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Petrelli F, Cortellini A, Indini A, Tomasello G, Ghidini M, Nigro O, Salati M, Dottorini L, Iaculli A, Varricchio A, Rampulla V, Barni S, Cabiddu M, Bossi A, Ghidini A, Zaniboni A. Association of Obesity With Survival Outcomes in Patients With Cancer: A Systematic Review and Meta-analysis. JAMA Netw Open 2021; 4:e213520. [PMID: 33779745 PMCID: PMC8008284 DOI: 10.1001/jamanetworkopen.2021.3520] [Citation(s) in RCA: 208] [Impact Index Per Article: 69.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 02/08/2021] [Indexed: 12/11/2022] Open
Abstract
Importance Obesity, defined as a body mass index (BMI) greater than 30, is associated with a significant increase in the risk of many cancers and in overall mortality. However, various studies have suggested that patients with cancer and no obesity (ie, BMI 20-25) have worse outcomes than patients with obesity. Objective To assess the association between obesity and outcomes after a diagnosis of cancer. Data Sources PubMed, the Cochrane Library, and EMBASE were searched from inception to January 2020. Study Selection Studies reporting prognosis of patients with obesity using standard BMI categories and cancer were included. Studies that used nonstandard BMI categories, that were limited to children, or that were limited to patients with hematological malignant neoplasms were excluded. Screening was performed independently by multiple reviewers. Among 1892 retrieved studies, 203 (17%) met inclusion criteria for initial evaluation. Data Extraction and Synthesis The Meta-analysis of Observational Studies in Epidemiology (MOOSE) and Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines were reporting guideline was followed. Data were extracted by multiple independent reviewers. Risk of death, cancer-specific mortality, and recurrence were pooled to provide an adjusted hazard ratio (HR) with a 95% CI . A random-effects model was used for the retrospective nature of studies. Main Outcomes and Measures The primary outcome of the study was overall survival (OS) in patients with cancer, with and without obesity. Secondary end points were cancer-specific survival (CSS) and progression-free survival (PFS) or disease-free survival (DFS). The risk of events was reported as HRs with 95% CIs, with an HR greater than 1 associated with a worse outcome among patients with obesity vs those without. Results A total of 203 studies with 6 320 365 participants evaluated the association of OS, CSS, and/or PFS or DFS with obesity in patients with cancer. Overall, obesity was associated with a reduced OS (HR, 1.14; 95% CI, 1.09-1.19; P < .001) and CSS (HR, 1.17; 95% CI, 1.12-1.23; P < .001). Patients were also at increased risk of recurrence (HR, 1.13; 95% CI, 1.07-1.19; P < .001). Conversely, patients with obesity and lung cancer, renal cell carcinoma, or melanoma had better survival outcomes compared with patients without obesity and the same cancer (lung: HR, 0.86; 95% CI, 0.76-0.98; P = .02; renal cell: HR, 0.74; 95% CI, 0.53-0.89; P = .02; melanoma: HR, 0.74; 95% CI, 0.57-0.96; P < .001). Conclusions and Relevance In this study, obesity was associated with greater mortality overall in patients with cancer. However, patients with obesity and lung cancer, renal cell carcinoma, and melanoma had a lower risk of death than patients with the same cancers without obesity. Weight-reducing strategies may represent effective measures for reducing mortality in these patients.
