Urologic Oncology: Seminars and Original Investigations
Original articleClinical—prostateAbdominal obesity as risk factor for prostate cancer diagnosis and high grade disease: A prospective multicenter Italian cohort study
Introduction
Obesity is a growing public health concern in European countries: though prevalence is lower than in the United States [1], the last 15 years have witnessed an increase of obesity in European men of approximately 30% [1].
Numerous studies in the United States have found a significant association of obesity, defined as a body mass index (BMI) ≥ 30 kg/m2, and a higher incidence of prostate cancer (CaP) [2], worse pathology [3], poor outcome after treatment [4], and increased prostate cancer specific mortality [5], [6], [7]. However, different results have been yielded by several studies on European populations: no association was found between obesity and CaP in European men [8], [9], [10], [11], [12].
Results of epidemiologic studies strictly depend on the population characteristics. Prevalence of obesity, metabolic syndrome, and body habits may differ between North American and European patients and this may well explain the different relation between obesity and CaP observed in different studies, although European data raise the hypothesis that other factors such as diet may also play a role in determining the risk of CaP [1]. Another important issue is that Europe is composed of different populations living in different latitudes with very different dietary habits, and what may be true in Northern Europe does not necessarily apply to the Southern Region [8], [9], [10], [11], [12]. Furthermore, differences in PSA screening may result in significant differences in the composition of patient cohort undergoing prostate biopsy. Our Italian population is considered as a sub-screening population for the observed PSA range and frequency of positive digital rectal examination [13].
Moreover, most studies have categorized body habitus utilizing only BMI, while data on waist circumference, a more precise measurement of abdominal adiposity, which has been associated with CaP in non-obese European men [12], is seldom available; this may have led to a bias in examining the impact of obesity and more generally body habitus on CaP.
Given the increase of obesity in Europe seen in the last decade [1], the high prevalence of obesity in Italy (approximately 25% of the population [1]), and the strong evidence of an association between obesity and CaP in American men, we hypothesized that obese Italian men are indeed at higher risk for CaP and high-grade disease.
To address this issue, we prospectively collected anthropometric data on White Italian men undergoing trans-rectal ultrasound (TRUS) guided prostate biopsy in 3 equal access hospitals in central and southern Italy, and evaluated CaP risk as a function of BMI and waist circumference (WC).
Section snippets
Study design
After obtaining institutional review board approval and written informed consent, we prospectively enrolled patients referred to 3 equal-access clinics in Italy (Rome, Naples, and Vasto) with a PSA value ≥4 ng/ml or an abnormal digital rectal examination (DRE), who underwent transrectal ultrasound (TRUS) guided prostate biopsy between January 2008 and January 2011. We excluded from the study patients who had a history of CaP or prostate surgery and patients on 5α-reductase inhibitors. Prostate
Results
A total of 668 patients were available for final analysis. Baseline characteristics of the entire cohort are displayed on Table 1. Patients' characteristics according to body habitus are shown in Table 2.
Overall, CaP was detected in 246 patients (38%). Out of them, 136 (55%) patients had low-grade and 110 (45%) high-grade cancers. Age, PSA, DRE, and prostate volume did not significantly differed across the 4 body habitus groups (Table 2). BMI and waist circumference were highly co-linear on
Discussion
Obesity has been linked to CaP and adverse pathology in numerous studies in the United States [2], [3], [4], [17]. However, investigators have found no association in European populations [8], [9], [10], [11], advancing the hypothesis that the results obtained by the studies in the US may not be applicable to European men. However, the prevalence of obesity across European countries shows high variability [1]; therefore the impact of obesity on CaP in Europe could have been underestimated when
Conclusions
The results of our study suggest that obesity and in particular abdominal obesity is not uncommon finding in an Italian prostate biopsy population and it is associated with an increased risk of CaP and high-grade disease. Further studies are needed to confirm these findings in other European populations to evaluate which biological factors related to abdominal obesity are responsible for the observed results.
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