Colorectal cancer risk factors: Difference between revisions

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==Overview==
==Overview==
There are both genetic and environmental factors that can increase the risk of colorectal carcinoma (CRC). Some of the genetic risk factors are familial adenomatous polyposis and hereditary non-polyposis colorectal cancer. Some environmental risk factors are personal/family history, history of inflammatory bowel disease, diet, alcohol, cigarette smoking, race, and gender.
There are both [[genetic]] and environmental factors that can increase the risk of colorectal carcinoma (CRC). Some of the [[Genetics|genetic]] risk factors are [[familial adenomatous polyposis]] and [[Hereditary nonpolyposis colorectal cancer|hereditary non-polyposis colorectal cancer]]. Some environmental risk factors are personal/family history, history of [[inflammatory bowel disease]], [[Diet (nutrition)|diet]], [[alcohol]], [[cigarette smoking]], [[race]], and gender.


==Colorectal Cancer Risk Factors==
==Colorectal Cancer Risk Factors==
The causes and the risk factors for colorectal carcinoma are the similar. There are both genetic and environmental factors that can increase the risk of colorectal carcinoma<ref name="pmid20420944">{{cite journal| author=Chan AT, Giovannucci EL| title=Primary prevention of colorectal cancer. | journal=Gastroenterology | year= 2010 | volume= 138 | issue= 6 | pages= 2029-2043.e10 |pmid=20420944 | doi=10.1053/j.gastro.2010.01.057 | pmc=PMC2947820 |url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20420944  }}</ref>. FAP and HNPCC are the most common risk factors of CRC, but together these two conditions account for only about 5 percent of CRC<ref name="pmid7598472">{{cite journal| author=Burt RW, DiSario JA, Cannon-Albright L| title=Genetics of colon cancer: impact of inheritance on colon cancer risk. | journal=Annu Rev Med | year= 1995 | volume= 46 |issue=  | pages= 371-9 | pmid=7598472 | doi=10.1146/annurev.med.46.1.371 | pmc= |url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7598472  }} </ref>.
The causes and the risk factors for colorectal carcinoma are the similar. There are both [[genetic]] and environmental factors that can increase the risk of colorectal carcinoma.<ref name="pmid20420944">{{cite journal| author=Chan AT, Giovannucci EL| title=Primary prevention of colorectal cancer. | journal=Gastroenterology | year= 2010 | volume= 138 | issue= 6 | pages= 2029-2043.e10 |pmid=20420944 | doi=10.1053/j.gastro.2010.01.057 | pmc=PMC2947820 |url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20420944  }}</ref> [[FAP (gene)|FAP]] and [[Hereditary nonpolyposis colorectal cancer|HNPCC]] are the most common risk factors of CRC, but together these two conditions account for only about 5 percent of CRC.<ref name="pmid7598472">{{cite journal| author=Burt RW, DiSario JA, Cannon-Albright L| title=Genetics of colon cancer: impact of inheritance on colon cancer risk. | journal=Annu Rev Med | year= 1995 | volume= 46 |issue=  | pages= 371-9 | pmid=7598472 | doi=10.1146/annurev.med.46.1.371 | pmc= |url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7598472  }} </ref>


===Genetic Risk Factors===
===Genetic Risk Factors===
The table below lists the genetic risk factors for colorectal carcinoma:
The table below lists the [[genetic]] risk factors for colorectal carcinoma:<ref name="pmid598472">{{cite journal| author=Mazur IA| title=[Synthesis of imidazopyrimidines and imidazoquinazolines with a common nitrogen atom]. | journal=Farm Zh | year= 1977 | volume=  | issue= 6 |pages= 37-41 | pmid=598472 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=598472}}</ref><ref name="pmid21193451">{{cite journal| author=Parry S, Win AK, Parry B, Macrae FA, Gurrin LC, Church JM et al.| title=Metachronous colorectal cancer risk for mismatch repair gene mutation carriers: the advantage of more extensive colon surgery. | journal=Gut | year= 2011 | volume= 60 | issue= 7 | pages= 950-7 | pmid=21193451 | doi=10.1136/gut.2010.228056 | pmc=PMC3848416 |url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21193451  }}</ref>
{| {{table}}
{| style="border:#c9c9c9 1px solid; margin: 1em 1em 1em 0; border-collapse: collapse;" cellspacing="0" cellpadding="4" {{table}}
| align="center" style="background:#f0f0f0;"|'''Genetic Risk Factor'''
| style="background:#f0f0f0;" align="center" align="center" style="background:#4479BA; color: #FFFFFF;" + |'''Genetic Risk Factor'''


| align="center" style="background:#f0f0f0;"|'''Description'''
| style="background:#f0f0f0;" align="center" align="center" style="background:#4479BA; color: #FFFFFF;" + |'''Description'''


|-
|-


| '''Familial Adenomatous Polyposis (FAP)'''||AD inheritance; other variants include [[Gardner's syndrome]], Turcot's syndrome, and attenuated adenomatous polyposis coli; caused by germlines mutations in the APC gene<ref name="pmid598472">{{cite journal| author=Mazur IA| title=[Synthesis of imidazopyrimidines and imidazoquinazolines with a common nitrogen atom]. | journal=Farm Zh | year= 1977 | volume=  | issue= 6 |pages= 37-41 | pmid=598472 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=598472}}</ref>; colonic cancer occurs in 90% of untreated individuals around 45 years
| '''[[Familial Adenomatous Polyposis|Familial Adenomatous Polyposis (FAP)]]'''||
 
