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Lacey BWH, Armas N, Burrett JA, Peto R, Duenas A, Lewington S. P6143Body-mass index, blood pressure, diabetes and cardiovascular mortality in Cuba: prospective cohort study of 146,665 participants. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz746.0749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Cardiovascular disease (CVD) is a leading cause of premature death in Cuba, accounting for about one third of all deaths under age 70 years. Substantial uncertainty remains, however, about the relevance of major metabolic risk factors to CVD mortality in this population.
Purpose
To relate body-mass index (BMI), systolic blood pressure (SBP), and diabetes to risk of CVD death in Cuba.
Methods
In a prospective cohort study, 146,665 adults were recruited from the general population in five areas of Cuba between 1996 and 2002. Participants were interviewed, measured (height, weight and blood pressure) and followed up by electronic linkage to Cuban national death registries to Jan 1 2017; 24,345 participants were resurveyed between 2006 and 2008. After excluding all with missing data or chronic disease at recruitment or, to further limit reverse causality, those who died in the first 5 years, Cox regression (adjusted for age, sex, education, smoking, alcohol and, where appropriate, BMI) was used to relate mortality rate ratios (RRs) at ages 35–79 years to BMI, SBP and diabetes. Correlations of baseline and resurvey values were used to corrected RRs for regression dilution, and thereby estimate associations with long-term average (“usual”) levels of SBP and BMI.
Results
After exclusions, there were 117,008 participants age 35–79 (mean age 52 [SD 12]; 55% women). At recruitment, mean SBP was 124 mm Hg (SD 15), mean BMI was 24.2 kg/m2 (SD 3.6) and 5% had diabetes; mean SBP and diabetes prevalence were both strongly related to BMI. Correlations of resurvey and baseline measurements were 0.48 for SBP and 0.60 for BMI. At ages 35–79 years, there were 3780 CVD deaths (1871 ischaemic heart disease [IHD], 766 stroke, and 1143 other). CVD mortality was positively associated with BMI (down to about 22–23 kg/m2; figure), SBP and diabetes: 10 kg/m2 higher usual BMI approximately doubled CVD mortality (RR 1.90, 95% CI 1.61–2.24), as did 20 mmHg higher usual SBP (2.03, 1.88–2.20), and a prior diagnosis of diabetes (2.18, 1.97–2.42). The associations were similar in men and women. Given these associations, about one quarter (27%) of CVD deaths in this study were attributable to these metabolic risk factors combined.
Conclusion
These associations differ to those reported from other parts of Latin America, and are more consistent with studies in Europe and North America, highlighting the need for many more large-scale prospective studies in low and middle income countries. This study provides direct evidence for the expected benefit on CVD mortality of addressing major metabolic risk factors in Cuba. As the levels of these metabolic risk factors are increasing in Cuba, so too is their importance as determinants of premature CVD death.
Acknowledgement/Funding
Medical Research Council, British Heart Foundation, Cancer Research UK
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Affiliation(s)
- B W H Lacey
- University of Oxford, Nuffield Department of Population Health, Oxford, United Kingdom
| | - N Armas
- Institute of Cardiology, Havana, Cuba
| | - J A Burrett
- University of Oxford, Nuffield Department of Population Health, Oxford, United Kingdom
| | - R Peto
- University of Oxford, Nuffield Department of Population Health, Oxford, United Kingdom
| | - A Duenas
- Institute of Cardiology, Havana, Cuba
| | - S Lewington
- University of Oxford, Nuffield Department of Population Health, Oxford, United Kingdom
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Gnatiuc L, Alegre-Diaz J, Garcilazo-Avila A, Ramirez R, Gonzales-Carballo C, Solano-Sanchez M, Chiquete E, Wade R, Clarke R, Herrington WG, Collins R, Peto R, Tapia-Conyer R, Kuri-Morales P, Emberson J. P3824Body composition and mortality from vascular or metabolic causes among 150,000 participants in the Mexico City Prospective Study. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz745.0666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Higher body-mass index is associated with increased mortality from vascular disease, renal disease and other metabolic causes. However, body mass reflects both fat and lean mass, which may have very different effects on risk. We investigated the individual and joint relevance of fat and lean mass to mortality from these causes, using data from the Mexico City Prospective Study.
Methods
Between 1998 and 2004, 150,000 adults from Mexico City were recruited into a prospective study and tracked for cause-specific mortality for 14 years. Fat and lean mass at recruitment were predicted using Mexican-specific anthropometric equations, validated in a subset of participants with additional bio-impedance measures. Cox regression was used to assess the relevance of fat and lean mass at recruitment to mortality from a vascular, renal, or other metabolic cause at ages 35–74 years. Analyses were adjusted for age at risk, sex, residential district, education, recreational physical activity, smoking and alcohol consumption. To avoid reverse causality, analyses excluded those with diabetes or other chronic diseases at recruitment, and deaths in the first 5 years of follow-up. Mortality rate ratios (RRs) relate to the differences per SD of the usual values of various factors or the differences between the top tenth and bottom fifth of the values.
Results
Among 112,923 participants aged 35–74 years, mean (SD) fat mass in men and women was 22.0 (6.4) kgs and 29.4 (7.8) kgs respectively, while mean (SD) lean mass was 54.9 (7.2) kgs and 39.2 (5.0) kgs respectively. In both men and women, equation-predicted fat and lean mass closely matched the bio-impedance values (all r>0.86). Both fat and lean mass were positively and approximately log-linearly associated with mortality from a vascular or metabolic cause. However, the association of lean mass with mortality was more than accounted for by the correlation of lean with fat mass. Hence, after adjustment for fat mass, lean mass was inversely associated with risk. For a given amount of fat mass, the RR for vascular/metabolic mortality comparing those in the top tenth versus bottom fifth of the predicted lean mass was 0.35 (95% CI 0.24–0.52). Conversely, for a given amount of lean mass, the RR comparing those in the top tenth versus bottom fifth of the predicted fat mass was 4.06 (3.06–5.39). The RRs associated with each SD higher fat mass (1.51, 1.40–1.63) or lean mass (0.79, 0.73–0.86) appeared to be little affected by age, sex, or levels of other confounders, and were broadly similar for the major vascular, renal, and other metabolic mortality. The height-adjusted RRs were 1.41 (1.30–1.53) for fat mass and 0.91 (0.82–1.00) for lean mass.
Conclusions
In this Mexican cohort, predicted fat and lean mass had opposing effects on vascular and other metabolic deaths, with no evidence of any thresholds throughout the ranges studied.
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Affiliation(s)
- L Gnatiuc
- University of Oxford, CTSU, Nuffield Department of Population Health,, Oxford, United Kingdom
| | - J Alegre-Diaz
- National Autonomous University of Mexico, School of Medicine, Mexico City, Mexico
| | - A Garcilazo-Avila
- National Autonomous University of Mexico, School of Medicine, Mexico City, Mexico
| | - R Ramirez
- National Autonomous University of Mexico, School of Medicine, Mexico City, Mexico
| | - C Gonzales-Carballo
- National Autonomous University of Mexico, School of Medicine, Mexico City, Mexico
| | - M Solano-Sanchez
- National Autonomous University of Mexico, School of Medicine, Mexico City, Mexico
| | - E Chiquete
- National Autonomous University of Mexico, School of Medicine, Mexico City, Mexico
| | - R Wade
- University of Oxford, MRC Population Health Research Unit; Nuffield Department of Population Health, Oxford, United Kingdom
| | - R Clarke
- University of Oxford, CTSU, Nuffield Department of Population Health,, Oxford, United Kingdom
| | - W G Herrington
- University of Oxford, MRC Population Health Research Unit; Nuffield Department of Population Health, Oxford, United Kingdom
| | - R Collins
- University of Oxford, CTSU, Nuffield Department of Population Health,, Oxford, United Kingdom
| | - R Peto
- University of Oxford, CTSU, Nuffield Department of Population Health,, Oxford, United Kingdom
| | - R Tapia-Conyer
- National Autonomous University of Mexico, School of Medicine, Mexico City, Mexico
| | - P Kuri-Morales
- National Autonomous University of Mexico, School of Medicine, Mexico City, Mexico
| | - J Emberson
- University of Oxford, MRC Population Health Research Unit; Nuffield Department of Population Health, Oxford, United Kingdom
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Lacey B, Armas N, Burrett J, Peto R, Dueñas A, Lewington S. PO400 Diabetes and Cardiovascular Mortality In Cuba: A Prospective Study of 146,556 Adults. Glob Heart 2018. [DOI: 10.1016/j.gheart.2018.09.310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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Bennett D, Du H, Guo Y, Bian Z, Chen J, Collins R, Peto R, Li L, Clarke R, Chen Z. P661Associations of sedentary behaviour with myocardial infarction and stroke: findings from a 10-year prospective study of 0.5 million chinese adults. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy564.p661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- D Bennett
- University of Oxford, Oxford, United Kingdom
| | - H Du
- University of Oxford, Oxford, United Kingdom
| | - Y Guo
- Chinese Academy of Medical Sciences, Beijing, China People's Republic of
| | - Z Bian
- Chinese Academy of Medical Sciences, Beijing, China People's Republic of
| | - J Chen
- China National Center for Food Safety Risk Assessment, Beijing, China People's Republic of
| | - R Collins
- University of Oxford, Oxford, United Kingdom
| | - R Peto
- University of Oxford, Oxford, United Kingdom
| | - L Li
- Peking University, Chinese Academy of Medical Sciences, Beijing, China People's Republic of
| | - R Clarke
- University of Oxford, Oxford, United Kingdom
| | - Z Chen
- University of Oxford, Oxford, United Kingdom
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Gnatiuc L, Alegre-Diaz J, Wade R, Ramirez R, Herrington WG, Solano M, Clarke R, Lewington SL, Collins R, Peto R, Tapia-Conyer R, Emberson J, Kuri-Morales P. P6282Adiposity and vascular-metabolic mortality among 150,000 Mexican adults followed for 15 years. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy566.p6282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- L Gnatiuc
- University of Oxford, CTSU, Oxford, United Kingdom
| | - J Alegre-Diaz
- National Autonomous University of Mexico, School of Medicine, Mexico City, Mexico
| | - R Wade
- University of Oxford, MRC Population Health Research Unit; Nuffield Department of Population Health, Oxford, United Kingdom
| | - R Ramirez
- National Autonomous University of Mexico, School of Medicine, Mexico City, Mexico
| | | | - M Solano
- National Autonomous University of Mexico, School of Medicine, Mexico City, Mexico
| | - R Clarke
- University of Oxford, CTSU, Oxford, United Kingdom