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Affiliation(s)
- Fausto Petrelli
- Oncology Unit, Azienda Socio Sanitaria Territoriale Bergamo Ovest, Treviglio, Italy
| | - Alessio Cortellini
- Oncology Unit, Department of Biotechnology and Applied Clinical Sciences, San Salvatore Hospital, University of L’Aquila, L’Aquila, Italy
| | - Alice Indini
- Oncology Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ospedale Maggiore Policlinico, Milano, Italy
| | - Gianluca Tomasello
- Oncology Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ospedale Maggiore Policlinico, Milano, Italy
| | - Michele Ghidini
- Oncology Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ospedale Maggiore Policlinico, Milano, Italy
| | - Olga Nigro
- Oncology Unit, Azienda Socio Sanitaria Territoriale Sette Laghi, Ospedale di Circolo, Varese, Italy
| | - Massimiliano Salati
- Oncology Unit, University Hospital of Modena, Modena Cancer Centre, Modena, Italy
| | - Lorenzo Dottorini
- Oncology Unit, Azienda Socio Sanitaria Territoriale Bergamo Est, Seriate, Italy
| | - Alessandro Iaculli
- Oncology Unit, Azienda Socio Sanitaria Territoriale Bergamo Est, Seriate, Italy
| | - Antonio Varricchio
- Surgical Oncology Unit, Azienda Socio Sanitaria Territoriale Bergamo Ovest, Treviglio, Italy
| | - Valentina Rampulla
- Surgical Oncology Unit, Azienda Socio Sanitaria Territoriale Bergamo Ovest, Treviglio, Italy
| | - Sandro Barni
- Oncology Unit, Azienda Socio Sanitaria Territoriale Bergamo Ovest, Treviglio, Italy
| | - Mary Cabiddu
- Oncology Unit, Azienda Socio Sanitaria Territoriale Bergamo Ovest, Treviglio, Italy
| | - Antonio Bossi
- Endocrine Diseases Unit–Diabetes Regional Center, Azienda Socio Sanitaria Territoriale Bergamo Ovest, Treviglio, Italia
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Arthur R, Møller H, Garmo H, Häggström C, Holmberg L, Stattin P, Malmström H, Lambe M, Hammar N, Walldius G, Robinson D, Jungner I, Van Hemelrijck M. Serum glucose, triglycerides, and cholesterol in relation to prostate cancer death in the Swedish AMORIS study. Cancer Causes Control 2018; 30:195-206. [PMID: 30421156 DOI: 10.1007/s10552-018-1093-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Accepted: 10/29/2018] [Indexed: 12/11/2022]
Abstract
PURPOSE Lifestyle-related conditions such as obesity are associated with prostate cancer progression, but the associations with hyperglycemia and dyslipidemia are unclear. This study, therefore, aims to examine the association of glucose, triglycerides, and total cholesterol with prostate cancer death. METHODS From the Swedish AMORIS cohort, we selected 14,150 men diagnosed with prostate cancer between 1996 and 2011 who had prediagnostic measurements of serum glucose, triglycerides, and total cholesterol. Multivariable Cox proportional hazards regression models were used to determine the hazard ratios for death in relation to the aforementioned metabolic markers. RESULTS Using clinical cut-off points, a non-significant positive association was observed between glucose and prostate cancer death. When compared to those with glucose in the lowest quartile, those in the highest quartile had greater risk of prostate cancer death (HR 1.19; 95% CI 1.02-1.39). However, neither total cholesterol nor triglycerides were associated with prostate cancer death. Glucose and triglycerides were positively associated with overall, cardiovascular, and other deaths. Hypercholesterolemia was only associated with risk of CVD death. CONCLUSION Our results suggest that glucose levels may influence prostate cancer survival, but further studies using repeated measurements are needed to further elucidate how glucose levels may influence prostate cancer progression.
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Affiliation(s)
- Rhonda Arthur
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, New York, USA.
- Translational Oncology & Urology Research, Kings College London, London, UK.
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, 1300 Morris Park, Bronx, NY, USA.
| | - Henrik Møller
- Translational Oncology & Urology Research, Kings College London, London, UK
| | - Hans Garmo
- Translational Oncology & Urology Research, Kings College London, London, UK
- Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden
| | - Christel Häggström
- Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden
- Department of Biobank Research, Umeå University, Umeå, Sweden
| | - Lars Holmberg
- Translational Oncology & Urology Research, Kings College London, London, UK
| | - Pär Stattin
- Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden
| | - Håkan Malmström
- Unit of Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
- Biostatistics, Data Management and Medical Writing, Research & Development, Swedish Orphan Biovitrum (Sobi), Stockholm, Sweden
| | - Mats Lambe
- Regional Cancer Centre, Uppsala University Hospital, Uppsala, Sweden
| | - Niklas Hammar
- Medical Evidence & Observational Research, Global Medicines Development, AstraZeneca, Mölndal, Sweden
| | - Göran Walldius
- Unit of Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - David Robinson
- Department of Urology, Ryhov Hospital, Jönköping, Sweden
| | - Ingmar Jungner
- Department of Clinical Epidemiology, Karolinska Institutet and CALAB Research, Stockholm, Sweden
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Yunusova NV, Kondakova IV, Kolomiets LA, Afanas'ev SG, Kishkina AY, Spirina LV. The role of metabolic syndrome variant in the malignant tumors progression. Diabetes Metab Syndr 2018; 12:807-812. [PMID: 29699953 DOI: 10.1016/j.dsx.2018.04.028] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 04/09/2018] [Indexed: 02/07/2023]
Abstract
Metabolic syndrome (MS) is one of the leading risk factors for the development of some common cancers (endometrial cancer, postmenopausal breast cancer, colorectal cancer). Currently, a drug-induced metabolic syndrome related with androgen deprivation therapy in patients with prostate cancer represents a serious medical problem. Not only MS, or its individual components, but MS variants with different levels of leptin, adiponectin, visfatin, resistin are associated with tumor invasion, metastasis and survival rates in patients with MS-associated malignancies.
