Global survival trends for brain tumors, by histology: analysis of individual records for 556,237 adults diagnosed in 59 countries during 2000-2014 (CONCORD-3)

BACKGROUND

Survival is a key metric of the effectiveness of a health system in managing cancer. We set out to provide a comprehensive examination of worldwide variation and trends in survival from brain tumors in adults, by histology.

METHODS

We analyzed individual data for adults (15-99 years) diagnosed with a brain tumor (ICD-O-3 topography code C71) during 2000-2014, regardless of tumor behavior. Data underwent a 3-phase quality control as part of CONCORD-3. We estimated net survival for 11 histology groups, using the unbiased nonparametric Pohar Perme estimator.

RESULTS

The study included 556,237 adults. In 2010-2014, the global range in age-standardized 5-year net survival for the most common sub-types was broad: in the range 20%-38% for diffuse and anaplastic astrocytoma, from 4% to 17% for glioblastoma, and between 32% and 69% for oligodendroglioma. For patients with glioblastoma, the largest gains in survival occurred between 2000-2004 and 2005-2009. These improvements were more noticeable among adults diagnosed aged 40-70 years than among younger adults.

CONCLUSIONS

To the best of our knowledge, this study provides the largest account to date of global trends in population-based survival for brain tumors by histology in adults. We have highlighted remarkable gains in 5-year survival from glioblastoma since 2005, providing large-scale empirical evidence on the uptake of chemoradiation at population level. Worldwide, survival improvements have been extensive, but some countries still lag behind. Our findings may help clinicians involved in national and international tumor pathway boards to promote initiatives aimed at more extensive implementation of clinical guidelines.

Abstract P1-08-08: Not presented

This abstract was not presented at the conference.

Citation Format: Rapiti E, Schaffar R, Bouchardy C, Neyroud-Caspar I, Benhamou S. Not presented [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-08-08.

Stage IVB endometrial cancer: clinical course and survival of patients with single and multiple metastases

OBJECTIVE

Metastatic endometrial cancer (EC) at initial presentation is a rare disease. The present aim was to evaluate prognostic factors and overall survival in patients diagnosed with metastatic EC.

STUDY DESIGN

Using data from the Geneva Cancer Registry, the authors included all patients diagnosed with Stage IVB EC from 1980-2007. Estimates of survival were calculated using the Kaplan-Meier method and compared using the log-rank test.

RESULTS

A total of 38 patients were identified. The most frequent metastases were peritoneal or pleural carcinomatosis (66%, n=25) and hematogenous metastases (53%, n=20). Five-year survival rate was 5.7% (95% confidence interval: 0.0-13.3), and median survival was 7.6 months. Survival of patients with a single metastasis at the time of diagnosis was longer than for patients with multiple metastases (16 versus two months, respectively; p < 0.00 1).

CONCLUSION

Metastatic EC is rare disease with very poor prognosis particularly for patients with multiple site metastases.

Breast cancer management and outcome according to surgeon's affiliation: a population-based comparison adjusted for patient's selection bias

BACKGROUND

Studies have reported that breast cancer (BC) units could increase the quality of care but none has evaluated the efficacy of alternative options such as private BC networks, which is our study objective.

PATIENTS AND METHODS

We included all 1404 BC patients operated in the public unit or the private network and recorded at the Geneva Cancer Registry between 2000 and 2005. We compared quality indicators of care between the public BC unit and the private BC network by logistic regression and evaluated the effect of surgeon's affiliation on BC-specific mortality by the Cox model adjusting for the propensity score.

RESULTS

Both the groups had high care quality scores. For invasive cancer, histological assessment before surgery and axillary lymph node dissection when indicated were less frequent in the public sector (adjusted odds ratio (OR): 0.4, 95% confidence interval (CI) 0.3-0.7, and OR: 0.4, 95% CI 0.2-0.8, respectively), while radiation therapy after breast-conserving surgery was more frequent (OR: 2.5, 95% CI 1.4-4.8). Surgeon affiliation had no substantial effect on BC-specific mortality (adjusted hazard ratio (HR): 0.8, 95% CI 0.5-1.4).

CONCLUSIONS

This study suggests that private BC networks could be an alternative to public BC units with both structures presenting high quality indicators of BC care and similar BC-specific mortality.

Changes in incidence, survival and mortality of prostate cancer in Europe and the United States in the PSA era: additional diagnoses and avoided deaths

BACKGROUND

We describe changes in prostate cancer incidence, survival and mortality and the resulting impact in additional diagnoses and avoided deaths in European areas and the United States.

METHODS

Using data from 12 European cancer registries and the Surveillance, Epidemiology and End Results program, we describe changes in prostate cancer epidemiology between the beginning of the PSA era (USA: 1985-1989, Europe: 1990-1994) and 2002-2006 among patients aged 40-64, 65-74, and 75+. Additionally, we examine changes in yearly numbers of diagnoses and deaths and variation in male life expectancy.

RESULTS

Incidence and survival, particularly among patients aged <75, increased dramatically, yet both remain (with few exceptions in incidence) lower in Europe than in the United States. Mortality reductions, ongoing since the mid/late 1990 s, were more consistent in the United States, had a distressingly small absolute impact among patients aged 40-64 and the largest absolute impact among those aged 75+. Overall ratios of additional diagnoses/avoided deaths varied between 3.6 and 27.6, suggesting large differences in the actual impact of prostate cancer incidence and mortality changes. Ten years of remaining life expectancy was reached between 68 and 76 years.

CONCLUSION

Policies reflecting variation in population life expectancy, testing preferences, decision aids and guidelines for surveillance-based management are urgently needed.

