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Cancer Epidemiology Biomarkers & Prevention

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Cancer Epidemiology Biomarkers & Prevention

Much of the suffering and death from cancer could be prevented by more systematic efforts to reduce tobacco use, improve diet, increase physical activity, reduce obesity, and expand the use of established screening tests. Monitoring the prevalence of cancer risk factors and screening is important to measure progress and strengthen cancer prevention and early detection efforts. In this review article, we provide recent prevalence estimates for several cancer risk factors, including tobacco, obesity, physical activity, nutrition, ultraviolet radiation exposure as well as human papillomavirus and hepatitis B vaccination coverage and cancer screening prevalence in the United States. In 2013, cigarette smoking prevalence was 17.8% among adults nationally, but ranged from 10.3% in Utah to 27.3% in West Virginia. In addition, 15.7% of U.S. high school students were current smokers. In 2011–2012, obesity prevalence was high among both adults (34.9%) and adolescents (20.5%), but has leveled off since 2002. About 20.2% of high school girls were users of indoor tanning devices, compared with 5.3% of boys. In 2013, cancer screening prevalence ranged from 58.6% for colorectal cancer to 80.8% for cervical cancer and remains low among the uninsured, particularly for colorectal cancer screening where only 21.9% of eligible adults received recommended colorectal cancer screening. Cancer Epidemiol Biomarkers Prev; 24(4); 637–52. ©2015 AACR.


Background: No studies have estimated the population-level burden of morbidity in individuals diagnosed with cancer as children (ages 0–19 years). We updated prevalence estimates of childhood cancer survivors as of 2011 and burden of morbidity in this population reflected by chronic conditions, neurocognitive dysfunction, compromised health-related quality of life, and health status (general health, mental health, functional impairment, functional limitations, pain, and fear/anxiety).

Methods: Surveillance, Epidemiology, and End Results (SEER) Program data from 1975 to 2011 were used to update the prevalence of survivors of childhood cancers in the United States. Childhood Cancer Survivor Study data were used to obtain estimates of morbidity burden indicators, which were then extrapolated to SEER data to obtain population-level estimates.

Results: There were an estimated 388,501 survivors of childhood cancer in the United States as of January 1, 2011, of whom 83.5% are ≥5 years after diagnosis. The prevalence of any chronic condition among ≥5-year survivors ranged from 66% (ages 5–19) to 88% (ages 40–49). Estimates for specific morbidities ranged from 12% (pain) to 35% (neurocognitive dysfunction). Generally, morbidities increased by age. However, mental health and anxiety remained fairly stable, and neurocognitive dysfunction exhibited initial decline and then remained stable by time since diagnosis.

Conclusions: The estimated prevalence of survivors of childhood cancer is increasing, as is the estimated prevalence of morbidity in those ≥5 years after diagnosis.

Impact: Efforts to understand how to effectively decrease morbidity burden and incorporate effective care coordination and rehabilitation models to optimize longevity and well-being in this population should be a priority. Cancer Epidemiol Biomarkers Prev; 24(4); 653–63. ©2015 AACR.


Background: Low-dose computed tomography (LDCT) screening reduces lung cancer–specific and overall mortality. We sought to assess lung cancer screening practices and attitudes among primary care providers (PCPs) in the era of new LDCT screening guidelines.

Methods: In 2013, we surveyed PCPs at an academic medical center (60% response) and assessed: lung cancer screening use, perceived screening effectiveness, knowledge of screening guidelines, perceived barriers to LDCT use, and interest in LDCT screening education.

Results: Few PCPs (n = 212) reported ordering lung cancer screening: chest X-ray (21%), LDCT (12%), and sputum cytology (3%). Only 47% of providers knew three or more of six guideline components for LDCT screening; 24% did not know any guideline components. In multiple logistic regression analysis, providers who knew three or more guideline components were more likely to order LDCT (OR, 7.1; 95% confidence intervals, 2.0–25.6). Many providers (30%) were unsure of the effectiveness of LDCT. Mammography, colonoscopy, and Pap smear were rated more frequently as effective in reducing cancer mortality compared with LDCT (all P values < 0.0001). Common perceived barriers included patient cost (86.9% major or minor barrier), harm from false positives (82.7%), patients' lack of awareness (81.3%), risk of incidental findings (81.3%), and insurance coverage (80.1%).

Conclusions: LDCT lung cancer screening is currently an uncommon practice at an academic medical center. PCPs report ordering chest X-ray, a nonrecommended screening test, more often than LDCT. PCPs had a limited understanding of lung cancer screening guidelines and LDCT effectiveness. Provider educational interventions are needed to facilitate shared decision-making with patients.

Impact: This study describes some of the first data available about PCPs' use of lung cancer screening tests since the publication of multiple professional guidelines endorsing LDCT. Knowledge gaps were identified that may hinder the uptake of evidence-based lung cancer screening guidelines. Cancer Epidemiol Biomarkers Prev; 24(4); 664–70. ©2015 AACR.


Background: In U.S. women, lifetime risk of ovarian cancer is 1.37%, but some women are at a substantially lower or higher risk than this average.

Methods: We have characterized the distribution of lifetime risk in the general population. Published data on the relative risks and their variances for five well-accepted risk and protective factors for ovarian cancer, oral contraceptive use, parity, tubal ligation, endometriosis, and first-degree family history of ovarian cancer in conjunction with a genetic risk score using genome-wide significant common, low penetrance variants were used. The joint distribution of these factors (i.e., risk/protective factor profiles) was derived using control data from four U.S. population–based studies, providing a broad representation of women in the United States.

Results: A total of 214 combinations of risk/protective factors were observed, and the lifetime risk estimates ranged from 0.35% [95% confidence interval (CI), 0.29–0.42] to 8.78% (95% CI, 7.10–10.9). Among women with lifetime risk ranging from 4% to 9%, 73% had no family history of ovarian cancer; most of these women had a self-reported history of endometriosis.

Conclusions: Profiles including the known modifiable protective factors of oral contraceptive use and tubal ligation were associated with a lower lifetime risk of ovarian cancer. Oral contraceptive use and tubal ligation were essentially absent among the women at 4% to 9% lifetime risk.

Impact: This work demonstrates that there are women in the general population who have a much higher than average lifetime risk of ovarian cancer. Preventive strategies are available. Should effective screening become available, higher than average risk women can be identified. Cancer Epidemiol Biomarkers Prev; 24(4); 671–6. ©2015 AACR.


Background: New biomarkers for early detection of cancer must pass through several phases of development. Early phases provide information on diagnostic properties but not on population benefits and harms. Prostate cancer antigen 3 (PCA3) is a promising prostate cancer biomarker still in early development. We use simulation modeling to project the impact of adding PCA3 to prostate-specific antigen (PSA) screening on prostate cancer detection and mortality in the United States.

Methods: We used data from a recent study of PCA3 in men referred for prostate biopsy to extend an existing simulation model of PSA growth, disease progression, and survival. We specified several PSA-PCA3 strategies designed to improve specificity and reduce overdiagnosis. Using these strategies to screen a cohort of men biennially between ages 50 and 74, we projected true- and false-positive tests, overdiagnoses, and lives saved relative to a PSA-based strategy with a cutoff of 4.0 ng/mL for biopsy referral.

Results: We identified several PSA-PCA3 strategies that substantially reduced false-positive tests and overdiagnoses while preserving the majority of lives saved. PCA3>35 for biopsy referral in men with PSA between 4.0 and 10.0 ng/mL retained 85% of lives saved while approximately halving false positives and reducing overdiagnoses by 25%.

Conclusions: Adding PCA3 to PSA screening can significantly reduce adverse screening outcomes. Strategies can be identified that preserve most of the lives saved relative to PSA-based screening.

