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South Africa's HIV epidemic has evolved over time in terms of numbers of people living with HIV, access to antiretroviral treatment (ART) and age. These changes have profoundly influenced local cancer patterns. The Johannesburg Cancer Study has, over a period of 22 years (1995-2016), recruited over 20 000 incident black cancer patients who consented to provide answers to a questionnaire and blood samples (serum, DNA). This has presented a unique opportunity to examine the evolving association of HIV with cancer in Africa. We used logistic regression models to explore case-control associations between specific cancers and HIV, using participants with non-infection related cancers as controls. Using data of 20 835 cancer patients with confirmed HIV status, we found the following cancers to be associated with HIV: Kaposi's sarcoma (OR

Summary Background Prevention, control, and treatment of respiratory tract cancers are important steps towards achieving target 3.4 of the UN Sustainable Development Goals (SDGs)—a one-third reduction in premature mortality due to non-communicable diseases by 2030. We aimed to provide global, regional, and national estimates of the burden of tracheal, bronchus, and lung cancer and larynx cancer and their attributable risks from 1990 to 2019. Methods Based on the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 methodology, we evaluated the incidence, mortality, years lived with disability, years of life lost, and disability-adjusted life-years (DALYs) of respiratory tract cancers (ie, tracheal, bronchus, and lung cancer and larynx cancer). Deaths from tracheal, bronchus, and lung cancer and larynx cancer attributable to each risk factor were estimated on the basis of risk exposure, relative risks, and the theoretical minimum risk exposure level input from 204 countries and territories, stratified by sex and Socio-demographic Index (SDI). Trends were estimated from 1990 to 2019, with an emphasis on the 2010–19 period. Findings Globally, there were 2·26 million (95% uncertainty interval 2·07 to 2·45) new cases of tracheal, bronchus, and lung cancer, and 2·04 million (1·88 to 2·19) deaths and 45·9 million (42·3 to 49·3) DALYs due to tracheal, bronchus, and lung cancer in 2019. There were 209 000 (194 000 to 225 000) new cases of larynx cancer, and 123 000 (115 000 to 133 000) deaths and 3·26 million (3·03 to 3·51) DALYs due to larynx cancer globally in 2019. From 2010 to 2019, the number of new tracheal, bronchus, and lung cancer cases increased by 23·3% (12·9 to 33·6) globally and the number of larynx cancer cases increased by 24·7% (16·0 to 34·1) globally. Global age-standardised incidence rates of tracheal, bronchus, and lung cancer decreased by 7·4% (−16·8 to 1·6) and age-standardised incidence rates of larynx cancer decreased by 3·0% (−10·5 to 5·0) in males over the past decade; however, during the same period, age-standardised incidence rates in females increased by 0·9% (−8·2 to 10·2) for tracheal, bronchus, and lung cancer and decreased by 0·5% (−8·4 to 8·1) for larynx cancer. Furthermore, although age-standardised incidence and death rates declined in both sexes combined from 2010 to 2019 at the global level for tracheal, bronchus, lung and larynx cancers, some locations had rising rates, particularly those on the lower end of the SDI range. Smoking contributed to an estimated 64·2% (61·9–66·4) of all deaths from tracheal, bronchus, and lung cancer and 63·4% (56·3–69·3) of all deaths from larynx cancer in 2019. For males and for both sexes combined, smoking was the leading specific risk factor for age-standardised deaths from tracheal, bronchus, and lung cancer per 100 000 in all SDI quintiles and GBD regions in 2019. However, among females, household air pollution from solid fuels was the leading specific risk factor in the low SDI quintile and in three GBD regions (central, eastern, and western sub-Saharan Africa) in 2019. Interpretation The numbers of incident cases and deaths from tracheal, bronchus, and lung cancer and larynx cancer increased globally during the past decade. Even more concerning, age-standardised incidence and death rates due to tracheal, bronchus, lung cancer and larynx cancer increased in some populations—namely, in the lower SDI quintiles and among females. Preventive measures such as smoking control interventions, air quality management programmes focused on major air pollution sources, and widespread access to clean energy should be prioritised in these settings. Funding Bill & Melinda Gates Foundation.

Kaposi Sarcoma (KS) is endemic in several countries in Southern and Eastern Africa, relatively rare worldwide but a leading cancer among people living with HIV. KS has always been more common in adult males than females. We assessed the prevalence of known cancer modifying factors (parity, hormonal contraceptive use in females, sex-partners, smoking and alcohol consumption in both sexes), and their relationship to KS, and whether any of these could account for the unequal KS sex ratios. We calculated logistic regression case-control adjusted odds ratios (ORadj), and 95% confidence intervals (95%CI), between KS and each of the modifying factors, using appropriate comparison controls. Controls were cancer types that had no known relationship to exposures of interest (infection or alcohol or smoking or contraceptive use). The majority of the 1275 KS cases were HIV positive (97%), vs. 15.7% in 10,309 controls. The risk of KS among those with HIV was high in males (ORadj=116.70;95%CI=71.35–190.88) and females (ORadj=93.91;95%CI=54.22–162.40). Among controls, the prevalence of smoking and alcohol consumption was five and three times higher in males vs. females. We found a positive association between KS and heavy vs. non-drinking (ORadj=1.31;95%CI=1.03–1.67), and in current heavy vs. never smokers (ORadj=1.82;95%CI=1.07–3.10). These associations remained positive for alcohol consumption (but with wider CIs) after stratification by sex, and restriction to HIV positive participants. We found no evidence of interactions of smoking and alcohol by sex. Smoking and alcohol consumption may provide a possible explanation for the KS sex differences, given both exposures are more common in men, but confounding and bias cannot be fully ruled out. The role smoking and alcohol play in relation to viral loads of HIV/KSHV, differences in immunological responses or other genetic differences between males and females warrant further studies.

