Ovarian Cancer Risk Unaffected by Smoking but Possibly Lowered by Caffeine Consumption CME

Ovarian Cancer Risk Unaffected by Smoking but Possibly Lowered by Caffeine Consumption CME

News Author: Roxanne Nelson
CME Author: Désirée Lie, MD, MSEd

Complete author affiliations and disclosures, and other CME information, are available at the end of this activity.

Release Date: January 23, 2008Valid for credit through January 23, 2009

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Physicians should only claim credit commensurate with the extent of their participation in the activity.


The content of this CME activity, “Ovarian Cancer Risk Unaffected by Smoking but Possibly Lowered by Caffeine Consumption,” was developed by the faculty.

To participate in this activity: 1) review the target audience, learning objectives and author disclosures, 2) study the education content 3) answer the posttest and evaluation 4) view/print certificate View details

Learning Objectives

Upon completion of this activity, participants will be able to:

  1. Describe the association between smoking and the risk for ovarian cancer.
  2. Describe the association between caffeine and alcohol intake and the risk for ovarian cancer.
Authors and Disclosures
Roxanne Nelson
Disclosure: Roxanne Nelson, has disclosed no relevant financial information.
Désirée Lie, MD, MSEd
Disclosure: Désirée Lie, MD, MSEd, has disclosed no relevant financial relationships.
Brande Nicole Martin
Disclosure: Brande Nicole Martin has disclosed no relevant financial information.

January 23, 2008 — Aside from a link to mucinous tumors, cigarette smoking does not seem to raise the risk for ovarian cancer. Alcohol use was also not associated with an increased risk, according to a new study published in the January 18 Online First issue of Cancer. However, the researchers noted an inverse association between caffeine intake and the risk for ovarian cancer, especially in women who have not previously used exogenous hormones.

The association of modifiable factors such as smoking and the consumption of caffeine and alcohol and the risk for ovarian cancer remains unclear. Results of a meta-analysis found no overall association between smoking and the risk for ovarian cancer, but that current smokers did have twice the risk for mucinous tumors. Several other studies have suggested a positive association for all subtypes of invasive epithelial ovarian cancer incidence or mortality among women who are current and long-term smokers.

“Substantial evidence supports that smoking only increases the risk of a specific subtype of ovarian cancer, the mucinous type,” lead author Shelley Tworoger, PhD, an assistant professor of medicine and epidemiology at Harvard Medical School, Boston, Massachusetts, told Medscape Oncology. “However, because of the many health benefits of smoking cessation, it is important to encourage people to stop smoking.”

Previous studies have also shown the association between alcohol and ovarian cancer generally to be either modestly inverse or null. Some data also have shown caffeine to be inversely associated with the risk for ovarian cancer, although the association with the consumption of caffeinated beverages such as tea and coffee has been inconsistent.

In the current study, Dr. Tworoger and colleagues examined the associations between smoking, alcohol intake, caffeine consumption, and the risk for ovarian cancer, using the Nurses’ Health Study (NHS). Data were prospectively examined among 110,454 women for the smoking analyses and 80,253 women for the dietary analyses.

The NHS began in 1976, and the cohort was followed up every 2 years to update exposure variables and ascertain newly diagnosed disease. A food frequency questionnaire was added in 1980 and was administered every 2 to 4 years. Using this database, the researchers identified 737 incident cases of epithelial ovarian cancer between June 1, 1976, and June 1, 2004, among the total cohort that participated in the NHS. Among respondents to the 1980 food frequency questionnaire, 507 cases were identified.

An association between current or past smoking and the risk for ovarian cancer was not observed, and the risk did not seem to rise with increasing duration of smoking or pack-years. However, the researchers did find that smoking was significantly associated with the risk for mucinous tumors: a relative risk (RR) of 2.22 for current smokers and 2.02 for past smokers. The risk of developing a mucinous tumor was also associated with the duration of tobacco use.

An association between alcohol intake and ovarian cancer risk was not observed, but a small inverse association between caffeine intake and ovarian cancer risk was observed. The inverse association was most pronounced in women who had never used oral contraceptives or received hormone replacement therapy during menopause. Consumption of caffeinated coffee and tea were associated with ovarian cancer risk, but not the intake of caffeinated cola drinks.

“As for the caffeine, coffee, and tea relationships, it is too early to make clinical recommendations,” said Dr. Tworoger. “We hope that other studies will examine the relationship between these factors and ovarian cancer risk in an effort to confirm these relationships. However, women who are concerned about their risk of ovarian cancer should speak with their doctor about possible lifestyle changes.”

The study was supported by grants from the National Institutes of Health.

Cancer. Published online January 18, 2008.

Learning Objectives for This Educational Activity

Upon completion of this activity, participants will be able to:

  1. Describe the association between smoking and the risk for ovarian cancer.
  2. Describe the association between caffeine and alcohol intake and the risk for ovarian cancer.

