Association between sleep-disordered breathing, obstructive sleep apnea, and cancer incidence: a systematic review and meta-analysis

A narrative review of the relationship between head and neck cancer and obstructive sleep apnea: Clinical studies and statistical analysis

Obstructive sleep apnea (OSA) is an underestimated and overlooked comorbidity in head and neck cancer (HNC) care. Refining HNC-OSA management requires an improved grasp of the HNC-OSA relationship. Thus, this paper reviews the current course of HNC therapy, causal and associative relationships before and after treatment, and statistical methods quantifying HNC-OSA interactions. This evaluation serves a dual purpose: to support oncologists and sleep physicians in improving the treatment outcomes of patients undergoing HNC treatment by considering OSA as a comorbidity and to assist researchers in selecting suitable analytical models for investigating the correlation between OSA and HNC. The investigation confirms a positive correlation between the apnea-hypopnea index (AHI) and primary tumor size, consistent with prior findings. Case studies also reported new evidence of lipoma and head-neck tumors triggering OSA, and sleep apnea surgery prompting tumor development. This paper provides an overview of existing statistical models and offers suggestions for model selection and a framework for designing experiments that delve into research questions surrounding the link between OSA and HNC across various stages of cancer treatment. Despite progress, understanding the HNC-OSA interplay remains incomplete due to limited histological, molecular, and clinical data. Future studies with longitudinal data are crucial for comprehensive insights.

Obstructive sleep apnea severity, circulating biomarkers, and cancer risk

STUDY OBJECTIVES

To determine whether obstructive sleep apnea (OSA) severity and/or biomarkers of inflammation/angiogenesis are associated with incident cancer in this clinical cohort.

METHODS

Consenting adult patients at the University of British Columbia Hospital between 2003 and 2014 completed a questionnaire about their medical history and sleep habits prior to undergoing a polysomnogram. Blood samples were collected the morning after polysomnography and processed for biomarkers of inflammation and angiogenesis. The clinical, polysomnography, and biomarker data were linked to the British Columbia Cancer Registry to ascertain incident cancer diagnoses. Cox proportional hazard regression was used to assess the association between OSA severity and biomarker concentrations with cancer risk.

RESULTS

A total of 1,990 patients were included in the analysis with a mean follow-up time of 12.8 years; 181 of them (9.1%) developed cancer after polysomnography. OSA severity was significantly associated with cancer risk after controlling for relevant covariates (hazard ratio = 1.08 per 10 events/h apnea-hypopnea index increase, confidence interval = 1.02-1.15, P = .015). In an exploratory analysis, 2 biomarkers were significantly associated with an increased cancer risk after controlling for relevant covariates (hazard ratio per interquartile range pg/mL increase of endostatin = 1.45, confidence interval = 1.12-1.87, P = .01 and hazard ratio for interquartile range pg/mL increase of vascular cell adhesion molecule-1 = 1.48, confidence interval = 1.04-2.11, P = .03, respectively).

CONCLUSIONS

OSA severity was an independent risk factor for cancer. Furthermore, 2 circulating markers were significantly associated with cancer risk. If these preliminary findings can be reproduced in other cohorts, biomarkers could potentially be used to prognosticate patients with OSA with respect to cancer risk.

CITATION

Hirsch Allen AJ, Kendzerska T, Bhatti P, et al. Obstructive sleep apnea severity, circulating biomarkers, and cancer risk. J Clin Sleep Med. 2024;20(9):1415-1422.

The Association of Obstructive Sleep Apnea with Urological Cancer Incidence and Mortality-A Systematic Review and Meta-analysis

BACKGROUND AND OBJECTIVE

While obstructive sleep apnea (OSA) and urological cancer are both strongly associated with hypoxia, controversy exists regarding their association with each other. This study aims to summarize and synthesize evidence to clarify the association between OSA and urological cancer incidence and mortality.

METHODS

According to a prespecified protocol, PubMed, Embase, Cochrane Library, and Scopus were searched from inception to November 16, 2023, for observational and randomized studies reporting the association of OSA with urological cancer incidence or mortality. We pooled maximally covariate-adjusted hazard ratios (HRs) using a random-effects inverse variance-weighted model. Two reviewers independently assessed the quality of evidence using the Newcastle-Ottawa Scale and the Grading of Recommendations, Assessment, Development and Evaluation framework.

KEY FINDINGS AND LIMITATIONS

From 1814 records, we included 12 studies comprising 9 290 818 participants in total, of which nine studies were analyzed quantitatively. OSA patients had an increased risk of kidney (HR: 1.75, 95% confidence interval [CI]: 1.21-2.53) and bladder (HR: 1.76, 95% CI: 1.05-2.96) cancer. However, OSA was not associated with prostate cancer incidence (HR: 1.29, 95% CI: 0.82-2.04). We systematically reviewed evidence surrounding OSA and testicular cancer incidence and urological cancer mortality.

CONCLUSIONS AND CLINICAL IMPLICATIONS

OSA may be associated with a higher risk of kidney and bladder cancer, but not prostate cancer. Future work may help clarify the possibility of a dose-response relationship between OSA and urological cancer, and the effect of OSA treatment on urological cancer incidence or progression.

PATIENT SUMMARY

This research highlights a potential longitudinal association between OSA and kidney and bladder cancer, but not prostate cancer.

Sex-specific associations between habitual snoring and cancer prevalence: insights from a US Cohort Study

Study Objectives

To investigate the sex-specific association between habitual snoring and overall cancer prevalence and subtypes, and to examine the influence of age, body mass index (BMI), and sleep duration on this association.

Methods

This study utilized data from the National Health and Nutrition Examination Survey cycles between 2005 and 2020 and included 15 892 participants aged 18 and over. We employed inverse probability of treatment weighting based on propensity scores to adjust for confounders when comparing the prevalence of cancer between habitual snorers and non-habitual snorers for each sex and cancer type. Subgroup analyses were conducted based on sleep duration, age, and BMI categories.

Results

The cohort (mean age 48.2 years, 50.4% female, and 30.5% habitual snorers) reported 1385 cancer cases. In men, habitual snoring was linked to 26% lower odds of any cancer (OR 0.74, 95% CI: 0.66 to 0.83), while in women, it showed no significant difference except lower odds of breast cancer (OR 0.77, 95% CI: 0.63 to 0.94) and higher odds of cervix cancer (OR 1.54, 95% CI: 1.18 to 2.01). Age and sleep duration significantly influenced the snoring-cancer relationship, with notable variations by cancer type and sex.

Conclusions

Habitual snoring exhibits sex-specific associations with cancer prevalence, showing lower prevalence in men and varied results in women. These findings emphasize the critical need for further research to uncover the biological mechanisms involved. Future investigations should consider integrating sleep characteristics with cancer prevention and screening strategies, focusing on longitudinal research and the integration of genetic and biomarker analyses to fully understand these complex relationships.

Influence of Impaired Diffusing Capacity and Sleep-disordered Breathing on Nocturnal Hypoxemia and Health Outcomes in Men with and without Human Immunodeficiency Virus

Rationale: Nocturnal hypoxemia is common in sleep-disordered breathing (SDB) and is associated with increased morbidity and mortality. Although impaired diffusing capacity of the lung for carbon monoxide (DlCO) is associated with daytime hypoxemia, its influence on SDB-related nocturnal hypoxemia is not known. Objectives: To characterize the effects of DlCO impairment on SDB-related nocturnal hypoxemia and associated health outcomes. Methods: Data from a multicenter cohort of men with and without human immunodeficiency virus (HIV) infection, with concomitant measures of DlCO and home-based polysomnography (n = 544), were analyzed. Multivariable quantile regression models characterized associations between DlCO and several measures of SDB-related hypoxemia (e.g., total sleep time with oxygen saturation as measured by pulse oximetry [SpO2] < 90% [T90]). Structural equation models were used to assess associations of impaired DlCO and SDB-related hypoxemia measures with prevalent hypertension and type 2 diabetes. Results: DlCO impairment (<80% predicted) was associated with sleep-related hypoxemia. Participants with severe SDB (apnea-hypopnea index ⩾ 30 events/h) and impaired DlCO had higher T90 (median difference, 15.0% [95% confidence interval (CI), 10.3% to 19.7%]) and average SDB-related desaturation (median difference, 1.0 [95% CI, 0.5 to 1.5]) and lower nadir SpO2 (median difference, -8.2% [95% CI, -11.4% to -4.9%]) and average SpO2 during sleep (median difference, -1.1% [95% CI, -2.1% to -0.01%]) than those with severe SDB and preserved DlCO. Higher T90 was associated with higher adjusted odds of prevalent hypertension (odds ratio, 1.39 [95% CI, 1.14 to 1.70]) and type 2 diabetes (odds ratio, 1.25 [95% CI, 1.07 to 1.46]). Conclusions: DlCO impairment in severe SDB was associated with sleep-related hypoxemia, prevalent hypertension, and type 2 diabetes. Assessment of SDB should be considered in those with impaired DlCO to guide testing and risk stratification strategies.

