1
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Zha JM, Zhang M, Wang T, Li HS, Ban QY, Liu M, Jiang XX, Guo SY, Wang J, Zhou YR, Liu YH, He WQ, Xu H. Association of Overweight and Inflammatory Indicators with Breast Cancer: A Cross-Sectional Study in Chinese Women. Int J Womens Health 2024; 16:783-795. [PMID: 38737496 PMCID: PMC11086397 DOI: 10.2147/ijwh.s428696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 04/26/2024] [Indexed: 05/14/2024] Open
Abstract
Objective This cross-sectional study aimed to explore the association of overweight and inflammatory indicators with breast cancer risk in Chinese patients. Methods Weight, height, and peripheral blood inflammatory indicators, including white blood cell count (WBC), neutrophil count (NE), lymphocyte count (LY), platelet count (PLT) and the concentration of hypersensitivity C-reactive protein (hsCRP), were collected in 383 patients with benign breast lumps (non-cancer) and 358 patients with malignant breast tumors (cancer) at the First Affiliated Hospital of Soochow University, China, from March 2018 to July 2020. Body mass index (BMI), neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR) and systemic immune-inflammation index (SII) were determined according to the ratio equation. The correlations among overweight, inflammatory indicators, and the proportion of non-cancer or cancer cases were analyzed. Results BMI is associated with an increased breast cancer risk. Compared with non-cancer patients, the average WBC count, NE count, NLR, and level of hsCRP were significantly higher in cancer patients. The level of hsCRP was closely associated with the size of malignant breast tumors. Conclusion We conclude that overweight and high levels of hsCRP may serve as putative risk factors for malignant breast tumors in Chinese women.
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Affiliation(s)
- Juan-Min Zha
- Department of Oncology, the First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, 215006, People’s Republic of China
| | - Mei Zhang
- Department of Oncology, the First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, 215006, People’s Republic of China
| | - Tao Wang
- Jiangsu Key Laboratory of Neuropsychiatric Diseases and Cambridge-Suda (CAM-SU) Genomic Resource Center, Medical College of Soochow University, Suzhou, Jiangsu, People’s Republic of China
| | - Hua-Shan Li
- Department of Oncology, the First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, 215006, People’s Republic of China
- Jiangsu Key Laboratory of Neuropsychiatric Diseases and Cambridge-Suda (CAM-SU) Genomic Resource Center, Medical College of Soochow University, Suzhou, Jiangsu, People’s Republic of China
| | - Quan-Yao Ban
- Department of Oncology, the First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, 215006, People’s Republic of China
| | - Mei Liu
- Department of Oncology, the First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, 215006, People’s Republic of China
| | - Xue-Xue Jiang
- Department of Oncology, the First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, 215006, People’s Republic of China
| | - Shi-Ying Guo
- Jiangsu Key Laboratory of Neuropsychiatric Diseases and Cambridge-Suda (CAM-SU) Genomic Resource Center, Medical College of Soochow University, Suzhou, Jiangsu, People’s Republic of China
| | - Jing Wang
- Jiangsu Key Laboratory of Neuropsychiatric Diseases and Cambridge-Suda (CAM-SU) Genomic Resource Center, Medical College of Soochow University, Suzhou, Jiangsu, People’s Republic of China
| | - Ya-Ru Zhou
- Jiangsu Key Laboratory of Neuropsychiatric Diseases and Cambridge-Suda (CAM-SU) Genomic Resource Center, Medical College of Soochow University, Suzhou, Jiangsu, People’s Republic of China
| | - Yu-Hong Liu
- Jiangsu Key Laboratory of Neuropsychiatric Diseases and Cambridge-Suda (CAM-SU) Genomic Resource Center, Medical College of Soochow University, Suzhou, Jiangsu, People’s Republic of China
| | - Wei-Qi He
- Department of Oncology, the First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, 215006, People’s Republic of China
- Jiangsu Key Laboratory of Neuropsychiatric Diseases and Cambridge-Suda (CAM-SU) Genomic Resource Center, Medical College of Soochow University, Suzhou, Jiangsu, People’s Republic of China
| | - Hong Xu
- Department of Oncology, the First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, 215006, People’s Republic of China
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2
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Kityo A, Lee SA. Longitudinal changes in high sensitivity C-reactive protein associated with serum uric acid in the Korean Genome and Epidemiology Study. Sci Rep 2024; 14:374. [PMID: 38172510 PMCID: PMC10764782 DOI: 10.1038/s41598-023-50951-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 12/28/2023] [Indexed: 01/05/2024] Open
Abstract
Cross-sectional studies support the role of serum uric acid (SUA) in inflammation, but evidence from cohort studies is scarce. Longitudinal associations between SUA and high-sensitivity C-reactive protein (hs-CRP) were examined in the general population. Data for participants from the Health Examinees-Gem cohort (n = 50,028; 40-69 years; 67% women) who were examined between 2004 and 2013 and followed up until 2016 were analyzed. SUA and hs-CRP were measured at baseline and during follow-up. SUA was evaluated as a continuous variable and was also divided into sex-specific quartiles. Mean hs-CRP levels at follow-up were evaluated using multivariable proportional odds regression, with non-linear smoothed baseline hs-CRP levels serving as a covariate. Selected pathological markers were also examined in relation to hs-CRP. Increased levels of SUA at baseline were related to increased levels of hs-CRP at follow-up [regression coefficient per mg/dL increase in baseline SUA (β) = 0.08, 95% confidence interval (CI), 0.040-0.128]. A dose-response relationship was observed, (P for linear trend = 0.0015). The mean values of hs-CRP were highest among participants with the highest follow-up but lowest baseline SUA levels. Elevated hs-CRP levels at follow up (> 3 mg/L) were positively related to fasting blood glucose levels, triglycerides levels, liver enzymes, and blood pressure, but negatively related to high density lipoprotein cholesterol levels per unit increase in baseline hs-CRP. High SUA levels were associated with high hs-CRP levels, suggesting a potential role of SUA in inflammation. However, additional research is needed to confirm these findings.
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Affiliation(s)
- Anthony Kityo
- Department of Preventive Medicine, School of Medicine, Kangwon National University, Gangwon, 24341, Republic of Korea
| | - Sang-Ah Lee
- Department of Preventive Medicine, School of Medicine, Kangwon National University, Gangwon, 24341, Republic of Korea.
- Interdisciplinary Graduate Program in Medical Bigdata Convergence, Kangwon National University, Gangwon, 24341, Republic of Korea.
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3
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Lou MW, Drummond AE, Swain CT, Milne RL, English DR, Brown KA, van Roekel EH, Skinner TL, Moore MM, Gaunt TR, Martin RM, Lewis SJ, Lynch BM. Linking Physical Activity to Breast Cancer via Inflammation, Part 2: The Effect of Inflammation on Breast Cancer Risk. Cancer Epidemiol Biomarkers Prev 2023; 32:597-605. [PMID: 36867866 PMCID: PMC10150245 DOI: 10.1158/1055-9965.epi-22-0929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 12/09/2022] [Accepted: 02/27/2023] [Indexed: 03/05/2023] Open
Abstract
This review synthesized and appraised the evidence for an effect of inflammation on breast cancer risk. Systematic searches identified prospective cohort and Mendelian randomization studies relevant to this review. Meta-analysis of 13 biomarkers of inflammation were conducted to appraise the evidence for an effect breast cancer risk; we examined the dose-response of these associations. Risk of bias was evaluated using the ROBINS-E tool and the quality of evidence was appraised with Grading of Recommendations Assessment, Development, and Evaluation. Thirty-four observational studies and three Mendelian randomization studies were included. Meta-analysis suggested that women with the highest levels of C-reactive protein (CRP) had a higher risk of developing breast cancer [risk ratio (RR) = 1.13; 95% confidence interval (CI), 1.01-1.26] compared with women with the lowest levels. Women with highest levels of adipokines, particularly adiponectin (RR = 0.76; 95% CI, 0.61-0.91) had a reduced breast cancer risk, although this finding was not supported by Mendelian randomization analysis. There was little evidence of an effect of cytokines, including TNFα and IL6, on breast cancer risk. The quality of evidence for each biomarker ranged from very low to moderate. Beyond CRP, the published data do not clearly support the role of inflammation in the development of breast cancer.
