Associations of red and processed meat with survival after colorectal cancer and differences according to timing of dietary assessment

Prognostic value of post-operative iron biomarkers in colorectal cancer: population-based patient cohort

BACKGROUND

Post-operative anaemia is linked to iron deficiency. We investigated the prognostic value of post-operative iron biomarkers in colorectal cancer (CRC).

METHODS

Ferritin, transferrin, iron, and transferrin saturation (TS%) were measured from blood collected at a single time-point post-surgery in 2769 CRC patients. Associations between iron biomarkers with cancer-specific survival (CSS) and overall survival (OS) were assessed using Cox regression with hazard ratios (HR), stratified by post-operative time of blood collection (<1-month/≥1-month).

RESULTS

After a median follow-up of 9.5 years, 52.6% of patients had died. For iron biomarkers assessed <1-month post-surgery, higher compared to normal TS% was associated with shorter CSS (HR [95% CI] = 2.36 [1.25-4.46]), and higher iron levels with better OS (upper vs. median tertile: HR [95% CI] = 0.79 [0.65-0.97]). When assessed ≥1-month post-surgery, elevated ferritin was associated with poor CSS (high vs. normal: HR [95% CI] = 1.44 [1.10-1.87]), and low TS% with worse CSS (low vs. normal: HR [95% CI] = 1.60 [1.24-2.06]). Similar but weaker associations were observed for OS.

CONCLUSION

Monitoring of serum ferritin and TS% beyond 1-month post-surgery may be relevant for risk stratification of patients with operable CRC. Future studies should validate our findings.

Post-diagnosis dietary factors, supplement use and colorectal cancer prognosis: A Global Cancer Update Programme (CUP Global) systematic literature review and meta-analysis

The role of diet in colorectal cancer prognosis is not well understood and specific lifestyle recommendations are lacking. We searched for randomised controlled trials (RCTs) and longitudinal observational studies on post-diagnosis dietary factors, supplement use and colorectal cancer survival outcomes in PubMed and Embase from inception until 28th February 2022. Random-effects dose-response meta-analyses were conducted when at least three studies had sufficient information. The evidence was interpreted and graded by the CUP Global independent Expert Committee on Cancer Survivorship and Expert Panel. Five RCTs and 35 observational studies were included (30,242 cases, over 8700 all-cause and 2100 colorectal cancer deaths, 3700 progression, recurrence, or disease-free events). Meta-analyses, including 3-10 observational studies each, were conducted for: whole grains, nuts/peanuts, red and processed meat, dairy products, sugary drinks, artificially sweetened beverages, coffee, alcohol, dietary glycaemic load/index, insulin load/index, marine omega-3 polyunsaturated fatty acids, supplemental calcium, circulating 25-hydroxyvitamin D (25[OH]D) and all-cause mortality; for alcohol, supplemental calcium, circulating 25(OH)D and colorectal cancer-specific mortality; and for circulating 25(OH)D and recurrence/disease-free survival. The overall evidence was graded as 'limited'. The inverse associations between healthy dietary and/or lifestyle patterns (including diets that comprised plant-based foods), whole grains, total, caffeinated, or decaffeinated coffee and all-cause mortality and the positive associations between unhealthy dietary patterns, sugary drinks and all-cause mortality provided 'limited-suggestive' evidence. All other exposure-outcome associations provided 'limited-no conclusion' evidence. Additional, well-conducted cohort studies and carefully designed RCTs are needed to develop specific lifestyle recommendations for colorectal cancer survivors.

Post-diagnosis physical activity and sedentary behaviour and colorectal cancer prognosis: A Global Cancer Update Programme (CUP Global) systematic literature review and meta-analysis

Low physical activity and high sedentary behaviour have been clearly linked with colorectal cancer development, yet data on their potential role in colorectal cancer survival is limited. Better characterisation of these relationships is needed for the development of post-diagnosis physical activity and sedentary behaviour guidance for colorectal cancer survivors. We searched PubMed and Embase through 28 February 2022 for studies assessing post-diagnosis physical activity, and/or sedentary behaviour in relation to all-cause and cause-specific mortality and recurrence after colorectal cancer diagnosis. Total and recreational physical activity were assessed overall and by frequency, duration, intensity, and volume using categorical, linear, and non-linear dose-response random-effects meta-analyses. The Global Cancer Update Programme (CUP Global) independent Expert Committee on Cancer Survivorship and Expert Panel interpreted and graded the likelihood of causality. We identified 16 observational studies on 82,220 non-overlapping patients from six countries. Physical activity was consistently inversely associated with colorectal cancer morbidity and mortality outcomes, with 13%-60% estimated reductions in risk. Sedentary behaviour was positively associated with all-cause mortality. The evidence had methodological limitations including potential confounding, selection bias and reverse causation, coupled with a limited number of studies for most associations. The CUP Global Expert panel concluded limited-suggestive evidence for recreational physical activity with all-cause mortality and cancer recurrence. Total physical activity and its specific domains and dimensions, and sedentary behaviour were all graded as limited-no conclusion for all outcomes. Future research should focus on randomised trials, while observational studies should obtain objective and repeated physical activity measures and better adjustment for confounders.

Ultra-processed food consumption and mortality among patients with stages I-III colorectal cancer: a prospective cohort study

Background

Ultra-processed foods (UPFs) are emerging as a risk factor for colorectal cancer (CRC), yet how post-diagnostic UPF intake may impact CRC prognosis remains unexplored.

