Several studies have found a connection between eating red and processed meat and colorectal cancer.  But the reason for that connection hasn’t been clear.

To answer the question, researchers collected detailed information about the type of meat eaten by a large group of over 300,000 men and women and how the meat was  cooked.

Linking that information to data on meat iron content, chemicals used in processing meat, and chemicals produced when meat is cooked at high temperatures, they were able to  find that heme iron, nitrates and nitrites, and heterocyclic amines (HCAs) from high-temperature cooking increase risk for colon and rectal cancer.

Among 300,948 patients enrolled in a large, prospective trial,  2,719 developed colorectal cancer.  When researchers ranked diets from those who ate the least red and processed meat to those who ate the most, they found:

• Heme iron was associated with a 13 percent increase in risk.
• Nitrates from processed meats increased risk by 16 percent.
• HCAs produced during high temperature cooking raised risk by 19 percent.

Generally, risks were higher for rectal cancer than for colon cancer, with the exception HCA proteins, which only increased colon cancer risk.

• Heme iron is available in the diet from meat, poultry and fish.  Nonheme iron comes from plants, including lentils and beans.  It is also added to enriched cereals, flour, and grain.
• Nitrates and nitrites are used to process meat into bacon, hot dogs, and sausage.
• HCAs are produced during high temperature cooking like grilling.

Amanda J. Cross and her associates concluded,

In conclusion, we found a positive association for red and processed meat intake and colorectal cancer; heme iron, nitrate/nitrite, and heterocyclic amines from meat may explain these associations.

SOURCE: Cross et al.,Cancer Research, Volume 70, Number 6, March 15,2010.

Today is National Start Walking Day.  Not only can regular walking reduce risk for heart disease, it can be part of an exercise program to prevent colorectal cancer and support survivorship.

Thirty minutes of walking at a moderate pace has been shown to reduce risk of getting colorectal cancer.  Plus exercise after surgery for stage III colon cancer reduced the chances of its coming back.

The National Heart, Lung, and Blood Institute suggests starting slow by walking for 30 minutes three days a week.

All adults should set a long-term goal to accumulate at least 30 minutes or more of moderate-intensity physical activity on most, and preferably all, days of the week. This regimen can be adapted to other forms of physical activity, but walking is particularly attractive because of its safety and accessibility.

They also point out that you can combine several short periods of exercise during the day.

Start walking!

Although many of the provisions of the new law are phased in to take effect gradually until the entire law is implemented in 2018, some benefits will be available immediately.

Highlights of the provisions that will benefit individuals people facing cancer treatment include: prohibiting insurance companies from dropping patients who become sick; eliminating lifetime and annual limits on coverage; prohibiting insurance companies from denying coverage because of pre-existing conditions; and limits on on out-of-pocket expenses.

You can review a chart developed by C3 with key issues affecting colorectal cancer prevention and treatment that are part of the health care reform legislation.

While historic, enactment of this new law is just one step in an ongoing process.  Even after all the provisions in the new law take effect in 2018, many Americans may be newly insured but will still fail to receive the right treatment at the right time.  The Colorectal Cancer Coalition continues to support research to help develop new treatments and to support efforts to increase awareness about the importance of early detection and screening.

BENEFITS IF YOU HAVE BEEN DIAGNOSED WITH COLORECTAL CANCER:

• Beginning immediately, health insurance plans cannot drop you or reduce your benefits just because you become sick, a process called rescission.
• After January 1, 2014, insurance plans will not be able to deny coverage or charge higher premiums if you have a pre-existing condition.  Until that time, people with pre-existing conditions will be able to find affordable insurance in special high-risk pools supported with federal funds.  For people with inherited colorectal cancer who worry about testing for a genetic condition, the law specifically includes genetic information among the health conditions for which there cannot be discrimination.
• Six months after the the law is enacted, insurance companies can no longer place lifetime limits on healthcare coverage, nor can they impose restrictive annual limits.  In 2014, all group and individual plans must eliminate annual limits.  Even if you need expensive cancer care, you will no longer need to worry about your insurance refusing to meet those costs.
• Depending on your income, there will be limits on the amount of money you need to pay out-of-pocket for health care for you and for your family each year.
• In 2014, uninsured people will have access to several new options including higher income limits for Medicaid and participation in an American Health Benefit Exchange.  The exchanges will clearly outline costs and benefits of each health care policy so consumers can make  informed choices about care.  Subsidies will be available to keep costs affordable.

