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Is the Association with Fiber from Foods in Colorectal Cancer Confounded by Folate Intake?

¹ Medical Research Council Dunn Human Nutrition Unit; ² Strangeways Research Laboratory, University of Cambridge, Cambridge, United Kingdom; ³ International Agency for Research on Cancer (IARC-WHO), Lyon, France; ⁴ Institut National de la Sante et de la Recherche Medicale, Institut Gustave Roussy, Villejuif, France; ⁵ German Cancer Research Center, Heidelberg, Germany; ⁶ German Institute of Human Nutrition, Potsdam-Rehbücke, Germany; ⁷ Institute of Cancer Epidemiology, Danish Cancer Society, Copenhagen, Denmark; ⁸ Institute of Epidemiology and Social Medicine, University of Aarhus, Aarhus, Denmark; ⁹ Andalusian School of Public Health, Granada, Spain; ¹⁰ Department of Public Health of Guipuzkoa, San Sebastian, Spain; ¹¹ Catalan Institute of Oncology, Barcelona, Spain; ¹² Public Health Institute of Navarra, Pamplona, Spain; ¹³ Epidemiology Department, Health Council of Murcia, Murcia, Spain; ¹⁴ Public Health Directorate for Health and Social Services of Asturias, Oviedo, Spain; ¹⁵ Epidemiology Unit, Cancer Research UK, University of Oxford, Oxford, United Kingdom; ¹⁶ University of Athens Medical School, Athens, Greece; ¹⁷ Department of Epidemiology, National Cancer Institute, Milan, Italy; ¹⁸ Cancer Registry, Azienda Ospedaliera "Civile M.P. Arezzo," Ragusa, Italy; ¹⁹ Molecular and Nutritional Epidemiology Unit, Centro per lo Studio e la Prevenzione Oncologica, Scientific Institute of Tuscany, Florence, Italy; ²⁰ Department of Clinical and Experimental Medicine, Federico II University, Naples, Italy; ²¹ Cancer Epidemiology Department, University of Turin, Turin, Italy; ²² Department of Epidemiology and Public Health, Imperial College of Science, Technology and Medicine, London, United Kingdom; ²³ National Institute of Public Health and the Environment, Bilthoven, the Netherlands; ²⁴ Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands; ²⁵ Malmö Diet and Cancer Study, Lund University, Malmö, Sweden; ²⁶ Department of Nutritional Research, University of Umeå, Umeå, Sweden; and ²⁷ Institute of Community Medicine, University of Tromsø, Tromsø, Norway

Requests for reprints: Elio Riboli, Nutrition and Hormones Group, IARC-WHO, 150 cours Albert-Thomas, 69372 Lyon cedex 08, France. Phone: 33-472-73-84-11; Fax: 33-472-73-83-61.

The effect of multivariate adjustment including folate on the strong protective effect of fiber in foods on colorectal cancer risk in the European Prospective Investigation into Cancer and Nutrition was investigated in 1,721 cases identified in the latest follow-up. The inclusion of an additional 656 cases confirmed our previously published results, with a strong and significant reduction in colorectal cancer risk of 9% for each uncalibrated quintile increase in fiber (P_{linear trend} < 0.001) compared with an 8% reduction in our previous report, which had not been adjusted for folate. Inclusion of the other covariates (physical activity, alcohol, smoking, and red and processed meat) confirmed this significant inverse association for colon cancer and strengthened the association with left-sided colon cancer (P < 0.001). After maximum adjustment, the association between fiber and rectal cancer was not significant, as in our previous analysis. The association with fiber from different food sources was analyzed, but again, there were no significance trends after maximum adjustment.

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