New York Svatava Stašková. The USA The United States of America New York.
USA New York
4
8/16/2019 USA New York http://slidepdf.com/reader/full/usa-new-york 1/4 Gut, 1980, 21, 1090-1092 Epidemiology Gallstones and the risk of cancer A B LOWENFELS From the Department of Surgery, New York Medical College, New York, USA SUMMARY For both males and females the age-standardised prevalence of asymptomatic gallstones found at necropsy in 15 countries correlated strongly with age-standardised mortality from cancers of the uterus, large bowel, and stomach. When deaths from cholecystitis were used as another measure of the frequency of gallstones similar positive correlations were observed across 28 countries. The results suggest that cholelithiasis and several common cancers share similar epidemiological and perhaps metabolic factors. In addition to the well-known association between cholelithiasis and biliary tract malignancy it has been suggested that gallstones may be linked through diet with colorectal cancer. However, efforts to correlate these two diseases in individual population groups have yielded confficting results,2-5 perhaps because of methodological problems in choosing appropriate controls. As gallstones are largely made up of cholesterol, any link between gallstones and bowel cancer might lend additional support to the cholesterol/bile acid hypothesis for the aetiology of bowel cancer. Furthermore, it seems reasonable that the presence or absence of gallstones might prove to be a more reliable indication of cholesterol burden than blood cholesterol, which is difficult to associate with .diet and which has not been positively correlated with colon cancer.6 To clarify the problem of gallstones and cancer, the prevalence of gallstones in various countries has been estimated and correlated with available data on cancer mortality. Methods The prevalence of gallstones in healthy, asympto- matic individuals has been determined in only a few countries and therefore the reported frequency of asymptomatic gallstones discovered at necropsy was used as a substitute. From a review of available published studies since 1950, 15 countries were *Address for correspondence: Department of Surgery, Munger Pavilion, New York Medical College, Valhalla, New York, USA 10595. Received for publication 5 August 1980 selected where there were sufficient age-specific data to calculate age-standardised rates for males and females above the age of 20 years.7-2 Prevalence rates were age-standardised by decade to a world population. In addition, as death from biliary tract disease is nearly always related to gallstones, it seemed reason- able to use available mortality data for cholecystitis as another measure of the frequency of gallstones in different countries. Age-specific cholecystitis mor- tality rates by decade for 1978 and 1979 were collected from World Health Organization reports and used to calculate age-standardised rates for 28 countries where there were 100 or more deaths from cholecystitis.22 Age-standardised deaths from cho- lecystitis were relatedto the age-adjusted prevalence of gallstones at necropsy for both males (r=0.76; P= <0.01) and females (r=0.82; P= <0.01). Table 1 Age-adjusted prevalence of asymptomatic gallstones at necropsy in 15 countries Country Gallstone prevalence ( ) Females Males Chile7 42-0 16-7 Czechoslovakia8 23-3 13-2 Swedeng 22-4 9.1 Scotland10 21-7 9-9 England 1 20-5 12-2 WGermany 2 20-0 7-2 New Zealand13 14-2 9-0 United States1 14-1 5-2 Australia 1 13-9 6-0 Japan16 13-0 5-3 Ireland 7 12-4 3-4 Norway16 10-4 5-3 Greece1 6-8 3.5 Singapore 6-6 4.3 Thailand 4-2 2-3 1090 group.bmj.com on April 13, 2016 - Published by http://gut.bmj.com/ Downloaded from
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G u t ,
1 9 8 0 ,
2 1 ,
1 0 9 0 - 1 0 9 2
E p i d e m i o l o g y
G a l l s t o n e s
a n d
t h e
r i s k
o f
c a n c e r
A B
LOWENFELS
F r o m
t h e
D e p a r t m e n t o f
S u r g e r y ,
New Y o r k
M e d i c a l
C o l l e g e ,
New
Y o r k ,
USA
S U M M A R Y
F o r
b o t h
m a l e s
a n d f e m a l e s t h e
a g e - s t a n d a r d i s e d p r e v a l e n c e
o f
a s y m p t o m a t i c g a l l s t o n e s
f o u n d
a t
n e c r o p s y
i n 1 5 c o u n t r i e s
c o r r e l a t e d
s t r o n g l y
w i t h
a g e - s t a n d a r d i s e d m o r t a l i t y
f r o m c a n c e r s
o f
t h e
u t e r u s ,
l a r g e b o w e l ,
a n d s t o m a c h . When
d e a t h s
f r o m
c h o l e c y s t i t i s
w e r e u s e d a s
a n o t h e r
m e a s u r e
o f
t h e
f r e q u e n c y
o f
g a l l s t o n e s
s i m i l a r
p o s i t i v e
c o r r e l a t i o n s
w e r e
o b s e r v e d
a c r o s s
2 8 c o u n t r i e s .
