Calcium supplements for the prevention of colorectal adenomas. Calcium Polyp Prevention Study Group

Evaluation of fecal mutagenicity and colorectal cancer risk

Colorectal cancer is one of the most common internal malignancies in Western society. The cause of this disease appears to be multifactorial and involves genetic as well as environmental aspects. The human colon is continuously exposed to a complex mixture of compounds, which is either of direct dietary origin or the result of digestive, microbial and excretory processes. In order to establish the mutagenic burden of the colorectal mucosa, analysis of specific compounds in feces is usually preferred. Alternatively, the mutagenic potency of fecal extracts has been determined, but the interpretation of these more integrative measurements is hampered by methodological shortcomings. In this review, we focus on exposure of the large bowel to five different classes of fecal mutagens that have previously been related to colorectal cancer risk. These include heterocyclic aromatic amines (HCA) and polycyclic aromatic hydrocarbons (PAH), two exogenous factors that are predominantly ingested as pyrolysis products present in food and (partially) excreted in the feces. Additionally, we discuss N-nitroso-compounds, fecapentaenes and bile acids, all fecal constituents (mainly) of endogenous origin. The mutagenic and carcinogenic potency of the above mentioned compounds as well as their presence in feces, proposed mode of action and potential role in the initiation and promotion of human colorectal cancer are discussed. The combined results from in vitro and in vivo research unequivocally demonstrate that these classes of compounds comprise potent mutagens that induce many different forms of genetic damage and that particularly bile acids and fecapentaenes may also affect the carcinogenic process by epigenetic mechanisms. Large inter-individual differences in levels of exposures have been reported, including those in a range where considerable genetic damage can be expected based on evidence from animal studies. Particularly, however, exposure profiles of PAH and N-nitroso compounds (NOC) have to be more accurately established to come to a risk evaluation. Moreover, lack of human studies and inconsistency between epidemiological data make it impossible to describe colorectal cancer risk as a result of specific exposures in quantitative terms, or even to indicate the relative importance of the mutagens discussed. Particularly, the polymorphisms of genes involved in the metabolism of heterocyclic amines are important determinants of carcinogenic risk. However, the present knowledge of gene-environment interactions with regard to colorectal cancer risk is rather limited. We expect that the introduction of DNA chip technology in colorectal cancer epidemiology will offer new opportunities to identify combinations of exposures and genetic polymorphisms that relate to increased cancer risk. This knowledge will enable us to improve epidemiological study design and statistical power in future research.

Dietary factors and cancer risk

OBJECTIVES

To discuss the relationship between dietary factors and cancer risk reduction, the status of prevention trials in progress, and current dietary recommendations.

DATA SOURCES

Published research and review articles, medical books, and web sites.

CONCLUSIONS

Evidence indicates that dietary factors can reduce the risk of developing cancer. The dietary recommendations for cancer risk reduction are consistent with those for prevention of other chronic diseases and are thus useful for the majority of the population.

IMPLICATIONS FOR NURSING PRACTICE

In their role as educators, it is essential for nurses to provide accurate and timely information on diet and cancer risk reduction to their patients and the public and to encourage compliance with dietary recommendations.

Diet and prevention of colorectal cancer

There is a 20-fold difference in incidence rates of colorectal cancer between the areas of highest incidence (North America and Australia) and lowest incidence (India). Animal studies, epidemiologic research, and clinical trials continue to focus on diet in the search for responsible environmental factors. Between 1997 and 1999, a number of research areas have had considerable activity, and they provide the focus for this review. Among foods, vegetables, cereals, and soy have been topics of recent research. Nutrients from foods and supplements have also gained attention, including n-3 fatty acids, calcium, and B vitamins. Gene-environment interactions are beginning to be studied in populations. Studies of the interaction between polymorphisms in the gene for methylenetetrahydrofolate reductase (MTHFR) and dietary components for risk of both colorectal cancer and adenomatous polyps provide a glimpse into the future of diet and cancer research.

