Pancreatic cancer risk factors

37% of pancreatic cancer cases each year in the UK are linked to major lifestyle and other risk factors.[1]

Pancreatic cancer is associated with a number of risk factors.[2,3]

Pancreatic 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)
  • Tobacco, smokeless
  • Tobacco smoking
  • Body fatness
  • Alcohol
  • Thorium-232 and its decay products
  • X-radiation
  • Gamma-radiation
  • Abdominal fatness
  • Adult attained height
  • Red meat
 
  • Foods containing folate
  • Fruits
  • Physical activity

International Agency for Research on Cancer (IARC) and The World Cancer Research Fund/American Institute for Cancer Research (WCRF/AICR) classifications. Find out more about IARC and WCRF/AICR classifications.

References

  1. Parkin DM, Boyd L, Walker LC. The fraction of cancer attributable to lifestyle and environmental factors in the UK in 2010. Br J Cancer 2011;105(S2):S77-S81.
  2. International Agency for Research on Cancer. List of Classifications by cancer sites with sufficient or limited evidence in humans, Volumes 1 to 105*. Available from:http://monographs.iarc.fr/ENG/Classification/index.php. Accessed May 2014.
  3. World Cancer Research Fund/American Institute for Cancer Research. Food, Nutrition, Physical Activity, and the Prevention of Cancer: a Global Perspective. Washington DC: AICR; 2007.
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Tobacco smoking and smokeless tobacco are classified by the International Agency for Research on Cancer (IARC) as causes of pancreatic cancer.[1] An estimated 29% of pancreatic cancers in the UK are linked to tobacco smoking.[2]

References

  1. International Agency for Research on Cancer. List of Classifications by cancer sites with sufficient or limited evidence in humans, Volumes 1 to 105*. Available from:http://monographs.iarc.fr/ENG/Classification/index.php. Accessed May 2014.
  2. Parkin DM, Boyd L, Walker LC. The fraction of cancer attributable to lifestyle and environmental factors in the UK in 2010. Br J Cancer 2011;105(S2):S77-S81.
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Pancreatic cancer risk is 2.2 times higher in current smokers compared with never-smokers, a pooled analysis showed.[1] Risk increases with the number of cigarettes smoked per day, and duration of cigarette smoking, meta- and pooled analyses have shown.[1,2]

Pancreatic cancer risk in those who quit smoking 20 years ago is similar to that of never-smokers, a pooled analysis showed.[1]

Pancreatic cancer risk is increased to a similar extent in people who smoke cigars only and people who smoke cigarettes only, a pooled analysis showed.[3] Pancreatic cancer risk is not associated with pipe-only smoking.[3]

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Pancreatic cancer risk is not associated with exposure to environmental tobacco smoke during childhood or adulthood, a meta-analysis showed.[1]

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Pancreatic cancer risk is around 60% higher among ever-users of snus, compared with snus never-users, a meta-analysis showed.[1] However, pancreatic cancer risk is not associated with ever-use of smokeless tobacco overall, compared with never-use of any tobacco, a pooled analysis showed.[2]

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Body fatness is classified by the International Agency for Research on Cancer (IARC) and the World Cancer Research Fund/American Institute for Cancer Research (WCRF/AICR) as a cause of pancreatic cancer.[1,2] Abdominal fatness is classified by WCRF/AICR as a probable cause of pancreatic cancer.[2] An estimated 12% of pancreatic cancers in the UK are linked to overweight and obesity.[3]

Pancreatic cancer risk increases by 10% per 5-unit body mass index (BMI) increase, a meta-analysis showed.[4] Pancreatic cancer risk increases by 11% per 10cm waist circumference increase, and by 19% per 0.1-unit waist-to-hip ratio increment, this meta-analysis showed.[4]

References

  1. International Agency for Research on Cancer. List of Classifications by cancer sites with sufficient or limited evidence in humans, Volumes 1 to 105*. Available from:http://monographs.iarc.fr/ENG/Classification/index.php. Accessed May 2014.
  2. World Cancer Research Fund/American Institute for Cancer Research. Food, Nutrition, Physical Activity, and the Prevention of Cancer: a Global Perspective. Washington DC: AICR; 2007.
  3. Parkin DM, Boyd L, Walker LC. The fraction of cancer attributable to lifestyle and environmental factors in the UK in 2010. Br J Cancer 2011;105(S2):S77-S81.
  4. Aune D, Greenwood DC, Chan DS, et al. Body mass index, abdominal fatness and pancreatic cancer risk: a systematic review and non-linear dose-response meta-analysis of prospective studies. Ann Oncol 2012;23(4):843-52. Epub 2011 Sep 2.
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Alcohol consumption is classified by the International Agency for Research on Cancer (IARC) as a possible cause of pancreatic cancer.[1] The World Cancer Research Fund/American Institute for Cancer Research (WCRF/AICR) make no judgment on the association between pancreatic cancer risk and alcohol consumption, due to limited evidence.[2]

