Publications by authors named "Leah M Ferrucci"

45 Publications

Association of epigenetic age acceleration with risk factors, survival, and quality of life in patients with head and neck cancer.

Int J Radiat Oncol Biol Phys 2021 Apr 18. Epub 2021 Apr 18.

Emory University School of Nursing.

Purpose: Epigenetic age acceleration (EAA) is robustly linked with mortality and morbidity. This study examined risk factors of EAA and its association with overall survival (OS), progression-free survival (PFS), and quality of life (QOL) in patients with head and neck cancer (HNC) receiving radiotherapy.

Methods And Materials: Patients without distant metastasis were enrolled and followed before and end of radiotherapy, and 6-months and 12-months post-radiotherapy. EAA was calculated with DNAmPhenoAge at all four times. Risk factors included demographics, lifestyle, clinical characteristics, treatment-related symptoms, and blood biomarkers. Survival data were collected until August 2020; QOL was measured using Functional Assessment of Cancer Therapy-HNC.

Results: Increased comorbidity, HPV-unrelated, and severer treatment-related symptoms were associated with higher EAA (p=0.03 to <0.001). A non-linear association (quadratic) between body mass index (BMI) and EAA was observed: decreased BMI (when BMI<35,p=0.04) or increased BMI (when BMI≥35,p=0.01), was linked to higher EAA. Increased EAA (per year) was associated with worse OS (hazard ratio (HR)=1.11,95% CI=[1.03,1.18],p=0.004; HR=1.10,95% CI=[1.01,1.19], p=0.02, for EAA at 6-months and 12-months post-treatment, respectively), PFS (HR=1.10, 95% CI=[1.02,1.19], p=0.02; HR=1.14, 95% CI=[1.06,1.23], p<0.001; HR=1.08,95% CI=[1.02,1.14], p=0.01, for EAA before, end, and 6-months post-radiotherapy, respectively), and QOL over time (β=-0.61,p=0.001). An average of 3.25-3.33 years of age acceleration across time, which was responsible for 33% to 44% higher HRs of OS and PFS, was observed in those who died or developed recurrences compared to those who did not (all p<0.001).

Conclusion: Compared to demographic and lifestyle factors, clinical characteristics were more likely to contribute to faster biological aging in patients with HNC. Acceleration in epigenetic age resulted in more aggressive adverse events including OS and PFS. EAA could be considered as a marker for cancer outcomes, and decelerating aging could improve survival and QOL.
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http://dx.doi.org/10.1016/j.ijrobp.2021.04.002DOI Listing
April 2021

Examining the effect of obesity-associated gene variants on breast cancer survivors in a randomized weight loss intervention.

Breast Cancer Res Treat 2021 Mar 6. Epub 2021 Mar 6.

Yale School of Public Health, MPH, 55 Church Street, Suite 801, New Haven, CT, 06510, USA.

Purpose: Our study examined whether common variants of obesity-associated genes FTO, MC4R, BDNF, and CREB1 moderated the effects of a lifestyle intervention on weight change among breast cancer survivors.

Methods: 151 breast cancer survivors with a body mass index ≥ 25 kg/m were randomly assigned to a 6-month weight loss intervention or usual care group. Genotyping of FTO rs9939609, MC4R rs6567160, BDNF rs11030104, CREB1 rs17203016 was performed. Linear mixed models were used including the main effects of genotype (assuming a dominant genetic model), treatment arm on weight and percent body fat changes, and genotype by treatment interaction variable. All statistical tests were evaluated against a Bonferroni-corrected alpha of 0.0125.

Results: Women in the intervention group achieved significantly greater weight loss than the usual care group (5.9% vs 0.4%, p < 0.001), regardless of genotype. Changes in weight and percent body fat did not differ significantly between carriers of the FTO rs9939609, MC4R rs6567160, BDNF rs11030104, and CREB1 rs17203016 risk alleles compared to non-carriers (p-interaction > 0.0125 for each single-nucleotide polymorphisms).

Conclusions: Women who are genetically predisposed to obesity and recently diagnosed with breast cancer may achieve significant and clinically meaningful weight loss through healthy eating and exercise.

Clinical Trial Registration: NCT02863887 (Date of Registration: August 11, 2016); NCT02110641 (Date of Registration: April 10, 2014).
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http://dx.doi.org/10.1007/s10549-021-06151-5DOI Listing
March 2021

Skin carotenoids are inversely associated with adiposity in breast cancer survivors.

Nutr Res 2020 07 24;79:77-86. Epub 2020 May 24.

Yale School of Public Health, 60 College St, New Haven, CT 06511; Yale Cancer Center, PO Box 208028, New Haven, CT 06519. Electronic address:

Carotenoids are antioxidants which may mitigate some of the adverse effects of obesity, a condition associated with poor outcomes in breast cancer patients. We hypothesized that baseline skin carotenoids would be inversely associated with adiposity in breast cancer survivors and would increase with weight loss. Skin carotenoid score (SCS) was assessed by resonance Raman spectroscopy in breast cancer survivors (body mass index ≥25 kg/m) enrolled in a 6-month randomized controlled weight loss trial (n = 47). Measurements included total body fat using dual-energy X-ray absorptiometry, height, weight, waist and hip circumference, dietary intake, and serum biomarkers. Associations between SCS, adiposity measures, and serum biomarkers were assessed at baseline, as was the change in SCS from baseline to 6 months, in the intervention and usual care groups. At baseline, SCS was inversely correlated with all adiposity measures (P ≤ .05). In multivariate analyses, baseline percent body fat had the strongest association with baseline SCS (partial R= 0.20). Baseline SCS was significantly inversely associated with log C-reactive protein levels (regression coefficient β ± SE: -0.051± 0.019; P = .011) and log leptin (β ± SE: -0.019± 0.009; P = .046), but the associations were no longer significant after adjustment for adiposity. Over the 6-month study, the intervention group had a 17.6% increase in SCS compared to a 1.5% decrease in the usual care group (P = .28). In our study of overweight and obese breast cancer survivors, dual-energy X-ray absorptiometry-measured body fat explained a large portion of the variation in skin carotenoids at baseline, suggesting a stronger association than that previously seen in studies using less accurate measures of adiposity.
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http://dx.doi.org/10.1016/j.nutres.2020.05.012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7409553PMC
July 2020

Association between coffee drinking and telomere length in the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial.