Bioavailability of the calcium in fortified soy imitation milk, with some observations on method

BACKGROUND

Calcium-fortified soy milk is growing in popularity, particularly among vegetarians, but the bioavailability of its calcium was not previously known. Additionally, the validity of isotopic labeling methods for fortified liquid products had not been established.

OBJECTIVES

The objectives of this study were to compare the bioavailability of the calcium in fortified soy milk with that of calcium in cow milk and to evaluate the method of labeling soy milk for bioavailability testing.

DESIGN

A within-subject comparison of extrinsically labeled cow milk with intrinsically and extrinsically labeled soy milks was undertaken in 16 healthy men. In all tests, 300-mg Ca loads were given as a part of a light breakfast after an overnight fast. The milks were physically partitioned into liquid and solid phases to enable evaluation of tracer distribution.

RESULTS

Calcium from intrinsically labeled soy milk was absorbed at only 75% the efficiency of calcium from cow milk. Extrinsic labeling of soy milk did not produce uniform tracer distribution throughout the liquid and solid phases and resulted in a 50% overestimate of true absorbability.

CONCLUSION

Calcium-fortified soy milk does not constitute a calcium source comparable to cow milk, and extrinsic labeling of such calcium particulate suspensions does not produce the uniform tracer distribution needed for bioavailability testing. Hence, intrinsic labeling of the fortificant is required for such liquid suspensions.

The impact of colorectal cancer screening on life expectancy

METHODS

The purpose of this study was to assess the effect of screening for colorectal cancer on life expectancy and estimate the number of colonoscopies needed per life year saved. The declining exponential approximation of life expectancy was used to calculate the effect of colorectal cancer screening on expected remaining lifetime. The annual number of deaths from colorectal cancer and the size of the population were obtained from the vital statistics of the United States. Published reports were consulted to determine the decrease in mortality from colorectal cancer achieved by fecal occult blood testing, screening sigmoidoscopy or colonoscopy. A Markov chain analysis was used to determine the endoscopic resources required to screen and survey the entire population of U.S. residents age 50 years until death or age 85 years.

RESULTS

Colorectal cancer decreases the life expectancy of U.S. residents aged 50 to 54 years by 292 days and those aged 70 to 74 years by 70 days. Screening with fecal occult blood tests extends expected lifetime of the 2 age groups by 51 and 12 days, respectively, whereas screening with sigmoidoscopy leads to increases of 86 and 21 days. Colonoscopic screening increases expected lifetime by 170 and 41 days, respectively. The number of colonoscopies needed to save 1 year of expected life ranges from 2.9 to 6.0, depending on the type of screening regimen used.

CONCLUSIONS

The extension of life through screening colonoscopy is two or three times longer than the extension achieved through flexible sigmoidoscopy or fecal occult blood test, respectively. Although a large number of colonoscopies are required to screen the U.S. population, relatively few colonoscopies need to be invested per year of life expectancy saved.

Lack of effect of a low-fat, high-fiber diet on the recurrence of colorectal adenomas. Polyp Prevention Trial Study Group

BACKGROUND

We tested the hypothesis that dietary intervention can inhibit the development of recurrent colorectal adenomas, which are precursors of most large-bowel cancers.

METHODS

We randomly assigned 2079 men and women who were 35 years of age or older and who had had one or more histologically confirmed colorectal adenomas removed within six months before randomization to one of two groups: an intervention group given intensive counseling and assigned to follow a diet that was low in fat (20 percent of total calories) and high in fiber (18 g of dietary fiber per 1000 kcal) and fruits and vegetables (3.5 servings per 1000 kcal), and a control group given a standard brochure on healthy eating and assigned to follow their usual diet. Subjects entered the study after undergoing complete colonoscopy and removal of adenomatous polyps; they remained in the study for approximately four years, undergoing colonoscopy one and four years after randomization.

