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  • 1.
    Bergdahl, Ingvar A
    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, Oncology.
    Eriksson, Kåre
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Damber, Lena
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Järvholm, Bengt
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Lung cancer and exposure to quartz and diesel exhaust in Swedish iron ore miners with concurrent exposure to radon2010In: Occupational and Environmental Medicine, ISSN 1351-0711, E-ISSN 1470-7926, Vol. 67, no 8, p. 513-518Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: Studies of underground miners have documented an increased risk of lung cancer mainly linked to radon exposure but possibly influenced by other concurrent exposures. METHODS: A cohort study was carried out in 8321 iron ore miners with low exposure to radon, employed in 1923-1998 and followed up for lung cancer in 1958-2000. Historical exposures to radon, crystalline silica and diesel exhaust were assessed. Data including exposure to radon, quartz and diesel exhaust from another mine with higher exposure to radon were reanalysed. RESULTS: Miners had increased risk for lung cancer (SIR 1.48 (95% CI 1.22 to 1.78), based on 112 cases during 227,000 person-years). The increased risk could not be explained by exposure to radon or diesel exhaust but was associated with exposure to crystalline silica: SIR 0.96 (0.53 to 1.62), 1.45 (1.10 to 1.87), 1.99 (1.31 to 2.90) and 1.77 (0.92 to 3.10) in groups with exposure to 0, 0-2, 2-5 and >5 mg years/m3, respectively. Reanalysis of data from the other mine indicated that quartz was a possible confounder in the analysis of relationship between radon and lung cancer. In the highest radon exposed group, the point estimate for the RR decreased from 5.65 to 3.90 when adjusting for concurrent exposure to quartz. CONCLUSIONS: Crystalline silica, a known carcinogen, probably affects lung cancer risk in iron ore miners. The main implication of the results is for interpretation of the dose-response curve for radon and lung cancer in underground iron ore miners. Since exposure to radon and quartz is often correlated, quartz exposure can be an important confounder.

  • 2.
    Bergenheim, Tommy
    et al.
    Umeå University, Faculty of Medicine, Pharmacology and Clinical Neuroscience, Neurosurgery.
    Malmström, Annika
    Bolander, Hans
    Michanek, Annika
    Stragliotto, Giuseppe
    Damber, Lena
    Umeå University, Faculty of Medicine, Radiation Sciences, Oncology.
    Björ, Ove
    Umeå University, Faculty of Medicine, Radiation Sciences, Oncology.
    Henriksson, Roger
    Umeå University, Faculty of Medicine, Radiation Sciences, Oncology.
    Registrering av primära hjärntumörer mått på nationell vårdkvalitet. Regionala skillnader avslöjade.2007In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 104, no 5, p. 332-341Article in journal (Refereed)
  • 3.
    Björ, Bodil
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Burström, Lage
    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, Oncology.
    Nathanaelsson, Lena
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Damber, Lena
    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.
    Fifty-year-follow-up of mortality among a cohort of iron-ore miners in Sweden, with specific reference to myocardial infarction mortality2009In: Occupational and Environmental Medicine, ISSN 1351-0711, E-ISSN 1470-7926, Vol. 66, no 4, p. 264-268Article in journal (Refereed)
    Abstract [en]

    Objectives: This study investigates both general mortality and mortality from myocardial infarction among men employed in iron-ore mines in Sweden.

    Methods: The mortality of employees (surface and underground workers) at the iron-ore mines in Malmberget and Kiruna, Sweden was investigated. The study cohort comprised men who had been employed for at least 1 year between 1923 and 1996. The causes of death were obtained from the national cause of death register from 1952 to 2001. Indirect standardised mortality ratios (SMR) were calculated for four main causes. Mortality specifically from myocardial infarction was also analysed.

