López-Hernández D

Research Article

Austin J Obstet Gynecol. 2014;1(3): 7.

Type 2 Diabetes Mellitus and Habits Lifestyle Increases the Risk of Cervical Cancer: a Cross-Sectional Population-Based Study

López-Hernández D*

Department of Epidemiology and Biostatistical Center for Research and Continuing Education, Mexico

*Corresponding author: López-Hernández D, Department of Epidemiology and Biostatistical, CENINVEC, Oyameles No. 30, Col. La Perla, Ciudad Nezahualcoyotl, C.P. 57820, Mexico State, Mexico

Received: July 02, 2014; Accepted: Aug 04, 2014; Published: Aug 05, 2014

Abstract

Background: Timely detection allows the inclusion of vulnerable populations into the cervical cancer (CC) screening programs, particularly in low- and middle-income countries. The aim was determine both the prevalence and the risk of CC in patients who have type 2 diabetes mellitus (T2DM).

Methods: A cross-sectional population-based survey in Mexico was conducted using a probabilistic, multistage, and stratified cluster sampling design. The structured questionnaire included information on geographic region, personal history, and life styles, and anthropometric measures. A total of 160 cases of CC (median age 48 years, range 24-81) and 25,262 control females (median age 39 years, range 20-99) were included.

Results: The prevalence of CC in women with T2DM was significantly higher compared with females without diabetes (1,336 vs. 576 subjects per 100,000 inhabitants, p<0.001). In all univariate (U) and multivariate (M) logistic regression models (LRM), the ORs for CC displayed a significant association with diabetes (ULRM OR=2.338; 95% CI 1.511-3.618, p<0.001, MLRM1 OR=2.098; 95% CI 1.345-3.272, p=0.001, MLRM2 OR=1.719; 95% CI 1.0.33-2.862, p=0.001) and tobacco smoking (ULRM OR=1.979; 95% CI 1.368-2.863, p<0.001, MLRM1 OR=1.847; 95% CI 1.234-2.765, p=0.003, MLRM2 OR=1.859; 95% CI 1.191-2.902, p=0.006). The ULRM indicated a significant association for separate (OR=1.906; 95% CI 1.178-3.085, p=0.009), widowed (OR=1.615; 95% CI 1.059-2.462, p=0.026) and single MS (OR=3.297; 95% CI 1.618-6.717, p=0.001). The MLRM2 indicated a similar association for the variables sedentary (OR=8.676; 95% CI 1.204-62.497, p=0.032), physical activity (OR=0.115; 95% CI 0.016-0.827, p=0.032) and body fat percentage (OR=1.084; 95% CI 1.023-1.149, p=0.006).

Conclusion: This study supports an association between personal history of diabetes and tobacco smoking and life styles with CC.

Keywords: Cervical cancer; Diabetes; Risk factors; Logistic regression; Lifestyle characteristics; Sociodemographic components

Introduction

Diabetes and cancer are two common non-communicable chronic diseases that have an enormous impact on worldwide health and the economy [1], and they are a considerable public health problem. Diabetes Mellitus (DM) affects more that 100 million people around the world [2]. Several studies have reported that people with diabetes have a significantly higher risk of many forms of cancer [1]. In addition, diabetes is associated with an increased risk of total cancer mortality [3-8] and with site-specific mortality from cancer of the endometrium [9,10], breast [10-14], colorectum [10,15-18], pancreas [10,19-22], liver [10,23-25], and prostate [26- 29]. Moreover an association between abnormal glucose tolerance and the risk of cancer mortality has also been demonstrated for Western countries [30-32]. Recently, several studies reported a direct association between various cancers [33], including cervical cancer [34], and with both Metabolic Syndrome (MetS) and individual components of MetS [33-42]. Several epidemiologic studies have reported diabetes as a risk factor for endometrial cancer, independent from obesity [41,43-46]. Studies conducted in the United State of America, Canada and Spain has revealed that women with diabetes undergo mammography and Papanicolaou (paP) smear procedures less frequently than women without diabetes [46-51]. In addition, one study in Mexico reported a direct association between both low-grade cervical lesions and infection with human papilloma virus type 1 with glucose concentration [52]. Given the substantial increase of both non-communicable chronic diseases such as diabetes mellitus and the high prevalence of cervical cancer, there is a great interest in determining susceptible populations and cofactors that could increase the mortality and the risk of cervical cancer; additionally there are limited information about the relationship of type 2 DM (T2DM) and cervical cancer. Therefore the aim of the present study was to determine both the prevalence and the risk of cervical cancer among women with diabetes.

