The impact of tobacco smoking and alcohol drinking on survival of patients with non-Hodgkin lymphoma

Pre- and Postnatal Exposures to Tobacco Smoking and Survival of Childhood Acute Lymphoblastic and Myeloid Leukemias in California, United States

BACKGROUND

Tobacco smoke adversely affects the prognosis of adult cancers including myeloid leukemia, but less is known in children.

METHODS

We evaluated whether pre- and postnatal exposures to tobacco smoke decrease 5-year survival of 1,235 childhood acute lymphoblastic leukemia (ALL) and 188 childhood acute myeloid leukemia (AML) cases derived from a population-based case-control study in California. Cases were diagnosed between 1995 and 2015 (median follow-up time of 13.2 years overall). We obtained data on tobacco smoking (before conception, during pregnancy, after birth), parental education and income, clinical features, and vital status through 2020. Cox proportional hazards regression was used to calculate hazard ratios (HR) and 95% confidence intervals (CI) for mortality associated with smoking, adjusting for sociodemographic characteristics and risk group (ALL only).

RESULTS

About 23% of mothers and 39% of fathers reported smoking and 130 children with ALL and 52 with AML died within 5 years. For AML, increased risks of death were observed among children whose fathers smoked before conception compared with nonsmoking fathers [HR = 1.41; 95% confidence interval (CI), 0.95-3.44 and 3.47; 95% CI, 1.37-8.81, respectively for <20 vs. ≥20 cigarettes per day; Ptrend = 0.01]. HR for child's passive smoking was 1.74, 95% CI, 0.81-3.73. Paternal preconception smoking may also reduce 5-year survival among ALL with favorable prognostic molecular subtypes (high hyperdiploidy and absence of IKZF1 gene deletion), although the associations did not reach statistical significance (Pheterogeneity = 0.07).

CONCLUSIONS

Paternal preconception smoking decreased 5-year survival of childhood AML.

IMPACT

Knowledge of exposure to tobacco smoking should be integrated in the treatment plan of childhood leukemias.

Perceptions of Facilitators and Barriers to Smoking Cessation Among Patients and Providers in a Cancer Center: A Single Institution Qualitative Exploratory Study

PURPOSE

Cancer patients who remain tobacco users have poorer outcomes, including increased mortality and decreased treatment tolerance; however, cessation post-diagnosis is challenging. Our formative research explored cessation-related perspectives among patients and staff at one National Cancer Institute-designated cancer center, to inform improving cessation services within oncology care.

METHODS

Using a descriptive phenomenological approach, a purposive sample of current cancer patients (n = 13) and cancer center physicians and cessation program staff (n = 9) were recruited to complete one-on-one audio-recorded in-depth qualitative interviews, to explore experiences providing or receiving cessation support, and perspectives on patients' readiness and needs regarding cessation. Thematic coding utilized Green's predisposing, enabling, and reinforcing framework to identify factors having positive, negative, or mixed impact on delivery of best-practices cessation services (ie, 5As) and patient cessation success.

RESULTS

Patients identified cancer diagnosis as a wake-up call, existing health problems, persistent healthcare providers, cost of cigarettes, and societal disapproval of smoking as factors facilitating quitting. Futility of quitting after a cancer diagnosis, cost and logistics of program participation, clinician time constraints, and lifetime addiction made quitting harder. Family, friends, stigma and motivation, and pharmacotherapies played mixed roles. Patients felt survivor-focused cessation programs, including stress management, could better enable quitting. Provider-anticipated problems with implementing cessation counseling included so-called "therapeutic nihilism" (ie, pessimism regarding cessation post-diagnosis), lack of training and standardized approaches, and time and documentation burden. Clinicians saw both policies and peer clinician "champions" as potentially increasing prioritization of cessation within oncology.

CONCLUSIONS

Findings highlight unmet needs for patients and providers regarding provision of effective cessation care. Despite survival benefit, cessation is still not standard within cancer care. Our results show that many patients would benefit from standardized programs where they are routinely asked about cessation. Providers would benefit from both structural enhancements and professional education to ensure that evidence-based cessation services tailored to cancer patients, are offered throughout treatment and survivorship.

Associations between Smoking and Alcohol and Follicular Lymphoma Incidence and Survival: A Family-Based Case-Control Study in Australia

The association between smoking and alcohol consumption and follicular lymphoma (FL) incidence and clinical outcome is uncertain. We conducted a population-based family case-control study (709 cases: 490 controls) in Australia. We assessed lifetime history of smoking and recent alcohol consumption and followed-up cases (median = 83 months). We examined associations with FL risk using unconditional logistic regression and with all-cause and FL-specific mortality of cases using Cox regression. FL risk was associated with ever smoking (OR = 1.38, 95%CI = 1.08−1.74), former smoking (OR = 1.36, 95%CI = 1.05−1.77), smoking initiation before age 17 (OR = 1.47, 95%CI = 1.06−2.05), the highest categories of cigarettes smoked per day (OR = 1.44, 95%CI = 1.04−2.01), smoking duration (OR = 1.53, 95%CI = 1.07−2.18) and pack-years (OR = 1.56, 95%CI = 1.10−2.22). For never smokers, FL risk increased for those exposed indoors to >2 smokers during childhood (OR = 1.84, 95%CI = 1.11−3.04). For cases, current smoking and the highest categories of smoking duration and lifetime cigarette exposure were associated with elevated all-cause mortality. The hazard ratio for current smoking and FL-specific mortality was 2.97 (95%CI = 0.91−9.72). We found no association between recent alcohol consumption and FL risk, all-cause or FL-specific mortality. Our study showed consistent evidence of an association between smoking and increased FL risk and possibly also FL-specific mortality. Strengthening anti-smoking policies and interventions may reduce the population burden of FL.

