Opium Use and Risk of Pancreatic Cancer: A Prospective Cohort Study

Incidence and risk factors of pancreatic cancer during 15 years follow-up in the Golestan Cohort Study in Iran

BACKGROUND

Cancer is one of the main causes of death in the worldwide. Pancreatic Cancer (PC) is prevalent in developed and increasing in developing countries. PC is important because of its low survival rate, high fatality, and increasing incidence. Therefore, identifying risk factors to prevent its development is necessary. This study aimed to determine incidence of PC and its risk factors in the Golestan Cohort Study (GCS) in Iran.

METHOD

This study is a prospective population-based cohort study in the frame of GCS with 15 years of follow-up for PC. GCS was launched in the Golestan province of Iran with 50045 participants who were 40 to 75 years old. variables included: age, gender, education status, smoking, alcohol consumption, opium usage, type of blood group, dyslipidemia, body mass index (BMI), waist circumference (WC), family history (FH) of PC, ethnicity, and history of diabetes mellitus (DM).

RESULT

Among 50045 participants of GCS during 15 years of follow up, 100 people were diagnosed PC. PC incidence was 0.2%. Age-standardized incidence rate (ASR) of PC in the study population was 11.12 per 100,000 person-years. People with age ≥60 years were 46, in 50-59 years old group were 36, and 18 of them were <50 years (p<0.001). The smoking rate in PC group was 27% (p<0.01). Univariate model of cox regression analysis showed age 50-59, ≥60 years compared to <50 years [HR:3.006, 95%CI (1.707-5.294), p<0.001], [HR: 6.727, 95% CI (3.899-11.608), p<0.001], male gender [HR:1.541, 95%CI (1.041-2.281), p = 0.031], opium use [HR:1.436, 95% CI (0.887-2.324), p = 0.141], and smoking [HR:1.884, 95%CI (1.211-2.929), p = 0.005] were predictors for PC. In the multivariate model after adjusting, age 50-59 [HR:2.99, 95% CI (1.698-5.265), p<0.001], and ≥60 years [HR: 6.564, 95% CI (3.797-11.346), p<0.001] was the only predictor for PC.

CONCLUSION

This study revealed an incidence of PC 0.2% in GCS in Iran. Main risk factor for PC was older age.

Prevalence of tobacco use among cancer patients in Iran: a systematic review and meta-analysis

BACKGROUND

The prevalence of tobacco use among various cancer types in Iran remains a significant concern, necessitating a comprehensive analysis to understand the extent and patterns of consumption. This study aimed to systematically review and analyze existing literature to delineate the prevalence of tobacco use across different cancer types in Iran, thereby providing a robust basis for future interventions and policy formulations.

METHODS

Adhering to the PRISMA guidelines, we conducted a systematic review and meta-analysis of literature available in PubMed and Scopus databases. The initial search identified 351 records, out of which 44 studies were selected based on their relevance and design. These studies spanned various time frames, starting from the 2001s up until 2022, and encompassed diverse geographical locations and cancer types in Iran. To avoid bias and potential data overlap, we opted to incorporate a single comprehensive study from the Golestan Cohort, encompassing all data, while excluding 10 other studies. Our final analysis incorporated data from 34 studies, which accounted for 15,425 patients and 5,890 reported smokers. Statistical analyses were performed to calculate the overall proportion of tobacco consumption and to conduct subgroup analyses based on different variables such as cancer types, gender, geographical locations, and types of tobacco used.

RESULTS

The analysis revealed a substantial prevalence of tobacco use among cancer patients in Iran, with an overall consumption rate of 43%. This rate varied significantly, ranging from 10 to 88% across individual studies. Subgroup analyses further highlighted disparities in tobacco consumption rates across different demographics, geographic areas, and cancer types. Notably, the 'ever' smokers category exhibited the highest prevalence of tobacco use. The study also identified a worrying trend of high cigarette smoking rates, along with variable consumption patterns of other forms of tobacco, including waterpipe, 'Naas', and 'Pipe'.

CONCLUSIONS

This systematic review and meta-analysis underscores a significant association between tobacco consumption and various cancer types in Iran, with a prevalence rate among cancer patients being three times higher than the average Iranian population. The findings indicate substantial heterogeneity in tobacco use patterns, emphasizing the need for targeted interventions to address this pressing health issue. The study serves as a critical resource for shaping future policies and strategies aimed at curbing tobacco use and mitigating its adverse effects on cancer prevalence in Iran.

Promoter Methylation of Two HOXA9 and NISCH Genes in Opium Users

BACKGROUND

Opiate abuse has been critically increased in the world, especially in Iran. Owing to the association of opiate use with multiple human cancers and neurological disorders, seeking for genetic and epigenetic effects of opium can pave the way for early diagnosis of major health defects in addicted users. Accordingly, the present study aimed to determine the methylation status of the promoter of two genes, which are actively involved in neurodevelopment and cancer evolution.

METHODS

DNA was isolated from peripheral blood of 28 opium abusers and 19 healthy controls and then subjected to sonication. Sonicated DNAs undergone methylated DNA immunoprecipitation-real time polymerase chain reaction (MeDIP-Real Time PCR) using specific primer pairs designed for HOXA9 and NISCH genes. Obtained data were analyzed using SPSS software.