Impact: Simulation modeling provides advance projections of population outcomes of new screening biomarkers and may help guide early detection research. Cancer Epidemiol Biomarkers Prev; 24(4); 677–82. ©2015 AACR.


Background: The increasing incidence of oropharyngeal cancer in many developed countries has been attributed to human papillomavirus type 16 (HPV16) infections. Recently, HPV16 E6 serology has been identified as a promising early marker for oropharyngeal cancer. Therefore, characterization of HPV16 E6 seropositivity among individuals without cancer is warranted.

Methods: A total of 4,666 controls were pooled from several studies of cancer and HPV seropositivity, all tested within the same laboratory. HPV16 E6 seropositive controls were classified as having (i) moderate [mean fluorescent intensity (MFI) ≥ 484 and <1,000] or (ii) high seroreactivity (MFI ≥ 1,000). Associations of moderate and high HPV16 E6 seroreactivity with (i) demographic risk factors; and seropositivity for (ii) other HPV16 proteins (E1, E2, E4, E7, and L1), and (iii) E6 proteins from non-HPV16 types (HPV6, 11, 18, 31, 33, 45, and 52) were evaluated.

Results: Thirty-two (0.7%) HPV16 E6 seropositive controls were identified; 17 (0.4%) with moderate and 15 (0.3%) with high seroreactivity. High HPV16 E6 seroreactivity was associated with former smoking [odds ratio (OR), 5.5; 95% confidence interval (CI), 1.2–51.8], and seropositivity against HPV16 L1 (OR, 4.8; 95% CI, 1.3–15.4); E2 (OR, 7.7; 95% CI, 1.4–29.1); multiple HPV16 proteins (OR, 25.3; 95% CI, 2.6–119.6 for three HPV16 proteins beside E6) and HPV33 E6 (OR, 17.7; 95% CI, 1.9–81.8). No associations were observed with moderate HPV16 E6 seroreactivity.

Conclusions: High HPV16 E6 seroreactivity is rare among individuals without diagnosed cancer and was not explained by demographic factors.

Impact: Some HPV16 E6 seropositive individuals without diagnosed HPV-driven cancer, especially those with seropositivity against other HPV16 proteins, may harbor a biologically relevant HPV16 infection. Cancer Epidemiol Biomarkers Prev; 24(4); 683–9. ©2015 AACR.


Background: The association between body fatness before adulthood and later risk of colorectal cancer remains unclear. We hypothesized that, independent of adult body fatness, early life body fatness would be associated with a higher risk of developing colorectal cancer.

Methods: We assessed body fatness during childhood and adolescence using a validated 9-level somatotype and inquired body weight in young adulthood in the Nurses' Health Study and Health Professionals Follow-up Study. We used the Cox proportional hazard regression modeling to estimate relative risks [RR, 95% confidence intervals (CI)] adjusting for adult body mass index (BMI) and other known colorectal cancer risk factors.

Results: We identified 2,100 incident colorectal cancer cases (1,292 in women and 808 in men) during 22 years of follow-up. Among women, the RR (95% CI) for childhood body fatness of level 5 or higher versus level 1 was 1.28 (1.04–1.58; Ptrend = 0.08) and for adolescent body fatness, it was 1.27 (1.01–1.60; Ptrend = 0.23). The corresponding RRs for men were 1.04 (0.82–1.31; Ptrend = 0.48) and 0.98 (0.75–1.27; Ptrend = 0.20), respectively. Results were generally similar across anatomic subsites within the colorectum. In addition, the RRs comparing BMI categories ≥27.5 to <19 kg/m2 were 1.44 (1.06–1.95, at age 18; Ptrend = 0.009) for women and 1.18 (0.84–1.65, at age 21; Ptrend = 0.57) for men.

Conclusion: Increased body fatness in early life, independent of adult obesity, might be a risk factor for colorectal cancer in women, but we observed a weaker association in men.

Impact: Our findings support the growing evidence that early life body fatness affects the risk of colorectal cancer many decades later. Cancer Epidemiol Biomarkers Prev; 24(4); 690–7. ©2015 AACR.


Background: Mutations in BRCA1/2 confer a high risk of breast cancer, but literature values of this risk vary. A genotype–phenotype correlation has been found in both genes, and the effect of reproductive factors differs according to mutation location. Therefore, we hypothesize that such a variation may exist for other factors related to estrogen exposure.

Methods: We used a weighted Cox regression model to assess variation in breast cancer risk with these factors using location of mutation in homogeneous breast cancer risk region of BRCA1/2 in the GENEPSO study.

Results: We found that late age at menarche reduced breast cancer risk by 31% and that among BRCA1 carriers, a long or a short menstrual cycle increased risk (by 65% and 73%, respectively). Among premenopausal women, overweight was associated with a 45% decrease in risk whereas underweight was associated with an increased risk (HR, 2.40). A natural menopause, mainly after age 50, was associated with a high breast cancer risk (HR, 2.46), and a significant interaction between menopause status and the location of mutations was found leading up to 10% variation in absolute risk according to the age at menopause.

Conclusions: As observed in the general population, a late menarche, a long or a short menstrual cycle, over- or underweight, and being postmenopausal were associated with breast cancer risk in BRCA1/2 carriers. The association with the menopause was observed only when the mutation was located in the "high-risk" zones.

Impact: Taking into account modifier factors, location of mutation might be important for the clinical management of BRCA1/2 mutation carriers. Cancer Epidemiol Biomarkers Prev; 24(4); 698–707. ©2015 AACR.


Background: Research biobanks collect biologic samples and health information. Previous work shows that biobank participants desire general study updates, but preferences about the method or frequency of these communications have not been explored. Thus, we surveyed participants in a long-standing research biobank.

Methods: Eligible participants were drawn from a study of patients with personal/family history suggestive of Cowden syndrome, a poorly recognized inherited cancer syndrome. Participants gave blood samples and access to medical records and received individual results but had no other study interactions. The biobank had 3,618 participants at sampling. Survey eligibility included age ≥18 years, enrollment within the biobank's first 5 years, normal PTEN analysis, and contiguous U.S. address. Multivariate logistic regression analyses identified predictors of participant interest in Internet-based versus offline methods and methods allowing participant–researcher interaction versus one-way communication. Independent variables were narrowed by independent Pearson correlations by cutoff P < 0.2, with P < 0.02 considered significant.

Results: Surveys were returned from 840 of 1,267 (66%) eligible subjects. Most (97%) wanted study updates, with 92% wanting updates at least once a year. Participants preferred paper (66%) or emailed (62%) newsletter methods, with 95% selecting one of these. Older, less-educated, and lower-income respondents strongly preferred offline approaches (P < 0.001). Most (93%) had no concerns about receiving updates and 97% were willing to provide health updates to researchers.

Conclusion: Most participants were comfortable receiving and providing updated information. Demographic factors predicted communication preferences.

Impact: Researchers should make plans for ongoing communication early in study development and funders should support the necessary infrastructure for these efforts. Cancer Epidemiol Biomarkers Prev; 24(4); 708–12. ©2015 AACR.


Background: Cigarette smoking (smoking), hormone therapy (MHT), and folate intake (folate) are each thought to influence colorectal cancer risk, but the underlying molecular mechanisms remain incompletely defined. Expression of estrogen receptor β (ESR2) has been associated with colorectal cancer stage and survival.

Methods: In this prospective cohort study, we examined smoking, MHT, and folate-associated colorectal cancer risks by ESR2 protein expression level among participants in the Iowa Women's Health Study (IWHS). Self-reported exposure variables were assessed at baseline. Archived, paraffin-embedded colorectal cancer tissue specimens were collected and evaluated for ESR2 protein expression by IHC. Multivariate Cox regression models were fit to estimate relative risks (RR) and 95% confidence intervals (CI) for associations between smoking, MHT, or folate and ESR2-defined colorectal cancer subtypes.