No Association Observed Between Coffee Intake and Risk of Non-Hodgkin's Lymphoma among Postmenopausal Women

BACKGROUND

Some preliminary studies indicate that components in coffee may have anticarcinogenic effects. However, the association between coffee-drinking habits and the risk of NHL remain controversial.

OBJECTIVE

To examine the relationship between coffee intake and non-Hodgkin's lymphoma (NHL) incidence in a large prospective study of postmenopausal US women.

DESIGN AND PARTICIPANTS/SETTING

The participants included 74,935 women from the Women's Health Initiative Observational Study (WHI-OS) who were recruited from 1993 through 1998. Information about coffee-drinking habits was collected at baseline via self-administered questionnaires.

MAIN OUTCOME MEASURES

Newly diagnosed NHL was validated by medical records and pathology records. Separate analyses were performed for the following three subtypes of NHL: diffuse large B-cell lymphoma (DLBCL (n=244)), follicular lymphoma (FL (n=166)), and chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL (n=64)).

STATISTICAL ANALYSES PERFORMED

Age-adjusted and multivariable-adjusted Cox proportional hazards models were used to determine associations of coffee intake (specifically, the total amount of coffee consumed daily, coffee types, and coffee preparation methods) with risk of NHL.

RESULTS

A total of 851 women developed NHL during a median 18.34 years of follow-up (range, 0.01 to 24.30 years; SD ± 6.63 years). Overall, no associations were observed between coffee intake and risk of NHL regardless of the total amount of daily coffee intake (P-value for trend test = 0.90), caffeinated (P-value=0.55) or decaffeinated coffee intake (P-value=0.78), and filtered or unfiltered coffee intake (P-value=0.91) after controlling for sociodemographic factors, lifestyle risk factors, and clinical risk factors/current medical conditions. No significant associations were observed between coffee intake with specific subtypes of NHL. A statistically significant interaction was found between alcohol intake, coffee intake, and incident NHL (P-value for interaction=0.02) based on the adjusted analysis. Specifically, among women who frequently consumed alcohol (>7 drinks/week), those who had moderate coffee intake (2-3 cups coffee/day) had a significantly reduced risk of developing NHL (HR:0.61, 95%CI: 0.36-0.98), compared to those who did not drink coffee.

CONCLUSION

The findings from this study do not support an association between coffee consumption and NHL risk, irrespective of the total amount of daily coffee intake, coffee types, or coffee preparation methods.

A French multicentric prospective prognostic cohort with epidemiological, clinical, biological and treatment information to improve knowledge on lymphoma patients: study protocol of the "REal world dAta in LYmphoma and survival in adults" (REALYSA) cohort

Background

Age-adjusted lymphoma incidence rates continue to rise in France since the early 80’s, although rates have slowed since 2010 and vary across subtypes. Recent improvements in patient survival in major lymphoma subtypes at population level raise new questions about patient outcomes (i.e. quality of life, long-term sequelae). Epidemiological studies have investigated factors related to lymphoma risk, but few have addressed the extent to which socioeconomic status, social institutional context (i.e. healthcare system), social relationships, environmental context (exposures), individual behaviours (lifestyle) or genetic determinants influence lymphoma outcomes, especially in the general population. Moreover, the knowledge of the disease behaviour mainly obtained from clinical trials data is partly biased because of patient selection.

Methods

The REALYSA (“REal world dAta in LYmphoma and Survival in Adults”) study is a real-life multicentric cohort set up in French areas covered by population-based cancer registries to study the prognostic value of epidemiological, clinical and biological factors with a prospective 9-year follow-up. We aim to include 6000 patients over 4 to 5 years. Adult patients without lymphoma history and newly diagnosed with one of the following 7 lymphoma subtypes (diffuse large B-cell, follicular, marginal zone, mantle cell, Burkitt, Hodgkin, mature T-cell) are invited to participate during a medical consultation with their hematologist. Exclusion criteria are: having already received anti-lymphoma treatment (except pre-phase) and having a documented HIV infection. Patients are treated according to the standard practice in their center. Clinical data, including treatment received, are extracted from patients’ medical records. Patients’ risk factors exposures and other epidemiological data are obtained at baseline by filling out a questionnaire during an interview led by a clinical research assistant. Biological samples are collected at baseline and during treatment. A virtual tumor biobank is constituted for baseline tumor samples. Follow-up data, both clinical and epidemiological, are collected every 6 months in the first 3 years and every year thereafter.

Discussion

This cohort constitutes an innovative platform for clinical, biological, epidemiological and socio-economic research projects and provides an opportunity to improve knowledge on factors associated to outcome of lymphoma patients in real life.

