Increased cancer mortality following a history of nonmelanoma skin cancer

CONTEXT: Cancer registries have reported an increased incidence of melanoma and certain noncutaneous cancers following nonmelanoma skin cancer (NMSC). Whether these findings were attributable to intensified surveillance, shared risk factors, or increased cancer susceptibility remains unclear. OBJECTIVE: To determine whether a history of NMSC predicts cancer mortality. DESIGN: Prospective cohort with 12-year mortality follow-up adjusted for multiple risk factors. SETTING: Cancer Prevention Study II, United States and Puerto Rico. PARTICIPANTS: Nearly 1.1 million adult volunteers who completed a baseline questionnaire in 1982. MAIN OUTCOME MEASURE: Deaths due to all cancers and common cancers. RESULTS: After adjusting for age, race, education, smoking, obesity, alcohol use, and other conventional risk factors, a baseline history of NMSC was associated with increased total cancer mortality (men's relative risk [RR], 1.30; 95% confidence interval [CI], 1.23-1.36; women's RR, 1.26; 95% CI, 1.17-1.35). Exclusion of deaths due to melanoma reduced these RRs only slightly. Mortality was increased for the following cancers: melanoma (RR, 3.36 in men, 3.52 in women); pharynx (RR, 2.77 in men, 2.81 in women); lung (RR, 1.37 in men, 1.46 in women); non-Hodgkin lymphoma (RR, 1.32 in men, 1.50 in women); in men only, salivary glands (RR, 2.96), prostate (RR, 1.28), testis (RR, 12.7), urinary bladder (RR, 1.41), and leukemia (RR, 1.37); and in women only, breast (RR, 1.34). All-cause mortality was slightly increased (adjusted men's RR, 1.03 [95% CI, 1.00-1.06]; women's RR, 1.04 [95% CI, 1.00-1.09]). CONCLUSIONS: Persons with a history of NMSC are at increased risk of cancer mortality. Although the biological mechanisms are unknown, a history of NMSC should increase the clinician's alertness for certain noncutaneous cancers as well as melanoma.     

Breast cancer epidemiology: summary and future directions

The most common cancer in US women and the 2nd leading cause of cancer death is breast cancer. Between 1980-1987 in the US. age-adjusted incidence rates of breast cancer rose rapidly. They are also rising rapidly in several Asian countries (e.g., in Japan) which have the lowest incidence rates. These rapid increases may mean that environmental factors are responsible. Incidence rates rise greatly with age until the late 40s. US women at highest risk of breast cancer are Jewish women, urban women, single women, and women living in the northern US. Women at lowest risk include Mormon and Seventh-Day Adventist women, Hispanic and Asian women, rural women, women living in the southern US, and married women. Factors that have a relative risk greater than 2 are mother and sister with history of breast cancer, especially if diagnoses at an early age; atypical epithelial cells in nipple aspirate fluid; nodular densities on the mammogram; history of cancer in 1 breast; mother or sister with history of breast cancer; biopsy-confirmed benign proliferative breast disease; hyperplastic epithelial cells without atypia in nipple aspirate fluid; and radiation to chest in moderate to high doses. Ovarian hormones appear to stimulate cell division in the breast, thus elevated levels may be risk factors. Exogenous hormones may also increase the risk. Women are exposed to these exogenous hormones through estrogen replacement therapy, progestin only pills, oral contraceptives, long-acting injectable contraceptives, and diethylstilbestrol. Postmenopausal obesity increases the risk while premenopausal obesity decreases the risk. A high fat diet in childhood and adolescence may increase the risk. Alcohol drinking may also increase the risk. Older, white, and nulliparous women are more likely to have estrogen receptor-positive cancers. Breast cancer in males tends to share the same risk factors as well as its own unique factors. Prevention of postmenopausal obesity is the only established primary prevention effort. Screening is the only secondary prevention means.     

