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Socioeconomic status and education as risk determinants of gastrointestinal cancer
Abstract
Standardized incidence ratios were calculated for cancers of the gastrointestinal tract in different socioeconomic and educational groups in Finland. The series constituted all patients with cancers of the esophagus, stomach, colon, rectum, liver (primary only), gallbladder, and pancreas recorded in the Finnish Cancer Registry in 1971-1975 (8,802 cases). Data on socioeconomic status and education were obtained from the records of the national census of December 31, 1970. Cancers of the colon and rectum were associated with high socioeconomic status and higher levels of education, cancers of the esophagus and stomach with lower classes. These associations are most likely to be mediated by dietary habits. No clear-cut association was found for other cancers.
... [6,7]. Low socioeconomic position has been shown to be associated with an increased risk of all these cancers, regardless of whether it is measured by educational level, [8][9][10][11][12][13][14][15] income, [10,12] occupation, [8,[10][11][12][13]15,16] or material deprivation. [12,17] Also, those being single might be at increased risk compared to cohabitants. ...
... [6,7]. Low socioeconomic position has been shown to be associated with an increased risk of all these cancers, regardless of whether it is measured by educational level, [8][9][10][11][12][13][14][15] income, [10,12] occupation, [8,[10][11][12][13]15,16] or material deprivation. [12,17] Also, those being single might be at increased risk compared to cohabitants. ...
... An inverse association between socioeconomic position and these cancers has been seen in other settings, regardless of whether the measurement of socioeconomic position was educational level, income, or occupation. [8][9][10][11][12][13][14][15][16][17] However, the present study is the by far largest ever addressing this important topic, and the large study size allows for robust subgroup analyses. There was a clear educational gradient with the highest risk for those with the fewest years of schooling and the lowest risk for those with 15 years or more of study. ...
Socio-demographic factors and area of residence might influence the development of esophageal and gastric cancer. Large-scale population-based research can determine the role of such factors.
This population-based cohort study included all Swedish residents aged 30-84 years in 1990-2007. Educational level, marital status, place of birth, and place of residence were evaluated with regard to mortality from esophageal or gastric cancer. Cox regression yielded hazard ratios (HR) with 95% confidence intervals (CI), adjusted for potential confounding.
Among 84 920 565 person-years, 5125 and 12 230 deaths occurred from esophageal cancer and gastric cancer, respectively. Higher educational level decreased the HR of esophageal cancer (HR = 0.61, 95%CI 0.42-0.90 in women, HR = 0.71, 95%CI 0.60-0.84 in men) and gastric cancer (HR = 0.80, 95%CI 0.63-1.03 in women, HR = 0.73, 95%CI 0.64-0.83 in men). Being unmarried increased HR of esophageal cancer (HR = 1.64, 95%CI 1.35-1.99 in women, HR = 1.64, 95%CI 1.50-1.80 in men), but not of gastric cancer. Being born in low density populated areas increased HR of gastric cancer (HR = 1.23, 95%CI 1.10-1.38 in women, HR = 1.37, 95%CI 1.25-1.50 in men), while no strong association was found with esophageal cancer. Living in densely populated areas increased HR of esophageal cancer (HR = 1.31, 95%CI 1.14-1.50 in women, HR = 1.40, 95%CI 1.29-1.51 in men), but not of gastric cancer.
These socio-demographic inequalities in cancer mortality warrant efforts to investigate possible preventable mechanisms and to promote and support healthier lifestyles among deprived groups.
... Differences in cancer incidence and healthcare access by socioeconomic status could explain this result. When studying the occurrence of cancers of GI tract by socioeconomic status and education, Pukkala and Teppo [1986] found a higher incidence of cancers of colon and rectum among individuals of higher socio-economic status (12). Other studies have also found a positive association between colon cancer and socioeconomic status (13,14). ...
... Differences in cancer incidence and healthcare access by socioeconomic status could explain this result. When studying the occurrence of cancers of GI tract by socioeconomic status and education, Pukkala and Teppo [1986] found a higher incidence of cancers of colon and rectum among individuals of higher socio-economic status (12). Other studies have also found a positive association between colon cancer and socioeconomic status (13,14). ...
... Other studies have also found a positive association between colon cancer and socioeconomic status (13,14). Dietary habits and lifestyle could account for such occurrences (12,14). Besides the variation in cancer incidence by socioeconomic status, access-related factors could attribute for the positive relationship seen between hospitalization rates and income and insurance (15,16). ...
The purpose of this study was to determine the inpatient burden among patients with gastrointestinal stromal tumors (GISTs). The study assessed hospitalization rates of GISTs and compared hospital characteristics among patients with and without GISTs. Further, predictors of total charges and mortality among patients with GISTs were identified.The 2009 Healthcare Utilization Project Nationwide Inpatient Sample (HCUP-NIS) database was analyzed for this study. Inpatient burden among patients with GISTs (cases) was compared to that among patients without GISTs or any diagnosis of cancer (controls). Linear regression was used to determine the factors predicting total charges, and logistic regression was used to determine predictors of mortality. Analyses were performed using SAS version 9.2.In 2009, there were 14,562 hospitalizations among patients with GISTs at a rate of 44/100,000 admissions. Hospitalization rates among patients with GISTs varied by patient-, hospital-, and discharge-level characteristics. Patients with GISTs had longer length of stay (LOS), total charges, and mortality rate as compared to the control group. Total charges for hospitalizations among patients with GISTs varied by household income, hospital location and region, LOS, and number of diagnoses on record, respectively. When examining the predictors of mortality, household income, hospital region, and number of diagnoses on record emerged significant.By examining the inpatient burden among patients with GISTs, this study fills a critical gap in this area of research. Future studies could merge medical services claims data with cancer registry data to study in-depth the humanistic and economic burden associated with GISTs.
... Different associations between socioeconomic status (SES) and colon cancer risk have been observed depending on study design. Correlation (Baquet et al., 1991) and crosssectional (Williams and Horm, 1977;Faivre et al., 1989) studies did not show consistent associations, but case-control (Papadimitriou et al., 1984;Ferraroni et al., 1989;Bidoli et al., 1992) and cohort studies (Pukkala and Teppo, 1986;Vagero and Persson, 1986;Leon, 1988) showed predominantly positive associations between SES and colon cancer risk. In these studies hardly any adjustment was made for potential confounders. ...
... The association between education and colon cancer risk is not clear for women. A correlation study (Baquet et al., 1991), a cross-sectional study (Faivre et al., 1989) and a case-control study (Bidoli et al., 1992) reported no association between education and colon cancer risk for women, while an inverse association was found in a crosssectional study (Williams and Horm, 1977), and in two cohort studies in Scandinavia (Pukkala and Teppo, 1986;Vagero and Persson, 1986) significant positive associations were reported. We did not find an association between education and colon cancer, which is consistent with the finding that health differences between SES categories for women are Socioeconomic status and colon cancer Incidence AJM van Loon et al P 885 smaller in The Netherlands than in most other European countries and North America (Kunst et al., 1993), probably because of relatively small differences in education within the female population. ...
... Almost all studies that used occupation as SES indicator reported significant positive (age-adjusted) associations for men (Pukkala and Teppo, 1986;Vagero and Persson, 1986;Leon, 1988;Bidoli et al., 1992), similar to our results. One study found only a positive association with left colon cancer and not with right colon cancer (Faivre et al., 1989). ...
The association between socioeconomic status and colon cancer was investigated in a prospective cohort study that started in 1986 in The Netherlands among 120,852 men and women aged 55-69 years. At baseline, data on socioeconomic status, alcohol consumption and other dietary and non-dietary covariates were collected by means of a self-administered questionnaire. For data analysis a case-cohort approach was used, in which the person-years at risk were estimated using a randomly selected subcohort (1688 men and 1812 women). After 3.3 years of follow-up, 312 incident colon cancer cases were detected: 157 men and 155 women. After adjustment for age, we found a positive association between colon cancer risk and highest level of education (trend P = 0.13) and social standing (trend P = 0.008) for men. Also, male, upper white-collar workers had a higher colon cancer risk than blue-collar workers (RR = 1.42, 95% CI 0.95-2.11). Only the significant association between social standing and colon cancer risk persisted after additional adjustment for other risk factors for colon cancer (trend P = 0.005), but the higher risk was only found in the highest social standing category (RR highest/lowest social standing = 2.60, 95% CI 1.31-5.14). In women, there were no clear associations between the socioeconomic status indicators and colon cancer.
... In Europe, most studies have reported higher colon cancer incidence in high SES groups compared to low SES classes [15][16][17][18], although some recent studies have found no differences in incidence by SES [19,20]. Higher incidence rates of colon cancer have been reported to be associated with high SES in Finland by two earlier studies [17,21]. High SES was associated also with higher rectal cancer incidence in the study published in 1986, investigating a period from 1971 to 1975. ...
... The incidence rates for CRC were on average higher among those with high education and high SES compared to those with lower education and those in low SES position. This is consistent with results from earlier Finnish studies [17,21] and other studies from Europe [15,16,30]. The decrease in the incidence differences due to a steep increase of colon cancer incidence in the group with lowest education is consistent with the results from a study in Norway: They observed the same phenomenon considering socioeconomic differences [22]. ...
