Breastfeeding Associations with Childhood Obesity and Body Composition: Findings from a Racially Diverse Maternal-Child Cohort

Background: Studies suggest breastfeeding lowers obesity risk in childhood, but generalizability of existing evidence is limited. We examined associations of breastfeeding with childhood overweight, obesity, and percentage body fat, in a racially diverse maternal-child cohort. Methods: This cross-sectional study included 823 children, ages 4-8 years, enrolled in the Environmental Exposures and Child Health Outcomes (ECHO) cohort, a subset of the National Institute of Child Health and Human Development Fetal Growth Studies cohort. Logistic regression was used to estimate odds ratios and 95% confidence intervals (CIs) for overweight [BMI (kg/m²) 85th to <95th percentile] and obesity (BMI ≥95th percentile) in relation to breastfeeding including duration of exclusive and total breastfeeding. Linear regression was used to evaluate association between breastfeeding and percentage body fat measured by bioelectrical impedance analysis. Results: Fifty-two percent of children were male, 32% non-Hispanic Black, 29% Hispanic, 27% non-Hispanic White, and 13% Asian; 16% were overweight and 13% obese. Six months of exclusive breastfeeding, compared with no breastfeeding, was associated with 60% lower odds of obesity (95% CI 0.18-0.91) adjusting for age, gender, race, socioeconomic status, maternal BMI, and child's activity. Percentage body fat was inversely associated with breastfeeding duration. For none, <6, and ≥6 months of exclusive breastfeeding, adjusted mean percentage body fat was 16.8, 14.5, and 13.4, respectively. Results did not differ by gender, race/ethnicity, or maternal BMI status. Conclusions: Exclusive breastfeeding for the first 6 months of life is inversely and significantly associated with obesity and percentage body fat at ages 4-8 years. These findings support current breastfeeding guidelines.

Factors Associated With Readmission in the United States Following Hospitalization With Coronavirus Disease 2019

BACKGROUND

Patients hospitalized for coronavirus disease 2019 (COVID-19) may experience complications following hospitalization and require readmission. In this analysis, we estimated the rate and risk factors associated with COVID-19-related readmission and inpatient mortality.

METHODS

In this retrospective cohort study, we used deidentified chargemaster data from 297 hospitals across 40 US states on patients hospitalized with COVID-19 from 15 February 2020 through 9 June 2020. Demographics, comorbidities, acute conditions, and clinical characteristics of first hospitalization are summarized. Multivariable logistic regression was used to measure risk factor associations with 30-day readmission and in-hospital mortality.

RESULTS

Among 29 659 patients, 1070 (3.6%) were readmitted. Readmitted patients were more likely to have diabetes, hypertension, cardiovascular disease (CVD), or chronic kidney disease (CKD) vs those not readmitted (P < .0001) and to present on first admission with acute kidney injury (15.6% vs 9.2%), congestive heart failure (6.4% vs 2.4%), or cardiomyopathy (2.1% vs 0.8%) (P < .0001). Higher odds of readmission were observed in patients aged >60 vs 18-40 years (odds ratio [OR], 1.92; 95% confidence interval [CI], 1.48-2.50) and those admitted in the Northeast vs West (OR, 1.43; 95% CI, 1.14-1.79) or South (OR, 1.28; 95% CI, 1.11-1.49). Comorbidities including diabetes (OR, 1.34; 95% CI, 1.12-1.60), CVD (OR, 1.46; 95% CI, 1.23-1.72), CKD stage 1-5 (OR, 1.51; 95% CI, 1.25-1.81), and CKD stage 5 (OR, 2.27; 95% CI, 1.81-2.86) were associated with higher odds of readmission; 12.3% of readmitted patients died during second hospitalization.

CONCLUSIONS

Among this large US population of patients hospitalized with COVID-19, readmission was associated with certain comorbidities and acute conditions during first hospitalization. These findings may inform strategies to mitigate risks of readmission due to COVID-19 complications.

