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__NOTOC__
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{{Colon cancer}}
{{Colon cancer}}
'''Editor(s)-in-Chief:''' [[C. Michael Gibson, M.S., M.D.]] [mailto:charlesmichaelgibson@gmail.com] Phone:617-632-7753; Elliot B. Tapper, M.D., Beth Israel Deaconess Medical Center
To view the primary prevention of familial adenomatous polyposis (FAP), click [[Familial adenomatous polyposis primary prevention|'''here''']]<br>
To view the primary prevention of hereditary nonpolyposis colorectal cancer (HNPCC), click [[Hereditary nonpolyposis colorectal cancer primary prevention|'''here''']]<br><br>
{{CMG}} {{AE}} Saarah T. Alkhairy, M.D., Elliot B. Tapper, M.D.
 


==Overview==
==Overview==
Most colorectal cancers should be preventable, through increased surveillance, improved lifestyle, and, probably, the use of dietary chemopreventative agents.
Most colorectal cancers should be preventable through surveillance, improved lifestyle and nutrition, and other techniques such as increased intake of vitamin B6 and aspirin.
 
==Colorectal Cancer Primary Prevention==


==Prevention techniques==
===Surveillance===
===Surveillance===
Most colorectal cancer arise from adenomatous polyps. These lesions can be detected and removed during [[colonoscopy]]. Studies show this procedure would decrease by > 80% the risk of cancer death, provided it is started by the age of 50, and repeated every 5 or 10 years.<ref>Winawer SJ, Zauber AG, Ho MN, O'Brien MJ, Gottlieb LS, Sternberg SS, Waye JD, Schapiro M, Bond JH, Panish JF, Ackroyd F, Shike M, Kurtz RC, Hornsby-Lewis L, Gerdes H, Stewart ET, The National Polyp Study Workgroup. ''Prevention of colorectal cancer by colonoscopic polypectomy.'' [[N Engl J Med]] 1993;329:1977-81. PMID 8247072.</ref>
The most common indicator of high risk is a first-degree relative with colorectal cancer<ref name="Lieberman2009">{{cite journal|last1=Lieberman|first1=David A.|title=Screening for Colorectal Cancer|journal=New England Journal of Medicine|volume=361|issue=12|year=2009|pages=1179–1187|issn=0028-4793|doi=10.1056/NEJMcp0902176}}</ref>.
*If the first-degree relative was diagnosed with CRC before 50 years of age
:*The individual should be suspected of a hereditary syndrome and referred to a specialist
:*The specialist will obtain a complete family history, consider genetic counseling and testing, and determine appropriate timing for endoscopic surveillance
*If a first-degree relative was diagnosed with CRC at 50 years of age or older
:*The lifetime risk of CRC nearly doubles among his or her family members
:*Colonoscopy is the preferred screening test for these individuals
:*Screening should be initiated either when they are 40 years old or when they are 10 years younger than the age at which the family member received the diagnosis, whichever comes first
* If the individual is diagnosed with chronic ulcerative colitis or colitis due to Crohn's disease
:*There is an increased risk for CRC and the individual should undergo surveillance with colonoscopy, generally beginning 8 to 10 years after the diagnosis


As per current guidelines under [[National Comprehensive Cancer Network]], in average risk individuals with negative family history of colon cancer and personal history negative for [[adenomas]] or [[Inflammatory Bowel diseases]], flexible sigmoidoscopy every 5 years with fecal occult blood testing annually or double contrast barium enema are other options acceptable for screening rather than colonoscopy every 10 years (which is currently the Gold-Standard of care).
===Lifestyle & Nutrition===
*A healthy body weight
*Active lifestyle<ref name="pmid19209175">{{cite journal| author=Wolin KY, Yan Y, Colditz GA, Lee IM| title=Physical activity and colon cancer prevention: a meta-analysis. | journal=Br J Cancer | year= 2009 | volume= 100 | issue= 4 | pages= 611-6 | pmid=19209175 | doi=10.1038/sj.bjc.6604917 | pmc=PMC2653744 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19209175  }} </ref>