We reviewed the literature on the importance of selected anti-high-risk human papillomavirus (HR-HPV) antibodies (namely, 16/18 and early oncoproteins E6 and E7) as potential serological markers for early detection of individuals at high risk of cervical cancer. We searched for studies in PubMed and Embase databases published from 2010 to 2020 on antibodies against HR-HPV E6 and E7 early proteins and cervical cancer. Pooled sensitivity and specificity for HPV16 and HPV18 antibodies were calculated using a bivariate hierarchical random-effects model. A total of 69 articles were identified; we included three studies with 1550 participants. For the three HPV16/18 E6 and E7 antibody tests, enzyme-linked immunosorbent assay-based assays had a sensitivity of 18% for detecting CIN2+ (95% confidence interval [CI]: 15-21) and a specificity of 96% (95% CI: 92-98), for slot-blot, sensitivity was 28.9% (95% CI: 23.3-35.1) and specificity was 72% (95% CI: 66.6-77.0) for detecting CIN2+, and for multiplex HPV serology assay based on a glutathione S-transferase, sensitivity was 16% (95% CI: 8.45-28.6) and specificity was 98% (95% CI: 97-99) for detecting invasive cervical cancer. HR-HPV16/18 E6 and E7 serological markers showed high specificity, but sensitivity was suboptimal for the detection of cervical cancer in either population screening settings or as point-of-care screening tests.

Background This population-based cross-stional and panel study investigated disparities in the management of coronary heart disease (CHD) by level of socioeconomic status. Methods CHD patients (aged ≥18 years), treated in 438 general practices in Australia, with ≥3 recent encounters with their general practitioners, with last encounter being during 2016–2018, were included. Secondary prevention prescriptions and number of treatment targets achieved were each modelled using a Poisson regression adjusting for demographics, socioeconomic indicators, remoteness of patient’s residence, comorbidities, lifetime follow-up, number of patient–general practitioner encounters and cluster effect within the general practices. The latter model was constructed using the Generalised Estimating Equations approach. Sensitivity analysis was run by comorbidity. Results Of 137,408 patients (47% women), approximately 48% were prescribed ≥3 secondary prevention medications. However, only 44% were screened for CHD-associated risk factors. Of the latter, 45% achieved ≥5 treatment targets. Compared with patients from the highest socioeconomic status fifth, those from the lowest socioeconomic status fifth were 8% more likely to be prescribed more medications for secondary prevention (incidence rate ratio (95% confidence interval): 1.08 (1.04–1.12)) but 4% less likely to achieve treatment targets (incidence rate ratio: 0.96 (0.95–0.98)). These disparities were also observed when stratified by comorbidities. Conclusion Despite being more likely to be prescribed medications for secondary prevention, those who are most socioeconomically disadvantaged are less likely to achieve treatment targets. It remains to be determined whether barriers such as low adherence to treatment, failure to fill prescriptions, low income, low level of education or other barriers may explain these findings.

This paper delineates how a program of tobacco smoking cessation after a cancer diagnosis was achieved by engagement of multiple stakeholders, government, and non-government authorities in one jurisdiction in Australia, New South Wales. While it had become increasingly obvious that smoking cessation imparts benefits akin to other known treatment modalities, knowledge of this generalisation is without benefit unless this information is delivered in a trusted context and means to quit are made available. Against a backdrop of little enthusiasm among clinicians, the Cancer Institute NSW, charged with implementing tobacco control strategies, decided to focus its 2017 annual colloquium on the topic. While the evidence was unequivocal, better clarity was needed that this was indeed a clinical responsibility, and on the resources needed. The Clinical Oncology Society of Australia, (COSA) a non-governmental peak national body representing cancer care professionals, addressed this challenge. The society's governing body resolved to develop a position statement indicating how smoking cessation might be integrated within hospital-based cancer care. The position statement, endorsed by nineteen other cancer and non-cancer organisations, provided reassurance to the Institute to improve record capture of hospital smoking information; upskill all clinical staff and develop an automatic "patient opt out" referral to existing resources such as the Quitline. Early pilot work shows that people newly diagnosed with cancer who smoke and who were advised at that time to quit increased from 55% in 2016 to 72% in 2019.