T h e r e s u l t s
s u g g e s t
t h a t
c h o l e l i t h i a s i s a n d s e v e r a l common
c a n c e r s s h a r e s i m i l a r
e p i d e m i o l o g i c a l
a n d
p e r h a p s
m e t a b o l i c
f a c t o r s .
I n a d d i t i o n
t o
t h e w e l l - k n o w n
a s s o c i a t i o n
b e t w e e n
c h o l e l i t h i a s i s
a n d
b i l i a r y
t r a c t
m a l i g n a n c y
i t h a s
b e e n
s u g g e s t e d
t h a t
g a l l s t o n e s may
b e
l i n k e d
t h r o u g h
d i e t
w i t h c o l o r e c t a l
c a n c e r .
H o w e v e r ,
e f f o r t s
t o
c o r r e l a t e t h e s e
t w o d i s e a s e s i n
i n d i v i d u a l
p o p u l a t i o n g r o u p s
h a v e
y i e l d e d
c o n f f i c t i n g
r e s u l t s , 2 - 5
p e r h a p s
b e c a u s e
o f
m e t h o d o l o g i c a l
p r o b l e m s
i n
c h o o s i n g a p p r o p r i a t e
c o n t r o l s .
A s g a l l s t o n e s
a r e
l a r g e l y
m a d e
u p
o f
c h o l e s t e r o l ,
a n y
l i n k
b e t w e e n
g a l l s t o n e s
a n d
b o w e l c a n c e r
m i g h t
l e n d a d d i t i o n a l s u p p o r t
t o
t h e
c h o l e s t e r o l / b i l e
a c i d
h y p o t h e s i s
f o r
t h e
a e t i o l o g y
o f b o w e l c a n c e r .
F u r t h e r m o r e ,
i t
s e e m s
r e a s o n a b l e
t h a t
t h e
p r e s e n c e
o r
a b s e n c e
o f
g a l l s t o n e s
m i g h t p r o v e
t o
b e
a
more
r e l i a b l e
i n d i c a t i o n
o f c h o l e s t e r o l b u r d e n
t h a n
b l o o d
c h o l e s t e r o l ,
w h i c h
i s
d i f f i c u l t
t o
a s s o c i a t e w i t h
. d i e t
a n d
w h i c h
h a s
n o t
b e e n
p o s i t i v e l y
c o r r e l a t e d
w i t h c o l o n
c a n c e r . 6
To
c l a r i f y
t h e
p r o b l e m
o f
g a l l s t o n e s
a n d
c a n c e r ,
t h e
p r e v a l e n c e
o f
g a l l s t o n e s
i n
v a r i o u s
c o u n t r i e s
h a s
b e e n e s t i m a t e d
a n d c o r r e l a t e d
w i t h
a v a i l a b l e
d a t a
o n
c a n c e r
m o r t a l i t y .
M e t h o d s
T h e
p r e v a l e n c e
o f
g a l l s t o n e s
i n
h e a l t h y ,
a s y m p t o -
m a t i c
i n d i v i d u a l s
h a s
b e e n
d e t e r m i n e d
i n
o n l y
a
f e w
c o u n t r i e s
a n d
t h e r e f o r e
t h e
r e p o r t e d
f r e q u e n c y
o f
a s y m p t o m a t i c g a l l s t o n e s
d i s c o v e r e d
a t
n e c r o p s y
w a s
u s e d
a s
a
s u b s t i t u t e .
From a
r e v i e w
o f
a v a i l a b l e
p u b l i s h e d
s t u d i e s
s i n c e
1 9 5 0 ,
1 5
c o u n t r i e s
w e r e
* A d d r e s s
f o r
c o r r e s p o n d e n c e :
D e p a r t m e n t
o f
S u r g e r y ,
M u n g e r
P a v i l i o n ,
Ne w
Y o r k M e d i c a l
C o l l e g e , V a l h a l l a ,
N ew
Y o r k ,
USA
1 0 5 9 5 .