    Results: 4504 deaths in the cohort gave an SMR for total mortality of 1.05 (95% CI 1.02 to 1.09). Mortality was significantly higher for lung cancer (SMR 1.73, 95% CI 1.52 to 1.97). There was an increased risk of injuries and poisonings (SMR 1.34, 95% CI 1.24 to 1.46) and respiratory diseases (SMR 1.14, 95% CI 1.00 to 1.28). There were 1477 cases of myocardial infarction, resulting in an SMR of 1.12 (95% CI 1.07 to 1.18). SMR was higher (1.35, 95% CI 1.22 to 1.50) for men aged ≤60 years than for those >60 years of age (1.06, 95% CI 1.00 to 1.13).

    Conclusions: Mortality from myocardial infarction was higher than expected. There was also an increased risk of death from injuries and poisonings, lung cancer and respiratory diseases, as well as higher general mortality. Our findings support the results of previous studies that there is an association between working in the mining industry and adverse health outcomes.

  • 4.
    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.

  • 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.
    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.

  • 6.
    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.

  • 7.
    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.

  • 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.
    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.

  • 9.
    Damber, Lena
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Lung cancer in males: an epidemiological study in northern Sweden with special regard to smoking and occupation1986Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    In a case-control study comprising 589 cases of male lung cancer in northern Sweden longitudinal data concerning occupations, employments and smoking habits were collected by questionnaires.

    Pipe smoking was as common as cigarette smoking and gave very similar relative risk. The pipe smoking cases, however, had significantly higher mean age and mean smoking years at the time of diagnosis than the cigarette smoking cases. In ex- smokers, the relative risk gradually decreased from 5 years after smoking cessation but this decrease was much less pronounced in ex-pipe smokers than in ex-cigarette smokers. High relative risks were obtained for small cell and squamous cell carcinomas. For adenocarcinoma the relative risk was considerably lower but still significantly increased. The population etiologic fraction attributable to smoking was about 80% in this series.

    Some occupational groups (underground miners, copper smelter workers, electricians and plumbers) exposed to previously known lung carcinogenic agents had considerably increased odds ratios, which persisted after adjustment for smoking. A slightly elevated odds ratio was observed in a group of blue collar workers potentially exposed to lung carcinogenic agents but this elevation generally disappeared after adjustment for smoking. For two specific subgroups, asphalt and concrete workers and pulp workers, the overrisk persisted after adjustment for smoking. Farmers and foresters had strikingly low odds ratios, which could only partly be explained by their more moderate smoking habits. The population etiologic fraction attributable to occupation was in the reported material assessed to 9 per cent.

    Professional drivers had higher average tobacco consumption than non-drivers, which explained the slightly increased crude odds ratio found for the occupational group as a whole. Smoking drivers in an upper age group (70 and over), however, had a high relative risk of lung cancer, while in a lower age group (under 70) no significant increase was found. The results in the older age group suggested a multiplicative effect between smoking and the occupational exposure.

    The study clearly verified the increased lung cancer risk in underground miners. An obvious dose-response relation was found with high risk after long time exposure. All analyses concerning underground miners suggested an interaction of a multiplicative type between underground mining and smoking in the causation of lung cancer. The cases of small cell carcinoma among the underground miners had shorter average latency time and in contrast to the other part of the material, shorter average age than the cases with epidermoid cancer.

  • 10. Hassler, Sven
    et al.
    Sjölander, Per
    Grönberg, Henrik
    Johansson, Robert
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Damber, Lena
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Cancer in the Sami population of Sweden in relation to lifestyle and genetic factors2008In: European Journal of Epidemiology, ISSN 0393-2990, E-ISSN 1573-7284, Vol. 23, no 4, p. 273-280Article in journal (Refereed)
    Abstract [en]

