Age-specific differences in tumour characteristics between screen-detected and non-screen-detected breast cancers in women aged 40-74 at diagnosis in Sweden from 2008 to 2017.

OBJECTIVE: To analyze differences between screen-detected and non-screen-detected invasive breast cancers by tumour characteristics and age at diagnosis in the nationwide population-based mammography screening program in Sweden. METHODS: Data were retrieved from the National Quality Register for Breast Cancer for 2008-2017. Logistic regression analysis was used to estimate the likelihood for a tumour to be screen-detected by tumour characteristics and age group at diagnosis. RESULTS: In total there were 51,429 invasive breast cancers in the target age group for mammography screening of 40-74 years. Likelihood of screen detection decreased with larger tumour size, lymph node metastases, higher histological grade and distant metastasis. Odds ratios (ORs) for negative oestrogen (ER) and progesterone (PgR) were 0.41 and 0.57; for positive HER2, 0.62; for Ki-67 high versus low, 0.49. Molecular sub-types had OR of 0.56, 0.40 and 0.28, respectively, for luminal B-like, HER2-positive and triple negative versus luminal A-like. Adjusting for tumour size (T), lymph node status (N), age, year and county at diagnosis slightly elevated the ORs. Statistically significant interactions between tumour characteristics and age were found (p < 0.05) except for ER and PgR. The age group 40-49 deviated most from the other age groups. CONCLUSIONS: Our study demonstrates that screen-detected invasive breast cancers had more favourable tumour characteristics than non-screen-detected after adjusting for age, year and county of diagnosis, and even after adjusting for T and N. The trend towards favourable tumour characteristics was less pronounced in the 40-49 age group compared to the other age groups, except for ER and PgR.

Routine Fecal Occult Blood Screening and Colorectal Cancer Mortality in Sweden.

Importance: Population-based colorectal cancer (CRC) screening programs are implemented worldwide, but there are difficulties evaluating their effectiveness. The magnitude of routine CRC screening effectiveness regarding cancer-specific mortality is unclear. Objective: To evaluate cancer-specific mortality associated with early vs late or no invitation for routine CRC screening using fecal occult blood testing. Design, Setting, and Participants: This prospective cohort study was performed in the region of Stockholm-Gotland, Sweden, between January 1, 2008, and December 31, 2021. All individuals of the target population of screening born from 1938 to 1954 were included. Data were analyzed from December 12, 2022, to June 25, 2023. Exposures: Individuals were invited early (2008-2012), late (2013-2015), or not at all to screening with biennial guaiac-based fecal occult blood test. The early invitation group was considered the exposure group and the late or no invitation group was considered the control group. Main Outcomes and Measures: The main outcome was cancer-specific mortality, defined as CRC registered in the Cancer Register with CRC as underlying cause of death in the Cause of Death Register. Excess mortality was calculated as all-cause deaths among the individuals with CRC subtracted from the expected number of deaths had they not had CRC. Poisson regression analysis based on deaths and person-years was used to estimated mortality rate ratio (RR) with 95% CIs, adjusted for follow-up years and attained age. Results: In total, 379 448 individuals (193 436 [51.0%] female) were invited for CRC screening, including 203 670 individuals in the exposure group and 175 778 in the control group. The mean screening participation rate was 63.3%, and there was a maximum of 14 years follow-up. There were 834 CRC deaths in 2 190 589 person-years in the exposure group, compared with 889 CRC deaths in 2 249 939 person-years in the control group. Individuals who underwent early CRC screening had reduced adjusted risk of CRC mortality (RR, 0.86; 95% CI, 0.78-0.95) and excess mortality (RR, 0.84; 95% CI, 0.75-0.93). Conclusions and Relevance: This prospective cohort study of routine screening with fecal occult blood testing found a 14% decrease in CRC mortality associated with screening. The true association of screening with reduced mortality is expected to be higher due to some coexistence of testing in the control group and CRC deaths diagnosed more than 2 years after screening.

