Prognostic and predictive value of thymidylate synthase expression in primary colorectal cancer.

AIM: To investigate thymidylate synthase (TS) expression in primary colorectal cancer (CRC) as a prognostic and predictive marker of benefit for adjuvant chemotherapy. PATIENTS AND METHODS: TS expression was immuno0-histochemically (IHC) assessed on tumors from 1,389 patients with stage II and III CRC randomly assigned to either surgery alone or surgery plus 5-fluorouracil (5-FU)-based adjuvant chemotherapy. RESULTS: In the subgroup treated with surgery alone (n=708), TS expression was prognostic using the classification of TS 0-1 versus 2-3 (p=0.045) as well as TS classified as 0-2 versus 3 (p=0.002). A high TS expression was associated with a shorter overall survival. Among patients with TS grade 3 (n=460), the subgroup treated with adjuvant chemotherapy had a significant longer OS (p=0.005). CONCLUSION: In this study TS, immunohistochemically assessed, is a prognostic factor in CRC patients treated with surgery alone. Patients with the highest level of TS expression (grade 3) had an improved clinical outcome following adjuvant 5-FU-based chemotherapy.

Transtheoretical model: investigation of adolescents' sunbathing behaviour.

The incidence of malignant melanoma and non-melanoma skin cancers has increased rapidly in Sweden as well as in other western countries during the last 20 years. Adolescents are an important group in skin cancer prevention. Interventions targeting this group have been reported to affect knowledge and attitudes, but the effect on sun protection behaviour has been slight. The aim of this study was to investigate the applicability of the Transtheoretical Model (TTM) for skin cancer prevention for adolescents. A random sample of 1200 18-year-olds living in Stockholm County was selected from the national census registry. A questionnaire that included three of the major constructs of the TTM (i.e. stages of change, processes of change and decisional balance) was sent by mail. The majority of the teenagers were in the precontemplation stage for giving up intentional tanning. The relations between the stages of change and two other major constructs of the TTM, processes of change and decisional balance, were consistent with data on other health behaviours. The results may aid in developing successful skin cancer prevention programmes. The results give support for the stages of change measurement used in this study and that utilizing the TTM in skin cancer prevention may be appropriate.

A randomised population-based intervention to examine the effects of the ultraviolet index on tanning behaviour.

The aim of the following study was to examine the effects of the Ultraviolet (UV) Index and a personal ultraviolet radiation (UVR) intensity indicator on tanning behaviour compared with general, written information about sun protection. A population-based random sample in Sweden was randomly assigned to four groups receiving different information packages (n=3200). Questionnaires were sent before and after the summer of 2001. Positive attitudes towards sunbathing as well as tanning and sunburn frequencies decreased. Knowledge about UV radiation and the use of sun protection increased for all groups. There were no between-group differences. Sun-related behaviours and beliefs changed, but information about the UV Index or a personal UVR intensity indicator did not decrease sunbathing and sunburn more than general, written information.

Localized scleroderma in a woman irradiated at two sites for endometrial and breast carcinoma: a case history and a review of the literature.

Localized scleroderma is an uncommon side-effect of radiotherapy. We report a unique case with multiple asynchronous primary malignant tumors, which developed localized scleroderma after radiotherapy. A 67-year-old healthy woman received external irradiation for endometrial cancer. Three years later she underwent partial mastectomy and postoperative radiotherapy because of breast cancer. A progressive fibrosis developed in the breast. Within 12 months similar skin reactions were also seen in the irradiated abdominal wall and on both lower extremities. Biopsies revealed scleroderma lesions of breast and abdominal wall and scleroderma-like lesions on the legs. The lesions dissolved partially without generalization. This case, in contrast to most of the cases previously reported in the literature, illustrates not only lesions outside of radiation ports, but also that radiotherapy given to one cancer site can affect distant skin at a previously irradiated cancer site. When a localized scleroderma is diagnosed, further curative radiotherapy should be cautiously prescribed irrespective of cancer site.

'You and your skin': a short-duration presentation of skin cancer prevention for teenagers.

The effectiveness of a short-duration presentation of the educational material 'You and Your Skin' was tested on 184 adolescents (age 13-15) at the Year 7 and 8 levels. A non-equivalent control group design was used with pre-testing and post-testing 3 months after the intervention. The intervention increased the students' knowledge of known risks factors for skin cancers. However, the students' attitudes to abstaining from sunbathing and tanning was not significantly affected. The effect of the intervention on the stage of change was primarily a progression from the precontemplation stage to the contemplation stage regarding avoiding the mid-day sun. We conclude that a brief presentation of the educational kit 'You and Your Skin' can be used to increase knowledge, but there is a need for a more extensive intervention effort to affect students' readiness to change their behavior and attitude towards sunbathing and tanning. Therefore, it is important to emphasize the necessity of using the educational kit as a multi-lesson programme with its several group exercises.