R e c e i v e d
f o r
p u b l i c a t i o n
5
A u g u s t
1 9 8 0
s e l e c t e d w h e r e
t h e r e w e r e s u f f i c i e n t
a g e - s p e c i f i c
d a t a
t o
c a l c u l a t e a g e - s t a n d a r d i s e d r a t e s f o r
m a l e s a n d
f e m a l e s a b o v e
t h e a g e o f
2 0 y e a r s . 7 - 2
P r e v a l e n c e
r a t e s
w e r e
a g e - s t a n d a r d i s e d b y d e c a d e t o
a
w o r l d
p o p u l a t i o n .
I n
a d d i t i o n ,
a s
d e a t h f r o m
b i l i a r y
t r a c t d i s e a s e
i s
n e a r l y a l w a y s r e l a t e d t o g a l l s t o n e s , i t s e e m e d
r e a s o n -
a b l e
t o u s e a v a i l a b l e m o r t a l i t y d a t a f o r
c h o l e c y s t i t i s
a s
a n o t h e r
m e a s u r e
o f t h e f r e q u en c y o f g a l l s t o n e s i n
d i f f e r e n t c o u n t r i e s . A g e - s p e c i f i c
c h o l e c y s t i t i s m o r -
t a l i t y
r a t e s b y
d e c a d e f o r
1 9 7 8
a n d
1 9 7 9
w e r e
c o l l e c t e d f r o m
W o r l d
H e a l t h
O r g a n i z a t i o n
r e p o r t s
a n d u s e d
t o c a l c u l a t e
a g e - s t a n d a r d i s e d
r a t e s
f o r
2 8
c o u n t r i e s
w h e r e
t h e r e w e r e 1 0 0 o r m o r e d e a t h s f r o m
c h o l e c y s t i t i s . 2 2
A g e - s t a n d a r d i s e d d e a t h s f r o m
c h o -
l e c y s t i t i s
w e r e
r e l a t e d t o
t h e a g e - a d j u s t e d
p r e v a l e n c e
o f
g a l l s t o n e s a t
n e c r o p s y
f o r
b o t h m a l e s ( r= 0 . 7 6 ;
P=
< 0 . 0 1 )
a n d
f e m a l e s
( r = 0 . 8 2 ;
P=
< 0 . 0 1 ) .
T a b l e 1
A g e - a d j u s t e d
p r e v a l e n c e o f
a s y m p t o m a t i c
g a l l s t o n e s
a t
n e c r o p s y
i n
1 5 c o u n t r i e s
C o u n t r y
G a l l s t o n e
p r e v a l e n c e
( )
F e m a l e s
M a l e s
C h i l e 7
4 2 - 0
1 6 - 7
C z e c h o s l o v a k i a 8 2 3 - 3 1 3 - 2
S w e d e n g 2 2 - 4
9 . 1
S c o t l a n d 1 0
2 1 - 7
9 - 9
E n g l a n d 1
2 0 - 5
1 2 - 2
W
G e r m a n y 2
2 0 - 0
7 - 2
Ne w
Z e a l a n d 1 3
1 4 - 2
9 - 0
U n i t e d S t a t e s 1
1 4 - 1
5 - 2
A u s t r a l i a 1
1 3 - 9 6 - 0
J a p a n 1 6
1 3 - 0
5 - 3
I r e l a n d 7
1 2 - 4 3 - 4
N o r w a y 1 6
1 0 - 4 5 - 3
G r e e c e 1
6 - 8 3 . 5
S i n g a p o r e
6 - 6 4 . 3
T h a i l a n d
4 - 2 2 - 3
1 0 9 0
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E p i d e m i o l o g y :
g a l l s t o n e s
a n d
t h e r i s k
o f c a n c e r
T a b l e
2
A g e - a d j u s t e d
g a l l s t o n e p r e v a l e n c e
a t
n e c r o p s y ,
1 9 5 2 - 7 9 ,
a n d
a g e - a d j u s t e d
m o r t a l i t y
f r o m
c a n c e r ,
1 9 7 4 - 7 5 ,
i n 1 5
c o u n t r i e s *
S i m p l e c o r r e l a t i o n
c o e f f i c i e n t s
Tumour l o c a t i o n
F e m a l e s
M a l e s
U t e r u s
0 . 9 3 t
C o l o r e c t a l
0 7 3 *
0 - 6 3 §
S t o m a c h
0 - 5 1
0 - 4 5
S t o m a c h
( e x c l u d i n g J a p a n )
0 . 7 5 *
0 . 7 1 *
A l l
s i t e s
0 . 6 0 §
0 . 5 2 * *
Lung
0 - 0 2
0 - 3 1
P r o s t a t e
0 - 3 3
B r e a s t
0 - 2 3
S k i n
0 - 0 2
0 . 0 5
* S a m e
c o u n t r i e s a s
shown i n
t a b l e 1 .