Prevalence of obstructive sleep apnoea syndrome in oncological patients: A systematic review and meta-analysis

BACKGROUND

Obstructive sleep apnoea syndrome (OSAS) has garnered increasing attention in recent years due to its potential association with cancer. This systematic review and meta-analysis aimed to assess the prevalence of OSAS in cancer patients through a comprehensive analysis of existing literature.

METHODS

This systematic review and meta-analysis, conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol, aimed to evaluate the prevalence of OSAS in cancer patients. A comprehensive search of electronic databases was performed to identify relevant studies published up to September 2021. Eligible studies reporting on the prevalence of OSAS in cancer patients, encompassing various study designs, were included in the analysis. Pooled estimates of the odds ratios (OR) with 95% confidence intervals (CIs) were calculated using a random effects model. Heterogeneity among the studies was assessed using the I2 statistic.

RESULTS

Seventeen studies fulfilled the inclusion criteria and were subsequently included in the review. The prevalence of OSAS in cancer patients was estimated to have an overall OR of 0.80 (95% CI: 0.75-0.85). In comparison with non-cancer patients, cancer patients had a statistically significant greater risk of OSAS, as indicated by the total estimated RR for the prevalence of OSAS in cancer patients, which was 0.89 (95% CI: 0.86-0.92). Nonetheless, there was a significant amount of heterogeneity (I2 = 96%) among the studies.

CONCLUSION

The overall data analysed in this review indicates that patients with cancer had far reduced likelihood of developing OSAS than individuals without cancer. However, the significant variation across the included studies highlights the need for additional investigation to fully clarify the complex association between OSAS and cancer incidence. These results emphasise how critical it is to identify OSAS as a possible comorbidity in cancer patients, one that should be taken into account for clinical management and ongoing research.

Sleep disorders and cancer incidence: examining duration and severity of diagnosis among veterans

Introduction

Sleep disruption affects biological processes that facilitate carcinogenesis. This retrospective cohort study used de-identified data from the Veterans Administration (VA) electronic medical record system to test the hypothesis that patients with diagnosed sleep disorders had an increased risk of prostate, breast, colorectal, or other cancers (1999-2010, N=663,869). This study builds upon existing evidence by examining whether patients with more severe or longer-duration diagnoses were at a greater risk of these cancers relative to those with a less severe or shorter duration sleep disorder.

Methods

Incident cancer cases were identified in the VA Tumor Registry and sleep disorders were defined by International Classification of Sleep Disorder codes. Analyses were performed using extended Cox regression with sleep disorder diagnosis as a time-varying covariate.

Results

Sleep disorders were present among 56,055 eligible patients (8% of the study population); sleep apnea (46%) and insomnia (40%) were the most common diagnoses. There were 18,181 cancer diagnoses (41% prostate, 12% colorectal, 1% female breast, 46% other). The hazard ratio (HR) for a cancer diagnosis was 1.45 (95% confidence interval [CI]: 1.37, 1.54) among those with any sleep disorder, after adjustment for age, sex, state of residence, and marital status. Risks increased with increasing sleep disorder duration (short [<1-2 years] HR: 1.04 [CI: 1.03-1.06], medium [>2-5 years] 1.23 [1.16-1.32]; long [>5-12 years] 1.52 [1.34-1.73]). Risks also increased with increasing sleep disorder severity using cumulative sleep disorder treatments as a surrogate exposure; African Americans with more severe disorders had greater risks relative to those with fewer treatments and other race groups. Results among patients with only sleep apnea, insomnia, or another sleep disorder were similar to those for all sleep disorders combined.

Discussion

The findings are consistent with other studies indicating that sleep disruption is a cancer risk factor. Optimal sleep and appropriate sleep disorder management are modifiable risk factors that may facilitate cancer prevention.

Screening for obstructive sleep apnea in patients with cancer - a machine learning approach

Background

Obstructive sleep apnea (OSA) is a highly prevalent sleep disorder associated with daytime sleepiness, fatigue, and increased all-cause mortality risk in patients with cancer. Existing screening tools for OSA do not account for the interaction of cancer-related features that may increase OSA risk.

Study Design and Methods

This is a retrospective study of patients with cancer at a single tertiary cancer institution who underwent a home sleep apnea test (HSAT) to evaluate for OSA. Unsupervised machine learning (ML) was used to reduce the dimensions and extract significant features associated with OSA. ML classifiers were applied to principal components and model hyperparameters were optimized using k-fold cross-validation. Training models for OSA were subsequently tested and compared with the STOP-Bang questionnaire on a prospective unseen test set of patients who underwent an HSAT.

Results

From a training dataset of 249 patients, kernel principal component analysis (PCA) extracted eight components through dimension reduction to explain the maximum variance with OSA at 98%. Predictors of OSA were smoking, asthma, chronic kidney disease, STOP-Bang score, race, diabetes, radiation to head/neck/thorax (RT-HNT), type of cancer, and cancer metastases. Of the ML models, PCA + RF had the highest sensitivity (96.8%), specificity (92.3%), negative predictive value (92%), F1 score (0.93), and ROC-AUC score (0.88). The PCA + RF screening algorithm also performed better than the STOP-Bang questionnaire alone when tested on a prospective unseen test set.

Conclusions

The PCA + RF ML model had the highest accuracy in screening for OSA in patients with cancer. History of RT-HNT, cancer metastases, and type of cancer were identified as cancer-related risk factors for OSA.

Does OSA Increase Risk for Cancer?: A Large Historical Sleep Clinic Cohort Study

BACKGROUND

The relationship between OSA and cancer is unclear.

RESEARCH QUESTION

What is the association between OSA and cancer prevalence and incidence in a large Western Australian sleep clinic cohort (N = 20,289)?

STUDY DESIGN AND METHODS

OSA severity was defined by apnea-hypopnea index (AHI) and nocturnal hypoxemia (duration and percentage at oxygen saturation < 90%) measured by in-laboratory polysomnogram. Measures of potential confounding included age, sex, BMI, smoking status, socioeconomic status, and BP. Outcomes were determined from the Western Australian cancer and death registries. Analyses were confined within periods using consistent AHI scoring criteria: January 1, 1989, to July 31, 2002 (American Sleep Disorders Association criteria), and August 1, 2002, to June 30, 2013 (Chicago criteria). We examined associations of AHI and nocturnal hypoxemia with cancer prevalence using logistic regression and cancer incidence using Cox regression analyses.

RESULTS

Cancer prevalence at baseline was 329 of 10,561 in the American Sleep Disorders Association period and 633 of 9,728 in the Chicago period. Nocturnal hypoxemia but not AHI was independently associated with prevalent cancer following adjustment for participant age, sex, BMI, smoking status, socioeconomic status, and BP. Of those without prevalent cancer, cancer was diagnosed in 1,950 of 10,232 (American Sleep Disorders Association) and 623 of 9,095 (Chicago) participants over a median follow-up of 11.2 years. Compared with the reference category (no OSA, AHI < 5 events per hour), univariable models estimated higher hazard ratios for cancer incidence for mild (AHI 5-15 events per hour), moderate (AHI 15.1-30 events per hour), and severe (AHI > 30 events per hour) OSA. Multivariable analyses consistently revealed associations between age and, in some cases, sex, BMI, and smoking status, with cancer incidence. After adjusting for confounders, multivariable models showed no independent association between OSA severity and increased cancer incidence.

INTERPRETATION

Nocturnal hypoxemia is independently associated with prevalent cancer. OSA severity is associated with incident cancer, although this association seems secondary to other risk factors for cancer development. OSA is not an independent risk factor for cancer incidence.

Cancer Metabolism as a Therapeutic Target and Review of Interventions

Cancer is amenable to low-cost treatments, given that it has a significant metabolic component, which can be affected through diet and lifestyle change at minimal cost. The Warburg hypothesis states that cancer cells have an altered cell metabolism towards anaerobic glycolysis. Given this metabolic reprogramming in cancer cells, it is possible to target cancers metabolically by depriving them of glucose. In addition to dietary and lifestyle modifications which work on tumors metabolically, there are a panoply of nutritional supplements and repurposed drugs associated with cancer prevention and better treatment outcomes. These interventions and their evidentiary basis are covered in the latter half of this review to guide future cancer treatment.

Incidence disparities of obstructive sleep apnea-associated lung cancer by gender; Korean National Health Insurance data analysis

Introduction

Obstructive sleep apnea (OSA) is known to increase the risk of various cancers. By analyzing the Korea National Health Insurance Service (KNHIS) registry, the impact of OSA on the lung cancer incidence was analyzed in a retrospective cohort group.

Methods

A retrospective cohort of adult patients newly registered with OSA in the KNHIS data from 2007 to 2017 was included and observed until December 2019 (12 years). The main outcome measure was newly diagnosed lung cancer. The control group was set with age and sex that matched those in the OSA group.

