The screening histories of women with invasive cervical cancer, Connecticut.

OBJECTIVES: Each case of a continuous series of invasive cervical cancer cases was studied with a structured review procedure conducted by an expert panel to assess the reason that it was not detected before it became invasive. METHODS: All cases of invasive cervical cancer diagnosed in a 5-year period among Connecticut residents were identified; a screening history and screening outcome were obtained for 72% (481 of 664). RESULTS: Two hundred fifty women (51.9%) had suboptimal screening. One hundred thirty-seven women (28.5%) had never had a screening test, and their mean age was greater than that of the rest of the study population (64.5 years vs 46.5 years). Of the 344 women who had ever had a Pap test, 113 (32.8%) had their last Pap test 5 or more years before their diagnosis of invasive cancer; 52 (15.1%) were not followed up properly; 33 (9.6%) had their last smear misread as normal; and 118 (34.3%) developed cervical cancer within 3 years of their last Pap test. CONCLUSIONS: Physicians, nurses, and other care providers need to ensure that woman have timely and accurate screening with proper follow-up, make increased efforts to reach older women, and improve quality control of Pap smear readings.

Early menopause in long-term survivors of cancer during adolescence.

OBJECTIVE: We attempted to investigate the risk of early menopause after treatment for cancer during childhood or adolescence. STUDY DESIGN: We interviewed 1067 women in whom cancer was diagnosed before age 20, who were at least 5-year survivors, and who were still menstruating at age 21. Self-reported menopause status in survivors was compared with that in 1599 control women. RESULTS: Cancer survivors, with disease diagnosed between ages 13 and 19, had a risk of menopause four times greater than that of controls during the ages 21 to 25; the risk relative to controls declined thereafter. Significantly increased relative risks of menopause during the early 20s occurred after treatment with either radiotherapy alone (relative risk 3.7) or alkylating agents alone (relative risk 9.2). During ages 21 to 25 the risk of menopause increased 27-fold for women treated with both radiation below the diaphragm and alkylating agent chemotherapy. By age 31, 42% of these women had reached menopause compared with 5% for controls. CONCLUSION: Treatment for cancer during adolescence carries a substantial risk for early menopause among women still menstruating at age 21. Increasing use of radiation and chemotherapy, together with the continued trend toward delayed childbearing, suggests that these women should be made aware of their smaller window of fertility so that they can plan their families accordingly.

Histologic and clinical characteristics associated with rapidly progressive invasive cervical cancer: a preliminary report from the Yale Cancer Control Research Unit.

Histologic and clinical characteristics associated with rapidly progressive invasive cervical cancer are presented in this preliminary report from a population-based study involving all patients in Connecticut diagnosed with cervical cancer from March 1, 1985. Rapidly progressive invasive cervical cancer, i.e., invasive cancer diagnosed within three years of a true negative Pap smear, is more likely to occur in younger women with high annual incomes (61 percent greater than $40,000) who report a greater frequency of benign gynecologic conditions (uterine leiomyomata, vaginitis) compared to a control cervical cancer group. These preliminary data suggest that as many as 35 percent of the rapidly progressive cervical cancers are likely to be adenocarcinomas. Because they are mostly endocervical in origin, they may not be detected cytologically if scrapers or cotton swabs are used to sample the endocervical canal. New cytologic screening techniques using brushes may identify these lesions earlier and should routinely be employed in cytologic screening for cervical neoplasia. The difficulty in early detection of this form of the disease requires that physicians rapidly assess patients with unexplained pelvic and lower abdominal pain, vaginal discharge, or abnormal vaginal bleeding since early recognition is the only chance for cure. Further analyses of this population of women will be made to identify additional risk factors when the study data are complete.

Reproductive problems and birth defects in survivors of Wilms' tumor and their relatives.

In a retrospective cohort study of 47 Wilms' tumor survivors and their 77 sibling controls, female survivors had a fourfold excess risk (risk ratio, 4.1; 95% confidence interval, 1.7-10.1) for any adverse livebirth outcome, including birth defects, compared with their sibling controls. Wives of male survivors had no apparent excess risk for problem pregnancies. The families had a number of severe reproductive problems and major birth defects, such as primary amenorrhea in two survivors, bicornuate uterus in two survivors and one control, and mental retardation in one male survivor and a male control. The son of a female survivor died after bilateral Wilms' tumors. Birth defects in the offspring of female survivors are compatible either with intrauterine constraint, possibly due to radiation-induced fibrosis or with the complex of malformations associated with Wilms' tumor. Female survivors of Wilms' tumor appear to be at increased risk for a variety of reproductive problems, from sterility to fetal loss, early delivery, and birth defects in offspring. Furthermore, relatives of survivors of Wilms' tumor may be at risk of having associated birth defects, with clinically significant consequences.

