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This content is from the “Advancing the Science of Cancer in Latinos: 2024 Conference Proceedings.”
Obesity and Cancer: What We Know Now About Individual- and Structural-Level Factors
Dr. Monica C. Serra is Associate Professor and Research Health Scientist in the Department of Medicine, Division of Geriatrics, Gerontology & Palliative Medicine and the Sam and Ann Barshop Institute for Longevity and Aging Studies at University of Texas Health Science Center San Antonio (UTHSCSA).
Obesity and cancer
Dr. Serra began by discussing obesity and severe obesity, which have become more common in the US in recent years. In 2011, 27% of adults 18 years of age or older had obesity or severe obesity, and by 2020, 32% of adults 18 years of age or older had obesity or severe obesity. Furthermore, in 2011 only 12 states had an obesity rate over 30%, while in 2021 that number had grown to 41 states. Non-Hispanic White individuals in the US have an obesity rate of 42.2%, non-Hispanic Black individuals have an obesity rate of 49.6%, and Latino individuals have an obesity rate of 44.8%.

Higher body mass index (BMI) at the time cancer is diagnosed or after having survived cancer is associated with higher risk of developing a second, unrelated cancer. Cancers associated with obesity include endometrial, esophageal adenocarcinoma, gastric cardia, liver, kidney, multiple myeloma, meningioma, pancreatic, colorectal, gallbladder, breast, and more. In fact, individuals with severe obesity are 7 times more likely to develop endometrial cancer than those who are not obese.
Increased cancer risk is not only associated with overall body obesity, but may be affected by where the excess body fat is distributed. Fat accumulation in the android region, or the abdomen, may carry a different risk than fat accumulation in the gynoid region, or the thighs. Visceral fat is also associated with a higher risk of breast cancer development than subcutaneous fat.
Potential mechanisms for the increased risk of cancer associated with obesity include the local production of hormones such as estrogen, growth factors, and inflammatory cytokines, as well as a hypoxic environment. These factors may change how cells divide and can increase the chances of mutated cell production. Insulin and insulin-like growth factor-1 (IGF-1) may also contribute to the development of colon, kidney, prostate, and endometrial cancers. Cell growth and metabolic regulators, including mammalian target of rapamycin (mTOR) and adenosine monophosphate (AMP)-activated protein kinase, may represent another potential mechanism. In actuality, multiple of these potential mechanisms may be at play in each individual case. One further complication is that obesity can lead to difficulties in screening and management.
Individual- and structural-level factors
Individual-level factors contributing to the development of cancer go beyond weight, and include physical activity, dietary nutrients, consumption of processed foods, consumption of red and processed meat, consumption of sugar, alcohol consumption, the use of supplements, and more. In fact, every 10% increase in processed food consumption is associated with an increased incidence of cancer. Genetic factors also play a role in obesity, with specific genes influencing birth weight, waist-to-hip ratio, visceral adiposity, BMI, extreme obesity, and body fat.
Structural-level factors, such as socioeconomic status, access to healthcare, food environment, and urban design also play a role in cancer risk. It is known that recommended cancer screening tests and treatment guidelines reduce the risk of cancer. However, individuals with low income, low health literacy, long travel distances to screening sites, and lack of health insurance are less likely to have recommended screening and treatment. In fact, although 77.5% of employed women are up to date on breast cancer screenings, only 67.8% of unemployed women are up to date on breast cancer screenings.
Food environment includes the availability, affordability, cost, and sustainability of food. Residence in a food desert is associated with higher 5-year colorectal cancer mortality, while less food insecurity and healthier food are associated with lower colorectal cancer incidence and mortality.
Dr. Serra emphasized the difference between correlation and causation in the context of obesity and cancer. Nearly all the evidence linking obesity to cancer risk comes from large cohort studies, however, data from observational studies cannot definitively establish that obesity causes cancer. Although intervention studies are very costly, they are needed for a more decisive understanding, and should address the intersection of individual- and structural-level factors.
In summary, great challenges exist in tackling obesity and cancer risk at both individual- and structural- levels. Much more work is needed in this area to understand causation and effective interventions. Possible promising areas for research include microbiome research, a better understanding of inflammation and immune response, precision medicine approaches, lifestyle interventions, and therapeutic approaches.
Using an “Exercise is Medicine” Approach among Latino Cancer Survivors: Challenging the Research Gap
Dr. Christina M. Dieli-Conwright is Associate Professor of Medicine at Dana-Farber Cancer Institute and Harvard Medical School.
