Heavy smoking and lung cancer: are women at higher risk? Result of the ICARE study.

BACKGROUND: Whether women are more or equally susceptible to the carcinogenic effects of cigarette smoke on the lungs compared with men is a matter of controversy. Using a large French population-based case-control study, we compared the lung cancer risk associated with cigarette smoking by gender. METHODS: The study included 2276 male and 650 female cases and 2780 male and 775 female controls. Lifetime smoking exposure was represented by the comprehensive smoking index (CSI), which combines the duration, intensity and time since cessation of smoking habits. The analysis was conducted among the ever smokers. All of the models were adjusted for age, department (a regional administrative unit), education and occupational exposures. RESULTS: Overall, we found that the lung cancer risk was similar among men and women. However, we found that women had a two-fold greater risk associated with a one-unit increase in CSI than men of developing either small cell carcinoma (OR=15.9, 95% confidence interval (95% CI) 7.6, 33.3 and 6.6, 95% CI 5.1, 8.5, respectively; P<0.05) or squamous cell carcinoma (OR=13.1, 95% CI 6.3, 27.3 and 6.1, 95% CI 5.0, 7.3, respectively; P<0.05). The association was similar between men and women for adenocarcinoma. CONCLUSION: Our findings suggest that heavy smoking might confer to women a higher risk of lung cancer as compared with men.

[The French mesothelioma network from 1998 to 2013]. / Mésothéliome: les dispositifs en place en France « le réseau mésothéliome ¼ 1998-2013.

Mesothelioma is a rare disease less than 0.3% of cancers in France, very aggressive and resistant to the majority of conventional therapies. Asbestos exposure is nearly the only recognized cause of mesothelioma in men observed in 80% of case. In 1990, the projections based on mortality predicted a raise of incidence in mesothelioma for the next three decades. Nowadays, the diagnosis of this cancer is based on pathology, but the histological presentation frequently heterogeneous, is responsible for numerous pitfalls and major problems of early detection toward effective therapy. Facing such a diagnostic, epidemiological and medico-legal context, a national and international multidisciplinary network has been progressively set up in order to answer to epidemiological survey, translational or academic research questions. Moreover, in response to the action of the French Cancer Program (action 23.1) a network of pathologists was organized for expert pathological second opinion using a standardized procedure of certification for mesothelioma diagnosis. We describe the network organization and show the results during this last 15years period of time from 1998-2013. These results show the major impact on patient's management, and confirm the interest of this second opinion to provide accuracy of epidemiological data, quality of medico-legal acknowledgement and accuracy of clinical diagnostic for the benefit of patients. We also show the impact of these collaborative efforts for creating a high quality clinicobiological, epidemiological and therapeutic data collection for improvement of the knowledge of this dramatic disease.

Measuring social inequalities in cause-specific mortality in France: comparison between linked and unlinked approaches.

BACKGROUND: Monitoring the time trends in socioeconomic inequalities in mortality by cause is a key public health issue. The aim of this study was to compare methods to measure social inequalities in cause-specific mortality in the French population aged 25-55 years. More specifically, it compares bias and precision related to the use of occupational class declared at the last census (linked data) to the one declared at the time of death on the death certificate (unlinked data). METHODS: We used a representative sample of 1% of the French population. Causes of death were obtained by direct linkage with the French national death registry. Occupational class was classified into eight categories. Taking professionals and managers as the reference, relative risks of mortality by cause and their 95% confidence intervals were estimated using Poisson models for the 1983-1989, 1991-1997, and 2000-2006 periods. The relative risks were calculated with both linked data and exhaustive unlinked data. RESULTS: Over the 2000-2006 period, occupational classes declared at census and on the death certificate were consistent for half of the deaths. Relative risks for manual workers were found to be similar between the two approaches over the 1983-1989 and 1991-1997 periods, and higher for the unlinked approach over the 2000-2006 period. Over the latter period, the order and magnitude of relative risks varied similarly by occupational class and cause of death for both approaches. Confidence intervals obtained from linked data were wide. CONCLUSION: Occupational class derived from the death certificate must be used with caution as a measure for epidemiological purposes and the available linked data do not allow accurate estimates of social inequalities in cause-specific mortality. Other solutions should be considered in order to improve the follow-up of social inequalities in mortality. This would require the collection of educational level on the death certificate or the linkage of the cause of death database with other exhaustive and informative databases.