Background: Understanding the magnitude of cancer burden attributable to potentially modifiable risk factors is crucial for development of effective prevention and mitigation strategies. We analysed results from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 to inform cancer control planning efforts globally. Methods: The GBD 2019 comparative risk assessment framework was used to estimate cancer burden attributable to behavioural, environmental and occupational, and metabolic risk factors. A total of 82 risk-outcome pairs were included on the basis of the World Cancer Research Fund criteria. Estimated cancer deaths and disability-adjusted life-years (DALYs) in 2019 and change in these measures between 2010 and 2019 are presented. Findings: Globally, in 2019, the risk factors included in this analysis accounted for 4·45 million (95% uncertainty interval 4·01-4·94) deaths and 105 million (95·0-116) DALYs for both sexes combined, representing 44·4% (41·3-48·4) of all cancer deaths and 42·0% (39·1-45·6) of all DALYs. There were 2·88 million (2·60-3·18) risk-attributable cancer deaths in males (50·6% [47·8-54·1] of all male cancer deaths) and 1·58 million (1·36-1·84) risk-attributable cancer deaths in females (36·3% [32·5-41·3] of all female cancer deaths). The leading risk factors at the most detailed level globally for risk-attributable cancer deaths and DALYs in 2019 for both sexes combined were smoking, followed by alcohol use and high BMI. Risk-attributable cancer burden varied by world region and Socio-demographic Index (SDI), with smoking, unsafe sex, and alcohol use being the three leading risk factors for risk-attributable cancer DALYs in low SDI locations in 2019, whereas DALYs in high SDI locations mirrored the top three global risk factor rankings. From 2010 to 2019, global risk-attributable cancer deaths increased by 20·4% (12·6-28·4) and DALYs by 16·8% (8·8-25·0), with the greatest percentage increase in metabolic risks (34·7% [27·9-42·8] and 33·3% [25·8-42·0]). Interpretation: The leading risk factors contributing to global cancer burden in 2019 were behavioural, whereas metabolic risk factors saw the largest increases between 2010 and 2019. Reducing exposure to these modifiable risk factors would decrease cancer mortality and DALY rates worldwide, and policies should be tailored appropriately to local cancer risk factor burden. We are grateful to the surveillance systems, including cancer registries, that generated and shared observed cancer burden data. S M Aljunid acknowledges the Department of Health Policy and Management, College of Public Health, Kuwait University for the approval and support to participate in this research project. H Ariffin acknowledges support from the Ministry of Higher Education, Malaysia (grant FRGS/1/2021/SKK0/UM/01/1). F Barra acknowledges support from Lega Italiana per la Lotta contro i Tumori - LILT - Bando 5 x 1000 anno 2019. L Belo and M Carvalho acknowledge the support from FCT in the scope of the project UIDP/04378/2020 and UIDB/04378/2020 of UCIBIO and the project LA/P/0140/2020 of i4HB. A J Cohen was supported by the Health Effects Institute, Boston, MA, USA. J Conde acknowledges financial support from the European Research Council - ERC Starting Grant 848325. V M Costa acknowledges her grant (SFRH/BHD/110001/2015), received by Portuguese national funds through Fundação para a Ciência e Tecnologia (FCT), IP, under the Norma Transitória DL57/2016/CP1334/CT0006. T C Ekundayo was supported by the African-German Network of Excellence in Science (AGNES), the Federal Ministry of Education and Research (BMBF) and the Alexander von Humboldt Foundation (AvH). N Ghith acknowledges support from a grant from Novo Nordisk Foundation (NNF16OC0021856). J C Glasbey is support by a Doctoral Research Fellowship from the National Institute of Health Research (NIHR300175). V K Gupta and V B Gupta acknowledge funding support from National Health and Medical Research Council (NHMRC), Australia. C Herteliu, A Pana, and M Ausloos acknowledge partial support by a grant of the Romanian National Authority for Scientific Research and Innovation, CNDS-UEFISCDI, project number PN-III-P4-ID-PCCF-2016-0084. C Herteliu is also partially supported by a grant of the Romanian Ministry of Research Innovation and Digitalization, MCID, project number ID-585-CTR-42-PFE-2021. S Hussain was supported from Operational Programme Research, Development and Education–Project, Postdoc2MUNI (number CZ.02.2. 69/0.0/0.0/18_053/0016952). M Jakovljevic acknowledges partial support through the grant OI 175 014 of the Ministry of Education Science and Technological Development of the Republic of Serbia. J H Kauppila acknowledges research grants from Sigrid Jusélius Foundation and the Finnish Cancer Foundation. M N Khatib acknowledges support from Datta Meghe Institute of Medical Sciences (deemed-to-be-university). Y J Kim was supported by the Research Management Centre, Xiamen University Malaysia [XMUMRF/2020-C6/ITCM/0004]. S L Koulmane Laxminarayana acknowledges institutional assistance by Manipal Academy of Higher Education, Manipal. K Krishan is supported by the UGC Centre of Advanced Study (Phase II), awarded to the Department of Anthropology, Panjab University, Chandigarh, India. I Landires is a member of the Sistema Nacional de Investigación (SNI), which is supported by Panama’s Secretaría Nacional de Ciencia, Tecnología e Innovación (SENACYT). M-C Li was supported by the Ministry of Science and Technology, Taiwan (MOST 110-2314-B-003-001). G Liu acknowledges support from the CREATE Hope scientific fellowship from Lung Foundation Australia. J Liu acknowledges support from the National Natural Science Foundation (72122001). J A Loureiro was supported by Scientific Employment Stimulus (FCT; CEECINST/00049/2018). E Mathews is supported by a Clinical and Public Health Early Career Fellowship (grant number IA/CPHE/17/1/503345) from the DBT India Alliance/Wellcome Trust Department of Biotechnology, India Alliance (2018–2023). T J Meretoja was supported by an unrestricted grant from Cancer Foundation Finland sr. S Mohammed acknowledges a fellowship grant from Alexander von Humboldt Foundation, outside the submitted work. M Molokhia is supported by the National Institute for Health Research Biomedical Research Center at Guy’s and St Thomas’ National Health Service Foundation Trust and King’s College London. L Monasta received support from the Italian Ministry of Health at the Institute for Maternal and Child Health IRCCS Burlo Garofolo, Trieste - Italy (RC 34/2017). U Mons is supported by the Marga and Walter Boll Foundation, Kerpen, Germany. M A Moosavi acknowledges the financial support of National Institute of Genetics Engineering and Biotechnology (NIGEB). J Musa acknowledges support from the NIH/FICK43TW011416 for research-protected time for cervical cancer research and career development at University of Jos. V Nuñez-Samudio is a member of the Sistema Nacional de Investigación (SNI), which is supported by Panama’s Secretaría Nacional de Ciencia, Tecnología e Innovación (SENACYT). O O Odukoya acknowledges support by the Fogarty International Center of the National Institutes of Health under the award number K43TW010704 for research-protected time. The content is solely the responsibility of all the authors and does not necessarily represent the official views of the National Institutes of Health. A S Oguntade acknowledges funding by a doctoral scholarship from the Nuffield Department of Population Health, University of Oxford (Oxford Population Health). J R Padubidri acknowledges Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal for their constant support in research collaborations. R G Pestell acknowledges support from NIH grant W81XWH1810605 Breast Cancer Research, Breakthrough Grant R21 CA235139-01. Z Z Piracha acknowledges the International Center of Medical Sciences Research (ICMSR), Islamabad (44000), Pakistan. R A Radhakrishnan acknowledges support from Wellcome Trust/DBT India Alliance - IA/CPHI/18/1/503927. U Saeed acknowledges the International Center of Medical Sciences Research (ICMSR), Islamabad, Pakistan. A M Samy acknowledges the support from Ain Shams University and the Egyptian Fulbright Mission Program. F Sha was supported by the Shenzhen Science and Technology Program (grant number KQTD20190929172835662). H R Shahsavari acknowledges the Institute for Advanced Studies in Basic Sciences (IASBS) Research Council. A Shetty acknowledges Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal for all the academic support. D A S Silva acknowledges financing in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior—Brazil (CAPES)—Finance Code 001 and D A S Silva is supported in part by CNPq-Brazil (309589/2021-5). L M L R Silva was supported by project CENTRO-04-3559-FSE-000162, Fundo Social Europeu (FSE). Am Singh is supported by the International Graduate Research Scholarship, University of Tasmania. R Suliankatchi Abdulkader acknowledges support from ICMR—National Institute of Epidemiology. B Unnikrishnan acknowledges Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal. H Xiao acknowledges support from the Public Health Sciences Division of the Fred Hutchinson Cancer Research Center. X Xu is supported by the University of New South Wales (Australia) Scientia Program. C Yu was supported by the National Natural Science Foundation of China (grant number 82173626) and Wuhan Medical Research Program of Joint Fund of Hubei Health Committee (grant number WJ2019H304). Sí

