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1.  Seropositivity to Helicobacter pylori and risk of pancreatic cancer 
Helicobacter pylori seropositivity has been inconsistently associated with pancreatic cancer. We, therefore, investigated the association between H. pylori seropositivity and pancreatic cancer in a case-control study nested within Alpha-Tocopherol, Beta-Carotene Cancer Prevention Study (ATBC) cohort of male Finnish male smokers. Pancreatic cancer cases (n=353) and control subjects (n=353) were matched on date of baseline serum collection, age at randomization, and follow-up time (up to 23.9 years). We used a multiplex serology assay to determine the serostatus of antibodies against 15 H. pylori specific antigens in fasting serum samples. Conditional logistic regression was used to calculate the odds ratio (OR) and 95% confidence intervals (CI). Neither targeted H. Pylori antigens in serum nor the combination of all was associated with development of pancreatic cancer (combination of all: OR=0.85, 95% CI= 0.49–1.49). Our results suggest that H. pylori is not a risk factor for pancreatic cancer.
PMCID: PMC3858455  PMID: 24089457
Helicobacter pylori; pancreatic cancer
2.  Teaching Population Health: A Competency Map Approach to Education 
A 2012 Institute of Medicine report is the latest in the growing number of calls to incorporate a population health approach in health professionals’ training. Over the last decade, Duke University, particularly its Department of Community and Family Medicine, has been heavily involved with community partners in Durham, North Carolina to improve the local community’s health. Based on these initiatives, a group of interprofessional faculty began tackling the need to fill the curriculum gap to train future health professionals in public health practice, community engagement, critical thinking, and team skills to improve population health effectively in Durham and elsewhere.
The Department of Community and Family Medicine has spent years in care delivery redesign and curriculum experimentation, design, and evaluation to distinguish the skills trainees and faculty need for population health improvement and to integrate them into educational programs. These clinical and educational experiences have led to a set of competencies that form an organizational framework for curricular planning and training. This framework delineates which learning objectives are appropriate and necessary for each learning level, from novice through expert, across multiple disciplines and domains. The resulting competency map has guided Duke’s efforts to develop, implement, and assess training in population health for learners and faculty. In this article, the authors describe the competency map development process as well as examples of its application and evaluation at Duke and limitations to its use with the hope that other institutions will apply it in different settings.
PMCID: PMC3636155  PMID: 23524919
3.  A prospective study of obesity, weight change and the risk of adenoma recurrence 
Endoscopy  2012;44(9):813-818.
Background and study aims
Obesity is a risk factor for colorectal neoplasia. Lifestyle modifications including weight loss have been advocated to reduce the risk. However, no prospective study has evaluated if weight loss actually affects adenoma recurrence. We examined whether weight change (loss or gain) over four years is associated with adenoma recurrence.
Patients and methods
1,826 participants with colorectal adenoma in the Polyp Prevention Trial had height and weight measured at baseline. Adenoma recurrence was determined by end of trial colonoscopy 4 years after study entry when participants’ weights were re-measured. We used Poisson regression models to evaluate body mass index (BMI), weight change over 4 years and the risk of any adenoma and advanced adenoma recurrence.
723 (39.6%) participants had adenoma recurrence, of whom 118 (6.5%) had advanced adenoma recurrence. Among those with baseline BMI < 25 kg/m2 (n=466), BMI = 25–29 kg/m2 (n=868), and BMI ≥ 30 kg/m2 (n=492), the recurrence rate was 34.5%, 41% and 41.9%, respectively. Obesity was associated with an increased risk of adenoma (RR=1.19; 95%CI: 1.01–1.39) and advanced adenoma recurrence (RR=1.62; 95%CI: 1.01–2.57). However, when compared with those with relatively stable weight (< 5 pound weight change) over the 4-year trial, weight gain or loss was not associated with adenoma recurrence. This was consistent, regardless of the baseline BMI.