P1-08-13: Determinants of Risk, Characteristics and Prognosis of Breast Cancer Occurring after Hodgkin Lymphoma

Background Several studies have evaluated the excess of breast cancer (BC) risk after Hodgkin lymphoma (HL) but none has reported of all the aspects of BC occurring after HL including determinants of risk, comparison with other BC profile, treatment and outcome. This is the aim of our study.

Patients and Methods We used data from the Surveillance, Epidemiology and End Results (SEER) Programme of the National Cancer Institute. To assess the risk and determinants of BC after HL we included all 9'620 women with first primary HL diagnosed between 1973 and 2007 and calculated age and period standardized incidence ratio (SIR) of BC as compared with general population. We also compared tumour characteristics and treatment between BC after HL (n= 316) vs. all other first primary BC occurring during the same period (n=450'413) by logistic regression. Finally, we compared breast cancer specific mortality between the two groups by Cox model.

Results Overall, HL patients had an increased risk of developing BC (SIR: 2.4, 95% confidence interval [CI]: 2.2−2.7); the risk decreased with increasing age at HL, and disappeared when HL occurred after 50 years. BC risk was the same among those treated with or without radiotherapy until 15 years after HL and then an excess appeared in the irradiated group and persisted over 30 years after diagnosis of HL. Compared with other BC, BC after HL occurred at younger age (Adjusted odds ratio [OR] for age 40–59 vs. &lt; 40 years 0.25, 95% CI: 0.20−0.33), was diagnosed at an early stage (OR for regional extension vs. localized 0.63, 95% CI: 0.42−0.89), expressed less frequently hormone receptors (OR for negative vs. positive status: 1.34, 95% CI: 0.99−1.81), was located more frequently in external quadrants (OR for internal vs. external: 0.61, 95% CI: 0.42−0.89), and received less frequently radiotherapy (OR for use vs. non use: 0.30, 95%CI: 0.22-042). The last two results were limited to patients who had received radiotherapy for HL. BC after HL presented higher breast cancer mortality (Hazard ratio: 1.36, 95%CI: 1.05−1.76) after adjustment for patients, tumour and treatment characteristics.

Conclusion: This study provides valuable results on various aspects of BC occurring after HL. In particular, we found earlier stage at diagnosis of BC probably linked to higher surveillance, more aggressive tumours probably due to iatrogenic effect of HL treatment, more frequent occurrence in outer quadrants less protected during mantel radiation. Also, this study confirms the poorer prognostic of those BC not explained by differences in patient, tumour or treatment characteristics.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P1-08-13.

Abstract P4-09-06: Breast Cancer Prognosis Is Inherited Independently of Patient, Tumor and Treatment Characteristics

Fondation Jean Dausset, Paris, France; Karolinska Institute, Stockolm, Sweden; Geneva University Hospitals, Switzerland Introduction: Several studies have suggested that survival of breast cancer is inherited, but none has assessed if this observation is linked to shared tumor characteristics or type of treatment. We studied the association of survival among first-degree relatives (FDRs) with breast cancer, taking into account characteristics of patients, tumors and treatments. Methods: In the population-based Geneva Breast Cancer Registry, we identified 162 pairs of FDRs diagnosed with breast cancer. Based on the breast cancer specific survival status of their proband (i.e. the mother or older sister), we categorized FDRs into poor, medium and good familial survival risk groups. We compared patient, tumor and treatment characteristics between categories and calculated standardized mortality ratios (SMRs) and adjusted disease specific mortality for each group. Results: Breast cancer patients in the poor familial survival risk group were more likely to be diagnosed at later stages than those in the good familial survival risk group. Similarly, they had higher SMRs than those in the medium and good survival risk groups (18.7, 95% Confidence Interval [CI]: 9.4-33.5 versus 16.5 95% CI: 7.6-31.4 and 9.4, 95% CI: 3.4-20.3, respectively). After adjustment for prognostic factors, women in the poor familial survival risk group were almost five times more likely to die of breast cancer than those in the good survival risk group (adjusted Hazard Ratio 4.8, 95% CI: 1.4-16.4).

Conclusion: This study shows that breast cancer prognosis clusters within families, and suggests that the hereditary component is independent of patient, tumor characteristics and type of treatment.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P4-09-06.

Impact of a positive family history on diagnosis, management, and survival of breast cancer: different effects across socio-economic groups

BACKGROUND

This study aims to investigate whether increased awareness of breast cancer, due to a positive family history (FH), reduces diagnostic, therapeutic, and survival differences between women of low versus high socio-economic status (SES).

METHODS

All breast cancer patients registered between 1990 and 2005 at the population-based Geneva Cancer Registry were included. With multivariate logistic and Cox regression analysis, we estimated the impact of SES and FH on method of detection, treatment, and mortality from breast cancer.

RESULTS

SES discrepancies in method of detection and suboptimal treatment, as seen among women without a FH, disappeared in the presence of a positive FH. SES differences in stage and survival remained regardless of the presence of a positive FH. Overall, positive FH was associated with better survival. This effect was the strongest in women of high SES (age-adjusted Hazard Ratio [HR(ageadj)] 0.54 [0.3-1.0]) but less pronounced in women of middle (0.77 [0.6-1.0]), and absent in women of low SES (0.80 [0.5-1.2]).

CONCLUSION

A positive FH of breast cancer may reduce SES differences in access to screening and optimal treatment. However, even with better access to early detection and optimal treatment, women of low SES have higher risks of death from their disease than those of high SES.

