Self-administered questionnaire compared with a personal diary for assessment of current use of hormone therapy: an analysis of 16,060 women

Multilingual Framework for Risk Assessment and Symptom Tracking (MRAST)

The importance and value of real-world data in healthcare cannot be overstated because it offers a valuable source of insights into patient experiences. Traditional patient-reported experience and outcomes measures (PREMs/PROMs) often fall short in addressing the complexities of these experiences due to subjectivity and their inability to precisely target the questions asked. In contrast, diary recordings offer a promising solution. They can provide a comprehensive picture of psychological well-being, encompassing both psychological and physiological symptoms. This study explores how using advanced digital technologies, i.e., automatic speech recognition and natural language processing, can efficiently capture patient insights in oncology settings. We introduce the MRAST framework, a simplified way to collect, structure, and understand patient data using questionnaires and diary recordings. The framework was validated in a prospective study with 81 colorectal and 85 breast cancer survivors, of whom 37 were male and 129 were female. Overall, the patients evaluated the solution as well made; they found it easy to use and integrate into their daily routine. The majority (75.3%) of the cancer survivors participating in the study were willing to engage in health monitoring activities using digital wearable devices daily for an extended period. Throughout the study, there was a noticeable increase in the number of participants who perceived the system as having excellent usability. Despite some negative feedback, 44.44% of patients still rated the app's usability as above satisfactory (i.e., 7.9 on 1-10 scale) and the experience with diary recording as above satisfactory (i.e., 7.0 on 1-10 scale). Overall, these findings also underscore the significance of user testing and continuous improvement in enhancing the usability and user acceptance of solutions like the MRAST framework. Overall, the automated extraction of information from diaries represents a pivotal step toward a more patient-centered approach, where healthcare decisions are based on real-world experiences and tailored to individual needs. The potential usefulness of such data is enormous, as it enables better measurement of everyday experiences and opens new avenues for patient-centered care.

The tyranny of the averages and the indiscriminate use of risk factors in public health: The case of coronary heart disease

Modern medicine is overwhelmed by a plethora of both established risk factors and novel biomarkers for diseases. The majority of this information is expressed by probabilistic measures of association such as the odds ratio (OR) obtained by calculating differences in average “risk” between exposed and unexposed groups. However, recent research demonstrates that even ORs of considerable magnitude are insufficient for assessing the ability of risk factors or biomarkers to distinguish the individuals who will develop the disease from those who will not. In regards to coronary heart disease (CHD), we already know that novel biomarkers add very little to the discriminatory accuracy (DA) of traditional risk factors. However, the value added by traditional risk factors alongside simple demographic variables such as age and sex has been the subject of less discussion. Moreover, in public health, we use the OR to calculate the population attributable fraction (PAF), although this measure fails to consider the DA of the risk factor it represents. Therefore, focusing on CHD and applying measures of DA, we re-examine the role of individual demographic characteristics, risk factors, novel biomarkers and PAFs in public health and epidemiology. In so doing, we also raise a more general criticism of the traditional risk factors’ epidemiology. We investigated a cohort of 6103 men and women who participated in the baseline (1991–1996) of the Malmö Diet and Cancer study and were followed for 18 years. We found that neither traditional risk factors nor biomarkers substantially improved the DA obtained by models considering only age and sex. We concluded that the PAF measure provided insufficient information for the planning of preventive strategies in the population. We need a better understanding of the individual heterogeneity around the averages and, thereby, a fundamental change in the way we interpret risk factors in public health and epidemiology.

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There is a plethora of differences in “average” risk between exposed and unexposed groups of individuals.

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Individual heterogeneity around average values is seldom considered in Public Health.

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Measures of discriminatory accuracy (DA) informs on the underlying individual heterogeneity.

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Most know risk factors and other categorizations associated with diseases have low DA.

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We need a fundamental change in the way we investigate risk factors and other categorizations in Public Health.

Neighborhood social participation, use of anxiolytic-hypnotic drugs, and women's propensity for disability pension: a multilevel analysis

Aims: The increasing number of people on disability pension in Sweden is of concern for Swedish policy-makers, and there is a need for a better understanding of the mechanisms behind disability pension. We investigated (i) whether women living in the same neighborhood have a similar propensity for disability pension that relates to neighborhood social participation, and (ii) whether there is an association between anxiolytic-hypnotic drug (AHD) use and disability pension in women that is modified by the neighborhood context. Methods: We used multilevel logistic regression with 12,156 women aged 45 to 64 (first level) residing in 95 neighborhoods (second level) in the city of Malmö (250,000 inhabitants), Sweden, who participated in the Malmö Diet and Cancer Study (1991—96). Results: Both AHD use (OR=2.09, 95% CI 1.65, 2.65) and neighborhood rate of low social participation (OR=11.85, 95% CI 5.09, 27.58) were associated with higher propensity for disability pension. The interval odds ratio indicated that the influence of neighborhood social participation was large compared with the unexplained variance between the neighborhoods. The association between AHD use and disability pension was not modified by the neighborhood context. The median odds ratio was 1.44 after adjusting for individual characteristics and 1.27 after the additional adjusting for neighborhood social participation. Conclusions: Women living in the same neighborhood appear to have a similar propensity for disability pension, beyond individual characteristics, and this contextual effect seems largely explained by neighborhood social participation. In addition, AHD use might increase the propensity for disability pension in women.

Low-Grade Inflammation, Oxidative Stress and Risk of Invasive Post-Menopausal Breast Cancer - A Nested Case-Control Study from the Malmö Diet and Cancer Cohort

OBJECTIVE

Although cancer promotes inflammation, the role of inflammation in tumor-genesis is less well established. The aim was to examine if low-grade inflammation is related to post-menopausal breast cancer risk, and if obesity modifies this association.