* Autosomal dominant inheritance
To view Gardner's syndrome, Turcot's syndrome, and attenuated adenomatous polyposis coli , click [[Hereditary nonpolyposis colorectal cancer classification|'''here''']]<br>
* Other variants include [[Gardner's syndrome]], [[Turcot syndrome|Turcot's syndrome]], and attenuated adenomatous polyposis coli
* Caused by germlines mutations in the [[APC gene]]
* Colonic cancer occurs in 90% of untreated individuals around 45 years
To view [[Gardner's syndrome]], [[Turcot syndrome|Turcot's syndrome]], and attenuated adenomatous polyposis coli , click [[Hereditary nonpolyposis colorectal cancer classification|'''here''']]<br>
|-
|-


| '''MUTYH-associated Polyposis (MAP)'''||AR inheritance; caused by biallelic germline [[mutations]] in the base excision repair gene mutY homolog (MYH or MUTYH)
| '''MUTYH-associated Polyposis (MAP)'''||
* Autosomal resistant inheritance
* Caused by bi-allelic germline [[mutations]] in the [[Base excision repair|base excision repair gene]] mutY homolog (MYH or MUTYH)


|-
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| '''Lynch Syndrome AKA Hereditary Non-polyposis Colorectal Cancer (HNPCC)'''||AD inheritance; caused by a defect in one of the mismatch repair genes, most commonly hMLH1, hMSH2, hMSH6, or PMS2; the mean age at initial cancer diagnosis is around 48 years<ref name="pmid21193451">{{cite journal| author=Parry S, Win AK, Parry B, Macrae FA, Gurrin LC, Church JM et al.| title=Metachronous colorectal cancer risk for mismatch repair gene mutation carriers: the advantage of more extensive colon surgery. | journal=Gut | year= 2011 | volume= 60 | issue= 7 | pages= 950-7 | pmid=21193451 | doi=10.1136/gut.2010.228056 | pmc=PMC3848416 |url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21193451  }}</ref>
| '''[[Hereditary nonpolyposis colorectal cancer|Lynch Syndrome]] AKA Hereditary Non-polyposis Colorectal Cancer (HNPCC)'''||
* Autosomal dominant inheritance
* Caused by a defect in one of the [[Mismatch repair|mismatch repair genes]], most commonly hMLH1, hMSH2, hMSH6, or PMS2
* Mean age at initial cancer diagnosis is around 48 years