Results

The hazard ratio (HR) of OSA for lung cancer incidence showed a significantly reduced HR of 0.87 (95% CI, 0.82-0.93). The observed significance of this finding was limited to male OSA patients [HR, 0.84 (95% CI, 0.78-0.90)], while no significant association was found in female OSA patients [HR, 1.05 (95% CI, 0.91-1.21)], irrespective of their age.

Discussion

OSA patients have a lower risk of developing lung cancer, but this risk reduction is gender-specific, as female OSA patients do not show a reduction in hazard ratio.

Testicular Cancer Incidence among Obstructive Sleep Apnea (OSA) Patients: South Korean National Health Insurance Data

Obstructive sleep apnea (OSA) has been linked to an increased risk of acquiring many types of cancer. No data on the prevalence of testicular cancer in OSA patients have been reported in the literature. The goal of the present investigation is to find out the impact of OSA on the incidence of testicular cancer based on the Korea National Health Insurance Service (KNHIS) dataset. A cohort of adult male patients newly registered with OSA in the KNHIS data from 2007 to 2014 who had no history of any previous cancer diagnosis was included. The main outcome measure was newly diagnosed testicular cancer in the National Medical Expenses Support Program. The control group was set at five times larger than the OSA group, and it was matched with age and sex. The cumulative incidence and hazard ratio (HR) for the development of testicular cancer were compared between the OSA and control groups. Further subgroup analysis was conducted in the three different age groups. In the study period, a total of 152,801 male adult patients newly diagnosed with OSA were included, whereas 764,005 individuals were recruited as the control group. The HR of OSA for developing testicular cancer was 1.58 (95% confidence interval [CI]: 0.92-2.60), showing no significant HR regardless of confounding adjustment. However, the subgroup analysis revealed a significantly increased HR to develop testicular cancer of 3.39 (95% CI: 1.08-10.06) in groups aged more than 65, whereas the age ranges of 20-40 and 40-64 showed no significance (1.19 (0.44-2.75) and 1.27 (0.50-2.80), respectively). OSA may not influence the incidence of testicular cancer in the general adult population. However, compared to younger males, males over 65 may be more susceptible to OSA when it comes to developing testicular cancer.

Chronic Obstructive Pulmonary Disease Is Associated with Worse Oncologic Outcomes in Early-Stage Resected Pancreatic and Periampullary Cancers

Pancreatic ductal adenocarcinoma (PDAC) is the 3rd leading cause of cancer mortality in the United States. Hypoxic and hypercapnic tumor microenvironments have been suggested to promote tumor aggressiveness. The objective of this study was to evaluate the association between chronic obstructive pulmonary disease (COPD) and oncologic survival outcomes in patients with early-stage PDAC and periampullary cancers. In this case-control study, patients who underwent a pancreaticoduodenectomy during 2014-2021 were assessed. Demographic, perioperative, histologic, and oncologic data were collected. A total of 503 PDAC and periampullary adenocarcinoma patients were identified, 257 males and 246 females, with a mean age of 68.1 (±9.8) years and a mean pre-operative BMI of 26.6 (±4.7) kg/m². Fifty-two percent of patients (N = 262) reported a history of smoking. A total of 42 patients (8.3%) had COPD. The average resected tumor size was 2.9 ± 1.4 cm and 65% of the specimens (N = 329) were positive for lymph-node involvement. Kaplan-Meier analysis showed that COPD was associated with worse overall and disease-specific survival (p < 0.05). Cox regression analysis showed COPD to be an independent prognostic factor (HR = 1.5, 95% CI 1.0-2.3, p = 0.039) along with margin status, lymphovascular invasion, and perineural invasion (p < 0.05 each). A 1:3 nearest neighbor propensity score matching was also employed and revealed COPD to be an independent risk factor for overall and disease-specific survival (OR 1.8 and OR 1.6, respectively; p < 0.05 each). These findings may support the rationale posed by in vitro laboratory studies, suggesting an important impact of hypoxic and hypercapnic tumor respiratory microenvironments in promoting therapy resistance in cancer.

Association of Smoking and Respiratory Disease History with Pancreatic Pathologies Requiring Surgical Resection

BACKGROUND

The purpose of this study was to examine the relationship between various respiratory conditions, including hypercapnic respiratory disease, and a multitude of resected pancreatic lesions.

METHODS

This retrospective case-control study queried a prospectively maintained database of patients who underwent pancreaticoduodenectomy between January 2015 and October 2021. Patient data, including smoking history, medical history, and pathology reports, were recorded. Patients with no smoking history and no concomitant respiratory conditions were designated as the control group.

RESULTS

A total of 723 patients with complete clinical and pathological data were identified. Male current smokers showed increased rates of PDAC (OR 2.33, 95% CI 1.07-5.08, p = 0.039). Male patients with COPD had a markedly increased association with IPMN (OR 3.02, CI 1.08-8.41, p = 0.039), while females with obstructive sleep apnea had a four-fold increase in risk of IPMN compared to women in the control group (OR 3.89, CI 1.46-10.37, p = 0.009). Surprisingly, female patients with asthma had a decreased incidence of pancreatic and periampullary adenocarcinoma (OR 0.36, 95% CI 0.18-0.71. p < 0.01).

CONCLUSION

This large cohort study reveals possible links between respiratory pathologies and various pancreatic mass-forming lesions.

Comparative study of a wearable intelligent sleep monitor and polysomnography monitor for the diagnosis of obstructive sleep apnea

PURPOSE

Due to the lack of an objective population-based screening tool for obstructive sleep apnea (OSA), a large number of patients with potential OSA have not been identified in the general population. Our study compared an objective wearable sleep monitoring device with polysomnography (PSG) to provide a reference for OSA screening in a large population.

METHODS

Using a self-control method, patients admitted to our sleep center from July 2020 to March 2021 were selected for overnight PSG and wearable intelligent sleep monitor (WISM) at the same time. The sensitivity and specificity of the device for the diagnosis of OSA were evaluated.

RESULTS

A total of 196 participants (mean age: 45.1 ± 12.3 years [18-80 years]; 168 men [86%]) completed both PSG and WISM monitoring. Using an apnea-hypopnea index (AHI) ≥ 5 events/h as the diagnostic criterion, the sensitivity, specificity, kappa value, and area under the receiver operating characteristic curve of the WISM for OSA diagnosis were 93%, 77%, 0.6, and 0.95, respectively. Using an AHI ≥ 15 events/h as the diagnostic criterion for moderate-to-severe OSA, these values were 92%, 89%, 0.8, and 0.95, respectively. The mean difference in the AHI between PSG and the artificial intelligence oxygen desaturation index from the WISM was 6.8 events/h (95% confidence interval: - 13.1 to 26.7).

CONCLUSION

Compared with the PSG, WISM exhibits good sensitivity and specificity for the diagnosis of OSA. This small, simple, and easy-to-use device is more suitable for OSA screening in a large population because of its single-step application procedure.

The invisible costs of obstructive sleep apnea (OSA): Systematic review and cost-of-illness analysis

BACKGROUND

Obstructive sleep apnea (OSA) is a risk factor for several diseases and is correlated with other non-medical consequences that increase the disease's clinical and economic burden. However, OSA's impact is highly underestimated, also due to substantial diagnosis gaps.

OBJECTIVE

This study aims at assessing the economic burden of OSA in the adult population in Italy by performing a cost-of-illness analysis with a societal perspective. In particular, we aimed at estimating the magnitude of the burden caused by conditions for which OSA is a proven risk factor.

METHODS

A systematic literature review on systematic reviews and meta-analyses, integrated by expert opinion, was performed to identify all clinical and non-clinical conditions significantly influenced by OSA. Using the Population Attributable Fraction methodology, a portion of their prevalence and costs was attributed to OSA. The total economic burden of OSA for the society was estimated by summing the costs of each condition influenced by the disease, the costs due to OSA's diagnosis and treatment and the economic value of quality of life lost due to OSA's undertreatment.

RESULTS

Twenty-six clinical (e.g., diabetes) and non-clinical (e.g., car accidents) conditions were found to be significantly influenced by OSA, contributing to an economic burden ranging from €10.7 to €32.0 billion/year in Italy. The cost of impaired quality of life due to OSA undertreatment is between €2.8 and €9.0 billion/year. These costs are substantially higher than those currently borne to diagnose and treat OSA (€234 million/year).

CONCLUSIONS

This study demonstrates that the economic burden due to OSA is substantial, also due to low diagnosis and treatment rates. Providing reliable estimates of the economic impact of OSA at a societal level may increase awareness of the disease burden and help to guide evidence-based policies and prioritisation for healthcare, ultimately ensuring appropriate diagnostic and therapeutic pathways for patients.