| | - S L Lewington
- University of Oxford, MRC Population Health Research Unit; Nuffield Department of Population Health, Oxford, United Kingdom
| | - R Collins
- University of Oxford, CTSU, Oxford, United Kingdom
| | - R Peto
- University of Oxford, CTSU, Oxford, United Kingdom
| | - R Tapia-Conyer
- National Autonomous University of Mexico, School of Medicine, Mexico City, Mexico
| | - J Emberson
- University of Oxford, MRC Population Health Research Unit; Nuffield Department of Population Health, Oxford, United Kingdom
| | - P Kuri-Morales
- National Autonomous University of Mexico, School of Medicine, Mexico City, Mexico
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Gnatiuc L, Herrington WG, Halsey J, Tuomilehto J, Fang X, Kim HC, De Bacquer D, Dobson AJ, Criqui MH, Jacobs DR, Leon DA, Peters SAE, Ueshima H, Sherliker P, Peto R, Collins R, Huxley RR, Emberson JR, Woodward M, Lewington S, Aoki N, Arima H, Arnesen E, Aromaa A, Assmann G, Bachman DL, Baigent C, Bartholomew H, Benetos A, Bengtsson C, Bennett D, Björkelund C, Blackburn H, Bonaa K, Boyle E, Broadhurst R, Carstensen J, Chambless L, Chen Z, Chew SK, Clarke R, Cox C, Curb JD, D'Agostino R, Date C, Davey Smith G, De Backer G, Dhaliwal SS, Duan XF, Ducimetiere P, Duffy S, Eliassen H, Elwood P, Empana J, Garcia-Palmieri MH, Gazes P, Giles GG, Gillis C, Goldbourt U, Gu DF, Guasch-Ferre M, Guize L, Haheim L, Hart C, Hashimoto S, Hashimoto T, Heng D, Hjermann I, Ho SC, Hobbs M, Hole D, Holme I, Horibe H, Hozawa A, Hu F, Hughes K, Iida M, Imai K, Imai Y, Iso H, Jackson R, Jamrozik K, Jee SH, Jensen G, Jiang CQ, Johansen NB, Jorgensen T, Jousilahti P, Kagaya M, Keil J, Keller J, Kim IS, Kita Y, Kitamura A, Kiyohara Y, Knekt P, Knuiman M, Kornitzer M, Kromhout D, Kronmal R, Lam TH, Law M, Lee J, Leren P, Levy D, Li YH, Lissner L, Luepker R, Luszcz M, MacMahon S, Maegawa H, Marmot M, Matsutani Y, Meade T, Morris J, Morris R, Murayama T, Naito Y, Nakachi K, Nakamura M, Nakayama T, Neaton J, Nietert PJ, Nishimoto Y, Norton R, Nozaki A, Ohkubo T, Okayama A, Pan WH, Puska P, Qizilbash N, Reunanen A, Rimm E, Rodgers A, Saitoh S, Sakata K, Sato S, Schnohr P, Schulte H, Selmer R, Sharp D, Shifu X, Shimamoto K, Shipley M, Silbershatz H, Sorlie P, Sritara P, Suh I, Sutherland SE, Sweetnam P, Tamakoshi A, Tanaka H, Thomsen T, Tominaga S, Tomita M, Törnberg S, Tunstall-Pedoe H, Tverdal A, Ueshima H, Vartiainen E, Wald N, Wannamethee SG, Welborn TA, Whincup P, Whitlock G, Willett W, Woo J, Wu ZL, Yao SX, Yarnell J, Yokoyama T, Yoshiike N, Zhang XH. Sex-specific relevance of diabetes to occlusive vascular and other mortality: a collaborative meta-analysis of individual data from 980 793 adults from 68 prospective studies. Lancet Diabetes Endocrinol 2018; 6:538-546. [PMID: 29752194 PMCID: PMC6008496 DOI: 10.1016/s2213-8587(18)30079-2] [Citation(s) in RCA: 129] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Revised: 02/20/2018] [Accepted: 02/26/2018] [Indexed: 01/06/2023]
Abstract
BACKGROUND Several studies have shown that diabetes confers a higher relative risk of vascular mortality among women than among men, but whether this increased relative risk in women exists across age groups and within defined levels of other risk factors is uncertain. We aimed to determine whether differences in established risk factors, such as blood pressure, BMI, smoking, and cholesterol, explain the higher relative risks of vascular mortality among women than among men. METHODS In our meta-analysis, we obtained individual participant-level data from studies included in the Prospective Studies Collaboration and the Asia Pacific Cohort Studies Collaboration that had obtained baseline information on age, sex, diabetes, total cholesterol, blood pressure, tobacco use, height, and weight. Data on causes of death were obtained from medical death certificates. We used Cox regression models to assess the relevance of diabetes (any type) to occlusive vascular mortality (ischaemic heart disease, ischaemic stroke, or other atherosclerotic deaths) by age, sex, and other major vascular risk factors, and to assess whether the associations of blood pressure, total cholesterol, and body-mass index (BMI) to occlusive vascular mortality are modified by diabetes. RESULTS Individual participant-level data were analysed from 980 793 adults. During 9·8 million person-years of follow-up, among participants aged between 35 and 89 years, 19 686 (25·6%) of 76 965 deaths were attributed to occlusive vascular disease. After controlling for major vascular risk factors, diabetes roughly doubled occlusive vascular mortality risk among men (death rate ratio [RR] 2·10, 95% CI 1·97-2·24) and tripled risk among women (3·00, 2·71-3·33; χ2 test for heterogeneity p<0·0001). For both sexes combined, the occlusive vascular death RRs were higher in younger individuals (aged 35-59 years: 2·60, 2·30-2·94) than in older individuals (aged 70-89 years: 2·01, 1·85-2·19; p=0·0001 for trend across age groups), and, across age groups, the death RRs were higher among women than among men. Therefore, women aged 35-59 years had the highest death RR across all age and sex groups (5·55, 4·15-7·44). However, since underlying confounder-adjusted occlusive vascular mortality rates at any age were higher in men than in women, the adjusted absolute excess occlusive vascular mortality associated with diabetes was similar for men and women. At ages 35-59 years, the excess absolute risk was 0·05% (95% CI 0·03-0·07) per year in women compared with 0·08% (0·05-0·10) per year in men; the corresponding excess at ages 70-89 years was 1·08% (0·84-1·32) per year in women and 0·91% (0·77-1·05) per year in men. Total cholesterol, blood pressure, and BMI each showed continuous log-linear associations with occlusive vascular mortality that were similar among individuals with and without diabetes across both sexes. INTERPRETATION Independent of other major vascular risk factors, diabetes substantially increased vascular risk in both men and women. Lifestyle changes to reduce smoking and obesity and use of cost-effective drugs that target major vascular risks (eg, statins and antihypertensive drugs) are important in both men and women with diabetes, but might not reduce the relative excess risk of occlusive vascular disease in women with diabetes, which remains unexplained. FUNDING UK Medical Research Council, British Heart Foundation, Cancer Research UK, European Union BIOMED programme, and National Institute on Aging (US National Institutes of Health).
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Morris D, Bulbulia R, Pan H, Rothwell P, Mehta Z, Peto R, Halliday A. 5774A novel clinical risk score to identify people with asymptomatic carotid artery stenosis with a higher risk of stroke. Eur Heart J 2017. [DOI: 10.1093/eurheartj/ehx493.5774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Alegre-Diaz J, Gnatiuc L, Wade R, Ramirez R, Herrington W, Lewington S, Lopez Cervantes M, Solano M, Peto R, Collins R, Tapia-Conyer R, Kuri-Morales P, Emberson J. P6257Blood pressure and death from vascular and metabolic diseases in Mexico City: 12-year follow-up of 150,000 adults. Eur Heart J 2017. [DOI: 10.1093/eurheartj/ehx493.p6257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- J. Alegre-Diaz
- National Autonomous University of Mexico, School of Medicine, Mexico City, Mexico
| | - L. Gnatiuc
- University of Oxford, CTSU, Nuffield Department of Population Health,, Oxford, United Kingdom
| | - R. Wade
- University of Oxford, MRC Population Health Research Unit; Nuffield Department of Population Health, Oxford, United Kingdom
| | - R. Ramirez
- National Autonomous University of Mexico, School of Medicine, Mexico City, Mexico
| | - W.G. Herrington
- University of Oxford, CTSU, Nuffield Department of Population Health,, Oxford, United Kingdom
| | - S.L. Lewington
- University of Oxford, MRC Population Health Research Unit; Nuffield Department of Population Health, Oxford, United Kingdom
| | - M. Lopez Cervantes
- National Autonomous University of Mexico, School of Medicine, Mexico City, Mexico
| | - M. Solano
- National Autonomous University of Mexico, School of Medicine, Mexico City, Mexico
| | - R. Peto
- University of Oxford, CTSU, Nuffield Department of Population Health,, Oxford, United Kingdom
| | - R. Collins
- University of Oxford, CTSU, Nuffield Department of Population Health,, Oxford, United Kingdom
| | - R. Tapia-Conyer
- National Autonomous University of Mexico, School of Medicine, Mexico City, Mexico
| | - P. Kuri-Morales
- National Autonomous University of Mexico, School of Medicine, Mexico City, Mexico
| | - J.R. Emberson
- University of Oxford, MRC Population Health Research Unit; Nuffield Department of Population Health, Oxford, United Kingdom
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Lacey B, Dobell E, Armas N, Burrett J, Peto R, Duenas A, Lewington S. P6258Burden of hypertension and associated risks for cardiovascular mortality in Cuba: prospective cohort study of 150,000 men and women. Eur Heart J 2017. [DOI: 10.1093/eurheartj/ehx493.p6258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Chen Y, Bennett D, Clarke R, Guo Y, Yu C, Bian Z, Ma L, Huang Y, Sun Q, Zhang N, Zheng X, Chen J, Peto R, Kendler KS, Li L, Chen Z. Patterns and correlates of major depression in Chinese adults: a cross-sectional study of 0.5 million men and women. Psychol Med 2017; 47:958-970. [PMID: 27919307 PMCID: PMC5341494 DOI: 10.1017/s0033291716002889] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Revised: 09/25/2016] [Accepted: 10/13/2016] [Indexed: 11/23/2022]
Abstract
BACKGROUND Worldwide 350 million people suffer from major depression, with the majority of cases occurring in low- and middle-income countries. We examined the patterns, correlates and care-seeking behaviour of adults suffering from major depressive episode (MDE) in China. METHOD A nationwide study recruited 512 891 adults aged 30-79 years from 10 provinces across China during 2004-2008. The 12-month prevalence of MDE was assessed by the Modified Composite International Diagnostic Interview-short form. Logistic regression yielded adjusted odds ratios (ORs) of MDE associated with socio-economic, lifestyle and health-related factors and major stressful life events. RESULTS Overall, 0.7% of participants had MDE and a further 2.4% had major depressive symptoms. Stressful life events were strongly associated with MDE [adjusted OR 14.7, 95% confidence interval (CI) 13.7-15.7], with a dose-response relationship with the number of such events experienced. Family conflict had the highest OR for MDE (18.9, 95% CI 16.8-21.2) among the 10 stressful life events. The risk of MDE was also positively associated with rural residency (OR 1.5, 95% CI 1.4-1.7), low income (OR 2.3, 95% CI 2.1-2.4), living alone (OR 2.6, 95% CI 2.3-3.0), smoking (OR 1.4, 95% CI 1.3-1.6) and certain other mental disorders (e.g. anxiety, phobia). Similar, albeit weaker, associations were observed with depressive symptoms. Among those with MDE, about 15% sought medical help or took psychiatric medication, 15% reported having suicidal ideation and 6% reported attempting suicide. CONCLUSIONS Among Chinese adults, the patterns and correlates of MDE were generally consistent with those observed in the West. The low rates of seeking professional help and treatment highlight the great gap in mental health services in China.