Pelvic inflammatory disease and risk of epithelial ovarian cancer: a national population-based case-control study in Sweden.

BACKGROUND: Epithelial ovarian cancer is an insidious disease, and women are often diagnosed when the disease is beyond curative treatment. Accordingly, identifying modifiable risk factors is of paramount importance. Inflammation predisposes an individual to cancer in various organs, but whether pelvic inflammatory disease is associated with an increased risk of epithelial ovarian cancer has not been fully determined. OBJECTIVE: This study aimed to investigate a possible association between clinically verified pelvic inflammatory disease and the risk of epithelial ovarian cancer. STUDY DESIGN: In this national population-based case-control study, all women in Sweden diagnosed with epithelial ovarian cancer between 1999 and 2020 and 10 controls for each were identified, matched for age and residential district. Using several Swedish nationwide registers, data on previous pelvic inflammatory disease and potential confounding factors (age, parity, educational level, and previous gynecologic surgery) were retrieved. Adjusted odds ratios and 95% confidence intervals were estimated using conditional logistic regression. Histotype-specific analyses were performed for the subgroup of women diagnosed with epithelial ovarian cancer between 2015 and 2020. Moreover, hormonal contraceptives and menopausal hormone therapy were adjusted in addition to the aforementioned confounders. RESULTS: This study included 15,072 women with epithelial ovarian cancer and 141,322 controls. Most women (9102 [60.4%]) had serous carcinoma. In a subgroup of cases diagnosed between 2015 and 2020, high-grade serous carcinoma (2319 [60.0%]) was identified. A total of 168 cases (1.1%) and 1270 controls (0.9%) were diagnosed with pelvic inflammatory disease. Previous pelvic inflammatory disease was associated with an increased risk of epithelial ovarian cancer (adjusted odds ratio, 1.39; 95% confidence interval, 1.17-1.66) and serous carcinoma (adjusted odds ratio, 1.46; 95% confidence interval, 1.18-1.80) for the entire study population. For the subgroup of women diagnosed in 2015-2020, pelvic inflammatory disease was associated with high-grade serous carcinoma (adjusted odds ratio, 1.43; 95% confidence interval, 1.01-2.04). The odds ratios of the other histotypes were as follows: endometrioid (adjusted odds ratio, 0.13; 95% confidence interval, 0.02-1.06), mucinous (adjusted odds ratio, 1.55; 95% confidence interval, 0.56-4.29), and clear cell carcinoma (adjusted odds ratio, 2.30; 95% confidence interval, 0.90-5.86). A dose-response relationship was observed between the number of pelvic inflammatory disease episodes and the risk of epithelial ovarian cancer (Ptrend<.001). CONCLUSION: A history of pelvic inflammatory disease is associated with an increased risk of epithelial ovarian cancer and a dose-response relationship is evident. Histotype-specific analyses show an association with increased risk of serous epithelial ovarian cancer and high-grade serous carcinoma and potentially also with clear cell carcinoma, but there is no significant association with other histotypes. Infection and inflammation of the upper reproductive tract might have serious long-term consequences, including epithelial ovarian cancer.

Growing rods in meningomyelocele lead to increased risk for complications in comparison with fusion; a retrospective study of 30 patients treated for at the University Hospital of Uppsala.