Methods

Data collected from food frequency questionnaires were used to estimate intakes of total UPFs and UPF subgroups (serving/d) at least 6 months but less than 4 years post-diagnosis among 2498 patients diagnosed with stages I-III CRC within the Nurses' Health Study and Health Professionals Follow-up Study during 1980-2016. Hazard ratios (HR) and 95% confidence intervals (CIs) of all-cause, CRC- and cardiovascular disease (CVD)-specific mortality in association with UPF consumption were estimated using an inverse probability weighted multivariable Cox proportional hazards regression model, adjusted for confounders.

Findings

The mean (SD) age of patients at diagnosis was 68.5 (9.4) years. A total of 1661 deaths were documented, including 321 from CRC and 335 from CVD. Compared to those in the lowest quintile (median = 3.6 servings/d), patients in the highest quintile (median = 10 servings/d) of post-diagnostic UPF intake had higher CVD mortality (HR = 1.65, 95% CI = 1.13-2.40) but not CRC or all-cause mortality. Among UPF subgroups, higher consumption of fats/condiments/sauces was associated with a higher risk of CVD-specific mortality (highest vs. lowest quintile of intake, HR = 1.96, 95% CI = 1.41-2.73), and higher intake of ice cream/sherbet was associated with an increased risk of CRC-specific mortality (highest vs. lowest quintile, HR = 1.86, 95% CI: 1.33-2.61). No statistically significant association was found between UPF subgroups and overall mortality.

Interpretation

Higher post-diagnostic intake of total UPFs and fats/condiments/sauces in CRC survivors is associated with higher CVD mortality, and higher ice cream/sherbet intake is linked to higher CRC mortality.

Funding

US National Institutes of Health and the American Cancer Society.

Post-operative C-reactive protein as a strong independent predictor of long-term colorectal cancer outcomes: consistent findings from two large patient cohorts

BACKGROUND

Post-surgery blood-based biomarkers may be useful for guiding treatment and surveillance decisions among colorectal cancer (CRC) patients. However, most candidate biomarkers provide little if any predictive value beyond stage at diagnosis. We aimed to investigate the independent prognostic value of post-operative serum C-reactive protein (CRP), a highly sensitive biomarker of inflammation, for long-term CRC outcomes in two large patient cohorts.

MATERIALS AND METHODS

CRP levels were measured from serum samples of CRC patients collected ≥1 month post-surgery in the German DACHS (n = 1416) and the UK Biobank (n = 1149) cohorts. Associations of post-operative CRP with overall survival (OS) and CRC-specific survival (CSS) were assessed using Cox regression and presented as hazard ratios (HRs) with 95% confidence intervals (CIs), adjusted for key sociodemographic and clinical covariates.

RESULTS

In both cohorts, consistent strong dose-response relationships between post-operative CRP and both OS and CSS were observed. Adjusted HRs (95% CI) for CRP >10 versus <3 mg/l were 1.93 (1.58-2.35) and 2.70 (2.03-3.59) in the DACHS cohort, and 2.70 (1.96-3.71) and 2.61 (1.83-3.72) in the UK Biobank cohort, respectively. Associations between post-operative CRP and OS were particularly strong among younger patients (<65 years at diagnosis; P value for interaction by age <0.01).

CONCLUSIONS

Serum CRP determined a month or more after surgery may be useful as a strong independent prognostic biomarker for guiding therapeutic decisions and for surveillance of the course of disease of CRC patients, particularly those <65 years of age at diagnosis.

Post-Diagnosis Dietary Patterns among Cancer Survivors in Relation to All-Cause Mortality and Cancer-Specific Mortality: A Systematic Review and Meta-Analysis of Cohort Studies

The role of overall diet on longevity among cancer survivors (CS) needs further elucidation. We performed a systematic review of the literature and a meta-analysis of related cohort studies published up to October 2022 investigating post-diagnosis a priori (diet quality indices) and a posteriori (data-driven) dietary patterns (DPs) in relation to all-cause and cancer-specific mortality. Pooled hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated using random-effects meta-analyses comparing highest versus lowest categories of adherence to DPs. We assessed heterogeneity and risk of bias in the selected studies. A total of 19 cohort studies with 38,846 adult CS, some assessing various DPs, were included in the meta-analyses. Higher adherence to a priori DPs was associated with lower all-cause mortality by 22% (HR = 0.78, 95% CI: 0.73-0.83, I2 = 22.6%) among all CS, by 22% (HR = 0.78, 95% CI: 0.73-0.84, I2 = 0%) among breast CS and by 27% (HR = 0.73, 95% CI: 0.62-0.86, I2 = 41.4%) among colorectal CS. Higher adherence to a "prudent/healthy" DP was associated with lower all-cause mortality (HR = 0.79, 95% CI: 0.64-0.97 I2 = 49.3%), whereas higher adherence to a "western/unhealthy" DP was associated with increased all-cause mortality (HR = 1.48, 95% CI: 1.26-1.74, I2 = 0%) among all CS. Results for cancer-specific mortality were less clear. In conclusion, higher adherence to a "healthy" DP, either a priori or a posteriori, was inversely associated with all-cause mortality among CS. A "healthy" overall diet after cancer diagnosis could protect and promote longevity and well-being.

Health-Promoting Lifestyle among the Survivors of Colorectal Cancer: An Integrative Review

Introduction

Health-promoting lifestyle (HPL) among the survivors of colorectal cancer (CRC) is essential to reduce CRC complications, prevent its recurrence, and improve survival. Nonetheless, there is no comprehensive definition for the concept of HPL in CRC survivors. This study aimed to define the concept of HPL among CRC survivors based on the existing literature.

