Timeliness of Breast Cancer Diagnosis and Initiation of Treatment in the National Breast and Cervical Cancer Early Detection Program, 1996�C2005

Objectives. To determine the effects of program policy changes, we examined service delivery benchmarks for breast cancer screening in the National Breast and Cervical Cancer Early Detection Program (NBCCEDP).Methods. We analyzed NBCCEDP data for women with abnormal mammogram or clinical breast examination (n = 382 416) from which 23 701 cancers were diagnosed. We examined time to diagnosis and treatment for 2 time periods: 1996 to 2000 and 2001 to 2005. We compared median time for diagnostic, treatment initiation, and total intervals with the Kruskal–Wallis test. We calculated adjusted proportions (predicted marginals) with logistic regression to examine diagnosis and treatment within program benchmarks (≤ 60 days) and time from screening to treatment (≤ 120 days).Results. Median diagnostic intervals decreased by 2 days (25 vs 23; P < .001). Median treatment initiation intervals increased by 2 days (12 vs 14; P < .001). Total intervals decreased by 3 days (43 vs 40; P < .001). Women meeting the 60-day benchmark for diagnosis improved the most for women with normal mammograms and abnormal clinical breast examinations from 77% to 82%.Conclusions. Women screened by the NBCCEDP received diagnostic follow-up and initiated treatment within preestablished program guidelines.Screening for breast cancer reduces morbidity and mortality from breast cancer when women receive timely follow-up and appropriate treatment.¹ There are few data to indicate what the optimal diagnostic and treatment intervals are that might ensure the best chances of survival from breast cancer detected by screening with mammography.^2,3 Recent information from organized screening programs in Canada and the United Kingdom showed that women who waited longer than 6 to 12 months for diagnostic workup were more likely to have larger cancers and more positive lymph nodes, which might lead to poorer survival.^2,3 In the case of symptomatic women, delays greater than 3 to 6 months to start therapy are associated with poorer survival.⁴Recent modeling studies have shown that the declines in mortality are attributable to both early detection and subsequent treatment.¹ Minority women, uninsured women, and women from lower socioeconomic backgrounds often do not have access to early detection.^5–7 These women are less likely to participate in mammography screening,⁸ less likely to have timely and complete follow-up after an abnormal screening test result,^9,10 more likely to be diagnosed with late-stage breast cancer,^6,7,11 more likely to die from breast cancer once diagnosed,^6,7 and might be more likely to receive suboptimal treatment.^12–15The National Breast and Cervical Cancer Early Detection Program (NBCCEDP) was authorized by Congress in 1990 to reach underserved women.¹⁶ Since the inception of the program, the NBCCEDP has established service delivery benchmarks to ensure timely and complete diagnostic follow-up and treatment initiation for underserved women screened through the program.¹⁷ Previous analysis of program benchmarks demonstrated that the national program was meeting its predefined quality standards of having a diagnosis within 60 days of an abnormal screening test result and initiation of treatment within 60 days of diagnosis.¹⁸ Legislation for program enhancements that added case management services, which was fully implemented in 2000, and a Medicaid waiver authorized by Congress in 2000 and fully implemented in 2003, should have improved the program''s ability to meet these standards.^19–22Accordingly, we hypothesized that NBCCEDP service delivery benchmarks would improve over time with shortening of time intervals after an abnormal mammogram or clinical breast examination (CBE) finding to final diagnosis, as well as the interval to treatment initiation after diagnosis, and the interval to treatment initiation after abnormal screening test result. We investigated this by using 2 time periods, 1996 to 2000 and 2001 to 2005,²⁰ to examine the effects of program policy changes on intervals in the 2001–2005 period.^20–22     

Breast Cancer Stage at Diagnosis: Is Travel Time Important?

