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Stomach cancer risk factors

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

Around 75% of stomach cancers in the UK are linked to lifestyle: 78% in males and 69% in females.1

Generally the studies cited in this section are on stomach adenocarcinoma.

 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.

 

Helicobacter pylori

H. pylori is a cause of stomach cancer in humans, the International Agency for Research on Cancer (IARC) states.6 Infection is generally acquired during childhood, and is highest in parts of the developing world.7 Infection is more common in older people in England and Wales (30% in those born before 1940, compared with less than 5% in those born during the 1980s), which is thought to reflect falling prevalence in successive generations.8,9 Around 32% of stomach cancers in the UK in 2010 were linked to H. pylori infection, it has been estimated.9

Infection with H. pylori causes chronic inflammation of the stomach tissue, leading in a minority of infected individuals, to development of pre-cancerous lesions, which progress in severity, from mild and severe chronic gastritis, through to atrophic gastritis, and gastric atrophy.10 This is a major risk factor for stomach cancer, and risk increases with the extent of the atrophy.11

Retrospective studies of the risk of stomach cancer in relation to H. pylori infection underestimate the true risk, due to loss of infection with onset of cancer. H pylori does not colonise areas of cancer, intestinal metaplasia, or atrophy, and there is evidence that with the development of advanced gastric disease the organism can be lost from the stomach. An overall odds ratio (OR) of around three was shown for non-cardia stomach cancer, but this increased to an OR of around six for those who were tested for H. pylori ten or more years prior to the development of stomach cancer, according to a pooled analysis of studies where H. pylori infection was assessed prior to the development of cancer.12 The authors concluded that the latter is the best estimate for the increase in non-cardia stomach cancer associated with H. pylori infection, and that previous meta-analyses, which included studies that assessed H. pylori infection status after development of cancer, had underestimated the risk. Infection with cytotoxin CagA-positive H. pylori carries a higher risk than infection with CagA-negative strains.10,13

H. pylori infection does not increase risk of gastric cardia cancer overall.12 However, gastric atrophy is linked to an increased risk. It is possible that there are two types of gastric cardia adenocarcinomas, one linked to gastric atrophy (and H. pylori infection), and one which resembles oesophageal adenocarcinomas, on which gastric atrophy has no effect, or even a protective effect.14,15 H. pylori eradication treatment can reduce risk of gastric cancer, a meta-analysis has shown.16

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Tobacco

Smoking causes stomach cancer, and accounted for more than a fifth of stomach cancers in the UK in 2010, it has been estimated.6,17 Current smokers have a 57% increased risk overall.18 Men have a higher smoking-related risk than women, with a risk increase for current or ever-smoking men of 62% and 59%, respectively, compared with 20% and 11% for women.19,20 Smoking increases the risk both cardia and non-cardia stomach cancer.19 Risk increases with number of cigarettes smoked per day, and declines after smoking cessation.20

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Diet

Fruit and vegetables overall

High intake of fruit and vegetables overall reduces stomach cancer risk, according to meta-analyses.23-25 Results are generally non-significant in cohort studies,26-30 although there are exceptions.28,32 The risk reduction may be limited to smokers.30,32

Subgroups of fruit and vegetables

High citrus fruit reduces risk of stomach cancer by 28%, according to a meta-analysis.33 There may be a 62% risk reduction risk reduction for cardia cancer for the highest versus lowest intake of citrus fruit.26 Allium vegetables (onions, garlic, shallots, leeks, chives etc) have been shown to reduce stomach cancer risk (46% risk reduction for highest versus lowest intake).34 Brassica vegetables reduce risk of cardia cancer (28% risk reduction per 25g/day), according to a cohort study.26

Pickled vegetables

There is limited evidence that consumption of traditional Asian pickled vegetables increases stomach cancer risk, according to IARC.6

Risk increases by 28% for the highest intake, according to a Japanese / Korean meta-analysis.25

High intake of any pickled food increases risk by 32–56%, according to another meta-analysis of studies in East Asian countries.35

