Ann Epidemiol Research Articles

Corrigendum to “Calculating risk and prevalence ratios and differences in R: Developing intuition with a hands-on tutorial and code” [Ann Epidemiol 86 (2023) 104–109]

Corrigendum to “Calculating risk and prevalence ratios and differences in R: Developing intuition with a hands-on tutorial and code” [Ann Epidemiol 86 (2023) 104–109]

Improving Transparency of Decision Models Through the Application of Decision Analytic Models with Omitted Objects Displayed (DAMWOOD).

The coronavirus disease 2019 (COVID-19) pandemic has increased public awareness of the influence of epidemiological and economic decision models on public policy decisions. Alongside this is an increased scrutiny on the development, analysis, reporting and utilisation of decision models for public policy making. Therefore, it is important that model developers can clearly explain and justify to all stakeholders what is included and excluded from a model developed to support decision-making, to both improve transparency and trust in decision-making. Our aim is to provide tools for improving communication between modellers and decision-makers, leading to improved transparency in decision-making. To do so, we extend the recently described directed acyclic graphs with omitted objects displayed (DAGWOOD) approach from Haber et al. (Ann Epidemiol 68:64-71, 2022) to decision analytic models, giving the decision analytic models with omitted objects displayed (DAMWOOD) approach. DAMWOOD is a framework for the identification of objects omitted from a decision model, as well as for consideration of the effects of omissions on model outcomes. Objects omitted from a decision model are classed as either an exclusion (known and unknown confounders), misdirection (alternative model pathways) or structure (e.g. model type, methods for estimating relationships between objects). DAMWOOD requires model developers to use explicit statements and provide illustration of included and omitted objects, supporting communication with model users and stakeholders, allowing them to provide input and feedback to modellers about which objects to include or omit in a model. In developing DAMWOOD, we considered two challenges we encountered in modelling for pandemic policy response. First, the scope of the decision problem is not always made sufficiently explicit by decision-makers, requiring modellers to intuit which policy options should be considered, and/or which outcomes should be considered in their evaluation. Second, there is rarely sufficient transparency to ensure stakeholders can see what is included in models and why. This limits stakeholders' ability to advocate to decision-makers for the prioritisation of specific outcomes and challenge the model results. To illustrate the application of DAMWOOD, we apply it to a previously published COVID-19 vaccine allocation optimisation model. The DAMWOOD diagrams illustrate the ways in which it is possible to improve the communication of model assumptions. The diagrams make explicit which outcomes are omitted and provide information on the expected impact of the omissions on model results. We discuss the usefulness of DAMWOOD for framing the decision problem, communicating the model structure and results and engaging with those making and affected by the decisions the model is developed to inform.

Part I: Interactive case: Menopause

Part I: Interactive case: Menopause

Prevelance of Common Aeroallergens in Allergic Rhinitis and its Correlation with Bronchial Asthma: A Study on 798 Patients by Skin Prick Test.

Allergic rhinitis affects 30% of the Indian population (Dey et al. in Int Arch Allergy Immunol 178:60-65, 2019). Patients can be sensitive to single or multiple allergens. Polysensitization is more common (Bousquet et al. in Ann Epidemiol 20:797-803, 2010; Arbes et al. in J Allergy Clin Immunol 116:377-383, 2005). Sensitization to multiple allergens may have a role in the severity and the association of Asthma in such patients. A total of 798 patients with allergic rhinitis (SFAR ≥ 7) were included. Disease severity and associated symptoms were evaluated using questionnaire. Each patient underwent a Skin prick test with an allergen panel of 35 allergens each (Annesi-Maesano et al. in Allergy 57:107-114, 2002) and the results were evaluated to study the association of asthma and severity of Allergic rhinitis. Data consisting of 389 (48.7%) males and 409 (51.3%) females were assessed. A total of 82.2% of the study population of symptomatic patients were sensitized to at least one of the allergens. Seventy patients (8.78%) had associated asthma. Forty-four patients were polysensitized and fifteen were mono sensitized. Among polysensitized patients, 36 patients had sensitization to at least 6 different allergens. Dermatophagoides pteronyssinus was the most common allergen among asthma patients. This study provides a thorough knowledge of locally prevalent aeroallergens which is essential for the prompt diagnosis and treatment of allergic patients. Skin prick test can be a non-invasive vital tool in analyzing patterns of allergen exposure, the prevalence of allergen, sensitizing potential of different allergens in that specific geographic area.

