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Alcohol abuse and the risk of pancreatic cancer.

https://arctichealth.org/en/permalink/ahliterature9936
Source
Gut. 2002 Aug;51(2):236-9
Publication Type
Article
Date
Aug-2002
Author
W. Ye
J. Lagergren
E. Weiderpass
O. Nyrén
H-O Adami
A. Ekbom
Author Affiliation
Department of Medical Epidemiology, Karolinska Institutet, Stockholm, Sweden. weiye@mbox.ki.se
Source
Gut. 2002 Aug;51(2):236-9
Date
Aug-2002
Language
English
Publication Type
Article
Keywords
Adult
Aged
Alcoholism - complications
Chi-Square Distribution
Chronic Disease
Female
Humans
Incidence
Liver Cirrhosis, Alcoholic - complications
Male
Middle Aged
Pancreatic Neoplasms - epidemiology - etiology
Pancreatitis - complications
Prospective Studies
Registries
Research Support, Non-U.S. Gov't
Retrospective Studies
Risk
Smoking - adverse effects
Sweden - epidemiology
Abstract
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.
PubMed ID
12117886 View in PubMed
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Alcohol consumption in patients with primary sclerosing cholangitis.

https://arctichealth.org/en/permalink/ahliterature122648
Source
World J Gastroenterol. 2012 Jun 28;18(24):3105-11
Publication Type
Article
Date
Jun-28-2012
Author
Hannes Hagström
Per Stål
Knut Stokkeland
Annika Bergquist
Author Affiliation
Department of Gastroenterology and Hepatology, Karolinska University Hospital, Karolinska Institutet, 14186 Stockholm, Sweden. hannes.hagstrom@ki.se
Source
World J Gastroenterol. 2012 Jun 28;18(24):3105-11
Date
Jun-28-2012
Language
English
Publication Type
Article
Keywords
Adult
Aged
Alcohol drinking - epidemiology
Analysis of Variance
Binge Drinking - epidemiology
Chi-Square Distribution
Cholangitis, Sclerosing - diagnosis - epidemiology
Disease Progression
Elasticity Imaging Techniques
Female
Humans
Liver Cirrhosis, Alcoholic - diagnosis - epidemiology
Male
Middle Aged
Predictive value of tests
Questionnaires
Registries
Retrospective Studies
Risk assessment
Risk factors
Sweden - epidemiology
Time Factors
Young Adult
Abstract
To assess the alcohol drinking patterns in a cohort of primary sclerosing cholangitis (PSC) patients and the possible influence on the development of fibrosis.
Ninety-six patients with PSC were evaluated with a validated questionnaire about a patient's lifetime drinking habits: the lifetime drinking history (LDH) questionnaire. In addition, clinical status, transient elastography and biochemistry values were analysed and registered. Patients were defined as having either significant or non-significant fibrosis. Significant fibrosis was defined as either an elastography value of = 17.3 kPa or the presence of clinical signs of cirrhosis. Patients were divided into two groups depending on their alcohol consumption patterns; no/low alcohol consumption (one drink or unit/d) and moderate/high alcohol consumption (= 1 drink or unit/d). LDH data were calculated to estimate lifetime alcohol intake (LAI), current alcohol intake, drinks per year before and after diagnosis of PSC. We also calculated the number of episodes of binge-drinking (defined as consuming = 5 drinks per occasion) in total, before and after the diagnosis of PSC.
The mean LAI was 3882 units of alcohol, giving a mean intake after onset of alcohol consumption of 2.6 units per week. Only 9% of patients consumed alcohol equal to or more than one unit per day. Current alcohol intake in patients with significant fibrosis (n = 26) was less than in patients without significant fibrosis (n = 70), as shown by lower values of phosphatidylethanol (B-PEth) (0.1 ?mol/L vs 0.33 ?mol/L, respectively, P = 0.002) and carbohydrate-deficient transferrin (CDT) (0.88% vs 1.06%, respectively, P = 0.02). Self-reported LAI was similar between the two groups. Patients with significant fibrosis reduced their alcohol intake after diagnosis from 103 to 88 units per year whereas patients without fibrosis increased their alcohol intake after PSC diagnosis from 111 to 151 units/year. There were no correlations between elastography values and intake of alcohol (units/year) (r = -0.036).
