Reproductive factors and risks of biliary tract cancers and stones: a population-based study in Shanghai, China

Interplay of Cardiometabolic Syndrome and Biliary Tract Cancer: A Comprehensive Analysis with Gender-Specific Insights

BTC overall incidence is globally increasing. CCA, including its subtypes, is a form of BTC. MetS, obesity, MASLD, and diabetes are all linked to CCA in interconnected ways. The link between obesity and CCA is less well-defined in Eastern countries as compared to Western. Although more research is needed to determine the relationship between MASLD and extrahepatic CCA (eCCA), MASLD may be a concurrent risk factor for intrahepatic CCA, particularly in populations with established or unidentified underlying liver disease. Interestingly, the risk of biliary tract cancer (BTC) seemed to be higher in patients with shorter diabetes durations who were not treated with insulin. Therefore, early detection and prevention of chronic liver disease, as well as additional intervention studies, will undoubtedly be required to determine whether improvements to MetS, weight loss, and diabetes therapy can reduce the risk and progression of BTC. However, further studies are needed to understand how reproductive hormones are involved in causing BTC and to develop consistent treatment for patients. Finally, it is critical to carefully assess the cardiological risk in BTC patients due to their increased intrinsic cardiovascular risk, putting them at risk for thrombotic complications, cardiovascular death, cardiac metastasis, and nonbacterial thrombotic endocarditis. This review aimed to provide an updated summary of the relation between the abovementioned cardio-metabolic conditions and BTC.

Association of female reproductive and hormonal factors with gallbladder cancer risk in Asia: A pooled analysis of the Asia Cohort Consortium

The female predominance of gallbladder cancer (GBC) has led to a hypothesis regarding the hormone-related aetiology of GBC. We aimed to investigate the association between female reproductive factors and GBC risk, considering birth cohorts of Asian women. We conducted a pooled analysis of 331,323 women from 12 cohorts across 4 countries (China, Japan, Korea, and Singapore) in the Asia Cohort Consortium. Cox proportional hazard models were used to estimate the hazard ratios (HRs) and corresponding 95% confidence intervals (CIs) to assess the association between reproductive factors (age at menarche, parity, age at first delivery, breastfeeding, and age at menopause) and GBC risk. We observed that a later age at menarche was associated with an increased risk of GBC (HR 1.4, 95% CI 1.16-1.70 for 17 years and older vs. 13-14 years), especially among the cohort born in 1940 and later (HR 2.5, 95% CI 1.50-4.35). Among the cohort born before 1940, women with a later age at first delivery showed an increased risk of GBC (HR 1.56, 95% CI 1.08-2.24 for 31 years of age and older vs. 20 years of age and younger). Other reproductive factors did not show a clear association with GBC risk. Later ages at menarche and at first delivery were associated with a higher risk of GBC, and these associations varied by birth cohort.

Association between type 2 diabetes, alcohol intake frequency, age at menarche, and gallbladder cancer: a two-sample Mendelian randomization study

Background

Gallbladder cancer (GBC) is a rare malignancy of the digestive tract, characterized by a remarkably poor prognosis. Currently, there is a controversy on the relationship between type 2 diabetes (T2D) and GBC. Additionally, no definitive conclusions were established regarding the causal relationships between alcohol intake frequency (AIF), age at menarche (AAM) and GBC. The objective of this study was to elucidate the causal association between T2D, AIF, AAM, and GBC.

Methods

Single-nucleotide polymorphisms (SNPs) associated with exposures and outcomes were sourced from the Integrative Epidemiology Unit (IEU) Open Genome-Wide Association Study (GWAS) database. Specifically, the data of GBC comprised 907 East Asians (pathological results of all cases were registered into Biobank Japan) and 425,707 SNPs; T2D comprised 655,666 Europeans with 5,030,727 SNPs; AIF comprised 462,346 Europeans and 9,851,867 SNPs; AAM comprised 243,944 Europeans and 9,851,867 SNPs. The measurement of exposure traits is collected uniformly from the UK Biobank (UKB) database and presented in the form of standard deviation (SD) or the logarithmic form of the odds ratio (logOR). We employed a two-sample Mendelian randomization (MR) analysis to discern the causalities between T2D, AIF, AAM, and GBC. Sensitivity analyses were conducted to identify and address potential heterogeneity, horizontal pleiotropy, and outliers.

Results

Our findings indicated that T2D reduced GBC risk [odds ratio (OR) =0.044; 95% confidence interval (CI): 0.004-0.55; P=0.015, inverse variance-weighted (IVW)]. However, no causal relationship was observed between AIF (OR =0.158; 95% CI: 5.33E-05 to 466.84; P=0.65, IVW), AAM (OR =0.19; 95% CI: 0.0003-140.34; P=0.62, IVW), and GBC. Sensitivity analysis revealed no evidence of horizontal pleiotropy, heterogeneity, or outliers, suggesting the robustness and reliability of our conclusions.

Conclusions

T2D emerged as a potentially protective factor against GBC, whereas neither AIF nor AAM demonstrated a causal relationship with GBC risk. Regulation of glucose metabolism may be one of the methods for preventing GBC.

Menopausal hormone therapy increases the risk of gallstones: Health Insurance Database in South Korea (HISK)-based cohort study

OBJECTIVE

To determine whether menopausal hormone therapy (MHT) increases the risk of gallstones and gallbladder cancer.

DESIGN

A retrospective cohort study.

