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.

Wireless phone use in childhood and adolescence and neuroepithelial brain tumours: Results from the international MOBI-Kids study

In recent decades, the possibility that use of mobile communicating devices, particularly wireless (mobile and cordless) phones, may increase brain tumour risk, has been a concern, particularly given the considerable increase in their use by young people. MOBI-Kids, a 14-country (Australia, Austria, Canada, France, Germany, Greece, India, Israel, Italy, Japan, Korea, the Netherlands, New Zealand, Spain) case-control study, was conducted to evaluate whether wireless phone use (and particularly resulting exposure to radiofrequency (RF) and extremely low frequency (ELF) electromagnetic fields (EMF)) increases risk of brain tumours in young people. Between 2010 and 2015, the study recruited 899 people with brain tumours aged 10 to 24 years old and 1,910 controls (operated for appendicitis) matched to the cases on date of diagnosis, study region and age. Participation rates were 72% for cases and 54% for controls. The mean ages of cases and controls were 16.5 and 16.6 years, respectively; 57% were males. The vast majority of study participants were wireless phones users, even in the youngest age group, and the study included substantial numbers of long-term (over 10 years) users: 22% overall, 51% in the 20-24-year-olds. Most tumours were of the neuroepithelial type (NBT; n = 671), mainly glioma. The odds ratios (OR) of NBT appeared to decrease with increasing time since start of use of wireless phones, cumulative number of calls and cumulative call time, particularly in the 15-19 years old age group. A decreasing trend in ORs was also observed with increasing estimated cumulative RF specific energy and ELF induced current density at the location of the tumour. Further analyses suggest that the large number of ORs below 1 in this study is unlikely to represent an unknown causal preventive effect of mobile phone exposure: they can be at least partially explained by differential recall by proxies and prodromal symptoms affecting phone use before diagnosis of the cases. We cannot rule out, however, residual confounding from sources we did not measure. Overall, our study provides no evidence of a causal association between wireless phone use and brain tumours in young people. However, the sources of bias summarised above prevent us from ruling out a small increased risk.

Predictors of oropharyngeal cancer survival in Europe

OBJECTIVES

HPV16-positive oropharyngeal cancer (OPC) patients experience better outcomes compared to HPV16-negative patients. Currently, strategies for treatment de-escalation are based on HPV status, smoking history and disease stage. However, the appropriate cut-point for smoking and the role of other non-clinical factors in OPC survival remains uncertain.

MATERIALS AND METHODS

We examined factors associated with OPC outcome in 321 patients recruited in a large European multi-center study. Seropositivity for HPV16 E6 was used as a marker of HPV16 positive cancer. Hazard ratios (HR) and confidence intervals (CI) were estimated using Cox proportional models adjusted for potential confounders.

RESULTS

Overall 5-year survival following OPC diagnosis was 50%. HPV16-positive OPC cases were at significantly lower risk of death (aHR = 0.51, 95% CI: 0.32-0.80). A significant effect on OPC survival was apparent for female sex (aHR 0.50: 95% CI: 0.29-0.85) and being underweight at diagnosis (aHR: 2.41, 95% CI: 1.38-4.21). A 10 pack year smoking history was not associated with overall survival. Higher stage at diagnosis appeared as the only factor significantly associated with OPC recurrence (aHR: 4.88, 95% CI: 2.12-11.21).

CONCLUSION

This study confirms that HPV16 status is an independent prognostic factor for OPC survival while female sex lowers risk of death and being underweight at diagnosis increases the risk of death. Smoking was not an independent predictor of OPC survival.

Incidence of Breast Cancer in Piedmont: 1979–1981

A population-based survey of histologically diagnosed breast cancer was carried out among residents in Piedmont. A total of 5267 incident cases occurring in 1979–1981 was collected, corresponding to an age-standardized (on the world population) incidence rate of 49.5/100,000 per year. Rates (standardized on the population of Piedmont in 1981) were highest in the city of Torino (112.4/100,000 per year) and lowest in the province of Cuneo (67.5), whereas in the other provinces they ranged between 85.3 and 90.0. Estimation of rates in the 54 Local Health Authorities of Piedmont detected up to 2-fold differences between adjacent areas. A correlation was found between rates and size of the population of town of residence. Comparison with age-specific incidence rates from the Cancer Registry of the nearby province of Varese suggested a loss of nonhistologically confirmed cases selectively in older age groups. The distribution of cases diagnosed in 1979 by histologic type is presented. The proportion of diagnoses reported in terms which were consistent with the 1978 WHO Histological Typing of Breast Tumours was 61.3%. It was highest among cases identified in Pathology Services located in University Hospitals and/or diagnosing more than 50 breast cancers per year.

Cancer of the Breast in Women Born in Southern Italy and who Migrated to the City of Torino

Individual demographic data of 459 women living in Torino with incident breast cancer diagnosed in 1979 were compared with those of a random sample of 1800 women drawn from the list of residents in the same city. Among women aged 25–44 and 45+ years, age-adjusted odds ratios for birth in southern Italy were respectively 1.3 (95% CL, 0.1–2.1) and 0.7 (95% CL, 0.5–0.9). In women aged 45+ years, odds ratios increased with length of residence in Torino.

Baldness and testicular cancer: the EPSAM case-control study

The etiology of testicular cancer is largely unexplained. Research has mainly focused on prenatal exposures, especially to sex hormones, while less attention has been paid to exposures that may act also postnatally. As baldness has been previously associated with testicular cancer risk we focused on baldness and body hairiness, which are both associated with androgen activity. We used data of the Postnatal Exposures and Male Health (EPSAM) study, a case-control study on testicular cancer conducted in the Province of Turin, Italy, involving cases diagnosed between 1997 and 2008. Information was collected using mailed questionnaires. Analyses included 255 cases and 459 controls. We calculated ORs and 95% CIs to estimate testicular cancer risk among those who developed baldness and among those with body hairiness. We found an inverse association between testicular cancer and baldness (OR: 0.67, 95% CI: 0.46-0.98) and body hairiness (OR: 0.78, 95% CI: 0.53-1.16), although the latter had wider CIs. The inverse association between baldness and testicular cancer is consistent with the results from previous studies. These results suggest that androgens activity may influence testicular cancer risk.