Kaposi’s sarcoma (KS) has become a common AIDS-defining cancer in sub-Saharan Africa. Kaposi’s sarcoma-associated human herpesvirus strongly modulated by HIV-related immune suppression are the principal causes of this cancer. No other risk factors have been identified as playing a strong role. HIV prevention programs and good coverage of antiretroviral therapy (ART) in developed countries resulted in a remarkable decline in HIV-KS incidence and better KS prognosis. By contrast, in sub-Saharan Africa, population ART rollout has lagged, but clinical studies have shown positive results in reduction of KS incidence and better KS prognosis. However, the effect of ART rollout in relation to population KS incidence is unclear. We describe the incidence of KS in sub-Saharan Africa, in four time-periods, (1) before 1980 (before HIV/AIDS era); (2) 1981–2000 (early HIV/AIDS era, limited or no ART coverage); (3) 2001–2010 (early ART coverage period); and (4) 2011–2016 (fair to good ART coverage period). We used KS incidence data available from WHO-International Agency for Research on Cancer (IARC) publications and the Africa Cancer Registry Network. National HIV prevalence and ART coverage data were derived from UNAIDS/WHO. A rapid increase in KS incidence was observed throughout sub-Saharan Africa as the HIV epidemic progressed, reaching peak incidences in Period 2 (pre-ART rollout) of 50.8 in males and 20.3 per 100 000 in females (Zimbabwe, Harare). The overall unweighted average decline in KS incidence between 2000 and 2010 and 2011–2016 was 27%, but this decline was not statistically significant across the region. ART rollout coincides with a decline in KS incidence across several regions in sub-Saharan Africa. The importance of other risk factors such as reductions in HIV incidence could not be ascertained.

Background In populations with high rates of human immunodeficiency virus (HIV)-coinfection, the nature of the relationship between human papillomavirus (HPV)-16 and -18 (L1, E6 and E7) antibodies and cervical cancer is still uncertain. We measured the association between seropositivity to HPV (L1, E6 and E7) proteins and cervical cancer among black South African women with and without HIV co-infection. Methods We used questionnaire data and serum collected from consecutively recruited patients with a newly diagnosed cancer from the Johannesburg Cancer Study from 1346 cervical cancer cases and 2532 controls (diagnosed with other non-infection related cancers). Seropositivity to HPV proteins was measured using a multiplex serological assay based on recombinant glutathione S-transferase (GST) fusion proteins. We measured associations between their presence and cervical cancer using unconditional logistic regression models and evaluated the sensitivity and specificity of these HPV biomarkers. Results Among controls, HIV-negative women from rural areas compared to urban had significantly higher HPV seroprevalence, HPV16 E7 (8.6% vs 3.7%) and HPV18 E7 (7.9% vs 2.0%). HPV16 E6 and E7 antibodies were positively associated with cervical cancer in HIV-positive (Adjusted Odds Ratio (AOR) = 33; 95% CI 10–107) and HIV-negative women (AOR = 97; 95% CI 46–203). In HIV-positive women, HPV E6/E7 antibodies had low sensitivity (43.0%) and high specificity (90.6%) for cervical cancer detection. In HIV-negative women, HPV E6/E7 antibodies sensitivity was 70.6% and specificity was 89.7%. Conclusions Our data show that HPV (L1, especially E6 and E7) antibody positivity is associated with cervical cancer in both HIV-positive and HIV-negative women. Nonetheless, being HIV-positive plays an important role in the development of cervical cancer.

Background: Sun exposure causes cutaneous squamous (SCC) and basal cell (BCC) carcinomas. Human papillomavirus (HPV) infection might cause SCC. Methods: We examined associations of β and γ HPV infection in skin-swab DNA and serum antibodies with skin cancer risk, and modification of the carcinogenic effects of sun exposure by them, in case–control studies of 385 SCC cases, 832 BCC cases, and 1,100 controls nested in an Australian prospective cohort study (enrolled 2006–2009). Results: Presence of β-1 and β-3 HPV DNA appeared to increase risks for SCC and BCC by 30% to 40% (P adjusted Conclusions: Our substantive findings are at the level of genus β HPV. Like SCC, BCC risk may increase with increasing numbers of β HPV types on skin. Impact: The consistency in our findings that HPV infection may moderate the effects of sun exposure, the main environmental cause of SCC and BCC, merits further investigation.

