Umed A. Ajani

Annual Report to the Nation on the Status of Cancer, 1975–2005, Featuring Trends in Lung Cancer, Tobacco Use, and Tobacco Control

Background The American Cancer Society, the Centers for Disease Control and Prevention (CDC), the National Cancer Institute (NCI), and the North American Association of Central Cancer Registries (NAACCR) collaborate annually to provide updated information on cancer occurrence and trends in the United States. This year’s report includes trends in lung cancer incidence and death rates, tobacco use, and tobacco control by state of residence. Methods Information on invasive cancers was obtained from the NCI, CDC, and NAACCR and information on mortality from the CDCs National Center for Health Statistics. Annual percentage changes in the age-standardized incidence and death rates (2000 US population standard) for all cancers combined and for the top 15 cancers were estimated by joinpoint analysis of long-term (1975–2005) trends and by least squares linear regression of short-term (1996–2005) trends. All statistical tests were two-sided. Results Both incidence and death rates from all cancers combined decreased statistically significantly (P < .05) in men and women overall and in most racial and ethnic populations. These decreases were driven largely by declines in both incidence and death rates for the three most common cancers in men (lung, colorectum, and prostate) and for two of the three leading cancers in women (breast and colorectum), combined with a leveling off of lung cancer death rates in women. Although the national trend in female lung cancer death rates has stabilized since 2003, after increasing for several decades, there is prominent state and regional variation. Lung cancer incidence and/or death rates among women increased in 18 states, 16 of them in the South or Midwest, where, on average, the prevalence of smoking was higher and the annual percentage decrease in current smoking among adult women was lower than in the West and Northeast. California was the only state with decreasing lung cancer incidence and death rates in women. Conclusions Although the decrease in overall cancer incidence and death rates is encouraging, large state and regional differences in lung cancer trends among women underscore the need to maintain and strengthen many state tobacco control programs.

Annual Report to the Nation on the Status of Cancer, 1975–2007, Featuring Tumors of the Brain and Other Nervous System

Background The American Cancer Society, the Centers for Disease Control and Prevention (CDC), the National Cancer Institute, and the North American Association of Central Cancer Registries (NAACCR) collaborate annually to provide updated information on cancer occurrence and trends in the United States. This year’s report highlights brain and other nervous system (ONS) tumors, including nonmalignant brain tumors, which became reportable on a national level in 2004. Methods Cancer incidence data were obtained from the National Cancer Institute, CDC, and NAACCR, and information on deaths was obtained from the CDC’s National Center for Health Statistics. The annual percentage changes in age-standardized incidence and death rates (2000 US population standard) for all cancers combined and for the top 15 cancers for men and for women were estimated by joinpoint analysis of long-term (1992–2007 for incidence; 1975–2007 for mortality) trends and short-term fixed interval (1998–2007) trends. Analyses of malignant neuroepithelial brain and ONS tumors were based on data from 1980–2007; data on nonmalignant tumors were available for 2004–2007. All statistical tests were two-sided. Results Overall cancer incidence rates decreased by approximately 1% per year; the decrease was statistically significant (P < .05) in women, but not in men, because of a recent increase in prostate cancer incidence. The death rates continued to decrease for both sexes. Childhood cancer incidence rates continued to increase, whereas death rates continued to decrease. Lung cancer death rates decreased in women for the first time during 2003–2007, more than a decade after decreasing in men. During 2004–2007, more than 213 500 primary brain and ONS tumors were diagnosed, and 35.8% were malignant. From 1987–2007, the incidence of neuroepithelial malignant brain and ONS tumors decreased by 0.4% per year in men and women combined. Conclusions The decrease in cancer incidence and mortality reflects progress in cancer prevention, early detection, and treatment. However, major challenges remain, including increasing incidence rates and continued low survival for some cancers. Malignant and nonmalignant brain tumors demonstrate differing patterns of occurrence by sex, age, and race, and exhibit considerable biologic diversity. Inclusion of nonmalignant brain tumors in cancer registries provides a fuller assessment of disease burden and medical resource needs associated with these unique tumors.