PSC patients have low alcohol consumption. The lack of correlation between fibrosis and alcohol intake indicates that a low alcohol intake is safe in these patients.
Notes
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PubMed ID
22791946 View in PubMed
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Alcoholism and liver cirrhosis in the etiology of primary liver cancer.

https://arctichealth.org/en/permalink/ahliterature11847
Source
Int J Cancer. 1992 Jul 30;51(6):898-902
Publication Type
Article
Date
Jul-30-1992
Author
H O Adami
A W Hsing
J K McLaughlin
D. Trichopoulos
D. Hacker
A. Ekbom
I. Persson
Author Affiliation
Cancer Epidemiology Unit, University Hospital, Uppsala, Sweden.
Source
Int J Cancer. 1992 Jul 30;51(6):898-902
Date
Jul-30-1992
Language
English
Publication Type
Article
Keywords
Aged
Alcoholism - complications - epidemiology
Cohort Studies
Female
Follow-Up Studies
Humans
Incidence
Liver Cirrhosis - complications - epidemiology
Liver Cirrhosis, Alcoholic - complications - epidemiology
Liver Neoplasms - epidemiology - etiology
Male
Middle Aged
Registries
Research Support, Non-U.S. Gov't
Sweden - epidemiology
Abstract
The aim of this study was to determine the risk of developing primary liver cancer in patients with a diagnosis of alcoholism, liver cirrhosis, or both. Three population-based, mutually exclusive cohorts were defined on the basis of hospital discharge diagnosis between 1965 and 1983. Complete follow-up through 1984--excluding the first year of follow-up--showed that among 8,517 patients with a diagnosis of alcoholism, 13 cancers occurred, vs. 4.2 expected (standardized incidence ratio (SIR) = 3.1; 95% confidence interval (CI) = 1.6 to 5.3); among 3,589 patients with liver cirrhosis, 59 cancers occurred, vs. 1.7 expected (SIR = 35.1; 95% CI = 26.7 to 45.3), and among 836 patients with both diagnoses, 11 cancers occurred, vs. 0.3 expected (SIR = 34.3; 95% CI = 17.1 to 61.3). Thus, alcoholism alone entailed a moderately increased risk and alcoholism with liver cirrhosis did not increase the high relative risk for liver cancer more than cirrhosis alone. We conclude that alcohol intake may be a liver carcinogen only by being causally involved in the development of cirrhosis; and further, that the risk of developing liver cancer following cirrhosis in this population is similar to or higher than that after chronic hepatitis-B-virus infection in other Western countries.
PubMed ID
1639537 View in PubMed
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Alcoholism in social classes and occupations in Sweden.

https://arctichealth.org/en/permalink/ahliterature11036
Source
Int J Epidemiol. 1997 Jun;26(3):584-91
Publication Type
Article
Date
Jun-1997
Author
T. Hemmingsson
I. Lundberg
A. Romelsjö
L. Alfredsson
Author Affiliation
Department of Occupational Health, NVSO, Karolinska Hospital, Stockholm, Sweden.