III Italian Consensus Conference on Malignant Mesothelioma of the Pleura. Epidemiology, Public Health and Occupational Medicine related issues

The III Italian Consensus Conference on Pleural Mesothelioma (MM) convened on January 29th 2015. This report presents the conclusions of the 'Epidemiology, Public Health and Occupational Medicine' section. MM incidence in 2011 in Italy was 3.64 per 100,000 person/years in men and 1.32 in women. Incidence trends are starting to level off. Ten percent of cases are due to non-occupational exposure. Incidence among women is very high in Italy, because of both non-occupational and occupational exposure. The removal of asbestos in place is proceeding slowly, with remaining exposure. Recent literature confirms the causal role of chrysotile. Fibrous fluoro-edenite was classified as carcinogenic by IARC (Group 1) on the basis of MM data. A specific type (MWCNT-7) of Carbon Nanotubes was classified 2B. For pleural MM, after about 45 years since first exposure, the incidence trend slowed down; with more studies needed. Cumulative exposure is a proxy of the relevant exposure, but does not allow to distinguish if duration or intensity may possibly play a prominent role, neither to evaluate the temporal sequence of exposures. Studies showed that duration and intensity are independent determinants of MM. Blood related MM are less than 2.5%. The role of BAP1 germline mutations is limited to the BAP1 cancer syndrome, but negligible for sporadic cases. Correct MM diagnosis is baseline; guidelines agree on the importance of the tumor gross appearance and of the hematoxylin-eosin-based histology. Immunohistochemical markers contribute to diagnostic confirmation: the selection depends on morphology, location, and differential diagnosis. The WG suggested that 1) General Cancer Registries and ReNaM Regional Operational Centres (COR) interact and systematically compare MM cases; 2) ReNaM should report results presenting the diagnostic certainty codes and the diagnostic basis, separately; 3) General Cancer Registries and COR should interact with pathologists to assure the up-to-date methodology; 4) Necroscopy should be practiced for validation. Expert referral centres could contribute to the definition of uncertain cases. Health surveillance should aim to all asbestos effects. No diagnostic test is recommended for MM screening. Health surveillance should provide information on risks, medical perspective, and smoking cessation. The economic burden associated to MM was estimated in 250,000 Euro per case.

Prediction of mortality and macrovascular complications in type 2 diabetes: validation of the UKPDS Outcomes Model in the Casale Monferrato Survey, Italy

AIMS/HYPOTHESIS

The United Kingdom Prospective Diabetes Study (UKPDS) Outcomes Model can be used to estimate the lifetime occurrence of major diabetes-related complications in order to calculate health economic outcomes. The aim of the study was to assess the performance of the model by comparing the predicted and observed mortality and the incidence of macrovascular complications in an Italian population-based cohort with type 2 diabetes.

METHODS

We used data from the Casale Monferrato Survey, a cohort enrolled in 1988 and surveyed in 1991 (n = 1,967) to assess the prevalence of cardiovascular risk factors. In 2000, a new survey included all the members of the original cohort who were still alive (n = 860), and in addition all individuals identified with a new diagnosis of type 2 diabetes since 1993 (n = 2,389). We compared the mortality predicted by the model for the 1991 survey over the subsequent 17-year period with the observed risk. The following outcomes were analysed in the 2000 survey: myocardial infarction (MI), other ischaemic heart disease, stroke, congestive heart failure (CHF) and amputation.

RESULTS

For all-cause mortality, the predictions from the model at 5 and 10 years (23% and 47%, respectively) were identical to the observed risks. At 15 years, the risk of death was slightly overestimated (an estimate of 67% vs 64% observed, 95% CI 61%, 66%). The performance of the model was best for patients with a recent history of disease (duration <6 years). Among the complications, the predicted cumulative incidences of MI and CHF were very close to those observed.

CONCLUSIONS/INTERPRETATION

External validation is essential to assess the accuracy of simulation models. The UKPDS Outcomes Model satisfactorily predicted a set of actual incidences of mortality and complications in an Italian diabetes cohort up to a duration of approximately 12 years. The longer term performance of such models should be carefully evaluated.

Role of medical history and medication use in the aetiology of upper aerodigestive tract cancers in Europe: the ARCAGE study

BACKGROUND

The study aimed to investigate the role of medical history (skin warts, Candida albicans, herpetic lesions, heartburn, regurgitation) and medication use (for heartburn; for regurgitation; aspirin) in the aetiology of upper aerodigestive tract (UADT) cancer.

METHODS

A multicentre (10 European countries) case-control study [Alcohol-Related CAncers and GEnetic susceptibility (ARCAGE) project].

RESULTS

There were 1779 cases of UADT cancer and 1993 controls. History of warts or C. albicans infection was associated with a reduced risk [odds ratio (OR) 0.80, 95% confidence interval (CI) 0.68-0.94 and OR 0.73, 95% CI 0.60-0.89, respectively] but there was no association with herpetic lesions, heartburn, regurgitation or medication for related symptoms. Regurgitation was associated with an increased risk for cancer of the oesophagus (OR 1.47, 95% CI 0.98-2.21). Regular aspirin use was not associated with risk of UADT cancer overall but was associated with a reduced risk for cancer of oesophagus (OR 0.51, 95% CI 0.28-0.96), hypopharynx (OR 0.53, 95% CI 0.28-1.02) and larynx (OR 0.74, 95% CI 0.54-1.01).

