Colon Cancer HealthRisk Assessment

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Medically Reviewed By: Expert-24 Medical Review Board on March 27, 2014 | References | Terms of Use & Privacy

HEALTHTOOLS™ (HEALTHRISK™ AND HEALTHAGE™) DOES NOT PROVIDE MEDICAL ADVICE. It is intended for informational purposes only. It is not a substitute for professional medical advice, diagnosis or treatment. Never ignore professional medical advice in seeking treatment because of something you have read on the site. If you think you may have a medical emergency, immediately call your doctor or dial 911.

Expert Review Panel – Expert-24 Ltd

Terms of reference

The aim of the Expert Review Panel is to ensure that all Expert-24 clinical and epidemiological content is robust, independent and up to date.

Qualifications

Medical Director and Editor

Dr. Timothy Dudley

Chairman of the Expert Review Panel

Dr. Robin Christie

Current authors and reviewers for the Health Risk Assessment

Dr. Martin Dawes

Dr. Jonathan Mant

Emeritus authors and reviewers for the Health Risk Assessment

The following individuals were deeply involved in the creation of the health risk assessment at its inception, but are no longer active reviewers on the panel:

Dr. John Fletcher

Dr. Emma Boulton

Professor Larry Ramsay

Professor Klim McPherson



Patient-centered health risk using an Evidence Based Medicine approach

Who created it and how often is it reviewed and updated?


This health risk assessment is brought to you by Expert-24 Limited. Expert-24 Ltd has full editorial control over content and strives to ensure that the content is: 


Why is this health risk assessment different than others?

Most health risk assessments say if a person is at high, medium or low risk of either dying from or developing a given medical condition. Most also indicate what lifestyle factors contribute to this risk. What they do not say is the magnitude of each risk for an individual and how much that person’s risk will decrease if they change their lifestyle. For example, if one is at moderate risk of two diseases, say bowel cancer and heart disease, most people would be unaware that their risk of heart disease is still five times higher than their risk of bowel cancer. 

In order to construct an electronic risk assessment tool for health and disease states, it is necessary to provide supporting research evidence and a method of encapsulating the best estimate of relative risk. For each medical condition, it is necessary to present credible estimates of risk, based on evidence from relevant, peer reviewed medical research. Important features of the risk assessment tool are: 

The aim of this project is to provide healthy people with a quantitative assessment of their personal risk of developing some important diseases and some of the factors that influence their risk. This is an ambitious task and we would not claim to have produced the definitive approach. Although we believe this is the most informative collection of disease prediction equations available at the present time they do have limitations. The ones we are aware of are outlined below.

What exactly does a given percentage risk mean?

Someone looking at their risk of lung cancer until the age of 50 should read this model as saying, "Assuming survival to age 50 the chance of developing lung cancer during that time would be (some predicted value)". This approach has the appeal that changing risk factors will have the expected impact on cumulative risk and the mathematics remains transparent. We chose the risk of developing a certain condition rather than the risk of dying from it because for many people the fear of living and dealing with a disabling disease is as frightening as dying from it. 

This is different than lifetime risk calculations, which generally calculate the risk of dying from a given condition. Lifetime risk must take account of the fact that we all die of something in the end and calculating the relative contribution of common competing causes of death at various ages is difficult. Not only that, but the interpretation by users is complex. For example, a user of an interactive model predicting lifetime risk of lung cancer would see their individual risk of lung cancer fall with increasing cigarette consumption, because they would be dying of heart disease and chronic lung disease before they could get lung cancer.


How accurate are these percentages?

These models are good for illustrating the change in risk due to the presence or absence of single risk factors for prediction times of up to 5 years. They are likely to be reasonably good for 15 or 20 years and for combinations of several risk factors. For longer prediction times and varying more than, say, four risk factors the results should be regarded as illustrative rather than precise. The absolute level of risk for an individual may also be wide of the mark because the majority of overall risk remains unexplained in most research studies. This is why "confidence intervals" have not been included. That said these prediction equations do calculate the best estimate of risk that can be provided on the data given. 

