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Bowel cancer risk factors overview

54% of bowel cancer cases each year in the UK are linked to major lifestyle and other risk factors.1

Bowel cancer risk is associated with a number of risk factors (Table 4.1).3,112

Table 4.1: Bowel Cancer Risk Factors

Increase risk ('sufficient' or 'convincing' evidence) May increase risk ('limited' or 'probable' evidence) Decreases risk ('sufficient' or 'convincing' evidence) May decrease risk ('limited' or 'probable' evidence)
  • X radiation, gamma radiationa
  • Alcoholic drinksb
  • Tobacco smoking
  • Red meat
  • Processed meat
  • Body fatness
  • Abdominal fatness
  • Adult-attained height
  • Asbestos
  • Schistosoma japonicum
  • Physical activityc
  • Dietary fibre in foods
  • Garlic
  • Milk
  • Calcium

International Agency for Research on Cancer (IARC) and World Cancer Research Fund/American Institute for Cancer Research (WCRF/AICR) classifications. Find out more about IARC and WCRF/AICR classifications.
a IARC classifies evidence on X radiation and gamma radiation as sufficient for colon and limited for rectum; b IARC classification does not specify sex, WCRF/AICR classifies evidence on alcoholic drinks as convincing for males and probable for females; c WCRF/AICR classifies the evidence on physical activity as stronger for colon than rectum.

Use our interactive tool to explore risk factors for bowel cancer.

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Age and sex

Bowel cancer risk is strongly related to age and sex.

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Diet

Dietary factors classified by WCRF/AICR in relation to bowel cancer risk (Table 4.1) include;3

  • Red meat, processed meat (increases risk)
  • Dietary fibre, garlic, milk, calcium (probably decreases risk)
  • Haem iron, dietary animal fat, cheese, dietary sugars (possibly increases risk)
  • Non-starchy vegetables, fruit, dietary folate, dietary and supplementary selenium, fish, dietary vitamin D (possibly decreases risk)

Other dietary factors have been studied but their relation to bowel cancer risk is not classified by WCRF/AICR because evidence is too limited to draw conclusions.3

Red meat and processed meat

Red meat and processed meat are classified by WCRF/AICR as causes of bowel cancer (Table 4.1).3 Haem iron (found in red meat) is classified by WCRF/AICR as a possible cause of bowel cancer, based on limited evidence.3 An estimated 21% of bowel cancers in the UK are linked to eating red and processed meat.9

Bowel cancer risk is 17-30% higher per 100-120g/day of red meat intake, meta-analyses have shown.4-7

Bowel cancer risk is 9-50% higher per 25-50g/day of processed meat intake, meta-analyses have shown;4-7 however bowel cancer risk was not associated with processed meat intake in a pooled analysis of UK case-control studies.8

Colon cancer risk is 12% higher per 1mg/day of haem iron intake, a meta-analysis showed;149 though bowel cancer risk was not associated with dietary iron intake in a pooled analysis of UK cohort studies.43

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Possible dietary causes

Foods containing animal fats are classified by WCRF/AICR as possible causes of bowel cancer, based on limited evidence.3

Bowel cancer risk is not associated with dietary fat intake, a meta-analysis showed.21

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Cheese is classified by WCRF/AICR as a possible cause of bowel cancer, based on limited evidence.3 This may be linked with saturated fatty acids.3

Bowel cancer risk is not associated with cheese and other non-milk dairy product intake, meta-analyses and a large cohort study have shown.22,24,167

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Foods containing sugar are classified by WCRF/AICR as a possible cause of bowel cancer, based on limited evidence.3

Bowel or colon cancer risk is not associated with glycaemic index or glycaemic load, a meta-analysis of cohort studies showed;168 Colon cancer risk is not associated with intake of sugar-sweetened soft drinks, a pooled analysis showed.27

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Colon cancer risk may be 29% higher in people with the highest egg consumption, compared with those with the lowest, a meta-analysis showed.157

