Modelling the outcomes of different red blood cell transfusion strategies for the treatment of traumatic haemorrhage in the prehospital setting in the United Kingdom.

BACKGROUND AND OBJECTIVES: The limited supply and increasing demand of group O RhD-negative red blood cells (RBCs) have resulted in other transfusion strategies being explored by blood services that carry potential risks but may still provide an overall benefit to patients. Our aim was to analyse the potential economic benefits of prehospital transfusion (PHT) against no PHT. MATERIALS AND METHODS: The impact of three PHT strategies (RhD-negative RBC, RhD-positive RBC and no transfusion) on quality-adjusted-life-years (QALYs) of all United Kingdom trauma patients in a given year and the subset of patients considered most at risk (RhD-negative females <50 years old), was modelled. RESULTS: For the entire cohort and the subset of patients, transfusing RhD-negative RBCs generated the most QALYs (141,899 and 2977, respectively), followed by the RhD-positive RBCs (141,879.8 and 2958.8 respectively), and no prehospital RBCs (119,285 and 2503 respectively). The QALY difference between RhD-negative and RhD-positive policies was smaller (19.2, both cohorts) than RhD-positive and no RBCs policies in QALYs term (22,600 all cohort, 470 for a subset), indicating that harms from transfusing RhD-positive RBCs are lower than harms associated with no RBC transfusion. A survival increase from PHT of 0.02% (entire cohort) and 0.7% (subset cohort) would still make the RhD-positive strategy better in QALYs terms than no PHT. CONCLUSION: While the use of RhD-positive RBCs carries risks, the benefits measured in QALYs are higher than if no PHT are administered, even for women of childbearing potential. Group O RhD-positive RBCs could be considered when there is a national shortage of RhD-negative RBCs.

Efforts needed for preventing breast and colorectal cancer through changes in dietary patterns.

BACKGROUND: Prospective cohort studies on diet and cancer report risk associations as hazard ratios. But hazard ratios do not inform on the number of people who need to alter their dietary behaviours for preventing cancer. The objective of this study is to estimate the number of people that need to alter their diet for preventing one additional case of female breast or colorectal cancer. METHODS: Based on the largest prospective studies done in the USA and in Europe, we computed the number of subjects who need to alter their diet. RESULTS: For preventing one case of breast cancer, European women should increase their fruit consumption by 100 g/day during 33 000 person-years, and US women by 60 g/day during 10 600 person-years. For vegetables, European women should increase their consumption by 160 g/day during 26 900 person-years and US women by 100 g/day during 19 000 person-years. For preventing one case of colorectal cancer, European subjects should decrease their red meat consumption by 20 g/day during 26 100 person-years, and US subjects by 30 g/day during 8170 person-years. For processed meat, European subjects should decrease their consumption by 20 g/day during 17 400 person-years, and US subjects by 10 g/day during 7940 person-years. CONCLUSIONS: Large number of subjects would need to alter their intake of fruits, vegetables, red and processed meat during many years in order to prevent one additional breast or colorectal cancer.

The information distortion bias: implications for medical decisions.

CONTEXT: Every diagnosis involves an act of decision making, which requires proper evaluation of information. However, even seemingly objective information can require interpretation, often without our conscious awareness. In this cross-cutting edge article we describe the phenomenon of leader-driven information distortion (ID) and its implications for medical education. INFORMATION DISTORTION: Recent research indicates that one threat to good decisions is a biased interpretation of information to favour one alternative course of action over another. Once an alternative emerges as a leader during a decision there is a strong tendency to evaluate subsequent information as supporting that option. This can occur when deciding between two competing diagnoses. It is particularly a concern if diagnostic tests provide potentially ambiguous results. This leader-driven ID is pre-decisional in nature, in that it develops during a decision and involves the interpretation of information available prior to the final decision or diagnosis, with different interpretations possible depending on whichever alternative is the leader. Studies reveal that the distortion bias is pervasive in decisions, and that awareness of the act of distortion is low in decision makers. APPLICATION TO MEDICAL EDUCATION: Empirical research has confirmed the presence of leader-driven ID in hypothetical diagnoses made by physicians. ID creates two threats to medical decisions: First, it can make a diagnosis sticky in that it is resistant to being overturned by contradictory information. Second, it can promote unwarranted certainty in a diagnosis. The outcome may be premature closure, unnecessary testing or incorrect treatment, resulting in delayed or missed diagnoses. METHODS: This paper summarises research related to leader-driven ID in medical and professional decisions and discusses various approaches directed towards reducing ID. A framework and language are provided for thinking about and discussing ID in medical decisions and medical education. Courses of action for mitigating the effects of ID are suggested.

