Dairy products and its association with incidence of cardiovascular disease: the Malmö diet and cancer cohort

It is unclear whether specific dairy products are associated with risk of cardiovascular disease (CVD). The aim of this project was therefore to examine the association between intake of milk, cheese, cream and butter, and incidence of CVD in the Swedish Malmö Diet and Cancer cohort. Milk was separated into fermented (yoghurt and cultured sour milk) versus non-fermented milk, and low-fat versus high-fat milk. Among 26,445 individuals without a history of myocardial infarction, stroke and diabetes (44–74 years; 62% females), 2,520 CVD cases (coronary and stroke events) were identified during a mean follow-up time of 12 years. Dietary data was collected using a modified diet history method. Overall consumption of dairy products was inversely associated with risk of CVD (P _trend = 0.05). Among the specific dairy products, a statistically significant inverse relationship was observed only for fermented milk. The highest versus lowest intake category of fermented milk was associated with 15% (95% CI: 5–24%; P _trend = 0.003) decreased incidence of CVD. We observed a statistically significant interaction between sex and cheese intake (P = 0.046). Cheese intake was significantly associated with decreased CVD risk in women (P _trend = 0.03), but not in men (P _trend = 0.98). The main finding was that a high intake of fermented milk may reduce the risk of CVD. This study suggests that it is important to examine dairy products separately when investigating their health effects.     

Trends in diet and breast cancer mortality in England and Wales 1928–1977

Trends in age‐adjusted breast cancer mortality and consumption of meat, fat, sugar, cereal, and fruit and vegetables were studied for England and Wales over the 50‐year period from 1928 to 1977. At the onset of World War II, there was a marked reduction in both breast cancer mortality and intake of sugar, meat and fat, and an increased consumption of cereals and vegetables. Consumption of these foodstuffs returned to pre‐war levels by 1954, but breast cancer mortality did not return to pre‐war levels until some 15 years later. The association between the various dietary components and subsequent breast cancer mortality was determined for various lag intervals. Significant correlations were found for cereal, fat, sugar and meat consumption, the correlation being maximal for a diet‐breast cancer death lag interval of 12 years.

These findings add weight to the hypothesis that breast cancer development is related to a diet rich in meat, fat and sugar, and that some protection against cancer may be afforded by a reduction in these dietary components and an increase in cereal consumption.     

Estimating breast cancer incidence in Hispanic women in Connecticut, 1989–1991

Objectives. The objective of this study was to estimate incidence rates for breast cancer, the most commonly occurring cancer in women, in the growing Hispanic population of Connecticut.

Methods. The population‐based Connecticut Tumor Registry (CTR) routinely obtains only limited information on Hispanic origin and maiden name. In this study, surnames of CTR breast cancer patients diagnosed in 1989–1991 were matched with a list of Spanish surnames. To assess misclassification, both surnames and maiden names (from death certificates) of female Connecticut residents who had died in 1989–1991 from any cause of death at 20 years of age and older were matched with the Spanish‐surname list.

Results. Age‐specific incidence rates (1989–1991) for ‘Hispanic’ women (with Spanish surname) were lower than those for ‘non‐Hispanic’ white women (with non‐Spanish surname) for age 35–39 years and older. Errors in these estimated rates were probably small because among decedents the number with a Spanish surname differed by only 9% from the number with a Spanish maiden name; false positives were almost balanced by false negatives.

Conclusion. Matching of surnames in the cancer registry with a Spanish surname list provided reasonably accurate estimates of cancer incidence rates in Hispanic women, although individual women were misclassified as ‘Hispanic’ or ‘non‐Hispanic’.     

