Oncol Rev (2011) 5:5–11
DOI 10.1007/s12156-010-0061-0
REVIEW
Colon cancer in rapidly developing countries: review
of the lifestyle, dietary, consanguinity and hereditary risk factors
Abdulbari Bener
Received: 29 October 2009 / Accepted: 5 August 2010 / Published online: 17 August 2010
Ó Springer-Verlag 2010
Abstract Colon cancer rates are rising dramatically in
once low incidence nations. These nations are undergoing
rapid economic development and are known as ‘‘nations in
transition’’ (NIT). This review identifies some of the most
common etiological risk factors of colon cancer in these
nations and evaluates the existing epidemiological evidence. The main risk factors which were found to be prevalent in NIT include: lifestyle factors such as physical
inactivity, obesity and abdominal adiposity, alcohol consumption and cigarette smoking; dietary factors such as
fatty food and red meat consumption. Protective factors
included white meat and fiber consumption. Several studies
found to have significantly higher rates of colon cancer
among the young population (\40 years old). There
appears to be a quantitative and qualitative increase in risk
to relatives of patients diagnosed at a young age compared
with those diagnosed later in life, at least part of which is
likely to be the result of a hereditary susceptibility. Close
relatives of patients with colon cancer are at an increased
risk of developing a colon cancer. Close relatives of early
onset cases warrant more intensive endoscopic screening
and at an earlier age than relatives of patients diagnosed at
A. Bener (&)
Department of Medical Statistics and Epidemiology,
Hamad Medical Corporation, PO Box 3050, Doha, Qatar
e-mail: abener@hmc.org.qa; abb2007@qatar-med.cornell.edu
A. Bener
Department of Public Health, Weill Cornell Medical College,
PO Box 3050, Doha, Qatar
A. Bener
Department of Evidence for Population Health Unit,
School of Epidemiology and Health Sciences,
University of Manchester, Manchester, UK
older ages. Furthermore, these suggest the existence of
genetic predispositions in these nations which need to be
investigated further and have implications for screening
programs. In conclusion, public health awareness campaigns promoting prevention of modifiable risk factors and
screening initiatives with guidelines suited to the age-specific incidence rates of NIT are needed very urgently.
Keywords Epidemiology Colon cancer Life-style Dietary Consanguinity Hereditary
Background
Colon cancer is strongly correlated with various environmental and genetic factors, which make primary prevention
fundamental to public health initiatives [1]. While high
colon cancer incidence rates were mainly found in developed nations, these are now increasing dramatically in
rapidly developing nations [2] (Fig. 1). These rapidly
developing countries are known as ‘‘nations in transition’’
(NIT). Although other reviews have noted these trends and
documented the various screening programs around the
globe [3], none have specifically looked at the common
etiological factors in these nations, which are contributing
to these rising trends.
Colon cancer has many known preventable risk factors
which numerous studies have documented. Each risk factor
has different degrees of association with colon cancer,
especially in relation to geographic location. Previous
reviews related to colon cancer have focused on specific
risk factors such as physical inactivity [4], dietary fiber
intake [5], red meat intake [6] obesity [7] and the hereditary syndromes and genetics of colon cancer [8]. This
review differs from these in that it will provide an overview
123
6
Fig. 1 Cycle of exposure to
colon cancer risk in developed
and developing nations. Once
low incidence and risk regions
(developing nations) slowly get
exposed to risk factors which
increase the incidence of
disease, while high incidence
regions implement strategies
and campaigns to reduce
exposure to risks and stabilize
or decrease the incidence of
disease. *All rates are for males
[3]
Oncol Rev (2011) 5:5–11
NATIONS IN TRANSITION
Increasing Rates of Colon Cancer
DEVELOPING NATIONS
•
Improving SES and affluence
Example:
Low Incidence Rates of Colon
Cancer
•
Have lowest SES
Example:
India (4.1/100.000)*
•
Dietary / Lifestyle Habits
• High fiber
• Low meat
• Low Fat/Sugar
• High Vegetables and Fruit
intake.
•
Kuwait (15/100,000)*
Dietary Habits:
•
Low fiber
•
Higher Meat intakes
•
High Fat & refined
Carbohydrate
Lifestyle
•
Sedentary
•
Increasing Obesity Rates
Developed Nations
High incidence rates but stable or
decreasing
•
Have high SES
Example:
•
USA (41/100 000)*
Introduced Prevention Programs
• Encouraged Physical Activity
• Low fat, high fiber diets
• Campaigns against Smoking and
Alcohol consumption
Introduced Screening Programs
of the combination of risk factors that have led to the rising
trends of colon cancer in NIT (Fig. 2).