BENEFITS IF YOU WANT TO PREVENT COLORECTAL CANCER:

• If you are privately insured through your employer or the insurance exchanges, preventive services are covered fully without your having to meet a deductible or pay a co-pay.
• If you are on Medicare, cost-sharing for preventive screenings will end on January 1, 2011.  In addition, there will be no additional co-payments if a polyp is discovered and has to be removed during the screening exam.  Medicare will also pay for an annual check-up.
• If you are on Medicaid preventive services will be provided at no cost.

OTHER IMPACTS ON COLORECTAL CANCER PREVENTION:

While not specifically addressing colorectal cancer, wellness and prevention of illness are addressed in several new initiatives established and funded by the law including:

• Establishment of a National Prevention, Health Promotion and Public Health Council to coordinate prevention, wellness, and public health strategies.
• Establishment of a Prevention and Public Health Fund to expand and sustain funding for prevention and public health programs, as well as task forces on Preventive Services and Community Preventive Services to develop, update, and disseminate evidenced-based recommendations on the use of clinical and community prevention services.
• Grants to support evidence-based community prevention and wellness programs that strengthen prevention activities, reduce chronic disease rates and address health disparities, especially in rural and frontier areas.  Funding for five years beginning in FY 2010.

If you have questions about how the new law will affect you, the New York Times has an interactive site where you can look at your personal impact whether you are insured or uninsured and whether your current insurance is on your own, through an employer, or via Medicare or Medicaid.

Foods rich in omega-3 fats, especially those in fish and seafood, may reduce your risk of getting colon cancer.

Scientists and students at the University of California Irvine will be celebrating the first annual International Omega-3 Awareness Day with speakers, activities, and special music from 3 to 6:30 in the Student Center.

At the 2009 AACR Frontiers in Cancer Prevention Research conference, Sangmi Kim, PhD reported on research that found people who ate the most foods rich in omega-3 fatty acids had almost a 40 percent reduced risk of colon cancer.  While Kim found the risk reduction in the 1,500 whites his team studied, there was no similar benefit for 370 African Americans.

Kim and his colleagues asked 1,509 whites and 369 African Americans, half of whom had colon cancer, about the foods they typically ate in the past twelve months.  They found that compared to the 25 percent who ate the least omega-3 rich foods, the top 25 percent had a 39 percent reduction in colon cancer in the distal bowel — the section of colon closest to the rectum.

He said,

An increase in dietary intake of long-chain omega-3 fatty acids, which mainly come from fish and seafood, may be beneficial in the prevention of distal large bowel cancer.

Looking back at almost 3,300 colonoscopies performed in community gastroenterology practices in Germany, researchers found a substantial reduction in large polyps or cancers in the left side of the colon and rectum among patients who had had a colonoscopy in the past ten years compared to those who hadn’t had one.

However, in the upper part of the colon, risk for an advanced polyp or cancer was the same whether or not the patient had a previous colonoscopy.

Overall, colonoscopy reduced the risk of a cancer or an advanced adenoma by 50 percent.

Doctors found an advanced colorectal neoplasm, defined as cancer or an advanced adenoma, in about 1 in 10 people who had not had a previous colonoscopy (11.4 percent).  If the person had a colonoscopy in the past ten years, fewer advanced neoplasms were found (6.1 percent), but location in the colon mattered.

The right side of the colon (proximal) was defined as the cecum, ascending colon, and transverse colon.  The left side (distal) was the descending colon, sigmoid colon, and rectum.

If an individual had a colonoscopy in the previous ten years, the risk of finding a large polyp or cancer in the left side was about a third of that of someone who hadn’t had an exam (relative risk 0.33).  However, there was no reduction in the risk of right sided advanced neoplasms.

