Impact ofCigarette Smoking on Ovarian Cancer inSulaimani City | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Mosul Journal of Nursing (Print ISSN: 2311-8784 Online ISSN: 2663-0311) | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Article 11, Volume 9, Issue 1, January 2021, Pages 101-109 PDF (863.64 K) | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Document Type: Original Articles | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
DOI: 10.33899/mjn.2021.168291 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Authors | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Amani Fadhil Abbas1; Hadeel Abdulelah Ibrahim2 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1College of Nursing, University of Sulaimani, Sulaimaniyah, Republic of Iraq Roseamany16@yahoo.com | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2College of Nursing, University of Sulaimani, Sulaimaniyah, Republic of Iraq: hadeel.ibrahim@univsul.edu.iq | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Abstract | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Background—Smoking is a risk factor for mucinous ovarian cancer, but its effects on other ovarian cancer subtypes and on overall ovarian cancer risk are unclear. Methods— This study was a case control study; it was conducted in Hiwa hospital for oncology in Sulaimani city. This study conducted from the 1st of June, 2019 to 1st of April 2020, involving 100 ovarian cancer patients and 100 female appeared normal without ovarian cancer as a controls. All subjects who agreed to participate signed a consent form, answered a data collection sheet about personal information as age, education, marital state ,education, economic status , physical activity and special habits especially exposure to passive smoking. Results— The mean age of the examined subjects wss 44.9 ± 13.9 and 37.9 ± 13.7 for both cases and control groups respectively, with a significant difference (p< 0.001) Most cases were house wife 65% and 32% were illiterate with high significant difference (p< 0.001). 40 % of cases were Sufficient economic state . About cigarette smoking (5% , 3%)of women were active, (2%, 0%) quit, and (31%, 16%) passive smokers and the remaining( 62%, 81%) were never smokers in case and control groups respectively . So passive women more prone to ovarian cancer with a significant difference p =0.02 Especially those with > 5 years passive smoker (87.1%) comparing with 5 years and less in cases group and compared to control groups p< 0.001 . This study revealed that passive smoking was associated with serous ovarian cancer(15.5%). Majority of the patients complained from abdominal pain and abdominal distension (76%) as the first presenting symptom . Conclusions— the mean age of Ovarian cancer woman was 44.9 ± 13.9 and most of the age of patients had ovarian cancer were between 40-50 Years. Passive smoker women more prone to ovarian cancer especially those with > 5 years passive smoker . Passive cigarette smoking may be associated with serous ovarian cancer. Keywords: Age, Cigarette smoking, sign &symptom | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Age; Cigarette smoking; sign &symptom | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Full Text | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Impact ofCigarette Smoking on Ovarian Cancer inSulaimani City DOI: 10.33899/mjn.2021.168291 ©2020, College of Nursing, University of Mosul. Creative Commons Attribution 4.0 International License AmaniFadhil Abbas[1]HadeelAbdulelah Ibrahim[2] Abstract Background—Smoking is a risk factor for mucinous ovarian cancer, but its effects on other ovarian cancer subtypes and on overall ovarian cancer risk are unclear. Methods— This study was a case control study; it was conducted in Hiwa hospital for oncology in Sulaimani city. This study conducted from the 1st of June, 2019 to 1st of April 2020, involving 100 ovarian cancer patients and 100 female appeared normal without ovarian cancer as a controls. All subjects who agreed to participate signed a consent form, answered a data collection sheet about personal information as age, education, marital state ,education, economic status , physical activity and special habits especially exposure to passive smoking. Results— The mean age of the examined subjects wss 44.9 ± 13.9 and 37.9 ± 13.7 for both cases and control groups respectively, with a significant difference (p< 0.001) Most cases were house wife 65% and 32% were illiterate with high significant difference (p< 0.001). 