The role of pregnancy, perinatal factors and hormones in maternal cancer risk: a review of the evidence

Environmental basis for early onset breast cancer

Pregnancy provokes a heightened amino acid requirement, especially in the third trimester. Alterations to late pregnancy amino acid metabolism have been associated with environmental breast carcinogen exposures, including DDT and PFAS. This project examined whether maternal serum amino acids in late pregnancy are associated with subsequent breast cancer risk. Archival third-trimester serum samples from 172 women who were later diagnosed with breast cancer were compared to samples from 351 women without known breast cancer. A prospective metabolome-wide association study (MWAS) for breast cancer cases showed that associated amino acid pathways included lysine, arginine, proline, aspartate, asparagine, alanine, tyrosine, tryptophan, histidine and branched-chain amino acids. Lower mean concentrations of individual amino acids, including histidine, threonine, lysine, and proline, were associated with an increased risk of breast cancer, and network analyses showed that these amino acids were negatively associated with protective breast cancer risk factors. Prospective MWAS for breast cancer cases diagnosed within 15 years of sample collection showed pathway associations for tryptophan, histidine, lysine methionine, and cysteine metabolism. Nutrient stresses caused by low amino acid levels impair immunosurveillance and activate oncogenic mechanisms of cell survival, thereby providing mechanisms by which environmental exposures in late pregnancy can contribute to breast cancer risk.

The Impact of Malignancy on the Risk of Venous Thromboembolism in Pregnant Women: A Systematic Review

Background and Aims

Venous thromboembolism (VTE) is a distinct malignancy complication that raises the risk of demise in cancer patients by up to thrice. However, pregnant females have a 4-5 times greater chance of getting VTE than nonpregnant women. The current systematic review aimed to elucidate the impact of malignancy on the risk of VTE in pregnant females.

Methods

We carried out a systematic search in multiple databases, including PubMed (Medline), Google Scholar, and Scopus, up to January 2023. Finally, 441 related articles were extracted from the databases. After screening the title, abstract, and full text, seven articles were included in the study.

Results

Seven studies (six cohorts and one cross-sectional) with 58,854,195 pregnant females (22,396 cancer patients) were included. These studies were done in the United States of America, Canada, Brazil, and Denmark. All of the studies except one study demonstrated that cancer in pregnant patients increased the risk of deep vein thrombosis (DVT). The risk of VTE prevalence in pregnant females with a record of malignancy was significantly higher than in free cancer groups, and the highest aOR was correlated to myeloid leukemia.

Conclusions

Evidence in this systematic review showed that pregnant women with malignancy are more susceptible to VTE and other coagulation disorders. Physicians and health policymakers should be of high vigilance to pregnancy-associated VTE, especially in women who have cancer.

Maternal age at first birth and uterine cancer risk: A comprehensive analysis using NHANES data (2003-2018)

BACKGROUND

Several reproductive factors, including parity and age at menarche, have been identified as risk factors for uterine cancers. However, the association between maternal age at first birth and uterine cancer remains conflicting.

METHODS

This cross-sectional study included females aged 20 years and older with at least one live birth across eight National Health and Nutrition Examination Survey (NHANES) cycles (2003-2018). We used design-adjusted logistic regression, with multiple imputation for missing data, to explore the association of age at first birth and uterine cancer. As a sensitivity analysis, the sample was restricted to post-menopausal females; logistic regression analyses were repeated.

RESULTS

Among 7095 participants, 104 had uterine cancer. The adjusted odds ratio (aOR) for uterine cancer for participants with a first live birth at ≥25 years was 0.66 (95 % confidence interval (CI): 0.33-1.35) compared to those with a first birth at <20 years. For participants with a first birth between 20-24 years, the aOR was 0.93 (95 % CI: 0.51-1.69). Multiple imputation and sensitivity analyses yielded similar non-significant results.

CONCLUSION

Our findings suggest no statistically significant association between maternal age at first live birth and uterine cancer, aligning with existing literature. Further research is needed to explore other reproductive factors and their role in uterine cancer risk.

Oncologic Surgery for Lower Gastrointestinal Tumors during Pregnancy: A Literature Review

Background

Colorectal cancer (CRC) during pregnancy can be a challenging situation due to the spatial confinement of the tumor with the growing uterus carrying the fetus. It is one of the more common tumor entities occurring in pregnant women, and therefore, it has to be taken into account if "patients describe suspicious" symptoms.

Summary

Diagnosis and treatment are complex and require a specialized multidisciplinary team of visceral oncologists with expertise in colorectal surgery, gastrointestinal oncologists, gynecologists, obstetricians, and neonatologists to coordinate the optimal treatment plan with the patient. Multimodal treatment options depend on gestational age and tumor stage. Radical surgical oncologic therapy at the latest possible stage of pregnancy is often the only feasible, potentially curative treatment option. Chemotherapy and radiotherapy should be postponed to the postpartum period, if possible. Neonatological aspects, including the high risk of serious complications for the infant during and after anesthesia for oncologic surgery, such as cerebral hemorrhage, pulmonary hypoplasia, and necrotizing enterocolitis, must always be in the focus when considering the optimal timing of surgery, as well as the prognosis of the mother concerning her tumor.

Key Message

Treatment of CRC during pregnancy is based on highly individualized therapeutic decisions rather than on standardized guideline recommendations. Surgical resection via partial colectomy, anterior rectal resections, and abdominoperineal extirpations are feasible. However, it has always to be considered if surgery has to be performed in elective situations or damage control procedures due to emergencies, such as mechanical ileus or perforations with intra-abdominal sepsis.

Pregnancy and the Risk for Cancer in Neurofibromatosis 1

BACKGROUND

Neurofibromatosis type 1 (NF1) is associated with a high risk for cancer. Benign cutaneous neurofibromas of women with NF1 may increase in size and number during pregnancy. However, it is not known whether pregnancy affects the risk for cancer in NF1.

METHODS

We retrieved the pregnancies of women in the Finnish NF1 cohort and in a 10-fold control cohort from the Finnish Medical Birth Register. Cancers occurring during or after pregnancy were obtained from the Finnish Cancer Registry and summarized using standardized incidence ratio (SIR). The cancer incidence of nonNF1 mothers of individuals with NF1 was also estimated.

RESULTS

Totals of 263 pregnancies in 136 women with NF1 and 3176 pregnancies in 1720 controls were observed. In the NF1 group, two cancers were identified during pregnancy and the year following the delivery (SIR 6.44, 95% CI 1.07-19.89). Among controls, the SIR was markedly lower (0.25, 95% CI 0.01-1.08). Within 1-10 years after pregnancy, the SIR of women with NF1 was 7.54 (95% CI 4.15-12.41). The SIR of women with NF1 aged 20-49 years, and without a known history of deliveries was 8.63 (95% CI 6.08-11.81). The nonNF1 mothers displayed a SIR of 0.81 (95% CI 0.66-1.00) after giving birth to a child with NF1.

CONCLUSIONS

The pregnancy-related cancer incidence in women with NF1 is similar to women with NF1 aged 20-49 years overall, although notably higher than in the general population. Giving birth to a child with NF1 does not affect the risk for cancer in women without NF1.

Cancer Prevalence across Vertebrates

Cancer is pervasive across multicellular species, but what explains the differences in cancer prevalence across species? Using 16,049 necropsy records for 292 species spanning three clades of tetrapods (amphibians, sauropsids, and mammals), we found that neoplasia and malignancy prevalence increases with adult mass (contrary to Peto's paradox) and somatic mutation rate but decreases with gestation time. The relationship between adult mass and malignancy prevalence was only apparent when we controlled for gestation time. Evolution of cancer susceptibility appears to have undergone sudden shifts followed by stabilizing selection. Outliers for neoplasia prevalence include the common porpoise (<1.3%), the Rodrigues fruit bat (<1.6%), the black-footed penguin (<0.4%), ferrets (63%), and opossums (35%). Discovering why some species have particularly high or low levels of cancer may lead to a better understanding of cancer syndromes and novel strategies for the management and prevention of cancer. Significance: Evolution has discovered mechanisms for suppressing cancer in a wide variety of species. By analyzing veterinary necropsy records, we can identify species with exceptionally high or low cancer prevalence. Discovering the mechanisms of cancer susceptibility and resistance may help improve cancer prevention and explain cancer syndromes. See related commentary by Metzger, p. 14.

Using Machine Learning and Artificial Intelligence to Predict Diabetes Mellitus among Women Population

BACKGROUND

Diabetes Mellitus is a chronic health condition (long-lasting) due to inadequate control of blood levels of glucose. This study presents a prediction of Type 2 Diabetes Mellitus among women using various Machine Learning Algorithms deployed to predict the diabetic condition. A University of California Irvine Diabetes Mellitus Dataset posted in Kaggle was used for analysis.

METHODS

The dataset included eight risk factors for Type 2 Diabetes Mellitus prediction, including Age, Systolic Blood Pressure, Glucose, Body Mass Index, Insulin, Skin Thickness, Diabetic Pedigree Function, and Pregnancy. R language was used for the data visualization, while the algorithms considered for the study are Logistic Regression, Support Vector Machines, Decision Trees and Extreme Gradient Boost. The performance analysis of these algorithms on various classification metrics is also presented here, considering the Area Under the Curve and Receiver Operating Characteristics score is the best for Extreme Gradient Boost with 85%, followed by Support Vector Machines and Decision Trees.