Background:
The aim of this study was to investigate if the incidence of colorectal cancer (CRC) is associated with education and socioeconomic status (SES) in Finland, and if there are any changes in incidence differences between the groups over the period 1976–2014.
Material and methods:
CRC cases (N = 77,614) were retrieved from the Finnish Cancer Registry and linked with information on the education level and SES from Statistics Finland. We used Poisson regression model to quantify differences in incidence rates between the groups, and to assess changes over calendar time.
Results and conclusions:
Colon cancer incidence was higher among the highly educated, than in those with basic education. Similar differences were observed by SES in men. Incidence rates increased steeply over time among men with basic education (from 16.7/100,000 in 1976–1979 to 31.8 in 2010–2014), resulting in narrowed differences between the groups (p < .001). Incidence trends of proximal and distal colon and rectal cancer in men showed similar patterns. Heterogeneity across time periods by SES was observed only in colon cancer incidence in men (p = .009). No such large differences were detected in women. Steep increase in colon cancer incidence in men with basic education, and the respective persistent high incidence in the highly educated highlights the importance of focusing the preventive measures on modifiable lifestyle factors in order to reduce CRC incidence and to narrow the educational and socioeconomic health differences.
... Previous studies have shown that some cancers may be related to education level. For example, cancers of the colon and rectum were associated with higher levels of education, but cancers of the esophagus and stomach with lower classes [30]. These associations are most likely to be mediated by dietary habits [30]. ...
... For example, cancers of the colon and rectum were associated with higher levels of education, but cancers of the esophagus and stomach with lower classes [30]. These associations are most likely to be mediated by dietary habits [30]. There are five cancer sites inversely related to education level: colon, pancreas, breast, kidney, and thyroid cancers; however, no consistent gradient in risk with education was observed for the six other neoplasms considered, including rectum, prostate, bladder, Hodgkin disease, and multiple myeloma [31]. ...
Background: Little is known about age differences in the associations of anxiety, depression, and psychological distress (PD) with
... Consistent with other studies, we found elevated risks of squamous cell esophageal cancer for single men compared with married men (16)(17)(18)(19), an inverse association with level of education (20-24), a greater risk for low status occupations compared with high status occupations (whether measured by job titles or educational requirements) (20,21,25), and an increased risk associated with incomes at or below the poverty level (26). In our study, adjustment for annual income reduced the magnitude and significance of the risks associated with other indicators of social class. ...
... Although social class has been linked to squamous cell esophageal cancer in a number of studies (15,(19)(20)(21)(22)(24)(25)(26)(27)(28)(29), the underlying exposures or characteristics responsible for the association are unclear. Low social class is a surrogate for a set of lifestyle and other environmental factors including poor housing, unemployment or workplace hazards, limited access to medical care, stress, poor nutrition, and exposure to infectious agents (14). ...
... Stomach cancer has very often been found to be inversely related to socioeconomic status (SES) [1][2][3][4][5][6][7][8][9][10][11][12] ; all studies but one 1 showed inverse associations between level of education or occupation and stomach cancer risk. However, in these studies hardly any adjustment was made for potential confounders. ...
... 7 8 From the six studies 3 4 6-8 12 in which occupation was used as SES indicator, four found a significant inverse association. 3 6 8 12 In one case-control study 4 a non-significant inverse association was reported, while a cohort study showed no clear association. 7 In the latter the incidence of stomach cancer among managerial and clerical workers was significantly lower compared with the stomach cancer risk in the whole population, but unskilled workers did not have a significantly higher risk. In four studies lifestyle characteristics such as smoking, 2-4 alcohol consumption 3 or vegetable consumption 12 were included. ...
To study the association between socioeconomic status (SES) and stomach cancer incidence (cardia and non-cardia) and the role of lifestyle factors in explaining this association.
Prospective cohort study on diet and cancer that started in 1986. Data were collected by means of a self administered questionnaire.
Population originating from 204 municipalities in the Netherlands.
58,279 men aged 55-69 years. After 4.3 years of follow up, 162 incident stomach cancer cases were detected (49 cardia and 113 non-cardia cases).
After adjustment for age, a lower overall stomach cancer risk was found for men with the highest attained level of education (RR highest/lowest level = 0.54, 95% CI 0.33, 0.89, trend, p = 0.02). This association became less strong after additional adjustment for smoking, intake of vitamin C, beta carotene, alcohol and coffee, family history of stomach cancer, and history of stomach disorders (RR = 0.61, 95% CI 0.34, 1.07, trend, p = 0.11). No clear association was found between occupation based SES indicators and stomach cancer risk. Analyses per subsite of stomach cancer revealed that for people with the highest level of education the age adjusted rate ratio for cardia cancer changed from 0.37 (95% CI = 0.13, 1.00) to 0.60 (95% CI = 0.19, 1.87) after additional adjustment for lifestyle variables, whereas the rate ratio for non-cardia cancer (RR = 0.59, 95% CI 0.33, 1.05) did not change after additional adjustment.
... Consistent with other studies, we found elevated risks of squamous cell esophageal cancer for single men compared with married men (16)(17)(18)(19), an inverse association with level of education (20-24), a greater risk for low status occupations compared with high status occupations (whether measured by job titles or educational requirements) (20,21,25), and an increased risk associated with incomes at or below the poverty level (26). In our study, adjustment for annual income reduced the magnitude and significance of the risks associated with other indicators of social class. ...
... Although social class has been linked to squamous cell esophageal cancer in a number of studies (15,(19)(20)(21)(22)(24)(25)(26)(27)(28)(29), the underlying exposures or characteristics responsible for the association are unclear. Low social class is a surrogate for a set of lifestyle and other environmental factors including poor housing, unemployment or workplace hazards, limited access to medical care, stress, poor nutrition, and exposure to infectious agents (14). ...
PURPOSE: To investigate the relationship between social class factors and squamous cell esophageal cancer and the extent to which alcohol, tobacco, diet, and social class contribute to the five-fold higher incidence among black than white men in the United States.METHODS: Interviews were conducted with 347 incident cases of squamous cell esophageal cancer (119 white males and 228 black males) and 1354 population-based controls (743 white males and 611 black males) from Atlanta, Detroit, and New Jersey. Risks were estimated using unconditional logistic regression controlling for potential confounders.RESULTS: Elevated risks of squamous cell esophageal cancer were associated with indicators of low social class, especially low annual income. The adjusted odds ratios (ORs) for subjects with incomes < $10,000 versus incomes of $25,000 or more were 4.3 (95% CI = 2.1-8.7) for whites and 8.0 (95% CI = 4.3-15.0) for blacks. The combination of all four major risk factors: annual income less than $25,000, moderate/heavy use of alcohol, use of tobacco for six months or longer, and consumption of less than 2.5 servings of raw fruits and vegetables per day accounted for almost all of the squamous cell esophageal cancers in whites (98%) and blacks (99%), and for 99% of the excess incidence among black men.CONCLUSIONS: Lifestyle modifications, especially a lower intake of alcoholic beverages, would markedly decrease the incidence of this cancer in both races and narrow the racial disparity in risk. Further studies into the determinants of social class may help identify a new set of exposures for this tumor that are amendable to intervention.
... This result is likely explained by prostate cancer patients being a heterogeneous group regarding cancer characteristics and prognosis [31]. As early as 1986, Pukkala and Teppo [32] concluded that colorectal cancers are associated with higher SES and education compared to oesophageal and gastric cancers, which are associated with lower SES. Savijärvi et al. [33] confirmed these results in 2019 but reported a shift among men with low education having an increased proportion of colorectal cancer. ...
Introduction
As the global burden of chronic cancer increases, its correlation to lifestyle, socioeconomic status (SES) and health equity becomes more important. The aim of the present study was to provide a snapshot of the socioeconomic and lifestyle patterns for different cancer types in patients at a Nordic tertiary cancer clinic.
Materials and methods
In a descriptive observational study, questionnaires addressed highest-attained educational level, occupational level, economy, relationship status, exposures, and lifestyle habits. The questionnaire was distributed to all cancer patients attending the cancer clinic. Treating physicians added further information about the cancer disease, including primary origin, pathology report, TNM-classification and stage.
Results
Patients with lung cancer had the lowest SES, and patients with gastrointestinal (GI) cancer, other cancer types and prostate cancer had the second, third and fourth lowest SES, respectively. However, breast cancer patients had the highest SES. Lifestyle and exposure patterns differed among the major cancer types. Lung cancer patients reported the highest proportion of unfavourable lifestyle and exposure patterns, and patients with GI cancer, prostate cancer and other cancer types had the second, third and fourth highest proportion of unfavourable lifestyle and exposure patterns, respectively. The most favourable exposure and lifestyle patterns were observed in breast cancer patients.
Conclusions
The present study indicated significant socioeconomic and lifestyle differences among cancer types at a Nordic cancer centre, with differences in lifestyle being more prominent than socioeconomic differences.
... A relationship between low SES and increased risk of cancer has been reported in previous studies. 42 In the Linxian general population cohort study by Tran et al. the importance of SES in reducing the burden of diseases was emphasized. 43 Unfortunately, we failed to collect data on the SES at baseline. ...
Background
To investigate oral leukoplakia (OL) and risk of upper gastrointestinal (UGI) cancer deaths in the Linxian Dysplasia Nutrition Intervention Trial (NIT) cohort.