PATIENTS OR OTHER PARTICIPANTS

Data from the Korea National Health Insurance Corporation was obtained between January 1, 2002, and December 31, 2019.

INTERVENTIONS

Participants were divided into MHT and non-MHT groups; the MHT group was analyzed in detail by dividing participants into tibolone, combined estrogen plus progestin by the manufacturer (CEPM) or physician (CEPP), oral estrogen alone, and topical estrogen subgroups.

MAIN OUTCOME MEASURES

The incidence of gallstones and gallbladder cancer was compared between the two groups.

RESULTS

This study enrolled 1,004,034 and 381,711 patients in the non-MHT and the MHT groups, respectively. The incidence of gallstones was 2.6% in the non-MHT group and 3.4%, 2.6%, 3.4%, 3.2%, and 4.4% in the tibolone, CEPM, oral estrogen alone, CEPP, and topical estrogen groups, respectively. Cox proportional hazard analysis revealed that all hormones increased the risk of gallstones ([tibolone] hazard ratio [HR]: 1.347, 95% confidence interval [CI]: 1.309-1.387, [CEPM] HR: 1.146, 95% CI: 1.1-1.19, [oral estrogen alone] HR: 1.241, 95% CI: 1.18-1.305, [CEPP] HR: 1.164, 95% CI: 1.01-1.341, [topical estrogen] HR: 1.602, 95% CI: 1.295-1.983). However, the risk of gallbladder cancer did not change with any hormone therapy.

CONCLUSIONS

All types of MHT including tibolone, increased the risk of gallstones. This risk was the highest with topical estrogen, which may be a result of selection bias due to concerns regarding the adverse effects of CEE and MPA.

Gallbladder disease is associated with the risk of cardiovascular disease among Uyghurs in Xinjiang: a prospective cohort study

BACKGROUND

Gallbladder disease (GBD) can increase the risk of cardiovascular disease (CVD). However, GBD has rarely been reported in the less developed, rural areas of Xinjiang. This study aimed to determine the prevalence of GBD and incidence of CVD in a prospective cohort study in rural Xinjiang. Moreover, the study aimed to explore the association between GBD and CVD within this cohort.

METHODS

The study cohort included 11,444 Uyghur adults in Xinjiang, 3^rd division, from the 51st Mission. Study groups were classified according to whether GBD was present or absent at baseline. The occurrence of CVD was the end event. Demographic, anthropometric, and biochemical data were recorded, and the incidence of CVD in the GBD and non-GBD groups analysed. Cox proportional hazards regression models were used to assess the association between GBD and CVD and factors associated with their incidence. Several subgroup analyses were performed to assess CVD incidence in different subgroups. The interaction between GBD and cardiometabolic risk factors, and subsequent risk of developing CVD, was evaluated.

RESULTS

Prevalence of GBD in the study cohort was 10.29%. After a median follow-up of 4.92 years, the cumulative incidence of CVD in the study cohort was 10.49%, 8.43% in males and 12.65% in females. CVD incidence was higher in the GBD group (34.04% vs. 7.78%, HR = 4.96, 95% CI: 4.40-5.59). After multivariate adjustment, the risk of CVD remained higher in the GBD group (HR = 2.89, 95% CI: 2.54-3.29). Subgroup analyses showed male sex, smoking, alcohol consumption, lack of exercise, and abnormal renal function were all associated with increased risk of CVD. Moreover, the risk of CVD was markedly higher in GBD combined with cardiometabolic risk factors (hypertension, T2DM, dyslipidaemia, overweight, and abdominal obesity), than in cardiometabolic risk factors alone and this was higher in the GBD group than in the non-GBD group regardless of whether cardiometabolic risk factors were combined.

CONCLUSION

GBD is an important independent risk factor for CVD development. Awareness of these associations will raise concerns among clinicians about the risk of cardiovascular disease in patients with GBD.

Descriptive epidemiology of biliary tract cancer incidence and geographic variation in Japan

OBJECTIVE

The epidemiologic features of each biliary tract cancer (BTC) subtype have not been studied and disclosed in detail. The objective of this study was to provide an up-to-date description of the epidemiologic features of BTC by subtypes, especially in terms of the geographic variation of its incidence.

METHODS

We calculated the age-standardized incidence rate (ASR) of each BTC subtype at national and prefectural levels using the data from the national cancer registry in 2016 and 2017. The geographic distribution of each BTC subtype incidence was assessed by calculating the ASR ratio (ASRR) against median ASR at the prefectural level and reflecting them on the Japanese map.

RESULTS

A total of 58 438 people diagnosed with malignant BTC were registered in the national cancer registry in 2016 and 2017 [12 497 for intrahepatic bile duct cancer (IHBDC), 16 568 for gallbladder cancer (GBC), 24 602 for extrahepatic bile duct cancer (EHBDC), 4613 for ampulla of Vater cancer (AVC) and 158 for others]. ASR was higher in men than in women for IHBDC, EHBDC and AVC, and similar between men and women for GBC. The ASR of EHBDC was approximately 2 times higher than those of the other subtypes for men and similar to that of GBC for women. The geographic distribution of ASRR was different among BTC subtypes, with larger variability in EHBDC, which was remarkably higher in the north-eastern region in both men and women.

CONCLUSION

The pattern of the geographic distribution of incidence in each BTC subtype was different, which suggests different etiology among subtypes.