tp=
< 0 - 0 0 1 ; p = < 0 0 1 ;
§ P =
< 0 - 0 2 ;
* * P = 0 . 0 5 .
B o t h
o f
t h e s e m e a s u r e s
o f
t h e
f r e q u e n c y
o f
g a l l -
s t o n e s
i n
v a r i o u s
c o u n t r i e s
w e r e t h e n
c o r r e l a t e d w i t h
a g e - s t a n d a r d i s e d
m o r t a l i t y
r a t e s f o r
common
human
c a n c e r s 2 3
a n d
s i m p l e
c o r r e l a t i o n
c o e f f i c i e n t s
r )
w e r e
c a l c u l a t e d .
S i n g a p o r e
w a s
e x c l u d e d
f r o m
t h e
a n a l y s i s
o f
u t e r i n e
c a n c e r
b e c a u s e t h e t o t a l
n u m b e r o f
d e a t h s
f o r t h a t s i t e
w a s l e s s t h a n
1 0 0 .
R e s u l t s
T h e
a g e - s t a n d a r d i s e d
p r e v a l e n c e
o f
a s y m p t o m a t i c
g a l l s t o n e s
d i s c o v e r e d a t
n e c r o p s y ( T a b l e
1 )
v a r i e d
m a r k e d l y
f r o m
c o u n t r y
c o u n t r y
a n d ,
a s
e x p e c t e d ,
g a l l s t o n e s w e r e
a p p r o x i m a t e l y
t w i c e
a s common
i n
f e m a l e s a s
i n
m a l e s .
S i g n i f i c a n t
p o s i t i v e
c o r r e l a t i o n s
w e r e
f o u n d
b e t w e e n
t h e
n e c r o p s y p r e v a l e n c e
o f
g a l l s t o n e s a n d
c o l o r e c t a l
c a n c e r s ,
a s w e l l
a s
a l l
c a n c e r s
i n
b o t h m a l e s
a n d
f e m a l e s
( T a b l e
2 ) .
T h e
c o r r e l a t i o n
b e t w e e n
g a s t r i c
c a n c e r
a n d
t h e
n e c r o p s y
p r e v a l a n c e
o f
g a l l s t o n e s , w h i c h w a s
n e a r l y s i g n i f i c a n t
c )
W
z
U )
_ J
_ i
4 : x
Q 5
9
z
W
c r
L L
0
W
U )
0
o x
w
9
T a b l e 3
A g e - a d j u s t e d
m o r t a l i t y
f r o m
c h o l e c y s t i t i s ,
1 9 7 8 - 7 9 ,
a n d
a g e - a d j u s t e d
m o r t a l i t y f r o m
c a n c e r ,
1 9 7 4 - 7 5 ,
i n 2 8
c o u n t r i e s *
S i m p l e
c o r r e l a t i o n
c o e f f i c i e n t s
T u m o u r
l o c a t i o n
F e m a l e s
M a l e s
U t e r u s
0 . 6 8 t
C o l o r e c t a l
0 . 5 5
0 - 5 1 *
S t o m a c h
0 . 6 4 t
0 . 6 4 t
A l l
s i t e s
0 - 4 6 t
0 . 4 0 * *
L u n g
-022 00 7
P r o s t a t e
0 - 2 6
B r e a s t
0 - 0 1
S k i n
- 0 0 2
0 - 0 4
U S A ,
A u s t r a l i a ,
A u s t r i a ,
B e l g i u m ,
B u l g a r i a , C a n a d a , C h i l e , C z e c h o -
s l o v a k i a ,
D e n m a r k ,
E n g l a n d
a n d
W a l e s ,
F i n l a n d , F r a n c e , W
G e r m a n y ,
G r e e c e ,
H u n g a r y ,
J a p a n ,
N e t h e r l a n d s ,
N o r w a y ,
P h i l i p p i n e s ,
P o l a n d ,
R o u m a n i a ,
S c o t l a n d ,
S p a i n , S w e d e n , S w i t z e r l a n d ,
T h a i l a n d ,
U r u g u a y ,
Y u g o s l a v i a .
