The Prognosis of Leptin rs2167270 G > A (G19A) Polymorphism in the Risk of Cancer: A Meta-Analysis

Background Although the effect of the LEP G19A (rs2167270) polymorphism on cancers is assumed, the results of its influence have been contradictory. A meta-analysis was conducted to precisely verify the relationships between LEP G19A and the development of digestion-related cancers. Methods Investigators systematically searched the literature in PubMed, Embase, and Web of Science and used STATA software 14.0 for the meta−analysis. The odds ratios (ORs) and 95% confidence intervals (CIs) were calculated to evaluate the associations. Subgroup analyses stratified by ethnicity, cancer type, and cancer system were further conducted to assess the relationship between the LEP G19A polymorphism and digestion-related cancers. Results In the overall population, we found a significant relationship with overall cancer (allele comparison: OR = 0.921, p = 0.000; dominant comparison: OR = 0.923, p = 0.004; recessive comparison: OR = 0.842, p = 0.000; homozygote model: OR = 0.0843, p = 0.001). In a subgroup analysis conducted by ethnicity, we obtained significant results in Asians (Asian allele comparison: OR = 0.885, p = 0.000; dominant comparison: OR = 0.862, p = 0.000; homozygote model: OR = 0.824, p = 0.039; and heterozygote comparison: OR = 0.868, p = 0.000) but not in Caucasians. In a subgroup analysis conducted by cancer type and cancer system, we obtained significant results that the LEP G19A polymorphism may decrease the risk of colorectal cancer, esophageal cancer, digestive system cancer, and urinary system cancer. Conclusions This meta-analysis revealed that the LEP G19A polymorphism may decrease the risk of cancer.


INTRODUCTION
It is well known that cancer is one of major causes of death with over 6.1 million projected to die each year, and morbidity rates have increased gradually over the past decade (1,2), so it has been a public health burden worldwide. The reason for cancer is complicated and the etiology and mechanism of carcinogenesis are not clearly elucidated to date. It was widely accepted that the interplay between environmental factors, genetics, and lifestyle plays an important role in the carcinogenesis according to epidemiology. There is mounting evidence indicating that many metabolic diseases such as obesity and diabetes may significantly increase the risk of cancer (3)(4)(5). The polymorphism of obesity and diabetes gene may be associated with genetic susceptibility of cancer.
Leptin (LEP), a 16-kDa hormone of energy expenditure, is a balancing mediator of homeostasis by regulating acquisition and consumption of energy, which was a basic pathophysiological process in normal cells and cancer cells. Many epidemiological studies have revealed the link between LEP and the development of many kinds of cancers (6)(7)(8). Among the pathophysiological mechanisms of cancer, LEP seems relevant to the proliferation of cancer stem cells (9). Some studies also revealed that LEP through its signal pathways regulating energy intake and expenditure [MAPK, PI3K, mTOR, and JAK/STAT (10,11)] produced an effect in angiogenesis processes that were critical in the genesis and development of cancer (12). Pathophysiological mechanisms of cancer such as inflammation, invasion, and metastasis are also favored by LEP (13)(14)(15). So, LEP may be involved in various pathological processes of carcinogenesis.
Single-nucleotide polymorphism can change the functions of genes and the expression of protein. LEP G19A polymorphism, positioning at the 5′-untranslated region of gene, may impact mRNA translation and change the serum level of LEP. With the development of molecular epidemiology, various studies have demonstrated that LEP G19A polymorphism is related to cancer risk (16)(17)(18)(19). However, results between G19A polymorphism with cancers have been inconsistent or inconclusive. Therefore, we performed a metaanalysis to verify the correlation between the G19A mutation of the LEP gene and susceptibility to cancers.
In this study, we conducted a meta-analysis to verify whether the G19A polymorphism of the LEP gene affects the risk of cancer.

Literature Search
A comprehensive literature search of PubMed, Embase, and Web of Science was performed to search all potential studies that involved the relevance between the G19A polymorphism and cancers prior to June 2021. Our study contained the following terms: ("leptin" OR "LEP" OR "G19A" OR "rs2167270") AND ("polymorphism" OR "variant" OR "mutation") AND ("malignancy" OR "cancer" OR "carcinoma" OR "neoplasm").

Inclusion and Exclusion Criteria
The inclusion criteria were as follows: (1) investigate the association between the LEP G19A (rs2167270) mutation and cancers; (2) meet cohort design or case-control design; (3) abundant data should behave to estimate an odds ratio (OR) and 95% confidence interval; (4) results were reported in English; and (5) include human subjects. We adopted the following exclusion criteria: (1) duplicated studies; (2) studies in which subjects were not human; and (3) studies in which we could not obtain sufficient raw data.