PURPOSE: To compare the complication rates of two different types of posterior instrumentation in patients with MMC, namely, definitive fusion and fusionless surgery (growing rods). METHODS: Single-center retrospective study of 30 MMC patients that underwent posterior instrumentation for deformity (scoliosis and/or kyphosis) treatment from 2008 until 2020. The patients were grouped based on whether they received definitive fusion or a growth-accommodating system, whether they had a complication that led to early surgery, osteotomy or non-osteotomy. Number of major operations, Cobb angle correction and perioperative blood loss were the outcomes. RESULTS: 18 patients received a growing system and 12 were fused at index surgery. The growing system group underwent a mean of 2.38 (± 1.03) surgeries versus 1.91 (± 2.27) in the fusion group, p = 0.01. If an early revision was necessitated due to a complication, then the number of major surgeries per patient was 3.37 (± 2.44) versus 1.77 (± 0.97) in the group that did not undergo an early revision, p = 0.01. Four patients developed a superficial and six a deep wound infection, while loosening/breakage occurred in 10 patients. The Cobb angle was improved from a mean of 69 to 22 degrees postoperatively. Osteotomy did not lead to an increase in perioperative blood loss or number of major operations. CONCLUSION: Growing systems had more major operations in comparison with fusion surgery and early revision surgery led to higher numbers of major operations per patient; these differences were statistically significant. Definitive fusion at index surgery might be the better option in some MMC patients with a high-risk profile.

The determinants of postpartum contraceptive use in Nigeria.

Introduction: Postpartum contraception is vital for maternal and child health, and reduces the risk of infant mortality. The Health Belief Model (HBM) is a widely accepted framework for exploring health behaviors, such as contraceptive use. Therefore, this study aimed to investigate the factors influencing postpartum contraceptive use in Nigeria and to contextualize the findings within the framework of the HBM. Methods: This study was a secondary analysis of cross-sectional data collected from the Demographic Health Survey conducted in Nigeria (NDHS). In total, 28,041 women were included in this study. Self-reported contraceptive use was the outcome, while the explanatory variables included maternal age, place of residence, region of residence, religion, marital status, educational level, household wealth quintiles, knowledge of the ovulatory cycle, decision-maker for health care, and distance to health care facilities. Descriptive statistics and multivariate logistic regression were used to summarize and identify factors influencing postpartum contraceptive use. The HBM was used to discuss the main findings. Results: The prevalence of postpartum contraceptive use in Nigeria is 27%. Our findings showed that the odds of using contraceptives during the postpartum period were higher among women who knew their ovulation cycles, lived in urban areas in the southern region, had no distance barriers to health care, and were 25-49 years old. Education, wealth, and marital status also increase the odds of contraceptive use. However, women who lived in the northeast and northwest regions or shared decision-making with their partners had lower odds. Conclusion: This study highlights the need for region-specific and age-focused interventions to increase contraceptive use in Nigeria. Additionally, increasing accessibility and affordability of contraceptives for younger and economically disadvantaged women, along with promoting women's autonomy in decision-making, can further enhance contraceptive use across Nigeria.

Reliability and validity testing of team emergency assessment measure in a distributed team context.

Medical multi-professional teams are increasingly collaborating via telemedicine. In distributed team settings, members are geographically separated and collaborate through technology. Developing improved training strategies for distributed teams and finding appropriate instruments to assess team performance is necessary. The Team Emergency Assessment Measure (TEAM), an instrument validated in traditional collocated acute-care settings, was tested for validity and reliability in this study when used for distributed teams. Three raters assessed video recordings of simulated team training scenarios (n = 18) among teams with varying levels of proficiency working with a remotely located physician via telemedicine. Inter-rater reliability, determined by intraclass correlation, was 0.74-0.92 on the TEAM instrument's three domains of leadership, teamwork, and task management. Internal consistency (Cronbach's alpha) ranged between 0.89-0.97 for the various domains. Predictive validity was established by comparing scores with proficiency levels. Finally, concurrent validity was established by high correlations, >0.92, between scores in the three TEAM domains and the teams' overall performance. Our results indicate that TEAM can be used in distributed acute-care team settings and consequently applied in future-directed learning and research on distributed healthcare teams.

Is ultra-hypo-fractionated radiotherapy more cost-effective relative to conventional fractionation in treatment of prostate cancer? A cost-utility analysis alongside a randomized HYPO-RT-PC trial.