CONCLUSIONS

A history of some infections appears to be a marker for decreased risk of UADT cancer. The role of medical history and medication use varied by UADT subsites with aspirin use associated with a decreased risk of oesophageal cancer and suggestive of a decreased risk of hypopharyngeal and laryngeal cancers.

High prevalence of oral human papillomavirus infection in Fanconi's anemia patients

BACKGROUND

Fanconi's anemia (FA) is a rare recessive genetic disorder characterized by bone marrow failure, developmental and congenital abnormalities, which frequently evolves to aplastic anemia and neoplasias, primarily acute leukemia and head-neck carcinomas. Risk of malignancies increases after hematopoietic stem cell transplantation (HSCT), and the role of human papillomavirus (HPV) in FA carcinogenesis have been proposed.

OBJECTIVE

To investigate prevalence of oral HPV in FA patients without oral malignant lesions.

MATERIALS AND METHODS

After oral examination, 76 subjects without detectable oral malignant lesions were included and classified in four groups: 20 FA submitted to HSCT (I), 22 FA not submitted to HSCT (II), 18 severe aplastic anemia (SAA) submitted to HSCT (III) and 16 healthy subjects (IV). Liquid-based cytology sampling, HPV screening by polymerase chain reaction and genotyping by reverse hybridization were performed.

RESULTS

The HPV detection rates were: group I 35%, group II 27.3%, group III 38% and group IV 6.25%. Prevalence of high risk HPV types, mainly HPV16, was detected. Compared with control group, suggestions for increased likelihood of being HPV infected in SAA (OR = 9.55, 95% CI: 1.01-125.41) and FA patients submitted to HSCT (OR = 8.08, 0.83-72.29) emerged.

CONCLUSION

Patients without oral malignant lesions submitted to HSCT, have high prevalence of oral HPV. HPV screening and close follow up should be considered in these patients.

Occupational exposure to pesticides and bile tract carcinoma in men: results from a European multicenter case-control study

OBJECTIVES

To estimate the associations between occupational exposure to pesticides and extrahepatic biliary tract carcinoma in men, a population-based case-control study was carried out.

METHODS

Cases (n = 104), aged 35-70, diagnosed in 1995-1997, were sampled by active reporting systems from hospitals. Controls (n = 1,401) were a random sample of the general male population. Information on occupation and confounding factors was obtained by questionnaires. Exposures were quantified with respect to time, application methods, and use of personal protective equipment. Intensity was evaluated by using a published algorithm which weighted the exposure assigned according to the use of personal protective equipment and mode of application. Logistic regression analyses were conducted adjusted for gallstones, age, and country.

RESULTS

Being ever exposed to pesticides resulted in an odds ratio (OR) of 1.0 [95%-confidence interval (CI) 0.6-1.6]. A modestly elevated risk was found for backpack mounted sprayers OR = 1.4 [95% CI 0.7-2.6] and vine farmers OR = 2.5 [95% CI 0.9-7.2]. Using time periods and exposure frequency as intensity measure, no elevated risks were found. The only exception was year of maximum exposure which yielded an OR of 1.6 [95% CI 0.7-3.5]. However, no clear trend was observed in this analysis.

CONCLUSIONS

This study does not rule out that pesticide exposure represents an occupational risk factor for extrahepatic biliary tract carcinoma, but no indication of a strong association was observed. Some modes of exposure were weakly, albeit not significantly associated with carcinoma risk. The observed estimates of effects may be influenced by a lack of precise exposure assessment. Different chemical compositions of pesticides were utilized during a long time span of pesticide exposure, and it should be considered that the exposure is assessed with substantial uncertainty that could non-differential and bias results toward the null.

Socioeconomic factors associated with risk of upper aerodigestive tract cancer in Europe

INTRODUCTION

In the European Union, there are 180,000 new cases of upper aerodigestive tract (UADT) cancer cases per year--more than half of whom will die of the disease. Socioeconomic inequalities in UADT cancer incidence are recognised across Europe. We aimed to assess the components of socioeconomic risk both independently and through their influence on the known behavioural risk factors of smoking, alcohol consumption and diet.

PATIENTS AND METHODS

A multicentre case-control study with 2198 cases of UADT cancer and 2141 controls from hospital and population sources was undertaken involving 14 centres from 10 countries. Personal interviews collected information on demographics, lifetime occupation history, smoking, alcohol consumption and diet. Socioeconomic status was measured by education, occupational social class and unemployment. Odds ratios (ORs) and 95% confidence intervals (CIs) were computed using unconditional logistic regression.

RESULTS

When controlling for age, sex and centre significantly increased risks for UADT cancer were observed for those with low versus high educational attainment OR=1.98 (95% CI 1.67, 2.36). Similarly, for occupational socioeconomic indicators--comparing the lowest versus highest International Socio-Economic Index (ISEI) quartile for the longest occupation gave OR=1.60 (1.28, 2.00); and for unemployment OR=1.64 (1.24, 2.17). Statistical significance remained for low education when adjusting for smoking, alcohol and diet behaviours OR=1.29 (1.06, 1.57) in the multivariate analysis. Inequalities were observed only among men but not among women and were greater among those in the British Isles and Eastern European countries than in Southern and Central/Northern European countries. Associations were broadly consistent for subsite and source of controls (hospital and community).

CONCLUSION

Socioeconomic inequalities for UADT cancers are only observed among men and are not totally explained by smoking, alcohol drinking and diet.

