Obesity and Pancreatic Cancer: Recent Progress in Epidemiology, Mechanisms and Bariatric Surgery

Digestive cancers: mechanisms, therapeutics and management

Cancers of the digestive system are major contributors to global cancer-associated morbidity and mortality, accounting for 35% of annual cases of cancer deaths. The etiologies, molecular features, and therapeutic management of these cancer entities are highly heterogeneous and complex. Over the last decade, genomic and functional studies have provided unprecedented insights into the biology of digestive cancers, identifying genetic drivers of tumor progression and key interaction points of tumor cells with the immune system. This knowledge is continuously translated into novel treatment concepts and targets, which are dynamically reshaping the therapeutic landscape of these tumors. In this review, we provide a concise overview of the etiology and molecular pathology of the six most common cancers of the digestive system, including esophageal, gastric, biliary tract, pancreatic, hepatocellular, and colorectal cancers. We comprehensively describe the current stage-dependent pharmacological management of these malignancies, including chemo-, targeted, and immunotherapy. For each cancer entity, we provide an overview of recent therapeutic advancements and research progress. Finally, we describe how novel insights into tumor heterogeneity and immune evasion deepen our understanding of therapy resistance and provide an outlook on innovative therapeutic strategies that will shape the future management of digestive cancers, including CAR-T cell therapy, novel antibody-drug conjugates and targeted therapies.

The Association Between Preoperative Sarcopenia and Sarcopenic Obesity and the Occurrence of Postoperative Complications in Patients Undergoing Pancreaticoduodenectomy for Periampullary Malignancies-A Literature Review

BACKGROUND

Sarcopenia and sarcopenic obesity, perceived as a reflection of cancer-induced cachexia, are often diagnosed in patients with periampullary malignancies. The pathophysiology of those conditions is multifactorial regarding the tumor microenvironment, immunological response, and the relationship to surrounding tissues.

METHODS

The PubMed and SCOPUS databases were systematically searched between November 2023 and December 2023. A total of 254 studies were primarily identified. Regarding the inclusion and exclusion criteria, 26 studies were finally included in the review.

RESULTS

Evaluated papers disclosed that sarcopenia was significantly associated with a higher incidence of postoperative complications, including pancreatic fistula (POPF) type B and C, with the odds ratio (OR) ranging from 2.65 (95%CI 1.43-4.93, p = 0.002) to 4.30 (95%CI 1.15-16.01, p < 0.03). Sarcopenic patients also suffered more often from delayed gastric emptying (DGE) with an OR of 6.04 (95%CI 1.13-32.32, p = 0.036). Infectious complications, postoperative hemorrhage, and intra-abdominal abscesses occurred more often in sarcopenic patients. Surgical complications were also noted more frequently when sarcopenic obesity was present. Preoperative nutritional prehabilitation seems to reduce the risk of postoperative complications. However, more prospective studies are needed.

CONCLUSIONS

Sarcopenia and sarcopenic obesity were associated with a higher incidence of multiple postoperative complications, including POPF (type B and C), DGE, hemorrhage, and infectious complications.

Metabolic-Bariatric Surgery Reduces Pancreatic Cancer Risk: A Meta-Analysis of Over 3.7 Million Adults, Independent of Type 2 Diabetes Status

AIMS

To investigate the impact of Metabolic-Bariatric surgery (MBS) on pancreatic cancer (PCa) risk in individuals with obesity based on type 2 diabetes(T2D) status.

MATERIALS AND METHODS

We conducted a systematic review and meta-analysis following the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines (PROSPERO: CRD42022367749). The primary outcomes were the PCa incidence rates in participants with or without T2D who underwent MBS compared with the control (non-MBS) group. Subgroup analyses based on the MBS types were performed and a random-effects model was employed. Sensitivity analysis was conducted by applying the leave-one-out meta-analysis technique and excluding studies with a short follow-up. Heterogeneity was evaluated using the I2 index and Cochran's Q test. Publication bias was assessed with Egger's test and the risk of bias was assessed with the Cochrane Risk-of-Bias tool.

RESULTS

Twelve studies, with 3,711,243 participants, were included. PCa risk was lower in the MBS group for both T2D and the overall population than in the non-MBS group (RR = 0.46, 95% CI: 0.30-0.71 and RR = 0.21; 95% CI: 0.07-0.57, respectively), with consistent findings after excluding studies with < 3-year follow-up. A favourable impact was also observed in individuals without T2D (RR = 0.56, 95% CI: 0.41-0.78). When comparing the types of MBS versus control, a significant difference was observed for sleeve gastrectomy (SG) (RR = 0.24; 95% CI, 0.12-0.46 for SG and RR = 0.52; 95% CI, 0.25-1.09 for Roux-En-Y bypass). Egger's test showed no indication of publication bias (p = 0.417).