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Affiliation(s)
- Makayla W.C. Lou
- Cancer Epidemiology Division, Cancer Council Victoria, Victoria, Australia
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Australia
| | - Ann E. Drummond
- Cancer Epidemiology Division, Cancer Council Victoria, Victoria, Australia
| | | | - Roger L. Milne
- Cancer Epidemiology Division, Cancer Council Victoria, Victoria, Australia
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Australia
- Precision Medicine, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia
| | - Dallas R. English
- Cancer Epidemiology Division, Cancer Council Victoria, Victoria, Australia
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Australia
| | - Kristy A. Brown
- Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Eline H. van Roekel
- Department of Epidemiology, GROW School for Oncology and Developmental Biology, Maastricht University, Maastricht, the Netherlands
| | - Tina L. Skinner
- School of Human Movement and Nutrition Sciences, Faculty of Health and Behavioural Sciences, University of Queensland, Brisbane, Australia
| | - Melissa M. Moore
- Medical Oncology, St Vincent's Hospital, Melbourne, Australia
- Department of Medicine, The University of Melbourne, Melbourne, Australia
| | - Tom R. Gaunt
- Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Richard M. Martin
- Bristol Medical School, University of Bristol, Bristol, United Kingdom
- NIHR Biomedical Research Centre at University Hospitals Bristol and Weston NHS Foundation Trust and the University of Bristol, Bristol, United Kingdom
| | - Sarah J. Lewis
- Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Brigid M. Lynch
- Cancer Epidemiology Division, Cancer Council Victoria, Victoria, Australia
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Australia
- Physical Activity Laboratory, Baker Heart and Diabetes Institute, Melbourne, Australia
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4
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Mikkelsen MK, Lindblom NAF, Dyhl-Polk A, Juhl CB, Johansen JS, Nielsen D. Systematic review and meta-analysis of C-reactive protein as a biomarker in breast cancer. Crit Rev Clin Lab Sci 2022; 59:480-500. [PMID: 35403550 DOI: 10.1080/10408363.2022.2050886] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Inflammation is an enabling characteristic of the hallmarks of cancer. There has therefore been increasing interest in the clinical value of circulating inflammatory biomarkers in cancer. In this review, we summarize results on C-reactive protein (CRP), alone or as part of the Glasgow Prognostic Score (GPS, composed of CRP and serum albumin), as a biomarker of prognosis or prediction and monitoring of therapeutic response in patients with breast cancer. A systematic literature search was performed in Medline and Embase from 1990 to August 2021. The association of serum CRP and overall survival and disease/progression-free survival was summarized in meta-analyses using a random effects model. The results from a total of 35 included studies (20,936 patients) were divided according to three identified patient settings (metastatic, non-metastatic, and general setting). Most of the studies examined prognostic utility. Several larger studies observed associations between high serum CRP and poor survival, but the meta-analyses suggested a limited value in a non-metastatic and general breast cancer setting (populations with unknown or varied disease stage). In metastatic patients, however, more consistent findings supported an association between serum CRP and prognosis (hazard ratio for overall survival: 1.87 (95% CI 1.31-2.67). Only five studies examined a role in prediction or monitoring of therapeutic response. One study reported a significant association between serum CRP levels and response to chemotherapy. Findings regarding serum CRP as a biomarker in breast cancer appear inconsistent, particularly in non-metastatic and general breast cancer, where the prognostic value could not be confirmed. In patients with metastatic breast cancer we suggest that high serum CRP is an indicator of poor prognosis. Too few studies assessed the role of serum CRP in prediction or monitoring of treatment response to allow conclusions.
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Affiliation(s)
- Marta Kramer Mikkelsen
- Department of Oncology, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark
| | | | - Anne Dyhl-Polk
- Department of Oncology, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark
| | - Carsten Bogh Juhl
- Department of Physiotherapy and Occupational Therapy, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark.,Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense M, Denmark
| | - Julia Sidenius Johansen
- Department of Oncology, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark.,Department of Medicine, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Dorte Nielsen
- Department of Oncology, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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5
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Cairat M, Rinaldi S, Navionis AS, Romieu I, Biessy C, Viallon V, Olsen A, Tjønneland A, Fournier A, Severi G, Kvaskoff M, Fortner RT, Kaaks R, Aleksandrova K, Schulze MB, Masala G, Tumino R, Sieri S, Grasso C, Mattiello A, Gram IT, Olsen KS, Agudo A, Etxezarreta PA, Sánchez MJ, Santiuste C, Barricarte A, Monninkhof E, Hiensch AE, Muller D, Merritt MA, Travis RC, Weiderpass E, Gunter MJ, Dossus L. Circulating inflammatory biomarkers, adipokines and breast cancer risk-a case-control study nested within the EPIC cohort. BMC Med 2022; 20:118. [PMID: 35430795 PMCID: PMC9014562 DOI: 10.1186/s12916-022-02319-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 02/28/2022] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Inflammation has been hypothesized to play a role in the development and progression of breast cancer and might differently impact breast cancer risk among pre and postmenopausal women. We performed a nested case-control study to examine whether pre-diagnostic circulating concentrations of adiponectin, leptin, c-reactive protein (CRP), tumour necrosis factor-α, interferon-γ and 6 interleukins were associated with breast cancer risk, overall and by menopausal status. METHODS Pre-diagnostic levels of inflammatory biomarkers were measured in plasma from 1558 case-control pairs from the European Prospective Investigation into Cancer and Nutrition (EPIC) cohort. We used conditional logistic regression to estimate the odds ratios (ORs) of breast cancer at blood collection, per one standard deviation increase in biomarker concentration. RESULTS Cases were diagnosed at a mean age of 61.4 years on average 8.6 years after blood collection. No statistically significant association was observed between inflammatory markers and breast cancer risk overall. In premenopausal women, borderline significant inverse associations were observed for leptin, leptin-to-adiponectin ratio and CRP [OR= 0.89 (0.77-1.03), OR= 0.88 (0.76-1.01) and OR= 0.87 (0.75-1.01), respectively] while positive associations were observed among postmenopausal women [OR= 1.16 (1.05-1.29), OR= 1.11 (1.01-1.23), OR= 1.10 (0.99-1.22), respectively]. Adjustment for BMI strengthened the estimates in premenopausal women [leptin: OR = 0.83 (0.68-1.00), leptin-to-adiponectin ratio: OR = 0.80 (0.66-0.97), CRP: OR = 0.85 (0.72-1.00)] but attenuated the estimates in postmenopausal women [leptin: OR = 1.09 (0.96-1.24), leptin-to-adiponectin ratio: OR = 1.02 (0.89-1.16), CRP: OR = 1.04 (0.92-1.16)]. CONCLUSIONS Associations between CRP, leptin and leptin-to-adiponectin ratio with breast cancer risk may represent the dual effect of obesity by menopausal status although this deserves further investigation.