Familial Aggregation of Age-related Maculopathy

Purpose To determine whether age-related maculopathy aggregates in families by evaluating whether its prevalence is higher among relatives of case subjects with age-related maculopathy compared with relatives of control subjects without age-related maculopathy. Methods Individuals with (n = 119) and without (n = 72) age-related maculopathy were identified. First-degree relatives of case and control probands (parents, siblings, or offspring) 40 years of age or older were asked whether they had ever been diagnosed with macular degeneration. Medical records of 177 case and 146 control relatives confirmed the presence or absence of age-related maculopathy. Results The prevalence of medical-record confirmed age-related maculopathy was significantly higher among first-degree relatives of case probands (23.7%) compared with first-degree relatives of control probands (11.6%) with an age-and sex-adjusted odds ratio (OR), 2.4; 95% confidence interval (CI), 1.2 to 4.7; P = .013. Relatives of 78 case probands with exudative disease had a significantly higher prevalence of maculopathy (26.9%) compared with relatives of the 72 unaffected control probands (11.6%) (adjusted OR, 3.1; 95% CI, 1.5 to 6.7; P = .003), whereas the prevalence of age-related maculopathy among relatives of 41 probands with dry maculopathy (19.2%) was slightly but not significantly higher (adjusted OR, 1.5; 95% CI, 0.6 to 3.7; P = .36). Conclusions The prevalence of age-related maculopathy among first-degree relatives of subjects with age-related maculopathy, particularly with exudative disease, is greater than among first-degree relatives of subjects without this disease. Results suggest that macular degeneration has a familial component and that genetic or shared environmental factors, or both, contribute to its development.

Moderate Alcohol Consumption and the Risk of Sudden Cardiac Death Among US Male Physicians

BACKGROUND Individuals who consume high amounts of alcohol (>5 drinks/d) have increased risks of ventricular arrhythmia and sudden cardiac death (SCD). However, the relationship is less clear for drinkers of light-to-moderate amounts. METHODS AND RESULTS We prospectively assessed whether light-to-moderate alcohol drinkers have a decreased risk of SCD among 21 537 male participants in the Physicians Health Study who were free of self-reported cardiovascular disease and provided complete information on alcohol intake at study entry. Over 12 years of follow-up, 141 SCDs were confirmed. After control for multiple confounders, men who consumed 2 to 4 drinks/wk (RR=0.40; 95% CI, 0.22 to 0.75; P=0.004) or 5 to 6 drinks/wk (RR=0.21; 95% CI, 0.08 to 0.56; P=0.002) at baseline had significantly reduced risks of SCD compared with those who rarely or never consumed alcohol. The relationship for SCD was U-shaped (P=0. 002), with the risk approaching unity at >/=2 drinks/d. In contrast, the relationship of alcohol intake and nonsudden CHD death was L-shaped or linear (P for trend=0.02). CONCLUSIONS In these prospective data, men who consumed light-to-moderate amounts of alcohol (2 to 6 drinks/wk) had a significantly reduced risk of SCD compared with those who rarely or never consumed alcohol.

Recovery of Ventricular Function after Myocardial Infarction in the Reperfusion Era: The Healing and Early Afterload Reducing Therapy Study

