Interaction of sedentary behaviour and educational level in breast cancer risk.

OBJECTIVE: This cross-sectional study aims to analyse the relationship between sedentary behaviour and breast cancer (BC) risk from a social perspective. METHODS: Women aged 45-70 who participated in the Valencia Region Breast Cancer Screening Programme (2018-2019) were included, with a total of 121,359 women analysed, including 506 with cancer and 120,853 without cancer. The response variable was BC (screen-detected) and the main explanatory variable was sedentary behaviour (≤2 / >2-≤3 / >3-≤5 / >5 hours/day, h/d). Nested logistic regression models (M) were estimated: M1: sedentary behaviour adjusted for age and family history of BC; M2: M1 + hormonal/reproductive variables (menopausal status, number of pregnancies, hormone replacement therapy; in addition, months of breastfeeding was added for a subsample of women with one or more live births); M3: M2 + lifestyle variables (body mass index, smoking habits); M4: M3 + socioeconomic variables (educational level, occupation); Final model: M4 + gender variables (childcare responsibilities, family size). Interaction between sedentary behaviour and educational level was analysed in the Final model. Moreover, for the whole sample, postmenopausal women and HR+ BC, the Final model was stratified by educational level. RESULTS: Sedentary behaviour was associated with an increased risk of BC with a nearly statistically significant effect in the Final model (>2-≤3 h/d: OR = 1.22 (0.93-1.61); >3-≤5 h/d: OR = 1.14 (0.86-1.52); >5: OR = 1.19 (0.89-1.60)). For women with a low educational level, sitting more than 2 h/d was associated with an increased risk of BC in the whole sample (>2-≤3 h/d OR = 1.93 (1.19-3.21); in postmenopausal women (>2-≤3 h/d, OR = 2.12 (1.18-2.96), >5h/d OR = 1.75 (1.01-3.11)) and in HR+ BC (>2-≤3h/d, OR = 2.15 (1.22-3.99)). Similar results were observed for women with one or more live births. Conclusions Sitting >2 h/d is associated with BC risk in women with low educational level, especially in postmenopausal women and those with live births.

Impact of different age ranges on the benefits and harms of the breast cancer screening programme by the EU-TOPIA tool.

BACKGROUND: The recommendation for the implementation of mammography screening in women aged 45-49 and 70-74 is conditional with moderate certainty of the evidence. The aim of this study is to simulate the long-term outcomes (2020-50) of using different age range scenarios in the breast cancer screening programme of the Valencia Region (Spain), considering different programme participation rates. METHODS: Three age range scenarios (S) were simulated with the EU-TOPIA tool, considering a biennial screening interval: S1, 45-69 years old (y); S2, 50-69 y and S3, 45-74 y. Simulations were performed for four participation rates: A = current participation (72.7%), B = +5%, C = +10% and D = +20%. Considered benefits: number (N°) of in situ and invasive breast cancers (BC) (screen vs. clinically detected), N° of BC deaths and % BC mortality reduction. Considered harms: N° of false positives (FP) and % overdiagnosis. RESULTS: The results showed that BC mortality decreased in all scenarios, being higher in S3A (32.2%) than S1A (30.6%) and S2A (27.9%). Harms decreased in S2A vs. S1A (N° FP: 236 vs. 423, overdiagnosis: 4.9% vs. 5.0%) but also benefits (BC mortality reduction: 27.9% vs. 30.6%, N° screen-detected invasive BC 15/28 vs. 18/25). In S3A vs. S1A, an increase in benefits was observed (BC mortality reduction: 32.2% vs. 30.6%), N° screen-detected in situ B: 5/2 vs. 4/3), but also in harms (N° FP: 460 vs. 423, overdiagnosis: 5.8% vs. 5.0%). Similar trends were observed with increased participation. CONCLUSIONS: As the age range increases, so does not only the reduction in BC mortality, but also the probability of FP and overdiagnosis.

Interval Cancer in Population-Based Colorectal Screening Programmes: Incidence and Characteristics of Tumours.

The objective of this study is to evaluate interval cancer (IC) in colorectal cancer (CRC) screening, which is CRC diagnosed in an individual after having received a negative faecal occult blood test and before the next invitation to participate in screening. A follow-up study was conducted on a cohort of participants in the first three screening rounds of four colorectal cancer screening programmes in Spain, n = 664,993. A total of 321 ICs and 2120 screen-detected cancers (SCs) were found. The IC and SC rates were calculated for each guaiac (gFOBT) or immunochemical (FIT) test. A Cox regression model was used to estimate the hazard ratios (HR) of IC risk factors. A nested case-control study was carried out to compare IC and SC tumour characteristics. The IC rate was 1.16‱ with the gFOBT and 0.35‱ with the FIT. Men and people aged 60-69 showed an increased probability of IC (HR = 1.81 and HR = 1.95, respectively). There was a decreased probability of IC in individuals who regularly participated in screening, HR = 0.62 (0.47-0.82). IC risk gradually rose as the amount of Hb detected in the FIT increased. IC tumours were in more advanced stages and of a larger size than SC tumours, and they were mostly located in the cecum. These results may play a key role in future strategies for screening programmes, reducing IC incidence.