Is this useful in the end? We believe it is. We believe that putting some quantification on risk allows users to explore the possible impact on their health of altering what they do. We find this approach more informative than a bland statement of "high risk" that is often value laden or that a certain action will "cut down" a risk without any indication of by how much.

Is risk really reversible?

This is a difficult question to answer, but in many cases the answer seems to be, "yes". This is good news for people with high risks who are older. Intuition might tell you that you are constantly doing damage to your body that accumulates over time, and in many cases that may be true. An example of this is in skin cancer, where the earlier and more often you are badly burned in life, the higher your risk of skin cancer. Staying out of the sun when you are old cannot reverse this risk. 
However, there is good evidence that for heart disease, for example, your risks can be significantly reduced no matter what your age. Cholesterol reduction by medications called "statins" reduces the risk of heart attack, angina or sudden death from heart problems by up to 30%, and this is entirely independent of age. Similarly, blood pressure reduction by drugs reduces the risk of stroke and heart disease by 25% - again entirely independent of age. Because in general it is older people who have the highest risks, they actually stand to benefit the most from treatment. 

The risk for developing heart disease in tobacco users has been shown to decline to a level comparable with a person who has never smoked within 2-3 years of giving up. Furthermore, the risk of having a stroke is reversed after 5-10 years of stopping. Studies have also shown that life expectancy improves even in people who stop smoking later in life (i.e. at 65 years or older). 

The reduction of risk that can be obtained from changing lifestyle habits such as diet, alcohol consumption and exercise is largely unknown. Therefore, the amount of risk reduction that can be expected from optimizing these habits needs to be viewed with caution. Certainly they should not take the place of blood pressure control, cholesterol control, and smoking cessation as goals.


How good is the evidence?

Our aim in searching for evidence was to identify up to ten high quality, relevant research studies for each topic. We used Medline to search using free text, MeSH terms and thesaurus search terms specific to each medical condition. To narrow the documents we used filters using "risk" and study design type; cohorts, case control, longitudinal, follow up. Searches were limited to studies published in English language and human studies. Although a comprehensive systematic review of the literature on each disease was not possible due to the scope of this project, we feel that the evidence used represents a reasonable cross-section of high-quality literature on the subjects in question. 
What we have done is to seek out plausible values of relative risk to use in the prediction equations. We have used an approach that searches for high quality research studies and have then applied our judgment tempered by Austin Bradford Hill's criteria for causation when selecting which risks to use. Hill's criteria are: strength, consistency, specificity, temporality, biological gradient, plausibility, coherence, experimental evidence and analogy. 

If this sometimes appears somewhat subjective then that is because at times it is a matter of judgment. The judgments have seldom altered the relative risk by more than a small amount. For each risk factor we had to choose a value to use in the model and have been faced at times with a range from which to choose. While a meta-analysis may provide the best point estimate, one is not always available and would be spurious to conduct on the sample of studies we have used for each condition. Given the level of uncertainty surrounding an individual's absolute personal risk we are comfortable with a comparatively lesser degree of uncertainty regarding a risk factor's relative risk.

What is the mathematical model that is used?

The actual mathematical and statistical models and risk coefficients that are used to determine risk are proprietary at this time, but have been validated by the authors and reviewers to be appropriate for use in this setting. 

References: Colon Cancer

Most recently reviewed:

  1. 1. Gonzalez CA and Riboli E. Diet and Cancer Prevention: Contributions from the European Prospective Investigation into Cancer and Nutrition Study. Euro J Cancer 46 (2010) 2555 –2562.
  2. Food, Nutrition, Physical Activity and the Prevention of Cancer: A Global Perspective. World Cancer Research Fund and the American Institute for Cancer Research. 2007 Part
  3. Chapter 4.
  4. Park 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
  5. Fedirko V et al. Alcohol Drinking and Colorectal Cancer Risk: an Overall and Dose-Response Meta-analysis of Published Studies. Annals Onc. Feb. 2011: 2-15.

