Factors associated with advanced-stage diagnosis of cervical cancer in Estonia: a population-based study.

OBJECTIVES: Cervical cancer (CC) remains a crucial public health issue in Estonia, with high incidence and late diagnosis. The aim of this study was to examine time trends of stage-specific CC incidence in Estonia and factors associated with advanced-stage diagnosis of CC. STUDY DESIGN: This was a nationwide population-based retrospective study. METHODS: Data on CC cases diagnosed in Estonia in 2007-2018 were obtained from the Estonian Cancer Registry, including tumour, nodes, metastases stage at diagnosis. Sociodemographic data were obtained from the Population Registry. To estimate the risk of advanced-stage diagnosis (stages II-IV vs stage I) associated with sociodemographic factors, Poisson regression with robust variance was used to calculate univariate and multivariate prevalence ratios (PR) with 95% confidence intervals (CIs). Time trends of stage-specific CC incidence for 2005-2019 were examined with joinpoint analysis. RESULTS: Incidence of stage I CC showed a significant decline of 4.9% per year since 2007, whereas no change was seen for other stages. Of the 2046 women diagnosed in 2007-2018, 1137 (55.6%) were diagnosed at an advanced stage; this proportion increased from 51% in 2007-2009 to 58% in 2015-2018 (P = 0.004). Multivariate regression analysis showed that advanced-stage diagnosis was associated with age (PR 2.16, 95% CI 1.87-2.49 for women aged ≥75 years compared with those aged 30-44 years), educational level (PR 1.32, 95% CI 1.15-1.51 for women with basic/primary education compared to university education) and marital status (PR 1.14, 95% CI 1.01-1.29 for single women compared to married/cohabiting women). No associations were observed by region of residence or nationality. CONCLUSIONS: To reduce CC mortality, it is crucial to improve prevention and early diagnosis of CC in Estonia through human papillomavirus vaccination and effective and quality-assured screening particularly targeting high-risk groups as well as encouraging symptom awareness and regular check-ups among older women.

European all-cause excess and influenza-attributable mortality in the 2017/18 season: should the burden of influenza B be reconsidered?

OBJECTIVES: Weekly monitoring of European all-cause excess mortality, the EuroMOMO network, observed high excess mortality during the influenza B/Yamagata dominated 2017/18 winter season, especially among elderly. We describe all-cause excess and influenza-attributable mortality during the season 2017/18 in Europe. METHODS: Based on weekly reporting of mortality from 24 European countries or sub-national regions, representing 60% of the European population excluding the Russian and Turkish parts of Europe, we estimated age stratified all-cause excess morality using the EuroMOMO model. In addition, age stratified all-cause influenza-attributable mortality was estimated using the FluMOMO algorithm, incorporating influenza activity based on clinical and virological surveillance data, and adjusting for extreme temperatures. RESULTS: Excess mortality was mainly attributable to influenza activity from December 2017 to April 2018, but also due to exceptionally low temperatures in February-March 2018. The pattern and extent of mortality excess was similar to the previous A(H3N2) dominated seasons, 2014/15 and 2016/17. The 2017/18 overall all-cause influenza-attributable mortality was estimated to be 25.4 (95%CI 25.0-25.8) per 100,000 population; 118.2 (116.4-119.9) for persons aged 65. Extending to the European population this translates into over-all 152,000 deaths. CONCLUSIONS: The high mortality among elderly was unexpected in an influenza B dominated season, which commonly are considered to cause mild illness, mainly among children. Even though A(H3N2) also circulated in the 2017/18 season and may have contributed to the excess mortality among the elderly, the common perception of influenza B only having a modest impact on excess mortality in the older population may need to be reconsidered.

Evolution of severe trauma in Estonia comparing early versus established independence of the state.

