Pre-diagnostic anthropometry and survival after colorectal cancer diagnosis in Western European populations

The global, regional, and national burden of colorectal cancer attributable to smoking from 1990 to 2021: a population-based study

Colorectal cancer (CRC) is the third leading cause of cancer-related deaths worldwide, with smoking being a significant risk factor. Understanding the temporal and spatial patterns of the CRC burden attributable to smoking is crucial for global public health strategies. Data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 were used to calculate the number of deaths, disability-adjusted life years (DALYs), age-standardized mortality rate (ASMR) per 100 000 population, and age-standardized disability-adjusted life year rate (ASDR). The average annual percentage change (AAPC) was calculated from 1990 to 2021 to analyze disease burden trends. Frontier analysis was conducted to assess efficiency, and predictions were made for the next decade. In 2021, the global death toll and DALYs attributable to smoking were 47 613 and 1 235 667, respectively. From 1990 to 2021, the absolute number of deaths and DALYs increased, while ASMR (AAPC: -1.20) and ASDR (AAPC: -1.22) showed a significant decline. The disease burden was notably higher in males than females. Analysis by the Social Development Index revealed that more developed regions had a higher burden than less developed areas. China ranked first in the number of deaths and DALYs, while Greenland had the highest ASMR and ASDR. From 1990 to 2021, the age-standardized burden of CRC attributable to smoking decreased globally. However, the absolute burden remains a significant public health challenge, requiring sustained and targeted interventions.

The role of obesity in mortality from digestive diseases in UK Biobank

Most current studies use body mass index (BMI) or waist circumference (WC) to define obesity, and BMI, which reflects subcutaneous fat independent of visceral fat, is the most commonly used indicator of obesity. WC reflects subcutaneous and visceral fat. This research aims to investigate the effect of obesity on mortality in people with digestive diseases. According to BMI and WC, we divided patients with obesity into the following four groups: general obesity, abdominal obesity, combined obesity, and non-obese. The effects of different obesity types on mortality in a population with digestive diseases were analysed via Cox regression and inverse probability-weighted Cox regression. Our research employed multivariate imputation via the chained equations method to interpolate missing values. A total of 254,445 participants, with a mean age of 57.8 ± 7.8 years, were included in the analysis. Of these participants, 227,111 (89.3%) participants were censored, and 27,334 (10.7%) participants died. Abdominal obesity and combined obesity were independent predictors of mortality in patients with digestive diseases. The combination of BMI and WC was valuable and significant for considering the type of obesity. In addition, our study revealed that sex, socioeconomic status, lifestyle habits, and physical activity were also associated with death in people with digestive disorders. Combined obesity, which is determined by both BMI and WC, is an important factor that influences mortality in a population with digestive diseases, and it plays a stronger role than abdominal obesity alone. These modifiable risk factors for mortality can provide guidance to populations with digestive diseases to avoid poor lifestyles and prolong survival time.

Initial sarcopenia and body composition changes as prognostic factors in cervical cancer patients treated with concurrent chemoradiation: An artificial intelligence-based volumetric study

OBJECTIVES

This study aimed to investigate the influence of baseline sarcopenia and changes in body composition on survival during cervical cancer treatment.

METHODS

Patients diagnosed with stage IB1-IVB cervical cancer who underwent primary concurrent chemoradiation therapy (CCRT) between 2002 and 2022 were included. The exclusion criteria were prior radical hysterectomy, lack of pretreatment computed tomography (CT) imaging, or significant comorbidities. An artificial intelligence-based automatic segmentation program assessed body composition by analyzing CT images, defining L3 sarcopenia (L3 skeletal muscle index [SMI] <39cm2/m2) and volumetric sarcopenia (volumetric SMI <180.4 cm3/m3). Comparative and multivariate analyses identified the prognostic factors. The impact of body component changes during CCRT was explored.

RESULTS

Among 347 patients, there were 125 recurrences and 59 deaths (median follow-up, 50.5 months). Seven patients were excluded from the volumetric sarcopenia analysis because of incomplete baseline CT data, and 175 patients were included in the analysis of body composition changes. Patients with L3 sarcopenia had a lower 5-year progression-free survival (PFS) rate (55.6% vs. 66.2%, p = 0.027), while those with volumetric sarcopenia showed a poorer 5-year overall survival rate (76.5% vs. 85.1%, p = 0.036). Patients with total fat loss during CCRT had a worse 5-year PFS rate than those with total fat gain (61.9% vs. 73.8%, p = 0.029). Multivariate analyses revealed that total fat loss (adjusted hazard ratio [aHR], 2.172; 95% confidence interval [CI], 1.066-4.424; p = 0.033) was a significant factor for recurrence, whereas L3 sarcopenia was not. Volumetric sarcopenia increased the risk of death by 1.75-fold (aHR, 1.750; 95% CI, 1.012-3.025; p = 0.045).

CONCLUSIONS

Among patients with cervical cancer undergoing CCRT, initial volumetric sarcopenia and fat loss during treatment are survival risk factors. These findings suggest the potential importance of personalized supportive care, including tailored nutrition and exercise interventions.

Identifying modifiable risk factors to prevent aggressive colorectal cancer

It remains unclear if pre-diagnostic factors influence the developmental pathways of colorectal cancer (CRC) that could enhance tumor aggressiveness. This study used prospective data from 205,489 cancer-free US health professionals to investigate the associations of 31 known or putative risk factors with the risk of aggressive CRC. Tumor aggressiveness was characterized by three endpoints: aggressive CRC (cancer that causes death within 5 years of diagnosis), fatal CRC, and tumor stage at diagnosis. The data augmentation method was used to assess the difference in the associations between risk factors and endpoints. We documented 3201 CRC cases, of which 899 were aggressive. The protective associations of undergoing lower endoscopy (hazard ratios [HR] 0.43, 95% confidence interval (CI) 0.37, 0.49 for aggressive versus HR 0.61, 95% CI 0.56, 0.67 for non-aggressive) and regular use of aspirin (HR 0.70, 95% CI 0.61, 0.81 versus HR 0.84, 95% CI 0.77, 0.92) were stronger for aggressive than non-aggressive CRC (pHeterogeneity <0.05). Lower intake of whole grains or cereal fiber and greater dietary inflammatory potential were associated with a higher risk of aggressive but not non-aggressive CRC. The remaining risk factors showed comparable associations with aggressive CRC and non-aggressive CRC. Aggressive cases were more likely to have KRAS-mutated tumors but less likely to have distal or MSI-high tumors (p < .007). Similar results were observed for fatal CRC and advanced tumor stages at diagnosis. These findings provide initial evidence for the role of pre-diagnostic risk factors in the pathogenesis of aggressive CRC and suggest research priorities for preventive interventions.

Comprehensive analysis of the prognostic value of pre-treatment nutritional indicators in elderly rectal cancer patients

Nutritional status assessment has been deemed essential in treating elderly cancer patients. This study aims to investigate and compare the prognostic value and clinical utility of pre-treatment nutritional indicators in elderly rectal cancer (RC) patients. We retrospectively collected data from 361 elderly rectal cancer patients. The optimal cut-off values for pre-treatment nutritional indicators were calculated using ROC curve analysis. Univariate and multivariate Cox analyses were conducted to identify independent prognostic nutritional indicators. The predictive performance and clinical utility of these independent nutritional indicators was evaluated using time-dependent ROC. Multivariate analyses showed that body mass index (BMI), prognostic nutritional index (PNI), geriatric nutrition risk index (GNRI), and platelet-albumin ratio (PAR) independently predicted overall survival and progression-free survival in elderly RC patients (all p < 0.05), except for advanced lung cancer inflammation index (ALI). According to the nomogram model, the pre-treatment nutritional prognosis score was calculated and the patients were risk stratified. The KM curve showed that the survival of the high-risk group was significantly worse than that of the low-moderate risk group. Time-dependent ROC indicated that novel nutritional prognostic indicator (NNPI) had the best predictive ability compared with the independent prognostic nutritional indicator. Subgroup analysis also showed that NNPI had prognostic value across different clinical factors and had significant clinical utility. In elderly RC patients, BMI, PNI, GNRI, PAR, and NNPI serve as objective assessment tools for nutrition-related mortality risk. Identifying elderly patients at higher nutritional risk can guide early clinical nutritional interventions and improve patient outcomes.