tP=
< 0 - 0 0 1 4 ;
P=
< 0 - 0 1 ;
§ P =
<0
0 2 ;
* * P =
< 0 - 0 5 .
i n
t h e
1 5
c o u n t r i e s s t u d i e d ,
b e c a m e
s i g n i f i c a n t i n
t h e
r e m a i n i n g
1 4
c o u n t r i e s ( f e m a l e s :
r = 0 - 7 5 ,
P= <0
0 1 ;
m a l e s :
r = 0 . 7 1 ,
P=
<0
0 1 ) w h e n
J a p a n , t h e
o b v i o u s
o u t - l i e r w a s
r e m o v e d .
I n
f e m a l e s ,
t h e
s t r o n g e s t
c o r -
r e l a t i o n
( r = 0 - 9 3 ;
P=
< 0 0 0 1 )
w a s d i s c o v e r e d
b e -
t w e e n
u t e r i n e c a n c e r
a n d
g a l l s t o n e s
( F i g u r e ) . A
s t r o n g
c o r r e l a t i o n
p e r s i s t e d
( r = 0 . 8 2 ; P=
< 0 0 0 1 )
e v e n
a f t e r
e x c l u s i o n
o f
C h i l e , a
c o u n t r y
w i t h
e x c e s -
s i v e
r a t e s f o r
c h o l e l i t h i a s i s
a n d
u t e r i n e
c a n c e r .
S i m i l a r
p o s i t i v e
c o r r e l a t i o n s w e r e
o b s e r v e d
b e -
t w e e n
a g e - s t a n d a r d i s e d
m o r t a l i t y
f r o m
c h o l e c y s t i t i s
a n d
a g e - s t a n d a r d i s e d
c a n c e r m o r t a l i t y
i n t h e
2 8
c o u n t r i e s s t u d i e d
( T a b l e
3 ) .
D i s c u s s i o n
T h e
i d e a l
m e t h o d
o f
m e a s u r i n g
g a l l s t o n e
f r e q u e n c y
w o u l d b e t o
u s e
r a d i o g r a p h i c
s u r v e y s i n
a s y m p t o -
50r
4 0 1
a -
C . )
W
z
C
n
C )
W
_ J
5
w
I L l
z
3 0 1 -
20
1 0 1 -
o
SWEDEN
CZECHOSLOVAKIA
S C O T LA ND .0
COTL N
0
U K
US A
N . Z .
AUSTRALIA
JAPAN
IRELAND
NORWAY
*GREECE|
THAILAND
5
1 0
15
AGE-ADJUSTED
M O R T A L I T Y
R A T E
F R O M
UTERINE
CANCER/I00,00
0
F i g u r e
S c a t t e r g r a m
s h o w i n g
r e l a t i o n s h i p
b e t w e e n
a g e -
a d j u s t e d
m o r t a l i t y
r a t e
from
u t e r i n e
c a n c e r / 1 0 0
0 0 0
a n d
a g e -
a d j u s t e d f r e q u e n c y
of
a s y m p t o m a t i c
g a l l s t o n e s
i n
f e m a l e s
a t
necropsy
i n 1 4
c o u n t r i e s .
20
CHILE
a
a
1 0 9 1
a a
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1 0 9 2
L o w e n f e l s
m a t i c i n d i v i d u a l s .
S u c h i n f o r m a t i o n i s
n o t a v a i l a b l e
a n d
t h e r e f o r e
t h e t w o m e t h o d s
u s e d r e p r e s e n t
a
c o m p r o m i s e . C l e a r l y
t h e
p r e v a l e n c e
o f
g a l l s t o n e s
i n a
n e c ro p s y p o pu l a t i o n may
d i f f e r f r o m t h e
p o p u l a t i o n
a t
l a r g e ,
a n d
d e a t h s f r o m
c h o l e c y s t i t i s ,
a l t h o u g h
u s u a l l y
c a u s e d
b y
c h o l e l i t h i a s i s ,
may b e
i n f l u e n c e d
b y
c o n f o u n d i n g
v a r i a b l e s
s u c h
a s t h e
a v a i l a b i l i t y
o f m e d i c a l
c a r e .