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Affiliation(s)
- Manon Cairat
- Nutrition and Metabolism Branch, International Agency for Research on Cancer, World Health Organization, 150 cours Albert Thomas, 69372, Lyon, CEDEX 08, France
| | - Sabina Rinaldi
- Nutrition and Metabolism Branch, International Agency for Research on Cancer, World Health Organization, 150 cours Albert Thomas, 69372, Lyon, CEDEX 08, France
| | - Anne-Sophie Navionis
- Nutrition and Metabolism Branch, International Agency for Research on Cancer, World Health Organization, 150 cours Albert Thomas, 69372, Lyon, CEDEX 08, France
| | - Isabelle Romieu
- National Institute of Public Health, Centre for Population Health Research, Cuernavaca, Morelos, Mexico City, Mexico
| | - Carine Biessy
- Nutrition and Metabolism Branch, International Agency for Research on Cancer, World Health Organization, 150 cours Albert Thomas, 69372, Lyon, CEDEX 08, France
| | - Vivian Viallon
- Nutrition and Metabolism Branch, International Agency for Research on Cancer, World Health Organization, 150 cours Albert Thomas, 69372, Lyon, CEDEX 08, France
| | - Anja Olsen
- Danish Cancer Society Research Center, Copenhagen, Denmark
- Department of Public Health, University of Aarhus, Aarhus, Denmark
| | - Anne Tjønneland
- Danish Cancer Society Research Center, Copenhagen, Denmark
- Department of Public Health, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Agnès Fournier
- Université Paris-Saclay, UVSQ, Inserm, Gustave Roussy, Équipe "Exposome Et Hérédité", CESP UMR1018, 94805, Villejuif, France
| | - Gianluca Severi
- Université Paris-Saclay, UVSQ, Inserm, Gustave Roussy, Équipe "Exposome Et Hérédité", CESP UMR1018, 94805, Villejuif, France
- Department of Statistics, Computer Science and Applications (DISIA), University of Florence, Florence, Italy
| | - Marina Kvaskoff
- Université Paris-Saclay, UVSQ, Inserm, Gustave Roussy, Équipe "Exposome Et Hérédité", CESP UMR1018, 94805, Villejuif, France
| | - Renée T Fortner
- Division of Cancer Epidemiology, German Cancer Research Center (DFKZ), Heidelberg, Germany
| | - Rudolf Kaaks
- Division of Cancer Epidemiology, German Cancer Research Center (DFKZ), Heidelberg, Germany
| | - Krasimira Aleksandrova
- Department Epidemiological Methods and Etiological Research, Leibniz Institute for Prevention Research and Epidemiology-BIPS, Bremen, Germany
- Faculty of Human and Health Sciences, University of Bremen, Bremen, Germany
| | - Matthias B Schulze
- Department of Molecular Epidemiology, German Institute of Human Nutrition Potsdam-Rehbruecke, Nuthetal, Germany
- Institute of Nutritional Science, University of Potsdam, Nuthetal, Germany
| | - Giovanna Masala
- Cancer Risk Factors and Life-Style Epidemiology Unit, Institute for Cancer Research, Prevention and Clinical Network - ISPRO, Florence, Italy
| | - Rosario Tumino
- Hyblean Association for Epidemiological Research AIRE -ONLUS, Ragusa, Italy
| | - Sabina Sieri
- Epidemiology and Prevention Unit, Fondazione IRCCS Istituto Nazionale Dei Tumori Di Milano, Via Venezian, Milano, Italy
| | - Chiara Grasso
- Cancer Epidemiology Unit, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Amalia Mattiello
- Dipartimento Di Medicina Clinica E Chirurgia, Federico II University, Naples, Italy
| | - Inger T Gram
- Department of Community Medicine, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromsø, Norway
| | - Karina Standahl Olsen
- Department of Community Medicine, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromsø, Norway
| | - Antonio Agudo
- Unit of Nutrition and Cancer, Catalan Institute of Oncology - ICO, L'Hospitalet de Llobregat, Spain
- Nutrition and Cancer Group; Epidemiology, Public Health, Cancer Prevention and Palliative Care Program; Bellvitge Biomedical Research Institute - IDIBELL, L'Hospitalet de Llobregat, Spain
| | - Pilar Amiano Etxezarreta
- Ministry of Health of the Basque Government, Sub Directorate for Public Health and Addictions of Gipuzkoa, San Sebastian, Spain
- Biodonostia Health Research Institute, Epidemiology of Chronic and Communicable Diseases Group, San Sebastián, Spain
- Centro De Investigación Biomédica En Red De Epidemiología Y Salud Pública (CIBERESP), Madrid, Spain
| | - Maria-Jose Sánchez
- Centro De Investigación Biomédica En Red De Epidemiología Y Salud Pública (CIBERESP), Madrid, Spain
- Escuela Andaluza De Salud Pública (EASP), Granada, Spain
- Instituto De Investigación Biosanitaria Ibs.GRANADA, Granada, Spain
- Department of Preventive Medicine and Public Health, University of Granada, Granada, Spain
| | - Carmen Santiuste
- Centro De Investigación Biomédica En Red De Epidemiología Y Salud Pública (CIBERESP), Madrid, Spain
- Department of Epidemiology, Murcia Regional Health Council, IMIB-Arrixaca, Murcia, Spain
| | - Aurelio Barricarte
- Centro De Investigación Biomédica En Red De Epidemiología Y Salud Pública (CIBERESP), Madrid, Spain
- Navarra Public Health Institute, Pamplona, Spain
- Navarra Institute for Health Research (IdiSNA), Pamplona, Spain
| | - Evelyn Monninkhof
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Anouk E Hiensch
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - David Muller
- Department Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, UK
| | - Melissa A Merritt
- Department Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, UK
- University of Hawaii Cancer Center, Cancer Epidemiology Program, 701 Ilalo St., Honolulu, HI, 96813, USA
| | - Ruth C Travis
- Cancer Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, OX3 0NR, UK
| | - Elisabete Weiderpass
- Nutrition and Metabolism Branch, International Agency for Research on Cancer, World Health Organization, 150 cours Albert Thomas, 69372, Lyon, CEDEX 08, France
| | - Marc J Gunter
- Nutrition and Metabolism Branch, International Agency for Research on Cancer, World Health Organization, 150 cours Albert Thomas, 69372, Lyon, CEDEX 08, France
| | - Laure Dossus
- Nutrition and Metabolism Branch, International Agency for Research on Cancer, World Health Organization, 150 cours Albert Thomas, 69372, Lyon, CEDEX 08, France.
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6
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Gupta A, Oyekunle T, Salako O, Daramola A, Alatise O, Ogun G, Adeniyi A, Deveaux A, Saraiya V, Hall A, Ayandipo O, Olajide T, Olasehinde O, Arowolo O, Adisa A, Afuwape O, Olusanya A, Adegoke A, Tollefsbol TO, Arnett D, Muehlbauer MJ, Newgard CB, Akinyemiju T. Association of high-sensitivity C-reactive protein and odds of breast cancer by molecular subtype: analysis of the MEND study. Oncotarget 2021; 12:1230-1242. [PMID: 34194621 PMCID: PMC8238238 DOI: 10.18632/oncotarget.27991] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 06/02/2021] [Indexed: 12/24/2022] Open
Abstract
Breast cancer (BC) in Nigeria is characterized by disproportionately aggressive molecular subtypes. C-reactive protein (CRP) is associated with risk and aggressiveness for several types of cancer. We examined the association of high-sensitivity CRP (hsCRP) with odds of BC by molecular subtype among Nigerian women. Among 296 newly diagnosed BC cases and 259 healthy controls, multivariable logistic regression models were used to estimate adjusted odds ratios (aOR) and 95% confidence intervals (CI) for the association between hsCRP and odds of BC overall and by molecular subtype (luminal A, luminal B, HER2-enriched and triple-negative or TNBC). High hsCRP (> 3 mg/L) was observed in 57% of cases and 31% of controls and was associated with 4 times the odds of BC (aOR: 4.43; 95% CI: 2.56, 7.66) after adjusting for socio-demographic, reproductive, and clinical variables. This association persisted regardless of menopausal status and body mass index (BMI) category. High hsCRP was associated with increased odds of TNBC (aOR: 3.32; 95% CI: 1.07, 10.35), luminal A BC (aOR: 4.03; 95% CI: 1.29, 12.64), and HER2-enriched BC (aOR: 6.27; 95% CI: 1.69, 23.25). Future studies are necessary in this population to further evaluate a potential role for CRP as a predictive biomarker for BC.
