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The Journal of Clinical Endocrinology & Metabolism Vol. 89, No. 3 1160-1163
Copyright © 2004 by The Endocrine Society

Circulating Adiponectin and Endometrial Cancer Risk

Luigino Dal Maso, Livia S. A. Augustin, Aspasia Karalis, Renato Talamini, Silvia Franceschi, Dimitrios Trichopoulos, Christos S. Mantzoros and Carlo La Vecchia

Servizio di Epidemiologia e Biostatistica, Centro di Riferimento Oncologico (L.D.M., L.S.A.A., R.T.), Aviano 33081, Italy; Department of Nutritional Sciences, Faculty of Medicine, University of Toronto and the Clinical Nutrition and Risk Factor Modification Center, St. Michael’s Hospital (L.S.A.A.), Toronto M5C 2T2, Canada; Human Nutrition Research Unit, Division of Endocrinology, Diabetes and Metabolism, Beth Israel Deaconess Medical Center, Harvard Medical School (A.K, C.S.M.), Boston, Massachusetts 02215; International Agency for Research on Cancer (S.F.), Lyon 69008, France; Department of Epidemiology, Harvard School of Public Health (D.T.), Boston, Massachusetts 02215; Istituto di Ricerche Farmacologiche Mario Negri (C.L.V.), Milan 20157, Italy; and Istituto di Statistica Medica e Biometria, Università degli Studi di Milano (C.L.V.), Milan 20133, Italy

Address all correspondence and requests for reprints to: Dr. Luigino Dal Maso, Servizio di Epidemiologia e Biostatistica, Centro di Riferimento Oncologico, Institute for Cancer Research and Treatment, Via Pedemontana Occidentale, 33081 Aviano (PN), Italy. E-mail: epidemiology{at}cro.it.


    Abstract
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 Abstract
 Introduction
 Subjects and Methods
 Results
 Discussion
 References
 
Circulating levels of adiponectin, a hormone with insulin-sensitizing properties, are decreased in conditions related to obesity and hyperinsulinemia, which are recognized risk factors for endometrial cancer. Eighty-seven cases with incident, histologically confirmed endometrial cancer and 132 controls admitted for acute, nonneoplastic diseases were interviewed in northeastern Italy between 1999 and 2002, and blood samples were collected. Levels of adiponectin were evaluated in samples by means of a RIA. An inverse association with endometrial cancer risk emerged for plasma adiponectin levels [odds ratio (OR), 0.42; 95% confidence interval, 0.19–0.94] when comparing the highest vs. the lowest tertiles. Similar results emerged for serum adiponectin (OR, 0.30; 95% confidence interval, 0.14–0.68). The association was stronger in pre- than in postmenopausal women, but no significant heterogeneity was observed across strata of body mass index (BMI) or parity. BMI and adiponectin showed independent effects on the risk of endometrial cancer according to a multiplicative model (OR, 6.45 in the highest level of BMI and in the lowest one of adiponectin).


    Introduction
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 Abstract
 Introduction
 Subjects and Methods
 Results
 Discussion
 References
 
ADIPONECTIN IS A recently discovered protein secreted by adipocytes that acts as an antidiabetic and antiatherogenic hormone (1, 2, 3). Circulating levels of adiponectin are reduced in conditions related to insulin resistance and hyperinsulinemia, such as visceral obesity and type 2 diabetes (3). These conditions are also recognized risk factors for endometrial cancer (4, 5). The associations of overweight and obesity with endometrial cancer have generally been explained in terms of increased aromatization of androstenedione to estrone in adipose tissue and, hence, in circulating estrogen levels. However, the association between diabetes and endometrial cancer is not totally accounted for by overweight (6, 7, 8, 9). Insulin resistance and related low adiponectin levels may, therefore, help explain the missing link among obesity, diabetes, and endometrial cancer risk (10, 11).

In a case-control study of 84 cases and 84 controls from Greece (12), an increase in adiponectin by 1 SD was associated with an odds ratio (OR) of endometrial cancer of 0.44 among women under 65 yr of age, after allowance for body mass index (BMI). To provide additional information on the issue, we have conducted a hospital-based case-control study of endometrial cancer in Pordenone (North-Eastern Italy). As limited evidence is available concerning the possible role of plasma and serum levels of adiponectin and their potential impact on chronic diseases such as endometrial cancer, we performed the adiponectin assay on both serum and plasma.


