Healthy eating index and ovarian cancer risk

Association between diet quality and ovarian cancer risk and survival

BACKGROUND

Research on diet quality and ovarian cancer is limited. We examined the association between diet quality and ovarian cancer risk and survival in a large prospective cohort.

METHODS

We used data from women in the prospective National Institutes of Health-AARP Diet and Health Study enrolled from 1995 to 1996 who were aged 50-71 years at baseline with follow-up through December 31, 2017. Participants completed a 124-item food frequency questionnaire at baseline, and diet quality was assessed via the Healthy Eating Index-2015, the alternate Mediterranean diet score, and the Dietary Approaches to Stop Hypertension score. Primary outcomes were first primary epithelial ovarian cancer diagnosis from cancer registry data and among those diagnosed with ovarian cancer all-cause mortality. We used a semi-Markov multistate model with Cox proportional hazards regression to account for semicompeting events.

RESULTS

Among 150 643 participants with a median follow-up time of 20.5 years, 1107 individuals were diagnosed with a first primary epithelial ovarian cancer. There was no evidence of an association between diet quality and ovarian cancer risk. Among those diagnosed with epithelial ovarian cancer, 893 deaths occurred with a median survival of 2.5 years. Better prediagnosis diet quality, according to the Healthy Eating Index-2015 (quintile 5 vs quintile 1: hazard ratio [HR] = 0.75, 95% confidence interval [CI] = 0.60 to 0.93) and alternate Mediterranean diet score (quintile 5 vs quintile 1: HR = 0.68, 95% CI = 0.53 to 0.87), was associated with lower all-cause mortality. There was no evidence of an association between Dietary Approaches to Stop Hypertension score and all-cause mortality.

CONCLUSIONS

Better prediagnosis diet quality was associated with lower all-cause mortality after ovarian cancer diagnosis but was not associated with ovarian cancer risk.

Associations between Two Dietary Quality Scores and Pancreatic Cancer Risk in a US National Prospective Cohort Study

OBJECTIVE

Most previous studies investigated the associations between intake of individual nutrients and risk of disease, which failed to consider the potential interactions and correlations between various nutrients contained in food. Although dietary quality scores provide a comprehensive evaluation of the entire diet, it remains elusive whether they are associated with the risk of pancreatic cancer.

METHODS

Dietary intake data collected with the Dietary Questionnaire (DQX) and Diet History Questionnaire (DHQ) were used to calculate HEI-2015 and DQI-R scores for participants in the Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial. A high score indicates an increased intake of adequacy components and a decreased intake of moderation components. This study included 252 cases of pancreatic cancer documented from 58,477 persons during a median follow-up of 12.2 years in the DQX cohort and 372 cases of pancreatic cancer ascertained from 101,721 persons during a median follow-up of 8.9 years in the DHQ cohort. Cox proportional hazards regression analysis was performed to calculate hazard ratios (HR) and 95% confidence intervals (CI) for the associations between the two dietary quality scores and pancreatic cancer risk.

RESULTS

After adjustment for confounders, HEI-2015 and DQI-R scores were not significantly associated with pancreatic cancer risk. However, a significantly lower risk was observed for overweight persons with a higher HEI-2015 score in the DQX cohort (HR [95% CI] comparing the highest with lowest tertile: 0.52 [0.32, 0.85], p for trend = 0.009) and those with higher scores of some individual components.

CONCLUSION

Collectively, overall dietary quality is not associated with an altered risk of pancreatic cancer in this US population.

Prevention of Epithelial Ovarian Cancer

Given the challenges with achieving effective and durable treatment for epithelial ovarian cancer, primary prevention is highly desirable. Fortunately, decades of research have provided evidence for several strategies that can be deployed to optimize risk reduction. These include surgery, chemoprevention, and lifestyle factor modifications. These broad categories vary in terms of the magnitude of risk reduction possible, the possible short-term and long-term side effects, the degree of difficulty, and acceptability. Thus, the concept of a risk-based model to personalize preventive interventions is advocated to guide discussion between care providers and women at risk. For women with inherited major gene mutations that greatly increase risk of ovarian cancer, surgical approaches have favorable risk to benefit ratios. Chemoprevention and lifestyle factor modifications portend a lower degree of risk reduction but confer lower risk of undesirable side effects. Since complete prevention is not currently possible, better methods for early detection remain a high priority.

Impact of Lifestyle Interventions on Gynecologic Cancers: Beyond Diet and Exercise

A Lifestyle Medicine approach to compliment cancer care is less commonly researched or implemented for women with gynecologic cancers as compared to better funded malignancies such as breast, prostate, and colorectal. Yet, several gynecologic malignancies are linked to obesity, estrogen/metabolic signaling pathways, and altered tumor microenvironment which could benefit greatly from a lifestyle medicine program. Lifestyle medicine, an evidenced-based branch of science, has expanded to the prevention and treatment of disorders caused by lifestyle factors (including cancer). Modifiable lifestyle factors such as obesity, lack of physical activity/nutrient density, microbial dysbiosis, sleep disturbance, and chronic stressors contribute greatly to cancer morbidity and mortality worldwide. This overarching area of research is evolving with some subtopics in their infancy requiring further investigation. Modern tools have allowed for better understanding of mechanisms by which adiposity and inactivity affect tumor promoting signaling pathways as well as the local tumor environment. Through the evolving use of these sophisticated techniques, novel prognostic biomarkers have emerged to explore efficacy of pharmacologic and lifestyle interventions in cancer. This state-of-the-art review article appraises recent evidence for a lifestyle medicine approach, beyond diet and exercise, to optimize survivorship and quality of life for patients with gynecologic cancers and introduces the 8-week web-based comprehensive HEAL-GYN program.

