Flavio Xavier, Lucelia de Azevedo H enn, M arja O liveira, Luciane O rlandine
S m o k in g an d its relatio n to th e h isto lo g ical ty p e, su rv iv al,
an d p ro g n o sis am o n g p atien ts w ith p rim ary lu n g can cer
Servifo de Pneumologia
do Hospital das Clinicas de Porto Alegre,
Universidade Federal do Rio Grande do Sul- Porto Alegre, Brazil
T h e fr e q u e n c y o f s m o k in g a m o n g p a tie n ts w ith p r im a r y lu n g c a n c e r d ia g n o s e s a d m itte d to th e H o s p ita l d e C lin ic a s d e P o r to A le g r e ( H C P A ) d u r in g th e 1 9 8 0 's w a s in v e s tig a te d . T h e o b je c tiv e o f th is s tu d y w a s to a n a ly z e c ig a r e tte c o n s u m p tio n p a tte r n s th r o u g h th e n u m b e r o f c ig a r e tte s s m o k e d p e r d a y a n d th e a g e a t w h ic h s m o k in g b e g a n , c o r r e la tin g th is d a ta to th e o v e r a ll s u r v iv a l r a te a n d h is to lo g ic a l ty p e o f th e lu n g c a n c e r . M e th o d s : T h is r e tr o s p e c tiv e s tu d y a n a ly z e d p a tie n ts w ith p r im a r y lu n g c a n c e r d ia g n o s e d a t th e H C P A b e tw e e n J a n u a r y 1 9 8 0 a n d D e c e m b e r 1 9 8 9 . A ll p a tie n ts c o n s id e r e d u n d e r w e n t fo llo w - u p fo r a t le a s t th r e e y e a r s . P a tie n t in fo r m a tio n w a s o b ta in e d e ith e r fr o m th e h o s p ita l's r e c o r d s o r b y c o n ta c tin g p a tie n ts v ia le tte r o r p h o n e . R e s u lts : M o r e th a n 9 0 p e r c e n t o f th e p a tie n ts w e r e s m o k e r s o r h a d s m o k e d p r e v io u s ly ; m o s t h a d s ta r te d s m o k in g b e fo r e th e a g e o f 2 0 . T h e o v e r a ll 2 4 - m o n th s u r v iv a l r a te a fte r d ia g n o s is v a r ie d d e p e n d in g o n w h e th e r th e p a tie n t h a d s m o k e d le s s th a n 4 0 c ig a r e tte s p e r d a y o r n o t. T h e p e r c e n ta g e o f s m o k e r s a n d n o n - s m o k e r s w a s e s ta b lis h e d fo r e a c h h is to lo g ic a l ty p e , w ith th e b r o n c h o a lv e o la r a d e n o c a r c in o m a ty p e s h o w in g th e h ig h e s t p e r c e n ta g e o f n o n - s m o k e r s ( 4 0 p e r c e n t) . C o n c lu s io n :T h e o v e r a ll s u r v iv a l r a te s o f p a tie n ts w ith lu n g c a n c e r w a s r e la te d to th e n u m b e r o f c ig a r e tte s s m o k e d , a n d n o t to th e fa c t o f th e p a tie n t h a v in g s m o k e d o r n o t. T h e n u m b e r o f s m o k e r s a m o n g p a tie n ts w ith lu n g c a n c e r w a s n o t s o h ig h o n ly fo r th e b r o n c h o a lv e o la r a d e n o c a r c in o m a h is to lo g ic a l ty p e .
U N IT E R M S : L u n g c a n c e r , to b a c c o , p r o g n o s is , h is to lo g y .