RESULTS

A total of 1905 of the randomized subjects (91.6 percent) completed the study. Of the 958 subjects in the intervention group and the 947 in the control group who completed the study, 39.7 percent and 39.5 percent, respectively, had at least one recurrent adenoma; the unadjusted risk ratio was 1.00 (95 percent confidence interval, 0.90 to 1.12). Among subjects with recurrent adenomas, the mean (+/-SE) number of such lesions was 1.85+/-0.08 in the intervention group and 1.84+/-0.07 in the control group. The rate of recurrence of large adenomas (with a maximal diameter of at least 1 cm) and advanced adenomas (defined as lesions that had a maximal diameter of at least 1 cm or at least 25 percent villous elements or evidence of high-grade dysplasia, including carcinoma) did not differ significantly between the two groups.

CONCLUSIONS

Adopting a diet that is low in fat and high in fiber, fruits, and vegetables does not influence the risk of recurrence of colorectal adenomas.

Lack of effect of a high-fiber cereal supplement on the recurrence of colorectal adenomas. Phoenix Colon Cancer Prevention Physicians' Network

BACKGROUND

The risks of colorectal cancer and adenoma, the precursor lesion, are believed to be influenced by dietary factors. Epidemiologic evidence that cereal fiber protects against colorectal cancer is equivocal. We conducted a randomized trial to determine whether dietary supplementation with wheat-bran fiber reduces the rate of recurrence of colorectal adenomas.

METHODS

We randomly assigned 1429 men and women who were 40 to 80 years of age and who had had one or more histologically confirmed colorectal adenomas removed within three months before recruitment began to a supervised program of dietary supplementation with either high amounts (13.5 g per day) or low amounts (2 g per day) of wheat-bran fiber. The primary end point was the presence or absence of new adenomas at the time of follow-up colonoscopy. Subjects and physicians, including colonoscopists, were unaware of the group assignments.

RESULTS

Of the 1303 subjects who completed the study, 719 had been randomly assigned to the high-fiber group and 584 to the low-fiber group. The median times from randomization to the last follow-up colonoscopy were 34 months in the high-fiber group and 36 months in the low-fiber group. By the time of the last follow-up colonoscopy, at least one adenoma had been identified in 338 subjects in the high-fiber group (47.0 percent) and in 299 subjects in the low-fiber group (51.2 percent). The multivariate adjusted odds ratio for recurrent adenoma in tile high-fiber group, as compared with the low-fiber group, was 0.88 (95 percent confidence interval, 0.70 to 1.11; P=0.28), and the relative risk of recurrence according to the number of adenomas, in the high-fiber group as compared with the low-fiber group, was 0.99 (95 percent confidence interval, 0.71 to 1.36; P=0.93).

CONCLUSIONS

As used in this study, a dietary supplement of wheat-bran fiber does not protect against recurrent colorectal adenomas.

Recent advances in cancer chemoprevention, with emphasis on breast and colorectal cancer

Chemoprevention is a recently introduced and rapidly growing area of oncology that is identifying agents with a potentially preventive role in cancer. Several clinical trials have recently shown the feasibility of this approach in reducing the risk of major human cancers. In the USA, a large trial that demonstrated a reduction of approximately 50% in the risk of developing breast cancer led to Food and Drug Administration (FDA) approval of tamoxifen as a preventive agent in women at increased risk. Although the results could not be reproduced in two smaller European trials, further investigations into this agent are clearly warranted. Raloxifene, another selective oestrogen receptor modulator which has reduced the risk of breast cancer in a trial in women with osteoporosis, is being compared with tamoxifen in a large primary prevention trial in at-risk women. Retinoids are a group of compounds that have proved especially effective in reducing the occurrence of second primary tumours in subjects with skin, head and neck or liver cancer. Fenretinide, a synthetic retinoic acid derivative, has recently been shown to decrease the occurrence of a second breast malignancy in premenopausal women. Results with non-steroidal anti-inflammatory drugs (NSAIDs) have proved consistently encouraging in epidemiological studies in lowering the incidence of colorectal cancer. Clinical trials with selective cyclo-oxygenase inhibitors potentially devoid of gastrointestinal (GI) toxicity are currently underway in at-risk subjects. Calcium and selenium have also received much attention as chemopreventive agents. Originally investigated against skin cancer, selenium showed efficacy in reducing prostate, lung and colon cancer incidence. Similarly, vitamin E was effective in reducing prostate cancer incidence and mortality in a lung cancer prevention trial in heavy smokers. The challenges of conducting well-designed and unequivocal chemoprevention trials are considerable, but advances in techniques of identification of at-risk subjects and establishing surrogate endpoint biomarkers should contribute greatly to future studies. Current knowledge suggests that a pharmacological approach to preventing cancer, using natural or synthetic agents, could become an important way forward.

