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.

CASE-REPORT Association between an ACAN gene variable number tandem repeat polymorphism and lumbar disc herniation: a case control study

We investigated the association between an aggrecan gene (ACAN) polymorphism and lumbar disc herniation (LDH). This was a case-control study with quinquennial age and gender groups. The study comprised 119 men and women aged between 20 and 60 from Goiânia (Brazil). Of these, 39 were allocated to the case group (Ca) and 80 to the control group (Ct). We gathered sociodemographic and clinical data, and peripheral blood samples. DNA was isolated for genotyping the ACAN variable number tandem repeat (VNTR) via conventional polymerase chain reaction (PCR). Data were statistically analyzed using the chi-square test, multiple comparison analysis, the Student t-test, and odds ratios, with a level of significance set at 5% (P ≤ 0.05). The groups were homogenous in terms of sociodemographic, anthropometric, and life style variables. The allele score for the ACAN VNTR was significantly lower in volunteers with LDH; the A22 allele was significantly more prevalent in this same group; the Ca group presented greater frequency of short alleles A13-A25, whereas the Ct group presented a higher frequency of long alleles. However, this difference was not statistically significant. In both groups, the most common alleles were A28, A27, and A29, and the A26/A26 genotype was significantly more common in the Ca group. The results showed an association between short alleles and LDH among the investigated adults (Ca), corroborating the hypothesis that aggrecan with shorter repeat lengths can lead to a reduction in the physiological proteoglycan function of intervertebral disc hydration and, consequently, increased individual susceptibility to LDH.

The role of oral hygiene in head and neck cancer: results from International Head and Neck Cancer Epidemiology (INHANCE) consortium

BACKGROUND

Poor oral hygiene has been proposed to contribute to head and neck cancer (HNC) risk, although causality and independency of some indicators are uncertain. This study investigates the relationship of five oral hygiene indicators with incident HNCs.

METHODS

In a pooled analysis of 8925 HNC cases and 12 527 controls from 13 studies participating in the International Head and Neck Cancer Epidemiology Consortium, comparable data on good oral hygiene indicators were harmonized. These included: no denture wear, no gum disease (or bleeding), <5 missing teeth, tooth brushing at least daily, and visiting a dentist ≥once a year. Logistic regression was used to estimate the effects of each oral hygiene indicator and cumulative score on HNC risk, adjusting for tobacco smoking and alcohol consumption.

RESULTS

Inverse associations with any HNC, in the hypothesized direction, were observed for <5 missing teeth [odds ratio (OR) = 0.78; 95% confidence interval (CI) 0.74, 0.82], annual dentist visit (OR = 0.82; 95% CI 0.78, 0.87), daily tooth brushing (OR = 0.83, 95% CI 0.79, 0.88), and no gum disease (OR = 0.94; 95% CI 0.89, 0.99), and no association was observed for wearing dentures. These associations were relatively consistent across specific cancer sites, especially for tooth brushing and dentist visits. The population attributable fraction for ≤ 2 out of 5 good oral hygiene indicators was 8.9% (95% CI 3.3%, 14%) for oral cavity cancer.

CONCLUSION

Good oral hygiene, as characterized by few missing teeth, annual dentist visits, and daily tooth brushing, may modestly reduce the risk of HNC.

Education, tobacco smoking, alcohol consumption, and IL-2 and IL-6 gene polymorphisms in the survival of head and neck cancer