Methodology and Initial Results From a Real-World Observational Cohort of Patients With Inflammatory Bowel Disease: TARGET-IBD

Background

Data on care patterns for inflammatory bowel disease (IBD) from large-scale, diverse clinical cohorts in real-world practice are sparse. We developed a real-world cohort of patients receiving care at academic and community sites, for comparative study of therapies and natural history of IBD.

Methods

We describe novel methodology of central abstraction of clinical data into a real-world IBD registry with patient reported outcomes (PROs). Baseline demographics, clinical characteristics, healthcare utilization, and disease metrics were assessed. Bivariate statistics were used to compare demographic and clinical data by Crohn disease (CD) or ulcerative colitis (UC) and site of care (academic, community).

Results

In 1 year, 1343 IBD patients (60.1% CD, 38.9% UC) were recruited from 27 academic (49.5%) and community (50.5%) sites, exceeding expectations (110% enrolled). Most participants also consented to provide PROs (59.5%) or biosamples (85.7%). Overall, 48.7% of the cohort provided a baseline PRO, and 62.6% provided a biosample. Compared to UC, CD subjects had higher prior (34.1% CD vs 7.7% UC; P < 0.001) and current (72.1% vs 47.9%; P < 0.001) biologic utilization. CD participants from academic sites had more complicated disease than those from community sites (62.5% vs 46.8% stricturing/penetrating; 33.5% vs 27% perianal; 36.8% vs 14.5% prior biologic, respectively). Nearly all (90.4%) participants had endoscopic data of whom 37.7% were in remission. One-year retention was 98.4%.

Conclusions

Centralized data abstraction and electronic PRO capture provided efficient recruitment into a large real-world observational cohort. This novel platform provides a resource for clinical outcomes and comparative effectiveness research in IBD.

Abstract 4235: Race differences in treatment and survival of ovarian cancer

Black women have lower incidence rates of ovarian cancer than white women in the U.S., but their cancers are more often fatal. Factors associated with lower survival among blacks include advanced stage at diagnosis and fewer women receiving a surgery-chemotherapy sequence consistent with national guidelines for treatment of primary ovarian cancer. We examined treatment and survival among 365 white and 95 black ovarian cancer patients captured by the Hollings Cancer Center Cancer Registry in Charleston, S.C. from 2000 to 2015 with the aim of identifying factors to explain observed racial disparities. Outcomes of interest were receipt of a cytoreductive surgery-chemotherapy sequence, with or without neoadjuvant therapy, and overall survival (OS) calculated as months from diagnosis to death. We used unconditional logistic regression to estimate odds ratios (ORs) of black vs. white race associated with receipt of surgery-chemotherapy, controlling for clinical stage, histology, insurance status, smoking status, and severity of comorbidities (none, mild, moderate, moderate-severe, severe), assessed using the age-adjusted Charlson index. For survival comparisons, we plotted Kaplan-Meier curves by race and estimated the death hazard ratio (HR) using Cox proportional hazards regression. We assessed statistical interaction between race and comorbidities using −2 log likelihood tests. Age, stage and histology distributions were similar between blacks and whites; however, white women were more likely than blacks to be current or former smokers (44% vs. 32%) and to have private health insurance (38% vs. 26%), while blacks were more likely to have moderate-severe or severe comorbidities (37% vs. 30%), although differences were not statistically significant. There were significant racial differences in receipt of surgery-chemotherapy (blacks 44% vs. whites 69%, p&lt;0.0001). Women who did not receive a surgery-chemotherapy sequence were 3 times more likely to be black (adjusted OR 3.13, 95% confidence interval (CI) 1.90−5.16), but the disparity was observed only in women with comorbidity as opposed to none (interaction p=0.01). Median OS was 29.3 months among black women and 49.2 months among whites (log rank p&lt;0.001). The survival disadvantage among blacks persisted after controlling for treatment, comorbidities, stage, smoking, and insurance (HR 1.87, 95% CI 1.41−2.48), and no statistical interaction between race and comorbidities was evident (p=0.17). In this study, black women, particularly those with comorbidities, were significantly less likely than whites to receive a surgery-chemotherapy sequence for treatment of ovarian cancer. Black race was associated with an 87% higher fatality rate independent of treatment, stage, comorbidities, and insurance status. More research is needed to understand race-specific reasons for nonadherence to guideline based care and racial disparities in survival after ovarian cancer diagnosis.

