Better tools for better estimates: improving approaches to handling missing data in Swiss cancer registries.

OBJECTIVE: Various approaches have been used in the literature to handle missing vital status data in cancer registries. We aimed to compare these approaches to determine which led to the least biased estimates in typical analytic tasks of cancer registries. METHODS: A simulation study was performed using data from the Swiss National Agency for Cancer Registration for six tumor types. First, 5%, 10% and 15% missingness in the vital status were introduced artificially in the complete data. Second, missing vital status data were handled by applying no, single or multiple imputations. Five-year overall survival estimates, relative survival or standardized incidence ratio were computed. Estimates were compared with the true value. RESULTS: Standardized incidence ratio estimates for colorectal cancer obtained with multiple imputation yielded least biased results (-0.06 to -0.04), but the widest confidence intervals. Single imputation was more biased (-0.32) than using no imputation at all (-0.21). A similar pattern was observed for overall survival and relative survival. CONCLUSION: This simulation study indicated that often used single imputation (sometimes referred to as simulating follow-up times) techniques to fill in missing vital status data are likely too biased to be useful in practice. Multiple imputation approaches yielded standardized incidence ratio, overall and relative survival estimates with the least bias, indicating reasonable performance that is likely to generalize to other settings.

Cancer cases attributable to modifiable lifestyle risk factors in Switzerland between 2015 and 2019.

Several modifiable lifestyle risk factors have been linked to higher cancer risk in the literature. Determining the proportion and number of cancer cases attributable to these risk factors is pivotal in informing effective cancer prevention and control plans that have the greatest effect on reducing cancer incidence. We aimed to estimate the proportion and number of incident cancer cases that were attributable to modifiable lifestyle risk factors (ie, tobacco smoking, high alcohol consumption, excess body weight, physical inactivity and unhealthy diet) in Switzerland between 2015 and 2019. The exposure prevalence of selected risk factors was estimated based on the representative national nutrition survey menuCH, the associated relative risks were obtained from systematic literature reviews and the numbers of incident cancer cases were provided by the National Institute for Cancer Epidemiology and Registration. The fractions and numbers of attributable cases were calculated overall, by sex and by the three major language regions of Switzerland. The investigated modifiable risk factors combined were linked to 25.2% of potentially preventable incident cancer cases in Switzerland between 2015 and 2019. The proportion and numbers were slightly larger in males (28.4%, 6945 cases per year) than in females (21.9%, 4493 cases per year), and variations were observed between language regions. Tobacco smoking, excess body weight and high alcohol consumption were the leading contributors to lifestyle-attributable cancer cases. The observed differences in the leading risk factors both within Switzerland and compared to other countries underline the need for regionally and nationally tailored cancer prevention and education strategies.

Adherence to the EAT-Lancet reference diet is associated with a reduced risk of incident cancer and all-cause mortality in UK adults.

Food systems have been identified as significant contributors to the global environmental emergency. However, there is no universally agreed-upon definition of what constitutes a planetary healthy, sustainable diet. In our study, we investigated the association between the EAT-Lancet reference diet, a diet within the planetary boundaries, and incident cancer, incident major cardiovascular events, and all-cause mortality. Higher adherence to the EAT-Lancet reference diet was associated with lower incident cancer risk (hazard ratio [HR]continuous: 0.99; 95% confidence interval [CI]: 0.98-0.99]) and lower all-cause mortality (HR continuous: 0.98; 95% CI: 0.98-0.99), while mostly null associations were detected for major cardiovascular event risk (HR continuous: 1.00; 95% CI: 0.98-1.01). Stratified analyses using potentially modifiable risk factors led to similar results. Our findings, in conjunction with the existing literature, support that adoption of the EAT-Lancet reference diet could have a benefit for the prevention of non-communicable diseases.

Net survival of women diagnosed with breast tumours: a population-based study in Switzerland.

