Uterine artery embolisation or myomectomy for women with uterine fibroids wishing to avoid hysterectomy: a cost-utility analysis of the FEMME trial.

OBJECTIVES: To assess the cost-effectiveness of uterine artery embolisation (UAE) and myomectomy for women with symptomatic uterine fibroids wishing to avoid hysterectomy. DESIGN: Economic evaluation alongside the FEMME randomised controlled trial. SETTING: 29 UK hospitals. POPULATION: Premenopausal women who had symptomatic uterine fibroids amenable to UAE or myomectomy wishing to avoid hysterectomy. 254 women were randomised to UAE (127) and myomectomy (127). METHODS: A within-trial cost-utility analysis was conducted from the perspective of the UK NHS. MAIN OUTCOME MEASURES: Quality-adjusted life years (QALYs) measured using the EuroQoL EQ-5D-3L, combined with costs to estimate cost-effectiveness over 2 and 4 years of follow-up. RESULTS: Over a 2-year time horizon, UAE was associated with higher mean costs (difference £645; 95% CI -1381 to 2580) and lower QALYs (difference -0.09; 95% CI -0.11 to -0.04) when compared with myomectomy. Similar results were observed over the 4-year time horizon. Thus, UAE was dominated by myomectomy. Results of the sensitivity analyses were consistent with the base case results for both years. Over 2 years, UAE was associated with higher costs (difference £456; 95% CI -1823 to 3164) and lower QALYs (difference -0.06; 95% CI -0.11 to -0.02). CONCLUSIONS: Myomectomy is a cost-effective option for the treatment of uterine fibroids. The differences in costs and QALYs are small. Women should be fully informed and have the option to choose between the two procedures. TWEETABLE ABSTRACT: Fully informed women with uterine fibroids should have a choice between uterine artery embolisation or myomectomy.

Navigating physical activity engagement following a diagnosis of cancer: A qualitative exploration.

This qualitative descriptive study explored cancer survivors' experiences of barriers and facilitators to undertaking physical activity to inform how services and professionals might offer better support. Purposive and theoretical sampling was used to recruit 25 people who were up to 5 years post-cancer diagnosis. Participants took part in face to face, semi-structured interviews, and transcripts were analysed using thematic analysis. The analysis identified five interrelated themes which represented cancer survivors' views: 1) You're on your own-a sense of abandonment post-treatment, and lack of sufficient and tailored information; 2) Dis-ease-disruption to self and identity, and a heightened awareness of physical self and fragility; 3) Becoming acclimatised-physical activity in the face of treatment-related side effects and residual impairment; 4) Importance of others-encouragement and support from health professionals, family and friends, and cancer-specific exercise groups; 5) Meanings people ascribed to physical activity-these were central and could help or hinder engagement. Our findings suggest being able to live well and re-engage in meaningful activities following a diagnosis of cancer is both complex and challenging. There appear to be gaps in current service provision in supporting the broader health and well-being of cancer survivors.

Interventions to address sexual problems in people with cancer.

BACKGROUND: Sexual dysfunction in people with cancer is a significant problem. The present clinical practice guideline makes recommendations to improve sexual function in people with cancer. METHODS: This guideline was undertaken by the Interventions to Address Sexual Problems in People with Cancer Expert Panel, a group organized by the Program in Evidence-Based Care (pebc). Consistent with the pebc standardized approach, a systematic search was conducted for existing guidelines, and the literature in medline and embase for the years 2003-2015 was systematically searched for both systematic reviews and primary literature. Evidence found for men and for women was evaluated separately, and no restrictions were placed on cancer type or study design. Content and methodology experts performed an internal review of the resulting draft recommendations, which was followed by an external review by targeted experts and intended users. RESULTS: The search identified 4 existing guidelines, 13 systematic reviews, and 103 studies with relevance to the topic. The present guideline provides one overarching recommendation concerning the discussion of sexual health and dysfunction, which is aimed at all people with cancer. Eleven additional recommendations made separately for men and women deal with issues such as sexual response, body image, intimacy and relationships, overall sexual functioning and satisfaction, and vasomotor and genital symptoms. CONCLUSIONS: To our knowledge this clinical practice guideline is the first to comprehensively evaluate interventions for the improvement of sexual problems in people with cancer. The guideline will be a valuable resource to support practitioners and clinics in addressing sexuality in cancer survivors.

