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  • 1. Akesson, K
    et al.
    Nyström, Lennarth
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Färnkvist, L
    Östman, J
    Lernmark, A
    Kockum, I
    Eriksson, Jan
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Increased risk of diabetes among relatives of female insulin-treated patients diagnosed at 15-34 years of age.2005In: Diabetic medicine, ISSN 0742-3071, Vol. 22, no 11, p. 1551-7Article in journal (Refereed)
  • 2. Ancelle-Park, R.
    et al.
    Armaroli, P.
    Ascunce, N.
    Bisanti, L.
    Bellisario, C.
    Broeders, M.
    Cogo, C.
    de Koning, H.
    Duffy, S. W.
    Frigerio, A.
    Giordano, L.
    Hofvind, S.
    Jonsson, Håkan
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Lynge, E.
    Massat, N.
    Miccinesi, G.
    Moss, S.
    Naldoni, C.
    Njor, S.
    Nyström, Lennarth
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Paap, E.
    Paci, E.
    Patnick, J.
    Ponti, A.
    Puliti, D.
    Segnan, N.
    Von Karsa, L.
    Tornberg, S.
    Zappa, M.
    Zorzi, M.
    Summary of the evidence of breast cancer service screening outcomes in Europe and first estimate of the benefit and harm balance sheet2012In: Journal of Medical Screening, ISSN 0969-1413, E-ISSN 1475-5793, Vol. 19, p. 5-13Article in journal (Refereed)
    Abstract [en]

    Objectives To construct a European 'balance sheet' of key outcomes of population-based mammographic breast cancer screening, to inform policy-makers, stakeholders and invited women. Methods From the studies reviewed, the primary benefit of screening, breast cancer mortality reduction, was compared with the main harms, over-diagnosis and false-positive screening results (FPRs). Results Pooled estimates of breast cancer mortality reduction among invited women were 25% in incidence-based mortality studies and 31% in case-control studies (38% and 48% among women actually screened). Estimates of over-diagnosis ranged from 1% to 10% of the expected incidence in the absence of screening. The combined estimate of over-diagnosis for screened women, from European studies correctly adjusted for lead time and underlying trend, was 6.5%. For women undergoing 10 biennial screening tests, the estimated cumulative risk of a FPR followed by non-invasive assessment was 17%, and 3% having an invasive assessment. For every 1000 women screened biennially from age 50-51 until age 68-69 and followed up to age 79, an estimated seven to nine lives are saved, four cases are over-diagnosed, 170 women have at least one recall followed by non-invasive assessment with a negative result and 30 women have at least one recall followed by invasive procedures yielding a negative result. Conclusions The chance of saving a woman's life by population-based mammographic screening of appropriate quality is greater than that of over-diagnosis. Service screening in Europe achieves a mortality benefit at least as great as the randomized controlled trials. These outcomes should be communicated to women offered service screening in Europe.

  • 3.
    Andersen, C. D.
    et al.
    Department of Clinical Sciences, Lund University, Malmö, Sweden.
    Bennet, L.
    Center for Primary Health Care Research, Lund University/Region Skåne, Malmö, Sweden.
    Nyström, Lennarth
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Lindblad, U.
    Department of Primary Health Care, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden.
    Lindholm, E.
    Department of Clinical Sciences, Lund University, Malmö, Sweden.
    Groop, L.
    Department of Clinical Sciences, Lund University, Malmö, Sweden.
    Rolandsson, Olov
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Worse glycaemic control in LADA patients than in those with type 2 diabetes, despite a longer time on insulin therapy2013In: Diabetologia, ISSN 0012-186X, E-ISSN 1432-0428, Vol. 56, no 2, p. 252-258Article in journal (Refereed)
    Abstract [en]

    Our aim was to study whether glycaemic control differs between individuals with latent autoimmune diabetes in adults (LADA) and patients with type 2 diabetes, and whether it is influenced by time on insulin therapy. We performed a retrospective study of 372 patients with LADA (205 men and 167 women; median age 54 years, range 35-80 years) from Swedish cohorts from SkAyenne (n = 272) and Vasterbotten (n = 100). Age- and sex-matched patients with type 2 diabetes were included as controls. Data on the use of oral hypoglycaemic agents (OHAs), insulin and insulin-OHA combination therapy was retrieved from the medical records. Poor glycaemic control was defined as HbA(1c) a parts per thousand yen7.0% (a parts per thousand yen53 mmol/mol) at follow-up. The individuals with LADA and with type 2 diabetes were followed for an average of 107 months. LADA patients were leaner than type 2 diabetes patients at diagnosis (BMI 27.7 vs 31.0 kg/m(2); p < 0.001) and follow-up (BMI 27.9 vs 30.2 kg/m(2); p < 0.001). Patients with LADA had been treated with insulin for longer than those with type 2 diabetes (53.3 vs 28.8 months; p < 0.001). There was no significant difference between the patient groups with regard to poor glycaemic control at diagnosis, but more patients with LADA (67.8%) than type 2 diabetes patients (53.0%; p < 0.001) had poor glycaemic control at follow-up. Patients with LADA had worse glycaemic control at follow-up compared with participants with type 2 diabetes (OR = 1.8, 95% CI 1.2, 2.7), adjusted for age at diagnosis, HbA(1c), BMI at diagnosis, follow-up time and duration of insulin treatment. Individuals with LADA have worse glycaemic control than patients with type 2 diabetes despite a longer time on insulin therapy.

  • 4. Bakhtadze, E
    et al.
    Borg, H
    Stenström, G
    Fernlund, P
    Arnqvist, H J
    Ekbom-Schnell, A
    Bolinder, J
    Eriksson, Jan
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Gudbjörnsdottir, S
    Nyström, Lennarth
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Groop, L C
    Sundkvist, G
    HLA-DQB1 genotypes, islet antibodies and beta cell function in the classification of recent-onset diabetes among young adults in the nationwide Diabetes Incidence Study in Sweden.2006In: Diabetologia, ISSN 0012-186X, E-ISSN 1432-0428, Vol. 49, no 8, p. 1785-1794Article in journal (Refereed)
  • 5. Bakhtadze, E
    et al.
    Cervin, C
    Lindholm, E
    Borg, H
    Nilsson, P
    Arnqvist, H J
    Bolinder, J
    Eriksson, Jan W
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Gudbjörnsdottir, S
    Nyström, Lennarth
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Agardh, C-D
    Landin-Olsson, M
    Sundkvist, G
    Groop, L C
    Common variants in the TCF7L2 gene help to differentiate autoimmune from non-autoimmune diabetes in young (15-34 years) but not in middle-aged (40-59 years) diabetic patients.2008In: Diabetologia, ISSN 1432-0428, Vol. 51, no 12, p. 2224-32Article in journal (Refereed)
    Abstract [en]

