1
|
Baker JR, Umesh S, Jenab M, Schomburg L, Tjønneland A, Olsen A, Boutron-Ruault MC, Rothwell JA, Severi G, Katzke V, Johnson T, Schulze MB, Masala G, Agnoli C, Simeon V, Tumino R, Bueno-de-Mesquita HB, Gram IT, Skeie G, Bonet C, Rodriguez-Barranco M, Houerta JM, Gylling B, Van Guelpen B, Perez-Cornago A, Aglago E, Freisling H, Weiderpass E, Cross AJ, Heath AK, Hughes DJ, Fedirko V. Prediagnostic Blood Selenium Status and Mortality among Patients with Colorectal Cancer in Western European Populations. Biomedicines 2021; 9:1521. [PMID: 34829750 PMCID: PMC8614984 DOI: 10.3390/biomedicines9111521] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Revised: 10/12/2021] [Accepted: 10/15/2021] [Indexed: 12/24/2022] Open
Abstract
A higher selenium (Se) status has been shown to be associated with lower risk for colorectal cancer (CRC), but the importance of Se in survival after CRC diagnosis is not well studied. The associations of prediagnostic circulating Se status (as indicated by serum Se and selenoprotein P (SELENOP) measurements) with overall and CRC-specific mortality were estimated using multivariable Cox proportional hazards regression among 995 CRC cases (515 deaths, 396 from CRC) in the European Prospective Investigation into Cancer and Nutrition (EPIC) cohort. Se and SELENOP serum concentrations were measured on average 46 months before CRC diagnosis. Median follow-up time was 113 months. Participants with Se concentrations in the highest quintile (≥100 µg/L) had a multivariable-adjusted hazard ratio (HR) of 0.73 (95% CI: 0.52-1.02; Ptrend = 0.06) for CRC-specific mortality and 0.77 (95% CI: 0.57-1.03; Ptrend = 0.04) for overall mortality, compared with the lowest quintile (≤67.5 µg/L). Similarly, participants with SELENOP concentrations in the highest (≥5.07 mg/L) compared with the lowest quintile (≤3.53 mg/L) had HRs of 0.89 (95% CI: 0.64-1.24; Ptrend = 0.39) for CRC-specific mortality and 0.83 (95% CI: 0.62-1.11; Ptrend = 0.17) for overall mortality. Higher prediagnostic exposure to Se within an optimal concentration (100-150 µg/L) might be associated with improved survival among CRC patients, although our results were not statistically significant and additional studies are needed to confirm this potential association. Our findings may stimulate further research on selenium's role in survival among CRC patients especially among those residing in geographic regions with suboptimal Se availability.
Collapse
Affiliation(s)
- Jacqueline Roshelli Baker
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA 30322, USA; (J.R.B.); (S.U.)
| | - Sushma Umesh
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA 30322, USA; (J.R.B.); (S.U.)
| | - Mazda Jenab
- International Agency for Research on Cancer, 69372 Lyon, France; (M.J.); (E.A.); (H.F.); (E.W.)
| | - Lutz Schomburg
- Institut für Experimentelle Endokrinologie, Charité—Universitätsmedizin Berlin, CVK, Südring 10, 13353 Berlin, Germany;
| | - Anne Tjønneland
- Danish Cancer Society Research Center, Diet, Genes and Environment, Strandboulevarden 49, DK-2100 Copenhagen, Denmark; (A.T.); (A.O.)
| | - Anja Olsen
- Danish Cancer Society Research Center, Diet, Genes and Environment, Strandboulevarden 49, DK-2100 Copenhagen, Denmark; (A.T.); (A.O.)
| | - Marie-Christine Boutron-Ruault
- CESP (UMR1018), Faculté de Médecine, Université Paris-Saclay, Inserm, Gustave Roussy, 94805 Villejuif, France; (M.-C.B.-R.); (J.A.R.); (G.S.)
| | - Joseph A. Rothwell
- CESP (UMR1018), Faculté de Médecine, Université Paris-Saclay, Inserm, Gustave Roussy, 94805 Villejuif, France; (M.-C.B.-R.); (J.A.R.); (G.S.)
| | - Gianluca Severi
- CESP (UMR1018), Faculté de Médecine, Université Paris-Saclay, Inserm, Gustave Roussy, 94805 Villejuif, France; (M.-C.B.-R.); (J.A.R.); (G.S.)
- Department of Statistics, Computer Science and Applications (DISIA), University of Florence, 50123 Florence, Italy
| | - Verena Katzke
- Division of Cancer Epidemiology, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany; (V.K.); (T.J.)
| | - Theron Johnson
- Division of Cancer Epidemiology, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany; (V.K.); (T.J.)
| | - Matthias B. Schulze
- Department of Molecular Epidemiology, German Institute of Human Nutrition Potsdam-Rehbruecke, 14558 Nuthetal, Germany;
- Institute of Nutrition Science, University of Potsdam, 14558 Nuthetal, Germany
| | - Giovanna Masala
- Cancer Risk Factors and Lifestyle Epidemiology Unit, Institute for Cancer Research, Prevention and Clinical Network-ISPRO, 50141 Florence, Italy;
| | - Claudia Agnoli
- Epidemiology and Prevention Unit, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, 20133 Milan, Italy;
| | - Vittorio Simeon
- Dipartimento di Salute Mentale e Fisica e Medicina Preventiva, Università degli Studi della Campania ‘Luigi Vanvitelli’, 80121 Naples, Italy;
| | - Rosario Tumino
- Cancer Registry and Histopathology Department, Provincial Health Authority (ASP 7), 97100 Ragusa, Italy;
| | - H. Bas Bueno-de-Mesquita
- Center for Nutrition and Health, National Institute for Public Health and the Environment, 3720 Bilthoven, The Netherlands;
| | - Inger Torhild Gram
- Department of Community Medicine, The Arctic University of Norway, N-9037 Tromsø, Norway; (I.T.G.); (G.S.)