The association of education, tobacco smoking, alcohol consumption, and interleukin-2 (IL-2 +114 and -384) and -6 (IL-6 -174) DNA polymorphisms with head and neck squamous cell carcinoma (HNSCC) was investigated in a cohort study of 445 subjects. IL-2 and IL-6 genotypes were determined by real-time PCR. Cox regression was used to estimate hazard ratios (HR) and 95% confidence intervals (95%CI) of disease-specific survival according to anatomical sites of the head and neck. Mean age was 56 years and most patients were males (87.6%). Subjects with 5 or more years of schooling had better survival in larynx cancer. Smoking had no effect on HNSCC survival, but alcohol consumption had a statistically significant effect on larynx cancer. IL-2 gene +114 G/T (HR = 0.52; 95%CI = 0.15-1.81) and T/T (HR = 0.22; 95%CI = 0.02-3.19) genotypes were associated with better survival in hypopharynx cancer. IL-2 +114 G/T was a predictor of poor survival in oral cavity/oropharynx cancer and larynx cancer (HR = 1.32; 95%CI = 0.61-2.85). IL-2 -384 G/T was associated with better survival in oral cavity/oropharynx cancer (HR = 0.80; 95%CI = 0.45-1.42) and hypopharynx cancer (HR = 0.68; 95%CI = 0.21-2.20), but an inverse relationship was observed for larynx cancer. IL-6 -174 G/C was associated with better survival in hypopharynx cancer (HR = 0.68; 95%CI = 0.26-1.78) and larynx cancer (HR = 0.93; 95%CI = 0.42-2.07), and C/C reduced mortality in larynx cancer. In general, our results are similar to previous reports on the value of education, smoking, alcohol consumption, and IL-2 and IL-6 genetic polymorphisms for the prognosis of HNSCC, but the risks due to these variables are small and estimates imprecise.

Alcohol and tobacco, and the risk of cancers of the upper aerodigestive tract in Latin America: a case-control study

BACKGROUND

Cancers of the upper aerodigestive tract (UADT; including oral cavity, pharynx, larynx and oesophagus) have high incidence rates all over the world, and they are especially frequent in some parts of Latin America. However, the data on the role of the major risk factors in these areas are still limited.

METHODS

We have evaluated the role of alcohol and tobacco consumption, based on 2,252 upper aerodigestive squamous-cell carcinoma cases and 1,707 controls from seven centres in Brazil, Argentina, and Cuba.

RESULTS

We show that alcohol drinkers have a risk of UADT cancers that is up to five times higher than that of never-drinkers. A very strong effect of aperitifs and spirits as compared to other alcohol types was observed, with the ORs reaching 12.76 (CI 5.37-30.32) for oesophagus. Tobacco smokers were up to six times more likely to develop aerodigestive cancers than never-smokers, with the ORs reaching 11.14 (7.72-16.08) among current smokers for hypopharynx and larynx cancer. There was a trend for a decrease in risk after quitting alcohol drinking or tobacco smoking for all sites. The interactive effect of alcohol and tobacco was more than multiplicative. In this study, 65% of all UADT cases were attributable to a combined effect of alcohol and tobacco use.

CONCLUSIONS

In this largest study on UADT cancer in Latin America, we have shown for the first time that a prevailing majority of UADT cancer cases is due to a combined effect of alcohol and tobacco use and could be prevented by quitting the use of either of these two agents.

Involvement of CYP1A1, GST, 72TP53 polymorphisms in the pathogenesis of thyroid nodules

Specific genotypes appear to be related to the development of thyroid disease. We examined whether polymorphisms of the genes CYP1A1, GSTM1, GSTT1, and TP53 at codon 72 are associated with increased risk for thyroid nodules. Blood samples were obtained from 122 thyroid patients with nodules and from 134 healthy control individuals from Goiânia city, GO, Brazil. We found no significant association of CYP1A1m1 and CYP1A1m2 genotypes with thyroid diseases (P > 0.05). The null genotypes of GSTM1 and GSTT1 genes were predominant in patients with nodules, indicating that individuals that possess these genotypes have a predisposition for thyroid disease. The genotype p53Arg Arg was associated with a low risk for thyroid cancer (OR = 0.15; P < 0.0001), indicating that the arginine allele in homozygosis could have a protective effect against carcinogenesis. On the other hand, the p53ArgPro genotype was significantly associated with malignant neoplastic nodules (OR = 3.65; P = 0.001). Interindividual variation in susceptibility to thyroid diseases could provide new perspectives for early diagnosis, prognosis and treatment, indicating which patients with thyroid nodules will benefit from treatment, depending on specific polymorphic profiles.

Childhood leukaemias and lymphomas in Greece (1996-2006): a nationwide registration study

BACKGROUND

Monitoring time trends in the incidence of childhood leukaemias and lymphomas requires efficient and continuous data collecting systems. In countries without official cancer registries, such as Greece, ad hoc nationwide registration of incident childhood leukaemias and lymphomas could help elucidate the underlying aetiology and monitor socioeconomic differentials in health care delivery.

