CLINICAL MEDICAL EDUCATION

DIET AND COLORECTAL CANCER : IS THERE NEW EVIDENCE?

Pembimbing:

dr. Wahyu Djatmiko, SpPD K. HOM

Disusun oleh:

Nurullia Rahmawati G4A017075

SMF ILMU PENYAKIT DALAM

RSUD PROF. MARGONO SOEKARJO
FAKULTAS KEDOKTERAN DAN ILMU-ILMU KESEHATAN
UNIVERSITAS JENDRAL SOEDIRMAN
2019
 LEMBAR PENGESAHAN

CLINICAL MEDICAL EDUCATION

DIET AND COLORECTAL CANCER : IS THERE NEW EVIDENCE?

Diajukan untuk memenuhi salah satu syarat mengikuti program profesi dokter
di Bagian Ilmu Penyakit Dalam RSUD Prof. Dr. Margono Soekarjo

Disusun Oleh :

Nurullia Rahmawati G4A017075

Pada tanggal, Maret 2019

Mengetahui

Pembimbing,

dr. Wahyu Djatmiko,Sp.PD-K.HOM

CLINICAL CONTEXT

Colorectal cancer (CRC) is the third most common form of cancer diagnosed in the
United States, excluding nonmelanoma skin cancers. A previous meta-analysis by
Samad and colleagues, published in the May 2005 issue of Colorectal
Disease, notes that adults' risk for CRC rises within 2 to 3 generations after
migration from low- to high-incidence areas for CRC. Clearly, there are lifestyle
and environmental variables that affect the incidence of CRC.[1]

The meta-analysis by Samad and colleagues assessed 19 cohort studies and 28 case-
control studies that investigated the role of physical activity in the prevention of
CRC. Physical activity was associated with a reduction in the risk for incident colon
cancer of slightly more than 20% among males, with little difference in this effect
between occupational and leisure-time physical activity. The risk ratio for colon
cancer in comparing physically active women with inactive women was 0.71 (95%
confidence interval [CI], 0.57-0.88), but there was no effect of occupational
physical activity on the risk for colon cancer among women. Of note, physical
activity was not protective against rectal cancer in either sex.

The composition of diet is also known to affect the risk for CRC, but much of the
data establishing certain foods as cancer risk factors is derived from older research.
The current study assesses the role of diet as a risk factor for CRC in a more modern
cohort in the United Kingdom.

Study Synopsis and Perspective

Consuming a moderate amount of red meat and/or processed meat is associated

with an increased risk of developing CRC, according to new findings.

The study authors found that eating an average of 76 g red meat or processed meat
a day, which is in line with current government recommendations from the United
Kingdom, was associated with a 20% higher chance of developing CRC compared
with consuming only about 21 g/day.
Alcohol consumption also raised the risk for CRC, but eating fiber from bread and
cereals lowered it. "Our results strongly suggest that people who eat red and
processed meat 4 or more times a week have a higher risk of developing bowel
cancer than those who eat red and processed meat less than twice a week," said
coauthor Tim Key, DPhil, deputy unit director and professor of epidemiology,
University of Oxford, United Kingdom, in a statement. "There's substantial
evidence that red and processed meat are linked to bowel cancer, and the World
Health Organization classifies processed meat as carcinogenic and red meat as
probably carcinogenic, but most previous research looked at people in the 1990s or
earlier, and diets have changed significantly since then, so our study gives a more
up-to-date insight that is relevant to meat consumption today," he said.

The study, by Kathryn E. Bradbudy, PhD, from the Cancer Epidemiology Unit,
Nuffield Department of Population Health, University of Oxford, United Kingdom,
and the National Institute for Health Innovation, School of Population Health,
University of Auckland, New Zealand, and colleagues was published online April
17 in the International Journal of Epidemiology.[2]

Consistent With Previous Data

During the last decade, much has been written on lifestyle, including diet, and the
association with cancer risk. A number of studies have found varying associations
between the consumption of red meat and cancer.