| | - Guri Skeie
- Department of Community Medicine, The Arctic University of Norway, N-9037 Tromsø, Norway; (I.T.G.); (G.S.)
| | | | - Miguel Rodriguez-Barranco
- Escuela Andaluza de Salud Pública (EASP), Instituto de Investigación Biosanitaria ibs. Granada, 18014 Granada, Spain;
- Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), 28029 Madrid, Spain;
| | - José María Houerta
- Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), 28029 Madrid, Spain;
- Department of Epidemiology, Murcia Regional Health Council, IMIB-Arrixaca, 30008 Murcia, Spain
| | - Björn Gylling
- Department of Medical Biosciences, Umea University, 901 87 Umea, Sweden;
| | | | - Aurora Perez-Cornago
- Cancer Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford OX3 7LF, UK;
| | - Elom Aglago
- International Agency for Research on Cancer, 69372 Lyon, France; (M.J.); (E.A.); (H.F.); (E.W.)
| | - Heinz Freisling
- International Agency for Research on Cancer, 69372 Lyon, France; (M.J.); (E.A.); (H.F.); (E.W.)
| | - Elisabete Weiderpass
- International Agency for Research on Cancer, 69372 Lyon, France; (M.J.); (E.A.); (H.F.); (E.W.)
| | - Amanda J. Cross
- School of Public Health, Imperial College London, London SW7 2AZ, UK; (A.J.C.); (A.K.H.)
| | - Alicia K. Heath
- School of Public Health, Imperial College London, London SW7 2AZ, UK; (A.J.C.); (A.K.H.)
| | - David J. Hughes
- Cancer Biology and Therapeutics Group, School of Biomolecular and Biomedical Science, UCD Conway Institute, University College Dublin, D04 V1W8 Dublin, Ireland
| | - Veronika Fedirko
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA 30322, USA; (J.R.B.); (S.U.)
- Department of Epidemiology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| |
Collapse
|
2
|
Abstract
PURPOSE OF REVIEW Selenium, a trace element, is ubiquitous in the environment. The main source of human exposure is diet. Despite its nutritional benefits, it is one of the most toxic naturally occurring elements. Selenium deficiency and overexposure have been associated with adverse health effects. Its level of toxicity may depend on its chemical form, as inorganic and organic species have distinct biological properties. RECENT FINDINGS Nonexperimental and experimental studies have generated insufficient evidence for a role of selenium deficiency in human disease, with the exception of Keshan disease, a cardiomyopathy. Conversely, recent randomized trials have indicated that selenium overexposure is positively associated with type 2 diabetes and high-grade prostate cancer. In addition, a natural experiment has suggested an association between overexposure to inorganic hexavalent selenium and two neurodegenerative diseases, amyotrophic lateral sclerosis and Parkinson's disease. Risk assessments should be revised to incorporate the results of studies demonstrating toxic effects of selenium. Additional observational studies and secondary analyses of completed randomized trials are needed to address the uncertainties regarding the health risks of selenium exposure.
Collapse
|
3
|
Vinceti M, Vicentini M, Wise LA, Sacchettini C, Malagoli C, Ballotari P, Filippini T, Malavolti M, Rossi PG. Cancer incidence following long-term consumption of drinking water with high inorganic selenium content. THE SCIENCE OF THE TOTAL ENVIRONMENT 2018; 635:390-396. [PMID: 29674262 DOI: 10.1016/j.scitotenv.2018.04.097] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 04/06/2018] [Accepted: 04/06/2018] [Indexed: 06/08/2023]
Abstract
Selenium, a trace element to which humans are exposed mainly through diet, has been involved in the etiology of human cancer. We investigated the long-term effects of selenium exposure on cancer incidence using data from a natural experiment in Northern Italy. During the 1970s-1980s, in a part of the Italian municipality of Reggio Emilia, residents were inadvertently exposed to unusually high levels of inorganic hexavalent selenium (selenate) through drinking water. We followed the exposed residents for 28years, generating data on incidence (when available) and mortality rates for selected cancer sites; the remaining municipal residents comprised the unexposed (reference) group. We observed no substantial difference in overall cancer incidence comparing exposed and unexposed cohorts. We detected, however, a higher incidence of cancer at some sites, and for a few of them, namely cancers of the buccal cavity and pharynx, melanoma, urinary tract and lymphoid tissue, the excess incidence was particularly evident in the first period of follow-up but decreased over time. Overall, these results suggest that consumption of water with levels of selenium in its inorganic hexavalent form close to the European standard, 10μg/L, may have unfavourable effects on cancer incidence.
Collapse
Affiliation(s)
- Marco Vinceti
- CREAGEN, Research Center of Environmental, Genetic and Nutritional Epidemiology, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Via Campi 287, 41125 Modena, Italy; Department of Epidemiology, Boston University School of Public Health, 715 Albany Street, Boston, MA, United States.