Long-Term Exposure to Nitrate and Trihalomethanes in Drinking Water and Prostate Cancer: A Multicase-Control Study in Spain (MCC-Spain).

BACKGROUND: Nitrate and trihalomethanes (THMs) in drinking water are widespread and are potential human carcinogens. OBJECTIVE: We evaluated the association between drinking-water exposure to nitrate and THMs and prostate cancer. METHODS: During the period 2008-2013, 697 hospital-based incident prostate cancer cases (97 aggressive tumors) and 927 population-based controls were recruited in Spain, providing information on residential histories and type of water consumed. Average nitrate and THMs levels in drinking water were linked with lifetime water consumption to calculate waterborne ingestion. Odds ratios (OR) and 95% confidence intervals (CI) were estimated using mixed models with recruitment area as random effect. Effect modification by tumor grade (Gleason score), age, education, lifestyle, and dietary factors was explored. RESULTS: Mean (±standard deviation) adult lifetime waterborne ingested nitrate (milligrams per day), brominated (Br)-THMs (micrograms per day), and chloroform (micrograms per day) were 11.5 (±9.0), 20.7 (±32.4), and 15.1 (±14.7) in controls. Waterborne ingested nitrate >13.8 vs. <5.5mg/d was associated with an OR of 1.74 (95% CI: 1.19, 2.54) overall, and 2.78 (95% CI: 1.23, 6.27) for tumors with Gleason scores ≥8. Associations were higher in the youngest and those with lower intakes of fiber, fruit/vegetables, and vitamin C. Waterborne ingested THMs were not associated with prostate cancer. Residential tap water levels of Br-THMs and chloroform showed, respectively, inverse and positive associations with prostate cancer. CONCLUSIONS: Findings suggest long-term waterborne ingested nitrate could be a risk factor of prostate cancer, particularly for aggressive tumors. High intakes of fiber, fruit/vegetables and vitamin C may lower this risk. Association with residential levels but not ingested chloroform/Br-THM may suggest inhalation and dermal routes could be relevant for prostate cancer. https://doi.org/10.1289/EHP11391.

Construction of an individual socioeconomic status index for analysing inequalities in colorectal cancer screening.

OBJECTIVE: To construct an individual socioeconomic status index (ISESI) with information available in the Population Information System of the Region of Valencia, Spain, and use it to analyse inequalities in a colorectal cancer screening programme (CRCSP). METHODS: Cross-sectional study of men and women aged between 50 and 75 at the time of the study (2020) that were selected from the target population of the Region of Valencia CRCSP. (study sample 1,150,684). First, a multiple correspondence analysis was performed to aggregate information from the Population Information System of the Region of Valencia into an ISESI. Second, data from the 2016 Region of Valencia Health Survey were used for validation, and finally the relationship between CRCSP participation and the ISESI was analysed by logistic regression models. RESULTS: The variables included in the index were nationality, employment status, disability, healthcare coverage, risk of vulnerability and family size. The most important categories for determining the highest socioeconomic status were being employed and not being at risk of social vulnerability, and being unemployed and at risk of social vulnerability for determining the lowest socioeconomic status. Index validation demonstrated internal and external coherence for measuring socioeconomic status. The relationship between CRCSP participation and the ISESI categorised by quartile (Q) showed that Q4 (the lowest socioeconomic status) was less likely to participate OR = 0.769 (0.757-0.782) than Q1 (the highest socioeconomic status), and the opposite was found for Q2 OR = 1.368 (1.347-1.390) and Q3 OR = 1.156 (1.137-1.175). CONCLUSIONS: An ISESI was constructed and validated using Population Information System data and made it possible to evaluate inequalities in colorectal cancer screening.

Meat Intake, Cooking Methods, Doneness Preferences and Risk of Gastric Adenocarcinoma in the MCC-Spain Study.

BACKGROUND: The association of meat intake with gastric adenocarcinoma is controversial. We examined the relation between white, red, and processed meat intake and gastric adenocarcinoma, considering doneness preference and cooking methods, by histological subtype and anatomical subsite. METHODS: MCC-Spain is a multicase-control study that included 286 incident gastric adenocarcinoma cases and 2993 controls who answered a food-frequency questionnaire. The association of gastric adenocarcinoma with meat intake, doneness preference and cooking methods was assessed using binary multivariate logistic regression mixed models and a possible interaction with sex was considered. Multinomial logistic regression models were used to estimate risk by tumor subsite (cardia vs. non-cardia) and subtype (intestinal vs. diffuse). Sensitivity analyses were conducted comparing models with and without data on Helicobacter pylori infection. RESULTS: The intake of red and processed meat increased gastric adenocarcinoma risk (OR for one serving/week increase (95% CI) = 1.11 (1.02;1.20) and 1.04 (1.00;1.08), respectively), specifically among men and for non-cardia and intestinal gastric adenocarcinoma. Those who consume well done white or red meat showed higher risk of non-cardia (white: RRR = 1.57 (1.14;2.16); red: RRR = 1.42 (1.00;2.02)) and intestinal tumors (white: RRR = 1.69 (1.10;2.59); red: RRR = 1.61 (1.02;2.53)) than those with a preference for rare/medium doneness. Stewing and griddling/barbequing red and white meat, and oven baking white meat, seemed to be the cooking methods with the greatest effect over gastric adenocarcinoma. The reported associations remained similar after considering Helicobacter pylori seropositivity. CONCLUSIONS: Reducing red and processed meat intake could decrease gastric adenocarcinoma risk, especially for intestinal and non-cardia tumors. Meat cooking practices could modify the risk of some gastric cancer subtypes.