Characteristics and outcome of prostate cancer with PSA <4 ng/ml at diagnosis: a population-based study

This population-based study aims to assess prognosis of prostate cancer diagnosed with prostate-specific antigen (PSA) levels <4 ng/ml in routine care. Materials and methods We compared prostate cancer patients with low PSA values (n=59) with other prostate cancer patients (n=1330) by logistic regression and the Cox model using data from the Geneva Cancer Registry. Results Patients with low PSA values more frequently had early-stage and well differentiated tumours. Nevertheless, 35% presented with aggressive tumour characteristics or metastases. After adjustment for other prognostic factors, prostate cancer-specific mortality was similar for both groups (hazard ratio: 1.1; 95%CI: 0.6-2.2). Conclusion We conclude that cancer with low PSA values at diagnosis is not indolent.

Tumor location does not influence the survival effects of radiotherapy in node-negative breast cancer

Abstract #4134

Background&#x2028; Medial (inner quadrants) tumor location has been shown to adversely influence survival in breast cancer. We investigated whether tumor location should alter the choice of local-regional treatments (surgery, with or without radiation therapy - RT), in women with node-negative breast cancer.&#x2028; Materials and methods&#x2028; Data were abstracted from the Surveillance, Epidemiology, and End Results (SEER) 2006's database for 58,709 women aged 25-95 years, diagnosed between 1988-1997 with non-metastatic T1-2 node-negative breast cancer, who underwent breast conserving surgery (BCS) and axillary dissection. We used Cox proportional hazards to examine the effect of tumor location (medial versus other) on overall mortality after accounting for other prognostic factors (covariates listed in footnote table 1) and interactions identified by the Akaike Information Criteria.&#x2028; Results&#x2028; There were no notable differences in patients' characteristics according to tumor location. Among them, 25,232 had BCS, 33,477 had mastectomy. However the distribution according to the use of adjuvant RT showed marked heterogeneity. RT was used in 88% of BCS and in 3% of mastectomy patients. In the multivariate analysis that adjusted against the imbalances, medial location was associated with an increased mortality, hazard ratio (HR) 1.08 (95% confidence interval 1.04-1.13). Mastectomy had no significant impact on survival, HR=0.99 (0.92-1.07). RT was associated with a significant mortality reduction, HR=0.81 (0.75-0.88). There was no interaction between tumor location and surgery, or between tumor location and RT, while the interaction between surgery and RT was significant, HR=1.31 (1.14-1.51). The corresponding factorial summary showed no subgroup effect of tumor location: RT after BCS was associated with the same mortality reduction of 19% regardless of tumor location, and RT after mastectomy was associated with the same relative increase of 7% regardless of tumor location (Table 1).&#x2028; Conclusion&#x2028; We confirm the poorer prognosis associated with tumor medial location. However there was no subgroup effect. The survival outcomes of local-regional treatments were not affected by tumor location, arguing that tumor location is not a sufficient indication to modify local-regional treatments in node-negative patients. Local-regional treatment should be based on tumor characteristics and not tumor location.&#x2028; &#x2028;

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 4134.

Hormonal therapy for oestrogen receptor-negative breast cancer is associated with higher disease-specific mortality

BACKGROUND

Tamoxifen has a remarkable impact on the outcome of oestrogen receptor (ER)-positive breast cancer. Without proven benefits, tamoxifen is occasionally prescribed for women with ER-negative disease. This population-based study aims to estimate the impact of tamoxifen on the outcome of ER-negative disease.

METHODS

We identified all women (n = 528) diagnosed with ER-negative invasive breast cancer between 1995 and 2005. With Cox regression analysis, we calculated breast cancer mortality risks of patients treated with tamoxifen compared with those treated without tamoxifen. We adjusted these risks for the individual probabilities (propensity scores) of having received tamoxifen.

RESULTS

Sixty-nine patients (13%) with ER-negative disease were treated with tamoxifen. Five-year disease-specific survival for women treated with versus without tamoxifen were 62% [95% confidence interval (CI) 48% to 76%] and 79% (95% CI 75% to 83%), respectively (P(Log-rank) < 0.001). For ER-negative patients, risk of death from breast cancer was significantly increased in those treated with tamoxifen compared with patients treated without tamoxifen (adjusted hazard ratio = 1.7, 95% CI 1.1-2.9, P = 0.031).

CONCLUSION

Our results show that patients with ER-negative breast cancer treated with tamoxifen have an increased risk of death from their disease. Tamoxifen use should be avoided for these patients.

The attitude and knowledge of cervical cancer by Cameroonian women; a clinical survey conducted in Maroua, the capital of Far North Province of Cameroon

This study was conducted to assess the knowledge, attitudes, and assumption of cervical cancer by women living in Maroua, the capital of the Far North Province of Cameroon. In a 1-month period, 171 women were surveyed as to their socioeconomic status, sexual habits, prior knowledge of cervical cancer, its prevention, and their attitudes toward cervical cancer. Of 171 women, 48 (28%) had prior knowledge of cervical cancer; they were classified as the "aware group" compared with 123 of 171 (72%) women who were uninformed about cervical cancer and they were classified as the "unaware group" (UG). The UG of women tended to be single mothers, illiterate, housewives, and had their first child before the age of 20 (P < 0.005). Despite the awareness of cervical cancer by 28% of women, only a minority of them, 4 of 48 (8.3%), underwent a preventative screening test. Only 71 of 171 (41.5%) women stated that they would be having a screening test in the future. The awareness of cervical cancer by women in Cameroon is still inadequate. Thus, to avoid deaths from cervical cancer, a curable and preventable disease, the need of an aggressive campaign to make Cameroonian women aware of cervical cancer and its prevention is needed.

