Women should not exceed one drink/day, and women at elevated risk for breast cancer should avoid alcohol or consume alcohol occasionally only.

The existing data provide little detail about the epidemiology of pediatric cancers in Mozambique. We aimed at characterizing the spectrum of pediatric cancers (0-14 years) diagnosed in Mozambique in two different calendar periods. Data were obtained from the Pathology Department of the Maputo Central Hospital (DP-HCM) (1999-2000 and 2009-2010), which receives virtually all samples for histopathological diagnosis in Maputo, with the exception of leukemia, and from the population-based Cancer Registry of Beira (2009-2010). In 1999-2000, the DP-HCM diagnosed 61 cancers. Burkitt lymphoma, malignant bone tumors, and rhabdomyosarcomas accounted for 24.6%, 11.5%, and 9.8% of all cases, respectively. In 2009-2010, the number of cancers increased to 150, reflecting a two- to threefold increase in the proportion of Kaposi sarcomas, non-Hodgkin lymphomas, nephroblastomas, and neuroblastomas. In 2009-2010, the Cancer Registry of Beira registered 34 cases, corresponding to an incidence rate of 9.7/100,000 inhabitants in this age group; Kaposi sarcomas, lymphomas, retinoblastomas, and nephroblastomas accounted for 29.4%, 23.5%, 8.8%, and 8.8% of all cases, respectively. These data show that pediatric cancers account for an appreciable burden in Mozambique, probably reflecting a high frequency of HIV-associated cancers and improved access to diagnosis, and highlight the potential for improving surveillance in this low resource setting.

The sensitivity analyses suggested in the Letter to the Editor by de Vries et al. was performed, but no material change in relative risk for bladder cancer was found. This is not surprising given the limited contribution of the studies excluded in the sensitivity analyses.

The substantial decreases in CVD mortality over the last decades have overcome the impact of the growth and ageing of populations in the overall number of deaths, while stabilization in the number of cancer deaths was observed only in some of the high-income countries.

Background: data on the prevalence of use, beliefs and attitude towards doping substances and practices among Italian athletes are scarce. Methods: we interviewed 508 Italian athletes in sports facilities, using an anonymous structured questionnaire to collect information on the athletes’ beliefs about the role in performance and side effects of selected doping practices and substances, the reasons for use, obstacles in obtaining drugs, responsibility in the decision, changes in use in recent years, and anti-doping controls. Results: among the athletes, 88.2% believed that supplements were effective to improve performance and 4.8% that they were potentially dangerous. They believed that 87.0% of top-level athletes frequently use supplements, namely 69.1% anti-inflammatories and 56.9% creatine. Doping was widespread in the opinion of 87.4% of athletes, and 45.3% thought it was used at all competition levels. Among those interviewed, 43.9% reported that athletes and coaches together were responsible for use, and 25.2% that it was easy to obtain substances. Lastly, 34.8% believed that doping use increased during 2002-05, and 54.7% thought that anti-doping controls should be more frequent. Conclusions: this survey indicates that athletes believe that doping (mainly supplement use) is widespread at all competition levels, that athletes are aware of the seriousness of adverse effects and ask for more severe control and emphasis on potential dangers in the press.

We thank Drs. Franceschi and Vaccarella1 for their interest in our work, and for the additional comments and insights they provided on the recent apparent epidemic of early papillary thyroid cancers.2 The choice of the scales in figures of trends in rates in different countries remains arbitrary. The use of different scales for various countries optimizes the within-country information, whereas the use of a single scale for all countries optimizes the between-country comparison; however, it makes difficult to investigate country-specific trends, in particular for those with low rates. A key observation by Drs. Franceschi and Vaccarella is that the rise in female thyroid cancer incidence over the last two decades has been largely heterogeneous across selected high-income countries providing data, and that there are at least three countries (Denmark, UK and Japan) where the rise has been modest in absolute terms—though not in relative ones—as indicated in Figure 5. Such a moderate rise has already been observed in selected well-surveilled populations.3 Drs. Franceschi and Vaccarella attributed the relatively modest absolute rise in thyroid cancer incidence in Denmark, UK and Japan to different organization in their health systems and in their utilization of innovative diagnostic practices, although the quantification of the role of these factors remains elusive. We agree with Drs. Franceschi and Vaccarella that overdiagnosis of thyroid cancer can have serious long-term consequences, and that more conservative approaches to the management of low-risk thyroid cancers are required. We also agree that the implementation of randomized clinical trials on such management would assist in providing evidence-based indications. The authors thank Mrs I. Garimoldi for editorial assistance.