FINDINGS

HOXA9 and NISCH genes were found to be significantly methylated in addicted users compared to controls (P<0.001) which was significantly associated with the mean of the age regarding HOXA9 gene (P=0.002). Neither opium amount nor duration or route of using was associated with the methylation status of HOXA9 or NISCH genes.

CONCLUSION

Hypermethylation of HOXA9 and NISCH genes as tumor suppressor in opium-addicted individuals can be considered as confirmatory evidence for carcinogenesis of opium. Further studies are required to figure out the role of epigenetic alterations in cancer evolution among opium users.

Aspirin Use and Risk of Pancreatic Ductal Adenocarcinoma: A Large Case-Control Study

BACKGROUND

Pancreatic ductal adenocarcinoma (PDAC) is one of the deadliest cancers, with a five-year survival rate of approximately 5%. The incidence and mortality rates of PDAC are increasing, and the results of medical treatments remain unsatisfactory. Some conflicting evidence suggests that aspirin intake may reduce the risk of PDAC. This study aimed to evaluate the association between regular low-dose aspirin use (80-mg aspirin tablets, 5-7 tablets/week) and the risk of PDAC.

METHODS

This prospective, hospital-based, case-control study was performed on 470 PDAC patients (case group) and 526 sex and age-matched controls, in Tehran, Iran from 2011 to 2018. The participants were interviewed regarding the patterns of aspirin use. Data are expressed as mean±SD or frequency and percentage as appropriate. Differences in frequency between the case and control groups were evaluated based on the analysis of the contingency table (χ2 test and Fisher's exact test). Propensity score models were designed to calculate odds ratios (OR) and 95% confidence intervals (95% CIs) for PDAC with respect to aspirin use, adjusted for age, sex, smoking status, opium use, diabetes mellitus, place of residence, and family history of cancer in first-degree relatives.

RESULTS

About 60% of PDAC patients were male in this study. Also, 25.2% of PDAC patients had a family history of cancer in one of their first-degree relatives, 21.99% were smokers, 13.9% were opium users, and 11.7% had a history of diabetes. Aspirin was used by 22.77% of PDAC patients and 18.25% of the controls. Ever aspirin use (OR: 1.01, 95% CI: 0.89 - 1.14) was not associated with PDAC.

CONCLUSION

Overall, aspirin use was not associated with a reduced risk of PDAC.

The carcinogenicity of opium consumption: a systematic review and meta-analysis

The carcinogenicity of opium consumption was recently evaluated by a Working Group convened by the International Agency for Research on Cancer (IARC). We supplement the recent IARC evaluation by conducting an extended systematic review as well as a quantitative meta-analytic assessment of the role of opium consumption and risk for selected cancers, evaluating in detail various aspects of study quality on meta-analytic findings. We searched the published literature to identify all relevant studies on opium consumption and risk of selected cancers in humans through 31 October, 2022. Meta-relative risks (mRRs) and associated 95% confidence intervals (CIs) were estimated using random-effects models for studies of cancer of the urinary bladder, larynx, lung, oesophagus, pancreas, and stomach. Heterogeneity among studies was assessed using the I2 statistic. We assessed study quality and conducted sensitivity analyses to evaluate the impact of potential reverse causation, protopathic bias, selection bias, information bias, and confounding. In total, 2 prospective cohort studies and 33 case-control studies were included. The overall pooled mRR estimated for 'ever or regular' versus 'never' use of opium ranged from 1.50 (95% CI 1.13-1.99, I2 = 0%, 6 studies) for oesophageal cancer to 7.97 (95% CI 4.79-13.3, I2 = 62%, 7 studies) for laryngeal cancer. Analyses of cumulative opium exposure suggested greater risk of cancer associated with higher opium consumption. Findings were robust in sensitivity analyses excluding studies prone to potential methodological sources of biases and confounding. Findings support an adverse association between opium consumption and cancers of the urinary bladder, larynx, lung, oesophagus, pancreas and stomach.

Opium consumption and pancreatic cancer: A meta-analysis

Pancreatic cancer represents a serious public health problem worldwide. Due to its high mortality, efforts on identifying risk factors are very important since only a few risk-related factors have been well established. The present study aimed to address this knowledge gap by estimating the risk of pancreatic cancer associated with opium use. We performed a thorough literature search of PubMed, Web of Science and Scopus, which yielded 3 case-control and 1 cohort study which were included in the analysis. A meta-analysis was conducted using the DerSimonian and Laird inverse-variance approach as the random effects method. The pooled risk ratio for pancreatic cancer in opium users was significantly increased (RR=1.98, 95 % CI 1.33-2.96, p = 0.0008) compared to never users. Subgroup analyses identified a significantly increased risk for pancreatic cancer in men (RR=1.74, 95 % CI 1.22-2.47, p = 0.002), in persons who consumed both raw teriak and refined shireh opium (RR=4.21, 95 % 1.27-13.93, p = 0.02) and in persons who smoked opium (RR=4.21, 95 % 1.27-13.93, p = 0.02). The findings of this study will help in efforts aimed at prevention of pancreatic cancer. Still, further epidemiological research is necessary.

