The built environment and cancer survivorship: A scoping review

BACKGROUND

There are more than 32 million cancer survivors worldwide. The built environment is one of the contextual factors that may influence cancer survivorship. However, studies investigating the interdisciplinary field of the built environment and cancer survivorship are lacking.

OBJECTIVE

To conduct a systematic review of the existing literature regarding the relationship between the built environment and cancer survivorship, identify any knowledge gaps, and recommend future research directions.

METHODS

A systematic literature search was performed by searching OVID Medline, Embase, CINAHL, and Web of Science Core Collection.

RESULTS

Of 4235 unique records identified, 26 studies met eligibility criteria. Neighborhood walkability and greenness were the most examined built environment characteristics among the included studies. Walkability was found to be associated with various cancer survivorship experience, including increased levels of physical activity, lowered body mass index, and improved quality of life. The association between greenness and cancer survivorship outcomes were inconsistent across the included studies. Additionally, studies have reported the relationship between light and noise pollution and sleep among cancer survivors. Regarding blue space, in one qualitative study, breast cancer survivors brought up the healing properties of water.

CONCLUSION

Our scoping review demonstrated a breadth of current cancer survivorship research in the field of neighborhood walkability and greenness, but fewer studies detailing other aspects of the built environment as defined by this review, such as light pollution, noise pollution, and blue space. We identified future research directions for those interested in this interdisciplinary field, which can provide insights for urban planners and policy makers on how to best leverage the built environment to promote the health and wellbeing of cancer survivors.

Adiposity, Weight Change, and Urinary Melatonin Levels among Men in the Multiethnic Cohort

BACKGROUND

Low levels of 6-sulfatoxymelatonin, the primary urinary metabolite of melatonin, have been linked to cancer and cardiometabolic outcomes in White and female populations.

METHODS

We examined the association between adulthood adiposity and 6-sulfatoxymelatonin levels in a racially and ethnically diverse population. Our study included 4,078 men in the Multiethnic Cohort with adiposity measurements at enrollment (1993-1996) and biomarkers measured in urines collected in 1995 and 2005. Multivariable linear regression models were used to estimate the percent change in 6-sulfatoxymelatonin levels and 95% confidence intervals (CI). Associations were examined separately by racial/ethnic group.

RESULTS

The prevalence of obesity varied by race and ethnicity, from 10% for Japanese American men to 34% for Native Hawaiian men. Compared with men with normal body mass index (BMI), men who were overweight (-7.8%; 95% CI, -11.9 to -3.5%) and obese (-18.1%; 95% CI, -23.2 to -12.6%) had significantly lower 6-sulfatoxymelatonin levels adjusting for potential confounding factors. Increasing weight gain in adulthood was also associated with lower 6-sulfatoxymelatonin (Ptrend < 0.0001). The inverse associations for BMI and weight change were qualitatively similar across racial and ethnic groups.

CONCLUSIONS

Obesity is inversely associated with melatonin in a racially diverse population. This finding is relevant given higher rates of obesity among Black, Native Hawaiian, and Latino men, as well as potential racial and ethnic differences in circadian function.

IMPACT

Melatonin may be a relevant biomarker among obesity-associated malignancies and could shed light on a potential mechanism of cancer disparities.

Association between Outdoor Light at Night and Prostate Cancer in the Health Professionals Follow-up Study

BACKGROUND

Circadian disruption is a potential risk factor for advanced prostate cancer, and light at night (LAN) exposure may disrupt circadian rhythms. We evaluated whether outdoor LAN increases the risk of prostate cancer.

METHODS

We prospectively followed 49,148 participants in the Health Professionals Follow-up Study from 1986 through 2016. We estimated baseline and cumulative time-varying outdoor LAN with ∼1 km2 resolution using data from the US Defense Meteorological Satellite Program's Operational Linescan System, which was assigned to participants' geocoded addresses. Participants reside in all 50 U.S. states and reported a work or home address. We used multivariable Cox models to estimate HRs and 95% confidence intervals (CI) for the association between outdoor LAN and risk of overall (7,175 cases) and fatal (915 cases) prostate cancer adjusting for individual and contextual factors.