Citation Format: Janet S. Hildebrand, Kristin Wallace, Linda E. Kelemen. Race differences in treatment and survival of ovarian cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 4235.

Walking in Relation to Mortality in a Large Prospective Cohort of Older U.S. Adults

INTRODUCTION

Engaging in >150 minutes of moderate-intensity or 75 minutes of vigorous-intensity physical activity weekly is recommended for optimal health. The relationship between walking, the most common activity especially for older adults, and total mortality is not well documented.

METHODS

Data from a large U.S. prospective cohort study including 62,178 men (mean age 70.7 years) and 77,077 women (mean age 68.9 years), among whom 24,688 men and 18,933 women died during 13 years of follow-up (1999-2012), were used to compute multivariable-adjusted hazard rate ratios and 95% CIs for walking as the sole form of activity or adjusted for other moderate- or vigorous-intensity physical activity in relation to total and cause-specific mortality (data analysis 2015-2016).

RESULTS

Inactivity compared with walking only at less than recommended levels was associated with higher all-cause mortality (hazard rate ratio=1.26, 95% CI=1.21, 1.31). Meeting one to two times the recommendations through walking only was associated with lower all-cause mortality (hazard rate ratio=0.80, 95% CI=0.78, 0.83). Associations with walking adjusted for other moderate- or vigorous-intensity physical activity were similar to walking only. Walking was most strongly associated with respiratory disease mortality followed by cardiovascular disease mortality and then cancer mortality.

CONCLUSIONS

In older adults, walking below minimum recommended levels is associated with lower all-cause mortality compared with inactivity. Walking at or above physical activity recommendations is associated with even greater decreased risk. Walking is simple, free, and does not require any training, and thus is an ideal activity for most Americans, especially as they age.

Associations of Coffee Drinking and Cancer Mortality in the Cancer Prevention Study-II

Background: Associations of coffee consumption with cancer mortality are inconsistent for many types of cancer, and confounding by smoking is an important concern.Methods: Cox proportional hazards regression was used to estimate multivariable-adjusted HRs for coffee consumption associated with death from all cancers combined and from specific cancer types among 922,896 Cancer Prevention Study-II participants ages 28-94 years who completed a four-page questionnaire and were cancer free at baseline in 1982.Results: During follow-up through 2012, there were 118,738 cancer-related deaths. There was a nonlinear association between coffee consumption and all-cancer death among current smokers and former smokers and no association among never smokers. Among nonsmokers, a 2 cup/day increase in coffee consumption was inversely associated with death from colorectal [HR = 0.97; 95% confidence interval (CI) 0.95-0.99], liver [HR = 0.92; 95% CI, 0.88-0.96], and female breast (HR = 0.97; 95% CI, 0.94-0.99) cancers, and positively associated with esophageal cancer-related death (HR = 1.07; 95% CI, 1.02-1.12). For head and neck cancer, a nonlinear inverse association was observed starting at 2-3 cups per day (HR = 0.72; 95% CI, 0.55-0.95), with similar associations observed at higher levels of consumption.Conclusions: These findings are consistent with many other studies that suggest coffee drinking is associated with a lower risk of colorectal, liver, female breast, and head and neck cancer. The association of coffee consumption with higher risk of esophageal cancer among nonsmokers in our study should be confirmed.Impact: These results underscore the importance of assessing associations between coffee consumption and cancer mortality by smoking status. Cancer Epidemiol Biomarkers Prev; 26(10); 1477-86. ©2017 AACR.

The American Cancer Society's Cancer Prevention Study 3 (CPS-3): Recruitment, study design, and baseline characteristics

BACKGROUND

Prospective cohort studies contribute importantly to understanding the role of lifestyle, genetic, and other factors in chronic disease etiology.