Investigating the Obesity Paradox in Colorectal Cancer: An Analysis of Prospectively Collected Data in a Diverse Cohort

BACKGROUND

Prior studies are inconclusive regarding the effect of obesity on mortality in persons with colorectal cancer (CRC). We sought to determine the association of pre-diagnosis body mass index (BMI) trajectories on mortality after CRC diagnosis.

METHODS

Utilizing the Multiethnic Cohort, we included adults aged 18-75 between 1 January 1993 and 1 January 2019 with a diagnosis of CRC and at least three available BMIs. The primary exposure, BMI, was subjected to group-based trajectory modeling (GBTM). We evaluated all-cause and CRC-specific mortality, using Cox proportional hazard (PH) models.

RESULTS

Of 924 persons, the median age was 60 years, and 54% were female. There was no statistically significant association between pre-cancer BMI trajectory and either all-cause or cancer-specific mortality. In competing risk analysis, the risk of CRC-specific mortality was higher for African Americans (HR = 1.56, 95% CI [1.00-2.43], p = 0.048) and smokers (HR = 1.59, 95% CI [1.10-2.32], p = 0.015). Risk of all-cause mortality was higher for Hawaiian persons (HR = 2.85, 95% CI [1.31-6.21], p = 0.009) and persons with diabetes (HR = 1.83, 95% CI [1.08-3.10], p = 0.026).

CONCLUSIONS

Pre-diagnosis BMI trajectories were not associated with mortality after CRC diagnosis, whereas race/ethnicity, diabetes, and smoking were associated with an increased risk of death. Our findings suggest the obesity paradox alone does not account for mortality after CRC diagnosis.

Biological functions and therapeutic potential of CKS2 in human cancer

The incidence of cancer is increasing worldwide and is the most common cause of death. Identification of novel cancer diagnostic and prognostic biomarkers is important for developing cancer treatment strategies and reducing mortality. Cyclin-dependent kinase subunit 2 (CKS2) is involved in cell cycle and proliferation processes, and based on these processes, CKS2 was identified as a cancer gene. CKS2 is expressed in a variety of tissues in the human body, but its abnormal expression is associated with cancer in a variety of systems. CKS2 is generally elevated in cancer, plays a role in almost all aspects of cancer biology (such as cell proliferation, invasion, metastasis, and drug resistance) through multiple mechanisms regulating certain important genes, and is associated with clinicopathological features of patients. In addition, CKS2 expression patterns are closely related to cancer type, stage and other clinical variables. Therefore, CKS2 is considered as a tool for cancer diagnosis and prognosis and may be a promising tumor biomarker and therapeutic target. This article reviews the biological function, mechanism of action and potential clinical significance of CKS2 in cancer, in order to provide a new theoretical basis for clinical molecular diagnosis, molecular targeted therapy and scientific research of cancer.

Post-diagnosis physical activity and sedentary behaviour and colorectal cancer prognosis: A Global Cancer Update Programme (CUP Global) systematic literature review and meta-analysis

Low physical activity and high sedentary behaviour have been clearly linked with colorectal cancer development, yet data on their potential role in colorectal cancer survival is limited. Better characterisation of these relationships is needed for the development of post-diagnosis physical activity and sedentary behaviour guidance for colorectal cancer survivors. We searched PubMed and Embase through 28 February 2022 for studies assessing post-diagnosis physical activity, and/or sedentary behaviour in relation to all-cause and cause-specific mortality and recurrence after colorectal cancer diagnosis. Total and recreational physical activity were assessed overall and by frequency, duration, intensity, and volume using categorical, linear, and non-linear dose-response random-effects meta-analyses. The Global Cancer Update Programme (CUP Global) independent Expert Committee on Cancer Survivorship and Expert Panel interpreted and graded the likelihood of causality. We identified 16 observational studies on 82,220 non-overlapping patients from six countries. Physical activity was consistently inversely associated with colorectal cancer morbidity and mortality outcomes, with 13%-60% estimated reductions in risk. Sedentary behaviour was positively associated with all-cause mortality. The evidence had methodological limitations including potential confounding, selection bias and reverse causation, coupled with a limited number of studies for most associations. The CUP Global Expert panel concluded limited-suggestive evidence for recreational physical activity with all-cause mortality and cancer recurrence. Total physical activity and its specific domains and dimensions, and sedentary behaviour were all graded as limited-no conclusion for all outcomes. Future research should focus on randomised trials, while observational studies should obtain objective and repeated physical activity measures and better adjustment for confounders.

Pre-diagnostic circulating resistin concentrations and mortality among individuals with colorectal cancer: Results from the European Prospective Investigation into Cancer and Nutrition study

Resistin is a protein involved in inflammation and angiogenesis processes and may play a role in the progression of colorectal cancer (CRC). However, it remains unclear whether resistin is associated with increased mortality after CRC diagnosis. We examined pre-diagnostic serum resistin concentrations in relation to CRC-specific and all-cause mortality among 1343 incident CRC cases from the European Prospective Investigation into Cancer and Nutrition cohort. For CRC-specific mortality as the primary outcome, hazard ratios (HRs) and 95% confidence intervals (95% CI) were estimated from competing risk analyses based on cause-specific Cox proportional hazards models and further in sensitivity analyses using Fine-Gray proportional subdistribution hazards models. For all-cause mortality as the secondary outcome, Cox proportional hazards models were used. Subgroup analyses were performed by sex, tumor subsite, tumor stage, body mass index and time to CRC diagnosis. Resistin was measured on a median of 4.8 years before CRC diagnosis. During a median follow-up of 8.2 years, 474 deaths from CRC and 147 deaths from other causes were observed. Resistin concentrations were not associated with CRC-specific mortality (HRQ4vsQ1  = 0.95, 95% CI: 0.73-1.23; Ptrend  = .97; and HRper doubling of resistin concentration  = 1.00; 95% CI: 0.84-1.19; P = .98) or all-cause mortality. Results from competing risk (sensitivity) analysis were similar. No associations were found in any subgroup analyses. These findings suggest no association between pre-diagnostic circulating resistin concentrations and CRC-specific or all-cause mortality among persons with CRC, and the potential insignificance of resistin in CRC progression.

Adiposity and cancer survival: a systematic review and meta-analysis

PURPOSE

The increasing availability of clinical imaging tests (especially CT and MRI) that directly quantify adipose tissue has led to a rapid increase in studies examining the relationship of visceral, subcutaneous, and overall adiposity to cancer survival. To summarize this emerging body of literature, we conducted a systematic review and meta-analysis of imaging-measured as well as anthropometric proxies for adipose tissue distribution and cancer survival across a wide range of cancer types.

METHODS

Using keywords related to adiposity, cancer, and survival, we conducted a systematic search of the literature in PubMed and MEDLINE, Embase, and Web of Science Core Collection databases from database inception to 30 June 2021. We used a random-effect method to calculate pooled hazard ratios (HR) and corresponding 95% confidence intervals (CI) within each cancer type and tested for heterogeneity using Cochran's Q test and the I2 test.

RESULTS

We included 203 records for this review, of which 128 records were utilized for quantitative analysis among 10 cancer types: breast, colorectal, gastroesophageal, head and neck, hepatocellular carcinoma, lung, ovarian, pancreatic, prostate, and renal cancer. We found that imaging-measured visceral, subcutaneous, and total adiposity were not significantly associated with increased risk of overall mortality, death from primary cancer, or cancer progression among patients diagnosed with these 10 cancer types; however, we found significant or high heterogeneity for many cancer types. For example, heterogeneity was similarly high when the pooled HRs (95% CI) for overall mortality associated with visceral adiposity were essentially null as in 1.03 (0.55, 1.92; I2 = 58%) for breast, 0.99 (0.81, 1.21; I2 = 71%) for colorectal, versus when they demonstrated a potential increased risk 1.17 (0.85, 1.60; I2 = 78%) for hepatocellular carcinoma and 1.62 (0.90, 2.95; I2 = 84%) for renal cancer.

