Association of Anorexia Nervosa With Risk of Cancer: A Systematic Review and Meta-analysis

Importance: Anorexia nervosa is recognized as an important cause of morbidity in young people. However, the risk of cancer in people with anorexia nervosa remains uncertain. Objetive: To evaluate the association of anorexia nervosa with the risk of developing or dying of cancer. Data Source: MEDLINE, Scopus, Embase, and Web of Science from database inception to January 9, 2019. Study Selection: Published observational studies in humans examining the risk of cancer in people with anorexia nervosa compared with the general population or those without anorexia nervosa. Studies needed to report incidence or mortality rate ratios (RRs). Data Extraction and Synthesis: Screening, data extraction, and methodological quality assessment were performed by at least 2 researchers independently. A random-effects model was used to synthesize individual studies. Heterogeneity (I2) was assessed and 95% prediction intervals (PIs) were calculated. Main Outcomes and Measures: All cancer incidence and cancer mortality associated with anorexia nervosa. Secondary outcomes were site-specific cancer incidence and mortality. Results: Seven cohort studies published in 10 articles (42 602 participants with anorexia nervosa) were included. Anorexia nervosa was not associated with risk of developing any cancer (4 studies in women; RR, 0.97; 95% CI, 0.89-1.06; P = .53; I2, 0%; 95% PI, 0.80-1.18; moderate confidence). Anorexia nervosa was associated with decreased breast cancer incidence (5 studies in women; RR, 0.60; 95% CI, 0.50-0.80; P < .001; I2, 0%; 95% PI, 0.44-0.83; high confidence). Conversely, anorexia nervosa was associated with increased risk of developing lung cancer (3 studies in women; RR, 1.50; 95% CI, 1.06-2.12; P = .001; I2, 0%; 95% PI, 0.19-16.46; low confidence) and esophageal cancer (2 studies in women; RR, 6.10; 95% CI, 2.30-16.18; P < .001; I2, 0%; low confidence). Conclusions and Relevance: Among people with anorexia nervosa, risk of developing cancer did not differ compared with the general population, but a significantly reduced risk of breast cancer was observed. Understanding the mechanisms underlying these associations could have important preventive potential.This study was supported by the Generalitat Valenciana and Carlos III Health Institute. Drs Catalá-López and Tabarés-Seisdedos received funding from the Generalitat Valenciana, the Spanish Ministry of Science, Innovation and Universities (CIBERSAM), and the Carlos III Health Institute. Dr Driver received support from a merit review grant from the US Department of Veterans Affairs. Dr Page received support from an early career fellowship from the Australian National Health and Medical Research Council. Dr Hutton received support from a new investigator award from the Canadian Institutes of Health Research and the Canadian Drug Safety and Effectiveness Network. Dr Ridao received funding from the Spanish Health Services Research on Chronic Patients Network and the Carlos III Health Institute.S