Prostate cancer screening (United States)

In 1995, there will be 244,000 new cases of prostate cancer, and 40,400 deaths from prostate cancer, among men in the United States. The American Cancer Society reports that the incidence rate of prostate cancer is increasing at an accelerated pace, and was 21 percent higher in 1994 than in 1993. The major reason for this steep rise is likely to be due to increased popularity of prostate cancer screening which, by identifying latent, asymptomatic cases, may convert them into clinical cases. Is screening—an important means of cancer control for many sites—a reasonable approach for prostate cancer control? The answer is not straightforward because prostate cancer is not one, but three diseases: a latent form which will cause no harm; a progressive form which will become symptomatic and can kill; and a rapidly progressive form so malignant that it is likely to kill, whether detected early or late. Screen-detection may be worthwhile only for the second form, as tumors of the first form need never be detected, and tumors of the third form progress so rapidly that timely screen-detection is nearly impossible and, if accomplished, may be valueless. As there is no way to differentiate among the three diseases when screening, the possible deleterious effects of screen-detection must be weighed against the benefits.Dr Waterbor is with the Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, AL, USA. Dr Bueschen is with the Division of Urology, Department of Surgery, School of Medicine, University of Alabama at Birmingham. Address correspondence to Dr Waterbor, University of Alabama at Birmingham, Department of Epidemiology, Tidwell Hall 201, 720 S 20th Street, Birmingham, AL 35924-0008, USA.     

Prostate cancer: trends in mortality and stage-specific incidence rates by racial/ethnic group in Los Angeles County,California (United States)

Between 1976 and 1988 in the United States, the secular trends in age-adjusted incidence rates of prostate cancer were significantly different by racial/ethnic group (P<0.001), and increased significantly only among non-Hispanic Whites at a rate of 2.7 percent (95 percent confidence interval [CI]=2.3–3.1%) annually. While incidence rates of regional disease increased significantly (7.7 percent to 11.3 percent annually) among all racial/ethnic groups during this period, localized disease increased significantly only among non-Hispanic Whites, by 1.8 percent (CI=1.4–2.3%) annually. Prostate cancer mortality in Los Angeles County (California) remained constant among Hispanics, non-Hispanic Whites, and Asians, but increased 1.6 percent (CI=0–3.2%) annually among Blacks. While the increase in localized disease rates of non-Hispanic Whites may be due to increased detection of asymptomatic disease, this apparently has not occurred among other racial/ethnic groups in Los Angeles County. The secular increase in regional disease rates among all racial/ethnic groups without a concurrent increase in mortality (except Blacks), suggests increased accuracy of staging rather than a true increase in incidence may account for these trends. Adjusted for socioeconomic status, year and age at diagnosis, Black and Hispanic men were at significantly higher risk of being diagnosed with non-localized disease (odds ratio = 1.39 and 1.24, respectively) than were non-Hispanic Whites.Drs Ross and Bernstein are also with the Cancer Surveillance ProgramThis work was supported in part by grant CA17054 from the US National Institutes of Health, and grant SIG#20 from the American Cancer Society. Cancer incidence data were collected under Subcontract 050H-8709 with the California Public Health Foundation. The subcontract is supported by the California Department of Health Services as part of its statewide cancer reporting program, mandated by Health and Safety Code Section 210 and 2113.     

Prostate cancer incidence,clinical stage and survival in relation to obesity: A prospective cohort study in Denmark

