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  • 1.
    Asklund, Thomas
    et al.
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Björ, Ove
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Malmström, Annika
    Blomquist, Erik
    Henriksson, Roger
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Överlevnanden vid maligna gliom har ökat senaste tio åren. Analys av kvalitetsregisterdata.2012In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 109, no 17-18, p. 875-878Article in journal (Refereed)
    Abstract [en]

    The annual incidence rate of high grade malignant glioma (WHO grade III-IV) in Sweden is approximately 400 patients. The objective for the Swedish National CNS-tumor Group is to lay a foundation for research efforts and facilitate implementation and assessment of therapeutic strategies and health care for this patient group. In the analyses the diagnoses of high grade malignant gliomas are compared for the years 1999-2003, 2004-2006 and 2007-2009 for the Northern Region, the Uppsala Region and the South-east Region of Sweden, a population of 1844 patients. Survival was estimated from Kaplan-Meier survival curves, and a log-rank test was performed to assess whether the survival curves differed. The crude hazard ratio between years of diagnosis was estimated from a Cox regression model. Median survival for all patients 2004-2006 was 10.0 months (95 % confidence interval (CI) 8.9-10.9) compared to 8.1 months 1999-2003 (95 % CI 7.3-8.8). For patients 60-69 years of age almost a doubling of the survival rate has occurred during the last decade. Medan survival has increased from 5.8 months (95 % CI 5.1-7.5) 1999-2003 to 8.5 months (95 % CI 7.0-10.3) for 2004-2006 and to 10.5 months (95 % CI 9.0-12.6) for 2007-2009. Concomitant radiochemotherapy, but also the development of neurosurgical and radiotheraputic techniques and a more active therapeutic attitude, including the older patient groups, have probably contributed to the improved survival rate. A national population based registry, with a close to 100% registration compliance for important diagnostic and outcome parameters is probably an efficient instrument for evaluation of quality measures and implementation of new therapeutic strategies.

  • 2.
    Asklund, Thomas
    et al.
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Malmstrom, Annika
    Björ, Ove
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Blomquist, Erik
    Henriksson, Roger
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Considerable improvement in survival for patients aged 60-84 years with high grade malignant gliomas - Data from the Swedish Brain Tumour Population-based Registry2013In: Acta Oncologica, ISSN 0284-186X, E-ISSN 1651-226X, Vol. 52, no 5, p. 1043-1046Article in journal (Refereed)
  • 3.
    Asklund, Thomas
    et al.
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Malmström, Annika
    Bergqvist, Michael
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Björ, Ove
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Henriksson, Roger
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Brain tumors in Sweden: Data from a population-based registry 1999-20122015In: Acta Oncologica, ISSN 0284-186X, E-ISSN 1651-226X, Vol. 54, no 3, p. 377-384Article in journal (Refereed)
    Abstract [en]

    Background. The Swedish brain tumor registry has, since it was launched in 1999, provided significant amounts of data on histopathological diagnoses and on important aspects of surgical and medical management of these patients. The purpose is mainly quality control, but also as a resource for research.

    Methods. Three Swedish healthcare regions, constituting 40% of the Swedish population, have had an almost complete registration. The following parameters are registered: diagnosis according to SNOMED/WHO classification, symptoms, performance status, pre- and postoperative radiology, tumor size and localization, extent of surgery and occurrence of postoperative complications, postoperative treatment, such as radiotherapy and/or chemotherapy, other treatments, complications and toxicity, occurrence of reoperation/s, participation in clinical trials, multidisciplinary conferences and availability of a contact nurse.

    Results. Surgical radicality has been essentially constant, whereas the use of early (within 72 hours) postoperative CT and MRI has increased, especially for high-grade glioma, which is a reflection of quality of surgery. Survival of patients with high-grade glioma has increased, especially in the age group 60-69. Patients aged 18-39 years had a five-year survival of 40%. Waiting times for the pathological report has been slightly prolonged. Geographical differences do exist for some of the variables.

    Conclusion. Population-based registration is valuable for assessment of clinical management, which could have impact on patient care. As a result of short survival and/or the propensity to affect cognitive functions this patient group has considerable difficulties to make their voices heard in society. We therefore believe that a report like the present one can contribute to the spread of knowledge and increase the awareness for this patient group among caregivers and policy makers.

  • 4.
    Björ, Ove
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Strategies for assessing health risks from two occupational cohorts within the domain of northern Sweden2013Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Background Studies based on a cohort design requires access to both subject-specific and period-specific information. In order to conduct an occupational cohort study, access to exposure information and the possibility and permission to link information on outcomes from other registers are generally necessary. The analysis phase is also aggravated by its added complexity because of the longitudinal dimension of the cohort’s data.This thesis aims at increasing the knowledge on hazards from work on fatalities and cancer within the domain of cohort studies on miners and metal refiners and to study the complexity of the analysis by discussing and suggesting analytical strategies.