The New Standardized Malaysian Healthy Eating Index

Healthy Eating Index (HEI) is a diet quality measure that assesses the population's compliance towards dietary guidelines. In Malaysia, diet quality measure, though existing, has some limitations in terms of application and relevance. This study aims to develop a new standardized Malaysian Healthy Eating Index (S-MHEI) that can measure the diet quality of all Malaysians regardless of their energy requirement level. The Malaysian Dietary Guidelines (MDG) 2010 and MDG for Children and Adolescents (MDGCA) 2013 were used as main references in developing the index components. In addition, the latest Malaysian Adults Nutrition Survey (MANS) and Adolescent Nutrition Survey (ANS) were also referred to ensure the relevance of the components selected. For adequacy components, the least restrictive method was used in setting the standard for the scoring system. Meanwhile, the scoring system for moderation components was built based on the Recommended Nutrient Intake (RNI) 2017. The new S-MHEI comprises of 11 components with a maximum total score of 100. The least restrictive method allowed the index to be used across energy requirement levels. However, the index will not be sensitive towards adhering to the specific recommended amount of intake-which in effect, made the index focus on measuring diet quality rather than diet quantity.

Association Between Diet Quality and Risk of Ovarian and Endometrial Cancers: A Systematic Review of Epidemiological Studies

Objectives

The relationship between diet quality indices and risk of ovarian and endometrial cancers were unclear. We aimed at conducting a systematic review to evaluate the epidemiological evidence.

Methods

Embase, PubMed, Web of Science and Scopus databases were searched for eligible studies up to December 2020. Epidemiological studies reported the association of the diet quality with risk of ovarian and endometrial cancers were evaluated.

Results

Eleven eligible studies were identified, of which six studies were case-control studies, four were cohort studies, and one was case-cohort study. All studies were considered as high-quality with low risk of bias. Seven studies evaluated the association of diet quality with risk of ovarian cancer. Four studies reported null association for diet quality indices such as Healthy Eating Index (HEI)-2005, HEI-2010, Mediterranean Diet Score (MDS) and Recommended Foods Score (RFS). Two studies reported significantly inverse association for Alternate Healthy Eating Index (AHEI)-2010 and Healthy Diet Score (HDS) indices. One study reported significantly increased risk of ovarian cancer associated with higher level of Dietary Guidelines for Americans Index. Dose-response analysis showed pooled relative risks of 0.98 (95%Cl: 0.95, 1.01) and 0.94 (95%Cl: 0.77, 1.13) for each 10 points increase in the HEI-2005 and AHEI-2010 indices. Seven studies evaluated the association of diet quality with risk of endometrial cancer. Three studies reported significantly inverse association of diet quality as assessed by the MDS and Diet Score Quintiles with risk of endometrial cancer. Four studies reported null association for other diet quality indices including HEI-2005, HEI-2010, RFS and HDS. Dose-response analysis showed a pooled relative risk of 0.87 (95%CI: 0.81, 0.93) for one unit increment of the MDS.

Conclusion

This study suggests little evidence on the association between diet quality and risk of ovarian cancer. Adherence to high quality diet, as assessed by MDS, might be associated with lower the risk of endometrial cancer.

Association between Healthy Eating Index-2015 and Breast Cancer Risk: A Case-Control Study

OBJECTIVE

Diet quality is known to influence cancer risk. The Healthy Eating Index (HEI) is one of the most frequently used measures of diet quality. However, the association between HEI-2015 and breast cancer risk is not known. The present study was undertaken to evaluate the association between HEI-2015 and breast cancer risk.

METHODS

A case-control study comprising 134 breast cancer patients and 265 cancer-free controls were conducted. Dietary intakes were assessed using a validated food frequency questionnaire (FFQ), from which the HEI-2015 score was calculated. Logistic regression was used to derive the odds ratios (ORs) for measuring the association between HEI-2015 scores and breast cancer risk.

RESULTS

Subjects in the top quartile of HEI-2015 had a 46% lower chance of breast cancer compared with subjects in the bottom quartile (OR 0.54; 95% CI 0.30, 0.98). After adjustment for potential confounders such as age, age at menarche, oral contraceptive drug use, menopausal status, marital status, body mass index, smoking and education level, the association between HEI-2015 score and a lower risk of breast cancer was enhanced (OR 0.32; 95% CI 0.16, 0.65).

CONCLUSION

We successfully demonstrated that a higher HEI-2015 score was associated with a reduced breast cancer risk.

Association of Diet Quality and Physical Activity on Obesity-Related Cancer Risk and Mortality in Black Women: Results from the Women's Health Initiative

BACKGROUND

Obesity-related cancers disproportionately affect the Black community. We assessed the relationship between diet quality, physical activity, and their combined effect on obesity-related cancer risk and mortality in Black women enrolled in the Women's Health Initiative (WHI).

METHODS

Data from postmenopausal (50-79 years of age) Black women enrolled in WHI clinical trials or observational studies were analyzed. Exposure variables included baseline physical activity [metabolic equivalent of tasks (MET)-hours/week of moderate-to-vigorous physical activity (MVPA)] and diet quality [Healthy Eating Index (HEI)-2015]. Outcomes included adjudicated obesity-related cancer incidence and mortality. Cox proportional hazard models were used to evaluate the association between MVPA and HEI-2015 and obesity-related cancer risk and mortality.