| | - Massimo Vicentini
- Epidemiology Unit, Local Health Authority, IRCCS, Viale Giovanni Amendola, 2, 42122 Reggio Emilia, Italy
| | - Lauren A Wise
- Department of Epidemiology, Boston University School of Public Health, 715 Albany Street, Boston, MA, United States
| | - Claudio Sacchettini
- Epidemiology Unit, Local Health Authority, IRCCS, Viale Giovanni Amendola, 2, 42122 Reggio Emilia, Italy
| | - Carlotta Malagoli
- CREAGEN, Research Center of Environmental, Genetic and Nutritional Epidemiology, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Via Campi 287, 41125 Modena, Italy
| | - Paola Ballotari
- Epidemiology Unit, Local Health Authority, IRCCS, Viale Giovanni Amendola, 2, 42122 Reggio Emilia, Italy
| | - Tommaso Filippini
- CREAGEN, Research Center of Environmental, Genetic and Nutritional Epidemiology, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Via Campi 287, 41125 Modena, Italy
| | - Marcella Malavolti
- CREAGEN, Research Center of Environmental, Genetic and Nutritional Epidemiology, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Via Campi 287, 41125 Modena, Italy
| | - Paolo Giorgi Rossi
- Epidemiology Unit, Local Health Authority, IRCCS, Viale Giovanni Amendola, 2, 42122 Reggio Emilia, Italy
| |
Collapse
|
4
|
Vinceti M, Crespi CM, Malagoli C, Bottecchi I, Ferrari A, Sieri S, Krogh V, Alber D, Bergomi M, Seidenari S, Pellacani G. A Case-Control Study of the Risk of Cutaneous Melanoma Associated with Three Selenium Exposure Indicators. TUMORI JOURNAL 2018; 98:287-95. [DOI: 10.1177/030089161209800302] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Aims and background A direct association between exposure to the metalloid selenium and risk of cutaneous melanoma has been suggested by some observational and experimental cohort studies, whereas other studies have yielded inconsistent results. Since some of the inconsistencies may be due to exposure misclassification arising from the use of exposure indicators that do not adequately reflect body tissue selenium content or the levels of the biologically relevant species of this metalloid, we examined this issue using multiple indicators of exposure. Methods We analyzed the relation of selenium exposure with risk of cutaneous melanoma using two different biomarkers, plasma and toenail selenium concentration, and estimated dietary selenium intake in a population-based case-control series (54 cases, 56 controls) from an Italian community. Results In unmatched and matched logistic regression models as well as nonparametric generalized additive models, higher plasma selenium levels were strongly associated with excess disease risk. In contrast, toenail and dietary selenium exhibited little relation with melanoma risk. The pattern of correlation among indicators of exposure differed by disease status, with dietary intake associated with plasma selenium levels in patients but not in controls. Conclusions Our data showed that different selenium exposure indicators can yield different inferences about melanoma risk. Although the series was small, our results are consistent with a positive association between circulating levels of selenium and melanoma risk. Further investigation of the exposure classification performance of various selenium biomarkers and of metabolic patterns of the metalloid and of its speciation are needed to help elucidate the relation between selenium exposure and human health.
Collapse
Affiliation(s)
- Marco Vinceti
- Environmental, Genetic and Nutritional
Epidemiology Research Center (CREAGEN), Department of Public Health Sciences,
University of Modena and Reggio Emilia, Reggio Emilia, Italy
| | - Catherine M Crespi
- Department of Biostatistics,
University of California Los Angeles School of Public Health, Los Angeles,
California, USA
| | - Carlotta Malagoli
- Environmental, Genetic and Nutritional
Epidemiology Research Center (CREAGEN), Department of Public Health Sciences,
University of Modena and Reggio Emilia, Reggio Emilia, Italy
| | - Ilaria Bottecchi
- Environmental, Genetic and Nutritional
Epidemiology Research Center (CREAGEN), Department of Public Health Sciences,
University of Modena and Reggio Emilia, Reggio Emilia, Italy
| | - Angela Ferrari
- Environmental, Genetic and Nutritional
Epidemiology Research Center (CREAGEN), Department of Public Health Sciences,
University of Modena and Reggio Emilia, Reggio Emilia, Italy
| | - Sabina Sieri
- Nutritional Epidemiology Unit,
National Cancer Institute, Milan, Italy
| | - Vittorio Krogh
- Nutritional Epidemiology Unit,
National Cancer Institute, Milan, Italy
| | - Dorothea Alber
- Department of Trace Element Research
in the Life Sciences, Helmholtz Center, Berlin, Germany
| | - Margherita Bergomi
- Environmental, Genetic and Nutritional
Epidemiology Research Center (CREAGEN), Department of Public Health Sciences,
University of Modena and Reggio Emilia, Reggio Emilia, Italy
| | - Stefania Seidenari
- Department of Dermatology, University
of Modena and Reggio Emilia, Modena, Italy
| | - Giovanni Pellacani
- Department of Dermatology, University
of Modena and Reggio Emilia, Modena, Italy
| |
Collapse
|
5
|
Vinceti M, Filippini T, Del Giovane C, Dennert G, Zwahlen M, Brinkman M, Zeegers MPA, Horneber M, D'Amico R, Crespi CM. Selenium for preventing cancer. Cochrane Database Syst Rev 2018; 1:CD005195. [PMID: 29376219 PMCID: PMC6491296 DOI: 10.1002/14651858.cd005195.pub4] [Citation(s) in RCA: 121] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND This review is the third update of the Cochrane review "Selenium for preventing cancer". Selenium is a naturally occurring element with both nutritional and toxicological properties. Higher selenium exposure and selenium supplements have been suggested to protect against several types of cancer. OBJECTIVES To gather and present evidence needed to address two research questions:1. What is the aetiological relationship between selenium exposure and cancer risk in humans?2. Describe the efficacy of selenium supplementation for cancer prevention in humans. SEARCH METHODS We updated electronic