Impact of a telephone-first consultation system in general practice.

PURPOSE OF THE STUDY: Increasing pressure on general practice prompts innovative change in service organisation. This study sought to evaluate the impact of introducing a telephone-first consultation system in a socioeconomically deprived population. STUDY DESIGN: An interrupted time series of preplanned outcomes for 2 years before and 1 year postintroduction of a telephone-first system was used to measure the volume and type of general practitioner (GP) consultations and the number of patients consulted per year. Emergency department (ED) and GP out-of-hours attendances, the number of outpatient referrals, and the number of requests for laboratory tests were measured as secondary outcomes. RESULTS: The telephone-first system was associated with a 20% increase in total GP consultations (telephone and face-to-face, effect estimate at 12 months, p=0.001). Face-to-face consultations decreased by 39% (p<0.001), while telephone consultations increased by 131% (p<0.001). The volume of individual patient requests for a GP consultation and the number of treatment room nurse consultations did not change. Secondary outcome measures showed no change in hospital outpatient referrals, number of requests for laboratory tests, and ED or GP out-of-hours attendances. CONCLUSIONS: A telephone-first system in a deprived urban general practice can decrease delays to GP-patient contacts. The number of patients seeking a medical intervention did not differ irrespective of the consultation system used. The telephone-first system did not affect GP out-of-hours, laboratory investigations or secondary care contacts.

Changing global policy to deliver safe, equitable, and affordable care for women's cancers.

Breast and cervical cancer are major threats to the health of women globally, particularly in low-income and middle-income countries. Radical progress to close the global cancer divide for women requires not only evidence-based policy making, but also broad multisectoral collaboration that capitalises on recent progress in the associated domains of women's health and innovative public health approaches to cancer care and control. Such multisectoral collaboration can serve to build health systems for cancer, and more broadly for primary care, surgery, and pathology. This Series paper explores the global health and public policy landscapes that intersect with women's health and global cancer control, with new approaches to bringing policy to action. Cancer is a major global social and political priority, and women's cancers are not only a tractable socioeconomic policy target in themselves, but also an important Trojan horse to drive improved cancer control and care.

Novel |V_{us}| Determination Using Inclusive Strange τ Decay and Lattice Hadronic Vacuum Polarization Functions.

We propose and apply a new approach to determining |V_{us}| using dispersion relations with weight functions having poles at Euclidean (spacelike) momentum which relate strange hadronic τ decay distributions to hadronic vacuum polarization (HVP) functions obtained from lattice quantum chromodynamics. We show examples where spectral integral contributions from the region where experimental data have large errors or do not exist are strongly suppressed but accurate determinations of the relevant lattice HVP combinations remain possible. The resulting |V_{us}| agrees well with determinations from K physics and three-family Cabibbo-Kobayashi-Maskawa unitarity. Advantages of this new approach over the conventional hadronic τ decay determination employing flavor-breaking sum rules are also discussed.

Endogenous and exogenous testosterone and the risk of prostate cancer and increased prostate-specific antigen (PSA) level: a meta-analysis.

OBJECTIVE: To review and quantify the association between endogenous and exogenous testosterone and prostate-specific antigen (PSA) and prostate cancer. METHODS: Literature searches were performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Prospective cohort studies that reported data on the associations between endogenous testosterone and prostate cancer, and placebo-controlled randomized trials of testosterone replacement therapy (TRT) that reported data on PSA and/or prostate cancer cases were retained. Meta-analyses were performed using random-effects models, with tests for publication bias and heterogeneity. RESULTS: Twenty estimates were included in a meta-analysis, which produced a summary relative risk (SRR) of prostate cancer for an increase of 5 nmol/L of testosterone of 0.99 (95% confidence interval [CI] 0.96, 1.02) without heterogeneity (I² = 0%). Based on 26 trials, the overall difference in PSA levels after onset of use of TRT was 0.10 ng/mL (-0.28, 0.48). Results were similar when conducting heterogeneity analyses by mode of administration, region, age at baseline, baseline testosterone, trial duration, type of patients and type of TRT. The SRR of prostate cancer as an adverse effect from 11 TRT trials was 0.87 (95% CI 0.30; 2.50). Results were consistent across studies. CONCLUSIONS: Prostate cancer appears to be unrelated to endogenous testosterone levels. TRT for symptomatic hypogonadism does not appear to increase PSA levels nor the risk of prostate cancer development. The current data are reassuring, although some caution is essential until multiple studies with longer follow-up are available.

