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Kristensson FM, Andersson-Assarsson JC, Peltonen M, Jacobson P, Ahlin S, Svensson PA, Sjöholm K, Carlsson LMS, Taube M. Breast Cancer Risk After Bariatric Surgery and Influence of Insulin Levels: A Nonrandomized Controlled Trial. JAMA Surg 2024:2818742. [PMID: 38748431 PMCID: PMC11097101 DOI: 10.1001/jamasurg.2024.1169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 03/08/2024] [Indexed: 05/18/2024]
Abstract
Importance Obesity and insulin are risk factors for breast cancer, and retrospective studies suggest bariatric surgery reduces breast cancer risk in women. However, long-term prospective data on breast cancer risk after bariatric surgery and the role of baseline insulin levels are lacking. Objective To examine if bariatric surgery is associated with breast cancer incidence in women and if treatment benefit is modified by baseline insulin levels. Design, Setting, and Participants The Swedish Obese Subjects (SOS) study was a nonrandomized intervention trial designed to investigate the long-term effects of bariatric surgery on obesity-related mortality and morbidity. Study recruitment took place between 1987 and 2001, and median (IQR) follow-up time was 23.9 years (20.1-27.1) years. The study was conducted at 25 public surgical departments and 480 primary health care centers in Sweden and included 2867 women aged 37 to 60 years and with body mass index 38 or greater (calculated as weight in kilograms divided by height in meters squared). Intervention In the surgery group (n = 1420), 260 women underwent gastric banding, 970 vertical banded gastroplasty, and 190 gastric bypass. The remaining contemporaneously matched control individuals (n = 1447) received usual obesity care. Main Outcome and Measures Breast cancer, the main outcome of this secondary report, was not a predefined outcome in the SOS study. Breast cancer events were identified in the Swedish National Cancer Registry. Results The study population comprised 2867 women with a mean (SD) age of 48.0 (6.2) years. During follow-up, there were 154 breast cancer events, 66 in the surgery group and 88 in the usual care group, and a decreased risk of breast cancer was observed in the bariatric surgery group (hazard ratio [HR], 0.68; 95% CI, 0.49-0.94; P = .019; adjusted HR, 0.72; 95% CI, 0.52-1.01; P = .06). The surgical treatment benefit on breast cancer risk was greater in women with baseline insulin levels above the median 15.8 μIU/L (HR, 0.48; 95% CI, 0.31-0.74; P = .001; adjusted HR, 0.55; 95% CI, 0.35-0.86; P = .008) compared to those below (HR, 0.95; 95% CI, 0.59-1.53; P = .84; adjusted HR, 1.01; 95% CI, 0.61-1.66; P = .97; interaction P = .02). Conclusions and Relevance This prospective clinical trial indicated a reduced risk of breast cancer after bariatric surgery in women with obesity. The surgical treatment benefit was predominantly seen in women with hyperinsulinemia. Trial Registration ClinicalTrials.gov Identifier: NCT01479452.