Methods
A total of 3318 subjects with esophageal squamous dysplasia enrolled on 1 May 1985, and were followed up until 30 September 2015. Participants with OL at baseline were treated as an exposed group, while the remainder was selected as a control group. All subjects were followed monthly and reviewed quarterly by the Linxian Cancer Registry. Cox proportional hazard model was used to estimate hazard ratios (HRs) and 95% confidence intervals (95% CIs).
Results
During the 30‐year follow‐up, a total of 902 UGI cancer deaths occurred, including 541 esophageal squamous cell carcinoma (ESCC) related, 284 gastric cardia carcinoma (GCC) related, and 77 gastric noncardia carcinoma (GNCC) related deaths. Relative to subjects without OL, the long‐term risk of ESCC mortality in participants with OL increased by 26.1% (HR = 1.26, 95% CI: 1.05–1.52). In the subgroup analyses, adverse effects of OL on ESCC mortality were observed especially in younger subjects (HR = 1.48, 95% CI: 1.11–1.97), females (HR = 1.44, 95% CI: 1.11–1.89), non‐smokers (HR = 1.44, 95% CI: 1.15–1.81), nondrinkers (HR = 1.28, 95% CI: 1.04–1.57), and individuals with a family history of cancer (HR = 1.37, 95% CI: 1.05–1.79). No associations were observed between OL and risk of GCC and GNCC mortality.
Conclusions
OL may increase the long‐term risk of ESCC mortality, especially in younger subjects, females, nondrinkers, non‐smokers, and subjects with a family cancer history. Future studies are needed to explore the potentially etiological mechanism.
... Underlying genetic polymorphisms and race-specific genetic susceptibility may prove to play a significant role in the pathogenesis of SCC. Many recent studies have found various single nucleotide polymorphisms (SNPs) in micro RNA (miRNA) sequences in SCC patients compared with controls [26][27]. These mutations, under the potential effects of factors like alcohol and tobacco, may lead to an alteration of miRNA expression and contribute to carcinogenesis. ...
Objectives
This study seeks to delineate trends in esophageal cancer patients in an American cohort and, in particular, examine the impact of race and histology on survival.
Methods
The association between over 50 variables between histology and race subgroups was evaluated. Survival was calculated using Kaplan-Meier curves and a multivariable Cox regression analysis (MVA) was performed.
Results
Poorer survival was noted in black vs. white (193 ± 65 days vs. 254 ± 39, 95% CI 205-295, p=0.07) and squamous cell cancer (SCC) vs. adenocarcinoma (AC) (233 ± 24 days vs. 303 ± 48, 95% CI 197-339, p=0.01) patients. In patients with resectable cancer, blacks had poorer survival than whites (253 ± 46 days vs. 538 ± 202, 95% CI 269-603, p=0.03), and SCC had poorer survival than AC (333 ± 58 vs. 638 ± 152 days, 95% CI 306-634, p=0.006). A higher percentage of white patients received surgery compared to black patients (36% vs. 8%, p=0.08). MVA revealed that only surgery was an independent predictor of mortality (p=0.001).
Conclusion
Black race and SCC were associated with poorer survival. On MVA, surgery was an independent predictor of mortality. Clinicians should be aggressive in offering potentially curative procedures to patients and eliminating socioeconomic barriers.
... Therefore, there are increasing demands to have such characteristics available in the cancer registries. There is a long tradition of linking the cancer patient file with census variables for research purposes (e.g., [23,24,[36][37][38]). Such record linkages have required separate permissions. ...
Background: The Nordic Cancer Registries are among the oldest population-based registries in the world, with more than 60 years of complete coverage of what is now a combined population of 26 million. However, despite being the source of a substantial number of studies, there is no published paper comparing the different registries. Therefore, we did a systematic review to identify similarities and dissimilarities of the Nordic Cancer Registries, which could possibly explain some of the differences in cancer incidence rates across these countries.
Methods: We describe and compare here the core characteristics of each of the Nordic Cancer Registries: (i) data sources; (ii) registered disease entities and deviations from IARC multiple cancer coding rules; (iii) variables and related coding systems. Major changes over time are described and discussed.
Results: All Nordic Cancer Registries represent a high quality standard in terms of completeness and accuracy of the registered data.
Conclusions: Even though the information in the Nordic Cancer Registries in general can be considered more similar than any other collection of data from five different countries, there are numerous differences in registration routines, classification systems and inclusion of some tumors. These differences are important to be aware of when comparing time trends in the Nordic countries.
... Furthermore, food frequency questionnaires may be usefully complemented by biomarker studies as a more objective method to estimate intake of specific nutrients [84]. The inverse association of education level with gastric cancer risk in our meta-analysis is in line with previous findings [85,86]. Education captures aspects of the construct SES and may be particularly related to H. pylori infection, lifestyle habits and/or diet. ...
Background:
Latin America has among the highest gastric cancer incidence rates in the world, for reasons that are still unknown. In order to identify region-specific risk factors for gastric cancer, we conducted a meta-analysis summarizing published literature.
Methods:
Searches of PubMed and regional databases for relevant studies published up to December 2011 yielded a total of 29 independent case-control studies. We calculated summary odds ratios (OR) for risk factors reported in at least five studies, including socioeconomic status (education), lifestyle habits (smoking and alcohol use), dietary factors (consumption of fruits, total vegetables, green vegetables, chili pepper, total meat, processed meat, red meat, fish, and salt), and host genetic variants (IL1B-511T, IL1B-31C, IL1RN*2, TNFA-308A, TP53 codon 72 Arg, and GSTM1 null). Study-specific ORs were extracted and summarized using random-effects models.
Results:
Chili pepper was the only region-specific factor reported in at least five studies. Consistent with multifactorial pathogenesis, smoking, alcohol use, high consumption of red meat or processed meat, excessive salt intake, and carriage of IL1RN*2 were each associated with a moderate increase in gastric cancer risk. Conversely, higher levels of education, fruit consumption, and total vegetable consumption were each associated with a moderately decreased risk. The other exposures were not significantly associated. No prospective study data were identified.
Conclusion:
Risk factor associations for gastric cancer in Latin America are based on case-control comparisons that have uncertain reliability, particularly with regard to diet; the specific factors identified and their magnitudes of association are largely similar to those globally recognized. Future studies should emphasize prospective data collection and focus on region-specific exposures that may explain high gastric cancer risk.
... Educational inequalities have been shown in the risk of other cancers, like gastric and esophageal cancer; a lower socioeconomic position as measured by educational level was associated with a higher gastric or esophageal cancer risk [16,17]. Furthermore, an association between breast cancer and lung cancer risk and educational level was found [18,19]. ...
Until now, studies examining the relationship between socioeconomic status and pancreatic cancer incidence have been inconclusive.
To prospectively investigate to what extent pancreatic cancer incidence varies according to educational level within the European Prospective Investigation into Cancer and Nutrition (EPIC) study.
In the EPIC study, socioeconomic status at baseline was measured using the highest level of education attained. Hazard ratios by educational level and a summary index, the relative indices of inequality (RII), were estimated using Cox regression models stratified by age, gender, and center and adjusted for known risk factors. In addition, we conducted separate analyses by age, gender and geographical region.
Within the source population of 407, 944 individuals at baseline, 490 first incident primary pancreatic adenocarcinoma cases were identified in 9 European countries. The crude difference in risk of pancreatic cancer according to level of education was small and not statistically significant (RII=1.14, 95% CI 0.80-1.62). Adjustment for known risk factors reduced the inequality estimates to only a small extent. In addition, no statistically significant associations were observed for age groups (adjusted RII(≤ 60 years)=0.85, 95% CI 0.44-1.64, adjusted RII(>60 years)=1.18, 95% CI 0.73-1.90), gender (adjusted RII(male)=1.20, 95% CI 0.68-2.10, adjusted RII(female)=0.96, 95% CI 0.56-1.62) or geographical region (adjusted RII(Northern Europe)=1.14, 95% CI 0.81-1.61, adjusted RII(Middle Europe)=1.72, 95% CI 0.93-3.19, adjusted RII(Southern Europe)=0.75, 95% CI 0.32-1.80).
Despite large educational inequalities in many risk factors within the EPIC study, we found no evidence for an association between educational level and the risk of developing pancreatic cancer in this European cohort.
... An evaluation of absolute rates revealed that it was attributable to an increase in incidence among higher educated men, possibly related to new diagnostic techniques, leading to earlier diagnosis among asymptomatic patients (Bos et al., 2000); the absence of a similar effect among women is not clear. The international literature is contradictory, with reports of both direct (Pukkala and Teppo, 1986; Lynge and Thygesen, 1990; La Vecchia et al., 1992) and inverse relationships (Mellemgaard et al., 1994; Schlehofer et al., 1995), likely owing to the low attributable risks of the main risk factors such as smoking, diet, obesity and hypertension (Chow et al., 1996). The strong protection against melanoma in lower SES groups is likely to be attributable both to greater recreational exposure to the sun (Zanetti et al., 1992) and to earlier diagnosis among higher social classes (Montella et al., 2002). ...
