Plasma carotenoids as biomarkers of intake of fruits and vegetables: ecological-level correlations in the European Prospective Investigation into Cancer and Nutrition (EPIC)

OBJECTIVE

The aim of this study was to assess the ability of a single 24-h dietary recall (24HDR) and food questionnaires (FQ) to predict plasma carotenoid levels at the ecological level by assessing the relationship between mean plasma carotenoid levels and mean intake of fruit and vegetables measured by 24HDR and FQ across 16 European regions.

DESIGN

A random subsample of 3089 subjects was included, stratified by age and gender. They provided blood samples and dietary information between 1992 and 2000 as part of the European Prospective Investigation into Cancer and Nutrition.

RESULTS

Using Spearman's correlation coefficients, the correlations between mean regional 24HDR fruit and vegetable variables and corresponding mean plasma carotenoid levels were generally higher than the correlations using FQ means. The highest correlation was between the 24HDR citrus fruit variable and beta-cryptoxanthin (r = 0.90). For 24HDR, total fruits and vegetables were highly correlated with lutein, zeaxanthin, and beta-cryptoxanthin (r = 0.83-0.87), while vegetables were more closely related with lutein (r = 0.69) and zeaxanthin (r = 0.68), and fruits correlated with zeaxanthin (r = 0.87) and beta-cryptoxanthin (r = 0.84). Root vegetables (r = 0.81) and total carrots (r = 0.71) were well correlated with alpha-carotene. In the multivariate models adjusting for age, body mass index, and season, and using observations of means stratified by sex and region, the association was generally higher for 24HDR compared to FQ.

CONCLUSION

Mean regional intakes of fruits and vegetables in several European countries were closely correlated with corresponding mean plasma levels of individual carotenoids. Fruits and vegetables measured by 24HDR were generally better able to predict plasma carotenoids at the ecological level.

Survival differences between European and US patients with colorectal cancer: role of stage at diagnosis and surgery

BACKGROUND

Population based colorectal cancer survival among patients diagnosed in 1985-89 was lower in Europe than in the USA (45% v 59% five year relative survival).

AIMS

To explain this difference in survival using a new analytic approach for patients diagnosed between 1990 and 1991.

SUBJECTS

A total of 2492 European and 11 191 US colorectal adenocarcinoma patients registered by 10 European and nine US cancer registries.

METHODS

We obtained clinical information on disease stage, number of lymph nodes examined, and surgical treatment. We analysed three year relative survival, calculating relative excess risks of death (RERs, referent category US patients) adjusted for age, sex, site, surgery, stage, and number of nodes examined, using a new multivariable approach.

RESULTS

We found that 85% of European patients and 92% of US patients underwent surgical resection. Three year relative survival was 69% for US patients and 57% for European patients. After adjustment for age, sex, and site, the RER was significantly high in all 10 European populations, ranging from 1.07 (95% confidence interval 0.86-1.32) (Modena, Italy) to 2.22 (1.79-2.76) (Thames, UK). After further adjustment for stage, surgical resection, and number of nodes examined (a determinant of stage), RERs ranged from 0.77 (0.62-0.96) to 1.59 (1.28-1.97). For some European registries the excess risk was small and not statistically significant.

CONCLUSIONS

US-Europe survival differences in colorectal cancer are large but seem to be mostly attributable to differences in stage at diagnosis. There are wide variations in diagnostic and surgical practice between Europe and the USA.

European health systems and cancer care

INTRODUCTION

Data on the survival of all incident cases collected by population-based cancer registries make it possible to evaluate the overall performance of diagnostic and therapeutic actions on cancer in those populations. EUROCARE-3 is the third round of the EUROCARE project, the largest cancer registry population based collaborative study on survival in European cancer patients. The EUROCARE-3 study analysed the survival of cancer patients diagnosed from 1990 to 1994 and followed-up to 1999. Sixty-seven cancer registries of 22 European countries characterised by differing health systems participated in the study. This paper includes essays providing brief overviews of the state and evolution of the health systems of the considered countries and comments on the relation between cancer survival in Europe and some European macro-economic and health system indicators, in the 1990s.