METHODS

We registered all cases and produced age, gender, type and immunophenotype specific figures and overall crude and age adjusted annual incidence rates and secular trends for 863 leukaemia and 311 lymphoma incident cases diagnosed in children <15 years of age across Greece during 1996-2006, namely the first 11 years of the Nationwide Registry for Childhood Hematological Malignancies.

RESULTS

The epidemiological profiles of leukaemias/lymphomas in Greece are similar to those in industrialised countries. No secular trends are observed for either malignancy during the studied period. However, the calculated incidence for leukaemia (46.60 cases per 1 million children annually) is among the highest in the EU-27 (19% higher than average; p<0.001), whereas that for lymphoma (16.8 cases per 1 million children annually) is around the EU-27 average.

CONCLUSIONS

Minimal secular changes in childhood leukaemias/lymphomas have been noted recently in the EU-27, which cannot be easily explained in countries with small populations. Therefore, centralised EU databases such as the Automated Childhood Cancer Information System (ACCIS) should be enlarged to generate sufficient statistical power for monitoring time trends. It would be interesting to explore whether different lifestyle patterns across the EU might be responsible for the observed excess leukaemia incidence in countries such as Greece.

Interaction between tobacco and alcohol consumption and the risk of cancers of the upper aero-digestive tract in Brazil

The authors investigated the joint effects of tobacco and alcohol consumption on the risk of squamous cell carcinomas of the upper aero-digestive tract (UADT) using data from a hospital-based case-control study conducted in southern Brazil, 1986-1989. A total of 784 cases of cancers of the mouth, pharynx, and larynx and 1,578 non-cancer controls matched on age, sex, hospital catchment area, and period of admission were interviewed about their smoking and drinking habits and other characteristics. Using logistic regression, evidence was found for interaction between the cumulative exposures for smoking and alcohol on UADT cancer risk. The joint effects for pharyngeal cancers exceeded the levels expected under a multiplicative model for moderate smokers (p = 0.007). There was little statistical evidence, however, for interaction on cancers of the mouth (p = 0.28) or larynx (p = 0.95). Among never smokers, heavy drinkers had 9.2 times (95% confidence interval 1.7, 48.5) greater risk of cancers of mouth, pharynx, and supraglottis than never drinkers, with a dose-response trend (p = 0.013) with cumulative consumption. The authors conclude that the interaction occurring in the pharynx between smoking and alcohol on UADT cancers is not uniform, with varying effects depending on the level of smoking exposure. Alcohol may act as both a promoter for tobacco and as an independent risk factor.

Use of wood stoves and risk of cancers of the upper aero-digestive tract: a case-control study

BACKGROUND

Incidence rates for cancers of the upper aero-digestive tract in Southern Brazil are among the highest in the world. A case-control study was designed to identify the main risk factors for carcinomas of mouth, pharynx, and larynx in the region. We tested the hypothesis of whether use of wood stoves is associated with these cancers.

METHODS

Information on known and potential risk factors was obtained from interviews with 784 cases and 1568 non-cancer controls. We estimated the effect of use of wood stove by conditional logistic regression, with adjustment for smoking, alcohol consumption and for other sociodemographic and dietary variables chosen as empirical confounders based on a change-in-estimate criterion.

RESULTS

After extensive adjustment for all the empirical confounders the odds ratio (OR) for all upper aero-digestive tract cancers was 2.68 (95% confidence interval [CI] : 2.2-3.3). Increased risks were also seen in site-specific analyses for mouth (OR = 2.73; 95% CI: 1.8-4.2), pharyngeal (OR = 3.82; 95% CI: 2.0-7.4), and laryngeal carcinomas (OR = 2.34; 95% CI: 1.2-4.7). Significant risk elevations remained for each of the three anatomic sites and for all sites combined even after we purposefully biased the analyses towards the null hypothesis by adjusting the effect of wood stove use only for positive empirical confounders.

CONCLUSIONS

The association of use of wood stoves with cancers of the upper aero-digestive tract is genuine and unlikely to result from insufficient control of confounding. Due to its high prevalence, use of wood stoves may be linked to as many as 30% of all cancers occurring in the region.