There is no clear link between obesity and prostate cancer incidence but an association has been reported between obesity and fatal prostate cancer. We report on two prospective cohort analyses on (i) the incidence of prostate cancer in relation to obesity in a cohort of men with no previous cancer, and on (ii) the stage distribution and prostate cancer specific mortality in relation to obesity among men with prostate cancer. The “Diet, Cancer and Health” prospective cohort study was established in Denmark in 1993–1997 and accrued 26,944 men aged 50–64 years. Data were extracted on height, weight, body mass index (BMI), waist circumference and body fat percentage. Information on cancer incidence and deaths were obtained by record linkage with the Danish Cancer Register and the Danish Death Register. The incidence rate of prostate cancer was similar or slightly lower in obese men compared with nonobese men, but obese men tended to be diagnosed with more advanced prostate cancer. The proportion of Stage 3–4 cancers was 37% in the lowest BMI quartile and 48% in the highest (p = 0.006). Obese men with prostate cancer had higher prostate cancer specific mortality. The hazard ratio comparing the highest and the lowest quartiles of BMI was 1.48 (95% confidence interval: 1.06–2.05; p‐value for trend: 0.002). The association was attenuated but not eliminated by statistical adjustment for stage, and the data are suggestive of a stage‐independent causal pathway where prostate cancer in obese men has higher fatality, even in early‐stage disease.     

The relationship between cancer incidence,stage and poverty in the United States

We extend a prior analysis on the relation between poverty and cancer incidence in a sample of 2.90 million cancers diagnosed in 16 US states plus Los Angeles over the 2005–2009 period by additionally considering stage at diagnosis. Recognizing that higher relative disparities are often found among less‐common cancer sites, our analysis incorporated both relative and absolute measures of disparities. Fourteen of the 21 cancer sites analyzed were found to have significant variation by stage; in each instance, diagnosis at distant stage was more likely among residents of high‐poverty areas. If the incidence rates found in the lowest‐poverty areas for these 21 cancer sites were applied to the entire country, 18,000 fewer distant‐stage diagnoses per year would be expected, a reduction of 8%. Conversely, 49,000 additional local‐stage diagnoses per year would be expected, an increase of 4%. These figures, strongly influenced by the most common sites of prostate and female breast, speak to the trade‐offs inherent in cancer screening. Integrating the type of analysis presented here into routine cancer surveillance activities would permit a more complete understanding of the dynamic nature of the relationship between socioeconomic status and cancer incidence.     

Prostate cancer diagnosis,staging and survival

Prostate cancer is the most common malignancy in men and the second most common cancer related death. Through research, we have found that African–American men and men with a family history of prostate cancer have a significantly higher risk of prostate cancer. In the 90's the mortality rate from prostate cancer decreased, presumably due to PSA testing. Patients with organ-confined tumors, particularly if they have a moderate Gleason score have an excellent chance of long-term survival with radical prostatectomy or external beam radiation therapy. Advances in detecting micrometastatic disease are needed to further impact on this disease.     

Premorbid diet in relation to survival from prostate cancer (Canada)

Objectives: To examine the associations between prediagnostic energy, fat, and vitamin A intake and survival from prostate cancer.Methods: Two hundred and seven cases of prostate cancer from Toronto and 201 cases from Vancouver provided diet histories at diagnosis between 1989 and 1992 and were followed for survival from prostate cancer. After exclusions for various reasons, 263 cases (135 from Toronto, 128 from Vancouver) were analyzed in Cox proportional hazards models.Results: Following adjustments for clinical stage, histologic grade, and other factors, significantly lower risks of dying from prostate cancer in the highest compared with the lowest tertiles of monounsaturated fat intakes were observed in each city and in the combined city analyses (combined cities: hazard ratio [HR] = 0.3; 95% confidence interval (CI) = 0.1–0.7). Survival from prostate cancer was significantly better for cases in the highest tertile of energy intake in Toronto (HR = 0.1; CI = 0.01–0.6) in contrast to that in Vancouver where these cases did relatively worse (HR = 2.6; CI = 0.6–10.7). Other nutrients were either not consistently or not significantly associated with prostate cancer survival in the two cities.Conclusions: This bi-center cohort study observed a consistent and significant inverse association between the premorbid intake of monounsaturated fat and risk of death from prostate cancer. The inconsistent results for energy intake between cities could potentially be attributed to non-respondent bias in Toronto.     

