Bininrkern n Canner Chernapreverition Miller, AS., Bartsch, h Battetfa, P. Dragntnd, L and Vainio, H. ada IARC ScLentUic Publications Na. 154 International Agency for Research on Canner, Lyon, 2001
Intermediate effect markers foi colorectal cancer
Recurrence or regression of adenomatous polyps is considered to be both a biomarker of risk and an intermediate (surrogate) end-point. The observational epidemiology of adenomas resembles closely that of invasive cancer, and the findings in chemoprevention trials that have been completed closely mirror that common epidemiology. Although it is possible that both the clinical trials and the epidemiology may be wrong, these common findings suggest that adenomas in general are valid end-points. Aberrant crypt foci show promise as biomarkers, both as markers of risk and as interme- diate end-points for chemoprevention trials. If issues of cost can be overcome, assessment of ras mutations in stool appears to be a promising technique for screening for large bowel neoplasms. The lack of specificity of the technique limits its utility as a sole end-point in prevention studies, however. Mucosal proliferation has been used both as a biomarker of risk and as an intermediate end-point. The utility of these measures is not clear, however, since there has been discordance between the epidemiological findings regarding proliferation and established risk factors for colorectal neoplasia. The inherent variability of the measures and the technical problems asso- ciated with their use are further impediments. However, rectal mucosal proliferation may be suitable for studies in single institutions, or in consortia with very aggressive quality control.
Adenomatous polyps endoscopic surveillance of the bowel can be Colorectal adenomas are well demarcated tumours assumed to be close to 100% if pathological exam- of the large bowel mucosa, and are composed of ination is conducted. However, the sensitivity is crypts with cells showing features of epithelial dys- likely to be somewhat lower than this. For large plasia. This histological definition implies nothing adenomas (1 cm or greater in estimated diameter), about the gross shape of the lesion, although com- the miss rate is small (less than 5%; Hixson et al., monly it is polypoid, protruding into the lumen of 1991), but for smaller polyps it has been found to the bowel, sometimes on a stalk. Since such adeno- be 15-25% (Hixson et al., 1990; Hoff & Vatn, 1985; matous polyps are raised lesions, they are easily Rex etal., 1997), visible by endoscopy and (unless very large) can be The existence of 'flat adenomas'—those that are removed endoscopically. Adenomatous polyps not substantially raised above the mucosal sur- have been widely applied in large bowel chemo- face—somewhat complicates this assessment. Such prevention studies both as an entry criterion and adenomas have been noted most often in Asia, but as an intermediate outcome end-point (Baron, have also been seen in North America and Europe 1996). (Jaramillo et al., 1995; Lanspa et al., 1992; Owen, However adenomatous polyps are used, there is 1996). The presence of such adenomas may measurement error associated with their identifi- decrease the sensitivity of adenoma detection by cation by endoscopy. To distinguish these polyps endoscopy, but will not greatly affect the predictive from non-adenomatous large bowel polyps in value of the detected lesions, at least for the raised research studies, it is important that each polyp be cancers and adenomas traditionally studied in biopsied for histological examination. Since the western countries. Increased awareness of these microscopic identification of adenomatous tissue lesions and newer endoscopic techniques such as is generally not difficult, the net specificity of magnifying endoscopy may resolve some of the
113 Bomarkers b Cancer Chemoprevention geographical differences in the apparent incidence These data show that the association between and prevalence of these lesions. adenomatous polyps and synchronous or metachronous neoplasia depends on the charac- Adenomas as biomarkers teristics of the presenting polyp (Atkin et al., 1992; Adenomatous polyps are clearly established mark- Aubert et al., 1982). In essence, it appears that ers of risk of colorectal neoplasia. Individuals with while advanced lesions are predictive of both simple adenomas in the distal bowel (for example, within and advanced lesions, the simple lesions are asso- the reach of a sigmoidoscope) have an increased ciated only with an increased risk of synchronous risk of proximal adenomas or cancer (Levin et al., or metachronous simple lesions. Since low-risk 1999; Lieberman & Smith, 1991). Advanced ade- adenomas do not lead to high-risk adenomas (not nomas—those with large size (typically >1 cm), vil- to speak of cancer), it is possible that advanced and bus histology or advanced dysplasia—are more simple adenomas reflect different biological pathways. likely to harbour invasive cancer than simple ade- nomas (without those features) (Gatteschi et al., Adenomas as surrogate end-points: the 1991; Muto et al., 1975; Shinya & Wolff, 1979). adenoma-carcinoma sequence Advanced features in distal adenomas also are pre- It is thought that the overwhelming majority of dictive of proximal adenomas (Levin et al., 1999; colorectal cancers arise from adenomatous tissue— Schoen et al., 1998; Wallace et al., 1998) as well as this is the well known adenoma-carcinoma proximal advanced adenomas (Levin et al., 1999; sequence. Evidence for the adenoma-carcinoma Schoen et al., 1998; Wallace et al., 1998; Zarchy & sequence is largely indirect. A substantial propor- Ershoff, 1994). In some multivariate analyses, all of tion of colorectal cancers have contiguous these factors have emerged as independent predic- adenomatous tissue, suggesting that the former tors (Gatteschi et al., 1991), although others have grew out of the latter (Eide, 1983; Peipins & found that while histology and number of polyps Sandier, 1994). Also, in a high proportion of large are independent predictors of risk, size is not adenomas (particularly large villous adenomas), (Atkin et al., 1992; Levin et al., 1999). there are foci of carcinoma (Muto etal., 1975). The Patients with adenomas anywhere in the bowel distribution of adenomas within the bowel differs also have an increased risk of later (metachronous) from that of colorectal cancer (Peipins & Sandler, adenomas or cancer (Atkin et al., 1992; Lotfi et al., 1994), but large adenomas (carrying greater risk of 1986; Simons et al., 1992; Stryker et al., 1987). developing malignancy) have a site distribution Characteristics of the presenting adenomas that similar to that of cancer (Konishi & Morson, 1982; are predictive of subsequent neoplastic develop- Matek et al., 1986). Polyps (unknown histology) ment include large size, villous histology, multiple have been observed to grow in a location in which adenomas, and higher degrees of dysplasia (Atkin cancer was later found (Stryker et al., 1987). Also, et aL, 1992; Grossman et al., 1989; Simons et al., adenomas and carcinomas share a number of 1992; van Stolk et al., 1998; Winawer et al., 1993; metabolic characteristics, including abnormalities Yang etal., 1998). The same characteristics are also in DNA ploidy, mucins, metabolic enzymes and predictive of later adenomas with advanced patho- cytoskeletal proteins (Tierney et al., 1990). In each logical features (Atkin et al., 1992; Yang et al., case, these changes follow what appears to be a 1998). In multivariate analyses, histology appears progression of changes from normal mucosa to explain the association of size with risk of through adenoma to carcinoma. It is important to metachronous tumours (Atkin et al., 1992; Simons note that this progression has been described et al., 1992). Unfortunately, in virtually all of the largely in histopathological terms; it is actually a studies of later cancer risks in patients with adeno- matter of dysplasia progressing to carcinoma. The mas, comparisons have been made with the term polyp', a gross pathology descriptor, has no general population, rather than with individuals particular histopathological meaning. The screened intensively for colorectal cancer like the existence of the adenoma-carcinoma sequence subjects with adenomas. Consequently, the does not necessarily imply that the polyp- excess cancer risks are almost certainly under- carcinoma sequence holds all the time (Morson, estimated. 1984).