The objective of this study was to investigate the relationship between cancer incidence and socioeconomic status, and to examine the temporal trends in social inequalities in cancer risk. Educational differentials in the incidence of cancer (25 sites) among adult residents of Turin (Italy) were examined using data from the Turin Longitudinal Study and the Piedmont Cancer Registry. The relationship between cancer incidence and educational level was evaluated over three 5-year periods between 1985 and 1999 using Poisson models. An estimated 17% of malignancies among men in the low-educational group were attributable to education, whereas women with a low educational level were slightly protected. Less-educated men had higher risks of upper aero-digestive tract, stomach, lung, liver, rectal, bladder, central nervous system and ill-defined cancers, and lower risks of melanoma, kidney and prostate cancers. Women with lower educational levels were at higher risk of stomach, liver and cervical cancers, whereas they were less likely to be diagnosed with melanoma, ovarian and breast cancers. For most sites, the educational gradient in risk did not vary substantially over time. The educational inequalities in cancer incidence observed in this cohort appear similar in magnitude and direction to socioeconomic inequalities found in other Western countries; for some cancer sites results partly differ from the results of other studies, and require further investigation. A thorough understanding of the relative burden of well-documented causes of social inequalities in cancer risk is essential to address preventive measures and to direct future research on unexplained social differences.
Periodontal Disease, Tooth Loss, and Squamous Cell Esophageal Cancer : A Case–Control Study
Hospital-based case-control study datum were used to analyze the disparity and relation between social classes for Afghan men and local Pashtoons of Quetta and surroundings All the four major risk factors like low income, moderate/heavy Hot Tea intake, tobacco use, and infrequent consumption of raw fruits and vegetables contributed for almost all of the squamous cell esophageal cancers in Local Pashtoon in Quetta (98%) and Afghans (99%) and for 99% of the excess Frequency among Afghan men. The poverty was a major risk factor Therefore, lifestyle changes, especially a lowered intake of Hot Tea i.e., beverages, would markedly decrease the Frequency of squamous cell esophageal cancer in both Social groups and would decrease the Social disparity in risk. Further studies are required which may help to identify a new set of exposures of OSCC that are preventable and changeable.
This chapter discusses record linkage in small-area studies. Record linkage refers to the combination of data items, often from different files, for a certain unit of observation. In epidemiology, record linkage is often used to connect data for a particular individual. It is used for causal research and applied when the data on causes (treatment, exposure, etc) are to be related to the effect (survival/risk of the disease). Examples of record linkage to individual health area are presented.
In large parts of the world, esophageal cancer is a very common disease, and the potential for cure is worse than for most other malignancies. The remarkably uneven geographic distribution, and the apparently small proportion that can be attributed to genetic factors, seem to imply that strong external risk factors-possibly reinforced by genetically determined susceptibility-are in operation. The dramatic rise in incidence of the adenocarcinomas poses a special challenge to epidemiologists. Such a rapid change is bound to depend on changes in the exposure to important causal factors. The well documented increase in the prevalence of obesity in many populations might be one such factor. However, there are many conflicting observations and there is clearly room for alternative hypotheses. It appears that a number of other promising leads need be followed up, requiring joint and decisive efforts by epidemiologists and basic scientists.
Background. Different lifestyle choices are commonly regarded as a reflection of socioeconomic status, and the latter is inversely correlated with the risk of developing stomach cancer. However, the details of this association are still unclear in terms of the degree to which lifestyle factors are having impact. To explain the correlation between socioeconomic status and stomach cancer, we therefore examined the roles played by different lifestyle factors.
Methods. A prospective cohort study of diet and cancer was initiated in Japan during 1988. Data were collected by means of a self-administered questionnaire. A follow-up survey was conducted annually, and the cause of death was recorded from the death certificate. The total of 127,477 study participants resided in 45 areas of Japan, and we retrieved data for 18,746 mend and 26,184 women for the present analysis. After 328,030 person-years of follow-up, 379 deaths from stomach cancer were detected: 261 in men and 118 in women.
Results. For men, the age-adjusted relative risk was lowest in the highly educated group (relative risk = 0.72, 95% CI: 0.50–1.04). Relative risk after adjustment for age and dietary choices (including pickles, vegetables, fruit, green tea, and preference for salty foods) was the same as the age-adjusted relative risk (relative risk = 0.72, 95% CI: 0.50–1.04).
Conclusion. The expected inverse correlation between education level and death from stomach cancer was observed in men. However, this association could not be explained by differences in dietary habits, smoking, or alcohol consumption associated with socioeconomic status.
To the authors' knowledge, little work has been done concerning adolescent precursors for gastroesophageal cancer. In the current study, the association of adolescent overweight as well as socioeconomic status (SES) with the incidence of esophageal adenocarcinoma (EAC), gastroesophageal junction adenocarcinoma (GEJAC), and noncardia gastric cancer (NCGC) was evaluated.
Body mass index (BMI) was measured in 1 million Israeli adolescent males who underwent a general health examination at a mean age of 17.3 ± 0.5 years from 1967 to 2005. Overweight was defined as a BMI ≥ 85th percentile of the standard US distribution in adolescence. Incident cancer was identified by linkage with the Israeli National Cancer Registry.
A total of 182 incident cancer cases were documented (52 combined EAC and GEJAC cases and 130 NCGC cases). Adolescent overweight at baseline (BMI ≥ 85th percentile) was associated with an increased risk in the combined group of cases of EAC and GEJAC (multivariable hazards ratio [HR], 2.1; 95% confidence interval [95% CI], 1.1-4.3 [P = .032]). Low SES (the lowest category vs the highest) as well as low number of years of education (≤ 9 years) were associated with an increased risk of intestinal-type NCGC (multivariable HR, 2.2; 95% CI, 1.0-4.8 [P = .041] and multivariable HR, 1.9; 95% CI, 1.1-3.19 [P = .020], respectively). The adjusted risk of NCGC was higher in immigrants born in Asian countries and the former Soviet Union.
Overweight during adolescence was found to be substantially associated with the subsequent development of EAC and GEJAC. In addition, although potential confounding by Helicobacter pylori infection status or lifestyle factors was not fully accounted for in the analyses, lower SES as well as immigration from higher-risk countries are important determinants of NCGC. Cancer 2013. © 2013 American Cancer Society.
The Los Alamos National Laboratory (LANL) Decommissioning Project has decontaminated, demolished, and decommissioned a process exhaust system, two filter plenum buildings, and a firescreen plenum structure at Technical Area 21 (TA-2 1). The project began in August 1995 and was completed in January 1996. These high-efficiency particulate air (HEPA) filter plenums and associated ventilation ductwork provided process exhaust to fume hoods and glove boxes in TA-21 Buildings 2 through 5 when these buildings were active plutonium and uranium processing and research facilities. This paper summarizes the history of TA-21 plutonium and uranium processing and research activities and provides a detailed discussion of integrated work process controls, characterize-as-you-go methodology, unique engineering controls, decontamination techniques, demolition methodology, waste minimization, and volume reduction. Also presented in detail are the challenges facing the LANL Decommissioning Project to safely and economically decontaminate and demolish surplus facilities and the unique solutions to tough problems. This paper also shows the effectiveness of the integrated work package concept to control work through all phases.
Objective:
To analyze scores on a scale designed to measure helplessness, a cognitive variable, as a possible mediator of the association between formal education level and mortality over 5 years in patients with rheumatoid arthritis (RA).
Methods:
A cohort of 1,416 patients with RA from 15 private practices in 6 states and Washington, DC was monitored for over 5 years. Demographic, socioeconomic, therapy, functional status, and psychological variables were analyzed as possible predictors of mortality in invariable and multivariable Cox Proportional Hazards models.
Results:
In a 5-year followup, 1,384 patients were accounted for (97.3%), including 174 who died versus 111 expected (standardized mortality ratio = 1.54). Higher mortality was associated significantly with low formal education, high age, poor scores for activities of daily living (ADL) on a modified health assessment questionnaire (MHAQ), and poor scores on a helplessness scale (all P < 0.01) in univariable analyses. High age, few years of formal education, and poor MHAQ ADL scores were all significant independent predictors of mortality when analyzed simultaneously in a Cox Proportional Hazards model. When helplessness scale scores were included in a model, scores greater than 2.4 (on a scale of 1 to 4), higher age, male gender, and increased MHAQ ADL difficulty scores were all independently significantly predictive of 5-year mortality (P < 0.05), while years of education was no longer a significant predictor.
Conclusion:
Scores on a helplessness scale appear to mediate a component of the association between formal education level and 5-year mortality in these patients with RA. Health professionals and policy makers might consider interventions directed at modification of helplessness as adjunctive to standard interventions to improve outcomes in RA.
An examination of the risk of pancreatic cancer associated with occupation, by industrial branch and job title, was undertaken in a nationwide case-referent study in Finland. The results are based on job history information from the next-of-kin of 625 incident cases of primary malignant exocrinic pancreatic neoplasms, and of 1,700 cancer referents (stomach, colon, and rectum). All cases and referents were between 40 and 74 years at diagnosis. The diagnoses were made in 1984-87, and both cases and referents were known to be dead by April 1, 1990. The source of the cases and referents was the Finnish Cancer Registry. Increases in risk of pancreatic cancer were suggested for a small number of industrial branches and job titles, including stone mining (odds ratio 3.7), cement and building materials (11.1), pharmacists and sales associates in pharmacies (12.9), male wood machinists (4.1), male gardeners (6.7), female textile workers (5.4), and male transport inspectors and supervisors (9.4). The exposures potentially implicated are discussed. In agreement with the overall results of epidemiologic studies conducted elsewhere, direct occupational determinants probably do not account for a substantial share of the etiology of pancreatic cancer, at least in conditions resembling Finnish working environments some 15-40 years ago.