Feasibility of a randomized trial of a high‐vegetable diet to prevent breast cancer recurrence

Epidemiologic evidence supports the concept that diet influences risk for breast cancer and suggests that prognosis after the diagnosis of breast cancer may also be related to modifiable nutritional factors. The purpose of this study was to investigate the feasibility of a randomized trial of a high‐vegetable, reduced‐fat, and increased‐fiber diet intervention to reduce risk for recurrence among breast cancer survivors. This major change in dietary pattern was promoted through intensive telephone counseling. Participants were 93 women who had been diagnosed with breast cancer (stages I, II, and IIIA) within the previous four years and who had completed their initial treatment. We assessed adherence to the study diet using repeated 24‐hour dietary recalls at 6 and 12 months and measurement of circulating carotenoid concentrations. Six months after randomization, the intervention group had significantly increased their mean intake of vegetables (+4.6 servings/day), fruit (+0.7 servings/day), and fiber (+6.4 g/1,000 kcal) and significantly reduced their intake of dietary fat (‐9.9% of energy) compared with the control group. Circulating concentrations of carotenoids also increased in the intervention group. These changes persisted at the 12‐month visit. Results of this study demonstrate that telephone counseling can be a useful approach in diet intervention and that breast cancer survivors can adopt and maintain a high‐vegetable, reduced‐fat dietary pattern.     

Effect of using repeated measurements of a Mediterranean style diet on the strength of the association with cardiovascular disease during 12 years: the Doetinchem Cohort Study

Background

In cohort studies, often only one baseline measurement of dietary intake is available. This may underestimate the strength of the association with cardiovascular diseases (CVD).

Objective

The main objective is to compare the strength of the association of a Mediterranean style diet with CVD using one baseline measurement of diet versus three repeated measurements over a 10-year period.

Design

We used dietary and lifestyle data of three rounds of the Doetinchem Cohort Study. At baseline, 7,769 persons aged 20–65 years were examined. Diet was assessed with a 178 item validated food-frequency questionnaire and operationalized with the Mediterranean Diet Score (MDS) ranging from 0 to 9. Cox proportional hazards models were used to estimate hazard ratios (HRs) and 95 % confidence intervals (CI). Analyses were adjusted for age, sex, and repeated measurements of smoking, sports, total energy intake, and educational level.

Results

Comparing an MDS of ≥5.5–9 to an MDS of 0–<3.5, baseline MDS was associated with a 23 % lower risk [HR 0.77 (95 % CI 0.53–1.11)] and the updated mean with a 35 % lower risk [HR 0.65 (0.43–0.97)] of a composite of fatal CVD, nonfatal myocardial infarction, and stroke (composite CVD). For fatal CVD, baseline MDS was associated with a 13 % lower risk [HR 0.87 (0.36–2.07)] and the updated mean with a 56 % lower risk [HR 0.44 (0.19–1.05)].

Conclusion

The strength of the association between a Mediterranean style diet and CVD is likely underestimated because most studies so far used only one baseline measurement.     

Atrial fibrillation in the Malmö diet and cancer study: a study of occurrence,risk factors and diagnostic validity

The validity of atrial fibrillation (AF) diagnoses in national registers for use as endpoints in prospective studies has not been evaluated. We studied the validity of AF diagnoses in Swedish national hospital discharge and cause of death registers and the occurrence of and risk factors for AF in a middle-aged Swedish population using these registers. Our study included the 30,447 individuals (age 44–73) who attended baseline visits in 1991–1996 of the Malmö Diet and Cancer study. Individuals with a first AF diagnosis were identified by record linkage with national registers. A subset of cases was randomly selected for validation by examination of electrocardiograms and patient records. Electrocardiograms were available in 98% of the validation sample (95% definitive AF, 3% no AF). The 2% with ECGs unavailable had probable AF. Baseline AF prevalence was 1.3%, higher in men and increased with age. During 11.2 years of follow-up 1430 first AF diagnoses occurred. Risk factors were age, hypertension, BMI, diabetes, history of heart failure, history of myocardial infarction and, in men but not women, current smoking. The strongest risk factors were history of heart failure (hazard ratio men 4.5, women 8.7) and myocardial infarction (hazard ratio men 2.0, women 1.8). The largest population attributable risks were observed for hypertension (men 38%, women 34%) and obesity (men 11%, women 10%). In conclusion, case misclassification of AF in national registers is small, indicating feasibility of use in prospective studies. Hypertension and obesity account for large portions of population risk in middle-aged individuals with low prevalence of manifest cardiac disease.     

