Obesity and lung cancer—a narrative review

BACKGROUND AND OBJECTIVE: A highly nuanced relationship exists between obesity and lung cancer. The association between obesity and lung cancer risk/prognosis varies depending on age, gender, race, and the metric used to quantify adiposity. Increased body mass index (BMI) is counterintuitively associated with decreased lung cancer incidence and mortality, giving rise to the term ‘obesity paradox’. Potential explanations for this paradox are BMI being a poor measure of obesity, confounding by smoking and reverse causation. A literature search of this topic yields conflicting conclusions from various authors. We aim to clarify the relationship between various measures of obesity, lung cancer risk, and lung cancer prognosis. METHODS: The PubMed database was searched on 10 August 2022 to identify published research studies. Literature published in English between 2018 and 2022 were included. Sixty-nine publications were considered relevant, and their full text studied to collate information for this review. KEY CONTENT AND FINDINGS: Lower lung cancer incidence and better prognosis was associated with increased BMI even after accounting for smoking and pre-clinical weight loss. Individuals with high BMI also responded better to treatment modalities such as immunotherapy compared to individuals with a normal BMI. However, these associations varied highly depending on age, gender, and race. Inability of BMI to measure body habitus is the main driver behind this variability. The use of anthropometric indicators and image-based techniques to quantify central obesity easily and accurately is on the rise. Increase in central adiposity is associated with increased incidence and poorer prognosis of lung cancer, contrasting BMI. CONCLUSIONS: The obesity paradox may arise due to the improper use of BMI as a measure of body composition. Measures of central obesity better portray the deleterious effects of obesity and are more appropriate to be discussed when talking about lung cancer. The use of obesity metrics based on anthropometric measurements and imaging modalities has been shown to be feasible and practical. However, a lack of standardization makes it difficult to interpret the results of studies using these metrics. Further research must be done to understand the association between these obesity metrics and lung cancer.