RESULTS

The Logistic Regression is showing low performance. But the Decision Trees and Extreme Gradient Boost show promising performance against all the classification metrics. But the Support Vector Machines offers a lower support value; hence it cannot be claimed to be a good classifier. The model showed that the most significant predictors of Type 2 Diabetes Mellitus were strongly correlated with Glucose Levels and mediumly correlated with Body Mass Index, whereas Age, Skin Thickness, Systolic Blood Pressure, Insulin, Pregnancy, and Pedigree Function were less significant. This type of real-time analysis has proved that the symptoms of Type 2 Diabetes Mellitus in women fall entirely different compared to men, which highlights the importance of Glucose Levels and Body Mass Index in women.

CONCLUSION

The prediction of Type 2 Diabetes Mellitus helps public health professionals to help people by suggesting proper food intake and adjusting lifestyle activities with good fitness management in women to make glucose levels and body mass index controlled. Therefore, the healthcare systems should give special attention to diabetic conditions in women to reduce exacerbations of the disease and other associated symptoms. This work attempts to predict the occurrence of Type 2 Diabetes Mellitus among women on their behavioral and biological conditions.

Endometrial cancer and simultaneous pregnancy, an unusual combination. Case report

Uterine cancer is the fourth most common cancer in women. Declining fertility, combined with increasing overweight and diabetes, might be some of the causes accountable for the rapid increase in the incidence of endometrial cancer (EC). Around 5% of EC are diagnosed in women aged under 40 years. We present a case of EC in a 36-year-old woman confirmed by hysteroscopy-directed biopsy, who became pregnant before receiving any primary treatment. She had no other significant medical or family history of interest. Image staging found a uterine-confined disease. The pregnancy had a normal course. The patient refused any type of treatment after delivery; thus, she was closely monitored every 3 months. No signs of disease recurrence were detected during the follow-up. Pregnancy may be possible with early EC and it might an effective treatment for the disease in this case. The pregnancy acts as treatment and the gestation could continue until term without complications, in this patient diagnosed with EC.

Therapeutic potential of silica nanoparticles, cisplatin, and quercetin on ovarian cancer: In vivo model

The present study evaluated the effect of silica nanoparticles, quercetin, and cisplatin against ovarian cancer. Cisplatin is a potent antineoplastic agent but has greater toxicity against cancer. Quercetin is a powerful flavonoid with remarkable anti-cancer activity due to its anti-apoptotic nature. Forty female albino rats were randomly divided into eight groups, with five rats per group. Group 1 (G1) was normal control, G2 received Carboxymethylcellulose; G3 was the normal control and treated with quercetin, G4 was given silica nanoparticles, G5 was treated with cisplatin. G6 was the tumor control. Tumor induction was done by 7, 12-dimethylbenz (a) anthracene (DMBA), G7 was treated with quercetin-cisplatin-silica nanoparticles, and in G8 quercetin-cisplatin silica nanoparticles were used to treat the induced tumor. Chemically synthesized silica nanoparticles were characterized by scanning electron microscopy (SEM), energy dispersive X-ray (EDX), and Fourier Transform Infrared (FTIR). After the treatment, animals were sacrificed and tested for biochemical and hormonal assays. G6 displayed increased body weight and a significant rise in CA125 as compared to G1. G6 also exhibited an altered hormonal profile, with a particular increase in estrogen, FSH, and testosterone, along with reduced LH and progesterone levels. Lipid profile, liver enzymes, and renal parameters (urea and creatinine) increased in G6, but G8 significantly ameliorated all damaging effects of DMBA as observed in G6. The current study revealed that silica nanoparticles combined with cisplatin and quercetin demonstrated greater protection against drastic changes induced by carcinogens in ovarian cancer mice models.

A dose-response meta-analysis of the relationship between number of pregnancies and risk of gynecological cancers

BACKGROUND

Despite several investigations, the association between the number of pregnancies and gynecological cancers remains inconclusive. To address this issue, we conducted a dose-response meta-analysis of observational studies.

METHODS

We searched PubMed, Web of Science, and Scopus databases up to Jun 8, 2023, to identify observational studies that examined the association between the number of pregnancies and gynecologic cancers. To assess the heterogeneity across studies, we used the χ2 test and I2 statistics. We also explored the possibility of publication bias using Begg's and Egger's tests. The overall effect sizes were reported as odds ratios (ORs) with a 95% confidence interval (CI) using a random-effects model.

RESULTS

Out of the 87,255 studies initially identified, a total of 101 studies involving 8,230,754 participants were included in the final meta-analysis. Our analysis revealed a positive trend between the number of pregnancies and cervical cancer; however, this association was not found to be statistically significant except for fifth pregnancy. Conversely, our findings showed a significant decreasing trend between the number of pregnancies and the risk of endometrial and ovarian cancers. There was insufficient evidence to establish a relationship between the number of pregnancies and the risk of vaginal, vulvar, and fallopian tube cancers.

CONCLUSIONS

Our study found a positive trend between the number of pregnancies and cervical cancer and a significant decreasing trend between the number of pregnancies and endometrial and ovarian cancers. These findings may have implications for counseling women about their reproductive health and the potential risks and benefits of pregnancy.

Early-pregnancy sex steroid and thyroid function hormones, thyroid autoimmunity, and maternal papillary thyroid cancer incidence in the Finnish Maternity Cohort

Thyroid cancer more commonly affects women than men and is the third most frequently diagnosed cancer among women of reproductive age. We conducted a nested case-control study within the Finnish Maternity Cohort to evaluate pre-diagnostic sex steroid and thyroid function markers in relation to subsequent maternal papillary thyroid cancer. Cases (n = 605) were women ages 18-44 years, who provided an early-pregnancy (<20 weeks gestation) blood sample and were diagnosed with papillary thyroid cancer up to 11 years afterward. Controls (n = 1185) were matched to cases 2:1 by gestational age, mother's age, and date at blood draw. Odds ratios (ORs) for the associations of serum thyroid peroxidase antibodies (TPO-Ab), thyroglobulin antibodies (Tg-Ab), thyroid stimulating hormone (TSH), free thyroxine (fT4), free triiodothyronine (fT3), progesterone, and estradiol with papillary thyroid cancer were estimated using conditional logistic regression. TPO-Ab and Tg-Ab positivity (>95th percentile among controls) were associated with more than 3-fold (OR = 3.32, 95% confidence interval [CI] 2.33-4.72) and 2-fold (OR = 2.03, 95% CI 1.41-2.93) increased odds of papillary thyroid cancer, respectively. These associations were similar by time since blood draw, parity, gestational age, smoking status, and age and stage at diagnosis. In models excluding TPO-Ab or Tg-Ab positivity, TPO-Ab (quartile 4 vs. 1: OR = 1.66, 95% CI 1.17-2.37, p-trend = .002) and Tg-Ab (quartile 4 vs. 1: OR = 1.74, 95% CI 1.22-2.49, p-trend = .01) levels were positively associated with papillary thyroid cancer. No associations were observed for estradiol, progesterone, TSH, fT3, or fT4 overall. Our results suggest that thyroid autoimmunity in early pregnancy may increase the risk of maternal papillary thyroid cancer.

Global burden of gynaecological cancers in 2022 and projections to 2050

Background

The incidence and mortality of gynaecological cancers can significantly impact women's quality of life and increase the health care burden for organisations globally. The objective of this study was to evaluate global inequalities in the incidence and mortality of gynaecological cancers in 2022, based on The Global Cancer Observatory (GLOBOCAN) 2022 estimates. The future burden of gynaecological cancers (GCs) in 2050 was also projected.

Methods

Data regarding to the total cases and deaths related to gynaecological cancer, as well as cases and deaths pertaining to different subtypes of GCs, gathered from the GLOBOCAN database for the year 2022. Predictions for the number of cases and deaths in the year 2050 were derived from global demographic projections, categorised by world region and Human Development Index (HDI).

Results

In 2022, there were 1 473 427 new cases of GCs and 680 372 deaths. The incidence of gynecological cancer reached 30.3 per 100 000, and the mortality rate hit 13.2 per 100 000. The age-standardised incidence of GCs in Eastern Africa is higher than 50 per 100 000, whereas the age-standardised incidence in Northern Africa is 17.1 per 100 000. The highest mortality rates were found in East Africa (ASMR (age-standardised mortality rates) of 35.3 per 100 000) and the lowest in Australia and New Zealand (ASMR of 8.1 per 100 000). These are related to the endemic areas of HIV and HPV. Very High HDI countries had the highest incidence of GCs, with ASIR (age-standardised incidence rates) of 34.8 per 100 000, and low HDI countries had the second highest incidence rate, with an ASIR of 33.0 per 100 000. Eswatini had the highest incidence and mortality (105.4 per 100 000; 71.1 per 100 000) and Yemen the lowest (5.8 per 100 000; 4.4 per 100 000). If the current trends in morbidity and mortality are maintained, number of new cases and deaths from female reproductive tract tumours is projected to increase over the next two decades.