[Changing social disparities and mortality in France (1968-1996): cause of death analysis by educational level]. / Evolution temporelle des inégalités sociales de mortalité en France entre 1968 et 1996. Etude en fonction du niveau d'études par cause de décès.

BACKGROUND: Little information is available on temporal trend in socioeconomic inequalities in cause of death mortality in France. The aim of this paper was to study educational differences in mortality in France by cause of death and their temporal trend. METHODS: We used a representative sample of 1% of the French population and compared four periods (1968-1974, 1975-1981, 1982-1988, 1990-1996). Causes of death were obtained by direct linkage with the French national death registry. Education was measured at the beginning of each period, and educational disparities in mortality were studied among men and women aged 30-64 at the beginning of each period. Analyses were conducted for all deaths and for the following causes of death: all cancers, lung cancer (among men), upper aerodigestive tract cancers (among men), breast cancer (among women), colorectal cancer, other cancers, cardiovascular diseases, ischaemic heart diseases, cerebrovascular diseases, other cardiovascular diseases, external causes, other causes of death. Socioeconomic inequalities were quantified with relative risks and relative indices of inequality. The relative indices of inequality measures socioeconomic inequalities across the population and can be interpreted as the ratio of mortality rates of those with the lowest to those with the highest socioeconomic status. RESULTS: Analyses showed an increase in educational differences in all cause mortality among men (the relative indices of inequality increased from 1.96 to 2.77 from the first to the last period) and among women (the relative indices of inequality increased from 1.87 to 2.53). Socioeconomic inequalities increased for all cause of death studied among women, and for cancer and cardiovascular diseases among men. The contribution of cancer mortality to difference in overall mortality between the lowest and the highest levels of education increased strongly over the whole study period, especially among women. CONCLUSION: This study shows that large socioeconomic inequalities in mortality are observed in France, and that they increase over time among men and women.

Occupational cancer in France: epidemiology, toxicology, prevention, and compensation.

This article is a description of the current situation in France with regard to occupational cancer: research, prevention, and occupation. Toxicologic experiments are carried out using (italic)in vitro(/italic) and (italic)in vivo(/italic) tests, particularly using transgenic mice. Several epidemiologic studies have been conducted over the last decades: population-based case-control studies; mortality studies and cancer incidence studies carried out in historical cohorts of workers employed in the industry; and case-control studies nested in occupational cohorts. French ethical aspects of toxicologic and epidemiologic studies are described. The results thus obtained are used to establish regulations for the prevention and the compensation of cancers attributable to occupational exposure. This French regulation for prevention of occupational cancer involves several partners: (italic)a(/italic)) the states authorities, including labor inspectors, responsible for preparing and implementing the labor legislation and for supervising its application, particularly in the fields of occupational health and safety and working conditions; (italic)b(/italic)) the Social Security Organisation for the analysis of present or potential occupational risks based on tests, visits in plants, complaints or requests from various sources, and statistics. These activities are performed within the framework of the general French policy for the prevention of occupational cancer. This organization includes the National Institute for Research and Safety, particularly involved in research in the various fields of occupational risks--animal toxicology, biologic monitoring, exposure measurements epidemiology, psychology, ergonomy, electronic systems and machineries, exposure to chemicals, noise, heat, vibration, and lighting; and (italic)c(/italic)) companies where the regulation defines the role of the plant manager, the occupational physician, and the Health, Safety and Working Conditions Committee (comprising the manager, employees' representatives, the occupational physician, and the safety department) in dealing with any problem regarding safety, occupational hygiene, and working conditions. These organizations along with medical practitioners are involved with the compensation of occupational cancers. The regulation for compensation includes the tables of occupational cancer, the possibility of recognition of a cancer case when the requirements of the tables are not met, and the postprofessional follow-up of workers exposed to a carcinogenic agent.

Patterns of remission and relapse in obsessive-compulsive disorder: a 2-year prospective study.