Recent studies have produced inconsistent results in their examination of the potential association between proximity to healthcare or mammography facilities and breast cancer stage at diagnosis. Using a multistate dataset, we re-examine this issue by investigating whether travel time to a patient’s diagnosing facility or nearest mammography facility impacts breast cancer stage at diagnosis. We studied 161,619 women 40 years and older diagnosed with invasive breast cancer from ten state population based cancer registries in the United States. For each woman, we calculated travel time to their diagnosing facility and nearest mammography facility. Logistic multilevel models of late versus early stage were fitted, and odds ratios were calculated for travel times, controlling for age, race/ethnicity, census tract poverty, rural/urban residence, health insurance, and state random effects. Seventy-six percent of women in the study lived less than 20 min from their diagnosing facility, and 93 percent lived less than 20 min from the nearest mammography facility. Late stage at diagnosis was not associated with increasing travel time to diagnosing facility or nearest mammography facility. Diagnosis age under 50, Hispanic and Non-Hispanic Black race/ethnicity, high census tract poverty, and no health insurance were all significantly associated with late stage at diagnosis. Travel time to diagnosing facility or nearest mammography facility was not a determinant of late stage of breast cancer at diagnosis, and better geographic proximity did not assure more favorable stage distributions. Other factors beyond geographic proximity that can affect access should be evaluated more closely, including facility capacity, insurance acceptance, public transportation, and travel costs.     

Association between Rice Consumption and Selected Indicators of Dietary and Nutritional Status using National Health and Nutrition Examination Survey 2007–2008

The present study was aimed at evaluating whether white rice, brown rice, and rice flour consumption has any association with selected measures of dietary intake and nutritional status, including various variables of energy intake, major vitamin and mineral intakes, weigh status, blood pressure, cholesterol level, and serum folate level for adults 20 years and older. Data from the National Health and Nutrition Examination Survey (NHANES) 2007–2008 and the Food Commodity Intake Database were used. Rice consumers had a significantly higher energy intake, yet they had lower percentage calorie intake from fat and saturated fat. Rice consumers also had significantly higher intakes of a range of nutrients. Rice consumers had lower waist circumference, triceps skinfold, and were significantly more likely to have a body mass index less than or equal to 25.     

Does Distance Matter? Distance to Mammography Facilities and Stage at Diagnosis of Breast Cancer in Kentucky

ABSTRACT:  Background: National and regional data indicate that breast cancer early detection is low in Kentucky, especially rural regions, perhaps because access to mammography services can be problematic. Objective: This study examined the distance between residences of women diagnosed with breast cancer and the nearest mammography facility, as a risk factor for advanced stage diagnosis in rural populations. Methods: 1999-2003 Kentucky Cancer Registry data were used for this study. A total of 12,322 women, aged 40 and older at diagnosis, with no previous history of cancer, and with known cancer stage were included. Travel distance was obtained using a geographic information system (GIS). Hierarchical logistic regression models were used to analyze the relationship between travel distance and advanced stage diagnosis. Results: Advanced diagnoses had longer average travel distances than early stage diagnoses (P < 0.01). After adjusting for age, race, insurance, and education at census tract level, the odds of advanced diagnosis were significantly greater for women residing over 15 miles from a facility, compared to those living within 5 miles (adjusted OR = 1.50, 95% CI = 1.25-1.80). Conclusion: Although socioeconomic status, race, and age may help explain advanced diagnoses, longer travel distance also adversely affects early detection for rural populations. Accurate measurement of spatial accessibility indicators, such as travel distance, facilitates identification of at-risk groups so that interventions can be developed to reduce this disease.     

Rural–Urban Trends and Patterns in Cervical Cancer Mortality, Incidence, Stage, and Survival in the United States, 1950–2008

This study examined disparities in cervical cancer mortality rates among US women in metropolitan and non-metropolitan areas from 1950 through 2007. Inequalities in incidence, stage of disease at diagnosis, and patient survival were analyzed during 2000–2008. Age-adjusted mortality, incidence, and 5-year relative survival rates were calculated for women in metropolitan and non-metropolitan areas, and differences in relative risks were tested for statistical significance. Log-linear regression was used to analyze annual rates of change in mortality over time. During the last five decades, women in non-metropolitan areas had significantly higher cervical cancer mortality than those in metropolitan areas. Disparities persisted against a backdrop of consistently declining mortality rates. Throughout 1969–2007, both white and black women in non-metropolitan areas maintained significantly higher cervical cancer mortality rates than their metropolitan counterparts. Among black women, cervical cancer mortality declined at a faster pace in metropolitan than in non-metropolitan areas. In both metropolitan and non-metropolitan areas, black women had twice the mortality rate of white women. During 2000–2008, white, black, and American Indian women in non-metropolitan areas had significantly higher cervical cancer incidence rates than their metropolitan counterparts. Survival rates were significantly lower in non-metropolitan areas, particularly among rural black women. The 5-year survival rate for black women diagnosed with cervical cancer was 50.8% in non-metropolitan areas, compared with 60.2% for black women and 71.0% for white women in metropolitan areas. Disparities in survival existed after controlling for disease stage. Rural–urban disparities in cervical cancer have persisted despite steep declines in incidence and mortality rates.     