METHODS

In the Malmö Diet and Cancer cohort, a nested case-control study was defined among 8,513 women free of cancer and aged 55-73 years at baseline (1991-96); 459 were diagnosed with invasive breast cancer during follow-up (until December 31st, 2010). In laboratory analyses of blood from 446 cases, and 885 controls (matched on age and date of blood sampling) we examined systemic inflammation markers: oxidized (ox)-LDL, interleukin (IL)-1β, IL-6, IL-8, tumor necrosis factor (TNF)-α, white blood cells, lymphocytes and neutrophils. Odds ratios (OR) and 95% confidence intervals (CI) for breast cancer risk was calculated using multivariable conditional logistic regression.

RESULTS

Inverse associations with breast cancer were seen in fully-adjusted models, for 2nd and 3rd tertiles of ox-LDL, OR (95% CI): 0.65 (0.47-0.90), 0.63 (0.45-0.89) respectively, p-trend = 0.01; and for the 3rd tertile of TNF-α, 0.65 (0.43-0.99), p-trend = 0.04. In contrast, those in the highest IL-1β category had higher risk, 1.71 (1.05-2.79), p-trend = 0.01. Obesity did not modify associations between inflammation biomarkers and breast cancer.

CONCLUSION

Our study does not suggest that low-grade inflammation increase the risk of post-menopausal breast cancer.

Efficient Research Design

In designing economic evaluations alongside clinical trials, analysts are frequently faced with alternative methods of collecting the same data, the extremes being top-down (“gross costing”) and bottom-up (“micro-costing”) approaches. A priori, bottom-up approaches may be considered superior to top-down approaches but are also more expensive to collect and analyze. In this article, we use value-of-information analysis to estimate the efficient mix of observations on each method in a proposed clinical trial. By assigning a prior bivariate distribution to the 2 data collection processes, the predicted posterior (i.e., preposterior) mean and variance of the superior process can be calculated from proposed samples using either process. This is then used to calculate the preposterior mean and variance of incremental net benefit and hence the expected net gain of sampling. We apply this method to a previously collected data set to estimate the value of conducting a further trial and identifying the optimal mix of observations on drug costs at 2 levels: by individual item (process A) and by drug class (process B). We find that substituting a number of observations on process A for process B leads to a modest £35,000 increase in expected net gain of sampling. Drivers of the results are the correlation between the 2 processes and their relative cost. This method has potential use following a pilot study to inform efficient data collection approaches for a subsequent full-scale trial. It provides a formal quantitative approach to inform trialists whether it is efficient to collect resource use data on all patients in a trial or on a subset of patients only or to collect limited data on most and detailed data on a subset.

Trends of postmenopausal estrogen plus progestin prevalence in the United States between 1970 and 2010

OBJECTIVE

To estimate long term trends in estrogen-progestin prevalence for the U.S. female population by year and age.

METHODS

We integrated data on oral estrogen-progestin use from the National Health and Nutrition Examination Survey 1999-2010 with data from the National Prescription Audit 1970-2003. Distributions of estrogen-progestin by age from the National Health and Nutrition Examination Survey were applied to the prescription data, and calibration and interpolation procedures were used to generate estrogen-progestin prevalence estimates by single year of age and single calendar year for 1970-2010.

RESULTS

Estimated prevalence of oral estrogen-progestin was below 0.5% in the 1970s, began to rise in the early 1980s, and almost tripled between 1990 and the late 1990s. The age-adjusted prevalence for women aged 45-64 years peaked at 13.5% in 1999 with highest use among 57-year-old women (23.2%). Prevalence of estrogen-progestin use declined dramatically in the early 2000s with only 2.7% of women aged 45-64 years using estrogen-progestin in 2010, which is comparable to prevalence levels in the mid-1980s.

CONCLUSION

The dramatic rise and fall of estrogen-progestin use over the past 40 years provides an illuminating case study of prescription practices before, during, and after the development of evidence regarding benefits and harms.

LEVEL OF EVIDENCE

: II.

Accuracy of Self-Reported Breast Cancer Information among Women from the Ontario Site of the Breast Cancer Family Registry

Obtaining complete medical record information can be challenging and expensive in breast cancer studies. The current literature is limited with respect to the accuracy of self-report and factors that may influence this. We assessed the agreement between self-reported and medical record breast cancer information among women from the Ontario site of the Breast Cancer Family Registry. Women aged 20–69 years diagnosed with incident breast cancer 1996–1998 were identified from the Ontario Cancer Registry, sampled on age and family history. We calculated kappa statistics, proportion correct, sensitivity, specificity, and positive and negative predictive values and conducted unconditional logistic regression to examine whether characteristics of the women influenced agreement. The proportions of women who correctly reported having received a broad category of therapy (hormone therapy, chemotherapy, radiation, or surgery) as well as sensitivity and specificity were above 90%, and the kappa statistics were above 0.80. The specific type of hormonal or chemotherapy was reported with low-to-moderate agreement. Aside from recurrence, no factors were consistently associated with agreement. Thus, most women were able to accurately report broad categories of treatment but not necessarily specific treatment types. The finding of this study can aid researchers in the use and design of self-administered treatment questionnaires.

A sustained decline in postmenopausal hormone use: results from the National Health and Nutrition Examination Survey, 1999-2010

OBJECTIVE

Short-term declines in postmenopausal hormone use were observed after the Women's Health Initiative trial results in 2002. Although concerns about the trial's generalizability have been expressed, long-term trends in hormone use in a nationally representative sample have not been reported. We sought to evaluate national trends in the prevalence of hormone use and to assess variation by type of formulation and patient characteristics.

METHODS

We examined postmenopausal hormone use during 1999-2010 using cross-sectional data from 10,107 women aged 40 years and older in the National Health and Nutrition Examination Survey.

