Nutrient-based dietary patterns and endometrial cancer risk: an Italian case–control study

Are Major a Posteriori Dietary Patterns Reproducible in the Italian Population? A Systematic Review and Quantitative Assessment

Although a posteriori dietary patterns (DPs) naturally reflect actual dietary behavior in a population, their specificity limits generalizability. Among other issues, the absence of a standardized approach to analysis have further hindered discovery of genuinely reproducible DPs across studies from the same/similar populations. A systematic review on a posteriori DPs from principal component analysis or exploratory factor analysis (EFA) across study populations from Italy provides the basis to explore assessment and drivers of DP reproducibility in a case study of epidemiological interest. First to our knowledge, we carried out a qualitative (i.e., similarity plots built on text descriptions) and quantitative (i.e., congruence coefficients, CCs) assessment of DP reproducibility. The 52 selected articles were published in 2001-2022 and represented dietary habits in 1965-2022 from 70% of the Italian regions; children/adolescents, pregnancy/breastfeeding women, and elderly were considered in 15 articles. The included studies mainly derived EFA-based DPs on food groups from food frequency questionnaires and were of "good quality" according to standard scales. Based on text descriptions, the 186 identified DPs were collapsed into 113 (69 food-based and 44 nutrient-based) apparently different DPs (39.3% reduction), later summarized along with the 3 "Mixed-Salad/Vegetable-based Patterns," "Pasta-and-Meat-oriented/Starchy Patterns," and "Dairy Products" and "Sweets/Animal-based Patterns" groups, by matching similar food-based and nutrient-based groups of collapsed DPs. Based on CCs (215 CCs, 68 DPs, 18 articles using the same input lists), all pairs of DPs showing the same/similar names were at least "fairly similar" and ∼81% were "equivalent." The 30 "equivalent" DPs ended up into 6 genuinely different DPs (80% reduction) that targeted fruits and (raw) vegetables, pasta and meat combined, and cheese and deli meats. Such reduction reflects the same study design, list of input variables, and DP identification method followed across articles from the same groups. This review was registered at PROSPERO as CRD42022341037.

Adherence to the World Cancer Research Fund/American Institute for Cancer Research recommendations and endometrial cancer risk: a multicentric case-control study

The World Cancer Research Fund/American Institute for Cancer Research (WCRF/AICR) published evidence-based recommendations for cancer prevention focusing on body weight, physical activity, and diet. Our aim is to evaluate whether adherence to the WCRF/AICR recommendations could reduce endometrial cancer risk. We used data from a multicentric, Italian hospital-based case-control study (1992-2006) including 454 endometrial cancer cases and 908 age-matched controls. Adherence to the WCRF/AICR recommendations was measured using a score (range: 0-7) based on seven components: body mass index (BMI), physical activity and five dietary items; higher scores indicated higher adherence. Odds ratios (OR) were estimated by multiple (adjusted) conditional logistic regression models including terms for major confounders and energy intake. Adherence to the WCRF/AICR recommendations was inversely related to endometrial cancer risk (OR = 0·42, 95 % confidence interval (CI) 0·30, 0·61 for the highest compared with the lowest score quartile), with a significant trend of decreasing risk with increasing adherence. An inverse association was also observed for a score including only dietary recommendations (OR = 0·67, 95 % CI 0·46, 0·96 for the highest compared with the lowest score tertile). In stratified analyses, the association was stronger among women with a normal weight, those who were older, and consequently those in post-menopause, and those with ≥ 2 children. In conclusion, high adherence to the WCRF/AICR recommendations has a favourable role in endometrial cancer risk, which is not fully explained by body weight.

Endometriosis Stem Cells as a Possible Main Target for Carcinogenesis of Endometriosis-Associated Ovarian Cancer (EAOC)

Endometriosis is a serious recurrent disease impairing the quality of life and fertility, and being a risk for some histologic types of ovarian cancer defined as endometriosis-associated ovarian cancers (EAOC). The presence of stem cells in the endometriotic foci could account for the proliferative, migrative and angiogenic activity of the lesions. Their phenotype and sources have been described. The similarly disturbed expression of several genes, miRNAs, galectins and chaperones has been observed both in endometriotic lesions and in ovarian or endometrial cancer. The importance of stem cells for nascence and sustain of malignant tumors is commonly appreciated. Although the proposed mechanisms promoting carcinogenesis leading from endometriosis into the EAOC are not completely known, they have been discussed in several articles. However, the role of endometriosis stem cells (ESCs) has not been discussed in this context. Here, we postulate that ESCs may be a main target for the carcinogenesis of EAOC and present the possible sequence of events resulting finally in the development of EAOC.