|}
|}


The table below lists the environmental risk factors for colorectal carcinoma:
===Environmental Risk Factors===
{| {{table}}
The table below lists the environmental risk factors for colorectal carcinoma:<ref name="pmid8531963">{{cite journal| author=Winawer SJ, Zauber AG, Gerdes H, O'Brien MJ, Gottlieb LS, Sternberg SS et al.| title=Risk of colorectal cancer in the families of patients with adenomatous polyps. National Polyp Study Workgroup. | journal=N Engl J Med | year= 1996 | volume= 334 | issue= 2 | pages= 82-7 | pmid=8531963 | doi=10.1056/NEJM199601113340204 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8531963  }} </ref><ref name="pmid1736104">{{cite journal| author=Atkin WS, Morson BC, Cuzick J| title=Long-term risk of colorectal cancer after excision of rectosigmoid adenomas. | journal=N Engl J Med | year= 1992 | volume= 326 | issue= 10 | pages= 658-62 | pmid=1736104 | doi=10.1056/NEJM199203053261002 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1736104  }} </ref><ref name="pmid2215606">{{cite journal| author=Ekbom A, Helmick C, Zack M, Adami HO| title=Ulcerative colitis and colorectal cancer. A population-based study. | journal=N Engl J Med | year= 1990 | volume= 323 | issue= 18 | pages= 1228-33 | pmid=2215606 | doi=10.1056/NEJM199011013231802 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2215606  }} </ref><ref name="pmid15743345">{{cite journal| author=Agrawal S, Bhupinderjit A, Bhutani MS, Boardman L, Nguyen C, Romero Y et al.| title=Colorectal cancer in African Americans. | journal=Am J Gastroenterol | year= 2005 | volume= 100 | issue= 3 | pages= 515-23; discussion 514 | pmid=15743345 | doi=10.1111/j.1572-0241.2005.41829.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15743345  }} </ref><ref name="pmid22665813">{{cite journal| author=Henderson TO, Oeffinger KC, Whitton J, Leisenring W, Neglia J, Meadows A et al.| title=Secondary gastrointestinal cancer in childhood cancer survivors: a cohort study. | journal=Ann Intern Med | year= 2012 | volume= 156 | issue= 11 | pages= 757-66, W-260 | pmid=22665813 | doi=10.7326/0003-4819-156-11-201206050-00002 | pmc=PMC3554254 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22665813  }} </ref><ref name="pmid20610543">{{cite journal| author=Jemal A, Siegel R, Xu J, Ward E| title=Cancer statistics, 2010. | journal=CA Cancer J Clin | year= 2010 | volume= 60 | issue= 5 | pages= 277-300 | pmid=20610543 | doi=10.3322/caac.20073 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20610543  }} </ref><ref name="SchoenfeldCash2005">{{cite journal|last1=Schoenfeld|first1=Philip|last2=Cash|first2=Brooks|last3=Flood|first3=Andrew|last4=Dobhan|first4=Richard|last5=Eastone|first5=John|last6=Coyle|first6=Walter|last7=Kikendall|first7=James W.|last8=Kim|first8=Hyungjin Myra|last9=Weiss|first9=David G.|last10=Emory|first10=Theresa|last11=Schatzkin|first11=Arthur|last12=Lieberman|first12=David|title=Colonoscopic Screening of Average-Risk Women for Colorectal Neoplasia|journal=New England Journal of Medicine|volume=352|issue=20|year=2005|pages=2061–2068|issn=0028-4793|doi=10.1056/NEJMoa042990}}</ref><ref name="pmid7593429">{{cite journal| author=Delhougne B, Deneux C, Abs R, Chanson P, Fierens H, Laurent-Puig P et al.| title=The prevalence of colonic polyps in acromegaly: a colonoscopic and pathological study in 103 patients. | journal=J Clin Endocrinol Metab | year= 1995 | volume= 80 | issue= 11 | pages= 3223-6 | pmid=7593429 | doi=10.1210/jcem.80.11.7593429 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7593429}} </ref><ref name="pmid20883538">{{cite journal| author=Park JM, Choi MG, Kim SW, Chung IS, Yang CW, Kim YS et al.| title=Increased incidence of colorectal malignancies in renal transplant recipients: a case control study. | journal=Am J Transplant | year= 2010 | volume= 10 | issue= 9 | pages= 2043-50 | pmid=20883538 | doi=10.1111/j.1600-6143.2010.03231.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20883538  }} </ref><ref name="pmid7749056">{{cite journal| author=Giovannucci E| title=Insulin and colon cancer. | journal=Cancer Causes Control | year= 1995 | volume= 6 | issue= 2 | pages= 164-79 | pmid=7749056 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7749056  }} </ref><ref name="pmid12588695">{{cite journal| author=Harnack L, Jacobs DR, Nicodemus K, Lazovich D, Anderson K, Folsom AR| title=Relationship of folate, vitamin B-6, vitamin B-12, and methionine intake to incidence of colorectal cancers. | journal=Nutr Cancer | year= 2002 | volume= 43 | issue= 2 | pages= 152-8 | pmid=12588695 | doi=10.1207/S15327914NC432_5 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12588695  }} </ref><ref>{{Cite journal
| align="center" style="background:#f0f0f0;"|'''Environmental Risk Factor'''
| author = [[Carmen Jochem]] & [[Michael Leitzmann]]
| title = Obesity and Colorectal Cancer
| journal = [[Recent results in cancer research. Fortschritte der Krebsforschung. Progres dans les recherches sur le cancer]]
| volume = 208
| pages = 17–41
| year = 2016
| month =
| doi = 10.1007/978-3-319-42542-9_2
| pmid = 27909900
}}</ref><ref name="pmid19088354">{{cite journal| author=Botteri E, Iodice S, Bagnardi V, Raimondi S, Lowenfels AB, Maisonneuve P| title=Smoking and colorectal cancer: a meta-analysis. | journal=JAMA | year= 2008 | volume= 300 | issue= 23 | pages= 2765-78 | pmid=19088354 | doi=10.1001/jama.2008.839 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19088354  }} </ref><ref name="pmid7104616">{{cite journal| author=Stewart M, Macrae FA, Williams CB| title=Neoplasia and ureterosigmoidostomy: a colonoscopy survey. | journal=Br J Surg | year= 1982 | volume= 69 | issue= 7 | pages= 414-6 | pmid=7104616 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7104616  }} </ref><ref name="pmid17895457">{{cite journal| author=Chan AO, Jim MH, Lam KF, Morris JS, Siu DC, Tong T et al.| title=Prevalence of colorectal neoplasm among patients with newly diagnosed coronary artery disease. | journal=JAMA | year= 2007 | volume= 298 | issue= 12 | pages= 1412-9 | pmid=17895457 | doi=10.1001/jama.298.12.1412 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17895457  }} </ref><ref name="pmid24569462">{{cite journal| author=Lynch BM, Boyle T| title=Distinguishing sedentary from inactive: implications for meta-analyses. | journal=Br J Cancer | year= 2014 | volume= 111 | issue= 11 | pages= 2202-3 | pmid=24569462 | doi=10.1038/bjc.2014.106 | pmc=PMC4260011 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24569462  }} </ref><ref name="pmid11950810">{{cite journal| author=Evans HS, Møller H, Robinson D, Lewis CM, Bell CM, Hodgson SV| title=The risk of subsequent primary cancers after colorectal cancer in southeast England. | journal=Gut | year= 2002 | volume= 50 | issue= 5 | pages= 647-52 | pmid=11950810 | doi= | pmc=PMC1773208 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11950810  }} </ref><ref name="pmid10378216">{{cite journal| author=Glade MJ| title=Food, nutrition, and the prevention of cancer: a global perspective. American Institute for Cancer Research/World Cancer Research Fund, American Institute for Cancer Research, 1997. | journal=Nutrition | year= 1999 | volume= 15 | issue= 6 | pages= 523-6 | pmid=10378216 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10378216  }} </ref><ref name="pmid15644544">{{cite journal| author=Chao A, Thun MJ, Connell CJ, McCullough ML, Jacobs EJ, Flanders WD et al.| title=Meat consumption and risk of colorectal cancer. | journal=JAMA | year= 2005 | volume= 293 | issue= 2 | pages= 172-82 | pmid=15644544 | doi=10.1001/jama.293.2.172 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15644544  }} </ref>
{| style="border:#c9c9c9 1px solid; margin: 1em 1em 1em 0; border-collapse: collapse;" cellspacing="0" cellpadding="4" {{table}}
| style="background:#f0f0f0;" align="center" align="center" style="background:#4479BA; color: #FFFFFF;" + |'''Environmental Risk Factor'''


