To cite this article: Yan B, et al. Consumption of processed and pickled food and esophageal cancer risk: A systematic review and meta-analysis. Bull Cancer (2018), https://doi.org/10.1016/j.bulcan.2018.08.006 Bull Cancer 2018; //: ///
Consumption of processed and pickled food and esophageal cancer risk: A systematic review and meta-analysis
Original article
en ligne sur / on line on www.em-consulte.com/revue/bulcan www.sciencedirect.com
Binyuan Yan 1, Lei Zhang 2, Zhongjun Shao 1
Received 1st June 2018 Accepted 2 August 2018 Available online:
1. School of Public Health, Fourth Military Medical University, Department of Epidemiology, Xi'an, Shanxi Province 710032, China 2. Fourth Military Medical University, Nutrition and Food Hygiene, Xi'an, Shanxi Province 710032, China
Correspondence: Zhongjun Shao, School of Public Health, Fourth Military Medical University, Department of Epidemiology, No. 169 Changle west RD, Xi'an, Shanxi Province 710032, China.
[email protected]
Keywords Esophageal cancer Processed food Pickled food Meta-analysis
Summary Previous investigations yielded inconsistent results for association of esophageal cancer (EC) risk and intake of processed food (including pickled food) or pickled food alone. The aim of this study was to perform a systematic review and meta-analysis of data exploring association of EC risk and intake of processed food (including pickled food) or pickled food alone. We systematically searched on PubMed and Web of Science for association of EC risk and intake of processed and pickled food published from 1964 to April 2018. We computed the multivariate odd ratio (OR) or relative risk (RR) and 95% confidence intervals (CI), comparing the highest and the lowest categories of processed or pickled food intake. The present meta-analysis showed that the highest categories of processed food intake were associated with a 78% increase in EC risk compared with the lowest categories. In addition, meta-analysis results indicated that the combined OR/RRs (95%CI) of studies comparing the highest and lowest categories were 2.10 (1.64–2.69) for pickled food. Subgroup study indicated significant positive associations between EC risk and intake of processed food or pickled food in case-control studies (combined ORs: processed food: 1.93 (95% CI: 1.66–2.24), pickled food: 2.28 (95%CI: 1.93–2.70)), whereas no significant associations were detected between them in cohort studies (combined RRs: processed food: 1.24 (95%CI: 0.98– 1.58), pickled food: 1.43 (95%CI: 0.85–2.42)). In conclusion, this study suggests that both a high consumption of processed and pickled food may increase the EC risk.
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tome xx > n8x > xx 2018 https://doi.org/10.1016/j.bulcan.2018.08.006 © 2018 Société Française du Cancer. Published by Elsevier Masson SAS. All rights reserved.
BULCAN-620
To cite this article: Yan B, et al. Consumption of processed and pickled food and esophageal cancer risk: A systematic review and meta-analysis. Bull Cancer (2018), https://doi.org/10.1016/j.bulcan.2018.08.006
Original article
B. Yan, L. Zhang, Z. Shao
Introduction
Inclusion criteria and exclusion criteria
Epidemiological evidence indicates that esophageal cancer (EC) is the ninth most common cancer and the sixth most common cause of cancer death globally [1]. This cancer is looking for better treatments, and is actually related to an evident decline in health-related quality of life (HRQoL), and poor prognosis. Esophageal squamous cell carcinoma (ESCC) and esophageal adenocarcinoma (EAC) are the most common histological types of EC. According to previous studies, epidemiological characteristics are distinct for each histopathological type of oesophageal cancer. ESCC seems to be related to black race, as well as smoking and alcohol consumption, whereas EAC is associated with Barrett's oesophagus, white race and higher body mass index [2]. The pathophysiological mechanism of EC is generally initiated by carcinogenic compounds directly in contact with the esophageal mucosa. In dietary factors, the consumption of red meat [3] and very hot drinks are risk factors [4]. In recent two decades, plenty of studies indicated that intake of processed and pickled food might be associated with an increased risk of EC. However, some studies indicated no effect of processed or pickled food intake on risk of EC. Bosetti et al. reported non-significant associations between high consumption of processed meat and increased risk of EC [5]. In addition, Takezaki et al. indicated no influence of pickled meat on EC [6]. Processed food includes food processed by curing, smoking, salting, fermented or the addition of preservatives. A meta-analysis published in 2013 summarized the evidence about the association between processed meat intake and the risk of EC [7]. However, the study did not include some studies regarding pickled food. In the present investigation, we aim to perform a systematic review and meta-analysis to evaluate the association of EC risk and intake of processed food (including pickled food) or pickled food independently. In addition, we conducted subgroup studies according to different histological types of EC, research types and different countries where the study was conducted.