Educational achievement of long-term survivors of childhood and adolescent cancer.

In a retrospective cohort study, the level of education attained by 2,283 long-term survivors of childhood and adolescent cancer was investigated and compared with that of 3,270 sibling controls. Survivors of central nervous system tumors were significantly less likely than controls to complete eight grades of school or, if they completed high school, to enter college. No significant differences in educational achievement were found for survivors of non-central nervous system cancers. The educational deficit of survivors of brain tumors was especially striking for tumors of the ventricles or cerebral hemispheres, and the deficit was more severe for those treated with radiation therapy than by surgery alone. Early age at diagnosis of a central nervous system tumor was associated with a larger educational deficit than late age at diagnosis. These findings are reassuring for the majority of long-term survivors of childhood and adolescent cancers given therapies used prior to 1975.

Bladder cancer and occupational exposure to leather.

A large case-control study of bladder cancer (2982 cases; 5782 controls) included information about occupational exposure to leather. Occupational histories of exposed white study subjects were reviewed and 150 were determined to have had "true" on the job exposure to leather. The odds ratio estimate (OR) of bladder cancer associated with such exposure in white subjects (n = 8063) was 1.4 (95% confidence limits = 1.0, 1.9) after adjustment for sex, age, and cigarette smoking. The risk was highest in those first employed in a leather job before 1945, although no dose-response relation with duration of leather employment was found. Subjects employed in "dusty" leather jobs had a slightly higher risk than those with other types of leather jobs. Our results are consistent with reports of an increased risk of bladder cancer associated with exposure to leather. Although the agents responsible have not been identified, our findings of an increased risk associated with exposure in the earlier years of this century and in dusty jobs suggest that leather dusts may be important.

Abortion before first livebirth and risk of breast cancer.

The present study examined the association between abortion prior to a first livebirth and breast cancer risk among a cohort of 3,315 women who had been delivered of liveborn children between 1946 and 1965 in a group of private gynaecology practices in Connecticut and followed through 1980 for the incidence of cancer. Among women with one livebirth at the time of cohort identification, a spontaneous abortion before this livebirth was associated with a 3.5-fold increase in the risk of breast cancer. The elevation in risk was independent of some of the major risk factors of breast cancer and became more pronounced as the number of years since the abortion increased.

Psychosocial consequences of childhood and adolescent cancer survival.

A Connecticut Addendum to a multi-center National Cancer Institute study was developed to investigate psychosocial effects of long-term childhood and adolescent cancer survival. Cases (450), drawn from the files of the Connecticut Tumor Registry and 587 of their siblings were located and interviewed. Overall response rate was 84%. The frequency of lifetime major depression in survivors (males, 15%; females, 22%) did not appear to differ from that of their siblings (males, 12%; females, 24%) and was similar to those reported in the literature for the general population. The usual correlates of depression (sex, marital status, perception of health) were observed, independent of a history of a childhood malignancy. There were no differences in the reported frequencies of suicide attempts, running away or psychiatric hospitalizations for either sex. Eighty percent of the male survivors were rejected from the armed forces, 13% from college and 32% from employment. These values were significantly higher than those of the male siblings. Female survivors were significantly more likely than their sisters to be denied entrance into the military (p less than 0.05), but no differences were observed between females with respect to college or employment. Both sexes had more difficulty obtaining health and life insurance than their siblings (p less than 0.0001). Although survivors of childhood and adolescent cancer do not seem to be at excess risk for major depression, they do appear to have difficulty attaining certain major socioeconomic goals.

The relationship of cancer incidence to terrestrial radiation and population density in Connecticut, 1935-1974.