CONCLUSION

Greater adiposity at diagnosis (directly measured by imaging) is not associated with worse survival among cancer survivors. However, heterogeneity and other potential limitations were noted across studies, suggesting differences in study design and adiposity measurement approaches, making interpretation of meta-analyses challenging. Future work to standardize imaging measurements and data analyses will strengthen research on the role of adiposity in cancer survival.

Associations of cigarette smoking, alcohol drinking and body mass index with survival after colorectal cancer diagnosis by anatomic subsite: a prospective patient cohort study in Japan

BACKGROUND

Cigarette smoking, alcohol drinking and obesity are known to be risk factors for colorectal cancer. These factors may affect survival after diagnosis, but evidence has been inconsistent. We investigated subsite-specific associations between prediagnosis smoking, alcohol drinking and body mass index and survival in colorectal cancer.

METHODS

Subjects were 1300 patients (colon 778; rectum 502; concurrent 20) with histologically confirmed colorectal cancer diagnosed during 1997-2013 at a single institution in Japan. Histories of smoking and alcohol drinking, height and prediagnosis weight were assessed using a self-administered questionnaire. Using Cox proportional hazards model, hazard ratios and 95% confidence intervals of mortality were estimated.

RESULTS

During a median follow-up period of 6.7 years, 479 deaths were documented. Ever-smoking was associated with an increased risk of all-cause death among patients with colon cancer (hazard ratio: 1.47; 95% confidence interval: 1.07-2.02 compared with never-smoking). According to colon subsite, this increased risk was clear in patients with proximal colon cancer (hazard ratio: 2.09; 95% confidence interval: 1.28-3.40). There was no association between smoking and rectal cancer survival. Alcohol drinking was not associated with survival for either colon or rectal cancer. Among patients with rectal cancer, higher body mass index was associated with a lower risk of all-cause (Ptrend = 0.0006) and disease-specific death (Ptrend = 0.02). For colon cancer, lower body mass index tended to be associated with a higher risk of all-cause death (Ptrend = 0.05).

CONCLUSIONS

The results indicate that lifestyles identified as risk factors for colorectal cancer may impact differently on patient survival according to anatomic subsite.

Association of Body Mass Index with Survival in Asian Patients with Colorectal Cancer

Purpose

The clinical significance of body mass index (BMI) on long-term outcomes has not been extensively investigated in Asian patients with colorectal cancer (CRC). This study aims to describe the association between BMI and survival, plus providing BMI cutoff value for predicting prognosis in CRC patients.

Materials and Methods

A total of 1,182 patients who had undergone surgery for stage I–III CRC from June 2004 to February 2014 were included. BMI was categorized into four groups based on the recommendation for Asian ethnicity. The optimal BMI cutoff value was determined to maximize overall survival (OS) difference.

Results

In multivariable analysis, underweight BMI was significantly associated with poor OS (hazard ratio [HR], 2.38; 95% confidence interval [CI], 1.55 to 3.71; p < 0.001) and obese BMI was associated with better OS (HR, 0.72; 95% CI, 0.53 to 0.97; p=0.036) compared with the normal BMI. Overweight and obese BMI were associated with better recurrence-free survival (HR, 0.64; 95% CI, 0.42 to 0.99; p=0.046 and HR, 0.58; 95% CI, 0.38 to 0.89; p=0.014, respectively) compared with the normal BMI group. BMI cutoff value was 20.44 kg/m². Adding the BMI cutoff value to cancer staging could increase discriminatory performance in terms of integrated area under the curve and Harrell’s concordance index.

Conclusion

Compared to normal BMI, underweight BMI was associated with poor survival whereas obese BMI was associated with better survival. BMI cutoff value of 20.44 kg/m² is a useful discriminator in Asian patients with CRC.

Association of Obesity With Survival Outcomes in Patients With Cancer: A Systematic Review and Meta-analysis

Importance

Obesity, defined as a body mass index (BMI) greater than 30, is associated with a significant increase in the risk of many cancers and in overall mortality. However, various studies have suggested that patients with cancer and no obesity (ie, BMI 20-25) have worse outcomes than patients with obesity.

Objective

To assess the association between obesity and outcomes after a diagnosis of cancer.

Data Sources

PubMed, the Cochrane Library, and EMBASE were searched from inception to January 2020.

Study Selection

Studies reporting prognosis of patients with obesity using standard BMI categories and cancer were included. Studies that used nonstandard BMI categories, that were limited to children, or that were limited to patients with hematological malignant neoplasms were excluded. Screening was performed independently by multiple reviewers. Among 1892 retrieved studies, 203 (17%) met inclusion criteria for initial evaluation.

Data Extraction and Synthesis

The Meta-analysis of Observational Studies in Epidemiology (MOOSE) and Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines were reporting guideline was followed. Data were extracted by multiple independent reviewers. Risk of death, cancer-specific mortality, and recurrence were pooled to provide an adjusted hazard ratio (HR) with a 95% CI . A random-effects model was used for the retrospective nature of studies.

Main Outcomes and Measures

The primary outcome of the study was overall survival (OS) in patients with cancer, with and without obesity. Secondary end points were cancer-specific survival (CSS) and progression-free survival (PFS) or disease-free survival (DFS). The risk of events was reported as HRs with 95% CIs, with an HR greater than 1 associated with a worse outcome among patients with obesity vs those without.

Results

A total of 203 studies with 6 320 365 participants evaluated the association of OS, CSS, and/or PFS or DFS with obesity in patients with cancer. Overall, obesity was associated with a reduced OS (HR, 1.14; 95% CI, 1.09-1.19; P < .001) and CSS (HR, 1.17; 95% CI, 1.12-1.23; P < .001). Patients were also at increased risk of recurrence (HR, 1.13; 95% CI, 1.07-1.19; P < .001). Conversely, patients with obesity and lung cancer, renal cell carcinoma, or melanoma had better survival outcomes compared with patients without obesity and the same cancer (lung: HR, 0.86; 95% CI, 0.76-0.98; P = .02; renal cell: HR, 0.74; 95% CI, 0.53-0.89; P = .02; melanoma: HR, 0.74; 95% CI, 0.57-0.96; P < .001).

Conclusions and Relevance

In this study, obesity was associated with greater mortality overall in patients with cancer. However, patients with obesity and lung cancer, renal cell carcinoma, and melanoma had a lower risk of death than patients with the same cancers without obesity. Weight-reducing strategies may represent effective measures for reducing mortality in these patients.

The impact of anthropometric parameters on colorectal cancer prognosis: A systematic review and meta-analysis

BACKGROUND & AIMS

Our study aims to clarify the relationship between weight parameters and colorectal cancer outcomes.

METHODS

NCBI, Embase, Cochrane, and Web of Science were searched from inception to December 2019. Studies reporting colorectal cancer (CRC) mortality, recurrence, disease-free survival, overall survival, overall mortality stratified by pre-diagnosis BMI or post-diagnosis weight change, were included in the analysis. Random effects analysis was performed for all outcomes, with heterogeneity assessed by the I² statistic.

RESULTS

Our meta-analysis included 45 studies encompassing 607,266 patients. Obesity was associated with increased odds of overall mortality and CRC-specific mortality compared to normal weight (p < 0.001). Patients with underweight BMI had increased odds of CRC-specific mortality compared to normal BMI but were not significantly different from obese BMI.

CONCLUSIONS

Obese and underweight BMI are associated with increased CRC-specific and overall mortality compared to normal BMI. Long term prognosis was similar for patients with obese and underweight BMI.

A paradox between preoperative overweight/obesity and change in weight during postoperative chemotherapy and its relationship to survival in stage Ⅱ and Ⅲ colorectal cancer patients

BACKGROUND & AIMS

The roles of obesity and weight management in colorectal cancer (CRC) recurrence and survival have gained a considerable amount of attention. However, whether a change in weight affects the risk of recurrence and death remains unclear.