CONCLUSIONS

MBS is associated with reduced PCa risk regardless of T2D, with a more pronounced effect in T2D patients. Additional research is needed to investigate the impact of MBS types on PCa.

Hormone replacement therapy and risk of pancreatic cancer in postmenopausal women: Evidence from the US National Inpatient Sample 2008-2018

Background

Pancreatic cancer is a serious, usually fatal disease and one of the most aggressive malignancies. Research into whether hormone replacement therapy (HRT) might protect against pancreatic cancer has yielded mixed results. This study aimed to investigate the potential association between HRT and the risk of pancreatic cancer in postmenopausal women.

Methods

This population-based, retrospective study extracted data from the US National Inpatient Sample (NIS) 2008-2018. Hospitalized females aged ≥55 years were eligible for inclusion. Associations between HRT, other study variables, and pancreatic cancer diagnosis were determined using univariate and multivariable regression analyses.

Results

After 1:4 matching by age, data of postmenopausal women with (n = 35,309) and without (n = 141,236) HRT were included in the analysis. The mean age was 73.4 years. Multivariable analyses showed that women with HRT had significantly decreased odds of pancreatic cancer (adjusted OR [aOR], 0.69, 95 % CI: 0.53-0.90). Compared to patients without HRT, patients with HRT in the 55-64-year-old group (aOR 0.48, 95 % CI: 0.32-0.74), 65-74-year-old group (aOR 0.49, 95 % CI: 0.34-0.71), non-hypertensive group (aOR 0.55, 95 % CI: 0.38-0.79), and non-hyperlipidemia group (aOR 0.59, 95 % CI: 0.42-0.82) had significantly decreased odds of pancreatic cancer.

Conclusions

In US postmenopausal women, HRT is associated with a reduced risk of pancreatic cancer, especially those aged 55-74 year. Further study is needed to clarify the mechanisms underlying the associations.

Small non-coding RNAs and pancreatic ductal adenocarcinoma: Linking diagnosis, pathogenesis, drug resistance, and therapeutic potential

This review comprehensively investigates the intricate interplay between small non-coding RNAs (sncRNAs) and pancreatic ductal adenocarcinoma (PDAC), a devastating malignancy with limited therapeutic options. Our analysis reveals the pivotal roles of sncRNAs in various facets of PDAC biology, spanning diagnosis, pathogenesis, drug resistance, and therapeutic strategies. sncRNAs have emerged as promising biomarkers for PDAC, demonstrating distinct expression profiles in diseased tissues. sncRNA differential expression patterns, often detectable in bodily fluids, hold potential for early and minimally invasive diagnostic approaches. Furthermore, sncRNAs exhibit intricate involvement in PDAC pathogenesis, regulating critical cellular processes such as proliferation, apoptosis, and metastasis. Additionally, mechanistic insights into sncRNA-mediated pathogenic pathways illuminate novel therapeutic targets and interventions. A significant focus of this review is dedicated to unraveling sncRNA mechanisms underlying drug resistance in PDAC. Understanding these mechanisms at the molecular level is imperative for devising strategies to overcome drug resistance. Exploring the therapeutic landscape, we discuss the potential of sncRNAs as therapeutic agents themselves as their ability to modulate gene expression with high specificity renders them attractive candidates for targeted therapy. In summary, this review integrates current knowledge on sncRNAs in PDAC, offering a holistic perspective on their diagnostic, pathogenic, and therapeutic relevance. By elucidating the roles of sncRNAs in PDAC biology, this review provides valuable insights for the development of novel diagnostic tools and targeted therapeutic approaches, crucial for improving the prognosis of PDAC patients.

Long-term systemic effects of metabolic bariatric surgery: A multidisciplinary perspective

Background

Obesity is a global health crisis with profound implications on various body systems, contributing to a series of comorbidities. Metabolic Bariatric Surgery (MBS) has emerged as an effective treatment option for severe obesity, with significant weight reduction and potential systemic physiological alterations.

Objectives

This narrative review aims to provide a comprehensive analysis of the long-term effects of MBS on a wide array of body systems, including the heart, liver, kidneys, reproductive system, skin, lungs, digestive tract, pancreas, and blood, as well as related cancers of these organs.