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Affiliation(s)
- Felipe M. Kristensson
- Institute of Medicine, Department of Molecular and Clinical Medicine, the Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
- Department of Surgery, Region Västra Götaland, Sahlgrenska University Hospital/Östra, Gothenburg, Sweden
| | - Johanna C. Andersson-Assarsson
- Institute of Medicine, Department of Molecular and Clinical Medicine, the Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | | | - Peter Jacobson
- Institute of Medicine, Department of Molecular and Clinical Medicine, the Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Sofie Ahlin
- Institute of Medicine, Department of Molecular and Clinical Medicine, the Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
- Department of Clinical Physiology, Region Västra Götaland, NU Hospital Group, Trollhättan, Sweden
| | - Per-Arne Svensson
- Institute of Medicine, Department of Molecular and Clinical Medicine, the Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
- Institute of Health and Care Sciences, the Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Kajsa Sjöholm
- Institute of Medicine, Department of Molecular and Clinical Medicine, the Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Lena M. S. Carlsson
- Institute of Medicine, Department of Molecular and Clinical Medicine, the Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Magdalena Taube
- Institute of Medicine, Department of Molecular and Clinical Medicine, the Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
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Igwe JK, Surapaneni PK, Cruz E, Cole C, Njoku K, Kim J, Alaribe U, Weze K, Mohammed B. Bariatric Surgery and Inflammatory Bowel Disease: National Trends and Outcomes Associated with Procedural Sleeve Gastrectomy vs Historical Bariatric Surgery Among US Hospitalized Patients 2009-2020. Obes Surg 2023; 33:3472-3486. [PMID: 37804470 PMCID: PMC10603008 DOI: 10.1007/s11695-023-06833-7] [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: 04/18/2023] [Revised: 09/04/2023] [Accepted: 09/15/2023] [Indexed: 10/09/2023]
Abstract
PURPOSE The association between bariatric surgery and IBD-related inpatient outcomes is not well characterized. We report, analyze, and compare inpatient trends and outcomes among encounters with a history of bariatric surgery (Hx-MBS) compared to those receiving bariatric surgery during index admission (PR-MBS) admitted from 2009 to 2020. METHODS Retrospective cohort design: the 2009-2020 National Inpatient Sample (NIS) databases were used to identify hospital encounters with patients aged ≥ 18 years with a history of MBS (Hx-MBS) or with procedure coding indicating MBS procedure (PR-MBS) according to International Classification of Diseases, Ninth (ICD-9-CM/ ICD-9-PCS) or Tenth Revision (ICD-10-CM/ICD-10-PCS) Clinical Modification/Procedure Coding System during index admission (ICD-9-CM: V4586; ICD-10-CM: Z9884; ICD-9-PR: 4382, 4389; ICD-10-PR: 0DB64Z3, 0DB63ZZ). Pearson χ2 analysis, analysis of variance, multivariable regression analyses, and propensity matching on independent variables were conducted to analyze significant associations between variables and for primary outcome inflammatory bowel disease-related admission, and secondary outcomes: diagnosis of nonalcoholic steatohepatitis, nonalcoholic fatty liver disease, or chronic mesenteric ischemia during admission. RESULTS We identified 3,365,784 (76.20%) Hx-MBS hospitalizations and 1,050,900 hospitalizations with PR-MBS (23.80%). Propensity score matching analysis demonstrated significantly higher odds of inflammatory bowel disease, and chronic mesenteric ischemia for Hx-MBS compared to PR-MBS, and significantly lower odds of nonalcoholic steatohepatitis and nonalcoholic fatty liver disease for Hx-MBS compared to PR-MBS. CONCLUSION In our study, Hx-MBS was associated with significantly increased odds of inflammatory bowel disease and other GI pathologies compared to matched controls. The mechanism by which this occurs is unclear. Additional studies are needed to examine these findings.
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Affiliation(s)
- Joseph-Kevin Igwe
- School of Medicine, Department of Medicine, Stanford University, 291 Campus Drive, Stanford, CA, 94305, USA.
- Department of Medicine, Morehouse School of Medicine, 720 Westview Dr. SW, Atlanta, GA, 30313, USA.
- American Heart Association Strategically Focused Research Network on the Science of Diversity in Clinical Trials Research Fellowship, 5001 S Miami Blvd #300, Durham, NC, 27703, USA.