Reproductive factors and gall-bladder cancer, and the effect of common genetic variants on these associations: a case-control study in India

BACKGROUND

In India, as elsewhere, the incidence of gall-bladder cancer (GBC) is substantially higher in women than in men. Yet, the relevance of reproductive factors to GBC remains poorly understood.

METHODS

We used logistic regression adjusted for age, education and area to examine associations between reproductive factors and GBC risk, using 790 cases of histologically confirmed GBC and group-matched 1726 visitor controls. We tested the interaction of these associations by genetic variants known to increase the risk of GBC.

RESULTS

Parity was strongly positively associated with GBC risk: each additional pregnancy was associated with an ∼25% higher risk {odds ratio [OR] 1.26 [95% confidence interval (95% CI) 1.17-1.37]}. After controlling for parity, GBC risk was weakly positively associated with later age of menarche [postmenopausal women, OR 1.11 (95% CI 1.00-1.22) per year], earlier menopause [OR 1.03 (95% CI 1.00-1.06) per year] and shorter reproductive lifespan [OR 1.04 (95% CI 1.01-1.07) per year], but there was little evidence of an association with breastfeeding duration or years since last pregnancy. Risk alleles of single-nucleotide polymorphisms in the ABCB4 and ABCB1 genetic regions had a multiplicative effect on the association with parity, but did not interact with other reproductive factors.

CONCLUSIONS

We observed higher GBC risk with higher parity and shorter reproductive lifespan, suggesting an important role for reproductive and hormonal factors.

Menopausal hormone therapy and risk of biliary tract cancers

BACKGROUND AND AIMS

Gallbladder cancer (GBC) has a female predominance, whereas the other biliary tract cancers (BTCs) have a male predominance, suggesting that sex hormones may be involved in carcinogenesis. We sought to evaluate the association between menopausal hormone therapy (MHT) and the risk of BTC in women.

APPROACH AND RESULTS

This nested case-control study was conducted in the UK Clinical Practice Research Datalink. Cases diagnosed between 1990 and 2017 with incident primary cancers of the gallbladder (GBC), cholangiocarcinoma (CCA), ampulla of Vater (AVC), and mixed type were matched to 5 controls on birth year, diagnosis year, and years in the general practice using incidence density sampling. Conditional logistic regression was used to calculate ORs and 95% CIs for associations between MHT use and BTC type. The sample consisted of 1,682 BTC cases (483 GBC, 870 CCA, 105 AVC, and 224 mixed) and 8,419 matched controls with a mean age of 73 (SD, 11) years. Combined formulations (estrogen-progesterone) were associated with an increased GBC risk (OR, 1.97; 95% CI, 1.08, 3.59). Orally administered MHT was associated with an increased GBC risk (OR, 2.28; 95% CI, 1.24, 4.17). Estrogen-only formulations (OR, 0.59; 95% CI, 0.34, 0.93) and cream or suppository administrations (OR, 0.57; 95% CI, 0.34, 0.95) were associated with decreased CCA risk. The number of prescriptions, dose, duration of use, and time since last use were not associated with GBC or CCA risk. MHT use was not associated with risk of AVC or mixed cancer.

CONCLUSIONS

Combination MHT formulations and oral administrations were associated with increased GBC risk, whereas estrogen-only formulations were associated with a lower CCA risk. MHT formulation and administration should be carefully considered when prescribing.

Global, regional, and national burden of biliary tract cancer from 1990 to 2017 based on the 2017 Global Burden of Disease study

BACKGROUND

Biliary tract cancer (BTC) is a rare malignant neoplasm with poor prognosis. We aimed to report the rates and the trends of biliary tract cancer at the global level from 1990 to 2017 according to gender, age and social-demographic index (SDI).

METHODS

Data on biliary tract cancer between 1990 and 2017 was acquired from the 2017 Global Burden of Disease (GBD) study including the incidence, death and disability adjusted life-years (DALY). We also calculated estimated annual percentage changes (EAPC) to quantificationally describe the trend of incidence, death and DALY over time.

RESULTS

Overall, the number of biliary tract cancer increased from 119,943 in 1990 to 210,878 in 2017. The age-standardized incidence rate (ASIR) decreased continuously in this period with an EAPC of -0.56 (-0.67 to -0.45). The age-standardized death rate (ASDR) declined from 2.79 (95 % CI 2.68 - 3.14) in 1990 to 2.23 (95 % CI 1.99 - 2.38) per 100,000 persons in 2017. In terms of SDI, ASIR and ASDR were increased in low- and low-middle- SDI regions, but decreased in the other three regions, so was the age-standardized DALY rate. The ASR (Age-standardized incidence/mortality/DALY rate) varied across the world, with the highest ASIR and ASDR in Chile, and the lowest ones in Iraq.

CONCLUSION

The ASIR, ASDR and age-standardized DALY rate of biliary tract cancer have decreased at the global level. However, changes in rates vary among different counties and regions, suggesting it is more reasonable to adopt targeted and specific measures to decrease the occurrence of cancer.

Gallstones, Body Mass Index, C-Reactive Protein, and Gallbladder Cancer: Mendelian Randomization Analysis of Chilean and European Genotype Data

BACKGROUND AND AIMS

Gallbladder cancer (GBC) is a neglected disease with substantial geographical variability: Chile shows the highest incidence worldwide, while GBC is relatively rare in Europe. Here, we investigate the causal effects of risk factors considered in current GBC prevention programs as well as C-reactive protein (CRP) level as a marker of chronic inflammation.