Material and Methods

Study design, data collection and participants

A cross-sectional population-based survey from Mexico was conducted from October 2005 to May 2006. The survey includes data from 48 304 households [53-55] of urban (≥2 500 inhabitants) and rural (<2 500 inhabitants) geographic regions of Mexico [53- 55]. Sociodemographic and personal health questionnaires, lifestyles habits and blood pressure were obtained from all participants. For the present study, only the data from adult women were selected. A total of 25, 422 women (median age 39, range 20-99) were included. However, because in the survey the response rates for anthropometric measurements were 79.6%, the associated analysis between cervical cancer and anthropometric measurements was reported in a previous publication [56], which included 20,236 women. Height was measured to the nearest 0.1 cm using a stadiometer, and body weight was measured using a digital scale [53,54]. Body mass index (BMI) was calculated according to Quetelet's index (kg/m²), and the body fat percentage (BFP) was obtained using the Deurenberg equation [BFP = 1.2(BMI) + 0.23(age) -10.8(sex) - 5.4]. Waist circumference (WC) was measured at the midpoint between the highest part of the iliac crest and the lowest part of the rib margin of the median axial line [53,54].

Survey instrument

The National Survey of Health and Nutrition 2006 (ENSANUT 2006; Encuesta Nacional de Salud y Nutrición 2006, for its acronym in Spanish) had a probabilistic, multistage, stratified cluster sampling design. The structured questionnaire included information on sociodemographic characteristics such as geographic region, literacy and marital status. In addition, the instrument also included personal history of type 2 diabetes mellitus (T2DM) and cervical cancer; lifestyle habits, such as tobacco smoking, alcohol consumption, physical activity, sedentary habits; and anthropometric measures.

Ethical review

The protocol was approved by the Research, Ethics and Bio-security committees of the National Institute of Public Health [53-55]. All participants signed an informed letter of consent after receiving an explanation of the nature, objectives and the risks inherent to the study [53-55].

Statistical analysis

Categorical variables were described by both the absolute frequency and percentage and the corresponding 95% confidence interval (CI). All categorical variables were compared using a Yates corrected chi square test. The continuous variables from the different groups were compared by the Mann-Whitney U and Student's t tests. The rates of specific prevalence for cervical cancer in patients with diabetes and the crude odds ratios (ORs) were calculated. To estimate the association of cervical cancer with sociodemographic characteristics, literacy, marital status, T2DM and lifestyle habits, both univariable and multivariable logistic regression analysis was used to obtain the ORs and their corresponding 95% CIs. The same method was used when including anthropometric measurements in the regression model. Thus, two multivariate regression models were calculated: one model without anthropometric measurements and an additional model that included these measures. A p value < 0.05 (2-sided testing) was considered significant.

Results

A total of 160 cases of cervical cancer (median age 48 years, range 24-81) and 25,262 control females (median age 39 years, range 20-99) were included. Table 1 expresses the distribution of cases for cervical cancer and controls in relation to selected sociodemographic and lifestyle characteristics. The prevalence of cervical cancer was similar in women who lived in rural, urban and metropolitan areas.

Table 1: General, sociodemographic, lifestyle, and clinical characteristics of the study population.