AIMS OF THE STUDY: Although the incidence of breast carcinoma in situ has been increasing, the prognosis of breast carcinoma in situ patients has not been extensively investigated. Thus, we aimed to compare the characteristics of invasive breast tumours based on whether or not they were preceded by a breast carcinoma in situ and to estimate the 5-year net survival of patients diagnosed with different breast tumours. METHODS: Data from women diagnosed with breast tumours between 2003 and 2016 were used in our analyses. Net survival analyses were performed using inverse probability of censoring weights (nonparametric Pohar Perme estimator). Under certain assumptions, differences in survival between the cancer population and the general population can be considered to be attributable to the cancer diagnosis (NS). RESULTS: Descriptive observation of tumour characteristics indicated that invasive breast tumours following a breast carcinoma in situ were more frequently detected at an earlier stage and had less missing information in tumour-specific variables, compared to invasive breast tumours not preceded by a breast carcinoma in situ. Breast carcinoma in situ patients had a 5-year net survival of 1.02 (95% CI: 1.01-1.03), whereas patients diagnosed with invasive breast cancer without a recorded breast carcinoma in situ had a 5-year net survival of 0.89 (95% CI: 0.88-0.90). Patients diagnosed first with breast carcinoma in situ and then with invasive breast cancer had a 5-year net survival of 0.92 (95% CI: 0.85-1.01). CONCLUSION: Invasive breast tumours that were preceded by a breast carcinoma in situ were detected more frequently at an earlier stage, compared to those that were not. The estimated 5-year net survival of patients with breast tumours was good.

Time-trends and age and stage differences in 5-year relative survival for common cancer types by sex in the canton of Zurich, Switzerland.

BACKGROUND: Survival trends help to evaluate the progress made to reduce the burden of cancer. The aim was to estimate the trends in 5-year relative survival of patients diagnosed with breast, prostate, lung, colorectal cancer and skin melanoma in the time periods 1980-1989, 1990-1999, 2000-2009 and 2010-2015 in the Canton of Zurich, Switzerland. Furthermore, we investigated relative survival differences by TNM stage and age group. METHODS: Data from the Cancer Registry of Zurich was used from 1980 to and including 2015, including incident cases of breast (N = 26,060), prostate (N= 23,858), colorectal (N= 19,305), lung cancer (N= 16,858) and skin melanoma (N= 9780) with follow-up until 31 December 2020. The cohort approach was used to estimate 5-year relative survival. RESULTS: The 5-year relative survival increased significantly between 1980 and 1989, and 2010 and2015: from 0.70 to 0.89 for breast, from 0.60 to 0.92 for prostate, from 0.09 to 0.23 (men) and from 0.10 to 0.27 (women) for lung, from 0.46 to 0.66 (men) and from 0.48 to 0.68 (women) for colorectal cancer, and from 0.74 to 0.94 (men) and from 0.86 to 0.96 (women) for skin melanoma. Survival for stage IV tumors was considerably lower compared to lower-staged tumors for all cancer types. Furthermore, relative survival was similar for the age groups <80 years but lower for patients aged 80 years and older. CONCLUSION: The observed increasing trends in survival are encouraging and likely reflect raised awareness around cancer, improved diagnostic methods, and improved treatments. The fact that stage I tumor patients have generally high relative survival reflects the efforts made regarding early detection.

Retrospective analysis of the uptake of active surveillance for low-risk prostate cancer in Zurich, Switzerland.

OBJECTIVES: Active surveillance for low-risk prostate cancer closely monitors patients conservatively instead of the pursuit of active treatment to reduce overtreatment of insignificant disease. Since 2009, active surveillance has been recommended as the primary management option in the European Association of Urology guidelines for low-risk disease. The present study aimed to investigate the use and uptake of active surveillance over 10 years in our certified prostate cancer centre (University Hospital of Zurich) compared with those derived from the cancer registry of the canton of Zurich, Switzerland. MATERIALS AND METHODS: We retrospectively identified all men diagnosed with low-risk prostate cancer at our institution and from the cancer registry of the canton of Zurich from 2009 to 2018. The primary treatment of each patient was recorded. Descriptive statistics were used to analyze the use of different treatments in our centre. The results were compared with those derived from the cancer registry. RESULTS: A total of 3393 men with low-risk prostate cancer were included in this study (University Hospital of Zurich: n = 262; cancer registry: n = 3131). In the University Hospital of Zurich and cancer registry cohorts, 146 (55.7%) and 502 (16%) men underwent active surveillance, respectively. The proportions of local treatment [115 (43.9%) vs 2220 (71%)] and androgen deprivation therapy [0 (0%) vs 43 (1.4%)] were distinctly lower in the University Hospital of Zurich cohort than in the cancer registry cohort. The uptake of active surveillance over the years was high in the University Hospital of Zurich cohort (35.4% in 2009 and 88.2% in 2018) but only marginal in the cancer registry cohort (12.2% in 2009 and 16.2% in 2018). CONCLUSION: Despite clear guideline recommendations, active surveillance for low-risk prostate cancer is still widely underused. Our analysis showed that access to a certified interdisciplinary tumour board significantly increases the use of active surveillance.