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Affiliation(s)
- Y. Chen
- Nuffield Department of Population
Health, Medical Research Council Population Health Research Unit (MRC
PHRU) & Clinical Trial Service Unit and Epidemiological Studies Unit
(CTSU), University of Oxford,
Oxford, UK
- Nuffield Department of Population
Health, Clinical Trial Service Unit & Epidemiological
Studies Unit (CTSU), University of Oxford, Oxford,
UK
| | - D. Bennett
- Nuffield Department of Population
Health, Medical Research Council Population Health Research Unit (MRC
PHRU) & Clinical Trial Service Unit and Epidemiological Studies Unit
(CTSU), University of Oxford,
Oxford, UK
| | - R. Clarke
- Nuffield Department of Population
Health, Medical Research Council Population Health Research Unit (MRC
PHRU) & Clinical Trial Service Unit and Epidemiological Studies Unit
(CTSU), University of Oxford,
Oxford, UK
| | - Y. Guo
- Chinese Academy of Medical Sciences, Dong Cheng
District, Beijing, People's Republic of
China
| | - C. Yu
- Chinese Academy of Medical Sciences, Dong Cheng
District, Beijing, People's Republic of
China
- Department of Epidemiology and
Biostatistics, School of Public Health, Peking University Health
Science Center, Beijing, People's Republic
of China
| | - Z. Bian
- Chinese Academy of Medical Sciences, Dong Cheng
District, Beijing, People's Republic of
China
| | - L. Ma
- Suzhou CDC, 72 Sanxiang
Road, Suzhou, People's Republic of China
| | - Y. Huang
- Guanxi Provincial CDC, 18
Jinzhou Road, Nanning, Guanxi, People's Republic of China
| | - Q. Sun
- Pengzhou CDC, 331 Longta
Road, Pengzhou, Sichuan, People's Republic of China
| | - N. Zhang
- Sichuan Provincial CDC, 6
Chendu City Middle School Road, Chendu, People's Republic of
China
| | - X. Zheng
- Meilan CDC, 70 Meilan
District, Haikou, People's Republic of China
| | - J. Chen
- China National Center for Food Safety Risk
Assessment, Chaoyang District, Beijing,
People's Republic of China
| | - R. Peto
- Nuffield Department of Population
Health, Medical Research Council Population Health Research Unit (MRC
PHRU) & Clinical Trial Service Unit and Epidemiological Studies Unit
(CTSU), University of Oxford,
Oxford, UK
| | - K. S. Kendler
- Department of Psychiatry,
Virginia Commonwealth University, Virginia Institute for Psychiatric and
Behavioural Genetics, Richmond, VA,
USA
| | - L. Li
- Chinese Academy of Medical Sciences, Dong Cheng
District, Beijing, People's Republic of
China
- Department of Epidemiology and
Biostatistics, School of Public Health, Peking University Health
Science Center, Beijing, People's Republic
of China
| | - Z. Chen
- Nuffield Department of Population
Health, Medical Research Council Population Health Research Unit (MRC
PHRU) & Clinical Trial Service Unit and Epidemiological Studies Unit
(CTSU), University of Oxford,
Oxford, UK
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Emberson J, Alegre-Diaz J, Halsey J, Collins R, Peto R, Kuri-Morales P, Tapia-Conyer R. Null Relationship of BMI to Diabetes Prevalence at Baseline in the Mexico City Prospective Study of 150,000 Adults with Stored Blood and 10-year Mortality Follow-Up. Int J Epidemiol 2015. [DOI: 10.1093/ije/dyv096.179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Bragg F, Li L, Smith M, Guo Y, Chen Y, Millwood I, Bian Z, Walters R, Chen J, Yang L, Collins R, Peto R, Lu Y, Yu B, Xie X, Lei Y, Luo G, Chen Z. Associations of blood glucose and prevalent diabetes with risk of cardiovascular disease in 500 000 adult Chinese: the China Kadoorie Biobank. Diabet Med 2014; 31:540-51. [PMID: 24344928 PMCID: PMC4114560 DOI: 10.1111/dme.12392] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2013] [Revised: 11/04/2013] [Accepted: 12/12/2013] [Indexed: 12/14/2022]
Abstract
AIMS To examine the relationship of self-reported diabetes, and of random blood glucose levels among individuals without known diabetes, with the prevalence of cardiovascular disease in Chinese adults. METHODS We examined cross-sectional data from the China Kadoorie Biobank of 0.5 million people aged 30-79 years recruited from 10 diverse regions of China in the period 2004-2008. Logistic regression was used to estimate the odds ratios of prevalent cardiovascular disease associated with self-reported diabetes, and with measured random blood glucose levels among participants with no history of diabetes, adjusting simultaneously for age, sex, area, education, smoking, alcohol, blood pressure and physical activity. RESULTS A total of 3.2% of participants had self-reported diabetes (men 2.9%; women 3.3%) and 2.8% had screen-detected diabetes (men 2.6%; women 2.8%), i.e. they had no self-reported history of diabetes but a blood glucose level suggestive of a diagnosis of diabetes. Compared with individuals without a history of diabetes, the odds ratios associated with self-reported diabetes were 2.18 (95% CI 2.06-2.30) and 1.88 (95% CI 1.75-2.01) for prevalent ischaemic heart disease and stroke/transient ischaemic attack, respectively. Among participants without self-reported diabetes there was a positive association between random blood glucose and ischaemic heart disease and stroke/transient ischaemic attack prevalence (P for trend <0.0001). Below the diabetic threshold (<11.1 mmol/l) each additional 1 mmol/l of random blood glucose was associated with 4% (95% CI 2-5%) and 5% (95% CI 3-7%) higher odds of prevalent ischaemic heart disease and stroke/transient ischaemic attack, respectively. CONCLUSIONS In this adult Chinese population, self-reported diabetes was associated with a doubling of the odds of prevalent cardiovascular disease. Below the threshold for diabetes there was still a modest, positive association between random blood glucose and prevalent cardiovascular disease.
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Affiliation(s)
- F. Bragg
- Clinical Trial Service Unit and Epidemiological Studies Unit
(CTSU) Nuffield Department of Population Health University of OxfordUK
| | - L. Li
- Department of Public Health Beijing UniversityBeijing China
- Correspondence to: Zhengming Chen.
E‐mail: or Liming Li. E‐mail:
| | - M. Smith
- Clinical Trial Service Unit and Epidemiological Studies Unit
(CTSU) Nuffield Department of Population Health University of OxfordUK
| | - Y. Guo
- Chinese Academy of Medical Sciences Beijing China
| | - Y. Chen
- Clinical Trial Service Unit and Epidemiological Studies Unit
(CTSU) Nuffield Department of Population Health University of OxfordUK
| | - I. Millwood
- Clinical Trial Service Unit and Epidemiological Studies Unit
(CTSU) Nuffield Department of Population Health University of OxfordUK
| | - Z. Bian
- Chinese Academy of Medical Sciences Beijing China
| | - R. Walters
- Clinical Trial Service Unit and Epidemiological Studies Unit
(CTSU) Nuffield Department of Population Health University of OxfordUK
| | - J. Chen
- China National Center for Food Safety Risk
Assessment Beijing China
| | - L. Yang
- Clinical Trial Service Unit and Epidemiological Studies Unit
(CTSU) Nuffield Department of Population Health University of OxfordUK
| | - R. Collins
- Clinical Trial Service Unit and Epidemiological Studies Unit
(CTSU) Nuffield Department of Population Health University of OxfordUK
| | - R. Peto
- Clinical Trial Service Unit and Epidemiological Studies Unit
(CTSU) Nuffield Department of Population Health University of OxfordUK
| | - Y. Lu
- Suzhou Centre for Disease Control and
Prevention Suzhou China
| | - B. Yu
- Nangang Centre for Disease Control and
Prevention Harbin China
| | - X. Xie
- Liuyang Centre for Disease Control and
Prevention Liuyang China
| | - Y. Lei
- Maiji Centre for Disease Control and Prevention Tianshui China
| | - G. Luo
- Pengzhou Centre for Disease Control and
Prevention Pengzhou China
| | - Z. Chen
- Clinical Trial Service Unit and Epidemiological Studies Unit
(CTSU) Nuffield Department of Population Health University of OxfordUK
- Correspondence to: Zhengming Chen.