Relation between Breast Cancer and High Glycemic Index or Glycemic Load: A Meta-analysis of Prospective Cohort Studies.

Breast cancer is the commonest form of cancer in women worldwide. It has been suggested that chronic hyperinsulinemia associated with insulin resistance plays a role in breast cancer etiology. To test the hyperinsulinemia hypothesis, a dietary pattern associated with a high glycemic index and glycemic load, both proxies for chronic hyperinsulinemia, should be associated with an increased risk of breast cancer. A meta-analysis restricted to prospective cohort studies was undertaken using a random effects model with tests for statistical significance, publication bias and heterogeneity. The metric for analysis was the risk of breast cancer in the highest relative to the lowest glycemic index and glycemic load dietary pattern. A dietary pattern with a high glycemic index was associated with a summary relative risk (SRR) of 1.05 (95% CI: 1.00, 1.11), and a high glycemic load with a SRR of 1.06 (95% CI: 1.00, 1.13). Adjustments for body mass index [BMI], physical activity and other lifestyle factors did not influence the SRR, nor did menopausal status and estrogen receptor status of the tumor. In conclusion, the current evidence supports a modest association between a dietary pattern with high glycemic index or glycemic load and the risk of breast cancer.

An assessment of the barriers to accessing the Basic Package of Health Services (BPHS) in Afghanistan: was the BPHS a success?

Afghanistan is one of the most fragile and conflict-affected countries in the world. It has experienced almost uninterrupted conflict for the last thirty years, with the present conflict now lasting over a decade. With no history of a functioning healthcare system, the creation of the Basic Package of Health Services (BPHS) in 2003 was a response to Afghanistan's dire health needs following decades of war. Its objective was to provide a bare minimum of essential health services, which could be scaled up rapidly through contracting mechanisms with Non-Governmental Organisations (NGOs). The central thesis of this article is that, despite the good intentions of the BPHS, not enough has been done to overcome the barriers to accessing its services. This analysis, enabled through a review of the existing literature, identifies and categorises these barriers into the three access dimensions of: acceptability, affordability and availability. As each of these is explored individually, analysis will show the extent to which these barriers to access are a critical issue, consider the underlying reasons for their existence and evaluate the efforts to overcome these barriers. Understanding these barriers and the policies that have been implemented to address them is critical to the future of health system strengthening in Afghanistan.

Eradicating polio in Pakistan: an analysis of the challenges and solutions to this security and health issue.

Since the launch of the Global Polio Eradication Initiative (GPEI) in 1988 the global incidence of poliomyelitis has fallen by nearly 99 %. From a situation where wild type poliovirus was endemic in 125 countries across five continents, transmission is now limited to regions of just three countries - Pakistan, Afghanistan and Nigeria. A sharp increase in Pakistan's poliomyelitis cases in 2014 prompted the International Health Regulations Emergency Committee to declare the situation a 'public health emergency of international concern'. Global polio eradication hinges on Pakistan's ability to address the religious, political and socioeconomic barriers to immunisation; including discrepancies in vaccine coverage, a poor health infrastructure, and conflict in polio-endemic regions of the country. This analysis provides an overview of the GPEI, focusing on the historical and contemporary challenges facing Pakistan's polio eradication programme and the impact of conflict and insecurity, and sheds light on strategies to combat vaccine hesitancy, engage local communities and build on recent progress towards polio eradication in Pakistan.

Active and passive smoking and risk of breast cancer: a meta-analysis.