Determinants and changes in adherence to the World Cancer Research Fund/American Institute for Cancer Research cancer-prevention recommendations over the past 25†years in Switzerland.

OBJECTIVES: The World Cancer Research Fund (WCRF) and the American Institute for Cancer Research (AICR) established 10 lifestyle recommendations for cancer prevention. The current study examines the proportion and changes over 25 years of adherence to these recommendations and their determinants in Switzerland. METHODS: On the basis of six Swiss Health Surveys (1992-2017, N = 110 478), an index reflecting adherence to the 2018 WCRF/AICR cancer-prevention recommendations was created. Multinomial logistic regression models were fitted to investigate changes over time and determinants of a cancer-protective lifestyle. RESULTS: Adherence to cancer-prevention recommendations was moderate and higher in the years 1997-2017 compared to 1992. Higher adherence was observed among women (odds ratio [OR]high vs. low adherence ranging from 3.31 to 3.74) and participants with a tertiary education level (ORhigh vs. low adherence ranging from 1.71 to 2.18), and lower adherence among participants of the oldest age group (ORhigh vs. low adherence ranging from 0.28 to 0.44) and participants of the Switzerland (lat.: Confoederatio helvetica)-French language regions (ORhigh vs. low adherence ranging from 0.53 to 0.73). CONCLUSION: Our results showed that cancer-prevention recommendations are not well followed by the general Swiss population, as the adherence to a cancer-protective lifestyle was generally moderate; however, adherence to cancer-prevention recommendations improved over the past 25 years. Sex, age group, education level, and language regions were significant determinants of adherence to a cancer-protective lifestyle. Further actions at the governmental and individual levels promoting the adoption of a cancer-protective lifestyle are needed.

Predicting second breast cancer among women with primary breast cancer using machine learning algorithms, a population-based observational study.

Breast cancer survivors often experience recurrence or a second primary cancer. We developed an automated approach to predict the occurrence of any second breast cancer (SBC) using patient-level data and explored the generalizability of the models with an external validation data source. Breast cancer patients from the cancer registry of Zurich, Zug, Schaffhausen, Schwyz (N = 3213; training dataset) and the cancer registry of Ticino (N = 1073; external validation dataset), diagnosed between 2010 and 2018, were used for model training and validation, respectively. Machine learning (ML) methods, namely a feed-forward neural network (ANN), logistic regression, and extreme gradient boosting (XGB) were employed for classification. The best-performing model was selected based on the receiver operating characteristic (ROC) curve. Key characteristics contributing to a high SBC risk were identified. SBC was diagnosed in 6% of all cases. The most important features for SBC prediction were age at incidence, year of birth, stage, and extent of the pathological primary tumor. The ANN model had the highest area under the ROC curve with 0.78 (95% confidence interval [CI] 0.750.82) in the training data and 0.70 (95% CI 0.61-0.79) in the external validation data. Investigating the generalizability of different ML algorithms, we found that the ANN generalized better than the other models on the external validation data. This research is a first step towards the development of an automated tool that could assist clinicians in the identification of women at high risk of developing an SBC and potentially preventing it.

Stroke-associated infections in patients with and without cancer.