Risk of cancer itself strongly impacted by previous colonoscopy. Cancer was found in 41 of 2,701 patients who hadn’t had colonoscopy (1.5 percent) compared to only 1 person in the 586 who had one. (0.2 percent).

Hermann Brenner, MD, MPH and his team concluded,

Prevalence of left-sided advanced colorectal neoplasms, but not right-sided advanced neoplasms, was strongly reduced within a 10-year period after colonoscopy, even in the community setting.

In an editorial that accompanied the Brenner study in the Journal of the National Cancer Institute, surgeon Nancy Baxter, MD, MPH and gastroenterologist Linda Rabeneck MD, MPH asked,

Is there an incremental benefit of colonoscopy over flexible sigmoidoscopy for colorectal cancer screening? If so, is the incremental benefit of sufficient magnitude to justify the additional risks and costs of colonoscopy for screening in the population?  Simply put, is the effectiveness of colonoscopy “good enough” for population-based screening? As more observational evidence accumulates, the answer to this question becomes less certain.

Drs. Baxter and Rabeneck point out that there may be biological differences between lesions on the right side of the colon that make it more difficult for colonoscopy to identify and remove them.  They tend to be flatter and may arise through different molecular pathways.

SOURCES: Brenner et al., Journal of the National Cancer Institute, Advanced Access, December 30, 2009.

Baxter and Rabeneck, Journal of the National Cancer Institute, Advanced Access, December 30, 2009 (free complete text).

What Does This Mean for Patients?

This study adds evidence that screening colonoscopy may be mostly effective in preventing cancers on the left side of the colon but may not reduce risk of proximal or right-sided cancer.

This is not a reason to avoid colonoscopy at all. Overall, in the German study it reduced advanced polyps and cancers by 50 percent — a significant improvement.

However, people need to be aware that colonoscopy is not perfect.  Even in people without family history or medical problems like ulcerative colitis or Crohn’s disease, cancer can occur in between screening colonoscopies.  It is critical to be aware of the symptoms of colorectal cancer and get an evaluation of them, including another colonoscopy, if they occur.

It may also strengthen the value of flexible sigmoidoscopy as a screening tool, particularly in situations where colonoscopy is not easily available or affordable.

Carolyn "Bo" Aldige

C3 congratulates the Prevent Cancer Foundation on their 25th anniversary this month.

We are proud of the work they do, especially in encouraging screening to prevent colorectal cancer.  This March they will sponsor the 12th Dialogue for Action Prevention Hits the Headlines.

Prevent Cancer also sponsors the Super Colon Tour, an educational program accompanied by a large crawl-through colon.  2010 tour appearances are being scheduled now.

Founded in 1985 by Carolyn “Bo” Aldige in memory of her father, Edward P. Richardson, who died of cancer, it was known until recently as the Cancer Research and Prevention Foundation. The foundation has funded research, provided public education, and helped raise awareness that cancer can be prevented, treated, and beaten.

We wish them many more successful years.

Being overweight was a key reason for at least 124,000 new cancers in European countries in 2008, including nearly 24,000 from colorectal cancer.

3.2 percent of new cancer diagnoses in men and 8.8 percent of women’s cancers could be attributed to excessive body mass index (BMI).  This was a dramatic increase from  2002 that found 70,000 cases of cancer directly related to obesity out of 2.2 million European cancers overall.

Percentages of cases related to high BMI varied greatly among European countries with the from a low of 2.1% in women and 2.4% in men in Denmark, to 8.2% in women and 3.5% in men in the Czech Republic.

About 64 percent of new cases were attributed to just three cancers: endometrial cancer (33,421), post-menopausal breast cancer (27,770) and colorectal cancer (23,730).

Dr, Andrew Renehan, from the University of Manchester, in the United Kingdom led a analysis estimating the numbers of new cancers and their relationship to obesity.  The model built on information available from the World Health Organization and the International Agency for Research on Cancer.