A minority of patients experience progression to clinically significant left ventricular dysfunction and enlargement after myocardial infarction (1). However, patients with worsening left ventricular function after myocardial infarction are at significantly greater risk for congestive heart failure and death (2, 3). Advances in the care of acute myocardial infarction over the past decadeparticularly the use of mechanical and pharmacologic reperfusion therapieshave reduced the risk for left ventricular dysfunction (4) and improved morbidity and mortality after myocardial infarction (5). Improvements in left ventricular function can be apparent shortly after myocardial infarction and have generally been attributed to recovery from myocardial stunning (6). However, the great heterogeneity in patients after myocardial infarction underscores the importance of identifying factors that influence the progression and regression of left ventricular dysfunction. The Healing and Early Afterload Reduction Therapy (HEART) trial (7) was a randomized, double-blind study of the hemodynamic effects of early versus delayed administration of three regimens of ramipril, an angiotensin-converting enzyme (ACE) inhibitor, after myocardial infarction. Patients were followed by performing serial echocardiography within the first 24 hours after myocardial infarction and at 14 and 90 days after myocardial infarction. Patients treated with ramipril experienced significant improvements in ejection fraction at 14 days after myocardial infarction, but all echocardiographic measures of ventricular size and function were similar in the three treatment groups by 90 days (7). The present analysis assessed clinical and echocardiographic predictors of recovery of ventricular function in the 88% of patients in HEART who underwent reperfusion therapy (65% received thrombolysis alone, 15% had percutaneous transluminal coronary angioplasty alone, and 8% had both). Methods Patients The HEART study enrolled 352 patients with acute anterior Q-wave myocardial infarction. Patients with ST-segment elevation or new Q waves in two or more contiguous leads were also eligible. Patients underwent echocardiography within 24 hours after myocardial infarction (before randomization [day 1]) and at 14 and 90 days after myocardial infarction. Patients were randomly assigned to receive one of three dosing regimens of ramipril: placebo for 14 days, followed by full-dose (10 mg) ramipril; low-dose (0.625 mg) ramipril for 90 days; or full-dose ramipril for 90 days. Thus, by day 14, all patients were treated with ACE inhibition. Inclusion and exclusion criteria and details of the titration scheme and patient characteristics are described elsewhere (7). Serial echocardiographic data from days 1, 14, and 90 were available in 249 patients. Baseline data were available for an additional 12 patients who died during follow-up. Patients with day-1 echocardiograms of insufficient quality and those who were alive at 90 days but for whom echocardiograms at this time point were not available were excluded from analysis. Of the 352 patients enrolled in the study, 48 did not have echocardiograms of sufficient quality for analysis, and 18 (including 13 who died) did not have all three echocardiograms. We also excluded 25 patients who did not receive reperfusion therapy. Echocardiographic Analysis Echocardiographic measurements were made in triplicate by using a Nova Microsonics (Mahwah, New Jersey) workstation, as described elsewhere (7). The echocardiographic reader was blinded to treatment assignment. Endocardial borders from end-diastolic and end-systolic frames were digitized manually, and left ventricular volumes were assessed by using the Simpson rule method. Infarct segment length was assessed by manually tracing the akinetic or dyskinetic segment and was expressed as a percentage of the endocardial perimeter. The reproducibility of the echocardiographic measurements is reported elsewhere (7). Statistical Analysis Patients were categorized into three groups according to degree of recovery of left ventricular function. Patients were categorized as having 1) complete recovery of function if functional abnormalities observed on day 1 improved to normal [left ventricular ejection fraction > 0.55 and absence of regional akinesis or dyskinesis], 2) partial recovery of function if ejection fraction improved and the extent of regional akinesis or dyskinesis decreased from day 1, or no 3) recovery if neither of these criteria was fulfilled or death occurred before 90 days. Left ventricular enlargement (remodeling) was defined as an increase in ventricular end-diastolic volume between day 1 and day 90 and was treated as a continuous variable. Univariate and multivariate logistic regression were used to assess relationships between day 1 values and recovery of function. Values are expressed as the mean (SD). A P value less than 0.05 was considered statistically significant. Stata statistical software (Stata Corp., College Station, Texas) was used for analyses. Results Baseline Characteristics and Left Ventricular Enlargement Clinical and echocardiographic data were obtained on day 1 before randomization (Table 1). Included and excluded patients differed significantly only with regard to age (59.4 12.3 years vs. 64.2 12.9 years; P�=�0.001). Patients with partial recovery had lower ejection fraction and larger volumes than did those with no recovery or complete recovery, and patients with full recovery had shorter infarct segments than did those with partial recovery or no recovery (Table 1). Fewer patients in the complete recovery group than in the partial or no recovery groups were diabetic, but this difference was not statistically significant. The recovery groups did not significantly differ with regard to other baseline characteristics or in the distribution of drug treatment. Table 1. Baseline Characteristics of Patients by Recovery Group Recovery of Left Ventricular Function On day 1, only 9 of 261 (3.4%) patients had normal ventricular function (ejection fraction > 0.55 and no akinesis or dyskinesis). The change in left ventricular ejection fraction varied widely and improved by day 90 in 171 of 261 (66%) patients (Figure 1). The mean change in ejection fraction during this time was 0.045 0.098. Most of this change occurred in the first 14 days (mean change in ejection fraction from day 1 to 14, 0.038 0.091); minimal additional change occurred between days 14 and 90 (Table 2). Of the 252 patients with abnormal left ventricular function on day 1 (ejection fraction < 0.55 or any akinesis or dyskinesis), 13% had complete recovery of ventricular function by day 14 and 22% of patients had complete recovery by day 90. An additional 36% of patients had partial recovery of function by day 90, defined as improvement in ejection fraction from day 1 values and shortening of the akinetic or dyskinetic segment. The remaining patients had functional deterioration (decrease in ejection fraction or increase in the length of the infarct segment from day 1; 103 patients) or died (12 patients). At 90 days, 53% (132 of 249) of patients had greater than 5% improvement in ejection fraction from baseline, but only 16% (39 of 249) had a decrease in ejection fraction greater than 5%. The length of the infarct segment decreased in the group as a whole from 27.0% 10.9% at day 1 to 19.1% 13.1% at day 14 and 16.9% 13.7% at day 90. Figure 1. Distribution of change in ejection fraction from day 1 to 90. Table 2. Echocardiographic Variables throughout the Study We previously reported a statistically significant increase in ejection fraction from day 1 to 14 in patients receiving full-dose (10 mg) ramipril (7), although ejection fraction did not differ among the groups by day 90. In the current analysis, we found no differences in the percentage of patients with full recovery of function by day 14 or day 90 according to treatment group. In addition, recovery groups did not differ in time to reperfusion (Table 1) or the proportion of patients who recovered according to type of reperfusion therapy. Predictors of Recovery of Function Baseline clinical characteristics, including age, sex, and Killip class, did not predict recovery of function. In contrast, peak creatine kinase level (which occurred a mean of 27 17 hours after onset of symptoms), a crude assessment of the extent of necrosis, and left ventricular function on day 1 (ejection fraction and extent of akinesis or dyskinesis) were significant predictors of recovery of function in univariate and multivariate analyses. The percentage of patients with complete recovery of function decreased as the creatine kinase quartile increased (P for trend < 0.001) (Figure 2). In a multiple logistic regression analysis that included peak creatine kinase level, baseline ejection fraction, infarct segment length, Killip class, age, sex, and drug therapy, peak creatine kinase level remained the strongest independent predictor of recovery. Each 100-unit increase in creatine kinase level was associated with a 4.3% decreased odds of full recovery (P�=�0.001). Figure 2. Percentage of patients with complete recovery of function by increasing quartile of peak creatine kinase level. P Left Ventricular Enlargement and Recovery of Function Overall, left ventricular enlargement (remodeling) was inversely related to improvement in ejection fraction over 90 days (r = 0.27; P�<�0.001). Nevertheless, during this time, ejection fraction improved by 4.5% 9.5% despite an increase in end-diastolic volume of 5.6 25.7 mL. The majority of this change occurred in the first 14 days after myocardial infarction. Patients who recovered function demonstrated the least enlargement. Left ventricular volume decreased by 7.6 18.4 mL from day 1 to day 90 in patients with complete recovery of function, compared with an increase of 9.4 26.3 mL in all other patients (P�<�0.001). Left ventricular e