114 Intermediate effect markers for colorectal cancer
Perhaps the strongest evidence for the preneo- adenomatous polyps may not confer a benefit in plastic nature of adenomatous polyps is the terms of reduction of cancer incidence, if the ade- somatic genetic changes seen in them. These nomas prevented are those that would not somatic changes fit clearly into a progression, sit- progress. However, removing adenomas within the ting between normal mucosa and invasive carci- reach of a sigmoidoscope reduces the subsequent noma (Kinzler & Vogelstein, 1996; Potter, 1999). risk of cancer in the same region of the bowel, a There is a similarly high prevalence of mutations finding that is difficult to explain on the basis of of the APC gene in colorectal cancer and in ade- bias (Muller & Sonnenberg, 1995; Murakami et al., nomas (even small adenomas) (Boland et al., 1995; 1990; Newcomb et al., 1992; Selby et al., 1992). Kinzler & Vogelstein, 1996; Powell et al., 1992); Assuming that physical removal of adenomatous mutations in this gene seem to be important in polyps does lower the risk of subsequent carci- turning individual cells onto a dysplastic path. The noma, this is evidence that at least a substantial prevalence of Kirstin-ras (K-ras) and p53 mutations proportion of cancers would have grown from the increases as one considers progressively small ade- small adenomas detected and removed. This also nomas (< 1 cm), large adenomas (~i 1 cm) and inva- suggests that flat adenomas (presumably unde- sive carcinoma (Boland et al., 1995; Kinzler & tected by endoscopy) are not the principal precur- Vogelstein, 1996). Various genetic changes have sors of carcinomas in the populations from which been seen at the transition from normal mucosa to the reports derived. small adenoma (APC), and from adenoma to severe dysplasia or carcinoma (p53, TGF4I in microsatel- Epidemiology of large bowel adenomas versus the lite unstable tumours) (Ahuja et al., 1998; Boland et epidemiology of colorectal cancer al., 1995; Grady et al., 1998). In general, the epidemiology of large bowel Some mutations appear to be more common in adenomas appears to be similar to that of colorec- early adenomas than in later tumours. -Catenin tal cancer itself (Potter, 1996; World Cancer mutations, for example, have been seen more com- Research Fund & American Institute for Cancer monly in small adenomas than in larger ones from Research, 1997), Vegetable intake (and, less consis- the same patient population. It is possible that tently, intake of fruits) has been inversely associ- these mutations mark tumours that are unlikely to ated with risk, and red meat directly associated progress (at least in size) (Samowitz et cil., 1999), or with both types of neoplasm. For both, cereal fibre this may have been a chance finding. has generally been unassociated with risk, while Assuming that colorectal cancers grow out of findings regarding dietary fat and other types of large adenomas and that large polyps were first fibre have been variable. Protective effects of folate small polyps, we can qualify small adenomas as have been reported, particularly in association precancerous lesions. Nonetheless, it is clear that with high alcohol intake. In observational studies, only a small minority of these adenomas will calcium intake has been variably related to risk of progress to carcinoma within a human lifetime both adenomas and cancer (Bergsma-Kadijk et al., (Eide, 1986; Knoernschild, 1963; Peipins & 1996; Martinez & Willett, 1998) and coffee intake Sandier, 1994) and some polyps (unknown histol- may be inversely related to the risk of both ogy) regress or disappear (Cole et al., 1959; Hoff et (Giovannucci, 1998). Exercise seems inversely al., 1986; Hofstad et al., 1994; Knoernschild, 1963; related to both colon cancer and colorectal Nicholls et al., 1988; Welin et al., 1963). It is not adenomas, but findings regarding obesity have known if large advanced adenomas grow from been variable for both types of tumour (Peipins & small advanced adenomas, or whether the Sandier, 1994; Potter, 1996; World Cancer Research advanced features are acquired with growth. It is Fund & American Institute for Cancer Research, also not clear that all large bowel adenocarcinomas 1997). Associations with cholecystectomy also have progressed through a stage of adenoma that appear to be similar (Peipins & Sandler, 1994). could be distinctly recognized as such (and poten- Studies that included both colorectal cancers and tially removed before malignant conversion) colorectal adenomas have provided particularly (Bedenne et al., 1992). Thus it is possible that an interesting data in this regard, with broadly similar intervention that prevents only small, simple patterns of risk factors for invasive cancer and
