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1.  Esophageal cancer incidence and mortality in China, 2009 
Journal of Thoracic Disease  2013;5(1):19-26.
Objective
Esophageal cancer incident cases and deaths in 2009 were retrieved from national database of population based cancer registry to describe esophageal cancer burden in registration areas.
Methods
In 2012, 104 population-based cancer registries reported cancer incidence and mortality data of 2009 to Chinese National Central Cancer Registry. Total 72 registries’ data met the national criteria to be pooled and analyzed. The crude incidence and mortality rates of esophageal cancer were calculated by age, gender and area. China sensus in 1982 and Segi’s world population were applied for age standardized rates.
Results
The crude incidence of esophageal cancer ranked fifth in all cancer sites with rate of 22.14/100,000 (30.44/100,000 for male and 13.64/100,000 for female, 14.21/100,000 in urban and 38.44/100,000 in rural). Age-standardized rates by China population (CASR) and World population (WASR) for incidence were 10.88/100,000 and 14.81/100,000 respectively. The crude mortality of esophageal cancer ranked fourth in all cancer sites with rate of 16.77/100,000 (23.29/100,000 for male and 10.11/100,000 for female, 10.59/100,000 in urban and 29.47/100,000 in rural). The CASR and WASR for mortality were 7.75/100,000 and 10.76/100,000 respectively. For both of incidence and mortality, the rates of esophageal cancer were much higher in males than in females, in rural areas than in urban areas. The overall age-specific incidence and mortality rates showed that both rates were relatively low before 45 years old, and then gradually increased, reaching peak in age group of 80-84.
Conclusions
The burden of esophageal cancer remained high in China, especially for males in rural areas. Effective prevention and control action, such as health education, nutrition intervention and screening should be enhanced in the future.
doi:10.3978/j.issn.2072-1439.2013.01.04
PMCID: PMC3547988  PMID: 23372946
Esophageal cancer; incidence; mortality; cancer registry; China
2.  WHAT PROPORTION OF LUNG CANCER IN NEVER-SMOKERS CAN BE ATTRIBUTED TO KNOWN RISK FACTORS? 
Though tobacco smoking is the primary risk factor for lung cancer, a significant fraction of lung cancer deaths occur in lifetime non-smokers. In this paper, we calculate the burden of lung cancer in never-smokers attributable to previously identified risk factors in North America, Europe, and China, using population-based estimates of exposure prevalence and estimates of relative risk derived from recently published meta-analyses. Population attributable fractions (PAFs) for individual risk factors ranged from 0.40% to 19.93%. Due to differences in the prevalence of exposures, the PAFs associated with several of the risk factors varied greatly by geographical region. Exposure to the selected risk factors appeared to explain a much larger proportion of lung cancer cases in never-smokers in China than in Europe and North America. Our results demonstrate the geographic variability of the epidemiology of lung cancer in never-smokers, and highlight the need for further research in this area, particularly in Europe and North America.
doi:10.1002/ijc.27477
PMCID: PMC3359408  PMID: 22322343
lung cancer; population attributable fraction; non-smokers
3.  Estimation of cancer incidence and mortality attributable to alcohol drinking in china 
BMC Public Health  2010;10:730.
Background
Cancer constitutes a serious burden of disease worldwide and has become the second leading cause of death in China. Alcohol consumption is causally associated with the increased risk of certain cancers. Due to the current lack of data and the imperative need to guide policymakers on issues of cancer prevention and control, we aim to estimate the role of alcohol on the cancer burden in China in 2005.
Methods
We calculated the proportion of cancers attributable to alcohol use to estimate the burden of alcohol-related cancer. The population attributable fraction was calculated based on the assumption of no alcohol drinking. Data on alcohol drinking prevalence were from two large-scale national surveys of representative samples of the Chinese population. Data on relative risk were obtained from meta-analyses and large-scale studies.
Results
We found that a total of 78,881 cancer deaths were attributable to alcohol drinking in China in 2005, representing 4.40% of all cancers (6.69% in men, 0.42% in women). The corresponding figure for cancer incidence was 93,596 cases (3.63% of all cancer cases). Liver cancer was the main alcohol-related cancer, contributing more than 60% of alcohol-related cancers.
Conclusions
Particular attention needs to be paid to the harm of alcohol as well as its potential benefits when making public health recommendations on alcohol drinking.
doi:10.1186/1471-2458-10-730
PMCID: PMC3009646  PMID: 21108783
4.  Alcohol, Tobacco and Diet in Relation to Esophageal Cancer: The Shanghai Cohort Study 
Nutrition and cancer  2008;60(3):354-363.
Prospective data on environmental exposures, especially with respect to alcohol, tobacco and diet, in relation to the risk of esophageal cancer in high risk populations are sparse. We analyzed data from a population-based cohort of 18 244 middle-aged and older men in Shanghai to identify risk factors for esophageal cancer in this high-risk population. The cohort was followed through 2006 and 101 incident esophageal cancer cases were identified. Cox proportional hazards models were used to estimate hazard ratios (HR) and their corresponding 95% confidence intervals (CI) for associations between exposures and esophageal cancer risk. With adjustment for tobacco use and other potential confounders, regular drinkers versus nondrinkers of alcoholic beverages had a 2-fold risk of developing esophageal cancer (HR = 2.02, 95% CI = 1.31–3.12). With adjustment for alcohol and other potential confounders, long-term smokers (40+ years) versus nonsmokers of cigarettes showed a 2-fold risk of developing esophageal cancer (HR=2.06, 95% CI=1.11–3.82). Increased consumption of fruits (including oranges/tangerines), seafood and milk were found to be protective against the development of esophageal cancer; HRs were decreased by 40%–60% for high versus low consumers after adjustment for cigarette smoking, alcohol drinking and other confounders.
doi:10.1080/01635580701883011
PMCID: PMC2409004  PMID: 18444169
alcohol; tobacco; diet; esophageal cancer; Chinese
5.  The Independent Effects of Cigarette Smoking, Alcohol Consumption, and Serum Aspartate Aminotransferase on the Alanine Aminotransferase Ratio in Korean Men for the Risk for Esophageal Cancer 
Yonsei Medical Journal  2010;51(3):310-317.