METHODS

A retrospective study was conducted using Kaplan-Meier curves, multivariable Cox proportional hazards models, and restricted cubic splines in 902 patients with stage Ⅱ and Ⅲ CRC to investigate the impact of the preoperative BMI and change in weight during postoperative chemotherapy on disease-free survival (DFS) and overall survival (OS).

RESULTS

The lowest risk of cancer events (recurrence/metastasis and new CRC cases) and death occurred in patients who had a normal weight (BMI range from 18.5 to 23.9 kg/m²) or had weight gain of < 5%; the patients who were underweight (BMI ≤ 18.5 kg/m²) or overweight/obese (BMI ≥ 24.0 kg/m²) and had weight loss or weight gain of ≥ 5% had a higher risk of cancer events and death. The association between preoperative BMI and the risk of cancer events and death exhibited U-shaped curves; the inflection points were at BMI = 24 kg/m² and BMI = 25 kg/m² for the risk of cancer events and death, respectively. The association between the change in weight and risk of death also exhibited a U-shaped curve, while the association between the change in weight and risk of cancer events was nearly linear. Multivariable Cox proportional hazards models showed that the preoperative BMI and change in weight played bidirectional roles in both the OS and DFS.

CONCLUSIONS

An obesity paradox exists in patients with CRC, with both weight loss and excessive weight gain being detrimental. Patients with CRC may require a reasonable weight management program, and gaining < 5% of the preoperative weight might be an appropriate goal at 6 months after surgery.

Microsatellite Instability and Life Style Factors in Sporadic Colorectal Cancer

Background:

Colorectal cancer (CRC) in Egypt is a relatively high young onset disease. As a form of heterogeneous cancer, there is interplay between genetic and environmental factors. We aimed at probing the association of life style factors and Microsatellite Instability (MSI) status that could provide more insights on carcinogenic process of CRC.

Methods:

One hundred incident sporadic CRC patients were involved. Information on risk factors of CRC was obtained and microsatellite instability status was predicted through evaluation of MMR protein expression via immunohistochemistry (IHC).

Results:

Median age was 47.50 years, females represented 54.0% and 36% of patients were Microsatellite Instability High (MSI-H). Most patients with right sided colon cancer (78.3%) were MSI-H while mostly stable or low MSS/MSI-L for left-sided colon and rectum (78.6%, 74.3% respectively, p<0.001). Patients with low physical activity had higher risk of MSS/MSI-L than those with moderate or high activity p =0.026. Patients with BMI greater than 30 Kg/m² had higher MSS/MSI-L (75.5%) than those with BMI between 25-30 Kg/m² (60.6%) and those with normal BMI <25 (38.9%), p for trend = 0.006. On subgroup analyses, the association of high BMI with MSS/MSI-L was only shown in patients younger than 40 years, females, stage III, non-mucin secreting adenocarcinoma and a significant interaction with physical activity.

Conclusion:

In Conclusion, the present study confirms the increased risk of MSS/MSI-L with increased BMI and speculates this association to be modified by patient’s life style and tumor characteristics. Further research is needed to validate present results.

Impact of adiposity on staging and prognosis of colorectal cancer

Abdominal visceral fat is a well-recognized a risk for colorectal cancer (CRC). In contrast to the risk for CRC, the impact of adiposity in disease staging and patient survival is less well-established. Our aim was to critically review the literature on the influence of adiposity assessed by different methods routinely used in clinical settings, on CRC staging and prognosis. In the 32 studies reviewed, overweight was initially identified as a survival advantage, an evidence that was later challenged by studies suggesting that body adiposity is likely to have a deleterious effect in CRC outcomes, particularly in males. Hence, whether obesity has a negative impact in CRC staging or prognosis remains controversial. In sum, addressing the impact of body fat in CRC biological behavior is still an unmet need. Understanding how adiposity influences CRC staging and prognosis could allow further patient risk stratification for devising targeted interventions and improve clinical outcomes.

Lifestyle and dietary environmental factors in colorectal cancer susceptibility

Colorectal cancer (CRC) incidence changes with time and by variations in diet and lifestyle, as evidenced historically by migrant studies and recently by extensive epidemiologic evidence. The worldwide heterogeneity in CRC incidence is strongly suggestive of etiological involvement of environmental exposures, particularly lifestyle and diet. It is established that physical inactivity, obesity and some dietary factors (red/processed meats, alcohol) are positively associated with CRC, while healthy lifestyle habits show inverse associations. Mechanistic evidence shows that lifestyle and dietary components that contribute to energy excess are linked with increased CRC via metabolic dysfunction, inflammation, oxidative stress, bacterial dysbiosis and breakdown of gut barrier integrity while the reverse is apparent for components associated with decreased risk. This chapter will review the available evidence on lifestyle and dietary factors in CRC etiology and their underlying mechanisms in CRC development. This short review will also touch upon available information on potential gene-environment interactions, molecular sub-types of CRC and anatomical sub-sites within the colorectum.

Adult Overweight and Survival from Breast and Colorectal Cancer in Swedish Women

BACKGROUND

The impact of overweight duration and intensity during adulthood on the prognosis after a cancer diagnosis remains largely unknown. We investigated this association in Swedish women with breast and colorectal cancer.

METHODS

A cohort of 47,051 women from the Swedish Lifestyle and Health Study was included, of whom 1,241 developed postmenopausal breast (mean age at diagnosis, 57.5 years) and 259 colorectal (mean age at diagnosis, 59.1 years) cancer. Trajectories of body mass index (BMI) between ages 20 and 50 years were estimated for the full cohort using a quadratic growth model and studied in relation to risk of death from any cause using multivariate Cox regression models among cancer survivors.

RESULTS

Compared with patients with cancer who were never overweight (BMI < 25) during early adulthood (ages 20-50 years), the risk of early death from breast cancer increased by 3% [hazard ratio (HR) = 1.03; 95% confidence interval (CI), 1.01-1.05] and from colorectal cancer by 4% (HR = 1.04; 95% CI, 1.01-1.06) for every year lived with overweight. A higher intensity of overweight (i.e., a combination of duration and degree of overweight-a concept comparable to pack-years of cigarette smoking) further increased the risk of dying in this population. Although risks were slightly more pronounced for women diagnosed with late-stage breast cancer, no clear association was found for colorectal cancer.

CONCLUSIONS

Our results suggest that adulthood overweight duration and intensity have a long-lasting influence on breast and colorectal cancer survival.

IMPACT

Our study highlights the need for effective prevention of overweight and obesity starting at an early age.

The Plausibility of Obesity Paradox in Cancer-Point

In contrast to the convincing evidence that obesity (measured by body mass index, BMI) increases the risk of many different types of cancer, there is an ambiguity in the role of obesity in survival among cancer patients. Some studies suggested that higher BMI decreased mortality risk in cancer patients, a phenomenon called the obesity paradox. The spurious positive association between BMI and cancer survival is likely to be explained by several methodologic limitations including confounding, reverse causation, and collider stratification bias. Also, the inadequacy of BMI as a measure of body fatness in cancer patients commonly experiencing changes in body weight and body composition may have resulted in the paradox. Other factors contributing to the divergent results in literature are significant heterogeneity in study design and method (e.g., study population, follow-up length); time of BMI assessment (pre-, peri-, or post-diagnosis); and lack of consideration for variability in the strength and directions of associations by age, sex, race/ethnicity, and cancer subtype. Robust but practical methods to accurately assess body fatness and body compositions and weight trajectories in cancer survivors are needed to advance this emerging field and to develop weight guidelines to improve both the length and the quality of cancer survival. Cancer Res; 78(8); 1898-903. ©2018 AACR.

Bevacuzimab May Be Less Effective in Obese Metastatic Colorectal Cancer Patients

PURPOSE

The purpose of this study was to investigate whether obesity affects survival in metastatic colorectal cancer (mCRC) patients treated with bevacizumab combined with chemotherapy.

METHODS

A total of 563 patients with mCRC who had received first-line chemotherapy in combination with bevacizumab were studied. Patients were grouped as obese (BMI levels > 30) or non-obese (BMI levels < 30). Progression-free survival (PFS) and overall survival (OS) were analyzed. Primary tumor location was also investigated in terms of PFS and OS.