Background: Cancer in stroke patients is associated with higher levels of inflammatory biomarkers and unfavorable poststroke outcomes. We thus explored whether there is a link between cancer and stroke-associated infections. Methods: Medical records of patients with ischemic stroke in 2014-2016 registered in the Swiss Stroke Registry of Zurich were retrospectively analyzed. Incidence, characteristics, treatment, and outcome of stroke-associated infections diagnosed within 7 days after stroke onset were tested for an association with cancer. Results: Among 1181 patients with ischemic stroke, 102 patients with cancer were identified. Stroke-associated infections occurred in 179 and 19 patients (17% and 19%) without and with cancer (P = .60), respectively, among them pneumonia in 95 and 10 patients (9% and 10%) and urinary tract infections in 68 and 9 patients (6% and 9%) (P = .74 and P = .32). Use of antibiotics was similar between groups. Levels of C-reactive protein (CRP) (P < .001), erythrocyte sedimentation rate (ESR) (P = .014) and procalcitonin (P = .015) were higher and levels of albumin (P = .042) and protein (P = .031) were lower in patients with cancer than without cancer. Among patients without cancer, higher CRP (P < .001), ESR (P < .001) and procalcitonin (P = .04) and lower albumin (P < .001) were associated with stroke-associated infections. Among cancer patients with or without infections, no significant differences in these parameters were observed. In-hospital mortality was associated with cancer (P < .001) and with stroke-associated infections (P < .001). However, among patients with stroke-associated infections, cancer was not associated with in-hospital mortality (P = .24) or 30-day mortality (P = .66). Conclusions: Cancer does not represent a risk factor for stroke-associated infections in this patient cohort.

Association of Healthful Plant-based Diet Adherence With Risk of Mortality and Major Chronic Diseases Among Adults in the UK.

Importance: Plant-based diets have gained popularity for both environmental and health reasons, but a comprehensive assessment of their quality in relation to risk of mortality and major chronic diseases is lacking. Objective: To examine whether healthful vs unhealthful plant-based dietary patterns are associated with mortality and major chronic diseases among UK adults. Design, Setting, and Participants: This prospective cohort study used data from adults in the UK Biobank, a large-scale population-based study. Participants were recruited between 2006 and 2010 and followed up using record linkage data until 2021; follow-up for different outcomes ranged between 10.6 and 12.2 years. Data analysis was conducted from November 2021 to October 2022. Exposures: Adherence to a healthful vs unhealthful plant-based diet index (hPDI vs uPDI) derived from 24-hour dietary assessments. Main Outcomes and Measures: The main outcomes were hazard ratios (HRs) and 95% CIs of mortality (overall and cause specific), cardiovascular disease (CVD [total, myocardial infarction, ischemic stroke, and hemorrhagic stroke]), cancer (total, breast, prostate, and colorectal), and fracture (total, vertebrae, and hip) across quartiles of hPDI and uPDI adherence. Results: This study included 126 394 UK Biobank participants. They had a mean (SD) age of 56.1 (7.8) years; 70 618 (55.9%) were women. The majority of participants (115 371 [91.3%]) were White. Greater adherence to the hPDI was associated with lower risks of total mortality, cancer, and CVD, with HRs (95% CIs) of 0.84 (0.78-0.91), 0.93 (0.88-0.99), and 0.92 (0.86-0.99), respectively, for participants in the highest hPDI quartile compared with the lowest. The hPDI was also associated with lower risks of myocardial infarction and ischemic stroke, with HRs (95% CIs) of 0.86 (0.78-0.95) and 0.84 (0.71-0.99), respectively. By contrast, higher uPDI scores were associated with higher risks of mortality, CVD, and cancer. The associations observed did not show heterogeneity across strata of sex, smoking status, body mass index, or socioeconomic status or with polygenic risk scores (specifically with regard to CVD end points). Conclusions and Relevance: The findings of this cohort study of middle-aged UK adults suggest that a diet characterized by high-quality plant-based foods and lower intakes of animal products may be beneficial for health, irrespective of established chronic disease risk factors and genetic predisposition.

Is Following a Cancer-Protective Lifestyle Linked to Reduced Cancer Mortality Risk?

