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Bowel cancer risk factors

The key risk factors for bowel cancer are discussed on this page. Bowel cancer risk is also strongly linked with age and sex.

Around 54% of bowel cancers in the UK are linked to lifestyle.1

Meta-analyses and systematic reviews are cited where available, as they provide the best overview of all available research and most take study quality into account. Individual case-control and cohort studies are reported where such aggregated data are lacking.

Diet

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

Other dietary factors (including fish, folate and selenium) 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.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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Dietary animal fat

Foods containing animal fats are classified by WCRF/AICR as possible causes of bowel cancer.3

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

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Cheese

Cheese is classified by WCRF/AICR as a possible cause of bowel cancer.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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Dietary sugars

Foods containing sugar are classified by WCRF/AICR as a possible cause of bowel cancer.3

Bowel or colon cancer risk is probably not associated with glycaemic index or glycaemic load, some meta-analyses have shown;26,168,176,197 however other meta-analyses have reported slightly increased risks.25 Colon cancer risk is not associated with intake of sugar-sweetened soft drinks, a pooled analysis showed.27

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Garlic

Though garlic is classified by WCRF/AICR as probably protective against bowel cancer,3 bowel cancer risk is 18% higher among ever-users of garlic supplements, compared with never-users, a meta-analysis showed.169

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Eggs

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.3 An estimated 13% of bowel cancers in the UK are linked to overweight or obesity.65

Body mass index (BMI)

Bowel cancer risk is 33% higher in people who are obese by BMI, compared with those who are a healthy-weight, a meta-analysis showed.158 The association with BMI is stronger for men than women,57-60 and among women may vary with use of hormone replacement therapy (HRT) and menopausal status.60-64 The association with BMI is stronger for cancer of the distal colon than of the proximal colon or rectum,159 meta-analyses show.

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

Abdominal fatness

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

Bowel adenoma risk is 39% higher in people with the largest waist circumference, compared with 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).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 1.6-6.2 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 6.2 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

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Tobacco

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

Bowel cancer risk is 20-21% higher in current cigarette smokers compared with never-smokers, meta-analyses of cohort studies have shown.11,72 The association is stronger in (perhaps limited to) males, stronger for rectal than colon cancer, and possibly limited to cohort studies.11,72-74,198 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 has shown.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 showed, though uncomplicated diverticulitis does not increase risk.101,130

Bowel cancer risk is 4% lower in IBD patients treated with thiopurines, compared with IBD patients not receiving this treatment, a meta-analysis of cohort studies showed.152

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Gallbladder disease

There is some evidence that people who have had their gallbladder removed may have a modest increase in bowel cancer and colorectal adenoma risk.107-109 However, not all studies have shown an association.110,111,124,125 Gallstones may also be associated with increased risks of rectal cancer and adenomatous polyps in the colon; given that people who have their gallbladder removed usually have gallstones, this may be a mechanism for the association between gallbladder removal and bowel cancer.124,125

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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 The association between diabetes and bowel cancer risk may vary by type of treatment, though treatment type often relates to diabetes stage, which may further confound findings.

Metformin is associated with an 11-36% decrease in bowel cancer risk, while insulin is associated with a 37-61% increased risk, meta-analyses comparing users of these treatments with non-users showed.123,131-133

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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), compared with people without the syndrome, a meta-analysis has 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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Infections

Anal cancer risk is also associated with infections.

Human papillomavirus (HPV)

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

H Pylori

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

Human immunodeficiency virus (HIV)

Bowel cancer risk is not associated with human immunodeficiency virus (HIV) infection, meta-analyses and a cohort study show.138-140

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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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Radiation

A study published in 2011 estimated that more than 1% of bowel cancers in the UK in 2010 were linked to radiation exposure. The majority of the attributable cases (around 500) were linked to diagnostic radiation, while around 85 cases were attributed to radiotherapy for a previous cancer and around 35 cases to background radiation.114

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Family history and genetic syndromes

Familial adenomatous polyposis (FAP) and hereditary non-polyposis colorectal cancer (HNPCC)

About 5% of bowel cancers are linked to FAP, HNPCC and the polyposis syndromes.115 Because FAP and HNPCC are relatively rare, they account for only small proportions of bowel cancer overall: FAP accounts for less than 1% of bowel cancers, and HNPCC for 1-4% of colon cancers.99,117 These syndromes are often linked with early-onset bowel cancer: almost all FAP patients develop bowel cancer by age 40,116 and around 9 in 10 males and 7 in 10 females with HNPCC develop bowel cancer by age 70.118

Other genetic syndromes

Around 20% of bowel cancers are associated with hereditary factors in the absence of FAP and HNPCC.115 Bowel cancer risk is around twice as high in people with a first-degree relative with the disease, compared to the general population, with an even greater risk if there are multiple or young affected relatives.119,120 Bowel adenoma risk is 70% higher in those with a first-degree family history of bowel cancer.121

