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Xiao Y, Shen Y, Song H, Gao F, Mao Z, Lv Q, Qin C, Yuan L, Wu D, Chu H, Wang M, Du M, Zheng R, Zhang Z. AKR1C2 genetic variants mediate tobacco carcinogens metabolism involving bladder cancer susceptibility. Arch Toxicol 2024; 98:2269-2279. [PMID: 38662237 DOI: 10.1007/s00204-024-03737-y] [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: 11/07/2023] [Accepted: 03/18/2024] [Indexed: 04/26/2024]
Abstract
Tobacco carcinogens metabolism-related genes (TCMGs) could generate reactive metabolites of tobacco carcinogens, which subsequently contributed to multiple diseases. However, the association between genetic variants in TCMGs and bladder cancer susceptibility remains unclear. In this study, we derived TCMGs from metabolic pathways of polycyclic aromatic hydrocarbons and tobacco-specific nitrosamines, and then explored genetic associations between TCMGs and bladder cancer risk in two populations: a Chinese population of 580 cases and 1101 controls, and a European population of 5930 cases and 5468 controls, along with interaction and joint analyses. Expression patterns of TCMGs were sourced from Nanjing Bladder Cancer (NJBC) study and publicly available datasets. Among 43 TCMGs, we observed that rs7087341 T > A in AKR1C2 was associated with a reduced risk of bladder cancer in the Chinese population [odds ratio (OR) = 0.84, 95% confidence interval (CI) = 0.72-0.97, P = 1.86 × 10-2]. Notably, AKR1C2 rs7087341 showed an interaction effect with cigarette smoking on bladder cancer risk (Pinteraction = 5.04 × 10-3), with smokers carrying the T allele increasing the risk up to an OR of 3.96 (Ptrend < 0.001). Genetically, rs7087341 showed an allele-specific transcriptional regulation as located at DNA-sensitive regions of AKR1C2 highlighted by histone markers. Mechanistically, rs7087341 A allele decreased AKR1C2 expression, which was highly expressed in bladder tumors that enhanced metabolism of tobacco carcinogens, and thereby increased DNA adducts and reactive oxygen species formation during bladder tumorigenesis. These findings provided new insights into the genetic mechanisms underlying bladder cancer.
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Affiliation(s)
- Yanping Xiao
- Departments of Environmental Genomics and Genetic Toxicology, The Key Laboratory of Modern Toxicology of Ministry of Education, Center for Global Health, Jiangsu Key Laboratory of Cancer Biomarkers, Prevention and Treatment, Collaborative Innovation Center for Cancer Personalized Medicine, School of Public Health; Institute of Clinical Research, The Affiliated Taizhou People's Hospital of Nanjing Medical University; Department of Urology, The Yancheng School of Clinical Medicine of Nanjing Medical University (The Third People's Hospital of Yancheng), Nanjing Medical University, Nanjing, 211166, China
| | - Yang Shen
- Department of Urology, The Second Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Second Chinese Medicine Hospital, Nanjing, 210017, China
| | - Hui Song
- Departments of Environmental Genomics and Genetic Toxicology, The Key Laboratory of Modern Toxicology of Ministry of Education, Center for Global Health, Jiangsu Key Laboratory of Cancer Biomarkers, Prevention and Treatment, Collaborative Innovation Center for Cancer Personalized Medicine, School of Public Health, Nanjing Medical University, Nanjing, 211166, China
| | - Fang Gao
- Departments of Environmental Genomics and Genetic Toxicology, The Key Laboratory of Modern Toxicology of Ministry of Education, Center for Global Health, Jiangsu Key Laboratory of Cancer Biomarkers, Prevention and Treatment, Collaborative Innovation Center for Cancer Personalized Medicine, School of Public Health, Nanjing Medical University, Nanjing, 211166, China
- Key Laboratory of Environmental Medicine Engineering, Ministry of Education, School of Public Health, Southeast University, Nanjing, 210009, China
| | - Zhenguang Mao
- Departments of Environmental Genomics and Genetic Toxicology, The Key Laboratory of Modern Toxicology of Ministry of Education, Center for Global Health, Jiangsu Key Laboratory of Cancer Biomarkers, Prevention and Treatment, Collaborative Innovation Center for Cancer Personalized Medicine, School of Public Health, Nanjing Medical University, Nanjing, 211166, China
| | - Qiang Lv
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210036, China
| | - Chao Qin
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210036, China
| | - Lin Yuan
- Department of Urology, Jiangsu Province Hospital of Traditional Chinese Medicine, Nanjing, 210029, China
| | - Dongmei Wu