Epidemiologic aspects of gallbladder cancer: a case-control study of the SEARCH Program of the International Agency for Research on Cancer

BACKGROUND: There are few previous epidemiologic studies of gallbladder cancer, a rare but nearly always lethal gastrointestinal cancer with a demonstrated greater frequency in adult women and older subjects of both sexes, and also in the members of populations throughout central and eastern Europe and certain racial groups such as native American Indians. Unfortunately, the prospects for the prevention of this form of cancer are poor. PURPOSE: Our purpose in conducting this study was to investigate possible new risk factors for gallbladder cancer and to strengthen our understanding of established causal agents that may be involved in this disease. METHODS: A large, collaborative, multicenter, case-control study of cancer of the gallbladder was conducted in five centers located in Australia (Adelaide), Canada (Montreal and Toronto), The Netherlands (Utrecht), and Poland (Opole) from January 1983 through July 1988. Case subjects with gallbladder cancer were accrued by the centers from hospital pathology records and from reports to regional cancer registries. Cancer diagnosis was confirmed by either biopsy, cholecystectomy, or at the time of autopsy. Control subjects were randomly assigned at each center from the population. The pooled analysis included 196 case subjects and 1515 control subjects (who did not report previous cholecystectomy). Ninety-eight percent of the subjects were white. Personal interviews of case subjects, control subjects, and surrogates (spouse or next of kin) were conducted by trained personnel. RESULTS: After adjusting for potential confounding factors (age, sex, center, type of interview, years of schooling, alcohol intake, and lifetime cigarette smoking), a history of gallbladder symptoms requiring medical attention (e.g., reduced bile secretion from the gallbladder into the small intestine due to obstructions of the common bile or cystic ducts) was the major risk factor associated with this form of cancer (odds ratio [OR] = 4.4; 95% confidence interval [CI] = 2.6-7.5). This association was present even in subjects who had their first gallbladder examination because of symptoms present more than 20 years earlier (OR = 6.2; 95% CI = 2.8-13.4). Other variables associated with gallbladder cancer risk included an elevated body mass index, high total energy intake, high carbohydrate intake (after adjustment for total energy intake), and chronic diarrhea. All of these risk factors have been previously associated with gallstone disease. CONCLUSIONS: These findings are consistent with a major role of gallstones, or risk factors for gallstones, in the cause of gallbladder cancer. Additional information on whether or not screening high-risk subjects for gallstones or gallbladder cancer is needed.     

Usefulness of K-ras gene mutation at codon 12 in bile for diagnosing biliary strictures

Point mutations of the K-ras gene at codon 12 are often detected in the pancreatic juice of patients with pancreatic cancer. Detection of these mutations may, thus, have diagnostic implications. K-ras mutations may also have diagnostic potential for other biliary tumors. We sought to detect K-ras mutations in DNA obtained from bile in patients with biliary tract cancers, pancreatic cancer and benign biliary disease but who had obstructive jaundice. In 35 patients, bile was collected during percutaneous transhepatic choledocal drainage (PTCD) catheters. K-ras gene mutations at codon 12 in the samples were examined using mutant-allele-specific-amplification (MASA). We compared these results with cytological analyses of bile. K-ras mutations at codon 12 in bile were detected in 11 of 14 (79%) of the patients with biliary duct cancer, 3 of 9 (33%) with pancreatic cancer but not in patients with gallbladder cancer (n=3), papilla of Vater's cancer (n=3) or benign biliary diseases (n=6). In the patients, where cytological evaluation did not reveal malignant cells, K-ras mutations in bile were detected in 5 of 7 (71%) patients with biliary duct cancer and 2 of 5 (40%) with pancreatic cancer. This approach, when used in conjunction with bile cytology, may improve the yield in diagnosing suspected malignant tumors of the pancreatic-biliary system.     

The "epidemic" of breast cancer in the U.S.--determining the factors

Breast cancer incidence rates in the United States rose by 24% between 1973 and 1991. Mortality during this period, however, remained stable. Both the 5-year relative survival rate and the rates of in situ and stage I breast cancers have been increasing, while the incidence of later-stage cancers has been decreasing. Increased mammography screening may explain the documented jump in breast cancer incidence rates during the mid-1980s. Differences in the distribution of breast cancer risk factors may account, in part, for the temporal trends in breast cancer incidence. In particular, breast cancer risk factors may vary by birth cohort, including age at menarche, age at first birth, physical activity, obesity, diet, alcohol intake, estrogen therapy, and exposure to environmental organochlorines. After decades of epidemiologic research, a preventive approach to breast cancer that focuses on the physiologic effects of the sex steroid hormones, and their potential interactions with family history, is being carefully formulated.     