OVERVIEW OF THE EUROPEAN HEALTH SYSTEMS

The European health systems underwent a great deal of reorganisation in the last decade; a general tendency being to facilitate expanding involvement of the private sector in health care, a process which occurred mainly in the eastern countries (i.e. the Czech Republic, Estonia, Poland, Slovakia and Slovenia). In contrast, organisational changes in the northern European countries (i.e. Denmark, Iceland, Finland and Sweden) tended to confirm the established public sector systems. Other countries, including the UK and some southern European countries (i.e. England, Scotland, Wales, Malta and Italy) have reduced the public role while the systems remain basically public, at least at present. Our findings clearly suggest that cancer survival (all cancer combined) is related to macro-economic variables such as the gross domestic product (GDP), the total national (public and private) expenditure on health (TNEH) and the total public expenditure on health (TPEH). We found, however, that survival is related to wealth (GDP), but only up to a certain level, after which survival continues to be related to the level of health investment (both TNEH and TPEH). According to the Organisation for Economic Co-operation and Development (OECD), the TNEH increased during the 1990s in all EUROCARE-3 countries, while the ratio of TPEH to TNEH reduced in all countries except Portugal.

CONCLUSIONS

Cancer survival depends on the widespread application of effective diagnosis and treatment modalities, but our enquiry suggests that the availability of these depends on macro-economic determinants, including health and public health investment. Analysis of the relationship between health system organisation and cancer outcome is complicated and requires more information than is at present available. To describe cancer and cancer management in Europe, the European Cancer Health Indicator Project (EUROCHIP) has proposed a list of indicators that have to be adopted to evaluate the effects on outcome of proposed health system modifications.

Cancer mortality trends in the EU and acceding countries up to 2015

BACKGROUND

Examination of trends in cancer mortality in Europe over the past 30 years has shown that, after long-term rises, age-standardised mortality from most common cancer sites has fallen in the EU since the late 1980s. This study aimed to examine trends in the age-specific and age-standardised cancer mortality rates and numbers of cancer deaths up to 2020 for all cancers and various specific sites for all 15 EU countries, the 10 acceding countries, Bulgaria and Romania (currently applicant countries, along with Turkey), and Iceland, Norway and Switzerland of the four EEA countries.

PATIENTS AND METHODS

Mortality rates were modelled as a function of age, calendar period and birth cohort. Birth cohort was calculated as age subtracted from calendar period.

RESULTS

As a consequence of the generally decreasing trends in the age-standardised rates, the best estimate is that there will be approximately 1.25 million cancer deaths in 2015, which is almost 130,000 (11%) more deaths than in 2000, but 155,000 (11%) fewer deaths than the 1.4 million projected in 2015 on the basis of demographic changes alone. The increases in the forecast numbers of cancer deaths in 2015 are proportionally larger in males than in females (13% and 10%, respectively) and proportionally larger in the acceding countries than in the current EU member countries (14% and 11%, respectively).

CONCLUSIONS

Our forecasts are conservative best estimates of future cancer mortality. There is clearly scope for large improvements in survival, and hence reductions in cancer mortality, in some countries, through eliminating these differences using existing knowledge and treatment regimes.

Differences in the epidemic rise and decrease of prostate cancer among geographical areas in Southern Europe. an analysis of differential trends in incidence and mortality in France, Italy and Spain

This is a population-based study aimed at evaluating incidence and mortality trends for prostate cancer in France, Italy and Spain, during the prostate-specific antigen (PSA) era, considering elderly people aged 70 years and over and younger adults aged between 40 and 69 years. Trends were estimated by a log-linear Poisson regression model and expressed as an Estimated Annual Percent Change (EAPC). Incidence increased sharply in almost all areas. Spain showed the lowest increases. Incidence started to rise around 1985 in France and after 1990 in Italy and Spain. Mortality increased until the late 1980s in all countries, then declined in France and Italy (-2.5% in 40-69 year age group), but not in Spain. Younger people showed a much higher rise in incidence than the elderly, while mortality decreased mainly in the younger adults. The decrease in mortality was more marked in those areas and the younger age group where the rise in incidence was higher and started earlier, i.e. in France and in younger people, suggesting that the PSA test may have had a positive effect on mortality, although other clinical advances also have to be taken into account.