115 Biomarkers in Cancer Chemoprevention adenomas (Benito etal., 1991, 1993; Boutron etal., In familial adenomatous polyposis (FAP), vita- 1996; Faivre et al., 1997; Fuchs et al., 1999; min C supplementation yielded weak indications Giovarinucci et al., 1993, 1994, 1995a, b, 1998; of a reduction in polyp burden (Bussey et al., KampmanetaL, 1994; Kearney etaL, 1996; Kuneet 1982), although in a larger study, ascorbate plus al., 1987, 1991; Martinez et al., 1996; Platz et al., a-tocopherol had no effect (DeCosse et ai., 1989). 1997), although one such study suggested a differ- There were weak suggestions that cereal fibre was ence in the effect of folate (Boutron-Ruault et a!,, similarly beneficial in conjunction with ascorbate 1996). plus c-tocopherol (DeCosse et al., 1989). Several studies of sulindac have shown dear evidence that Adenomas in chemoprevention trials treatment with this nonsteroidal anti-inflamma- In general, the findings from intervention trials tory drug (NSAID) can lead to a reduction in that used adenomas as end-points have confirmed polyps (Giardiello et ai., 1993; Labayle etal., 1991; those from observational epidemiology. Nugent et al., 1993). Recurrence of sporadic adenornatous polyps has been used as an end-point for several clinical trials Aberrant crypt foci of calcium supplementation. The largest of these, Aberrant crypt foci are groups of crypts that are the Calcium Polyp Prevention Study, randomized morphologically altered: delineated from the sur- 930 subjects to treatment with placebo or 3000 mg rounding glands, larger than normal, often with of calcium carbonate (1200 mg of elemental cal- dilated lumina (Fenoglio-Preiser & Noffsinger, cium). There was a modest protective effect of cal- 1999). Vital stains such as methylene blue accen- cium. A subsequent trial, using 2 g of elemental tuate the aberrant crypt foci. The lesions are histo- calcium per day reported a similar relative risk, logically heterogeneous, variably including hyper- which failed to reach statistical significance with a plastic and dysplastic crypts. The multiplicity of smaller sample size (Faivre et al., 1999). In several aberrant crypt foci (i.e., the number of crypts trials, fl-carotene has had no effect on adenoma involved) can vary from one to as many as several occurrence (Greenberg et al., 1994; Kikendall et ai., hundred. 1990; MacLennan et al., 1995), nor has ascorbate Aberrant crypt foci were first noted in rats plus -tocopherol (Greenberg et ai., 1994; treated with carcinogens, and several aspects of McKeown-Eyssen et al., 1988). their occurrence suggest that they may be preneo- In agreement with the observational studies, plastic (Bird, 1995; McLellan et ai., 1991; Pretlow, cereal fibre supplements did not affect sporadic 1995). Their numbers correlate with the dose of adenoma recurrence in two trials, either alone carcinogen used, and aberrant crypt foci have not (Alberts et ai., 2000; MacLennan et al., 1995) or often been seen in untreated animals, in those with a low-fat diet (MacLennan et al., 1995). Two treated with carcinogens that target other organs other trials that investigated a low-fat/high-fibre or in those treated with toxic non-carcinogenic diet also failed to find an effect (McKeown-Eyssen compounds such as cholic acid (Bird, 1995; et ai., 1994; Schatzkin et al., 2000). The earlier of Pretlow etal., 1992). With increasing time after car- these studies (McKeown-Eyssen et al., 1994) relied cinogen administration, the number, size and heavily on a cereal fibre supplement, and so did degree of dysplasia of the aberrant crypt foci not focus on the fibre moieties most strongly increase. Known promoters or inhibitors of associated with reduced risk of colorectal neopla- colorectal carcinogenesis seem to have the same sia. In the more recent trial (Schatzkin et ai., effect on the number and multiplicity of aberrant 2000), subjects in the intervention arm were crypt foci (Bird, 1995). Clonai expansion and advised to increase dietary fibre by increasing dysplasia may be separate processes (Bird, 1995; intake of fruits and vegetables. No data were Jen et al., 1994). In these experimental situations, presented regarding changes in vegetable intake aberrant crypt foci have been found to have some during the study (separately from changes in of the features of carcinogenesis, such as hyper- fruit). If vegetable intake increased substantially, proliferation and mutated p53 (Fenoglio-Preiser & these negative findings may conflict with the Noffsinger, 1999; Olivo & Wargovich, 1998; observational data. Pretlow, 1995; Roncucci, 1992). A natural history
116 Intermediate effect markers for coloreclal cancer
study found that after administration of Noffsinger, 1999), but APC and p53 mutations are carcinogen, areas of aberrant crypt foci were likely relatively uncommon (Fenoglio-Preiser & to later contain adenomas or carcinoma, although Noffsinger, 1999; Jen et al., 1994; Loti et al., 1996; some areas of aberrant crypt foci clearly regressed Otori et ciL, 1998; Pretlow et al., 1993; Smith et al., (Shpitz et ciL, 1996). Aberrant crypt foci have been 1994; Yamashita et al., 1995). APC mutations in widely used in animal studies of chemopreventive aberrant crypt foci may correlate with dysplastic agents. In one large-scale investigation of numer- histology (Otori et al., 1998). Human aberrant ous agents, the response of aberrant crypt foci to crypt foci with carcinoma in situ have been the interventions was thought to correlate reason- observed (Konstantakos et al., 1996; Siu et al., ably well with earlier efficacy studies (Olivo & 1997), In one study, a correlation of number of Wargovich, 1998; Wargovich et al., 1996). aberrant crypt foci with numbers of adenomas was Aberrant crypt foci have also been observed in observed (Takayama et al., 1998). The histology of the human colorectal mucosa. Relatively high aberrant crypt foci is not uniform among the numbers have been found in the bowel mucosa of crypts: determination of the hyperplastic/dysplas- patients with FAP or with sporadic colorectal can- tic nature of the aberrant crypt foci may require cer (Fenoglio -Preiser .