    AIMS/HYPOTHESIS: Type 1 diabetes in children is characterised by autoimmune destruction of pancreatic beta cells and the presence of certain risk genotypes. In adults the same situation is often referred to as latent autoimmune diabetes in adults (LADA). We tested whether genetic markers associated with type 1 or type 2 diabetes could help to discriminate between autoimmune and non-autoimmune diabetes in young (15-34 years) and middle-aged (40-59 years) diabetic patients. METHODS: In 1,642 young and 1,619 middle-aged patients we determined: (1) HLA-DQB1 genotypes; (2) PTPN22 and INS variable-number tandem repeat (VNTR) polymorphisms; (3) two single nucleotide polymorphisms (rs7903146 and rs10885406) in the TCF7L2 gene; (4) glutamic acid decarboxylase (GAD) and IA-2-protein tyrosine phosphatase-like protein (IA-2) antibodies; and (5) fasting plasma C-peptide. RESULTS: Frequency of risk genotypes HLA-DQB1 (60% vs 25%, p = 9.4 x 10(-34); 45% vs 18%, p = 1.4 x 10(-16)), PTPN22 CT/TT (34% vs 26%, p = 0.0023; 31% vs 23%, p = 0.034), INS VNTR class I/I (69% vs 53%, p = 1.3 x 10(-8); 69% vs 51%, p = 8.5 x 10(-5)) and INS VNTR class IIIA/IIIA (75% vs 63%, p = 4.3 x 10(-6); 73% vs 60%, p = 0.008) was increased in young and middle-aged GAD antibodies (GADA)-positive compared with GADA-negative patients. The type 2 diabetes-associated genotypes of TCF7L2 CT/TT of rs7903146 were significantly more common in young GADA-negative than in GADA-positive patients (53% vs 43%; p = 0.0004). No such difference was seen in middle-aged patients, in whom the frequency of the CT/TT genotypes of TCF7L2 was similarly increased in GADA-negative and GADA-positive groups (55% vs 56%). CONCLUSIONS/INTERPRETATION: Common variants in the TCF7L2 gene help to differentiate young but not middle-aged GADA-positive and GADA-negative diabetic patients, suggesting that young GADA-negative patients have type 2 diabetes and that middle-aged GADA-positive patients are different from their young GADA-positive counterparts and share genetic features with type 2 diabetes.

  • 6. Becker, Nikolaus
    et al.
    Hakama, Matti
    Nyström, Lennarth
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Evaluation of effectiveness of quality-assured mammography screening in Germany: sample size considerations and design options.2007In: Eur J Cancer Prev, ISSN 0959-8278, Vol. 16, no 3, p. 225-31Article in journal (Refereed)
  • 7. Berglund, Anna
    et al.
    Lindberg, Marianne
    Nyström, Lennarth
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Lindmark, Gunilla
    Combining the perspectives of midwives and doctors improves risk assessment in early pregnancy.2007In: Acta Obstet Gynecol Scand, ISSN 0001-6349, Vol. 86, no 2, p. 177-84Article in journal (Refereed)
  • 8.
    Blomstedt, Yulia
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Umeå University, Faculty of Social Sciences, Centre for Demographic and Ageing Research (CEDAR).
    Norberg, Margareta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Umeå University, Faculty of Social Sciences, Centre for Demographic and Ageing Research (CEDAR).
    Stenlund, Hans
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Nyström, Lennarth
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Lönnberg, Göran
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Boman, Kurt
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Wall, Stig
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Umeå University, Faculty of Social Sciences, Centre for Demographic and Ageing Research (CEDAR).
    Impact of a combined community and primary care prevention strategy on all-cause and cardiovascular mortality: a cohort analysis based on 1 million person-years of follow-up in Västerbotten County, Sweden, during 1990-20062015In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 5, no 12, article id e009651Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To evaluate the impact of the Västerbotten Intervention Programme (VIP) by comparing all eligible individuals (target group impact) according to the intention-to-treat principle and VIP participants with the general Swedish population.

    DESIGN: Dynamic cohort study.

    SETTING/PARTICIPANTS: All individuals aged 40, 50 or 60 years, residing in Västerbotten County, Sweden, between 1990 and 2006 (N=101 918) were followed from their first opportunity to participate in the VIP until age 75, study end point or prior death.

    INTERVENTION: The VIP is a systematic, long-term, county-wide cardiovascular disease (CVD) intervention that is performed within the primary healthcare setting and combines individual and population approaches. The core component is a health dialogue based on a physical examination and a comprehensive questionnaire at the ages of 40, 50 and 60 years.

    PRIMARY OUTCOMES: All-cause and CVD mortality.

    RESULTS: For the target group, there were 5646 deaths observed over 1 054 607 person-years. Compared to Sweden at large, the standardised all-cause mortality ratio was 90.6% (95% CI 88.2% to 93.0%): for women 87.9% (95% CI 84.1% to 91.7%) and for men 92.2% (95% CI 89.2% to 95.3%). For CVD, the ratio was 95.0% (95% CI 90.7% to 99.4%): for women 90.4% (95% CI 82.6% to 98.7%) and for men 96.8% (95% CI 91.7 to 102.0). For participants, subject to further impact as well as selection, when compared to Sweden at large, the standardised all-cause mortality ratio was 66.3% (95% CI 63.7% to 69.0%), whereas the CVD ratio was 68.9% (95% CI 64.2% to 73.9%). For the target group as well as for the participants, standardised mortality ratios for all-cause mortality were reduced within all educational strata.

    CONCLUSIONS: The study suggests that the VIP model of CVD prevention is able to impact on all-cause and cardiovascular mortality when evaluated according to the intention-to-treat principle.

  • 9. Bolinder, J
    et al.
    Fernlund, P
    Borg, H
    Arnqvist, H J
    Björk, E
    Blohmé, G
    Eriksson, Jan
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Nyström, Lennarth
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Östman, J
    Sundkvist, G
    Hyperproinsulinemia segregates young adult patients with newly diagnosed autoimmune (type 1) and non-autoimmune (type 2) diabetes.2005In: Scand J Clin Lab Invest, ISSN 0036-5513, Vol. 65, no 7, p. 585-94Article in journal (Refereed)
  • 10.
    Bordás, Pál
    et al.
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Jonsson, Håkan
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Nyström, Lennarth
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Cajander, Stefan
    Lenner, Per
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Early breast cancer deaths in women aged 40-74 years diagnosed during the first 5 years of organised mammography service screening in north Sweden2004In: Breast, ISSN 0960-9776, E-ISSN 1532-3080, Vol. 13, no 4, p. 276-283Article in journal (Refereed)
  • 11.
    Bordás, Pál
    et al.
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Jonsson, Håkan
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Nyström, Lennarth
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Lenner, Per
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Interval cancer incidence and episode sensitivity in the Norrbotten mammography screening programme, Sweden2009In: Journal of Medical Screening, ISSN 0969-1413, E-ISSN 1475-5793, Vol. 16, no 1, p. 39-45Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: To estimate the interval cancer incidence, its determinants and the episode sensitivity in the Norrbotten Mammography Screening Programme (NMSP).

    SETTING: Since 1989, women aged 40-74 years (n = 55,000) have been invited to biennial screening by the NMSP, Norrbotten county, Sweden.

    METHODS: Data on 1047 invasive breast cancers from six screening rounds of the NMSP (1989-2002) were collected. We estimated the invasive interval cancer rates, rate ratios and the episode sensitivity using the detection and incidence methods. A linear Poisson-model was used to analyse association between interval cancer incidence and sensitivity.

    RESULTS: 768 screen-detected and 279 interval cancer cases were identified. The rate ratio of interval cancer decreased with age. The 50-59 year age group showed the highest rate ratio (RR = 0.52, 95% CI 0.41-0.65) and the 70-74 year age group the lowest (RR = 0.23, 95% CI 0.15-0.36). The rate ratios for the early (0-12 months) and late (13-24 months) interval cancers were similar (RR = 0.18, 95% CI 0.15-0.22 and 0.20, 95% CI 0.17-0.24). There was a significantly lower interval cancer incidence in the prevalence round as compared with the incidence rounds. According to the detection method the episode sensitivity increased with age from 57% in the age group 40-49 years to 84% in the age group 70-74 years. The corresponding figures for the incidence method were 50% and 77%, respectively.

    CONCLUSION: Our study showed an interval cancer incidence of 38% and the episode sensitivity of 62-73%, depending on the method of calculation. Our results are of clinically acceptable level and concert with the reference values of the European guidelines.