E‐mail: or Liming Li. E‐mail:
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Chen Y, Li L, Zhang Q, Guo Y, Whitlock G, Bian Z, Clarke R, Peto R, Collins R, Chen Z. Use of drug treatment for secondary prevention of cardiovascular disease in urban and rural communities of China: findings from the China Biobank study of 0.5 million people. Eur Heart J 2013. [DOI: 10.1093/eurheartj/eht309.p4305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Pirie K, Peto R, Reeves G. The 21st Century Hazards of Smoking and Benefits of Stopping: A Prospective Study of One Million Women in the UK. J Vasc Surg 2013. [DOI: 10.1016/j.jvs.2013.03.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Abstract
OBJECTIVE To investigate the impact of smoking on overall mortality and life expectancy in a large Japanese population, including some who smoked throughout adult life. DESIGN The Life Span Study, a population-based prospective study, initiated in 1950. SETTING Hiroshima and Nagasaki, Japan. PARTICIPANTS Smoking status for 27,311 men and 40,662 women was obtained during 1963-92. Mortality from one year after first ascertainment of smoking status until 1 January 2008 has been analysed. MAIN OUTCOME MEASURES Mortality from all causes in current, former, and never smokers. RESULTS Smokers born in later decades tended to smoke more cigarettes per day than those born earlier, and to have started smoking at a younger age. Among those born during 1920-45 (median 1933) and who started smoking before age 20 years, men smoked on average 23 cigarettes/day, while women smoked 17 cigarettes/day, and, for those who continued smoking, overall mortality was more than doubled in both sexes (rate ratios versus never smokers: men 2.21 (95% confidence interval 1.97 to 2.48), women 2.61 (1.98 to 3.44)) and life expectancy was reduced by almost a decade (8 years for men, 10 years for women). Those who stopped smoking before age 35 avoided almost all of the excess risk among continuing smokers, while those who stopped smoking before age 45 avoided most of it. CONCLUSIONS The lower smoking related hazards reported previously in Japan may have been due to earlier birth cohorts starting to smoke when older and smoking fewer cigarettes per day. In Japan, as elsewhere, those who start smoking in early adult life and continue smoking lose on average about a decade of life. Much of the risk can, however, be avoided by giving up smoking before age 35, and preferably well before age 35.
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Affiliation(s)
- R Sakata
- Department of Epidemiology, Radiation Effects Research Foundation, Hiroshima, Japan
| | - P McGale
- Clinical Trial Service Unit, University of Oxford, Oxford OX3 7LF, UK
| | - E J Grant
- Department of Epidemiology, Radiation Effects Research Foundation, Hiroshima, Japan
| | - K Ozasa
- Department of Epidemiology, Radiation Effects Research Foundation, Hiroshima, Japan
| | - R Peto
- Clinical Trial Service Unit, University of Oxford, Oxford OX3 7LF, UK
| | - S C Darby
- Clinical Trial Service Unit, University of Oxford, Oxford OX3 7LF, UK
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Li L, Guo Y, Chen Z, Chen J, Peto R. Epidemiology and the control of disease in China, with emphasis on the Chinese Biobank Study. Public Health 2012; 126:210-213. [PMID: 22325671 DOI: 10.1016/j.puhe.2011.11.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/30/2011] [Indexed: 11/27/2022]
Abstract
Similar to many other developing countries, China is facing a double burden of disease as a result of epidemiological transition. Non-communicable diseases (NCDs) represent a major challenge, having an adverse effect on the health of the Chinese population and increasing the economic burden of health care. In today's era of evidence-based medicine and decision making, China, as a developing country, has a lack of local scientific evidence which will affect the effectiveness of NCD prevention and control. As such, and on the basis of decades of cooperation and trust with the University of Oxford, the Chinese Biobank Study [Kadoorie Study of Chronic Disease in China (KSCDC)] was commenced in 2004. KSCDC, an international prospective project, aims to establish the basis of a blood-based health database, using genetic, environmental and lifestyle aspects to investigate and understand the causes, risk factors, pathogenesis, prevalence patterns and trends of major chronic diseases in China (such as stroke, coronary heart disease, cancer, diabetes, hypertension, chronic obstructive pulmonary disease etc.). This study has a duration of 15-20 years, and will provide scientific evidence for strategic planning of NCD prevention and control, and development of new treatment and intervention approaches. In total, approximately 510,000 adults aged 30-79 years have been recruited from the general population in 10 geographically defined regions (five rural and five urban) of China, with differing disease profiles and differing risk exposures. Extensive data collection has been undertaken with questionnaires, physical measurements, and collection and storage of blood samples. KSCDC is a multi-factor, multi-disease, multi-disciplinary large-scale chronic disease epidemiological study, and is also one of the largest long-term blood-based population cohort studies ever conducted in the world. It is worth mentioning that all gene specimens are kept in China, and all associated intellectual property rights are owned by international cooperation groups; this breaks new ground for Chinese and foreign international cooperation. This article describes the study design, baseline description and main results to date.
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Affiliation(s)
- L Li
- School of Public Health, Peking University, Xueyuan Road 38, Beijing, China; Chinese Academy of Medical Sciences, Beijing, China.
| | - Y Guo
- Chinese Academy of Medical Sciences, Beijing, China
| | - Z Chen
- Clinical Trial Service Unit and Epidemiological Studies Unit, University of Oxford, UK
| | - J Chen
- Chinese Center for Disease Control and Prevention, Beijing, China
| | - R Peto
- Clinical Trial Service Unit and Epidemiological Studies Unit, University of Oxford, UK
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Peto R, Davies C, Godwin J, Gray R, Pan HC, Clarke M, Cutter D, Darby S, McGale P, Taylor C, Wang YC, Bergh J, Di Leo A, Albain K, Swain S, Piccart M, Pritchard K. Comparisons between different polychemotherapy regimens for early breast cancer: meta-analyses of long-term outcome among 100,000 women in 123 randomised trials. Lancet 2012; 379:432-44. [PMID: 22152853 PMCID: PMC3273723 DOI: 10.1016/s0140-6736(11)61625-5] [Citation(s) in RCA: 1438] [Impact Index Per Article: 119.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Moderate differences in efficacy between adjuvant chemotherapy regimens for breast cancer are plausible, and could affect treatment choices. We sought any such differences. METHODS We undertook individual-patient-data meta-analyses of the randomised trials comparing: any taxane-plus-anthracycline-based regimen versus the same, or more, non-taxane chemotherapy (n=44,000); one anthracycline-based regimen versus another (n=7000) or versus cyclophosphamide, methotrexate, and fluorouracil (CMF; n=18,000); and polychemotherapy versus no chemotherapy (n=32,000). The scheduled dosages of these three drugs and of the anthracyclines doxorubicin (A) and epirubicin (E) were used to define standard CMF, standard 4AC, and CAF and CEF. Log-rank breast cancer mortality rate ratios (RRs) are reported. FINDINGS In trials adding four separate cycles of a taxane to a fixed anthracycline-based control regimen, extending treatment duration, breast cancer mortality was reduced (RR 0·86, SE 0·04, two-sided significance [2p]=0·0005). In trials with four such extra cycles of a taxane counterbalanced in controls by extra cycles of other cytotoxic drugs, roughly doubling non-taxane dosage, there was no significant difference (RR 0·94, SE 0·06, 2p=0·33). Trials with CMF-treated controls showed that standard 4AC and standard CMF were equivalent (RR 0·98, SE 0·05, 2p=0·67), but that anthracycline-based regimens with substantially higher cumulative dosage than standard 4AC (eg, CAF or CEF) were superior to standard CMF (RR 0·78, SE 0·06, 2p=0·0004). Trials versus no chemotherapy also suggested greater mortality reductions with CAF (RR 0·64, SE 0·09, 2p<0·0001) than with standard 4AC (RR 0·78, SE 0·09, 2p=0·01) or standard CMF (RR 0·76, SE 0·05, 2p<0·0001). In all meta-analyses involving taxane-based or anthracycline-based regimens, proportional risk reductions were little affected by age, nodal status, tumour diameter or differentiation (moderate or poor; few were well differentiated), oestrogen receptor status, or tamoxifen use. Hence, largely independently of age (up to at least 70 years) or the tumour characteristics currently available to us for the patients selected to be in these trials, some taxane-plus-anthracycline-based or higher-cumulative-dosage anthracycline-based regimens (not requiring stem cells) reduced breast cancer mortality by, on average, about one-third. 10-year overall mortality differences paralleled breast cancer mortality differences, despite taxane, anthracycline, and other toxicities. INTERPRETATION 10-year gains from a one-third breast cancer mortality reduction depend on absolute risks without chemotherapy (which, for oestrogen-receptor-positive disease, are the risks remaining with appropriate endocrine therapy). Low absolute risk implies low absolute benefit, but information was lacking about tumour gene expression markers or quantitative immunohistochemistry that might help to predict risk, chemosensitivity, or both. FUNDING Cancer Research UK; British Heart Foundation; UK Medical Research Council.
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Affiliation(s)
- R Peto
- University of Oxford, Oxford, UK.
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Darby S, McGale P, Correa C, Taylor C, Arriagada R, Clarke M, Cutter D, Davies C, Ewertz M, Godwin J, Gray R, Pierce L, Whelan T, Wang Y, Peto R. Effect of radiotherapy after breast-conserving surgery on 10-year recurrence and 15-year breast cancer death: meta-analysis of individual patient data for 10,801 women in 17 randomised trials. Lancet 2011; 378:1707-16. [PMID: 22019144 PMCID: PMC3254252 DOI: 10.1016/s0140-6736(11)61629-2] [Citation(s) in RCA: 2525] [Impact Index Per Article: 194.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND After breast-conserving surgery, radiotherapy reduces recurrence and breast cancer death, but it may do so more for some groups of women than for others. We describe the absolute magnitude of these reductions according to various prognostic and other patient characteristics, and relate the absolute reduction in 15-year risk of breast cancer death to the absolute reduction in 10-year recurrence risk. METHODS We undertook a meta-analysis of individual patient data for 10,801 women in 17 randomised trials of radiotherapy versus no radiotherapy after breast-conserving surgery, 8337 of whom had pathologically confirmed node-negative (pN0) or node-positive (pN+) disease. FINDINGS Overall, radiotherapy reduced the 10-year risk of any (ie, locoregional or distant) first recurrence from 35·0% to 19·3% (absolute reduction 15·7%, 95% CI 13·7-17·7, 2p<0·00001) and reduced the 15-year risk of breast cancer death from 25·2% to 21·4% (absolute reduction 3·8%, 1·6-6·0, 2p=0·00005). In women with pN0 disease (n=7287), radiotherapy reduced these risks from 31·0% to 15·6% (absolute recurrence reduction 15·4%, 13·2-17·6, 2p<0·00001) and from 20·5% to 17·2% (absolute mortality reduction 3·3%, 0·8-5·8, 2p=0·005), respectively. In these women with pN0 disease, the absolute recurrence reduction varied according to age, grade, oestrogen-receptor status, tamoxifen use, and extent of surgery, and these characteristics were used to predict large (≥20%), intermediate (10-19%), or lower (<10%) absolute reductions in the 10-year recurrence risk. Absolute reductions in 15-year risk of breast cancer death in these three prediction categories were 7·8% (95% CI 3·1-12·5), 1·1% (-2·0 to 4·2), and 0·1% (-7·5 to 7·7) respectively (trend in absolute mortality reduction 2p=0·03). In the few women with pN+ disease (n=1050), radiotherapy reduced the 10-year recurrence risk from 63·7% to 42·5% (absolute reduction 21·2%, 95% CI 14·5-27·9, 2p<0·00001) and the 15-year risk of breast cancer death from 51·3% to 42·8% (absolute reduction 8·5%, 1·8-15·2, 2p=0·01). Overall, about one breast cancer death was avoided by year 15 for every four recurrences avoided by year 10, and the mortality reduction did not differ significantly from this overall relationship in any of the three prediction categories for pN0 disease or for pN+ disease. INTERPRETATION After breast-conserving surgery, radiotherapy to the conserved breast halves the rate at which the disease recurs and reduces the breast cancer death rate by about a sixth. These proportional benefits vary little between different groups of women. By contrast, the absolute benefits from radiotherapy vary substantially according to the characteristics of the patient and they can be predicted at the time when treatment decisions need to be made. FUNDING Cancer Research UK, British Heart Foundation, and UK Medical Research Council.