    The reindeer herding Sami of Sweden have low incidences of cancer. The aim of the present study was to investigate the cancer risk in a large cohort of Swedish Sami, containing Sami with different lifestyle and genetic Sami heritage. A cohort of 41,721 Sami identified in official national registers between 1960 and 1997, was divided into two sub-populations -- reindeer herding Sami (RS) and non-reindeer herding Sami (NRS). A demographically matched non-Sami reference population (NS) was used as standard when incidence and mortality ratios were calculated. Incidence and mortality data were obtained from the Swedish Cancer and Cause of Death Registers for the period 1961-2003. For Sami men, lower risks were found for cancers of the colon and prostate, and for malignant melanoma and non-Hodkins lymphoma, but higher for stomach cancer. The Sami women showed higher risks for cancers of the stomach and the ovaries, but lower risk for cancer of the bladder. The RS demonstrated lower relative cancer risks compared with the NRS. The lowest relative risk was found among the RS men, while the highest were observed among the NRS women. The RS men who had adopted a more westernized lifestyle showed a similar relative risk for prostate cancer as that of the NS living in the same region. Most of these differences in cancer risks could probably be ascribed to differences in lifestyle. It is concluded that the traditional Sami lifestyle contains elements, e.g. dietary contents and physical activity that may protect them from developing cancer.

  • 11.
    Jonsson, Håkan
    et al.
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Bergdahl, Ingvar A
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Åkerblom, Gustav
    Eriksson, Kåre
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Andersson, Kurt
    Kågström, Leif
    Järvholm, Bengt
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Damber, Lena
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Lung cancer risk and radon exposure in a cohort of iron ore miners in Malmberget, Sweden2010In: Occupational and Environmental Medicine, ISSN 1351-0711, E-ISSN 1470-7926, Vol. 67, no 8, p. 519-525Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: Lung cancer caused by radon in miners is a well-known risk. However, the risk estimates vary between studies and between mines. We have studied the dose response-relationship in a Swedish iron ore mine where two other studies have previously reached different risk estimates. As this mine has relatively low radon levels, the results are highly relevant for risk estimation in non-uranium underground mines.

    METHODS: A new cohort of 5486 male workers employed from 1923 to 1996 was established. Cumulative radon exposures were assessed based on a large number of measurements, including reconstructions of historical conditions. 122 lung cancer cases occurred during the follow-up period of 1958-2000.

    RESULTS: The average cumulative exposure in underground workers was 32 kBq year/m(3) (65 working level months (WLM)), experienced over 14.6 years. The excess RR (ERR) per kBq year/m(3) was 0.046 (95% CI 0.015 to 0.077; 0.022 ERR/WLM). Confounding by quartz may affect these results but appears to account only for 10-20% of the risk. The results for squamous cell and small cell lung cancer were 0.049 and 0.072, respectively. However, no increased risk was observed for adenocarcinoma (0.000 ERR per kBq year/m(3), 95% CI -0.017 to 0.017).

    CONCLUSION: Our overall risk estimate is about half of that found in the first Malmberget study but twice that found in the same cohort in the previously published pooled analysis. Radon did not increase the risk for adenocarcinoma in the lung.

  • 12. Jorgren, F.
    et al.
    Johansson, Robert
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Damber, Lena
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Lindmark, G.
    Anastomotic leakage after surgery for rectal cancer: a risk factor for local recurrence, distant metastasis and reduced cancer-specific survival?2011In: Colorectal Disease, ISSN 1462-8910, E-ISSN 1463-1318, Vol. 13, no 3, p. 272-283Article in journal (Refereed)
    Abstract [en]

    Aim The impact of anastomic leakage (AL) on the oncological outcome after anterior resection (AR) for rectal cancer is still controversial. We explored the impact of AL regarding local recurrence (LR), distant metastasis and overall recurrence (OAR). Overall and cancer-specific survival was analysed. Method Patients undergoing AR for rectal cancer with a registered AL between 1995 and 1997 and a control group were identified in the Swedish Rectal Cancer Registry. The medical records were retrieved for additional data and validation. Differences in the oncological outcome at 5-year follow-up were analysed with multivariate methods. Results After validation, 114 patients with AL and 136 control patients with locally radical surgery for tumours in tumour-node-metastasis stages I-III were analysed. There was no difference detected between patients with AL and control patients regarding rates of LR [8% (9 of 114) vs 9% (12 of 136); P = 0.97], distant metastasis [18% (20 of 114) vs 23% (31 of 136); P = 0.37] and OAR [19% (22 of 114) vs 28% (38 of 136); P = 0.15]. The 5-year cancer-specific survival was almost 80% in both groups. In multivariate analysis, AL was not a risk factor of LR, distant metastasis or OAR and had no impact on 5-year overall or 5-year cancer-specific survival. Irrespective of the occurrence of AL, preoperative radiotherapy (P = 0.055) and rectal washout (P = 0.046) reduced the LR rate, but did not influence survival. Conclusion Anastomotic leakage was not proved to be a risk factor of worse oncological outcome. Hence, additional adjuvant treatment or extended follow-up on the basis of the occurrence of AL after AR might not be justified.