Short-term mortality risk in children and young adults with type 1 diabetes: the population-based Registry of the Province of Turin, Italy

Short-term mortality risk in young diabetic people is an indicator of quality of care. We assessed this in the Italian incident population-based registry of Turin. The study base included 1210 incident cases (n=677 aged 0-14 years and n=533 aged 15-29 years) with diabetes, onset period 1974-2000 in the Province of Turin, Italy. The relevant timescale for analysis was the time since the onset of diabetes to death, or till 31 December 2003. Standardized mortality ratio (SMR) for all-cause mortality was computed using the Italian population as a standard, by 5 years, age group, sex, and calendar period. Mean attained age of the incident cohort was 29.7 years (range 5.2-49.7 years). During a mean follow-up period of 15.8 years (range 2.0-29.9 years), there were 19 deaths in 15,967. Nine person-years of observation (n=9.5 expected deaths), giving an all-cause mortality rate of 1.19/1000 person-years (95% CI 0.76-1.87) and an SMR of 1.96 (1.25-3.08). In no cases did death occur at the onset of diabetes or in childhood. Out of 19 deaths, 9 were diabetes related (n=6 coma and n=3 end-stage renal disease). In Cox regression analysis, the hazard ratio (HR) was higher in adult-onset than in childhood-onset diabetes (HR=3.90, 95% CI 1.14-13.39), independently of calendar period and gender. (1) Children and young adults with type 1 diabetes experienced a two-fold higher short-term mortality risk than Italian people of similar age and sex and (2) the risk was higher in adult-onset than in childhood-onset diabetes. The quality of diabetes care should be improved to prevent early deaths.

Using directed acyclic graphs to consider adjustment for socioeconomic status in occupational cancer studies

There is an ongoing debate on whether analyses of occupational studies should be adjusted for socioeconomic status (SES). In this paper directed acyclic graphs (DAGs) were used to evaluate common scenarios in occupational cancer studies with the aim of clarifying this issue. It was assumed that the occupational exposure of interest is associated with SES and different scenarios were evaluated in which (a) SES is not a cause of the cancer under study, (b) SES is not a cause of the cancer under study, but is associated with other occupational factors that are causes of the cancer, (c) SES causes the cancer under study and is associated with other causal occupational factors. These examples illustrate that a unique answer to the issue of adjustment for SES in occupational cancer studies is not possible, as in some circumstances the adjustment introduces bias, in some it is appropriate and in others both the adjusted and the crude estimates are biased. These examples also illustrate the benefits of using DAGs in discussions of whether or not to adjust for SES and other potential confounders.

Excess of mesotheliomas after exposure to chrysotile in Balangero, Italy

BACKGROUND

Chrysotile from the mine in Balangero, Italy is considered to be free of tremolite. In a cohort study of miners and millers only two pleural cancers were reported, a finding considered to indicate that chrysotile has a low potency for inducing mesothelioma. However, follow-up ended in 1987 and white-collar workers and the employees of subcontractors were not studied.

METHODS

To complete the case ascertainment, the study searched the Registry of Malignant Mesotheliomas of Piedmont for records of cases of pleural mesothelioma among the following: mine employees; employees of subcontractors or of other firms transporting or refining Balangero asbestos, asbestos ore or mine tailings; individuals exposed to air pollution from the mine or living with mine employees; and individuals exposed to mine tailings from Balangero.

RESULTS

The study identified four new cases of pleural mesothelioma among blue-collar workers in the mine, in addition to the two reported in the cohort study. Thus, six mesotheliomas occurred, compared to the 1.5 expected (p<0.01). The study also identified three mesothelioma cases among white-collar employees at the mine, five in workers in the mine hired by subcontracting firms, and three among workers processing Balangero chrysotile outside the mine. Finally, 10 additional cases due to non-occupational exposure or exposure to re-used mine tailings were identified.

CONCLUSIONS

The cluster of 14 mesothelioma cases among workers who were active in the mine and 13 among other people exposed to Balangero chrysotile provides further evidence that tremolite-free chrysotile is carcinogenic.

The impact of diabetes on prescription drug costs: the population-based Turin study

AIMS/HYPOTHESIS

The aim of our study was to compare prescription drug costs in diabetic and non-diabetic individuals in a large population-based Italian cohort covered by the National Health System.

METHODS

We identified diabetic residents in Turin on 31 July 2003 through multiple independent data sources (diabetes registry, hospital discharges and prescriptions data sources). All prescriptions registered in the 12 month period 1 August 2003 to 31 July 2004 were examined to compare prevalence of treatment and costs in diabetic (n = 33,797) and non-diabetic individuals (n = 863,876). A log-linear model was employed to estimate age- and sex-adjusted ratios of costs.

RESULTS

Costs per person per year were 830.90euros in diabetic patients and 182.80euros in non-diabetic individuals (age- and sex-adjusted rate ratio 2.8, 95% CI 2.7-2.9). Diabetes treatment accounted for 18.5% of the total cost. Compared with non-diabetic individuals, the excess of expenditure was particularly high in diabetic patients aged <45 years (rate ratio 9.3), in those with type 1 diabetes (rate ratio 7.7) and in insulin users (rate ratio 4.8). The cost of diet-treated patients was similar to those treated with oral drugs. Diabetes was associated with an increased prevalence of treatment for most drug categories; one-third of the diabetic cohort received ACE inhibitors, anti-thrombotic drugs and statins.

CONCLUSIONS/INTERPRETATION

This population-based study shows that diabetes has a great impact on prescription drug costs, independently of main confounders, particularly in insulin-treated patients, suggesting that a wide range of comorbidities affect their health. Costs are expected to further increase if the transferability of knowledge provided by evidence-based guidelines on diabetic patients is completed over the coming years.

Evaluating cardiovascular mortality in type 2 diabetes patients: an analysis based on competing risks Markov chains and additive regression models

RATIONALE, AIMS AND OBJECTIVES

Type 2 diabetes represents a condition significantly associated with increased cardiovascular mortality. The aims of the study are: (i) to estimate the cumulative incidence function for cause-specific mortality using Cox and Aalen model; (ii) to describe how the prediction of cardiovascular or other causes mortality changes for patients with different pattern of covariates; (iii) to show if different statistical methods may give different results.