IN T R O D U C T IO N
D
2 0 p e rc e n tu rin g 1 9 9 0 , a p p ro x im a te lyo f a ll d e a th s ) in th e U n ite d4 1 9 ,0 0 0 d e a th s (a b o u tS ta te s w e rea ttrib u te d to s m o k in g . In c lu d e d in th is n u m b e r
w e re 1 5 0 ,0 0 0 d e a th s fro m n e o p la s ia . I S m o k in g is s till
th e m o s t p re v a le n t c a u s e o f p re m a tu re d e a th s in th a t
c o u n try .2 In B ra z il, it is e s tim a te d th a t s m o k in g is
re s p o n s ib le fo r 1 2 5 ,0 0 0 d e a th s p e r y e a r~ 3 In L a tin
A m e ric a , to b a c c o c o n s u m p tio n is a n im p o rta n t ris k fa c to r
fo r th e d e v e lo p m e n t o f lu n g n e o p la s ia .4
.5 L u n g c a n c e r is
th e p rin c ip a l c a u s e o f d e a th fro m c a n c e r in b o th s e x e s ,c i
A ddress for correspondence:
Flavia Xavier
R ua Alcides G onzaga, 1 5 -Boa Vista
Porto Alegre/R S - Brazil- C EP 09480-020
a n d s m o k in g is re s p o n s ib le fo r a p p ro x im a te ly 8 7 p e rc e n t
o f a ll lu n g c a n c e r d e a th s .2 T h is s tu d y 's o b je c tiv e s w e re
to in v e s tig a te th e in c id e n c e o f s m o k in g a m o n g p a tie n ts
w ith p rim a ry lu n g n e o p la s ia , a n d its re la tio n to s u rv iv a l
b a s e d o n th e n e o p la s ia h is to lo g ic a l ty p e , a s w e ll a s o n
th e a g e a t w h ic h s m o k in g b e g a n a n d th e n u m b e r o f
c ig a re tte s s m o k e d p e r d a y .
M E T H O D S
T h e s tu d y w a s c o m p o s e d o f p a tie n ts w ith p rim a ry
lu n g tu m o rs a n d h is to lo g ic a l p ro o f o f th e d is e a s e w h o h a d
b e e n tre a te d b y th e P n e u m o lo g y D e p a rtm e n t o f th e
H o s p ita l d e C lin ic a s d e P o rto A le g re (H C P A ) th ro u g h o u t
th e 1 9 8 0 's (J a n u a ry 1 9 8 0 to D e c e m b e r 1 9 8 9 ). P a tie n ts '
id e n tific a tio n
d a ta , n u m b e r
o f c ig a re tte s
s m o k e d
p e r d a y ,
a g e a t w h ic h th e y b e g a n s m o k in g ,
a n d in fo rm a tio n
o n th e
h is to lo g y
o f th e n e o p la s ia
w e re s y s te m a tic a lly
ta k e n fro m
h o s p ita l
re c o rd s .
In
th e
s u rv iv a l
a n a ly s is ,
o n ly
th o s e
p a tie n ts fo r w h o m
it w a s p o s s ib le re tro s p e c tiv e ly
to o b ta in
in fo rm a tio n
o n s u rv iv a l tim e a fte r tre a tm e n t - b e it th ro u g h
re v ie w in g
th e re c o rd s
o r a c tiv e
c o m m u n ic a tio n
w ith th e
p a tie n t - w e re s tu d ie d .
P a tie n ts
w e re a lw a y s e x c lu d e d
if th e re w a s d o u b t a s
to th e p rim a ry
s ite o f th e le s io n , a n d w h e n th e p a tie n t h a d
o n ly c lin ic a l c rite ria fo r lu n g c a n c e r w ith o u t th e p o s s ib ility
o f c o n firm in g
th e d ia g n o s is .
N o n -i n d u s tri a l i z e d
c i g a re tte s
a n d
c i g a rs
w e re
in c lu d e d
a s b e in g
e q u iv a le n t
to th re e
n o rm a l
c ig a re tte s .
F ig u re 1 - S m o k in g fre q u e n c y a m o n g s t lu n g c a n c e r p a tie n ts .
P a tie n ts
w h o
c o u ld
n o t
p re c is e ly
g iv e
th e
q u a n tity
c o n s u m e d ,
o r th e a g e a t w h ic h u s e b e g a n ,
w e re e x c lu d e d
o n ly fro m c a lc u la tio n s
in w h ic h th e u n k n o w n
v a ria b le
w a s
c o n s id e re d .
T h e d a ta w a s c o m p u te d
a n d a n a ly z e d
u s in g
th e c o m p u tin g
p ro g ra m
E p i In fo , v e rs io n
5 .0
Ib .
R E S U L T S
In
a s a m p le
o f 3 7 8
p a tie n ts
w ith
p rim a ry
lu n g
n e o p la s ia ,
th e re
w a s
in fo rm a tio n
o n
c ig a re tte
c o n s u m p tio n
h a b its o f 3 6 8 p a tie n ts .
T h e h is to lo g ic a l
ty p e
c o u ld
b e d e te rm in e d
fo r 3 6 7 p a tie n ts ,
e p id e rm o id
b e in g
th e m o s t p re v a le n t.
F R E Q U E N C Y O F S M O K IN G
F ig u re
Id e p ic ts th e p e rc e n ta g e
o f s m o k e rs
a n d n o n
-s m o k e r-s
a m o n g
th e p a tie n ts
s tu d ie d .