searches of the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 2), MEDLINE (Ovid, 2013 to January 2017, week 4), and Embase (2013 to 2017, week 6), as well as searches of clinical trial registries. SELECTION CRITERIA We included randomised controlled trials (RCTs) and longitudinal observational studies that enrolled adult participants. DATA COLLECTION AND ANALYSIS We performed random-effects (RE) meta-analyses when two or more RCTs were available for a specific outcome. We conducted RE meta-analyses when five or more observational studies were available for a specific outcome. We assessed risk of bias in RCTs and in observational studies using Cochrane's risk assessment tool and the Newcastle-Ottawa Scale, respectively. We considered in the primary analysis data pooled from RCTs with low risk of bias. We assessed the certainty of evidence by using the GRADE approach. MAIN RESULTS We included 83 studies in this updated review: two additional RCTs (10 in total) and a few additional trial reports for previously included studies. RCTs involved 27,232 participants allocated to either selenium supplements or placebo. For analyses of RCTs with low risk of bias, the summary risk ratio (RR) for any cancer incidence was 1.01 (95% confidence interval (CI) 0.93 to 1.10; 3 studies, 19,475 participants; high-certainty evidence). The RR for estimated cancer mortality was 1.02 (95% CI 0.80 to 1.30; 1 study, 17,444 participants). For the most frequently investigated site-specific cancers, investigators provided little evidence of any effect of selenium supplementation. Two RCTs with 19,009 participants indicated that colorectal cancer was unaffected by selenium administration (RR 0.99, 95% CI 0.69 to 1.43), as were non-melanoma skin cancer (RR 1.16, 95% CI 0.30 to 4.42; 2 studies, 2027 participants), lung cancer (RR 1.16, 95% CI 0.89 to 1.50; 2 studies, 19,009 participants), breast cancer (RR 2.04, 95% CI 0.44 to 9.55; 1 study, 802 participants), bladder cancer (RR 1.07, 95% CI 0.76 to 1.52; 2 studies, 19,009 participants), and prostate cancer (RR 1.01, 95% CI 0.90 to 1.14; 4 studies, 18,942 participants). Certainty of the evidence was high for all of these cancer sites, except for breast cancer, which was of moderate certainty owing to imprecision, and non-melanoma skin cancer, which we judged as moderate certainty owing to high heterogeneity. RCTs with low risk of bias suggested increased melanoma risk.Results for most outcomes were similar when we included all RCTs in the meta-analysis, regardless of risk of bias. Selenium supplementation did not reduce overall cancer incidence (RR 0.99, 95% CI 0.86 to 1.14; 5 studies, 21,860 participants) nor mortality (RR 0.81, 95% CI 0.49 to 1.32; 2 studies, 18,698 participants). Summary RRs for site-specific cancers showed limited changes compared with estimates from high-quality studies alone, except for liver cancer, for which results were reversed.In the largest trial, the Selenium and Vitamin E Cancer Trial, selenium supplementation increased risks of alopecia and dermatitis, and for participants with highest background selenium status, supplementation also increased risk of high-grade prostate cancer. RCTs showed a slightly increased risk of type 2 diabetes associated with supplementation. A hypothesis generated by the Nutritional Prevention of Cancer Trial - that individuals with low blood selenium levels could reduce their risk of cancer (particularly prostate cancer) by increasing selenium intake - has not been confirmed. As RCT participants have been overwhelmingly male (88%), we could not assess the potential influence of sex or gender.We included 15 additional observational cohort studies (70 in total; over 2,360,000 participants). We found that lower cancer incidence (summary odds ratio (OR) 0.72, 95% CI 0.55 to 0.93; 7 studies, 76,239 participants) and lower cancer mortality (OR 0.76, 95% CI 0.59 to 0.97; 7 studies, 183,863 participants) were associated with the highest category of selenium exposure compared with the lowest. Cancer incidence was lower in men (OR 0.72, 95% CI 0.46 to 1.14, 4 studies, 29,365 men) than in women (OR 0.90, 95% CI 0.45 to 1.77, 2 studies, 18,244 women). Data show a decrease in risk of site-specific cancers for stomach, colorectal, lung, breast, bladder, and prostate cancers. However, these studies have major weaknesses due to study design, exposure misclassification, and potential unmeasured confounding due to lifestyle or nutritional factors covarying with selenium exposure beyond those taken into account in multi-variable analyses. In addition, no evidence of a dose-response relation between selenium status and cancer risk emerged. Certainty of evidence was very low for each outcome. Some studies suggested that genetic factors might modify the relation between selenium and cancer risk - an issue that merits further investigation. AUTHORS' CONCLUSIONS Well-designed and well-conducted RCTs have shown no beneficial effect of selenium supplements in reducing cancer risk (high certainty of evidence). Some RCTs have raised concerns by reporting a higher incidence of high-grade prostate cancer and type 2 diabetes in participants with selenium supplementation. No clear evidence of an influence of baseline participant selenium status on outcomes has emerged in these studies.Observational longitudinal studies have shown an inverse association between selenium exposure and risk of some cancer types, but null and direct relations have also been reported, and no systematic pattern suggesting dose-response relations has emerged. These studies suffer from limitations inherent to the observational design, including exposure misclassification and unmeasured confounding.Overall, there is no evidence to suggest that increasing selenium intake through diet or supplementation prevents cancer in humans. However, more research is needed to assess whether selenium may modify the risk of cancer in individuals with a specific genetic background or nutritional status, and to investigate possible differential effects of various forms of selenium.