Trial registration

2018-A01332–53, ClinicalTrials.gov identifier: NCT03869619.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10433-4.

The association of physical activity before and after lymphoma diagnosis with survival outcomes

The impact of physical activity (PA) on lymphoma survival is not known. The association of PA and change in PA with overall (OS), lymphoma-specific (LSS) and event-free (EFS) survival was evaluated in a prospective cohort of newly diagnosed lymphoma patients (2002-2012). We calculated Leisure Score Indexes (mLSI) from the self-reported usual adult PA (baseline) and at 3-years post-diagnosis (FU3), grouping patients by active vs insufficiently active by the American Cancer Society PA guidelines. Associations of PA with survival were assessed using hazard ratios (HRs) and 95% confidence intervals (CI) from Cox models stratified by lymphoma subtype, adjusted for age, sex, baseline BMI, and comorbidity score with change scores further adjusted for baseline PA. Three thousand sixty participants were evaluable at baseline and 1371 at FU3. Active patients had superior survival from baseline [HR (CI): OS 0.82 (0.72-0.94); LSS 0.74 (0.61-0.90); EFS 0.92 (0.82-1.02)] and FU3 [HR (CI): OS 0.64 (0.46-0.88); LSS 0.32 (0.18-0.59); EFS 0.82 (0.61-1.10)] compared to insufficiently active. An increase in mLSI from baseline to FU3 (vs stable mLSI) was associated with superior OS (HR = 0.70, CI 0.49-1.00) and LSS (HR = 0.49, CI 0.26-0.94).The continuous change in mLSI at FU3 was significantly associated with OS, LSS and EFS; maintained across subgroups and appeared linear. Higher PA among lymphoma patients at diagnosis and 3 years is significantly associated with OS, LSS, and EFS. Increasing PA after diagnosis is significantly associated with improved OS and LSS supporting an important role for PA in lymphoma survivorship and the need for intervention trials.

Effects of alcohol drinking and smoking on pancreatic ductal adenocarcinoma mortality: A retrospective cohort study consisting of 1783 patients

The effects of alcohol drinking and smoking on pancreatic ductal adenocarcinoma (PDAC) mortality are contradictory. Individuals who were diagnosed as PDAC and hospitalized at the China National Cancer Center between January 1999 and January 2016 were identified and included in the study. Ultimately, 1783 consecutive patients were included in the study. Patients were categorized as never, ex-drinkers/smokers or current drinkers/smokers. Hazard ratios (HRs) of all-cause mortality and 95% confidence intervals (CIs) were estimated using Cox proportional hazards models. Compared with never drinkers, the HRs were 1.25 for ever drinkers, 1.24 for current drinkers, and 1.33 for ex-drinkers (trend P = 0.031). Heavy drinking and smoking period of 30 or more years were positive prognostic factors for PDAC. For different smoking and alcohol drinking status, only subjects who are both current smokers and current drinkers (HR, 1.45; 95% CI, 1.03–2.05) were associated with reduced survival after PDAC compared to those who were never smokers and never drinkers. Patients who are alcohol drinkers and long-term smokers before diagnosis have a significantly higher risk of PDAC mortality. Compared to those who neither smoker nor drink, only patients who both smokers and drinkers were associated with reduced survival from PDAC.

Cigarette Smoking and Pancreatic Cancer Survival

Purpose Cigarette smoking is associated with increased incidence of pancreatic cancer. However, few studies have prospectively evaluated the association of smoking with patient survival. Patients and Methods We analyzed survival by smoking status among 1,037 patients from two large US prospective cohort studies diagnosed from 1986 to 2013. Among 485 patients from four prospective US cohorts, we also evaluated survival by prediagnostic circulating levels of cotinine, a metabolite of nicotine that is proportional to tobacco smoke exposure. On the basis of prediagnosis cotinine levels, we classified patients as nonsmokers (< 3.1 ng/mL), light smokers (3.1-20.9 ng/mL), or heavy smokers (≥ 21.0 ng/mL). We estimated hazard ratios (HRs) for death by using Cox proportional hazards models, with adjustment for age, sex, race/ethnicity, body mass index, diabetes status, diagnosis year, and cancer stage. Results The multivariable-adjusted HR for death was 1.37 (95% CI, 1.11 to 1.69) comparing current smokers with never smokers ( P = .003). A statistically significant negative trend in survival was observed for increasing pack-years of smoking ( P_trend = .008), with HR for death of 1.49 (95% CI, 1.05 to 2.10) for > 60 pack-years of smoking versus never smoking. Survival among former smokers was similar to that for never smokers, regardless of time since quitting. Heavy smokers defined by prediagnostic circulating cotinine levels had a multivariable-adjusted HR for death of 1.76 (95% CI, 1.23 to 2.51) compared with nonsmokers. Among patients with circulating cotinine levels measured within 5 years before diagnosis, heavy smokers had a multivariable-adjusted HR for death of 2.47 (95% CI, 1.24 to 4.92) compared with nonsmokers. Conclusion Cigarette smoking was associated with a reduction in survival among patients with pancreatic cancer.