Cancer incidence among firefighters in Seattle and Tacoma,Washington (United States)

In order to determine if exposure to carcinogens in fire smoke increases the risk of cancer, we examined the incidence of cancer in a cohort of 2,447 male firefighters in Seattle and Tacoma, (Washington, USA). The study population was followed for 16 years (1974–89) and the incidence of cancer, ascertained using a population-based tumor registry, was compared with local rates and with the incidence among 1,878 policemen from the same cities. The risk of cancer among firefighters was found to be similar to both the police and the general male population for most common sites. An elevated risk of prostate cancer was observed relative to the general population (standardized incidence ratio [SIR]=1.4, 95 percent confidence interval [CI]=1.1–1.7) but was less elevated compared with rates in policement (incidence density ratio [IDR]=1.1, CI=0.7–1.8) and was not related to duration of exposure. The risk of colon cancer, although only slightly elevated relative to the general population (SIR=1.1, CI=0.7–1.6) and the police (IDR=1.3, CI=0.6–3.0), appeared to increase with duration of employment. Although the relationship between firefighting and colon cancer is consistent with some previous studies, it is based on small numbers and may be due to chance. While this study did not find strong evidence for an excess risk of cancer, the presence of carcinogens in the firefighting environment warrants periodic re-evaluation of cancer incidence in this population and the continued use of protective equipment.This research was partially funded through a cooperative agreement with the US Fire Administration of the Federal Emergency Management Agency (EMW 85-K-2089). Dr Demers was supported by a Training Grant in Environmental Epidemiology and Biostatistics from the US National Institute for Environmental Health Sciences (T32 ES07262).     

Time trends of breast cancer survival in Europe in relation to incidence and mortality

Increasing breast cancer survival, observed in most western countries, is not easily interpreted: it could be due to better treatment, more effective treatment due to earlier diagnosis or simply lead-time bias. Increased diagnostic activity (e.g., screening) can inflate both incidence and survival. To understand interrelations between incidence, mortality and survival trends and their consequences, we analyzed survival trends in relation to mortality and incidence. Starting with observed survival from EUROCARE, mortality from WHO and using the MIAMOD method, we estimated breast cancer incidence trends from 1970 to 2005 in 10 European countries. To smooth out peaks in incidence and survival due to early diagnosis activity, survival trends were assumed similar to those observed by EUROCARE in 1983-1994. The following patterns emerged: (1) increasing survival with increasing incidence and declining or stable mortality (Sweden, Finland); (2) slight survival increase, marked incidence increase and slight mortality decrease (Denmark, the Netherlands and France); (3) increasing survival, marked decrease in mortality and tendency to incidence stabilization (UK); (4) marked survival increase, steady or decreasing mortality and moderate increases in incidence (Spain, Italy); (5) stable survival, increasing incidence and mortality (Estonia). In most countries survival increased, indicating a real advantage for patients when accompanied by decreasing or stable mortality, and attributable to improved cancer care (Sweden, UK, France, Italy and Spain). In Finland (with high survival), the Netherlands and Denmark, increasing mortality and incidence indicate increasing breast cancer risk, probably related to life-style factors. In Estonia, low and stable survival in the context of increasing incidence and mortality suggests inadequate care.     

Influence of education level on breast cancer risk and survival in Sweden between 1990 and 2004