Introduction The All Causes of Death Surveillance (ACDS) system was used to measure smoking-attributed mortality by inserting questions on smoking on death certificates. Smoking status information of the deceased has been routinely collected in death certificates since 2010. We describe a death registry-based case-control study using smoking and cause-of-death data for the period 2010-15. Methods From 2010, three questions about the smoking status of the deceased were inserted in a revised death certificate: 1) Smoking status (current smoker, quit smoking, never smoker); 2) Number of cigarettes per day smoked; and 3) Number of years of smoking. A data-accuracy survey of 1788 telephone interviews of the family of the deceased was also conducted. Smoking habits (current/ex-smoker vs non-smoker) were compared in study cases (persons who died of lung cancer and other diseases known to be caused by smoking) and the controls (never smokers). Multivariate logistic regression analysis was conducted to estimate relative risks, RR (odds ratios) for smoking-attributed mortality, for lung cancer and all causes of death related to smoking, adjusted for 5-year interval age groups, education, marital status, and year of death. Results During the study period (2010-15), the annual crude death reporting rates ranged from 6.5‰ to 7.0‰. The reporting rates of smoking status, smoking history and the number of cigarettes smoked daily were 95.5%, 98.6% and 98.6%, respectively. Compared to never smokers, the RR of ever smoking in males was 1.38 (95% CI: 1.33-1.43) for all causes of smoking-related deaths and 3.07 (95% CI: 2.91-3.24) for lung cancer, while in females the values were 1.46 (95% CI: 1.39-1.54) for all causes of smoking-related deaths and 4.07 (95% CI: 3.81-4.35) for lung cancer. The results in Tianjin are in accord with published results from previous studies. Conclusions Levels and trends in smoking attributed mortality can be measured at low cost by using the stable, complete and effective ACDS system in Tianjin.

The Johannesburg Cancer Study (JCS) aims were to examine whether cancer risk factors identified in Western countries applied to black patients in Johannesburg, South Africa and to understand the impact of HIV on cancer risk, with a view to identifying previously unrecognised HIV associated cancers. A total of 24 971 black patients with an incident histologically proven (>95%) cancer of any type were enrolled between 1995-2016. Response rates were >90%. Patients provided informed consent, lifestyle and demographic information using a structured questionnaire; 19 351 provided a serum sample and 18 972 a whole blood sample for genomic analyses. This is currently the largest cancer epidemiological biobank in Africa. JCS uses a cancer case-control method; controls being cancer types unrelated to exposures of interest. Published results show the importance of HIV in several cancers known to be infection associated e.g. Kaposi sarcoma (OR = 1683; CI = 595-5194) in those with high Kaposi-sarcoma-associated-herpesvirus titres; no effect of HIV on lung or liver cancer-in the latter showing a strong association with HBVDNA, sAg and c positivity (OR = 47; CI = 21-104). Comparable data to higher-income country studies include lung cancer ORs in relation to smoking (15+g tobacco/day) (ORMales = 37; CI = 21-67, ORFemales = 18.5; CI = 8-45) and associations between alcohol and oesophageal cancer in smokers (ORM&F = 4.4; CI = 3-6). Relationship between hormonal contraception declined to null 10 or more years after stopping for breast (OR = 1.1; CI = 0.9-1.4) and cervical cancer (OR = 1.0;CI = 0.8-1.2), and protective effects shown, five or more years after stopping for ovarian (OR = 0.6; CI = 0.4-1) and endometrial cancer (OR = 0.4; CI = 0.2-0.9). Preferential access is based on data requests promoting data pooling, equal collaborative opportunities and enhancement of research capacity in South Africa. The JCS is a practical and valid design in otherwise logistically difficult settings.

We describe our experience in several settings, following a suggestion in 1983 to add questions on the smoking status of the deceased on the UK death certificate as an effective way to monitor the evolution of the smoking epidemic. In South Africa in 1997 and in Tianjin Municipality, China, in 2010, questions about the smoking habits of the deceased were inserted on the official death certificates. In both places a system now exists to routinely collect information on smoking status in relation to causes of death. Results from two million South African and 300 000 Chinese deceased individuals have been reported, and the sample size in both places continues to grow. An unsuccessful attempt was made in 2008 to insert smoking questions on the Australian death notification forms but comments and concerns from the registrars of births, marriages and deaths have international applicability. In both China and South Africa, inserting questions on smoking on the death notification forms was not a trivial task-in each it required, as a minimum, significant commitment from several government agencies. Benefits, however, include a better local understanding of the smoking epidemic and allowing for planning and monitoring of tobacco control programmes. Documenting the varied experiences of collecting information on smoking on death notification forms is useful to those wishing to introduce such questions in their own settings. This is pertinent especially at a time when vital registration systems are being improved, with an aim to monitoring sustainable development goals.

Background Over two-thirds of the world’s cancer deaths occur in economically developing countries; however, the societal costs of cancer have rarely been assessed in these settings. Our aim was to estimate the value of productivity lost in 2012 due to cancer-related premature mortality in the major developing economies of Brazil, the Russian Federation, India, China and South Africa (BRICS). Methods We applied an incidence-based method using the human capital approach. We used annual adult cancer deaths from GLOBOCAN2012 to estimate the years of productive life lost between cancer death and pensionable age in each country, valued using national and international data for wages, and workforce statistics. Sensitivity analyses examined various methodological assumptions. Results The total cost of lost productivity due to premature cancer mortality in the BRICS countries in 2012 was $46·3 billion, representing 0·33% of their combined gross domestic product. The largest total productivity loss was in China ($28 billion), while South Africa had the highest cost per cancer death ($101,000). Total productivity losses were greatest for lung cancer in Brazil, the Russian Federation and South Africa; liver cancer in China; and lip and oral cavity cancers in India. Conclusion Locally-tailored strategies are required to reduce the economic burden of cancer in developing economies. Focussing on tobacco control, vaccination programs and cancer screening, combined with access to adequate treatment, could yield significant gains for both public health and economic performance of the BRICS countries.