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Hong LS, Li L, Smith M, Lacey B, Guo Y, Lewington S, Whitlock G, Collins R, Chen J, Peto R, Chen Z. P2-116 Adiposity and its contribution to individual and regional differences in blood pressure: The Kadoorie Biobank Study of 0.5 million people in China. Br J Soc Med 2011. [DOI: 10.1136/jech.2011.142976i.51] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Du, D Bennett H, Li L, Whitlock G, Collins R, Guo Y, Peto R, Chen J, Chen Z. P2-66 Physical activity and its associations with prevalence of overweight, hypertension, diabetes and ischaemic heart disease in the Kadoorie Biobank study of 0.5 million people in China. Br J Soc Med 2011. [DOI: 10.1136/jech.2011.142976i.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Yang L, Zhou M, Sherliker P, Yang G, Peto R, Wang J, Millwood I, Hu Y, Smith M, Chen Z. P2-334 Alcohol and mortality among 220 000 men in China, 1990-2005: a nationally representative prospective study. Br J Soc Med 2011. [DOI: 10.1136/jech.2011.142976k.66] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Clark S, Hill M, Peto R, Collins R. P1-412 Stability of biomarkers in plasma frozen at various temperatures for several years: implications for prospective epidemiological studies. Br J Soc Med 2011. [DOI: 10.1136/jech.2011.142976g.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Lewington S, Lee L, Sherliker P, Collins R, Yu G, Millwood I, Chen J, Yang L, Lacey B, Whitlock G, Peto R, Chen Z. O1-4.3 Seasonal variation in blood pressure among Chinese adults: the Kadoorie Biobank Study of 0.5 million people in China. Br J Soc Med 2011. [DOI: 10.1136/jech.2011.142976a.32] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Millwood I, Lee L, Yang L, Yu G, Collins R, Lewington S, Chen J, Peto R, Chen Z. P2-189 Prevalence and patterns of alcohol consumption in Chinese men and women: the Kadoorie Biobank Study of 0.5 million people in China. Br J Soc Med 2011. [DOI: 10.1136/jech.2011.142976j.24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Li L, Guo Y, Chen Z, Chen J, Peto R. Plenary XI Epidemiology and the control of disease in China, with emphasis on the Chinese Biobank (KSCDC) project. Br J Soc Med 2011. [DOI: 10.1136/jech.2011.142976a.7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Chen Z, Guo Y, Smith M, Chen J, Collins R, Peto R, Li L. P2-41 Prevalence of smoking and its association with mortality in China: findings of the Kadoorie Biobank Study of 0.5 million people. Br J Soc Med 2011. [DOI: 10.1136/jech.2011.142976h.77] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Beral V, epidemiology PO, Peto R. Authors' reply. West J Med 2011. [DOI: 10.1136/bmj.d4217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Correa C, McGale P, Taylor C, Wang Y, Clarke M, Davies C, Peto R, Bijker N, Solin L, Darby S. Overview of the randomized trials of radiotherapy in ductal carcinoma in situ of the breast. J Natl Cancer Inst Monogr 2010; 2010:162-77. [PMID: 20956824 PMCID: PMC5161078 DOI: 10.1093/jncimonographs/lgq039] [Citation(s) in RCA: 418] [Impact Index Per Article: 29.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Individual patient data were available for all four of the randomized trials that began before 1995, and that compared adjuvant radiotherapy vs no radiotherapy following breast-conserving surgery for ductal carcinoma in situ (DCIS). A total of 3729 women were eligible for analysis. Radiotherapy reduced the absolute 10-year risk of any ipsilateral breast event (ie, either recurrent DCIS or invasive cancer) by 15.2% (SE 1.6%, 12.9% vs 28.1% 2 P <.00001), and it was effective regardless of the age at diagnosis, extent of breast-conserving surgery, use of tamoxifen, method of DCIS detection, margin status, focality, grade, comedonecrosis, architecture, or tumor size. The proportional reduction in ipsilateral breast events was greater in older than in younger women (2P < .0004 for difference between proportional reductions; 10-year absolute risks: 18.5% vs 29.1% at ages <50 years, 10.8% vs 27.8% at ages ≥ 50 years) but did not differ significantly according to any other available factor. Even for women with negative margins and small low-grade tumors, the absolute reduction in the 10-year risk of ipsilateral breast events was 18.0% (SE 5.5, 12.1% vs 30.1%, 2P = .002). After 10 years of follow-up, there was, however, no significant effect on breast cancer mortality, mortality from causes other than breast cancer, or all-cause mortality.
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MESH Headings
- Adult
- Aged
- Antineoplastic Agents, Hormonal/therapeutic use
- Breast Neoplasms/drug therapy
- Breast Neoplasms/radiotherapy
- Breast Neoplasms/surgery
- Carcinoma, Ductal, Breast/epidemiology
- Carcinoma, Ductal, Breast/prevention & control
- Carcinoma, Intraductal, Noninfiltrating/drug therapy
- Carcinoma, Intraductal, Noninfiltrating/radiotherapy
- Carcinoma, Intraductal, Noninfiltrating/surgery
- Chemotherapy, Adjuvant
- Combined Modality Therapy
- Female
- Humans
- Mastectomy, Segmental
- Meta-Analysis as Topic
- Middle Aged
- Multicenter Studies as Topic/statistics & numerical data
- Neoplasm Recurrence, Local/epidemiology
- Neoplasm Recurrence, Local/prevention & control
- Neoplasms, Second Primary/epidemiology
- Neoplasms, Second Primary/prevention & control
- Radiotherapy, Adjuvant/statistics & numerical data
- Randomized Controlled Trials as Topic/statistics & numerical data
- Tamoxifen/therapeutic use
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Pirie K, Peto R, Reeves G, Beral V. The benefits of stopping smoking. Br J Soc Med 2009. [DOI: 10.1136/jech.2009.096719y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Gomes M, Faiz M, Gyapong J, Warsame M, Agbenyega T, Babiker A, Baiden F, Yunus EB, Binka F, Clerk C, Folb P, Hassan R, Hossain A, Kimbute O, Kitua A, Krishna S, Makasi C, Mensah N, Mrango Z, Olliaro P, Peto R, Peto T, Rahman M, Ribeiro I, Samad R, White N. Treating severe malaria with pre-referral artesunate saves lives and prevents CNS damage. Neurotoxicol Teratol 2009. [DOI: 10.1016/j.ntt.2009.04.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Sleight P, Yusuf S, Peto R, Rossi P, Ramsdale D, Bennett D, Bray C, Furse L. Early intravenous atenolol treatment in suspected acute myocardial infarction. Acta Med Scand Suppl 2009; 651:185-92. [PMID: 7034474 DOI: 10.1111/j.0954-6820.1981.tb03655.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Gomes MF, Faiz MA, Gyapong JO, Warsame M, Agbenyega T, Babiker A, Baiden F, Yunus EB, Binka F, Clerk C, Folb P, Hassan R, Hossain MA, Kimbute O, Kitua A, Krishna S, Makasi C, Mensah N, Mrango Z, Olliaro P, Peto R, Peto TJ, Rahman MR, Ribeiro I, Samad R, White NJ. Pre-referral rectal artesunate to prevent death and disability in severe malaria: a placebo-controlled trial. Lancet 2009; 373:557-66. [PMID: 19059639 PMCID: PMC2646124 DOI: 10.1016/s0140-6736(08)61734-1] [Citation(s) in RCA: 150] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Most malaria deaths occur in rural areas. Rapid progression from illness to death can be interrupted by prompt, effective medication. Antimalarial treatment cannot rescue terminally ill patients but could be effective if given earlier. If patients who cannot be treated orally are several hours from facilities for injections, rectal artesunate can be given before referral and acts rapidly on parasites. We investigated whether this intervention reduced mortality and permanent disability. METHODS In Bangladesh, Ghana, and Tanzania, patients with suspected severe malaria who could not be treated orally were allocated randomly to a single artesunate (n=8954) or placebo (n=8872) suppository by taking the next numbered box, then referred to clinics at which injections could be given. Those with antimalarial injections or negative blood smears before randomisation were excluded, leaving 12 068 patients (6072 artesunate, 5996 placebo) for analysis. Primary endpoints were mortality, assessed 7-30 days later, and permanent disability, reassessed periodically. All investigators were masked to group assignment. Analysis was by intention to treat. This study is registered in all three countries, numbers ISRCTN83979018, 46343627, and 76987662. RESULTS Mortality was 154 of 6072 artesunate versus 177 of 5996 placebo (2.5%vs 3.0%, p=0.1). Two versus 13 (0.03%vs 0.22%, p=0.0020) were permanently disabled; total dead or disabled: 156 versus 190 (2.6%vs 3.2%, p=0.0484). There was no reduction in early mortality (56 vs 51 deaths within 6 h; median 2 h). In patients reaching clinic within 6 h (median 3 h), pre-referral artesunate had no significant effect on death after 6 h or permanent disability (71/4450 [1.6%] vs 82/4426 [1.9%], risk ratio 0.86 [95% CI 0.63-1.18], p=0.35). In patients still not in clinic after more than 6 h, however, half were still not there after more than 15 h, and pre-referral rectal artesunate significantly reduced death or permanent disability (29/1566 [1.9%] vs 57/1519 [3.8%], risk ratio 0.49 [95% CI 0.32-0.77], p=0.0013). INTERPRETATION If patients with severe malaria cannot be treated orally and access to injections will take several hours, a single inexpensive artesunate suppository at the time of referral substantially reduces the risk of death or permanent disability. FUNDING UNICEF/UNDP/World Bank Special Programme for Research and Training in Tropical Diseases (WHO/TDR); WHO Global Malaria Programme (WHO/GMP); Sall Family Foundation; the European Union (QLRT-2000-01430); the UK Medical Research Council; USAID; Irish Aid; the Karolinska Institute; and the University of Oxford Clinical Trial Service Unit (CTSU).