Weight loss or gain over 4 years does not affect adenoma recurrence. Our study does not support weight loss alone as an effective intervention for reducing adenoma recurrence.
PMCID: PMC3910085  PMID: 22926666
Adenomatous polyps; body mass index; colonoscopy; weight loss
4.  Measuring telomere length for the early detection of precursor lesions of esophageal squamous cell carcinoma 
BMC Cancer  2013;13:578.
Esophageal cancer is the sixth leading cause of cancer death worldwide; current early detection screening tests are inadequate. Esophageal balloon cytology successfully retrieves exfoliated and scraped superficial esophageal epithelial cells, but cytologic reading of these cells has poor sensitivity and specificity for detecting esophageal squamous dysplasia (ESD), the precursor lesion of esophageal squamous cell carcinoma (ESCC). Measuring telomere length, a marker for chromosomal instability, may improve the utility of balloon cytology for detecting ESD and early ESCC.
We examined balloon cytology specimens from 89 asymptomatic cases of ESD (37 low-grade and 52 high-grade) and 92 age- and sex-matched normal controls from an esophageal cancer early detection screening study. All subjects also underwent endoscopy and biopsy, and ESD was diagnosed histopathologically. DNA was extracted from the balloon cytology cells, and telomere length was measured by quantitative PCR. A receiver operating characteristic (ROC) curve was plotted for telomere length as a diagnostic marker for high-grade dysplasia.
Telomere lengths were comparable among the low- and high-grade dysplasia cases and controls, with means of 0.96, 0.96, and 0.92, respectively. The area under the ROC curve was 0.55 for telomere length as a diagnostic marker for high-grade dysplasia. Further adjustment for subject characteristics, including sex, age, smoking, drinking, hypertension, and body mass index did not improve the use of telomere length as a marker for ESD.
Telomere length of esophageal balloon cytology cells was not associated with ESCC precursor lesions. Therefore, telomere length shows little promise as an early detection marker for ESCC in esophageal balloon samples.
PMCID: PMC3882883  PMID: 24308314
Esophageal squamous cell carcinoma; Esophageal squamous dysplasia; Early detection; Screening; Balloon cytology; Telomeres
5.  Genetic Variants in Epidermal Growth Factor Receptor Pathway Genes and Risk of Esophageal Squamous Cell Carcinoma and Gastric Cancer in a Chinese Population 
PLoS ONE  2013;8(7):e68999.
The epidermal growth factor receptor (EGFR) signaling pathway regulates cell proliferation, differentiation, and survival, and is frequently dysregulated in esophageal and gastric cancers. Few studies have comprehensively examined the association between germline genetic variants in the EGFR pathway and risk of esophageal and gastric cancers. Based on a genome-wide association study in a Han Chinese population, we examined 3443 SNPs in 127 genes in the EGFR pathway for 1942 esophageal squamous cell carcinomas (ESCCs), 1758 gastric cancers (GCs), and 2111 controls. SNP-level analyses were conducted using logistic regression models. We applied the resampling-based adaptive rank truncated product approach to determine the gene- and pathway-level associations. The EGFR pathway was significantly associated with GC risk (P = 2.16×10−3). Gene-level analyses found 10 genes to be associated with GC, including FYN, MAPK8, MAP2K4, GNAI3, MAP2K1, TLN1, PRLR, PLCG2, RPS6KB2, and PIK3R3 (P<0.05). For ESCC, we did not observe a significant pathway-level association (P = 0.72), but gene-level analyses suggested associations between GNAI3, CHRNE, PAK4, WASL, and ITCH, and ESCC (P<0.05). Our data suggest an association between specific genes in the EGFR signaling pathway and risk of GC and ESCC. Further studies are warranted to validate these associations and to investigate underlying mechanisms.
PMCID: PMC3715462  PMID: 23874846
6.  Achieving Health for a Lifetime: A Community Engagement Assessment Focusing on School-Age Children to Decrease Obesity in Durham, North Carolina 
North Carolina medical journal  2013;74(1):18-26.
