Association between malignancies of the upper aerodigestive tract and uterine cervix.

Cancers of the cervix and buccal cavity share histologic, epidemiologic, and exposure characteristics. In particular, cigarette smoking and human papillomavirus (HPV) have been cited as etiologic cofactors of both malignancies. Using incidence data from the Surveillance, Epidemiology, and End Results (SEER) program of the National Cancer Institute for the years 1973 through 1984, we evaluated the incidence of second cancers of the buccal cavity following an initial cervical cancer. Standardized incidence ratios (SIR) were uniformly elevated for both white (SIR = 2.0), and black (SIR = 3.5) women. There were also elevated risks for the development of cervical cancer following an initial buccal cavity cancer (SIRs = 3.3 and 2.5, respectively). A similar pattern was evident for laryngeal cancer among white women. HPV transmission could account in part for the paired occurrence of these two anatomically distinct cancer sites. Cigarette smoking could act as a synergistic cofactor in the malignant transformation of viral genome-harboring tissue.

Cancer control and the older person. Prevention and detection in older persons.

Older persons are appropriate targets for a range of prevention and early detection interventions, however, greater emphasis should be given to structuring the delivery of prevention and detection services to the special needs of this population. This may require research and program development to reach older persons in the most effective and cost-effective manner. The American Cancer Society and other program efforts must accommodate the heterogeneity and special needs of segments of the older population. Racial and cultural minorities, impoverished persons, the cognitively impaired, and the physically impaired are four groups requiring special attention. Early detection guidelines specific to older persons should be developed.

Familial patterns of prostate cancer: a case-control analysis.

Epidemiological data have not yet enabled physicians to look beyond age and race to identify men at increased risk for prostate cancer. We conducted a hospital-based case-control study of familial patterns of prostate cancer with self-reported data from a risk-factor questionnaire. There were 385 patients with histologically confirmed prostate cancer, and 385 race and age-matched (+/- 5 years) controls with other cancers. Family history, available for 378 patients and 383 controls, was positive for prostate cancer in 13.0% versus 5.7%, respectively. The difference was significant at p = 0.01. The over-all age-adjusted risk estimate for men with a first-degree relative with prostate cancer was significantly elevated (odds ratio of 2.41), as were the individual risk estimates for having a father or brother with prostate cancer (odds ratio of 2.24 and 2.66). Having a second-degree relative (grandfather or uncle) with prostate cancer also conferred elevated but not statistically significant risk. These data accord well with the few previously published case-control studies of familiarity of prostate cancer. On the basis of these findings, one should consider recommending participation in early detection programs for prostate cancer in a man whose father or brother has had the disease.

Risk profiles of women with cervical neoplasia.

Risk-factor profiles were compared in M.D. Anderson Cancer Center patients with various uterine cervix histologic diagnoses. Intraepithelial neoplasia (n = 171) and condyloma (n = 82) were associated with significantly lower patient age (mean 23.6 and 25.8 years, respectively). In addition, these two groups were lowest in annual income, age at beginning intercourse and at first pregnancy, and highest in percentages of black and Hispanic patients, number of sexual partners, and history of gonorrhea. Women with squamous carcinoma in situ (n = 47), who were about a decade older, exhibited a similar socioeconomic distribution and sexual history. All three groups also reported high prevalences of current smokers, were most likely to use oral contraceptives, and were least likely to use diaphragms or condoms. Patients with invasive squamous cell carcinoma (n = 77) had a mean age of 46.3 years, a large lowest-income constituency, and the highest mean number of pregnancies; they were least likely to have used oral contraceptives. Adenocarcinoma (n = 21) was epidemiologically distinct: a predominance of white woman characterized by high socioeconomic status, elevated body mass index, and non of the liberal sexual practices of the other groups. Primary and secondary prevention strategies must be tailored to the unique needs and socioeconomic status of the young at-risk populations.

History of cigarette smoking and risk of leukemia and myeloma: results from the Adventist health study.