PLoS One 2020 8;15(1):e0226972. Epub 2020 Jan 8.

Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD, United States of America.

Mounting evidence indicates that coffee, a commonly consumed beverage worldwide, is inversely associated with various chronic diseases and overall mortality. Few studies have evaluated the effect of coffee drinking on telomere length, a biomarker of chromosomal integrity, and results have been inconsistent. Understanding this association may provide mechanistic insight into associations of coffee with health. The aim of our study was to test the hypothesis that heavier coffee intake is associated with greater likelihood of having above-median telomere length. We evaluated the cross-sectional association between coffee intake and relative telomere length using data from 1,638 controls from four previously conducted case-control studies nested in the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial. Coffee intake was assessed using a food frequency questionnaire, and relative telomere length was measured from buffy-coat, blood, or buccal cells. We used unconditional logistic regression models to generate multivariable-adjusted, study-specific odds ratios for the association between coffee intake and relative telomere length. We then conducted a random-effects meta-analysis to determine summary odds ratios. We found that neither summary continuous (OR = 1.01, 95% CI = 0.99-1.03) nor categorical (OR <3 cups/day vs. none = 1.37, 95% CI = 0.71-2.65; OR ≥3 cups/day vs. none = 1.47, 95% CI = 0.81-2.66) odds ratio estimates of coffee drinking and relative telomere length were statistically significant. However, in the largest of the four contributing studies, moderate (<3 cups/day) and heavy coffee drinkers (≥3 cups/day) were 2.10 times (95% CI = 1.25, 3.54) and 1.93 times as likely (95% CI = 1.17, 3.18) as nondrinkers to have above-median telomere length, respectively. In conclusion, we found no evidence that coffee drinking is associated with telomere length. Thus, it is unlikely that telomere length plays a role in potential coffee-disease associations.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0226972PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6948744PMC
April 2020

Endocrine-related quality of life in a randomized trial of exercise on aromatase inhibitor-induced arthralgias in breast cancer survivors.

Cancer 2019 07 6;125(13):2262-2271. Epub 2019 Mar 6.

Yale School of Public Health, New Haven, Connecticut.

Background: The objective of this study was to evaluate the role of a 12-month exercise intervention on endocrine-related quality of life (QOL) and overall QOL among breast cancer survivors with aromatase inhibitor (AI)-induced arthralgia in the Hormones and Physical Exercise (HOPE) Study.

Methods: This was a randomized controlled trial of 121 breast cancer survivors who were currently receiving AIs and experiencing at least mild arthralgia. QOL was assessed using the Functional Assessment of Cancer Therapy (FACT) questionnaires and the 36-Item Short Form Survey (SF-36) at baseline, 6 months, and 12 months. Participants were randomized to either a 1-year gym-based, supervised exercise intervention group (150 minutes of aerobic exercise and 2 strength-training sessions each week) or a usual care group. Effects of the intervention on QOL were assessed using mixed-model, repeated-measures analysis.

Results: At 12 months, the exercise group had greater improvement in the overall QOL measures as well as the breast cancer-specific (scores, 2.2 vs 0.7; P = .02), endocrine-specific (scores, 5.6 vs 1.6; P < .001), and fatigue-specific (score, 5.8 vs 0.5; P < .001) subscales compared with the usual care group. The results indicated a stronger effect at 12 months versus 6 months after the intervention.

Conclusions: Combined aerobic and resistance exercise, such as treadmill walking and strength training, improved endocrine-related and overall QOL among breast cancer survivors who were experiencing adverse side effects from AIs. Because adverse side effects associated with AI use are quite common and this is the main reason for treatment discontinuation, this nonpharmacologic intervention could benefit many breast cancer survivors and increase successful adherence to AIs in breast cancer treatment.
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http://dx.doi.org/10.1002/cncr.32051DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6731173PMC
July 2019

Concordance of cancer registry and self-reported race, ethnicity, and cancer type: a report from the American Cancer Society's studies of cancer survivors.

Cancer Causes Control 2019 Jan 3;30(1):21-29. Epub 2018 Nov 3.

Department of Chronic Disease Epidemiology, Yale Comprehensive Cancer Center, Yale School of Public Health, 55 Church Street, Suite 801, New Haven, CT, 06510, USA.

Purpose: To examine the concordance between cancer registry and self-reported data for race, Hispanic ethnicity, and cancer type in the American Cancer Society's Studies of Cancer Survivors (SCS) I and II.

Methods: We calculated sensitivity, specificity, positive predictive value, and Kappa statistics for SCS-I and II. The gold standard for cancer type was registry data and for race and ethnicity was self-reported questionnaire data.

Results: Among 6,306 survivors in SCS-I and 9,170 in SCS-II, overall agreement (Kappa) for cancer type was 0.98 and 0.99, respectively. Concordance was strongest for breast and prostate cancer (Sensitivity ≥ 0.98 in SCS-I and II). For race, Kappa was 0.85 (SCS-I) and 0.93 (SCS-II), with strong concordance for white (Sensitivity = 0.95 in SCS-I and 0.99 in SCS-II) and black survivors (Sensitivity = 0.94 in SCS-I and 0.99 in SCS-II), but weak concordance for American Indian/Alaska Native (Sensitivity = 0.23 in SCS-I and 0.19 in SCS-II) and Asian/Pacific Islander survivors (Sensitivity = 0.43 in SCS-I and 0.87 in SCS-II). Agreement was moderate for Hispanic ethnicity (Kappa = 0.73 and 0.71; Sensitivity = 0.74 and 0.76, in SCS-I and SCS-II, respectively).

Conclusions: We observed strong concordance between cancer registry data and self-report for cancer type in this national sample. For race and ethnicity, however, concordance varied significantly, with the poorest concordances observed for American Indian/Alaska Native and Asian/Pacific Islander survivors. Ensuring accurate recording of race/ethnicity data in registries is crucial for monitoring cancer trends and addressing cancer disparities among cancer survivors.
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http://dx.doi.org/10.1007/s10552-018-1091-3DOI Listing
January 2019

Randomized controlled trial of weight loss versus usual care on telomere length in women with breast cancer: the lifestyle, exercise, and nutrition (LEAN) study.