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Affiliation(s)
- Anjali Gupta
- Trinity College of Arts and Sciences, Duke University, Durham, NC, USA
- Department of Population Health Sciences, School of Medicine, Duke University, Durham, NC, USA
| | - Taofik Oyekunle
- Department of Population Health Sciences, School of Medicine, Duke University, Durham, NC, USA
| | - Omolola Salako
- College of Medicine & Lagos University Teaching Hospital, University of Lagos, Lagos State, Nigeria
| | - Adetola Daramola
- College of Medicine & Lagos University Teaching Hospital, University of Lagos, Lagos State, Nigeria
| | - Olusegun Alatise
- Obafemi Awolowo University Teaching Hospital, Ile-Ife, Osun State, Nigeria
| | - Gabriel Ogun
- University College Hospital, University of Ibadan, Ibadan, Oyo State, Nigeria
| | | | - April Deveaux
- Department of Population Health Sciences, School of Medicine, Duke University, Durham, NC, USA
| | - Veeral Saraiya
- Department of Epidemiology, UNC Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Allison Hall
- Department of Pathology, School of Medicine, Duke University, Durham, NC, USA
| | - Omobolaji Ayandipo
- University College Hospital, University of Ibadan, Ibadan, Oyo State, Nigeria
| | - Thomas Olajide
- College of Medicine & Lagos University Teaching Hospital, University of Lagos, Lagos State, Nigeria
| | | | - Olukayode Arowolo
- Obafemi Awolowo University Teaching Hospital, Ile-Ife, Osun State, Nigeria
| | - Adewale Adisa
- Obafemi Awolowo University Teaching Hospital, Ile-Ife, Osun State, Nigeria
| | - Oludolapo Afuwape
- University College Hospital, University of Ibadan, Ibadan, Oyo State, Nigeria
| | - Aralola Olusanya
- University College Hospital, University of Ibadan, Ibadan, Oyo State, Nigeria
| | - Aderemi Adegoke
- Our Lady of Apostle Catholic Hospital, Ibadan, Oyo State, Nigeria
| | - Trygve O. Tollefsbol
- Department of Biology, College of Arts and Sciences, University of Alabama at Birmingham, AL, USA
| | - Donna Arnett
- College of Public Health, University of Kentucky, Lexington, KY, USA
| | | | | | | | - Tomi Akinyemiju
- Department of Population Health Sciences, School of Medicine, Duke University, Durham, NC, USA
- Duke Cancer Institute, School of Medicine, Duke University, Durham, NC, USA
- Duke Global Health Institute, Duke University, Durham, NC, USA
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7
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Gonzalo-Encabo P, McNeil J, Pérez-López A, Valades D, Courneya KS, Friedenreich CM. Weight Regain and Breast Cancer-Related Biomarkers Following an Exercise Intervention in Postmenopausal Women. Cancer Epidemiol Biomarkers Prev 2021; 30:1260-1269. [PMID: 33737300 DOI: 10.1158/1055-9965.epi-20-1652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 02/04/2021] [Accepted: 03/08/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Epidemiologic studies have reported associations between weight fluctuations and postmenopausal breast cancer risk; however, the biological markers involved in this association are unknown. This study aimed to explore the associations between breast cancer-related biomarkers and weight regain following exercise-induced weight loss. METHODS From the 400 participants included in the Breast Cancer and Exercise Trial in Alberta, a total of 214 lost weight during the intervention and had follow-up blood samples, body composition, and covariate measurements. Outcomes were measured at baseline, 12 months (end of the study), and 24 months (follow-up). RESULTS During follow-up, weight regain was 1.80 kg [95% confidence interval (CI): -0.40-3.90], and was significantly associated with increases in estradiol [treatment effect ratio (TER) = 1.03; 95% CI, 1.01-1.04], estrone (TER = 1.02; 95% CI, 1.01-1.03), free estradiol (TER = 1.04; 95% CI, 1.02-1.05), the homeostatic model assessment for insulin resistance (TER = 1.03; 95% CI, 1.02-1.05), and insulin (TER = 1.03; 95% CI, 1.01-1.04), and decreases in sex hormone-binding globulin (SHBG; TER = 0.98; 95% CI, 0.97-0.99) levels. Nonstatistically significant associations were found for glucose and C-reactive protein. Furthermore, a statistically significant linear trend of increasing levels for all biomarkers, and decreasing SHBG, across weight regain categories was found. CONCLUSIONS These results suggest that weight regain following exercise-induced weight loss is associated with breast cancer-related biomarker changes in postmenopausal women. IMPACT These findings provide evidence to support the importance of developing effective strategies to prevent weight regain and, consequently, decrease postmenopausal breast cancer risk via changes in adiposity-related biomarkers.
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Affiliation(s)
- Paola Gonzalo-Encabo
- Department of Cancer Epidemiology and Prevention Research, Cancer Care Alberta, Alberta Health Services, Calgary, Alberta, Canada
- Department of Biomedical Sciences, Area of Sport and Physical Education (GRIGEDE), University of Alcalá, Alcalá de Henares, Madrid, Spain
- Department of Medicine and Medical Specialties, Faculty of Medicine and Health Sciences, University of Alcalá, Alcalá de Henares, Madrid, Spain
| | - Jessica McNeil
- Department of Cancer Epidemiology and Prevention Research, Cancer Care Alberta, Alberta Health Services, Calgary, Alberta, Canada
- Department of Kinesiology, School of Health and Human Sciences, University of North Carolina Greensboro, Greensboro, North Carolina, United States of America
| | - Alberto Pérez-López
- Department of Biomedical Sciences, Area of Sport and Physical Education (GRIGEDE), University of Alcalá, Alcalá de Henares, Madrid, Spain
| | - David Valades
- Department of Biomedical Sciences, Area of Sport and Physical Education (GRIGEDE), University of Alcalá, Alcalá de Henares, Madrid, Spain
| | - Kerry S Courneya
- Faculty of Kinesiology, Sport and Recreation, University of Alberta, Edmonton, Alberta, Canada
| | - Christine M Friedenreich
- Department of Cancer Epidemiology and Prevention Research, Cancer Care Alberta, Alberta Health Services, Calgary, Alberta, Canada.
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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8
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Arthur RS, Dannenberg AJ, Rohan TE. The association of prediagnostic circulating levels of cardiometabolic markers, testosterone and sex hormone-binding globulin with risk of breast cancer among normal weight postmenopausal women in the UK Biobank. Int J Cancer 2021; 149:42-57. [PMID: 33567105 DOI: 10.1002/ijc.33508] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 01/07/2021] [Accepted: 02/03/2021] [Indexed: 01/22/2023]
Abstract
Emerging evidence suggests that normal weight postmenopausal women with a relative excess of body fat are at increased breast cancer risk. However, little is known about the associations between obesity-related blood markers and risk of breast cancer among these individuals. In this prospective study comprising 58 629 normal weight postmenopausal women (body mass index between 18.5 kg/m2 and 24.9 kg/m2 ) who were enrolled in the UK Biobank cohort between 2006 and 2010, we examined the associations of glycated hemoglobin, triglycerides, high-density lipoprotein cholesterol, C-reactive protein (CRP), testosterone and sex hormone-binding globulin (SHBG) with risk of breast cancer. A total of 1268 postmenopausal breast cancer cases were ascertained during a median follow-up period of 7 years. Women with CRP, total testosterone and free testosterone (FT) levels in the highest quintile had increased risk of breast cancer compared to those in the lowest quintile (HRQ5 vs Q1 : 1.35, 95% confidence interval [CI]: 1.12-1.63, HR Q5 vs Q1 : 1.47, 95% CI: 1.20-1.80 and HR Q5 vs Q1 : 1.53, 95% CI: 1.23-1.90, respectively), whereas those with SHBG in the highest quintile had reduced risk (HR Q5 vs Q1 : 0.70, 95% CI: 0.56-0.88). These associations were attenuated but persisted after additional adjustment for BMI, fat mass index (whole body fat mass [kg]/height [m2 ]) or waist circumference and after mutual adjustment for testosterone, CRP and/or SHBG. Our study suggests that the risk of postmenopausal breast cancer among normal weight women is increased in association with relatively high levels of CRP and testosterone and with relatively low levels of SHBG.
