Clinical Predictors of Response to Anti-PD-1 First-Line Treatment in a Single-Centre Patient Cohort: A Real-World Study

AIMS

Cutaneous melanoma is one of the most immunogenic tumours. Immunotherapy with checkpoint inhibitors, such as anti-PD-1 antibodies, has significantly improved the prognosis in metastatic melanoma. However, only half of the patients respond to this therapy and have a favourable outcome. Identifying factors associated with treatment failure and early identification of responders are both important to select the best treatment approach for each patient. The aim of our study was to investigate clinical biomarkers of response to treatment with anti-PD-1 antibodies.

MATERIALS AND METHODS

We selected all patients with stage IV melanoma (n = 147), subjected to first-line treatment with anti-PD-1 in the last 10 years. We investigated the associations between patients' different clinical features and progression-free survival, using the Cox proportional hazards models.

RESULTS

In the multivariate analysis, an increased risk of disease progression was observed among patients with stage M1d metastases (hazard ratio 3.30; 95% confidence interval 1.58-6.91), compared with patients with stage M1a-M1b. Moreover, the risk of progression was greater in patients with the Eastern Cooperative Oncology Group Performance Status (ECOG PS) 1 (hazard ratio 2.04; 95% confidence interval 1.02-4.06) and in patients with ECOG PS ≥ 2 (hazard ratio 2.19; 95% confidence interval 1.05-4.55) compared with ECOG PS 0. High levels of lactate dehydrogenase (hazard ratio 2.06; 95% confidence interval 1.18-3.59) and the presence of respiratory diseases (hazard ratio 4.14; 95% confidence interval 1.42-12.0) at the beginning of anti-PD-1 treatment were also associated with an increased risk of disease progression. In a subgroup analysis, neutrophil count and neutrophil/lymphocyte ratio before anti-PD-1 treatment were higher in patients who underwent disease progression.

CONCLUSION

In our study population, independent predictors of disease progression among patients treated with first-line anti-PD-1 were as follows: ECOG PS, staging, lactate dehydrogenase and the presence of respiratory diseases.

The bovine cumulus proteome is influenced by maturation condition and maturational competence of the oocyte

In vitro maturation (IVM) of oocytes has still a negative impact on the developmental competence of oocytes. Therefore, this study analysed the cumulus proteome of individual cumulus-oocyte complexes (COCs) with and without maturational competence, matured under in vivo or in vitro conditions (n = 5 per group). A novel, ultrasensitive mass spectrometry (MS) based protein profiling approach, using label-free quantification, was applied. The detected cumulus proteome included 2226 quantifiable proteins and was highly influenced by the maturation condition (479 differentially expressed proteins) as well as maturational competence of the corresponding oocyte (424 differentially expressed proteins). Enrichment analysis showed an overrepresentation of the complement and coagulation cascades (CCC), ECM-receptor interaction and steroid biosynthesis in cumulus of COCs that matured successfully under in vivo conditions. Verification of the origin of CCC proteins was achieved through detection of C3 secretion into the maturation medium, with significantly increasing concentrations from 12 (48.4 ng/ml) to 24 hours (68 ng/ml: p < 0.001). In relation, concentrations in follicular fluid, reflecting the in vivo situation, were >100x higher. In summary, this study identified important pathways that are impaired in IVM cumulus, as well as potential markers of the maturational competence of oocytes.

Pregnancy and melanoma: a European-wide survey to assess current management and a critical literature overview

BACKGROUND

Management of melanoma during pregnancy can be extremely challenging. The reported incidence of melanoma in pregnancy ranges from 2.8 to 5.0 per 100 000 pregnancies. There are no guidelines for the management of melanoma during pregnancy.

METHODS

The survey was designed to investigate the opinions of melanoma physicians on decision making in relation to pregnancy and melanoma. A clinical scenario-based survey on management of pregnancy in melanoma was distributed all over Europe via the membership of the EORTC and other European melanoma societies.

RESULTS

A total of 290 questionnaires were returned with a larger participation from southern Europe. A large heterogeneity was found for the answers given in the different clinical scenarios with 50% of the answers showing discordance, especially regarding sentinel lymph node biopsy during pregnancy. Discordant answers were also found for the counselling of women about a potential delay in getting pregnant after a high-risk melanoma (35% for a 2 year wait minimum vs. 57% no waiting needed), while for thin melanomas, as expected, there was more concordance with 70% of the physicians recommending no delay. Fifteen per cent of physicians recommended an abortion in stage II melanoma during the third month of pregnancy. Twenty per cent of the responders advised against hormonal replacement therapy in melanoma patients.

CONCLUSIONS

The management of melanoma during pregnancy varies widely in Europe. At present, there is a lack of consensus in Europe, which may lead to very important decisions in women with melanoma, and guidelines are needed.