Trends in risk factors for cardiovascular disease among children and adolescents in the United States.

Background. The increasing prevalence of obesity among children and adolescents in recent decades might have affected trends in obesity-associated risk factors for cardiovascular disease. Participants and Methods. We used data for 12 665 children and adolescents, 2 to 17 years of age, from the Third National Health and Nutrition Examination Survey (1988–1994) and for 3611 children and adolescents from National Health and Nutrition Examination Survey 1999–2000. Results. For participants 2 to 17 years of age, waist circumference increased 1.6 cm among male subjects and 2.4 cm among female subjects. Mean systolic blood pressure increased by 2.2 mm Hg among children and adolescents 8 to 17 years of age. There were significant decreases in concentrations of triglycerides (8.8 mg/dL) and glucose (2.5 mg/dL) among children and adolescents 12 to 17 years of age. Mean concentrations of total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, and glycosylated hemoglobin were relatively unchanged. Some changes in means of risk factors varied according to age. Conclusions. The temporal trends for risk factors among children and adolescents during the 1990s exhibited different patterns. The effects of the increasing prevalence of obesity on the cardiovascular health of children and adolescents remain unclear.

Cancer incidence rates and trends among children and adolescents in the United States, 2001-2009.

OBJECTIVES: Cancer continues to be the leading disease-related cause of death among children and adolescents in the United States. More current information is needed to describe recent cancer trends and identify demographic and geographic variations. METHODS: We analyzed data from the National Program of Cancer Registries and Surveillance, Epidemiology, and End Results statewide registries representing 94.2% of the US population to identify cancers diagnosed among persons aged 0 to 19 years during 2001–2009. Age-adjusted rates and annual percentage change for trends were calculated. Data were stratified by age, gender, race, ethnicity, and geography. RESULTS: We identified 120 137 childhood and adolescent cancer cases during 2001–2009 with an age-adjusted incidence rate of 171.01 per million. The overall rate of all cancers combined remained stable over time (annual percent change [APC], 0.3%; 95% confidence interval [CI], −0.1 to 0.7). There was an increase in the overall cancer trend among African American children and adolescents (APC, 1.3%; 95% CI, 0.2 to 2.5). An increasing trend for thyroid cancer was observed among both genders (APC, 4.9%; 95% CI, 3.2 to 6.6) and specifically among adolescents and those in the Northeast, South, and West regions of the United States. Renal carcinoma incidence was increasing significantly overall (APC, 5.4%; 95% CI, 2.8 to 8.1). Extracranial and extragonadal germ cell tumors and melanoma were both significantly decreasing. CONCLUSIONS: This study reports the novel finding that renal carcinoma rates are increasing among children and adolescents. This study confirms that thyroid cancer rates are increasing and further describes rising cancer rates among African Americans.

Brief Communication: The Prevalence of High Intake of Vitamin E from the Use of Supplements among U.S. Adults