Dose-Adjusted Etoposide, Prednisone, Vincristine, Cyclophosphamide, and Doxorubicin (EPOCH) With or Without Rituximab as First-Line Therapy for Aggressive Non-Hodgkin Lymphoma

INTRODUCTION

Dose-adjusted etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin (DA-EPOCH) was developed in an effort to overcome inadequate drug concentrations and compensate for increased drug clearance. The goal of the present study was to examine the risk factors and outcomes of patients with aggressive non-Hodgkin lymphoma (aNHL) treated with DA-EPOCH.

PATIENTS AND METHODS

We report the data from 136 patients with previously untreated aNHL who received infusional DA-EPOCH chemotherapy with or without rituximab from 2005 to 2013. Overall survival was estimated using Kaplan-Meier methods. Univariate and multivariate logistic regression was used to determine the factors associated with death, progression, or relapse at 2 years.

RESULTS

The overall response rate was 82%. The relapse-free survival rate at 1, 3, and 5 years was 68%, 63%, and 52% with 95% confidence intervals (CIs) of 0.59% to 0.85%, 0.54% to 0.70%, and 0.31% to 0.70%, respectively. Patients with T-cell aNHL had an increased risk of death, progression, or relapse (Odds Ratio, 3.5; 95% CI, 1.4-8.8) compared with those with B-cell aNHL. In multivariate analysis, current smoking, disease in the bone marrow, and the number of cycles completed were independent predictors of death and relapse.

CONCLUSION

Our data suggest that EPOCH with or without rituximab is active in both B- and T-cell aNHL. Toxicity did not significantly affect timing of treatment delivery or treatment outcomes. Dose adjustment by hematopoietic nadir similarly had no effect. The effect of smoking during chemotherapy should be evaluated further.

New insights into the epidemiology of non-Hodgkin lymphoma and implications for therapy

Non-Hodgkin lymphoma (NHL) comprises numerous biologically and clinically heterogeneous subtypes, with limited data examining the risk factors for these distinct disease entities. Many limitations exist when studying lymphoma epidemiology; therefore, until recently, little was known regarding the etiology of NHL subtypes. This review highlights the results of recent pooled analyses examining the risk factors for NHL subtypes. We outline the heterogeneity and commonality among the risk factors for NHL subtypes, with proposed subtype-specific as well as shared etiologic mechanisms. In addition, we describe how the study of lymphoma epidemiology may translate into prevention or therapeutic targeting as we continue to explore the complexities of lifestyle and genetic factors that impact lymphomagenesis.

Alcohol consumption and antitumor immunity: dynamic changes from activation to accelerated deterioration of the immune system

The molecular mechanisms of how alcohol and its metabolites induce cancer have been studied extensively. However, the mechanisms whereby chronic alcohol consumption affects antitumor immunity and host survival have largely been unexplored. We studied the effects of chronic alcohol consumption on the immune system and antitumor immunity in mice inoculated with B16BL6 melanoma and found that alcohol consumption activates the immune system leading to an increase in the proportion of IFN-γ-producing NK, NKT, and T cells in mice not injected with tumors. One outcome associated with enhanced IFN-γ activation is inhibition of melanoma lung metastasis. However, the anti-metastatic effects do not translate into increased survival of mice bearing subcutaneous tumors. Continued growth of the subcutaneous tumors and alcohol consumption accelerates the deterioration of the immune system, which is reflected in the following: (1) inhibition in the expansion of memory CD8+ T cells, (2) accelerated decay of Th1 cytokine-producing cells, (3) increased myeloid-derived suppressor cells, (4) compromised circulation of B cells and T cells, and (5) increased NKT cells that exhibit an IL-4 dominant cytokine profile, which is inhibitory to antitumor immunity. Taken together, the dynamic effects of alcohol consumption on antitumor immunity are in two opposing phases: the first phase associated with immune stimulation is tumor inhibitory and the second phase resulting from the interaction between the effects of alcohol and the tumor leads to immune inhibition and resultant tumor progression.

Tobacco use in the oncology setting: advancing clinical practice and research

Although tobacco is a well-established causal agent for many human cancers, less emphasis has been placed on translating this evidence by evaluating the effects of continued tobacco use after a cancer diagnosis. A broad assessment of the effects of continued tobacco use demonstrates that tobacco increases cancer treatment toxicity, recurrence, second primary tumors, and mortality in patients with cancer. Few studies report the potential benefits of cessation after a cancer diagnosis, but data suggest improved treatment outcomes in patients with cancer who quit smoking. Improving tobacco cessation treatment efficacy and access to cessation support has been sparsely researched in the oncology setting compared with the general population; however, patients with cancer are receptive to standard evidence-based tobacco cessation guidelines. Several studies demonstrate moderate tobacco cessation success in patients with cancer using the general principles of evidence-based tobacco cessation support. Several systems-level issues and research efforts are needed to standardize tobacco use definitions, increase access to tobacco cessation support, improve tobacco cessation efficacy, understand the time-dependent effects of tobacco and cessation on cancer biology, and realize the potential benefits of tobacco cessation for patients with cancer.