Clinical Context

Increasing parity and oral contraceptive risk have been shown to be inversely associated with ovarian cancer risk, but these are not modifiable risk factors. Smoking, caffeine, and alcohol intake are modifiable behaviors, with an uncertain association with ovarian cancer risk. In other studies, caffeine has been found to be inversely associated with a 40% risk reduction for the top vs the bottom quintile of intake, and the association is stronger in never-users of oral contraceptives, but alcohol has not been found to be associated consistently. Smoking may be associated with ovarian cancer risk, and mucinous tumors are more similar to colonic cancers and susceptible to cigarette smoke carcinogenesis.

This is a prospective longitudinal cohort study in the NHS examining the association between smoking, alcohol, and caffeine intake and subsequent incidence of ovarian cancer in a cohort followed up for more than 20 years.

Study Highlights

  • Included were women from an original cohort of 121,701 US female registered nurses aged 30 to 55 years who returned a baseline questionnaire in 1976 and were followed up every 2 years by questionnaire.
  • Smoking history was assessed at baseline and dietary history from 1980 with use of a food frequency questionnaire.
  • On each questionnaire, women were asked about current vs past smoking and number of cigarettes smoked, and pack-years were calculated.
  • For alcohol, intake of beer, wine, and liquor in the previous year was assessed, and content of each beverage was calculated as 13.2 g per bottle or can of beer, 10.8 g per glass of wine, and 15.1 g per standard drink of liquor.
  • Caffeine content was calculated as 137 mg per cup of coffee, 47 mg per cup of tea, 46 mg per can or bottle of soda, and 7 mg per serving of chocolate, with frequency of consumption ranging from never to 6 or more times daily.
  • The population was 97% white, 2% African American, and 1% Asian.
  • For the smoking analysis, those who reported a diagnosis of cancer, bilateral oophorectomy, or pelvic irradiation were excluded, leaving 110,454 women for analysis.
  • For the alcohol and caffeine analysis, those with incomplete or implausible food frequency questionnaires were excluded, leaving 80,253 women for analysis.
  • Incident cases of epithelial ovarian cancer were identified by biennial questionnaire, and for those reporting a new ovarian cancer or identified through death certificates, pathology reports and medical records were used to verify diagnosis and histologic features of the cancers, subtype, morphologic types, and stage.
  • Incident rates for each type of exposure were calculated.
  • There were 507 incident cases (443 invasive and 64 borderline) identified.
  • At midpoint of the study, those who drank 15 g or more of alcohol daily or in the top quintile of caffeine intake were more likely to be smokers.
  • Duration of oral contraceptive use was greater among those who drank 15 g or more of alcohol daily.
  • There was no association between current or past smoking, pack-years smoked, or duration of smoking and the risk for ovarian cancer.
  • Smoking was significantly associated with mucinous tumors for all current smokers (RR, 2.22) and former smokers (RR, 2.02) vs never-smokers.
  • The association with mucinous tumors was also significant for duration (RR, 1.44 per 20 years) and pack-years (RR, 1.30 per 20 pack-years).
  • There was a significant inverse trend seen between caffeine intake and the risk for ovarian cancer (P for trend = .03).
  • The RR for top vs bottom quintile of intake was 0.80, for 3 or more cups vs no coffee daily was 0.75, and protection was greater in never-users of oral contraceptives and hormone therapy (RR, 0.65 and 0.57, respectively).
  • There was no association between decaffeinated coffee and the risk for ovarian cancer.
  • There was no association between cola intake and ovarian cancer, and an inverse trend was seen for nonherbal tea.
  • Total alcohol intake was not associated with the risk for ovarian cancer.
  • The associations seen did not vary by age, parity, tubal ligation, and body mass index.

Pearls for Practice

  • Smoking is not associated with increased incidence of ovarian cancer except mucinous tumors.
  • Caffeine intake is protective for ovarian cancer, whereas alcohol intake is not associated with the risk for ovarian cancer.

According to the study by Tworoger and colleagues, which of the following factors is associated with increased risk for ovarian cancer?
Current vs never smoking
Past vs never smoking
Smoking more than 20 cigarettes per day vs no smoking
None of the above
According to the study by Tworoger and colleagues, which of the following beverages is most likely to be protective for ovarian cancer?
Decaffeinated coffee
Coffee
Cola
Alcohol

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Target Audience

This article is intended for primary care clinicians, gynecologists, and other specialists who care for women at risk for ovarian cancer.

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News Author

Roxanne Nelson
is a staff journalist for Medscape Hematology-Oncology.

Disclosure: Roxanne Nelson, has disclosed no relevant financial information.

CME Author

Désirée Lie, MD, MSEd
Clinical Professor, Family Medicine, University of California, Orange; Director, Division of Faculty Development, UCI Medical Center, Orange, California

Disclosure: Désirée Lie, MD, MSEd, has disclosed no relevant financial relationships.

Brande Nicole Martin
is the News CME editor for Medscape Medical News.

Disclosure: Brande Nicole Martin has disclosed no relevant financial information.

Medscape Medical News 2008. ©2008 Medscape

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