Biliary lithiasis in the elderly patient: morbidity and mortality due to biliary surgery

BACKGROUND/AIMS: Diseases of the biliary tract are the most common conditions requiring intra-abdominal surgery in elderly patients. Complications and adverse outcomes of gallstones are more frequent in older people. The present study was undertaken to analyze factors that contributed to overall morbidity and mortality after open cholecystectomy. Laparoscopic surgery and other new techniques were compared with the open method. METHODOLOGY: We studied retrospectively 76 patients that were 80 years and older. Each patient underwent operation in our unit. 40 patients had fewer than 30 days of clinical history, and 69 patients (90.8%) were emergency admissions. From a clinical point of view, 33 patients (43.4%) had jaundice on arrival and 21 (27.6%) fever. The operative findings included gallbladder wall infection in 46 patients (60.5%) and common bile duct stones in 25. Uni- and multivariate analysis was performed to discriminate variables in mortality and morbidity. RESULTS: Nine patients (11.8%) died, and 38 had complications in the postoperative period. The main causes of death were pulmonary complications (4) and multisystem organ failure (3). Morbidity was mainly due to wound infection (14), urinary infection (13) and respiratory disease (10). Three variables influenced morbidity: sex (male), cardiovascular disease and jaundice upon admission. In the regression model only cardiovascular disease and jaundice were of independent influence. The mortality rate was associated with pre-operative jaundice. CONCLUSIONS: Mortality and morbidity are related mainly to preoperative presentation. Jaundice is the main determinant of the outcome.     

Pathophysiology of gallstone formation

There are two types of gallstones: cholesterol and pigment stones. The pathogenesis is divided into three phases: supersaturation, nucleation and stone growth. Hypersecretion of biliary cholesterol, crystallization promoting and inhibiting factors, gallbladder hypomotility, arachidonyl lecithin, prostaglandins, mucin and calcium play an important role in the formation of gallstones. For the formation of pigment stones a decreased secretion of biliary acids, an increased secretion of unconjugated bilirubin into the bile and an infection of the biliary tract are the most important causative factors.     

Women and cancer

Cancer will be diagnosed in more than a half a million women this year. Prognosis and curability are associated with the stage of the cancer at diagnosis. If cancer is detected at an early stage, more than 75% of women can expect long-term survival or cure for the most common cancers, excluding lung. Promoting health behaviors that reduce risk and recommending screening tests are critical activities for the practitioner that may affect survival rates and quality of life of women with cancer diagnoses. Risk factors, incidence, presenting symptoms, staging, treatment and 5-year survival rates associated with 12 major cancer sites in women are presented. Diagnosis and survival for minority populations are reviewed, highlighting the need to improve cancer screening and detection for this group of women.     

Estimation and projections of colorectal cancer trends in Italy

BACKGROUND: Occurrence of and prognosis for tumours of the colon and rectum are thought to be changing rapidly due to simultaneous changes in risk factor prevalence, early diagnosis and treatment. In this paper time trends of morbidity, survival and mortality for colorectal cancer during the period 1970-1990 are estimated and analysed. METHODS: Mortality trends were obtained from official death certificates. Relative survival rates were computed from population-based cancer registries. Incidence and prevalence rates were estimated from mortality and survival data. RESULTS: Incidence rates were increasing during the period considered, with a lower rate of increase for the youngest birth cohorts. Relative survival rates of both colon and rectum cancers were higher for women, and for younger age groups, and were positively associated with period of diagnosis. No significant survival difference among the cancer registries used was found. A total of about 155,000 prevalent cases, 40% of which had been diagnosed > or = 7 years before, were estimated in the Italian population for the year 1990. Mortality rates were slightly increasing for men and stable for women. Projections of colorectal cancer trends to the year 2000 indicate major expected rises in both incidence and prevalence. CONCLUSION: Colorectal cancer represents a problem of growing impact for health services in Italy. This conclusion can probably be extended to many developed countries.     

Enlarged fetal gallbladder: prognostic importance for aneuploidy or biliary abnormality at antenatal US

PURPOSE: To test the strength of the association of cholecystomegaly with aneuploidy and biliary abnormality and to assess the prognostic importance of the detection of an enlarged fetal gallbladder at antenatal ultrasonography (US). MATERIALS AND METHODS: Gallbladder size was prospectively evaluated during 842 consecutive second-and third-trimester US examinations in 775 fetuses. The area of the gallbladder was calculated on the image that depicted the maximal gallbladder size, and the actual gallbladder areas was compared with the gallbladder area expected on the basis of the gestational age. Fetuses with an enlarged gallbladder were followed up. RESULTS: Forty-three fetuses had an enlarged gallbladder (area more than 2 SDs above the mean for gestational age). Outcome was normal in 38 of the 39 fetuses who could be followed up. With the exception of a single baby with an isolated ventricular septal defect, which closed spontaneously, none of the babies with an enlarged fetal gallbladder had structural anatomic defects or evidence of aneuploidy or a biliary tract abnormality. CONCLUSION: Identification of an enlarged gallbladder at antenatal US does not appear to be associated with a substantially increased risk of chromosomal aneuploidy or biliary tract malformation.     