- Departments of Environmental Genomics and Genetic Toxicology, The Key Laboratory of Modern Toxicology of Ministry of Education, Center for Global Health, Jiangsu Key Laboratory of Cancer Biomarkers, Prevention and Treatment, Collaborative Innovation Center for Cancer Personalized Medicine, School of Public Health, Nanjing Medical University, Nanjing, 211166, China
| | - Haiyan Chu
- Departments of Environmental Genomics and Genetic Toxicology, The Key Laboratory of Modern Toxicology of Ministry of Education, Center for Global Health, Jiangsu Key Laboratory of Cancer Biomarkers, Prevention and Treatment, Collaborative Innovation Center for Cancer Personalized Medicine, School of Public Health, Nanjing Medical University, Nanjing, 211166, China
| | - Meilin Wang
- Departments of Environmental Genomics and Genetic Toxicology, The Key Laboratory of Modern Toxicology of Ministry of Education, Center for Global Health, Jiangsu Key Laboratory of Cancer Biomarkers, Prevention and Treatment, Collaborative Innovation Center for Cancer Personalized Medicine, School of Public Health, Nanjing Medical University, Nanjing, 211166, China
| | - Mulong Du
- Departments of Environmental Genomics and Genetic Toxicology, The Key Laboratory of Modern Toxicology of Ministry of Education, Center for Global Health, Jiangsu Key Laboratory of Cancer Biomarkers, Prevention and Treatment, Collaborative Innovation Center for Cancer Personalized Medicine, School of Public Health, Nanjing Medical University, Nanjing, 211166, China.
- Department of Biostatistics, Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, 211166, China.
| | - Rui Zheng
- Departments of Environmental Genomics and Genetic Toxicology, The Key Laboratory of Modern Toxicology of Ministry of Education, Center for Global Health, Jiangsu Key Laboratory of Cancer Biomarkers, Prevention and Treatment, Collaborative Innovation Center for Cancer Personalized Medicine, School of Public Health, Nanjing Medical University, Nanjing, 211166, China.
| | - Zhengdong Zhang
- Departments of Environmental Genomics and Genetic Toxicology, The Key Laboratory of Modern Toxicology of Ministry of Education, Center for Global Health, Jiangsu Key Laboratory of Cancer Biomarkers, Prevention and Treatment, Collaborative Innovation Center for Cancer Personalized Medicine, School of Public Health; Institute of Clinical Research, The Affiliated Taizhou People's Hospital of Nanjing Medical University; Department of Urology, The Yancheng School of Clinical Medicine of Nanjing Medical University (The Third People's Hospital of Yancheng), Nanjing Medical University, Nanjing, 211166, China.
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Kim HJ, Kim KH, Lee SW, Swan H, Kazmi SZ, Kim YS, Kim KU, Kim M, Cha J, Kang T, Hann HJ, Ahn HS. Familial Risk and Interaction With Smoking and Alcohol Consumption in Bladder Cancer: A Population-Based Cohort Study. World J Oncol 2023; 14:382-391. [PMID: 37869241 PMCID: PMC10588503 DOI: 10.14740/wjon1639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 08/01/2023] [Indexed: 10/24/2023] Open
Abstract
Background Although genetic factors are known to play a role in the pathogenesis of bladder cancer, population-level familial risk estimates are scarce. We aimed to quantify the familial risk of bladder cancer and analyze interactions between family history and smoking or alcohol consumption. Methods Using the National Health Insurance database, we constructed a cohort of 5,524,403 study subjects with first-degree relatives (FDRs) and their lifestyle risk factors from 2002 to 2019. Familial risk was calculated using hazard ratios (HRs) with 95% confidence intervals (CIs) that compare the risk of individuals with and without affected FDRs. Interactions between family history and smoking or alcohol intake were assessed on an additive scale using the relative excess risk due to interaction (RERI). Results Offspring with an affected parent had a 2.09-fold (95% CI: 1.41 - 3.08) increased risk of disease compared to those with unaffected parents. Familial risks of those with affected father and mother were 2.26 (95% CI: 1.51 - 3.39) and 1.10 (95% CI: 0.27 - 4.41), respectively. When adjusted for lifestyle factors, HR reduced slightly to 2.04 (95% CI: 1.38 - 3.01), suggesting that a genetic predisposition is the main driver in the familial aggregation. Smokers with a positive family history had a markedly increased risk of disease (HR: 3.60, 95% CI: 2.27 - 5.71), which exceeded the sum of their individual risks, with statistically significant interaction (RERI: 0.72, 95% CI: 0.31 - 1.13). For alcohol consumption, drinkers with a positive family history also had an increased risk of disease, although the interaction was not statistically significant (RERI: 0.05, 95% CI: -3.39 - 3.48). Conclusion Smokers and alcohol consumers with a positive family history of bladder cancer should be considered a high-risk group and be advised to undergo genetic counseling.
