Tag: colorectal cancer

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Disappointing Colorectal Cancer Screening Results with Colonoscopy

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Colon cancer cells
Colon cancer cells. Source: National Cancer Institute on Unsplash

A randomised study of northern European data shows that colonoscopy screening reduces the risk of colorectal cancer by 18%, much smaller than experts previously assumed. The results of the study appear in the New England Journal of Medicine.

Colonoscopy may not even perform better than screening with faecal tests, said Louise Emilsson, docent at the Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, and national Swedish principal investigator of the study.

Prior to the publication of this study, experts assumed that screening with colonoscopy had significantly better effect than screening with faecal tests. Faecal tests are used in colorectal cancer screening programs in many countries, and other countries have introduced screening with colonoscopy based on the fact that researchers via observational and modelling studies estimated that up to nine out of ten cases of colorectal cancer could be prevented with a colonoscopy screening. With faecal tests, similar models has estimated the effect to be two to three out of ten.

In the NordICC study, the researchers investigated the extent to which colonoscopy screening actually prevents colorectal cancer. Overall, 1.2% of those randomised to no screening were diagnosed with colon cancer during ten years, compared to 0.98% in those offered screening.

This translates to an 18% reduced risk of colorectal cancer among the participants who were offered colonoscopy screening. Furthermore, 455 colonoscopies were required to prevent one single case of colorectal cancer. Colonoscopy is fairly invasive and costly procedure, involving preparation, bowel prep with laxatives, and a 30-45 minute examination of the bowel with a camera inserted via the rectum. The figure of 455 procedures to prevent one case of cancer is certainly disappointing, Louise Emilsson concluded.

Colorectal cancer mortality was also found to be lower than expected in the NordICC study. Only three in a thousand died of the disease within ten years, regardless of whether they were offered screening or not, and thus, there was no significant difference between the groups in terms of mortality. The low mortality rate is however encouraging and likely caused by significantly improved treatment options over the past ten years.

Source: Karolinska Institutet

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Can a Banana per Day Keep the Oncologist Away?

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Banana
Photo by Mike Dorner on Unsplash

A trial in people with hereditary colon cancer has shown that daily supplements of resistant starch, equivalent to a slightly green banana per day, had a major preventative effect against many cancers. Published in Cancer Prevention Research, the findings showed that, while bowel cancers were unaffected, the supplement reduced cancers in other parts of the body by more than half.

This effect was particularly pronounced for upper gastrointestinal cancers including oesophageal, gastric, biliary tract, pancreatic and duodenum cancers. What is even more remarkable is that the effects lasted for 10 years after the participants stopped taking the supplements.

The CAPP2 trial involved almost 1000 patients with Lynch syndrome from around the world and revealed that a regular dose of resistant starch, also known as fermentable fibre, taken for an average of two years, cut their risk for many cancers.

The present study is a planned double blind 10 year follow-up, supplemented with comprehensive national cancer registry data for up to 20 years in 369 of the participants.

A previous study as part of the same trial and published in The Lancet revealed that aspirin reduced cancer of the large bowel by 50%.

“We found that resistant starch reduces a range of cancers by over 60%. The effect was most obvious in the upper part of the gut,” explained Professor John Mathers at Newcastle University. “This is important as cancers of the upper GI tract are difficult to diagnose and often are not caught early on.

“Resistant starch can be taken as a powder supplement and is found naturally in peas, beans, oats and other starchy foods. The dose used in the trial is equivalent to eating a daily banana; before they become too ripe and soft, the starch in bananas resists breakdown and reaches the bowel where it can change the type of bacteria that live there.

“Resistant starch is a type of carbohydrate that isn’t digested in your small intestine, instead it ferments in your large intestine, feeding beneficial gut bacteria – it acts in effect, like dietary fibre in your digestive system. This type of starch has several health benefits and fewer calories than regular starch. We think that resistant starch may reduce cancer development by changing the bacterial metabolism of bile acids and to reduce those types of bile acids that can damage our DNA and eventually cause cancer. However, this needs further research.”

Professor Sir John Burn, from Newcastle University and Newcastle Hospitals NHS Foundation Trust who ran the trial with Prof Mathers, said: “When we started the studies over 20 years ago, we thought that people with a genetic predisposition to colon cancer could help us to test whether we could reduce the risk of cancer with either aspirin or resistant starch.