N e v e r t h e l e s s ,
d e s p i t e
t h e s e d r a w b a c k s , t h e r e
w e r e
s i m i l a r
c o r r e l a t i o n s
b e t w e e n
b o t h m e t h o d s
u s e d t o e s t i m a t e
g a l l s t o n e
f r e q u e n c y a n d
c a n c e r
m o r t a l i t y
d a t a .
T h e c o r r e l a t i o n
b e t w e e n
c h o l e l i t h i a s i s
a n d
u t e r i n e
c a n c e r
w a s
e x c e p t i o n a l l y
s t r o n g
a n d
i s
c o n s i s t e n t
w i t h
a
p r e v i o u s
r e p o r t
o f
a n
i n c r e a s e d f r e q u e n c y
o f
g a l l s t o n e s
i n women
w i t h e n d o me t ri a l c a n c e r . 2 4
T h e a s s o c i a t i o n
b e t w e e n
g a l l s t o n e s
a n d c o l o r e c t a l
c a n c e r
w a s
a l s o
s t r o n g .
A s i n c r e a s e d c h o l e s t e r o l
e x c r e t i o n ma y
b e
i m p l i c a t e d
a s
a c a u s a t i v e f a c t o r
i n
c h o l e l i t h i a s i s 2 5
a n d a s c h o l e s t e r o l
i s t h e
m a j o r
s o u r c e
f o r
b i l e
a c i d s ,
t h i s s t u d y
s t r e n g t h e n s
t h e c h o -
l e s t e r o l / b i l e
a c i d
h y p o t h e s i s
f o r t h e
a e t i o l o g y
o f
c o l o r e c t a l
c a n c e r .
T h e r e i s n o
r e a d y e x p l a n a t i o n
f o r t h e
u n e x p e c t e d
c o r r e l a t i o n
b e t w e e n
g a l l s t o n e s
a n d
g a s t r i c
c a n c e r .
I t
i s
o f i n t e r e s t
t h a t t h i s
f i n d i n g
i s c o n s i s t e n t
w i t h
t h e
o b s e r v a t i o n
t h a t
P i m a
I n d i a n s
o f
t h e
S o u t h w e s t
U n i t e d
S t a t e s ,
who
a r e known
t o
h a v e a
g r e a t
e x c e s s
o f
g a l l s t o n e s ,
a l s o
h a v e
a
h i g h e r
t h a n
e x p e c t e d
i n c i d e n c e
o f
g a s t r i c
c a n c e r . 2 6
T h e f i n d i n g s r e p o r t e d h e r e ,
a l t h o u g h
n o t
i m p l y i n g
a
c a u s a l
r e l a t i o n s h i p ,
a r e
c o n s i s t e n t
w i t h
t h e
h y p o -
t h e s i s
t h a t
g a l l s t o n e s
a n d s e v e r a l common human
c a n c e r s
s h a r e
common
r i s k f a c t o r s .
A d d i t i o n a l
s t u d i e s
o f
t h e
i n c i d e n c e
o f
c a n c e r
i n
c a r e f u l l y
s e l e c t e d
p a t i e n t s
w i t h a n d w i t h o u t
g a l l s t o n e s
a r e
p l a n n e d .
I t h a n k Dr M
M o n k ,
Dr
W R o s e n t h a l , a n d
Dr
C
M u i r f o r t h e i r
h e l p f u l
a d v i c e .
R e f e r e n c e s
B u r k i t t
D P ,
T u n s t a l l
M.
G a l l s t o n e s :
G e o g r a p h i c a l a n d
c h r o n o l o g i c a l
f e a t u r e s .
J
T r o p
Med
Hyg
1 9 7 5 ;
7 8 :
1 4 0 - 4 .
2 C a p r o n
J P ,
D e l a m a r r e
J ,
C a n a r e l l i
J P ,
B r o u s s e
N ,
D u p a s
J L . D o e s c h o l e c y s t e c t o m y p r e d i s p o s e
t o t h e
d e v e l o p m e n t
o f
c o l o r e c t a l
c a n c e r ? G a s t r o e n t e r o l .