Obesity and non-Hodgkin lymphoma survival in an ethnically diverse population: the Multiethnic Cohort study

PURPOSE

Obesity increases mortality for several malignancies, but for non-Hodgkin lymphoma (NHL), the association between body mass index (BMI) and survival is unclear. We examined the association of pre-diagnostic BMI with overall and NHL-specific survival in the multiethnic cohort (MEC) study of African Americans, Native Hawaiians, Japanese Americans, Latinos, and Caucasians.

METHODS

MEC participants free of NHL at cohort entry and diagnosed with NHL during follow-up were included in the analyses (n = 1,331). BMI was based on self-reported weight and height at cohort entry and after 6.1 years of cohort entry. Cox proportional hazards regression was used to calculate hazard ratios (HR) and 95 % confidence intervals (CI) with BMI as time-varying exposure in relation to all-cause and NHL-specific mortality while adjusting for known confounders.

RESULTS

The mean age at NHL diagnosis was 70.5 (range 45-89) years. After a mean follow-up of 4.3 ± 3.5 years, 667 deaths including 450 NHL-specific deaths occurred. In multivariable models, obese patients (BMI ≥30.0 kg/m(2)) had higher all-cause (HR 1.46, 95 % CI 1.13-1.87) and NHL-specific (HR 1.77, 95 % CI 1.30-2.41) mortality compared with patients with high-normal BMI (22.5-24.9 kg/m(2)). For overweight patients (BMI = 25.0-29.9 kg/m(2)), the respective HRs were 1.21 (95 % CI 0.99-1.49) and 1.36 (95 % CI 1.06-1.75). Cases with low-normal BMI (<22.5 kg/m(2)) experienced a significant 45 % higher all-cause and a 40 % higher NHL-specific mortality. After stratification by NHL type, the adverse effect of BMI was stronger for chronic lymphocytic leukemia/small lymphocytic lymphoma than for diffuse large B cell lymphoma and follicular lymphoma.

CONCLUSIONS

Pre-diagnostic BMI may be a suitable prognostic marker for NHL patients.

Smoking and body mass index and survival in pancreatic cancer patients

OBJECTIVE

The objective of this study was to provide further information on the role of personal characteristics and lifestyle factors, including obesity, diabetes, and tobacco smoking, on survival from pancreatic cancer.

METHODS

We obtained follow-up data of pancreatic cancer patients enrolled in 2 Italian case-control studies. Information on characteristics and habits up to the time of diagnosis was collected by trained interviewers. Vital status was ascertained through population registers and record linkage with health system databases. Hazard ratios (HRs) of all-cause mortality and 95% confidence intervals (CIs) were estimated using Cox proportional hazards models.

RESULTS

Follow-up information was retrieved for 648 cancer patients. Compared with subjects with body mass index of less than 25 kg/m, the HRs were 1.14 (95% CI, 0.94-1.39) for overweight (ie, 25-29.9 kg/m) and 1.32 (95% CI, 0.98-1.79) for obese (ie, ≥30 kg/m) patients (trend P = 0.046). The HRs were 1.37 (95% CI, 1.14-1.65) for ever, 1.30 (95% CI, 1.03-1.65) for ex-smokers, and 1.42 (95% CI, 1.16-1.73) for current versus never smokers. Increasing amount and duration of smoking were associated with reduced survival after pancreatic cancer. No association emerged with diabetes, alcohol consumption, and diet.

CONCLUSIONS

Smoking and overweight before diagnosis may play a role in the prognosis of pancreatic cancer, besides its etiology.

Trends in concussion return-to-play timelines among high school athletes from 2007 through 2009

CONTEXT

Whereas guidelines about return-to-play (RTP) after concussion have been published, actual prognoses remain elusive.

OBJECTIVE

To develop probability estimates for time until RTP after sport-related concussion.

DESIGN

Descriptive epidemiology study.

SETTING

High school.

PATIENTS OR OTHER PARTICIPANTS

Injured high school varsity, junior varsity, or freshman athletes who participated in 1 of 13 interscholastic sports at 7 area high schools during the 2007-2009 academic years.

INTERVENTION(S)

Athletic trainers employed at each school collected concussion data. The athletic trainer or physician on site determined the presence of a concussion. Athlete-exposures for practices and games also were captured.

MAIN OUTCOME MEASURE(S)

Documented concussions were categorized by time missed from participation using severity outcome intervals (same-day return, 1- to 2-day return, 3- to 6-day return, 7- to 9-day return, 10- to 21-day return, >21-day return, no return [censored data]). We calculated Kaplan-Meier time-to-event probabilities that included censored data to determine the probability of RTP at each of these time intervals.

RESULTS

A total of 81 new concussions were documented in 478 775 athlete-exposures during the study period. After a new concussion, the probability of RTP (95% confidence interval) was 2.5% (95% confidence interval = 0.3, 6.9) for a 1- to 2-day return, 71.3% (95% confidence interval = 59.0, 82.9) for a 7- to 9-day return, and 88.8% (95% confidence interval = 72.0, 97.2) for a 10- to 21-day return.

CONCLUSIONS

For high school athletes, RTP within the first 2 days after concussion was unlikely. After 1 week, the probability of return rose substantially (approximately 71%). Prognostic indicators are used to educate patients about the likely course of disease. Whereas individual symptoms and recovery times vary, prognostic time-to-event probabilities allow clinicians to provide coaches, parents, and athletes with a prediction of the likelihood of RTP within certain timeframes after a concussion.