RESULTS

There was no association between the interquartile range increase in cumulative LAN and total (HR, 1.02; 95% CI, 0.98-1.06) or fatal (HR, 1.05; 95% CI, 0.96-1.15) prostate cancer in adjusted models. However, there was a positive association between baseline LAN and total prostate cancer among non-movers (HR, 1.06; 95% CI, 1.00-1.14) including among highly screened participants (HR, 1.11; 95% CI, 1.01-1.23).

CONCLUSIONS

There was a suggestive positive association between baseline outdoor LAN and total prostate cancer. Additional studies with different measures of outdoor LAN and in more diverse populations are necessary.

IMPACT

To our knowledge, this is the first longitudinal cohort study exploring the relationship between outdoor LAN and prostate cancer.

Racial disparities in prostate cancer among black men: epidemiology and outcomes

Prostate cancer has the widest racial disparities of any cancer, and these disparities appear at every stage of the cancer continuum. This review focuses on the disparities in prostate cancer between Black and White men, spanning from prevention and screening to clinical outcomes. We conduct an expansive review of the literature on racial disparities in prostate cancer, interpret the findings, and discuss areas of unmet need in research. We provide an overview of epidemiologic concepts necessary to understanding the current state of prostate cancer disparities, discuss the complexities of studying race, and review potential drivers of disparities in incidence and mortality. We argue that the cause of this disparity is multifactorial and due to a combination of social and environmental factors. The path forward needs to focus on enrolling and retaining Black men in prostate cancer clinical trials and observational studies and identifying potential interventions to improve prevention and clinical outcomes in Black men.

Racial Disparities in Prostate Cancer: Evaluation of Diet, Lifestyle, Family History, and Screening Patterns

BACKGROUND

Racial disparities in prostate cancer incidence and mortality rates are considerable. We previously found in the Health Professionals Follow-up Study (HPFS) that African-American men had an 80% higher prostate cancer risk than White men. With 21 additional years of follow-up and four-fold increase in cases, we undertook a contemporary analysis of racial differences in prostate cancer incidence and mortality in HPFS.

METHODS

For 47,679 men, we estimated HRs and 95% confidence intervals (CI) for the association between race and risk of prostate cancer through 2016 using Cox proportional hazards regression. Multivariable models (mHR) were adjusted for lifestyle, diet, family history, and PSA screening collected on biennial questionnaires.

RESULTS

6,909 prostate cancer cases were diagnosed in White, 89 in African-American, and 90 in Asian-American men. African-Americans had higher prostate cancer incidence (mHR = 1.31; 95% CI, 1.06-1.62) and mortality (mHR = 1.67; 95% CI, 1.00-2.78), and lower PSA screening prevalence than White men. The excess risk was greater in the pre-PSA screening era (HR = 1.68; 95% CI, 1.14-2.48) than the PSA screening era (HR = 1.20; 95% CI, 0.93-1.56). Asian-Americans had lower prostate cancer risk (mHR = 0.74; 95% CI, 0.60-0.92), but similar risk of fatal disease compared with white men.

CONCLUSIONS

Racial differences in prostate cancer incidence and mortality in HPFS are not fully explained by differences in lifestyle, diet, family history, or PSA screening.

IMPACT

Additional research is necessary to address the disproportionately higher rates of prostate cancer in African-American men.

Urinary 6-sulfatoxymelatonin Levels and Prostate Cancer Risk among Men in the Multiethnic Cohort

BACKGROUND

The circadian hormone melatonin has anticancer properties, and prior studies suggest a positive association between low melatonin and prostate cancer risk. The purpose of this study was to examine urinary melatonin levels and prostate cancer in a racially/ethnically diverse cohort.

METHODS

We conducted a nested case-control study, including 1,263 prostate cancer cases and 2,346 controls, sampled from participants in the Multiethnic Cohort Study with prediagnostic urine samples assayed for 6-sulfatoxymelatonin, the primary melatonin metabolite. Conditional logistic regression was used to examine the association between melatonin levels and the development of prostate cancer outcomes (all incident cases, advanced, lethal, high-grade, and aggressive), overall and by race/ethnicity.