Studies on active and passive tobacco smoking and breast cancer have found inconsistent results. A meta-analysis of observational studies on tobacco smoking and breast cancer occurrence was conducted based on systematic searches for studies with retrospective (case-control) and prospective (cohort) designs. Eligible studies were identified, and relative risk measurements were extracted for active and passive tobacco exposures. Random-effects meta-analyses were used to compute summary relative risks (SRR). Heterogeneity of results between studies was evaluated using the (I (2)) statistics. For ever active smoking, in 27 prospective studies, the SRR for breast cancer was 1.10 (95 % CI [1.09-1.12]) with no heterogeneity (I (2) = 0 %). In 44 retrospective studies, the SRR was 1.08 (95 % CI [1.02-1.14]) with high heterogeneity (I (2) = 59 %). SRRs for current active smoking were 1.13 (95 % CI [1.09-1.17]) in 27 prospective studies and 1.08 (95 % CI [0.97-1.20]) in 22 retrospective studies. The results were stable across different subgroup analyses, notably pre/post-menopause, alcohol consumption adjustments, including/excluding passive smokers from the referent group. For ever passive smoking, in 11 prospective studies, the SRR for breast cancer was 1.07 (95 % CI [1.02-1.13]) with no heterogeneity (I (2) = 1 %). In 20 retrospective studies, the SRR was 1.30 (95 % CI [1.10-1.54]) with high heterogeneity (I (2) = 74 %). Too few prospective studies were available for meaningful subgroup analyses. There is consistent evidence for a moderate increase in the risk of breast cancer in women who smoke tobacco. The evidence for a moderate increase in risk with passive smoking is more substantial than a few years ago.

Different time trends by gender for the incidence of Hodgkin's lymphoma among young adults in the USA: a birth cohort phenomenon.

OBJECTIVES: Hodgkin's lymphoma (HL) is one of the most common cancers among young adults. We investigated the time trends for HL among the 20-44 age group in the USA by gender to identify the potential factors accounting for the incidence trends. METHODS: Using data from the National Cancer Institute's Surveillance, Epidemiology, and End Results program for 1973-2010, we conducted age-period-cohort modeling to evaluate birth cohort patterns on incidence trends of HL over time. RESULTS: For all races combined, the age-adjusted incidence patterns were similar to that of whites. The birth cohort patterns for whites and all races were similar, but the patterns differed according to gender. Specifically, except for the 1970-1975 birth cohort, all other birth cohorts showed an increasing birth cohort trend for females. Conversely, there was a decreasing cohort trend in males beginning in the 1960 birth cohort regardless of the assumptions of the period effect. CONCLUSION: The established risk factors for HL can seemingly not explain the gender disparities of the cohort pattern, which necessitates further analytical epidemiological studies to explore the risk factors for this disease with respect to potential differences by gender and by histological subtype.

Polymorphisms in DNA repair genes, hair dye use, and the risk of non-Hodgkin lymphoma.

PURPOSE: Genetic polymorphisms in DNA repair genes and hair dye use may both have a role in the development of non-Hodgkin lymphoma (NHL). We aimed to examine the interaction between variants in DNA repair genes and hair dye use with risk of NHL in a population-based case-control study of Connecticut women. METHODS: We examined 24 single nucleotide polymorphisms in 16 DNA repair genes among 518 NHL cases and 597 controls and evaluated the associations between hair dye use and risk of overall NHL and common NHL subtypes, stratified by genotype, using unconditional logistic regression. RESULTS: Women who used hair dye before 1980 had a significantly increased risk of NHL, particularly for the follicular lymphoma (FL) subtype, but not for diffuse large B-cell lymphoma. The following genotypes in combination with hair dye use before 1980 were associated with FL risk: BRCA2 rs144848 AC+CC [odds ratio (OR) (95% confidence interval (CI)) 3.28(1.27-8.50)], WRN rs1346044 TT [OR(95% CI) 2.70(1.30-5.65)], XRCC3 rs861539 CT+TT [OR(95% CI) 2.76(1.32-5.77)], XRCC4 rs1805377 GG [OR(95% CI) 2.07(1.10-3.90)] and rs1056503 TT [OR(95% CI) 2.17(1.16-4.07)], ERCC1 rs3212961 CC [OR(95% CI) 1.93(1.00-3.72)], RAD23B rs1805329 CC [OR(95% CI) 2.28(1.12-4.64)], and MGMT rs12917 CC, rs2308321 AA, and rs2308327 AA genotypes [OR(95% CI) 1.96(1.06-3.63), 2.02(1.09-3.75), and 2.23(1.16-4.29), respectively]. In addition, a significant interaction with risk of overall NHL was observed between WRN rs1346044 and hair dye use before 1980 (p(interaction) = 0.032). CONCLUSIONS: Our results indicated that genetic variation in DNA repair genes modifies susceptibility to NHL in relation to hair dye use, particularly for the FL subtype and in women who began using hair dye before 1980. Further studies are needed to confirm these observations.

