Clinical assessment of axillary lymph nodes and tumor size in breast cancer compared with histopathological examination: a population-based analysis of 2,537 women.

BACKGROUND: The clinical assessment of axillary lymph nodes status and tumor size is important for the management of patients with breast cancer. The first goal of this study was to determine the accuracy of axillary lymph node status in relation to the presence of metastases as revealed by histopathological examination. The second goal was to compare the tumor size as assessed by physical examination, with the size obtained by histopathological examination. METHODS: This study was based on a consecutive series of 2,537 patients diagnosed with breast cancer in Malmö, Sweden, between 1987 and 2002. These patients had available information in the South Swedish Breast Cancer Group registry, corresponding to 97 %. The axillary lymph nodes status was compared with the results of the histopathological examination for the presence of metastases. Tumor size by physical examination was compared with the tumor size after histopathological examination. RESULTS: There were 674 women with axillary lymph nodes metastases according to histological examination; only 206 of these cases had palpable lymph nodes at clinical examination. The sensitivity was 30 % and the specificity 93 %. There were 812 tumors measured to be larger than 20 mm according to histopathological examination, but only 665 of these tumors were considered larger than 20 mm by clinical examination. This corresponded to a sensitivity of 81 % and a specificity of 80 %. CONCLUSIONS: We conclude that the possibility of axillary metastases estimated by clinical examination is subjected to a large proportion of false-positive and false-negative results. Similarly, tumor size estimated by clinical examination is subject to under- and overestimation in comparison to histopathological examination.

Determinants of non- response to a second assessment of lifestyle factors and body weight in the EPIC-PANACEA study.

BACKGROUND: This paper discusses whether baseline demographic, socio-economic, health variables, length of follow-up and method of contacting the participants predict non-response to the invitation for a second assessment of lifestyle factors and body weight in the European multi-center EPIC-PANACEA study. METHODS: Over 500.000 participants from several centers in ten European countries recruited between 1992 and 2000 were contacted 2-11 years later to update data on lifestyle and body weight. Length of follow-up as well as the method of approaching differed between the collaborating study centers. Non-responders were compared with responders using multivariate logistic regression analyses. RESULTS: Overall response for the second assessment was high (81.6%). Compared to postal surveys, centers where the participants completed the questionnaire by phone attained a higher response. Response was also high in centers with a short follow-up period. Non-response was higher in participants who were male (odds ratio 1.09 (confidence interval 1.07; 1.11), aged under 40 years (1.96 (1.90; 2.02), living alone (1.40 (1.37; 1.43), less educated (1.35 (1.12; 1.19), of poorer health (1.33 (1.27; 1.39), reporting an unhealthy lifestyle and who had either a low (<18.5 kg/m2, 1.16 (1.09; 1.23)) or a high BMI (>25, 1.08 (1.06; 1.10); especially ≥30 kg/m2, 1.26 (1.23; 1.29)). CONCLUSIONS: Cohort studies may enhance cohort maintenance by paying particular attention to the subgroups that are most unlikely to respond and by an active recruitment strategy using telephone interviews.

The association of education with body mass index and waist circumference in the EPIC-PANACEA study.

BACKGROUND: To examine the association of education with body mass index (BMI) and waist circumference (WC) in the European Prospective Investigation into Cancer and Nutrition (EPIC). METHOD: This study included 141,230 male and 336,637 female EPIC-participants, who were recruited between 1992 and 2000. Education, which was assessed by questionnaire, was classified into four categories; BMI and WC, measured by trained personnel in most participating centers, were modeled as continuous dependent variables. Associations were estimated using multilevel mixed effects linear regression models. RESULTS: Compared with the lowest education level, BMI and WC were significantly lower for all three higher education categories, which was consistent for all countries. Women with university degree had a 2.1 kg/m2 lower BMI compared with women with lowest education level. For men, a statistically significant, but less pronounced difference was observed (1.3 kg/m2). The association between WC and education level was also of greater magnitude for women: compared with the lowest education level, average WC of women was lower by 5.2 cm for women in the highest category. For men the difference was 2.9 cm. CONCLUSION: In this European cohort, there is an inverse association between higher BMI as well as higher WC and lower education level. Public Health Programs that aim to reduce overweight and obesity should primarily focus on the lower educated population.

The role of smoking and diet in explaining educational inequalities in lung cancer incidence.