METHODS

Cox and Aalen additive regression model through the Markov chain approach, are used to estimate the cause-specific hazard for cardiovascular or other causes mortality in a cohort of 2865 type 2 diabetic patients without insulin treatment. The models are compared in the estimation of the risk of death for patients of different severity.

RESULTS

For younger patients with a better covariates profile, the Cumulative Incidence Function estimated by Cox and Aalen model was almost the same; for patients with the worst covariates profile, models gave different results: at the end of follow-up cardiovascular mortality rate estimated by Cox and Aalen model was 0.26 [95% confidence interval (CI) = 0.21-0.31] and 0.14 (95% CI = 0.09-0.18).

CONCLUSIONS

Standard Cox and Aalen model capture the risk process for patients equally well with average profiles of co-morbidities. The Aalen model, in addition, is shown to be better at identifying cause-specific risk of death for patients with more severe clinical profiles. This result is relevant in the development of analytic tools for research and resource management within diabetes care.

Estimated glomerular filtration rate, albuminuria and mortality in type 2 diabetes: the Casale Monferrato study

AIMS/HYPOTHESIS

Estimated glomerular filtration rate (eGFR) predicts mortality in non-diabetic populations, but its role in people with type 2 diabetes is unknown. We assessed to what extent a reduction in eGFR in people with type 2 diabetes predicts 11-year all-cause and cardiovascular mortality, independently of AER and other cardiovascular risk factors.

MATERIALS AND METHODS

The study population was the population-based cohort (n = 1,538; median age 68.9 years) of the Casale Monferrato Study. GFR was estimated by the abbreviated Modification of Diet in Renal Disease Study equation.

RESULTS

At baseline, the prevalence of chronic kidney disease (eGFR <60 ml min(-1) 1.73 m(-2)) was 34.3% (95% CI 33.0-36.8). There were 670 deaths in 10,708 person-years of observation. Hazard ratios of 1.23 (95% CI 1.03-1.47) for all-cause mortality and 1.18 (95% CI 0.92-1.52) for cardiovascular mortality were observed after adjusting for cardiovascular risk factors and AER. When five levels of eGFR were analysed we found that most risk was conferred by eGFR 15-29 ml min(-1) 1.73 m(-2), whereas no increased risk was evident in people with eGFR values between 30 and 59 ml min(-1) 1.73 m(-2). In an analysis stratified by AER categories, a significant increasing trend in risk with decreasing eGFR was evident only in people with macroalbuminuria.

CONCLUSIONS/INTERPRETATION

Our study suggests that in type 2 diabetes macroalbuminuria is the main predictor of mortality, independently of both eGFR and cardiovascular risk factors, whereas eGFR provides no further information in normoalbuminuric people.

Estimated glomerular filtration rate, albuminuria and mortality in type 2 diabetes: the Casale Monferrato study

AIMS/HYPOTHESIS

Estimated glomerular filtration rate (eGFR) predicts mortality in non-diabetic populations, but its role in people with type 2 diabetes is unknown. We assessed to what extent a reduction in eGFR in people with type 2 diabetes predicts 11-year all-cause and cardiovascular mortality, independently of AER and other cardiovascular risk factors.

MATERIALS AND METHODS

The study population was the population-based cohort (n = 1,538; median age 68.9 years) of the Casale Monferrato Study. GFR was estimated by the abbreviated Modification of Diet in Renal Disease Study equation.

RESULTS

At baseline, the prevalence of chronic kidney disease (eGFR <60 ml min(-1) 1.73 m(-2)) was 34.3% (95% CI 33.0-36.8). There were 670 deaths in 10,708 person-years of observation. Hazard ratios of 1.23 (95% CI 1.03-1.47) for all-cause mortality and 1.18 (95% CI 0.92-1.52) for cardiovascular mortality were observed after adjusting for cardiovascular risk factors and AER. When five levels of eGFR were analysed we found that most risk was conferred by eGFR 15-29 ml min(-1) 1.73 m(-2), whereas no increased risk was evident in people with eGFR values between 30 and 59 ml min(-1) 1.73 m(-2). In an analysis stratified by AER categories, a significant increasing trend in risk with decreasing eGFR was evident only in people with macroalbuminuria.

CONCLUSIONS/INTERPRETATION

Our study suggests that in type 2 diabetes macroalbuminuria is the main predictor of mortality, independently of both eGFR and cardiovascular risk factors, whereas eGFR provides no further information in normoalbuminuric people.

Occupational exposure to diesel exhausts and risk for lung cancer in a population-based case–control study in Italy

BACKGROUND

We studied the effect of exposure to diesel exhausts on lung cancer risk in a population-based case-control study in the city of Turin, Italy.

PATIENTS AND METHODS

Information on occupational histories of 595 incident lung cancer cases diagnosed in 1991-1992 and 845 population controls was obtained. During the interviews, diesel job-specific modules (D-JSMs) were administered whenever subjects had worked in occupations included in the following nine categories: railroad workers, miners, professional drivers and transport conductors, heavy-machine operators, mechanics and testers, filling station attendants, motor-vehicle park attendants, transport equipment operators, and occupations carried out in/near urban roads. All D-JSMs were evaluated for probability, intensity and frequency of exposure.

RESULTS

The odds ratio for ever exposure to diesel exhausts was 1.04 (95% confidence interval 0.79-1.37), after adjusting for age, sex, smoking and having worked in occupations entailing exposure to known lung carcinogens. No association was found with intensity, probability and duration of exposure.

CONCLUSIONS

Although misclassification of the exposure may have contributed to the negative results, we did not find an association between occupational exposure to diesel exhausts and lung cancer risk.

Evaluating hospital costs in type 2 diabetes care: does the choice of the model matter?