GWAS of follicular lymphoma reveals allelic heterogeneity at 6p21.32 and suggests shared genetic susceptibility with diffuse large B-cell lymphoma.

Non-Hodgkin lymphoma (NHL) represents a diverse group of hematological malignancies, of which follicular lymphoma (FL) is a prevalent subtype. A previous genome-wide association study has established a marker, rs10484561 in the human leukocyte antigen (HLA) class II region on 6p21.32 associated with increased FL risk. Here, in a three-stage genome-wide association study, starting with a genome-wide scan of 379 FL cases and 791 controls followed by validation in 1,049 cases and 5,790 controls, we identified a second independent FL-associated locus on 6p21.32, rs2647012 (OR(combined)  = 0.64, P(combined)  = 2 × 10(-21)) located 962 bp away from rs10484561 (r(2)<0.1 in controls). After mutual adjustment, the associations at the two SNPs remained genome-wide significant (rs2647012:OR(adjusted)  = 0.70, P(adjusted)  =  4 × 10(-12); rs10484561:OR(adjusted)  = 1.64, P(adjusted)  = 5 × 10(-15)). Haplotype and coalescence analyses indicated that rs2647012 arose on an evolutionarily distinct haplotype from that of rs10484561 and tags a novel allele with an opposite (protective) effect on FL risk. Moreover, in a follow-up analysis of the top 6 FL-associated SNPs in 4,449 cases of other NHL subtypes, rs10484561 was associated with risk of diffuse large B-cell lymphoma (OR(combined)  = 1.36, P(combined)  =  1.4 × 10(-7)). Our results reveal the presence of allelic heterogeneity within the HLA class II region influencing FL susceptibility and indicate a possible shared genetic etiology with diffuse large B-cell lymphoma. These findings suggest that the HLA class II region plays a complex yet important role in NHL.

Motion compensated cone-beam CT reconstruction using ana priorimotion model from CT simulation: a pilot study.

Objective. To combat the motion artifacts present in traditional 4D-CBCT reconstruction, an iterative technique known as the motion-compensated simultaneous algebraic reconstruction technique (MC-SART) was previously developed. MC-SART employs a 4D-CBCT reconstruction to obtain an initial model, which suffers from a lack of sufficient projections in each bin. The purpose of this study is to demonstrate the feasibility of introducing a motion model acquired during CT simulation to MC-SART, coined model-based CBCT (MB-CBCT).Approach. For each of 5 patients, we acquired 5DCTs during simulation and pre-treatment CBCTs with a simultaneous breathing surrogate. We cross-calibrated the 5DCT and CBCT breathing waveforms by matching the diaphragms and employed the 5DCT motion model parameters for MC-SART. We introduced the Amplitude Reassignment Motion Modeling technique, which measures the ability of the model to control diaphragm sharpness by reassigning projection amplitudes with varying resolution. We evaluated the sharpness of tumors and compared them between MB-CBCT and 4D-CBCT. We quantified sharpness by fitting an error function across anatomical boundaries. Furthermore, we compared our MB-CBCT approach to the traditional MC-SART approach. We evaluated MB-CBCT's robustness over time by reconstructing multiple fractions for each patient and measuring consistency in tumor centroid locations between 4D-CBCT and MB-CBCT.Main results. We found that the diaphragm sharpness rose consistently with increasing amplitude resolution for 4/5 patients. We observed consistently high image quality across multiple fractions, and observed stable tumor centroids with an average 0.74 ± 0.31 mm difference between the 4D-CBCT and MB-CBCT. Overall, vast improvements over 3D-CBCT and 4D-CBCT were demonstrated by our MB-CBCT technique in terms of both diaphragm sharpness and overall image quality.Significance. This work is an important extension of the MC-SART technique. We demonstrated the ability ofa priori5DCT models to provide motion compensation for CBCT reconstruction. We showed improvements in image quality over both 4D-CBCT and the traditional MC-SART approach.

Mechanism for the enhanced peroxidation of linoleic acid by a titanium dioxide/hypochlorite system.