Anabolic-androgenic steroids: Considerations for forensic psychiatry, sports psychiatry, and the law

Anabolic-androgenic steroids: Considerations for forensic psychiatry, sports psychiatry, and the law

Toward Greater Pre-exposure Prophylaxis Equity: Increasing Provision and Uptake for Black and Hispanic/Latino Individuals in the U.S.

Pre-exposure prophylaxis (PrEP) is highly effective at preventing HIV acquisition and is a critical tool in the Ending the HIV Epidemic in the U.S. initiative. However, major racial and ethnic disparities across the pre-exposure prophylaxis continuum, secondary to structural inequities and systemic racism, threaten progress. Many barriers, operating at the individual, network, healthcare, and structural levels, impede PrEP access and uptake within Black and Hispanic/Latino communities. This review provides an overview of those barriers and the innovative and collaborative solutions that health departments, healthcare organizations, and community partners have implemented to increase PrEP provision and uptake among disproportionately affected communities. Promising strategies at the individual and network levels focus on increasing patient support throughout the PrEP continuum, positioning and training community members to expand knowledge of and interest in PrEP, and leveraging mobile technologies to support PrEP uptake. Healthcare-level solutions include expanding the venues and types of healthcare professionals that can provide PrEP, and structural- and policy-level options focus on financial assistance programs and health insurance expansion. Key research gaps include demonstrating that pilot studies and interventions remain effective at scale and across varied contexts. Although the last 2 decades have provided effective tools to end the HIV epidemic, realizing this vision for the U.S. will require addressing persistent and pervasive HIV-related disparities in Black and Hispanic/Latino communities. Federal, state, and local partners should expand efforts to address longstanding health and structural inequities and partner with disproportionately affected communities to rapidly expand PrEP scale-up.

Pre-exposure Prophylaxis Uptake, Adherence, and Persistence: A Narrative Review of Interventions in the U.S.

Since 2012, HIV pre-exposure prophylaxis (PrEP) has been available to prevent HIV transmission; yet, uptake, adherence, and persistence to PrEP have been suboptimal. This narrative review examines the latest interventions and programs to improve all 3 stages of PrEP adherence and reviews ongoing studies to promote effective PrEP use. From 2017 to 2020, a total of 20 studies analyzed different individual- and structural-level approaches to increase PrEP adherence, including behavior change interventions, technology-based interventions (e.g., short message service messages and mobile applications), and alternate delivery strategies (e.g., pharmacy-based PrEP, integration with other services, and home delivery). Most published interventions involved men who have sex with men, although 3 assessed women (2 transgender, 1 cisgender). Randomized, controlled data support 3 behavioral change interventions and 1 technology-based intervention. Alternate delivery strategies seem promising, although more robust study designs are generally needed. In addition, data on the alignment of ongoing HIV risk and PrEP persistence (i.e., prevention-effective adherence) were limited. The authors also identified 20 ongoing studies that are promoting PrEP adherence. Future work should be inclusive of all at-risk groups in the U.S., including African American and Latinx heterosexual populations and people who inject drugs. Proven and promising approaches may work well in combination and may also need to be adapted with the introduction of long-acting pre-exposure prophylaxis formulations. Collectively, this body of work indicates considerable progress toward understanding the role PrEP adherence will play in Ending the HIV Epidemic in the U.S. that will be bolstered by the outcomes of ongoing trials.