BACKGROUND: Studies in many countries have reported higher lung cancer incidence and mortality in individuals with lower socioeconomic status. METHODS: To investigate the role of smoking in these inequalities, we used data from 391,251 participants in the European Prospective Investigation into Cancer and Nutrition study, a cohort of individuals in 10 European countries. We collected information on smoking (history and quantity), fruit and vegetable consumption, and education through questionnaires at study entry and gathered data on lung cancer incidence for a mean of 8.4 years. Socioeconomic status was defined as the highest attained level of education, and participants were grouped by sex and region of residence (Northern Europe, Germany, or Southern Europe). Relative indices of inequality (RIIs) of lung cancer risk unadjusted and adjusted for smoking were estimated using Cox regression models. Additional analyses were performed by histological type. RESULTS: During the study period, 939 men and 692 women developed lung cancer. Inequalities in lung cancer risk (RII(men) = 3.62, 95% confidence interval [CI] = 2.77 to 4.73, 117 vs 52 per 100,000 person-years for lowest vs highest education level; RII(women) = 2.39, 95% CI = 1.77 to 3.21, 46 vs 25 per 100,000 person-years) decreased after adjustment for smoking but remained statistically significant (RII(men) = 2.29, 95% CI = 1.75 to 3.01; RII(women) = 1.59, 95% CI = 1.18 to 2.13). Large RIIs were observed among men and women in Northern European countries and among men in Germany, but inequalities in lung cancer risk were reverse (RIIs < 1) among women in Southern European countries. Inequalities differed by histological type. Adjustment for smoking reduced inequalities similarly for all histological types and among men and women in all regions. In all analysis, further adjustment for fruit and vegetable consumption did not change the estimates. CONCLUSION: Self-reported smoking consistently explains approximately 50% of the inequalities in lung cancer risk due to differences in education.

Lung cancers attributable to environmental tobacco smoke and air pollution in non-smokers in different European countries: a prospective study.

BACKGROUND: Several countries are discussing new legislation on the ban of smoking in public places, and on the acceptable levels of traffic-related air pollutants. It is therefore useful to estimate the burden of disease associated with indoor and outdoor air pollution. METHODS: We have estimated exposure to Environmental Tobacco Smoke (ETS) and to air pollution in never smokers and ex-smokers in a large prospective study in 10 European countries (European Prospective Investigation into Cancer and Nutrition)(N = 520,000). We report estimates of the proportion of lung cancers attributable to ETS and air pollution in this population. RESULTS: The proportion of lung cancers in never- and ex-smokers attributable to ETS was estimated as between 16 and 24%, mainly due to the contribution of work-related exposure. We have also estimated that 5-7% of lung cancers in European never smokers and ex-smokers are attributable to high levels of air pollution, as expressed by NO2 or proximity to heavy traffic roads. NO2 is the expression of a mixture of combustion (traffic-related) particles and gases, and is also related to power plants and waste incinerator emissions. DISCUSSION: We have estimated risks of lung cancer attributable to ETS and traffic-related air pollution in a large prospective study in Europe. Information bias can be ruled out due to the prospective design, and we have thoroughly controlled for potential confounders, including restriction to never smokers and long-term ex-smokers. Concerning traffic-related air pollution, the thresholds for indicators of exposure we have used are rather strict, i.e. they correspond to the high levels of exposure that characterize mainly Southern European countries (levels of NO2 in Denmark and Sweden are closer to 10-20 ug/m3, whereas levels in Italy are around 30 or 40, or higher).Therefore, further reduction in exposure levels below 30 ug/m3 would correspond to additional lung cancer cases prevented, and our estimate of 5-7% is likely to be an underestimate. Overall, our prospective study draws attention to the need for strict legislation concerning the quality of air in Europe.

Non-attendance in breast cancer screening is associated with unfavourable socio-economic circumstances and advanced carcinoma.

Our first objective was to assess changes in non-attendance, proportion of advanced breast cancer and survival in Malmö Mammographic Service Screening Program, MMSSP, compared to a former trial, Malmö Mammographic Screening Trial, MMST. Our second objective was to describe non-attenders in MMSSP in socio-economic terms and risk for advanced breast cancer compared to attenders. Information from hospital and national registers was used to identify 33,800 women invited to service screening in MMSSP 1990-93. Attendance rates at first screening, the proportion of advanced breast cancers (Stage II-IV) and survival among non-attenders in MMSSP were compared to the non-attenders and with the control group of the former trial, MMST. Various socio-economic factors were assessed as potential predictors of non-attendance in MMSSP. Odds ratios (OR) and 95% confidence interval (CI) were computed. Incidence of breast cancer during a 10-year-period, relative risks and 95% CI among non-attenders compared to attenders in MMSSP were computed. Attendance rates were significantly lower in MMSSP but a lower proportion of advanced breast cancers and a somewhat better survival among breast cancer cases (not significant) was seen in non-attenders in MMSSP compared to MMST. In MMSSP non-attendance was associated with being unmarried, being born abroad, being not currently employed, crowded housing conditions and low income. Incidence of advanced breast cancer was significantly higher among non-attenders than among attenders. Attendance has decreased over time and potential reasons are discussed. Stage distribution and survival among non-attenders seem to have improved. Several socio-economic factors predict non-attendance and non-attenders are at higher risk for advanced breast cancer.