Pre-diagnosis cigarette smoking and overall survival in non-Hodgkin lymphoma

We examined whether smoking prior to non-Hodgkin lymphoma (NHL) diagnosis was associated with overall survival (OS) and conducted a meta-analysis to assess the evidence relating pre-diagnosis cigarette smoking with OS. Among 523 NHL patients, worse OS was suggested for greater pre-diagnostic smoking habits when compared to never smokers. In the meta-analysis (n = 5 patient populations), inferior OS was observed for greater number of cigarettes smoked per day, years of cigarette smoking, and pack-years of cigarette smoking. The inferior survival was more pronounced for follicular than for diffuse large B cell lymphoma. Pre-diagnosis cigarette smoking may adversely impact the survival of NHL patients.

Association of smoking history with cancer recurrence and survival in stage III-IV male gastric cancer patients

BACKGROUND

Smoking and drinking alcohol are major risk factors for cancer development, and we investigated their effects on gastric cancer prognosis following initial resection.

METHODS

Data from male patients with stage III-IV gastric adenocarcinoma who underwent surgery between 2001 and 2006 were retrospectively reviewed. Patients were followed up until 2011. Kaplan-Meier plots and Cox proportional hazards regressions were applied for survival rates.

RESULTS

Among 238 patients, 151 (63.4%) smoked and 146 (61.3%) drank alcohol. Current smokers had an increased risk of cancer recurrence or death from any cause [adjusted HR (aHR), 1.94; 95% confidence interval (CI), 1.18-3.21], cancer recurrence (aHR, 1.89; 95% CI, 1.12-3.21), and overall mortality (aHR, 2.14; 95% CI, 1.23-3.73) compared with never-smokers. Patients with a lifetime cigarette smoking of <40 and ≥ 40 pack-years had increased cancer recurrence or death from any cause (aHR, 1.72 and 2.43, respectively; 95% CI, 1.03-2.86 and 1.38-4.30, respectively), cancer recurrence (aHR, 1.63 and 2.61, respectively; 95% CI, 0.95-2.79 and 1.43-4.77, respectively), and overall mortality (aHR, 1.92 and 2.75, respectively; 95% CI, 1.09-3.38 and 1.47-5.12, respectively) compared with never-smokers. However, drinking alcohol was not associated with postsurgery survival.

CONCLUSIONS

Cigarette-smoking history at the time of diagnosis, but not drinking history, is associated with cancer recurrence and poor survival after surgery in male patients with stage III-IV gastric cancer.

IMPACT

These findings encourage physicians to advise patients with gastric cancer to stop smoking to obtain a general health benefit and likely improvement in the gastric cancer course.

Dietary intake of fruits and vegetables and overall survival in non-Hodgkin lymphoma

In a cohort of 301 patients with non-Hodgkin lymphoma (NHL), we examined whether the pre-diagnostic consumption of fruits and vegetables, or of nutrients concentrated in fruits and vegetables, was associated with overall survival (OS). Proportional hazards models were used to calculate hazard ratios (HRs) and 95% confidence intervals (CIs) for all-cause mortality. A total of 91 deaths occurred in the patient cohort over a median follow-up period of 8.2 years. No association with OS was detected for a dietary pattern characterized by high intakes of fruits, vegetables and starch; fruit intake; vegetable intake; or nutrient intake in patients diagnosed with overall NHL, follicular lymphoma or diffuse large B-cell lymphoma. Higher intakes of carotene-rich vegetables (HR = 0.4 [0.2-1.0]; p trend = 0.05) and α-carotene (HRT3 vs. T1 = 0.4 [0.2-0.9]; p trend = 0.03) were associated with better OS among ever smokers. Overall, our data suggest that the intake of fruits and vegetables prior to diagnosis is not associated with OS in patients with NHL.

Assessing tobacco use by cancer patients and facilitating cessation: an American Association for Cancer Research policy statement

When diagnosed with cancer, patients can immediately make a meaningful positive impact on their health by stopping their tobacco use. Scientific evidence clearly shows that tobacco use in patients with cancer leads to poorer outcomes. The specific biological processes driving tobacco consumption's interference in cancer therapy are the subject of continuing research, but the evidence is clear that tobacco use in patients with cancer leads to decreased treatment efficacy and safety, decreased survival, decreased quality of life, increased treatment-related toxicity, and increased risk of cancer recurrence and second primary tumors. Data suggest that tobacco cessation can improve outcomes and survival in patients with cancer, yet full execution of evidence-based cessation interventions is infrequent in oncology settings. Therefore, both improved provision of cessation assistance to all patients with cancer who use tobacco or have recently quit and further study of the deleterious effects of tobacco use and benefits of tobacco cessation on cancer progression and treatment are needed and recommended by the American Association for Cancer Research. Progress on both fronts begins with universal assessment and documentation of tobacco use as a standard of quality cancer care regardless of treatment setting and will be further facilitated through the development of reliable, valid, and standard measures of tobacco use, incorporation of evidence-based procedures into quality and accreditation procedures, and the development of appropriate training, clinical infrastructure, and incentives for delivery of tobacco cessation interventions.