OBJECTIVE: This study examined the course of illness in patients with obsessive-compulsive disorder (OCD) over a 2-year period. METHOD: Sixty-six patients with a primary diagnosis of DSM-III-R OCD were followed prospectively for 2 years. Baseline information was collected on demographic characteristics, Axis I and II diagnoses, and severity of OCD symptoms. Follow-up measures obtained at 3, 6, 12, and 24 months after baseline assessment included information on symptomatic and diagnostic status as well as behavioral and somatic treatments received. RESULTS: The probability of full remission from OCD over the 2-year period was 12%. The probability of partial remission was 47%. After achieving remission from OCD, the probability of relapse was 48%. No factors were identified that significantly predicted full or partial remission. Seventy-seven percent (N = 51) of the subjects received a serotonin reuptake inhibitor (SRI) for > or =12 weeks, and 68% (N = 45) received medium-to-high doses of SRIs for > or =12 weeks. Only 18% received a full trial of behavior therapy. CONCLUSION: Despite exposure to at least 1 adequate trial of an SRI, the likelihood of full remission of OCD in this study was low. Results of this study also suggest that behavior therapy may be under-utilized.

Sources of discrepancies between a job exposure matrix and a case by case expert assessment for occupational exposure to formaldehyde and wood-dust.

Two methods used for retrospective evaluation of occupational exposures, a case by case assessment by expert and the application of a job exposure matrix (JEM), are compared using occupational histories collected for a case-control study on sinonasal cancer. The objective was to identify the main sources of discrepancies and to contribute to an optimal use of a JEM for population-based case-control studies. Comparisons were based on job periods, and were performed separately for two substances: formaldehyde and wood-dust. Job periods were classified according to the category of exposure assigned by the matrix, and to the probability and level of exposure assessed by the study expert. The sources of discrepancies were examined for job periods probably or definitely exposed according to the JEM and unexposed for the expert, or unexposed in the JEM and probably or definitely exposed to medium or high level for the expert. Such discrepancies were observed for 8% of the job periods for formaldehyde and 3% of the job periods for wood-dust. The agreement between the two approaches was better for wood-dust than for formaldehyde. The relative importance of different sources of discrepancies was not the same for formaldehyde and wood-dust. For formaldehyde a substantial part of the discrepancies was due to disagreements between the study expert and the matrix experts, which were mostly differences in threshold limits between 'not exposed' and 'definitely exposed at a low level'. Differences between experts' opinions did not explain the discordances observed for wood-dust. The presence of additional information in the questionnaire was an important source of discrepancy for the two substances.(ABSTRACT TRUNCATED AT 250 WORDS)

Smoking, alcohol drinking and cancer risk for various sites of the larynx and hypopharynx. A case-control study in France.

The aim of this work was to study the effects of alcohol and tobacco consumption on laryngeal and hypopharyngeal cancer and to compare these across subsites (glottis, supraglottis, epilarynx, hypopharynx). Data from a hospital-based case-control study including 504 male cases (105 glottic cancers, 80 supraglottic cancers, 97 epilaryngeal cancers and 201 hypopharyngeal cancers) and 242 male controls with non-respiratory cancers were used for this analysis. Information about sociodemographic characteristics, detailed alcohol and tobacco consumption was collected through face-to-face interviews. Statistical analysis used logistic regression, and subsites were compared with polytomous logistic regressions. The risk of laryngeal and hypopharyngeal cancer increased with tobacco (duration and amount) and alcohol consumption; the effect of both agents was multiplicative. From the lowest to the highest consumption level, odds ratios ranged from 1.4 to 5.9 among regular drinkers and from 3 to 44 among current smokers. Risks among ex-smokers were approximately one-third of those for current smokers. Slightly elevated odds ratios were associated with consumption of black tobacco (OR=1.2) and hand-rolled cigarettes (OR=1.2). The risk of cancer was not clearly associated with the type of alcoholic beverage. Subsites did not differ significantly according to tobacco smoking, but differed according to alcohol consumption, with a significantly higher increased risk for hypopharyngeal than for glottic and supraglottic cancers.

A study of the interaction of alcohol drinking and tobacco smoking among French cases of laryngeal cancer.