Methods

This integrative review was conducted in 2021 using Whittemore and Knafl's method. The national and international databases of SID, Magiran, ProQuest, Medline, ScienceDirect, Web of Science, and Scopus were searched. Quality appraisal was performed using the Mixed Methods Appraisal Tool (MMAT) and the data were analyzed using the four-step approach proposed by Whittemore and Knafl.

Results

After data evaluation, 167 documents were included in final analysis. In total, 1863 codes were generated and categorized into eighteen main categories and the three main themes of antecedents, attributes, and consequences. Accordingly, HPL among CRC survivors was defined as "a set of behaviors in the areas of health responsibility, physical activity, nutrition, spiritual growth, psychological management, and interpersonal relations which are affected by socio-demographic characteristics, clinical characteristics, psychological status, physical conditions, time and place limitations, and patient education, and lead to better disease prognosis, better general health status, better bio-psycho-social status, and better quality of life".

Conclusion

The definition of HPL among CRC survivors provided in the present study can be used in counseling, educational, supportive, and care programs for CRC survivors in order to improve their quality of life and survival.

Vitamin D Status, Cdx2 Genotype, and Colorectal Cancer Survival: Population-Based Patient Cohort

According to recent evidence, the prognostic value of Vitamin D (VitD) status for colorectal cancer (CRC) patients might be confined to patients with the GG genotype of Cdx2, a functional polymorphism of the VitD receptor gene. We aimed to validate these findings in a cohort of CRC patients. Post-operative serum 25-hydroxyvitamin D concentration was determined by mass spectrometry and Cdx2 genotyping was performed from blood or buccal swabs using standard methods. Joint associations of VitD status and Cdx2 with overall survival (OS), CRC-specific survival (CSS), recurrence-free survival (RFS), and disease-free survival (DFS) were assessed using Cox regression. For patients with GG genotype, adjusted hazard ratios (95% confidence interval) for the associations of sufficient compared with deficient VitD were 0.63 (0.50-0.78), 0.68 (0.50-0.90), 0.66 (0.51-0.86), and 0.62 (0.50-0.77) for OS, CSS, RFS, and DFS, respectively. These associations were weaker and not statistically significant for the AA/AG genotype. Interaction between VitD status and genotype did not reach statistical significance. VitD deficiency is an independent predictor of poorer survival, particularly for the GG Cdx2 carriers, suggesting a potential role of VitD supplementation according to VitD status and genotype, which should be evaluated in randomised trials.

Alcohol Use and the Risk of Colorectal Liver Metastasis: A Systematic Mapping Review

The consumption of alcohol has long been associated with the development of liver disease as well as cancers including colorectal cancer (CRC). Leading healthcare concerns include the prevalent use of alcohol and the high burden of CRC mortality. Many CRC deaths are attributed to the development of colorectal liver metastasis (CRLM) as the liver is the foremost site of CRC spread. However, an association has not been defined for the role of alcohol intake and related liver injury with the development of CRLM. Here, a mapping review of recent research was undertaken to evaluate the relationship between alcohol consumption and the risk of CRLM. The literature search revealed 14 articles meeting the inclusion criteria that included patient database analyses and preclinical studies. Most of the human data analyses found alcohol use independently associates with worse CRC outcomes. The preclinical evaluations identified several pathways involved in the alcohol-mediated promotion of CRLM burden and CRC cell metastatic behavior. The limited number of studies identified exposes a significant need for more prospective analyses to define the role of alcohol intake and advanced CRC as well as the translation of preclinical research to fully characterize targetable mechanisms for the generation of new therapeutic options.

Effect of dietary consumption on the survival of esophageal squamous cell carcinoma: a prospective cohort study

BACKGROUND/OBJECTIVES

This prospective cohort study was to assess the association of pre-diagnostic dietary intake and dietary pattern with the survival of esophageal squamous cell carcinoma (ESCC) patients.

SUBJECTS/METHODS

855 patients were recruited and successfully followed. Information on diet over past five years before diagnosis was collected using a food frequency questionnaire, and dietary patterns were extracted using principal component analysis. Hazard ratio (HR) with 95% confidence interval (95% CI) was calculated using the Cox proportional hazard model.

RESULTS

164 (19.18%) ESCC patients survived during the follow-up. Every 25-g increment intake of pickled vegetables was associated with a 6.0% (HR: 1.060, 95% CI: 1.003-1.121) increased risk of death after adjustment for covariates. When comparing the highest with lowest tertiles of energy-adjusted intake, pickled vegetables intake was associated with a 21.9% elevated risk of death (HR: 1.219, 95% CI: 1.014-1.465), while fish and shrimp intake was associated with a 19.4% (HR: 0.816, 95% CI: 0.675-0.986) reduced risk of death. Three dietary patterns were defined and labeled as patterns I, II, and III. Every 10-score increment of dietary pattern II, characterized with a higher loading of preserved vegetables, pickled vegetables, and salted meat, was associated with a 1.7% (HR: 1.017, 95% CI: 1.003-1.032) increased risk of death.

CONCLUSIONS

A diet characterized with higher loading of preserved vegetables, pickled vegetables, and salted meat, was negatively associated with death risk among ESCC patients. Prospective studies concerning the role of post-diagnosis dietary intake in ESCC prognosis are needed.

