Catherine R. Messina

Cigarette Smoking and Pancreatic Cancer: A Pooled Analysis From the Pancreatic Cancer Cohort Consortium

Smoking is an established risk factor for pancreatic cancer; however, detailed examination of the association of smoking intensity, smoking duration, and cumulative smoking dose with pancreatic cancer is limited. The authors analyzed pooled data from the international Pancreatic Cancer Cohort Consortium nested case-control study (1,481 cases, 1,539 controls). Odds ratios and 95% confidence intervals were calculated by using unconditional logistic regression. Smoking intensity effects were examined with an excess odds ratio model that was linear in pack-years and exponential in cigarettes smoked per day and its square. When compared with never smokers, current smokers had a significantly elevated risk (odds ratio (OR) = 1.77, 95% confidence interval (CI): 1.38, 2.26). Risk increased significantly with greater intensity (> or =30 cigarettes/day: OR = 1.75, 95% CI: 1.27, 2.42), duration (> or =50 years: OR = 2.13, 95% CI: 1.25, 3.62), and cumulative smoking dose (> or =40 pack-years: OR = 1.78, 95% CI: 1.35, 2.34). Risk more than 15 years after smoking cessation was similar to that for never smokers. Estimates of excess odds ratio per pack-year declined with increasing intensity, suggesting greater risk for total exposure delivered at lower intensity for longer duration than for higher intensity for shorter duration. This finding and the decline in risk after smoking cessation suggest that smoking has a late-stage effect on pancreatic carcinogenesis.

Association of active and passive smoking with risk of breast cancer among postmenopausal women: a prospective cohort study

Objective To examine the association between smoking and risk of invasive breast cancer using quantitative measures of lifetime passive and active smoking exposure among postmenopausal women. Design Prospective cohort study. Setting 40 clinical centres in the United States. Participants 79 990 women aged 50–79 enrolled in the Women’s Health Initiative Observational Study during 1993–8. Main outcome measures Self reported active and passive smoking, pathologically confirmed invasive breast cancer. Results In total, 3520 incident cases of invasive breast cancer were identified during an average of 10.3 years of follow-up. Compared with women who had never smoked, breast cancer risk was elevated by 9% among former smokers (hazard ratio 1.09 (95% CI 1.02 to 1.17)) and by 16% among current smokers (hazard ratio 1.16 (1.00 to 1.34)). Significantly higher breast cancer risk was observed in active smokers with high intensity and duration of smoking, as well as with initiation of smoking in the teenage years. The highest breast cancer risk was found among women who had smoked for ≥50 years or more (hazard ratio 1.35 (1.03 to1.77) compared with all lifetime non-smokers, hazard ratio 1.45 (1.06 to 1.98) compared with lifetime non-smokers with no exposure to passive smoking). An increased risk of breast cancer persisted for up to 20 years after smoking cessation. Among women who had never smoked, after adjustment for potential confounders, those with the most extensive exposure to passive smoking (≥10 years’ exposure in childhood, ≥20 years’ exposure as an adult at home, and ≥10 years’ exposure as an adult at work) had a 32% excess risk of breast cancer compared with those who had never been exposed to passive smoking (hazard ratio 1.32 (1.04 to 1.67)). However, there was no significant association in the other groups with lower exposure and no clear dose response to cumulative passive smoking exposure. Conclusions Active smoking was associated with an increase in breast cancer risk among postmenopausal women. There was also a suggestion of an association between passive smoking and increased risk of breast cancer.

Factors that predict incomplete colonoscopy: thinner is not always better

Abstract OBJECTIVE: The aim of this study was to determine whether anatomic factors such as body mass index (BMI) impacts the success rate of cecal intubation during colonoscopy. METHODS: We retrospectively reviewed the cecal intubation rate of 2000 colonoscopies performed at our institution from March 1997 to March 1999. The analysis sample was composed of charts for all incomplete procedures and a sample (23%) of complete examinations that were randomly selected. Data collected included age, gender, height, weight, bowel habits, abdominal surgery, psychiatric medication use, the presence of diverticular disease, amount of sedation administered, and location and reason for halting the examination. Patients were divided by BMI: thin (BMI ≤22.1), average weight (BMI >22.1–25.0), overweight (BMI = 25.1–29.9), and obese (BMI >30). RESULTS: Colonoscopies in women had a lower adjusted completion rate (94.8%) than in men (98.2%) (p CONCLUSIONS: Women with a low BMI (especially