RESULTS

The analytical sample included 9,886 Black women, with a baseline mean body mass index (BMI) of 31.1 kg/m² (SD = 6.8); mean HEI-2015 score of 63.2 (SD = 11.0, possible range 0 to 100); and mean MVPA of 5.0 (SD = 9.4) MET-hours/week. Over an average of 13 years of follow-up, 950 (9.6%) obesity-related cancer cases were observed, with 313 (32.9%) resulting in death. Physical activity [HR, 1.05; 95% confidence interval (CI), 0.86-1.30], diet quality (HR, 0.99; 95% CI, 0.92-1.08), and their combination (HR, 1.05; 95% CI, 0.85-1.29) were not associated with risk for any or site-specific obesity-related cancers. Similarly, these health behaviors had no association with mortality.

CONCLUSIONS

Diet quality, physical activity and their combined effect, as measured, were not associated with obesity-related cancer risk and mortality in Black women enrolled in WHI.

IMPACT

Other social, behavioral, and biological factors may contribute to racial disparities observed in obesity-related cancer rates.

Joint exposure to smoking, excessive weight, and physical inactivity and survival of ovarian cancer patients, evidence from the Ovarian Cancer Association Consortium

PURPOSE

Previous epidemiologic studies have shown that smoking, obesity, and physical inactivity are associated with poor survival following a diagnosis of ovarian cancer. Yet, the combined relationship of these unfavorable lifestyle factors on ovarian cancer survival has not been sufficiently investigated.

METHODS

Using data pooled from 13 studies, we examined the associations between combined exposures to smoking, overweight/obesity weight, and physical inactivity and overall survival (OS) as well as progression-free survival (PFS) among women diagnosed with invasive epithelial ovarian carcinoma (n = 7,022). Using age- and stage-adjusted Cox proportional hazards regression models, we estimated hazard ratios (HRs) and 95% confidence intervals (CIs) associated with joint exposure to these factors.

RESULTS

Combined exposure to current smoking, overweight/obesity, and physical inactivity prior to diagnosis was associated with a significantly increased risk of mortality compared to women who never smoked, had normal body mass index (BMI), and were physically active (HR = 1.37; 95% CI 1.10-1.70). The association for a joint exposure to these factors exceeded that of each exposure individually. In fact, exposure to both current smoking and overweight/obesity, and current smoking and physical inactivity was also associated with increased risk of death (HR = 1.28; 95% CI 1.08-1.52, and HR = 1.26; 95% CI 1.04-1.54, respectively). The associations were of a similar magnitude when former smoking was assessed in combination with the other exposures and when excessive weight was limited to obesity only. No significant associations were observed between joint exposure to any of these factors and PFS.

CONCLUSIONS

Joint exposure to smoking, excessive weight, and physical inactivity may negatively impact survival of ovarian cancer patients. These results suggest the importance of examining the combined effect of lifestyle factors on ovarian cancer patients' survival.

Empirically derived dietary patterns and ovarian cancer risk: a meta-analysis

Dietary patterns, which reflect overall diet and possible nutrient and food interactions, have been reported to be related to ovarian cancer (OC) risk. However, studies on the relationship between dietary patterns and OC risk have been inconsistent. Thus, we carried out a systematic meta-analysis to assess the relationship between dietary patterns and the risk of OC. Relevant studies are identified by searching the Medline and Embase electronic databases up to December 2016. The Cochrane Q statistic and the I statistical were used to evaluate heterogeneity. A total of 22 studies fulfilled the inclusion criteria and were included in this meta-analysis. There was evidence of a decreased risk for OC in the highest versus the lowest categories of healthy dietary pattern [odds ratio (OR)=0.86; 95% confidence interval (CI): 0.74-0.99; P=0.04]. An increased risk of OC was shown for the highest versus the lowest category of a western-style dietary pattern (OR=1.19; 95% CI: 1.01-1.41; P=0.04). No significant association with OC risk was observed in the highest versus the lowest category of a heavy drinking pattern (OR=0.89; 95% CI: 0.67-1.19; P=0.42). The results of this meta-analysis suggest that a healthy dietary pattern is associated with reduced risk for OC and a western-style dietary pattern is associated with an increased risk of OC. Further studies are needed to confirm our results.

An Evaluation of Factors Predicting Diet Quality among Cancer Patients

A high diet quality is associated with a lower risk of cancer mortality. However, the predictive factors of diet quality among cancer patients are not well understood. This study determines the socio-demographic and disease-related factors that affect diet quality among cancer patients. Two hundred and forty-two cancer patients completed questionnaires assessing sociodemographic and disease-related characteristics. Diet quality was measured using the Healthy Eating Index 2010 (HEI). Independent sample t-tests and one-way ANOVA with post-hoc analysis using the Tukey HSD test were used to compare mean HEI scores across these characteristics. A regression model was used to determine factors that predicted diet quality. The overall HEI score among cancer patients was 61.59 (SD = 11.67). Patients with a high school degree or General Education Diploma (GED) or less had lower HEI scores (β = -4.03, p = 0.04; β = -7.77, p = 0.001, respectively) compared to those with college degrees. Additionally, homemakers had significantly higher HEI scores (β = 7.95, p = 0.008) compared to those who worked at least 40 hours per week. Also, individuals with some types of cancers (e.g., endometrial or uterine) had significantly higher HEI scores (β = 12.56, p = 0.002) than those with other cancers (e.g., head and neck). Our findings will help oncology healthcare providers identify and target cancer patients with specific demographic characteristics who are at increased risk for consuming poor-quality diets with much needed food resource interventions.