& Noffsinger, 1999; serial sectioning, and mixed foci are common Nascimbeni et al., 1999; Roncucci et al., 1991), but (Nascimbeni et al., 1999; Pretlow, 1995; Siu et al., are also seen in patients with non-neoplastic bowel 1997). It is possible that hyperplastic aberrant disorders (Fenoglio-Preiser & Noffsinger, 1999). crypt foci may evolve into dysplastic aberrant The numbers of aberrant crypt foci are progres- crypt foci (Otori et al., 1995). On the other hand, sively higher in the more distal regions of the it has been suggested that aberrant crypt foci are bowel (Bouzourene et al., 1999; Roncucci et ciL, precursors of both adenomas and hyperplastic 1991; Shpitz et al., 1998; Yamashita et al., 1995), polyps (Fenoglio-Preiser & Noffsinger, 1999). although dysplastic aberrant crypt foci may be Aberrant crypt foci have been used in only one preferentially found more proximally (Nascimbeni human chemoprevention study—a non-random- et al., 1999; Roncucci et al., 1998). ized parallel arm study that found sulindac to be Aberrant crypt foci may be observed in vivo very effective in inducing regression of aberrant using magnifying endoscopy and methylene blue crypt foci (Takayama et cil., 1998). staining (Takayama et al., 1998). There appears to be an association between the appearance of the Stool K-ras lumina of the crypts and dysplastic aberrant crypt The mucosa of the large bowel is a rapidly prolif- foci (Fenoglio-Preiser & Noffsinger, 1999; Roncucci erating tissue, turning over completely in four days et al., 1991). Although one study reported excel- (Smith-Ravin et al., 1995). Despite the enzymes lent concordance between endoscopic appearance and debris present in the stool environment, suffi- and histological characteristics (Takayama et al., cient DNA from cells shed into the lumen is passed 1998), it is likely that there is considerable mea- in stool to permit amplification with the poly- surement error in the assessment of aberrant crypt merase chain reaction (PCR) (Sidransky et al., foci with magnifying endoscopy. 1992). The amount of DNA obtained per 100 mg Some aberrant crypt foci seem to be mono- stool has varied from less than 1 pg to 9 pg. In clonal, and hence neoplastic (Fenoglio-Preiser & patients with large bowel carcinoma, it is possible Noffsinger, 1999; Siu etal., 1999). In humans, aber- that the proportion of the DNA in stool derived rant crypt foci have been found to display some of from the tumour itself could be sufficient to permit the characteristics of colorectal carcinogenesis: amplification and detection (Sidransky et al., hyperproliferation, overexpression of carcino- 1992). The K-ras gene is particularly attractive for embryonic antigen, MSI phenotype, and somatic use in stool diagnostics because, when present, the APC and K-ras mutations (Augenlicht et al., 1996; mutations typically cluster in a few codons and are Fenoglio-Preiser & Noffsinger, 1999; Heinen et ciL, therefore relatively easy to detect. 1996; PolyaketaL, 1996; Shpitz et al., 1997; 1998). Assay for mutated K-ras reveals a high proportion K-ras mutations are very common (in various of carcinomas that themselves contain mutated K- studies ranging up to 100%; Fenoglio-Preiser & ras (Hasegawa et al., 1995; Nollau etal., 1996; Ratto
117 Biomarkers in Cancer Chemoprevention etaL, 1996; Sidransky etal., 1992). Adenomas with requiring radioactive materials; and other, simpler mutated ras can also be detected in this way labelling agents have superseded tritiated thymi- (Hasegawa et al., 1995; Sidransky et al., 1992). The dine. One of these, bromodeoxyuridine, is also sensitivity of the approach clearly depends on the incorporated into DNA during S phase in tissue methods used (Hasegawa et al., 1995); sensitivity explant culture, but it can be recognized by may be lower for lesions in the right bowel immunohistochemistry, and so avoids the use of (Hasegawa et al., 1995). Colonic effluent from radioactive materials. Immunohistochemical bowel preparations has also been used as a source detection of endogenous nuclear proteins, prolif- material (Tobi et al., 1994), as have washings erating cell nuclear antigen and Ki-67 has also obtained during endoscopy (Smith-Ravin et al., been used to assess proliferation, although these 1995). This technique revealed mutated ras in antigens are expressed over a wider range of the some patients with a history of colorectal neopla- cell cycle than thymidine and bromodeoxyuridine sia or with a family history, although colonoscopy (Biasco et al., 1994; Risio, 1994). These techniques disclosed no neoplasm (Tobi et al.; 1994; Villa et are relatively easy to use, since uptake of the label al., 1996). Mutated ras has also been detected in during explant culture is not required (Biasco et al., the stool of patients with pancreatic cancer ductal 1994; Einspahr et al., 1997; Risio, 1994; Rozen, hyperplasia (Caldas et al., 1994). 