===Lifestyle & Nutrition===
*A healthy diet - a high intake of dietary fiber from eating fruits, vegetables, cereals, and other high fiber food products) and a low intake of fat and red meat (from eating fruits, vegetables, cereals, and other high fiber food products)<ref name="pmid11287446">{{cite journal| author=Terry P, Giovannucci E, Michels KB, Bergkvist L, Hansen H, Holmberg L et al.| title=Fruit, vegetables, dietary fiber, and risk of colorectal cancer. | journal=J Natl Cancer Inst | year= 2001 | volume= 93 | issue= 7 | pages= 525-33 | pmid=11287446 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11287446  }} </ref>
The comparison of colorectal cancer incidence in various countries strongly suggests that sedentarity, overeating (i.e., high caloric intake), and perhaps a diet high in meat (red or processed) could increase the risk of colorectal cancer. In contrast, a healthy body weight, physical fitness, and good nutrition decreases cancer risk in general.  Accordingly, lifestyle changes could decrease the risk of colorectal cancer as much as 60-80%.<ref>{{cite journal|last=Cummings |first=JH |coauthors=Bingham SA |title=Diet and the prevention of cancer |journal=[[British Medical Journal|BMJ]] |year=1998|issue317|pages=1636-40 |url=http://bmj.bmjjournals.com/ |id=PMID 9848907}}</ref>
*Reduction of alcohol and cigarette smoking
 
===Other===
*Increased intake of vitamin B6 (pyridoxine) intake<ref name="pmid20233826">{{cite journal| author=Larsson SC, Orsini N, Wolk A| title=Vitamin B6 and risk of colorectal cancer: a meta-analysis of prospective studies. | journal=JAMA | year= 2010 | volume= 303 | issue= 11 | pages= 1077-83 | pmid=20233826 | doi=10.1001/jama.2010.263 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20233826  }} </ref>


A high intake of dietary fiber (from eating fruits, vegetables, cereals, and other high fiber food products) has, until recently, been thought to reduce the risk of colorectal cancer and adenoma. In the largest study ever to examine this theory (88,757 subjects tracked over 16 years), it has been found that a fiber rich diet does not reduce the risk of colon cancer. <ref>{{cite journal |title=Dietary Fiber and the Risk of Colorectal Cancer and Adenoma in Women |journal=New England Journal of Medicine |year=1999 |issue=340 |pages=169-76 |url=http://content.nejm.org/cgi/content/full/340/3/169}}</ref> A 2005 meta-analysis study further supports these findings.<ref>{{cite journal |title=Dietary Fiber and Colorectal Cancer: An Ongoing Saga |journal=Journal of the American Medical Association |year=2005 |issue=294(22) |pages=2904 - 2906 |url=http://jama.ama-assn.org/cgi/content/extract/294/22/2904 |id=PMID 16352792}}</ref>
*increased intake of dietary or supplemental calcium<ref name="pmid19237724">{{cite journal| author=Park Y, Leitzmann MF, Subar AF, Hollenbeck A, Schatzkin A| title=Dairy food, calcium, and risk of cancer in the NIH-AARP Diet and Health Study. | journal=Arch Intern Med | year= 2009 | volume= 169 | issue= 4 | pages= 391-401 | pmid=19237724 | doi=10.1001/archinternmed.2008.578 | pmc=PMC2796799 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19237724  }} </ref>


The Harvard School of Public Health states:
*Increased intake of Vitamin D and its metabolites<ref name="pmid21861107">{{cite journal| author=Byers SW, Rowlands T, Beildeck M, Bong YS| title=Mechanism of action of vitamin D and the vitamin D receptor in colorectal cancer prevention and treatment. | journal=Rev Endocr Metab Disord | year= 2012 | volume= 13 | issue= 1 | pages= 31-8 | pmid=21861107 | doi=10.1007/s11154-011-9196-y | pmc=PMC3262916 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21861107  }} </ref>
"Health Effects of Eating Fiber: Long heralded as part of a healthy diet, fiber appears to reduce the risk of developing various conditions, including heart disease, diabetes, diverticular disease, and constipation.  Despite what many people may think, however, fiber probably has little, if any effect on colon cancer risk." <ref>{{cite web|title=Health Effects of Eating Fiber |url=http://www.hsph.harvard.edu/nutritionsource/fiber.html}}</ref>