We retained articles that provided relative risk (RR) or odd ratio (OR) estimates and the 95% confidence intervals (CI) for the association between processed and pickled food intake and EC. In addition, these articles should report either the two main histological subtypes, ESCC or EAC or the overall incidence of EC. Moreover, the included study should be a case-control or cohort design. Studies pertaining to conditions other than processed food or EC were rejected. In addition, reviews, meta-analyses and case studies were removed.
Methods Search strategy
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We searched for articles published on the PubMed and Web of Science databases from 1964 to April 2018. The search terms used were: ("pickle'' OR "pickled'' OR "moldy'' OR "fermented'' OR "saltextractible'' OR "salted'' OR "eingelegt'') AND ("oesophageal'' OR "oesophagus'' OR "esophageal'') AND ("cancer'' OR "carcinoma'' OR "adenocarcinoma'' OR "neoplasm'' OR "neoplasia OR "neoplastic'') and ("processed food'' OR "processed meat'') AND ("oesophageal'' OR "oesophagus'' OR "esophageal'') AND ("cancer'' OR "carcinoma'' OR "adenocarcinoma'' OR "neoplasm'' OR "neoplasia'' OR "neoplastic'') for pickled food and processed food, respectively. All publications were in English, and we retained a total of 124 studies for processed food and 170 studies for pickled food with the exception of duplicates.
Data collection Finally, we included 36 articles for processed food (including pickled food) and 18 articles for pickled food. We recorded following data from the full texts of these included studies: author, publication year, the country where the study was performed, numbers of cases and controls or cohort size, histological types of EC, the study period, food type, comparison levels of the exposure, research type, the multivariate adjusted ORs or RRs with corresponding 95% CI for the highest vs. lowest categories of processed or pickled food intake.
Meta-analysis We computed the multivariate ORs or RRs and 95% CI, comparing the highest and the lowest categories of processed or pickled food intake. Q test was conducted to estimate heterogeneity between studies, and I2 was computed to assess the amount of variation derived from heterogeneity. We performed random effect models to generate summary effect size of studies with invariably high heterogeneity (Q test, P 0.05). In turn, we performed fixed effects models to summarize the effect size in the absence of between-study heterogeneity (Q test, P > 0.05). To evaluate the stability of the meta-analysis and explore the source of heterogeneity, sensitivity analysis was conducted by removing 1 individual study each time. Additionally, we performed subgroup analysis (for different research types, different histological types of EC and different countries where the study was conducted) to detect the effect of heterogeneous research types, histological types of EC and regional differences on the heterogeneity of the meta-analysis. Egger's regression test, Begg's adjusted rank correlation test, and funnel plot were conducted to evaluate publication bias. All these statistical analyses were implemented with STATA 12.0 software.