    Subjects and Methods
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 Abstract
 Introduction
 Subjects and Methods
 Results
 Discussion
 References
 
Between 1999 and 2002, we interviewed 87 women, aged 34–78 yr (median age, 62 yr) with incident, histologically confirmed endometrial cancer. Three (4%) cases had stage 0, 50 (62%) had stage I, 11 (14%) stage II, and 17 (21%) had stage III or IV. Controls were 132 women, aged 29–79 yr (median age, 61 yr), who had an intact uterus and had been admitted to the same hospital network for acute nonneoplastic conditions unrelated to gynecological, hormonal, or metabolic disorders or to dietary modifications. Eighty-seven percent of controls were admitted for traumas, and 13% for other miscellaneous illnesses, such as eye, nose, or throat disorders.

Trained interviewers in hospital wards collected information on sociodemographic and anthropometric characteristics, smoking habits, physical activity, height and weight, selected medical conditions, menstrual and reproductive factors, and use of hormone replacement therapy. To assess the diet, including total energy intake, a validated food frequency questionnaire was used, including 78 foods, food groups, or recipes (13).

Two controls (1.4%) and no cases refused the interview. All study participants signed written informed consent and donated a 15-ml blood sample [7.5-ml Vacutainer (SARSTED, Nümbrecht, Germany) tubes with EDTA and 7.5-ml Vacutainer tubes without EDTA] on the day the interview took place (generally the first day of the hospital stay). Blood samples were kept refrigerated and were processed, within 12 h from collection, at the National Cancer Institute of Aviano. They were centrifuged at 1500 rpm for 20 min, extracted, and distributed into different cryotubes of serum, plasma, buffy coat, and red blood cells. All samples were stored at -80 C. Serum and plasma samples were sent to the Human Nutritional Research Unit, Harvard Medical School (Boston, MA), for testing (12). Adiponectin analysis was blindly performed by RIA with a sensitivity of 2 ng/ml and an intraassay coefficient of variation of 8%.

ORs and the corresponding 95% confidence intervals (CI) for tertiles of plasma and serum adiponectin were computed using unconditional multiple logistic regression models, including terms for age, education, parity, smoking status, BMI (kilograms per meter squared) and hormone replacement therapy (14). To evaluate dose-response effects, tests for linear trend were assessed, by means of the {chi}2 ({chi}12 trend) on the variables considered categorical by computing the difference between the deviance of the model with and that without the variables of interest (14).


    Results
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 Abstract
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 Subjects and Methods
 Results
 Discussion
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Table 1Go shows the distribution of cases and controls by sociodemographic and other selected variables. Cases were more frequently overweight (OR, 5.87 for BMI >=30 vs. BMI < 25), less frequently parous (OR, 0.49), tended to report later menopause (OR, 1.86), and more frequently had a family history of endometrial cancer (OR, 2.01) than controls. Plasma adiponectin was weakly correlated with age (Spearman r = 0.09), energy intake (r = -0.08), and BMI (r = -0.18). Plasma and serum levels of adiponectin showed a strong correlation (r = 0.61).


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TABLE 1. Distribution of 87 cases of endometrial cancer and 132 controls, OR, and corresponding 95% CI by sociodemographic factors and selected variables

 
Table 2Go shows the associations of endometrial cancer with plasma and serum adiponectin levels. The OR was 0.42 (95% CI, 0.19–0.94) for the highest tertile of plasma adiponectin and 0.30 (95% CI, 0.14–0.68) for the highest tertile of serum adiponectin. Premenopausal women showed a stronger inverse association with levels of plasma adiponectin (OR, 0.06; 95% CI, 0.00–0.73).


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TABLE 2. OR and corresponding 95% CI of endometrial cancer according to plasma and serum levels of adiponectin in the total population and in different strata of menopausal status

 
The relation among adiponectin, BMI, and endometrial cancer risk is examined in Fig. 1Go and Table 3Go. Cases showed a lower median level of plasma adiponectin [median, 11.4; interquartile range (IQR), 6.5–17.1], than controls (median, 16.0; IQR, 8.4–22.5; Fig. 1Go). Conversely, BMI was higher in cases (median, 27.8; IQR, 25.4–32.0) than controls (median, 25.1; IQR, 22.3–27.9).