    Methods The study population for this thesis consisted of a cohort of 2264 blue-collar aluminium smelter workers (paper I) and a cohort of 13000 blue-collar iron-ore miners (papers II-IV), both followed for over 50 years. The outcomes were collected from the Swedish Cause of Death Register and the Swedish Cancer Register. The primary methods of analysis were either Standardized Morbidity Ratios (SMR) or internal comparisons based on Cox or Poisson regression modeling. In paper IV, a g-estimation based on an accelerated failure-time model was performed to estimate the survival ratio.

    Results The results from paper I suggested that working as a blue-collar worker metal refiner was associated with increased rates of incidental lung cancer. Elevated rates among short term workers were observed for several outcomes. Paper I also showed that the choice of reference population when calculating SMR could influence the conclusions of the results. In paper II, several outcomes were elevated among the miners compared to the reference population from northern Sweden. However, no outcome except lung cancer was associated with cumulative employment time. The most recurrent pattern of the results was the negative association between cumulative employment time underground and several outcomes. The results from paper III showed that cumulative employment time working outdoors was associated with increased rates of cerebrovascular disease mortality. However, employment with heavy physical workloads did not explain the previously observed decreasing rates in the selected groups of outcomes. The adjustment for the healthy worker survivor effect by g-estimation in paper IV suggested that exposure from respirable dust was associated with elevated mortality risks that could not be observed with standard analytical methods.

    Conclusion Our studies found several rates from the cohorts that were elevated compared to external refererence populations but also that long term employments generally were associated with decreasing rates. Furthermore, incidental lung cancer rates was found elevated for the metal refiners. Among the miners, mortality rates of cerebrovascular diseases depended on if work was performed outdoor (higher rates) or underground (lower rates). Methodologically, this thesis has discussed different analytical strategies for handling confounding in occupational cohort studies. Paper IV showed that the healthy worker survivor effect could be adjusted for by performing g-estimation.

  • 5.
    Björ, Ove
    et al.
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Damber, Lena
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Edström, Clarence
    Nilsson, Tohr
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Long-term follow-up study of mortality and the incidence of cancer in a cohort of workers at a primary aluminum smelter in Sweden2008In: Scandinavian Journal of Work, Environment and Health, ISSN 0355-3140, E-ISSN 1795-990X, Vol. 34, no 6, p. 463-470Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: Previous studies on mortality and the incidence of cancer among workers at primary aluminum smelters have produced conclusive results indicating an elevated risk of bladder cancer. An increased risk of lung cancer has also been reported several times. The objective of this study was to examine mortality and the incidence of cancer at a Swedish aluminum smelter when different neighboring reference populations were used to evaluate any relationships to the length of employment. METHODS: A historical cohort--comprised of 2264 male nonoffice workers employed from 1942 on and tracked up to the year 2000--was examined. With the use of three reference populations for mortality and four for cancer incidence, standardized mortality and incidence ratios were calculated, together with hazard ratios derived from Cox regression models. RESULTS: This study showed an excess risk of mortality due to chronic obstructive lung disease, mental disorders, and diseases of the digestive system among the short-term workers. An elevated risk of cancer was found for the lungs, central nervous system, and esophagus. The highest lung cancer risk was observed for the workers employed for > or = 10 years in the factory when they were compared with the reference group from northern Sweden (standardized incidence ratio 1.99, 95% confidence ratio 1.21-3.07). CONCLUSIONS: The results support previous studies that demonstrated an excess risk of lung cancer, but, in contrast to the results of most studies, cancer of the central nervous system was also elevated. This study did not, however, verify an association between this type of exposure and cancer of the urinary organs.

  • 6.
    Björ, Ove
    et al.
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Damber, Lena
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Jonsson, Håkan
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Nilsson, Tohr
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine. Sundsvall Hosp, Dept Occupat & Environm Med, Sundsvall, Sweden.
    A comparison between standard methods and structural nested modelling when bias from a healthy worker survivor effect is suspected: an iron-ore mining cohort study2015In: Occupational and Environmental Medicine, ISSN 1351-0711, E-ISSN 1470-7926, Vol. 72, no 7, p. 536-542Article in journal (Refereed)
    Abstract [en]