  • 13. Jörgren, Fredrik
    et al.
    Johansson, Robert
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Damber, Lena
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Lindmark, Gudrun
    Oncological outcome after incidental perforation in radical rectal cancer surgery2010In: International Journal of Colorectal Disease, ISSN 0179-1958, E-ISSN 1432-1262, Vol. 25, no 6, p. 731-740Article in journal (Refereed)
    Abstract [en]

    Identification of risk factors of poor oncological outcome in rectal cancer surgery is of utmost importance. This study examines the impact of incidental perforation on the oncological outcome. Using the Swedish Rectal Cancer Registry, patients were selected who received major abdominal surgery for rectal cancer between 1995 and 1997 with registered incidental perforation. A control group was also selected for analysis of the oncological outcome after 5-year follow-up. Multivariate analysis was performed. Registry data were validated, and additional data were supplemented from medical records. After validation and exclusion of non-radically operated patients, 118 patients with incidental perforation and 155 controls in TNM stages I-III were included in the analysis. The rate of local recurrence (LR) [20% (23/118) vs. 8% (12/155) (p = 0.007)] was significantly higher among patients with perforation, whereas the rates of distant metastasis [27% (32/118) vs. 21% (33/155) (p = 0.33)] and overall recurrence (OAR) [35% (41/118) vs. 25% (38/155) (p = 0.087)] were not significantly different between the groups. Overall as well as cancer-specific 5-year survival rates were significantly reduced for the patients with perforation [44 vs. 64% (p = 0.002) and 66 vs. 80% (p = 0.026), respectively]. In the multivariate analysis, perforation was a significant risk factor of increased rates of LR and OAR as well as reduced 5-year overall and cancer-specific survival. Incidental perforation in rectal cancer surgery is an important risk factor of poor oncological outcome and should be considered in the discussion concerning postoperative adjuvant treatment as well as the follow-up regime.

  • 14. Jörgren, Fredrik
    et al.
    Johansson, Robert
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Damber, Lena
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Lindmark, Gudrun
    Risk factors of rectal cancer local recurrence: population-based survey and validation of the Swedish rectal cancer registry2010In: Colorectal Disease, ISSN 1462-8910, E-ISSN 1463-1318, Vol. 12, no 10, p. 977-986Article in journal (Refereed)
    Abstract [en]

    Aim: Despite advances in rectal cancer treatment, local recurrence (LR) remains a significant problem. To select high-risk patients for different treatment options aimed at reducing LR, it is essential to identify LR risk factors. Method: Local recurrence and survival rates of 4153 patients registered 1995-1997 in the Swedish Rectal Cancer Registry were analysed. LR risk factors were analysed by multivariate methods. For LR patients the registry was validated and additional data retrieved. Results: The 5-year overall and cancer-specific survival rates were 45% and 62% respectively. LR was registered in 326 (8%) patients. After R0-resections for tumours in TNM stages I-III, LR developed in 10% of tumours at 0-5 cm, 8% at 6-10 cm and 6% at 11-15 cm above the anal verge. Preoperative radiotherapy (RT) reduced the LR rate irrespective of height [0-5 cm: OR 0.50 (0.30-0.83), 6-10 cm: OR 0.42 (0.25-0.71), and 11-15 cm: OR 0.29 (0.13-0.64)]. Patients without preoperative RT had significantly higher LR risk after rectal perforation [OR 2.50 (1.48-4.24)], and almost significantly decreased LR risk when rectal washout was performed [OR 0.65 (0.43-1.00)]. Preoperative RT prolonged time to LR but did not significantly influence the survival among LR patients. LR was an isolated tumour manifestation in 103 (39%) patients with validated LR. Conclusion: Preoperative RT should be considered for rectal cancer also in the upper third of the rectum. Intraoperative perforation should be avoided, and rectal washout is indicated as valuable. Follow-up for the detection of isolated LR is important. Extended follow up should be considered for patients treated with RT.

