A causal association between Epstein-Barr virus infection and lung cancer: A two-sample Mendelian Randomization study

Abstract

Background

The association between Epstein-Barr virus (EBV) and lung cancer risk remains controversial. Here, we used a two-sample Mendelian randomization (MR) analysis to test the causal relationship between EBV and lung cancer.

Methods

Data regarding lung cancer (outcomes) were collected from the Finnish database; the Genome-Wide Association Study (GWAS) summary-level dataset for EBV was obtained from the Open Forum Infect Dis. The inverse-variance weighted (IVW) method was used as a primary analytical approach; weighted median, MR-Egger, and weighted mode methods were used to ensure the robustness of the data. The MR-Egger regression assessed horizontal pleiotropy, and the MR pleiotropy residual sum and outlier (MR-PRESSO) method identified potential outliers. Cochran’s Q test evaluated heterogeneity among instrumental variables (IVs).

Results

IVW analysis indicated several significant causal effects. Genetically elevated levels of EBV ZEBRA and EBNA-1 antibodies increased the risk of SQC (OR=1.26 and OR=1.33, respectively). Increased EBNA-1 antibodies also raised the risk of overall lung cancer and small cell lung cancer. Conversely, higher VCA p18 antibody levels were associated with a decreased risk of lung adenocarcinoma (OR=0.70). Sensitivity analyses suggested these findings were robust, with no significant evidence of horizontal pleiotropy or heterogeneity.

Conclusion

Our data suggests a causal effect between EBV and the progression of lung cancer.

Keywords

EBV lung cancer single nucleotide polymorphism Mendelian Randomization causality

Introduction

Lung cancer (LC) is the leading cause of cancer deaths globally.¹ LC is characterized by significant pathological heterogeneity and is commonly classified into small-cell lung cancer (SCLC) and non-small-cell lung cancer (NSCLC).² SCLC has a poor prognosis due to its highly invasive and neuroendocrine cell-derived characteristics and poor prognosis,³ whereas NSCLC predominates and encompasses three main subtypes: squamous cell carcinoma (SQC), adenocarcinoma (AdC) and large cell carcinoma (LCC).⁴ Although advances in treatment strategies have been made, the treatment of SCLC and NSCLC remains challenging. The prognosis remains distressingly poor, with a low 5-year survival rate.⁵

In addition to the well-known tobacco smoke as a major risk factor, air pollution, genetic susceptibility, specific occupational exposures, and certain viral infections are also strongly associated with the development of lung cancer, such as the high-risk human papillomavirus (HPV), Merkel cell polyomavirus (MCPyV), and EBV.^6,7 EBV belongs to the group of enveloped gamma herpesviruses. EBV first invades cells within the Waldeyer’s ring structure and then infects immature B cells, prompting latent infection and transformation into memory B cells, which then disseminate throughout the systemic circulatory system.⁸ Globally, EBV infection is highly prevalent, with the majority of people infected in childhood or adolescence entering a long-term latent state; the vast majority of infected individuals are asymptomatic. A meta-analysis integrating data on 886 lung cancer patients from 14 studies revealed that EBV infection was significantly associated with a more than fourfold increased risk of lung cancer, especially the rarer pulmonary lymphoepithelioma-like carcinoma subtype in non-small cell lung cancer.⁹ Numerous studies have also confirmed the presence of EBV in lung cancer through diverse detection techniques. For example, a study in Spain used the Epstein-Barr encoding region in situ hybridization (EBER ISH) technique to detect 19 cases of AdC and SQC, of which 12 (63.2%) were positive.¹⁰ In contrast, in an Italian study, EBV was detected in 26% (i.e.,21/65 cases) of breath condensate samples from 65 patients with NSCLC, as well as in 20% (i.e.,1/5 cases) of 5 patients with SCLC, as detected by real-time PCR.¹¹ Some studies, however, did not detect EBV by ISH in lung AdC and mesothelioma samples.¹² Also, studies on SCLC did not detect EBV gene expression even after the gold standard assay analysis of EBER-ISH.¹³ Therefore, the causality of whether EBV directly causes lung cancer is still insufficiently confirmed and subject to some controversy and uncertainty.

To overcome the limitations of traditional observational studies, such as cross-sectional design, small sample size, insufficient follow-up time, differences in control group selection, and the effects of possible reverse causality and confounding factors, we used MR design to assess the association between EBV infection and lung cancer risk. The MR design utilizes genetic variants as instrumental variables for exposure because these genetic variants are randomly assigned to individuals at embryonic developmental stages and are theoretically independent of other traits (potential confounders or environmental factors), thereby reducing residual confounding effects and minimizing the impact of reverse causation.¹⁴ The aim of this study was to investigate whether EBV infection increases the risk of lung cancer. Based on the existing accumulation of evidence, we hypothesized that there is an association between EBV infection and the development and progression of lung cancer.

Methods

Study design

The MR analysis followed the Strengthening the Reporting of Observational Studies in Epidemiology using Mendelian Randomization (STROBE-MR) guidelines.¹⁵ The analysis adhered to three assumptions of MR studies (Figure 1)¹⁶: (1) IVs are strongly associated with exposure; (2) selected IVs are not associated with potential confounders; (3) IVs have a dependent, but not directly related, effect on the outcome through exposure (EMDIN C A 2017). Data used in this analysis came from approved studies that obtained informed consent from all participants.

Figure 1.

Description of the study design in MR study.

Data sources

Data regarding lung cancer (outcomes) were collected from the Finnish database (see Table S1). The Genome-Wide Association Study (GWAS) summary-level dataset for EBV, including anti-EBV IgG, VCA p18, ZEBRA, EBNA-1, and EA-D antibodies, was obtained from the Open Forum Infect Dis.¹⁷(see Table S2). The dataset is derived from the UK Biobank cohort of serologic measurements and genome-wide genotyping for up to 10,000 infectious diseases.

