Pre-diagnostic vitamin D concentrations and cancer risks in older individuals: an analysis of cohorts participating in the CHANCES consortium

The associations of circulating 25-hydroxyvitamin D [25(OH)D] concentrations with total and site-specific cancer incidence have been examined in several epidemiological studies with overall inconclusive findings. Very little is known about the association of vitamin D with cancer incidence in older populations. We assessed the association of pre-diagnostic serum 25(OH)D levels with incidence of all cancers combined and incidence of lung, colorectal, breast, prostate and lymphoid malignancies among older adults. Pre-diagnostic 25(OH)D concentrations and cancer incidence were available in total for 15,486 older adults (mean age 63, range 50–84 years) participating in two cohort studies: ESTHER (Germany) and TROMSØ (Norway); and a subset of previously published nested-case control data from a another cohort study: EPIC-Elderly (Greece, Denmark, Netherlands, Spain and Sweden) from the CHANCES consortium on health and aging. Cox proportional hazards or logistic regression were used to derive multivariable adjusted hazard and odds ratios, respectively, and their 95 % confidence intervals across 25(OH)D categories. Meta-analyses with random effects models were used to pool study-specific risk estimates. Overall, lower 25(OH)D concentrations were not significantly associated with increased incidence of most of the cancers assessed. However, there was some evidence of increased breast cancer and decreased lymphoma risk with higher 25(OH)D concentrations. Our meta-analyses with individual participant data from three large European population-based cohort studies provide at best limited support for the hypothesis that vitamin D may have a major role in cancer development and prevention among European older adults.     

Health effects of phenoxy herbicides. A review

A review of epidemiological studies on the health effects of exposure to phenoxy herbicides suggests that exposure may be associated with an increased incidence of cancer and unfavorable outcomes of pregnancy. Studies on cancer have found increased risks of 5.3, 6.8 and 3.96 for soft-tissue sarcoma, 7.7 and 6.0 for stomach cancer, 2.05 for lung cancer, 4.8 for lymphoma, 2.3 for all cancers combined, and 5.2 for liver cancer after exposure to 2,4,5-T or dioxin contaminants. Several studies have suggested a possible increase in birth defects after paternal exposure. An increased risk of hydatidiform mole is suggested by Vietnamese studies on the effects of maternal exposure.     

Estimated effects of hydrazine exposure on cancer incidence and mortality in aerospace workers

BACKGROUND: Animal studies suggest that hydrazine is a lung carcinogen, but human studies have been rare, rather small, and limited to cancer mortality. METHODS: We examined cancer mortality and incidence in a cohort of aerospace workers with varying exposure to hydrazine contained in rocket fuels-extending previous mortality follow-up from 1994 to 2001 and investigating cancer incidence for the period 1988-2000 using population-registry data. We newly estimated hydrazine effects adjusting for occupational exposures to other carcinogens assessed through a job-exposure matrix. Rate-ratio estimates were derived from Cox proportional hazards and random-effects models using time-dependent exposure measures for hydrazine adjusting for trichloroethylene, polycyclic aromatic hydrocarbons, benzene, and mineral oil exposures. RESULTS: Exposure to hydrazine was positively associated with lung cancer incidence (estimated rate ratio for high vs low exposure with 20-year lag = 2.5; 95% confidence interval = 1.3-4.9) and with colorectal cancer incidence (2.2; 1.0-4.6). Dose-response associations were observed for both outcomes; similar associations were found for lung cancer mortality but not for colorectal cancer mortality. Effect estimates for cancers of the pancreas, blood and lymph system, and kidneys were based on small numbers rendering our analyses uninformative, and patterns considering exposure levels and lags were inconsistent. Use of random-effect models did not change our results. CONCLUSIONS: The findings reported here are consistent with our previous results for lung cancer mortality; our new results suggest that exposure to hydrazine increases the risk of incident lung cancers. We also found, for the first time, an increased risk of colon cancers. Results for other cancer sites are inconclusive.     