APPROACH AND RESULTS

We applied two-sample Mendelian randomization (MR) using publicly available data and our own data from a retrospective Chilean and a prospective European study. Causality was assessed by inverse variance weighted (IVW), MR-Egger regression, and weighted median estimates complemented with sensitivity analyses on potential heterogeneity and pleiotropy, two-step MR, and mediation analysis. We found evidence for a causal effect of gallstone disease on GBC risk in Chileans (P = 9 × 10-5 ) and Europeans (P = 9 × 10-5 ). A genetically elevated body mass index (BMI) increased GBC risk in Chileans (P = 0.03), while higher CRP concentrations increased GBC risk in Europeans (P = 4.1 × 10-6 ). European results suggest causal effects of BMI on gallstone disease (P = 0.008); public Chilean data were not, however, available to enable assessment of the mediation effects among causal GBC risk factors.

CONCLUSIONS

Two risk factors considered in the current Chilean program for GBC prevention are causally linked to GBC risk: gallstones and BMI. For Europeans, BMI showed a causal effect on gallstone risk, which was itself causally linked to GBC risk.

The State of Perplexity During Management of Gall Bladder Malignancy in an Expectant Young Mother

During pregnancy, diagnosed cancer causes a major disturbance in the life of a pregnant woman and her family. The advanced stage of illness requiring systemic treatment inevitably leads the treating practitioner, with two lives at risk, into an ethical dilemma. The unborn child can be affected by the application of cancer medication to the mother as it is exposed to fetotoxic drugs. On the other hand, withholding therapy to allow fetal maturity may make the disease of the mother metastatic. Gall bladder carcinoma is often diagnosed as an unresectable disease (metastatic or locally advanced) due to its nonspecific symptomatology and carries the worst prognosis of any gastrointestinal or hepatobiliary neoplasm. We report a case of locally advanced gall bladder cancer (GBC) diagnosed during late pregnancy wherein the mother opted to continue the pregnancy without any intervention. A review of literature has been done to investigate the role of female hormones in a pregnancy complicating GBC with emphasis on management dilemma and the associated pitfalls.

Associations between reproductive factors and biliary tract cancers in women from the Biliary Tract Cancers Pooling Project

BACKGROUND & AIMS

Gallbladder cancer (GBC) is known to have a female predominance while other biliary tract cancers (BTCs) have a male predominance. However, the role of female reproductive factors in BTC etiology remains unclear.

METHODS

We pooled data from 19 studies of >1.5 million women participating in the Biliary Tract Cancers Pooling Project to examine the associations of parity, age at menarche, reproductive years, and age at menopause with BTC. Associations for age at menarche and reproductive years with BTC were analyzed separately for Asian and non-Asian women. Hazard ratios (HRs) and 95% CIs were estimated using Cox proportional hazards models, stratified by study.

RESULTS

During 21,681,798 person-years of follow-up, 875 cases of GBC, 379 of intrahepatic bile duct cancer (IHBDC), 450 of extrahepatic bile duct cancer (EHBDC), and 261 of ampulla of Vater cancer (AVC) occurred. High parity was associated with risk of GBC (HR ≥5 vs. 0 births 1.72; 95% CI 1.25-2.38). Age at menarche (HR per year increase 1.15; 95% CI 1.06-1.24) was associated with GBC risk in Asian women while reproductive years were associated with GBC risk (HR per 5 years 1.13; 95% CI 1.04-1.22) in non-Asian women. Later age at menarche was associated with IHBDC (HR 1.19; 95% CI 1.09-1.31) and EHBDC (HR 1.11; 95% CI 1.01-1.22) in Asian women only.

CONCLUSION

We observed an increased risk of GBC with increasing parity. Among Asian women, older age at menarche was associated with increased risk for GBC, IHBDC, and EHBDC, while increasing reproductive years was associated with GBC in non-Asian women. These results suggest that sex hormones have distinct effects on cancers across the biliary tract that vary by geography.

LAY SUMMARY

Our findings show that the risk of gallbladder cancer is increased among women who have given birth (especially women with 5 or more children). In women from Asian countries, later age at menarche increases the risk of gallbladder cancer, intrahepatic bile duct cancer and extrahepatic bile duct cancer. We did not see this same association in women from Western countries. Age at menopause was not associated with the risk of any biliary tract cancers.

Gallbladder and extrahepatic bile duct cancers in the Americas: Incidence and mortality patterns and trends

Trends in gallbladder cancer incidence and mortality in populations across the Americas can provide insight into shifting epidemiologic patterns and the current and potential impact of preventative and curative programs. Estimates of gallbladder and extrahepatic bile duct cancer incidence and mortality for the year 2018 were extracted from International Agency for Research on Cancer (IARC) GLOBOCAN database for 185 countries. Recorded registry-based incidence from 13 countries was extracted from IARCs Cancer Incidence in Five Continents series and corresponding national deaths from the WHO mortality database. Among females, the highest estimated incidence for gallbladder and extrahepatic bile duct cancer in the Americas were found in Bolivia (21.0 per 100,000), Chile (11.7) and Peru (6.0). In the US, the highest incidence rates were observed among Hispanics (1.8). In the Chilean population, gallbladder cancer rates declined in both females and males between 1998 and 2012. Rates dropped slightly in Canada, Costa Rica, US Whites and Hispanics in Los Angeles. Gallbladder cancer mortality rates also decreased across the studied countries, although rising trends were observed in Colombia and Canada after 2010. Countries within Southern and Central America tended to have a higher proportion of unspecified biliary tract cancers. In public health terms, the decline in gallbladder cancer incidence and mortality rates is encouraging. However, the slight increase in mortality rates during recent years in Colombia and Canada warrant further attention. Higher proportions of unspecified biliary tract cancers (with correspondingly higher mortality rates) suggest more rigorous pathology procedures may be needed after surgery.