IVs selection

We calculated the variation in EBV explained by IVs, and the IVs included in this study were required to meet the following criteria: (i) autosomal duplex sequence SNPs significantly associated with the whole genome of EBV antibody were screened, i.e., meeting the criterion of P < 5 x 10^-6; (ii) SNPs with a minimum allele frequency (MAF) > 0.01 were screened; (iii) SNPs with an R² < 0.001 and window size = 10,000kb were excluded. (iv) according to the criteria of R² < 0.001 and window size = 10,000kb, the linkage disequilibrium (LD) effect among SNPs was eliminated; (v) when the screened IV did not exist in the summary data of the ending, SNPs with high LD (R² > 0.8) with the IV were searched for as surrogate SNPs, which were replaced; (vi) the F value of each SNP in the IV was calculated to assess the IV strength and to exclude possible weak instrumental variable bias between the IV and the exposure factors, which was calculated by the following formula: F = R²x(N-2)/(1-R²), with R² being the proportion of the variance of the exposure that can be explained by SNPs in the IV, and an F value of >10 was considered as a strong genetic IV.¹⁸

MR analysis

We utilized MR analysis in order to determine a non-zero causal relationship between EBV and lung cancer. IVW was used as the primary analytical method in this analysis, and dominance ratios (odds ratios, ORs) and 95% confidence intervals (CIs) were calculated to assess the relationship between EBV and lung cancer. IVW is the predominant method for interpreting MR results and is considered the most robust indicator without evidence of directional multi-directionality among the selected IVs, as it calculates a weighted average of effect sizes by computing the inverse variance of each SNP as weights.¹⁹ The robustness of the results was additionally tested using the MR-Egger, weighted median, and weighted mode methods.²⁰ The weighted median method assumes that half of the instrumental variables are valid and analyzes the causal association between exposure and outcome.

All analyses in this study were performed using the “TwoSampleMR” package (version R 4.2.3). Scatter plots, forest plots and funnel plots were used for visualization. Leave-one-out analysis (LOO analysis) was used to estimate the effect of the remaining SNPs on the results by sequentially removing individual SNPs and then performing IVW analysis again to determine whether a single SNP drove causality.

Sensitivity analysis

Sensitivity analysis was used to detect potential pleiotropy that may exist in MR studies. In this study, heterogeneity between IVs was assessed by Cochran’s Q test, and heterogeneity was considered low when P > 0.05, i.e., the valuation between instrumental variables varied randomly and exerted little influence on the IVW results.²⁰ If there was no significant heterogeneity, a fixed-effects model was used; otherwise, a random-effects model was applied. Considering also the influence of pleiotropy of genetic variation on the estimation of the association effect, this study used MR-Egger regression to explore the existence of horizontal pleiotropy, and when the intercept term of MR-Egger regression tends to zero or is not statistically significant, it suggests that there is no pleiotropy, and the exclusion assumption can be regarded as valid.²¹ In addition, this study used the MR pleiotropy residual sum and outlier (MR-PRESSO) method to detect possible outliers (i.e.,SNPs with P < 0.05) and re-estimated the causal associations after eliminating them, thus correcting for horizontal pleiotropy.²² All statistical tests were two-sided and were performed using the TwoSampleMR and MR-PRESSO packages in R software (version 4.2.3).

Results

IVs selection

In our study, when conducting MR analyses with exposure defined by seropositivity for anti-EBV IgG, EBV EA-D antibody, EBV EBNA-1 antibody levels, EBV VCA p18 antibody, ZEBRA antibody levels, EBNA-1 antibody levels, and EA-D antibody levels, we respectively identified 25, 5, 6, 18, and 18 relevant IVs, respectively (the mean F-statistics for these IVs was 22.84, 43.75, 107.62, 27.89, and 49.3, reflecting their overall predictive strengths; the minimum F-statistics was 20.84, 30.06, 31.14, 87.77, and 20.86, while and the maximum values reaching 31.4, 66.74, 342.35, 87.77, and 336.72 respectively. More data are shown in Table S3-S7.

MR data and sensitivity analysis

IVW suggested that Epstein-Barr virus EA-D antibody levels (OR=0.85, 95% CI= 0.73 - 0.98, P=0.0295, Table 1, Figure S1) and EBV EBNA-1 antibody levels (OR=0.89, 95% CI= 0.81 - 0.98, P=0.0162, Table 1, Figure S2) causally affect malignant neoplasm of bronchus and lung; EBV EBNA-1 antibody levels causally affect non-small cell lung cancer (SQC) (OR=0.65, 95% CI=0.52 - 0.81, P=0.0011, Table 1, Figure S3), while EBV EBNA-1 antibody levels causally affect small cell lung cancer (OR=0.74, 95% CI=0.57 - 0.97, P=0.0296, Table 1, Figure S4). MR-Egger regression results suggested that horizontal pleiotropy did not affect all analyses between exposure and outcome (Table 2). Also, MR-PRESSO analysis detected no outliers, confirming the robustness of these results (Table 3).

Table 1.

A causal association between EBV and lung cancer.