Breast Cancer Res Treat 2018 Nov 30;172(1):105-112. Epub 2018 Jul 30.

Yale Cancer Center, Yale University School of Medicine, 333 Cedar St, PO Box 208032, New Haven, CT, 06520-8032, USA.

Purpose: Some studies suggest that telomere shortening may be associated with increased breast cancer risk and mortality. Obesity is also associated with increased breast cancer risk and mortality. Few studies have examined changes in telomere length in overweight or obese breast cancer survivors. The purpose of our study was to examine the effect of a 6-month diet- and exercise-induced weight loss intervention versus usual care on telomere length in breast cancer survivors.

Methods: 151 breast cancer survivors with body mass index (BMI) ≥ 25 kg/m were randomly assigned to a 6-month weight loss intervention (n = 93) or to usual care (n = 58). Fasting blood samples, height, weight, physical activity, and diet were measured at baseline and 6-months. Relative telomere length (RTL) was measured by quantitative-polymerase chain reaction (qPCR) done on buffy coat-extracted genomic DNA. Mean baseline to 6-month changes were compared between groups (intention-to-treat) using generalized estimating equations.

Results: Complete telomere data were available in 125 participants. Women were 58 ± 8 years, with BMI 33.0 ± 6.2 kg/m and were 2.9 ± 2.5 years from diagnosis; 90% were non-Hispanic white, and 76% had stage 0/I breast cancer. After 6 months, women randomized to weight loss had 3% telomere lengthening compared to 5% shortening in the usual care group (p = 0.12). Among women with stage 0/I, the intervention group experienced 7% telomere lengthening compared to 8% shortening in the usual care group (p = 0.01). No intervention effect was observed in women with stage II/III breast cancer.

Conclusion: Our findings suggest a weight loss intervention in stage 0 and 1 breast cancer survivors may lead to telomere lengthening, compared to a shortening in their usual care counterparts.
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http://dx.doi.org/10.1007/s10549-018-4895-7DOI Listing
November 2018

Cross-sectional assessment of ultraviolet radiation-related behaviors among young people after a diagnosis of melanoma or basal cell carcinoma.

J Am Acad Dermatol 2018 Jul 29;79(1):149-152. Epub 2017 Dec 29.

Yale School of Public Health, New Haven, Connecticut; Yale Cancer Center, New Haven, Connecticut; Center for Food Safety and Applied Nutrition, Food and Drug Administration, College Park, Maryland.

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http://dx.doi.org/10.1016/j.jaad.2017.12.056DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6004335PMC
July 2018

Changes in diet quality in a randomized weight loss trial in breast cancer survivors: the lifestyle, exercise, and nutrition (LEAN) study.

NPJ Breast Cancer 2016 24;2:16026. Epub 2016 Aug 24.

Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT, USA.

Obesity is associated with increased breast cancer recurrence and mortality. Though some post-diagnosis weight loss interventions have achieved weight loss outcomes, it is unclear whether they also improve diet quality. In the Lifestyle, Exercise, and Nutrition (LEAN) study, overweight or obese breast cancer survivors were randomized to either usual care group (=33) or the 6-month lifestyle intervention (=67). Dietary intake was assessed at baseline and 6 months using a validated food frequency questionnaire, and overall diet quality was calculated using the Healthy Eating Index (HEI)-2010 (range 0-100). Intervention effects on diet were evaluated with generalized linear models. Among the 81 participants (51 intervention, 30 usual care) with dietary data, the mean baseline HEI score was 70.5 (s.d.=8.8) and was improved at 6 months (intervention group=6.8 point increase vs usual care=3.1, =0.09). Intervention group participants achieved greater reductions in percent of energy from total fat (-4.2% vs -1.2%; =0.013) and saturated fat (-2.2% vs -1.1%; =0.003), and greater increases in fiber (4.8 g per 1000 kcal vs 1.3 g per 1000 kcal; =0.007) and fruit (0.5 servings vs 0.0 servings; =0.006) intake. Intervention group participants who lost ⩾5% body weight (=27) demonstrated significantly greater improvements in HEI score (10.4 vs 2.8) than those who lost <5% (=23). The intervention increased fruit and fiber intake and decreased percent energy from fat, and those with greater weight loss achieved greater increases in overall diet quality. These findings support the ability of a weight loss intervention to improve diet among breast cancer survivors.
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http://dx.doi.org/10.1038/npjbcancer.2016.26DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5515327PMC
August 2016

Compliance with indoor tanning bans for minors among businesses in the USA.

Transl Behav Med 2017 12;7(4):637-644

Yale School of Public Health, 55 Church Street, Suite 801, New Haven, CT, 06510, USA.

Indoor tanning is a known risk factor for skin cancer and is especially dangerous for adolescents. Some states have passed indoor tanning bans for minors, but business compliance with the bans is not well understood. Thus far, studies have assessed ban compliance in one or two states at a time. This study aimed to assess compliance with indoor tanning bans for minors and knowledge of dangers and benefits of tanning among indoor tanning businesses. Female research assistants posing as minors telephoned a convenience sample of 412 businesses in 14 states with tanning bans for minors under age 17 or 18. We evaluated differences in compliance by census region and years since ban was implemented and differences in reported dangers and benefits by compliance. Most (80.1%) businesses told the "minor" caller she could not use the tanning facilities. Businesses in the south and in states with more recent bans were less compliant. Among those (n = 368) that completed the full interview, 52.2% identified burning and 20.1% mentioned skin cancer as potential dangers. However, 21.7% said dangers were no worse than the sun and 10.3% denied any dangers. Stated benefits included vitamin D (27.7%), social/cosmetic (27.2%), and treats skin diseases (26.4%), with only 4.9% reporting no benefits. While most businesses followed the indoor tanning ban when a minor called, one-fifth did not. Many stated inaccurate health claims. Additional enforcement or education might increase compliance with indoor tanning bans and action is needed to prevent businesses from stating false health information.
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http://dx.doi.org/10.1007/s13142-017-0510-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5684080PMC
December 2017

Pre-diagnosis diet and survival after a diagnosis of ovarian cancer.

Br J Cancer 2017 Jun 2;116(12):1627-1637. Epub 2017 May 2.

Gynaecological Cancers Group, QIMR Berghofer Institute of Medical Research, 300 Herston Road, Herston, Queensland 4006, Australia.

