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CME / ABIM MOC / CE

Can Lifestyle Changes Reduce Colorectal Cancer Risk?

  • Authors: News Author: Laird Harrison; CME Author: Laurie Barclay, MD
  • CME / ABIM MOC / CE Released: 2/17/2023
  • Valid for credit through: 2/17/2024, 11:59 PM EST
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  • Credits Available

    Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™

    ABIM Diplomates - maximum of 0.25 ABIM MOC points

    Nurses - 0.25 ANCC Contact Hour(s) (0 contact hours are in the area of pharmacology)

    Pharmacists - 0.25 Knowledge-based ACPE (0.025 CEUs)

    Physician Assistant - 0.25 AAPA hour(s) of Category I credit

    IPCE - 0.25 Interprofessional Continuing Education (IPCE) credit

    You Are Eligible For

    • Letter of Completion
    • ABIM MOC points

Target Audience and Goal Statement

This activity is intended for gastroenterologists, family medicine/primary care physicians, internists, hematologists/oncologists, nurses, pharmacists, physician assistants, and other members of the healthcare team for patients with or at risk for colorectal cancer (CRC).

The goal of this activity is for learners to be better able to describe the effect of changes in smoking habits, body mass index (BMI), physical activity level, alcohol consumption, and an overall healthy lifestyle index (HLI) combining these 4 factors, on subsequent CRC incidence in the European Prospective Investigation into Cancer (EPIC) cohort.

Upon completion of this activity, participants will:

  • Describe the effect of changes in individual lifestyle habits and overall HLI on subsequent CRC incidence, according to an analysis from the EPIC cohort
  • Identify clinical implications of the effect of changes in individual lifestyle habits and overall HLI on subsequent CRC incidence, according to an analysis from the EPIC cohort
  • Outline implications for the healthcare team


Disclosures

Medscape, LLC requires every individual in a position to control educational content to disclose all financial relationships with ineligible companies that have occurred within the past 24 months. Ineligible companies are organizations whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

All relevant financial relationships for anyone with the ability to control the content of this educational activity are listed below and have been mitigated. Others involved in the planning of this activity have no relevant financial relationships.


News Author

  • Laird Harrison

    Freelance writer, Medscape

    Disclosures

    Laird Harrison has no relevant financial relationships.

CME Author

  • Laurie Barclay, MD

    Freelance writer and reviewer
    Medscape, LLC

    Disclosures

    Laurie Barclay, MD, has no relevant financial relationships. 

Editor/Compliance Reviewer

  • Amanda Jett, PharmD, BCACP

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Amanda Jett, PharmD, BCACP, has no relevant financial relationships.

Nurse Planner

  • Leigh Schmidt, MSN, RN, CNE, CHCP

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Leigh Schmidt, MSN, RN, CNE, CHCP, has no relevant financial relationships.

Peer Reviewer

This activity has been peer reviewed and the reviewer has no relevant financial relationships.


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In support of improving patient care, Medscape, LLC is jointly accredited with commendation by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

IPCE

This activity was planned by and for the healthcare team, and learners will receive 0.25 Interprofessional Continuing Education (IPCE) credit for learning and change.

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  • Medscape, LLC designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™ . Physicians should claim only the credit commensurate with the extent of their participation in the activity.

    Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 0.25 MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.

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This activity is designed to be completed within the time designated on the title page; physicians should claim only those credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the activity online during the valid credit period that is noted on the title page. To receive AMA PRA Category 1 Credit™, you must receive a minimum score of 70% on the post-test.

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CME / ABIM MOC / CE

Can Lifestyle Changes Reduce Colorectal Cancer Risk?

Authors: News Author: Laird Harrison; CME Author: Laurie Barclay, MDFaculty and Disclosures

CME / ABIM MOC / CE Released: 2/17/2023

Valid for credit through: 2/17/2024, 11:59 PM EST

processing....

Clinical Context

Worldwide, colorectal cancer (CRC) is the third most commonly diagnosed cancer and the second leading cause of cancer death. The number of healthy lifestyle behaviors is inversely associated with CRC risk.

When planning cancer-preventive strategies, policy makers should consider the impact of lifestyle behaviors and of lifestyle changes in the recommended direction on cancer risk; however, the impact of various lifestyle changes on CRC risk has not previously been determined.

Study Synopsis and Perspective

Changes regarding smoking, drinking, body weight, and physical activity may change the risk for CRC, the results of a study on a large European cohort suggest.

"This is a clear message that practicing clinicians and gastroenterologists could give to their patients and to CRC screening participants to improve CRC prevention," wrote Edoardo Botteri, PhD, Cancer Registry of Norway, Oslo, and colleagues in an article published in The American Journal of Gastroenterology.