BACKGROUND: Economic evidence for comparing low fraction with ultra-hypo fractionated (UHF) radiation therapy in the treatment of intermediate-to-high-risk prostate cancer (PC) is lacking, especially in Europe. This study presents an economic evaluation performed alongside an ongoing clinical trial. AIM: To investigate up to 6 years' follow-up whether conventional fractionation (CF, 78.0 Gy in 39 fractions, 5 days per week for 8 weeks) is more cost-effective than UHF (42.7 Gy in 7 fractions, 3 days per week for 2.5 weeks inclusive of 2 weekends) radiotherapy in treatment for patients with intermediate-to-high-risk PC. METHOD: HYPO-RT-PC trial is an open-label, randomized, multicenter (10 in Sweden; 2 in Denmark) phase-3 trial. Patients from Sweden (CF 434; UHF 445) were included in this study. The trial database was linked to the National Patient Registry (NPR). Costs for inpatient/non-primary outpatient care for each episode were retrieved. For calculating Quality-adjusted life years (QALYs), the EORTC QLQ-C30 questionnaire was mapped to the EQ-5D-3L index. Multivariable regression analyses were used to compare the difference in costs and QALYs, adjusting for age and baseline costs, and health status. The confidence interval for the difference in costs, QALYs and incremental cost-effectiveness ratio effectiveness ratio (ICER) was estimated by the bootstrap percentile method. RESULTS: No significant differences were found in ICER between the two arms after 6 years of follow-up. CONCLUSION: The current study did not support that the ultra-hypo-fractionated treatment was more cost-effective than the conventional fraction treatment up to the sixth year of the trial.

Preoperative MRI and Intraoperative Monitoring Differentially Prevent Neurological Sequelae in Idiopathic Scoliosis Surgical Correction, While Curves >70 Degrees Increase the Risk of Neurophysiological Incidences

The aim was to investigate the role of preoperative magnetic resonance imaging (MRI) and intraoperative monitoring (IOM) in the prevention of correction-related complications in idiopathic scoliosis (IS). We conducted a retrospective case study of 129 patients with juvenile and adolescent IS. The operations took place between 2005 and 2018 in Uppsala University Hospital. Data from MRI scans and IOM were collected. The patients were divided into groups depending on Lenke's classification, sex, major curve (MC) size, and onset age. Neurophysiological incidences were reported in ten patients (7.8%), while nine of them had no signs of intraspinal pathology. Six patients (4.7%) had transient incidences; however, in four patients (3.1%), an intervention was required for the normalization of action potentials. Three of them had an MC >70 degrees, which was significantly higher than the expected value. Eight patients (6.1%) had intraspinal pathologies, and two of them (1.5%) underwent decompression. We suggest the continuation of MRI screening preoperatively and, most importantly, the use of IOM. In three cases with no signs of pathology in the MRI, IOM prevented possible neurological injuries. MCs >70 degrees should be considered a risk factor for the occurrence of neurophysiological deficiencies that require action to be normalized.

Open-air storage with and without composting as post-treatment methods to degrade pharmaceutical residues in anaerobically digested and dewatered sewage sludge.

Over a period of 12 months, the fate of three hormones, 12 antibiotics and 30 pharmaceutically active substances (PhACs) was investigated during open-air storage without and with composting of anaerobically digested and dewatered sewage sludge. The effect of oxidation conditions during storage on degradation of hormones and PhACs in the sludge biomass was also examined. Under summer and winter conditions in Uppsala County, Sweden, two field-scale sludge windrows were constructed: open-air storage of sewage sludge windrow without composting (NO-COM)) and open-air storage windrow with composting (COM). NO-COM achieved effective removal of ∑Hormones (85%) and ∑Antibiotics (95%), but lower removal of ∑PhACs (34%), during the study year. The top layers of the sludge pile had significantly lower concentrations of ∑PhACs (3100-5100 ng/g ash) than deeper layers (8000-11,000 ng/g ash). After one year of composting, the degradation in the COM windrow resulted in concentrations of ∑Hormones (

Perceived changes in capability during the COVID-19 pandemic: A Swedish cross-sectional study from June 2020.

