BACKGROUND: The reasons for the increasing incidence of and strong male predominance in patients with oesophageal and cardia adenocarcinoma remain unclear. The authors hypothesised that airborne occupational exposures in male dominated industries might contribute. METHODS: In a nationwide Swedish population based case control study, 189 and 262 cases of oesophageal and cardia adenocarcinoma respectively, 167 cases of oesophageal squamous cell carcinoma, and 820 frequency matched controls underwent personal interviews. Based on each study participant's lifetime occupational history the authors assessed cumulative airborne occupational exposure for 10 agents, analysed individually and combined, by a deterministic additive model including probability, frequency, and intensity. Furthermore, occupations and industries of longest duration were analysed. Relative risks were estimated by odds ratios (OR), with 95% confidence intervals (CI), using conditional logistic regression, adjusted for potential confounders. RESULTS: Tendencies of positive associations were found between high exposure to pesticides and risk of oesophageal (OR 2.3 (95% CI 0.9 to 5.7)) and cardia adenocarcinoma (OR 2.1 (95% CI 1.0 to 4.6)). Among workers highly exposed to particular agents, a tendency of an increased risk of oesophageal squamous cell carcinoma was found. There was a twofold increased risk of oesophageal squamous cell carcinoma among concrete and construction workers (OR 2.2 (95% CI 1.1 to 4.2)) and a nearly fourfold increased risk of cardia adenocarcinoma among workers within the motor vehicle industry (OR 3.9 (95% CI 1.5 to 10.4)). An increased risk of oesophageal squamous cell carcinoma (OR 3.9 (95% CI 1.2 to 12.5)), and a tendency of an increased risk of cardia adenocarcinoma (OR 2.8 (95% CI 0.9 to 8.5)), were identified among hotel and restaurant workers. CONCLUSIONS: Specific airborne occupational exposures do not seem to be of major importance in the aetiology of oesophageal or cardia adenocarcinoma and are unlikely to contribute to the increasing incidence or the male predominance.
BACKGROUND: Although most epidemiological studies do not support a role for alcohol in the aetiology of pancreatic cancer, an increased risk among heavy drinkers cannot be excluded. METHODS: In a retrospective cohort based on the Swedish Inpatient Register, we analysed the risk of pancreatic cancer among patients admitted to hospital for alcoholism (n=178 688), alcoholic chronic pancreatitis (n=3500), non-alcoholic chronic pancreatitis (n=4952), alcoholic liver cirrhosis (n=13 553), or non-alcoholic liver cirrhosis (n=7057) from 1965 to 1994. Follow up through to 1995 was accomplished by linkage to nationwide registers. Standardised incidence ratios (SIRs) express the relative risks by taking the general Swedish population as reference. To minimise the possible influence of selection bias, we excluded the first year observations. RESULTS: Alcoholics had only a modest 40% excess risk of pancreatic cancer (SIR 1.4, 95% confidence interval (CI) 1.2-1.5). Overrepresented smokers among alcoholics might confound a true SIR of unity among alcoholics to approximately 1.4. SIR among alcoholic chronic pancreatitis patients (2.2, 95% CI 0.9-4.5) was considerably lower than that among non-alcoholic chronic pancreatitis patients (8.7, 95% CI 6.8-10.9), and decreased with increasing duration of follow up in both groups, indicating that most of the excess might be explained by reversed causation from undiagnosed cancers. Among patients with alcoholic liver cirrhosis, the increased risk of pancreatic cancer was also moderate (SIR 1.9, 95% CI 1.3-2.8) while no significant excess risk was found among non-alcoholic liver cirrhosis patients (SIR 1.2, 95% CI 0.6-2.2). CONCLUSIONS: The excess risk for pancreatic cancer among alcoholics is small and could conceivably be attributed to confounding by smoking.
Antioxidant vitamins have attracted considerable attention in previous studies of esophageal squamous-cell carcinoma, but dietary studies of adenocarcinoma of the esophagus and gastric cardia remain sparse. Treating these tumors as distinct diseases, we studied intakes of vitamin C, beta-carotene and alpha-tocopherol in a nationwide population-based case-control study in Sweden, with 185, 165, and 258 cases of esophageal adenocarcinoma, esophageal squamous-cell carcinoma, and gastric cardia adenocarcinoma, respectively, and 815 controls. Subjects with a high parallel intake of vitamin C, beta-carotene, and alpha-tocopherol showed a 40-50% decreased risk of both histological types of esophageal cancer compared with subjects with a low parallel intake. Antioxidant intake was not associated with the risk of gastric cardia adenocarcinoma. Separately, vitamin C and beta-carotene reduced the risk of esophageal cancers more than alpha-tocopherol. We found that antioxidant intake is associated with similar risk reductions for both main histological types of esophageal cancer. Our findings indicate that antioxidants do not explain the diverging incidence rates of the 2 histological types of esophageal cancer. Moreover, our data suggest that inverse associations with esophageal squamous-cell carcinoma and adenocarcinoma may be stronger among subjects under presumed higher oxidative stress due to smoking or gastroesophageal reflux, respectively. Our results may be relevant for the implementation of focused, cost-effective preventive measures.