Results: Informative environmental exposure and protein expression data were available for 491 incident colorectal cancer cases. Positive associations between ESR2-low and -high tumors and several smoking-related variables were noted, most prominently with average number of cigarettes per day (RR, 4.24; 95% CI, 1.81–9.91 for ESR2-low and RR, 2.15; 95% CI, 1.05–4.41 for ESR2-high for ≥40 cigarettes compared with nonsmokers). For MHT, a statistically significant association with ESR2-low tumors was observed with longer duration of exposure (RR, 0.54; 95% CI, 0.26–1.13 for >5 years compared with never use). No associations were found for folate.

Conclusions: In this study, smoking and MHT were associated with ESR2 expression patterns.

Impact: These data support possible heterogeneous effects from smoking and MHT on ERβ-related pathways of colorectal carcinogenesis in older women. Cancer Epidemiol Biomarkers Prev; 24(4); 713–9. ©2015 AACR.


Background: Fatalistic beliefs may be implicated in longer help-seeking intervals, and consequently, greater risk of advanced stage at cancer diagnosis.

Methods: We examined associations between fatalism and stage at diagnosis in a population-based cohort of 4,319 U.S. patients with newly diagnosed lung or colorectal cancer participating in the Cancer Care Outcomes and Research Surveillance (CanCORS) study. Fatalistic beliefs were assessed with an established measure. A fatalism score (range, 4–16) was created by summing Likert scale responses to four items. Cancer stage at diagnosis was abstracted from medical records by trained staff. Logistic regression was used to assess the association between fatalism score and advanced stage at diagnosis (IV vs. I–III), adjusting for sociodemographic and clinical characteristics.

Results: Overall, 917 (21%) patients had stage IV cancers (lung: 28%, colorectal: 16%). The mean fatalism score was 10.7 (median = 11; interquartile range, 9–12). In adjusted analyses, a higher fatalism score was associated with greater odds of stage IV diagnosis (OR per unit increase in fatalism = 1.05; 95% confidence interval 1.02–1.08; P = 0.003). Patients with the highest fatalism score had an adjusted 8.9% higher frequency of stage IV diagnosis compared with patients with the lowest score (25.4% vs. 16.5%).

Discussion: In this large and socioeconomically, geographically, and ethnically diverse population of patients with lung and colorectal cancer, fatalistic beliefs were associated with higher risk of advanced stage at diagnosis. Longitudinal studies are needed to confirm causation.

Impact: These findings support the value of incorporating information about the curability of early-stage cancers in public education campaigns. Cancer Epidemiol Biomarkers Prev; 24(4); 720–6. ©2015 AACR.


Background: There is substantial evidence that use of NSAIDs reduces the risk of colorectal cancer, but no subgroup has been identified for which the chemoprevention effect outweighs the risk of side effects.

Methods: We tested the interaction between NSAID use and multiple risk factors on colorectal cancer risk in the VITAL cohort. A total of 73,458 individuals ages 50 to 76 years completed a questionnaire between 2000 and 2002, and 674 incidental colorectal cancer cases were identified through 2010.

Results: In stratified analysis, high use of any type of NSAIDs (4+ days/week for 4+ years) was statistically significantly associated with a lower risk of colorectal cancer across all subgroups stratified by sex, body mass index, physical activity, smoking, alcohol intake, screening, and dietary factors. There was a suggestion of stronger associations among men, obese individuals, and heavier drinkers; however, none of these tests for interaction reached statistical significance. The associations were almost identical for subjects with higher overall colorectal cancer risk scores [HR, 0.62; 95% confidence interval (CI), 0.49–0.79] and those with lower risk scores (HR, 0.61; 95% CI, 0.42–0.88). Differential effects by cancer subsites and stages were tested. NSAID use was associated with a greater risk reduction of proximal colon cancer versus distal (P for difference = 0.06) and distant stage versus local (P for difference = 0.04).

Conclusion: The association between high use of NSAIDs and colorectal cancer risk does not differ significantly among subgroups.

Impact: Our results suggest that NSAIDs have a generally beneficial role in colorectal cancer prevention, largely unmodified by other exposures. Cancer Epidemiol Biomarkers Prev; 24(4); 727–35. ©2015 AACR.


Background: Awareness of individual risk may encourage improved prevention and early detection of melanoma.

Methods: We evaluated the accuracy of self-reported pigmentation and nevus phenotype compared with clinical assessment, and examined agreement between nevus counts from selected anatomical regions. The sample included 456 cases with invasive cutaneous melanoma diagnosed between ages 18 to 39 years and 538 controls from the population-based Australian Melanoma Family Study. Participants completed a questionnaire about their pigmentation and nevus phenotype, and attended a dermatologic skin examination.

Results: There was strong agreement between self-reported and clinical assessment of eye color [, = 0.78; 95% confidence interval (CI), 0.74–0.81]; and moderate agreement for hair color ( = 0.46; 95% CI, 0.42–0.50). Agreement between self-reported skin color and spectrophotometer-derived measurements was poor ( = 0.12; 95% CI, 0.08–0.16) to moderate (Spearman correlation rs = –0.37; 95% CI, –0.32 to –0.42). Participants tended to underestimate their nevus counts and pigmentation; men were more likely to underreport their skin color. The rs was 0.43 (95% CI, 0.38–0.49) comparing clinical total body nevus counts with self-reported nevus categories. There was good agreement between total body nevus counts and site-specific nevus counts, particularly on both arms.

Conclusions: Young adults have suboptimal accuracy when assessing important risk characteristics including nevus numbers and pigmentation. Measuring nevus count on the arms is a good predictor of full body nevus count.

Impact: These results have implications for the likely success of targeted public health programs that rely on self-assessment of these factors. Cancer Epidemiol Biomarkers Prev; 24(4); 736–43. ©2015 AACR.


Background: Intermittent claudication, muscle ischemia due to reduced arterial circulation, may be associated with an increased risk of cancer risk and death due to neoplasm-induced hypercoagulability and angiogenesis, or to shared risk factors, but the relation is not well understood.

Methods: We conducted a population-based cohort study using the Danish National Registry of Patients to identify patients with intermittent claudication from 1980 to 2011 and no history of cancer. We followed these patients for incident cancers using the Danish Cancer Registry and compared cancer incidence among patients with intermittent claudication to that expected in the general population. We also compared the survival of patients with cancer with and without claudication, matched for sex, cancer site, stage, age at diagnosis, and diagnosis year.

Results: A total of 53,762 patients with intermittent claudication were identified. We observed 6,270 incident cancers over a total 269,430 years of follow-up (mean, 5.0), compared with 4,306 cancer cases expected [standardized incidence ratio = 1.46; 95% confidence interval (CI), 1.42–1.49]. Cancer risk also increased after the exclusion of patients with a prior diagnosis of cerebrovascular disease, myocardial infarction, or diabetes, particularly for tobacco-related cancers. The elevated cancer risk persisted over 10 years of follow-up. For patients with cancer, diagnosis of intermittent claudication within 3 months preceding the cancer diagnosis did not influence survival, but before 3 months, was associated with modestly worse survival (mortality rate ratio = 1.19; 95% CI, 1.14–1.25).

Conclusions: Intermittent claudication is associated with an increased risk of cancer and poorer subsequent survival.

Impact: Clinical attention following intermittent claudication diagnosis may reveal incident cancers. Cancer Epidemiol Biomarkers Prev; 24(4); 744–8. ©2015 AACR.


Background: Little is known about whether history of allergies and atopy is related to the occurrence of keratinocyte cancers. Thus, we evaluated the association between history of allergies and atopy and the incidence of squamous cell carcinoma (SCC) and early onset basal cell carcinoma (BCC).