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Affiliation(s)
- M F Gomes
- UNICEF/UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases, Geneva, Switzerland.
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Zaridze D, Maximovitch D, Lazarev A, Igitov V, Boroda A, Boreham J, Boyle P, Peto R, Boffetta P. Alcohol poisoning is a main determinant of recent mortality trends in Russia: evidence from a detailed analysis of mortality statistics and autopsies. Int J Epidemiol 2008; 38:143-53. [DOI: 10.1093/ije/dyn160] [Citation(s) in RCA: 99] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Abstract
As ways of discouraging tobacco consumption, the effects of increases in price and in quantitative information may have been under-emphasized. To decrease the hazards of tobacco, switches from cigarettes to pipes, cigars or 'smokeless' tobacco may be useful, as may a reduction in cigarette tar delivery. Indeed, the spread of existing tar level reductions from capitalist to socialist countries might prevent tens of thousands of lung cancer deaths each year in the early decades of the next century, and (perhaps by attempts to engineer cigarettes so that smokers of lower tar cigarettes are less likely to 'compensate' by taking more smoke) it should eventually also be possible to change cigarettes so as also to reduce their effects on heart and lung disease. Changes in consumption and in composition of tobacco products are complementary, not competing, strategies. If both are pursued effectively, then although the life expectancy of old people may not be much improved, the proportion of adults who die before reaching old age will decrease substantially.
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Beral V, Doll R, Hermon C, Peto R, Reeves G. Ovarian cancer and oral contraceptives: collaborative reanalysis of data from 45 epidemiological studies including 23,257 women with ovarian cancer and 87,303 controls. Lancet 2008; 371:303-14. [PMID: 18294997 DOI: 10.1016/s0140-6736(08)60167-1] [Citation(s) in RCA: 501] [Impact Index Per Article: 31.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Oral contraceptives were introduced almost 50 years ago, and over 100 million women currently use them. Oral contraceptives can reduce the risk of ovarian cancer, but the eventual public-health effects of this reduction will depend on how long the protection lasts after use ceases. We aimed to assess these effects. METHODS Individual data for 23,257 women with ovarian cancer (cases) and 87,303 without ovarian cancer (controls) from 45 epidemiological studies in 21 countries were checked and analysed centrally. The relative risk of ovarian cancer in relation to oral contraceptive use was estimated, stratifying by study, age, parity, and hysterectomy. FINDINGS Overall 7308 (31%) cases and 32,717 (37%) controls had ever used oral contraceptives, for average durations among users of 4.4 and 5.0 years, respectively. The median year of cancer diagnosis was 1993, when cases were aged an average of 56 years. The longer that women had used oral contraceptives, the greater the reduction in ovarian cancer risk (p<0.0001). This reduction in risk persisted for more than 30 years after oral contraceptive use had ceased but became somewhat attenuated over time-the proportional risk reductions per 5 years of use were 29% (95% CI 23-34%) for use that had ceased less than 10 years previously, 19% (14-24%) for use that had ceased 10-19 years previously, and 15% (9-21%) for use that had ceased 20-29 years previously. Use during the 1960s, 1970s, and 1980s was associated with similar proportional risk reductions, although typical oestrogen doses in the 1960s were more than double those in the 1980s. The incidence of mucinous tumours (12% of the total) seemed little affected by oral contraceptives, but otherwise the proportional risk reduction did not vary much between different histological types. In high-income countries, 10 years use of oral contraceptives was estimated to reduce ovarian cancer incidence before age 75 from 1.2 to 0.8 per 100 users and mortality from 0.7 to 0.5 per 100; for every 5000 woman-years of use, about two ovarian cancers and one death from the disease before age 75 are prevented. INTERPRETATION Use of oral contraceptives confers long-term protection against ovarian cancer. These findings suggest that oral contraceptives have already prevented some 200,000 ovarian cancers and 100,000 deaths from the disease, and that over the next few decades the number of cancers prevented will rise to at least 30,000 per year.
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Kearney PM, Blackwell L, Collins R, Keech A, Simes J, Peto R, Armitage J, Baigent C. Efficacy of cholesterol-lowering therapy in 18,686 people with diabetes in 14 randomised trials of statins: a meta-analysis. Lancet 2008; 371:117-25. [PMID: 18191683 DOI: 10.1016/s0140-6736(08)60104-x] [Citation(s) in RCA: 1338] [Impact Index Per Article: 83.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Although statin therapy reduces the risk of occlusive vascular events in people with diabetes mellitus, there is uncertainty about the effects on particular outcomes and whether such effects depend on the type of diabetes, lipid profile, or other factors. We undertook a prospective meta-analysis to help resolve these uncertainties. METHODS We analysed data from 18 686 individuals with diabetes (1466 with type 1 and 17,220 with type 2) in the context of a further 71,370 without diabetes in 14 randomised trials of statin therapy. Weighted estimates were obtained of effects on clinical outcomes per 1.0 mmol/L reduction in LDL cholesterol. FINDINGS During a mean follow-up of 4.3 years, there were 3247 major vascular events in people with diabetes. There was a 9% proportional reduction in all-cause mortality per mmol/L reduction in LDL cholesterol in participants with diabetes (rate ratio [RR] 0.91, 99% CI 0.82-1.01; p=0.02), which was similar to the 13% reduction in those without diabetes (0.87, 0.82-0.92; p<0.0001). This finding reflected a significant reduction in vascular mortality (0.87, 0.76-1.00; p=0.008) and no effect on non-vascular mortality (0.97, 0.82-1.16; p=0.7) in participants with diabetes. There was a significant 21% proportional reduction in major vascular events per mmol/L reduction in LDL cholesterol in people with diabetes (0.79, 0.72-0.86; p<0.0001), which was similar to the effect observed in those without diabetes (0.79, 0.76-0.82; p<0.0001). In diabetic participants there were reductions in myocardial infarction or coronary death (0.78, 0.69-0.87; p<0.0001), coronary revascularisation (0.75, 0.64-0.88; p<0.0001), and stroke (0.79, 0.67-0.93; p=0.0002). Among people with diabetes the proportional effects of statin therapy were similar irrespective of whether there was a prior history of vascular disease and irrespective of other baseline characteristics. After 5 years, 42 (95% CI 30-55) fewer people with diabetes had major vascular events per 1000 allocated statin therapy. INTERPRETATION Statin therapy should be considered for all diabetic individuals who are at sufficiently high risk of vascular events.
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Clarke M, Coates AS, Darby SC, Davies C, Gelber RD, Godwin J, Goldhirsch A, Gray R, Peto R, Pritchard KI, Wood WC. Adjuvant chemotherapy in oestrogen-receptor-poor breast cancer: patient-level meta-analysis of randomised trials. Lancet 2008; 371:29-40. [PMID: 18177773 DOI: 10.1016/s0140-6736(08)60069-0] [Citation(s) in RCA: 220] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND The long-term effects of adjuvant polychemotherapy regimens in oestrogen-receptor-poor (ER-poor) breast cancer, and the extent to which these effects are modified by age or tamoxifen use, can be assessed by an updated meta-analysis of individual patient data from randomised trials. METHODS Collaborative meta-analyses of individual patient data for about 6000 women with ER-poor breast cancer in 46 trials of polychemotherapy versus not (non-taxane-based polychemotherapy, typically about six cycles; trial start dates 1975-96, median 1984) and about 14 000 women with ER-poor breast cancer in 50 trials of tamoxifen versus not (some trials in the presence and some in the absence of polychemotherapy; trial start dates 1972-93, median 1982). FINDINGS In women with ER-poor breast cancer, polychemotherapy significantly reduced recurrence, breast cancer mortality, and death from any cause, in those younger than 50 years and those aged 50-69 years at entry into trials of polychemotherapy versus not. In those aged younger than 50 years (1907 women, 15% node-positive), the 10-year risks were: recurrence 33% versus 45% (ratio of 10-year risks 0.73, 2p<0.00001), breast cancer mortality 24% versus 32% (ratio 0.73, 2p=0.0002), and death from any cause 25% versus 33% (ratio 0.75, 2p=0.0003). In women aged 50-69 years (3965 women, 58% node-positive), the 10-year risks were: recurrence 42% versus 52% (ratio 0.82, 2p<0.00001), breast cancer mortality 36% versus 42% (ratio 0.86, 2p=0.0004), and death from any cause 39% versus 45% (ratio 0.87, 2p=0.0009). Few were aged 70 years or older. Tamoxifen had little effect on recurrence or death in women who were classified in these trials as having ER-poor disease, and did not significantly modify the effects of polychemotherapy. INTERPRETATION In women who had ER-poor breast cancer, and were either younger than 50 years or between 50 and 69 years, these older adjuvant polychemotherapy regimens were safe (ie, had little effect on mortality from causes other than breast cancer) and produced substantial and definite reductions in the 10-year risks of recurrence and death. Current and future chemotherapy regimens could well yield larger proportional reductions in breast cancer mortality.