Trends in Health Insurance Status of US Children and their Parents, 1998–2008

In the United States (US), a parent’s health insurance status affects their children’s access to health care making it critically important to examine trends in coverage for both children and parents. To gain a better understanding of these health insurance trends, we assessed the coverage status for both children and their parents over an 11-year time period (1998–2008). We conducted secondary analysis of data from the nationally-representative Medical Expenditure Panel Survey. We examined frequency distributions for full-year child/parent insurance coverage status by family income, conducted Chi-square tests of association to assess significant differences over time, and explored factors associated with full-year insurance coverage status in 1998 and in 2008 using logistic regression. When considering all income groups together, the group with both child and parent insured decreased from 72.4 % in 1998 to 67.2 % in 2008. When stratified by income, the percentage of families with an insured child, but an uninsured parent increased for low-income families from 12.4 to 25.1 % and from 3.8 to 7.1 % for middle-income families when comparing 1998–2008. In regression analyses, family income remained the strongest characteristic associated with a lack of full-year health insurance. As future policy reforms take shape, it will be important to look beyond children’s coverage patterns to assess whether gains have been made in overall family coverage.     

Intakes of Vitamin A,C, and E,and β-Carotene Are Associated With Risk of Cervical Cancer: A Case-Control Study in Korea

Cervical cancer is one of the most common gynecological malignancies in Korea, although the incidence has been declining in recent years. This study explored whether antioxidant vitamin intakes influenced the risk of cervical cancer. The association between antioxidant vitamin intakes and cervical cancer risk was calculated for 144 cervical cancer cases and 288 age-matched, hospital-based controls using unconditional logistic regression models. Cases reported statistically lower mean dietary intakes of vitamin A, β -carotene, and vitamin C than did controls. Total intakes of vitamins A and E, which included both dietary and supplement intake, were also lower in cases. Those patients in the highest quartiles of dietary vitamin A, β -carotene, and vitamin C intakes had statistically significantly lower cervical cancer risks than those in the lowest quartiles for vitamin A, β -carotene, and vitamin C: odds ratio (OR) = 0.36 [95% confidence interval (CI) = 0.19–0.69), OR = 0.48 (CI = 0.26–0.88), and OR = 0.36 (CI = 0.18–0.69), respectively. Total intakes of vitamins A, C, and E were strongly inversely associated with cervical cancer risk: OR = 0.35 (CI = 0.19–0.65), OR = 0.35 (CI = 0.19–0.66), and OR = 0.53 (CI = 0.28–0.99), respectively. The findings support a role for increased antioxidant vitamin intake in decreasing the risk of cervical cancer. These associations need to be assessed in large prospective studies with long-term follow-up.     