  
    Variables
    Total
      N=25422
    Non-cervical    cancer n=25262
      n, (%;    CI95%)
    Cervical    cancer
      n=160
      n, (%;    CI95%)
    p Value
  
  
    Rural
    6666
    6626 (26.2; 25.7-26.8)
    40 (25; 18-32) 
    NS
  
  
    Urban
    7355
    7311 (28.9; 28.4-29.5)
    44 (28;21-34)
    NS
  
  
    Metropolitan
    11401
    11325 (44.8; 44.2-45.4)
    76 (48; 40-55)
    NS
  
  
    Literacy
    22243
    22110 (87.5; 87.1-87.9)
    133 (83; 77-89)
    NS
  
  
    Free union
    3261
    3237 (12.8; 12.4-13.2)
    24 (15; 09-21)
    NS
  
  
    Married
    13430
    13353 (52.9; 52.2-53.5)
    77 (48; 40-56)
    NS
  
  
    Separate
    1687
    1668 (6.6; 6.3-6.9)
    19 (12; 07-17)
    0.012
  
  
    Divorced
    548
    542 (2.1; 2.0-2.3)
    6 (4; 1-7)
    NS
  
  
    Widower
    2736
    2710 (10.7; 10.3-11.1)
    26 (16; 11-22)
    0.034
  
  
    Single    person
    3743
    3735 (14.8; 14.3-15.2)
    8 (5; 2-8)
    0.001
  
  
    Sedentary
    1436
    1430 (5.7; 5.4-5.9)
    6 (4; 1-7)
    NS
  
  
    Physical    activity
    23986
    23832 (94.3; 94.1-94.6)
    154 (96; 93-99)
    NS
  
  
    Tobacco    smoking
    3370
    3333 (13.2; 12.8-13.6)
    37 (23; 17-30)
    <0.001
  
  
    Alcohol    drinking
    6699
    6649 (26.3; 25.8-26.9)
    50 (31; 24-38)
    NS
  
  
    Diabetes    mellitus
    1797
    1773 (7.0; 6.7-7.3)
    24 (15; 09-21)
    <0.001



Table 1:  General, sociodemographic, lifestyle, and clinical characteristics of the study population.

The prevalence rate of cervical cancer in women with T2DM (1,336 subjects per 100,000 inhabitants) was significantly higher (p <0.001) than their counterparts without diabetes (576 subjects per 100,000 inhabitants), and their risk is twice as high (OR=2.34; CI 95% 1.47-3.68, p = 0.0001620). On the other hand, the averages for weight, BMI and WC were calculated only for 20,236 women and had a similar distribution between the cases and controls [56] (for a total of 131 cases: weight 67.42 ± 13.43, BMI 29.04 ± 5.13 and WC 95 ± 12; for 20,105 controls: weight 66.49 ± 14.27, BMI 28.59 ± 5.63 and WC 93 ± 13). However, the BFP was higher (p=0.012) in females with cervical cancer (n=131, 40 ± 7) than in women without cancer [56] (n= 20,105, 39 ± 8).

Table 2 shows the OR analysis and the corresponding 95% CIs. The estimated ORs for cervical cancer, in both logistic regression models, display a significant direct association only for diabetes and tobacco smoking, but the univariate regression model indicated a similar significant association for diabetes, tobacco smoking, and for three marital statuses: separate, widowed and single person.

Table 2: Univariate and multivariate logistic regression models (multivariate model 1).



  
     
    Univariate
     
     
    Multivariate
     
     
  
  
    Variables
    B
    OR (CI 95%)
    p Value
    B
    OR (CI 95%)
    p Value
  
  
    DM
    0.849
    2.338 (1.511-3.618)
    <0.001
    0.741
    2.098 (1.345-3.272)
    0.001
  
  
    Rural
    -0.065
    0.938 (0.655-1.342)
    NS
    -0.037
    0.963 (0.642-1.446)
    NS
  
  
    Urban
    -0.071
    0.931 (0.658-1.319)
    NS
    -0.086
    0.917 (0.628-1.339)
    NS
  
  
    Metropolitan
    0.107
    1.113 (0.816-1.520)
    NS
    0.037
    1.038 (0.691-1.558)
    NS
  