  • 15. Jörgren, Fredrik
    et al.
    Johansson, Robert
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology. Regional Cancer Centre North, Umeå University.
    Damber, Lena
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology. Regional Cancer Centre North, Umeå University.
    Lindmark, Gudrun
    Validity of the Swedish Rectal Cancer Registry for patients treated with major abdominal surgery between 1995 and 19972013In: Acta Oncologica, ISSN 0284-186X, E-ISSN 1651-226X, Vol. 52, no 8, p. 1707-1714Article in journal (Refereed)
    Abstract [en]

    Background. Founded in 1995, the Swedish Rectal Cancer Registry (SRCR) is frequently used for rectal cancer research. However, the validity of the registry has not been extensively studied. This study aims to validate a large amount of registry data to assess SRCR quality.

    Material and methods. The study comprises 906 patients treated with major abdominal surgery registered in the SRCR between 1995 and 1997. SRCR data for 14 variables were scrutinized for validity against the medical records. Kappa's and Kendall's correlation coefficients for agreement between SRCR data and medical records data were calculated for 13 variables.

    Results. For 11 variables, concerning the tumor, neoadjuvant therapy, the surgical procedure, local radicality and TNM stage, data were missing in 5% or less of the registrations; for the remaining three variables, anastomotic leakage, local and distant recurrence, data were missing in 13-38%. For the variables surgery performed or not and type of surgical procedure, no data were missing. Erroneous registrations were found in less than 10% of all variables; for the variables preoperative chemotherapy and surgery performed or not, all registrations were correct. For the variables concerning neoadjuvant therapy, local radicality according to the surgeon as well as the pathologist and distant metastasis, the false-positive or- negative registrations were equally distributed, and for the variables rectal washout, rectal perforation, anastomotic leakage and local recurrence there was a discrepancy in distribution. The correlation coefficient for 12 variables ranged from 0.82 to 1.00, and was 0.78 for the remaining variable.

    Conclusion. The validity of the SRCR was good for the initial three registry years. Thus, research based on SRCR data is reliable from the beginning of the registry's use.

  • 16. Lubin, Jay H.
    et al.
    Adams, M. Jacob
    Shore, Roy
    Holmberg, Erik
    Schneider, Arthur B.
    Hawkins, Michael M.
    Robison, Leslie L.
    Inskip, Peter D.
    Lundell, Marie
    Johansson, Robert
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Kleinerman, Ruth A.
    de Vathaire, Florent
    Damber, Lena
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Sadetzki, Siegal
    Tucker, Margaret
    Sakata, Ritsu
    Veiga, Lene H. S.
    Thyroid Cancer Following Childhood Low-Dose Radiation Exposure: A Pooled Analysis of Nine Cohorts2017In: Journal of Clinical Endocrinology and Metabolism, ISSN 0021-972X, E-ISSN 1945-7197, Vol. 102, no 7, p. 2575-2583Article in journal (Refereed)
    Abstract [en]

    Context: The increased use of diagnostic and therapeutic procedures that involve radiation raises concerns about radiation effects, particularly in children and the radiosensitive thyroid gland.

    Objectives: Evaluation of relative risk (RR) trends for thyroid radiation doses <0.2 gray (Gy); evidence of a threshold dose; and possible modifiers of the dose-response, e.g., sex, age at exposure, time since exposure.

    Design and Setting: Pooled data from nine cohort studies of childhood external radiation exposure and thyroid cancer with individualized dose estimates, ≥1000 irradiated subjects or ≥10 thyroid cancer cases, with data limited to individuals receiving doses <0.2 Gy.

    Participants: Cohorts included the following: childhood cancer survivors (n = 2); children treated for benign diseases (n = 6); and children who survived the atomic bombings in Japan (n = 1). There were 252 cases and 2,588,559 person-years in irradiated individuals and 142 cases and 1,865,957 person-years in nonirradiated individuals.