Sleep-disordered breathing and risk of lung cancer: a meta-analysis longitudinal follow-up studies

Consensus remains lack regarding whether sleep-disordered breathing (SDB) is an independent risk factor for lung cancer. We therefore conducted a meta-analysis to clarify the relationship of SDB and lung cancer. Longitudinal follow-up studies investigating the association between SDB and incidence of lung cancer were included by search of electronic databases including PubMed, Embase, and Cochrane's Library. A random-effects model was adopted to combine the results. Seven studies were included. Pooled results showed that presence of SDB was independently associated with higher incidence of lung cancer [adjusted risk ratio (RR): 1.28; 95% confidence interval (CI), 1.11-1.47; P < 0.001; I2 = 37%]. Sensitivity analysis limited to studies with adjustment of smoking showed consistent results (three studies, RR: 1.34; 95% CI, 1.22-1.48; P < 0.001; I2 = 8%). Subgroup analysis suggested that the association between SDB and higher risk of lung cancer was not significantly affected by study characteristics such as study design, source of population, sample size, evaluation methods for SDB, follow-up duration, methods for validation of lung cancer, or score of study quality (P values for subgroup difference all >0.05). No significant publication bias was observed (P for Egger's regression test = 0.258). These results suggested that SDB may be an independent risk factor of lung cancer in adult population. Intensive screening and prevention of lung cancer in subjects with SDB should be considered.

Association of obstructive sleep apnea and nocturnal hypoxemia with all-cancer incidence and mortality: a systematic review and meta-analysis

STUDY OBJECTIVES

Biological models suggest that obstructive sleep apnea (OSA) is potentially carcinogenic. We aimed to clarify the inconsistent epidemiological literature by considering various traditional and novel OSA severity indices.

METHODS

We systematically searched PubMed, Embase, Scopus, and the Cochrane Library for observational or randomized studies of associations of OSA, measured by diagnostic codes or any index, each with all-cancer incidence or mortality in adults, compared with participants with no/mild OSA. Two reviewers independently selected studies, extracted data, and evaluated study bias using the Newcastle-Ottawa scale and quality of evidence using GRADE (Grading of Recommendations Assessment, Development, and Evaluation). We performed inverse variance-weighted, random-effects meta-analyses and sensitivity analyses.

RESULTS

We included 20 observational studies (5,340,965 participants), all with moderate/low bias, from 1,698 records. Based on T90 (sleep duration with oxygen saturation < 90%), patients with OSA who had moderate (T90 > 1.2%, hazard ratio [HR] = 1.28, 95% confidence interval [CI] = 1.07-1.54) and severe nocturnal hypoxemia (T90 > 12%, HR = 1.43, 95% CI = 1.16-1.76) experienced 30%-40% higher pooled all-cancer risk than normoxemic patients, after multiple adjustment for covariates including obesity. Furthermore, severe nocturnal hypoxemia nearly tripled all-cancer mortality (HR = 2.66, 95% CI = 1.21-5.85). Patients with apnea-hypopnea index-defined severe OSA, but not moderate OSA, had higher all-cancer risk (HR = 1.18, 95% CI = 1.03-1.35) but similar all-cancer mortality as patients without OSA. An OSA diagnosis was not associated with all-cancer risk. Evidence quality ranged from low to moderate. Insufficient evidence was available on the oxygen desaturation index, lowest/median saturation, and arousal index.

CONCLUSIONS

In patients with OSA, nocturnal hypoxemia is independently associated with all-cancer risk and mortality. Future studies should explore if risk differs by cancer type, and whether cancer screening and OSA treatment are beneficial.

SYSTEMATIC REVIEW REGISTRATION

Registry: PROSPERO; URL: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=220836; Identifier: CRD42021220836.

CITATION

Tan BKJ, Teo YH, Tan NKW, et al. Association of obstructive sleep apnea and nocturnal hypoxemia with all-cancer incidence and mortality: a systematic review and meta-analysis. J Clin Sleep Med. 2022;18(5):1427-1440.

Multimorbidity and overall comorbidity of sleep apnoea: a Finnish nationwide study

The prevalence of sleep apnoea is increasing globally; however, population-based studies have reported a wide variation of prevalence estimates, and data on incidence of clinically diagnosed sleep apnoea are scant. Data on the overall burden of comorbidities or multimorbidity in individuals with incident sleep apnoea are scarce, and the pathways to multimorbidity have only marginally been studied. To study the current epidemiology of sleep apnoea in Finland, overall burden of comorbidities, and multimorbidity profiles in individuals with incident sleep apnoea, we conducted a register-based, nationwide, retrospective study of data from January 2016 to December 2019. The prevalence of clinically diagnosed sleep apnoea was 3.7% in the Finnish adult population; 1-year incidence was 0.6%. Multimorbidity was present in 63% of individuals at the time of sleep apnoea diagnosis. Of those with incident sleep apnoea, 34% were heavily multimorbid (presenting with four or more comorbidities). The three most common chronic morbidities before sleep apnoea diagnosis were musculoskeletal disease, hypertension and cardiovascular disease. In multimorbid sleep apnoea patients, hypertension and metabolic diseases including obesity and diabetes, cardiovascular diseases, musculoskeletal diseases and dorsopathies, in different combinations, encompassed the most frequent disease pairs preceding a sleep apnoea diagnosis. Our study adds to the few population-based studies by introducing overall and detailed figures on the burden of comorbidities in sleep apnoea in a nationwide sample and provides up-to-date information on the occurrence of sleep apnoea as well as novel insights into multimorbidity in individuals with incident sleep apnoea.

Two-thirds of individuals with sleep apnoea are multimorbid at diagnosis and one-third are heavily multimorbid. Dorsopathies, musculoskeletal diseases, hypertension and metabolic diseases are the most common comorbidities preceding sleep apnoea diagnosis.https://bit.ly/36WMlX1

Cancer and obstructive sleep apnea: An updated meta-analysis

OBJECTIVE

The relationship between cancers and obstructive sleep apnea (OSA) has been discussed for decades. However, the previous meta-analysis led to opposite conclusions. To further investigate this controversial issue, we performed this systematic review and meta-analysis update.

METHODS

PubMed, Embase, and the Cochrane Library were systematically searched and studies on "cancer and OSA" were all included. Two reviewers independently searched articles, extracted data, and assessed the quality of included studies. Moreover, the overall incidence of cancer and OSA in corresponding populations was calculated.

RESULTS

Of the 1434 titles identified, 22 articles involving more than 32.1 million patients were included in this meta-analysis. An overall incidence of OSA positive individuals in cancer was 46 (95%CI, 27-67)%, and the prevalence of cancers in OSA patients reached 1.53 (95%CI, 1.01-2.31) times higher than non-OSA individuals.

CONCLUSION

This meta-analysis indicated that there was a high prevalence of OSA in cancer patients, and individuals with OSA were more likely to develop tumors, and the incidence was related to the severity of OSA.

An umbrella review of systematic reviews and meta-analyses of observational investigations of obstructive sleep apnea and health outcomes

PURPOSE

The previous analysis of systematic reviews and meta-analyses have illustrated that obstructive sleep apnea (OSA) is correlated with multiple health outcomes. In the present research, our main aim was to execute an umbrella review to assess the available evidence for the associations between OSA and health outcomes.

METHODS

Herein, a meta-analysis of previous observational investigations that have reported associations between OSA and health outcomes in all human populations and settings was performed. We used these studies to execute an umbrella review of available meta-analyses and systematic reviews.

RESULTS

Sixty-six articles comprising 136 unique outcomes were enrolled in this analysis. Of the 136 unique outcomes, 111 unique outcomes had significant associations (p < 0.05). Only 7 outcomes (coronary revascularization after PCI, postoperative respiratory failure, steatosis, alaninetrans aminase (ALT) elevation, metabolic syndrome (MS), psoriasis, and Parkinson's disease) had a high quality of evidence. Twenty-four outcomes had a moderate quality of evidence, and the remaining 80 outcomes had a weak quality of evidence. Sixty-nine outcomes exhibited significant heterogeneity. Twenty-five outcomes exhibited publication bias. Sixty-three (95%) studies showed critically low methodological quality.

CONCLUSION

Among the 66 meta-analyses exploring 136 unique outcomes, only 7 statistically significant outcomes were rated as high quality of evidence. OSA may correlate with an increased risk of coronary revascularization after PCI, postoperative respiratory failure, steatosis, ALT elevation, MS, psoriasis, and Parkinson's disease.

The Association of Obstructive Sleep Apnea With Breast Cancer Incidence and Mortality: A Systematic Review and Meta-analysis

Purpose

Emerging evidence from animal models suggests that intermittent hypoxia due to obstructive sleep apnea (OSA) is a risk factor for breast cancer. Despite their biological plausibility, human epidemiological studies have reported conflicting results. Therefore, we conducted a meta-analysis to delineate this relationship.