40 % of cases were Sufficient economic state . About cigarette smoking (5% , 3%)of women were active, (2%, 0%) quit, and (31%, 16%) passive smokers and the remaining( 62%, 81%) were never smokers in case and control groups respectively . So passive women more prone to ovarian cancer with a significant difference p =0.02 Especially those with > 5 years passive smoker (87.1%) comparing with 5 years and less in cases group and compared to control groups p< 0.001 . This study revealed that passive smoking was associated with serous ovarian cancer(15.5%). Majority of the patients complained from abdominal pain and abdominal distension (76%) as the first presenting symptom . Conclusions— the mean age of Ovarian cancer woman was 44.9 ± 13.9 and most of the age of patients had ovarian cancer were between 40-50 Years. Passive smoker women more prone to ovarian cancer especially those with > 5 years passive smoker . Passive cigarette smoking may be associated with serous ovarian cancer. Keywords: Age, Cigarette smoking, sign &symptom Introduction Ovarian cancer is the most lethal gynecologic malignancy and is the fifth most common cause of cancer-related death among women (ZohreMomenimovahed et al., 2019). Although ovarian cancer has a lower prevalence incomparison with breast cancer, it is three times more lethal,The highmortality rate of ovarian cancer is caused by asymptomatic and secret growth of thetumor, delayed onset of symptoms, and lack of proper screening that result in itsdiagnosis in the advanced stages (Badgwell & Bast, 2007 ; Yoneda et al., 2012)There are three forms of ovarian tumors,each originating from a different cell type; epithelial tumors (90%of cases), germ cell tumors (5% of cases), and stromal tumors (5% of cases) (Sumanasekera et al., 2018; Torre et al., 2018). Epithelial tumors are the most usually diagnosed OC in women (Goff et al., 2013; Humans 2004). The etiology of ovarian cancer is still unclear (Gharwan et al., 2015). multiple factors, such as genetic/ hereditary factors, high levels of estrogens, gonadotropins, exposure to a number of environmental toxicants can increase risk for ovarian cancer. Choosing healthy lifestyles such as diets rich in glutathione and other antioxidants, maintaining a healthy weight, and regular exercise may provide protective measures against ovarian cancer (Sumanasekera et al., 2018). It is believed that ovarian cancer is a multifactorial disease and it is a result of the interaction of hereditary, reproductive, hormonal, dietary factors and smoking (Hunn & Rodriguez , 2012). Methods— This study was a case control study; it was conducted in Hiwa hospitalfor oncology in Sulaimani city. This study conducted from the 1st of June, 2019 to 1st of April 2020, involving 100 ovarian cancer patients and 100 female appeared normal without ovarian cancer as a controls. All subjects who agreed to participate signed a consent form, answered a data collection sheet about personal information as age, education, marital state ,education, economic status , physical activity and special habits especially exposure to passive smoking. Results---The mean age of the examined subjects that ranged from 15 to 72 years old is 44.9 ± 13.9 and 37.9 ± 13.7 for both cases and control groups respectively, with a significant difference (p< 0.001) ,and most of the age of patients had ovarian cancer were between40-50 Years (29% vs. 19%) with high significant difference (p = 0.004), Figure 1, Table 1. Most cases were house wife 65% and 32% were illiterate with high significant difference (p< 0.001). 40 % of cases were Sufficient economic state which is less than control group were 69 % Sufficient economic state with high significant difference (p< 0.001). marital status p=0.13 and physical activity p=0.06 did not differ significantly between cases and controls.
Figure 1: Distribution of age between cases and control Table 1: Socio-demographics characteristics of cases and control groups.
Table 2 shows that (5% , 3%)of women were active, (2%, 0%) quit, and (31%, 16%) passive smokers and the remaining( 62%, 81%) were never smokers in case and control groups respectively . So passive women more prone to ovarian cancer with a significant difference p =0.02 Especially those with > 5 years passive smoker (87.1%) comparing with 5 years and less in cases group and compared to control groups p< 0.001 table 3.