Salt

Salt and salty foods are a ‘probable’ cause of stomach cancer, the WCRF/AICR 2007 report states.21 Around a quarter of stomach cancers in the UK in 2010 were linked to excess salt intake (defined as more than 6g/day), and the proportion was highest in men (31%), it has been estimated.36

Salt could increase stomach cancer risk by increasing extent of H. pylori infection, by causing inflammation and by damaging the stomach tissue directly, it has been proposed.37 Salt intake increases risk only in people infected with H. pylori, according to a Japanese cohort study.38

Risk estimates vary substantially between studies, which may be because of methodological problems with assessing salt intake,39 and further study is needed of a potential role of other chemicals found in foods high in salt, such as nitrite and nitrate (see below).40

There is limited evidence that Chinese-style salted fish causes stomach cancer, IARC states.6

Meat

There is mixed evidence for an association of stomach cancer with intake of various types of meat.

Processed meat increases the risk of stomach cancer by 15–38% per 30g/day, according to a meta-analysis.41 The WCRF/AICR 2007 report classifies the evidence of an association of stomach cancer with processed meat as ‘limited – suggestive’.21

High intake of meat overall may also increase stomach cancer risk, with a 33% risk increase for those with the highest intake shown in the European Prospective Investigation into Cancer (EPIC).31 A doubling in dietary heme iron (found in red meat) increases risk by 13%, also according to EPIC.42 However, no association with red meat intake was shown in another recent cohort study,43 or with red or processed meat.44 Findings from earlier studies are also inconsistent.45 The WCRF/AICR 2007 report states the evidence for an association between unprocessed meat and stomach cancer is ‘limited – no conclusion’.21

The risk of red and processed meat intake may be limited to non-cardia stomach cancer, and to those infected with H. pylori, according to an EPIC analysis.45

Vitamins and other minerals

The evidence that dietary selenium reduces stomach cancer risk is ‘limited – suggestive’, the WCRF/AICR 2007 report states, while evidence for selenium supplements is ‘limited – no conclusion’, it states.21 A borderline significant risk reduction for cardia stomach cancer in relation to higher selenium levels (48% risk reduction for highest versus lowest levels) has been shown.46

The WCRF/AICR 2007 report classifies the evidence for an association of stomach cancer, protective or otherwise, with vitamin C, vitamin D, carotenoids, thiamin, riboflavin, calcium, iron and multivitamin/mineral supplements as ‘limited – no conclusion’.21 Beta-carotene supplementation actually increases stomach cancer risk in smokers and those who have worked with asbestos, according to a meta-analysis of randomised controlled trials (RCTs).47

N-nitroso compounds (including nitrosamines)

There is probable evidence that nitrite or nitrate intake, resulting in formation of a group of chemicals known as N-nitroso compounds (NOC), can increase stomach cancer risk, according to IARC.6,48 Risk of stomach cancer is almost doubled in those with the highest intake of N-nitrosodimethylamine (NDMA) – a type of NOC that can occur in foods – according to a cohort study, although results of earlier studies of NDMA intake were inconsistent.49 The WCRF/AICR 2007 report states the evidence for an association between stomach cancer and NDMA is ‘limited – no conclusion’.

Other dietary factors

Cereal fibre, but not fibre from fruit or vegetables, is associated with a reduced risk of stomach cancer, according to the EPIC study (31% risk reduction for highest versus lowest intake).50 However, the WCRF/AICR report states evidence for an association of fibre intake with stomach cancer is ‘limited – no conclusion’.21

A Mediterranean-style diet, defined as being high in fruit, vegetables, legumes, fish, cereals and olive oil, and low in meat and dairy products, as well as moderate alcohol consumption, has been associated with a reduced risk of stomach cancer in the EPIC study: The risk of stomach cancer overall is 33% lower in those with the most (compared with least) Mediterranean-style diet.31 Vegetarians may have a 64% lower risk of stomach cancer than meat-eaters, according to one cohort study.51

