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Di Maso M, Augustin LSA, Jenkins DJA, Crispo A, Toffolutti F, Negri E, La Vecchia C, Ferraroni M, Polesel J. Adherence to a Cholesterol-Lowering Diet and the Risk of Pancreatic Cancer: A Case-Control Study. Nutrients 2024; 16:2508. [PMID: 39125388 PMCID: PMC11314520 DOI: 10.3390/nu16152508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2024] [Revised: 07/24/2024] [Accepted: 07/29/2024] [Indexed: 08/12/2024] Open
Abstract
BACKGROUND Pancreatic cancer risk has been associated with increased serum cholesterol level, which is in turn partially influenced by diet. This study aimed at evaluating the association between pancreatic cancer risk and the adherence to a plant-based cholesterol-lowering diet. METHODS Data were derived from an Italian case-control study including 258 pancreatic cancer patients and 551 controls. The cholesterol-lowering diet score was based on seven components: high intakes of (i) non-cellulosic polysaccharides (a proxy of viscous fibers), (ii) monounsaturated fatty acids, (iii) legumes, and (iv) seeds/corn oils (a proxy of phytosterols); and low intakes of (v) saturated fatty acids, (vi) dietary cholesterol, and (vii) food with a high glycemic index. The score was calculated adding one point for each fulfilled component, thus ranging from zero (no adherence) to seven (complete adherence). The odds ratios (ORs) and 95% confidence intervals (CIs) were estimated through the logistic regression model. RESULTS Scores 5-7 were associated with reduced cancer risk (OR = 0.30; 95% CI: 0.18-0.52) compared to scores 0-2. CONCLUSIONS Adherence to a plant-based cholesterol-lowering diet was associated with a reduced risk of pancreatic cancer.
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Affiliation(s)
- Matteo Di Maso
- Department of Clinical Sciences and Community Health, Department of Excellence 2023–2027, Branch of Medical Statistics, Biometry and Epidemiology “G.A. Maccacaro”, Università degli Studi di Milano, via Celoria 22, 20133 Milan, Italy; (M.D.M.); (M.F.)
| | - Livia S. A. Augustin
- Epidemiology and Biostatistics Unit, Istituto Nazionale Tumori—IRCCS—“Fondazione G. Pascale”, via M. Semmola 1, 80131 Naples, Italy; (L.S.A.A.); (A.C.)
| | - David J. A. Jenkins
- Departments of Nutritional Science and Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON M5S 1A8, Canada;
- Clinical Nutrition and Risk Factor Modification Centre, St. Michael’s Hospital, Toronto, ON M5C 2T2, Canada
- Division of Endocrinology and Metabolism, Department of Medicine, St. Michael’s Hospital, Toronto, ON M5C 2T2, Canada
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, ON M5C 2T2, Canada
| | - Anna Crispo
- Epidemiology and Biostatistics Unit, Istituto Nazionale Tumori—IRCCS—“Fondazione G. Pascale”, via M. Semmola 1, 80131 Naples, Italy; (L.S.A.A.); (A.C.)
| | - Federica Toffolutti
- Unit of Cancer Epidemiology, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, via F. Gallini 2, 33081 Aviano, Italy; (F.T.); (J.P.)
| | - Eva Negri
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, Università di Bologna, via P. Palagi 9, 40138 Bologna, Italy;
| | - Carlo La Vecchia
- Department of Clinical Sciences and Community Health, Department of Excellence 2023–2027, Branch of Medical Statistics, Biometry and Epidemiology “G.A. Maccacaro”, Università degli Studi di Milano, via Celoria 22, 20133 Milan, Italy; (M.D.M.); (M.F.)
| | - Monica Ferraroni
- Department of Clinical Sciences and Community Health, Department of Excellence 2023–2027, Branch of Medical Statistics, Biometry and Epidemiology “G.A. Maccacaro”, Università degli Studi di Milano, via Celoria 22, 20133 Milan, Italy; (M.D.M.); (M.F.)
- Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, via F. Sforza 35, 20122 Milan, Italy
| | - Jerry Polesel
- Unit of Cancer Epidemiology, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, via F. Gallini 2, 33081 Aviano, Italy; (F.T.); (J.P.)
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Mei J, Qian M, Hou Y, Liang M, Chen Y, Wang C, Zhang J. Association of saturated fatty acids with cancer risk: a systematic review and meta-analysis. Lipids Health Dis 2024; 23:32. [PMID: 38291432 PMCID: PMC10826095 DOI: 10.1186/s12944-024-02025-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 01/20/2024] [Indexed: 02/01/2024] Open
Abstract
OBJECTIVE Extensive research has explored the link between saturated fatty acids (SFAs) and cardiovascular diseases, alongside other biological dysfunctions. Yet, their association with cancer risk remains a topic of debate among scholars. The present study aimed to elucidate this association through a robust meta-analysis. METHODS PubMed, Embase, Cochrane Library, and Web of Science databases were searched systematically to identify relevant studies published until December 2023. The Newcastle-Ottawa Scale was used as the primary metric for evaluating the quality of the included studies. Further, fixed- or random-effects models were adopted to determine the ORs and the associated confidence intervals using the Stata15.1 software. The subsequent subgroup analysis revealed the source of detection and the cancer types, accompanied by sensitivity analyses and publication bias evaluations. RESULTS The meta-analysis incorporated 55 studies, comprising 38 case-control studies and 17 cohort studies. It revealed a significant positive correlation between elevated levels of total SFAs and the cancer risk (OR of 1.294; 95% CI: 1.182-1.416; P-value less than 0.001). Moreover, elevated levels of C14:0, C16:0, and C18:0 were implicated in the augmentation of the risk of cancer. However, no statistically significant correlation of the risk of cancer was observed with the elevated levels of C4:0, C6:0, C8:0, C10:0, C12:0, C15:0, C17:0, C20:0, C22:0, and C24:0. Subgroup analysis showed a significant relationship between excessive dietary SFA intake, elevated blood SFA levels, and heightened cancer risk. Increased total SFA levels correlated with higher risks of breast, prostate, and colorectal cancers, but not with lung, pancreatic, ovarian, or stomach cancers. CONCLUSION High total SFA levels were correlated with an increased cancer risk, particularly affecting breast, prostate, and colorectal cancers. Higher levels of specific SFA subtypes (C14:0, C16:0, and C18:0) are also linked to an increased cancer risk. The findings of the present study would assist in providing dietary recommendations for cancer prevention, thereby contributing to the development of potential strategies for clinical trials in which diet-related interventions would be used in combination with immunotherapy to alter the levels of SFAs in patients and thereby improve the outcomes in cancer patients. Nonetheless, further high-quality studies are warranted to confirm these associations.