1992). The whole crypt mitotic count is another Other molecular targets have also been measure of proliferation for the bowel (Goodlad et described. A deletion in the APC gene has been al., 1991; Murray etal., 1995; Tosteson etal., 1996). detected in stool (Nollau et al., 1996), but this issue In limited studies, it did not show strong correla- has not been otherwise studied. The large size of tion with the labelling index (the proportion of the APC gene makes effective screening of this cells in a crypt that are labelled) computed using gene difficult in tumours, not to speak of stool. proliferating cell nuclear antigen (Keku et al., 1998; Similar considerations apply to p53. The amount Murray et al., 1995). Whole crypt production rate of DNA on the surface of stool has also been inves- (Allan & Jewell, 1983) and flow cytometry tigated in one study: in individuals with colorectal (Nakamura et al., 1995) have also been used in var- cancer, a greater amount of DNA was detected ious studies. (Loktionov et al., 1998). The stool content of There are clear impediments to the use of mRNA for CD44, a cell surface glycoprotein, has mucosal proliferation as a biomarker of risk or as also been associated with large bowel adenocarci- an intermediate-effect biomarker. Application in norna (Yamao et al., 1998). epidemiological studies has been difficult, in part Assessment of K-ras in stool has limited sensi- because of the demands on personnel to properly tivity for detection of large bowel neoplasia—the handle the biopsy specimens (Baron etal., 1995a). proportion of colorectal cancers that contain Whatever the label, these techniques require mutated ras is typically less than 50% (Andreyev et manipulation of biopsy specimens in such a way al., 1998), although adenomas and aberrant crypt that crypt architecture is maintained and then fix- foci may have a higher prevalence of ras mutation ation until labelling and scoring. Scoring involves (len et al., 1994; Martinez et al., 1999; McLellan et computation of the labelling index. Although al., 1993). measurement of proliferation indices can be repro- ducible (Bostick etal., 1997a; Einspahr et al., 1997; Mucosal proliferation Lyles et al., 1994), careful assessments of the vari- Mucosal proliferation is thought to play a promi- ability of the measurements (Anti et al., 1994a; nent role in carcinogenesis, and consequently, has Bostick etal., 1997a; Lyles etal., 1994; Macrae etal., appeal as a biomarker. Mucosal proliferation in 1994; McShane et al., 1998) have clearly identified epithelial tissues was first measured using tissue the potential for measurement error and intra-sub- explant culture of biopsy specimens, labelling ject variability. dividing cells with tritiated thymidine, which is Proliferation in the upper (luminal) parts of the incorporated into DNA during S phase (Risio, crypt is a more sensitive marker of increased 1994; Rozen, 1992). This technique suffers from proliferation, and consequently the labelling index the disadvantages of being time-consuming and is also commonly computed in crypt compart-
118 Intermediate effect markers for colorectal cancer ments (typically quintiles of cells by position from posis colon cancer (HNPCC) (Jass et ciL, 1997). bottom to top of crypt (Rozen, 1992). There is only Increased proliferation has also been observed in a weak correlation between the overall labelling normal mucosa of patients with hyperplastic index and the proliferation in the upper crypts polyps (Risio et ciL, 1995). (Bostick et at, 1997a; Risio et at, 1991). Although In some studies, proliferation has been seen to there are differences in the labelling indices gener- increase with age (Paganelli et ai., 1990; Roncucci ated by the various labels, in general they are et al., 1998), but in several large investigations, no highly correlated (Bostick et ai., 1997a; Diebold et age association was seen (Bostick et ai., 1997b; ai., 1992; Earnest et at, 1993; Kubben et at, 1994; Caderni et al., 1999; Keku et al., 1998). In observa- Lacy et ai., 1991; Richter et at, 1992; Weisgerber et tional studies, mucosal proliferation has not been at, 1993). Nonetheless, some investigators have consistently associated with intake of any nutrient found proliferating cell nuclear antigen to be a less (Bostick et al., 1997 b; Caderni et al., 1999; Keku et effective label than others (Bromley et ai., 1996; ai., 1998). However, there have been suggestions Risio et at, 1993). No consistent differences have that high intake of red meat may be associated emerged in proliferation measurements in various with increased proliferation (Bostick etal., 1997 b; segments of the large bowel (Cats et ai., 1991; Caderni et at, 1999). Terpstra et al., 1987). There have been numerous clinical trials of Many studies have demonstrated that colorectal dietary supplementation that studied proliferation carcinomas and adenomas exhibit a higher as an end-point. In one trial, supplementation labelling index than normal-appearing mucosa with wheat bran had no effect on proliferation (Kanemitsu et al., 1985; Risio et ai., 1988, 1993; (overall, or in the upper crypt) (Alberts et ai., 1997), Shpitz et ai., 1997). Moreover, the normal mucosa although in a smaller study (that used crypt cell of individuals with colorectal cancer or colorectal production rate), decreased proliferation was adenomas seems to have higher indices than the reported (Rooney et cil., 1994). In another cross- mucosa of unaffected individuals (Bleiberg et cil., over study, a low-fat diet in association with oat 1985; Lipkin et at, 1987; Paganelli et ai., 1991; bran or wheat bran had no effect on overall Risio et ai., 1991; Roncucci et al., 1991; Stadler et labelling index or proliferation in the upper crypt al., 1988; Terpstra et al., 1987). The proliferative (Macrae et al., 1997). In a five-day study, a high-fat zone also has been observed to shift towards the diet (with much of the fat