AIMS: Measures against COVID-19 potentially impact quality of life in different ways. The capability approach by Amartya Sen with a broad and consistent framework for measuring quality of life is suited to capture the various consequences. We aimed to examine (a) whether individuals experienced change in 10 capability dimensions during the first half of 2020, (b) which dimensions were affected most, and (c) whether changes were unequally distributed in terms of gender, education, income, geography, housing, living situation and place of birth. METHODS: We assessed self-reported capability change in Sweden in 10 capability dimensions in a cross-sectional online survey among 500 participants on a five-item Likert scale. We analysed the distribution of answers by comparing the balance of positive and negative perceived changes and used mixed effects logistic regression to examine associations with background characteristics of the participants. RESULTS: Reported perceived negative changes outweighed positive changes, and a higher proportion stated negative perceived changes if they also stated having low capability in the same dimension. In the capabilities of financial situation, political resources and health, the proportions of perceived negative change were highest. Odds for perceived negative change compared to no or positive change were higher for lower incomes, living in smaller municipalities compared to living in medium-sized municipalities, being born outside Europe, living in the south of Sweden, and renting instead of owning housing. CONCLUSIONS: Self-reported negative capability change, and associated inequalities related to socioeconomic position, place of birth and regional residence should be of concern for policymakers.

What Is Commensality? A Critical Discussion of an Expanding Research Field.

Commensality (the act of eating together) is studied in a range of disciplines and often considered important for social communion, order, health and well-being, while simultaneously being understood as in decline (especially the family meal). However, such claims are also contested in various ways. In this paper, we discuss the expanding field of commensality research and critically reflect on the debates surrounding its social functions, including its role in public health. We illuminate the deep social and cultural significance of commensality, through time and space, and conclude that whether or not commensality is the preferred social form of eating for any given individual, it is difficult to escape its sociocultural desirability and idealization. As a cross-cultural phenomenon in both past, present, and future, we suggest that commensality deserves further research. This includes commensality as a research topic in itself and as an entry point to unveil different dimensions of social relations between people, as well as interactions between humans and material objects.

The Inverse Association of Body Mass Index with Lung Cancer: Exploring Residual Confounding, Metabolic Aberrations and Within-Person Variability in Smoking.

BACKGROUND: The inverse observational association between body mass index (BMI) and lung cancer risk remains unclear. We assessed whether the association is explained by metabolic aberrations, residual confounding, and within-person variability in smoking, and compared against other smoking-related cancers. METHODS: We investigated the association between BMI, and its combination with a metabolic score (MS) of mid-blood pressure, glucose, and triglycerides, with lung cancer and other smoking-related cancers in 778,828 individuals. We used Cox regression, adjusted and corrected for within-person variability in smoking (status/pack-years), calculated from 600,201 measurements in 221,958 participants. RESULTS: Over a median follow-up of 20 years, 20,242 smoking-related cancers (6,735 lung cancers) were recorded. Despite adjustment and correction for substantial within-person variability in smoking, BMI remained inversely associated with lung cancer [HR per standard deviation increase, 0.87 (95% confidence interval 0.85-0.89)]. Individuals with BMI less than 25 kg/m2 and high MS had the highest risk [HR 1.52 (1.44-1.60) vs. BMI ≥25 with low MS]. These associations were weaker and nonsignificant among nonsmokers. Similar associations were observed for head and neck cancers and esophageal squamous cell carcinoma, whereas for other smoking-related cancers, we generally observed positive associations with BMI. CONCLUSIONS: The increased lung cancer risk with low BMI and high MS is unlikely due to residual confounding and within-person variability in smoking. However, similar results for other cancers strongly related to smoking suggest a remaining, unknown, effect of smoking. IMPACT: Extensive smoking-adjustments may not capture all the effects of smoking on the relationship between obesity-related factors and risk of smoking-related cancers.