The prime objective of primary health care provision is the maintenance or improvement of the population's health. The equitable distribution of resources is paramount to this and measures of disadvantage are implemented to assess differential levels of need as a basis for calculating deprivation payments according to general practitioner workload. Despite research that highlights the benefits of measures of social disadvantage, indices have not been used to fundamentally shape resource allocation for health authorities. This paper uses the results from a patient survey into utilization behaviour to define and model the determinants of the need for health care based on components of relative need and accessibility. Proxy indicators are derived from routine sources of data to create an Index of Relative Disadvantage (IRD). A sensitivity analysis confirms the robustness of the index and shows that—although the index employs a wider range of variables than most previous deprivation indices—there is no gross data redundancy. Simplified versions of the index are also explored and evaluated. The IRD developed here is closely correlated with other indices of disadvantage, but its greater breadth and more logical construction mean that it may be more likely to be a more widely applicable instrument for health care planning of resource allocation.
Survival differences in stomach cancer are depended on patient, tumour and treatment factors. Some populations are more prone to develop stomach cancer, such as people with low socioeconomic status (SES). The aim of this population based study was to assess whether differences in socioeconomic status (SES) alone, after adjusting for confounding factors, also influence survival.
From 1989 to 2007 all patients with stomach cancer were selected from the cancer registry of the Comprehensive Cancer Centre North-East. Postal code at diagnosis was used to determine SES, dividing patients in three groups; low, intermediate and high SES. Associations between age, localization, grade, stage, and treatment were determined using Chi-square analysis. Relative survival analysis was used to estimate relative excess risk (RER) of dying according to SES.
In low SES neighbourhoods diagnosis was established at older age. More distal tumours were detected in patients with low SES, whereas pathology showed more poorly differentiated tumours in patients with high SES. Overall, more resections were performed in, and more chemotherapy was administrated to patients in high SES neighbourhoods. After adjusting for confounding factors, the risk of dying was lower for patients with high SES (RER 0.89, 95% Confidence Interval 0.81-0.98) compared to patients with low SES.
SES proved to be an independent prognostic factor for survival in patients with stomach cancer.
A cohort of 3637 female and 168 male hair-dressers in Finland was followed up for cancer through the Finnish Cancer Registry in 1970-1987. Compared with the total population, the women had a significantly elevated risk (standardized incidence ratio 1.7) during the first third of the observation period, but not thereafter. For the total follow-up period, the relative risks were highest for nonmelanoma skin cancer (2.0), lung cancer (1.7), ovarian cancer (1.6), cervical cancer (1.5), and cancer of the pancreas (1.5); only the risk of ovarian cancer was statistically significant. A decrease in relative risk with time was observed for many primary sites, e.g., pancreas, cervix uteri, central nervous system, and thyroid. The opposite was true for lung and skin: An increased risk was found only in 1982-1987. The excess was most prominent in the oldest age groups with the longest time span since the first employment as a hairdresser. Among men, too, the general cancer risk was highest (1.6) during the first third of the observation period. An excess of cancers of the lung and the pancreas was observed. The small numbers, however, did not allow any further conclusions. The changes in the cancer risk pattern over time may be associated with changes in working conditions in hairdressing salons.
This study utilizes unit list mortality data for New South Wales, Australia in differential mortality analysis, at state and local levels, and examines geographic patterns of stomach, colo-rectum, respiratory system, female breast cancer and total cancer mortality in Sydney. Associations between manual occupations, low socioeconomic status and male stomach and respiratory cancer mortality were found, as were higher mortality from stomach and respiratory cancer among European-born immigrants in manual occupations. However, unexpected associations were also found between high mortality from stomach and respiratory cancers and managerial occupations. There were also more acute associations between colo-rectum and female breast cancer and higher status areas. Further, mortality variations between specific occupational groups occurred when martial status was controlled for, and the strongest variations were between married and never married males where the social isolation risk factors were presumed to be operative. The highest mortality at the local level in Sydney occurred where more than one at risk population resided and where other influences may have been operative.
Methods. Social class differences in colon cancer survival were studied in 3147 patients with colon cancer diagnosed in Finland from 1979–1982. Of these patients, 2969 were eligible for survival analysis.
Results. A clear social class gradient in colon cancer survival was detected. The difference in the age-adjusted relative risk of death due to colon cancer between the highest (I) and lowest (IV) social class was 19%. Stage of disease at diagnosis accounted for a substantial proportion of differences in survival, and treatment accounted for the rest of them. Differences in treatment by social class were most apparent among patients with advanced or unknown stage of disease at diagnosis. Controlling for the place of residence had little effect on the survival differences. Delay in diagnosis did not account for the observed differences in survival by social class. Cancer 1992; 70:402–409.
A cohort of all people in Denmark aged 20-59 years on 1 January 1981 was followed up for four years for emigration, death and hospital admission for ischaemic heart disease (IHD) as the primary diagnosis. The data set allows tabulation of rates of hospitalization by occupation, position and industry. Well-known classic associations for IHD have been reproduced. Examples are: male bus drivers had a standardized hospitalization ratio (SHR) of 136; for male urban bus drivers SHR = 143, male taxi drivers SHR = 168, fishermen SHR = 129, men occupied in hotels and restaurants SHR = 140, women in hotels and restaurants SHR = 157. The consistency with previous findings is an argument that new significant associations should be treated as substantiated hypotheses if no selection bias is known. Examples of groups at significant excess risk of IHD are those self-employed in the textile industry, self-employed hairdressers, foremen in the construction industry, bakers, medical and industrial laboratory technicians, telephone assistants and unskilled tube and sheet workers in shipyards.
The relationship between cancer and socioeconomic position is examined for men using data from three sources—the Whitehall Study of London civil servants, the OPCS Longitudinal Study and the Registrar General's Decennial Supplement. Mortality from, or registration for, malignant neoplasms was higher overall in lower socioeconomic groups. There was considerable variation in the strength, and to a lesser extent direction, of the association of specific cancer sites and socioeconomic position within each of the studies. However, between the studies the relationships between socioeconomic position and the particular cancers were very similar.
The similarity in results, taken in conjunction with the differences in design and methods of the three studies, makes it very unlikely that these consistent associations are due to artefacts. The heterogeneity in relationships between specific cancer sites and socioeconomic position suggests that no single factor—such as differences in general susceptibility or differences in smoking behaviour—can account for these associations. However socioeconomic differentials displayed by a particular malignancy do offer clues to its aetiology, and provide an indication of the scope that exists for reducing the burden of cancer within a population.
Pancreatic cancer is the fifth leading cause of cancer death, second only to cancer of the colon among neoplasms of the gastrointestinal tract. It is estimated that 27000 new cases and 24500 deaths attributed to pancreatic cancer will occur in the United States in 1988. Death rates have risen steadily in the U.S. since approximately 1930 with a recent leveling off, and this trend also has been observed in similarly developed countries. The time trends for pancreatic cancer in both males and females have been examined in relation to cigarette use in the U.S. Although the correlation is not as dramatic as that for lung cancer, pancreatic cancer mortality rates for both males and females have paralleled the prevalence rates of cigarette smoking with the expected latency lag of several decades. Although ecologic correlations such as this have been used to support meaningless associations, the temporal relation between cigarette usage and pancreatic cancer supports the validity of cigarette smoking as a risk factor for pancreatic cancer established in analytic epidemiologic studies.
Latitude influences the availability of fresh fruits and vegetables (which are associated with cancer protection) and the use of food preservation methods (which are associated with increased cancer). Such dietary differences might be reflected in the frequency of death from cancer of the digestive tract. Female mortality rates for states and provinces of the US and China, both of which cover a wide latitude range, were chosen to investigate latitude- and time-related changes. Mortality for cancer of the stomach, liver, and rectum did increase with latitude in both nations, which is consistent with the hypothesis. Exceptions were cancer of the colon and esophagus; these cancers had a variable association with latitude and did not decline markedly in the US by 1970-1979 as did mortality rates from cancer of the other digestive tract sites. Increased refrigeration and improved transportation, both of which result in increased consumption of fresh fruits and vegetables, and decreased use of older food preservation methods may be responsible for the US decline in mortality rates from stomach, liver, and rectal cancers.
Ferraroni M {Institute of Medical Statistics, University of Milan, 20133 Milan, Italy), Negri E, La Vecchia C, D'Avanzo B and Franceschi S. Socioeconomic indicators, tobacco and alcohol in the aetiology of digestive tract neoplasms. International Journal of Epidemiology 1989, 18: 556–562.