Epidemiology
The highest incidence rates of colon cancer are found in the
wealthiest developed nations, while the lowest rates are
found in some of the poorest developing nations [3]
(Table 1). This geographic variation has been mainly
attributed to the differences in diet and lifestyle. This
proposition has been confirmed by the numerous ‘‘migration studies’’ which have documented the dramatic rise in
incidence rates of colon cancer in migrants from low
incidence regions, who have settled in high incidence
regions [9]. Moreover, in recent years, with the economic
development of many nations (NIT), rates of colon cancer
are rapidly on the rise, while rates in previously high
123
incidence regions have stabilized if not slightly decreased,
largely due to intervention and screening programs [3].
A common finding is that the highest colon cancer
incidence rates are found in the urban centers of these
nations [10]. In contrast to developed nations, many
developing and NIT have significantly higher rates of
young individuals (\40 years) with colon cancer [11–13].
Men and women have a similar lifetime risk of developing
colon cancer of 6% although they are affected differently
by the etiological risk factors, which will be elaborated
further throughout this paper [14].
Lifestyle risk factors
Changing lifestyle habits in NIT have been persistently
presented as key contributing factors to the increasing
trends of colon cancer [15]. Indeed, the most consistent
Oncol Rev (2011) 5:5–11
7
Lifestyle
Factors
36
65
37
85
66
67
Hereditary
Factors
40
Dietary
Factors
Fig. 2 Venn diagram showing the overlapping of lifestyle with
dietary and hereditary risk factors for colon cancer of Qatari studied
subjects (both cases and controls) (N = 428*)#. *Total number of
cases and controls in Venn diagram = 396 as 32 controls did not have
any of the three risk factors. Dietary factor = 283, hereditary
factor = 229, lifestyle factor = 223. #Bener et al. (2010). Impacts
of family history and life style habits on colorectal cancer risk: a
case–control study. Asian Pac J Cancer Prev (in press)
Table 1 Estimated global cases of colorectal cancer in 2008
Estimated numbers of cases
(thousands)
Men
Women
Both
sexes
World
663
570
1,233
More developed regions
389
337
726
Less developed regions
273
232
505
WHO European region
238
211
449
WHO Western Pacific region
224
170
394
WHO Americas region
122
118
240
WHO South East Asian regions
50
47
97
WHO African region
WHO Eastern Mediterranean region
14
13
12
10
26
23
European union
182
150
332
China
125
95
48
USA
79
74
153
India
20
16
36
Globocan 2008 cancer fact sheet. Available at: http://globocan.iarc.fr/
factsheets/cancers/colorectal.asp. Accessed 20 June 2010
epidemiological evidence links physical inactivity, obesity,
and central adiposity with increased colon cancer risk [4,
16, 17].
Physical activity is generally accepted as a protective
factor for colon cancer; evidence from both prospective
and case–control studies has been strong and consistent
[18]. These wide-ranging studies have found consistent
relations between physical activity and risk of colon cancer
for both genders, in a wide spectrum of populations and
thus it is unlikely that all these relations are due to
uncontrolled confounding [19]. Indeed physically active
men and women are at around half the risk of developing
colon cancer than their less active counterparts [20].
The shift from manual to sedentary work and leisure
activities in NIT are allowing these populations at
increased risk of developing colon cancer [21]. Thus, it is
not surprising that colon cancer rates were found to be the
highest in the main cities (i.e. urbanized areas) where
sedentary lifestyles were predominantly prevalent [10, 15].
Another explanation for limited physical activity in some
of these NIT is the hot and humid climate which restricts
the amount of time spent outdoors [22].
Coinciding with these more sedentary lifestyle habits are
increased in the consumption of foods high in fat, sugar,
and salt which have led to soaring obesity rates, particularly in urbanized regions of NIT [21]. In fact, studies
conducted in both developed nations and NIT have documented obesity as a risk factor for colon cancer [16, 23].
Obesity has generally been found to be a stronger risk
factor for men [24]. Stronger associations have been documented for central adiposity than BMI [17, 25]. In contrast to BMI, stronger associations between colon cancer
risk and central adiposity were observed for women [17].
Other major lifestyle risk factors of colon cancer include
alcohol consumption and cigarette smoking. The evidence
is consistent and strong relating alcohol consumption and
colon cancer risk; however, this only appeared to be the
case among men [26, 27]. Cigarette smoking was found to
increase colon cancer risk, in both genders, in all sites of
the colon [26, 28].
