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Davis EW, Attwood K, Prunier J, Paragh G, Joseph JM, Klein A, Roche C, Barone N, Etter JL, Ray AD, Trabert B, Schabath MB, Peres LC, Cannioto R. The association of body composition phenotypes before chemotherapy with epithelial ovarian cancer mortality. J Natl Cancer Inst 2024:djae112. [PMID: 38802116 DOI: 10.1093/jnci/djae112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Revised: 04/17/2024] [Accepted: 05/11/2024] [Indexed: 05/29/2024] Open
Abstract
BACKGROUND The association of body composition with epithelial ovarian carcinoma (EOC) mortality is poorly understood. To date, evidence suggests high adiposity associates with decreased mortality (an obesity paradox), but the impact of muscle on this association has not been investigated. Herein, we define associations of muscle and adiposity joint-exposure body composition phenotypes with EOC mortality. METHODS Body composition from 500 women in The Body Composition and Epithelial Ovarian Cancer Survival Study was dichotomized as normal/low skeletal muscle index (SMI), a proxy for sarcopenia and high/low adiposity. Four phenotypes were classified as fit/reference (normal SMI/low adiposity; 16.2%), overweight/obese (normal SMI/high adiposity; 51.2%), sarcopenia/overweight-obese (low SMI/high adiposity; 15.6%), and sarcopenia/cachexia (low SMI/low adiposity; 17%). We used multivariable Cox models to estimate associations of each phenotype with mortality for EOC overall and high-grade serous ovarian carcinoma (HGSOC). RESULTS Overweight/obesity was associated with up to 51% and 104% increased mortality in EOC and HGSOC (HR = 1.51, 95% CI: 1.05-2.19 and HR = 2.04, 95% CI: 1.29-3.21). Sarcopenia/overweight-obesity was associated with up to 66% and 67% increased mortality in EOC and HGSOC (HR = 1.66, 95% CI: 1.13-2.45 and HR = 1.67, 95% CI: 1.05-2.68). Sarcopenia/cachexia was associated with up to 73% and 109% increased mortality in EOC and HGSOC (HR = 1.73, 95% CI: 1.14-2.63 and HR = 2.09, 95% CI: 1.25-3.50). CONCLUSIONS Overweight/obesity, sarcopenia/overweight-obesity and sarcopenia/cachexia phenotypes were each associated with increased mortality in EOC and HGSOC. Exercise and dietary interventions could be leveraged as ancillary treatment strategies for improving outcomes in the most fatal gynecological malignancy with no previously established modifiable prognostic factors.
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Affiliation(s)
- Evan W Davis
- Department of Cancer Prevention and Control, Roswell Park Comprehensive Cancer Center, Buffalo, 14263, NY, USA
| | - Kristopher Attwood
- Department of Biostatistics and Bioinformatics, Roswell Park Comprehensive Cancer Center, Buffalo, 14263, NY, USA
| | - Joseph Prunier
- Lake Erie College of Osteopathic Medicine, Elmira, 14901, NY, USA
| | - Gyorgy Paragh
- Department of Dermatology, Roswell Park Comprehensive Cancer Center, Buffalo, 14263, NY, USA
| | - Janine M Joseph
- Department of Cancer Prevention and Control, Roswell Park Comprehensive Cancer Center, Buffalo, 14263, NY, USA
| | - André Klein
- Department of Research Information Technology, Roswell Park Comprehensive Cancer Center, Buffalo, 14263, NY, USA
| | - Charles Roche
- Department of Diagnostic Radiology, Roswell Park Comprehensive Cancer Center, Buffalo, 14263, NY, USA
| | - Nancy Barone
- Department of Cancer Prevention and Control, Roswell Park Comprehensive Cancer Center, Buffalo, 14263, NY, USA
| | - John Lewis Etter
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, 14623, NY, USA
| | - Andrew D Ray
- Department of Cancer Prevention and Control, Roswell Park Comprehensive Cancer Center, Buffalo, 14263, NY, USA
- Department of Rehabilitation, Roswell Park Comprehensive Cancer Center, Buffalo, 14263, NY, USA
| | - Britton Trabert
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, 84112, UT, USA
- Huntsman Cancer Institute at the University of Utah, Cancer Control and Population Sciences, Salt Lake City, 84112, UT, USA
| | - Matthew B Schabath
- Department of Cancer Epidemiology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, 33612, FL, USA
| | - Lauren C Peres
- Department of Cancer Epidemiology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, 33612, FL, USA
| | - Rikki Cannioto
- Department of Cancer Prevention and Control, Roswell Park Comprehensive Cancer Center, Buffalo, 14263, NY, USA
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Morton M, Patterson J, Sciuva J, Perni J, Backes F, Nagel C, O'Malley DM, Chambers LM. Malnutrition, sarcopenia, and cancer cachexia in gynecologic cancer. Gynecol Oncol 2023; 175:142-155. [PMID: 37385068 DOI: 10.1016/j.ygyno.2023.06.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 06/14/2023] [Accepted: 06/18/2023] [Indexed: 07/01/2023]
Abstract
Patients with gynecologic cancers are at risk for malnutrition, cancer cachexia, and sarcopenia. Accumulating data supports that malnourished patients with gynecologic cancer have worse overall survival, increased healthcare utilization and costs, and a higher incidence of postoperative complications and treatment toxicity than those who are not malnourished. Malnutrition is defined as insufficient energy intake, leading to altered body composition and subsequent impaired physical and cognitive function, and can result in sarcopenia and cachexia, defined as the loss of lean body mass and loss of body weight respectively. The etiology of cancer-related malnutrition is complex, resulting from a systemic pro-inflammatory state of malignancy with upregulation of muscle degradation pathways and metabolic derangements, including lipolysis and proteolysis, that may not respond to nutritional repletion alone. Numerous validated scoring systems and radiographic measures have been described to define and quantify the severity of malnutrition and muscle loss in both clinical and research settings. "Prehabilitation" and optimization of nutrition and functional status early in therapy may combat the development or worsening of malnutrition and associated syndromes and ultimately improve oncologic outcomes, but limited data exist in the context of gynecologic cancer. Multi-modality nutrition and physical activity interventions have been proposed to combat the biophysical losses related to malnutrition. Several trials are underway in gynecologic oncology patients to address these aims, but significant gaps in knowledge persist. Pharmacologic interventions and potential immune targets for combating cachexia related to malignancy are discussed in this review and may provide opportunities to target disease and cachexia. This article reviews currently available data regarding the implications, diagnostics, physiology, and intervention strategies for gynecologic oncology patients with malnutrition and its associated conditions.
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Affiliation(s)
- Molly Morton
- Division of Gynecologic Oncology; The Ohio State University Wexner Medical Center, The James Cancer Hospital and Solove Research Institute, Starling Loving Hall, M210, 320 W. 10(th) Avenue, Columbus, OH 43210, United States of America.
| | - Jenna Patterson
- Department of Obstetrics and Gynecology; The Ohio State University Wexner Medical Center, 456 W 10(th) Avenue, Columbus, OH 43210, United States of America
| | - Jessica Sciuva
- The Ohio State University College of Medicine; 370 W. 9(th) Ave, Columbus, OH 43210, United States of America
| | - Jaya Perni
- The Ohio State University; 281 W Lane Ave, Columbus, OH 43210, United States of America
| | - Floor Backes
- Division of Gynecologic Oncology; The Ohio State University Wexner Medical Center, The James Cancer Hospital and Solove Research Institute, Starling Loving Hall, M210, 320 W. 10(th) Avenue, Columbus, OH 43210, United States of America
| | - Christa Nagel
- Division of Gynecologic Oncology; The Ohio State University Wexner Medical Center, The James Cancer Hospital and Solove Research Institute, Starling Loving Hall, M210, 320 W. 10(th) Avenue, Columbus, OH 43210, United States of America
| | - David M O'Malley
- Division of Gynecologic Oncology; The Ohio State University Wexner Medical Center, The James Cancer Hospital and Solove Research Institute, Starling Loving Hall, M210, 320 W. 10(th) Avenue, Columbus, OH 43210, United States of America
| | - Laura M Chambers
- Division of Gynecologic Oncology; The Ohio State University Wexner Medical Center, The James Cancer Hospital and Solove Research Institute, Starling Loving Hall, M210, 320 W. 10(th) Avenue, Columbus, OH 43210, United States of America
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3
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Thomson CA, Crane TE, Miller A, Gold MA, Powell M, Bixel K, Van Le L, DiSilvestro P, Ratner E, Lele S, Guntupalli S, Huh W, Robertson SE, Modesitt S, Casey AC, Basen-Engquist K, Skiba M, Walker J, Kachnic L, Alberts DS. Lifestyle intervention in ovarian cancer enhanced survival (LIVES) study (NRG/GOG0225): Recruitment, retention and baseline characteristics of a randomized trial of diet and physical activity in ovarian cancer survivors. Gynecol Oncol 2023; 170:11-18. [PMID: 36608382 PMCID: PMC10023359 DOI: 10.1016/j.ygyno.2022.12.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 12/16/2022] [Accepted: 12/26/2022] [Indexed: 01/06/2023]
Abstract
OBJECTIVE The Lifestyle Intervention for oVarian cancer Enhanced Survival (LIVES) is a national study of a combined diet and physical activity intervention for stage II-IV ovarian cancer survival, an under-represented cancer in lifestyle behavioral intervention research. Here, we present the data on recruitment, retention, and baseline demographic, clinical and lifestyle behavior characteristics of the LIVES study participants. METHODS The LIVES study (NRG Oncology/GOG 0225) is a Phase III diet plus physical activity intervention trial testing the hypothesis that ovarian cancer survivors in the lifestyle intervention will demonstrate better progression-free survival than those in the control condition. Study interventions were delivered via centralized telephone-based health coaching. Baseline descriptive statistics were computed for demographic, clinical, and lifestyle behavior characteristics. RESULTS The LIVES study exceeded its recruitment goals, enrolling 1205 ovarian cancer survivors from 195 NRG/NCORP-affiliated oncology practices across 49 states from 2012 to 2018. The mean age of enrollees was 59.6 years; the majority (69.4%) with stage III disease; 89% White, 5.5% Hispanic; 64% overweight/obese. Baseline self-reported diet showed a mean daily intake of 6.6 servings of fruit and vegetables, 62.7 fat grams, and 21.7 g of fiber. Physical activity averaged 13.0 MET-hours/week of moderate to vigorous physical activity; 50.9 h/week of sedentary time. Retention rates exceeded 88%. CONCLUSION The LIVES study demonstrates efficiency in recruiting and retaining ovarian cancer survivors in a 24-month study of diet and physical activity intervention with a primary endpoint of progression free survival that will be reported. TRIAL REGISTRATION ClinicalTrials.govNCT00719303.
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Affiliation(s)
- Cynthia A Thomson
- Mel & Enid Zuckerman College of Public Health, University of Arizona, Tucson, AZ, USA.
| | - Tracy E Crane
- Mel & Enid Zuckerman College of Public Health, University of Arizona, Tucson, AZ, USA; Division of Medical Oncology, Miller School of Medicine, Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL, USA.
| | - Austin Miller
- NRG Oncology, Clinical Trials Development Division, Biostatistics & Bioinformatics, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA.
| | - Michael A Gold
- Oklahoma Cancer Specialists and Research Institute, Tulsa, OK, USA.
| | - Matthew Powell
- Washington University School of Medicine, St. Louis, MO, USA.
| | - Kristin Bixel
- Ohio State University Comprehensive Cancer Center-James Cancer Hospital and Solove Research Institute, Columbus, OH, USA.
| | - Linda Van Le
- University of North Carolina School of Medicine, UNC Hospitals, 101 Manning Dr, Chapel Hill, NC, USA.
| | | | - Elena Ratner
- Yale University School of Medicine, New Haven, CT, USA.
| | | | - Saketh Guntupalli
- University of Colorado Cancer Center - Anschutz Cancer Pavilion, Aurora, CO, USA.
| | - Warner Huh
- University of Alabama at Birmingham Hospital, Birmingham, AL, USA.
| | | | - Susan Modesitt
- University of Virginia, Emily Couric Clinical Cancer Center, Charlottesville, VA, USA.
| | | | - Karen Basen-Engquist
- Professor of Behavioral Science, Director of the Center for Energy Balance in Cancer Prevention & Survivorship, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA.
| | - Meghan Skiba
- Mel & Enid Zuckerman College of Public Health, University of Arizona, Tucson, AZ, USA.
| | - Joan Walker
- University of Oklahoma, Oklahoma City, OK, USA.
| | - Lisa Kachnic
- Columbia University, Herbert Irving Comprehensive Cancer Center, New York, NY, USA.
| | - David S Alberts
- Medicine, Pharmacology, Public Health, Nutritional Sciences & BIO5, Emeritus, University of Arizona Cancer Center, Tucson, AZ, 85719, USA.