Lifestyle factors, autoimmune disease and family history in prognosis of non-hodgkin lymphoma overall and subtypes

Lifestyle factors and medical history are known to influence risk of non-Hodgkin lymphoma (NHL). Whether these factors affect the prognosis of NHL, especially its subtypes, is unclear. To investigate this, the association between these factors and all-cause and lymphoma-related mortality was assessed in a population-based cohort of 1,523 Swedish NHL patients included in the Scandinavian Lymphoma Etiology study in 1999-2002. Participants contributed time from NHL diagnosis until death or October 1, 2010, with virtually complete follow-up through linkage to the Swedish Cause of Death Register. Hazard ratios (HR) and 95% confidence intervals (CI) were estimated using stratified and multivariable-adjusted Cox regression models. During a median follow-up of 8.8 years, 670 patients (44%) died, with the majority of deaths attributed to lymphoma (86%). Current versus never smoking at diagnosis was associated with increased rate of all-cause death for all NHL (HR = 1.5, 1.2-1.8) and diffuse large B-cell lymphoma (HR = 1.8, 1.2-2.7). Low educational level (HR = 1.3, 1.1-1.7, <9 vs. >12 years) and NHL risk-associated autoimmune disease (HR = 1.4, 1.0-1.8) were associated with death for all NHL combined. However, evidence of an association with lymphoma-related death was limited. Body mass index, recent sunbathing and family history of hematopoietic malignancy were not consistently associated with death after NHL or its specific subtypes. These results add to the evidence that cigarette smoking, socioeconomic status and certain autoimmune diseases affect survival after NHL. Further investigations are needed to determine how these factors should be incorporated into clinical prognostic assessment.

Association of family history with cancer recurrence and survival in patients with gastric cancer

PURPOSE

Family history of gastric cancer is a major risk factor for the disease. In this study, we investigated the prognoses of patients with gastric cancer with a family history.

PATIENTS AND METHODS

We retrospectively reviewed data from 1,273 patients with gastric adenocarcinoma who had undergone gastrectomy between 2001 and 2005 at a tertiary cancer center hospital. A positive family history was defined as a self-reported history of cancer in first- or second-degree relatives. Patients were followed up until December 2009 for death or recurrence. Clinicopathologic characteristics were compared by family history. Kaplan-Meier plots and Cox proportional hazards regressions were applied for disease-free survival (DFS), recurrence-free survival (RFS), and overall survival (OS).

RESULTS

Of 1,273 patients, 263 patients (20.6%) had first-degree relatives with a history of gastric cancer. First-degree family history of gastric cancer was associated with better DFS, RFS, and OS (P = .012, .006, and .005, respectively). In patients with stage I or II gastric cancer, first-degree family history was not associated with survival. However, it was associated with a reduced risk of recurrence or mortality in patients with stage III or IV gastric cancer. Compared with patients without a family history, the adjusted hazard ratios for those with a first-degree family history of gastric cancer were 0.49 (95% CI, 0.29 to 0.84) for DFS, 0.51 (95% CI, 0.30 to 0.87) for RFS, and 0.47 (95% CI, 0.26 to 0.84) for OS in patients with stage III or IV gastric cancer.

CONCLUSION

A first-degree family history of gastric cancer is associated with improved survival after curative-intent surgery in patients with stage III or IV gastric cancer.

Risk Factors of Non-Hodgkin Lymphoma

INTRODUCTION: Despite decades of intensive research, Non-Hodgkin Lymphoma (NHL) remains poorly understood and is largely incurable. NHL is a heterogeneous group of malignancies with multiple subtypes, each of which has distinct morphologic, immunophenotypic, and clinical features. Identifying the risk factors for NHL may improve our understanding of the underlying biological mechanisms and have an impact on clinical practice. AREAS COVERED: This article provides a review of several aspects of NHL, including epidemiology and subtype classification, clinical, environmental, genetic, and genomic risk factors identified for etiology and prognosis, and available statistical and bioinformatics tools for identification of genetic and genomic risk factors from the analysis of high-throughput studies. EXPERT OPINION: Multiple clinical and environmental risk factors have been identified. However, they have failed to provide practically effective prediction. Genetic and genomic risk factors identified from high-throughput studies have suffered a lack of reproducibility. The identification of genetic/genomic risk factors demands innovative statistical and bioinformatics tools. Although multiple analysis methods have been developed, there is still room for improvement. There is a critical need for well-designed, prospective, large-scale pangenomic studies.

Smoking, alcohol use, obesity, and overall survival from non-Hodgkin lymphoma: a population-based study

BACKGROUND

Smoking, alcohol use, and obesity appear to increase the risk of developing non-Hodgkin lymphoma (NHL), but to the authors' knowledge, few studies to date have assessed their impact on NHL prognosis.

METHODS

The association between prediagnosis cigarette smoking, alcohol use, and body mass index (BMI) and overall survival was evaluated in 1286 patients enrolled through population-based registries in the United States from 1998 through 2000. Hazard ratios (HRs) and 95% confidence intervals (95% CIs) were estimated using Cox regression, adjusting for clinical and demographic factors.