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Abstract
OBJECTIVE To assess the prophylactic efficacy of aspirin and a high-dose antioxidant vitamin combination in patients with peripheral arterial disease (PAD) in terms of reduction of the risk of a first vascular event (myocardial infarction, stroke, vascular death) and critical limb ischaemia. DESIGN Randomized, placebo-controlled, double-blind clinical trial with 2 x 2 factorial design. SETTING Thirty-seven European angiology/vascular medicine units. SUBJECTS A total of 366 outpatients with stage I-II PAD documented by angiography or ultrasound, with ankle/brachial index <0.85 or toe index <0.6; 210 patients completed the follow-up. INTERVENTIONS Four treatment groups: (i) oral aspirin (100 mg daily), (ii) oral antioxidant vitamins (600 mg vitamin E, 250 mg vitamin C and 20 mg beta-carotene daily), (iii) both or (iv) neither, given for 2 years. MAIN OUTCOME MEASURE Major vascular events (cardiovascular death, myocardial infarction or stroke) and critical leg ischaemia. RESULTS Seven of 185 patients allocated aspirin and 20 of 181 allocated placebo suffered a major vascular event (risk reduction 64%, P = 0.022); five and eight patients, respectively, suffered critical leg ischaemia (total 12 vs. 28, P = 0.014). There was no evidence that antioxidant vitamins were beneficial (16/185 vs. 11/181 vascular events). Neither treatment was associated with any significant increase in adverse events. Inclusion of this trial in a meta-analysis of other randomized trials of anti-platelet therapy in PAD makes the overall results highly significant (P < 0.001) and suggests that low-dose aspirin reduces the incidence of vascular events by 26%. CONCLUSIONS For the first time direct evidence shows that low-dose aspirin should routinely be considered for PAD patients, including those with concomitant type 2 diabetes.
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Clarke M, Collins R, Darby S, Davies C, Elphinstone P, Evans V, Godwin J, Gray R, Hicks C, James S, MacKinnon E, McGale P, McHugh T, Peto R, Taylor C, Wang Y. Effects of radiotherapy and of differences in the extent of surgery for early breast cancer on local recurrence and 15-year survival: an overview of the randomised trials. Lancet 2005; 366:2087-106. [PMID: 16360786 DOI: 10.1016/s0140-6736(05)67887-7] [Citation(s) in RCA: 3519] [Impact Index Per Article: 185.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND In early breast cancer, variations in local treatment that substantially affect the risk of locoregional recurrence could also affect long-term breast cancer mortality. To examine this relationship, collaborative meta-analyses were undertaken, based on individual patient data, of the relevant randomised trials that began by 1995. METHODS Information was available on 42,000 women in 78 randomised treatment comparisons (radiotherapy vs no radiotherapy, 23,500; more vs less surgery, 9300; more surgery vs radiotherapy, 9300). 24 types of local treatment comparison were identified. To help relate the effect on local (ie, locoregional) recurrence to that on breast cancer mortality, these were grouped according to whether or not the 5-year local recurrence risk exceeded 10% (<10%, 17,000 women; >10%, 25,000 women). FINDINGS About three-quarters of the eventual local recurrence risk occurred during the first 5 years. In the comparisons that involved little (<10%) difference in 5-year local recurrence risk there was little difference in 15-year breast cancer mortality. Among the 25,000 women in the comparisons that involved substantial (>10%) differences, however, 5-year local recurrence risks were 7% active versus 26% control (absolute reduction 19%), and 15-year breast cancer mortality risks were 44.6% versus 49.5% (absolute reduction 5.0%, SE 0.8, 2p<0.00001). These 25,000 women included 7300 with breast-conserving surgery (BCS) in trials of radiotherapy (generally just to the conserved breast), with 5-year local recurrence risks (mainly in the conserved breast, as most had axillary clearance and node-negative disease) 7% versus 26% (reduction 19%), and 15-year breast cancer mortality risks 30.5% versus 35.9% (reduction 5.4%, SE 1.7, 2p=0.0002; overall mortality reduction 5.3%, SE 1.8, 2p=0.005). They also included 8500 with mastectomy, axillary clearance, and node-positive disease in trials of radiotherapy (generally to the chest wall and regional lymph nodes), with similar absolute gains from radiotherapy; 5-year local recurrence risks (mainly at these sites) 6% versus 23% (reduction 17%), and 15-year breast cancer mortality risks 54.7% versus 60.1% (reduction 5.4%, SE 1.3, 2p=0.0002; overall mortality reduction 4.4%, SE 1.2, 2p=0.0009). Radiotherapy produced similar proportional reductions in local recurrence in all women (irrespective of age or tumour characteristics) and in all major trials of radiotherapy versus not (recent or older; with or without systemic therapy), so large absolute reductions in local recurrence were seen only if the control risk was large. To help assess the life-threatening side-effects of radiotherapy, the trials of radiotherapy versus not were combined with those of radiotherapy versus more surgery. There was, at least with some of the older radiotherapy regimens, a significant excess incidence of contralateral breast cancer (rate ratio 1.18, SE 0.06, 2p=0.002) and a significant excess of non-breast-cancer mortality in irradiated women (rate ratio 1.12, SE 0.04, 2p=0.001). Both were slight during the first 5 years, but continued after year 15. The excess mortality was mainly from heart disease (rate ratio 1.27, SE 0.07, 2p=0.0001) and lung cancer (rate ratio 1.78, SE 0.22, 2p=0.0004). INTERPRETATION In these trials, avoidance of a local recurrence in the conserved breast after BCS and avoidance of a local recurrence elsewhere (eg, the chest wall or regional nodes) after mastectomy were of comparable relevance to 15-year breast cancer mortality. Differences in local treatment that substantially affect local recurrence rates would, in the hypothetical absence of any other causes of death, avoid about one breast cancer death over the next 15 years for every four local recurrences avoided, and should reduce 15-year overall mortality.
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Affiliation(s)
- M Clarke
- Clinical Trial Service Unit, Oxford, UK
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Chen ZM, Pan HC, Chen YP, Peto R, Collins R, Jiang LX, Xie JX, Liu LS. Early intravenous then oral metoprolol in 45,852 patients with acute myocardial infarction: randomised placebo-controlled trial. Lancet 2005; 366:1622-32. [PMID: 16271643 DOI: 10.1016/s0140-6736(05)67661-1] [Citation(s) in RCA: 566] [Impact Index Per Article: 29.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Despite previous randomised trials of early beta-blocker therapy in the emergency treatment of myocardial infarction (MI), uncertainty has persisted about the value of adding it to current standard interventions (eg, aspirin and fibrinolytic therapy), and the balance of potential benefits and hazards is still unclear in high-risk patients. METHODS 45,852 patients admitted to 1250 hospitals within 24 h of suspected acute MI onset were randomly allocated metoprolol (up to 15 mg intravenous then 200 mg oral daily; n=22,929) or matching placebo (n=22,923). 93% had ST-segment elevation or bundle branch block, and 7% had ST-segment depression. Treatment was to continue until discharge or up to 4 weeks in hospital (mean 15 days in survivors) and 89% completed it. The two prespecified co-primary outcomes were: (1) composite of death, reinfarction, or cardiac arrest; and (2) death from any cause during the scheduled treatment period. Comparisons were by intention to treat, and used the log-rank method. This study is registered with ClinicalTrials.gov, number NCT 00222573. FINDINGS Neither of the co-primary outcomes was significantly reduced by allocation to metoprolol. For death, reinfarction, or cardiac arrest, 2166 (9.4%) patients allocated metoprolol had at least one such event compared with 2261 (9.9%) allocated placebo (odds ratio [OR] 0.96, 95% CI 0.90-1.01; p=0.1). For death alone, there were 1774 (7.7%) deaths in the metoprolol group versus 1797 (7.8%) in the placebo group (OR 0.99, 0.92-1.05; p=0.69). Allocation to metoprolol was associated with five fewer people having reinfarction (464 [2.0%] metoprolol vs 568 [2.5%] placebo; OR 0.82, 0.72-0.92; p=0.001) and five fewer having ventricular fibrillation (581 [2.5%] vs 698 [3.0%]; OR 0.83, 0.75-0.93; p=0.001) per 1000 treated. Overall, these reductions were counterbalanced by 11 more per 1000 developing cardiogenic shock (1141 [5.0%] vs 885 [3.9%]; OR 1.30, 1.19-1.41; p<0.00001). This excess of cardiogenic shock was mainly during days 0-1 after admission, whereas the reductions in reinfarction and ventricular fibrillation emerged more gradually. Consequently, the overall effect on death, reinfarction, arrest, or shock was significantly adverse during days 0-1 and significantly beneficial thereafter. There was substantial net hazard in haemodynamically unstable patients, and moderate net benefit in those who were relatively stable (particularly after days 0-1). INTERPRETATION The use of early beta-blocker therapy in acute MI reduces the risks of reinfarction and ventricular fibrillation, but increases the risk of cardiogenic shock, especially during the first day or so after admission. Consequently, it might generally be prudent to consider starting beta-blocker therapy in hospital only when the haemodynamic condition after MI has stabilised.
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Affiliation(s)
- Z M Chen
- Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Richard Doll Building, Old Road Campus, Oxford OX3 7LF, UK.
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Chen ZM, Jiang LX, Chen YP, Xie JX, Pan HC, Peto R, Collins R, Liu LS. Addition of clopidogrel to aspirin in 45,852 patients with acute myocardial infarction: randomised placebo-controlled trial. Lancet 2005; 366:1607-21. [PMID: 16271642 DOI: 10.1016/s0140-6736(05)67660-x] [Citation(s) in RCA: 1460] [Impact Index Per Article: 76.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Despite improvements in the emergency treatment of myocardial infarction (MI), early mortality and morbidity remain high. The antiplatelet agent clopidogrel adds to the benefit of aspirin in acute coronary syndromes without ST-segment elevation, but its effects in patients with ST-elevation MI were unclear. METHODS 45,852 patients admitted to 1250 hospitals within 24 h of suspected acute MI onset were randomly allocated clopidogrel 75 mg daily (n=22,961) or matching placebo (n=22,891) in addition to aspirin 162 mg daily. 93% had ST-segment elevation or bundle branch block, and 7% had ST-segment depression. Treatment was to continue until discharge or up to 4 weeks in hospital (mean 15 days in survivors) and 93% of patients completed it. The two prespecified co-primary outcomes were: (1) the composite of death, reinfarction, or stroke; and (2) death from any cause during the scheduled treatment period. Comparisons were by intention to treat, and used the log-rank method. This trial is registered with ClinicalTrials.gov, number NCT00222573. FINDINGS Allocation to clopidogrel produced a highly significant 9% (95% CI 3-14) proportional reduction in death, reinfarction, or stroke (2121 [9.2%] clopidogrel vs 2310 [10.1%] placebo; p=0.002), corresponding to nine (SE 3) fewer events per 1000 patients treated for about 2 weeks. There was also a significant 7% (1-13) proportional reduction in any death (1726 [7.5%] vs 1845 [8.1%]; p=0.03). These effects on death, reinfarction, and stroke seemed consistent across a wide range of patients and independent of other treatments being used. Considering all fatal, transfused, or cerebral bleeds together, no significant excess risk was noted with clopidogrel, either overall (134 [0.58%] vs 125 [0.55%]; p=0.59), or in patients aged older than 70 years or in those given fibrinolytic therapy. INTERPRETATION In a wide range of patients with acute MI, adding clopidogrel 75 mg daily to aspirin and other standard treatments (such as fibrinolytic therapy) safely reduces mortality and major vascular events in hospital, and should be considered routinely.