Conclusions

In 2022, gynaecological cancers accounted for 1 473 427 new cases and 680 372 deaths globally, with significant regional disparities in incidence and mortality rates. The highest rates were observed in Eastern Africa and countries with very high and low HDI, with Eswatini recording the most severe statistics. If current trends continue, the number of new cases and deaths from gynaecological cancers is expected to rise over the next two decades, highlighting the urgent need for effective interventions.

Sociodemographic inequalities in breast cancer screening attendance in Germany following the implementation of an Organized Screening Program: Scoping Review

BACKGROUND

Organized breast cancer screening (BCS) programs are effective measures among women aged 50-69 for preventing the sixth cause of death in Germany. Although the implementation of the national screening program started in 2005, participation rates have not yet reached EU standards. It is unclear which and how sociodemographic factors are related to BCS attendance. This scoping review aims to identify sociodemographic inequalities in BCS attendance among 50-69-year-old women following the implementation of the Organized Screening Program in Germany.

METHODS

Following PRISMA guidelines, we searched the Web of Science, Scopus, MEDLINE, PsycINFO, and CINAHL following the PCC (Population, Concept and Context) criteria. We included primary studies with a quantitative study design and reviews examining BCS attendance among women aged 50-69 with data from 2005 onwards in Germany. Harvest plots depicting effect size direction for the different identified sociodemographic inequalities and last two years or less BCS attendance and lifetime BCS attendance were developed.

RESULTS

We screened 476 titles and abstracts and 33 full texts. In total, 27 records were analysed, 14 were national reports, and 13 peer-reviewed articles. Eight sociodemographic variables were identified and summarised in harvest plots: age, education, income, migration status, type of district, employment status, partnership cohabitation and health insurance. Older women with lower incomes and migration backgrounds who live in rural areas and lack private insurance respond more favourably to BCS invitations. However, from a lifetime perspective, these associations only hold for migration background, are reversed for income and urban residency, and are complemented by partner cohabitation. Finally, women living in the former East German states of Saxony, Mecklenburg-Western Pomerania, Saxony-Anhalt, and Thuringia, as well as in the former West German state of Lower Saxony, showed higher BCS attendance rates in the last two years.

CONCLUSION

High-quality research is needed to identify women at higher risk of not attending BCS in Germany to address the existing research's high heterogeneity, particularly since the overall attendance rate still falls below European standards.

PROTOCOL REGISTRATION

https://osf.io/x79tq/ .

Ovarian cancer: A review for primary care providers

ABSTRACT

Ovarian cancer is the second most common gynecologic cancer in the United States and the deadliest gynecologic cancer worldwide, with a 5-year survival rate of less than 50%. Because of its vague symptoms, more than half of patients present with advanced disease and metastasis. This article reviews the epidemiology, pathogenesis, risk factors, screening, presentation, and diagnosis of ovarian cancer, in addition to providing an overview of the standard approach to treatment and novel targeted biologic therapies.

The Associations and Causal Relationships of Ovarian Cancer - Construction of a Prediction Model

Purpose

To explore the risk and protective factors for developing ovarian cancer and construct a risk prediction model.

Methods

Information related to patients diagnosed with ovarian cancer on the electronic medical record data platform of three tertiary hospitals in Guangdong Province from May 2018 to September 2023 was collected as the case group. Patients with non-ovarian cancer who attended the clinic during the same period were included in the control group. Logistic regression analysis was used to screen the independent variables and explore the factors associated with the development of ovarian cancer. An ovarian cancer risk prediction model was constructed using a decision tree C4.5 algorithm. The ROC and calibration curves were plotted, and the model was validated.

Results

Logistic regression analysis identified independent risk and protective factors for ovarian cancer. The sample size was divided into training and test sets in a ratio of 7:3 for model construction and validation. The AUC of the training and test sets of the decision tree model were 0.961 (95% CI:0.944-0.978) and 0.902 (95% CI:0.840-0.964), respectively, and the optimal cut-off values and their coordinates were 0.532 (0.091, 0.957), and 0.474 (0.159, 0.842) respectively. The accuracies of the training and test sets were 93.3% and 84.2%, respectively, and their sensitivities were 95.7% and 84.2%, respectively.

Conclusion

The constructed ovarian cancer risk prediction model has good predictive ability, which is conducive to improving the efficiency of early warning of ovarian cancer in high-risk groups.

Causal effects of hypertensive disorders of pregnancy on future gynecologic tumors: A two-sample Mendelian randomization study

BACKGROUND

Numerous observational studies have investigated the potential link between hypertensive disorders of pregnancy (HDPs) and the subsequent risks of gynecologic tumors, yet the findings have been inconsistent. In this study, we utilized Mendelian randomization (MR) approach to assess the influence of HDPs on the future risks of ovarian, cervical, endometrial, and breast cancer and uterine fibroids, controlling for confounding factors.

METHODS

The genome-wide association studies (GWAS) summary data relevant to HDPs was obtained from the FinnGen databases (10,736 cases and 136,325 controls). Gynecologic tumor outcomes were extracted from the IEU Open GWAS project and UK Biobank (47,690 cases and 1, 092,073 controls). The inverse variance weighted (IVW) approach was selected as the principal method for MR analysis, supplemented by MR-Egger, weighted median, weighted model, simple model methods, MR pleiotropy residual sum and outlier (MR-PRESSO) test, and leave-one-out method. Multivariate MR (MVMR) analysis was conducted after adjusting systolic blood pressure (SBP), body mass index (BMI) and type 2 diabetes mellitus (T2DM).

RESULTS

Our univariate MR analysis (UVMR) results revealed no significant relationship between HDPs and the risks of ovarian cancer (odds ratio [OR] = 0.924, p = 0.360), cervical cancer (OR = 1.230, p = 0.738), endometrial cancer (OR = 1.006, p = 0.949), uterine fibroids (OR = 1.155, p = 0.158), and breast cancer (OR = 0.792, p = 0.241) by IVW test. Similar results were observed in gestational hypertension and preeclampsia/eclampsia. Additionally, our study detected neither heterogeneity nor pleiotropy. MVMR analysis also provided no evidence of a causal association between HDPs and common gynecologic tumors after adjusting SBP, BMI, and T2DM.

CONCLUSION

We discovered no causal relationship between HDPs and ovarian, cervical, endometrial, breast cancer, and uterine fibroids in European populations. However, present analysis did not explore the effect of HDPs on the subtypes of gynecologic tumors across varied ethnic populations, which may require additional research.

Associations between pregnancy-related factors and birth characteristics with risk of rare uterine cancer subtypes: a Nordic population-based case-control study

PURPOSE

Uterine sarcomas are a rare group of uterine malignancies. Due to the low incidence and changes in uterine sarcoma classification, risk factors are not well characterized. Our objective was to evaluate risk factors for uterine sarcoma and compare risk factors between uterine sarcoma, malignant mixed Mullerian tumors (MMMTs), and type I endometrial carcinomas.

METHODS

This nested case-control study utilized linked data from population-based medical birth and cancer registries in Denmark, Finland, Norway, and Sweden. Up to 10 controls were matched on country and birth year for each uterine cancer case. Using multivariable adjusted multinomial logistic regression, estimates of the associations between pregnancy-related factors and risk of uterine sarcoma, MMMTs, and type I endometrial carcinomas were determined.

RESULTS

Having a very-low-birth-weight infant (< 1500 vs. 2500-3999 g: OR [95% CI] 2.83 [1.61-4.96]) was associated with an increased risk of uterine sarcoma. Whereas, having a more recent pregnancy was associated with reduced risks of MMMT (< 10 vs. ≥ 30 years: 0.66 [0.20-2.23]) and type 1 endometrial carcinomas (0.35 [0.30-0.41]) but not uterine sarcomas (1.33 [0.90-1.98], p-heterogeneity < 0.01).

CONCLUSION

Our study provides evidence that risk factors for uterine sarcoma and MMMT, previously grouped with uterine sarcomas, vary substantially. Additionally, MMMT and type I endometrial carcinomas are more similar than uterine sarcoma in that pregnancy complications like gestational hypertension and preeclampsia were associated with reduced risks of both but not uterine sarcoma, suggesting different etiologies.

Association of hormonal and reproductive factors with differentiated thyroid cancer risk in women: a pooled prospective cohort analysis

BACKGROUND

The incidence of differentiated thyroid cancer (DTC) is higher in women than in men but whether sex steroid hormones contribute to this difference remains unclear. Studies of reproductive and hormonal factors and thyroid cancer risk have provided inconsistent results.

METHODS

Original data from 1 252 907 women in 16 cohorts in North America, Europe, Australia and Asia were combined to evaluate associations of DTC risk with reproductive and hormonal factors. Multivariable-adjusted Cox proportional hazard models were used to estimate hazard ratios (HRs) and 95% CIs.

