Fruit and colon cancer.
Total fruit and total colon cancer risk.
Data about the relation between total fruit and total colon cancer risk was provided by a pooled analysis of 14 cohorts (Koushik A [29]) and 6 additional cohorts,
including 9,794 + X cases (the amount of cases was not defined in one cohort of very large size: Park Y [27]).
A significant protective effect was found in the pooled analysis (RR = 0.87 [0.77-0.97; P = 0.04] for men & women combined), in one additional cohort of small
size among women only (Shibata A [1]), and in one cohort of very large size among men only (Nomura AM [30]), though the trend was not significant in the latter cohort.
These analysis included 6.631 cases (< 68% of all cases). In addition, a nonsignificant protective effect was found in one cohort of
very large size (van Duijnhoven FJ [18]) including a total of 1,828 cases (< 19% of all cases).
The average RR = 0.87 (excluding incomplete data from Park Y [27]). Stratified by gender, the RR's were 0.90 for men, and 0.84 for women; but one cohort could not
be included in this analysis, because no amount of cases was provided, stratified by gender (Sato Y [24]).
Stratified by gender, protective effects from the pooled analysis were restricted to women, and the trend became nonsignificant.
Inclusion of intermediate levels of consumption:
Among women, significant protective effects were found at different levels of consumption (100- < 300 g/day, and ≥ 400 g/dag) in the pooled analysis (Koushik A [29]).
In addition, a significant protective effect was found at the level of consumption of > 246 g/day in one additional cohort of small size (Shibata A [1]).
Among men, a significant protective effect was found in one cohort at 740 g/day (Nomura AM [30]):
Effect modification:
- No effect modification was found by age at diagnosis (29), follow-up period (29), BMI (15, 18, 25), multivitamin supplement use (25, 29), family history of colorectal cancer (6, 8), having had a sigmoidoscopy or colonoscopy, or a polyp detected (6), HRT therapy (7), alcohol consumption (15, 18, 25), and physical activity (25).
- Most (7, 18, 25), but not all (6) cohorts showed no effect modification by smoking status.
- One (25), but not the other (18) cohort showed no effect modification by meat consumption.
Conclusion: A significant protective effect was found in a pooled analysis of 14 cohorts, and 2 additional cohorts, though effects were restricted to one gender in the latter 2 cohorts. A protective effect was found in one cohort of very large size, but this effect was nonsignificant. Total fruit possibly protects against total colon cancer risk (- 13%). The evidence was restricted to women, though the average effect size does not exclude the possibility of an effect among men. Protective effects among women were found at the level of consumption of 100- < 300 g/day and ≥ 400 g/day. No evidence was found for effect modification.
| Author | Cohort name | Cases | Relative Risk (RR) |
|---|---|---|---|
| 30) Nomura AM (2008) | The Multiethnic Cohort Study | 734 men, and 617 women | Men: RR = 0.75 (0.58-0.97; P = 0.11). Women: RR = 0.87 (0.65-1.15). |
| 29) Koushik A (2007) | Pooled analysis of 14 cohorts | 1,890 men, and 3,902 women | Men: RR = 0.93 (0.76-1.14; P = 0.23). Women: RR = 0.84 (0.74-0.96; P = 0.08). |
| 27) Park Y (2007) | The NIH-AARP Diet and Health Study | Not defined | Men: 1.11 (0.93-1.32; P = 0.55). Women: RR = 0.96 (0.75-1.24; P = 0.67). |
| 25) Tsubono Y (2005) | The JPHC Study | 300 men, and 156 women | Men: RR = 1.02 (0.61-1.70; P = 0.57). Women: RR = 0.87 (0.49-1.52; P = 0.86). |
| 24) Sato Y (2005) | The Miyagi Cohort Study | 165 (not defined, stratified by gender) | Men: RR = 1.75 (0.89-3.44; P = 0.23). Women: RR = 0.99 (0.23-4.25; P = 0.79). |
| 18) van Duijnhoven FJ (2009) | The EPIC Study | 1,828 | HR = 0.84 (0.71-1.00; P = 0.07). |
| 1) Shibata A (1992) | The Leisure World Study | 97 men, and 105 women | Men: RR = 1.12 (0.69-1.81). Women: RR = 0.50 (0.31-0.80; P = < 0.05). |
| Total number of cases: 9,794 + X | Average RR = 0.87 |
