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Evidence-based Counseling for GI Malignancy Risk Reduction

Evidence-based Counseling for GI Malignancy Risk Reduction

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Evidence-based Counseling for GI Malignancy Risk Reduction

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  1. Evidence-based Counseling for GI Malignancy Risk Reduction Mark Y. Liu, DO, FAAFP Tripler Army Medical Center Honolulu, Hawaii The views expressed in this presentation are those of the author and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the US Government.

  2. Aloha! 6 Million cans of Spam/year Highest Life Expectancy in the U.S = 80

  3. Case Study • Ashley, a 48 year-old woman, just learned that her 70 year-old father has inoperable gastric cancer. She wants to know if she is at risk of developing gastric cancer because she grew up eating the same smoked meats her father ate. Ashley also asks what she can do to lower her risk of developing this cancer. She has heard that calcium supplements might help prevent gastrointestinal cancers and ask whether she should begin taking a calcium supplement.

  4. Background • 140,000 + develop GI cancers each year • 49,000 die • 9% of all cancer mortalities • Screening and avoidance of risk factors

  5. I. Lifestyle Risk Factors • Lifestyle factors • 2 Major longitudinal studies • Participants with 4 healthful lifestyle factors, had 1/3 the risk of developing cancer • Obesity, smoking, poor diet, physical inactivity

  6. 1. Obesity • 65% overweight, 30% obese • Increases CRC, pancreatic and esophageal CAs • Etiology of 20% of all cancers • Weight reduction leads to 60% less cancer mortality

  7. 2. Smoking • Implicated in 30% of all cancer-related mortalities • Oral cavity, esophagus, pancreas, liver, stomach and colon • All forms of tobacco • Conversely, smoking cessation reduces risk

  8. 3. Diet

  9. 4. Physical Inactivity Physical Activity GI CA risks • 3.5 hours/week of moderate exercise = 24% reduction of CRC risk • Theories: Hormones; Growth Factors Immune function; Prostaglandin

  10. Extra: Alcohol Consumption • 1 Drink (10g) increases risk of cancers of: • Oropharynx • Esophagus • Rectum • Poorly understood • Solvent properties?

  11. II. Heredity • Heredity vs. diet/lifestyle

  12. III. Infections • Helicobacter pylori – Gastric CA • Epstein-Barr virus – Gastric CA • Human papillomavirus – Esophageal CA • JC polymavirus – Colon CA

  13. Chemoprevention • Aspirin • Anti-inflammatory properties • 2007 USPSTF Recommendation • 2011 meta-analysis of 8 trials • Reduces risks for esophageal, gastric, pancreatic and colorectal cancers • 50% reduction of CRC mortalities after 5 years • No dosage difference

  14. Chemoprevention • Vitamin and Mineral Supplementation • Vitamin D, calcium & magnesium • Strongest evidence for calcium – lowers CRC • ACG recommends 3 g/day

  15. Recommendations • Lifestyle counseling • Inquire family history • Rule out infections • Discuss role of chemoprevention

  16. Case Revisited • You inform Ashley that there is association between gastric cancer and diet • You obtain a detailed family history to exclude hereditary syndromes • You order a test for H. pylori infection • You recommend regular use of low-dose ASA • You recommend calcium supplementation for chemoprevention and bone health

