Calcium, vitamin D, and dairy foods and the occurrence of colon cancer in men

Food groups and colon cancer risk in African-Americans and Caucasians

The disparities in colon cancer incidence between African-Americans and other U.S. ethnic groups are largely unexplained. This report examines associations of various food groups with colon cancer in African-Americans and Caucasians from a case-control study. Incident cases of histologically confirmed colon cancer, age 40-80 years, (n = 613) and matched controls (n = 996) were interviewed in-person to ascertain potential colon cancer risk factors. Diet over the year before diagnosis or interview date was assessed using a validated food frequency questionnaire adapted to include regional foods. Multivariate logistic regression models estimated energy-adjusted and non-energy adjusted odds ratios (OR). Controls generally reported higher consumption (daily amount and weekly frequency) of fruits, vegetables and dark green, deep yellow fruits/vegetables, whereas cases consumed more refined carbohydrates and fats, oils and snacks. Regardless of ethnic group or energy adjustment, high and frequent vegetable consumption (particularly dark green vegetables) was protective, consistent with 20-50% reductions in risk. In Caucasians, high refined carbohydrate and red meat consumption (amount and frequency) was associated with a statistically significant 2-fold increased risk in non-energy adjusted models. In African-Americans, frequent intake of dairy foods was associated with a doubling in risk (OR = 1.9, 95% CI = 1.1-3.4) in non-energy-adjusted models, whereas frequent fruit consumption correlated with a non-significant 30% lower risk. These findings add to growing evidence that plant foods may protect against colon cancer; however, the effects of the other food groups varied by ethnic group and energy adjustment. These results may also explain some of the ethnic differences in colon cancer incidence.

'Economy' line foods from four supermarkets and brand name equivalents: a comparison of their nutrient contents and costs

BACKGROUND

Achieving healthy eating targets for low income households can be difficult because of economic barriers. Several UK supermarkets have introduced 'value line' or 'economy line' foods to improve their attractiveness to low income consumers.

MATERIALS AND METHODS

The costs and nutrient contents of five 'economy' line products of four major English supermarkets - Asda, KwikSave, Sainsbury and Tesco - were compared with branded (but not 'own label') equivalents. Single samples of tinned tomatoes, long-life orange juice, potatoes, sausages and white bread were purchased in each supermarket. They represented items of potential importance in relation to 'healthy' choices in the shopping baskets of low income households. Nutrients analysed were fat, sodium, potassium, iron, calcium, vitamin C, and energy.

RESULTS

Economy line foods had a nutrient composition similar to and often better than the branded goods. The economy line products frequently had nutrient contents more in line with the Balance of Good Health (e.g. lower fat and sodium) compared with the branded goods. In terms of nutrients per pence, the economy line products were far better value for money compared with the branded lines.

CONCLUSION

Economy line foods represent excellent value for money and are not nutritionally inferior to the branded products. They have a potentially important role to play in the promotion of healthy eating, especially amongst low income households.

Reviews: A Critical Review of Studies on Vitamin D in Relation to Colorectal Cancer

Vitamin D intake has been hypothesized to reduce the risk of several types of cancer. Vitamin D and its analogues have demonstrated anticancer activity in vitro and in animal models. However, the risk of colorectal cancer in relation to dietary vitamin D remains controversial. A literature search was performed for articles on epidemiologic studies of vitamin D and colorectal cancer and the mechanisms involved. Studies that combine multiple sources of vitamin D or examine serum 25(OH)D3 usually find that above-average vitamin D intake and serum metabolite concentrations are associated with significantly reduced incidence of colorectal cancer. A number of mechanisms have been identified through which vitamin D may reduce the risk of colorectal and several other types of cancer. Although studies that include vitamin D from all sources or serum 25(OH)D3 usually show significantly reduced incidence of colorectal cancer in association with vitamin D, analyses limited to dietary vitamin D tend to have mixed results. The likely reason that dietary vitamin D is not a significant risk reduction factor for colorectal cancer in many studies is that dietary sources provide only a portion of total vitamin D, with supplements and synthesis of vitamin D in the skin in association with solar UV-B radiation providing the balance. There is strong evidence from several different lines of investigation supporting the hypothesis that vitamin D may reduce the risk of colorectal cancer. Further study is required to elucidate the mechanisms and develop guidelines for optimal vitamin D sources and serum levels of vitamin D metabolites.