Anxiety and depression in breast cancer patients at low risk of recurrence compared with the general population: a valid comparison?

Breast cancer and its treatment have been associated with psychological morbidity. In this study our aim was to quantify the excess anxiety and depression resulting from breast cancer. We compared 538 newly diagnosed breast cancer patients at low risk of recurrence (87.0% responded) to 872 women randomly selected from the Danish general population (69.7% responded) using the Hospital Anxiety and Depression Scale (HADS). Contrary to expectations, the proportions classified as "cases" of anxiety and depression were not significantly different in the two groups. The breast cancer patients' mean HADS scores were significantly lower than those in the general population sample (anxiety, P = 0.021; depression, P < 0.001), indicating less anxiety and depression. However, we question the validity of this comparison. The HADS may not be suitable for use in the general population and there may be methodological problems in comparisons of groups whose life situations are very different.     

Media coverage of women's health issues: is there a bias in the reporting of an association between hormone replacement therapy and breast cancer?

Media coverage of scientific research plays a major role in shaping public opinion and influencing medical practice. When an association is controversial, such as with hormone replacement therapy (HRT) and breast cancer, it is important that a balanced picture of the scientific literature be reported. The objective of this study was to assess whether scientific publications that do and do not support an HRT/breast cancer association were cited in the media in proportions similar to those with which they appear in the scientific literature. Scientific publications reporting on the HRT/breast cancer association published from January 1, 1995, to June 30, 2000, were identified through a systematic Medline search. Media reports from newspapers, magazines, television, and radio that reported on HRT and breast cancer were retrieved from an online database. Investigators independently recorded characteristics of the scientific publications and media reports. A total of 32 scientific publications were identified: 20 (62.5%) concluded there was an increased risk of breast cancer associated with HRT (positive publications), and 12 (37.5%) concluded there was no evidence for an association (null publications). Nearly half (47%) of the scientific publications were not cited by the media. There were 203 media citations of scientific publications: 82% were of positive publications and 18% were of null publications, representing a significant excess of citations of positive publications (p < 0.01). Media coverage of this controversial issue is based on a limited sample of the scientific publications. Moreover, the excess of media citations for positive scientific publications suggests a bias against null scientific publications.     

Diet and cancer: Food additives,coffee, and alcohol∗

In this study, the effects of dietary fat and selenium on the development of putative preneoplastic foci induced by aflatoxin B, were examined. Rat hepatic y‐glutamyl transpeptidase (GGT) activity, selenium‐dependent glutathione peroxidase activity, glutathione, and total lipid were analyzed 3 and 13 weeks after the start of dietary and carcinogen treatment. Results indicate that high dietary fat has an enhancing effect on the development of preneoplastic foci. A high‐fat, selenium‐deficient diet resulted in an increase in foci development, but the increase was not significant. An interaction between aflatoxin and the two nutrients was also observed in liver glutathione content and GGT activity at Week 3.     

Neighbourhood deprivation and alcohol consumption: does the availability of alcohol play a role?