The global burden of cancer

The number of new cancer cases, and the annual incidence rates, of 25 different cancers have been estimated for the year 1990 for every country of the world. The distributions of the most common cancers in men and women are presented for 23 broad 'Areas'. The total number (excluding non-melanoma skin cancer) was 8.1 million, just over half of which occur in the developing countries. The most common cancer is lung cancer, which accounts for 18% of cancers of men worldwide. Stomach cancer is second in frequency (almost 10% of all new cancers) and breast cancer--by far the most important cancer of women (21% of the total) is third. There are very large differences in the relative importance of the different cancers by world area; some of the factors, environmental and genetic, underlying the geographic distributions, are discussed.     

Colorectal cancer incidence and survival among Alaska Natives, 1969-1993

BACKGROUND: Although colorectal cancer rates are low among most groups of Native Americans in North America, rates for Alaska Natives have been substantially elevated compared with US rates for all races combined. METHODS: To better describe the epidemiology of colorectal cancer incidence and survival among Alaska Natives, stratified by gender and tribal/ethnic affiliation, we examined data collected by the Alaska Native Cancer Registry 1969-1993. We calculated age-adjusted and age-specific incidence as well as actuarial survival rates, and examined histological type, site, stage at diagnosis, and treatment. We compared these data to colorectal cancer data from whites living in western Washington. RESULTS: In all, 587 colorectal cancer cases were identified among Alaska Natives over the 25-year period, for an age-adjusted annual incidence rate of 71.4/100000 in women, and 69.3/100000 in men. Compared to Alaska Indians, colon cancer rates were significantly higher in Aleuts (relative risk [RR] = 1.6, 95% CI: 1.2-2.2) and in Eskimos (RR = 1.5, 95% CI: 1.2-1.8), while rectal cancer rates did not differ by race/ethnicity. Alaska Natives experienced a 50% higher incidence rate of colorectal cancer overall compared to western Washington whites (RR = 1.5, 95% CI: 1.3-1.6), although rectal cancer rates were similar in the two populations. The highest RR were seen among Alaska Native women; Aleuts and Eskimos had colon cancer rates more than twice that of western Washington white women. No unusual qualitative features were found in the cancers occurring in Alaska Natives. Actuarial colorectal cancer survival rates for Alaska Natives overall were 74% at one year and 42% at 5 years; these rates were very similar to those observed for the western Washington population. Both one and 5-year survival rates showed a significant trend towards improvement over time. CONCLUSIONS: Alaska Natives had substantially higher colorectal cancer incidence rates compared to western Washington whites. Rates were particularly high for Aleut and Eskimo women. These data suggest a need for intensified secondary prevention strategies for this high-risk population, while further research is needed to identify modifiable risk factors.     

Efficacy of bilateral prophylactic mastectomy in women with a family history of breast cancer

BACKGROUND: Options for women at high risk for breast cancer include surveillance, chemoprevention, and prophylactic mastectomy. The data on the outcomes for surveillance and prophylactic mastectomy are incomplete. METHODS: We conducted a retrospective study of all women with a family history of breast cancer who underwent bilateral prophylactic mastectomy at the Mayo Clinic between 1960 and 1993. The women were divided into two groups - high risk and moderate risk - on the basis of family history. A control study of the sisters of the high-risk probands and the Gail model were used to predict the number of breast cancers expected in these two groups in the absence of prophylactic mastectomy. RESULTS: We identified 639 women with a family history of breast cancer who had undergone bilateral prophylactic mastectomy: 214 at high risk and 425 at moderate risk. The median length of follow-up was 14 years. The median age at prophylactic mastectomy was 42 years. According to the Gall model, 37.4 breast cancers were expected in the moderate-risk group; 4 breast cancers occurred (reduction in risk, 89.5 percent; P<0.001). We compared the numbers of breast cancers among the 214 high-risk probands with the numbers among their 403 sisters who had not undergone prophylactic mastectomy. Of these sisters, 38.7 percent (156) had been given a diagnosis of breast cancer (115 cases were diagnosed before the respective proband's prophylactic mastectomy, 38 were diagnosed afterward, and the time of the diagnosis was unknown in 3 cases). By contrast, breast cancer was diagnosed in 1.4 percent (3 of 214) of the probands. Thus, prophylactic mastectomy was associated with a reduction in the incidence of breast cancer of at least 90 percent. CONCLUSIONS: In women with a high risk of breast cancer on the basis of family history, prophylactic mastectomy can significantly reduce the incidence of breast cancer.     