A Metallomic Approach to Assess Associations of Serum Metal Levels With Gallstones and Gallbladder Cancer

BACKGROUND AND AIMS

Exposure to metals may promote the risk for cancers. We evaluated the associations of a broad spectrum of metals with gallbladder cancer (GBC) and gallstones.

APPROACH AND RESULTS

A total of 259 patients with GBC, 701 patients with gallstones, and 851 population-based controls were enrolled in Shanghai, China. A metallome panel was used to simultaneously detect 18 metals in serum through inductively coupled plasma-mass spectrometry. Logistic regression models were used to estimate crude or adjusted odds ratios (OR_adj ) with 95% confidence intervals (CIs) for the association between metal levels and gallbladder disease. Among the 18 metals tested, 12 were significantly associated with GBC and six with gallstones (P_corrected  < 0.002). Boron, lithium, molybdenum, and arsenic levels were associated with GBC compared to gallstones as well as with gallstones compared to population-based controls. Elevated levels of cadmium, chromium, copper, molybdenum, and vanadium were positively associated with GBC versus gallstones; and the OR_adj for the highest tertile (T3) compared to the lowest tertile (T1) ranged from 1.80 to 7.28, with evidence of dose-response trends (P < 0.05). Arsenic, boron, iron, lithium, magnesium, selenium, and sulfur were inversely associated with GBC, with the T3 versus T1 OR_adj ranging from 0.20 to 0.69. Arsenic, boron, calcium, lithium, molybdenum, and phosphorus were negatively associated with gallstones, with the T3 versus T1 OR_adj ranging from 0.50 to 0.75 (P < 0.05).

CONCLUSIONS

Metals were associated with both GBC and gallstones, providing cross-sectional evidence of association across the natural history of disease. Longitudinal studies are needed to evaluate the temporality of metal exposure and gallbladder diseases and to investigate the mechanisms of disease pathogenesis.

Trends of gallbladder cancer incidence, mortality, and diagnostic approach in urban Shanghai between 1973 and 2009

PURPOSE

To describe and interpret secular time trends in gallbladder cancer (GBC) incidence, mortality, and diagnostic approach using 37 years of cancer registry data in urban Shanghai.

METHODS

Data on registration of GBC in urban Shanghai during 1973 and 2009 were collected by the Shanghai Cancer Registry. To describe time trends and to identify specific time points when significant changes occurred, we used joinpoint regression analysis.

RESULTS

The age-standardized rates (ASRs) of incidence increased from 1.1/100,000 (1973-1975) to 2.9/100,000 (2006-2009) in men and from 1.7/100,000 (1973-1975) to 3.9/100,000 (2006-2009) in women. ASRs of incidence increased significantly with estimated annual percent changes (EAPCs) of 2.8% in men and 2.5% in women. The mortality trends increased significantly, with EAPCs of 2.8% in men and 2.5% in women. The increasing incidence and mortality rates were primarily observed in men ⩾60 years of age and in women ⩾70 years of age. Notable downward trends in incidence and mortality were identified among women age 60-69 years over the last decade. The percentage of GBC diagnosed by pathology increased steadily over the years while the percentage of GBC diagnosed by imaging, surgery, and biochemistry sharply increased from 1987 onwards.

CONCLUSIONS

Thirty-seven years of cancer registry data document a tremendous increase in incidence/mortality and a slight decline in incidence/mortality over the last decades for GBC, especially among women, in Shanghai. The development of diagnostic approaches and aging population may play important roles.

Menopausal hormone therapy and biliary tract cancer: a population-based matched cohort study in Sweden

BACKGROUND

This study tested the hypothesis that contemporary menopausal hormonal therapy (MHT) increases the risk of biliary tract cancer. The risk of cancer of the biliary tract (gallbladder and extra-hepatic bile ducts) may be increased following estrogen exposure.

MATERIAL AND METHODS

This was a nationwide population-based matched cohort study in Sweden. Data from the Swedish Prescribed Drug Register identified all women exposed to systemic MHT in 2005-2012. Group-level matching (1:3 ratio) was used to select women unexposed to MHT from the same study base, matched for history of delivery, thrombotic events, hysterectomy, age, smoking- and alcohol related diseases, obesity, and diabetes. Conditional logistic regression was used to calculate odds ratios (OR) and 95% confidence intervals (CI).

RESULTS

Comparing 290,186 women exposed to MHT with 870,165 unexposed, MHT did not increase the OR of biliary tract cancer. The OR of gallbladder cancer was rather decreased in MHT users (OR 0.58, 95% CI 0.43-0.79), but this association became attenuated and statistically non-significant after adjusting for gallstone disease (OR 0.84, 95% CI 0.60-1.15). The OR of extra-hepatic bile duct cancers was 0.83 (95% CI 0.61-1.15). There were no clear differences when the analyses were stratified for estrogen or estrogen/progestogen combinations. MHT increased the risk of gallstone disease (OR 6.95, 95% CI 6.64-7.28).