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Affiliation(s)
- Natalia V Yunusova
- Laboratory of tumor Biochemistry, Cancer Research Institute, Tomsk National Research Medical Center, Russian Academy of Science, 634009, Tomsk, Kooperativny str., 5, Russia; Biochemistry Division, Siberian State Medical University, 634050, Tоmsk, Moskovskiy str. 2., Russia
| | - Irina V Kondakova
- Laboratory of tumor Biochemistry, Cancer Research Institute, Tomsk National Research Medical Center, Russian Academy of Science, 634009, Tomsk, Kooperativny str., 5, Russia
| | - Larisa A Kolomiets
- Department of Oncogynecology, Cancer Research Institute, Тomsk National Research Medical Center, Russian Academy of Science, 634009, Tomsk, Kooperativny str., 5, Russia; Oncology Division, Siberian State Medical University, 634050, Tоmsk, Moskovskiy str. 2., Russia
| | - Sergey G Afanas'ev
- Abdominal Oncology Department, Cancer Research Institute, Tomsk National Research Medical Center, Russian Academy of Science, 634009, Tomsk, Kooperativny str., 5, Russia; 2 - Siberian State Medical University, 634050, Tоmsk, Moskovskiy str. 2., Russia
| | - Anastasia Yu Kishkina
- Laboratory of tumor Biochemistry, Cancer Research Institute, Tomsk National Research Medical Center, Russian Academy of Science, 634009, Tomsk, Kooperativny str., 5, Russia
| | - Liudmila V Spirina
- Laboratory of tumor Biochemistry, Cancer Research Institute, Tomsk National Research Medical Center, Russian Academy of Science, 634009, Tomsk, Kooperativny str., 5, Russia; Biochemistry Division, Siberian State Medical University, 634050, Tоmsk, Moskovskiy str. 2., Russia.
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Abstract
PURPOSE OF REVIEW To investigate the association between obesity and prostate cancer (PCa). RECENT FINDINGS Obesity has been proposed to be involved in the pathogenesis of PCa through different biological mechanisms that include deregulation of the insulin axis, sex hormone secretion, adipokines signaling, and oxidative stress. Hypertrophic peritumoral adipocytes may also facilitate the local spread of PCa through the chemo-attraction of tumor cells. Clinical studies demonstrate that obesity might have clinical implications also in disease detection and management. Obese men have been shown to be less likely to be diagnosed with early-stage disease. Moreover, they are at increased risk of experiencing upgrading and upstaging when managed with active surveillance. However, the association between obesity and the risk of PCa recurrence and mortality after radical treatment is still debated. SUMMARY Obesity may facilitate the development and progression of PCa trough different biologic mechanisms that may pose obese men at higher risk of advanced and high-grade disease. However, the association between obesity and long-term oncologic outcome after radical treatments appears unclear.