Clinical experience with heart transplantation in infants

Patients with typical symptoms of biliary tract disease but no gallstones on ultrasonography may benefit from cholecystectomy for presumed chronic acalculous cholecystitis. We retrospectively analyzed the outcome of 50 patients with a preoperative diagnosis of chronic acalculous cholecystitis based upon history (chronic or recurrent, postprandial right upper quadrant abdominal pain), the absence of acid-peptic disease, and normal biliary sonography treated with laparoscopic cholecystectomy (LC) and transcholecystic cholangiography from 1991 to 1996. All patients had preoperative cholecystokinin-stimulated hepatobiliary scintigraphy (CCK-HBS). There were 42 women and 8 men with a mean age of 43 years. CCK-HBS was abnormal in 45 patients (< or = 35 per cent gallbladder ejection fraction or nonfilling of the gallbladder). There was no postoperative mortality and one morbidity (urinary retention). All patients had microscopic evidence of chronic cholecystitis. At mean follow-up of 30 months, (range, 7-62 months) 39 patients (78%) were free of abdominal pain. Thirty-five of 45 patients with abnormal CCK-HBS were pain free (positive predictive value, 0.78). Four of five patients with normal CCK-HBS were pain free (negative predictive value, 0.20). The positive and negative likelihood ratios for CCK-HBS were 0.99 and 1.13, respectively, confirming that this test was not useful for predicting benefit from LC. Seven patients with persistent right upper quadrant pain had abnormal postoperative sphincter of Oddi manometry; they improved after endoscopic sphincterotomy. Patients with symptoms typical of biliary colic with normal gallbladder sonography and absence of acid-peptic disease benefit from LC in the majority of cases. Those who remain symptomatic after LC may benefit from endoscopic retrograde cholangiopancreatography with sphincter of Oddi manometry and endoscopic sphincterotomy when manometry is abnormal.     

Squalene promotes the formation of non-bilayer structures in phospholipid model membranes

From the study on correlation between the depth of cancer invasion and the results of surgery, early cancer of the biliary tract may be defined as cancer cell invasion limited to the mucosal or muscularis propria in the case of carcinoma of the gallbladder, and to the mucosal or fibro-muscular layer in the case of carcinoma of the bile duct. With few exceptions, these tumors had no lymph node metastasis, venous invasion, perineural infiltration or involvement of the lymphatic vessels. Since the cumulative 5-year survival rate was 100% after resection of early cancer, the choice of surgical procedures was considered to be extended cholecystectomy for early cancer of the gallbladder, and the standard radical resective operation for early cancer of the bile duct. An accurate diagnosis was not made preoperatively in most cases of early cancer of the biliary tract. The diagnostic approach is discussed, including the recently developed imaging modalities, such as endoscopic ultrasonography and percutaneous transhepatic cholecystoscopy or cholangioscopy.     

A description of age, sex, and site distributions of colon carcinoma in three geographic areas

BACKGROUND: Site of the carcinoma within the colon in relation to age and sex may provide clues into the etiology of the disease. Incidence of colon carcinoma by age, sex, and tumor site at a population-based level are reported infrequently. The goal of this study was to describe the distribution of colon carcinoma (excluding cancers of the rectosigmoid junction and rectum) by age at diagnosis, sex, and site of the tumor within the colon. These factors were also evaluated in conjunction with disease stage at the time of diagnosis. METHODS: Data from three geographically distinct populations were used to describe rates of colon carcinoma and the distribution of tumors by age, tumor site, and stage at diagnosis. All colon carcinoma cases diagnosed within a 3-year period within the areas are included. RESULTS: Approximately 50% of all cancers in men and greater than 50% of cancers in women were in the proximal segment of the colon. Men who were diagnosed prior to age 50 and both men and women diagnosed at age 70 or older had predominantly proximal cancers. People with proximal cancers and people diagnosed prior to age 50 were more likely to have more advanced disease. CONCLUSIONS: Both men and women have more proximal cancers with advancing age, which are associated with more advanced disease. Observed trends in cancer site distributions could reflect screening practices, environmental and genetic factors, or a combination of these variables.     