Source
Int J Epidemiol. 1997 Jun;26(3):584-91
Date
Jun-1997
Language
English
Publication Type
Article
Keywords
Alcohol drinking - epidemiology
Alcoholism - epidemiology
Cohort Studies
Confidence Intervals
Cross-Sectional Studies
Databases, Factual
Employment - statistics & numerical data
Female
Humans
Liver Cirrhosis, Alcoholic - epidemiology
Male
Military Personnel - statistics & numerical data
Occupations - classification - statistics & numerical data
Odds Ratio
Registries
Research Support, Non-U.S. Gov't
Retrospective Studies
Social Class
Sweden - epidemiology
Twins - statistics & numerical data
Abstract
BACKGROUND: A number of studies have shown variations in the occurrence of alcoholism between different socioeconomic groups and occupations, but it has not been clear to what extent this is related to the average alcohol consumption in the same socioeconomic groups or occupations. METHODS: The relationship between socioeconomic group and occupation and hospital discharge 1981-1983 due to 'diagnoses related to alcoholism' (AD) (alcohol psychosis, alcoholism, and alcohol intoxication) and liver cirrhosis was studied in a cohort of 375,035 men and 140,139 women in 13 counties in Sweden who had reported the same occupation in the censuses of 1960 and 1970. Data on alcohol consumption in different socioeconomic groups and occupations were collected from a conscription investigation and from the Swedish twin registry with data from 1969/70 and 1973 respectively. RESULTS: Intermediate or higher non-manual employees had lower risk of AD as well as of liver cirrhosis compared to manual workers for both sexes. Among males several, mostly blue-collar, occupations had increased relative risks of AD. A high level of association was found between the relative risks of AD and liver cirrhosis in socioeconomic groups, and the relative risk of AD in occupations, and the average alcohol consumption in the same socioeconomic groups/occupations among males. Such an association was not evident among women. CONCLUSION: The study shows, contrary to previous Swedish evidence, that there is a strong relationship between the incidence of alcoholism in socioeconomic groups and occupations and the average alcohol consumption in these groups among men.
PubMed ID
9222784 View in PubMed
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An epidemiologic study of hepatocellular carcinoma in Canada.

https://arctichealth.org/en/permalink/ahliterature187668
Source
Can J Public Health. 2002 Nov-Dec;93(6):443-6
Publication Type
Article
Author
Susie elSaadany
Martin Tepper
Yang Mao
Robert Semenciw
Antonio Giulivi
Author Affiliation
Health-Care Acquired Infections Division, Health Canada. susie_elsaadany@hc-sc.gc.ca
Source
Can J Public Health. 2002 Nov-Dec;93(6):443-6
Language
English
Publication Type
Article
Keywords
Canada - epidemiology
Carcinoma, Hepatocellular - epidemiology - mortality
Female
Hepatitis B - epidemiology
Hepatitis C - epidemiology
Humans
Incidence
Least-Squares Analysis
Liver Neoplasms - epidemiology - mortality
Male
Prevalence
Registries
Sex Factors
Abstract
To provide information on poorly described Canadian hepatocellular cancer epidemiology, we analyzed incident cases abstracted from the Canadian Cancer Registration Database (1969-1997) and Canadian annual death data (1969-1998). Age, sex, geographic distribution, and secular trends were described. Projection models were developed for the next decade.
Results indicated much higher incidence and mortality rates in males than females, with substantial increases for both with age. Age-standardized incidence rates increased an average of 3.4% per year in males, 1.2% per year in females (1969-1997). Age-standardized mortality rates increased an average of 1.48% in males, but decreased an average of 0.46% per year in females (1969-1998). Join-point analysis of the linear trends in the age-standardized incidence and mortality rates suggested that a new trend started to emerge about 1991. The fitted non-linear multiplicative model predicted the occurrence of 1,565 new cases and 802 deaths in the year 2010. HCC incidence was the highest in British Colombia, followed by Quebec, and the lowest in the Atlantic region.
Incidence rates of hepatocellular carcinoma have increased substantially, consistent with the reported increase in the prevalence of Hepatitis C Virus (HCV) and Hepatitis B Virus (HBV) infections in recent decades.
PubMed ID
12448868 View in PubMed
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Are liver function tests, pancreatitis and cholecystitis predictors of common bile duct stones? Results of a prospective, population-based, cohort study of 1171 patients undergoing cholecystectomy.