Methods: As part of a population-based case–control study, interviews were conducted with 1,050 residents of New Hampshire (375 early onset BCC cases and 251 controls, 254 SCC cases and 432 controls). ORs of SCC and early onset BCC and history of allergy and atopic dermatitis were computed using logistic regression, while controlling for potential confounding factors.

Results: An overall inverse association was observed between a history of allergy and early onset BCC [OR, 0.61; 95% confidence interval (CI), 0.38–0.97] but not SCC (OR, 1.18; 95% CI, 0.78–1.79). Among women, we found reduced ORs of both early onset BCC and of SCC in relation to allergy history (early onset BCC OR, 0.53; 95% CI, 0.31–0.92 and SCC OR, 0.59; 95% CI, 0.29–1.19). Among men, we observed no clear association with early onset BCC (OR, 0.87; 95% CI, 0.39–1.99) and an increased risk of SCC (OR, 1.58; 95% CI, 0.93–2.69).

Conclusion: Our findings suggest that allergies and atopy may influence risk of early onset BCC and SCC, and that effects may be gender specific.

Impact: A deeper understanding of the immune mechanisms underlying allergies and atopy may provide new routes of preventing keratinocyte cancers. Cancer Epidemiol Biomarkers Prev; 24(4); 749–54. ©2015 AACR.


Background: Recently, the Nordic diet has gained interest, and a healthy Nordic food index has been developed, which has been found inversely related to colorectal cancer among Danish women. This single finding, however, requires replication in other cohorts.

Methods: We conducted a prospective study in the Women's Lifestyle and Health cohort, including 45,222 women, recruited in 1991–92, and followed up ever since through Swedish registries. Participants were classified according to the Nordic food index (consisting of whole grain bread, oatmeal, apples/pears, cabbages, root vegetables, and fish/shellfish), and the association between adherence and colorectal cancer was assessed using the Cox proportional hazards models.

Results: In the fully adjusted models, we found no association, neither with the continuous index score [incidence rate ratio (IRR), 1.04; 95% confidence interval (CI), 0.95–1.12, per 1-point increment] nor in the categorical analyses (IRR, 1.09; 95% CI, 0.78–1.52 for highest vs. lowest adherers).

Conclusion: The present study does, thus, not support a previous finding of an inverse association between a healthy Nordic food index and colorectal cancer.

Impact: This article adds new evidence to the field of the Nordic diet in disease prevention. Cancer Epidemiol Biomarkers Prev; 24(4); 755–7. ©2015 AACR.


There has been limited research examining the role of geographic factors in human papillomavirus (HPV) vaccine uptake among adolescent girls. This study is one of the first to investigate and identify community-level geographic factors that may be associated with HPV vaccine uptake in the United States. We analyzed data from the 2011 and 2012 National Immunization Survey-Teen to examine associations of HPV vaccine initiation (receipt of at least one dose based on healthcare provider records) among female adolescents aged 13 to 17 years (N = 20,565) with ZIP code level geographic factors that were linked to the survey. Analyses were conducted using weighted logistic regression that included state-random effects. HPV vaccine initiation was approximately 53% in both 2011 and 2012. Racial composition and urban/rural residence were both independently associated with vaccine initiation (P = < 0.05). Initiation was higher among girls living in communities where the majority (>50%) of the population was Hispanic compared to communities where the majority of the population was non-Hispanic white (69.0% vs 49.9%; Adjusted Odds Ratio (AOR) 1.55, 95% CI, 1.33–1.80). Girls living in high population density areas (urban) had higher HPV vaccine initiation compared to those living in low population density areas (rural) (56% vs 44.6%; AOR 1.37, 95% CI, 1.13–1.65). Initiation was also higher among girls living in the most impoverished communities compared to girls living in the least impoverished communities (61% vs 50.4%), but community-level poverty was not significant in the adjusted analysis. Higher HPV vaccination coverage in poor urban communities with a high proportion of racial/ethnic minorities may be partly attributable to targeted interventions and the continued effectiveness of the Vaccines for Children program (VFC), which provides recommended vaccines at no cost to eligible children. Learning more about factors that influence higher HPV vaccination initiation rates among certain groups might inform intervention strategies for groups with lower initiation rates.


Cervical cancer (CC) incidence and mortality rates are increased among African American women. We sought to examine the availability of CC prevention services, such as the HPV vaccine and Pap tests, at college health centers among Historically Black Colleges and Universities (HBCUs) compared to Predominantly White Institutions (PWIs). Methods: We analyzed data from a sample of colleges and universities identified using the National Center for Education Statistics' College Navigator tool. Identified HBCUs were matched with a randomly selected four year PWI within the same state, resulting in an analytic sample of 162 colleges and universities. We collected data on health services and institutional characteristics via the institutions' websites, the College Navigator Tool, and by telephone interviews with health centers. We examined whether institutions provided HPV vaccine or Pap tests to students and identified correlates of each using logistic regression. Results: A total of 131 (81%) colleges and universities had operating health centers, of which 121 (92%) were successfully contacted via telephone. HBCUs were less likely than PWIs to offer the HPV vaccine (21% vs.46%; p-value < 0.05) or Pap tests (49% vs. 67%; p-value <0.05). However, in multivariate logistic regression models, the difference was no longer statistically significant. Significant variables were setting (non- rural vs. rural) and enrollment size. Institutions in a non-rural setting (OR = 4.42; 95% CI, 1.01–19.42) were more likely to offer the HPV vaccine, and institutions with higher enrollments (per every 1,000 increase) were more likely to offer the HPV vaccine (OR = 1.24; 95% CI, 1.10–1.39) or Pap tests (OR = 1.18; 95% CI, 1.0–1.39) to students. Conclusion: Many colleges and universities are not offering the HPV vaccine or Pap tests to students. Student enrollment size and non-rural setting of the institution are important determinants of whether a college or university offers CC prevention services. Given that HBCUs support a large concentration of minority students who are at risk of cervical cancer, a greater effort should be employed at these smaller institutions to increase the availability of CC prevention services.


Continued smoking after diagnosis jeopardizes cancer survivors' health and well-being. Quitline-based smoking cessation treatment is convenient, widely available and free, yet the appropriateness of this treatment approach for survivors is not known. We assessed satisfaction among participants in an enhanced quitline intervention as part of a randomized clinical trial assessing feasibility. Methods: We recruited cancer survivors through the NCI Community Clinical Oncology Program (CCOP) network within 6 months of treatment who smoked within the last 7 days and randomized them 2:1 to an enhanced quitline- based intervention (brief in-person motivational interviewing counseling session, quitline telephone counseling, 6 weeks of nicotine replacement patches) or usual care. We collected treatment satisfaction data and self-reported smoking status at 12 weeks and confirmed smoking status for reported non-smokers using a semi-quantitative urinary cotinine assessment. Results: We enrolled 146 survivors (75% female, 79% non-Hispanic white, mean age = 58 years). At entry, survivors reported smoking an average of 15 cigarettes per day; 77% reported smoking within 30 minutes of awakening. Assessments were completed by 63% of the quitline group and 75% of the usual care group at 12 weeks (P > 0.05). 83% of participants in the intervention arm (n = 98) completed at least one quitline call, and 18% completed ≥3 calls. Use of nicotine patches was 61% in the quitline group and 42% in usual care. Quitline participants were generally satisfied with both the in-person counseling (mean satisfaction score = 4.2 (SD = 1.0), on 1–5 scale) and the quitline telephone counseling (mean satisfaction score = 3.4 (SD = 1.3)). 87% would recommend the quitline program to others. Self-reported 7-day point prevalence cessation was 26% in the quitline group and 17% in the usual care arm (P = 0.33). Conclusions: An enhanced quitline smoking cessation intervention appears to be acceptable to cancer survivors and to result in a trend towards slightly higher cessation at 12 weeks. Increased efforts to retain survivors in treatment and encourage the use of nicotine replacement may be necessary to increase the impact of this intervention approach.