Preventive Nutrition: Heart Disease and Cancer

Two of the leading chronic diseases are cardiovascular disease (CVD) and cancer. A cornerstone of prevention for CVD and cancer is a healthy dietary pattern throughout the lifespan. Dietary patterns represent the totality of the diet and reflect habitual consumption of combinations and quantities of foods and nutrients that cumulatively affect health and disease. This article summarizes recent evidence on the relationship of diet quality as measured by adherence to healthy dietary patterns and CVD and cancer risk reduction. Optimal adherence to a healthy dietary pattern decreases CVD and cancer risk; even small changes in diet quality are beneficial.

Health-Promoting Lifestyle in Colorectal Cancer Survivors: A Qualitative Study on the Experiences and Perspectives of Colorectal Cancer Survivors and Healthcare Providers

OBJECTIVE

Understanding the experiences of survivors and healthcare providers about health-promoting lifestyle (HPL) in colorectal cancer (CRC) survivors is important in planning for coping with the disease, managing treatment side effects, increasing survival, and improving quality of life (QOL). This study was conducted to explore the experiences and perspectives of CRC survivors and healthcare providers about HPL in CRC survivors.

METHODS

This descriptive qualitative study was performed in 2020 at Omid and Imam Reza Hospitals in Mashhad, Iran. Participants were CRC survivors (n = 12) and healthcare providers (n = 33) who were selected by purposive sampling. Data were collected using in-depth semi-structured interview by face to face and then analyzed by Zhang and Wildemuth content analysis method. MaxQDA software was used to organize the data.

RESULTS

Following the treatment of cancer, CRC survivors seek to make changes in lifestyle and they choose a HPL that maintains or improves their health. HPL in CRC survivors includes nutrition, activity and rest, health responsibility, interpersonal relations, spiritual growth, and psychological management. The results showed that HPL can lead to motivation, the ability to self-care and improve daily performance, reduce treatment complications, and increase the QOL.

CONCLUSIONS

CRC survivors can help change their lifestyle patterns with healthy eating, treatment adherence, regular physical activity, and good sleep habits. Furthermore, effective personal and social relationships, spiritual growth, and management of psychological disorders develop health-promoting behaviors in them. CRC survivors also face challenges and limitations in their life after treatment; identifying the components of a HPL in CRC survivors can lead to desirable care, treatment, education, and counseling services.

Dietary Intake in Association with All-Cause Mortality and Colorectal Cancer Mortality among Colorectal Cancer Survivors: A Systematic Review and Meta-Analysis of Prospective Studies

Simple Summary

Given that an extensive range of dietary factors has not been investigated among colorectal cancer (CRC) survivors to date, we carried out a systematic review and meta-analysis to determine the effects of both prediagnostic and postdiagnostic dietary intake on all-cause mortality and CRC-specific mortality among CRC survivors. In total, 45 studies were included in the final analysis of 35 food items, 8 macronutrients, 27 micronutrients, 2 dietary patterns, and 13 dietary indexes in association with all-cause mortality and CRC-specific mortality. We found that an unhealthy dietary pattern increased the risks of both all-cause mortality and CRC-specific mortality. The role of prediagnostic and postdiagnostic intake such as macronutrients and fatty acids could be different in the risk of all-cause mortality. Overall, comprehensive evidence for the effect of substantial numbers of prediagnostic and postdiagnostic dietary items on mortality outcomes is reported in this study.

Abstract

We carried out a systematic review and meta-analysis to determine the effects of both prediagnostic and postdiagnostic dietary intake on all-cause mortality and CRC-specific mortality among CRC survivors. An extensive search of PubMed and Embase was conducted to identify eligible studies. We applied a random-effects model to estimate the pooled relative risks (RRs)/hazard ratios (HRs) and their 95% confidence intervals (CIs). As a result, a total of 45 studies were included in the final analysis. Pooled effect sizes from at least three study populations showed that whole grains and calcium were inversely associated with all-cause mortality, with RRs/HRs (95% CIs) of 0.83 (0.69–0.99) and 0.84 (0.73–0.97), respectively. In contrast, a positive association between an unhealthy dietary pattern and both all-cause mortality (RR/HR = 1.47, 95% CI = 1.05–2.05) and CRC-specific mortality (RR/HR = 1.52, 95% CI = 1.13–2.06) was observed among CRC survivors. In the subgroup analysis by CRC diagnosis, prediagnostic and postdiagnostic dietary intake such as carbohydrates, proteins, lipids, and fiber were observed to have different effects on all-cause mortality. Overall, an unhealthy dietary pattern increased the risks of both all-cause mortality and CRC-specific mortality. The role of prediagnostic and postdiagnostic intake of dietary elements such as macronutrients and fatty acids could be different in the risk of all-cause mortality.

Estimation of Absolute Risk of Colorectal Cancer Based on Healthy Lifestyle, Genetic Risk, and Colonoscopy Status in a Population-Based Study

BACKGROUND & AIMS

Estimates of absolute risk of colorectal cancer (CRC) are needed to facilitate communication and better inform the public about the potentials and limits of cancer prevention.

METHODS

Using data from a large population-based case-control study in Germany (Darmkrebs: Chancen der Verhütung durch Screening [DACHS] study, which began in 2003) and population registry data, we calculated 30-year absolute risk estimates for development of CRC based on a healthy lifestyle score (derived from 5 modifiable lifestyle factors: smoking, alcohol consumption, diet, physical activity, and body fatness), a polygenic risk score (based on 90 single-nucleotide polymorphisms), and colonoscopy history.

