Evidence-based Counseling for GI Malignancy Risk Reduction

1. Evidence-based Counseling for GI Malignancy Risk Reduction Mark Y. Liu, DO, FAAFP Tripler Army Medical Center Honolulu, Hawaii The views expressed in this presentation are those of the author and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the US Government.

2. Aloha! 6 Million cans of Spam/year Highest Life Expectancy in the U.S = 80

3. Case Study • Ashley, a 48 year-old woman, just learned that her 70 year-old father has inoperable gastric cancer. She wants to know if she is at risk of developing gastric cancer because she grew up eating the same smoked meats her father ate. Ashley also asks what she can do to lower her risk of developing this cancer. She has heard that calcium supplements might help prevent gastrointestinal cancers and ask whether she should begin taking a calcium supplement.

4. Background • 140,000 + develop GI cancers each year • 49,000 die • 9% of all cancer mortalities • Screening and avoidance of risk factors

5. I. Lifestyle Risk Factors • Lifestyle factors • 2 Major longitudinal studies • Participants with 4 healthful lifestyle factors, had 1/3 the risk of developing cancer • Obesity, smoking, poor diet, physical inactivity

6. 1. Obesity • 65% overweight, 30% obese • Increases CRC, pancreatic and esophageal CAs • Etiology of 20% of all cancers • Weight reduction leads to 60% less cancer mortality

7. 2. Smoking • Implicated in 30% of all cancer-related mortalities • Oral cavity, esophagus, pancreas, liver, stomach and colon • All forms of tobacco • Conversely, smoking cessation reduces risk

8. 3. Diet

10. 4. Physical Inactivity Physical Activity GI CA risks • 3.5 hours/week of moderate exercise = 24% reduction of CRC risk • Theories: Hormones; Growth Factors Immune function; Prostaglandin

11. Extra: Alcohol Consumption • 1 Drink (10g) increases risk of cancers of: • Oropharynx • Esophagus • Rectum • Poorly understood • Solvent properties?

12. II. Heredity • Heredity vs. diet/lifestyle

13. III. Infections • Helicobacter pylori – Gastric CA • Epstein-Barr virus – Gastric CA • Human papillomavirus – Esophageal CA • JC polymavirus – Colon CA

14. Chemoprevention • Aspirin • Anti-inflammatory properties • 2007 USPSTF Recommendation • 2011 meta-analysis of 8 trials • Reduces risks for esophageal, gastric, pancreatic and colorectal cancers • 50% reduction of CRC mortalities after 5 years • No dosage difference

15. Chemoprevention • Vitamin and Mineral Supplementation • Vitamin D, calcium & magnesium • Strongest evidence for calcium – lowers CRC • ACG recommends 3 g/day

16. Recommendations • Lifestyle counseling • Inquire family history • Rule out infections • Discuss role of chemoprevention

17. Case Revisited • You inform Ashley that there is association between gastric cancer and diet • You obtain a detailed family history to exclude hereditary syndromes • You order a test for H. pylori infection • You recommend regular use of low-dose ASA • You recommend calcium supplementation for chemoprevention and bone health

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