    Objectives Iron-ore miners are exposed to extremely dusty and physically arduous work environments. The demanding activities of mining select healthier workers with longer work histories (ie, the Healthy Worker Survivor Effect (HWSE)), and could have a reversing effect on the exposure-response association. The objective of this study was to evaluate an iron-ore mining cohort to determine whether the effect of respirable dust was confounded by the presence of an HWSE. Methods When an HWSE exists, standard modelling methods, such as Cox regression analysis, produce biased results. We compared results from g-estimation of accelerated failure-time modelling adjusted for HWSE with corresponding unadjusted Cox regression modelling results. Results For all-cause mortality when adjusting for the HWSE, cumulative exposure from respirable dust was associated with a 6% decrease of life expectancy if exposed >= 15 years, compared with never being exposed. Respirable dust continued to be associated with mortality after censoring outcomes known to be associated with dust when adjusting for the HWSE. In contrast, results based on Cox regression analysis did not support that an association was present. Conclusions The adjustment for the HWSE made a difference when estimating the risk of mortality from respirable dust. The results of this study, therefore, support the recommendation that standard methods of analysis should be complemented with structural modelling analysis techniques, such as g-estimation of accelerated failure-time modelling, to adjust for the HWSE.

  • 7.
    Björ, Ove
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Jonsson, Håkan
    Umeå University, Faculty of Medicine, Department of Radiation Sciences.
    Damber, Lena
    Umeå University, Faculty of Medicine, Department of Radiation Sciences.
    Burström, Lage
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Nilsson, Tohr
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Do physical workload or temperature characteristics in an outdoor workingenvironment explain deviating rates of mortality and incidental cancer? A cohort study based on iron-ore mining.Manuscript (preprint) (Other academic)
    Abstract [en]

    Background A cohort study that examined iron ore mining found negative associations between cumulative working time employed underground and several severe outcomes. In this cohort study, and using the same group of miners, we examined whether heavy physical workload or the temperature characteristics represented by an outdoor working environment could explain these lower rates.

    Method This study was based on a Swedish iron ore mining cohort consisting of 13000 workers employed between 1923 and 1998. Exposure was defined as cumulative employment time in heavy physical workload or outdoor work. Poisson regression models were used to generate smoothed estimates of standardized morbidity ratios and adjusted rate ratios, both models by cumulative exposure time. SMRs for different cohort subgroups were used to compare the occurrence of cerebrovascular disease mortality to the reference population.

    Results The adjusted rate ratio between employment classified as outdoor work ≥25 years and short term outdoor work was 1.62 (95% CI 1.07–2.42). The subgroup underground work ≥15 years deviated most in occurrence of cerebrovascular disease mortality compared with the reference population: SMR (0.70 (95% CI 0.56–0.85)). No elevated rates were associated with cumulative employment time representing heavy physical workloads.

    Conclusion Employment in temperature shifting outdoor environments was associated with elevated rates of cerebrovascular disease mortality. In contrast, work in tempered underground employment was associated with a protecting effect. Based on selected groups of mortalities, physically heavy workloads did not protect for mortality later in life.

  • 8.
    Björ, Ove
    et al.
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Jonsson, Håkan
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Damber, Lena
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Burström, Lage
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Nilsson, Tohr
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Is outdoor work associated with elevated rates of cerebrovascular disease mortality?: a cohort study based on iron-ore mining2016In: Journal of Occupational Medicine and Toxicology, ISSN 1745-6673, E-ISSN 1745-6673, Vol. 11, article id 40Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: A cohort study that examined iron ore mining found negative associations between cumulative working time employed underground and several outcomes, including mortality of cerebrovascular diseases. In this cohort study, and using the same group of miners, we examined whether work in an outdoor environment could explain elevated cerebrovascular disease rates.

    METHODS: This study was based on a Swedish iron ore mining cohort consisting of 13,000 workers. Poisson regression models were used to generate smoothed estimates of standardized mortality ratios and adjusted rate ratios, both models by cumulative exposure time in outdoor work.

    RESULTS: The adjusted rate ratio between employment classified as outdoor work ≥25 years and outdoor work 0-4 years was 1.62 (95 % CI 1.07-2.42). The subgroup underground work ≥15 years deviated most in occurrence of cerebrovascular disease mortality compared with the external reference population: SMR (0.70 (95 % CI 0.56-0.85)).

    CONCLUSIONS: Employment in outdoor environments was associated with elevated rates of cerebrovascular disease mortality. In contrast, work in tempered underground employment was associated with a protecting effect.