On account of limited recent data regarding the role of education in breast cancer risk and prognosis, we conducted this study to assess the association between education level and in situ and invasive breast cancer risk and invasive breast cancer survival, using the 2006 update of the Swedish Family-Cancer Database. Cox's proportional hazards models were used to calculate the hazard ratio (HR) and 95% confidence interval (CI) adjusted for age, time-period, parity, age at first birth, county of residence, and family history of breast cancer. Compared to women completing less than 9 years of education, university graduates were more likely to be diagnosed with in situ (HR = 1.44, 95% CI: 1.28-1.63) and invasive (HR = 1.28, 95% CI: 1.20-1.36) breast cancer, and the lack of homogeneity between these two HRs was statistically significant, p = 0.007. Further stratification revealed that the lack of homogeneity was greatest for breast cancers diagnosed before age 50. Compared to women completing less than 9 years of education, university graduates were associated with the highest survival following a breast cancer diagnosis (lowest fatality hazard ratio), HR = 0.68, 95% CI: 0.61-0.75. Further research is warranted to elucidate possible behaviors or characteristics associated with education that could explain the differences in incidence and survival, such as compliance with cancer screening.     

Epstein-Barr virus serology and gastric cancer incidence and survival

Among 185 cases of gastric cancer and 200 controls in Linxian, China, Epstein-Barr virus (EBV) seropositivity was not associated with increased risk of gastric cancer. High EBV nuclear antigen titres were associated with longer survival in cardia cancer cases, possibly due to chance.     

A prospective cohort study on consumption of alcoholic beverages in relation to prostate cancer incidence (The Netherlands)

Objectives: To examine alcohol consumption in relation to prostate cancer incidence in the Netherlands Cohort Study.Methods: At baseline in 1986, 58,279 men aged 55–69 years completed a self-administered questionnaire on diet, consumption of alcoholic beverages and other risk factors for cancer. For data processing and analyses the case–cohort approach was used. After 6.3 years of follow-up, 680 incident primary prostate cancer cases were available for analysis.Results: In multivariate analyses adjusted for age, socioeconomic status and family history of prostate cancer, no association between total alcohol consumption, alcohol intake from beer and liquor and prostate cancer risk was found. Increased associations were found for alcohol from white wine and fortified wines compared to nondrinkers, but not for red wine. The RRs (95% CI) in the intake category of > 15g/day were 3.3 (1.2–9.2) and 2.3 (1.2–4.7), respectively, after additional adjustment for total alcohol intake. There was, however, no significant trend in risk. Alcohol intake was more strongly related with localized than with advanced prostate tumors.Conclusion: Our results do not support an important role for alcohol in prostate cancer etiology. Nevertheless, for specific types of alcoholic beverages, particularly wines, a positive association was suggested which needs examination in further studies.     

Dietary intake of flavonoids and oesophageal and gastric cancer: incidence and survival in the United States of America (USA)

Background:

Flavonoids, polyphenolic compounds concentrated in fruits and vegetables, have experimentally demonstrated chemopreventive effects against oesophageal and gastric cancer. Few epidemiologic studies have examined flavonoid intake and incidence of these cancers, and none have considered survival.

Methods:

In this USA multicentre population-based study, case participants (diagnosed during 1993–1995 with oesophageal adenocarcinoma (OEA, n=274), gastric cardia adenocarcinoma (GCA, n=248), oesophageal squamous cell carcinoma (OES, n=191), and other gastric adenocarcinoma (OGA, n=341)) and frequency-matched controls (n=662) were interviewed. Food frequency questionnaire responses were linked with USDA Flavonoid Databases and available literature for six flavonoid classes and lignans. Case participants were followed until 2000 for vital status. Multivariable-adjusted odds ratios (ORs) and hazard ratios (HRs) (95% confidence intervals (CIs)) were estimated, comparing highest with lowest intake quartiles, using polytomous logistic and proportional hazards regressions, respectively.

Results:

Little or no consistent association was found for total flavonoid intake (main population sources: black tea, orange/grapefruit juice, and wine) and incidence or survival for any tumour type. Intake of anthocyanidins, common in wine and fruit juice, was associated with a 57% reduction in the risk of incident OEA (OR=0.43, 95% CI=0.29–0.66) and OES (OR=0.43, 95% CI=0.26–0.70). The ORs for isoflavones, for which coffee was the main source, were increased for all tumours, except OES. Anthocyanidins were associated with decreased risk of mortality for GCA (HR=0.63, 95% CI=0.42–0.95) and modestly for OEA (HR=0.87, 95% CI=0.60–1.26), but CIs were wide.