The relationship between education, social class, smoking habits, alcohol consumption and the risk of digestive tract neoplasms was analysed in a case–control study of 50 cases of cancer of the mouth or pharynx, 209 of the oesophagus, 397 of the stomach, 455 of the colon, 295 of the rectum, 151 of the liver, 214 of the pancreas, and a total of 1944 control subjects admitted for acute, non-neoplastic or digestive tract disorders. Cancers of the mouth or pharynx, oesophagus and stomach were inversely and strongly related to education, with risk estimates ranging between 0.2 and 0.4 for the highest education categories. Significant, but weaker inverse relations were evident for rectal and liver cancer, too, whereas the risk of colon cancer was elevated among more educated individuals. There was no relationship between education and pancreatic cancer. The pattern of risk was largely comparable when the head of the household's occupation was used as indicator of social class. There were strong direct associations between cigarette (as well as pipe or cigar) smoking and cancers of the mouth or pharynx and oesophagus, and a moderate one with pancreatic cancer, but none of the other sites considered was related to smoking habits. Cancers of the mouth or pharynx and oesophagus were independently and strongly related to alcohol consumption, too, while the associations between alcohol and liver or pancreatic cancer were moderate and not significant. Cancers of the stomach, colon and rectum were unrelated to measures of alcohol consumption.
Multiplicative Poisson models were used to identify subgroups of the Danish population at high and low risk of developing cancer of the right or left side of the colon, and cancer of the rectum. The analysis was based on cross-linked data from the 1970 census and the Danish Cancer Registry, where a 10-year follow-up period yielded some 20,000 colo-rectal cancers, in approximately 2.5 million persons. The risk of cancer of the right side of the colon in longer educated men living in apartment houses was almost twice as high as in farmers living in single family houses (relative risk 1.84; 95% confidence interval 1.42-2.37). A two-fold ratio (RR 2.18; 95% CI 1.70-2.62) was also seen in the risk of cancer of the left side of the colon between men with longer education in Greater Copenhagen and farmers in Jutland. The annual number of colon cancer cases in men in Denmark could be reduced by 27% if the incidence for all men was equal to that found for the low risk group of farmers.
Cases of cancer notified to the Danish Cancer Registry during the period 1970 to 1984 in the age groups 16 to 66 years have been linked to information on employment kept on file in the nationwide Supplementary Pension Fund since 1964. Industrial hygienists classified industrial groups as defined by the Pension Fund with regard to exposure to wood dust, and a list of industries with major exposure to wood dust was defined. The risk for cancer of the respiratory system and the gastrointestinal tract was evaluated by means of a proportional cancer incidence analysis. A fourfold increase in risk for sinonasal cancer was found among men involved in the manufacture of wooden furniture, and a twofold increase in risk for gastric cancer was seen in all of the component industries of basic wood-processing. In contrast, no excess of gastric cancer could be detected in men working in the manufacture of wooden building materials and wooden furniture, and a risk below unity was seen for those in carpentry and joinery. The elevated risk for gastric cancer in some wood-processing industries is probably due to social factors also common to men in agriculture and manufacturing. The absence of an increased risk for gastric cancer in trades in which a high risk for sinonasal cancer is seen indicates that wood dust is not of aetiological importance for gastric cancer. No excess of total lung cancer or of the adenocarcinoma subtype was seen in any of the wood-processing industries.
This study shows that, unlike most diseases, some cancer forms are more common in upper social classes. All cancer cases diagnosed in Finland in 1971-75 aged 30-69 and recorded in the Finnish Cancer Registry (n = 36,500) were linked to the file of the 1970 Population Census of Finland with data on socio-economic status and education. Cancers related to both high socio-economic status and high level of education in men were colon, prostate, testis, kidney and melanoma of the skin, and in women colon, breast, and corpus uteri. Since 1953, the incidence of all these cancers had been rising, although that of the testicular cancer had levelled off in the seventies.
In this article studies on the association between socioeconomic status (SES) and risk for cancer at different sites are reviewed.
The review is restricted to studies conducted in affluent societies, after 1970. Only studies using income, education and/or occupation as SES indicators are included.
A more or less consistent positive association between SES and cancer risk was found for colon and breast cancer. More or less consistent inverse associations were found for lung, stomach, oropharyngeal and esophageal cancer. Inconsistent associations were reported for cancer of the rectum and pancreas. Possible explanations for SES differences in cancer risk are discussed with special emphasis on lifestyle variables related to cancer risk.
It is concluded that it is still unclear whether the reported associations can be (partially) attributed to lifestyle related risk factors for cancer such as smoking, nutritional habits, drinking habits and reproductive factors.
The purpose of this study was to investigate the relationship between exposure to mutagenic drinking water and cancers of the gastrointestinal and urinary tract.
Past exposure to drinking water mutagenicity was assessed in 56 Finnish municipalities for the years 1955 and 1970. The cases of bladder, kidney, stomach, colon, and rectum cancers were derived from two periods (1967 to 1976 and 1977 to 1986). Age, sex, social class, urban living, and time period were taken into account in the Poisson regression analysis.
Statistically significant exposure-response association was observed between exposure and incidence of bladder, kidney, and stomach cancers. In an ordinary municipality using chlorinated surface water, this exposure would indicate a relative risk of 1.2 for bladder cancer and of 1.2 to 1.4 for kidney cancer compared with municipalities where nonmutagenic drinking water was consumed.
The acidic mutagenic compounds present in drinking water may play a role in the etiology of kidney and bladder cancers, but, because the results are based on aggregate data, they should be interpreted with caution.
This study examined 500 low socioeconomic adults' perceptions and practices regarding bowel cancer. At least 20 percent of respondents incorrectly believed homosexual men are more likely to develop bowel cancer, exercising regularly will not affect bowel cancer, bowel cancer does not run in families, and eating foods high in fat does not increase bowel cancer risks. Approximately 7 in 10 respondents did not perceive themselves as more susceptible to developing bowel cancer even though the same number of respondents acknowledged that poor people are more likely to develop bowel cancer. The majority (54 percent) believed that if you develop bowel cancer, it will kill you. The majority of respondents did not believe that fecal occult blood tests could help save their lives if they had bowel cancer since 90 percent perceived bowel cancer as incurable even if found early. The main barriers to screening for bowel cancer identified by the respondents were: being too embarrassed to have a proctoscopic exam (77%), not wanting to know if they had bowel cancer (78%), preferring to die rather than have their bowel removed for cancer (80%), and trouble with transportation (81%). Thirty percent of the respondents had personally done a stool occult blood test and the same number claimed they had a proctoscopic exam. The results of this survey indicate that there is considerable room for improvement in knowledge, perceptions, and practices of economically disadvantaged subjects regarding bowel cancer.
Vesterinen E (Department of Allergic Diseases, Helsinki University Central Hospital, Meilahdentie Helsinki, Finland), Pukkala
E, Timonen T and Aromaa A. Cancer incidence among 78 000 asthmatic patients. International Journal of Epidemiology 1993; 22: 976-982. The risk of cancer was evaluated among 77 952 asthma patients with bronchial asthma. The series was obtained
through linkage of two registers: the Finnish Social Insurance Institution's file of asthma patients and the Finnish Cancer
Registry. There was a significant excess risk of lung cancer in both sexes, the standardized incidence ratio (SIR) being 1.32
among men and 1.66 among women. In women, the risk of cancer of the rectum was significantly increased (SIR 1.42), whereas
the risks of cancer of the corpus uteri and multiple myeloma were lower than expected (SIR 0.76 and 0.53, respectively). In
men, the incidence of cancer of the larynx was significantly reduced (SIR 0.63) and that of the bladder increased (SIR 1.25).
When both sexes were combined, cancers of the colon (SIR 1.17) and rectum (SIR 1.28) also showed a significantly elevated
risk. A reduction in risk was seen in stomach cancer (SIR 0.88) and lymphatic leukaemia (SIR 0.55). The increased lung cancer
risk may be due to local inflammatory changes. It is possible that differences in the immune system, e.g. natural killer cell
activity, explain some of the reduced cancer risks
To describe the variation in the incidence of colorectal cancer across Northern Ireland and relate it to factors associated with community deprivation.
This was a cross sectional descriptive study.
Incidence data were obtained from a population based register for the period 1990-91. Small areas were characterised by their "affluence", or lack of it, by deriving a Townsend deprivation score for each electoral ward, using information from the 1991 census. PARTICIPANTS, MAIN OUTCOME MEASURES, AND STATISTICAL METHODS: The age standardised incidence was calculated for all colorectal cancer cases diagnosed histologically in 1990-91. Electoral wards were grouped into quintiles of the population after ranking of their Townsend scores and the association with incidence was studied using Poisson regression.
The age standardised colorectal cancer incidence ranged from 22.5 (for quintile 1) to 29.9/100,000 (quintile 5) for men but the trend for women was less regular and rates were 18.4, 23.8, 27.3, 26.5, and 23.9/100,000 for quintiles 1-5 respectively (that is, from the most "affluent" to the most "deprived" fifths of the population). After adjusting for age and sex in Poisson regression, there was a significant association between the total colorectal cancer incidence and levels of community deprivation. The rate ratio for the most deprived quintile of the population (compared with the least) was 1.28 (95% CI 1.06,1.53). The effect was stronger for rectal cancer than for colonic cancer. There was no association between community deprivation and the cancer stage at diagnosis.
In this population, the colorectal cancer incidence is associated with the level of material deprivation. The disease stages at the time of diagnosis in patients from more deprived areas seem to be comparable with those of patients from affluent areas. As others have shown, associations such as these are not explicable entirely on the basis of the distribution of known risk factors. Further research is needed to determine plausible mechanisms for the association.
