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Glucose, Lipids and Gamma-Glutamyl Transferase Measured Before

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Glucose, Lipids and Gamma-Glutamyl Transferase Measured Before Bosco et al. BMC Cancer (2018) 18:205 https://doi.org/10.1186/s12885-018-4111-5 RESEARCH ARTICLE Open Access Glucose, lipids and gamma-glutamyl transferase measured before prostate cancer diagnosis and secondly diagnosed primary tumours: a prospective study in the Swedish AMORIS cohort Cecilia Bosco1*, Hans Garmo1,2, Niklas Hammar3,6, Göran Walldius4, Ingmar Jungner5, Håkan Malmström3,8, Lars Holmberg1,7 and Mieke Van Hemelrijck1,3 Abstract Background: Improvements in detection and treatment of prostate cancer (PCa) translate into more men living with PCa, who are therefore potentially at risk of a secondly diagnosed primary tumour (SDPTs). Little is known about potential biochemical mechanisms linking PCa with the occurrence of SDPTs. The current study aims to investigate serum biomarkers of glucose and lipid metabolism and gamma-glutamyl transferase (GGT) measured prior to PCa diagnosis and their association with the occurrence of SDPTS. Methods: From the Swedish AMORIS cohort, we selected all men diagnosed with PCa between 1996 and 2011, with at least one of the five biomarkers of interest (glucose, fructosamine, triglycerides, total cholesterol (TC), GGT) measured on average 16 years before PCa diagnosis (n = 10,791). Multivariate Cox proportional hazards models were used to determine hazard ratios (HR) for risk of SDPTs (overall and subtypes) by levels of the five biomarkers. Effect modification of treatment was assessed. Results: 811 SDPTS were diagnosed during a median follow-up time of 5 years. Elevated levels of triglycerides (HR: 1.37, 95%CI: 1.17–1.60), TC (HR: 1.22, 95%CI: 1.04–1.42) and GGT (HR: 1.32, 95%CI: 1.02–1.71) were associated with an increased risk of SDPTs. Risk of SDPTs subtypes varied by biomarkers. Conclusion: Elevated levels of biomarkers of lipid metabolism and GGT measured prior to PCa diagnosis were associated with an increased risk of SDPTs, suggesting a potential common biochemical background for development of PCa and SDPTs. Keywords: Prostate cancer, Second primary tumours, Triglycerides, Gamma-glutamyl transferase, Glucose, Total cholesterol * Correspondence: [email protected] 1King’s College London, Translational Oncology & Urology Research (TOUR) Division of Cancer Studies King’s College London Research Oncology, 3rd Floor, Bermondsey Wing, Guy’s Hospital, London SE1 9RT, UK Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Bosco et al. BMC Cancer (2018) 18:205 Page 2 of 9 Background biomarkers activate a shared carcinogenic mechanism or Due to advances in detection and treatment, prevalence of because they are the consequence of a common under- prostate cancer (PCa) is increasing [1]. These trends trans- lying alteration [6, 11, 12] . We therefore conducted a late into more men living longer with PCa diagnosis and hypothesis-generating study to evaluate how serum consequently being at risk of getting diagnosed with a sec- biomarkers of common metabolisms are associated with ond primary tumour. Travis et al. suggested grouping of development of PCa and subsequent other cancers. second primary malignancies based on leading etiological causes: treatment-related, syndromic, and those due to Methods shared etiologic factors [1]. Most studies to date have fo- Study population cused on primary cancer treatment related second pri- The AMORIS study has been described in detail else- mary malignancies [2, 3] and little is known about other where [13–15]. This database includes 812,073 Swedish causes of these tumours. However, it was recently sug- men and women with blood samples evaluated by the gested that radiotherapy is only responsible for < 10% of Central Automation Laboratory (CALAB) in Stockholm, second primary malignancies, implying a larger role for Sweden, during the period 1985–1996. Individuals re- lifestyle, genetic or biochemical related factors in their de- cruited were either healthy and having laboratory testing velopment [4]. There are several definitions for second as part of a general check-up or outpatients referred for primary malignancies, and although most definitions con- laboratory testing. None of the participants were inpa- template the fact that it cannot be a metastasis of a first tients at the time of sampling ([16, 17]. The CALAB primary tumour, there is an implicit notion that second database was linked to several Swedish national regis- primary malignancies