Interleukin-33 and Soluble ST2 as Potential Biomarkers of Cancer in Opium Users: A Nested Case-Control Study

BACKGROUND

Opium abuse is one of the social hazards in the Middle Eastern countries. Opium consumption attributes to various malignancies. However, the exact molecular mechanism of this correlation still remains unclear. Cancer and inflammation are closely correlated. Interleukin-33 (IL-33) and its receptors, transmembrane ST2 (ST2L) and soluble ST2 (sST2), have been significantly associated with tumorigenicity. The present study aimed to investigate whether IL-33 and sST2 levels serve as cancer biomarkers in opium users.

METHODS

Serum samples were collected from 100 opium users and 100 healthy non-opium users in a nested case-control design. The subjects with over five years of history of opium abuse were enrolled. To assess the incidence of malignancies, the opium users were followed up from 2014 to 2019. Serum levels of IL-33 and sST2 were measured using an ELISA kit. For comparison of IL-33 and sST2 levels between the groups, two-tailed Student's t test and Mann-Whitney U test were utilized, accordingly. Logistic regression analysis was performed to evaluate the influence of confounders on the incidence of cancer.

RESULTS

During the five-year follow-up, eight opium users were diagnosed with cancer. Cancer was developed by 9.3 folds in the individuals abusing opium compared to that in the non-opium users (P=0.040, OR=9.3; 95%CI [1.1-79.4]). Serum levels of IL-33 were found to be significantly higher in the opium users than those in the healthy control group (P=0.001). The sST2 levels were significantly lower in the opium users (P=0.001). The opium users with cancer exhibited significantly higher levels of IL-33 and lower levels of sST2 than the cancer-free ones (P=0.001).

CONCLUSION

Decline in sST2 levels and rise in the level of IL-33 are valuable biomarkers in predicting cancers. Regarding the significant alterations in the levels of these biomarkers in the opium users, as well as those in the opium users diagnosed with cancer, IL-33 and sST2 may serve as potential biomarkers in the early prediction of cancer.

Modifiable and Non-Modifiable Risk Factors for the Development of Non-Hereditary Pancreatic Cancer

Pancreatic cancer is becoming an increasing healthcare concern. Though it is a 14th most common cancer worldwide, its incidence is steadily rising. Results of currently available therapies are still not satisfactory. Therefore, great attention should be put on the identification and reduction of risk factors for pancreatic cancer. A thorough up-to-date review of available data on the impact of well-established and novel risk factors of pancreatic cancer development have been performed. Several risk factors associated with lifestyle have significant impact on the risk of pancreatic cancer (i.e., smoking, obesity, alcohol consumption). Physicians should also be aware of the novel findings suggesting increasing role of microbiome, including viral and bacterial infections, in the development of pancreatic cancer. A growing body of evidence suggest also an increased risk during certain occupational exposures. In general, lifestyle seems to be a major contributor in the development of pancreatic cancer. Special attention should be given to individuals with a vicious cluster consisting of metabolic syndrome, tobacco smoking and alcohol consumption. Physicians should urge patients to comply to healthy diet, cessation of smoking and moderation of alcohol consumption, which may halve pancreatic cancer incidence. Further studies are warranted to explore the potential use of therapeutic approach on novel risk factors (e.g., microbiome).

Novel role of the Mu-opioid receptor in pancreatic cancer: potential link between opioid use and cancer progression

Opioids are the most popular drugs for both acute and chronic pain management. The G protein-coupled mu-opioid receptor (MOR) is the therapeutic target for most clinically used opioids, including morphine. A mounting number of publications suggest a relationship between the MOR and possible cancer progression and recurrence extending to managing chronic cancer pain. In this study, we studied the possible link between opioid use and pancreatic cancer (PC) progression. We found increased MOR expression in murine and human PC cell lines, human PC-derived organoids, and in the undifferentiated or poorly differentiated areas of surgically resected PC tissues. Direct stimulation of MOR by morphine (MOR agonist) caused a significant dose-dependent increase in proliferation, invasion, and levels of stemness markers in PC cells. In a co-culture system, MOR stimulation of macrophages also resulted in increased proliferation of PC cells. MOR overexpression increased proliferation and cancer stemness, whereas knock-down of MOR followed opposite results in the PC cells. Morphine induced chemoresistance to conventional chemotherapeutic agents used for PC treatment. Overall, our results suggest that MOR is expressed in pancreatic cancer and may be involved in tumor progression and chemoresistance.

Opium Use and Cancer Risk: A Comprehensive Systematic Review and Meta-Analysis of Observational Studies

BACKGROUND

Epidemiological studies have reported inconsistent associations between opium use and cancer risk. We therefore conducted a systematic review and meta-analysis to investigate the relationship between opium use and cancer risk.

METHODS

We searched PubMed, Scopus, ISI Web of Knowledge, and Google Scholar until February 2021 and references of retrieved relevant articles for observational studies that reported the risk of cancer in relation to opium use. Random-effects models were used to calculate pooled effect sizes (ESs) as well as 95% confidence intervals (CIs) for the association between opium use and cancer risk by considering opium doses and types, duration of consumption, and routes of opium use.