  • 9.
    Björ, Ove
    et al.
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Jonsson, Håkan
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Damber, Lena
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Wahlström, Jens
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Nilsson, Tohr
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Reduced mortality rates in a cohort of long-term underground iron-ore miners2013In: American Journal of Industrial Medicine, ISSN 0271-3586, E-ISSN 1097-0274, Vol. 56, no 5, p. 531-540Article in journal (Refereed)
    Abstract [en]

    Background Historically, working in iron-ore mines has been associated with an increased risk of lung cancer and silicosis. However, studies on other causes of mortality are inconsistent and in the case of cancer incidence, sparse. The aim of this study was to examine the association between iron-ore mining, mortality and cancer incidence.

    Methods A 54-year cohort study on iron-ore miners from mines in northern Sweden was carried out comprising 13,000 workers. Standardized rate ratios were calculated comparing the disease frequency, mortality, and cancer incidence with that of the general population of northern Sweden. Poisson regression was used to evaluate the association between the durations of employment and underground work, and outcome.

    Results Underground mining was associated with a significant decrease in adjusted mortality rate ratios for cerebrovascular and digestive system diseases, and stroke. For several outcomes, elevated standardized rate ratios were observed among blue-collar workers relative to the reference population. However, only the incidence of lung cancer increased with employment time underground (P<0.001).

    Conclusions Long-term iron-ore mining underground was associated with lower rates regarding several health outcomes. This is possibly explained by factors related to actual job activities, environmental exposure, or the selection of healthier workers for long-term underground employment.

    Am. J. Ind. Med. 56:531540, 2013. (c) 2013 Wiley Periodicals, Inc.

  • 10. Forsell, Karl
    et al.
    Björ, Ove
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Järvholm, Bengt
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Sustainable Health.
    Nilsson, R.
    Andersson, E.
    Hematologic malignancy on tankers: A case -referent study among male Swedish seafarersManuscript (preprint) (Other (popular science, discussion, etc.))
  • 11. Glimelius, Bengt
    et al.
    Melin, Beatrice
    Umeå University, Faculty of Medicine, Department of Radiation Sciences.
    Enblad, Gunilla
    Alafuzoff, Irina
    Beskow, Anna
    Ahlström, Håkan
    Bill-Axelson, Anna
    Birgisson, Helgi
    Björ, Ove
    Umeå University, Faculty of Medicine, Department of Radiation Sciences.
    Edqvist, Per-Henrik
    Hansson, Tony
    Helleday, Thomas
    Hellman, Per
    Henriksson, Kerstin
    Hesselager, Göran
    Hultdin, Magnus
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Pathology.
    Häggman, Michael
    Höglund, Martin
    Jonsson, Håkan
    Umeå University, Faculty of Medicine, Department of Radiation Sciences.
    Larsson, Chatarina
    Lindman, Henrik
    Ljuslinder, Ingrid
    Umeå University, Faculty of Medicine, Department of Radiation Sciences.
    Mindus, Stephanie
    Nygren, Peter
    Pontén, Fredrik
    Riklund, Katrine
    Umeå University, Faculty of Medicine, Department of Radiation Sciences.
    Rosenquist, Richard
    Sandin, Fredrik
    Schwenk, Jochen M.
    Stenling, Roger
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Pathology.
    Stålberg, Karin
    Stålberg, Peter
    Sundström, Christer
    Thellenberg Karlsson, Camilla
    Umeå University, Faculty of Medicine, Department of Radiation Sciences.
    Westermark, Bengt
    Bergh, Anders
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Pathology.
    Claesson-Welsh, Lena
    Palmqvist, Richard
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Pathology.
    Sjöblom, Tobias
    U-CAN: a prospective longitudinal collection of biomaterials and clinical information from adult cancer patients in Sweden2018In: Acta Oncologica, ISSN 0284-186X, E-ISSN 1651-226X, Vol. 57, no 2, p. 187-194Article in journal (Refereed)
    Abstract [en]

    Background: Progress in cancer biomarker discovery is dependent on access to high-quality biological materials and high-resolution clinical data from the same cases. To overcome current limitations, a systematic prospective longitudinal sampling of multidisciplinary clinical data, blood and tissue from cancer patients was therefore initiated in 2010 by Uppsala and Umea Universities and involving their corresponding University Hospitals, which are referral centers for one third of the Swedish population.

    Material and Methods: Patients with cancer of selected types who are treated at one of the participating hospitals are eligible for inclusion. The healthcare-integrated sampling scheme encompasses clinical data, questionnaires, blood, fresh frozen and formalin-fixed paraffin-embedded tissue specimens, diagnostic slides and radiology bioimaging data.