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FIG. 1. Distribution of endometrial cancer cases and controls according to plasma levels of adiponectin (micrograms per milliliter) and BMI (kilograms per meter squared).

 

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TABLE 3. OR and corresponding 95% CI of endometrial cancer according to the combined effect of plasma levels of adiponectin and BMI

 
The combined effect of plasma adiponectin and BMI in endometrial cancer risk in women is shown in Table 3Go. Compared with subjects with low BMI and high plasma adiponectin, the OR for women with high BMI and low plasma adiponectin was 6.45 (95% CI, 2.55–16.35). Similar results were seen for serum adiponectin (OR, 10.17; 95% CI: 3.82–27.09). Additional analyses with respect to the combination of high total energy intake (>=2300 kcal) and low adiponectin levels led to an OR of 2.75 (95% CI, 1.16–6.52) for plasma and 3.19 (95% CI, 1.36–7.44) for serum adiponectin (data not shown in tables). The exclusion of patients diagnosed at stage III or IV (17 cases) did not materially change any of the results. Moreover, the additional adjustment for waist to hip ratio did not appreciably modify the results.


    Discussion
 Top
 Abstract
 Introduction
 Subjects and Methods
 Results
 Discussion
 References
 
The present analysis provides strong evidence that serum and plasma levels of adiponectin are inversely related to endometrial cancer risk, even after allowance for BMI and other major identified potential confounding factors (15). The combination of high BMI and low adiponectin levels led to a more than 6-fold excess risk.

As in a Greek study (12), the inverse association was apparently stronger in younger women, particularly in premenopausal ones. The inclusion of young women with anovulation or polycystic ovary syndrome (4, 16), a disease characterized by several factors directly associated with endometrial cancer (4, 11, 17), may at least in part explain this finding.

The observation that overweight and adiponectin have independent roles in endometrial cancer risk indicates that the two mechanisms, possibly reflecting excess estrogen levels and insulin resistance, have multiplicative effects in endometrial carcinogenesis. We also observed that diets with high glycemic index and load, which are related to high levels of blood glucose, insulin, and possibly IGFs, are directly related to endometrial cancer risk (18).

Insulin stimulates the growth of endometrial stromal cells through direct binding to insulin receptors on endometrial cell membranes (19). An association between adiponectin and leptin binding protein was recently demonstrated (20), even if the direction of the causal relationship between them and the possibility of regulation by another, as yet unidentified, common factor deserves further investigation. However, the limited information available on the potential interaction among adiponectin, leptin, insulin, and IGF components on the mechanism of endometrial carcinogenesis (12) suggests cautious conclusions. Furthermore, adiponectin levels, as recently shown, are negatively and independently associated with estradiol, whereas no association emerged between leptin, cortisol, or free testosterone and adiponectin (21).

Although our study was hospital-based, it is unlikely that bias or confounding substantially influenced the main findings, because the catchment areas of cases and controls were similar, participation was practically complete, major identified risk factors were consistent with our knowledge of endometrial carcinogenesis, and allowance was made for major potential confounding factors. Reproducibility of self-reported medical history, menstrual, and reproductive factors were satisfactory (22). Moreover, self-reported anthropometric measures were not biased between cases and controls (23). Interview and blood collection were made in the majority of study subjects on the first day of hospital admission and for cancer cases always before surgical or radiation treatment. Moreover, in the present study the distribution of endometrial cancer cases by stage was similar to that reported in a larger series from developed countries (24) with a predominance of localized (stage I) cancers.

In conclusion, analyses of adiponectin in serum and plasma samples yielded consistent results; thus, either plasma or serum measurements could be used in future studies.


    Acknowledgments
 
We thank Mrs. O. Volpato for training and supervising the interviewers, and Mrs. L. Mei for editorial assistance.


    Footnotes
 
This work was supported by the Italian Association for Cancer Research and the Italian League against Tumours.

Abbreviations: BMI, Body mass index; CI, confidence interval; IQR, interquartile range; OR, odds ratio.

Received October 6, 2003.

Accepted December 16, 2003.


    References
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 Introduction
 Subjects and Methods
 Results
 Discussion
 References
 

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