Stability of questionnaire items measuring behaviours, attitudes and stages of change related to sun exposure.

The use of questionnaires in epidemiological studies needs more methodological research. The time and effort spent on questionnaire design is often limited. Studies on the construction of questionnaires could lead to a higher quality of data, enhanced comparability and improved credibility of epidemiological findings. The aim of the present study was to examine the test-retest reliability of some common items measuring sun-related variables. A sample of 52 female Swedish nurses attending a postgraduate course in research methodology was chosen. They completed a questionnaire on two occasions spaced 3 weeks apart in the winter of 2000. When the results were analysed, items on sun-related behaviours and sunbed use were sufficiently reliable. The items on skin type and sunburn showed moderate stability. Stage of change related to sunlight exposure, items measuring beliefs about sunbathing along with items assessing self-efficacy and risk perception with regards to sunbathing showed lower stability. The results showed that many essential items concerning exposure to ultraviolet radiation and sunburns were sufficiently stable, but other items were less stable and could be improved upon; suggestions for improving these items are presented. The study illustrates the value of reliability testing in the process of item construction. Using methodological studies to improve the reliability and validity of data is an important step toward higher standards for questionnaire surveys.

Focusing management in implementing a smoking ban in a university hospital in Sweden.

To explore the impact of various steps when introducing a smoking ban at the Karolinska Hospital (1000 beds; 6000 employees) in Stockholm, Sweden, a multiple evaluation strategy was performed over 5 years. All heads of clinical departments (N = 41) and a random sample of employees (n = 517) and a convenience sample of hospital labour managers (n = 17) were separately addressed through questionnaire surveys at different time intervals after the introduction of the ban in 1992. An observational and interview study completed the follow-up. The implementation process was supplemented by a comprehensive information strategy over 5 years. The two most important steps during implementation were management support and focus on environmental tobacco. The ban was well known at introduction. Heads of clinical departments reported a third of staff to be satisfied with the restrictions. In contrast, the staff survey revealed 62% to be positive. A shift in favour of a radical tobacco-free hospital was perceived during follow-up. Co-operation between hospital board, heads of clinical departments and local labour managers proved successful. The consecutive evaluations served as tools in labour management and contributed to staff compliance. A total ban, including the selling of tobacco and smoking in the hospital grounds is still to be achieved.

Tanning habits and sunburn in a Swedish population age 13-50 years.

As part of a skin cancer control programme, we studied the occurrence of self-reported outdoor tanning, sunbed use and ultraviolet (UV)-induced erythema in an urban area. A cross-sectional questionnaire study of 6000 adolescents aged 13-19 years, and 4000 adults aged 20-50 years was applied. Non-response was analysed for outdoor tanning and sunbed use. Results, in general, did not differ between responders and non-responders. Females aged 17-29 years tanned outdoors most frequently. Sunbed use and related erythema was twice as common in young females. In males, outdoor tanning was not age-related. In the past 12 months, 55% reported sunburn and/or burn from sunbed use, one-third were burned in Sweden, one-quarter on sunny resorts abroad. Sunburn occurs frequently. Compliance with recommendations for sunbed use is poor, especially among adolescents and young adults. To reduce the occurrence of erythema, the influence of risk settings upon behaviours is a critical issue for exploration.

Beliefs, knowledge and attitudes as predictors of sunbathing habits and use of sun protection among Swedish adolescents.

In 1996, a random population sample of 2615 adolescents completed a questionnaire concerning habitual sun-related behaviours, attitudes towards sunbathing, and knowledge about skin cancer. Females, older adolescents, those with less sun-sensitive skin, those with higher knowledge and those with a positive attitude towards sunbathing were more likely to be frequent sunbathers. Younger adolescents, those who today sunbathe moderately, and those with sensitive skin were more likely to believe that they would sunbathe more often in the future. Males, adolescents with less sensitive skin, those with a positive attitude towards sunbathing and those sunbathing often, were less likely to use protection when sunbathing. Interventions to decrease sun exposure among adolescents should focus on changing attitudes toward sunbathing and having a tan, since knowledge of skin cancer and the damaging affect of sunbathing did not seem to effect current sunbathing habits, or use of sun protection.

Readiness to change sun-protective behaviour.