Purpose
The goal of this study is to assess the interactions among alcohol consumption, cigarette smoking, and aspartate aminotransferase (AST) / alanine aminotransferase (ALT) ratios on esophageal cancer.
Materials and Methods
Alcohol and the risk of incidence and death from esophageal cancer were examined in a 14-year prospective cohort study of 782,632 Korean men, 30 to 93 years of age, who received health insurance from the National Health Insurance Corporation and had a medical evaluation from 1992 to 1995.
Results
Smoking, alcohol intake, and AST/ALT ratios were associated with the increased risk of esophageal cancer in a dose-dependent manner independent of each other. Smoking was associated with an increased risk of incidence [Hazard ratio (HR) = 2.2, 95% CI = 1.8 to 2.5] and mortality (HR = 2.5, 2.0 to 3.1). Combined HR of incidence for alcohol consumption (> 25 g/day) and smoking was 4.5 (3.8-5.5); for alcohol (> 25 g/day) and the AST/ALT ratio (≥ 2.0), it was 5.8 (4.6-7.2); for smoking and the AST/ALT ratio (≥ 2.0), it was 6.3 (5.1-7.5). Similar results were seen for mortality from esophageal cancer. Subjects who drank ≥ 25 g/day with an AST/ALT ratio ≥ 2 had a higher risk of esophageal cancer incidence (HR = 6.5, 4.8 to 8.7) compared with those who drank ≥ 25 g/day with an AST/ALT ratio < 2 (HR = 2.2, 1.9 to 2.6).
Conclusion
Alcohol, smoking, and the AST/ALT ratio are independently associated with increased risk of esophageal cancer but did not interact synergistically. The combination of the AST/ALT ratio with a questionnaire for alcohol consumption may increase the effectiveness for determining the risk of esophageal cancer.
doi:10.3349/ymj.2010.51.3.310
PMCID: PMC2852784  PMID: 20376881
Alcohol; smoking; alanine transaminase; aspartate aminotransferases; esophageal neoplasms
6.  Using Current Smoking Prevalence to Project Lung Cancer Morbidity and Mortality in Georgia by 2020 
Introduction
Tobacco use is the leading preventable cause of disease and premature death in the United States. In Georgia, approximately 18% of adults smoke cigarettes, and 87% of men’s lung cancer deaths and 70% of women’s lung cancer deaths are due to smoking. From 2004–2008, the age-adjusted lung cancer incidence rate in Georgia was 112.8 per 100,000 population, and the mortality rate was 88.2 per 100,000 population.
Methods
The Georgia Behavioral Risk Factor Surveillance System Survey was used to estimate trends in current adult smoking prevalence (1985–2010). Georgia smoking–attributable cancer mortality was estimated using a method similar to the Centers for Disease Control and Prevention’s Smoking-Attributable Morbidity, Mortality, and Economic Costs application. Data on cancer incidence (1998–2008) were obtained from the Georgia Comprehensive Cancer Registry, and data on cancer deaths (1990–2007) were obtained from the Georgia Department of Public Health Vital Records Program.
Results
From 1985 through 1993, the prevalence of smoking among Georgians declined by an average of 3% per year in men and 0.2% in women. From 2001 through 2008, lung cancer incidence rates declined in men and increased in women. Lung cancer mortality rates declined in men and women from 2000 through 2007. By 2020, Georgia lung cancer incidence rates are projected to decrease for men and increase for women. Lung cancer mortality is projected to decrease for both men and women.
Conclusion
The lung cancer mortality rates projected in this study are far from meeting the Healthy People 2020 goal (46 per 100,000 population). Full implementation of comprehensive tobacco-use control programs would significantly reduce tobacco-use–related morbidity and mortality.
doi:10.5888/pcd10.120271
PMCID: PMC3664207  PMID: 23660116
7.  Esophageal cancer in Canada: Trends according to morphology and anatomical location 
BACKGROUND:
Esophageal adenocarcinoma has one of the fastest rising incidence rates and one of the lowest survival rates of any cancer type in the Western world. However, in many countries, trends in esophageal cancer differ according to tumour morphology and anatomical location. In Canada, incidence and survival trends for esophageal cancer subtypes are poorly known.
METHODS:
Cancer incidence and mortality rates were obtained from the Canadian Cancer Registry, the National Cancer Incidence Reporting System and the Canadian Vital Statistics Death databases for the period from 1986 to 2006. Observed trends (annual per cent change) and five-year relative survival ratios were estimated separately for esophageal adenocarcinoma and squamous cell carcinoma, and according to location (upper, middle, or lower one-third of the esophagus). Incidence rates were projected up to the year 2026.