RESULTS

During follow-up, 2142 women were diagnosed with DTC. Factors associated with higher risk of DTC included younger age at menarche (<10 vs 10-11 years; HR, 1.28; 95% CI, 1.00-1.64), younger (<40; HR, 1.31; 95% CI, 1.05-1.62) and older (≥55; HR, 1.33; 95% CI, 1.05-1.68) ages at menopause (vs 40-44 years), ever use of menopausal hormone therapy (HR, 1.16; 95% CI, 1.02-1.33) and previous hysterectomy (HR, 1.25; 95% CI, 1.13-1.39) or bilateral oophorectomy (HR, 1.14; 95% CI, 1.00-1.29). Factors associated with lower risk included longer-term use (≥5 vs <5 years) of oral contraceptives (HR, 0.86; 95% CI, 0.76-0.96) among those who ever used oral contraception and baseline post-menopausal status (HR, 0.82; 95% CI, 0.70-0.96). No associations were observed for parity, duration of menopausal hormone therapy use or lifetime number of reproductive years or ovulatory cycles.

CONCLUSIONS

Our study provides some evidence linking reproductive and hormonal factors with risk of DTC. Results should be interpreted cautiously considering the modest strength of the associations and potential for exposure misclassification and detection bias. Prospective studies of pre-diagnostic circulating sex steroid hormone measurements and DTC risk may provide additional insight.

Sex differences in frailty among older adults

By definition, aging is a natural, gradual and continuous process. On the other hand, frailty reflects the increase in vulnerability to stressors and shortens the time without disease (health span) while longevity refers to the length of life (lifespan). The average life expectancy has significantly increased during the last few decades. A longer lifespan has been accompanied by an increase in frailty and decreased independence in older adults, with major differences existing between men and women. For example, women tend to live longer than men but also experience higher rates of frailty and disability. Sex differences prevent optimization of lifestyle interventions and therapies to effectively prevent frailty. Sex differences in frailty and aging are rooted in a complex interplay between uncontrollable (genetic, epigenetic, physiological), and controllable factors (psychosocial and lifestyle factors). Thus, understanding the underlying causes of sex differences in frailty and aging is essential for developing personalized interventions to promote healthy aging and improve quality of life in older men and women. In this review, we have discussed the key contributors and knowledge gaps related to sex differences in aging and frailty.

Clinical Features and Management of Lung Cancer During Pregnancy: A Narrative Review Based on Reported Cases

This review aims to provide a summary of the clinical characteristics and outcomes of lung cancer during pregnancy. A comprehensive literature search yielded 93 cases of lung cancer during pregnancy from 1953 to 2022, with an average maternal age of ∼34 years old. The initial symptoms reported were often nonspecific, such as cough, dyspnea, and chest pain. Cancer-related treatments, including surgery, radiotherapy, chemotherapy, and tyrosine kinase inhibitors, have shown beneficial effects on maternal outcomes. A majority of the newborns were born without malformation or diseases, but extended follow-up remains necessary. Early diagnosis of lung cancer is imperative for reducing the risks of placental and fetal metastasis and enhancing overall survival.

Reevaluating the Role of Progesterone in Ovarian Cancer: Is Progesterone Always Protective?

Ovarian cancer (OC) represents a collection of rare but lethal gynecologic cancers where the difficulty of early detection due to an often-subtle range of abdominal symptoms contributes to high fatality rates. With the exception of BRCA1/2 mutation carriers, OC most often manifests as a post-menopausal disease, a time in which the ovaries regress and circulating reproductive hormones diminish. Progesterone is thought to be a "protective" hormone that counters the proliferative actions of estrogen, as can be observed in the uterus or breast. Like other steroid hormone receptor family members, the transcriptional activity of the nuclear progesterone receptor (nPR) may be ligand dependent or independent and is fully integrated with other ubiquitous cell signaling pathways often altered in cancers. Emerging evidence in OC models challenges the singular protective role of progesterone/nPR. Herein, we integrate the historical perspective of progesterone on OC development and progression with exciting new research findings and critical interpretations to help paint a broader picture of the role of progesterone and nPR signaling in OC. We hope to alleviate some of the controversy around the role of progesterone and give insight into the importance of nPR actions in disease progression. A new perspective on the role of progesterone and nPR signaling integration will raise awareness to the complexity of nPRs and nPR-driven gene regulation in OC, help to reveal novel biomarkers, and lend critical knowledge for the development of better therapeutic strategies.

Trans-ethnic Mendelian randomization study of systemic lupus erythematosus and common female hormone-dependent malignancies

BACKGROUND

Observational research has reported that systemic lupus erythematosus (SLE) is related to common female hormone-dependent cancers, but the underlying causal effect remains undefined. This study aimed to explore the causal association of these conditions by Mendelian randomization (MR) analysis.

METHODS

We selected instrumental variables for SLE from genome-wide association studies (GWASs) conducted in European and East Asian populations. The genetic variants for female malignant neoplasms were obtained from corresponding ancestry GWASs. We utilized inverse variance weighted (IVW) as the primary analysis, followed by sensitivity analysis. Furthermore, we conducted multivariable MR (MVMR) to estimate direct effects by adjusting for the body mass index and estradiol. Finally, we implemented reverse direction MR analysis and gave a negative example to test the reliability of MR results.

RESULTS

We found SLE was significantly negatively associated with overall endometrial cancer risk (odds ratio [OR] = 0.961, 95% confidence interval [CI] = 0.935-0.987, P  = 3.57E-03) and moderately inversely related to endometrioid endometrial cancer (ENEC) (OR = 0.965, 95% CI = 0.936-0.995, P  = 0.024) risk in the European population by IVW. We replicated these results using other MR models and detected a direct effect by MVMR (overall endometrial cancer, OR = 0.962, 95% CI = 0.941-0.983, P  = 5.11E-04; ENEC, OR = 0.964, 95% CI = 0.940-0.989, P  = 0.005). Moreover, we revealed that SLE was correlated with decreased breast cancer risk (OR = 0.951, 95% CI = 0.918-0.986, P  = 0.006) in the East Asian population by IVW, and the effect was still significant in MVMR (OR = 0.934, 95% CI = 0.859-0.976, P  = 0.002). The statistical powers of positive MR results were all >0.9.

CONCLUSION

This finding suggests a possible causal effect of SLE on the risk of overall endometrial cancer and breast cancer in European and East Asian populations, respectively, by MR analysis, which compensates for inherent limitations of observational research.

Awake craniotomy during pregnancy: A systematic review of the published literature

Neurosurgical pathologies in pregnancy pose significant complications for the patient and fetus, and physiological stressors during anesthesia and surgery may lead to maternal and fetal complications. Awake craniotomy (AC) can preserve neurological functions while reducing exposure to anesthetic medications. We reviewed the literature investigating AC during pregnancy. PubMed, Scopus, and Web of Science databases were searched from the inception to February 7th, 2023, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. Studies in English investigating AC in pregnant patients were included in the final analysis. Nine studies composed of nine pregnant patients and ten fetuses (one twin-gestating patient) were included. Glioma was the most common pathology reported in six (66.7%) patients. The frontal lobe was the most involved region (4 cases, 44.4%), followed by the frontoparietal region (2 cases, 22.2%). The awake-awake-awake approach was the most common protocol in seven (77.8%) studies. The shortest operation time was two hours, whereas the longest one was eight hours and 29 min. The mean gestational age at diagnosis was 13.6 ± 6.5 (2-22) and 19.6 ± 6.9 (9-30) weeks at craniotomy. Seven (77.8%) studies employed intraoperative fetal heart rate monitoring. None of the AC procedures was converted to general anesthesia. Ten healthy babies were delivered from patients who underwent AC. In experienced hands, AC for resection of cranial lesions of eloquent areas in pregnant patients is safe and feasible and does not alter the pregnancy outcome.

An epigenetic hypothesis for ovarian cancer prevention by oral contraceptive pill use

BACKGROUND

Ovarian cancer is the second most common gynecological cancer type after uterine cancers. In 2020, according to worldwide statistics, there were more than 313,000 new cases of ovarian cancer. Most concerning with ovarian cancer is the poor overall survival, with only 30% of patients surviving for longer than 5 years after diagnosis. The reason for this poor outcome includes late diagnosis due to non-specific symptoms and a lack of any highly effective biomarkers of the early stages of ovarian carcinogenesis. However, it is important to note that some modifiable lifestyle factors can be preventative [pregnancy, breastfeeding and combined oral contraceptives pill (COCP) use].

RESULTS

There is now increasing data reporting the role of epigenetic changes, which are detectable in ovarian cancer tumors, suggesting the possibility that epigenetics may also play a key role in the mechanism of long-term effective prevention of ovarian cancer. To our knowledge, there is a lack of high-quality data on the molecular mechanisms of ovarian cancer prevention, although several hypotheses have been proposed.

CONCLUSIONS

This review focusses on the evidence for a proposed novel hypothesis-that COCPs act as a chemoprevention through the impact on the epigenome of the cells of origin of ovarian cancer-fallopian tubes epithelium.