  • 12.
    Bordás, Pál
    et al.
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Jonsson, Håkan
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Nyström, Lennarth
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Lenner, Per
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Survival from invasive breast cancer among interval cases in the mammography screening programmes of northern Sweden2007In: Breast, ISSN 0960-9776, E-ISSN 1532-3080, Vol. 16, no 1, p. 47-54Article in journal (Refereed)
  • 13.
    Bordás, Pál
    et al.
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Jonsson, Håkan
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Nyström, Lennarth
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Péntek, Zoltán
    Lenner, Per
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Radiological review of interval cancer in the Norrbotten mammography screening program, SwedenManuscript (preprint) (Other academic)
  • 14. Broeders, M J M
    et al.
    Scharpantgen, A
    Ascunce, N
    Gairard, B
    Olsen, A H
    Mantellini, P
    Mota, T Cerdá
    Van Limbergen, E
    Séradour, B
    Ponti, A
    Trejo, L Salas
    Nyström, Lennarth
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Comparison of early performance indicators for screening projects within the European Breast Cancer Network: 1989-2000.2005In: Eur J Cancer Prev, ISSN 0959-8278, Vol. 14, no 2, p. 107-16Article in journal (Refereed)
  • 15. Broeders, Mireille
    et al.
    Moss, Sue
    Nyström, Lennarth
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Njor, Sisse
    Jonsson, Håkan
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Poop, Ellen
    Massat, Nathalie
    Duffy, Stephen
    Lynge, Elsebeth
    Paci, Eugenio
    The impact of mammographic screening on breast cancer mortality in Europe: a review of observational studies2012In: Journal of Medical Screening, ISSN 0969-1413, E-ISSN 1475-5793, Vol. 19, p. 14-25Article in journal (Refereed)
    Abstract [en]

    Objectives To assess the impact of population-based mammographic screening on breast cancer mortality in Europe, considering different methodologies and limitations of the data. Methods We conducted a systematic literature review of European trend studies (n = 17), incidence-based mortality (IBM) studies (n = 20) and case-control (CC) studies (n = 8). Estimates of the reduction in breast cancer mortality for women invited versus not invited and/or for women screened versus not screened were obtained. The results of IBM studies and CC studies were each pooled using a random effects meta-analysis. Results Twelve of the 17 trend studies quantified the impact of population-based screening on breast cancer mortality. The estimated breast cancer mortality reductions ranged from 1% to 9% per year in studies reporting an annual percentage change, and from 28% to 36% in those comparing post- and prescreening periods. In the IBM studies, the pooled mortality reduction was 25% (relative risk [RR] 0.75, 95% confidence interval [CI] 0.69-0.81) among invited women and 38% (RR 0.62, 95% CI 0.56-0.69) among those actually screened. The corresponding pooled estimates from the CC studies were 31% (odds ratio [OR] 0.69, 95% CI 0.57-0.83), and 48% (OR 0.52, 95% CI 0.42-0.65) adjusted for self-selection. Conclusions Valid observational designs are those where sufficient longitudinal individual data are available, directly linking a woman's screening history to her cause of death. From such studies, the best 'European' estimate of breast cancer mortality reduction is 25-31% for women invited for screening, and 38-48% for women actually screened. Much of the current controversy on breast cancer screening is due to the use of inappropriate methodological approaches that are unable to capture the true effect of mammographic screening.

  • 16.
    Chikovore, Jeremiah
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Lindmark, Gunilla
    Nyström, Lennarth
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Mbizvo, MT
    Ahlberg, BM
    The hide and seek game: men’s perspectives on abortion and contraceptive use within marriage in a rural community in Zimbabwe2002In: Journal of Biosocial Science, ISSN 0021-9320, E-ISSN 1469-7599, Vol. 34, no 3, p. 317-332Article in journal (Refereed)
    Abstract [en]

    This paper is based on a study aimed at understanding the perceptions of men to induced abortion and contraceptive use within marriage in rural Zimbabwe. Two qualitative methods were combined. Men were found to view abortion not as a reproductive health problem for women. Instead, they described abortion as a sign of illicit sexual activity and contraceptive use as a strategy married women use to conceal their involvement in extramarital sexual activity. Men felt anxious and vulnerable for lack of control over women. In the absence of verbal communication on sexual matters, women and men resort to what are called here 'hide-and-seek' strategies, where women acquire and use contraceptives secretly while men search for evidence of such use. It is concluded that promoting women's sexual and reproductive health requires both short- and long-term strategies. The short-term strategy would entail providing women with reproductive technology they can use without risking violence. The long-term strategy would entail understanding men's concerns and the way these are manifested. In turn this requires the use of methodologies that encourage dialogue with research participants, in order to capture their deep meanings and experiences.

  • 17. Chikovore, Jeremiah
    et al.
    Nyström, Lennarth
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Lindmark, Gunilla
    Ahlberg, Beth Maina
    "How Can I Gain Skills if I Don't Practice?'' The Dynamics of Prohibitive Silence against Pre-Marital Pregnancy and Sex in Zimbabwe2013In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 8, no 1, p. e53058-Article in journal (Refereed)
    Abstract [en]

    Young people face sexual and reproductive health (SRH) problems including Human immunodeficiency virus (HIV) and Acquired immunodeficiency syndrome (AIDS). It is critical to continue documenting their situation including the contexts they live in. As part of a larger study that explored perspectives of men to SRH and more specifically abortion and contraceptive use, 546 pupils (51% female; age range 9-25 years) from a rural area in Zimbabwe were invited to write anonymously questions about growing up or other questions they could not ask adults for fear or shame. The pupils were included following descriptions by adults of the violence that is unleashed on unmarried young people who engaged in sex, used contraceptives, or simply suggested doing so. The questions by the young people pointed to living in a context of prohibitive silence; their sexuality was silenced and denied. As a consequence they had poor knowledge and their fears and internal conflicts around sexuality and pregnancy were not addressed. Current action suggests concerted effort at the policy level to deal with young people's SRH in Zimbabwe. It nevertheless remains necessary, as a way to provide support to these efforts, to continue examining what lessons can be drawn from the past, and how the past continues to reflect in and shape present dynamics and relations. There is also need to look more critically at life skill education, which has previously been described as having failed to address adequately the practical needs of young people. Life skill education in Zimbabwe has rarely been systematically evaluated. A fuller understanding is also needed of the different factors co-existing in contemporary African societies and how they have been and continue to be constituted within history, and the implications to the promotion of adolescent SRH.

  • 18.
    Dahlquist, G G
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Pundziūte-Lyckå, A
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Nyström, L
    Birthweight and risk of type 1 diabetes in children and young adults: a population-based register study.2005In: Diabetologia, ISSN 0012-186X, Vol. 48, no 6, p. 1114-7Article in journal (Refereed)
    Abstract [en]

    AIMS/HYPOTHESIS: We investigated the association between type 1 diabetes and birthweight by age at disease onset. METHODS: This population-based case-referent study used data from two nationwide case registers that are linked to the Swedish Medical Birth Registry and cover incident cases of type 1 diabetes in the 0- to 14-year (since 1 July 1977) and 15- to 34-year age groups (since 1 January 1983). Of the cases linked to the Medical Birth Registry, a total of 9,283 cases with onset before 15 years of age was recorded before 1 January 2003, and 1,610 cases were recorded with onset before 30 years of age and born after 1973 (together 95% of eligible cases). Multiple births and babies of diabetic mothers were excluded. Sex-specific birthweight by gestational week is expressed as multiples of the standard deviation (SDS) and adjusted for year of birth, maternal age and parity. RESULTS: Cases with onset before 10 years of age (n = 5,792) showed a significant linear trend in odds ratio (OR) by SDS of adjusted birthweight (OR by SDS: 0.062; 95% CI: 0.037-0.086; p < 0.0001), while cases with onset at the age of 10-29 years showed no significant trend (OR by SDS: 0.004; 95% CI: -0.007 to 0.0014; p = 0.22). CONCLUSIONS/INTERPRETATION: The association between type 1 diabetes risk and birthweight seems to be limited to cases with disease onset in younger years.