RESULTS

In 1999-2000, the prevalence of oral postmenopausal hormone use was 22.4% (95% confidence interval [CI] 19.0-25.8) overall, 13.3% (95% CI 11.0-15.5) for estrogen only, and 8.3% (95% CI 6.2-10.4) for estrogen plus progestin. A sharp decline in use of all formulations occurred in 2003-2004, when the overall prevalence decreased to 11.9% (95% CI 9.6-14.2). This decline was initially limited to non-Hispanic whites; use among non-Hispanic blacks and Hispanics did not decline substantially until 2005-2006. Hormone use continued to decline through 2009-2010 across all patient demographic groups, with the current prevalence now at 4.7% (95% CI 3.3-6.1) overall, 2.7% (95% CI 1.9-3.4) for estrogen only, and 1.7% (95% CI 0.7-2.7) for estrogen plus progestin. Patient characteristics currently associated with hormone use include history of hysterectomy, non-Hispanic white race or ethnicity, and income.

CONCLUSION

Postmenopausal hormone use in the United States has declined in a sustained fashion to low levels across a wide variety of patient subgroups.

Plasma folate concentrations are positively associated with risk of estrogen receptor beta negative breast cancer in a Swedish nested case control study

Folate's role in breast cancer development is controversial. Not only estrogen receptor (ER) alpha status, but also ERbeta status of tumors may have confounded results from previous epidemiological studies. We aimed to examine associations between plasma folate concentration and postmenopausal breast cancer defined by ER status. This nested case-control study, within the Malmö diet and cancer cohort, included 204 incident breast cancer cases with information on ERalpha and ERbeta status determined by immunochemistry on tissue micro-array sections. Plasma folate concentration was analyzed for the cases and 408 controls (matched on age and blood sample date). Odds ratios (OR) for ER-defined breast cancers in tertiles of plasma folate concentration were calculated with unconditional logistic regression. All tests were 2-sided. Women in the third tertile of plasma folate concentration (> 12 nmol/L) had higher incidence of ERbeta- breast cancer than women in the first tertile (OR: 2.67; 95% CI: 1.44-4.92; P-trend = 0.001). We did not observe significant associations between plasma folate concentration and other breast cancer subgroups defined by ER status. We observed a difference between risks for ERbeta + and ERbeta- cancer (P-heterogeneity = 0.003). Our findings, which indicate a positive association between plasma folate and ERbeta- breast cancer, highlight the importance of taking ERbeta status into consideration in studies of folate and breast cancer. The study contributes knowledge concerning folate's multifaceted role in cancer development. If replicated in other populations, the observations may have implications for public health, particularly regarding folic acid fortification.

Increased breast cancer risk at high plasma folate concentrations among women with the MTHFR 677T allele

BACKGROUND

Folate is involved in DNA synthesis and methylation and may thereby influence carcinogenesis.

OBJECTIVES

We examined plasma folate (P-folate) concentration in relation to genotypes of the folate-metabolizing enzyme methylenetetrahydrofolate reductase [MTHFR 677C-->T (rs1801133) and 1298A-->C (rs1801131)]. We also explored whether P-folate was associated with risk of postmenopausal breast cancer overall and in subgroups with genetic variants of the MTHFR single nucleotide polymorphisms (SNPs).

DESIGN

This nested case-control study included 313 cases (age 55-73 y at baseline) with invasive breast cancer and 626 control subjects, matched on age and blood-sample date, from the population-based Malmö Diet and Cancer cohort. P-folate and MTHFR genotypes were determined for 310 cases and 611 controls. P-folate according to genotype was calculated by using analysis of variance. Odds ratios were obtained by using logistic regression. All tests were 2-sided.

RESULTS

The variant 677T allele was associated with lower P-folate. In women with the 677T allele, a high P-folate concentration was associated with increased breast cancer risk (P for trend across P-folate tertiles = 0.03). Interaction was seen between the 677C-->T SNP and P-folate (P = 0.002). A positive association, which was seen between P-folate and breast cancer risk in 1298AA women (P = 0.01), was probably due to linkage between the 2 SNPs. Overall, and in women with other genotypes, no significant associations were observed.

CONCLUSIONS

Our results suggest an association of high P-folate concentration with increased risk of postmenopausal breast cancer in carriers of the 677T allele. The findings underline the importance of genetic variation of MTHFR in the complex relation between folate and cancer.

The protective association of high plasma enterolactone with breast cancer is reasonably robust in women with polymorphisms in the estrogen receptor alpha and beta genes

It is plausible that polymorphisms in the estrogen receptor alpha and beta genes (ESR1 and ESR2) may modulate the association between enterolactone and breast cancer. Seven polymorphisms in ESR1 (rs827422, rs1709184, rs2347867, rs3020328, rs72207, rs2982896, and rs2234693) and 5 polymorphisms in ESR2 (rs915057, rs1269056, rs1256033, rs3020450, and rs3020443) were selected. The risk of breast cancer for these polymorphisms was estimated among 542 cases and 1076 matched controls from the population-based Malmö Diet and Cancer cohort. The joint effect of these polymorphisms and enterolactone was estimated among those individuals about whom we had information on enterolactone blood concentration (365 cases and 728 controls). Breast cancer risk was not significantly associated with any of the selected polymorphisms. We found a tendency for an interaction between a polymorphism in intron 3 of ESR1 (rs2347867) and enterolactone concentration (P = 0.07). Breast cancer and enterolactone concentration were not associated among those homozygous for the major allele (A) (P = 0.93), whereas we found an inverse association among carriers of the minor allele (G) (P = 0.007). None of the other polymorphisms seem to modify the association between enterolactone and breast cancer. This study suggests that the protective association of enterolactone is reasonably robust across the investigated genotypes. The suggested interaction between enterolactone concentration and rs2347867 needs to be confirmed in larger samples.

Folate intake, methylenetetrahydrofolate reductase polymorphisms, and breast cancer risk in women from the Malmö Diet and Cancer cohort

BACKGROUND

Single nucleotide polymorphisms (SNP) of the folate-metabolizing enzyme methylenetetrahydrofolate reductase (MTHFR) may modify associations between folate intake and breast cancer. We examined if the association between tertiles of dietary folate equivalents (DFE) and breast cancer was different in subgroups according to genotypes of the MTHFR 677 C>T (rs1801133) and 1298A>C (rs1801131) SNPs and if the polymorphisms per se were associated with breast cancer.