Collapse
Affiliation(s)
- Marco Vinceti
- Boston University School of Public HealthDepartment of Epidemiology715 Albany StreetBoston, MAUSA02118
- University of Modena and Reggio EmiliaResearch Center in Environmental, Nutritional and Genetic Epidemiology (CREAGEN), Department of Biomedical, Metabolic and Neural SciencesVia Campi 287ModenaItaly41125
| | - Tommaso Filippini
- University of Modena and Reggio EmiliaResearch Center in Environmental, Nutritional and Genetic Epidemiology (CREAGEN), Department of Biomedical, Metabolic and Neural SciencesVia Campi 287ModenaItaly41125
| | - Cinzia Del Giovane
- University of BernInstitute of Primary Health Care (BIHAM)Gesellschaftsstrasse 49BernSwitzerland3012
- University of Modena and Reggio EmiliaCochrane Italy, Department of Diagnostic, Clinical and Public Health MedicineVia del Pozzo, 71ModenaItaly41100
| | - Gabriele Dennert
- University of Applied Sciences DortmundSocial Medicine and Public Health with Focus on Gender and Diversity, Department of Applied Social SciencesEmil‐Figge‐Str. 44DortmundGermanyD‐44227
| | - Marcel Zwahlen
- University of BernInstitute of Social and Preventive Medicine (ISPM)Finkelhubelweg11BernSwitzerland3012
| | - Maree Brinkman
- Nutrition Biomed Research InstituteDepartment of Nutritional Epidemiology and Clinical StudiesArgyle Place SouthMelbourneVictoriaAustralia3053
- Chairgroup of Complex Genetics and Epidemiology, School for Nutrition and Translational Research in Metabolism, Care and Public Health Research InstituteUnit of Nutritional and Cancer EpidemiologyMaastricht UniversityMaastrichtNetherlands
| | | | - Markus Horneber
- Paracelsus Medical University, Klinikum NurembergDepartment of Internal Medicine, Division of Oncology and HematologyProf.‐Ernst‐Nathan‐Str. 1NurembergGermanyD‐90419
| | - Roberto D'Amico
- University of Modena and Reggio EmiliaCochrane Italy, Department of Diagnostic, Clinical and Public Health MedicineVia del Pozzo, 71ModenaItaly41100
| | - Catherine M Crespi
- University of California Los AngelesBiostatisticsFielding School of Public Health650 Charles Young Drive South, A2‐125 CHS, Box 956900Los AngelesCaliforniaUSA90095‐6900
| | | |
Collapse
|
6
|
Abstract
The relation between selenium and cancer has been one of the most hotly debated topics in human health over the last decades. Early observational studies reported an inverse relation between selenium exposure and cancer risk. Subsequently, randomized controlled trials showed that selenium supplementation does not reduce the risk of cancer and may even increase it for some types, including advanced prostate cancer and skin cancer. An increased risk of diabetes has also been reported. These findings have been consistent in the most methodologically sound trials, suggesting that the early observational studies were misleading. Other studies have investigated selenium compounds as adjuvant therapy for cancer. Though there is currently insufficient evidence regarding the utility and safety of selenium compounds for such treatments, this issue is worthy of further investigation. The study of selenium and cancer is complicated by the existence of a diverse array of organic and inorganic selenium compounds, each with distinct biological properties, and this must be taken into consideration in the interpretation of both observational and experimental human studies.
Collapse
Affiliation(s)
- Marco Vinceti
- Environmental, Genetic and Nutritional Epidemiology Research Center (CREAGEN), University of Modena and Reggio Emilia, Modena, Italy; Boston University School of Public Health, Boston, MA, United States.
| | - Tommaso Filippini
- Environmental, Genetic and Nutritional Epidemiology Research Center (CREAGEN), University of Modena and Reggio Emilia, Modena, Italy
| | - Silvia Cilloni
- Environmental, Genetic and Nutritional Epidemiology Research Center (CREAGEN), University of Modena and Reggio Emilia, Modena, Italy
| | - Catherine M Crespi
- Jonsson Comprehensive Cancer Center, UCLA Fielding School of Public Health, University of California, Los Angeles, CA, United States
| |
Collapse
|
7
|
Bhavani P, Subramanian P, Shanmugapriya S. Modulating effects of vanillic acid on circadian pattern of indices of redox homeostasis in N-Methly-N′-Nitro-N-Nitrosoguanidine induced endometrial carcinoma in rats. BIOL RHYTHM RES 2016. [DOI: 10.1080/09291016.2016.1173362] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
|
8
|
Jablonska E, Vinceti M. Selenium and Human Health: Witnessing a Copernican Revolution? JOURNAL OF ENVIRONMENTAL SCIENCE AND HEALTH. PART C, ENVIRONMENTAL CARCINOGENESIS & ECOTOXICOLOGY REVIEWS 2015; 33:328-68. [PMID: 26074278 DOI: 10.1080/10590501.2015.1055163] [Citation(s) in RCA: 95] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
In humans, selenium was hypothesized to lower the risk of several chronic diseases, mainly due to the antioxidant activity of selenium-containing proteins. Recent epidemiologic and laboratory studies, however, are changing our perception of the biological effects of this nutritionally essential trace element. We reviewed the most recent epidemiologic and biochemical literature on selenium, synthesizing the findings from these studies into a unifying view. Randomized trials have shown that selenium did not protect against cancer and other chronic diseases, but even increased the risk of specific neoplasms such as advanced prostate cancer and skin cancer, in addition to type 2 diabetes. Biochemical studies indicate that selenium may exert a broad pattern of toxic effects at unexpectedly low concentrations. Furthermore, its upregulation of antioxidant proteins (selenium-dependent and selenium-independent) may be a manifestation of self-induced oxidative stress. In conclusion, toxic effects of selenium species occur at lower concentrations than previously believed. Those effects may include a large range of proteomic changes and adverse health effects in humans. Since the effects of environmental exposure to this element on human health still remain partially unknown, but are potentially serious, the toxicity of selenium exposure should be further investigated and considered as a public health priority.