Salt intake and gastric cancer: a pooled analysis within the Stomach cancer Pooling (StoP) Project.

PURPOSE: Previous studies show that consuming foods preserved by salting increases the risk of gastric cancer, while results on the association between total salt or added salt and gastric cancer are less consistent and vary with the exposure considered. This study aimed to quantify the association between dietary salt exposure and gastric cancer, using an individual participant data meta-analysis of studies participating in the Stomach cancer Pooling (StoP) Project. METHODS: Data from 25 studies (10,283 cases and 24,643 controls) from the StoP Project with information on salt taste preference (tasteless, normal, salty), use of table salt (never, sometimes, always), total sodium intake (tertiles of grams/day), and high-salt and salt-preserved foods intake (tertiles of grams/day) were used. A two-stage approach based on random-effects models was used to pool study-specific adjusted (sex, age, and gastric cancer risk factors) odds ratios (aORs), and the corresponding 95% confidence intervals (95% CI). RESULTS: Gastric cancer risk was higher for salty taste preference (aOR 1.59, 95% CI 1.25-2.03), always using table salt (aOR 1.33, 95% CI 1.16-1.54), and for the highest tertile of high-salt and salt-preserved foods intake (aOR 1.24, 95% CI 1.01-1.51) vs. the lowest tertile. No significant association was observed for the highest vs. the lowest tertile of total sodium intake (aOR 1.08, 95% CI 0.82-1.43). The results obtained were consistent across anatomic sites, strata of Helicobacter pylori infection, and sociodemographic, lifestyle and study characteristics. CONCLUSION: Salty taste preference, always using table salt, and a greater high-salt and salt-preserved foods intake increased the risk of gastric cancer, though the association was less robust with total sodium intake.

Prostate cancer genetic propensity risk score may modify the association between this tumour and type 2 diabetes mellitus (MCC-Spain study).

BACKGROUND: Some studies have reported an inverse association between type 2 diabetes mellitus (T2DM) and prostate cancer (PCa), but results on this issue are still inconsistent. In this study, we evaluate whether this heterogeneity might be related to differences in this relationship by tumour or by individual genetic susceptibility to PCa. METHODS: We studied 1047 incident PCa cases and 1379 randomly selected controls, recruited in 7 Spanish provinces for the population-based MCC-Spain case-control. Tumour were classified by aggressiveness according to the International Society of Urological Pathology (ISUP), and we constructed a PCa polygenic risk score (PRS) as proxy for genetic susceptibility. The epidemiological questionnaire collected detailed self-reported data on T2DM diagnosis and treatment. The association between T2DM status and PCa was studied by fitting mixed logistic regression models, and, for its association by aggressiveness of PCa, with multinomial logistic regression models. To evaluate the possible modulator role of PRS in this relationship, we included the corresponding interaction term in the model, and repeated the analysis stratified by PRS tertiles. RESULTS: Globally, our results showed an inverse association between T2DM and overall PCa limited to grade 1 tumours (ORISUP = 1: 0.72; 95% CI: 0.53-0.98), which could be compatible with a detection bias. However, PCa risk also varied with duration of diabetes treatment -inversely to metformin and positively with insulin-, without differences by aggressiveness. When we considered genetic susceptibility, T2DM was more strongly associated with lower PCa risk in those with lower PRS (ORtertile 1: 0.31; 95% CI: 0.11-0.87), independently of ISUP grade. CONCLUSIONS: Our findings reinforce the need to include aggressiveness and susceptibility of PCa, and T2DM treatments in the study of the relationship between both diseases.

Differences in breast cancer-risk factors between screen-detected and non-screen-detected cases (MCC-Spain study).