Introduction Physical activity (PA) has been associated with lower risk of cardiovascular diseases, but the evidence linking PA with lower cancer risk is inconclusive. We examined the independent and interactive effects of PA and obesity using body mass index (BMI) as a proxy for obesity, on the risk of developing prostate (PC), postmenopausal breast (BC), colorectal (CRC), ovarian (OC) and uterine (UC) cancers. Methods We estimated odds ratios (OR) and 95% confidence intervals (CI), adjusting for cancer specific confounders, in 6831 self-reported cancer cases and 1992 self-reported cancer-free controls from the Cancer Lifestyle and Evaluation of Risk Study, using unconditional logistic regression. Results For women, BMI was positively associated with UC risk; specifically, obese women (BMI ≥30 kg/m2) had nearly twice the risk of developing UC compared to women with healthy-BMI-range (

Background: Human papillomavirus (HPV) infection is highly prevalent worldwide and may have a role, with sun exposure, in causing cutaneous squamous cell carcinoma. Little is known about the relationship of UV exposure and seroprevalence of cutaneous HPVs in the general population. Methods: Using multiplex serology, we estimated the seroprevalence of 23 beta and 7 gamma HPVs and 7 other antigens (mu HPV1, HPV63, nu HPV41, alpha HPV16; polyomaviruses HPyV7 and MCV; p53) in a population-based sample of 1,161 Australian 45 and Up Study participants with valid data from blood specimens collected from 2010 to 2012. We calculated prevalence ratios (PR) for the association of each antigen with residential ambient solar UV and other UV-related variables. Results: Seropositivity for at least one beta or gamma HPV was high at 88% (beta HPVs 74%, gamma HPVs 70%), and less in women than men [e.g., PR beta-2 HPV38 = 0.70; 95% confidence interval (CI), 0.56–0.87; any gamma = 0.90; 95% CI, 0.84–0.97]. A high ambient UV level in the 10 years before study enrollment was associated with elevated seroprevalence for genus beta (PRtertile3vs1 any beta = 1.17; 95% CI, 1.07–1.28), and beta-1 to beta-3 species, but not for gamma HPVs. Other UV-related measures had less or no evidence of an association. Conclusions: Seroprevalence of cutaneous beta HPVs is higher with higher ambient UV exposure in the past 10 years. Impact: The observed association between ambient UV in the past 10 years and cutaneous HPVs supports further study of the possible joint role of solar UV and HPV in causing skin cancer.

ObjectivesTo determine whether sex differences exist in the management of patients with a history of coronary heart disease (CHD) in primary care.MethodsGeneral practice records of patients aged ≥18 years with a history of CHD in a large general practice dataset in Australia, MedicineInsight, were analysed. Sex-specific, age-standardised proportions of patients prescribed with recommended medications; assessed for cardiovascular risk factors; and achieved treatment targets according to the General Practice Management Plan were reported.ResultsRecords of 130 926 patients (47% women) from 438 sites were available from 2014 to 2018. Women were less likely to be prescribed with recommended medications (prescribed ≥3 medications: women 44%, men 61%; pConclusionGaps in preventative management including prescription of indicated medications and risk factor monitoring have been reported from the late 1990s and this large-scale general practice data analysis indicate they still persist. Moreover, the gap is larger in women compared to men. We need new ways to address these gaps and the sex inequity.

Prostate cancer (PC) is the most common non-cutaneous cancer in men worldwide. The relationships between PC and possible risk factors for PC cases (n = 1,181) and male controls (n = 875) from the New South Wales (NSW) Cancer, Lifestyle and Evaluation of Risk Study (CLEAR) were examined in this study. The associations between PC risk and paternal history of PC, body mass index (BMI), medical conditions, sexual behaviour, balding pattern and puberty, after adjusting for age, income, region of birth, place of residence, and PSA testing, were examined. Adjusted risk of PC was higher for men with a paternal history of PC (OR = 2.31; 95%CI: 1.70–3.14), personal history of prostatitis (OR = 2.30; 95%CI: 1.44–3.70), benign prostatic hyperplasia (OR = 2.29; 95%CI: 1.79–2.93), being overweight (vs. normal; OR = 1.24; 95%CI: 0.99–1.55) or obese (vs. normal; OR = 1.44; 95%CI: 1.09–1.89), having reported more than seven sexual partners in a lifetime (vs.

Epidemiological and mechanistic evidence on the causative role of human papillomaviruses (HPV) in esophageal squamous cell carcinoma (ESCC) is unclear. We retrieved alcohol- and formalin-fixed paraffin-embedded ESCC tissues from 133 patients seropositive for antibodies against HPV early proteins, from high-incidence ESCC regions: South Africa, China and Iran. With rigorous care to prevent nucleic acid contamination, we analyzed these tissues for the presence of 51 mucosotropic human alpha-papillomaviruses by two sensitive, broad-spectrum genotyping methods, and for the markers of HPV-transformed phenotype: (i) HPV16/18 viral loads by quantitative real-time PCR, (ii) type-specific viral mRNA by E6*I/E6 full-length RT-PCR assays and (iii) expression of cellular protein p16(INK4a). Of 118 analyzable ESCC tissues, 10 (8%) were positive for DNA of HPV types: 16 (4 tumors); 33, 35, 45 (1 tumor each); 11 (2 tumors) and 16, 70 double infection (1 tumor). Inconsistent HPV DNA+ findings by two genotyping methods and negativity in qPCR indicated very low viral loads. A single HPV16 DNA+ tumor additionally harbored HPV16 E6*I mRNA but was p16(INK4a) negative (HPV16 E1 seropositive patient). Another HPV16 DNA+ tumor from an HPV16 E6 seropositive patient showed p16(INK4a) upregulation but no HPV16 mRNA. In the tumor tissues of these serologically preselected ESCC patients, we did not find consistent presence of HPV DNA, HPV mRNA or p16(INK4a) upregulation. These results were supported by a meta-analysis of 14 other similar studies regarding HPV-transformation of ESCC. Our study does not support the etiological role of the 51 analyzed mucosotropic HPV types in the ESCC carcinogenesis.