The risks of leukemia and myeloma associated with cigarette smoking were evaluated in a cohort study of 34,000 Seventh-day Adventists. Although Seventh-day Adventists do not smoke by church proscription, many are adult converts who smoked cigarettes prior to their baptism into the church. In comparison with those who never smoked, ex-smokers experience a relative risk of 2.00 (95% confidence interval = 1.01-3.95) for leukemia and 3.01 (95% confidence interval = 1.13-8.05) for myeloma. Risks increased in a dose-response fashion with increasing numbers of cigarettes smoked daily for both leukemia (trend P = .009) and myeloma (trend P = .005). Also, the risks of both leukemia and myeloma increased with the total duration of cigarette smoking. The cigarette smoking-leukemia relationship was strongest for myeloid leukemia, for which ex-smokers experienced a relative risk of 2.24 (95% confidence interval = 0.91-5.53). These data lend support to the hypothesis that cigarette smoke may induce malignant degeneration in bone marrow and its products.

Salivary gland cancer. A case-control investigation of risk factors.

Unlike most upper aerodigestive tract cancers, salivary gland cancers are relatively infrequent, are characterized by a diversity of histologic subtypes, and have never been etiologically associated with tobacco exposure. We present the results of a case-control study of risk factors for these cancers, with risk estimates derived from self-administered comprehensive risk-factor questionnaires distributed to patients at The University of Texas M. D. Anderson Cancer Center, Houston. Cases were 64 patients with histologically confirmed salivary gland cancer. Control subjects, randomly selected from the same patient population excluding patients with cancer of the head and neck or nonmelanoma skin cancer, were frequency-matched to the cases by age, sex, and ethnicity to achieve a 2:1 control subjects/cases ratio. On multivariate analysis, prior radiotherapy was a significant risk factor for both men (odds ratio [OR] = 2.1) and women (OR = 2.3). Among women, higher educational attainment (OR = 2.4), alcohol use (OR = 2.0), and hairdye use (OR = 2.5) were also significantly associated with risk. There were no significant differences between cases and control subjects with respect to tobacco exposure or specific occupational or leisure-time exposures. There is biological plausibility for associations with hairdye use and alcohol exposure.

Salivary gland cancer and risk of subsequent skin cancer.

There are epidemiologic similarities between salivary and skin neoplasms that could be attributed to exposure to ultraviolet radiation. To explore further the etiologic parallels between these two types of cancer, we studied the multiple primary association between salivary gland cancer with that of other cancers known to be induced by ultraviolet light exposure, using data from the SEER program for 1973-1984. Because nonmelanoma skin cancers other than cancers of the lip are not routinely reported to the SEER registries, we specifically evaluated the associations with melanoma and lip cancers. Expected numbers of subsequent primaries (melanoma and lip) for the 904 white men and 784 white women with an initial salivary gland cancer were computed from incidence rates using the Connecticut Tumor Registry. There were significantly increased risks for subsequent lip cancer among men (RR = 8.7) and for melanoma among women (RR = 7.1). Among men there was also a significant association between an initial lip cancer and risk of subsequent salivary gland cancer (RR = 12.7). These observations, together with reported increases in incidence of these tumors, suggest a common etiology, which could partly be explained because of exposure to ultraviolet radiation.

Cigarette smoking patterns in patients after treatment of upper aerodigestive tract cancers.

There is a paucity of data on variables predictive of successful smoking cessation in cancer patients. In this questionnaire-based study, we report the smoking status of 75 patients (46 men, 29 women) with head and neck cancer followed for a minimum of 30 months after definitive therapy. Seventy-one percent of the men and 61% of the women who were current smokers at diagnosis stopped smoking subsequent to diagnosis and treatment. Only 29% and 39%, respectively, continued to smoke, most at decreased intensity. Patients with laryngeal cancer were most likely to have stopped (83%). Conversely, patients with oral cavity cancer were most likely to be continuing smokers (66%). In addition, older age, college education, and lighter smoking habits were somewhat predictive of successful cessation. Fear of recurrent disease and physician advice were the questionnaire-listed incentives most often chosen as contributing to success in cessation. The role health professionals can play in counseling cancer patients to stop smoking is stressed.