RESULTS:
Annual age-standardized incidence rates for esophageal cancer in 2004 to 2006 were 6.1 and 1.7 per 100,000 for males and females, respectively. Esophageal adenocarcinoma incidence rose by 3.9% (males) and 3.6% (females) per year for the period 1986 to 2006, with the steepest increase in the lower one-third of the esophagus (4.8% and 5.0% per year among males and females, respectively). In contrast, squamous cell carcinoma incidence declined by 3.3% (males) and 3.2% (females) per year since the early 1990s. The five-year relative survival ratio for esophageal cancer was 13% between 2004 and 2006, approximately a 3% increase since the period from 1992 to 1994. Projected incidence rates showed increases of 40% to 50% for esophageal adenocarcinoma and decreases of 30% for squamous cell carcinoma by 2026.
DISCUSSION:
Although esophageal cancer is rare in Canada, the incidence of esophageal adenocarcinoma has doubled in the past 20 years, which may reflect the increasing prevalence of obesity and gastroesophageal reflux disease. Declines in squamous cell carcinoma may be the result of the decreases in the prevalence of smoking in Canada. Given the low survival rates and the potential for further increases in incidence, esophageal adenocarcinoma warrants close attention.
PMCID: PMC3472913  PMID: 23061066
Adenocarcinoma; Esophageal cancer; Incidence; Mortality; Squamous cell carcinoma; Survival
8.  Endoscopy in screening for digestive cancer 
The aim of this study is to describe the role of endoscopy in detection and treatment of neoplastic lesions of the digestive mucosa in asymptomatic persons. Esophageal squamous cell cancer occurs in relation to nutritional deficiency and alcohol or tobacco consumption. Esophageal adenocarcinoma develops in Barrett’s esophagus, and stomach cancer in chronic gastric atrophy with Helicobacter pylori infection. Colorectal cancer is favoured by a high intake in calories, excess weight, low physical activity. In opportunistic or individual screening endoscopy is the primary detection procedure offered to an asymptomatic individual. In organized or mass screening proposed by National Health Authorities to a population, endoscopy is performed only in persons found positive to a filter selection test. The indications of primary upper gastrointestinal endoscopy and colonoscopy in opportunistic screening are increasingly developing over the world. Organized screening trials are proposed in some regions of China at high risk for esophageal cancer; the selection test is cytology of a balloon or sponge scrapping; they are proposed in Japan for stomach cancer with photofluorography as a selection test; and in Europe, America and Japan; for colorectal cancer with the fecal occult blood test as a selection test. Organized screening trials in a country require an evaluation: the benefit of the intervention assessed by its impact on incidence and on the 5 year survival for the concerned tumor site; in addition a number of bias interfering with the evaluation have to be controlled. Drawbacks of screening are in the morbidity of the diagnostic and treatment procedures and in overdetection of none clinically relevant lesions. The strategy of endoscopic screening applies to early cancer and to benign adenomatous precursors of adenocarcinoma. Diagnostic endoscopy is conducted in 2 steps: at first detection of an abnormal area through changes in relief, in color or in the course of superficial capillaries; then characterization of the morphology of the lesion according to the Paris classification and prediction of the risk of malignancy and depth of invasion, with the help of chromoscopy, magnification and image processing with neutrophil bactericidal index or FICE. Then treatment decision offers 3 options according to histologic prediction: abstention, endoscopic resection, surgery. The rigorous quality control of endoscopy will reduce the miss rate of lesions and the occurrence of interval cancer.
doi:10.4253/wjge.v4.i12.518
PMCID: PMC3536848  PMID: 23293721
Esophagus; Stomach; Colon; Adenoma; Adenocarcinoma; Endoscopy; Screening
9.  Epidemiologic differences in esophageal cancer between Asian and Western populations 
Chinese Journal of Cancer  2012;31(6):281-286.
Esophageal cancer is a common cancer worldwide and has a poor prognosis. The incidence of esophageal squamous cell cancer has been decreasing, whereas the incidence of esophageal adenocarcinoma has been increasing rapidly, particularly in Western men. Squamous cell cancer continues to be the major type of esophageal cancer in Asia, and the main risk factors include tobacco smoking, alcohol consumption, hot beverage drinking, and poor nutrition. In contrast, esophageal adenocarcinoma predominately affects the whites, and the risk factors include smoking, obesity, and gastroesophageal reflux disease. In addition, Asians and Caucasians may have different susceptibilities to esophageal cancer due to different heritage backgrounds. However, comparison studies between these two populations are limited and need to be addressed in the near future. Ethnic differences should be taken into account in preventive and clinical practices.
doi:10.5732/cjc.011.10390
PMCID: PMC3777490  PMID: 22507220
Esophageal cancer; epidemiology; molecular epidemiology; ethnicity
10.  Cancer burden in China: a Bayesian approach 
BMC Cancer  2013;13:458.
Background
Cancer is a serious health issue in China, but accurate national counts for cancer incidence are not currently available. Knowledge of the cancer burden is necessary for national cancer control planning. In this study, national death survey data and cancer registration data were used to calculate the cancer burden in China using a Bayesian approach.
Methods
Cancer mortality and incidence rates for 2004–2005 were obtained from the National Cancer Registration database. The third National Death Survey (NDS), 2004–2005 database provided nationally representative cancer mortality rates. Bayesian modeling methods were used to estimate mortality to incidence (MI) ratios from the registry data and national incidence from the NDS for specific cancer types by age, sex and urban or rural location.