RESULTS

In total, 21 observational articles, with a total sample size of 64,412 individuals and 6,658 cases of cancer, were included in this systematic review and meta-analysis. Ever opium users, compared with never opium users, had 3.53 times greater risk of overall cancer (pooled ES: 3.53, 95% CI: 2.60-4.79, P ≤ 0.01). This positive association was also seen for some individual types of cancers except for esophageal and colon cancers. Also, we found that higher opium doses and higher duration of consumption were associated with an increased risk of overall and individual types of cancer. However, the associations between opium doses and the risk of head and neck and larynx cancers were not significant. In terms of the routes of opium use, both opium ingestion and smoking were positively associated with the risk of cancer. Regarding opium types, we found that using teriak, but not shireh, could increase the risk of cancer.

CONCLUSIONS

Our findings showed that opium use, particularly in the form of teriak, is a risk factor for cancer.

Diabetes Mellitus, Obesity, and Risk of Pancreatic Ductal Adenocarcinoma: a Large Case-Control Study from Iran

BACKGROUND

Pancreatic cancer (PC) is a deadly, globally increasing cancer. The causes of PC are still insufficiently known, however smoking, diabetes mellitus (DM), and obesity have been identified as risk factors of PC, mostly in the developed countries. We evaluated these risk factors and their contribution to PC among an Iranian population.

METHODS

Cases and controls were selected from patients who were registered to a tertiary gastrointestinal diseases referral hospital in Tehran, Iran, from Jan 2012 to Jan 2018. Information on risk factors was collected by personal interview using a structured questionnaire. Logistic regression models were used to calculate adjusted odds ratios (AORs) and 95% confidence intervals (CIs).

RESULTS

We recruited 470 new patients with histopathological PC diagnosis and 526 sex and age-matched controls. Cigarette-smoking [AOR: 1.65 (1.15-2.38)], opium use [AOR: 1.58 (1.06-2.35)], DM [AOR: 1.99 (1.31-3.02)], and having a history of any cancer in a first-degree family member [AOR: 1.53 (1.14-2.05)] were associated with an increased risk of PC. We did not find an association between obesity [AOR: 0.99 (0.71-1.38)] and PC. Approximately 4.6%, 5.9%, 8.2%, and 10.9% risk of PC were related to cigarette-smoking, opium use, DM, and family history of any cancer, respectively.

CONCLUSION

This study supports that DM is associated with PC risk; however, similar to many studies in Asia, obesity is not associated with PC in Iranians. DM has the highest impact on PC development in Iranian women.

Opium use as an independent risk factor for pancreatic cancer: A case-control study

BACKGROUND

Pancreatic cancer (PC) is ranked as the seventh leading cause of cancer deaths worldwide. The current study was conducted to explore the correlation between the use of opium and its derivatives (opium) and PC in Iran.

METHODS

In this case-control study which was conducted in Kerman province, south east part of Iran; 176 patients with PC, and 352 healthy individuals as the control group were matched in terms of age, sex, and place of residence. A structured questionnaire including questions of opium usage, alcohol usage, cigarette smoking, and diet was used to collect the data. The relation between the use of opium and PC was adjusted for tobacco smoking, education, daily intake of fruit, vegetables, red meat, and hydrogenated fats and analyzed using the conditional logistic regression.

RESULTS

There was a positive relationship between the opium use and the increased risk of PC (Adjusted Odds Ratio (AOR) = 4.33, 95 % CI: 2.09-8.95), which was even stronger than its association with cigarette smoking (AOR = 1.67, 95 % CI: 0.86-3.24), although their difference was not statistically significant. A significant dose-response relation was detected between the use of opium; as the relation was stronger in heavy users (AOR low users = 4.93, 95 % CI: 1.79-13.54 and AOR heavy users = 5.10, 95 % CI: 2.10-12.35). Moreover, PC was higher among participants starting the use of opium at a younger age than those who started opium at an older age (AOR = 8.03, 95 % CI: 3.19-20.23).

CONCLUSION

This study demonstrated that opium use is associated with a high and strong risk of PC as an independent risk factor. Further studies should be done to reduce the use of opium in Iran and other world countries.

Opium Usage and Risk of Head and Neck Cancer: A Systematic Review and Meta-Analysis

INTRODUCTION

Opium is among the most used substance of abuse worldwide. More than 50 million opium users are there worldwide, majority of whom are in Asia. Opium usage have been reported to be associated with cancer. This study aimed to find the association between opium use or abuse and head and neck cancer.

METHODS

A systematic search was conducted in Medline, Scopus, Cochrane, and Google Scholar database for studies published from inception till 1st November 2019. Two authors independently reviewed the studies, did quality assessment, and extracted data in standardized data extraction form. Pooled estimate of OR for risk of head and neck cancer was calculated using random effects model using the method of DerSimonian and Laird, with the estimate of heterogeneity being taken from the inverse-variance model. Subgroup and sensitivity analysis were performed. The protocol was registered in PROSPERO (CRD42020156049).

RESULTS

Fourteen studies were included in data synthesis (11 case control studies and 3 cohort studies). Eleven case control studies were included in synthesizing the results for meta-analysis. Pooled odds ratio for risk of cancer among opium users for the 11-case control study was 3.85 (2.18-6.79). Heterogeneity was high (I-squared=92.0%, Tau-squared=0.88). There was no publication bias in the study. Subgroup analysis showed highest OR for pooled estimate for risk of laryngeal cancer (19.98 (11.04-36.15)).