Obesity is a prominent problem in the United States and in North Carolina. One way of combating it is with community-engaged interventions that foster collaboration between health-oriented organizations and community residents.
Our purpose was to assemble a multifaceted group in Durham, North Carolina, to identify factors affecting obesity-related lifestyle behaviors; assess policies, resources, and the population's perception of the problem of obesity; and develop plans to improve health outcomes related to obesity.
A team consisting of more than 2 dozen partners was assembled to form Achieving Health for a Lifetime (AHL) in order to study and address obesity in the community, initially focusing on elementary school-age children. The team developed a resource guide by collecting information by telephone interviews of provider organizations; geospatial resource maps were created using high-resolution geographic information systems, Duke's Data Support Repository, and county and city records; and focus groups were conducted using the nominal group technique.
The AHL team, in collaboration with 2 other teams focused on diabetes and cardiovascular disease, identified 32 resources for diabetes, 20 for obesity, and 13 for cardiovascular disease. Using Geographic Information Systems (GIS), the team identified an area of Durham that had only 1 supermarket, but 34 fast-food restaurants and 84 convenience stores.
The focus on particular neighborhoods means that the information obtained might not pertain to all neighborhoods.
The AHL team was able to assemble a large community partnership in Durham that will allow the members of the community to continue to work toward making residents healthier. Communities facing similar challenges can learn from this experience.
PMCID: PMC3626092  PMID: 23530374
7.  Dietary Lignan and Proanthocyanidin Consumption and Colorectal Adenoma Recurrence in the Polyp Prevention Trial 
Lignans and proanthocyanidins are plant polyphenols that have shown protective properties against colorectal neoplasms in some human studies. Using logistic regression, we estimated odds ratios (ORs) and 95% confidence intervals (CIs) to prospectively evaluate the association between lignan and proanthocyanidin intake, estimated from databases linked to a food frequency questionnaire, and adenoma recurrence in 1,859 participants of the Polyp Prevention Trial. Overall, individual or total lignans or proanthocyanidins were not associated with colorectal adenoma recurrence. However, in sex-specific analyses, total lignan intake was positively associated with any adenoma recurrence in women (highest versus lowest lignan intake quartile OR = 2.07, 95% CI: 1.22-3.52, P trend = 0.004) but not in men (P interaction = 0.04). To conclude, dietary lignan and proanthocyanidin consumption was not generally related to colorectal adenoma recurrence; however, high lignan intake may increase the risk of adenoma recurrence in women.
PMCID: PMC3235262  PMID: 21618513
cancer prevention; colorectal adenoma; colorectal cancer; lignans; proanthocyanidins
8.  Meta-analysis shows that prevalence of Epstein-Barr virus-positive gastric cancer differs based on sex and anatomic location 
Gastroenterology  2009;137(3):824-833.
Background & Aims
Epstein-Barr virus (EBV) has been causally associated with cancer; some gastric carcinomas have a monoclonal EBV genome in every cancer cell, indicating that they arose from a single infected progenitor cell. However, the proportion of EBV-positive gastric carcinomas is uncertain and the etiological significance is unknown.
We conducted a meta-analysis of 70 studies including 15,952 cases of gastric cancer assessed by in situ hybridization for EBV-encoded small RNA.
The pooled prevalence estimate of EBV-positivity was 8.7% (95% CI: 7.5, 10.0) overall, with a two-fold difference by sex: 11.1% (95% CI: 8.7, 14.1) of gastric cancer cases in males vs. 5.2% (95% CI: 3.6, 7.4) of cases in females. Tumors arising in the gastric cardia (13.6%) or corpus (13.1%) were more than twice as likely to be EBV-positive as those in the antrum (5.2%; p<0.01 for both comparisons). EBV-prevalence was four times higher (35.1%) for tumors in post-surgical gastric stump/remnants. Over 90% of lymphoepithelioma-like carcinomas were EBV-positive but only 15 studies reported any cases of this type; prevalence did not significantly differ between the more common diffuse (7.6%) and intestinal (9.5%) histologies. EBV-prevalence was similar in cases from Asia (8.3%), Europe (9.2%), and the Americas (9.9%).