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Occupational exposures

Around 2% of stomach cancers in the UK in 2010 were linked to occupational exposures, it has been estimated.52 Work in the rubber production industry causes stomach cancer, and there is limited evidence that exposure to asbestos and inorganic lead causes stomach cancer, IARC states.6

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Ionising radiation

Radiation exposure increases stomach cancer risk.6 Around 1% of stomach cancers in the UK in 2010 were linked to radiotherapy received for a previous cancer, or diagnostic radiology, it has been estimated.53 Men treated for testicular cancer have a two–four-fold increase in stomach cancer risk, which is consistent with an effect of radiotherapy.54,55 After radiotherapy for cervical cancer, there is smaller risk increase, of about a third, according to follow-up of women treated at 13 registries worldwide.56 However, findings of earlier studies were inconsistent. An increased risk of stomach cancer following treatment for thyroid cancer has also been shown.57

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Family history and genetic conditions

Family history

Stomach cancer risk may be higher in families with hereditary prostate cancer.62 An increased risk has been shown for individuals from BRCA2 mutation families.63 People from BRCA1 mutation families do not appear to have an increased stomach cancer risk.64

Overall, a family history of stomach cancer is associated with a two- to ten-fold increase in stomach cancer risk, and known cancer syndromes are thought to only partially explain this risk.65

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Genetic conditions

It has been estimated that 1–3% of stomach cancers occur as a result of inherited stomach cancer predisposition syndromes.58

Hereditary diffuse gastric cancer (HDGC) is a rare form of the disease associated with germ-line mutations in the E-cadherin (CDH1) gene. The cumulative risk of stomach cancer in carriers of CDH1 mutations is 67% for men and 83% for women, according to an International Gastric Cancer Linkage Consortium study.59 However, CDH1 mutations are only found in a minority of families fulfilling the criteria for HDGC, and other related genes remain to be identified.60

Stomach cancer has also been associated with the following syndromes: hereditary non-polyposis colorectal cancer, Li-Fraumeni, familial adenomatous polyposis, and Peutz-Jeghers.61

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Alcohol

The evidence for an effect of alcohol on stomach cancer risk is ‘limited – no conclusion’, the WCRF/AICR 2007 report states.21 However, while moderate alcohol has not been shown to increase stomach cancer risk,66-68 heavy alcohol consumption may increase risk.69 Risk increases by 20% for an alcohol intake of ≥50g/day (one UK unit contains 8 grams of alcohol), compared with people who drink occasionally or not at all, according to a meta-analysis.70 For those drinking ≥60g/day of alcohol, risk increases by 65% compared with light drinkers (0.1–4.9g/day).69

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Medical conditions and treatments

Reflux

A history of reflux symptoms or excess acid increases risk of cardia cancers, case-control studies have shown, with a more than doubling of risk shown for individuals with these conditions for 16 years or longer.71,72 Not all studies show an association, however.73

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Diabetes

Diabetes mellitus has been associated with an increased risk of gastric cancer by 77% in patients from East Asia, however no relationship has been identified for Western patients, a large meta-analysis showed.108 Gastric cancer risk is increased to a greater extent among diabetic women (90% increase compared with non-diabetic women) than diabetic men (24% increase).108

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Stomach surgery

Previous gastrectomy may increase stomach cancer risk two-three decades later, with more than a doubling of risk shown in the latest long-term analysis of patients receiving surgery for stomach ulcer.85 The risk increase is lower (48%) for patients operated on 15 or more years previously.86 Reduced gastric acidity following surgery might increase susceptibility to bacterial infections, including H. pylori, thereby increasing cancer risk.85,86

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Blood group

Blood group A is associated with a higher risk of stomach cancer, compared with having blood group O, while blood group O is associated with a higher risk of peptic ulcer than the other ABO blood groups.87,88 The risk increase for stomach cancer in those with blood group A is 20%, according to an analysis of blood donor records going back several decades.88 The risk increase may be limited to diffuse-type stomach cancer (one of the two histological types of stomach adenocarcinomas), for which risk is doubled, a recent study has shown.89 A possible explanations is different susceptibility and immunological response to H. pylori infection in people with different blood groups.88

