jc ejournal 18122012 Breast cancer among shift workers.pptx

8142019 jc ejournal 18122012 Breast cancer among shift workerspptx

httpslidepdfcomreaderfulljc-ejournal-18122012-breast-cancer-among-shift-workerspptx 160

Moderator Dr Asha Bellad

Presenter Dr Sushrit A Neelopant

E-journal club 18-12-2012



Authors1 Anders Knutsson Department of Health Sciences Mid Sweden

University Sundsvall Sweden

2 Lars Alfredsson Institute of Environmental Medicine KarolinskaInstitutet Stockholm Sweden

3 Berndt Karlsson Clinic of Occupational and EnvironmentalMedicine Umearing Sweden

4 Torbjoumlrn Aringkerstedt Stress Research Institute Stockholm UniversityStockholm Sweden

5 Eleonor I Fransson School of Health Sciences Joumlnkoumlping UniversityJoumlnkoumlping Sweden

6 Peter Westerholm Occupational and Environmental MedicineUppsala University Uppsala Sweden

7 Hugo Westerlund Stress Research Institute Stockholm UniversityStockholm Sweden



bullPrevalence of odd work hours - increased - Europe and

many other countries

bull17 - shift work 10 - night work

53 - weekend 20 - on call

bull

Association of Shift work ndash sleep disorders fatigue accidents cardiovascular disease

gastrointestinal disorders and cancer

bullIARC- 2007- ldquoShift work that involves circadian disruptionis probably carcinogenic to humansrdquo



breast cancer-

bullsufficient evidence among experimental animalsbulllimited evidence in epidemiological studies on humans

shift work - associated with-

breast cancer prostate cancer endometrial cancercolorectal cancer and Non-Hodgkinrsquos lymphoma

The most extensively studied cancer in this context is

female breast cancer



bullIn a recent review nine epidemiological studies ndash

six were positive

bullAn additional four studies have been published-

Three were positive

bullAll living organisms- adapted to the 24-hour alternating

pattern of days and nights

bullThis endogenous circadian rhythm is entrained to the

individualrsquos environment by light stimulus through the

eyes

bullThe master clock- in a paired (SCN) in the hypothalamus

helps the organism to adjust to the environmental 24-

hour cycles



bullPresent in all organs of the human body clock cells have

the ability to create an endogenous biological rhythm

bullThe peripheral clock cells- outside the hypothalamus are

influenced by the SCN clock but they are also entrained

by the timing of food intake

bullThe clock cells have specific clock genes that create a

circadian rhythm by means of a cyclic production ofspecific proteins



bullCLOCK genes - in crucial functions of cell biology

eg cell proliferation DNA repair and apoptosis

bullThe cell division is temporally regulated and this

rhythmic control affects the rate of the DNA replication

bullIn experimental studies on rodents it has been shown

that eradication of the SCN leads to disturbance of thecircadian rhythm and increases the growth of malignant

tumours



bullExposure to light at night (LAN) has a similar effect on

the circadian system

bullAnimal experiments have demonstrated that LAN

accelerates the growth of breast cancer cells

bullA recent epidemiological study on women with

experience of long-term night shift work showed that

shift work was associated with epigenetic changes of the

clock genes CLOCK and CRY

bullThe same epigenetic changes have been observed in

breast cancer case ndashcontrol studies



bullMelatonin - chronobiotic hormone - by the pineal gland

- transmits information on environmental darkness and

lightness

bullMelatonin - anticarcinogenic actions that are mediated

by a number of mechanisms including

antioxidant and antimitotic activity amp antiestrogenic

properties

bullSince oestrogen promotes growth of breast cancer cells

deficiency of melatonin stimulates their growth



bullMelatonin - manufactured and secreted- during night

bull

Exposure to LAN- melatonin decreases acutely

bullDepending on the time when LAN occurs it can also

shift the phase of melatonin in blood

bullErren amp Reiter- definition of circadian disruption or

chronodisruption

ldquoa breakdown of phasing internal biological systemsappropriately relative to the external ie environmental

changes which leads to chronobiological disordersrdquo



bullThe best markers of chronodisruption-

melatonin or its metabolites- saliva urine and blood

bullAs concerns shift work shifts including night work are

supposed to be the strongest chronodisruptor

bullReason - night work apparently associated with exposure

to LAN



bull Exposure to LAN- will shift the melatonin acrophase

forward

bull Exposure - early morning- the shift of the acrophase will

be backward

bull late evening or early morning shifts - chronodisruptive

properties



bullNeed for more studies - comparing the risk of breast

cancer in relation to different shift systems also systems

that do not include night work

bullThe aim of the present study - to compare the risk of

breast cancer among women with day work and shift

work with and without night shifts



Methods

bullThe data were obtained from the WOLF (Work Lipids

and Fibrinogen) occupational cohort study that included

subjects who were employed in different public and

private companies

bullThe baseline study was first carried out in Stockholm

Sweden from 1992 ndash1995 (WOLFS N=5698)

bull In order to include more subjects who worked in blue-

collar jobs a new data collection was carried out in two

counties in the north of Sweden from 1996 ndash1997

(WOLFN N=4718)



bullMethods ctd

bullAll subjects were employed at baseline (aged 19 ndash70

years) and worked in 60 different companies

bullThe major branches - pharmaceutical industry

transportation public administration telecommunication

sales work schools the paper and pulp industry banksoffices and the mechanical industry

bullThe overall participation rate - 80

bullThe subjects who participated in the 1996 ndash1997 datacollection were invited to a follow-up examination which

was performed during 2000 ndash2003 (WOLFF N=5433)



Methods cntd

bull

Of those3630 were re-examined and 1803 were recruited for the

first time

bullAll women who entered the cohort in 1992 ndash19951996 ndash1997 and 2000 ndash2003 were included in total 4087

employees

bullAmong those it was possible to classify exposure toshift and day work among 4036 women comprising the

analytic sample for this study



Methods ctd

bull At baseline

the participants answered a questionnaire (at home) and

examined by nurses at 33 occupational health units

bull The questionnaire - work tasks occupation work hours

education work environment stress behavioural factorsfamily physical activity sleep health pharmaceuticals

hereditary issues and foreign extraction

bull The medical examination- height weight abdominal

circumference hip circumference and blood pressure

bull The nurses- trained beforehand to ensure standard

procedure



A new questionnaire was sent to all participants in 2009 In total 2148 women answered

the questionnaire in 2009 (WOLFU) Figure shows the flow chart in the present study