Laryngeal cancer represents an important cause of cancer in France, and the individual effects of alcohol and tobacco on this cancer site are well known. However the problem of the interaction between these agents is less extensively documented, and the role of the high consumptions of alcohol has not been studied frequently. A case-control analysis was undertaken to investigate the joint effect of alcohol and tobacco by comparing 197 glottic and 214 supraglottic cancer cases to 4135 controls representative of the French general population. Heavy drinkers were available from the two groups of cases, the highest alcohol category being equivalent to a consumption of more than 2 litres of wine per day. The relative risks estimated for heavy drinkers and smokers were high, and the results indicated an even stronger effect of alcohol drinking and tobacco smoking on the upper part of the laryngeal region. Additive and multiplicative models were fitted to the data. The multiplicative hypothesis was found to be the most appropriate, implying that the risks associated with alcohol and tobacco multiply when the exposures occur simultaneously. The public health implications of this result and the contribution of heavy drinkers and smokers to the frequency of upper respiratory and digestive tract cancers are discussed.

Effectiveness of propranolol for cocaine dependence treatment may depend on cocaine withdrawal symptom severity.

Propranolol may reduce symptoms of autonomic arousal associated with early cocaine abstinence and improve treatment outcome. This trial was an 8-week, double-blind, placebo-controlled trial of propranolol in 108 cocaine dependent subjects. The primary outcome measure was quantitative urinary benzoylecgonine levels. Secondary outcome measures included treatment retention, addiction severity index results, cocaine craving, mood and anxiety symptoms, cocaine withdrawal symptoms, and adverse events. Propranolol treated subjects had lower cocaine withdrawal symptom severity but otherwise did not differ from placebo treated subjects in any outcome measure. However, in a secondary, exploratory analysis, subjects with more severe cocaine withdrawal symptoms responded better to propranolol in comparison to placebo. In these subjects, propranolol treatment was associated with better treatment retention and lower urinary benzoylecgonine levels as compared with the placebo treatment. Propranolol may be useful only for the treatment of cocaine dependent patients with severe cocaine withdrawal symptoms.

History of previous nasal diseases and sinonasal cancer: a case-control study.

A case-control study on cancer of the nose and paranasal sinuses, and several risk factors including previous nasal diseases and symptoms, was performed in France from January 1986 through February 1988. The frequency of previous nasal diseases and symptoms was analyzed by histologic type of cancer. Different results were observed for squamous cell carcinomas and adenocarcinomas. In men, there were statistically significant associations between squamous cell carcinomas and sinusitis, bleeding from the nose, polyps, rhinitis, and trauma to the nose; and between adenocarcinomas, bleeding from the nose, and rhinitis. In women, there was an association between squamous cell carcinomas and nasal polyps.

Alcohol and tobacco consumption in cancer of the mouth, pharynx, and larynx: a study of 316 female patients.

Three hundred sixteen female patients with cancer of the larynx, pharynx, and mouth were examined and the following cancer sites were compared with respect to alcohol and tobacco consumption: oropharynx, hypopharynx, larynx, epilarynx, lip, and mouth. The mean daily tobacco consumption of smokers and ex-smokers was not significantly different between cancer locations; however, significant differences between cancer sites were observed with regard to the proportion of nonsmokers. The percentage of nonsmokers was the highest for cancer of the lips and the lowest for cancer of the epilarynx. Cancer locations differed significantly depending on daily alcohol consumption. Consumption was the lowest for patients with cancer of the lips. The percentage of nondrinkers was high for cancers of the lips and larynx and low for cancer of the epilarynx. Examination of the nonsmoking/nondrinking females (27.2%) did not reveal any features specific to this group, except that the patients were older.

Occupational factors of anxiety and depressive disorders in the French National Electricity and Gas Company. The Anxiety-Depression Group.

Very few studies described the prevalence of mental disorders in the workplace by using standard diagnostic criteria. A two-stage case-control study of anxiety and depression was initiated by Electricité de France and Gaz de France, the French Nationwide Company producing electricity and gas, using the General Health Questionnaire with 12 items as a screening test and the Composite International Diagnostic Interview as diagnostic instrument. Its aim was to point out occupational situations that promote the occurrence of anxiety and depression crises. Annual prevalence of depression was estimated at 7.6% in men (95% confidence interval [CI], 5.5 to 9.7) and at 17.9% in women (95% CI, 9.9 to 25.8), and that of anxiety at 9.6% (95% CI, 6.9 to 12.3) in men and 26.3% (95% CI, 17.2 to 35.4) in women. Workers in hazardous occupations were found to be protected from these disorders, whereas supervisory staff tended to be prone to developing them. Important changes in work or in its organization seemed to be risk factors. Extra-professional variables and occupational characteristics were included in a logistic regression model. The odds ratios corresponding to recent job changes and a supervisory position were significantly elevated (odds ratios = 1.7 and 2.4, respectively). These results suggest that some occupational events, such as major changes in work content or organization may cause or precipitate anxiety and/or depressive disorders.