Background: The relationship between diet and survival after ovarian cancer diagnosis is unclear as a result of a limited number of studies and inconsistent findings.

Methods: We examined the association between pre-diagnostic diet and overall survival in a population-based cohort (n=811) of Australian women diagnosed with invasive epithelial ovarian cancer between 2002 and 2005. Diet was measured by validated food frequency questionnaire. Deaths were ascertained up to 31 August 2014 via medical record review and Australian National Death Index linkage. We conducted Cox proportional hazards regression analysis, controlling for diagnosis age, tumour stage, grade and subtype, residual disease, smoking status, body mass index, physical activity, marital status, and energy intake.

Results: We observed improved survival with highest compared with lowest quartile of fibre intake (hazard ratio (HR)=0.69, 95% CI: 0.53-0.90, P-trend=0.002). There was a suggestion of better survival for women with highest compared with lowest intake category of green leafy vegetables (HR=0.79, 95% CI: 0.62-0.99), fish (HR=0.74, 95% CI: 0.57-0.95), poly- to mono-unsaturated fat ratio (HR=0.76, 95% CI: 0.59-0.98), and worse survival with higher glycaemic index (HR=1.28, 95% CI: 1.01-1.65, P-trend=0.03).

Conclusions: The associations we observed between healthy components of diet pre-diagnosis and ovarian cancer survival raise the possibility that dietary choices after diagnosis may improve survival.
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http://dx.doi.org/10.1038/bjc.2017.120DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5518850PMC
June 2017

Body mass index, height and early-onset basal cell carcinoma in a case-control study.

Cancer Epidemiol 2017 02 28;46:66-72. Epub 2016 Dec 28.

Yale School of Public Health, New Haven, CT, 06520, United States; Yale Cancer Center, New Haven, CT, 06520, United States. Electronic address:

Introduction: Basal cell carcinoma (BCC) is the most common malignancy in the US. Body mass index (BMI) and height have been associated with a variety of cancer types, yet the evidence regarding BCC is limited. Therefore, we evaluated BMI and height in relation to early-onset BCC (under age 40) and explored the potential role of ultraviolet (UV) radiation exposure and estrogen-related exposures in the BMI-BCC relationship.

Methods: BCC cases (n=377) were identified through a central dermatopathology facility in Connecticut. Control subjects (n=389) with benign skin conditions were randomly sampled from the same database and frequency matched to cases on age (median=36, interquartile range 33-39), gender, and biopsy site. Participants reported weight (usual adult and at age 18), adult height, sociodemographic, phenotypic, and medical characteristics, and prior UV exposures. We calculated multivariate odds ratios (ORs) and 95% confidence intervals (CIs) using unconditional logistic regression models.

Results: Adult BMI was inversely associated with early-onset BCC (obese vs. normal OR=0.43, 95% CI=0.26-0.71). A similar inverse association was present for BMI at age 18 (OR=0.54, 95% CI=0.34-0.85). Excluding UV exposures from the BMI models and including estrogen-related exposures among women only did not alter the association between BMI and BCC, indicating limited mediation or confounding. We did not observe an association between adult height and BCC (OR per cm=1.00, 95% CI=0.98-1.02).

Conclusions: We found a significant inverse association between BMI and early-onset BCC, but no association between height and BCC. This association was not explained by UV exposures or estrogen-related exposures in women.
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http://dx.doi.org/10.1016/j.canep.2016.12.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5272867PMC
February 2017

Health-related quality of life in ovarian cancer survivors: Results from the American Cancer Society's Study of Cancer Survivors - I.

Gynecol Oncol 2016 06 19;141(3):543-549. Epub 2016 Apr 19.

Yale Cancer Center, New Haven, CT, United States; Yale School of Public Health, New Haven, CT, United States.

Objective: There are limited data on outcomes and predictors of health-related quality of life (HRQOL) of ovarian cancer survivors. Therefore, we examined the trajectory and predictors of HRQOL one- and two-years post-diagnosis in this population.

Methods: 365 ovarian cancer survivors, a subset of participants in the longitudinal American Cancer Society's Study of Cancer Survivors-I, completed questionnaires at one-year post-diagnosis on sociodemographics, clinical factors, and HRQOL (SF-36). 284 women had HRQOL data at two-years post-diagnosis. In this secondary data analysis, we examined HRQOL at both time points, changes in HRQOL and predictors of HRQOL with univariate and multivariate linear regression.

Results: Mean mental and physical HRQOL scores one-year post-diagnosis were 49.37 (SD±11.59) and 45.96 (SD±10.89), respectively. Older age, lower income, higher disease stage, more comorbidities and greater symptom burden were associated with poorer physical functioning one year post-diagnosis. Younger age, higher stage, having an existing mental health issue, greater symptom burden, and not receiving chemotherapy were associated with poorer mental functioning. Disease recurrence between one- and two-years post-diagnosis and greater symptom burden were predictors of declining physical functioning from one- to two-years post-diagnosis. Mental functioning did not change significantly between assessments.

Conclusions: Overall mental and physical functioning of these ovarian cancer survivors was similar to the general population. However, lower HRQOL was associated with a number of variables, including disease recurrence, treatment status, symptom burden, age, and number of comorbidities. These findings can help health care providers identify survivors who may benefit from relevant interventions.
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http://dx.doi.org/10.1016/j.ygyno.2016.04.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4913461PMC
June 2016

Health information needs and preferences in relation to survivorship care plans of long-term cancer survivors in the American Cancer Society's Study of Cancer Survivors-I.

J Cancer Surviv 2016 08 7;10(4):674-85. Epub 2016 Jan 7.

Yale School of Public Health, Yale University, 55 Church Street, Suite 801, New Haven, CT, 06510, USA.

Purpose: Survivorship care plans (SCPs) provide cancer patients and health care providers with a treatment summary and outline of recommended medical follow-up. Few studies have investigated the information needs and preferred sources among long-term cancer survivors.

Methods: Cancer survivors of the ten most common cancers enrolled in the longitudinal Study of Cancer Survivors-I (SCS-I) completed a survey 9 years post-diagnosis (n = 3138); at time of diagnosis of the SCS-I cohort, SCPs were not considered usual care. We assessed participants' current desire and preferred sources for information across ten SCP items and evaluated factors associated with information need 9 years after diagnosis.