A flowchart for description of the WOLF cohort WOLFS= WOLF Stockholm WOLFN= WOLF

Norrland WOLFF=follow-up of WOLFN and new recruitment to WOLFN lrarr participants who leave the cohort

WOLFS (1992 1995)



(i) ldquoDo you work shiftsrdquo

(a) no

(b) 2 shifts(c) 3 shifts with

continuous operation

(d) according to a rota

(irregular scheduling or

working hours round the

clock and over the whole

week according to a

particular work schedule)

(e) other type of shift

(a) no

(b) 2 shifts

(c) 3 shifts withcontinuous operation


without night shifts

(e) according to a rota

with night shifts

(f) permanent night work

(g) Other type of shift

ldquoWhich option is best suited

in terms of your current

working hours If you are

not employed right now we

want you to think of the time

just before you stopped

workingrdquo

a day work (0600 ndash1800)

b evening work (1800 ndash2200)

c night work (1800 ndash

0600hrs)

d shift work not night

e shift work including night

f according to a rota notnight

g according to a including

night

h other working hours

WOLFS (1992 ndash1995)WOLFN (1996 ndash1997) WOLFF (2000 ndash2003) WOLFU -2009



(ii) ldquoHow many hours do

you normally work per

week including overtimeand how are these hours

distributed

on averagerdquo

(a) day work (0600 ndash

1800) number ofhours=xx

(b) evening work (1800 ndash

2200 ) number of

hours=xx

(c) night work (2200 ndash0600 ) number of

hours=xx

In addition the WOLFF

questionnaire asked if the

respondent had changedshift system during the

last five years ndash either

from shift to day or vice

versa

(ii) ldquoOver how many years

of your career have you

worked shifts If you havenever worked shifts

enter 0 yearsrdquo

(iii) ldquoHow many years

have included nightwork If you have never

worked shifts with night

work indicate the last

year you worked shifts

and enter 0 yearsrdquo

WOLFS (1992 ndash1995)WOLFN (1996 ndash1997)

WOLFF (2000 ndash2003) WOLFU -2009



Methods ctd

bullDay work on all occasions when the subject participated- dayworker

bullShift work without night work on ge1 occasion and day work for the

rest - worker with shift work without night work

bullIf the data indicated shift work with night work on ge1 occasion and

day work or shift work without night for the rest - worker with night

shift work

bullInformation on shiftday work was obtained from 1459 participants

from baseline only In total 2148 subjects participated in baseline

and WOLFU and 429 subjects participated on all three occasions

(WOLFN or WOLFS WOLFF and WOLFU)



Methods ctd

Breast cancer

bullData on cancer incidence - obtained from the Swedish cancer

registry from its establishment in 1958 to 2008

bullReporting is mandatory and covers the total population

bullIt includes individual data on -

personal id number sex place of residence site of tumourhistological type basis and date of diagnosis date and cause of

death date of migration and whether a patient was registered as a

resident in Sweden at the end of a specific year



bullThe date and causes of death were obtained from the Swedish

death registry between 1992 ndash2008

bullBreast cancer codes according ICD-7 (170) or ICD-10 (C50) were

used to define incident breast cancer cases

bullAll deceased women with breast cancer as an underlying cause

in the death certificate (N=8) were included in the Swedish

cancer registry in the present study

bullExclusion criteria

bullCases without a cancer notification but reported to the Cause

of Death Register are not included

bullWomen who developed breast cancer between 1958 and

baseline were excluded from the analyses (N=10)



Covariates

bull

Information on potential confounders was collected at baselineanthropometric variables and educational level no of children

smoking menopausal status oral contraceptive use hormones

other than contraceptives alcohol intake and educational level

bull Body mass index and waist ndashhip ratio - calculated based on the

anthropometric measures



Statistical analysis

bullAll statistical analyses were performed using SPSSWindows

version 170 (SPSS Inc Chicago IL USA)

bullThe results are expressed as percentages for dichotomous

variables and means for continuous variables

bullChi-square test was used for categorical variables

bullNumber of children- tested by Mann Whitney U-test (due to a

skewed distribution)

bullTwo-tailed tests were used



bullCox regression analysis- multivariable analysis

bullHazard ratios (HR) are expressed with 95 confidence intervals

(95 CI)

bullAttained age was used as time variable

bullWhen restricting the population to lt60 years of age censoring was

done for time of death time of diagnosis or when the subjectreached age 60 whichever came first

bullThe working time variable was categorized into day work and shift

work with and without night work



The following were potential confounding variables from baseline

(i) body mass index (BMI)

(ii) waist-hip ratio

(iii)educational level

(iv)current smoking (current versus not current smoker)

(v) ever smoker (ever versus never smoker)(vi)menopausal status and

(vii)treatment with hormones other than oral contraceptives



bullHigh level of alcohol intake was defined as consumption of

alcoholic beverages (beer wine or liquor) on average ge6 times

per week

bullLow level was defined as less than that

bullAll variables were not kept in the main model because they

only marginally influenced the HR

bullTherefore the final model included only exposure to dayshift

work number of children and alcohol intake



Results

bullThe mean follow-up time (time from baseline to censorship) was

124 years (range 02 ndash161)

bullWhen censoring participants for time of death time of diagnosis

or 31 December 2008 the total number of person-years in the

cohort was 49973

bullBreast cancer was diagnosed among 97 women between baseline

and follow-up

bullThree of these were excluded because data on the shift workvariable were missing