    Results: In this ongoing effort, 12,265 patients with brain tumors, breast cancers, colorectal cancers, gynecological cancers, hematological malignancies, lung cancers, neuroendocrine tumors or prostate cancers have been included until the end of 2016. From the 6914 patients included during the first five years, 98% were sampled for blood at diagnosis, 83% had paraffin-embedded and 58% had fresh frozen tissues collected. For Uppsala County, 55% of all cancer patients were included in the cohort.

    Conclusions: Close collaboration between participating hospitals and universities enabled prospective, longitudinal biobanking of blood and tissues and collection of multidisciplinary clinical data from cancer patients in the U-CAN cohort. Here, we summarize the first five years of operations, present U-CAN as a highly valuable cohort that will contribute to enhanced cancer research and describe the procedures to access samples and data.

  • 12. Hansdotter, Ida
    et al.
    Björ, Ove
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Andreasson, Anna
    Agreus, Lars
    Hellstrom, Per
    Forsberg, Anna
    Talley, Nicholas J.
    Vieth, Michael
    Wallner, Bengt
    Hill classification is superior to the axial length of a hiatal hernia for assessment of the mechanical anti-reflux barrier at the gastroesophageal junction2016In: Endoscopy International Open, ISSN 2364-3722, Vol. 4, no 3, p. E311-E317Article in journal (Refereed)
    Abstract [en]

    Background and study aims: The pathogenesis of gastroesophageal reflux disease (GERD) is multifactorial, including the mechanical anti-reflux barrier of the gastroesophageal junction. This barrier can be evaluated endoscopically in two ways: by measuring the axial length of any hiatal hernia present or by assessing the gastroesophageal flap valve. The endoscopic measurement of axial length is troublesome because of the physiological dynamics in the area. Grading the gastroesophageal flap valve is easier and has proven reproducible. The aim of the present study was to compare the two endoscopic grading methods with regard to associations with GERD. Patients and methods: Population-based subjects underwent endoscopic examination assessing the axial length of hiatus hernia, the gastroesophageal flap valve using the Hill classification, esophagitis using the Los Angeles (LA) classification, and columnar metaplasia using the Z-line appearance (ZAP) classification. Biopsies were taken from the squamocolumnar junction to assess the presence of intestinal metaplasia. Symptoms were recorded with the validated Abdominal Symptom Questionnaire. GERD was defined according to the Montreal definition. Results: In total, 334 subjects were included in the study and underwent endoscopy; 86 subjects suffered from GERD and 211 presented no symptoms or signs of GERD. Based on logistic regression, the estimated area under the curve statistic (AUC) for Hill (0.65 [95 % CI 0.59-0.72]) was higher than the corresponding estimate for the axial length of a hiatal hernia (0.61 [95 % CI 0.54-0.68]), although the difference was not statistically significant (P=0.225). Conclusion: From our data, and in terms of association with GERD, the Hill classification was slightly stronger compared to the axial length of a hiatal hernia, but we could not verify that the Hill classification was superior as a predictor. The Hill classification may replace the axial length of a hiatal hernia in the endoscopic assessment of the mechanical anti-reflux barrier of the gastroesophageal junction.

  • 13. Johansson, Karl-Axel
    et al.
    Nilsson, Per
    Zackrisson, Björn
    Ohlson, Birgitta
    Kjellén, Elisabeth
    Mercke, Claes
    Alvarez-Fonseca, Mauricio
    Billström, Anette
    Björk-Eriksson, Thomas
    Björ, Ove
    Ekberg, Lars
    Friesland, Signe
    Karlsson, Magnus
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Radiation Physics.
    Lagerlund, Magnus
    Lundkvist, Lena
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Löfroth, Per-Olov
    Löfvander-Thapper, Kerstin
    Nilsson, Alla
    Nyman, Jan
    Persson, Essie
    Reizenstein, Johan
    Rosenbrand, Hans-Olov
    Wiklund, Fredrik
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Wittgren, Lena
    The quality assurance process for the ARTSCAN head and neck study - A practical interactive approach for QA in 3DCRT and IMRT2008In: Radiotherapy and Oncology, ISSN 0167-8140, E-ISSN 1879-0887, Vol. 87, no 2, p. 290-299Article in journal (Refereed)
    Abstract [en]

    AIM: This paper describes the quality assurance (QA) work performed in the Swedish multicenter ARTSCAN (Accelerated RadioTherapy of Squamous cell CArcinomas in the head and Neck) trial to guarantee high quality in a multicenter study which involved modern radiotherapy such as 3DCRT or IMRT.