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Affiliation(s)
- Jin Mei
- Medical College of Shihezi University, Bei-Er-Lu, Shihezi, Xinjiang, 832000, China
| | - Meiyu Qian
- Medical College of Shihezi University, Bei-Er-Lu, Shihezi, Xinjiang, 832000, China
| | - Yanting Hou
- Medical College of Shihezi University, Bei-Er-Lu, Shihezi, Xinjiang, 832000, China
| | - Maodi Liang
- Medical College of Shihezi University, Bei-Er-Lu, Shihezi, Xinjiang, 832000, China
| | - Yao Chen
- Medical College of Shihezi University, Bei-Er-Lu, Shihezi, Xinjiang, 832000, China
| | - Cuizhe Wang
- Medical College of Shihezi University, Bei-Er-Lu, Shihezi, Xinjiang, 832000, China
| | - Jun Zhang
- Medical College of Shihezi University, Bei-Er-Lu, Shihezi, Xinjiang, 832000, China.
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Macronutrients Not Micronutrients Are Associated With the Risk of Pancreatic Cancer: A Jordanian Case-Control Study. Pancreas 2022; 51:1011-1018. [PMID: 36607948 DOI: 10.1097/mpa.0000000000002131] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVES Pancreatic cancer (PC) has been related directly to many risk factors; however, diet is considered one of the most modifiable risk factors. This study is designed to observe the associations between the intake of macromicronutrients and the risk of pancreatic cancer in a Jordanian population. METHODS A case-control study included 100 patients with the incident and histologically confirmed PC and 309 control subjects frequency-matched on age, educational level, occupation, and marital status. Face-to-face interview was used to collect the study's sociodemographic, physical activity, and dietary information. Intakes of macronutrients and micronutrients were assessed by a validated food-frequency questionnaire. Multinomial logistic regression was used to calculate odds ratios and confidence intervals. RESULTS The patients reported higher consumption of almost all the macromicronutrients and micronutrients as compared with control subjects. The highest tertile of dietary intake of carbohydrates, sugars, fats, saturated fats, monounsaturated fats, trans fats, cholesterol, and vitamin B3 was positively associated with PC risk (Ptrend < 0.05). However, dietary intakes of polyunsaturated fats, omega-3, and some vitamins and minerals were not associated (Ptrend > 0.05) with the risk of PC. CONCLUSIONS Our findings support the positive role of proteins, carbohydrates, sugars, fats, saturated fats, monounsaturated fats, trans fats, and cholesterol on pancreatic carcinogenesis.
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Zhang T, Wu S, Xu F, Chang J, Guo Y, Zhou Z, Xu R, Wang T, Wang X, Wang M, Qin S, Zhang S, Li J. The Association between Dietary Protein Intake and the Risk of Pancreatic Cancer: Evidence from 14 Publications. Nutr Cancer 2022; 74:3172-3178. [PMID: 35414283 DOI: 10.1080/01635581.2022.2059529] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 10/07/2021] [Accepted: 12/20/2021] [Indexed: 10/18/2022]
Abstract
Many studies have been published to assess the association about dietary protein intake on the risk of pancreatic cancer, but with inconsistent result. This meta-analysis aimed to evaluate whether protein intake could affect the risk of pancreatic cancer. A systematic literature search was performed in PubMed, EMBASE and Web of Science up to October 1, 2019. Pooled relative risks (RR) and 95% confidence intervals (CI) were calculated using a random-effect model. A total of 14 studies (12 case-control studies and two cohort studies) were included. Overall, total protein intake had no significant association on the risk of pancreatic cancer (RR = 1.02, 95%CI= 0.85-1.22, I2=45.7%). Subgroup analyses showed such relationships were almost not influenced by study design and geographic location. Interestingly, when we performed the subgroup analysis by protein type, the opposite association was found in animal protein intake (RR = 1.37, 95%CI= 0.93-2.01) and vegetable protein intake (RR = 0.78, 95%CI= 0.54-1.14), although these two groups were not statistically significant. In conclusion, this meta-analysis indicated that dietary total protein intake may be not associated with the risk of pancreatic cancer. However, protein type may be affecting the result which was found from our research. Therefore, studies with detailed information, especially protein type, are warranted to further confirm these findings.