Alcohol consumption levels are very low in many
nations that lie within NIT as it is prohibited for cultural or
religious reasons, some of these nations have even prohibited the sale of alcohol, thus alcohol consumption has a
minimal effect on colon cancer rates in many NIT [29]. On
the other hand, the increasing rates of smoking, in developing nations and NIT is a worrying trend that has implications for the rising trends of colon cancer [30]. More
studies are needed in these regions to determine the sociocultural factors related to the increased number of smokers,
in order to establish effective anti-smoking campaigns.
Dietary risk and protective factors
Dietary factors have also been associated with colon cancer; however, their relations are somewhat weaker than the
previously mentioned lifestyle risk factors. Fat intake has
been proposed to be associated with colon cancer risk.
While the theoretical evidence appears plausible, the epidemiological evidence is very weak. For instance Slattery’s
(1997) [31] study of fat intake among various age-groups
123
8
found that only fat intake from food preparation was
associated with increased risk of colon cancer in older
women, but no relation was observed for any other
demographic group. These findings were confirmed by the
North Carolina Colon Cancer Study [32] which found no
association between trans-fatty acid intake and colon cancer risk, in a large cohort of African Americans and Whites
from various geographical areas; other studies have documented similar results [33].
Like dietary fat intake, many theoretical associations
between red meat intake and colon cancer have been proposed. This has been persistently presented as a risk factor,
as dramatically higher consumption of red meat exists in
developed countries where incidence rates of colon cancer
are markedly higher, than in developing countries where
consumption levels of red meat are low [34]. Indeed, with
increasing affluence, consumption levels of red meat have
risen considerably in NIT where incidence rates of colon
cancer are also on the rise [35].
The epidemiological evidence has generally associated
red meat consumption with increased colon cancer risk.
Both the Cancer Prevention Study II Nutrition Cohort [36]
and the prospective EPIC cohort study [37] found that red
meat intake was positively associated with increased colon
cancer risk; however, these findings were not statistically
significant. Nonetheless the EPIC cohort study found after
further analyses of the subgroups of red meats, where
intake of each meat was mutually adjusted for intake of the
other meats, only the trend for increased colorectal cancer
risk with increased pork intake remained statistically significant [37].
White meat (fish and poultry) on other hand, was found
to either not increase the risk of colon cancer or was even
protective against it [37, 38]. In particular, poultry was
found to contain methionine, which has a protective effect
against cancer [39].
High consumption of fiber, whether through cereal or
plant sources, was thought to be a large determinant in the
huge gap in incidence rates of colon cancer globally [40].
Thus, it was proposed that in NIT, people were consuming
less fiber in their diets due to changes to ‘‘Westernized’’
diets. Indeed, many biological theories have been proposed
for fiber’s role in reducing colon cancer risk [41].
Numerous case–control [5, 42, 43] and prospective
studies [44, 45] have confirmed the protective effect of
fiber intake against colon cancer. However, this protective
effect was found to slightly differ between the genders and
type of fiber intake. For instance, the inverse association
between fiber from whole grain sources and colon cancer
was found to be stronger among men [40]; on the other
hand, the inverse association between fiber from vegetable
and fruit sources and colon cancer was found to be stronger
among women [41].
123
Oncol Rev (2011) 5:5–11
Hereditary factors and consanguinity
Unlike the dietary and lifestyle risk factors for colon cancer, hereditary colon cancer is not modifiable; however, a
good knowledge of such a family history has implications
for early detection and screening. Most recently, study by
Katalinic et al. [46] reported that taking familial and
hereditary risks into account a total of 6.7% of all Germans
in the age group 30–49 years would be classified as
familial risk persons. Approximately 20% of colon cancer
diagnoses have some definable hereditary factor while
specific germline mutations are characterized in approximately 5% of all colon cancer cases [47]. The three main
hereditary forms of colon cancer are: hereditary non-polyposis colorectal cancer (HNPCC) which is the most
commonly occurring hereditary syndrome with an estimated incidence of 5–7% of all colon cancer cases [48];
Familial adenomatous polyposis (FAP) which is inherited
as an autosomal dominant manner [48]; and familial colon
cancer where no specific gene is identified but colon cancer
occurs in numerous first degree family members [8]. Each
syndrome has different symptoms and results in colon
cancer in different sites of the colon [8]. However, a
common factor that they all share is the early onset of
diagnosis, usually \40 years of age [49, 50].
