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Hand hygiene intervention to optimise soil-transmitted helminth infection control among primary school children: the Mikono Safi cluster randomised controlled trial in northwestern Tanzania
Get PDFSoil-transmitted helminth (STH) infections are highly prevalent in resource-limited countries. We assessed the effect of a combination intervention aiming to enhance handwashing with soap on STH reinfection following mass drug administration among primary school children in Kagera region, Northwestern Tanzania.
Methods
We conducted a cluster randomised trial in sixteen primary schools with known high STH prevalence. Schools were randomly assigned in a 1:1 ratio to either receive the intervention or continue with routine health education. The intervention included teacher-led classroom teaching, parental engagement sessions, environmental modifications and improved handwashing stations. The evaluation involved two cross-sectional surveys in a representative sample of students, with the end-line survey conducted 12 months after the baseline survey. The primary outcome was the combined prevalence of Ascaris lumbricoides and Trichuris trichiura infections at the end-line survey. Secondary outcomes included reported handwashing behaviour, the prevalence and intensity of individual STHs, and hand contamination with STH ova and coliform bacteria. End-line STH prevalence and intensity were adjusted for baseline differences of potential confounders.
Results
At the end-line survey, 3081 school children (1566 from intervention schools and 1515 from control schools) provided interview data and stool specimens. More school children in the intervention group reported the use of water and soap during handwashing compared to school children in the control group (58% vs. 35%; aOR=1.76, 95%CI 1.28–2.43, p=0.001). The combined prevalence of A. lumbricoides and T. trichiura infections was 39% in both trial arms (aOR = 1.19; 95%CI 0.74–1.91). The prevalence of A. lumbricoides was 15% in the intervention and 17% in the control arm (aOR =1.24, 95%CI 0.59–2.59) and that of T. trichiura was 31% in both arms (aOR=1.17, 95%CI 0.73–1.88). No significant differences were found for STH infection intensity in both the main study and the hand contamination sub-study.
Conclusions
The intervention was effective in increasing reported handwashing behaviour at school, but failed to show a similar effect in the home. The intervention had no effect on STH infection, possibly due to infection in the home environment, other transmission routes such as contaminated water or food or limited changes in school children’s handwashing behaviour.
Trial registration
The trial was registered on June 21, 2017, by the International Standard Randomised Controlled Trial Number (ISRCTN45013173).
Peer Review reports
Background
Soil-transmitted helminth (STH) infections are a major global health problem, with more than one billion people estimated to be affected worldwide [1]. The infections are particularly frequent among school children in low- and middle-income countries (LMICs) in whom they are associated with anaemia and impaired physical and cognitive development [2, 3]. Deworming by using anti-helminthic drugs as part of regular mass drug administration (MDA) is advocated by WHO as a strategy for STH control in high prevalence areas in LMICs [1]. In Tanzania, annual MDA campaigns are conducted in primary schools as part of the national neglected tropical diseases (NTD) control programme [4]. However, STH prevalence remains high in many communities [5, 6] as MDA is often followed by rapid re-infection [7]. Poor water, sanitation and hygiene (WASH) practices have been proposed as a likely explanation [8].
The role of handwashing with soap in preventing STH transmission is yet to be established given inconsistent results from recent studies. A systematic review and meta-analysis reported in 2014 suggested that hand hygiene or other individual WASH interventions may reduce the odds of STH re-infection following deworming by 33–70% [9]. However, a more recent review reported inconsistent findings, with hand hygiene effectiveness ranging from zero to 59% [10]. None of the studies included in this review assessed the effect of handwashing with soap alone as a single intervention on STH re-infection after treatment.
