[Follow-up of subjects occupationally exposed to asbestos, what are the objectives, the benefits, and the possible risks?]. / Quels sont les objectifs du suivi post-professionnel, les bénéfices attendus et les risques possibles? Objectifs médicaux en termes de morbidité, mortalité et qualité de vie.

The follow-up of workers occupationally exposed to asbestos has two possible beneficial effects: (1) individually, both medical by screening for diseases related to asbestos and social by notification of occupational disease and/or compensation from the indemnity funds for asbestos victims; (2) collectively, by the establishment of epidemiological surveillance (follow-up of cohorts) and evaluation of the impact of follow-up in terms of health benefits and compensation. The respiratory disorders related to asbestos are: cancer (malignant pleural mesothelioma and bronchial carcinoma), asbestos-related pulmonary fibrosis, and pleural disease (plaques, pleural fibrosis and benign pleurisy). In the light of the data currently available and the effectiveness of the tools used, medical and public health benefits of screening for mesothelioma have not been demonstrated. The early diagnosis of primary bronchial carcinoma can theoretically improve the prognosis of the subjects screened, particularly by identification of stage I disease on CT (pulmonary nodules). This is a common finding but there are a large number of false-positives. While we await the results of several international randomised trials, the benefits of a screening programme for bronchial carcinoma in the population at risk have not been demonstrated. There is no effective treatment for asbestosis but this is an independent risk factor for bronchial carcinoma and it is evidence of heavy asbestos exposure. Stopping smoking in subjects suffering from asbestosis will reduce the incidence of bronchial carcinoma. There is no effective treatment for asbestos-related benign pleural diseases but these are markers of exposure. The presence of pleural plaques has not been shown to be an aetiological factor for thoracic cancers. Post-occupational follow-up may involve risks to health, particularly repeated irradiation and invasive diagnostic procedures. It is also necessary to consider the psychological consequences inherent in all screening programmes. In conclusion, post-occupational follow-up might reduce the mortality of lung cancer by screening for localised disease and its incidence by a targeted anti-smoking programme. The theoretical benefits, that have not yet been demonstrated, have to be seen in perspective with the risks to physical and psychological health related to both screening and diagnostic procedures.

Screening, risk assessment, and the approach to therapy in patients with prostate cancer.

The major challenge in prostate cancer is to identify patients at higher risk of death and to distinguish them from those more likely to die from other causes. Stratification of patients into risk groups can be used to guide management decisions at each disease stage. This review discusses the measures, tools, and nomograms available for risk assessment in prostate cancer. For patients with localized hormone-sensitive disease, the choice is between active surveillance and radical treatment, with focal therapy an emerging option. Current guidelines recommend treatment of patients with a life expectancy ≥10 years, although active surveillance is being used with increasing frequency for low-risk patients, even with a long life expectancy. A number of risk stratification methods have been devised to assess the risk of biochemical recurrence (BCR) after treatment, with prostate-specific antigen (PSA) level, Gleason score, clinical stage, and tumor mass/volume all shown to be predictive of BCR. Among men with BCR after treatment, PSA doubling time (PSADT) was the best predictor of further progression. Although studies in patients with castration-resistant prostate cancer have shown that PSA level and PSADT are associated with a risk of developing metastatic disease, there is currently no clear surrogate for disease progression or overall survival for this patient group and no standard second- or third-line therapy after progression on first-line chemotherapy. The use of newly developed risk-stratification models and markers of disease progression should assist in the earlier identification of disease progression, allowing the optimal treatment of such patients.

Dairy intake and 1,25-dihydroxyvitamin D levels in men at high risk for prostate cancer.

OBJECTIVE: Dairy food intake has been associated with prostate cancer in previous work, but the mechanism by which this occurs is unknown. Dairy calcium may suppress circulating levels of potentially cancer-protective 1,25-hydroxyvitamin D (1,25(OH)2D). We examined the associations of dairy, milk, calcium, and vitamin D intake with plasma 1,25(OH)2D levels among 296 men (194 black, 102 non-black) enrolled in a high risk program for prostate cancer from 10/96 to 10/07. METHODS: All participants completed diet and health history questionnaires and provided plasma samples, which were assessed for levels of 25-hydroxyvitamin D and 1,25(OH)2D. We used multivariate linear regression to examine associations with 1,25(OH)2D. RESULTS: After adjustment for age, race, energy intake, BMI, and alcohol intake, we observed no associations for any of our variables of interest with 1,25(OH)2D, or any meaningful differences in estimates by race or vitamin D status. CONCLUSION: Our findings, in a sample including a large proportion of black participants, do not confirm previous findings showing an inverse association between calcium intake and 1,25(OH)2D levels. As such, they suggest that future work should explore other mechanisms by which dairy foods and calcium might increase prostate cancer risk.

