Original Research
Elevated cancer risk in Holocaust survivors residing in Israel: A retrospective cohort study

https://doi.org/10.1016/j.ejca.2018.03.011Get rights and content

Highlights

  • In this study, 294,543 Holocaust survivors and 55,340 comparison group participants were included.

  • All cancer types examined were found to be more common in Holocaust survivors.

  • This higher incidence of cancer remained statistically significant in a multivariable analysis.

  • Most associations were stronger for males.

Abstract

Background

The purpose of this study was to examine the incidence of malignant diseases among Holocaust survivors in Israel compared with European and American immigrants who did not experience the Holocaust.

Methods

Study subjects included Holocaust survivors born in European countries under Nazi occupation before 1945, who immigrated to Israel after 1945 and were alive as of the year 2000. Living survivors were identified based on recognition criteria in accordance with the Holocaust Survivor Benefits Law. The comparison group consisted of Clalit enrollees who were born before 1945 in European countries not under Nazi occupation and were alive in 2000 or were born in any European country or America, immigrated to Israel before 1939 and were alive in 2000. The incidence of malignant diseases was compared in univariate and Poisson regression models analyses, controlling for age, smoking, obesity, diabetes and place of residence.

Results

The study included 294,543 Holocaust survivors, and the mean age at the beginning of follow-up was 74 ± 8.7 years; 43% males. In multivariable analyses, the rate ratio (RR) values for males and females were 1.9 and 1.3 for colon cancer, 1.9 and 1.4 for lung cancer, 1.6 and 1.4 for bladder cancer and 1.2 and 1.3 for melanoma, respectively. For prostate cancer in males, the RR was 1.4, while for breast cancer in females, it was 1.2.

Conclusions

The incidence of malignant diseases among Holocaust survivors residing in Israel was higher than that among non-Holocaust survivors. These associations remained statistically significant in a multivariable analysis and were stronger for males.

Introduction

The Holocaust, the genocide of six million Jews between 1939 and 1945 at the hands of the Nazi regime in Europe, spawned extreme living conditions such as hunger and very low caloric intake, poor hygiene and mental and physical injuries. As of 2015, there are 189,000 Holocaust survivors living in Israel. Approximately 25% of them live below the poverty line and most live on an allowance constituting about one-third of the average national salary [1]. Three-quarters of these survivors report at least one medical problem [1].

Several studies have reported associations between the Holocaust and long-term outcomes among survivors (Fig. 1). Studies conducted during the 1950s examined mainly the psychological effects suffered, termed “concentration camp syndrome” [2]. Studies that examined the long-term health effects in adults born during the Holocaust demonstrated a higher prevalence of cardiovascular risk factors (e.g. hypertension, dyslipidaemia, obesity and diabetes mellitus), chronic heart failure, depression and cancer ([3], [4], [5], Fig. 1).

One of the adverse health effects found in Holocaust survivors as described in the literature [6], [7], [8], [9] is cancer. It is the leading cause of death in Israel today with an incidence rate for all types of cancer of approximately 20/1000 in individuals older than 70 years; the most common types of cancer in the population older than 65 years are colon (17%), prostate (13%), breast (10%), and lung (8.7%) cancer [9].

Previously published Israeli studies are described in Fig. 1. The relative risks of various types of cancer investigated in one study [6] ranged from 1.2 to 3.5 in men and from 1.3 to 2.3 in women, depending on the birth cohort [6], [7]. Another study [8] showed a hazard ratio (HR) of 1.1 for cancer in general, as well as a higher risk of lung and colorectal cancers [8, Fig. 1].

Several studies describe the incidence of malignancies related to harsh life conditions and similarly show an elevated risk of cancer. These include studies conducted on the Cambodian population exposed to genocide during the Pol Pot regime [10] and a study on women suffering from severe caloric restriction during World War II (WW II) with a subsequent risk of breast cancer [11].

Because of the lack of information specifically regarding malignancies, as well as the fact that legal decisions concerning compensation of Holocaust survivors afflicted by cancer are based solely on one former study [8] and include just lung and colorectal cancer, it became necessary to establish the relationship between surviving the Holocaust and the incidence of cancer. In addition, in previous studies, no adjustments were made for certain individual risk factors. For these two reasons, therefore, we conducted the most comprehensive study done to date of the risk of cancer in Israeli Holocaust survivors. Furthermore, while most research studies have defined Holocaust survivor status based on country of birth and year of immigration, we used a more specific definition for living survivors based on the legal recognition of Holocaust survivorship, as explained in the Methods section, while only deceased survivors were identified on the basis of country of birth and year of immigration.

Section snippets

Methods

This retrospective cohort study was based on the data warehouse of Clalit, with about 4.5 million enrollees, Israel's largest healthcare organisation. The database contains information regarding the recognition of Holocaust survivors who are entitled to special benefits, including benefits from the Israeli health services, such as a refund of copayment for medications and various treatments, defined under Israeli legislation, including the Disabled Due to War against the Nazis’ Law (1954), the

Results

Study participants included 294,543 Holocaust survivors (2.2 million person-years, mean age 73 ± 8) and 55,340 comparison group subjects (456,000 person-years, mean age 77 ± 10; Table 1). A similar sex distribution was found for both groups; however, there was a statistically significant difference between the groups in terms of type of residence, as Holocaust survivors were less likely to live in rural settings (5.2% versus 17%). In addition, a statistically significant higher prevalence of

Discussion

The current population-based study is one of the largest conducted studies in the field. Our results confirmed that the incidence of malignant diseases in Holocaust survivors was higher; when adjusted for cofounders and stratified by sex in multivariable analysis, they demonstrate that being exposed to the Holocaust is an independent risk factor for developing malignancies such as breast cancer in women, prostate cancer in men and melanoma and colon, bladder and lung cancer in both sexes.

Our

Conflict of interest statement

None declared.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.

Acknowledgements

This study was conducted as part of the requirements for graduation from the Goldman Medical School of the Faculty of Health Sciences, Ben-Gurion University of the Negev.

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