“Patients with Lynch syndrome are high risk as they are more likely to develop cancers so finding that aspirin can reduce the risk of large bowel cancers and resistant starch other cancers by half is vitally important.

“Based on our trial, NICE now recommend Aspirin for people at high genetic risk of cancer, the benefits are clear – aspirin and resistant starch work.”

Between 1999 and 2005, nearly 1000 participants began either taking resistant starch in a powder form every day for two years or aspirin or a placebo.

At the end of the treatment stage, there was no overall difference between those who had taken resistant starch or aspirin and those who had not. However, the research team anticipated a longer-term effect and designed the study for further follow-up.

During follow-up, only five new cases of upper GI cancers were diagnosed among the 463 participants who had taken the resistant starch compared with 21 among the 455 who were on the placebo.

The team are now leading the international trial, CaPP3, involving more than 1800 participants with Lynch syndrome to look at whether smaller, safer doses of aspirin can be used to help reduce the cancer risk.

Source: Newcastle University

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Living Donors Liver Transplant a Viable Option in Colorectal Cancer

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Doctors and nurses performing a surgery
Photo by Piron Guillaume on Unsplash

A recent study published in JAMA Surgery has demonstrated the viability of living-donor liver transplant for patients who have systemically controlled colorectal cancer and liver tumours that cannot be surgically removed.

“This study proves that transplant is an effective treatment to improve quality of life and survival for patients with colorectal cancer that metastasised to the liver,” said senior study author Dr Gonzalo Sapisochin.

The study focused on colorectal cancer partly for its tendency to spread to the liver. Nearly half of all patients with colorectal cancer develop liver metastases within a few years of diagnosis and 70% of liver tumours in these patients cannot be removed without removing the entire liver.

Unfortunately, most of these patients cannot get deceased-donor liver transplants because their liver function is fairly normal in spite of their tumours. This puts them near the bottom of the national organ transplant waiting list.

Thanks to recent advances in cancer treatments, many of these patients are able to get their cancer under systemic control, which means only their liver tumours prevent them getting a ‘cancer free’ label. It also increases the odds that these patients – and their new livers – will remain cancer free, which is crucial when balancing the benefit to the patient with the risk to a living donor.

“I’ve seen so many cancer patients, whose cancers were not spreading, but we couldn’t remove the tumours from their livers and we knew they would die,” said first study author Dr Roberto Hernandez-Alejandro. “We hoped living-donor liver transplant could give them another chance.”

Because it offered a last resort, the study attracted patients from near and far. All patients and donors went through a rigorous screening process to ensure they were good candidates for the procedure, and they were educated about the risks of the surgery and the possibility of cancer recurrence.

Patients and donors underwent staggered surgeries to fully remove patients’ diseased livers and replace them with half of their donors’ livers. Over time, both patients’ and donors’ livers regenerated and regain normal function.

Patient imaging and blood analysis was closely monitored for any signs of cancer recurrence and will continue to be followed for up to five years after their surgery. At the time of study publication, two patients had follow-up of two or more years and both remained alive and well, cancer-free.

“We have seen very good outcomes with this protocol, with 100 percent survival and 62 percent of patients remaining cancer free one year and a half after surgery,” said study author Dr Mark Cattral. “It is very strong data to support that we can offer this treatment safely and make appropriate use of scarce life-saving organs.”

Source: University Health Network

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Taller Adults Have a Greater Colorectal Cancer Risk

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Photo by Monstera from Pexels

Taller adults may be more likely than shorter ones to develop colorectal cancer or precancerous colon polyps, according to a new meta-analysis published in Cancer Epidemiology, Biomarkers & Prevention. While the association between taller height and colorectal cancer has been previously investigated, the researchers say those studies offered conflicting results, used inconsistent measures of height and did not include the risk of adenomas.

“This is the largest study of its kind to date. It builds on evidence that taller height is an overlooked risk factor, and should be considered when evaluating and recommending patients for colorectal cancer screenings,” said Associate Professor Gerard Mullin, MD. Greater height is still not proven to be causative, nor is it a great a risk factor as genetics, he and his team cautioned. However, it does add to long-standing evidence linking height to colorectal cancer risk.