Prediction of stillbirth from maternal demographic and pregnancy characteristics.

OBJECTIVES: To develop a model for prediction of stillbirth based on maternal characteristics and components of medical history and to evaluate the performance of screening with this model for all stillbirths and those due to impaired placentation and to unexplained causes. METHODS: This was a prospective screening study of 113 415 singleton pregnancies at 11 + 0 to 13 + 6 weeks' gestation and at 19 + 0 to 24 + 6 weeks. The study population included 113 019 live births and 396 (0.35%) antepartum stillbirths; 230 (58%) were secondary to impaired placentation and 166 (42%) were due to other or unexplained causes. Multivariable logistic regression analysis was used to determine the factors from maternal characteristics and medical history which provided a significant contribution to the prediction of stillbirth. RESULTS: The risk for stillbirth increased with maternal weight (odds ratio (OR), 1.01 per kg above 69 kg), was higher in women of Afro-Caribbean racial origin (OR, 2.01), those with assisted conception (OR, 1.79), cigarette smokers (OR, 1.71), and in those with a history of chronic hypertension (OR, 2.62), systemic lupus erythematosus/antiphospholipid syndrome (OR, 3.61) or diabetes mellitus (OR, 2.55) and was increased in women with a history of previous stillbirth (OR, 4.81). Screening with the model predicted 26% of unexplained stillbirths and 31% of those due to impaired placentation, at a false-positive rate of 10%; within the impaired-placentation group the detection rate of stillbirth < 32 weeks' gestation was higher than that of stillbirth ≥ 37 weeks (38% vs 28%). CONCLUSIONS: A model based on maternal characteristics and medical history recorded in early pregnancy can potentially predict one-third of subsequent stillbirths. The extent to which such stillbirths could be prevented remains to be determined. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Enzogenol for cognitive functioning in traumatic brain injury: a pilot placebo-controlled RCT.

BACKGROUND AND PURPOSE: Enzogenol, a flavonoid-rich extract from Pinus radiata bark with antioxidant and anti-inflammatory properties has been shown to improve working memory in healthy adults. In traumatic brain injury (TBI), oxidation and inflammation have been linked to poorer cognitive outcomes. Hence, this phase II, randomized controlled trial investigated safety, compliance and efficacy of Enzogenol for improving cognitive functioning in people following mild TBI. METHODS: Sixty adults, who sustained a mild TBI, 3-12 months prior to recruitment, and who were experiencing persistent cognitive difficulties [Cognitive Failures Questionnaire (CFQ) score > 38], were randomized to receive Enzogenol (1000 mg/day) or matching placebo for 6 weeks. Subsequently, all participants received Enzogenol for a further 6 weeks, followed by placebo for 4 weeks. Compliance, side-effects, cognitive failures, working and episodic memory, post-concussive symptoms and mood were assessed at baseline, 6, 12 and 16 weeks. Simultaneous estimation of treatment effect and breakpoint was effected, with confidence intervals (CIs) obtained through a treatment-placebo balance-preserving bootstrap procedure. RESULTS: Enzogenol was found to be safe and well tolerated. Trend and breakpoint analyses showed a significant reduction in cognitive failures after 6 weeks [mean CFQ score, 95% CI, Enzogenol versus placebo -6.9 (-10.8 to -4.1)]. Improvements in the frequency of self-reported cognitive failures were estimated to continue until week 11 before stabilizing. Other outcome measures showed some positive trends but no significant treatment effects. CONCLUSIONS: Enzogenol supplementation is safe and well tolerated in people after mild TBI, and may improve cognitive functioning in this patient population. This study provides Class IIB evidence that Enzogenol is well tolerated and may reduce self-perceived cognitive failures in patients 3-12 months post-mild TBI.

Understanding hope after stroke: a systematic review of the literature using concept analysis.