Cigar and pipe smoking are considered risk factors for head and neck cancers, but the magnitude of effect estimates for these products has been imprecisely estimated. By using pooled data from the International Head and Neck Cancer Epidemiology (INHANCE) Consortium (comprising 13,935 cases and 18,691 controls in 19 studies from 1981 to 2007), we applied hierarchical logistic regression to more precisely estimate odds ratios and 95% confidence intervals for cigarette, cigar, and pipe smoking separately, compared with reference groups of those who had never smoked each single product. Odds ratios for cigar and pipe smoking were stratified by ever cigarette smoking. We also considered effect estimates of smoking a single product exclusively versus never having smoked any product (reference group). Among never cigarette smokers, the odds ratio for ever cigar smoking was 2.54 (95% confidence interval (CI): 1.93, 3.34), and the odds ratio for ever pipe smoking was 2.08 (95% CI: 1.55, 2.81). These odds ratios increased with increasing frequency and duration of smoking (Ptrend ≤ 0.0001). Odds ratios for cigar and pipe smoking were not elevated among ever cigarette smokers. Head and neck cancer risk was elevated for those who reported exclusive cigar smoking (odds ratio = 3.49, 95% CI: 2.58, 4.73) or exclusive pipe smoking (odds ratio = 3.71, 95% CI: 2.59, 5.33). These results suggest that cigar and pipe smoking are independently associated with increased risk of head and neck cancers.

The aim of the study was to identify and quantify the reasons for the high bladder cancer rates in Turkey. We conducted a case-control study in Manisa, Turkey, in 2011. The study included 173 patients with incident, histologically confirmed bladder cancer and 282 controls who were frequency matched by age, sex and geographic area, admitted to the main hospital of Manisa for a wide range of acute diseases. Adjusted odds ratios (ORs) and the corresponding 95% confidence intervals (CIs) were derived from multiple logistic regression models. Compared with never smokers, the OR was 2.9 (95% CI 1.5-5.4) for moderate (<20 cigarettes/day) and 4.0 (95% CI 1.7-9.6) for heavy smokers. The association was stronger for unfiltered black tobacco (OR=5.4) and for longer duration of smoking (≥40 years, OR=5.3). There was a strong inverse correlation with social class indicators, with ORs of 0.2 (95% CI 0.1-0.4) for more-educated compared with less-educated individuals. There was no significant association with a group of five occupations a priori defined as being of high risk (OR=1.3), nor with farming (OR=1.2). Bladder cancer risk was directly related to the history of urinary tract infections (OR=1.9, 95% CI 1.2-3.1) but not to diabetes (OR=0.7) or kidney (OR=0.7) and prostate (OR=1.3) diseases. Tobacco is the major risk factor for bladder cancer in Manisa, being responsible for 56% of cases; urinary tract infections account for 19% of cases, whereas the role of occupational exposure is limited in this, predominantly rural, population.

There are suggestions of an anticancerogenic effect of allium vegetables and their associated organosulfur components against several cancer types, including gastric cancer, but the issue remains open to discussion and quantification. The present critical review discussed the history, the health properties, the chemistry, the anticancerogenic evidences from experimental studies, and the anticancer mechanisms of allium vegetables. We also summarized findings from epidemiological studies concerning the association between different types of allium vegetables and gastric cancer risk, published up to date. Available data, derived mainly from case-control studies, suggested a favorable role of high intakes of allium vegetables, mainly garlic and onion, in the etiology of gastric cancer. In particular, of 10 studies, 7 suggested a favorable role of high intake of total allium vegetables and gastric cancer. All 14 studies on garlic and most studies on onion (more than 80%) reported a beneficial role of these allium types against gastric cancer. However several limitations, including possible publication bias and the difficulty to establish a dose-risk relationship, suggest caution in the interpretation. Evidences on other types of allium vegetables, as well as on the influence of different gastric cancer anatomical and histological types, are less consistent.