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Affiliation(s)
- Tao Zhang
- Department of General Surgery, Shandong, Provincial Qianfoshan Hospital, Shandong University, Jinan, Shandong Province, China
- Department of General Surgery, The First Affiliated Hospital of Shandong First Medical University, Jinan, Shandong Province, China
| | - Shusheng Wu
- Department of Vascular Surgery, Shandong Provincial Third Hospital, Shandong University, Jinan, Shandong Province, China
| | - Feiyang Xu
- Department of General Surgery, The First Affiliated Hospital of Shandong First Medical University, Jinan, Shandong Province, China
| | - Junpeng Chang
- Department of General Surgery, The First Affiliated Hospital of Shandong First Medical University, Jinan, Shandong Province, China
| | - Yaxun Guo
- Department of General Surgery, Shandong, Provincial Qianfoshan Hospital, Shandong University, Jinan, Shandong Province, China
| | - Zhengtong Zhou
- Department of General Surgery, Shandong, Provincial Qianfoshan Hospital, Shandong University, Jinan, Shandong Province, China
- Department of General Surgery, The First Affiliated Hospital of Shandong First Medical University, Jinan, Shandong Province, China
| | - Rongwei Xu
- Department of General Surgery, Shandong, Provincial Qianfoshan Hospital, Shandong University, Jinan, Shandong Province, China
- Department of General Surgery, The First Affiliated Hospital of Shandong First Medical University, Jinan, Shandong Province, China
| | - Tiancheng Wang
- Department of General Surgery, Shandong, Provincial Qianfoshan Hospital, Shandong University, Jinan, Shandong Province, China
- Department of General Surgery, The First Affiliated Hospital of Shandong First Medical University, Jinan, Shandong Province, China
| | - Xianming Wang
- Department of General Surgery, Shandong, Provincial Qianfoshan Hospital, Shandong University, Jinan, Shandong Province, China
- Department of General Surgery, The First Affiliated Hospital of Shandong First Medical University, Jinan, Shandong Province, China
| | - Minghai Wang
- Department of General Surgery, Shandong, Provincial Qianfoshan Hospital, Shandong University, Jinan, Shandong Province, China
- Department of General Surgery, The First Affiliated Hospital of Shandong First Medical University, Jinan, Shandong Province, China
| | - Shiyong Qin
- Department of General Surgery, Shandong, Provincial Qianfoshan Hospital, Shandong University, Jinan, Shandong Province, China
- Department of General Surgery, The First Affiliated Hospital of Shandong First Medical University, Jinan, Shandong Province, China
| | - Shuguang Zhang
- Department of General Surgery, Shandong, Provincial Qianfoshan Hospital, Shandong University, Jinan, Shandong Province, China
- Department of General Surgery, The First Affiliated Hospital of Shandong First Medical University, Jinan, Shandong Province, China
| | - Jie Li
- Department of General Surgery, Shandong, Provincial Qianfoshan Hospital, Shandong University, Jinan, Shandong Province, China
- Department of General Surgery, The First Affiliated Hospital of Shandong First Medical University, Jinan, Shandong Province, China
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Ghamarzad Shishavan N, Masoudi S, Mohamadkhani A, Sepanlou SG, Sharafkhah M, Poustchi H, Mohamadnejad M, Hekmatdoost A, Pourshams A. Dietary intake of fatty acids and risk of pancreatic cancer: Golestan cohort study. Nutr J 2021; 20:69. [PMID: 34271937 PMCID: PMC8285839 DOI: 10.1186/s12937-021-00723-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 06/22/2021] [Indexed: 02/08/2023] Open
Abstract
Background As pancreatic cancer (PC) is a malignancy with poor prognosis, finding strategies for its prevention became a notable priority. Among all the factors influencing the risk of PC, dietary items especially fats are considered as the most modifiable risk factors.This study is designed to assess the associations of dietary intake of fatty acids with the risk of PC incidence. Methods A total of 50,045 adults between 40 and 75 years old participated in this cohort study in 2004–2008 and were followed up to the present. Intakes of fatty acids was evaluated by validated food-frequency questionnaire (FFQ). Cox proportional hazards regression model was used to estimate hazard ratio (HR) with 95 % confidence interval of differing levels of dietary intakes of fatty acids for incidence of PC. Results At the end of follow-up period, 76 cases of PC were identified and 46,904 participants without history of cancer, acute kidney disorders, fibrosis and cirrhosis were included in the study. Dietary total saturated fatty acids (SFAS) was associated with PC risk (HR = 1.05 (1.01–1.09), Ptrend=0.01), whereas dietary total monounsaturated fatty acids (MUFAS) was inversely associated with the risk of PC (HR = 0.92 (0.86–0.99), Ptrend=0.04). Dietary total polyunsaturated fatty acids (PUFAS) did show a protective but not significant association with the risk of PC (HR = 0.91(0.84-1.00), Ptrend=0.05). Conclusions The amount of total fat intake is not a risk factor for PC in our study and focusing on the intake of specific fatty acids becomes more striking. Unsaturated fatty acids including PUFAS and especially MUFAS are considered as protective dietary factors in PC prevention. In contrast, total SFAS is positively associated with the increased risk of PC. However, very long chain and odd-chain saturated fatty acids intake may be protective against PC.
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Affiliation(s)
- Neda Ghamarzad Shishavan
- Digestive Oncology Research Center, Digestive Disease Research Institute, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Sahar Masoudi
- Digestive Oncology Research Center, Digestive Disease Research Institute, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Ashraf Mohamadkhani
- Liver and Pancreatobiliary Diseases Research Center, Digestive Disease Research Institute, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Sadaf G Sepanlou
- Digestive Oncology Research Center, Digestive Disease Research Institute, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Maryam Sharafkhah
- Digestive Oncology Research Center, Digestive Disease Research Institute, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Hossein Poustchi
- Liver and Pancreatobiliary Diseases Research Center, Digestive Disease Research Institute, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Mehdi Mohamadnejad
- Digestive Oncology Research Center, Digestive Disease Research Institute, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Azita Hekmatdoost
- Departments of Clinical Nutrition and Dietetics, Faculty of Nutrition and Food Technology, National Nutrition and Food Technology Research Institute, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Akram Pourshams
- Digestive Oncology Research Center, Digestive Disease Research Institute, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran.