RESULTS

Among 1,263 cases, 135 were advanced stage, 101 were lethal cases, and 282 were high-grade disease. Median melatonin levels were similar in controls [17.12 ng/mL; interquartile range (IQR), 19.78] and cases (17.93 ng/mL; IQR, 19.76), and we found no significant association between urinary melatonin levels and prostate cancer risk overall or in any clinical or racial subgroup.

CONCLUSIONS

In this diverse cohort, there was no significant association between melatonin and any prostate cancer outcome, nor were there any differences by racial/ethnic group.

IMPACT

These results do not support a strong association between melatonin levels and risk of prostate cancer.

Prenatal and Perinatal Factors and Risk of Cancer in Middle and Older Adulthood among Men

BACKGROUND

Prenatal factors have been associated with risk of cancers later in life, although studies in men have largely been case-control and focused on birth size only.

METHODS

We used data from 5,845 men in the Health Professionals Follow-up Study (HPFS) to prospectively examine associations between several prenatal and perinatal factors and incident adult cancer risk. In 1994, mothers of participants reported information on characteristics and behaviors related to their pregnancy with their sons. We used multivariable Cox proportional hazards models to calculate HRs and 95% confidence intervals (CI) of associations between prenatal and perinatal risk factors and cancer risk.

RESULTS

During 20 years of follow-up, 1,228 incident cases of overall cancer were documented. Men with a birth weight of ≥4 kg had a 21% increased risk of overall cancer (HR, 1.21; 95% CI, 1.02-1.43) compared with those with a birth weight of 2.5 to 3.9 kg. Greater weight gain during pregnancy (>13.6 kg vs. 6.8-8.6 kg) was also associated with a higher risk of overall cancer (HR, 1.22; 95% CI, 1.02-1.46), and was stronger for men whose mothers had a prepregnancy BMI<21 kg/m² (HR, 1.30; 95% CI, 1.00-1.67) compared with body mass index (BMI) ≥21 kg/m² (HR, 1.14; 95% CI, 0.85-1.51). There was no association between maternal age and overall cancer risk.

CONCLUSIONS

Higher birth weight and maternal weight gain are associated with increased cancer risk in adult men.

IMPACT

Our findings support the hypothesis that the in utero environment plays a role in the etiology of cancer in middle and older adulthood.

Tackling Diversity in Prostate Cancer Clinical Trials: A Report From the Diversity Working Group of the IRONMAN Registry

Prostate cancer disproportionately affects racial and ethnic minority populations. Reasons for disparate outcomes among minority patients are multifaceted and complex, involving factors at the patient, provider, and system levels. Although advancements in our understanding of disease biology have led to novel therapeutics for men with advanced prostate cancer, including the introduction of biomarker-driven therapeutics, pivotal translational studies and clinical trials are underrepresented by minority populations. Despite attempts to bridge the disparities gap, there remains an unmet need to expand minority engagement and participation in clinical trials to better define the impact of therapy on efficacy outcomes, quality of life, and role of biomarkers in diverse patient populations. The IRONMAN registry (ClinicalTrials.gov identifier: NCT03151629), a global, prospective, population-based study, was borne from this unmet medical need to address persistent gaps in our knowledge of advanced prostate cancer. Through integrated collection of clinical outcomes, patient-reported outcomes, epidemiologic data, and biospecimens, IRONMAN has the goal of expanding our understanding of how and why prostate cancer outcomes differ by race and ethnicity. To this end, the Diversity Working Group of the IRONMAN registry has developed informed strategies for site selection, recruitment, engagement and retention, and trial design and eligibility criteria to ensure broad inclusion and needs awareness of minority participants. In concert with systematic strategies to tackle the complex levels of disparate care, our ultimate goal is to expand minority engagement in clinical research and bridge the disparities gap in prostate cancer care.