PURPOSE: Trauma mechanisms and patterns of severe injuries during the Estonian independence have not been evaluated. The aim of the study was to compare the incidence and outcomes of severe injuries between time periods of early independence from the Soviet Union and the present time. METHODS: After the ethics review board approval, all adult trauma admissions to major trauma facilities in 1993-1994 and 2013-2014 with Injury Severity Score >15 were identified. Data collection included demographics, injury severity variables, interventions, and in-hospital outcomes. Primary outcome was in-hospital mortality. Secondary outcomes included incidence of penetrating trauma, hospital length of stay (HLOS), and in-hospital complications. Primary outcome difference comparing the two time segments was determined using logistic regression analysis. RESULTS: A total of 1064 patients were included, 593 and 471 from 1993-1994 to 2013-2014, respectively. Incidence of penetrating trauma during 1993-1994 was 11.1 % and in 2013-2014 at 6.4 % (p = 0.007). Gunshot injuries constituted 62.1 and 23.3 % of all penetrating trauma in 1993-1994 and 2013-2014, respectively (p < 0.001). The overall mean HLOS was 15.5 ± 19.8 days and did not differ between the periods. The rate of adjusted complications showed a trend for a decreased incidence (adj. p = 0.064). Adjusted mortality rate was 50.3 and 16.4 % during 1993-1994 and 2013-2014, respectively (adj. OR 7.01; 95 % CI 4.69-10.47; p < 0.001). CONCLUSIONS: Effective law enforcement, gun control, evolution of trauma system, and reduction of interpersonal violence have all contributed to a significant decrease in penetrating trauma incidence and all-cause adjusted mortality during the 20 years of Estonian independence.

Methylene blue intra-arterial staining of resected colorectal cancer specimens improves accuracy of nodal staging: A randomized controlled trial.

INTRODUCTION: Metastatic involvement of regional lymph nodes is a major prognostic factor of colorectal cancer, which influences also its treatment strategy. International consensus foresees retrieval of ≥12 lymph nodes from colorectal specimens. The aim of the study was to assess the effect of intra-arterial staining of colorectal specimens with methylene blue on lymph node harvest. MATERIALS AND METHODS: A total of 266 radically operated colorectal cancer patients were randomized into the methylene blue staining and non-staining groups. In the staining group, methylene blue solution was injected into the colorectal specimen's artery after its removal. The specimens were analysed for lymph node count, diameter and metastatic involvement. RESULTS: The median number of lymph nodes was higher in the staining group, 27 (95% CI 23-31%), compared with the control group, 16 (95% CI 14-19, p < 0.001). The number of examined lymph-nodes was ≥12 in 86% of the cases in the staining group and in 69% of the cases in the control group (p = 0.001). In the staining group more small-diameter (≤4 mm) lymph nodes were examined (median number 20.5 vs. 10, p < 0.001). The proportion of patients with metatatic lymph nodes was 42% in the staining group and 43% in the control group (NS). CONCLUSIONS: Methylene blue staining improves significantly staging accuracy through finding more small-diameter lymph nodes. It enables to detect ≥12 lymph nodes in the majority of cases. We recommend routine use of this technique in all colorectal resections with curative intent.

Cancer patient survival in Estonia 1995-2009: time trends and data quality.

BACKGROUND: Survival from most cancers in Estonia has been consistently below European average. The objective of this study was to examine recent survival trends in Estonia and to quantify the effect on survival estimates of the temporary disruption of the Estonian Cancer Registry (ECR) practices in 2001-2007 when death certificates could not be used for case ascertainment. PATIENTS AND METHODS: ECR data on all adult cases of 16 common cancers diagnosed in Estonia during 1995-2008 and followed up for vital status until 2009 were used to estimate relative survival ratios (RSR). We used cohort analysis for patients diagnosed in 1995-1999 and 2000-2004; and period hybrid approach to obtain the most recent estimates (2005-2009). We compared five-year RSRs calculated from data sets with and without death certificate initiated (DCI) cases. RESULTS: A total of 64328 cancer cases were included in survival analysis. Compared with 1995-1999, five-year age-standardized RSR increased 20 percent units for prostate cancer, reaching 76% in 2005-2009. A rise of 10 percent units or more was also seen for non-Hodgkin lymphoma (five-year RSR 51% in 2005-2009), and cancers of rectum (49%), breast (73%) and ovary (37%). The effect of including/excluding DCI cases from survival analysis was small except for lung and pancreatic cancers. CONCLUSIONS: Relative survival continued to increase in Estonia during the first decade of the 21st century, although for many cancers, a gap between Estonia and more affluent countries still exists. Cancer control efforts should aim at the reduction of risk factors amenable to primary prevention, but also at the improvement of early diagnosis and ensuring timely and optimal care to all cancer patients.

Suicides among cancer patients in Estonia: a population-based study.