https://arctichealth.org/en/permalink/ahliterature132934
Source
HPB (Oxford). 2011 Aug;13(8):519-27
Publication Type
Article
Date
Aug-2011
Author
Per Videhult
Gabriel Sandblom
Claes Rudberg
Ib Christian Rasmussen
Author Affiliation
Department of Surgery, Central Hospital, Västerås, Sweden. pervidehult@yahoo.se
Source
HPB (Oxford). 2011 Aug;13(8):519-27
Date
Aug-2011
Language
English
Publication Type
Article
Keywords
Adult
Age Factors
Alkaline Phosphatase - blood
Bilirubin - blood
Biological Markers - blood
Cholangiography
Cholecystectomy
Cholecystitis - diagnosis - epidemiology - surgery
False Negative Reactions
False Positive Reactions
Female
Gallstones - diagnosis - epidemiology - surgery
Humans
Liver Function Tests
Logistic Models
Male
Middle Aged
Odds Ratio
Pancreatitis - diagnosis - epidemiology
Predictive value of tests
Prospective Studies
Registries
Risk assessment
Risk factors
Sex Factors
Sweden - epidemiology
Abstract
The purpose of this study was to explore the accuracy of elevated liver function values, age, gender, pancreatitis and cholecystitis as predictors of common bile duct stones (CBDS).
All patients operated on for gallstone disease over a period of 3 years in a Swedish county of 302,564 citizens were registered prospectively. Intraoperative cholangiography (IOC) was used to detect CBDS.
A total of 1171 patients were registered; 95% of these patients underwent IOC. Common bile duct stones were found in 42% of patients with elevated liver function values, 20% of patients with a history of pancreatitis and 9% of patients with cholecystitis. The presence of CBDS was significantly predicted by elevated liver function values, but not by age, gender, history of acute pancreatitis or cholecystitis. A total of 93% of patients with normal liver function tests had a normal IOC. The best agreement between elevated liver function values and CBDS was seen in patients undergoing elective surgery without a history of acute pancreatitis or cholecystitis.
Although alkaline phosphatase (ALP) and bilirubin levels represented the most reliable predictors of CBDS, false positive and false negative values were common, especially in patients with a history of cholecystitis or pancreatitis, which indicates that other mechanisms were responsible for elevated liver function values in these patients.
Notes
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PubMed ID
21762294 View in PubMed
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Canadian home parenteral nutrition (HPN) registry: validation and patient outcomes.

https://arctichealth.org/en/permalink/ahliterature127079
Source
JPEN J Parenter Enteral Nutr. 2012 Jul;36(4):407-14
Publication Type
Article
Date
Jul-2012
Author
G. Fernandes
B. Kaila
K N Jeejeebhoy
L. Gramlich
D. Armstrong
J P Allard
Author Affiliation
University Health Network, Toronto General Hospital, Toronto, Ontario, Canada.
Source
JPEN J Parenter Enteral Nutr. 2012 Jul;36(4):407-14
Date
Jul-2012
Language
English
Publication Type
Article
Keywords
Bilirubin - blood
Canada
Female
Follow-Up Studies
Hospitalization
Humans
Liver Diseases - etiology - physiopathology
Male
Nutrition Assessment
Parenteral Nutrition, Home - adverse effects - methods
Potassium - blood
Quality of Life
Registries
Treatment Outcome
Abstract
In Canada, there are an estimated 400 home parenteral nutrition (HPN) patients. In 2006, a registry was created to gather patient outcome information. The aim of this study was to validate the registry and report on HPN patient outcomes.
Several demographic, clinical parameters were collected. For the validation, paired t test and intraclass correlation coefficient (ICC) were used to assess agreement between repeat entries. For the outcome report, paired t test was used to assess changes, and survival analysis was performed using the Kaplan-Meier method. Results are expressed as mean ± SEM.
On validation, there was high correlation/agreement (P
PubMed ID
22326909 View in PubMed
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Canadian home total parenteral nutrition registry: preliminary data on the patient population.

https://arctichealth.org/en/permalink/ahliterature160745
Source
Can J Gastroenterol. 2007 Oct;21(10):643-8
Publication Type
Article
Date
Oct-2007
Author
Maitreyi Raman
Leah Gramlich
Scott Whittaker
Johane P Allard
Author Affiliation
University Health Network, Toronto, Canada.