EBV-positive gastric cancers greatly differ from other gastric carcinomas based on sex, anatomic subsite, and surgically disrupted anatomy, indicating that it is a distinct etiologic entity. Epidemiologic studies comparing EBV-positive and -negative gastric cancers are warranted to investigate EBV’s role in gastric carcinogenesis.
PMCID: PMC3513767  PMID: 19445939
Epstein-Barr virus; gastric cancer; meta-analysis; prevalence
9.  Serum ghrelin is inversely associated with risk of subsequent oesophageal squamous cell carcinoma 
Gut  2011;61(11):1533-1537.
Oesophageal cancers rank as the eighth most common cancer and the sixth most common cause of cancer death, worldwide. Gastric atrophy, as determined by a low serum pepsinogen I/II ratio, may be associated with an increased risk of oesophageal squamous cell carcinoma (OSCC). Ghrelin, a hormone which, like pepsinogen, is produced in the fundic glands of the stomach, may be a sensitive and specific marker of gastric atrophy, but its association with OSCC is not known.
To examine the relationship between baseline serum ghrelin concentration and subsequent risk of OSCC, we conducted a nested case-control study within the Alpha-Tocopherol, Beta-Carotene Cancer Prevention (ATBC) Study. 82 cases of OSCC were matched (1:1) by age and date of blood draw to controls from the ATBC study. Serum ghrelin was measured by radioimmunoassay. Odds ratios (OR) and 95% confidence intervals (95% CI) were calculated using conditional logistic regression with adjustment for potential confounders.
For those individuals in the lowest quartile of serum ghrelin, compared to those in the highest, the multivariate odds ratio of subsequent OSCC was 6.83 (95% CI: 1.46, 31.84). These associations were dose dependent (P for trend = 0.005 for both), and independent of the effects of low pepsinogen I/II ratio (a marker of gastric fundic atrophy) and Helicobacter pylori infection. The significance of these associations remained even for individuals developing OSCC up to 10 years after baseline ghrelin measurement, though they become attenuated after 10 years.
Lower baseline concentrations of serum ghrelin were associated with an increase in risk of OSCC. Further studies are needed to confirm this finding in other populations and to explore the role of ghrelin in the aetiology of OSCC.
PMCID: PMC3462270  PMID: 22180062
ghrelin; oesophageal squamous cell carcinoma; atrophy
10.  Hyperplastic polyps and the risk of adenoma recurrence in the Polyp Prevention Trial 
Background and Aims
Recent observational and genetic studies suggest that some hyperplastic polyps may be associated with increased risk of colorectal cancer. Prospective information on the risk of adenoma recurrence associated with hyperplastic polyps is limited. We sought to investigate whether the coexistence of hyperplastic polyps with adenomatous polyps increases the risk of adenoma recurrence.
We used multiple unconditional logistic regression models to examine the association between baseline hyperplastic polyps and subsequent adenoma recurrence during a three-year follow up, among 1,637 participants in the Polyp Prevention Trial.
A total of 437 participants (26.7%) had hyperplastic polyps coexisting with adenomas at baseline. Of these, 132 (30.2%) had at least one hyperplastic polyp in the proximal colon while 305 (69.8%) had only distal hyperplastic polyps. When compared with subjects without any hyperplastic polyps at baseline, there was no statistically significant association between presence of baseline hyperplastic polyps and recurrence of any adenoma, OR 1.19 (95% CI: 0.94–1.51) or advanced adenoma, OR 1.25 (95% CI: 0.78–2.03). Also, there was no association between hyperplastic polyp location and adenoma recurrence: OR 1.01 (95% CI: 0.69–1.48) for any proximal hyperplastic polyp and OR 1.26 (95% CI: 0.96–1.65) for distal hyperplastic polyps.