Pregnancy complications and endometrial cancer in women with polycystic ovarian syndrome: a Korean National Health Insurance Service study

OBJECTIVE

Polycystic ovarian syndrome is associated with diverse pregnancy related complications and endometrial cancer. However, research on the relationship between pregnancy complications and endometrial cancer in women with polycystic ovarian syndrome is scarce. We aimed to examine the association between gestational diabetes mellitus, pregnancy induced hypertension, and preterm birth and the risk of endometrial cancer in women with polycystic ovarian syndrome.

METHODS

We analyzed data from the National Health Information Database established by the Korean National Health Insurance Service between January 2002 and December 2019. We included women with gestational diabetes mellitus, pregnancy induced hypertension, preterm birth, and endometrial cancer from among the polycystic ovarian syndrome population. All conditions were diagnosed according to the Korean Informative Classification of Diseases, 10th revision codes. Age, area of residence, income, body mass index, waist circumference, total cholesterol, high density lipoprotein, low density lipoprotein, triglycerides, fasting blood sugar, and creatinine levels were included as covariates in the multiple logistic regression analysis.

RESULTS

Of 467 221 women with polycystic ovarian syndrome included, 5099 had endometrial cancer. Age, residence, income, body mass index, waist circumference, total cholesterol, high density lipoprotein, low density lipoprotein, triglycerides, fasting blood sugar, and creatinine levels differed significantly between the endometrial cancer and non-endometrial cancer groups (p≤0.001-0.032). Among the polycystic ovarian syndrome population, the odds ratios (ORs) of endometrial cancer were 1.50, 1.43, and 1.23 in women with a history of gestational diabetes mellitus, pregnancy induced hypertension, and preterm birth, respectively, compared with those without a history of these conditions (OR 1.50, 95% confidence interval (CI) 1.32 to 1.69, p<0.001; 1.43, 1.04 to 1.97, p=0.027; and 1.23, 1.05 to 1.45, p=0.011, respectively).

CONCLUSION

Our results suggest that a history of pregnancy complications (gestational diabetes mellitus, pregnancy induced hypertension, and preterm birth) increases the risk of endometrial cancer in women with polycystic ovarian syndrome.

Third Trimester Serum Amino Acid Metabolism is Associated with Maternal Breast Cancer Diagnosed within 15 years of Pregnancy

A prospective metabolome-wide association study revealed widespread amino acid limitation in late pregnancy is associated with early onset breast cancer. Archival third trimester pregnancy serum samples from 172 women who subsequently were diagnosed with breast cancer within 38 years after pregnancy were compared to 351 women without breast cancer. No individual metabolite differed after false discovery rate adjustment, indicating that individual metabolites are unlikely to be useful for classification or prediction. Despite this, pathway enrichment analysis showed that amino acid pathways, including lysine, arginine, proline, aspartate, asparagine, alanine, tyrosine, tryptophan, histidine, branched-chain amino acid and urea cycle, were enriched among metabolites that differed at raw p < 0.05. Several of these pathways previously were linked to breast carcinogen exposures, including dichlorodiphenyltrichloroethane and perfluorinated alkyl substances. Network analyses showed that amino acids correlated with parity and the ratio of estriol to estrone and estradiol known risk factors for breast cancer in this cohort. Overall, amino acid associations were stronger for early onset breast cancer, defined here as occurring within the first 15 years following pregnancy. Although results must be interpreted cautiously, lower amino acid concentrations for histidine, threonine and proline, and stronger associations for tryptophan, histidine, and lysine pathways with breast cancer within 15 years, suggests that amino acid limitations during late pregnancy contribute to metabolic reprogramming that is causally related to early onset breast cancer. Environmental chemical effects on nutrient sensing could account for these effects through known oncogenic mechanisms linked to nutrient stress.

Exposome epidemiology for suspect environmental chemical exposures during pregnancy linked to subsequent breast cancer diagnosis

Breast cancer is now the most common cancer globally, accounting for 12% of all new annual cancer cases worldwide. Despite epidemiologic studies having established a number of risk factors, knowledge of chemical exposure risks is limited to a relatively small number of chemicals. In this exposome research study, we used non-targeted, high-resolution mass spectrometry of pregnancy cohort biospecimens in the Child Health and Development Studies to test for associations with breast cancer identified via the California Cancer Registry. Second and third trimester archival samples were analyzed from 182 women who subsequently developed breast cancer and 384 randomly selected women who did not develop breast cancer. Environmental chemicals were annotated with the Toxin and Toxin-Target Database for chemical signals that were higher in breast cancer cases and used with an exposome epidemiology analytic framework to identify suspect chemicals and associated metabolic networks. Network and pathway enrichment analyses showed consistent linkage in both second and third trimesters to inflammation pathways, including linoleate, arachidonic acid and prostaglandins, and identified new suspect environmental chemicals associated with breast cancer, i.e., an N-substituted piperidine insecticide and a common commercial product, 2,4-dinitrophenol, linked to variations in amino acid and nucleotide pathways in second trimester and benzo[a]carbazole and a benzoate derivative linked to glycan and amino sugar metabolism in third trimester. The results identify new suspect environmental chemical risk factors for breast cancer and provide an exposome epidemiology framework for discovery of suspect environmental chemicals and potential mechanistic associations with breast cancer.

Serum levels of tumor markers and their clinical significance in epithelial ovarian cancer

OBJECTIVES

Tumor markers have been widely used clinically. Detection of serum CA125 is one of the commonly used clinical methods for early screening and early diagnosis of epithelial ovarian cancer, but it is difficult to diagnose epithelial ovarian cancer with a single specific tumor marker. In this study, the combinatorial tumor marker detection method was used to compare the value of each tumor marker alone and different combinations in the diagnosis of epithelial ovarian cancer.

METHODS

The clinical data of patients with epithelial ovarian cancer (n=65) and ovarian benign disease (n=29) were collected. Multiple tumor marker protein chip was used to detect cancer antigen 125 (CA125), carbohydrate antigen 242 (CA242), alpha-fetoprotein (AFP), beta-human chorionic gonadotropin (β-HCG), carcinoembryonic antigen (CEA), cancer antigen 199 (CA199), neuron-specific enolase (NSE), Ferritin, cancer antigen 153 (CA153), and human growth hormone (HGH) serum levels, and to compare the differences between the benign and malignant ovarian tumors. The correlation between tumor markers and clinicopathologic features for ovarian epithelial carcinoma was analyzed by χ2 test. Spearman rank analysis showed the correlation between CA125 expression level and other tumor markers in epithelial ovarian cancer and the correlation between age and the above 10 tumor markers. Sensitivity, specificity, positive predictive value, negative predictive value, Youden index, and diagnostic efficiency were used to evaluate the diagnostic value of single tumor marker and the combination of tumor markers.

RESULTS

The levels of β-HCG, NSE, CA153, and CA125 in the epithelial ovarian cancer group were higher than those in the ovarian benign disease group. The level of NSE in the serum of patients with epithelial ovarian cancer was related to the clinical stage of patients. In addition, the levels of CA242, β-HCG, CEA, NSE, Ferritin, CA153 in the serum of patients with epithelial ovarian cancer were positively correlated with CA125 (rs=0.497, P<0.001; rs=0.612, P<0.001; rs=0.358, P=0.003; rs=0.680, P<0.001; rs=0.322, P=0.009; rs=0.609, P<0.001, respectively), and the levels of β-HCG, Ferritin, CA153 were positively correlated with the patient's age (rs=0.256, P=0.040; rs=0.325, P=0.008; rs=0.249, P=0.046, respectively). In the diagnosis of epithelial ovarian cancer, the sensitivity, Youden index, and diagnostic efficiency of CA125 detection alone were higher than the results of the other 9 separate detections. When CA153, CA199, CA242, Ferritin, and CEA were combined with CA125, the sensitivity of the combined detection of different combinations was higher than that of CA125 alone. The combined detection sensitivities of CA125+CEA and CA125+Ferritin+CEA were 89.2% and 90.8%, respectively, and the diagnostic efficiencies were both 84.1%, which were higher than those of other combinations. The Youden index of CA125+CEA joint detection was 0.616, which was higher than those of other combinations.

CONCLUSIONS

CA125 has a high diagnostic value in the diagnosis of epithelial ovarian cancer. The detection of combined tumor markers in serum has higher sensitivity and specificity in epithelial ovarian cancer.

Reproductive and hormonal factors and risk of renal cell carcinoma among women in the European Prospective Investigation into Cancer and Nutrition

BACKGROUND

Renal cell carcinoma (RCC) is twice as common among men compared with women, and hormonal factors have been suggested to partially explain this difference. There is currently little evidence on the roles of reproductive and hormonal risk factors in RCC aetiology.

MATERIALS & METHODS

We investigated associations of age at menarche and age at menopause, pregnancy-related factors, hysterectomy and ovariectomy and exogenous hormone use with RCC risk among 298,042 women in the European Prospective Investigation into Cancer and Nutrition (EPIC) study.

