Philippe Autier

Diabetes and breast cancer risk: a meta-analysis

Background:The potential of an increased risk of breast cancer in women with diabetes has been the subject of a great deal of recent research.Methods:A meta-analysis was undertaken using a random effects model to investigate the association between diabetes and breast cancer risk.Results:Thirty-nine independent risk estimates were available from observational epidemiological studies. The summary relative risk (SRR) for breast cancer in women with diabetes was 1.27 (95% confidence interval (CI), 1.16–1.39) with no evidence of publication bias. Prospective studies showed a lower risk (SRR 1.23 (95% CI, 1.12–1.35)) than retrospective studies (SRR 1.36 (95% CI, 1.13–1.63)). Type 1 diabetes, or diabetes in pre-menopausal women, were not associated with risk of breast cancer (SRR 1.00 (95% CI, 0.74–1.35) and SRR 0.86 (95% CI, 0.66–1.12), respectively). Studies adjusting for body mass index (BMI) showed lower estimates (SRR 1.16 (95% CI, 1.08–1.24)) as compared with those studies that were not adjusted for BMI (SRR 1.33 (95% CI, 1.18–1.51)).Conclusion:The risk of breast cancer in women with type 2 diabetes is increased by 27%, a figure that decreased to 16% after adjustment for BMI. No increased risk was seen for women at pre-menopausal ages or with type 1 diabetes.

Recreational exposure to sunlight and lack of information as risk factors for cutaneous malignant melanoma. Results of an European Organization for Research and Treatment of Cancer (EORTC) case-control study in Belgium, France and Germany. The EORTC Malignant Melanoma Cooperative Group.

This study addressed the impact of exposure to ultraviolet radiation on the risk of cutaneous malignant melanoma (CMM), as well as the behavioural components at stake in its occurrence. We performed a one-to-one unmatched case-control study among subjects aged 20 years or more with naturally non-pigmented skin in Germany, France and Belgium. Fourhundred and twenty consecutive patients with CMM diagnosed from 1 January 1991 on were derived from hospital registries; 447 controls were chosen ramdomly in the same municipality as cases. Subjects unaware of the dangers of exaggerated exposure to sunlight display an estimated CMM risk of 3.72 (95% confidence interval 2.63-5.26). The number of holiday weeks spent annually in sunny resorts and sunbathing during the hot hours of the day are strong risk factors in the three countries, but not the number of years spent outdoors, as farmers or building workers. Multiple logistic adjustments on the host characteristics increases the CMM risk associated with recreational exposure to sunlight, as well as the adjustment on the unawareness of the dangers of exaggerated exposure to sunlight. Recreational exposure to sunlight and sunburn early in life seem capable of fostering the proliferation of pigmented lesions of the skin. Our data support the hypothesis that most CMM develop from pigmented lesions of the skin containing initiated melanocytes, and that the cell proliferation due to brutal, intermittent exposures to solar radiation amplifies the likelihood of a melanocyte entering into a malignant process. These results reinforce the conviction that for controlling the rising incidence of CMM, information about the CMM risk must be widely disseminated, mainly through recommending a prudent attitude towards exposure to sunlight.

Cancer control in women. Update 2003

The global cancer burden in women appeared to be increasing quickly at the end of the twentieth century with notable increases in the absolute numbers of cases of breast, cervix, lung and colorectal cancer of concern. However, prospects for cancer control in women appear to be good within our current knowledge and deserve close attention. Rates of lung cancer in women are increasing substantially in many countries and seem set to overtake breast cancer as the commonest form of cancer death in women in many parts of the world. These changes are due to the effects of cigarette smoking, a habit which women widely embraced during the second half of the last century. The high levels of smoking current in young women, which have yet to have their full impact on death rates, constitute an important hazard not only for future cancer risks but for several other important causes of death.

Professional rehabilitation of lymphoma patients: a study of psychosocial factors associated with return to work

During the last ten years a substantial reduction in mortality has been obtained for Hodgkins and non-Hodgkins lymphoma. Since lymphoma treatment is often accompanied by side effects and long-term sequelae, however, patients often have problems with rehabilitation. It is thus very important that these problems and needs be identified. Going back to work is one of the main objectives of rehabilitation and can be taken as a valuable indicator of the problems and needs of such patients. We therefore conducted a study at the Jules Bordet Institute between December 1989 and December 1990. Of the patients in remission and able to go back to work, only 54% of them have done so. Anxiety, depression, and treatment toxicity interfere with return to work, and the likelihood of job reentry increases with the time lapse since the end of treatment. Rehabilitation programs must focus on alleviating illness and treatment sequelae as soon as treatment ends.