We conducted a cluster randomised trial to assess the effect of a combination intervention aiming to enhance handwashing with soap on STH re-infection following MDA among primary school children in Kagera region, northwestern Tanzania. This region has high prevalence of Ascaris lumbricoides and Trichuris trichiura infections, which are species of STH known to be transmitted predominantly through the oral ingestion of worm eggs [5, 6]
Benefits and harms of Risperidone and Paliperidone for treatment of patients with schizophrenia or bipolar disorder: a meta-analysis involving individual participant data and clinical study reports
Get PDFSchizophrenia and bipolar disorder are severe mental illnesses which are highly prevalent worldwide. Risperidone and Paliperidone are treatments for either illnesses, but their efficacy compared to other antipsychotics and growing reports of hormonal imbalances continue to raise concerns. As existing evidence on both antipsychotics are solely based on aggregate data, we aimed to assess the benefits and harms of Risperidone and Paliperidone in the treatment of patients with schizophrenia or bipolar disorder, using individual participant data (IPD), clinical study reports (CSRs) and publicly available sources (journal publications and trial registries).
Methods
We searched MEDLINE, Central, EMBASE and PsycINFO until December 2020 for randomised placebo-controlled trials of Risperidone, Paliperidone or Paliperidone palmitate in patients with schizophrenia or bipolar disorder. We obtained IPD and CSRs from the Yale University Open Data Access project. The primary outcome Positive and Negative Syndrome Scale (PANSS) score was analysed using one-stage IPD meta-analysis. Random-effect meta-analysis of harm outcomes involved methods for coping with rare events. Effect-sizes were compared across all available data sources using the ratio of means or relative risk. We registered our review on PROSPERO, CRD42019140556.
Results
Of the 35 studies, IPD meta-analysis involving 22 (63%) studies showed a significant clinical reduction in the PANSS in patients receiving Risperidone (mean difference − 5.83, 95% CI − 10.79 to − 0.87, I2 = 8.5%, n = 4 studies, 1131 participants), Paliperidone (− 6.01, 95% CI − 8.7 to − 3.32, I2 = 4.3%, n = 13, 3821) and Paliperidone palmitate (− 7.89, 95% CI − 12.1 to − 3.69, I2 = 2.9%, n = 5, 2209). CSRs reported nearly two times more adverse events (4434 vs. 2296 publication, relative difference (RD) = 1.93, 95% CI 1.86 to 2.00) and almost 8 times more serious adverse events (650 vs. 82; RD = 7.93, 95% CI 6.32 to 9.95) than the journal publications. Meta-analyses of individual harms from CSRs revealed a significant increased risk among several outcomes including extrapyramidal disorder, tardive dyskinesia and increased weight. But the ratio of relative risk between the different data sources was not significant. Three treatment-related gynecomastia events occurred, and these were considered mild to moderate in severity.
Conclusion
IPD meta-analysis conclude that Risperidone and Paliperidone antipsychotics had a small beneficial effect on reducing PANSS score over 9 weeks, which is more conservative than estimates from reviews based on journal publications. CSRs also contained significantly more data on harms that were unavailable in journal publications or trial registries. Sharing of IPD and CSRs are necessary when performing meta-analysis on the efficacy and safety of antipsychotics
Interventions to control nosocomial transmission of SARS-CoV-2: a modelling study
Get PDFEmergence of more transmissible SARS-CoV-2 variants requires more efficient control measures to limit nosocomial transmission and maintain healthcare capacities during pandemic waves. Yet the relative importance of different strategies is unknown.
Methods
We developed an agent-based model and compared the impact of personal protective equipment (PPE), screening of healthcare workers (HCWs), contact tracing of symptomatic HCWs and restricting HCWs from working in multiple units (HCW cohorting) on nosocomial SARS-CoV-2 transmission. The model was fit on hospital data from the first wave in the Netherlands (February until August 2020) and assumed that HCWs used 90% effective PPE in COVID-19 wards and self-isolated at home for 7 days immediately upon symptom onset. Intervention effects on the effective reproduction number (RE), HCW absenteeism and the proportion of infected individuals among tested individuals (positivity rate) were estimated for a more transmissible variant.