METHODS

This nested case-control study included 544 incident cases with invasive breast cancer and 1,088 controls matched on age and blood sampling date from the population-based Malmö Diet and Cancer cohort. Genotyping of the MTHFR SNPs was done with PCR-based matrix-assisted laser desorption/ionization time-of-flight mass spectrometry. Odds ratios (OR) were obtained by unconditional logistic regression.

RESULTS

DFE was positively associated with breast cancer in MTHFR 677CT/TT-1298AA women (P for trend = 0.01) but inversely associated in compound heterozygous women (P for trend = 0.01). Interaction was observed between DFE and the 1298C allele (P = 0.03). The 677T allele was associated with increased breast cancer risk in women above 55 years [multivariate adjusted OR, 1.34; 95% confidence interval (95% CI), 1.01-1.76] and an interaction was observed between the T allele and age (P = 0.03). Homozygosis for the 1298C allele was associated with increased risk in women between 45 and 55 years (multivariate adjusted OR, 1.89; 95% CI, 1.09-3.29).

CONCLUSION

In conclusion, a positive association between DFE and breast cancer was observed in MTHFR 677CT/TT-1298AA women but an inverse association was observed in 677CT-1298AC women. The 677T allele was associated with higher breast cancer risk in women above 55 years of age.

Use of prescription and nonprescription medications and supplements by cancer patients during chemotherapy: questionnaire validation

BACKGROUND

Cancer patients take medications for coexisting disease and self-medicate with over-the-counter drugs (OTCs). A complete analysis of the use of prescription drugs, OTCs, and supplements during cancer treatment has never been done.

METHODS

The study developed and validated a self-administered questionnaire on the use of concomitant medications by patients undergoing treatment with chemotherapy. The questionnaire listed 510 prescription medications, OTCs, and supplements (including vitamins, minerals, and herbs). Fifty-two subjects completed the questionnaire while visiting the infusion clinic to receive chemotherapy. On a subsequent visit the subjects brought their medications to the clinic and a pharmacist reviewed their completed questionnaire.

RESULTS

Ninety-six percent of the subjects reported taking prescription medications within 3 days prior to chemotherapy, 71% reported taking OTCs and 69% reported use of supplements. The subjects took an average of 5.5 (range 0-13) prescription drugs, 2.2 (0-20) OTCs, and 1.9 (0-11) supplements. Twenty-one drugs were each taken by at least 10% of the subjects. Acetaminophen was taken by 59.6% of the subjects. One subject reported taking five acetaminophen-containing drugs. The questionnaire's sensitivity was 92.0%, specificity 99.9%.

CONCLUSION

Within 3 days prior to chemotherapy, subjects took an average of 9.6 concomitant medications, many of which alter drug metabolism and or disposition. In clinical trials, multivariate analysis of all concomitant medications could add to clinically relevant data to identify drug interactions that negate or potentiate the efficacy of cancer treatment regimens. In some instances, apparent resistance of tumors to chemotherapy may be the result of drug interactions.

Sensitivity and specificity of recalled vasomotor symptoms in a multiethnic cohort

Many epidemiologic studies include symptom checklists assessing recall of symptoms over a specified time period. Little research exists regarding the congruence of short-term symptom recall with daily self-reporting. The authors assessed the sensitivity and specificity of retrospective reporting of vasomotor symptoms using data from 567 participants in the Study of Women's Health Across the Nation (1997-2002). Daily assessments were considered the "gold standard" for comparison with retrospective vasomotor symptom reporting. Logistic regression was used to identify predictors of sensitivity and specificity for retrospective reporting of any vasomotor symptoms versus none in the past 2 weeks. Sensitivity and specificity were relatively constant over a 3-year period. Sensitivity ranged from 78% to 84% and specificity from 85% to 89%. Sensitivity was lower among women with fewer symptomatic days in the daily assessments and higher among women reporting vasomotor symptoms in the daily assessment on the day of retrospective reporting. Specificity was negatively associated with general symptom awareness and past smoking and was positively associated with routine physical activity and Japanese ethnicity. Because many investigators rely on symptom recall, it is important to evaluate reporting accuracy, which was relatively high for vasomotor symptoms in this study. The approach presented here would be useful for examining other symptoms or behaviors.

Agreement of self-reported estrogen use with prescription data: an analysis of women from the Kuopio Osteoporosis Risk Factor and Prevention Study

OBJECTIVE

Self-reported data are usually used for the evaluation of the effects of hormone therapy in population studies. We examined the agreement between self-reported hormone therapy use and nationwide prescription data from the Social Insurance Institution of Finland to evaluate the accuracy of self-reports.

DESIGN

The 10-year questionnaire of the population-based Kuopio Osteoporosis Study was sent in 1999 to 12,562 women aged 57 to 67 years; 11,377 women who completed questionnaires were eligible for analysis. We asked women whether they had been taking estrogen hormone therapy as a gel, plaster, or tablet for the treatment of climacteric symptoms or osteoporosis and if the answer was yes, to specify the brand and duration of treatment for each year from 1994 to 1999.

RESULTS

Among the 11,377 women, 3,105 (27.3%) reported the use of an estrogen-based preparation in 1996 to 1999, and 97.6% were confirmed by Social Insurance Institution of Finland to have been prescribed hormone therapy during that time. In these women the median duration of use was 32 months (range, 1-41), according to Social Insurance Institution of Finland data. An additional 1,738 women had been prescribed hormone therapy for short periods, but those women did not report it. The duration of self-reported hormone therapy use was compared to the duration of prescriptions. A difference of 3 months or less per year was observed in 63.4% to 77.0% of women during the years 1996-1998.