Objectives: This study investigates the association between a cancer protective lifestyle (defined based on the revised World Cancer Research Fund (WCRF) and the American Institute for Cancer Research (AICR) cancer prevention recommendations) and mortality in Switzerland. Methods: Based on the cross-sectional, population-based National Nutrition Survey, menuCH (n = 2057), adherence to the WCRF/AICR recommendations was assessed via a score. Quasipoisson regression models were fitted to examine the association of adherence to the WCRF/AICR recommendations with mortality at the Swiss district-level. Spatial autocorrelation was tested with global Moran's I. Integrated nested Laplace approximation models were fitted when significant spatial autocorrelation was detected. Results: Participants with higher cancer prevention scores had a significant decrease in all-cause (relative risk 0.95; 95% confidence interval 0.92, 0.99), all-cancer (0.93; 0.89, 0.97), upper aero-digestive tract cancer (0.87; 0.78, 0.97), and prostate cancer (0.81; 0.68, 0.94) mortality, compared to those with lower scores. Conclusion: The inverse association between adherence to the WCRF/AICR recommendations and mortality points out the potential of the lifestyle recommendations to decrease mortality and especially the burden of cancer in Switzerland.

Prediagnostic serum calcium concentrations and risk of colorectal cancer development in 2 large European prospective cohorts.

BACKGROUND: Higher dietary calcium consumption is associated with lower colorectal cancer (CRC) risk. However, little data are available on the association between circulating calcium concentrations and CRC risk. OBJECTIVES: To explore the association between circulating calcium concentrations and CRC risk using data from 2 large European prospective cohort studies. METHODS: Conditional logistic regression models were used to calculate multivariable-adjusted ORs and 95% CIs in case-control studies nested within the European Prospective Investigation into Cancer and Nutrition (EPIC; n-cases = 947, n-controls = 947) and the UK Biobank (UK-BB; n-cases = 2759, n-controls = 12,021) cohorts. RESULTS: In EPIC, nonalbumin-adjusted total serum calcium (a proxy of free calcium) was not associated with CRC (OR: 0.94; 95% CI: 0.85, 1.03; modeled as continuous variable, per 1 mg/dL increase), colon cancer (OR: 0.93; 95% CI: 0.82, 1.05) or rectal cancer (OR: 1.01; 95% CI: 0.84, 1.20) risk in the multivariable adjusted model. In the UK-BB, serum ionized calcium (free calcium, most active form) was inversely associated with the risk of CRC (OR: 0.85; 95% CI: 0.76, 0.95; per 1 mg/dL) and colon cancer (OR: 0.78; 95% CI: 0.68, 0.90), but not rectal cancer (OR: 1.02; 95% CI: 0.83, 1.24) in multivariable adjusted models. Meta-analysis of EPIC and UK-BB CRC risk estimates showed an inverse risk association for CRC in the multivariable adjusted model (OR: 0.90; 95%CI: 0.84, 0.97). In analyses by quintiles, in both cohorts, higher levels of serum calcium were associated with reduced CRC risk (EPIC: ORQ5vs.Q1: 0.69; 95% CI: 0.47, 1.00; P-trend = 0.03; UK-BB: ORQ5vs.Q1: 0.82; 95% CI: 0.72, 0.94; P-trend < 0.01). Analyses by anatomical subsite showed an inverse cancer risk association in the colon (EPIC: ORQ5vs.Q1: 0.63, 95% CI: 0.39, 1.02; P-trend = 0.05; UK-BB: ORQ5vs.Q1: 0.75; 95% CI: 0.64, 0.88; P-trend < 0.01) but not the rectum. CONCLUSIONS: In UK-BB, higher serum ionized calcium levels were inversely associated with CRC, but the risk was restricted to the colon. Total serum calcium showed a null association in EPIC. Additional prospective studies in other populations are needed to better investigate these associations.

A risk model for prediction of diagnosis of cancer after ischemic stroke.

