Fração atribuível populacional: planejamento de ações de prevenção de doenças no Brasil

Epidemiology is the study of occurrence, distribution and determinants of health-related events, including the application of that knowledge to the prevention and control of health problems. However, epidemiological studies, in most cases, have limited their research questions to determinants of health outcomes. Research related to the application of knowledge for prevention and control of diseases have been neglected. In this comment, we present a description of how population attributable fraction estimates can provide important elements for planning of prevention and control of diseases in Brazil.Epidemiologia é o estudo da ocorrência, distribuição e determinantes de eventos relacionados à saúde da população, incluindo a aplicação desse conhecimento para a prevenção e o controle dos problemas de saúde. Entretanto, estudos epidemiológicos, na maioria das vezes, têm limitado suas perguntas de pesquisa aos fatores determinantes de desfechos em saúde. Pesquisas relacionadas à aplicação do conhecimento para ações de prevenção e controle de doenças têm sido negligenciadas. Nesse comentário, apresentamos uma descrição de como as estimativas de fração atribuível populacional podem fornecer importantes elementos para planejamento de ações de prevenção e controle de doenças no Brasil

Why precision medicine is not the best route to a healthier world

Precision medicine has been announced as a new health revolution. The term precision implies more accuracy in healthcare and prevention of diseases, which could yield substantial cost savings. However, scientific debate about precision medicine is needed to avoid wasting economic resources and hype. In this commentary, we express the reasons why precision medicine cannot be a health revolution for population health. Advocates of precision medicine neglect the limitations of individual-centred, high-risk strategies (reduced population health impact) and the current crisis of evidence-based medicine. Overrated “precision medicine” promises may be serving vested interests, by dictating priorities in the research agenda and justifying the exorbitant healthcare expenditure in our finance-based medicine. If societies aspire to address strong risk factors for non-communicable diseases(such as air pollution, smoking, poor diets, or physical inactivity), they need less medicine and more investment in population prevention strategies

Preventable fractions of colon and breast cancers by increasing physical activity in Brazil: perspectives from plausible counterfactual scenarios

Background: Physical activity is associated with lower risk of colon and breast cancers. Herein we estimated preventable fractions of colon and breast cancers in Brazil by increasing population-wide physical activity to different counterfactual scenarios. Methods: We used data from a representative national survey in Brazil and corresponding relative risks of colon and postmenopausal breast cancers from a meta-analysis. Estimated cancer incidence was retrieved from GLOBOCAN and Brazilian National Cancer Institute. Five counterfactual scenarios for physical activity were considered: (i) theoretical minimum risk exposure level (≥8,000 metabolic equivalent of tasks-minute/week – MET-min/week); (ii) physical activity recommendation (≥600 MET-min/week); (iii) a 10% reduction in prevalence of insufficient physical inactivity (<600 MET-min/week); (iv) physical activity level in each state equals the most active state in Brazil; (v) closing the gender differences in physical activity. Results: About 19% (3,630 cases) of colon cancers and 12% (6,712 cases) of postmenopausal breast cancers could be prevented by increasing physical activity to ≥8,000 MET-min/week. Plausible counterfactual scenarios suggested the following impact on cancer prevention: reaching physical activity recommendation: 1.3% (1,113 cases) of breast and 6% (1,137 cases) of colon; 10% reduction in physical inactivity prevalence: 0.2% (111 cases) of breast and 0.6% (114 cases) of colon; most active state scenario: 0.3% (168 cases) of breast and 1% (189 cases) of colon; reducing gender differences in physical activity: 1.1% (384 cases) of breast and 0.6% (122 cases) of colon. Conclusions: High levels of physical activity are required to achieve sizable impact on breast and colon cancer prevention in Brazil

Economic burden of colorectal and breast cancers attributable to lack of physical activity in Brazil