Beneficial Effect of Consecutive Screening Mammography Examinations on Mortality from Breast Cancer: A Prospective Study.

Background Previously, the risk of death from breast cancer was analyzed for women participating versus those not participating in the last screening examination before breast cancer diagnosis. Consecutive attendance patterns may further refine estimates. Purpose To estimate the effect of participation in successive mammographic screening examinations on breast cancer mortality. Materials and Methods Participation data for Swedish women eligible for screening mammography in nine counties from 1992 to 2016 were linked with data from registries and regional cancer centers for breast cancer diagnosis, cause, and date of death (Uppsala University ethics committee registration number: 2017/147). Incidence-based breast cancer mortality was calculated by whether the women had participated in the most recent screening examination prior to diagnosis only (intermittent participants), the penultimate screening examination only (lapsed participants), both examinations (serial participants), or neither examination (serial nonparticipants). Rates were analyzed with Poisson regression. We also analyzed incidence of breast cancers proving fatal within 10 years. Results Data were available for a total average population of 549 091 women (average age, 58.9 years ± 6.7 [standard deviation]). The numbers of participants in the four groups were as follows: serial participants, 392 135; intermittent participants, 41 746; lapsed participants, 30 945; and serial nonparticipants, 84 265. Serial participants had a 49% lower risk of breast cancer mortality (relative risk [RR], 0.51; 95% CI: 0.48, 0.55; P < .001) and a 50% lower risk of death from breast cancer within 10 years of diagnosis (RR, 0.50; 95% CI: 0.46, 0.55; P < .001) than serial nonparticipants. Lapsed and intermittent participants had a smaller reduction. Serial participants had significantly lower risk of both outcomes than lapsed or intermittent participants. Analyses correcting for potential biases made little difference to the results. Conclusion Women participating in the last two breast cancer screening examinations prior to breast cancer diagnosis had the largest reduction in breast cancer death. Missing either one of the last two examinations conferred a significantly higher risk. Published under a CC BY 4.0 license. Online supplemental material is available for this article. See also the editorial by Stephen A. Feig in this issue.

Temporal and cultural limits of privacy in smartphone app usage.

Large-scale collection of human behavioural data by companies raises serious privacy concerns. We show that behaviour captured in the form of application usage data collected from smartphones is highly unique even in large datasets encompassing millions of individuals. This makes behaviour-based re-identification of users across datasets possible. We study 12 months of data from 3.5 million people from 33 countries and show that although four apps are enough to uniquely re-identify 91.2% of individuals using a simple strategy based on public information, there are considerable seasonal and cultural variations in re-identification rates. We find that people have more unique app-fingerprints during summer months making it easier to re-identify them. Further, we find significant variations in uniqueness across countries, and reveal that American users are the easiest to re-identify, while Finns have the least unique app-fingerprints. We show that differences across countries can largely be explained by two characteristics of the country specific app-ecosystems: the popularity distribution and the size of app-fingerprints. Our work highlights problems with current policies intended to protect user privacy and emphasizes that policies cannot directly be ported between countries. We anticipate this will nuance the discussion around re-identifiability in digital datasets and improve digital privacy.

Early detection of breast cancer rectifies inequality of breast cancer outcomes.

OBJECTIVES: To explain apparent differences among mammography screening services in Sweden using individual data on participation in screening and with breast cancer-specific survival as an outcome. METHODS: We analysed breast cancer survival data from the Swedish Cancer Register on breast cancer cases from nine Swedish counties diagnosed in women eligible for screening. Data were available on 38,278 breast cancers diagnosed and 4312 breast cancer deaths. Survival to death from breast cancer was estimated using the Kaplan-Meier estimate, for all cases in each county, and separately for cases of women participating and not participating in their last invitation to screening. Formal statistical comparisons of survival were made using proportional hazards regression. RESULTS: All counties showed a reduction in the hazard of breast cancer death with participation in screening, but the reductions for individual counties varied substantially, ranging from 51% (95% confidence interval 46-55%) to 81% (95% confidence interval 74-85%). Survival rates in nonparticipating women ranged from 53% (95% confidence interval 40-65%) to 74% (95% confidence interval 72-77%), while the corresponding survival in women participating in screening varied from 80% (95% confidence interval 77-84%) to 86% (95% confidence interval 83-88%), a considerably narrower range. CONCLUSIONS: Differences among counties in the effect of screening on breast cancer outcomes were mainly due to variation in survival in women not participating in screening. Screening conferred similarly high survival rates in all counties. This indicates that the performance of screening services was similar across counties and that detection and treatment of breast cancer in early-stage reduces inequalities in breast cancer outcome.