  
    Literacy
    -0.353
    0.702 (0.464-1.064)
    NS
    -0.284
    0.753 (0.484-1.169)
    NS
  
  
    Free union
    0.183
    1.201 (0.777-1.856)
    NS
    -0.162
    0.851 (0.480-1.506)
    NS
  
  
    Married
    -0.189
    0.827 (0.606- 1.129)
    NS
    -0.381
    0.683 (0.430-1.086)
    NS
  
  
    Separate
    0.645
    1.906 (1.178-3.085)
    0.009
    0.188
    1.206 (0.658-2.212)
    NS
  
  
    Divorced
    0.575
    1.777 (0.783-4.035)
    NS
    0.115
    1.122 (0.453-2.779)
    NS
  
  
    Widower
    0.479
    1.615 (1.059-2.462)
    0.026
    0.174
    1.190 (0.672-2.105)
    NS
  
  
    SP*
    1.193
    3.297 (1.618-6.717)
    0.001
    -0.703
    0.495 (0.224-1.092)
    NS
  
  
    Sedentary
    -0.432
    0.649 (0.287-1.470)
    NS
    0.596
    1.815 (0.794-4.148)
    NS
  
  
    PA*
    0.432
    1.540 (0.680-3.487)
    NS
    0.596
    0.551 (0.241-1.259)
    NS
  
  
    TS*
    0.683
    1.979 (1.368-2.863)
    <0.001
    0.614
    1.847 (1.234-2.765)
    0.003
  
  
    AD*
    0.241
    1.272 (0.910-1.780)
    NS
    0.094
    1.099 (0.763-1.582)
    NS



Table 2:  Univariate and multivariate logistic regression models (multivariate model 1).

Table 3 provides details on an additional multivariate logistic regression model that included the anthropometric measures. The OR analysis revealed a significant association between cervical cancer and diabetes mellitus, sedentary, physical activity, tobacco smoking and body fat percentage.

Table 3: Additional multivariate logistic regression model (multivariate model 2).



  
     
    Multivariate    analysis
  
  
    Variables
    B
    OR (CI 95%)
    p Value
  
  
    Diabetes    Mellitus
    0.542
    1.719 (1.0.33-2.862)
    0.001
  
  
    Rural
    0.157
    1.170 (0.724-1.892)
    NS
  
  
    Urban
    -0.235
    0.791 (0.514-1.216)
    NS
  
  
    Metropolitan
    0.235
    1.265 (0.822-1.9469
    NS
  
  
    Literacy
    -0.278
    0.758 (0.463-1.239)
    NS
  
  
    Free union
    0.141
    1.152 (0.388-3.420)
    NS
  
  
    Married
    -0.301
    0.740 (0.265-2.067)
    NS
  
  
    Separate
    0.433
    1.557 (0.521-4.649)
    NS
  
  
    Divorced
    0.338
    1.403 (0.459-4.288)
    NS
  
  
    Widower
    -0.321
    0.725 (0.237-2.217)
    NS
  
  
    Single    Person
    -1.005
    0.366 (0.106-1.270)
    NS
  
  
    Sedentary
    2.161
    8.676 (1.204-62.497)
    0.032
  
  
    Physical    Activity
    2.164
    0.115 (0.016-0.827)
    0.032
  
  
    Tobacco    Smoking
    0.620
    1.859 (1.191-2.902)
    0.006
  
  
    Alcohol    Drinking
    0.181
    1.198 (0.803-1.787)
    NS
  
  
    Weight
    0.009
    1.009 (0.980-1.039)
    NS
  
  
    Body Mass    Index
    -0.111
    0.895 (0.802-0.998)
    NS
  
  
    Waist    Circumference
    -0.000998
    0.999 (0.991-1.007)
    NS
  
  
    Body Fat    Percentage
    0.081
    1.084 (1.023-1.149)
    0.006



Table 3: Additional multivariate logistic regression model (multivariate model 2).

