Gene Expression Profiling of Peripheral Blood and Endometrial Cancer Risk Factors: Systems Epidemiology Approach in the NOWAC Postgenome Cohort Study

Introduction: More than 47,000 women will be diagnosed with endometrial cancer in 2012, making it the most common gynecologic cancer among women in the United States. Data from the SEER registry from 1975-2009 report the incidence rate of endometrial cancer is lower among black women than white women (19.2 and 27.5 cases per 100,000 women, respectively). Tumor histology also varies by racial group, with a larger proportion of black women diagnosed with non-endometrioid tumors compared to their white counterparts. It is possible that risk factors for endometrial cancer may differ between black and white women; the small number of black women in individual studies has precluded these analyses. The aim of this study was to investigate risk factors for endometrial cancer in blacks using a pooled analysis. For comparison, we pooled data on risk factors among non-Hispanic white women in the same studies. Methods: We have data from eleven studies that included >10 black cases and >10 black controls (7 cohort studies and 4 case-control studies). The following information was collected from each study: age at diagnosis/study entry, education, body mass index (BMI), smoking status, reproductive variables, hormone use, and self-reported diabetes and hypertension. Unconditional logistic regression was used to estimate odds ratios and 95% confidence intervals for each risk factor in blacks and whites separately. Estimates for endometrioid tumors will also be presented. Results: Data were pooled for 2,011 black women (516 cases and 1,495 controls) and 19,297 white women (5,693 cases and 13,604 controls). In univariate analyses, the following variables were associated with endometrial cancer in both black and white women: BMI, smoking, oral contraceptive use for 10 years or more, and diabetes. In models adjusted for these variables, along with age and study site, obesity (BMI ≥ 30) was associated with an approximate 3-fold increase in risk for both black and white women (OR=2.80, 95% CI: 2.00, 3.92 and OR=3.26, 95% CI: 2.96, 3.59, respectively). Diabetes was also associated with a 30-40% increase in risk among both groups. Cigarette smoking was associated with reduced risk of endometrial cancer among both blacks and whites (OR=0.66, 95%CI: 0.47, 0.94 and OR=0.62, 95% CI: 0.54, 0.71, respectively). Increasing parity was more strongly associated with decreased risk in whites (p-trend <0.001) than blacks (p-trend = 0.09). Similarly, age at first birth was also more protective in whites (p-trend<0.001) than blacks (p-trend=0.76). Conclusions: Overall, risk factors for endometrial cancer are similar in black and white women, with the exception of some of the reproductive factors, which do not appear to afford protection in blacks to the same extent as in whites. Citation Format: Michele L. Cote, Tala Alhajj, Julie J. Ruterbusch, Louise A. Brinton, William J. Blot, Chu Chen, Brian E. Henderson, Pamela L. Horn-Ross, Laurence N. Kolonel, Timothy R. Rebbeck, Veronica W. Setiawan, Lisa B. Signorello, Michael S. Simon, Noel S. Weiss, Nico Wentzensen, Hannah P. Yang, Sara H. Olson. Risk factors for endometrial cancer in black and white women: A pooled analysis from the Epidemiology of Endometrial Cancer Consortium (E2C2). [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 2285. doi:10.1158/1538-7445.AM2013-2285