RESULTS

During 15 years of follow-up, 438 RCC cases were identified. Parous women had higher rates of RCC compared with nulliparous women (HR = 1.71, 95% CI 1.18, 2.46), and women who were older at age of first pregnancy had lower rates of RCC (30 years + vs. <20 years HR = 0.53, 95% CI 0.34, 0.82). Additionally, we identified a positive association for hysterectomy (HR = 1.43 95% CI 1.09, 1.86) and bilateral ovariectomy (HR = 1.67, 95% CI 1.13, 2.47), but not unilateral ovariectomy (HR = 0.99, 95% CI 0.61, 1.62) with RCC risk. No clear associations were found for age at menarche, age at menopause or exogenous hormone use.

CONCLUSION

Our results suggest that parity and reproductive organ surgeries may play a role in RCC aetiology.

Pregnancy-associated Cancer and Chemotherapy during Pregnancy

The diagnosis of pregnancy-associated cancer, although rare, is a condition of great human and social significance and difficult clinical management. A pregnancy-associated neoplasm is defined as a cancer diagnosis made during pregnancy or within 12 months after delivery/abortion. The most common cancers in pregnancy occur most frequently in women of reproductive age with an incidence overall like that observed in non-pregnant women of the same age. This incidence is likely to increase in view of both the expected increase in certain malignancies among young women (particularly breast cancer and melanoma) and the increasing frequency of pregnancies undertaken later in life (fourth and fifth decades of life) that is characterizing modern society. Chemotherapy is generally contraindicated before 12 weeks of pregnancy due to the increased risk of congenital anomalies while exposure in the second and third trimester of pregnancy to chemotherapy has been associated with more growth restriction and preterm delivery. Clinical decisions about the optimal management should consider maternal and fetal characteristics with the involvement of a multidisciplinary team.

Exposome Epidemiology for Suspect Environmental Chemical Exposures during Pregnancy Linked to Subsequent Breast Cancer Diagnosis

Breast cancer is now the most common cancer globally, accounting for 12% of all new annual cancer cases worldwide. Despite epidemiologic studies having established a number of risk factors, knowledge of chemical exposure risks is limited to a relatively small number of chemicals. In this exposome research study, we used non-targeted, high-resolution mass spectrometry (HRMS) of pregnancy cohort biospecimens in the Child Health and Development Studies (CHDS) to test for associations with breast cancer identified via the California Cancer Registry. Second (T2) and third (T3) trimester archival samples were analyzed from 182 women who subsequently developed breast cancer and 384 randomly selected women who did not develop breast cancer. Environmental chemicals were annotated with the Toxin and Toxin-Target Database (T3DB) for chemical signals that were higher in breast cancer cases and used with an exposome epidemiology analytic framework to identify suspect chemicals and associated metabolic networks. Network and pathway enrichment analyses showed consistent linkage in both T2 and T3 to inflammation pathways, including linoleate, arachidonic acid and prostaglandins, and identified new suspect environmental chemicals associated with breast cancer, i.e., an N-substituted piperidine insecticide and a common commercial product, 2,4-dinitrophenol (DNP), linked to variations in amino acid and nucleotide pathways in T2 and benzo[a]carbazole and a benzoate derivative linked to glycan and amino sugar metabolism in T3. The results identify new suspect environmental chemical risk factors for breast cancer and provide an exposome epidemiology framework for discovery of suspect environmental chemicals and potential mechanistic associations with breast cancer.

Association between excessive fetal growth and maternal cancer in Shanghai, China: a large, population-based cohort study

The prevalence of high birth weight or large for gestational age (LGA) infants is increasing, with increasing evidence of pregnancy-related factors that may have long-term impacts on the health of the mother and baby. We aimed to determine the association between excessive fetal growth, specifically LGA and macrosomia, and subsequent maternal cancer by performing a prospective population-based cohort study. The data set was based on the Shanghai Birth Registry and Shanghai Cancer Registry, with medical records from the Shanghai Health Information Network as a supplement. Macrosomia and LGA prevalence was higher in women who developed cancer than in women who did not. Having an LGA child in the first delivery was associated with a subsequently increased risk of maternal cancer (hazard ratio [HR] = 1.08, 95% confidence interval [CI] 1.04-1.11). Additionally, in the last and heaviest deliveries, there were similar associations between LGA births and maternal cancer rates (HR = 1.08, 95% CI 1.04-1.12; HR = 1.08, 95% CI 1.05-1.12, respectively). Furthermore, a substantially increased trend in the risk of maternal cancer was associated with birth weights exceeding 2500 g. Our study supports the association between LGA births and increased risks of maternal cancer, but this risk requires further investigation.

Pre-eclampsia during pregnancy and risk of endometrial cancer: a systematic review and meta-analysis

BACKGROUND

Pre-eclampsia may be associated with the development of endometrial cancer; however, previous findings have been conflicting.

OBJECTIVES

To investigate if pre-eclampsia is associated with an increased risk of endometrial cancer.

METHOD

Two independent reviewers screened titles and abstracts of studies identified in MEDLINE, Embase, and Web of Science databases from inception until March 2022. Studies were included if they investigated pre-eclampsia and subsequent risk of endometrial cancer (or precursor lesions). Random-effects meta-analysis was used to calculate pooled hazard ratios (HRs) and 95% confidence intervals (CIs) for the association between pre-eclampsia during pregnancy and endometrial cancer risk.

MAIN RESULTS

There were seven articles identified which investigated endometrial cancer, of which one also investigated endometrial cancer precursors. Overall, the studies include 11,724 endometrial cancer cases. No association was observed between pre-eclampsia and risk of endometrial cancer with moderate heterogeneity observed (pooled HR 1.07, 95% CI 0.79-1.46, I2 = 34.1%). In sensitivity analysis investigating risk of endometrial neoplasia (atypical hyperplasia, carcinoma in situ, or cancer), there was some evidence that pre-eclampsia was associated with an increased risk (HR 1.34, 95% CI 1.15-1.57, I2 = 29.6%).

CONCLUSIONS

Pre-eclampsia was not associated with an increased risk of endometrial cancer. Additional large studies with information on pre-eclampsia sub-type aiming to investigate endometrial cancer precursor conditions are merited.

Abortion and Female Cancer Risks among Women Aged 20 to 45 Years: A 10-Year Longitudinal Population-Based Cohort Study in Taiwan

BACKGROUND

Female cancers, including breast, cervical, uterine, and ovarian cancer, remain among the ten most common cancers among women worldwide, but the relationship between female cancers and abortion from previous studies is inconsistent. This study aimed to investigate risks of incident female cancers among women aged 20 to 45 years who underwent abortion in Taiwan compared with those who did not.

METHOD

A longitudinal observational cohort study was conducted using three nationwide population-based databases in Taiwan, focusing on 20- to 45-year-old women, with 10 years of follow-up. Matched cohorts were identified with propensity score 1-to-3 matching between 269,050 women who underwent abortion and 807,150 who did not. Multivariable Cox proportional hazard modeling was used for analysis after adjusting for covariates including age, average monthly payroll, fertility, diabetes mellitus, polycystic ovarian syndrome, endometrial hyperplasia, endometriosis, hormone-related drugs, and Charlson comorbidity index.

RESULTS

We found lower risk of uterine cancer (hazard ratio [HR]: 0.77, 95% CI: 0.70-0.85) and ovarian cancer (HR: 0.81, 95% CI: 0.75-0.88), but no significant difference in risk of breast cancer or cervical cancer, among matched abortion compared with non-abortion cohorts. Regarding subgroup analysis, cervical cancer risk was higher for parous women who underwent abortion, and uterine cancer risk was lower for nulliparous women who underwent abortion compared with non-abortion groups.

CONCLUSIONS

Abortion was related to lower uterine and ovarian cancer risk but was not associated with risks of incident breast cancer or cervical cancer. Longer follow-up may be necessary to observe risks of female cancers at older ages.

Do Aging and Parity Affect VEGF-A/VEGFR Content and Signaling in the Ovary?-A Mouse Model Study

In this study, the effects of aging and parity on VEGF-A/VEGFR protein content and signaling in the mice ovaries were determined. The research group consisted of nulliparous (virgins, V) and multiparous (M) mice during late-reproductive (L, 9-12 months) and post-reproductive (P, 15-18 months) stages. Whilst ovarian VEGFR1 and VEGFR2 remained unchanged in all the experimental groups (LM, LV, PM, PV), protein content of VEGF-A and phosphorylated VEGFR2 significantly decreased only in PM ovaries. VEGF-A/VEGFR2-dependent activation of ERK1/2, p38, as well as protein content of cyclin D1, cyclin E1, and Cdc25A were then assessed. In ovaries of LV and LM, all of these downstream effectors were maintained at a comparable low/undetectable level. Conversely, the decrease recorded in PM ovaries did not occur in the PV group, in which the significant increase of kinases and cyclins, as well phosphorylation levels mirrored the trend of the pro-angiogenic markers. Altogether, the present results demonstrated that, in mice, ovarian VEGF-A/VEGFR2 protein content and downstream signaling can be modulated in an age- and parity-dependent manner. Moreover, the lowest levels of pro-angiogenic and cell cycle progression markers detected in PM mouse ovaries sustains the hypothesis that parity could exert a protective role by downregulating the protein content of key mediators of pathological angiogenesis.