Data Extraction
Investigators extracted genotype data independently, and every data point reached a consensus. The extracted data contained the (1) name of the first author; (2) year of publication; (3) ethnicity of cases and controls; (4) cancer type of studies; and (5) frequency of LEP G19A in genes.

Statistical Analysis
We computed ORs and their 95% CIs to estimate the association between the LEP G19A (rs2167270) mutation and cancers. The pooled ORs and their 95% CIs were computed for genes using the following five models: dominant model (AA + AG vs. GG), recessive model (AA vs. GG + AG), allele model (A vs. G), homozygous model (AA vs. GG), and heterozygote model (AG vs. GG).
The Q test was used to estimate heterogeneity between different studies, and p < 0.05 was considered significant for heterogeneity. In addition, inconsistency was quantified by the I 2 statistic. Twenty-five percent and 50% of the I 2 values indicated low and high levels of heterogeneity, respectively. An I 2 < 50% suggested that no heterogeneity existed. When heterogeneity existed, the fixed effects model (FEM) was utilized; otherwise, the random-effects model (REM) was utilized for calculation.
To evaluate the specific effects of ethnicity, cancer type, and cancer system, investigators performed subgroup analyses by ethnicity, cancer type, and cancer system. Sensitivity analyses were performed to evaluate the stability of the results. A funnel plot of Egger's or Begg's test was conducted to reveal possible publication bias. We used the Newcastle-Ottawa Scale to assess the including literature quality. All meta-analyses were performed using STATA software (Version 12.0, College Station, TX).

Effect of the LEP G19A Polymorphism on Cancers
We investigated the effect of the LEP G19A mutation on cancer susceptibility in five genetic models. In all models, if the heterogeneity was less than 50%, the authors applied fixed models, whereas if the heterogeneity was greater than 50%, random models were used.
In a subgroup analysis conducted by ethnicity, we obtained significant results in Asians in four models (allele comparison: OR = 0.885, p = 0.000; dominant comparison: OR = 0.862, p = 0.000; homozygote model: OR = 0.824, p = 0.039; and heterozygote comparison: OR = 0.868, p = 0.000); we also obtained significant results in the mixed recessive model: OR = 0.785, p = 0.1006. We obtained no significant results in the Caucasian population in five models ( Table 3 and Figure 2).
In a subgroup analysis conducted by cancer type, we obtained significant results that the LEP G19A polymorphism decreased the risk of colorectal cancer in one model (recessive model: OR = 0.816, p = 0.010); decreased the risk of esophageal cancer in two models (allele model: OR = 0.888, p = 0.014; dominant comparison: OR = 0.874, p = 0.022); and decreased the risk of other types of cancer in three models (allele comparison: OR = 0.866, p = 0.010; dominant comparison: OR = 0.842, p = 0.010; heterozygote comparison: OR = 0.849, p = 0.018) ( Table 3 and Figure 2).
In a subgroup analysis conducted by cancer system, we obtained significant results that the LEP G19A polymorphism decreased the risk of digestive system cancer in three models (allele comparison: OR = 0.937, p = 0.016; recessive comparison: OR = 0.838, p = 0.005; homozygote comparison: OR = 0.863, p = 0.028); we also obtained significant results that the LEP G19A polymorphism decreased the risk of urinary system cancer in three models (allele comparison: OR = 0.881, p = 0.022; dominant comparison: OR = 0.842, p = 0.019; heterozygote comparison: OR = 0.855, p = 0.043) ( Table 3 and Figure 2).

Sensitivity Analysis and Publication Bias
We used Begg's and Egger's tests to evaluate publication bias in all models. All results of Begg's and Egger's tests were >0.05 in all models and funnel plots, revealing that publication bias may not exist among our studies ( Table 2, Figures 3 and 4). We conducted a sensitivity analysis, and pooled ORs and the corresponding 95% CIs were computed. The results did not show a significant change even though one study was deleted each time, which suggested that the results were statistically stable ( Figure 5).