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Overweight and obesity

Body fatness and abdominal fatness are classified by WCRF/AICR as causes of colon and rectum cancer (Table 4.1).3 An estimated 13% of bowel cancers in the UK are linked to overweight or obesity.65

Bowel cancer risk is 33% higher in people who are obese (body mass index [BMI] 30+), compared with those who are a healthy weight, a meta-analysis showed.158 The association is stronger for colon cancer than rectum cancer.158

The association with BMI is stronger for men than women, a meta-analysis showed.158 The association is stronger in premenopausal than postmenopausal women.60

Bowel cancer risk among men is 10% higher per 5 BMI units gained during adulthood, a meta-analysis showed.226 Bowel cancer risk among women is not associated with weight gain during adulthood.226

Bowel adenoma risk is 47% higher in people who are obese compared with those who are healthy-weight, a meta-analysis showed.160

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Bowel cancer risk is 46% higher in people with the largest waist circumference, versus those with the smallest, a meta-analysis showed.158

Bowel adenoma risk is 39% higher in people with the largest waist circumference, versus those with the smallest, a meta-analysis showed.161

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Alcohol

Alcoholic beverages are classified by IARC and WCRF/AICR as a cause of colon and rectum cancers (WCRF/AICR classify the association as convincing for males and probable for females) (Table 4.1).3,162 An estimated 11% of bowel cancer cases in the UK are linked to alcohol consumption.71

Bowel cancer risk is 21% higher in people who drink around 1.5-6 UK alcohol units per day, compared with non-/occasional drinkers, a meta-analysis showed.70 Bowel cancer risk is 52% higher in those who consume around 6 units or more per day, compared with non-/occasional drinkers.70 Bowel cancer risk increases by 7% per unit of alcohol consumed per day.70

Bowel adenoma risk is 27% higher in people who drink around 3 units per day, a meta-analysis showed; the association is limited to colon adenoma, not rectal.208

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Tobacco

Tobacco smoking is classified by IARC as a cause of colon and rectum cancers (Table 4.1).162 An estimated 8% of bowel cancer cases in the UK are linked to tobacco smoking.

Bowel cancer risk is 17-21% higher in current cigarette smokers compared with never-smokers, meta-analyses of cohort studies have shown.11,72,74 The association may be stronger in males than females, and stronger for rectal than colon cancer.11,72,74

Bowel cancer risk is 17-25% higher in former cigarette smokers compared with never smokers, meta-analyses have shown.72-74

Bowel cancer risk increases with the number of cigarettes smoked per day, by 7-11% per 10 cigarettes per day, a meta-analysis has shown.73 Bowel cancer risk is higher in people who start smoking younger.74

Bowel adenoma risk is around twice as high in current smokers compared with never-smokers, a meta-analysis showed.75

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Medical conditions and treatments

Adenoma/polyps

Around 1% of people with larger (20mm+) adenomas, or adenomas with high-grade dysplasia, develop bowel cancer within around 4 years of having their adenomas removed, a pooled analysis showed.195 Risk of advanced bowel cancer is 80% higher in people with low-risk polyps detected at first colonoscopy, compared with people with no polyps detected at first colonoscopy, a meta-analysis showed.196

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Inflammatory bowel disease

Bowel cancer risk is 70% higher in people with IBD (ulcerative or Crohn's colitis) compared with the general population, a meta-analysis showed.99 Bowel cancer risk increases with extent and duration of IBD; patients who have IBD for 20 years or more have a 5% risk of developing bowel cancer.99,100 Bowel cancer risk may vary by location of IBD lesions.102

Bowel cancer risk is increased in patients with complicated diverticulitis, a meta-analysis and large cohort study have shown, though uncomplicated diverticulitis does not increase risk.101,130

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Gallbladder disease

Rectal cancer risk is 33% higher in people with gallstones versus those without, a meta-analysis showed.125 Colon adenoma risk is more than doubled in people with gallstones versus those without, a meta-analysis showed.124