The relatively large incidence of colon cancer among
young adults (those \40) in developing countries in comparison to developed countries, has led to speculation about
the genetic predisposition of people living in these regions
for colon cancer [51, 52]. Indeed, this finding was consistent across developing nations ranging 20–30% in countries
including: Egypt [51], Jordan [49], Saudi Arabia [52], Iran
[12], and among native South Africans [11].
While this trend has been observed in these countries,
very few studies have gone beyond this observation and
conducted research to explore the mechanism/s and the
causes for this difference. One of the main studies which
have investigated this finding further was conducted among
the native population in South Africa [11]. This study [11]
found that one of the main pathways of colon cancer was
HPNCC––indeed, noted that it was difficult to collect
accurate information about family history and so devised a
molecular technique to do so. Similar studies have been
conducted in Egypt [51], and Taiwan [53] and found that
there were unique pathways of colorectal cancer among
their populations in comparison to ‘‘western populations’’.
Several studies found to have significantly higher rates of
colon cancer among the young population (\40 years old)
[46–53]. There appears to be a quantitative and qualitative
increase in risk to relatives of patients diagnosed at a young
age compared with those diagnosed later in life, at least
part of which is likely to be the result of a hereditary
susceptibility. Close relatives of patients with colorectal
Oncol Rev (2011) 5:5–11
cancer are at an increased risk of developing a colon cancer. Close relatives of early onset cases warrant more
intensive endoscopic screening at an earlier age than relatives of patients diagnosed at older ages. [54]. Furthermore, these suggest the existence of genetic predispositions
in these nations which need to be investigated further and
have implications for screening programs.
Another possible explanation for the high incidence
rates among young people in developing countries and NIT
is the practice of consanguinity [55]. Consanguinity is
common in nations of the Middle East, Africa, South Asia,
and South East Asia where many of NIT are located [56].
Since colon cancer is inherited as an autosomal dominant
manner, consanguinity increases its potential incidence
[56]. The role of consanguinity in colon cancer incidence
rates has been investigated, in a small pilot study in Egypt
[50] and in a larger representative cross-sectional study in
Qatar [56], these studies found that colon cancer rates were
higher in those who had consanguineous parents. No study
has of yet been conducted to investigate the mechanism
through which consanguinity impacts on colon cancer.
Nonetheless, while genetic predisposition may explain
to a large extent the incidence of colon cancer in young
people in developing countries and NIT, a few other factors
need to be considered which also play a role in explaining
this phenomenon. One of the main other explanations for
the high incidence of colon cancer among those under
40 years in these regions is the young age structure of
populations; whereas in developed nations, they tend to
have an ‘‘aging population’’ [12]. Moreover, this younger
generation, tends to be more conforming to western lifestyle habits which are conducive to colon cancer, in comparison to the older generation who have very low
incidence rates [57].
Furthermore, colorectal cancer is the second leading
cause of cancer deaths in the United States [58] in both
men and women and is thus a major public health problem,
in 2007, approximately 153,760 people in the United States
were diagnosed with colorectal cancer and about 52,180
died of the disease, overall prevalence of those at risk for
hereditary colorectal cancer in United States was 26% for
all sites, ranging 11–39% across sites and tools. This study
is significant because it revealed a fairly high percentage of
people at risk for hereditary colorectal cancer and showed
how an initial risk assessment can be easily done by professional nurses and other healthcare providers who are in a
unique position to help reduce the incidence and mortality
from colorectal cancer.
The hereditary nature of colon cancer has implications
for screening initiatives. With such high incidence rates
among the young, in NIT and developing nations, guidelines which suggest screening for those above 50 need to be
reconsidered and readdressed [59].
9
Conclusion
The rising rates of colon cancer in NIT can be attributed
to lifestyle, dietary and hereditary factors. The literature
reported significantly higher rates of colon cancer among
the young population (\40 years old). There appears to
be a quantitative and qualitative increase in risk to relatives of patients diagnosed at a young age compared with
those diagnosed later in life, at least part of which is
likely to be the result of a hereditary susceptibility. Close
relatives of patients with colorectal cancer are at an
increased risk of developing a colorectal. Close relatives
of early onset cases warrant more intensive endoscopic
screening at an earlier age than relatives of patients
diagnosed at older ages. While rates in NIT have not yet
reached those of developed nations, the growth is rapid
and demands immediate action in terms of modifying risk
factors, and implementing screening guidelines and programs that represent the threat of colon cancer in these
regions.
Conflict of interest I declare that no benefits in any form have been
received or will be received from a commercial party related directly
or indirectly to the subject of this article. I also declare that I have no
conflict of interest in connection with this paper.
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