The coexistence of hyperplastic polyps with adenomas, irrespective of location, does not confer an increased risk of adenoma recurrence beyond that of adenomatous polyps alone within three years of follow-up. Prospective long-term studies on adenoma recurrence risk associated with hyperplastic polyps in screening populations are needed.
PMCID: PMC3498978  PMID: 18849014
Hyperplastic polyps; adenomatous polyps; colonoscopy; adenoma recurrence; surveillance guidelines
11.  Height at diagnosis and birth-weight as risk factors for osteosarcoma 
Cancer causes & control : CCC  2011;22(6):899-908.
Osteosarcoma typically occurs during puberty. Studies of the association between height and/or birth-weight and osteosarcoma are conflicting. Therefore, we conducted a large pooled analysis of height and birth-weight in osteosarcoma.
Patient data from 7 studies of height, and 3 of birth-weight were obtained, resulting in 1067 cases with height and 434 cases with birth-weight data. We compared cases to the 2000 US National Center for Health Statistics Growth Charts by simulating 1000 age and gender matched controls per case. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for associations between height or birth-weight and risk of osteosarcoma for each study were estimated using logistic regression. All of the case data were combined for an aggregate analysis.
Compared to average birth-weight subjects (2665–4045g), individuals with high birth-weight (≥4046g) had an increased osteosarcoma risk (OR 1.35, 95%CI 1.01–1.79). Taller than average (51st–89th percentile) and very tall individuals (≥90th percentile) had an increased risk of osteosarcoma (OR 1.35, 95%CI 1.18–1.54, and OR 2.60, 95%CI 2.19–3.07, respectively; Ptrend <0.0001).
This is the largest analysis of height at diagnosis and birth-weight in relation to osteosarcoma. It suggests that rapid bone growth during puberty and in utero contributes to OS etiology.
PMCID: PMC3494416  PMID: 21465145
osteosarcoma; height; birth-weight; meta-analysis; epidemiology
12.  Prospective Study of Serum Cysteine Levels and Oesophageal and Gastric Cancers in China 
Gut  2011;60(5):618-623.
Cancers of the upper gastrointestinal tract remain a significant cause of morbidity and mortality. Cysteine, known to be involved in a myriad of immuno-modulatory, anti-oxidant, and anti-carcinogenic pathways, has not been investigated in the aetiology of oesophageal or gastric cancers. To examine the relationship between serum cysteine concentration and risk of these cancers we conducted a nested case-cohort study within the General Population Nutrition Intervention Trial in Linxian, China.
498 oesophageal squamous cell carcinomas (OSCC) and 255 gastric cardia adenocarcinomas (GCA) were matched by age and sex to 947 individuals from the wider cohort. We calculated hazard ratios (HR) and 95% confidence intervals (95% CI) using the case-cohort estimator for the Cox proportional hazards models, stratified on age and sex, with adjustment for potential confounders.
Higher concentrations of serum cysteine were significantly associated with a lower risk of both OSCC and GCA. For those in the highest quartile of serum cysteine, compared to those in the lowest, the multivariate HRs were 0.70 for OSCC (95% CI: 0.51, 0.98) and 0.59 for GCA (95% CI: 0.38, 0.91). These associations were dose dependent (P for trend = 0.006 and 0.008, respectively). These inverse associations were not significantly modified by other risk factors, with the exception of age, where a stronger association was noted among persons in the older age strata.
Higher serum concentrations of cysteine were associated with a significantly reduced risk of OSCC and GCA. Cysteine should be further investigated for its potential as a chemopreventive agent for upper gastrointestinal cancers.
PMCID: PMC3428021  PMID: 21242262
oesophageal squamous cell carcinoma; gastric cardia cancer; hazard ratio; cysteine
13.  The Relationship Between Serum Ghrelin and the Risk of Gastric and Esophagogastric Junctional Adenocarcinomas 
Cancers of the upper gastrointestinal tract remain a substantial cause of morbidity and mortality worldwide. Ghrelin is a hormone produced in the oxyntic glands of the stomach, and under conditions of chronic inflammation and atrophy, serum ghrelin concentrations decrease. However, the relationship between ghrelin and the risk of gastric and esophagogastric junctional cancers has not been investigated.