Outcome	Exposure	N.SNP	Methods	OR_CI	P-value
Malignant neoplasm of bronchus and lung	Epstein-Barr virus EA-D antibody levels	5	Inverse variance weighted	0.85 (0.73 - 0.98)	0.0295
Malignant neoplasm of bronchus and lung	Epstein-Barr virus EA-D antibody levels	5	MR Egger	0.64 (0.25 - 1.62)	0.4136
Malignant neoplasm of bronchus and lung	Epstein-Barr virus EA-D antibody levels	5	Weighted median	0.89 (0.75 - 1.07)	0.2229
Malignant neoplasm of bronchus and lung	Epstein-Barr virus EA-D antibody levels	5	Weighted mode	0.89 (0.71 - 1.12)	0.3824
Non-small cell lung cancer_adenocarcinoma	Epstein-Barr virus EA-D antibody levels	5	Inverse variance weighted	0.89 (0.69 - 1.16)	0.4073
Non-small cell lung cancer_adenocarcinoma	Epstein-Barr virus EA-D antibody levels	5	MR Egger	0.48 (0.1 - 2.21)	0.4129
Non-small cell lung cancer_adenocarcinoma	Epstein-Barr virus EA-D antibody levels	5	Weighted median	0.89 (0.64 - 1.23)	0.4767
Non-small cell lung cancer_adenocarcinoma	Epstein-Barr virus EA-D antibody levels	5	Weighted mode	0.82 (0.52 - 1.29)	0.4409
Non-small cell lung cancer	Epstein-Barr virus EA-D antibody levels	5	Inverse variance weighted	0.97 (0.81 - 1.16)	0.7346
Non-small cell lung cancer	Epstein-Barr virus EA-D antibody levels	5	MR Egger	0.49 (0.19 - 1.28)	0.2405
Non-small cell lung cancer	Epstein-Barr virus EA-D antibody levels	5	Weighted median	1.03 (0.84 - 1.26)	0.7732
Non-small cell lung cancer	Epstein-Barr virus EA-D antibody levels	5	Weighted mode	1.03 (0.81 - 1.32)	0.8101
Non-small cell lung cancer_squamous	Epstein-Barr virus EA-D antibody levels	5	Inverse variance weighted	0.75 (0.51 - 1.09)	0.1281
Non-small cell lung cancer_squamous	Epstein-Barr virus EA-D antibody levels	5	MR Egger	0.47 (0.04 - 5.63)	0.5916
Non-small cell lung cancer_squamous	Epstein-Barr virus EA-D antibody levels	5	Weighted median	0.85 (0.6 - 1.22)	0.3883
Non-small cell lung cancer_squamous	Epstein-Barr virus EA-D antibody levels	5	Weighted mode	0.84 (0.56 - 1.28)	0.4692
Bronchus and lung	Epstein-Barr virus EA-D antibody levels	5	Inverse variance weighted	0.54 (0.29 - 1.02)	0.0566
Bronchus and lung	Epstein-Barr virus EA-D antibody levels	5	MR Egger	0.35 (0.01 - 23.96)	0.6591
Bronchus and lung	Epstein-Barr virus EA-D antibody levels	5	Weighted median	0.51 (0.24 - 1.11)	0.0901
Bronchus and lung	Epstein-Barr virus EA-D antibody levels	5	Weighted mode	0.52 (0.2 - 1.36)	0.255
Small cell lung cancer	Epstein-Barr virus EA-D antibody levels	5	Inverse variance weighted	0.75 (0.5 - 1.13)	0.1753
Small cell lung cancer	Epstein-Barr virus EA-D antibody levels	5	MR Egger	0.94 (0.09 - 10.16)	0.9652
Small cell lung cancer	Epstein-Barr virus EA-D antibody levels	5	Weighted median	0.75 (0.46 - 1.23)	0.2534
Small cell lung cancer	Epstein-Barr virus EA-D antibody levels	5	Weighted mode	0.74 (0.39 - 1.4)	0.4051
Malignant neoplasm of bronchus and lung	Anti-Epstein-Barr virus IgG seropositivity	23	Inverse variance weighted	0.99 (0.64 - 1.52)	0.9553
Malignant neoplasm of bronchus and lung	Anti-Epstein-Barr virus IgG seropositivity	23	MR Egger	1.24 (0.45 - 3.41)	0.6809
Malignant neoplasm of bronchus and lung	Anti-Epstein-Barr virus IgG seropositivity	23	Weighted median	1.07 (0.59 - 1.95)	0.8151
Malignant neoplasm of bronchus and lung	Anti-Epstein-Barr virus IgG seropositivity	23	Weighted mode	1.04 (0.41 - 2.65)	0.9284
Non-small cell lung cancer_adenocarcinoma	Anti-Epstein-Barr virus IgG seropositivity	23	Inverse variance weighted	1.5 (0.68 - 3.33)	0.3142
Non-small cell lung cancer_adenocarcinoma	Anti-Epstein-Barr virus IgG seropositivity	23	MR Egger	1.1 (0.17 - 7.14)	0.921
Non-small cell lung cancer_adenocarcinoma	Anti-Epstein-Barr virus IgG seropositivity	23	Weighted median	2.07 (0.64 - 6.65)	0.2234
Non-small cell lung cancer_adenocarcinoma	Anti-Epstein-Barr virus IgG seropositivity	23	Weighted mode	3.38 (0.48 - 24.06)	0.2366
Non-small cell lung cancer	Anti-Epstein-Barr virus IgG seropositivity	23	Inverse variance weighted	0.94 (0.58 - 1.53)	0.8118
Non-small cell lung cancer	Anti-Epstein-Barr virus IgG seropositivity	23	MR Egger	0.95 (0.31 - 2.96)	0.9332
Non-small cell lung cancer	Anti-Epstein-Barr virus IgG seropositivity	23	Weighted median	1.14 (0.57 - 2.28)	0.7089
Non-small cell lung cancer	Anti-Epstein-Barr virus IgG seropositivity	23	Weighted mode	1.36 (0.4 - 4.58)	0.6236
Non-small cell lung cancer_squamous	Anti-Epstein-Barr virus IgG seropositivity	23	Inverse variance weighted	1.21 (0.51 - 2.85)	0.6702
Non-small cell lung cancer_squamous	Anti-Epstein-Barr virus IgG seropositivity	23	MR Egger	1.18 (0.16 - 8.97)	0.8712
Non-small cell lung cancer_squamous	Anti-Epstein-Barr virus IgG seropositivity	23	Weighted median	1.47 (0.46 - 4.77)	0.5169
Non-small cell lung cancer_squamous	Anti-Epstein-Barr virus IgG seropositivity	23	Weighted mode	1.92 (0.34 - 10.79)	0.4666
Bronchus and lung	Anti-Epstein-Barr virus IgG seropositivity	23	Inverse variance weighted	0.8 (0.09 - 6.86)	0.8412
Bronchus and lung	Anti-Epstein-Barr virus IgG seropositivity	23	MR Egger	19.97 (0.15 - 2690.54)	0.2447
Bronchus and lung	Anti-Epstein-Barr virus IgG seropositivity	23	Weighted median	0.26 (0.02 - 4.41)	0.3529
Bronchus and lung	Anti-Epstein-Barr virus IgG seropositivity	23	Weighted mode	0.19 (0.01 - 7.09)	0.3787
Small cell lung cancer	Anti-Epstein-Barr virus IgG seropositivity	23	Inverse variance weighted	0.85 (0.24 - 3.01)	0.8017