    Intervention: There were no interventions.

    Main Outcome Measure: Incident thyroid cancers.

    Results: For both <0.2 and <0.1 Gy, RRs increased with thyroid dose (P < 0.01), without significant departure from linearity (P = 0.77 and P = 0.66, respectively). Estimates of threshold dose ranged from 0.0 to 0.03 Gy, with an upper 95% confidence bound of 0.04 Gy. The increasing dose–response trend persisted >45 years after exposure, was greater at younger age at exposure and younger attained age, and was similar by sex and number of treatments.

    Conclusions: Our analyses reaffirmed linearity of the dose response as the most plausible relationship for “as low as reasonably achievable” assessments for pediatric low-dose radiation-associated thyroid cancer risk.

  • 17.
    Mogren, Ingrid
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology. Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Malmer, Beatrice
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Tavelin, Björn
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Damber, Lena
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Reproductive factors have low impact on the risk of different primary brain tumours in offspring2003In: Neuroepidemiology, ISSN 0251-5350, E-ISSN 1423-0208, Vol. 22, no 4, p. 249-254Article in journal (Refereed)
    Abstract [en]

    Objectives: The aim of our study was to investigate whether reproductive factors influence the risk of primary brain tumours (PBT) in offspring. Methods: Data on all deliveries in two Swedish counties from 1955 to 1990 were extracted from two birth registries. The follow-up period closed at the end of 1994, with subjects followed up to early middle age. Incidence rates of malignancy for 1958-1994 were obtained from the Swedish Cancer Registry. Standardised incidence ratios (SIR) and relative risks were calculated for astrocytomas, primitive neuroectodermal tumour, ependymoma and meningiomas in offspring. Results: Few associations were detected. High birth weight indicated an increased risk for astrocytomas grade I and II for all primary brain tumours, and the risk was close to significance for astrocytomas grade I-II (SIR = 3.64; CI = 0.98-9.31). For children under 15 years of age the risk for astrocytomas grade I and II was further increased (SIR = 4.44; Cl = 1.19-11.38). Conclusions:A consistent pattern of non-association indicated a low impact of intrauterine environment on the future development of primary brain tumours in offspring up to early middle age.

  • 18. Påhlman, Lars
    et al.
    Bohe, Måns
    Cedermark, Björn
    Dahlberg, Michael
    Lindmark, Gudrun
    Sjödahl, Rune
    Öjerskog, Björn
    Damber, Lena
    Umeå University, Faculty of Medicine, Radiation Sciences, Oncology.
    Johansson, Robert
    Umeå University, Faculty of Medicine, Radiation Sciences, Oncology.
    The Swedish rectal cancer registry.2007In: British Journal of Surgery, ISSN 0007-1323, Vol. 94, no 10, p. 1285-1292Article in journal (Refereed)
  • 19.
    Stattin, Pär
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Urology and Andrology.
    Sandin, Fredrik
    Ortqvist, David
    Damber, Lena
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Holmberg, Erik
    Cederberg, Hakan
    Lambe, Mats
    ONLINE REPORT IN REAL TIME FROM THE NATIONAL PROSTATE CANCER REGISTER (NPCR) OF SWEDEN, A NEW AND EFFICIENT TOOL FOR QUALITY ASSURANCE2014In: BMJ Quality and Safety, ISSN 2044-5415, E-ISSN 2044-5423, Vol. 23, no 4, p. 350-350Article in journal (Other academic)
  • 20. Veiga, Lene H. S.
    et al.
    Holmberg, Erik
    Anderson, Harald
    Pottern, Linda
    Sadetzki, Siegal
    Adams, M. Jacob
    Sakata, Ritsu
    Schneider, Arthur B.
    Inskip, Peter
    Bhatti, Parveen
    Johansson, Robert
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Neta, Gila
    Shore, Roy
    de Vathaire, Florent
    Damber, Lena
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Kleinerman, Ruth
    Hawkins, Michael M.
    Tucker, Margaret
    Lundell, Marie
    Lubin, Jay H.
    Thyroid Cancer after Childhood Exposure to External Radiation: An Updated Pooled Analysis of 12 Studies2016In: Radiation Research, ISSN 0033-7587, E-ISSN 1938-5404, Vol. 185, no 5, p. 473-484Article in journal (Refereed)
    Abstract [en]