The incidence of malignant melanoma and non-melanoma skin cancers has increased rapidly in Sweden during the last 20 years. The best-known way to revert this trend is primary prevention. Matching health messages to readiness to change in the population may enhance the effect of community-based prevention. The aims of this study were to investigate readiness to change sun-protective behaviour in two groups (visitors to mobile screening units and beach-goers) and to test a single-item algorithm in assessing the stage of change in sun-protective behaviour. Seven hundred and forty-two visitors to the mobile screening units and 202 individuals on nearby beaches answered a short questionnaire. The assessment of readiness to change was based on stages of change in sun-protective behaviour modified from the Transtheoretical Model of Behaviour Change. As expected, the visitors to the screening units were more often in action/maintenance stages than the beach group for most sun-protective behaviours. In conclusion, the single-item algorithm method appears to be sensitive to assess readiness to change sun-protective behaviour, based on the Transtheoretical Model of Behaviour Change. This method can be incorporated into population surveys and may aid in developing successful skin cancer prevention programmes.

Population UV-dose and skin area--do sunbeds rival the sun?

From the perspective of skin cancer risks, sunbed tanning may give the population group of Swedish adolescents a yearly total dose in terms of ultraviolet radiant energy to the skin which is comparable to sunlight. For populations, a dosage scheme is applied, where exposed skin area is estimated to be two to ten times larger in tanning units than in outdoor sunlight. The normal dose fluence rate is multiplied by the exposure time and by the exposed body surface area. A study of sunbed use among adolescents was reinvestigated. Skin dose from artificial tanning in that population group is calculated and compared to sun exposure for erythemally effective radiation and for UVA (315-400 nm). Skin doses from tanning units to the adolescent population agree with estimates based on information concerning sunbed lamp sales/year. For the population, the erythemal skin dose from tanning units exceeds an increase in solar ultraviolet radiation to the skin projected from 10% ozone depletion. The dosage scheme might help to interpret data suggesting an increased melanoma risk among young people using sunbeds > or = 10 times per year. Tanning and sunburns in sunbeds and in sunlight is discussed with regard to skin area.

Sunbathing and sunbed use related to self-image in a randomized sample of Swedish adolescents.

In 1996 a randomized sample of 4,020 Swedish adolescents from three birth cohorts were sent a questionnaire consisting of 50 items concerning habitual sun-related behaviours and attitudes, knowledge about melanoma, risk perception and self-image. A total of 2,615 questionnaires were returned. Girls sunbathed and used sunbeds more than boys at all ages. Sunbathing and sunbed use increased with age. Boys who were most satisfied and girls least satisfied with themselves sunbathed most. Those who were least satisfied with themselves used sunbeds most frequently. Girls reported a higher perceived susceptibility to melanoma than did boys. The perception of susceptibility increased with age. Those who were least satisfied with themselves reported feeling most susceptible. The overall main reason for sunbathing was appearance, both for own sunbathing, and to an even higher degree, as a supposed reason for other adolescents' behaviour, and was reported most frequently by girls and the older age groups. The second most 'important' reason for sunbathing was 'feeling warm and comfortable'. Preventive programmes aimed at a change of sun related behaviours among Swedish adolescents have to be tailored to the climate and cultural conditions and must take into account that having a tan, and the warmth of the sun, are highly valued by most adolescents.

Maintaining a smoke-free policy: an observational and interview study at a university hospital in Sweden.

In the first half of 1992, the Board of Directors at the Karolinska Hospital decided that, as of 1 September 1992, smoking indoors would be prohibited for staff in the hospital. A year later, a new Tobacco Act was introduced in Sweden involving a general ban on smoking in all health care premises, including rooms which patients would have cause to visit or frequent regularly. Four years after the implementation of the policy decision, an evaluation was made based on the principles of data and method triangulation. In all, four sub-studies were carried out: (1) an observational study about outdoor smoking; (2) interviews with gardeners, cleaners and hospital hostesses/hosts; (3) inventory of sales points for tobacco products, the extent of tobacco advertising and an interview with the staff at a shop and a café; and (4) an observational study about the appearance of signs on buildings about the smoking policy. The results of the study shows that smoking was found mainly among the staff of the hospital, particularly around the entrances. No visible tobacco advertising could be seen at the hospital sales point, and a drop in tobacco sales was noted. The experiences of a smoke-free Karolinska Hospital are that a policy decision requires continuous follow-up and evaluation. Furthermore, the actions taken must be subject to quality control, and, simultaneously, smoke-quitting activities must be organized for staff who still smoke.

Supplementary iron intake and risk of cancer: reversed causality?