given as a bolus) was lumen (Ponz de Leon et at, 1988; Risio et al., 1991; associated with a higher overall labelling index Terpstra et at, 1987; Wilson et ai., 1990). A few than a lower-fat diet or a high-fat diet without the studies, however, found no association of prolifer- bolus (Stadler et al., 1988). Fish oil (eicosapen- ation with the presence of adenomas or cancer taenoic and docosahexaenoic acids) decreased pro- (Keku et al., 1998; Jass et ai., 1997; Kashtan et al., liferation both overall and in the upper crypt (Anti 1993; Nakamura et ai., 1995; Wong et al., 1995). et at, 1992, 1994b), and subjects given a fish oil There has been only one published investigation of supplement had lower proliferation than subjects the relationship between proliferative indices and given corn oil (Bartram et al., 1993). In another subsequent neoplasia: high indices were predictive study, only subjects with initially high prolifera- of adenoma recurrence (Anti et ai., 1993). tion had a response to fish oil (Anti et at, 1994b), Although data are not consistent, FAP patients suggesting a component of regression to the mean. may have increased proliferation indices In one investigation, a combination of vitamin (ljeschner & Lipkin, 1975; Lipkin et ai., 1984; Mills A, cr-tocopherol and ascorbic acid reduced prolifer- et al., 1995; Nakamura et al., 1993), and there have ation in the upper crypts (Paganelli et ai., 1992). In been indications of increased proliferation in nor- another study, vitamin C lowered proliferation in mal-appearing mucosa of affected and unaffected all crypt compartments, while p3-carotene (9 mg subjects in other types of high-risk families (Cats et per day for a month) significantly reduced it only al., 1991; Gerdes et ai., 1993; Lipkin et ai., 1984, in the lower parts of the crypt, and a-tocopherol 1985; Lynch etai., 1985; Patchett etat, 1997). One had no effect (Cahill et al., 1993). Another study small study found no evidence of hyperproliferative found that supplementation with 30 mg epithelium in patients with hereditary nonpoly- I-carotene did not affect proliferation in any crypt
119 Biomarkers in Cancer Chemoprevention compartment (Frommel et ai., 1995), although an Rittenbaugh, C., Vargas, P.A., Bhattacharyya, A.B., Earnest, D.L., Sampliner, R.E. and the Phenix Colon analysis, published only in an abstract, indicated a Cancer Prevention Physicians' Network. (2000) Lack of beneficial effect (lower proliferation) in the upper effect of a high-fiber cereal supplement on the recurrence crypt (Macrae et al., 1991). of colorectal adenomas. New Engl. J. Med., 342, Mucosal proliferation has been most intensively 1156-1162 studied with regard to calcium supplementation. Allan, A. & Jewell, D.P. (1983) In vitro model for the Here, the findings are quite mixed, as in the epi- assessment of luminal factors on rectal mucosa. Gut, 24, demiology of carcinoma and adenoma. Some stud- 812-817 ies have shown a decrease in proliferation with cal- Andreyev, H.J., Norman, AR., Cunningham, D., Oates, cium supplementation (Barsoum et al., 1992; J.R. & Clarke, P.A. (1998) Kirsten ras mutations in Bostick et al., 1995; Cats et ai., 1995; Lipkin & patients with colorectal cancer: the multicenter 'RAS- 1992), while Newmark, 1985; Wargovich et ai., CAL" study. J. Nat! Cancer Inst., 90, 675-684 others have shown no effect (Baron et al., 1995b; Anti, M., Marra, G., Armelao, F., Bartoli, G.M., Ficarelli, Bostick et ai., 1993; Stem et al., 1990; Weisgerber et ai., R., Percesepe, A., Dc Vitis, I., Maria, G., Sofo, L., 1996) or even an increase (Gregoire et al., 1989; Rapaccini, G.L., Gentiloni, N., Piccioni, E. & Miggiano, Kleibeuker et al., 1993). Two studies of high versus G. (1992) Effect of omega-3 fatty acids on rectal mucosal low consumption of dairy food also came to differing cell proliferation in subjects at risk for colon cancer. conclusions (Holt et al., 1998; Karagas et al., 1998). Gastroenterology, 103, 883-891 Treatment with NSAIDs, consistently found to Anti, M., Marra, G., Armelao, F., Percesepe, A., Ficarelli, be inversely associated with risk of colorectal can- R., Ricciuto, G.M., Valenti, A., Rapaccini, G.L., 0e Vitis, cer and colorectal adenoma, appears to be unre- I., D'Agostino, G., Brighi, S. & Vecchio, EM. (1993) Rectal lated to mucosal proliferation (Aoki et al., 1996; epithelial cell proliferation patterns as predictors of Earnest et al., 1993; Labayle etaL, 1991; Pasricha et adenomatous colorectal polyp recurrence. Gut, 34, al., 1995; Spagnesi et al., 1994). However, in one 525-530 study of FAP, sulindac lowered the labelling index Anti, M., Marra, G., Percesepe, A., Armelao, F. & (Nugent et al., 1993). Gasbarrini, G. (1994a) Reliability of rectal epithelial The observational epidemiology of large bowel kinetic patterns as an intermediate biomarker of colon mucosal proliferation is not well developed, but cancer, J. Cell. Biochem., Suppl. 