The relation between dietary habits and urinary levels of 3-phenoxybenzoic acid, a pyrethroid metabolite

Concerns about pesticide exposure through food consumption have increased during the past several years. Pyrethroids are applied as insecticides throughout the world. Human metabolism of pyrethroids results in urinary metabolites that are suitable for biological monitoring. The objective of our study was to investigate the relation between food consumption and urinary levels of 3-phenoxybenzoic acid (3-PBA), a general metabolite of pyrethroids, in a non-occupational exposed adult population from the IDI-IRCCS, Rome, Italy. Information on socio-demographic characteristics, smoking, diet and self-reported household pesticide exposure was collected. Urinary 3-PBA level of each subject was measured and adjusted by urinary creatinine. We found that people consuming both raw and cooked vegetables five times weekly or more had higher mean levels of 3-PBA in urine (1.03 μg/g creatinine versus 0.52 μg/g creatinine; p=0.009 and 0.99 μg/g creatinine versus 0.58 μg/g creatinine; p=0.01, respectively) than subjects consuming less than five times weekly. In a multivariate model, after adjusting for age, sex, BMI, smoking and household insecticide exposure, high intake of raw vegetables (OR: 5.31; 95%CI: 1.32-21.3) and high intake of cooked vegetables, in particular cruciferous (OR: 4.67; 95%CI: 1.07-20.5) and leafy vegetables (OR: 6.88; 95%CI: 1.50-31.7), were associated with high urine 3-PBA levels (≥0.70 μg/g creatinine). The results of this study suggest that part of the variation in pyrethrois intake is explained by vegetable intake.

Expression of the soluble vascular endothelial growth factor receptor-1 in cutaneous melanoma: role in tumour progression

BACKGROUND

Vascular endothelial growth factor (VEGF)-A, placenta growth factor (PlGF) and their corresponding membrane receptors are involved in autocrine and paracrine regulation of melanoma growth and metastasis. Besides the membrane receptors, a soluble form of the VEGF receptor (VEGFR)-1 (sVEGFR-1) has been identified, that behaves both as a decoy receptor, sequestering VEGF-A and PlGF, and as an extracellular matrix (ECM) molecule, promoting endothelial cell adhesion and migration through the interaction with α5β1 integrin.

OBJECTIVES

To analyse whether sVEGFR-1 plays a role during melanoma progression.

METHODS

sVEGFR-1 expression was evaluated in a panel of 36 melanoma cell lines and 11 primary human melanocyte cultures by quantitative real-time polymerase chain reaction analysis and in specimens of primary or metastatic melanoma lesions from 23 patients by immunohistochemical analysis.

RESULTS

sVEGFR-1 expression was highly upregulated in melanoma cell lines with respect to human melanocytes. Interestingly, cell lines obtained from cutaneous metastases showed a significant reduction of sVEGFR-1 expression, as compared with cell lines derived from primary tumours. These results were confirmed by immunohistochemical analysis of sections from primary skin melanomas and the corresponding cutaneous metastases, suggesting that modulation of sVEGFR-1 expression influences ECM invasion by melanoma cells and metastasis localization. Moreover, we provide evidence that adhesion of melanoma cells to sVEGFR-1 is favoured by the activation of a VEGF-A/VEGFR-2 autocrine loop.

CONCLUSIONS

Our data strongly suggest that sVEGFR-1 plays a role in melanoma progression and that low sVEGFR-1/VEGF-A and sVEGFR-1/transmembrane VEGFR-1 ratios might predict a poor outcome in patients with melanoma.

A protective effect of the Mediterranean diet for cutaneous melanoma

BACKGROUND

Many studies have investigated the Mediterranean diet as a risk factor for cancer, none of which has included cutaneous melanoma. The latter is usually fatal, rendering knowledge about prevention extremely important. We assessed the role of some food components of the Mediterranean diet and cutaneous melanoma.

METHODS

A hospital-based case-control study was conducted in the inpatient wards of IDI-San Carlo Rome, Italy including 304 incident cases of cutaneous melanoma and 305 controls, frequency matched to cases. Information on socio-demographic characteristics, medical history, smoking, sun exposure, pigmentary characteristics and diet was collected. Logistic regression was the method used to estimated odds ratio and 95% CIs.