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Affiliation(s)
- Rhonda S Arthur
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Andrew J Dannenberg
- Division of Gastroenterology and Hepatology, Department of Medicine, Weill Cornell Medical College, New York, New York, USA
| | - Thomas E Rohan
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, USA
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9
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Michels N, van Aart C, Morisse J, Mullee A, Huybrechts I. Chronic inflammation towards cancer incidence: A systematic review and meta-analysis of epidemiological studies. Crit Rev Oncol Hematol 2021; 157:103177. [PMID: 33264718 DOI: 10.1016/j.critrevonc.2020.103177] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 10/26/2020] [Accepted: 11/09/2020] [Indexed: 12/17/2022] Open
Abstract
This systematic review and meta-analysis provides epidemiological data on the relationship between chronic inflammation, as measured by inflammatory blood parameters, and cancer incidence. Two independent researchers searched PubMed, Web Of Science and Embase databases until October 2020. In vitro studies, animal studies, studies with chronically-ill subjects or cross-sectional studies were excluded. Quality was assessed with the Newcastle-Ottawa scale. The 59 nested case-control, 6 nested case-cohort and 42 prospective cohort studies considered 119 different inflammatory markers (top three: CRP, fibrinogen and IL6) and 26 cancer types (top five: colorectal, lung, breast, overall and prostate cancer). Nineteen meta-analyses resulted in ten significant positive associations: CRP-breast (OR = 1.23[1.05-1.43];HR = 1.14[1.01-1.28)), CRP-colorectal (OR = 1.34[1.11-1.60]), CRP-lung (HR = 2.03[1.59-2.60]), fibrinogen-lung (OR = 2.56[1.86-3.54]), IL6-lung (OR = 1.41[1.12-1.78]), CRP-ovarian (OR = 1.41[1.10-1.80]), CRP-prostate (HR = 1.09[1.03-1.15]), CRP-overall (HR = 1.35[1.16-1.57]) and fibrinogen-overall (OR = 1.22[1.07-1.39]). Study quality improvements can be done by better verification of inflammatory status (more than one baseline measurement of one parameter), adjusting for important confounders and ensuring long-term follow-up.
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Affiliation(s)
- Nathalie Michels
- Department of Public Health and Primary Care, Ghent University, Belgium.
| | - Carola van Aart
- Department of Public Health and Primary Care, Ghent University, Belgium
| | - Jens Morisse
- Department of Public Health and Primary Care, Ghent University, Belgium
| | - Amy Mullee
- UCD Institute of Food and Health, Dublin, Ireland
| | - Inge Huybrechts
- International Agency for Research on Cancer, Nutrition and Metabolism Section, Lyon, France
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10
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Hart PC, Rajab IM, Alebraheem M, Potempa LA. C-Reactive Protein and Cancer-Diagnostic and Therapeutic Insights. Front Immunol 2020; 11:595835. [PMID: 33324413 PMCID: PMC7727277 DOI: 10.3389/fimmu.2020.595835] [Citation(s) in RCA: 90] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 10/07/2020] [Indexed: 01/08/2023] Open
Abstract
Cancer disease describes any pathology involving uncontrolled cell growth. As cells duplicate, they can remain localized in defined tissues, forming tumor masses and altering their microenvironmental niche, or they can disseminate throughout the body in a metastatic process affecting multiple tissues and organs. As tumors grow and metastasize, they affect normal tissue integrity and homeostasis which signals the body to trigger the acute phase inflammatory response. C-reactive protein (CRP) is a predominant protein of the acute phase response; its blood levels have long been used as a minimally invasive index of any ongoing inflammatory response, including that occurring in cancer. Its diagnostic significance in assessing disease progression or remission, however, remains undefined. By considering the recent understanding that CRP exists in multiple isoforms with distinct biological activities, a unified model is advanced that describes the relevance of CRP as a mediator of host defense responses in cancer. CRP in its monomeric, modified isoform (mCRP) modulates inflammatory responses by inserting into activated cell membranes and stimulating platelet and leukocyte responses associated with acute phase responses to tumor growth. It also binds components of the extracellular matrix in involved tissues. Conversely, CRP in its pentameric isoform (pCRP), which is the form quantified in diagnostic measurements of CRP, is notably less bioactive with weak anti-inflammatory bioactivity. Its accumulation in blood is associated with a continuous, low-level inflammatory response and is indicative of unresolved and advancing disease, as occurs in cancer. Herein, a novel interpretation of the diagnostic utility of CRP is presented accounting for the unique properties of the CRP isoforms in the context of the developing pro-metastatic tumor microenvironment.
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Affiliation(s)
- Peter C Hart
- Roosevelt University, College of Science, Health and Pharmacy, Schaumburg, IL, United States
| | - Ibraheem M Rajab
- Roosevelt University, College of Science, Health and Pharmacy, Schaumburg, IL, United States
| | - May Alebraheem
- Roosevelt University, College of Science, Health and Pharmacy, Schaumburg, IL, United States
| | - Lawrence A Potempa
- Roosevelt University, College of Science, Health and Pharmacy, Schaumburg, IL, United States
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11
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Stasiewicz B, Wadolowska L, Biernacki M, Slowinska MA, Drozdowski M. Hybrid Dietary-Blood Inflammatory Profiles and Postmenopausal Breast Cancer: A Case-Control Study. Nutrients 2020; 12:nu12113503. [PMID: 33202561 PMCID: PMC7697398 DOI: 10.3390/nu12113503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 11/04/2020] [Accepted: 11/13/2020] [Indexed: 12/24/2022] Open
Abstract
The carcinogenesis process is associated with inflammation, which can be modified by diet. There is limited evidence regarding the inflammatory status and diet in association with breast cancer (BC). The aim of this study was to investigate the association of hybrid dietary-blood inflammatory profiles (HD-BIPs) with postmenopausal breast cancer occurrence. The case-control study was conducted among 420 women (230 controls, 190 primary BC cases) aged 40–79 years from north-eastern Poland. Blood levels of C-reactive protein (CRP), interleukin-6 (IL-6) and leukocyte count were marked in 129 postmenopausal women (82 controls, 47 cases). The 62-item food frequency questionnaire (FFQ-6) was used to the dietary data collection. Two HD-BIPs were found using the Principal Component Analysis (PCA). The “Pro-healthy/Neutral-inflammatory” profile was characterized by the frequent consumption of wholemeal cereals/coarse groats, legumes, vegetables, fruits, nuts/seeds and fish. The “Unhealthy/Pro-inflammatory” profile was characterized by the frequent consumption of red/processed meats, animal fats, sugar/honey/sweets, refined cereals/fine groats, and an increased concentration of CRP, IL-6 and granulocyte-to-lymphocyte ratio. The lower odds ratio (OR) of breast cancer was associated with the higher adherence to the “Pro-healthy/Neutral-inflammatory” profile (OR = 0.38; 95% Cl: 0.18–0.80; p < 0.01 for the higher level vs. lower level, crude model; OR for one-point score increment: 0.61; 95% Cl: 0.42–0.87; p < 0.01, adjusted model). The higher OR of breast cancer was associated with the higher adherence to the “Unhealthy/Pro-inflammatory” profile (OR = 3.07; 95%Cl: 1.27–7.44; p < 0.05 for the higher level v.s. lower level, adjusted model; OR for one-point score increment: 1.18; 95%Cl: 1.02–1.36; p < 0.05, adjusted model). This study revealed that the consumption of highly processed, high in sugar and animal fat foods should be avoided because this unhealthy diet was positively associated with postmenopausal breast cancer occurrence through its pro-inflammatory potential. Instead, the frequent consumption of low-processed plant foods and fish should be recommended since this pro-healthy diet was inversely associated with the cancer occurrence even though its anti-inflammatory potential has not been confirmed in this study sample.
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Affiliation(s)
- Beata Stasiewicz
- Department of Human Nutrition, Faculty of Food Sciences, University of Warmia and Mazury in Olsztyn, Sloneczna 45f, 10-718 Olsztyn, Poland; (L.W.); (M.A.S.)