Index-Based Dietary Patterns and the Risk of Prostate Cancer

Prostate cancer is the second leading cause for cancer incidence in male. Although this high incidence is due to prostate specific antigen screening, other risk-factors, such as diet, might also be involved. The results of previous studies on the association between prostate cancer risk and individual dietary components have been conflicting. Thus, evaluation by dietary pattern analysis rather than individual dietary factors is suggested. The purpose of this study was to review the association of prostate cancer with a priori dietary indices, which are less studied and reviewed to date compared to a posteriori indices. Studies reviewed in this research were published from January 1997 to March 2017. Seventeen studies with nine indices were selected. In Mediterranean Diet Score (MDS), all four studies were non-significant. In Dietary Inflammatory Index (DII), 3 out of 4 studies significantly increased risk by 1.33-2.39 times, suggesting that a higher pro-inflammatory diet may be a possible prostate cancer risk factor. In Oxidative Balance Score (OBS), 2 out of 5 studies had decreased risk by 0.28 and 0.34 times, whereas 1 study had increased risk by 1.17 times. Among other indices, Healthy Eating Index (HEI) and prostate cancer dietary index were associated with decreased risk, while the results from 2 studies of Low Carbohydrate, High Protein Diet (LCHP) score were conflicting. In conclusion, we observed that it is insufficient to support the association between a priori indices and prostate cancer risk, except for MDS and DII, which had relatively constant results among studies. Therefore, further studies are required to identify consistent criteria for each a priori index, and should be conducted actively in various populations.

Dietary inflammatory index and ovarian cancer risk in a New Jersey case-control study

OBJECTIVE

Diet may influence the development of ovarian cancer. Although it has been shown that inflammation plays an important etiologic role in ovarian carcinogenesis, little is known about the influence of the inflammatory potential of food consumption. The aim of this study was to evaluate the effect of a proinflammatory diet, as indicated by a high dietary inflammatory index (DII^®) score, on ovarian cancer risk, in a New Jersey population.

METHODS

Data from a case-control study conducted in New Jersey were used to estimate the relation between DII score and the risk for ovarian cancer. The study consisted of 205 cases with incident, histologically confirmed ovarian cancer, and 390 controls identified by random-digit dialing, based on Centers for Medicare & Medicaid Service lists, and area sampling. Computation of the DII was based on the intake of selected dietary factors assessed by a validated food frequency questionnaire (FFQ). Logistic regression models were fit to estimate odds ratios (ORs) and 95% confidence intervals (CIs) adjusted for potential covariates.

RESULTS

Although there was no significant association observed in pre- and perimenopausal women, a significant association was observed between the most proinflammatory DII scores and ovarian cancer among postmenopausal women (OR_{Quartile4 vs1}, 1.89; 95% CI, 1.02-3.52; P_trend = 0.03).

CONCLUSION

Findings from the present study suggested that a proinflammatory diet may increase risk for ovarian cancer among postmenopausal women, and warrants further study to confirm this association.

History of thyroid disease and survival of ovarian cancer patients: results from the Ovarian Cancer Association Consortium, a brief report

BACKGROUND

Findings from in vitro studies suggest that increased exposure to thyroid hormones can influence progression of ovarian tumours. However, epidemiologic evidence on this topic is limited.

METHODS

We pooled data from 11 studies from the Ovarian Cancer Association Consortium. Using multivariate Cox proportional hazards models, we estimated associations between hyper- and hypothyroidism and medications prescribed for these conditions with 5-year all-cause survival among women diagnosed with invasive ovarian cancer.

RESULTS

Overall, there was a nonsignificant association with history of hyperthyroidism (n=160 cases) and mortality (HR=1.22; 95% CI=0.97-1.53). Furthermore, diagnosis of hyperthyroidism within the 5 years before ovarian cancer diagnosis was associated with an increased risk of death (HR=1.94; 95% CI=1.19-3.18). A more modest association was observed with history of hypothyroidism (n=624 cases) and mortality (HR=1.16; 95% CI=1.03-1.31). Neither duration of hypothyroidism nor use of thyroid medications was associated with survival.

CONCLUSIONS

In this large study of women with ovarian cancer, we found that recent history of hyperthyroidism and overall history of hypothyroidism were associated with worse 5-year survival.

Dietary Quality and Ovarian Cancer Risk in African-American Women

This study evaluated 3 index-based dietary patterns-Healthy Eating Index (HEI)-2005, HEI-2010, and Alternate Healthy Eating Index (AHEI)-2010-in relation to ovarian cancer risk in African-American women. The study was conducted among 415 ovarian cancer cases and 629 age- and site-matched controls of African-American descent recruited from the population-based African American Cancer Epidemiology Study. Multivariable unconditional logistic regression models were used to estimate odds ratios and 95% confidence intervals between quartiles of dietary quality indices and ovarian cancer risk, adjusting for potential confounders. We found that higher AHEI-2010 scores, but not HEI-2005 or HEI-2010 scores, were associated with lower risk of ovarian cancer (comparing the highest quartile (4th) vs. lowest (1st), odds ratio (OR) = 0.66, 95% confidence interval (CI): 0.45, 0.98; P for trend = 0.05). When stratified by menopausal status, no noteworthy associations were observed among premenopausal women. However, among postmenopausal women, greater adherence to HEI-2010 (quartile 4 vs. quartile 1, OR = 0.57, 95% CI: 0.36, 0.92; P for trend = 0.03) and AHEI-2010 (quartile 4 vs. quartile 1, OR = 0.49, 95% CI: 0.31, 0.78; P for trend = 0.01) were inversely associated with ovarian cancer. Our findings indicate that adherence to an overall healthy dietary pattern may reduce ovarian cancer risk in African-American women, and particularly among postmenopausal African-American women.