Results
Introduction of a variant with 56% higher transmissibility increased — all other variables kept constant — RE from 0.4 to 0.65 (+ 63%) and nosocomial transmissions by 303%, mainly because of more transmissions caused by pre-symptomatic patients and HCWs. Compared to baseline, PPE use in all hospital wards (assuming 90% effectiveness) reduced RE by 85% and absenteeism by 57%. Screening HCWs every 3 days with perfect test sensitivity reduced RE by 67%, yielding a maximum test positivity rate of 5%. Screening HCWs every 3 or 7 days assuming time-varying test sensitivities reduced RE by 9% and 3%, respectively. Contact tracing reduced RE by at least 32% and achieved higher test positivity rates than screening interventions. HCW cohorting reduced RE by 5%. Sensitivity analyses show that our findings do not change significantly for 70% PPE effectiveness. For low PPE effectiveness of 50%, PPE use in all wards is less effective than screening every 3 days with perfect sensitivity but still more effective than all other interventions
Liquid biopsy posttreatment surveillance in endemic nasopharyngeal carcinoma: a cost-effective strategy to integrate circulating cell-free Epstein-Barr virus DNA
Get PDFThe optimal posttreatment surveillance strategy for nasopharyngeal carcinoma (NPC) remains unclear. Circulating cell-free Epstein-Barr virus (cfEBV) DNA has been recognized as a promising biomarker to facilitate early detection of NPC recurrence. Therefore, we aim to determine whether integrating circulating cfEBV DNA into NPC follow-up is cost-effective.
Methods
For each stage of asymptomatic nonmetastatic NPC patients after complete remission to primary NPC treatment, we developed a Markov model to compare the cost-effectiveness of the following surveillance strategies: routine follow-up strategy, i.e., (1) routine clinical physical examination; routine imaging strategies, including (2) routine magnetic resonance imaging plus computed tomography plus bone scintigraphy (MRI + CT + BS); and (3) routine 18F-fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT); cfEBV DNA-guided imaging strategies, including (4) cfEBV DNA-guided MRI + CT + BS and (5) cfEBV DNA-guided PET/CT. Clinical probabilities, utilities, and costs were derived from published studies or databases. Sensitivity analyses were performed.
Results
For all disease stages, cfEBV DNA-guided imaging strategies demonstrated similar survival benefits but were considerably more economical than routine imaging strategies. They only required approximately one quarter of the number of imaging studies compared with routine imaging strategies to detect one recurrence. Specifically, cfEBV DNA-guided MRI + CT + BS was most cost-effective for stage II (incremental cost-effectiveness ratio [ICER] 46,860/QALY) patients, while cfEBV DNA-guided PET/CT was most cost-effective for stage IV patients ($62,269/QALY). However, routine follow-up was adequate for stage I patients due to their low recurrence risk.
Conclusions
The cfEBV DNA-guided imaging strategies are effective and cost-effective follow-up methods in NPC. These liquid biopsy-based strategies offer evidence-based, stage-specific surveillance modalities for clinicians and reduce disease burden for patients
Increased habitual flavonoid intake predicts attenuation of cognitive ageing in twins
Get PDFAlthough the pathophysiology of cognitive decline is multifactorial, and modifiable by lifestyle, the evidence for the role of diet on cognitive function is still accumulating, particularly the potentially preventive role of constituents of plant-based foods.
Methods
We aimed to determine whether higher habitual intake of dietary flavonoids, key components of plant-based diets, were associated with improved cognition and medial temporal lobe volumes using three complementary approaches (longitudinal, cross-sectional and co-twin analyses). In 1126 female twins (n=224 with a 10-year follow-up of diet and cognition data) aged 18–89 years, habitual intakes of total flavonoids and seven subclasses (flavanones, anthocyanins, flavan-3-ols, flavonols, flavones, polymeric flavonoids (and proanthocyanidins separately)) were calculated using validated food frequency questionnaires. Cognition was assessed using the Cambridge Neuropsychological Test Automated Battery test. Hippocampal volumes were measured in a subset using magnetic resonance imaging (16 monozygotic-twin pairs). Statistical models were adjusted for a range of diet and lifestyle factors.