Guidelines reviewed annually:

  1. NHS Cancer screening programmes at: http://www.cancerscreening.nhs.uk/
  2. US National Cancer Institute at: www.cancer.gov and http://www.cancer.gov/colorectalcancerrisk/

Selected articles from previous reviews:

  1. Limsui D et al. Cigarette smoking and colorectal cancer risk by molecularly defined subtypes. JNCI 2010; 102(14): 1012-1022
  2. Gonzalez CA and Riboli E. Diet and cancer prevention: Contributions from the European Prospective Investigation into Cancer and Nutrition (EPIC) study. European Journal of Cancer 2010; 46: 2555-2562.
  3. Soderlund S et al. Inflammatory bowel disease confers a lower risk of colorectal cancer to females than to males. Gastroenterology Vol 138, Issue 5, 1697-1703, May 2010.
  4. Peter M Rothwell et al. Long-term effect of aspirin on colorectal cancer incidence and mortality: 20-year follow-up of five randomised trials Lancet 2010; 376: 1741–50
  5. Van Duijnhoven, FJB et al. Fruit, vegetables, and colorectal cancer risk: the European Prospective Investigation into Cancer and Nutrition. Am J Clin Nutr 2009; 89: 1441-1452.
  6. Wolin KY et al. Physical Activity and colon cancer prevention: a meta-analysis. British J Cancer (10 Feb. 2009) 100, 611-616.
  7. Freedman, AN et al. Colorectal Cancer Risk Prediction Tool for White Men and Women Without Known Susceptibility. J Clin Onc 2009 (vol.27 no.5): 686-693
  8. Edoardo Botteri, M.Sc. et al. Smoking and Colorectal Cancer: a meta-analysis. JAMA 2008; 300(23): 2765-2778.
  9. Levin, B et al. Screening and surveillance for the early detection of colorectal cancer and adenomatous polyps, 2008. A joint guideline from the American Cancer Society, the US Multi-society Task Force on Colorectal Cancer, and the American College of Radiology. CA Cancer J Clin 2008; 58: 130-160.
  10. Larsson DC, Wolk A. Obesity and colon and rectal cancer risk: meta-analysis of prospective studies. Am. J. Clin. Nutr. 2007 Sep; 86 (3): 556-65.
  11. Park Y et al. Fruit and Vegetable Intakes and Risk of Colorectal Cancer in the NIH-AARP Diet and Health Study. Am J Epidemiology 2007; 166(2): 170-180
  12. Itzkowitz SH and Yio X. Inflammation and Cancer IV. Colorectal cancer in inflammatory bowel disease: the role of inflammation. Am J Physiol. Gastro Liver Physio 287:G7-G17, 2004
  13. Benetou, V. et al. Conformity to traditional Mediterranean diet and cancer incidence: Greek EPIC cohort. British J. Ca. (1 July, 2008) 99, 191-195
  14. Segnan N, Senore C, Andreoni B, et al, for the SCORE3 Working Group-Italy. Comparing attendance and detection rate of colonoscopy with sigmoidoscopy and FIT for colorectal cancer screening. Gastroenterology 2007;132(7):2304-2312.
  15. Kushi, L.H. et al. American Cancer Society Guidelines on Nutrition and Physical Activity for Cancer Prevention: Reducing the Risk of Cancer With Healthy Food Choices and Physical Activity CA Cancer J. Clin. 2006; 56 (5):254-281
  16. Sanjoaquin MA et al. "Folate intake and colorectal cancer risk: a meta-analytical approach", Int J Cancer Feb 2005, 113(5): 825-8.
  17. Cho E et al. :Dairy foods, calcium and colorectal cancer: a pooled analysis of 10 cohort studies", J Natl Cancer Inst. July 2004, 96(13): 1015-22.
  18. Colangelo LA et al. "Cigarette smoking and colorectal carcinoma mortality in a cohort with long-term follow-up", Cancer Jan 2004 100(2): 288-93
  19. Key TJ et al. "Diet, nutrition and the prevention of cancer", Public Health Nutr. Feb 2004 7(1A): 187-200