  • 19.
    Dahlquist, Gisela
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Nyström, Lennarth
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Patterson, Christopher C.
    Centre for Public Health, Queen’s University, Belfast, Northern Ireland .
    Incidence of Type 1 Diabetes in Sweden Among Individuals Aged 0-34 Years, 1983-2007: An analysis of time trends2011In: Diabetes Care, ISSN 0149-5992, E-ISSN 1935-5548, Vol. 34, no 8, p. 1754-1759Article in journal (Refereed)
    Abstract [en]

    Objective: To clarify whether the increase in childhood type 1 diabetes is mirrored by a decrease in older age-groups, resulting in younger age at diagnosis.

    Research design and methods: We used data from two prospective research registers, the Swedish Childhood Diabetes Register, which included case subjects aged 0–14.9 years at diagnosis, and the Diabetes in Sweden Study, which included case subjects aged 15–34.9 years at diagnosis, covering birth cohorts between 1948 and 2007. The total database included 20,249 individuals with diabetes diagnosed between 1983 and 2007. Incidence rates over time were analyzed using Poisson regression models.

    Results: The overall yearly incidence rose to a peak of 42.3 per 100,000 person-years in male subjects aged 10–14 years and to a peak of 37.1 per 100,000 person-years in female subjects aged 5–9 years and decreased thereafter. There was a significant increase by calendar year in both sexes in the three age-groups <15 years; however, there were significant decreases in the older age-groups (25- to 29-years and 30- to 34-years age-groups). Poisson regression analyses showed that a cohort effect seemed to dominate over a time-period effect.

    Conclusions: Twenty-five years of prospective nationwide incidence registration demonstrates a clear shift to younger age at onset rather than a uniform increase in incidence rates across all age-groups. The dominance of cohort effects over period effects suggests that exposures affecting young children may be responsible for the increasing incidence in the younger age-groups.

     

  • 20. Duffy, SW
    et al.
    Chen, THH
    Smith, RA
    Jonsson, Håkan
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Lenner, Per
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Nyström, Lennarth
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Törnberg, S
    Frisell, J
    Holmberg, L
    Effect of mammographic service screening on stage at presentation of breast cancers in Sweden.2007In: Cancer, ISSN 0008-543X, Vol. 109, no 11, p. 2205-2212Article in journal (Refereed)
  • 21. Duffy, SW
    et al.
    Tabar, L
    Chen, THH
    Smith, RA
    Holmberg, L
    Jonsson, Håkan
    Lenner, Per
    Nyström, Lennarth
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Törnberg, S
    Reduction in breast cancer mortality from organized service screening with mammography: 1. Further confirmation with extended data.2006In: Cancer Epid Biomarkers & Prevention, Vol. 15, p. 45-51Article in journal (Refereed)
  • 22. Duffy, SW
    et al.
    Tabar, L
    Chen, THH
    Smith, RA
    Holmberg, L
    Jonsson, Håkan
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Lenner, Per
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Nyström, Lennarth
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Törnberg, S
    Reduction in Breast Cancer Mortality from the Organised Service Screening with Mammography:: 2. Validation with Alternative Analytic Methods2006In: Cancer Epidemiology Biomarkers & Prevention, Vol. 15, p. 52-56Article in journal (Refereed)
  • 23.
    Franklin, Karl A
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Pulmonary Medicine. Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Gi­slason, Thorarinn
    Omenaas, Ernst
    Jogi, Rain
    Jensen, Erik Juel
    Lindberg, Eva
    Gunnbjörnsdottir, Maria
    Nyström, Lennarth
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Laerum, Birger N
    Björnsson, Eythor
    Toren, Kjell
    Janson, Christer
    The influence of active and passive smoking on habitual snoring.2004In: Am J Respir Crit Care Med, ISSN 1073-449X, Vol. 170, no 7, p. 799-803Article in journal (Refereed)
  • 24.
    Franklin, Karl
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Pulmonary Medicine.
    Janson, Christer
    Gíslason, Thórarinn
    Gulsvik, Amund
    Gunnbjörnsdottir, Maria
    Laerum, Birger N
    Lindberg, Eva
    Norrman, Eva
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Pulmonary Medicine.
    Nyström, Lennarth
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Omenaas, Ernst
    Torén, Kjell
    Svanes, Cecilie
    Early life environment and snoring in adulthood.2008In: Respiratory research (Online), ISSN 1465-9921, E-ISSN 1465-993X, Vol. 9, no 63Article in journal (Refereed)
    Abstract [en]

    Background: To our knowledge, no studies of the possible association of early life environment with snoring in adulthood have been published. We aimed to investigate whether early life environment is associated with snoring later in life. 

    Methods: A questionnaire including snoring frequency in adulthood and environmental factors in early life was obtained from 16,190 randomly selected men and women, aged 25-54 years, in Sweden, Norway, Iceland, Denmark and Estonia (response rate 74%). 

    Results: A total of 15,556 subjects answered the questions on snoring. Habitual snoring, defined as loud and disturbing snoring at least 3 nights a week, was reported by 18%. Being hospitalized for a respiratory infection before the age of two years (adjusted odds ratio (OR) = 1.27; 95% confidence interval (CI) 1.01-1.59), suffering from recurrent otitis as a child (OR = 1.18; 95% CI 1.05-1.33), growing up in a large family (OR = 1.04; 95% CI 1.002-1.07) and being exposed to a dog at home as a newborn (OR = 1.26; 95% CI 1.12-1.42) were independently related to snoring later in life and independent of a number of possible confounders in adulthood. The same childhood environmental factors except household size were also related with snoring and daytime sleepiness combined. 

    Conclusion: The predisposition for adult snoring may be partly established early in life. Having had severe airway infections or recurrent otitis in childhood, being exposed to a dog as a newborn and growing up in a large family are environmental factors associated with snoring in adulthood.

  • 25.
    Frumence, Gasto
    et al.
    Department of Development Studies, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
    Emmelin, Maria
    Department of Clinical Sciences, Social Medicine and Global Health, Lund University, Malmö.
    Eriksson, Malin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Kwesigabo, Gideon
    Department of Biostatistics and Epidemiology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
    Killewo, Japhet
    Department of Biostatistics and Epidemiology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
    Moyo, Sabrina
    Department of Microbiology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania..
    Nyström, Lennarth
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Access to social capital and risk of HIV infectionin Bukoba urban district, Kagera region, Tanzania2014In: Archives of Public Health, ISSN 0778-7367, E-ISSN 2049-3258, Vol. 72, no 1, p. 1-11Article in journal (Refereed)
    Abstract [en]

    BACKGROUND:

    Kagera is one of the 22 regions of Tanzania mainland, which has witnessed a decline in HIV prevalence during the past two decades; decreasing from 24% in 1987 to 4.7 in 2009 in the urban district of Bukoba. Access to social capital, both structural and cognitive, might have played a role in this development. The aim was to examine the association between individual structural and cognitive social capital and socio-economic characteristics and the likelihood of being HIV infected.

    METHODS:

    We conducted a population-based cross-sectional study of 3586 participants, of which 3423 (95%) agreed to test for HIV following pre-test counseling. The HIV testing was performed using enzyme-linked immunosorbent assay (ELISA) antibody detection tests. Multiple logistic regression analysis was applied to estimate the impact of socio-economic factors, individual structural and cognitive social capital and HIV sero-status.