RESULTS

We analyzed data from 4220 patients with CRC and 3338 individuals without CRC. Adherence to a healthy lifestyle and colonoscopy in the preceding 10 years were associated with a reduced relative risk of CRC in men and women. We observed a higher CRC risk in participants with high or intermediate genetic risk scores. For 50-year-old men and women without a colonoscopy, the absolute risk of CRC varied according to the polygenic risk score and the healthy lifestyle score (men, 3.5%-13.4%; women, 2.5%-10.6%). For 50-year-old men and women with a colonoscopy, the absolute risk of developing CRC was much lower but still varied according to the polygenic risk score and the healthy lifestyle score (men, 1.2%-4.8%; women, 0.9%-4.2%). Among all risk factor profiles, the 30-year absolute risk estimates consistently decreased with adherence to a healthy lifestyle.

CONCLUSIONS

In a population-based study, we found that a colonoscopy can drastically reduce the absolute risk of CRC and that the genetically predetermined risk of CRC can be further reduced by adherence to a healthy lifestyle. Our results show the magnitude of CRC prevention possible through colonoscopy and lifestyle at a predefined genetic risk. This observational study has been registered in the German Clinical Trials Register (DRKS00011793), which is a primary registry in the World Health Organization Registry Network.

Epidemiology characteristics of ethnic minority colorectal cancer in Yunnan in Southwestern China

BACKGROUND

Colorectal cancer (CRC) is one of the world's deadliest cancers, and its mortality rate has been on the rise in China. Yunnan is a region with a higher concentration of ethnic minorities. CRC affects many people from ethnic minority groups, which differ from Han in terms of their age and gender compositions.

METHODS

We collected samples from 1,016 cases of CRC patients along with their case files at Yunnan Provincial Cancer Hospital from the period between January 2013 and December 2018.

RESULTS

In total, 7.1% (n=72) of all lung cancer cases diagnosed from 2013 to 2018 in Yunnan Provincial Cancer Hospital occurred in patients 40 years old or younger, 44% (n=447) were 40 to 60 years old, and 48.9% (n=497) were 60 years old or above. The composition ratio of CRC patients in the different age groups differed significantly and enhanced significantly with age, with a statistical significance of P<0.05. A total of 33.6% (n=38) of 113 minority patients and 16.8% (n=152) of 903 Han patients reported a history of smoking, and 23.0% (n=26) of 113 minority patients and 14.6% (n=132) of Han patients had a history of drinking. Long-term smoking and drinking are significantly associated with the incidence of CRC, and this was more significant among ethnic minorities (P<0.05).

CONCLUSIONS

The high incidence of CRC in Yunnan is strongly related to patients' lifestyles, and diet should be a core focus of efforts to prevent and treat CRC. Early screening and regular check for common tumor markers can also help to reduce the incidence of CRC and provide a basis for improvements in CRC treatment and prognosis in Yunnan.

Nutritional status and follicular-derived thyroid cancer: An update

The incidence of differentiated thyroid cancer has been increasing in the last decades all over the world. Such a steady growth cannot be entirely attributable to more intensive thyroid nodule screening and more sensitive diagnostic procedures. Several environmental factors have changed with sufficient rapidity in the same time frame and may represent credible candidates for this increase. They include modified iodine intake, lifestyle-associated risk factors, exposure to various toxic compounds, pollutants and xenobiotics, nutritional deficiencies, eating habits and comorbidities. Foremost, nutritional patterns have gained high interest as possible promoters and modifiable risk factors for thyroid cancer in recent years. The aim of this narrative review is to focus on the relationship between thyroid cancer and nutritional factors, dietary habits and obesity. Low iodine intake has been associated to increased risk of thyroid cancer, favoring the development of more aggressive histotypes. Moreover, correction of iodine deficiency can shift thyroid cancer subtypes toward less aggressive forms, without affecting the overall risk for cancer. Actually, evidence regarding the association between selenium and vitamin D deficiency and thyroid cancer is very limited, despite their well-known anti-cancer potentials, and the clinical usefulness of their supplementation is still uncertain in this setting. Albeit the relationship between single foods and thyroid cancer is difficult to examine, fish and iodine-rich foods, vegetables, and fruits might exert protective effects on thyroid cancer risk. Conversely, no clear association has been found for other foods to date. Lastly, a clear association between obesity and the risk of thyroid cancer, with more aggressive behavior, seems to emerge from most studies, likely involving variations in thyroid function and chronic inflammation mediated by cytokines, insulin, leptin and adiponectins. Although no definite association between dietary factors and thyroid cancer has been firmly established so far, some nutritional patterns, together with excessive weight, seem to play a relevant role in thyroid cancer carcinogenesis as well as in its severity and aggressiveness. These effects may play an additive role to the well-established one exerted by environmental carcinogens, such as pollutants and radiation exposure.

Polyunsaturated fatty acids and DNA methylation in colorectal cancer

Colorectal cancer (CRC) has been designated a major global problem, especially due to its high prevalence in developed countries. CRC mostly occurs sporadically (75%-80%), and only 20%-25% of patients have a family history. Several processes are involved in the development of CRC such as a combination of genetic and epigenetic alterations. Epigenetic changes, including DNA methylation play a vital role in the progression of CRC. Complex interactions between susceptibility genes and environmental factors, such as a diet and sedentary lifestyle, lead to the development of CRC. Clinical and experimental studies have confirmed the beneficial effects of dietary polyunsaturated fatty acids (PUFAs) in preventing CRC. From a mechanistic viewpoint, it has been suggested that PUFAs are pleiotropic agents that alter chromatin remodeling, membrane structure and downstream cell signaling. Moreover, PUFAs can alter the epigenome via modulation of DNA methylation. In this review, we summarize recent investigations linking PUFAs and DNA methylation-associated CRC risk.