BACKGROUND: The incidence of esophageal and gastric cardia adenocarcinoma is, for unknown reasons, increasing dramatically. A weak and inconsistent association between body mass index (BMI) and adenocarcinoma of the esophagus and gastric cardia has been reported. OBJECTIVE: To reexamine the association between BMI and development of adenocarcinoma of the esophagus and gastric cardia. DESIGN: Nationwide, population-based case-control study. SETTING: Sweden, 1995 through 1997. PATIENTS: Patients younger than 80 years of age who had recently received a diagnosis were eligible. Comprehensive organization ensured rapid case ascertainment. Controls were randomly selected from the continuously updated population register. Interviews were conducted with 189 patients with adenocarcinoma of the esophagus and 262 patients with adenocarcinoma of the gastric cardia; for comparison, 167 patients with incident esophageal squamous-cell carcinoma and 820 controls were also interviewed. MEASUREMENTS: Odds ratios were determined from BMI and cancer case-control status. Odds ratios estimated the relative risk for the two adenocarcinomas studied and were calculated by multivariate logistic regression with adjustment for potential confounding factors. RESULTS: A strong dose-dependent relation existed between BMI and esophageal adenocarcinoma. The adjusted odds ratio was 7.6 (95% CI, 3.8 to 15.2) among persons in the highest BMI quartile compared with persons in the lowest. Obese persons (persons with a BMI > 30 kg/m2) had an odds ratio of 16.2 (CI, 6.3 to 41.4) compared with the leanest persons (persons with a BMI
BACKGROUND & AIMS: Barrett's esophagus, which is linked to adenocarcinoma of the esophagus, is associated with reflux of bile. Duodenogastric reflux is increased after cholecystectomy. This study aims to evaluate if cholecystectomy is associated with an increased risk of adenocarcinoma of the esophagus. METHODS: A population-based cohort study of cholecystectomized patients in Sweden between 1965 and 1997 cross-linked with the Swedish Cancer Register. RESULTS: Cholecystectomized patients had an increased risk of adenocarcinoma of the esophagus (standardized incidence ratio [SIR], 1.3; 95% confidence interval [CI], 1.0-1.8). Esophageal squamous-cell carcinoma was not found to be associated with cholecystectomy (SIR, 0.9; 95% CI, 0.7-1.1). Patients with gallstone disease on whom surgery was not performed did not have an increased risk of adenocarcinoma or squamous-cell carcinoma of the esophagus. CONCLUSIONS: Cholecystectomy is associated with a moderately increased risk of adenocarcinoma of the esophagus, possibly by the toxic effect of refluxed duodenal juice on the esophageal mucosa. Further studies are needed regarding the link between bile reflux and esophageal carcinogenesis.
BACKGROUND: The incidence of esophageal adenocarcinoma is increasing rapidly. Gastroesophageal reflux is a strong risk factor for this disease. The increase in incidence of esophageal adenocarcinoma coincided with the introduction of medications that promote reflux by relaxing the lower esophageal sphincter (LES), such as nitroglycerin, anticholinergics, beta-adrenergic agonists, aminophyllines, and benzodiazepines. OBJECTIVE: To test the possible association between use of LES-relaxing medications and risk for adenocarcinoma of the esophagus and gastric cardia. DESIGN: A nationwide population-based case-control study with in-person interviews. SETTING: Sweden, 1995 through 1997. PATIENTS: 189 patients with newly diagnosed esophageal adenocarcinoma, 262 with adenocarcinoma of the gastric cardia, and 167 with esophageal squamous-cell carcinoma were compared with 820 population-based controls. MEASUREMENTS: Estimated incidence rate ratios, calculated by using multivariate logistic regression from case-control data with adjustment for potential confounding. RESULTS: Past use of LES-relaxing drugs was positively associated with risk for esophageal adenocarcinoma. Among daily, long-term users (>5 years) of LES-relaxing drugs, the estimated incidence rate ratio was 3.8 (95% CI, 2.2 to 6.4) compared with persons who had never used these drugs. Drugs of all classes contributed to the increased risk, but the association was particularly strong for anticholinergics. Short-term use of other types of LES-relaxing drugs did not seem to be strongly associated with risk. The association almost disappeared after adjustment for reflux symptoms, indicating that promotion of reflux is the link between use of LES-relaxing drugs and esophageal adenocarcinoma. If 15,490 men in any age group take LES-relaxing drugs daily for 5 years, 1 additional case of adenocarcinoma would be expected (number needed to treat for harm); in men older than 60 years of age, the number needed to treat for harm is 5,570. Assuming a causal relation, about 10% of the esophageal adenocarcinomas occurring in the population may be attributable to intake of LES-relaxing drugs. Cardia adenocarcinoma and esophageal squamous-cell carcinoma were not associated with use of LES-relaxing drugs. CONCLUSIONS: The widespread use of LES-relaxing drugs may have contributed to the increasing incidence of esophageal adenocarcinoma.