Survival differences in cancer patients according to socioeconomic status (SES) have been reported for several organs, but the relationship with gastric cancer prognosis has not been conclusively defined. The present study analysed the survival of 122 incident, histologically confirmed gastric cancer patients diagnosed between 1985 and 1987 in Genoa, Italy and enrolled in a multicentric case-control study on gastric cancer occurrence and dietary habits. Adjusting for age at diagnosis, tumour stage, histopathological grading and surgery (i.e. curative gastric resection), Cox's proportional hazards regression model showed statistically significant hazard ratio (HR) (relative risk) estimates below unity for education (> 5 versus < or = 5 years of schooling, HR = 0.40, P = 0.003) and occupation (higher versus lower income job, HR = 0.59, P = 0.030). Also, the same final regression model revealed a positive prognostic effect for origin (Southern Italy migrants versus Genoa natives) (HR = 0.56, P = 0.039) and female gender (HR = 0.58, P = 0.020). High SES, origin from lower risk area for gastric cancer occurrence and female gender are positive prognostic categories for gastric cancer patients.
Despite the fact that socioeconomic status (SES) has been shown to have important implications in health related issues, population-based cancer registries in the United States do not routinely collect SES information. This study presents a model to estimate the SES of cancer patients in the registry database.
At the Los Angeles Cancer Surveillance Program (CSP), we developed a model to estimate each cancer patient's SES from aggregate measurements of the census tract of residence (n = 1,640) at time of diagnosis. We then applied the SES estimates to observe the relationship between SES and risk of cancers of the female breast and reproductive organs including cancers of the ovary, cervix uteri, and corpus uteri. The analyses were performed on the cumulative records (n = 127,819) of cancer patients diagnosed between 1972 and 1992 in Los Angeles County, California, for the mutually exclusive racial/ethnic groups of non-Hispanic Whites, Hispanic Whites, Blacks, Asians, and persons of other ethnic groups.
We found SES is positively associated with female breast cancer, ovarian cancer, and cancer of the corpus uteri, but inversely associated with cervical cancer. These SES trends were quite consistent across age groups among non-Hispanic White women. Variations by race/ethnicity in the SES patterns were also found, with Asians exhibiting little association.
Our model of measuring SES is sufficiently sensitive to capture the trends. Adopting the aggregate approach to measure SES in population-based registry data appears to be useful.
Socioeconomic correlates of cancer of the large bowel differ in various countries and calendar periods and may differ for the colon and rectum. Thus, the relationship between education and social class and risk of cancers of the colon and rectum was considered.
Combination of two hospital-based case-control studies conducted in six Italian centres between 1985 and 1996. Cases were 3533 patients aged < 79, with histologically confirmed cancer of the colon (n = 2180) or rectum (n = 1353), and controls were 7062 patients admitted to hospital for a wide spectrum of acute, non-neoplastic, non-digestive tract diseases.
Compared to individuals with < 7 years of education the multivariate odds ratios (OR) of colon cancer for those with > or = 16 years were 2.45 (95% confidence interval [CI]: 1.87-3.23) in men and 1.29 (95% CI: 0.88-1.90) in women, with significant trends in risk. No significant association emerged between education and risk of rectal cancer, with OR of 1.18 (95% CI: 0.83-1.70) and 1.01 (95% CI: 0.61-1.67) respectively for men and women in the highest educational category compared to the lowest. Social class was also related to colon cancer risk: the OR were 2.30 (95% CI: 1.82-2.90) in men and 1.33 (95% CI: 1.03-1.73) in women in the highest versus the lowest social class. No association was found between social class and rectal cancer risk, with OR of 1.18 for either men or women in the highest as compared to the lowest social class. No significant heterogeneity was found for the association between education and colon cancer risk in either sex across strata of age at diagnosis, coffee, alcohol and vegetable intake, family history of the disease, and in anatomical subsites within the colon.
This study, based on a uniquely large dataset, indicates that there are different social class correlates for colon and rectal cancer. Consequently the two sites should not be combined in studies considering lifestyle factors in the aetiology of these neoplasms.
Data from a population-based case-control study were used to evaluate the relation between social class factors and squamous cell esophageal cancer and the extent to which alcohol, tobacco, diet, and low income contribute to the higher incidence among Black men than among White men in the United States. A total of 347 male cases (119 White, 228 Black) and 1,354 male controls (743 White, 611 Black) were selected from three US geographic areas (Atlanta, Georgia, Detroit, Michigan, and New Jersey). Cases were residents of the study areas aged 30-79 years who had been diagnosed with histologically confirmed esophageal cancer between 1986 and 1989. The adjusted odds ratios for subjects with annual incomes less than $10,000 versus incomes of $25,000 or more were 4.3 (95% confidence interval: 2.1, 8.7) for Whites and 8.0 (95% confidence interval: 4.3, 15.0) for Blacks. The combination of all four major risk factors-low income, moderate/heavy alcohol intake, tobacco use, and infrequent consumption of raw fruits and vegetables-accounted for almost all of the squamous cell esophageal cancers in Whites (98%) and Blacks (99%) and for 99% of the excess incidence among Black men. Thus, lifestyle modifications, especially a lowered intake of alcoholic beverages, would markedly decrease the incidence of squamous cell esophageal cancer in both racial groups and would narrow the racial disparity in risk. Further studies on the determinants of social class may help to identify a new set of exposures for this tumor that are amenable to intervention.
To assess how the risk of cancer of the colon and rectum relates to place of birth and socio-economic status, we analysed data from an Italian case-control study. Data included 1225 cases with a recent diagnosis of cancer of the colon (ages 19-74 years), 728 cases of cancer of the rectum (ages 23-74 years) and 4154 controls (ages 19-74 years), frequency-matched with cases by age and catchment area and admitted to hospitals for a wide spectrum of acute non-neoplastic conditions. Compared with residents born in the north of Italy, migrants from the centre and south had an odds ratio (OR) of 0.7 (95% CI 0.5-0.9) for colon cancer and OR of 0.9 (95% CI 0.7-1.2) for cancer of the rectum. The inverse association of migration with colon cancer was stronger among women (OR 0.5, 95% CI 0.4-0.8) than among men (OR 0.8, 95% CI 0.6-1.1), and was independent of education and occupation. Among migrants, the direct association between education and colon cancer risk was less clear than among non-migrants. In conclusion, place of origin played an independent role in colon cancer aetiology. Results on rectal cancer were less clear, although in the same direction. Among migrants, those less susceptible to behavioural changes (e.g. women) retained most of the benefit associated with their place of origin.
To investigate the incidence of colorectal cancer in the Split-Dalmatia County in the 1981-1998 period, and compare it with the incidence in the Republic of Croatia.
The data were obtained using case records and registries of all hospitals and Public Health Institute in the County and the Croatian Cancer Registry. Age-standardized incidence per 100,000 was calculated from the number of patients with colorectal cancer and the number of inhabitants.
There were 2,454 new cases of colorectal cancer (1,383 men and 1,071 women) in the Split-Dalmatia County in 1981-1998. Colon cancer was diagnosed in 55% of the cases. Age-standardized incidence rates for colorectal carcinoma per 100,000 population were 11.4 (men 14.8, women 9.0) in 1981, and 63.5 (men 93.1, women 42.5) in 1998. The total incidence increased from 16.1 (colon cancer 7.9, rectal cancer 8.2) in 1981-1985 period to 52.8 (colon cancer 30.5, rectal cancer 22.3) in 1994-1998 period, or approximately 3.3 times. The colorectal cancer incidence rate in the Split-Dalmatia County increased from 16.2 in 1985 to 46.4 in 1995, and in whole Croatia from 32.4 in 1985 to 37.8 in 1995.
There was a great increase in the reported incidence of colorectal cancer in the Split-Dalmatia County in the 1981-1998 period. The relative increase of incidence in the colorectal cancer was much greater in the Split-Dalmatia County than in Croatia as a whole. These changes call for preventive and screening measures for colorectal carcinoma.
We evaluated cancer mortality patterns among hairdressers and barbers, according to occupation, coded on 7.2 million death certificates in 24 states from 1984 to 1995. Of the 38,721 deaths among white and black hairdressers and barbers of both sexes, 9495 were from all malignant neoplasms. Mortality odds ratios were significantly elevated for all malignant neoplasms, lung cancer, and all lymphatic and hemopoietic cancers among black and white female hairdressers. White female hairdressers had significant excess mortality from cancers of the stomach, colon, pancreas, breast, and bladder and from non-Hodgkin's lymphoma and lymphoid leukemia; mortality from these cancers was also elevated among black female hairdressers. White male hairdressers had significantly elevated mortality from non-melanoma skin cancer and non-Hodgkin's lymphoma. Mortality from all malignant neoplasms, although significantly elevated among both white and black female hairdressers, was significantly below the null for white male hairdressers. Black and white male barbers had significantly elevated mortality from stomach and pharyngeal cancer, respectively. A significant deficit in mortality from all neoplasms and cancers of the pancreas, lung, and prostate was noted for white male barbers. This large study of cancer mortality among hairdressers and barbers showed some differences in mortality patterns by gender and race. Further studies are required to determine if specific occupational exposures may explain some of the elevated cancer rates.
Few studies have compared socioeconomic inequalities in the prevalence of both fatal and non-fatal diseases. This paper aims to give the first international overview for several common chronic diseases.