Insulinemic and Inflammatory Dietary Patterns and Risk of Prostate Cancer

BACKGROUND

Hyperinsulinemia and inflammation are inter-related pathways that link diet with the risk of several chronic diseases. Evidence suggests that these pathways may also increase prostate cancer risk.

OBJECTIVE

To determine whether hyperinsulinemic diet and inflammatory diet are associated with prostate cancer incidence and mortality.

DESIGN, SETTING, AND PARTICIPANTS

We prospectively followed 41 209 men in the Health Professionals Follow-up Study (1986-2014). Scores for two validated dietary patterns were calculated from food frequency questionnaires at baseline and updated every 4 yr.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Total, advanced, and lethal prostate cancer outcomes were assessed. Multivariable-adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) were determined for associations between two empirical hypothesis-oriented dietary patterns-empirical dietary index for hyperinsulinemia and empirical dietary inflammatory pattern-and prostate cancer risk estimated using Cox proportional hazard regression.

RESULTS AND LIMITATIONS

During 28 yr of follow-up, 5929 incident cases of total prostate cancer, including 1019 advanced and 667 fatal, were documented. In multivariable-adjusted models, there was a 7% higher risk of advanced prostate cancer (HR: 1.07; 95% CI: 1.01-1.15) and a 9% higher risk of fatal prostate cancer (HR: 1.09; 95% CI: 1.00-1.18) per standard deviation (SD) increase in the hyperinsulinemic diet. When stratified by age, the hyperinsulinemic diet was associated with only earlier-onset aggressive prostate cancer (men under 65 yr), with per SD HRs of 1.20 (95% CI: 1.06-1.35) for advanced, 1.22 (1.04-1.42) for fatal, and 1.20 (1.04-1.38) for lethal. The inflammatory diet was not associated with prostate cancer risk in the overall study population, but was associated with earlier-onset lethal prostate cancer (per SD increase HR: 1.16; 95% CI: 1.00-1.35).

CONCLUSIONS

Hyperinsulinemia and inflammation may be potential mechanisms linking dietary patterns with the risk of aggressive prostate cancer, particularly earlier-onset disease.

PATIENT SUMMARY

Avoiding inflammatory and hyperinsulinemic dietary patterns may be beneficial for the prevention of clinically relevant prostate cancer, especially among younger men.

Abstract 4648: Insulinemic and inflammatory dietary patterns and risk of prostate cancer

Background: Studies of diet and prostate cancer have primarily focused on individual dietary factors, often with null or mixed findings. Assessment of dietary patterns is an alternative approach and has been increasingly used in nutritional epidemiology, providing the advantage of better accounting for added effects and interactions of dietary components. Hyperinsulinemia and inflammation are interrelated biological pathways that link diet with risk of several cancers, and studies have suggested that these may also increase prostate cancer risk. Whether dietary patterns based on these pathways contribute to the development and progression of prostate cancer is unclear.

Methods: We followed 39,776 men in the Health Professionals Follow-up Study (1986-2014) to examine associations between two empirical hypothesis-oriented dietary patterns with risk of total, local, advanced, and fatal prostate cancer. The two dietary patterns - empirical dietary index for hyperinsulinemia (EDIH) and empirical dietary inflammatory pattern (EDIP) - were constructed using the weighted sum of food groups that predicted plasma C-peptide (EDIH) and inflammatory biomarkers (EDIP). Dietary scores were calculated from food frequency questionnaires at baseline and updated every 4 years. Multivariable-adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated using Cox proportional hazards regression.

Results: We documented 5,682 incident cases of total prostate cancer and 658 cases of fatal prostate cancer over 868,552 person-years of follow-up. In multivariable-adjusted models, men in the highest EDIH quintile had an 18% higher risk of advanced prostate cancer (HR: 1.18, 95% CI: 0.96-1.45; P=0.04 for trend) and a 24% higher risk of fatal prostate cancer (HR: 1.24, 95% CI: 0.96-1.59; P=0.03 for trend) compared to men in the lowest quintile. There were no significant associations for EDIP and prostate cancer risk. BMI did not modify the association for either dietary pattern.