Chromosome sensitivity to bleomycin-induced mutagenesis, an independent risk factor for upper aerodigestive tract cancers.

Defective DNA repair capability, measured by enumerating mutagen-induced chromosomal lesions, might explain variable host susceptibility to the action of environmental carcinogens. We compared sensitivity to bleomycin-induced chromosome damage in 75 patients (53 men and 22 women) with previously untreated upper aerodigestive tract malignancies with that in 62 healthy control subjects. Data on tobacco and alcohol use were derived from a detailed, self-administered cancer risk factor questionnaire. Forty-five patients and 13 controls were sensitive to bleomycin-induced mutagenesis (average breaks/cell greater than 0.8). Differential susceptibility was detected in patients categorized by primary tumor location. Odds ratios for chromosome sensitivity were significantly elevated for all sites (odds ratio = 10.3 for pharyngeal cancers, 8.0 for laryngeal cancers, and 3.8 for oral cavity cancers). On logistic regression analysis, chromosome sensitivity remained a strong and independent risk factor after adjustment for potential confounding from age, sex, and tobacco and alcohol use (odds ratio = 4.3, 95% confidence limits = 2.0, 10.2). Despite the small study size and design constraints, the strength of the association with chromosome sensitivity even after adjustment for potential confounders is impressive and suggests a promising avenue for further research. The preventive implications of a valid marker for carcinogen sensitivity are manifold.

Food group contributions to nutrient intake in whites, blacks, and Mexican Americans in Texas.

The existence of three different ethnic groups, living within a defined geographic area in Texas and maintaining fairly distinct life-styles, provided an excellent opportunity to compare their dietary behaviors. Information about food consumption was obtained by 24-hour dietary recall from a group of 431 whites, blacks, and Mexican Americans residing in two counties in southeast Texas. Food group and subgroup contributions to 11 nutrients were calculated. The intake patterns of Mexican Americans demonstrated both an adherence to traditional or familiar Mexican food items, such as beans and tortillas, and a preference for foods not previously reported to be commonly consumed by that ethnic group, specifically beef. The current study provides a base of information necessary to implement dietary changes acceptable within the context of a particular culture's world view. Results revealed differences in food intake patterns that would be helpful in designing practical nutrition education programs specifically targeted toward these ethnic groups. For example, inadequate sources of nutrients were identified, as were sources of excess fat.

Incidence and anatomic distribution of cutaneous melanoma among United States Hispanics.

Using the data base for melanoma incidence compiled by the Surveillance, Epidemiology, and End Results (SEER) Program of the National Cancer Institute, we compared the incidence and anatomic distribution of primary cutaneous melanomas in Hispanic and non-Hispanic Caucasian populations and in blacks between 1973 and 1981. Cases were divided into United States whites, New Mexico (NM) whites (non-Hispanic Caucasians), NM Hispanics, Puerto Rico (PR) residents by definition Hispanic, and US blacks. Among whites, the highest incidence was 8.0 per 100,000 and was ten times that of US blacks. The incidence among PR and NM Hispanic residents was 1.6 to 3.7 times that of US blacks. The anatomic distribution among NM Hispanics was similar to US and NM whites for both genders. In contrast, among PR residents the anatomic distribution in both genders was most common for the leg, similar to that for blacks. Spaniards who migrated to PR have more admixture with blacks from Africa than Spaniards who migrated to the mainland. This suggests a genetic predilection for the occurrence of melanoma on the lower extremity among PR residents as opposed to NM Hispanics.

Encouraging trends in lung cancer mortality in Texas, 1970 to 1986.

Trends in lung cancer mortality among white and black men and women in Texas for the years 1970 to 1986 offer some measure of optimism. A decline in mortality for men and women aged 35 to 44 years and for men aged 45 to 54 years is now evident. However, the rates in older men and women continue to rise. Following a long trend of ascending death rates, a plateau in the overall age-adjusted death rates among white men is now suggested. A similar decline for women will probably not be evident until early in the next century. These patterns are consistent with profound changes that have occurred in the prevalence of cigarette smoking over the past 30 years. It is urgent to maintain the momentum by emphasizing smoking cessation and prevention programs.