Exercise and cancer
Dr. Dieli-Conwright began by defining exercise oncology as the utilization of exercise or physical fitness to enhance the lives of people diagnosed with cancer or at risk of developing cancer. Exercise oncology research has evolved over the last 100 years, beginning with the discovery in 1921 that cancer mortality is inversely proportional to muscular strength. In 1952, the first clinical trial evaluating exercise for lymphedema following mastectomy was conducted. The first American College of Sports Medicine (ACSM) roundtable was convened in 2010, leading to the publishing of exercise guidelines, which were updated in 2019. The number of research manuscripts focused on exercise oncology has greatly increased in the years since the ACSM publications.

The 2010 roundtable’s published Exercise Guidelines for Cancer Survivors recommended 150 minutes of moderate-intensity physical activity per week, or 75 minutes of vigorous-intensity physical activity per week. Updated 2019 guidelines changed recommendations to 30 minutes of moderate intensity physical activity, 3 times per week. Similarly, 2010 guidelines recommended resistance exercise 2 or more days per week, involving the 8 major muscle groups. Updated guidelines specified 2 times per week, 30 minutes per session, 2-3 sets, involving large muscle groups.
Disparities in Latino cancer patients
Cancer health disparities in the US are influenced by behavioral factors, including tobacco use, diet, excess body weight, and physical inactivity. Many of the cancers with the highest incidence and mortality among Latino individuals are cancers that are known to be positively influenced by engaging in a physically active lifestyle. These include prostate, colon and rectum, and kidney and renal pelvis cancers, which represent 3 of the 4 most common cancers in Latino males; and breast, uterine corpus, and colon and rectum cancers, the 3 most common cancers in Latino females.
Existing energy balance research is largely focused on non-Hispanic White populations, despite the higher rates of obesity, physical inactivity, and comorbidities observed in minority groups. Exercise interventions specifically for Latino cancer survivors are sparse. Walking and aerobic plus resistance exercise have been studied, but to date no trials exist looking at resistance exercise alone among Latino participants. Studies that have been performed are also mostly home-based, or conducted in community centers and churches with little supervision. Despite limitations, these studies have shown that exercise can increase moderate to vigorous physical activity minutes, cardiorespiratory fitness, muscle strength, and quality of life, while reducing fatigue.
Barriers to energy balance interventions for Latino populations can be divided into barriers for researchers and barriers for participants. For researchers, the following barriers exist: (1) the urban location of most research institutes limiting rural or suburban participation; (2) uneven distribution of minority populations making access to participants more difficult; and (3) a lack of understanding of the decline of study participation. Participants also face significant barriers: (1) limited access to resources, (2) extended transportation time, (3) high family needs, and (4) a lack of understanding of the intervention. Potential facilitators to address these barriers include multi-center trial designs facilitating participation from various geographic locations, survey or focus-group studies to comprehend unique barriers and preferences of intervention, more accessible intervention design such as remote-based delivery (e.g., telephone, online format), and culturally tailored intervention methods including the use of the local community and engagement of family members.
Latino exercise oncology research
Dr. Dieli-Conwright and colleagues have initiated research into several interventions. The first established that exercise for 16 weeks can reduce metabolic syndrome in sedentary, overweight or obese breast cancer survivors, more than half of which were Latina. Another study showed significant improvements in cardiometabolic, physical, and psychosocial health outcomes among sedentary, overweight or obese breast cancer patients through high-intensity interval training; 75% of participants were Latina.
Lessons learned about conducting a clinical exercise trial in minority cancer survivors included the following: all staff were bilingual, supervised and flexible exercise sessions were offered, recruitment involved collaboration with medical oncologists, testing measures were carefully interpreted, and many follow-up calls were given to ensure participation. Furthermore, not every culture perceives exercise as commonplace, so sensitivity must be shown.
Future work by Dr. Dieli-Conwright and colleagues includes the Reducing Metabolic Dysregulation in Obese Hispanic/Latina Breast Cancer Survivors using Physical Activity (ROSA) trial, the Testing Home-based ExeRcise Strategies to Improve Exercise Participation and CardioVascular Health in UndersErved Minority Patients with Cancer Undergoing Chemotherapy (THRIVE) trial, and the Exercise to Enhance Cardiovascular Health among Black Prostate Cancer Patients with Androgen Deprivation Therapy (POWER) trial. Because exercise is medicine, and exercise is feasible among Latino cancer patients, exercise may offset cancer health disparities. Multi-center, culturally tailored, randomized controlled trials are needed to further this work.