Socioeconomic status and the risk of cervical intraepithelial neoplasia grade 3 among oncogenic human papillomavirus DNA-positive women with equivocal or mildly abnormal cytology.

BACKGROUND: Low socioeconomic status (SES) is a reported risk factor for cervical carcinoma, but few studies have taken into account adequately the possibly confounding effects of oncogenic human papillomavirus (HPV) infection as well as access to screening and subsequent treatment. METHODS: Women (n = 5060 women) with a mean age of 27.5 years and with equivocal or mild cytologic cervical abnormalities were enrolled in the Atypical Squamous Cells of Undetermined Significance/Low-Grade Squamous Intraepithelial Lesion (ASCUS-LSIL) Triage Study (ALTS), a clinical trial that evaluated management strategies. The women were seen every 6 months for 2 years. The enrollment questionnaire assessed three indicators of SES: race/ethnicity, education, and source of payment for medical care. Multivariate logistic regression models were used to identify predictors of oncogenic HPV DNA positivity at enrollment and to assess associations between the SES indicators and risk of cervical intraepithelial neoplasia grade 3 (precancer) and carcinoma (> or = CIN3) identified throughout the study (n = 506 women) among oncogenic HPV-positive women (n = 3133 women). RESULTS: SES indicators were not associated significantly with oncogenic HPV infection after adjustment for age at enrollment, recent and lifetime number of sexual partners, study center, and smoking history. Among women with oncogenic HPV, the risk of > or = CIN3 increased with decreasing education (less than high school education: odds ratio [OR], 2.4; 95% confidence interval [95%CI], 1.5-3.7 vs. completed college). Black women (OR, 0.5; 95%CI, 0.4-0.7) and white/Hispanic women (OR, 0.4; 95%CI, 0.2-0.8) were at decreased risk for > or = CIN3 compared with white/non-Hispanic women. The source of payment for medical care was not associated with risk. CONCLUSIONS: Factors associated with lower SES, such as low education, may serve as a surrogate for unknown factors that influence progression to > or = CIN3 among women with oncogenic HPV infection. In this controlled setting with equalized follow-up and treatment, the decreased risk of > or = CIN3 associated with black and white/Hispanic race/ethnicity could be further examined. Ongoing efforts should emphasize methods for equalizing screening and follow-up among women of varying SES, regardless of race or ethnicity.

Factors associated with non-epithelial ovarian cancer among Mexican women: a matched case-control study.

The purpose of this study was to identify risk factors associated with the development of non-epithelial ovarian cancer in Mexican women. A case-control study was carried out on women registered with the Mexican Institute of Social Security in Mexico City over a period of two years (1995-97). Twenty-eight new cases were recruited from the Gynecology and Obstetrics Hospital no. 4, "Luis Castelazo Ayala", and were matched by age with 84 controls selected randomly. Eighteen (64.3%) cases of germ cell tumors and 10 (35.7%) stromal sex cord tumors were found. The number of full term pregnancies was associated inversely to development of stromal sex cord tumors with lower risk in women with more than three full term pregnancies (odds ratio, 0.02: 95% confidence interval, 0.001-0.56) compared to nulliparous women. No associations were found respecting to germ cell tumors. Parity was inversely associated to development of stromal sex cord tumors, probably as a result of the endocrine system's influence on the ovaries. The development of germ cell tumors could be associated to factors not evaluated in this study.

Assessment of the carcinogenicity associated with oral exposures to hydrogen peroxide.