===Chemoprevention===
*Increased intake of dietary magnesium<ref name="pmid15632340">{{cite journal| author=Larsson SC, Bergkvist L, Wolk A| title=Magnesium intake in relation to risk of colorectal cancer in women. | journal=JAMA | year= 2005 | volume= 293 | issue= 1 | pages= 86-9 | pmid=15632340 | doi=10.1001/jama.293.1.86 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15632340  }} </ref>
More than 200 agents, including the above cited phytochemicals, and other food components like calcium or folic acid (a B vitamin), and [[NSAID]]s like aspirin, are able to decrease carcinogenesis in preclinical models: Some studies show full inhibition of carcinogen-induced tumours in the colon of rats. Other studies show strong inhibition of spontaneous intestinal polyps in mutated mice (Min mice). Chemoprevention clinical trials in human volunteers have shown smaller prevention, but few intervention studies have been completed today. Calcium, aspirin and celecoxib supplements, given for 3 to 5 years after the removal of a polyp, decreased the recurrence of polyps in volunteers (by 15-40%). The "chemoprevention database" shows the results of all published scientific studies of chemopreventive agents, in people and in animals.<ref>{{cite web |url=http://www.inra.fr/reseau-nacre/sci-memb/corpet/indexan.html |title=Colorectal Cancer Prevention: Chemoprevention Database |accessdate=2007-08-23 |format= |work=}}</ref>


====Aspirin chemoprophylaxis====
*Increased intake of omega 3 fatty acids<ref name="pmid22513196">{{cite journal| author=Wu S, Feng B, Li K, Zhu X, Liang S, Liu X et al.| title=Fish consumption and colorectal cancer risk in humans: a systematic review and meta-analysis. | journal=Am J Med | year= 2012 | volume= 125 | issue= 6 | pages= 551-9.e5 | pmid=22513196 | doi=10.1016/j.amjmed.2012.01.022 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22513196  }} </ref>
Aspirin should not be taken routinely to prevent colorectal cancer, even in people with a family history of the disease, because the risk of bleeding and kidney failure from high dose aspirin (300mg or more) outweigh the possible benefits.<ref>{{cite web |title=Task Force Recommends Against Use of Aspirin and Non-Steroidal Anti-Inflammatory Drugs to Prevent Colorectal Cancer |url=http://www.ahrq.gov/news/press/pr2007/aspnsaidpr.htm |author=Agency for Healthcare Research and Quality | accessdate=2007-05-07 |date=2007-03-05 |publisher=United States Department of Health &amp; Human Services }}</ref>


A [[clinical practice guideline]] by the [http://www.ahrq.gov/clinic/uspstfix.htm U.S. Preventive Services Task Force (USPSTF)] recommended against taking [[aspirin]] ([http://www.ahrq.gov/clinic/3rduspstf/ratings.htm grade D recommendation]).<ref name="pmid17339621">{{cite journal |author= |title=Routine aspirin or nonsteroidal anti-inflammatory drugs for the primary prevention of colorectal cancer: U.S. Preventive Services Task Force recommendation statement |journal=Ann. Intern. Med. |volume=146 |issue=5 |pages=361-4 |year=2007 |id=pmid=17339621 |doi=}} PMID 17339621</ref> The Task Force acknowledged that aspirin may reduce the incidence of colorectal cancer, but "concluded that harms outweigh the benefits of aspirin and NSAID use for the prevention of colorectal cancer".  A subsequent [[meta-analysis]] concluded "300 mg or more of aspirin a day for about 5 years is effective in primary prevention of colorectal cancer in randomised controlled trials, with a latency of about 10 years".<ref name="pmid17499602">{{cite journal |author=Flossmann E, Rothwell PM |title=Effect of aspirin on long-term risk of colorectal cancer: consistent evidence from randomised and observational studies |journal=Lancet |volume=369 |issue=9573 |pages=1603-13 |year=2007 |pmid=17499602 |doi=10.1016/S0140-6736(07)60747-8}} PMID 17499602</ref>  However, long-term doses over 81 mg per day may increase bleeding events.<ref name="pmid17488967">{{cite journal |author=Campbell CL, Smyth S, Montalescot G, Steinhubl SR |title=Aspirin dose for the prevention of cardiovascular disease: a systematic review |journal=JAMA |volume=297 |issue=18 |pages=2018-24 |year=2007 |pmid=17488967 |doi=10.1001/jama.297.18.2018}} PMID 17488967</ref>
*Aspirin and other nonsteroidal antiinflammatory drugs (NSAIDs)<ref name="pmid21144578">{{cite journal| author=Rothwell PM, Fowkes FG, Belch JF, Ogawa H, Warlow CP, Meade TW| title=Effect of daily aspirin on long-term risk of death due to cancer: analysis of individual patient data from randomised trials. | journal=Lancet | year= 2011 | volume= 377 | issue= 9759 | pages= 31-41 | pmid=21144578 | doi=10.1016/S0140-6736(10)62110-1 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21144578  }}  [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21403065 Review in: Ann Intern Med. 2011 Mar 15;154(6):JC3-2]  [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21555322 Review in: Evid Based Nurs. 2011 Jul;14(3):71] </ref>