| align="center" style="background:#f0f0f0;"|'''Description'''
| style="background:#f0f0f0;" align="center" align="center" style="background:#4479BA; color: #FFFFFF;" + |'''Description'''


|-
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| '''Family History'''||There is a risk if there is a single affected first-degree relative with CRC; the risk further increases if two first-degree relatives have CRC or the diagnosis was below ages 50-60 years; may have increased risk if a first-degree family member has an adenomatous colonic polyp<ref name="pmid8531963">{{cite journal| author=Winawer SJ, Zauber AG, Gerdes H, O'Brien MJ, Gottlieb LS, Sternberg SS et al.| title=Risk of colorectal cancer in the families of patients with adenomatous polyps. National Polyp Study Workgroup. | journal=N Engl J Med | year= 1996 | volume= 334 | issue= 2 | pages= 82-7 | pmid=8531963 | doi=10.1056/NEJM199601113340204 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8531963  }} </ref>
| '''Family History'''||Risk increases with number of family members affected and the age of diagnosis
* If there is a single affected first-degree relative with CRC; the risk further increases if two first-degree relatives have CRC diagnosis
* If age of diagnosis is less than 50-60 years, the risk significantly increases especially if the family member has an [[Adenomatous Polyposis Coli|adenomatous colonic polyp]]


|-
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| '''Personal History'''||There is a risk if there is a history of CRC or adenomatous polyps, particularly if they are multiple [[polyps]] >1 cm, or if the polyps are villous/tubulovillous<ref name="pmid1736104">{{cite journal| author=Atkin WS, Morson BC, Cuzick J| title=Long-term risk of colorectal cancer after excision of rectosigmoid adenomas. | journal=N Engl J Med | year= 1992 | volume= 326 | issue= 10 | pages= 658-62 | pmid=1736104 | doi=10.1056/NEJM199203053261002 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1736104  }} </ref>
| '''Personal History'''||Risk increases if there is a personal history of CRC or [[adenomatous polyps]], particularly:
* If they are multiple [[polyps]] >1 cm, or  
* If the polyps are [[Villous adenoma|villous]] or [[Tubular adenoma|tubulovillous]]


|-
|-


| '''Ulcerative Colitis'''||The increase in risk begins about 8 to 10 years after the initial diagnosis of [[pancolitis]]  and at 15 to 20 years if the colitis is limited to the left colon; by the fourth decade of disease it reaches as high as 30% in patients with [[pancolitis]]; [[pseudopolyps]] and [[strictures]] may increase the risk<ref name="pmid2215606">{{cite journal| author=Ekbom A, Helmick C, Zack M, Adami HO| title=Ulcerative colitis and colorectal cancer. A population-based study. | journal=N Engl J Med | year= 1990 | volume= 323 | issue= 18 | pages= 1228-33 | pmid=2215606 | doi=10.1056/NEJM199011013231802 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2215606  }} </ref>
| '''[[Ulcerative Colitis]]'''||The increase in risk begins about 8 to 10 years after the initial diagnosis of [[pancolitis]]  and at 15 to 20 years  
* If the [[colitis]] is limited to the left [[colon]]
* By the fourth decade of disease it reaches as high as 30% in patients with [[pancolitis]]; [[pseudopolyps]] and [[strictures]] may increase the risk


|-
|-


| '''Crohn's Disease'''||There is an increased risk if 1/3 or more of the colonic mucosa is involved
| '''[[Crohn's disease|Crohn's Disease]]'''||There is an increased risk:
* If 1/3rd or more of the [[Colon (anatomy)|colonic]] mucosa is involved


|-
|-


| '''Age'''||The risk of developing CRC increases with age; the majority of cases occur in the 60s and 70s, while cases before age 50 are uncommon unless a family history of early colon cancer is present; cancer in african american individuals tends to occur earlier<ref name="pmid15743345">{{cite journal| author=Agrawal S, Bhupinderjit A, Bhutani MS, Boardman L, Nguyen C, Romero Y et al.| title=Colorectal cancer in African Americans. | journal=Am J Gastroenterol | year= 2005 | volume= 100 | issue= 3 | pages= 515-23; discussion 514 | pmid=15743345 | doi=10.1111/j.1572-0241.2005.41829.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15743345  }} </ref>
| '''Age'''||The risk of developing CRC increases with age;  
* Majority of cases occur in the 60s and 70s, while cases before age 50 are uncommon unless a family history of early colon cancer is present
* Cancer in African American individuals tends to occur earlier


|-
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| '''Abdominal Radiation'''||Adult survivors of childhood malignancy who received [[abdominal]] radiation are at significant risk<ref name="pmid22665813">{{cite journal| author=Henderson TO, Oeffinger KC, Whitton J, Leisenring W, Neglia J, Meadows A et al.| title=Secondary gastrointestinal cancer in childhood cancer survivors: a cohort study. | journal=Ann Intern Med | year= 2012 | volume= 156 | issue= 11 | pages= 757-66, W-260 | pmid=22665813 | doi=10.7326/0003-4819-156-11-201206050-00002 | pmc=PMC3554254 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22665813  }} </ref>
| '''Abdominal Radiation'''||
* Adult survivors of childhood malignancy who received [[abdominal]] [[Radiation therapy|radiation]] are at significant risk