PURPOSE: Hope is said to be important in recovery from illness or injury, supporting adjustment, perseverance, and positive outcomes. There has been little exploration of hope in people after stroke. This is reflected in the literature, which lacks consistent definition and terminology. This purpose of this article is to clarify the concept of hope after stroke and to synthesize the findings to propose a working model of hope. METHOD: A systematic literature search was completed. Articles were included if they explored hope from the perspective of people with stroke or if hope was reported as a key finding in a study. Coding, analytic questions, and matrices were used to extract data and to compare, contrast, and synthesize conceptualizations, processes, and outcomes of hope. This was guided by a concept analysis methodology. RESULTS: The literature search identified 20 articles that met the inclusion criteria. Analysis of these articles suggested hope was conceptualized in 3 interrelated ways - as an inner state, as being outcome-oriented, and as an active process. Findings suggested that internal and external resources contributed to the development of hope. Hope was perceived to be linked with positive outcomes and functioned as a motivator and source of strength through recovery. Hope reflected elements also found in the concepts of expectations, goals, and optimism. CONCLUSION: This novel approach to analysis has furthered the understanding of hope. It has proposed a working model of hope that could be used by clinicians in considering hope with their clients and patients.

In-circuit high-frequency jet ventilation to reduce organ motion in a child undergoing sarcoma ablation.

Patients with primary or metastatic solid tumours can be treated with minimally invasive image-guided procedures as an alternative to surgical resection. Reducing organ motion during these procedures is crucial so that tumours can be accurately targeted and treatment delivered within a small margin, limiting potential damage to adjacent structures. As ventilation is the main cause of motion, there has been a shift from conventional ventilation towards the use of in-circuit high-frequency jet ventilation techniques for these procedures. We present the case of a 7-year-old who required computed tomography-guided microwave ablation of a right lung metastatic nodule under general anaesthesia. The patient's lungs were ventilated with in-circuit high-frequency jet ventilation in order to provide optimum conditions for ablation. The treatment was successfully completed and she was discharged home the following day. High-frequency jet ventilation is regularly used in our institution for adult computed tomography-guided treatments and to our knowledge, this application has not been described yet in a child this young. Our experience suggests that this technique can be safely used in paediatric patients, though further investigation of the optimum parameters for in-circuit high-frequency jet ventilation in this population is warranted.

Going home to get on with life: patients and carers experiences of being discharged from hospital following a stroke.

PURPOSE: In this paper we aim to develop the understanding of what constitutes a 'good' or 'poor' experience in relation to the transition from hospital to home following a stroke. METHOD: Semi-structured interviews were carried out with 20 people and 13 carers within one month of being discharged from hospital following a stroke. Interviews covered views of mobility recovery and support from therapy and services. Interviews were transcribed verbatim, coded and analysed in depth in order to explore the discharge process. RESULTS: Participants described models of recovery, which involved a sense of momentum and getting on with their life. Discharge was successful if: (i) This sense of momentum was maintained, (ii) they felt supported, and (iii) they felt informed about what was happening. Discharge was seen as difficult when: (a) Momentum was perceived to be lost, (b) people did not feel supported, or (c) they felt in the dark about the plans or their recovery. CONCLUSIONS: The discharge experience could be improved by healthcare professionals understanding and exploring patients' individual models of recovery. This would allow professionals to: (a) Access patients concerns, (b) develop programmes addressing these, (c) correct misinterpretations, (d) keep people fully informed, and (e) share and validate the experience, to reduce their sense of isolation.

Resuming previously valued activities post-stroke: who or what helps?

PURPOSE: In this article, we aim to develop the understanding of what helps or hinders resumption of valued activities up to 12-months post-stroke. METHOD: As part of a longitudinal study, semi-structured interviews were conducted with 19 people with stroke and eight informal carers 12-months post-stroke. Interviews covered ongoing effects of stroke, experience of trying to resume activities highlighted as important pre-stroke and factors that influenced progress. Interviews were transcribed, coded and analysed in depth to explore this aspect of the experience of living with stroke. RESULTS: Valued activities discussed related to employment; domestic and social roles including driving; hobbies, sports and socialising. Outcomes for individuals were influenced by: aspects of physical or cognitive disability; environmental factors; the adaptability of the individual; support from others and professional help. Inability to resume activities impacted on people's sense of self and quality of life, but some tolerated change and presented themselves as adaptable. CONCLUSIONS: This study indicates a long-term role for rehabilitation services such as: identifying the significance of different types of activities; providing access to support and treatment for debilitating symptoms such as fatigue and dizziness; addressing patients' emotional and behavioural responses to their condition; working with patients' wider social networks and where appropriate, supporting adaptation to a changed way of life.

A UK multicentre retrospective cohort study comparing hysterectomy and uterine artery embolisation for the treatment of symptomatic uterine fibroids (HOPEFUL study): main results on medium-term safety and efficacy.

