Preventable Incidence and Mortality of Carcinoma Associated With Lifestyle Factors Among White Adults in the United States

Preliminary Effectiveness Study of a Community-Based Wellness Coaching for Cancer Survivors Program

Purpose: Substantial cancer burden may be prevented through lifestyle modifications. The purpose of this study was to determine the preliminary effectiveness of health coaching for the improvement of health, fitness, and overall well-being of cancer survivors in a community setting. Methods: Participants were recruited from Cancer Support Community Delaware locations. Health coaching was provided to people diagnosed with cancer anywhere along the survivorship continuum. Coaches provided 6 individual sessions. Surveys were sent pre- and post-intervention on topics including fitness, eating habits, sleep, perceived stress, anxiety, depression, and quality of life. Results were analyzed using multilevel modeling. Results: 48 participants completed an average of 85% of health coaching sessions. Coaching participants noted improvements in weekly physical activity frequency, including moderate–vigorous physical activity. Increases were found in healthy eating behavior. Participants reported improvements in the quality of their sleep, including changes in sleep duration and sleep efficiency. Significant reductions were found in perceived stress, anxiety, and depression. Importantly, participants reported improved quality of life, particularly in areas of physical and emotional well-being, as well as functional and total well-being. Conclusion: Preliminary findings indicate significant behavior change in measured outcomes and suggest health coaching may be an important tool for cancer survivorship.

Associations of Evolutionary-Concordance Diet and Lifestyle Pattern Scores with Incident, Sporadic Colorectal Adenoma in a Pooled Case-Control Study

Differences in diet and lifestyle relative to those of our Paleolithic-era ancestors may explain current high incidences of chronic diseases, including colorectal cancer (CRC), in Westernized countries. Previously reported evolutionary-concordance diet and lifestyle pattern scores, reflecting closeness of diet and lifestyle patterns to those of Paleolithic-era humans, were associated with lower CRC incidence. Separate and joint associations of the scores with colorectal adenoma among men and women are unknown. To address this, we pooled data from three case-control studies of incident, sporadic colorectal adenomas (n = 771 cases, 1,990 controls), used participants' responses to food frequency and lifestyle questionnaires to calculate evolutionary-concordance diet and lifestyle pattern scores, and estimated the scores' associations with adenomas using multivariable unconditional logistic regression. The multivariable-adjusted odds ratios comparing those in the highest relative to the lowest diet and lifestyle score quintiles were 0.84 (95% confidence interval [CI] 0.62, 1.12; P_trend:0.03) and 0.41 (95% CI 0.29, 0.59; P_trend:<0.0001), respectively. The inverse associations were stronger for high-risk adenomas, and among those with both high relative to those with both low diet and lifestyle scores. These results suggest that more evolutionary-concordant diet and lifestyle patterns, separately and jointly, may be associated with lower risk for incident, sporadic colorectal adenoma.Supplemental data for this article is available online at https://doi.org/10.1080/01635581.2021.2002919 .

A two-front nutritional environment fuels colorectal cancer: perspectives for dietary intervention

Colorectal cancer (CRC) develops and progresses in a nutritional environment comprising a continuously changing luminal cocktail of external dietary and microbial factors on the apical side, and a dynamic host-related pool of systemic factors on the serosal side. In this review, we highlight how this two-front environment influences the bioenergetic status of colonocytes throughout CRC development from (cancer) stem cells to cancer cells in nutrient-rich and nutrient-poor conditions, and eventually to metastatic cells, which, upon entry to the circulation and during metastatic seeding, are forced to metabolically adapt. Furthermore, given the influence of diet on the two-front nutritional environment, we discuss dietary strategies that target the specific metabolic preferences of these cells, with a possible impact on colon cancer cell bioenergetics and CRC outcome.

Current practices in the instruction of lifestyle medicine in medical curricula

OBJECTIVE

A review of current practices of educational interventions for lifestyle medicine was performed to inform the design of interventions with long-term goals of improving patient outcomes.

METHODS

Systematic review of PubMed, MedEdPORTAL, and Cochrane using keywords "lifestyle medicine," "education," "medical students," and "medical school" was done by 3 independent reviewers. Location, learner, curricular hours, focus, outcomes, and impact are reported.

RESULTS

Of 452 identified citations, 32 met criteria. Most studies (81%) were conducted in the U.S. and designed for medical students (72%). Studies focused primarily on nutrition (78%) and exercise (59%). Curricula were delivered on average across 13.7 h. Lectures were used in 53% of papers. The outcomes most commonly studied were satisfaction (66%,), knowledge perception (66%), and reported clinical practices (34%). Intervention impact at level 2b (31%) and level 3 (34%) were most common.

CONCLUSION

Medical educators looking to integrate lifestyle education curriculum should consider current resources as a starting point, especially ones with higher outcome measurements.

PRACTICE IMPLICATIONS

Novel interventions should target lifestyle medicine competencies with equitable distribution among learners using active learning approaches. The authors propose initial efforts focusing on instruction of clinical educators and practicing physicians, with advocacy for increased reimbursement.

A review of physical activity in pancreatic ductal adenocarcinoma: Epidemiology, intervention, animal models, and clinical trials

Pancreatic ductal adenocarcinoma (PDAC) is one of the deadliest types of cancer, and the increasing incidence of PDAC may be related to the prevalence of obesity. Physical activity (PA), a method known to mitigate obesity by increasing total energy expenditure, also modifies multiple cellular pathways associated with cancer hallmarks. Epidemiologic evidence has shown that PA can lower the risk of developing a variety of cancers, reduce some of the detrimental side effects of treatments, and improve patient's quality of life during cancer treatment. However, little is known about the pathways underlying the correlations observed between PA interventions and PDAC. Moreover, there is no standard dose of PA intervention that is ideal for PDAC prevention or as an adjuvant of cancer treatments. In this review, we summarize relevant literature showing how PDAC patients can benefit from PA, the potential of PA as an adjuvant treatment for PDAC, the studies using preclinical models of PDAC to study PA, and the clinical trials to date assessing the effects of PA in PDAC.

OUP accepted manuscript

Background

Methods

Results

Conclusions

Cancer outcomes research - a European challenge Part II: Opportunities and priorities

In Part I of our review of cancer outcome research, we analysed pros and cons of various measures relevant to quantifying the burden of cancer. Based on our recommendations in Part I, we now discuss in Part II opportunities and priorities in four areas of outcome research: primary prevention; early detection screening; treatment; and quality‐of‐life assessment. We recommend the establishment of an infrastructure that facilitates high‐quality research in these areas: (a) progress in primary prevention can be assessed most directly by monitoring cancer incidence although the interpretation of temporal trends is notoriously confounded by numerous factors that complicate causal inference. (b) preventive screening, with the aim to prevent advanced disease, appears to work well in in some tumours but not in others. It will require randomized control trials (RCTs) to quantify benefits and harms although conclusive studies are increasingly difficult to undertake. We therefore propose learning screening programmes (randomization at the time of rolling out population‐based programmes) as the most feasible approach. (c) New therapeutic interventions tailored to the individual patient often require assessment in RCTs with rather complex and dynamic structure, making their design and analyses increasingly challenging but also more suited to be executed as academic, PI‐initiated trials. (d) We next discuss assessment of quality‐of‐life aspects. Quality of life is a neglected component in outcome research with an urgent need for development, validation and standardization. We finally recommend four initiatives that would pave the way for a valid and informative assessment of the goals for improved cancer control in Europe as defined by the European Academy of Cancer Sciences.

Unrestrained eating behavior and risk of mortality: A prospective cohort study

BACKGROUND & AIMS

Unrestrained eating behavior has been thought to be a proxy for diet frequency, timing, and caloric intake. We investigated the association of unrestrained eating with mortality risk in the Nurses' Health Study prospectively.

METHODS

During follow-up (1994-2016), 21,953 deaths were documented among 63,999 eligible participants in analyses of eating anything at any time, 22,120 deaths were documented among 65,839 participants in analyses of no concern with figure change. Hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated using Cox proportional hazards models.