Context Vitamin E supplements (400 IU or more daily) have no clear clinical benefits and may be harmful. Contribution Self-reported data from 4609 adults who participated in the 19992000 National Health and Nutrition Examination Survey showed that about 11% consumed at least 400 IU of vitamin E daily. Use was highest among older white adults who also consumed other antioxidant supplements. Cautions We do not know the form of vitamin E that adults consumed, but -tocopherol is the form most commonly found in supplements. Implications Many adults may be taking vitamin E supplements that have no proven clinical benefits and might be harmful. The Editors In a recent meta-analysis of randomized clinical trials, Miller and colleagues reported that the intake of vitamin E of at least 400 IU per day from supplements was associated with a small increase in mortality from all causes (1). The recent findings of the Womens Health Study, in which participants consumed 600 IU of vitamin E every other day, were consistent with the results from this meta-analysis (2, 3). Furthermore, the Heart Outcomes Prevention Evaluation researchers linked the use of 400 IU of vitamin E per day to an increased risk for congestive heart failure (4). Vitamin E intake of 400 IU per day or greater can practicably be achieved only through supplementation. Among adults older than 20 years of age who participated in the U.S. Department of Agricultures 19941996 Continuing Surveys of Food Intake by Individuals, the median intake of vitamin E was 5.6 mg of -tocopherol equivalents per day (6.7 IU) for men and 4.0 (4.8 IU) for women (5). Supplemental use of vitamins and minerals has increased in the United States, and supplemental use of vitamin E increased rapidly between 1987 and 2000 (6, 7). The extent to which supplements containing high doses of vitamin E are used in the United States remains incompletely documented, however. Therefore, our objectives were to estimate the percentage of U.S. adults who use supplements leading to intake of vitamin E of 400 IU or greater per day and to examine the social and demographic variations in these estimates. Methods We used data from the National Health and Nutrition Examination Survey (NHANES) conducted from 1999 to 2000 (8). This survey included a representative sample of the civilian, noninstitutionalized U.S. population selected through stratified, multistage sampling. Trained interviewers, using a computer-assisted personal interview system, interviewed participants at home. Subsequently, participants completed additional questionnaires (including a single 24-hour dietary recall); underwent basic neurosensory, anthropometric, fitness, and oral health evaluations; and provided a blood sample at the mobile examination center. The response rate was 81.9% for those interviewed and 76.3% for those examined. An Institutional Review Board at the Centers for Disease Control and Prevention approved the survey. Participants provided informed consent. Participants who responded affirmatively to the question Have you used or taken any vitamins, minerals, or other dietary supplements in the past month? were asked to provide additional details about the dose, frequency, and duration of use. The interviewer also asked to see the containers of the supplements to record information about the name and manufacturer of the supplements. If participants could not produce the containers, interviewers asked them to recall this information. We estimated the dietary intake of vitamin E from a single 24-hour recall. Laboratory personnel measured serum concentrations of - and -tocopherol using a Waters Alliance high-performance liquid chromatography system (Waters Corp., Milford, Massachusetts). A detailed description of laboratory quality control procedures used in the survey can be accessed at the Centers for Disease Control and Prevention Web site (9). Among participants age 20 years or older, we estimated the percentage (95% CI) who 1) did not use supplements or used supplements that did not contain vitamin E, 2) consumed less than 400 IU per day from the use of supplements, and 3) used supplements providing at least 400 IU per day. We examined the variation in the intake of vitamin E, 400 IU or greater per day, by the following characteristics of participants: age; sex; race or ethnicity; educational status; presence of chronic conditions (coronary heart disease, angina pectoris, stroke, and diabetes); smoking behavior; strata of blood pressure; serum total cholesterol concentration; and body mass index. We present results only for the 3 major racial or ethnic groups (white, African-American, and Mexican-American) because the sample sizes for the other groups were small. Other results are based on all available data. For 2-sample tests of proportions, we used a t-test. For characteristics with 3 levels, we tested the differences in the intake of vitamin E from supplements with a test for linear trend. We used SUDAAN