Breast cancer survivors may experience deterioration of physical function. This is important because poor physical function may be associated with premature mortality, injurious falls, bone fracture, and disability. We conducted a post hoc analysis to explore the potential efficacy of slowly-progressive weight lifting to reduce the incidence of physical function deterioration among breast cancer survivors. Methods: Between October 2005 and August 2008, we conducted a single-blind, 12-month, randomized controlled trial of twice-weekly slowly-progressive weight lifting or standard care among 295 non-metastatic breast cancer survivors. In this post hoc analysis of data from the Physical Activity and Lymphedema Trial, we examined incident deterioration of physical function after 12-months, defined as a ≥10-point decline in the physical function subscale of the Medical Outcomes Short-Form 36-item (SF-36) questionnaire. We calculated the relative risk (RR) and 95% confidence interval (95% CI) using an unadjusted generalized linear model. Results: Study participants were 56 ± 9 years old (range 36–80). Median adherence to the weight lifting protocol was 81% over 12-months. As compared with the control group, the weight lifting group had greater improvements in upper- and lower-body strength at 12-months (both comparisons P < 0.001). The proportion of participants who experienced incident physical function deterioration after 12-months was 16.3% (24/147) in the control group and 8.1% (12/148) in the weight lifting group [RR: 0.49 (95% CI, 0.25–0.96); P = 0.04]. No serious or unexpected adverse events occurred that were related to weight lifting. Conclusion: Slowly-progressive weight lifting compared to standard care reduced the incidence of physical function deterioration among breast cancer survivors. These data are hypothesis generating. Future studies should directly compare the efficacy of weight lifting to other modalities of exercise, such as brisk walking, to appropriately inform the development of a confirmatory study designed to preserve physical function among breast cancer survivors.


Few prospective studies have investigated the relationship between pre-diagnostic obesity, smoking and prostate cancer (PCa) survival by timing of measurement, by age at diagnosis, and evaluated the interaction between obesity and smoking. METHODS: We conducted a multinational survival analysis among 10,106 PCa cases (1,007 PCa deaths and 2,893 total deaths) from eight cohorts with an average of 8.2 years of follow up. Hazard ratio (HR) of PCa death was estimated using Cox proportional hazard model, adjusting for age, alcohol intake, diabetes status, cohort and duration between baseline and diagnosis and subsequently adjusted for tumor stage and grade. RESULTS: Higher prediagnostic BMI was related to higher risk of PCa death. With each 5 kg/m2 increase in BMI, the multivariate HR for PCa death was 1.08 (95% CI, 1.02–1.14) among overall participants (p-trend = 0.01) and 1.33 (95% CI, 1.18–1.51) among never or former smokers (p-trend < 0.001). This positive trend for PCa mortality was mainly observed among men with BMI measured more than 5 years before diagnosis, and among those age >65 years old at diagnosis. Compared with never smokers, current smokers had significantly elevated risk of PCa death, with a HR of 1.92 (95% CI, 1.52–2.43) regardless of the time of measurement, age at diagnosis and BMI. After further adjusting for tumor stage and grade, the association between BMI, smoking and PCa death was attenuated but remained statistical significant. CONCLUSIONS: In this consortium study of eight large cohorts, smoking and overweight/obesity before diagnosis were significant predictors for subsequent PCa-specific mortality. Smoking significantly modifies the association of BMI and PCa-specific mortality.


Breast cancer (BC) incidence varies across countries and across US ethnic groups. US Immigrants often exhibit an intermediate level of risk between those observed in their birth country and in the US. This transition of risk may partly be explained by uptake of risk factors associated with acculturation. Investigating whether immigration and acculturation risk patterns are similarly reflected in disease biomarkers can provide insight into mechanisms underlying the transition of risk. We examined differences in the distribution of BC risk factors, absolute risk estimates and mammographic density by ethnicity and acculturation. We used data from 366 women recruited from an urban mammography clinic (ages 40–64 years) to compare BC risk factors and Gail model risk estimates across US-born white, US-born African American [AA], US-born Hispanic and foreign-born Hispanic women. We used linear regression models to examine the associations of immigration and acculturation indicators (e.g., generational status, age and life stage at immigration, language use) with percent density and dense breast area, measured from mammograms. Differences in BC risk factors were mostly observed for ethnic groups, with white women having higher reproductive and lifestyle risk profiles (e.g., lower parity, older age at first birth, higher alcohol intake), Hispanics having shorter height and AAs having larger body mass index (BMI) and waist circumference. The average lifetime and 5-year Gail estimates were highest in whites (11.4% & 1.4%), intermediate in AAs (7.2% & 1.0%) and lowest in Hispanics (6.9% & 0.7% in US-born and 6.6% & 0.8% in foreign-born). After adjusting for age, BMI and parity, lower linguistic acculturation, shorter residence in the US, and later age at immigration were associated with lower percent density (all p values for trend across acculturation levels <0.05); e.g., monolingual Spanish and bilingual speakers respectively had on average 5.6% (95% CI, –10.0––1.3) and 3.8% (95% CI, –8.1–0.4) lower percent density than monolingual English speakers. Similar but more modest associations were observed for dense area. The increase in BC risk after immigration to the US and subsequent acculturation may operate via influences on mammographic density in Hispanic women.


Pre-surgical BRCA1/2 genetic testing provides valuable risk information to guide a newly-diagnosed breast cancer patient's decision about whether to have a contralateral prophylactic mastectomy (CPM) to reduce her future risk of cancer in her unaffected breast. Although BRCA1/2 mutation noncarriers face a much lower objective ten-year risk of developing contralateral disease (approximately 3–10%) as compared to the risk of BRCA1/2 mutation carriers (27–37%), some noncarriers still choose to undergo a CPM. The psychosocial factors that motivate this decision are not well understood and warrant investigation. Thus, as part of a prospective study of pre-surgical BRCA1/2 testing, we examined the frequency and psychosocial correlates of the decision to undergo a CPM among newly-diagnosed breast cancer patients who were identified as BRCA1/2 mutation noncarriers. Self-report questionnaire data from 90 BRCA1/2 noncarriers (median age = 43 years, range = 29–59) were analyzed. A sizeable minority of the BRCA1/2 noncarriers (24.4%) chose to undergo a CPM after learning their mutation status (compared to 88% of the 8 BRCA1/2 carriers in the sample). Both bivariate and multivariable analyses indicated that perceiving that one's physician had recommended CPM (OR = 11.17, P = 0.007), perceiving greater risk for contralateral breast cancer (OR = 6.46, P = 0.02), and perceiving greater pros of CPM (OR = 1.37, P = 0.004) were all significantly associated with noncarriers' decision to undergo CPM. However, factors including age, Ashkenazi Jewish ethnicity, breast cancer-related distress, perceived cons of CPM, and decisional conflict regarding CPM were not related to the CPM decision (all ps > 0.05). Results demonstrate that although noncarriers' decision making regarding CPM was unrelated to sociodemographic and emotional factors, their cognitive perceptions of contralateral disease risk, surgical benefits, and physician recommendations were particularly important. Future studies should examine the content of patient-physician communication regarding CPM and hereditary risk in greater detail, and explore how these conversations shape and interact with women's past experiences, emotions, and beliefs to influence their cancer prevention decisions.