Adolescence and Gender Equality in Health

Adolescence and Gender Equality in Health

Abstract 4240: Rare candidate variants shared among affected family members in the African American Hereditary Prostate Cancer Study families

Abstract Purpose: Prostate cancer is the most common cancer in males, but also exhibits a ∼1.5-2-fold higher incidence in African American men compared with whites. Epidemiologic evidence supports a large heritable contribution to prostate cancer, with over 100 susceptibility loci identified to date that can explain ∼33 % of the familial risk. A portion of the undefined risk may be due to rare susceptibility variants. The African American Hereditary Prostate Cancer (AAHPC) Study, established in 1997, enrolled 77 AA families from seven clinical sites across the United States (Ann Epidemiol, 2000). The aim of this study is to identify rare, predictive, deleterious variants through exome sequencing of 99 cases from 26 families selected from the AAHPC families (2 to 3 affected men sequenced per family) and three female 1000 Genome controls. Methods: To explore the contribution of rare variation in coding regions of 38 known cancer-causing genes to prostate cancer risk (PCa), we sequenced the exomes of 99 AAHPC cases at a mean coverage of 30x. Post-variant calling quality control (QC) was implemented using Golden Helix SVS 8 software with filters set for removal of variants with Read Depth >10, Quality Score >10, and Quality Score: Read Depth Ratio > 0.5. Mendelian inconsistency was checked using PLINK. Prioritization of all candidate genes/variants were evaluated using online databases including 1000 Genomes and ANNOVAR for non-reference allele frequency and predictions of functional impact. Conclusions. Through exome sequencing of 99 AAHPC cases and 3 female 1000 Genome controls, we identified 37 non-synonymous single nucleotide variants that are considered damaging by at least one predictive scoring tool in our 38 candidate genes. However, most of these variants were common and thus unlikely to be causal. We observed three rare variants that were considered damaging by three predictive scoring tools in two known PCa genes, PCNT and ZFHX3. These 3 variants were each observed in a single different family (in 1 of 3 affected individuals). Interesting rare candidate variants (MAF ≤ 0.01) rs190517526 & rs114692729 were found in known cancer susceptibility loci (CD82 and EZH2). The CD82 variant was observed in all 3 sequenced affecteds in one family and the EZH2 variant was observed in 2 of 3 sequenced affecteds in a different family. These predicted damaging variants in these four genes represent potentially novel causal candidates for some of the 26 AAHPC families sequenced here. Future work will carefully analyze the remainder of the genome in the other 21 sequenced families including planned sequencing of additional family members. Citation Format: Deyana D. Lewis, Shukmei Wong, Angela S. Baker, Isaac Powell, John D. Carpten, Joan E. Bailey-Wilson, Cheryl Cropp. Rare candidate variants shared among affected family members in the African American Hereditary Prostate Cancer Study families [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 4240.

PTU-011 Small Bowel Malignancy in Patients Undergoing Capsule Endoscopy in A Tertiary Care Academic Institution