The objective of this study was to determine the suicide risk among cancer patients in Estonia. This risk was examined in a cohort of 65,419 persons diagnosed with cancer in 1983-1998. Standardised mortality ratios (SMR) were calculated using the suicide rates of the population of Estonia as a reference. During 192,078 person-years of follow-up between 1983 and 2000, 197 suicides occurred in the cohort. An increased suicide risk was found for men (SMR=1.73; 95% Confidence Interval (CI) 1.45-2.01), but not for women (SMR=0.50; 95% CI 0.37-0.66). Men had the highest risk 90-179 days following their diagnosis (SMR=4.27; 95% CI 2.81-6.21). During this time interval, among men, the risk was more pronounced for cancers of the oesophagus (SMR=35.63; 95% CI 9.71-91.22) and pancreas (SMR=14.53; 95% CI 1.76-52.50). This study provides further evidence that cancer is a risk factor for suicide, at least in men.

Wood dust exposure and cancer incidence: a retrospective cohort study of furniture workers in Estonia.

BACKGROUND: Occupational wood dust exposure is associated with increased risk of sinonasal cancer in men. However, little is known whether it is associated with sinonasal cancer in women or with malignancies of other sites. METHODS: In a retrospective cohort study of furniture workers, cancer incidence in 3723 men and 3063 women between 1968 and 1995 was compared to the incidence in the general population of Estonia. Cancer risks were analyzed by employment duration and occupation. RESULTS: The standardized incidence ratio (SIR) for all cancers did not differ significantly from one. Two men and one woman had sinonasal cancer (expected 1.07 and 0.53, respectively). Significantly increased risk of colon cancer was seen in the cohort (SIR 1.65, 95% confidence interval (CI) 1.22-2.17). Subjects employed for 10 years and over had significant excess of colon cancer (SIR 2.29, 95% CI 1.28-3.77) and rectal cancer (SIR 2.10, 95% CI 1.05-3.76) in the analysis by employment duration using exposure with a latency of 20 years. The nonsignificant excess of pharyngeal cancer in men (SIR 1.82) and lung cancer in women (SIR 1.43) was restricted to short-term workers. CONCLUSIONS: This study found an excess of colon and rectal cancer in furniture workers. There was no increase in total cancer risk.

Epidemiological data sources in Estonia: a survey of registries and databases.

BACKGROUND: Central and Eastern European countries offer opportunities for studying the health effects of historical and present exposures, as well as the transition to a market economy. A prerequisite for research is the availability of good-quality information. This study was undertaken to describe sources of individual data that are available for epidemiological research in Estonia. Particular attention was paid to the methods of operation of health registries. METHODS: Information was collected during site visits, interviews with registry personnel and from published reports. For health registries, information was specifically requested on data collection, scope of recorded data, quality control, electronic linkage capability and use of data in research. RESULTS: The authors describe 35 data sources containing individual information on vital status, mortality, morbidity, natality and women's health, health and health care, and occupation. The most important health registries are the cancer registry, with data from 1968, and the medical birth registry, with data from 1992. Computerised cause-of-death information is available from 1983. Electronic linkage can be done with most of the data sources, the main matching variable being the eleven-digit personal identification number. Factors potentially affecting data-quality in health registries are undefined legal basis, scarcity of funding and staff, poor acknowledgement of problems, and rare scientific use of registry DISCUSSION: Various data sources are available for epidemiological research in Estonia. Thus far, collected data have largely been an under-used scientific resource. In health registries, more attention should be paid to quality control and continuous involvement of researchers.

Feasibility of cohort studies in Estonia.

OBJECTIVES: To describe the methodology and feasibility of follow up for vital status in retrospective cohort studies in Estonia. METHODS: A cohort of 7412 workers who had been employed at two factories in Tallinn between 1946 and 1988 was followed up for vital status from the date of first employment until death, emigration, or the end of the study, 31 December 1995, whichever occurred first. The cohort was electronically linked with the National Population Registry of Estonia that was created in 1992 and includes personal identification numbers of Estonian citizens and residents, and the Mortality Database that contains information from death certificates issued in 1983-95. A manual search was carried out on several non-computerised population data sources and archives. RESULTS: By 31 December 1995, the vital status of 6780 (91.5%) subjects could be traced (4495 (60.6%) subjects were alive, 1993 (26.9%) had died, and 292 (3.9%) had emigrated). Analysis by calendar period of leaving work showed that the proportion of subjects traced was lowest in the group of workers who had left work between 1946 and 1955 (58.4%), especially those whose age at leaving work was < 30 (53.2%) or > 60 years (42.3%). Among subjects who left work in 1956-65, 1966-75, and 1976-88, the follow up rate was 84.7%, 94.6%, and 98.2%, respectively. CONCLUSIONS: The findings, which are especially important for occupational epidemiology, confirm the feasibility of conducting retrospective cohort studies in Estonia. Most of the issues discussed in the paper apply to other former Soviet countries.