Time of Metastasis and Outcome in Colorectal Cancer

OBJECTIVE

The aim of this study was to evaluate outcomes of metastases at various time intervals after colorectal cancer (CRC) diagnosis.

BACKGROUND

Earlier studies have indicated a short time interval between CRC diagnosis and distant metastases to be associated with poor prognosis. The majority of studies assessed outcome from CRC diagnosis or metastasis resection rather than from metastasis diagnosis and might be subject to immortal time bias.

METHODS

Patients in the population-based DACHS study were stratified: metastases at/within 1 month (immediate), 2 to 6 months (early), 7 to 12 months (intermediate), and >12 months (late) after CRC diagnosis. The primary endpoint was overall survival (OS) from metastasis diagnosis. Cox proportional hazards regression models were used to calculate hazard ratios (HRs) and 95% confidence intervals (CI). HRs were adjusted for important confounders and immortal time.

RESULTS

A total of 1027 patients were included. T4 (P < 0.0001) and node-positive tumors (P < 0.0001) were more frequent in the immediate group. Lung metastases (P < 0.0001) and single-site metastases (P < 0.0001) were more prevalent in the late group. In multivariable analysis, immediate metastases were not associated with poor OS compared to metastases at later time points (late vs immediate: HR 1.21; 95% CI, 0.98-1.48). Subgroup analyses revealed poor OS of late versus immediate metastases for females (1.45; 1.08-1.96), proximal colon cancer (1.54; 1.09-2.16), and N0 (1.46; 1.00-2.12) or N1 disease (1.88; 1.17-3.05).

CONCLUSIONS

Immediate or early metastases are not associated with unfavorable outcome compared to late metastases. These findings challenge the current notion of poor outcome for CRC with immediate or early metastases.

Global differences in the prevalence of the CpG island methylator phenotype of colorectal cancer

Background

CpG Island Methylator Phenotype (CIMP) is an epigenetic phenotype in CRC characterized by hypermethylation of CpG islands in promoter regions of tumor suppressor genes, leading to their transcriptional silencing and loss of function. While the prevalence of CRC differs across geographical regions, no studies have compared prevalence of CIMP-High phenotype across regions. The purpose of this project was to compare the prevalence of CIMP across geographical regions after adjusting for variations in methodologies to measure CIMP in a meta-analysis.

Methods

We searched PubMed, Medline, and Embase for articles focusing on CIMP published from 2000 to 2018. Two reviewers independently identified 111 articles to be included in final meta-analysis. We classified methods used to quantify CIMP into 4 categories: a) Classical (MINT marker) Panel group b) Weisenberg-Ogino (W-O) group c) Human Methylation Arrays group and d) Miscellaneous group. We compared the prevalence of CIMP across geographical regions after correcting for methodological variations using meta-regression techniques.

Results

The pooled prevalence of CIMP-High across all studies was 22% (95% confidence interval:21–24%; I² = 94.75%). Pooled prevalence of CIMP-H across Asia, Australia, Europe, North America and South America was 22, 21, 21, 27 and 25%, respectively. Meta-regression analysis identified no significant differences in the prevalence of CIMP-H across geographical regions after correction for methodological variations. In exploratory analysis, we observed variations in CIMP-H prevalence across countries.

Conclusion

Although no differences were found for CIMP-H prevalence across countries, further studies are needed to compare the influence of demographic, lifestyle and environmental factors in relation to the prevalence of CIMP across geographical regions.

Association Between Intake of Red and Processed Meat and Survival in Patients With Colorectal Cancer in a Pooled Analysis

BACKGROUND & AIMS

Red and processed meat intake is associated with colorectal cancer (CRC) incidence, but it is not clear if intake is associated with patient survival after diagnosis.

METHODS

We pooled data from 7627 patients with stage I-IV CRC from 10 studies in the International Survival Analysis in Colorectal Cancer Consortium. Cox proportional hazards regression models were used to evaluate the associations of intake of red and processed meat before diagnosis with overall and CRC-specific survival.

RESULTS

Among 7627 patients with CRC, 2338 died, including 1576 from CRC, over a median follow-up time of 5.1 years. In multivariable-adjusted analyses, higher intake of red or processed meat was not associated with overall survival of patients with stage I-III CRC: Q4 vs Q1 red meat hazard ratio [HR], 1.08 (95% CI, 0.93-1.26) and Q4 vs Q1 processed meat HR, 1.10 (95% CI, 0.93-1.32) or with CRC-specific survival: Q4 vs Q1 red meat HR, 1.09 (95% CI, 0.89-1.33) and Q4 vs Q1 processed meat HR, 1.11 (95% CI, 0.87-1.42). Results were similar for patients with stage IV CRC. However, patients with stage I-III CRC who reported an intake of processed meat above the study-specific medians had a higher risk of death from any cause (HR, 1.12; 95% CI, 1.01-1.25) than patients who reported eating at or less than the median.

CONCLUSION

In this large consortium of CRC patient cohorts, intake of red and processed meat before a diagnosis of CRC was not associated with shorter survival time after diagnosis, although a possible weak adverse association cannot be excluded. Studies that evaluate dietary data from several time points before and after cancer diagnosis are required to confirm these findings.