BACKGROUND

Awareness of the economic burden of diabetes has led to a number of studies on economic issues. However, comparison among cost-of-illness studies is problematic because different methods are used to arrive at a final cost estimate.

OBJECTIVE

The aim of the study is to show how estimates of hospitalisation costs for diabetic patients can vary significantly in relation to the statistical method adopted in the analysis.

RESEARCH DESIGN AND METHODS

The study analyses diabetic patients' costs as a function of demographic and clinical covariates, by applying the following statistical survival models: the parametric survival model assuming Weibull distribution, the Cox proportional hazard (PH) model and the Aalen additive regression for modelling costs. The Aalen approach is robust both for the non proportionality in hazard and for departures from normality. In addition it is able to easily model the effect of covariates on the extreme costs. This cost analysis is based on data collected for a retrospective observational study analysing repeated hospitalisations (N = 4816) in a cohort of 3892 diabetic patients.

RESULTS

There is agreement in all models with the effects of the considered covariates (age, sex, duration of disease and presence of other pathologies). An effect of over- or under-estimation, according to the chosen model due to arguably inappropriate model fitting, was observed, being more evident for some specific profiles of the patients, and overall accounting for as much as 20% of the estimated effect. The Aalen model was able to cope with all the other models in furnishing unbiased estimates with the advantage of a greater flexibility in representing the covariates' effect on the cost process.

CONCLUSIONS

An appropriate choice of the model is crucial in avoiding misinterpretation of cost determinants of type 2 diabetes care. For our data set the Aalen model proved itself to be a realistic and informative way to characterise the effect of covariates on costs.

Effect of age on the association of non-high-density-lipoprotein cholesterol and apolipoprotein B with cardiovascular mortality in a Mediterranean population with type 2 diabetes: the Casale Monferrato study

AIMS/HYPOTHESIS

Measurement of plasma apolipoprotein (Apo) B may improve prediction of cardiovascular risk, as it provides a measure of the total number of atherogenic particles. The aim of this population-based study was to compare the association of non-HDL-cholesterol, ApoB and the ApoB:ApoA-I ratio with cardiovascular mortality in people with type 2 diabetes.

SUBJECTS AND METHODS

We assessed the association of lipids, lipoprotein lipids and apolipoproteins with 11-year mortality from cardiovascular disease in the population-based cohort of the Casale Monferrato Study (1,565 people with diabetes; median age 68.9 years), and determined the effect of age (< or =70 and >70 years) on these relationships.

RESULTS

On the basis of 341 deaths from cardiovascular disease in 10,809 person-years of observation, there was a decreasing trend in risk adjusted for multiple factors across quartiles of total cholesterol, and LDL- and non-HDL-cholesterol in people aged >70 years, but no trend in those aged < or =70 years. Age did not affect the protective effect of HDL-cholesterol. ApoB and ApoB:ApoA-I were associated with outcome in people in both age groups independently of non-HDL-cholesterol. After adjustment for multiple factors, including non-HDL-cholesterol, the hazard ratios for ApoB:ApoA-I in the upper vs lower quartile were 2.98 (95% CI 1.15-7.75; p for trend=0.009) for people aged < or =70 years and 1.94 (95% CI 1.20-3.13; p for trend=0.003) for those aged >70 years.

CONCLUSIONS/INTERPRETATION

In this cohort of Mediterranean subjects with diabetes, ApoB and the ApoB:ApoA-I ratio were associated with cardiovascular disease mortality independently of non-HDL-cholesterol. Our findings support the recommendation that ApoB and ApoA-I should be measured routinely in all people with diabetes, particularly in the elderly.

Impact of immigration and HIV infection on tuberculosis incidence in an area of low tuberculosis prevalence

The aim of this study is to assess the effects of immigration from countries with a high prevalence of tuberculosis (HPCs), of HIV/AIDS prevalence, and the ageing of the indigenous population, on tuberculosis distribution in a low-prevalence area (LPCs), the Piedmont Region of Italy. Tuberculosis incidence and HIV cases were identified by linking records from the surveillance systems. Overall, 640 tuberculosis cases were identified and crude annual incidence was found to be 17.3/100000. The incidence rate ratio for HIV infection as a risk factor for tuberculosis (11.4 and 51.9 among individuals from HPCs and LPCs respectively) was greater than that for immigration from HPCs (6.7 and 30.9 among HIV+ and HIV- individuals). Immigration accounted for a larger number of incident cases [population attributable risk % (PAR %): 31.8 and 52.8% among HIV+ and HIV- individuals] than did HIV infection (PAR %: 5.4 and 11.1% among individuals from HPCs and LPCs). Efforts should be made to identify and treat young immigrants from HPCs.

Undetected burden of tuberculosis in a low-prevalence area

SETTING

Under-ascertainment and under-reporting of tuberculosis (TB) hampers surveillance and control. Case detection is improved by record linkage of case registers and under-reporting can be estimated by capture-recapture (CR) analysis.

OBJECTIVES

To assess the completeness of the TB registration systems and estimation of TB incidence and under-reporting in the Piedmont Region of Italy in 2001.

METHODS

Record linkage of the 'physician notification system', the TB laboratory register and the hospital records register, and subsequent three-sample CR analysis.

RESULTS

Record linkage identified 657 TB cases; CR analysis estimated 47 (95%CI 31-71) unrecorded cases. Under-reporting of the 'physician notification system' was estimated at 21% (95%CI 20-23). The overall estimated TB incidence rate was 16.7 cases per 100000 population (95%CI 16.3-17.3), varying according to the subset investigated: 12.7 for individuals from low TB prevalence countries and 214.1 for immigrants from high TB prevalence countries; 13.1 and 25.8 for persons aged < and > or = 60 years, respectively; and 32.1 in Turin, the regional capital and 10.8 in the rest of the region.