METHODS

The American Cancer Society (ACS) recruited a new prospective cohort study, Cancer Prevention Study 3 (CPS-3), between 2006 and 2013 from 35 states and Puerto Rico. Enrollment took place primarily at ACS community events and at community enrollment "drives." At enrollment sites, participants completed a brief survey that included an informed consent, identifying information necessary for follow-up, and key exposure information. They also provided a waist measure and a nonfasting blood sample. Most participants also completed a more comprehensive baseline survey at home that included extensive medical, lifestyle, and other information. Participants will be followed for incident cancers through linkage with state cancer registries and for cause-specific mortality through linkage with the National Death Index.

RESULTS

In total, 303,682 participants were enrolled. Of these, 254,650 completed the baseline survey and are considered "fully" enrolled; they will be sent repeat surveys periodically for at least the next 20 years to update exposure information. The remaining participants (n = 49,032) will not be asked to update exposure information but will be followed for outcomes. Twenty-three percent of participants were men, 17.3% reported a race or ethnicity other than "white," and the median age at enrollment was 47 years.

CONCLUSIONS

CPS-3 will be a valuable resource for studies of cancer and other outcomes because of its size; its diversity with respect to age, ethnicity, and geography; and the availability of blood samples and detailed questionnaire information collected over time. Cancer 2017;123:2014-2024. © 2017 American Cancer Society.

Body mass index and all-cause mortality in a large prospective cohort of white and black U.S. Adults

Remaining controversies on the association between body mass index (BMI) and mortality include the effects of smoking and prevalent disease on the association, whether overweight is associated with higher mortality rates, differences in associations by race and the optimal age at which BMI predicts mortality. To assess the relative risk (RR) of mortality by BMI in Whites and Blacks among subgroups defined by smoking, prevalent disease, and age, 891,572 White and 38,119 Black men and women provided height, weight and other information when enrolled in the Cancer Prevention Study II in 1982. Over 28 years of follow-up, there were 434,400 deaths in Whites and 18,702 deaths in Blacks. Cox proportional-hazards regression was used to estimate multivariable-adjusted relative risks (RR) and 95% confidence intervals (CI). Smoking and prevalent disease status significantly modified the BMI-mortality relationship in Whites and Blacks; higher BMI was most strongly associated with higher risk of mortality among never smokers without prevalent disease. All levels of overweight and obesity were associated with a statistically significantly higher risk of mortality compared to the reference category (BMI 22.5-24.9 kg/m2), except among Black women where risk was elevated but not statistically significant in the lower end of overweight. Although absolute mortality rates were higher in Blacks than Whites within each BMI category, relative risks (RRs) were similar between race groups for both men and women (p-heterogeneity by race  = 0.20 for men and 0.23 for women). BMI was most strongly associated with mortality when reported before age 70 years. Results from this study demonstrate for the first time that the BMI-mortality relationship differs for men and women who smoke or have prevalent disease compared to healthy never-smokers. These findings further support recommendations for maintaining a BMI between 20-25 kg/m2 for optimal health and longevity.

Coffee, tea, and fatal oral/pharyngeal cancer in a large prospective US cohort

Epidemiologic studies suggest that coffee intake is associated with reduced risk of oral/pharyngeal cancer. The authors examined associations of caffeinated coffee, decaffeinated coffee, and tea intake with fatal oral/pharyngeal cancer in the Cancer Prevention Study II, a prospective US cohort study begun in 1982 by the American Cancer Society. Among 968,432 men and women who were cancer free at enrollment, 868 deaths due to oral/pharyngeal cancer occurred during 26 years of follow-up. Cox proportional hazards regression was used to estimate multivariable-adjusted relative risk. Intake of >4 cups/day of caffeinated coffee was associated with a 49% lower risk of oral/pharyngeal cancer death relative to no/occasional coffee intake (relative risk = 0.51, 95% confidence interval: 0.40, 0.64) (1 cup/day = 237 ml). A dose-related decline in relative risk was observed with each single cup/day consumed (P(trend) < 0.001). The association was not modified by sex, smoking status, or alcohol use. An inverse association for >2 cups/day of decaffeinated coffee intake was suggested (relative risk = 0.61, 95% confidence interval: 0.37, 1.01). No association was found for tea drinking. In this large prospective study, caffeinated coffee intake was inversely associated with oral/pharyngeal cancer mortality. Research is needed to elucidate biologic mechanisms whereby coffee might help to protect against these often fatal cancers.