Results Search results Figure 1 shows the initial research results and gradual exclusion procedures. The present meta-analysis included studies regarding pickled food in studies regarding processed food. In addition, table I summarized study characteristics and results. We conducted a meta-analysis of 6 cohort studies which included 4228 cases and 1660984 participants for processed food and
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To cite this article: Yan B, et al. Consumption of processed and pickled food and esophageal cancer risk: A systematic review and meta-analysis. Bull Cancer (2018), https://doi.org/10.1016/j.bulcan.2018.08.006
Original article
Consumption of processed and pickled food and esophageal cancer risk: A systematic review and meta-analysis
Figure 1 Flow of information through the different phases of a systematic review
Meta-analysis results The present meta-analysis result showed that the highest categories of processed food intake were associated with a 78% increase in EC risk compared with the lowest categories (95%CI: 1.53–2.07;
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figure 2). In addition, the meta-analysis indicated significant heterogeneities between different studies (Q test, P < 0.001). Subgroup study indicated significant positive associations in casecontrol studies (case-control studies: combined ORs = 1.93 (95% CI: 1.66–2.24)); however, no significant positive association were found when we examined only the cohort studies (combined RRs = 1.24 (95%CI: 0.98–1.58); figure 3). High processed food intakes were correlated to increased EAC and ESCC risks (EAC: combined OR/RRs = 1.54 (95%CI: 1.26–1.88); ESCC: combined OR/RRs = 1.85 (95%CI: 1.49–2.30); Supplementary data, figure 1). In addition, subgroup study showed significant positive associations between increased EC risk and higher processed food intake in both occident and China (occident: combined OR/RRs = 1.70 (95%CI: 1.41–2.04); China: combined OR/RRs = 1.88 (95%CI: 1.46– 2.42); Supplementary data, figure 2). A sensitivity analysis indicated no changes in the direction of effect when any one study was excluded (Supplementary data, figure 3). Begg's test, Egger's tests and funnel plots showed no significant publication bias in included studies (Egger's test (P = 0.065), Begg's test (P = 0.492); Supplementary data, figure 4).
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2 cohort studies which included 3120 cases and 42277 controls for pickled food (table I). In addition, 30 case-control studies including 18897 cases and 23316 matched controls and 16 casecontrol studies including 14746 cases and 14427 matched controls were included for processed and pickled food, respectively. For studies for processed food, 9 studies examined EAC as the primary endpoints, 17 studies reported the results for ESCC, 10 studies examined both ESCC and EAC as the primary endpoints or did not differentiate between histological subtypes. Among the 36 studies for processed food, 22 studies were conducted in occident, 14 in China. For studies for pickled food, 11 studies examined ESCC as the primary endpoints, 7 studies examined both ESCC and EAC as the primary endpoints or did not differentiate between histological subtypes. Among the 18 studies for pickled food, 6 studies were conducted in Uruguay, 12 in China.
To cite this article: Yan B, et al. Consumption of processed and pickled food and esophageal cancer risk: A systematic review and meta-analysis. Bull Cancer (2018), https://doi.org/10.1016/j.bulcan.2018.08.006
Original article
B. Yan, L. Zhang, Z. Shao