BACKGROUND: Previous studies suggest that the physical availability of alcohol may mediate the association between neighbourhood-level material deprivation and alcohol consumption. This study tests the relationships between neighbourhood-level deprivation, alcohol availability, and individual-level alcohol consumption using a multilevel analysis. METHODS: Data are from cross-sectional surveys conducted between 1979 and 1990 as part of the Stanford Heart Disease Prevention Program (SHDPP). Women and men (n = 8197) living in four northern/central California cities and 82 neighbourhoods were linked to neighbourhood deprivation variables derived from the US census (e.g. unemployment, crowded housing) and to measures of alcohol availability (density of outlets in the respondent's neighbourhood, nearest distance to an outlet from the respondent's home, and number of outlets within a half mile radius of the respondent's home). Separate analyses were conducted for on- and off-sale outlets. RESULTS: The most deprived neighbourhoods had substantially higher levels of alcohol outlet density than the least deprived neighbourhoods (45.5% vs 14.8%, respectively). However, multilevel analyses showed that the least deprived neighbourhoods were associated with the heaviest alcohol consumption, even after adjusting for individual-level sociodemographic characteristics (OR 1.30, CI 1.08-1.56). Alcohol availability was not associated with heavy drinking and thus did not mediate the relationship between neighbourhood deprivation and heavy alcohol consumption. CONCLUSIONS: Although alcohol availability is concentrated in the most deprived neighbourhoods, women and men in least deprived neighbourhoods are most likely to be heavy drinkers. This mismatch between supply and demand may cause people in the most deprived neighbourhoods to disproportionately suffer the negative health consequences of living near alcohol outlets.     

Patterns of alcohol drinking and its association with obesity: data from the third national health and nutrition examination survey, 1988–1994

Background  

Recent reports suggest that alcohol use may have a protective effect on obesity. This study explores association between obesity and alcohol consumption in the non-smoking U.S. adult population.     

The association of race/ethnicity,socioeconomic status,and physician recommendation for mammography: who gets the message about breast cancer screening?

OBJECTIVES: This study investigated the association between physician recommendation for mammography and race/ethnicity, socioeconomic status, and other characteristics in a rural population. METHODS: In 1993 through 1994, we surveyed 1933 Black women and White women 52 years and older in 10 rural counties. RESULTS: Fifty-three percent of the women reported a physician recommendation in the past year. White women reported recommendations significantly more often than did Black women (55% vs 45%; odds ratio = 1.49). Controlling for educational attainment and income eliminated the apparent racial/ethnic difference. After control for 5 personal, 4 health, and 3 access characteristics, recommendation for mammography was found to be more frequent among women who had access to the health care system (i.e., had a regular physician and health insurance). Recommendation was less frequent among women who were vulnerable (i.e., were older, had lower educational attainment, had lower annual family income). CONCLUSIONS: Socioeconomic status, age, and other characteristics--but not race/ethnicity--were related to reports of a physician recommendation, a precursor strongly associated with mammography use. Efforts to increase physician recommendation should include complementary efforts to help women address socioeconomic and other barriers to mammography use.     

How much of the data published in observational studies of the association between diet and prostate or bladder cancer is usable for meta-analysis?

Epidemiologic investigations often report dose-response associations, which may be combined in meta-analyses. The authors examined how often the log odds, risk, or hazard ratio per unit increase in exposure, and its standard error, can be estimated from results reported from observational studies of diet and prostate or bladder cancer so that results are usable in meta-analyses estimating dose-response associations. Eight electronic databases were searched for studies reporting on the association of diet, nutrition, or physical activity with these cancers. A total of 767 papers reported 3,284 results; 1,999 (61%) results, reported in 545 (71%) papers, were usable in dose-response meta-analyses. The most important reason that results were not usable was the absence of sufficient information on exposure levels in the different groups. The proportion of results usable in "high-low" meta-analyses (comparisons of extreme categories) was similar (62%). Results that showed evidence of an association were more likely to be usable than results that found no such evidence. Insufficient detail in reporting of results of observational studies can lead to exclusion of these results from meta-analyses and is an important threat to the validity of systematic reviews of such research. Results providing evidence of associations may be overrepresented in meta-analyses of observational studies.     

Mammographic breast density and risk of breast cancer: Masking bias or causality?