In T a b le
3 , s e x
is
a ls o d iffe re n tia te d ;
m e n c o m p ris e
a s ig n ific a n tly
g re a te r
p e rc e n ta g e
o f s m o k e rs
a n d n o n -s m o k e rs
(p < O .O O
I) .In th is s a m p le o f lu n g c a n c e r p a tie n ts ,
th e p e rc e n ta g e
o f s m o k e rs
is g re a te r th a n th e p e rc e n ta g e
o f n o n -s m o k e rs
o r e x -s m o k e rs ,
in d e p e n d e n t
o f s e x . T h e a v e ra g e
s u rv iv a l
tim e a fte r d ia g n o s is
(fo r th o s e p a tie n ts
fo r w h o m
s u rv iv a l
Table 2
Smoking
x Histological
Type
S m o k in g E p i A d e n o A d e n o * L a rg e S m a ll M ix e d U n d e t. T o ta l
Y e s
118
68
6
11
48
6
0
257
N o
2
11
6
0
1
0
0
20
E x -S m o k e r
30
32
3
2
19
3
1
90
T o ta l
150
111
15
13
68
9
1
367
O b s : O n e s m o k e r h a d n o c o n firm e d h is to lo g ic a l ty p e . O th e r p a tie n ts la c k e d in fo rm a tio n
o n s m o k in g .
L e g e n d : E p i = e p id e rm o id ; A d e n o = a d e n o c a rc in o m a p e r s a y ; A d e n o * = a d e n o c a rc in o m a
b ro n c h o a lv e a o la r; L a rg e = .Ia rg e c e lls ; S m a ll = s m a ll c e lls ; U n d e t. = u n d e rte rm in e d
X A V IE R ,F .; H E N N , L .A ; O L IV E IR A ,M . & O R L A N D IN E , L . - S m o k in g a n d its re la tio n to th e h is to lo g ic a l ty p e , s u rv iv a l, a n d p ro g n o s is a m o n g p a tie n ts w ith p rim a ry lu n g c a n c e r
1 3 0 0
T a b le 3
N u m b e r o f cig /d a y b y se x
C ig /d a y
M e n
W o n e n
T o ta l
W ith K n o w n S u rviva l
S u rviva l in M o n th s
1 0 -1 9
6 (8 % )
3 (2 1 % )
9 (1 0 % )
8
1 1
2 0 -2 9
3 4 (4 6 % )
9 (6 4 % )
4 3 (4 8 % )
2 9
1 5
3 0 -3 9
7 (9 % )
1 (7 % )
8 (9 % )
7
1 4
4 0 -4 9
1 5 (2 0 % )
1 (7 % )
1 6 (1 8 % )
9
1 0
= > 5 0
1 2 (1 6 % )
0
1 2 (1 3 % )
1 0
4 .3
T o ta l
7 4
1 4
8 8
inform ation
w as available)
w as 14 m onths for the sm okers,
14 m onths
for the non-sm okers,
and 12 m onths for the
ex-sm okers.
T able
2 represents
the
sm oking
habit
distribution
betw een
the
diverse
histological
groups
of pulm onary
neoplasia.
F igure
2 depicts
these
percentages.
T he
histological
subgroup
adeonocarcinom a
w as subdivided
into adenocarcinom a
per say, represented
by "A deno,"
and
bronchoalveolar
adenocarcinom a,
represented
by
"A deno*".
O nly
in this second
group w as the percentage
of non-sm okers
not expressive
(40 percent
or 6/1 5). T he
epiderm oid
has the few est non-sm oking
patients com pared
to the bronchoalveolar
adenocarcinom a
as w ell as to the
adenocarcinom a
per say (p= .O O
I).
1 0 0
8 0 ",
6 0
4 0
2 0
0
E p i A d n A d n * L a
H isto lo g ica lT yp e
M ix
N U M B E R O F C IG A R E T T E S S M O K E D P E R
D A Y
T he average
num ber
of cigarettes
sm oked per day in
the total
group
w as 26. T able
3 divides
the num ber
of
cigarettes
sm oked
per day (cig/day)
into five categories.
F orty-eight
percent
of the patients
had
a consum ption
pattern
of 20-30
cig/day.
W om en
less frequently
sm oked
m ore that 40 cig/day
than did m en. In our patient sam ple,
there
w ere
none
w ho
sm oked
less than
10 cig/day.
T he
survival
tim e for each category
is given for those patients
w ith available
survival
inform ation.