Past occupational exposure to asbestos among men in France.

OBJECTIVES: This study aimed at reconstructing changes in the frequency and levels of occupational asbestos exposure in France over the past century. METHODS: Work histories were collected during 11 population-based case-referent studies recently carried out in France, and an asbestos-specific job-exposure matrix including 10 625 jobs was used to estimate indices of past occupational asbestos exposure. The results were estimated from a sample of 4287 subjects, bootstrapped 200 times. RESULTS: The distribution of socioeconomic categories within the sample was compared with that of the general population in 1954, 1962, 1968, 1975, and 1982. The proportion of blue-collar workers was similar. The highest proportion of exposed subjects was found between 1950 and 1980. Around 10% of each 10-year age class was exposed to asbestos. For those born in 1930-1939, 15.2% was exposed between the ages of 20 and 29 years. For each age class born in 190-1939, the proportion exposed at least once by 60 years of age ranged from 18.2% to 24.5 % and, of those exposed, the cumulative duration of exposure ranged from 11.3 to 15.4 years by the age of 60 years. A population exposure index showed that the heaviest exposure occurred between 1960 and 1970 and that the age classes born between 1920 and 1929 were the most heavily exposed. Time trends showed that the mean value of this index for the men aged 20-59 years reached a peak in the 1960s and then decreased. CONCLUSIONS: This study presents data of reasonable validity about occupational asbestos exposure in France and its trends over the past century; the data are being used to forecast the development of male mortality from mesothelioma in France.

Cocaine withdrawal symptoms and initial urine toxicology results predict treatment attrition in outpatient cocaine dependence treatment.

This study evaluated the ability of cocaine withdrawal symptoms, measured by the Cocaine Selective Severity Assessment (CSSA) and initial urine toxicology results, to predict treatment attrition among 128 cocaine dependent veterans participating in a 4-week day hospital treatment program. The CSSA was administered and a urine toxicology screen was obtained at intake and at the start of the day hospital (about 1 week later). The combination of a positive urine toxicology screen and a high CSSA score at intake predicted failure to complete treatment. Urine toxicology results at the start of the day hospital, but not at intake, predicted failure to complete treatment. Among participants without other psychiatric illness, high CSSA scores at intake predicted failure to complete treatment. The presence of cocaine withdrawal symptoms and a positive urine toxicology screen are clinically useful predictors of treatment attrition.

[Selection effects in epidemiological cohorts: nature, causes and consequences]. / Les effets de sélection dans les cohortes épidémiologiques Nature, causes et conséquences.

Selection effects in cohort studies occur when the population observed over time differs from the target population due to the inclusion or follow-up of the subjects. Selection effects may bias the estimation of the frequency of the disease and of the exposure of interest, or the estimation of the association between disease and exposure. In industrial cohorts, where subjects are not volunteers, the reasons why they were hired and they stay working in a company are often linked with lifestyle factors or health problems that can be associated with the diseases or the exposures of interest. This phenomenon is known as the "healthy worker effect". When the cohort includes volunteers, other selection effects associated with the reasons why the individuals participate in the study and stay in the cohort may occur. The time course of both exposure of interest and health status during follow-up may also be associated with the probability of staying in the cohort. We describe the main components of the various selection effects associated with inclusion of the subjects at baseline, with their follow-up during the observation of the cohort, and we examine the main components of the selection effects and their consequences.

[Occupational exposure to wood dust. Health effects and exposure limit values]. / Exposition professionnelle aux poussières de bois. Effets sur la santé et valeurs limites d'exposition.