| Author | Cohort name | Subjects | Years of follow-up | Cases | End point | Consumption of | Relative Risk (RR) | Adjustments | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 30) Nomura AM (2008) | The Multiethnic Cohort Study. | 85,903 men and 105,108 women aged 45-75. (Hawaii and California) | 7.3 (1993-96 to 2001) | 734 men, and 617 women | Colon cancer risk (only invasive adenocarcinoma) | Fruit (not defined. including fruit juices) |
Age, family history of colorectal cancer, history of colorectal polyp, pack-years of cigarette smoking, BMI, hours of vigorous activity, aspirin use, multivitamin use, replacement hormone use, log energy intake, alcohol, red meat, folate, vitamin D, and calcium. |
29) Koushik A. (2007) | Pooled Analysis of 14 Cohort Studies. | 756,217 subjects (242,362 men and 513,855 women) | 6-20 years | 5792 (3902 women, 1890 men) | Colon cancer risk | Total fruit (fruits and fruit juices) |
INCLUSION CRITERIA: |
INCLUDED STUDIES (Follow-up years/No. of colon cancer cases). In the analysis, an extended follow-up period for most of the studies was included:
RELATIVE RISK:
A statistically significant lower risk of colon cancer was observed for total fruits in the Nurses' Health Study (b) only. The results for total fruits not including fruit juices (results not shown) were similar to the results for total fruits. BMI; height; education; physical activity; family history of colorectal cancer; postmenopausal hormone use; oral contraceptive use; use of nonsteroidal anti-inflammatory drugs; multivitamin use; smoking habits (never/past/current + amount); red meat; total milk; alcohol; and total energy. Age in years and year of questionnaire return were included as stratification variables. |
27) Park Y. (2007) | The NIH-AARP Diet And Health Study. | 488,043 (291,094 men and 196,949 women) aged 50-71. | (USA) 4,3 | (1996-2000) No data shown. | (2,972 for total colorectal cancer risk ([2,048 men and 924 women]) Colon cancer risk | Fruit (not defined) |
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One serving = 1 medium-sized piece of fruit, 1/2 cup of cut fruit, or 6 ounces of juice (1 cup = 237 mL, 1 ounce = 29.6 mL). education, physical activity, smoking (smoking/past/current. And < or = 20 vs > 20 cigarettes/day), alcohol, red meat, dietary calcium, total energy. |
Additional adjustment for race; BMI; family history of colorectal cancer; colorectal cancer screening; use of multivitamins, NSAID's, and menopausal hormone therapy in women; and vitamin D intake showed similar results. Mutual adjustment for intakes of fruits and vegetables did not change the results. Adjustment for dietary fiber did not change the results. 25) Tsubono Y. (2005) | The JPHC Study. | A pooled analysis of 2 prospective studies with 88,658 Japanese men and women. | Cohort I included 40,106 subjects 40-59 years (19,345 men and 20,761 women). Cohort II included 48,552 subjects 40-69 years (23,180 men and 25,372 women). Cohort I: 9 (1990-99). | Cohort II: 6 (1993-99) 456 | (300 men, 156 women) Colon cancer risk | Total fruit | Cohort I: two fruits (fruit and fruit juice). Cohort II: three fruits (apples, oranges, and fruit juice)
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Stratified analyses by covariates included in multivariate models did not reveal remarkable effect modifications (no data shown). Analyses based on the octiles of total fruit consumption did not show significant associations (no data shown). sex, age, public health centre area, BMI, frequency of sports, smoking, alcohol consumption, vitamin supplement use, energy, cereals, meat, and fish by each cohort. |
24) Sato Y. (2005) | The Miyagi Cohort Study. | 47,605 subjects (22,836 men and 24,769 women) aged 40-64. | (Japan) 1990-1997 | 165 | (No data about amount of male and female cases) Colon cancer risk | Total fruit (orange, other fruits and fresh fruit juices) |
RR = 1.45 (0.85-2.47; P = 0.28) for the highest vs lowest quartile of consumption. | Amount specific data (g): ≤ 95: RR = 1. 96-196: RR = 1.30 (0.85-1.98). 170-241: RR = 1.16 (0.71-1.89). ≥ 242: RR = 1.45 (0.85-2.47).