Results
The total estimated incident cancer cases in 2005 were 2,956,300 (1,762,000 males, 1,194,300 females). World age standardized incidence rates were 236.2 per 100,000 in males and 168.9 per 100,000 in females in urban areas and 203.7 per 100,000 and 121.8 per 100,000 in rural areas.
Conclusions
MI ratios are useful for estimating national cancer incidence in the absence of representative incidence or survival data. Bayesian methods provide a flexible framework for smoothing rates and representing statistical uncertainty in the MI ratios. Expansion of China’s cancer registration network to be more representative of the country would improve the accuracy of cancer burden estimates.
doi:10.1186/1471-2407-13-458
PMCID: PMC3850959  PMID: 24093796
Bayes Theorem; China; Incidence; Mortality; Neoplasm
11.  Mortality attributable to passive smoking in Spain, 2002 
Tobacco Control  2007;16(6):373-377.
Objective
Exposure to environmental tobacco smoke (ETS) is associated with a variety of health effects, including lung cancer and ischaemic heart disease. The objective of this study was to estimate the number of deaths caused by exposure to ETS among non‐smokers in Spain during the year 2002
Methods
Prevalence of ETS exposure among never smokers was gathered from three region based health interview surveys. The relative risks of lung cancer and ichaemic heart diseases were selected from three meta‐analyses. Population attributable risk (PAR) was computed using a range of prevalences (minimum‐maximum). The number of deaths attributable to ETS was calculated by applying PARs to mortality not attributable to active smoking in 2002. The analyses were stratified by sex, age and source of exposure (home, workplace and both combined). In addition, a sensitivity analysis was performed for different scenarios.
Results
Among men, deaths attributable to ETS ranged from 408 to 1703. From 247 to 1434 of these deaths would be caused by the exposure only at home, 136–196 by exposure only in the workplace and 25–73 by exposure at both home and the workplace. Among women, the number of attributable deaths ranged from 820 to 1534. Between 807 and 1477 of these deaths would be caused by exposure only at home, 9–32 by exposure only in the workplace and 4–25 by exposure both at home and in the workplace.
Conclusion
Exposure to ETS at home and at work in Spain could be responsible for 1228–3237 of deaths from lung cancer and ischaemic heart disease. These data confirm that passive smoking is an important public health problem in Spain that needs urgent attention.
doi:10.1136/tc.2006.019679
PMCID: PMC2807185  PMID: 18048612
environmental tobacco smoke; cancer; Spain
12.  Epidemiology of Esophageal Cancer in Japan and China 
Journal of Epidemiology  2013;23(4):233-242.
In preparation for a collaborative multidisciplinary study of the pathogenesis of esophageal cancer, the authors reviewed the published literature to identify similarities and differences between Japan and China in esophageal cancer epidemiology. Esophageal squamous cell carcinoma (ESCC) is the predominant histologic type, while the incidence of esophageal adenocarcinoma remains extremely low in both countries. Numerous epidemiologic studies in both countries show that alcohol consumption and cigarette smoking are contributing risk factors for ESCC. There are differences, however, in many aspects of esophageal cancer between Japan and China, including cancer burden, patterns of incidence and mortality, sex ratio of mortality, risk factor profiles, and genetic variants. Overall incidence and mortality rates are higher in China than in Japan, and variation in mortality and incidence patterns is greater in China than in Japan. During the study period (1987–2000), the decline in age-adjusted mortality rates was more apparent in China than in Japan. Risk factor profiles differed between high- and low-incidence areas within China, but not in Japan. The association of smoking and drinking with ESCC risk appears to be weaker in China than in Japan. Genome-wide association studies in China showed that variants in several chromosome regions conferred increased risk, but only genetic variants in alcohol-metabolizing genes were significantly associated with ESCC risk in Japan. A well-designed multidisciplinary epidemiologic study is needed to examine the role of diet and eating habits in ESCC risk.
doi:10.2188/jea.JE20120162
PMCID: PMC3709543  PMID: 23629646
esophageal cancer; epidemiology; risk factor
13.  Cytokeratin immunoexpression in esophageal squamous cell carcinoma of high-risk population in Northeast India 
Esophageal cancer is a frequently fatal malignancy, and is described in certain regions in Northeast India with an incidence of esophageal squamous cell carcinoma is many fold higher than the rest of the population. The population in Northeast India is at higher risk due to poor nutritional status, consumption of fermented betel quid and other oral tobacco products besides smoking and alcohol intake. Cytokeratins are the major constituents of the esophageal epithelium and may show gain or loss of cytokeratins as the cancer progresses from normal epithelium to invasive phenotype. In the present study we studied the immunohistochemical expression of five cytokeratins (CK4, CK5, CK8, CK14, and CK17) in the normal esophageal epithelium and esophageal squamous cell carcinoma from both the general population and the high-risk population of Assam in Northeast India. The cytokeratin expression profile was similar to other published data in general. Further analysis demonstrated differences in cytokeratin expression between the general and the high-risk tumor samples. CK5 and CK 8 expression altered in the high-risk population. The significance of these differences is unclear, but suggests a connection to the etiological factors.
doi:10.1097/PAI.0b013e31819d3753
PMCID: PMC2836392  PMID: 19417629
Cytokeratins; esophageal cancer; high-risk; immunohistochemistry; squamous cell carcinoma; tissue microarray
14.  Heavy alcohol intake is a risk factor for esophageal squamous cell carcinoma among middle-aged men: A case-control and simulation study 
Molecular and Clinical Oncology  2013;1(5):811-816.