Recent increase of breast cancer incidence among women under the age of forty

Using data from the Geneva Cancer Registry, we found that in 2002–2004, breast cancer incidence in women aged 25–39 years increased by 46.7% per year (95% CI: 7.1–74.0, P=0.015), which surveillance or detection bias may not fully explain.

Hormone replacement therapy, mammography screening and changing age-specific incidence rates of breast cancer: an ecological study comparing two European populations

BACKGROUND

In 2003, for the first time, US breast cancer incidence rates have fallen. Experts argue whether this is due to the reduced uptake of screening mammography or to lower use of Hormone Replacement Therapy (HRT). This study aims to disentangle the respective impact of screening and HRT on age-incidence rates and histology of breast cancer, by comparing two populations with comparably high levels of screening mammography, but with different prevalence of HRT.

METHODS

We included all invasive breast cancers recorded at the Geneva cancer registry (n = 4,909) and the Netherlands Cancer Registry (n = 152,428) between 1989-2003. We compared age-specific incidence rates and trends in histological subtyping between the two populations.

RESULTS

Between 1989-1991, incidence rates increased with age in both populations. In 2001-2003, women aged 60-64 years showed highest incidence rates in Geneva, while in the Netherlands incidence rates continued to increase with age. The annual increase in ductal cancer incidence was similar in the Netherlands (2.3%) and Geneva (2.5%), but the annual increase in lobular cancer was sharper in Geneva (10%) than in the Netherlands (5%).

CONCLUSION

The sharp differences in age distribution and histological subtyping of breast cancer between two European populations are not attributable to screening, since both populations have a high uptake of mammography screening. Since the prevalence of HRT use is very high in Geneva and rather low in the Netherlands, HRT may explain these discrepancies. However, other etiological factors and differences in histological assessment may also have played a role.

Impact of familial risk factors on management and survival of early-onset breast cancer: a population-based study

This population-based study evaluates the impact of a strong family history of breast cancer on management and survival of women with early-onset disease. We identified all breast cancer patients ⩽50 years, recorded between 1990 and 2001 at the Geneva familial breast cancer registry. We compared patients at high familial risk and low familial risk in terms of tumour characteristics, method of detection, treatment, survival and breast cancer mortality risk. Compared to patients at low familial risk (n=575), those at high familial risk (n=58) received significantly more often systemic therapy, especially for node-negative or receptor-positive disease. Five-year disease-specific survival rates of patients at high vs low familial risk were 86 and 90%, respectively. After adjustment, there was no difference in breast cancer mortality in general. A strong family history nonsignificantly increased breast cancer mortality in patients ⩽40 years (adjusted hazard ratio (HR) 4.0, 95% CI 0.8–19.7) and in patients treated without chemotherapy (adjusted HR 2.7, 95% CI 0.6–12.5). A strong family history of breast cancer is associated with an increased use of systemic therapy in early-onset patients. Although a strong family history does not seem to affect survival in general, it may impair survival of very young patients and patients treated without adjuvant chemotherapy. Owing to the limited number of patients in this study, these results should be used only to generate hypotheses.

Poorer survival of elderly patients with ovarian cancer: a population-based study

OBJECTIVE

To compare ovarian cancer survival in elderly and young patients.

MATERIAL AND METHODS

Using the Geneva Cancer Registry, we identify women diagnosed with primary ovarian cancer between 1980 and 1998. We compared tumors characteristics, treatment patterns of young patients (<or=70 years) versus older patients (>70 years) by logistic regression. To evaluate the effect of age on prognosis, we compared disease specific survival by Cox proportional hazard analysis, taking into account other prognostic factors.

RESULTS

This study included 285 patient aged 70 years and 451<or=70 years. Older women presented more advanced stage and at equal stage were less often treated by optimal surgery and chemotherapy. Five-year of disease specific survival was 18% (95% CI: 13-23%) and 53% (95% CI: 48-58%) among old versus young women. Over ovarian mortality was only partly explained by these differences and after adjustment for tumor characteristics and treatment, older women still had a 1.8-fold increased risk of dying of ovarian cancer compared to younger (HR 1.8, 95% CI: 1.4-2.4).

CONCLUSION

Age strongly decreases ovarian cancer mortality. This over mortality is only partly explained by later diagnosis and suboptimal treatment.

Fibromyalgia: a randomised, controlled trial of a treatment programme based on self management

OBJECTIVE

To evaluate the efficacy of a treatment programme for patients with fibromyalgia (FM) based on self management, using pool exercises and education.

METHODS

Randomised controlled trial with a 6 month follow up to evaluate an outpatient multidisciplinary programme; 164 patients with FM were allocated to an immediate 6 week programme (n = 84) or to a waiting list control group (n = 80). The main outcomes were changes in quality of life, functional consequences, patient satisfaction and pain, using a combination of patient questionnaires and clinical examinations. The questionnaires included the Fibromyalgia Impact Questionnaire (FIQ), Psychological General Well-Being (PGWB) index, regional pain score diagrams, and patient satisfaction measures.

RESULTS

61 participants in the treatment group and 68 controls completed the programme and 6 month follow up examinations. Six months after programme completion, significant improvements in quality of life and functional consequences of FM were seen in the treatment group as compared with the controls and as measured by scores on both the FIQ (total score p = 0.025; fatigue p = 0.003; depression p = 0.031) and PGWB (total score p = 0.032; anxiety p = 0.011; vitality p = 0.013,). All four major areas of patient satisfaction showed greater improvement in the treatment than the control groups; between-group differences were statistically significant for "control of symptoms", "psychosocial factors", and "physical therapy" No change in pain was seen.