RESULTS

After careful control for several sun exposure and pigmentary characteristics, we found a protective effect for weekly consumption of fish (OR, 0.65, 95%CI = 0.43-0.97), shellfish (OR, 0.53, 95%CI = 0.31-0.89), fish rich in n-3 fatty acids (OR, 0.52, 95%CI = 0.34-0.78), daily tea drinking (OR, 0.42, 95%CI, 0.18-0.95; P(trend) = 0.025) and high consumption of vegetables (OR, 0.50, 95%CI = 0.31-0.80, P(trend) = 0.005) in particular carrots, cruciferous and leafy vegetables and fruits (OR, 0.54, 95%CI =0.33-0.86, P(trend) = 0.013), in particular citrus fruits. No association was found for alcohol consumption and any other food items.

CONCLUSION

Overall, our findings suggest that some dietary factors present in the Mediterranean diet might protect from cutaneous melanoma.

Quality of life impairment and psychological distress in elderly patients with psoriasis

BACKGROUND/AIMS

The management of psoriasis, which has a major impact on quality of life (QoL), deserves a specific attention to elderly patients' problems and needs. Our aim was to describe the QoL of elderly patients with psoriasis.

METHODS

This is a cross-sectional study on 305 psoriatic inpatients, aged > or = 65 years. QoL, measured by the Skindex-29, was compared in groups of patients based on clinical and sociodemographic characteristics, and the possible determinants of psychological distress were investigated.

RESULTS

The mean age of the patients was 71 years (range: 65-93). Clinical severity tended to increase with age. Psychological distress was higher in patients > 70 years of age, while QoL showed an improvement for all the Skindex-29 scales in older age groups. Gender (women vs. men), and Skindex-29 emotions and functioning scales emerged as associated with psychological distress, after adjusting for age and clinical severity.

CONCLUSION

These observations indicate that clinical severity of psoriasis increases among very elderly patients and is associated with different levels of skin-related QoL and psychological distress. It is important for dermatologists to be aware of the specific impact of psoriasis in the different subgroups of the elderly population, to meet the peculiar needs of each group.

Home breastfeeding support by health professionals: findings of a randomized controlled trial in a population of Italian women

AIM

We conducted a randomized controlled trial to assess the effectiveness of a support intervention delivered by health professionals to increase the rate and duration of breastfeeding.

METHODS

A randomized controlled intervention study was conducted in the period 2000-2001 among 605 mothers who had given birth in a public maternity ward located in the city of Rome, Italy. The intervention consisted of a home visit by a midwife from the maternity ward of the hospital. The outcome of the study was the infant's feeding habits, assessed by a 24-h recall. The effect of the intervention on the duration of breastfeeding was estimated by the Kaplan-Meier method and by the Cox multivariate regression model.

RESULTS

According to intention-to-treat analysis, there was no significant difference between the intervention and the control group, after controlling for confounding factors (hazard ratio (HR) 1.04; 95% confidence interval (95% CI): 0.85-1.26). The duration of breastfeeding was shorter (HR 1.61; 95% CI: 1.13-2.31) for women in the intervention group who refused the obstetric visit.

CONCLUSION

Our study shows that an early home support programme delivered by health professionals was not effective in increasing breastfeeding initiation and duration.

Dietary factors associated with wheezing and allergic rhinitis in children

The effect of dietary factors on asthma is controversial. This study examined food consumption and the use of fats in relation to wheezing and allergic rhinitis in children. Baseline questionnaire data on individual and family characteristics were recorded by parents of 5,257 children aged 6-7 yrs living in central Italy participating in the International Study on Asthma and Allergies in Childhood study. A total of 4,104 children (78.1%) were reinvestigated after 1 yr using a second parental questionnaire to record occurrence of respiratory symptoms over the intervening 12 months. Consumption of foods rich in antioxidants, such as vitamins C and E, animal fats, and food containing omega-3 fatty acids were investigated using a food-frequency questionnaire. Frequency of use of fats was also evaluated. Wheezing, shortness of breath with wheeze, and symptoms of allergic rhinitis in the past 12 months were considered. Intake of cooked vegetables, tomatoes, and fruit were protective factors for any wheeze in the last 12 months and shortness of breath with wheeze. Consumption of citrus fruit had a protective role for shortness of breath with wheeze. Consumption of bread and margarine was associated with an increased risk of wheeze, while bread and butter was associated with shortness of breath with wheeze. Dietary antioxidants in vegetables may reduce wheezing symptoms in childhood, whereas both butter and margarine may increase the occurrence of such symptoms.

Lung cancer and cigarette smoking in Europe: an update of risk estimates and an assessment of inter-country heterogeneity

Ten case-control studies have been carried out in 6 European countries to investigate the major risk factors for lung cancer. Carcinogenic effect from cigarette smoke was the most relevant interest in our study, which has included 7,609 cases of lung cancer and 10,431 controls, mainly population based. The results indicate elevated odds ratios (ORs; 23.9 among men and 8.7 among women) with attributable risks exceeding 90% for men and close to 60% for women. A large, and statistically significant, variability of the results across countries was detected after adjusting for the most common confounding variables, and after controlling, at least in part, for the instability of the ORs due to the small number of non-smokers in some of the study subsets. This pattern of lung cancer risk associated with cigarettes smoke, across different European regions, reflects inherent characteristics of the studies as well as differences in smoking habits, particularly calendar periods of starting, and it is likely to have been influenced by effect modifiers like indoor radon exposure, occupation, air pollution and dietary habits.