RESULTS

Eating anything at any time was associated with an increased mortality from cancer (overall HR, 95%CI: 1.07, 1.00-1.13; driven by gastrointestinal tract cancer: 1.30, 1.10-1.54) and respiratory disease (1.16, 1.05-1.29), and decreased cardiovascular disease-specific mortality (0.92, 0.86-0.99), compared to those without this behavior; however, no association was observed between this behavior and all-cause mortality (1.02, 0.99-1.05). Women who reported having no concern with figure change experienced higher risk of mortality from all-cause (1.08, 1.05-1.11), cancer (1.08, 1.02-1.14), and respiratory disease (1.18, 1.08-1.30), compared to those not reporting this behavior. Their combined effect was associated with a higher all-cause (1.09, 1.04-1.14), cancer-specific (overall: 1.18, 1.09-1.28; gastrointestinal tract cancer: 1.36, 1.08-1.71; lung cancer: 1.09; 1.04-1.14), and respiratory disease-specific (1.30, 1.13-1.50) mortality, and was inversely associated with cardiovascular disease-specific mortality (0.88, 0.80-0.98), compared to those exhibiting the opposite.

CONCLUSIONS

Unrestrained eating was associated with increased risk of all-cause, cancer-specific (particularly for gastrointestinal tract cancer and lung cancer), and respiratory disease-specific mortality, and decreased risk of cardiovascular disease-specific mortality.

Public awareness of environmental risk factors of cancer and attitude towards its prevention among the Lebanese general population

Introduction

Since the majority of cancers occur as a result of modifiable risk factors, cancer is being seen more as a preventable disease. The primary objective of our study was to assess the level of awareness of environmental risk factors of cancer among the Lebanese general population. The secondary objective focused on identifying the predictors of the preventability of the disease.

Methods

We conducted a cross-sectional study between June and July 2020. An online questionnaire was used to collect data pertaining to the knowledge of environmental risk factors of cancer, source of information and personal practice of the participants. Bivariate and multivariate analyzes were performed.

Results

About 387 respondents agreed to participate in the study. The study showed low awareness regarding infectious agents, lifestyle, diet and many work exposures. The predictors of the attitude of respondents regarding the preventability of cancer were: believing that cancer has an environmental cause (p=.014), not having a healthy lifestyle (p = 0.004), not smoking waterpipe (p = 0.023), being single (p = 0.013), and having a university degree (p = 0.049).

Conclusions

Efforts should be made to improve awareness of the cancer risk factors regarding infectious agents, lifestyle, diet and many work exposures. This can also be followed by further studies assessing the impact of these community and governmental cancer prevention initiatives on cancer risk factors level of awareness.

Trends in high-risk rates and screening rates for the population-based cancer screening program on esophageal, stomach and liver cancer in China, 2010-2016

Background

A population-based cancer screening program in rural China, targeting three types of cancer that are most prevalent in these areas, including esophageal, stomach, and liver cancer was awarded by the government in China since 2007. A two-step design with cancer risk assessment based on questionnaire interview and HBsAg test strip and subsequent clinical intervention for high-risk populations was adopted with free of charge at the local hospitals designated in the program. The participate rate including high-risk rates and screening rates was important to find appropriate strategies to improve the overall awareness of the program.

Methods

Data from the cancer screening program between 2010 and 2016 were used to calculate higher rate (high-risk population/ participants recruited) and screening rate (participants received screening/ high-risk population).

Results

From 2010 to 2016, 1,637,429 residents were recruited in the program and filled the questionnaires, 350,646 (21.4%) for esophagus cancer, 273,715 (16.7%) for stomach cancer and 1,013,068 (61.9%) for liver cancer. 471,974 participants were assessed as high-risk population including 114,786 (24.3%) high risk for esophagus cancer, 161,809 (34.3%) high risk for stomach cancer and 195,379 (41.4%) high risk for liver cancer, respectively. 249,185 (52.8%) participants who were assessed as high risk received clinical screening. There were 64,710 (26.0%) for esophagus cancer screening, 71,365 (28.6%) for stomach cancer screening and 113,110 (45.4%) for liver cancer screening, respectively.

Conclusion

Our findings will provide important references for designing effective population-based screening strategies to enhance the screening acceptance by health action plan in the future.

Microbiome and Cancers of the Esophagus: A Review

Esophageal cancer (EC) is an aggressive malignant disease ranking amongst the leading causes of cancer deaths in the world. The two main histologic subtypes, esophageal squamous cell carcinoma (ESCC) and esophageal adenocarcinoma (EAC), have distinct geographic and temporal patterns and risk factor profiles. Despite decades of research, the factors underlying these geo-temporal patterns are still not fully understood. The human microbiome has recently been implicated in various health conditions and disease, and it is possible that the microbiome may play an important role in the etiology of EC. Although studies of the microbiome and EC are still in their early stages, we review our current understanding of the potential links between ESCC, EAC, and bacterial communities in the oral cavity and esophagus. We also provide a summary of the epidemiology of EC and highlight some key challenges and future directions.

Optimizing Positivity Thresholds for a Risk-Adapted Screening Strategy in Colorectal Cancer Screening

INTRODUCTION

Risk-adapted screening combining the Asia-Pacific Colorectal Screening score, fecal immunochemical test (FIT), and colonoscopy improved the yield of colorectal cancer screening than FIT. However, the optimal positivity thresholds of risk scoring and FIT of such a strategy warrant further investigation.

METHODS

We included 3,407 participants aged 50-74 years undergoing colonoscopy from a colorectal cancer screening trial. For the risk-adapted screening strategy, subjects were referred for subsequent colonoscopy or FIT according to their risk scores. Diagnostic performance was evaluated for FIT and the risk-adapted screening method with various positivity thresholds. Furthermore, a modeled screening cohort was established to compare the yield and cost using colonoscopy, FIT, and the risk-adapted screening method in a single round of screening.

RESULTS

Risk-adapted screening method had higher sensitivity for advanced neoplasm (AN) (27.6%-76.3% vs 13.8%-17.3%) but lower specificity (46.6%-90.8% vs 97.4%-98.8%) than FIT did. In a modeled screening cohort, FIT-based screening would be slightly affected because the threshold varied with a reduction of 76.0%-80.9% in AN detection and 82.0%-84.4% in cost when compared with colonoscopy. By contrast, adjusting the threshold of Asia-Pacific Colorectal Screening score from 3 to 5 points for risk-adapted screening varied from an increase of 12.6%-14.1% to a decrease of 55.6%-60.1% in AN detection, with the reduction of cost from 4.2%-5.3% rising to 66.4%-68.5%.

DISCUSSION

With an appropriate positivity threshold tailored to clinical practice, the risk-adapted screening could save colonoscopy resources and cost compared with the colonoscopy-only and FIT-only strategies.

Unrestrained eating behavior and risk of digestive system cancers: a prospective cohort study

BACKGROUND

Unrestrained eating behavior, as a potential proxy for diet frequency, timing, and caloric intake, has been questioned as a plausible risk factor for digestive system cancers, but epidemiological evidence remains sparse.

OBJECTIVES

We investigated prospectively the associations between unrestrained eating behavior and digestive system cancer risk.

METHODS

Participants in the Nurses' Health Study who were free of cancer and reported dietary information in 1994 were followed for ≤18 y. Cox models were used to estimate HRs and 95% CIs for unrestrained eating (eating anything at any time, no concern with figure change, or both) and risk of digestive system cancers.