A Medicare-Associated Spike in U.S. Cancer Rates at Age 65, 2000–2010

Age 65 represents a transition point where most U.S. residents begin Medicare coverage. We examined whether or not delays in medical care near this age extend to cancer diagnosis. We calculated single-year-of-age cancer incidence rates by site and stage for the most common cancer sites (i.e., prostate, female breast, lung, and colorectal) for the 2000–2010 period using data from the SEER 18 registries, and we used Poisson regression to identify a possible age-65 effect. The analysis was repeated on comparable Canadian data. Cancer rates at age 65 were found to be as much as 15% above expected in the U.S. data, with the age-65 effect strongly associated with site- and stage-specific survival. A smaller association was seen in the Canadian data. We found strong evidence that diagnosis of less severe cancers spikes at age 65. Delay of medical care prior to this age has complex policy implications.The 65th birthday is a major life milestone for many Americans. It corresponds to the age when nearly all become eligible for health-care coverage through Medicare, when many begin receiving Social Security benefits, and when many choose to retire. This age boundary has been shown to have profound effects on health and health-care utilization. For example, rates of medical screening, diagnosis, and treatment for conditions that are low urgency, asymptomatic, and reimbursable by Medicare are found at much higher levels among those aged 65 years than those aged 64 years.^1–3 It has been suggested that this phenomenon is driven by the low-cost “Welcome to Medicare” physical examination instituted in 2005, but too few people have taken advantage of this feature for it to explain much of the difference.⁴In contrast, rates of “nondeferrable admissions,” defined as conditions where hospital admission rates through emergency departments do not diminish on weekends, show no change at age 65 years.⁵ For those who are uninsured or underinsured, there are clear financial incentives to postpone nonurgent medical encounters until Medicare is available. The effect is too large, however, to be explained by the behavior of the uninsured and underinsured alone. Even some people who are fully insured postpone treatment until age 65 years, either because of the perception that Medicare is a more generous health-care plan than other insurance plans or because postponing is more convenient.⁵ Recovering from a hip replacement while retired, for example, may be more practical than attempting to do so while employed.None of the existing research on pent-up demand for Medicare has, to our knowledge, specifically considered cancer incidence. We hypothesized that cancer should follow the same pattern as seen for other medical conditions. Specifically, screen-detected, asymptomatic, nonlethal tumors should show an unusually high incidence rate at age 65 years relative to other ages, while advanced-stage, low-survival tumors should show no difference. If correct, this observation should inform the current discussion regarding the extent to which certain cancers are being overdiagnosed and overtreated as a consequence of aggressive screening,⁶ as the Medicare program may be unwittingly bearing an undue share of the cost of such treatment. Conversely, underdiagnosis and undertreatment of those approaching 65 years of age may also be unduly shortening life spans among this group.We measured the elevation in cancer rates at age 65 years above what would be expected based on the otherwise smooth trend between ages 55 and 75 years. We considered prostate, female breast, lung, and colorectal cancers—the four most common cancer sites—which accounted for approximately 54% of all incident cases in the United States during the 2000–2010 period. Each of these cancers is detectable through screening, although at the time of writing only colorectal cancer screening for those aged 50–75 years was unequivocally endorsed by the U.S. Preventive Services Task Force (USPSTF).⁷ Breast cancer screening for women aged 50–74 years is generally recommended, but the guidelines for women older than 40 years of age are currently under review.^8,9 Lung cancer screening is recommended only for current or recent heavy smokers aged 55–80 years,¹⁰ and prostate cancer screening is not recommended at all.¹¹ We further investigated the relationship between the age-65 effect and the severity of the cancer, as measured by five-year survival. Finally, we compared the results from the United States with equivalent results from Canada, where no change in health-care insurance status occurs at age 65, but where 65 is also a popular retirement age.     

Determinants of Breast, Cervical and Colorectal Cancer Screening Adherence in Mexican–American Women

Despite the effectiveness of cancer screening procedures, its utilization among Latinas remains low. Guided, in part, by the Behavioral Model for Vulnerable Populations, this study examined the associations between predisposing, enabling, and need factors with self-reported breast, cervical, and colorectal cancer screening adherence. Participants were 319 Mexican–American women, from a range of socioeconomic backgrounds, living near the United States-Mexico border. Women were adherent with breast cancer (BC) screening (≥42 years) if they had received at least one mammogram within the last 2 years, with cervical cancer (CC) screening (≥40 years) if they had received at least one Pap exam in the last 3 years, and with colorectal cancer (CRC) screening (≥52 years) if they had undergone one or more of the following: Fecal Occult Blood Test within the last year, or sigmoidoscopy in the last 5 years, or colonoscopy within the last 10 years. BC and CC screenings were higher in the current sample compared to national and state figures: 82% with mammography and 86% adherent with Pap exam screening. However, only 43% were adherent with CRC screening recommendations. Characteristics associated with mammography adherence included CC adherence and usual source of care. BC adherence was associated to CC adherence. Characteristics associated with CRC adherence included BC adherence, being premenopausal, and insurance coverage. A key correlate of cancer screening adherence was adherence to other preventive services. Results underscore the need for continued efforts to ensure that Latinas of all SES levels obtain regular and timely cancer screenings.     