    MATERIALS AND METHODS: The study was closed in June 2006 with 750 randomised patients. Radiation therapy-related data for every patient were sent by each participating centre to the QA office where all trial data were reviewed, analysed and stored. In case of any deviation from the protocol, an interactive process was started between the QA office and the local responsible clinician and/or physicist to increase the compliance to the protocol for future randomised patients. Meetings and workshops were held on a regular basis for discussions on various trial-related issues and for the QA office to report on updated results.

    RESULTS AND DISCUSSION: This review covers the 734 patients out of a total of 750 who had entered the study. Deviations early in the study were corrected so that the overall compliance to the protocol was very high. There were only negligible variations in doses and dose distributions to target volumes for each specific site and stage. The quality of the treatments was high. Furthermore, an extensive database of treatment parameters was accumulated for future dose-volume vs. endpoint evaluations.

    CONCLUSIONS: This comprehensive QA programme increased the probability to draw firm conclusions from our study and may serve as a concept for QA work in future radiotherapy trials where comparatively small effects are searched for in a heterogeneous tumour population.

  • 14.
    Stattin, Pär
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Urology and Andrology. Urologi och andrologi.
    Björ, Ove
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology. Onkologi.
    Ferrari, Pietro
    Nutrition and Hormones Group, International Agency for Research on Cancer-World Health Organization, Lyon, France.
    Lukanova, Annekatrin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Nutritional Research.
    Lenner, Per
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology. Onkologi.
    Lindahl, Bernt
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Hallmans, Göran
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Nutritional Research.
    Kaaks, Rudolf
    Division of Cancer Epidemiology, German Cancer Research Center Im Neuenheimer, Heidelberg, Germany.
    Prospective study of hyperglycemia and cancer risk.2007In: Diabetes Care, ISSN 0149-5992, E-ISSN 1935-5548, Vol. 30, no 3, p. 561-567Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To investigate whether hyperglycemia is associated with increased cancer risk.

    RESEARCH DESIGN AND METHODS: In the Västerbotten Intervention Project of northern Sweden, fasting and postload plasma glucose concentrations were available for 33,293 women and 31,304 men and 2,478 incident cases of cancer were identified. Relative risk (RR) of cancer for levels of fasting and postload glucose was calculated with the use of Poisson models, with adjustment for age, year of recruitment, fasting time, and smoking status. Repeated measurements 10 years after baseline in almost 10,000 subjects were used to correct RRs for random error in glucose measurements.

    RESULTS: Total cancer risk in women increased with rising plasma levels of fasting and postload glucose, up to an RR for the top versus bottom quartile of 1.26 (95% CI 1.09-1.47) (P(trend) <0.001) and 1.31 (1.12-1.52) (P(trend) = 0.001), respectively. Correction for random error in glucose measurements increased these risks up to 1.75 (1.32-2.36) and 1.63 (1.26-2.18), respectively. For men, corresponding uncorrected RR was 1.08 (0.92-1.27) (P(trend) = 0.25) and 0.98 (0.83-1.16) (P(trend) = 0.99), respectively. Risk of cancer of the pancreas, endometrium, urinary tract, and of malignant melanoma was statistically significantly associated with high fasting glucose with RRs of 2.49 (1.23-5.45) (P(trend) = 0.006), 1.86 (1.09-3.31) (P(trend) = 0.02), 1.69 (0.95-3.16) (P(trend) = 0.049), and 2.16 (1.14-4.35) (P(trend) = 0.01), respectively. Adjustment for BMI had no material effect on risk estimates.

    CONCLUSIONS: The association of hyperglycemia with total cancer risk in women and in women and men combined for several cancer sites, independently of obesity, provides further evidence for an association between abnormal glucose metabolism and cancer.

     

  • 15.
    Wahlin, Anders
    et al.
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Billström, Rolf
    Björ, Ove
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Ahlgren, Tomas
    Hedenus, Michael
    Höglund, Martin
    Lindmark, Anders
    Markevärn, Berit
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Nilsson, Bo
    Sallerfors, Bengt
    Brune, Mats
    Results of risk-adapted therapy in acute myeloid leukaemia. A long-term population-based follow-up study2009In: European Journal of Haematology, ISSN 0902-4441, E-ISSN 1600-0609, Vol. 83, no 2, p. 99-107Article in journal (Refereed)
    Abstract [en]