Obesity and Ovarian Cancer

Ovarian cancer is the most fatal gynecologic cancer and is an important source of cancer-related mortality, particularly in developed countries. Despite substantial research examining adiposity (primarily adult body mass index [BMI]), the overall evidence suggests only a weak positive association between adiposity and risk of ovarian cancer, with stronger associations observed for population-based case-control studies compared to prospective studies. Ovarian cancer is not one disease and emerging data suggest that higher BMI may only be associated with risk of certain histologic subtypes, including low-grade serous and invasive mucinous tumors. Interestingly, some larger studies and meta-analyses have reported a stronger relationship with premenopausal ovarian cancers, which are more likely to be of these subtypes. Relatively few studies have conducted detailed examinations of other adiposity-related factors such as measures of abdominal adiposity, early-life body size and weight change. While the underlying mechanisms that may relate adiposity to risk are unclear, increased inflammatory biomarkers have been associated with risk and hormonal factors, including androgen levels, may be important for the development of mucinous tumors. Future research should leverage the large sample sizes of consortia to evaluate associations by key tumor characteristics as well as consider patterns of weight change over the life course with both ovarian cancer risk and survival.

Lycopene reduces ovarian tumor growth and intraperitoneal metastatic load

Mutagens like oxidants cause lesions in the DNA of ovarian and fallopian tube epithelial cells, resulting in neoplastic transformation. Reduced exposure of surface epithelia to oxidative stress may prevent the onset or reduce the growth of ovarian cancer. Lycopene is well-known for its excellent antioxidant properties. In this study, the potential of lycopene in the prevention and treatment of ovarian cancer was investigated using an intraperitoneal animal model. Lycopene prevention significantly reduced the metastatic load of ovarian cancer-bearing mice, whereas treatment of already established ovarian tumors with lycopene significantly diminished the tumor burden. Lycopene treatment synergistically enhanced anti-tumorigenic effects of paclitaxel and carboplatin. Immunostaining of tumor and metastatic tissues for Ki67 revealed that lycopene reduced the number of proliferating cancer cells. Lycopene decreased the expression of the ovarian cancer biomarker, CA125. The anti-metastatic and anti-proliferative effects were accompanied by down-regulated expression of ITGA5, ITGB1, MMP9, FAK, ILK and EMT markers, decreased protein expression of integrin α5 and reduced activation of MAPK. These findings indicate that lycopene interferes with mechanisms involved in the development and progression of ovarian cancer and that its preventive and therapeutic use, combined with chemotherapeutics, reduces the tumor and metastatic burden of ovarian cancer in vivo.

History of hypertension, heart disease, and diabetes and ovarian cancer patient survival: evidence from the ovarian cancer association consortium

PURPOSE

Survival following ovarian cancer diagnosis is generally low; understanding factors related to prognosis could be important to optimize treatment. The role of previously diagnosed comorbidities and use of medications for those conditions in relation to prognosis for ovarian cancer patients has not been studied extensively, particularly according to histological subtype.

METHODS

Using pooled data from fifteen studies participating in the Ovarian Cancer Association Consortium, we examined the associations between history of hypertension, heart disease, diabetes, and medications taken for these conditions and overall survival (OS) and progression-free survival (PFS) among patients diagnosed with invasive epithelial ovarian carcinoma. We used Cox proportional hazards regression models adjusted for age and stage to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) overall and within strata of histological subtypes.

RESULTS

History of diabetes was associated with increased risk of mortality (n = 7,674; HR = 1.12; 95% CI = 1.01-1.25). No significant mortality associations were observed for hypertension (n = 6,482; HR = 0.95; 95% CI = 0.88-1.02) or heart disease (n = 4,252; HR = 1.05; 95% CI = 0.87-1.27). No association of these comorbidities was found with PFS in the overall study population. However, among patients with endometrioid tumors, hypertension was associated with lower risk of progression (n = 339, HR = 0.54; 95% CI = 0.35-0.84). Comorbidity was not associated with OS or PFS for any of the other histological subtypes. Ever use of beta blockers, oral antidiabetic medications, and insulin was associated with increased mortality, HR = 1.20; 95% CI = 1.03-1.40, HR = 1.28; 95% CI = 1.05-1.55, and HR = 1.63; 95% CI = 1.20-2.20, respectively. Ever use of diuretics was inversely associated with mortality, HR = 0.71; 95% CI = 0.53-0.94.

CONCLUSIONS

Histories of hypertension, diabetes, and use of diuretics, beta blockers, insulin, and oral antidiabetic medications may influence the survival of ovarian cancer patients. Understanding mechanisms for these observations could provide insight regarding treatment.

Dietary inflammatory index and ovarian cancer risk in a large Italian case-control study

BACKGROUND

While inflammation has been shown to play an important etiologic role in ovarian carcinogenesis, little is known about the association between inflammatory properties of diet and ovarian cancer risk.

METHODS

We explored the association between the dietary inflammatory index (DII) and ovarian cancer risk in a multicentric Italian case-control study conducted between 1992 and 1999. Cases were 1,031 women with incident, histologically confirmed ovarian cancer from four areas in Italy. Controls were 2,411 women admitted to the same network of hospitals as the cases for acute, non-malignant and non-gynecological conditions, unrelated to hormonal or digestive-tract diseases or committed to long-term modifications of diet. DII scores were computed based on 31 nutrients and food items assessed using a reproducible and validated 78-item food frequency questionnaire. Odds ratios (ORs) were estimated through logistic regression models adjusting for age, total energy intake and other recognized confounding factors.