Concern regarding hydrogen peroxide (H(2)O(2)) carcinogenicity arises from its ability to act as a strong oxidizing agent. In short-term genotoxicity tests, H(2)O(2) has given predominantly positive results; however, these assays have been performed using either bacterial strains engineered to be exquisitely sensitive to oxidant damage, or mammalian cells deficient in antioxidant enzymes. Significantly, the addition of antioxidant protective measures (normally present in vivo) to these assay systems protects against H(2)O(2) genotoxicity. In most whole animal studies, H(2)O(2) exposure neither initiates nor promotes tumors. In mice, however, 0.4% H(2)O(2) in drinking water was reported to induce hyperplastic lesions of the duodenum and to erode areas in the glandular stomach epithelium. Owing to the chemistry of dilute H(2)O(2) solutions and the anatomy/physiology of the gastrointestinal tract, it is unlikely that orally ingested H(2)O(2) reaches the duodenum. Instead, greatly decreased water consumption and the resultant abrasion of the luminal lining on ingestion of pelleted dry rodent chow is the most likely cause of the observed gastric and duodenal lesions following H(2)O(2) administration in drinking water. Significantly, when hamsters received high doses of H(2)O(2) by gastric intubation (and water intake was not affected), the gastric and duodenal epithelia appeared normal. In-depth analysis of the available data supports the conclusion that oral ingestion of H(2)O(2) should not be considered a carcinogenic threat.

Epidemiology, stage at diagnosis, and tumor biology of breast carcinoma in multiracial and multiethnic populations.

All women, regardless of their racial or ethnic origin or heritage, are at risk of developing breast cancer. Variations in breast carcinoma incidence rates among multicultural populations suggest that etiologic factors differ in their biologic expression and impact on disease outcome. Key among those factors that affect breast carcinoma development are the roles of genetics and the environment, the reproductive experience and the effects of endogenous and exogenous hormones in women, the change in immune status and host vulnerability, and the biologic determinants of breast carcinoma. Cultural dynamics, sociodemographic differences, and behavioral characteristics across population subgroups modulate how biologic disease is expressed among different races and ethnic groups. These interactions contribute to the observed variations in breast carcinoma incidence, mortality, and survival. Stage, a measure of disease status, is used to assess prognosis, plan treatment, and evaluate outcome. Numerous studies have reported a more advanced stage of breast carcinoma at diagnosis in racial/ethnic subgroups, especially among women from African American, Hispanic, American Indian, and native Hawaiian cultures. Factors associated with advanced stage at diagnosis in multicultural populations range from changes in the basic biological characteristics at the molecular and cellular level, to more complex behavioral attributes unique to a particular multicultural population, to societal issues-such as access to care and socioeconomic conditions-all of which impact on the health measure called "stage at diagnosis." Rapid advancements in knowledge of cancer biology and of genetic markers and tumor products are providing new mechanisms for identifying etiologic pathways that can be utilized for better screening, detection, treatment and monitoring of disease. Further studies are needed that evaluate the biologic and molecular alterations in tumor development, progression, and response to therapy. Public health attention needs to be directed toward the societal influences that impact breast carcinoma development, as well as augmenting recognition of the need for culturally appropriate, broad-based behavioral changes at the community level. In addition, continued efforts are needed to ensure the inclusion of multicultural population subgroups and minority investigators in all aspects of research-basic, clinical and applied.

Dietary and/or nutritional risk factors and breast carcinoma: consumer response.

The author is a former state legislator and feminist activist. Having traveled extensively in Asia, she questions the comparison of U.S. statistics regarding dietary/nutritional risk factors with those from countries whose public health standards are below that of the U.S. The author also notes that only recently has the U.S. had a critical mass of women in Congress that led to the funding of the first Women's Health Initiative. Countries in Asia have few women in positions of political power to advocate for public policies regarding women's health issues, especially concerning the gathering of data regarding breast carcinoma, which is considered a culturally sensitive topic. Although soy is considered a healthy staple of the majority of Asian diets because of its phytoestrogens, there is a mixed message to American consumers because cancer, rather than heart disease, is the leading cause of death among Asian females.

Magnetic resonance imaging and audiologic assessment of middle ear effusions in patients with nasopharyngeal carcinoma before radiation therapy.

OBJECTIVE: The aim of this study was to assess the performance of clinical methods, viz. otoscopy, pure-tone audiometry, and tympanometry in diagnosing middle ear effusions (MEEs) using magnetic resonance imaging as a reference standard. STUDY DESIGN: A retrospective study of 46 patients with newly diagnosed nasopharyngeal carcinoma was performed comparing clinical evaluation and audiometry results with magnetic resonance imaging findings obtained before radiation therapy. RESULTS: Twenty-two (25%) of the temporal bones imaged had both MEE and mastoid effusions, 24 (27%) had only middle ear fluid, and 29 (33%) had mastoid fluid alone. The sensitivity for tympanometry, audiometry, and otoscopy in detecting fluid in the middle ear was 96%, 92%, and 80%, respectively. Although tympanometry was most sensitive in diagnosing MEE, there was no statistically significant difference when comparing the overall accuracy of pure-tone audiometry air-bone gap and tympanometry (p = 0.7, chi-square test). Flat curve tympanograms (type B) only achieved a sensitivity of 45% but were of high specificity (92%). Forty-nine percent with negative pressure tympanograms (mean air pressures > -100 daPa) had no MEE. CONCLUSIONS: Using magnetic resonance imaging as a reference standard, tympanometry is the most sensitive audiologic test in detecting the presence of MEE. The overall accuracy of tympanometry, pure-tone audiometry air-bone gap, and otologic examination was, however, not significantly different.