====Calcium====
*Postmenopausal hormone therapy (both combined estrogen plus progestin and unopposed estrogen)- not recommended for chemoprevention of colon cancer in women because of the associated long-term risks of therapy<ref name="pmid21365647">{{cite journal| author=Lin KJ, Cheung WY, Lai JY, Giovannucci EL| title=The effect of estrogen vs. combined estrogen-progestogen therapy on the risk of colorectal cancer. | journal=Int J Cancer | year= 2012 | volume= 130 | issue= 2 | pages= 419-30 | pmid=21365647 | doi=10.1002/ijc.26026 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21365647  }} </ref>
A [[meta-analysis]] by the [[Cochrane Collaboration]] of [[randomized controlled trials]] published through 2002  concluded "Although the evidence from two RCTs suggests that calcium supplementation might contribute to a moderate degree to the prevention of colorectal adenomatous polyps, this does not constitute sufficient evidence to recommend the general use of calcium supplements to prevent colorectal cancer.".<ref name="pmid16034903">{{cite journal |author=Weingarten MA, Zalmanovici A, Yaphe J |title=Dietary calcium supplementation for preventing colorectal cancer and adenomatous polyps |journal=Cochrane database of systematic reviews (Online) |volume= |issue=3 |pages=CD003548 |year=2005 |pmid=16034903 |doi=10.1002/14651858.CD003548.pub3}}</ref> Subsequently, one [[randomized controlled trial]] by the [[Women's Health Initiative]] (WHI) reported negative results.<ref name="pmid16481636">{{cite journal |author=Wactawski-Wende J, Kotchen JM, Anderson GL, ''et al'' |title=Calcium plus vitamin D supplementation and the risk of colorectal cancer |journal=N. Engl. J. Med. |volume=354 |issue=7 |pages=684-96 |year=2006 |pmid=16481636 |doi=10.1056/NEJMoa055222}}</ref>  A second [[randomized controlled trial]] reported reduction in all cancers, but had insufficient colorectal cancers for analysis.<ref name="pmid17556697">{{cite journal |author=Lappe JM, Travers-Gustafson D, Davies KM, Recker RR, Heaney RP |title=Vitamin D and calcium supplementation reduces cancer risk: results of a randomized trial |journal=Am. J. Clin. Nutr. |volume=85 |issue=6 |pages=1586-91 |year=2007 |pmid=17556697 |doi=|url=http://www.ajcn.org/cgi/content/full/85/6/1586}}</ref>


==Vaccine==
In November 2006, it was announced that a [[vaccine]] had been developed and tested with very promising results.<ref>[http://www.dailymail.co.uk/pages/live/articles/news/news.html?in_article_id=416006&in_page_id=1770 Wheldon, Julie. Vaccine for kidney and bowel cancers 'within three years' ''The Daily Mail'' [[2006-11-13]]]]</ref>  The new vaccine, called [[TroVax]], works in a totally different way to existing treatments by harnessing the patient's own immune system to fight the disease. Experts say this suggests that [[gene therapy]] vaccines could prove an effective treatment for a whole range of cancers.  [http://www.oxfordbiomedica.co.uk/ Oxford BioMedica] is a British spin-out from Oxford University specializing in the development of gene-based treatments.  Phase III trials are underway for renal cancers and planned for colon cancers.<ref>[http://www.medscape.com/viewarticle/561321?src=mp Vaccine Works With Chemotherapy in Colorectal Cancer (Reuters) [[2007-08-13]]]</ref>


==References==
==References==

Revision as of 15:13, 15 July 2015

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To view the primary prevention of familial adenomatous polyposis (FAP), click here
To view the primary prevention of hereditary nonpolyposis colorectal cancer (HNPCC), click here

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Saarah T. Alkhairy, M.D., Elliot B. Tapper, M.D.


Overview

Most colorectal cancers should be preventable through surveillance, improved lifestyle and nutrition, and other techniques such as increased intake of vitamin B6 and aspirin.

Colorectal Cancer Primary Prevention

Surveillance

The most common indicator of high risk is a first-degree relative with colorectal cancer[1].