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Schildkraut JM, Johnson C, Dempsey LF, Qin B, Terry P, Akonde M, Peters ES, Mandle H, Cote ML, Peres L, Moorman P, Schwartz AG, Epstein M, Marks J, Bondy M, Lawson AB, Alberg AJ, Bandera EV. Survival of epithelial ovarian cancer in Black women: a society to cell approach in the African American cancer epidemiology study (AACES). Cancer Causes Control 2023; 34:251-265. [PMID: 36520244 PMCID: PMC9753020 DOI: 10.1007/s10552-022-01660-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 12/05/2022] [Indexed: 12/23/2022]
Abstract
PURPOSE The causes for the survival disparity among Black women with epithelial ovarian cancer (EOC) are likely multi-factorial. Here we describe the African American Cancer Epidemiology Study (AACES), the largest cohort of Black women with EOC. METHODS AACES phase 2 (enrolled 2020 onward) is a multi-site, population-based study focused on overall survival (OS) of EOC. Rapid case ascertainment is used in ongoing patient recruitment in eight U.S. states, both northern and southern. Data collection is composed of a survey, biospecimens, and medical record abstraction. Results characterizing the survival experience of the phase 1 study population (enrolled 2010-2015) are presented. RESULTS Thus far, ~ 650 patients with EOC have been enrolled in the AACES. The five-year OS of AACES participants approximates those of Black women in the Surveillance Epidemiology and End Results (SEER) registry who survive at least 10-month past diagnosis and is worse compared to white women in SEER, 49 vs. 60%, respectively. A high proportion of women in AACES have low levels of household income (45% < $25,000 annually), education (51% ≤ high school education), and insurance coverage (32% uninsured or Medicaid). Those followed annually differ from those without follow-up with higher levels of localized disease (28 vs 24%) and higher levels of optimal debulking status (73 vs 67%). CONCLUSION AACES is well positioned to evaluate the contribution of social determinants of health to the poor survival of Black women with EOC and advance understanding of the multi-factorial causes of the ovarian cancer survival disparity in Black women.
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Affiliation(s)
- Joellen M Schildkraut
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA.
| | - Courtney Johnson
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Lauren F Dempsey
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Bo Qin
- Cancer Epidemiology and Health Outcomes, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
| | - Paul Terry
- Department of Medicine, University of Tennessee Medical Center-Knoxville, Knoxville, TN, USA
| | - Maxwell Akonde
- Department of Medicine, University of Tennessee Medical Center-Knoxville, Knoxville, TN, USA
| | - Edward S Peters
- Department of Epidemiology, College of Public Health, University of Nebraska Medical Center, Omaha, NE, USA
| | - Hannah Mandle
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Michele L Cote
- Indiana University Melvin and Bren Simon Comprehensive Cancer Center, Indiana University, Indianapolis, IN, USA
| | - Lauren Peres
- Department of Cancer Epidemiology, H. Lee Moffit Cancer Center and Research Institute, Tampa, FL, USA
| | - Patricia Moorman
- Department of Family Medicine and Community Health, Duke University School of Medicine, Durham, NC, USA
| | - Ann G Schwartz
- Department of Oncology, Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, MI, USA
| | - Michael Epstein
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Jeffrey Marks
- Department of Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Melissa Bondy
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - Andrew B Lawson
- Department of Public Health Sciences, College of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Anthony J Alberg
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA
| | - Elisa V Bandera
- Cancer Epidemiology and Health Outcomes, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
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5
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Sicardo Jiménez S, Vinolo-Gil MJ, Carmona-Barrientos I, Martin-Vega FJ, García-Muñoz C, Guillén Vargas AR, Gonzalez-Medina G. The Influence of Therapeutic Exercise on Survival and the Quality of Life in Survivorship of Women with Ovarian Cancer. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:16196. [PMID: 36498270 PMCID: PMC9740561 DOI: 10.3390/ijerph192316196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 11/28/2022] [Accepted: 11/29/2022] [Indexed: 06/17/2023]
Abstract
BACKGROUND Ovarian cancer is the most difficult of all gynaecological cancers to treat, mainly due to its late diagnosis. Although exercise interventions have been reported to be safe and beneficial for ovarian cancer, treatment does not include it and is usually a combination of chemotherapy and surgery. It is increasingly common to include exercise as a tool to increase survival in the cancer population. The aim of this study was to determine the influence of therapeutic exercise on survival and the quality of life in survivorship in women with ovarian cancer. METHODS Literature review of clinical trials, reviews and pilot studies compiled in three databases collected in PubMed, PEDro and Scopus. RESULTS Of the 44 articles found, 10 were selected. Improvements in survival, quality of life and comorbidities associated with ovarian cancer were found with exercise interventions as a treatment tool. CONCLUSIONS Through the application of therapeutic exercise, improvements in survival and quality of life were observed, as well as in the general symptomatology of ovarian cancer. No adverse effects have been found with its use, but future studies with larger sample sizes with more detailed and individualised interventions combined with conventional treatment are needed.
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Affiliation(s)
| | - Maria Jesus Vinolo-Gil
- Department of Nursing and Physiotherapy, University of Cadiz, 11009 Cadiz, Spain
- Rehabilitation Clinical Management Unit, Interlevels-Intercenters Hospital Puerta del Mar, Hospital Puerto Real, Cadiz Bay-La Janda Health District, 11006 Cadiz, Spain
- Research Unit, Department Biomedical Research and Innovation Institute of Cadiz (INiBICA), Puerta del Mar University Hospital, University of Cadiz, 11009 Cadiz, Spain
| | - Ines Carmona-Barrientos
- Department of Nursing and Physiotherapy, University of Cadiz, 11009 Cadiz, Spain
- Research Unit, Department Biomedical Research and Innovation Institute of Cadiz (INiBICA), Puerta del Mar University Hospital, University of Cadiz, 11009 Cadiz, Spain
- CTS-986 Physical Therapy and Health (FISA), University Institute of Research in Social Sustainable Development (INDESS), 11009 Cadiz, Spain
| | | | | | | | - Gloria Gonzalez-Medina
- Department of Nursing and Physiotherapy, University of Cadiz, 11009 Cadiz, Spain
- Research Unit, Department Biomedical Research and Innovation Institute of Cadiz (INiBICA), Puerta del Mar University Hospital, University of Cadiz, 11009 Cadiz, Spain
- CTS-986 Physical Therapy and Health (FISA), University Institute of Research in Social Sustainable Development (INDESS), 11009 Cadiz, Spain
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McKenzie ND, Ahmad S. Impact of Lifestyle Interventions on Gynecologic Cancers: Beyond Diet and Exercise. Am J Lifestyle Med 2022. [DOI: 10.1177/15598276221123764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
A Lifestyle Medicine approach to compliment cancer care is less commonly researched or implemented for women with gynecologic cancers as compared to better funded malignancies such as breast, prostate, and colorectal. Yet, several gynecologic malignancies are linked to obesity, estrogen/metabolic signaling pathways, and altered tumor microenvironment which could benefit greatly from a lifestyle medicine program. Lifestyle medicine, an evidenced-based branch of science, has expanded to the prevention and treatment of disorders caused by lifestyle factors (including cancer). Modifiable lifestyle factors such as obesity, lack of physical activity/nutrient density, microbial dysbiosis, sleep disturbance, and chronic stressors contribute greatly to cancer morbidity and mortality worldwide. This overarching area of research is evolving with some subtopics in their infancy requiring further investigation. Modern tools have allowed for better understanding of mechanisms by which adiposity and inactivity affect tumor promoting signaling pathways as well as the local tumor environment. Through the evolving use of these sophisticated techniques, novel prognostic biomarkers have emerged to explore efficacy of pharmacologic and lifestyle interventions in cancer. This state-of-the-art review article appraises recent evidence for a lifestyle medicine approach, beyond diet and exercise, to optimize survivorship and quality of life for patients with gynecologic cancers and introduces the 8-week web-based comprehensive HEAL-GYN program.
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Affiliation(s)
| | - Sarfraz Ahmad
- Gynecologic Oncology Program, AdventHealth Cancer Institute, Orlando, FL, USA
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Gersekowski K, Delahunty R, Alsop K, Goode EL, Cunningham JM, Winham SJ, Pharoah P, Song H, Jordan S, Fereday S, DeFazio A, Friedlander M, Obermair A, Webb PM. Germline BRCA variants, lifestyle and ovarian cancer survival. Gynecol Oncol 2022; 165:437-445. [PMID: 35400525 PMCID: PMC9133192 DOI: 10.1016/j.ygyno.2022.03.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 03/23/2022] [Accepted: 03/25/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Women with ovarian cancer who have a pathogenic germline variant in BRCA1 or BRCA2 (BRCA) have been shown to have better 5-year survival after diagnosis than women who are BRCA-wildtype (non-carriers). Modifiable lifestyle factors, including smoking, physical activity and body mass index (BMI) have previously been associated with ovarian cancer survival; however, it is unknown whether these associations differ by germline BRCA status. METHODS We investigated measures of lifestyle prior to diagnosis in two cohorts of Australian women with invasive epithelial ovarian cancer, using Cox proportional hazards regression to calculate adjusted hazard ratios (HRs) and 95% confidence intervals (CIs). RESULTS In the combined studies (n = 1923), there was little association between physical activity, BMI or alcohol intake and survival, and no difference by BRCA status. However, the association between current smoking status before diagnosis and poorer survival was stronger for BRCA variant carriers (HR 1.98; 95% CI 1.20-3.27) than non-carriers (HR 1.18; 95% CI 0.96-1.46; p-interaction 0.02). We saw a similar differential association with smoking when we pooled results from two additional cohorts from the USA and UK (n = 2120). Combining the results from all four studies gave a pooled-HR of 1.94 (95% CI 1.28-2.94) for current smoking among BRCA variant carriers compared to 1.08 (0.90-1.29) for non-carriers. CONCLUSIONS Our results suggest that the adverse effect of smoking on survival may be stronger for women with a BRCA variant than those without. Thus, while smoking cessation may improve outcomes for all women with ovarian cancer, it might provide a greater benefit for BRCA variant carriers.
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Affiliation(s)
- Kate Gersekowski
- Population Health Department, QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
| | - Rachel Delahunty
- Women's Cancer Program, Peter MacCallum Cancer Centre, Melbourne, Victoria 3000, Australia; Sir Peter MacCallum Department of Oncology, The University of Melbourne, Victoria 3010, Australia
| | - Kathryn Alsop
- Women's Cancer Program, Peter MacCallum Cancer Centre, Melbourne, Victoria 3000, Australia; Sir Peter MacCallum Department of Oncology, The University of Melbourne, Victoria 3010, Australia
| | - Ellen L Goode
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - Julie M Cunningham
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Stacey J Winham
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - Paul Pharoah
- Department of Public Health and Primary Care, University of Cambridge, Centre for Cancer Genetic Epidemiology, Cambridge, UK; Department of Oncology, University of Cambridge, Centre for Cancer Genetic Epidemiology, Cambridge, UK
| | - Honglin Song
- Department of Public Health and Primary Care, University of Cambridge, Cardiovascular Epidemiology Unit, Cambridge, UK
| | - Susan Jordan
- School of Public Health, University of Queensland, Brisbane, Queensland, Australia
| | - Sian Fereday
- Women's Cancer Program, Peter MacCallum Cancer Centre, Melbourne, Victoria 3000, Australia; Sir Peter MacCallum Department of Oncology, The University of Melbourne, Victoria 3010, Australia
| | - Anna DeFazio
- Department of Gynaecological Oncology, Westmead Hospital, Centre for Cancer Research, Westmead Institute for Medical Research, The University of Sydney, Sydney, NSW, Australia; The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, Sydney, NSW, Australia
| | - Michael Friedlander
- Prince of Wales Clinical School University of New South Wales, Department of Medical Oncology, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - Andreas Obermair
- Queensland Centre for Gynaecological Cancer Research, The University of Queensland, Brisbane, Queensland, Australia
| | - Penelope M Webb
- Population Health Department, QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia.