Results
Higher intakes of flavanones (tertile (T)3-T1=0.45, 95%CI 0.13,0.77; p=0.01) and anthocyanins (T3-T1=0.45, 95%CI 0.08,0.81; p=0.02) were associated with improvements in age-related cognition score over 10 years. In cross-sectional analysis higher intake of flavanones (T3-T1= 0.12, 95% CI 0.02, 0.21; p=0.02) and proanthocyanidins (T3-T1= 0.13, 95% CI 0.02, 0.24; p=0.02) were associated with improved paired-associates learning. Higher intake of anthocyanins was significantly associated with improved executive function (T3-T1= −0.52, 95% CI 0.19, 0.84; p=0.001) and with faster simple reaction times (T3-T1= −18.1, 95% CI −35.4, −0.7; p=0.04). In co-twin analysis, those with higher anthocyanin (2.0%, p=0.01) and proanthocyanidin (2.0%, p=0.02) intakes at baseline had the largest left hippocampal volumes after 12 years
Refining pancreatic ductal adenocarcinoma molecular subtype and precision therapeutics with single-nucleus RNA-seq
Get PDFPancreatic cancer is predicted to become the second leading cause of cancer-related deaths in the USA by 2030 with a 5-year survival rate of only 9% [1, 2]. Pancreatic ductal adenocarcinoma (PDAC) is the most common form of pancreatic malignancy and remains a treatment-refractory disease. So far, apart from surgical resection, conventional chemotherapies, radiotherapies, few therapeutic strategies, adjuvant or neoadjuvant, are available for improved PDAC patient benefit. In recent years, more research efforts have been devoted to developing targeted therapeutics via discovery of novel molecular vulnerabilities and molecular subtyping of various diseases. For PDAC, despite many attempts to refine its molecular taxonomy over the years, the current molecular subtyping still does not efficiently inform novel molecular vulnerabilities for the development of targeted therapies. Thus, fine-tuning the resolution of PDAC molecular subtyping has become a pivotal need.
Here, we discuss a manuscript from Hwang et al. which focused on the optimization of a single-nucleus RNA-sequencing (snRNA-seq) technique to understand how preoperative treatment may impact residual tumors. Moreover, we examine how this technique can further contribute to the field by identifying additional molecular vulnerabilities that can be harnessed for informative stratification during PDAC patient clinical management and targeted combinations with neoadjuvant therapies [3].
Use of snRNA-seq for frozen archival PDAC specimen
Single-cell technologies, especially single-cell RNA-seq, have been regularly used in elucidating intertumoral tumor microenvironment (TME) and heterogeneity as well as expanding upon data from traditional bulk RNA profiling of various tumors. However, the use of scRNA-seq is not as prevalent in PDAC as in other cancers due to high intrinsic nuclease content and dense desmoplastic stroma. High-resolution transcriptional networks and any resulting patient stratification from bulk RNA analyses also tend to be obscured because of lower-quality sample collection due to the complicated PDAC TME. Hwang and colleagues propose an optimized snRNA-seq technique for better recovery of PDAC cancer cell profile without compromising the spectrum of cell states. The authors demonstrate, with frozen archival specimens not commonly considered for analysis, the potential of snRNA-seq to capture various cell types with comparable quality to that obtained from gold standard multiplex profiling in situ. This technique also enables processing of banked frozen tissue samples dating back at least 7 years, while bypassing some of the challenges involved in sample preparation for traditional single-cell RNA-seq, such as balancing sample viability and accurate cell type representation. Thus, the use of snRNA-seq provides an exciting avenue to further resolve PDAC molecular subtypes and gain novel insights for precision medicine approaches based on tumor reprogramming profile.