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Affiliation(s)
- Hyun Jung Kim
- Department of Preventive Medicine, College of Medicine, Korea University, Seoul 02841, Korea
| | - Kyoung-Hoon Kim
- Evidence-Based Research Division, Health Insurance Review and Assessment Service, Gangwon-do (Bangok-dong) 26465, Korea
| | - Sung Won Lee
- Department of Urology, Samsung Medical Center, Samsung Biomedical Research Institute, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
| | - Heather Swan
- Department of Preventive Medicine, College of Medicine, Korea University, Seoul 02841, Korea
| | - Sayada Zartasha Kazmi
- Department of Preventive Medicine, Seoul National University College of Medicine, Seoul 03080, Korea
| | - Young Shin Kim
- Department of Preventive Medicine, College of Medicine, Korea University, Seoul 02841, Korea
| | - Kyeong Uoon Kim
- Department of Nursing, Seojeong University, Gyeonggi-do, Korea
| | - Minjung Kim
- Department of Public Health, Graduate School, Korea University, Seoul, Korea
| | - Jaewoo Cha
- Department of Public Health, Graduate School, Korea University, Seoul, Korea
| | - Taeuk Kang
- Health and Wellness College, Sungshin Women’s University, Seoul, Korea
| | - Hoo Jae Hann
- Medical Research Institute, College of Medicine, Ewha Womans University, Seoul, Korea
| | - Hyeong Sik Ahn
- Department of Preventive Medicine, College of Medicine, Korea University, Seoul 02841, Korea
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Li X, Zhang Y, Zhang C, Zheng Y, Liu R, Xiao S. Education counteracts the genetic risk of Alzheimer's disease without an interaction effect. Front Public Health 2023; 11:1178017. [PMID: 37663829 PMCID: PMC10471486 DOI: 10.3389/fpubh.2023.1178017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 07/31/2023] [Indexed: 09/05/2023] Open
Abstract
Background Alzheimer's disease (AD) is a major cause of disability and mortality in older adults. This study aimed to investigate the association of AD with education and genetic factors. Methods We conducted a prospective cohort study using data from the UK Biobank. Genetic risk was assessed using a polygenic risk score for AD. The educational level was categorized as either low, intermediate, or high. AD was defined using the International Classification of Diseases and Related Health Problems, 10th revision. Logistic regression models were used to investigate the independent and combined effects of genetic factors and educational levels on the risk of AD. Results We included 318,535 participants in this study (age: 56.53 ± 8.09 years; male: 44.81%). Compared with a low genetic risk, a high genetic risk was associated with a significantly greater risk of AD (OR = 7.09, 95% CI: 6.09-8.26). A high educational level was associated with a 30% lower risk of AD compared with a low educational level (OR = 0.70, 95% CI: 0.60-0.81). Combining genetic risk and education categories, individuals with a low genetic risk and high educational level had a more than 90% (OR = 0.09, 95% CI: 0.05-0.16) lower risk of AD compared to those with a high genetic risk and low educational level. There was no significant interaction between genetic risk and educational level regarding AD risk (p for interaction = 0.359). Conclusion Education counteracts the genetic risk of AD, without an interaction effect. Increasing education to reduce the incidence of AD is of same importance across individuals with different genetic risk.
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Affiliation(s)
- Xuping Li
- Xiangya School of Public Health, Central South University, Changsha, Hunan, China
| | - Yushi Zhang
- Yale School of Public Health, New Haven, CT, United States
| | - Chengcheng Zhang
- Xiangya School of Public Health, Central South University, Changsha, Hunan, China
| | - Ying Zheng
- Xiangya School of Public Health, Central South University, Changsha, Hunan, China
| | - Ruilin Liu
- The Clinical Center for Gene Diagnosis and Therapy, The Second Xiangya Hospital of Central South University, Central South University, Changsha, China
| | - Shuiyuan Xiao
- Xiangya School of Public Health, Central South University, Changsha, Hunan, China
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Xia Q, Li J, Shen Y, Zhang D. Tea Drinking and the Risk of Carcinoma of the Urinary Bladder: A Meta-Analysis. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE : ECAM 2023; 2023:2891120. [PMID: 37064949 PMCID: PMC10104736 DOI: 10.1155/2023/2891120] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 07/13/2022] [Accepted: 08/06/2022] [Indexed: 04/18/2023]
Abstract
Objective For evaluation of the correlation between tea drinking and the risk of carcinoma of the urinary bladder. Methods By searching PubMed, Embase, and Cochrane Library databases, the original studies on tea drinking and carcinoma of the urinary bladder risk were collected, the data were extracted, and meta-analysis package 5.2-0 of R language was used for meta-analysis. Results This study contained 11 researches, composed of 7686 patients and 10320 controls. Tea drinking was not linked to carcinoma of the urinary bladder risk (OR:1.02, 95%CI: 0.95-1.11). Conclusion Tea drinking may not be linked to carcinoma of the urinary bladder, but more definitive results are needed from higher-quality trials.