Excess body weight is a known risk factor for endometrial cancer but whether it differentially affects histological subtypes of endometrial cancer is unclear. The two proposed main subtypes are the “estrogen-dependent Type I” and “non estrogen-dependent and clinically aggressive Type II”. Little is known about risk factors for Type II tumors mainly because most epidemiologic studies lack sufficient cases to study these rare tumors separately. Here we examined the association between recent adult body mass index (BMI) and endometrial tumor subtypes in a pooled analysis of 25 studies in the Epidemiology of Endometrial Cancer Consortium (E2C2). Individual-level data from 10 cohort studies and 15 case-control studies provided a total of 14,409 endometrial cancer cases and 35,950 controls for this analysis. Cohort studies were analyzed using a nested case-control design. The majority of women were white (86%) and postmenopausal (83%). Endometrial cancer cases were classified into two subtypes: Type I (endometrioid adenocarcinomas, adenocarcinoma tubular, papillary adenocarcinomas, mucinous adenocarcinomas, adenocarcinomas with squamous metaplasia, n=13,286) and Type II (serous, squamous cell, small cell, mixed cell, n=1,123). The associations of BMI with the risk of tumor subtypes were evaluated by calculating odds ratios (OR) and 95% confidence intervals (95% CI) using polytomous logistic regression models. Potential confounders included in the analysis were age, race, parity, age at menarche, oral contraceptive (OC) use, menopausal hormone (PMH) use, and smoking status. BMI was positively associated with both Type I and Type II tumors, but the association was stronger for Type I than for Type II tumors (P value for the difference in OR between Type I and Type II was <0.0001). The OR associated with each five kg/m2 increase in BMI (OR5) was 1.58 (95% CI: 1.55, 1.62) for Type I and 1.35 (95% CI: 1.28, 1.42) for Type II. In the analysis of individual histologic types, the OR5 was lowest for serous tumors (1.28), moderate for mixed cell and clear cell (1.33-1.37), and highest for endometrioid tumors (1.60) and various adenocarcinoma groups (1.54-1.58). The associations of BMI with both Type I and II tumors were greater among postmenopausal women who never used PMH [OR5 = 1.84 (95% CI: 1.78, 1.89) for Type I and 1.48 (95% CI: 1.38, 1.58) for Type II] than among estrogen-only users [OR5 = 1.20 (95% CI: 1.13, 1.28) for Type I and 1.05 (95% CI: 0.87, 1.26) for Type II] or among estrogen-progestin users [OR5 = 1.33 (95% CI: 1.25, 1.41) for Type I and 1.12 (95% CI: 0.95, 1.33) for Type II]. Other known endometrial cancer risk factors such as OC use, parity, and smoking did not appear to modify the association between BMI and tumor subtype. In this large pooled analysis, we observed that BMI is a risk factor for all types of endometrial cancer, although, the association is consistently stronger for Type I than for Type II tumors. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 1029. doi:1538-7445.AM2012-1029

Risk factors among young women with endometrial cancer: A Danish case-control study

Adipose tissue (AT) transcriptome studies provide holistic pictures of adaptation to weight and related bioclinical settings changes. To implement AT gene expression profiling and investigate the link between changes in bioclinical parameters and AT gene expression during 3 steps of a 2-phase dietary intervention (DI). AT transcriptome profiling was obtained from sequencing 1051 samples, corresponding to 556 distinct individuals enrolled in a weight loss intervention (8-week low-calorie diet (LCD) at 800 kcal/day) followed with a 6-month ad libitum randomized DI. Transcriptome profiles obtained with QuantSeq sequencing were benchmarked against Illumina RNAseq. Reverse transcription quantitative polymerase chain reaction was used to further confirm associations. Cell specificity was assessed using freshly isolated cells and THP-1 cell line. During LCD, 5 modules were found, of which 3 included at least 1 bioclinical variable. Change in body mass index (BMI) connected with changes in mRNA level of genes with inflammatory response signature. In this module, change in BMI was negatively associated with changes in expression of genes encoding secreted protein (GDF15, CCL3, and SPP1). Through all phases of the DI, change in GDF15 was connected to changes in SPP1, CCL3, LIPA and CD68. Further characterization showed that these genes were specific to macrophages (with LIPA, CD68 and GDF15 expressed in anti-inflammatory macrophages) and GDF15 also expressed in preadipocytes. Network analyses identified a novel AT feature with GDF15 upregulated with calorie restriction induced weight loss, concomitantly to macrophage markers. In AT, GDF15 was expressed in preadipocytes and macrophages where it was a hallmark of anti-inflammatory cells.