SummaryBackgroundThere are sparse data in Africa on the association between HIV infection and deaths from underlying medical conditions. Using records from the Chris Hani Baragwanath Hospital (CHBH) in Soweto, South Africa, we determined mortality from medical conditions associated with HIV.MethodsFrom January 2006 to December 2009 AB collected data on 15,725 deaths including age, sex, day of admittance and death, HIV status, ART initiation and CD4+ cell counts and reviewed the underlying cause of death using medical notes. Conditions known to be associated with HIV were cases; conditions not associated with HIV were controls. We calculate the HIV odds-ratios for cases relative to controls and HIV-attributable deaths as the fraction of those with each condition, the disease-attributable fraction (DA), and as the fraction of all deaths, the population-attributable fraction (PAF).InterpretationThe high prevalence of HIV among those that died in the medical wards at the CHBH, especially in those below the age of 50 years, demonstrates the impact of the HIV-epidemic on adult mortality and hospital services and the extent to which early antiretroviral treatment would have reduced the burden of both. Of the deaths included in the analysis the prevalence of HIV was 61% and the prevalence of AIDS related conditions was 69%. The HIV-attributable fraction was 36% in the whole sample and 60% in those that were HIV-positive. Cryptococcosis, Kaposi’s sarcoma and Pneumocystis jeroveci are highly predictive of HIV while TB, gastroenteritis and anaemia are very strongly associated with HIV. The greatest number of deaths attributable to HIV was among those dying of TB or of other respiratory conditions.FundingNo funding was received for this study.

A small percentage of women with cervical HPV infection progress to cervical neoplasia, and the risk factors determining progression are incompletely understood. We sought to define the genetic loci involved in cervical neoplasia and to assess its heritability using unbiased unrelated case/control statistical approaches. We demonstrated strong association of cervical neoplasia with risk and protective HLA haplotypes that are determined by the amino-acids carried at positions 13 and 71 in pocket 4 of HLA-DRB1 and position 156 in HLA-B. Furthermore, 36% (standard error 2.4%) of liability of HPV-associated cervical pre-cancer and cancer is determined by common genetic variants. Women in the highest 10% of genetic risk scores have approximately >7.1% risk, and those in the highest 5% have approximately >21.6% risk, of developing cervical neoplasia. Future studies should examine genetic risk prediction in assessing the risk of cervical neoplasia further, in combination with other screening methods., Author summary Around 1% of women with cervical human papillomavirus (HPV) infection progress to cervical cancer. Previous studies had indicated that a person’s genetic makeup could predispose to HPV-associated cervical cancer, and that some of the genes likely to be involved include the immune-related human leukocyte antigen (HLA) genes among the major histocompatibility complex (MHC). However, it has been difficult to determine which alleles might be associated with cervical pre-cancer or cancer due to the complex and high level of co-inheritance of MHC alleles. Here, we performed a genome-wide association study that assessed the correlation of genetic variants among those with cervical cancer and healthy controls. We show that host genetics is a major determinant of HPV-associated cervical cancer, with 36% of liability due to common genetic variants in the population, and identify both risk and protective HLA alleles. Our study was also sufficiently powerful to identify particular residue variants on a number of the immune-related proteins that provide risk or protection, providing further insight into the biological basis for cervical cancer development. Our findings could lay the foundation for screening for people at increased risk of developing cancer following HPV infection, and aid in the treatment and prognosis of cervical cancer.

Background Human papillomavirus (HPV) vaccines protect against HPV types 16/18, but do not eliminate the need to detect pre-cancerous lesions. Australian women vaccinated as teenage girls are now entering their mid-thirties. Since other oncogenic HPV types have been shown to be more prevalent in women ≥30 years old, understanding high grade cervical lesions in older women is still important. Hormonal contraceptives (HC) and smoking are recognised cofactors for the development of pre-malignant lesions. Methods 886 cases with cervical intraepithelial neoplasia (CIN) 2/3 and 3636 controls with normal cytology were recruited from the Pap Test Register of NSW, Australia. All women were aged 30–44 years. Conditional logistic regression was used to quantify the relationship of HC and smoking to CIN 2/3 adjusted for various factors. Results Current-users of HC were at higher risk for CIN 2/3 than never-users [odds ratio (OR) = 1.50, 95%CI = 1.03–2.17] and risk increased with increasing duration of use [ORs:1.13 (0.73–1.75), 1.51 (1.00–2.72), 1.82 (1.22–2.72) for

Randomised controlled trials and large-scale observational studies have found that current use of menopausal hormone therapy (MHT) is associated with an increased risk of breast cancer; this risk is higher for oestrogen-progestagen combination therapy than for oestrogen-only therapy. Our study was designed to estimate MHT-associated breast cancer risk in a population of Australian women. Data were analysed for postmenopausal women with self-reported incident invasive breast cancer (n = 1,236) and cancer-free controls (n = 862), recruited between 2006 and 2014 into a large case-control study for all cancer types, the NSW CLEAR study. Information on past and current MHT use was collected from all participants, along with other lifestyle and demographic factors, using a self-administered questionnaire. Unmatched multivariable logistic regression was performed, adjusting for socio-demographic, reproductive and health behaviour variables, body mass index and breast screening history. Compared to never users of MHT, the adjusted odds ratio (aOR) for breast cancer in current users of any type of MHT was 2.09 (95% CI: 1.57-2.78; p < 0.0001) and for past users of any type of MHT was 1.03 (0.82-1.28; p = 0.8243). For current users of oestrogen-only and oestrogen-progestagen therapy, aORs were 1.80 (1.21-2.68; p = 0.0039) and 2.62 (1.56-4.38; p = 0.0003), respectively. These findings are consistent with those from other international observational studies, that current, but not past, use of MHT is associated with a substantially increased risk of breast cancer.