Healthy Lifestyle Factors Associated With Lower Risk of Colorectal Cancer Irrespective of Genetic Risk

BACKGROUND & AIMS

The combined effects of healthy lifestyle factors on colorectal cancer (CRC) risk are unclear. We aimed to develop a healthy lifestyle score, to investigate the joint effects of modifiable lifestyle factors on reduction of CRC risk and determine whether associations differ with genetic risk.

METHODS

We collected data from a large population-based case-control study in Germany and used multiple logistic regression analyses to examine associations between the healthy lifestyle score (derived from 5 modifiable lifestyle factors: smoking, alcohol consumption, diet, physical activity, and body fatness) and CRC risk. We created a genetic risk score, based on 53 risk variants, to investigate the association of the healthy lifestyle score and risk of CRC, stratified by genetic risk.

RESULTS

We included 4092 patients with CRC and 3032 individuals without CRC (controls) in our analysis. In adjusted models, compared with participants with 0 or 1 healthy lifestyle factor, participants with 2 (odds ratio [OR] 0.85; 95% confidence interval [CI] 0.67-1.06), 3 (OR 0.62; 95% CI 0.50-0.77), 4 (OR 0.53; 95% CI 0.42-0.66), or 5 (OR 0.33; 95% CI 0.26-0.43) healthy lifestyle factors had increasingly lower risks of CRC (P trend <.0001). We found no differences among subgroups stratified by genetic risk score, history of colonoscopy, or family history of CRC. Overall, 45% of CRC cases (95% CI 34%-53%) could be attributed to nonadherence to all 5 healthy lifestyle behaviors.

CONCLUSIONS

In a large population-based case-control study, we identified a combination of lifestyle factors that appears to reduce risk of CRC, regardless of the patient's genetic profile. These results reinforce the importance of primary prevention of CRC.

The colorectal cancer epidemic: challenges and opportunities for primary, secondary and tertiary prevention

Colorectal cancer (CRC) is both one of the most common and one of the most preventable cancers globally, with powerful but strongly missed potential for primary, secondary and tertiary prevention. CRC incidence has traditionally been the highest in affluent Western countries, but it is now increasing rapidly with economic development in many other parts of the world. CRC shares several main risk factors, such as smoking, excessive alcohol consumption, physical inactivity and being overweight, with other common diseases; therefore, primary prevention efforts to reduce these risk factors are expected to have multiple beneficial effects that extend beyond CRC prevention, and should have high public health impact. A sizeable reduction in the incidence and mortality of CRC can also be achieved by offering effective screening tests, such as faecal immunochemical tests, flexible sigmoidoscopy and colonoscopy, in organised screening programmes which have been implemented in an increasing number of countries. Countries with early and high uptake rates of effective screening have exhibited major declines in CRC incidence and mortality, in contrast to most other countries. Finally, increasing evidence shows that the prognosis and quality of life of CRC patients can be substantially improved by tertiary prevention measures, such as the administration of low-dose aspirin and the promotion of physical activity.

Progress in primary prevention of colorectal cancer

Colorectal cancer (CRC) is one of the most common malignant tumors in the digestive tract, with high incidence and mortality. Most of CRC cases are diagnosed at the late stage, and the treatment effect is therefore poor. Thus, the prevention of CRC is particularly important. There have been many studies on the prevention of CRC in recent years. This paper will summarize the latest research on the primary prevention of CRC.

Dose-Response Relationship between Serum Retinol Levels and Survival in Patients with Colorectal Cancer: Results from the DACHS Study

Current knowledge on the role of retinol in the prognosis of patients with colorectal cancer (CRC) is very limited. We investigated the association of serum retinol levels with survival outcomes in a large cohort of 2908 CRC patients from Germany. Retinol concentrations were determined in serum collected shortly after diagnosis by mass spectrometry. Associations between serum retinol levels and survival outcomes were assessed using multivariable Cox regression and dose-response analyses. The joint association of serum retinol and serum 25-hydroxyvitamin D₃ (25(OH)D₃) with survival outcomes was also examined. During a median follow-up of 4.8 years, 787 deaths occurred, 573 of which were due to CRC. Dose-response curves showed an inverse relationship between serum retinol levels and survival endpoints in the range of <2.4 µmol/L, but no associations at higher levels. Low (<1.2 µmol/L) versus high (≥2.4 µmol/L) serum retinol levels were associated with poorer overall survival (Hazard ratio (HR) = 1.46, 95% confidence interval (CI) = 1.19–1.78, P-trend = 0.0003) and CRC-specific survival (HR = 1.69, 95% CI = 1.33–2.15, P-trend < 0.0001). Joint presence of low serum retinol (<1.2 µmol/L) and low 25(OH)D₃ (<30 nmol/L) was associated with a particularly strong decrease in overall and CRC-specific survival. Low serum retinol levels were identified as a predictor of poor survival in CRC patients, in particular when co-occurring with low serum concentrations of 25(OH)D₃. The clinical implications of these findings require further investigation.

Impact of dietary patterns and the main food groups on mortality and recurrence in cancer survivors: a systematic review of current epidemiological literature

OBJECTIVE

To determine whether there is an association between dietary patterns/indices and foods from the main food groups (highest vs lowest intakes) prior to or after cancer diagnosis and mortality and cancer recurrence in cancer survivors.

PARTICIPANTS

Survivors of common cancers with a 10-year survival rate of ≥50%: bladder, bowel, breast, cervical, kidney, laryngeal, prostate, testicular, uterine cancer, malignant melanoma and (non-)Hodgkin's lymphoma.

OUTCOME MEASURES

Mortality (overall, cancer-specific, from other causes) and cancer recurrence.