CONCLUSIONS

A postal inquiry is a reliable method of recording long-term hormone therapy use.

Equity in the use of antithrombotic drugs, beta-blockers and statins among Finnish coronary patients

Background

Earlier studies have mainly reported the use of antithrombotic drugs, beta-blockers and statins among hospital patient populations or MI patients. This study aimed to describe the use of these drugs among middle-aged Finnish coronary patients and to identify patient groups in risk of being prescribed inadequate medication for secondary prevention of coronary heart disease.

Methods

One-year follow-up survey data from a random sample of a cohort of coronary patients were used along with register data linked to the survey. The response rate was 54% (n = 2650). The main outcome measures were use of antithrombotic drugs, beta-blockers and statins and the data were analysed using logistic regression analysis.

Results

Among men and women, respectively, 82% and 81% used beta-blockers, 95% and 89% used antithrombotic drugs, and 62% and 59% used statins. Younger men and men from higher socioeconomic groups were more likely to use statins, even after controlling for disease severity and comorbidity. In women, the age trend was reversed and no socioeconomic differences were found. Drug use increased with increased disease severity, but diabetes had only a slight effect.

Conclusion

The use of antithrombotic drugs and beta-blockers among Finnish coronary patients seemed to be rather appropriate and, to some extent, prescription practices of preventive medication varied according to patients' risk of coronary events. However, statin use was remarkably low among men with low socio-economic status, and there is need to improve preventive drug treatment among diabetic coronary patients.

Test-retest reliability of self-reported reproductive and lifestyle data in the context of a German case-control study on breast cancer and postmenopausal hormone therapy

PURPOSE

Studies using survey questionnaires to collect epidemiologic data rely on the accuracy of participants' self-reporting. As part of the quality control protocol for a large population-based case-control study of the association between postmenopausal hormone therapy (HT) and breast cancer in German women (the Mammakarzinom-Risikofaktoren-Erhebung [MARIE] study), the authors used test-retest to evaluate the reliability of women's self-reporting of a number of putative breast cancer risk factors, including HT, reproductive history, family history, and lifestyle.

METHODS

Of those women interviewed between November 2002 and July 2003, 62 cases and 61 controls were re-interviewed an average of 10 months later, using a shortened version of the original study questionnaire.

RESULTS

Agreement between the first and second interviews was assessed using Cohen's kappa and proportion of agreement. There was very good overall agreement between the two questionnaires for HT ever/never use (kappa = 0.90), type of therapy (kappa = 0.83), and form of application (kappa = 0.73) and good agreement for duration of use (kappa = 0.60). Agreement for other factors ranged from kappa = 1.00 for age at first birth to kappa = 0.43 for weekend bicycle riding. Agreement was nondifferential by disease status.

CONCLUSIONS

These findings indicate that the MARIE survey instrument was of good quality and had a low likelihood of misclassification.

High folate intake is associated with lower breast cancer incidence in postmenopausal women in the Malmö Diet and Cancer cohort

BACKGROUND

Epidemiologic studies of associations between folate intake and breast cancer are inconclusive, but folate and other plant food nutrients appear protective in women at elevated risk.

OBJECTIVE

The objective was to examine the association between folate intake and the incidence of postmenopausal breast cancer.

DESIGN

This prospective study included all women aged >or=50 y (n = 11699) from the Malmö Diet and Cancer cohort. The mean follow-up time was 9.5 y. We used a modified diet-history method to collect nutrient intake data. At the end of follow-up, 392 incident invasive breast cancer cases were verified. We used proportional hazard regression to calculate hazard ratios (HRs).

RESULTS

Compared with the lowest quintile, the incidence of invasive breast cancer was reduced in the highest quintile of dietary folate intake (HR: 0.56; 95% CI: 0.35, 0.90; P for trend = 0.02); total folate intake, including supplements (HR: 0.56; 95% CI: 0.34, 0.91; P for trend = 0.006); and dietary folate equivalents (HR: 0.59; 95% CI: 0.36, 0.97; P for trend = 0.01).

CONCLUSION

A high folate intake was associated with a lower incidence of postmenopausal breast cancer in this cohort.

The association between breastfeeding and breast cancer occurrence among Israeli Jewish women: a case control study

PURPOSE

Breast cancer remains the major malignant disease among Israeli women, with about 4,000 new cases diagnosed annually, and a steadily increasing incidence rates. Early in this century investigators noted that nulliparity and a history of never having breastfed were more common in women with breast cancer than without the disease. Epidemiological evidence on those issues remains controversial. The purpose of this study was to clarify those controversial.

METHODS

A hospital-based case control study was carried out at Nahariya hospital (North of Israel) to assess the risk of breast cancer in relation to breastfeeding history. A total of 256 recent cases of breast cancer (diagnosed between January 1999 and February 2005) and 536 controls were included. Detailed information regarding breastfeeding, menstruation, reproductive factors and confounders was collected. Adjusted odds ratios and 95% confidence intervals were calculated.

RESULTS

Short duration of lifetime breastfeeding, late age at first breastfeeding and experience of insufficient milk were found to increase breast cancer risk. When women who had ever breastfed their infants were compared with females who had not, breastfeeding was found to be protective (OR of 0.39; 95% CI 0.26-0.59).

CONCLUSIONS

These findings may have significant impact on intervention planning aimed towards breast cancer reduction among Israeli Jewish women.