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8
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Stenzel AE, Thomaier L, Jewett PI, Dona AC, Brown K, Gotlieb R, Blaes A, Teoh D, Vogel RI. Interactions between physical activity and type of cancer treatment received on associations with psychosocial outcomes among gynecologic cancer survivors. Gynecol Oncol 2022; 166:85-89. [PMID: 35525600 DOI: 10.1016/j.ygyno.2022.04.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Revised: 04/19/2022] [Accepted: 04/21/2022] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Physical activity is associated with improved cancer outcomes; however, it is unclear which patients may benefit most from increased physical activity. We evaluated whether associations between meeting the American Cancer Society (ACS) physical activity recommendations and psychosocial outcomes in gynecologic cancer survivors varied by type of treatments received. METHODS We recruited English-speaking adult gynecologic cancer patients from an academic gynecologic oncology practice to participate in a prospective cohort study. Participants completed a survey at study entry regarding their psychosocial health-including distress, depression, anxiety, post-traumatic stress disorder, and quality of life (QoL)-and physical activity. Multivariate linear regression models for each psychosocial outcome tested for interactions between physical activity and each effect modifier (receipt of chemotherapy, radiation therapy, and/or minimally invasive surgery), adjusted for age, pain, body mass index, primary cancer diagnosis, cancer stage, time since diagnosis, and annual household income. RESULTS Among a total of 362 participants, 213 (59%) met ACS physical activity recommendations. We found evidence of interactions between physical activity and receipt of chemotherapy for depression, anxiety, and QoL scores; those who had received chemotherapy had a stronger association between physical activity and these psychosocial outcomes, compared to those who had not. We found no evidence of interactions between physical activity and receipt of radiation therapy or minimally invasive surgery for any of the outcomes. CONCLUSIONS Gynecologic cancer survivors who received chemotherapy had significant associations between psychosocial health and physical activity, suggesting they may derive greatest benefit from prescribed exercise.
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Affiliation(s)
- Ashley E Stenzel
- Department of Obstetrics, Gynecology and Women's Health, Division of Gynecologic Oncology, University of Minnesota, Minneapolis, MN, USA; Program in Health Disparities Research, Department of Family Medicine and Community Health, University of Minnesota, Minneapolis, MN, USA
| | - Lauren Thomaier
- Department of Obstetrics, Gynecology and Women's Health, Division of Gynecologic Oncology, University of Minnesota, Minneapolis, MN, USA
| | - Patricia I Jewett
- Department of Obstetrics, Gynecology and Women's Health, Division of Gynecologic Oncology, University of Minnesota, Minneapolis, MN, USA; Department of Medicine, Division of Hematology and Oncology, University of Minnesota, Minneapolis, MN, USA
| | - Allison C Dona
- School of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Katherine Brown
- Department of Obstetrics, Gynecology and Women's Health, Division of Gynecologic Oncology, University of Minnesota, Minneapolis, MN, USA
| | - Rachael Gotlieb
- School of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Anne Blaes
- Department of Medicine, Division of Hematology and Oncology, University of Minnesota, Minneapolis, MN, USA
| | - Deanna Teoh
- Department of Obstetrics, Gynecology and Women's Health, Division of Gynecologic Oncology, University of Minnesota, Minneapolis, MN, USA
| | - Rachel I Vogel
- Department of Obstetrics, Gynecology and Women's Health, Division of Gynecologic Oncology, University of Minnesota, Minneapolis, MN, USA.
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Gaitskell K, Hermon C, Barnes I, Pirie K, Floud S, Green J, Beral V, Reeves GK. Ovarian cancer survival by stage, histotype, and pre-diagnostic lifestyle factors, in the prospective UK Million Women Study. Cancer Epidemiol 2022; 76:102074. [PMID: 34942490 PMCID: PMC8785125 DOI: 10.1016/j.canep.2021.102074] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 10/13/2021] [Accepted: 11/16/2021] [Indexed: 01/22/2023]
Abstract
BACKGROUND Ovarian cancer is the fifth leading cause of cancer mortality in UK women. Ovarian cancer survival varies by disease stage at diagnosis, but evidence is mixed on the effect of tumour histological type (histotype) and other factors. METHODS 1.3 million UK women completed a detailed health questionnaire in 1996-2001 and were followed for incident cancers and deaths via linkage to national databases. Using Cox regression models, we estimated adjusted relative risks (RRs) of death from ovarian cancer, by stage at diagnosis, tumour histotype, and 16 other personal characteristics of the women. RESULTS During 17.7 years' average follow-up, 13,222 women were diagnosed with ovarian cancer, and 8697 of them died from the disease. Stage at diagnosis was a major determinant of survival (stage IV vs I, RR=10.54, 95% CI: 9.16-12.13). Histotype remained a significant predictor after adjustment for stage and other factors, but associations varied over the follow-up period. Histotype-specific survival was worse for high-grade than low-grade tumours. Survival appeared worse with older age at diagnosis (per 5 years: RR=1.19, 95% CI: 1.15-1.22), higher BMI (per 5-unit increase: RR=1.06, 95% CI: 1.02-1.11), and smoking (current vs never: RR=1.17, 95% CI: 1.07-1.27), but there was little association with 13 other pre-diagnostic reproductive, anthropometric, and lifestyle factors. CONCLUSION Stage at diagnosis is a strong predictor of ovarian cancer survival, but tumour histotype and grade remain predictors of survival even after adjustment for stage and other factors, contributing further evidence of biological dissimilarity between the ovarian cancer histotypes. Obesity and smoking represent potentially-modifiable determinants of survival, but the stronger association with stage suggests that improving earlier diagnosis would have a greater impact on increasing ovarian cancer survival.
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Affiliation(s)
- Kezia Gaitskell
- Cancer Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK; Nuffield Division of Clinical Laboratory Sciences, Radcliffe Department of Medicine, University of Oxford, Oxford, UK; Department of Histopathology, John Radcliffe Hospital, Oxford, UK.
| | - Carol Hermon
- Cancer Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK.
| | - Isobel Barnes
- Cancer Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK.
| | - Kirstin Pirie
- Cancer Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK.
| | - Sarah Floud
- Cancer Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK.
| | - Jane Green
- Cancer Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK.
| | - Valerie Beral
- Cancer Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK.
| | - Gillian K Reeves
- Cancer Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK.
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10
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Brieger KK, Phung MT, Mukherjee B, Bakulski KM, Anton-Culver H, Bandera EV, Bowtell DDL, Cramer DW, deFazio A, Doherty JA, Fereday S, Fortner RT, Gentry-Maharaj A, Goode EL, Goodman MT, Harris HR, Matsuo K, Menon U, Modugno F, Moysich KB, Qin B, Ramus SJ, Risch HA, Rossing MA, Schildkraut JM, Trabert B, Vierkant RA, Winham SJ, Wentzensen N, Wu AH, Ziogas A, Khoja L, Cho KR, McLean K, Richardson J, Grout B, Chase A, Deurloo CM, Odunsi K, Nelson BH, Brenton JD, Terry KL, Pharoah PDP, Berchuck A, Hanley GE, Webb PM, Pike MC, Pearce CL. High Prediagnosis Inflammation-Related Risk Score Associated with Decreased Ovarian Cancer Survival. Cancer Epidemiol Biomarkers Prev 2022; 31:443-452. [PMID: 34789471 PMCID: PMC9281656 DOI: 10.1158/1055-9965.epi-21-0977] [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: 08/12/2021] [Revised: 09/16/2021] [Accepted: 11/08/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND There is suggestive evidence that inflammation is related to ovarian cancer survival. However, more research is needed to identify inflammation-related factors that are associated with ovarian cancer survival and to determine their combined effects. METHODS This analysis used pooled data on 8,147 women with invasive epithelial ovarian cancer from the Ovarian Cancer Association Consortium. The prediagnosis inflammation-related exposures of interest included alcohol use; aspirin use; other nonsteroidal anti-inflammatory drug use; body mass index; environmental tobacco smoke exposure; history of pelvic inflammatory disease, polycystic ovarian syndrome, and endometriosis; menopausal hormone therapy use; physical inactivity; smoking status; and talc use. Using Cox proportional hazards models, the relationship between each exposure and survival was assessed in 50% of the data. A weighted inflammation-related risk score (IRRS) was developed, and its association with survival was assessed using Cox proportional hazards models in the remaining 50% of the data. RESULTS There was a statistically significant trend of increasing risk of death per quartile of the IRRS [HR = 1.09; 95% confidence interval (CI), 1.03-1.14]. Women in the upper quartile of the IRRS had a 31% higher death rate compared with the lowest quartile (95% CI, 1.11-1.54). CONCLUSIONS A higher prediagnosis IRRS was associated with an increased mortality risk after an ovarian cancer diagnosis. Further investigation is warranted to evaluate whether postdiagnosis exposures are also associated with survival. IMPACT Given that pre- and postdiagnosis exposures are often correlated and many are modifiable, our study results can ultimately motivate the development of behavioral recommendations to enhance survival among patients with ovarian cancer.
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Affiliation(s)
- Katharine K. Brieger
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Minh Tung Phung
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Bhramar Mukherjee
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Kelly M. Bakulski
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Hoda Anton-Culver
- Department of Medicine, University of California Irvine, Irvine, CA, USA
| | - Elisa V. Bandera
- Cancer Epidemiology and Health Outcomes, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
| | - David D. L. Bowtell
- Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Victoria, Australia
| | - Daniel W. Cramer
- Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, MA, USA
- Obstetrics and Gynecology Epidemiology Center, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Anna deFazio
- Centre for Cancer Research, The Westmead Institute for Medical Research, and The University of Sydney, New South Wales, Australia
- Department of Gynaecological Oncology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Jennifer A. Doherty
- Huntsman Cancer Institute, Department of Population Health Sciences. University of Utah. Salt Lake City, UT, USA
| | - Sian Fereday
- Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Victoria, Australia
| | - Renée T. Fortner
- Division of Cancer Epidemiology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | | | - Ellen L. Goode
- Department of Quantitative Health Sciences, Division of Epidemiology, Mayo Clinic, Rochester, MN, USA
| | - Marc T. Goodman
- Samuel Oschin Comprehensive Cancer Institute, Cancer Prevention and Genetics Program, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Community and Population Health Research Institute, Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Holly R. Harris
- Program in Epidemiology, Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
- Department of Epidemiology, University of Washington School of Public Health, Seattle, WA, USA
| | - Keitaro Matsuo
- Division of Cancer Epidemiology and Prevention, Aichi Cancer Center Research Institute, Nagoya, Japan
- Department of Cancer Epidemiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Usha Menon
- MRC Clinical Trials Unit, Institute of Clinical Trials & Methodology, UCL, London, UK
| | - Francesmary Modugno
- Women’s Cancer Research Center. Magee-Women’s Research Institute and Hillman Cancer Center, Pittsburgh, PA, USA
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, Pittsburg, PA, USA
| | - Kirsten B. Moysich
- Division of Cancer Prevention and Control, Roswell Park Comprehensive Cancer Center. Buffalo, NY, USA
| | - Bo Qin
- Cancer Epidemiology and Health Outcomes, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
| | - Susan J. Ramus
- School of Women’s and Children’s Health, Faculty of Medicine, University of NSW Sydney, Sydney, New South Wales, Australia
- The Kinghorn Cancer Centre, Garvan Institute of Medical Research, Sydney, New South Wales, Australia
| | - Harvey A. Risch
- Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT, USA
| | - Mary Anne Rossing
- Program in Epidemiology, Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
- Department of Epidemiology, University of Washington School of Public Health, Seattle, WA, USA
| | | | - Britton Trabert
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, USA
| | - Robert A. Vierkant
- Department of Quantitative Health Sciences, Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN, USA
| | - Stacey J. Winham
- Department of Quantitative Health Sciences, Division of Computational Biology, Mayo Clinic, Rochester, MN, USA
| | - Nicolas Wentzensen
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, USA
| | - Anna H. Wu
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Argyrios Ziogas
- Department of Medicine, University of California Irvine, Irvine, CA, USA
| | - Lilah Khoja
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Kathleen R. Cho
- Department of Pathology, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Karen McLean
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Jean Richardson
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | | | | | | | - Kunle Odunsi
- Department of Gynecological Oncology, Roswell Park Cancer Institute, Buffalo, New York, USA
| | - Brad H. Nelson
- Deeley Research Centre, British Columbia Cancer Agency, Victoria, British Columbia, Canada
| | - James D. Brenton
- Cancer Research UK Cambridge Institute, University of Cambridge, Cambridge, UK
| | - Kathryn L. Terry
- Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, MA, USA
- Obstetrics and Gynecology Epidemiology Center, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Paul D. P. Pharoah
- Centre for Cancer Genetic Epidemiology, Department of Oncology. University of Cambridge, Cambridge, UK
- Centre for Cancer Genetic Epidemiology, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Andrew Berchuck
- Division of Gynecologic Oncology, Duke University School of Medicine, Durham, NC, USA
| | - Gillian E. Hanley
- University of British Columbia Faculty of Medicine, Department of Obstetrics & Gynecology, Vancouver, Canada
| | - Penelope M. Webb
- Department of Population Health, QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
| | - Malcolm C. Pike
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Celeste Leigh Pearce
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI, USA
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11
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Morrisson MJ, Bi F, Yang K, Cady SL, Hartwich TMP, Cerchia AP, Li Z, Kim J, Irwin ML, Yang-Hartwich Y. Effect of exercise on peritoneal microenvironment and progression of ovarian cancer. Am J Cancer Res 2021; 11:5045-5062. [PMID: 34765311 PMCID: PMC8569339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 06/12/2021] [Indexed: 06/13/2023] Open
Abstract
Ovarian cancer is one of the deadliest gynecological malignancies and lacks treatments that do not significantly impact patient health-related quality of life. Exercise has been associated with reduced cancer risk and improved clinical outcomes; however the underlying molecular mechanisms are unknown. In this study, we utilized a treadmill-running exercise model to investigate the effects of exercise on high-grade serous ovarian carcinoma (HGSOC) progression and chemotherapy outcomes. We found that treadmill-running suppressed peritoneal colonization of tumors in a syngeneic mouse ovarian cancer model. Acute exercise stimulated the production of CCL2 and IL-15 in the peritoneal microenvironment while downregulating CCL22, VEGF, and CCL12. Using a co-culture model, we demonstrated the role of CCL2 in mediating the activity of peritoneal cells to inhibit cancer cell viability. We showed that the activation of M1 macrophages may contribute to the exercise-induced changes in the peritoneal microenvironment. We identified that chronic exercise modulates gene expression of intraperitoneal fat tissues related to lipid formation, thermogenesis, browning, and inflammation, which can contribute to inhibiting the colonization of metastatic ovarian cancer. Treadmill running also lowered blood urea nitrogen levels and reduced incidence of neutropenia and thrombocytopenia during chemotherapy in a mouse model, suggesting the potential beneficial effects of exercise in improving chemotherapy outcomes. Our data provided new insights into the acute and chronic effects of physical activity on ovarian cancer at the molecular and in vivo levels.
