Tuesday, December 5, 2023
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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.
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CME / ABIM MOC / CE Released: 2/17/2023
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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.
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 |
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 |
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]