Methods

We searched the PubMed, Embase, Scopus, and Cochrane Library databases for eligible studies from inception until June 6, 2021. Two reviewers selected randomized trials or observational studies reporting the association between OSA and breast cancer incidence compared with those without OSA. Two reviewers extracted relevant data and assessed the quality of evidence using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework and Newcastle-Ottawa Scale (NOS). We pooled the maximally covariate-adjusted hazard ratios (HRs) using a random-effects inverse variance-weighted meta-analysis and performed pre-specified subgroup analyses.

Results

We included six studies out of 1,707 records, comprising a combined cohort of 5,165,200 patients. All studies used the International Classification of Diseases codes to classify OSA and breast cancer. OSA patients had a 36% increased breast cancer risk (HR, 1.36; 95% confidence interval [CI], 1.03–1.80; N = 6, I² = 96%) compared to those without OSA. Most studies adjusted for confounders, such as age, sex, obesity, diabetes mellitus, alcohol use, and hypertension. Subgroup analyses for studies with (1) multivariate adjustment and (2) at least five years of follow-up yielded HRs of 1.35 (95% CI, 0.98–1.87; N = 5, I² = 96%) and 1.57 (95% CI, 1.14–2.18; N = 4; I² = 90%), respectively. One Mendelian randomization study suggested a causal relationship, with a two-fold increase in the odds of breast cancer in patients with OSA.

Conclusion

This meta-analysis suggested that OSA is a risk factor for breast cancer. Future studies should explore the dose-response relationship between OSA and breast cancer, and whether treatment may mitigate breast cancer risk or progression.

Cannabinoid receptors promote chronic intermittent hypoxia-induced breast cancer metastasis via IGF-1R/AKT/GSK-3β

The progression of breast cancer is closely related to obstructive sleep apnea-hypopnea syndrome (OSAHS). Low concentrations of cannabinoids promote tumor proliferation. However, the role of cannabinoid receptors (CBs) in chronic intermittent hypoxia (CIH)-induced breast cancer has not been reported. The migration and invasion of breast cancer cell lines (MCF-7 and T47D) were measured by scratch assay and transwell assay. Gene and protein expressions were analyzed by qPCR and western blotting. Tumor xenograft mice model were established to evaluate the function of CBs. We observed that chronic hypoxia (CH) and CIH increased CBs expression and promoted migration and invasion in breast cancer. Mice grafted with MCF-7 exhibited obvious tumor growth, angiogenesis, and lung metastasis in CIH compared with CH and control. In addition, CIH induced CBs expression, which subsequently activated insulin-like growth factor-1 receptor (IGF-1R)/AKT/glycogen synthase kinase-3β (GSK-3β) axis. Knockdown of CBs alleviated CIH-induced migration and invasion of breast cancer in vitro. Furthermore, CIH exaggerated the malignancy of breast cancer and silencing of CBs suppressed tumor growth and metastasis in vivo. Our study contributed to understanding the role of CIH in breast cancer development modulation.

The association of obstructive sleep apnea with melanoma incidence and mortality: a meta-analysis of 5,276,451 patients

BACKGROUND

Melanoma is the most aggressive and lethal form of skin cancer. While emerging in-vivo evidence suggests that intermittent hypoxia, a hallmark feature of obstructive sleep apnea (OSA), may induce melanoma tumorigenesis, the epidemiological association between OSA and melanoma has been inconsistent.

METHODS

We performed a literature search of PubMed, Embase, Scopus and Cochrane Library from inception until 6 June 2021. Two reviewers independently selected randomized trials or observational studies that reported the association of OSA with melanoma incidence or mortality in adults, in comparison to participants with no OSA. Two reviewers independently extracted relevant data and assessed the quality of evidence using the GRADE framework and the Newcastle-Ottawa Scale (NOS). We pooled data using an inverse variance-weighted meta-analysis and ran pre-specified subgrourp analyses.

RESULTS

The meta-analysis included six studies out of 1897 records, comprising a combined cohort of 5,276,451 patients. All studies were adjusted for covariates, with majority of studies adjusting for age (N=5) and sex (N = 4). Compared to those without OSA, patients with OSA had 71% higher pooled hazards of melanoma (HR = 1.71; 95% CI: 1.08-2.69, I² = 99%). Subgroup analyses for studies with (1) median follow-up duration of at least five years, (2) prospective study design, (3) adjustment for obesity yielded HRs of 1.88 (95%CI:1.32-2.67, N = 5), 1.11 (95%CI:0.77-1.60, N = 2) and 1.52 (95%CI:0.75-3.08, N = 3) respectively. One study investigating the relationship between OSA and melanoma mortality detected no association. There were insufficient studies to assess publication bias.

CONCLUSIONS

Meta-analysis of mainly retrospective observational studies, with significant heterogeneity, suggests increased melanoma incidence in OSA patients. Future studies should prospectively explore the differential risk of melanoma for varying OSA severity, and whether timely OSA treatment may mitigate this risk.

Polysomnographic Markers of Obstructive Sleep Apnea Severity and Cancer-Related Mortality: A Large Retrospective Multicenter Clinical Cohort Study

RATIONALE

The evidence for an association between cancer survival and obstructive sleep apnea (OSA) remains under-explored.

OBJECTIVES

To evaluate an association between markers of OSA severity (respiratory disturbances, hypoxemia, and sleep fragmentation) and cancer-related mortality in individuals with previously diagnosed cancer.

METHODS

We conducted a multicenter retrospective cohort study using linked clinical and provincial health administrative data on consecutive adults who underwent a diagnostic sleep study between 1994 and 2017 in four Canadian academic hospitals and were previously diagnosed with cancer through the Ontario Cancer Registry. Multivariable cause-specific Cox regressions were utilized to address the research objective.

RESULTS

We included 2,222 subjects. Over a median follow-up time of 5.6 years (IQR: 2.7-9.1), 261/2,222 (11.7%) individuals with prevalent cancer died from cancer-related causes, which accounted for 44.2% (261/590) of all-cause death. Controlling for age, sex, alcohol use disorder, prior heart failure, COPD, hypertension, diabetes, treatment for OSA, clinic site, year of the sleep study, and time since the cancer diagnosis, measures of hypoxemia and sleep fragmentation, but not apnea-hypopnea index were significantly associated with the cancer-specific mortality: % time spent with SaO2 <90% (HR per 5% increase: 1.05; 95% CI: 1.01-1.09); mean SaO2 (HR per 3% increase: 0.79; 0.68-0.92); and % of Stage 1 Sleep (HR per 16% increase: 1.27; 1.07-1.51).

CONCLUSION

In a large clinical cohort of adults with suspected OSA and previously diagnosed cancer, measures of nocturnal hypoxemia and sleep fragmentation as markers of OSA severity were significantly associated with cancer-related mortality, suggesting the need for more targeted risk awareness.

The Relationship Between Primary Sleep Disorders and Temporomandibular Disorders: An 8-Year Nationwide Cohort Study in South Korea

Background

While evidence is accumulating to propose a specific contribution of sleep disorders and low quality sleep in the pathogenesis of temporomandibular disorders (TMD), management of primary sleep disorders in the process of preventing and treating TMD still remains scientifically unsupported.

Objective

To investigate the association of primary sleep disorders with TMD risk in South Korea.

Patients and Methods

This study was based on the National Health Insurance Service-National Health Screening Cohort (NHIS-HEALS) of South Korea with 468,882 participants. After excluding participants diagnosed in 2002, those with a diagnosis of a primary sleep disorder in 2003–2005 were recruited. All participants diagnosed with TMD between January 1, 2006 and December 31, 2013 received follow-up. Cox proportional hazards regression was performed to determine the adjusted hazard ratios (aHR) and 95% confidence interval (CI) for TMD according to the presence or absence of a primary sleep disorder diagnosis.

Results

After adjusting for all covariates, primary sleep disorder patients had a 44% higher risk for TMD compared with non-sleep disorder participants (aHR 1.44, 95% CI 1.02–2.04). The incidence rate of TMD was nearly twice as high in participants with sleep disorders compared with those without (6.08 vs 3.27, per 10⁴ person-years). In subgroup analysis, an association was observed with those over 60 years old or who frequently exercised physically.

Conclusion

Primary sleep disorders could be an important independent risk factor for the initiation and maintenance of TMD. Patients with sleep disorders should be monitored for possible co-occurrence of TMD-related symptoms that could aggravate sleep disorders in turn.

Sleep-disordered breathing and risk of the breast cancer: A meta-analysis of cohort studies

BACKGROUND

Sleep-disordered breathing (SDB) has been related to a higher risk of breast cancer whereas the results of previous studies are inconsistent. We, therefore, performed a meta-analysis to evaluate the association between SDB and subsequent risk of breast cancer in women.

METHODS

Cohort studies that investigated the temporal relationship between SDB and breast cancer incidence were obtained via search of PubMed, Embase and Web of Science from inception to 30 January 2021. Only studies with multivariate analyses were included. A fixed or a randomised effect model was applied according to the heterogeneity.

