To Örebro University

Background: Dietary patterns with anti-inflammatory properties have been linked to lower risks of several chronic diseases and some cancers, but their impact on survival after cancer is less well understood.

Objective: We assessed whether a higher prediagnostic Anti-Inflammatory Diet Index (AIDI) score was associated with all-cause mortality after urologic cancer diagnosis, with urologic cancer-specific mortality evaluated as a secondary end point.

Design, setting, and participants: In the Cohort of Swedish Men and the Swedish Mammography Cohort, incident urologic cancers and deaths were identified through Swedish registers. AIDI was derived from food-frequency questionnaires (1997; 2009 in a subset) and defined as the assessment at least 2 yr before diagnosis, preferentially 2009 when available. Follow-up ran from diagnosis to death, emigration, or December 31, 2020.

Outcome measurements and statistical analysis: Cox models estimated hazard ratios (HRs) per 1 standard deviation (SD) higher AIDI, adjusting for demographic factors, lifestyle, comorbidities, and total energy intake. Fine-Gray models assessed urologic cancer-specific mortality while accounting for death from other causes as a competing event.

Results and limitations: Among 7686 patients with valid AIDI, 6609 had complete covariate data, including 4990 patients with prostate cancer. During follow-up, 3281 deaths occurred, including 1435 urologic cancer deaths. Each 1-SD higher AIDI was associated with lower all-cause mortality (HR = 0.91, 95% confidence interval [CI] = 0.88-0.95). Evidence for an association with urologic cancer-specific mortality was weak and borderline in cause-specific Cox models (HR = 0.95, 95% CI = 0.90-1.00) and was attenuated in competing-risk analysis (subdistribution HR = 0.97, 95% CI = 0.92-1.02).

Conclusions: Higher prediagnostic AIDI was associated with lower all-cause mortality after urologic cancer diagnosis. Whether this reflects a causal effect of diet or residual confounding, healthy-lifestyle clustering, health care engagement bias, or differences in competing noncancer mortality requires further study. 

BACKGROUND: Dietary patterns influencing systemic levels of inflammation have been proposed and investigated as possible determinants of cancer risk. We evaluated the association between the anti-inflammatory potential of diet and the risk of bladder cancer (BC).

METHODS: The Anti-Inflammatory Diet Index (AIDI), composed of 16 food groups (11 anti- and 5 pro-inflammatory), was used to score dietary patterns in N=79,292 individuals derived from the Cohort of Swedish Men (COSM, established in 1997) and the Swedish Mammography Cohort (SMC, established in 1987). Dietary information was collected in 1997 and 2009; repeated-measure analyses used a cumulative-average AIDI. Incident BC cases were identified from the Swedish Cancer Register using ICD-10 code C67, and baseline study questionnaire was used to assess covariates. We estimated multivariable hazard ratios across AIDI quartiles using Cox models.

RESULTS: After a 22-year follow-up, 1,165 individuals were diagnosed with BC, of whom 249 had non-muscle invasive (NMI) BC, 201 muscle invasive (MI) BC and 715 unknown stage. In repeated-measures analyses, the highest anti-inflammatory quartile (Q4) was associated with lower BC risk compared with the lowest quartile (Q1) (HR 0.74, 95% CI 0.61-0.89). Stratifying for tumour stage, there was a clear association between AIDI-score and MIBC (HR 0.35, 95% CI 0.22-0.57), but not for NMIBC (HR 0.86, 95% CI 0.57-1.28).

CONCLUSIONS: An anti-inflammatory dietary pattern was associated with lower BC risk, with the clearest association for MIBC. IMPACT: These findings support the role of dietary inflammation in BC aetiology and suggest that promoting anti-inflammatory dietary patterns could contribute to cancer prevention strategies.

BACKGROUND AND PURPOSE: This retrospective cohort study aimed to explore the association between short-term genitourinary (GU) and gastrointestinal (GI) toxicity and oncological outcomes in high-risk prostate cancer patients treated with external beam radiotherapy (EBRT) alone or with high-dose-rate brachytherapy (HDR-BT).