Small cell lung cancer	Anti-Epstein-Barr virus IgG seropositivity	23	MR Egger	0.22 (0.01 - 4.31)	0.3326
Small cell lung cancer	Anti-Epstein-Barr virus IgG seropositivity	23	Weighted median	0.9 (0.17 - 4.75)	0.9027
Small cell lung cancer	Anti-Epstein-Barr virus IgG seropositivity	23	Weighted mode	0.88 (0.09 - 8.88)	0.9162
Malignant neoplasm of bronchus and lung	Epstein-Barr virus EBNA-1 antibody levels	5	Inverse variance weighted	0.89 (0.81 - 0.98)	0.0162
Malignant neoplasm of bronchus and lung	Epstein-Barr virus EBNA-1 antibody levels	5	MR Egger	0.77 (0.62 - 0.97)	0.108
Malignant neoplasm of bronchus and lung	Epstein-Barr virus EBNA-1 antibody levels	5	Weighted median	0.87 (0.78 - 0.96)	0.0058
Malignant neoplasm of bronchus and lung	Epstein-Barr virus EBNA-1 antibody levels	5	Weighted mode	0.86 (0.77 - 0.96)	0.0591
Non-small cell lung cancer_adenocarcinoma	Epstein-Barr virus EBNA-1 antibody levels	5	Inverse variance weighted	1.1 (0.86 - 1.4)	0.463
Non-small cell lung cancer_adenocarcinoma	Epstein-Barr virus EBNA-1 antibody levels	5	MR Egger	1.04 (0.54 - 2.03)	0.9122
Non-small cell lung cancer_adenocarcinoma	Epstein-Barr virus EBNA-1 antibody levels	5	Weighted median	1.1 (0.9 - 1.35)	0.3521
Non-small cell lung cancer_adenocarcinoma	Epstein-Barr virus EBNA-1 antibody levels	5	Weighted mode	1.11 (0.9 - 1.37)	0.394
Non-small cell lung cancer	Epstein-Barr virus EBNA-1 antibody levels	5	Inverse variance weighted	0.93 (0.83 - 1.05)	0.2489
Non-small cell lung cancer	Epstein-Barr virus EBNA-1 antibody levels	5	MR Egger	0.77 (0.6 - 0.98)	0.125
Non-small cell lung cancer	Epstein-Barr virus EBNA-1 antibody levels	5	Weighted median	0.9 (0.8 - 1.01)	0.0804
Non-small cell lung cancer	Epstein-Barr virus EBNA-1 antibody levels	5	Weighted mode	0.9 (0.79 - 1.02)	0.1618
Non-small cell lung cancer_squamous	Epstein-Barr virus EBNA-1 antibody levels	5	Inverse variance weighted	0.68 (0.54 - 0.86)	0.0011
Non-small cell lung cancer_squamous	Epstein-Barr virus EBNA-1 antibody levels	5	MR Egger	0.56 (0.31 - 1.02)	0.1554
Non-small cell lung cancer_squamous	Epstein-Barr virus EBNA-1 antibody levels	5	Weighted median	0.63 (0.51 - 0.78)	2.12E-05
Non-small cell lung cancer_squamous	Epstein-Barr virus EBNA-1 antibody levels	5	Weighted mode	0.65 (0.52 - 0.81)	0.0195
Bronchus and lung	Epstein-Barr virus EBNA-1 antibody levels	5	Inverse variance weighted	0.73 (0.44 - 1.19)	0.2022
Bronchus and lung	Epstein-Barr virus EBNA-1 antibody levels	5	MR Egger	0.66 (0.17 - 2.47)	0.577
Bronchus and lung	Epstein-Barr virus EBNA-1 antibody levels	5	Weighted median	0.69 (0.45 - 1.07)	0.0961
Bronchus and lung	Epstein-Barr virus EBNA-1 antibody levels	5	Weighted mode	0.69 (0.43 - 1.1)	0.1912
Small cell lung cancer	Epstein-Barr virus EBNA-1 antibody levels	5	Inverse variance weighted	0.74 (0.57 - 0.97)	0.0296
Small cell lung cancer	Epstein-Barr virus EBNA-1 antibody levels	5	MR Egger	0.98 (0.52 - 1.85)	0.9595
Small cell lung cancer	Epstein-Barr virus EBNA-1 antibody levels	5	Weighted median	0.75 (0.55 - 1.01)	0.0577
Small cell lung cancer	Epstein-Barr virus EBNA-1 antibody levels	5	Weighted mode	0.82 (0.6 - 1.12)	0.2803
Malignant neoplasm of bronchus and lung	Epstein-Barr virus ZEBRA antibody levels	15	Inverse variance weighted	1.03 (0.93 - 1.13)	0.6176
Malignant neoplasm of bronchus and lung	Epstein-Barr virus ZEBRA antibody levels	15	MR Egger	0.84 (0.72 - 0.98)	0.0508
Malignant neoplasm of bronchus and lung	Epstein-Barr virus ZEBRA antibody levels	15	Weighted median	1 (0.89 - 1.12)	0.9684
Malignant neoplasm of bronchus and lung	Epstein-Barr virus ZEBRA antibody levels	15	Weighted mode	1 (0.9 - 1.11)	0.9582
Malignant neoplasm of bronchus and lung	Epstein-Barr virus ZEBRA antibody levels/After exclusion	10	Inverse variance weighted	1.04 (0.91 - 1.19)	0.5295
Malignant neoplasm of bronchus and lung	Epstein-Barr virus ZEBRA antibody levels/After exclusion	10	MR Egger	0.96 (0.71 - 1.3)	0.8064
Malignant neoplasm of bronchus and lung	Epstein-Barr virus ZEBRA antibody levels/After exclusion	10	Weighted median	1 (0.84 - 1.19)	0.976
Malignant neoplasm of bronchus and lung	Epstein-Barr virus ZEBRA antibody levels/After exclusion	10	Weighted mode	0.99 (0.81 - 1.21)	0.8999
Non-small cell lung cancer_adenocarcinoma	Epstein-Barr virus ZEBRA antibody levels	15	Inverse variance weighted	0.99 (0.84 - 1.16)	0.8601
Non-small cell lung cancer_adenocarcinoma	Epstein-Barr virus ZEBRA antibody levels	15	MR Egger	0.89 (0.66 - 1.22)	0.49
Non-small cell lung cancer_adenocarcinoma	Epstein-Barr virus ZEBRA antibody levels	15	Weighted median	0.8 (0.65 - 0.99)	0.0362
Non-small cell lung cancer_adenocarcinoma	Epstein-Barr virus ZEBRA antibody levels	15	Weighted mode	0.78 (0.62 - 0.98)	0.0502
Non-small cell lung cancer	Epstein-Barr virus ZEBRA antibody levels	15	Inverse variance weighted	1.02 (0.91 - 1.14)	0.747
Non-small cell lung cancer	Epstein-Barr virus ZEBRA antibody levels	15	MR Egger	0.83 (0.69 - 1)	0.0749
Non-small cell lung cancer	Epstein-Barr virus ZEBRA antibody levels	15	Weighted median	0.99 (0.88 - 1.13)	0.9153
Non-small cell lung cancer	Epstein-Barr virus ZEBRA antibody levels	15	Weighted mode	1 (0.89 - 1.14)	0.9608
Non-small cell lung cancer	Epstein-Barr virus ZEBRA antibody levels/After exclusion	10	Inverse variance weighted	1.02 (0.88 - 1.18)	0.78