OBJECTIVES: Comparison of medium-term safety and efficacy of hysterectomy and uterine artery embolisation (UAE) for symptomatic uterine fibroids. DESIGN: Multicentre retrospective cohort. SETTING: 18 UK NHS hospital trusts. PARTICIPANTS: Four hundred and fifty nine women who had hysterectomy within a national audit during 12 months from October 1994 (VALUE study) (average follow up of 8.6 years) and 649 women receiving UAE from 1996 to 2002 (average follow up of 4.6 years). METHODS: Clinical data from existing hospital records and patient completed postal questionnaires. MAIN OUTCOME MEASURES: Complication rates, side effects of embolisation, satisfaction with treatment, relief from symptoms and requirement for further fibroid treatment. RESULTS: Fewer complications were experienced by women receiving UAE (19 versus 26% hysterectomy, P = 0.001), the adjusted odds ratio for UAE versus hysterectomy was 0.48 (95% CI 0.26-0.89). One-third of women undergoing UAE experienced anticipated general side effects associated with the procedure. More women in the hysterectomy cohort reported relief from fibroid symptoms (95 versus 85%, P < 0.0001) and feeling better (96 versus 84%, P < 0.0001), but only 85% would recommend the treatment to a friend compared with 91% in the UAE arm (P = 0.007). There was a 23% (95% CI 19-27%) chance of requiring further treatment for fibroids after UAE. Twenty-seven women who had had UAE reported 37 pregnancies after treatment resulting in 19 live births. CONCLUSIONS: UAE results in fewer complications than hysterectomy. Side effects after embolisation should be anticipated, and almost one-quarter of women having UAE were likely to require further treatment for fibroid symptoms. Both treatments appear to be safe and effective over the medium term, and the choice of treatment may be a matter of personal preference for each individual woman.

Uterine artery embolisation or hysterectomy for the treatment of symptomatic uterine fibroids: a cost-utility analysis of the HOPEFUL study.

OBJECTIVES: To evaluate the relative cost-effectiveness of uterine artery embolisation (UAE) and hysterectomy in women with symptomatic uterine fibroids from the perspective of the UK NHS. DESIGN: Cost-utility analysis. SETTING: Eighteen UK NHS hospital trusts. POPULATION OR SAMPLE Women who underwent UAE (n= 649; average follow up of 8.6 years) or hysterectomy (n= 459; average follow up of 4.6 years) for the treatments of symptomatic fibroids. METHODS: A probabilistic decision model was carried out based on data from a large comparative cohort and the literature. The two interventions were evaluated over the time horizon from the initial procedure to menopause. Extensive sensitivity analysis was carried out to test model assumptions and parameter uncertainties. MAIN OUTCOME MEASURES: Costs of procedures and complications and quality of life expressed as quality-adjusted life years (QALYs). RESULTS: Overall, UAE was associated with lower mean cost (2536 pounds sterling versus 3282 pounds sterling) and a small reduction in quality of life (8.203 versus 8.241 QALYs) when compared with hysterectomy. However, when the quality of life associated with the conservation of the uterus was incorporated in the model, UAE was shown to be the dominant strategy--lower costs and greater QALYs. CONCLUSIONS: UAE is a less expensive option to the health service compared with hysterectomy, even when the costs of repeat procedures and associated complications are factored in. The quality of life implications in the short term are also predicted to favour UAE; however, this advantage may be eroded over time as women undergo additional procedures to deal with recurrent fibroids. Given the hysterectomy is the current standard treatment for symptomatic fibroids, offering women UAE as an alternative treatment for fibroids is likely to be highly cost-effective for those women who prefer uterus-conserving treatment.

Arsenic bioaccessibility and speciation in clams and seaweed from a contaminated marine environment.