Population-based study of cutaneous malignant melanoma in the Granada province (Spain), 1985-1992

Cutaneous melanoma has received substantial attention during the last years because of the increase in its incidence which has been registered in many countries. This paper aims at describing the incidence and characteristics of all new cutaneous malignant melanoma cases during 1985-1992 reported to the Granada Cancer Registry (Spain) in the context of Mediterranean populations. A population-based study with 247 cutaneous melanoma cases was carried out. The variables used were: sex, age, anatomic site, hystological type, level of invasion and tumour thickness. The Age-Standardised incidence Rate per World population (ASRW) was 2.9 for males and 3.7 for females in the whole period. An increasing incidence trend for both males and females was found. The ASRW in 1985-1987, 1988-1990 and 1991-1992 was respectively 2.2, 2.9 and 3.2 for males and 3, 3.4, 4.7 for females. The most frequent location was trunk for males (36%) and lower extremities for females (44%). The most frequent hystological type for both males and females was superficial spreading melanoma. Seventy-six percent of males and 60% of females were diagnosed Clark's level III or over. Average tumour thickness was 3.3 mm for males and 2.4 mm for females. The results of this study can be a guidance for the setting up of health policies which would contribute to the prevention of the disease and to an improvement in care. Because of the increase in incidence rates and the high percentage of cases which were diagnosed at advanced stages, it is advised that prevention campaigns are addressed to the Granada population.

Cancer survival increases in Europe, but international differences remain wide

The EUROCARE project analysed cancer survival data from 45 population-based cancer registries in 17 European countries, revealing wide international differences in cancer survival. We calculated 5-year relative survival for 1836287 patients diagnosed with one of 13 cancers during the period 1978-1989. The data, from 20 cancer registries in 13 countries, were grouped into four regions: Finland, Sweden, Iceland (Northern Europe); Denmark, England and Scotland (UK and Denmark); France, The Netherlands, Germany, Italy and Switzerland (Western Europe); Estonia and Poland (Eastern Europe), and broken down into four periods (1978-1980, 1981-1983, 1984-1986, 1987-1989). For each cancer, mean European and regional survival was estimated as the weighted mean of 5-year relative survival in each country. Survival increased with time for all tumours, particularly for cancers of testis (12% increase, i.e. from 79.9 to 91.9%), breast, large bowel, skin melanoma (approximately 9-10%), and lymphomas (approximately 7%). For most solid tumours, survival was highest in Northern Europe and lowest in Eastern Europe, and also low in the UK and Denmark. Regional variation was less marked for the lymphomas. Survival improved more in Western than Northern Europe, and the differences between these regions fell for bowel cancer (from 8.0% for those diagnosed in 1978-1980 to 2% for those diagnosed in 1987-1989), breast cancer (from 7.4% to 3.9%), skin melanoma (from 13.4% to 11.0%) and Hodgkin's disease (from 7.2 to 0.6%). For potentially curable malignancies such as Hodgkin's disease, large bowel, breast and testicular cancers, there were substantial increases in survival, suggesting an earlier diagnosis and more effective treatment. The persisting regional differences suggest there are corresponding differences in the availability of diagnostic and therapeutic facilities, and in the effectiveness of healthcare systems.