CONCLUSION

There was almost four-fold rise in risk of head and neck cancer among opium users compared to non-users.

Opium as a carcinogen: A systematic review and meta-analysis

BACKGROUND

Opium and its pyrolysates have been investigated as potential carcinogenic material through several studies in different body systems; however, the results were controversial and no consensus was achieved with this regard. Thus, we aimed to systematically review and meta-analyze all existed evidence regarding association between opium consumption and cancer.

METHODS

Four major electronic databases including ISI Web of Science, PubMed, Scopus, and Embase along with Magiran and SID were searched thoroughly for all published articles from inception up to September 25, 2020. All studies were appraised critically by Newcastle Ottawa Scale (NOS) checklist. Relevant demographic data and the intended results of the selected studies were extracted and their Odds ratios (OR) were pooled using Comprehensive Meta-analysis (CMA). The cumulative risk of opium for developing different cancers was calculated.

FINDINGS

34 studies comprised of 18,230 individuals were entered in our systematic review and finally 32 publications were enrolled in meta-analysis. Overall, using the random effects model, opium consumption was associated with increased rate of malignancies in both minimally[OR = 4.14 95%CI = (3.32-5.15)] and fully adjusted [OR = 4.35 95%CI = (3.36-5.62)] analyses. Moreover, using random effects fully adjusted model, the subgroup analysis revealed increased risk for larynx [OR = 9.58 95%CI = (6.31-14.53)], respiratory [OR = 9.02 95%CI = (6.27-12.96)], head and neck [OR = 8•03 95%CI = (4.03-16.00)], and colon [OR=5.58 95%CI = (3.14-9.92)] cancers for opium consumers compared to non-consumers.

INTERPRETATION

Opium consumption is highly associated with all reported types of cancers, especially in fully adjusted model; however, basic pathophysiology should be further investigated.

FUNDING

None.

Opioid use as a potential risk factor for pancreatic cancer in the United States: An analysis of state and national level databases

Pancreatic cancer (PC) rate is increasing in the U.S. The use of prescription and illicit opioids has continued to rise nationally in recent years as well. Opioids have been shown to have a deleterious effect on multiple types of cancer with recent data suggesting opium use as a risk factor for PC. Using national databases, we tested whether opioid usage pattern over time could explain the state and national-based variations in PC rates in the U.S. Opioid death rate (as a surrogate for prescription and illicit opioid use) was extracted from the CDCs Wonder online data through the Vital Statistics Cooperative Program. Incidence of pancreatic cancer was retrieved from the online CDCs data base gathered from the U.S. Cancer Statistics Working Group. Prevalence of obesity, tobacco and alcohol use was collected from Behavioral risk factor surveillance system. Mixed-effects regression models were used to test the association between levels of PC rate and opioid death/use rates during the years 1999–2016. A rise in PC was seen over time at the national and state levels. Similarly, the opioid death rates increased over time. Among other potential PC risk factors, only obesity prevalence showed an increase during the study period. A state’s opioid death rate at 4 years prior significantly predicted initial incidence of PC (β = 0.1848, p<0.0001) and had a significant effect on the estimated annual change in the rate of PC (β = -.0193,p<0.0001). Opioid use may be an un-identified risk factor contributing to the increasing incidence of PC in the U.S. These novel findings need to be verified by population-based studies.

Is opium use associated with an increased risk of lung cancer? A case-control study

Background

In recent years, lung cancer (LC) incidence has increased in Iran. The use of opium and its derivatives (O&D) has increased as well. This study aimed to investigate the association between the use of O&D and LC incidence.

Methods

In this case-control study conducted in Kerman, Iran; 140 patients with lung cancer and 280 healthy controls matched by age, sex, and place of residence were included. Data, including O&D use, cigarette smoking, alcohol use, and diet, were collected using a structured questionnaire. The relation between the use of O&D and LC was evaluated using conditional logistic regression adjusted for tobacco smoking, education, daily intake of fruit, vegetables, red meat, and hydrogenated fats.

Results

Opium ever-use was associated with an increased risk of LC (Adjusted Odds Ratio (AOR) =5.95, 95% CI: 1.87–18.92). Participants were divided into low and high use groups based on the median of opium use in the control group. A significant dose-response relation was observed between the amount of daily O&D use and LC; and the relation was stronger in high users (AOR _{low users} = 3.81% CI: 1.13–12.77 and OR _{high users} = 9.36, 95% CI: 2.05–42.72). Also, LC was higher among participants starting the use of O&D at younger ages (≤ 41 years old vs never users AOR = 8.64, 95% CI: 1.90–39.18) compared to those who started at an older age (> 41 years old vs never users, AOR = 4.71, 95% CI: 1.38–16.08). The association between opium, and lung cancer among non-smokers was OR: 6.50 (95% CI: 2.89 to 14.64).

Conclusion

The results of this study show that opium use is probably a dose related risk factor for lung cancer.

Opium and risk of gastrointestinal cancer: a case-control study

Background/aim

Gastrointestinal (GI) cancers are among the most common cancers in the world. Many risk factors may increase the chance of developing GI cancers. In recent years, a number of epidemiological studies have reported evidence of carcinogenic effects of opium in humans. This study aimed to investigate the relationship between opium use and GI cancer.