RESULTS

During follow-up, 2064 digestive system cancer cases were documented among 70,450 eligible participants in analyses of eating anything at any time, In total, 2081 digestive system cancer cases were documented among 72,468 eligible participants in analyses of no concern with figure change. In fully adjusted analyses, women with the behavior of eating anything at any time had a higher risk of overall digestive system cancer (HR: 1.22; 95% CI: 1.10, 1.35), overall gastrointestinal tract cancer ((HR: 1.33; 95% CI: 1.18, 1.50), buccal cavity and pharynx cancer (HR: 1.50; 95% CI: 1.02, 2.21), esophageal cancer (HR: 1.62; 95% CI: 1.01, 2.62), small intestine cancer (HR: 1.92; 95% CI: 1.02,3. 59), and colorectal cancer (HR: 1.20; 95% CI: 1.04, 1.38), and a non-statistically significant increased risk of stomach cancer (HR: 1.54; 95% CI: 0.96,2.48), compared with women without this behavior. No statistically significant association was observed for pancreatic cancer and liver and gallbladder cancer. The combined effect of eating anything at any time and having no concern with figure change was associated with a significantly increased risk of overall digestive system cancer (HR: 1.27; 95% CI: 1.10, 1.46), overall gastrointestinal tract cancer (HR: 1.45; 95% CI: 1.23, 1.71), and colorectal cancer (HR: 1.34; 95% CI: 1.11, 1.63), compared with women exhibiting the opposite.

CONCLUSIONS

Unrestrained eating behavior was independently associated with increased risk of gastrointestinal tract cancers. The potential importance of unrestrained eating behavior modification in preventing gastrointestinal tract cancers should be noted.

Antibiotic Use Associated With Risk of Colorectal Polyps in a Nationwide Study

BACKGROUND & AIMS

Use of antibiotics affects the composition of the microbiome and might affect development of colorectal polyps, which are precursors to colorectal cancer.

METHODS

We performed a nested case-control study in Sweden of 45,744 patients with a colorectal polyp (cases) in the nationwide gastrointestinal ESPRESSO histopathology cohort, using unaffected full siblings as controls (n = 93,307). Polyps were classified by morphology SnoMed codes into conventional adenomas and serrated polyps. Through linkage to the Prescribed Drug Register, we assessed use and cumulative dispensations of antibiotic until 1 year prior to polyp diagnosis for cases and their sibling controls.

RESULTS

During a median study period of 6.9 years, compared with non-users, users of antibiotics (including 28,884 cases [63.1%] and 53,222 sibling controls [57.0%]) had a higher risk of colorectal polyps (odds ratio [OR], 1.08; 95% CI, 1.04-1.13). Risk increased with higher number of dispensations (OR for ≥ 6 dispensations, 1.33; 95% CI, 1.25-1.43) (P_trend < .0001). We observed a stronger association with polyps for broad-spectrum antibiotics (OR comparing users to non-users, 1.23; 95% CI, 1.18-1.29) than for narrow-spectrum antibiotics (OR, 1.05; 95% CI, 1.01-1.10), and for tetracyclines and quinolones (OR, 1.21) than penicillin and other classes (ORs ranged from 1.04 to 1.16). The findings remained robust with several sensitivity analyses, including use of a 2-year lead-in period for antibiotic assessment and correction for misclassification in controls. Use of broad-spectrum antibiotics was more strongly associated with risk of serrated polyps (OR, 1.29; 95% CI, 1.21-1.38) compared with risk of conventional adenomas (OR, 1.17; 95% CI, 1.11-1.24). We found no differences in risk of colon vs rectal polyps with antibiotic use (P_{heterogeneity} > .10). We found stronger associations for younger (<50 years) vs older adults (≥50 years) for users of quinolones, sulfonamides, trimethoprim, and cephalosporins (P_interaction < .001).

CONCLUSIONS

In a nationwide case-control study in Sweden, after accounting for hereditary and early life environmental factors, antibiotic use was associated with increased risk of colorectal polyps. Our findings indicate a role for intestinal dysbiosis in early stages of colorectal carcinogenesis.

Chanwuyi Lifestyle Medicine Program Alleviates Immunological Deviation and Improves Behaviors in Autism

Given the association between deviated inflammatory chemokines, the pathogenesis of autism spectrum disorders (ASD), and our previous findings of the Chanwuyi Lifestyle Medicine Program regarding improved cognitive and behavioral problems in ASD, the present study aims to explore if this intervention can alter pro-inflammatory chemokines concentration. Thirty-two boys with ASD were assigned to the experimental group receiving the Chanwuyi Lifestyle Medicine Program for 7 months or the control group without a change in their lifestyle. The experimental group, but not the control group, demonstrated significantly reduced CCL2 and CXCL8, a trend of reduction in CCL5, and elevation of CXCL9. The experimental group also demonstrated significantly reduced social communication problems, repetitive/stereotypic behaviors, and hyperactive behaviors. The present findings support the potential efficacy and applicability of the Chanwuyi Lifestyle Medicine Program for reducing both behavioral problems and immunological dysfunction in ASD. Further studies are warranted to verify its treatment effect and its association with brain functions.

The influence of monoclonal antibodies for cancer treatment on the endocrine system

Cancer is one of the main causes of mortality worldwide. Thanks to scientific research, new methods of cancer treatment, including molecularly targeted therapy, are being developed. Monoclonal antibodies are used to treat many diseases, including some types of cancer, and affect various systems of the human body. The presented article aims to present the adverse effects of molecularly targeted cancer therapy on the endocrine system based on the current literature data. Immune checkpoint inhibitors, such as anti-CTLA-4 and anti-PD-1 or its ligand PD-L1, can cause a variety of autoimmune adverse effects, among others, thyroid dysfunction, hypophysitis, and diabetes mellitus. The authors also paid attention to monitoring selected diagnostic parameters to prevent endocrine adverse effects during a therapy with monoclonal antibodies. The development of adverse effects may sometimes progress atypically and rapidly, and may be a life-threatening condition. Clinicians should choose individual schemes of treatment for particular patients. The patient’s condition should also be monitored before, during and after the therapy. The decision about the continuation of treatment with monoclonal antibodies should be based especially on a risk connected with the cessation of treatment. Clinical trials should be continued to improve knowledge about the side effects of monoclonal antibodies.

Socioeconomic Inequalities in Premature Cancer Mortality Among U.S. Counties During 1999 to 2018

BACKGROUND

This study investigated socioeconomic inequalities in premature cancer mortality by cancer types, and evaluated the associations between socioeconomic status (SES) and premature cancer mortality by cancer types.

METHODS

Using multiple databases, cancer mortality was linked to SES and other county characteristics. The outcome measure was cancer mortality among adults ages 25-64 years in 3,028 U.S. counties, from 1999 to 2018. Socioeconomic inequalities in mortality were calculated as a concentration index (CI) by income (annual median household income), educational attainment (% with bachelor's degree or higher), and unemployment rate. A hierarchical linear mixed model and dominance analyses were used to investigate SES associated with county-level mortality. The analyses were also conducted by cancer types.

RESULTS

CIs of SES factors varied by cancer types. Low-SES counties showed increasing trends in mortality, while high-SES counties showed decreasing trends. Socioeconomic inequalities in mortality among high-SES counties were larger than those among low-SES counties. SES explained 25.73% of the mortality. County-level cancer mortality was associated with income, educational attainment, and unemployment rate, at -0.24 [95% (CI): -0.36 to -0.12], -0.68 (95% CI: -0.87 to -0.50), and 1.50 (95% CI: 0.92-2.07) deaths per 100,000 population with one-unit SES factors increase, respectively, after controlling for health care environment and population health.

CONCLUSIONS

SES acts as a key driver of premature cancer mortality, and socioeconomic inequalities differ by cancer types.

IMPACT

Focused efforts that target socioeconomic drivers of mortalities and inequalities are warranted for designing cancer-prevention implementation strategies and control programs and policies for socioeconomically underprivileged groups.

Prediction of Incident Cancers in the Lifelines Population-Based Cohort

Simple Summary

The accurate prediction of incident cancers could be relevant to understanding and reducing cancer incidence. The aim of this study was to develop machine learning (ML) models that could predict an incident diagnosis of cancer. Data were available for 116,188 cancer-free participants and 4232 incident cancer cases. The main outcome was an incident cancer (excluding skin cancer) during follow-up assessment in a population-based cohort. The performance of three ML algorithms was evaluated using supervised binary classification to identify incident cancers among participants. An overall area under the receiver operator curve (AUC) < 0.75 was obtained; the highest AUC was for prostate cancer AUC > 0.80. Linear and non-linear ML algorithms including socioeconomic, lifestyle, and clinical variables produced a moderate predictive performance of incident cancers in the Lifelines cohort.