    In 1997-2003, a protocol for treatment of acute myeloid leukaemia (AML) (except promyelocytic leukaemia) was activated in four Swedish health care regions covering 50% of the national population. Based on cytogenetics and clinical findings, patients aged 18-60 yr were assigned to one of three risk groups. In this report we account for the long-term clinical outcome of enrolled patients. Patients received idarubicin and cytarabine in standard doses as induction therapy and consolidation courses included high-dose cytarabine. Allogeneic stem cell transplantation (allo-SCT) from an human leucocyte antigen-identical sibling was recommended in standard and poor-risk patients, whereas unrelated donor transplant was reserved for poor-risk patients. Autologous (auto-SCT) was optional for standard or poor risk patients not eligible for allo-SCT. Two hundred seventy-nine patients with de novo or secondary (9%) AML, median age 51 (18-60) yr, corresponding to 77% of all patients in the population, were included. Twenty (7%) patients were assigned to the good risk group, whereas 150 (54%) and 109 patients (39%) were assigned to standard- and poor-risk groups, respectively. Induction failures accounted for 55 patients; 16 early deaths eight of whom had white blood cell (WBC) >100 at diagnosis, and 39 refractory disease. Thus, complete remission (CR) rate was 80%. At study closure, the median follow-up time of living patients was 90 months. Median survival time from diagnosis in the whole group was 27 months and 4-yr overall survival (OS) rate was 44%. In good, standard, and poor risk groups, 4-yr OS rates were 60, 57 and 24%, respectively. Median relapse-free survival (RFS) time in CR1 was 25 months and RFS at 4 yr was 44%. Four-year RFS rates were significantly (P < 0.001) different between the three risk groups; 64% in good risk, 51% in standard risk and 27% in poor risk patients. One hundred-ten transplantations were performed in CR1; 74 allo-SCT (50 sibling, 24 unrelated donor), and 36 auto-SCT. Non-relapse mortality was 16% for allo-SCT patients. Outcome after relapse was poor with median time to death 163 d and 4-yr survival rate 17%. Three conclusions were: (i) these data reflect treatment results in a minimally selected population-based cohort of adult AML patients <60 yr old; (ii) a risk-adapted therapy aiming at early allogeneic SCT in patients with a high risk of relapse is hampered by induction deaths, refractory disease, and early relapses; and (iii) high WBC count at diagnosis is confirmed as a strong risk factor for early death but not for relapse.

  • 16.
    Wallner, Bengt
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Björ, Ove
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Andreasson, Anna
    Hellström, Per M.
    Forsberg, Anna M.
    Talley, Nicholas J.
    Agreus, Lars
    Identifying clinically relevant sliding hiatal hernias: a population-based endoscopy study2018In: Scandinavian Journal of Gastroenterology, ISSN 0036-5521, E-ISSN 1502-7708, Vol. 53, no 6, p. 657-660Article in journal (Refereed)
    Abstract [en]

    Objectives: The clinical relevance of small to moderate sliding hiatal hernias is controversial. The aims of the present study were to (1) investigate which symptoms are associated with sliding hiatal hernias and (2) define the length of a sliding hiatal hernia at which gastrointestinal symptoms occur.

    Methods: A study population representative of the general Swedish population answered a questionnaire regarding gastrointestinal symptoms and was investigated with an upper endoscopy. The length of any sliding hiatal hernia was measured.

    Results: Only reflux-related symptoms were associated with length of the hiatal hernia (acid regurgitation OR 1.46, CI 1.19–1.79, heartburn OR 1.27, CI 1.05–1.54), and the association did not become significant until an axial hiatal hernia length of 2 cm.

    Conclusions: Only reflux symptoms could be attributed to sliding hiatal hernias. Hiatal hernias less than 2 cm should be considered clinically insignificant.

  • 17.
    Wallner, Bengt
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
    Björ, Ove
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Andreasson, Anna
    Vieth, Michael
    Schmidt, Peter T.
    Hellstrom, Per M.
    Forsberg, Anna
    Talley, Nicholas J.
    Agreus, Lars
    Z-line alterations and gastroesophageal reflux: an endoscopic population-based prospective cohort study2019In: Scandinavian Journal of Gastroenterology, ISSN 0036-5521, E-ISSN 1502-7708, Vol. 54, no 9, p. 1065-1069Article in journal (Refereed)
    Abstract [en]