Identification of autoantibodies in human plasma recognizing an apoB-100 LDL receptor binding site peptide

The aim of this study was to test the hypothesis that autoantibodies recognize amino acid sequences in the LDL receptor binding region of apolipoprotein B-100 (apoB-100). Autoantibodies against an unmodified or malondialdehyde (MDA)-modified LDL receptor binding site peptide were determined by ELISA in baseline plasma samples of 78 cases with coronary events and 149 matched controls recruited from the prospective Malmö Diet Cancer Study. IgG and IgM recognizing this peptide were detected in all subjects but did not differ between cases and controls. Inverse associations were observed between IgG against the native binding site and plasma oxidized LDL (r = -0.21, P < 0.005), but there were no significant associations with total or LDL cholesterol levels. In univariate analyses, inverse associations were found between baseline carotid intima-media thickness and IgG against the MDA-modified binding site (r = -0.14, P < 0.05), but this association was lost when controlling for other major cardiovascular risk factors. Specificity studies demonstrated that the binding of autoantibodies to these sequences could be inhibited by oxidized but not by native LDL. Autoantibodies recognizing the LDL receptor binding site in apoB-100 are frequently expressed. Their association with plasma oxidized LDL suggests that they have been generated in response to breakdown products of LDL oxidation, but their influence on cholesterol metabolism and the development of atherosclerosis appears limited.

Anxiolytic–hypnotic drug use associated with trust, social participation, and the miniaturization of community: A multilevel analysis

The concept of social capital has gained wide interest in public health research in recent years. However, we suggest a concept that was introduced and developed by Fukuyama, named "miniaturization of community", as an alternative to that of social capital. The concept of miniaturization of community emphasizes that a high level of social participation can be accompanied by a low level of trust, both at the individual and at the community level, which may in turn result in social disorder and lack of social cohesion. When society becomes more disordered, people may tend to feel more insecure and anxious. Use of anxiolytic-hypnotic drugs (AHDs) could under such circumstances be a coping strategy. In this study, we first wanted to investigate whether the contextual component of the miniaturization of community concept (i.e. area high social participation and low trust) is associated with individual AHD use, over and above individual characteristics. Secondly, we aimed to study whether people living in the same municipality share a similar probability of AHD use, after adjusting for individual characteristics, and if so, how large this contextual phenomenon is. We used data on 20,319 women and 17,850 men aged 18-79 years from 58 municipalities in six regions in central Sweden, who participated in the Life & Health year 2000 postal survey. We applied multilevel logistic regression analysis with individuals at the first level and areas at the second level. Our results suggest that living in an area with a high level of miniaturization of community seems to be associated with individual AHD use, beyond people's individual characteristics including their own level of social participation and trust. The concept of miniaturization of community may be an extension of the classic concept of social capital and may increase our understanding of contextual effects on health.

Fat From Different Foods Show Diverging Relations With Breast Cancer Risk in Postmenopausal Women

The aim was to explore previous findings within the Malmö Diet and Cancer cohort (Sweden) that omega6-fatty acid intakes are positively associated with breast cancer risk among women 50 yr of age and older and specifically examine relations between breast cancer risk and fat from different food groups. Incident breast cancer cases (n = 237) were matched to controls (n = 673) on age and screening date. A modified diet history method, a structured questionnaire, and anthropometric measurements provided data. Fat-food variables from 24 food groups were computed. Conditional logistic regression examined breast cancer risk associated with energy-adjusted exposure categories of fat-food variables. Fat from fermented milk products was negatively associated with breast cancer risk (trend, P = 0.003). The highest quartiles of vegetable oil-based dietary fats (odds ratio, OR = 1.74; confidence interval, CI = 1.12-2.72) and dried soup powders (OR = 1.59; CI = 1.04-2.43) showed positive associations. Dietary fiber did not influence associations.

Agreement between self-reported breast cancer treatment and medical records in a population-based Breast Cancer Family Registry

PURPOSE

Although self-report data on treatment for breast cancer are collected in some large epidemiologic studies, their accuracy is unknown.

METHODS

As part of a population-based Breast Cancer Family Registry, questionnaires on initial breast cancer treatment and subsequent recurrence were mailed to Australian women diagnosed between 1991 and 1998. These self-report data were validated against medical records for 895 women.

RESULTS

The median recall period was 3.2 years, mean age at diagnosis was 44 years, and 81% of women had early-stage breast cancer. Agreement between the two data sources was very high for general questions about type of treatment (100%, 99%, 99%, and 94% for surgery, radiotherapy, chemotherapy, hormonal therapy, respectively). For more specific questions about details of each treatment received, agreement was: for radiation therapy, 96% and 99% for radiation to the breast and chest wall, respectively; for surgery, 83%, 97%, and 88% for lumpectomy, mastectomy, and lymph node dissection, respectively; for hormonal therapy, 94% for tamoxifen; and for chemotherapy, range between 76% and 93%. There was 97% agreement about whether there had been a recurrence, and agreement about the location of recurrence was at least 90% for all sites. Agreement regarding stage at diagnosis was 62%, with discrepancies mostly due to women with locoregional disease incorrectly reporting distant spread.

CONCLUSION

This self-report questionnaire can be used to collect accurate data on broad categories of initial breast cancer treatment and recurrence, and even for more detailed information on specifics of treatment and site of recurrence.

Invoices and farmer interviews for vaccine-exposure measurement in turkey-broiler production

Exposure measurement in pharmaco-epidemiological studies can be based on various sources that do not always concur. However, reliability is an important criterion when selecting the method used to assess exposure and interpreting the results obtained. An analysis based on invoices might be more informative and more accurate to assess vaccines exposure (yes/no) in turkey broiler production than a questionnaire administered to farmers, which is nevertheless more feasible and less time-consuming. We compared the two methods to assess vaccination exposure in 239 turkey broiler flocks reared in 129 farms in 2000-2001. The agreement (crude agreement and kappa) was calculated, and association between discrepancy and farm and flock characteristics was investigated. Marek's-disease vaccine, Newcastle-disease vaccine, turkey haemorrhagic-enteritis vaccine and turkey-rhinotracheitis vaccine exposures were reported on the questionnaire for 2.1, 27.6, 93.0, and 98.3% of flocks, respectively, and for 2.1, 29.3, 89.4, and 86.6%, of invoices for the flocks studied, respectively. A discrepancy was observed in 24.9% of flocks. A discrepancy was observed more frequently in specialised farms without any other animal production (OR = 3.6; CI = 1.5, 8.9) and when the farmer did not know whether vaccination had been performed in the hatchery (OR = 7.1; CI = 2.6, 19.7).