Abstract

Cancer incidence is rising, and accurate prediction of incident cancers could be relevant to understanding and reducing cancer incidence. The aim of this study was to develop machine learning (ML) models that could predict an incident diagnosis of cancer. Participants without any history of cancer within the Lifelines population-based cohort were followed for a median of 7 years. Data were available for 116,188 cancer-free participants and 4232 incident cancer cases. At baseline, socioeconomic, lifestyle, and clinical variables were assessed. The main outcome was an incident cancer during follow-up (excluding skin cancer), based on linkage with the national pathology registry. The performance of three ML algorithms was evaluated using supervised binary classification to identify incident cancers among participants. Elastic net regularization and Gini index were used for variables selection. An overall area under the receiver operator curve (AUC) <0.75 was obtained, the highest AUC value was for prostate cancer (random forest AUC = 0.82 (95% CI 0.77–0.87), logistic regression AUC = 0.81 (95% CI 0.76–0.86), and support vector machines AUC = 0.83 (95% CI 0.78–0.88), respectively); age was the most important predictor in these models. Linear and non-linear ML algorithms including socioeconomic, lifestyle, and clinical variables produced a moderate predictive performance of incident cancers in the Lifelines cohort.

Associations Among Sleep and Cancer Risk Behaviors: a Scoping Review of Experimental Studies in Healthy Adult Populations

BACKGROUND

Links among poor sleep and cancer risk behaviors have been largely overlooked in the context of cancer prevention and behavioral medicine. The goal of this scoping review was to determine the extent and nature of experimental studies conducted with healthy adult populations that tested the associations among poor sleep and cancer risk behaviors.

METHOD

Electronic databases and major sleep journals were searched to identify experimental studies in healthy adult samples published through January 2018. Studies examined associations among eight pairings of manipulated behaviors and outcomes ("independent variable (IV)-outcome pairs"): the impact of sleep manipulations on physical activity (PA), diet, alcohol consumption, and tobacco use outcomes; and the impact of PA, diet, alcohol consumption, and tobacco use manipulations on sleep outcomes. Studies were characterized in terms of sample characteristics; study design; IV type, dose, and duration; and outcome measurement and duration.

RESULTS

Abstracts of 5697 papers and 345 full texts were screened. Eighty-eight studies describing 125 comparisons met inclusion criteria. Only two studies tested the association between tobacco use and sleep; none tested whether sleep influenced alcohol consumption. Sample sizes were typically small, most studies used crossover designs, and studies tended to include younger and more male participants. Within each IV-outcome pair, there was substantial heterogeneity in how behaviors were manipulated, outcome measurement, and type of control group. Few studies assessed mechanisms.

CONCLUSION

There is a need for larger experimental studies with more representative samples. Overall, heterogeneity and limitations in study designs make it difficult to synthesize evidence across studies.

The state of nutrition in medical education in the United States

Despite the significant impact diet has on health, there is minimal nutrition training for medical students. This review summarizes published nutrition learning experiences in US medical schools and makes recommendations accordingly. Of 902 articles, 29 met inclusion criteria, describing 30 learning experiences. Nutrition learning experiences were described as integrated curricula or courses (n = 10, 33%), sessions (n = 17, 57%), or electives (n = 3, 10%). There was heterogeneity in the teaching and assessment methods utilized. The most common was lecture (n = 21, 70%), often assessed through pre- and/or postsurveys (n = 19, 79%). Six studies (26%) provided experience outcomes through objective measures, such as exam or standardized patient experience scores, after the nutrition learning experience. This review revealed sparse and inconsistent data on nutrition learning experiences. However, based on the extant literature, medical schools should build formal nutrition objectives, identify faculty and physician leadership in nutrition education, utilize preexisting resources, and create nutrition learning experiences that can be applied to clinical practice.

Long-Term Colorectal Cancer Incidence and Mortality After Colonoscopy Screening According to Individuals' Risk Profiles

BACKGROUND

It remains unknown whether the benefit of colonoscopy screening against colorectal cancer (CRC) and the optimal age to start screening differ by CRC risk-profile.

METHODS

Among 75,873 women and 42,875 men, we defined a CRC risk score (0-8) based on family history, aspirin, height, body mass index, smoking, physical-activity, alcohol, and diet. We calculated colonoscopy screening-associated hazard ratios (HRs) and absolute risk reductions (ARRs) for CRC incidence and mortality and age-specific CRC cumulative incidence according to risk score. All statistical tests were 2-sided.

RESULTS

During a median of 26 years' follow-up, we documented 2,407 CRC cases and 874 CRC deaths. While the screening-associated hazard ratio did not vary by risk score, the absolute risk reductions in multivariable-adjusted 10-year CRC incidence more than doubled for individuals with score 6-8 (ARR = 0.34%, 95% CI = 0.26% to 0.42%) compared to 0-2 (ARR = 0.15%, 95% CI = 0.12% to 0.18%; Ptrend<0.001). Similar results were found for CRC mortality (ARR = 0.22% [95% CI = 0.21% to 0.24%] vs. 0.08% [95% CI = 0.07% to 0.08%]; Ptrend<0.001). The absolute risk reduction in mortality of distal-colon and rectal cancers was four-fold higher for score 6-8 than 0-2 (distal-colon cancer: ARR = 0.08% [95% CI = 0.07% to 0.08%] vs. 0.02% [95% CI = 0.02% to 0.02%], Ptrend <0.001; rectal cancer: ARR = 0.08% [95% CI = 0.08% to 0.09%] vs. 0.02% [95% CI = 0.02% to 0.03%], Ptrend <0.001). When using age 45 years as the benchmark to start screening, individuals with risk score of 0-2, 3, 4, 5, and 6-8 attained the threshold CRC risk level (10-year cumulative risk of 0.47%) at age 51, 48, 45, 42, and 38 years, respectively.

CONCLUSIONS

The absolute benefit of colonoscopy screening is more than twice higher for individuals with the highest than lowest CRC risk profile. Individuals with a high and low risk profile may start screening up to 6-7 years earlier and later, respectively, than the recommended age 45 years.

Personalized nutrition for colorectal cancer

The substantial burden of colorectal cancer and its increasing trend in young adults highlight the importance of dietary and lifestyle modifications for improved cancer prevention and survivorship. In this chapter, we review the cutting-edge evidence for the interplay between diet/lifestyle and the gut microbiota in the incidence and prognosis of colorectal cancer. We focus on factors for which there are data supporting their importance for the gut microbiota and colorectal cancer, including excess body weight, fiber, red and processed meat, and coffee. We discuss the potential precision nutrition approaches for modifying and exploiting the gut microbiota for improved cancer prevention and survivorship.

A comparison of methods in estimating population attributable risk for colorectal cancer in the United States

Population attributable risk (PAR) is becoming more widely used for quantifying preventability of cancer. However, its estimations have had a wide range, leading to questions about the true preventability. Our study aimed to compare the two PAR estimation methods (ie, literature-based method and low-risk method) for colorectal cancer (CRC) in the US population based on the same set of modifiable risk factors: physical activity, body mass index, alcoholic drinks, red meat, processed meat, dietary fiber, dietary calcium and cigarette smoking. For the literature-based method, 65% and 53%, and for the low-risk method, 62% and 49% of CRC cases for males and females, respectively, were attributable to the eight dietary and lifestyle risk factors. Additional sensitivity analyses were conducted with respect to the different choices of risk factors, relative risks (RRs) and exposure prevalence estimates used in the literature-based method. The PARs including only the "convincing" factors and excluding "probable" factors defined by the WCRF/AICR were 50% for males and 34% for females. Using RRs derived from different studies changed the PARs considerably (57%-74% for males and 37%-60% for females). Our study assessed the robustness of PAR calculations through a direct comparison between the two methods using different assumptions and data and generally found high concordance. From the additional analyses, we found that the choice of risk factors and RRs could substantially influence the PAR estimates. Given the findings, future studies reporting PAR should consider presenting a range of PAR estimates based on choices of risk factors and RRs.