Results: The proportion of long-term cancer survivors endorsing a need for cancer and health information 9 years post-diagnosis ranged from 43 % (cancer screening) to 9 % (consequences of cancer on ability to work). Print media and personalized reading materials were the most preferred information sources. Younger age, higher education, race other than non-Hispanic white, later cancer stage, having breast cancer, having ≥2 comorbidities, and self-reporting poor health were associated with greater informational need (p < 0.05).

Conclusions/implications For Cancer Survivors: Long-term cancer survivors continue to report health information needs for most SCP items and would prefer a print format; however, level of need differs by socio-demographic and cancer characteristics. Cancer survivors who did not previously receive a SCP may still benefit from receiving SCP content, and strategies for enabling dissemination to long-term survivors warrant further investigation.
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http://dx.doi.org/10.1007/s11764-015-0513-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5032143PMC
August 2016

Family history of skin cancer is associated with early-onset basal cell carcinoma independent of MC1R genotype.

Cancer Epidemiol 2015 Dec 14;39(6):1078-83. Epub 2015 Sep 14.

Yale School of Public Health, New Haven, CT 06520, United States; Yale Cancer Center, New Haven, CT 06520, United States. Electronic address:

Background: As a marker of genetic susceptibility and shared lifestyle characteristics, family history of cancer is often used to evaluate an individual's risk for developing a particular malignancy. With comprehensive data on pigment characteristics, lifestyle factors, and melanocortin 1 receptor (MC1R) gene sequence, we sought to clarify the role of family history of skin cancer in early-onset basal cell carcinoma (BCC).

Materials And Methods: Early onset BCC cases (n=376) and controls with benign skin conditions (n=383) under age 40 were identified through Yale dermatopathology. Self-report data on family history of skin cancer (melanoma and non-melanoma skin cancer), including age of onset in relatives, was available from a structured interview. Participants also provided saliva samples for sequencing of MC1R.

Results: A family history of skin cancer was associated with an increased risk of early-onset BCC (OR 2.49, 95% CI 1.80-3.45). In multivariate models, family history remained a strong risk factor for early-onset BCC after adjustment for pigment characteristics, UV exposure, and MC1R genotype (OR 2.41, 95% CI 1.74-3.35).

Conclusions: Risk for BCC varied based upon the type and age of onset of skin cancer among affected relatives; individuals with a first-degree relative diagnosed with skin cancer prior to age 50 were at highest risk for BCC (OR 4.79, 95% CI 2.90-7.90). Even after taking into account potential confounding effects of MC1R genotype and various lifestyle factors that close relatives may share, family history of skin cancer remained strongly associated with early-onset BCC.
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http://dx.doi.org/10.1016/j.canep.2015.09.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4679454PMC
December 2015

Subsequent skin cancer in patients with early-onset basal cell carcinoma.

Australas J Dermatol 2015 Aug;56(3):236-7

Yale School of Public Health, New Haven, Connecticut, USA.

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http://dx.doi.org/10.1111/ajd.12338DOI Listing
August 2015

Indoor tanning and the MC1R genotype: risk prediction for basal cell carcinoma risk in young people.

Am J Epidemiol 2015 Jun 8;181(11):908-16. Epub 2015 Apr 8.

Basal cell carcinoma (BCC) incidence is increasing, particularly in young people, and can be associated with significant morbidity and treatment costs. To identify young individuals at risk of BCC, we assessed existing melanoma or overall skin cancer risk prediction models and built a novel risk prediction model, with a focus on indoor tanning and the melanocortin 1 receptor gene, MC1R. We evaluated logistic regression models among 759 non-Hispanic whites from a case-control study of patients seen between 2006 and 2010 in New Haven, Connecticut. In our data, the adjusted area under the receiver operating characteristic curve (AUC) for a model by Han et al. (Int J Cancer. 2006;119(8):1976-1984) with 7 MC1R variants was 0.72 (95% confidence interval (CI): 0.66, 0.78), while that by Smith et al. (J Clin Oncol. 2012;30(15 suppl):8574) with MC1R and indoor tanning had an AUC of 0.69 (95% CI: 0.63, 0.75). Our base model had greater predictive ability than existing models and was significantly improved when we added ever-indoor tanning, burns from indoor tanning, and MC1R (AUC = 0.77, 95% CI: 0.74, 0.81). Our early-onset BCC risk prediction model incorporating MC1R and indoor tanning extends the work of other skin cancer risk prediction models, emphasizes the value of both genotype and indoor tanning in skin cancer risk prediction in young people, and should be validated with an independent cohort.
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http://dx.doi.org/10.1093/aje/kwu356DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4445390PMC
June 2015

Indoor tanning in businesses and homes and risk of melanoma and nonmelanoma skin cancer in 2 US case-control studies.

J Am Acad Dermatol 2014 Nov 23;71(5):882-7. Epub 2014 Jul 23.

Yale School of Public Health, New Haven, Connecticut; Yale Cancer Center, New Haven, Connecticut.

Background: Indoor tanning increases skin cancer risk. Beyond early research describing melanoma and sun lamps, few recent reports describe where individuals indoor tan and whether skin cancer risk varies by location (business, home-based).

Objective: We sought to assess where individuals tanned indoors and skin cancer risk by tanning device location.

Methods: Multivariate logistic regression was conducted in 2 US case-control studies of melanoma (1161 cases, 1083 controls, ages 25-59 years) and early-onset basal cell carcinoma (375 cases, 382 controls, age<40 years) conducted between 2004 and 2010.

Results: Most indoor tanners (86.4%-95.1%), especially younger individuals, tanned exclusively in businesses. Persons who used indoor tanning exclusively in businesses were at increased risk of melanoma (odds ratio 1.82, 95% confidence interval 1.47-2.26) and basal cell carcinoma (odds ratio 1.69, 95% confidence interval 1.15-2.48) compared with non-users. Melanoma risk was also increased in the small number who reported tanning indoors only at home relative to non-users (odds ratio 4.14, 95% confidence interval 1.75-9.78); 67.6% used sun lamps.

Limitations: Self-reported tanning and potential recall bias are limitations.