RESULTS

The median age of the patients was 59 years. The non-obese group had longer PFS than the obese group (P = 0.030). The 2-year survival rate of the non-obese group was also significantly higher (P = 0.036). The median PFS of non-obese patients was significantly longer in Kras wild-type patients (10.1 vs. 8.1 months, P = 0.010). Among patients with left-sided primary tumor location, median PFS and OS were significantly higher in the non-obese group (PFS non-obese, 11.5 months; obese, 8.8 months; P = 0.002) (OS non-obese, 29.4 months; obese, 21.4 months; P = 0.026).

CONCLUSIONS

Efficacy of bevacizumab may be lower in obese patients. Among patients with Kras wild-type left-sided tumors treated with bevacizumab-based regimens, the prognosis could be worse for obese patients than that for non-obese patients. There is a need for prospectively designed studies of obese patients to prove the efficacy and dosages of bevacizumab in treatment of mCRC.

Influence of Body Mass Index on Long-Term Outcome in Patients with Rectal Cancer-A Single Centre Experience

BACKGROUND

Excess bodyweight is known to influence the risk of colorectal cancer; however, little evidence exists for the influence of the body mass index (BMI) on the long-term outcome of patients with rectal cancer.

METHODS

We assessed the impact of the BMI on the risk of local recurrence, distant metastasis and overall-survival in 612 patients between 2003 and 2010 after rectal cancer diagnosis and treatment at the University Hospital Erlangen. A Cox-regression model was used to estimate the hazard ratio and multivariate risk of mortality and distant-metastasis. Median follow up-time was 58 months.

RESULTS

Patients with obesity class II or higher (BMI ≥ 35 kg/m², n = 25) and patients with underweight (BMI < 18.5 kg/m², n = 5) had reduced overall survival (hazard ratio (HR) = 1.6; 95% confidence interval (CI) 0.9-2.7) as well as higher rates of distant metastases (hazard ratio HR = 1.7; 95% CI 0.9-3.3) as compared to patients with normal bodyweight (18.5 ≤ BMI < 25 kg/m², n = 209), overweight (25 ≤ BMI <30 kg/m², n = 257) or obesity class I (30 ≤ BMI <35 kg/m², n = 102). There were no significant differences for local recurrence.

CONCLUSIONS

Underweight and excess bodyweight are associated with lower overall survival and higher rates of distant metastasis in patients with rectal cancer.

Adiposity and gastrointestinal cancers: epidemiology, mechanisms and future directions

Excess adiposity is a risk factor for several cancers of the gastrointestinal system, specifically oesophageal adenocarcinoma and colorectal, small intestine, pancreatic, liver, gallbladder and stomach cancers. With the increasing prevalence of obesity in nearly all regions of the world, this relationship could represent a growing source of cancers of the digestive system. Experimental and molecular epidemiological studies indicate important roles for alterations in insulin signalling, adipose tissue-derived inflammation and sex hormone pathways in mediating the association between adiposity and gastrointestinal cancer. The intestinal microbiome, gut hormones and non alcoholic fatty liver disease (NAFLD) also have possible roles. However, important gaps remain in our knowledge. For instance, our understanding of how adiposity throughout the life course is related to the risk of gastrointestinal cancer development and of how obesity influences gastrointestinal cancer prognosis and survival is limited. Nonetheless, the increasing use of state-of-the-art analytical methods (such as omics technologies, Mendelian randomization and MRI) in large-scale epidemiological studies offers exciting opportunities to advance our understanding of the complex relationship between adiposity and gastrointestinal cancers. Here, we examine the epidemiology of associations between obesity and gastrointestinal cancer, explore potential mechanisms underlying these relationships and highlight important unanswered research questions.

Association Analysis between Body Mass Index and Genomic DNA Methylation across 15 Major Cancer Types

Cancer incidence and mortality increase with increasing body mass index (BMI), but BMI-associated epigenetic alterations in cancer remain elusive. We hypothesized that BMI would be associated with DNA methylation alterations in cancers. To test this hypothesis, here, we estimated the associations between DNA methylation and BMI through two different methods across 15 cancer types, at approximately 485,000 CpG sites and 2415 samples using data from The Cancer Genome Atlas. After comparing the DNA methylation levels in control BMI and high BMI individuals, we found differentially methylated CpG sites (DMSs) in cholangiocarcinoma (CHOL), colon adenocarcinoma (COAD), and uterine corpus endometrial carcinoma (UCEC) (False Discovery Rate < 0.05). The DMSs of COAD or UCEC were enriched in several obesity-induced and cancer-related pathways. Next, when BMI was used as a continuous variable, we identified BMI-associated methylated CpG sites (BMS) (P (Bonferroni) < 0.05) in CHOL (BMS = 1), COAD (BMS = 1), and UCEC (BMS = 4) using multivariable linear regression. In UCEC, three of the BMSs can predict the clinical outcomes and survival of patients with the tumors. Overall, we observed associations between DNA methylation and high BMI in CHOL, COAD, and UCEC. Furthermore, three BMI-associated CpGs were identified as potential biomarkers for UCEC prognosis.

Overexpression of long non-coding RNA colon cancer-associated transcript 2 is associated with advanced tumor progression and poor prognosis in patients with colorectal cancer

The aim of the present study was to explore the clinicopathological and prognostic significance of long non-coding RNA (lncRNA) colon cancer-associated transcript 2 (CCAT2) expression in human colorectal cancer (CRC). Expression levels of lncRNA CCAT2 in CRC, adjacent non-tumor and healthy colon mucosa tissues were detected by quantitative polymerase chain reaction. The disease-free survival and overall survival rates were evaluated using the Kaplan-Meier method, and multivariate analysis was performed using Cox proportional hazard analysis. The expression level of lncRNA CCAT2 in CRC tissues was increased significantly compared with adjacent normal tissues or non-cancerous tissues. CCAT2 expression was observed to be progressively increased between tumor-node-metastasis (TNM) stages I and IV. A high level of CCAT2 expression was revealed to be associated with poor cell differentiation, deeper tumor infiltration, lymph node metastasis, distance metastasis, vascular invasion and advanced TNM stage. Compared with patients with low levels of CCAT2 expression, patients with high levels of CCAT2 expression had shorter disease-free survival and overall survival times. Multivariate analyses indicated that high CCAT2 expression was an independent poor prognostic factor. Therefore, increased lncRNA CCAT2 expression maybe a potential diagnostic biomarker for CRC, and an independent predictor of prognosis in patients with CRC.

The Impact of Body Mass Index and Waist Circumference on Health-related Quality of Life Among Colorectal Cancer Survivors: Results from the PROFILES Registry

BACKGROUND

We aimed to assess the association of waist circumference (WC) and body mass index (BMI) with health-related quality of life (HRQL) among colorectal cancer (CRC) survivors.

METHODS

CRC survivors diagnosed between 2000 and 2009 completed questionnaires in August 2013 (with self-reported weight, height, and self-assessed WC) and January 2014 (with HRQL using the EORTC-QLQ-C30). Clinical characteristics were retrieved from the Netherlands Cancer Registry. In multivariable linear regression analyses associations of BMI only, WC only and both BMI and WC with HRQL outcomes were assessed.

RESULTS

1,111 CRC survivors were included of whom 34% had a normal weight (18.5 ≤ BMI < 25 kg/m²), 49% had overweight (25 ≤ BMI < 30 kg/m²), 17% had obesity (BMI ≥ 30 kg/m²), and 44% had an increased WC (i.e., >102 and >88 cm for men and women, respectively). Both BMI and WC were separately associated with worse global health status, functioning, and more symptoms of fatigue. Increased WC was associated with lower physical, role and emotional functioning, regardless of BMI, with average differences ranging between 3 and 5 points.

CONCLUSION

Future research on HRQL among CRC survivors should consider both BMI and WC. Furthermore, weight reduction trials should not only focus on general weight loss but also on the loss of abdominal fat.