Collapse
Affiliation(s)
- Ewa Jablonska
- a Department of Toxicology and Carcinogenesis , Nofer Institute of Occupational Medicine , Lodz , Poland
| | | |
Collapse
|
9
|
Vinceti M, Dennert G, Crespi CM, Zwahlen M, Brinkman M, Zeegers MPA, Horneber M, D'Amico R, Del Giovane C. Selenium for preventing cancer. Cochrane Database Syst Rev 2014; 2014:CD005195. [PMID: 24683040 PMCID: PMC4441528 DOI: 10.1002/14651858.cd005195.pub3] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND This review is an update of the first Cochrane publication on selenium for preventing cancer (Dennert 2011).Selenium is a metalloid with both nutritional and toxicological properties. Higher selenium exposure and selenium supplements have been suggested to protect against several types of cancers. OBJECTIVES Two research questions were addressed in this review: What is the evidence for:1. an aetiological relation between selenium exposure and cancer risk in humans? and2. the efficacy of selenium supplementation for cancer prevention in humans? SEARCH METHODS We conducted electronic searches of the Cochrane Central Register of Controlled Trials (CENTRAL, 2013, Issue 1), MEDLINE (Ovid, 1966 to February 2013 week 1), EMBASE (1980 to 2013 week 6), CancerLit (February 2004) and CCMed (February 2011). As MEDLINE now includes the journals indexed in CancerLit, no further searches were conducted in this database after 2004. SELECTION CRITERIA We included prospective observational studies (cohort studies including sub-cohort controlled studies and nested case-control studies) and randomised controlled trials (RCTs) with healthy adult participants (18 years of age and older). DATA COLLECTION AND ANALYSIS For observational studies, we conducted random effects meta-analyses when five or more studies were retrieved for a specific outcome. For RCTs, we performed random effects meta-analyses when two or more studies were available. The risk of bias in observational studies was assessed using forms adapted from the Newcastle-Ottawa Quality Assessment Scale for cohort and case-control studies; the criteria specified in the Cochrane Handbook for Systematic Reviews of Interventions were used to evaluate the risk of bias in RCTs. MAIN RESULTS We included 55 prospective observational studies (including more than 1,100,000 participants) and eight RCTs (with a total of 44,743 participants). For the observational studies, we found lower cancer incidence (summary odds ratio (OR) 0.69, 95% confidence interval (CI) 0.53 to 0.91, N = 8) and cancer mortality (OR 0.60, 95% CI 0.39 to 0.93, N = 6) associated with higher selenium exposure. Gender-specific subgroup analysis provided no clear evidence of different effects in men and women (P value 0.47), although cancer incidence was lower in men (OR 0.66, 95% CI 0.42 to 1.05, N = 6) than in women (OR 0.90, 95% CI 0.45 to 1.77, N = 2). The most pronounced decreases in risk of site-specific cancers were seen for stomach, bladder and prostate cancers. However, these findings have limitations due to study design, quality and heterogeneity that complicate interpretation of the summary statistics. Some studies suggested that genetic factors may modify the relation between selenium and cancer risk-a hypothesis that deserves further investigation.In RCTs, we found no clear evidence that selenium supplementation reduced the risk of any cancer (risk ratio (RR) 0.90, 95% CI 0.70 to 1.17, two studies, N = 4765) or cancer-related mortality (RR 0.81, 95% CI 0.49 to 1.32, two studies, N = 18,698), and this finding was confirmed when the analysis was restricted to studies with low risk of bias. The effect on prostate cancer was imprecise (RR 0.90, 95% CI 0.71 to 1.14, four studies, N = 19,110), and when the analysis was limited to trials with low risk of bias, the interventions showed no effect (RR 1.02, 95% CI 0.90 to 1.14, three studies, N = 18,183). The risk of non-melanoma skin cancer was increased (RR 1.44, 95% CI 0.95 to 1.17, three studies, N = 1900). Results of two trials-the Nutritional Prevention of Cancer Trial (NPCT) and the Selenium and Vitamin E Cancer Trial (SELECT)-also raised concerns about possible increased risk of type 2 diabetes, alopecia and dermatitis due to selenium supplements. An early hypothesis generated by NPCT that individuals with the lowest blood selenium levels at baseline could reduce their risk of cancer, particularly of prostate cancer, by increasing selenium intake has not been confirmed by subsequent trials. As the RCT participants were overwhelmingly male (94%), gender differences could not be systematically assessed. AUTHORS' CONCLUSIONS Although an inverse association between selenium exposure and the risk of some types of cancer was found in some observational studies, this cannot be taken as evidence of a causal relation, and these results should be interpreted with caution. These studies have many limitations, including issues with assessment of exposure to selenium and to its various chemical forms, heterogeneity, confounding and other biases. Conflicting results including inverse, null and direct associations have been reported for some cancer types.RCTs assessing the effects of selenium supplementation on cancer risk have yielded inconsistent results, although the most recent studies, characterised by a low risk of bias, found no beneficial effect on cancer risk, more specifically on risk of prostate cancer, as well as little evidence of any influence of baseline selenium status. Rather, some trials suggest harmful effects of selenium exposure. To date, no convincing evidence suggests that selenium supplements can prevent cancer in humans.