Conclusion: Business-only tanning, despite claims of "safe" tanning, was positively associated with a significant risk of melanoma and basal cell carcinoma. Home tanning was uncommon and mostly from sun lamps, which were rarely used by younger participants. Regardless of location, indoor tanning was associated with increased risk of skin cancer.
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http://dx.doi.org/10.1016/j.jaad.2014.06.046DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4250424PMC
November 2014

Novel gene identified in an exome-wide association study of tanning dependence.

Exp Dermatol 2014 Oct;23(10):757-9

Yale School of Public Health, New Haven, CT, USA; Yale Cancer Center, New Haven, CT, USA.

Growing evidence suggests that some individuals may exhibit symptoms of dependence to ultraviolet light, a known carcinogen, in the context of tanning. Genetic associations with tanning dependence (TD) have not yet been explored. We conducted an exome-wide association study in 79 individuals who exhibited symptoms of TD and 213 individuals with volitional exposure to ultraviolet light, but who were not TD based on three TD scales. A total of 300 000 mostly exomic single nucleotide polymorphisms primarily in coding regions were assessed using an Affymetrix Axiom array. We performed a gene burden test with Bonferroni correction for the number of genes examined (P < 0.05/14 904 = 3.36 × 10(-6) ). One gene, patched domain containing 2 (PTCHD2), yielded a statistically significant P-value of 2.5 × 10(-6) (OR = 0.27) with fewer individuals classified as TD having a minor allele at this locus. These results require replication, but are the first to support a specific genetic association with TD.
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http://dx.doi.org/10.1111/exd.12503DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4204712PMC
October 2014

Systemic glucocorticoid use and early-onset basal cell carcinoma.

Ann Epidemiol 2014 Aug 22;24(8):625-7. Epub 2014 May 22.

Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT; Yale Cancer Center, New Haven, CT. Electronic address:

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http://dx.doi.org/10.1016/j.annepidem.2014.05.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4119504PMC
August 2014

Tea, coffee, and caffeine and early-onset basal cell carcinoma in a case-control study.

Eur J Cancer Prev 2014 Jul;23(4):296-302

aDepartments of Chronic Disease Epidemiology and Biostatistics, Yale School of Public Health bYale Cancer Center cDepartments of Dermatology and Surgery dDepartment of Genetics, Yale University School of Medicine, New Haven, Connecticut eDepartment of Neurological Surgery fDepartment of Epidemiology and Biostatistics, University of California, San Francisco (UCSF), San Francisco, California, USA.

Tea and coffee are hypothesized to play a protective role in skin carcinogenesis through bioactive components, such as caffeine, yet the epidemiologic evidence is mixed. Existing data support an inverse association with basal cell carcinoma (BCC), more so than for melanoma or squamous cell carcinoma. To understand whether tea, coffee, and caffeine are related to early-onset BCC, we evaluated data from 767 non-Hispanic Whites under age 40 in a case-control study in Connecticut. BCC cases (n=377) were identified through Yale's Dermatopathology database. Controls (n=390) were randomly sampled from individuals in the same database with benign skin diagnoses and frequency matched to cases on age, sex, and biopsy site. Participants completed an in-person interview including assessment of caffeinated coffee and hot tea. We calculated multivariate odds ratios (ORs) and 95% confidence intervals (CIs) with unconditional logistic regression for regular consumption and frequency and duration measures. Combined regular consumption of caffeinated coffee plus hot tea was inversely associated with early-onset BCC (OR=0.60, 95% CI=0.38-0.96). Those in the highest category of caffeine from these sources had a 43% reduced risk of BCC compared with nonconsumers (OR=0.57, 95% CI=0.34-0.95, P-trend=0.037). Our findings suggest a modest protective effect for caffeinated coffee plus tea in relation to early-onset BCC that may, in part, be due to caffeine. This study adds to the growing body of literature suggesting potential health benefits from these beverages.
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http://dx.doi.org/10.1097/CEJ.0000000000000037DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4059399PMC
July 2014

Dietary iron, iron homeostatic gene polymorphisms and the risk of advanced colorectal adenoma and cancer.

Carcinogenesis 2014 Jun 17;35(6):1276-83. Epub 2014 Feb 17.

Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Department of Health and Human Services, Bethesda, MD 20892, USA.

Dietary iron intake and variation in iron homeostasis genes may affect colorectal neoplasia risk. We conducted two nested case-control studies within the Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial: one of advanced colorectal adenoma (1205 cases; 1387 controls) and one of colorectal cancer (370 cases; 401 controls). Iron intake was estimated with a food frequency questionnaire and genotyping was performed for 21 genes. Unconditional logistic regression was used to estimate odds ratio (OR) and 95% confidence intervals (95% CIs) for colorectal neoplasia risk within quartiles of intake. Several single nucleotide polymorphisms (SNPs) modified the association between iron intake and the risk of adenoma or cancer. Dietary iron was positively associated with colorectal adenoma among three SNPs of HEPHL1, including carriers of the AA genotype at rs7946162 (ORQ4-Q1 = 2.22, 95% CI 1.15-4.27, Ptrend = 0.03; Pinteraction = 0.10), the TT genotype at rs2460063 (ORQ4-Q1 = 2.39, 95% CI 1.26-4.54, Ptrend = 0.02; Pinteraction = 0.04) and the GG genotype at rs7127348 (ORQ4-Q1 = 2.40, 95% CI 1.23-4.67, Ptrend = 0.02; Pinteraction = 0.09). Heme iron was positively associated with colorectal cancer among those with GG genotypes for ACO1 rs10970985 (ORQ4-Q 1 = 2.45, 95% CI 3.40-8.06, Ptrend = 0.004; Pinteraction = 0.05). However, none of the associations were statistically significant after adjustment for multiple comparisons. Future studies should target the specific genes and SNPs for which the association was significant prior to multiple comparison correction.
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http://dx.doi.org/10.1093/carcin/bgu028DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4043236PMC
June 2014

Indoor tanning and tanning dependence in young people after a diagnosis of basal cell carcinoma.

JAMA Dermatol 2013 Sep;149(9):1110-1

Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut2Yale Cancer Center, New Haven, Connecticut.

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http://dx.doi.org/10.1001/jamadermatol.2013.5104DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3782995PMC
September 2013

Developing a heme iron database for meats according to meat type, cooking method and doneness level.

Food Nutr Sci 2012 Jul;3(7):905-913

Nutritional Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, 6120 Executive Blvd, Rockville, MD, 20852.