    RESULTS:

    Individuals who had access to low levels of both structural and cognitive individual social capital were four and three times more likely to be HIV positive compared to individuals who had access to high levels. The associations remained statistically significant for both individual structural and cognitive social capital after adjusting for potential confounding factors such as age, sex, marital status, occupation, level of education and wealth index (OR =8.6, CI: 5.7-13.0 and OR =2.4, CI: 1.6-3.5 for individual structural and cognitive social capital respectively). For both women and men access to high levels of individual structural and cognitive social capital decreased the risk of being HIV infected. This study confirms previous qualitative studies indicating that access to structural and cognitive social capital is protective to HIV infection.

    CONCLUSIONS:

    We suggest that policy makers and programme managers of HIV interventions may consider strengthening and facilitating access to social capital as a way of promoting HIV preventive information and interventions in order to reduce new HIV infections in Tanzania.

  • 26.
    Frumence, Gasto
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Emmelin, Maria
    Kwesigabo, Gideon
    Killewo, Japhet
    Eriksson, Malin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Nyström, Lennarth
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Social capital and HIV infection in Bukoba urban district, Kagera region, TanzaniaIn: Article in journal (Refereed)
  • 27.
    Frumence, Gasto
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Emmelin, Maria
    Kwesigabo, Gideon
    Killewo, Japhet
    Eriksson, Malin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Nyström, Lennarth
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Social capital and HIV risk related behaviors in Kagera region, TanzaniaIn: Article in journal (Refereed)
  • 28.
    Frumence, Gasto
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Eriksson, Malin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Nyström, Lennarth
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Killewo, Japhet
    Emmelin, Maria
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Exploring the role of cognitive and structural social capital in the declining trends of HIV/AIDS in the Kagera region of Tanzania: A grounded theory study2011In: African Journal of AIDS Research, ISSN 1608-5906, E-ISSN 1727-9445, Vol. 10, no 1, p. 1-13Article in journal (Refereed)
    Abstract [en]

    The article presents a synthesis of data from three village case studies focusing on how structural and cognitivesocial capital may have influenced the progression of the HIV epidemic in the Kagera region of Tanzania. Groundedtheory was used to develop a theoretical model describing the possible links between structural and cognitivesocial capital and the impact on sexual health behaviours. Focus group discussions and key informant interviewswere carried out to represent the range of experiences of existing social capital. Both structural and cognitive socialcapital were active avenues for community members to come together, empower each other, and develop norms,values, trust and reciprocal relations. This empowerment created an enabling environment in which members couldadopt protective behaviours against HIV infection. On the one hand, we observed that involvement in formal andinformal organisations resulted in a reduction of numbers of sexual partners, led people to demand abstinencefrom sexual relations until marriage, caused fewer opportunities for casual sex, and gave individuals the agency todemand the use of condoms. On the other hand, strict membership rules and regulations excluded some members,particularly excessive alcohol drinkers and debtors, from becoming members of the social groups, which increasedtheir vulnerability in terms of exposure to HIV. Social gatherings (especially those organised during the night) werealso found to increase youths’ risk of HIV infection through instances of unsafe sex. We conclude that even thoughsocial capital may at times have negative effects on individuals’ HIV-prevention efforts, this study provides initialevidence that social capital is largely protective through empowering vulnerable groups such as women and thepoor to protect against HIV infection and by promoting protective sexual behaviours.

  • 29. Frumence, Gasto
    et al.
    Killewo, Japhet
    Kwesigabo, Gideon
    Nyström, Lennarth
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Eriksson, Malin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Emmelin, Maria
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Social capital and the decline in HIV transmission: a case study in three villages in the Kagera region of Tanzania2010In: SAHARA-J: Journal of Social Aspects of HIV/AIDS, ISSN 1729-0376, E-ISSN 1813-4424, Vol. 7, no 3, p. 9-20Article in journal (Refereed)
    Abstract [en]

    We present data from an exploratory case study characterising the social capital in three case villages situated in areas of varying HIV prevalence in the Kagera region of Tanzania. Focus group discussions and key informant interviews revealed a range of experiences by community members, leaders of organisations and social groups. We found that the formation of social groups during the early 1990s was partly a result of poverty and the many deaths caused by AIDS. They built on a tradition to support those in need and provided social and economic support to members by providing loans. Their strict rules of conduct helped to create new norms, values and trust, important for HIV prevention. Members of different networks ultimately became role models for healthy protective behaviour. Formal organisations also worked together with social groups to facilitate networking and to provide avenues for exchange of information. We conclude that social capital contributed in changing HIV related risk behaviour that supported a decline of HIV infection in the high prevalence zone and maintained a low prevalence in the other zones.

  • 30. Gani, M. Showkat
    et al.
    Chowdhury, A. Mushtaque R.
    Nyström, Lennarth
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Urban-Rural and Socioeconomic Variations in the Knowledge of STIs and AIDS Among Bangladeshi Adolescents2014In: Asia-Pacific Journal of Public Health, ISSN 1010-5395, Vol. 26, no 2, p. 182-195Article in journal (Refereed)
    Abstract [en]

    This study used data from the Bangladesh Adolescents Survey 2005 to identify socioeconomic and urban-rural determinants of knowledge regarding sexually transmitted infections (STIs) including HIV/AIDS transmission. A cluster sampling of 11986 adolescents was conducted from April to August 2005. Data were analyzed using SPSS applying principle component analysis, multivariate logistic regression analysis, and prevalence ratios (PRs) with 95% confidence intervals (CIs). Overall knowledge of transmission of STIs was poor (4.5%), showing urban adolescents having twice the knowledge of rural adolescents (PR = 1.9; 95% CI = 1.6-2.2). HIV/AIDS knowledge level was high (68%), with a 40% higher knowledge among urban adolescents (PR = 1.4; 95% CI = 1.3-1.4). Probability of knowledge of STIs and HIV/AIDS transmission was lowest in 12- to 14-year-old uneducated female household workers of the poorest socioeconomic status in rural settings (0.0002 and 0.064, respectively). The urban-rural factor was more important than the socioeconomic factor. Health promotion and education programs can play an important role in improving the sexual reproductive health knowledge situation.

  • 31. Giordano, Livia
    et al.
    von Karsa, Lawrence
    Tomatis, Mariano
    Majek, Ondrej
    de Wolf, Chris
    Lancucki, Lesz
    Hofvind, Solveig
    Nyström, Lennarth
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Segnan, Nereo
    Ponti, Antonio
    Mammographic screening programmes in Europe: organization, coverage and participation2012In: Journal of Medical Screening, ISSN 0969-1413, E-ISSN 1475-5793, Vol. 19, p. 72-82Article in journal (Refereed)
    Abstract [en]

    Objectives To summarize participation and coverage rates in population mammographic screening programmes for breast cancer in Europe. Methods We used the European Network for Information on Cancer (EUNICE), a web-based data warehouse (EUNICE Breast Cancer Screening Monitoring, EBCSM) for breast cancer screening, to obtain information on programme characteristics, coverage and participation from its initial application in 10 national and 16 regional programmes in 18 European countries. Results The total population targeted by the screening programme services covered in the report comprised 26.9 million women predominantly aged 50-69. Most of the collected data relates to 2005, 2006 and/or 2007. The average participation rate across all programmes was 53.4% (range 19.4-88.9% of personally invited); or 66.4% excluding Poland, a large programme that initiated personal invitations in 2007. Thirteen of the 26 programmes achieved the European Union benchmark of acceptable participation (>70%), nine achieved the desirable level (>75%). Despite considerable invitation coverage across all programmes (79.3%, range 50.9-115.2%) only 48.2% (range 28.4-92.1%) of the target population were actually screened. The overall invitation and examination coverage excluding Poland was 70.9% and 50.3%, respectively. Conclusions The results demonstrate the feasibility of European-wide screening monitoring using the EBCSM data warehouse, although further efforts to refine the system and to harmonize standards and data collection practices will be required, to fully integrate all European countries. The more than threefold difference in the examination coverage should be taken into account in the evaluation of service screening programmes.