TABLE I Characteristics of the studies included in the meta-analysis Reference and country (Yu, Garabrant et al. 1988) [18] USA
(Yu, Taylor et al. 1993) [19] China
275/275
EAC
275/275
EAC
1162/12693
All
Food item; comparison
Research type
1976–1980
Fried bacon or ham; 5+/wk Case-control study vs. 2 1/wk 1976–1980 Barbecued or smoked meat; 5 Case-control study +/wk vs. 2 1/wk 1974–1989 Pickled vegetables; regular vs. Cohort study occasional/never 1984–1992 Ham; category III vs. I Case-control study
OR/RR (95% CI) 2.00 (1.12–3.57) 1.70 (0.93–3.10) 1.03 (0.92–1.15)
(Tavani, Negri et al. 1994) [20] Italy
46/230
All
(De Stefani, Deneo-Pellegrini et al. 1999) [21] Uruguay (Bosetti, La Vecchia et al. 2000) [5] Italy
82/248
ESCC
N/A
Salted meats; Q4 vs. Q1
Case-control study
Processed meat; Q5 vs. Q1
Case-control study
1.39 (0.85–2.26) 4.48 (2.05–9.79)
(Levi, Pasche et al. 2000) [22] Switzerland (Takezaki, Gao et al. 2001) [6] China
1.40 (0.60–3.28) 2.5 (1.1–5.4)
304/743
ESCC
1992–1997
101/327
All
1992–1999
199/333
All
Processed meat; > 3.2 freq/ Case-control study wk vs. < 0.8 freq/wk 1990–1992 Pickled vegetables; Q4 vs. Q1 Case-control study
199/333
All
1990–1992
Salted meat; Q3 vs. Q1
Case-control study
0.93 (0.38–2.29)
199/333
All
1990–1992
Salted fish; Q3 vs. Q1
Case-control study
1.78 (0.96–3.30) 0.76 (0.43–1.34)
2.36 (1.20–4.65)
199/333
All
1990–1992
Fermented foods; Q4 vs. Q1
Case-control study
124/449
EAC
1986–1987
Processed meat; Q4 vs. Q1
Case-control study
1.7 (0.71–3.9)
[24] China
1248/1248
All
1997–2000
Sowbelly; daily vs. < 1/wk
Case-control study
2.28 (1.6–3.3)
(Cross, Freedman et al. 2011) [25] USA
630/494979
EAC
1995–1996
Processed meat; Q4 vs. Q1
Cohort study
1.08 (0.81–1.43)
215/494979
ESCC
1995–1996
Processed meat; Q4 vs. Q1
Cohort study
1.32 (0.83–2.10)
1248/1248
ESCC
Case-control study
3.21 (2.45–4.19)
166/664
ESCC
Case-control study
2.19 (1.21–3.98)
284/480
ESCC
Case-control study
3.4 (1.9–6.2)
284/480
ESCC
Case-control study
2.3 (1.2–4.2)
284/480
ESCC
Case-control study
2.5 (1.3–4.5)
138/1271
All
Case-control study
4.48 (2.05–9.79)
1958/29584
ESCC
Cohort study
1.09 (0.76–1.56)
185/185
All
Case-control study
0.66 (0.31–1.41)
185/185
All
Case-control study
2.12 (1.00–4.49)
(Chen, Ward et al. 2002) [23] USA
(Ke, Yu et al. 2002) [15] China
185/815
EAC
1997–2000 Fermented fish sauce; yes vs. no 1998–2000 Salted meat; 79+ vs. 0 servings per year 1996–2002 Fermented bean products; > 1/wk vs. < 1/wk 1996–2002 Salted food; > 1/wk vs. < 1/ wk 1996–2002 Pickled vegetables; > 1/wk vs. < 1/wk 1992–2002 Processed meat; > 3.2 freq/ wk vs. < 0.8 freq/wk 1986–2001 Pickled vegetables; 1 freq/ year vs. < 0 freq/year 2003–2004 Processed meat; > 3meals/wk vs. < 1 meal/wk 2003–2004 Picked vegetables; > 3 meals/ wk vs. < 1 meal/wk 1995–1997 Processed meat; T3 vs. T1
Case-control study
1.6 (0.9–3.1)
(Gonzalez, Jakszyn et al. 2006) [31] 10 European countries (Wu, Tseng et al. 2007) [32] USA
65/521457
EAC
1992–1998
Processed meat; T3 vs. T1
Cohort study
3.54 (1.57–7.99)
206/1308
EAC
1992–1997
Processed meat; Q4 vs. Q1
Case-control study
1.23 (0.71–2.13)
(Sapkota, Hsu et al. 2008) [33] European countries (Chen, Lee et al. 2009) [34] Taiwan, China
187/1110
ESCC
1.12 (0.52–2.41)
343/755
ESCC
1999–2003 Processed meat; 1 freq/wk Case-control study vs. < 1 freq/mo 1996–2005 Cured meat; 1/wk vs. < 1/wk Case-control study
343/755
ESCC
343/755
ESCC
343/755
ESCC
9252/3798
All
(De Stefani, Deneo-Pellegrini et al. 2003) [26] Uruguay (Hung, Huang et al. 2004) [27] Taiwan, China
(Levi, Pasche et al. 2004) [28] Switzerland (Tran, Sun et al. 2005) [16] China (Yang, Wang et al. 2005) [29] China
(Bahmanyar and Ye 2006) [30] Sweden
(De Stefani, Aune et al. 2009) [35] Uruguay