The relationship of cancer incidence to terrestrial radiation and population density was investigated. Cancer incidence was obtained using 40 years of age-standardized data from the Connecticut Tumor Registry, and environmental radiation was estimated using data from an airborne gamma radiation survey of the entire state. These variables were examined ecologically, using the 169 towns of the state as the analytic units in a weighted regression analysis. The study design involves a large population base in a state having relatively high terrestrial radiation exposure levels overall and reasonable variation in exposure between towns. For all cancer combined, only one of the eight sex-specific analyses by decade yielded a significant radiation regression coefficient, and this was negative. In the sex- and site-specific analyses, almost all the coefficients for radiation were not significantly different from zero. In contrast, significant positive relationships of cancer incidence with population density were found for all cancer, for cancer of the lung for both sexes, for stomach, colonic, and prostatic cancer for males, and for lymphomas, thyroid, breast, and ovarian cancer for females. Both the radiation and population density relationships were adjusted for socioeconomic status. Socioeconomic status was significantly negatively associated with stomach and lung cancer in males and with cervical cancer in females; it was also positively associated with lymphomas and breast cancer in females. A power calculation revealed that, despite the relatively large size of this study, there was only a small probability of detecting a radiation effect of the strength anticipated from previous estimates.

Bladder tumor incidence among workers exposed to benzidine: a thirty-year follow-up.

Linkage with records of the Connecticut Tumor Registry was used to determine cancer incidence in a cohort of workers (n = 984) at a benzidine manufacturing facility. Compared to the findings for the Connecticut population, there was a statistically significant excess of bladder tumor among male cohort members [standardized incidence ratio (SIR) = 343; 95% confidence limits (CL) = 148, 676; n = 830], which was confined to those with the highest estimated level of benzidine exposure (SIR = 1,303; CL = 479, 2,839; n = 105). No significantly elevated risks were found for cancers at other anatomic sites in men or at any anatomic sites in women; nor was there any pattern of increasing risk with increasing benzidine exposure for sites other than bladder. In addition, the elevated bladder cancer risk was greater for men first employed during the earliest years of the plant, namely, 1945-49 (SIR = 976; CL = 262, 2,498) as compared to those first employed in 1950-54 (SIR = 213; CL = 3, 1,184) after equalization of duration of follow-up. These results suggest that the major preventive measures instituted around 1950 may have reduced bladder cancer risk in this plant.

Cancer risk among women exposed to exogenous estrogens during pregnancy.

A cohort of 3,139 obstetric patients, who delivered children between 1946 and 1965, was followed retrospectively to assess the relationship between exposure to diethylstilbestrol [(DES) CAS: 56-53-1; alpha, alpha'-diethyl-4,4'-stilbenediol] or other estrogenic substances during pregnancy and subsequent cancer incidence. Among the 1,531 women exposed to DES, the relative risk (RR) for all cancers was 1.46 [95% confidence interval (CI), 1.07-2.00]. The RR for cancers of the breast, cervix, and ovary were 1.37 (adjusted), 1.40, and 2.83, respectively, but none of these estimates was statistically significant. For breast cancer an RR in excess of 2.28 can be excluded, with 95% CI for doses averaging 2,100 mg. Within the exposed group there was no evidence for a dose-response relationship.

Cancer incidence among cosmetologists.

This cohort study examined cancer incidence in 13,650 Connecticut cosmetologists who had held licenses for 5 years or more and had begun hairdressing school prior to January 1, 1966. Cancer incidence rates for the general Connecticut population, 1935-78, were compared with those for 11,845 female and 1,805 male cosmetologists. The females had a standardized cancer incidence ratio (SIR) of 112 (P less than .01). A significant excess of lung cancer (SIR = 141) and excesses of brain (SIR = 168) and ovarian cancer (SIR = 134) of borderline significance were observed. No significant cancer risk was evident for female cosmetologists licensed since 1935, even for those with 35 years or more of follow-up, although the SIRs for brain cancer, lymphoma, and leukemia were elevated. Female cosmetologists who entered the profession between 1925 and 1934, however, experienced a significant overall cancer incidence (SIR = 129) and significant excesses of respiratory, breast, corpus uterine, and ovarian cancers. Those with 35 years or more from time of first license appeared to be at the highest risk. Among males the overall cancer incidence rate was close to that expected (SIR = 105). Smoking habits and reproductive factors that could not be taken into account may explain some of the excesses among females. Although no specific occupational agent could be identified, the excess numbers of leukemias in females and brain cancers among males and females merit continued surveillance.

Mesothelioma in Connecticut, 1955-1977. Occupational and geographic associations.

