Holocaust Experience and Mortality Patterns: 4-Decade Follow-up in a Population-Based Cohort

Abstract

Study of mortality associated with exposure to the Holocaust is relevant for better understanding the effects of man-made massive killings on survivors. Previous studies did not investigate long-term cause-specific mortality of Holocaust survivors. We compared mortality rates of Israelis born in European countries controlled by the Nazis to Israelis of European descent without this exposure. Records of 22,671 people (5,042 survivors, 45% women) from the population-based Jerusalem Perinatal Study (1964-1976) were linked to the Population Registry updated through 2016. Cox models were used with two-sided tests of statistical significance. Risk of all-cause mortality was higher in the exposed women (hazard ratio (HR) = 1.15; 95% confidence interval (CI): 1.05, 1.27) as compared to unexposed. No association was found between the exposure and male all-cause mortality. In both sexes, the survivors had higher cancer-specific mortality (HR=1.17; CI: 1.01, 1.35 in women and HR=1.14; CI: 1.01, 1.28 in men). The exposed men also had excess mortality due to coronary heart disease (HR=1.39; CI: 1.09, 1.77) and lower mortality due to other known causes combined (HR=0.86; CI: 0.75, 0.99). In summary, Holocaust experience was associated with excess of all-cause and cancer-specific female and cancer- and coronary heart disease -specific male mortality.

The Holocaust Is a Significant and Independent Risk Factor of Late-Onset Cancers: A Systematic Review of the Literature and Original Data on Jewish Israeli, Jewish Non-Israeli and Non-Jewish Non-Israeli Survivors

“…Nevertheless, the final count of cancer Jewish Israeli HS cannot be inferior to 56060 subjects, which corresponds to the largest cHS population studied by Keinan-Boker and colleagues in 2009 (16). In five studies the cancer site was not declared (23,24,31,32,34). Apart from oncologic (15,16,(23)(24)(25)(26)(27)(28)(29)(30)(31)(32)(33)(34)(35)(36).…”

“…After PTSD and other psychiatric disturbances, cardiovascular and other internal diseases, Holocaust-related cancer has to be intended as the last -in temporal succession -of the atrocities inflicted and bequeathed by the Nazi to the Jewry. A statistically significant association between cancer and HS was demonstrated in 10 studies (16,(23)(24)(25)(26)(27)(28)(29)(30)(31), whereas only 2 works did not find any difference with control groups (32,34) and in 4 further studies of psychiatric interest the data was not even taken into account (15,33,35,36). It is important to say that the papers finding a Holocaust-cancer correlation have been published more recently and by oncologically-oriented journals in comparison with the other publications (which did not find or investigate this feature) which appear more dated and focused on mental science.…”

“…In fact, differently from other countries (such as USA, Canada and Australia) where many HS settled, in Israel studies on HS were/are more feasible due to the availability of databases with death and population records (11). The main features of cHS are listed in Table I (15,16,(23)(24)(25)(26)(27)(28)(29)(30)(31)(32)(33)(34)(35)(36). We found 16 original studies: 8 were retrospective (15,16,23,25,(33)(34)(35)(36), 1 was half retrospective half cross-sectional (24), while the other 7 analyzed historical cohorts with a prospective investigation (questionnaires or updated follow-ups) (26)(27)(28)(29)(30)(31)(32).…”

“…The main features of cHS are listed in Table I (15,16,(23)(24)(25)(26)(27)(28)(29)(30)(31)(32)(33)(34)(35)(36). We found 16 original studies: 8 were retrospective (15,16,23,25,(33)(34)(35)(36), 1 was half retrospective half cross-sectional (24), while the other 7 analyzed historical cohorts with a prospective investigation (questionnaires or updated follow-ups) (26)(27)(28)(29)(30)(31)(32). The first work published in a non-psychological journal dates back to the year 2009 (16); before that, as stated in the introduction section, all the analyses and discussion on cHS subjects were essentially addressed by specialists belonging to the science of the mind and personality who first noted and studied their reaction to the long-term consequences of the Holocaust, including cancer (15,(32)(33)(34)(35)(36).…”

“…During the Third Reich, all the HS constantly experienced extreme situations such as metabolic insults (famine with caloric restriction down to 220-800 kCal/day with macro and micronutrient deficiency), environmental factors (cold winter temperatures, overcrowding, daily exposure to genotoxic waste produced by incinerators of the camps), biologic agents (infectious diseases, human experiments in death camps), physical (unceasing activity) and psycho-emotional (forced separation from family, seeing of relatives' and strangers' assassinations, coercion, exile, persecution, living under a false identity, anxiety, sleep deprivation,) abuse (26). Although starvation can theoretically reduce the procancer effects of some metabolic factors (reduction of body mass index and levels of sexual hormones with consecutive amenorrhea, late onset of menarche and early menopause), most studies showed that exposure to energy restriction (especially at an early age) was associated with an increased incidence of cancer compared to control groups (16,(23)(24)(25)(26)(28)(29)(30)(31): the epigenetic modifications (such as DNA hypermethylation causing chromosomal instability and oncogene activation) are thought by many the most plausible molecular pattern for explaining such a higher metabolicrelated cumulative risk of tumor (26,28,30). As posited by the reviewed studies, stress is another condition impacting the risk of cancer through direct and indirect processes (26).…”