Nanosized titanium dioxide (TiO2) is a common component of sunscreen preparations and cosmetics as it reflects UV and visible light in accordance to Rayleigh's law. However, in aqueous environments, TiO2 is an efficient photocatalyst, producing superoxide O2⁻· and hydroxyl (HO·) radicals, which are highly damaging to biomolecules. We investigated the role of TiO2 in promoting the peroxidation of linoleic acid (LA) alone and in the presence of hypochlorous acid (HOCl). TiO2 significantly enhanced peroxidation of LA, which was further enhanced in the presence of HOCl. This latter finding involved the formation of singlet molecular oxygen in a Russell-type mechanism appearing to involve preformed lipid hydroperoxides (LOOH). In addition to lipid peroxidation, HOCl also mediated formation of 18:1 monochlorohydrins, which in the presence of TiO2 appeared to decompose to kinetic products which supplemented peroxidation of linoleic acid. We present a theoretical mechanism which fits the available experimental data and may partially explain the dichotomy associated with HOCls role in lipid modification.

Epidemiology of head and neck squamous cell carcinoma not related to tobacco or alcohol.

PURPOSE OF REVIEW: This review intends to present some epidemiological findings regarding the epidemiology of head and neck squamous cell carcinoma not related to alcohol or tobacco (HNSCCNAT). RECENT FINDINGS: Twenty-five percent of squamous cell carcinomas of head and neck are not related to tobacco or alcohol consumption. The risk factors for this group of malignancies are not very well established yet. HNSCCNAT are more likely to occur in the oropharynx. The diagnosis is more frequent at young age (before 50). The prevalence of human papillomavirus (HPV-positive) infection is high. SUMMARY: Monitoring HPV status in head and neck cancer patients who are not tobacco or alcohol consumers will enable physicians to better plan treatment.

Serum insulin and C-peptide concentration and breast cancer: a meta-analysis.

PURPOSE: Chronic hyperinsulinemia may play a role in breast cancer etiology. We performed a meta-analysis examining whether serum concentrations of insulin and C-peptide are associated with increased breast cancer risk. METHODS: We restricted our analyses to prospective studies. After a systematic literature search, we computed summary relative risks (SRRs) and 95 % confidence intervals (95 % CIs) using random effect models applied to the relative risk associated with the highest versus lowest quantile of serum concentrations. We also graphically examined results in order to identify whether dose-response relationships were present. RESULTS: Six articles including 1,890 cases were retrieved for serum insulin levels and five for serum C-peptide levels including 1,759 cases. SRR and 95 % CI were 1.08 (0.66-1.78) for insulin and 1.04 (0.77-1.41) for C-peptide. Heterogeneity of results between studies was high for insulin and inexistent for C-peptide. Restricting the analysis to women diagnosed with breast cancer before or after menopause did not alter results. In insulin studies, SRR computed from relative risks not adjusted for body mass index (and other risk factors) was 1.22 (0.91-1.63). The SRR fell to 1.02 (0.53-1.97) in studies that adjusted for body mass index and other factors. Similar drops occurred in C-peptide studies, from 1.11 (0.87-1.41) to 1.06 (0.70-1.61). No consistent dose-response relationship was apparent in either pre- or post-menopausal cancers. CONCLUSIONS: Our meta-analysis of observational studies found no evidence of an association between serum insulin or C-peptide concentrations and breast cancer risk. Increased risk found by some studies may have been due to inadequate control for adiposity.

A birth cohort analysis of the incidence of ascending and descending colon cancer in the United States, 1973-2008.

OBJECTIVES: There is evidence indicating that the trends in colorectal cancer (CRC) incidence rates in the United States differ according to CRC subsites, including for ascending cancer which has shown a different pattern from the overall trends. We investigated the time trends for ascending and descending colon cancer in the United States by race and gender to identify the specific components that may account for the incidence trends. METHODS: Using data from the National Cancer Institute's Surveillance, Epidemiology, and End Results program for 1973-2008, we conducted age-period-cohort modeling to evaluate birth cohort patterns and evaluate age-period-cohort effects on incidence trends of colon cancer over time. RESULTS: A clear birth cohort pattern was observed for both ascending and descending colon cancer, and the incidence rates of ascending colon cancer in the more recent birth cohorts were higher compared to earlier cohorts particularly for black males and females. This increase was most obvious in the younger age groups and appeared to accelerate, especially for black females. For descending colon cancer, the study suggested an increase in the birth cohort slope in the later birth cohorts for all gender and race groups, after a period of decline in earlier birth cohorts. CONCLUSION: The increase in incidence rates of both ascending and descending colon cancer in more recent birth cohorts for blacks suggests the need for targeted public health strategies to increase CRC screening. Further, additional etiological studies are warranted to evaluate factors responsible for the observed trends in more recent birth cohorts, including differences by subsites, race, and/or gender.