Age at diagnosis was lower in the two groups with shift work compared with those in the

day working group Shift workers with night work tended to have a shorter time from

baseline to diagnosis than day workers



Results of the Cox regression analysis showed increased HR for shift workers with night

work compared with day workers



Discussion

bull

This study indicates that shift work with night shifts is associatedwith an increased risk of breast cancer

bullThis finding is consistent with a number of published

epidemiological studies

bullThe adjusted risk was 202 which is comparable with the other

studies



bullLimitations

bull In the study it was not possible to obtain data on- the duration of

lifetime exposure for all participants only for those who answeredthe questionnaire in 2009

bull Results showed that shifts without night work were associated

with a HR of 123 which is not statistically significant

bull A case ndashcontrol study from the USA showed an OR of 108 (95 CI

081 ndash144) among evening shift workers

bull The evening shift however was a mix of evening and night worksince it started in the afternoon and could end as late as 0200

hours



bullResults ctd

bullWhen considering only cumulative incidence there were only

marginal differences between the three work schedules

bullHowever the shift workers with night shifts were younger at

inclusion and diagnosed with breast cancer earlier than the day

workers

bullThe time between baseline and diagnosis was significantly shorter

among those who worked shifts with night work than those who

worked days only This might indicate that the tumour progression

was faster among night shift workers

bullThis indicates that the lag between exposure and cancer is not very

long and supports the hypothesis that shifts with night work is a

causal factor



Results ctd

bullInconsistencies in previous research on night work and cancer

can be due to a poor definition of the shift work variable

bullOne might hypothesize that some women have increased

vulnerability due to genetic differences or behavioural factors

bullWhen they are exposed to shift work cancer might develop

early



bullThe risk factors for breast cancer

age at birth of first child number of children obesity use of

contraceptive pills hormone treatment nulliparity smokingalcohol consumption and short time of breast feeding

bullConfounding variables were tested-

by entering contraceptive pills other hormonal treatment

menopausal status obesity number of children smoking (ever and

current) alcohol intake and educational level into the analyses



bullLimitations

bullReliance on self-reported exposure can involve anamnestic

mistakes

bull Difficulties in correctly recalling previous exposure

bullOf those who reported no experience of shift work in the final

follow-up 22 actually had reported current exposure to shift work

at baseline

bullThe agreement between information given at baseline and follow-

up however was better when considering shift work with nightshifts



bullOf those who reported no experience of night shift work at

follow-up only 2 reported night work at baseline

bullIt appears that retrospective information about night shift

experience is more reliable than information about shifts without

night work

bullIn 53 of the subjects- retrospective information about lifetime

exposure to shift work

bull in 36 - only baseline information



bull The baseline questionnaire provided information only on

current shift work night work and it is probable that some

subjects who were classified as day workers based on thisinformation only were actually former shift workers

bull It is not possible to draw any conclusions about how this

misclassification could have biased the results



bullThe size of the study a larger number of participants may have

yielded clearer results in some of the analyses

bull Strength of the present study is the longitudinal prospective

cohort design

bullIn the literature- only three prospective cohort studies on the

association between shift work and breast cancer were found

bullTwo were positive and one was negative



bullThe majority of published studies have been case ndashcontrol studies

in which possible recall bias limits the validity of exposure

information

bullThe unique person identification number available for all Swedish

citizens makes it possible to obtain almost complete data from the

Swedish cancer registry on cancer incidence during follow-up

bullAnother advantage - access to information on several potential

confounding factors that could be taken into account in theanalyses



bullIn order to try preventive measures it is necessary to elucidate

the mechanism behind the increased cancer risk

bullIf the melatonin suppression is the crucial factor one preventive

method could be to reduce exposure to LAN

bullIt would also be possible to use only red light at night because

red light does not interfere with melatonin production

bullIf the major problem is the challenge of the circadian rhythm or

interaction between night work and genetic predisposition other

preventive measures should be evaluated

C l i i d i k f b t hift k



bull Conclusion- increased risk of breast cancer among shift workers

who have had night work in their schedule

bullShift workers who did not have night work had a small and

statistically insignificant risk compared with day workers

bullThe finding supports previous research reporting an increasedbreast cancer risk among night shift workers

bull

It cannot be ruled out that also shift workers without nightwork are at a higher risk of cancer than day workers



CROSS REFERENCE

Sleep duration melatonin and breast cancer among Chinesewomen in SingaporeAnna H Wu Renwei Wang Woon-Puay Koh Frank Z Stanczyk Hin-Peng Lee and Mimi

C Yu

Five hundred and twenty-five incident cases of breast cancer were

identified among the remaining 33528 women after up to 11 years

of follow-up

Among women postmenopausal at baseline breast cancer risk

decreased with increasing sleep duration

Those who reported 9+ h of sleep showed a relative risk of 067

compared with women who reported le6 h of sleep



This inverse association was observed primarily in lean women

In this study population irrespective of gender urinary 6-

sulfatoxymelatonin levels increased with increasing self-

reported hours of sleep after adjustment for age and time of

day of urine collection

Melatonin levels were 42 higher in those with 9+ versusthose with le6 h of sleep

Conclusion Sleep duration may influence breast cancer risk

possibly via its effect on melatonin levels



CROSS REFERENCE

Sleep duration and the risk of breast cancer the Ohsaki Cohort

Study

M Kakizaki S Kuriyama T Sone et alBritish Journal of Cancer

In a prospective study of 23995 Japanese women short sleep

duration was associated with higher risk of breast cancer

compared with women who slept 7 h per day

The multivariate hazard ratio of those who slept lt6 h per day was

162

Significant inverse association between sleep duration and breast

cancer risk in Japanese women



CRITICAL APPRAISAL



Journal

Scand J Work Environ Health

Peer reviewed

Indexed



Title

bull Breast cancer among shift workers results ofthe WOLF longitudinal cohort study

bull Concise and informative

bull Primary objective stated

bull Study area amp population ndash not mentioned

bull Study design mentioned

bull Key words



Authors

bull Address E-mail id of corresponding authormentioned

bull [E-mail AndersKnutssonmiunse]

bull Affiliation- Department of Health Sciences Mid

Sweden University SE-85170 Sundsvall

Sweden



Introduction

Problem statement with background discussed

Research question- Whether shift work (with or without nightwork) is associated with increased risk of breast cancer

The rationale is stated satisfactorily

Need for the study identified

Knowledge gap- highlighted

Adequate references quoted



Methods

Study Design Prospective study (Part of the largerongoing cohort sample)

Sampling and recruitment details have been explainedsystematically

Data source ndash details mentioned elaborately

Sample size calculation is not mentioned



Methods

bull The study setting- Community (public and privatecompanies) ndash ideal

bull The confounding factors - influencing the levels of

Iodine should have been addressed

bull Exclusion and Inclusion criteria mentioned

bull Standardization of the instruments validation of

scales ndash should have been mentionedbull Ethical clearance is obtained from respective