Nitrated and oxidized plasma proteins in smokers and lung cancer patients

Cigarette smoking is a cause of lung cancer and other respiratory diseases. Oxidants either present in cigarette smoke and/or formed in the lung of smokers may trigger oxidative and nitrative damage to DNA and cellular components, contributing to carcinogenesis. We have used immunodot and Western blot analyses to measure nitrated (nitrotyrosine-containing) and oxidized (carbonyl-containing) proteins in plasma samples collected from 52 lung cancer patients and 43 control subjects (heavy and light smokers, nonsmokers with or without exposure to environmental tobacco smoke). The levels of nitrated proteins were significantly higher in lung cancer patients than in controls (P = 0.003). On the other hand, the levels of oxidized proteins were significantly higher in smokers than in nonsmokers (P < 0.001). Western-blot analyses showed the presence of two to five nitrated proteins and one oxidized protein. Using immunoprecipitation and Western-blot analyses with eight different antibodies against human plasma proteins, we identified fibrinogen, transferrin, plasminogen, and ceruloplasmin as nitrated proteins and fibrinogen as the only oxidized protein present in human plasma of lung cancer patients and smokers. Our results indicate that cigarette smoking increases oxidative stress and that during lung cancer development, formation of reactive nitrogen species results in nitration and oxidation of plasma proteins.

Lung cancer and cigarette smoking in women: a multicenter case-control study in Europe

The association between cigarette smoking and lung cancer risk in women was investigated within the framework of a case-control study in 9 centres from 6 European countries. Cases were 1,556 women up to 75 years of age with histologically confirmed primary lung cancer; 2, 450 controls with age distribution similar to cases were selected. The predominant cell type was adenocarcinoma (33.5%), with similar proportions for squamous-cell type (26.4%) and small-cell carcinoma (22.3%). Overall, smoking cigarettes at any time was associated with a 5-fold increase in lung cancer risk (odds ratio 5.21, 95% confidence interval 4.49-6.04); corresponding figures for current smoking habits were 8.94, 7.54-10.6. The association showed a dose-response relationship with duration of the habit and daily and cumulative lifetime smoking. A significant excess risk of 70% was associated with every 10 pack-years smoked. After 10 years of smoking cessation, the relative risk decreased to 20% compared to current smokers. The following characteristics were associated with a higher relative risk: inhalation of smoke, smoking non-filter cigarettes, smoking dark-type cigarettes and starting at young age. The association was observed for all major histological types, being the strongest for small-cell type carcinoma, followed by squamous-cell type and the lowest for adenocarcinoma. The proportion of lung-cancer cases in the population attributable to cigarette smoking ranged from 14% to 85%. We concluded that women share most features of the association between cigarette smoking and lung cancer observed in men.

Occupational risks for lung cancer among nonsmokers

We conducted a case-control study in 12 European study centers to evaluate the role of occupational risk factors among nonsmokers. We obtained detailed occupational histories from 650 nonsmoking cases (509 females/141 males) and 1,542 nonsmoking controls (1,011 females/531 males). On the basis of an a priori definition of occupations and industries that are known (list A) or suspected (list B) to be associated with lung carcinogenesis, we calculated odds ratios (ORs) for these occupations, using unconditional logistic regression models and adjusting for sex, age, and center effects. Among nonsmoking men, an excess relative risk was observed among those who had worked in list-A occupations [OR = 1.52; 95% confidence interval (C) = 0.78-2.97] but not in list-B occupations (OR = 1.05; 95%), CI = 0.60-1.83). Among nonsmoking women, there was an elevation of risk for list-A occupations (OR = 1.50; 95% CI = 0.49-4.53), although this estimate was imprecise, given that less than 1% of cases and controls were exposed. Exposure to list-B occupations was associated with an increase in relative risk (OR = 1.69; 95% CI = 1.09-2.63) in females, but not in males. Women who had been laundry workers or dry cleaners had an OR of 1.83 (95% CI = 0.98-3.40). Our findings confirm that certain occupational exposures are associated with an increased risk for lung cancer among both female and male nonsmokers; however, knowledge on occupational lung carcinogens is biased toward agents to which mainly men are exposed.