Materials and methods

This case-control study was performed on 95 patients with GI cancer and 190 healthy individuals (matched for age, sex, place of residence, and smoking) in Rafsanjan, Iran, in 2018. Diet information, as well as history of smoking, the use of hookah, opium, and its derivatives was collected using a checklist in interview sessions. Conditional logistic regression was performed to investigate the proposed relationship and to estimate odds ratios (OR).

Results

After adjusting the confounding variables, the use of opium was significantly associated with an increased risk of GI cancer development (OR = 5.95, 95% CI: 2.4–14.9). Also, a dose-response association was found between the cumulative use of opium and the risk of GI cancers. Consumption of fruit and vegetables reduced the risk of developing GI cancers in opium users (OR = 4.9 and 4.7, respectively).

Conclusion

Opium, in the form used among drug users in this area, can lead to an increased risk of GI cancers. Fruit and vegetables have a protective and modifying effect on the risk of GI cancer development caused by opium consumption.

Overexpression of Adiponectin Receptors in Opium Users with and without Cancer

Aim

Opium addiction is a serious public health concern in the Middle East countries causing various illnesses. Opium use is associated with an increased risk of several cancers; however, the underlying mechanisms are not yet fully elucidated. Altered levels of adiponectin and its related main receptors, Adiponectin receptor 1 and 2 (AdipoR1 and AdipoR2) have been associated with several malignancies. Opium users are at risk of various cancers. All together let us to the hypothesis that probable overexpression of AdipoRs in opium users might be linked to the occurrence of cancer in this population.

Methods

One hundred opium users along with 100 healthy non-opium users were enrolled in the study. Opium users were followed up for 5 years (2014–2019) to evaluate the occurrence of malignancies. AdipoR1 and AdipoR2 expressions were measured using a flow cytometry method.

Results

Expression of AdipoR1 and AdipoR2 was significantly higher in opium users compared with the healthy control group (P=0.0001 and 0.0001, respectively). Eight opium users developed cancer during the follow-up period. Subjects abusing opium developed cancer by 8.6 folds comparing to non-opium users (P=0.034; OR=8.6; 95% CI (1.06–70.1)). Expression of these two receptors was significantly higher in opium users developing cancer compared with cancer-free opium (P=0.001).

Conclusion

Considering the significant overexpression of AdipoR1 and AdipoR2 in opium users and in opium users who developed malignancies and the association between upregulation of these receptors in most cancers affecting opium users and assessment of AdipoRs may serve as an early detection tool of cancer in this population.

Pancreatic Cancer in Iran: an Epidemiological Review

PURPOSE

Pancreatic cancer is the seventh cause of death in men in the world and also is one of the most common malignancies worldwide with poor prognosis. Due to the lack of epidemiological aspects of pancreatic cancer in Iran, this study aimed to investigate the epidemiological aspects of pancreatic cancer in Iran.

METHODS

In February 2019, A search was conducted with the keywords "Pancreatic Neoplasm," "Pancreas Neoplasms," "Cancer of Pancreas," "Pancreas Cancer," "Pancreatic Cancer," "Cancer of the Pancreas," and "Iran" in their title or abstract and MeSH. The databases of Medline, Web of Science, Scopus, SID, IranMedex, and Google Scholar were searched. The title and abstract of the papers were reviewed, and articles that addressed the epidemiological aspects of pancreatic cancer were included; in total, 20 full papers were reviewed.

RESULTS

According to studies, the incidence and mortality rate of pancreatic cancer is steadily increasing with age. Actually, men are more likely to develop this carcinoma than women. Smoking, aging, and lifestyle changes are the most important risk factors for pancreatic cancer in Iran. Due to the lack of initial symptoms or a specific marker for early diagnosis of pancreatic cancer, this cancer is detected lately and therefore low survival rate is observed.

CONCLUSION

Mortality and incidence of pancreatic cancer is increasing in Iran. Pancreatic cancer is more common in men than women. Based on the results of this study, pancreatic cancer depends largely on the lifestyle. Survival of pancreatic cancer is low in untreated patients.

Opium use and subsequent incidence of cancer: results from the Golestan Cohort Study

BACKGROUND

Evidence is emerging for a role of opiates in various cancers. In this study, we aimed to investigate the association between regular opium use and cancer incidence.

METHODS

This study was done in a population-based cohort of 50 045 individuals aged 40-75 years from northeast Iran. Data on participant demographics, diet, lifestyle, opium use, and different exposures were collected upon enrolment using validated questionnaires. We used proportional hazards regression models to estimate hazard ratios (HRs) and corresponding 95% CIs for the association between opium use and different cancer types.