DISCUSSION
It has been confirmed that the occurrence of cancer is a complex, multistep, and multifactorial event that contains various genetic,   environmental, and lifestyle factors, such as smoking, drinking, obesity, and genetic factor. Multiple studies have revealed that metabolic-related factors are associated with the risk of cancer (35)(36)(37). The LEP, metabolic-related factors regulating balancing by regulating acquisition and energy consumption, was confirmed relevant to cancer (38)(39)(40). The LEP G19A polymorphism may alter the transcription of mRNA and the level of LEP was confirmed to be associated with any kind of cancer (21,22,(24)(25)(26). However, the conclusions of those studies were inconsistent. Two meta-analyses were researched by Liu et al. (41), including 10 studies, and Yang et al. (29), including 13 studies, generating conflicting results in subgroup analysis and  lacking subgroup analysis of the cancer system. Meanwhile, an expanding body of literature on the relationship between LEP G19A polymorphism and cancer risk has been published. Therefore, we conducted this meta-analysis to address this relevance between the LEP G19A polymorphism and cancer risk. Our current meta-analysis contained 19 studies of cancers containing 9,878 patients, and 14,251 controls were pooled, which contained more participants and cancer types than the previous meta-analysis. Overall, we found a significant correlation between the LEP G19A mutation and susceptibility to cancers under four models (allele model, dominant model, recessive model, and homozygote model), which means that this mutation may decrease the risk of overall cancer. This result was confirmed in a meta-analysis conducted by Liu et al. (41) and Yang et al. (29). Studies (42,43) confirmed that the LEP G19A mutation might reduce mRNA translation with a lower serum level of LEP, which may attenuate the cancer risk as a protective factor.
Obesity was defined as an imbalance between caloric consumption and energy expenditure. Meanwhile, the LEP is a metabolic-related factor regulating balancing by regulating acquisition and consumption of energy. So it seems that obesity has a positive correlation with LEP polymorphism. However, some studies showed that there was no association between LEP polymorphism and obesity (44,45). Mizuta et al. (46) study showed that LEP G19A was not associated with obesity. The study by Nesrine et al. (47) even showed that different polymorphisms of the LEP gene have distinct correlations with obesity. Our study showed that LEP G19A polymorphism decreases cancer risk, but the exact mechanism is unknown and mounting evidence indicates that obesity may greatly increase the risk of cancer (3)(4)(5). This provides us with a  hint that LEP G19A polymorphism may not lead to cancer by gaining weight. Further studies are needed to elucidate the mechanism of action of LEP G19A polymorphism and cancer.
When stratified by ethnicity, we found a significant correlation between this mutation and Asians and no significant in Caucasians, which means that this mutation may decrease the risk of Asian people not Caucasians. This difference might be caused by a discrepancy in the interplay between genes and the environment. Moreover, the frequency of the A allele in Caucasians (68%) and Asians (44%) might be the reason for contributing to the discrepancy in the non-significant results in Caucasians. When stratified by cancer type and cancer system, it was first to describe the association between LEP G19A mutation and the cancer system. We found a significant correlation between this mutation and colorectal cancer, esophageal cancer, digestive system cancer, and urinary system cancer, which means that this mutation may decrease the risk of colorectal cancer, esophageal cancer, digestive system cancer, and urinary system cancer, but we found no correlation between this mutation and the other cancer system; the reason for this difference in risk with different tumors is as yet unknown, possibly due to LEP and its receptors playing various roles in the mediation of physiological reactions and carcinogenesis in different pathological types of cancer.
Heterogeneity may exist in our meta-analysis of cancer in the overall analysis. Stratified analyses indicated that heterogeneity was significant in some subgroups (e.g., Asians, esophageal cancer, and urinary system cancer). These factors may cause heterogeneity in our study. We checked the stability of our pooled results by sensitivity analyses. The trend of relevance was not significantly changed in the sensitivity analyses, which meant that the pooled results in our meta-analysis were statistically stable. We used Begg's and Egger's tests to evaluate publication bias. Begg's and Egger's tests' p-values > 0.05 in all models, so that publication bias may exist in this meta-analysis.
The following limitations should be mentioned: (1) The number of studies focused on the relationship between LEP G19A and cancer was relatively small, so little information about stratified analyses of ethnicity, cancer type, and cancer system was available; therefore, further studies are required to determine the actual relationship in all populations. (2) Our study had no access to other potential factors influencing the results, such as other lifestyles, environments, and ages.

CONCLUSION
In conclusion, this meta-analysis suggests that the LEP G19A mutation may decrease the risk of overall cancer, colorectal cancer, esophageal cancer, digestive system cancer, and urinary system cancer. In the future, more comprehensive objects containing genetic environmental interaction are warranted to discover the correlation between LEP G19A mutation and the risk of cancer.

DATA AVAILABILITY STATEMENT
The original contributions presented in the study are included in the article/supplementary material. Further inquiries can be directed to the corresponding author.

AUTHOR CONTRIBUTIONS
AZ, SW, FZ, WL, QL, and XL conceived the study. FZ, WL, and QL contributed to data acquisition, data interpretation, and statistical analysis. AZ, SW, and XL contributed to the study design, statistical analysis, writing, and revising of the manuscript critically. All authors contributed to the article and approved the submitted version.