Conclusions:

Our findings, if confirmed, suggest that increased dietary anthocyanidin intake may reduce incidence and improve survival for these cancers.     

Lung cancer incidence and survival in different ethnic groups in South East England

Background:

This study aimed to examine the incidence and survival of lung cancer patients from several different ethnic groups in a large ethnically diverse population in the United Kingdom.

Methods:

Data on residents of South East England diagnosed with lung cancer between 1998 and 2003 were extracted from the Thames Cancer Registry database. Age- and socioeconomic deprivation-standardised incidence rate ratios were calculated for males and females in each ethnic group. Overall survival was examined using Cox regression, adjusted for age, socioeconomic deprivation, stage of disease and treatment. Results are presented for White, Indian, Pakistani, Bangladeshi, Black Caribbean, Black African and Chinese patients, apart from female survival results where only the White, South Asian and Black ethnic groups were analysed.

Results:

Compared with other ethnic groups of the same sex, Bangladeshi men, White men and White women had the highest incidence rates. Bangladeshi men had consistently higher survival estimates compared with White men (fully adjusted hazard ratio 0.46; P<0.001). Indian (0.84; P=0.048), Black Caribbean (0.87; P=0.47) and Black African (0.68; P=0.007) men also had higher survival estimates. South Asian (0.73; P=0.006) and Black (0.74; P=0.004) women had higher survival than White women.

Conclusion:

Smoking prevention messages need to be targeted for different ethnic groups to ensure no groups are excluded. The apparent better survival of South Asian and Black patients is surprising, and more detailed follow-up studies are needed to verify these results.     

Trends in childhood rhabdomyosarcoma incidence and survival in the United States, 1975‐2005

BACKGROUND:

Rhabdomyosarcoma (RMS) is the most common soft tissue sarcoma in children and adolescents aged <20 years; its etiology remains largely unknown. It is believed that embryonal (ERMS) and alveolar rhabdomyosarcoma (ARMS), the most common subtypes, arise through distinct biologic mechanisms. The authors of this report evaluated incidence and survival trends by RMS demographic subgroups to inform future etiologic hypotheses.

METHODS:

Incidence and survival trends in RMS among children and adolescents aged <20 years were analyzed using data from the Surveillance, Epidemiology, and End Results Program. Frequencies, age‐adjusted incidence and survival rates, and joinpoint regression results, including annual percentage change (APC) and 95% confidence interval (CI), were calculated.

RESULTS:

Between 1975 and 2005, the incidence of ERMS was stable, whereas a significant increase in the incidence of ARMS was observed (APC, 4.20%; 95%CI, 2.60%‐5.82%). This trend may have been attributable in part to shifts in diagnosis, because a significant negative trend in RMS, not otherwise specified was observed concurrently. A bimodal age peak for ERMS was observed, with the second, smaller peak in adolescence noted for males only; ARMS incidence did not vary by age or sex. Five‐year survival rates for RMS and ERMS increased during the period from 1976 to 1980 (52.7% and 60.9%, respectively) to the period from 1996 to 2000 (61.8% and 73.4%, respectively), whereas there was little improvement for ARMS (40.1% and 47.8%, respectively).

CONCLUSIONS:

Observed differences in incidence and survival for 2 major RMS subtypes across sex and age subgroups further supported the hypothesis that there are unique underlying etiologies for these tumors. Exploration of these differences presents an opportunity to increase current knowledge of RMS. Cancer 2009. © 2009 American Cancer Society.     