Despite lack of survival benefit, an increasing number of women diagnosed with ductal carcinoma in situ (DCIS) opt for removal of the unaffected breast in addition to the breast with known pathology, i.e. contralateral prophylactic mastectomy (CPM). Little is known about women's decision-making processes that contribute to this rising trend, particularly for DCIS. Further obscuring the decision is the highly variable terminology used to discuss breast cancer pathologies and treatments. The purpose of this study was to investigate factors impacting risk comprehension and decision-making related to increased risk for breast cancer or DCIS. We conducted a retrospective and prospective pilot study to evaluate women's perceived contralateral breast cancer risk, health literacy, numeracy, and comprehension of terms used in genetics and breast cancer. Clinical data such as breast MRI, genetic testing, family history, and breast cancer risk derived from predictive models were also collected. Women with DCIS and those high-risk for development of invasive breast cancer were eligible, and 68 patients participated. Of the cohort, 33 (48.5%) women considered pursuing CPM and 11 (16.2%) underwent CPM. Anxiety about cancer recurrence was the top reason for considering CPM. Undergoing CPM was significantly associated with plastic surgery consultation, increased 10-year breast cancer risk, genetic counseling, and genetic testing. The consideration of CPM was also associated with higher incomes. Numeracy, health and genetic literacy, and terminology scores were not significant predictors of CPM. Lastly, 83.8% of respondents stated DCIS qualified as breast cancer, but only 39.7% of patients correctly defined DCIS. When asked to interpret the phrase "indolent lesion of epithelial origin" (new terminology advocated to replace "DCIS"), 27.9% of respondents believed it referred to cancer, 47.1% did not, and 23.5% were unsure. Patients commonly thought "lesion" meant "skin wound" or "sore". Decision-making related to DCIS remains complex. Although CPM has not shown a survival advantage and can have significant complications, CPM rates continue to rise. Recognizing patients' knowledge of risk communication and terminology is vital to support shared and informed surgical decisions.


The association between changing body mass index (BMI) and mammographic breast density is important to better evaluate how to adjust for BMI gain/loss in longitudinal studies of density and breast cancer risk. Increasing BMI has been associated with decreasing percent dense area but the effect on absolute dense area is unclear. No studies have explored a longitudinal association using volumetric density measurement. Methods: We examined the association between change in BMI and change in volumetric breast density among 24,556 women who received breast imaging at the San Francisco Mammography Registry from 2007–2013. Height and weight were self-reported at the time of mammography. Breast density was assessed using single x-ray absorptiometry (SXA) volumetric measurement. The cross-sectional and longitudinal associations between BMI and absolute dense volume (DV) and percent dense volume (PDV) were assessed using multivariable adjusted regression. Results: Women were primarily Caucasian (66%) or Asian (25%) and most were postmenopausal (64%) at time of first mammogram. In cross-sectional analysis, BMI was positively associated with DV (β = 2.95 cm3, 95% CI, 2.69–3.21) and inversely associated with PDV (β = –2.03%, 95% CI, –2.09––1.98). In longitudinal analysis, an annual increase in BMI was associated with an annual decrease in both DV (β = –1.01 cm3/year, 95% CI, –1.59––0.42) and PDV (β = –1.17%/year, 95% CI, –1.31––1.04). Findings were consistent between pre- and postmenopausal women. The annual decrease in DV was strongest among premenopausal women who were initially overweight or obese (P < 0.01 for interaction by initial BMI). Conclusion: Our findings support an inverse association between change in BMI and change in PDV. Longitudinal studies of PDV and breast cancer risk, or those using PDV as an indicator of breast cancer risk, should consider adjusting for change in BMI. The association between increasing BMI and decreasing DV is unexpected and will require confirmation using volumetric methods.


Depression and antidepressant (AD) use have each been hypothesized to increase breast cancer risk, yet previous studies have not considered these exposures together. Thus, it is unclear whether increased risk due to depression may actually be attributable to AD use, or vice versa. Methods: We utilized data from 77,482 women enrolled in the prospective Nurses' Health Study cohort in which data on depression and AD use were collected simultaneously beginning in 2000. Women self-reported whether they had ever been diagnosed with depression by a clinician as well as their use of specific types of ADs. Self-reported breast cancer cases through 2012 were adjudicated and only confirmed invasive cases included as outcomes (N = 2,567). Logistic regression models were utilized to evaluate the effects of baseline depression and AD use, both independently and with mutual adjustment, on breast cancer risk. Results: The average age of participants was 66.2 (SD 7.1) years; 8.9% were clinically depressed and 8.7% used ADs. In separate models adjusted for age, body mass index, and menopausal status, we observed no statistically significant associations between depression (OR 0.94, 95% CI, 0.81–1.08) or AD use (OR 1.07, 95% CI, 0.93–1.22). When these exposures were included together in the same model, depression remained unassociated with breast cancer risk (OR 0.87, 95% CI, 0.74–1.03) while AD use exhibited a small, borderline significant increase in risk (OR 1.15, 95% CI, 0.98–1.35). The latter association remained consistent for selective serotonin reuptake inhibitors (SSRIs; OR 1.16, 95% CI, 0.96–1.39) but was not apparent for other classes of ADs (OR 1.07, 95% CI, 0.85–1.35). Conclusions: These initial results indicate that depression is not associated with breast cancer risk, while we could not exclude a slight increase in risk associated with SSRI use. Further analyses will update exposure information over follow-up and also evaluate whether associations differ by menopausal status or hormone receptor disease subtypes. Clarifying the effects of these exposures on breast cancer risk will provide critical information for the millions of women who are depressed and/or use ADs.


During adolescence the breasts undergo rapid growth and development under the influence of sex hormones. Although the hormonal etiology of breast cancer is hypothesized, it remains unknown whether adolescent sex hormones are associated with adult breast density, which is a strong risk factor for breast cancer. METHODS: Percentage of dense breast volume (%DBV) was measured in 2006 by magnetic resonance imaging in 177 women aged 25–29 years who participated in the Dietary Intervention Study in Children from 1988–1997 and had sex hormones and sex hormone binding globulin (SHBG) measured in serum collected on 1–4 occasions between 8 and 17 years of age. Multivariable linear mixed-effect regression models were used to evaluate the associations of adolescent sex hormones and SHBG with %DBV. RESULTS: Dehydroepiandrosterone sulfate (DHEAS) and SHBG measured in premenarche serum samples were significantly positively associated with %DBV (all Ptrend ≤ 0.03) but not when measured in postmenarche samples (all Ptrend ≥ 0.42). The multivariable geometric mean of %DBV across quartiles of premenarcheal DHEAS and SHBG increased from 16.7% to 22.1% and from 14.1% to 24.3%, respectively. Estrogens, progesterone, androstenedione, and testosterone were not associated with %DBV pre- or post-menarche (all Ptrend ≥ 0.16). CONCLUSIONS: Our results suggest that higher DHEAS and SHBG levels during adolescence, particularly before the onset of menarche, are associated with higher%DBV in young women. Whether this association translates into an increased risk of breast cancer later in life is currently unknown.


Use of electronic nicotine delivery systems, most commonly called e-cigarettes (e-cigs,) has been rising over the past few years, with the greatest use among traditional cigarette smokers. The utility and harm of this group of emerging tobacco products are under debate. While some propose them as novel tobacco cessation tools, others decry their potential for sustained addiction and negative health effects. We examined smokers' e-cig use and smoking behaviors at hospitalization and 6 months later. Methods: 979 smokers hospitalized at a tertiary care medical center were recruited to a longitudinal observational study and provided baseline data during hospitalization and 6-months later. Past 30-day (current) e-cig use and smoking rates at both baseline and 6-month follow-up were examined with t-tests. Chi square test examined baseline e-cig use and 6-month smoking status. Results: 823 (84.1%) participants provided data at both time points: mean age was 46 years; 53.6% were White, 44.0% were Black, and 2.5% other; 22.5% had less than a high school degree, 38.8% had a high school diploma/GED, and 38.7% had some college or more; 30.8% were married/domestic partner and 53.6% were male. Current e-cig use was reported by 171 (20.7%) at baseline and 246 (29.9%) at 6-month follow- up, with 98 (11.9%) reporting current e-cig use at both time points. At 6-months follow- up, 12.2% of baseline current e-cig users vs. 13.4% of baseline non-users reported quitting smoking (P = 0.80), with 22% of baseline e-cig users who quit still using e-cigs at 6–months follow-up. Baseline current e-cig users reported higher daily cigarette consumption (14.1 vs. 11.9; P = 0.010) at baseline but not 6-months later (10.3 vs. 9.8; P = 0.619); whereas, continuing smokers with current e-cig use at 6 months follow-up reported fewer cigarettes per day (8.4 vs. 10.5; P = 0.008). Conclusions: Among adult smokers, current e-cig use at hospitalization was associated with higher cigarette consumption at baseline but was not predictive of quitting or consumption (among continuing smokers) at 6-months follow-up. Further, current e-cig use at 6 months was associated with a greater reduction in cigarettes smoked per day among continuing smokers at 6-months after hospitalization.