It remains controversial which characteristics may predict occult cancer in stroke patients. Characteristics of patients with ischemic stroke registered in the Zurich Swiss Stroke Registry (2014 to 2016) were tested for associations with cancer diagnosis after stroke with consideration of death as competing risk for cancer diagnosis. Among 1157 patients, 34 (3%) and 55 patients (5%) were diagnosed with cancer within 1 and 3 years after stroke. Levels of white blood cells (WBC) > 9,600/µl (subdistribution hazard ratio (SHR) 3.68, p = 0.014), platelets > 400,000/µl (SHR 7.71, p = 0.001), and d-dimers ≥ 3 mg/l (SHR 3.67, p = 0.007) were independently associated with cancer diagnosis within 1 year after stroke. Occurrence of ischemic lesions in ≥ 2 vascular territories not attributed to cardioembolic etiology was associated with cancer diagnosed within 1 year after stroke in univariable analysis (SHR 3.69, p = 0.001). The area under the curve of a score from these parameters (score sum 0-4) was 0.73. A score of ≥ 2 had a sensitivity of 43% and specificity of 92% for prediction of cancer diagnosis within 1 year after stroke. We suggest further validation of a score of WBC, platelets, d-dimers and multiple ischemic lesions without cardioembolic stroke etiology for prediction of cancer diagnosis after stroke.

How prevalent is a cancer-protective lifestyle? Adherence to the 2018 World Cancer Research Fund/American Institute for Cancer Research cancer prevention recommendations in Switzerland.

Population monitoring of lifestyle behaviours that are crucial as risk and protective factors for major chronic diseases is vital for the identification of priority areas for public health. In this study, we aimed to investigate the prevalence of adherence to the World Cancer Research Fund/American Institute for Cancer Research (WCRF/AICR) cancer prevention recommendations in Switzerland, overall and by selected sociodemographic and lifestyle characteristics. Data from the population-based, cross-sectional survey menuCH were used. We constructed a score reflecting adherence to the 2018 WCRF/AICR cancer prevention recommendations. Multinomial logistic regression models were fitted to investigate the association of sociodemographic and lifestyle characteristics with the level of adherence to the WCRF/AICR cancer prevention recommendations. The least frequently met cancer prevention recommendations were the ones on fibre intake (met by 13·7 %), red and processed meat (25·4 %), and ultra-processed food (33·3 %) consumption, while the recommendation on physical activity was met by almost 80 %. Women and individuals with tertiary education were more likely to have a score of ≥ 5 (as a reflection of adherence to the cancer prevention recommendations), compared with men or those who completed secondary education, respectively. Current smokers were less likely to have a score of ≥ 5, compared with never smokers. A high proportion of the population in Switzerland was found to not adhere closely to the WCRF/AICR cancer prevention recommendations. Differences were detected based on sociodemographic characteristics. Education and policy actions are needed to facilitate the adoption of a cancer-protective lifestyle.

Alcohol consumption: context and association with mortality in Switzerland.

PURPOSE: Non-communicable diseases generate the largest number of avoidable deaths often caused by risk factors such as alcohol, smoking, and unhealthy diets. Our study investigates the association between amount and context of alcohol consumption and mortality from major non-communicable diseases in Switzerland. METHODS: Generalized linear regression models were fitted on data of the cross-sectional population-based National Nutrition Survey menuCH (2014-2015, n = 2057). Mortality rates based on the Swiss mortality data (2015-2018) were modeled by the alcohol consumption group considering the amount and context (i.e., during or outside mealtime) of alcohol consumption and potential confounders. The models were checked for spatial autocorrelation using Moran's I statistic. Integrated nested Laplace approximation (INLA) models were fitted when evidence for missing spatial information was found. RESULTS: Higher mortality rates were detected among drinkers compared to non-drinkers for all-cancer (rate ratio (RR) ranging from 1.01 to 1.07) and upper aero-digestive tract cancer (RR ranging from 1.15 to 1.20) mortality. Global Moran's I statistic revealed spatial autocorrelation at the Swiss district level for all-cancer mortality. An INLA model led to the identification of three districts with a significant decrease and four districts with a significant increase in all-cancer mortality. CONCLUSION: Significant associations of alcohol consumption with all-cancer and upper aero-digestive tract cancer mortality were detected. Our study results indicate the need for further studies to improve the next alcohol-prevention scheme and to lower the number of avoidable deaths in Switzerland.