Source
Can J Gastroenterol. 2007 Oct;21(10):643-8
Date
Oct-2007
Language
English
Publication Type
Article
Keywords
Adult
Aged
Bone Diseases - metabolism
Canada - epidemiology
Catheterization, Central Venous
Chronic Disease
Female
Humans
Intestinal Diseases - therapy
Liver - drug effects
Male
Middle Aged
Models, Statistical
Parenteral Nutrition, Home Total - adverse effects - statistics & numerical data
Prevalence
Quality of Life
Registries
Abstract
Long-term administration of home total parenteral nutrition (HTPN) has permitted patients with chronic intestinal failure to survive for prolonged periods of time. However, HTPN is associated with numerous complications, all of which increase morbidity and mortality. In Canada, a comprehensive review of the HTPN population has never been performed.
To report on the demographics, current HTPN practice and related complications in the Canadian HTPN population.
This was a cross-sectional study. Five HTPN programs in Canada participated. Patients' data were entered by the programs' TPN team into a Web site-based registry. A unique confidential record was created for each patient. Data were then downloaded into a Microsoft Excel (Microsoft Corp, USA) spreadsheet and imported into SPSS (SPSS Inc, USA) for statistical analysis.
One hundred fifty patients were entered into the registry (37.9% men and 62.1% women). The mean (+/- SD) age was 53.0+/-14 years and the duration requiring HTPN was 70.1+/-78.1 months. The mean body mass index before the onset of HTPN was 19.8+/-5.0 kg/m(2). The primary indication for HTPN was short bowel syndrome (60%) secondary to Crohn's disease (51.1%), followed by mesenteric ischemia (23.9%).
over one year, 62.7% of patients were hospitalized at least once, with 44% of hospitalizations related to TPN. In addition, 28.6% of patients had at least one catheter sepsis (double-lumen more than single-lumen; P=0.025) and 50% had at least one catheter change. Abnormal liver enzymes were documented in 27.4% of patients and metabolic bone disease in 60% of patients, and the mean Karnofsky score was 63.
In the present population sample, the data suggest that HTPN is associated with significant complications and health care utilization. These results support the use of a Canadian HTPN registry to better define the HTPN population, and to monitor complications for quality assurance and future research.
Notes
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PubMed ID
17948134 View in PubMed
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The Canadian Organ Replacement Register.

https://arctichealth.org/en/permalink/ahliterature213046
Source
Clin Transpl. 1996;:91-107
Publication Type
Article
Date
1996
Author
S R Walker
D A Parsons
P. Coplestons
S S Fenton
P D Greig
Author Affiliation
Canadian Institute for Health Don Mills, Ontario, Canada.
Source
Clin Transpl. 1996;:91-107
Date
1996
Language
English
Publication Type
Article
Keywords
Adolescent
Adult
Aged
Cadaver
Canada
Child
Child, Preschool
Family
Female
Geography
Graft Survival
Heart Transplantation - statistics & numerical data
Humans
Infant
Kidney Transplantation - statistics & numerical data
Liver Transplantation - statistics & numerical data
Living Donors
Lung Transplantation - statistics & numerical data
Male
Middle Aged
Pancreas Transplantation - statistics & numerical data
Registries
Renal Replacement Therapy - statistics & numerical data
Survival Rate
Tissue Donors
Tissue and Organ Procurement - organization & administration - statistics & numerical data
Transplantation - mortality - physiology - statistics & numerical data
Waiting Lists
Abstract
The analyses presented in this chapter are a subset of the yearly audit of organ donation and transplantation in Canada published in the CORR Annual Report. They represent the collaborative efforts and the voluntary contributions of many of the transplant physicians, surgeons, nurses and coordinators in Canada. In Canada, organ donation has remained static at approximately 14 per million population. Despite many local and provincial as well as corporate initiatives, this rate is approximately half the current rate in many regions of the U.S.A. and Spain. The modest increases in transplant activity represent an increase in the use of living donors, reassessment of