Search

Background: Individuals with a personal history of nonmelanoma skin cancer (NMSC) may have an increased risk of subsequent noncutaneous malignancies. To test this hypothesis, we carried out a community-based, prospective cohort study., Methods: In the CLUE (Give Us a Clue to Cancer and Heart Disease) II cohort, which was established in Washington County, MD, in 1989, the risk of new malignancies was compared among individuals with (n = 769) and without (n = 18,405) a personal history of NMSC (total n = 19,174) during a 16-year follow-up period. Pathologically confirmed NMSC (and other malignancies) were ascertained from the Washington County Cancer Registry. Cox regression analysis with time-dependent covariates was used to determine the hazard ratios (presented as multivariable-adjusted relative risks [RRs]) and 95% confidence intervals (CIs) of second primary malignancies associated with a previously confirmed NMSC diagnosis. All statistical tests were two-sided., Results: The crude incidence rate (per 10,000 person-years) of subsequent cancers other than NMSC among participants with a positive personal history of NMSC was 293.5 and with a negative history was 77.8. Compared with persons with no personal history of NMSC, those with such a history had a statistically significantly increased risk of being diagnosed with a subsequent cancer other than NMSC (RR = 1.99, 95% CI = 1.70 to 2.33) after adjusting for age, sex, body mass index, smoking status, and educational level. The association was observed for both basal cell carcinoma (multivariable-adjusted RR = 2.03, 95% CI = 1.70 to 2.42) and squamous cell carcinoma (multivariable-adjusted RR = 1.97, 95% CI = 1.50 to 2.59) of the skin. NMSC was a statistically significantly stronger cancer risk factor in younger age groups than in older age groups (P for interaction = .022)., Conclusions: This community-based, prospective cohort study provides evidence for an association between an NMSC diagnosis and an increased risk of subsequent cancer, even after adjusting for individual-level risk factors.

Objective: We aimed to achieve accurate statistical modeling of a putative relationship between carotid endarterectomy (CEA) annual surgeon and hospital volume and in-hospital mortality., Design of Study: We performed a secondary data analysis of 10 years (1994-2003) of the Maryland hospital discharge database. Annual volume was defined as the total number of procedures performed for the time in the dataset divided by the total years in the dataset. Non-linear relationships between death and average volumes were explored with logit-transformed lowess smoothing functions, followed by random effect models and inspection of data likelihood under each combination of spline knots. A marginal model with generalized estimating equations was used to represent population-average response as a function of covariates and to account for clustering in the data. Patient comorbidity was assessed using the Deyo modification of the Charlson Index., Setting: The Maryland hospital discharge database is a 100% sample of all hospitals in the state., Subjects: CEA was identified through ICD-9 and diagnosis codes, using a previously reported algorithm., Main Outcome Measure: Estimated odds ratios predicting in-hospital death, alpha set at 0.05., Results: During the study period, 22,772 patients with surgeon identifiers underwent CEA in Maryland, resulting in 123 in-hospital deaths (0.54%). The crude odds ratio of death for the entire surgeon dataset was 0.9838, meaning that the odds of death decreased by an average of 0.0162 for each additional annual procedure. Surgeon volume of four to 15 CEAs per year was highly significant: for an increase in annual surgeon volume by one procedure per year, the estimated odds of death decreased by 0.065 when controlling for hospital volume, age, and comorbidity (P = .351). Surgeons in other volume categories also demonstrated lower odds of death with increased annual volume, but these odds ratios did not attain statistical significance. Surgeons performing 15 CEAs per year had an odds ratio of 0.997 (P = .485). Hospitals that saw >130 CEAs per year had an odds ratio of death of 0.945 per additional procedure, or 0.055 decrease in the odds of death (P = 0.013), whereas hospitals performing /=130 CEAs per year) showing a statistically significant decrease in the odds ratio of death. As studies on volume-outcome relationships can have important implications for health policy and surgical training, such studies should consider non-linear effects in their modeling of procedural volume.