- Correspondence: ; Tel.: +48-895245518
| | - Lidia Wadolowska
- Department of Human Nutrition, Faculty of Food Sciences, University of Warmia and Mazury in Olsztyn, Sloneczna 45f, 10-718 Olsztyn, Poland; (L.W.); (M.A.S.)
| | - Maciej Biernacki
- Department of Surgery, University of Warmia and Mazury in Olsztyn, 11-041 Olsztyn, Poland;
| | - Malgorzata Anna Slowinska
- Department of Human Nutrition, Faculty of Food Sciences, University of Warmia and Mazury in Olsztyn, Sloneczna 45f, 10-718 Olsztyn, Poland; (L.W.); (M.A.S.)
| | - Marek Drozdowski
- Department of Psychology and Sociology of Health and Public Health, School of Public Health, University of Warmia and Mazury in Olsztyn, 11-041 Olsztyn, Poland;
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12
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Price TR, Friedenreich CM, Robson PJ, Li H, Brenner DR. High-sensitivity C-reactive protein, hemoglobin A1c and breast cancer risk: a nested case-control study from Alberta's Tomorrow Project cohort. Cancer Causes Control 2020; 31:1057-1068. [PMID: 32959132 DOI: 10.1007/s10552-020-01329-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Accepted: 07/24/2020] [Indexed: 12/14/2022]
Abstract
PURPOSE Our aim is to examine the associations between high-sensitivity C-reactive protein (hsCRP) and hemoglobin A1c (HbA1c), common biomarkers of inflammation and insulin resistance, respectively, with breast cancer risk, while adjusting for measures of excess body size. METHODS We conducted a nested case-control study within the Alberta's Tomorrow Project cohort (Alberta, Canada) including 197 incident breast cancer cases and 394 matched controls. The sample population included both pre- and postmenopausal women. Serum concentrations of hsCRP and HbA1c were measured from blood samples collected at baseline, along with anthropometric measurements, general health and lifestyle data. Conditional logistic regression was used to evaluate associations between hsCRP, HbA1c, and breast cancer risk adjusted for excess body size (body fat percentage) and other risk factors for breast cancer. RESULTS Higher concentrations of hsCRP were associated with elevated breast cancer risk (odds ratio [OR] 1.27; 95% confidence interval [95% CI] 1.03-1.55). The observed associations were unchanged with adjustment for body fat percentage. Higher HbA1c concentrations were not significantly associated with an increased breast cancer risk (OR 1.22; 95% CI 0.17-8.75). CONCLUSION These data suggest that hsCRP may be associated with elevated breast cancer risk, independent of excess body size. However, elevated concentrations of HbA1c did not appear to increase breast cancer risk in apparently healthy women.
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Affiliation(s)
- Tiffany R Price
- Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Christine M Friedenreich
- Department of Cancer Epidemiology and Prevention Research, Alberta Health Services, Calgary, AB, Canada
| | - Paula J Robson
- Cancer Research & Analytics, CancerControl Alberta, Alberta Health Services, Edmonton, AB, Canada
| | - Haocheng Li
- Department of Mathematics and Statistics, University of Calgary, Calgary, AB, Canada
| | - Darren R Brenner
- Department of Cancer Epidemiology and Prevention Research, Alberta Health Services, Calgary, AB, Canada.
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13
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Jung SY, Scott PA, Papp JC, Sobel EM, Pellegrini M, Yu H, Han S, Zhang ZF. Genome-wide Association Analysis of Proinflammatory Cytokines and Gene-lifestyle Interaction for Invasive Breast Cancer Risk: The WHI dbGaP Study. Cancer Prev Res (Phila) 2020; 14:41-54. [PMID: 32928877 DOI: 10.1158/1940-6207.capr-20-0256] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 07/21/2020] [Accepted: 08/25/2020] [Indexed: 12/11/2022]
Abstract
Immune-related etiologic pathways to influence invasive breast cancer risk may interact with lifestyle factors, but the interrelated molecular genetic pathways are incompletely characterized. We used data from the Women's Health Initiative Database for Genotypes and Phenotypes Study including 16,088 postmenopausal women, a population highly susceptible to inflammation, obesity, and increased risk for breast cancer. With 21,784,812 common autosomal single-nucleotide polymorphisms (SNP), we conducted a genome-wide association (GWA) gene-environment interaction (G × E) analysis in six independent GWA Studies for proinflammatory cytokines [IL6 and C-reactive protein (CRP)] and their gene-lifestyle interactions. Subsequently, we tested for the association of the GWA SNPs with breast cancer risk. In women overall and stratified by obesity status (body mass index, waist circumference, and waist-to-hip ratio) and obesity-related lifestyle factors (exercise and high-fat diet), 88 GWA SNPs in 10 loci were associated with proinflammatory cytokines: 3 associated with IL6 (1 index SNP in MAPK1 and 1 independent SNP in DEC1); 85 with CRP (3 index SNPs in CRPP1, CRP, RP11-419N10.5, HNF1A-AS1, HNF1A, and C1q2orf43; and two independent SNPs in APOE and APOC1). Of those, 27 in HNF1A-AS1, HNF1A, and C1q2orf43 displayed significantly increased risk for breast cancer. We found a number of novel top markers for CRP and IL6, which interacted with obesity factors. A substantial proportion of those SNPs' susceptibility influenced breast cancer risk. Our findings may contribute to better understanding of genetic associations between pro-inflammation and cancer and suggest intervention strategies for women who carry the risk genotypes, reducing breast cancer risk. PREVENTION RELEVANCE: The top GWA-SNPs associated with pro-inflammatory biomarkers have implications for breast carcinogenesis by interacting with obesity factors. Our findings may suggest interventions for women who carry the inflammatory-risk genotypes to reduce breast cancer risk.
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Affiliation(s)
- Su Yon Jung
- Translational Sciences Section, Jonsson Comprehensive Cancer Center, School of Nursing, University of California, Los Angeles, Los Angeles, California.
| | - Peter A Scott
- Department of Ecology and Evolutionary Biology, University of California, Los Angeles, Los Angeles, California
| | - Jeanette C Papp
- Department of Human Genetics, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Eric M Sobel
- Department of Human Genetics, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California.,Department of Computational Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Matteo Pellegrini
- Department of Molecular, Cell and Developmental Biology, Life Sciences Division, University of California, Los Angeles, Los Angeles, California
| | - Herbert Yu
- Cancer Epidemiology Program, University of Hawaii Cancer Center, Honolulu, Hawaii
| | - Sihao Han
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, California
| | - Zuo-Feng Zhang
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, California.,Center for Human Nutrition, David Geffen School of Medicine, University of California, Los Angeles, California
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14
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Kehm RD, McDonald JA, Fenton SE, Kavanaugh-Lynch M, Leung KA, McKenzie KE, Mandelblatt JS, Terry MB. Inflammatory Biomarkers and Breast Cancer Risk: A Systematic Review of the Evidence and Future Potential for Intervention Research. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17155445. [PMID: 32731638 PMCID: PMC7432395 DOI: 10.3390/ijerph17155445] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 07/16/2020] [Accepted: 07/24/2020] [Indexed: 12/18/2022]
Abstract
Measuring systemic chronic inflammatory markers in the blood may be one way of understanding the role of inflammation in breast cancer risk, and might provide an intermediate outcome marker in prevention studies. Here, we present the results of a systematic review of prospective epidemiologic studies that examined associations between systemic inflammatory biomarkers measured in blood and breast cancer risk. From 1 January 2014 to 20 April 2020, we identified 18 unique studies (from 16 publications) that examined the association of systemic inflammatory biomarkers measured in blood with breast cancer risk using prospectively collected epidemiologic data. Only one marker, C-reactive protein, was studied extensively (measured in 13 of the 16 publications), and had some evidence of a positive association with breast cancer risk. Evidence associating other inflammatory biomarkers and more comprehensive panels of markers with the development of breast cancer is limited. Future prospective evidence from expanded panels of systemic blood inflammatory biomarkers is needed to establish strong and independent links with breast cancer risk, along with mechanistic studies to understand inflammatory pathways and demonstrate how breast tissue responds to chronic inflammation. This knowledge could ultimately support the development and evaluation of mechanistically driven interventions to reduce inflammation and prevent breast cancer.
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Affiliation(s)
- Rebecca D. Kehm
- Department of Epidemiology, Mailman School of Public Health, Columbia University, 722 W 168th St, New York, NY 10032, USA; (R.D.K.); (J.A.M.)
| | - Jasmine A. McDonald
- Department of Epidemiology, Mailman School of Public Health, Columbia University, 722 W 168th St, New York, NY 10032, USA; (R.D.K.); (J.A.M.)