must have started developing after tries such as the Swedish National Cancer Register, the the first primaries. This implicit notion may be accurate Hospital Discharge Register, the Cause of Death Register, for those second malignancies in which the lag time be- the consecutive Swedish Censuses during 1970–1990, tween treatment of the first primary tumour or long-term and the National Register of Emigration using the Swed- exposure to certain factors has taken place before the oc- ish 10-digit personal identity number [18–20]. currence of the second primary malignancy. However, for We selected all men diagnosed with PCa whom had at those tumours diagnosed within relatively short period of least one of the five biomarkers of interest (glucose, total time after diagnosis of first primary malignancies these cholesterol, triglycerides, fructosamine and GGT) mea- factors are less likely to play a role in the development of sured before PCa diagnosis. To obtain information on a second primary malignancy. Here, we refer to second stage and treatment of PCa, we used a linkage of the primary tumours as those primary tumours (non-meta- AMORIS cohort with the National Prostate Cancer static) of any organ/tissue diagnosed after diagnosis of Register (NPCR), resulting in a total of 14,021 PCa men PCa. “Second” does not refer to when the tumour started [21]. As carcinogenesis may initiate several years before developing, it refers to when it was diagnosed in relation diagnosis, we divided the time between blood measure- to PCa diagnosis. Therefore, to emphasize this concept, ment and PCa diagnosis into 5 periods to exhibit this below we will refer to these tumours as “secondly diag- potential lag time: 0–5, 5–10, 10–15, 15–20 years and nosed primary tumours” (SDPTs). more than 20 years before PCa diagnosis. For the Abnormal metabolism in cancer cells has been well current study, we focused on those measurements taken studied and continues to be of high interest as a poten- 10–15 and 15–20 years prior to PCa diagnosis (n = tial target for drug development [5]. It is therefore of 10,794 cases). Excluding the most recent periods limits interest to investigate serum biomarkers measured be- the potential effects of reverse causation. Moreover, PCa fore a first primary cancer as these could activate is known to have a long natural history [22]. If men had mechanisms leading to other cancer development or be more than one measurement taken within the period a consequence of common alterations that will lead to a studied, the measurement closed to the mid-point of the second cancer [6]. interval was selected. Follow-up started at time of PCa Studies based on the Swedish Apolipoprotein diagnosis and ended at time of occurrence of a SDPT, MOrtality RISk (AMORIS) have reported that the inter- emigration, death or end of the study (December 31st play between serum lipids, glucose and gamma-glutamyl 2011), whichever came first (Fig. 1). transferase (GGT) increases the risk of prostate cancer Information on educational level was retrieved from (PCa) [7–9]. Since cancer development following expos- the Population and Housing Census for 1970–1990. ure to risk factors may take several decades [10], we Using information from the National Patient Register, hypothesized that these elevated serum levels of glucose, we calculated the Charlson comorbidity index (CCI), total cholesterol, triglycerides, fructosamine and GGT which includes 19 diseases, with each disease category measured before PCa diagnosis may also be associated assigned a weight. The sum of an individual’s weights with development of SDPTs – either because these was used to create a score, resulting in four comorbidity Bosco et al. BMC Cancer (2018) 18:205 Page 3 of 9 Fig. 1 Selection of men with PCa from the AMORIS cohort to study the association between metabolism markers and risk of Second Primary Tumours levels ranging from no comorbidity to severe comorbid- association by allowing all cases to be included and con- ity (0, 1, 2, and ≥3) [23]. tributing to the analysis. More specifically, we applied multivariate imputation using chained equations Exposure variables (MICE), also known as imputation using fully condi- The main exposure variables of interest were the above- tional specifications [26]. The MICE method imputes mentioned five biomarkers. We used both quartiles and multiple variables sequentially using univariate fully con- medical cut-offs for the analyses. Medical cut-offs for ditional specifications. glucose (6.11 mmol/L), total cholesterol
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