Conclusion: Hyperinsulinemia may be a potential mechanism linking dietary patterns and risk of aggressive prostate cancer. Additional studies to define mechanisms of action and interventions to reduce prostate cancer risk are warranted.

Citation Format: Benjamin C. Fu, Fred K. Tabung, Claire H. Pernar, Weike Wang, Amparo G. Gonzalez-Feliciano, Ilkania M. Chowdhury-Paulino, Steven K. Clinton, Edmund Folefac, Mingyang Song, Adam S. Kibel, Edward L. Giovannucci, Lorelei A. Mucci. Insulinemic and inflammatory dietary patterns and risk of prostate cancer [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 4648.

Abstract C046: Racial and ethnic differences in the association of body mass index (BMI) and melatonin levels among men in the Multiethnic Cohort Study

Purpose Obesity and circadian rhythm disruption are risk factors for various cancers, including advanced prostate cancer. Given the differences in obesity rates by racial groups, the emerging evidence suggesting racial differences in circadian function, and the well-known racial disparities in cancer incidence and mortality, we aimed to explore the association between obesity and melatonin levels within a diverse population and assess how this association differed by racial/ethnic group. Methods This study leveraged 2,786 male controls from a nested case-control study within the Multiethnic Cohort Study. Melatonin was measured by its primary metabolite, 6-sulfatoxymelatonin, in first-morning void and overnight urine samples collected between 2001 and 2006 prior to cancer diagnosis. We categorized men based on body mass index (BMI) as underweight:&lt;18.5 kg/m2; normal: 18.5 kg/m2 to &lt;25 kg/m2; overweight: 25 kg/m2 to &lt;30 kg/m2; and obese: 30 kg/m2. We used linear regression models to evaluate the association between obesity and melatonin levels, adjusted for urinary creatinine levels, age, race/ethnicity, occupation, years of schooling, month of urine collection, sleep duration, physical activity, smoking, and alcohol use. We further examined associations between obesity and melatonin within racial/ethnic groups. Results The prevalence of obesity differed by race/ethnicity, with 34.3% of Native Hawaiian (NH), 25.0% of African American (AA), 22.1% of Latino, 14.8% of White, and 10.6% of Japanese men categorized as obese (chisq p-value &lt; 0.001). Latino and White men had the highest levels of melatonin with a median of 25.1 ng melatonin/mg creatinine; the median levels in Japanese (23.4 ng/mg), AA (23.0 ng/mg), and NH men (22.3 ng/mg) were lower (Kruskal-Wallis p-value=0.03). These differences remained after adjusting for BMI, with AAs having the lowest and Latinos the highest melatonin levels. In multivariable models, men who were obese had melatonin levels that were 16.9% (95% CI: 9.8%, 23.5%) lower than normal weight (NW) men. When stratified by race/ethnicity, we found that obese white men had 16.5% (95% CI: 3.0%, 28.1%) lower levels than NW white men; obese NH men had 23.7% (95% CI: 2.9%, 40.0%) lower levels than NW NH men; and obese Japanese men had 18.4% (95% CI: 7.5%, 28.1%) lower levels than NW Japanese men. Although not statistically significant, obesity was associated with lower melatonin levels among AA (13.9% lower, 95% CI: 29.6% lower, 5.2 % higher) and Latino (8.6% lower, 95% CI: 28.5% lower, 17.0% higher) men. Conclusion To our knowledge, this is the first study looking at the association between obesity and melatonin levels in a diverse population of men. We found that obese men had lower melatonin levels and that melatonin levels and obesity rates differed by racial groups. These findings will be expanded on to investigate the interplay between melatonin, obesity and race/ethnicity on risk of prostate cancer and potentially point to an underlying reason for racial disparities in cancer.

Citation Format: Ilkania M Chowdhury-Paulino, Iona Cheng, Unnur A Valdimarsdottir, Loic Le Marchand, Christopher A Haiman, Lynne Wilkens, Lorelei A Mucci, Sarah C Markt. Racial and ethnic differences in the association of body mass index (BMI) and melatonin levels among men in the Multiethnic Cohort Study [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr C046.