Table 4 shows the distribution of the selected sociodemographic and lifestyle characteristics for diabetic patients. According to the analysis, the prevalence of all selected characteristics is similar in diabetic women with and without cervical cancer. In the same manner, the percentage of people with life styles changes such as dietary (n=387/1773, 21.83%; CI 95% 19.90-23.75 vs. n=4/24, 16.67%; CI 95% 1.76-31.58) and physical activity (n=106/1773, CI 95% 5.98; 4.87-7.08 vs. n=1/24, 4.17; CI 95% -3.83-12.16) modifications and pharmacological treatment (n=1498/1773, 84.49%; CI 95% 82.80- 86.17 vs. n=21/24, 87.50%; CI 95% 74.27-100) was similar. However, the percentage of women that use herbal and natural remedies was higher in diabetic patients with cervical cancer than among their counterparts without cancer (n=94/1773, 5.30%; CI 95% 4.26-6.34 vs. n=5/24, 20.83%; CI 95% 4.59-37.08; p=0.008).

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Citation: López-Hernández D. Type 2 Diabetes Mellitus and Habits Lifestyle Increases the Risk of Cervical Cancer: a Cross-Sectional Population-Based Study. Austin J Obstet Gynecol. 2014;1(3): 7. ISSN:2378-1386

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Variables	Total diabetic patients n=1797 n (%; CI95%)	Non cervical cancer n=1773 n (%; CI95%)	Cervical cancer n=24 n (%; CI95%)	p Value
Rural	390 (22; 20-24)	382 (22; 20-23)	8 (33.3; 14.5-52.2)	NS
Urban	564 (31; 29-34)	559 (31; 29-33)	5 (20.8; 4.6-37.1)	NS
Metropolitan	843 (47; 45-49)	832 (47; 45-49)	11 (45.8; 25.9-65.8)	NS
Literacy	1423 (79.2; 77.3-81.1)	1407 (79; 77-81)	16 (66.7; 47.8-85.5)	NS
Free union	157 (8.7; 7.4-10)	152 (9; 7-10)	5 (20.8; 4.6-37.1)	NS
Married	938 (52.2; 4.9-5.5)	927 (52; 50-55)	11 (45.8; 25.9-65.8)	NS
Separate	146 (8; 7-9)	143 (8; 7-9)	3 (12.5; 0.0-25.7)	NS
Divorced	43 (2.4; 1.7-3.1)	43 (2; 2-3)	0 (0.0; 0.0-0.0)	NS
Widower	402 (22; 20-24)	397 (22; 20-24)	5 (20.8; 4.6-37.1)	NS
Single person	109 (6; 5-7)	109 (6; 5-7)	0 (0.0; 0.0-0.0)	NS
Sedentary	188 (10.5; 9-12)	185 (10; 9-12)	3 (12.5; 0.0-25.7)	NS
Physical activity	1609 (89.5-91)	1588 (90; 88-91)	21 (88; 74-100)	NS
Tobacco smoking	258 (14.4; 12.7-16.1)	251 (14; 13-16)	7 (29.2; 11.0-47.4)	NS
Alcohol drinking	392 (22; 20-24)	387 (22; 20-24)	5 (20.8; 4.6-37.1)	NS
Weight	68.55 ± 17.16	68.53 ± 17.22	70.44 ± 12.21	NS
BMI*	29.88 ± 6.17	29.87 ± 6.19	30.53 ± 5.16	NS
WC*	100.94 ± 18.59	100.95 ± 18.67	100.33 ± 11.93	NS
BFP*	43.32 ±7.51	43.32 ± 7.51	43.42 ± 7.29	NS

Type 2 Diabetes Mellitus and Habits Lifestyle Increases the Risk of Cervical Cancer: a Cross-Sectional Population-Based Study

Abstract

Introduction

Material and Methods

Study design, data collection and participants

Survey instrument

Ethical review

Statistical analysis

Results

Discussion

Possible molecular mechanisms for increased cervical cancer in patients with type two diabetes mellitus

Limits

Conclusion

Disclosure

References