“One possible reason for this link is that adult height correlates with body organ size. More active proliferation in organs of taller people could increase the possibility of mutations leading to malignant transformation,” said co-first author Elinor Zhou, MD.

The researchers first identified 47 international, observational studies involving 280 660 cases of colorectal cancer and 14 139 cases of colorectal adenoma. They also included original data from the Johns Hopkins Colon Biofilm study, which recruited 1459 adult patients undergoing outpatient colonoscopies to investigate the relationship between cancer and biofilm on the colon.

Because the definition of tallness differs around the world, the researchers compared the highest versus the lowest height percentile of various study groups. “The findings suggest that, overall, the tallest individuals within the highest percentile of height had a 24% higher risk of developing colorectal cancer than the shortest within the lowest percentile. Every 10-centimeter increase (about 4 inches) in height was found to be associated with a 14% increased risk of developing colorectal cancer and 6% increased odds of having adenomas,” said A/Prof Mullin.

In the US, the average height for men is 175.3cm, and for women it is 162.6 inches. This means men who are 185.4cm and women who are 172.7cm (10cm above the average US height) or taller are at a 14% increased risk of colorectal cancer and a 6% increased risk of adenomas.

The percentage results were adjusted for known risk factors of colorectal cancer, including non-modifiable factors such as age, familial colorectal cancer history and a personal history of chronic inflammatory bowel disease. Though not directly comparable due to differences in measurement scale, tallness may impart an order of magnitude of colorectal cancer risk similar to better-known modifiable factors such as cigarette smoking, moderate alcohol consumption and high processed red meat intake. At present, gastroenterologists focus on genetic and age-related risks for colorectal cancer screenings recommendations.

While colorectal cancer is the third most common cancer in both men and women in the US, fewer people are diagnosed with colorectal cancer each year has dropped overall since the mid-1980s, mainly due to prevention and screening. However, the downward trend is mostly in older adults. Among adults under 50, colorectal cancer deaths have increased 2% per year from 2007 to 2016, an as yet unexplained phenomenon.

“Greater awareness by the public and government will help promote more interest and funding for more research, which ultimately could change guidelines for physicians to consider height as a risk for cancer,” said A/Prof Mullin. “There are well-known modifiable dietary associations for colorectal cancer, such as processed red meats and smoking, but guidelines currently are fixated on family history, and height is clinically neglected when it comes to risk screening.”

Dr Zhou says more research is needed to define particular taller populations at risk for colon cancer. “For instance, tall athletes and individuals with inherited tallness, such as those with Marfan syndrome, could be screened earlier and the impact of height further explored,” she said. “We need more studies before we can definitively say at what height you would need earlier colorectal cancer screening.”

Source: John Hopkins Medicine

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In Metastatic Colon Cancer, Youth is no Advantage

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Colon cancer cells. Source: National Cancer Institute on Unsplash

Even though young patients with metastatic colorectal cancer tend to be more fit and receive more intensive treatment than older patients, both groups survive for roughly the same amount of time, according to a new study by Dana-Farber Cancer Institute investigators.

The findings, published in the Journal of the National Cancer Institute, come as colorectal cancer rates in young people are rising. The researchers said the results are somewhat surprising, as younger patients, who usually have fewer complicating health factors, might be expected to survive longer than older patients.

“As a group, younger patients are more physically active and have higher performance status and are better able to perform the activities of daily living than older patients. They also tend to be treated with higher doses of therapy and have less severe side effects,” said study senior author Kimmie Ng, MD, MPH, director of the Young-Onset Colorectal Cancer Center at Dana-Farber. “This is the first study to compare survival in younger versus older patients participating in a clinical trial of treatment for metastatic colorectal cancer.”

The study drew on clinical trial data which tested a combination of chemotherapy and biologic therapy in patients with metastatic colorectal cancer, comparing patients under 50 with those over 50.

“We found no significant difference in overall survival between the two groups,” said Dana-Farber’s Marla Lipsyc-Sharf, MD, the first author of the study. The median survival for patients with young-onset colorectal cancer was 27.07 months vs. 26.12 months for the older-onset group. Progression-free survival – how long patients lived before the cancer worsened – was also similar for the two groups: 10.87 months for the younger patients vs. 10.55 for the older ones.

