08/04/2022
Disruption of nocturnal MLT secretion in night shift workers has been associated with modestly increased risk for breast and other cancer types.5-8 A 2005 meta-analysis of 13 observational studies found significantly increased breast cancer incidence among female airline cabin crew (standardized incidence ratio = 1.44; 95% confidence interval [CI] = 1.26-1.65) and in female night workers (relative risk [RR] = 1.51; 95% CI = 1.36-1.68).9 More recently, the International Agency for Research on Cancer reclassified “shiftwork that involves circadian disruption”10 from a possible to a probable (group 2A) human carcinogen, in recognition of this relationship.
On the strength of these findings, Denmark has become the first country to declare breast cancer an “occupational disease.”11 Danish women with breast cancer have begun receiving compensation if, without any other risk factors, they had been working at least 1 night shift a week for the past 20 years.10,11 This development highlights MLT as highly relevant not only within the field of medical oncology but also in the area of public health.
As a possible explanation of the mechanism by which MLT may affect breast cancer risk, the melatonin hypothesis suggests that lowered levels of MLT secretion at night may lead to increased estrogen levels and increased turnover of breast epithelial stem cells, with subsequent increased risk of malignant transformation.12 MLT appears to impact estrogen metabolism through selective estrogen receptor modulator (SERM) and selective estrogen enzyme modulator (SEEM) activity.13
In addition to hormonal effects, MLT is thought to possess immunopotentiating and oncostatic effects by increasing the activity of T and B lymphocytes, monocytes, natural killer cells, and immunoactive cytokines (IFN [interferon]-γ, IL [interleukin]-2, IL-6, and IL-12) as well as promoting apoptosis and inhibiting angiogenesis.2,3 Human intervention trials of MLT for the prevention of cancer are notably lacking; however, studies of MLT for active treatment of cancer have been promising.
In 2005, we published a meta-analysis reviewing 10 human trials of MLT in solid tumor cancers and reported findings of mortality at 1 year (RR = 0.66; 95% CI = 0.59-0.73).4 Many of these trials were conducted in conjunction with chemotherapeutic agents, including tamoxifen, cisplatin, etoposide, IL-2, and radiotherapy. Although the pooled analysis showed benefit on survival, the impacts of MLT on chemotherapy-induced side effects such as alopecia, asthenia, and thrombocytopenia were not reviewed. This systematic review and meta-analysis updates our 2005 meta-analysis. In addition to updating pooled survival statistics, this review holds special relevance to the use of MLT alongside chemotherapy: it assesses the impact of MLT with chemotherapy on therapeutic efficacy, measured as patient survival, and assesses the tolerability of chemotherapy, measured as the extent of chemotherapy-associated toxicities.