Psychological Distress in Cancer Patients Attending the European Institute of Oncology in Milan

Background: The determination of the extent and specific features of the psychological distress to be expected in a cancer centre may influence the choice of interventions to be implemented for addressing these problems. This study was aimed at estimating the prevalence of psychological distress in patients attending a second reference cancer centre in Milan (Italy), and at identifying associated factors. Patients and Methods: 190 consecutive patients were assessed within 3 days of hospital discharge using the Hospital Anxiety and Depression Scale. Results: Major depressive disorders or generalised anxiety disorders were estimated in 16% of the patients. Only 2 of these patients were referred to the psycho-oncology unit, hence the psychological distress of many patients was not considered during their hospital stay. In the multiple regression analysis, independent predictors of psychological distress were female gender, experience of disturbance in family and social life due to illness, nausea and vomiting, and perception of being in a poor state of health (R2 = 0.31, p value < 0.001), while physical functioning, fatigue and pain, significant factors in univariate analysis (p < 0.05), sociodemographic and clinical factors were not predictors. Conclusion: The psycho-oncology team should focus on helping doctors and nurses identify the patients’ psychological problems, dealing with them or making a referral.

Cost-effectiveness analysis of antiemetic treatment

To address the economic issues posed by the introduction of 5-hydroxytryptamine3 receptor antagonist (5-HT3 RA), we performed a cost-effectiveness analysis based on clinical trial data published in the recent literature. Cost calculations include initial treatment and a second-line salvage treatment. The average cost and incremental cost were established. Incremental cost corresponds to the extra cost involved in achieving total control of emesis in 1% extra patients. If 5-HT3 RA is not part of the initial treatment, salvage treatment with ondansetron is not cost-effective. Moreover, starting with the combination of ondansetron plus dexamethasone saves more money than starting with ondansetron alone. However, if the difference in emesis control is only minimal, treatment with the 5-HT3 RA remains more expensive.

Reply: To PMID 22984785.

The major point of concern relates to the combined analysis of randomised controlled trials (RCTs) and non-RCTs. The lack of sufficient RCTs is blamed for this questionable inclusion of non-RCTs. The diversity of study designs of observational studies and non-RCTs translates to an almost unacceptable amount of heterogeneity. The evaluation of a single summary estimate of effect by combining RCTs and non-RCTs is thus inappropriate, as evidenced by the finding of both visual and statistical heterogeneity in the published forest plots. Further, a concerted effort to minimise publication bias in such a work should have included an attempt to analyse data from unpublished RCTs. The search strategy used has only identified five out of the nine completed RCTs comparing photoselective vaporisation of the prostate with conventional TURP for BPH.

Guidelines for investigation of associations between insulin and cancer risk using prescription databases.

e12061 Background: Analysis of associations between insulin and cancer risk using Prescription Databases and Cancer Registers is complicated and should only be undertaken with extreme caution and employing advanced statistical and epidemiological methodologies. Methods: Interaction between methodologists, diabetologists and oncologists is also critical. Failure to do so can result in unfortunate events with potential societal implications as could have happened following the recent publication of a flawed database analysis of the association between a long-acting insulin analogue and an increased risk of cancer. Such reports cause unnecessary confusion and concern among patients and their physicians. Results: Prescription Databases were not established with such analyses in mind, and cannot identify many critical limitations such as changes in insulin type during study observation (“switchers”). Notably, those who use more than one type of insulin simultaneously pose specific problems but restriction of t...

Essential considerations in the investigation of associations between insulin and cancer risk using prescription databases.

Studies of disease outcomes using administrative databases have identified a number of problems with the approach that suggest the need for a high level of expertise in their conduct. This is particularly true in the case of the investigation of the role of different insulins and the risk of cancer, which poses particular issues addressed below. The greatest handicap is that the database has not been created specifically to study insulin as a cause of cancer, or indeed, cancer as an outcome. Given the relative rarity of some forms of cancer, it will frequently be necessary to perform simultaneous studies in different regions or countries to obtain enough events of interest to perform a meaningful study (in the statistical sense). This adds an extra degree of difficulty in that, since no two prescription databases are the same, these differences need to be taken into account at the start of the study. All such observational studies must be conducted according to good research practice [1] and good epidemiology practice guidelines [2], including those specific to pharmaco-epidemiology [3]. However, there are a number of issues, some essential and some desirable, specific to the study of insulin and cancer, which must be taken into consideration.