19, 68-75 some published findings (NSAIDs, age) have Anti, M., Armelao, F., Marra, G., Percesepe, A., Bartoli, diverged from clinical trial and epidemiological G.M., Palozza, P., Parrella, P., Canetta, C., Gentiloni, N. & findings. However, in clinical trials, the mixed De Vitis, I. (1994b) Effects of different doses of fish oil on findings regarding calcium supplementation could rectal cell proliferation in patients with sporadic colonic be taken to reflect the weak findings in observa- adenomas. Gastroenterology, 107, 1892-1894 tional studies and the mixed epidemiological Aoki, T., Boland, C. & Brenner, D. (1992) Aspirin modu- results. lation of premalignailt biomarkers in rectal mucosa of high-risk subjects. Gastroenterology, 110, A484 References Atkin, W.S., Morson, B.C. & Cuzick, J. (1992) Long-term Ahua, N., Li, Q., Mohan, AL., Baylin, S.B. & Issa, J.P. risk of colorectal cancer after excision of rectosigmoid (1998) Aging and DNA methylation in colorectal mucosa adenomas. New Engl. J. Med., 326, 658-662 and cancer. Cancer Res., 58, 5489-5494 Aubert, H., Treille, C., Faure, H., Fouret, J., Lachet, B. & Alberts, D., Einspahr, J., Ritenbaugh, C., Aickin M., Rees- Rachail, M. (1982) Interêt de la surveillance des malades McGee, S., Atwood, J., Emerson, S., Mason-Liddil, N. polypectomisés dans la prévention du cancer réctocol- Bettinger, L., Pate!, J., Bellapravalu, S., Ramanuam, P.S., ique. A propos de 123 cas. Gas troenterol. Clin. Biol., 6, Phelps, J. & Clark, U. (1997) The effect of wheat bran 183-187 fiber and calcium supplementation on rectal mucosal proliferation rates in patients with resected adenomatous Augenlicht, LH., Richards, C., Corner, G. & Pretlow, T.P. colorectal polyps. Cancer Eptdemiol. Biomarkers Prey., 6, (1996) Evidence for genomic instability in human 161-169 colonic aberrant crypt foci. Oncogene, 12, 17674772 Alberts, D.S., Elena, M., Roe, D.J., Guillen-Rodriguez, Baron, J.A. (1996) Large bowel adenomas: markers of risk J. Cell. Biochem., Suppl., J.M., Marshall, J.R., Leeuwen, J.B.v., Reid, M.E., and endpoints. 25, 142-148
120 Intermediate effect markers for colorectal cancer
Baron, J.A., Wargovich, MJ., Tosteson, T.D., Sandier, R., Bostick, R.M., Potter, J.D., Fosdick, L., Grambsch, P., Haile, R., Summers, R., van Stolk, R., Rothstein, R. & Lampe,J.W., Wood, JR., Louis, T.A., Ganz, R. & Grandits, Weiss, J. (1995a) Epidemiological use of rectal prolifera- G. (1993) Calcium and colorectal epithelial cell tion measures. Cancer Epidemio!. Biomarkers Prev., 4, proliferation: a preliminary randomized, double-blinded, 57-61 placebo-controlled clinical trial. J. Nat! Cancer Inst., 85, Baron, J.A., Tosteson, T.D., Wargovich, MJ., Sandier, R., 132-141 Mandel, J., Bond, J., Haile, R., Summers, R., van Stolk, R., Bostick, R.M., Fosdick, L., Wood, J.R., Grambsch, P., Rothstein, R. & Weiss, J. (1995b) Calcium supplementa- Grandits, G.A., Lillemoe, T.J., Louis, TA. & Potter, J.D. tion and rectal mucosal proliferation: a randomized con- (1995) Calcium and colorectal epithelial cell prolifera- trolled trial. J. Nat! Cancer Inst., 87, 1303-1307 tion in sporadic adenoma patients: a randomized, dou- Barsoum, G.H., Hendrickse, C., Winslet, M.C., Youngs, ble-blinded, placebo-controlled clinical trial. J. Nat! D., Donovan, LA., Neoptolemos, J.P. & Keighley, M.R. Cancer Inst., 87,1307-4315 (1992) Reduction of mucosal crypt cell proliferation in Bostick, R.M., Fosdick, L., Lillemoe, T.J., Overn, P., Wood, patients with colorectal adenomatous polyps by dietary JR., Grambsch, P., Elmer, P. & Potter, J.D. (1997a) calcium supplementation. Br. J. Surg., 79, 581-583 Methodological findings and considerations in measur- Bartram, H.P., Gostner, A., Scheppach, W., Reddy, ES., ing colorectal epithelial cell proliferation in humans. Cancer Epideniio!, Biomarkers Prev., Rao, CV., Dusel, G., Richter, F., Richter, A. & Kasper, H. 6, 931-942 (1993) Effects of fish oil on rectal cell proliferation, Bostick, R.M., Fosdick, L., Grandits, G.A., Lillemoe, T.J., mucosal fatty acids, and prostaglandin E2 release in Wood, J.R., Grambsch, P., Louis, T.A. & Potter, J.D. healthy subjects. Gastroenterology, 105, 1317-1322 (1997b) Colorectal epithelial cell proliferative kinetics and risk factors for colon cancer in sporadic adenoma Bedenne, L., Faivre, J., Boutron, MC., Piard, F., Cauvin, J.M. & Hillon, P. (1992) Adenoma-carcinoma sequence or patients. Cancer Epidemiol. Biomarkers Prev., 6, 1011-1019 "de novo" carcinogenesis? A study of adenoniatous rem- Boutron, M.C., Faivre, J., Marteau, P., Couillault, C., nants in a population-based series of large bowel cancers. Senesse, P. & Quipourt, V. (1996) Calcium, phosphorus, Cancer, 69, 883-888 vitamin D, dairy products and colorectal carcinogene- Benito, E., Stiggelbout, A,, Bosch, EX,, Obrador, A., sis: a French case-control study . Br. J. Cancer, 74, 145-151 Kaldor, J., Mulet, M. & Mufioz, N. (1991) Nutritional fac- tors in colorectal cancer risk: a case-control study in Boutron-Ruault, M.C., Senesse, P., Faivre, J., Couillault, Majorca. lut. J. Cancer, 49, 161-167 C. & Belghiti, C. (1996) Folate and alcohol intakes: Benito, E., Cabeza, E., Moreno, V., Obrador, A. & Bosch, related or independent roles in the adenoma-carcinoma sequence? Nufr. Cancer, F.X. (1993) Diet and colorectal adenomas: a case-control 26, 33 7-346 study in Majorca. mt. J. Cancer, 55, 213-219 Bouzourene, H., Chaubert, P., Seelentag, W., Bosnian, F.T. & Saraga, Bergsma.Kadijk, J.A., van 't Veer, P., Kampman, E. & E. (1999) Aberrant crypt foci in patients with Burema, J. (1996) Calcium does not protect against neoplastic and nonneoplastic colonic disease. Human Pat/wI., 66-71 colorectal neoplasia. Epidemiology, 7, 590-597 30, Bromley, M., Rew, D., Becciolini, A., Biasco, G., Paganelli, G.M., Santucci, R., Brandi, G. & Baizi, M., Barbara, L. (1994) Methodological problems in the use of Chadwick, C., Hewitt, D., Li, Y.Q. & Potten, C.S. (1996) rectal cell proliferation as a biomarker of colorectal can- A