PURPOSE: The variation in breast cancer (BC)-risk factor associations between screen-detected (SD) and non-screen-detected (NSD) tumors has been poorly studied, despite the interest of this aspect in risk assessment and prevention. This study analyzes the differences in breast cancer-risk factor associations according to detection method and tumor phenotype in Spanish women aged between 50 and 69. METHODS: We examined 900 BC cases and 896 controls aged between 50 and 69, recruited in the multicase-control MCC-Spain study. With regard to the cases, 460 were detected by screening mammography, whereas 144 were diagnosed by other means. By tumor phenotype, 591 were HR+, 153 were HER2+, and 58 were TN. Lifestyle, reproductive factors, family history of BC, and tumor characteristics were analyzed. Logistic regression models were used to compare cases vs. controls and SD vs. NSD cases. Multinomial regression models (controls used as a reference) were adjusted for case analysis according to phenotype and detection method. RESULTS: TN was associated with a lower risk of SD BC (OR 0.30 IC 0.10-0.89), as were intermediate (OR 0.18 IC 0.07-0.44) and advanced stages at diagnosis (OR 0.11 IC 0.03-0.34). Nulliparity in postmenopausal women and age at menopause were related to an increased risk of SD BC (OR 1.60 IC 1.08-2.36; OR 1.48 IC 1.09-2.00, respectively). Nulliparity in postmenopausal women was associated with a higher risk of HR+ (OR 1.66 IC 1.15-2.40). Age at menopause was related to a greater risk of HR+ (OR 1.60 IC 1.22-2.11) and HER2+ (OR 1.59 IC 1.03-2.45) tumors. CONCLUSION: Reproductive risk factors are associated with SD BC, as are HR+ tumors. Differences in BC-risk factor associations according to detection method may be related to prevailing phenotypes among categories.

[Results of 10 years of the Colorectal Cancer Prevention Program in the Valencian Community.] / Resultados de 10 años del Programa de Prevención de Cáncer Colorrectal en la Comunitat Valenciana.

OBJECTIVE: The population-based Program for the Prevention of Colorectal Cancer (PPCRC) was implemented in 2005 in the Valencian Community, following the guidelines of the European Union. To achieve the desired effectiveness in these programs, it is necessary to achieve a series of requirements, assessable through the program indicators. The objective of this study was to analyze the evolution of the program indicators from 2006 to 2016. METHODS: The accumulated indicators for the period were calculated. The Poisson regression model was used to compare the indicators by age groups and sex, by type of screening, by type of fecal occult blood test (FOBT) and by year. RESULTS: The number of people invited to participate was 1,934,266. The participation rate was 44.4%, being 87.6% in the subsequent screening and 33.7% in the initial one, with men over 60 having the lowest participation figures. Except for the positive predictive value (PPV) for low risk adenomas, which was higher in a group of men aged 50 to 59 years of successive screening, the detection rates and PPV for the different types of lesions were higher in the initial screening, with immunological test and in the group of men over 60 years old. Throughout the period, there was a decrease in the test positivity rates and in the advanced adenomas and cancers detection rates. CONCLUSIONS: The PPCCR reaches levels of quality for which the effectiveness of the program is demonstrated. However, the insufficient participation of some population groups highlights the need to carry out studies to achieve the desired objectives in all population groups and thus result in greater effectiveness of the program.

OBJETIVO: El Programa Poblacional de Preven-ción de Cáncer Colorrectal (PPCCR) se implantó en 2005 en la Comunitat Valenciana, siguiendo las directrices de la Unión Europea. Para alcanzar la efectividad deseada en estos programas es necesario conseguir una serie de requisitos, valorables mediante los indicadores del programa. El objetivo del presente estudio fue analizar la evolución de los indicadores del programa de 2006 a 2016. METODOS: Se calcularon los indicadores acumulados para el periodo. Se empleó el modelo de regresión de Poisson para comparar los indicadores por grupos de edad y sexo, por tipología de cribado, por tipo de test de sangre oculta en heces (TSOH) y por año. RESULTADOS: El número de personas invitadas a participar fue de 1.934.266. La tasa de participación fue del 44,4%, siendo del 87,6% en el cribado sucesivo y del 33,7% en el inicial, teniendo los hombres mayores de 60 años las menores cifras de participación. Excepto el valor predictivo positivo (VPP) para adenomas de bajo riesgo, que fue superior en grupo de hombres de 50 a 59 años en cribado sucesivo, las tasas de detección y VPP para los diferentes tipos de lesiones fueron mayores en el cribado inicial, con el tipo de test inmunológico y en el grupo de hombres mayores de 60 años. A lo largo del periodo se produjo un descenso en las tasas de positividad para el test y las tasas de detección de adenomas avanzados y cánceres. CONCLUSIONES: El PPCCR alcanza niveles de calidad para los que se demuestra la eficacia del programa. Sin embargo, la participación insuficiente de algunos grupos poblacionales remarca la necesidad de realizar estudios para conseguir los objetivos deseados en todos los grupos poblacionales y así redundar en una mayor eficacia del programa.

Optimal cut-off value for detecting colorectal cancer with fecal immunochemical tests according to age and sex.