Colonic bacterial flora: changing understandings in the molecular age

The human intestinal microbiota is a complex bacterial consortium that is critical to normal health. The microflora is present at concentrations of 10(11)-10(12) cells/g of intestinal contents; the number of species present may exceed 500, although exact numbers remain to be defined, due in part to the fact that <30% of microorganisms are culturable with current microbiologic methods. Molecular tools based on 16S rDNA sequence similarities such as fluorescent in-situ hybridization (FISH), denaturing gradient gel electrophoresis (DGGE), quantitative dot blot hybridization, restriction fragment length polymorphism (RFLP) and large scale 16S rDNA sequencing have helped to overcome limitations of conventional microbiological plating methods in studying the fecal microflora composition. However, these tools are just now beginning to be applied to understand the dynamics of this complex community, and its relationship to diet and human health. There is a need to understand both the limitations of the current data and the importance of moving forward with the best possible molecular and epidemiologic techniques as we deal with these critical questions.

Dietary calcium and vitamin D intake and risk of colorectal cancer: a prospective cohort study in women

Although laboratory data and a few adenoma prevention trials suggest that calcium supplementation may reduce the risk of colorectal neoplasia, the results of observational studies of calcium intake and colorectal cancer risk are contradictory. However, few studies have examined the association among women or effects in specific colon subsites. Women with colorectal cancer diagnosed through 31 December 2000 were identified by linkage to regional cancer registries. During an average 11.3 yr of follow-up of 61,463 women, we observed 572 incident cases of colorectal cancer. Using data obtained from a 67-item food frequency questionnaire and Cox proportional hazards models to estimate rate ratios and 95% confidence intervals, we found an inverse association between dietary calcium intake and colorectal cancer risk. Women with the highest calcium intake (median 914 mg/day) had a reduced risk of colorectal cancer (rate ratio = 0.72, 95% confidence interval = 0.056-0.93, P for trend = 0.02) compared with women with the lowest intake (median 486 mg/day). Furthermore, our results suggest that the inverse association may be strongest in relation to distal cancers and among older women. The association with dairy products was less clear, suggesting that calcium intake per se is more important than specific calcium sources. Vitamin D intake was not clearly associated with risk. In sum, our data suggest that high calcium intake may lower colorectal cancer risk.

Dairy products and colorectal cancer. A review of possible mechanisms and epidemiological evidence

OBJECTIVES

This review provides an overview of the principal hypotheses and epidemiological evidence of the possible links between colorectal cancer and intake of milk and/or dairy products.

METHODS

The first section outlines the main hypotheses about the possible effect of calcium, vitamin D, fats and other milk components. The possible role of acid lactic bacteria in fermented products is also discussed. The second section is a summary of the published epidemiological evidence. The results on milk, cheese and yoghurt are summarized using a meta-analytical approach. The results of studies on calcium and vitamin D are briefly described.

RESULTS

Case-control studies are heterogeneous and, on average, do not provide evidence of association between total intake of total dairy products, milk, cheese or yoghurt and colorectal cancer risk. The average result from cohort studies support the hypothesis of a protective effect of total dairy products (odds ratio (OR): 0.62; 95% confidence interval (CI): 0.52-0.74; P heterogeneity test: 0.93) and for milk (OR: 0.80; 95% CI: 0.68-0.95; P heterogeneity: 0.77). No association was found between cheese (OR: 1.10; 95% CI: 0.88-1.36; P heterogeneity: 0.55) or yoghurt (OR: 1.03; 95% CI: 0.83-1.28; P heterogeneity: 0.69) in cohort studies.

CONCLUSIONS

Cohort studies consistently found a protective effect of total dairy products and milk intake, but the evidence is not supported by case-control studies. No relationship was found with cheese or yoghurt intake. As the number of cohort studies is still limited, their results need to be confirmed by other prospective studies.

Vitamin D and systemic cancer: is this relevant to malignant melanoma?