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Conteduca V, Caffo O, Galli L, Maugeri A, Scarpi E, Maines F, Chiuri VE, Lolli C, Kinspergher S, Schepisi G, Santoni M, Santini D, Fratino L, Burgio SL, Salvi S, Menna C, De Giorgi U. Association among metabolic syndrome, inflammation, and survival in prostate cancer. Urol Oncol 2018; 36:240.e1-240.e11. [PMID: 29402534 DOI: 10.1016/j.urolonc.2018.01.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Revised: 11/22/2017] [Accepted: 01/09/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND Metabolic syndrome (MS) and inflammation (INF) alterations are among the factors involved in cancer progression. The study aimed to assess the relationship between MS and INF and its effect on progression-free/overall survival (PFS/OS) in metastatic castration-resistant prostate cancer (mCRPC) treaed with abiraterone or enzalutamide. METHODS We, retrospectively, evaluated patients with mCRPC in 7 Italian Institutes between March 2011 and October 2016. MS was defined by modified adult treatment panel-III criteria. INF was characterized by at least one of these criteria: neutrophil to lymphocyte ratio ≥ 3, elevated erythrocyte sedimentation rate or C-reactive protein. RESULTS Eighty-three of 551 (15.1%) patients met MS criteria at baseline and 34 (6.2%) during treatment. MS patients (MS+) presented a greater INF profile compared to MS- (P<0.0001). Median PFS was 3.7 for MS+ vs. 8.7 months for MS- (hazard ratio [HR] = 2.77; 95% CI: 2.12-3.61; P<0.0001). Median OS was 6.9 and 19 months in MS+ and MS-, respectively (HR = 3.43; 95% CI: 2.56-4.58; P<0.0001). We also demonstrated INF led to shorter PFS and OS (4.5 vs. 8.5 months, HR = 1.48, 95% CI: 1.15-1.90, P = 0.002, and 11.2 vs. 18.8 months, HR =1.66, 95% CI: 1.26-2.18, P = 0.0003, respectively). The combination of MS with INF provided the identification of high-risk prognostic group (MS+/INF+ vs. MS-/INF-) with worse PFS (3.7 vs. 9 months, HR = 2.7, 95% CI: 1.88-3.89, P<0.0001) and OS (6.3 vs. 20.4 months, HR = 4.04, 95% CI: 2.75-5.93, P<0.0001). Multivariable analysis confirmed that MS was independently associated with PFS (HR = 2.07; 95% CI: 1.03-4.18; P = 0.041) and OS (HR = 4.87; 95% CI: 2.36-10.03; P<0.0001). The absence of INF as an independent predictor of survival underlined the correlation between MS/INF. CONCLUSIONS Pretreatment identification of MS and INF alterations might represent an available and easy tool for better prognostication of patients with mCRPC. A prospective evaluation is warranted.
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Affiliation(s)
- Vincenza Conteduca
- Medical Oncology Department, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy.
| | - Orazio Caffo
- Medical Oncology Department, Santa Chiara Hospital, Trento, Italy
| | - Luca Galli
- Department of Oncology, Azienda Ospedaliero, Universitaria Pisana, Istituto Toscano Tumori, Santa Chiara Hospital, Trento, Italy
| | - Antonio Maugeri
- Oncology Pharmacy Laboratory, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy
| | - Emanuela Scarpi
- Department of Biostatistics and Clinical Trials, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy
| | - Francesca Maines
- Medical Oncology Department, Santa Chiara Hospital, Trento, Italy
| | | | - Cristian Lolli
- Medical Oncology Department, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy
| | | | - Giuseppe Schepisi
- Medical Oncology Department, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy
| | - Matteo Santoni
- Department of Medical Oncology, University Hospital of Ancona, Ancona, Italy
| | - Daniele Santini
- Medical Oncology Department, Campus Bio-Medico, University of Rome, Rome, Italy
| | - Lucia Fratino
- Medical Oncology Department, National Cancer Institute, Aviano, Italy
| | - Salvatore Luca Burgio
- Medical Oncology Department, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy
| | - Samanta Salvi
- Biosciences Laboratory Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy
| | - Cecilia Menna
- Medical Oncology Department, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy
| | - Ugo De Giorgi
- Medical Oncology Department, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy
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Crawley D, Chamberlain F, Garmo H, Rudman S, Zethelius B, Holmberg L, Adolfsson J, Stattin P, Carroll P, Van Hemelrijck M. A systematic review of the literature exploring the interplay between prostate cancer and type two diabetes mellitus. Ecancermedicalscience 2018; 12:802. [PMID: 29456619 PMCID: PMC5813911 DOI: 10.3332/ecancer.2018.802] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Indexed: 11/12/2022] Open
Abstract
Prostate cancer (PCa) and type two diabetes mellitus (T2DM) are both increasing prevalent conditions and often occur concurrently. However, the relationship between the two is more complex than just two prevalent conditions co-existing. This review systematically explores the literature around the interplay between the two conditions. It covers the impact of pre-existing T2DM on PCa incidence, grade and stage, as well as exploring the impact of T2DM on PCa outcomes and mortality and the interaction between T2DM and PCa treatments.