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Affiliation(s)
- Madeline J Morrisson
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of MedicineNew Haven, CT 06510, USA
| | - Fangfang Bi
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of MedicineNew Haven, CT 06510, USA
- Sheng Jing Hospital of China Medical UniversityShenyang 110004, Liaoning, China
| | - Kevin Yang
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of MedicineNew Haven, CT 06510, USA
| | - Sarah L Cady
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of MedicineNew Haven, CT 06510, USA
| | - Tobias MP Hartwich
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of MedicineNew Haven, CT 06510, USA
| | - Alexandra P Cerchia
- Department of Biology and Environmental Science, University of New HavenWest Haven, CT 06516, USA
| | - Zhigui Li
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of MedicineNew Haven, CT 06510, USA
| | - Jaeyeon Kim
- Department of Biochemistry and Molecular Biology, Indiana University School of MedicineIndianapolis, IN 46202, USA
- Melvin & Bren Simon Cancer Center, Indiana University School of MedicineIndianapolis, IN 46202, USA
| | - Melinda L Irwin
- Yale School of Public HealthNew Haven, CT 06510, USA
- Yale Cancer CenterNew Haven, CT 06510, USA
| | - Yang Yang-Hartwich
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of MedicineNew Haven, CT 06510, USA
- Yale Cancer CenterNew Haven, CT 06510, USA
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12
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Cannioto R. Investigating Contributions of Physical Inactivity and Obesity to Racial Disparities in Cancer Risk and Mortality Warrants More Consideration. J Natl Cancer Inst 2021; 113:647-649. [PMID: 33252653 PMCID: PMC8168126 DOI: 10.1093/jnci/djaa189] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 11/13/2020] [Indexed: 12/26/2022] Open
Affiliation(s)
- Rikki Cannioto
- Department of Cancer Prevention and Control, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
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13
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Wang T, Townsend MK, Eliassen AH, Terry KL, Song M, Irwin ML, Tworoger SS. Prediagnosis and postdiagnosis leisure time physical activity and survival following diagnosis with ovarian cancer. Int J Cancer 2021; 149:1067-1075. [PMID: 33963766 DOI: 10.1002/ijc.33676] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 04/16/2021] [Accepted: 05/05/2021] [Indexed: 12/23/2022]
Abstract
Little is known about the influence of prediagnosis and postdiagnosis physical activity on ovarian cancer survival. We investigated this association in two large cohorts, the Nurses' Health Study (NHS) and NHSII. Analyses included 1461 women with confirmed invasive, epithelial ovarian cancer and data on physical activity. Cox regression models were used to estimate hazard ratios (HR) and 95% confidence intervals (CI) for ovarian cancer-specific mortality. Ovarian cancer-specific mortality was not associated with physical activity reported 1-8 years before diagnosis overall (≥7.5 vs <1.5 MET-hours/week, HR = 0.96), for high-grade serous/ poorly differentiated tumors, or non-serous/ low-grade serous tumors (P-heterogeneity = .45). An inverse association was observed for activity 1-4 years after diagnosis (≥7.5 vs <1.5 MET-hours/week, HR = 0.67, 95%CI: 0.48-0.94), with similar results by histotype (P-heterogeneity = .53). Women who decreased their activity from ≥7.5 MET-hours/week 1-8 years before diagnosis to <7.5 MET-hours/week 1-4 years after diagnosis, compared to those with <7.5 MET-hours/week across periods, had a 49% increased risk of death (HR = 1.49, 95%CI: 1.07-2.08). Physical activity after, but not before, ovarian cancer diagnosis was associated with better prognosis.
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Affiliation(s)
- Tianyi Wang
- Department of Cancer Epidemiology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Mary K Townsend
- Department of Cancer Epidemiology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - A Heather Eliassen
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA.,Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Kathryn L Terry
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA.,Obstetrics and Gynecology Epidemiology Center, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Mingyang Song
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA.,Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA.,Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Melinda L Irwin
- Department of Chronic Disease Epidemiology, Yale University School of Public Health, New Haven, Connecticut, USA
| | - Shelley S Tworoger
- Department of Cancer Epidemiology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA.,Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
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14
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Buras AL, Hathaway CA, Wang T, Townsend MK, Tworoger SS. The association of resistance training with risk of ovarian cancer. Cancer Med 2021; 10:2489-2495. [PMID: 33704932 PMCID: PMC7982607 DOI: 10.1002/cam4.3804] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 02/03/2021] [Accepted: 02/08/2021] [Indexed: 01/24/2023] Open
Abstract
Background Increasing evidence, including multiple putative inflammatory risk factors (e.g., c‐reactive protein, and adiposity), supports that inflammation plays an important role in ovarian carcinogenesis. Resistance training (RT) is associated with lower levels of circulating inflammatory markers, independent of physical activity. Methods We evaluated the relationship between RT and risk of ovarian cancer accounting for other physical activity (e.g., walking) in two large prospective cohorts, the Nurses’ Health Study (NHS) and NHSII. Key Results In total, analyses included 42,005 NHS participants (2000–2016) and 67,289 NHSII participants (2001–2017) with RT assessed every 4 years. Multivariable Cox proportional hazards models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) of RT with ovarian cancer risk overall and by tumor subtype, adjusting for known and putative ovarian cancer risk factors. We identified a total of 609 cases over 1,748,884 person‐years. No association was observed with overall ovarian cancer risk (RT ≥60 vs 0 min/wk, HR = 0.95, 95%CI: 0.74–1.22) or by histotype (comparable HR = 0.86 and 0.98 for type I and II tumors, respectively). Results did not differ by body mass index (Pinteraction = 0.97), or other physical activity (Pinteraction = 0.31). Conclusions & Inferences We observed no evidence that moderate levels of RT were associated with risk of ovarian cancer. Further investigations are required to confirm these findings.
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Affiliation(s)
- Andrea L Buras
- Department of Gynecologic Oncology, Moffitt Cancer Center, Tampa, FL, USA.,Department of Obstetrics & Gynecology, University of South Florida, Tampa, FL, USA
| | | | - Tianyi Wang
- Department of Cancer Epidemiology, Moffitt Cancer Center, Tampa, FL, USA
| | - Mary K Townsend
- Department of Cancer Epidemiology, Moffitt Cancer Center, Tampa, FL, USA
| | - Shelley S Tworoger
- Department of Cancer Epidemiology, Moffitt Cancer Center, Tampa, FL, USA.,Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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15
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Biller VS, Leitzmann MF, Sedlmeier AM, Berger FF, Ortmann O, Jochem C. Sedentary behaviour in relation to ovarian cancer risk: a systematic review and meta-analysis. Eur J Epidemiol 2021; 36:769-780. [PMID: 33492550 PMCID: PMC8417015 DOI: 10.1007/s10654-020-00712-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 12/15/2020] [Indexed: 01/02/2023]
Abstract
Sedentary behaviour is an emerging risk factor for several site-specific cancers. Ovarian cancers are often detected at late disease stages and the role of sedentary behaviour as a modifiable risk factor potentially contributing to ovarian cancer risk has not been extensively examined. We systematically searched relevant databases from inception to February 2020 for eligible publications dealing with sedentary behaviour in relation to ovarian cancer risk. We conducted a systematic review and meta-analysis, calculating summary relative risks (RR) and 95% confidence intervals (CI) using a random-effects model. We calculated the E-Value, a sensitivity analysis for unmeasured confounding. We tested for publication bias and heterogeneity. Seven studies (three prospective cohort studies and four case–control studies) including 2060 ovarian cancer cases were analysed. Comparing highest versus lowest levels of sedentary behaviour, the data indicated a statistically significant increase in the risk of ovarian cancer in relation to prolonged sitting time (RR = 1.29, 95% CI = 1.07–1.57). Sub-analyses of prospective cohort studies (RR = 1.33, 95% CI = 0.92–1.93) and case–control studies (RR = 1.28, 95% CI = 0.98–1.68) showed statistically non-significant results. Sensitivity analysis showed that an unmeasured confounder would need to be related to sedentary behaviour and ovarian cancer with a RR of 1.90 to fully explain away the observed RR of 1.29. Our analyses showed a statistically significant positive association between sedentary behaviour and ovarian cancer risk.
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Affiliation(s)
- Veronika S Biller
- Department of Epidemiology and Preventive Medicine, University of Regensburg, Regensburg, Germany.
| | - Michael F Leitzmann
- Department of Epidemiology and Preventive Medicine, University of Regensburg, Regensburg, Germany
| | - Anja M Sedlmeier
- Department of Epidemiology and Preventive Medicine, University of Regensburg, Regensburg, Germany
| | - Felix F Berger
- Department of Epidemiology and Preventive Medicine, University of Regensburg, Regensburg, Germany
| | - Olaf Ortmann
- Department of Gynaecology and Obstetrics, University of Regensburg, Regensburg, Germany
| | - Carmen Jochem
- Department of Epidemiology and Preventive Medicine, University of Regensburg, Regensburg, Germany
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16
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Wei C, Liu X, Wang Q, Li Q, Xie M. Identification of Hypoxia Signature to Assess the Tumor Immune Microenvironment and Predict Prognosis in Patients with Ovarian Cancer. Int J Endocrinol 2021; 2021:4156187. [PMID: 34950205 PMCID: PMC8692015 DOI: 10.1155/2021/4156187] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 11/19/2021] [Accepted: 11/25/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The 5-year overall survival rate of ovarian cancer (OC) patients is less than 40%. Hypoxia promotes the proliferation of OC cells and leads to the decline of cell immunity. It is crucial to find potential predictors or risk model related to OC prognosis. This study aimed at establishing the hypoxia-associated gene signature to assess tumor immune microenvironment and predicting the prognosis of OC. METHODS The gene expression data of 378 OC patients and 370 OC patients were downloaded from datasets. The hypoxia risk model was constructed to reflect the immune microenvironment in OC and predict prognosis. RESULTS 8 genes (AKAP12, ALDOC, ANGPTL4, CITED2, ISG20, PPP1R15A, PRDX5, and TGFBI) were included in the hypoxic gene signature. Patients in the high hypoxia risk group showed worse survival. Hypoxia signature significantly related to clinical features and may serve as an independent prognostic factor for OC patients. 2 types of immune cells, plasmacytoid dendritic cell and regulatory T cell, showed a significant infiltration in the tissues of the high hypoxia risk group patients. Most of the immunosuppressive genes (such as ARG1, CD160, CD244, CXCL12, DNMT1, and HAVCR1) and immune checkpoints (such as CD80, CTLA4, and CD274) were upregulated in the high hypoxia risk group. Gene sets related to the high hypoxia risk group were associated with signaling pathways of cell cycle, MAPK, mTOR, PI3K-Akt, VEGF, and AMPK. CONCLUSION The hypoxia risk model could serve as an independent prognostic indicator and reflect overall immune response intensity in the OC microenvironment.