We conducted a nested case–control study within the Finnish Alpha-Tocopherol, Beta-Carotene Cancer Prevention Study to examine the relationship between serum ghrelin concentration and the risk of gastric noncardia adenocarcinoma (GNCA) and esophagogastric junctional adenocarcinoma (EGJA). Data from 261 GNCA patients, 98 EGJA patients, and 441 control subjects were analyzed. Odds ratios (ORs) and 95% confidence intervals (95% CIs) were calculated using logistic regression with adjustment for potential confounders. Lag analysis was also performed to investigate the temporal nature of the associations between baseline serum pepsinogen I and ghrelin in GNCA and EGJA patients. All statistical tests were two-sided.
Lower concentrations of serum ghrelin were statistically significantly associated with an increased risk of both GNCA (adjusted OR = 1.75, 95% CI = 1.49 to 2.04; P < .001) and EGJA (adjusted OR = 1.56, 95% CI = 1.28 to 1.89, P < .001). A multivariable model found that the risk of both GNCA and EGJA were statistically significantly increased for those individuals in the lowest quartile of serum ghrelin levels compared with those in the highest quartile (OR of GNCA = 5.63, 95% CI = 3.16 to 10.03; OR of EGJA = 4.90, 95% CI = 2.11 to 11.35). The statistical significance of these associations remained even after restricting the analysis to those patients who developed cancer more than 10 years after baseline serum ghrelin measurements.
Low baseline concentrations of serum ghrelin were associated with a statistically significant increase in the risk of GNCA and EGJA, suggesting a potential role for gastric hormones in carcinogenesis.
PMCID: PMC3139586  PMID: 21693726
14.  Treating Pediatric Obesity in the Primary Care Setting to Prevent Chronic Disease 
The national and international epidemic of chronic disease, including among children, is largely fueled by increasing obesity. It is recommended that primary care play a key role in the treatment of pediatric obesity.
A written survey was administered to providers and staff at 13 primary care practices across North Carolina, assessing perceptions on multiple dimensions of pediatric obesity treatment and knowledge of dietitian services.
The response rate for the survey was 66.9% (n = 273). Although providers reported feeling comfortable and confident in many areas of childhood obesity, perceived effectiveness was low. Moreover, comfort and confidence were lower for non–primary care providers (PCPs) involved in obesity treatment than for PCPs, and PCP comfort and confidence levels were low for the ability to conduct motivational interviewing and for knowledge of billing for obesity as a diagnosis. Personnel perceived that there were benefits to having a registered dietitian (RD) in their practice and generally understood RD capacity. Survey results provided no evidence that integration of an RD into the practice changed perceptions or knowledge over the course of 1 year.
The present study included only 13 practices, mostly rural and all of at least moderate size.
Significant change is required if primary care practices are to play the role envisioned for them in stemming childhood obesity and chronic disease. Change will require identifying and addressing specific knowledge and skill gaps, such as those identified in this study. Respondents’ positive perceptions of the benefits of RD integration suggest the importance of exploring this clinical model.