Dietary iron intake and body iron stores have been suggested to increase cancer risk, especially colorectal cancer. Within a population-based case-control study in Stockholm county 1993-94, information on dietary and supplementary iron intake were collected through a food frequency questionnaire. An initially noted positive association between intake of supplementary iron and colorectal cancer risk was reversed when intake 5 years prior to cancer diagnosis was subtracted. Reversed causality due to early disease giving symptoms of iron shortage, resulting in iron supplementation, is an issue to consider when a possible association between intake of iron and cancer risk is investigated.

Sunbed use in Swedish urban adolescents related to behavioral characteristics.

BACKGROUND: Sunbed use among Swedish adolescents has not been extensively studied, nor has the social learning process associated with it. The purpose of this study was to explore Swedish adolescents' sunbed use in relation to sex, age, smoking, perceived physical attractiveness, attitudes to artificial and natural UV exposure, psychosomatic symptoms, and risk knowledge. METHODS: In the spring of 1993, 60 school classes comprising 1,502 students ages 14-19 were randomly selected to answer a questionnaire concerning sunbed use and sunbathing habits, smoking, perceived physical attractiveness, psychosomatic symptoms, and need for information about and knowledge of the risks of UV exposure. RESULTS: Of 1,252 respondents, 57% had used sunbeds (females 70%, males 44%) > or = four times during the previous year. A marked increase (P < 0.001) in both sunbed use and smoking was detected between the 8th and the 9th grade (at ages 14-15). Sunbed use was also significantly correlated with sex, age, excessive tanning in natural sunlight, and low perceived physical attractiveness. The need for information on risks of high UV exposure was greatest among the best informed students and among students with high UV exposure (sunbed use, excessive tanning in natural sunlight). CONCLUSIONS: It seems doubtful whether further information on UV risks would result in altered behavior among highly exposed students, who seem receptive to information and have good knowledge. For a better understanding of the mechanisms underlying the association between sunbed use, smoking, and self-esteem, more in-depth, qualitative studies are required.

Sunbed use in relation to phenotype, erythema, sunscreen use and skin diseases. A questionnaire survey among Swedish adolescents.

Sunbed use was studied in relation to phenotype, erythema, sunscreen use and skin disease. The study population comprised 14-19 year-old Stockholm adolescents in 60 randomly selected classes, with 1252 students providing information. More than half (57%) reported sunbed use > or = 4 times during the previous year. Skin type III dominated (64%). Excessive exposure (> or = 10 times/year) was not correlated to skin type. Sunscreens were most commonly used by sunbed users. Of all sunbed users, 44% reported erythema. Adolescents with acne/seborrhoca, eczema or psoriasis used sunbeds more than others without skin diseases. The proportion with sunbed erythema (44%) indicates an unrecognized susceptibility to artificial ultraviolet radiation (UVR) among adolescents. The association between high exposure to UVR and sunscreen use stresses the importance of sunscreens being used as supplementary protection, not as a tool for tanning.

Health promotion in schools: policies and practices in Stockholm county, 1990.

A survey was undertaken of the policies and practices concerning organisation and implementation of health education and health promotion in schools in 151 of the total 213 Local Educational Areas (LEAs) in Stockholm county in 1990. Health education was included in the workplan of 49% of the responding LEAs, while 39% of respondents had a local action programme or guidelines for health education. Topic areas taught to all pupils and considered most important included alcohol, drug abuse, smoking, sex education, bullying, nutrition and physical exercise. Most senior level schools (55-83%) had written policies concerning pupils using alcohol, drugs or smoking in school, and 68% of LEAs had restrictions on staff smoking in school. Continuing health education was desired by 87% of the respondents. A written programme/plan regarding health education was identified as an important indicator of interest and commitment in health education and health policy issues by the local school.

Primary prevention of malignant melanoma in the Stockholm Cancer Prevention Programme.

Malignant melanoma is the most rapidly increasing tumour in Sweden. Sunburns in childhood and adolescence are considered a major risk factor. The Stockholm Cancer Prevention Programme addresses strategies to establish sun awareness in the population of Stockholm county by using existing networks of standardized child health and preschool services, educational systems including schools, colleges of nursing sciences and preschool teaching (integration of sun awareness in curricula, and in a new syllabus for environmental theory), the Federation of Swedish Pharmacies, and media. Health education is designed for key persons in these organizations and the media, who in turn diffuse sun awareness via their respective organizations. The education programme only deals with primary prevention by behavioural changes in exposure to UV rays, ie excessive exposure to sun, and it is primarily intended to raise sun awareness. Experiences have shown that information diffusion was good in spite of limited staff resources.