Confounding expectations even further, patients under age 35 had the shortest median overall survival of any age group: 21.95 months vs 26.12 months in older-onset patients. Because the study included relatively few patients younger than 35, the difference is not considered statistically significant, researchers noted, but it aligns with previous research suggesting that very young patients have worse outcomes.

Cases are markedly on the rise: between 2000 and 2013, incidence of the disease in people under age 50 increased approximately 22%, even as overall incidence of colorectal cancer has declined. Yet despite a wellspring of new research, no definitive cause for the increase has been found.

“If current trends hold, colorectal cancer is projected to be the second leading cancer and leading cause of cancer death in patients ages 20–49 by the year 2040,” Lipsyc-Sharf stated. “It is important to understand survival in this population in order to develop tailored treatments.”

That younger patients fare no better than older ones despite more favourable factors could suggest that colorectal cancer is more aggressive at an earlier age. But there is no conclusive evidence that that is the case.

“Research has yet to identify consistent molecular differences in the colorectal cancer cells of younger patients and older patients,” Dr Lipsyc-Sharf noted. Current studies also are exploring whether differences in the intestinal microbiome of younger and older patients might explain the increased incidence of early-onset colorectal cancer.

Source: Dana Farber Cancer Institute

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Second or Third-degree Relatives Still Share Colon Cancer Risk

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Colon cancer cells. Source: National Cancer Institute on Unsplash

A new study has found that having second- or third-degree relatives with colorectal cancer increases a person’s risk of developing the disease.

Early colonoscopy screening is often recommended for first-degree relatives of someone diagnosed with early-onset (before age 50) colorectal cancer, cases of which have been increasing significantly over the past few decades. But the study suggests that early screening may be beneficial for second- and third-degree relatives as well.

The study reviewed more than 1500 early-onset colon cancer cases in the Utah Cancer Registry,found that first-degree relatives of someone diagnosed with early-onset colorectal cancer are 6 times more likely to be diagnosed with colorectal cancer before age 50, while second-degree relatives (aunts, grandparents etc) are 3 times likelier and third-degree relatives (first cousins etc) 1.56 times likelier.

“Our study provides new insight into the magnitude of risk for more distant relatives of colorectal cancer cases, and in particular, for relatives of cases who were diagnosed before age 50,” said first author Heather Ochs-Balcom, associate professor of epidemiology and environmental health, UB School of Public Health and Health Professions. “This work is important given the rising rates of early-onset colorectal cancer.”

There was also 2.6-fold higher risk of colorectal cancer at any age if they have a first-degree relative with early-onset colon cancer. The risk is 1.96 and 1.3 times greater for second- and third-degree relatives, respectively. In addition, the risk for all degrees of relatives for early-onset colon cancer is higher than the risk for colon cancer at any age.

The findings, published in Cancer Epidemiology, suggest that early colonoscopy screening may be beneficial for second-degree relatives and possibly third-degree relatives, in addition to first-degree relatives of individuals diagnosed with colorectal cancer before age 50.

The researchers also point out that relatives may benefit from being more aware of their extended family history and sharing this information with their physician when making cancer-screening decisions.

Source: University at Buffalo

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Could Cutting Sugary Drinks Reduce Cancer Risk in Women?

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A higher intake of sugar-sweetened beverages (SSBs) in adulthood and adolescence was linked to an increased risk of early-onset colorectal cancer (CRC) in women, according to data from a large prospective study.

The Nurses’ Health Study II followed over 95 000 registered nurses from 1991 to 2015. Those consuming at least two SSB servings a day in adulthood had more than double the early-onset CRC risk of those consuming less than one serving a week. This rose by 16% with each extra serving per day.

In the adolescent years of ages 13 to 18, each serving-per-day increment was associated with a 32% higher risk of early-onset CRC. Meanwhile, replacing each SSB serving per day for adults with a serving of a non-SSB drink was associated with a 17-36% lower risk.

“Considering the well-established, adverse health consequences of SSBs and the highest consumption being characterized in adolescents and young adults under age 50 years, our findings reinforce the public health importance of limiting SSB intake for better health outcomes,” Yin Cao, ScD, MPH, of Washington University in St. Louis, and co-researchers wrote.