Relationship between dental factors and risk of upper aerodigestive tract cancer

We examined the relationship between dental health variables and risk of upper aerodigestive tract (UADT) cancers in a case-control study in Southern Brazil. The study population included 717 cases of cancers of the mouth, pharynx, and larynx and 1434 controls matched on age, gender, period of admission and study site. The association with dental factors was investigated by conditional logistic regression using extensive adjustment for a priori and empirical confounders, including tobacco and alcohol consumption, diet and sociodemographic variables. Lifetime use of dentures was not associated with risk of any UADT cancer, but history of oral sores secondary to ill-fitting dentures was associated with cancers of the mouth (odds ratio [OR] = 2.3, 95% confidence interval [CI] 1.2-4.6) and of the pharynx (OR = 2.7, 95% CI 1.1-6.2) among those using dentures. The association for mouth cancers was restricted primarily to an increased risk of tongue neoplasms (OR = 9.1, 95% CI 1.9-43.4). Less than daily tooth brushing frequency was also associated with risk of cancer of the tongue (OR = 2.1, 95% CI 1.0-4.3) and of other parts of the mouth (OR = 2.4, 95% CI 1.0-5.4). Having broken teeth was not significantly associated with risk of UADT cancer of any site. We conclude that poor oral hygiene due to infrequent tooth brushing and sores caused by dentures are risk factors for cancer of the mouth and that these associations are unlikely to be due to insufficient control of confounding.

137Cesium-induced chromosome aberrations analyzed by fluorescence in situ hybridization: eight years follow up of the Goiânia radiation accident victims

The radiation accident in focus here occurred in a section of Goiânia (Brazil) where more than a hundred individuals were contaminated with 137Cesium on September 1987. In order to estimate the absorbed radiation doses, initial frequencies of dicentrics and rings were determined in 129 victims [A.T. Ramalho, PhD Thesis, Subsidios a tecnica de dosimetria citogenetica gerados a partir da analise de resultados obtidos com o acidente radiologico de Goiânia, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil, 1992]. We have followed some of these victims cytogenetically over the years seeking for parameters that could be used as basis for retrospective radiation dosimetry. Our data on translocation frequencies obtained by fluorescence in situ hybridization (FISH) could be directly compared to the baseline frequencies of dicentrics available for those same victims. Our results provided valuable information on how precise these estimates are. The frequencies of translocations observed years after the radiation exposure were two to three times lower than the initial dicentrics frequencies, the differences being larger at higher doses (>1 Gy). The accuracy of such dose estimates might be increased by scoring sufficient amount of cells. However, factors such as the persistence of translocation carrying lymphocytes, translocation levels not proportional to chromosome size, and inter-individual variation reduce the precision of these estimates.

Molecular analysis of T-lymphocyte HPRT- mutations in individuals exposed to ionizing radiation in Goiânia, Brazil

We have characterized 54 HPRT- point mutations in T-lymphocytes from 17 individuals exposed to ionizing radiation of 137Cs in Goiania, Brazil and compared this spectrum to that of 30 HPRT- mutants from 9 unexposed Brazilian controls. The average internal exposure of the exposed group was 205 mCi, and the average external exposure was 1.7 Gy. The average HPRT- mutant frequency for the exposed group was 13.3 x 10(-5), approximately a 10-fold increase over the mutant frequency of the unexposed controls, which was 1.56 x 10(-5). The types of point mutations characterized included base substitutions, small deletions, frameshifts, insertions, complex mutations, and losses of exon sequences from the mRNA. The relative frequency of the different mutation types was similar in the two studied groups. However, in our study the distribution of events within the hprt coding sequence seemed to cluster at the same regions of the gene. These observations imply that the hprt gene does not present a homogeneous target to radiation mutagenesis, and perhaps this class of information may be used to detect radiation exposure in human populations.