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Affiliation(s)
- Chunyan Wei
- Department of Gynaecology and Obstetrics, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Xiaoqing Liu
- Department of Gynaecology and Obstetrics, Maternal and Child Health Hospital of Shangzhou District, Shangluo, Shanxi Province, China
| | - Qin Wang
- Department of Gynaecology and Obstetrics, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Qipei Li
- Department of Gynaecology and Obstetrics, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Min Xie
- Department of Gynaecology and Obstetrics, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
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17
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Demand for integrative medicine among women with breast and gynecological cancer: a multicenter cross-sectional study in Southern and Northern Germany. Arch Gynecol Obstet 2020; 303:1315-1330. [PMID: 33263787 PMCID: PMC8053147 DOI: 10.1007/s00404-020-05880-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 11/04/2020] [Indexed: 02/01/2023]
Abstract
Purpose The aim of this multicenter cross-sectional study was to analyze a cohort of breast (BC) and gynecological cancer (GC) patients regarding their interest in, perception of and demand for integrative therapeutic health approaches. Methods BC and GC patients were surveyed at their first integrative clinic visit using validated standardized questionnaires. Treatment goals and potential differences between the two groups were evaluated. Results 340 patients (272 BC, 68 GC) participated in the study. The overall interest in IM was 95.3% and correlated with older age, recent chemotherapy, and higher education. A total of 89.4% were using integrative methods at the time of enrolment, primarily exercise therapy (57.5%), and vitamin supplementation (51.4%). The major short-term goal of the BC patients was a side-effects reduction of conventional therapy (70.4%); the major long-term goal was the delay of a potential tumor progression (69.3%). In the GC group, major short-term and long-term goals were slowing tumor progression (73.1% and 79.1%) and prolonging survival (70.1% and 80.6%). GC patients were significantly more impaired by the side-effects of conventional treatment than BC patients [pain (p = 0.006), obstipation (< 0.005)]. Conclusion Our data demonstrate a high overall interest in and use of IM in BC and GC patients. This supports the need for specialized IM counseling and the implementation of integrative treatments into conventional oncological treatment regimes in both patient groups. Primary tumor site, cancer diagnosis, treatment phase, and side effects had a relevant impact on the demand for IM in our study population.
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18
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Hansen JM, Nagle CM, Ibiebele TI, Grant PT, Obermair A, Friedlander ML, DeFazio A, Webb PM. A healthy lifestyle and survival among women with ovarian cancer. Int J Cancer 2020; 147:3361-3369. [PMID: 32542708 DOI: 10.1002/ijc.33155] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 05/21/2020] [Accepted: 05/25/2020] [Indexed: 12/22/2022]
Abstract
Ovarian cancer has a poor survival rate and, understandably, women often want to know whether there is anything they can do to improve their prognosis. Our goal was to investigate the association between a healthy lifestyle prediagnosis and postdiagnosis and survival in a cohort of Australian women with invasive epithelial ovarian cancer. We calculated a healthy lifestyle index (HLI) based on women's self-reported smoking status, height, weight, physical activity, diet and alcohol consumption before diagnosis (n = 678) and after completing primary treatment (n = 512). Clinical data and vital status for each woman were ascertained through medical records. Cox proportional hazards regression was conducted to calculate hazard ratios (HR) and 95% confidence interval (CI) for all-cause mortality. There was a suggestive association between a more healthy lifestyle before diagnosis and better survival (HR 0.79, 95% CI: 0.59-1.04), however, the association was stronger for lifestyle after diagnosis, with women in the highest tertile having significantly better survival than women in the lowest tertile (HR 0.61, 95% CI: 0.40-0.93; P-trend = .02). Current smoking, particularly postdiagnosis, was associated with higher mortality (HR 1.68, 95% CI: 1.17-2.42; HR 2.82, 95% CI: 1.29-6.14, for prediagnosis and postdiagnosis smoking, respectively), but women who quit after diagnosis had survival outcomes similar to nonsmokers (HR 0.99, 95% CI: 0.57-1.72). Higher physical activity after diagnosis was associated with better survival (HR 0.60, 95% CI: 0.39-0.92; P-trend = .02). A healthy lifestyle after diagnosis, in particular not smoking and being physically active, may help women with ovarian cancer improve their prognosis.
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Affiliation(s)
- Jessy M Hansen
- Gynaecological Cancers Group, QIMR Berghofer Medical Research Institute, Brisbane, Australia.,School of Public Health, University of Queensland, Brisbane, Australia
| | - Christina M Nagle
- Gynaecological Cancers Group, QIMR Berghofer Medical Research Institute, Brisbane, Australia
| | - Torukiri I Ibiebele
- Gynaecological Cancers Group, QIMR Berghofer Medical Research Institute, Brisbane, Australia
| | - Peter T Grant
- Gynaecological Oncology Unit, Mercy Hospital for Women, Melbourne, Australia
| | - Andreas Obermair
- Queensland Centre for Gynaecological Cancer, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Michael L Friedlander
- Prince of Wales Clinical School, University of New South Wales and Department of Medical Oncology, Prince of Wales Hospital, Sydney, Australia
| | - Anna DeFazio
- Department of Gynaecological Oncology, Westmead Hospital, Sydney, Australia.,The Westmead Institute for Medical Research, The University of Sydney, Sydney, Australia
| | - Penelope M Webb
- Gynaecological Cancers Group, QIMR Berghofer Medical Research Institute, Brisbane, Australia.,School of Public Health, University of Queensland, Brisbane, Australia
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- Gynaecological Cancers Group, QIMR Berghofer Medical Research Institute, Brisbane, Australia
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19
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Jones TL, Sandler CX, Spence RR, Hayes SC. Physical activity and exercise in women with ovarian cancer: A systematic review. Gynecol Oncol 2020; 158:803-811. [PMID: 32616402 DOI: 10.1016/j.ygyno.2020.06.485] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 06/10/2020] [Indexed: 01/17/2023]
Abstract
OBJECTIVE A consistent body of evidence supports participating in physical activity (PA) post-cancer diagnosis as beneficial to function, quality-of-life and potentially survival. However, diagnosis of late stage disease, poor prognosis, receipt of high doses of adjuvant therapy and presence of severe acute and persistent treatment-related side-effects may alter how these findings translate to women with ovarian cancer. Therefore, the objectives of this review were to (I) describe PA levels post-diagnosis of ovarian cancer, (II) explore the relationship between PA levels and health outcomes, and (III) evaluate the effect of exercise interventions for women with ovarian cancer. METHODS PubMed, EMBASE, Scopus and CINAHL were systematically searched to December 31, 2019. Two independent reviewers assessed articles for eligibility. Studies were eligible if they evaluated the relationship between PA levels or an exercise intervention and health outcomes following ovarian cancer. Methodological quality was assessed by two independent reviewers using the Joanna Briggs Institute Critical Appraisal Tools. Descriptive statistics were used to collate relevant data. RESULTS 34 articles were eligible for inclusion. Results demonstrated that most women decrease PA from pre- to post-diagnosis and remain insufficiently active following diagnosis. Higher levels of PA were associated with higher health-related quality-of-life (HRQOL), and lower levels of anxiety and depression. Exercise appears safe and feasible during and following treatment and leads to improvements in HRQOL, fatigue and additional physical and psychological outcomes. CONCLUSIONS Findings suggest that PA is relevant to health outcomes for women with ovarian cancer. Interventions that aid women to stay or become sufficiently active, including through exercise interventions during or following treatment have potential to improve the lives of those with ovarian cancer. Future work evaluating targeted interventions that can accommodate disease-specific challenges is now required to ensure scientific findings can translate into improved ovarian cancer care.
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Affiliation(s)
- Tamara L Jones
- Institute of Health and Biomedical Innovation, Queensland University of Technology, 60 Musk Avenue, Kelvin Grove, QLD 4059, Australia; School of Public Health and Social Work, Queensland University of Technology, 60 Musk Avenue, Kelvin Grove, QLD 4059, Australia.
| | - Carolina X Sandler
- Institute of Health and Biomedical Innovation, Queensland University of Technology, 60 Musk Avenue, Kelvin Grove, QLD 4059, Australia; School of Exercise and Nutrition Science, Queensland University of Technology, 60 Musk Avenue, Kelvin Grove, QLD 4059, Australia
| | - Rosalind R Spence
- Menzies Health Institute Queensland, Griffith University, G40 Griffith Health Centre, Level 8.86, Gold Coast campus, QLD 4222, Australia; Institute of Health and Biomedical Innovation, Queensland University of Technology, 60 Musk Avenue, Kelvin Grove, QLD 4059, Australia
| | - Sandra C Hayes
- Institute of Health and Biomedical Innovation, Queensland University of Technology, 60 Musk Avenue, Kelvin Grove, QLD 4059, Australia; Menzies Health Institute Queensland, Griffith University, G40 Griffith Health Centre, Level 8.86, Gold Coast campus, QLD 4222, Australia
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20
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Pratapwar M, Stenzel AE, Joseph JM, Fountzilas C, Etter JL, Mongiovi JM, Cannioto R, Moysich KB. Physical Inactivity and Pancreatic Cancer Mortality. J Gastrointest Cancer 2020; 51:1088-1093. [PMID: 32524304 DOI: 10.1007/s12029-020-00441-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine the association between pre-diagnostic recreational physical inactivity (RPI) and pancreatic cancer (PC) mortality. METHODS This analysis included 107 patients seen at Roswell Park Comprehensive Cancer Center diagnosed with PC between 1989 and 1998. Cox proportional hazards models were used to determine hazard ratios (HR) and 95% confidence intervals (CI) for PC mortality associated with self-reported pre-diagnostic RPI. Models were adjusted for known prognostic factors, including age, sex, stage at diagnosis, smoking status, and body mass index (BMI). Results were also stratified by sex, BMI, smoking status, histology, and treatment status. RESULTS We observed a significant association between RPI and PC mortality in all patients (HR = 1.72, 95% CI = 1.06-2.79), as well as among overweight or obese patients (HR = 2.74, 95% 95% CI = 1.42-5.29), females (HR = 2.63; 95% CI, 1.08-6.39), and non-smokers (HR = 1.72; 95% CI, 1.02-2.89). CONCLUSION These results suggest that RPI prior to PC diagnosis is associated with a higher risk of death. Future studies with larger sample sizes are needed to explore whether this association varies across tumor histology.
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Affiliation(s)
- Megha Pratapwar
- Summer Research Experience Program in Cancer Science, Williamsville East High School, East Amherst, Buffalo, NY, USA
| | - Ashley E Stenzel
- Department of Cancer Prevention and Control, Roswell Park Comprehensive Cancer Center, Elm & Carlton St, Buffalo, NY, USA
| | - Janine M Joseph
- Department of Cancer Prevention and Control, Roswell Park Comprehensive Cancer Center, Elm & Carlton St, Buffalo, NY, USA
| | - Christos Fountzilas
- Department of Gastrointestinal Medical Oncology, Roswell Park Comprehensive Cancer Center, Elm & Carlton St, Buffalo, NY, USA
| | - John Lewis Etter
- Department of Cancer Prevention and Control, Roswell Park Comprehensive Cancer Center, Elm & Carlton St, Buffalo, NY, USA
| | - Jennifer M Mongiovi
- Department of Cancer Prevention and Control, Roswell Park Comprehensive Cancer Center, Elm & Carlton St, Buffalo, NY, USA
| | - Rikki Cannioto
- Department of Cancer Prevention and Control, Roswell Park Comprehensive Cancer Center, Elm & Carlton St, Buffalo, NY, USA
| | - Kirsten B Moysich
- Department of Cancer Prevention and Control, Roswell Park Comprehensive Cancer Center, Elm & Carlton St, Buffalo, NY, USA.
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21
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Fried J, Etter JL, Stenzel AE, Joseph JM, Cannioto R, Danziger IR, Moysich KB. Physical inactivity and head and neck cancer mortality. Head Neck 2020; 42:2516-2523. [PMID: 32478442 DOI: 10.1002/hed.26283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 04/03/2020] [Accepted: 05/12/2020] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND This study was performed to examine the association between adulthood recreational physical inactivity (PIA) and mortality among patients with cancers of the head and neck. METHODS Patients with head and neck cancer at Roswell Park between years 1990 to 1998 were included (N = 305). Multivariable Cox proportional hazard ratios (HR) with corresponding 95% confidence intervals (CI) were used to analyze the association between PIA and risk of dying. RESULTS There was a 1.40-fold increase in risk of dying among PIA patients, when compared to active patients with head and neck cancers (HR = 1.40, CI: 1.03-1.91). This was observed greater in PIA women (HR = 2.40, CI: 1.28-4.52), patients who were overweight/obese (HR = 1.76, CI: 1.09-2.85), patients with pharynx as the primary site (HR = 1.85, CI: 1.01-3.38), and patients with distant metastasis (HR = 5.19, CI: 1.37-19.65). CONCLUSION Physically inactive patients with head and neck cancers are at significantly greater risk of dying when compared to patients who are active.