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Aspirin

Risk of stomach cancer death is reduced by 58% in the long term in those receiving any dose of aspirin for a minimum of four years, versus those not receiving it, according to a systematic review of RCTs. There was a delay of ten years between randomisation and the observed risk reduction.90

Earlier meta-analyses broadly support this finding, although results were stronger in analyses limited to case-control studies.91,92 Where cohort studies have shown a risk reduction with aspirin of other NSAIDs, it appears to be limited to non-cardia stomach cancer.92,93 However, in a view of the increased risk of gastrointestinal bleeding with regular NSAID use, the possible risks and benefits need to be carefully considered.

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Statins

Ever having taken statins is associated with a 32% reduced risk of stomach cancer, and risk reduces further with longer use, according to a case-control study.94 However, earlier studies did not show a risk reduction.95,96

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Proton pump inhibitors (PPIs)

Having a prescription for proton pump inhibitors (PPIs), used to treat stomach ulcers, is associated with an increased risk of stomach cancer. This is probably the result of H. pylori infection (see Helicobacter pylori), which causes stomach ulcers, rather than an effect of the PPI treatment itself.97

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Tamoxifen

Tamoxifen treatment almost doubles stomach cancer risk, according to a meta-analysis, although the summary risk ratio was non-significant when based on RCTs only.98

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Immune system

People with pernicious anaemia, an autoimmune disease with localised effects in the stomach, have a two-to-three times higher risk of stomach cancer.74-77

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Other infections

Epstein-Barr virus (EBV)

Infection with the Epstein-Barr virus (EBV) may increase stomach cancer risk, according to IARC.6 About 9% of stomach cancers contain EBV, meta-analyses indicate,78 although the specific role of the virus in development of stomach cancer remains unclear.79,80

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Human immunodeficiency virus (HIV)

People with HIV/AIDS, or who have had a previous organ transplant, have double the risk of stomach cancer of the general population, a meta-analysis shows.84

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Overweight and obesity

High body mass index (BMI) increases the risk of cancers in the cardia, with a 20–68% risk increase shown for being overweight or obese.101,102 There is substantial variation between the results of the individual studies included in these analyses.101,102 Overweight/obesity does not increase risk of non-cardia stomach cancer.103

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Height

Shorter people have a decreased risk of stomach cancer death, a meta-analysis showed, with the risk 5% lower per 6.5cm shorter.109 However, the association may be in men only.110

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Reproductive factors

Age at menopause

Post-menopausal women have a 59% higher risk of stomach cancer than women of the same age who are pre-menopausal or going through the menopause, and risk increases by 18% for every five-year reduction in age at menopause, according to the UK Million Women Study.104 Having a longer period of fertility has been shown to reduce stomach cancer risk by around a quarter.98

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Hormone replacement therapy (HRT)

Every having taken hormone replacement therapy is associaed with a 22% reduction in stomach cancer.99 However, HRT increases breast, ovarian and endometrial cancer risk, and 1% of cancer cases overall in women in the UK in 2010 were linked to its use, it has been estimated.100

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Physical activity

Stomach cancer risk is 13-28% lower in the most physically active people compared with the least, meta-analyses have shown.107,111,112

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Factors shown to have no effect on stomach cancer risk

A range of reproductive and hormonal factors, including age at menarche, parity, age at first birth and use of oral contraceptives, have no effect on stomach cancer risk, according to a meta-analysis.98

Smokeless tobacco use is not linked to stomach cancer risk in the majority of studies.105,106 Because exposure to tobacco-related nitrosamines (see N-nitroso compounds section above) is high in those using smokeless tobacco more studies are needed.20

The WCRF/AICR 2007 report classifies the evidence for an association of stomach cancer, protective or otherwise, with vitamin C, vitamin D, carotenoids, thiamin, riboflavin, calcium, iron and multivitamin/mineral supplements as ‘limited – no conclusion’.21

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