In the fecal immunological test, a suitable cut-off value may be selected to classify results as either positive or negative. Our aim is to estimate the optimal cut-off value for detecting colorectal cancer in different age and sex groups. This is a multicentric retrospective cohort study of participants in CRC screening programs with FIT between 2006 and 2012. A total of 545,505 participations were analyzed. Cancers diagnosed outside of the program were identified after a negative test result (IC_test) up until 2014. The Wilcoxon test was used to compare fecal hemoglobin levels. ROC curves were used to identify the optimal cut-off value for each age and sex group. Screening program results were estimated for different cut-off values. The results show that the Hb concentration was higher in colorectal cancer (average = 179.6µg/g) vs. false positives (average = 55.2µg/g), in IC_test (average = 3.1µg/g) vs. true negatives (average = 0µg/g), and in men (average = 166.2µg/g) vs. women (average = 140.2µg/g) with colorectal cancer. The optimal cut-off values for women were 18.3µg/g (50-59y) and 14.6µg/g (60-69y), and 16.8µg/g (50-59y) and 19.9µg/g (60-69y) for men. Using different cut-off values for each age and sex group lead to a decrease in the IC_test rate compared to the 20µg/g cut-off value (from 0.40‰ to 0.37‰) and an increase in the false positive rate (from 6.45% to 6.99%). Moreover, test sensitivity improved (90.7%), especially in men and women aged 50-59y (89.4%; 90%) and women aged 60-69y (90.2%). In conclusion, the optimal cut-off value varies for different sex and age groups and the use of an optimal cut-off value for each group improves sensitivity and leads to a small decrease in IC_tests, but also to a larger increase in false positives.

Consumption of ultra-processed foods and drinks and colorectal, breast, and prostate cancer.

AIMS: To study whether the consumption of ultra-processed foods and drinks is associated with breast, colorectal, and prostate cancers. METHODS: Multicentric population-based case-control study (MCC-Spain) conducted in 12 Spanish provinces. Participants were men and women between 20 and 85 years of age with diagnoses of colorectal (n = 1852), breast (n = 1486), or prostate cancer (n = 953), and population-based controls (n = 3543) frequency-matched by age, sex, and region. Dietary intake was collected using a validated food frequency questionnaire. Foods and drinks were categorized according to their degree of processing based on the NOVA classification. Unconditional multivariable logistic regression was used to evaluate the association between ultra-processed food and drink consumption and colorectal, breast, and prostate cancer. RESULTS: In multiple adjusted models, consumption of ultra-processed foods and drinks was associated with a higher risk of colorectal cancer (OR for a 10% increase in consumption: 1.11; 95% CI 1.04-1.18). The corresponding odds for breast (OR 1.03; 95% CI 0.96-1.11) and prostate cancer (OR 1.02; 95% CI 0.93-1.12) were indicative of no association. CONCLUSIONS: Results of this large population-based case-control study suggest an association between the consumption of ultra-processed foods and drinks and colorectal cancer. Food policy and public health should include a focus on food processing when formulating dietary guidelines.

[Inequalities in access to cancer screening programmes in Spain and how to reduce them: data from 2013 and 2020.] / Desigualdades de acceso a los programas de cribado del cáncer en España y cómo reducirlas: datos de 2013 y 2020.

OBJECTIVE: The European Commission recommends ensuring equity in cancer screening. The aim of this study was to find out if there were inequalities in access to cancer screening programmes in Spain. METHODS: A transversal study was carried out by means of a survey addressed to the people responsible for breast, colorectal (CRC) and cervical cancer screening programmes in the 19 Autonomous Communities (AC) of Spain in 2013 and 2020. Information was collected on organizational characteristics, inequalities in access and interventions to reduce them. A descriptive analysis was made by AC and time period, by calculating frequencies and percentages, depending on the type of programme (breast, CRC and cervix). RESULTS: In 2013, 14 ACs participated for the breast programme, 8 for the CRC and 7 for the cervical programme; and in 2020, 14, 13 and 11 ACs respectively. All breast programmes were population-based in both periods (14/14 in 2013 and 14/14 in 2020), as well as CRC ones (8/8 in 2013 and 13/13 in 2020), with an increase in cervical cancer programmes (0/7 en 2013 y 6/11 en 2020). In both periods, social groups not included in the target population and groups that were less involved were identified, with differences according to the type of programme. A total of 53 interventions were carried out to reduce inequalities in access (27 in breast, 22 in RCC and 4 in cervical), 66% of them aimed at specific social groups (35/53). CONCLUSIONS: Inequalities in access to cancer screening programmes in Spain are identified, as well as interventions to reduce them.

OBJETIVO: La Comisión Europea recomienda asegurar la equidad en el cribado del cáncer. El objetivo de este estudio fue conocer si existían desigualdades en el acceso a los programas de cribado del cáncer en España. METODOS: Se realizó un estudio transversal mediante encuesta dirigida a las personas responsables de los programas de cribado del cáncer de mama, colorrectal (CCR) y cérvix de las diecinueve Comunidades Autónomas (CCAA) del Estado Español en 2013 y 2020. Se recogió información sobre características organizativas, desigualdades de acceso e intervenciones para reducirlas. Se hizo un análisis descriptivo por CCAA y periodo temporal, mediante el cálculo de frecuencias y porcentajes, en función del tipo de programa (mama, CCR y cérvix). RESULTADOS: En 2013 participaron catorce CCAA para el programa de mama, ocho para el de CCR y siete para el de cérvix, y en 2020, catorce, trece y once CCAA, respectivamente. Todos los programas de mama eran poblacionales en ambos periodos (14/14 en 2013 y 14/14 en 2020), así como los de CCR (8/8 en 2013 y 13/13 en 2020), con un aumento en el caso de los programas de cribado del cáncer de cérvix (0/7 en 2013 y 6/11 en 2020). Se identificaron en ambos periodos grupos sociales no incluidos en la población diana y grupos que, estando incluidos, participaban menos, con diferencias según el tipo de programa. Se realizaron un total de cincuenta y tres intervenciones para reducir desigualdades en el acceso (veintisiete en mama, veintidós en CCR y cuatro en cérvix), el 66% de ellas dirigidas a grupos sociales específicos (35/53). CONCLUSIONES: Se identifican desigualdades de acceso a los programas de cribado del cáncer en España, así como intervenciones para reducirlas.