University and Medical Association



Statistical Analysis

bull Appropriate methodology used ndash

bull Chi-square

bull Mann Whitney U-test

bull Cox regression analysis - multivariable

analysis

bull

Hazard ratiobull Statistical Analysis SPSSWindows version

170 (SPSS Inc Chicago IL USA)



Results

bull Results are given in tables

bull The article convinces the reader that the study

is true

bull Observations are summarized and discussed

bull Statistical significance of the values showing

positive association ndash mentioned



Discussion

Possible reasoning of the available results andcomparison done with relevant studies doneelsewhere

Other relevant studies related ndash similarities isquoted

Contrary results of other studies mentioned

honestly

Strengths and limitations are mentioned



References

Vancouver style

No of references 46 - adequate

Recent references are mentioned ndash 23

Bibliography section not used



Abstract

Well structured

219 words

Presented as Objective

Methods

Results

Conclusions

Date of receipt acceptance mentioned

Precise and informative



THANK YOU



Authors1 Anders Knutsson Department of Health Sciences Mid Sweden

University Sundsvall Sweden

2 Lars Alfredsson Institute of Environmental Medicine KarolinskaInstitutet Stockholm Sweden

3 Berndt Karlsson Clinic of Occupational and EnvironmentalMedicine Umearing Sweden

4 Torbjoumlrn Aringkerstedt Stress Research Institute Stockholm UniversityStockholm Sweden

5 Eleonor I Fransson School of Health Sciences Joumlnkoumlping UniversityJoumlnkoumlping Sweden

6 Peter Westerholm Occupational and Environmental MedicineUppsala University Uppsala Sweden

7 Hugo Westerlund Stress Research Institute Stockholm UniversityStockholm Sweden







bull






breast cancer-









six were positive


Three were positive





eyes



hour cycles


















tumours

















lightness




properties






bull





chronodisruption










to LAN




forward


be backward


properties











Methods




private companies






(WOLFN N=4718)



bullMethods ctd











Methods cntd

bull


first time


employees





Methods ctd

bull At baseline









procedure







WOLFS (1992 1995)




(a) no







week according to a



(a) no

(b) 2 shifts





with night shifts









workingrdquo




0600hrs)





night








distributed

on averagerdquo




2200 ) number of

hours=xx


hours=xx






versa




enter 0 yearsrdquo











Methods ctd






shift work







Methods ctd

Breast cancer
























Covariates

bull





















(95 CI)



















per week








Results





cohort was 49973


and follow-up















Discussion

bull





studies



bullLimitations








hours



bullResults ctd





workers







causal factor



Results ctd






early












bullLimitations


mistakes




at baseline









night work
















cohort design








information

























bull




CROSS REFERENCE


C Yu



of follow-up

















CROSS REFERENCE


Study






162





CRITICAL APPRAISAL



Journal


Peer reviewed

Indexed



Title






bull Key words



Authors





Sweden



Introduction









Methods







Methods












bull Chi-square



analysis

bull





Results



is true






Discussion




honestly




References

Vancouver style






Abstract

Well structured

219 words


Methods

Results

Conclusions





THANK YOU







bull






breast cancer-









six were positive


Three were positive





eyes



hour cycles


















tumours

















lightness




properties






bull





chronodisruption










to LAN




forward


be backward


properties











Methods




private companies






(WOLFN N=4718)



bullMethods ctd











Methods cntd

bull


first time


employees





Methods ctd

bull At baseline









procedure







WOLFS (1992 1995)




(a) no







week according to a



(a) no

(b) 2 shifts





with night shifts









workingrdquo




0600hrs)





night








distributed

on averagerdquo




2200 ) number of

hours=xx


hours=xx






versa




enter 0 yearsrdquo











Methods ctd






shift work







Methods ctd

Breast cancer
























Covariates

bull





















(95 CI)



















per week








Results





cohort was 49973


and follow-up















Discussion

bull





studies



bullLimitations








hours



bullResults ctd





workers







causal factor



Results ctd






early












bullLimitations


mistakes




at baseline









night work
















cohort design








information

























bull




CROSS REFERENCE


C Yu



of follow-up

















CROSS REFERENCE


Study






162





CRITICAL APPRAISAL



Journal


Peer reviewed

Indexed



Title






bull Key words



Authors





Sweden



Introduction









Methods







Methods












bull Chi-square



analysis

bull





Results



is true






Discussion




honestly




References

Vancouver style






Abstract

Well structured

219 words


Methods

Results

Conclusions





THANK YOU



breast cancer-









six were positive


Three were positive





eyes



hour cycles


















tumours

















lightness




properties






bull





chronodisruption










to LAN




forward


be backward


properties











Methods




private companies






(WOLFN N=4718)



bullMethods ctd











Methods cntd

bull


first time


employees





Methods ctd

bull At baseline









procedure







WOLFS (1992 1995)




(a) no







week according to a



(a) no

(b) 2 shifts





with night shifts









workingrdquo




0600hrs)





night








distributed

on averagerdquo




2200 ) number of

hours=xx


hours=xx






versa




enter 0 yearsrdquo











Methods ctd






shift work







Methods ctd

Breast cancer
























Covariates

bull





















(95 CI)



















per week








Results





cohort was 49973


and follow-up















Discussion

bull





studies



bullLimitations








hours



bullResults ctd





workers







causal factor



Results ctd






early












bullLimitations


mistakes




at baseline









night work
















cohort design








information

























bull




CROSS REFERENCE


C Yu



of follow-up

















CROSS REFERENCE


Study






162





CRITICAL APPRAISAL



Journal


Peer reviewed

Indexed



Title






bull Key words



Authors





Sweden



Introduction









Methods







Methods












bull Chi-square



analysis

bull





Results



is true






Discussion




honestly




References

Vancouver style






Abstract

Well structured

219 words


Methods

Results

Conclusions





THANK YOU




six were positive


Three were positive





eyes



hour cycles


















tumours

















lightness




properties






bull





chronodisruption










to LAN




forward


be backward


properties











Methods




private companies






(WOLFN N=4718)



bullMethods ctd











Methods cntd

bull


first time


employees





Methods ctd

bull At baseline









procedure







WOLFS (1992 1995)