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Affiliation(s)
- Danielle Crawley
- Translational Oncology and Urology Research Group, King's College London, London SE1 9RT, UK
| | - Florence Chamberlain
- Department of Medical Oncology, Guy's and St Thomas' NHS Foundation Trust, London SE1 9RT, UK
| | - Hans Garmo
- Translational Oncology and Urology Research Group, King's College London, London SE1 9RT, UK
| | - Sarah Rudman
- Department of Medical Oncology, Guy's and St Thomas' NHS Foundation Trust, London SE1 9RT, UK
| | - Björn Zethelius
- Department of Public Health and Geriatrics, Uppsala University, Uppsala 751 05, Sweden.,Medical Products Agency, Uppsala 751 03, Sweden
| | - Lars Holmberg
- Translational Oncology and Urology Research Group, King's College London, London SE1 9RT, UK.,Department of Surgical Sciences, Uppsala University, Uppsala 751 05, Sweden
| | - Jan Adolfsson
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm 171 77, Sweden
| | - Par Stattin
- Department of Surgical Sciences, Uppsala University, Uppsala 751 05, Sweden
| | - Paul Carroll
- Department of Diabetes and Endocrinology, Guy's and St Thomas' NHS Foundation Trust, London, SE1 9RT UK
| | - Mieke Van Hemelrijck
- Translational Oncology and Urology Research Group, King's College London, London SE1 9RT, UK
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Bosco C, Wong C, Garmo H, Crawley D, Holmberg L, Hammar N, Adolfsson J, Stattin P, Van Hemelrijck M. Drugs for metabolic conditions and prostate cancer death in men on GnRH agonists. BJU Int 2017; 121:260-267. [PMID: 28940667 DOI: 10.1111/bju.14023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To evaluate whether drugs for metabolic conditions influence prostate cancer-specific mortality in men starting gonadotrophin-releasing hormone (GnRH) agonists, as it is unclear whether metabolic syndrome and its related drugs is affecting treatment response in men with prostate cancer on GnRH agonists. PATIENTS AND METHODS We selected all men receiving GnRH agonists as primary treatment in the Prostate Cancer data Base Sweden (PCBaSe) (n = 9267). Use of drugs for metabolic conditions (i.e. anti-diabetes, anti-dyslipidaemia, and antihypertension) in relation to all-cause, cardiovascular disease (CVD), and prostate cancer-specific death were studied using multivariate Cox proportional hazard and Fine and Gray competing regression models. RESULTS In all, 6322 (68%) men used at least one drug for a metabolic condition at GnRH agonist initiation: 46% on antihypertensive drugs only, 32% on drugs for dyslipidaemia and hypertension, and ~10% on drugs for more than two metabolic conditions. Cox models indicated a weak increased risk of prostate cancer death in men who were on drugs for hypertension only (hazard ratio [HR] 1.12, 95% confidence interval [CI] 1.03-1.23) or drugs for hyperglycaemia (HR 1.19, 95% CI 1.06-1.35) at GnRH agonist initiation. However, upon taking into account competing risk from CVD death, none of the drugs for metabolic conditions were associated with an increased risk of prostate cancer death. CONCLUSION We did not find evidence for a better or worse response to GnRH agonists in men with prostate cancer who were also on drugs for hypertension, dyslipidaemia, or hyperglycaemia.
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Affiliation(s)
- Cecilia Bosco
- School of Cancer and Pharmaceutical Sciences, Translational Oncology and Urology Research, King's College London, London, UK
| | - Chloe Wong
- School of Cancer and Pharmaceutical Sciences, Translational Oncology and Urology Research, King's College London, London, UK
| | - Hans Garmo
- School of Cancer and Pharmaceutical Sciences, Translational Oncology and Urology Research, King's College London, London, UK.,Regional Cancer Centre, Uppsala University, Uppsala, Sweden
| | - Danielle Crawley
- School of Cancer and Pharmaceutical Sciences, Translational Oncology and Urology Research, King's College London, London, UK
| | - Lars Holmberg
- School of Cancer and Pharmaceutical Sciences, Translational Oncology and Urology Research, King's College London, London, UK
| | - Niklas Hammar
- Unit of Epidemiology, Institute of Environmental Medicine, Stockholm, Sweden.,Medical Evidence and Observational Research, Global Medical Affairs, AstraZeneca, Mölndal, Sweden
| | - Jan Adolfsson
- CLINTEC Department, Karolinska Institutet, Stockholm, Sweden
| | - Pär Stattin
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Mieke Van Hemelrijck
- School of Cancer and Pharmaceutical Sciences, Translational Oncology and Urology Research, King's College London, London, UK.,Unit of Epidemiology, Institute of Environmental Medicine, Stockholm, Sweden
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