  • If the first-degree relative was diagnosed with CRC before 50 years of age
  • The individual should be suspected of a hereditary syndrome and referred to a specialist
  • The specialist will obtain a complete family history, consider genetic counseling and testing, and determine appropriate timing for endoscopic surveillance
  • If a first-degree relative was diagnosed with CRC at 50 years of age or older
  • The lifetime risk of CRC nearly doubles among his or her family members
  • Colonoscopy is the preferred screening test for these individuals
  • Screening should be initiated either when they are 40 years old or when they are 10 years younger than the age at which the family member received the diagnosis, whichever comes first
  • If the individual is diagnosed with chronic ulcerative colitis or colitis due to Crohn's disease
  • There is an increased risk for CRC and the individual should undergo surveillance with colonoscopy, generally beginning 8 to 10 years after the diagnosis

Lifestyle & Nutrition

  • A healthy body weight
  • Active lifestyle[2]
  • A healthy diet - a high intake of dietary fiber from eating fruits, vegetables, cereals, and other high fiber food products) and a low intake of fat and red meat (from eating fruits, vegetables, cereals, and other high fiber food products)[3]
  • Reduction of alcohol and cigarette smoking

Other

  • Increased intake of vitamin B6 (pyridoxine) intake[4]
  • increased intake of dietary or supplemental calcium[5]
  • Increased intake of Vitamin D and its metabolites[6]
  • Increased intake of dietary magnesium[7]
  • Increased intake of omega 3 fatty acids[8]
  • Aspirin and other nonsteroidal antiinflammatory drugs (NSAIDs)[9]
  • Postmenopausal hormone therapy (both combined estrogen plus progestin and unopposed estrogen)- not recommended for chemoprevention of colon cancer in women because of the associated long-term risks of therapy[10]


References

  1. ↑ Lieberman, David A. (2009). "Screening for Colorectal Cancer". New England Journal of Medicine. 361 (12): 1179–1187. doi:10.1056/NEJMcp0902176. ISSN 0028-4793.
  2. ↑ Wolin KY, Yan Y, Colditz GA, Lee IM (2009). "Physical activity and colon cancer prevention: a meta-analysis". Br J Cancer. 100 (4): 611–6. doi:10.1038/sj.bjc.6604917. PMC 2653744. PMID 19209175.
  3. ↑ Terry P, Giovannucci E, Michels KB, Bergkvist L, Hansen H, Holmberg L; et al. (2001). "Fruit, vegetables, dietary fiber, and risk of colorectal cancer". J Natl Cancer Inst. 93 (7): 525–33. PMID 11287446.
  4. ↑ Larsson SC, Orsini N, Wolk A (2010). "Vitamin B6 and risk of colorectal cancer: a meta-analysis of prospective studies". JAMA. 303 (11): 1077–83. doi:10.1001/jama.2010.263. PMID 20233826.
  5. ↑ Park Y, Leitzmann MF, Subar AF, Hollenbeck A, Schatzkin A (2009). "Dairy food, calcium, and risk of cancer in the NIH-AARP Diet and Health Study". Arch Intern Med. 169 (4): 391–401. doi:10.1001/archinternmed.2008.578. PMC 2796799. PMID 19237724.
  6. ↑ Byers SW, Rowlands T, Beildeck M, Bong YS (2012). "Mechanism of action of vitamin D and the vitamin D receptor in colorectal cancer prevention and treatment". Rev Endocr Metab Disord. 13 (1): 31–8. doi:10.1007/s11154-011-9196-y. PMC 3262916. PMID 21861107.
  7. ↑ Larsson SC, Bergkvist L, Wolk A (2005). "Magnesium intake in relation to risk of colorectal cancer in women". JAMA. 293 (1): 86–9. doi:10.1001/jama.293.1.86. PMID 15632340.
  8. ↑ Wu S, Feng B, Li K, Zhu X, Liang S, Liu X; et al. (2012). "Fish consumption and colorectal cancer risk in humans: a systematic review and meta-analysis". Am J Med. 125 (6): 551–9.e5. doi:10.1016/j.amjmed.2012.01.022. PMID 22513196.
  9. ↑ Rothwell PM, Fowkes FG, Belch JF, Ogawa H, Warlow CP, Meade TW (2011). "Effect of daily aspirin on long-term risk of death due to cancer: analysis of individual patient data from randomised trials". Lancet. 377 (9759): 31–41. doi:10.1016/S0140-6736(10)62110-1. PMID 21144578. Review in: Ann Intern Med. 2011 Mar 15;154(6):JC3-2 Review in: Evid Based Nurs. 2011 Jul;14(3):71
  10. ↑ Lin KJ, Cheung WY, Lai JY, Giovannucci EL (2012). "The effect of estrogen vs. combined estrogen-progestogen therapy on the risk of colorectal cancer". Int J Cancer. 130 (2): 419–30. doi:10.1002/ijc.26026. PMID 21365647.


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