the traditional donor risk factors (including age) and expansion of the potential donors for each organ. Analysis of the renal transplant activity has determined that the likelihood of being transplanted during the first year on the list was less than 40%. A graft loss rate of 4% per year after the first year was observed for a cadaveric kidney, compared with graft loss rates of 3% and 2% per year for living-related and living-unrelated donor kidneys, respectively. Cox regressional analysis identified that the major determinants of patient survival were the transplant year, the region where the transplant was performed, the presence of diabetes, the recipient's age, and whether the kidney was from a living donor. Liver transplantation has increased each year at the transplant centers in Vancouver, Edmonton, London, Toronto, Montreal, and Halifax. Patient and graft survival rates have improved since 1985 and the most significant determinant of patient survival following transplantation was the patient's medical status at the time of transplantation. Living-related liver donor transplant programs have begun in London and Toronto. Pancreas transplantation remains limited across Canada, but with the development of new pancreas programs in Toronto and Halifax, an increase in the availability of this therapy for Type 1 diabetics is anticipated. Heart transplantation has recovered from a decline in 1991-1992 to approximately 6 hearts per million population. There has been a trend towards better one- and 3-year patient survival rates since 1985. With the development of a lung transplantation program in Winnipeg, lung transplantation has increased. This likely reflects increased utilization of the available donor lungs. A particular increase in double-lung transplants was noted.
PubMed ID
9286560 View in PubMed
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Cancer incidence among alcoholic liver disease patients in Finland: A retrospective registry study during years 1996-2013.

https://arctichealth.org/en/permalink/ahliterature274985
Source
Int J Cancer. 2016 Jun 1;138(11):2616-21
Publication Type
Article
Date
Jun-1-2016
Author
Perttu Sahlman
Markku Nissinen
Eero Pukkala
Martti Färkkilä
Source
Int J Cancer. 2016 Jun 1;138(11):2616-21
Date
Jun-1-2016
Language
English
Publication Type
Article
Keywords
Adult
Aged
Carcinoma, Hepatocellular - complications - epidemiology - pathology
Female
Finland - epidemiology
Humans
Liver Diseases, Alcoholic - complications - epidemiology - pathology
Liver Neoplasms - complications - epidemiology - pathology
Male
Middle Aged
Registries
Retrospective Studies
Risk factors
Abstract
Both alcohol abuse and liver cirrhosis are known risk factors for various cancers. This article was aimed to assess the long-term risk of malignancies among patients with severe alcoholic liver disease (ALD), i.e., alcoholic liver cirrhosis and alcoholic hepatitis. A cohort of 8,796 male and 3,077 female ALD patients from 1996 to 2012 was identified from the Finnish National Hospital Discharge Register. This nationwide cohort was combined with the data from the Finnish Cancer Registry for incidence of malignancies during the years 1996-2013. The cancer cases diagnosed were compared with the number of cancers in the general population. The number of malignancies in our cohort was 1,052 vs. 368 expected. There was statistically significant excess of cancers of the liver, (standardized incidence ratio [SIR] 59.20; 95% CI 53.11-65.61), pancreas (SIR 3.71; 95% CI 2.72-4.94), pharynx (SIR 9.25; 95% CI 6.05-13.56), mouth (SIR 8.31; 95% CI 4.84-13,29), oesophagus (SIR 7.92; 95% CI 5.49-11.07), tongue (SIR 7,21; 95% CI 3.60-12.89), larynx (SIR 5.20; 95% CI 2.77-8.89), lung (SIR 2.77; 95% CI 2.27-3.32), stomach (SIR 2.76; 95% CI 1.79-4.07), kidney (SIR 2.69; 95% CI 1.84-3.79) and colon (SIR 2.33; 95% CI 1.70-3.11). There was no decreased risk of any cancer among ALD patients. Severe ALD is associated with markedly increased risk of malignancies. The risk is especially high for hepatocellular carcinoma, but also significantly increased for cancers of the upper aerodigestive tract, pancreas and kidneys, and warrants cancer surveillance in selected cases.
PubMed ID
26756434 View in PubMed
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