Rectal cancer risk and bowel adenoma risk is not associated with undergoing cholecystectomy (gallbladder removal), meta-analyses have shown.124,125,209

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Diabetes

Bowel cancer risk is 22-30% higher in people with type II diabetes, compared with non-diabetics, meta-analyses show.103-106,134

Bowel cancer risk among diabetics may vary by treatment type, though treatment type often relates to diabetes stage, which may further confound findings. Bowel cancer risk is lower in metformin users compared with non-users, meta-analyses of cohort studies have shown;123,131,215 however this may be for women only.221 Bowel cancer risk is not associated with insulin use compared with non-use, meta-analyses of cohort studies have shown.132,133

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Metabolic syndrome

Bowel cancer risk is 33-41% higher in people with metabolic syndrome (characterised by a combination of diabetes, high blood pressure, and abdominal obesity), versus people without the syndrome, meta-analyses have shown.173,174

Bowel adenoma risk may be increased in people with non-alcoholic fatty liver disease (the hepatic manifestation of metabolic syndrome), a number of individual studies indicate.175

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Occupational exposures

Asbestos

Asbestos is classified by IARC as a probable cause of bowel cancer, based on limited evidence (Table 4.1).162

Bowel cancer risk may be higher in people with heavy prolonged occupational asbestos exposure, a cohort study showed.193

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Immune system

Infections

Schistosoma japonicum is classified by IARC as a probable cause of bowel cancer, based on limited evidence (Table 4.1).162

Bowel cancer risk is up to tenfold higher in people with Human papillomavirus (HPV) infection, compared with healthy controls, meta-analyses have shown.135,194

Bowel cancer risk is 39% higher in people with H Pylori infection, compared with uninfected people, meta-analyses have shown.136,137 Colon cancerrisk is 30% higher in people with H Pylori.136,137

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Autoimmune conditions

Bowel cancer risk is 33% higher in people with sarcoidosis, versus those without the condition, a meta-analysis showed.225

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Previous cancer

Bowel cancer risk is higher in survivors of bowel,181 head and neck,181,182 oesophageal,181 larynx,181 lung,181 prostate,181,182 cervix,181,199 uterus,181 or breast182 cancers; chronic lymphocytic leukaemia181 and melanoma182, cohort studies have shown.

Digestive cancer risk is 10-28 times higher in children, teenagers and young adults who had any type of cancer in childhood, compared with the general population, a cohort study showed.200

This may relate to a combination of shared risk factors for the primary and secondary cancer, and to the effect of treatment (e.g. radiotherapy) for the primary cancer.

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Ionising radiation

X radiation and gamma radiation are classified by IARC as causes of colon cancer; they are classified as probable causes of rectum cancer, based on limited evidence (Table 4.1).162 An estimated 2% of bowel cancer cases in the UK are linked to ionising radiation.114

Colon cancer risk is 53% higher in atomic bomb survivors compared with the general population, a cohort study has shown.211

Bowel cancer risk decreases with increasing age at radiation exposure.212 Less than 1% of people chronically exposed to 0.1Gy radiation in early childhood will develop bowel cancer in their lifetime.212

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Family history and genetic syndromes

Genetic syndromes

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Family history

Around 20% of bowel cancers are associated with hereditary factors other than FAP and HNPCC.115

Bowel cancer risk is 80% higher in people with a first-degree relative (parent, sibling, child) with the disease, a meta-analysis showed.120 Bowel cancer risk among people with a first-degree family history is higher in those with more than one affected relative, or a relative diagnosed at a younger age.119

Bowel adenoma risk is 70% higher in people with a first-degree relative with bowel cancer, a meta-analysis showed.121

Bowel cancer risk is not associated with having an adoptive parent with the disease, a cohort study showed; this may indicate genetic/biological factors rather than environmental factors underpin the familial risk.217