Weight and Mental Health Status in Massachusetts,National Survey of Children’s Health, 2007

This study explores how weight status is related to mental health status among Massachusetts children, aged 10–17 years. We used data from the 2007 National Survey of Children’s Health to examine the association between weight status (body mass index-for-age) and parent-reported mental health status among Massachusetts children (N = 827). Multivariable log binomial regression was performed to calculate the adjusted prevalence ratios (aPR) of three mental health outcomes (behavioral, emotional, and social) as related to weight status, after controlling for covariates including physical activity, sex, race/ethnicity, maternal education, poverty status, special health needs, and neighborhood safety. Almost one-third (32.5 %) of Massachusetts children were either overweight or obese. Sex was a significant effect modifier of the association between weight status and negative emotions. After stratifying by sex and controlling for covariates, the relationship between weight status and negative emotions remained significant among girls (aPR = 1.8, 95 % CI 1.3–2.6). Children who did not exercise at all were significantly more likely to exhibit negative behaviors (aPR = 1.3, 95 % CI 1.0–1.6), negative emotions (boys’ aPR = 3.3, 95 % CI 1.6–6.9; girls’ aPR = 2.6, 95 % CI 1.5–4.5), and fewer social skills (aPR = 1.9, 95 % CI 1.3–2.9) than those who exercised at least 20 min every day of the week. Overweight/obese children, especially girls, were more likely than children of normal weight to have parent-reported negative emotions, suggesting an association between weight status and mental health. Lower levels of physical activity were associated with negative mental health outcomes, supporting the benefits of physical activity for all children.     

Maternal Pre-Pregnancy Obesity and Diagnosis of Asthma in Offspring at Age 3 Years

Objective The objective of this study was to examine the relationship between maternal pre-pregnancy obesity and a diagnosis of asthma in offspring at age 3 years. Methods A population-based sample of children born in large U.S. cities in 1998–2000 was followed since birth (N = 1971). The main outcome measure was whether the mother reported at 3 years that the child had ever been diagnosed with asthma. Multilevel logistic regression models were used to estimate the association between maternal pre-pregnancy obesity and child asthma diagnosis, as well as the extent to which the association can be explained by sociodemographic, medical, obstetric, and behavioral factors associated with both conditions. Results Children with obese mothers had 52% higher odds of having an asthma diagnosis by age 3 (OR = 1.52; 95% CI: 1.18–1.93). Sociodemographic, medical, obstetric, and behavioral factors explained some, but not all, of the association. Conclusions Maternal pre-pregnancy obesity is associated with diagnosis of asthma in offspring at age 3 years. The results from this study are preliminary and need to be replicated and further explored, but are suggestive of a complex intergenerational linkage between obesity and asthma.     

Association of Strong Smoke-Free Laws With Dentists’ Advice to Quit Smoking, 2006–2007

Objectives. We examined the association of smoke-free laws with dentists’ advice to quit smoking and referral to a quit line, among smokers who reported visiting the dentist in the past 12 months.Methods. We used the 2006 to 2007 Tobacco Use Supplement of the Current Population Survey merged with the American Nonsmokers'' Rights Foundation Local Ordinance Database of smoke-free laws. The dependent variables were advice from a dentist to quit smoking and referral to a quit line, and the independent variable of interest was 100% smoke-free law coverage. We controlled for respondent demographics and an index of state-level smoking ban attitudes (included to ensure that the effect detected was not the result of social attitudes).Results. Smoke-free law coverage was associated with dental advice to quit smoking (odds ratio [OR] = 1.27; 95% confidence interval [CI] = 1.01, 1.59; P = .041), but not with referral to a quit line (OR = 1.33; 95% CI = 0.79, 2.25; P = .283).Conclusions. Interventions with dentists are needed to increase referrals to quit lines and other smoking cessation efforts.Smoking causes oral disease and dental therapy failures.1–8 Tobacco cessation interventions delivered by dentists during oral examination are associated with cessation.9–12 Although dentists can effectively promote cessation, particularly when they receive training to do so,13–17 such practices are not widespread.18–22 The US Public Health Service clinical practice guidelines promote the 5A''s—ask about tobacco use, advise to quit, assess willingness to make a quit attempt, assist in the quit attempt, and arrange follow-up—as a standard tobacco use intervention.1 Implementing just part of the 5A''s, such as advising patients to quit, can affect patient behavior.16,17,23,24Several studies found that although oral health care providers are willing to implement the first 2 steps of the 5A''s (ask, advise) they are reluctant to implement the last 3 (assess, assist, and arrange).10,16,18,23,25 A survey of dentists in California, Pennsylvania, and West Virginia found that most dentists reported asking patients about tobacco use and advising them to quit, but fewer than half the dentists who asked about smoking provided follow-up or assistance with quitting.25 These low rates are similar to those of health care providers in other areas.18 As a result, some organizations advocate the 2A''s+R (ask, advise, refer to a quit line) model of intervention.26 A study that compared the effectiveness of the 5A''s and 2A''s+R models in dental settings found that a greater proportion of patients receiving the 5A''s intervention quit but that the 2 groups showed no significant difference in abstinence at the 12-month follow-up.26Strong smoke-free laws are associated with changes in norms, attitudes, and behaviors surrounding tobacco use. These smoke-free laws may also encourage dental care providers to perceive smoking as denormalized or increase the salience of tobacco use for these providers, so that they are more likely to recommend a smoking cessation intervention. In the United States, implementation of 100% smoke-free laws is associated with a reduction in smoking prevalence and consumption,27 decreased cardiovascular and pulmonary hospital admissions,28 voluntary smoke-free home rules,29 and reduced maternal smoking.30,31 We hypothesized that the implementation of 100% smoke-free laws would affect not only individual health-related behavior, but also health care provider behavior, particularly in an area, such as oral health, where cessation training is not yet routinely implemented. We examined the effect of 100% smoke-free laws on dentist implementation of the 2A''s+R model of intervention, particularly dental advice to quit and referral to a quit line, or cessation help line.     