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| '''Race'''||The African American race has the highest CRC race of all the ethnic groups; the mortality in is 20% higher in the African American race compared to the Caucasian race<ref name="pmid20610543">{{cite journal| author=Jemal A, Siegel R, Xu J, Ward E| title=Cancer statistics, 2010. | journal=CA Cancer J Clin | year= 2010 | volume= 60 | issue= 5 | pages= 277-300 | pmid=20610543 | doi=10.3322/caac.20073 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20610543  }} </ref>
| '''Race'''||The African American race has the highest CRC race of all the ethnic groups
* The mortality is 20% higher in the African American race compared to the Caucasian race


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| '''Gender'''||CRC mortality is about 20-40 percent higher in men than in women <ref name="SchoenfeldCash2005">{{cite journal|last1=Schoenfeld|first1=Philip|last2=Cash|first2=Brooks|last3=Flood|first3=Andrew|last4=Dobhan|first4=Richard|last5=Eastone|first5=John|last6=Coyle|first6=Walter|last7=Kikendall|first7=James W.|last8=Kim|first8=Hyungjin Myra|last9=Weiss|first9=David G.|last10=Emory|first10=Theresa|last11=Schatzkin|first11=Arthur|last12=Lieberman|first12=David|title=Colonoscopic Screening of Average-Risk Women for Colorectal Neoplasia|journal=New England Journal of Medicine|volume=352|issue=20|year=2005|pages=2061–2068|issn=0028-4793|doi=10.1056/NEJMoa042990}}</ref>
| '''Gender'''||
* CRC mortality is about 20-40 percent higher in men than in women  


  |-
  |-


| '''Acromegaly'''||Patients with acromegaly are more likely to have multiple adenomatous [[polyps]]<ref name="pmid7593429">{{cite journal| author=Delhougne B, Deneux C, Abs R, Chanson P, Fierens H, Laurent-Puig P et al.| title=The prevalence of colonic polyps in acromegaly: a colonoscopic and pathological study in 103 patients. | journal=J Clin Endocrinol Metab | year= 1995 | volume= 80 | issue= 11 | pages= 3223-6 | pmid=7593429 | doi=10.1210/jcem.80.11.7593429 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7593429}} </ref>
| '''Acromegaly'''||
* Patients with [[acromegaly]] are more likely to have multiple [[adenomatous polyps]]


|-
|-


| '''Immunosuppression'''||Immunosuppression causes have been linked with increased CRC risk, for example, renal transplantation <ref name="pmid20883538">{{cite journal| author=Park JM, Choi MG, Kim SW, Chung IS, Yang CW, Kim YS et al.| title=Increased incidence of colorectal malignancies in renal transplant recipients: a case control study. | journal=Am J Transplant | year= 2010 | volume= 10 | issue= 9 | pages= 2043-50 | pmid=20883538 | doi=10.1111/j.1600-6143.2010.03231.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20883538  }} </ref>
| '''Immunosuppression'''||
* [[Immunosuppression]] increases the risk of developing CRC, for example in [[renal transplantation]]


|-
|-


| '''Diabetes Mellitus and Insulin Resistance'''||Although it is not clear why but one possible explanation linking diabetes to CRC is [[hyperinsulinemia]]  insulin is an important growth factor for colonic mucosal cells and stimulates colonic [[tumor]] cells<ref name="pmid7749056">{{cite journal| author=Giovannucci E| title=Insulin and colon cancer. | journal=Cancer Causes Control | year= 1995 | volume= 6 | issue= 2 | pages= 164-79 | pmid=7749056 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7749056  }} </ref>
| '''Diabetes Mellitus and Insulin Resistance'''||Although it is not clear why but one possible explanation linking diabetes to CRC is [[hyperinsulinemia]]   
* [[Insulin]] is an important growth factor for [[Colon (anatomy)|colonic]] mucosal cells and stimulates colonic [[tumor]] cells


|-
|-


| '''Alcohol'''||The elevated risk may be related to interference of [[folate]] absorption by [[alcohol]] and decreased folate intake<ref name="pmid12588695">{{cite journal| author=Harnack L, Jacobs DR, Nicodemus K, Lazovich D, Anderson K, Folsom AR| title=Relationship of folate, vitamin B-6, vitamin B-12, and methionine intake to incidence of colorectal cancers. | journal=Nutr Cancer | year= 2002 | volume= 43 | issue= 2 | pages= 152-8 | pmid=12588695 | doi=10.1207/S15327914NC432_5 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12588695  }} </ref>
| '''Alcohol'''||
* The elevated risk may be related to interference of [[folate]] absorption by [[alcohol]] and decreased folate intake


|-
|-


| '''Obesity'''||It was reported that each 5 kg/m2 increase in BMI was associated with a 24 percent increased incidence of both colon and rectal cancer in men, and a 9 percent higher incidence of colon cancer in women<ref name="pmid12588695">{{cite journal| author=Harnack L, Jacobs DR, Nicodemus K, Lazovich D, Anderson K, Folsom AR| title=Relationship of folate, vitamin B-6, vitamin B-12, and methionine intake to incidence of colorectal cancers. | journal=Nutr Cancer | year= 2002 | volume= 43 | issue= 2 | pages= 152-8 | pmid=12588695 | doi=10.1207/S15327914NC432_5 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12588695  }} </ref>
| '''Obesity'''||Every 5 kg/m2 increase in BMI was associated with:
* Twenty four percent increased incidence of both [[Colorectal cancer|colon]] and [[rectal cancer]] in men
* Nine percent higher incidence of colon cancer in women