CONCLUSION

A 6 week self management based programme of pool exercises and education can improve the quality of life of patients with FM and their satisfaction with treatment. These improvements are sustained for at least 6 months after programme completion.

Neurophysiologic evidence for a central sensitization in patients with fibromyalgia

OBJECTIVE

To determine whether abnormalities of peripheral and central nociceptive sensory input processing exist outside areas of spontaneous pain in patients with fibromyalgia (FM) as compared with controls, by using quantitative sensory testing (QST) and a neurophysiologic paradigm independent from subjective reports.

METHODS

A total of 164 outpatients with FM who were attending a self-management program were invited to participate in the study. Data for 85 patients were available and were compared with those for 40 non-FM controls matched for age and sex. QST was performed using thermal, mechanical, and electrical stimuli at locations of nonspontaneous pain. Pain assessment was 2-fold and included use of subjective scales and the spinal nociceptive flexion reflex (NFR), a specific physiologic correlate for the objective evaluation of central nociceptive pathways. Questionnaires regarding quality of life and the impact of FM were available.

RESULTS

Participants were mainly middle-aged women, with a mean disease duration of 8 years. Between-group differences were significant for neurophysiologic, clinical, and quality of life measures. In patients with FM, peripheral QST showed significantly altered cold and heat pain thresholds, and tolerance to cold pain was radically reduced. The median NFR threshold in patients with FM (22.7 mA [range 17.5-31.7]) was significantly decreased compared with that in controls (33 mA [range 28.1-41]). A cutoff value of <27.6 mA for NFR provided sensitivity of 73% and specificity of 80% for detecting central allodynia in the setting of FM.

CONCLUSION

Our results strongly, although indirectly, point to a state of central hyperexcitability of the nociceptive system in patients with FM. The NFR can be used to assess central allodynia in FM. It may also help discriminate patients who may benefit from use of centrally acting analgesics.

[Cause of death among workers of a refinery in Rome]

We evaluated mortality among subjects employed in an oil refinery plant in Rome, Italy. We studied two subgroups of refinery employees: blue collar and white collar workers. A total of 682 men (505 blue collars, 148 white collars, 29 unknown) employed between 1965 and 1992, were followed up for mortality since employment in the plant to July 1999. Standardized Mortality Ratios (SMR), and their 90% Confidence Intervals (90% CI), comparing mortality rates of the cohort members with those of the general population of the Lazio region. For blue collar workers, we performed analyses by latency since first employment and by duration of employment for selected cancer sites. We observed 94 total deaths (100.8 expected) (SMR = 0.93; 90% CI = 0.78-1.11) among blue collar workers and 16 total deaths (31.7 expected) (SMR = 0.50; 90% CI = 0.32-0.77) among white collar workers, and a large deficit of deaths from non-neoplastic cardiovascular diseases (respectively SMR = 0.60; 90% CI = 0.41-0.86 and SMR = 0.18; 90% CI = 0.03-0.56). All cancer mortality was slightly increased only in blue collars (SMR = 1.27 CI = 0.97-1.65). There was an excess risk from cancer of the lung (20 obs SMR = 1.80, 90% CI = 1.19-2.62), bladder (5 obs SMR = 3.19, 90% CI = 1.26-6.72), and benign/unspecified cancer of the brain (4 obs SMR = 4.11, 90% CI = 1.12-10.6). The lower mortality from cardiovascular disease indicates the presence of a strong healthy worker effect. The findings of elevated mortality from cancer of the lung and bladder in blue collar workers are in agreement with those of other studies. Confounding factors from cigarette smoking might have played only a marginal role in influencing the results. Exposure to polynuclear aromatic hydrocarbons (PAHs) is a plausible explanation for the excesses found.

Characteristics of nonsmoking women exposed to spouses who smoke: epidemiologic study on environment and health in women from four Italian areas

The aim of this study was to evaluate whether risk factors associated with cardiovascular or respiratory diseases and lung cancer occur differently among nonsmoking women in Italy with and without exposure to environmental tobacco smoke (ETS) from husbands that smoke. We performed a cross-sectional study of 1,938 nonsmoking women in four areas of Italy. Data on respiratory and cardiovascular risk factors and on diet were collected using self-administered questionnaires. Medical examinations and blood tests were administered; urine cotinine levels were measured. Nonsmoking women ever exposed to husbands' smoking were compared with unexposed women for several factors: education, husband's education, household crowding, number of children, current or past occupation, exposure to toxic substances at work, parental diseases, self-perceived health status, physician-diagnosed hypertension, hypercholesterol, diabetes, osteoporosis, chronic respiratory diseases, blood pressure medications, lifestyle and preventive behaviors, dietary variables, systolic and diastolic blood pressure, body mass index, waist-hip ratio, triceps skin folds, plasma antioxidant (pro-) vitamins (- and ss-carotene, retinol, l-ascorbic acid, -tocopherol, lycopene), serum total and HDL cholesterol, and triglycerides. Women married to smokers were more likely to be less educated, to be married to a less educated husband, and to live in more crowded dwellings than women married to nonsmokers. Women married to smokers were significantly less likely to eat cooked [odds ratio (OR) = 0.72; 95% confidence interval (CI), 0.55-0.93] or fresh vegetables (OR = 0.63; CI, 0.49-0.82) more than once a day than women not exposed to ETS. Exposed women had significantly higher urinary cotinine than unexposed subjects (difference: 2.94 ng/mg creatinine). All the other variables were not more prevalent among exposed compared to unexposed subjects. The results regarding demographic factors are easily explained by the social class distribution of smoking in Italy. A lower intake of vegetables among exposed women in our study is consistent with the available literature. Overall, our results do not support previous claims of more frequent risk factors for cardiovascular and pulmonary diseases among ETS-exposed subjects. In Italy, as elsewhere in Europe and North America, women who have never smoked but are married to smokers are likely to be of lower social class than those married to never-smokers. However, once socioeconomic differences are considered, the possibility of confounding in studies on the health effects of ETS is minimal.