Diet and overall survival in a cohort of very elderly people

We conducted a 5-year cohort study among 162 self-sufficient residents in a public home for the elderly in Rome, Italy, to evaluate the association between the consumption of specific food groups and nutrients and overall 5-year survival. We used a validated, semiquantitative food-frequency questionnaire to assess diet at baseline. Individuals consuming citrus fruit at least twice a week had an adjusted risk of dying that was half that of individuals who consumed citrus fruit less than once a week [relative risk (RR) = 0.52; 95% confidence interval (CI) = 0.28-0.95] (with adjustment for gender, age, education, body mass index, smoking status, cognitive function, and chronic diseases). The adjusted RRs of mortality were 0.38 (95% CI = 0.14-1.01) for consumption of milk and yogurt at least three times a week vs less than once a week; 0.21 (95% CI = 0.08-0.35) for moderate consumption of espresso coffee (1-2 cups weekly) vs less than once a week; and 0.35 (95% CI = 0.17-0.69) for > 2 cups a week of espresso coffee vs less than once a week. High levels of intake of ascorbic acid, riboflavin, and linoleic acid were associated with 50-60% decreases in mortality risk. High consumption of meat was associated with a higher risk of mortality (RR = 9.72; 95% CI = 2.68-35.1) among subjects with chronic diseases. Our findings indicate that frequent consumption of citrus fruit, milk, and yogurt; low consumption of meat; and high intake of vitamin C, riboflavin, and linoleic acid are associated with longevity.

p53 mutations and exposure to environmental tobacco smoke in a multicenter study on lung cancer

Biomarker data may provide a way to strengthen the link between environmental tobacco smoke (ETS) exposure and lung cancer shown in epidemiological studies. We conducted a multicenter case-control study to investigate the association between ETS exposure and lung cancer in never-smokers using p53 mutations as a biomarker of tobacco-related carcinogenesis. Paraffin-embedded tissue or fresh tissue samples from 91 never-smokers and 66 smokers with histologically confirmed lung cancer and interview data about smoking habits and ETS exposure were analyzed for mutations in the p53 gene. Statistical analysis was performed using multivariate logistic regression. Among the lifelong nonsmokers, the overall mutation prevalence was 10% (nine cases). Among 48 never-smokers ever exposed to spousal ETS, 13% (six cases) showed mutations. Smokers exhibited 17 (26%) mutations. A 3-fold [odds ratio, 2.9; 95% confidence interval (CI), 1.2-7.2] increased risk of p53 mutation was observed for smokers as compared with all never-smokers combined (i.e., irrespective of ETS exposure). The increase was 4.4-fold (95% CI, 1.2-16.2) when compared with never-smokers without ETS exposure. Among never-smokers, the risk of mutation was doubled (odds ratio, 2.0; 95% CI, 0.5-8.7) for exposure to spousal ETS only, based on 6 exposed cases with mutation and 42 exposed cases without mutation. The risk was 1.5 (95% CI, 0.2-8.8) for those ever exposed to spousal or workplace ETS as compared with those never exposed to spousal or workplace ETS. For smokers, the most common mutation type was G:C to T:A transversion (31%), whereas G:C to A:T transitions were predominant among never smokers (57%). In conclusion, our study indicates a significant 3-4-fold increased risk of p53 mutation in smoking lung cancer cases, and it suggests that mechanisms of lung carcinogenesis in ETS-exposed never-smokers include mutations in the p53 gene, similar to that seen in smokers. However, the mutation patterns observed also suggest a difference between smokers and never-smokers. Clearly, additional investigations of the role of p53 mutation as a biomarker for tobacco-related carcinogenesis, including that related to ETS, are indicated.

Consumption of fresh fruit rich in vitamin C and wheezing symptoms in children. SIDRIA Collaborative Group, Italy (Italian Studies on Respiratory Disorders in Children and the Environment)

BACKGROUND

A beneficial effect of fresh fruit consumption on lung function has been observed in several studies. The epidemiological evidence of the effect on respiratory symptoms and asthma is limited. The consumption of fruit rich in vitamin C was examined in relation to wheezing and other respiratory symptoms in cross sectional and follow up studies of Italian children.

METHODS

Standardised respiratory questionnaires were filled in by parents of 18 737 children aged 6-7 years living in eight areas of Northern and Central Italy. The winter intake of citrus fruit and kiwi fruit by the children was categorised as less than once per week, 1-2 per week, 3-4 per week, and 5-7 per week. A subset of 4104 children from two areas was reinvestigated after one year using a second parental questionnaire to record the occurrence of wheezing symptoms over the intervening period.