Pancreatic cancer risk is 22% higher in people who consume 3 or more alcoholic drinks per day, and 60% higher in people who consume 5 or more alcoholic drinks per day, compared with those who consume less than 1 alcoholic drink per day, meta- and pooled analyses have shown.[3,4] Pancreatic cancer risk is not associated with drinking fewer than 3 or 4 alcoholic drinks per day, meta- and pooled analyses have shown.[3,4] The association may vary by sex, though evidence from pooled analyses of cohort studies remains unclear.[5,6]

References

  1. International Agency for Research on Cancer. List of Classifications by cancer sites with sufficient or limited evidence in humans, Volumes 1 to 105*. Available from:http://monographs.iarc.fr/ENG/Classification/index.php. Accessed May 2014.
  2. World Cancer Research Fund/American Institute for Cancer Research. Food, Nutrition, Physical Activity, and the Prevention of Cancer: a Global Perspective. Washington DC: AICR; 2007.
  3. Lucenteforte E, La Vecchia C, Silverman D, et al. Alcohol consumption and pancreatic cancer: a pooled analysis in the International Pancreatic Cancer Case-Control Consortium (PanC4). Ann Oncol 2012;23 (2):374-82.
  4. Tramacere I, Scotti L, Jenab M, et al. Alcohol drinking and pancreatic cancer risk: A meta-analysis of the dose-risk relation. Int J Cancer 2010; 126(6):1474-86.
  5. Genkinger JM, Spiegelman D, Anderson KE, et al. Alcohol intake and pancreatic cancer risk: a pooled analysis of fourteen cohort studies. Cancer Epidemiol Biomarkers Prev 2009;18(3):765-76.
  6. Michaud DS, Vrieling A, Jiao L, et al. Alcohol intake and pancreatic cancer: a pooled analysis from the pancreatic cancer cohort consortium (PanScan). Cancer Causes Control 2010;21(8):1213- 25.
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Thorium-232 and its decay products, X-radiation, and Gamma-radiation are classified by the International Agency for Research on Cancer (IARC) as causes of pancreatic cancer.[1]

Pancreatic cancer mortality risk is not increased in atomic bomb survivors.[2]

An estimated 2% of pancreatic cancers in males in the UK, and 4% in females, are linked to radiotherapy for previous cancer.[3,4]

References

  1. International Agency for Research on Cancer. List of Classifications by cancer sites with sufficient or limited evidence in humans, Volumes 1 to 105*. Available from: http://monographs.iarc.fr/ENG/Classification/index.php. Accessed May 2014.
  2. Ozasa K, Shimizu Y, Suyama A, et al. Studies of the mortality of atomic bomb survivors, Report 14, 1950-2003: an overview of cancer and noncancer diseases. Radiat Res 2012;177(3):229- 43.
  3. Parkin DM, Boyd L, Walker LC. The fraction of cancer attributable to lifestyle and environmental factors in the UK in 2010. Br J Cancer 2011;105(S2):S77-S81.
  4. Parkin DM, Darby SC. Cancers in 2010 attributable to ionising radiation in the UK. Br J Cancer 2011;105(S2):S57-S65.
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Greater adult attained height is classified by the World Cancer Research Fund/American Institute for Cancer Research (WCRF/AICR) as a probable cause of pancreatic cancer.[1] Height probably indicates genetic, environmental, hormonal and nutritional factors, rather than directly causing pancreatic cancer.[1]

Pancreatic cancer risk is not associated with adult height, meta- and pooled analyses have shown.[2,3]