- Herbert Irving Comprehensive Cancer Center, Columbia University Medical Center, 1130 St Nicholas Ave, New York, NY 10032, USA
| | - Suzanne E. Fenton
- National Toxicology Program Laboratory, National Institute of Environmental Health Sciences, Research Triangle Park, 111 TW Alexander Drive, Durham, NC 27709, USA;
| | - Marion Kavanaugh-Lynch
- California Breast Cancer Research Program, University of California, 300 Lakeside Drive, Oakland, CA 94612, USA; (M.K.-L.); (K.E.M.)
| | | | - Katherine E. McKenzie
- California Breast Cancer Research Program, University of California, 300 Lakeside Drive, Oakland, CA 94612, USA; (M.K.-L.); (K.E.M.)
| | - Jeanne S. Mandelblatt
- Department of Oncology, Cancer Prevention and Control Program, Georgetown-Lombardi Comprehensive Cancer Center, Georgetown University, 3800 Reservoir Rd. NW, Washington, DC 20057, USA
- Correspondence: (J.S.M.); (M.B.T.)
| | - Mary Beth Terry
- Department of Epidemiology, Mailman School of Public Health, Columbia University, 722 W 168th St, New York, NY 10032, USA; (R.D.K.); (J.A.M.)
- Herbert Irving Comprehensive Cancer Center, Columbia University Medical Center, 1130 St Nicholas Ave, New York, NY 10032, USA
- Correspondence: (J.S.M.); (M.B.T.)
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15
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DuPré NC, Heng YJ, Raby BA, Glass K, Hart JE, Chu JH, Askew C, Eliassen AH, Hankinson SE, Kraft P, Laden F, Tamimi RM. Involvement of fine particulate matter exposure with gene expression pathways in breast tumor and adjacent-normal breast tissue. ENVIRONMENTAL RESEARCH 2020; 186:109535. [PMID: 32668536 PMCID: PMC7368092 DOI: 10.1016/j.envres.2020.109535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 03/18/2020] [Accepted: 04/12/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Fine particulate matter (PM2.5) has been associated with breast cancer specific mortality, particularly for women with Stage I cancer. We examined the biological pathways that are perturbed by PM2.5 exposures by analyzing gene expression measurements from breast tissue specimens. METHODS The Nurses' Health Studies (NHS and NHSII) are prospective cohorts with archival breast tissue specimens from breast cancer cases. Global gene expression data were ascertained with the Affymetrix Glue Human Transcriptome Array 3.0. PM2.5 was estimated using spatio-temporal models linked to participants' home addresses. All analyses were performed separately in tumor (n = 591) and adjacent-normal (n = 497) samples, and stratified by estrogen receptor (ER) status and stage. We used multivariable linear regression, gene-set enrichment analyses (GSEA), and the least squares kernel machine (LSKM) to assess whether 3-year cumulative average pre-diagnosis PM2.5 exposure was associated with breast-tissue gene expression pathways among predominately Stage I and II women (90.7%) and postmenopausal (81.2%) women. Replication samples (tumor, n = 245; adjacent-normal, n = 165) were measured on Affymetrix Human Transcriptome Array (HTA 2.0). RESULTS Overall, no pathways in the tumor area were significantly associated with PM2.5 exposure. Among 272 adjacent-normal samples from Stage I ER-positive women, PM2.5 was associated with perturbations in the oxidative phosphorylation, protein secretion, and mTORC1 signaling pathways (GSEA and LSKM p-values <0.05); however, results were not replicated in a small set of replication samples (n = 80). CONCLUSIONS PM2.5 was generally not associated with breast tissue gene expression though was suggested to perturb oxidative phosphorylation and regulation of proteins and cellular signaling in adjacent-normal breast tissue. More research is needed on the biological role of PM2.5 that influences breast tumor progression.
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Affiliation(s)
- Natalie C DuPré
- Channing Division of Network Medicine, Brigham & Women's Hospital and Harvard Medical School, Boston, MA, USA; Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA; Department of Epidemiology and Population Health, University of Louisville School of Public Health and Information Sciences, Louisville, KY, USA.
| | - Yujing J Heng
- Department of Pathology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Cancer Research Institute, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Benjamin A Raby
- Channing Division of Network Medicine, Brigham & Women's Hospital and Harvard Medical School, Boston, MA, USA; Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Kimberly Glass
- Channing Division of Network Medicine, Brigham & Women's Hospital and Harvard Medical School, Boston, MA, USA; Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, MA, 02215, USA; Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, 02215, USA
| | - Jaime E Hart
- Channing Division of Network Medicine, Brigham & Women's Hospital and Harvard Medical School, Boston, MA, USA; Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Jen-Hwa Chu
- Section of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Catherine Askew
- Department of Biostatistics and Epidemiology, School of Public Health and Health Sciences, University of Massachusetts Amherst, Amherst, MA, USA
| | - A Heather Eliassen
- Channing Division of Network Medicine, Brigham & Women's Hospital and Harvard Medical School, Boston, MA, USA; Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Susan E Hankinson
- Channing Division of Network Medicine, Brigham & Women's Hospital and Harvard Medical School, Boston, MA, USA; Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA; Department of Biostatistics and Epidemiology, School of Public Health and Health Sciences, University of Massachusetts Amherst, Amherst, MA, USA
| | - Peter Kraft
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA; Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, 02215, USA
| | - Francine Laden
- Channing Division of Network Medicine, Brigham & Women's Hospital and Harvard Medical School, Boston, MA, USA; Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA; Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Rulla M Tamimi
- Channing Division of Network Medicine, Brigham & Women's Hospital and Harvard Medical School, Boston, MA, USA; Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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16
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Wareham NE, Li Q, Sengeløv H, Da Cunha-Bang C, Gustafsson F, Heilmann C, Perch M, Rasmussen A, Sørensen SS, Mocroft A, Lundgren JD. "Risk of de novo or secondary cancer after solid organ or allogeneic haematopoietic stem cell transplantation". J Cancer Res Clin Oncol 2019; 145:3125-3135. [PMID: 31587105 DOI: 10.1007/s00432-019-03039-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 09/25/2019] [Indexed: 12/14/2022]
Abstract
PURPOSE Solid organ (SOT) and allogeneic haematopoietic stem cell (HSCT) transplant recipients have elevated risks of de novo or secondary cancer. We explored risk factors hereof. METHODS Among SOT and HSCT between January 2004 and December 2014, standardised incidence ratio (SIR) of de novo/secondary cancer compared with the Danish population was determined and risk factors were identified using Poisson regression. RESULTS During a median of 3.4 (IQR 1.3-6.4) and 2.6 (0.8-5.4) person-years (PY) after SOT and HSCT, a total of 212/1656 (13%) and 75/992 (8%) persons developed cancer; SIR 3.61 (3.0-4.3) and 2.2 (1.6-3.0), resp.). SIR correlated with younger age and was highest for skin and haematological cancers for both types of transplantation. Within the cohort, cancer was associated with older age (adjusted incidence rate ratio > 50 vs ≤ 19 years, among SOT and HSCT: 9.4 (3.4-25.7) and 25.4 (5.1-126.0), resp.) and current elevated C-reactive protein (CRP) (≥ 10 vs < 10 mg/L: 2.5 (1.8-3.4) and 2.3 (1.4-3.9), resp.), but neither with prior cancer nor type of immunosuppressants. CONCLUSION Rates of de novo or secondary cancers are elevated in both SOT and HSCT compared with the general population and mainly for skin and haematological cancers. Among transplant recipients, older age and current elevated CRP are risk factors.