    Background and study aims: Barrett's esophagus is a premalignant condition in the distal esophagus associated with esophageal adenocarcinoma. Since gastroesophageal reflux is known to be of etiological importance in both Barrett's esophagus and esophageal adenocarcinoma, we aimed to study which endoscopic alterations at the Z-line can be attributed to a previous history of reflux symptoms. Patients and methods: From 1988, a population cohort in Sweden has been prospectively studied regarding gastrointestinal symptoms, using a validated questionnaire. In 2012, the population was invited to undergo a gastroscopy and participate in the present study. In order to determine which endoscopic alterations that can be attributed to a previous history of gastroesophageal reflux, three different endoscopic definitions of columnar-lined esophagus (CLE) were used: (1) ZAP I, An irregular Z-line with a suspicion of tongue-like protrusions; (2) ZAP II/III, Distinct, obvious tongues of metaplastic columnar epithelium; (3) CLE >= 1 cm, The Prague C/M-classification with a minimum length of 1 cm. Results: A total of 165 community subjects were included in the study. Of these, 40 had CLE >= 1 cm, 99 had ZAP I, and 26 had ZAP II/III. ZAP II/III was associated with an over threefold risk of previous GER symptoms (OR: 3.60, CI: 1.49-8.70). No association was found between gastroesophageal reflux and ZAP I (OR: 2.06, CI: 0.85-5.00), or CLE >= 1 cm (OR: 1.64, CI: 0.77-3.49). Conclusions: In a general community, the only endoscopic alteration to the Z-line definitely linked to longstanding GER symptoms was the presence of obvious tongues of metaplastic columnar epithelium (ZAP II/III).

  • 18.
    Zackrisson, Björn
    et al.
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Nilsson, Per
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Radiation Physics.
    Kjellén, Elisabeth
    Skåne University Hospital, Lund and Malmö, Sweden.
    Johansson, Karl-Axel
    Sahlgrenska University Hospital, Göteborg, Sweden.
    Modig, Hans
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Brun, Eva
    Skåne University Hospital, Lund and Malmö, Sweden.
    Nyman, Jan
    Sahlgrenska University Hospital, Göteborg, Sweden.
    Friesland, Signe
    Karolinska University Hospital, Stockholm, Sweden.
    Reizenstein, Johan
    Örebro University Hospital, Örebro, Sweden.
    Sjödin, Helena
    Karolinska University Hospital, Stockholm, Sweden.
    Ekberg, Lars
    Skåne University Hospital, Lund and Malmö, Sweden.
    Lödén, Britta
    Karlstad Central Hospital, Karlstad, Sweden.
    Mercke, Claes
    Karolinska University Hospital, Stockholm, Sweden.
    Fernberg, Jan-Olof
    Karolinska University Hospital, Stockholm, Sweden.
    Franzén, Lars
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Ask, Anders
    Skåne University Hospital, Lund and Malmö, Sweden.
    Persson, Essie
    Örebro University Hospital, Örebro, Sweden.
    Wickart-Johansson, Gun
    Karolinska University Hospital, Stockholm, Sweden.
    Lewin, Freddi
    Karolinska University Hospital, Stockholm, Sweden.
    Wittgren, Lena
    Skåne University Hospital, Lund and Malmö, Sweden.
    Björ, Ove
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Björk-Eriksson, Thomas
    Sahlgrenska University Hospital, Göteborg, Sweden.
    Two-year results from a Swedish study on conventional versus accelerated radiotherapy in head and neck squamous cell carcinoma - The ARTSCAN study2011In: Radiotherapy and Oncology, ISSN 0167-8140, E-ISSN 1879-0887, Vol. 100, no 1, p. 41-48Article in journal (Refereed)
    Abstract [en]

    Background and purpose: Studies on accelerated fractionation (AF) in head and neck cancer have shown increased local control and survival compared with conventional fractionation (CF), while others have been non-conclusive. In 1998 a national Swedish group decided to perform a randomised controlled clinical study of AF.

    Materials and methods: Patients with verified squamous cell carcinoma of the oral cavity, oropharynx, larynx (except glottic T1-T2, N0) and hypopharynx were included. Patients with prior chemotherapy or surgery were excluded. Patients were randomised to either CF (2Gy/day, 5days/week for 7 weeks, total dose 68Gy) or to AF (1.1Gy+2.0Gy/day, 5days/week for 4.5weeks, total dose 68Gy). An extensive quality assurance protocol was followed throughout the study. The primary end point was loco-regional tumour control (LRC) at two years after treatment. RESULTS: The study was closed in 2006 when 750 patients had been randomised. Eighty-three percent of the patients had stages III-IV disease. Forty eight percent had oropharyngeal, 21% laryngeal, 17% hypopharyngeal and 14% oral cancers. There were no significant differences regarding overall survival (OS) or LRC between the two regimens. The OS at two years was 68% for AF and 67% for CF. The corresponding figures for LRC were 71% and 67%, respectively. There was a trend towards improved LRC for oral cancers treated (p=0.07) and for large tumours (T3-T4) (p=0.07) treated with AF. The AF group had significantly worse acute reactions, while there was no significant increase in late effects.

    Conclusion: Overall the AF regimen did not prove to be more efficacious than CF. However, the trend towards improved results in AF for oral cancers needs to be further investigated.

     

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