Background: The increasing number of cancer patients has an escalating economic impact to public health systems (approximately, International dollars- Int$60 billion annually in Brazil). Physical activity is widely recognized as one important modifiable risk factor for cancer. Herein, we estimated the economic costs of colon and postmenopausal breast cancers in the Brazilian Unified Health System (SUS) attributable to lack of physical activity. Methods: Population attributable fractions were calculated using prevalence data from 57,962 adults who answered a physical activity questionnaire in the Brazilian National Health Survey, and relative risks of colon and breast cancer from a meta-analysis. Annual costs (1 Int$ = 2.1 reais) with hospitalization, chemotherapy and radiotherapy were obtained from the Hospital and Ambulatory Information Systems of the Brazilian SUS. Two counterfactual scenarios were considered: theoretical minimum risk exposure level (≥8000 MET-min/week) and physical activity guidelines (≥600 MET-min/week). Results: Annually, the Brazilian SUS expended Int$4.5 billion in direct costs related to cancer treatment, of which Int$ 553 million due to colon and breast cancers. Direct costs related to colon and breast cancers attributable to lack of physical activity were Int$23.4 million and Int$ 26.9 million, respectively. Achieving at least the physical activity guidelines would save Int$10.3 mi (colon, Int$ 6.4 mi; breast, Int$3.9 mi). Conclusions: Lack of physical activity accounts for Int$ 50.3 million annually in direct costs related to colon and post-menopausal breast cancers. Population-wide interventions aiming to promote physical activity are needed to reduce the economic burden of cancer in Brazil

Hyperprogressive Disease during Anti-PD-1 (PDCD1) / PD-L1 (CD274) Therapy: A Systematic Review and Meta-Analysis

Hyperprogressive disease (HPD) is a recently acknowledged pattern of rapid tumor progression after the initiation of immune checkpoint inhibitors. HPD has been observed across various types of tumors and has been associated with poor survival. We performed a meta-analysis to identify baseline (i.e., prior to programmed cell death 1 [PD-1, PDCD1] / programmed cell death 1 ligand 1 [PD-L1, CD274] inhibitor therapy) patient factors associated with risks of developing HPD during PD-1/PD-L1 inhibitor therapy. We searched eight databases until 6 June 2019. We calculated the summary odds ratio (OR) and its 95% confidence interval (CI) using the random-effects model and explored between-study heterogeneity and small-study effects. A total of nine articles was eligible (217 HPD cases, 1519 cancer patients) for meta-analysis. There was no standard definition of HPD, and the incidence of HPD ranged from 1 to 30%. We identified twenty-three baseline patient factors, of which five factors were statistically significantly associated with HPD. These were serum lactate dehydrogenase (LDH) above the upper normal limit (OR = 1.89, 95% CI = 1.02-3.49, p = 0.043), more than two metastatic sites (OR = 1.86, 1.34-2.57, p &lt; 0.001), liver metastases (OR = 3.33, 2.07-5.34, p &lt; 0.001), Royal Marsden Hospital prognostic score of 2 or above (OR = 3.33, 1.96-5.66, p &lt; 0.001), and positive PD-L1 expression status that was inversely correlated with HPD (OR = 0.60, 0.36-0.99, p = 0.044). Between-study heterogeneity was low. Evidence of small-study effect was found in one association (PD-L1 expression). Subset analyses of patients with non-small cell lung cancer showed similar results. Future studies are warranted to identify underlying molecular mechanisms and to test their roles as predictive biomarkers of HPD