The bioaccessible concentration and speciation of arsenic (soluble in a gastrointestinal medium and available for absorption into the bloodstream) were determined in softshell clams (Mya arenaria), harvested by local residents until 2005, and in seaweed (Fucus sp.) from an arsenic-contaminated marine site in Seal Harbour, Nova Scotia, Canada. Bioaccessibility extractions to simulate the human gastrointestinal environment (pH 1.5 and glycine for 1h followed by pancreatin, bile extract and pH adjustment to 7 for an additional 4h) and speciation of arsenic in extracts (HPLC-HG-AAS to target inorganic arsenic species) and whole samples (XANES) were carried out. Total arsenic for the clams from the contaminated area ranged from 218 to 228 ppm wet weight, with a bioaccessible fraction of 34-46%, and the major bioaccessible species of arsenic were inorganic. The seaweed from the contaminated area contained 27-43 ppm wet weight total arsenic, with the bioaccessible fraction ranging from 63% to 81%, and inorganic arsenic was also predominant. The predominantly inorganic nature of arsenic in the whole samples was confirmed by XANES. In concurrence with the closure of the area for clam harvesting, the clams and seaweed from Seal Harbour should probably not be used for human consumption.

Maternal age and breast cancer risk.

Maternal age at time of birth was investigated as a risk factor for breast cancer in a study of 1,176 matched case-control pairs. There was no pattern of increasing adjusted relative risk of breast cancer with increasing maternal age, nor was the mean maternal age of cases older than that of controls. Similar negative results were found among the subset of subjects up to 35 years old, a group previously found to show marked maternal age effects. Thus previous reports of an association between breast cancer and advanced maternal age may have been due to chance, extraneous factors, or a misleading reliance on unadjusted mean maternal ages, rather than on relative risks.

Snoezelen multi-sensory environments: task engagement and generalization.

These experiments explored whether behavioral improvements observed during Snoezelen OT treatment sessions carried over to two different settings for three people with moderate/severe intellectual disability, autism and severe challenging behaviors. Experiment 1 explored engagement during a functional task immediately following the treatment sessions while experiment 2 explored changes in the frequencies of challenging behaviors on the days after treatment sessions. Investigators found carryover for two of the three participants to both post-session engagement as well as to the daily frequency of challenging behaviors on days following the OT sessions.

Readmission to hospital 5 years after hysterectomy or endometrial resection in a national cohort study.

OBJECTIVES: To investigate the readmission experience of a large national prospective cohort of women up to 5 years after undergoing either transcervical resection of the endometrium (TCRE) or hysterectomy to assess reasons for readmission and whether TCRE can be viewed as a definitive substitute for hysterectomy. DESIGN AND PARTICIPANTS: Data are from the VALUE/MISTLETOE prospective national cohort studies of hysterectomy and TCRE respectively. 5294 women who underwent hysterectomy for dysfunctional uterine bleeding in 1994/5 and 4032 women who underwent TCRE in 1993/4 and who responded to postal questionnaires were included. Surgeons gathered operative details. Women completed postal follow up questionnaires at 3 and 5 years after surgery asking about readmission to hospital and reasons for readmission. Adjusted proportional hazard ratios were calculated for likelihood of readmission in each category comparing types of surgery. RESULTS: 41.7% of women undergoing hysterectomy and 44.6% of women undergoing TCRE experienced one or more readmissions to hospital overall within 5 years (adjusted hazard ratio for all readmissions (AHR) 0.87 (95% confidence interval (CI) 0.80 to 0.95)). 12.6% of hysterectomy patients and 30.3% of TCRE patients were readmitted for gynaecological reasons (AHR 0.40 (95% CI 0.33 to 0.48)). Rates of readmission for gynaecological reasons were similar up to 6 months but were markedly reduced for hysterectomy compared with TCRE patients towards the end of the follow up period (AHR for readmission at 3-5 years 0.28 (95% CI 0.20 to 0.39)). CONCLUSIONS: There are differences in the pattern of readmission to hospital after hysterectomy and TCRE for dysfunctional uterine bleeding. Women undergoing a hysterectomy are less likely to be readmitted to hospital up to 5 years after their operation overall, and are significantly less likely to be readmitted for reasons related to their operation, particularly for gynaecological reasons. Hysterectomy appears to be a more definitive operation. The different options for surgery for dysfunctional uterine bleeding are not interchangeable; they represent different patterns of care. Information should be available to women and practitioners to inform choices between these options.

Assessing symptom improvement after elective prostatectomy for benign prostatic hypertrophy.