Non-small cell lung cancer	Epstein-Barr virus ZEBRA antibody levels/After exclusion	10	MR Egger	1.03 (0.74 - 1.44)	0.8595
Non-small cell lung cancer	Epstein-Barr virus ZEBRA antibody levels/After exclusion	10	Weighted median	1.04 (0.87 - 1.25)	0.6839
Non-small cell lung cancer	Epstein-Barr virus ZEBRA antibody levels/After exclusion	10	Weighted mode	1.04 (0.82 - 1.31)	0.7528
Non-small cell lung cancer_squamous	Epstein-Barr virus ZEBRA antibody levels	15	Inverse variance weighted	1.26 (1.02 - 1.55)	0.0331
Non-small cell lung cancer_squamous	Epstein-Barr virus ZEBRA antibody levels	15	MR Egger	1.12 (0.74 - 1.69)	0.6076
Non-small cell lung cancer_squamous	Epstein-Barr virus ZEBRA antibody levels	15	Weighted median	1.42 (1.14 - 1.78)	0.002
Non-small cell lung cancer_squamous	Epstein-Barr virus ZEBRA antibody levels	15	Weighted mode	1.38 (1.09 - 1.74)	0.0172
Bronchus and lung	Epstein-Barr virus ZEBRA antibody levels	15	Inverse variance weighted	1.09 (0.77 - 1.53)	0.6391
Bronchus and lung	Epstein-Barr virus ZEBRA antibody levels	15	MR Egger	1.31 (0.68 - 2.52)	0.4381
Bronchus and lung	Epstein-Barr virus ZEBRA antibody levels	15	Weighted median	1.21 (0.76 - 1.92)	0.4265
Bronchus and lung	Epstein-Barr virus ZEBRA antibody levels	15	Weighted mode	1.26 (0.77 - 2.04)	0.3713
Small cell lung cancer	Epstein-Barr virus ZEBRA antibody levels	15	Inverse variance weighted	1.34 (0.95 - 1.88)	0.0958
Small cell lung cancer	Epstein-Barr virus ZEBRA antibody levels	15	MR Egger	0.72 (0.41 - 1.25)	0.2627
Small cell lung cancer	Epstein-Barr virus ZEBRA antibody levels	15	Weighted median	1.09 (0.79 - 1.51)	0.5991
Small cell lung cancer	Epstein-Barr virus ZEBRA antibody levels	15	Weighted mode	1.04 (0.75 - 1.46)	0.8121
Small cell lung cancer	Epstein-Barr virus ZEBRA antibody levels/After exclusion	13	Inverse variance weighted	1.46 (0.98 - 2.2)	0.066
Small cell lung cancer	Epstein-Barr virus ZEBRA antibody levels/After exclusion	13	MR Egger	0.9 (0.39 - 2.1)	0.8154
Small cell lung cancer	Epstein-Barr virus ZEBRA antibody levels/After exclusion	13	Weighted median	1.28 (0.76 - 2.13)	0.3523
Small cell lung cancer	Epstein-Barr virus ZEBRA antibody levels/After exclusion	13	Weighted mode	1.13 (0.58 - 2.17)	0.7305
Malignant neoplasm of bronchus and lung	Epstein-Barr virus VCA p18 antibody levels	16	Inverse variance weighted	0.98 (0.87 - 1.11)	0.7984
Malignant neoplasm of bronchus and lung	Epstein-Barr virus VCA p18 antibody levels	16	MR Egger	1.08 (0.82 - 1.43)	0.6003
Malignant neoplasm of bronchus and lung	Epstein-Barr virus VCA p18 antibody levels	16	Weighted median	0.96 (0.82 - 1.12)	0.5928
Malignant neoplasm of bronchus and lung	Epstein-Barr virus VCA p18 antibody levels	16	Weighted mode	0.88 (0.64 - 1.22)	0.458
Non-small cell lung cancer_adenocarcinoma	Epstein-Barr virus VCA p18 antibody levels	16	Inverse variance weighted	0.84 (0.69 - 1.01)	0.0679
Non-small cell lung cancer_adenocarcinoma	Epstein-Barr virus VCA p18 antibody levels	16	MR Egger	1.27 (0.85 - 1.88)	0.2611
Non-small cell lung cancer_adenocarcinoma	Epstein-Barr virus VCA p18 antibody levels	16	Weighted median	0.99 (0.77 - 1.28)	0.963
Non-small cell lung cancer_adenocarcinoma	Epstein-Barr virus VCA p18 antibody levels	16	Weighted mode	0.99 (0.73 - 1.35)	0.9679
Non-small cell lung cancer_adenocarcinoma	Epstein-Barr virus VCA p18 antibody levels/After exclusion	13	Inverse variance weighted	0.7 (0.56 - 0.87)	0.0016
Non-small cell lung cancer_adenocarcinoma	Epstein-Barr virus VCA p18 antibody levels/After exclusion	13	MR Egger	1.18 (0.67 - 2.06)	0.5838
Non-small cell lung cancer_adenocarcinoma	Epstein-Barr virus VCA p18 antibody levels/After exclusion	13	Weighted median	0.73 (0.53 - 1)	0.0508
Non-small cell lung cancer_adenocarcinoma	Epstein-Barr virus VCA p18 antibody levels/After exclusion	13	Weighted mode	0.68 (0.45 - 1.03)	0.0961
Non-small cell lung cancer	Epstein-Barr virus VCA p18 antibody levels	16	Weighted mode	0.8 (0.61 - 1.06)	0.1445
Non-small cell lung cancer_squamous	Epstein-Barr virus VCA p18 antibody levels	16	Inverse variance weighted	1.03 (0.82 - 1.31)	0.7782
Non-small cell lung cancer_squamous	Epstein-Barr virus VCA p18 antibody levels	16	MR Egger	0.88 (0.52 - 1.51)	0.6511
Non-small cell lung cancer_squamous	Epstein-Barr virus VCA p18 antibody levels	16	Weighted median	1.11 (0.81 - 1.51)	0.5141
Non-small cell lung cancer_squamous	Epstein-Barr virus VCA p18 antibody levels	16	Weighted mode	1.12 (0.69 - 1.82)	0.6539
Bronchus and lung	Epstein-Barr virus VCA p18 antibody levels	16	Inverse variance weighted	0.74 (0.49 - 1.13)	0.1668
Bronchus and lung	Epstein-Barr virus VCA p18 antibody levels	16	MR Egger	0.51 (0.2 - 1.33)	0.1921
Bronchus and lung	Epstein-Barr virus VCA p18 antibody levels	16	Weighted median	0.74 (0.42 - 1.31)	0.3048
Bronchus and lung	Epstein-Barr virus VCA p18 antibody levels	16	Weighted mode	0.76 (0.37 - 1.54)	0.4502
Small cell lung cancer	Epstein-Barr virus VCA p18 antibody levels	16	Inverse variance weighted	1.07 (0.81 - 1.4)	0.6408
Small cell lung cancer	Epstein-Barr virus VCA p18 antibody levels	16	MR Egger	1.57 (0.85 - 2.89)	0.1679
Small cell lung cancer	Epstein-Barr virus VCA p18 antibody levels	16	Weighted median	1.07 (0.75 - 1.54)	0.704
Small cell lung cancer	Epstein-Barr virus VCA p18 antibody levels	16	Weighted mode	1.11 (0.72 - 1.72)	0.6331