Methods

A systematic search was conducted in academic databases (PubMed, ISI Web of Science, and Scopus) for observational studies and reviews published between July 2000 and December 2023, investigating the association between MBS and the subsequent function of different organ systems. High-quality studies were prioritized to ensure reliable evidence synthesis.

Results

MBS has demonstrated favorable outcomes in reducing cardiovascular disease risk, improving cardiac function, and alleviating heart failure symptoms. It has also been associated with improved respiratory function, remission of obstructive sleep apnea, and reduced cancer incidence and mortality. Additionally, MBS has shown benefits in managing gastrointestinal disorders, enhancing glycemic control, and promoting pancreatic beta-cell regeneration in type 2 diabetes mellitus. However, some methods of MBS are associated with a higher risk of cholelithiasis, GERD, and pancreatic exocrine insufficiency.

Conclusion

MBS has far-reaching systemic effects beyond weight loss, offering potential long-term benefits for various organ systems and comorbidities associated with obesity. For many patients with severe obesity, the potential benefits of Metabolic and Bariatric Surgery (MBS) can outweigh the associated risks. However, careful evaluation by a qualified healthcare professional is crucial to determine candidacy and ensure a successful outcome. Further research is needed to fully elucidate the long-term impacts and tailor personalized treatment approaches.

Investigating the causal association between obesity and risk of hepatocellular carcinoma and underlying mechanisms

Obesity is a global health concern and independent risk factor for cancers including hepatocellular carcinoma (HCC). However, evidence on the causal links between obesity and HCC is limited and inconclusive. This study aimed to investigate the causal relationship between obesity-related traits and HCC risk and explore underlying mechanisms using bioinformatics approaches. Two-sample Mendelian randomization analysis was conducted leveraging publicly available genome-wide association study summary data on obesity traits (body mass index, body fat percentage, waist circumference, waist-to-hip ratio, visceral adipose tissue volume) and HCC. Associations of obesity with primary mechanisms (insulin resistance, adipokines, inflammation) and their effects on HCC were examined. Differentially expressed genes in obesity and HCC were identified and functional enrichment analyses were performed. Correlations with tumor microenvironment (TME) and immunotherapy markers were analyzed. Genetically predicted higher body mass index and body fat percentage showed significant causal relationships with increased HCC risk. Overall obesity also demonstrated causal links with insulin resistance, circulating leptin levels, C-reactive protein levels and risk of severe insulin resistant type 2 diabetes. Four differentially expressed genes (ESR1, GCDH, FAHD2A, DCXR) were common in obesity and HCC. Enrichment analyses indicated their roles in processes like RNA capping, viral transcription, IL-17 signaling and endocrine resistance. They exhibited negative correlations with immune cell infiltration and immunotherapy markers in HCC. Overall obesity likely has a causal effect on HCC risk in Europeans, possibly via influencing primary mechanisms. The identified differentially expressed genes may be implicated in obesity-induced hepatocarcinogenesis through regulating cell cycle, inflammation and immune evasion. Further research on precise mechanisms is warranted.

Global Burden of Pancreatic Cancer Attributable to High Body-Mass Index in 204 Countries and Territories, 1990-2019

(1) Background: This study aimed to assess the global burden of pancreatic cancer attributable to a high BMI in 1990-2019. (2) Methods: An ecological study was carried out. Data about deaths and Disability-Adjusted Life Years (DALYs) for pancreatic cancer were extracted from the Global Burden of Disease (GBD) study. The age-standardized rates (ASRs, per 100,000) were presented. In order to determine trends of pancreatic cancer burden, joinpoint regression analysis was used to calculate the average annual percent change (AAPC). (3) Results: The highest ASRs of DALYs of pancreatic cancer were found in the United Arab Emirates (47.5 per 100,000), followed by countries with about 25.0 per 100,000 (such as Hungary, Czechia, and Montenegro). From 1990 to 2019, the ASRs of deaths and DALYs of pancreatic cancer attributable to a high BMI significantly increased (p < 0.001) for both sexes in all ages, and across all SDI quintiles and all GBD regions. The highest fraction of DALYs attributable to a high BMI was found in the United States of America and China (equally about 15.0%), followed by the Russian Federation, India, Germany, and Brazil (about 5.0%, equally). (4) Conclusions: Further analytical epidemiological studies are necessary to elucidate the relationship between pancreatic cancer and a high BMI.