Comparison of fatty acid profile in plasma phospholipids in women from Granada (southern Spain) and Malmö (southern Sweden)

We conducted a first pilot study on healthy women living in two countries with different dietary habits, Granada in the south of Spain and Malmö in the south of Sweden, in order to compare their levels of plasma phospholipid fatty acids, and to examine the relationship between the differences in food consumption. This study is part of a pilot study which is nested in the European Prospective Investigation into Cancer and Nutrition, a multi-centre prospective cohort study on diet, plasma concentrations of antioxidants and fatty acids, and markers of oxidative stress. Thirty-nine women in Granada and thirty-eight women in Malmö, aged 45-50 years (all pre-menopausal) were selected among the female participants in the cohorts from these two countries. Individual measurements of the women's habitual diet were obtained by a food frequency questionnaire. 24-hour diet recalls were used for the standardised measurement of diet at group level. Plasma phospholipid fatty acid composition was determined by capillary gas chromatography. We found a different fatty acid profile in plasma between the two populations, with higher mean levels of palmitic acid (16:0), palmitoleic acid (16:1) (n-7), oleic acid (18:1), alpha-linolenic acid (18:3) (n-3) and eicosapentaenoic acid (20:5) (n-3), and lower mean levels of stearic acid (18:0) in Malmö compared to Granada. Women in Malmö consumed more meat, alcoholic beverages and sugar, and less fish and shellfish than women in Granada. We conclude that the fatty acid composition in plasma phospholipids is different between women from the two European centres. For polyunsaturated fatty acids, differences were observed for (n-3) fatty acids. In relation to these differences, we observed that specific food intakes, particularly meat and fish, varied between the two centres.

Understanding variations in survival for colorectal cancer in Europe: a EUROCARE high resolution study

BACKGROUND

Marked differences in population based survival across Europe were found for colorectal cancers diagnosed in 1985-1989.

AIMS

To understand the reasons for these differences in survival in a new analysis of colorectal cancers diagnosed between 1988 and 1991.

SUBJECTS

A total of 2720 patients with adenocarcinoma of the large bowel from 11 European cancer registries (CRs).

METHODS

We obtained information on stage at diagnosis, diagnostic determinants, and surgical treatment (not routinely collected by CRs) and analysed the data in relation to three year observed survival, calculating relative risks (RRs) of death and adjusting for age, sex, site, stage, and determinants of stage.

RESULTS

Three year observed survival rates ranged from 25% (Cracow) to 59% (Modena), and were low in the Thames area (UK) (38%). Survival rates between registries for "resected" patients varied less than those for all patients. When age, sex, and site were considered, RRs ranged from 0.7 (95% confidence intervals (CI) 0.6-0.9) (Modena) to 2.3 (95% CI 1.9-2.9) (Cracow). After further adjustment by stage, between registry RR variation was between 0.8 (95% CI 0.6-0.9) and 1.8 (95% CI 1.5-2.2). Inter-registry RR differences were slightly reduced when the determinants of stage (number of nodes examined and liver imaging) were included in the model. The reduction was marked for the UK registries.

CONCLUSIONS

The wide differences across Europe in colorectal cancer survival depend to a large extent on differences in stage at diagnosis. There are wide variations in diagnostic and surgical practices. There was a twofold range in the risk of death from colorectal cancer even after adjustment for surgery and disease stage.

Variations in survival from breast cancer in Europe by age and country, 1978-1989. EUROCARE Working Group

The objective of this study, part of the wider EUROCARE II collaborative project, was to examine variations by age and country in the relative survival of women from breast cancer in Europe, based on data fro 145,000 cases in 1985-1989 and trends based on (245,000) cases for 1978-1989. Data were supplied by 42 cancer registries in 17 countries to a common protocol. Results for some countries where the participating registries covered only small proportions of the total population may not be representative of the whole country. In 1985-1989 there were wide differences among the 17 countries: survival was above the European average in Iceland, Finland, Sweden, Switzerland, France and Italy; around average in Denmark, The Netherlands, Germany and Spain; below average in Scotland, England and Slovenia; and well below average in Slovakia, Poland and Estonia. In France, Spain and Italy, but not in the U.K., there were wide differences in survival among the participating registries. Survival generally declined with age, particularly in the elderly (75 years and over)--this was most marked in Denmark, Scotland and England. Over the period 1978-1989, 1-year survival improved by 2% overall and 5-year survival by 6%. There were improvements in 5-year survival in all countries except Iceland, Germany, Switzerland and Estonia, and in all age groups except the youngest (15-44 years). It is likely that differences in the access to and quality of care in the various countries played a large part in explaining the differences in survival.