Refined molecular taxonomy informing prognostic patient stratification
Apart from accurately capturing the malignant and non-malignant compartments of human PDAC tumors, the snRNA-seq analyses, combined with spatially resolved transcriptomics, also revealed a novel, clinically relevant molecular taxonomy with better patient stratification potential than that from the two previously identified consensus molecular subtypes, basal-pancreatic and classical-pancreatic [4]. Under the refined molecular taxonomy of PDAC proposed in the preprint, patients can be further stratified into prognostic risk groups based on malignant cell and cancer-associated fibroblast programs beyond just their conventional, consensus tumor profile
Identification of NOTCH4 mutation as a response biomarker for immune checkpoint inhibitor therapy
Get PDFmmune checkpoint inhibitor (ICI) therapy elicits durable antitumor responses in patients with many types of cancer. Genomic mutations may be used to predict the clinical benefits of ICI therapy. NOTCH homolog-4 (NOTCH4) is frequently mutated in several cancer types, but its role in immunotherapy is still unclear. Our study is the first to study the association between NOTCH4 mutation and the response to ICI therapy.
Methods
We tested the predictive value of NOTCH4 mutation in the discovery cohort, which included non-small cell lung cancer, melanoma, head and neck squamous cell carcinoma, esophagogastric cancer, and bladder cancer patients, and validated it in the validation cohort, which included non-small cell lung cancer, melanoma, renal cell carcinoma, colorectal cancer, esophagogastric cancer, glioma, bladder cancer, head and neck cancer, cancer of unknown primary, and breast cancer patients. Then, the relationships between NOTCH4 mutation and intrinsic and extrinsic immune response mechanisms were studied with multiomics data.
Results
We collected an ICI-treated cohort (n = 662) and found that patients with NOTCH4 mutation had better clinical benefits in terms of objective response rate (ORR: 42.9% vs 25.9%, P = 0.007), durable clinical benefit (DCB: 54.0% vs 38.1%, P = 0.021), progression-free survival (PFS, hazard ratio [HR] = 0.558, P < 0.001), and overall survival (OS, HR = 0.568, P = 0.006). In addition, we validated the prognostic value of NOTCH4 mutation in an independent ICI-treated cohort (n = 1423). Based on multiomics data, we found that NOTCH4 mutation is significantly associated with enhanced immunogenicity, including a high tumor mutational burden, the expression of costimulatory molecules, and activation of the antigen-processing machinery, and NOTCH4 mutation positively correlates activated antitumor immunity, including infiltration of diverse immune cells and various immune marker sets.
Conclusions
Our findings indicated that NOTCH4 mutation serves as a novel biomarker correlated with a better response to ICI therapy
Human papillomavirus (HPV) testing for cervical cancer screening in a middle-income country: comment on a large real-world implementation study in China
Get PDFCervical cancer can effectively be prevented by human papillomavirus (HPV) vaccination and early detection and treatment of precancerous lesions (screening). Nevertheless, cervical cancer remains a global public health problem and an important threat to women’s health worldwide. It is the fourth most common cancer in women with more than 600,000 cases and 342,000 deaths in 2020 [1]. Approximately 90% of cervical cancer deaths occur in low- and middle-income countries, underlining the substantial global inequality in disease burden [1]. In May 2018, the World Health Organization (WHO) called for global action to eliminate cervical cancer as a public health problem [2]. The WHO urged member states to scale up efforts to implement preventive strategies against cervical cancer, including HPV vaccination, screening, and treatment for precancerous lesions and cancer [2].
Cervical cancer screening by HPV testing
Cervical cancer screening has traditionally been based on detection of cytological abnormalities in cervical cell samples, so-called cytology-based screening. This method has effectively reduced cervical cancer incidence in high-income countries when implemented in organized programs [3, 4]. However, in low- and middle-income countries, implementing cytology-based screening has been challenging, because it requires substantial provider training, continued quality assurance, and repeated testing at relatively short intervals [3, 4]. Visual inspection with acetic acid is used as a screening method in some low-resource settings, but this method has substantial inter-observer variability and limited sensitivity [3].