The American Institute for Cancer Research and the World Cancer Research Fund
published several reports during the last 10 years or so on the effect of diet,
nutrition, and/or physical activity on risk for several cancer types. Their most recent
study, published in 2017, found that consuming red meat and processed meat may
increase the risk for CRC, as may drinking 2 or more alcoholic beverages per day.
On the flip side, eating whole grains daily and ramping up activity levels can reduce
the risk.
In 2015, the World Health Organization's International Agency for Research on
Cancer classified processed meat as carcinogenic to humans (group 1) on the basis
of sufficient evidence for CRC. In addition, said the group, there was a positive
association with stomach cancer.

The International Agency for Research on Cancer has also classified red meat as
being "probably carcinogenic to humans" (group 2A). The decision was based on
relevant data that show strong mechanistic evidence of a carcinogenic effect. This
association was observed mainly for CRC, but also for pancreatic cancer and
prostate cancer.

The authors of the current study point out that most previous studies that found an
increased risk for CRC in those who consume high quantities of red meat and
processed meat were conducted during the 1990s or earlier, and that patterns in
meat consumption have since changed. In addition, few studies have used
remeasured intakes to reduce the effect of measurement error.

In the current study, 475,581 individuals who were aged 40 to 69 years at

recruitment (2006-2010) filled out a short food frequency questionnaire. Dietary
intake was remeasured in a large subsample of 175,402 persons.

At an average follow-up time of 5.7 years, 2609 cases of CRC had occurred. On
multivariable analysis, the hazard ratio (HR) for incident CRC was 1.20 among
persons who consumed an average of 76 g/day of red meat or processed meat in
comparison with those who consumed an average of 21 g/day (per 50-g/day
increment: HR, 1.17).

Red Meat Increases Risk

For red meat, the HR was 1.15 for persons who consumed an average 54 g/day
compared with those who reported consuming an average of 8 g/day (per 50-g/day
increment: HR, 1.18). For processed meat, the HR was 1.19 for those who
consumed 29 g/day compared with those who consumed an average of 5 g/day (per
25-g/day increment: HR, 1.19).

Dr Key and colleagues also evaluated the effect of other foods and alcohol. They
found that fiber intake from bread and breakfast cereals was associated with a
reduced risk for CRC (HR for the highest vs lowest fifth of intake,
0.86; Ptrend=.005).

Intakes of fruit and vegetable fiber were not associated with risk for CRC
(Ptrend=.728 and P trend=.633, respectively). With regard to the consumption of
alcoholic beverages, beer was associated with an increased risk for CRC (HR for
each 10-g/day increment of alcohol from beer, 1.11). For each 10-g/day increment
of alcohol from wine, the HR was 1.05; for each 10-g/day increment of alcohol
from spirits, the HR was 1.08.

Commenting on the study, Gunter Kuhnle, PhD, an associate professor of nutrition

and health at the University of Reading, United Kingdom, told Medscape Medical
News that he feels the study primarily confirms previous results that show an
association between the intake of red meat and processed meat and CRC. "This had
been shown in a number of observational studies," he said. "By confirming these
results, the study obviously strengthens the evidence, especially as it was conducted
in a very different cohort from previous studies.

"The more interesting aspect of the study, in my opinion, is the results for fiber,"
Dr Kuhnle added. "Again, they are not new, but confirm and strengthen the
evidence we have that show that fiber intake can mitigate the risk of red/processed
meat."

The study was supported by Girdlers' New Zealand Health Research Council
Fellowship, Cancer Research UK, the UK Medical Research Council, and the
Wellcome Trust. The authors have disclosed no relevant financial relationships.

Int J Epidemiol. Published online April 17, 2019.