RESULTS

Eight cohort studies with 1 398 113 women were included. Pooled results with a randomised-effect model showed that compared with women without SDB at baseline, women with SDB had a significantly increased risk of breast cancer (risk ratio [RR]: 1.36, 95% confidence interval [CI]: 1.08 to 1.71, P = .01) with significant heterogeneity (P for Cochrane's Q test < .001, I²  = 95%). Subgroup analyses showed that SDB seemed to confer a more remarkably increased risk of breast cancer in elderly women (RR: 3.00, 95% CI: 1.33 to 6.76, P = .008) than that in non-elderly women (RR: 1.15, 95% CI: 1.02 to 1.29, P = .02; P for subgroup difference = .04). However, the association was not significantly affected by country of the study, study design, diagnostic strategy for SDB or adjustment of obesity (P for subgroup analyses all > .05).

CONCLUSIONS

SDB may be an independent risk factor for breast cancer in women, particularly in elderly females.

Association of Obstructive Sleep Apnea with the Aging Process

Rationale: Evidence suggests that the physiopathologic consequences of obstructive sleep apnea (OSA) resemble those induced by aging. Some studies report that the deleterious effects associated with OSA might be age dependent. Objectives: To evaluate the association of OSA with the aging process and to determine whether this association is maintained across different age groups. Methods: This was an observational, prospective study including 599 patients with suspected OSA. Five hallmarks of aging were evaluated: alteration of cellular communication (serum CRP [C-reactive protein] concentration), deregulation of nutrient sensing (insulin resistance), telomere attrition (leukocyte telomeric length), mitochondrial dysfunction (leukocyte mitochondrial DNA copy number), and genomic instability (urinary 8-hydroxy-2-deoxyguanosine concentration). For age-stratified analyses, subjects were divided into four groups according to the apnea-hypopnea index (AHI) and the median age (50 yr): young patients without OSA (age < 50 yr old, AHI < 15 events/h), young patients with OSA (age < 50 yr old, AHI ⩾ 15 events/h), older patients without OSA (age ⩾ 50 yr old, AHI < 15 events/h), and older patients with OSA (age ⩾ 50 yr old, AHI ⩾ 15 events/h). Results: A dose-response relationship was found between the AHI, arousal index, and time during the night spent with an oxygen saturation less than 90% and the following hallmarks: alteration of cellular communication, deregulation of nutrient sensing, mitochondrial dysfunction, and genomic instability. Considering age-stratified analyses, OSA was associated with an increase in several hallmarks of aging in young patients, but no significant association of OSA was identified in older patients. Conclusions: In subjects under 50 years of age, OSA is associated with an increase in specific hallmarks of aging, independent of several known confounding factors.

Obstructive sleep apnoea after radiotherapy for head and neck cancer

Objective

The aim of this study is to focus attention on obstructive sleep apnoea hypopnoea syndrome (OSHAS) as a sequela of non-surgical treatments of selected head and neck cancer (HNca), sharing our experience in drug-induced sleep endoscopy (DISE). To the best of our knowledge, this is the first study that documents dynamic anatomical and functional alterations during sleep in irradiated OSAHS patients by DISE.

Methods

A retrospective study of patients affected by OSAHS referring to our department from January 2018 to December 2019 was carried out. Inclusion criteria were: patients who underwent radiation or chemo-radiation for HNca affecting upper airways that presented sleep-related breathing disorders after treatment.

Results

6 patients with moderate to severe OSAHS and a clinical story of previous non-surgical treatment for an HNca were enrolled. DISE showed in all patients typical anatomical alterations observed in irradiated individuals. Four patients were treated with continuous positive airway pressure, while 2 subjects were treated with tailored minimal invasive surgery without post-operative complications.

Conclusions

Our results suggest that minimal invasive surgical treatments can be a good therapeutic option in very selected patients with post-irradiation iatrogenic OSAHS.

Obstructive sleep apnea and incidence of malignant tumors: a meta-analysis

OBJECTIVES

This paper assessed the connection between obstructive sleep apnea (OSA) and the incidence of malignant tumors.

METHODS

PubMed, Cochrane, Scopus, Health Source Nursing Academic Edition, EMBASE, and Web of Sciences were searched until the date of July 25, 2020. The analysis included an assessment of the overall incidence of OSA malignancies, the incidence of OSA malignancies by age and gender, and the incidence of different types of malignancies in patients with OSA. The total rate and the corresponding 95% confidence interval (CI) of the incidence of malignant tumors in patients with OSA were calculated. Patients with OSA were classified according to age, gender, and different types of malignant tumors for meta-analysis.

RESULTS

A total of 12 studies involving 862,820 participants were included in this meta-analysis. Random effect model analysis showed that the total incidence of malignant tumors in patients with OSA was 0.046% (95% CI: 0.027-0.065, P < 0.001), higher than that of malignant tumors in the general population. According to the analytical results classified by gender, the incidence of malignant tumor in female patients with OSA was 4.0% (95% CI: 0.014-0.066), higher than that in male patients at 3.5% (95% CI: 0.012-0.058). The analytical results classified by age showed that the incidence of malignant tumors in patients with OSA aged below 60 years was 1.8% (95% CI: 0.000-0.036), lower than that in patients aged above 60 years at 4.3% (95% CI: 0.002-0.084). The analytical results classified by the types of malignant tumors showed that the incidences of breast cancer, lung cancer, colorectal cancer, prostate cancer, kidney cancer, pancreatic cancer, and melanoma in patients with OSA were 0.5% (95% CI: 0.001-0.008), 0.5% (95% CI: 0.002-0.009), 0.5% (95% CI: 0.003-0.008), 1.1% (95% CI: 0.002-0.021), 0.3% (95% CI: 0.001-0.005), 0.1% (95% CI: 0.001-0.002), and 0.4% (95% CI: 0.003-0.005), respectively. Among them, the incidence of prostate cancer was the highest, followed by breast cancer, lung cancer, colorectal cancer, melanoma, and kidney cancer, whereas the incidence of pancreatic cancer was the lowest. However, the incidence of specific malignant tumors in patients with OSA did not have a significant increase compared with that in the general population.

CONCLUSIONS

The analytical results of this meta-analysis suggested that OSA may be associated with an overall increase in the incidence of malignancies based on the currently available data, but the connection with specific types of malignancies was not significant. Further studies are needed to explore this association in the future.

Investigation into the association between obstructive sleep apnea and incidence of all-type cancers: a systematic review and meta-analysis

Obstructive sleep apnea (OSA) is one of the most common sleep-related breathing disorders and is featured by complete or partial obstruction of the upper airway using sleep. Conflicting reports regarding the association between obstructive sleep apnea (OSA) and cancer incidence are existing in different studies. The aim of this study is to determine whether OSA is independently associated with incidence of all-type cancers by using the meta-analysis. Medline, Embase, PubMed, Ovid, the Cochrane Library database, Web of Science, and Google Scholar were searched by two independent reviewers until 31 January 2021. Studies that evaluated OSA and the cancer incidence were included. Pooled risk ratios (RR) and corresponding 95% confidence intervals (CI) were calculated. Twelve studies, involved 184,915 participants, were pooled in this meta-analysis. Fixed-effects model analysis showed that patients with OSA had an increased risk of cancer incidence (RR: 1.52, 95% CI: 1.39-1.66, P < 0.001). The subgroup analysis showed that the pooled RRs of cancer incidence were 1.14 (95% CI: 1.04-1.25, P = 0.006) for mild OSA, 1.36 (95% CI: 1.32-1.92; P < 0.001) for moderate OSA and 1.59 (95% CI: 1.45-1.74; P < 0.001) for severe OSA, respectively. Patients with moderate and severe OSA were identified to have an increased risk of cancer incidence when compared to patients with mild OSA. In addition, patients with severe OSA also showed an increased risk of incident cancer (RR: 1.18, 95% CI: 1.08-1.28, P < 0.001) when compared to patients with moderate OSA. In conclusion, from most updated literatures, our meta-analysis results indicated that OSA was independently associated with incidence of all-type cancers when stratified the severity of OSA. However, further detailed analysis and clinical studies are warranted to decipher the association between OSA and cancer prevalence.

Sleep apnoea and incident malignancy in type 2 diabetes

Background

Sleep apnoea and type 2 diabetes (T2D) have been linked to malignancy. The aim of the present study was to evaluate the association between sleep apnoea and incidence of malignancy in patients with T2D.

Methods

The DIACORE (DIAbetes COhoRtE) study is a prospective, population-based cohort study in T2D patients. In the sleep disordered breathing substudy, the apnoea–hypopnoea index (AHI), oxygen desaturation index (ODI) and percentage of night-time spent with a peripheral oxygen saturation of <90% (t_sat90%) were assessed using a two-channel ambulatory monitoring device. Malignancy diagnoses were gathered using self-reported medical history data validated by medical records. Hazard ratios (HRs) for incident malignancy were derived by Cox regression adjusting for sex, age, body mass index, smoking status, alcohol intake, socioeconomic status and HbA1c.