BACKGROUND: Elective surgery for benign prostatic hypertrophy requires estimates of likely improvement. METHODS: Data are from a prospective study of all patients without cancer who underwent transurethral prostatectomy. After eliminating patients for whom surgery was not elective, we examined symptom improvement. RESULTS: Surgery was effective in reducing symptoms for all but those with very mild preoperative symptoms. For the remainder, the average level of postoperative outcomes achieved was independent of the initial symptom severity. CONCLUSIONS: Elective prostatectomy is effectiveness for improving symptoms. The improvement is typically sustained, and for some symptoms improvement continues during the first year after surgery. Patients with severe symptoms were as likely to achieve the same level of postoperative improvement as were patients with less severe problems initially. However, patients with very mild symptoms benefited little or none from surgery.

Therapeutic controversy: The safety of third-generation oral contraceptives.

PIP: This paper presents the contributions of Drs. Barbieri, Speroff, Walker, and McPherson to the debate on the safety of third-generation oral contraceptives (OCs). In the overview by Barbieri, the issues of how to assess the quality of the evidence and developing a meaningful framework for integrating an analysis of the benefits and risks of a contraceptive hormone are discussed. He also reflects on the leadership role the endocrinologist must assume in better defining the pharmaco-endocrinology of gestodene and desogestrel. Speroff concludes that modern low-dose OCs are very safe. It was noted that the use of OCs yields an overall improvement in individual health, and from a public health point of view the collection of effects associated with OCs leads to a decrease in the cost of health care. In contrast, Walker argues that low-estrogen OCs containing desogestrel and gestodene carry a modestly elevated risk of venous thromboembolism in comparison to other low-estrogen OCs in widespread use. This statement is supported by McPherson, who emphasizes that the risk associated with OCs is real and should be avoided.^ieng

Mortality in vegetarians and nonvegetarians: detailed findings from a collaborative analysis of 5 prospective studies.

We combined data from 5 prospective studies to compare the death rates from common diseases of vegetarians with those of nonvegetarians with similar lifestyles. A summary of these results was reported previously; we report here more details of the findings. Data for 76172 men and women were available. Vegetarians were those who did not eat any meat or fish (n = 27808). Death rate ratios at ages 16-89 y were calculated by Poisson regression and all results were adjusted for age, sex, and smoking status. A random-effects model was used to calculate pooled estimates of effect for all studies combined. There were 8330 deaths after a mean of 10.6 y of follow-up. Mortality from ischemic heart disease was 24% lower in vegetarians than in nonvegetarians (death rate ratio: 0.76; 95% CI: 0.62, 0.94; P<0.01). The lower mortality from ischemic heart disease among vegetarians was greater at younger ages and was restricted to those who had followed their current diet for >5 y. Further categorization of diets showed that, in comparison with regular meat eaters, mortality from ischemic heart disease was 20% lower in occasional meat eaters, 34% lower in people who ate fish but not meat, 34% lower in lactoovovegetarians, and 26% lower in vegans. There were no significant differences between vegetarians and nonvegetarians in mortality from cerebrovascular disease, stomach cancer, colorectal cancer, lung cancer, breast cancer, prostate cancer, or all other causes combined.

Systematic review of the prospective cohort studies on meat consumption and colorectal cancer risk: a meta-analytical approach.

The relation between meat consumption and colorectal cancer risk remains controversial. In this report, we quantitatively reviewed the prospective observational studies that have analyzed the relation between meat consumption and colorectal cancer. We conducted electronic searches of MEDLINE, EMBASE, and CANCERLIT databases through to the end of June 1999 and manual searches of references from retrieved articles. We used both fixed and random-effects meta-analytical techniques to estimate the overall association and to investigate possible sources of heterogeneity among studies. Thirteen studies were eligible for inclusion in the meta-analysis. Pooled results indicate that a daily increase of 100 g of all meat or red meat is associated with a significant 12-17% increased risk of colorectal cancer. The marginally significant between-study heterogeneity for all meat and red meat was explained by a number of study-level covariates. A significant 49% increased risk was found for a daily increase of 25 g of processed meat. The individual study estimates for processed meat showed no detectable heterogeneity. On the basis of this quantitative review of prospective studies, the overall association between meat consumption and risk of colorectal cancer appears to be positive, with marginal heterogeneity between studies. The finding for processed meat and data from experimental studies suggests that it may also be an important predictor of colorectal cancer risk. However, because only a few of the studies reviewed here attempted to examine the independent effect of meat intake on colorectal cancer risk, the possibility that the overall association may be confounded or modified by other factors cannot be excluded.