Umbrella review finds suggestive links between healthy lifestyles and lower endometrial cancer incidence

An umbrella review of 21 systematic reviews found suggestive evidence that healthy dietary patterns, particularly a Mediterranean diet, and combined healthy diet and lifestyle approaches are associated with lower endometrial cancer incidence. Evidence concerning outcomes after diagnosis—including recurrence, survival, mortality, quality of life and cardiometabolic events—was limited and insufficient to establish whether these associations extend to survivorship.

The researchers included systematic reviews, with or without meta-analyses, of randomized trials, cohort studies and case-control studies involving women aged 18 or older who were either cancer-free or diagnosed with endometrial cancer. Eligible studies examined composite dietary quality indices, dietary patterns, lifestyle indices or lifestyle interventions in relation to endometrial cancer risk, cancer-specific or overall survival, recurrence, quality of life and new-onset cardiometabolic diseases.

PubMed, Embase, Scopus, Web of Science, CINAHL and the Cochrane Library were searched from their inception through 3 December 2024. Nine included reviews addressed diet quality, including seven meta-analyses, while 12 addressed lifestyle exposures or interventions, including eight meta-analyses. The source reviews assessed endometrial cancer risk in 14 instances, all-cause or cancer-specific mortality in five, recurrence in four, overall or cancer-specific survival in three, quality of life in five and cardiometabolic events in one.

Two reviewers independently screened studies, extracted data and appraised methodological quality using a modified AMSTAR 2 tool. Ten reviews were rated moderate or high quality, while 11 were rated low or critically low. Four meta-analyses were reanalysed with random-effects models because the remaining analyses overlapped with those results; the investigators selected more recent, comprehensive or higher-quality reviews where possible. Certainty was classified as convincing, highly suggestive, suggestive, weak or non-significant using prespecified criteria.

Higher adherence to a Mediterranean diet score was associated with 29% lower odds of endometrial cancer in a pooled analysis of two case-control studies (pooled OR 0.71, 95% CI 0.51–0.98; p=0.036; I²=44.7%). The evidence was graded as weak, or class IV. A separate prospective cohort study reported a hazard ratio rather than an odds ratio, so it was not pooled with the case-control results; when examined separately, it did not show a statistically significant association. The inverse estimate therefore depended mainly on two case-control studies, which are susceptible to selection bias.

Western dietary patterns were associated with 20% higher odds of endometrial cancer in a pooled analysis of three studies with sufficient data (pooled OR 1.20, 95% CI 1.03–1.39; p=0.022; I²=0%). This evidence was also classified as weak, or class IV. A prudent dietary pattern was associated with lower odds in the analysis, but the association was not statistically significant and the evidence was classified as non-significant.

Combined healthy diet and lifestyle approaches were associated with a 46% lower hazard of endometrial cancer incidence (pooled HR 0.54, 95% CI 0.42–0.71; p<0.001). Investigators classified this as suggestive, or class III, evidence, although heterogeneity was high at I²=86%. The five underlying studies were large cohort studies. Differences in population characteristics, follow-up periods of approximately eight to 18 years, and the number and type of components included in lifestyle scores may help explain variation among the estimates.

Among women diagnosed with endometrial cancer, lifestyle interventions showed no statistically significant associations with global or domain-specific quality of life across follow-up periods ranging from nine weeks to 12 months and across validated assessment instruments. No significant associations were identified with recurrence, all-cause or cancer-specific mortality, or cardiometabolic events. Few studies reported these post-diagnosis outcomes, follow-up was generally short, and some analyses contained few or no events, limiting interpretation.

The review had several limitations. Each reanalysed meta-analysis included no more than five studies, preventing estimation of 95% prediction intervals and formal assessment of small-study effects and excess-significance bias. Diet and lifestyle indices differed between studies, as did effect measures, and residual confounding could not be excluded. The evidence was predominantly observational, dietary-pattern analyses relied heavily on case-control studies, and all included reviews were published in English despite no language restriction in the search. Overall, the authors said larger, higher-quality observational and interventional studies are needed to examine both endometrial cancer incidence and outcomes among survivors while accounting for changes in diet and lifestyle over time.

Subject of Research: Umbrella review of dietary and lifestyle indices in relation to endometrial cancer incidence and post-diagnosis outcomes

Article Title: Dietary and lifestyle quality and endometrial cancer: Incidence and survivorship outcomes—An umbrella review of systematic reviews and meta-analyses

Article References: Al Ramadhani, R., Arvin, N., Moussa, S., Janda, M., Playdon, M. C., & Obermair, A. (2026). Dietary and lifestyle quality and endometrial cancer: Incidence and survivorship outcomes—An umbrella review of systematic reviews and meta-analyses. PLOS One, 21(10), e0360238. https://doi.org/10.1371/journal.pone.0360238

Image Credits: AI Generated

DOI: 10.1371/journal.pone.0360238

Keywords: endometrial cancer, umbrella review, diet quality, Mediterranean diet, healthy lifestyle, cancer incidence, survivorship, quality of life, systematic reviews, meta-analysis, Dietary, lifestyle