CONCLUSIONS

When multiple recording systems are available, record linkage and CR analysis can be used to assess TB incidence and the completeness of different registers, contributing to a more accurate surveillance of local TB epidemiology.

Mortality within the first 10 years of the disease in type 2 diabetic patients

BACKGROUND AND AIMS

An excess of long-term mortality in type 2 diabetes is mainly due to cardiac diseases, predicted by diabetes-related conditions; less is known about early death from clinical diagnosis. The aim of this study was to evaluate pattern and predictors of mortality after a 4.5 year follow-up in a cohort of type 2 diabetic patients, according to diabetes duration.

METHODS AND RESULTS

A mortality follow-up was carried out in 1200 patients with < or = 5 years diabetes duration and 2692 patients with >5 (median 2 and 15) years diabetes duration in 1995. Four-year survival was 92.0% and 83.7%, respectively; most deaths are due to cardiovascular diseases (36% and 41%, respectively). The duration of diabetes is no longer a significant predictor of death after adjustments for age, HbA1c and chronic complications (which are all significantly higher in patients who have had diabetes for longer time). In a Cox proportional hazard model, best predictors of death are nephropathy, insulin therapy and pre-existent co-morbidity in both groups. Nephropathy is significantly associated with cardiovascular deaths in the younger cohort.

CONCLUSION

Clinical nephropathy is a significant predictor of early and late mortality from clinical diagnosis, above all cardiovascular deaths, indicating that an aggressive approach should be adopted for prevention or treatment of renal impairment right from the clinical onset of diabetes.

Life expectancy as an indicator of outcome in follow-up of population-based cancer registries: the example of childhood leukemia

BACKGROUND

Survival analysis is a standard methodology to assess progress in oncology disease treatment. However, survival analysis commonly only measures survival during the treatment period (and the period immediately afterwards), and does not provide an estimate of life expectancy, which is often of more interest to patients and to health policy makers. In this paper we propose a method to estimate childhood acute lymphoblastic leukemia (ALL) life expectancy through the integration of traditional survival analysis and life expectancy tables.

PATIENTS AND METHODS

The study included 305 incident cases registered by the Childhood Cancer Registry of Piedmont in 1979-1991. Vital status on 30 June 2004 was known for 304 cases. Survival analyses were carried out using the Kaplan-Meier method and the Gompertz model, according to the time period of diagnosis and gender.

RESULTS

Cumulative survival at 5 years increased from 58.6% (95% CI 48.9-68.3) for cases diagnosed in March 1979-July 1982 to 79.1% (95% CI 70.8-87.5) in March 1987-February 1991 (P = 0.002). Average life expectancy increased from 46.1 years for boys and 42.6 years for girls diagnosed in March 1979-July 1982 to 58.3 and 69.1, respectively, in March 1987-February 1991.

CONCLUSIONS

These analyses show an improvement over the time period of diagnosis of life expectancy for children with ALL.

Fibrinogen and AER are major independent predictors of 11-year cardiovascular mortality in type 2 diabetes: the Casale Monferrato Study

AIMS/HYPOTHESIS

Fibrinogen and elevated AER increase cardiovascular mortality, but few data are available in the type 2 diabetic population. We have conducted an 11-year follow-up study of the Casale Monferrato cohort to assess: (1) the long-term predictive role of AER independently of conventional risk factors; (2) the shape of its relationship with cardiovascular mortality; and (3) whether fibrinogen has a predictive effect independent of the increased cardiovascular risk associated with nephropathy.

METHODS

During the follow-up period (1991-2001) a population-based cohort of 1,565 patients was regularly examined, and measurements of HbA1c were centralised. Multivariate Cox proportional hazards modelling was employed to assess the role of fibrinogen and AER as predictors of all-cause and cardiovascular mortality, independently of baseline variables and individual cumulative average values of HbA1c during follow-up.

RESULTS

In 10,890.2 person-years of observations, 685 deaths were identified, giving an all-cause mortality rate of 63.4 per 1,000 person-years (95% CI 58.8-68.3). In Cox regression analyses, the strongest predictor of cardiovascular mortality was macroalbuminuria (relative risk 2.18, 95% CI 1.62-2.94), which was mainly associated with a high risk of short-term mortality. No increased risk was evident until the upper microalbuminuric range of AER values. Plasma fibrinogen was also a major independent predictor, and its role was not modified by AER, or by the exclusion of subjects developing chronic renal failure or diabetic nephropathy during follow-up.

CONCLUSIONS/INTERPRETATION

The results indicate that: (1) AER is the main independent predictor of 11-year cardiovascular mortality; (2) this effect is mainly evident in the upper range of microalbuminuria and in macroalbuminuria; and (3) fibrinogen has an independent effect on cardiovascular mortality, but no synergistic effect with AER, suggesting that both endothelial dysfunction and chronic inflammation are involved in the excess cardiovascular mortality of type 2 diabetic patients.

Renal damage in patients with Type 2 diabetes: a strong predictor of mortality

AIMS

(i) To compare mortality rates in a cohort of Type 2 diabetic patients with those of the general population; (ii) to assess the prognostic role of pre-existing chronic conditions; (iii) to evaluate the impact of different severity of renal damage on mortality.

METHODS

All 3892 patients with Type 2 diabetes attending our Diabetic Clinic during 1995 and alive on 1 January 1996 were identified and followed for 4.5 years. Information on vital status (100% complete) and causes of death (98.5% complete) for 599 deceased subjects was derived from death certificates.

RESULTS

In comparison with the general population, standardized mortality ratios (x 100) were: 125 (95% confidence interval 104-148) in patients aged < 75 and 85 (75-95) in patients > or = 75 years. Cardiovascular diseases and diabetes were responsible for most of the excess deaths. In a Cox-proportional hazard model, renal damage was a powerful predictor of death (hazard ratio = 2.39; 95% confidence intervals = 2.00-2.85). The severity of renal damage was associated with increasing hazard ratios for death from all-cause mortality and from specific causes (especially coronary artery disease, other cardiovascular causes and diabetes) after multiple adjustments. Other significant predictors of death were: greater age, glycated haemoglobin, smoking, lower body mass index, pre-existing coronary and peripheral artery disease and known co-morbidity (cirrhosis and cancer).