Despite the advances in surgical techniques and treatments, the prognosis of esophageal cancer remains poor, since the disease is usually diagnosed at an advanced stage. Therefore, prevention plays an important role in reducing mortality. Smoking and alcohol intake are modifiable habits and are important risk factors for esophageal cancer. However, the number of large-scale studies that have investigated the association of the amount and duration of smoking and alcohol intake with esophageal cancer risk, while accounting for the effects of gender and cancer subtypes (squamous cell carcinoma and adenocarcinoma), is limited. Therefore, in this hospital-based matched case-control study we investigated this association while accounting for gender and subtype differences. Chinese male patients <60 years of age with esophageal squamous cell carcinoma (ESCC) from the Fourth Hospital of Hebei Medical University in China and healthy individuals were enrolled between January, 2002 and December, 2006. Each ESCC patient was age-matched to a control subject and a total of 535 pairs were enrolled in this study. The combined variables of amount and duration were created to elucidate their effect and association with ESCC. Multiple conditional logistic regression analysis was used to estimate the odds ratio (OR) and 95% confidence interval (CI) in this model, which included a family history of esophageal cancer, a combined smoking variable and a combined alcohol variable. A simulation study was subsequently performed to confirm the reliability of the results. The results of the present study demonstrated that a family history of esophageal cancer and the combined alcohol variable were significantly associated with ESCC risk. Heavy alcohol consumption and intake for ≤20 years increased the risk compared with no intake (OR=1.91, 95% CI: 1.25–2.92). Heavy alcohol consumption and intake for >20 years exhibited an even higher risk (OR=7.25, 95% CI: 3.12–16.83). These results were similar to those of the simulation. Heavy alcohol intake, even for a short duration, is a critical risk factor and may lead to the development of ESCC in Chinese males.
doi:10.3892/mco.2013.142
PMCID: PMC3915638  PMID: 24649251
alcohol intake; conditional logistic regression analysis; esophageal squamous cell carcinoma; matched case-control study; middle-aged Chinese men; simulation
15.  Attributable Causes of Cancer in China: Fruit and Vegetable 
Objective
To provide an evidence-based and consistent assessment of the burden of cancer attributable to inadequate fruit and vegetable intake in China in 2005.
Methods
The proportions of cancers attributable to low consumption of vegetable and fruit were calculated separately to estimate the burden of related cancers for the year 2005 in China. Data on the prevalence of exposure were derived from a Chinese nutrition and health survey. Data on relative risks were mainly derived from meta-analysis. Attributable fractions were calculated based on the counterfactual scenario which was a shift in the exposure distribution.
Results
The total cancer burden attributable to inadequate consumption of fruit was up to 233,000 deaths (13.0% of all cancers) and 300,000 cases (11.6% of all cancers) in 2005. Increasing consumption of vegetable to the highest quintile could avoid total cancer deaths and cases by 3.6% (64,000 persons) and 3.4% (88,000 persons). The contributions to cancer burden were higher in rural areas than in urban areas. They have greater influence on men than on women. The largest proportions of cancer burden attributable to low fruit and vegetable intake were for oral and pharyngeal cancers.
Conclusion
This study showed that inadequate intake of fruit and vegetable makes a significant contribution to the cancer burden. Increasing consumption of fruit and vegetable could prevent many cancer deaths and save many lives. Promoting the consumption of fruit and vegetable is an important component in diet-based strategies for preventing cancer.
doi:10.1007/s11670-011-0171-7
PMCID: PMC3587560  PMID: 23467575
Fruit; Vegetable; Cancer; Population attributable fraction; China
16.  Analysing the Large Decline in Coronary Heart Disease Mortality in the Icelandic Population Aged 25-74 between the Years 1981 and 2006 
PLoS ONE  2010;5(11):e13957.
Background
Coronary heart disease (CHD) mortality rates have been decreasing in Iceland since the 1980s. We examined how much of the decrease between 1981 and 2006 could be attributed to medical and surgical treatments and how much to changes in cardiovascular risk factors.
Methodology
The previously validated IMPACT CHD mortality model was applied to the Icelandic population. The data sources were official statistics, national quality registers, published trials and meta-analyses, clinical audits and a series of national population surveys.
Principal Findings
Between 1981 and 2006, CHD mortality rates in Iceland decreased by 80% in men and women aged 25 to 74 years, which resulted in 295 fewer deaths in 2006 than if the 1981 rates had persisted. Incidence of myocardial infarction (MI) decreased by 66% and resulted in some 500 fewer incident MI cases per year, which is a major determinant of possible deaths from MI. Based on the IMPACT model approximately 73% (lower and upper bound estimates: 54%–93%) of the mortality decrease was attributable to risk factor reductions: cholesterol 32%; smoking 22%; systolic blood pressure 22%, and physical inactivity 5% with adverse trends for diabetes (−5%), and obesity (−4%). Approximately 25% (lower and upper bound estimates: 8%–40%) of the mortality decrease was attributable to treatments in individuals: secondary prevention 8%; heart failure treatments 6%; acute coronary syndrome treatments 5%; revascularisation 3%; hypertension treatments 2%, and statins 0.5%.