  • 32. Gómez Real, F
    et al.
    Svanes, C
    Björnsson, E H
    Franklin, Karl
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Franklin, K
    Gislason, D
    Gislason, T
    Gulsvik, A
    Janson, C
    Jögi, R
    Kiserud, T
    Norback, D
    Nyström, Lennarth
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Torén, K
    Wentzel-Larsen, T
    Omenaas, E
    Hormone replacement therapy, body mass index and asthma in perimenopausal women: a cross sectional survey.2006In: Thorax, ISSN 0040-6376, Vol. 61, no 1, p. 34-40Article in journal (Refereed)
  • 33.
    Hellquist, Barbro Numan
    et al.
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Czene, Kamila
    Karolinska Inst, Dept Med Epidemiol & Biostat, Stockholm, Sweden.
    Hjälm, Anna
    Umeå University, Faculty of Social Sciences, Department of Geography and Economic History. Umeå University, Faculty of Social Sciences, Centre for Population Studies (CPS).
    Nyström, Lennarth
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Jonsson, Håkan
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Effectiveness of population-based service screening with mammography for women ages 40 to 49 years with a high or low risk of breast cancer: socioeconomic status, parity, and age at birth of first child2015In: Cancer, ISSN 0008-543X, E-ISSN 1097-0142, Vol. 121, no 2, p. 251-258Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Invitation to mammography screening of women aged 40 to 49 years is a matter of debate in many countries and a cost-effective alternative in countries without screening among women aged 40 to 49 years could be inviting those at higher risk. The relative effectiveness of mammography screening was estimated for subgroups based on the breast cancer risk factors parity, age at time of birth of first child, and socioeconomic status (SES).

    METHODS: The SCReening of Young Women (SCRY) database consists of all women aged 40 to 49 years in Sweden between 1986 and 2005 and was split into a study and control group. The study group consisted of women residing in areas in which women aged 40 to 49 years were invited to screening and the control group of women in areas in which women aged 40 to 49 years were not invited to screening. Rate ratio (RR) estimates were calculated for 2 exposures: invitation and attendance.

    RESULTS: There were striking similarities noted in the RR pattern for women invited to and attending screening and no statistically significant difference or trend in the RR was noted by risk group. The RR estimates increased by increasing parity for parity of 0 to 2 and ranged from 0.55 (95% confidence interval [95% CI], 0.38-0.79) to 0.79 (95% CI, 0.65-0.95) for attending women. The RR for women with high SES was lower than that for women with low SES (RR, 0.72 [95% CI, 0.60-0.86] and RR, 0.79 [95% CI, 0.63-0.99], respectively). For women aged 20 to 24 years at the time of the birth of their first child, the RR was 0.73 (95% CI, 0.58-0.91) and estimates for other ages were similar.

    CONCLUSIONS: There was no statistically significant difference noted in the relative effectiveness of mammography screening by parity, age at the time of birth of the first child, or SES. Cancer 2014.

  • 34.
    Hellquist, Barbro Numan
    et al.
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Czene, Kamila
    Department of Medical Epidemiology and Biostatistics, Karolinska Institutet.
    Hjälm, Anna
    Umeå University, Faculty of Social Sciences, Centre for Population Studies (CPS). Umeå University, Faculty of Social Sciences, Department of Geography and Economic History, Economic and social geography.
    Nyström, Lennarth
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Jonsson, Håkan
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Effectiveness of population-based service screening with mammography for women ages 40 to 49 years with high and low risk of breast cancer: socioeconomic status, parity and age at birth of first childManuscript (preprint) (Other academic)
    Abstract [en]

    Background Whether women in age 40-49 years should be invited to mammography screening or not is debated in many countries and a cost-effective alternative in countries with no screening in age 40-49 years could be selective screening i.e. inviting women at higher risk. In the current study relative effectiveness of mammography screening was estimated for subgroups based on the breast cancer risk factors parity, age at birth of first child and socioeconomic status (SES).

    Methods The SCReening of Young women (SCRY) database consist of all women in age 40-49 years in Sweden in 1986-2005 and is split into a study and control group. The study group consists of women in areas where women age 40-49 years were invited to screening and the control group of women in areas where women 40-49 years were not. Rate ratio (RR) estimates were calculated for risk groups. Two exposures were considered; invitation to mammography screening and attendance.

    Results There were striking similarities in the RR pattern for women invited to and attending in screening for all three risk factors and there was no statistically significant difference or trend in the RR by risk group. The RR estimates increased by increasing parity for parity 0 to 2 and ranged from 0.55 (95% CI 0.38-0.79) to 0.79 (95% CI 0.65-0.95) for women attending screening. The RR for white collar workers (low SES) was lower than for blue collar workers (high SES), 0.72 (95% CI 0.60-0.86) and 0.79 (95% CI 0.63-0.99) respectively for attending. For women 20-24 years at birth of first child RR was estimated at 0.73 (95% CI 0.58-0.91) for attending and estimates for other ages were similar.

    Conclusion There was no statistically significant difference in relative effectiveness of mammography screening by parity, age at birth of first child or socio-economic status.

  • 35.
    Hellquist, Barbro Numan
    et al.
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Jonsson, Håkan
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Nyström, Lennarth
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Unclear methods in estimate of screening effect in women ages 40-49 years Author Reply2012In: Cancer, ISSN 0008-543X, E-ISSN 1097-0142, Vol. 118, no 4, p. 1170-1171Article in journal (Refereed)
  • 36.
    Hellquist Numan, Barbro
    et al.
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Duffy, Stephen W
    Cancer Research UK, Department of Epidemiology, Mathematics, and Statistics, Wolfson Institute of Preventive Medicine, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom.
    Abdsaleh, Shahin
    Department of Medical Imaging, Uppsala University Hospital, Uppsala, Sweden.
    Björneld, Lena
    Department of Radiology, Sahlgrenska University Hospital, Sahlgrenska, Sweden.
    Bordás, Pál
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Tabár, László
    Department of Mammography, Falun Central Hospital, Falun, Sweden.
    Viták, Bedrich
    Mammography Department, Linköping University Hospital, Linköping, Sweden.
    Zackrisson, Sophia
    Department of Clinical Sciences in Malmö, Diagnostic Radiology, Lund University, Lund, Sweden.
    Nyström, Lennarth
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Jonsson, Håkan
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Effectiveness of population-based service screening with mammography for women ages 40 to 49 years: evaluation of the Swedish Mammography Screening in Young Women (SCRY) cohort2011In: Cancer, ISSN 0008-543X, E-ISSN 1097-0142, Vol. 117, no 4, p. 714-722Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The effectiveness of mammography screening for women ages 40 to 49 years still is questioned, and few studies of the effectiveness of service screening for this age group have been conducted.

    METHODS: Breast cancer mortality was compared between women who were invited to service screening at ages 40 to 49 years (study group) and women in the same age group who were not invited during 1986 to 2005 (control group). Together, these women comprise the Mammography Screening of Young Women (SCRY) cohort, which includes all Swedish counties. A prescreening period was defined to facilitate a comparison of mortality in the absence of screening. The outcome measure was refined mortality, ie, breast cancer death for women who were diagnosed during follow-up at ages 40 to 49 years. Relative risks (RRs) with 95% confidence intervals (CIs) were estimated.

    RESULTS: There was no significant difference in breast cancer mortality during the prescreening period. During the study period, there were 803 breast cancer deaths in the study group (7.3 million person-years) and 1238 breast cancer deaths in the control group (8.8 million person-years). The average follow-up was 16 years. The estimated RR for women who were invited to screening was 0.74 (95% CI, 0.66-0.83), and the RR for women who attended screening was 0.71 (95% CI, 0.62-0.80).

    CONCLUSIONS: In this comprehensive study, mammography screening for women ages 40 to 49 years was efficient for reducing breast cancer mortality.