Socioeconomic status and survival of persons with AIDS before and after the introduction of highly active antiretroviral therapy. Lazio AIDS Surveillance Collaborative Group

We estimated the AIDS survival by neighborhood socioeconomic status before (1993-1995) and after (1996-1997) the introduction of highly active antiretroviral therapy in Rome, Italy, in a retrospective cohort of persons with AIDS followed through July 31, 1998. Participants included 1,474 persons with AIDS residing in Rome who were diagnosed in 1993-1997. We calculated hazard ratios (HRs) of death for two diagnostic periods (before and after highly active antiretroviral therapy was introduced) by neighborhood socioeconomic status categorized into four levels (level I = highest socioeconomic status), using the Cox model and adjusting for gender, age, intravenous drug use, CD4 cell count at diagnosis, AIDS-defining disease, and hospital of diagnosis. Thirty-four per cent of persons with AIDS (N = 503) had survived as of mid-1998. For persons with AIDS diagnosed in 1993-1995, we found little difference in the risk of death by neighborhood socioeconomic status. For 1996-1997, the risk of death was greater for persons with lower neighborhood socioeconomic status, especially for levels III and IV [HR = 2.81 (95% confidence interval = 1.38-5.76), and HR = 2.55 (95% confidence interval = 1.27-5.14), respectively, compared with level I]. Stratified analyses showed that the greatest difference was found for women and drug users. In conclusion, even in a country with universal health coverage that provides therapy at no cost, differences in survival of persons with AIDS have emerged by neighborhood socioeconomic status since highly active antiretroviral therapy was introduced. Inequalities in health-care access or in medical management, or poor adherence to treatment, could explain the observed heterogeneity.

Diet and overall survival in a cohort of very elderly people

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

Changes in survival among people with AIDS in Lazio, Italy from 1993 to 1998. Lazio AIDS Surveillance Collaborative Group

OBJECTIVES

To investigate temporal changes in survival of persons with AIDS (PWA) diagnosed in Lazio, Italy.

DESIGN

Longitudinal study of 2862 PWA registered at the AIDS Surveillance System in the period 1 January 1993 to 30 June 1997 and followed for vital status up to 31 May 1998.

METHODS

Hazard ratios (HR) of death were calculated by year of diagnosis and by year of follow-up, adjusting for gender, age, modality of exposure, CD4 cell count at diagnosis, and AIDS-defining illness, using the Cox proportional regression model.

RESULTS

In the period 1 January 1993 to 31 May 1998, 1914 PWA died. The multivariate model showed a decrease of the risk of death for patients diagnosed from 1995 onward compared with patients diagnosed in 1993 [1995: HR 0.82; 95% confidence intervals (CI) 0.73-0.93; 1996: HR 0.44; 95% CI 0.38-0.51; first semester of 1997: HR 0.47; 95% CI 0.37-0.59]. The model with the year of follow-up modeled as time-dependent variable showed a statistically significant decline in the risk of death starting from the first quarter of 1997 (HR 0.62; 95% CI 0.48-0.80) and reached the minimum in the first two quarters of 1998 (first quarter: HR 0.13; 95% CI 0.08-0.21; second quarter: HR 0.14, 95% CI 0.08-0.25). There was a small difference in the magnitude of the risk estimates among genders, with a slower improvement in survival among females [first semester of 1997 for males HR was 0.51 (95% CI 0.39-0.66) whereas for females HR was 0.80 (95% CI 0.51-1.27)].

CONCLUSIONS

Survival of PWA in a population-based study improved significantly in the era when highly active antiretroviral therapy became available, but such improvement is not homogeneous among genders.

End stage renal disease among ceramic workers exposed to silica

OBJECTIVES

To evaluate whether ceramic workers exposed to silica experience an excess of end stage renal disease.

METHODS

On the basis of a health surveillance programme, a cohort of 2980 male ceramic workers has been enrolled during the period 1974-91 in Civitacastellana, Lazio, Italy. For each worker, employment history, smoking data, and x ray film readings were available. The vital status was ascertained for all cohort members. All 2820 people still alive and resident in the Lazio region as in June 1994 were searched for a match in the regional end stage renal diseases registry, which records (since June, 1994) all patients undergoing dialysis treatment in public and private facilities of the region. Expected numbers of prevalent cases from the cohort were computed by applying the rate of patients on dialysis treatment by the age distribution of the cohort.

RESULTS

A total of six cases was detected when 1.87 were expected (observed/expected (O/E) = 3.21; 95% confidence interval (95% CI) 1.17 to 6.98). The excess risk was present among non-smokers (O = 2; O/E = 4.34) and smokers (O = 4; O/E = 2.83), as well as among workers without silicosis (O = 4; O/E = 2.78) and workers with silicosis (O = 2; O/E = 4.54). The risk was higher among subjects with < 20 years since first employment (O = 4; O/E = 4.65) than among those employed > 20 years.

CONCLUSION

These results provide further evidence that exposure to silica dust among ceramic workers is associated with nephrotoxic effects.