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Affiliation(s)
- Qier Xia
- Suzhou Medical College of Soochow University, Soochow 215000, China
- Department of Urology, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, No. 158, Shangtang Road, Xiacheng District, Hangzhou 310014, Zhejiang, China
- Department of Urology, Pudong New Area People's Hospital, Shanghai 201299, China
| | - Jun Li
- Department of Urology, Pudong New Area People's Hospital, Shanghai 201299, China
| | - Yifan Shen
- Department of Urology, Pudong New Area People's Hospital, Shanghai 201299, China
| | - Dahong Zhang
- Suzhou Medical College of Soochow University, Soochow 215000, China
- Department of Urology, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, No. 158, Shangtang Road, Xiacheng District, Hangzhou 310014, Zhejiang, China
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Bladder cancer-associated microbiota: Recent advances and future perspectives. Heliyon 2023; 9:e13012. [PMID: 36704283 PMCID: PMC9871226 DOI: 10.1016/j.heliyon.2023.e13012] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 11/30/2022] [Accepted: 01/12/2023] [Indexed: 01/18/2023] Open
Abstract
Recent evidence suggests that the human genitourinary microbiome plays a significant role in mediating the development and progression of urological tumors, including bladder cancer (BC). Clinicians widely recognize the role of Bacille Calmette Guérin (BCG), an attenuated Mycobacterium tuberculosis vaccine, in the management of intermediate- and high-risk NMIBC. However, compared to the large body of evidence on the gut microbiota and gastrointestinal tumors, limited information is available about the interaction between BC and the genitourinary microbiome. This is an expanding field that merits further investigation. Urologists will need to consider the potential impact of the microbiome in BC diagnosis, prevention of recurrence and progression, and treatment prospects in the future. This review highlights the approaches adopted for microbiome research and the findings and inadequacies of current research on BC.
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Deng S, Meng F, Wang L, Yang Z, Xuan L, Xuan Z, Wang J. Global research trends in non-muscle invasive bladder cancer: Bibliometric and visualized analysis. Front Oncol 2022; 12:1044830. [PMID: 36465379 PMCID: PMC9713934 DOI: 10.3389/fonc.2022.1044830] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 10/26/2022] [Indexed: 11/26/2023] Open
Abstract
BACKGROUND Bladder cancer is one of the most common urological cancers. Non-muscle invasive bladder cancer (NMIBC) accounts for about 75-85% of all newly diagnosed bladder cancers. Globally, there are many NMIBC-related publications. However, a bibliometric analysis of these publications has not been performed. OBJECTIVE This study aims to systematically analyze and visualize NMIBC-related publications through bibliometrics, and to reveal identified topics, hotspots, and knowledge gaps in related fields. METHODS Based on the Web of Science core collection database, we firstly analyzed the quantity and quality of publications in the field of NMIBC, secondly profiled the publishing groups in terms of country, institution, author's publication and cooperation network, and finally sorted out and summarized the hot topics of research. RESULTS This bibliometric analysis was conducted from 2001 to 2022. The analysis identified 2,185 articles and reviews, which were published in 402 journals. The number of publications and citations on NMIBC-related research has steadily increased over the last two decades. Furthermore, academic institutions in Europe and the United States play a leading role in NMIBC research. The country, institution, journal, and author with the most publications were the United States (559), Radboud University Nijmegen (88), Urologic oncology: Seminars and Original Investigations (141), and Witjes J (74), respectively. The most frequently used keywords were Bladder cancer (793), Recurrence (671), Urothelial carcinoma (593), Progression (523), Bacillus-calmette-guerin (411), Transitional-cell carcinoma (401), Carcinoma (366), Risk (297), Transurethral resection (286), and Non-muscle-invasive bladder cancer (280). CONCLUSION More and more scholars are devoted to the research of related NMIBC. This bibliometric analysis revealed that the main research topics and hotspots in NMIBC included pathological staging, clinical diagnosis and treatment, and bladder perfusion.