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Monroy-Iglesias MJ, Dolly S, Sarker D, Thillai K, Van Hemelrijck M, Santaolalla A. Pancreatic Cancer Exposome Profile to Aid Early Detection and Inform Prevention Strategies. J Clin Med 2021; 10:1665. [PMID: 33924591 PMCID: PMC8069449 DOI: 10.3390/jcm10081665] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 03/19/2021] [Accepted: 04/08/2021] [Indexed: 12/12/2022] Open
Abstract
Pancreatic cancer (PCa) is associated with a poor prognosis and high mortality rate. The causes of PCa are not fully elucidated yet, although certain exposome factors have been identified. The exposome is defined as the sum of all environmental factors influencing the occurrence of a disease during a life span. The development of an exposome approach for PCa has the potential to discover new disease-associated factors to better understand the carcinogenesis of PCa and help with early detection strategies. Our systematic review of the literature identified several exposome factors that have been associated with PCa alone and in combination with other exposures. A potential inflammatory signature has been observed among the interaction of several exposures (i.e., smoking, alcohol consumption, diabetes mellitus, obesity, and inflammatory markers) that further increases the incidence and progression of PCa. A large number of exposures have been identified such as genetic, hormonal, microorganism infections and immune responses that warrant further investigation. Future early detection strategies should utilize this information to assess individuals' risk for PCa.
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Affiliation(s)
- Maria J. Monroy-Iglesias
- Translational Oncology & Urology Research (TOUR), School of Cancer and Pharmaceutical Sciences, King’s College London, London SE1 9RT, UK; (M.J.M.-I.); (M.V.H.)
| | - Saoirse Dolly
- Department of Medical Oncology, Guy’s and St Thomas’ NHS Foundation Trust, London SE1 9RT, UK; (S.D.); (D.S.); (K.T.)
| | - Debashis Sarker
- Department of Medical Oncology, Guy’s and St Thomas’ NHS Foundation Trust, London SE1 9RT, UK; (S.D.); (D.S.); (K.T.)
- School of Cancer and Pharmaceutical Sciences, King’s College London, London SE1 9RT, UK
| | - Kiruthikah Thillai
- Department of Medical Oncology, Guy’s and St Thomas’ NHS Foundation Trust, London SE1 9RT, UK; (S.D.); (D.S.); (K.T.)
| | - Mieke Van Hemelrijck
- Translational Oncology & Urology Research (TOUR), School of Cancer and Pharmaceutical Sciences, King’s College London, London SE1 9RT, UK; (M.J.M.-I.); (M.V.H.)
| | - Aida Santaolalla
- Translational Oncology & Urology Research (TOUR), School of Cancer and Pharmaceutical Sciences, King’s College London, London SE1 9RT, UK; (M.J.M.-I.); (M.V.H.)
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Zheng J, Guinter MA, Merchant AT, Wirth MD, Zhang J, Stolzenberg-Solomon RZ, Steck SE. Dietary patterns and risk of pancreatic cancer: a systematic review. Nutr Rev 2018; 75:883-908. [PMID: 29025004 DOI: 10.1093/nutrit/nux038] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Context Pancreatic cancer has the highest case fatality rate of all major cancers. Objective A systematic review using PRISMA guidelines was conducted to summarize the associations between dietary patterns and risk of pancreatic cancer. Data Sources PubMed and Web of Science databases were searched for case-control and cohort studies published up to June 15, 2016. Study Selection Eligible studies included a dietary pattern as exposure and pancreatic cancer incidence or mortality as outcome and reported odds ratios, hazard ratios, or relative risks, along with corresponding 95%CIs. Data Extraction Important characteristics of each study, along with the dietary assessment instrument, the component foods or nutrients included in each dietary pattern or the scoring algorithm of a priori dietary patterns, were presented. For each dietary pattern identified, the estimate of association and the 95%CI comparing the highest versus the lowest category from the model with the most covariate adjustment were reported. Results A total of 16 studies were identified. Among the 8 studies that examined data-driven dietary patterns, significant positive associations were found between pancreatic cancer risk and the Animal Products, Starch Rich, and Western dietary patterns, with effect estimates ranging from 1.69 to 2.40. Significant inverse relationships were found between risk of pancreatic cancer and dietary patterns designated as Fruits and Vegetables, Vitamins and Fiber, and Prudent, with effect estimates ranging from 0.51 to 0.55. Eight studies of a priori dietary patterns consistently suggested that improved dietary quality was associated with reduced risk of pancreatic cancer. Conclusions Better diet quality is associated with reduced risk of pancreatic cancer. The associations between dietary patterns and pancreatic cancer were stronger in case-control studies than in cohort studies and were stronger among men than among women.
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Affiliation(s)
- Jiali Zheng
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina, USA.,Cancer Prevention and Control Program, University of South Carolina, Columbia, South Carolina, USA
| | - Mark A Guinter
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina, USA.,Cancer Prevention and Control Program, University of South Carolina, Columbia, South Carolina, USA
| | - Anwar T Merchant
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina, USA
| | - Michael D Wirth
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina, USA.,Cancer Prevention and Control Program, University of South Carolina, Columbia, South Carolina, USA.,Connecting Health Innovations LLC, Columbia, South Carolina, USA
| | - Jiajia Zhang
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina, USA
| | - Rachael Z Stolzenberg-Solomon
- Division of Cancer Epidemiology and Genetics, Nutritional Epidemiology Branch, National Cancer Institute, Rockville, Maryland, USA
| | - Susan E Steck
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina, USA.,Cancer Prevention and Control Program, University of South Carolina, Columbia, South Carolina, USA
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Abstract
Adequate protein intake is critical for health and development. Generally, protein of animal origin is of higher quality for humans owing to its amino acid pattern and good digestibility. When administered in mixtures it can enhance the quality of plant proteins, but its availability is often low in low-income communities, especially in young children, the elderly, and pregnant and lactating women, who have increased requirements and in whom high-quality protein also stimulates (bone) growth and maintenance. Although high protein intake was associated with increased type 2 diabetes mellitus risk, milk and seafood are good sources of branched chain amino acids and taurine, which act beneficially on glucose metabolism and blood pressure. However, high consumption of protein-rich animal food is also associated with adverse health effects and higher risk for noncommunicable diseases, partly related to other components of these foods, like saturated fatty acids and potential carcinogens in processed meat but also the atherogenic methionine metabolite homocysteine. In moderation, however, animal proteins are especially important for health maintenance in vulnerable persons.