Sustainable Diets and Cancer: a Systematic Review.

PURPOSE OF REVIEW: This review aimed to investigate the association of sustainable diets in relation to cancer risk, cancer recurrence, and cancer-specific mortality in adults. RECENT FINDINGS: More than 500 articles were initially identified. Nine articles were eligible for inclusion, presenting data from 8 prospective cohort studies, conducted in Europe and the USA. The sustainability indicators investigated were greenhouse gas emissions, food biodiversity, land use, exposure to pesticides or organic food consumption, and the EAT-Lancet diet. One study reported a sustainability index that combined multiple sustainability indicators. A modest inverse association between higher adherence to sustainable diets and cancer incidence or cancer mortality was observed in most studies. While sustainable diets may decrease cancer risk or mortality, the reviewed studies were heterogeneous regarding sustainability indicators and cancer outcomes. A common definition of dietary sustainability would facilitate better generalization of future research findings. Also, studies among non-western populations are needed.

Is Season of Diagnosis a Predictor of Cancer Survival? Results from the Zurich Cancer Registry.

In Switzerland, there is a large seasonal variation in sunlight, and vitamin D deficiency is relatively common during winter. The season of diagnosis may be linked to cancer survival via vitamin D status. Using data from the Cancer Registry of Zurich, Zug, Schaffhausen, and Schwyz with more than 171,000 cancer cases registered since 1980, we examined the association of the season of diagnosis with survival for cancers including prostate (ICD10 code C61; International Categorization of Diseases, version 10), breast (C50), colorectal (C18-21), lung (C34), melanoma (C43), and all sites combined. Cox proportional hazards regression models were used to assess the differences in the all-cause mortality by the season of the diagnosis. Winter was used as the reference season. Hazard ratios (HR) and 95% confidence intervals (CI) were calculated for all the cancers combined (excluding nonmelanoma skin cancer) and for prostate (in men), breast (in women), colorectal, lung cancer, and melanomas, separately. A diagnosis in summer and/or autumn was associated with improved survival in all the sites combined for both sexes (men: HR 0.97 [95% CI 0.96-0.99]; women: HR 0.97 [95% CI 0.94-0.99]) and in colorectal (HR 0.91 [95% CI 0.84-0.99]), melanoma (HR 0.81 [95% CI 0.65-1.00]), and breast cancer (HR 0.91 [95% CI 0.94-0.99]) in women. Our study results suggest that a cancer diagnosis in summer and/or autumn is associated with a better prognosis. The improved seasonal survival coincides with the seasonal variation of sun-induced vitamin D, and vitamin D may play a protective and beneficial role in cancer survival.

Investigation of Alcohol-Drinking Levels in the Swiss Population: Differences in Diet and Associations with Sociodemographic, Lifestyle and Anthropometric Factors.

Alcohol-drinking levels in Switzerland were investigated to identify dietary differences and explore the relationship between drinking levels and sociodemographic, lifestyle and anthropometric factors using the National Nutrition Survey menuCH (n = 2057, 18−75 years). After two 24 h dietary recalls (24HDRs), participants were categorized into four subgroups: abstainers (both self-declared alcohol avoidance and no alcohol reported); no alcohol reported; moderate drinkers (women/men < 12 g/<24 g mean daily alcohol, respectively); and heavy drinkers (women/men > 12 g/>24 g mean daily alcohol, respectively). Differences in diet between these groups were described by comparing daily total energy and non-alcohol energy intake, macronutrient energy contribution, food group intake, and diet quality (Alternate Healthy Eating Index excluding alcohol). The sociodemographic, anthropometric and lifestyle factors that determine alcohol-drinking levels were investigated using multinomial logistic regression. Abstainers reported the lowest daily energy intake (total and non-alcohol), heavy drinkers had the highest total energy intake and the lowest diet quality, and moderate drinkers had the highest non-alcohol energy intake. Sex, age, language region, body mass index, household size, smoking status, self-reported health status and following a diet were significantly associated with different alcohol-drinking subgroups. Results could facilitate interventions that target subgroups who exceed safe alcohol-drinking levels and lead unfavorable lifestyles.

