Pre-diagnosis Dairy Product Intake and Ovarian Cancer Mortality: Results From the Ovarian Cancer Follow-Up Study (OOPS)

The Dairy and Cancer Controversy: Milking the Evidence

PURPOSE OF REVIEW

Cancer risk reduction remains a significant concern for both individuals with a cancer diagnosis and those aiming to prevent it. Dairy products, a source of beneficial dietary nutrients, have sparked controversy regarding their impact on cancer risk.

RECENT FINDINGS

Evidence indicates that dairy consumption, particularly milk, can decrease colorectal cancer risk. However, cow's milk, a key dairy product, exposes individuals to growth hormones, notably insulin-like growth factor-1, potentially elevating cancer risk. Extensive research supports the link between dairy intake and heightened prostate cancer risk. Nonetheless, investigations into dairy's association with breast, ovarian, and other cancers yield mixed results. The overall data on dairy and cancer remains inconclusive. Available data suggests that a diet emphasizing fiber-rich foods such as whole grains, fruits, and vegetables, while restricting milk and dairy intake-similar to the Mediterranean dietary pattern-might mitigate cancer incidence. However, further research is crucial to elucidate the precise role of dairy products in overall cancer risk.

Association of pre-diagnosis specific color groups of fruit and vegetable intake with ovarian cancer survival: results from the ovarian cancer follow-up study (OOPS)

Background: The colors of fruits and vegetables (FV) reflect the presence of pigmented bioactive compounds. The evidence of pre-diagnosis specific FV color group intake contributing to ovarian cancer (OC) survival is limited and inconsistent. Methods: A prospective cohort study was conducted between 2015 and 2020 with 700 newly diagnosed OC patients. Pre-diagnosis dietary information was assessed by a validated food frequency questionnaire. We classified FV into five groups based on the color of their edible parts (e.g., green, red/purple, orange/yellow, white, and uncategorized groups). Cox proportional hazard models were used to calculate hazard ratios (HRs) and 95% confidence intervals (CIs) for the association of specific color groups of FV before diagnosis with OC survival. Potential multiplicative and additive interactions were assessed. Results: 130 patients died during a median follow-up of 37.57 (interquartile: 24.77-50.20) months. We observed the improved survival with a higher pre-diagnosis intake of total FV (HRtertile 3 vs. tertile 1 = 0.63, 95%CI = 0.40-0.99), total vegetables (HRtertile 3 vs. tertile 1 = 0.57, 95%CI = 0.36-0.90), and red/purple FV (HRtertile 3 vs. tertile 1 = 0.52, 95%CI = 0.33-0.82). In addition, we observed significant dose-response relationships for per standard deviation increment between total vegetable intake (HR = 0.79, 95%CI = 0.65-0.96) and red/purple group intake (HR = 0.77, 95%CI = 0.60-0.99) before diagnosis with OC survival. Additionally, pre-diagnosis green FV intake was borderline associated with better OC survival (HRper standard deviation increment = 0.83; 95%CI = 0.69-1.00). In contrast, we did not observe significant associations between pre-diagnosis intake of total fruits, orange/yellow, white, and uncategorized groups and OC survival. Conclusion: Pre-diagnosis FV intake from various color groups, especially the green and red/purple ones, may improve OC survival. Further studies are needed to validate our findings.

The association of macronutrient quality and its interactions with energy intake with survival among patients with ovarian cancer: results from a prospective cohort study

BACKGROUND

Emerging evidence supports shifting the focus from the quantity of macronutrients to quality to obtain greater benefits for the prognosis of ovarian cancer (OC). Additionally, despite the high relevance between macronutrient quality and quantity, the interaction of these parameters on OC survival remains unknown.

OBJECTIVE

A multidimensional macronutrient quality index (MQI) was applied to investigate the association between overall macronutrient quality and the survival of patients with OC.

METHODS

A prospective cohort study was conducted with 701 females diagnosed with OC who were enrolled from 2015 to 2020. Dietary intake information was obtained from a validated food frequency questionnaire. The MQI was calculated based on 3 quality indices: carbohydrate quality index (CQI), fat quality index (FQI), and protein quality index (PQI). Cox proportional hazards regression was conducted to calculate HRs and 95% CIs. Furthermore, we evaluated whether energy intake status (total energy intake and energy balance) modified the association between MQI and OC survival.

RESULTS

During a median follow-up period of 38 (interquartile: 35-40) mo, 130 deaths occurred. The prediagnosis high MQI scores were associated with substantially improved survival among females with OC (HR_{tertile 3 vs. tertile 1} = 0.50, 95% CI: 0.33, 0.77). For sub-indices of the MQI, higher CQI (HR = 0.60, 95% CI: 0.36, 0.99), higher FQI (HR = 0.55, 95% CI: 0.34, 0.87), and higher PQI (HR = 0.58, 95% CI: 0.35, 0.94) scores were all associated with better survival. Notably, significant interactions were observed for the MQI score with total energy intake and energy balance as well as the quantity and quality of carbohydrates on survival.