Table 2: Distribution of smoking in both cases and control groups
Table 3 Duration (years) of passive smoker between cases and patient
This study revealed that passive smoking was associated with serous ovarian cancer(15.5%) then Mucinous(5.1%),Endometriod (3.4%), adult granulosa, Teratoma (2.9%)and Dysgerminoma(1.2%) ovarian cancer figure (2 )
Figure 2: Relationship between Passive smoker and Type of ovarian cancer
Figure 3 :Signs and symptoms among cases of ovarian cancer. Majority of the patients complained from abdominal pain and abdominal distension (76%) as the first presenting symptom followed by Indigestion (58 %), Change in bowel habit (56%), urinary complaints (dysuria, retention ,frequency of micturition) (48%), weight lose (33%), Extreme fatigue (10%) and postmenopausal bleeding (9 %) . Discussion In this study, the mean age of Ovarian cancer woman was 44.9 ± 13.9and most of the age of patients had ovarian cancer were between 40-50 Years. The epithelial ovarian cancer is an age-related disease, and is considered primarily a postmenopausal disease(Chornokuret al., 2013; Chan et al., 2006). Increased incidence of this cancer is more pronounced in women over 65 years of age(Mohammadian et al., 2012)According to previous studies, median age atdiagnosis is 50–79 years.( Chan et al., 2006; Arora et al.,2018; Zheng et al.,2018) The relationship between age and the outcome of ovarian cancer is uncertain. Although many researchers have pointed out that the younger age of ovarian cancer is associated with the improved outcome(Arora et al.,2018;, Chan et al., 2003; Chan et al., 2004), other stated age is not an independent prognostic factor(Chan et al., 2004).Older age in this disease is associated with more advanced disease and lower survival rate(Chan et al., 2006; Massi et al., 1996).Older women are treated less aggressively in contrast with younger ovarian cancer patients, and, thus, survival is lower in these group(Poole et al., 2013)An age of over 64 years is one of the predictors of mortality in people with ovarian cancer(Ørskov et al.,2016)
Most cases were house wife and illiterate with Barely Sufficientor insufficient economic state, because job strain may capture facets of psychosocial stress that affect health as demonstrated by consistent associations with cardiovascular disease risk and mortality among individuals mostly from the U.S. and Europe (Huang et al.,2015; Kivimaki & Kawachi, 2015), and because ovarian cancer seems susceptible to stress-related biological alterations, we hypothesized stress-related house wife, low education, insufficient economic state characteristics would be associated with increased risk of incident ovarian cancer
Another variable in the life style characteristics is performing physical activity and the results of present study most patients were not performing any physical activity. Physical activity may decrease risk of ovarian cancer by decreasing exposure to estrogen. Physical activity inhibits ovulation temporarily,. In addition, regular physical activity may lengthen ovulatory cycles, thereby decreasing lifetime exposure to endogenous estrogens. Physical activity also leads to decreased body fat, which may cause lower levels of extra glandular estrogen production, Moreover, increased physical activity may reduce chronic inflammation, which may play a role in the development of ovarian cancer (Lindsay et al., 2004) the present study shows that most participant were never smokers in case and control groups then passive smoker ovarian cancer women were double the passive smoker control with significant difference, So passive women more prone to ovarian cancer, especially those with > 5 years passive smoker.Also passive smoking was associated with serous ovarian cancer more than Mucinous , Endometriod , adult granulosa, Teratoma and Dysgerminoma ovarian cancer .this result which in line with other studywhich conclude that Cigarette smoking may be associated with serous ovarian cancer among AA(Kelemen et al., 2017), which differs from associations reported among Caucasians(Faber et al., 2013). In contrary to present study Literatures reported that passive smoking is associated with decreased risk of ovarian cancer among individuals with daily ETS (Environmental tobacco smoke) exposure. This effect may be due to the immunosuppressive effects of nicotine as well as the role of tobacco smoke as an up regulator of metabolism (Baker et al., 2006). Chemicals in tobacco smoke are a mixed bag of directly genotoxic DNA damaging compounds (initiators), compounds that enhance the action of these initiators (promoters), and compounds that do both. Some of these substances are more abundant in side stream smoke, which comes off the tip of the cigarette, than the smoke inhaled by smokers themselves (McCarty et al., 2009). This side stream smoke is a major source of secondhand smoke (SHS). Many studies have reported that toxicants from cigarette smoke can form the DNA adducts which is believed to represent the first step of carcinogenesis. Which, if not repaired or if repaired incorrectly, these modifications may lead to mutations and cancer (Jenkins et al., 2000). This study revealed that majority of the patients complained from abdominal pain and abdominal distension as the first presenting symptom followed by Indigestion , Change in bowel habit , urinary complaints (dysuria, retention ,frequency of micturition) , weight lose , Extreme fatigue and postmenopausal bleeding , Similarly, (Khan &Sultana, 2010) showed that abdominal pain as the most common symptom followed by abdominal distension, urinary complaints, vaginal discharge, and postmenopausal bleeding. a study conducted in Nigeria (Odukogbe et al., 2004) stated abdominal distension to be the most common presenting feature with a higher proportion of patients presented with advanced stage disease which is similar to our study. Others also reported abdominal distension as a common feature in their study (Gaughan et al., 2006; Petignat et al., 1997) . (Khan & Sultana) no specific sign or symptom for early stage or for late stage disease In early as well as in late stage (Khan &Sultana, 2010). References Arora N, Talhouk A, McAlpine JN, Law MR, Hanley GE. Long term mortality among women with epithelial ovarian cancer: a population-based study in British Columbia, Canada. BMC Cancer. 2018;18(1):1039. Badgwell D, Bast JRC. Early detection of ovarian cancer. DisMarkers. 2007;23(5–6):397–410. Baker JA, Odunuga OO, Rodabaugh KJ, Reid ME, Menezes RJ, Moysich KB. Active and passive smoking and risk of ovarian cancer. Int J Gynecol Cancer. 2006;16(Suppl 1):211–8. Chan J, Urban R, Cheung M, et al. Ovarian cancer in younger vs older women: a population-based analysis. Br J Cancer. 2006;95 (10):1314. Chan JK, Loizzi V, Magistris A, et al. Differences in prognostic molecular markers between women over and under 45 years of age with advanced ovarian cancer. Clin Cancer Res. 2004;10 (24):8538–8543. doi:10.1158/1078-0432.CCR-04-0626 .