(a) no







week according to a



(a) no

(b) 2 shifts





with night shifts









workingrdquo




0600hrs)





night








distributed

on averagerdquo




2200 ) number of

hours=xx


hours=xx






versa




enter 0 yearsrdquo











Methods ctd






shift work







Methods ctd

Breast cancer
























Covariates

bull





















(95 CI)



















per week








Results





cohort was 49973


and follow-up















Discussion

bull





studies



bullLimitations








hours



bullResults ctd





workers







causal factor



Results ctd






early












bullLimitations


mistakes




at baseline









night work
















cohort design








information

























bull




CROSS REFERENCE


C Yu



of follow-up

















CROSS REFERENCE


Study






162





CRITICAL APPRAISAL



Journal


Peer reviewed

Indexed



Title






bull Key words



Authors





Sweden



Introduction









Methods







Methods












bull Chi-square



analysis

bull





Results



is true






Discussion




honestly




References

Vancouver style






Abstract

Well structured

219 words


Methods

Results

Conclusions





THANK YOU


















tumours

















lightness




properties






bull





chronodisruption










to LAN




forward


be backward


properties











Methods




private companies






(WOLFN N=4718)



bullMethods ctd











Methods cntd

bull


first time


employees





Methods ctd

bull At baseline









procedure







WOLFS (1992 1995)




(a) no







week according to a



(a) no

(b) 2 shifts





with night shifts









workingrdquo




0600hrs)





night








distributed

on averagerdquo




2200 ) number of

hours=xx


hours=xx






versa




enter 0 yearsrdquo











Methods ctd






shift work







Methods ctd

Breast cancer
























Covariates

bull





















(95 CI)



















per week








Results





cohort was 49973


and follow-up















Discussion

bull





studies



bullLimitations








hours



bullResults ctd





workers







causal factor



Results ctd






early












bullLimitations


mistakes




at baseline









night work
















cohort design








information

























bull




CROSS REFERENCE


C Yu



of follow-up

















CROSS REFERENCE


Study






162





CRITICAL APPRAISAL



Journal


Peer reviewed

Indexed



Title






bull Key words



Authors





Sweden



Introduction









Methods







Methods












bull Chi-square



analysis

bull





Results



is true






Discussion




honestly




References

Vancouver style






Abstract

Well structured

219 words


Methods

Results

Conclusions





THANK YOU









tumours

















lightness




properties






bull





chronodisruption










to LAN




forward


be backward


properties











Methods




private companies






(WOLFN N=4718)



bullMethods ctd











Methods cntd

bull


first time


employees





Methods ctd

bull At baseline









procedure







WOLFS (1992 1995)




(a) no







week according to a



(a) no

(b) 2 shifts





with night shifts









workingrdquo




0600hrs)





night








distributed

on averagerdquo




2200 ) number of

hours=xx


hours=xx






versa




enter 0 yearsrdquo











Methods ctd






shift work







Methods ctd

Breast cancer
























Covariates

bull





















(95 CI)



















per week








Results





cohort was 49973


and follow-up















Discussion

bull





studies



bullLimitations








hours



bullResults ctd





workers







causal factor



Results ctd






early












bullLimitations


mistakes




at baseline









night work
















cohort design








information

























bull




CROSS REFERENCE


C Yu



of follow-up

















CROSS REFERENCE


Study






162





CRITICAL APPRAISAL



Journal


Peer reviewed

Indexed



Title






bull Key words



Authors





Sweden



Introduction









Methods







Methods












bull Chi-square



analysis

bull





Results



is true






Discussion




honestly




References

Vancouver style






Abstract

Well structured

219 words


Methods

Results

Conclusions





THANK YOU

















lightness




properties






bull





chronodisruption










to LAN




forward


be backward


properties











Methods




private companies






(WOLFN N=4718)



bullMethods ctd











Methods cntd

bull


first time


employees





Methods ctd

bull At baseline









procedure







WOLFS (1992 1995)




(a) no







week according to a



(a) no

(b) 2 shifts





with night shifts









workingrdquo




0600hrs)





night








distributed

on averagerdquo




2200 ) number of

hours=xx


hours=xx






versa




enter 0 yearsrdquo











Methods ctd






shift work







Methods ctd

Breast cancer
























Covariates

bull





















(95 CI)



















per week








Results





cohort was 49973


and follow-up















Discussion

bull





studies



bullLimitations








hours



bullResults ctd





workers







causal factor



Results ctd






early












bullLimitations


mistakes




at baseline









night work
















cohort design








information

























bull




CROSS REFERENCE


C Yu



of follow-up

















CROSS REFERENCE


Study






162





CRITICAL APPRAISAL



Journal


Peer reviewed

Indexed



Title






bull Key words



Authors





Sweden



Introduction









Methods







Methods












bull Chi-square



analysis

bull





Results



is true






Discussion




honestly




References

Vancouver style






Abstract

Well structured

219 words


Methods

Results

Conclusions





THANK YOU





lightness




properties






bull





chronodisruption










to LAN




forward


be backward


properties











Methods




private companies






(WOLFN N=4718)



bullMethods ctd











Methods cntd

bull


first time


employees





Methods ctd

bull At baseline









procedure







WOLFS (1992 1995)




(a) no







week according to a



(a) no

(b) 2 shifts





with night shifts









workingrdquo




0600hrs)





night








distributed

on averagerdquo




2200 ) number of

hours=xx


hours=xx






versa




enter 0 yearsrdquo











Methods ctd






shift work







Methods ctd

Breast cancer
























Covariates

bull





















(95 CI)



















per week








Results





cohort was 49973


and follow-up















Discussion

bull





studies



bullLimitations








hours



bullResults ctd





workers







causal factor



Results ctd






early












bullLimitations


mistakes




at baseline









night work
















cohort design








information

























bull




CROSS REFERENCE


C Yu



of follow-up

















CROSS REFERENCE


Study






162





CRITICAL APPRAISAL



Journal


Peer reviewed

Indexed



Title






bull Key words



Authors





Sweden



Introduction









Methods







Methods












bull Chi-square



analysis

bull





Results



is true






Discussion




honestly




References

Vancouver style






Abstract

Well structured

219 words


Methods

Results

Conclusions





THANK YOU




bull





chronodisruption










to LAN




forward


be backward


properties











Methods




private companies






(WOLFN N=4718)



bullMethods ctd











Methods cntd

bull


first time


employees





Methods ctd

bull At baseline









procedure







WOLFS (1992 1995)