PMCID: PMC3368341  PMID: 22619846
15.  Do Interleukin Polymorphisms Play a Role in the Prevention of Colorectal Adenoma Recurrence by Dietary Flavonols? 
Chemopreventive dietary compounds, such as flavonols, may inhibit colorectal carcinogenesis partly by altering cytokine expression and attenuating inflammation. Single nucleotide polymorphisms (SNPs) in the promoter regions of genes encoding cytokines may influence flavonol-induced changes in cytokine expression and consequently cancer risk. Using logistic regression, we estimated odds ratios (OR) and 95% confidence intervals (CI) for the association between SNPs of interleukin (IL)-1β, 6, 8, and 10, alone or combined with flavonol intake or serum IL concentration changes, and adenoma recurrence in 808 participants from the intervention arm of the Polyp Prevention Trial, a 4-year intervention study evaluating the effectiveness of a low-fat, high-fiber, high-fruit and vegetable diet on adenoma recurrence.. Overall, SNPs in genes encoding IL-1β, 6, 8, and 10 were not associated with their corresponding serum concentrations or adenoma recurrence. However, individuals homozygous for IL-10 -592 C (OR = 2.23, 95% CI: 1.07–4.66, P interaction = 0.03) or IL-10 -819 C (OR = 2.18, 95% CI: 1.05–4.51, P interaction = 0.05) had an elevated risk of high risk adenoma recurrence when their serum IL-10 concentrations increased during the trial. In addition, IL-6 -174 GG in combination with above median flavonol intake (OR = 0.14, 95% CI: 0.03–0.66) or with decreased IL 6 concentrations (OR = 0.14, 95% CI: 0.03–0.65) reduced the risk of advanced adenoma recurrence, although the interaction term was not statistically significant. In conclusion, our results suggest that IL SNPs, in combination with a flavonol-rich diet or decreased serum IL, may lower the risk of adenoma recurrence.
PMCID: PMC3029494  PMID: 21160427
adenoma recurrence; flavonols; interleukins
16.  Serum adiponectin, leptin, C-peptide, homocysteine, and colorectal adenoma recurrence in the Polyp Prevention Trial 
Serum adiponectin, leptin, C-peptide, and homocysteine are indicators for obesity, hyperinsulinemia, and chronic inflammation, which have all been associated with colorectal cancer.
To determine whether serum adiponectin, leptin, C-peptide, and homocysteine are associated with fat, fiber, fruit & vegetable, flavonol, or dry bean intake, and colorectal adenoma recurrence.
Using logistic regression, we estimated odds ratios (ORs) and 95% confidence intervals (CIs) for adenoma recurrence in 627 participants from the control arm of the Polyp Prevention Trial, a 4-year trial that examined the effectiveness of a low-fat, high-fiber, high-fruit & vegetable diet on adenoma recurrence.
Serum concentrations of C-peptide and homocysteine were inversely related to fiber, fruits & vegetables, and flavonol intake and positively related to percentage of calories from fat (all Ptrend ≤ 0.01). High homocysteine concentrations were associated with any (4th versus 1st quartile, OR = 2.26, 95% CI: 1.30-3.94) and more than one adenoma recurrence (OR = 2.11, 95% CI: 1.01-4.40). Individuals in the highest, versus lowest, tertile of serum leptin concentration had a decreased risk of advanced adenoma recurrence (OR = 0.22, 95% CI: 0.06-0.79).
Our results suggest that serum homocysteine may serve as an indicator of dietary exposure, including a low-fat and high-fiber, -fruit & vegetable, and -flavonol diet, as well as colorectal adenoma recurrence.
Discovering biomarkers that are both modifiable and can predict cancer risk is critical. We identified serum homocysteine as a novel indicator that is modified by diet and predicts risk of adenoma recurrence.
PMCID: PMC2882997  PMID: 20501764
colorectal adenoma; colorectal cancer; flavonols; adiponectin; leptin; C-peptide; homocysteine
17.  Sex Disparities in Colorectal Cancer Incidence by Anatomic Subsite, Race and Age 
Though incidence of colorectal cancer (CRC) in the US, has declined in recent years, rates remain higher in men than women and the male-to-female incidence rate ratio (MF IRR) increases progressively across the colon from the cecum to the rectum. Rates among races/ethnicities other than Whites or Blacks have not been frequently reported. To examine CRC rates by sex across anatomic subsite, age, and racial/ethnic groups, we used the National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) program for cases diagnosed among residents of 13 registries during 1992–2006. Incidence rates were expressed per 100,000 person-years and age-adjusted to the 2000 US Standard Population; MF IRR and 95% confidence intervals were also calculated. Among each racial/ethnic group, the MF IRR increased fairly monotonically from close to unity for cecal cancers to 1.81 (Hispanics) for rectal cancers. MF IRRs increased with age most rapidly for distal colon cancers from <1.0 at ages <50 years to 1.4–1.9 at older ages. The MF IRR for rectal cancers also rose with age from about 1.0 to 2.0. For proximal cancer, the MF IRR was consistently <1.5; among American Indian/Alaska Natives it was <1.0 across all ages. The MF IRRs for CRC vary markedly according to subsite and age but less by racial/ethnic group. These findings may partially reflect differences in screening experiences and access to medical care but also suggest that etiologic factors may be playing a role.