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Affiliation(s)
- Ibrahim Elmadfa
- Department of Nutritional Sciences, Faculty of Life Sciences, University of Vienna, Vienna 1010, Austria;,
| | - Alexa L. Meyer
- Department of Nutritional Sciences, Faculty of Life Sciences, University of Vienna, Vienna 1010, Austria;,
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9
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Yao X, Tian Z. Saturated, Monounsaturated and Polyunsaturated Fatty Acids Intake and Risk of Pancreatic Cancer: Evidence from Observational Studies. PLoS One 2015; 10:e0130870. [PMID: 26110621 PMCID: PMC4481405 DOI: 10.1371/journal.pone.0130870] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2014] [Accepted: 05/26/2015] [Indexed: 11/24/2022] Open
Abstract
Background Although the relationship between dietary monounsaturated fatty acids (MUFAs), polyunsaturated fatty acids (PUFAs), and saturated fatty acids (SFAs) intake and pancreatic cancer risk has been reported by several studies, the evidence is controversial. We firstly conducted this comprehensive meta-analysis to summarize the aforementioned evidence from observational studies. Methods The MEDLINE (PubMed), Embase, and ISI Web of Science databases were used to search for epidemiological studies of dietary SFA, MUFA, and PUFA and pancreatic cancer risk that were published until the end of June 2014. Random- or fixed-effects models were used to estimate the relative risks (RRs) and 95% confidence intervals (CIs). We also carried out subgroup, sensitivity, and publication bias analyses. Results We identified 13 case-control studies and 7 prospective studies which including 6270 pancreatic cancer cases in the meta-analysis of SFA, MUFA, and PUFA and risk of pancreatic cancer. The summary RR was 1.13 (95%CI = 0.94-1.35, I2 = 70.7%) for SFA, 1.00 (95%CI = 0.87-1.14, I2 = 43.4%) for MUFA, and 0.87 (95%CI = 0.75-1.00, I2 = 55.3%) for PUFA for high versus low intake categories. We found no evidence of publication bias. Conclusion In summary, findings of this study supports an inverse association between diets high in PUFA and pancreatic cancer risk. Further large prospective studies are warranted to report the results stratified by the subtypes of MUFA and PUFA and adjust for other potential risk factors to eliminate residual confounding.
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Affiliation(s)
- Xu Yao
- Department of General Surgery, Shengjing Hospital, China Medical University, Shenyang, P. R. China
| | - Zhong Tian
- Department of General Surgery, Shengjing Hospital, China Medical University, Shenyang, P. R. China
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Wang J, Wang WJ, Zhai L, Zhang DF. Association of cholesterol with risk of pancreatic cancer: A meta-analysis. World J Gastroenterol 2015; 21:3711-3719. [PMID: 25834340 PMCID: PMC4375597 DOI: 10.3748/wjg.v21.i12.3711] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2014] [Revised: 10/07/2014] [Accepted: 11/11/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the effect of dietary cholesterol and serum total cholesterol (TC) on the risk of pancreatic cancer.
METHODS: A literature search was performed up to June 2014 in PubMed, EMBASE, China National Knowledge Infrastructure and China Biology Medical literature database for relevant articles published in English or Chinese. Pooled relative risks (RRs) with 95% confidence intervals (CIs) were calculated with a random-effects model.
RESULTS: We included 14 published articles with 439355 participants for dietary cholesterol, and 6 published articles with 1805697 participants for serum TC. For the highest vs lowest category of dietary cholesterol, the pooled RR (95%CI) of pancreatic cancer was 1.308 (1.097-1.559). After excluding two studies (RR > 3.0), the pooled RR (95%CI) was 1.204 (1.050-1.380). In subgroup analysis stratified by study design, the pooled RRs (95%CIs) were 1.523 (1.226-1.893) for case-control studies and 1.023 (0.871-1.200) for cohort studies. The association of dietary cholesterol with the risk of pancreatic cancer was significant for studies conducted in North America [1.275 (1.058-1.537)] and others [2.495 (1.565-3.977)], but not in Europe [1.149 (0.863-1.531)]. No significant association [1.003 (0.859-1.171)] was found between the risk of pancreatic cancer and serum TC.
CONCLUSION: Dietary cholesterol may be associated with an increased risk of pancreatic cancer in worldwide populations, except for Europeans. The results need to be confirmed further.