Are Dietary Patterns Related to Cognitive Performance in 7-Year-Old Children? Evidence from a Birth Cohort in Friuli Venezia Giulia, Italy

Research from different sources supports a link between nutrition and neurodevelopment, but evidence is still sparse regarding the relationship between a posteriori dietary patterns (DPs) and cognitive performance in school-aged children. Within the Northern Adriatic Cohort II, Friuli Venezia Giulia, Italy, 379 7-year-old children were cross-sectionally evaluated. Dietary patterns were identified through a principal component factor analysis based on 37 nutrients from children’s 3-day dietary records. The Wechsler Intelligence Scale of Children (WISC-IV) test provided measures of cognitive performance, including the full-scale intelligence quotient (FSIQ) and single index scores. Each DP was related to FSIQ or single index scores through multiple robust linear regression models. We identified five DPs named “Dairy Products”, “Plant-based Foods”, “Fats”, “Meat and Potatoes”, and “Seafood” (63% of variance explained). After adjustment, no significant relationship was observed with the FSIQ score; positive associations were found between the “Seafood” DP and Verbal Comprehension Index or Perceptual Reasoning Index. The “Meat and Potatoes” and “Dairy Products” DPs were inversely associated with the Verbal Comprehension Index and Processing Speed Index scores, respectively. In the absence of a relation with the overall FSIQ score, single DPs might influence specific cognitive functions, including verbal and reasoning abilities, as targeted by single indexes, in the expected direction.

Spatiotemporal trends in burden of uterine cancer and its attribution to body mass index in 204 countries and territories from 1990 to 2019

BACKGROUND

Uterine cancer is one of the most common female cancers worldwide, with huge heterogeneity in morbidity and mortality. Although a high body-mass index (BMI) has been linked to uterine cancer, systematic reports about the influence of high BMI and its temporal trends are scarce.

METHODS

The annual morbidity, mortality, and disability-adjusted life years (DALYs) of uterine cancer in 204 countries or territories were retrieved from the GBD 2019 study. To reflect trends in disease burden, we also calculated the estimated annual percentage change (EAPC) based on the age-standardized rates of uterine cancer from 1990 to 2019.

RESULTS

The global incident cases of uterine cancer increased 2.3 times from 187,190 in 1990 to 435,040 in 2019. Although the age-standardized incidence rate (ASIR) of uterine cancer increased worldwide from 8.67/100,000 in 1990 to 9.99/100,000 in 2019, the age-standardized death rate (ASDR) and DALY rate decreased during the same period. High socio-demographic index (SDI) countries tended to have a higher ASIR than developing regions, and their increasing trend in ASIR was also more pronounced. The disease was rare before 40 years old, but its risk rose sharply among women aged 50-70. A high BMI was linked to more than one-third of deaths from uterine cancer in 2019.

CONCLUSIONS

The incidence in developed areas was significantly higher than in developing areas and also increased much more rapidly. Elderly females, especially those with a high BMI, have a higher risk of uterine cancer. Therefore, more health resources may be needed to curb the rising burden in specific populations.

A Posteriori Dietary Patterns and Rheumatoid Arthritis Disease Activity: A Beneficial Role of Vegetable and Animal Unsaturated Fatty Acids

To our knowledge, no studies have investigated the relationship between a posteriori dietary patterns (DPs)-representing current dietary behavior-and disease activity in patients with rheumatoid arthritis (RA). We analyzed data from a recent Italian cross-sectional study including 365 RA patients (median age: 58.46 years, 78.63% females). Prevalent DPs were identified through principal component factor analysis on 33 nutrients. RA activity was measured according to the Disease Activity Score on 28 joints (DAS28) and the Simplified Disease Activity Index (SDAI). Single DPs were related to disease activity through linear and logistic regression models, adjusted for the remaining DPs and confounders. We identified five DPs (~80% variance explained). Among them, Vegetable unsaturated fatty acids (VUFA) and Animal unsaturated fatty acids (AUFA) DPs were inversely related to DAS28 in the overall analysis, and in the more severe or long-standing RA subgroups; the highest score reductions (VUFA: 0.81, AUFA: 0.71) were reached for the long-standing RA. The SDAI was inversely related with these DPs in subgroups only. This Italian study shows that scoring high on DPs based on unsaturated fats from either source provides independent beneficial effects of clinical relevance on RA disease activity, thus strengthening evidence on the topic.