Type II diabetes mellitus and the incidence of epithelial ovarian cancer in the cancer prevention study-II nutrition cohort

BACKGROUND

Despite consistent associations of type II diabetes mellitus with hormonally related cancers such as breast and endometrium, the relation between type II diabetes mellitus and ovarian cancer risk is unclear.

METHODS

Associations of type II diabetes mellitus status, duration, and insulin use with epithelial ovarian cancer overall, and with serous and nonserous histologic subtypes were examined in the Cancer Prevention Study-II Nutrition Cohort, a prospective study of U.S. men and women predominantly aged 50 years and older. Between 1992 and 2007, 524 incident epithelial ovarian cancer cases were identified among 63,440 postmenopausal women. Multivariable-adjusted relative risks (RR) and 95% confidence intervals (CI) were computed using extended Cox regression to update diabetes status and bilateral oophorectomy status during follow-up.

RESULTS

Type II diabetes mellitus status (RR = 1.05; 95% CI, 0.75-1.46) and duration were not associated with epithelial ovarian cancer risk. Although not statistically significantly different (P(difference) = 0.39), the RR was higher for type II diabetes mellitus with insulin use (RR = 1.28; 95% CI, 0.74-2.24) than for type II diabetes mellitus without insulin use (RR = 0.96; 95% CI, 0.64-1.43). Diabetes seemed to be more strongly associated with nonserous (RR = 1.41; 95% CI, 0.70-2.85) than serous (RR = 0.71; 95% CI, 0.41-1.23) histologic subtypes.

CONCLUSIONS

Type II diabetes mellitus was not associated with risk of epithelial ovarian cancer, although higher risks with nonserous subtypes and among insulin users cannot be ruled out.

IMPACT

Larger studies are needed to clarify associations of type II diabetes mellitus with or without insulin use with risk of ovarian cancer overall and by histologic subtypes.

Abstract 661: Physical activity, sitting time, and postmenopausal breast cancer risk by histopathologic characteristics in a large US cohort

There is convincing evidence that physical activity is associated with lower risk of postmenopausal breast cancer, likely through its impact on circulating sex hormones, improved insulin sensitivity, and/or weight control. However, the relationship between time spent sitting and breast cancer is not well-defined. Furthermore, it is unclear whether the relationship of physical activity or sitting time with postmenopausal breast cancer varies by histopathologic characteristics of the tumor (defined by stage, histology, or estrogen/progesterone receptor (ER/PR) status), use of postmenopausal hormones (PMH), or body mass index (BMI). Therefore, we examined recreational physical activity and leisure-time spent sitting in relation to breast cancer risk among 73,608 postmenopausal women who were cancer-free and enrolled in the American Cancer Society Cancer Prevention Study II (CPS-II) Nutrition Cohort, a prospective study of cancer incidence and mortality that began in 1992. From 1992-2007, 4,622 incident breast cancer cases were identified. Cox proportional hazards regression modeling was used to compute rate ratios (RR) and 95% confidence intervals (CI) while adjusting for potential confounders including age, race, education, BMI, PMH use, and other breast cancer risk factors. Women who engaged in the highest amount of physical activity (&gt;42 MET-hours/week) had 22% lower risk of breast cancer compared to women with the least activity (0-&lt;7 MET-hours/week) (RR 0.78, 95% CI 0.63-0.95; trend p=0.09). Women who walked an hour per day were 15% less likely to develop breast cancer during follow-up compared to women who walked fewer than 3 hours per week (95% CI 0.76-0.95). Sitting time was not associated with breast cancer risk (RR=0.98, 95% CI 0.89-1.09 for 6+ vs &lt;3 hours/day spent sitting). When examining associations by stage, the association between physical activity and breast cancer risk was only observed for localized breast cancer (RR=0.67, 95% CI 0.51-0.89; trend p=0.03), and not for in situ or regional/distant stage. The association did not differ by histology or ER/PR status. The association between physical activity and risk was not modified by BMI (interaction p=0.73) or by PMH (interaction p=0.74), although the lower RR associated with the highest level of physical activity was noted only in non-users of PMH. These findings provide further evidence that physical activity is associated with lower risk of postmenopausal breast cancer and that the benefits of physical activity do not appear to be limited to any specific subgroup of women.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 661. doi:1538-7445.AM2012-661