Sedentary behavior and health outcomes among older Adults: a systematic review

Introdução: Idosos passam a maior parte do dia em comportamento sedentário. Apesar dessa alta exposição, o impacto do comportamento sedentário na saúde dessa população ainda não foi aprofundado. Objetivo: Revisar sistematicamente as evidências de associação entre o comportamento sedentário e desfechos relacionados à saúde de idosos acima de 60 anos de idade. Métodos: Foram revisadas as bases de dados Medline, Embase, Lillacs, Web of Science, SportsDiscus, PsychInfo, Cinahl e Sedentary Behavior Research Database por estudos observacionais publicados até o mês de maio de 2013, bem como os membros do Sedentary Behaviour Research Network, para identificar artigos potencialmente elegíveis. Após a inclusão, a qualidade metodológica da evidência de cada estudo foi avaliada, utilizando-se o GRADE. Resultados: Foram identificados 23 artigos elegíveis, dos quais apenas 2 (8%) apresentaram alta qualidade de evidência. O tempo gasto em comportamento sedentário foi relacionado a um aumento no risco de mortalidade por todas as causas. Estudos com qualidade moderada de evidências indicaram relação entre o comportamento sedentário e síndrome metabólica, circunferência da cintura e excesso de peso/obesidade. Os resultados de outros desfechos como saúde mental e câncer de rim ainda são insuficientes para conclusões definitivas. Conclusão: Esta revisão sistemática defende a relação entre o comportamento sedentário e aumento da mortalidade em idosos. Futuros estudos com alta qualidade metodológica serão necessários para a verificação de demais desfechos em saúde e para a criação de diretrizes e recomendações sobre comportamento sedentário de idososBackground: In the last decade, sedentary behavior has emerged as a new risk factor for health. The elderly spend most of their awake time in sedentary activities. Despite this high exposure, the impact of this sedentary behavior on the health of this population has not yet been reviewed. Purpose: We systematically reviewed evidence for associations between sedentary behavior and multiple health outcomes in adults over 60 years of age. Methods: We searched the Medline, Embase, Web of Science, SportsDiscus, PsycInfo, Cinahl, LILACS, and Sedentary Research Database for observational studies published up to May 2013. Additionally, we contacted members of the Sedentary Behaviour Research Network to identify articles that were potentially eligible. After inclusion, the methodological quality of the evidence was assessed in each study. Results: We included 24 eligible articles in our systematic review, of which only 2 (8%) provided high-quality evidence. Greater sedentary time was related to an increased risk of all-cause mortality in the older adults. Some studies with a moderate quality of evidence indicated a relationship between sedentary behavior and metabolic syndrome, waist circumference, and overweightness/obesity. The findings for other outcomes such as mental health and renal cancer cells remain insufficient to draw conclusions. Conclusion: This systematic review supports the relationship between sedentary behavior and mortality in older adults. Additional studies with high methodological quality are still needed to develop informed guidelines for addressing sedentary behavior in older adult

Physical Activity and cancer: epidemiological evidence and perspectives for cancer prevention in Brazil