CONCLUSIONS

Contemporary MHT does not seem to increase the risk of biliary tract cancer. The decreased risk of gallbladder cancer may be explained by the increased use of surgery for symptomatic gallstones in MHT users.

Reproductive factors and gallbladder/bile duct cancer: a population-based cohort study in Japan

Reproductive/menstrual factors may be involved in the etiology of gallbladder cancer (GBC) and bile duct cancer (BDC). However, the results from previous epidemiological studies have been inconsistent. We investigated the association of reproductive/menstrual factors with the risk for GBC and BDC in a population-based prospective cohort study in Japan. Data on reproductive/menstrual factors were collected through a self-administered questionnaire at baseline. The hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated using the Cox proportional hazard model. A total of 55 786 women enrolled between 1990 and 1994 were included in the analysis, and 115 GBC and 113 BDC cases were identified, with 944 861 person-years follow-up until 2010. For GBC, irregular and longer cycles were moderately associated with an increased risk [HR=2.12 (95% CI: 1.30-3.47) and HR=1.76 (95% CI: 1.08-2.89), respectively]. This effect tended to be greater in premenopausal than in postmenopausal women. Furthermore, older age at first pregnancy tended to be associated with an increased risk [HR=1.84 (95% CI: 1.03-3.29), P-trend=0.036], whereas increased duration of fertility tended to be associated with a decreased risk [HR=0.59 (95% CI: 0.35-1.01), P-trend=0.055] of GBC. No clear association with BDC was observed. This finding suggests that women with irregular or longer cycles may have an increased risk for GBC and female hormones may play an important role in the etiology of GBC.

A Study of Alcohol Consumption and Obesity as Main Risk Factor for Symptomatic Gallbladder Stone: a Case-Control Study

Background: Gallbladder stone (GBS) is a common gastrointestinal disease that can progress to severe cholecystitis and is a strong risk factor for gallbladder cancer (GBC). The present study was conducted to evaluate region-specific causes of GBS which was proved as major risk factor for GBC in Jeju Island, Korea. Methods: Age and sex match case-control study was performed among 171 pairs of case and controls. The cases were patients who were diagnosed with GBS, had definite clinical symptoms, and underwent a cholecystectomy in Cheju Halla General Hospital, Jeju, Korea during 2010-2014. The control group included 1:1 age and sex-matched participants without GBS at the Health Promotion Center in the same institute during the same period. We compared the histories of previous chronic diseases (hypertension, diabetes, hyperlipidaemia, vascular occlusive diseases, or parity), alcohol consumption (standard drinks/week [SDW]), smoking habits, body mass index (BMI), and presence of concomitant polypoid lesions of the gallbladder. Results: A dose-dependent positive relationship existed between BMI and the risk of GBS: BMI 23–27.4 kg/m2, OR=2.5, , p=0.24; 27.5–29.9 kg/m2, OR=8.9, p=0.002; ≥30 kg/m2, OR=7.2, p=0.004. A negative correlation existed between alcohol consumption and the risk of GBS: Standard drinks per week (SDW), OR=0.24, p=0.002; 15–29.9 SDW, OR=0.26, p=0.022; ≥30 SDW, OR=0.2, 95% p=0.005. Conclusion: The present results suggest that a higher BMI and less alcohol consumption are associated with a risk of symptomatic GBS.

Exogenous estrogen and the risk of biliary tract cancer - a population-based study in a cohort of Swedish men treated for prostate cancer

BACKGROUND

To assess the role of exogenous estrogen in the etiology of biliary tract cancer, a nationwide population-based cohort study in Sweden was performed.

METHODS

The study included all men in Sweden with prostate cancer diagnosed in 1961-2008. Due to treatment standards, patients diagnosed in 1961-1980 were considered more exposed to estrogen, while those diagnosed in 1981-2008 were regarded less exposed. Standardized incidence ratios (SIRs) with 95% confidence intervals (CIs) were calculated to estimate the risk of biliary tract cancer in cohort members compared to the corresponding Swedish male population.

RESULTS

After 849 307 person-years of follow-up in 203 131 prostate cancer patients, there were 41 incident gallbladder cancers and 36 cancers of the extra-hepatic bile ducts. In overall, there were no apparent differences in the risk of gallbladder cancer or bile duct cancer between patients diagnosed in 1961-1980 and patients diagnosed in 1981-2008. However, in patients diagnosed in 1961-1980, there was a statistically non-significant increased risk of gallbladder cancer (SIR 1.34; 95% CI 0.71-2.29) and extra-hepatic bile duct cancer (SIR 1.20; 95% CI 0.55-2.28) > 5 years of follow-up after the prostate cancer diagnosis. No such association was found for patients diagnosed in 1981-2008. Sensitivity analyses excluding prostate cancer patients exposed to potential confounding factors did not change the SIRs.

CONCLUSIONS

Long exposure to high doses of exogenous estrogen might increase the risk of biliary tract cancer. However, any potential excess risk of bile duct cancer resulted by prolonged exposure to high doses of exogenous estrogen seems to be small.

Incidence of cancer among grand multiparous women in Finland with special focus on non-gynaecological cancers: A population-based cohort study

BACKGROUND

Many studies have previously revealed evidence of an association between grand multiparity (five or more deliveries) and gynaecological cancer. Oestrogen has an impact on cancer formation and the amount of circulating oestrogen is significantly higher during pregnancy. Also the lifestyle of grand multiparous women differs somewhat from the average population. Considering these factors it is plausible that also non-gynaecological cancers are associated with multiparity. The aim of our study was to determine cancer incidence among grand multiparous women, with special attention to non-gynaecological cancers.