Improving Smoking Cessation for Latinos Using a Community-Based Approach
Dr. Anapaula Cupertino is Professor of Public Health Sciences and Oncology at the University of Rochester Medical Center and Wilmot Cancer Institute’s first Associate Director of Community Outreach, Engagement, and Disparities.
The JUNTOS Center for Advancing Latino Health

Dr. Cupertino’s presentation began by discussing tobacco-related disparities among Latino individuals, specifically in the area around Rochester, New York, where 17% of non-Hispanic White individuals are smokers, compared to 21% of Latino individuals. This may be associated with the high number of Latinos of Puerto Rican descent in the Rochester area; the Study of Latinos (SOL) study identified high smoking rates in Puerto Rico. This illustrates the importance of tailoring interventions to the target population of a local area, taking into consideration ancestry, socioeconomic status, and cultural considerations.
Although smoking cessation programs, including behavioral counseling and medication, are known to be effective, tailoring these interventions to specific populations can be difficult. In 2007, Dr. Cupertino and colleagues began the JUNTOS Center for Advancing Latino Health in Kansas City, Kansas in order to engage the Latino community there. The community advisory board was instrumental in shaping the work.
In order to engage the community effectively, trust had to be established, and the needs of the community had to be addressed. The highest priority among Latino community members in the Kansas
City area, for example, was immigration status and diabetes. By focusing on these areas, Dr. Cupertino and colleagues were able to establish the necessary trust to push for studies addressing smoking cessation. This trust-based approach is in contrast with the typical approach of only engaging communities when participant recruitment is needed. Instead, community leaders and experts must work together to develop the intervention content and modes of delivery.
Text- and app-based approaches
One approach that was unsuccessful among the Kansas City community was phone-based counseling for smoking cessation. Instead, community feedback indicated that Facebook or WhatsApp were more commonly used and were more comfortable mediums. Funding and partnerships to develop an app-based intervention were difficult due to inherent biases about Latino levels of literacy. Finally, a partnership was initiated with Agile Health Solutions, a company that had developed a text message-based smoking cessation program in Australia and England. However, previous Latino engagement with this program was less than one percent.
The first study after the partnership of JUNTOS and Agile Health involved 20 participants and resulted in 30% smoking cessation, indicating that concerns over Latino literacy were wildly overblown. Furthermore, whereas previous text-based programs averaged an interactivity of 11 messages, the study with Latino participants averaged an interactivity of 38 messages. These messages were also highly personalized and highly supportive, indicating an effectiveness among the Latino community not seen elsewhere.
One complaint from participants was the inaccuracy of the translation of the text messages. To address this, the National Institutes of Health (NIH) funded a more appropriate linguistic adaptation, which was then used to engage larger populations, yielding similar cessation rates. Although the value of the linguistic adaptation may be questioned in light of the similar results, the trust built by listening and taking action on community concerns was invaluable.
A randomized controlled trial
A randomized controlled trial was conducted in which 228 participants were randomized to receive the mobile text message- and web-based interactive intervention, or educational material. Both groups had access to medication, but the text-based intervention was individualized to assess coping strategies, when the participants smoked, tools during withdrawal, and more. Text messages were also adjusted to include more information about nicotine replacement therapy (NRT), familismo, and stress, at the request of community members. A relapse track was also developed for those who were not able to quit at the first intervention.
Eligibility for participation included being Latino, more than 21 years of age, and smoking at least 3 days per week. The majority of smoking cessation clinical trials require English proficiency, so the availability of this intervention in English and Spanish meant much more Latino inclusion. In fact, 71% of participants in the randomized controlled trial chose the Spanish option. Results of the study showed that 31% of participants randomized to receive text message- and web-based intervention self-reported quitting, with very high engagement. Some participants even sent as many as 684 messages.
Dr. Cupertino and colleagues seek to use this intervention beyond the US, and into Mexico, Central America, and the rest of Latin America. Another area of future research is to engage with HIV patients, and develop a program for vaping among young Latinos as well. Further work in progress includes an intervention for transgender smokers in Argentina.
By The Numbers
142
Percent
Expected rise in Latino cancer cases in coming years