CONCLUSIONS

Intake of high-quality macronutrients before diagnosis was associated with improved survival among females with OC, especially for those with energy imbalance. Am J Clin Nutr 2023;xxx:xx-xx.

Survival of epithelial ovarian cancer in Black women: a society to cell approach in the African American cancer epidemiology study (AACES)

PURPOSE

The causes for the survival disparity among Black women with epithelial ovarian cancer (EOC) are likely multi-factorial. Here we describe the African American Cancer Epidemiology Study (AACES), the largest cohort of Black women with EOC.

METHODS

AACES phase 2 (enrolled 2020 onward) is a multi-site, population-based study focused on overall survival (OS) of EOC. Rapid case ascertainment is used in ongoing patient recruitment in eight U.S. states, both northern and southern. Data collection is composed of a survey, biospecimens, and medical record abstraction. Results characterizing the survival experience of the phase 1 study population (enrolled 2010-2015) are presented.

RESULTS

Thus far, ~ 650 patients with EOC have been enrolled in the AACES. The five-year OS of AACES participants approximates those of Black women in the Surveillance Epidemiology and End Results (SEER) registry who survive at least 10-month past diagnosis and is worse compared to white women in SEER, 49 vs. 60%, respectively. A high proportion of women in AACES have low levels of household income (45% < $25,000 annually), education (51% ≤ high school education), and insurance coverage (32% uninsured or Medicaid). Those followed annually differ from those without follow-up with higher levels of localized disease (28 vs 24%) and higher levels of optimal debulking status (73 vs 67%).

CONCLUSION

AACES is well positioned to evaluate the contribution of social determinants of health to the poor survival of Black women with EOC and advance understanding of the multi-factorial causes of the ovarian cancer survival disparity in Black women.

Purine Intake and All-Cause Mortality in Ovarian Cancer: Results from a Prospective Cohort Study

BACKGROUND

Current biological evidence suggests that purine involvement in purine metabolism may contribute to the development and progression of ovarian cancer (OC), but the epidemiological association is currently unknown.

METHODS

A total of 703 newly diagnosed patients with OC aged 18-79 years were included in this prospective cohort study. Utilizing a verified food-frequency questionnaire, the participants' dietary consumption was gathered. Using medical records and ongoing follow-up, the deaths up until 31 March 2021 were determined. To assess the hazard ratios (HRs) and 95% confidence intervals (CIs) of purine intake with OC mortality, Cox proportional-hazard models were utilized.

RESULTS

During the median follow-up of 31 months (interquartile: 20-47 months), 130 deaths occurred. We observed an improved survival for the highest tercile of total purine intake compared with the lowest tercile (HR = 0.39, 95% CI = 0.19-0.80; p trend < 0.05), and this protective association was mainly attributed to xanthine intake (HR = 0.52, 95% CI = 0.29-0.94, p trend < 0.05). Additionally, we observed a curving relationship in which OC mortality decreased with total purine intake, and the magnitude of the decrease was negatively correlated with intake (p non-linear < 0.05). Significant inverse associations were also observed in subgroup analyses and sensitivity analyses according to demographic and clinical characteristics. Moreover, we observed that xanthine intake and hypoxanthine intake had a multiplicative interaction with ER and PR expression (p < 0.05), respectively.

CONCLUSION

A high total purine and xanthine intake was linked to a lower risk of OC mortality. Further clarification of these findings is warranted.

Prediagnosis Depression Rather Than Anxiety Symptoms Is Associated with Decreased Ovarian Cancer Survival: Findings from the Ovarian Cancer Follow-Up Study (OOPS)