Mortality surveillance and occupational hazards: the Solutia mortality experience 1980-94

OBJECTIVES—Several investigators argue that company wide mortalities for recent workers allow early identification of potential workplace hazards. Mortalities for recent workers were compared with published studies of workers with specific exposures in the same company to find whether mortality surveillance results could be used to identify previously unknown health effects from workplace hazards.
METHODS—Relative risks for causes of death in published substance specific studies at the plants were compared with the relative risks in the mortality surveillance of workers 20 or more years after first being employed.
RESULTS—As reported by other companies, low mortalities were found among workers in the mortality surveillance. The mortality surveillance reports often found no increased risk of disease at plants in which substance specific studies had found no effects. However, disease specific relative risks were not found by the mortality surveillance predictions of relative risks in the substance specific studies with increased risk.
CONCLUSION—Mortality surveillance is of limited use for identifying health effects from past workplace exposures to specific materials. The healthy worker and survivor effects, the failure to identify subsets of workers exposed to potentially toxic substances, the typically long induction period between exposure and disease, and the inability of recent mortality levels to reflect historical conditions all may make it difficult to use mortality surveillance to identify workplace hazards. Combining mortality surveillance with studies of workers with potentially toxic exposures helps identify occupational hazards.


Keywords: mortality surveillance; occupational cancer; bladder cancer; leukaemia     

Increasing incidence and mortality related to liver cancer in Australia: time to turn the tide

Objective : Assess national and jurisdictional incidence and mortality trends for primary liver cancer in Australia. Methods : Analysis of Australian Cancer Incidence and Mortality data published in 2017 by the AIHW. Age‐standardised rates (ASR) for 1982 to 2014/2015. Piecewise linear regression was used to assess temporal trends. For the purposes of comparison, data were also extracted for all cancers with greater burdens of disease (lung, colorectal, breast, prostate, pancreatic, and brain cancers and melanoma of the skin). Results : Since 1982, the average annual percentage change (AAPC) for ASR incidence of liver cancer was 4.858% (95%CI 4.558–5.563). This marked a 306% increase from 1.822/100,000 persons (95%CI 1.586–2.058) in 1982 to 7.396/100,000 persons (95%CI 7.069–7.723) in 2014. AAPC for ASR mortality was 3.013% (95%CI 2.448–3.521): an increase of 184% from 2.323/100,000 persons (95%CI 2.052–2.594) in 1982 to 6.593/100,000 (95%CI 6.290–6.896) in 2015. ASR incidence and mortality were highest in the NT (12.607/100,000 persons), VIC (8.229/100,000) and NSW (7.798/100,000). In comparison to the other selected cancers, higher AAPC for both incidence and mortality of liver cancer were observed. Conclusion : Incidence and mortality associated with liver cancer have increased substantially in the past three decades, in contrast to the improved outcomes observed for many other cancers. Jurisdictional incidence rates reflect higher prevalence of hepatitis B and C. Implications for public health : In the context of Australian cancer prevention and care programs, liver cancer is an outlier. Strategies to mitigate risk factors and improve surveillance of liver health for at‐risk groups are urgently required.     

Risk of respiratory cancer around a sewage plant in Prato,Italy

In this study, the authors evaluated the risk of respiratory cancer related to environmental pollutants among a population that resided near a sewage plant in Prato, Italy. Subjects included lung cancer deaths (1987-1996) and incident cases of lung and laryngeal cancers (1987-1994) among residents of Prato. The authors used the mortality or incidence rates for the entire population of Prato (by gender and by 5-yr age group) to calculate the expected cases in each census unit. Data were analyzed and adjusted for an index of social deprivation (Stone test). Among males, the excess risk of lung cancer mortality decreased as distance from the plant increased for 2 time periods (1987-1996 [p = .008] and 1990-1996 [p = .030]) and for lung cancer incidence during 1987-1994 (p = .011). Similar results were obtained when sewage plant workers were excluded from the analysis. A similar, but not statistically significant, trend was observed among female incident lung cancer cases, as well as among male incident laryngeal cancer cases. Despite methodological limitations common to geographic studies, the results were consistent with those previously published on mortality excesses for lung cancer among plant workers under study. The role of environmental pollutants as a risk for respiratory cancer must be further clarified with additional epidemiological studies and an environmental monitoring program.     