Table 2.

Heterogeneity and horizontal pleiotropy analysis.

Outcome	Exposure	Heterogeneity		Pleiotropy
Outcome	Exposure	Q statistic (IVW)	P Value	MR-egger intercept	P Value
Malignant neoplasm of bronchus and lung	Epstein-Barr virus EA-D antibody levels	4.269	0.371	0.035	0.584000219
Non-small cell lung cancer_adenocarcinoma	Epstein-Barr virus EA-D antibody levels	2.426	0.658	0.076	0.473256059
Non-small cell lung cancer	Epstein-Barr virus EA-D antibody levels	5.312	0.257	0.083	0.251846273
Non-small cell lung cancer_squamous	Epstein-Barr virus EA-D antibody levels	7.16	0.128	0.057	0.734217561
Bronchus and lung	Epstein-Barr virus EA-D antibody levels	4.613	0.329	0.053	0.850881915
Small cell lung cancer	Epstein-Barr virus EA-D antibody levels	0.97	0.914	-0.027	0.862242328
Malignant neoplasm of bronchus and lung	Anti-Epstein-Barr virus IgG seropositivity	13.674	0.913	-0.01	0.631213974
Non-small cell lung cancer_adenocarcinoma	Anti-Epstein-Barr virus IgG seropositivity	19.124	0.638	0.014	0.721212069
Non-small cell lung cancer	Anti-Epstein-Barr virus IgG seropositivity	16.786	0.775	0	0.985672196
Non-small cell lung cancer_squamous	Anti-Epstein-Barr virus IgG seropositivity	12.298	0.951	0.001	0.985079696
Bronchus and lung	Anti-Epstein-Barr virus IgG seropositivity	31.792	0.081	-0.14	0.170023897
Small cell lung cancer	Anti-Epstein-Barr virus IgG seropositivity	23.011	0.401	0.059	0.338935763
Malignant neoplasm of bronchus and lung	Epstein-Barr virus EBNA-1 antibody levels	2.784	0.595	0.032	0.261753709
Non-small cell lung cancer_adenocarcinoma	Epstein-Barr virus EBNA-1 antibody levels	8.038	0.09	0.012	0.877742461
Non-small cell lung cancer	Epstein-Barr virus EBNA-1 antibody levels	4.992	0.288	0.045	0.182126604
Non-small cell lung cancer_squamous	Epstein-Barr virus EBNA-1 antibody levels	6.327	0.176	0.042	0.550485891
Bronchus and lung	Epstein-Barr virus EBNA-1 antibody levels	6.342	0.175	0.023	0.877150643
Small cell lung cancer	Epstein-Barr virus EBNA-1 antibody levels	1.397	0.845	-0.063	0.40825311
Malignant neoplasm of bronchus and lung	Epstein-Barr virus ZEBRA antibody levels	20.669	0.11	0.037	0.0125682
Malignant neoplasm of bronchus and lung	Epstein-Barr virus ZEBRA antibody levels (after exclusion)	3.16	0.958	0.012	0.572
Non-small cell lung cancer_adenocarcinoma	Epstein-Barr virus ZEBRA antibody levels	15.129	0.369	0.018	0.480237843
Non-small cell lung cancer	Epstein-Barr virus ZEBRA antibody levels	21.841	0.082	0.038	0.026567486
Non-small cell lung cancer	Epstein-Barr virus ZEBRA antibody levels (after exclusion)	1.331	0.998	-0.002	0.948
Non-small cell lung cancer_squamous	Epstein-Barr virus ZEBRA antibody levels	23.148	0.058	0.022	0.520160607
Bronchus and lung	Epstein-Barr virus ZEBRA antibody levels	6.737	0.944	-0.034	0.526414351
Small cell lung cancer	Epstein-Barr virus ZEBRA antibody levels	28.673	0.012	0.113	0.023010476
Small cell lung cancer	Epstein-Barr virus ZEBRA antibody levels (after exclusion)	18.371	0.105	0.073	0.23
Malignant neoplasm of bronchus and lung	Epstein-Barr virus VCA p18 antibody levels	24.941	0.051	-0.013	0.481732864
Non-small cell lung cancer_adenocarcinoma	Epstein-Barr virus VCA p18 antibody levels	10.236	0.595	-0.062	0.072
Non-small cell lung cancer_adenocarcinoma	Epstein-Barr virus VCA p18 antibody levels (after exclusion)	17.661	0.281	-0.057	0.038176049
Non-small cell lung cancer	Epstein-Barr virus VCA p18 antibody levels	19.048	0.212	-0.016	0.368360061
Non-small cell lung cancer_squamous	Epstein-Barr virus VCA p18 antibody levels	22.863	0.087	0.022	0.524260104
Bronchus and lung	Epstein-Barr virus VCA p18 antibody levels	17.909	0.267	0.051	0.410992555
Small cell lung cancer	Epstein-Barr virus VCA p18 antibody levels	10.212	0.806	-0.053	0.185683153

Table 3.

MR-PRESSO analysis.

