Risk Factors

The study of risk and protective factors can help to quantify the proportion of the cancer burden explained by known causes and to estimate the avoidable cases or deaths. Many factors have been postulated as either determinants of CRC or increasing its risk. The possible analysis of risk factors suffers from the same shortcomings of analytical epi-demiological studies investigating the complex issues of diet and lifestyle [49, 50].

Not all identified causes of CRC are, of course, equally modifiable. A distinction must, therefore, be

Table 6. Age-standardised 5-year survival (%) after diagnosis (colon and rectum cancer and colorectal cancer) and total health expenditure (HE) PPP US $ per capita in 2002 in different countries

Country HE 5-year survival rate

Table 6. Age-standardised 5-year survival (%) after diagnosis (colon and rectum cancer and colorectal cancer) and total health expenditure (HE) PPP US $ per capita in 2002 in different countries

Country HE 5-year survival rate

Colon cancer

Rectum cancer

Colorectal cancer

M

F

M

F

M

F

Estonia

625

38.0

37.0

32.5

28.2

35.5

33.5

Poland

654

26.3

28.7

27.3

28.5

26.8

28.6

Slovakia

698

39.9

43.7

26.1

31.2

32.7

37.7

Czech Republic

1118

38.1

36.4

26.8

38.2

32.3

37.1

Slovenia

1405

34.8

38.8

33.0

34.0

33.9

36.3

Spain

1646

55.0

55.8

50.0

52.5

53.0

54.7

Portugal

1702

49.0

43.5

42.7

44.1

46.3

43.6

Malta

1709

35.9

53.3

39.6

57.2

38.5

53.9

Finland

1943

54.0

52.7

49.3

50.8

51.7

52.0

United Kingdom

2160

45.3

47.2

42.0

45.5

44.1

46.7

Italy

2166

51.2

52.1

46.0

48.9

49.3

51.2

Austria

2220

55.1

58.4

44.2

46.1

50.8

54.0

Sweden

2517

52.2

54.4

52.4

57.1

52.3

55.4

Denmark

2580

43.2

47.6

41.8

44.6

42.6

46.6

The Netherlands

2643

51.9

54.0

55.2

53.9

53.2

54.0

France

2736

55.9

58.7

51.5

62.3

54.1

60.0

Iceland

2807

45.9

55.2

-

49.0

47.5

53.3

Germany

2817

50.5

54.5

46.9

51.5

49.0

53.5

Norway

3083

51.4

53.6

50.6

56.2

51.1

54.5

Switzerland

3445

55.0

56.3

55.8

57.3

55.2

56.9

made between "identified not avoidable" causes of cancer and "avoidable" causes of cancer. There is no clear line between environmental identified causes and avoidable causes. We do not have a clear line between the two, as it depends on the extent to which we consider environment, health behaviour and, in general, external modifiable factors.

CRC is a multifactorial disease in which pathogen-esis plays a role as well as inherited predisposition and environmental factors. Epidemiological evidence suggests that diet and other environmental factors may have a major impact on incidence variations among countries and the global burden of the disease [51-53]. In Europe and the United States, up to 5% of the general population may develop this cancer by the age of 75 [54].

CRC is sporadic when it has not been evidenced that there is a predisposition to the disease and, thus, the individual does not carry a high-risk mutation. CRC is regarded as "inherited", when there is a clear genetic transmission in familial pedigree, while it is considered "familiar" if there is a number of persons affected in a family with a proportional risk increase. Approximately 75% of CRCs are sporadic and develop in people with no specific risk factors. On the other hand, 25% of all these cancers occur in people with significant risk factors, most of which, 15-20%, develop in people with either a positive family history, a personal history of CRC or polyps. The remain ing cases occur in people with genetic predispositions such as hereditary non-polyposis CRC (HNPCC, 4-7%), familial adenomatous polyposis (FAP, 1%) or in people with inflammatory bowel disease (l%) [55].

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