T he num ber
of cigarettes
consum ed
per day show ed
a correlation
to the
survival
tim e
after the lung
cancer
diagnosis.
In F igure
3, patients
for w hom
inform ation
on
the am ount
of cigarettes
sm oked
per day w as available
in
the records w ere divided
into those w ho sm oked m ore than
40
cigarettes
per
day,
and
those
w ho
sm oked
less.
F ollow ing
the graph
along
the m onths
after diagnosis,
a
F ig u re 2 - S m o kin g x H isto lo g ica l T yp e
% a live
1 0 0
..---80
60
40
20
>
=
4 0 cig /d a yo
M o n th s
F ig u re 3 - S u rviva l x N u m b e r o f cig /d a y sm o ke d
superior
survival
rate can be observed
in the group
w ho
sm oked
few er cigarettes
per day.
T able 4 relates the histological
type to the num ber
of
cigarettes
sm oked
per
day.
T he
histological
subtype
bronchoalveolar
adenocarcinom a
(A deno*)
had the largest
A g e # o f P a tie n ts
5 6 7 8 9
1 0 • • • • • • • • • • • • • • • • • • • • • • • 1 1
1 2 • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • 1 3 • • • • • • • • • • • • • • • • • • • • • • • •
1 4 • • • • • • • • • • • • • • • • • • • • • • • • • • • 15 •••••••••••••••••••••••••••••••••••••••••••••••••••••• 1 6 • • • • • • • • • • • • • • • • • • • • •
1 7 • • • • • • • • • • • • • • • • • • • 1 8 • • • • • • • • • • • • • • • • • • • • • • • • •
1 9
2 0 • • • • • • • • • • • • • • • • • •
F ig u r e 4 - N u m b e r o f p a tie n ts w h o b e g a n to s m o k e a t e a c h a g e
p e r c e n t a g e o f p a t i e n t s w h o h a d s m o k e d b e t w e e n 2 0 - 2 9
c i g / d a y . T h i s s a m e a m o u n t i s s i m i l a r f o r t h e p a t i e n t s w i t h
n e o p l a s i a c l a s s i f i e d a s a d e n o c a r c i n o m a p e r s a y , a n d t h o s e
w i t h t h e e p i d e r m o i d h i s t o l o g y .
A G E A T W H IC H S M O K IN G
S T A R T E D
A m a j o r i t y o f t h e p a t i e n t s b e g a n t o s m o k e b e t w e e n
t h e a g e s o f 1 0 - 2 0 . P e r c e n t a g e - w i s e , t h e r e w e r e m o r e
w o m e n w h o b e g a n t o s m o k e b e f o r e t h e a g e o f 1 0 t h a n
m e n , a n d a g a i n i n t h e c a t e g o r y o f t h o s e w h o b e g a n a f t e r
3 0 , t h e r e a r e m o r e w o m e n t h a n m e n . S u r v i v a l i s n o t r e l a t e d
t o t h e a g e a t w h i c h t h e p a t i e n t b e g a n t o s m o k e , a t l e a s t f o r
t h o s e p a t i e n t s f o r w h o m i t w a s p o s s i b l e t o d e t e r m i n e
s u r v i v a l ( T a b l e 5 ) .
T a b le 4
N u m b e r o f c ig /d a y x H is to lo g ic a lT y p e
C ig /d a y E p i A d e n o A d e n o * L a r g e S m a ll M ix e d
1 0 - 1 9 4 ( 1 1 % ) 2 ( 7 % ) 1 ( 2 0 % ) 0 2 ( 1 0 % ) 0
2 0 - 2 9 1 8 ( 5 2 % ) 1 4 ( 5 1 % ) 2 ( 4 0 % ) 0 9 ( 4 5 % ) 0
3 0 - 3 9 2 ( 6 % ) 4 ( 1 4 % ) 0 0 2 ( 1 0 % ) 0
4 0 - 4 9 3 ( 9 % ) 6 ( 2 2 % ) 0 1 5 ( 2 5 % ) 1
+ > 5 0 7 ( 2 0 % ) 1 ( 4 % ) 2 ( 4 0 % ) 0 2 ( 1 0 % ) 0
T o ta l 3 4 2 7 5 1 2 0 1
L e g e n d : E p i= e p id e r m o id ; A d e n o = a d e n o c a r c in o m a p e r s a y ; A d e n o * = a d e n o c a r c in o m a b r o n c h o a lv e a o la r ; L a r g e = la r g e c e lls ; S m a ll = s m a ll c e lls .