(a) no







week according to a



(a) no

(b) 2 shifts





with night shifts









workingrdquo




0600hrs)





night








distributed

on averagerdquo




2200 ) number of

hours=xx


hours=xx






versa




enter 0 yearsrdquo











Methods ctd






shift work







Methods ctd

Breast cancer
























Covariates

bull





















(95 CI)



















per week








Results





cohort was 49973


and follow-up















Discussion

bull





studies



bullLimitations








hours



bullResults ctd





workers







causal factor



Results ctd






early












bullLimitations


mistakes




at baseline









night work
















cohort design








information

























bull




CROSS REFERENCE


C Yu



of follow-up

















CROSS REFERENCE


Study






162





CRITICAL APPRAISAL



Journal


Peer reviewed

Indexed



Title






bull Key words



Authors





Sweden



Introduction









Methods







Methods












bull Chi-square



analysis

bull





Results



is true






Discussion




honestly




References

Vancouver style






Abstract

Well structured

219 words


Methods

Results

Conclusions





THANK YOU








to LAN




forward


be backward


properties











Methods




private companies






(WOLFN N=4718)



bullMethods ctd











Methods cntd

bull


first time


employees





Methods ctd

bull At baseline









procedure







WOLFS (1992 1995)




(a) no







week according to a



(a) no

(b) 2 shifts





with night shifts









workingrdquo




0600hrs)





night








distributed

on averagerdquo




2200 ) number of

hours=xx


hours=xx






versa




enter 0 yearsrdquo











Methods ctd






shift work







Methods ctd

Breast cancer
























Covariates

bull





















(95 CI)



















per week








Results





cohort was 49973


and follow-up















Discussion

bull





studies



bullLimitations








hours



bullResults ctd





workers







causal factor



Results ctd






early












bullLimitations


mistakes




at baseline









night work
















cohort design








information

























bull




CROSS REFERENCE


C Yu



of follow-up

















CROSS REFERENCE


Study






162





CRITICAL APPRAISAL



Journal


Peer reviewed

Indexed



Title






bull Key words



Authors





Sweden



Introduction









Methods







Methods












bull Chi-square



analysis

bull





Results



is true






Discussion




honestly




References

Vancouver style






Abstract

Well structured

219 words


Methods

Results

Conclusions





THANK YOU




forward


be backward


properties











Methods




private companies






(WOLFN N=4718)



bullMethods ctd











Methods cntd

bull


first time


employees





Methods ctd

bull At baseline









procedure







WOLFS (1992 1995)




(a) no







week according to a



(a) no

(b) 2 shifts





with night shifts









workingrdquo




0600hrs)





night








distributed

on averagerdquo




2200 ) number of

hours=xx


hours=xx






versa




enter 0 yearsrdquo











Methods ctd






shift work







Methods ctd

Breast cancer
























Covariates

bull





















(95 CI)



















per week








Results





cohort was 49973


and follow-up















Discussion

bull





studies



bullLimitations








hours



bullResults ctd





workers







causal factor



Results ctd






early












bullLimitations


mistakes




at baseline









night work
















cohort design








information

























bull




CROSS REFERENCE


C Yu



of follow-up

















CROSS REFERENCE


Study






162





CRITICAL APPRAISAL



Journal


Peer reviewed

Indexed



Title






bull Key words



Authors





Sweden



Introduction









Methods







Methods












bull Chi-square



analysis

bull





Results



is true






Discussion




honestly




References

Vancouver style






Abstract

Well structured

219 words


Methods

Results

Conclusions





THANK YOU











Methods




private companies






(WOLFN N=4718)



bullMethods ctd











Methods cntd

bull


first time


employees





Methods ctd

bull At baseline









procedure







WOLFS (1992 1995)




(a) no







week according to a



(a) no

(b) 2 shifts





with night shifts









workingrdquo




0600hrs)





night








distributed

on averagerdquo




2200 ) number of

hours=xx


hours=xx






versa




enter 0 yearsrdquo











Methods ctd






shift work







Methods ctd

Breast cancer
























Covariates

bull





















(95 CI)



















per week








Results





cohort was 49973


and follow-up















Discussion

bull





studies



bullLimitations








hours



bullResults ctd





workers







causal factor



Results ctd






early












bullLimitations


mistakes




at baseline









night work
















cohort design








information

























bull




CROSS REFERENCE


C Yu



of follow-up

















CROSS REFERENCE


Study






162





CRITICAL APPRAISAL



Journal


Peer reviewed

Indexed



Title






bull Key words



Authors





Sweden



Introduction









Methods







Methods












bull Chi-square



analysis

bull





Results



is true






Discussion




honestly




References

Vancouver style






Abstract

Well structured

219 words


Methods

Results

Conclusions





THANK YOU



Methods




private companies






(WOLFN N=4718)



bullMethods ctd











Methods cntd

bull


first time


employees





Methods ctd

bull At baseline









procedure







WOLFS (1992 1995)




(a) no







week according to a



(a) no

(b) 2 shifts





with night shifts









workingrdquo




0600hrs)





night








distributed

on averagerdquo




2200 ) number of

hours=xx


hours=xx






versa




enter 0 yearsrdquo











Methods ctd






shift work







Methods ctd

Breast cancer
























Covariates

bull





















(95 CI)



















per week








Results





cohort was 49973


and follow-up















Discussion

bull





studies



bullLimitations








hours



bullResults ctd





workers







causal factor



Results ctd






early












bullLimitations


mistakes




at baseline









night work
















cohort design








information

























bull




CROSS REFERENCE


C Yu



of follow-up

















CROSS REFERENCE


Study






162





CRITICAL APPRAISAL



Journal


Peer reviewed

Indexed



Title






bull Key words



Authors





Sweden



Introduction









Methods







Methods












bull Chi-square



analysis

bull





Results



is true






Discussion




honestly




References

Vancouver style






Abstract

Well structured

219 words


Methods

Results

Conclusions





THANK YOU



bullMethods ctd











Methods cntd

bull


first time


employees





Methods ctd

bull At baseline









procedure







WOLFS (1992 1995)