Patient/material and methods: High-risk prostate cancer patients treated at Örebro University Hospital (2008-2021) were divided into two cohorts based on treatment modality: EBRT-only (66 Gy/22 fractions), EBRT-BT (42 Gy/14 fractions + 14.5 Gy HDR-BT-boost). Maximum 6-month toxicity grade was categorised as: GU-low (grade 0-1), GU-high (grade ≥ 2), GI-low (grade 0) and GI-high (grade ≥ 1), respectively. Freedom from biochemical failure (FFBF), metastasis-free survival (MFS) and overall survival were compared between the low- and high- toxicity groups, using Kaplan-Meier and Cox proportional hazards regression. Prostate cancer-specific mortality was compared between the groups using the Aalen-Johansen method and Fine-Gray regression.

RESULTS: The EBRT-only cohort encompassed 114 and 162 patients for GU- and GI-analyses. The EBRT-BT cohort comprised 306 patients for GU- and 344 patients for GI-analyses. High GU-toxicity was associated with inferior FFBF (adjusted hazard ratio (aHR) = 2.57, 95% Confidence Interval [CI] = 1.32-5.00) and MFS (aHR = 2.22, 95% CI = 1.21-4.07) in the EBRT-only but not in the EBRT-BT cohort. No statistically significant associations were found between GI-toxicity and oncological outcomes.

INTERPRETATION: Early grade ≥ 2 GU-toxicity was linked to worse FFBR and MFS after EBRT alone, whereas no such association was seen after EBRT-BT. GI toxicity showed no prognostic impact. These exploratory findings warrant validation in larger studies addressing interactions between patient-, tumour- and treatment-related factors.

Introduction & Objectives: In 2014 the Swedish National Board of Health and Welfare (NBHW, Swedish: Socialstyrelsen) recommended regional healthcare providers to investigate the effects of systematic information and organised PSA-testing for prostate cancer detection. In response to this, in 2015 the healthcare region of Värmland launched ia population-based PSA information and testing programme. For five years all men in totally 25 age groups between 50 to 74 years were invited, thereafter the programme continued and repeat invitations were adapted to intervals of 2 or 6 years depending on PSA-level. In the years 2019-2020 the Stockholm3-test was tested in a study form and from June 2022 it was implemented in the investigation of elevated PSA. Here, we present descriptive results of population-based regional PSA-testing with an algoritm including the Stockholm3-test. Objective: To describe participation rates, resource utilisation and diagnostic outcomes.

Materials & Methods: Men invited in September 2019–May 2020 and in June 2022 to December 2024 aged 50-69 years with PSA≥ 3 ng/ml or aged > 69 years with PSA ≥ 5 ng/ml underwent a Stockholm3-test for risk stratification. With a Stockholm3-test risk score ≥ 11% and a test specified prostate cut off volume underwent TRUL and DRE and with a volume below cut off or suspect DRE further investigation with MRI or direct biopsy was recommended. Men with PI-RADS 3 on MRI and PSA density ≥ 0.15 ng/ml/cm3 or PI-RADS 4–5 underwent biopsy. Men with PI-RADS < 3 on MRI but a PSA density ≥ 0.20 ng/ml/cm3 or a Stockholm3 score ≥ 40% were also biopsiesed. Numbers and proportions of participation, elevated PSA, Stockholm3 risk scores, PI-RADS scores, biopsy procedures and cancer detection, as well as treatment decisions were evaluated. Resource utilisations were calculated.

Results: A total of 21 031 (41%) of 51 414 invited men participated; 2704 (12.9%) had elevated PSA, 2578 had a Stockholm3-test. Of these 799 (31%) a score <11% and the investigation concluded, 1065 (41%) a score of 11-29% of whom 596 (23%) with a prostate volume ≥ cut off were concluded, 523 (20%) men with a score of 11-39% with no given cut off volume and 191 (7,4%) with a score ≥ 40 underwent MRI before biopsy decision. This resulted in clinical examination in 1434 cases (56%), MRI in 987 cases (38%) and of 691 men (26,8%) with a biopsyindication 685 (26,6%) underwent biopsies. On biopsy, 305 (45%) had cancer ISUP grade 2-5 and 234 (34%) ISUP grade 1. Most men with cancer proceeded to treatment with curative intent (56%) or to active surveillance (40%).