During the past two decades, HPV testing has emerged as a new and highly effective screening method against cervical cancer. Randomized trials in high-income [5] and middle-income [6] countries have demonstrated that HPV testing is more sensitive and prevents more cervical cancers than cytology. These findings have been corroborated by real-world implementation studies in high-income countries, e.g., the Netherlands [7] and Denmark [8]. A challenge with HPV testing, however, is that most HPV infections are transient, and therefore, triage testing of HPV positive women is recommended to prevent over-referral and over-treatment [4, 7, 8].
A large observational study of HPV testing in a middle-income country
Until now, there has been limited evidence on the real-world performance of HPV testing for cervical cancer screening in middle-income countries [9]. In this issue of BMC Medicine, Zhao et al. report results from a large implementation study of HPV-based cervical cancer screening in China [10]. This population-based observational study included approximately 1.1 million women, of whom 800,000 received HPV-based and 300,000 received cytology-based screening. In the HPV group, HPV-positive women were triaged by cytology alone or HPV16/18 genotyping and cytology.
To our knowledge, the study by Zhao et al. is the largest to date on the performance of HPV testing versus cytology for cervical cancer screening in a middle-income country. In line with findings from high-income settings [5, 7, 8], the authors found that HPV testing detected more cases of cervical intraepithelial neoplasia grade 2 or worse (CIN2+) than cytology-based screening, underlining the superior sensitivity of HPV testing. However, in contrast to results in high-income settings [7, 8], the referral rate to immediate colposcopy was lower for HPV than cytology-based screening. As noted by the authors [10], this likely reflects that in the Chinese cytology-based screening program, all women with atypical squamous cells of undetermined significance or worse were referred directly to colposcopy, because not all laboratories could perform HPV triage testing for mild abnormalities, and compliance with repeat cytology could not be ensured [10]. Thus, in the Chinese setting, HPV-based screening was more efficient than cytology-based screening, since it simultaneously increased CIN2+-detection, decreased immediate colposcopy referrals, and markedly improved the positive predictive value (PPV) of referral.
Interestingly, Zhao et al. [10] also performed an analysis stratified by county income level (lower-middle or upper-middle income). They found that the increased CIN2+-detection for HPV compared with cytology-based screening was most pronounced in lower-middle income areas, likely reflecting the lower quality of cytology in these settings. However, the PPV of colposcopy referral increased with HPV-based screening in both lower-middle income and upper-middle income areas, supporting the higher efficiency of HPV-based screening irrespective of income level [10]
The East African Community (EAC) mobile laboratory networks in Kenya, Burundi, Tanzania, Rwanda, Uganda, and South Sudan—from project implementation to outbreak response against Dengue, Ebola, COVID-19, and epidemic-prone diseases
Get PDFEast Africa is home to 170 million people and prone to frequent outbreaks of viral haemorrhagic fevers and various bacterial diseases. A major challenge is that epidemics mostly happen in remote areas, where infrastructure for Biosecurity Level (BSL) 3/4 laboratory capacity is not available. As samples have to be transported from the outbreak area to the National Public Health Laboratories (NPHL) in the capitals or even flown to international reference centres, diagnosis is significantly delayed and epidemics emerge.
Main text
The East African Community (EAC), an intergovernmental body of Burundi, Rwanda, Tanzania, Kenya, Uganda, and South Sudan, received 10 million € funding from the German Development Bank (KfW) to establish BSL3/4 capacity in the region. Between 2017 and 2020, the EAC in collaboration with the Bernhard-Nocht-Institute for Tropical Medicine (Germany) and the Partner Countries’ Ministries of Health and their respective NPHLs, established a regional network of nine mobile BSL3/4 laboratories. These rapidly deployable laboratories allowed the region to reduce sample turn-around-time (from days to an average of 8h) at the centre of the outbreak and rapidly respond to epidemics.