Circulating miR-21 as a potential biomarker in human digestive system carcinoma: a systematic review and diagnostic meta-analysis

Purpose: Gastrointestinal cancers (GICs) account for about a quarter of cancers. Lately, the circulating microRNAs as a non-invasive biomarker for identifying and monitoring diseases have been recognized. Several studies have examined the role of miR-21 in digestive system carcinoma. We conducted a meta-analysis to assess the diagnostic role of miR-21 in GICs.Methods: Seventeen studies involving 1700 individuals were included in this meta-analysis. The pooled sensitivity, specificity, PLR, NLR, DOR, AUC, SROC, and Q* index were calculated based on true-positive, true-negative, false-negative, and false-positive. Moreover, the subgroup analyses have been performed for miR-21 based on sample types (serum/plasma), normalized genes (U6, miR-16, and miR-39), and ethnicity.Results: The pooled sensitivity 0.722 (95% CI: 0.70-0.74), specificity 0.820 (95% CI: 0.801-0.838), PLR 4.375 (95% CI: 3.226-5.933), NLR 0.308 (95% CI: 0.239-0.398), DOR 16.06 (95% CI: 9.732-26.53) as well as AUC 0.86, and Q* index 0.79 represented the high-grade diagnostic precision of miR-21 in identifying GICs (ESCC, GC, CRC, HCC, and PC).Conclusion: This meta-analysis demonstrated that circulating miR-21 levels can be used to monitor the digestive system carcinomas. Therefore, miR-21 can be a useful biomarker of progression and fair diagnosis in GICs patients.

Healthy lifestyle, endoscopic screening, and colorectal cancer incidence and mortality in the United States: A nationwide cohort study

BACKGROUND

Healthy lifestyle and screening represent 2 major approaches to colorectal cancer (CRC) prevention. It remains unknown whether the CRC-preventive benefit of healthy lifestyle differs by endoscopic screening status, and how the combination of healthy lifestyle with endoscopic screening can improve CRC prevention.

METHODS AND FINDINGS

We assessed lifestyle and endoscopic screening biennially among 75,873 women (Nurses' Health Study, 1988 to 2014) and 42,875 men (Health Professionals Follow-up Study, 1988 to 2014). We defined a healthy lifestyle score based on body mass index, smoking, physical activity, alcohol consumption, and diet. We calculated hazard ratios (HRs) and population-attributable risks (PARs) for CRC incidence and mortality in relation to healthy lifestyle score according to endoscopic screening. Participants' mean age (standard deviation) at baseline was 54 (8) years. During a median of 26 years (2,827,088 person-years) follow-up, we documented 2,836 incident CRC cases and 1,013 CRC deaths. We found a similar association between healthy lifestyle score and lower CRC incidence among individuals with and without endoscopic screening, with the multivariable HR per one-unit increment of 0.85 (95% CI, 0.80 to 0.90) and 0.85 (95% CI, 0.81 to 0.88), respectively (P-interaction = 0.99). The fraction of CRC cases that might be prevented (PAR) by endoscopic screening alone was 32% (95% CI, 31% to 33%) and increased to 61% (95% CI, 42% to 75%) when combined with healthy lifestyle (score = 5). The corresponding PAR (95% CI) increased from 15% (13% to 16%) to 51% (17% to 74%) for proximal colon cancer and from 47% (45% to 50%) to 75% (61% to 84%) for distal CRC. Results were similar for CRC mortality. A limitation of our study is that our study participants are all health professionals and predominantly whites, which may not be representative of the general population.

CONCLUSIONS

Our study suggests that healthy lifestyle is associated with lower CRC incidence and mortality independent of endoscopic screening. An integration of healthy lifestyle with endoscopic screening may substantially enhance prevention for CRC, particularly for proximal colon cancer, compared to endoscopic screening alone.

MicroRNA-223 in gastrointestinal cancers: A systematic review and diagnostic meta-analysis

BACKGROUND

Several studies have been conducted on the diagnostic role of miR-223 in cancers related to the digestive system. However, the diagnostic role of this microRNA in gastrointestinal (GI) cancers has not been fully elucidated. This meta-analysis aimed to accurately assess the diagnostic role of circulating miR-223 in GI cancers.

METHODS

A literature search was performed in PubMed/Medline, Science Direct, Web of Science, Google Scholar, Embase and Scopus, up to 1st May 2020 databases. Twelve studies were eligible and included in the analysis. Meta-Disc software was used to calculate the pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, diagnostic odds ratio, area under the curve (AUC) and the summary receiver operating characteristic (SROC) based on true positive, true negative, false negative and false positive for each gastrointestinal cancer separately and in total.

RESULTS

Twelve case-control studies were included with 1859 participants (1080 cases and 779 controls). Pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio and diagnostic odds ratio were 0.77 (95% CI: 0.74-0.79), 0.75 (95% CI: 0.72-0.78), 3.04 (95% CI: 2.20-4.18), 0.31 (95% CI: 0.22-0.42) and 10.77 (95% CI: 5.96-19.47), respectively. AUC was 0.83, suggesting a high-grade diagnostic precision of miR-223 in gastrointestinal cancers. Besides, subgroup analyses were performed to assess the diagnostic power of miR-223 based on the type of gastrointestinal cancer, sample type and country via calculating pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio and diagnostic odds ratio.

CONCLUSION

Our meta-analysis showed the value of circulating miR-223 levels in the early diagnosis of diverse digestive system carcinomas.

Supervised mutational signatures for obesity and other tissue-specific etiological factors in cancer

Determining the etiologic basis of the mutations that are responsible for cancer is one of the fundamental challenges in modern cancer research. Different mutational processes induce different types of DNA mutations, providing 'mutational signatures' that have led to key insights into cancer etiology. The most widely used signatures for assessing genomic data are based on unsupervised patterns that are then retrospectively correlated with certain features of cancer. We show here that supervised machine-learning techniques can identify signatures, called SuperSigs, that are more predictive than those currently available. Surprisingly, we found that aging yields different SuperSigs in different tissues, and the same is true for environmental exposures. We were able to discover SuperSigs associated with obesity, the most important lifestyle factor contributing to cancer in Western populations.

Mucins, gut microbiota, and postbiotics role in colorectal cancer

An imbalance in the crosstalk between the host and gut microbiota affects the intestinal barrier function, which results in inflammatory diseases and colorectal cancer. The colon epithelium protects itself from a harsh environment and various pathogenic organisms by forming a double mucus layer, primarily comprising mucins. Recent studies are focusing on how dietary patterns alter the gut microbiota composition, which in turn regulates mucin expression and maintains the intestinal layers. In addition, modulation of gut microbiota by microbiotic therapy (involving fecal microbiota transplantation) has emerged as a significant factor in the pathologies associated with dysbiosis. Therefore, proper communication between host and gut microbiota via different dietary patterns (prebiotics and probiotics) is needed to maintain mucus composition, mucin synthesis, and regulation. Here, we review how the interactions between diet and gut microbiota and bacterial metabolites (postbiotics) regulate mucus layer functionalities and mucin expression in human health and disease.

Positive Association between Triglyceride-Rich Lipoprotein Cholesterol and Diabetes Mellitus in Hypertensive Patients

BACKGROUND

The association between triglyceride-rich lipoprotein cholesterol (TRL-C) and diabetes mellitus (DM) remains unclear because of limited research and data. The aim of this study was to explore the independent association between TRL-C and DM in hypertensive patients and to examine whether a healthy lifestyle would have an impact on this relationship.

METHODS

In this study, data from 13,721 hypertensive patients who were not treated with lipid-lowering drugs were analyzed. TRL-C was calculated from total cholesterol (TC) minus [LDL cholesterol + HDL cholesterol]. DM was defined as fasting plasma glucose of ≥7.0 mmol/L and/or self-reported history of hypoglycemic drug use.