Introduction Cancer of the small-bowel (SB) is rare accounting for Methods Retrospective study; the records of all patients who underwent SBCE at our centre from Mar 2005 – Oct 2015 were reviewed; we retrieved those whose CEs were reported as suggestive of neoplasia. Further data was gathered on preceding and subsequent investigations, management and outcome of these patients. Results From a total of 1949 CE studies (1082 PillCamTM/867 MiroCamTM), SB neoplasia was diagnosed in 7 patients (0.36%; 2 F/5 M; median age 50, range 34–67). Two had lymphoma, 2 gastrointestinal stromal tumours (GIST), 2 duodenal adenocarcinomas, 1 jejunal metastasis from a sarcomatoid lung tumour. In these patients, CE was performed for: iron-deficiency anaemia (IDA) (n = 5), diarrhoea (n = 1) & suspicion of SB lymphoma (n = 1). 6/7 patients had prior negative bidirectional GI endoscopies; 1 had a normal gastroscopy. Prior to CE, two patients had abdominal USS, 4 had CT scan, 2 had SB follow-through and 1 had a bone marrow aspirate. Two patients had capsule retention; one was removed with a gastroscope, the other with push enteroscopy. All 7 patients had further investigations after CE. Six had a chest, abdomen & pelvis CT scan for staging. Two patients had push enteroscopy, both of whom were diagnosed with duodenal adenocarcinoma. One had double balloon enteroscopy (DBE), two had colonoscopy, two had UGIE; there was one abdominal USS and one bone marrow aspirate. Four pts underwent SB resection. Following resection, 1 patient with GIST had imatinib chemotherapy. Of the two individuals with duodenal adenocarcinoma, one underwent gastroenterostomy and the other had an elective Whipple procedure. Four patients passed away. Two remain under follow up with oncology and one with the GI team. Conclusion SB cancers are rare and our experience is in agreement with other studies. The median age of 50 indicates that SB malignancy is more common in relatively younger patients. Unexplained iron deficiency anaemia was the main presenting complaint in our patients which triggered further investigation despite negative bidirectional endoscopies. CE is effective in picking up SB neoplasia where other imaging modalities have failed. References 1 Schottenfeld D, Beebe-Dimmer JL, Vigneau FD. The epidemiology and pathogenesis of neoplasia in the small intestine. Ann Epidemiol 2009;19:58–69. 2 Pennazio M, Rondonotti E, de Franchis R. Capsule endoscopy in neoplastic diseases. World J Gastroenterol 2008;14:5245–53. 3 Pennazio M, Spada C, Eliakim R, et al. Small-bowel capsule endoscopy and device-assisted enteroscopy for diagnosis and treatment of small-bowel disorders: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy 2015;47:352–86. 4 Rondonotti E, Pennazio M, Toth E, et al. Small-bowel neoplasms in patients undergoing video capsule endoscopy: a multicenter European study. Endoscopy 2008;40:488–95. Disclosure of Interest C. Johnston: None Declared, D. Yung: None Declared, A. Koulaouzidis Grant/research support from: ESGE- Given®Imaging Research grant 2011, J. Plevris: None Declared

Chronic Disabling Fatigue in Adolescents

Chronic Disabling Fatigue in Adolescents

Multiple-allergen and single-allergen immunotherapy strategies in polysensitized patients: Looking at the published evidence

In allergen immunotherapy there is debate as to whether polysensitized patients are best treated with many allergens simultaneously (chosen according to the sensitization profile, a predominantly North American approach) or a single allergen (chosen according to the most clinically problematic allergy, a predominantly European approach). In patients seeking treatment for moderate-to-severe respiratory allergies, polysensitization is more prevalent (range, 50% to 80%) than monosensitization in both the United States and Europe. Safe, effective, single-allergen preparations will most likely have been tested in polysensitized patients. In robust, large-scale clinical trials of grass pollen sublingual tablets, polysensitized patients benefited at least as much from allergen immunotherapy as monosensitized patients. A recent review of multiallergen immunotherapy concluded that simultaneous delivery of multiple unrelated allergens can be clinically effective but that there was a need for additional investigation of therapy with more than 2 allergen extracts (particularly in sublingual allergen immunotherapy). More work is also required to determine whether single-allergen and multiallergen immunotherapy protocols elicit distinct immune responses in monosensitized and polysensitized patients. Sublingual and subcutaneous multiallergen immunotherapy in polysensitized patients requires more supporting data to validate its efficacy in practice.

Influence of vitamin D levels on bone mineral density and osteoporosis

BACKGROUND AND OBJECTIVES:The effects of vitamin D on bone mass remain to be understood. This study was conducted with the objective of evaluating the influence of 25-hydroxyvitamin D (25OHD) levels on bone mineral density (BMD) among Saudi nationals.DESIGN AND SETTING:Cross-sectional study carried out at university hospital from 1 February 2008 to 31 May 2008.SUBJECTS AND METHODS:Healthy Saudi men and women in the peak bone mass (PBM) age group and those aged ≥50 years were recruited from the outpatient department of King Fahd University Hospital, Al Khobar, Saudi Arabia, between February 1, 2008, and May 31, 2008. Patient age and sex were documented, and body mass index was calculated. Hematological, biochemical, and serum 25OHD tests were performed. BMD was determined by dual-energy x-ray absorptiometry of the upper femur and lumbar spine. Patients were divided into three groups, based on their 25OHD level.RESULTS:Data from 400 patients were analyzed. Among individuals with a normal 25OHD level, 50% of women and 7% of men in the PBM age group and 26.4% of women and 49.2% of men aged ≥50 years had low bone mass. In patients with 25OHD insufficiency, 84.2% of women and 88.9% of men in the PBM age group and 83.3% of women and 80% of men aged ≥50 years had low bone mass. Results for patients with 25OHD deficiency revealed that none of the men and women in the PBM age group or ≥50 years old had normal BMD. Significant positive correlations between 25OHD level and BMD and significant negative correlations with parathyroid hormone were shown in most of the groups.CONCLUSIONS:This study showed that the vitamin D level significantly influences BMD reading among Saudi individuals. Evaluation and treatment of hypovitaminosis D should be considered during management of low bone mass.