| | | | - Erin Cruz
- School of Medicine, Department of Medicine, Stanford University, 291 Campus Drive, Stanford, CA, 94305, USA
| | - Cedric Cole
- Department of Medicine, Morehouse School of Medicine, 720 Westview Dr. SW, Atlanta, GA, 30313, USA
| | - Kingsley Njoku
- Department of Medicine, Emory University School of Medicine, Atlanta, USA
| | - Jisoo Kim
- Department of Surgery, Texas Tech University Health Sciences Center at El Paso, El Paso, USA
| | - Ugo Alaribe
- School of Medicine, Caribbean Medical University, Willemstad, USA
| | - Kelechi Weze
- Department of Medicine, Morehouse School of Medicine, 720 Westview Dr. SW, Atlanta, GA, 30313, USA
| | - Bilal Mohammed
- Department of Medicine, Ascension Saint Vincent, Indianapolis, USA
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Adams TD, Meeks H, Fraser A, Davidson LE, Holmen J, Newman M, Ibele AR, Playdon M, Hardikar S, Richards N, Hunt SC, Kim J. Long-term cancer outcomes after bariatric surgery. Obesity (Silver Spring) 2023; 31:2386-2397. [PMID: 37605634 PMCID: PMC10449359 DOI: 10.1002/oby.23812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 04/22/2023] [Indexed: 08/23/2023]
Abstract
OBJECTIVE Obesity is associated with increased cancer risk. Because of the substantial and sustained weight loss following bariatric surgery, postsurgical patients are ideal to study the association of weight loss and cancer. METHODS Retrospectively (1982-2019), 21,837 bariatric surgery patients (surgery, 1982-2018) were matched 1:1 by age, sex, and BMI with a nonsurgical comparison group. Procedures included gastric bypass, gastric banding, sleeve gastrectomy, and duodenal switch. Primary outcomes included cancer incidence and mortality, stratified by obesity- and non-obesity-related cancers, sex, cancer stage, and procedure. RESULTS Bariatric surgery patients had a 25% lower risk of developing any cancers compared with a nonsurgical comparison group (hazard ratio [HR] 0.75; 95% CI 0.69-0.81; p < 0.001). Cancer incidence was lower among female (HR 0.67; 95% CI 0.62-0.74; p < 0.001) but not male surgery patients, with the HR lower for females than for males (p < 0.001). Female surgery patients had a 41% lower risk for obesity-related cancers (i.e., breast, ovarian, uterine, and colon) compared with nonsurgical females (HR 0.59; 95% CI 0.52-0.66; p < 0.001). Cancer mortality was significantly lower after surgery in females (HR 0.53; 95% CI 0.44-0.64; p < 0.001). CONCLUSIONS Bariatric surgery was associated with lower all-cancer and obesity-related cancer incidence among female patients. Cancer mortality was significantly lower among females in the surgical group versus the nonsurgical group.
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Affiliation(s)
- Ted D. Adams
- Intermountain Surgical Specialties/Digestive Health Clinical Program, Intermountain Healthcare, Salt Lake City, Utah, USA
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
- Department of Nutrition and Integrative Physiology, University of Utah, Salt Lake City, Utah, USA
| | - Huong Meeks
- Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah, USA
| | - Alison Fraser
- Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah, USA
| | - Lance E. Davidson
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
- Department of Exercise Sciences, Brigham Young University, Provo, Utah, USA
| | - John Holmen
- Intermountain Biorepository, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Michael Newman
- University of Utah Health, Data Science Services, Salt Lake City, Utah, USA
| | - Anna R. Ibele
- Division of General Surgery, Department of General Surgery, University of Utah, Salt Lake City, Utah, USA
| | - Mary Playdon
- Department of Nutrition and Integrative Physiology, University of Utah, Salt Lake City, Utah, USA
- Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah, USA
| | - Sheetal Hardikar
- Population Sciences, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah, USA
| | - Nathan Richards
- Intermountain Surgical Specialties/Digestive Health Clinical Program, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Steven C. Hunt
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
- Department of Genetic Medicine, Weill Cornell Medicine, Doha, Qatar
| | - Jaewhan Kim
- Department of Physical Therapy, College of Health, University of Utah, Salt Lake City, Utah, USA
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Sauter ER. Obesity, metabolic and bariatric surgery, and cancer prevention: what do we need to learn and how do we get there? Surg Obes Relat Dis 2023; 19:781-787. [PMID: 36918327 PMCID: PMC10293064 DOI: 10.1016/j.soard.2023.01.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 01/29/2023] [Indexed: 02/10/2023]