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Height

Greater adult attained height is classified by WCRF/AICR as a cause of bowel cancer (Table 4.1).3

Colon cancer risk is 11% (females) and 9% (males) higher per 5cm height increment, a pooled analysis showed.143 Rectum/anus cancer risk is 9% (females) and 6% (males) higher per 5cm height increment.143

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Factors shown to decrease or have no effect on bowel cancer risk

Decrease

Physical activity is classified by WCRF/AICR as protective against bowel cancer (with evidence stronger for colon than rectum cancer) (Table 4.1).3 An estimated 3% of bowel cancers (5% of colon cancers) in the UK are linked to inadequate physical activity.69

Colon cancer risk is 17-24% lower in the most physically active people, compared with the least physically active, meta-analyses of cohort studies have shown.67,146,147 Colon cancer risk is 27% higher in the most sedentary people compared with the least, a meta-analysis of cohort studies showed.148

Rectal cancer risk is not associated with physical activity, a meta-analysis showed.146 Rectal cancer risk is 6% higher in the most sedentary people compared with the least, a meta-analysis of cohort studies showed.148

Colon adenoma risk is 16% lower in the most physically active people, compared with the least physically active, a meta-analysis showed.68

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Dietary fibre, garlic, milk, and calcium are classified by WCRF/AICR as probably protective against bowel cancer (Table 4.1).3

Non-starchy vegetables, fruit, dietary folate, dietary or supplementary selenium, fish, and dietary vitamin D are classified by WCRF/AICR as possibly protective against bowel cancer, based on limited evidence.21

Bowel cancer risk is lower in people with higher intake of the following foods, meta- and pooled analyses, systematic reviews or cohort studies have shown:

  • Dietary fibre – 12% of bowel cancers in the UK are linked to eating less than 23g/day of fibre.15 10% decreased risk per 10g/day total dietary fibre and cereal fibre (no association with fruit and vegetable fibre).14
  • Whole grains – 20% lower risk per 90g/day.14
  • Dietary fibre (bowel adenoma) – 9% lower risk per 10g/day of total dietary fibre (cereal and fruit fibre only, not vegetable fibre).145
  • Vegetables overall (colon cancer) – 2% lower risk per 100g/day.16,154,155
  • Milk – 20-30% lower risk per 200-250g/day22,23 (may be limited to non-fermented milk and males).167
  • Milk (colon cancer) – 9-15% lower risk per 200-250g/day.22,23
  • Total calcium – 8% lower risk per 300mg/day;156 22% lower risk with highest intake versus lowest23 (some evidence less effect of dietary than supplementary calcium,23,43 some evidence no association with non-dairy dietary calcium24).
  • Calcium supplements – 9% lower risk per 300mg/day156 (though some evidence of no association.29,47,48)

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Bowel cancer risk is lower in people with the highest versus the lowest intake of the following foods, meta- and pooled analyses, systematic reviews or cohort studies have shown:

  • Cruciferous vegetables (colon cancer) – 9-22% lower risk.16,154,155
  • Fruits (colon cancer) – 11% lower risk.16
  • Fish – 7% lower risk (though no association with colon adenoma risk188).228
  • Dietary zinc – 20% decreased risk with highest intake versus lowest.129
  • Dietary vitamin C (distal colon cancer) – 40% lower risk.206
  • Dietary vitamin E (distal colon cancer) – 35% lower risk.206
  • Dietary (not supplements) beta-carotene (colon cancer) – 31% lower risk.206

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Bowel cancer risk is lower in people with higher levels of the following micronutrients, meta- and pooled analyses, systematic reviews or cohort studies have shown:

  • Retinol blood levels (colon cancer) – 37% lower risk for highest versus lowest levels.206
  • Vitamin D blood levels (25(OH)D) – 15-26% lower risk per 10-20ng/mL 50-52,183 (some evidence of modification by tumour states, other lifestyle factors and other medical conditions,141,142,204 some evidence vitamin D modifies effect of calcium49, some evidence no effect of dietary vitamin D43).