Bowel cancer risk may also be slightly increased in those with a second-degree relative with bowel adenoma, a case-control study showed.128 BRCA1 mutations may account for some of this excess familial risk, particularly in younger women.153

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Height

For every 5cm increase in height, colon cancer risk is 11% higher in females and 9% higher in males, and rectum/anus cancer risk is 9% higher in females and 6% higher in males, a pooled analysis of Nordic data showed.143 The association with height was significant only for colon cancer, not rectal, in a US pooled cohort study.144

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

Decrease

Dietary fibre is classified by WCRF/AICR as protective against bowel cancer.3 Garlic, milk, and calcium are classified by WCRF/AICR as probably protective against bowel cancer.3 Non-starchy vegetables, fruit, and dietary vitamin D are classified by WCRF/AICR as possibly protective against bowel cancer, based on limited evidence.21

Bowel cancer risk is reduced 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% decreased risk per 90g/day of whole grains.14
  • Dietary fibre (bowel adenoma) - 9% decreased risk per 10g/day of total dietary fibre (cereal and fruit fibre only, not vegetable fibre).145
  • Vegetables overall (colon cancer) - 2% decreased risk per 100g/day.16,154,155
  • Cruciferous vegetables (colon cancer) - 9-22% decreased risk with highest intake versus lowest.16,154,155
  • Fruits (colon cancer) - 11% decreased risk with highest intake versus lowest.16,
  • Milk - 20-30% decreased risk per 200-250g/day22,23 (perhaps limited to non-fermented milk and males).167
  • Milk (colon cancer) - 9-15% decreased risk per 200-250g/day.22,23
  • Total calcium - 8% decreased risk per 300mg/day;156 22% decreased 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% decreased risk per 300mg/day156 (though some evidence of no association.29,47,48)
  • Dietary zinc - 20% decreased risk with highest intake versus lowest.129
  • Vitamin D blood levels (25(OH)D) - 15-26% decreased risk per 10-20ng/mL50-52,183 (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).
  • Dietary (not supplements) beta-carotene (colon cancer) - 31% decreased risk for highest versus lowest intake.206
  • Retinol blood levels (colon cancer) - 37% decreased risk for highest versus lowest levels.206
  • Dietary vitamin C (distal colon cancer) - 40% decreased risk for highest versus lowest levels.206
  • Dietary vitamin E (distal colon cancer) - 35% decreased risk for highest versus lowest levels.206

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

Colon cancer risk is 14-30% lower in the most physically active people, compared with the least physically active, meta-analyses have shown.66,67,146-148

Rectal cancer risk appears not to be associated with physical activity levels, meta-analyses have shown.66,146,148

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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Bowel cancer risk is reduced with use of the following medications, meta- and pooled analyses, systematic reviews or cohort studies have shown:

  • Hormone replacement therapy – 16% reduced risk for ever-use versus never-use, and some suggestion of stronger association in current versus past users87-89,184 (though some evidence this risk decrease has ‘little clinically meaningful impact’185).
  • Oral contraceptives – 14-19% reduced risk for ever-use versus never-use.96,187
  • Aspirin – 32-49% reduced risk for daily use for 5 years or more, versus non-use.126
  • Aspirin (bowel adenoma) – 17% reduced risk for aspirin versus placebo.186

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No effect

WCRF/AICR make no judgement on the association between bowel cancer risk and intake of fish, folate, selenium, 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:

  • Fish10-13,127 (though some evidence of rectal cancer risk decrease127), also no association with colon adenoma risk.188
  • Dietary omega-3 or -6 fatty acids.43
  • Allium vegetables (though some evidence of colon cancer risk increase in women).169
  • Dietary folate28,43 (though some evidence of risk decrease30,35).
  • Folic acid supplements29,31 (though some evidence of risk increase with long term use31).
  • Selenium29,38,39,189 (though some evidence of risk decrease37 perhaps limited to males36).
  • Dietary/supplementary vitamin B640,43 (though some evidence of risk decrease with higher blood levels,40 and some evidence of rectal cancer risk increase.41
  • Vitamin B1242-44 (though some evidence of rectal cancer risk decrease45,46).
  • Coffee.27,170-172,177 (though some evidence of risk decrease178)
  • Tea (all types) (though some evidence of a risk increase177
  • Vitamin D supplements.183
  • 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 risk decrease, 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 risk decrease).163-165
  • ACE-inhibitors (though some evidence of risk decrease).163,164

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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 risk increase soon after IBS diagnosis probably reflects increased medical monitoring or initial misdiagnosis of bowel cancer as IBS).150,151
  • Occupational asbestos exposure (though some evidence of colon cancer risk increase with long-term high exposure).193
  • Constipation201 (some evidence of risk increase201,202 though may be limited to poorly-managed constipation203).
  • Parity (number of children given birth to).205

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