Abstract B84: Lower vitamin D status among black Americans may explain much of the racial disparities in cancer outcomes

Abstract The purpose of this study is to examine published data on disparities in cancer survival rates to see whether disparities in serum 25-hydroxyvitamin D [25(OH)D] levels could explain a significant portion of the findings. African-Americans generally have higher cancer incidence rates and lower cancer survival rates than White-Americans. Many studies have found that after adjusting for cancer stage at time of diagnosis and quality of treatment, race is the only factor that accounts for the disparity. Numerous ecological and a reasonable number of observational studies have found solar ultraviolet-B doses, vitamin D intake, and/or prediagnostic serum 25-hydroxyvitamin D [25(OH)D] levels inversely correlated with incidence and/or mortality rates for about 20 types of cancer (1). African-Americans have lower population mean serum 25(OH)D levels in the United States: 16 ng/mL vs. 26 ng/mL (2). Based on observational studies of prediagnostic serum 25(OH)D and incidence rates for breast and colorectal cancer (3) and cardiovascular disease (4,5), as well as all-cause mortality rates (4), this difference seems to account for the approximately 25% increased all-cause mortality rate for African-Americans compared to white Americans (6). The journal literature will be searched for papers published in the United States reporting disparities in cancer survival after accounting for other factors. Attention will be given to examining differences for the well-known vitamin D-sensitive cancers and other types of cancer. One recent paper reported that the well-documented vitamin D-sensitive cancers: bladder, breast, colorectal, esophageal, uterine, and, likely, head and neck, have the highest difference in black-white survival rates, while those cancers with uncertain relation to vitamin D: liver, lung, pancreatic, and prostate cancer, have much lower differences (7). Thus, disparities in serum 25(OH)D levels likely explain much of the disparities in cancer outcomes attributed to African-American race. Increasing serum 25(OH)D levels for all but especially African-Americans to above 40 ng/mL appears to be the most efficient way to reduce cancer incidence and mortality rates in general and disparities in particular.

O-029 Oral contraceptive and hormone replacement therapy in women with cerebral aneurysms

Background and purposeAlthough ruptured cerebral aneurysms are more common in postmenopausal women than in premenopausal women, or men, the putative hormonal role that underlies this disparity is poorly understood. Prior...

Prediction Models That Include Genetic Data

Can alternative modeling approaches that integrate genetic data help to improve the prediction of risk for common diseases? In this issue of Circulation: Cardiovascular Genetics , Stengard et al1 set out to answer this question with regard to several genetic variations of the APOE gene and risk for ischemic heart disease (IHD). In their study, they included 3686 women and 2772 men with no medical history of IHD from the Copenhagen City Heart Study and sought to correlate IHD events to risk factors such as abnormal lipid levels, hypertension, diabetes, smoking history, and various APOE genotype data during a mean of 6.5 years of follow-up. Article see p 22 The traditional statistical approach to this analysis would be to use Cox proportional hazard modeling to map the hazard of developing IHD to a linear combination of significant risk factors. Stengard et al adopted an interesting alternative procedure that is consistent with the intuition that risk factors may have different effects in subjects with different unmeasured exposures (for example different genetic backgrounds and/or other unknown variables). Therefore, rather than looking for the risk factors that have a homogeneous effect on the hazard for IHD, the authors used the rule induction algorithm PRIM to discover subgroups of subjects with varying combinations of phenotypic risk factors for IHD and APOE alleles e2, e3, and e4. They then used the PRIM again to further segregate these subgroups according to additional genotypes in …

Institutionalized ghosting: policy contexts and language use in erasing the person with Alzheimer's.