Previous studies have shown a correlation between cancer in general and unhealthy lifestyle factors. They have also shown an association between weight gain and an increased risk for CRC and a reduced risk with smoking cessation, but Botteri and colleagues could not find any published research on the association of other lifestyle factors and the risk for CRC specifically, they wrote.

To help fill this gap, they followed 295,865 people who participated in the European Prospective Investigation into Cancer (EPIC) for a median of 7.8 years. The participants were mostly aged from 35 to 70 years and lived in Denmark, France, Germany, Greece, Italy, the Netherlands, Norway, Spain, Sweden, and the United Kingdom.

The researchers calculated a healthy lifestyle index (HLI) score on the basis of smoking status, alcohol consumption, body mass index (BMI), and physical activity. The median time between baseline and the follow-up questionnaire was 5.7 years.

They awarded points as indicated in the following table.

Smoking

Alcohol Consumption

Physical Activity*

BMI

Never smoked = 4

< 6 g/d = 4

Fifth quintile = 4

< 22 = 4

Stopped for > 10 years = 3

6 to 11.9 g/d = 3

Fourth quintile
= 3

22 to 23.9 = 3

Stopped for ≤ 10 years = 2

12 to 23.9 g/d = 2

Third quintile = 2

24 to 25.9 = 2

≤ 15 cigarettes/d = 1

24 to 59.9 g per day = 1

Second quintile
= 1

26 to 29.9 = 1

> 15 cigarettes/d = 0

≥ 60 g/d = 0

First quintile = 0

≥ 30 = 0

*In metabolic equivalent tasks.

Participants' scores ranged from 0 to 16. At baseline, the mean HLI score was 10.04 ± 2.8. It dipped slightly to 9.95 ± 2.7 at follow-up.

Men had more favorable changes than women, and the associations between the HLI score and CRC risk were only statistically significant among men.

Overall, a 1-unit increase in the HLI score was associated with a 3% lower risk for CRC.

When the HLI scores were grouped into tertiles, improvements from an "unfavorable lifestyle" (ie, 0-9) to a "favorable lifestyle" (ie, 12-16) were associated with a 23% lower risk for CRC (compared with no change). Likewise, a decline from a "favorable lifestyle" to an "unfavorable lifestyle" was associated with a 34% higher risk.

Changes in the BMI score from baseline showed a trend toward an association with CRC risk.

Decreases in alcohol consumption were significantly associated with a reduction in CRC risk among participants aged 55 years or younger at baseline.

Increases in physical activity were significantly associated with a lower risk for proximal colon cancer, especially in younger participants.

On the other hand, reductions in smoking were associated with an increase in CRC risk. This correlation might be the result of "inverse causation," the researchers noted; that is, people may have quit smoking because they experienced early symptoms of CRC. Smoking had only a marginal influence on the HLI calculations in this study because only a small proportion of participants changed their smoking rates.

Information on diet was collected only at baseline, so changes in this factor could not be measured. The researchers adjusted their analysis for diet at baseline, but they acknowledged that their inability to incorporate diet into the HLI score was a limitation of the study.

Similarly, they used education as a marker of socioeconomic status but acknowledge that this is only a proxy.

"The HLI score may therefore not accurately capture the complex relationship between lifestyle habits and risk for CRC," they wrote.

Still, if the results of this observational study are confirmed by other research, the findings could provide evidence to design intervention studies to prevent CRC, they concluded.

The study was supported by the grant LIBERTY from the French Institut National du Cancer. The coordination of EPIC is financially supported by International Agency for Research on Cancer and by the Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, which has additional infrastructure support provided by the NIHR Imperial Biomedical Research Centre. The national cohorts are supported by Danish Cancer Society (Denmark); Ligue Contre le Cancer, Institut Gustave Roussy, Mutuelle G´en´erale de l'Education Nationale, and Institut National de la Sant´e et de la Recherche M´edicale (France); German Cancer Aid, German Cancer Research Center, German Institute of Human Nutrition Potsdam-Rehbruecke, and Federal Ministry of Education and Research (Germany); Associazione Italiana per la Ricerca sul Cancro-Italy, Compagnia di SanPaolo and National Research Council (Italy); Dutch Ministry of Public Health, Welfare and Sports, Netherlands Cancer Registry, LK Research Funds, Dutch Prevention Funds, Dutch Zorg Onderzoek Nederland, World Cancer Research Fund, and Statistics Netherlands; Health Research Fund--Instituto de Salud Carlos III, Regional Governments of Andalucía, Asturias, Basque Country, Murcia, and Navarra, and the Catalan Institute of Oncology (Spain); Swedish Cancer Society and Swedish Research Council and County Councils of Skane and Västerbotten (Sweden); and Cancer Research UK and Medical Research Council. The researchers reported no relevant financial relationships.