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Numbers of Cancer Years of cases/controls subtype diagnosis
0.80 (0.43–1.50)
1996–2005 Fermented bean product; 1/ Case-control study wk vs. < 1/wk 1996–2005 Salted food; 1/wk vs. < 1/wk Case-control study
1.6 (0.9–2.7)
1996–2005 Pickled vegetables; 1/wk vs. Case-control study < 1/wk 1988–2005 Salted meat; category III vs. I Case-control study
1.5 (0.9–2.6)
1.5 (0.8–2.5)
2.28 (1.75–2.97)
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To cite this article: Yan B, et al. Consumption of processed and pickled food and esophageal cancer risk: A systematic review and meta-analysis. Bull Cancer (2018), https://doi.org/10.1016/j.bulcan.2018.08.006
TABLE I (Continued). Reference and country (Sun, Chen et al. 2010) [36] China
Numbers of Cancer Years of cases/controls subtype diagnosis
Food item; comparison
Research type
OR/RR (95% CI)
250/750
All
2009–2010
Pickled food
(Hajizadeh, Jessri et al. 2011) [37] Iran
47/96
ESCC
N/A
Processed meat; T3 vs. T1
Case-control study
1.10 (0.36–2.47)
(O'Doherty, Cantwell et al. 2011) [38] UK (De Stefani, Deneo-Pellegrini et al. 2012) [39] Uruguay
224/256
EAC
2002–2005
Processed meat; Q4 vs. Q1
Case-control study
1.41 (0.67–2.95)
234/2020
ESCC
1.90 (1.15–3.15)
234/2020
ESCC
16/120852
ESCC
1996–2004 Salted meat; > 91 servings/yr Case-control study vs. 0 servings/yr 1996–2004 Processed meat; category III Case-control study vs. I 1986–2002 Processed meat; Q5 vs. Q1 Cohort study
14/120852
ESCC
1986–2002
Processed meat; T3 vs. T1
Cohort study
0.63 (0.28–1.43)
24/120852
EAC
1986–2002
Processed meat; Q5 vs. Q1
Cohort study
0.94 (0.46–1.91)
Processed meat; T3 vs. T1
Cohort study
(Keszei, Schouten et al. 2012) [40] Netherlands
7/120852
EAC
1986–2002
(Song, Wang et al. 2012) [41] China
254/254
ESCC
2008–2010
(Ward, Cross et al. 2012) [42] USA
124/449
EAC
1992–1994
137/481419
EAC
1992–1998
72/72
ESCC
2012–2012
876/1492
ESCC
1990–2005
(Jakszyn, Lujan-Barroso et al. 2013) [43] European countries (Song, Zhao et al. 2013) [44] China (De Stefani, Boffetta et al. 2014) [45] Uruguay
Case-control study 2.273 (1.350–3.828)
0.76 (0.51–1.13) 3.47 (1.21–9.94)
0.58 (0.22–1.51)
Preserved vegetables; Case-control study > 3 freq/wk vs. < 1 freq/wk Processed meat; > 52.3 Case-control study vs. 16.1 g/day Processed meat; T3 vs. T1 Cohort study
5.01 (2.07–12.17)
Preserved vegetable; yes or no Processed meat; Q4 vs. Q1
Case-control study
2.92 (1.32–6.47)
Case-control study
2.30 (1.72–3.07)
1.40 (0.62–3.16) 2.27 (1.33–3.89)
876/1492
ESCC
1990–2005
Salted meat; Q4 vs. Q1
Case-control study
3.82 (2.74–5.33)
(De Stefani, Deneo-Pellegrini et al. 2014) [46] Uruguay
234/936
ESCC
1996–2005
Processed meat; T3 vs. T1
Case-control study
1.49 (1.01–2.21)
234/936
ESCC
1996–2005
Salted meat; T3 vs. T1
Case-control study
1.91 (1.06–3.43)
(Lin, Wang et al. 2015) [47] China
942/942
ESCC
2011–2013
Case-control study
5.52 (3.49–8.74)
(Liu, Wang et al. 2017) [17] China
942/942
ESCC
Salted meat; T3 vs. never intake Processed meat; Q4 vs. Q1
Case-control study
2.84 (2.13–3.80)
(Tan, Lin et al. 2017) [48] China
125/250
All
1.31 (0.58–2.95)
125/250
All
2005–2011 Salted meat; 3 freq/wk vs. Case-control study < 1 freq/wk 2005–2011 Pickled vegetables; 3 freq/ Case-control study wk vs. < 1 freq/wk
2011–2013
Original article
Consumption of processed and pickled food and esophageal cancer risk: A systematic review and meta-analysis
2.64 (1.46–4.76)
CI: confidence intervals; EAC: Esophageal adenocarcinoma; EC: esophageal cancer; ESCC: Esophageal squamous cell carcinoma; freq/wk: frequency/week; mo: month; OR: odd ratio; Q: quartile; RR: relative risk; T: tertile; yr: year.