Cancer incidence in Alaska natives

A survey of cancer incidence among Alaska Natives for the 5-year period 1969-73 revealed fewer cancer cases overall than expected in relation to US rates, but significantly increased risk for certain cancer sites: the nasopharynx in both sexes (with excesses over 15-fold), the liver in males, and the salivary glands, gallbladder, kidney and thyroid in females. Compared with earlier reports, the observations suggest marked changes in cancer incidence among Alaska Natives over the past two decades, with declines in esophageal and invasive cervical cancers, and increases in cancers of the lung, colon and rectum.     

Patterns of cancer mortality among Native Americans

BACKGROUND: Native Americans have been reported to have lower cancer incidence and mortality than other racial groups in the U.S., although some have questioned whether this was due to racial misclassification. This study provides improved estimates of cancer mortality, determined from a sampling of people who live on Indian reservations. METHODS: The authors reviewed death certificates from U.S. counties that contain Indian lands, excluding certain areas with known problems of racial misclassification. Age-adjusted mortality rates for specific types of cancer were calculated using U.S. Census population figures, and these rates were compared with rates for all races in the U.S. RESULTS: This sample included 38% of the American Indian and Alaska Native populations. The age-adjusted annual mortality rate for all cancers combined was 148.2 per 100,000 for both genders, 133.1 for females, and 167.2 for males. The rates for males and for both genders combined, but not for females, were significantly lower than the U.S. rates for all races (P < 0.05). Females had significantly lower rates of death from carcinoma of the lung and breast and significantly higher rates of death from carcinoma of the cervix and gallbladder (P < 0.05). Males had significantly lower rates of death from carcinoma of the lung, colon, and prostate, and significantly higher rates of liver carcinoma. Both genders combined had significantly lower rates of death from lung and colon carcinoma and significantly higher rates of death from stomach, liver, kidney, and gallbladder carcinoma. Geographic differences were substantial, with the Northern and Plains regions experiencing much higher mortality from lung, colon, and breast carcinoma than the Southwest region. CONCLUSIONS: Compared with the general U.S. population, Native Americans experience quite different patterns of cancer mortality. Cancer prevention and control programs should be designed specifically for this minority population.     

Cancer incidence, mortality and survival: trends in four leading sites

Cancer mortality rates in the United States have stabilized in the past few years after rising for more than 50 years. Incidence and mortality rates for all cancers tend to be higher among men than women, among blacks than whites and among those over age 65. In 1994 cancer of the lung, prostate, breast, and colon/rectum (colorectal) will account for an estimated 57 percent of all new cancer cases and 55 percent of cancer deaths. Analysis of incidence, mortality and survival rates of these four major cancers indicate some encouraging trends. That is, even though age-adjusted incidence rates continue to increase, it appears that educational and screening efforts are having a positive influence on mortality rates. Lung cancer incidence has declined in recent years following a decrease in smoking among men that began some 20 years ago; evidence also indicates a start of a declining trend in their mortality from this disease, as well. Lung cancer incidence and mortality rates among women, however, continue to rise. In 1986 lung cancer became the leading cause of cancer deaths among women. Increased use and improved techniques of cancer detection for prostate, breast and colorectal cancers are resulting in larger numbers of these cancers being detected at early stages when they are more readily treatable. It is hoped that such activities will ultimately reduce mortality for these three major cancer sites.     

Lung cancer mortality in Casale Monferrato (Italy) and attributable risk to occupations in the asbestos-cement production

The study presents mortality rates for lung cancer in the town of Casale Monferrato, where the largest Italian asbestos cement-plant was located. Cases of lung cancer dying in 1989-94 were exhaustively searched for in the register of deaths. Each case of lung cancer has been identified as ever or never employed in the factory with a linkage to the rosters of employees in the plant. Women were also identified as ever or never married to an asbestos-cement worker. The number of person-years at risk for asbestos cement workers and their wives was measured on the basis of the most recent follow-up. Mortality rates were computed separately for those exposed (workers and wives of workers) and for those with no evidence of exposure. Mortality rates for non-exposed were similar to rates in Piedmont (the region where Casale is located). The relative risk (ever exposed vs. never exposed) was 2.8 among men and 2.1 among women. Attributable risk among the exposed was 64.5% for men and 53.1% for women while among the general population it was 18.1% for men and 13.2% for women. The study confirms the dramatic effect of occupational asbestos exposure in Casale Monferrato but does not suggest an increase in lung cancer mortality among people with no occupational activity in the asbestos-cement production.