The ordinary social engagement of human life would not usually be considered an arena for language policy. Yet clinical evidence mounts that social interaction improves our lives as we age. Since social engagement decreases cardiovascular risks (Ramsay et al. in Ann Epidemiol 18:476-483, 2008) and delays memory loss among those living in communities (Ertel et al. in Am J Public Health 98:1215-1220, 2008), practices that prohibit social interaction threaten human well-being. For persons who have Alzheimer's disease (AD), social interaction continues to play an integral part in cognitive function and delays in memory loss, according to a longitudinal study of social networks (Bennett et al. in Lancet Neurol 5:406-412, 2007). Increasingly, person-centered care that promotes social engagement for those with AD is promoted as an institutional policy to improve outcomes of dementia care (Edvardsson et al. in Int Psychogeriatr 20:764-776, 2008). Yet the training of caregivers may neither reflect person-centered care nor include attention to communication, suggesting covert policies in practice.

Commentary: How does 'insurance' improve equity in health?

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Reply

We thank the editors for selecting our study for discussion and appreciate the reviewer's comment. First, we would like to highlight that our data do not conflict with recent studies by Lee et al (Hepatology 2008;47:880–887) and others showing a relationship between elevated alanine aminotransferase (ALT) and mortality. Rather, our data suggest that if studies of mortality were to incorporate multiple measurements of liver enzymes to minimize the substantial amount of misclassification in the normal range, the observed associations would be even stronger (Am J Epidemiol 1988;127:377–386; Ann Epidemiol 1998;8:56–63). We agree that, because the NHANES III sera for the biochemistry profile was stored at −20°C and then thawed at room temperature there could have been degradation of the aminotransferases activities. However, this was true for both examinations and, to our knowledge, the short-term variability of these tests would not be influenced by the storage conditions of the samples. Furthermore, the method (analytical) coefficient of variations were small—3.2% for ALT, 3.4% for aspartate aminotransferase (AST), 3.0% for total bilirubin, 1.7% for γ-glutamyltransferase, and 6.5% for alkaline phosphatase (Clin Chem 2005:51:450–452). In addition, our data are consistent with prior studies which have shown that elevated liver tests (ALT) among asymptomatic individuals return to normal in approximately 33% of individuals (Ann Intern Med 1987;107:137–144). Finally, although it may be true that fasting status and diurnal variation can influence the levels of liver tests, our findings did not vary by fasting status. We agree that the decision to undertake additional extensive work-up in the clinical setting depends on 3 factors: (1) findings in the medical history, (2) findings on the physical examination, and (3) the levels of ALT or AST. Indeed, in our study the higher the level of the enzyme, the less likely it was to return to normal. The American Association for the Study of Liver Disease recently endorsed this conclusion, recommending specifically that a serum ALT level <5 times the upper limit of the normal range should be rechecked before an extensive workup in undertaken (Hepatology 2008;47:1363–1369). Our data highlight the utility of routine retesting of liver enzyme levels in clinical practice. Clearly, the art of medicine is in deciding when the likelihood of significant liver disease is high enough to warrant further testing and when simply repeating the test is the better approach. Clinical Implications of Short-Term Variability in Liver Function Test ResultsGastroenterologyVol. 135Issue 3PreviewLazo M, Selvin E, Clark JM. (Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomburg School of Public Health, Baltimore, Maryland). Brief communication: Clinical implications of short-term variability in liver function test results. Ann Intern Med 2008;148;348–352. Full-Text PDF