T o ta l
9 ( 1 0 % )
4 3 ( 4 8 % )
8 ( 9 % )
1 6 ( 1 8 % )
1 2 ( 1 3 % )
88
T a b l e 5 i l l u s t r a t e s
t h e n u m b e r o f p a t i e n t s
w h o b e g a n t o s m o k e a t
e a c h a g e ; c h a r a c t e
-r i s t i c a l l y , t h e g r e a t e r
n u m b e r b e g a n i n
a d o l e s c e n c e . E i g h t y
p e r c e n t b e g a n t o s m o k e
b e f o r e t h e a g e o f 2 0 .
T h e a g e a t w h i c h i t w a s
m o s t c o m m o n t o s t a r t
s m o k i n g w a s
IS.
T a b le 5
A g e s m o k in g s ta r te d b y s e x
A g e s m o k in g s ta r te d M e n W o m e n T o ta l W ith k n o w n s u r v iv a l S u r v iv a l in m o n th s
b e fo r e 1 0 1 7 ( 6 % ) 4 ( 1 0 % ) 2 1 ( 7 % ) 1 1 ( 5 2 % ) 2 1
1 0 - 1 9 2 0 3 ( 7 6 % ) 1 9 2 2 2 ( 7 3 % ) 1 4 9 ( 6 7 % ) 1 4
5 0 %
2 0 - 2 9 3 8 ( 1 4 % ) 8 ( 2 0 % ) 4 6 ( 1 5 % ) 2 4 ( 7 5 % ) 1 8
o v e r 3 0 7 ( 2 % ) 7 ( 1 8 % ) 1 4 ( 4 % ) 8 ( 5 7 % ) 1 6
T o ta l 2 6 5 3 8 3 0 3
X A V IE R ,F .; H E N N , L .A ; O L IV E IR A ,M . & O R L A N D IN E , L . - S m o k in g a n d its r e la tio n to th e h is to lo g ic a l ty p e , s u r v iv a l, a n d p r o g n o s is a m o n g p a tie n ts w ith p r im a r y lu n g c a n c e r
1302
D IS C U S S IO N
A m ong
the
patients
diagnosed
w ith
prim ary
pulm onary
neoplasia
in the decade of the 1980's at H eP A ,
a sm oking habit w as encountered
in m ore than 50 percent.
A t the tim e
of diagnosis,
68 percent
w ere
currently
sm oking,
and 23 percent
w ere ex-sm okers.
T his habit w as only not associated in a greater m anner
w hen the histological
type w as bronchoaveolar.
A sm oking
habit w as not differentially
related to the average survival
tim e for lung cancer.
N evertheless,
survi val for patients w ho sm oked over
40 cig/day
w as w orse than for those w ho sm oked
few er.
O n average,
patients
that sm oked
m ore than 50 cig/day
survived
only half the tim e after a neoplasia
diagnosis
as
patients
w ho sm oked
less than this. T his study could not
distinguish
a relationship
betw een the num ber of cigarettes
sm oked per day and any of the histological
neoplasia types.
H alf of the patients
started
sm oking
betw een
ages
10-15, w ith 15 being the m ost com m on
age to begin. T here
w as also no relation
betw een
the age consum ption
began
and lung cancer survival
tim e.
T hus,
in
the
sam ple
studied,
outside
of
the
histological
type
bronchoalveolar
adenocarcinom a,
a
sm oking
habit w as related
to pulm onary
neoplasia.
T he
adenocarcinom a
and epiderm oid
types w ere differentiated
as to the percentage
of non-sm okers.
T he
num ber
of
cigarettes
sm oked
per
day
w as
not
related
to the
histological
type, put could prognosticate
a poorer survival
tim e after a neoplasia
diagnosis
for those sm okers
over 40
cig/day. T he age at w hich
sm oking
began
w as betw een
10-15 years-old for half of the patients, but w as not related
to the survival tim e for lung cancer.