Câncer é a segunda maior causa de morte no Brasil e no mundo. Esse cenário tende a se agravar devido ao crescimento e envelhecimento populacional e ao aumento da prevalência das causas de câncer na população. Compreender o papel da atividade física na redução do risco de câncer é de grande interesse na literatura epidemiológica. Os objetivos deste estudo foram (i) avaliar a associação entre atividade física e o risco de câncer na população; (ii) estimar a potencial contribuição da atividade física na prevenção e controle do câncer no Brasil. Cinco manuscritos compuseram essa tese. O primeiro apresentou revisão de literatura sobre a consistência da evidência epidemiológica sobre a associação entre atividade física e 22 tipos de câncer. Os resultados indicaram que a atividade física em adultos está associada com menor risco de sete tipos de câncer. No entanto, houve evidência consistente apenas para os cânceres de cólon e mama pós-menopausa. Evidência para outros tipos de câncer apresentou indícios de viés e heterogeneidade na literatura. O segundo manuscrito avaliou a associação entre atividade física durante a adolescência e risco de adenoma colorretal, um precursor de câncer colorretal. Os resultados indicaram que a atividade física durante a adolescência também pode contribuir para menor risco de câncer colorretal, independentemente da atividade física na fase adulta. Mulheres que praticaram mais atividade física na adolescência apresentaram menor risco de adenoma colorretal do que aquelas que praticaram menos atividade física. O terceiro manuscrito investigou a influência do tipo e intensidade da atividade física para redução de biomarcadores inflamatórios e de resposta à insulina relacionados ao risco de câncer. A atividade física foi associada com menor concentração desses biomarcadores. As associações foram mais fortes em participantes que praticaram atividade física aeróbica e de força combinadas. Não houve benefício adicional de atividades físicas de intensidade vigorosa, comparado com atividades moderadas. O quarto e o quinto avaliaram, respectivamente, a preventabilidade de câncer mediante o aumento da atividade física no Brasil; a magnitude dessa preventabilidade vis-à-vis a redução de fatores de risco relacionados ao estilo de vida. Aproximadamente 10 mil casos de câncer (12% dos casos de câncer de mama pós-menopausa e 19% dos casos de câncer de cólon) poderiam ser prevenidos por ano mediante o aumento da atividade física. No entanto, tabagismo ainda é a principal causal de câncer no Brasil, seguido de excesso de peso/obesidade e consumo de álcool. A redução de todos fatores de risco relacionados ao estilo de vida (tabagismo, excesso de peso, consumo de álcool, falta de atividade física, e alimentação não saudável) poderia prevenir até 27% de todos os casos de câncer e 34% de todas as mortes por câncer no Brasil. Em conclusão, atividade física, desde a infância até a fase adulta, pode reduzir o risco de alguns tipos de câncer. Mecanismos biológicos corroboram essas associações e indicam maior benefício para atividades aeróbicas e de força combinadas. Resultados das estimativas de preventabilidade de câncer mediante aumento da atividade física podem ser úteis para estratégias de prevenção e controle do câncer no BrasilCancer is the second leading cause of death in Brazil and worldwide. This scenario has an aggravating effect due to expected population aging and growth and the increasing prevalence of cancer causes. To understand the role of physical activity in reducing the risk of cancer is of high interest in epidemiological literature. The objectives of this study were: (i) to evaluate the association between physical activity and risk of cancer in the population; (ii) to estimate the potential contribution of physical activity for cancer prevention and control in Brazil. Five manuscripts composed this thesis. The first presented a review of the literature on the consistency of epidemiological evidence between physical activity and 22 types of cancer. The results showed that physical activity in adults was associated with a lower risk of seven types of cancer. However, only breast post-menopausal and colon cancers were supported by convincing evidence. Evidence for the other types of cancer presented hints of bias and heterogeneity in the literature. The second manuscript examined the association between physical activity during the adolescence and risk of colorectal adenomas, a precursor of colorectal cancer. Physical activity during the adolescence was associated with lower the risk of colorectal cancer, independent of physical activity during adulthood. Women with high physical activity during adolescence presented lower risk of adenomas later in life compared to those with lower physical activity. The third manuscript investigated the influence of type and intensity of physical activity with cancer biomarkers of inflammatory and insulin response. High physical activity was associated with favorable concentration of cancer biomarkers. Associations were stronger for combined aerobic and resistance training. There were no additional benefits of engaging in vigorous physical activity over moderate activities. The fourth and fifth manuscripts evaluated, respectively, the preventability of cancer by increasing physical activity in Brazil; and the magnitude of this preventability vis-à-vis the reduction of other lifestyle risk factors. About 10 thousand cancer cases per year (12% of postmenopausal cancers and 19% of colon cancers) could be avoided by increasing population-wide physical activity in Brazil. However, smoking is still the major cause of cancer in Brazil, followed by overweight/obesity and alcohol consumption. The reduction of all lifestyle risk factors (smoking, overweight/obesity, alcohol consumption, lack of physical activity and unhealthy diet) could potentially avoid up to 27% of all cancer cases and 34% of all cancer deaths in Brazil. In conclusion, physical activity, from childhood to adulthood, may reduce the risk of some types of cancer. Biological mechanisms corroborate these associations and indicate more favorable outcomes for combined aerobic and resistance training. Our findings on preventability of cancer by increasing population-wide physical activity may be useful for cancer prevention strategies in Brazi