|-
|-


| '''Cigarette Smoking'''||It was reported that the risk of developing CRC was increased among cigarette smokers compared to those who never smoked; for both incidence and mortality, the association was stronger for cancer of the [[rectum]] than the colon<ref name="pmid19088354">{{cite journal| author=Botteri E, Iodice S, Bagnardi V, Raimondi S, Lowenfels AB, Maisonneuve P| title=Smoking and colorectal cancer: a meta-analysis. | journal=JAMA | year= 2008 | volume= 300 | issue= 23 | pages= 2765-78 | pmid=19088354 | doi=10.1001/jama.2008.839 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19088354  }} </ref>
| '''Cigarette Smoking'''||Risk of developing CRC was increased among cigarette smokers compared to those who never smoked;  
* For both [[incidence]] and [[mortality]], the association was stronger for cancer of the [[rectum]] than the [[Colorectal cancer|colon]]


|-
|-


| '''Uretercolic Anastomoses'''||There is increased risk of neoplasia in close proximity to the ureteric [[stoma]]<ref name="pmid7104616">{{cite journal| author=Stewart M, Macrae FA, Williams CB| title=Neoplasia and ureterosigmoidostomy: a colonoscopy survey. | journal=Br J Surg | year= 1982 | volume= 69 | issue= 7 | pages= 414-6 | pmid=7104616 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7104616  }} </ref>
| '''Uretercolic Anastomoses'''||
* There is increased risk of [[neoplasia]] in close proximity to the ureteric [[stoma]]


|-
|-


| '''Diet'''||Long-term consumption of red meat or processed meats, diets low in vegetables and high in fats may be associated with an increased risk of CRC{<ref name="pmid15644544">{{cite journal| author=Chao A, Thun MJ, Connell CJ, McCullough ML, Jacobs EJ, Flanders WD et al.| title=Meat consumption and risk of colorectal cancer. | journal=JAMA | year= 2005 | volume= 293 | issue= 2 | pages= 172-82 | pmid=15644544 | doi=10.1001/jama.293.2.172 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15644544  }} </ref><ref name="pmid10378216">{{cite journal| author=Glade MJ| title=Food, nutrition, and the prevention of cancer: a global perspective. American Institute for Cancer Research/World Cancer Research Fund, American Institute for Cancer Research, 1997. | journal=Nutrition | year= 1999 | volume= 15 | issue= 6 | pages= 523-6 | pmid=10378216 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10378216  }} </ref>
| '''Diet'''||Diets associated with an increased risk of CRC include:
* Long-term consumption of red meat or processed meats
* Diets low in vegetables and high in fats  


|-
|-


| '''Coronary Heart Disease'''||The presence of [[coronary heart disease]] has been associated with an increased risk of CRC{<ref name="pmid17895457">{{cite journal| author=Chan AO, Jim MH, Lam KF, Morris JS, Siu DC, Tong T et al.| title=Prevalence of colorectal neoplasm among patients with newly diagnosed coronary artery disease. | journal=JAMA | year= 2007 | volume= 298 | issue= 12 | pages= 1412-9 | pmid=17895457 | doi=10.1001/jama.298.12.1412 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17895457  }} </ref>
| '''Coronary Heart Disease'''||
* The presence of [[coronary heart disease]] has been associated with an increased risk of CRC
|-
|-


| '''Sedentary Lifestyle'''||Regular exercise stimulates peristalsis, thereby decreasing transit time for [[carcinogenic]] substances in the colon<ref name="pmid24569462">{{cite journal| author=Lynch BM, Boyle T| title=Distinguishing sedentary from inactive: implications for meta-analyses. | journal=Br J Cancer | year= 2014 | volume= 111 | issue= 11 | pages= 2202-3 | pmid=24569462 | doi=10.1038/bjc.2014.106 | pmc=PMC4260011 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24569462  }} </ref>
| '''Sedentary Lifestyle'''||
* Regular exercise stimulates peristalsis, thereby decreasing transit time for [[carcinogenic]] substances in the colon
|-
|-


| '''Other cancers'''||[[Ovarian]], [[endometrial]], and [[breast]] cancer; there is an increase in risk is more likely if the first primary is diagnosed at an early age<ref name="pmid11950810">{{cite journal| author=Evans HS, Møller H, Robinson D, Lewis CM, Bell CM, Hodgson SV| title=The risk of subsequent primary cancers after colorectal cancer in southeast England. | journal=Gut | year= 2002 | volume= 50 | issue= 5 | pages= 647-52 | pmid=11950810 | doi= | pmc=PMC1773208 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11950810  }} </ref>
| '''Other cancers'''||The following cancers have been associated with an CRC especially if the first diagnosis was made at an early age:
* [[Ovarian]]
* Endometrial
* Breast cancer
|}
|}


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To view the risk factors of familial adenomatous polyposis (FAP), click here
To view the risk factors of hereditary nonpolyposis colorectal cancer (HNPCC), click here

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Saarah T. Alkhairy, M.D.