Background: Animal studies have demonstrated that iron may be related to carcinogenesis, and human studies found that heme iron can increase the formation of -nitroso compounds, which are known carcinogens.

Objectives: One of the postulated mechanisms linking red meat intake to cancer risk involves iron. Epidemiologic studies attempt to investigate the association between heme iron intake and cancer by applying a standard factor to total iron from meat. However, laboratory studies suggest that heme iron levels in meat vary according to cooking method and doneness level. We measured heme iron in meats cooked by different cooking methods to a range of doneness levels to use in conjunction with a food frequency questionnaire to estimate heme iron intake.

Methods: Composite meat samples were made to represent each meat type, cooking method and doneness level. Heme iron was measured using atomic absorption spectrometry and inductively coupled plasma-atomic emission spectrometry.

Results: Steak and hamburgers contained the highest levels of heme iron, pork and chicken thigh meat had slightly lower levels, and chicken breast meat had the lowest.

Conclusions: Although heme iron levels varied, there was no clear effect of cooking method or doneness level. We outline the methods used to create a heme iron database to be used in conjunction with food frequency questionnaires to estimate heme iron intake in relation to disease outcome.
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http://dx.doi.org/10.4236/fns.2012.37120DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3583546PMC
July 2012

Meat-related mutagen exposure, xenobiotic metabolizing gene polymorphisms and the risk of advanced colorectal adenoma and cancer.

Carcinogenesis 2012 Jul 2;33(7):1332-9. Epub 2012 May 2.

Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Department of Health and Human Services Bethesda, MD, USA.

Meat mutagens, including heterocyclic amines (HCAs), polycyclic aromatic hydrocarbons (PAHs) and N-nitroso compounds (NOCs), may be involved in colorectal carcinogenesis depending on their activation or detoxification by phase I and II xenobiotic metabolizing enzymes (XME). Using unconditional logistic regression to estimate odds ratios (OR) and 95% confidence intervals (CI), we examined the intake of five meat mutagens and >300 single nucleotide polymorphisms (SNPs) in 18 XME genes in relation to advanced colorectal adenoma (1205 cases and 1387 controls) and colorectal cancer (370 cases and 401 controls) within the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial. Dietary intake of meat mutagens was assessed using a food frequency questionnaire with a detailed meat-cooking module. An interaction was observed between 2-amino-3,8-dimethylimidazo[4,5-f]quinoxaline (MeIQx) intake and the NAT1 polymorphism rs6586714 in the adenoma study (P(interaction) = 0.001). Among individuals carrying a GG genotype, high MeIQx intake was associated with a 43% increased risk of adenoma (95% CI 1.11-1.85, P(trend) = 0.07), whereas the reverse was observed among carriers of the A variant (OR = 0.50, 95% CI 0.30-0.84, P(trend) = 0.01). In addition, we observed some suggestive (P < 0.05) modifying effects for SNPs in other XME genes (UGT1A, CYP2E1, EPHX1, AHR and GSTM3), but these were not significant after adjustment for multiple testing. This large and comprehensive study of XME genes, meat mutagens and the risk of colorectal tumours found that a NAT1 polymorphism modified the association between MeIQx intake and colorectal adenoma risk.
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http://dx.doi.org/10.1093/carcin/bgs158DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3499048PMC
July 2012

Lessons learned from randomized clinical trials of micronutrient supplementation for cancer prevention.

Annu Rev Nutr 2012 Aug 18;32:369-90. Epub 2012 Apr 18.

Yale School of Public Health, Yale University, New Haven, Connecticut 06520, USA.

This review discusses the results of randomized clinical trials of supplemental micronutrients for cancer prevention completed over the past 20 years, including trials of beta-carotene and retinol, vitamins C and E, selenium, folic acid, and vitamin D. Some trials observed significant reductions in risk, whereas others observed significant increases in risk of the primary cancer endpoint. In considering these trials, it appears that supplementation targeted to populations with low status of the nutrient of interest may prevent cancer, whereas supplementation in populations with higher status or to achieve pharmacological exposures may promote cancer. Observational epidemiologic evidence coupled with these trial results supports the concept of a U-shaped curve for micronutrients in relation to cancer prevention. Based on these data, nutrient supplements are not currently recommended for cancer prevention in the general population. The hypothesis that groups with low nutrient status may benefit from supplementation has yet to be formally tested.
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http://dx.doi.org/10.1146/annurev-nutr-071811-150659DOI Listing
August 2012

Lifetime history of indoor tanning in young people: a retrospective assessment of initiation, persistence, and correlates.

BMC Public Health 2012 Feb 10;12:118. Epub 2012 Feb 10.

Yale School of Public Health,New Haven CT 06520, USA.

Background: Despite educational and public health campaigns to convey the risks of indoor tanning, many individuals around the world continue to engage in this behavior. Few descriptive studies of indoor tanning have collected information pertaining to the lifetime history of indoor tanning, thereby limiting our ability to understand indoor tanning patterns and potentially target interventions for individuals who not only initiate, but continue to persistently engage in indoor tanning.

Methods: In-person interviews elicited detailed retrospective information on lifetime history of indoor tanning among white individuals (n = 401) under age 40 seen by a dermatologist for a minor benign skin condition. These individuals were controls in a case-control study of early-onset basal cell carcinoma. Outcomes of interest included ever indoor tanning in both males and females, as well as persistent indoor tanning in females - defined as females over age 31 who tanned indoors at least once in the last three or all four of four specified age periods (ages 11-15, 16-20, 21-30 and 31 or older). Multivariate logistic regression was used to identify sociodemographic and lifestyle correlates of ever and persistent indoor tanning in females.

Results: Approximately three-quarters (73.3%) of females and 38.3% of males ever tanned indoors, with a median age of initiation of 17.0 and 21.5, respectively. Among indoor tanners, 39.3% of females and 21.7% of males reported being burned while indoor tanning. Female ever indoor tanners were younger, had darker color eyes, and sunbathed more frequently than females who never tanned indoors. Using unique lifetime exposure data, 24.7% of female indoor tanners 31 and older persistently tanned indoors starting as teenagers. Female persistent indoor tanners drank significantly more alcohol, were less educated, had skin that tanned with prolonged sun exposure, and sunbathed outdoors more frequently than non-persistent tanners.