Evaluating local differences in breast cancer incidence rates: A census-based methodology (United States)

Objectives: We used readily accessible, existing data to assess whether or not geographic variation in breast cancer incidence rates in the San Francisco Bay Area was related to the unequal distribution of known breast cancer risk factors.Methods: Cancer registry and 1990 census block-group data were used to look at the associations between breast cancer incidence and known risk factors (including parity, urban/rural status, and socioeconomic indicators) in 25 California counties. Average annual age-adjusted invasive breast cancer incidence rates were calculated for the period 1988-1992, and adjusted morbidity ratios were computed.Results: While breast cancer incidence in Marin County was 9 percent higher than that of the other 24 counties combined (relative risk=1.09, 95 percent confidence interval=1.01-1.18), this increase appeared to be due to the unequal distribution of known risk factors. Block-groups that had a high level of any risk factor had higher incidence rates, regardless of geographic location. After multivariate adjustment, breast cancer incidence no longer differed between Marin and the other counties (adjusted morbidity ratio=1.02).Conclusions: The results suggest that the unequal distribution of known risk factors was responsible for Marin County's high breast cancer incidence rate.     

Assessment of mediators of racial disparities in cervical cancer survival in the United States

Cervical cancer (CC) morbidity and mortality have decreased in the United States, but they remain high among black women. We assessed racial disparities in CC mortality, accounting for socioeconomic status (SES). We linked data from the 1988 to 2007 Surveillance Epidemiology and End Results (SEER) database to the US Census. Additional SES information was obtained through linkage with Area Resource Files. We used the Kaplan–Meier method for estimating probabilities following CC diagnosis and Cox proportional hazards regression to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for CC mortality by race. The models were incrementally adjusted for marital status, registry, period, stage, age at diagnosis, histology, treatment, household income, poverty and unemployment rates. We stratified the analyses by disease stage and American state. A total of 44,554 women with CC were identified. Compared to white women, black women had a higher risk of dying from CC; crude and adjusted HRs were 1.41 (CI: 1.34–1.48) and 1.09 (CI: 1.03–1.15), respectively. Corresponding estimates for Hispanic women were 0.85 (CI: 0.80–0.89) and 0.75 (CI: 0.71–0.80). Black women diagnosed at late disease stages had a higher risk of CC death, whereas Hispanic women diagnosed at early and late stages had significantly lower risks. Black CC patients in California experienced poorer survival relative to white women. Conversely, longer CC survival was seen among Hispanic women in California, Georgia and Utah. While crude estimates indicated an increased CC death risk among black women, risks diminished upon adjustment for clinical and sociodemographic characteristics.     

Marijuana use and cancer incidence (California, United States)

The purpose of this retrospective cohort study was to examine therelationship of marijuana use to cancer incidence. The study populationconsisted of 64,855 examinees in the Kaiser Permanente multiphasic healthcheckup in San Francisco and Oakland (California, United States), between1979-85, aged 15 to 49 years, who completed self-ad-ministered questionnairesabout smoking habits, including marijuana use. Follow-up for cancer incidencewas conducted through 1993 (mean length 8.6 years). Compared withnonusers/experimenters (lifetime use of less than seven times), ever- andcurrent use of marijuana were not associated with increased risk of cancer ofall sites (relative risk [RR] = 0.9, 95 percent confidence interval [CI] =0.7-1.2 for ever-use in men; RR = 1.0, CI = 0.8-1.1 in women) in analysesadjusted for sociodemographic factors, cigarette smoking, and alcohol use.Marijuana use also was not associated with tobacco-related cancers or withcancer of the following sites: co lorectal, lung, melanoma, prostate, breast,cervix. Among nonsmokers of tobacco cigarettes, ever having used marijuanawas associated with increased risk of prostate cancer (RR = 3.1, CI =1.0-9.5) and nearly significantly increased risk of cervical cancer (RR =1.4, CI = 1.0-2.1). We conclude that, in this relatively young study cohort,marijuana use and cancer were not associated in overall analyses, but thatassociations in nonsmokers of tobacco cigarettes suggested that marijuana usemight affect certain site-specific cancer risks.