Conclusions: Regional population-based PSA-screening followed by an investigation including Stockholm3-test combined with clinical evaluation and MRI prior to biopsy decision is feasible and may constitute a resource-efficient strategy.

Introduction & Objectives: The diagnostic workup for suspected prostate cancer is often emotionally distressing and may negatively affect patients’ well-being. Considerable variability exists in waiting times across diagnostic pathways, yet evidence on how such delays influence psychological distress is limited. Objective: To assess whether a fast-track diagnostic workup reduces psychological and physiological stress among men with suspected prostate cancer.

Materials & Methods: In this randomized clinical trial, 304 men referred for suspected prostate cancer at the Urology Department, Örebro University Hospital (Sweden), were randomized to either a fast-track diagnostic workup—aiming for the shortest possible waiting time—or usual care. Primary outcomes were patient-reported symptoms of distress (anxiety, depression, perceived stress, and sleep disruption); secondary outcomes included physiological stress markers, such as diurnal salivary cortisol. Data were collected from randomization to 12 months post-enrollment.

Results: Men in the fast-track group had a significantly shorter waiting time to their first consultation (median 7 days) compared with the usual care group (median 35 days). During the first six months, participants in the fast-track arm reported lower levels of distress, anxiety, and perceived stress, and improved sleep quality. Among those undergoing prostate biopsy, the strongest intervention effect was seen one to four weeks post-procedure. For men subsequently diagnosed with prostate cancer, the effect was most pronounced one week after biopsy. Differences between groups were no longer evident at 12 months. Diurnal cortisol profiles indicated a more favorable stress pattern in th efast-track group, especially during the period surrounding diagnostic disclosure.

Conclusions: A fast-track diagnostic workup for suspected prostate cancer substantially reduces psychological and physiological stress during the diagnostic phase. These findings support the implementation of accelerated diagnostic pathways in urological practice to improve patient experience and potentially reduce stress-related health risks.

OBJECTIVES: To report descriptive outcomes including prostate-specific antigen (PSA) testing, diagnostic activity and diagnostic outcomes during the initial 5 years of a regional mailed PSA information and testing programme.

SUBJECTS AND METHODS: Between 2015 and 2019 a letter regarding the pros and cons of PSA testing was sent to all men in the Värmland region of Sweden in every fifth year age group between 50 and 70 years. A total of 44 530 men were informed and instructed to contact their primary care centre if they wished to have a PSA test. Men with a PSA level ≥3 μg/L were referred to a urologist for evaluation. We used local and national registers to report trends in PSA testing, diagnostic activity, and diagnostic outcomes after programme implementation.

RESULTS: An average of 20% of informed men had a PSA test within 6 months, with increasing proportions over time. Among tested men, 3.5% had a PSA level ≥3 μg/L, 3.6% had a urology consultation, 1.5% underwent biopsies, and 0.8% were diagnosed with prostate cancer. The proportion who underwent magnetic resonance imaging was low. Between 2014 and 2017, the yearly number of PSA-tested men in the region increased from 4800 to 11 800 and the number of men undergoing prostate biopsies increased from 772 to 1217. Yearly prostate cancer incidence in the age group 50-74 years increased from 386 (2010-2013) to 659 cases/100 000 (2016-2019). We observed an increase mainly among intermediate- and low-risk tumours. At the end of the period, 80% of men in the older-age groups had had a PSA test during the preceding years.

CONCLUSIONS: Organising a population-based mailed PSA information programme combined with accessible testing in primary care is feasible on a regional scale in a Scandinavian healthcare setting and may reach high attendance. An observed increase in low-risk tumours inspires caution against programme implementation and highlights the importance of well-designed screening strategies and diagnostic algorithms to avoid over-detection.