Conclusions
Almost three quarters of the large CHD mortality decrease in Iceland between 1981 and 2006 was attributable to reductions in major cardiovascular risk factors in the population. These findings emphasize the value of a comprehensive prevention strategy that promotes tobacco control and a healthier diet to reduce incidence of MI and highlights the potential importance of effective, evidence based medical treatments.
doi:10.1371/journal.pone.0013957
PMCID: PMC2980472  PMID: 21103050
17.  Esophageal cancer epidemiology in blacks and whites: racial and gender disparities in incidence, mortality, survival rates and histology. 
BACKGROUND: Esophageal cancer rate disparities are pronounced for blacks and whites. This study presents black-white esophageal cancer incidence, mortality, relative survival rates, histology and trends for two five-year time periods--1991-1995 and 1996-2000--and for the time period 1991-2000. METHODS: The study used data from the National Cancer Institute's population-based Surveillance Epidemiology End Results (SEER) program with submission dates 1991-2000. Age-adjusted incidence, mortality, relative survival rates and histology for esophageal carcinoma were calculated for nine SEER cancer registries for 1991-2000. Rates were analyzed by race and gender for changes over specified time periods. RESULTS: Esophageal cancer age-adjusted incidence of blacks was about twice that of whites (8.63 vs. 4.39/100,000, p < 0.05). Age-adjusted mortality for blacks, although showing a declining trend, was nearly twice that of whites (7.79 vs. 3.96, p < 0.05). Although survival was poor for all groups, it was significantly poorer in blacks than in whites. Squamous cell carcinoma was more commonly diagnosed in blacks and white females, whereas adenocarcinoma was more common among white males (p < 0.001). CONCLUSIONS: Racial disparities in esophageal cancer incidence, mortality, survival and histology exist. Survival rates from this disease have not significantly improved over the decade. These data support the need for advances in prevention, early detection biomarker research and research on new, more effective treatment modalities for this disease.
Images
PMCID: PMC2594901  PMID: 16334494
18.  Occupation and cancer in Britain 
British Journal of Cancer  2010;102(9):1428-1437.
Background:
Prioritising control measures for occupationally related cancers should be evidence based. We estimated the current burden of cancer in Britain attributable to past occupational exposures for International Agency for Research on Cancer (IARC) group 1 (established) and 2A (probable) carcinogens.
Methods:
We calculated attributable fractions and numbers for cancer mortality and incidence using risk estimates from the literature and national data sources to estimate proportions exposed.
Results:
5.3% (8019) cancer deaths were attributable to occupation in 2005 (men, 8.2% (6362); women, 2.3% (1657)). Attributable incidence estimates are 13 679 (4.0%) cancer registrations (men, 10 063 (5.7%); women, 3616 (2.2%)). Occupational attributable fractions are over 2% for mesothelioma, sinonasal, lung, nasopharynx, breast, non-melanoma skin cancer, bladder, oesophagus, soft tissue sarcoma, larynx and stomach cancers. Asbestos, shift work, mineral oils, solar radiation, silica, diesel engine exhaust, coal tars and pitches, occupation as a painter or welder, dioxins, environmental tobacco smoke, radon, tetrachloroethylene, arsenic and strong inorganic mists each contribute 100 or more registrations. Industries and occupations with high cancer registrations include construction, metal working, personal and household services, mining, land transport, printing/publishing, retail/hotels/restaurants, public administration/defence, farming and several manufacturing sectors. 56% of cancer registrations in men are attributable to work in the construction industry (mainly mesotheliomas, lung, stomach, bladder and non-melanoma skin cancers) and 54% of cancer registrations in women are attributable to shift work (breast cancer).
Conclusion:
This project is the first to quantify in detail the burden of cancer and mortality due to occupation specifically for Britain. It highlights the impact of occupational exposures, together with the occupational circumstances and industrial areas where exposures to carcinogenic agents occurred in the past, on population cancer morbidity and mortality; this can be compared with the impact of other causes of cancer. Risk reduction strategies should focus on those workplaces where such exposures are still occurring.
doi:10.1038/sj.bjc.6605637
PMCID: PMC2865752  PMID: 20424618
occupation; cancer burden; attributable fraction; industry sector; carcinogen
19.  Food group intake and risk of subtypes of esophageal and gastric cancer 
Incidence rates for adenocarcinomas of the esophagus and gastric cardia have been increasing rapidly, while rates for non-cardia gastric adenocarcinoma and esophageal squamous cell carcinoma have declined. We examined food group intake as a risk factor for subtypes of esophageal and gastric cancers in a multi-center, population-based case-control study in Connecticut, New Jersey, and western Washington state. Associations between food groups and risk were estimated using adjusted odds ratios (OR), based on increasing intake of one serving per day. Total vegetable intake was associated with decreased risk of esophageal adenocarcinoma (OR = 0.85, 95% CI = 0.75, 0.96). Conversely, total meat intake was associated with increased risk of esophageal adenocarcinoma (OR = 1.43, 95% CI = 1.11, 1.83), gastric cardia adenocarcinoma (OR = 1.37, 95% CI = 1.08, 1.73), and non-cardia gastric adenocarcinoma (OR = 1.39, 95% CI = 1.12, 1.71), with red meat most strongly associated with esophageal adenocarcinoma risk (OR = 2.49, 95% CI = 1.39, 4.46). Poultry was most strongly associated with gastric cardia adenocarcinoma (OR = 1.89, 95% CI = 1.15, 3.11) and non-cardia gastric adenocarcinoma (OR = 1.90, 95% CI = 1.19, 3.03). High-fat dairy was associated with increased risk of both esophageal and gastric cardia adenocarcinoma. Higher intake of meats, particularly red meats, and lower intake of vegetables were associated with an increased risk of esophageal adenocarcinoma, while higher intake of meats, particularly poultry, and high-fat dairy was associated with increased risk of gastric cardia adenocarcinoma.
doi:10.1002/ijc.23544
PMCID: PMC3008621  PMID: 18537156
Esophageal neoplasms; gastric neoplasms; food groups; case-control
20.  Socio-Demographic and Geographical Factors in Esophageal and Gastric Cancer Mortality in Sweden 
PLoS ONE  2013;8(4):e62067.