Histologic differences in occupational risks of lung cancer incidence

A five-year total community study of lung cancer incidence by occupation revealed that 1) virtually all the cases occurred in smokers; 2) all major histologic types of lung cancer were strongly associated with smoking behavior; 3) in most high-risk occupations the significant elevations of risk were limited to one or two histologic types, a specificity suggestive of the importance of workplace carcinogen exposure; and 4) both sensitivity and specificity of the search for occupations with lung cancer hazards were greatly increased by use of histologic type rates rather than total lung cancer rates. The epidemiologic differences among histologic types suggest that the lung cancers might be a group of neoplastic diseases which share a major risk factor (smoking) in common but which differ in respect to exposure to other carcinogens. Eventual control of our lung cancer epidemic will require the allocation of much greater resources to documentation of the occupational risks.     

Cancer among meat industry workers

Several studies have found increased risks of cancer among workers in the meat industry, particularly lung and hematologic cancers. Relevant publications were obtained through a computerized literature search with the key words "cancer", "lung cancer", "hematologic neoplasms", "meat products", "abattoirs", and "slaughterhouses", and the evidence available from analyses of routine data, proportionate mortality and incidence studies, and cohort and case-control studies was reviewed. These analyses suggest a significant excess lung cancer risk among meat workers. This risk was associated the most strongly with exposure to animal slaughtering or freshly slaughtered meat or to biological material contained in blood and animal fecal matter, and it was greater than could be attributed to smoking. This finding suggests an etiologic role for biological exposure; however, the specific exposure(s) responsible are unknown, and further research is clearly required. The results of studies of hematologic cancers have been less consistent, but they suggest a small excess risk for leukemia in association with similar exposures.     

Estimation of annual incidence of lung cancer associated with work place exposure to passive smoking in France

This study attempted to estimate the number of annual new cases of lung cancer from workplace exposure to Environmental Tobacco Smoke (ETS) in France. The number of new lung cancer cases attributable to workplace ETS exposure in France was estimated with regard to the following factors: excess risk of lung cancer from workplace ETS exposure, incidence of lung cancer in non-exposed non-smokers, and number of French workers exposed to passive smoking. The excess risk of lung cancer from workplace ETS exposure was estimated as from 0.12 to 0.39 by different references. The French workforce, regularly exposed to ETS in their workplace is about 3.2 millions. The incidence of lung cancer of non-smokers without exposure to ETS is between 3.7 to 10 per hundred thousand. If these three factors are combined, it is estimated that exposure to workplace passive smoking causes around 14 to 125 new cases of lung cancer each year in France. New lung cancer cases from workplace exposure to ETS represent a few percent of all occupational lung cancers, and a minuscule number in regards to the whole lung cancer annual incidence (14 to 125 for 23,000 lung cancers in France=0.06% to 0.54%).     

Incidence and mortality due to cancer in Navarre, 1998-2002. Trends in the last 30 years

Between 1998-2002, 16,952 new cases of cancer were registered in Navarre. In men, the most frequently diagnosed cancers were in the following order: prostate, lung, colon and rectum, bladder and stomach, which accounted for 63.2%. In women, the sites were breast, colon and rectum, corpus uteri, stomach and ovary, which accounted for 57.6% of the cases. In the same period, 1998-2002, 4,127 men and 2,470 women died from cancer. Sixty percent of all deaths due to malign tumours in men were due to cancer of the lung, prostate, colon and rectum, stomach and bladder. In women this was due to cancers of colon and rectum, breast, stomach, pancreas and lung, which accounted for 49% of the cases. In men in Navarre there has been an increase in the incidence rates of cancer of the prostate, kidney and non-Hodgkin lymphoma. Avoidable cancers such as those related to smoking (lung, oral cavity and pharynx or pancreas) continue to rise, and represent a greater global risk of dying from cancer in the latest period studied than in the decades of the 1970s and 1980s. From 1995 up to the present, mortality due to cancer has moved from occupying the second place to become the first cause of death among men in Navarre. The global risk of death due to cancer in men is now equal to the first period studied, 1975-1977. Amongst women the global risk of death due to cancer fell by 25% between 1975 and 2002, basically at the cost of breast and stomach cancer. Tumours related to smoking increased both in mortality and in incidence and appear as a significant health problem amongst women in Navarre. Breast cancer has increased in incidence, with lower mortality figures than those of the first period 1975-1977. Invasive cancer of the cervix remains at very low rates in comparison with many European countries, including Spain. In both sexes colorectal and skin cancer has increased, while the incidence and mortality of stomach cancer continues to fall.     