Socioeconomic Status,Food Security,and Dental Caries in US Children: Mediation Analyses of Data From the National Health and Nutrition Examination Survey, 2007–2008

Objectives. We examined associations of household socioeconomic status (SES) and food security with children’s oral health outcomes.Methods. We analyzed 2007 and 2008 US National Health and Nutrition Examination Survey data for children aged 5 to 17 years (n = 2206) to examine the relationship between food security and untreated dental caries and to assess whether food security mediates the SES–caries relationship.Results. About 20.1% of children had untreated caries. Most households had full food security (62%); 13% had marginal, 17% had low, and 8% had very low food security. Higher SES was associated with significantly lower caries prevalence (prevalence ratio [PR] = 0.77; 95% confidence interval = 0.63, 0.94; P = .01). Children from households with low or very low food security had significantly higher caries prevalence (PR = 2.00 and PR = 1.70, respectively) than did children living in fully food-secure households. Caries prevalence did not differ among children from fully and marginally food-secure households (P = .17). Food insecurity did not appear to mediate the SES–caries relationship.Conclusions. Interventions and policies to ensure food security may help address the US pediatric caries epidemic.Tooth decay (dental caries) is the most prevalent disease worldwide and the most common pediatric disease in the United States.1,2 From 1999 to 2004, the prevalence of untreated tooth decay was 24.5% for children aged 6 to 11 years and 19.6% for adolescents aged 12 to 19 years.3 Untreated tooth decay can lead to difficulties eating and sleeping, pain, the need for invasive restorative treatment, emergency department visits and inpatient hospitalizations, poor quality of life, systemic health problems, and, in rare cases, death.4–7 To date, most public health efforts aimed at addressing the pediatric caries epidemic have focused on tooth-level interventions (e.g., topical fluorides, dental sealants). Although disparities in oral health are considered a measure of social injustice,8 comparatively less research has been conducted on the social determinants of pediatric oral health.9Low socioeconomic status (SES), one of the strongest determinants of caries in children,10–12 is associated with food insecurity,10–17 defined as inadequate access to food resulting in food shortages, disrupted eating patterns, and hunger.18 Food insecurity, in turn, is associated with oral health–related behaviors, including increased fermentable carbohydrate intake,19,20 a risk factor for dental caries.21,22 The American Dietetic Association recognizes the link between nutrition and oral health,23 and numerous studies have drawn associations between dietary factors and disparities in dental caries.24 Collectively, these studies suggest that food insecurity is related to caries and is a potential mechanism linking SES and caries, but these relationships have not yet been evaluated empirically. We used nationally representative data from the United States to test 3 hypotheses: (1) food insecurity is positively associated with untreated dental caries, (2) food insecurity mediates the SES–caries relationship, and (3) food insecurity mediates the SES–caries relationship differentially for children from higher- versus lower-SES households.     

