Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + COLORECTAL CANCER Download Section PDF Listen +++ +++ Population ++ Adults. +++ Recommendations +++ AAFP 2018 ++ Modifiable Risk Factors Diet: Advise patients to increase consumption of fruits, non-starchy vegetables, and whole grains to reduce risk of colorectal cancer (CRC) (Gastroenterology. 2015;148(6):1244-1260) Cholesterol: 2-fold increased risk of CRC with increased intake. Fat: 25% increased risk of serrated polyps with increased fat intake. Dairy: 15% reduced risk of CRC with >8 oz of cow’s milk daily. Fiber: No reduced risk of CRC or adenomatous polyps with increased fiber intake. Red meat: 22% increased risk of CRC with increased red meat and processed meat intake. Lifestyle: Alcohol: 8% increased risk of CRC and 24% increased risk of serrated polyps. Reducing alcohol intake does not clearly lower risk for CRC or polyps. Cigarettes: 114% increased risk of high-risk adenomatous polyps and CRC in current smokers. Obesity: Bariatric surgery associated with 27% reduced risk of CRC in obese individuals. Increased BMI is associated with increased mortality from CRC. Occupational physical activity: 25% decreased risk of colon cancer and 12% decreased risk of rectal cancer. Recreational physical activity: 20% decreased risk of colon cancer and 13% decreased risk of rectal cancer. Medications: Statins: Weak evidence that statin use ≥5 y is associated with decreased risk of advanced adenomatous polyps. Calcium: 26% reduced risk of adenomatous polyps; 22% reduced risk of CRC in individuals taking 1400 mg daily calcium compared to 600 mg. Polyp Removal Based on fair evidence, removal of adenomatous polyps reduces the risk of CRC, especially polyps >1 cm. (Ann Intern Med. 2011;154:22) (Gastrointest Endosc. 2014;80:471) Based on fair evidence, complications of polyp removal include perforation of the colon and bleeding estimated at 7–9 events per 1000 procedures. Interventions without Benefit Vitamin D. Folic acid. Antioxidants. +++ USPSTF 2016 ++ Aspirin: Associated with 40% decreased CRC incidence after 5–10 y of use. Initiate low-dose aspirin for primary prevention of cardiovascular disease and CRC in persons aged 50–59 y with a 10-y cardiovascular event risk of ≥10%, no increased risk for bleeding, life expectancy of ≥10 y, and who are willing to take low-dose aspirin daily for 10 y. (USPSTF. Aspirin Use to Prevent Cardiovascular Disease and Colorectal Cancer. 2016.) Individualize decision to initiate low-dose aspirin for persons 60–69 y of age with similar risk profile, as there is increased risk for bleeding and decreased CRC prevention benefit. Do not initiate aspirin in persons <50 or ≥70 y of age. +++ Sources ++ USPSTF. Aspirin Use to Prevent Cardiovascular Disease and Colorectal Cancer. 2016. Am Fam Physician. 2018;97(10):658-665. + ESOPHAGEAL CANCER Download Section PDF Listen +++ +++ AAFP 2017 ++ Adenocarcinoma Risk Factors Age 50–60 y. Male sex (8-fold risk). White race (5-fold risk). Gastroesophageal reflux disease (5- to 7-fold risk, depending on symptom frequency). Obesity (2.4-fold risk with BMI ≥30), particularly central adiposity. Smoking (2-fold risk). Barrett’s esophagus (BE) (premalignant). Squamous Cell Carcinoma Risk Factors Age 60–70 y. Achalasia (10-fold risk). Smoking (9-fold risk). Alcohol use (3- to 5-fold risk with ≥3 drinks per day). Black Race (3-fold risk). High-starch diet without fruits or vegetables. +++ Source ++ Am Fam Physician. 2017;95(1):22-28. +++ Comments ++ Minimize exposure to risk factors. Longstanding GERD associated with BE and increased risk of esophageal CA. (PLOS. 2014;9:e103508) Radiofrequency ablation of BE with moderate or severe dysplasia may reduce risk of progression to malignancy. (N Engl J Med. 2009;360:2277-2288) Uncertain if elimination of GERD by surgical or medical therapy will reduce the risk of esophageal adenocarcinoma although a few trials show benefit. (Gastroenterology. 2010;138:1297) No trials in the United States have shown any benefit from the use of chemoprevention with vitamins and/or minerals to prevent esophageal cancer. (Am J Gastroenterol. 2014;109:1215) (Gut. 2016;65:548) + GASTRIC CANCER Download Section PDF Listen +++ ++ Modifiable Risk Factors H. pylori: Classified as Group 1 (definite) carcinogen by World Health Organization (WHO), H. pylori triggers a series of inflammatory reactions leading to chronic gastritis, stomach atrophy, and early steps in the carcinogenesis sequence. Screen for H. pylori in patients with peptic ulcer disease or gastric MALT lymphoma. (Am J Gastroenterol. 2007;102:1808-1825) A study over 15 y showed a 40% reduction in risk of gastric cancer with H. pylori eradication. (Ann Intern Med. 2009;151:121) (J Natl Cancer Inst. 2012;104:488) Diet: Increased risk with smoked foods (N-nitroso compounds), high salt diet. Decreased risk with fruit and non-starch vegetable intake. Cigarette use: 60% increased risk in current male smokers and 20% increased risk in female smokers, compared to non-smokers. Obesity: Increased risk with BMI ≥30. Physical activity: 21% decreased risk. Male sex: 2-fold to 5-fold risk compared to women, though postmenopausal women have increased risk approaching that of men. First-degree relative with gastric cancer: 2.6-fold to 3.5-fold risk. Clinical Consideration Patients with hereditary susceptibility (HNPCC, e-cadherin mutation, Li–Fraumeni syndrome), pernicious anemia, atrophic gastritis, partial gastrectomy, or gastric polyps should be followed carefully for early cancer symptoms and for upper endoscopy at intervals according to risk. +++ Sources ++ Am Fam Physician. 2017;95(1):22-28. Gastrointest Endosc. 2016;84(1):18-28. + HEPATOCELLULAR CANCER Download Section PDF Listen +++ +++ AASLD 2018, NCI 2019 ++ Modifiable Risk Factors Cirrhosis and associated risk factors: Chronic Hepatitis B (HBV) infection. Hepatitis C (HCV) infection. Extensive alcohol use. Non-alcoholic steatohepatitis (NASH). Hereditary hemochromatosis. Primary biliary cholangitis. Wilson’s disease. Aflatoxin B1 (fungal toxin that contaminates corn, grains and nuts that are not stored properly). Prevention Vaccinate against Hepatitis B. Treat Hepatitis C infection. Achieve alcohol cessation. Treat underlying risk factors as applicable. +++ Sources ++ AASLD. Hepatology. 2018;68(2):723-750. NCI. Adult Primary Liver Cancer Treatment (PDQ). 2019.