  • 37.
    Hellquist Numan, Barbro
    et al.
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Duffy, Stephen W
    Nyström, Lennarth
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Jonsson, Håkan
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Overdiagnosis in the population-based service screening programme with mammography for women aged 40 to 49 years in Sweden2012In: Journal of Medical Screening, ISSN 0969-1413, E-ISSN 1475-5793, Vol. 19, no 1, p. 14-19Article in journal (Refereed)
    Abstract [en]

    Objectives: To estimate the level of overdiagnosis of all breast cancers and of invasive breast cancers in women aged 40–49 invited to the subsequent screening rounds in the Swedish service-screening programme 1986–2005.

    Methods: To estimate the level of overdiagnosis in subsequent screening, the rate ratios (RR) of the breast cancer incidence in the study group (women in areas with screening in ages 40–49) and the control group (women in areas with no screening in ages 40–49) were calculated for all breast cancers and for invasive breast cancers. The RR estimates were adjusted for the prescreening difference in incidence between study and control group and for lead time.

    Results: The prescreening incidence rate ratio was estimated at 0.92 (95% confidence interval [CI]: 0.88–0.97). The number of breast cancer cases and person-years were 6047 and 3.8 million, and 7790 and 5.2 million, in the study group and control group respectively during the study period. The RR estimate for all cancers was 1.01 (95% CI: 0.94–1.08) when adjusted for prescreening difference and a lead time of 1.2 years. The corresponding estimate for invasive breast cancers was 0.95 (95% CI: 0.88–1.02).

    Conclusions: We found no significant overdiagnosis for women aged 40–49 in the Swedish service screening programme with mammography.

  • 38.
    Hellquist Numan, Barbro
    et al.
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Jonsson, Håkan
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Nyström, Lennarth
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Reply to effectiveness of population-based service screening with mammography for women ages 40-49 years: Evaluation of the swedish mammography screening in young women (SCRY) cohort2011In: Cancer, ISSN 0008-543X, E-ISSN 1097-0142, Vol. 117, no 17, p. 4100-4101Article in journal (Refereed)
  • 39. Holmberg, L
    et al.
    Duffy, SW
    Yen, AMF
    Tabár, L
    Vitak, B
    Nyström, Lennarth
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Frisell, J
    Differences in endpoints between the Swedish W-E (two county) trial of mammographic screening and the Swedish overview: methodological consequences.2009In: Journal of Medical Screening, ISSN 0969-1413, E-ISSN 1475-5793, Vol. 16, no 2, p. 73-80Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: To characterize and quantify the differences in the number of cases and breast cancer deaths in the Swedish W-E Trial compared with the Swedish Overview Committee (OVC) summaries and to study methodological issues related to trials in secondary prevention.

    SETTING: The study population of the W-E Trial of mammography screening was included in the first (W and E county) and the second (E-county) OVC summary of all Swedish randomized mammography screening trials. The OVC and the W-E Trial used different criteria for case definition and causes of death determination.

    METHOD: A Review Committee compared the original data files from W and E county and the first and second OVC. The reason for a discrepancy was determined individually for all non-concordant cases or breast cancer deaths.

    RESULTS: Of the 2615 cases included by the W-E Trial or the OVC, there were 478 (18%) disagreements. Of the disagreements 82% were due to inclusion/exclusion criteria, and 18% to disagreement with respect to cause of death or vital status at ascertainment. For E-County, the OVC inclusion rules and register based determination of cause of death (second OVC) rather than individual case review (W-E Trial and 1st OVC) resulted in a reduction of the estimate of the effect of screening, but for W-County the difference between the original trial and the OVC was modest.

    CONCLUSIONS: The conclusion that invitation to mammography screening reduces breast cancer mortality remains robust. Disagreements were mainly due to study design issues, while disagreements about cause of death were a minority. When secondary research does not adhere to the protocols of the primary research projects, the consequences of such design differences should be investigated and reported. Register linkage of trials can add follow-up information. The precision of trials with modest size is enhanced by individual monitoring of case status and outcome status such as determination of cause of death.

  • 40.
    Ivarsson, Anneli
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Hernell, Olle
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Nyström, Lennarth
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Persson, L A
    Children born in the summer have increased risk for coeliac disease.2003In: Journal of Epidemiology and Community Health, ISSN 0143-005X, E-ISSN 1470-2738, Vol. 57, no 1, p. 36-39Article in journal (Refereed)
  • 41.
    Ivarsson, Anneli
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Persson, L A
    Nyström, Lennarth
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Ascher, H
    Cavell, B
    Danielsson, L
    Dannaeus, A
    Lindberg, T
    Lindquist, B
    Stenhammar, L
    Hernell, Olle
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Epidemic of coeliac disease in Swedish children.2000In: Acta Paediatr, ISSN 0803-5253, Vol. 89, no 2, p. 165-71Article in journal (Refereed)
  • 42.
    Ivarsson, Anneli
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Persson, Lars Ake
    Nyström, Lennarth
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Hernell, Olle
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    The Swedish coeliac disease epidemic with a prevailing twofold higher risk in girls compared to boys may reflect gender specific risk factors.2003In: Eur J Epidemiol, ISSN 0393-2990, Vol. 18, no 7, p. 677-84Article in journal (Refereed)
  • 43. Janson, C
    et al.
    Norbäck, D
    Omenaas, E
    Gislason, T
    Nyström, Lennarth
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Jögi, R
    Lindberg, E
    Gunnbjörnsdottir, M
    Norrman, Eva
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Pulmonary Medicine.
    Wentzel-Larsen, T
    Svanes, C
    Jensen, E J
    Torén, K
    Insomnia is more common among subjects living in damp buildings.2005In: Occup Environ Med, ISSN 1470-7926, Vol. 62, no 2, p. 113-8Article in journal (Refereed)
  • 44.
    Jonsson, Håkan
    et al.
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Bordás, Pál
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Wallin, Hans
    Nyström, Lennarth
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Lenner, Per
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Service screening with mammography in Northern Sweden: effects on breast cancer mortality - an update.2007In: Journal of Medical Screening, ISSN 0969-1413, E-ISSN 1475-5793, Vol. 14, no 2, p. 87-93Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: To study the effectiveness of service screening with mammography in Northern Sweden.

    SETTING: Two counties which invited women aged 40-74 years to service screening with mammography were compared with two counties where service screening started 5-7 years later. There were 109,000 and 77,000 women in the study and control counties, respectively.

    METHODS: Cohorts in the study group were defined to include only breast cancer cases diagnosed after their first invitation to screening. Two outcome measures for breast cancer mortality were used; excess mortality and underlying cause of death (UCD). Detection mode was used to estimate the efficacy of screening for those women who actually attended screening. The cohorts were followed for 11 years.

    RESULTS: The relative rate (RR) of breast cancer death as excess mortality and UCD for women aged 40-74 years invited to screening, compared with women not yet invited, was 0.70 (95% confidence interval [CI] 0.56-0.87) and 0.74 (95% CI 0.62-0.88), respectively. The largest effect was seen in women aged 40-49 years (RR = 0.64 and RR = 0.62 for excess mortality and UCD, respectively). RR in age 40-74 years for women actually screened was 0.65 (95% CI 0.51-0.84) and 0.70 (95% CI 0.57-0.86) for excess mortality and UCD, respectively. The number of women needed to screen to save one life was 912 after 11 years of follow-up.

    CONCLUSIONS: This study confirms previous findings in the earlier follow-up and indicates a long-term reduction of breast cancer mortality by 26-30%. The efficacy among those who actually attended screening was about 5% larger.