No relations between breast cancer risk and fatty acids of erythrocyte membranes in postmenopausal women of the Malmö Diet Cancer cohort (Sweden)

OBJECTIVE

To examine the fatty acid composition of erythrocyte membranes, in relation to obesity indexes and breast cancer risk.

DESIGN

A nested case-control study.

SETTING

The Malmö Diet Cancer cohort, Sweden.

SUBJECTS

Among women 50 y or older at baseline (n=12 803), incident breast cancer cases (n=237) were matched to controls (n=673) on age and screening date.

METHODS

A diet history method, a structured questionnaire, anthropometrics and blood samples provided data. Analysis included partial correlation coefficients between dietary fatty acids (DFA) and fatty acids of erythrocyte membranes (EFA), and Spearman's rank order correlations between EFA and four obesity indexes. Conditional logistic regression examined breast cancer risks related to EFA.

RESULTS

DFA and EFA from fish and milk, and DFA and EFA linoleic acid, show significant positive associations. Relations are negative between indexes of obesity and "milk" EFA, but positive between indexes of obesity and indexes of delta9- and delta6-desaturase enzyme activity. No significant relations were observed between EFA and breast cancer risk.

CONCLUSIONS

Similar to other studies, dietary fish and milk fatty acids, and linoleic acid, are related to the corresponding EFA. Breast cancer risk was not significantly related to EFA in this study. However, the findings suggest positive relations between body mass index, body fat per cent and indexes of desaturase activity, and negative relations between central obesity and milk EFA.

SPONSORSHIP

The Swedish Cancer Society, the Swedish Medical Research Council, the European Commission, the Swedish Dairy Association and the City of Malmö.

The validity of self-reported use of hormone replacement therapy among Danish nurses

BACKGROUND

Recent findings from randomized clinical trials on the effects of hormone replacement therapy (HRT) among postmenopausal women contradict findings from observational studies indicating a protective effect on the development of cardiovascular disease. Most observational studies on HRT are based on self-reported data, although data on the validity of HRT in postmenopausal women are sparse.

METHODS

We examined self-reported HRT use from questionnaires administered in 1993 (n = 2694) and again in 1999 (n = 2666) to a cohort of Danish nurses living in two Danish counties compared with prescription-reimbursement data from two administrative databases through the Danish National Health Service.

RESULTS

The sensitivity and specificity of the self-reported, current HRT use in 1993 were 78.4%[95% confidence interval (95% CI) 75.4-81.4] and 98.4% (95% CI 97.8-98.9), respectively. In 1999, the estimates were 74.8% (95% CI 72.0-77.7) and 98.0% (95% CI 97.3-98.8), respectively. None of the factors examined--including age, alcohol intake, physical activity, smoking, presence of hypertension, and body mass index--was strongly associated with validity. We found a relatively high validity of self-reported data on HRT use. Furthermore, agreement between self-reported and registry-based data was not strongly associated with a range of demographic and lifestyle factors.

CONCLUSION

These findings suggest that use of self-reported data is not an important contributor to the apparent discrepancy between observational studies and randomized trials on the cardiovascular effects of HRT use.

Intakes of plant foods, fibre and fat and risk of breast cancer--a prospective study in the Malmö Diet and Cancer cohort

The objective of this study was to investigate prospectively the associations between intakes of plant foods, fibre and relative fat and risk of breast cancer in a subsample of 11 726 postmenopausal women in the Malmö Diet and Cancer cohort. Data were obtained by an interview-based diet history method, a structured questionnaire, anthropometrical measurements and national and regional cancer registries. During 89 602 person-years of follow-up, 342 incident cases were documented. Cox regression analysis examined breast cancer risks adjusted for potential confounders. High fibre intakes were associated with a lower risk of postmenopausal breast cancer, incidence rate ratio=0.58, 95% CI: 0.40, 0.84, for the highest quintile of fibre intake compared to the lowest quintile. The combination high fibre–low fat had the lowest risk when examining the effect in each cell of cross-classified tertiles of fibre and fat intakes. An interaction (P=0.049) was found between fibre- and fat-tertiles. There was no significant association between breast cancer risk and intakes of any of the plant food subgroups. These findings support the hypothesis that a dietary pattern characterised by high fibre and low fat intakes is associated with a lower risk of postmenopausal breast cancer.

Signaling does not adequately improve diary compliance

HYPOTHESIS

Compliance with a paper diary protocol would be improved by using auditory signaling.

BACKGROUND

Prior research has demonstrated that compliance with the reporting schedule in paper diary protocols is poor.

METHODS

Adults with chronic pain (N = 27) were recruited from the community to participate in a 24-day experience sampling protocol of 3 pain assessments per day (10:00 a.m., 4:00 p.m., 8:00 p.m.). Diaries were instrumented to record openings and closings, thereby permitting determination of date and time when the participant could have made diary entries. Participants were signaled with a programmed wristwatch at the onset of each 30-min assessment window. Two compliance windows were defined: -/+ 15 min and -/+ 45 min of the targeted assessment time.

RESULTS

Self-reported compliance based on participants' paper diaries was 85% and 91% for the 30- and 90-min windows. Verified compliance was 29% and 39% for the two windows. Signaling produced a significant increment in verified compliance when compared with an identical trial without signaling. A significant eroding of verified compliance was observed across the 3 weeks of the study.

CONCLUSIONS

Self-report dating of diary entries may be misleading investigators about compliance with diary protocols. Although auditory signaling enhances compliance, the result is still unsatisfactory.

Neighbourhood social participation and women's use of anxiolytic-hypnotic drugs: a multilevel analysis

STUDY OBJECTIVES

To identify and quantify a hypothesised collective effect of the neighbourhood on individual use of anxiolytic-hypnotic drugs (AHD). To analyse the general impact of neighbourhood social participation on use of AHD, adjusting for individual characteristics.