Mortality among male licensed pesticide users and their wives

BACKGROUND

We evaluated the mortality pattern of male licensed pesticide users and their wives in central Italy.

METHODS

The cohort consisted of 2978 male farmers licensed for buying and handling toxic pesticides during the period 1971-1973 and 2586 farmers' wives. The Standardized Mortality Ratio (SMRs) and their 95% Confidence Intervals (95% CI) were computed on the basis of regional death rates.

RESULTS

We found a lower than expected overall and cancer mortality. Non-Hodgkin's lymphoma was increased among women (SMR = 2.29, 0.62-5.86) but not in male farmers (SMR = 0.90, 0.24-2.30), while both sexes were characterized by an increased risk of leukemia (men: SMR = 1.44, 0.69-2.64; women: SMR = 2.41, 1.04-4.76), mainly due to myeloid leukemia (men: SMR = 2.43, 0.98-5.00; women: SMR = 3.14, 1.02-7.33).

CONCLUSIONS

Men and women tend to share the same mortality profile. The statistically significant increase of leukemia with a threefold increased risk of the myeloid subtype only among women suggests that different pattern of exposure or biological differences between genders should be considered in evaluating health risks in agricultural settings.

[Socioeconomic inequalities in health care efficacy. Three examples in Lazio region]

There has been a limited number of studies in Italy investigating the relationship between socioeconomic inequalities and efficacy of treatments. This paper reviews three case studies on the association between socioeconomic status and disease outcome in the Lazio Region, Italy. The studies investigated: a) the probability of renal transplantation among patients with endstage renal disease; b) the survival of AIDS patients before and after the introduction of the new antiretroviral therapies; c) the 30-day mortality of patients who underwent coronary artery bypass graft surgery. The three studies demonstrate the complex relationship between socioeconomic status and both access to, and efficacy of, important health interventions.

Asbestos and cancer: An overview of current trends in Europe

This review assesses the contribution of occupational asbestos exposure to the occurrence of mesothelioma and lung cancer in Europe. Available information on national asbestos consumption, proportions of the population exposed, and exposure levels is summarized. Population-based studies from various European regions on occupational asbestos exposure, mesothelioma, and lung cancer are reviewed. Asbestos consumption in 1994 ranged, per capita, between 0. 004 kg in northern Europe and 2.4 kg in the former Soviet Union. Population surveys from northern Europe indicate that 15 to 30% of the male (and a few percent of the female) population has ever had occupational exposure to asbestos, mainly in construction (75% in Finland) or in shipyards. Studies on mesothelioma combining occupational history with biologic exposure indices indicate occupational asbestos exposure in 62 to 85% of the cases. Population attributable risks for lung cancer among males range between 2 and 50% for definite asbestos exposure. After exclusion of the most extreme values because of methodologic aspects, most of the remaining estimates are within the range of 10 to 20%. Estimates of women are lower. Extrapolation of the results to national figures would decrease the estimates. Norwegian estimates indicate that one-third of expected asbestos-related lung cancers might be avoided if former asbestos workers quit smoking. The combination of a current high asbestos consumption per capita, high exposure levels, and high underlying lung cancer rates in Central Europe and the former Soviet Union suggests that the lung cancers will arise from the smoking-asbestos interaction should be a major concern.

Passive smoking and lung cancer in Chandigarh, India

The aim of this study is to assess the relationship between exposure to environmental tobacco smoke (ETS) and lung cancer in non-smokers, a case-control study among lifetime non-smokers was conducted in Chandigarh, India. Cases consisted of 58 non-smoking histologically confirmed lung cancer patients; two controls for each case were selected, one among other patients admitted to the wards and one among the visitors to hospital patients. Subjects were asked about ETS exposure from different tobacco products in childhood and in adulthood at home, at the work place and in vehicles. Multivariate logistic regression analysis was used to assess the effects of the ETS exposure variables on lung cancer. Exposure to ETS during childhood was strongly associated with lung cancer (odds ratio (OR) = 3.9; 95% confidence interval (CI) = 1.9-8.2), the effect mostly arising from exposure to cigarettes smoke. The excess risk was observed with either a smoking father or mother. An increasing risk was found with increasing number of smokers and duration of exposure. Restricting the analysis to women produced higher estimates of the risk. No increased risk was found with exposure to a smoking spouse, except for those exposed only to cigarette smoke (OR = 5.1; 95% CI = 1.5-17). A weak association was seen between lung cancer and ETS exposure at the workplace, which increased with the number of years of exposure. Exposure in vehicles also was detected as a risk factor for lung cancer in non-smokers. This study suggests that ETS exposure may be a strong risk factor for lung cancer also in India, a country with low prevalence of smoking and, therefore, low rates of lung cancer. Other studies need to be conducted in similar settings to confirm the role played by ETS exposure early in life in the causation of lung cancer.

Determinants of tuberculosis in an immigrant population in Rome: a case-control study

SETTING

An out-patient clinic for immigrants in Rome, Italy.

OBJECTIVE

To determine risk factors for tuberculosis among immigrants in Italy.

DESIGN

Case-control study. Cases comprised 44 individuals aged 15-55 years who had a first diagnosis of tuberculosis between 1989 and 1994 at the clinic. Controls comprised 264 individuals randomly recruited among immigrants who attended the clinic for other reasons within seven days before or after the case was diagnosed. Subject information included country of origin, date of first arrival in Italy, level of education, knowledge of the Italian language, and legal resident status.