    Studies have causally linked external thyroid radiation exposure in childhood with thyroid cancer. In 1995, investigators conducted relative risk analyses of pooled data from seven epidemiologic studies. Doses were mostly <10 Gy, although childhood cancer therapies can result in thyroid doses >50 Gy. We pooled data from 12 studies of thyroid cancer patients who were exposed to radiation in childhood (ages <20 years), more than doubling the data, including 1,070 (927 exposed) thyroid cancers and 5.3 million (3.4 million exposed) person-years. Relative risks increased supralinearly through 2-4 Gy, leveled off between 10-30 Gy and declined thereafter, remaining significantly elevated above 50 Gy. There was a significant relative risk trend for doses <0.10 Gy (P < 0.01), with no departure from linearity (P = 0.36). We observed radiogenic effects for both papillary and nonpapillary tumors. Estimates of excess relative risk per Gy (ERR/Gy) were homogeneous by sex (P = 0.35) and number of radiation treatments (P = 0.84) and increased with decreasing age at the time of exposure. The ERR/Gy estimate was significant within ten years of radiation exposure, 2.76 (95% CI, 0.94-4.98), based on 42 exposed cases, and remained elevated 50 years and more after exposure. Finally, exposure to chemotherapy was significantly associated with thyroid cancer, with results supporting a nonsynergistic (additive) association with radiation.

  • 21. Veiga, Lene H. S.
    et al.
    Lubin, Jay H.
    Anderson, Harald
    de Vathaire, Florent
    Tucker, Margaret
    Bhatti, Parveen
    Schneider, Arthur
    Johansson, Robert
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Inskip, Peter
    Kleinerman, Ruth
    Shore, Roy
    Pottern, Linda
    Holmberg, Erik
    Hawkins, Michael M.
    Adams, M. Jacob
    Sadetzki, Siegal
    Lundell, Marie
    Sakata, Ritsu
    Damber, Lena
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Neta, Gila
    Ron, Elaine
    A Pooled Analysis of Thyroid Cancer Incidence Following Radiotherapy for Childhood Cancer2012In: Radiation Research, ISSN 0033-7587, E-ISSN 1938-5404, Vol. 178, no 4, p. 365-376Article in journal (Refereed)
    Abstract [en]

    Childhood cancer five-year survival now exceeds 70-80%. Childhood exposure to radiation is a known thyroid carcinogen; however, data are limited for the evaluation of radiation dose-response at high doses, modifiers of the dose-response relationship and joint effects of radiotherapy and chemotherapy. To address these issues, we pooled two cohort and two nested case-control studies of childhood cancer survivors including 16,757 patients, with 187 developing primary thyroid cancer. Relative risks (RR) with 95% confidence intervals (CI) for thyroid cancer by treatment with alkylating agents, anthracyclines or bleomycin were 3.25 (0.9-14.9), 4.5 (1.4-17.8) and 3.2 (0.8-10.4), respectively, in patients without radiotherapy, and declined with greater radiation dose (RR trends, P = 0.02, 0.12 and 0.01, respectively). Radiation dose-related RRs increased approximately linearly for <10 Gy, leveled off at 10-15-fold for 10-30 Gy and then declined, but remained elevated for doses >50 Gy. The fitted RR at 10 Gy was 13.7 (95% CI: 8.0-24.0). Dose-related excess RRs increased with decreasing age at exposure (P < 0.01), but did not vary with attained age or time-since-exposure, remaining elevated 25+ years after exposure. Gender and number of treatments did not modify radiation effects. Thyroid cancer risks remained elevated many decades following radiotherapy, highlighting the need for continued follow up of childhood cancer survivors. (C) 2012 by Radiation Research Society

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