Dietary calcium supplementation increases apoptosis in the distal murine colonic epithelium

BACKGROUND

Increased dietary calcium might reduce colorectal cancer risk, possibly by reduction of colonic epithelial hyperproliferation, but not all studies have demonstrated this. Little is known about the effects of calcium on colonic apoptosis.

AIM

To quantify the effects of increasing calcium on apoptosis and cell proliferation in normal murine colonic crypt epithelium.

METHODS

Twenty one day old male C57B1/6 mice were fed either control AIN-76 diet (0.5% calcium wt/wt; n = 10) or the same supplemented with calcium carbonate (1.0% calcium; n = 10) for 12 weeks. Apoptotic cells in proximal and distal segments were counted and expressed as an apoptotic index (AI: frequency of apoptosis/100 longitudinal crypts). The bromodeoxyuridine (BrdU) labelling index was also determined. Differences were analysed by the student's t test.

RESULTS

In control animals, the AI was significantly higher in the caecum/proximal colon (mean, 28.6; SEM, 2.0) compared with the distal colon (mean, 19.9; SEM, 1.8; p = 0.004). In the calcium treated group, the AI in the caecum/proximal colon (mean, 30.6; SEM, 1.7) was similar to controls (p = 0.71) but the AI in the distal colon was significantly greater (mean, 32.6; SEM, 1.8; p = 0.001) than in control mice and was raised to values similar to those in the proximal colon. Calcium was also associated with reduced crypt cellularity and, in the proximal colon, a downward shift in the crypt position at which apoptosis occurred. There were no significant differences in the BrdU labelling index between groups or between proximal and distal colonic segments in each group.

CONCLUSIONS

Increased dietary calcium is associated with the induction of apoptosis in normal mouse distal colonic epithelium without affecting cell proliferation. This might contribute to its putative chemopreventive role in colorectal carcinogenesis. Whether this effect is direct or indirect requires further study.

Preclinical and early human studies of calcium and colon cancer prevention

Colorectal cancer continues to be a major cause of tumor mortality in the United States and other countries; despite attempts to improve the screening of high-risk populations, the incidence of this disease is still very high. Therefore, chemoprevention continues to be an important goal for the primary prevention of colorectal cancer. Among recent chemopreventive approaches, the administration of calcium and vitamin D continue to be evaluated in both preclinical and clinical studies. Many experimental findings described below have indicated associations between high calcium and vitamin D intake and decreased risk for colorectal cancer.