Background: The relationship between prediagnosis depression, anxiety symptoms, and ovarian cancer (OC) survival is unknown. We aimed to explore these associations to provide further epidemiological evidence. Methods: We investigated the relationship between prediagnosis depression, anxiety symptoms, and OC survival in a prospective cohort study of newly diagnosed OC patients aged 18−79 years. Depression and anxiety symptoms were assessed using the Patient Health Questionnaire 9 and Generalized Anxiety Disorder 7 at diagnosis, respectively. Deaths were ascertained until 31 March 2021 via medical records and active follow-up. Multivariable-adjusted Cox proportional hazards regression was used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) with prediagnosis depression and anxiety symptoms and all-cause mortality of OC. Results: We found 56 (9.4%) and 235 (39.3%) OC patients with depression and anxiety symptoms, respectively. During a median follow-up of 37.2 months (interquartile range 24.7−50.2 months), 130 deaths were confirmed. Compared with non-depression symptoms, patients with prediagnosis depressive symptoms showed a significantly increased risk of OC mortality (HR = 2.10, 95% CI: 1.20−3.70). Of note, the association was still robust when focusing on the OC patients with severe depressive symptoms (HR = 2.10, 95% CI: 1.07−4.12). However, we observed no association between prediagnosis anxiety symptoms of different severity and OC mortality. Interestingly, OC patients with combined moderate depression and anxiety symptoms had a significantly increased risk of OC mortality (HR = 3.23, 95% CI: 1.14−9.11) compared to those with no symptoms of depression and anxiety. Notably, Wilms’s tumor 1 was significantly associated with depression and anxiety symptoms (p < 0.05). Conclusions: Prediagnosis depression increases the risk of OC mortality. Large multicenter studies are required to confirm this finding.

Pre-Diagnosis Sleep Status and Survival after a Diagnosis of Ovarian Cancer: A Prospective Cohort Study

Objective: To explore if pre-diagnosis sleep status is associated with overall survival (OS) of ovarian cancer (OC). Methods: This is a prospective cohort study of 853 OC patients newly diagnosed between 2015 and 2020. Sleep status was measured by the Pittsburgh Sleep Quality Index (PSQI). Vital status of patients was obtained through active follow-up and linkage to medical records and cancer registry. The Cox proportional hazards regression model was utilized to calculate hazard ratios (HRs) and 95% confidence intervals (CIs) for aforementioned associations. Results: During the follow-up period (median: 37.57 months, interquartile: 25.00 to 50.17 months), 123 (18.39%) OC patients died. The HR (95%CI) for OS of OC was 2.13 (1.42−3.18) for sleeping after 22:00, compared with sleeping before 22:00; 2.43 (1.64−3.62) for poor sleep quality, compared to good sleep quality; 2.26 (1.37−3.72) for late bed-early rise and 1.93 (1.09−3.42) for late bed-late rise, compared with early bed-early rise; 0.40 (0.24−0.67) for night sleep duration of ≥7.5 h/day, compared with 7−7.5 h/day; 0.53 (0.29−0.98) for total sleep duration of ≥8 h/day, compared with 7.5−8 h/day. Further, the interaction effects were significant between residual lesions and wake-up time, night bedtime, sleep pattern, and between total sleep duration and menopausal status, parity. Additionally, there was a significant curvilinear association between PSQI score and OS (p nonlinear <0.05). Conclusions: Pre-diagnosis longer total and night sleep duration were associated with better OS, whereas later sleeping time, poor sleep quality, and bad sleep patterns were associated with poor OS among OC survivors.

Association between pre-diagnostic dietary copper, zinc, and copper-to-zinc ratio and severity of ovarian cancer

BACKGROUND

The impact of dietary trace elements intake on ovarian cancer (OC) severity is unknown.

OBJECTIVE

We firstly explore the relationship between dietary copper (Cu), zinc (Zn), and copper-to-zinc (Cu/Zn) ratio and severity of OC.

METHODS

This cross-sectional study included 701 women from the OC follow-up study between 2015 and 2020. Dietary information was collected by a validated food frequency questionnaire (FFQ). The severity information of OC including age at diagnosis, histological type, International Federation of Gynecology and Obstetrics (FIGO) stage, and histopathologic grade was ascertained from medical records. Logistic regression model was used to estimate the odds ratios (ORs) and 95% confidence intervals (CIs) of aforementioned associations.

RESULTS

Among 701 participants, the number of patients age at diagnosis older than 50 were 443 (63.2%). The number of patients diagnosed as serous, III-IV stage, and poorly differentiation OC were 477 (68.05%), 336 (47.93%), and 597 (85.16%), respectively. In addition, compared with the lowest tertile intake, higher possibility of non-serous OC was associated with the pre-diagnosis dietary Cu (OR = 2.39, 95% CI = 1.28-4.47, p trend < 0.05) and Cu/Zn ratio (OR = 2.06, 95% CI = 1.26-3.39, P trend < 0.05) in the highest tertile intake. The risk of poorly differentiation OC at diagnosis was significant inversely related to dietary Cu intake (OR = 0.40, 95% CI = 0.18-0.88, P trend < 0.05). Besides, the results of subgroup analyses were consistent with the main findings but not all of them showed statistical significance.

CONCLUSION

Pre-diagnostic dietary Cu and Cu/Zn ratio were contributed to reducing the severity of OC at diagnosis, especially for the risk of serous OC and poorly differentiation OC.

Phytosterol intake and overall survival in newly diagnosed ovarian cancer patients: An ambispective cohort study

Background

Phytosterol is a bioactive compound existing in all plant foods, which might have anticancer properties. The aim of this study was to first assess the impact of the pre-diagnosis phytosterol intake on overall survival (OS) of patients with ovarian cancer (OC).