ß-Carotene and Lung Cancer in Smokers: Review of Hypotheses and Status of Research

A number of epidemiological studies have reported associations of β-carotene plasma levels or intake with decreased lung cancer risk. However, intervention studies in smokers have unexpectedly reported increased lung tumor rates after high, long-term, β-carotene supplementation. Recently, detailed analyses by stratification for smoking habits of several large, long-term intervention or epidemiological trials are now available. The ATBC study, the CARET study, the Antioxidant Polyp Prevention trial, and the E3N study provide evidence that the adverse effects of β-carotene supplementation are correlated with the smoking status of the study participants. In contrast, the Physician Health Study, the Linxian trial, and a pooled analysis of 7 epidemiological cohort studies have not supported this evidence. The ferret and A/J mouse lung cancer model have been used to investigate the mechanism of interaction of β-carotene with carcinogens in the lung. Both models have specific advantages and disadvantages. There are a number of hypotheses concerning the β-carotene/tobacco smoke interaction including alterations of retinoid metabolism and signaling pathways and interaction with CYP enzymes and pro-oxidation/DNA oxidation. The animal models consistently demonstrate negative effects only in the ferret, and following dosing with β-carotene in corn oil at pharmacological dosages. No effects or even protective effects against smoke or carcinogen exposure were observed when β-carotene was applied at physiological dosages or in combination with vitamins C and E, either as a mixture or in a stable formulation. In conclusion, human and animal studies have shown that specific circumstances, among them heavy smoking, seem to influence the effect of high β-carotene intakes. In normal, healthy, nonsmoking populations, there is evidence of beneficial effects.     

Women’s Status and its Association With Home Delivery: A Cross-Sectional Study Conducted in Khyber-Pakhtunkhwa,Pakistan

Maternal and Child Health Journal - Home delivery is a predominant driver of maternal and neonatal deaths in developing countries. Despite the efforts of international organizations in Pakistan,...     

Individual and Neighborhood Determinants of Late HIV Diagnosis Among Latinos,Florida, 2007–2011

The objective of this study was to examine individual and neighborhood determinants of late HIV diagnosis by gender and birthplace among Latinos. Florida HIV surveillance data for 2007–2011 were merged with American Community Survey data to estimate the odds of late HIV diagnosis (AIDS within 3 months of HIV diagnosis). Of 5522 HIV-positive Latinos, 26.5 % were diagnosed late. The odds ratio (OR) for late diagnosis was 1.39 times higher for males than females [95 % confidence interval (CI) 1.14–1.69]. Neighborhood-level factors associated with late diagnosis included residing in the 3 highest quartiles of neighborhood unemployment for males. The OR was 1.22 times higher for foreign- than US-born Latinos (95 % CI 1.07–1.40). Among foreign-born, residing in areas in the 2nd and 3rd quartiles of unemployment, in rural areas, and areas with <25 % Hispanic/Latino population were associated with late diagnosis. Population-based HIV testing campaigns may require tailoring to ensure that they effectively reach male Latinos in areas with high unemployment and foreign-born Latinos in rural and predominantly non-Latino areas.     

Socioeconomic Status and Foodborne Pathogens in Connecticut,USA, 2000–2011

Foodborne pathogens cause >9 million illnesses annually. Food safety efforts address the entire food chain, but an essential strategy for preventing foodborne disease is educating consumers and food preparers. To better understand the epidemiology of foodborne disease and to direct prevention efforts, we examined incidence of Salmonella infection, Shiga toxin–producing Escherichia coli infection, and hemolytic uremic syndrome by census tract–level socioeconomic status (SES) in the Connecticut Foodborne Diseases Active Surveillance Network site for 2000–2011. Addresses of case-patients were geocoded to census tracts and linked to census tract–level SES data. Higher census tract–level SES was associated with Shiga toxin–producing Escherichia coli, regardless of serotype; hemolytic uremic syndrome; salmonellosis in persons ≥5 years of age; and some Salmonella serotypes. A reverse association was found for salmonellosis in children <5 years of age and for 1 Salmonella serotype. These findings will inform education and prevention efforts as well as further research.