RESUMO
O b je tiv o : A in c id e n c ia . d o h a b ito d o ta b a g is m o e n tr e p a c ie n te s c o m n e o p la s ia p r im a r ia d e p u lm a o , d ia g n o s tic a d a n o H C P A n a d e c a d a d e 8 0 , fo i in v e s tig a d a . O u tr o o b je tiv o d o tr a b a lh o fo i a n a lis a r0 p a d r a o d e c o n s u m o d e c ig a r r o s , a t r a v e s d a q u a n tid a d e d e c ig a r r o s c o n s u m id o s p o r d ia , a id a d e d o in ic io d o c o n s u m o , c o r r e la c io n a n d o - o c o m a s o b r e v id a d o p a c ie n te e 0 tip o h is to l6 g ic o d a n e o p la s ia . M a te r ia l e M e to d o s : p a c ie n te s c o m n e o p la s ia p r im a r ia d e p u lm a o , d ia g n o s tic a d a n o H C P A e n tr e ja n e ir o d e 1 9 8 0 e d e z e m b r o d e 1 9 8 9 , tiv e r a m a c o m p a n h a m e n to p o r n o m in im o tr e s a n o s .0 e s tu d o fo i r e tr o s p e c tiv o , te n d o s id o fe ito a tr a v e s d e r e g is tr o s h o s p ita la r e s e c o m u n ic a < ;:a o c o m o s p a c ie n te s p o r c a r ta e te le fo n e . R e s u lta d o s : U m p e r c e n tu a l d e 9 1 % d o s p a c ie n te s e r a fu m a n te o u e x - fu m a n te . A m a io r p a r te d o s p a c ie n te s c o m e < ;:o ua fu m a r a n te s d o s 2 0 a n o s . A s o b r e v id a a te 2 4 m e s e s a p 6 s 0
d ia g n 6 s tic o e r a d ife r e n te , c o n fo r m e 0 p a c ie n te fu m a s s e m e n o s d e 4 0 c ig a r r o s p o r d ia o u n a o .0 p e r c e n tu a l d e fu m a n te s e d e te r m in a d o p a r a o s d ife r e n te s tip o s h is to l6 g ic o s , s e n d o 0tip o a d e n o c a r c in o m a b r o n q u io lo a lv e o la r 0q u e m a io r in d ic e d e n a o -fu m a n te s a p r e s e n ta v a .C o n c lu s a o : a s o b r e v id a d o s p a c ie n te s e s te v e a s s o c ia d a c o m 0 n u m e r o d e c ig a r r o s fu m a d o s , m a s n a o c o m 0 fa to d o p a c ie n te te r fu m a d o o u n a o . A e le v a d a in c id e n c ia d e fu m a n te s e n tr e o s p a c ie n te s c o m n e o p la s ia p u lm o n a r ( 9 1 % ) s 6 n a o fo i ta o e x p r e s s iv a p a r a p a c ie n te s c o m 0 tip o a d e n o c a r c in o m a b r o n q u io lo a lv e o la r .
R E F E R E N C E S
I . C D C . C ig arette-sm o k in g attrib u tab le m o rtality an d y ears o f
p o ten tial life lo st. U n ited S tates: M M W R 1 9 9 3 ;4 2 :6 4 5 -9 .
2 . C D C . R ed u cin g th e h ealth co n seq u en ces o f sm o k in g : 2 5
y ears o f p ro g ress - A rep o rt o f th e S u rg eo n G en eral.
R o ck v ille, M ary lan d : U S D ep artm en t o f H ealth an d H u m an
S erv ices. P u b lic H ealth S erv ice C D C , D H H S p u b licatio n
n o . (C D C ), 1 9 8 9 ;8 9 :8 4 1 1
3 . D e S tefan i E , C o rrea P , O reg g ia F , et al. A lco h o l d rin k in g ,
m eat co n su m p tio n an d lu n g can cer. H am b u rg , G erm an y :
A sso ciatio n o f C an cer R eg istries, 1 9 9 0 : f\u g u st.
4 . Jo ly 0 , L u b ian JH , C arab allo so M . D ark to b acco an d lu n g
can cer in C u b a. J N atl C an cer In st 1 9 8 3 ;7 0 : 1 0 3 3 -9 .
5 . M iller B A , G lo ceck ler-R ies L A , H an k ey B F , K o sary C L ,
E d w ard s B K . In : C an cer S tatistics R ev iew , 1 9 7 3 -1 9 8 9 . U S
D ep artm en t o f H ealth an d H u m an S erv ices, P u b lic H ealth
S erv ice N atio n al In stitu te o f H ealth , N atio n al C an cer
In stitu te. B eth esd a, M ary lan d : D H H S p u b licatio n n o . (N IH )
1 9 9 2 ;9 2 :2 7 8 9 .
6 . R ig atto M . In : S ilv a L C C , ed . T ab ag ism o 2 n d ed . C o m p en d io
d e P n eu m o lo g ia. P o rto A leg re: F u n d o E d ito rial B Y K ,
1 9 9 1 :2 9 2 -3 1 1 .