Body mass index and risk of colorectal carcinoma subtypes classified by tumor differentiation status

Previous studies suggest that abnormal energy balance status may dysregulate intestinal epithelial homeostasis and promote colorectal carcinogenesis, yet little is known about how host energy balance and obesity influence enterocyte differentiation during carcinogenesis. We hypothesized that the association between high body mass index (BMI) and colorectal carcinoma incidence might differ according to tumor histopathologic differentiation status. Using databases of the Nurses' Health Study and Health Professionals Follow-up Study, and duplication-method Cox proportional hazards models, we prospectively examined an association between BMI and the incidence of colorectal carcinoma subtypes classified by differentiation features. 120,813 participants were followed for 26 or 32 years and 1528 rectal and colon cancer cases with available tumor pathological data were documented. The association between BMI and colorectal cancer risk significantly differed depending on the presence or absence of poorly-differentiated foci (P_{heterogeneity} = 0.006). Higher BMI was associated with a higher risk of colorectal carcinoma without poorly-differentiated foci (≥30.0 vs. 18.5-22.4 kg/m²: multivariable-adjusted hazard ratio, 1.87; 95% confidence interval, 1.49-2.34; P_trend < 0.001), but not with risk of carcinoma with poorly-differentiated foci (P_trend = 0.56). This differential association appeared to be consistent in strata of tumor microsatellite instability or FASN expression status, although the statistical power was limited. The association between BMI and colorectal carcinoma risk did not significantly differ by overall tumor differentiation, mucinous differentiation, or signet ring cell component (P_{heterogeneity} > 0.03, with the adjusted α of 0.01). High BMI was associated with risk of colorectal cancer subtype containing no poorly-differentiated focus. Our findings suggest that carcinogenic influence of excess energy balance might be stronger for tumors that retain better intestinal differentiation throughout the tumor areas.

Prediagnosis body mass index and waist-hip circumference ratio in association with colorectal cancer survival

The association of obesity on survival among patients with colorectal cancer (CRC) has not been well characterized. We investigated the association of prediagnostic body mass index (BMI)/waist-hip ratio (WHR) and total/cause-specific mortality in CRC patients. Our study included 1,452 patients who participated in two large cohort studies and were diagnosed with CRC during follow-up period. Participants were measured for anthropometrics and interviewed to collect relevant information at baseline, prior to any cancer diagnosis. Data on site-specific cancer incidence and cause-specific mortality were obtained via in-person surveys and annual record linkage with cancer and vital statistics registries. Cox proportional hazard models were used to evaluate the associations of BMI and WHR with survival. A total of 547 participants died during the follow-up period, including 499 who died of CRC. Relative to normal BMI (18.5 to <25.0 kg/m² ), obesity (BMI ≥ 30 kg/m² ) was associated with increased mortality resulting from all causes [hazard ratio (HR) = 1.5, 95% confidence interval (CI): 1.1-2.1] and CRC (HR = 1.5, 95% CI: 1.1-2.1). Elevated risk of death was also found among underweight patients (BMI < 18.5 kg/m² ), although not all risk estimates were statistically significant. Overweight BMI (25.0 to <30.0 kg/m² ) was not associated with risk of death among CRC patients, nor was WHR. In conclusion, prediagnostic BMI was associated with survival among CRC patients following a U-shape pattern; obesity was associated with high mortality after CRC diagnosis. These findings provide support for maintaining healthy weight to improve the survival of CRC patients.

Relationship of prediagnostic body mass index with survival after colorectal cancer: Stage-specific associations

Higher body mass index (BMI) is a well-established risk factor for colorectal cancer (CRC), but is inconsistently associated with CRC survival. In 6 prospective studies participating in the Genetics and Epidemiology of Colorectal Cancer Consortium (GECCO), 2,249 non-Hispanic white CRC cases were followed for a median 4.5 years after diagnosis, during which 777 died, 554 from CRC-related causes. Associations between prediagnosis BMI and survival (overall and CRC-specific) were evaluated using Cox regression models adjusted for age at diagnosis, sex, study and smoking status (current/former/never). The association between BMI category and CRC survival varied by cancer stage at diagnosis (I-IV) for both all-cause (p-interaction = 0.03) and CRC-specific mortality (p-interaction = 0.04). Compared to normal BMI (18.5-24.9 kg/m(2) ), overweight (BMI 25.0-29.9) was associated with increased mortality among those with Stage I disease, and decreased mortality among those with Stages II-IV disease. Similarly, obesity (BMI ≥30) was associated with increased mortality among those with Stages I-II disease, and decreased mortality among those with Stages III-IV disease. These results suggest the relationship between BMI and survival after CRC diagnosis differs by stage at diagnosis, and may emphasize the importance of adequate metabolic reserves for colorectal cancer survival in patients with late-stage disease.

Pre-diagnostic body mass index and weight change in relation to colorectal cancer survival among incident cases from a population-based cohort study

Background

Whether excess body weight influences colorectal cancer (CRC) survival is unclear. We studied pre-diagnostic body mass index (BMI) and weight change in relation to CRC-specific mortality among incident CRC cases within a large, Norwegian cohort.

Methods

Participants’ weight was measured at health examinations up to three times between 1974 and 1988. CRC cases were identified through linkage with the Norwegian Cancer Registry. In total, 1336 men and 1180 women with a weight measurement >3 years prior to diagnosis were included in analyses. Hazard ratios (HRs) and confidence intervals (CIs) were estimated with Cox regression.

Results

During a mean follow-up of 5.8 years, 507 men and 432 women died from CRC. Obesity (BMI ≥30 kg/m²) was associated with higher CRC-specific mortality than normal weight (BMI 18.5–25 kg/m²) in men with proximal colon cancer, HR = 1.85 (95 % CI 1.08–3.16) and in women with rectal cancer, HR = 1.93 (95 % CI 1.13–3.30). Weight gain was associated with higher CRC-specific mortality in women with CRC, colon cancer, and distal colon cancer, HRs per 5 kg weight gain were 1.18 (95 % CI 1.01–1.37), 1.22 (95 % CI 1.02–1.45), and 1.40 (95 % CI 1.01–1.95), respectively. Weight gain was not significantly associated with survival in men.

Conclusions

Maintaining a healthy weight may benefit CRC survival, at least in women.

Electronic supplementary material

The online version of this article (doi:10.1186/s12885-016-2445-4) contains supplementary material, which is available to authorized users.

Body mass index and colorectal cancer prognosis: a systematic review and meta-analysis

Colorectal cancer is one of the most common cancers worldwide. However, it is unclear what influence body mass index (BMI) has on colorectal cancer prognosis. We conducted a systematic review and meta-analysis of observational studies to examine the association of BMI with colorectal cancer outcomes. We searched MEDLINE and EMBASE databases from inception to February 2015 and references of identified articles. We selected observational studies that reported all-cause mortality, colorectal cancer-specific mortality, recurrence and disease-free survival according to BMI category. Random-effects meta-analyses were conducted to combine estimates. We included 18 observational studies. Obese patients had an increased risk of all-cause mortality [relative risk (RR) 1.14; 95 % confidence interval (CI) 1.07-1.21], cancer-specific mortality (RR 1.14; 95 % CI 1.05-1.24), recurrence (RR 1.07; 95 % CI 1.02-1.13) and worse disease-free survival (RR 1.07; 95 % CI 1.01-1.13). Underweight patients also had an increased risk of all-cause mortality (RR 1.43; 95 % CI 1.26-1.62), cancer-specific mortality (RR 1.50; 95 % CI 1.20-1.87), recurrence (RR 1.13; 95 % CI 1.05-1.21) and worse disease-free survival (RR 1.27; 95 % CI 1.13-1.43). Overweight patients had no increased risk for any of the outcomes studied. Both obese and underweight patients with colorectal cancer have an increased risk of all-cause mortality, cancer-specific mortality, disease recurrence and worse disease-free survival compared to normal weight patients.