Abstract
Obesity and associated metabolic dysfunction are on the rise in the United States and around the world. Metabolic dysfunction often leads to chronic disease, including cancer. Recent evidence suggests that weight loss among individuals with obesity may decrease cancer risk. Metabolic and bariatric surgery (MBS) leads to greater maximum and sustained weight loss than nonsurgical dietary strategies and demonstrates the most convincing evidence that weight loss lowers cancer risk. Caloric restriction diets combined with GLP-1 receptor agonists demonstrate weight loss intermediate between MBS and other nonsurgical diet strategies so long as individuals consistently take the medication. Weight regain after initial loss is a major problem with all weight loss strategies. To better prevent cancer in individuals with obesity, we need to individualize weight loss strategies, determining what strategy works for a given individual and how to implement it. We need to learn (1) what an individual's impediments to initial and sustained weight loss are; (2) what the optimal weight loss strategy, be it diet modification, diet modification + medication, or MBS followed by diet modification, is; (3) how exercise(s) should be incorporated into weight loss strategies; (4) where medications fit into the treatment strategy of individuals with obesity; and (5) what the mechanisms driving the influence of MBS on cancer risk are. We also need to (6) explore expanding the eligibility of MBS to individuals with a body mass index <35 kg/m2. Answers to these questions require a better understanding of how MBS impacts cancer risk, including in which groups (women versus men, which racial and ethnic groups, which cancers, which MBS procedure) MBS works best to reduce risk. The National Cancer Institute, through new funding opportunities, hopes to advance our understanding of how obesity drives cancer risk and how individuals with obesity can prevent cancer development and, among those with cancer, prevent disease recurrence.
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Affiliation(s)
- Edward R Sauter
- Division of Cancer Prevention, National Cancer Institute, Rockville, Maryland.
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Stroud AM, Coleman MF. Bariatric surgery in the prevention of obesity-associated cancers: mechanistic implications. Surg Obes Relat Dis 2023; 19:772-780. [PMID: 37120355 DOI: 10.1016/j.soard.2023.02.016] [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: 01/30/2023] [Revised: 02/16/2023] [Accepted: 02/16/2023] [Indexed: 03/04/2023]
Abstract
Obesity is associated with an increased risk of at least 13 different cancers, as well as worse cancer outcomes and increased cancer mortality. As rates continue to rise both in the United States and worldwide, obesity is poised to become the leading lifestyle-related risk factor for cancer. Currently, the most effective treatment for patients with severe obesity is bariatric surgery. Multiple cohort studies have demonstrated a consistent >30% decreased risk of cancer incidence in women, but not men, following bariatric surgery. However, the physiologic mechanisms driving obesity-associated cancer and the cancer-protective effect of bariatric surgery are not clearly defined. In this review, we highlight emerging concepts in the mechanistic understanding of obesity-associated cancer. Evidence from both human studies and preclinical animal models suggest that obesity drives carcinogenesis through dysregulation of systemic metabolism, immune dysfunction, and an altered gut microbiome. Additionally, we present related findings to suggest that bariatric surgery may disrupt and even reverse many of these mechanisms. Finally, we discuss the use of preclinical bariatric surgery animal models in the study of cancer biology. The prevention of cancer is emerging as an important indication for bariatric surgery. Elucidating the mechanisms through which bariatric surgery limits carcinogenesis is critical to developing a variety of interventions that intercept obesity-driven cancer.
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Affiliation(s)
- Andrea M Stroud
- Division of Bariatric Surgery, Oregon Health & Science University, Portland, Oregon.
| | - Michael F Coleman
- Department of Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Affiliation(s)
- Anita P Courcoulas
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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