  • 45.
    Jonsson, Håkan
    et al.
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Nyström, Lennarth
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Törnberg, S.
    Oncologic Centre, Karolinska Hospital, Stockholm, Sweden.
    Lenner, Per
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Service screening with mammography of women aged 50–69 years in Sweden: effects on mortality from breast cancer2001In: Journal of Medical Screening, ISSN 0969-1413, E-ISSN 1475-5793, Vol. 8, no 3, p. 152-160Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES:To estimate the effect of the population based service screening programme in Sweden on mortality from breast cancer among women aged 50–69. SETTING:In 1986, population based service screening with mammography started in Sweden, and by 1997 screening had been introduced in all counties. Half of the counties invite women from 40 years of age whereas women 50 and older are invited in the other counties. The upper age limit was either 69 or 74. Women in the age group 50–69 years are thus invited to screening in all counties.

    METHODS:The counties which started with mammographic screening in 1986–87 constituted the study group and were compared with the counties which started in 1993 or later. In 1987 the mean number of women aged 50–69 was 161 986 and 98 608 in the study and control groups, respectively. Refined excess mortality (smoothed with the Lowess method) from breast cancer and refined cause specific mortality from breast cancer were used as effect measures. To adjust for geographical differences in mortality from breast cancer a reference period was used. Allowance was made for two potential biases: (a) inclusion bias implying the inclusion of cases diagnosed before invitation to screening in the first screening round, and (b) lead time bias.

    RESULTS:After a mean follow up time of 10.6 years since the start of screening and a mean individual follow up time of 8.4 years, a non-significant reduction in refined excess mortality for breast cancer was estimated as relative risk (RR) 0.84 (95% confidence interval (95% CI) 0.67 to 1.05). After adjustment for inclusion and lead time biases the RR was 0.80 (20% reduction). Only 27% of the deaths from breast cancer in the total mortality for women aged 50–79 at death consisted of women aged 50–69 at diagnosis who were diagnosed after the start of screening. This figure has important implications for judgement of the impact of screening on age specific national breast cancer mortalities.

    CONCLUSIONS:A non-significant reduction in mortality from breast cancer was found in counties performing service screening with mammography in Sweden. Adjustment for possible biases changed the result towards a larger effect of screening. The results do not contradict the effects found in the Swedish randomised mammography trials.

  • 46.
    Jonsson, Håkan
    et al.
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Nyström, Lennarth
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Törnberg, Sven
    Department of Oncology, Oncologic Centre, Karolinska Hospital, Stockholm, Sweden.
    Lundgren, B.
    Lenner, Per
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Service screening with mammography: Long-term effects on breast cancer mortality in the county of Gävleborg, SwedenManuscript (preprint) (Other academic)
  • 47.
    Jonsson, Håkan
    et al.
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Törnberg, Sven
    Department of Oncology, Oncologic Centre, Karolinska Hospital, Stockholm, Sweden.
    Nyström, Lennarth
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Lenner, Per
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Service Screening with Mammography in Sweden: Evaluation of Effects of Screening on Breast Cancer Mortality in Age Group 40–49 Years2000In: Acta Oncologica, ISSN 0284-186X, E-ISSN 1651-226X, Vol. 39, no 5, p. 617-623Article in journal (Refereed)
    Abstract [en]

    The aim of the study was to develop a model for estimating the effect of the nation-wide service screening program with mammography on breast cancer mortality in Sweden. In 1997, the introduction of population-based service screening had been completed in all 26 counties. In approximately half of the counties suitable for evaluation, the lower age limit for invitation was 40 years (study population) and in the other half the age limit was 50 years (control population). The numbers of females aged 40-49 years for the two populations were 202 152 and 237 279, respectively (1988). The study and control populations were compared for the period 1986-1996 with regard to refined breast cancer mortality. To adjust for geographical differences, the period 1976-1986 was used as reference. With a mean follow-up time of 8 years, the estimated relative risk of breast cancer death in relation to invitation to service screening among women aged 40-49 years at breast cancer diagnosis was 0.91 (95% confidence interval 0.72-1.15). These findings were compatible with those presented in the previous overview of the Swedish randomized studies.

  • 48.
    Jonsson, Håkan
    et al.
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Törnberg, Sven
    Karolinska Hosp, Ctr Oncol, S-10401 Stockholm, Sweden.
    Nyström, Lennarth
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Lenner, Per
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Service screening with mammography of women aged 70-74 years in Sweden: effects on breast cancer mortality2003In: Cancer Detection and Prevention, ISSN 0361-090X, E-ISSN 1873-443X, Vol. 27, no 3, p. 360-369Article in journal (Refereed)
    Abstract [en]

    Since the benefit of mammography screening for women 70 years and older is unclear, the aim of the present study was to evaluate the effect on breast cancer mortality of the population-based service-screening program in Sweden inviting women 70-74 years. Among the counties with service-screening programs in Sweden which started 1986-1990 those with upper age limit 74 years were compared to counties with 69 years as upper age limit with respect to refined breast cancer mortality. Allowance was made for potential biases namely inclusion of cases diagnosed before invitation and lead time. Two methods for estimation of breast cancer mortality were used; underlying cause of death (UCD) and excess mortality. With a mean follow-up of 10.1 years a reduction of the breast cancer excess mortality was estimated at 24%. Using the underlying cause of death the corresponding result was 6%. A non-significant reduction in breast cancer mortality was found in the counties with service-screening program including the age group 70-74 years in Sweden. The estimated reduction was larger when using excess mortality compared to the use of individual underlying cause of death.

  • 49. Kemetli, Levent
    et al.
    Rutqvist, Lars Erik
    Jonsson, Håkan
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Nyström, Lennarth
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Lenner, Per
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Törnberg, Sven
    Temporal trends in the use of adjuvant systemic therapy in breast cancer: a population based study in Sweden 1976-2005.2009In: Acta Oncologica, ISSN 0284-186X, E-ISSN 1651-226X, Vol. 48, no 1, p. 59-66Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Both adjuvant therapy and mammography screening can decrease breast cancer mortality and there is a need of knowing to what extent those two modalities are used in the population. Screening coverage is well documented but there is a scarcity of population-based data on use of systemic adjuvant treatment.

    AIM: To describe the introduction, and trends in the use of adjuvant systemic therapy for breast cancer in two of six public health regions in Sweden.

    MATERIAL & METHODS: Population-based data on use of adjuvant therapy were available from databases with documented high quality and high coverage data for Stockholm (1976-2005) and North Sweden (1980-2003, and 2005).

    RESULTS: The use of systemic treatment was infrequent before the late 1980s in both regions, but increased during the 1990s. In 2005, the proportion of operable breast cancer patients treated with adjuvant endocrine therapy in the ages 40-59 was around 60 to 80%. The proportion adjuvant chemotherapy was less than 15% for the ages 70-74. For the north region the use of endocrine therapy increased successively over time, with an exception for age group 40-49 were a more rapidly increase occurred in the late 1990s. In Stockholm the increment was higher and more rapidly. There was no clear difference in chemotherapy use between the regions, and the use increased from the mid 1980s in age group 40-49, and in the early 1990s for women aged 50-59. In age group's 60-69 and 70-74 the use was relatively infrequent.

    CONCLUSIONS: Trends in, and levels of the use of adjuvant systemic therapy for breast cancer varied over time in the two study regions, particularly for endocrine therapy. We consider that the differences between the regions mainly reflect different interpretations of new scientific evidence. We stress the importance of a good documentation of all new treatment protocols.

  • 50. Kidanto, Hussein L
    et al.
    Massawe, Siriel N
    Nyström, Lennarth
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Lindmark, Gunilla
    Analysis of perinatal mortality at a teaching hospital in Dar es Salaam, Tanzania, 1999-20032006In: African Journal of Reproductive Health, ISSN 1118-4841, Vol. 10, no 2, p. 72-80Article in journal (Refereed)
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