Breast cancer screening with mammography in women aged 40-49 years: Impact of length of screening interval on effectiveness of the program.

OBJECTIVES: To estimate the impact on the effectiveness of Swedish breast cancer screening program in women aged 40-49 years of shortening the screening interval from 21 months to 18 or 12 months. METHODS: The reduction in breast cancer mortality among participants in screening with mammography was previously estimated in the Swedish SCReening of Young women (SCRY) study to be 29%. The expected increased effectiveness with a hypothetical shorter screening interval than the average of 21 months in SCRY was calculated using data about the women who died from breast cancer even though they participated in the SCRY program. RESULTS: During the study period, 547 women who participated in the index screening round died from breast cancer. Shortening the screening interval to 18 months led to an improved effectiveness of 0.7-3.9% considering interval cancers only and of 1.3-7.6% considering screening-detected cancers only, and for both interval and screening-detected cancers the improvement was 1.9-11.5% when the assumed mortality reduction for the deceased cases varied from 5% to 30%. Shortening the screening interval to 12 months increased the effectiveness by 1.6-9.8% for interval cancers and by 2.9-17.4% for both interval and screening-detected cancers. CONCLUSION: Shortening the screening interval for women aged 40-49 years to 18 or 12 months might further reduce the breast cancer mortality rate.

Effectiveness of Population-Based Service Screening with Mammography for Women Aged 70-74 Years in Sweden.

BACKGROUND: Consensus has been reached on the effectiveness of inviting women aged 50 to 69 years to mammography screening, but for older women, the evidence is scarce. The aim of this study was to estimate the marginal effectiveness of inviting women to mammography screening with an upper age limit of 74 years versus stopping at age 69 using data from the Swedish service-screening program. METHODS: A cohort design was used to compare the breast cancer mortality in the period 1986 to 2012 between geographic areas and periods where women were invited to screening up to the age of 74 years (study group) with those where women were invited up to age 69 (control group). The study group and the control group were compared using the incidence-based breast cancer mortality rate ratio where only breast cancer deaths in cases diagnosed at 70 to 74 years of age were counted. RESULTS: After 20 years of follow-up, there were 1,040 and 1,173 breast cancer deaths in the study and the control group, respectively. The breast cancer mortality rate ratio for women invited up to age 74 versus women invited up to age 69 was 0.80 [95% confidence interval (CI): 0.75-0.85] after bias adjustments. The corresponding rate ratio for participating women was 0.73 (95% CI: 0.66-0.81). CONCLUSIONS: Continuing to screen women up to 74 years of age is effective compared with stopping screening at 69 years. IMPACT: This large long-term study will add to the knowledge of the effect of mammography screening for women 70 to 74 years.

Mammography screening reduces rates of advanced and fatal breast cancers: Results in 549,091 women.