RESULTS

Subjects in the highest quartile of DII scores (i.e., with the most pro-inflammatory diets) had a higher risk of ovarian cancer compared to subjects in the lowest quartile (i.e., with an anti-inflammatory diet) (ORQuartile4vs1 1.47, 95% confidence interval, CI, 1.07, 2.01; p trend = 0.009). When analyses were carried out using continuous DII, a significant positive association with ovarian cancer was observed: the OR for one-unit increment in DII score (corresponding to approximately 8 % of its range in the current study, +6.0 to -6.20) was 1.08 (95% CI 1.02, 1.14).

CONCLUSION

A pro-inflammatory diet as indicated by higher DII scores is associated with increased ovarian cancer risk.

Lifestyle changes and the risk of developing endometrial and ovarian cancers: opportunities for prevention and management

Modifiable lifestyle factors, such as obesity, lack of physical activity, and smoking, contribute greatly to cancer and chronic disease morbidity and mortality worldwide. This review appraises recent evidence on modifiable lifestyle factors in the prevention of endometrial cancer (EC) and ovarian cancer (OC) as well as new evidence for lifestyle management of EC and OC survivors. For EC, obesity continues to be the strongest risk factor, while new evidence suggests that physical activity, oral contraceptive pills, and bariatric surgery may be protective against EC. Other medications, such as metformin and nonsteroidal anti-inflammatory drugs, may be protective, and interventional research is ongoing. For OC, we find increasing evidence to support the hypothesis that obesity and hormone replacement therapy increase the risk of developing OC. Oral contraceptive pills are protective against OC but are underutilized. Dietary factors such as the Mediterranean diet and alcohol consumption do not seem to affect the risk of either OC or EC. For EC and OC survivors, physical activity and weight loss are associated with improved quality of life. Small interventional trials show promise in increasing physical activity and weight maintenance for EC and OC survivors, although the impact on long-term health, including cancer recurrence and overall mortality, is unknown. Women's health providers should integrate counseling about these modifiable lifestyle factors into both the discussion of prevention for all women and the management of survivors of gynecologic cancers.

Obesity and survival among women with ovarian cancer: results from the Ovarian Cancer Association Consortium

BACKGROUND

Observational studies have reported a modest association between obesity and risk of ovarian cancer; however, whether it is also associated with survival and whether this association varies for the different histologic subtypes are not clear. We undertook an international collaborative analysis to assess the association between body mass index (BMI), assessed shortly before diagnosis, progression-free survival (PFS), ovarian cancer-specific survival and overall survival (OS) among women with invasive ovarian cancer.

METHODS

We used original data from 21 studies, which included 12 390 women with ovarian carcinoma. We combined study-specific adjusted hazard ratios (HRs) using random-effects models to estimate pooled HRs (pHR). We further explored associations by histologic subtype.

RESULTS

Overall, 6715 (54%) deaths occurred during follow-up. A significant OS disadvantage was observed for women who were obese (BMI: 30-34.9, pHR: 1.10 (95% confidence intervals (CIs): 0.99-1.23); BMI: ⩾35, pHR: 1.12 (95% CI: 1.01-1.25)). Results were similar for PFS and ovarian cancer-specific survival. In analyses stratified by histologic subtype, associations were strongest for women with low-grade serous (pHR: 1.12 per 5 kg m(-2)) and endometrioid subtypes (pHR: 1.08 per 5 kg m(-2)), and more modest for the high-grade serous (pHR: 1.04 per 5 kg m(-2)) subtype, but only the association with high-grade serous cancers was significant.

CONCLUSIONS

Higher BMI is associated with adverse survival among the majority of women with ovarian cancer.

A prospective cohort study of dietary indices and incidence of epithelial ovarian cancer

BACKGROUND

Several dietary indices have been developed to measure overall diet quality, including the Healthy Eating Index-2005 (HEI-2005), which measures adherence to the 2005 Dietary Guidelines from the USDA; the Alternative Healthy Eating Index-2010 (AHEI-2010), which is based on foods and nutrients predictive of chronic disease risk; and the Alternate Mediterranean Diet Score (aMDS), which is an index that characterizes traditional food patterns of Mediterranean countries. Few studies have evaluated diet quality and ovarian cancer risk.

METHODS

We assessed the associations of the HEI-2005, AHEI-2010, and aMDS with risk of epithelial ovarian cancer prospectively among women in the Nurses' Health Study. We used Cox proportional hazards models, adjusting for known ovarian cancer risk factors.

RESULTS

During 24 years of follow-up, we documented 696 incident epithelial ovarian cancer cases among 82,948 women with diet information. The multivariate adjusted hazard ratios (95% confidence interval; Ptrend) of epithelial ovarian cancer comparing the highest with the lowest quintile were 1.03 (0.80-1.34; 0.77) for the AHEI-2010, 0.85 (0.65-1.12; 0.57) for the HEI-2005, and 0.91 (0.71-1.18; 0.44) for the aMDS.

CONCLUSIONS

We did not observe any clear association of three diet quality scores with ovarian cancer risk. Further work should other metrics of evaluating diet quality that may be more relevant cancer risk.