INFORMATION SOURCES

PubMed, Embase and the Cochrane Library were searched from inception to April 2017. Additional studies were identified by searching reference lists. Two authors independently screened titles and abstracts, assessed study quality and extracted the data.

RESULTS

A total of 38 studies were included. The risk of bias was rated low for the included randomised controlled trials (RCTs) and moderate for the cohort studies. The quality of evidence was assessed with the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach and was rated moderate (RCTs), and (very)low (cohort studies). Reducing the amount of fat after diagnosis appears to decrease the risk of breast cancer recurrence. Adherence to a high-quality diet and prudent diet after diagnosis appears to decrease the risk of death from other causes (and overall mortality for high-quality diet) in breast cancer survivors. Adherence to a Western diet, before and after diagnosis, appears to increase the risk of overall mortality and death from other causes among breast cancer survivors. Evidence from studies among other cancer survivors was too limited or could not be identified.

CONCLUSION

For many cancer survivors, there is little evidence to date to indicate that particular dietary behaviours influence outcomes with regard to recurrence and mortality. Notwithstanding, limited evidence suggests that a low-fat diet, a high-quality diet and a prudent diet are beneficial for breast cancer survivors, while a Western diet is detrimental for breast cancer survivors.

Precision Nutrition for Targeting Lipid Metabolism in Colorectal Cancer

Cancer is a multistage and multifactorial condition with genetic and environmental factors modulating tumorogenesis and disease progression. Nevertheless, cancer is preventable, as one third of cancer deaths could be avoided by modifying key risk factors. Nutrients can directly affect fundamental cellular processes and are considered among the most important risk factors in colorectal cancer (CRC). Red and processed meat, poultry consumption, fiber, and folate are the best-known diet components that interact with colorectal cancer susceptibility. In addition, the direct association of an unhealthy diet with obesity and dysbiosis opens new routes in the understanding of how daily diet nutrients could influence cancer prognosis. In the “omics” era, traditional nutrition has been naturally evolved to precision nutrition where technical developments have contributed to a more accurate discipline. In this sense, genomic and transcriptomic studies have been extensively used in precision nutrition approaches. However, the relation between CRC carcinogenesis and nutrition factors is more complex than originally expected. Together with classical diet-nutrition-related genes, nowadays, lipid-metabolism-related genes have acquired relevant interest in precision nutrition studies. Lipids regulate very diverse cellular processes from ATP synthesis and the activation of essential cell-signaling pathways to membrane organization and plasticity. Therefore, a wide range of tumorogenic steps can be influenced by lipid metabolism, both in primary tumours and distal metastasis. The extent to which genetic variants, together with the intake of specific dietary components, affect the risk of CRC is currently under investigation, and new therapeutic or preventive applications must be explored in CRC models. In this review, we will go in depth into the study of co-occurring events, which orchestrate CRC tumorogenesis and are essential for the evolution of precision nutrition paradigms. Likewise, we will discuss the application of precision nutrition approaches to target lipid metabolism in CRC.

Carcinogenicity of consumption of red meat and processed meat: A review of scientific news since the IARC decision

In October 2015, the International Agency for Research on Cancer (IARC) issued a press release on the results of the evaluation of the carcinogenicity of red and processed meat. Based on the accumulated scientific literature, the consumption of red meat was classified as "probably carcinogenic to humans" and processed meat as "carcinogenic to humans". Given the importance of this topic, this review was aimed at revising the current state-of-the-art on the carcinogenicity of red and processed meat, some time after the IARC decision. Some new epidemiological studies and new reviews clearly supporting the IARC decision have been published during these months. However, a number of gaps still exist. It is basic to establish the mechanisms leading to the increased risk of colorectal cancer (CRC) and other cancers arising from red and processed meat consumption. Another important pending issue is to establish the role of known/suspected carcinogens contained in uncooked or unprocessed meats, as well as the influence of cooking. Finally, it would be highly recommended to conduct new epidemiological studies to elucidate whether the consumption of white meat, such as pork and/or poultry, are -positively or inversely-associated with an increased risk of CRC and other types of cancer.

Estimating the Effect of Targeted Screening Strategies: An Application to Colonoscopy and Colorectal Cancer

Supplemental Digital Content is available in the text.

Screening behavior depends on previous screening history and family members’ behaviors, which can act as both confounders and intermediate variables on a causal pathway from screening to disease risk. Conventional analyses that adjust for these variables can lead to incorrect inferences about the causal effect of screening if high-risk individuals are more likely to be screened. Analyzing the data in a manner that treats screening as randomized conditional on covariates allows causal parameters to be estimated; inverse probability weighting based on propensity of exposure scores is one such method considered here. I simulated family data under plausible models for the underlying disease process and for screening behavior to assess the performance of alternative methods of analysis and whether a targeted screening approach based on individuals’ risk factors would lead to a greater reduction in cancer incidence in the population than a uniform screening policy. Simulation results indicate that there can be a substantial underestimation of the effect of screening on subsequent cancer risk when using conventional analysis approaches, which is avoided by using inverse probability weighting. A large case–control study of colonoscopy and colorectal cancer from Germany shows a strong protective effect of screening, but inverse probability weighting makes this effect even stronger. Targeted screening approaches based on either fixed risk factors or family history yield somewhat greater reductions in cancer incidence with fewer screens needed to prevent one cancer than population-wide approaches, but the differences may not be large enough to justify the additional effort required. See video abstract at, http://links.lww.com/EDE/B207.