Risk of Respiratory Cancer around a Sewage Plant in Prato,Italy

In this study, the authors evaluated the risk of respiratory cancer related to environmental pollutants among a population that resided near a sewage plant in Prato, Italy. Subjects included lung cancer deaths (1987-1996) and incident cases of lung and laryngeal cancers (1987-1994) among residents of Prato. The authors used the mortality or incidence rates for the entire population of Prato (by gender and by 5-yr age group) to calculate the expected cases in each census unit. Data were analyzed and adjusted for an index of social deprivation (Stone test). Among males, the excess risk of lung cancer mortality decreased as distance from the plant increased for 2 time periods (1987-1996 [p = .008] and 1990-1996 [p = .030]) and for lung cancer incidence during 1987-1994 (p = .011). Similar results were obtained when sewage plant workers were excluded from the analysis. A similar, but not statistically significant, trend was observed among female incident lung cancer cases, as well as among male incident laryngeal cancer cases. Despite methodological limitations common to geographic studies, the results were consistent with those previously published on mortality excesses for lung cancer among plant workers under study. The role of environmental pollutants as a risk for respiratory cancer must be further clarified with additional epidemiological studies and an environmental monitoring program.     

Caloric intake, body weight, and cancer: a review

The literature is reviewed for evidence concerning the relation between caloric intake, body weight, and cancer. Convincing experimental data regarding caloric intake and benign and malignant tumor incidence have been available since the 1940s and demonstrate that caloric restriction significantly reduces tumor incidence for a variety of tumor types in several animal models. Some epidemiological investigations provide evidence for a positive calorie-cancer association in humans, although it is difficult (in these studies) to separate the effects of calories per se from those of dietary fat. A larger number of investigations have evaluated body weight alone, and high relative body weight or high caloric intake has been associated with increased risk of cancer of the breast, colon, rectum, prostate, endometrium, kidney, cervix, ovary, thyroid, and gallbladder. In contrast, lung, bladder, and stomach cancers appear to be inversely associated with body weight, and some prospective studies of men demonstrate greater total cancer mortality among lean individuals. However, in their analyses, few of these latter investigations considered the effects of cigarette smoking, antecedent illness, or competing causes of death. While the relations between caloric intake, other dietary macronutrients (e.g., fat), and body weight are complex and require further investigation, a complete review of the data suggests that reducing caloric intake and relative body weight may lead to a considerable decrease in cancer risk in humans.     

Meta-analysis of studies of occupational exposure to vinyl chloride in relation to cancer mortality

OBJECTIVE: A meta-analysis was made of studies addressing occupational exposure to vinyl chloride in relation to cancer mortality. METHODS: Two recently updated multicenter cohort studies and six smaller studies were identified. For selected neoplasms, standardized mortality ratios (SMR) and 95% confidence intervals (95% CI) were abstracted (or calculated from raw data). In cases of lack of heterogeneity (P-value > or = 0.01), meta-analyses were conducted using a random-effects model. RESULTS: With SMR values ranging from 1.63 to 57.1, all six studies for which these ratios could be obtained suggested an increased risk of liver cancer. For four of these studies, excesses persisted when known cases of angiosarcoma of the liver (ASL) were excluded. The meta-SMR for liver cancers other than ASL (based on the 2 large cohorts) was 1.35 (95% CI 1.04-1.77). The meta-SMR for lung cancer was 0.90 (95% CI 0.77-1.00, based on 5 studies), although higher SMR values were reported in early studies. The meta-SMR for brain cancer, based on 5 studies, was 1.26 (95% CI 0.98-1.62). For soft tissue sarcomas, the meta-SMR based on 4 studies was 2.52 (95% CI 1.56-4.07). The meta-SMR for lymphatic and hematopoietic neoplasms in the 2 large studies was 0.90 (95% CI 0.75-1.01), although 3 of the smaller studies reported significant excesses. CONCLUSIONS: Apart from the known risk of ASL, workers exposed to vinyl chloride may experience an increased risk of hepatocellular carcinoma and soft-tissue sarcoma; however, these results may have been influenced by the underdiagnosis of true ASL. Increased mortality from lung and brain cancers and from lymphatic and hematopoietic neoplasms cannot be excluded; mortality from other neoplasms does not appear to be increased.     