C l i n
B i o l
1 9 7 8 ;
2 :
3 8 3 - 9 .
3 C h o l u j B ,
C e k l o v s k y J ,
N o z i c k a
Z .
C h o l e c y s t e c t o m y
a n d c a r c i n o m a
o f t h e l a r g e i n t e s t i n e .
C e s k G a s t r o e n t e r o l
V y z 1 9 7 9 ;
3 3 : 1 3 - 2 5 .
4 H o a r e
AM,
C a r c i n o m a
o f t h e c o l o n
a n d c h o l e c y s t e c -
t o m y .
L a n c e t
1 9 7 4 ; 2 :
1 3 9 5 - 9 6 .
6 C a s t l e d e n
WM,
D o o u s s
TW,
J e n n i n g s
K P ,
L e i g h t o n
M.
G a l l s t o n e s ,
c a r c i n o m a
o f t h e
c o l o n a n d
d i v e r t i c u l a r
d i s e a s e . C l i n
O n c o l
1 9 7 8 ; 4 :
1 3 9 - 4 4 .
R o s e
G , B l a c k b u r n
H , K e y s A ,
T a y l o r
H L , K a n n e l
WB, P a u l
0 , R e i d
DD,
S t a m l e r
J . C o l o n c a n c e r
a n d
b l o o d
c h o l e s t e r o l .
L a n c e t 1 9 7 4 ;
1 :
1 8 1 - 3 .
7 M a r i n o v i c I , G u e r r a C ,
L a r a c h G . I n c i d e n c e
o f
c h o l e l i -
t h i a s i s
i n
a u t o p s y m a t e r i a l
a n d
a n a l y s i s o f t h e
c o m p o -
s i t i o n
o f c a l c u l i . R e v Med C h i l e
1 9 7 2 ;
1 0 0 :
1 3 2 0 - 2 7 .
8 Z a h o r
Z ,
S t e r n b y
NH,
K a g a n
A ,
Uemura
K , V a n e c e k
R ,
V i c h e r t
AM. F r e q u e n c y
o f c h o e l i t h i a s i s
i n
P r a g u e
a n d
M a l m o .
An
a u t o p s y
s t u d y .
S c a n d J
G a s t r o e n t e r o l
1 9 7 4 ; 9 : 3 - 7 .
9 L i n d s t r o m
C G .
F e q u e n c y o f g a l l s t o n e d i s e a s e i n
a
w e l l -
d e f i n e d S w e d i s h
p o p u l a t i o n . S c a n d
J G a s t r o e n t e r o l
1 9 7 7 ; 1 2 : 3 4 1 - 6 .
0 B a t e s o n
MC,
B o u c h i e r I A D .
P r e v a l e n c e o f
g a l l s t o n e s i n
D u n d e e :
a n e c r o p s y s t u d y .
B r Med
J
1 9 7 5 ; 4 :
4 2 7 - 3 0 .
B a r k e r D J P , G a r d n e r
M J , P o w e r
C ,
H u t t
MSR.
P r e v a l e n c e
o f
g a l l s t o n e s
a t
n e c r o p s y i n
n i n e
B r i t i s h
t o w n s :
a c o l l a b o r a t i v e
s t u d y .
B r Med
J
1 9 7 9 ; 2 :
1 3 8 9 -
9 2 .
1 2 R o d e w a l d H .
P a t h o l o g y
o f
t h e
g a l l b l a d d e r .
I I .
F r e -
q u e n c y
o f
g a l l s t o n e s .
Z b l
A l l g
P a t h o l
1 9 5 7 ; 9 6 : 3 0 0 - 2 .
1 3 D o o u s s
TW,
C a s t l e d e n
WM.
G a l l s t o n e s
a n d
c a r c i n o m a
o f
t h e
l a r g e
b o w e l
NZ
Med
J
1 9 7 3 ;
7 7 :
1 6 2 - 5 .
1 4 L i e b e r
MM. T h e i n c i d e n c e o f g a l l s t o n e s
a n d
t h e i r
c o r r e l a t i o n w i t h o t h e r
d i s e a s e s .
Ann
S u r g
1 9 5 2 ; 1 3 5 :
3 9 4 - 4 0 5 .