Perioperative outcomes in obese women with uterine cancer

To assess the impact of reproductive and anthropometric factors as a risk indicator for female cancers in hormone‐related organs, i.e., the breast, endometrium and ovary, we conducted a comparative case‐referent study using data from the Hospital‐based Epidemiologic Research Program at Aichi Cancer Center (HERPACC), Japan. The case group consisted of 1,465, 133 and 99 women who had first been diagnosed as having breast, endometrial and ovarian cancer, respectively. The referents were 25,488 female first‐visit outpatients who had not previously been diagnosed with any type of cancer. The odds ratios (ORs) and their 95% confidence intervals (95%CI) were estimated using an unconditional logistic regression model. An inverse association with experience of delivery and a positive association with body mass index (BMI) and with change of BMI after 20 years of age, were observed consistently for all three cancer sites. We observed similar risk and protective factors for breast and endometrial cancer, but the effect of reproduction and overweight condition (BMI≥25) were more prominent in endometrial cancer. Although the present study failed to find site‐specific risk factors for ovarian cancer, the results provided evidence that being overweight and/or weight gain in adult life is a common risk factor for all three cancer sites. The results obtained from this study suggested that avoidance of weight gain may reduce the risk of female hormone‐related cancers.

Hachisuga T, Kaetsu A, Sugimori H, Kamura T, Tsuneyoshi M, Kawarabayashi T. Risk factors for endometrial cancer in Japanese women. Int J Gynecol Cancer 1998; 8: 292–297. To elucidate the background for the development of endometrial carcinoma in Japanese females, we studied the risk factors for this disease in a hospital-based, case-control study conducted in the North Kyushu district of Japan from 1980 to 1989 in 242 female subjects with endometrial cancer and 1,021 controls. Furthermore, the association between the risk factors and the clinicopathologic features of endometrial cancer was also examined. In age-adjusted analyses, the risk of endometrial cancer was significantly elevated among gravidity [odds ratios (OR) = 5.00, 95% confidence interval (CI) = 3.09–8.11], nulliparity (OR = 4.01, 95% CI = 2.76–5.83), overweight [body mass index (BMI) of 24.5 to 30.5 OR = 1.85, 95% CI = 1.36–2.25], obesity (BMI <30.5, OR = 2.63, 95% CI = 1.14–6.04), hypertension (OR = 1.63, 95% CI = 1.10–2.43), and diabetes mellitus (OR = 3.03, 95% CI = 1. 74–5.29). This study showed that Japanese females have the same risk factors for endometrial cancer as those reported in Western countries. Further adjustment for parity had little impact on the BMI, hypertension, and diabetes mellitus. A multivariate analysis showed a strong positive association between nulliparity and endometrial cancer risk. Nulliparity is thus a major independent risk factor of endometrial cancer in Japan. Diabetes mellitus was also found to be a strong risk factor for endometrial cancer in this study. It is known that females with polycystic ovary syndrome (PCOS) are associated with increased risk of non-insulin-dependent diabetes, but we could not find non-insulin-dependent diabetes mellitus in 17 patients with endometrial cancer and PCO. A clinicopathologic examination revealed that women in the younger age group (less than 50 years of age) tended to have lower grade tumors, which were more frequently associated with hyperplasia and had a better prognosis than did those in the older age group (50 years of age or older). This may suggest that the tumors developing in the younger age group were more closely related to estrogen than those developing in the older age group, but risk factors that were found to be associated with a high endogenous level of estrogen did not show any meaningful difference between the younger and older age groups.

Adult obesity is a strong risk factor for endometrial cancer (EC); however, associations of early life obesity with EC are inconclusive. We evaluated associations of young adulthood (18-21 years) and adulthood (at enrolment) body mass index (BMI) and weight change with EC risk in the Epidemiology of Endometrial Cancer Consortium (E2C2). We pooled data from nine case-control and 11 cohort studies in E2C2. We performed multivariable logistic regression analyses to estimate odds ratios (OR) and 95% confidence intervals (95% CI) for BMI (kg/m2) in young adulthood and adulthood, with adjustment for BMI in adulthood and young adulthood, respectively. We evaluated categorical changes in weight (5-kg increments) and BMI from young adulthood to adulthood, and stratified analyses by histology, menopausal status, race and ethnicity, hormone replacement therapy (HRT) use and diabetes. We included 14 859 cases and 40 859 controls. Obesity in adulthood (OR = 2.85, 95% CI = 2.47-3.29) and young adulthood (OR = 1.26, 95% CI = 1.06-1.50) were positively associated with EC risk. Weight gain and BMI gain were positively associated with EC; weight loss was inversely associated with EC. Young adulthood obesity was more strongly associated with EC among cases diagnosed with endometrioid histology, those who were pre/perimenopausal, non-Hispanic White and non-Hispanic Black, among never HRT users and non-diabetics. Young adulthood obesity is associated with EC risk, even after accounting for BMI in adulthood. Weight gain is also associated with EC risk, whereas weight loss is inversely associated. Achieving and maintaining a healthy weight over the life course is important for EC prevention efforts.