Association between Nutrient-Based Dietary Patterns and Bladder Cancer in Italy

Limited knowledge is available on dietary patterns and bladder cancer risk. We analyzed data from an Italian case-control study carried out between 2003 and 2014, including 690 incident bladder cancer cases and 665 hospital-controls. We derived nutrient-based dietary patterns applying principal component factor analysis on 28 selected nutrients. We categorized factor scores according to quartiles, and estimated the odds ratios (ORs) and the corresponding 95% confidence intervals (CIs) through logistic regression models, adjusted for major confounding factors. We identified four dietary patterns named "Animal products", "Vitamins and fiber", "Starch-rich", and "Animal unsaturated fatty acids". We found an inverse association between the "Vitamins and fiber" pattern and bladder cancer (OR = 0.70, 95% CI: 0.48-0.99, IV versus I quartile category). Inverse relationships of borderline significance were also found for the "Animal products" and the "Animal unsaturated fatty acids" dietary patterns. No significant association was evident for the "Starch-rich" pattern. The current study allowed us to identify major dietary patterns in this Italian population. Our study confirms available evidence and shows that scoring high on a fruit-and-vegetables pattern provides beneficial effects on bladder cancer risk.

Correlation of high LAT1 expression with the prognosis of endometrioid carcinoma of the uterine corpus

The expression of L-type amino acid transporter 1 (LAT1) has been described to play essential roles in cancer cell growth and survival. To determine the significance of LAT1 in the prognosis of endometrial endometrioid carcinoma, we investigated LAT1 expression in 353 endometrioid carcinoma patients by immunohistochemical analysis using tissue microarray. The tumors in which stained tumor cells made up more than 25% of the tumor were graded as high expression. High expression of LAT1 was detected in 29 (8.2%) of patients. The ratio of high LAT1 expression did not significantly differ by age (< 60 vs. ≥ 60), FIGO stage (stage I/II vs. III/IV), histological grade (grade 1 vs. grade 2/3), or lymph node metastasis (positive vs. negative). However, high LAT1 expression in endometrioid carcinoma was associated with a poorer progression-free survival and overall survival, as per the results of the log-rank test (P = 0.0263 and 0.0404, respectively). Cox univariate and multivariate analyses revealed that high LAT1 expression is an independent marker of poor progression-free survival (hazard ratio = 2.598, P = 0.0137), in addition to a higher age (≥ 60 years vs. < 60 years), FIGO stage (stage III/IV vs. I/II), and histological grade (grade 2/3 vs. grade 1). In conclusion, we demonstrate that LAT1 is associated with a poor prognosis of endometrioid carcinoma of the uterine corpus.

Dietary Patterns in Italy and the Risk of Renal Cell Carcinoma

Background: Conclusive evidence on foods, nutrients, or dietary patterns and the risk of renal cell carcinoma (RCC) is lacking in the literature. Methods: We considered data from an Italian hospital-based case–control study (1992–2004) on 767 incident RCC cases and 1534 controls. A posteriori dietary patterns were identified by applying principal component factor analysis on 28 nutrients derived from a 78-item food-frequency questionnaire. We estimated the odds ratios (ORs) of RCC and corresponding 95% confidence intervals (CIs) for each quartile category (compared to the lowest one) using conditional multiple logistic regression models providing adjustment for major confounding factors. Results: We identified four dietary patterns, named “Animal products”, “Starch-rich”, “Vitamins and fiber”, and “Cooking oils and dressings”. Higher intakes of the “Starch-rich” pattern were positively associated with RCC risk (OR = 1.38, 95% CI: 1.04–1.82 for the highest quartile, p = 0.018). The association was inverse with the “Cooking oils and dressings” pattern (OR = 0.61, 95% CI: 0.47–0.80, p < 0.001), whereas no association was found with “Animal products” and “Vitamins and fiber” patterns. Conclusions: Higher intakes of starch-related foods may increase RCC risk, whereas consumption of olive and seed oils may favorably influence RCC risk.