Collapse
Affiliation(s)
- Marco Vinceti
- University of Modena and Reggio EmiliaDepartment of Diagnostic, Clinical and Public Health MedicineVia Campi 287ModenaItaly41125
| | - Gabriele Dennert
- University of Applied Sciences DortmundSocial Medicine and Public Health with Focus on Gender and Diversity, Department of Applied Social SciencesEmil‐Figge‐Str. 44DortmundGermanyD‐44227
| | - Catherine M Crespi
- University of California Los AngelesBiostatisticsFielding School of Public Health650 Charles Young Drive South, A2‐125 CHS, Box 95690090095‐6900USALos Angeles
| | - Marcel Zwahlen
- University of BernInstitute of Social and Preventive MedicineFinkelhubelweg11BernSwitzerland3012
| | - Maree Brinkman
- Cancer Council VictoriaCancer Epidemiology Centre615 St Kilda RdMelbourneAustralia3004
| | | | - Markus Horneber
- Paracelsus Medical University, Klinikum NurembergDepartment of Internal Medicine, Division of Oncology and HematologyProf.‐Ernst‐Nathan‐Str. 1NurembergGermanyD‐90419
| | - Roberto D'Amico
- University of Modena and Reggio EmiliaItalian Cochrane Centre, Department of Diagnostic, Clinical and Public Health MedicineVia del Pozzo 71ModenaItaly41124
| | - Cinzia Del Giovane
- University of Modena and Reggio EmiliaItalian Cochrane Centre, Department of Diagnostic, Clinical and Public Health MedicineVia del Pozzo 71ModenaItaly41124
| |
Collapse
|
10
|
Vinceti M, Crespi CM, Bonvicini F, Malagoli C, Ferrante M, Marmiroli S, Stranges S. The need for a reassessment of the safe upper limit of selenium in drinking water. THE SCIENCE OF THE TOTAL ENVIRONMENT 2013; 443:633-42. [PMID: 23220755 DOI: 10.1016/j.scitotenv.2012.11.025] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2012] [Revised: 11/06/2012] [Accepted: 11/06/2012] [Indexed: 05/25/2023]
Abstract
Results of recent epidemiologic studies suggest the need to reassess the safe upper limit in drinking water of selenium, a metalloid with both toxicological and nutritional properties. Observational and experimental human studies on health effects of organic selenium compounds consumed through diet or supplements, and of inorganic selenium consumed through drinking water, have shown that human toxicity may occur at much lower levels than previously surmised. Evidence indicates that the chemical form of selenium strongly influences its toxicity, and that its biological activity may differ in different species, emphasizing the importance of the few human studies on health effects of the specific selenium compounds found in drinking water. Epidemiologic studies that investigated the effects of selenate, an inorganic selenium species commonly found in drinking water, together with evidence of toxicity of inorganic selenium at low levels in from in vitro and animal studies, indicate that health risks may occur at exposures below the current European Union and World Health Organization upper limit and guideline of 10 and 40 μg/l, respectively, and suggest reduction to 1 μg/l in order to adequately protect human health. Although few drinking waters are currently known to have selenium concentrations exceeding this level, the public health importance of this issue should not be overlooked, and further epidemiologic research is critically needed in this area.
Collapse
Affiliation(s)
- Marco Vinceti
- CREAGEN - Environmental, Genetic and Nutritional Epidemiology Research Center, Department of Diagnostic and Clinical Medicine and of Public Health, University of Modena and Reggio Emilia, Modena, Italy.
| | | | | | | | | | | | | |
Collapse
|
11
|
Vinceti M, Crespi CM, Malagoli C, Bottecchi I, Ferrari A, Sieri S, Krogh V, Alber D, Bergomi M, Seidenari S, Pellacani G. A case-control study of the risk of cutaneous melanoma associated with three selenium exposure indicators. TUMORI JOURNAL 2012. [PMID: 22825502 DOI: 10.1700/1125.12394] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS AND BACKGROUND A direct association between exposure to the metalloid selenium and risk of cutaneous melanoma has been suggested by some observational and experimental cohort studies, whereas other studies have yielded inconsistent results. Since some of the inconsistencies may be due to exposure misclassification arising from the use of exposure indicators that do not adequately reflect body tissue selenium content or the levels of the biologically relevant species of this metalloid, we examined this issue using multiple indicators of exposure. METHODS We analyzed the relation of selenium exposure with risk of cutaneous melanoma using two different biomarkers, plasma and toenail selenium concentration, and estimated dietary selenium intake in a population-based case-control series (54 cases, 56 controls) from an Italian community. RESULTS In unmatched and matched logistic regression models as well as nonparametric generalized additive models, higher plasma selenium levels were strongly associated with excess disease risk. In contrast, toenail and dietary selenium exhibited little relation with melanoma risk. The pattern of correlation among indicators of exposure differed by disease status, with dietary intake associated with plasma selenium levels in patients but not in controls. CONCLUSIONS Our data showed that different selenium exposure indicators can yield different inferences about melanoma risk. Although the series was small, our results are consistent with a positive association between circulating levels of selenium and melanoma risk. Further investigation of the exposure classification performance of various selenium biomarkers and of metabolic patterns of the metalloid and of its speciation are needed to help elucidate the relation between selenium exposure and human health.
Collapse
Affiliation(s)
- Marco Vinceti
- Environmental, Genetic and Nutritional Epidemiology Research Center, Department of Public Health Sciences, University of Modena and Reggio Emilia, Reggio Emilia, Italy.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
12
|
Abstract
BACKGROUND Selenium is a trace element essential to humans. Higher selenium exposure and selenium supplements have been suggested to protect against several types of cancers. OBJECTIVES Two research questions were addressed in this review: What is the evidence for1. an aetiological relationship between selenium exposure and cancer risk in women and men?2. the efficacy of selenium supplementation for cancer prevention in women and men? SEARCH STRATEGY We searched electronic databases and bibliographies of reviews and included publications. SELECTION CRITERIA We included prospective observational studies to answer research question (a) and randomised controlled trials (RCTs) to answer research question (b). DATA COLLECTION AND ANALYSIS We conducted random effects meta-analyses of epidemiological data when five or more studies were retrieved for a specific outcome. We made a narrative summary of data from RCTs. MAIN RESULTS We included 49 prospective observational studies and six RCTs. In epidemiologic data, we found a reduced cancer incidence (summary odds ratio (OR) 0.69 (95% confidence interval (CI) 0.53 to 0.91) and mortality (OR 0.55, 95% CI 0.36 to 0.83) with higher selenium exposure. Cancer risk was more pronouncedly reduced in men (incidence: OR 0.66, 95% CI 0.42 to 1.05) than in women (incidence: OR 0.90, 95% CI 0.45 to 1.77). These findings have potential limitations due to study design, quality and heterogeneity of the data, which complicated the interpretation of the summary statistics.The RCTs found no protective efficacy of selenium yeast supplementation against non-melanoma skin cancer or L-selenomethionine supplementation against prostate cancer. Study results for the prevention of liver cancer with selenium supplements were inconsistent and studies had an unclear risk of bias. The results of the Nutritional Prevention of Cancer Trial (NPCT) and SELECT raised concerns about possible harmful effects of selenium supplements. AUTHORS' CONCLUSIONS No reliable conclusions can be drawn regarding a causal relationship between low selenium exposure and an increased risk of cancer. Despite evidence for an inverse association between selenium exposure and the risk of some types of cancer, these results should be interpreted with care due to the potential limiting factors of heterogeneity and influences of unknown biases, confounding and effect modification.The effect of selenium supplementation from RCTs yielded inconsistent results. To date, there is no convincing evidence that selenium supplements can prevent cancer in men, women or children.