Background
Socio-demographic factors and area of residence might influence the development of esophageal and gastric cancer. Large-scale population-based research can determine the role of such factors.
Methods
This population-based cohort study included all Swedish residents aged 30–84 years in 1990–2007. Educational level, marital status, place of birth, and place of residence were evaluated with regard to mortality from esophageal or gastric cancer. Cox regression yielded hazard ratios (HR) with 95% confidence intervals (CI), adjusted for potential confounding.
Results
Among 84 920 565 person-years, 5125 and 12 230 deaths occurred from esophageal cancer and gastric cancer, respectively. Higher educational level decreased the HR of esophageal cancer (HR = 0.61, 95%CI 0.42–0.90 in women, HR = 0.71, 95%CI 0.60–0.84 in men) and gastric cancer (HR = 0.80, 95%CI 0.63–1.03 in women, HR = 0.73, 95%CI 0.64–0.83 in men). Being unmarried increased HR of esophageal cancer (HR = 1.64, 95%CI 1.35–1.99 in women, HR = 1.64, 95%CI 1.50–1.80 in men), but not of gastric cancer. Being born in low density populated areas increased HR of gastric cancer (HR = 1.23, 95%CI 1.10–1.38 in women, HR = 1.37, 95%CI 1.25–1.50 in men), while no strong association was found with esophageal cancer. Living in densely populated areas increased HR of esophageal cancer (HR = 1.31, 95%CI 1.14–1.50 in women, HR = 1.40, 95%CI 1.29–1.51 in men), but not of gastric cancer.
Conclusion
These socio-demographic inequalities in cancer mortality warrant efforts to investigate possible preventable mechanisms and to promote and support healthier lifestyles among deprived groups.
doi:10.1371/journal.pone.0062067
PMCID: PMC3630145  PMID: 23637965
21.  Trends in smokeless tobacco use in the us workforce: 1987-2005 
The primary aim was to examine whether increasing workplace smoking restrictions have led to an increase in smokeless tobacco use among US workers. Smokeless tobacco exposure increases the risk of oral cavity, esophageal, and pancreatic cancers, and stroke. The prevalence of smokeless tobacco use decreased from 1987-2000, except among men 25-44. While smokeless tobacco use has declined in the general population, it may be that the prevalence of smokeless tobacco use has increased among workers due to workplace smoking restrictions, which have been shown to have increased over the years. Using the most current nationally representative National Health Interview Survey (NHIS) data, we examined whether increasing workplace smoking restrictions have led to an increase in smokeless tobacco use among US workers (n = 125,838). There were no significant changes in smokeless tobacco use prevalence from 1987-2005 (pooled prevalence = 3.53%); rates also were lower in smoke free workplaces. Worker groups with high rates of smokeless tobacco use included farm workers (10.51%) and blue collar workers (7.26%). Results indicate that smokeless tobacco prevention strategies targeting particular worker groups are warranted.
doi:10.1186/1617-9625-9-6
PMCID: PMC3118314  PMID: 21631951
22.  Liver cancer incidence and mortality in China, 2009 
Chinese Journal of Cancer  2013;32(4):162-169.
Liver cancer is a common cancer and a leading cause of cancer deaths in China. To aid the government in establishing a control plan for this disease, we provided real-time surveillance information by analyzing liver cancer incidence and mortality in China in 2009 reported by the National Central Cancer Registry. Liver cancer incidence and cases of death were retrieved from the national database using the ICD-10 topography code “C22”. Crude incidence and mortality were calculated and stratified by sex, age, and location (urban/rural). China's population in 1982 and Segi (world) population structures were used for age-standardized rates. In cancer registration areas in 2009, the crude incidence of liver cancer was 28.71/100,000, making it the fourth most common cancer in China, third most common in males, and fifth most common in females. The crude mortality of liver cancer was 26.04/100,000, making it the second leading cause of cancer death in China and urban areas and the third leading cause in rural areas. Incidence and mortality were higher in males than in females and were higher in rural areas than in urban areas. The age-specific incidence and mortality were relatively low among age groups under 30 years but dramatically increased and peaked in the 80–84 years old group. These findings confirm that liver cancer is a common and fatal cancer in China. Primary and secondary prevention such as health education, hepatitis B virus vaccination, and early detection should be carried out both in males and females, in urban and rural areas.