 Study Highlights

 Study data were drawn from the UK Biobank, which enrolled adults between the
ages of 40 and 69 years from 2006 to 2010. Adults with previous diagnoses of
cancer other than nonmelanoma skin cancer were excluded from the present
analysis.
 Participants completed an initial survey of 29 questions regarding their diet, as well
as 18 questions about alcohol consumption. Nearly half the study cohort also
completed at least 1 follow-up 24-hour dietary recall assessment after the survey.
 Researchers used cancer and death registries to find incident cases of CRC through
2014.
 The main study analysis divided participants into quartiles on the basis of their
consumption of certain foods and beverages. These quartiles were compared
regarding their risk for incident CRC. The study analysis adjusted for demographic,
health habit, and family history data, as well as waist circumference, parity,
menopause status, and the use of supplements and aspirin or ibuprofen.
 475,581 adults provided data for study analysis, and 2609 of these participants
developed CRC during a mean follow-up period of 5.7 years.
 Participants who consumed more red and processed meat had higher rates of
smoking and alcohol use, and lower consumption of dietary fiber.
 The HR for CRC in comparing the highest and lowest quartiles of red meat and
processed meat consumption was 1.20 (95% CI, 1.04-1.37).
 Increasing processed meat consumption by the equivalent of 1 strip of bacon or 1
slice of ham per day was associated with a 19% higher risk for CRC. Similarly,
increasing daily red meat intake by the equivalent of 1 thick slice of roast beef was
associated with an 18% increase in the risk for CRC.
 Adding fish (oily or nonoily) or milk to the diet had no significant effect on the risk
for CRC. In contrast, each 10 g/day increase in alcohol consumption was associated
with a HR of 1.06 (95% CI, 1.03-1.10) for CRC.
 The HR for CRC in comparing the highest and lowest intakes of bread and breakfast
cereals was 0.86 (95% CI, 0.76-0.98). However, the consumption of fruits and
vegetables did not significantly affect the risk for CRC.
 Other foods and beverages that did not significantly affect the risk for CRC included
poultry, cheese, tea, and coffee.
 The positive relationships between the consumption of red meat, processed meat,
and alcohol and the risk for CRC were significant among men, but not women.
 There was no heterogeneity between colon and rectal cancer for any of the risk
factors analyzed. However, red meat, processed meat, and alcohol were more likely
to promote distal vs proximal colon cancer.
Clinical Implications

 A previous meta-analysis found that both occupational and leisure-time physical

activity were associated with a lower risk for colon cancer among men, but only
leisure-time physical activity was associated with a lower risk for colon cancer
among women. Physical activity was not effective in preventing rectal cancer in
women or men.
 The current study demonstrates that the consumption of red meat, processed meat,
and alcohol were associated with higher risks for CRC, especially among men.
 Implications for the Healthcare Team: The current study describes foods and
beverages to target in counseling patients to reduce the risk for CRC.
CME Test

To receive AMA PRA Category 1 Credit™, you must receive a minimum score of
75% on the post-test.

Question 1 of 2

You are seeing a 44-year-old man who is interested in doing everything he can to
prevent cancer. What can you tell him about the results of the previous meta-
analysis by Samad and colleagues regarding physical activity and the risk for
colorectal cancer (CRC)?

Physical activity was effective in preventing the risk for colon cancer among
women only

Physical activity was effective in preventing the risk for colon cancer among men
only

Only leisure-time physical activity was effective in preventing the risk for colon
cancer among women and men

Physical activity was not effective in preventing the risk for rectal cancer
Question 2 of 2

2. Which one of the following foods or beverages had the most significant effect on
the risk for CRC in the current study by Bradbury and colleagues?

Coffee
Alcohol

Vegetables

Poultry
 Below are all the test questions with an explanation of the correct answer.

1. You are seeing a 44-year-old man who is interested in doing everything he can to
prevent cancer. What can you tell him about the results of the previous meta-
analysis by Samad and colleagues regarding physical activity and the risk for
colorectal cancer (CRC)?

Answer: Physical activity was not effective in preventing the risk for rectal cancer
This previous meta-analysis found that both occupational and leisure-time physical
activity were associated with a lower risk for colon cancer among men, but only
leisure-time physical activity was associated with a lower risk for colon cancer
among women. Physical activity was not effective in preventing rectal cancer in
women or men.

2. 2. Which one of the following foods or beverages had the most significant effect on
the risk for CRC in the current study by Bradbury and colleagues?

Answer: Alcohol
The current study demonstrates that the consumption of red meat, processed meat,
and alcohol were associated with higher risks for CRC. The consumption of fruits,
vegetables, poultry, and coffee did not significantly affect the risk for CRC.
Increased consumption of fiber from bread and breakfast cereal was associated with
a lower risk for CRC.