Residential proximity to industrial pollution sources and colorectal cancer risk: A multicase-control study (MCC-Spain).

BACKGROUND: Colorectal cancer is the third most frequent tumor in males and the second in females worldwide. In Spain, it is an important and growing health problem, and epidemiologic research focused on potential risk factors, such as environmental exposures, is necessary. OBJECTIVES: To analyze the association between colorectal cancer risk and residential proximity to industries, according to pollution discharge route, industrial groups, categories of carcinogens and other toxic substances, and specific pollutants released, in the context of a population-based multicase-control study of incident cancer carried out in Spain (MCC-Spain). METHODS: MCC-Spain included 557 colorectal cancer cases and 2948 controls in 11 provinces, frequency matched by sex, age, and region of residence. Distances were computed from subjects' residences to each of the 134 industries located in the study area. Logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (95%CIs) for categories of distance (from 1 km to 3 km) to industrial facilities, adjusting for matching variables and other confounders. RESULTS: Excess risk (OR; 95%CI) of colorectal cancer was detected near industries overall for all distances analyzed, from 1 km (2.03; 1.44-2.87) to 3 km (1.26; 1.00-1.59). In general, industries releasing pollutants to air showed higher excess risks than facilities releasing pollution to water. By industrial sector, excess risk (OR; 95%CI) was found near (≤3 km) production of metals (2.66; 1.77-4.00), surface treatment of metals (1.48; 1.08-2.02), glass and mineral fibers (2.06; 1.39-3.07), organic chemical industry (4.80; 3.20-7.20), inorganic chemical industry (6.74; 4.38-10.36), food/beverage sector (3.34; 2.38-4.68), and surface treatment using organic solvents (6.16; 4.06-9.36). By pollutants, the main excess risks (OR; 95%CI) were found near (≤3 km) industries releasing nonylphenol (9.19; 5.91-14.28), antimony (5.30; 3.45-8.15), naphthalene (3.11; 2.16-4.49), organotin compounds (2.64; 1.76-3.98), manganese (2.53; 1.63-3.93), dichloromethane (2.52; 1.74-3.66), and vanadium (2.49; 1.59-3.91). CONCLUSIONS: Our results support the hypothesis that residing in the proximity of industries may be a risk factor for colorectal cancer.

Green spaces, excess weight and obesity in Spain.

BACKGROUND: The epidemiological evidence on green spaces and obesity is inconsistent. OBJECTIVES: To study the association of access to green spaces and surrounding greenness with obesity in Spain. METHODS: We enrolled 2354 individuals 20-85 years from urban areas of seven provinces of Spain between 2008-13. Subjects were randomly selected population controls of the MCC-Spain case-control study. We geocoded current residences and defined exposures in a buffer of 300 m around them: i) access to green space, identified using Urban Atlas, and ii) levels of surrounding greenness, measured by the Normalized Difference Vegetation Index. We examined excess weight/obesity as binary outcomes based on body mass index and waist-hip ratio. We examined effect modification by genetic factors, sex and individual socio-economic status and mediation by physical activity and concentrations of PM2.5 and NO2. To assess potential effect modification by genetic factors, we used a polygenic risk score based on obesity polymorphisms detected in genome-wide association studies. We used logistic mixed-effects models with a random effect for catchment area adjusted for potential confounders. RESULTS: Access to green space was associated with a reduced risk of excess weight/obesity after adjusting for confounders [excess weight: OR (95%CI) = 0.82 (0.63, 1.07), p-value = 0.143; abdominal obesity: OR (95%CI) = 0.68 (0.45, 1.01), p-value = 0.057]. In the stratified analysis, this association was only observed in women. Associations between surrounding greenness and excess weight/obesity were null or modest based on a 1 IQR increase in NDVI [excess weight: OR (95%CI) = 0.99 (0.88, 1.11), p-value = 0.875; abdominal obesity: OR (95%CI) = 0.91 (0.79, 1.05), p-value = 0.186]. The observed associations were not mediated by physical activity or air pollution. DISCUSSION: Access to green space may be associated with decreased risk of excess weight/obesity among women in Spain. Mechanisms explaining this association remain unclear.

Risk factors for severe complications of colonoscopy in screening programs.