Adherence to cancer prevention recommendations and risk of breast cancer in situ in the United Kingdom Biobank.

A health-conscious lifestyle may protect against breast cancer in situ. However, breast cancer in situ is mainly detected by screening, and many studies lack information on screening participation. Thus, we evaluated the association between prediagnostic lifestyle and risk of breast cancer in situ, accounting for screening participation at recruitment. A score reflecting the adherence to the World Cancer Research Fund/American Institute for Cancer Research cancer prevention recommendations was constructed, using the recommendations on healthy body weight, physical activity, consumption of plant-based foods, red and processed meat, alcohol and avoidance of sugar. Cox proportional hazards regression models were used to investigate the association between the lifestyle score and breast cancer in situ risk, while accounting for important confounders. The lifestyle score was not significantly associated with breast cancer in situ risk (HRcontinuous  = 0.96, 95% CI = 0.91-1.03) in the overall cohort. In participants not reporting dietary changes in the past 5 years, the lifestyle score was inversely associated with breast cancer in situ risk (HRcontinuous  = 0.92, 95% CI = 0.85-0.99). In those reporting dietary changes in the past 5 years due to illness or other reasons, the lifestyle score was not associated with breast cancer in situ risk (HRcontinuous  = 1.04, 95% CI = 0.94-1.15). Lifestyle was inversely associated with breast cancer in situ risk in women not reporting recent changes in their dietary habits. This inverse association is consistent with inverse associations reported in previous studies. Our findings suggest that breast cancer in situ and invasive breast cancer share a similar risk factor profile.

Increased vitamin B6 turnover is associated with greater mortality risk in the general US population: A prospective biomarker study.

BACKGROUND & AIMS: Vitamin B6 status and mortality risk are inversely associated in different patient groups, while prospective studies in the general population are lacking. Here, for the first time, we evaluated the association between biomarkers of vitamin B6 status and mortality risk in a large population-based study. METHODS: The vitamin B6 vitamers pyridoxal-5'-phosphat (PLP) and 4-pyridoxic acid (4-PA) were measured by high-performance liquid chromatography in the National Health and Nutrition Examination Survey (NHANES) between 2005 and 2010. Participants' vital status and causes of death were recorded until December 2015. Multivariable Cox regression analyses were carried out to estimate Hazard Ratios (HRs) and 95% confidence intervals (CIs) of mortality across quintiles of PLP, 4-PA, and the ratio of 4-PA and PLP. RESULTS: Out of 15,304 study participants aged between 20 and 85 years at baseline, 1666 (7.7%) died during a median follow-up time of 7.8 years. An inverse association between PLP and mortality was found in a multivariable model adjusted for socioeconomic and lifestyle factors but became statistically non-significant upon adjustment for routine biomarkers (C-reactive protein, creatinine, albumin, and alkaline phosphatase). There was a significant linear trend for a positive association between 4-PA levels and mortality risk in the fully adjusted regression model, although a comparison of extreme quintiles (quintile 5 vs. quintile 1) did not show a significant difference (HRQ5vs.Q1 (95% CI): 1.19 (0.93, 1.51), plinear trend = 0.02). A positive association between the 4-PA/PLP ratio and all-cause mortality was observed in the multivariable model, with an HRsQ5vs.Q1 of 1.45 (95% CI: 1.14, 1.85; plinear trend<0.0001). There were no significant associations between the biomarkers and cardiovascular or cancer mortality. The association between 4-PA/PLP and mortality risk was heterogeneous across age groups, and only statistically significant among participants older than 65 years at baseline (HRQ5vs.Q1 (95% CI): 1.72 (1.29, 2.29), plinear trend<0.0001). In this group, 4-PA/PLP was also associated with cancer mortality, with an HR Q5vs.Q1 of 2.16 (1.20, 3.90), plinear trend = 0.02). CONCLUSION: Increased vitamin B6 turnover, as indicated by a higher 4-PA/PLP ratio, was associated with all-cause and cancer mortality among the older U.S. general population. Intervention trials are needed to assess whether older individuals with a high 4-PA/PLP ratio would benefit from increased vitamin B6 intake.