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Bowel cancer risk is lower in people who use the following medications or have the following medical conditions, meta- and pooled analyses, systematic reviews or cohort studies have shown:

  • Hormone replacement therapy – 16% lower risk for ever-use versus never-use, and some suggestion of stronger association in current versus past users87-89,184 (though some evidence this association has ‘little clinically meaningful impact’185).
  • Oral contraceptives – 14% lower risk for ever-use versus never-use.96
  • Aspirin – 32-49% lower risk for daily use for 5 years or more, versus non-use.126
  • Aspirin (bowel adenoma) – 17% lower risk for aspirin versus placebo.186
  • Parkinson’s disease – 24% lower risk in people with the condition versus those without222 (though some evidence lower risk is limited to males for rectal cancer223).

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No effect

WCRF/AICR make no judgement on the association between bowel cancer risk and intake of cereals, potatoes, poultry, shellfish and other seafood, other dairy products, total fat, fatty acid, cholesterol, sucrose, coffee, tea, caffeine, total carbohydrates, starch, vitamin A, retinol, vitamin C, vitamin E, multivitamins, non-dairy sources of calcium, methionine, beta-carotene, alpha-carotene, and lycopene, due to limited evidence.3

Bowel cancer risk is not associated with intake of the following foods, meta- and pooled analyses, systematic reviews or cohort studies have shown:

  • Dietary omega-3 or -6 fatty acids.43
  • Allium vegetables, e.g. garlic and onion (though some evidence of higher colon cancer risk in women,169 and lower bowel adenoma risk220).169,227
  • Garlic supplements (though some evidence of higher risk169).227
  • Dietary folate28,43 (though some evidence of lower risk30,35).
  • Folic acid supplements29,31 (though some evidence of higher risk with long term use31).
  • Selenium29,38,39,189 (though some evidence of lower risk37).
  • Dietary/supplementary vitamin B640,43 (though some evidence of lower risk with higher blood levels,40 and some evidence of higher rectal cancer risk.41
  • Vitamin B1242-44 (though some evidence of lower rectal cancer risk45,46).
  • Coffee.27,170-172,177 (though some evidence of lower risk178)
  • Tea (all types) (though some evidence of higher risk177)
  • Vitamin D supplements.183,218
  • Retinol (blood levels or dietary).43,206
  • Dietary vitamin A.43
  • Dietary thiamin.43
  • Dietary riboflavin.43
  • Dietary magnesium.43
  • Dietary potassium.43
  • Beta carotene supplements.189
  • Poultry (bowel adenoma).188
  • White meat (bowel adenoma).188
  • Green or black tea.177

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Bowel cancer risk is not associated with use of the following medications, meta- and pooled analyses, systematic reviews or cohort studies have shown:

  • Statins (though some evidence of lower risk, mainly in case-control studies);82-84,190,191 accordingly bowel cancer risk is not associated with total blood cholesterol level.192
  • Angiotensin receptor blockers (though some evidence of lower risk).163-165
  • ACE-inhibitors (though some evidence of lower risk).163,164
  • Thiopurines use among IBD patients (bowel neoplasia and bowel cancer).152,213

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Bowel cancer risk is not associated with these other factors, meta- and pooled analyses, systematic reviews or cohort studies have shown:

  • Irritable bowel syndrome (IBS) (no long-term risk increase; apparent higher risk soon after IBS diagnosis probably reflects increased medical monitoring or initial misdiagnosis of bowel cancer as IBS).150,151,224
  • Constipation201 (some evidence of higher risk201,202 though may be limited to poorly-managed constipation203).
  • Human immunodeficiency virus (HIV) infection.138-140
  • Parity (number of children given birth to).205
  • Drinking water disinfection by-products (some evidence of higher risk limited to case-control studies).214

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Updated: 17 February 2015