This study investigates the rate of missed opportunities for the HPV vaccine among eligible girls using statewide vaccine registry data. Methods: Using data from the Utah Statewide Immunization Information System (USIIS) from 2008–2012 for approximately 55,000 girls ages 11–18, we assessed the frequency of missed opportunities (receipt of other recommended vaccinations such as TDap, MCV4, and/or flu and not the HPV vaccine) among eligible female patients for the HPV vaccine. USIIS is a free, confidential, web-based information system that contains immunization histories for Utah residents of all ages. Records of all persons born in Utah since 1998 are in USIIS. USIIS is designed to help enrolled healthcare providers track immunization records for patient care by consolidating immunizations from enrolled providers into one centralized record. Vaccine administration from 86% of healthcare providers in Utah is reported to USIIS. USIIS data used for the study include date of birth, age, gender, ethnicity and race, zip code, and date and type of vaccine received. Descriptive statistics and chi- square tests were used to assess rate of missed opportunities for the HPV vaccine and associated demographic factors. Results: Approximately 65% of preteens (ages 11–12; N = 2,593) and 32% of female teens (ages 13–18; N = 4,937) had a missed opportunity for the HPV vaccine between years 2008–2012 in Utah (P < 0.001). Race and ethnicity related to rates of missed opportunities for the HPV vaccine among all girls ages 11–18 (Whites = 36%, N = 2,454; Hispanics = 21%, N = 254) (P < 0.001). Rural and urban locations were also associated with rates of missed opportunities for the HPV vaccine (urban = 31%, N = 4,448; large rural town = 42%, N = 202) (P < 0.001). Conclusions: For more than eight years, a vaccine to prevent cervical and other HPV-related cancers has been available, yet receipt of the 3-dose HPV vaccine in the United States is far below national goals for girls (33% vs. 80%; actual vs. target). Using statewide vaccine registry data, our study demonstrates that administering the HPV vaccine when providing other recommended adolescent vaccinations may dramatically improve rates of HPV vaccination among girls in a state with low HPV vaccine uptake. In addition, targeting rural communities and non-Hispanic White patients may further reduce missed opportunities.


This randomized controlled trial was designed to assess the effects of a 16-week combined (aerobic and resistance) exercise intervention on metabolic syndrome (MetS) in overweight and obese Latina breast cancer survivors (LBCS). MetS is associated with increased risk of cardiovascular diseases, type 2 diabetes, and possibly cancer recurrence, and is defined by increased waist circumference (WC), elevated blood glucose (BG), high triglycerides (TG), low high-density lipoprotein cholesterol (HDL), and elevated blood pressure (BP). Methods. Forty LBCS (BMI ≥ 25 kg/m2) were recruited from the USC Lee Breast Clinic and Los Angeles County Hospitals. Participants were randomized to either the Control (CON; n = 20) or the Exercise (EX; n = 20) groups. Participants were tested for MetS outcomes including BP, WC, fasting levels of FBG, HDL, and TG at baseline, post-intervention, and 12-weeks post- intervention (EX group only). The EX group participated in aerobic and resistance exercise sessions 3 times a week for 16 weeks, supervised by an exercise specialist at the WHEL. Aerobic exercise included cycling, walking, or jogging at 65–85% heart rate maximum. Resistance exercise was performed in circuit-fashion with 3 sets of 10–15 repetitions including upper and lower body exercises at 65–70% 1-repetition maximum. The CON group was asked to maintain less than 120 min/week of exercise during the study period. Repeated measures ANOVA was used to test for statistically significant between-group differences in MetS. Results. There were no significant group differences in MetS between the EX and CON groups at baseline (P > 0.01). However, post-intervention, all MetS components were significantly lower in the EX group than the CON group (P < 0.01). Further, in the EX group, MetS at 12-week post- intervention was not statistically different from post-intervention (P > 0.01). Conclusions. A 16-week supervised resistance and aerobic exercise intervention attenuated MetS in overweight and obese LBCS. Further, reductions in MetS components were maintained following the completion of the intervention, suggesting that the benefits of the intervention on MetS were sustainable in the absence of a supervised intervention.


Cancer is most often a disease of aging, and frequently, a disease for which obesity serves as a risk factor. Thus, many cancer survivors are older, overweight or obese, with higher illness burden, symptoms, and comorbidities. Against this backdrop, survivors are at increased risk for functional decline. The question is whether lifestyle interventions can still benefit older, sicker survivors? The purpose of this study was to examine how overweight long-term survivors' symptom severity prior to a diet and exercise intervention is associated with post-intervention function and to determine symptoms' effects on function through change in physical activity, diet quality, and weight status. Methods This is a secondary data analysis of 514 breast, prostate, and colorectal cancer survivors who participated in the one-year home-based diet and exercise intervention, Reach-Out to Enhance Wellness (RENEW) trial. Pre- and post-intervention data were analyzed. Measures of this study included pre-intervention symptoms, changes in weight, physical activity, diet quality, and post-intervention overall physical function (PF), and basic and advanced lower extremity function (BLEF and ALEF). Simple and serial mediation analyses were conducted to examine direct effects of symptom severity on BLEF and ALEF and the indirect effects of symptom severity through changes in diet quality, physical activity, and weight status. Results Increased symptom severity was directly associated with lower functioning scores for PF (b = –0.63 P < 0.001), BLEF (b = –0.33, P < 0.001) and ALEF (b = –0.22, P < 0.001). Indirect effects of symptom severity through weight loss, physical activity and diet were not significant. Weight loss and increased physical activity were significantly associated with higher PF and ALEF and higher diet quality was associated with higher BLEF. Conclusion Symptom severity of older, overweight cancer survivors negatively affects physical function. However, greater weight loss and physical activity were associated with higher functioning scores, regardless of symptom severity. Findings build from the recent emphasis on the negative effects of obesity on survivor outcomes to highlight weight loss as an important factor in maintaining function in older cancer survivors.


To examine the trend of racial disparity in receiving a physician recommendation for human papillomavirus (HPV) vaccine among US adolescent girls. Methods: We analyzed National Immunization Survey of Teens (NIS-Teen) 2008–2012 data and examined the trend of racial disparity in receiving a physician recommendation for HPV vaccine among 13–17 year old US adolescent girls. Results: Overall, the weighted proportion of girls who received a physician recommendation was 49.2%, 57.0%, 54.9%, 58.8% and 65.3% in 2008, 2009, 2010, 2011 and 2012, respectively (p for trend <0.001). The respective weighted proportion for non-Hispanic white, non-Hispanic black and Hispanic girls were: 53.6%, 60.7%, 59.0%, 63.4% and 70.2%; 42.7%, 50.0%, 46.3%, 52.5% and 62.8%; and 40.0%, 50.8%, 48.0%, 51.4% and 56.5% (P < 0.001 for all 5 years). After adjusting for demographic characteristics, separate weighted analysis for each year of data showed that non-Hispanic black and Hispanic girls were less likely to receive a physician recommendation than non-Hispanic white girls (P < 0.01 for all 5 years). However, there was no significant difference between Non-Hispanic black and Hispanic girls (P > 0.05 for all 5 years). Conclusions: Reasons for racial disparity in receiving a physician recommendation need to be identified and addressed to achieve the desired level of HPV vaccine uptake among US adolescent girls, irrespective of race/ethnicity.