statistical analysis software (Research Triangle Institute, Research Triangle Park, North Carolina) to account for the complex sampling design of the survey and to produce proper estimates of the standard errors (10). Results Figure 1 shows the numbers of participants who were included in the analyses. The participants who did not have a serum determination of -tocopherol were an average of 2.2 years older (P= 0.017) than the other participants, but the percentages who were male, were white, and who had at least a high school education did not significantly differ. Figure 1. Sample-size flow for 19992000 National Health and Nutrition Examination Survey. Overall, 11.3% (CI, 9.7% to 13.1%) of adults used supplements that led to a daily intake of 400 IU or greater, and 25.7% (CI, 24.0% to 27.5%) consumed less than 400 IU per day from such supplements. As illustrated in the Table, such intake increased with increasing age (P< 0.001 for linear trend), was about equal for men and women (P> 0.2), and was more common among white persons than African-American (P< 0.001) or Mexican-American persons (P< 0.001). Participants who had a history of coronary heart disease, angina pectoris, stroke, or diabetes were more likely to use high doses of vitamin E than participants without these conditions (P< 0.001 for all age-adjusted differences). Table. Unadjusted Percentages of Adults Aged 20 Years or Older Who Consume 400 IU of Vitamin E per Day from the Use of Vitamin, Mineral, or Dietary Supplements (19992000 National Health and Nutrition Examination Survey) The distribution of concentrations of serum -tocopherol for 3875 participants reflected the intake of vitamin E (Figure 2). For participants who did not use supplements or did not use supplements containing vitamin E, the median serum concentration of -tocopherol was 22.85 mol/L (n= 2506); in comparison, participants using supplements had median concentrations of 30.22 mol/L (intake of <400 IU per day; n= 953) and 49.03 mol/L (intake of 400 IU per day; n= 409). The ratios of concentrations of -tocopherol to total cholesterol for the 3 groups were, respectively, 4.47 mol/mmol (n= 2494), 5.85 mol/mmol (n= 947), and 9.04 mol/mmol (n= 408). Serum -tocopherol concentrations were 6.01 mol/L (no supplementation; n= 2172), 4.40 mol/L (<400 IU per day; n= 827), and 2.08 mol/L (400 IU per day; n= 377); the respective ratios of concentrations of - to -tocopherol were 3.61 mol/mol (n= 2161), 6.81 mol/mol (n= 824), and 24.22 mol/mol (n= 358). Figure 2. Concentrations of serum -tocopherol ( top ) and -tocopherol ( bottom ) among U.S. adults age 20 years or older by intake of vitamin E from the use of vitamin, mineral, or dietary supplements (19992000 National Health and Nutrition Examination Survey). To examine the Pearson correlation coefficients between log-transformed concentrations of the 2 tocopherols, we used a smaller set of participants (n= 1474) who attended the mobile examination center in the morning, had fasted at least 8 hours, and had concentrations of triglycerides measured using a reference method that was performed only among morning attendees. After adjustment for age and concentrations of total cholesterol and triglycerides, the Pearson correlation coefficient was 0.62. The adjusted correlations were 0.48 for participants who consumed at least 400 IU of vitamin E per day from supplements, 0.56 for participants who consumed less than 400 IU per day from such supplements, and 0.30 for participants who did not use supplements or did not consume vitamin E from supplements. Participants who used supplements containing vitamin E commonly used other antioxidants, such as vitamin C or -carotene. The percentages of participants who used supplements containing vitamin C were 84.9% (CI, 80.8% to 89.1%) among participants who consumed 400 IU per day of vitamin E from supplements, 97.9% (CI, 96.7% to 99.2%) among participants who consumed less than 400 IU per day from such supplements, and 6.4% (CI, 5.1% to 7.8%) among participants who did not use supplements or did not consume vitamin E from supplements. For -carotene, these percentages were 50.4% (CI, 42.8% to 58.1%), 66.0% (CI, 61.8% to 70.2%), and less than 1.0%, respectively. For the self-reported use of cholesterol-lowering medications, these percentages were 19.7% (CI, 14.8% to 24.6%), 7.1% (CI, 5.2% to 9.0%), and 6.3% (CI, 4.9% to 7.8%). Among 4239 participants who attended the mobile examination center and completed the 24-hour dietary recall, the median intake of vitamin E from diet was 7.40 mg of -tocopherol equivalents per day (8.8 IU) and ranged from 0.03 to 153.26 mg of -tocopherol equivalents per day (0.04 to 182.7 IU). Among participants who consumed at least 400 IU per day from supplements, 1 participants total intake of vitamin E from diet and supplements exceeded 400 IU per day. Discussion In this representative sample of U.S. adults, about 11.3% used supplements leading to an intake of vitamin E 400 IU per day