doi:10.5732/cjc.013.10027
PMCID: PMC3845572  PMID: 23489585
Liver cancer; cancer registry; incidence; mortality; China
23.  Effect of the interaction between the amount and duration of alcohol consumption and tobacco smoking on the risk of esophageal cancer: A case-control study 
The effects of alcohol consumption and tobacco smoking on the prevalence of esophageal cancer vary considerably by country, race and lifestyle. Few data exist on the effect of the interaction between the amount and duration of alcohol consumption and tobacco smoking on the incidence of esophageal cancer. In this case-control study, the cases included patients with histologically confirmed esophageal squamous cell carcinoma (ESCC) younger than 60 years of age and recruited between January 1, 2002 and December 31, 2006. The controls had no abnormality during a medical checkup. A total of 835 pairs were created by pairing each case to a gender- and age-matched control. Conditional logistic regression analysis was used to estimate adjusted odds ratios (ORs) and 95% confidence intervals. Univariate conditional logistic regression analyses revealed that the ORs according to both duration of alcohol consumption and tobacco smoking increased monotonically. Alcohol consumption and tobacco smoking may have a synergistic effect on the incidence of ESCC. Conditional logistic regression analysis using a forward stepwise selection procedure revealed that the incidence of ESCC was associated with the duration of tobacco smoking, the interaction between the amount and duration of alcohol consumption, and a family history of cancer. In particular, groups with a long duration of alcohol consumption and high alcohol intake had much higher ORs than those with short duration and low intake, which highlights the importance of the interaction between the amount and duration of alcohol intake. This study confirmed the significance of the interaction between alcohol consumption and tobacco smoking in esophageal cancer. This interaction between amount and duration is an accurate indicator for estimating the risk of esophageal cancer attributable to alcohol consumption and tobacco smoking. These findings suggest that decreasing the number of young and middle-aged drinkers and smokers will reduce the incidence of esophageal cancer.
doi:10.3892/etm.2010.152
PMCID: PMC3446748  PMID: 22993631
alcohol consumption; tobacco smoking; esophageal cancer; interaction between amount and duration
24.  N-acetyltransferase 2 Polymorphisms and Risk of Esophageal Cancer in a Chinese Population 
PLoS ONE  2014;9(2):e87783.
Esophageal cancer was the fifth most commonly diagnosed cancer and the fourth leading cause of cancer-related death in China in 2009. Genetic factors might play an important role in the carcinogenesis of esophageal squamous cell carcinoma (ESCC). We conducted a hospital-based case-control study to evaluate ten NAT2 tagging single nucleotide polymorphisms (SNPs) on the risk of ESCC. Six hundred and twenty-nine ESCC cases and 686 controls were recruited. Their genotypes were determined using the ligation detection reaction method. In the single locus analyses, there was a borderline statistically significant difference in genotype frequencies of NAT2 rs1565684 T>C SNP between the cases and the controls (p = 0.057). The NAT2 rs1565684 CC genotype was associated with a borderline significantly increased risk for ESCC (CC vs. TT: adjusted OR = 1.77, 95% CI = 0.97–3.21, p = 0.063 and CC vs. TT/TC: adjusted OR = 1.68, 95% CI = 0.93–3.04, p = 0.085). The association was evident among older patients and patients who never drunk. After the Bonferroni correction, in all comparison models, NAT2 rs1565684 T>C SNP was not associated with ESCC risk (p>0.05). For the other nine NAT2 SNPs, after Bonferroni correction, in all comparison models, the nine SNPs were also not associated with ESCC risk (p>0.05). Thus, nine NAT2 tagging SNPs were not associated with risk of ESCC. NAT2 rs1565684 T>C SNP might play a slight role in ESCC etiology. Additional, larger studies and tissue-specific biological characterization are required to confirm the current findings.
doi:10.1371/journal.pone.0087783
PMCID: PMC3929587  PMID: 24586291
25.  Using NHANES oral health examination protocols as part of an esophageal cancer screening study conducted in a high-risk region of China 
BMC Oral Health  2007;7:10.
Background
The oral health status of rural residents in the People's Republic of China has not been extensively studied and the relationship between poor oral health and esophageal cancer (EC) is unclear. We aim to report the oral health status of adults participating in an EC screening study conducted in a rural high-risk EC area of China and to explore the relationship between oral health and esophageal dysplasia.
Methods
National Health and Nutrition Examination Survey (NHANES) oral health examination procedures and the Modified Gingival Index (MGI) were used in a clinical study designed to examine risk factors for esophageal cancer and to test a new esophageal cytology sampling device. This study was conducted in three rural villages in China with high rates of EC in 2002 and was a collaborative effort involving investigators from the National Institutes of Health and the Cancer Institute of the Chinese Academy of Medical Sciences.
Results
Nearly 17% of the study participants aged 40–67 years old were edentulous. Overall, the mean number of adjusted missing teeth (including third molars and retained dental roots) was 13.8 and 35% had 7 contacts or less. Women were more likely to experience greater tooth loss than men. The average age at the time of first tooth loss for those with no posterior functional contacts was approximately 41 years for men and 36 years for women. The mean DMFT (decayed, missing, and filled teeth) score for the study population was 8.5. Older persons, females, and individuals having lower educational attainment had higher DMFT scores. The prevalence of periodontal disease (defined as at least one site with 3 mm of attachment loss and 4 mm of pocket depth) was 44.7%, and 36.7% of the study participants had at least one site with 6 mm or more of attachment loss. Results from a parsimonious multivariate model indicate that participants with poor oral health wemore likely to have esophageal dysplasia (OR = 1.59; 95% CI 1.06, 2.39).
Conclusion
This report describes the first use of NHANES oral health protocols employed in a clinical study conducted outside of the United States. The extent and severity of poor oral health in this Chinese study group may be an important health problem and contributing factor to the prevalence of EC.
doi:10.1186/1472-6831-7-10
PMCID: PMC1993835  PMID: 17640341

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