1,25-dihydroxyvitamin D3[1,25(OH)2D3] is a well-known potent regulator of cell growth and differentiation and there is recent evidence of an effect on cell death, tumour invasion and angiogenesis, which makes it a candidate agent for cancer regulation. The classical synthetic pathway of 1,25(OH)2D3 involves 25- and 1 alpha-hydroxylation of vitamin D3, in the liver and kidney, respectively, of absorbed or skin-synthesized vitamin D3. There is recent focus on the importance in growth control of local metabolism of 1,25(OH)2D3, which is a function of local tissue synthetic hydroxylases and particularly the principal catabolizing enzyme, 24-hydroxylase. The classical signalling pathway of 1,25(OH)2D3 employs the vitamin D nuclear receptor (VDR), which is a transcription factor for 1,25(OH)2D3 target genes. Effects of this pathway include inhibition of cellular growth and invasion. Cytoplasmic signalling pathways are increasingly being recognized, which similarly may regulate growth and differentiation but also apoptosis. 1,25(OH)2D3 has a major inhibitory effect on the G1/S checkpoint of the cell cycle by upregulating the cyclin dependent kinase inhibitors p27 and p21, and by inhibiting cyclin D1. Indirect mechanisms include upregulation of transforming growth factor-beta and downregulation of the epidermal growth factor receptor. 1,25(OH)2D3 may induce apoptosis either indirectly through effects on the insulin-like growth receptor and tumour necrosis factor-alpha or more directly via the Bcl-2 family system, the ceramide pathway, the death receptors (e.g. Fas) and the stress-activated protein kinase pathways (Jun N terminal kinase and p38). Inhibition of tumour invasion and metastasis potential has been demonstrated and mechanisms include inhibition of serine proteinases, metalloproteinases and angiogenesis. The lines of evidence for an effect of vitamin D3 in systemic cancer are the laboratory demonstration of relevant effects on cellular growth, differentiation, apoptosis, malignant cell invasion and metastasis; epidemiological findings of an association of the occurrence and outcome of cancers with derangements of vitamin D3/1,25(OH)2D3 and the association of functional polymorphisms of the VDR with the occurrence of certain cancers. In addition, vitamin D3 analogues are being developed as cancer chemotherapy agents. There is accumulating evidence that the vitamin D3/1,25(OH)2D3/VDR axis is similarly important in malignant melanoma (MM). MM cells express the VDR, and the antiproliferative and prodifferentiation effects of 1,25(OH)2D3 have been shown in cultured melanocytes, MM cells and MM xenografts. Recently, an inhibitory effect on the spread of MM cells has been demonstrated, low serum levels of 1,25(OH)2D3 have been reported in MM patients and the VDR polymorphisms have been shown to be associated with both the occurrence and outcome of MM. The relationship between solar irradiation and MM is more complex than for the systemic cancers. As in other cancers, there is evidence of a protective effect of vitamin D3 in MM, but ultraviolet radiation, which is a principal source of vitamin D3, is mutagenic. Further work is necessary on the influence of serum vitamin D3 levels on the occurrence and prognosis of MM, the effects of sun protection measures on serum vitamin D3 levels in temperate climates and epidemiological studies on geographical factors and skin type on the prognosis of MM. Meanwhile, it would seem mandatory to ensure an adequate vitamin D3 status if sun exposure were seriously curtailed, certainly in relation to carcinoma of breast, prostate and colon and probably also MM.

Primary prevention of colorectal cancer: diet and drugs

Primary prevention of colonic adenomas and cancer through dietary interventions or chemoprevention has great appeal. This article discusses primary prevention goals and promising nutritional or chemopreventive strategies. There is substantial observational evidence that diets high in total calories and fat and or low in fruits and vegetables or total fiber as well as low levels of physical activity are related to the risk of colonic neoplasia. Similar observational data indicate that diets high in specific nutrients such as antioxidant vitamins or calcium may be protective. The article describes some of the newer chemopreventive agents and reviews the data linking diet and lifestyle to colorectal cancer risk, focusing on interventions that have also been studied in prospective clinical trials. Finally the evidence supporting the role of non-steroidal anti-inflammatory drugs for the chemoprevention of CRC is reviewed and the status of several other promising newer agents that are entering human trials is summarized.

Serum 25-hydroxyvitamin D, dietary calcium intake, and distal colorectal adenoma risk

Vitamin D has recently emerged as a potentially protective agent against colorectal neoplasia. We assessed the associations between dietary vitamin D, plasma 25-hydroxyvitamin D [25(OH)D], dietary calcium, and colorectal adenomas in a large screening sigmoidoscopy-based case-control study in Southern California. Because conversion of serum 25(OH)D to serum 1,25-vitamin D is highly regulated by serum calcium, we also assessed modification of the 25(OH)D-adenoma association by calcium intake. Cases were 473 subjects with a primary adenoma, and controls were 507 subjects who had no adenomas at sigmoidoscopy and no history of adenomas. Compared with those in the lowest quartile of intake, those in the highest quartile of dietary vitamin D had an adjusted odds ratio (OR) of 0.83 [95% confidence interval (CI) = 0.49-1.41] and those in the highest quartile of dietary calcium had an OR of 0.82 (95% CI = 0.49-1.25). There was a suggestion that plasma 25(OH)D may be protective in this population (OR for highest vs. lowest quartile = 0.74, 95% CI = 0.51-1.09). A significant protective effect of 25(OH)D was clearly evident only in those with calcium intakes below (OR = 0.40 for highest vs. lowest quartile, 95% CI = 0.22-0.71, p for trend = 0.005) and above (OR = 1.17, 95% CI = 0.69-1.99, p for trend = 0.94) the median calcium intake.