  17. References: • American Cancer Society. Cancer facts and figures 2011. Available at Accessed February 2012. • Ford ES, Bergmann MM, Kröger J, et al. Healthy living is the best revenge: findings from the European Prospective Investigation into Cancer and Nutrition-Potsdam study. Arch Intern Med. 2009;169(15):1355-1362. • World Cancer Research Fund, American Institute for Cancer Research. Food, Nutrition, Physical Activity and the Prevention of Cancer: A Global Perspective. Washington, DC: WCRF/AICR; 2007. • Flegal KM, Carroll MD, Ogden CL, et al. Prevalence and trends in obesity among US adults, 1999-2000. JAMA. 2002;288(14):1723-1727. • Renehan AG, Tyson M, Egger M, et al. Body-mass index and incidence of cancer: a systematic review and meta-analysis of prospective observational studies. Lancet. 2008;371:569-578. • Wolin KY, Carson K, Colditz GA. Obesity and cancer. Oncologist. 2010;15(6):556-565. • Adams TD, Gress RE, Smith SC, et al. Long-term mortality after gastric bypass surgery. N Engl J Med. 2007;357(8):753-761. • Sasco AJ, Secretan MB, Straif K. Tobacco smoking and cancer: a brief review of recent epidemiological evidence. Lung Cancer. 2004;45(Suppl 2):S3-9. • Samet JM. The 1990 Report of the Surgeon General: The Health Benefits of Smoking Cessation. Am Rev Respir Dis. 1990;142(5):993-994. • Willett WC, Stampfer MJ, Colditz GA, et al. Relation of meat, fat, and fiber intake to the risk of colon cancer in a prospective study among women. N Engl J Med. 1990;323(24):1664-1672. • Chao A, Thun MJ, Connell CJ, et al. Meat consumption and risk of colorectal cancer. JAMA. 2005;293(2):172-182. • Norat T, Bingham S, Ferrari P, et al. Meat, fish, and colorectal cancer risk: the European Prospective Investigation into cancer and nutrition. J Natl Cancer Inst. 2005;97(12):906-916. • National Cancer Institute. Fact Sheet. Chemicals in meat cooked at high temperatures and cancer risk. Available at Accessed February 2012. • Beresford SA, Johnson KC, Ritenbaugh C, et al. Low-fat dietary pattern and risk of colorectal cancer: the Women’s Health Initiative Randomized Controlled Dietary Modification Trial. JAMA. 2006;295(6):643-654. • Tsugane S, Sasazuki S. Diet and the risk of gastric cancer: review of epidemiological evidence. Gastric Cancer. 2007;10(2):75-83. • You WC, Zhang L, Yang CS, et al. Nitrite, N-nitroso compounds, and other analytes in physiological fluids in relation to precancerous gastric lesions. Cancer Epidemiol Biomarkers Prev. 1996;5(1):47-52. • Larsson SC, Bergkvist L, Wolk A. Processed meat consumption, dietary nitrosamines and stomach cancer risk in a cohort of Swedish women. Int J Cancer. 2006;119(4):915-919. • Takachi R, Inoue M, Ishihara J, et al. Fruit and vegetable intake and risk of total cancer and cardiovascular disease: Japan Public Health Center-Based Prospective Study. Am J Epidemiol. 2008;167(1):59-70. • Park Y, Leitzmann MF, Subar AF, et al. Dairy food, calcium, and risk of cancer in the NIH-AARP Diet and Health Study. Arch Intern Med. 2009;169(4):391-401. • Bingham SA, Day NE, Luben R, et al. Dietary fibre in food and protection against colorectal cancer in the European Prospective Investigation into Cancer and Nutrition (EPIC): an observational study. Lancet. 2003;361(9368):1496-1501. Erratum in Lancet. 2003;362(9388):1000. • Ren JS, Freedman ND, Kamangar F, et al. Tea, coffee, carbonated soft drinks and upper gastrointestinal tract cancer risk in a large United States prospective cohort study. Eur J Cancer. 2010;46(10):1873-1881. • Ezzati M, Lopez AD, Rodgers A, et al. Selected major risk factors and global and regional burden of disease. Lancet. 2002;360(9343):1347-1360. • Wolin KY, Yan Y, Colditz GA, et al. Physical activity and colon cancer prevention: a meta-analysis. Br J Cancer. 2009;100(4):611-616. • Giovannucci E, Ascherio A, Rimm EB, et al. Physical activity, obesity, and risk for colon cancer and adenoma in men. Ann Intern Med. 1995;122(5):327-334.

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