Obesity associated pancreatic ductal adenocarcinoma: Therapeutic challenges

Obesity is a prominent health issue worldwide and directly impacts pancreatic health, with obese individuals exhibiting a significant risk for increasing pancreatic ductal adenocarcinoma (PDAC). Several factors potentially explain the increased risk for the development of PDAC, including obesity-induced chronic inflammation within and outside of the pancreas, development of insulin resistance and metabolic dysfunction, promotion of immune suppression within the pancreas during inflammation, pre- and malignant stages, variations in hormones levels (adiponectin, ghrelin, and leptin) produced from the adipose tissue, and acquisition of somatic mutations in tumor once- and suppressor proteins critical for pancreatic tumorigenesis. In this manuscript, we will explore the broad impact of these obesity-induced risk factors on the development and progression of PDAC, focusing on changes within the tumor microenvironment (TME) as they pertain to prevention, current therapeutic strategies, and future directions for targeting obesity management as they relate to the prevention of pancreatic tumorigenesis.

Gender differences in change of metabolic syndrome status and its components on all-cause and cause-specific mortalities: Over a decade follow-up study

BACKGROUND

Accumulating evidence suggests a close association between metabolic syndrome (MetS) and excess risk of mortality. However, whether the dynamic change of MetS and its components could affect cause-specific mortalities and how this relation could be influenced by gender is yet to be clarified.

METHODS AND RESULTS

In this longitudinal cohort, we entered 4904 Iranian adults>30 years (2820 women) from March-1999 and followed up until December-2018. MetS was determined using the joint interim societies (JIS) criteria. Due to change in MetS status over three years, we divided individuals into MetS-free, MetS-recovery, MetS-developed, and MetS-persistent groups. The same categories were defined for each MetS component. Multivariate Cox regression models were employed to compute the adjusted hazard ratios (HRs) and female-to-male relative HRs (F/M-RHRs) for risk of all-cause, cardiovascular (CV), non-CV, and cancer mortalities. To resolve reverse causation, mortalities during the first three years of follow-up were excluded. Subgroup analysis was conducted for non-diabetic and non-hypertensive participants. During 12.5 years of follow-up, 357 all-cause, 112 CV-, and 79 cancer-mortalities occurred. Compared to MetS-free, MetS-persistent raised all-cause- and CV-mortalities in both genders. Same association was found for non-diabetic (HR = 1.66 (1.03-3.00)) or non-hypertensive (HR = 1.89 (1.09-3.64)) women. Moreover, MetS-persistent women with neither hypertension nor diabetes had increased all-cause mortality risk by 88% (F/M-RHR = 3.99 (1.53-5.58)). Women with stable MetS had excess risk of cancer-mortality by 40% (F/M-RHR = 1.63 (1.02-5.06)). Generally, among both genders, recovery from MetS declined risk of mortality events. Regarding MetS components, persistent elevated fasting plasma glucose (FPG) was related to all-cause mortality in both genders, but with stronger association in women (F/M-RHR = 1.41 (1.11-2.49), and CV-mortality only in women (F/M-RHR = 3.04 (1.02-5.96). Both development and stable status of high blood pressure (BP) increased the risk of CV-mortality merely in women (F/M-RHR = 3.10 (0.60-6.87) and F/M-RHR = 3.24 (1.26-6.11), respectively). Development or recovery from each Triglyceride, HDL-C, and waist circumference variables did not solely affect risk of mortality events in both genders.

CONCLUSION

Stable status of MetS could increase risk of mortalities with an overall stronger association in women. Although elevated BP and FPG are the main drivers for mortality risk, MetS among women could carry the corresponding effect even in absence of hypertension and diabetes.

Elevated Glycated Haemoglobin (HbA1c) Is Associated with an Increased Risk of Pancreatic Ductal Adenocarcinoma: A UK Biobank Cohort Study

BACKGROUND

The role of dysglycaemia as a risk marker for Pancreatic Ductal Adenocarcinoma (PDAC) is uncertain. We investigated the relationship between glycated haemoglobin (HbA1c) and incident PDAC using a retrospective cohort study within the UK Biobank.

METHODS

A study involving 499,804 participants from the UK Biobank study was undertaken. Participants were stratified by diabetes mellitus (DM) status, and then by HbA1c values < 42 mmol/mol, 42-47 mmol/mol, or ≥48 mmol/mol. Cox proportional hazard models were used to describe the association between HbA1c category (with time-varying interactions) and incident PDAC.