Sunlight and mortality from breast, ovarian, colon, prostate, and non-melanoma skin cancer: a composite death certificate based case-control study

OBJECTIVES

To explore whether mortality from female breast, ovarian, colon, and prostate cancer were negatively associated with exposure to sunlight.

METHODS

A death certificate based case-control study of mortality was conducted into five cancers: female breast, ovarian, colon, prostate, and non-melanoma skin cancer (as a positive control) to examine associations with residential and occupational exposure to sunlight. Cases were all deaths from these cancers between 1984 and 1995 in 24 states of the United States. Controls, which were age frequency matched to a series of cases, excluded deaths from cancer and certain neurological diseases. Multiple logistic regression was used in a model that included age, sex, race, residential exposure to sunlight (based on region), and socioeconomic status, occupational exposure to sunlight, and physical activity (the last three based on usual occupation).

RESULTS

Residential exposure to sunlight was negatively and significantly associated with mortality from female breast, ovarian, prostate, and colon cancer. Only female breast and colon cancer, however, also showed significant negative associations with jobs with the highest occupational exposure to sunlight (odds ratio (OR) 0.82 (95% confidence interval (95% CI) 0.70 to 0.97) for female breast cancer; OR 0.90 (95% CI 0.86 to 0.94) for colon cancer). For both cancers, the negative association with occupational sunlight was greatest in the geographical region of highest exposure to sunlight and was independent of physical activity on the job. Non-melanoma skin cancer, as expected, was positively associated with both residential and occupational sunlight.

CONCLUSIONS

In this exploratory study, unlike mortality from non-melanoma skin cancer, mortality from female breast cancer and colon cancer were negatively associated with both residential and occupational sunlight.

Low-risk diet for colorectal cancer in Italy

An innovative approach was used to define a low-risk diet for colorectal cancer from a multicentric case-control study of 1953 incident cases and 4154 hospital controls from Italy. A logistic regression model was fitted on the reported intake of five macronutrients, and the estimated coefficients were used to compute a diet-related logistic risk score (LRS). The mean of LRS within risk decile ranged from 0.89 to 1.86. Total energy intake and absolute consumption of each macronutrient increased with increasing LRS. In relative terms, however, starch intake showed an almost threefold increase across subsequent score levels, while a decline was observed for unsaturated fat, sugar and protein. Saturated fat consumption remained fairly stable in relative terms. When food groups were considered, bread and cereals dishes, cakes and desserts and refined sugar were positively associated, while the consumption of vegetables, fruit, fish, poultry and olive oils was inversely associated with LRS.

Prospective study on milk products, calcium and cancers of the colon and rectum

OBJECTIVE

To study the relationship between consumption of milk and milk products, calcium, lactose and vitamin D and occurrence of colorectal cancers.

DESIGN

Prospective cohort study.

SUBJECTS

A total of 9959 men and women aged 15 y or older without history of cancer at baseline. During a 24 y follow-up, 72 new cancers of the large bowel (38 in the colon and 34 in the rectum) were detected.

RESULTS

Consumption of milk and total milk products was suggested to be inversely related to colon cancer incidence, whereas no similar association was seen for rectal cancer. The relative risk between the highest and lowest quartiles of intake adjusted for potential confounding factors was 0.46 (95% confidence interval 0.14-1.46, P for trend 0.09) for milk and 0.37 (95% CI=0.12-1.39, P for trend 0.06) for total milk products. Lactose intake showed a similar inverse relationship with colon cancer: the relative risk was 0.31 (95% CI=0.08-1.15, P for trend 0.03). Intake of vitamin D or total dietary calcium was not significantly related to colorectal cancer risk, whereas calcium provided by fermented milk products was associated with increased colorectal cancer incidence; in the highest quartile the multivariate adjusted relative risk for colorectal cancer was 2.07 (95% CI=1.00-4.28).

CONCLUSIONS

Our results indicate that individuals showing high consumption of milk have a potentially reduced risk of colon cancer; however, the association does not appear to be due to intake of calcium, vitamin D, or to specific effects of fermented milk.

SPONSORSHIP

This study was supported by a grant from the Swedish Cancer Foundation.