Prevalence of Colorectal Neoplasia in Smokers

OBJECTIVES:Smoking has been linked with colorectal neoplasia. Previous colonoscopy screening studies have omitted smoking and have examined only gender, age, and family history. Our aim was to use a screening population to measure the prevalence of neoplasia in smokers, the anatomic location of these lesions, and the strength of this association relative to other risk factors.METHODS:Data collected from the charts of 1988 screening colonoscopy patients included colonic findings, histology, risk factors for colorectal neoplasia, and smoking pattern. Current smokers were defined as those who had smoked more than 10 pack-years and were currently smoking or who had quit within the past 10 yr. Our outcomes were any adenomatous lesion and significant colonic neoplasia, which included adenocarcinoma, high grade dysplasia, villous tissue, large (>1 cm) adenomas, and multiple (more than two) adenomas.RESULTS:Multivariate analysis revealed that current smokers were more likely to have any adenomatous lesion (odds ratio [OR] = 1.89; 95% CI = 1.42–2.51; p < 0.001) as well as significant neoplasia (OR = 2.26; 95% CI = 1.56–3.27; p < 0.001) than those who had never smoked. The increased risk for smokers was predominantly for left-sided neoplasia. The risk for significant neoplasia was greater for smokers than for patients with a family history of colorectal cancer (OR = 1.20; 95% CI = 0.75–1.92; p > 0.05).CONCLUSIONS:Smoking is a significant risk factor for colorectal neoplasia in a screening population, especially for significant left-sided lesions. In our sample population, smoking posed a greater risk than family history of colorectal cancer.

Sedentary Behavior and Mortality in Older Women: The Women’s Health Initiative

BACKGROUND Although epidemiologic studies have shown associations between sedentary behavior and mortality, few have focused on older women with adequate minority representation and few have controlled for both physical activity and functional status. PURPOSE The objective of this study was to determine the relationship between sedentary time and total; cardiovascular disease (CVD); coronary heart disease (CHD); and cancer mortality in a prospective, multiethnic cohort of postmenopausal women. METHODS The study population included 92,234 women aged 50-79 years at baseline (1993-1998) who participated in the Womens Health Initiative Observational Study through September 2010. Self-reported sedentary time was assessed by questionnaire and examined in 4 categories (≤4, >4-8, ≥8-11, >11 hours). Mortality risks were examined using Cox proportional hazard models adjusting for confounders. Models were also stratified by age, race/ethnicity, body mass index, physical activity, physical function, and chronic disease to examine possible effect modification. Analyses were conducted in 2012-2013. RESULTS The mean follow-up period was 12 years. Compared with women who reported the least sedentary time, women reporting the highest sedentary time had increased risk of all-cause mortality in the multivariate model (HR=1.12, 95% CI=1.05, 1.21). Results comparing the highest versus lowest categories for CVD, CHD, and cancer mortality were as follows: HR=1.13, 95% CI=0.99, 1.29; HR=1.27, 95% CI=1.04, 1.55; and HR=1.21, 95% CI=1.07, 1.37, respectively. For all mortality outcomes, there were significant linear tests for trend. CONCLUSIONS There was a linear relationship between greater amounts of sedentary time and mortality risk after controlling for multiple potential confounders.

Prevalence and risk of colorectal neoplasia in consumers of alcohol in a screening population.

BACKGROUND AND AIMS:Although studies suggest a positive association between alcohol consumption and risk for colorectal neoplasia, the impact on screening has not been fully examined. It is also unclear whether all types of alcohol are associated with an increased risk. We performed a cross-sectional study to examine the impact of regular alcohol consumption on the detection of significant colorectal neoplasia in a screening population.METHODS:Data collected for 2,291 patients presenting for screening colonoscopy: known risk factors for colorectal neoplasia and alcohol drinking pattern. Our outcome was the endoscopic detection of significant colorectal neoplasia, which included adenocarcinoma, high-grade dysplasia, villous tissue, adenomas 1 cm or greater and multiple (>2) adenomas of any size.RESULTS:When compared to abstainers, we found an increased risk for significant neoplasia in those patients who consumed more than eight drinks of spirits alcohol (26.3%; OR = 2.53; 95% CI = 1.10–4.28; p < 0.01) and those who drank more than eight servings of beer per week (21.7%; OR = 2.43; 95% CI = 1.11–5.32; p= 0.02). Consuming one to eight glasses of wine per week was associated with a decreased risk for significant neoplasia (OR = 0.55; 95% CI = 0.34–0.87; p < 0.01).CONCLUSIONS:While there was a more than twofold increased risk of significant colorectal neoplasia in people who drink spirits and beer, people who drank wine had a lower risk. In our sample, people who drank more than eight servings of beer or spirits per week had at least a one in five chance of having significant colorectal neoplasia detected by screening colonoscopy.

Body mass index: a marker for significant colorectal neoplasia in a screening population.