(a) no







week according to a



(a) no

(b) 2 shifts





with night shifts









workingrdquo




0600hrs)





night








distributed

on averagerdquo




2200 ) number of

hours=xx


hours=xx






versa




enter 0 yearsrdquo











Methods ctd






shift work







Methods ctd

Breast cancer
























Covariates

bull





















(95 CI)



















per week








Results





cohort was 49973


and follow-up















Discussion

bull





studies



bullLimitations








hours



bullResults ctd





workers







causal factor



Results ctd






early












bullLimitations


mistakes




at baseline









night work
















cohort design








information

























bull




CROSS REFERENCE


C Yu



of follow-up

















CROSS REFERENCE


Study






162





CRITICAL APPRAISAL



Journal


Peer reviewed

Indexed



Title






bull Key words



Authors





Sweden



Introduction









Methods







Methods












bull Chi-square



analysis

bull





Results



is true






Discussion




honestly




References

Vancouver style






Abstract

Well structured

219 words


Methods

Results

Conclusions





THANK YOU



Methods cntd

bull


first time


employees





Methods ctd

bull At baseline









procedure







WOLFS (1992 1995)




(a) no







week according to a



(a) no

(b) 2 shifts





with night shifts









workingrdquo




0600hrs)





night








distributed

on averagerdquo




2200 ) number of

hours=xx


hours=xx






versa




enter 0 yearsrdquo











Methods ctd






shift work







Methods ctd

Breast cancer
























Covariates

bull





















(95 CI)



















per week








Results





cohort was 49973


and follow-up















Discussion

bull





studies



bullLimitations








hours



bullResults ctd





workers







causal factor



Results ctd






early












bullLimitations


mistakes




at baseline









night work
















cohort design








information

























bull




CROSS REFERENCE


C Yu



of follow-up

















CROSS REFERENCE


Study






162





CRITICAL APPRAISAL



Journal


Peer reviewed

Indexed



Title






bull Key words



Authors





Sweden



Introduction









Methods







Methods












bull Chi-square



analysis

bull





Results



is true






Discussion




honestly




References

Vancouver style






Abstract

Well structured

219 words


Methods

Results

Conclusions





THANK YOU



Methods ctd

bull At baseline









procedure







WOLFS (1992 1995)




(a) no







week according to a



(a) no

(b) 2 shifts





with night shifts









workingrdquo




0600hrs)





night








distributed

on averagerdquo




2200 ) number of

hours=xx


hours=xx






versa




enter 0 yearsrdquo











Methods ctd






shift work







Methods ctd

Breast cancer
























Covariates

bull





















(95 CI)



















per week








Results





cohort was 49973


and follow-up















Discussion

bull





studies



bullLimitations








hours



bullResults ctd





workers







causal factor



Results ctd






early












bullLimitations


mistakes




at baseline









night work
















cohort design








information

























bull




CROSS REFERENCE


C Yu



of follow-up

















CROSS REFERENCE


Study






162





CRITICAL APPRAISAL



Journal


Peer reviewed

Indexed



Title






bull Key words



Authors





Sweden



Introduction









Methods







Methods












bull Chi-square



analysis

bull





Results



is true






Discussion




honestly




References

Vancouver style






Abstract

Well structured

219 words


Methods

Results

Conclusions





THANK YOU







WOLFS (1992 1995)




(a) no







week according to a



(a) no

(b) 2 shifts





with night shifts









workingrdquo




0600hrs)





night








distributed

on averagerdquo




2200 ) number of

hours=xx


hours=xx






versa




enter 0 yearsrdquo











Methods ctd






shift work







Methods ctd

Breast cancer
























Covariates

bull





















(95 CI)



















per week








Results





cohort was 49973


and follow-up















Discussion

bull





studies



bullLimitations








hours



bullResults ctd





workers







causal factor



Results ctd






early












bullLimitations


mistakes




at baseline









night work
















cohort design








information

























bull




CROSS REFERENCE


C Yu



of follow-up

















CROSS REFERENCE


Study






162





CRITICAL APPRAISAL



Journal


Peer reviewed

Indexed



Title






bull Key words



Authors





Sweden



Introduction









Methods







Methods












bull Chi-square



analysis

bull





Results



is true






Discussion




honestly




References

Vancouver style






Abstract

Well structured

219 words


Methods

Results

Conclusions





THANK YOU




(a) no







week according to a



(a) no

(b) 2 shifts





with night shifts









workingrdquo




0600hrs)





night








distributed

on averagerdquo




2200 ) number of

hours=xx


hours=xx






versa




enter 0 yearsrdquo











Methods ctd






shift work







Methods ctd

Breast cancer
























Covariates

bull





















(95 CI)



















per week








Results





cohort was 49973


and follow-up















Discussion

bull





studies



bullLimitations








hours



bullResults ctd





workers







causal factor



Results ctd






early












bullLimitations


mistakes




at baseline









night work
















cohort design








information

























bull




CROSS REFERENCE


C Yu



of follow-up

















CROSS REFERENCE


Study






162





CRITICAL APPRAISAL



Journal


Peer reviewed

Indexed



Title






bull Key words



Authors





Sweden



Introduction









Methods







Methods












bull Chi-square



analysis

bull





Results



is true






Discussion




honestly




References

Vancouver style






Abstract

Well structured

219 words


Methods

Results

Conclusions





THANK YOU






distributed

on averagerdquo




2200 ) number of

hours=xx


hours=xx






versa




enter 0 yearsrdquo











Methods ctd






shift work







Methods ctd

Breast cancer
























Covariates

bull





















(95 CI)



















per week








Results





cohort was 49973


and follow-up















Discussion

bull





studies



bullLimitations








hours



bullResults ctd





workers







causal factor



Results ctd






early












bullLimitations


mistakes




at baseline









night work
















cohort design








information

























bull




CROSS REFERENCE


C Yu



of follow-up

















CROSS REFERENCE


Study






162





CRITICAL APPRAISAL



Journal


Peer reviewed

Indexed



Title






bull Key words



Authors





Sweden



Introduction









Methods







Methods












bull Chi-square



analysis

bull





Results



is true






Discussion




honestly




References

Vancouver style






Abstract

Well structured

219 words


Methods

Results

Conclusions





THANK YOU



Methods ctd






shift work







Methods ctd

Breast cancer
























Covariates

bull





















(95 CI)



