Prospective study reveals associations between colorectal cancer and type 2 diabetes mellitus or insulin use in men

BACKGROUND & AIMS

Type 2 diabetes mellitus (DM) is associated with an increased risk of colorectal cancer (CRC); it is not clear if this association varies by sex or other factors. Insulin use might also be associated with CRC risk. We investigated associations of type 2 DM and insulin use with CRC risk.

METHODS

The Cancer Prevention Study II Nutrition Cohort is a prospective study of cancer incidence. In 1992 or 1993, adult participants (n = 184,194) completed a detailed, self-administered questionnaire. Follow-up questionnaires were sent in 1997 and every 2 years thereafter. Cox proportional hazards regression analysis was used to calculate relative risks (RR) and 95% confidence intervals (CI), adjusting for covariates.

RESULTS

After exclusions, 73,312 men and 81,663 women remained in the final analytic cohort; 1567 men (227 with type 2 DM) and 1242 women (108 with type 2 DM) were diagnosed with colon or rectal cancer by 2007. Among men, type 2 DM was associated with increased risk of incident CRC compared to not having type 2 DM (RR: 1.24; 95% CI: 1.08-1.44); risk was higher for participants with type 2 DM using insulin (RR: 1.36; 95% CI: 1.05-1.78), and participants with type 2 DM not using insulin (RR: 1.22, 95% CI: 1.04-1.45). Among women, type 2 DM and insulin use were not associated with risk of incident CRC (RR: 1.01; 95% CI: 0.82-1.23 and RR: 0.95; 95% CI: 0.64-1.41, respectively).

CONCLUSIONS

There is a modest association between type 2 DM and CRC among men, but not women. Insulin use is not associated with a substantially increased risk of CRC.

Colorectal cancer incidence and postmenopausal hormone use by type, recency, and duration in cancer prevention study II

The Women's Health Initiative randomized trials showed a reduction in colorectal cancer risk with the use of estrogen plus progesterone (E + P), but not with estrogen alone (E-only), after intervention periods <7 years. Using data from the Cancer Prevention Study II Nutrition Cohort, we examined associations of colorectal cancer risk with E-only and E + P, including analyses by recency and duration of hormone use. During 13.2 years of follow-up, 776 cases of invasive colorectal cancer occurred among 67,412 postmenopausal women participants. Cox proportional hazards models were used to estimate multivariate-adjusted relative risks (RR) and 95% confidence intervals (95% CI) of colorectal cancer for current and former hormone users according to hormone type and duration of use. Relative to women who never used postmenopausal hormones, current, but not former, use of E-only was associated with a reduced risk of colorectal cancer (RR 0.76; 95% CI, 0.59-0.97). Among current E-only users, duration of use was inversely and linearly associated with risk (P(trend) = 0.01). Use of E-only for <5 years was not associated with reduced risk, whereas use for >or=20 years was associated with a 45% reduction in risk (RR, 0.55; 95% CI, 0.36-0.86). There were no statistically significant associations between E + P and colorectal cancer risk. Our results suggest a strong inverse association of long-term use of E-only with colorectal cancer risk, underscoring the importance of collecting data on duration of hormone use in epidemiologic studies of postmenopausal hormones and risk of disease.