Am J Gastroenterol.2022. [ePub ahead of print][1]

Study Highlights

  • Researchers used baseline and follow-up questionnaire data from the EPIC cohort (N = 295,865) to assess changes in lifestyle habits and their associations with CRC development (n = 2799).
  • They calculated HLI score from smoking status, alcohol intake, BMI, and physical activity at baseline and follow-up, ranging from 0 (worst) to 16 (best).
  • Median follow-up was 7.8 years; median time between questionnaires was 5.7 years.
  • Mean HLI score was 10.04 ± 2.8 at baseline; 9.95 ± 2.7 at follow-up.
  • Men had more favorable changes than women, overall and in each country.
  • Men with higher vs lower education had larger mean HLI score changes; women with higher vs lower education had smaller HLI decreases.
  • Associations between HLI score and CRC risk were only statistically significant among men.
  • Each HLI unit increase from baseline to follow-up assessment was associated with statistically significant 3% lower CRC risk, according to Cox regression models.
  • Among participants in the top tertile at baseline ("favorable lifestyle"; HLI ≥ 12), persons in the bottom tertile at follow-up ("unfavorable lifestyle"; HLI ≤ 9) had 34% higher CRC risk (HR 1.34 [95% CI: 1.02, 1.75]) than persons remaining in the top tertile.
  • Among persons in the bottom tertile at baseline, persons in the top tertile at follow-up had 23% lower risk (HR 0.77 [95% CI: 0.59, 1]) than persons remaining in the bottom tertile.
  • Increases in the alcohol, BMI, and physical activity scores but not in smoking score showed a trend toward an inverse association with CRC risk.
  • Decreases in alcohol consumption were significantly associated with reduction in CRC risk among participants aged ≤ 55 years at baseline.
  • Increases in physical activity were significantly associated with lower risk for proximal CRC, especially among younger participants.
  • Increases in smoking score were significantly associated with higher CRC risk among participants who were younger at baseline and had higher risk for distal colon cancer.
  • The investigators concluded that improving adherence to a healthy lifestyle was inversely associated with CRC risk, whereas worsening adherence was positively associated with CRC risk.
  • Similar associations between HLI changes and CRC risk were seen in both sexes, in different age groups, and for specific cancer sites, although the associations were only statistically significant in men.
  • The association of reductions in smoking with increased CRC risk may suggest reverse causation if people quit smoking because they experienced early CRC symptoms.
  • As only a small proportion of participants changed their smoking rates, smoking only marginally affected HLI calculations.
  • The findings justify and support recommendations for healthy lifestyle changes and healthy lifestyle maintenance for CRC prevention.
  • The finding that decreasing alcohol consumption was associated with lower CRC risk, especially in younger individuals, suggest that preventive measures for reducing alcohol consumption should more forcefully target young people.
  • Similarly, the associations between physical activity and CRC risk support promoting physical activity early in life.
  • If other studies confirm the finding of a significant association between changing lifestyle habits in adult life and CRC risk, it may provide strong evidence to design intervention studies for CRC prevention targeting middle-aged adults and other research on preventive strategies, which is urgently needed given the magnitude of the CRC burden.
  • To improve CRC prevention, practicing physicians and gastroenterologists can now give patients and CRC screening participants the clear message that lifestyle changes can affect CRC risk in both directions: Improving adherence to a healthy lifestyle was inversely associated with CRC risk, whereas worsening adherence was positively associated with CRC risk.
  • Study limitations include diet information collected only at baseline, precluding determination of change and incorporation in HLI; EPIC participants not representative of the general population because of healthy cohort effects; and reliance on education as a proxy marker of socioeconomic status, which affects both lifestyle and CRC risk.
  • The HLI score may therefore incompletely capture the complex relationship between lifestyle behaviors and CRC risk.

Clinical Implications

  • Improving adherence to a healthy lifestyle was inversely associated with CRC risk, whereas worsening adherence was positively associated with CRC risk.
  • The findings justify and support recommendations for healthy lifestyle changes and healthy lifestyle maintenance for CRC prevention.
  • Implications for the Healthcare Team: To improve CRC prevention, practicing the healthcare team can now give patients and CRC screening participants the clear message that lifestyle changes can affect CRC risk in both directions.

 

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