Results

Of 1239 patients with T2D (mean age 67 years, 41% female, mean body mass index 30.9 kg·m⁻²), 79 (6.4%) were first-time diagnosed with a malignancy within a median follow-up period of 2.7 years (interquartile range 2.2–4.5 years). AHI, ODI and t_sat90% were not associated with incident malignancy. In subgroup analysis, females showed increased cancer risk per AHI unit (adjusted HR 1.03 per AHI unit, 95% CI 1.00–1.06; p=0.028) and severe sleep apnoea (defined as AHI ≥30 events·h⁻¹; adjusted HR 4.19, 95% CI 1.39–12.77; p=0.012). This was not seen in males, and a significant interaction was observed (interaction terms p=0.048 and p=0.033, respectively).

Conclusion

Sleep apnoea was not associated with incident malignancy in T2D patients. However, stratified analysis revealed a significant association between sleep apnoea and incident malignancy in females, but not in males.

In patients with type 2 diabetes, sleep apnoea is not associated with the incidence of malignancy. However, stratified analysis shows that sleep apnoea is associated with incident malignancy in females, but not in males.https://bit.ly/37RAK8V

Sleep Duration and Snoring at Midlife in Relation to Healthy Aging in Women 70 Years of Age or Older

PURPOSE

Both short and long sleep durations are associated with higher mortality. This study examined the association between sleep duration and overall health among those who survive to older ages.

PARTICIPANTS AND METHODS

In the Nurses' Health Study, participants without major chronic diseases in 1986 and survived to age 70 years or older in 1995-2001 were included. Habitual sleep duration and snoring were self-reported in 1986. Healthy aging was defined as being free of 11 major chronic diseases and having no cognitive impairment, physical impairment, or mental health limitations. Logistic regression was used to estimate the odds ratios (ORs) and 95% confidence intervals (CIs) for healthy aging.

RESULTS

Of the 12,304 participants, 1354 (11.0%) achieved healthy aging. We observed a non-linear association between sleep duration and the odds of achieving healthy aging. Compared with women sleeping 7 hours per day, women with longer sleep duration were less likely to achieve healthy aging; there was also a suggestion of lower odds of healthy aging for shorter sleepers, although the associations did not reach statistical significance: the multivariate-adjusted ORs (95% CIs) of healthy aging for those sleeping ≤5, 6, 8, and ≥9 hours were 0.94 (0.70, 1.27), 0.88 (0.76, 1.02), 0.83 (0.72, 0.96), and 0.60 (0.43, 0.84), respectively. Similar non-linear associations were consistently observed for individual dimensions of healthy aging. Regular snoring was associated with 31% lower odds of healthy aging (95% CI: 0.54, 0.88), which was primarily due to lower odds of having no major chronic diseases.

CONCLUSION

Both short and long sleep durations as well as regular snoring at midlife were associated with lower odds of healthy aging in later life.

Obstructive Sleep Apnea Worsens Progression-Free and Overall Survival in Human Metastatic Colorectal Carcinoma

Sleep disorders have emerged as highly prevalent conditions, and along with improved understanding of such disorders, increased attention has gained the evidence that perturbation in sleep architecture and continuity may initiate, exacerbate, or modulate the phenotypic expression of multiple diseases including cancer. Furthermore, obstructive sleep apnea (OSA) has recently been implicated in increased incidence and more adverse prognosis of cancer in humans. This study was designed to confirm the high prevalence of OSA in human malignancies and assess its prognostic relevance in metastatic colorectal carcinomas (mCRCs). A prospective cohort of 52 subjects, affected by solid histologically confirmed metastatic malignancies, was analyzed, and among them, 29 mCRCs were studied for the prognostic role of OSA. OSA was diagnosed in 34.6% (18/52) of patients with a statistically significant difference in apnea-hyponea index between OSA and non-OSA subgroups (14.2 ± 12.2 vs. 2.1 ± 1.5, p < 0.01). Consistently, OSA was diagnosed in 34.5% (10/29) of mCRCs with lower rates of first-line therapy disease control in OSA compared to non-OSA patients (60% in OSA vs. 94.7% in non-OSA, p=0.03). Of note, progression-free and overall survival rates were significantly shorter in OSA (respectively, 9 and 22 months) compared non-OSA (20 and 40 months) mCRC patients (HR = 2.63; 95% CI 0.88-7.84, p=0.01 for PFS; HR = 3.93; 95% CI 1.13-13.73, p < 0.001 for OS). Finally, the multivariate analysis showed that OSA is an independent prognostic factor for PFS (p=0.0076) and OS (p=0.0017) in this cohort. Altogether, these data suggest that OSA is a potential clinical marker predictor of poor prognosis in patients with mCRC.

Obstructive Sleep Apnea and Incident Cancer: A Large Retrospective Multicenter Clinical Cohort Study

BACKGROUND

To examine the association between the severity of obstructive sleep apnea (OSA) and nocturnal hypoxemia with incident cancer.

METHODS

This was a multicenter retrospective clinical cohort study using linked clinical and provincial health administrative data on consecutive adults who underwent a diagnostic sleep study between 1994 and 2017 in four academic hospitals (Canada) who were free of cancer at baseline. Cancer status was derived from the Ontario Cancer Registry. Cox cause-specific regressions were utilized to address the objective and to calculate the 10-year absolute risk difference (ARD) in the marginal probability of incident cancer and the number needed to harm (NNH).

RESULTS

Of 33,997 individuals considered, 33,711 with no missing OSA severity were included: median age, 50 years; 58% male; and 23% with severe OSA (apnea-hypopnea index >30). Of the 18,458 individuals with information on sleep time spent with oxygen saturation (SaO₂) <90%, 5% spent >30% of sleep with SaO₂ <90% (severe nocturnal hypoxemia). Over a median of 7 years, 2,498 of 33,711 (7%) individuals developed cancer, with an incidence rate of 10.3 (10.0-10.8) per 1,000 person-years. Controlling for confounders, severe OSA was associated with a 15% increased hazard of developing cancer compared with no OSA (HR = 1.15, 1.02-1.30; ARD = 1.28%, 0.20-2.37; and NNH = 78). Severe hypoxemia was associated with about 30% increased hazard (HR = 1.32, 1.08-1.61; ARD = 2.38%, 0.47-4.31; and NNH = 42).

CONCLUSIONS

In a large cohort of individuals with suspected OSA free of cancer at baseline, the severity of OSA and nocturnal hypoxemia was independently associated with incident cancer.

IMPACT

These findings suggest the need for more targeted cancer risk awareness in individuals with OSA.

Obstructive sleep apnea and cancer: a complex relationship

PURPOSE OF REVIEW

Obstructive sleep apnea (OSA) has been recognized as a risk factor for cancer mainly through hypoxia, based on studies that did not distinguish among cancer types. The purpose of this review is to discuss the most recent data on epidemiology and pathophysiology of the OSA-cancer association.

RECENT FINDINGS

According to epidemiological studies, OSA may have different influences on each type of cancer, either increasing or decreasing its incidence and aggressiveness. Time spent with oxygen saturation below 90% appears the polysomnographic variable most strongly associated with unfavorable effects on cancer. Experimental studies support the role of hypoxia as an important risk factor for cancer growth and aggressiveness, especially when it shows an intermittent pattern. These effects are largely mediated by the hypoxia-inducible factor, which controls the synthesis of molecules with effects on inflammation, immune surveillance and cell proliferation. Sleep fragmentation participates in increasing cancer risk. Modulating effects of age remain controversial.

SUMMARY

Effects of OSA on cancer may largely vary among neoplastic diseases, both in their magnitude and direction. The worse risk associated with intermittent rather than persistent hypoxia, and the effects of OSA therapy on cancer natural history are still poorly known, and deserve new careful studies.

The Association of Sleep Disorders, Obesity and Sleep-Related Hypoxia with Cancer

BACKGROUND

Sleep disorders have emerged as potential cancer risk factors.

OBJECTIVE

This review discusses the relationships between sleep, obesity, and breathing disorders with concomitant risks of developing cancer.

RESULTS

Sleep disorders result in abnormal expression of clock genes, decreased immunity, and melatonin release disruption. Therefore, these disorders may contribute to cancer development. Moreover, in sleep breathing disorder, which is frequently experienced by obese persons, the sufferer experiences intermittent hypoxia that may stimulate cancer cell proliferation.

DISCUSSION

During short- or long- duration sleep, sleep-wake rhythm disruption may occur. Insomnia and obstructive sleep apnea increase cancer risks. In short sleepers, an increased risk of stomach cancer, esophageal squamous cell cancer, and breast cancer was observed. Among long sleepers (>9 hours), the risk of some hematologic malignancies is elevated.