Progress in cancer chemoprevention

More than 40 promising agents and agent combinations are being evaluated clinically as chemopreventive drugs for major cancer targets. A few have been in vanguard, large-scale intervention trials--for example, the studies of tamoxifen and fenretinide in breast, 13-cis-retinoic acid in head and neck, vitamin E and selenium in prostate, and calcium in colon. These and other agents are currently in phase II chemoprevention trials to establish the scope of their chemopreventive efficacy and to develop intermediate biomarkers as surrogate end points for cancer incidence in future studies. In this group are fenretinide, 2-difluoromethylornithine, and oltipraz. Nonsteroidal anti-inflammatories (NSAID) are also in this group because of their colon cancer chemopreventive effects in clinical intervention, epidemiological, and animal studies. New agents are continually considered for development as chemopreventive drugs. Preventive strategies with antiandrogens are evolving for prostate cancer. Anti-inflammatories that selectively inhibit inducible cyclooxygenase (COX)-2 are being investigated in colon as alternatives to the NSAID, which inhibit both COX-1 and COX-2 and derive their toxicity from COX-1 inhibition. Newer retinoids with reduced toxicity, increased efficacy, or both (e.g., 9-cis-retinoic acid) are being investigated. Promising chemopreventive drugs are also being developed from dietary substances (e.g., green and black tea polyphenols, soy isoflavones, curcumin, phenethyl isothiocyanate, sulforaphane, lycopene, indole-3-carbinol, perillyl alcohol). Basic and translational research necessary to progress in chemopreventive agent development includes, for example, (1) molecular and genomic biomarkers that can be used for risk assessment and as surrogate end points in clinical studies, (2) animal carcinogenesis models that mimic human disease (including transgenic and gene knockout mice), and (3) novel agent treatment regimens (e.g., local delivery to cancer targets, agent combinations, and pharmacodynamically guided dosing).

Chemoprevention: general perspective

Chemoprevention is the use of natural or synthetic compounds to block, reverse, or prevent the development of invasive cancers. Cellular carcinogenesis forms the biologic basis for the identification of chemopreventives, assessment of their activity, and ultimately the success or failure of a chemopreventive. Chemopreventive agents undergo multistep evaluations to assess efficacy that are similar in concept but vastly different in practice to standard ablative oncologic therapeutics. In vitro assessments of potential anticarcinogenesis efficacy include measurements of an agent's antioxidant activity, induction of phase II metabolizing enzymes and effects upon cellular proliferation and apoptotic control pathways. In vivo efficacy is assessed primarily in rodent models of carcinogenesis that are specific for a given organ target. The role of genetically modified animal models in the in vivo assessment of chemoprevention agents remains unclear. Clinical assessment of chemopreventive agent efficacy consists of a multistep process of identification of an optimal chemopreventive agent (phase 1), demonstration of efficacy in humans through the modulation of reversal of a tissue, biochemical, and molecular surrogates for neoplastic transformation and invasion (phase 2) and cancer risk reduction in large cohort trials (phase 3). Opportunities and future needs include the development of reliable, predictive in vivo models of carcinogenesis, careful exploration of the preventive pharmacology of therapeutic agents being used for non-cancer prevention indications, and the incorporation of genetic risk cohorts to define cancer chemopreventive efficacy.

Cancer screening in the elderly population

This article reviews the current state of knowledge regarding cancer screening in the geriatric population. Care of the elderly requires knowledge of underlying physiologic changes, comorbidities, quality-of-life factors, and life expectancies. There is always the danger that ageism may prevent elderly cancer patients from receiving the proper treatment. On the other hand, overzealous treatment can lead to adverse results if elderly patients are not properly targeted based on current evidence of the benefits and risks of specific screening practices.

Progress in cancer chemoprevention: development of diet-derived chemopreventive agents

Because of their safety and the fact that they are not perceived as "medicine," food-derived products are highly interesting for development as chemopreventive agents that may find widespread, long-term use in populations at normal risk. Numerous diet-derived agents are included among the >40 promising agents and agent combinations that are being evaluated clinically as chemopreventive agents for major cancer targets including breast, prostate, colon and lung. Examples include green and black tea polyphenols, soy isoflavones, Bowman-Birk soy protease inhibitor, curcumin, phenethyl isothiocyanate, sulforaphane, lycopene, indole-3-carbinol, perillyl alcohol, vitamin D, vitamin E, selenium and calcium. Many food-derived agents are extracts, containing multiple compounds or classes of compounds. For developing such agents, the National Cancer Institute (NCI) has advocated codevelopment of a single or a few putative active compounds that are contained in the food-derived agent. The active compounds provide mechanistic and pharmacologic data that may be used to characterize the chemopreventive potential of the extract, and these compounds may find use as chemopreventives in higher risk subjects (patients with precancers or previous cancers). Other critical aspects to developing the food-derived products are careful analysis and definition of the extract to ensure reproducibility (e.g., growth conditions, chromatographic characteristics or composition), and basic science studies to confirm epidemiologic findings associating the food product with cancer prevention.