Sex, age, smoking status, alcohol consumption, BMI, education, family history of cancer, walking time, and meat consumption. |
18) van Duijnhoven FJ (2009) | The EPIC Study | 452,755 subjects (131,985 men and 320,770 women) from 10 European countries. | 8.7-8.8 | (1992-2000 to 2006) 1,828 | Colon cancer incidence | All fruit (fresh fruit [ie, citrus fruit, hard fruit, stone fruit, grapes, berries and other fruit], mixed fruit [ie, fresh and canned fruit], olives, and nuts and seeds. | excluding fruit juices)
HR = 0.84 (0.71-1.00; P = 0.07) for the highest vs lowest quintile of consumption. | Amount specific data (g/d): < 92.8: HR = 1. 92.8-156.0: HR = 0.96 (0.82-1.11). 156.0-235.3: HR = 0.84 (0.72-0.99). 235.3-342.7: HR = 0.90 (0.77-1.06). > 342.7: HR = 0.84 (0.71-1.00).
Effect modification: No effect modification by smoking status, alcohol, or BMI was shown, but red and processed meat did modify the association with fruit (No data shown, but an inverse association was apparent among individuals in the highest tertile of red and processed meat consumption). Stratified by age at entry, sex, and center. Adjusted for energy from fat, energy from nonfat, weight, height, physical activity, smoking status, alcohol consumption, red and processed meat consumption, fish consumption, dietary fiber from cereal sources, and consumption of vegetables. |
15) Terry P (2001) | The Swedish Mammography Screening Cohort. | 61,463 women aged 40-74. | 9.6 | (1987-90 to 1998) 291 | Colon cancer risk | Fruit (including citrus fruit, fruit juice, bananas, apples, and pears) |
RR = 0.76 (0.55-1.06; P = 0.23) for the highest vs lowest quartile of consumption. | Amount specific data (servings/day): < 1.0: RR = 1. 1.0-1.5: RR = 0.54 (0.39-0.76). 1.5-2.0: RR = 0.74 (0.54-1.02). > 2.0: RR = 0.76 (0.55-1.06). The relationships between fruit and vegetable consumption and colon and rectal cancer risk were similar across different strata of alcohol consumption and body mass index. Age, consumption of red meat and dairy products, and total calories. |
9) Voorrips LE. (2000) | The Netherlands Cohort Study. | 62,573 women and 58,279 men aged 55-69. | (The Netherlands) 6.3 | (1986-1992) 611 | (331 men, 280 women) Total colon cancer risk | Total fruit (Mandarins, oranges/fresh orange juice, grapefruits/fresh grapefruit juice, grapes, bananas, appels/pears, strawberries, processed orange/grapefruit juice, other fruit juices) |
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Age, family history of colorectal cancer, and alcohol. Total energy intake, smoking, physical activity, and BMI were evaluated as potential confounders. |
8) Sellers TA (1998) | The Iowa Women's Health Study. | 35,216 women aged 55-69 years. | (USA) 10 | (1986-1995) 241 | (180 without, 61 with a family history of colon cancer) colon cancer risk | Total fruit |
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age, total energy, and history of rectal colon polyps. |
8) Steinmetz KA. (1994) | The Iowa Women's Health Study. | 35,216 women aged 55-69. | (USA) 5 | (1986-1990) 212? | Colon cancer risk | Fruit (Apples/pears, applesauce, bananas, blackberries, blueberries, cantaloupe, cherries, crenshaw melon, currants, dates, dried apples, dried apricots, dried currants, dried figs, dried papaya, dried peaches, dried pineapple, fruit cocktail, grapefruit, guavas, honeydew melon, kiwi fruit, lemons, limes, mangoes, nectarines, oranges, papaya, peaches/apricots/plums, persimmons, pineapple, plaintains, pomegranates, prunes, quince, raisins/grapes, raspberries, strawberries, tangerines, watermelon) |
RR = 0.86 (0.58-1.29) for the highest vs lowest quartile of consumption. | Amount specific data (servings/week): < 7.5: RR = 1. 7.5-11.9: RR = 0.85 (0.58-1.25). 12.0-17.4: RR = 0.95 (0.65-1.37). > 17.4: RR = 0.86 (0.58-1.29). Age, energy. The effect of adjustment of the vegetable and fruit associations for the following factors was negligible: BMI, parity, age at first live birth, physical activity, smoking, education, history of polyps or colitis, and alcohol intake. |
7) McCullough ML (2003) | The Cancer Prevention Study II Nutrition Cohort. | 62,609 men and 70,554 women aged 50-74. (The Nutrition Cohort is a subgroup of the approx. 1.2 million participants in CPS II). | 1992-93 to 1997 | 508 (298 men, 210 women) | colon cancer risk (fatal and nonfatal) | Fruit (defined as: Apples, applesauce, pears. Cantaloupe [in season]. Oranges. Grapefruit. Orange juice or grapefruit juice. Other fruit juices, fortified fruit drinks. Any other fruit, including bananas, fruit cocktail) |