MATERIAL AND METHODS

All 102 541 women alive in 1974-2011 and having had at least five deliveries were identified in the Finnish Population Register and followed up for cancer incidence through the Finnish Cancer Registry to the end of 2011. Standardised incidence ratios (SIRs) were defined as ratios between observed and expected numbers of cases, the latter ones based on incidence in the entire Finnish female population.

RESULTS

The overall incidence of non-gynaecological cancers was the same as in the reference population (SIR 0.98, 95% confidence interval 0.90-1.06). The incidence of cancers of the gall-bladder (SIR 1.42, 1.26-1.58), biliary tract (1.19, 1.04-1.35) and kidney (1.22, 1.14-1.31) was increased. There were significantly fewer cases than expected of urinary bladder cancer (SIR 0.70, 0.61-0.78), lung cancer (0.87, 0.81-0.92), colon cancer (0.94, 0.89-0.99) and all types of skin cancers. As a consequence of the decreased incidence of gynaecological cancers (SIR 0.74, 0.71-0.77) and breast cancer (0.60, 0.58-0.61), the SIR for cancer overall was 0.84 (0.83-0.85).

CONCLUSION

The study demonstrated that grand multiparous women have a similar overall risk of non-gynaecological cancers as other women, despite significant differences in some specific forms of cancer.

Reproductive factors and risk of biliary tract cancer in a population-based study

BACKGROUND

The strong female predominance of biliary tract cancer (BTC) may be related to reproductive factors. We aimed to clarify whether parity or age at first birth influence the risk of BTC.

METHODS

This was a population-based, case-control study including Swedish female and male cases of cancer of the gallbladder (GBC), extra hepatic bile ducts (EHCC), or the ampulla of Vater (AVC) between 1960 and 2008. For each case, 10 age- and sex-matched controls were randomly selected. Conditional logistic regression was used to calculate odds ratios (ORs) with 95% confidence intervals (CIs), adjusted for potential confounders.

RESULTS

In total, 1169 cases of GBC, 432 cases of EHCC and 295 cases of AVC were included. Multi- and nulliparous women and men had an increased risk of all tumor locations in the biliary tract compared to uniparous women and men, respectively. Whereas higher age at first birth was associated with a decreased risk of GBC in women, no such association was found in men. There were no clear differences in the risk of EHCC and AVC between women and men.

CONCLUSION

Sex hormones may play a role in the etiology of GBC. The associations between reproductive factors and EHCC and AVC are similar in women and men, which do not support the sex hormone hypothesis.

Parity and risk of death from gallbladder cancer among a cohort of premenopausal parous women in Taiwan

Little epidemiologic research has been done on the etiology of gallbladder cancer (GC). This cohort study was undertaken to examine whether there is an association between parity and risk of death from GC. The study cohort consisted of 1,292,462 women who had a first and singleton childbirth between 1 January 1978 and 31 December 1987. We tracked each woman from the time of their first childbirth to 31 December 2009, and their vital status was ascertained by linking records with the computerized mortality database. Cox proportional hazard regression models were used to estimate the hazard ratios (HR) of death from GC associated with parity. There were 257 GC deaths during 34,980,246 person-years of follow-up. The mortality rate of GC was 0.73 cases per 100,000 person-years. As compared with women who had given birth to only one child, the adjusted HR was 1.20 (95% CI = 0.79–1.83) for women who had two children, 1.47 (95% CI = 0.95–2.29) for women who had three children, and 1.68 (95% CI = 0.99–2.85) for women with four or more births. There was a significant increasing trend in the adjusted HRs for GC with increasing parity. The findings suggested that premenopausal women of higher parity may increase the risk of death from GC.

Prevalence of and risk factors for gallstones in Uighur and Han Chinese

AIM: To perform a single-centre survey of the prevalence of and possible risk factors for gallstones in Uighur and Han Chinese.

METHODS: Complete medical data for 9455 patients were collected from the medical centre of our hospital, and the overall prevalence of gallstones as well as the prevalence in different ethnic groups was studied. The risk factors for gallstones in different ethnic groups were identified in a univariate analysis, and variables with statistical significance were analysed by unconditional multiple logistic regression, to primarily explore the similarities and differences in gallstone risk factors between different ethnic groups.

RESULTS: The prevalence of gallstones was significantly higher in the Uighur population than in the Han population (22.87% vs 11.64%, P < 0.05). Further analysis of risk factors for gallstones based on the different ethnic areas revealed that age was a risk factor for gallstones in both groups; triglycerides, body-mass index (BMI) and high-density lipoprotein were risk factors for gallstones in the Han population, while total cholesterol (TC), gender and fatty liver were risk factors in the Uighur population. The Uighur patients were older than the Han patients, and had higher BMI, TC, low-density lipoprotein, female rate and fatty liver rate, while the incidence of hypertension was lower than that in the Han patients.

CONCLUSION: The prevalence of and risk factors for gallstones differ between the Uighur and Han populations.

Cancer risk in women with 10 or more deliveries

OBJECTIVE

To determine cancer incidence among Finnish women with 10 or more deliveries.