RESULTS

PDAC occurred in 1157 participants during 11.6 (10.9-12.3) years follow up [(median (interquartile range)]. In subjects without known DM at baseline, 12 months after recruitment, the adjusted hazard ratios (aHR, 95% CI) for incident PDAC for HbA1c 42-47 mmol/mol compared to HbA1c < 42 mmol/mol (reference group) was 2.10 (1.31-3.37, p = 0.002); and was 8.55 (4.58-15.99, p < 0.001) for HbA1c ≥ 48 mmol/mol. The association between baseline HbA1c and incident PDAC attenuated with increasing duration of time of follow-up to PDAC diagnosis.

CONCLUSIONS

Dysglycaemia detected by elevated HbA1c is associated with an increased risk of PDAC. The strength of the association between elevated HbA1c and incident PDAC is inversely proportional to the time from detecting dysglycaemia but remains significant for at least 60 months following HbA1c testing.

Correlation between pancreatic cancer and metabolic syndrome: A systematic review and meta-analysis

Objective

Pancreatic cancer is a globally frequent cause of death, which can be caused by many factors. This meta-analysis was performed to assess the correlation between pancreatic cancer and metabolic syndrome (MetS).

Methods

Publications were identified by searching PubMed, EMBASE, and the Cochrane Library for studies published until November 2022. Case-control and cohort studies published in English that provided information on the odds ratio (OR), relative risk (RR), or hazard ratio (HR) of metabolic syndrome and pancreatic cancer were included in the meta-analysis. Two researchers separately retrieved the core data from the included Random effects meta-analysis was conducted to summarize the findings. Results were presented as relative risk (RR) and 95% confidence interval (CI).

Results

MetS showed a strong association with an increased risk of developing pancreatic cancer (RR1.34, 95% CI1.23-1.46, P<0.001), and gender differences were also observed (men: RR 1.26, 95% CI 1.03-1.54, P=0.022; women: RR 1.64, 95% CI 1.41-1.90, P< 0.001). Moreover, an increased risk of developing pancreatic cancer was strongly linked to hypertension, poor high-density lipoprotein cholesterol, and hyperglycemia (hypertension: RR 1.10 CI 1.01-1.19, P=0.027; low high-density lipoprotein cholesterol: RR 1.24 CI 1.11-1.38, P<0.001; hyperglycemia: RR 1.55, CI 1.42-1.70, P< 0.001). However, pancreatic cancer was independent of obesity and hypertriglyceridemia (obesity: RR 1.13 CI 0.96-1.32, P=0.151, hypertriglyceridemia: RR 0.96, CI 0.87-1.07, P=0.486).

Conclusions

Although further prospective studies are required for confirmation, this meta-analysis indicated a strong relationship between MetS and pancreatic cancer. Regardless of gender, a greater risk of pancreatic cancer existed in people with MetS. Patients with MetS were more likely to develop pancreatic cancer, regardless of gender. Hypertension, hyperglycemia, and low HDL-c levels may largely account for this association. Further, the prevalence of pancreatic cancer was independent of obesity and hypertriglyceridemia.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42022368980.

The Related Metabolic Diseases and Treatments of Obesity

Obesity is a chronic disease characterized by the abnormal or excessive accumulation of body fat, affecting more than 1 billion people worldwide. Obesity is commonly associated with other metabolic disorders, such as type 2 diabetes, non-alcoholic fatty liver disease, cardiovascular diseases, chronic kidney disease, and cancers. Factors such as a sedentary lifestyle, overnutrition, socioeconomic status, and other environmental and genetic conditions can cause obesity. Many molecules and signaling pathways are involved in the pathogenesis of obesity, such as nuclear factor (NF)-κB, Toll-like receptors (TLRs), adhesion molecules, G protein-coupled receptors (GPCRs), programmed cell death 1 (PD-1)/programmed death-ligand 1 (PD-L1), and sirtuin 1 (SIRT1). Commonly used strategies of obesity management and treatment include exercise and dietary change or restriction for the early stage of obesity, bariatric surgery for server obesity, and Food and Drug Administration (FDA)-approved medicines such as semaglutide and liraglutide that can be used as monotherapy or as a synergistic treatment. In addition, psychological management, especially for patients with obesity and distress, is a good option. Gut microbiota plays an important role in obesity and its comorbidities, and gut microbial reprogramming by fecal microbiota transplantation (FMT), probiotics, prebiotics, or synbiotics shows promising potential in obesity and metabolic syndrome. Many clinical trials are ongoing to evaluate the therapeutic effects of different treatments. Currently, prevention and early treatment of obesity are the best options to prevent its progression to many comorbidities.