RESULTS

After adjusting for potential confounding factors, the TRL-C was significantly positively associated with elevated DM (odds ratio (OR): 1.73 and 95% confidence interval (CI): 1.54-1.94). In subgroup analysis, a healthy lifestyle (HL) failed to modify the positive association between TRL-C and DM (HL: OR 1.93, 95%CI 1.58-2.36; non-HL: OR 1.72, 95%CI 1.50-1.98; P for interaction = 0.38).

CONCLUSION

The results showed a positive association between TRL-C and DM in hypertensive patients. A healthy lifestyle failed to diminish the relationship between TRL-C and DM. The novel findings indicate that TRL-C might be a reliable marker of DM and may provide a new strategy for the prevention and treatment of DM.

Risk of Colorectal Carcinoma May Predispose to the Genetic Variants of the GST, CYP450, and TP53 Genes Among Nonsmokers in the Saudi Community

PURPOSE

Colorectal carcinoma (CRC) represents a considerable public health burden in Saudi Arabia. Several candidate genes and genetic variants have been associated with morbidity and mortality among patients with CRC. We explored whether allelic variants of the GSTM1, GSTT1, CYP450 (rs4646903 and rs1048943), and TP53 (rs1042522) genes predisposed nonsmoking Saudi individuals to increased risk for CRC.

PATIENTS AND METHODS

DNA from buccal cells of 158 participants (80 with CRC and 78 healthy controls) were analyzed for five SNPs using conventional PCR and TaqMan genotyping assays. The SNPStats software was utilized to choose the best interactive inheritance mode for selected SNPs (https://www.snpstats.net).

RESULTS

The mean age of diagnosis was 62.4±13.5 years (range, 40-83 years), with those aged 71-80 years and those aged 40-50 years accounting for the most diagnoses (35.7% and 28.6% of diagnosis, respectively). The GSTM1 and TP53 rs1042522 SNPs were associated with CRC (OR= 3.7; P< 0.0001, and OR= 1.6; P= 0.033, respectively). A plausible contribution to CRC was observed for the GSTM1 and TP53 rs1042522 SNPs (x ² _Yates= 14.7; P= 0.00013, and x ² _Yates= 11.2; P= 0.0008, respectively), while the GSTT1 null variant did not affect risk. Heterozygosity in the CYP450 (rs4646903 and rs1048943 SNPs) was associated with a significant risk for CRC. The GSTM1/GSTT1 and CYP450 rs4646903/rs1048943 SNP pairs were in linkage disequilibrium, and the associations were statistically significant (P= 0.01 and P= 4.6x10^‒7, respectively).

CONCLUSION

The GSTM1 and TP53 rs1042522 variants can increase the development of CRC in Saudi nonsmokers. Even the presence of one copy of a variant allele in the CYP1A1 gene can predispose CRC risk. Additional studies should also examine other SNP combinations with lifestyle factors that may help prevent, rather than facilitate, colorectal tumorigenesis.

Provider Discussion about Lifestyle by Cancer History: A Nationally Representative Survey

BACKGROUND

Providers are uniquely positioned to encourage health-promoting behaviors, particularly among cancer survivors where patients develop trust in providers.

METHODS

We utilized the National Health Interview Survey to identify adults who reported a visit to a provider in the prior year (44,385 individuals with no cancer history and 4,792 cancer survivors), and reported prevalence of provider discussions on weight loss, physical activity, diet, and smoking. We used generalized linear mixed models to examine predicted prevalence of provider lifestyle discussions by cancer history overall, and among those who do not meet body mass index (BMI), activity, or smoking guidelines.

RESULTS

Among those with a BMI of 25-<60 kg/m², 9.2% of those with a cancer history and 11.6% of those without a cancer history reported being told to participate in a weight loss program (P < 0.001). Overall, 31.7% of cancer survivors and 35.3% of those with no cancer history were told to increase their physical activity (P < 0.001). Only 27.6% of cancer survivors and 32.2% of those with no cancer history reported having a general discussion of diet (P < 0.001). Among smokers, 67.3% of cancer survivors and 69.9% of those with no cancer history reported counseling on smoking (P = 0.309).

CONCLUSIONS

Fewer cancer survivors, who are at increased risk for health complications, are reporting provider discussions about critical lifestyle issues than those with no cancer history.

IMPACT

Our nationally representative results suggest that providers are missing an opportunity for influencing patient lifestyle factors, which could lead to mitigation of late and long-term effects of treatment.

Forging Forward Together: Transforming Scientific Practice to Accelerate Scientific Progress

Rapidly advancing solutions requires our community to continuously re-examine successes of yesterday to inspire new approaches for today while collaboratively envisioning what’s needed for tomorrow.

Healthy lifestyle and cancer risk among Chinese population in the Dongfeng-Tongji cohort

BACKGROUND

Studies on the association between healthy lifestyle and cancer risk are limited among the old Chinese population.

METHODS

The healthy lifestyle score was derived from smoking, drinking, diet, body mass index and physical activity among 23734 retired employees from the Dongfeng-Tongji Cohort. Cox proportional hazards regression was used to calculate the hazard ratios (HRs) and the corresponding 95% confidence intervals (CIs). The rate advancement periods (RAPs) and the population attributable risk percentage (PAR%) were estimated to indicate the benefits of removing risk lifestyle factors.

RESULTS

During a median follow-up of 8.16 years, 2023 cancer cases were identified. Compared with 0-2 points of the healthy lifestyle score, the HRs were 0.87 (95% CI: 0.76, 0.99), 0.83 (95% CI: 0.73, 0.94), and 0.74 (95% CI: 0.64, 0.86) for 3, 4, and 5 points, respectively, with the corresponding RAPs of -4.40 (95% CI: -8.39, -0.41), -5.84 (95% CI: -9.77, -1.90), and -9.14 (95% CI: -14.03, -4.25), respectively. Approximately 15% of incident cancer cases among total population and 22% among men would be prevented by following all 5 healthy lifestyle factors.

CONCLUSIONS

The current study suggests that healthy lifestyle could reduce cancer risk in the retired Chinese population, especially in males. Key messages Healthy lifestyle derived by smoking, drinking, diet, body mass index and physical activity presented a strong protective effect on cancer risk among the retired Chinese population, especially in males. We employed the rate advancement periods and the population attributable risk percentage to indicate the benefits of adopting healthy lifestyle and we found that following all 5 healthy lifestyle factors could delay the risk of developing cancer by 9.14 years and prevent 15% of incident cancer cases.

Anxiety, Depression, and Colorectal Cancer Survival: Results from Two Prospective Cohorts

Given the unalterable nature of most risk factors for colorectal cancer (CRC) survival (e.g., disease stage), identifying modifiable determinants is critical. We investigated whether anxiety and depression were related to CRC survival using data from the Nurses' Health Study (NHS) and Health Professional Follow-up Study (HPFS). Participants who received a CRC diagnosis and provided information about anxiety (nNHS = 335; nHPFS = 232) and depression (nNHS = 893; nHPFS = 272) within 4 years of diagnosis were included. Cox regression models estimated hazard ratios (HR) and 95% confidence intervals (CI) of overall mortality, while controlling for covariates (sociodemographics, cancer characteristics, and lifestyle factors). Pooled risk estimates were derived from fixed effects meta-analyses of the cohorts. Among 1732 CRC patients, 814 deaths occurred during the 28-year follow-up. Each 1 standard deviation increase in anxiety or depression symptoms was associated with a similar 16% higher mortality risk (anxiety: 95% CI = 1.05-1.29; depression: 95% CI = 1.07-1.26). Comparable results were observed across all sensitivity analyses (introducing a 1-year lag, restricting to CRC-related mortality, considering potential behavioral pathways) and stratified models (cancer stage, sex). Our findings suggest greater anxiety and depression symptoms can not only impede adherence to healthy habits and reduce quality of life in cancer patients but could also be a marker for accelerated CRC progression.