Comment In: Ann Intern Med. 2000 Aug 1;133(3):227-910906839
There is widespread belief that obesity is associated with gastro-oesophageal reflux disease, but the scientific evidence is weak and contradictory. Our aim is to evaluate the relation between body mass and reflux oesophagitis.
A population-based case-control study of endoscopically verified case subjects with reflux oesophagitis, and of randomly selected, control subjects matched for age, sex and area of residence. Subjects were classified within three body mass index (BMI) categories: BMI 30 (obese). Odds ratios (OR) with 95% confidence intervals (CI) were the measures of association.
Of 179 matched case-control pairs included in the study, 71 pairs were female. In males, no association between overweight and/or obesity and the risk of reflux oesophagitis was found. In females, there was a strong association between increasing BMI and the risk of reflux oesophagitis, with an OR of 2.9 (95% CI: 1.1-7.6) in the BMI 25-30 group and 14.6 (95% CI: 2.6-80.9) in the BMI >30 group (P value for trend = 0.0007). The association between obesity and oesophagitis was further strengthened by the use of oestrogen replacement medication.
The study discloses a strong and dose-dependent association between body mass and reflux oesophagitis in women as opposed to no association among men. This association might be caused by increased oestrogen activity in overweight and obese females.
The urinary and bowel control was studied of 527 children with myelomeningocele aged between four and 18 years. Information was obtained from medical records and by parent questionnaire. 44 had normal urinary control, 50 had a urinary diversion and the remaining 433 had neuropathic bladder without urinary diversion, of whom 31 per cent expressed their bladder manually and 40 per cent used clean intermittent catheterisation (CIC). 60 per cent needed assistance emptying their bladder. Children using CIC were more continent and needed less help, but were more often treated with antibiotics. Of the 527 children, 412 had disturbed bowel control. 212 evacuated their bowels manually, of whom 90 per cent needed assistance. Parents judged urinary incontinence to be very stressful for 37 per cent of the children and faecal incontinence for 33 per cent. The authors conclude that social urinary continence should be defined as the ability to keep dry for three hours or more.
The gross motor function and disabilities in children with cerebral palsy in southern Sweden were investigated and related to clinical features. The study covered the birth year period 1990-1993 and comprised 167 children, 145 of them born in Sweden and 22 born abroad. The clinical features and gross motor function were analysed at a mean age of 6.8 y. Clinical features were obtained from a continuing healthcare follow-up programme. Gross motor function was classified according to the Gross Motor Function Classification System (GMFCS). Walking independently was possible for 86% of the hemiplegic, 63% of the pure ataxic, 61% of the diplegic and 21% of the dyskinetic children. None of the tetraplegic children was able to walk. The classification of gross motor function revealed that 59% of the children were categorized into levels I and II (mildly disabled), 14% into level III (moderately disabled) and 27% into levels IV and V (severely disabled). Children born abroad were more severely disabled. CONCLUSION: The standardized age-related classification system GMFCS enabled a specific description of gross motor function in relation to clinical features. Significant differences between GMFCS levels and subgroups of diagnosis, aetiology. intellectual capacity, epilepsy and visual impairment were found.
The prevalence, clinical features and gross motor function of children with cerebral palsy in southern Sweden were investigated. The study covered the birth year period 1990-1993, during which 65,514 livebirths were recorded in the area. On the census date (1 January 1998), 68366 children born in 1990-1993 lived in the area. The study comprised 167 children, 145 of them born in Sweden and 22 born abroad. The livebirth prevalence was 2.2 per 1,000, and the prevalence including children born abroad was 2.4 per 1,000. The distribution according to gestational age, birthweight and subdiagnoses was similar to that in earlier Swedish studies, except for a higher rate of dyskinetic syndromes in this study. CONCLUSION: The point prevalence of cerebral palsy was 2.4 and the livebirth prevalence was 2.2. Children born abroad had a higher prevalence and were more often severely disabled. Severe disability was often combined with associated impairments such as mental retardation, epilepsy and visual impairment.