Outcome	Exposure	Raw		Outlier corrected		Global p	Outliers	Distortion p
Outcome	Exposure	OR_CI	P	OR_CI	P	Global p	Outliers	Distortion p
Bronchus and lung	Anti-Epstein-Barr virus IgG seropositivity	0.7271 (0.0927 - 5.7052)	0.7644	NA (NA - NA)	NA	0.097	NA	NA
Bronchus and lung	Epstein-Barr virus EA-D antibody levels	0.5394 (0.286 - 1.0175)	0.1293	NA (NA - NA)	NA	0.416	NA	NA
Bronchus and lung	Epstein-Barr virus EBNA-1 antibody levels	0.7267 (0.4449 - 1.187)	0.2712	NA (NA - NA)	NA	0.378	NA	NA
Bronchus and lung	Epstein-Barr virus VCA p18 antibody levels	0.7422 (0.4863 - 1.1326)	0.187	NA (NA - NA)	NA	0.275	NA	NA
Bronchus and lung	Epstein-Barr virus ZEBRA antibody levels	1.0854 (0.8559 - 1.3764)	0.5101	NA (NA - NA)	NA	0.921	NA	NA
Malignant neoplasm of bronchus and lung	Anti-Epstein-Barr virus IgG seropositivity	0.8701 (0.5813 - 1.3023)	0.5056	NA (NA - NA)	NA	0.556	NA	NA
Malignant neoplasm of bronchus and lung	Epstein-Barr virus EA-D antibody levels	0.8496 (0.7336 - 0.9839)	0.095	NA (NA - NA)	NA	0.463	NA	NA
Malignant neoplasm of bronchus and lung	Epstein-Barr virus EBNA-1 antibody levels	0.8916 (0.8247 - 0.964)	0.0449	NA (NA - NA)	NA	0.559	NA	NA
Malignant neoplasm of bronchus and lung	Epstein-Barr virus VCA p18 antibody levels	0.9842 (0.8712 - 1.112)	0.8019	1.0168 (0.9157 - 1.1292)	0.7596	0.044	1	0.119
Malignant neoplasm of bronchus and lung	Epstein-Barr virus ZEBRA antibody levels	1.0259 (0.9279 - 1.1343)	0.6253	NA (NA - NA)	NA	0.142	NA	NA
Malignant neoplasm of bronchus and lung	Epstein-Barr virus ZEBRA antibody levels (after exclusion)	1.0429 (0.965 - 1.1271)	0.3162	NA (NA - NA)	NA	0.961	NA	NA
Non-small cell lung cancer_adenocarcinoma	Anti-Epstein-Barr virus IgG seropositivity	1.2913 (0.5991 - 2.783)	0.5206	NA (NA - NA)	NA	0.482	NA	NA
Non-small cell lung cancer_adenocarcinoma	Epstein-Barr virus EA-D antibody levels	0.8945 (0.7283 - 1.0985)	0.3474	NA (NA - NA)	NA	0.675	NA	NA
Non-small cell lung cancer_adenocarcinoma	Epstein-Barr virus EBNA-1 antibody levels	1.0966 (0.8573 - 1.4027)	0.5037	NA (NA - NA)	NA	0.291	NA	NA
Non-small cell lung cancer_adenocarcinoma	Epstein-Barr virus VCA p18 antibody levels	0.8377 (0.6926 - 1.0131)	0.0878	NA (NA - NA)	NA	0.284	NA	NA
Non-small cell lung cancer_adenocarcinoma	Epstein-Barr virus VCA p18 antibody levels (after exclusion)	0.697 (0.5666 - 0.8573)	0.0051	NA (NA - NA)	NA	0.663	NA	NA
Non-small cell lung cancer_adenocarcinoma	Epstein-Barr virus ZEBRA antibody levels	0.9858 (0.8407 - 1.1559)	0.8626	NA (NA - NA)	NA	0.233	NA	NA
Non-small cell lung cancer	Anti-Epstein-Barr virus IgG seropositivity	0.7966 (0.4771 - 1.3303)	0.3938	NA (NA - NA)	NA	0.273	NA	NA
Non-small cell lung cancer	Epstein-Barr virus EA-D antibody levels	0.9686 (0.8056 - 1.1646)	0.7516	NA (NA - NA)	NA	0.327	NA	NA
Non-small cell lung cancer	Epstein-Barr virus EBNA-1 antibody levels	0.9332 (0.8297 - 1.0496)	0.3131	NA (NA - NA)	NA	0.394	NA	NA
Non-small cell lung cancer	Epstein-Barr virus VCA p18 antibody levels	0.9268 (0.8222 - 1.0446)	0.2322	NA (NA - NA)	NA	0.194	NA	NA
Non-small cell lung cancer	Epstein-Barr virus ZEBRA antibody levels	1.0193 (0.9077 - 1.1445)	0.7517	NA (NA - NA)	NA	0.126	NA	NA
Non-small cell lung cancer	Epstein-Barr virus ZEBRA antibody levels (after exclusion)	1.0212 (0.965 - 1.0807)	0.4863	NA (NA - NA)	NA	1	NA	NA
Non-small cell lung cancer_squamous	Anti-Epstein-Barr virus IgG seropositivity	0.9797 (0.4703 - 2.0408)	0.9567	NA (NA - NA)	NA	0.8	NA	NA
Non-small cell lung cancer_squamous	Epstein-Barr virus EA-D antibody levels	0.7451 (0.5101 - 1.0885)	0.2028	NA (NA - NA)	NA	0.181	NA	NA
Non-small cell lung cancer_squamous	Epstein-Barr virus EBNA-1 antibody levels	0.6777 (0.5361 - 0.8566)	0.0312	NA (NA - NA)	NA	0.362	NA	NA
Non-small cell lung cancer_squamous	Epstein-Barr virus VCA p18 antibody levels	1.0341 (0.8186 - 1.3064)	0.7821	NA (NA - NA)	NA	0.086	NA	NA
Non-small cell lung cancer_squamous	Epstein-Barr virus ZEBRA antibody levels	1.2577 (1.0186 - 1.553)	0.0513	NA (NA - NA)	NA	0.08	NA	NA
Small cell lung cancer	Anti-Epstein-Barr virus IgG seropositivity	0.9316 (0.2742 - 3.1645)	0.9105	NA (NA - NA)	NA	0.457	NA	NA
Small cell lung cancer	Epstein-Barr virus EA-D antibody levels	0.7536 (0.6161 - 0.9218)	0.0512	NA (NA - NA)	NA	0.922	NA	NA
Small cell lung cancer	Epstein-Barr virus EBNA-1 antibody levels	0.7419 (0.6329 - 0.8698)	0.0212	NA (NA - NA)	NA	0.651	NA	NA
Small cell lung cancer	Epstein-Barr virus VCA p18 antibody levels	1.0666 (0.8531 - 1.3335)	0.5801	NA (NA - NA)	NA	0.832	NA	NA
Small cell lung cancer	Epstein-Barr virus ZEBRA antibody levels	1.335 (0.9502 - 1.8757)	0.118	1.2462 (0.9201 - 1.6879)	0.1785	0.036	1	0.578
Small cell lung cancer	Epstein-Barr virus ZEBRA antibody levels (after exclusion)	1.4633 (0.9752 - 2.1958)	0.0908	NA (NA - NA)	NA	0.131	NA	NA

We also found that EBV ZEBRA antibody levels are a risk factor for non-small cell lung cancer (SQC) (OR=1.26, 95% CI=1.02-1.55, P=0.0331, Table 1, Figure S5). MR-Egger regression results and MR-PRESSO analysis confirmed the robustness of these results (Tables 2 and 3). IVW also suggested that EBV ZEBRA antibody levels had no effect on other outcomes (all P>0.05). Yet, MR-Egger regression analysis showed some horizontal pleiotropy for EBV ZEBRA antibody levels and malignant neoplasm of bronchus and lung (P=0.572), non-small cell lung cancer (P=0.026), and small cell lung cancer (P=0.023). However, these results become insignificant after correction (removal of one SNP) (see Table 2). Also, after correction, no heterogeneity was found between EBV ZEBRA antibody levels and outcomes (Table 3).