Association between dietary fiber and endometrial cancer: a meta-analysis

To explore a potential relationship between dietary fiber consumption and risk of endometrial cancer (EC), eligible studies published up to 30 June 2018 were retrieved via computer searches and manual review of references. Random-effects models were used to calculate summary relative risk (RR) estimates based on contrasting high- and low-fiber intake values. Sensitivity analysis was conducted, and heterogeneity among study results was explored through stratified analyses by study design, geographic region, Newcastle-Ottawa Scale (NOS) score, impact factor, and adjustment for several confounders (age, body mass index, smoking, energy intake, and education). We extracted data from 16 studies (involving 6,563 cases). There was a significant association between dietary fiber intake and EC (RR = 0.86, 95% confidence interval [CI]: 0.78, 0.93). In stratified analysis, this trend was more pronounced in the case-control studies, and in studies conducted in the Americas and Asia. The relationship was further confirmed after adjusting for education level (RR = 0.74; 95% CI: 0.60, 0.88) and age (RR = 0.70; 95% CI: 0.57, 0.83), and NOS scores of 6 (RR = 0.81; 95% CI: 0.67, 0.95) and 7 (RR = 0.75; 95% CI: 0.62, 0.88). In conclusion, our meta-analysis revealed an inverse association between dietary fiber consumption and EC risk. Further efforts should be made to confirm these findings.

The Effects of the Dietary and Nutrient Intake on Gynecologic Cancers

The contribution of diet to cancer risk has been considered to be higher in advanced countries than in developing countries. In this paper, I review the current issues (a review of the relevant literature), and the effects of the dietary and nutrient intake on three types of gynecologic cancer (cervical, endometrial and ovarian cancers). In cervical cancer, the most important roles of diet/nutrition in relation to cancer are prophylaxis and countermeasures against human papillomavirus (HPV) infection. The main preventive and reductive factors of cervical cancer are antioxidants, such as vitamin A, C, D and E, carotenoids, vegetables and fruits. These antioxidants may have different abilities to intervene in the natural history of diseases associated with HPV infection. For endometrial cancer, the increase in peripheral estrogens as a result of the aromatization of androgens to estrogens in adipose tissue in obese women and insulin resistance are risk factors. Thus, we must mainly take care to avoid the continuous intake of fat energy and sugar. In ovarian cancer, the etiology has not been fully understood. To the best of our knowledge, the long-term consumption of pro-inflammatory foods, including saturated fat, carbohydrates and animal proteins is a risk factor. The intake of acrylamide is also a risk factor for both endometrial and ovarian cancer. Most papers have been epidemiological studies. Thus, further research using in vitro and in vivo approaches is needed to clarify the effects of the dietary and nutrient intake in detail.

The relation of healthy and Western dietary patterns to the risk of endometrial and ovarian cancers: a systematic review and meta-analysis

Dietary patterns have been used to explore the association between dietary factors and risk of endometrial (EC) and ovarian cancer (OC); however, the results are inconclusive. This meta-analysis aimed to analyze these associations. Methods: Pertinent studies published prior to March 2016 were systematically searched. The common dietary patterns were selected and adjusted risk estimates were derived by comparing the highest with the lowest categories of dietary pattern scores. Results: A total of 8 studies, 5 for endometrial cancer (1 cohort and 4 case-control studies including 2617 cases and 78082 participants/controls) and 3 for ovarian cancer (1 cohort and 2 case-control studies with 2025 cases and 101482 participants/controls) were included in this meta-analysis. A lower risk of EC was shown for the highest compared with the lowest category of the healthy dietary pattern (OR = 0.84, 95% CI: 0.72-0.98; P for heterogeneity = 0.10), whereas the Western dietary pattern was related to the higher risk of EC (OR = 1.19, 95% CI: 1.01-1.41; P for heterogeneity = 0.35). No significant relationship was found between the healthy dietary pattern (OR = 1.03, 95% CI: 0.69-1.53; P for heterogeneity = 0.01) and OC, while, adherence to the western pattern was associated with a 73% higher risk of OC (OR = 1.73, 95% CI: 1.08-2.37; P for heterogeneity = 0.06). Conclusion: A Western dietary pattern might be associated with a higher risk of endometrial and ovarian cancer.