Monitoring hprt mutant frequency over time in T-lymphocytes of people accidentally exposed to high doses of ionizing radiation

Modern technologies have provided the opportunity to monitor mutations in people in vivo. The subjects of this study were accidentally exposed to 137Cesium in a radiological accident that occurred in September 1987 in Goiânia, Brazil, during which more than 150 people received doses greater than 0.1 Gy and as high as 7 Gy. The objective of this study was to determine how long the hprt mutant T-cells in the peripheral blood contribute to mutant frequency by examining the time-course of the T-lymphocyte response to ionizing radiation. This report describes the results obtained over a period of 2.3 to 4.5 years subsequent to the accident, from 11 subjects with doses ranging from 1 to 7 Gy, and from nine control subjects selected from the same population. The mean In MF (+/- SE) of the control group was 2.5 (+/- 0.2) + In10(-6). The exposed group had a significantly increased mutant frequency; the mean In MF (+/- SE) were 3.3 (+/- 0.3) + In10(-6), 2.8 (+/- 0.2) + In10(-6), and 2.3 (+/- 0.2) + In10(-6), in the years 1990-1992 respectively. Based on the decline of mutant frequency and using Buckton's models [Buckton et al. (1967): Nature 214:470-473], we demonstrated that mutant T-cells have a short-term memory with a half-life of 2.1 years. This relatively short half-life limits the effective use of the hprt assay as the method of choice to monitor past exposure. The data also demonstrate a positive correlation with age, and an inverse correlation with plating efficiency.

Lifespan of human lymphocytes estimated during a six year cytogenetic follow-up of individuals accidentally exposed in the 1987 radiological accident in Brazil

Following the radiological accident which occurred in the city of Goiania (Brazil), in September 1987, a cytogenetic follow-up of 15 exposed patients was started, aiming to observe the mean lifetime of lymphocytes containing dicentric and ring aberrations. The results suggest that the disappearance rate of unstable aberrations follows a two-term exponential function. Up to 470 days after exposure, there is a rapid fall in the aberration frequency. After 470 days, the disappearance rate is very slow. These results may reflect different subpopulations of human lymphocytes, with different lifespans. The estimated average half-time of elimination of dicentrics and rings among the highly exposed group (doses above 1 Gy) was 110 days for the initial period after the exposure (up to 470 days). This value is significantly shorter than the usually accepted value of 3 years reported in the literature. Statistical analysis of possible correlations between the individual half-times and biological parameters, such as sex, age, leukopenia level shown during the critical period, absorbed dose (initial frequency of chromosomal aberrations) and the administration of the bone marrow stimulating factor (rHuGM-CSF) was performed. None of these parameters showed a correlation with the half-time of disappearance of chromosomal aberrations. For the individuals who had received less than 1 Gy the disappearance of aberrations was slower, with a half-time of 160 days during the period up to 470 days after exposure. Mean disappearance functions of unstable chromosome aberrations were inferred, to be applied in accident situations in which there is a blood sampling delay.

Maté, coffee, and tea consumption and risk of cancers of the upper aerodigestive tract in southern Brazil

Consumption of maté, a tea-like infusion of the herb Ilex paraguariensis, is common in South America. Drinkers have high risks of upper aerodigestive tract cancers, but it is conceivable that this high risk may be attributable to confounding by smoking alcohol, and other exposures. To test this hypothesis, we analyzed the data from a case-control study of upper aerodigestive tract cancers conducted in Southern Brazil. We matched noncancer controls (N = 756) to cases (N = 378) on the basis of age, sex, and period of admission. We estimated the effect of mateé consumption by conditional logistic regression with adjustment for smoking, alcohol, sociodemographics, and several dietary items, considered as confounders. The unadjusted relative risk (RR) for all upper aerodigestive tract cancers was 2.1 [95% confidence interval (CI) = 1.6-2.7]. Some excess risk persisted after adjustment for potential confounders (RR = 1.6; 95% CI = 1.2-2.2). Most of the excess risk for maté drinkers was for oral (RR = 1.9; 95% CI = 1.1-3.3) and laryngeal (RR = 2.2; 95% CI = 2.2; 95% CI = 1.1-4.5) cancers. There was no evidence of associations with coffee and tea drinking. We conclude that the association of maté consumption with upper aerodigestive tract cancer risk is unlikely to result from insufficient control of confounding by critical exposures. Owing to its high prevalence in Southern South America, maté drinking may be linked to as many as 20% of all cases occurring in this region.