  20. Weingarten MA et al. "Dietary calcium supplementation for preventing colorectal cancer and adenomatous polyps. Cochrane Database 2004 (1)CD 003548.
  21. Flanders WD et al. "Meat consumption and risk of colorectal cancer", JAMA Jan 12, 2005 293(2):172-82.
  22. Giovannucci, E., "Modifiable risk factors for colon cancer", Gastroenterology Clinics of North America, 01 Dec 2002; 31(4): 925-43.
  23. Slattery, M.L., "Physical activity and colon cancer: confounding or interaction?" Medicine and Science in Sports and Exercise. 01 June 2002; 34(6): 913-9.
  24. Juarranz, M., "Physical exercise, use of Plantago ovata and aspirin, and reduced risk of colon cancer", European Journal of Cancer Prevention, 01 Oct 2002; 11(5): 465-72.
  25. Bianchini, F., "Overweight, obesity, and cancer risk", Lancet Oncology, 01 Sep 2002; 3(9): 565-74.
  26. Wu, K., "Calcium intake and risk of colon cancer in women and men", Journal of the National Cancer Institute, 20 March 2002; 94(6): 437-46.
  27. Almendingen, K., "Lifestyle-related factors and colorectal polyps: preliminary results from a Norwegian follow-up and intervention study", European Journal of Cancer Prevention, 01 April 2002; 11(2): 153-8.
  28. Jarvinen et al, "Dietary fat, cholesterol and colorectal cancer in a prospective study", Br J Cancer 2001:85:357-61
  29. Fuchs et al, "Dietary fibre and the risk of colorectal cancer and adenoma in women", NEJM 1999:340:169-76
  30. Fernandez et al, "Oral contraceptives and colorectal cancer risk: a meta analysis", Br. J Cancer 2001 84:722-7
  31. Lund Nilsen et al, "Prospective study of colorectal cancer risk and physical activity, diabetes, blood glucose, and BMI: exploring the hyperinsulinaemia hypothesis", Br. J of Cancer 2001 84:417-22
  32. Michels et al, "Prospective study of fruit and vegetable consumption and incidence of colon and rectal cancers", J Natl Cancer Inst 2000; 92:1740-52
  33. Terry et al, "Fruit, vegetables, dietary fibre and risk of colorectal cancer", J of Natl Cancer Inst. 2001; 93 525-33
  34. Terry et al, "Prospective study of major dietary patterns and colorectal cancer risk in women", American Journal of Epidemiology 2001 154:1143-49
  35. Terry et al, "Coffee consumption and risk of colorectal cancer in a population based prospective cohort of Swedish women", Gut 2001 49:87-90
  36. Lindgren et al Gut, "Adenoma prevalence and cancer risk in familial non polyposis colorectal cancer", 2002 50:228-34
  37. Singh et al, "Dietary risk factors for colon cancer in a low risk population", American Journal of Epidemiology 1998 148:761-4
  38. Giovannucci E et al. Physical Activity, Obesity and Risk for Colon Cancer and Adeoma in Men. Ann Inter Med 1995;122:327-334
  39. Fuchs et al, "A prospective study of family history and the risk of colorectal cancer", NEJM 1994 331:1669-74
  40. Howe et al, "Dietary intake of fibre and decreased risk of cancers of the colon and rectum: evidence from the combined analysis of 13 case control studies", J Natl Cancer Inst 1992; 84:1887-1894
  41. Thun et al, "Risk factors for fatal colon cancer in a large prospective study", J Natl Cancer Inst 1992; 84:1491-1499
  42. Shibata et al, "Intake of vegetables, fruits, beta carotene, vitamin C and vitamin supplements and cancer incidence among the elderly: a prospective study", Br. J of Cancer 1992; 66:673-679

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