Combined effects of occupational exposure to hazardous operations and lifestyle-related factors on cancer incidence

We aimed to examine whether the number of types of hazardous operations at work experienced through a lifetime is associated with cancer incidence, and additionally examined the combined effects with lifestyle‐related factors. Using a nationwide, multicenter, hospital inpatient dataset (2005‐2015), we conducted a matched case‐control study with 1 149 296 study subjects. We classified the participants into those with none, 1, or 2 or more types of hazardous operation experience, based on information of special medical examinations taken, mandatory in Japan for workers engaged in hazardous operations. Using those with no experience as the reference group, we estimated the odds ratios for cancer incidence (all sites, lung, stomach, colon and rectum, liver, pancreas, bile duct, and bladder) by conditional logistic regression with multiple imputations. We also examined the effects of the combination with hazardous operations and lifestyle‐related factors. We observed increased risks for cancer of all sites, and lung, pancreas, and bladder cancer associated with the experience of hazardous operations. Multivariable‐adjusted ORs (95% CIs) of cancer incidence of all sites were 1 (reference), 1.16 (1.12, 1.21), and 1.17 (1.08, 1.27) for none, 1, and 2 or more types of hazardous operation experience, respectively (P for trend <.001). Potential combined associations of hazardous operations with smoking were observed for lung, pancreas, and bladder cancer, and with diabetes for pancreas cancer. Engaging in hazardous operations at work and in combination with lifestyle‐related factors may increase the risk of cancer. We highlight the potential for those engaged in hazardous work to avoid preventable cancers.

Exercise and immunometabolic regulation in cancer

Unhealthful lifestyle factors, such as obesity, disrupt organismal homeostasis and accelerate cancer pathogenesis, partly through metabolic and immunological dysregulation. Exercise is a prototypical strategy that maintains and restores homeostasis at the organismal, tissue, cellular and molecular levels and can prevent or inhibit numerous disease conditions, including cancer. Here, we review unhealthful lifestyle factors that contribute to metabolic and immunological dysregulation and drive tumourigenesis, focusing on patient physiology (host)-tissue-tumour microenvironment interactions. We also discuss how exercise may influence distant tissue microenvironments, thereby improving tissue function through both metabolic and immunospecific pathways. Finally, we consider future directions that merit consideration in basic and clinical translational exercise studies.

Teaching lifestyle medicine competencies in undergraduate medical education: active collaborative intervention for students at multiple locations

The aims of this study are to 1) design feasible active collaborative educational approaches to teach and assess three of the newly described lifestyle medicine (LM) competencies to students at multiple locations; and 2) determine whether a mixed, flexible instructional delivery approach impacts students' learning and perception of confidence in LM. The educational interventions were part of the undergraduate clinical medical education curriculum and have two parts: 1) an asynchronous session [online self-learning module (SLM)], and 2) a synchronous session using case-based collaborative learning delivered either mostly face to face, as determined by the instructor (approach A) or mostly virtual, as determined by the student (approach B). Both approaches were delivered in the curriculum as planned to 27 students in approach A (26% attending virtually) and 31 students in approach B (90% attending virtually). Approach B required more planning time. Approach A students (26 of 27) agreed that the SLM was valuable as an educational tool. The performance in the summative assessment was similar (P = 0.49) in both approaches [means (SD): 33.2 points (SD 10.6) approach A vs. 33.2 points (SD 10.1) approach B]. Students reported a similar increase in confidence (P = 0.33) with setting lifestyle change goals. The two educational approaches presented here address three of the new LM competencies using active collaborative learning. Both approaches are feasible for synchronous delivery to students located at local and distant sites, either face to face or virtual. The increase in the proportion of students attending virtually did not decrease the measured outcomes of learning and perceptions of confidence.

A Nationwide Network to Provide Supervised Exercise Therapy and Lifestyle Counseling for All Patients with Non-Communicable Diseases: Chronic CareNet

Non-communicable diseases (NCDs) are a major cause of disability and mortality worldwide. Physical inactivity is an important contributor to the development of NCDs. Increasing physical activity through supervised exercise therapy (SET) is proven to be effective, and is a key component in both the prevention and treatment of most NCDs. However, only a minority of patients with NCDs receive this treatment, mainly due to an insufficient number and poor accessibility of specialized physical therapists. The aim of this article is to describe a solution that, if indicated, enables all patients with NCDs in the Netherlands to receive SET by a specialized physical therapist: Chronic CareNet. Chronic CareNet is a nationwide network of specialized physical therapists, providing high quality SET and lifestyle counselling to patients with NCDs, initially focusing on peripheral arterial disease, chronic obstructive pulmonary disease and coronary heart disease. The network evolved from ClaudicatioNet. In order to monitor quality of care, therapists enroll in a continuous educational program, and process and outcome indicators are collected by all therapists, which can be compared with a nationwide benchmark (quality system). A robust infrastructure of information and communication technology provides an online care finder and referral system to locate and refer to nearby therapists. All elements of Chronic CareNet are essential, to ensure that all patients in the Netherlands have access to a nearby specialized therapist.

Lifestyle and reproductive health: the aetiology of ovarian cancer in Pakistan

Ovarian cancer is a fatal gynaecological cancer and eighth most common cancer in women globally. Lifestyle, reproductive and sociodemographic factors are among the influential parameters that may significantly affect the risk of ovarian cancer and its mortality rate. However, the epidemiological investigations have shown that the risk of ovarian cancers associated with these factors is different in varied geographical distributions. Lifestyle and reproductive factors have not been investigated thoroughly across a wide cultural diversity. The objective of this study is to investigate the association of these factors with ovarian cancer in Pakistan. This investigation will focus on the lifestyle effects of fat intake, intake of tea, habitual exercise, use of talc, personal hygiene, habit of holding urine for long time, obesity on ovarian cancer among Pakistani women.  Reproductive variables will include age at menarche, natural menopausal age, parity, nulliparity (miscarriages, abortion, stillbirths), infertility, fertility treatment, tubal ligation, oral contraceptive use, and family history of breast or ovarian cancer. Sociodemographic variables will include effect of age, income, education, and geographical location. A case-control study will be conducted in the major cancer hospitals of Pakistan and the patients will also be interviewed. The controls will be recruited outside the hospital. For controls the same age limit and residency requirements will be applied. The information gained from this research will be an important contribution to develop programs for health promotion, with a focus on ovarian cancer prevention and women's health. The findings could be used for health policies and planning to prevent ovarian cancer. The research will pave the way for a public policy and interventions to reduce the burden of ovarian cancer in Pakistan.

A bibliometric analysis of 23,492 publications on rectal cancer by machine learning: basic medical research is needed

BACKGROUND AND AIMS

The aim of this study was to analyse the landscape of publications on rectal cancer (RC) over the past 25 years by machine learning and semantic analysis.

METHODS

Publications indexed in PubMed under the Medical Subject Headings (MeSH) term 'Rectal Neoplasms' from 1994 to 2018 were downloaded in September 2019. R and Python were used to extract publication date, MeSH terms and abstract from the metadata of each publication for bibliometric assessment. Latent Dirichlet allocation was applied to analyse the text from the articles' abstracts to identify more specific research topics. Louvain algorithm was used to establish a topic network resulting in identifying the relationship between the topics.

RESULTS

A total of 23,492 papers published were identified and analysed in this study. The changes of research focus were analysed by the changing of MeSH terms. Studied contents extracted from the publications were divided into five areas, including surgical intervention, radiotherapy and chemotherapy intervention, clinical case management, epidemiology and cancer risk as well as prognosis studies.

CONCLUSIONS

The number of publications indexed on RC has expanded rapidly over the past 25 years. Studies on RC have mainly focused on five areas. However, studies on basic research, postoperative quality of life and cost-effective research were relatively lacking. It is predicted that basic research, inflammation and some other research fields might become the potential hotspots in the future.

Global Burden of 5 Major Types of Gastrointestinal Cancer

BACKGROUND & AIMS

There were an estimated 4.8 million new cases of gastrointestinal (GI) cancers and 3.4 million related deaths, worldwide, in 2018. GI cancers account for 26% of the global cancer incidence and 35% of all cancer-related deaths. We investigated the global burden from the 5 major GI cancers, as well as geographic and temporal trends in cancer-specific incidence and mortality.