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3.19); Supplementary data, figure 5). Subgroup study showed significant positive associations between increased EC risk and higher pickled food intake in both occident and China (occident: combined OR/RRs = 2.46 (95%CI: 1.91–3.15); China: combined OR/RRs = 2.01 (95%CI: 1.50–2.68); Supplementary data, figure 6). A sensitivity analysis showed no changes in the direction of effect when any one study was excluded (Supplementary data, figure 7). Egger's tests showed significant publication bias in all included studies (P = 0.001). But no significant publication bias in all case-control studies (Egger's test (P = 0.246), Begg's test (P = 1.000); Supplementary data, figure 8). Publication bias could not be made for all cohort studies because of the insufficient study number.
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Meta-analysis results indicated that the combined OR/RRs (95%CI) of studies comparing the highest and lowest categories were 2.10 (1.64–2.69) for pickled food (figure 4). In addition, significant heterogeneities were detected between different studies (Q test, P < 0.001). Subgroup analysis for case-control studies indicated that the highest categories of pickled intake showed a more than two-fold increased EC risk, compared with the lowest categories (OR: 2.28; 95%CI: 1.93– 2.70; figure 5); however, no significant positive association were found when we examined only the cohort studies (RR: 1.43; 95%CI: 0.85–2.42; figure 5). In addition, subgroup analysis indicated that high pickled food intakes were correlated to increased ESCC risks (combined OR/RRs = 2.35 (95%CI: 1.73–
To cite this article: Yan B, et al. Consumption of processed and pickled food and esophageal cancer risk: A systematic review and meta-analysis. Bull Cancer (2018), https://doi.org/10.1016/j.bulcan.2018.08.006
Original article
B. Yan, L. Zhang, Z. Shao
Figure 2 The combined OR/RRs and 95%CI of EC risk for the highest vs. lowest categories of processed food
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CI: confidence intervals; EC: esophageal cancer; OR: odd ratio; RR: relative risk.
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To cite this article: Yan B, et al. Consumption of processed and pickled food and esophageal cancer risk: A systematic review and meta-analysis. Bull Cancer (2018), https://doi.org/10.1016/j.bulcan.2018.08.006
Original article
Consumption of processed and pickled food and esophageal cancer risk: A systematic review and meta-analysis
Figure 3 The combined OR/RRs and 95%CI of EC risk for the highest vs. lowest categories of processed food for case-control studies and cohort studies
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CI: confidence intervals; EC: esophageal cancer; OR: odd ratio; RR: relative risk.
To cite this article: Yan B, et al. Consumption of processed and pickled food and esophageal cancer risk: A systematic review and meta-analysis. Bull Cancer (2018), https://doi.org/10.1016/j.bulcan.2018.08.006
Original article
B. Yan, L. Zhang, Z. Shao
Figure 4 The combined OR/RRs and 95%CI of EC risk for the highest vs. lowest categories of pickled food CI: confidence intervals; EC: esophageal cancer; OR: odd ratio; RR: relative risk.