Conclusions: Indoor tanning was strikingly common in this population, especially among females. Persistent indoor tanners had other high-risk behaviors (alcohol, sunbathing), suggesting that multi-faceted behavioral interventions aimed at health promotion/disease prevention may be needed in this population.
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http://dx.doi.org/10.1186/1471-2458-12-118DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3340300PMC
February 2012

Employment experience of cancer survivors 2 years post-diagnosis in the Study of Cancer Survivors-I.

J Cancer Surviv 2012 Jun 5;6(2):210-8. Epub 2012 Jan 5.

Yale School of Public Health, 55 Church Street, Suite 801, New Haven, 06510 CT, USA.

Introduction: A large percentage of cancer survivors are in the workforce and it is important to understand their experiences and challenges in the workplace and work status changes.

Method: We utilized multivariate logistic regression to evaluate sociodemographic, clinical, and psychosocial measures as potential predictors of having at least one negative work-related experience and reporting a reduction in workload among cancer survivors 2 years post-diagnosis in the longitudinal Study of Cancer Survivors-I.

Result: Many cancer survivors (62%) reported having at least one negative work-related experience 2 years post-diagnosis; they were more likely to be male (OR = 1.70, 95% CI = 1.32-2.18), have lower household income (>$80,000 vs. <$20,000; OR = 0.53, 95% CI = 0.35-0.79), be farther from diagnosis (OR = 1.06, 95% CI = 1.02-1.10), and have deteriorating physical (OR = 0.96, 95% CI = 0.94-0.98) and mental (OR = 0.94, 95% CI = 0.92-0.96) health. Among those employed full-time 1 year post-diagnosis, older age (65+ vs. <55; OR = 2.71, 95% CI = 1.18-6.24), negative work-related experiences (2+ vs. 0; OR = 1.78, 95% CI = 1.00-3.14), and deteriorating physical (OR = 0.93, 95% CI = 0.90-0.95) and mental (OR = 0.97, 95% CI = 0.95-0.99) health were associated with reporting a reduced workload 2 years post-diagnosis.

Discussions: Several sociodemographic and psychosocial characteristics were associated with negative work-related experiences and reduced workload in this population of cancer survivors who were working 1 to 2 years post-diagnosis. Additional research is needed to determine if these experiences and predictors are consistent in other cancer survivor populations.

Implications For Cancer Survivors: Being aware that some working cancer survivors may have negative work-related experiences and/or may not maintain full employment in later survivorship years may enable cancer survivors and employers to improve survivors' experiences at work.
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http://dx.doi.org/10.1007/s11764-011-0212-8DOI Listing
June 2012

Host phenotype characteristics and MC1R in relation to early-onset basal cell carcinoma.

J Invest Dermatol 2012 Apr 8;132(4):1272-9. Epub 2011 Dec 8.

Department of Chronic Disease Epidemiology, Yale School of Public Health, Yale University, New Haven, Connecticut 06520-8034, USA.

Basal cell carcinoma (BCC) incidence is increasing, particularly among adults under the age of 40 years. Pigment-related characteristics are associated with BCC in older populations, but epidemiologic studies among younger individuals and analyses of phenotype-genotype interactions are limited. We examined self-reported phenotypes and melanocortin 1 receptor gene (MC1R) variants in relation to early-onset BCC. BCC cases (n=377) and controls with benign skin conditions (n=390) under the age of 40 years were identified through Yale's Dermatopathology database. Factors most strongly associated with early-onset BCC were skin reaction to first summer sun for 1 hour (severe sunburn vs. tan odds ratio (OR)=12.27, 95% confidence interval (CI)=4.08-36.94) and skin color (very fair vs. olive OR=11.06, 95% CI=5.90-20.74). Individuals with two or more MC1R non-synonymous variants were 3.59 times (95% CI=2.37-5.43) more likely to have BCC than those without non-synonymous variants. All host characteristics and MC1R were more strongly associated with multiple BCC case status (37% of cases) than a single BCC case status. MC1R, number of moles, skin reaction to first summer sun for 1 hour, and hair and skin color were independently associated with BCC. BCC risk conferred by MC1R tended to be stronger among those with darker pigment phenotypes, traditionally considered to be at low risk of skin cancer.
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http://dx.doi.org/10.1038/jid.2011.402DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3305835PMC
April 2012

Indoor tanning and risk of early-onset basal cell carcinoma.

J Am Acad Dermatol 2012 Oct 9;67(4):552-62. Epub 2011 Dec 9.

Yale School of Public Health, New Haven, Connecticut 06520-8034, USA.

Background: Despite an increase in incidence of basal cell carcinoma (BCC) among young people and the ubiquity of indoor tanning in this population, few epidemiologic studies have investigated this exposure-disease relationship.

Objective: We sought to evaluate the association between indoor tanning and early-onset BCC.

Methods: Patients with BCC (n = 376) and control subjects with minor benign skin conditions (n = 390) who were younger than 40 years of age were identified through Yale Dermatopathology. Participants provided information on ever indoor tanning, age of initiation, frequency, duration, burns while tanning, and type of tanning device during an in-person interview. We calculated odds ratios (OR) and 95% confidence intervals (CI) using multivariate logistic regression with never indoor tanners as the referent group.

Results: Ever indoor tanning was associated with a 69% increased risk of early-onset BCC (95% CI 1.15-2.48). This association was stronger among females (OR 2.14, 95% CI 1.31-3.47), for multiple BCCs (OR 2.16, 95% CI 1.26-3.70), and for BCCs on the trunk and extremities (OR 2.81, 95% CI 1.57-5.02). Risk increased dose dependently with years using regular indoor tanning devices (P trend = .003), number of overall burns (P trend < .001), and burns to biopsy site (P trend < .001) from indoor tanning. Approximately one quarter (27%) of early-onset BCCs (or 43% among women) could be prevented if individuals never tanned indoors.

Limitations: Potential recall bias of indoor tanning by patients and generalizability of the control population suggest replication in other studies is warranted.

Conclusions: Indoor tanning was a strong risk factor for early-onset BCC, particularly among females. Indoor tanning should continue to be targeted by both policy-based and behavioral interventions, as the impact on BCC-associated morbidity may be substantial.
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http://dx.doi.org/10.1016/j.jaad.2011.11.940DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3307842PMC
October 2012