Severe complications (SC) in colonoscopy represent the most important adverse effect of colorectal cancer screening programs (CRCSP). The objective is to evaluate the risk factors for SC in colonoscopy indicated after a positive fecal occult blood test in population-based CRCSP. The SC (n = 161) identified from 48,730 diagnostic colonoscopies performed in a cohort of all the women and men invited from 2000 to 2012 in 6 CRCSP in Spain. A total of 318 controls were selected, matched for age, sex and period when the colonoscopy was performed. Conditional logistic regression models were estimated. The analysis was performed separately in groups: immediate-SC (same day of the colonoscopy); late-SC (between 1 and 30 days after); perforation; and bleeding events. SC occurred in 3.30‰ of colonoscopies. Prior colon disease showed a higher risk of SC (OR = 4.87). Regular antiplatelet treatment conferred a higher risk of overall SC (OR = 2.80) and late-SC (OR = 9.26), as did regular anticoagulant therapy (OR = 3.47, OR = 7.36). A history of pelvic-surgery or abdominal-radiotherapy was a risk factor for overall SC (OR = 5.03), immediate-SC (OR = 8.49), late-SC (OR = 4.65) and perforation (OR = 21.59). A finding of adenoma or cancer also showed a higher risk of overall SC (OR = 8.71), immediate-SC (OR = 12.67), late-SC (OR = 4.08), perforation (OR = 4.69) and bleeding (OR = 17.02). The risk of SC doesn't vary depending on the type of preparation or type of anesthesia. Knowing the clinical history of patients such as regular previous medication and history of surgery or radiotherapy, as well as the severity of the findings during the colonoscopy process could help to focus prevention measures in order to minimize SC in CRCSP.

Severe complications in colorectal cancer screening colonoscopies in the Valencian Community. / Complicaciones graves en las colonoscopias de cribado del cáncer colorrectal en la Comunidad Valenciana.

OBJECTIVE: To identify and characterise the severe complications of diagnostic confirmation colonoscopies carried out as part of the Colorectal Cancer Screening Program of the Valencian Community (CCSP-VC). METHOD: A retrospective observational study from 2005 to 2012. To identify complications, the CCSP-VC information system was used, as well as Spanish Minimum Basic Data Set hospital discharge summaries and medical records. Cumulative incidence rates were estimated for all complications, immediate complications (occurring the same day as the colonoscopy) and delayed complications (occurring 1-30 days after the colonoscopy) for the 1,000 colonoscopies performed. A bivariate analysis using the Chi-square test was performed for the onset of complications, according to gender, age and type of test (guaiac/immunological), as well as for the complication onset time (immediate/delayed) based on the type of colonoscopy (diagnostic/therapeutic) and type of complication (haemorrhage/perforation). RESULTS: Of the total 8,831 screening colonoscopies performed, 23 severe complications were observed, 13 of which were perforations (56.5%) and 10 haemorrhages (43.5%). No serious vagal syndrome, peritonitis or deaths were recorded. The cumulative incidence rate was 2.60‰; 2.85‰ for the guaiac test and 2.56‰ for the immunological test. The incidence rate was higher in men (2.93‰) than in women (2.16‰), as well as in older groups (3.02‰ versus 1.98‰). Of the total complications, 61% (n=14) were immediate. CONCLUSIONS: The severe complication rates of screening colonoscopies are a quality indicator for population-based colorectal cancer screening programs that require extensive research in order to maintain the appropriate risk/benefit ratio of such programs.

Factors influencing participation in colorectal cancer screening programs in Spain.

To analyze the sociodemographic and organizational factors influencing participation in population-based colorectal cancer screening programs (CRCSP) in Spain, a retrospective study was conducted in a cohort of people invited to participate in the first 3 screening rounds of 6 CRCSP from 2000 to 2012. Mixed logistic regression models were used to analyze the relationship between sociodemographic and organizational factors, such as the type of fecal occult blood test (FOBT) used and the FOBT delivery type. The analysis was performed separately in groups (Initial screening-first invitation, Subsequent invitation for previous never-responders, Subsequent invitation-regular, Subsequent invitation-irregular intervals). The results showed that, in the Initial screening-first invitation group, participation was higher in women than in men in all age groups (OR 1.05 in persons aged 50-59years and OR 1.12 in those aged 60-69years). Participation was also higher when no action was required to receive the FOBT kit, independently of the type of screening (Initial screening-first invitation [OR 2.24], Subsequent invitation for previous never-responders [OR 2.14], Subsequent invitation-regular [OR 2.03], Subsequent invitation-irregular intervals [OR 9.38]) and when quantitative rather than qualitative immunological FOBT (FIT) was offered (Initial screening-first invitation [OR 0.70], Subsequent invitation for previous never-responders [OR 0.12], Subsequent invitation-regular [OR 0.20]) or guaiac testing (Initial screening-first invitation [OR 0.81], Subsequent invitation for previous never-responders [OR 0.88], Subsequent invitation-regular [OR 0.73]). In conclusion, the results of this study show that screening participation could be enhanced by inclusion of the FOBT kit with the screening invitation and the use of the quantitative FIT.