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Affiliation(s)
- Neval E Wareham
- CHIP, Department of Infectious Diseases, Centre for Cardiac, Pulmonary and Infectious Diseases Vascular, University of Copenhagen, Rigshospitalet, Section 2100, Blegdamsvej 9, 2100 Copenhagen, Copenhagen Ø, Denmark.
| | - Qiuju Li
- Centre for Clinical Research, Epidemiology, Modelling and Evaluation (CREME), University College London, London, UK
| | - Henrik Sengeløv
- Department of Haematology, Rigshospitalet, Copenhagen, Denmark
| | | | - Finn Gustafsson
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
| | | | - Michael Perch
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
| | - Allan Rasmussen
- Department of Surgical Gastroenterology, Rigshospitalet, Copenhagen, Denmark
| | | | - Amanda Mocroft
- Centre for Clinical Research, Epidemiology, Modelling and Evaluation (CREME), University College London, London, UK
| | - Jens D Lundgren
- CHIP, Department of Infectious Diseases, Centre for Cardiac, Pulmonary and Infectious Diseases Vascular, University of Copenhagen, Rigshospitalet, Section 2100, Blegdamsvej 9, 2100 Copenhagen, Copenhagen Ø, Denmark
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17
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Amin N, Shafabakhsh R, Reiter RJ, Asemi Z. Melatonin is an appropriate candidate for breast cancer treatment: Based on known molecular mechanisms. J Cell Biochem 2019; 120:12208-12215. [PMID: 31041825 DOI: 10.1002/jcb.28832] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 03/19/2019] [Indexed: 12/12/2022]
Abstract
Breast cancer is the most prevalent cancer and one of the most important causes of death in women throughout the world. Breast cancer risk factors include smoking, alcohol consumption, personal and family history, hypertension, and hormone therapy, long-term use of nonsteroidal anti-inflammatory drugs and tobacco usage. Surgery, chemotherapy, radiotherapy, immunotherapy, and neoadjuvant therapy are the current means for breast cancer treatment. Despite hormonal agents and chemotherapy, which have beneficial effects on lowering breast cancer death rate, the reaction of different people to these treatments is still a challenging point. Melatonin (N-acetyl-5-methoxy tryptamine) is a methoxy indole compound that is mainly secreted by the pineal gland at night; it is as an antioxidant, anti-inflammatory, and oncostatic agent. On the basis of recent studies, melatonin has antitumor properties on different cancer types and it may suppress cancer development in vitro and as well as in animal models. It is suggested that melatonin inhibits the development of breast cancer by various mechanisms. This paper summarizes the roles of melatonin in breast cancer treatment from the aspect of its molecular actions.
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Affiliation(s)
- Negin Amin
- Research Center for Biochemistry and Nutrition in Metabolic Diseases, Kashan University of Medical Sciences, Kashan, Iran
| | - Rana Shafabakhsh
- Research Center for Biochemistry and Nutrition in Metabolic Diseases, Kashan University of Medical Sciences, Kashan, Iran
| | - Russel J Reiter
- Department of Cellular and Structural Biology, University of Texas Health Science Center, San Antonio, Texas
| | - Zatollah Asemi
- Research Center for Biochemistry and Nutrition in Metabolic Diseases, Kashan University of Medical Sciences, Kashan, Iran
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18
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Huang WQ, Long WQ, Mo XF, Zhang NQ, Luo H, Lin FY, Huang J, Zhang CX. Direct and indirect associations between dietary magnesium intake and breast cancer risk. Sci Rep 2019; 9:5764. [PMID: 30962499 PMCID: PMC6453912 DOI: 10.1038/s41598-019-42282-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Accepted: 03/27/2019] [Indexed: 01/07/2023] Open
Abstract
This study aimed to explore the effect of dietary magnesium intake on breast cancer risk both directly and indirectly via its effect on inflammatory markers C-reactive protein (CRP) and interleukin-6 (IL-6). This case-control study recruited 1050 case patients and 1229 control subjects. Inflammatory marker levels of 322 cases and 322 controls, randomly selected, were measured using ELISA, and data on dietary magnesium intake were collected using a food frequency questionnaire. Multivariable logistic regression was used to estimate the odds ratio (OR) and 95% confidence interval (CI), and path analysis was used to investigate the mediating effect. A higher magnesium intake was associated with a lower breast cancer risk (adjusted OR = 0.80, 95% CI = 0.65, 0.99). A positive association was found between the CRP level and breast cancer risk (adjusted OR = 1.43, 95% CI = 1.02-2.01). However, IL-6 was not found to be associated with breast cancer risk. Path analysis revealed that dietary magnesium affected breast cancer risk both directly and indirectly by influencing the CRP level. The results indicate that a direct negative association and an indirect association through influencing the CRP level were observed between dietary magnesium intake and breast cancer risk.
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Affiliation(s)
- Wu-Qing Huang
- Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, 510080, China
- Guangdong Provincial Key Laboratory of Food, Nutrition and Health, School of Public Health, Sun Yat-sen University, Guangzhou, 510080, China
| | - Wei-Qing Long
- Department of Clinical Laboratory, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510080, China
| | - Xiong-Fei Mo
- Department of Vascular Surgery, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510080, China
| | - Nai-Qi Zhang
- Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, 510080, China
| | - Hong Luo
- Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, 510080, China
| | - Fang-Yu Lin
- Nursing Department, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510080, China
| | - Jing Huang
- Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, 510080, China
| | - Cai-Xia Zhang
- Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, 510080, China.
- Guangdong Provincial Key Laboratory of Food, Nutrition and Health, School of Public Health, Sun Yat-sen University, Guangzhou, 510080, China.
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19
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Gathirua-Mwangi WG, Song Y, Monahan PO, Champion VL, Zollinger TW. Associations of metabolic syndrome and C-reactive protein with mortality from total cancer, obesity-linked cancers and breast cancer among women in NHANES III. Int J Cancer 2018; 143:535-542. [PMID: 29488212 DOI: 10.1002/ijc.31344] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 02/10/2018] [Accepted: 02/21/2018] [Indexed: 12/11/2022]
Abstract
Although metabolic syndrome (MetS) is a prognostic factor for cancer occurrence, the association of MetS and cancer mortality remains unclear. The purpose of this study was to evaluate whether MetS, components of MetS and C-reactive protein (CRP) are associated with cancer mortality in women. A total of 400 cancer deaths, with 140 deaths from obesity-linked-cancers (OLCas), [breast (BCa), colorectal, pancreatic and endometrial], linked through the National Death Index, were identified from 10,104 eligible subjects aged ≥18 years. Cox proportional hazards regression was used to estimate multivariable-adjusted hazard ratios (HR) for cancer mortality. MetS was associated with increased deaths for total cancer [HR = 1.33, 95% confidence interval (CI) 1.04-1.70] and BCa [HR = 2.1, 95% CI, 1.09-4.11]. The risk of total cancer [HR = 1.7, 95% CI, 1.12-2.68], OLCas [HR = 2.1, 95% CI, 1.00-4.37] and BCa [HR = 3.8, 95% CI, 1.34-10.91] mortality was highest for women with all MetS components abnormal, compared to those without MetS. Linear associations of blood-pressure [HR = 2.5, 1.02-6.12, Quartile (Q) 4 vs Q1, p trend = 0.004] and blood-glucose [HR = 2.2, 1.04-4.60, Q4 vs. Q1, p trend = 0.04] with total-OLCas mortality were observed. A threefold increased risk of BCa mortality was observed for women with enlarged waist circumference, ≥100.9 cm, [HR = 3.5, 1.14-10.51, p trend = 0.008] and in those with increased blood glucose, ≥101 mg/dL, [HR = 3.2, 1.11-9.20, p trend = 0.03] compared to those in Q1. None of the components of MetS were associated with total-cancer mortality. CRP was not associated with cancer mortality. In conclusion, MetS is associated with total-cancer and breast-cancer mortality, with waist circumference, blood pressure and blood glucose as independent predictors of OLCas and BCa mortality.
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Affiliation(s)
- Wambui G Gathirua-Mwangi
- Center for Nursing Research, School of Nursing, Indiana University, Indianapolis, IN.,Department of Epidemiology, Richard M. Fairbanks School of Public Health, Indiana University, Indianapolis, IN
| | - Yiqing Song
- Department of Epidemiology, Richard M. Fairbanks School of Public Health, Indiana University, Indianapolis, IN
| | - Patrick O Monahan
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN
| | - Victoria L Champion
- Center for Nursing Research, School of Nursing, Indiana University, Indianapolis, IN
| | - Terrell W Zollinger
- Center for Nursing Research, School of Nursing, Indiana University, Indianapolis, IN
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