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Abstract
OBJECTIVE To provide data on the impact of known risk factors on pancreatic cancer burden, we estimated the population attributable risks (PARs) in the Italian population. METHODS Data were derived from a case-control study conducted in Northern Italy between 1991 and 2008, including 326 case patients with incident pancreatic cancer and 652 hospital control subjects. RESULTS We found that 13.6% (95% confidence interval [CI], 6.3-20.8) of pancreatic cancers were attributable to tobacco smoking, 13.0% (95% CI, 2.7-23.2) were attributable to heavy alcohol drinking, 9.7% (95% CI, 5.3-14.1) were attributable to diabetes, 11.9% (95% CI, -8.0 to 31.8) were attributable to a low adherence to Mediterranean diet, and 0.6% (95% CI, -1.8 to 2.9) were attributable to a family history of pancreatic cancer. The PARs for tobacco smoking increased up to 25.7% when we considered it jointly with alcohol, up to 21.7% with diabetes, and up to 24.8% with low Mediterranean diet adherence. For all the risk factors considered, the PARs were higher in men than in women, the differences being particularly evident for heavy alcohol consumption and for a low Mediterranean diet adherence. CONCLUSIONS These results suggest that an appreciable proportion of pancreatic cancers could be avoided in this Italian population by intervention on a few selected modifiable lifestyle factors.
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Association between cholesterol intake and pancreatic cancer risk: evidence from a meta-analysis. Sci Rep 2015; 5:8243. [PMID: 25649888 PMCID: PMC4316166 DOI: 10.1038/srep08243] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Accepted: 12/16/2014] [Indexed: 11/20/2022] Open
Abstract
Quantification of the association between the intake of cholesterol and risk of pancreatic cancer is still conflicting. We therefore conducted a meta-analysis to summarize the evidence from epidemiological studies of cholesterol intake and the risk of pancreatic cancer. Pertinent studies were delivered by PubMed and Web of Knowledge issued through April of 2014. A random effects model was used to process the data for analysis. Sensitivity analysis and publication bias were conducted. Dose-response relationship was assessed by restricted cubic spline and variance-weighted least squares regression analysis. With 4513 pancreatic cases exemplified, 16 articles were applied in the meta-analysis. Pooled results suggest that cholesterol intake level was significantly associated with the risk of pancreatic cancer [summary relative risk (RR) = 1.371, 95%CI = 1.155–1.627, I2 = 58.2%], especially in America [summary RR = 1.302, 95%CI = 1.090–1.556]. A linear dose-response relation was attested that the risk of pancreatic cancer rises by 8% with 100 mg/day of cholesterol intake. [summary RR = 1.08, 95% CI = 1.04–1.13]. In conclusion, our analysis suggests that a high intake of cholesterol might increase the risk of pancreatic cancer, especially in America.
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Dietary inflammatory index and risk of pancreatic cancer in an Italian case-control study. Br J Nutr 2014; 113:292-8. [PMID: 25515552 DOI: 10.1017/s0007114514003626] [Citation(s) in RCA: 101] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Previous studies have shown that various dietary components may be implicated in the aetiology of pancreatic cancer. However, the possible relationship between diet-related inflammation and the risk of pancreatic cancer has not yet been investigated. We examined the ability of a newly developed literature-derived dietary inflammatory index (DII) to predict the risk of pancreatic cancer in a case-control study conducted in Italy between 1991 and 2008. This included 326 incident cases and 652 controls admitted to the major teaching and general hospitals for non-neoplastic diseases, frequency-matched to cases by study centre, sex and age. The DII was computed based on dietary intake assessed using a validated and reproducible seventy-eight-item FFQ. Logistic regression models were used to estimate multivariable OR adjusted for age, sex, study centre, education, BMI, smoking status, alcohol drinking and history of diabetes. Energy adjustment was performed using the residual method. Subjects with higher DII scores (i.e., representing a more pro-inflammatory diet) had a higher risk of pancreatic cancer, with the DII being used as both a continuous variable (ORcontinuous 1.24, 95% CI 1.11, 1.38) and a categorical variable (i.e., compared with the subjects in the lowest quintile of the DII, those in the second, third, fourth and fifth quintiles had, respectively, OR(quintile2 v. 1) 1.70, 95% CI 1.02, 2.80; OR(quintile3 v. 1) 1.91, 95% CI 1.16, 3.16; OR(quintile4 v. 1) 1.98, 95% CI 1.20, 3.27; OR(quintile5 v. 1) 2.48, 95% CI 1.50, 4.10; P trend= 0.0015). These data suggest that a pro-inflammatory diet increases the risk of pancreatic cancer.
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Pedersen AN, Kondrup J, Børsheim E. Health effects of protein intake in healthy adults: a systematic literature review. Food Nutr Res 2013; 57:21245. [PMID: 23908602 PMCID: PMC3730112 DOI: 10.3402/fnr.v57i0.21245] [Citation(s) in RCA: 83] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2013] [Revised: 04/24/2013] [Accepted: 04/25/2013] [Indexed: 01/20/2023] Open
Abstract
The purpose of this systematic review is to assess the evidence behind the dietary requirement of protein and to assess the health effects of varying protein intake in healthy adults. The literature search covered the years 2000-2011. Prospective cohort, case-control, and intervention studies were included. Out of a total of 5,718 abstracts, 412 full papers were identified as potentially relevant, and after careful scrutiny, 64 papers were quality graded as A (highest), B, or C. The grade of evidence was classified as convincing, probable, suggestive or inconclusive. The evidence is assessed as: probable for an estimated average requirement of 0.66 g good-quality protein/kg body weight (BW)/day based on nitrogen balance studies, suggestive for a relationship between increased all-cause mortality risk and long-term low-carbohydrate-high-protein (LCHP) diets; but inconclusive for a relationship between all-cause mortality risk and protein intake per se; suggestive for an inverse relationship between cardiovascular mortality and vegetable protein intake; inconclusive for relationships between cancer mortality and cancer diseases, respectively, and protein intake; inconclusive for a relationship between cardiovascular diseases and total protein intake; suggestive for an inverse relationship between blood pressure (BP) and vegetable protein; probable to convincing for an inverse relationship between soya protein intake and LDL cholesterol; inconclusive for a relationship between protein intake and bone health, energy intake, BW control, body composition, renal function, and risk of kidney stones, respectively; suggestive for a relationship between increased risk of type 2 diabetes (T2D) and long-term LCHP-high-fat diets; inconclusive for impact of physical training on protein requirement; and suggestive for effect of physical training on whole-body protein retention. In conclusion, the evidence is assessed as probable regarding the estimated requirement based on nitrogen balance studies, and suggestive to inconclusive for protein intake and mortality and morbidity. Vegetable protein intake was associated with decreased risk in many studies. Potentially adverse effects of a protein intake exceeding 20-23 E% remain to be investigated.