Micro-level data were pooled from non-standardized national health surveys conducted in eight European countries in the 1990s. Surveys ranged in size from 3700 to 41 200 participants. The prevalence of 17 chronic disease groups were analysed in relation to education. Standardized prevalence rates and age-adjusted odds ratios (ORs) were calculated.
Most diseases showed higher prevalence among the lower education group. Stroke, diseases of the nervous system, diabetes, and arthritis displayed relatively large inequalities (OR > 1.50). No socioeconomic differences were evident for cancer, kidney diseases, and skin diseases. Allergy was more common in the higher education group. Relative socioeconomic differences were often smaller among the 60-79 age group as compared with the 25-59 age group. Cancer was more prevalent among the lower educated in the 25-59 age group, but among the higher educated in the 60-79 age group. For diabetes, hypertension, and heart disease, socioeconomic differences were larger among women as compared with men. Inequalities in heart disease were larger in northern European countries as compared with southern European countries.
There are large variations between chronic diseases in the size and pattern of socioeconomic differences in their prevalence. The large inequalities that are found for some specific fatal diseases (e.g. stroke) and non-fatal diseases (e.g. arthritis) require special attention in equity-oriented research and policies.
The characteristics of the 3614 Los Angeles County residents in whom cancer of the exocrine pancreas was diagnosed during the period 1972–1977 were compared with those of all county residents and patients in whom any cancer was diagnosed during the same period. Seventy-nine percent of the diagnoses had been pathologically verified. This disease still preferentially afflicts the old, the black, and men, although the differences in risk with factors other than age are modest. The disease is not evenly distributed by social class, or over time, although it is not clear that the observed differences reflect etiology. The distributions with respect to important categories of occupation and industry, religion, marital status,' geography of residence, and birthplace were rather uniform. Although there is no obvious explanation for any of several unexpected minor inequities in the pattern of incidence, there is no compelling evidence to support any specific environmental cause. There is substantial evidence which is inconsistent with those environmental hypotheses that have been proposed previously.
Doctoral Thesis--University of Minnesota.
The incidence of large-bowel cancer in Cali, Colombia, for 1962-71 shows the upper socioeconomic classes to be a higher risk. This is the first report of a socioeconomic gradient in risk for this site. The gradients were most marked for cancer of the ascending through rectosigmoid colon and were minimal for cancer of the cecum and rectum. The Cali experience presents several parallels with information derived from comparisons of developed and developing countries and also appears consistent with recent information on the possible role of dietary factors in bowel cancer.
Carcinoma of the colon was studied in Omaha-Douglas County, Nebraska (population 345,000). A total of 154 cases of colon cancer were diagnosed in 1964 (44.7/100,000). The frequency distribution of these patients in specific census tracts of this community was determined. Statistical analysis of the data showed a greater frequency of colon cancer in patients living in census tracts with higher average income. Colon cancer appears to be nonrandomly distributed with respect to the income and socioeconomic status of its victims, suggesting that hypotheses consistent with environmental variables--particularly those characterizing extremely high versus extremely low socioeconomic groups, including occupation, diet and other life patterns--should be pursued. All of these data have implications for cancer epidemiology, cancer control, and carcinogenesis.
A case-control dietary study of 198 patients with cancer of the colon and two matched control groups demonstrated a significantly lower fiber consumption frequency among the cancer patients. This difference was not confined to a few items. Of the 73 items on the fiber list, 61 were eaten less often by the cancer patient than by a neighborhood control, and 57 were consumed less frequently than by a surgical control. These findings support the hypothesis that low-residue foods play an etiologic role in colon carcinogenesis. A mechanism related to the possible potential carcinogenic properties of degraded biliary compounds may be implicated.
Study of 220 Japanese stomach cancer patients and 440 hospital controls in Hawaii revealed that migrants (Issei) from prefectures with the highest stomach cancer risks in Japan continued to display an excess risk in Hawaii, but this effect did not persist among their Nisei offspring. Lower risks were suggested for Nisei, but not Issei adhering to Western-style diets. These nativity distinctions are consistent with other studies suggesting that early exposures are critical. Associations of stomach cancer with consumption of specific foods were noted. Elevated risks were described for Issei and Nisei users of pickled vegetables and dried/salted fish, the most frequent consumers having the highest risks. Since similar associations did not appear for raw fish and unprocessed vegetables, suspicion is directed to methods of preparation. Low risks were suggested for several Western vegetables, many of which are eaten raw. The associations for uncooked vegetables appeared independent of those found for pickled vegetables,- both persisted after control for other facets of vegetable consumption. Associations for tobacco, liquor, coffee, and milk were observed only in the Issei population. Points of consistency between the Hawaii findings and those assembled in Japan are cited. Experimental evidence bearing on the epidemiologic data for processed fish and vegetables is mentioned.
The correlation between alcohol consumption and morbidity from cancer was investigated in 2 male Finnish populations. For the first population, the files of the Finnish Cancer Registry on cancer of the esophagus, liver, and colon (1965-68) and lung (1968) in males were checked against the files of the 'alcohol misuser' registry; this group totaled approx 205,000 males registered due to conviction for drunkeness, sanctions imposed by the municipal Social Welfare Boards, and breaches against the regulations governing alcohol usage in connection with the buyer surveillance conducted by the Finnish State Alcohol Monopoly in 1944-59. Excess morbidity was observed from cancer of the esophagus (P<0.001), liver (P<0.05), and lung (P<0.001) but not from cancer of the colon. For the second population, the files on a group of chronic skid row alcoholics were studied. The mean annual number of males, >30 yr old, registered as alcoholics by the Social Welfare Board of Helsinki was 4,370 in 1967-70. The data of this registry were checked against those of the Finnish Cancer Registry (1967-70). Excess morbidity (P<0.05) was observed from cancer of the pharynx, esophagus, and lung; excess total cancer morbidity was also noted. The results agree with the hypothesis of a correlation between alcohol consumption and morbidity from cancer of the pharynx, esophagus, and liver. The high incidence of lung cancer in both populations may be attributed to concomitant heavy smoking, which may also be partly responsible for the excess morbidity from esophageal cancer.
Ecologic and individual risk indicators were derived from the population censuses of Finland Cancer Registry. The years covered in the study were 1955-1974 for the ecologic analysis and 1971-1975 for the analysis on individuals. The incidence of both diseases was high in an urban environment with high standard of living. The individuals with high risk of breast cancer were of high socioeconomic status and were well educated, whereas cervical cancer was common among women of low socioeconomic status and with less education. Conceptually similar indicators used on both the ecologic and individual levels characterize different aspects of risk; for example, a woman with a low standard of living in a well-to-do environment has a high risk of cervical cancer.
Mortality and incidence rates for pancreatic cancer in the United States were examined by various demographic characteristics. Disease rates have continued to increase over time but at a much slower pace than in earlier years. Most recently available rates for blacks were significantly higher than for whites and rates for males of each race were higher than for females. Income and education levels had little influence on incidence rates among either blacks or whites. Incidence rates were not significantly higher in urban as compared with rural areas of Iowa and Colorado. The two-year survival rate for pancreatic cancer was about 5% in recent years and did not vary significantly by race or sex. Smoking and diabetes, the two risk factors most consistently associated with the pancreatic cancer, explain only a small proportion of the disease. Much epidemiologic work remains to be done.
Primary prevention is of priority in cancer control. This primarily applies to malignant neoplasms whose direct cause is smoking. Modifications in nutrition by consuming more fresh vegetables and fruits, by reducing calories, by enhancing physical activity, and correspondingly, a decrease in body weight will result in lower incidence of cancer of the stomach, colon, breast, uterine body, prostate and affect the risk for malignancy associated with smoking and other environmental carcinogenic factors. Prevention of infectious exposures, including vaccination, is the most effective method for controlling cancer of the cervix uteri and liver, some leukemias and lymphomas, H. pylori-associated gastric cancer. The most important components of cancer control are to monitor the enterprises, ambient and room air for carcinogens and to lower adverse impact of ultraviolet and ionizing radiation on man. Progress in molecular biology enables one to involve into carcinogenesis at its each stage. The risk associated with carcinogenic exposure can be assessed by taking into account not only the carcinogenicity of an environmental factor and its dosage, but also individual sensitivity. Information on specific molecular genetic changes that are specific for different carcinogenic substances and tumors, the so-called finger prints, may be used for identification of a carcinogenic factor and correspondingly for prevention, as well as preclinical diagnosis and gene therapy at early stages of carcinogenesis.
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- H F Darn
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Cancer Risks by Site
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Occupational mortality in 1971-75 Study No. 54. Central Statistical Office of Fin-land
- H Sauli
Sauli, H. " Occupational mortality in 1971-75. " Study No. 54. Central Statistical Office of Fin-land, Helsinki, 1979.
Finnish Drinking Habits in 1969 and 1976. Alcohol Consumption and Alcohol Problems in Demographic Groups
- J Simpura
Simpura, J. " Finnish Drinking Habits in 1969 and 1976. Alcohol Consumption and Alcohol Problems in Demographic Groups. " Reports from the Social Research Institute of Alcohol Studies No.
Occupational mortality in 1971-75
- Sauli
Finnish Drinking Habits in 1969 and 1976
- Simpura
Demographic characteristics of cancer of the pancreas: Mortality, incidence, and survival
- Levin