyelitis among NHL patients, one among Hodgkin's disease and one among myeloid leukaemia patients, compared with none among the controls (Fisher's exact test for NHL and Hodgkin's disease, p= 0.03, one tail).

CONCLUSIONS

Some of these findings are confirmatory of previous evidence. Other observations, such as the putative role of the polio virus and of malaria are new. A unifying theory on the mechanisms by which previous medical history may increase the risk of haematolymphopoietic malignancies is still lacking.

Hematopoietic cancer and peptic ulcer: a multicenter case-control study

Helicobacter pylori has been suggested as a cause of gastric carcinoma and gastric non-Hodgkin's lymphoma (NHL). In a previous cohort study, a relative risk of six for gastric NHL was reported among subjects who tested positive for anti-H.pylori antibodies. The association between peptic ulcer and NHL has been studied in a population-based case-control investigation on hemato-lymphopoietic malignancies in Italy, based on face-to-face interviews to 2671 cases and 1718 controls (refusal rates 10 and 19%, respectively). Subjects who reported a diagnosis of peptic ulcer had a relative risk of 5.6 [95% confidence interval (CI) 3.8-8.0] for gastric NHL, whereas the estimate for non-gastric NHL was 1.3 (1.0-1.6). The association with recent diagnosis of ulcer was stronger, but the odds ratio (OR) was as high as 2.1 (95% CI 1.1-4.2) after >/=20 years since such diagnosis. After exclusion of the last 2 years before the diagnosis of NHL, and of ulcers diagnosed before 1978 (when gastroscopy became common in Italy), the OR was still 5.3 (95% CI 3.0-9.2). We found a strong effect modification by educational level, with ORs for ulcer more elevated in higher social groups. Gender was an effect modifier (OR = 4.1 in males, 9.2 in females; P = 0.03 for heterogeneity). The association with other gastrointestinal pathologies was much lower and statistically not significant. Almost all gastric lymphomas were B-cell NHLs of intermediate grade according to the working formulation; the majority belonged to the mucosa-associated lymphoid tissue (MALT) type. The association with ulcer was much stronger among MALT lymphomas, but only for recent ulcer diagnoses (2-10 years). Our study shows an increased risk for gastric NHL, very similar to the estimate reported in a previous cohort study. The risk was higher among more educated subjects.