RESULTS

In the cross sectional analysis, after controlling for several confounders (sex, study area, paternal education, household density, maternal smoking, paternal smoking, dampness or mould in the child's bedroom, parental asthma), intake of citrus fruit or kiwi fruit was a highly significant protective factor for wheeze in the last 12 months (odds ratio (OR) = 0.66, 95% confidence intervals (CI) 0.55 to 0.78, for those eating fruit 5-7 times per week compared with less than once per week), shortness of breath with wheeze (OR = 0.68, 95% CI 0.56 to 0.84), severe wheeze (OR = 0.59, 95% CI 0.40 to 0.85), nocturnal cough (OR = 0.73, 95% CI 0.65 to 0.83), chronic cough (OR = 0.75, 95% CI 0.65 to 0.88), and non-coryzal rhinitis (OR = 0.72, 95% CI 0.63 to 0.83). In the follow up study fruit intake recorded at baseline was a strong and independent predictor of all symptoms investigated except non-coryzal rhinitis. In most cases the protective effect was evident even among children whose intake of fruit was only 1-2 times per week and no clear dose-response relationship was found. The effect was stronger (although not significantly so (p = 0.13)) in subjects with a history of asthma; those eating fresh fruit at least once a week experienced a lower one year occurrence of wheeze (29. 3%) than those eating fruit less than once per week (47.1%) (OR = 0. 46, 95% CI 0.27 to 0.81).

CONCLUSIONS

Although the effect of other dietary components cannot be excluded, it is concluded that the consumption of fruit rich in vitamin C, even at a low level of intake, may reduce wheezing symptoms in childhood, especially among already susceptible individuals.

A multicenter case-control study of diet and lung cancer among non-smokers

OBJECTIVE

We have examined the role of dietary patterns and specific dietary nutrients in the etiology of lung cancer among non-smokers using a multicenter case-control study.

METHODS

506 non-smoking incident lung cancer cases were identified in the eight centers along with 1045 non-smoking controls. Dietary habits were assessed using a quantitative food-frequency questionnaire administered by personal interview. Based on this information, measures of total carotenoids, beta-carotene and retinol nutrient intake were estimated.

RESULTS

Protective effects against lung cancer were observed for high consumption of tomatoes, (odds ratio (OR) = 0.5; 95% confidence interval (CI) 0.4-0.6), lettuce (OR = 0.6; 95% CI 0.3-1.2), carrots (OR = 0.8; 95% CI 0.5-1.1), margarine (OR = 0.7; 95% CI 0.5-0.8) and cheese (OR = 0.7; 95% CI 0.5-1.0). Only weak protective effects were observed for high consumption of all carotenoids (OR = 0.8; 95% CI 0.6-1.0), beta-carotene (OR = 0.8; 95% CI 0.6-1.1) and retinol (OR = 0.9; 95% CI 0.7-1.1). Protective effects for high levels of fruit consumption were restricted to squamous cell carcinoma (OR = 0.7; 95% CI 0.4-1.2) and small cell carcinoma (OR = 0.7; 95% CI 0.4-1.2), and were not apparent for adenocarcinoma (OR = 0.9; 95% CI 0.6-1.3). Similarly, any excess risk associated with meat, butter and egg consumption was restricted to squamous and small cell carcinomas, but was not detected for adenocarcinomas.

CONCLUSIONS

This evidence suggests that the public health significance of increasing vegetable consumption among the bottom third of the population would include a reduction in the incidence of lung cancer among lifetime non-smokers by at least 25%, and possibly more. A similar protective effect for increased fruit consumption may be present for squamous cell and small cell lung carcinomas.

Exposure to environmental tobacco smoke and risk of adenocarcinoma of the lung

We conducted a case-control study of adenocarcinoma of the lung and exposure to environmental tobacco smoke (ETS) in 7 countries. We interviewed 70 cases of adenocarcinoma of the lung and 178 population or hospital controls. All subjects had smoked fewer than 400 cigarettes in their lifetimes. Ever exposure to ETS from the parents during childhood was associated with a decreased risk [odds ratio (OR) 0.6, 95% confidence interval (CI) 0.3-1.2], and there was a suggestion of a decreasing trend in risk with increasing duration of exposure. Ever exposure to ETS from the spouse was not associated with an increased risk (OR 1.0, 95% CI 0.5-1.8), while the OR of ever exposure to ETS at the workplace was 1.5 (95% CI 0.8-3.0). For both exposure sources, an increased risk was observed among the highly exposed, and the OR among those with the highest duration of exposure to ETS from the spouse or at the workplace was 1.8 (95% CI 0.5-6.2). A similar risk was estimated for current exposure to ETS from either source. Our results confirm previous reports of a weak effect of adult ETS exposure on risk of adenocarcinoma of the lung. Bias and confounding cannot be excluded as explanations for the apparent decrease in risk from childhood exposure.