Possible role of diet in cancer: systematic review and multiple meta-analyses of dietary patterns, lifestyle factors, and cancer risk

Context

Evidence of an association between dietary patterns derived a posteriori and risk of cancer has not been reviewed comprehensively.

Objective

The aim of this review was to investigate the relation between a posteriori-derived dietary patterns, grouped as healthy or unhealthy, and cancer risk. The relation between cancer risk and background characteristics associated with adherence to dietary patterns was also examined.

Data Sources

PubMed and Embase electronic databases were searched.

Study Selection

A total of 93 studies including over 85 000 cases, 100 000 controls, and 2 000 000 exposed individuals were selected.

Data Extraction

Data were extracted from each identified study using a standardized form by two independent authors.

Results

The most convincing evidence (significant results from prospective cohort studies) supported an association between healthy dietary patterns and decreased risk of colon and breast cancer, especially in postmenopausal, hormone receptor-negative women, and an association between unhealthy dietary patterns and increased risk of colon cancer. Limited evidence of a relation between an unhealthy dietary pattern and risk of upper aerodigestive tract, pancreatic, ovarian, endometrial, and prostatic cancers relied only on case-control studies. Unhealthy dietary patterns were associated with higher body mass index and energy intake, while healthy patterns were associated with higher education, physical activity, and less smoking. Potential differences across geographical regions require further evaluation.

Conclusions

The results suggest a potential role of diet in certain cancers, but the evidence is not conclusive and may be driven or mediated by lifestyle factors.

Dietary patterns and risk of recurrence and progression in non-muscle-invasive bladder cancer

The association of dietary factors with urinary bladder cancer prognosis has scarcely been investigated, and results of studies conducted to date are inconsistent. We investigated whether empirically derived dietary patterns are associated with risks of recurrence and progression in non-muscle-invasive bladder cancer (NMIBC) patients. Data from 595 newly diagnosed NMIBC patients from an ongoing prospective cohort study were used to derive dietary patterns using exploratory factor analysis. Factor scores were calculated and then categorized in sex-specific tertiles. Multivariable-adjusted proportional hazards regression models were used to estimate hazard ratios and 95% confidence intervals for the associations between tertiles of adherence to the dietary patterns and risks of recurrence and progression. We identified four dietary patterns: "fruits and vegetables," "Western," "low-fat," and "Tex-Mex." Patients in the highest tertile of adherence to the Western pattern experienced a 1.48 times higher risk of recurrence (95% CI 1.06-2.06) compared to patients in the lowest tertile. No statistically significant associations of a Western diet with risk of progression or of the other dietary patterns with risk of recurrence and progression were found. Overall, we found that adherence to a Western diet was associated with a higher risk of recurrence but further studies are needed to confirm our findings.

ASCT2 regulates glutamine uptake and cell growth in endometrial carcinoma

Glutamine commonly becomes a conditionally essential amino acid in cancer. Glutamine is supplied to the cell by transporters such as ASCT2 (SLC1A5), which is frequently upregulated in multiple cancers. Here we investigated the expression of ASCT2 in endometrial carcinoma, and evaluated the contribution of ASCT2 to glutamine uptake and endometrial cancer cell growth. Analysis of human gene expression data showed that ASCT2 was significantly upregulated in both endometrioid and serous subtypes of endometrial carcinoma, compared to normal, age-matched endometrium. Furthermore, immunohistochemical staining of primary human endometrioid adenocarcinomas showed that tumours stain positive for ASCT2 in either a uniform or mosaic expression pattern, while normal adjacent glands appeared predominantly negative for ASCT2 staining. Chemical inhibition of glutamine transport by benzylserine or GPNA led to a significant decrease in endometrial cancer cell growth and spheroid cross-sectional area. ASCT2 knockdown recapitulated the decrease of cell growth and spheroid cross-sectional area in HEC1A cells, suggesting a reliance on ASCT2-mediated glutamine uptake. ASCT2 knockdown in Ishikawa cells led to lower glutamine uptake and cell growth, but did not affect spheroid area. Ishikawa cells express higher levels of the glutamine transporter SNAT1 compared to HEC1A cells, suggesting these cells may rely on both ASCT2 and SNAT1 for glutamine uptake. Since SNAT1 is also significantly upregulated in the endometrioid and serous subtypes, these data indicate that ASCT2 and SNAT1 could be used as markers of malignancy, and/or potential therapeutic targets in patients with endometrial carcinoma.