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Affiliation(s)
- Jacob Fried
- Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - John Lewis Etter
- Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA.,Department of Cancer Prevention and Control, Roswell Park Comprehensive Cancer, Buffalo, New York, USA
| | - Ashley E Stenzel
- Department of Cancer Prevention and Control, Roswell Park Comprehensive Cancer, Buffalo, New York, USA
| | - Janine M Joseph
- Department of Cancer Prevention and Control, Roswell Park Comprehensive Cancer, Buffalo, New York, USA
| | - Rikki Cannioto
- Department of Cancer Prevention and Control, Roswell Park Comprehensive Cancer, Buffalo, New York, USA
| | - Iris R Danziger
- Department of Otolaryngology, Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Kirsten B Moysich
- Department of Cancer Prevention and Control, Roswell Park Comprehensive Cancer, Buffalo, New York, USA
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22
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Lindgren A, Dunberger G, Steineck G, Bergmark K, Enblom A. Identifying female pelvic cancer survivors with low levels of physical activity after radiotherapy: women with fecal and urinary leakage need additional support. Support Care Cancer 2019; 28:2669-2681. [PMID: 31641868 PMCID: PMC7181502 DOI: 10.1007/s00520-019-05033-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 08/08/2019] [Indexed: 12/17/2022]
Abstract
Objective To investigate the frequency of physical activity among female pelvic cancer survivors (i.e., gynecological, rectal, and anal cancer survivors) and to investigate if survivors who practiced physical activity less than once a week differed from survivors practicing physical activity at least once a week with respect to urinary and fecal leakage, clinical and sociodemographic characteristics, quality of life (QoL), and depressed and anxious mood. Methods Female pelvic cancer survivors (n = 578, mean age 64 years) answered a questionnaire 6–48 months after radiotherapy. A multivariable regression model analyzed factors covarying with frequency of physical activity. We compared QoL and depressed and anxious mood between women practicing physical activity at least or less than once a week. Results Of 568 women delivering data, 186 (33%) practiced physical activity less than once a week while 382 (67%) practiced physical activity at least weekly. Women who leaked a large or all volume of stools (p = 0.01), had just elementary school level of education (p < 0.001), smokers (p = 0.049), or had lymphedema without receiving lymphedema treatment (p = 0.030) were more likely to practice physical activity less than weekly (50%, 45%, 45%, and 37%, respectively) compared with other women. Women practicing physical activity at least weekly reported better QoL (p < 0.001) and lower frequency of depressed mood (p = 0.044) compared with the others. Conclusions Female cancer survivors experiencing fecal leakage were less likely to practice weekly physical activity than survivors without leakage. The survivors practicing weekly physical activity experienced better QoL and experienced depressed mood less frequently than the others.
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Affiliation(s)
- Anna Lindgren
- County Council of Östergötland and Department of Medical and Health Sciences, Division of Physiotherapy, Linköping University, SE-58183, Linköping, Sweden.
| | - G Dunberger
- Department of Health Care Sciences, Ersta Sköndal University College, Stockholm, Sweden
| | - G Steineck
- Department of Oncology-Pathology, Division of Clinical Cancer Epidemiology, Karolinska Institute, Stockholm, Sweden.,Department of Clinical Sciences, Division of Clinical Cancer Epidemiology, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - K Bergmark
- Department of Clinical Sciences, Division of Clinical Cancer Epidemiology, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - A Enblom
- County Council of Östergötland, Activity and Health and Division of Coordinated Cancer Evaluation, Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
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23
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Saner FAM, Herschtal A, Nelson BH, deFazio A, Goode EL, Ramus SJ, Pandey A, Beach JA, Fereday S, Berchuck A, Lheureux S, Pearce CL, Pharoah PD, Pike MC, Garsed DW, Bowtell DDL. Going to extremes: determinants of extraordinary response and survival in patients with cancer. Nat Rev Cancer 2019; 19:339-348. [PMID: 31076661 PMCID: PMC7255796 DOI: 10.1038/s41568-019-0145-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Research into factors affecting treatment response or survival in patients with cancer frequently involves cohorts that span the most common range of clinical outcomes, as such patients are most readily available for study. However, attention has turned to highly unusual patients who have exceptionally favourable or atypically poor responses to treatment and/or overall survival, with the expectation that patients at the extremes may provide insights that could ultimately improve the outcome of individuals with more typical disease trajectories. While clinicians can often recount surprising patients whose clinical journey was very unusual, given known clinical characteristics and prognostic indicators, there is a lack of consensus among researchers on how best to define exceptional patients, and little has been proposed for the optimal design of studies to identify factors that dictate unusual outcome. In this Opinion article, we review different approaches to identifying exceptional patients with cancer and possible study designs to investigate extraordinary clinical outcomes. We discuss pitfalls with finding these rare patients, including challenges associated with accrual of patients across different treatment centres and time periods. We describe recent molecular and immunological factors that have been identified as contributing to unusual patient outcome and make recommendations for future studies on these intriguing patients.
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Affiliation(s)
| | - Alan Herschtal
- Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Brad H Nelson
- Deeley Research Centre, British Columbia Cancer Agency, Victoria, British Columbia, Canada
| | - Anna deFazio
- Department of Gynaecological Oncology, Westmead Hospital, Westmead, New South Wales, Australia
- The University of Sydney, Sydney, New South Wales, Australia
- Centre for Cancer Research, The Westmead Institute for Medical Research, Sydney, New South Wales, Australia
| | - Ellen L Goode
- Department of Health Science Research, Division of Epidemiology, Mayo Clinic, Rochester, MN, USA
| | - Susan J Ramus
- School of Women's and Children's Health, University ofNew South Wales, Sydney, New South Wales, Australia
- Garvan Institute of Medical Research, Sydney, New South Wales, Australia
| | - Ahwan Pandey
- Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Jessica A Beach
- Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Sian Fereday
- Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Andrew Berchuck
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, USA
| | - Stephanie Lheureux
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Canada
| | - Celeste Leigh Pearce
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Paul D Pharoah
- Centre for Cancer Genetic Epidemiology, Department of Public Health and Primary Care, University of Cambridge, Strangeways Research Laboratory, Cambridge, UK
- Department of Oncology, Centre for Cancer Genetic Epidemiology, University of Cambridge, Strangeways Research Laboratory, Cambridge, UK
| | - Malcolm C Pike
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Dale W Garsed
- Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Victoria, Australia.
| | - David D L Bowtell
- Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Victoria, Australia.
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24
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Minlikeeva AN, Cannioto R, Jensen A, Kjaer SK, Jordan SJ, Diergaarde B, Szender JB, Odunsi K, Almohanna H, Mayor P, Starbuck K, Zsiros E, Bandera EV, Cramer DW, Doherty JA, DeFazio A, Edwards R, Goode EL, Goodman MT, Høgdall E, Matsuo K, Mizuno M, Nagle CM, Ness RB, Paddock LE, Pearce CL, Risch HA, Rossing MA, Terry KL, Wu AH, Modugno F, Webb PM, Moysich KB. Joint exposure to smoking, excessive weight, and physical inactivity and survival of ovarian cancer patients, evidence from the Ovarian Cancer Association Consortium. Cancer Causes Control 2019; 30:537-547. [PMID: 30905014 PMCID: PMC6614876 DOI: 10.1007/s10552-019-01157-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 03/09/2019] [Indexed: 12/15/2022]
Abstract
PURPOSE Previous epidemiologic studies have shown that smoking, obesity, and physical inactivity are associated with poor survival following a diagnosis of ovarian cancer. Yet, the combined relationship of these unfavorable lifestyle factors on ovarian cancer survival has not been sufficiently investigated. METHODS Using data pooled from 13 studies, we examined the associations between combined exposures to smoking, overweight/obesity weight, and physical inactivity and overall survival (OS) as well as progression-free survival (PFS) among women diagnosed with invasive epithelial ovarian carcinoma (n = 7,022). Using age- and stage-adjusted Cox proportional hazards regression models, we estimated hazard ratios (HRs) and 95% confidence intervals (CIs) associated with joint exposure to these factors. RESULTS Combined exposure to current smoking, overweight/obesity, and physical inactivity prior to diagnosis was associated with a significantly increased risk of mortality compared to women who never smoked, had normal body mass index (BMI), and were physically active (HR = 1.37; 95% CI 1.10-1.70). The association for a joint exposure to these factors exceeded that of each exposure individually. In fact, exposure to both current smoking and overweight/obesity, and current smoking and physical inactivity was also associated with increased risk of death (HR = 1.28; 95% CI 1.08-1.52, and HR = 1.26; 95% CI 1.04-1.54, respectively). The associations were of a similar magnitude when former smoking was assessed in combination with the other exposures and when excessive weight was limited to obesity only. No significant associations were observed between joint exposure to any of these factors and PFS. CONCLUSIONS Joint exposure to smoking, excessive weight, and physical inactivity may negatively impact survival of ovarian cancer patients. These results suggest the importance of examining the combined effect of lifestyle factors on ovarian cancer patients' survival.
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Affiliation(s)
- Albina N Minlikeeva
- Department of Cancer Prevention and Control, Roswell Park Comprehensive Cancer Center, A-352 Carlton House, Roswell Park Comprehensive Cancer Center, Elm and Carlton Streets, Buffalo, NY, 14263, USA
| | - Rikki Cannioto
- Department of Cancer Prevention and Control, Roswell Park Comprehensive Cancer Center, A-352 Carlton House, Roswell Park Comprehensive Cancer Center, Elm and Carlton Streets, Buffalo, NY, 14263, USA
| | - Allan Jensen
- Department of Virus, Lifestyle and Genes, Danish Cancer Society Research Center, Copenhagen, Denmark
| | - Susanne K Kjaer
- Department of Virus, Lifestyle and Genes, Danish Cancer Society Research Center, Copenhagen, Denmark
- Deparment of Gynaecology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Susan J Jordan
- Population Health Department, QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia
- The University of Queensland, School of Public Health, Herston, QLD, Australia
| | - Brenda Diergaarde
- Department of Human Genetics, University of Pittsburgh Graduate School of Public Health, and UPMC Hillman Cancer Center, Pittsburgh, PA, USA
| | | | - Kunle Odunsi
- Department of Surgery, Division of Gynecologic Oncology, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
- Center of Immunotherapy, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Hani Almohanna
- Department of Cancer Prevention and Control, Roswell Park Comprehensive Cancer Center, A-352 Carlton House, Roswell Park Comprehensive Cancer Center, Elm and Carlton Streets, Buffalo, NY, 14263, USA
| | - Paul Mayor
- Department of Surgery, Division of Gynecologic Oncology, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Kirsten Starbuck
- Department of Surgery, Division of Gynecologic Oncology, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Emese Zsiros
- Center of Immunotherapy, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Elisa V Bandera
- Cancer Prevention and Control Program, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
| | - Daniel W Cramer
- Obstetrics and Gynecology Epidemiology Center, Brigham and Women's Hospital, Boston, MA, USA
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Jennifer A Doherty
- Department of Epidemiology, The Geisel School of Medicine, Dartmouth College, Hanover, NH, USA
| | - Anna DeFazio
- Department of Gynecological Oncology, Westmead Hospital and the Westmead Institute for Medical Research, The University of Sydney, Sydney, NSW, Australia
| | - Robert Edwards
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Ovarian Cancer Center of Excellence, Womens Cancer Research Program, Magee-Womens Research Institute and University of Pittsburgh Cancer Institute, Pittsburgh, PA, USA
| | - Ellen L Goode
- Division of Epidemiology, Department of Health Science Research, Mayo Clinic, Rochester, MN, USA
| | - Marc T Goodman
- Cancer Prevention and Control, Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Estrid Høgdall
- Department of Virus, Lifestyle and Genes, Danish Cancer Society Research Center, Copenhagen, Denmark
- Department of Pathology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Keitary Matsuo
- Division of Molecular Medicine and Clinical Epidemiology, Aichi Cancer Center Research Institute, Nagoya, Japan
- Department of Epidemiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Mika Mizuno
- Department of Gynecological Oncology, Aichi Cancer Center Hospital, Nagoya, Aichi, Japan
| | - Christina M Nagle
- Population Health Department, QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia
- The University of Queensland, School of Public Health, Herston, QLD, Australia
| | - Roberta B Ness
- School of Public Health, The University of Texas, Houston, TX, USA
| | - Lisa E Paddock
- New Jersey Department of Health and Senior Services, New Jersey State Cancer Registry, Trenton, NJ, USA
- Rutgers Cancer Institute, New Brunswick, NJ, USA
| | - Celeste L Pearce
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI, USA
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California Norris Comprehensive Cancer Center, Los Angeles, CA, USA
| | - Harvey A Risch
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT, USA
| | - Mary Anne Rossing
- Program in Epidemiology, Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Kathryn L Terry
- Obstetrics and Gynecology Epidemiology Center, Brigham and Women's Hospital, Boston, MA, USA
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Anna H Wu
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California Norris Comprehensive Cancer Center, Los Angeles, CA, USA
| | - Francesmary Modugno
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Ovarian Cancer Center of Excellence, Womens Cancer Research Program, Magee-Womens Research Institute and University of Pittsburgh Cancer Institute, Pittsburgh, PA, USA
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Penelope M Webb
- Population Health Department, QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia
- The University of Queensland, School of Public Health, Herston, QLD, Australia
| | - Kirsten B Moysich
- Department of Cancer Prevention and Control, Roswell Park Comprehensive Cancer Center, A-352 Carlton House, Roswell Park Comprehensive Cancer Center, Elm and Carlton Streets, Buffalo, NY, 14263, USA.