References

  1. World Cancer Research Fund/American Institute for Cancer Research. Food, Nutrition, Physical Activity, and the Prevention of Cancer: a Global Perspective. Washington DC: AICR; 2007.
  2. Aune D, Vieira AR, Chan DS, et al. Height and pancreatic cancer risk: a systematic review and meta-analysis of cohort studies. Cancer Causes Control 2012;23(8):1213-22.
  3. Wirén S, Häggström C, Ulmer H, et al. Pooled cohort study on height and risk of cancer and cancer death. Cancer Causes Control 2014;25(2):151-9.
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Red meat is classified by the World Cancer Research Fund/American Institute for Cancer Research (WCRF/AICR) as a possible cause of pancreatic cancer.[1]

Pancreatic cancer risk is 29% higher per 120g/day red meat intake in men, a meta-analysis showed.[2] Pancreatic cancer risk is not associated with red meat intake in women.[2] This sex difference may reflect overall lower red meat consumption in women.[2]

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Pancreatic cancer risk is almost threefold higher in people with chronic pancreatitis, compared with healthy controls Open a glossary item, a pooled analysis showed.[1] Pancreatic cancer risk is higher still shortly after pancreatitis diagnosis, probably because of increased investigative activity in this period and/or initial misdiagnosis of pancreatic cancer as pancreatitis.[1]

Pancreatic cancer risk is increased more than 50-fold in people with hereditary pancreatitis.[2]

References

  1. Duell EJ, Lucenteforte E, Olson SH, et al. Pancreatitis and pancreatic cancer risk: a pooled analysis in the International Pancreatic Cancer Case-Control Consortium (PanC4). Ann Oncol 2012; 23(11):2964-70. doi: 10.1093/annonc/mds140.
  2. Haddad A, Kowdley GC, Pawlik TM, et al. Hereditary pancreatic and hepatobiliary cancers. Int J Surg Oncol. 2011;2011:154673
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Pancreatic cancer risk is 25% higher in people with gallstones (cholelithiasis) versus people without, a meta-analysis showed; gallstone disease and pancreatitis are often associated.[1] Pancreatic cancer risk may only be increased shortly after gallstones diagnosis, probably because of increased investigative activity in this period and/or gallstones being an early symptom of pancreatic cancer.[1]

Pancreatic cancer risk is 23% higher in people who have undergone gallbladder removal (cholecystectomy), a meta-analysis showed.[2]

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Pancreatic cancer risk is around twice higher in diabetics compared with non-diabetics, meta-analyses have shown.[1,2] Diabetes may be a cause or an early manifestation of pancreatic cancer, and may vary by treatment type (which itself reflects diabetes severity).[1]

Pancreatic cancer risk may be lower in metformin users versus non-users,[3,4] however there may be no association,[5,6] meta-analyses have shown. Pancreatic cancer risk may be lower in insulin users versus non-users,[7] however there may be no association,[6] meta-analyses have shown; risk may only be increased with shorter-term insulin use.[8] Pancreatic cancer risk is higher in sulfonylureas users versus non-users,[6] and is not associated with thiazolidinediones use,[6,9] meta-analyses have shown.

Pancreatic cancer risk is 58% higher in women with metabolic syndrome (characterised by overweight/obesity, ineffective insulin use, diabetes and hypertension), compared with the general population, a meta-analysis showed.[10] Pancreatic cancer risk is not associated with metabolic syndrome in men.[10]

References

  1. Ben Q, Xu M, Ning X, et al. Diabetes mellitus and risk of pancreatic cancer: A meta-analysis of cohort studies. Eur J Cancer. 2011 Sep;47(13):1928-37.
  2. Batabyal P, Vander Hoorn S, Christophi C, et al. Association of Diabetes Mellitus and Pancreatic Adenocarcinoma: A Meta-Analysis of 88 Studies. Ann Surg Oncol 2014.
  3. Wang Z, Lai ST, Xie L, et al. Metformin is associated with reduced risk of pancreatic cancer in patients with type 2 diabetes mellitus: A systematic review and meta-analysis. Diabetes Res Clin Pract 2014.
  4. Shen M, Boffetta P, Olsen JH, et al. A pooled analysis of second primary pancreatic cancer. Am J Epidemiol 2006; 163(6):502-11.
  5. Gandini S, Puntoni M, Heckman-Stoddard BM, et al. Metformin and cancer risk and mortality: a systematic review and meta-analysis taking into account biases and confounders. . Cancer Prev Res (Phila). 2014;7(9):867-85.
  6. Singh S, Singh PP, Singh AG, et al. Anti-diabetic medications and risk of pancreatic cancer in patients with diabetes mellitus: a systematic review and meta-analysis. Am J Gastroenterol 2013;108(4):510-9.
  7. Karlstad O, Starup-Linde J, Vestergaard P, et al. Use of insulin and insulin analogs and risk of cancer - systematic review and meta-analysis of observational studies. Curr Drug Saf.2013;8(5):333-48.
  8. Bosetti C, Rosato V, Li D, et al. Diabetes, antidiabetic medications, and pancreatic cancer risk: an analysis from the International Pancreatic Cancer Case-Control Consortium. Ann Oncol 2014;25(10):2065-72.
  9. Bosetti C, Rosato V, Buniato D, et al. Cancer risk for patients using thiazolidinediones for type 2 diabetes: a meta-analysis. Oncologist 2013;18(2):148-56.
  10. Esposito K, Chiodini P, Colao A, et al. Metabolic syndrome and risk of cancer: a systematic review and meta-analysis. Diabetes Care 2012;35(11):2402-11.
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Pancreatic cancer risk is not associated with history of gastric or duodenal ulcer Open a glossary item, a pooled analysis of case-control studies showed.[1] However, risk was around doubled in male gastric ulcer patients in a cohort study.[2]