Leptin levels in serum depending on Body Mass Index in patients with endometrial hyperplasia and cancer

High body mass index (BMI) is a causal risk factor for endometrial cancer but the molecular mechanisms underlying this association remain elusive. Here we sought to characterize the tumor genomic landscape of endometrial cancers that have developed on a germline genetic background of predisposition to elevated BMI. We built a polygenic score (PGS) for adult BMI in women using effect size estimates and allele information on 242 independent (r2&amp;lt;0.05) variants associated with BMI at genome-wide significance (P&amp;lt;5x10-9) in 379,501 women of European ancestry. We performed sample and germline (blood) genotype quality control and imputation into the 1000 Genomes reference panel on data from 354 endometrial cancer cases of genetically inferred European ancestry from The Cancer Genome Atlas (TCGA). We assigned each woman in this TCGA cohort her genetically predicted life-course BMI based on the BMI PGS and found this to be modestly correlated with BMI at the point of diagnosis (r2=0.23; P=2.1x10-5). Multivariable linear (default) and quasi-Poisson (for zero-inflated counts) regression models were used to test for associations between the BMI germline PGS and endometrial cancer tumor genomic, transcriptomic, proteomic, and immune traits in TCGA. All analyses were adjusted for age, stage, microsatellite status and 10 genetic principal components. Mutational signature models were also adjusted for signature accuracy. We ranked 18,458 genes based on the association between their tumor expression and the BMI PGS and performed gene set enrichment analysis to identify associations between the BMI PGS and upregulation of genes in the IL6-JAK-STAT3 signaling (false discovery rate (FDR)=8.50x10-7), inflammatory response (FDR=7.03x10-6), interferon gamma response (FDR=5.49x10-5) and glycolysis (FDR=3.28x10-4) pathways. High BMI PGS had an inverse association with endometrial tumor EGFR (FDR=0.07) protein levels of the 131 tumor proteins profiled by reverse phase protein array. Endometrial tumors that had developed on a germline background predictive of high BMI were also associated with increased infiltration of activated mast cells (FDR=9.55x10-3) in our evaluation of 22 tumor immune cell infiltrates quantified by the CIBERSORT algorithm, as well as the mitotic and aging clock-like single base substitution (SBS) signatures 1 (FDR=0.01) and 5 (FDR=0.04). The two SBS signature associations and the activated mast cell association with the BMI PGS were substantially more pronounced in the subgroup of endometrial cancers with microsatellite instability. Thus, we combined germline and somatic data using a novel approach to identify endometrial cancer tumor molecular features associated with genetically predicted higher BMI, providing precision multi-omic portraits of endometrial cancers that develop on a background of adiposity. Citation Format: George Richenberg, Victoria Gray, Carina Owen, Tom Gaunt, Caroline Relton, Emma Vincent, Siddhartha Kar. Germline genetically predicted body mass index is associated with endometrial cancer somatic transcriptomic, immune, and mutational signatures in The Cancer Genome Atlas [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 6504.