[Lesions Detected in Six Spanish Colorectal Cancer Screening Population Based Programmes. CRIBEA Project. Spain]. / Lesiones detectadas en seis programas poblacionales de cribado de cáncer colorrectal en España. Proyecto CRIBEA.

OBJECTIVE: In this study, the results of six Colorectal Cancer Screening Population Programmes are shown (Catalonia, Valence, Murcia, Cantabria, the Basque Country and the Canary Islands collected between 2005 and 2012. These programmes use the faeces occult blood test (FOBt) biennial. Objective: To determine and compare the results of lesions detected by the programmes, participation, sex, age and test used. METHODS: Retrospective cohort study based on people invited, aged between 50-74 years, in at least a complete round. Lesions considered: Advanced Adenomas (AA), Colorectal Invasive Cancer (CRC) and both of them, known as Advanced Neoplasia (AN). Logistic Regression and time trends are used. RESULTS: 1,995,719 of invitations registered, with an average participation-rate of 46.7%. 21,228 Advanced Neoplasias (2,813 CRC and 18,415 AA). Differences in detection rates observed between programmes (varying from 15.1‰ to 35.8‰ between participants). Participation rates were related to lesions' detection rates (OR 1.25 in 40-60% of participation). . Inmunochemical qualitative test showed an OR of 4.79 and quantitative test an OR of 7.30 over the guaiac test. Men showed an OR of 2.73 with respect to women. In 2012 the Advanced Neoplasia rate for women and men was 33.1 and 14.2 by 1,000 participants. CONCLUSIONS: The test used was the most important factor for detecting lesions. Time trends showed an increase in detected lesions caused by the change of the type of test in 2010.

OBJETIVO: En este estudio se presentan los resultados de seis programas poblacionales de cribado de cáncer colorrectal desde 2005 a 2012 (Cataluña, Valencia, Murcia, Cantabria, País Vasco y Canarias) que utilizan diferentes tipos de test de cribado de sangre oculta en heces (SOH) bienal. El objetivo fue describir y comparar los resultados en cuanto a lesiones detectadas tanto por programa, participación, sexo, edad, tipo de test y comunidad autónoma. METODOS: Estudio de cohorte retrospectivo de las personas participantes en al menos una ronda completa cuya edad estaba comprendida entre los 50 y los 74 años. Lesiones consideradas: adenomas avanzados (AA), cáncer aolorrectal invasivo (CCR) y la suma de ambos, neoplasia avanzada (NA). Se realizó un nálisis de regresión logística y estudio de tendencias temporales. RESULTADOS: Se obtuvieron 1.995.719 participaciones, lo que supuso el 46,7% de las invitaciones a participar. Se detectaron 21.228 neoplasias avanzadas (2.813 CCR y 18.415 AA). Se observaron diferencias en la detección de neoplasia avanzada (NA) entre los programas variando entre 15,1‰ y 35,8‰ participantes. La participación se relacionó con las tasas de detección (OR: 1,25 en 40-60% de participación). El test inmunoquímico cualitativo obtuvo una OR de 4,79 y el cuantitativo de 7,30 sobre guayaco. Los hombres tuvieron una OR de 2,73 sobre las mujeres, observándose en el 2012 una tasa de detección de neoplasia avanzada en hombres y mujeres de 33,1 y 14,2 x 1.000 respectivamente. CONCLUSIONES: El tipo de test resultó el factor más determinante en la detección de lesiones. Las tendencias temporales mostraron un aumento de la tasa de detección por el cambio de test a partir del 2010.

Implementation of colorectal cancer screening in Spain: main results 2006-2011.

The Spanish Cancer Screening Network involves the participation of all regional programmes and has been working for over 20 years to co-ordinate strategies and implement quality assurance in current and new regional programmes. In colorectal cancer, the target population is the group aged 50-69 years, who are offered biennial testing using the faecal occult blood test in all programmes, with follow-up colonoscopy if the faecal occult blood test is positive. This article presents the main trends, indicators and differences by sex. The main indicators from 2006 to 2011 were analysed: coverage, participation rate, positivity rate, colonoscopy uptake and lesions detected. Annual trends were adjusted by sex and region. In 2011, coverage was 9.74% of the Spanish target population. A total of 1 001 669 first invitations were registered from 2006 to 2011 and 596 649 individuals participated in the programmes (43.83% participation rate). Results were positive in 30 544 individuals (5.47%), with the lowest positivity rate occurring in 2007 (3.06%) and the highest in 2011 (6.30%) (P<0.001). In all, 27 568 colonoscopies were registered, with a high compliance rate (90.00% in 2011 and 95.59% in 2007) (P=0.381). The adenoma and colorectal cancer detection rates increased over the period, reaching 32.25/1000 and 3.42/1000 participants in 2011, respectively (P<0.001 and P=0.001). Comparison of differences by sex showed that detection rates were significantly higher in men than in women (P<0.001). Participation increased over time and has now reached an acceptable rate. Men show low participation but higher detection rates, indicating the need for further intervention. The Spanish Cancer Screening Network provides common evaluation, performance and organizational benchmarking.