Also, IVW suggested that EBV VCA p18 antibody levels had no effect on outcomes (all P>0.05). Yet, after correction, EBV VCA p18 antibody levels had a causal effect on non-small cell lung cancer (adenocarcinoma) (OR=0.7, 95% CI=0.56 - 0.87, P=0.0016, Table 1, Figure S6). The MR-Egger regression indicated some effect of horizontal pleiotropy on the results. However, these results become insignificant after correction (removal of one SNP) (see Table 2, P=0.072). Also, after correction, no heterogeneity was found between EBV ZEBRA antibody levels and non-small cell lung cancer (adenocarcinoma) (Table 3).

No association was found between other exposure factors and outcomes (all P>0.05).

Discussion

In this study, we employed MR analysis to investigate a causal relationship between EBV and lung cancer. Our data suggests that EBV ZEBRA antibody levels may be a risk factor for non-small cell lung cancer (specifically, SQC). We also found some causal effects between EBV EA-D antibody levels, EBV EBNA-1 antibody levels, and EBV VCA p18 and malignant neoplasm of the lung. These results may open new ways for diagnosis and treatment of lung cancer.

After primary infection, EBV can persist in the host throughout their lifetime in a latent form, from which it can reactivate specific stimuli. The ZEBRA protein plays a crucial role in switching the virus from a latent to a productive mode.²³ Studies have suggested that modulation of host gene expression by ZEBRA can deregulate the immune surveillance to favor tumor progression.²⁴ For example, Joab et al. detected IgG anti-ZEBRA antibodies in 87% of nasopharyngeal carcinoma patients.²⁵ Moreover, Huang and colleagues suggested that sporadic lytic EBV ZEBRA infection may contribute to the progression of breast cancer.²⁶ Yet, the effect of ZEBRA protein on lung carcinoma has still not been fully explored. This is the first study reporting that ZEBRA antibody levels may be a risk factor for lung cancer, although this effect was seen only for non-small cell carcinoma (SQC). SQC of the lungs is less common than adenocarcinoma, but it still makes up roughly one-third of all lung cancer diagnoses. This data may open new ways to diagnose SQC. Yet, the mechanism of action needs to be further explored. Although great progress has been made in understanding the link between ZEBRA protein and cancers,²⁷ many aspects of EBV ZEBRA-related oncogenesis are still unknown and represent a major challenge in cancer research.

Interestingly, in this study, we found that EBV EA-D, VCA p18, and EBNA-1 antibody levels negatively affect lung cancer, which is not consistent with most studies showing a positive association between the two. However, reports on the association between these antibodies and EBV are still sparse and show inconclusive results, which suggests there is a need for research in different groups in the future. For example, one study of lung AdC and mesothelioma did not detect EBV by ISH.¹² In another study, 23 Asian SCLCs were analyzed by EBER-ISH and EBV gene expression was not detected.¹³ In another study from Singapore, EBV was not detected by ISH in 110 lung AdCs.²⁸ Also, it should be considered that most EBV-associated diseases are represented by cancers occurring both in immunocompetent hosts and in patients with primary or acquired immunodeficiency. Also, for 30 to 40% of EBV genes, very little is known concerning their specific function.²⁹ In addition, some studies have suggested that EBV may interact with specific environmental factors (e.g., air pollutants, heavy metals, and certain chemicals) and, thus, indirectly affect lung cancer development.³⁰ For example, arsenic exposure can activate pathogenic gene expression of EBV, while certain pesticides and environmental pollutants may contribute to EBV activity and its association with lung carcinogenesis by inducing oxidative stress or interacting with EBV.³¹ Therefore, the associations between EBV infection and lung cancer development may need to be further explored.

The strengths of this study are that it is the first attempt to explore the causal relationship between EBV and lung cancer by two-sample MR analysis using GWAS summary-level statistics. The two-sample approach has much summary-level genetic data to minimize potential confounders and reverse causality. Next, the findings were validated through various sensitivity analyses, applying multiple MR methods and different modeling assumptions, and the effects of outliers and multidirectionality were comprehensively assessed. All the analyses showed that the results of the study were consistent with good stability and reliability. However, this study is limited by the low proportion of EBV variants explained by validated SNPs, which makes it difficult to capture weak effects. In addition, this study is based on data from European populations, which may not accurately reflect populations in other regions, such as China or other Asian countries where EBV is prevalent. In specific lung cancer types such as pulmonary lymphoepithelioma-like carcinoma, the virus’s infection shows a more pronounced correlation with disease progression, particularly with high detection rates in Asian populations.^32,33 This suggests that EBV’s role may be significantly influenced by tumor type and the genetic background of the population, highlighting the need for further elucidation of the mechanisms by which EBV operates within subtypes of lung cancer.^10,34 Future research should delve deeper into these mechanisms, especially within the context of geographic and ethnic disparities, aiming to inform more precise strategies for preventing, diagnosing, and treating lung cancer. Additionally, establishing unified detection standards and enhancing the sensitivity and specificity of diagnostic techniques are crucial for accurately delineating the true nature of the relationship between EBV and lung cancer.³⁵

The present study demonstrated through rigorous genetic evidence that there is a significant causal association between EBV and lung cancer. This study provides new insights into the role of EBV in the pathogenesis of lung cancer and emphasizes the need for more experimental studies in the future to clarify the specific mechanisms of EBV’s role in lung cancer development in order to better guide the prevention, early diagnosis, and development of therapeutic strategies for lung cancer.

Supplemental material

Supplemental material - A causal association between epstein-barr virus infection and lung cancer: A two-sample mendelian randomization study

Supplemental material for A causal association between epstein-barr virus infection and lung cancer: A two-sample mendelian randomization study by Jia Wang, Kai Wang and Zhishang Wang in Cancer Biomarkers.

Supplemental material

Supplemental material - A causal association between epstein-barr virus infection and lung cancer: A two-sample mendelian randomization study

Footnotes

ORCID iD

Kai Wang

Ethical considerations

This article is a Mendelian Randomization study. The data for this study were obtained from publicly available databases and published literature data and do not require ethical approval and written informed consent.

Author contributions

Jia Wang carried out the studies, participated in collecting data, and drafted the manuscript. Jia Wang and Zhishang Wang performed the statistical analysis and participated in its design. Jia Wang and Kai Wang participated in acquisition, analysis, or interpretation of data and draft the manuscript. All authors read and approved the final manuscript.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

All data generated or analyzed during this study are included in this article and supplementary information files.*

Supplemental material

Supplemental material for this article is available online.

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