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Bosetti C, Bravi F, Turati F, Edefonti V, Polesel J, Decarli A, Negri E, Talamini R, Franceschi S, La Vecchia C, Zeegers MP. Nutrient-based dietary patterns and pancreatic cancer risk. Ann Epidemiol 2013; 23:124-8. [PMID: 23332711 DOI: 10.1016/j.annepidem.2012.12.005] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2012] [Revised: 10/04/2012] [Accepted: 12/09/2012] [Indexed: 12/20/2022]
Abstract
PURPOSE Few data are available on the role of combinations of foods and/or nutrients on pancreatic cancer risk. To add further information on dietary patterns potentially associated to pancreatic cancer, we applied an exploratory principal component factor analysis on 28 major nutrients derived from an Italian case-control study. METHODS Cases were 326 incident pancreatic cancer cases and controls 652 frequency-matched controls admitted to hospital for non-neoplastic diseases. Dietary information was collected through a validated and reproducible food frequency questionnaire. Multiple logistic regression models adjusted for sociodemographic variables and major recognized risk factors for pancreatic cancer were used to estimate the odds ratios (OR) of pancreatic cancer for each dietary pattern. RESULTS We identified four dietary patterns-named "animal products," "unsaturated fats," "vitamins and fiber," and "starch rich," that explain 75% of the total variance in nutrient intake in this population. After allowing for all the four patterns, positive associations were found for the animal products and the starch rich patterns, the OR for the highest versus the lowest quartiles being 2.03 (95% confidence interval [CI], 1.29-3.19) and 1.69 (95% CI, 1.02-2.79), respectively; an inverse association emerged for the vitamins and fiber pattern (OR, 0.55; 95% CI, 0.35-0.86), whereas no association was observed for the unsaturated fats pattern (OR, 1.13; 95% CI, 0.71-1.78). CONCLUSIONS A diet characterized by a high consumption of meat and other animal products, as well as of (refined) cereals and sugars, is positively associated with pancreatic cancer risk, whereas a diet rich in fruit and vegetables is inversely associated.
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Affiliation(s)
- Cristina Bosetti
- Dipartimento di Epidemiologia, Istituto di Ricerche Farmacologiche Mario Negri Milan, Italy.
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Bosetti C, Rosato V, Polesel J, Levi F, Talamini R, Montella M, Negri E, Tavani A, Zucchetto A, Franceschi S, Corrao G, Vecchia CL. Diabetes Mellitus and Cancer Risk in a Network of Case-Control Studies. Nutr Cancer 2012; 64:643-51. [DOI: 10.1080/01635581.2012.676141] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Rosato V, Tavani A, Bosetti C, Pelucchi C, Talamini R, Polesel J, Serraino D, Negri E, La Vecchia C. Metabolic syndrome and pancreatic cancer risk: a case-control study in Italy and meta-analysis. Metabolism 2011; 60:1372-8. [PMID: 21550085 DOI: 10.1016/j.metabol.2011.03.005] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2011] [Revised: 03/07/2011] [Accepted: 03/10/2011] [Indexed: 01/26/2023]
Abstract
We assessed the relation between metabolic syndrome (MetS), its components, and pancreatic cancer risk in an Italian case-control study and performed a meta-analysis of epidemiological studies published up to February 2011. The case-control study included 326 patients with incident pancreatic cancer and 652 controls admitted to the same hospitals for acute, non-neoplastic conditions. MetS was defined as having at least 3 conditions among diabetes, drug-treated hypertension, hyperlipidemia, and body mass index at least 25 kg/m(2) at age 30 years. We computed multivariate odds ratios (ORs) and the corresponding 95% confidence intervals (CIs) from logistic regression models adjusted for tobacco smoking, education, and other sociodemographic variables. For the meta-analysis, we calculated summary relative risks (RRs) using random-effects models. The OR of pancreatic cancer in the case-control study was 2.36 (95% CI, 1.43-3.90) for diabetes, 0.77 (95% CI, 0.55-1.08) for hypertension, 1.38 (95% CI, 0.94-2.01) for hypercholesterolemia, and 1.27 (95% CI, 0.91-1.78) for being overweight at age 30 years. The risk was significantly increased for subjects with 3 or more MetS components (OR = 2.13, 95% CI 1.01-4.49) compared with subjects with no component, the estimates being consistent among strata of sex, age, and alcohol consumption. The meta-analysis included 3 cohort studies and our case-control study, and found a summary RR of 1.55 (95% CI, 1.19-2.01) for subjects with MetS. Metabolic syndrome is related to pancreatic cancer risk. Diabetes is the key component related to risk.