Introduction & Objectives: Tobacco smoking and occupational exposure to carcinogens constitute well-established risk factors for bladder cancer (BC), while limited evidence suggest a possible effect of dietary factors and inflammation on BC risk. Dietary patterns with impact on systemic levels of inflammation have further been proposed and investigated as possible determinants of cancer risk. In this cohort study, we evaluated the association between the anti-inflammatory potential of diet and the risk of BC.

Materials & Methods: Using the Swedish Infrastructure for Medical Population-Based Life-Course and Environmental Research (SIMPLER), we identified a study population of N=79,292 men and women derived from the two original cohorts Cohort of Swedish Men (COSM, established in 1997) and Swedish Mammography Cohort (SMC, established in 1987). We used a 96-item food frequency questionnaire (FFQ), completed at baseline in 1997 and repeated in 2009, to calculate the Anti-Inflammatory Diet Index (AIDI) for all participants. AIDI is a previously developed, empirically derived composite measure of dietary anti-inflammatory potential, based on the food groups previously found to have the strongest association with levels of systemic inflammation. The index comprises 16 food groups: 11 with proposed anti-inflammatory and 5 with proposed pro-inflammatory potential. We used ICD-10 code C67 to identify incident BC cases op to year 2020 in the Swedish National Cancer Register, and we used baseline study questionnaire to assess covariates, including smoking status and socioeconomic measures. We further used Cox proportional hazards regression models to estimate unadjusted and multivariable-adjusted hazard ratios (HRs) and 95% confidence intervals (95% CIs) for the association between quartiles of AIDI in the population and later BC diagnosis – overall as well as with outcome separated into non-muscle invasive (NMIBC: Ta or T1 or CIS and N0, M0) and muscle invasive (MIBC: ≤T2 or N1 or M1) BC for cases occurring after year 2004.

Results: During follow-up until 2020, 1165 BC cases occurred, of which 249 were non-muscle invasive, 201 muscle invasive and 715 of unknown stage. Overall, we observed an inverse association between the highest quartile of AIDI (Q4 vs. Q1, representing most anti-inflammatory diet compared to most pro-inflammatory) and later BC diagnosis (multivariable-adjusted HR 0.74, 95% CI 0.61-0.89, p-trend: 0.01). When separating outcome by stage, we observed an association for MIBC (HR 0.35, 95% CI 0.22-0.57), but not for NMIBC (HR 0.86, 95% CI 0.57-1.28).

Conclusions: We observed an inverse association between a measure of dietary anti-inflammatory potential and BC risk, particularly the risk of MIBC. Our observations support a possible implication of the inflammatory potential of diet in BC development and the more pronounced association observed for MIBC may hint at a true biological association.

INTRODUCTION: A diet rich in fruits, vegetables, coffee, and tea, limited red meat, and moderate alcohol intake may reduce the risk of renal cell carcinoma (RCC). The anti-inflammatory potential of diet has been proposed as a mechanism influencing cancer risk. This study assessed the association between an anti-inflammatory diet and RCC risk.

METHODOLOGY: Data from two Swedish cohorts, the Swedish-Mammography-Cohort and the Cohort-of-Swedish-Men, were analysed. Dietary habits were assessed using a 96-item food frequency questionnaire. The Anti-Inflammatory Diet Index (AIDI), composed of 16 food groups (11 anti-inflammatory and 5 pro-inflammatory), was used to score dietary patterns. RCC cases were identified from the Swedish Cancer Register using ICD-10 codes, and Cox proportional hazards models were used to estimate hazard ratios based on AIDI quartiles.

RESULTS: Among 71,421 participants, 431 RCC cases were identified during a 19.7-year follow-up. Higher AIDI scores were associated with a lower RCC risk (HR for Q4 vs. Q1: 0.68, CI: 0.52-0.89). In sex-stratified analyses (p-for heterogeneity = 0.006), the association was stronger in among women (HR: 0.47, CI: 0.30-0.75) but less clear in among men (HR: 0.83, CI: 0.63-1.24).

CONCLUSION: These data suggest that adherence to an anti-inflammatory diet may confer a reduced risk for RCC, especially among women.