Discussion
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The present meta-analysis indicated an approximately two-fold increased risk of EC associated with processed and pickled food intakes in the overall analysis. This study enabled the modification of the previous meta-analysis studies [7,8]. This study showed that the highest categories of processed food intake were associated with a 79% increase in EC risk compared with the lowest categories. In addition, subgroup analysis indicated that the results could not be affected by different histological types of EC and different countries where the study was conducted. However, no significant positive association was found when we examined only the cohort studies. The results of cohort studies are usually more reliable than retrospective case-control studies. Thus, more prospective cohort studies were essential for providing sufficient supportive evidence of association of an increased risk and consumption of processed food. Sensitivity analysis indicated that the results of the meta-analysis were reliable. In addition, included studies showed no publication bias. Processed food mainly included salt-processed food (pickled vegetables, salted fish and salted meat), fermented food (fermented fish sauce and fermented bean products) and smoking food (bacon). The definition and compositions of processed food might be different among studies, which contributes to inconsistent results on processed food
and EC [9]. Salted food is typically preserved by adding nitrate or nitrite, which increases the formation of N-nitroso compounds (NOCs), which were suggested to be animal carcinogens and possible human carcinogens [10,11]. Moreover, after being cooked or processed at high temperature, salted food may also contain other carcinogens, such as heterocyclic amines and polycyclic aromatic hydrocarbons [9]. Additionally, high concentrations of salt might increase the EC risk. Salt might directly damage esophageal mucosa, contributing to susceptibility to esophagitis and increasing the EC risk [12]. Regarding fermented food, studies have found the formation of carcinogenic N-(Nitrosomethyl) urea (NMU) in stomachs of pigs and human volunteers after given fermented fish sauce [13,14]. However, the association between fermented food intake and EC risk remains obscure. Ke et al. found a significant association of an increased EC risk and consumption of fermented fish sauce [15], whereas Takezaki et al. indicated no significant association between them [6]. More studies are essential for exploring their association. This study shows a more than two-fold increased risk of EC associated with pickled food intakes. However, subgroup analysis showed no significant association in cohort studies for pickled food. Traditionally, the results of cohort studies are usually more reliable than retrospective case-control studies,
tome xx > n8x > xx 2018
To cite this article: Yan B, et al. Consumption of processed and pickled food and esophageal cancer risk: A systematic review and meta-analysis. Bull Cancer (2018), https://doi.org/10.1016/j.bulcan.2018.08.006
Original article
Consumption of processed and pickled food and esophageal cancer risk: A systematic review and meta-analysis
Figure 5 The combined OR/RRs and 95%CI of EC risk for the highest vs. lowest categories of pickled food for case-control studies and cohort studies CI: confidence intervals; EC: esophageal cancer; OR: odd ratio; RR: relative risk.
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study indicated a more than two-fold increased risk of EC with a consumption of highest categories of pickled food compared to the lowest categories in China. Sensitivity analysis showed that the results of the meta-analysis appear to be reliable. However, Egger's tests showed a significant publication bias in all included studies. After excluding three cohort studies, this study showed no significant publication bias for all case-control studies. There were some limitations in the present meta-analysis study. Most studies compared the highest categories of processed or pickled food intake to the lowest categories. However, some studies did not quantify the consumption of processed or pickled
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because of the absence of recall and interviewer bias. However, more reasons could be envisaged to question the computed results from cohort studies. Two included cohort studies indicated no increased risk. One study was explored during a period when strong recommendations had been made against pickled vegetable use; such use in that study was very low. In addition, the absence of significant association in the study might also be due to inaccurate questionnaire responses [16]. Subgroup analysis indicated a significant increase in both EAC and ESCC risks and consumption of pickled food. All the included studies except studies explored by De Stefani et al. are from China. Subgroup
To cite this article: Yan B, et al. Consumption of processed and pickled food and esophageal cancer risk: A systematic review and meta-analysis. Bull Cancer (2018), https://doi.org/10.1016/j.bulcan.2018.08.006
Original article
B. Yan, L. Zhang, Z. Shao
food, they just compared regular intake of processed or pickled food to never intake of the food. In addition, plenty of studies included in the present meta-analysis study showed the role of dose-effect in the association between processed or pickled food intake and EC risks. In a recent study, the association between processed food intake and ESCC risks was significant in comparison of the highest with the lowest quartile (OR = 2.84 (95%CI: 2.13–3.80)), whereas the association was not significant in comparison of the second quartile with the lowest quartile (OR = 1.25 (95%CI: 0.92–1.71)) [17]. But in our study, we did not explore the role of dose-effect. Further studies are needed to explore the role of dose-effect. In conclusion, this study suggests that both a high consumption of processed and pickled food may increase the EC risk. However, no significant association was found for processed or pickled
food in cohort studies. Thus, large scale prospective studies are needed to determine whether processed and pickled food intakes increase the EC risk. Funding: no funding. Disclosure of interest: the authors declare that they have no competing interest.
Supplementary data Supplementary material available on the Internet site of Bulletin du cancer (https://doi.org/10. 1016/j.bulcan.2018.08.006).
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Original article
Consumption of processed and pickled food and esophageal cancer risk: A systematic review and meta-analysis