Female reproductive and hormonal factors and incidence of primary total knee arthroplasty due to osteoarthritis

To examine the associations of female reproductive and hormonal factors with incidence of total knee arthroplasty (TKA) for osteoarthritis (OA), and to determine whether the associations differ according to overweight/obesity status. This study included 22,289 women in the Melbourne Collaborative Cohort Study. Data on age at menarche, pregnancy, parity, years of menstruation, oral contraceptive (OC) use, menopausal status, and hormone replacement therapy (HRT) were collected in 1990-1994. Incidence of TKA during 2001-2013 was determined by linking cohort records to the Australian Orthopaedic Association National Joint Replacement Registry. All analyses were adjusted for age, body mass index (BMI) at midlife, change in BMI (from early reproductive age to midlife), country of birth, physical activity, smoking, and education level. Over the course of 12.7 years, 1,208 TKAs for OA were identified. Ever being pregnant was associated with increased risk of TKA (hazard ratio [HR] 1.32 [95% confidence interval (95% CI) 1.06-1.63]). Parity was positively associated with risk of TKA (P for trend = 0.003). OC users had increased risk of TKA compared with non-users (for OC use of <5 years, HR 1.25 [95% CI 1.08-1.45]; for OC use of ≥5 years, HR 1.17 [95% CI 1.00-1.37]). A 1-year increase in menstruation was associated with a 1% decrease in risk of TKA (HR 0.99 [95% CI 0.97-0.99]). These associations remained significant only in women of normal weight at early reproductive age. Current HRT users had increased risk of TKA compared with non-users (HR 1.37 [95% CI 1.14-1.64]); the association was significant only in non-obese women at midlife. Reproductive and hormonal factors were associated with risk of knee OA. These associations remained significant in women of normal weight at early reproductive age and in non-obese women at midlife. Further work is needed to understand the complex effect of these factors on knee OA.

Adult obesity is a well-established risk factor for endometrial cancer. However, little is known about the association of endometrial cancer risk with body size early in life and weight change during adulthood. We investigated whether women with greater early-age body size or with greater weight change during adulthood have an increased risk of endometrial cancer. We analysed data from a population-based case-control study of endometrial cancer conducted between 1997 and 2001 in Shanghai, China. Included in this analysis were 832 endometrial cancer cases aged 30-69 years and 846 population controls. Information on weight and height history from adolescence through adulthood was obtained via structured in-person interviews. A logistic regression model was used to derive odds ratios (ORs) and 95% confidence intervals (CIs) for endometrial cancer in association with adolescent and adult adiposity, as well as adult body weight change. All ORs were adjusted for age, education, menstrual status, duration of menstruation, number of pregnancies, oral contraceptive use, and family history of cancer. Perceived weights and heights during puberty that were greater than average were associated with a modestly increased risk of cancer. The association for perceived weight was substantially weakened after adjustment for current body mass index (BMI). High BMI at all adult ages significantly predicted endometrial cancer risk, with recent BMI being the strongest predictor. Further analyses disclosed that weight gain during adulthood, particularly during the peri-menopausal period (age 40-50 years), was associated with a significantly elevated risk of endometrial cancer, even among currently non-obese women. Gaining >5 kg between age 40 and 50 was related to ORs of 2.3 (95% CI 1.4-3.9) for women with a BMI<25 kg/m2 and 2.0 (95% CI 1.3-3.0) for women with BMI>or=25 kg/m2. Adult weight gain, particularly during the peri-menopausal period, plays a significant role in the development of endometrial cancer risk.

Excess weight near the time of diagnosis is a well-established risk factor for endometrial cancer; less is known about the influence of weight at earlier periods of a woman's life or weight gain in adulthood. In a case-control study in western New York State, interviews were conducted with 232 incident endometrial cancer cases, diagnosed between 1986 and 1991, and 631 community controls. Body mass index at 16 years of age and 20, 10, and 2 years before interview and changes in body mass index between these time periods were examined. While being relatively heavy at 16 years of age was associated with slightly increased risk [adjusted odds ratio (OR) = 1.28, 95% confidence interval (CI) = 0.84-1.96], large gains over the entire period from 16 years of age to 2 years ago (OR = 3.45, CI = 2.13-5.57) and high body mass index close to the time of diagnosis (OR = 3.21, CI = 2.01-5.15) were associated with greater risk. Differences in mean body mass index between cases and controls increased over time.

Body mass index trumps age in decision for endometrial biopsy: cohort study of symptomatic premenopausal women