ASCT2 regulates glutamine uptake and cell growth in endometrial carcinoma

Glutamine commonly becomes a conditionally essential amino acid in cancer. Glutamine is supplied to the cell by transporters such as ASCT2 (SLC1A5), which is frequently upregulated in multiple cancers. Here we investigated the expression of ASCT2 in endometrial carcinoma, and evaluated the contribution of ASCT2 to glutamine uptake and endometrial cancer cell growth. Analysis of human gene expression data showed that ASCT2 was significantly upregulated in both endometrioid and serous subtypes of endometrial carcinoma, compared to normal, age-matched endometrium. Furthermore, immunohistochemical staining of primary human endometrioid adenocarcinomas showed that tumours stain positive for ASCT2 in either a uniform or mosaic expression pattern, while normal adjacent glands appeared predominantly negative for ASCT2 staining. Chemical inhibition of glutamine transport by benzylserine or GPNA led to a significant decrease in endometrial cancer cell growth and spheroid cross-sectional area. ASCT2 knockdown recapitulated the decrease of cell growth and spheroid cross-sectional area in HEC1A cells, suggesting a reliance on ASCT2-mediated glutamine uptake. ASCT2 knockdown in Ishikawa cells led to lower glutamine uptake and cell growth, but did not affect spheroid area. Ishikawa cells express higher levels of the glutamine transporter SNAT1 compared to HEC1A cells, suggesting these cells may rely on both ASCT2 and SNAT1 for glutamine uptake. Since SNAT1 is also significantly upregulated in the endometrioid and serous subtypes, these data indicate that ASCT2 and SNAT1 could be used as markers of malignancy, and/or potential therapeutic targets in patients with endometrial carcinoma.

LAT1 is a putative therapeutic target in endometrioid endometrial carcinoma

l-type amino acid transporters (LAT1-4) are expressed in various cancer types and are involved in the uptake of essential amino acids such as leucine. Here we investigated the expression of LAT1-4 in endometrial adenocarcinoma and evaluated the contribution of LATs to endometrial cancer cell growth. Analysis of human gene expression data showed that all four LAT family members are expressed in endometrial adenocarcinomas. LAT1 was the most highly expressed, and showed a significant increase in both serous and endometrioid subtypes compared to normal endometrium. Endometrioid patients with the highest LAT1 levels exhibited the lowest disease-free survival. The pan-LAT inhibitor BCH led to a significant decrease in cell growth and spheroid area in four endometrial cancer cell lines tested in vitro. Knockdown of LAT1 by shRNA inhibited cell growth in HEC1A and Ishikawa cells, as well as inhibiting spheroid area in HEC1A cells. These data show that LAT1 plays an important role in regulating the uptake of essential amino acids such as leucine into endometrial cancer cells. Increased ability of BCH compared to LAT1 shRNA at inhibiting Ishikawa spheroid area suggests that other LAT family members may also contribute to cell growth. LAT1 inhibition may offer an effective therapeutic strategy in endometrial cancer patients whose tumours exhibit high LAT1 expression.

Dietary inflammatory index and endometrial cancer risk in an Italian case-control study

The relation between inflammation deriving from diet and endometrial cancer risk has not yet been investigated. In this study, we explored the association between the dietary inflammatory index (DII) and endometrial cancer risk in an Italian case-control study. Cases comprised 454 patients with incident, histologically confirmed carcinoma of the endometrium, and controls comprised 908 subjects admitted to the same network of hospitals as cases for a wide spectrum of acute, non-neoplastic conditions. DII scores were computed on the basis of dietary intake assessed using a reproducible and valid seventy-eight-item FFQ. OR were calculated through logistic regression models conditioned on age and study centre and adjusted for recognised confounding factors, including total energy intake. Women with the most pro-inflammatory diet had a higher risk for endometrial cancer compared with women with the most anti-inflammatory diet (OR(Quartile) 4 v. 1 1·46; 95% CI 1·02, 2·11; P(trend)=0·04). A pro-inflammatory diet may increase the risk for endometrial cancer.