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Affiliation(s)
- Z M Chen
- Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Richard Doll Building, Old Road Campus, Oxford OX3 7LF, UK.
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Baigent C, Keech A, Kearney PM, Blackwell L, Buck G, Pollicino C, Kirby A, Sourjina T, Peto R, Collins R, Simes R. Efficacy and safety of cholesterol-lowering treatment: prospective meta-analysis of data from 90,056 participants in 14 randomised trials of statins. Lancet 2005; 366:1267-78. [PMID: 16214597 DOI: 10.1016/s0140-6736(05)67394-1] [Citation(s) in RCA: 4661] [Impact Index Per Article: 245.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Results of previous randomised trials have shown that interventions that lower LDL cholesterol concentrations can significantly reduce the incidence of coronary heart disease (CHD) and other major vascular events in a wide range of individuals. But each separate trial has limited power to assess particular outcomes or particular categories of participant. METHODS A prospective meta-analysis of data from 90,056 individuals in 14 randomised trials of statins was done. Weighted estimates were obtained of effects on different clinical outcomes per 1.0 mmol/L reduction in LDL cholesterol. FINDINGS During a mean of 5 years, there were 8186 deaths, 14,348 individuals had major vascular events, and 5103 developed cancer. Mean LDL cholesterol differences at 1 year ranged from 0.35 mmol/L to 1.77 mmol/L (mean 1.09) in these trials. There was a 12% proportional reduction in all-cause mortality per mmol/L reduction in LDL cholesterol (rate ratio [RR] 0.88, 95% CI 0.84-0.91; p<0.0001). This reflected a 19% reduction in coronary mortality (0.81, 0.76-0.85; p<0.0001), and non-significant reductions in non-coronary vascular mortality (0.93, 0.83-1.03; p=0.2) and non-vascular mortality (0.95, 0.90-1.01; p=0.1). There were corresponding reductions in myocardial infarction or coronary death (0.77, 0.74-0.80; p<0.0001), in the need for coronary revascularisation (0.76, 0.73-0.80; p<0.0001), in fatal or non-fatal stroke (0.83, 0.78-0.88; p<0.0001), and, combining these, of 21% in any such major vascular event (0.79, 0.77-0.81; p<0.0001). The proportional reduction in major vascular events differed significantly (p<0.0001) according to the absolute reduction in LDL cholesterol achieved, but not otherwise. These benefits were significant within the first year, but were greater in subsequent years. Taking all years together, the overall reduction of about one fifth per mmol/L LDL cholesterol reduction translated into 48 (95% CI 39-57) fewer participants having major vascular events per 1000 among those with pre-existing CHD at baseline, compared with 25 (19-31) per 1000 among participants with no such history. There was no evidence that statins increased the incidence of cancer overall (1.00, 0.95-1.06; p=0.9) or at any particular site. INTERPRETATION Statin therapy can safely reduce the 5-year incidence of major coronary events, coronary revascularisation, and stroke by about one fifth per mmol/L reduction in LDL cholesterol, largely irrespective of the initial lipid profile or other presenting characteristics. The absolute benefit relates chiefly to an individual's absolute risk of such events and to the absolute reduction in LDL cholesterol achieved. These findings reinforce the need to consider prolonged statin treatment with substantial LDL cholesterol reductions in all patients at high risk of any type of major vascular event.
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Abstract
A total of 34,439 male British doctors, who reported their smoking habits in November 1951, were followed, with periodic up date of changes in their habits, until death, emigration, censoring. or November 2001. Information was obtained about their mortality from 28 of the 30 types of cancer in men reviewed by the International Agency for Research on Cancer (no death was recorded from the other two). In all, 11 of the 13 types in men that the Agency classed as liable to be caused by smoking were significantly related to smoking and the findings for the other two, which caused only few deaths, suggested they might be. Of the 13 types in men for which the Agency found only sparse or inconsistent data and for which we had data, only two appeared to be possibly related (one positively, one negatively), and the 638 deaths for the summed group were clearly unrelated to smoking. Of the two types for which the Agency thought that the relationship with smoking might be due to bias or confounding, the findings for one (prostate cancer) tended to support the belief that smoking was unrelated, and those for the other (colorectal cancer) showed a weak relationship with smoking, which (in a small subset) could not be attributed to confounding with the consumption of alcohol.
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Affiliation(s)
- R Doll
- Clinical Trial Service Unit & Epidemiological Studies Unit, Harkness Building, Radcliffe Infirmary, Oxford OX2 6HE, UK.
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Abstract
BACKGROUND In mid 1998, a question "Was the deceased a smoker five years ago?" was introduced on the newly revised South African death notification form. DESIGN A total of 16,230 new death notification forms from 1998 have been coded, and comparison of the prevalence of smoking among those who died of different causes was used to estimate, by case-control comparisons, tobacco attributed mortality in South Africa. Cases comprised deaths from causes known (from other studies) to be causally associated with smoking, and controls comprised deaths from medical conditions expected to be unrelated to smoking. Those who died from external causes, and from diseases strongly related to alcohol consumption, were excluded. SUBJECTS Reports were available from 5340 deceased adults (age 25+), whose smoking status was given by a family member. RESULTS Significantly increased risks were found for deaths from tuberculosis (odds ratio (OR) 1.61, 95% confidence interval (CI) 1.23 to 2.11), chronic obstructive pulmonary disease (COPD) (OR 2.5, 95% CI 1.9 to 3.4), lung cancer (OR 4.8, 95% CI 2.9 to 8.0), other upper aerodigestive cancer (OR 3.0, 95% CI 1.9 to 4.9) and ischaemic heart disease (OR 1.7, 95% CI 1.2 to 2.3). CONCLUSION If smokers had the same death rate as non-smokers, 58% of lung cancer deaths, 37% of COPD deaths, 20% of tuberculosis deaths, and 23% of vascular deaths would have been avoided. About 8% of all adult deaths in South Africa (more than 20 000 deaths a year) were caused by smoking.
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Affiliation(s)
- F Sitas
- National Health Laboratory Service, and Witwatersrand University, South Africa.
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48
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Affiliation(s)
- S M McGhee
- Department of Community Medicine, University of Hong Kong, 21 Sassoon Road, Pokfulam, Hong Kong, China
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49
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Halliday A, Mansfield A, Marro J, Peto C, Peto R, Potter J, Thomas D. Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms: randomised controlled trial. Lancet 2004; 363:1491-502. [PMID: 15135594 DOI: 10.1016/s0140-6736(04)16146-1] [Citation(s) in RCA: 1539] [Impact Index Per Article: 77.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Among patients with substantial carotid artery narrowing but no recent neurological symptom (stroke or transient ischaemia), the balance of surgical risks and long-term benefits from carotid endarterectomy (CEA) was unclear. METHODS During 1993-2003, 3120 asymptomatic patients with substantial carotid narrowing were randomised equally between immediate CEA (half got CEA by 1 month, 88% by 1 year) and indefinite deferral of any CEA (only 4% per year got CEA) and were followed for up to 5 years (mean 3.4 years). Kaplan-Meier analyses of 5-year risks are by allocated treatment. FINDINGS The risk of stroke or death within 30 days of CEA was 3.1% (95% CI 2.3-4.1). Comparing all patients allocated immediate CEA versus all allocated deferral, but excluding such perioperative events, the 5-year stroke risks were 3.8% versus 11% (gain 7.2% [95% CI 5.0-9.4], p<0.0001). This gain chiefly involved carotid territory ischaemic strokes (2.7% vs 9.5%; gain 6.8% [4.8-8.8], p<0.0001), of which half were disabling or fatal (1.6% vs 5.3%; gain 3.7% [2.1-5.2], p<0.0001), as were half the perioperative strokes. Combining the perioperative events and the non-perioperative strokes, net 5-year risks were 6.4% versus 11.8% for all strokes (net gain 5.4% [3.0-7.8], p<0.0001), 3.5% versus 6.1% for fatal or disabling strokes (net gain 2.5% [0.8-4.3], p=0.004), and 2.1% versus 4.2% just for fatal strokes (net gain 2.1% [0.6-3.6], p=0.006). Subgroup-specific analyses found no significant heterogeneity in the perioperative hazards or (apart from the importance of cholesterol) in the long-term postoperative benefits. These benefits were separately significant for males and females; for those with about 70%, 80%, and 90% carotid artery narrowing on ultrasound; and for those younger than 65 and 65-74 years of age (though not for older patients, half of whom die within 5 years from unrelated causes). Full compliance with allocation to immediate CEA or deferral would, in expectation, have produced slightly bigger differences in the numbers operated on, and hence in the net 5-year benefits. The 10-year benefits are not yet known. INTERPRETATION In asymptomatic patients younger than 75 years of age with carotid diameter reduction about 70% or more on ultrasound (many of whom were on aspirin, antihypertensive, and, in recent years, statin therapy), immediate CEA halved the net 5-year stroke risk from about 12% to about 6% (including the 3% perioperative hazard). Half this 5-year benefit involved disabling or fatal strokes. But, outside trials, inappropriate selection of patients or poor surgery could obviate such benefits.
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Affiliation(s)
- A Halliday
- ACST Office, St George's Hospital Medical School, London SW17 0RE, UK
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50
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Vineis P, Alavanja M, Buffler P, Fontham E, Franceschi S, Gao YT, Gupta PC, Hackshaw A, Matos E, Samet J, Sitas F, Smith J, Stayner L, Straif K, Thun MJ, Wichmann HE, Wu AH, Zaridze D, Peto R, Doll R. Tobacco and cancer: recent epidemiological evidence. J Natl Cancer Inst 2004; 96:99-106. [PMID: 14734699 DOI: 10.1093/jnci/djh014] [Citation(s) in RCA: 425] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Affiliation(s)
- P Vineis
- Unit of Cancer Epidemiology, University of Torino, CPO-Piemonte, via Santena 7 10126 Torino,Torino, Italy.
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