Chan JK, Loizzi V, Lin YG, et al. IV invasive epithelial ovarian carcinoma in younger versus older women: what prognostic fac tors are important? Obstet Gynecol. 2003;102(1):156–161.
Chornokur G, Amankwah EK, Schildkraut JM, Phelan CM. Global ovarian cancer health disparities. GynecolOncol. 2013;129(1):258–264. doi:10.1016/j.ygyno.2012.12.016 Faber MT, Kjaer SK, Dehlendorff C, et al. Cigarette smoking and risk of ovarian cancer: a pooled analysis of 21 case-control studies. Cancer Causes Control. 2013;24:989–1004. Gaughan E, Javaid T, Cooley S, Byrne P, Gaughan G. Study of ovarian cancer management. Ir Med J 2006; 99: 279-80. Gharwan H, Bunch KP, Annunziata CM (2015) The role of reproductive hormones in epithelial ovarian carcinogenesis. Endocrine-related cancer 22(6): 339-363. Goff BA, Balas C, Tenenbaum C (2013) Ovarian cancer national alliance a report of the 2012 Consensus Conference on Current Challenges in ovarian cancer. Gynecologic oncology 130(1): 9-11. Huang Y, Xu S, Hua J, Zhu D, Liu C, Hu Y, Liu T, Xu D. Association between job strain and risk of incident stroke: A meta-analysis. Neurology. 2015 . Humans IWGotEoCRt (2004) Tobacco smoke and involuntary smoking. IARC monographs on the evaluation of carcinogenic risks to humans / World Health Organization, International Agency for Research on Cancer 83: 1-1438. Hunn J & Rodriguez G, 2012: Ovarian cancer: etiology, risk factors, and epidemiologyClinObstet Gynecol. 2012 Mar;55(1):3-2
Jenkins RA, Tomkins B, Guerin MR - 2000 - The Chemistry of Environmental Tobacco Smoke:Composition and Measurement, Second Edition ,P5-8 Kelemen LE, Abbott S, QinB, Peres LC,et al : Cigarette smoking and the association with serous ovarian cancer in African American women: African American Cancer Epidemiology Study (AACES) Cancer Causes Control. 2017 Jul; 28(7): 699–708. Khan A, Sultana K : Presenting signs and symptoms of ovarian cancer at a tertiary care hospital . J Pak Med Assoc Vol. 60, No. 4, April 2010 Kivimaki M, Kawachi I. Work stress as a risk factor for cardiovascular disease. CurrCardiol Rep. 2015;17(9):630. Lindsay M. Hannan, Michael F. Leitzmann, James V. Lacey, Jr., et al. Physical Activity and Risk of Ovarian Cancer: A Prospective Cohort Study in the United States ,Cancer Epidemiol Biomarkers Prev 2004;13:765-770. Odukogbe AA, Adebamowo CA, Ola B, Olayemi O, Oladokun A, Adewole IF, et al. Ovarian Cancer in Ibandan: characteristics and management. J ObstetGynaecol 2004; 24: 294-7
Massi D, Susini T, Savino L, Boddi V, Amunni G, Colafranceschi M. Epithelial ovarian tumors in the reproductive age group: age is not an independent prognostic factor. Cancer. 1996; 77(6):1131–1136.
McCarty KM, Santella RM, Steck SE, Cleveland RJ, et al: BPAH–DNA Adducts, Cigarette Smoking, GST Polymorphisms, and Breast Cancer RiskEnvironmental Health Perspectives 2009, volume 117(4)552-558.