The Changing Incidence of In situ and Invasive Ductal and Lobular Breast Carcinomas: United States, 1999-2004

Background: National incidence rates for lobular and ductal breast cancers have not been available previously. Evidence suggests that the increased risk of breast cancer associated with combined hormone replacement therapy use is higher for invasive lobular cancers (ILC) than for invasive ductal cancers (IDC). This study provides U.S. incidence rates for these histologic types for both in situ and invasive cancers and assesses changes in the incidence of these cancers over time. Methods: Data for this study included incident ductal and lobular breast cancer cases diagnosed from 1999 through 2004 in central cancer registries in 44 states and the District of Columbia from the National Program of Cancer Registries and the Surveillance, Epidemiology, and End Results program. We estimated incidence per 100,000 women by 10-year age groups, race, and ethnicity. We also assessed the percent change in invasive and in situ cancer incidence over time. Results: We observed distinct differences in the change of incidence over time between in situ and invasive lobular and ductal breast cancers. The age-adjusted rates of ILC and IDC declined an average of 4.6% and 3.3% per year, respectively. Overall, ILC decreased 20.5% from 1999 to 2004. The patterns of ductal and lobular in situ cancer incidence were not consistent over time, and the total change was negligible. Conclusion: The declines in ILC observed in our study are consistent with a decrease in cancer incidence related to a reduced use of combined hormone replacement therapy. However, other factors could also be responsible for these changes. (Cancer Epidemiol Biomarkers Prev 2009;18(6):1763–9)

Descriptive epidemiology of malignant and nonmalignant primary spinal cord, spinal meninges, and cauda equina tumors, United States, 2004‐2007

Primary tumors of the spinal cord, spinal meninges, and cauda equina are relatively rare, and a paucity of population‐based data exist on tumors in these sites. This study intends to augment the current literature by examining incidence of these tumors on a national level.