Pancreatic cancer risk is 6 times higher in people who have had gastrectomy (full/partial stomach removal) in the past two years.[1] This probably reflects detection of prevalent cancer through increased investigative activity in this period, however post-operative bacteria growth may be implicated.[1,3]

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Pancreatic cancer risk is 40% higher in people with group A blood, compared with other blood groups, a meta-analysis showed.[1] Increased pancreatic cancer risk in people with group B or AB blood varies by H pylori infection prevalence in the population.[1]

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Pancreatic cancer risk is higher in people with previous upper aerodigestive (e.g. oral, larynx), gynaecological (e.g. cervix, uterus, ovary), urological (e.g. bladder, kidney), or other (e.g. female breast, testis, stomach) cancer types, a pooled analysis showed.[1] Pancreatic cancer risk varies with age at diagnosis of first cancer, and time since that diagnosis.[1,2]

This may reflect shared risk factors with the first cancer (e.g. smoking, reproductive factors, genetic conditions), or treatment for the first cancer (e.g. radiotherapy).[1]

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Pancreatic cancer risk is 62-76% higher in people with a first-degree relative Open a glossary item with the disease, meta- and pooled analyses have shown.[1,2] Risk is higher in those with more first-degree relatives affected, or first-degree relatives diagnosed at a younger age.[3] Pancreatic cancer risk is 45% higher in people with a first-degree relative with prostate cancer, a pooled analysis showed.[1]

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Pancreatic cancer risk is higher in people with the following rare genetic conditions, compared with the general population:[1,2]

  • Peutz-Jeghers syndrome - more than 100 times higher risk
  • Familial atypical multiple mole melanoma syndrome (FAMMM) - 13-38 times higher risk
  • Lynch syndrome/hereditary non-polyposis colorectal cancer (HNPCC) - up to around 9 times higher risk (some evidence of no association)
  • BRCA2 mutation - 3.5 times higher risk
  • BRCA1 mutation - up to 2.3 times higher risk (some evidence of no association).

These genetic syndromes explain a small proportion of familial pancreatic cancer.[1,2]

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Pancreatic cancer risk is 20-60% higher in people with chronic hepatitis B infection, compared with hepatitis B-negative people, meta-analyses have shown.[1-3,6]

Hepatitis C infection may also increase pancreatic cancer risk, but evidence remains unclear.[3-5]

References

  1. Wang Y, Yang S, Song F, et al. Hepatitis B virus status and the risk of pancreatic cancer: a meta-analysis. Eur J Cancer Prev. 2013 Jul;22(4):328-34.
  2. Luo G, Hao NB, Hu CJ, et al. HBV infection increases the risk of pancreatic cancer: a meta-analysis. Cancer Causes Control. 2013 Mar;24(3):529-37.
  3. Xu JH, Fu JJ, Wang XL, et al. Hepatitis B or C viral infection and risk of pancreatic cancer: a meta-analysis of observational studies. World J Gastroenterol. 2013 Jul 14;19(26):4234-41.
  4. Fiorino S, Chili E, Bacchi-Reggiani L, et al. Association between hepatitis B or hepatitis C virus infection and risk of pancreatic adenocarcinoma development: a systematic review and meta-analysis. Pancreatology. 2013 Mar-Apr;13(2):147-60.
  5. Xing S, Li ZW, Tian YF, et al. Chronic hepatitis virus infection increases the risk of pancreatic cancer: a meta-analysis. Hepatobiliary Pancreat Dis Int. 2013 Dec;12(6):575-83.
  6. Majumder S, Bockorny B, Baker WL, Dasanu CA. Association Between HBsAg Positivity and Pancreatic Cancer: a Meta-Analysis. J Gastrointest Cancer 2014;45(3):347-52.
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Pancreatic cancer risk is 56% higher in people in Europe with H pylori infection, compared with uninfected people, a meta-analysis showed.[1]