CONCLUSION

Several factors including insomnia, circadian disruption, obesity, and intermittent hypoxia in obstructive sleep apnea are contributing risk factors for increased risk of several types of cancers. However, further studies are needed to determine the more significant of these risk factors and their interactions.

American Cancer Society guideline for diet and physical activity for cancer prevention

The American Cancer Society (ACS) publishes the Diet and Physical Activity Guideline to serve as a foundation for its communication, policy, and community strategies and, ultimately, to affect dietary and physical activity patterns among Americans. This guideline is developed by a national panel of experts in cancer research, prevention, epidemiology, public health, and policy, and reflects the most current scientific evidence related to dietary and activity patterns and cancer risk. The ACS guideline focuses on recommendations for individual choices regarding diet and physical activity patterns, but those choices occur within a community context that either facilitates or creates barriers to healthy behaviors. Therefore, this committee presents recommendations for community action to accompany the 4 recommendations for individual choices to reduce cancer risk. These recommendations for community action recognize that a supportive social and physical environment is indispensable if individuals at all levels of society are to have genuine opportunities to choose healthy behaviors. This 2020 ACS guideline is consistent with guidelines from the American Heart Association and the American Diabetes Association for the prevention of coronary heart disease and diabetes as well as for general health promotion, as defined by the 2015 to 2020 Dietary Guidelines for Americans and the 2018 Physical Activity Guidelines for Americans.

Effect of Hypercapnia, an Element of Obstructive Respiratory Disorder, on Pancreatic Cancer Chemoresistance and Progression

BACKGROUND

Chronic obstructive respiratory disorders (ORDs) are linked to increased rates of cancer-related deaths. Little is known about the effects of hypercapnia (elevated CO₂) on development of pancreatic ductal adenocarcinoma (PDAC) and drug resistance.

STUDY DESIGN

Two PDAC cell lines were exposed to normocapnic (5% CO₂) and hypercapnic (continuous/intermittent 10% CO₂) conditions, physiologically similar to patients with active ORD. Cells were assessed for proliferation rate, colony formation, and chemo-/radiotherapeutic efficacy. In a retrospective clinical study design, patients with PDAC who had undergone pancreatic resection between 2002 and 2014 were reviewed. Active smokers were excluded to remove possible smoking-related protumorigenic influence. Clinical data, pathologic findings, and survival end points were recorded. Kaplan-Meier and Cox regression analyses were performed.

RESULTS

Exposure to hypercapnia resulted in increased colony formation and proliferation rates in vitro in both cell lines (MIA-PaCa-2: 111% increase and Panc-1: 114% increase; p < 0.05). Hypercapnia exposure induced a 2.5-fold increase in oxaliplatin resistance (p < 0.05) in both cell lines and increased resistance to ionizing radiation in MIA-PaCa-2 cells (p < 0.05). Five hundred and seventy-eight patients were included (52% were male, median age was 68.7 years [interquartile range 60.6 to 76.8 years]). Cox regression analysis, assessing TNM staging, age, sex, and ORD status, identified ORD as an independent risk factor for both overall survival (hazard ratio 1.64; 95% CI, 1.2 to 2.3; p < 0.05) and disease-free survival (hazard ratio 1.68; 95% CI, 1.06 to 2.67).

CONCLUSIONS

PDAC cells exposed to hypercapnic environments, which is common in patients with ORD, showed tumor proliferation, radioresistance, and chemoresistance. Patients with a history of ORD had a worse overall prognosis, suggesting that hypercapnic conditions play a role in the development and progression of PDAC and stressing the need for patient-tailored care.

The Association of Sleep Apnea and Cancer in Veterans

Objective

To test the association between preexisting obstructive sleep apnea (OSA) and subsequent cancer in a large long-term cohort of veteran patients.

Study Design

Retrospective matched cohort study.

Setting

The Veterans Affairs Health Care System.

Subjects and Methods

All veteran patients diagnosed with OSA between 1993 and 2013 by International Classification of Diseases, Ninth Revision ( ICD-9) codes in any Veterans Affairs facility and veteran patients without an OSA diagnosis, matched to patients with OSA by age and index year. Cancer diagnoses were identified by ICD-9 codes for the time period at least 2 years after OSA diagnosis or index date. We tested the association between OSA and cancer using multivariate Cox regression with time since cohort entry as the time axis, adjusting for potential confounders.

Results

The cohort included 1,377,285 patients (726,008 with and 651,277 without an OSA diagnosis) with mean age of 55 years, predominantly male (94%), a minority obese (32%), and median follow-up of 7.4 years (range, 2.0-25.2). The proportion of patients diagnosed with cancer was higher in those with vs without an OSA diagnosis (8.3% vs 3.6%; mean difference 4.8%; 95% confidence interval [CI], 4.7%-4.8%; P < .001). After adjusting for age, sex, year of cohort entry, smoking status, alcohol use, obesity, and comorbidity, the hazard of incident cancer was nearly double in patients with vs without an OSA diagnosis (hazard ratio, 1.97; 95% CI, 1.94-2.00; P < .001).

Conclusion

Preexisting OSA was strongly associated with subsequent cancer in this veteran cohort, independent of several known cancer risk factors. These findings suggest that OSA may be a strong, independent risk factor for subsequent cancer development.

Association between obstructive sleep apnoea and breast cancer: The Korean National Health Insurance Service Data 2007-2014

Some studies have argued that obstructive sleep apnoea (OSA) increases the risk of breast cancer. However, the results are often conflicting. This study aimed to investigate associations between OSA and breast cancer incidence using the Korea National Health Insurance Service (KNHIS) database. This retrospective cohort study analyzed data from the KNHIS database. A total of 45,699 women (≥20 years of age) newly diagnosed with OSA between 2007 and 2014 were included. The control groups were a 5-fold, age-matched women who had not been diagnosed with OSA. Mean follow-up duration was 3.7 ± 2.3 years. The primary endpoint was newly diagnosed breast cancer. The breast cancer hazard ratio (95% confidence interval) was calculated for patients with OSA and compared with that of the control group. The incidence of breast cancer among patients with OSA was significantly higher than that among the controls (1.20 [1.04–1.39]). In particular, the incidence of breast cancer was higher among patients aged ≥65 years (1.72 [1.10–2.71]). The result suggests that OSA may be a risk factor for breast cancer in women.

Impact of Intermittent Hypoxia on Sepsis Outcomes in a Murine Model

Sleep apnea has been associated with a variety of diseases, but its impact on sepsis outcome remains unclear. This study investigated the effect of intermittent hypoxia [IH]–the principal feature of sleep apnea–on murine sepsis. 5-week-old male C57BL6 mice were assigned to groups receiving severe IH (O2 fluctuating from room air to an O2 nadir of 5.7% with a cycle length of 90 seconds), mild IH (room air to 12%, 4 minutes/cycle), or room air for 3 weeks. Sepsis was induced by cecal ligation and puncture and survival was monitored. Sepsis severity was evaluated by murine sepsis scores, blood bacterial load, plasma tumor necrosis factor-α [TNF-α]/interleukin-6 [IL-6] levels and histopathology of vital organs. Compared with normoxic controls, mice subjected to severe IH had earlier mortality, a lower leukocyte count, higher blood bacterial load, higher plasma TNF-α and IL-6 levels, more severe inflammatory changes in the lung, spleen and small intestine. Mice subjected to mild IH did not differ from normoxic controls, except a higher IL-6 level after sepsis induced. The adverse impact of severe IH was reversed following a 10-day normoxic recovery. In conclusion, severe IH, not mild IH, contributed to poorer outcomes in a murine sepsis model.

Impacts of Sleep Duration and Snoring on The Risk of Esophageal Squamous Cell Carcinoma

Background Sleep duration and snoring are correlated with tumorigenesis while their associations with esophageal squamous cell carcinoma (ESCC) are unclear. The purpose of this study is to investigate the impacts of night sleep duration and snoring on ESCC risk.

Methods This study included a total of 527 esophageal squamous cell carcinoma patients and 505 gender- and age- matched healthy controls from five hospitals in China. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated by conditional logistic regression models.

Results Subjects with sleep duration <7 h (adjusted OR 3.18, 95%CI 1.55-6.53) and regular snoring (adjusted OR 2.56, 95%CI 1.82-3.59) were exposed to high esophageal squamous cell carcinoma risk. After the multivariate models adjusted for body mass index (BMI), the results changed slightly. In the stratified analysis regarding gender, the similar trends occurred in both men and women, and BMI ≥25.0 kg/m² (adjusted OR 0.68, 95%CI 0.48-0.96) was associated with decreased esophageal squamous cell carcinoma risk in men. Additionally, the esophageal squamous cell carcinoma risk attributable to sleep duration <7 h and regular snoring could be completely or partially diminished in subjects with BMI ≥25.0 kg/m².

Conclusion In both genders, short sleep duration (<7h) and regular snoring were significantly related to increased risk of esophageal squamous cell carcinoma independently.