This article presents a review of the health effects of occupational exposure to wood dusts and of the data that could be used for setting occupational exposure limits for this nuisance. The causal role of wood dust in the onset of sinonasal cancers is solidly established by numerous epidemiological studies, and the magnitude of the risk is particularly high for adenocarcinoma induced by exposure to hardwood dust. However, no current data allows to rule out the carcinogenic role of softwood dusts and, in the view of protecting the health of the workers, it does not seem relevant to distinguish these two types of wood. Various impairments of the lung function have been frequently associated with exposure to both 'allergenic' and 'non-allergenic' wood dusts and may occur at very low concentrations. According to the SUMER 94 and CAREX studies, about 200 000 workers are currently exposed to wood dusts in France (about 1% of the working population between 1990 and 1994). When taking into account full professional careers, the percentage of workers having been occupationally exposed can be estimated to be about 15% for men and 5% for women. Measurements performed in France between 1987 and 2000 show that exposure levels are high, about 50% of the samplings being over 1mg/m(3) (actual TWA in France). Although the studies present limits, particularly for the quantitative assessment of individual exposure levels, it seems that nonmalignant effects are susceptible to arise at the level of 1mg/m(3); a limit value of 0.5mg/m(3) would credibly allow to protect exposed workers from most of the risks of nonmalignant pulmonary effects. However, it is impossible to assure that this value will avoid the induction of sinonasal cancer, even if this level is certainly lower than the levels to which the cases of sinonasal cancers published in the literature were exposed.

[Regional differences in the compensation of pleural mesothelioma as occupational disease in France (1986-1993)]. / Disparités régionales de la reconnaissance du mésothéliome de la plèvre comme maladie professionnelle en France (1986-1993).

BACKGROUND: Occupational exposure to asbestos is responsible for 80% at least of all mesothelioma in developed countries. In France there are important regional differences in the rate of mesothelioma compensated as occupational diseases, without knowing if these differences could be explained by a real difference of risk. The objective here is to quantify these regional differences in relation with the differences of level of risk. METHODS: The analysis compares, for each of the 16 regions of the national social security system, mortality for both genders and among men by pleural cancer (ICD 163) in the general population and mesothelioma compensated as occupational diseases during the 1986-1993 period. We computed for each region the number of expected compensated mesothelioma under the hypothesis where the regional distributions of compensated mesothelioma and mesothelioma deaths are the same; as well as the percentage of compensated mesothelioma compared to the deaths, and the variation from the national mean under two hypotheses, high and low; and the probability that a mesothelioma is compensated as an occupational disease taking as a reference the "best" region. RESULTS: The compensation rate differed significantly among regions (p < 0.05) and for men, the rate between observed and expected numbers of compensated mesothelioma varied from 0.15 (region of Montpellier) to 2.29 (region of Nantes), a ratio over 15. For all of France, the compensation rate was 25% under the best hypothesis. The region of Nantes compensated 61.5% of the male mesothelioma as occupational diseases, while the region of Montpellier and Clermont-Ferrand only around 5%. The probability for a mesothelioma to be compensated, compared to the region of Nantes, was 2.5 times less in national average, and about 10 times less in Montpellier and Clermont-Ferrand regions. CONCLUSION: In spite of limits linked to the imprecision of the available data, important regional differences in term of compensation of mesothelioma as occupational diseases clearly exist. Indications lead to think that their origin lies essentially in differences between physicians when considering the occupational etiology of mesothelioma, but differences within the system of compensation of occupational diseases can not be excluded. An improvement of the national statistical system concerning occupational diseases is highly recommendable.

[Comparison of observed and expected person-years: a simulated approach]. / Comparaison d'années-personnes observées et attendues; une approche par simulation.

In Epidemiology, no simple test is available for comparing an observed number of exposed person-years with an expected number. The number of person-years is a sum of lengths of stays which is not normally distributed under the null hypothesis. A method is proposed and an example is given. The objective was to study in the French territory of New-Caledonia the relationship between past places of living and occurrence of respiratory cancers. The total observed number of person-years in a zone, among cases, was compared to an expected distribution, based on censuses and controlling for two confounding factors, period of stay and ethnic group. Different methods are compared: a test based on a simulated distribution, and parametric approaches with normality assumption. If the number of cases is small, the simulation test seems to be the best approach.

[Determinants of health in nurses]. / Les déterminants de la santé chez les infirmières.

A cross-sectional survey was carried out in 1980 among 824 nurses in 10 hospitals on the occasion of the annual checkups. The purpose was to describe the relationship between demographic and occupational characteristics and health, stressing the effects of work in shifts. Using Khi-2 tests and logistic models, the negative health effects of arduous shift work appear to be less than expected. This could be a result of the high turnover in the profession, which is characterized by a low average age and a short occupational lifetime.