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Pancreatic cancer risk is higher in people with periodontal disease or tooth loss, cohort studies have shown.[1,2] Porphyromonas gingivalis, a bacteria which causes periodontal disease, may be implicated.[1]

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An estimated 0.01% of pancreatic cancers in Great Britain are linked to occupational exposure to acrylamide (used in industry e.g. dye, fabric and paper manufacture; also found in foods).[1]

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Foods containing folate are classified by the World Cancer Research Fund/American Institute for Cancer Research (WCRF/AICR) as probably protective against pancreatic cancer.[1] Pancreatic cancer risk is 34% lower in people with the highest dietary folate intake, compared with those with the lowest intake, some meta-analyses have shown;[2,3] however, no association was shown in a pooled analysis of cohort studies.[4] Pancreatic cancer risk is not associated with supplemental folate intake (e.g. folic acid), a meta-analysis showed.[3]

References

  1. World Cancer Research Fund/American Institute for Cancer Research. Food, Nutrition, Physical Activity, and the Prevention of Cancer: a Global Perspective. Washington DC: AICR; 2007.
  2. Tio M, Andrici J, Cox MR, et al. Folate intake and the risk of upper gastrointestinal cancers: a systematic review and meta-analysis. J Gastroenterol Hepatol 2014;29(2):250-8.
  3. Lin HL, An QZ, Wang QZ, et al. Folate intake and pancreatic cancer risk: an overall and dose-response meta-analysis. Public Health 2013;127(7):607-13.
  4. Bao Y, Michaud DS, Spiegelman D, et al. Folate intake and risk of pancreatic cancer: pooled analysis of prospective cohort studies. J Natl Cancer Inst 2011;103(24):1840-50.
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Fruits are classified by the World Cancer Research Fund/American Institute for Cancer Research (WCRF/AICR) as possibly protective against pancreatic cancer.[1] However, pancreatic cancer risk is not associated with fruit or vegetable intake, a meta-analysis showed.[2] Pancreatic cancer risk may be lower in people with the highest citrus fruit intake, compared with those with the lowest, a meta-analysis showed.[3] However, pancreatic cancer risk may be 22% higher per 25g/day fructose intake, a meta-analysis showed.[4]

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Physical activity of all types (occupational, household, transport, and recreational) is classified by the World Cancer Research Fund/American Institute for Cancer Research (WCRF/AICR) as possibly protective against pancreatic cancer.[1] Pancreatic cancer risk is 28% lower in people with the highest levels of total physical activity compared with those with the lowest, a meta-analysis showed.[2] The association may be limited to occupational activity, not recreational.[2,3]

References

  1. World Cancer Research Fund/American Institute for Cancer Research. Food, Nutrition, Physical Activity, and the Prevention of Cancer: a Global Perspective. Washington DC: AICR; 2007.
  2. O'Rorke MA, Cantwell MM, Cardwell CR, et al. Can physical activity modulate pancreatic cancer risk? a systematic review and meta-analysis. Int J Cancer. 2010 Jun 15;126(12):2957-68.
  3. Bao Y, Michaud DS. Physical activity and pancreatic cancer risk: a systematic review. Cancer Epidemiol Biomarkers Prev, 2008. 17(10):2671-82.
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Pancreatic cancer risk is 25-27% lower in people with a history of allergy, meta- and pooled analyses have shown.[1,2] However, pancreatic cancer risk is not associated with asthma.[1,2]

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The World Cancer Research Fund/American Institute for Cancer Research (WCRF/AICR) make no judgment on the association between pancreatic cancer risk and intake of cereal (grains), dietary fibre, vegetables, pulses, soya, processed meat, poultry, fish, eggs, milk and dairy products, total fat, butter, plant oils, margarine, cholesterol, sugar (sucrose), tea (green or black), alcohol, nitrate and nitrite, total carbohydrate, folic acid supplements, vitamin C, vegetarianism, age at menarche, breastfeeding, or energy intake, due to limited evidence. Coffee is classified by WCRF/AICR as unlikely to have substantial effect on pancreatic cancer risk.[1]