Mohammadian M, Ghafari M, Khosravi B, et al. Variations in the incidence and mortality of ovarian cancer and their relationship with the human development index in European Countries in 2012. Biomed Res Ther. 2017;4(08):1541–1557. doi:10.15419/ bmrat.v4i08.228 Petignat P, Gaudin G, Vajda D, Joris F, Obrist R. Ovarian cancer: the symptoms and pathology. The cases of the Cantonal Cancer Registry (1989-1995). Schweiz Med Wochenschr 1997; 127: 1993-9. Poole EM, Merritt MA, Jordan SJ, et al. Hormonal and reproductive risk factors for epithelial ovarian cancer by tumor aggressiveness. Cancer EpidemiolPrev Biomarkers. 2013. doi:10.1158/1055-9965.EPI-12-1183-T
Ørskov M, Iachina M, Guldberg R, Mogensen O, Nørgård BM. Predictors of mortality within 1 year after primary ovarian cancer surgery: a nationwide cohort study. BMJ Open. 2016;6(4): e010123.
Sumanasekera W, BeckmannT, Fuller L, Castle M and Huff M, Epidemiology of Ovarian Cancer: Risk Factors and Prevention.. Biomed J Sci& Tech Res 11(2)-2018. Torre LA, Trabert B, DeSantis CE, Miller KD, Samimi G, et al. (2018) Ovarian cancer statistics, 2018. CA: A cancer journal for clinicians 68(4): 284-296.
Yoneda A, Lendorf ME, Couchman JR, Multhaupt HA. Breast andovarian cancers: a survey and possible roles for the cell surfaceheparan sulfate proteoglycans. J HistochemCytochem. 2012;60(1):9–21. Zheng G, Yu H, Kanerva A, Försti A, Sundquist K, Hemminki K. Familial risks of ovarian cancer by age at diagnosis, proband type and histology. PLoS One. 2018;13(10):e0205000.
ZohreMomenimovahed Z, Tiznobaik A, Taheri S, Salehiniya H Ovarian cancer in the world: epidemiology and risk factors. International Journal of Women's Health, 2019:11 287–299 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
References | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Arora N, Talhouk A, McAlpine JN, Law MR, Hanley GE. Long term mortality among women with epithelial ovarian cancer: a population-based study in British Columbia, Canada. BMC Cancer. 2018;18(1):1039.
Badgwell D, Bast JRC. Early detection of ovarian cancer. DisMarkers. 2007;23(5–6):397–410.
Baker JA, Odunuga OO, Rodabaugh KJ, Reid ME, Menezes RJ, Moysich KB. Active and passive smoking and risk of ovarian cancer. Int J Gynecol Cancer. 2006;16(Suppl 1):211–8.
Chan J, Urban R, Cheung M, et al. Ovarian cancer in younger vs older women: a population-based analysis. Br J Cancer. 2006;95 (10):1314.
Chan JK, Loizzi V, Magistris A, et al. Differences in prognostic molecular markers between women over and under 45 years of age with advanced ovarian cancer. Clin Cancer Res. 2004;10 (24):8538–8543. doi:10.1158/1078-0432.CCR-04-0626 .
Chan JK, Loizzi V, Lin YG, et al. IV invasive epithelial ovarian carcinoma in younger versus older women: what prognostic fac tors are important? Obstet Gynecol. 2003;102(1):156–161.
Chornokur G, Amankwah EK, Schildkraut JM, Phelan CM. Global ovarian cancer health disparities. GynecolOncol. 2013;129(1):258–264. doi:10.1016/j.ygyno.2012.12.016
Faber MT, Kjaer SK, Dehlendorff C, et al. Cigarette smoking and risk of ovarian cancer: a pooled analysis of 21 case-control studies. Cancer Causes Control. 2013;24:989–1004.
Gaughan E, Javaid T, Cooley S, Byrne P, Gaughan G. Study of ovarian cancer management. Ir Med J 2006; 99: 279-80.
Gharwan H, Bunch KP, Annunziata CM (2015) The role of reproductive hormones in epithelial ovarian carcinogenesis. Endocrine-related cancer 22(6): 339-363.
Goff BA, Balas C, Tenenbaum C (2013) Ovarian cancer national alliance a report of the 2012 Consensus Conference on Current Challenges in ovarian cancer. Gynecologic oncology 130(1): 9-11.