Although CRC has been on the decline, the age of early onset — that is, diagnosed before age 50 — has been increasing the past two decades. In comparison to adults born around 1950, those born around 1990 had twice the colon cancer risk and four times the rectal cancer risk.

An estimated 12% of the US population currently consume more than three SSB servings per day, as shown by National Health and Nutrition Examination Survey data. SSBs in the US are often include high fructose corn syrup as an ingredient, as opposed to South Africa which uses cane sugar.

In this study, the population consisted overwhelmingly of white females, ages 25 to 42, with an average age of approximately 42 at enrollment. Over up to 24-plus years of follow-up, 109 cases of early-onset CRC were recorded.

The researchers found that those with higher SSB intakes in adulthood tended to be less physically active and more likely to have a lower endoscopy history, to use non-steroidal anti-inflammatory drugs, and consume red and processed meats. They were also less likely to take multivitamins and to have a reduced intake of alcohol, fibre, folate, and calcium, and to have a poorer diet overall.

No association was found between intake of artificially sweetened beverages or fruit juice in adulthood and risk of early-onset CRC, mirroring past research.

The investigators listed a number of possible pathways for the effect of SSBs on early-onset CRC. 

For example, compared with isocaloric solid foods, energy-containing beverages do not create a feeling of satiation, leading to weight gain. SSBs also initiate rapid blood glucose response and insulin secretion, possibly leading to insulin resistance, inflammation, obesity, and type 2 diabetes — metabolic conditions which are linked to heightened CRC risk.

Other possibilities include intestinal dysbiosis and endotoxemia caused by high fructose levels , the principal sweetener in SSBs in the US and certain other countries, which can impair gut barrier function, increasing gut permeability, and possibly promote cancer formation. A recent experimental study suggested that the high-fructose corn syrup in SSBs from the US enhanced the growth of aggressive tumours in mice, regardless of weight and metabolic syndrome.

High-fructose corn syrup has also been linked to metabolic dysregulation, regardless of obesity.

Fortunately, overall SSB intake has been trending downward in recent years, and Dr Cao and co-authors concluded that further limiting consumption may be “an actionable strategy to curb the rising incidence of [early-onset] CRC.”

Study limitations, the researchers said, included possible unknown confounding variables, the few early-onset CRC cases prevented pinpointing the window of exposure, and there weren’t enough diabetic participants to stratify by a personal history of diabetes. Since the participants were mostly white women, the results were not readily generalisable to other ethnic groups or to men.

Source: MedPage Today

Source Reference: Hur J, et al “Sugar-sweetened beverage intake in adulthood and adolescence and risk of early-onset colorectal cancer among women” Gut 2021; DOI: 10.1136/gutjnl-2020-323450.

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Colorectal Cancer Risk Is Not Reduced by Maintaining Weight

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A new study shows that, contrary to conventional wisdom, significant weight changes before treatment do not by themselves increase the mortality risk from colorectal cancer, rather it is changes in body composition.

In a population-based cohort study, for every 5% loss of body weight after colorectal cancer diagnosis had a 41% increased mortality risk.

“The conventional wisdom has been that colorectal cancer patients should avoid losing or gaining weight during treatment,”  explained Dr Justin C Brown, Assistant Professor and Director of Cancer Metabolism Program, Pennington Biomedical Research Center. “But maintaining your weight does not mean your body composition remains the same. Muscle can change quite dramatically, and those changes are associated with a much higher risk of death.”

“This study highlights how body composition can have a powerful impact on long-term health. We at Pennington Biomedical are committed to conducting innovative research to enable cancer survivors around the world to achieve their best possible health,” said Dr John Kirwan, Executive Director.

The study enrolled 1921 patients with stage I-III colorectal cancer, measuring skeletal muscle and body weight at diagnosis and then an average of 15 months later. The definition of stable body weight was a change of less than 5% of weight at diagnosis.

Researchers found having a stable body weight hides changes in skeletal muscle loss. Women were particularly vulnerable to losing muscle. One in five women with stable body weight lost muscle, while less than one in 10 men did.

“More research is needed to determine whether physical activity offers the best solution to prevent muscle loss or fatty deposits in muscle,” Dr Brown said. “But the findings provide colorectal cancer patients with more incentive to engage in physical activity programs that maintain and build muscle.”

Source: News-Medical.Net