Materials and methods

This ambispective cohort study recruited 703 newly diagnosed OC patients to investigate the aforementioned associations. Dietary intake was assessed using a validated 111-item food frequency questionnaire. Deaths were ascertained until March 31, 2021, through active follow-up and medical records. Cox proportional hazards regression models were applied to calculate the hazard ratios (HRs) and 95% confidence intervals (CIs).

Results

During the median follow-up of 37.17 months, 130 deaths occurred. The median age at diagnosis of 703 OC patients was 53.00 (interquartile: 48.00–60.00) years. Of these, almost half patients (48.08%) were diagnosed in advanced International Federation of Gynecology and Obstetrics (FIGO) stage (III-IV). Additionally, more than half patients were serous carcinoma (68.14%), poorly differentiated (85.21%), and no residual lesions (78.66%). Patients consumed the highest tertile of dietary campesterol (HR = 0.54, 95% CI = 0.31–0.94, P trend < 0.05), stigmasterol (HR = 0.60, 95% CI = 0.37–0.98), and β-sitosterol (HR = 0.63, 95% CI = 0.40–0.99) were significantly associated with better OS compared with those with the lowest tertile of intake. The curvilinear associations were observed between total phytosterols and β-sitosterol intake and OC survival (P non-linear < 0.05). Significant associations were generally consistent across different subgroups stratified by demographical, clinical, and immunohistochemical characteristics. Moreover, there were significant interactions between phytosterol intake and age at diagnosis, body mass index, as well as expressions of Wilms’ tumor-1 and Progestogen Receptor (all P interaction < 0.05).

Conclusion

Pre-diagnosis higher campesterol, stigmasterol, and β-sitosterol intake were associated with better survival among OC patients.

A Follow-Up Study of Ovarian Cancer (OOPS): A Study Protocol

The ovarian cancer (OC) follow-up study (OOPS) is an on-going hospital-based large prospective longitudinal cohort study aimed to explore the relationship between pre/post-diagnostic biological, clinical, environmental, and lifestyle factors with focus on the diet and OC prognosis (including drug resistance, relapse, and mortality). Patients recruited during the baseline survey were between 18 and 79 years old, with histologically confirmed OC diagnosis. Their follow-up and medical treatment were conducted at the gynecological oncology ward at Shengjing Hospital of China Medical University, Shenyang, China after 2015. A total of 703 OC patients made up the final OOPS study population. The follow-up stage was conducted in both passive and active modes. In the passive mode, the follow-up was performed by linkage to the Liaoning Providence Center for Disease Control and Prevention every 6 months to obtain health outcome results. The status of lifestyle factors was re-estimated using the same measurements as those in the baseline survey. OC participants in the OOPS study completed a questionnaire and anthropometric examinations. In addition, biological specimens were collected during the baseline survey, which included blood, urine, and stool samples that were stored for further use. This article is intended to serve as an introduction to this project and to provide details for investigators who may be carry out related analysis.

Pre-diagnosis Dietary One-Carbon Metabolism Micronutrients Consumption and Ovarian Cancer Survival: A Prospective Cohort Study

Background and Aims

Epidemiological evidence on the relation between one-carbon metabolism (OCM) micronutrients intake and ovarian cancer (OC) survival are limited and conflicting. We evaluated the aforementioned associations in a prospective cohort-the Ovarian Cancer Follow-Up Study.

Methods

A total of 635 newly diagnosed OC patients aged 18–79 y were enrolled in the present study. Dietary intake related to one-carbon metabolism, including methionine, vitamins B2, B3, B6, B9, B12, choline, and betaine, was assessed using a validated 111-item food frequency questionnaire. Deaths were ascertained until March 31, 2021, via medical records and active follow-up. Cox proportional hazards regression model was used to evaluate the hazard ratios (HRs) and 95% confidence intervals (CIs) for these aforementioned associations.

Results

During a median follow-up of 37.2 months (interquartile: 24.7–50.2 months), 114 deaths were identified. We observed an improved survival with the highest compared with the lowest tertile of dietary vitamin B6 (HR = 0.52, 95%CI: 0.32–0.84, P-trend <0.05) and choline intake (HR = 0.50, 95%CI: 0.30–0.83, P-trend <0.05). No significant associations with OC survival were observed for dietary vitamins B2, B3, B9, B12, methionine, and betaine intake. We also observed a curvilinear association between vitamin B6 intake and OC survival (P non-linear <0.05).

Conclusion

Our study suggests that pre-diagnosis higher intake of vitamin B6 and choline may improve OC survival. Further clarification of these associations is warranted.