Individually randomized intervention trials for disease prevention and control

It is argued that randomized, controlled trials should fulfil a critical role in the identification of practical approaches to the prevention and control of chronic diseases. Because of the great public health potential of chemopreventive and behavioural approaches to chronic disease prevention there is need for a major interdisciplinary scientific effort aimed at intervention development. Because of the cost and duration of controlled trials to evaluate specific interventions there is a need for well-conducted feasibility, pilot and intermediate outcome trials, to inform and to justify corresponding full-scale trials having clinical disease outcomes. Compared to therapeutic trials, prevention trials need to have a greater emphasis on overall benefit versus risk assessment. Such trials need to be large enough, and of sufficient duration, to yield powerful tests of key hypotheses, and informative benefit versus risk summary statements. These requirements have a range of implications for intervention trial design, conduct, monitoring and reporting, which are reviewed and discussed. The clinical trial component of the ongoing Women's Health Initiative provides illustration throughout this discussion.

Colorectal hyperplastic polyps and risk of recurrence of adenomas and hyperplastic polyps. Polyps Prevention Study

We examined data from two large colorectal chemoprevention trials for possible associations of hyperplastic polyps and adenomas with subsequent development of these lesions. Hyperplastic polyps do not predict metachronous adenomas.

Nutrition in cancer prevention

Although variation in diet may account for approximately one third of the variation in cancer incidence worldwide, epidemiologic studies have proven to be a blunt instrument for identifying causal relationships between intakes of specific food constituents and cancer risk at specific sites. Diets rich in fruits and vegetables seem to be protective, but the adverse effects of beta carotene supplementation trials on lung cancer incidence in smokers caution against the attribution of benefit to single substances. Important diet-gene interactions may exist, as illustrated by differential responses to variation in folate status in those with methylenetetrahydrofolate reductase polymorphisms. Targeting initial intervention studies in those with explicit genetic predisposition to cancer may have both greater cost-effectiveness and fewer ethical difficulties than do similar studies in the general public.

Chemoprevention of epithelial cancers

Over the past 2 years, new insights into mutator and stromal epithelial cell interactions have enhanced the understanding of the carcinogenesis process and have identified potential new approaches to chemoprevention in diverse epithelial sites. Data testing the efficacy of chemopreventive agents in genetically mutated animal carcinogenesis models as screening tools for chemopreventive agents remain immature and point to a continued need for chemical carcinogenesis models to screen for the potential efficacy of chemopreventive agents. The Breast Cancer Prevention Trial is a published, risk-reduction trial that demonstrated a tamoxifen-induced reduction of the risk for breast cancer and focused attention on the clinical use of chemopreventive agents in healthy women. This trial highlighted the potential chemopreventive activity of selective estrogen-receptor antagonists as chemopreventives for breast cancer. New data from animal and human models continue to support the development of nonsteroidal anti-inflammatory agents as chemopreventives for colorectal cancer. Micronutrient- and diet-intervention trials for colorectal chemoprevention present a mixed picture. Although calcium and vitamin supplements, including folate, reduce the recurrence of adenomatous polyps in humans, the effect is small. Fiber supplementation does not reduce the incidence of polyps or colorectal cancer. New approaches for the chemoprevention of esophageal adenocarcinomas, hepatomas, and squamous cell skin cancers represent promising new approaches to the chemoprevention of epithelial cancers.