FINDINGS

During a median 10 years of follow-up, 1833 participants were diagnosed with cancer. Use of opium was associated with an increased risk of developing all cancers combined (HR 1·40, 95% CI 1·24-1·58), gastrointestinal cancers (1·31, 1·11-1·55), and respiratory cancers (2·28, 1·58-3·30) in a dose-dependent manner (ptrend<0·001). For site-specific cancers, use of opium was associated with an increased risk of developing oesophageal (1·38, 1·06-1·80), gastric (1·36, 1·03-1·79), lung (2·21, 1·44-3·39), bladder (2·86, 1·47-5·55), and laryngeal (2·53, 1·21-5·29) cancers in a dose-dependent manner (ptrend<0·05). Only high-dose opium use was associated with pancreatic cancer (2·66, 1·23-5·74). Ingestion of opium (but not smoking opium) was associated with brain (2·15, 1·00-4·63) and liver (2·46, 1·23-4·95) cancers in a dose-dependent manner (prend<0·01). We observed consistent associations among ever and never tobacco users, men and women, and individuals with lower and higher socioeconomic status.

INTERPRETATION

Opium users have a significantly higher risk of developing cancers in different organs of the respiratory, digestive, and urinary systems and the CNS. The results of this analysis show that regular use of opiates might increase the risk of a range of cancer types.

FUNDING

World Cancer Research Fund International, Cancer Research UK, Tehran University of Medical Sciences, US National Cancer Institute, International Agency for Research on Cancer.

Opiate and Tobacco Use and Exposure to Carcinogens and Toxicants in the Golestan Cohort Study

BACKGROUND

There is little information on human exposure to carcinogens and other toxicants related to opiate use, alone or in combination with tobacco.

METHODS

Among male participants of the Golestan Cohort Study in Northeast Iran, we studied 28 never users of either opiates or tobacco, 33 exclusive cigarette smokers, 23 exclusive users of smoked opiates, and 30 opiate users who also smoked cigarettes (dual users; 21 smoked opiates and 9 ingested them). We quantified urinary concentrations of 39 exposure biomarkers, including tobacco alkaloids, tobacco-specific nitrosamines, polycyclic aromatic hydrocarbons (PAH), and volatile organic compounds (VOC), and used decomposition to parse out the share of the biomarker concentrations explained by opiate use and nicotine dose.

RESULTS

Dual users had the highest concentrations of all biomarkers, but exclusive cigarette smokers and exclusive opiate users had substantially higher concentrations of PAH and VOC biomarkers than never users of either product. Decomposition analysis showed that opiate use contributed a larger part of the PAH concentrations than nicotine dose, and the sum of 2- and 3-hydroxyphenanthrene (∑2,3-phe) resulted almost completely from opiate use. Concentrations of most VOC biomarkers were explained by both nicotine dose and opiate use. Two acrylamide metabolites, a 1,3-butadiene metabolite and a dimethylformamide metabolite, were more strongly explained by opiate use. Acrylamide metabolites and ∑2,3-phe were significantly higher in opiate smokers than opiate eaters; other biomarkers did not vary by the route of opiate intake.

CONCLUSIONS

Both cigarette smokers and opiate users (by smoking or ingestion) were exposed to many toxicants and carcinogens.

IMPACT

This high exposure, particularly among dual opiate and cigarette users, can have a substantial global public health impact.

Opium Use and Head and Neck Cancers: A Matched Case-Control Study in Iran

Background:

Head and Neck (H and N) cancers include malignant tumors of the nasal cavity, pharynx, paranasal sinuses, oral cavity, larynx and salivary glands. Opium use might be related to these cancers. The aim of this study was to investigate the relation between Opium and its Derivatives (O and D) use and the incidence of H and N cancers.

Methods:

In this case-control study conducted in Kerman, 140 patients with H and N cancers and 280 healthy controls (matched for age, gender, and place of residence) were included. Information about their use of O and D, cigarette smoking, alcohol and diet were collected using a structured questionnaire. Conditional logistic regression was used to investigate the relation between variables.

Results:

The use of opioids was associated with an increased risk of HandN cancers (Adjusted OR: 8.13; CI: 4.08-16.2). A significant dose-response relation between O and D use was observed, with high use Adjusted OR=8.91; 95% CI: 4.03-19.65 and low use Adjusted OR=6.52; 95% CI: 3.18- 13.36. This dose-response association was stronger in patients with laryngeal cancer and opioids use, with high use Adjusted OR = 11.17; 95% CI=4.48-28.09 and low use Adjusted OR = 9.46; 95% CI= 3.97- 22.52.

Conclusion:

The results show that opium use can be considered as an important risk factor for H and N cancers. Also in Iran, opium seems to play a more important role than cigarette smoking.

Opioid-induced immunosuppression and carcinogenesis promotion theories create the newest trend in acute and chronic pain pharmacotherapy

Opioids are the main group of pharmacological agents used during the perioperative period and provide a sedative and analgesic component. The observations of opioid consumption in West Europe indicate that this group of drugs is widely used in chronic noncancer pain therapy. Nearly 20 years ago, the first publications indicating that opioids, as an element of perioperative pharmacotherapy in oncologic patients, increase the risk of tumor recurrence and affect further prognosis were presented. The actual publications suggest that there are multifactorial, complex mechanisms underlying the immunological impact and carcinogenesis promotion of opioids and that the intensity varies depending on the type of opioid. There are also questions about the immunosuppressive effects among patients receiving opioids in the treatment of chronic noncancer pain. The aim of the review article is to present information about the action of opioids on the immune system in carcinogenic settings and to define the clinical usefulness of this pharmacological phenomenon.