Exposure to environmental tobacco smoke and risk of adenocarcinoma of the lung

We conducted a case-control study of adenocarcinoma of the lung and exposure to environmental tobacco smoke (ETS) in 7 countries. We interviewed 70 cases of adenocarcinoma of the lung and 178 population or hospital controls. All subjects had smoked fewer than 400 cigarettes in their lifetimes. Ever exposure to ETS from the parents during childhood was associated with a decreased risk [odds ratio (OR) 0.6, 95% confidence interval (CI) 0.3-1.2], and there was a suggestion of a decreasing trend in risk with increasing duration of exposure. Ever exposure to ETS from the spouse was not associated with an increased risk (OR 1.0, 95% CI 0.5-1.8), while the OR of ever exposure to ETS at the workplace was 1.5 (95% CI 0.8-3.0). For both exposure sources, an increased risk was observed among the highly exposed, and the OR among those with the highest duration of exposure to ETS from the spouse or at the workplace was 1.8 (95% CI 0.5-6.2). A similar risk was estimated for current exposure to ETS from either source. Our results confirm previous reports of a weak effect of adult ETS exposure on risk of adenocarcinoma of the lung. Bias and confounding cannot be excluded as explanations for the apparent decrease in risk from childhood exposure.

Multicenter case-control study of exposure to environmental tobacco smoke and lung cancer in Europe

BACKGROUND

An association between exposure to environmental tobacco smoke (ETS) and lung cancer risk has been suggested. To evaluate this possible association better, researchers need more precise estimates of risk, the relative contribution of different sources of ETS, and the effect of ETS exposure on different histologic types of lung cancer. To address these issues, we have conducted a case-control study of lung cancer and exposure to ETS in 12 centers from seven European countries.

METHODS

A total of 650 patients with lung cancer and 1542 control subjects up to 74 years of age were interviewed about exposure to ETS. Neither case subjects nor control subjects had smoked more than 400 cigarettes in their lifetime.

RESULTS

ETS exposure during childhood was not associated with an increased risk of lung cancer (odds ratio [OR] for ever exposure = 0.78; 95% confidence interval [CI] = 0.64-0.96). The OR for ever exposure to spousal ETS was 1.16 (95% CI = 0.93-1.44). No clear dose-response relationship could be demonstrated for cumulative spousal ETS exposure. The OR for ever exposure to workplace ETS was 1.17 (95% CI = 0.94-1.45), with possible evidence of increasing risk for increasing duration of exposure. No increase in risk was detected in subjects whose exposure to spousal or workplace ETS ended more than 15 years earlier. Ever exposure to ETS from other sources was not associated with lung cancer risk. Risks from combined exposure to spousal and workplace ETS were higher for squamous cell carcinoma and small-cell carcinoma than for adenocarcinoma, but the differences were not statistically significant.

CONCLUSIONS

Our results indicate no association between childhood exposure to ETS and lung cancer risk. We did find weak evidence of a dose-response relationship between risk of lung cancer and exposure to spousal and workplace ETS. There was no detectable risk after cessation of exposure.

4-Hydroxy-1-(3-pyridyl)-1-butanone-hemoglobin adducts as biomarkers of exposure to tobacco smoke: validation of a method to be used in multicenter studies

Hemoglobin (Hb) adducts of 4-hydroxy-1-(3-pyridyl)-1-butanone (HPB), a metabolite of two tobacco-specific nitrosamines [4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone and N'-nitrosonornicotine], were measured as biomarkers of exposure to tobacco smoke as part of a study on genetic alterations and susceptibility to lung cancer among nonsmokers. HPB-Hb adducts were measured after collection of RBCs by Ficoll gradient in six collaborating centers, release of HPB by alkaline hydrolysis from Hb, clean-up by solid-phase extraction, and analysis of an electron-capturing derivative by gas chromatography-electron capture mass spectrometry. Prior to analysis of samples from study subjects, the reproducibility of this approach was validated in blood from donors. The coefficient of variation of reproducibility of paired aliquots from five samples ranged from 7 to 25%; the within-sample reproducibilities of four and eight aliquots were 4 and 16%, respectively. The study subjects consisted of 18 smokers and 52 never-smokers. HPB-Hb adduct levels were significantly higher (P = 0.02) in smokers (26 +/- 13 fmol HPB/g Hb) than in never-smokers (20 +/- 8 fmol HPB/g Hb). There was no difference between sexes. These results suggest that the level of HPB-Hb adducts, measured using a method modified to facilitate use in multicenter studies, can be a useful biomarker of exposure to tobacco smoke.