Background Continued smoking following a cancer diagnosis has adverse impacts on cancer treatment and puts individuals at risk of secondary cancers. Data on the prevalence and correlates of smoking among cancer patients are critical for successfully targeting smoking cessation interventions. Aims To explore among a sample of medical oncology outpatients (a) the prevalence of self-reported current smoking and (b) the demographic and psychosocial factors associated with self-reported smoking. Methods A heterogeneous sample of cancer patients aged 18 years or over was recruited from 1 of 11 medical oncology treatment centres across Australia. Patients completed a survey assessing the following: smoking status; socio-demographic, disease and treatment characteristics; time since diagnosis; anxiety; and depression. Factors associated with self-reported smoking were examined using a univariate and multivariate mixed-effects logistic regression. Results A total of 1379 patients returned surveys and 1338 were included in the analysis. The prevalence of current smoking was 10.9% (n = 146). After adjusting for treatment centre, patients aged 65 years and older and those without health concession cards were significantly less likely to smoke. Patients diagnosed with lung cancer and those without private health insurance were more likely to smoke. Discussion A minority of cancer patients reported continued smoking at an average time of 13 months post-diagnosis. Patients, who are younger, have been diagnosed with lung cancer and have lower socioeconomic status are at-risk groups and represent important targets for smoking cessation advice and intervention. Copyright © 2015 John Wiley & Sons, Ltd.

Background Australia commenced a publically-funded, National Human Papillomavirus (HPV) Vaccination Program in 2007 with a two year catch-up phase for females aged 12–26 years. Objective To identify the factors associated with the uptake of the HPV vaccine (which has a recommended 3-dose schedule in Australia) by young adult women vaccinated by general practitioners and community-based programs within the catch-up phase. Methods 1139 women who were eligible to receive the free HPV vaccine during the catch-up period were recruited in 2008–2009 (age 20–29 years at recruitment), in New South Wales, after having a normal (negative) cervical smear result recorded on the NSW Pap Test Register. Participants completed a self-administered questionnaire providing information on vaccination status, and sociodemographic and other factors. Results Overall, 880 (77%) women reported receiving ≥1 dose of the vaccine and 777 women (68%) reported receiving ≥2 doses. In multivariable analysis (adjusting for the period for which each woman was eligible for free HPV vaccination), uptake of ≥1 dose of the vaccine was significantly associated with being born in Australia (p < 0.01), being single (p = 0.02), being nulliparous (p < 0.01), living in a higher socioeconomic status area (p-trend = 0.03), living in more remote areas (p = 0.03), drinking alcohol (p < 0.01) and using hormonal contraceptives (p < 0.01). Although vaccinated women were more likely to have fewer sexual partners than unvaccinated women (p-trend = 0.02), they were also more likely to report a prior sexually transmitted infection (STI) (p = 0.03). Similar factors were associated with receiving ≥2 doses. Conclusions In this group, women living in higher socioeconomic status areas were more likely to be vaccinated against HPV in the catch-up phase of the national program. Although vaccinated women tended to have fewer sexual partners, they also reported prior STIs, which may be a marker of increased risk of prior exposure to HPV. The findings of this study reinforce the continuing need to prioritise equitable delivery of vaccination to various population subgroups. The study was funded by the National Health and Medical Research Council Australia (NHMRC Project Grant ID 387701) and by Cancer Council NSW.

Barrett's esophagus (BE), a common condition, is the only known precursor to esophageal adenocarcinoma (EAC). There is uncertainty about the best way to manage BE as most people with BE never develop EAC and most patients diagnosed with EAC have no preceding diagnosis of BE. Moreover, there have been recent advances in knowledge and practice about the management of BE and early EAC. To aid clinical decision making in this rapidly moving field, Cancer Council Australia convened an expert working party to identify pertinent clinical questions. The questions covered a wide range of topics including endoscopic and histological definitions of BE and early EAC; prevalence, incidence, natural history, and risk factors for BE; and methods for managing BE and early EAC. The latter considered modification of lifestyle factors; screening and surveillance strategies; and medical, endoscopic, and surgical interventions. To answer each question, the working party systematically reviewed the literature and developed a set of recommendations through consensus. Evidence underpinning each recommendation was rated according to quality and applicability.

Background Older people represent increasing proportions of the population with cancer. To understand the representivity of cancer treatments in older people, we performed a systematic literature review using PRISMA guidelines of the age distribution of clinical trial participants for three leading cancer types, namely breast, prostate, and lung. Methods We used PubMed to identify articles detailing meta or pooled-analyses of phase III, randomised controlled trials (RCTs) of survival for breast, prostate and lung cancer, published ≤5 years from 2016. We compared the age distribution of participants to that of these cancers for “More developed regions”. Results 4993 potential papers were identified, but only three papers on breast cancer, three on lung cancer, and none on prostate cancer presented the age distribution of their participants. Except for one paper of breast cancer, participants ≥70 years in all other papers were underrepresented. Conclusions We recommend the age distribution of patients be clearly reported in all clinical trials, as per guidelines. Clinical trials ought to be more representative of the populations most affected by the disease for which treatments are being tested. This should lead to better knowledge of effectiveness of treatments and better translation of trial results to optimal care of older cancer patients.

Retrospective case-control or prospective (followup) studies are important epidemiological tools and have provided useful infonnation on exposure disease associations. Prospective studies would be the ideal option, but m.any countries (Particularly in the developing world) do not have the necessary infrastructure to follow people up. Both retrospective and prospective studies are, however, som.etim. es conducted without due regard for their own lim.itations. These lim.itations are exacerbated when m.easures of exposure or disease are based on a single measurement and where the population under study is homogeneous with regard to exposure. The former is responsible for regression dilution bias and the latter for a lack of contrasts between exposure groups. Both factors would attenuate any relationship between exposure and disease. Ecological studies in epidemiology are weaker in design than case-control or prospective studies, but in some circumstances an ecological approach, which looks at the prevalence of an exposure or disorder in a number ofareas of varying disease rates, may offer some advantages.

The International Agency for Research on Cancer (IARC) and the US National Cancer Institute (NCI) have initiated a series of cancer-focused seminars [Scelo G, Hofmann JN, Banks RE et al. International cancer seminars: a focus on kidney cancer. Ann Oncol 2016; 27(8): 1382-1385]. In this, the second seminar, IARC and NCI convened a workshop in order to examine the state of the current science on esophageal squamous cell carcinoma etiology, genetics, early detection, treatment, and palliation, was reviewed to identify the most critical open research questions. The results of these discussions were summarized by formulating a series of 'difficult questions', which should inform and prioritize future research efforts.