METHODS

Finnish women with at least 10 childbirths before December 31, 2010 (n=4,967) were identified from the Finnish Population Register and followed for cancer incidence through the Finnish Cancer Registry to the end of 2010. Cancer risks in this cohort were expressed as ratios between observed and expected numbers of cases (standardized incidence ratios), both drawn from the Finnish Cancer Registry, with 95% confidence intervals (CIs).

RESULTS

Total cancer incidence was markedly lower than in the reference population (656 cases, standardized incidence ratio 0.76, 95% CI 0.73-0.79). There was clearly less breast (0.44, 0.35-0.53), ovarian (0.49, 0.28-0.80), endometrial (0.31, 0.17-0.44), and basal cell skin cancer (0.72, 0.60-0.85) than in the reference population. The incidence of thyroid cancer (2.33, 1.59-3.29), lip cancer (2.87, 1.05-6.24), and uterine sarcoma (3.41, 1.47-6.72) was markedly increased.

CONCLUSION

Women with 10 or more deliveries show a decreased overall cancer incidence as a result of decreased risks of cancers of the ovary, endometrium, and breast and basal cell carcinoma of the skin. The increased risks were observed in thyroid cancer and some rare cancer types.

Chronic inflammation and gallbladder cancer

Gallbladder cancer (GBC) is the most common biliary tract malignancy with an extremely poor prognosis. Epidemiological data have demonstrated that chronic inflammation resulting from infection of gallbladder or gallstones predispose individuals to GBC. Recent studies have begun to elucidate molecular mechanisms underlying the development of GBC in the setting of chronic inflammation. It is possible that persistently local inflammatory reactions may contribute to the development and progression of GBC through inducing genetic alterations, and subsequent promoting survival and proliferation of mutated sells, inhibiting apoptosis, stimulating angiogenesis and metastasis. This article reviews the current understanding of the involvement of chronic inflammation in gallbladder tumorigenesis.

Risk factors for gallbladder cancer: a case-control study

Risk factors for gallbladder cancer (GBC) except gallstones are not well known. The objective was to study the risk factors for GBC. In a case-control study, 200 patients with GBC, 200 healthy controls and 200 gallstones patients as diseased controls were included prospectively. The risk factors studied were related to socioeconomic profile, life style, reproduction, diet and bile acids. On comparing GBC patients (mean age 51.7 years; 130 females) with healthy controls, risk factors were chemical exposure [odd ratios (OR): 7.0 (2.7-18.2); p < 0.001)], family history of gallstones [OR: 5.3 (1.5-18.9); p < 0.01)], tobacco [OR: 4.1 (1.8-9.7); p < 0.001)], fried foods [OR: 3.1 (1.7-5.6); p < 0.001], joint family [OR: 3.2 (1.7-6.2); p < 0.001], long interval between meals [OR: 1.4 (1.2-1.6); p < 0.001] and residence in Gangetic belt [OR: 3.3 (1.8-6.2); p < 0.001]. On comparing GBC cases with gallstone controls, risk factors were female gender [OR: 2.4 (1.3-4.3); p = 0.004], residence in Gangetic belt [OR: 2.3 (1.2-4.4); p = 0.012], fried foods [OR: 2.5 (1.4-4.4); p < 0.001], diabetes [OR: 2.7 (1.2-6.4); p = 0.02)], tobacco [OR 3.8 (1.7-8.1); p < 0.001)] and joint family [OR: 2.1 (1.2-3.4); p = 0.004]. The ratio of secondary to primary bile acids was significantly higher in GBC cases than gallstone controls (20.8 vs. 0.44). Fried foods, tobacco, chemical exposure, family history of gallstones, residence in Gangetic belt and secondary bile acids were significant risk factors for GBC.

Comprehensive proteomic analysis of human bile

Bile serves diverse functions from metabolism to transport. In addition to acids and salts, bile is composed of proteins secreted or shed by the hepatobiliary system. Although there have been previous efforts to catalog biliary proteins, an in-depth analysis of the bile proteome has not yet been reported. We carried out fractionation of non-cancerous bile samples using a multipronged approach (SDS-PAGE, SCX and OFFGEL) followed by MS analysis on an LTQ-Orbitrap Velos mass spectrometer using high resolution at both MS and MS/MS levels. We identified 2552 proteins - the largest number of proteins reported in human bile till date. To our knowledge, there are no previous studies employing high-resolution MS reporting a more detailed catalog of any body fluid proteome in a single study. We propose that extensive fractionation coupled to high-resolution MS can be used as a standard methodology for in-depth characterization of any body fluid. This catalog should serve as a baseline for the future studies aimed at discovering biomarkers from bile in gallbladder, hepatic, and biliary cancers.

Acute pancreatitis in pregnancy: an overview

Acute pancreatitis is rare in pregnancy but it is associated with increased incidence of maternal and fetal mortality. It should be considered in the differential diagnosis of upper quadrant abdominal pain with or without nausea and vomiting. The commonest identified causes of acute pancreatitis in pregnancy are gallstones, alcohol and hypertriglyceridemia. The main laboratory finding is increased amylase activity. Appropriate investigations include ultrasound of the right upper quadrant and measurement of serum triglycerides and ionized calcium. Management of gallstone pancreatitis is controversial, although laparoscopic cholecystectomy and endoscopic retrograde cholangiopancreatography (ERCP) are often used and may be associated with lower complication rates. In hypertriglyceridemia-induced acute pancreatitis ω-3 fatty acids and even therapeutic plasma exchange can be used. We also discuss preventive measures.