A European validation study of smoking and environmental tobacco smoke exposure in nonsmoking lung cancer cases and controls

OBJECTIVES

The purpose of this study was to validate, in a case-control study, the reporting by lung cancer cases and controls of their own lifetime smoking habits and of the smoking habit of the spouse.

METHODS

In a multicenter (Sweden, Spain, Italy) case-control study of environmental tobacco smoke (ETS) and lung cancer, subjects were screened by repeated probing to exclude regular smokers of one cigarette/day or more for one year or more, and to quantify any occasional smoking. We then performed a short validation interview with next-of-kin in three centers.

RESULTS

Only five of 408 index subjects who had never smoked regularly (1.7 percent) were reported by next-of-kin to be former regular smokers. These subjects had a cumulative lifetime consumption of cigarettes below 1.1 pack years. Among 351 subjects with quantitative smoking information from both sources who reported ever smoking 400 cigarettes or less (the definition of never-smoker used in the multicenter ETS study), nine subjects (2.6 percent) had smoked more than this amount occasionally according to next-of-kin. Misclassification was not higher for cases than controls. Relative risks for lung cancer associated with indicators of ETS exposure were not substantially altered by excluding the nine possibly misclassified subjects. The reports from 223 pairs of index subjects and next-of kin regarding the cumulative amount smoked by the spouse agreed quite well (Spearman's rank correlation 0.75 for reported smokers, 0.92 for all subjects). Only one index subject failed to report a spouse who had smoked regularly (99 percent sensitivity).

CONCLUSIONS

Smoking status and exposure to spousal ETS as reported by lung cancer cases and controls agreed strongly with reports by next-of-kin. Overall, our results suggest that bias from smoker misclassification is likely to be insignificant, and they contribute to the evidence linking exposure to ETS with an increased risk of lung cancer.

The effect of zinc and vitamin A supplementation on immune response in an older population

OBJECTIVE

To determine if either supplemental vitamin A, zinc, or both increases cell-mediated immune response in an older population.

DESIGN

A double-blind, randomized, controlled trial of supplementation with vitamin A and zinc.

SETTING

Casa Di Riposo Roma III, a public home for older people in Rome, Italy.

SUBJECTS

The health and nutritional status of 178 residents were evaluated. One hundred thirty-six residents agreed to participate in the trial and were randomized into four treatment groups, and 118 of these residents completed the trial.

INTERVENTION

The four treatments consisted of: (1) Vitamin A (800 micrograms retinol palmitate); (2) Zinc (25 mg as zinc sulfate); (3) Vitamin A and Zinc (800 micrograms retinol palmitate and 25 mg as zinc sulfate); (4) Placebo capsules containing starch.

MAIN OUTCOME MEASUREMENTS

Immune tests-counts of leucocytes, lymphocytes, T-cell subsets, and lymphocyte proliferative response to mitogens-were measured before and after supplementation.

RESULTS

Zinc increased the number of CD4 + DR + T-cells (P = .016) and cytotoxic T-lymphocytes (P = .005). Subjects treated with vitamin A experienced a reduction in the number of CD3 + T-cells (P = .012) and CD4 + T-cells (P = .012).

CONCLUSIONS

These data indicate that zinc supplementation improved cell-mediated immune response, whereas vitamin A had a deleterious effect in this older population. Further research is needed to clarify the clinical significance of these findings.

Zinc supplementation and plasma lipid peroxides in an elderly population

OBJECTIVE

To determine the effect of vitamin A, zinc or both on plasma lipid peroxides in a healthy elderly population.

DESIGN

Double-blind randomized controlled trial supplementation of vitamin A and zinc.

SETTING

Public home for elderly people, in Rome, Italy.

SUBJECTS

A total of 178 residents of a Public home for elderly people were evaluated regarding health and nutritional status. 136 gave a written consensus to participate in the trial and were randomized in four groups of treatment. 118 elderly completed the trial.

INTERVENTIONS

Three months supplementation of the following treatments: (1) vitamin A (800 micrograms retinol palmitate); (2) zinc (25 mg zinc as sulphate); (3) vitamin A and zinc (800 micrograms retinol palmitate and 25 mg zinc as sulphate); (4) placebo (starch containing capsules).

MAIN OUTCOME MEASURES

Plasma lipid peroxides (TBA-RS) were measured before and after supplementation.

RESULTS

Zinc supplementation was associated with a decrease in plasma lipid peroxides (beta = -0.19; 95% confidence levels: -0.37, -0.002; p-value = 0.05) after adjusting for sex, smoking habits, baseline plasma lipid peroxides and vitamin A plasma levels.

CONCLUSIONS

Zinc supplementation decreased plasma lipid peroxides while vitamin A had no effect in this elderly population. Adequate zinc intake or supplementation could play an important role in the prevention and/ or modulation of diseases in the elderly people.