In the present article, the approach for implementing such a regional project is outlined and five major aspects (including recommendations) are described: (i) the overall project coordination activities through the EAC Secretariat and the Partner States, (ii) procurement of equipment, (iii) the established laboratory setup and diagnostic panels, (iv) regional training activities and capacity building of various stakeholders and (v) completed and ongoing field missions. The latter includes an EAC/WHO field simulation exercise that was conducted on the border between Tanzania and Kenya in June 2019, the support in molecular diagnosis during the Tanzanian Dengue outbreak in 2019, the participation in the Ugandan National Ebola response activities in Kisoro district along the Uganda/DRC border in Oct/Nov 2019 and the deployments of the laboratories to assist in SARS-CoV-2 diagnostics throughout the region since early 2020
Association of healthy lifestyle score with all-cause mortality and life expectancy: a city-wide prospective cohort study of cancer survivors
Get PDFAdherence to a healthy lifestyle could reduce the cancer mortality in the western population. We conducted a city-wide prospective study in China investigating the association of a healthy lifestyle score with all-cause mortality and the life expectancy in cancer survivors.
Methods
This prospective cohort study included 46,120 surviving patients who were firstly diagnosed with cancer in Guangzhou. Five low-risk lifestyle factors including never smoking, never alcohol use, regular physical activity (≥ 2 h/week), sufficient sleep (≥ 6 h/day), and normal or high BMI (≥ 18.5 kg/m2) were assessed and a lifestyle score (0–5, a higher score indicates healthier lifestyle) was generated. Hazard ratios (HRs) of all-cause mortality and the life expectancy by levels of the lifestyle scores were estimated.
Results
Of 46,120 cancer survivors registered from 2010 to 2017, during an average follow-up of 4.3 years (200,285 person-years), 15,209 deaths were recorded. Adjusted HRs for mortality in cancer survivors with lifestyle score of 0–2, versus 5, were 2.59 (95% confidence interval (CI): 2.03–3.30) in women, 1.91 (95%CI 1.77–2.05) in men, 2.28 (95%CI 2.03–2.55) in those aged <65 years, and 1.90 (95%CI 1.75, 2.05) in those aged ≥ 65 years. Life expectancy at age 55 for those with a score of 0–2 and 5 was 53.4 and 57.1 months, respectively. We also found that cancer survivors with healthy lifestyle scores of 5 showed 59.9 months of life expectancy on average, which was longer than those with a score of 0–2.
Conclusion
Adopting a healthy lifestyle was associated with a substantially lower risk of all-cause mortality and longer life expectancy in cancer survivors. Our findings should be useful for health education and health promotion in primary care and clinical practice.
Peer Review reports
Background
China has about one fifth of global cancer cases [1, 2]. Although cancer survival has overall increased during the past decades [3], people with cancer had a shorter life expectancy than their peers without the disease [4], ranging from 2.4 to 11.2 years, depending on methods and study populations [4, 5]. Efforts to reduce morbidity and mortality of cancer, such as adherence to a healthy lifestyle, have been advocated in the general population based on published studies [6,7,8,9]. For example, previous studies showed that four major unhealthy lifestyle factors (i.e., cigarette smoking, heavy alcohol use, lack of physical activity, and unhealthy diet) contributed to at least 60% of premature deaths, leading to a loss of 7.4–17.9 years in life expectancy [6, 10,11,12]. However, in cancer survivors, whether adopting a healthy lifestyle will also have similar beneficial effects on life expectancy is unclear.
Hence, our study hereby explored the associations of the individual and combined healthy lifestyle factors with the risk of mortality in cancer survivors, and estimated the association of adherence to healthy lifestyles with life expectancy. Results of this study will facilitate evidence-based tertiary preventive strategies for providing holistic care and improving the quality of life in cancer survivors [13, 14]