Masking bias is hypothesized to explain associations between breast density and breast cancer risk. Tumours in dense breasts may be concealed at the initial examination, but manifest themselves in later years, suggesting an increase in breast cancer incidence. We studied the association between breast density and breast cancer risk in 0, 1–2, 3–4 and 5–6 year periods between initial examination and diagnosis. We studied 359 cases and 922 referents, identified in a breast cancer screening programme in Nijmegen, the Netherlands. Breast density was assessed at the initial examination and classified as 'dense' (if > 25% of the breast was composed of density) or 'lucent' ( 25% density). In women examined with mid-1970s film screen mammography, we found that at time 0 the odds ratio (OR) for women with dense breasts compared to those with lucent breasts was 1.4 (95% confidence interval (CI): 0.7–6.2). After a 3–4 year period the risk was increased to 3.3 (95% CI: 1.5–7.1). Then, the risk decreased again (OR: 1.2, 95% CI: 0.6–2.7). This rise and decline in risk are in accordance with the masking hypothesis. The observation, however, that the risk at time 0 does not appear to be lower for women with dense breasts than for those with lucent breasts, seems to be inconsistent with the masking hypothesis and may be indicative of causality. The same analysis were performed in women whose initial screening examination was done with current high-quality mammography. Due to the small size of this study group no firm conclusions could be drawn, but it seems as if masking bias could still play a role with high-quality mammography.     

Cost-effectiveness of trastuzumab in metastatic breast cancer: Mainly a matter of price in the EU?

Trastuzumab (TR), a monoclonal antibody approved by EMA in 2000 and one of the first examples of “targeted therapy”, is indicated to treat human epidermal growth factor receptor 2 (HER2) positive breast cancer. TR, whose patent will expire in 2015 in Europe, has been judged positively for reimbursement by most public authorities in the EU. Here we critically review the existing evidence on TR in metastatic breast cancer (MBC), in line with the multidisciplinary health technology assessment (HTA) approach, to assess whether the existing evidence supports TR positive reimbursement decisions taken in MBC by EU health authorities. We did a literature search for the main HTA topics (efficacy, quality of life and ethics) on the PubMed international database (2000–2013). Then, we did a specific literature search to select the full economic evaluations (FEEs) conducted in EU countries focused on TR as first-line innovative therapy in MBC. We retrieved scant evidence in the literature to support TR reimbursement in MBC. We found only two clinical trials and their results were unclear because of the large proportion of patients who crossed over. Moreover, the quality of methods was poor in all four European FEEs selected. This example of HTA exercise on a mature monoclonal antibody in a specific indication casts doubts on how often the reimbursement decisions taken by EU health authorities in emotional pathologies like cancer are rational. These decisions should at least be reconsidered periodically on the basis of the latest evidence.     

Consumption of alcohol and risk of cancer among men: a 30 year cohort study in Lithuania

Studies have indicated hazardous consumption of large quantities of alcohol among adults in Lithuania. We assessed the associations of alcohol consumption at baseline with cancer incidence among men in a population-based cohort study, using Cox models adjusted for smoking, education and body mass index. Attained age was used as a time-scale. During follow-up (1978–2008) 1,698 men developed cancer. A higher amount of alcohol consumption (≥140.1 g/week vs. 0.1–10.0 g/week) was positively associated with increased risk of total cancer [hazard ratio (HR) = 1.36, 95 % confidence interval (95 % CI) 1.11, 1.65], upper aerodigestive tract cancer (HR = 2.79, 95 % CI 1.23, 6.34) and alcohol-related cancers (i.e. oral cavity, pharynx, larynx, oesophagus, colorectal and liver cancer) (HR = 1.88, 95 % CI 1.25, 2.85). Compared to occasional drinkers (a few times/year), drinkers 2–7 times/week showed an increased risk of total (HR = 1.45, 95 % CI 1.16, 1.83), alcohol-related (HR = 1.83 95 % CI 1.14, 2.93) and other cancers (HR = 1.35, 95 % CI 1.04, 1.76). Our results showed no statistically significant associations between quantity of alcohol intake per one occasion and risk of cancer. About 13 % of total, 35 % of upper aerodigestive tract, 22 % of alcohol-related and 10 % of other cancer cases were due to alcohol consumption in this cohort of men.