PMCID: PMC3031675  PMID: 20503269
colorectal cancer; sex ratio; incidence; SEER program; epidemiology; neoplasms
18.  Brief Report: Family cancer history affecting risk of colorectal cancer in a prospective cohort of Chinese women 
Cancer causes & control : CCC  2009;20(8):1517-1521.
An elevated risk of colorectal cancer has been associated with sporadic colorectal cancer in first degree relatives, mostly in Western populations. Limited data exists from traditionally low-risk areas, such as Asia, where the prevalence of risk factors may differ. We examined the association of family history of cancer and subsequent colorectal cancer risk in a cohort of traditionally low-risk Chinese women.
We followed 73,358 women in the Shanghai Women’s Health Study for cancer incidence until December 2005. After an average of 7 years of follow-up, 391 women were diagnosed with colorectal cancer. We calculated hazard ratios and 95% confidence intervals using Cox proportional hazards models adjusted for age, smoking, family income, education, body mass index, physical activity and history of diabetes.
We observed a significant association between colorectal cancer risk and history of a parent being diagnosed with colorectal cancer (hazard ratio: 3.34; 95% confidence interval: 1.58, 7.06). No association was observed for colorectal cancer diagnosed among siblings. Colorectal cancer risk was not influenced by a positive family history of cancer generally or any of the other cancers investigated (lung, breast, prostate, gastric, esophageal, endometrial, ovarian, urinary tract, central nervous system, small bowel).
Our cohort results suggest that, consistent with findings from Western populations, having a family history of colorectal cancer may influence colorectal cancer risk to a similar extent in a low-risk population.
PMCID: PMC2843785  PMID: 19418234
colorectal cancer; cohort studies; family history
19.  Efficacy and Efficiency of Webcast Orientations Versus Live Resident Orientations: Results of a 2-Year Survey 
Beginning a graduate medical education training program is associated with a steep learning curve for incoming residents.
To compare the efficacy and efficiency of live versus webcast formats for Institutional Orientation.
This 2-year non-blinded study, with a nonrandomized cohort, compares outcomes for trainees oriented Summer 2005 in a ‘‘live-lecture’’ format with trainees oriented Summer 2006 using a webcast format. Outcomes include posttest success, the time required, presentation quality and utility, and cost.
In 2005, 249 trainees attended the live orientation. Of the 211 who completed the posttest; 132 (63%) passed it within 3 attempts. Of the 241 trainees in 2006, 236 completed the posttest. Of these, 215 (91%) passed it within 3 attempts. Compared to the live-lecture cohort, the webcast cohort rated the posttest as more difficult. Despite performing better, significantly fewer trainees in the webcast cohort rated the posttest as “appropriate” (χ2 =  5 28.57, df 5 1, P , .001). There were no significant differences between the 2 groups on their perceptions of quality and utility of the presentations. While the first year cost of the webcast exceeded that of live lectures, the amortized cost was nearly identical to the live-lecture costs.
As corroborated by resident comments, the web-based approach was more effective because it provided trainees flexibility regarding when to study, options on how to view the material, and opportunities to review it if needed for mastery. We plan to continue using the webcast strategy, revising the content as needed.
PMCID: PMC2931214  PMID: 21975900

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