The global, regional, and national burden of pancreatic cancer and its attributable risk factors in 195 countries and territories, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017

Background

Worldwide, both the incidence and death rates of pancreatic cancer are increasing. Evaluation of pancreatic cancer burden and its global, regional, and national patterns is crucial to policy making and better resource allocation for controlling pancreatic cancer risk factors, developing early detection methods, and providing faster and more effective treatments.

Methods

Vital registration, vital registration sample, and cancer registry data were used to generate mortality, incidence, and disability-adjusted life-years (DALYs) estimates. We used the comparative risk assessment framework to estimate the proportion of deaths attributable to risk factors for pancreatic cancer: smoking, high fasting plasma glucose, and high body-mass index. All of the estimates were reported as counts and age-standardised rates per 100 000 person-years. 95% uncertainty intervals (UIs) were reported for all estimates.

Findings

In 2017, there were 448 000 (95% UI 439 000–456 000) incident cases of pancreatic cancer globally, of which 232 000 (210 000–221 000; 51·9%) were in males. The age-standardised incidence rate was 5·0 (4·9–5·1) per 100 000 person-years in 1990 and increased to 5·7 (5·6–5·8) per 100 000 person-years in 2017. There was a 2·3 times increase in number of deaths for both sexes from 196 000 (193 000–200 000) in 1990 to 441 000 (433 000–449 000) in 2017. There was a 2·1 times increase in DALYs due to pancreatic cancer, increasing from 4·4 million (4·3–4·5) in 1990 to 9·1 million (8·9–9·3) in 2017. The age-standardised death rate of pancreatic cancer was highest in the high-income super-region across all years from 1990 to 2017. In 2017, the highest age-standardised death rates were observed in Greenland (17·4 [15·8–19·0] per 100 000 person-years) and Uruguay (12·1 [10·9–13·5] per 100 000 person-years). These countries also had the highest age-standardised death rates in 1990. Bangladesh (1·9 [1·5–2·3] per 100 000 person-years) had the lowest rate in 2017, and São Tomé and Príncipe (1·3 [1·1–1·5] per 100 000 person-years) had the lowest rate in 1990. The numbers of incident cases and deaths peaked at the ages of 65–69 years for males and at 75–79 years for females. Age-standardised pancreatic cancer deaths worldwide were primarily attributable to smoking (21·1% [18·8–23·7]), high fasting plasma glucose (8·9% [2·1–19·4]), and high body-mass index (6·2% [2·5–11·4]) in 2017.

Interpretation

Globally, the number of deaths, incident cases, and DALYs caused by pancreatic cancer has more than doubled from 1990 to 2017. The increase in incidence of pancreatic cancer is likely to continue as the population ages. Prevention strategies should focus on modifiable risk factors. Development of screening programmes for early detection and more effective treatment strategies for pancreatic cancer are needed.

Funding

Bill & Melinda Gates Foundation.

Individual and Combined Effects of Environmental Risk Factors for Esophageal Cancer Based on Results From the Golestan Cohort Study

BACKGROUND & AIMS

Northeast Iran has one of the highest reported rates of esophageal squamous cell carcinoma (ESCC) worldwide. Decades of investigations in this region have identified some local habits and environmental exposures that increase risk. We analyzed data from the Golestan Cohort Study to determine the individual and combined effects of the major environmental risk factors of ESCC.

METHODS

We performed a population-based cohort of 50,045 individuals, 40 to 75 years old, from urban and rural areas across Northeast Iran. Detailed data on demographics, diet, lifestyle, socioeconomic status, temperature of drinking beverages, and different exposures were collected using validated methods, questionnaires, and physical examinations, from 2004 through 2008. Participants were followed from the date of enrollment to the date of first diagnosis of esophageal cancer, date of death from other causes, or date of last follow-up, through December 31, 2017. Proportional hazards regression models were used to estimate hazard ratios (HRs) and corresponding 95% confidence intervals (CIs) for the association between different exposures and ESCC.

RESULTS

During an average 10 years of follow-up, 317 participants developed ESCC. Opium smoking (HR 1.85; 95% CI 1.18-2.90), drinking hot tea (≥60°C) (HR 1.60; 95% CI 1.15-2.22), low intake of fruits (HR 1.48; 95% CI 1.07-2.05) and vegetables (HR 1.62; 95% CI 1.03-2.56), excessive tooth loss (HR 1.66; 95% CI 1.04-2.64), drinking unpiped water (HR 2.04; 95% CI 1.09-3.81), and exposure to indoor air pollution (HR 1.57; 95% CI 1.08-2.29) were significantly associated with increased risk of ESCC, in a dose-dependent manner. Combined exposure to these risk factors was associated with a stepwise increase in the risk of developing ESCC, reaching a more than 7-fold increase in risk in the highest category. Approximately 75% of the ESCC cases in this region can be attributed to a combination of the identified exposures.

CONCLUSIONS

Analysis of data from the Golestan Cohort Study in Iran identified multiple risk factors for ESCC in this population. Our findings support the hypothesis that the high rates of ESCC are due to a combination of factors, including thermal injury (from hot tea), exposure to polycyclic aromatic hydrocarbons (from opium and indoor air pollution), and nutrient-deficient diets. We also associated ESCC risk with exposure to unpiped water and tooth loss.