RESULTS

Through 2007, 442 patients had died (34%), and the median follow-up for surviving patients was 7.7 years. Compared with never smokers, former (HR, 1.59; 95% CI, 1.12-2.26) and current (HR, 1.50; 95% CI, 0.97-2.29) smokers had poorer survival, and poorer survival was found to be positively associated with smoking duration, number of cigarettes smoked per day, pack-years of smoking, and shorter time since quitting (all P <0.01). Alcohol use was associated with poorer survival (P = 0.03); compared with nonusers. Those drinking >43.1 g/week (median intake among drinkers) had poorer survival (HR, 1.55; 95% CI, 1.06-2.27), whereas those drinkers consuming less than this amount demonstrated no survival disadvantage (HR, 1.13; 95% CI, 0.75-1.71). Greater BMI was associated with poorer survival (P = 0.046), but the survival disadvantage was only noted among obese individuals (HR, 1.32 for BMI > or = 30 vs BMI 20-24.9; 95% CI, 1.02-1.70). These results held for lymphoma-specific survival and were broadly similar for diffuse large B-cell lymphoma and follicular lymphoma.

CONCLUSIONS

NHL patients who smoked, consumed alcohol, or were obese before diagnosis were found to have a poorer overall and lymphoma-specific survival.

Genetic polymorphisms in cytochrome P450s, GSTs, NATs, alcohol consumption and risk of non-Hodgkin lymphoma

The aim of this study was to investigate whether genetic polymorphisms in cytochrome P450s (CYPs), glutathione S-transferases (GSTs), and N-acetyltransferases (NATs) genes modify the relationship between alcohol consumption and risk of non-Hodgkin's lymphoma (NHL) in a population-based, case-control study including 1,115 Connecticut women. Although we did not find strong evidence that the genetic polymorphisms modify the relationship between alcohol consumption and risk of NHL, we identified significant interactions for multiple GSTs and NATs and alcohol intake among persons with DLBCL. Our results confer support investigation of the gene-environment interaction in a larger study population of DLBCL.

Alcohol consumption and non-Hodgkin lymphoma survival

INTRODUCTION

Epidemiological studies have shown that moderate alcohol drinkers have a lower death rate for all causes. Alcohol drinking has also been associated with reduced risk of non-Hodgkin lymphoma (NHL). Here, we examined the role of alcohol consumption on NHL survival by type of alcohol consumed and NHL subtype.

METHODS

A cohort of 575 female NHL incident cases diagnosed during 1996-2000 in Connecticut was followed-up for a median of 7.75 years. Demographic, clinical, and lifestyle information was collected at diagnosis. Survival analyses were conducted with Kaplan-Meier methods, and hazard ratios (HR) were estimated from Cox Proportional Hazards models.

RESULTS

Compared to never drinkers, wine drinkers experienced better overall survival (75% vs. 69% five-year survival rates, p-value for log-rank test = 0.030) and better disease free survival (70% vs. 67% five-year disease-free survival rates, p-value for log-rank test = 0.049). Analysis by NHL subtype shows that the favorable effect of wine consumption was mainly seen for patients diagnosed with diffuse large B-cell lymphoma (DLBCL) (wine drinkers for more than 25 years vs. never drinkers: HR = 0.36, 95% CI 0.14-0.94 for overall survival; HR = 0.38, 95% CI 0.16-0.94 for disease-free survival), and the adverse effect of liquor consumption was also observed among DLBCL patients (liquor drinkers vs. never drinkers: HR=2.49, 95% CI 1.26-4.93 for disease-free survival).

CONCLUSIONS

Our results suggest a moderate relationship between pre-diagnostic alcohol consumption and NHL survival, particularly for DLBCL. The results need to be replicated in larger studies.

IMPLICATIONS FOR CANCER SURVIVORS

Pre-diagnostic behaviors might impact the prognosis and survival of NHL patients.

Green tea consumption and hematologic malignancies in Japan: the Ohsaki study

Several biologic studies have reported that green tea constituents have antitumor effects on hematologic malignancies. However, the effects in humans are uncertain. The authors used data from the Ohsaki National Health Insurance Cohort Study in Japan to evaluate the association between green tea consumption and the risk of hematologic malignancies. Study participants were 41,761 Japanese adults aged 40-79 years without a history of cancer at baseline who answered a food frequency questionnaire survey in 1994. During 9 years of follow-up beginning in 1995, the authors documented 157 hematologic malignancies, including 119 cases of lymphoid neoplasms and 36 cases of myeloid neoplasms. Hazard ratios were calculated by using the Cox proportional hazards regression model. Risk of hematologic malignancies was inversely associated with green tea consumption. The multivariate-adjusted hazard ratio of hematologic malignancies for 5 cups/day or more compared with less than 1 cup/day of green tea was 0.58 (95% confidence interval: 0.37, 0.89). The corresponding risk estimate was 0.52 (95% confidence interval: 0.31, 0.87) for lymphoid neoplasms and 0.76 (95% confidence interval: 0.32, 1.78) for myeloid neoplasms. This inverse association was consistent across sex and body mass index strata. In conclusion, green tea consumption was associated with a lower risk of hematologic malignancies.