- Department of Immunology, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA.
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25
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Habitual recreational physical activity is associated with significantly improved survival in cancer patients: evidence from the Roswell Park Data Bank and BioRepository. Cancer Causes Control 2019; 30:1-12. [PMID: 30488344 PMCID: PMC9873357 DOI: 10.1007/s10552-018-1101-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Accepted: 11/22/2018] [Indexed: 01/26/2023]
Abstract
PURPOSE The association of recreational physical activity (RPA) with mortality is well established only for breast and colon cancers and few studies have evaluated relationships for exercising before and after diagnosis, across multiple disease sites. We examined the joint associations of pre- and post- diagnosis RPA with mortality in a cohort of 5,807 patients enrolled in the Data Bank and BioRepository at Roswell Park. METHODS Patients were classified into one of four activity categories (habitually active, increased activity after diagnosis, decreased activity after diagnosis, habitually inactive). Cox proportional hazards models were used to estimate the associations of activity status with mortality. RESULTS In comparison to patients who were habitually inactive, habitually active patients experienced a 39% decreased hazard of all-cause mortality (HR = 0.61, 95% CI 0.54-0.69) and a 36% decreased hazard of cancer-specific mortality (HR = 0.64, 95% CI 0.56-0.73). Previously inactive patients who began exercising after diagnosis experienced a 28% decreased hazard of all-cause (HR = 0.72, 95% CI 0.59-0.89) and cancer-specific mortality (HR = 0.72, 95% CI 0.57-0.91) in comparison to patients who remained inactive. Patients engaging in 3-4 sessions/week experienced the greatest survival advantages, but 1-2 sessions/week also yielded significant survival advantages in comparison to inactivity. CONCLUSION Low-to-moderate frequency pre- and post-diagnosis RPA was associated with significantly decreased mortality in patients diagnosed with a variety of malignancies. These observations solidify the clinical and public health importance of the message that some regular activity is better than inactivity, which is particularly encouraging, given that cancer survivors can be overwhelmed by current daily physical activity recommendations.
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Lee J. Physical activity, sitting time, and the risk of ovarian cancer: A brief research report employing a meta-analysis of existing. Health Care Women Int 2018; 40:433-458. [PMID: 30358498 DOI: 10.1080/07399332.2018.1505892] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
We investigated the associations between physical activity, physical inactivity, and ovarian cancer risk and identified the most effective physical activity intensity and amount to reduce ovarian cancer risk. Thirty-four studies were selected for the present meta-analysis. Physical activity helps decrease ovarian cancer risk. Moderate intensity and low amount of physical activity showed the greatest reduction of ovarian cancer risk and prolonged sitting time had the worst ovarian cancer risk. At least 2 h of moderate physical activity per week and <3 h of sitting time per day provided a preventive effect to ovarian cancer.
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Affiliation(s)
- Junga Lee
- a Sports Medicine and Science, Graduate School of Physical Education , Kyung Hee University, Global Campus , Republic of Korea
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A Physiological Profile of Ovarian Cancer Survivors to Inform Tailored Exercise Interventions and the Development of Exercise Oncology Guidelines. Int J Gynecol Cancer 2018; 27:1560-1567. [PMID: 29036032 DOI: 10.1097/igc.0000000000001044] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE Physical activity has become increasingly important in supportive cancer care. However, physical activity and exercise guidelines for ovarian cancer survivors remain generic. The aim of this narrative review is to summarize existing data regarding the physiological characteristics (treatment-related adverse effects, concurrent comorbidities, body weight and composition, physical fitness and function, and physical activity behavior) of ovarian cancer survivors to further understanding of their cancer-specific physical activity and exercise needs. We also highlight gaps in the current knowledge base. METHODS We undertook a narrative review of current literature on the physiological status of ovarian cancer survivors. We defined physiological status as treatment-related adverse effects, concurrent comorbidities, body weight and composition, physical fitness and function, and physical activity behavior. RESULTS In addition to disease- and treatment-related symptoms and adverse effects, the majority of ovarian cancer survivors have comorbidities, which may adversely affect treatment effectiveness and safety, as well as survival. Despite high overweight and obesity rates, a large percentage of women are malnourished at diagnosis, with potentially compromised muscle mass and muscle density. Low muscle density at diagnosis and loss of muscle mass during treatment may be associated with worse survival outcomes. A small number of studies have observed impaired physical function and cardiorespiratory fitness in ovarian cancer survivors. The majority of ovarian cancer survivors are insufficiently active or sedentary. CONCLUSIONS Our review suggests that ovarian cancer survivors could benefit from physical activity and exercise oncology interventions aimed at addressing detrimental changes to physiological status due to disease and treatment. However, current knowledge gaps regarding the physiological characteristics of ovarian cancer survivors throughout the entire survivorship spectrum challenge the development of tailored exercise intervention studies and exercise oncology guidelines.
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Etter JL, Cannioto R, Soh KT, Alquassim E, Almohanna H, Dunbar Z, Joseph JM, Balderman S, Hernandez-Ilizaliturri F, Moysich KB. Lifetime physical inactivity is associated with increased risk for Hodgkin and non-Hodgkin lymphoma: A case-control study. Leuk Res 2018; 69:7-11. [PMID: 29609041 DOI: 10.1016/j.leukres.2018.03.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Revised: 03/23/2018] [Accepted: 03/26/2018] [Indexed: 01/19/2023]
Abstract
BACKGROUND Although physical activity is a well-established risk factor for several cancer types, studies evaluating its association with lymphoma have yielded inconclusive results. In such cases where physical activity is not clearly associated with cancer risk in a dose-dependent manner, investigators have begun examining physical inactivity as an independent exposure of interest. METHODS Associations of self-reported, lifetime physical inactivity with risk of developing Hodgkin lymphoma (HL) and non-Hodgkin lymphoma (NHL) were evaluated in a hospital-based case control study using data from the Patient Epidemiology Data System at Roswell Park Comprehensive Cancer Center. Participants included 87 patients with HL and 236 patients with NHL as well as 348 and 952 cancer-free controls, respectively. Multivariable-adjusted logistic regression models were fit to calculate odds ratios (OR) and 95% confidence intervals (CI) estimating the association between physical inactivity and lymphoma risk. RESULTS We observed significant, positive associations between lifetime recreational physical inactivity and risk of both HL (OR = 1.90, 95% CI: 1.15-3.15) and NHL (OR = 1.35, 95% CI: 1.01-1.82). CONCLUSIONS The current analysis provides evidence for a positive association between physical inactivity and risk of both HL and NHL. These results add to a growing body of research suggesting that lifetime physical inactivity may be an important independent, modifiable behavioral risk factor for cancer.
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Affiliation(s)
- John Lewis Etter
- Department of Cancer Prevention and Control, Roswell Park Comprehensive Cancer Center, Buffalo, NY, United States
| | - Rikki Cannioto
- Department of Cancer Prevention and Control, Roswell Park Comprehensive Cancer Center, Buffalo, NY, United States
| | - Kah Teong Soh
- Department of Flow and Image Cytometry, Roswell Park Comprehensive Cancer Center, Buffalo, NY, United States
| | - Emad Alquassim
- Department of Cancer Prevention and Control, Roswell Park Comprehensive Cancer Center, Buffalo, NY, United States
| | - Hani Almohanna
- Department of Cancer Prevention and Control, Roswell Park Comprehensive Cancer Center, Buffalo, NY, United States
| | - Zachary Dunbar
- Department of Health Behavior, Roswell Park Comprehensive Cancer Center, Buffalo, NY, United States
| | - Janine M Joseph
- Department of Cancer Prevention and Control, Roswell Park Comprehensive Cancer Center, Buffalo, NY, United States
| | - Sophia Balderman
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY, United States
| | | | - Kirsten B Moysich
- Department of Cancer Prevention and Control, Roswell Park Comprehensive Cancer Center, Buffalo, NY, United States.
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Cannioto R, Etter JL, LaMonte MJ, Ray AD, Joseph JM, Al Qassim E, Eng KH, Moysich KB. LIFETIME PHYSICAL INACTIVITY IS ASSOCIATED WITH LUNG CANCER RISK AND MORTALITY. Cancer Treat Res Commun 2018; 14:37-45. [PMID: 29632898 DOI: 10.1016/j.ctarc.2018.01.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Investigations of the independent associations of physical inactivity with cancer endpoints have been mounting in the epidemiological literature, in part due to the high prevalence of physical inactivity among cancer patients and to evidence that inactivity associates with carcinogenesis via pathways independent of obesity. Yet, physical inactivity is not currently recognized as a well-established risk or prognostic factor for lung cancer. As such, we examined the associations of lifetime physical inactivity with lung cancer risk and mortality in a hospital-based, case-control study. PRESENTATION OF CASE Materials and Methods: The analyses included data from 660 lung cancer patients and 1335 matched cancer-free controls. Multivariable logistic regression analyses were utilized to assess the association between lifetime physical inactivity and lung cancer risk, and Cox proportional hazards models were utilized to estimate the association between lifetime physical inactivity and mortality among lung cancer cases.Results: We observed a significant positive association between lifetime physical inactivity and lung cancer risk: [Odds ratio (OR)=2.23, 95% confidence interval (CI): 1.77-2.81]; the association remained significant among never smokers (OR=3.00, 95% CI:1.33-6.78) and non-smokers (OR=2.33, 95% CI: 1.79-3.02). We also observed a significant positive association between lifetime physical inactivity and lung cancer mortality [Hazard ratio (HR)=1.40, 95% CI: 1.14-1.71]; the association remained significant in non-smokers (HR=1.51, 95% CI: 1.16-1.95). DISCUSSION/CONCLUSION These data add to the body of evidence suggesting that physical inactivity is an independent risk and prognostic factor for cancer. Additional research utilizing prospectively collected data is needed to substantiate the current findings.
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Affiliation(s)
- Rikki Cannioto
- Department of Cancer Prevention and Control, Roswell Park Comprehensive Cancer Center, Elm and Carlton Streets, Buffalo, New York 14263, United States of America
| | - John Lewis Etter
- Department of Cancer Prevention and Control, Roswell Park Comprehensive Cancer Center, Elm and Carlton Streets, Buffalo, New York 14263, United States of America
| | - Michael J LaMonte
- Department of Epidemiology and Environmental Health, University at Buffalo, 273 Farber Hall, Buffalo, New York 14214, United States of America
| | - Andrew D Ray
- Department of Rehabilitation Science, University at Buffalo, 632 Kimball Tower, Buffalo, New York 14214, United States of America
| | - Janine M Joseph
- Department of Cancer Prevention and Control, Roswell Park Comprehensive Cancer Center, Elm and Carlton Streets, Buffalo, New York 14263, United States of America
| | - Emad Al Qassim
- Department of Cancer Prevention and Control, Roswell Park Comprehensive Cancer Center, Elm and Carlton Streets, Buffalo, New York 14263, United States of America
| | - Kevin H Eng
- Department of Biostatistics, Roswell Park Comprehensive Cancer Center, Elm and Carlton Streets, Buffalo, New York 14263, United States of America
| | - Kirsten B Moysich
- Department of Cancer Prevention and Control, Roswell Park Comprehensive Cancer Center, Elm and Carlton Streets, Buffalo, New York 14263, United States of America
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Abbott SE, Camacho F, Peres LC, Alberg AJ, Bandera EV, Bondy M, Cote ML, Funkhouser E, Moorman PG, Peters ES, Qin B, Schwartz AG, Barnholtz-Sloan J, Terry P, Schildkraut JM. Recreational physical activity and survival in African-American women with ovarian cancer. Cancer Causes Control 2017; 29:77-86. [DOI: 10.1007/s10552-017-0986-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Accepted: 11/18/2017] [Indexed: 11/29/2022]
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Minlikeeva AN, Freudenheim JL, Cannioto RA, Szender JB, Eng KH, Modugno F, Ness RB, LaMonte MJ, Friel G, Segal BH, Odunsi K, Mayor P, Zsiros E, Schmalfeldt B, Klapdor R, Dӧrk T, Hillemanns P, Kelemen LE, Kӧbel M, Steed H, de Fazio A, Jordan SJ, Nagle CM, Risch HA, Rossing MA, Doherty JA, Goodman MT, Edwards R, Matsuo K, Mizuno M, Karlan BY, Kjær SK, Høgdall E, Jensen A, Schildkraut JM, Terry KL, Cramer DW, Bandera EV, Paddock LE, Kiemeney LA, Massuger LF, Kupryjanczyk J, Berchuck A, Chang-Claude J, Diergaarde B, Webb PM, Moysich KB. History of hypertension, heart disease, and diabetes and ovarian cancer patient survival: evidence from the ovarian cancer association consortium. Cancer Causes Control 2017; 28:469-486. [PMID: 28293802 PMCID: PMC5500209 DOI: 10.1007/s10552-017-0867-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Accepted: 02/06/2017] [Indexed: 12/18/2022]
Abstract
PURPOSE Survival following ovarian cancer diagnosis is generally low; understanding factors related to prognosis could be important to optimize treatment. The role of previously diagnosed comorbidities and use of medications for those conditions in relation to prognosis for ovarian cancer patients has not been studied extensively, particularly according to histological subtype. METHODS Using pooled data from fifteen studies participating in the Ovarian Cancer Association Consortium, we examined the associations between history of hypertension, heart disease, diabetes, and medications taken for these conditions and overall survival (OS) and progression-free survival (PFS) among patients diagnosed with invasive epithelial ovarian carcinoma. We used Cox proportional hazards regression models adjusted for age and stage to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) overall and within strata of histological subtypes. RESULTS History of diabetes was associated with increased risk of mortality (n = 7,674; HR = 1.12; 95% CI = 1.01-1.25). No significant mortality associations were observed for hypertension (n = 6,482; HR = 0.95; 95% CI = 0.88-1.02) or heart disease (n = 4,252; HR = 1.05; 95% CI = 0.87-1.27). No association of these comorbidities was found with PFS in the overall study population. However, among patients with endometrioid tumors, hypertension was associated with lower risk of progression (n = 339, HR = 0.54; 95% CI = 0.35-0.84). Comorbidity was not associated with OS or PFS for any of the other histological subtypes. Ever use of beta blockers, oral antidiabetic medications, and insulin was associated with increased mortality, HR = 1.20; 95% CI = 1.03-1.40, HR = 1.28; 95% CI = 1.05-1.55, and HR = 1.63; 95% CI = 1.20-2.20, respectively. Ever use of diuretics was inversely associated with mortality, HR = 0.71; 95% CI = 0.53-0.94. CONCLUSIONS Histories of hypertension, diabetes, and use of diuretics, beta blockers, insulin, and oral antidiabetic medications may influence the survival of ovarian cancer patients. Understanding mechanisms for these observations could provide insight regarding treatment.