He pointed out that as use of hormone replacement therapy decreased with its relationship to breast cancer, obesity emerged as a cause of new breast cancers.

Given the difficulty of addressing the epidemic of excessive weight gain in some European countries, Dr. Renehan called for new approaches to prevention of certain cancers with a strong obesity component.  He told the ECCO/ESMO conference,

The study also identifies priorities for research into certain cancers, namely endometrial, breast and colorectal cancers. In the face of an unabating obesity epidemic, and apparent failure of public health policies to control weight gain, there is a need to look at alternative strategies, including pharmacological approaches.

SOURCE: Renehan et al., European Journal of Cancer Supplements, Vol 7 No 2, September 2009, Page 79

Although initial reports found no reduction in polyps or cancer in people with Lynch syndrome who took aspirin and/or resistant starch supplements, longer follow-up tells a difference story.

About five years after trial participants began taking aspirin or a placebo, differences began to emerge. Even though patients in the trial only took aspirin for four years, later followup found significantly fewer colon colon cancers among those who had used  aspirin, as well as fewer Lynch-related cancers overall.   There were almost three times as many colon cancers in Lynch carriers who took a placebo compared to those who used aspirin.

The Colorectal Adenoma/Carcinoma Prevention Programme 2 (CAPP2) enrolled over 1,000 patients worldwide who carried a mutated gene that causes Lynch syndrome in a randomized study to compare daily aspirin use with or without resistant starch supplements to placebos.  Participants in the trial took aspirin, starch supplements, or placebos for four years.  An initial report in the New England Journal of Medicine found that neither aspirin or Novolose (resistant starch) made any difference in the development of polyps or cancer.

However, when the research team contacted over 600 of the original study members again, they found that, with longer follow-up, there was a significant difference in the development of colon cancer and other Lynch-related cancers.  Six patients who had taken aspirin had colon cancer compared to 16 who didn’t use it.  There was a reduction in endometrial cancer, as well.  Overall, there were 18 Lynch-related cancers in all among the aspirin-users, compared to 31 who didn’t take aspirin during the four years of the study.

Aspirin protected the people who took it for at least 6 years after they stopped.

Participants in the trial took 600 mg of aspirin daily.

Professor John Burn, from the Institute of Human Genetics at Newcastle University in the United Kingdom,who reported the newest results of CAPP2 at the ECCO/ESMO meeting in Berlin said,

Our original design allowed for long term post trial follow-up. We have managed to track down most of those who completed the trial – around 75% of the original consent cohort – with information extending up to 10 years from randomisation. We found that, around four years after randomisation, there was a divergence in the incidence of cancers between the aspirin and placebo groups. To date, there have been only six colon cancers in the aspirin group as opposed to 16 who took placebo. There is also a reduction in endometrial cancer. This is a statistically significant result and we are delighted – all the more so because we stopped giving the aspirin after four years, yet the effect is continuing, and is directly correlated with the duration of aspirin use on the trial.

Lynch syndrome, often called hereditary nonpolyposis colorectal cancer (HNPCC), is a type of inherited cancer of the digestive tract, particularly the colon and rectum. People with Lynch syndrome have an increased risk of cancers of the stomach, small intestine, liver, gallbladder ducts, upper urinary tract, brain, skin, and prostate. Women carriers also have a high risk of developing endometrial and ovarian cancers.

Patients with Lynch-related cancers are often diagnosed at a younger age, and their tumors develop more quickly.

Concluding, Prof.  Burn and his team recommended,

All those at risk of Lynch syndrome related cancer should consider long term aspirin use. Plans for a large scale randomised dose finding study of aspirin in Lynch syndrome will be presented.

SOURCE:  Burn et al., European Journal of Cancer Supplements, Volume 7 Number 2, September 2009, Page 320.

Through the Colorectal Cancer Control Program, five-year grants ranging from $358,283 to $1.1 million will support support screening and diagnostic follow–up care, data collection, outreach and public education, health care provider education, and program evaluation.  Projects can choose from among recommended screening methods including colonoscopy, sigmoidoscopy, or stool tests.