Critical review of the epidemiological literature on occupational exposure to perchloroethylene and cancer

Objectives Of an estimated 500,000 workers in the USA potentially exposed to perchloroethylene (PCE), the largest share is employed in the dry-cleaning industry. PCE, a non-flammable solvent, has commercial applications as a chemical intermediate, metal degreaser and, since the 1950s, primary solvent in the dry-cleaning industry. The International Agency for Research on Cancer (IARC) currently finds sufficient evidence to designate PCE as carcinogenic in animals, with limited evidence in humans. With regard to occupational exposure through dry-cleaning, PCE is considered to be possibly carcinogenic to humans. This review was conducted to assess the current epidemiological literature on PCE and specific cancers.Methods A comprehensive search was conducted to identify all available epidemiological literature pertaining to the carcinogenic effects of PCE. Forty-four papers that provided reasonable data on up to 17 cancer sites were critically reviewed in the context of the available background literature for each cancer site and were assessed on the basis of specified methodological and scientific quality criteria.Results While all the epidemiological studies selected for review investigated similar exposure–health outcome relationships, there was a broad diversity of proxy measurements of exposure to PCE, as well as numerous specific cancer outcomes of interest. The widespread lack of valid exposure measurements or other adequate indicators of potential for exposure were consistent limitations. We found no evidence of an association between breast, prostate, skin or brain cancer and exposure to PCE. A relationship between PCE and cancer of the following sites was considered unlikely: oral cavity, liver, pancreas, cervix lung. Scientific evidence was inadequate for laryngeal, kidney, esophageal and bladder cancers.Conclusions The current epidemiological evidence does not support a conclusion that occupational exposure to PCE is a risk factor for cancer of any specific site. Priority areas in which additional data are most needed include cancers of the esophagus and bladder.     

Diet quality and subsequent cancer incidence and mortality in a prospective cohort of women

BACKGROUND: We have previously reported on the utility of the Recommended Foods Score (RFS), a measure of overall diet quality, in detecting associations between diet and mortality in a cohort of older women. Using additional follow-up, we have now extended our analysis to detailed studies of associations between RFS and the mortality and incidence from common cancers. METHODS: The RFS, the sum of 23 recommended food items consumed at least weekly, was computed from a 62-item food frequency questionnaire completed at baseline by 42 254 women with a mean age of 61 years. Multivariate adjusted relative risk (RR) of cancer mortality and incidence of the cancers for which we were able to obtain data in relation to quartiles of RFS were examined using proportional hazards regression analyses after a median follow-up period of 9.5 years. RESULTS: We observed that RFS was inversely associated with total mortality (RR = 0.8; P < 0.001) cancer mortality (RR = 0.74; P < 0.001) as well as mortality from cancers of the breast (RR = 0.75; P < 0.06), colon/rectum (RR = 0.49; P < 0.01) and lung (RR = 0.54; P < 0.001). The risk of incident lung cancer (RR = 0.62; P < 0.001) was reduced in women in the highest vs the lowest quartile of RFS; for incident cancers of the breast, colorectum, endometrium, ovaries, and bladder, there was no RFS association. CONCLUSION: A dietary pattern reflecting a higher RFS was associated with decreased overall mortality in women, specifically cancers of the lung, colon/rectum, and to a lesser extent breast. Incidence was only decreased for lung cancers. These observations are consistent with the hypothesis that a high RFS dietary pattern, or associated lifestyle factors, might affect cancer progression and survival.     

Cancer incidence and mortality around the Pan Britannica Industries pesticide factory, Waltham Abbey.