METHODS

Data on primary cancers of the esophagus, stomach, colorectum, liver, and pancreas were extracted from the GLOBOCAN database for the year 2018, as well as from the Cancer Incidence in 5 Continents series, and the World Health Organization mortality database from 1960 onward. Age-standardized incidence and mortality rates were calculated by sex, country, and level of human development.

RESULTS

We observed geographic and temporal variations in incidence and mortality for all 5 types of GI cancers. Esophageal, gastric, and liver cancers were more common in Asia than in other parts of the world, and the burden from colorectal and pancreatic cancers was highest in Europe and North America. There was a uniform decrease in gastric cancer incidence, but an increasing incidence of colorectal cancer in formerly low-incidence regions during the studied time period. We found slight increases in incidence of liver and pancreatic cancer in some high-income regions.

CONCLUSIONS

Although the incidence of some GI cancer types has decreased, this group of malignancies continues to pose major challenges to public health. Primary and secondary prevention measures are important for controlling these malignancies-most importantly reducing consumption of tobacco and alcohol, obesity control, immunizing populations against hepatitis B virus infection, and screening for colorectal cancer.

Healthy Lifestyle for Prevention of Premature Death Among Users and Nonusers of Common Preventive Medications: A Prospective Study in 2 US Cohorts

Background

It remains unknown whether individuals who regularly use preventive medications receive the same benefit from healthy lifestyle as those who do not use medications. We aimed to examine the associations of healthy lifestyle with mortality according to use of major preventive medications, including aspirin, antihypertensives, and lipid‐lowering medications.

Methods and Results

Among 79 043 women in the Nurses' Health Study (1988–2014) and 39 544 men in the Health Professionals Follow‐up Study (1986–2014), we defined a healthy lifestyle score based on body mass index, smoking, physical activity, diet, and alcohol intake. We estimated multivariable hazard ratios (HRs) and population‐attributable risks of death from any cause, cardiovascular disease, cancer, and other causes in relation to healthy lifestyle according to medication use. We documented 35 195 deaths. A similar association of healthy lifestyle score with lower all‐cause mortality was observed among medication users (HR, 0.82 per unit increment; 95% CI, 0.81–0.82) and nonusers (HR, 0.81; 95% CI, 0.79–0.83) (P interaction=0.54). The fraction of premature deaths that might be prevented by adherence to the 5 healthy lifestyle factors among medication users and nonusers was 38% (95% CI, 32%–42%) and 40% (95% CI, 29%–50%) for all‐cause mortality, 37% (95% CI, 27%–46%) and 45% (95% CI, 18%–66%) for cardiovascular disease mortality, and 38% (95% CI, 28%–46%) and 33% (95% CI, 14%–49%) for cancer mortality, respectively.

Conclusions

Adherence to a healthy lifestyle confers substantial benefit for prevention of premature death among both regular users and nonusers of preventive medications. Adherence to a healthy lifestyle remains important even among individuals regularly using preventive medications.

Prevalence of Healthy Behaviors among Cancer Survivors in the United States: How Far Have We Come?

BACKGROUND

The 16.9 million cancer survivors in the United States are at increased risk for comorbidities and recurrence. However, this risk may be attenuated by a healthy lifestyle. This study describes health behaviors by cancer history to inform behavior change priorities.

METHODS

We analyzed 2013-2017 data from the National Health Interview Survey. There were 164,692 adults, of whom 12,648 reported a cancer history. We calculated prevalence of smoking, physical activity, alcohol consumption, body mass index (BMI), and sleep duration by cancer history, age, and cancer site. We conducted logistic regression to determine odds of meeting lifestyle recommendations by cancer history.

RESULTS

Overall, those with a cancer history were less likely to report current smoking (14.1% vs. 16.8%) and moderate/heavy drinking (18.8% vs. 21.9%) than those without a cancer history. However, a lower percentage of cancer survivors met physical activity guidelines (14.2% vs. 21.1%) or reported a healthy BMI (31.6% vs. 34.7%) compared with those without a cancer history. Cancer survivors were more likely to report excessive sleep (6.8% vs. 3.6%). In adjusted logistic regression, survivors were more likely to meet recommendations on smoking, physical activity, and BMI but were less likely to meet alcohol recommendations; meeting sleep recommendations did not differ by cancer history.

CONCLUSIONS

While cancer survivors had lower prevalence of smoking and moderate/heavy drinking, they also had lower prevalence of physical activity and healthy BMI, and reported longer sleep duration. Regression analyses suggested survivors only showed poorer behaviors for alcohol.

IMPACT

Targeted health promotion interventions among cancer survivors are needed.

Comparison of health behaviours between cancer survivors and the general population: a cross-sectional analysis of the Lifelines cohort

PURPOSE

To compare the differences in lifestyle behaviours between cancer survivors (CSs) and cancer-free participants in a large and representative population-based cohort.

METHODS

We included 115,257 adults from the Lifelines cohort. Cancer status was self-reported, and health behaviours were measured (e.g. body mass index [BMI]) or assessed by questionnaire (e.g. physical activity, smoking, alcohol consumption, sedentary behaviour and diet). The data were then categorised for logistic regression analysis, stratified and adjusted by sex and age (< 55 vs ≥ 55 years).

RESULTS

CSs (5473; 4.7%) were diagnosed 9 ± 8.5 years before data collection, were older (mean age 55.4 vs 44.4 years) and more often female (66.6% vs 33.4%) than the cancer-free participants. They were also more likely to be physically active and to have a better diet, and also less likely to be alcohol drinkers; but, were more likely to have a higher BMI, be former smokers and to be sedentary. After adjustment for sex and age, however, BMI was more likely to be normal, physical activity was more likely to be higher and smoking to be prevalent in CSs. Current smoking was also significantly higher among females and those aged < 55 years who were CSs than for those with no history of cancer.

CONCLUSIONS

In this population-based cohort, CSs have health behaviour comparable to those without a cancer diagnosis.

IMPLICATIONS FOR CANCER SURVIVORS

Smoking cessation strategies should target all CSs, but efforts could yield greatest benefit if they target females and those younger than 55 years.

Cardiorespiratory fitness and cancer in men with cardiovascular disease: Analysis from the Veterans Exercise Testing Study

Background

Cardiovascular disease and cancer share similar risk factors and are the leading causes of death worldwide. This study aimed to assess the association between cardiorespiratory fitness, cancer incidence and cancer mortality in men with cardiovascular disease.

Methods

Baseline cardiorespiratory fitness (treadmill exercise test) was assessed in 565 men aged 58.9 ± 17 with documented cardiovascular disease and free from any malignancy. Cox multivariable hazard models, population attributable fraction and exposure impact number were analyzed in model accounting for competing events for cancer outcomes.

Results

Mean cardiorespiratory fitness was 7.6 ± 3.4 metabolic equivalents. During a 12.0 ± 7.5 year follow-up, 147 participants developed any type of cancer, 70 died from cancer, and five died from causes other than cancer as competing events. Compared to low cardiorespiratory fitness (&lt;5 metabolic equivalents), moderate (5–10 metabolic equivalents) and high cardiorespiratory fitness (&gt;10 metabolic equivalents) were associated with 50% (0.50, 95% confidence interval (0.27–0.91)) and 68% (0.32 (0.11–0.88)) reduced risks for cancer mortality (p trend = 0.026), respectively. Survival time was longer among individuals with moderate (20.8 (19.7–22) years) and high (24.9 (23–26.7) years) compared to low cardiorespiratory fitness (17.2 (15.1–19.3) years), p &lt; 0.001. Population attributable fraction and exposure impact number for cancer mortality were 13% (4.1–17.7) and 10.8 (5.1–56.4), p = 0.01, respectively. Cardiorespiratory fitness was not associated with cancer incidence.

Conclusion

Higher cardiorespiratory fitness was independently associated with lower risk of cancer mortality and extended survival time in men with cardiovascular disease, although it was not associated with cancer incidence. Improving cardiorespiratory fitness through supervised exercise rehabilitation programs could potentially serve as a cost-effective public-health strategy for secondary prevention and survivorship in men with cardiovascular disease.