RESULTS

An increase of tuberculosis risk was observed with increasing tuberculosis incidence in the country of origin. Multivariate analysis showed an increased risk for those coming from Central and South America (odds ratio [OR] 5.5; 95% confidence interval [CI] 1.6-18.7). The adjusted odds ratio by time since entry in Italy increased during the second year of residence (OR 2.8; 95% CI 1.1-7.0), but decreased after that period. A trend toward increasing risk with decreasing educational level was observed.

CONCLUSIONS

These results demonstrate the need for a public health policy in Italy for tuberculosis control among immigrants which includes screening, prophylaxis and treatment.

Co-morbidity contributes to predict mortality of patients with chronic obstructive pulmonary disease

The aim of this study was to assess the prognostic role of co-morbidity in severe chronic obstructive pulmonary disease (COPD). A cohort of 270 COPD patients, mean (+/-SD) age 67+/-9 yrs, consecutively discharged from a University Hospital after an acute exacerbation was studied. Mean (+/-SD) forced expiratory volume in one second (FEV1) was 34+/-16% of predicted and FEV1/forced vital capacity (FVC) was 40.5+/-13.8%. The most common co-morbid diseases were: hypertension (28%), diabetes mellitus (14%), and ischaemic heart disease (10%). Clinical, electrocardiogram (ECG), and respiratory function data taken at the time of discharge were collected from the clinical records. The Charlson's index was used to quantify co-morbidity. Follow-up was conducted by means of telephone calls. Multivariate survival analysis was used to identify the independent predictors of death. The median survival of the cohort was 3.1 yrs. Death was predicted by the following variables: age (hazard rate (HR) 1.04; 95% confidence intervals (95% CI) 1.02-1.05), ECG signs of right ventricular hypertrophy (HR 1.76; 95% CI 1.30-2.38), chronic renal failure (HR 1.79; 95% CI 1.05-3.02), ECG signs of myocardial infarction or ischaemia (HR 1.42; 95% CI 1.02-1.96), FEV1 < 590 mL (HR 1.49; 95% CI 0.97-2.27). A score based upon these variables predicted mortality at 5 yrs with a sensitivity of 63% and a specificity of 77%. Selected co-morbid diseases and electrocardiogram signs of right ventricular hypertrophy play a major prognostic role in advanced chronic obstructive pulmonary disease. The clinical assessment of patients with chronic obstructive pulmonary disease should include these important and easily measurable variables.

Multiple imputation method for estimating incidence of HIV infection. The Multicenter Prospective HIV Study

BACKGROUND

CD4+ T-lymphocyte (CD4) and platelet counts are good predictors of the 'maturity' of HIV infection and can be used to impute the date of infection/seroconversion in individuals for whom this date is unknown.

METHODS

Data from the Italian Seroconversion Study were used to develop a Weibull regression model for time since seroconversion as a function of the haematologic markers. The model was used to impute time since HIV infection/seroconversion in individuals from a prevalent cohort, recruited through the Lazio regional HIV surveillance system.

RESULTS

The range of the imputed calendar times of infection/seroconversion in 2599 HIV prevalent individuals was 1972-1992; the earliest seroconversions occurred among injecting drug users (IDU). The peak of incidence was reached in 1986 with 340 seroconversions. Among males, the estimated median time from seroconversion to HIV diagnosis was shorter in IDU (30 months) as compared to non-IDU (36 months). This difference was smaller for females (26.6 versus 28.4 in IDU and non-IDU, respectively).

CONCLUSIONS

This method permits the estimation of population-based curves of HIV incidence, using data from surveillance. The results support the hypotheses of an early spread of the epidemic among IDU in the Lazio region, and of shorter lead times in this population.

A persistent rise in mortality among injection drug users in Rome, 1980 through 1992

OBJECTIVES

The purpose of the study was to analyze overall and cause-specific mortality among injection drug users in Rome.

METHODS

A cohort of 4200 injection drug users was enrolled in drug treatment centers from 1980 through 1988 and followed up until December 1992.

RESULTS

The age-adjusted mortality rate from all causes increased from 7.8/1000 person-years in 1985/86 to 27.7/1000 in 1991/92. The rise was mainly attributable to acquired immunodeficiency syndrome (AIDS), but mortality from overdose and other causes increased as well. The cumulative risk of death by the age of 40 was 29.3%.

CONCLUSIONS

The impact of AIDS deaths appears to be additional to a persistent increase of mortality for all other causes.

Mortality among workers at municipal waste incinerators in Rome: a retrospective cohort study

A retrospective mortality study of a cohort of 532 male subjects employed at two municipal plants for garbage recycling and incinerating has been conducted. All workers ever employed at the plants since 1962 were enrolled and followed up from January 1, 1965 to December 31, 1992. Standardized Mortality Ratios (SMRs) and 90% confidence intervals (90%CI) were calculated using regional population mortality rates. The study yielded a total of 8,585 person-years of observation. Mortality from all causes was significantly lower than expected (observed [obs] = 31; SMR = 0.71; 90%CI = 0.51-0.95). All cancer mortality was comparable with that of the general population (obs = 15; SMR = 0.95; 90%CI = 0.58-1.46). Mortality from lung cancer was reduced (obs = 3; SMR = 0.55; 90%CI = 0.15-1.42). Increased risk was found for gastric cancer (obs = 4; SMR = 2.79; 90%CI = 0.94-6.35). Analysis by latency indicated that the excess risk of gastric cancer was confined in the category with more than 10 years since first exposure. Our results for gastric and lung cancers indicate the need to further investigate the role on cancer of occupational exposure to organic dust and bacterial endotoxins in the waste management.