DESIGN

Cross sectional analysis performed by multilevel logistic regression with women at the first level and neighbourhoods at the second level.

SETTING

Malmö (250 000 inhabitants), Sweden.

PARTICIPANTS

15 456 women aged 45 to 73, residing in 95 neighbourhoods in Malmö, who took part in the Malmö diet and cancer study (1991-1996).

MAIN RESULTS

The prevalence of AHD use was 5.5% in the study sample. Overall, 1.7% of the total individual differences in the propensity for using AHD were explained by the neighbourhood level. This percentage, however, differed between different individuals. Low level of social participation in the neighbourhood was associated with higher probability of AHD use (OR = 3.10 (95% CI 1.51 to 6.41)), independently of individual age, low social participation, low educational level, and living alone. This association was reduced (OR = 2.01 (95% CI 0.97 to 4.14)) after the additional accounting for individual disability pension, low self rated health, stress, and medication for somatic disorders.

CONCLUSIONS

The neighbourhood level of social participation seems to affect individual use of AHD, possibly through individual characteristics. However, neighbourhood boundaries play a minor part in understanding individual AHD use in the city of Malmö.

Is there an interaction between self-rated health and medication with analgesics and hypnotics in the prediction of disability pension?

AIMS

Several studies have shown that self-rated health (SRH) is associated with drug use. The aim of this study was to investigate the possible interaction between SRH and use of analgesics and hypnotics and its ability to predict disability pension.

METHODS

In 1974-78. complete birth-year cohorts of middle-aged male residents in Malmö, Sweden, were invited to a health screening, and the cohort in this study comprised 5,798 men with complete data followed up for 11 years.

RESULTS

At inclusion, 27% rated their health as less than perfect, 11% used analgesics, 3% used hypnotics and, during follow-up. 12% received a disability pension. The adjusted hazard ratios of disability pension were 3.1 (CI: 2.6, 3.6) for those who had rated their health as less than perfect and 2.7 (2.3, 3.2) for subjects who used analgesics and/or hypnotics. For subjects with the combined risk of poor SRH and medication, the hazard ratio was 5.5 (4.6, 6.5). The granting of disability pension attributable to the interaction between poor SRH and medication was estimated at 47%, which was statistically significant.

CONCLUSIONS

Disability pension among middle-aged men was associated with self-rated health as well as medication and clear evidence of synergism between the two factors was found, while there were no indications of medication acting as a causal link between poor SRH and disability pension. Several mechanisms may contribute to the findings, but the information gained may be used as means to identify those at risk for disability pension.

A prospective study of adiposity and postmenopausal breast cancer risk: the Malmö Diet and Cancer Study

High BMI is a well-known risk factor for postmenopausal breast cancer. There have been some reports of excess risk in association with weight gain and WHR, but little is known about the influence of body fatness per se. Using data from the Malmö Diet and Cancer Study, a prospective cohort study, 12,159 postmenopausal women (59.9 +/- 7.7 years) were categorized by quintiles of baseline anthropometric and impedance measures and reported weight change since age 20. RRs from multivariate Cox regression models were calculated. All analyses were adjusted for age, height, smoking, alcohol consumption, occupation, marital status, parity, age at first pregnancy, age at menarche and current hormone use. During the 5.7 years of follow-up, there were 246 incident breast cancer cases. Weight, height, BMI and %BF were positively associated with risk of breast cancer (p(trend) <or= 0.02). %BF showed the strongest association, with an RR of 2.01 (95% CI 1.26-3.21) in the highest vs. lowest quintile. There was significant modification of this association by hormone use, suggesting a greater impact of body fatness among nonusers. Fat distribution was not independently associated with breast cancer risk. Women with weight gain >21 kg (top quintile) had an RR of 1.75 (95% CI 1.11-2.77) compared to women with low weight gain. Breast cancer risk in postmenopausal women is predicted by increased body fat and weight gain. %BF is a more discriminating risk factor for breast cancer incidence than the commonly used BMI.

Increased incidence of small and well-differentiated breast tumours in post-menopausal women following hormone-replacement therapy

Exposure to hormone-replacement therapy (HRT) has consistently been associated with an increased incidence of breast cancer, particularly of small tumours. Other tumour characteristics in relation to HRT have received less scientific attention. Our aim in this population-based prospective cohort study was to assess whether HRT is associated with an increased incidence of breast-cancer subgroups defined in terms of stage, type (according to the WHO system), Nottingham grade and the Nottingham Prognostic Index (NPI). Evaluation was based on a cohort of 5,865 post-menopausal women followed for an average of 9.8 years. Twenty percent of women reported current use of HRT at the time of the baseline interview. Record linkage with the Swedish Cancer Registry and local clinical registries identified 141 incident invasive breast-cancer cases. All tumours were reclassified by 1 pathologist. The incidence of breast cancer in HRT users was 377/10(5) and in non-users 221/10(5) person-years [relative risk (RR) = 1.72, 95% confidence interval (CI) 1.17-2.52]. This risk remained statistically significant after adjustment for established risk factors in a Cox proportional hazards analysis (RR = 1.66, 95% CI 1.12-2.45). Among HRT users, there was over-representation of cases with stage I tumours (adjusted RR = 2.33, 95% CI 1.44-3.76), of lobular carcinomas (RR = 4.38, 95% CI 1.60-12.0) and of tubular tumours (RR = 4.81, 95% CI 1.37-16.8). Nottingham grade I/II carcinomas (RR = 2.02, 95% CI 1.29-3.16) and cases with NPI < or = 3.4 (RR = 2.29, 95% CI 1.41-3.72) were similarly over-represented among HRT users. Incidence of breast cancer was increased in post-menopausal women who used HRT at baseline. Among HRT users, there was over-representation of tumours that, with regard to stage, type and grade, are associated with a favourable prognosis.