Cancer chemoprevention using natural vitamin D and synthetic analogs

Substantial epidemiologic data support a role for vitamin D in cancer prevention. However, dose-limiting hypercalcemic effects have proved a major obstacle to the development of natural vitamin D as a cancer chemopreventive. Structure-activity studies have sought to disassociate the toxicities and chemopreventive activities of vitamin D, and a number of synthetic deltanoids (vitamin D analogs) have shown considerable promise in this regard. Several such compounds have chemopreventive efficacy in preclinical studies, as does natural vitamin D. Data supporting further development of agents of this class include in vitro and in vivo evidence of antiproliferative, proapoptotic, prodifferentiating and antiangiogenic activities. Ongoing studies are aimed at further defining the molecular mechanisms through which vitamin D and synthetic deltanoids affect gene expression and cellular fate. Additional efforts are focused on establishing the chemopreventive index (efficacy vs toxicity) of each synthetic deltanoid.

Protective role of probiotics and prebiotics in colon cancer

Ingestion of viable probiotics or prebiotics is associated with anticarcinogenic effects, one mechanism of which is the detoxification of genotoxins in the gut. This mechanism was shown experimentally in animals with use of the rat colon carcinogen 1,2-dimethylhydrazine and by determining endpoints that range from tumorigenesis to induction of DNA damage. Because of the complexity of cancer initiation, cancer progression, and the exposure of cancer in the gut, many types of interactions may be envisaged. Notably, some of our newer studies showed that short-lived metabolite mixtures isolated from milk that was fermented with strains of Lactobacillus bulgaricus and Streptococcus thermophilus are more effective in deactivating etiologic risk factors of colon carcinogenesis than are cellular components of microorganisms. Ingestion of prebiotics results in a different spectrum of fermentation products, including the production of high concentrations of short-chain fatty acids. Gut flora, especially after the ingestion of resistant starch, induces the chemopreventive enzyme glutathione transferase pi in the colon of the rat. Together, these factors lead to a reduced load of genotoxic agents in the gut and to an increased production of agents that deactivate toxic components. Butyrate is one such protective agent and is associated with lowering cancer risk. It was recently shown that buytrate may inhibit the genotoxic activity of nitrosamides and hydrogen peroxide in human colon cells. In humans, the ingestion of probiotics leads to the excretion of urine with low concentrations of components that are genotoxic in human colon cells and high concentrations of components that induce oxidized DNA bases.

The role of vitamin D in normal and pathologic processes in the colon

Vitamin D(3) metabolites and analogues have recently been shown to play an important role in the regulation of a number of important cellular processes, including proliferation, differentiation, and apoptosis, in addition to their established roles in mineral homeostasis. The actions of these secosteroids involve both rapid, nongenomic effects and genomic effects; the latter mediated via the vitamin D receptor and other transcription factors. Their effects have been described in a variety of cell types, including normal and malignant colonocytes. This article summarizes the rapid and genomic actions of vitamin D(3) metabolites and analogues on normal and pathologic processes in the colon, with particular emphasis on the potential of these secosteroids to prevent colon cancer.

Prospective study of dietary supplements, macronutrients, micronutrients, and risk of bladder cancer in US men

Data derived from laboratory investigations suggest that a number of dietary variables may contribute to bladder carcinogenesis. Although bladder cancer is the fourth leading cause of cancer in men in the United States, dietary studies are few. The authors examined the relations between intakes of macro- and micronutrients and the risk of bladder cancer among men in the prospective Health Professionals Follow-Up Study. Each participant completed a 131-item food frequency questionnaire in 1986 and in 1990, from which nutrient intakes were calculated. During 12 years of follow-up, 320 cases of bladder cancer were diagnosed. No association was observed for total caloric or macronutrient intake and bladder cancer risk. Similarly, we found no relation for dietary intake of potassium, sodium, calcium, magnesium, phosphorus, iron, or water-soluble vitamins and bladder cancer risk. Total vitamin E intake and vitamin E supplements were inversely associated with risk. In addition, a dose-response relation was observed for duration of vitamin E supplement use. A suggestive inverse association was seen with dose of vitamin C supplement use. More studies are needed to determine the role of vitamins E and C supplement intake in bladder carcinogenesis.