per week








Results





cohort was 49973


and follow-up















Discussion

bull





studies



bullLimitations








hours



bullResults ctd





workers







causal factor



Results ctd






early












bullLimitations


mistakes




at baseline









night work
















cohort design








information

























bull




CROSS REFERENCE


C Yu



of follow-up

















CROSS REFERENCE


Study






162





CRITICAL APPRAISAL



Journal


Peer reviewed

Indexed



Title






bull Key words



Authors





Sweden



Introduction









Methods







Methods












bull Chi-square



analysis

bull





Results



is true






Discussion




honestly




References

Vancouver style






Abstract

Well structured

219 words


Methods

Results

Conclusions





THANK YOU



Methods ctd

Breast cancer
























Covariates

bull





















(95 CI)



















per week








Results





cohort was 49973


and follow-up















Discussion

bull





studies



bullLimitations








hours



bullResults ctd





workers







causal factor



Results ctd






early












bullLimitations


mistakes




at baseline









night work
















cohort design








information

























bull




CROSS REFERENCE


C Yu



of follow-up

















CROSS REFERENCE


Study






162





CRITICAL APPRAISAL



Journal


Peer reviewed

Indexed



Title






bull Key words



Authors





Sweden



Introduction









Methods







Methods












bull Chi-square



analysis

bull





Results



is true






Discussion




honestly




References

Vancouver style






Abstract

Well structured

219 words


Methods

Results

Conclusions





THANK YOU

















Covariates

bull





















(95 CI)



















per week








Results





cohort was 49973


and follow-up















Discussion

bull





studies



bullLimitations








hours



bullResults ctd





workers







causal factor



Results ctd






early












bullLimitations


mistakes




at baseline









night work
















cohort design








information

























bull




CROSS REFERENCE


C Yu



of follow-up

















CROSS REFERENCE


Study






162





CRITICAL APPRAISAL



Journal


Peer reviewed

Indexed



Title






bull Key words



Authors





Sweden



Introduction









Methods







Methods












bull Chi-square



analysis

bull





Results



is true






Discussion




honestly




References

Vancouver style






Abstract

Well structured

219 words


Methods

Results

Conclusions





THANK YOU



Covariates

bull





















(95 CI)



















per week








Results





cohort was 49973


and follow-up















Discussion

bull





studies



bullLimitations








hours



bullResults ctd





workers







causal factor



Results ctd






early












bullLimitations


mistakes




at baseline









night work
















cohort design








information

























bull




CROSS REFERENCE


C Yu



of follow-up

















CROSS REFERENCE


Study






162





CRITICAL APPRAISAL



Journal


Peer reviewed

Indexed



Title






bull Key words



Authors





Sweden



Introduction









Methods







Methods












bull Chi-square



analysis

bull





Results



is true






Discussion




honestly




References

Vancouver style






Abstract

Well structured

219 words


Methods

Results

Conclusions





THANK YOU
















(95 CI)



















per week








Results





cohort was 49973


and follow-up















Discussion

bull





studies



bullLimitations








hours



bullResults ctd





workers







causal factor



Results ctd






early












bullLimitations


mistakes




at baseline









night work
















cohort design








information

























bull




CROSS REFERENCE


C Yu



of follow-up

















CROSS REFERENCE


Study






162





CRITICAL APPRAISAL



Journal


Peer reviewed

Indexed



Title






bull Key words



Authors





Sweden



Introduction









Methods







Methods












bull Chi-square



analysis

bull





Results



is true






Discussion




honestly




References

Vancouver style






Abstract

Well structured

219 words


Methods

Results

Conclusions





THANK YOU





(95 CI)



















per week








Results





cohort was 49973


and follow-up















Discussion

bull





studies



bullLimitations








hours



bullResults ctd





workers







causal factor



Results ctd






early












bullLimitations


mistakes




at baseline









night work
















cohort design








information

























bull




CROSS REFERENCE


C Yu



of follow-up

















CROSS REFERENCE


Study






162





CRITICAL APPRAISAL



Journal


Peer reviewed

Indexed



Title






bull Key words



Authors





Sweden



Introduction









Methods







Methods












bull Chi-square



analysis

bull





Results



is true






Discussion




honestly




References

Vancouver style






Abstract

Well structured

219 words


Methods

Results

Conclusions





THANK YOU














per week








Results





cohort was 49973


and follow-up















Discussion

bull





studies



bullLimitations








hours



bullResults ctd





workers







causal factor



Results ctd






early












bullLimitations


mistakes




at baseline









night work
















cohort design








information

























bull




CROSS REFERENCE


C Yu



of follow-up

















CROSS REFERENCE


Study






162





CRITICAL APPRAISAL



Journal


Peer reviewed

Indexed



Title






bull Key words



Authors





Sweden



Introduction









Methods







Methods












bull Chi-square



analysis

bull





Results



is true






Discussion




honestly




References

Vancouver style






Abstract

Well structured

219 words


Methods

Results

Conclusions





THANK YOU





per week








Results





cohort was 49973


and follow-up















Discussion

bull





studies



bullLimitations








hours



bullResults ctd





workers







causal factor



Results ctd






early












bullLimitations


mistakes




at baseline









night work
















cohort design








information

























bull




CROSS REFERENCE


C Yu



of follow-up

















CROSS REFERENCE


Study






162





CRITICAL APPRAISAL



Journal


Peer reviewed

Indexed



Title






bull Key words



Authors





Sweden



Introduction









Methods







Methods












bull Chi-square



analysis

bull





Results



is true






Discussion




honestly




References

Vancouver style






Abstract

Well structured

219 words


Methods

Results

Conclusions





THANK YOU



Results





cohort was 49973


and follow-up















Discussion

bull





studies



bullLimitations








hours



bullResults ctd





workers







causal factor



Results ctd






early












bullLimitations


mistakes




at baseline









night work
















cohort design








information

























bull




CROSS REFERENCE


C Yu



of follow-up

















CROSS REFERENCE


Study






162





CRITICAL APPRAISAL



Journal


Peer reviewed

Indexed



Title






bull Key words



Authors





Sweden



Introduction









Methods







Methods












bull Chi-square



analysis

bull





Results



is true






Discussion




honestly




References

Vancouver style






Abstract

Well structured

219 words


Methods

Results

Conclusions





THANK YOU














Discussion

bull





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Documents

jc ejournal 18122012 Breast cancer among shift workers.pptx