Huang Y, Xu S, Hua J, Zhu D, Liu C, Hu Y, Liu T, Xu D. Association between job strain and risk of incident stroke: A meta-analysis. Neurology. 2015 .
Humans IWGotEoCRt (2004) Tobacco smoke and involuntary smoking. IARC monographs on the evaluation of carcinogenic risks to humans / World Health Organization, International Agency for Research on Cancer 83: 1-1438.
Hunn J & Rodriguez G, 2012: Ovarian cancer: etiology, risk factors, and epidemiologyClinObstet Gynecol. 2012 Mar;55(1):3-2
Jenkins RA, Tomkins B, Guerin MR - 2000 - The Chemistry of Environmental Tobacco Smoke:Composition and Measurement, Second Edition ,P5-8
Kelemen LE, Abbott S, QinB, Peres LC,et al : Cigarette smoking and the association with serous ovarian cancer in African American women: African American Cancer Epidemiology Study (AACES) Cancer Causes Control. 2017 Jul; 28(7): 699–708.
Khan A, Sultana K : Presenting signs and symptoms of ovarian cancer at a tertiary care hospital . J Pak Med Assoc Vol. 60, No. 4, April 2010
Kivimaki M, Kawachi I. Work stress as a risk factor for cardiovascular disease. CurrCardiol Rep. 2015;17(9):630.
Lindsay M. Hannan, Michael F. Leitzmann, James V. Lacey, Jr., et al. Physical Activity and Risk of Ovarian Cancer: A Prospective Cohort Study in the United States ,Cancer Epidemiol Biomarkers Prev 2004;13:765-770.
Odukogbe AA, Adebamowo CA, Ola B, Olayemi O, Oladokun A, Adewole IF, et al. Ovarian Cancer in Ibandan: characteristics and management. J ObstetGynaecol 2004; 24: 294-7
Massi D, Susini T, Savino L, Boddi V, Amunni G, Colafranceschi M. Epithelial ovarian tumors in the reproductive age group: age is not an independent prognostic factor. Cancer. 1996; 77(6):1131–1136.
McCarty KM, Santella RM, Steck SE, Cleveland RJ, et al: BPAH–DNA Adducts, Cigarette Smoking, GST Polymorphisms, and Breast Cancer RiskEnvironmental Health Perspectives 2009, volume 117(4)552-558.
Mohammadian M, Ghafari M, Khosravi B, et al. Variations in the incidence and mortality of ovarian cancer and their relationship with the human development index in European Countries in 2012. Biomed Res Ther. 2017;4(08):1541–1557. doi:10.15419/ bmrat.v4i08.228
Petignat P, Gaudin G, Vajda D, Joris F, Obrist R. Ovarian cancer: the symptoms and pathology. The cases of the Cantonal Cancer Registry (1989-1995). Schweiz Med Wochenschr 1997; 127: 1993-9.
Poole EM, Merritt MA, Jordan SJ, et al. Hormonal and reproductive risk factors for epithelial ovarian cancer by tumor aggressiveness. Cancer EpidemiolPrev Biomarkers. 2013. doi:10.1158/1055-9965.EPI-12-1183-T
Ørskov M, Iachina M, Guldberg R, Mogensen O, Nørgård BM. Predictors of mortality within 1 year after primary ovarian cancer surgery: a nationwide cohort study. BMJ Open. 2016;6(4): e010123.
Sumanasekera W, BeckmannT, Fuller L, Castle M and Huff M, Epidemiology of Ovarian Cancer: Risk Factors and Prevention.. Biomed J Sci& Tech Res 11(2)-2018.
Torre LA, Trabert B, DeSantis CE, Miller KD, Samimi G, et al. (2018) Ovarian cancer statistics, 2018. CA: A cancer journal for clinicians 68(4): 284-296.
Yoneda A, Lendorf ME, Couchman JR, Multhaupt HA. Breast andovarian cancers: a survey and possible roles for the cell surfaceheparan sulfate proteoglycans. J HistochemCytochem. 2012;60(1):9–21.
Zheng G, Yu H, Kanerva A, Försti A, Sundquist K, Hemminki K. Familial risks of ovarian cancer by age at diagnosis, proband type and histology. PLoS One. 2018;13(10):e0205000.
ZohreMomenimovahed Z, Tiznobaik A, Taheri S, Salehiniya H Ovarian cancer in the world: epidemiology and risk factors. International Journal of Women's Health, 2019:11 287–299 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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