Calcium and vitamin D. Their potential roles in colon and breast cancer prevention

The geographic distribution of colon cancer is similar to the historical geographic distribution of rickets. The highest death rates from colon cancer occur in areas that had high prevalence rates of rickets--regions with winter ultraviolet radiation deficiency, generally due to a combination of high or moderately high latitude, high-sulfur content air pollution (acid haze), higher than average stratospheric ozone thickness, and persistently thick winter cloud cover. The geographic distribution of colon cancer mortality rates reveals significantly low death rates at low latitudes in the United States and significantly high rates in the industrialized Northeast. The Northeast has a combination of latitude, climate, and air pollution that prevents any synthesis of vitamin D during a five-month vitamin D winter. Breast cancer death rates in white women also rise with distance from the equator and are highest in areas with long vitamin D winters. Colon cancer incidence rates also have been shown to be inversely proportional to intake of calcium. These findings, which are consistent with laboratory results, indicate that most cases of colon cancer may be prevented with regular intake of calcium in the range of 1,800 mg per day, in a dietary context that includes 800 IU per day (20 micrograms) of vitamin D3. (In women, an intake of approximately 1,000 mg of calcium per 1,000 kcal of energy with 800 IU of vitamin D would be sufficient.) In observational studies, the source of approximately 90% of the calcium intake was vitamin D-fortified milk. Vitamin D may also be obtained from fatty fish. In addition to reduction of incidence and mortality rates from colon cancer, epidemiological data suggest that intake of 800 IU/day of vitamin D may be associated with enhanced survival rates among breast cancer cases.

Parathyroid hormone may be a cancer promoter - an explanation for the decrease in cancer risk associated with ultraviolet light, calcium, and vitamin D

Epidemiological studies reporting an inverse association between sunlight exposure and risk for cancers of the breast, colon, and prostate, have not yet been explained. Since ultraviolet (UV) light promotes dermal vitamin D generation, studies suggesting that dietary calcium and vitamin D may likewise have cancer-preventive activity are potentially of relevance. UV light, calcium, and vitamin D have the common property of suppressing parathyroid hormone (PTH) production; these considerations raise the possibility that PTH may have promotional activity for certain cancers. PTH might function indirectly in this regard, by increasing hepatic production of the progression growth factor IGF-I, a likely cancer promoter. A more direct role is suggested by recent evidence that many cancers express receptors for PTH/PTH-related protein; these receptors mediate co-mitogenic and/or pro-invasive signals in some cancers. High risk for previous or concurrent neoplasms has been reported in patients with parathyroid adenomas. In light of the increase in cancer risk associated with hypertension, it is notable that PTH levels are typically increased in salt-sensitive hypertensives. Prospective case-control studies examining serum PTH in relation to subsequent cancer risk appear warranted.

A multiethnic cohort in Hawaii and Los Angeles: baseline characteristics

The authors describe the design and implementation of a large multiethnic cohort established to study diet and cancer in the United States. They detail the source of the subjects, sample size, questionnaire development, pilot work, and approaches to future analyses. The cohort consists of 215,251 adult men and women (age 45-75 years at baseline) living in Hawaii and in California (primarily Los Angeles County) with the following ethnic distribution: African-American (16.3%), Latino (22.0%), Japanese-American (26.4%), Native Hawaiian (6.5%), White (22.9%), and other ancestry (5.8%). From 1993 to 1996, participants entered the cohort by completing a 26-page, self-administered mail questionnaire that elicited a quantitative food frequency history, along with demographic and other information. Response rates ranged from 20% in Latinos to 49% in Japanese-Americans. As expected, both within and among ethnic groups, the questionnaire data show substantial variations in dietary intakes (nutrients as well as foods) and in the distributions of non-dietary risk factors (including smoking, alcohol consumption, obesity, and physical activity). When compared with corresponding ethnic-specific cancer incidence rates, the findings provide tentative support for several current dietary hypotheses. As sufficient numbers of cancer cases are identified through surveillance of the cohort, dietary and other hypotheses will be tested in prospective analyses.

In colorectal carcinoma patients, serum vitamin D levels vary according to stage of the carcinoma

BACKGROUND

Epidemiologic studies have demonstrated an inverse correlation between dietary calcium and vitamin D intake and the incidence of colorectal carcinoma. Elevated serum levels of 25-hydroxyvitamin D3 (25-OH-D3) are associated with a major reduction in the incidence of this neoplasm. The reduction in tumor size and number induced by calcium supplements in an experimental carcinogenesis model was neutralized by vitamin D3 deficiency. To the authors' knowledge, vitamin D serum levels have never been determined previously in colorectal carcinoma patients. They compared serum 1,25-dihydroxyvitamin D3 (1,25(OH)2D3), 25-OH-D3, and parathyroid hormone (PTH) levels of colorectal carcinoma patients with those of healthy controls.