Human micronucleus counts are correlated with age, smoking, and cesium-137 dose in the Goiânia (Brazil) radiological accident

A random sample of 276 people representing control, direct exposure, and probable indirect exposure in the Goiânia, Brazil radiological accident was examined using micronuclei as indicators of cytogenetic damage. The Goiânia subjects were analyzed for interactions of age, lifestyle, and ionizing radiation dose. Increases in micronucleus frequencies were most strongly correlated with the dose of ionizing radiation, but age, alcohol consumption, and smoking habits also affected micronucleus frequencies. Despite these additional influences, micronucleus frequencies can be useful as biological dosimeters.

Lateness of diagnosis of oral and oropharyngeal carcinoma: factors related to the tumour, the patient and health professionals

The risk of presenting with advanced stage vs. early stage disease was evaluated in a prospective study of 336 consecutive patients with oral and oropharyngeal carcinomas referred to three head and neck surgery services in Sao Paulo, Curitiba and Goiania during the period from February 1986 to December 1988. Income and educational levels were not associated with stage distribution. The risk of having advanced disease was dependent upon male gender. Another important determinant of advanced stage was tumour location on the less visible surfaces of the oral cavity and oropharynx. Although there was a clear increase in delay of referral among cases who were seen by more than one health professional, duration of symptoms and patient and professional delays were not associated with the risk of advanced disease in unifactorial analysis. The following factors were independently associated with the risk of advanced disease for lip carcinoma: a painful ulcer, alcoholism and delay caused by a non-specialist medical doctor. The risk factors associated to advanced oral carcinoma were: type of lesion, odynophagia/dysphagia, delay caused by a dentist and delay caused by a non-specialist medical doctor. Two of the most important immediate consequences of advanced stage were a conspicuous increase in treatment costs and a longer hospital stay.

A cytogenetic follow-up study of the victims of a radiation accident in Goiania (Brazil)

A radiation accident involving a cesium-137 therapy source occurred in Goiania (Brazil) in September 1987, in which more than 50 individuals were exposed to moderate to high doses (0.2-7 Gy) of gamma-radiation. A cytogenetic technique (i.e., frequencies of dicentrics and rings in peripheral lymphocytes) was employed to estimate the absorbed radiation dose. The follow-up study extending over more than 1 year indicated a decline in the frequencies of dicentrics in the lymphocytes. Using chromosome-specific biotinylated library probes for chromosomes 1, 2, 8 and 19, we studied the frequencies of chromosomal translocations and deletions and the incidence of aneuploidy in the lymphocytes of exposed individuals. In some individuals there was a significant increase in the frequency of translocations and aneuploidy. In other experiments, in which the frequencies of HPRT mutations were determined in lymphocytes using the BrdU-labeling method, some individuals showed an increase (from about 2- to 50-fold) in mutant frequencies.

Risk factors for oral cancer in Brazil: a case-control study

A case-control study of risk factors for carcinomas of the tongue, gum, floor, and other specified parts of the mouth was conducted in 3 metropolitan areas in Brazil: São Paulo (southeast), Curitiba (south), and Goiânia (central-west). We analyzed information on demographics, occupational history, environmental exposures, tobacco smoking and alcohol drinking habits, as well as diet, oral and other health characteristics obtained from interviews with 232 cases and 464 hospital non-cancer controls matched for 5-year age-group, sex, hospital catchment area and trimester of admission. Tobacco and alcohol consumption were the strongest risk factors irrespective of the anatomical site. The adjusted relative risks (RR) for ever vs. never smokers were: 6.3, 13.9, and 7.0, for industrial-brand cigarettes, pipe, and hand-rolled cigarettes, respectively. A strong correlation was seen between number of pack-years and risk. The RR for the heaviest vs. the lowest consumption categories (greater than 100 vs. less than 1 pack-years) was 14.8. Risk levels generally decreased to those of never smokers after 10 years had elapsed since stopping smoking. The risk associated with alcohol was mostly evident for wine (cancer of the tongue) and "cachaça" (all sites), a hard liquor distilled from sugar cane. Other important risk factors were drinking "chimarrão" (a type of maté), use of a wood stove for cooking, and frequent consumption of charcoal-grilled meat and manioc. Oral hygiene characteristics represented correlates of disease risk. A significant protective effect was observed for consumption of carotene-rich vegetables and citric fruits, but not for green vegetables in general.