All cases of malignant mesothelioma (201) and other primary malignant pleural tumors (19) reported to the Connecticut Tumor Registry from 1955 through 1977 were studied in an attempt to identify high-risk jobs, industries and geographic locations and to estimate the risk attributable to asbestos exposure in the workplace. Data were obtained from hospital records, death certificates and city directories for cases, case spouses and a random sample (604) of Connecticut decedents (1955-1975). Three cases involved histories of work in asbestos products manufacture, but there was no evidence of residential risk in that geographic area. Relative risk (RR) for carpenters and cabinetmakers was 2.25 (p less than .05); for plumbers and pipefitters, 3.87 (p less than .05); and for persons "ever employed" in the rubber industry, 5.08 (p less than .01). Occupational exposure was indicated in 85% of the cases; attributable risk (AR) was 36%. Risk increased with greater exposure and older age. AR was 81% in men aged 70 to 89 years at diagnosis. Reduction of unnecessary occupational asbestos exposure remains the highest public health priority.

Coffee drinking and bladder cancer in Connecticut.

The association between coffee consumption and bladder cancer is investigated in a population-based case-control study carried out in Connecticut during 1978-1979. Measures of coffee consumption employed include total weekly cups, years of consumption, and more than seven cups per week, in addition to use frequencies of specific coffee types. After adjustment for age and cigarette smoking, a significant elevation in risk for consuming more than seven cups weekly was found for males (odds ratio = 1.5) but not for females (odds ratio = 1.0); there was also some evidence of a dose-response relationship in males. Among nonsmokers of both sexes combined, the odds ratio for more than seven cups per week was 1.9. Male smokers showed age- and smoking-adjusted odds ratios for coffee similar to those of male nonsmokers. Female smokers had a decreased risk for bladder cancer associated with increased coffee consumption which reflects the substantially lowered risk among older (65 years and over) smoking women who may constitute a selected resistant group; odds ratios among younger female smokers were close to 1.0. Males also showed elevated risks associated with consumption of regular (non-decaffeinated) and ground (noninstant) coffees. No relationship with duration of consumption was found.

Trends in the incidence of cancer of the corpus uteri in Connecticut, 1964-1979, in relation to consumption of exogenous estrogens.

The incidence of cancer of the uterine corpus diagnosed in the localized 1964 and 1969. During the next six years, however, it increased substantially, reaching a peak in 1975, followed by an irregular decline through 1979. Women aged 45-64 years showed both the largest increase and the sharpest decline. The incidence of tumors diagnosed with regional or distant spread has been rising slightly but consistently through the period 1970-1979; this upward trend is statistically significant (p less than 0.01). Rates corrected for hysterectomized women not truly at risk are 40-50% higher than uncorrected rates but trends are the same. Explanations which are considered are changes in diagnostic practices and changes in risk factor prevalence. The use of noncontraceptive oral estrogens, a well documented risk factor for endometrial cancer, increased between 1964 and 1975 and then declined sharply through 1979 in the United States. The importance of these compounds in explaining the observed incidence trends is considered in terms of the major time- and stage-specific features of the exogenous estrogen-endometrial cancer association reported in the case-control studies.

Scrotal carcinoma in Connecticut metalworkers: sequel to a study of sinonasal cancer.

An excess risk for sinonasal cancer among Connecticut metalworkers with potential exposure to cutting oils led to the hypothesis of a relationship between the same occupational category and squamous cell carcinoma of the scrotum. Cases of this latter tumor (n = 45) diagnosed in 1935-1973 were identified by the Connecticut Tumor Registry. For decedents, male controls from Connecticut death certificates were matched to decedent cases on age, year of birth, and availability of occupational information; for living subjects, male controls from records of the Connecticut Department of Motor Vehicles were matched on the above variables and town of residence. Death certificates and city directories provided occupational information. For the narrowly defined indicator of cutting oil exposure (toolmaker, setter, set-up man, hardener, polisher, automatic screw machine operator), the odds ratio for squamous cell carcinoma of the scrotum was 4.9, 95% confidence limits (CL): 1.8, 15.9. The broad indicator of cutting oil exposure (not otherwise specified) categories plus machinist and machine operator (not otherwise specified) had an odds ratio of 10.5, 95% CL: 4.0, 36.9 and explained 57% of the cancers. For this broad category, the risk persisted in the most recent time period of diagnosis, 1966-1973 (OR = 18.6). For this broad category, major biases could not be detected when the following additional covariables were taken into account individually where possible: source of occupation, nativity, town of residence, stage at diagnosis, and cause of death. City directory and death certificate information implied that at least 80% of cases in the high risk category worked in the Connecticut region before age 40.