Periodontal diseases and cancer

Chronic periodontitis and aggressive periodontitis are inflammatory forms of periodontal disease (figure) caused by microorganisms from plaque biofilm that forms around the teeth. Chronic inflammation of the periodontium results in continuous release of cytokines, prostaglandins, bacterial toxins, and many other destructive enzymes from cells in the area. This chronic process leads to formation of periodontal pockets and progressive destruction of connective tissue and alveolar bone. 1 Pihlstrom B Michalowicz B Johnson N Periodontal diseases. Lancet. 2005; 366: 1809-1820 Summary Full Text Full Text PDF PubMed Scopus (2535) Google Scholar Chronic periodontitis and aggressive periodontitis are the most common causes of tooth loss in adults. Many studies have shown an association between periodontal diseases and systemic manifestations of cardiovascular disease, diabetes, and premature low-weight birth. 1 Pihlstrom B Michalowicz B Johnson N Periodontal diseases. Lancet. 2005; 366: 1809-1820 Summary Full Text Full Text PDF PubMed Scopus (2535) Google Scholar However, there is no evidence for a causal effect. A recent study assessed periodontitis and premature death in young adults in urban regions of Sweden. 2 Söder B Jin L Klinge B Söder P Periodontitis and premature death: a 16-year longitudinal study in a Swedish urban population. J Periodontal Res. 2007; 42: 361-366 Crossref PubMed Scopus (49) Google Scholar The findings showed that young individuals with periodontitis and missing molar teeth, compared with those with no periodontitis, had increased risk of premature death because of cancer, circulatory, and digestive diseases. In this issue of The Lancet Oncology, Michaud and colleagues 3 Michaud DS Liu Y Meyer M Giovannucci E Joshipura K Periodontal disease, tooth loss, and cancer risk in male health professionals: a prospective cohort study. Lancet Oncol. 2008; 9: 550-558 Summary Full Text Full Text PDF PubMed Scopus (261) Google Scholar present important data from a prospective study that shows an increase in cancer risk in a large population of well-characterised US male health professionals who self-reported having periodontal disease with alveolar bone loss. Their findings showed a significant association between periodontal disease and haematological, kidney, and pancreatic cancer. The cancer risk persisted in individuals who never smoked. In a previous study, 4 Michaud D Joshipura K Giovannucci E Fuchs C A prospective study of periodontal disease and pancreatic cancer in US male health professionals. J Natl Cancer Inst. 2007; 99: 171-175 Crossref PubMed Scopus (205) Google Scholar Michaud and co-workers suggested an association between periodontal disease and pancreatic cancer in the same population of health professionals. They concluded that plausible biological mechanisms, such as systemic inflammation or increased concentrations of carcinogenic compounds (or both) as a result of bacteria in the oral cavity of those with periodontal disease, could be involved in the development of cancer. Furthermore, a recent case–control study suggested that chronic periodontitis is associated with increased risk of developing tongue cancer. 5 Tezal M Sullivan M Reid M et al. Chronic periodontitis and the risk of tongue cancer. Arch Otolaryngol Head Neck Surg. 2007; 133: 450-454 Crossref PubMed Scopus (130) Google Scholar However, other researchers believe that the association between periodontal disease and cancer might be spurious. 6 Hujoel P Drangsholt M Spiekerman C Weiss N An exploration of the periodontitis-cancer association. Ann Epidemiol. 2003; 13: 312-316 Summary Full Text Full Text PDF PubMed Scopus (192) Google Scholar Therefore, future studies that assess in more detail potential mechanisms for the association between periodontal diseases and cancer are warranted. (A) Diagnosis should include clinical presentation, periodontal pocket probings, and radiographical assessment of bone levels. Note that the gingival tissues are red and swollen, and the level of the gingival margins is irregular. (B) Radiograph of top teeth shows only the tips of the roots inserted in alveolar bone (arrow). Periodontal disease, tooth loss, and cancer risk in male health professionals: a prospective cohort studyPeriodontal disease was associated with a small, but significant, increase in overall cancer risk, which persisted in never-smokers. The associations recorded for lung cancer are probably because of residual confounding by smoking. The increased risks noted for haematological, kidney, and pancreatic cancers need confirmation, but suggest that periodontal disease might be a marker of a susceptible immune system or might directly affect cancer risk. Full-Text PDF