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Fruit variety was unrelated to risk in either sex. There was no effect modification by hormone replacement therapy (women), smoking history or multivitamin use for any main exposure and risk of colon cancer. age, exercise, METs, aspirin, smoking, family history of colorectal cancer, BMI, education, energy, multivitamin use, total calcium and red meat intake. Alcohol intake was not included because it did not influence the effect estimates when entered in the multivariate models. |
6) Michels KB. (2000) | The Nurses' Health Study | & The Health Professionals' Follow-up Study. 88,764 women aged 34-59 and 47,325 men aged 40-75. | (USA) Women: 16 | (1980-1996). Men: 10 (1986-1996) 937 (368 men, 569 women) | colon cancer risk | A fruit was used in the definition "all fruit" if it was included in at least 2 (out of 4) different FFQs of the NHS. | All fruit (defined as: apples, applesauce, apricots, bananas, blueberries, cantaloupe, grapefruit, grapes, oranges, peaches, pears, plums, prunes, raisins, strawberries, watermelon, apple cider, apple juice, grapefruit juice, orange juice, other fruit juices)
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The null relation between fruit and vegetable consumption and colon cancer incidence was consistent across strata of vitamin supplement use and smoking status:
Similarly, no association was found among women or men who never smoked and never took vitamin supplements (data not shown). No effect modification was found by a family history of colorectal cancer, having had a sigmoidoscopy or colonoscopy, or having had a polyp detected (data not shown). age, family history of colorectal cancer, sigmoidoscopy, height, body mass index, pack-years of smoking, alcohol intake, physical activity, (women: menopausal status, postmenopausal hormone use,) aspirin use, vitamin supplement intake (ever use of multivitamins or vitamins A, C, or E), total caloric intake, and red meat consumption. |
6) Giovannucci E. (1994) | The Health Professionals Follow-up Study. | 47,949 men aged 40-75. | (USA) 1986-1992 | 205 | Colon cancer risk | Fruit (raisins, avocados, bananas, cantaloupes, watermelon, apples, pears, oranges, grapefruits, strawberries, blueberries, peaches, apricots, plums, and fruit juices) | RR = 0.98 (0.54-1.77; P = 0.52) for > 4 vs < 1 servings/day. | Not defined. |
2) Singh PN. (1998) | The Adventist Health Study. | 32,051 non-Hispanic white cohort members aged ≥ 25. | (USA) 6 | (1977-1982) Not defined for this variable. For other foods: 123-146 cases. | colon cancer risk (adenocarcinomas) | Fruit index (not defined) | Little evidence of an important association was found (no data shown). | Age, sex, BMI, physical activity, parental history of colon cancer, current smoking, past smoking, alcolhol consumption, and aspirin use. |
2) Morgan JW (1988) | The Adventist Health Study. | 35,000 Californian Seventh-day Adventists. | 6 | (1977-1982) 141? | Colon cancer incidence (adenocarcinomas) | Fruit index (not defined) | No significant relations were observed (no data shown). | Age and sex. |
1) Shibata A. (1992) | The Leisure World Study. | 11,580 residents of a retirement community. | (USA) 1981-1989 | 202 (97 men, 105 women) | Colon cancer risk | Fruits (Cantaloupe, mangos, watermelon, apricots, nectarines [including apricot nectar], peaches, papayas, persimmons, sour cherries, prunes, prune juice, apples, applesauce [not apple juice], bananas, avocados, guacamole, pineapple, pineapple juice, blackberries, blueberries, raspberries, boysenberries, loganberries, sweet cherries, fruit cocktail, oranges, tangerines, mandarin oranges, orange juice, white grapefruit and juice, pink/red grapefruit and juice, honeydew, casaba melons, strawberries, cranberry juice cocktail, plums, rhubarb, grapes, pears, figs, raisins, dates) |
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Age and smoking. |
Adjustment for BMI or physical activity did not materially alter the results (data not shown).
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