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Affiliation(s)
- Albina N Minlikeeva
- Deparment of Cancer Prevention and Control, Roswell Park Cancer Institute, A-352 Carlton House, Elm and Carlton Streets, Buffalo, NY, 14263, USA
| | - Jo L Freudenheim
- Deparment of Epidemiology and Environmental Health, University at Buffalo, Buffalo, NY, USA
| | - Rikki A Cannioto
- Deparment of Cancer Prevention and Control, Roswell Park Cancer Institute, A-352 Carlton House, Elm and Carlton Streets, Buffalo, NY, 14263, USA
| | - J Brian Szender
- Department of Surgery, Division of Gynecologic Oncology, Roswell Park Cancer Institute, Buffalo, NY, USA
| | - Kevin H Eng
- Department of Biostatistics and Bioinformatics, Roswell Park Cancer Institute, Buffalo, NY, USA
| | - Francesmary Modugno
- Department of Epidemiology, University of Pittsburgh, and University of Pittsburgh Cancer Institute, Pittsburgh, PA, USA
- Ovarian Cancer Center of Excellence, Womens Cancer Research Program, Magee-Womens Research Institute and University of Pittsburgh Cancer Institute, Pittsburgh, PA, USA
- Department of Obstetrics, Gynecology and Reproductive Sciences and Department of Epidemiology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Roberta B Ness
- The University of Texas, School of Public Health, Houston, TX, USA
| | - Michael J LaMonte
- Deparment of Epidemiology and Environmental Health, University at Buffalo, Buffalo, NY, USA
| | - Grace Friel
- Deparment of Cancer Prevention and Control, Roswell Park Cancer Institute, A-352 Carlton House, Elm and Carlton Streets, Buffalo, NY, 14263, USA
| | - Brahm H Segal
- Department of Medicine, Roswell Park Cancer Institute, Buffalo, NY, USA
- Department of Immunology, Roswell Park Cancer Institute, Buffalo, NY, USA
| | - Kunle Odunsi
- Department of Surgery, Division of Gynecologic Oncology, Roswell Park Cancer Institute, Buffalo, NY, USA
- Center of Immunotherapy, Roswell Park Cancer Institute, Buffalo, NY, USA
| | - Paul Mayor
- Department of Surgery, Division of Gynecologic Oncology, Roswell Park Cancer Institute, Buffalo, NY, USA
| | - Emese Zsiros
- Center of Immunotherapy, Roswell Park Cancer Institute, Buffalo, NY, USA
| | - Barbara Schmalfeldt
- Department of Gynecology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Rüdiger Klapdor
- Department of Obstetrics and Gynecology, Hannover Medical School, Hanover, Lower Saxony, Germany
| | - Thilo Dӧrk
- Department of Obstetrics and Gynecology, Hannover Medical School, Hanover, Lower Saxony, Germany
| | - Peter Hillemanns
- Department of Obstetrics and Gynecology, Hannover Medical School, Hanover, Lower Saxony, Germany
| | - Linda E Kelemen
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Martin Kӧbel
- Department of Pathology and Laboratory Medicine, Foothills Medical Center, University of Calgary, Calgary, AB, Canada
| | - Helen Steed
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Royal Alexandra Hospital, Edmonton, AB, Canada
| | - Anna de Fazio
- Department of Gynecological Oncology, Westmead Hospital and the Westmead Millenium Institute for Medical Research, The University of Sydney, Sydney, NSW, Australia
| | - Susan J Jordan
- Population Health Department, QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia
| | - Christina M Nagle
- Population Health Department, QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia
- School of Public Health, The University of Queensland, Brisbane, QLD, Australia
| | - Harvey A Risch
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT, USA
| | - Mary Anne Rossing
- Program in Epidemiology, Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Jennifer A Doherty
- Department of Epidemiology, The Geisel School of Medicine at Dartmouth Medical, Hanover, NH, USA
| | - Marc T Goodman
- Cancer Prevention and Control, Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Robert Edwards
- Ovarian Cancer Center of Excellence, Womens Cancer Research Program, Magee-Womens Research Institute and University of Pittsburgh Cancer Institute, Pittsburgh, PA, USA
- Department of Obstetrics, Gynecology and Reproductive Sciences and Department of Epidemiology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Keitaro Matsuo
- Division of Molecular Medicine, Aichi Cancer Center Research Institute, Nagoya, Aichi, Japan
| | - Mika Mizuno
- Department of Gynecological Oncology, Aichi Cancer Center Hospital, Nagoya, Aichi, Japan
| | - Beth Y Karlan
- Women's Cancer Program at the Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Susanne K Kjær
- Department of Virus, Lifestyle and Genes, Danish Cancer Society Research Center, Copenhagen, Denmark
- Department of Gynaecology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Estrid Høgdall
- Department of Virus, Lifestyle and Genes, Danish Cancer Society Research Center, Copenhagen, Denmark
- Department of Pathology, Herlev Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Allan Jensen
- Department of Virus, Lifestyle and Genes, Danish Cancer Society Research Center, Copenhagen, Denmark
| | - Joellen M Schildkraut
- Department of Public Health Sciences, School of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Kathryn L Terry
- Obstetrics and Gynecology Epidemiology Center, Brigham and Women's Hospital, Boston, MA, USA
| | - Daniel W Cramer
- Obstetrics and Gynecology Epidemiology Center, Brigham and Women's Hospital, Boston, MA, USA
| | - Elisa V Bandera
- Cancer Prevention and Control Program, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
| | - Lisa E Paddock
- New Jersey Department of Health and Senior Services, Trenton, NJ, USA
- School of Public Health, University of Medicine and Dentistry of New Jersey, Piscataway, NJ, USA
| | - Lambertus A Kiemeney
- Radboud University Medical Center, Radboud Institute for Health Sciences, and Radboud Institute for Molecular Life Sciences, Nijmegen, The Netherlands
| | - Leon F Massuger
- Radboud University Medical Center, Radboud Institute for Health Sciences, and Radboud Institute for Molecular Life Sciences, Nijmegen, The Netherlands
| | - Jolanta Kupryjanczyk
- Department of Pathology and Laboratory Diagnostics, The Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Warsaw, Poland
| | - Andrew Berchuck
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, USA
| | - Jenny Chang-Claude
- Division of Cancer Epidemiology, German Cancer Research Center, Heidelberg, Germany
- University Cancer Center Hamburg (UCCH), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Brenda Diergaarde
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, and University of Pittsburgh Cancer Institute, Pittsburgh, PA, USA
| | - Penelope M Webb
- Population Health Department, QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia
| | - Kirsten B Moysich
- Deparment of Cancer Prevention and Control, Roswell Park Cancer Institute, A-352 Carlton House, Elm and Carlton Streets, Buffalo, NY, 14263, USA.
- Deparment of Epidemiology and Environmental Health, University at Buffalo, Buffalo, NY, USA.
- Department of Immunology, Roswell Park Cancer Institute, Buffalo, NY, USA.
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Cannioto RA, Trabert B, Poole EM, Schildkraut JM. Ovarian cancer epidemiology in the era of collaborative team science. Cancer Causes Control 2017; 28:487-495. [PMID: 28283879 DOI: 10.1007/s10552-017-0862-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 01/29/2017] [Indexed: 01/10/2023]
Abstract
PURPOSE Over the past decade, a number of consortia have formed to further investigate genetic associations, pathogenesis, and epidemiologic risk and prognostic factors for ovarian cancer. Here, we review the benefits that ovarian cancer consortia provide as well as challenges that have arisen. Methods for managing key challenges are also discussed. METHODS We review the structural organization and some of the milestone epidemiologic publications of five consortia dedicated to the study of ovarian cancer, including the Ovarian Cancer Association Consortium (OCAC), the Ovarian Tumor Tissue Analysis (OTTA) Consortium, the Ovarian Cancer Cohort Consortium (OC3), the Collaborative Group on Epidemiological Studies of Ovarian Cancer (The Oxford Collaborative Group), and the Ovarian Cancer in Women of African Ancestry (OCWAA) consortium. RESULTS As ovarian cancer is a rare and heterogeneous disease, consortia have made important contributions in the study of risk factors by improving statistical power beyond what any single study, or even a few studies, would provide. Thus, a major accomplishment of consortial research is enhanced characterization of histotype-specific risk factor associations. In addition, consortia have facilitated impressive synergy between researchers across many institutions, spawning new collaborative research. Importantly, through these efforts, many challenges have been met, including difficulties with data harmonization and analysis, laying a road map for future collaborations. CONCLUSIONS While ovarian cancer consortia have made valuable contributions to the ovarian cancer epidemiological literature over the past decade, additional efforts comprising of new, well-designed case-control studies are needed to further elucidate novel, histotype-specific risk, and prognostic factors which are not consistently available in existing studies.
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Affiliation(s)
- Rikki A Cannioto
- Department of Cancer Prevention and Control, Roswell Park Cancer Institute, Buffalo, NY, USA
| | - Britton Trabert
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, USA
| | - Elizabeth M Poole
- Channing Division of Network Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Joellen M Schildkraut
- Department of Public Health Sciences, School of Medicine, The University of Virginia, Box 800765, Charlottesville, VA, 22903, USA.
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Webb PM, Jordan SJ. Epidemiology of epithelial ovarian cancer. Best Pract Res Clin Obstet Gynaecol 2016; 41:3-14. [PMID: 27743768 DOI: 10.1016/j.bpobgyn.2016.08.006] [Citation(s) in RCA: 559] [Impact Index Per Article: 69.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Accepted: 08/17/2016] [Indexed: 02/08/2023]
Abstract
Globally, ovarian cancer is the seventh most common cancer in women and the eighth most common cause of cancer death, with five-year survival rates below 45%. Although age-standardised rates are stable or falling in most high-income countries, they are rising in many low and middle income countries. Furthermore, with increasing life-expectancy, the number of cases diagnosed each year is increasing. To control ovarian cancer we need to understand the causes. This will allow better prediction of those at greatest risk for whom screening might be appropriate, while identification of potentially modifable causes provides an opportunity for intervention to reduce rates. In this paper we will summarise the current state of knowledge regarding the known and possible causes of epithelial ovarian cancer and discuss some of the main theories of ovarian carcinogenesis. We will also briefly review the relationship between lifestyle and survival after a diagnosis of ovarian cancer.
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Affiliation(s)
- Penelope M Webb
- QIMR Berghofer Medical Research Institute, Locked Bag 2000 Royal Brisbane Hospital, Brisbane, Queensland 4029, Australia; School of Public Health, The University of Queensland, Public Health Building, Corner of Herston Road & Wyndham Street, Herston, Queensland 4006, Australia.
| | - Susan J Jordan
- QIMR Berghofer Medical Research Institute, Locked Bag 2000 Royal Brisbane Hospital, Brisbane, Queensland 4029, Australia; School of Public Health, The University of Queensland, Public Health Building, Corner of Herston Road & Wyndham Street, Herston, Queensland 4006, Australia.
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