Dietary factors in human colorectal cancer

Colorectal cancer is a significant cause of mortality in Western societies. The progression of the disease from normal colonic epithelium to the acquisition of the malignant phenotype is accompanied by numerous genetic and epigenetic alterations. Compelling experimental and epidemiological evidence indicates that diet and nutrition are key factors in the modulation of colorectal cancer. A salient case in point is the recent observation that a dietary regimen based on a Western-style diet provokes in the rodent colon the appearance of preneoplastic lesions in the absence of any genotoxic insult. This review mainly describes dietary factors that inhibit the development and progression of colorectal cancer. Much is unknown about the precise mechanisms of action of chemically disparate nutrients and how they interfere with the development and progression of this disease. Current knowledge about this important issue is summarized. We believe that continuing scrutiny and precise assessment of the benefits (and potential risks) of nutrients in the treatment and prevention of colorectal cancer will prove significant to controlling this devastating disease.

Nutritional strategies in the prevention of colorectal cancer

A variety of dietary factors have been implicated as agents that can modulate the development of malignancies of the gastrointestinal tract, particularly colorectal cancer. The effects of fat, red meat, fruits, vegetables, and alcohol on colorectal carcinogenesis have been examined extensively and appear to play substantial roles. Although fiber may play a protective role, recent studies raise the question of whether the protection is conveyed by other components in fiber-laden foods. Folate, selenium, calcium, and omega-3 fatty acids have emerged as factors more recently but may be equally important agents in nutritional chemoprevention, whereas the role of antioxidant vitamins is less certain. Until more firm data are available, the dietary recommendations provided by the American Cancer Society and the National Cancer Institute are appropriate for use in counseling patients on this issue.

Colorectal cancer: molecules and populations

The epidemiology and molecular biology of colorectal cancer are reviewed with a view to understanding their interrelationship. Risk factors for colorectal neoplasia include a positive family history, meat consumption, smoking, and alcohol consumption. Important inverse associations exist with vegetables, nonsteroidal anti-inflammatory drugs (NSAIDs), hormone replacement therapy, and physical activity. There are several molecular pathways to colorectal cancer, especially the APC (adenomatous polyposis coli)-beta-catenin-Tcf (T-cell factor; a transcriptional activator) pathway and the pathway involving abnormalities of DNA mismatch repair. These are important, both in inherited syndromes (familial adenomatous polyposis [FAP] and hereditary nonpolyposis colorectal cancer [HNPCC], respectively) and in sporadic cancers. Other less well defined pathways exist. Expression of key genes in any of these pathways may be lost by inherited or acquired mutation or by hypermethylation. The roles of several of the environmental exposures in the molecular pathways either are established (e.g., inhibition of cyclooxygenase-2 by NSAIDs) or are suggested (e.g., meat and tobacco smoke as sources of specific blood-borne carcinogens; vegetables as a source of folate, antioxidants, and inducers of detoxifying enzymes). The roles of other factors (e.g., physical activity) remain obscure even when the epidemiology is quite consistent. There is also evidence that some metabolic pathways, e.g., those involving folate and heterocyclic amines, may be modified by polymorphisms in relevant genes, e.g., MTHFR (methylenetetrahydrofolate reductase) and NAT1 (N-acetyltransferase 1) and NAT2. There is at least some evidence that the general host metabolic state can provide a milieu that enhances or reduces the likelihood of cancer progression. Understanding the roles of environmental exposures and host susceptibilities in molecular pathways has implications for screening, treatment, surveillance, and prevention.

Calcium and the colon: recent findings

Results of recent intervention trials suggest that calcium from low-fat dairy foods modulates the rate of human colon cell proliferation and that calcium supplementation reduces the rate of colonic adenomatous polyps. Further research from longer-term studies is necessary to confirm these findings.

Prevention of Colorectal Cancer

Colorectal cancer is a preventable disease. We currently have the means to substantially decrease the incidence and mortality from this disease; we simply need to implement primary and secondary prevention measures. I encourage patients to eat a diet low in meat and high in vegetables, fruit, and fiber. I also encourage patients to avoid obesity and engage in a regular exercise program. I routinely screen persons at average risk using fecal occult blood tests or flexible sigmoidoscopy after the age of 50 years. Those at higher risk by virtue of family history, a personal history of ulcerative colitis, or previous adenoma should have colonoscopy performed using a schedule tailored to their risk profile.