Maternal Health, Pregnancy and Offspring Factors, and Maternal Thyroid Cancer Risk: A Nordic Population-Based Registry Study

Thyroid cancer incidence is higher in women than men, especially during the reproductive years, for reasons that remain poorly understood. Using population-based registry data from 4 Nordic countries through 2015, we examined associations of perinatal characteristics with risk of maternal thyroid cancer. Cases were women diagnosed with thyroid cancer ≥2 years after last birth (n = 7,425, 83% papillary). Cases were matched to controls (n = 67,903) by mother's birth year, country, and county of residence. Odds ratios (ORs) were estimated using conditional logistic regression models adjusting for parity. Older age at first pregnancy, postpartum hemorrhage (OR = 1.18, 95% (confidence interval) CI: 1.08, 1.29), and benign thyroid conditions (ORs ranging from 1.64 for hypothyroidism to 10.35 for thyroid neoplasms) were associated with increased thyroid cancer risk, as were higher offspring birth weight (per 1-kg increase, OR = 1.17, 95% CI: 1.12, 1.22) and higher likelihood of offspring being large for gestational age (OR = 1.26, 95% CI: 1.11, 1.43). Unmarried/noncohabiting status (OR = 0.91, 95% CI: 0.84, 0.98), maternal smoking (OR = 0.75, 95% CI: 0.67, 0.84), and preterm birth (OR = 0.90, 95% CI: 0.83, 0.98) were associated with reduced risk. Several factors (e.g., older age at first pregnancy, maternal smoking, goiter, benign neoplasms, postpartum hemorrhage, hyperemesis gravidarum, and neonatal jaundice) were associated with advanced thyroid cancer. These findings suggest that some perinatal exposures may influence maternal thyroid cancer risk.

Breast cancer prevention by short-term inhibition of TGFβ signaling

Cancer prevention has a profound impact on cancer-associated mortality and morbidity. We previously identified TGFβ signaling as a candidate regulator of mammary epithelial cells associated with breast cancer risk. Here, we show that short-term TGFBR inhibitor (TGFBRi) treatment of peripubertal ACI inbred and Sprague Dawley outbred rats induces lasting changes and prevents estrogen- and carcinogen-induced mammary tumors, respectively. We identify TGFBRi-responsive cell populations by single cell RNA-sequencing, including a unique epithelial subpopulation designated secretory basal cells (SBCs) with progenitor features. We detect SBCs in normal human breast tissues and find them to be associated with breast cancer risk. Interactome analysis identifies SBCs as the most interactive cell population and the main source of insulin-IGF signaling. Accordingly, inhibition of TGFBR and IGF1R decrease proliferation of organoid cultures. Our results reveal a critical role for TGFβ in regulating mammary epithelial cells relevant to breast cancer and serve as a proof-of-principle cancer prevention strategy.

Utility of Matrix Metalloproteinases in the Diagnosis, Monitoring and Prognosis of Ovarian Cancer Patients

Ovarian cancer is one of the most common gynecologic malignancies. It is characterized by a high mortality rate, which is mainly due to the asymptomatic course of the disease. In light of the high mortality rate and increasing morbidity, new diagnostic methods are being explored to enable earlier detection, better monitoring, and improved prognosis. Such diagnostic methods include the assessment of tumor markers in various biological samples. Among the markers currently being investigated, extracellular matrix metalloproteinases (MMPs) are of particular interest. The objective of this article was to compile the existing knowledge of MMPs in ovarian cancer patients and to describe their potential diagnostic utility. Additionally, this article provides an overview of the symptoms, complications, and risk factors associated with ovarian cancer and the role of MMPs in physiology and pathology. Preliminary results indicate that tissue expression and blood and body fluid levels of MMPs may be different in ovarian cancer patients than in healthy women. The expression and concentration of individual MMPs have been shown to be correlated with cancer stage and disease severity. In addition, the preliminary value of some of these enzymes in predicting prognosis is discussed. However, as the amount of data is limited, more studies are needed to fully evaluate the potential function of individual MMPs in ovarian cancer patients. Based on the knowledge gathered for this article, it seems that MMP-2, MMP-3, MMP-7, MMP-8, MMP-9, MMP-13, are tentatively the most useful. A thorough evaluation of their utility as modern biomarkers in ovarian cancer requires further investigation.

Pregnancy duration and ovarian cancer risk: A 50-year nationwide cohort study

A woman's reproductive history is strongly associated with her risk of ovarian cancer. However, it is unclear how pregnancies of different duration impact a woman's ovarian cancer risk, and therefore, what part of a pregnancy explains the protective effect. Using a cohort of all Danish women followed from 1968 to 2018, with prospectively registered information on reproductive history (eg, gestational duration of pregnancies, tubal ligation and resection and hormonal pharmaceutical use), we investigated the effect of pregnancy duration on ovarian cancer risk. We adjusted for potential confounders, such as age at pregnancy and time since pregnancy, using log-linear Poisson regression to isolate the effect of pregnancy duration on ovarian cancer risk. Among 2.5 million Danish women with 4.4 million pregnancies, a pregnancy was associated with a reduction of ovarian cancer risk of 21% (95% CI, 14%-28%), 26% (95% CI, 21%-31%), 12% (95% CI, 7%-17%) and 3% (95% CI, -5% to 11%) compared to one less, for the first, second, third and fourth pregnancy, respectively (P < .001 for heterogeneity), with similar effects of induced abortions, spontaneous abortions and childbirths. Sensitivity analysis of age at pregnancy, time since pregnancy and other potential confounders did not change these findings. The reduced ovarian cancer risk associated with pregnancy is primarily driven by the first three pregnancies, with similar effects of induced abortion, spontaneous abortions and childbirth, suggesting that mainly exposure to early pregnancy factors, and not pregnancy duration, protect against ovarian cancer.

Molecular Management of High-Grade Serous Ovarian Carcinoma

High-grade serous ovarian carcinoma (HGSOC) represents the most common form of epithelial ovarian carcinoma. The absence of specific symptoms leads to late-stage diagnosis, making HGSOC one of the gynecological cancers with the worst prognosis. The cellular origin of HGSOC and the role of reproductive hormones, genetic traits (such as alterations in P53 and DNA-repair mechanisms), chromosomal instability, or dysregulation of crucial signaling pathways have been considered when evaluating prognosis and response to therapy in HGSOC patients. However, the detection of HGSOC is still based on traditional methods such as carbohydrate antigen 125 (CA125) detection and ultrasound, and the combined use of these methods has yet to support significant reductions in overall mortality rates. The current paradigm for HGSOC management has moved towards early diagnosis via the non-invasive detection of molecular markers through liquid biopsies. This review presents an integrated view of the relevant cellular and molecular aspects involved in the etiopathogenesis of HGSOC and brings together studies that consider new horizons for the possible early detection of this gynecological cancer.

Gestational Hypertensive Disorders and Maternal Breast Cancer Risk in a Nationwide Cohort of 40,720 Parous Women

BACKGROUND

Preeclampsia and gestational hypertension are hypothesized to be associated with reduced maternal breast cancer risk, but the epidemiologic evidence is inconclusive. Our objective was to examine associations between gestational hypertensive disorders and breast cancer in a nationwide cohort of women with a family history of breast cancer.

METHODS

Women ages 35-74 years who had a sister previously diagnosed with breast cancer, but had never had breast cancer themselves, were enrolled in the Sister Study from 2003 to 2009 (N = 50,884). At enrollment, participants reported diagnoses of eclampsia, preeclampsia, or gestational hypertension in each pregnancy. We used Cox proportional hazards models to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for the association between history of a gestational hypertensive disorder and incident invasive breast cancer or ductal carcinoma in situ among 40,720 parous women. We used age as the time scale and adjusted for birth cohort, race-ethnicity, and reproductive, socioeconomic, and behavioral factors. We examined effect measure modification by risk factors for gestational hypertensive disease and breast cancer and assessed possible etiologic heterogeneity across tumor characteristics.

RESULTS

The prevalence of gestational hypertensive disease was 12%. During follow-up (mean = 10.9 years), 3,198 eligible women self-reported a breast cancer diagnosis. History of a gestational hypertensive disorder was not associated with breast cancer risk (HR = 1.0; 95% CI = 0.90, 1.1). We did not observe clear evidence of effect measure modification or etiologic heterogeneity.

CONCLUSIONS

History of a gestational hypertensive disorder was not associated with breast cancer risk in a cohort of women with a first-degree family history of breast cancer.

Understanding How Pregnancy Protects Against Ovarian and Endometrial Cancer Development: Fetal Antigens May Be Involved

It is well known that many factors, including infertility, obesity, type 2 diabetes, and family history of cancer, increase the risk of developing endometrial and ovarian cancer. However, multiparous women are known to have a lower risk of developing either ovarian or endometrial cancer than nonparous women. The lack of ovulation and shifting of sex hormonal balance, with decreased estrogen levels and increased progesterone levels during pregnancy, has traditionally been thought to be the major contributor to this decreased risk. However, in reality, the mechanisms underlying this phenomenon are relatively unknown. Increasing evidence suggests that endocrine factors are unlikely to completely explain the protective effect of pregnancies, and that multiple other nonendocrine mechanisms including fetal antigens and the newly proposed dormant cells hypothesis may also be involved. In this review, we summarize recent evidence and describe the potential underlying mechanisms that may explain how pregnancy protects against the development of ovarian and endometrial cancers in women's later life.