Obesity and colorectal cancer: molecular features of adipose tissue

The huge part of population in developed countries is overweight or obese. Obesity is often determined by body mass index (BMI) but new accurate methods and ratios have recently appeared to measure body fat or fat located in the intestines. Early diagnosis of obesity is crucial since it is considered an increasing colorectal cancer risk factor. On the one hand, colorectal cancer has been strongly associated with lifestyle factors. A diet rich in red and processed meats may increase colorectal cancer risk; however, high-fiber diets (grains, cereals and fruits) have been associated with a decreased risk of colorectal cancer. Other life-style factors associated with obesity that also increase colorectal cancer risk are physical inactivity, smoking and high alcohol intake. Cutting-edge studies reported that high-risk transformation ability of adipose tissue is due to production of different pro-inflammatory cytokines like IL-8, IL-6 or IL-2 and other enzymes like lactate dehydrogenase (LDH) and tumour necrosis factor alpha (TNFα). Furthermore, oxidative stress produces fatty-acid peroxidation whose metabolites possess very high toxicities and mutagenic properties. 4-hydroxy-2-nonenal (4-HNE) is an active compounds that upregulates prostaglandin E2 which is directly associated with high proliferative colorectal cancer. Moreover, 4-HNE deregulates cell proliferation, cell survival, differentiation, autophagy, senescence, apoptosis and necrosis via mitogen-activated protein kinase (MAPK), phosphoinositide 3-kinase (PIK3CA)—AKT and protein kinase C pathways. Other product of lipid peroxidation is malondialdehyde (MDA) being able to regulate insulin through WNT-pathway as well as having demonstrated its mutagenic capability. Accumulation of point mutation enables genomic evolution of colorectal cancer described in the model of Fearon and Vogelstein. In this review, we will summarize different determination methods and techniques to assess a truthfully diagnosis and we will explain some of the capabilities that performs adipocytes as the largest endocrine organ.

Severe obesity prior to diagnosis limits survival in colorectal cancer patients evaluated at a large cancer centre

Background:

In contrast to the consistent evidence for obesity and colorectal cancer (CRC) risk, the impact of obesity in CRC patients is less clear. In a well-characterised cohort of CRC patients, we prospectively evaluated class I and class II obesity with survival outcomes.

Methods:

The CRC patients (N=634) were followed from the date of diagnosis until disease progression/first recurrence (progression-free survival (PFS)) or death (overall survival (OS)). Body mass index (BMI) was calculated from reported usual weight prior to diagnosis. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated in models adjusted for clinicopathologic, treatment, and lifestyle factors.

Results:

Over a median follow-up of 4 years, 208 (33%) patients died and 235 (37%) recurred or progressed. Class II obesity, as compared with either overweight or normal weight, was associated with an increased risk of death (HR and 95% CI: 1.55 (0.97–2.48) and 1.65 (1.02–2.68), respectively), but no clear association was observed with PFS. In analyses restricted to patients who presented as stages I–III, who reported stable weight, or who were aged <50 years, obesity was associated with a significant two- to five-fold increased risk of death.

Conclusions:

In CRC patients evaluated at a large cancer centre, severely obese patients experienced worse survival outcomes independent of many other factors.

Awareness of Dietary and Alcohol Guidelines Among Colorectal Cancer Survivors

INTRODUCTION

Although dietary habits can affect colorectal cancer (CRC) survivors' health, it is unclear how familiar survivors are with dietary guidelines, what they believe about healthy eating and alcohol consumption, and what hinders healthy dietary habits after cancer. This study assessed CRC survivors' familiarity with dietary guidelines, their eating and drinking habits, and perceived facilitators and barriers to healthy eating after cancer, including social support and self-efficacy for maintaining a healthy diet and limiting alcohol.

METHODS

A total of 593 individuals (50% female; mean age, 74 years) diagnosed with CRC approximately 6 years prior to study entry in early 2010 were identified through California Cancer Registry records and participated in a cross-sectional mailed survey assessing health behavior after cancer (46% adjusted response rate). Analyses were conducted in 2014-2015.

RESULTS

Survivors were most familiar with-and most likely to follow-recommendations to choose low-fat foods; 15% had never heard of recommendations to limit alcohol. Survivors were more aware of recommendations involving messages to limit/avoid versus approach/choose certain foods. The most common barrier to a healthy diet involved the effort required (26%). Survivors received more family/friend support and provider recommendations for healthy eating than limiting alcohol.

CONCLUSIONS

Results provide an overview of awareness of and adherence to dietary recommendations among CRC survivors, highlighting the need for increasing awareness of recommendations that are especially relevant for survivors. Suggestions are made for modifying diet-related messages to facilitate comprehension and recall among CRC survivors, and increasing awareness among groups with the lowest awareness levels.

Excess body weight and colorectal cancer survival: the multiethnic cohort

PURPOSE

Excess body weight is a risk factor for colorectal cancer (CRC) and may also adversely affect survival in CRC patients.

METHODS

This study examined the relation of body mass index (BMI), which was self-reported at cohort entry and after 5.7 ± 0.8 years, with CRC-specific and all-cause survival among 4,204 incident cases of invasive CRC in the multiethnic cohort. Cox regression analysis with age as time metric and BMI as time-varying exposure was applied to estimate hazard ratios (HR) and 95% confidence intervals (CIs) while adjusting for relevant covariates.

RESULTS

Over 6.0 ± 4.7 years of follow-up, 1,976 all-cause and 1,095 CRC-specific deaths were recorded. The mean time interval between cohort entry and diagnosis was 7.6 ± 4.7 years. No association with CRC-specific survival was detected in men (HR5units = 0.94; 95%CI 0.84-1.04) or women (HR5units = 0.98; 95%CI 0.89-1.08). In men, all-cause survival also showed no relation with BMI (HR5unit = 0.97; 95%CI 0.90-1.06), whereas it was reduced in women (HR5units = 1.10; 95%CI 1.03-1.18). Interactions of BMI with ethnicity were only significant for obesity. Obese Latino and overweight Native Hawaiian men as well as overweight African-American women experienced significantly better CRC-specific survival than whites. Overweight Japanese men and African-American women had better all-cause survival and obese Latino women had the lowest all-cause survival (HRobese = 1.74; 95%CI 1.08-2.80).

CONCLUSIONS

This analysis detected little evidence for an adverse effect of excess body weight on CRC-specific survival, but all-cause survival was reduced in women. These findings suggest that adiposity may be less important for CRC survival than as an etiologic factor.

Associations of pre-diagnostic body mass index with overall and cancer-specific mortality in a large Austrian cohort

PURPOSE

Although obesity is a well-known risk factor for several cancers, its role on cancer survival is poorly understood.

METHODS

Within the VHM&PP cohort, 8,673 cancer patients (42.2% women) were followed over a median time of 11.9 years. Cox proportional hazard models were used to estimate the association of pre-diagnostic overweight (BMI 25.0-29.9 kg/m(2)) and obesity (BMI ≥ 30.0 kg/m(2)) with all-cause and cancer-specific mortality. Cubic restricted splines were additionally modeled.

RESULTS

During 71,126 person-years, 4,571 deaths were observed. Compared to normal weight, overweight was associated with statistically significantly decreased all-cause mortality (HR 0.93; 95% CI 0.87-0.997) and cancer-specific mortality (HR 0.91; 95% CI 0.84-0.99). Underweight was statistically significantly associated with 28% increased overall mortality, in particular in men [HR 2.02 (95% CI 1.43-2.83) vs. HR 0.96 (95% CI 0.71-1.30) in women]. J-shaped associations were found between BMI and mortality with the nadir around a BMI of 25 kg/m(2). Analysis by cancer site showed though not statistically significantly that overweight was associated with reduced mortality, while obesity was associated with increased cancer-specific mortality except cancers of the upper digestive tract. In patients with local stage colorectal cancers, obesity was associated with increased all-cause (vs. normal weight HR 1.90; 95% CI 1.03-3.52) and cancer-specific mortality (HR 3.17; 95% CI 1.29-7.81).

CONCLUSION

Overweight patients have a better overall prognosis, while for obesity no association and for underweight worse prognosis were found. Our results on common cancers indicate that there are tumor- and stage-specific differences.