5 C l e l a n d
J B .
G a l l s t o n e s
i n
7 , 0 0 0 p o s t m o r t e m
e x a m i n a -
t i o n s .
Med
J A u s t
1 9 5 3 ;
4 0 :
4 8 8 - 9 .
6 N e w m a n H F , N o r t h r u p J D . T h e
a u t o p s y i n c i d e n c e o f
g a l l s t o n e s . I n t
A b s t r S u r g 1 9 5 9 ; 1 0 9 :
1 - 1 3 .
H o g a n J ,
L o n e r g a n M ,
H o l l a n d P D .
T h e i n c i d e n c e
o f
c h o l e l i t h i a s i s
i n a n
a u t o p s y
s e r i e s .
I r
Med
J
1 9 7 7 ;
7 0 :
6 0 8 - 1 1 .
8 T o r v i k
A ,
H o i v i k B .
G a l l s t o n e s
i n
a n
a u t o p s y
s e r i e s .
I n c i d e n c e , c o m p l i c a t i o n s a n d
c o r r e l a t i o n s w i t h
c a r -
c i n o m a
o f
t h e g a l l b l a d d e r .
A c t a
C h i r
S c a n d
1 9 6 0 ;
1 2 0 :
1 6 8 - 7 4 .
9 K a l o s A , D e l i d o u
A ,
K o r d o s i s
T , A r c h i m a n d r i t i s
A ,
G a g a n i s
A , A n g e l o p o u l o s
B .
T h e i n c i d e n c e o f
g a l l -
s t o n e s
i n
G r e e c e ;
a n
a u t o p s y s t u d y .
A c t a
H e p a t o -
g a s t r o e n t e r o l
1 9 7 7 ; 2 4 :
2 0 - 3 .
2 0 H w a n g
W S .
C h o l e l i t h i a s i s
i n
S i n g a p o r e .
P a r t
I :
A
n e c r o p s y s t u d y .
G u t
1 9 7 0 ;
1 1 :
1 4 1 - 5 2 .
2 1 S t i t n i m a n k a r n
T .
T h e
n e c r o p s y
i n c i d e n c e
o f
g a l l s t o n e s
i n
T h a i l a n d .
Amer
JMed
S c i 1 9 6 0 ;
2 4 0 :
3 4 9 - 5 2 .
2 2 W H O .
W o r l d
h e a l t h s t a t i s t i c s
a n n u a l
1 9 7 8 ,
1 9 7 9 .
G e n e v a :
WH O ,
1 9 7 9 - 8 0 .
2 3 A m e r i c a n
C a n c e r
S o c i e t y , C a n c e r
f a c t s
a n d
f i g u r e s ,
1 9 8 0 . New Y o r k : A me r i c a n
C a n c e r
S o c i e t y ,
1 9 7 9 : 1 4 .
2 4 M a c k
TM,
P i k e
MC,
H e n d e r s o n B E ,
P f e f f e r
R I ,
G e r k i n s
V R ,
A r t h u r
M ,
Brown S E .
E s t r o g e n s
a n d
e n d o -
m e t r i a l c a n c e r
i n
a r e t i r e m e n t c o m m u n i t y . N
E n g l
J
Med
1 9 7 6 ; 2 9 4 : 1 2 6 2 - 7 .
2 5 V a l d i v i e s o
V ,
P a l m a
R ,
N e r v i
F ,
C o v a r r u b i a s
C ,
S e v e r i n
C . S e c r e t i o n o f
b i l i a r y
l i p i d s
i n
y o u n g
C h i l e a n
women
w i t h
c h o l e s t e r o l
g a l l s t o n e s .
G u t
1 9 7 9 ;
2 0 :
9 9 7 - 1 0 0 0 .
2 6 S i e v e r s
ML .
U n u s u a l
c o m p a r a t i v e
f r e q u e n c y
o f
g a s t r i c
c a r c i n o m a ,
p e r n i c i o u s a n e m i a ,
a n d
p e p t i c
u l c e r
i n
S o u t h w e s t e r n
A m e r i c a n I n d i a n s .
G a s t r o e n t e r o l o g y
1 9 7 3 ;
6 5 :
8 6 7 - 7 6 .
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Gallstones and the risk of cancer.
A B Lowenfels
doi: 10.1136/gut.21.12.10901980 21: 1090-1092Gut
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