Whole-lesion apparent diffusion coefficient (ADC) histogram as a quantitative biomarker to preoperatively differentiate stage IA endometrial carcinoma from benign endometrial lesions

BACKGROUND

To assess the value of whole-lesion apparent diffusion coefficient (ADC) histogram analysis in differentiating stage IA endometrial carcinoma (EC) from benign endometrial lesions (BELs) and characterizing histopathologic features of stage IA EC preoperatively.

METHODS

One hundred and six BEL and 126 stage IA EC patients were retrospectively enrolled. Eighteen volumetric histogram parameters were extracted from the ADC map of each lesion. The Mann-Whitney U or Student's t-test was used to compare the differences between the two groups. Models based on clinical parameters and histogram features were established using multivariate logistic regression. Receiver operating characteristic (ROC) analysis and calibration curves were used to assess the models.

RESULTS

Stage IA EC showed lower ADC_10th, ADC_90th, ADC_min, ADC_max, ADC_mean, ADC_median, interquartile range, mean absolute deviation, robust mean absolute deviation (rMAD), root mean squared, energy, total energy, entropy, variance, and higher skewness, kurtosis and uniformity than BELs (all p < 0.05). ADC_median yielded the highest area under the ROC curve (AUC) of 0.928 (95% confidence interval [CI] 0.895-0.960; cut-off value = 1.161 × 10^-3 mm²/s) for differentiating stage IA EC from BELs. Moreover, multivariate analysis demonstrated that ADC-score (ADC_10th + skewness + rMAD + total energy) was the only significant independent predictor (OR = 2.641, 95% CI 2.045-3.411; p < 0.001) for stage IA EC when considering clinical parameters. This ADC histogram model (ADC-score) achieved an AUC of 0.941 and a bias-corrected AUC of 0.937 after bootstrap resampling. The model performed well for both premenopausal (accuracy = 0.871) and postmenopausal (accuracy = 0.905) patients. Besides, ADC_min and ADC_10th were significantly lower in Grade 3 than in Grade 1/2 stage IA EC (p = 0.022 and 0.047). At the same time, no correlation was found between ADC histogram parameters and the expression of Ki-67 in stage IA EC (all p > 0.05).

CONCLUSIONS

Whole-lesion ADC histogram analysis could serve as an imaging biomarker for differentiating stage IA EC from BELs and assisting in tumor grading of stage IA EC, thus facilitating personalized clinical management for premenopausal and postmenopausal patients.

Imaging Cancer in Pregnancy

Pregnancy-associated cancer (PAC) is defined as cancer that is detected during pregnancy and up to 1 year postpartum. Although rare (~1:1000 pregnancies), PAC is increasing owing to postponed childbearing and advanced maternal age at conception. Cancer-related symptoms masked by physiologic gestational changes may delay diagnosis. Imaging, clinical management, and treatment require a carefully choreographed multidisciplinary team approach. The risk-benefit of every imaging modality, the strategies to balance the safety of mother and fetus, and the support of the patient and family at every step are crucial. US and MRI are preferred imaging modalities that lack ionizing radiation. Radiation dose concerns should be addressed, noting that most imaging examinations (including mammography, radiography, CT, and technetium 99m-labeled sulfur colloid sentinel lymph node staging) are performed at radiation levels below thresholds at which deterministic side effects are seen. Dose estimates should be provided after each examination. The use of iodinated intravenous contrast material is safe during pregnancy, but gadolinium-based contrast material should be avoided. Accurate diagnosis and staging combined with gestational age affect decisions about surgery and chemotherapy. Whole-body MRI with diffusion-weighted sequences is ideal to screen for primary and metastatic sites, determine disease stage, identify biopsy targets, and guide further cancer site-specific imaging. The authors provide an update of the imaging triage, safety considerations, cancer-specific imaging, and treatment options for cancer in pregnancy. An invited commentary by Silverstein and Van Loon is available online. Online supplemental material is available for this article. ^©RSNA, 2022.

Multimodal MRI-Based Radiomics-Clinical Model for Preoperatively Differentiating Concurrent Endometrial Carcinoma From Atypical Endometrial Hyperplasia

Objectives

To develop and validate a radiomics model based on multimodal MRI combining clinical information for preoperative distinguishing concurrent endometrial carcinoma (CEC) from atypical endometrial hyperplasia (AEH).

Materials and Methods

A total of 122 patients (78 AEH and 44 CEC) who underwent preoperative MRI were enrolled in this retrospective study. Radiomics features were extracted based on T2-weighted imaging (T2WI), diffusion-weighted imaging (DWI), and apparent diffusion coefficient (ADC) maps. After feature reduction by minimum redundancy maximum relevance and least absolute shrinkage and selection operator algorithm, single-modal and multimodal radiomics signatures, clinical model, and radiomics-clinical model were constructed using logistic regression. Receiver operating characteristic (ROC) analysis, calibration curves, and decision curve analysis were used to assess the models.

Results

The combined radiomics signature of T2WI, DWI, and ADC maps showed better discrimination ability than either alone. The radiomics-clinical model consisting of multimodal radiomics features, endometrial thickness >11mm, and nulliparity status achieved the highest area under the ROC curve (AUC) of 0.932 (95% confidential interval [CI]: 0.880-0.984), bootstrap corrected AUC of 0.922 in the training set, and AUC of 0.942 (95% CI: 0.852-1.000) in the validation set. Subgroup analysis further revealed that this model performed well for patients with preoperative endometrial biopsy consistent and inconsistent with postoperative pathologic data (consistent group, F1-score = 0.865; inconsistent group, F1-score = 0.900).

Conclusions

The radiomics model, which incorporates multimodal MRI and clinical information, might be used to preoperatively differentiate CEC from AEH, especially for patients with under- or over-estimated preoperative endometrial biopsy.

Multivariate analysis of independent roles of socioeconomic status, occupational physical activity, reproductive factors, and postmenopausal hormonal therapy in risk of breast cancer

PURPOSE

This case-control study assesses the independent roles of reproductive history, postmenopausal hormonal therapy (HT), socioeconomic status (SES), and occupational physical activity on the risk of breast cancer (BC).

METHODS

Odds ratios (OR) were estimated from conditional logistic multivariate regression model in a data set of 19,253 Finnish women diagnosed with BC between 1994 and 2013 and 96,265 age-matched population controls.

RESULTS

Both pre- and postmenopausal white-collar workers had significantly increased risk of ductal and lobular BC as compared to manual workers. Moderate occupational physical activity reduced risk of lobular BC by 14%. There was a transient increase in the risk of BC observed after each birth followed by a protective effect starting some years after the delivery. As the number of children increased, the short-term excess risk was lower and protective effect was observed earlier. Continuous estrogen-progestin therapy (EPT) significantly increased the risk of both ductal and lobular BC and the magnitude of risk was directly proportional to duration of use (OR for 5+ years of use 2.26, 95% confidence interval 2.12-2.42). Monthly EPT for 5+ years increased the risk (OR 1.32, 95% CI 1.20-1.45). Users of estradiol plus levonorgestrel intrauterine system devices showed ORs of 1.56 (95% CI 1.45-1.69) and 2.18 (95% CI 1.81-2.64) for ductal and lobular BC, respectively.

CONCLUSION

This study concludes that pregnancy has a dual effect on BC risk, with a transient increase in risk followed by a long-term protective effect. The SES and HT have a large effect on BC risk while occupational physical activity has only a small independent effect.

Safe pregnancy after liver transplantation: Evidence from a multicenter Italian collaborative study

BACKGROUND

Women who have undergone liver transplantation (LT) enjoy better health, and possibility of childbearing. However, maternal and graft risks, optimal immunosuppression, and fetal outcome is still to clarify.

AIM

Aim of the study was to assess outcomes of pregnancy after LT at national level.

METHODS

In 2019, under the auspices of the Permanent Transplant Committee of the Italian Association for the Study of the Liver, a multicenter survey including 14 Italian LT-centers was conducted aiming at evaluating the outcomes of recipients and newborns, and graft injury/function parameters during pregnancy in LT-recipients.

RESULTS

Sixty-two pregnancies occurred in 60 LT-recipients between 1990 and 2018. Median age at the time of pregnancy was 31-years and median time from transplantation to conception was 8-years. During pregnancy, 4 recipients experienced maternal complications with hospital admission. Live-birth-rate was 100%. Prematurity occurred in 25/62 newborns, and 8/62 newborns had low-birth-weight. Cyclosporine was used in 16 and Tacrolimus in 37 pregnancies, with no different maternal or newborn outcomes. Low-birth-weight was correlated to high values of AST, ALT and GGT.

CONCLUSION

Pregnancy after LT has good outcome; however, maternal complications and prematurity may occur. Compliance with the immunosuppression is fundamental to ensure the stability of graft function and prevent graft-deterioration.