Imaging body composition in cancer patients: visceral obesity, sarcopenia and sarcopenic obesity may impact on clinical outcome

In recent years, there has been increasing interest in the influence of body composition on oncological patient outcomes. Visceral obesity, sarcopenia and sarcopenic obesity have been identified as adverse factors in cancer patients. Imaging quantification of body composition such as lean muscle mass and fat distribution is a potentially valuable tool. This review describes the following imaging techniques that may be used to assess body composition: dual-energy X-ray absorptiometry (DXA), computed tomography (CT) and magnetic resonance imaging (MRI). CT and MRI are acquired as part of oncological patient care, thus providing an opportunity to integrate body composition assessment into the standard clinical pathway and allowing supportive care to be commenced as appropriate to improve outcome.

MAIN MESSAGES

• Sarcopenia, sarcopenic obesity and visceral obesity are adverse prognostic factors in cancer patients. • CT and MRI are the current gold standard in body composition evaluation. • Body composition may affect chemotherapy tolerance and toxicities.

Association between body mass index and mortality for colorectal cancer survivors: overall and by tumor molecular phenotype

BACKGROUND

Microsatellite instability (MSI) and BRAF mutation status are associated with colorectal cancer survival, whereas the role of body mass index (BMI) is less clear. We evaluated the association between BMI and colorectal cancer survival, overall and by strata of MSI, BRAF mutation, sex, and other factors.

METHODS

This study included 5,615 men and women diagnosed with invasive colorectal cancer who were followed for mortality (maximum: 14.7 years; mean: 5.9 years). Prediagnosis BMI was derived from self-reported weight approximately one year before diagnosis and height. Tumor MSI and BRAF mutation status were available for 4,131 and 4,414 persons, respectively. Multivariable hazard ratios (HR) and 95% confidence intervals (CI) were estimated from delayed-entry Cox proportional hazards models.

RESULTS

In multivariable models, high prediagnosis BMI was associated with higher risk of all-cause mortality in both sexes (per 5-kg/m(2); HR, 1.10; 95% CI, 1.06-1.15), with similar associations stratified by sex (Pinteraction: 0.41), colon versus rectum (Pinteraction: 0.86), MSI status (Pinteraction: 0.84), and BRAF mutation status (Pinteraction: 0.28). In joint models, with MS-stable/MSI-low and normal BMI as the reference group, risk of death was higher for MS-stable/MSI-low and obese BMI (HR, 1.32; P value: 0.0002), not statistically significantly lower for MSI-high and normal BMI (HR, 0.86; P value: 0.29), and approximately the same for MSI-high and obese BMI (HR, 1.00; P value: 0.98).

CONCLUSIONS

High prediagnosis BMI was associated with increased mortality; this association was consistent across participant subgroups, including strata of tumor molecular phenotype.

IMPACT

High BMI may attenuate the survival benefit otherwise observed with MSI-high tumors.

Joint prognostic effect of obesity and chronic systemic inflammation in patients with metastatic colorectal cancer

BACKGROUND

Obesity is strongly linked with chronic systemic inflammation, and each has been linked with disease progression and survival in patients with colorectal cancer (CRC). The authors investigated the joint prognostic effects of obesity and circulating cytokines in patients with metastatic CRC (mCRC), an understudied patient group.

METHODS

In 242 chemotherapy-naive patients with mCRC, the authors measured a multiplex cytokine panel and abstracted clinicopathological features, height, and weight from medical records. Overall survival (OS) was calculated from the date of mCRC diagnosis until the date of death from any cause and evaluated by Kaplan-Meier analysis and multivariable Cox proportional hazards regression models. Cut points for cytokines were determined by restricted cubic spline regression.

RESULTS

In multivariable models, elevated interleukin (IL)-8, IL-2 receptor alpha, and lactate dehydrogenase (LDH) emerged as significant predictors of poor OS (hazard ratio [HR] and 95% confidence interval [95% CI] for above vs below the (referent) knot point: 2.5 [95% CI, 1.7-3.7], 1.9 [95% CI, 1.3-2.7], and 2.2 [95% CI, 1.6-3.1], respectively; all P<.001). Obesity (body mass index ≥30 kg/m(2) ) was not found to be associated with OS, but appeared to modify the relationships observed with IL-8 and LDH, which were associated with a significant 4-fold and 5-fold risk of death, respectively, in obese patients compared with a 2-fold risk of death in nonobese patients (P for interaction of .06 and .04, respectively). Similar results emerged from joint effects analysis, in which obese patients with high IL-8 (or LDH) experienced the highest risk of death.

CONCLUSIONS

Although obesity itself was not found to be independently associated with survival in patients with mCRC, the adverse prognostic significance of LDH and IL-8 was found to be enhanced in obese patients.

Pre-diagnostic concordance with the WCRF/AICR guidelines and survival in European colorectal cancer patients: a cohort study

BACKGROUND

Cancer survivors are advised to follow lifestyle recommendations on diet, physical activity, and body fatness proposed by the World Cancer Research Fund/American Institute of Cancer Research (WCRF/AICR) for cancer prevention. Previous studies have demonstrated that higher concordance with these recommendations measured using an index score (the WCRF/AICR score) was associated with lower cancer incidence and mortality. The aim of this study was to evaluate the association between pre-diagnostic concordance with WCRF/AICR recommendations and mortality in colorectal cancer (CRC) patients.

METHODS

The association between the WCRF/AICR score (score range 0-6 in men and 0-7 in women; higher scores indicate greater concordance) assessed on average 6.4 years before diagnosis and CRC-specific (n = 872) and overall mortality (n = 1,113) was prospectively examined among 3,292 participants diagnosed with CRC in the European Prospective Investigation into Cancer and Nutrition (EPIC) cohort (mean follow-up time after diagnosis 4.2 years). Multivariable Cox proportional hazard models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for mortality.

RESULTS

The HRs (95% CIs) for CRC-specific mortality among participants in the second (score range in men/women: 2.25-2.75/3.25-3.75), third (3-3.75/4-4.75), and fourth (4-6/5-7) categories of the score were 0.87 (0.72-1.06), 0.74 (0.61-0.90), and 0.70 (0.56-0.89), respectively (P for trend <0.0001), compared to participants with the lowest concordance with the recommendations (category 1 of the score: 0-2/0-3). Similar HRs for overall mortality were observed (P for trend 0.004). Meeting the recommendations on body fatness and plant food consumption were associated with improved survival among CRC cases in mutually adjusted models.

CONCLUSIONS

Greater concordance with the WCRF/AICR recommendations on diet, physical activity, and body fatness prior to CRC diagnosis is associated with improved survival among CRC patients.

Association between body mass index and prognosis of colorectal cancer: a meta-analysis of prospective cohort studies

Studies have reported conflicting results on the association between body mass index (BMI) and prognosis of colorectal cancer. Therefore, we have conducted a meta-analysis of prospective studies, which examined the association of pre- and post-diagnostic BMI with colorectal cancer-specific mortality and all-cause mortality in patients with colorectal cancer. We searched Medline and EMBASE database published between 1970 and September 2014. A total of 508 articles were identified, of which 16 prospective cohort studies were included for the current meta-analysis. The analysis included 58,917 patients who were followed up over a period ranging from 4.9 to 20 years (median: 9.9 years). We found that being underweight before cancer diagnosis was associated with increased all-cause mortality (Relative risk [RR]: 1.63, 95% CI: 1.18-2.23, p < 0.01) and being obese (BMI ≥ 30 kg/m(2)) before cancer diagnosis was associated with increased colorectal cancer-specific mortality (RR: 1.22, 95% CI: 1.003-1.35, p < 0.01) and all-cause mortality (RR: 1.25, 95% CI: 1.14-1.36, p < 0.01). On the other hand, being underweight (RR: 1.33, 95% CI: 1.20-1.47, p < 0.01), obese (RR: 1.08, 95% CI: 1.03-1.3, p < 0.01), and class II/III obese (BMI ≥ 35 kg/m(2); RR: 1.13, 95% CI: 1.04-1.23, p < 0.01) after diagnosis were associated with significantly increased all-cause mortality. Being obese prior to diagnosis of colorectal cancer was associated with increased colorectal cancer-specific mortality and all-cause mortality, whereas being obese after diagnosis was associated with increased all-cause mortality. The associations with being underweight may reflect reverse causation. Maintaining a healthy body weight should be discussed with colorectal cancer survivors.