CONCLUSIONS

Renal damage of any severity is significantly associated with subsequent mortality from all causes and from cardiovascular diseases. These associations are not confounded by pre-existing co-morbidity or coronary diseases.

The cumulative risk of lung cancer among current, ex- and never-smokers in European men

Recent analyses based on UK data indicate that people who stop smoking, even well into middle age, avoid most of their subsequent risk of lung cancer. We investigated whether similar absolute risks of lung cancer in men are found in other European countries with different smoking patterns and at different stages of their lung cancer epidemic. Using data for men from a multicentre case–control study of lung cancer in the UK, Germany, Italy and Sweden, and including 6523 lung cancer cases and 9468 controls, we combined odds ratio estimates with estimates of national lung cancer incidence rates to calculate the cumulative risk of lung cancer among men by age 75. Lung cancer cumulative risks by age 75 among continuing smokers were similar for the UK, Germany and Italy at 15.7, 14.3 and 13.8% respectively, whereas the cumulative risk among Swedish male smokers was 6.6%. The proportion of the risk of lung cancer avoided by quitting smoking before the age of 40 was comparable between the four countries, at 80% in Italy and 91% in the UK, Germany and Sweden. Similarly, the proportion of the excess risk avoided by quitting before the age of 50 ranged from 57% in Italy to 69% in Germany. Our results support the important conclusion that for long-term smokers, giving up smoking in middle age avoids most of the subsequent risk of lung cancer, and that lung cancer mortality in European men over the next three decades will be determined by the extent to which current smokers can successfully quit smoking.

Meta-analysis of non-sentinel node metastases associated with micrometastatic sentinel nodes in breast cancer

BACKGROUND

The need for further axillary treatment in patients with breast cancer with low-volume sentinel node (SN) involvement (micrometastases or smaller) is controversial.

METHODS

Twenty-five studies reporting on non-SN involvement associated with low-volume SN involvement were identified using Medline and a meta-analysis was performed.

RESULTS

The weighted mean estimate for the incidence of non-SN metastases after low-volume SN involvement is around 20 per cent, whereas this incidence is around 9 per cent if the SN involvement is detected by immunohistochemistry (IHC) alone. Subset analyses suggest that studies with axillary dissection after any type of SN involvement result in somewhat higher estimates than studies allowing omission of axillary clearance, as do studies with more detailed histological evaluation of the SN compared with those with a less intensive histological protocol. Higher-quality papers yield lower pooled estimates than lower-quality papers.

CONCLUSION

The risk of non-SN metastasis with a low-volume metastasis in the SN is around 10-15 per cent, depending on the method of detection of SN involvement. This should be taken into account when assessing the risk of omission of axillary dissection after a positive SN biopsy yielding micrometastatic or immunohistochemically positive SNs.

Isolated systolic hypertension in a cohort of type 2 diabetic patients

BACKGROUND AND AIMS

Previous studies of the adverse effects of isolated and borderline isolated systolic hypertension excluded or under-represented type 2 diabetic patients. The aim of this study was to evaluate the prevalence and role of isolated and borderline isolated systolic hypertension in a cohort of 3892 type 2 diabetic patients.

METHODS AND RESULTS

The hypertensive patients were classified as treated (n= 1806; 46.4%), untreated diastolic hypertension (n=407; 10.4%), untreated isolated systolic hypertension (n=166; 4.3%) and untreated borderline isolated systolic hypertension (n=625; 16%). A Cox proportional hazard model including several confounders showed that the patients with untreated isolated systolic hypertension were at significantly higher risk of hospital admissions due to cerebrovascular diseases than the normotensive and untreated diastolic hypertensive patients (HR=2.05; 95% CI: 1.2-3.4 and HR=1.97; 95%CI: 1.1-3.5, respectively). In the same model, borderline isolated systolic hypertension significantly correlated with admissions for cerebrovascular diseases in comparison with normotensive patients (HR=1.73; 95% CI: 1.2-2.6).

CONCLUSIONS

This is the first report concerning the prevalence of isolated and borderline isolated systolic hypertension in a large cohort of type 2 diabetic patients. The results are in line with population-based estimates. Our data show that isolated systolic hypertension is an independent predictor of hospital admissions due to cerebrovascular diseases.

Risk of oral squamous cell carcinoma in 402 patients with oral lichen planus: a follow-up study in an Italian population

The most important complication of oral lichen planus (OLP) is the development of oral squamous cell carcinoma (OSCC) but this is a very controversial matter. The aim of the study was to estimate in a Northern Italian cohort of OLP patients the risk for OSCC. Four hundred and two patients with histologically confirmed OLP diagnosed from January 1988 to July 1999, were followed-up to the end of February 2001. The standardized incidence ratio (SIR) of OSCC was calculated for the entire cohort and specific for gender, type of OLP, therapy for OLP and hepatitis C virus (HCV) infection. The relative risk (RR) of OSCC according to HCV infection was also estimated in the cohort. During the follow-up period, two men (1.3%) and seven women (2.9%) developed an OSCC. The SIR was 44.9 (95% CI: 20.5-85.2), being higher among women, but statistically significant in both genders. The RR of OSCC for patients with HCV as compared with those without HCV infection was 3.16 (0.8-12.5). Patients with OLP had a significantly increased risk of OSCC, irrespective of the clinical type of OLP and therapy. HCV infection apparently increased the risk for OSCC although this result could reflect the role of confounders, such as liver cirrhosis.