Current drug treatment guidelines for epithelial ovarian cancer.

The management of ovarian cancer is developing rapidly with the improvements in specialist multidisciplinary care. Most patients present with advanced disease and require careful surgical debulking followed by platinum-based chemotherapy. The recent introduction of paclitaxel appears to have improved the prognosis of advanced ovarian cancer by an increment that is similar in size to that seen after the introduction of cisplatin in the 1970s. Further clinical trials are required to define the optimum combination and dose of the platinum and taxane analogues, and to establish the role of the many new agents currently undergoing clinical testing. Useful chemotherapy for second-line treatment in platinum-refractory patients is now available, which, combined with more aggressive surgical management, is leading to modest improvements in survival. Improvements in supportive care have enabled increasingly intensive chemotherapy to be given safely. Bone marrow support and inhibitors of specific organ toxicities are likely to be incorporated into treatment protocols over the next decade. The impact of these treatments on patients' quality of life and the economic consequences of a more active approach to management will require careful evaluation.

Dietary factors and the risk of epithelial ovarian cancer.

Dietary factors in the etiology of ovarian cancer were investigated with the use of data from a case-control study conducted in Northern Italy on 455 histologically confirmed epithelial carcinomas and 1,385 control subjects in the hospital for acute conditions unrelated to any of the known or potential risk factors for cancer of the ovary. Women with ovarian cancer reported significantly elevated frequency of consumption of meat [relative risk (RR) = 1.6 for greater than or equal to 7 vs. less than 4 portions/wk], ham (RR = 1.9 for greater than or equal to 4 vs. less than 2 portions/wk), and higher subjective scores of fat intake (RR = 2.1 for highest vs. lowest scores), particularly butter. In contrast, consumptions of fish, green vegetables, carrots, and wholemeal bread or pasta were less frequent in cases; the corresponding risk estimates for highest versus lowest frequencies ranged between 0.6 and 0.8. These results were not materially modified by adjustment for indicators of socioeconomic status, parity, and other identified determinants of ovarian cancer. No relation emerged between alcohol consumption and ovarian cancer risk. The present study provides interesting indications that help to explain the considerable variations in ovarian cancer rates in different populations and, if confirmed, could, in principle, have important public health implications. Due caution, however, is required in interpreting the present results because of the limitations of available information and of the uncertainties of other published material concerning diet and ovarian cancer.

Primary pulmonary sarcomas: etiology, clinical assessment and prognosis with a comparison to pulmonary carcinomas--a review of 41 cases and 394 other cases of the literature.

Primary sarcomas of the lungs occur at frequencies of 1:100, as compared with carcinomas reported in our retrospective studies covering 394 cases reported in the literature from 1957 to 1972 and 41 cases from 1957 to 1974. The average age was 45 years, the disease usually occurred between the ages of 35 and 65, the peak being between 45 and 60 years. Distribution between sexes was much the same as that seen in general. X-ray with rapid thoracotomy provided the best clinical results. The literature showed a postoperative survival time of 5 years in 19% and 44% of our own cases. The general metastasis, haematologenous and lymphogenous were more or less equal and recidive tendency in 7% essentially varied, as related to the single histological forms. Lymphosarcomas (28.6%) were the most frequent, the group of spindle-celled sarcomas, inclusive of leiomyosarcomas, occurred in 40%. Histological maturity of the tissues and the prognosis according to active therapy were in parallel. A comparison of 41 primary sarcomas of the lungs with the 192 cases of carcinomas seen in our clinic showed no connection between sarcomas of the lungs and smoking of cigarettes, pollution of the environment, industrial toxins or chronic bronchitis. These findings relate to the peripheral localization as well as to the lack of incidence among men, with regard to pulmonary adenocarcinomas. An overall view of the characteristics led to the assumption of a probable endogenous tumour. A summarization of the characteristics of pulmonary sarcomas and carcinomas revealed the role of primary sarcomas in the total complex of malignant tumours of the lungs.