Monitoring and benchmarking population diet quality globally: a step-wise approach

INFORMAS (International Network for Food and Obesity/non-communicable diseases Research, Monitoring and Action Support) aims to monitor and benchmark the healthiness of food environments globally. In order to assess the impact of food environments on population diets, it is necessary to monitor population diet quality between countries and over time. This paper reviews existing data sources suitable for monitoring population diet quality, and assesses their strengths and limitations. A step-wise framework is then proposed for monitoring population diet quality. Food balance sheets (FBaS), household budget and expenditure surveys (HBES) and food intake surveys are all suitable methods for assessing population diet quality. In the proposed 'minimal' approach, national trends of food and energy availability can be explored using FBaS. In the 'expanded' and 'optimal' approaches, the dietary share of ultra-processed products is measured as an indicator of energy-dense, nutrient-poor diets using HBES and food intake surveys, respectively. In addition, it is proposed that pre-defined diet quality indices are used to score diets, and some of those have been designed for application within all three monitoring approaches. However, in order to enhance the value of global efforts to monitor diet quality, data collection methods and diet quality indicators need further development work.

Tubal ligation and risk of ovarian cancer subtypes: a pooled analysis of case-control studies

BACKGROUND

Tubal ligation is a protective factor for ovarian cancer, but it is unknown whether this protection extends to all invasive histological subtypes or borderline tumors. We undertook an international collaborative study to examine the association between tubal ligation and ovarian cancer subtypes.

METHODS

We pooled primary data from 13 population-based case-control studies, including 10,157 patients with ovarian cancer (7942 invasive; 2215 borderline) and 13,904 control women. Invasive cases were analysed by histological type, grade and stage, and borderline cases were analysed by histological type. Pooled odds ratios were estimated using conditional logistic regression to match on site, race/ethnicity and age categories, and to adjust for age, oral contraceptive use duration and number of full-term births.

RESULTS

Tubal ligation was associated with significantly reduced risks of invasive serous (OR, 0.81; 95% CI, 0.74-0.89; P < 0.001), endometrioid (OR, 0.48; 95% CI, 0.40-0.59; P < 0.001), clear cell (OR, 0.52; 95% CI, 0.40-0.67; P < 0.001) and mucinous (OR, 0.68; 95% CI, 0.52-0.89; P = 0.005) cancers. The magnitude of risk reduction was significantly greater for invasive endometrioid (P < 0.0001) and clear cell (P = 0.0018) than for serous cancer. No significant associations were found with borderline serous or mucinous tumours.

CONCLUSIONS

We found that the protective effects of tubal ligation on ovarian cancer risk were subtype-specific. These findings provide insights into distinct aetiologies of ovarian cancer subtypes and mechanisms underlying the protective effects of tubal ligation.

Sugary food and beverage consumption and epithelial ovarian cancer risk: a population-based case-control study

BACKGROUND

Ovarian cancer is the deadliest gynecologic cancer in the US. The consumption of refined sugars has increased dramatically over the past few decades, accounting for almost 15% of total energy intake. Yet, there is limited evidence on how sugar consumption affects ovarian cancer risk.

METHODS

We evaluated ovarian cancer risk in relation to sugary foods and beverages, and total and added sugar intakes in a population-based case-control study. Cases were women with newly diagnosed epithelial ovarian cancer, older than 21 years, able to speak English or Spanish, and residents of six counties in New Jersey. Controls met same criteria as cases, but were ineligible if they had both ovaries removed. A total of 205 cases and 390 controls completed a phone interview, food frequency questionnaire, and self-recorded waist and hip measurements. Based on dietary data, we computed the number of servings of dessert foods, non-dessert foods, sugary drinks and total sugary foods and drinks for each participant. Total and added sugar intakes (grams/day) were also calculated. Multiple logistic regression models were used to estimate odds ratios and 95% confidence intervals for food and drink groups and total and added sugar intakes, while adjusting for major risk factors.

RESULTS

We did not find evidence of an association between consumption of sugary foods and beverages and risk, although there was a suggestion of increased risk associated with sugary drink intake (servings per 1,000 kcal; OR=1.63, 95% CI: 0.94-2.83).

CONCLUSIONS

Overall, we found little indication that sugar intake played a major role on ovarian cancer development.

Recent alcohol consumption and risk of incident ovarian carcinoma: a pooled analysis of 5,342 cases and 10,358 controls from the Ovarian Cancer Association Consortium

BACKGROUND

Studies evaluating the association between alcohol intake and ovarian carcinoma (OC) are inconsistent. Because OC and ovarian borderline tumor histologic types differ genetically, molecularly and clinically, large numbers are needed to estimate risk associations.

METHODS

We pooled data from 12 case-control studies in the Ovarian Cancer Association Consortium comprising 5,342 OC cases, 1,455 borderline tumors and 10,358 controls with quantitative information on recent alcohol intake to estimate odds ratios (OR) and 95% confidence intervals (CI) according to frequencies of average daily intakes of beer, wine, liquor and total alcohol.

RESULTS

Total alcohol intake was not associated with all OC: consumption of >3 drinks per day compared to none, OR=0.92, 95% CI=0.76-1.10, P trend=0.27. Among beverage types, a statistically non-significant decreased risk was observed among women who consumed >8 oz/d of wine compared to none (OR=0.83, 95% CI=0.68-1.01, P trend=0.08). This association was more apparent among women with clear cell OC (OR, 0.43; 95% CI, 0.22-0.83; P trend=0.02), although based on only 10 cases and not statistically different from the other histologic types (P value for statistical heterogeneity between histologic types = 0.09). Statistical heterogeneity of the alcohol- and wine-OC associations was seen among three European studies, but not among eight North American studies. No statistically significant associations were observed in separate analyses evaluating risk with borderline tumors of serous or mucinous histology. Smoking status did not significantly modify any of the associations.