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Affiliation(s)
- Sheng Deng
- Department of Andrology, Shunyi Hospital, Beijing Hospital of Traditional Chinese Medicine, Beijing, China
| | - Fanchao Meng
- Department of Urology Surgery, The Third Affiliated Hospital of Beijing University of Chinese Medicine, Beijing, China
| | - Lu Wang
- Department of Surgery, Beijing Xuanwu Traditional Chinese Medicine Hospital, Beijing, China
| | - Zhen Yang
- Department of Andrology, Shunyi Hospital, Beijing Hospital of Traditional Chinese Medicine, Beijing, China
| | - Lihua Xuan
- Department of Andrology, Shunyi Hospital, Beijing Hospital of Traditional Chinese Medicine, Beijing, China
| | - Zhihua Xuan
- Department of Andrology, Shunyi Hospital, Beijing Hospital of Traditional Chinese Medicine, Beijing, China
| | - Jisheng Wang
- Department of Andrology, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
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Al-Zalabani AH, Wesselius A, Yi-Wen Yu E, van den Brandt P, Grant EJ, White E, Skeie G, Liedberg F, Weiderpass E, Zeegers MP. Tea consumption and risk of bladder cancer in the Bladder Cancer Epidemiology and Nutritional Determinants (BLEND) Study: Pooled analysis of 12 international cohort studies. Clin Nutr 2022; 41:1122-1130. [PMID: 35413574 DOI: 10.1016/j.clnu.2022.03.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 02/25/2022] [Accepted: 03/12/2022] [Indexed: 12/20/2022]
Abstract
BACKGROUND & AIMS Tea has been shown to be associated with reduced risk of several diseases including cardiovascular diseases, stroke, metabolic syndrome, and obesity. However, the results on the relationship between tea consumption and bladder cancer are conflicting. This research aimed to assess the association between tea consumption and risk of bladder cancer using a pooled analysis of prospective cohort data. METHODS Individual data from 532,949 participants in 12 cohort studies, were pooled for analyses. Cox regression models stratified by study centre was used to estimate hazard ratios (HR) and corresponding 95% CIs. Fractional polynomial regression models were used to examine the dose-response relationship. RESULTS A higher level of tea consumption was associated with lower risk of bladder cancer incidence (compared with no tea consumption: HR = 0.87, 95% C.I. = 0.77-0.98 for low consumption; HR = 0.86, 95% C.I. = 0.77-0.96 for moderate consumption; HR = 0.84, 95% C.I. = 0.75-0.95 for high consumption). When stratified by sex and smoking status, this reduced risk was statistically significant among men and current and former smokers. In addition, dose-response analyses showed a lower bladder cancer risk with increment of 100 ml of tea consumption per day (HR-increment = 0.97; 95% CI = 0.96-0.98). A similar inverse association was found among males, current and former smokers while never smokers and females showed non-significant results, suggesting potential sex-dependent effect. CONCLUSIONS Higher consumption of tea is associated with reduced risk of bladder cancer with potential interaction with sex and smoking status. Further studies are needed to clarify the mechanisms for a protective effect of tea (e.g. inhibition of the survival and proliferation of cancer cells and anti-inflammatory mechanisms) and its interaction with smoking and sex.
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Affiliation(s)
- Abdulmohsen H Al-Zalabani
- Department of Family and Community Medicine, College of Medicine, Taibah University, Madinah, 41541, Saudi Arabia
| | - Anke Wesselius
- Department of Epidemiology, School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, the Netherlands.
| | - Evan Yi-Wen Yu
- Key Laboratory of Environmental Medicine and Engineering of Ministry of Education, Department of Epidemiology & Biostatistics, School of Public Health, Southeast University, Nanjing, China; Department of Epidemiology, CAPHRI Care and Public Health Research Institute, School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, the Netherlands
| | - Piet van den Brandt
- Department of Epidemiology, Schools for Oncology and Developmental Biology and Public Health and Primary Care, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Eric J Grant
- Department of Epidemiology Radiation Effects Research Foundation, Hiroshima, Japan
| | - Emily White
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Guri Skeie
- Department of Community Medicine, UiT the Arctic University of Norway, Tromsø, Norway
| | - Fredrik Liedberg
- Institution of Translational Medicine, Lund University, Malmö, Sweden
| | - Elisabete Weiderpass
- International Agency for Research on Cancer, World Health Organization, Lyon, France
| | - Maurice P Zeegers
- Department of Epidemiology, School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, the Netherlands; CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, the Netherlands
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