People who live in food-insecure households face significant unmet health needs. At the same time, this population may be under-represented in clinical research studies because of the population's limited and intermittent engagement with the health care system. We describe preliminary results of a research partnership between UT Southwestern Medical Center (UTSW) and Crossroads Community Services (CCS), the largest charitable food distributor of the North Texas Food Bank. The goal of the study is to improve understanding of this population's health- and mammography-related needs, knowledge and service utilization. Eight structured focus groups were conducted in English (n = 4) and Spanish (n = 4) at CCS. Discussions focused on 13 open-ended questions designed to solicit group communication about members' health status, healthcare access, mammography awareness and utilization, and attitudes toward participation in future health research. Participants included 42 CCS clients, about 90% of whom were Hispanic or African-American women. Key findings include: (1) Participants reported multiple co-morbid conditions among themselves and household members, yet utilization of health services was cost-dependent and often limited to emergency triage. (2) Many participants did not know what a mammogram was and utilization was closely linked to having health insurance, which most did not. (3) Despite reporting numerous daily life challenges, the majority were interested in participating in future research-related focus groups as a means of communicating their health needs and obtaining information and emotional support from peers. Recruitment from charitable food distribution sites will target a high-need, underserved population. The community-academic partnership between CCS and UTSW has created a robust foundation for cancer prevention research that has already produced important insights about the population's needs and willingness to participate in research. Ongoing research is focused on implementing longitudinal health assessments of CCS clients. These data will be used to guide future interventions to increase awareness and utilization of cancer prevention services, e.g. mammography, in a population facing multiple barriers to care.


The "Hispanic epidemiologic paradox" is the commonly observed phenomenon that foreign-born Hispanic mothers who emigrate to the United States have consistently good pregnancy outcomes, such as decreased rates of low birthweight, despite high levels of poverty. We examined whether this advantage extends to childhood cancer risk. Methods: The study included all children born in California from 1983–2007. Birthrolls were linked to California Cancer Registry records of children ages <6 who were diagnosed with cancer 1988–2007 (N = 8710 cases, 9,519,438 controls). The mother's Hispanic origin, ethnic ancestry, and country of birth were ascertained from the birth certificate. We used Cox proportional hazard models to estimate the risk for cancer based upon maternal birthplace and ethnic ancestry. Models stratified by tumor subtype and adjusted for maternal and paternal age. Summary of results: The children of foreign-born Hispanic women had lower rates of several cancers [acute lymphoblastic leukemia (ALL; odds ratio (OR) = 1.05, 95% confidence interval (CI) = 0.96–1.14); glioma (OR = 0.51, 95% CI, 0.43–0.59); neuroblastoma (OR = 0.46, 95% CI, 0.39–0.55)] in comparison to the children of US-born Hispanic women [ALL (OR = 1.23, 95% CI, 1.11–1.37); glioma (OR = 0.75, 95% CI, 0.62–0.90); neuroblastoma (OR = 0.63, 95% CI, 0.51–0.78); referent group was the children of US-born Whites]. The odds for rhabdomyosarcoma and acute myeloid leukemia were equivalent between Hispanics regardless of maternal place of birth. Hepatoblastoma was higher among the children of foreign-born mothers (OR = 1.35, 95% CI, 0.87–2.10) than those of US-born Hispanic mothers (OR = 0.93, 95% CI, 0.56–1.55) while bone tumors were higher among the children of US-born mothers (OR = 2.08, 95% CI, 1.11–3.88) compared to the children of foreign-born mothers (OR = 0.73, 95% CI, 0.38–1.41). Conclusions: With notable exceptions, the children of foreign-born Hispanic mothers tended to have cancer rates lower than those of US-born Hispanic mothers. Risk factors identified as driving the Hispanic paradox may be fruitful for study among these childhood cancer types.


This purpose of this study is to evaluate the willingness of women to change their breast cancer screening practices if given personalized recommendations based on risk factors such as breast density, family history and lifestyle. Methods: A random sample of 1,024 Virginia women between age 35–70 years and without breast cancer, reached by landline and cell phone, completed a 24-minute interview. Results: Just over half (54.6%) of women are definitely or probably willing to reduce their frequency of breast cancer screening if provided with personalized recommendations. This compares to 81.9% who are definitely or probably willing to increase screening. The most cited disadvantage for reduced screening was delayed detection of breast cancer (77%) while the most cited advantage for increased screening is earlier detection (82%). Women are willing to change their type of screening (92.3%). Women who were more likely to be willing to reduce screening are those with a lower perceived risk of breast cancer, less familiarity with risk factors and recommendations. When asked what they needed to know to make a change, women cited advice of a doctor (52.1%), research/evidence (38.9%) and comparison with old recommendations (22.5%) most frequently. Advice of a radiologist was only stated by 2.3% of the women. Conclusions: These results suggest that most women will be willing to change their breast cancer screening frequency especially if recommended by their primary care physician. Women do not view their radiologist as having a primary role in delivering screening recommendations; this underscores the need to educate primary healthcare providers regarding breast screening recommendations.


African-American (AA) men have the highest rates of prostate cancer incidence and mortality in the US. Understanding underlying reasons for this disparity could identify preventive interventions important to AA men. PURPOSE: To determine whether the association of obesity with prostate cancer risk differs between AA and non-Hispanic white (NHW) men and whether obesity modifies the excess risk associated with AA race. METHODS: This is a prospective study among 3398 AA and 22673 NHW men who participated in the Selenium and Vitamin E Cancer Prevention Trial (2001–2011). Using Cox regression, we estimated hazard ratios (HRs) and corresponding 95% confidence intervals (CIs) associated with AA and NHW race and body mass index (BMI) [kg/m2] on total, low- (Gleason score <7), and high-grade (Gleason score ≥7) prostate cancer incidence while adjusting for relevant covariates. RESULTS: There were 270, 148, and 88 cases of total, low-, and high-grade prostate cancers among AA men and a corresponding 1453, 898, and 441 cases in NHW men (median follow-up of 5.6 years). BMI was not associated with risk of total cancer among NHW men, but was positively associated with risk among AA men (BMI < 25 kg/m2 vs. ≥35 kg/m2, HR = 1.49; 95% CI, 0.95–2.34; Ptrend = 0.03). Consequently, the risk associated with AA race increased from 28% (HR = 1.28; 95% CI, 0.91–1.80) among men with BMI < 25 kg/m2 to 103% (HR = 2.03; 95% CI, 1.38–2.98) among AA men with BMI≥35 kg/m2 (Ptrend = 0.03). BMI was inversely associated with low-grade prostate cancer risk among NHW men (BMI < 25 kg/m2 vs. ≥35 kg/m2, HR = 0.80; 95% CI, 0.58–1.09; Ptrend = 0.02), but positively associated with risk among AA men (BMI < 25 kg/m2 vs. ≥35 kg/m2, HR = 1.77; 95% CI, 1.14–2.76; Ptrend = 0.05). BMI was positively associated with risk of high-grade prostate cancer in both NHW (BMI < 25 kg/m2 vs. ≥35 kg/m2, HR = 1.33; 95% CI, 0.90–1.97; Ptrend = 0.01) and AA men (BMI < 25 kg/m2 vs. ≥35 kg/m2, HR = 1.81; 95% CI, 0.79–4.11; Ptrend = 0.02), but associations were not significantly different. CONCLUSION: Obesity is more strongly associated with increased prostate cancer risk among AA than NHW men and reducing obesity among AA men could reduce the racial disparity in cancer incidence. Research is needed to test mechanisms underpinning these associations.