Background and Aims Although some studies suggest a positive association between increasing body mass index (BMI) and risk for colorectal neoplasia, the impact on screening has not been examined. We performed a cross-sectional study to examine the association of BMI and colorectal neoplasia in a screening population. Methods Data collected for 2493 patients presenting for screening colonoscopy included known risk factors for colorectal neoplasia, demographic information, and lifestyle factors. Our outcome was the endoscopic detection of significant colorectal neoplasia which included adenocarcinoma, high-grade dysplasia, villous tissue, adenomas 1 cm or greater and multiple (>2) adenomas of any size. Results Overall, we observed an increased risk and prevalence for significant colorectal neoplasia in women as BMI increased (P value for trend <0.002). This relationship was the strongest for the women with a BMI ≥40 (odds ratios=4.26; 95% confidence intervals=2.00-9.11). There was no such relationship in our male population. Conclusions Increasing BMI, in our population, was associated with an increase risk for colorectal neoplasia in female patients. This study reinforces the importance of screening colonoscopy especially in obese women.

Predictors of proximal neoplasia in patients without distal adenomatous pathology

BACKGROUND:Previous colorectal cancer screening studies have observed that some patients may have advanced proximal neoplasia without distal findings. Since these studies have included only gender, age, and family history as risk factors, they are limited in their ability to identify predictors of isolated proximal neoplasia.METHODS:Data were collected from the charts of 1,988 patients who presented for colonoscopy. Information gathered included endoscopic findings, histology, known risk factors for colorectal neoplasia, and smoking pattern. Our main outcome was the presence of proximal adenomatous neoplasia in patients who had no distal adenomas. We defined significant neoplasia as adenocarcinoma, high-grade dysplasia, villous polyps, adenomas 1 cm or greater or more than two adenomas of any size.RESULTS:Fifty-five patients had isolated significant proximal neoplasia that would have been missed on a flexible sigmoidoscopy. While patients older than 60 yr had a greater risk for this neoplasia (odds ratio = 3.01: 95% CI = 1.66–4.23; p < 0.001), those who took a daily aspirin had a reduced risk (OR = 0.60; 95% CI = 0.30–0.88; p < 0.05). A family history of colorectal cancer increased the patients risk of having any adenomas (OR = 2.01; 95% CI = 1.33–3.40; p < 0.01) or villous tissue (OR = 2.03; 95% CI = 1.27–3.51; p < 0.05) in the proximal colon without distal findings. Smoking was associated with an increased risk of large (> 1 cm) isolated proximal tubular polyps (OR = 2.71; 95% CI = 1.64–4.46; p < 0.01) as well as isolated significant proximal neoplasia (OR = 2.30; 95% CI = 1.59–3.31; p < 0.01).CONCLUSIONS:Age greater than 60 yr, a history of at least 10 pack-years of smoking, and a family history of colorectal cancer increased the risk of finding significant proximal polyps in patients without distal pathology.

Relationship of social support and social burden to repeated breast cancer screening in the Women's Health Initiative

Direct and interactive effects of social support, social burden (caregiving, negative life events, and social strain), education, and income on repeated use of breast cancer screening among a large (N=55,278), national sample of postmenopausal women participating in the Womens Health Initiative observational study were examined. Repeated screening decreased as emotional/informational support and positive social interactions decreased (ps<.01). Repeated mammography decreased with frequent caregiving (p<.01). Less social strain reduced the frequency of repeated breast self-examinations (BSEs; ps<.01), but frequent caregiving and more negative life events increased repeated use of BSE (ps<.01). Interactive effects suggested that emotional/informational but not tangible support is associated with repeated mammography and clinical breast examinations (ps<.01) and may be particularly important among low-income older women, especially those burdened by caregiving.

A provider intervention to improve colorectal cancer screening in county health centers.

Background:Publicly-funded health centers serve disadvantaged populations who underuse colorectal cancer screening (CRC). Because physicians play a key role in patient adherence to screening, provider interventions within health center practices could improve the delivery/utilization of CRC screening. Methods:A 2-group study design was used with 4 pairs of health centers randomized to the intervention or control condition. The provider intervention featured academic detailing of the small practice groups, followed by a strategic planning session with the entire health center staff using SWOT analysis. The outcome measure of provider endoscopy referral/fecal occult blood test dispensing and/or completion of CRC screening was determined by medical record audit (n = 2224). The intervention effect was evaluated using generalized estimating equations. Pre-post intervention patient surveys (n = 281) were conducted. Results:Chart audits of the 1 year period before and after the intervention revealed a 16% increase from baseline in CRC screening referral/dispensing/completion among intervention centers, compared with a 4% increase among controls, odds ratio (OR) = 2.25 (1.67–3.04) P < 0.001. Intervention versus control health center patient self-reports of lack of physician recommendation as a reason for not having CRC screening declined from baseline to follow-up (P = 0.04). Conclusions:Provider referrals/dispensing/completion of CRC screening within health centers was significantly improved and barriers reduced through a provider intervention combining continuing medical education with a team building strategic planning exercise.