BACKGROUND: It is of paramount importance to evaluate the impact of participation in organized mammography service screening independently from changes in breast cancer treatment. This can be done by measuring the incidence of fatal breast cancer, which is based on the date of diagnosis and not on the date of death. METHODS: Among 549,091 women, covering approximately 30% of the Swedish screening-eligible population, the authors calculated the incidence rates of 2473 breast cancers that were fatal within 10 years after diagnosis and the incidence rates of 9737 advanced breast cancers. Data regarding each breast cancer diagnosis and the cause and date of death of each breast cancer case were gathered from national Swedish registries. Tumor characteristics were collected from regional cancer centers. Aggregated data concerning invitation and participation were provided by Sectra Medical Systems AB. Incidence rates were analyzed using Poisson regression. RESULTS: Women who participated in mammography screening had a statistically significant 41% reduction in their risk of dying of breast cancer within 10 years (relative risk, 0.59; 95% CI, 0.51-0.68 [P < .001]) and a 25% reduction in the rate of advanced breast cancers (relative risk, 0.75; 95% CI, 0.66-0.84 [P < .001]). CONCLUSIONS: Substantial reductions in the incidence rate of breast cancers that were fatal within 10 years after diagnosis and in the advanced breast cancer rate were found in this contemporaneous comparison of women participating versus those not participating in screening. These benefits appeared to be independent of recent changes in treatment regimens.

Linear age-course effects on the associations between body mass index, triglycerides, and female breast and male liver cancer risk: An internal replication study of 800,000 individuals.

Apart from the consistently observed differential association between obesity and breast cancer risk by menopausal status, the associations between obesity and other metabolic imbalances with risks of cancers have not been systematically investigated across the age-course. We created two random 50-50% cohorts from six European cohorts comprising 813,927 individuals. In the "discovery cohort", we used Cox regression with attained age as time-scale and tested interactions between body mass index (BMI), blood pressure, plasma glucose, triglycerides and cholesterol, and attained age in relation to cancer risk. Results with a p-value below 0.05 were additionally tested in the "replication cohort" where a replicated result was considered evidence of a linear interaction with attained age. These findings were investigated by flexible parametric survival models for any age-plateaus in their shape of associations with cancer risk across age. Consistent with other studies, BMI was negatively related to breast cancer risk (n cases = 11,723) among younger (premenopausal) women. However, the association remained negative for several years after menopause and, although gradually weakening over age, the association became positive only at 62 years of age. This linear and positive age-interaction was also found for triglycerides and breast cancer, and for BMI and triglycerides in relation to liver cancer among men (n cases = 444). These findings are unlikely to be due to chance owing to the replication. The linear age-interactions in breast cancer may suggest an influence by other age-related factors than menopause; however, further investigation of age-related effect modifiers in both breast and liver cancer is needed.

Pharmaceuticals in source separated sanitation systems: Fecal sludge and blackwater treatment.

This study investigated, for the first time, the occurrence and fate of 29 multiple-class pharmaceuticals (PhACs) in two source separated sanitation systems based on: (i) batch experiments for the anaerobic digestion (AD) of fecal sludge under mesophilic (37 °C) and thermophilic (52 °C) conditions, and (ii) a full-scale blackwater treatment plant using wet composting and sanitation with urea addition. Results revealed high concentrations of PhACs in raw fecal sludge and blackwater samples, with concentrations up to hundreds of µg L-1 and µg kg-1 dry weight (dw) in liquid and solid fractions, respectively. For mesophilic and thermophilic treatments in the batch experiments, average PhACs removal rates of 31% and 45%, respectively, were observed. The average removal efficiency was slightly better for the full-scale blackwater treatment, with 49% average removal, and few compounds, such as atenolol, valsartan and hydrochlorothiazide, showed almost complete degradation. In the AD treatments, no significant differences were observed between mesophilic and thermophilic conditions. For the full-scale blackwater treatment, the aerobic wet composting step proved to be the most efficient in PhACs reduction, while urea addition had an almost negligible effect for most PhACs, except for citalopram, venlafaxine, oxazepam, valsartan and atorvastatin, for which minor reductions (on average 25%) were observed. Even though both treatment systems reduced initial PhACs loads considerably, significant PhAC concentrations remained in the treated effluents, indicating that fecal sludge and blackwater fertilizations could be a relevant vector for dissemination of PhACs into agricultural fields and thus the environment.