Cancer and age.

Age is the greatest risk factor for the development of cancer. For etiologic purposes, newly diagnosed cases of cancer among a defined population during a specified time (incidence) is the usual way of depicting cancer as it relates to age. Exposure to carcinogens in utero or perinatally can produce cancers soon after birth or years later. Cancers in older children have been related to growth factors and/or a single exposure to high doses of radiation. Hodgkin's disease occurring among young adults is different histologically, clinically, and prognostically than Hodgkin's disease among older adults. For the disease among young adults, the hypothesis is that clinical disease reflects the rare consequences of a prevalent infection of low pathogenicity; age of infection is determined by socioeconomic status. In older adults, it more closely resembles the lymphomas. This suggests dynamic trends associated with changing social environments related to etiologic factors. Among adults, the steady increase in colon cancer among both genders represents constant exposure to a carcinogen(s) starting in early life and persisting throughout older ages. Breast cancer is divided into pre- and postmenopausal phases on the basis of its age distribution. International differences in postmenopausal breast cancer suggest environmental factors in postmenopausal women and genetic and hormonal factors in premenopausal women. The age distribution of lung cancer increases linearly with the amount of cigarettes smoked and there is no indication of a threshold below which cigarette smoke is safe. The downturn among the oldest age groups results from competing causes of death or reflects a cohort effect of different exposure over time. Further, the pattern of lung cancer suggests exposure to a carcinogenic agent including substances that act principally as promoters.

Development of a food frequency instrument: ethnic differences in food sources.

Dietary intake was assessed among 431 black, white, and Mexican American men and women in southeast Texas using 24-hour dietary recall interviews. These data were collected to provide information on ethnic-specific food sources of selected nutrients; this information was used to construct a food frequency questionnaire for a study of nutrient intake and cancer. Nutrient content of total fat, total vitamin A, and vitamin C was determined for all foods consumed and was aggregated across unique food codes. These aggregated food codes were then ranked according to the contribution of each food to the total population intake of each nutrient. Ethnic differences existed in food sources of nutrients that would not be identified if data from only the analysis of the combined data set were used. Generally, however, the food sources identified from analyses of the combined data set included those foods that were important nutrient sources for each of the ethnic groups as well.

Personal risk factors. What do they mean?

Epidemiologic studies have identified myriad factors related to cancer risk. Risk can be quantified on the basis of demographic factors, genetics, occupation, medical conditions, and lifestyle. Existing evidence suggests that: (1) individuals at risk often are unaware of their risk; (2) physicians may not know well those factors associated with the highest cancer risk; and (3) methods to reduce risk have been under-applied because of lack of knowledge, lack of funds, or lack of motivation among both patients and physicians. Methods to reduce risk do not follow the usual medical model in that those groups requiring risk-modification intervention usually are symptom free. Evidence indicates that elimination of tobacco use would reduce lung cancer deaths by 83% and substantially reduce the incidence of head and neck malignancies. Broad application of mammographic screening would effect a 30% reduction in breast cancer mortality. Dietary modification could potentially reduce cancer mortality by 30%. An effective program to reduce cancer risk will accomplish the following: (1) develop new and refine existing risk factor measurements to improve identification of individuals at risk; (2) apply risk factor identification and modification more completely to populations known to be at risk; (3) use combinations of risk factors to identify subpopulations at the highest risk; (4) apply existing prevention and screening modalities more broadly and uniformly; (5) identify new screening strategies with improved test performance and cost effectiveness to maximize screening efficiency; and (6) provide accurate and rapid means of risk assessment and quantification using the best available multivariate estimates of risk. An emphasis on education of primary care physicians to practice cancer prevention programs focused on personal risk profiles is reasonable since the populations these physicians serve express risk factors which represent 50% of the attributable risk for cancer in the US. A summary of site-specific risk factors which are amenable to intervention by primary care physicians is provided.