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Affiliation(s)
- Valentina Rosato
- Department of Epidemiology, Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy
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Hu J, La Vecchia C, de Groh M, Negri E, Morrison H, Mery L. Dietary cholesterol intake and cancer. Ann Oncol 2011; 23:491-500. [PMID: 21543628 DOI: 10.1093/annonc/mdr155] [Citation(s) in RCA: 113] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND This study assesses the association between dietary cholesterol intake and the risk of various cancers. PATIENTS AND METHODS Mailed questionnaires were completed between 1994 and 1997 in eight Canadian provinces by 1182 incident histologically confirmed cases of the stomach, 1727 of the colon, 1447 of the rectum, 628 of the pancreas, 3341 of the lung, 2362 of the breast, 442 of the ovary, 1799 of the prostate, 686 of the testis, 1345 of the kidney, 1029 of the bladder, 1009 of the brain, 1666 non-Hodgkin's lymphomas (NHL), 1069 leukemia and 5039 population controls. Information on dietary habits and nutrition intake were obtained using a food frequency questionnaire, which provided data on eating habits 2 years before the study. Odds ratios (ORs) were derived by unconditional logistic regression to adjust for total energy intake and other potential confounding factors. RESULTS Dietary cholesterol was positively associated with the risk of cancers of the stomach, colon, rectum, pancreas, lung, breast (mainly postmenopausal), kidney, bladder and NHL: the ORs for the highest versus the lowest quartile ranged from 1.4 to 1.7. In contrast, cholesterol intake was inversely associated with prostate cancer. CONCLUSIONS Our findings add to the evidence that high cholesterol intake is linked to increased risk of various cancers. A diet low in cholesterol may play a role in the prevention of several cancers.
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Affiliation(s)
- J Hu
- Science Integration Division, Centre for Chronic Disease Prevention and Control, Public Health Agency of Canada, Ottawa, Canada.
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Abstract
OBJECTIVES To investigate the role of menstrual, reproductive, and hormonal factors, as well as benign female conditions, on pancreatic cancer risk. METHODS We analyzed the combined data from 2 Italian case-control studies including 285 female case patients of pancreatic cancer and 713 female controls. All subjects were interviewed by trained interviewers during their hospital stay using similar structured questionnaires. Odds ratios (ORs) and their corresponding 95% confidence intervals (CIs) were estimated using multiple logistic regression models adjusted for selected covariates. RESULTS Compared to nulliparae, the OR was 0.76 (95% CI, 0.51-1.12) for parous women and 0.46 (95% CI, 0.26-0.85) for women with 4 or more births, in the absence, however, of a significant trend with increasing number of births. Pancreatic cancer risk was also nonsignificantly reduced among women with age at first birth lower than 25 years (OR, 0.65; 95% CI, 0.42-1.01). Other factors, including age at menarche and menopause, menopausal status, type of menopause, history of spontaneous and induced abortions, use of oral contraceptives and hormone replacement therapy, and history of most female benign conditions were not related to pancreatic cancer risk. CONCLUSIONS This study provides little support for the hypothesis that menstrual, reproductive, or hormonal factors are related to the development of pancreatic cancer.
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Bravi F, Polesel J, Bosetti C, Talamini R, Negri E, Dal Maso L, Serraino D, La Vecchia C. Dietary intake of selected micronutrients and the risk of pancreatic cancer: an Italian case-control study. Ann Oncol 2010; 22:202-206. [PMID: 20530201 DOI: 10.1093/annonc/mdq302] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE several studies have shown an inverse relation between vegetable and fruit intake and pancreatic cancer, but no specific beneficial component of such foods has been consistently identified. We considered the role of 15 selected vitamins and carotenoids and 6 minerals on pancreatic cancer risk in an Italian case-control study. METHODS subjects were 326 patients with incident pancreatic cancer and 652 controls, admitted to the same hospitals as cases for acute conditions. Micronutrient computation was based on a validated and reproducible food-frequency questionnaire. We estimated the odds ratios (OR) and confidence intervals (CI) using conditional logistic regression models, adjusted for various confounding factors and for energy intake, according to the residual model. RESULTS comparing the highest to the lowest quintile of intake, the OR were 0.60 (95% CI 0.36-0.98) for vitamin E, 0.44 (95% CI 0.27-0.73) for vitamin C, 0.56 (95% CI 0.34-0.93) for folate, and 0.57 (95% CI 0.35-0.92) for potassium. No significant inverse associations were observed for α-carotene (OR = 0.69, 95% CI 0.43-1.12), β-carotene (OR = 0.64, 95% CI 0.39-1.06), and β-cryptoxanthin (OR = 0.66, 95% CI 0.39-1.09). No relation was found for other micronutrients considered. CONCLUSION our findings support a favorable role of vitamins E and C, selected carotenoids, and folate on pancreatic carcinogenesis.
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Affiliation(s)
- F Bravi
- Department of Epidemiology, Mario Negri Institute for Pharmacological Research, Milan; Department of Occupational Medicine 'Luigi Devoto Work Clinic', Section of Medical Statistics and Biometry 'Giulio A. Maccacaro', University of Milan, Milan.
| | - J Polesel
- Unit of Epidemiology and Biostatistics, Centro di Riferimento Oncologico, Aviano (PN), Italy
| | - C Bosetti
- Department of Epidemiology, Mario Negri Institute for Pharmacological Research, Milan
| | - R Talamini
- Unit of Epidemiology and Biostatistics, Centro di Riferimento Oncologico, Aviano (PN), Italy
| | - E Negri
- Department of Epidemiology, Mario Negri Institute for Pharmacological Research, Milan
| | - L Dal Maso
- Department of Occupational Medicine 'Luigi Devoto Work Clinic', Section of Medical Statistics and Biometry 'Giulio A. Maccacaro', University of Milan, Milan; Unit of Epidemiology and Biostatistics, Centro di Riferimento Oncologico, Aviano (PN), Italy
| | - D Serraino
- Unit of Epidemiology and Biostatistics, Centro di Riferimento Oncologico, Aviano (PN), Italy
| | - C La Vecchia
- Department of Epidemiology, Mario Negri Institute for Pharmacological Research, Milan; Department of Occupational Medicine 'Luigi Devoto Work Clinic', Section of Medical Statistics and Biometry 'Giulio A. Maccacaro', University of Milan, Milan
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