METHODS

Serum 1,25(OH)2D3, 25-OH-D3, and PTH levels were determined in 84 colorectal carcinoma patients (10 with Stage I, 29 with Stage II, 25 with Stage III, and 20 with Stage IV) and 30 healthy controls, all of whom were normocalcemic and not taking calcium or vitamin D supplements.

RESULTS

25-OH-D3 serum levels were higher in cancer patients than controls, irrespective of stage. Serum 1,25(OH)2D3 decreased with advancing stage: 73 +/- 18, 48 +/- 16, 39 +/- 12, 34 +/- 13, and 75 +/- 20 pg/mL in Stages I, II, III, IV, and controls, respectively. There was a corresponding increase in serum PTH levels: 58.0 +/- 9.4, 73.7 +/- 14.4, 79.0 +/- 21.3, 100.4 +/- 30.9, and 51.2 +/- 3.9 pg/mL in Stages I, II, III, IV, and controls, respectively. Serum vitamin D metabolite levels did not correlate with gender, age, tumor localization, or histologic grade.

CONCLUSIONS

An inverse correlation between serum levels of the active metabolite of vitamin D and colorectal carcinoma stage has been demonstrated for the first time, to the authors' knowledge, in colorectal carcinoma patients. Because 1,25(OH)2D3 has been shown to inhibit proliferation of colonic epithelial cells, decreased serum levels may facilitate the growth of colorectal carcinoma and influence its biologic behavior.

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

BACKGROUND AND METHODS

Laboratory, clinical, and epidemiologic evidence suggests that calcium may help prevent colorectal adenomas. We conducted a randomized, double-blind trial of the effect of supplementation with calcium carbonate on the recurrence of colorectal adenomas. We randomly assigned 930 subjects (mean age, 61 years; 72 percent men) with a recent history of colorectal adenomas to receive either calcium carbonate (3 g [1200 mg of elemental calcium] daily) or placebo, with follow-up colonoscopies one and four years after the qualifying examination. The primary end point was the proportion of subjects in whom at least one adenoma was detected after the first follow-up endoscopy but up to (and including) the second follow-up examination. Risk ratios for the recurrence of adenomas were adjusted for age, sex, lifetime number of adenomas before the study, clinical center, and length of the surveillance period.

RESULTS

The subjects in the calcium group had a lower risk of recurrent adenomas. Among the 913 subjects who underwent at least one study colonoscopy, the adjusted risk ratio for any recurrence of adenoma with calcium as compared with placebo was 0.85 (95 percent confidence interval, 0.74 to 0.98; P=0.03). The main analysis was based on the 832 subjects (409 in the calcium group and 423 in the placebo group) who completed both follow-up examinations. At least one adenoma was diagnosed between the first and second follow-up endoscopies in 127 subjects in the calcium group (31 percent) and 159 subjects in the placebo group (38 percent); the adjusted risk ratio was 0.81 (95 percent confidence interval, 0.67 to 0.99; P=0.04). The adjusted ratio of the average number of adenomas in the calcium group to that in the placebo group was 0.76 (95 percent confidence interval, 0.60 to 0.96; P=0.02). The effect of calcium was independent of initial dietary fat and calcium intake.

CONCLUSIONS

Calcium supplementation is associated with a significant - though moderate - reduction in the risk of recurrent colorectal adenomas.

Bacteria used for the production of yogurt inactivate carcinogens and prevent DNA damage in the colon of rats

Lactic acid-producing bacteria prevent carcinogen-induced preneoplastic lesions and tumors in rat colon. Because the mechanisms responsible for these protective effects are unknown, two strains of lactic acid bacteria, Lactobacillus delbrueckii ssp. bulgaricus 191R and Streptococcus salivarius ssp. thermophilus CH3, that are used to produce yogurt, were investigated in vitro and in vivo to elucidate their potential to deactivate carcinogens. Using the "Comet assay" to detect genetic damage, we found that L. bulgaricus 191R applied orally to rats could prevent 1, 2-dimethylhydrazine-induced DNA breaks in the colon in vivo, whereas St. thermophilus CH3 were not effective. However, in vitro, both strains prevented DNA damage induced by N-methyl-N'-nitro-N-nitrosoguanidine (MNNG) in isolated primary rat colon cells. Extracts prepared from milk fermented with St. thermophilus CH3 were as efficient in deactivating MNNG as was L-cysteine. Isolated metabolites arising from bacteria during fermentation in the colon or in milk [L(+) lactate, D(-) lactate, palmitic acid and isopalmitic acid] were not effective. We postulate that thiol-containing breakdown products of proteins, via catalysis by bacterial proteases, could be one mechanism by which MNNG or other carcinogens are deactivated in the gut lumen resulting in reduced damage to colonic mucosal cells.