Pancreatic cancer risk is not associated with the following factors, meta- and pooled analyses or systematic reviews have shown:

  • Processed meat (though some evidence of risk increase).[2]
  • Aspirin or non-aspirin non-steroidal anti-inflammatory drugs (NSAIDs).[3,4]
  • Sweetened carbonated drinks.[5]
  • Occupational exposure to diesel exhaust.[6]
  • Statins.[7]
  • Dietary sucrose.[8]
  • Dietary carbohydrates.[8]
  • Fish or omega-3 fatty acids.[9]
  • Dairy products (milk, cheese, cottage cheese, yogurt, ice-cream).[10]
  • Coffee.[11]
  • Vitamin D (blood levels, dietary[12] or supplements).[13]
  • Total fat.[14]
  • Age at menarche, age at menopause.[15]
  • Oral contraceptives, hormone replacement therapy.[15]
  • Tea.[16]

References

  1. World Cancer Research Fund/American Institute for Cancer Research. Food, Nutrition, Physical Activity, and the Prevention of Cancer: a Global Perspective. Washington DC: AICR; 2007.
  2. Larsson SC, Wolk A. Red and processed meat consumption and risk of pancreatic cancer: meta-analysis of prospective studies. British Journal of Cancer, 2012; doi: 10.1038/bjc.2011.585
  3. Larsson SC, Giovannucci E, Bergkvist L, et al. Aspirin and nonsteroidal anti-inflammatory drug use and risk of pancreatic cancer: a meta-analysis. Cancer Epidemiol Biomarkers Prev 2006; 15(12):2561-4.
  4. Cui XJ, He Q, Zhang JM, et al. High-Dose Aspirin Consumption Contributes to Decreased Risk for Pancreatic Cancer in a Systematic Review and Meta-analysis. Pancreas. 2014 Jan;43(1):135-40.
  5. Boyle P, Koechlin A, Autier P. Sweetened carbonated beverage consumption and cancer risk: meta-analysis and review. Eur J Cancer Prev 2014.
  6. Boffetta P. Lack of association between occupational exposure to diesel exhaust and risk of pancreatic cancer: a systematic evaluation of available data. Int Arch Occup Environ Health 2013.
  7. Cui X, Xie Y, Chen M, et al. Statin use and risk of pancreatic cancer: a meta-analysis. Cancer Causes Control 2012;23(7):1099-111.
  8. Aune D, Chan DS, Vieira AR. Dietary fructose, carbohydrates, glycemic indices and pancreatic cancer risk: a systematic review and meta-analysis of cohort studies. Ann Oncol 2012;23(10):2536-46.
  9. Qin B, Xun P, He K. Fish or long-chain (n-3) PUFA intake is not associated with pancreatic cancer risk in a meta-analysis and systematic review. J Nutr 2012;142(6):1067-73.
  10. Genkinger JM, Wang M, Li R, et al. Dairy products and pancreatic cancer risk: a pooled analysis of 14 cohort studies. Ann Oncol 2014.
  11. Turati F, Galeone C, Edefonti V, et al. A meta-analysis of coffee consumption and pancreatic cancer. Ann Oncol 2012;23(2):311-8.
  12. Liu SL, Zhao YP, Dai MH, et al. Vitamin D status and the risk of pancreatic cancer: a meta-analysis. Chin Med J (Engl) 2013;126(17):3356-9.
  13. Bjelakovic G, Gluud LL, Nikolova D, et al. Vitamin D supplementation for prevention of cancer in adults. Cochrane Database Syst Rev 2014;6:CD007469.
  14. Shen QW, Yao QY. Total fat consumption and pancreatic cancer risk: a meta-analysis of epidemiologic studies.. Eur J Cancer Prev. 2014.
  15. Wahi MM, Shah N, Schrock CE, et al. Reproductive factors and risk of pancreatic cancer in women: a review of the literature. Ann Epidemiol 2009;19(2):103-11.
  16. Chen K, Zhang Q, Peng M, et al. Relationship between tea consumption and pancreatic cancer risk: a meta-analysis based on prospective cohort studies and case-control studies. Eur J Cancer Prev 2014;23(5):353-60.
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