Overview

There are both genetic and environmental factors that can increase the risk of colorectal carcinoma (CRC). Some of the genetic risk factors are familial adenomatous polyposis and hereditary non-polyposis colorectal cancer. Some environmental risk factors are personal/family history, history of inflammatory bowel disease, diet, alcohol, cigarette smoking, race, and gender.

Colorectal Cancer Risk Factors

The causes and the risk factors for colorectal carcinoma are the similar. There are both genetic and environmental factors that can increase the risk of colorectal carcinoma.[1] FAP and HNPCC are the most common risk factors of CRC, but together these two conditions account for only about 5 percent of CRC.[2]

Genetic Risk Factors

The table below lists the genetic risk factors for colorectal carcinoma:[3][4]

Genetic Risk Factor Description
Familial Adenomatous Polyposis (FAP)
  • Autosomal dominant inheritance
  • Other variants include Gardner's syndrome, Turcot's syndrome, and attenuated adenomatous polyposis coli
  • Caused by germlines mutations in the APC gene
  • Colonic cancer occurs in 90% of untreated individuals around 45 years

To view Gardner's syndrome, Turcot's syndrome, and attenuated adenomatous polyposis coli , click here

MUTYH-associated Polyposis (MAP)
Lynch Syndrome AKA Hereditary Non-polyposis Colorectal Cancer (HNPCC)
  • Autosomal dominant inheritance
  • Caused by a defect in one of the mismatch repair genes, most commonly hMLH1, hMSH2, hMSH6, or PMS2
  • Mean age at initial cancer diagnosis is around 48 years

Environmental Risk Factors

The table below lists the environmental risk factors for colorectal carcinoma:[5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23]

Environmental Risk Factor Description
Family History Risk increases with number of family members affected and the age of diagnosis
  • If there is a single affected first-degree relative with CRC; the risk further increases if two first-degree relatives have CRC diagnosis
  • If age of diagnosis is less than 50-60 years, the risk significantly increases especially if the family member has an adenomatous colonic polyp
Personal History Risk increases if there is a personal history of CRC or adenomatous polyps, particularly:
Ulcerative Colitis The increase in risk begins about 8 to 10 years after the initial diagnosis of pancolitis and at 15 to 20 years
Crohn's Disease There is an increased risk:
  • If 1/3rd or more of the colonic mucosa is involved
Age The risk of developing CRC increases with age;
  • Majority of cases occur in the 60s and 70s, while cases before age 50 are uncommon unless a family history of early colon cancer is present
  • Cancer in African American individuals tends to occur earlier
Abdominal Radiation
  • Adult survivors of childhood malignancy who received abdominal radiation are at significant risk
Race The African American race has the highest CRC race of all the ethnic groups
  • The mortality is 20% higher in the African American race compared to the Caucasian race
Gender
  • CRC mortality is about 20-40 percent higher in men than in women
Acromegaly
Immunosuppression
Diabetes Mellitus and Insulin Resistance Although it is not clear why but one possible explanation linking diabetes to CRC is hyperinsulinemia
  • Insulin is an important growth factor for colonic mucosal cells and stimulates colonic tumor cells
Alcohol
  • The elevated risk may be related to interference of folate absorption by alcohol and decreased folate intake
Obesity Every 5 kg/m2 increase in BMI was associated with:
  • Twenty four percent increased incidence of both colon and rectal cancer in men
  • Nine percent higher incidence of colon cancer in women
Cigarette Smoking Risk of developing CRC was increased among cigarette smokers compared to those who never smoked;
Uretercolic Anastomoses
  • There is increased risk of neoplasia in close proximity to the ureteric stoma
Diet Diets associated with an increased risk of CRC include:
  • Long-term consumption of red meat or processed meats
  • Diets low in vegetables and high in fats
Coronary Heart Disease
Sedentary Lifestyle
  • Regular exercise stimulates peristalsis, thereby decreasing transit time for carcinogenic substances in the colon
Other cancers The following cancers have been associated with an CRC especially if the first diagnosis was made at an early age:

References

  1. ↑ Chan AT, Giovannucci EL (2010). "Primary prevention of colorectal cancer". Gastroenterology. 138 (6): 2029–2043.e10. doi:10.1053/j.gastro.2010.01.057. PMC 2947820. PMID 20420944.
  2. ↑ Burt RW, DiSario JA, Cannon-Albright L (1995). "Genetics of colon cancer: impact of inheritance on colon cancer risk". Annu Rev Med. 46: 371–9. doi:10.1146/annurev.med.46.1.371. PMID 7598472.
  3. ↑ Mazur IA (1977). "[Synthesis of imidazopyrimidines and imidazoquinazolines with a common nitrogen atom]". Farm Zh (6): 37–41. PMID 598472.
  4. ↑ Parry S, Win AK, Parry B, Macrae FA, Gurrin LC, Church JM; et al. (2011). "Metachronous colorectal cancer risk for mismatch repair gene mutation carriers: the advantage of more extensive colon surgery". Gut. 60 (7): 950–7. doi:10.1136/gut.2010.228056. PMC 3848416. PMID 21193451.
  5. ↑ Winawer SJ, Zauber AG, Gerdes H, O'Brien MJ, Gottlieb LS, Sternberg SS; et al. (1996). "Risk of colorectal cancer in the families of patients with adenomatous polyps. National Polyp Study Workgroup". N Engl J Med. 334 (2): 82–7. doi:10.1056/NEJM199601113340204. PMID 8531963.
  6. ↑ Atkin WS, Morson BC, Cuzick J (1992). "Long-term risk of colorectal cancer after excision of rectosigmoid adenomas". N Engl J Med. 326 (10): 658–62. doi:10.1056/NEJM199203053261002. PMID 1736104.
  7. ↑ Ekbom A, Helmick C, Zack M, Adami HO (1990). "Ulcerative colitis and colorectal cancer. A population-based study". N Engl J Med. 323 (18): 1228–33. doi:10.1056/NEJM199011013231802. PMID 2215606.
  8. ↑ Agrawal S, Bhupinderjit A, Bhutani MS, Boardman L, Nguyen C, Romero Y; et al. (2005). "Colorectal cancer in African Americans". Am J Gastroenterol. 100 (3): 515–23, discussion 514. doi:10.1111/j.1572-0241.2005.41829.x. PMID 15743345.
  9. ↑ Henderson TO, Oeffinger KC, Whitton J, Leisenring W, Neglia J, Meadows A; et al. (2012). "Secondary gastrointestinal cancer in childhood cancer survivors: a cohort study". Ann Intern Med. 156 (11): 757–66, W-260. doi:10.7326/0003-4819-156-11-201206050-00002. PMC 3554254. PMID 22665813.
  10. ↑ Jemal A, Siegel R, Xu J, Ward E (2010). "Cancer statistics, 2010". CA Cancer J Clin. 60 (5): 277–300. doi:10.3322/caac.20073. PMID 20610543.
  11. ↑ Schoenfeld, Philip; Cash, Brooks; Flood, Andrew; Dobhan, Richard; Eastone, John; Coyle, Walter; Kikendall, James W.; Kim, Hyungjin Myra; Weiss, David G.; Emory, Theresa; Schatzkin, Arthur; Lieberman, David (2005). "Colonoscopic Screening of Average-Risk Women for Colorectal Neoplasia". New England Journal of Medicine. 352 (20): 2061–2068. doi:10.1056/NEJMoa042990. ISSN 0028-4793.
  12. ↑ Delhougne B, Deneux C, Abs R, Chanson P, Fierens H, Laurent-Puig P; et al. (1995). "The prevalence of colonic polyps in acromegaly: a colonoscopic and pathological study in 103 patients". J Clin Endocrinol Metab. 80 (11): 3223–6. doi:10.1210/jcem.80.11.7593429. PMID 7593429.
  13. ↑ Park JM, Choi MG, Kim SW, Chung IS, Yang CW, Kim YS; et al. (2010). "Increased incidence of colorectal malignancies in renal transplant recipients: a case control study". Am J Transplant. 10 (9): 2043–50. doi:10.1111/j.1600-6143.2010.03231.x. PMID 20883538.
  14. ↑ Giovannucci E (1995). "Insulin and colon cancer". Cancer Causes Control. 6 (2): 164–79. PMID 7749056.
  15. ↑ Harnack L, Jacobs DR, Nicodemus K, Lazovich D, Anderson K, Folsom AR (2002). "Relationship of folate, vitamin B-6, vitamin B-12, and methionine intake to incidence of colorectal cancers". Nutr Cancer. 43 (2): 152–8. doi:10.1207/S15327914NC432_5. PMID 12588695.
  16. ↑ Carmen Jochem & Michael Leitzmann (2016). "Obesity and Colorectal Cancer". Recent results in cancer research. Fortschritte der Krebsforschung. Progres dans les recherches sur le cancer. 208: 17–41. doi:10.1007/978-3-319-42542-9_2. PMID 27909900.
  17. ↑ Botteri E, Iodice S, Bagnardi V, Raimondi S, Lowenfels AB, Maisonneuve P (2008). "Smoking and colorectal cancer: a meta-analysis". JAMA. 300 (23): 2765–78. doi:10.1001/jama.2008.839. PMID 19088354.
  18. ↑ Stewart M, Macrae FA, Williams CB (1982). "Neoplasia and ureterosigmoidostomy: a colonoscopy survey". Br J Surg. 69 (7): 414–6. PMID 7104616.
  19. ↑ Chan AO, Jim MH, Lam KF, Morris JS, Siu DC, Tong T; et al. (2007). "Prevalence of colorectal neoplasm among patients with newly diagnosed coronary artery disease". JAMA. 298 (12): 1412–9. doi:10.1001/jama.298.12.1412. PMID 17895457.
  20. ↑ Lynch BM, Boyle T (2014). "Distinguishing sedentary from inactive: implications for meta-analyses". Br J Cancer. 111 (11): 2202–3. doi:10.1038/bjc.2014.106. PMC 4260011. PMID 24569462.
  21. ↑ Evans HS, Møller H, Robinson D, Lewis CM, Bell CM, Hodgson SV (2002). "The risk of subsequent primary cancers after colorectal cancer in southeast England". Gut. 50 (5): 647–52. PMC 1773208. PMID 11950810.
  22. ↑ Glade MJ (1999). "Food, nutrition, and the prevention of cancer: a global perspective. American Institute for Cancer Research/World Cancer Research Fund, American Institute for Cancer Research, 1997". Nutrition. 15 (6): 523–6. PMID 10378216.
  23. ↑ Chao A, Thun MJ, Connell CJ, McCullough ML, Jacobs EJ, Flanders WD; et al. (2005). "Meat consumption and risk of colorectal cancer". JAMA. 293 (2): 172–82. doi:10.1001/jama.293.2.172. PMID 15644544.


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