The new funding builds on the successful CDC Colorectal Cancer Screening Demonstration Program in five sites across the US, including Baltimore, Long Island, Seattle and King County, Nebraska, and Missouri.

CDC Director Thomas Frieden, MD, MPH, pointed out,

Colorectal cancer kills more people than any other cancer except lung cancer. These colorectal cancer screening awards will save lives. We need to reach more adults aged 50 and over and others at high risk to prevent colorectal cancer.

Laura Seeff, M.D., the medical director of CDC′s colorectal cancer screening efforts, continued,

Screening tests can detect colorectal cancer at its earliest stages, when it is most treatable. This screening program has tremendous potential to address the disparities that exist in colorectal cancer screening and to save lives.

What This Means for Colorectal Cancer Prevention

C3 applauds this CDC initiative to reach and screen more uninsured people and people whose insurance does not cover colorectal cancer screening.  There is good evidence that screening saves lives.

However, we remain committed to see that all Americans can be screened for colorectal cancer using any of the recommended screening methods that they choose in consultation with their doctors.

• We support the passage of HR 1189  – the Colorectal Cancer Prevention, Early Detection, and Treatment Act — which would provide colorectal cancer screening to all uninsured and underinsured  Americans and treatment for colorectal cancers detected during screening as part of the program.
• We also support all efforts to provide full insurance coverage for colorectal cancer screening.

President Obama recognizes the value of colorectal cancer screening when he called it out in  his speech to Congress on September 9, 2009:

And insurance companies will be required to cover, with no extra charge, routine checkups and preventive care, like mammograms and colonoscopies. Because there’s no reason we shouldn’t be catching diseases like breast cancer and colon cancer before they get worse. That makes sense. It saves money and it saves lives

However, those women who were active in sports or who took aspirin regularly didn’t benefit from HRT.

As part of the Molecular Epidemiology of Colorectal Cancer (MECC) study, researchers questioned 2,400 Northern Israeli women with colon or rectal cancer about their use of hormone replacement therapy, using either pills or patches.  They matched the women with cancer to a control group with similar backgrounds.

They also asked about use of aspirin, statins, and non-steroidal anti-inflammatory drugs (NSAIDS).  Women answered diet and exercise questions, including whether or not they ate 5 or more vegetables daily or took part in sports.

Women with at least one first degree relative who had been diagnosed with colorectal cancer were listed as having a family history.

Reduction in risk remained the same between women with and without familycolorectal cancer history, those who ate more vegetables and those who didn’t, women with normal weight and obese women, and users and nonusers of statins.

There was a stronger advantage to using hormone replacement therapy for women who were sedentary.

However, women who were daily aspirin users and also took hormone replacement therapy had an increased risk of colorectal cancer.

Women who used HRT and took part in sports had no advantage from HRT, but also did not have an increased risk.

Even after adjusting for known risk factors for colorectal cancer – age, use of aspirin/NSAIDs, use of statins, vegetable consumption, sports activity — using hormone replacement therapy continued to have a significant effect in reducing the risk of colorectal cancer in this group of women.

Significantly, only the use of combined estrogen/progestin HRT in pill form reduced colorectal cancer risk.  Estrogen alone or HRT patches did not.

Writing in the Journal of Clinical Oncology, Gad Rennert, MD, and his team concluded,

The use of oral HRT was associated with a 63% relative reduction in the risk of colorectal cancer in postmenopausal women after adjustment for other known risk factors. This effect was not found in aspirin users and women with intensive sports participation.

SOURCE: Rennert et al, Journal of Clinical Oncology, published online ahead of print, August 24, 2009.

What This Means for Patients

Although use of hormone replacement therapy reduces risk for colorectal cancer in this study, other research has found that HRT increases risk for cardiovascular disease and breast cancer.

Combining daily aspirin and hormone replacement therapy may increase your risk for colorectal cancer, and if you are very active in sports, you may not have any further benefit from HRT.

Discuss your personal and family risks for heart disease, breast and ovarian cancer, and colorectal cancer in deciding how to use hormone replacement therapy.