Clinical models of chemoprevention for colon cancer

Colon cancer is a common malignancy in the westernized world and is incurable in its advanced stages. This article summarizes the currently available information on colorectal cancer chemoprevention. A brief outline of the incidence and etiologic factors is followed by a discussion of the evidence on which chemopreventive strategies for colon cancer are modeled. This includes a description of the development of surrogate endpoint biomarkers and experimental models to study colorectal cancer chemopreventives, a review of the promising colorectal cancer chemopreventives, and a discussion of the issues to be addressed in the design of future chemoprevention trials. The article concludes with an emphasis on the development and validation of biomarkers and selection of high-risk cohorts using genetic and epidemiologic tools as the main goals of future colon cancer chemoprevention trials before large-scale, risk-reduction trials are conducted.

Macronutrient intake and risk of colorectal cancer in Italy

To provide further insight on the relationship between macronutrients and colorectal cancer, overall and by specific subsite(s), we carried out between 1992 and 1996 in 6 Italian areas a case-control study on 1,953 individuals of both sexes with incident colorectal cancer (age range 19-74) and 4,154 controls (age range 19-74) in hospital with acute, non-neoplastic diseases. A validated food-frequency questionnaire was used, including questions on 78 foods or recipes and on individual fat-intake pattern. The risk of cancer of the colon and rectum increased with total energy intake (odds ratio in highest vs. lowest quintile 1.43 and 1.50, respectively). The risk also rose significantly with an increase of starch intake, whereas it moderately decreased with an increase of protein intake. Monounsaturated fat intake appeared uninfluential, while saturated fat intake showed a modest direct association with rectal cancer. Polyunsaturated fat intake was inversely associated with colon cancer risk, particularly with the right colon.

Influence of dietary levels of fat, cholesterol, and calcium on colorectal cancer

The associations between calcium, fat, and cholesterol intake and risk of colorectal cancer were studied in a case-control study conducted in Uruguay. A total of 282 incident and histologically proven cases of adenocarcinomas of the colon and rectum comprised the case series. Five hundred sixty-four hospitalized controls were selected from the same hospitals from which the cases were drawn. Calcium intake was associated with a significant decrease in the risk of colorectal cancer (odds ratio = 0.41, 95% confidence limit = 0.24-0.69 for the uppermost quartile of intake). The associations were similar for colon and rectal cancer. On the other hand, protein and total fat were associated with significantly increased risk of colorectal cancer. A strong interaction between calcium and fat (and cholesterol) intake was found. According to this interaction, calcium effect was maximal at low levels of dietary fat (and cholesterol intake), whereas fat (and cholesterol intake) showed a positive monotonic increase in risk of colorectal cancer at high levels of calcium intake. This finding should be further investigated in other epidemiologic and experimental studies.

Food groups and risk of colorectal cancer in Italy

The proportion of colorectal cancer attributed to dietary habits is high, but several inconsistencies remain, especially with respect to the influence of some food groups. To further elucidate the role of dietary habits, 1,225 subjects with cancer of the colon, 728 with cancer of the rectum and 4,154 controls, hospitalized with acute non-neoplastic diseases, were interviewed between 1992 and 1996 in 6 different Italian areas. The validated food-frequency questionnaire included 79 questions on food items and recipes, categorised into 16 food groups. After allowance for non-dietary confounding factors and total energy intake, significant trends of increasing risk of colorectal cancer with increasing intake emerged for bread and cereal dishes (odds ratio [OR] in highest vs. lowest quintile = 1.7), potatoes (OR = 1.2), cakes and desserts (OR = 1.1), and refined sugar (OR = 1.4). Intakes of fish (OR = 0.7), raw and cooked vegetables (OR = 0.6 for both) and fruit other than citrus fruit (OR = 0.7) showed a negative association with risk. Consumption of eggs and meat (white, red or processed meats) seemed uninfluential. Most findings were similar for colon and rectum, but some negative associations (i.e., coffee and tea, and fish) appeared stronger for colon cancer. Our findings lead us to reconsider the role of starchy foods and refined sugar in light of recent knowledge on the digestive physiology of carbohydrates and the insulin/colon cancer hypothesis. The beneficial role of most vegetables is confirmed, with more than 20% reduction in risk of colorectal cancer from the addition of one daily serving.