OBJECTIVES: To examine the incidence and mortality of cancer near the Pan Britannica Industries factory, Waltham Abbey, after reports of a possible cluster of all cancers and brain cancer in the vicinity. METHOD: Small area study of cancer incidence 1977-89, and mortality 1981-92, within a 7.5 km radius of the factory site. Postcoded cancer registrations and deaths in the study area were extracted from national data sets held by the Small Area Health Statistics Unit and compared with expected numbers computed by applying national rates stratified for age, sex, and deprivation to the local population (1981 and 1991 censuses). Observed/ expected (O/E) ratios were examined from 0-1 km and 0-7.5 km of the plant, and tests applied for a decline in relative risk with distance up to 7.5 km. RESULTS: There were 12,859 incidence cancers (1977-89) from 0-7.5 km (O/E ratio 1.04; 95% confidence interval (95% CI) 1.02 to 1.06) and 385 from 0-1 km (O/E 1.10; 1.00 to 1.22). There was an excess of skin melanoma from 0-1 km based on 11 cases (O/E 2.13; 1.06 to 3.80), and an excess from 0-7.5 km of cancer of the lung, stomach and pancreas combined, and prostate (O/Es ranged from 1.09 to 1.13). Only the findings from lung cancer were suggestive of a decline in risk with distance, especially in the later period (1982-9). There were 9196 cancer deaths (1981-92) from 0-7.5 km (O/E 1.04; 95% CI 1.02 to 1.06) and 308 from 0-1 km (O/E 1.24; 1.11 to 1.39); and 25507 non-cancer deaths (O/E 1.02; 1.01 to 1.04) from 0-7.5 km and 745 (O/E 1.14; 1.06 to 1.22) from 0-1 km. There was evidence of a decline in mortality with distance for all cancers combined, lung cancer (P = 0.001 for each), and colorectal cancer (P < 0.05), and also for non-cancers (P = 0.001). Proportional mortality analyses suggested a decline in risk with distance for lung cancer (P = 0.003) but not for all cancers or the site specific cancers examined. There was no evidence of an excess in the incidence or mortality from brain cancer. For cancer mortality in the inner-most wards, the findings were, for the most part, well within the range of variation across the region as a whole. CONCLUSIONS: The study provides limited and inconsistent evidence for a localised excess of cancer in the vicinity of the PBI plant. At present, further investigation does not seem warranted other than continued surveillance of mortality and cancer incidence in the locality.     

Mortality among Ontario members of the International Union of Bricklayers and Allied Craftworkers

BACKGROUND: Dust exposed workers may be at increased risk of pneumoconiosis, stomach cancer, lung cancer, and obstructive lung disease. Bricklayers may experience high exposures to silica and inorganic dusts. The aim of this study was to examine the mortality pattern of bricklayers to identify occupational associations with mortality. METHODS: A cohort of 10,953 workers was assembled from records of the International Union of Bricklayers and Allied Craftworkers (IUBAC). Mortality was ascertained by linkage to the Canadian Mortality Registry at Statistics Canada. Standardized Mortality Ratios (SMRs) were computed using Ontario general population mortality rates as the reference. RESULTS: Twenty or more years from first membership, SMRs for lung (158; 130-190) and stomach (235; 140-370) cancers were significantly elevated. There were four deaths from pneumoconiosis, but non-malignant respiratory mortality SMRs were not increased. CONCLUSIONS: Bricklayers and Allied Craftworkers are at risk from diseases associated with heavy exposure to inorganic dust: lung cancer, stomach cancer, and pneumoconiosis. Dust control as well as education and training of these workers to protect themselves against inhalation hazards is necessary.     

Cancer rates by county: how well does mortality relate to incidence?

The extent to which excess cancer mortality in a county is indicative of excess cancer incidence in the same county in the same time period was studied in white Iowa residents using routinely available 1973-1977 data. Evaluation consisted of population-weighted correlation analysis. The best correlations were obtained for cancers of the lung, pancreas, liver, stomach, brain (males), and kidney (males). These are the cancers for which excess mortality best indicates excess incidence. Correlations were low for prostate, female breast, and corpus uteri. The best indications of excess incidence are made for cancers with five year relative survival rates of 37.0 percent or less for males and 33.4 percent or less for females. Studies relating cancer mortality rates to occupational, environmental, or other demographic variables may be very misleading as to risk factors if the cancers selected have low correlations of incidence with mortality. Further development of the correlation model is recommended using data from all Surveillance, Epidemiology, and End Results Program counties for a ten-year period.     

News Coverage of Cancer in the United States: A National Sample of Newspapers,Television, and Magazines

A content analysis of cancer news coverage in a sample of local and national newspapers, television, and magazines was conducted for the years 2002 and 2003. Analyses compared proportions of mentions of cancer sites with proportional contribution to cancer incidence and mortality based on available epidemiological estimates. Analyses also examined relative attention provided to prevention, detection, treatment, causes, and outcomes of various cancers. Results indicated that coverage reflected incidence rates more closely than they did mortality rates, but in both cases coverage under-represented the contribution of lung cancer to morbidity and mortality and over-represented the contribution of breast cancer. Of greater public health concern was the limited coverage of prevention and detection even for highly preventable or relatively easily detected cancers. Implications of findings are discussed.