CONCLUSIONS

We found no evidence that recent moderate alcohol drinking is associated with increased risk for overall OC, or that variation in risk is associated strongly with specific histologic types. Understanding modifiable causes of these elusive and deadly cancers remains a priority for the research community.

Diet quality of Americans differs by age, sex, race/ethnicity, income, and education level

An index that assesses the multidimensional components of the diet across the lifecycle is useful in describing diet quality. The purpose of this study was to use the Healthy Eating Index-2005, a measure of diet quality in terms of conformance to the 2005 Dietary Guidelines for Americans, to describe the diet quality of Americans by varying sociodemographic characteristics in order to provide insight as to where diets need to improve. The Healthy Eating Index-2005 scores were estimated using 1 day of dietary intake data provided by participants in the 2003-2004 National Health and Nutrition Examination Survey. Mean daily intakes of foods and nutrients, expressed per 1,000 kilocalories, were estimated using the population ratio method and compared with standards that reflect the 2005 Dietary Guidelines for Americans. Participants included 3,286 children (2 to 17 years), 3,690 young and middle-aged adults (18 to 64 years), and 1,296 older adults (65+ years). Results are reported as percentages of maximum scores and tested for significant differences (P ≤ 0.05) by age, sex, race/ethnicity, income, and education levels. Children and older adults had better-quality diets than younger and middle-aged adults; women had better-quality diets than men; Hispanics had better-quality diets than blacks and whites; and diet quality of adults, but not children, generally improved with income level, except for sodium. The diets of Americans, regardless of socioeconomic status, are far from optimal. Problematic dietary patterns were found among all sociodemographic groups. Major improvements in the nutritional health of the American public can be made by improving eating patterns.

Ovarian cancer: etiology, risk factors, and epidemiology

Little is known regarding the early aspects of ovarian carcinogenesis. As a consequence, the identification of women at risk for the disease is based primarily on clinical grounds, with family history being the most important risk factor. In this review, we will discuss the various hypotheses regarding ovarian etiology and pathogenesis. In addition, we will discuss the epidemiology of ovarian cancer, including hereditary, reproductive, hormonal, inflammatory, dietary, surgical, and geographic factors that influence ovarian cancer risk.

Total and individual antioxidant intake and risk of epithelial ovarian cancer

BACKGROUND

Limiting oxidative stress to the ovarian epithelium has been proposed as a first-line defense against ovarian cancer. Although evidence for an association between individual dietary antioxidant intake and ovarian cancer risk is conflicting, the combined evidence suggests a modest inverse association. Our study aimed to evaluate the association between total antioxidant capacity (TAC) and individual antioxidant intakes (vitamin C, vitamin E, beta-carotene, selenium, lutein, and lycopene) and ovarian cancer risk.

METHODS

We conducted a population-based case-control study in New Jersey. Cases were women ages 21 years and older with newly diagnosed epithelial ovarian cancer who resided in six counties of New Jersey. Controls were women in the same age range who resided in the same geographic area. A total of 205 ovarian cancer cases and 390 controls were included. Dietary intake was ascertained using the Block food frequency questionnaire (FFQ), and TAC indices were constructed by linking FFQ-derived estimates to two standardized antioxidant capacity databases, the USDA Oxygen Radical Absorbance Capacity (ORAC) Database, and the University of Olso's Antioxidant Food Database. Multivariate logistic regression models were used to calculate odds ratios and 95 % confidence intervals while controlling for major ovarian cancer risk factors.

RESULTS

We found a strong inverse association with selenium from food sources (OR: 0.41; 95 % CI: 0.20-0.85, for the highest vs. lowest tertile of dietary selenium intake). However, there was little evidence of an association with dietary TAC or the others individual antioxidants. In contrast, compared to non-users, supplement users had significant increased risk for all micronutrients, but no statistically significant increased risk was observed for combined intake from foods and supplements of any of these antioxidants.

CONCLUSIONS

This study found an inverse association between selenium consumption from food sources and ovarian cancer risk, while there was little evidence of an association with TAC or any of the other individual antioxidants. Additional research is needed to confirm these findings.

Phytoestrogen consumption from foods and supplements and epithelial ovarian cancer risk: a population-based case control study

Background

While there is extensive literature evaluating the impact of phytoestrogen consumption on breast cancer risk, its role on ovarian cancer has received little attention.

Methods

We conducted a population-based case-control study to evaluate phytoestrogen intake from foods and supplements and epithelial ovarian cancer risk. Cases were identified in six counties in New Jersey through the New Jersey State Cancer Registry. Controls were identified by random digit dialing, CMS (Centers for Medicare and Medicaid Service) lists, and area sampling. A total of 205 cases and 390 controls were included in analyses. Unconditional logistic regression analyses were conducted to examine associations with total phytoestrogens, as well as isoflavones (daidzein, genistein, formononetin, and glycitein), lignans (matairesinol, lariciresinol, pinoresinol, secoisolariciresinol), and coumestrol.

Results

No statistically significant associations were found with any of the phytoestrogens under evaluation. However, there was a suggestion of an inverse association with total phytoestrogen consumption (from foods and supplements), with an odds ratio (OR) of 0.62 (95% CI: 0.38-1.00; p for trend: 0.04) for the highest vs. lowest tertile of consumption, after adjusting for reproductive covariates, age, race, education, BMI, and total energy. Further adjustment for smoking and physical activity attenuated risk estimates (OR: 0.66; 95% CI: 0.41-1.08). There was little evidence of an inverse association for isoflavones, lignans, or coumestrol.

Conclusions

This study provided some suggestion that phytoestrogen consumption may decrease ovarian cancer risk, although results did not reach statistical significance.