Collapse
Affiliation(s)
- Gabriele Dennert
- Institut für Transdisziplinäre Gesundheitsforschung, Berlin, Germany
| | - Marcel Zwahlen
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Maree Brinkman
- Department of General Practice, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Marco Vinceti
- Department of Public Health Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Maurice P A Zeegers
- Unit of Genetic Epidemiology, Department of Public Health & Epidemiology, Birmingham, UK
| | - Markus Horneber
- Medizinische Klinik 5-Schwerpunkt Onkologie/Haematologie, Klinikum Nord, Nuernberg, Germany
| |
Collapse
|
13
|
Kumar BS, Tiwari SK, Manoj G, Kunwar A, Amrita N, Sivaram G, Abid Z, Ahmad A, Khan AA, Priyadarsini KI. Anti-unlcer and antimicrobial activities of sodium selenite against Helicobacter pylori: In vitro and in vivo evaluation. ACTA ACUST UNITED AC 2010; 42:266-74. [DOI: 10.3109/00365540903493707] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
|
14
|
Vinceti M, Maraldi T, Bergomi M, Malagoli C. Risk of chronic low-dose selenium overexposure in humans: insights from epidemiology and biochemistry. REVIEWS ON ENVIRONMENTAL HEALTH 2009; 24:231-248. [PMID: 19891121 DOI: 10.1515/reveh.2009.24.3.231] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
The latest developments of epidemiologic and biochemical research suggest that current upper limits of intake for dietary selenium and for overall selenium exposure may be inadequate to protect human health. In particular, recent experimental and observational prospective studies indicate a diabetogenic effect of selenium at unexpectedly low levels of intake. Experimental evidence from laboratory studies and veterinary medicine appears to confirm previous epidemiologic observations that selenium overexposure is associated with an increased risk of amyotrophic lateral sclerosis, and a recent large trial indicated no beneficial effect in preventing prostate cancer. Moreover, the pro-oxidant properties of selenium species and the observation that the selenium-containing enzymes glutathione peroxidases are induced by oxidative stress imply that the increase in enzymatic activity induced by this metalloid may represent at least in part a compensatory response. Taken together, the data indicate that the upper safe limit of organic and inorganic selenium intake in humans may be lower than has been thought and that low-dose chronic overexposure to selenium may be considerably more widespread than supposed.
Collapse
Affiliation(s)
- Marco Vinceti
- CREAGEN-Environmental, Genetic & Nutritional Epidemiology Research Center, Department of Public Health Sciences, University of Modena and Reggio Emilia, Modena, Italy.
| | | | | | | |
Collapse
|
15
|
Koriyama C, Campos FI, Yamamoto M, Serra M, Carrasquilla G, Carrascal E, Akiba S. Toenail selenium levels and gastric cancer risk in Cali, Colombia. J Toxicol Sci 2008; 33:227-35. [DOI: 10.2131/jts.33.227] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Affiliation(s)
- Chihaya Koriyama
- Department of Epidemiology and Preventive Medicine, Kagoshima University Graduate School of Medical and Dental Sciences
| | - Francia I. Campos
- Department of Epidemiology and Preventive Medicine, Kagoshima University Graduate School of Medical and Dental Sciences
| | - Megumi Yamamoto
- Department of Basic Medical Sciences, National Institute for Minamata Disease
| | | | - Gabriel Carrasquilla
- Department of Microbiology, Faculty of Health Sciences, Universidad del Valle, San Fernando
| | - Edwin Carrascal
- Department of Pathology, Faculty of Health Sciences, Universidad del Valle, San Fernando
| | - Suminori Akiba
- Department of Epidemiology and Preventive Medicine, Kagoshima University Graduate School of Medical and Dental Sciences
| |
Collapse
|
16
|
N/A, 孙 丹, 房 静. N/A. Shijie Huaren Xiaohua Zazhi 2006; 14:1502-1506. [DOI: 10.11569/wcjd.v14.i15.1502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
|
17
|
Donma O, Donma MM, Sonmez S. Metal speciation, phytochemicals and Helicobacter pylori infection. Med Hypotheses 2006; 67:545-9. [PMID: 16632229 DOI: 10.1016/j.mehy.2006.02.045] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2006] [Accepted: 02/20/2006] [Indexed: 10/24/2022]
Abstract
Helicobacter pylori (HP) acquired in childhood is an important risk factor for gastric carcinoma. Once colonization is established, infection may be carried for life. The relationship between food intake and HP infection, the presence of metals and phytochemicals closely associated with oxidative stress within everyday diet are important topics to be considered. The possible anti-HP effects of phytochemicals, prooxidant effects exerted in the presence of metal species, intimate relations between some metals and HP, bivalent effects of some metal species in cancer, interactions between metal species and phytochemicals in HP infection are the topics, which require further research. Formulas or diets enriched with phytochemicals and metals against HP and, which are devoid of metals known to favour the growth of HP, may be suggested as the supplements to the classical treatment regimens. The importance of collective consideration of HP, metal species and phytochemicals should be emphasized.
Collapse
Affiliation(s)
- Orkide Donma
- Istanbul University, Cerrahpasa Medical Faculty, Istanbul, Turkey
| | | | | |
Collapse
|