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Epidemiology

The mediating role of combined lifestyle factors on the relationship between education and gastric cancer in the Stomach cancer Pooling (StoP) Project

British Journal of Cancer volume 127, pages 855–862 (2022)Cite this article

Subjects

Abstract

Background

The causal pathway between high education and reduced risk of gastric cancer (GC) has not been explained. The study aimed at evaluating the mediating role of lifestyle factors on the relationship between education and GC

Methods

Ten studies with complete data on education and five lifestyle factors (smoking, alcohol drinking, fruit and vegetable intake, processed meat intake and salt consumption) were selected from a consortium of studies on GC including 4349 GC cases and 8441 controls. We created an a priori score based on the five lifestyle factors, and we carried out a counterfactual-based mediation analysis to decompose the total effect of education on GC into natural direct effect and natural indirect effect mediated by the combined lifestyle factors. Effects were expressed as odds ratios (ORs) with a low level of education as the reference category.

Results

The natural direct and indirect effects of high versus low education were 0.69 (95% CI: 0.62–0.77) and 0.96 (95% CI: 0.95–0.97), respectively, corresponding to a mediated percentage of 10.1% (95% CI: 7.1–15.4%). The mediation effect was limited to men.

Conclusions

The mediation effect of the combined lifestyle factors on the relationship between education and GC is modest. Other potential pathways explaining that relationship warrants further investigation.

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Fig. 1: Directed acyclic graph showing the relationship between education and gastric cancer risk and the decomposition of the effects.
Fig. 2: Lifestyle factors across levels of education.
Fig. 3: Results of the moderated mediation analysis: mediation effects of lifestyle score on the relationship between education and gastric cancer moderated by sex, age group and geographic area.

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Data availability

The data that support the findings of our study are available from the Stomach cancer Pooling (StoP) Project but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are however, available from the authors upon reasonable request and with permission of the Steering Committee of the StoP Project.

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Acknowledgements

We thank the European Cancer Prevention (ECP) Organization for providing support for the project meetings.

Funding

This study was funded by the Associazione Italiana per la Ricerca sul Cancro (AIRC), Project no. 21378 (Investigator Grant).

Author information

Author notes

  1. These authors contributed equally: Gianfranco Alicandro, Paola Bertuccio.

Authors and Affiliations

  1. Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy

    Gianfranco Alicandro

  2. Cystic Fibrosis Center, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy

    Gianfranco Alicandro

  3. Department of Public Health, Experimental and Forensic Medicine, University of Pavia, Pavia, Italy

    Paola Bertuccio

  4. Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy

    Paola Bertuccio, Claudio Pelucchi, Rossella Bonzi, Eva Negri, Michela Dalmartello & Carlo La Vecchia

  5. Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy

    Giulia Collatuzzo, Eva Negri & Paolo Boffetta

  6. Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, MD, USA

    Linda M. Liao, Charles S. Rabkin, Rashmi Sinha & M. Constanza Camargo

  7. Pegaso Online University, Naples, Italy

    Eva Negri

  8. Department of Clinical Epidemiology, N.N. Blokhin National Medical Research Center for Oncology, Moscow, Russia

    David Zaridze & Dmitry Maximovich

  9. Instituto de Investigación Sanitaria y Biomédica de Alicante, Universidad Miguel Hernandez (ISABIAL-UMH), Alicante, Spain

    Jesus Vioque & Manoli Garcia de la Hera

  10. Consortium for Biomedical Research in Epidemiology and Public Health (CIBERESP), Madrid, Spain

    Jesus Vioque & Manoli Garcia de la Hera

  11. Epidemiology and Prevention Group, Center for Public Health Sciences, National Cancer Center, Tokyo, Japan

    Shoichiro Tsugane & Akihisa Hidaka

  12. National Institute of Health and Nutrition, National Institutes of Biomedical Innovation, Health and Nutrition, Tokyo, Japan

    Shoichiro Tsugane

  13. Nikkei Disease Prevention Center, São Paulo, Brazil

    Gerson Shigueaki Hamada

  14. Mexico National Institute of Public Health, Morelos, Mexico

    Lizbeth López-Carrillo

  15. Department of Biostatistics, Yale School of Public Health, Yale School of Medicine, New Haven, CT, USA

    Raúl Ulises Hernández-Ramírez

  16. Digestive Oncology Research Center, Digestive Disease Research Institute, Tehran University of Medical Sciences, Tehran, Iran

    Reza Malekzadeh

  17. Digestive Disease Research Center, Ardabil University of Medical Sciences, Ardabil, Iran

    Farhad Pourfarzi

  18. Department of Epidemiology, UCLA Fielding School of Public Health and Jonsson Comprehensive Cancer Center, Los Angeles, CA, USA

    Zuo-Feng Zhang

  19. Department of Medicine, Memorial Sloan Kettering Cancer Centre, New York, NY, USA

    Robert C. Kurtz

  20. Centro Internacional de Pesquisa, A. C. Camargo Cancer Center, São Paulo, Brasil

    Maria Paula Curado

  21. EPIUnit—Instituto de Saúde Pública da Universidade do Porto, Porto, Portugal

    Nuno Lunet

  22. Laboratório para a Investigação Integrativa e Translacional em Saúde Populacional (ITR), Porto, Portugal

    Nuno Lunet

  23. Departamento de Ciências da Saúde Pública e Forenses e Educação Médica, Faculdade de Medicina da Universidade do Porto, Porto, Portugal

    Nuno Lunet

  24. Stony Brook Cancer Center, Stony Brook University, Stony Brook, NY, USA

    Paolo Boffetta

Authors
  1. Gianfranco Alicandro
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  2. Paola Bertuccio
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  3. Giulia Collatuzzo
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  18. Lizbeth López-Carrillo
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  26. Nuno Lunet
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  28. Carlo La Vecchia
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Contributions

Conceptualisation: GA, PB, GC, PB; Methodology: GA, PB, GC, PB; Data collection: LML, CSR, EN, DZ, JV, ST, GSH, LL-C, RUH-R, RM, Z-FZ, CLV; Formal analysis and investigation: GA, PB; Writing—original draft preparation: GA, PB; Writing—review and editing: All authors; Funding acquisition: CLV; Resources: CLV; Supervision: CLV, CP.

Corresponding author

Correspondence to Gianfranco Alicandro.

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Competing interests

The authors declare no competing interests.

Ethics approval and consent to participate

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1964 and later versions. The StoP Project received ethical approval from the University of Milan Institutional Review Board (reference no. 19/15 of 01/04/2015). Informed consent was obtained for each subject included in the study.

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Alicandro, G., Bertuccio, P., Collatuzzo, G. et al. The mediating role of combined lifestyle factors on the relationship between education and gastric cancer in the Stomach cancer Pooling (StoP) Project. Br J Cancer 127, 855–862 (2022). https://doi.org/10.1038/s41416-022-01857-9

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