comparison of proliferation markers (BrdUrd, Ki-67, PCNA) determined at each cell position in the crypts of cer risk. J. Ce!!. Biochem. Suppl., 19, 55-60 normal human colonie mucosa. Ear. J. Histochern., 40, Bird, R.P. (1995) Role of aberrant crypt foci in under- 89-100 standing the pathogenesis of colon cancer. Cancer Letters, 93,55-71 Bussey, H.J., DeCosse, J.J., Deschner, E.E., Eyers, A.A., Lesser, M.L., Morson, B.C., Ritchie, S.M., Thomson,J.P. & Bleiberg, H., Ruyse, M. & Galand, P. (1985) Cell kinetic Wadsworth, J. (1982) A randomized trial of ascorbic acid indicators of premalignant stages of colorectal cancer. in polyposis cou. Cancer, 50, 1434-1439 Cancer, 56, 124-129 Caderni, G., Palli, D., Lancioni, L., Russo, A., Luceri, C., Boland, CR., Sato, J., Appelman, IHLD., Bresalìer, R.S. & Saieva, C., Trallori, G., Manneschi, L., Renai, F., Zacchi, Feinberg, A.P. (1995) Microallelotyping defines S., Salvadori, M. & Dolara, P. (1999) Dietary determinants the sequence and tempo of allelic losses at tumour of colorectal proliferation in the normal mucosa of suppressor gene loci during colorectal cancer progres- subjects with previous colon adenomas. Cancer sion. Nature Mcd., 1, 902-909 Epidemiol. Biomarkers Prev,, 8, 219-225
121 Biomarkers in Cancer Chernoprevention
Cahill, R.J., O'Sullivan, KR., Mathias, P.M., Beattie, S., Faivre, J., Boutron, M.C., Senesse, P., Couillault, C., Hamilton, H. & O'Morain, C. (1993) Effects of vitamin Belighiti, C. & Meny, B. (1997) Environmental and famil- antioxidant supplementation on cell kinetics of patients ial risk factors in relation to the colorectal adenoma-car- with adenomatous polyps. Gut, 34, 963-967 cinoma sequence: results of a case-control study in Burgundy (France) Eur. J. Cancer Prev., 6, 127-131 Caldas, C., Hahn, SA., Hruban, RH., Redston, MS., Yeo, Cj. & Kern, S.E.I. (1994) Detection of K-ras mutations in Faivre, J., Bonithon-Kopp, C., Kronborg, O., Rath, U. & the stool of patients with pancreatic adenocarcinoma Giacosa, A. (1999) A randomized trial of calcium and and pancreatic ductal hyperplasia. Cancer Res., 54, fiber supplementaOtion in the prevention of recurrence 3568-3573 of colorectal adenomas. A European intervention study. Gastroenterology, 116, A56 Cats, A., DeVries, E.G.E. & l
122 Intermediate effect markers for colorectal cancer
Giovannucci, E., Ascherio, A., Rimm, RB., Colditz, G.A., Hixson, L.J., Fennerty, M.B., Sampliner, R.E. & Garewal, Stampfer, M.J. & Willett, W.C. (1995a) Physical activity, H.S. (1991) Prospective blinded trial of the colonoscopic obesity, and risk for colon cancer and adenoma in men. miss-rate of large colorectal polyps. Gastrointest. Endosc., Ann. list. Med., 122, 327-334 37,125-127 Giovannucci, E., Rimm, E.B., Ascherio, A., Stampfer, M.J., Hoff, G. & Vatn, M. (1985) Epidemiology of polyps in the Colditz, G.A. & Willett, W.C. (1995b) Alcohol, low- rectum and sigmoid colon. Endoscopic evaluation of size methionine-low-folate diets, and risk of colon cancer in and localization of polyps. Scand. J. Gastroenterol., 20, men. 1, Nati Cancer Inst., 87, 265-273 356-360 Giovannucci, E., Stampfer, M.J., Colditz, G.A., Hunter, Hoff, G., Foerster, A., Vatn, MR., Sauar, J. & Larsen, S. Dj., Fuchs, C., Rosner, BA., Speizer, F.E. & Willett, W.C. (1986) Epidemiology of polyps in the rectum and (1998) Multivitamin use, folate, and colon cancer in colon. Recovery and evaluation of unresected polyps Z women in the Nurses' Health Study. Ann. mt. Med., 129, years after detection. Scand. J. GastroenteroL, 21, 517-524 85 3-8 62 Goodlad, RA., Levi, S., Lee, CX, Mandir, N., Hodgson, Hofstad, E., Vatn, M., Larsen, S. & Osnes, M. (1994) H. & Wright, N.A. (1991) Morphometry and cell prolif- Growth of colorectal polyps: recovery and evaluation of eration in endoscopic biopsies: evaluation of a tech- unresected polyps of less than 10 mm, 1 year after detec- nique. Gastroenterology, lOi, 1235-1241 tion. Scand. J. GastroenteroL, 29, 640-645 Grady, W.M., Rajput, A., Myeroff, L., Liu, D,F., Kwon, K., Halt, P.R., Atillasoy, E.0., Gilman, J., Guss, J., Moss, S.F., Willis, J. & Markowitz, S. (1998) Mutation of the type II Newmark, H., Fan, K., Yang, K. & Lipkin, M. (1998) transforming growth factor-beta receptor is coincident Modulation of abnormal colonic epithelial cell prolifer- with the transformation of human colon adenomas to ation and differentiation by low-fat dairy foods: a ran- malignant carcinomas. Cancer Res., 58, 3101-3104 domized controlled trial. J. Am. Med. Ass., 280, Greenberg, E.R., Baron, J.A., Tosteson, T.D., Freeman, 1074-1079 D.H., Jr, Beck, Gj., Bond, J.H., Colacchio, T.A., Coller, Jaramillo, E., Watanabe, M., Slezak, P. & Rubio, C. (1995) J,A., Franki, H.D., Halle, R.W., Mandel, J.S., Nierenberg, Flat neoplastic lesions of the colon and rectum detected D.W., Rothstein, R., Snover, D.C., Stevens, M.H., by high-resolution video endoscopy and chromoscopy. Summers, R.W. & van Stolk, R.W. for the Polyp Gastrontes. Endosc., 42, 114-122 Prevention Study Group (1994) A clinical trial of antiox- Jass, JR., Ajioka, Y., Radojkovic, M., Allison, L.J. & Lane, idant vitamins to prevent colorectal adenoma. Polyp M.R. (1997) Failure to detect colonic mucosal hyperpro- Prevention Study Group, New Engl. 1. Med., 331, 141-447 liferation in mutation positive members of a family with Gregoire, R.C., Stern, H.S., Yeung, K.S., Stadler, J., hereditary non-polyposis colorectal cancer. Histo- Langley, S., Furrer, R. & Bruce, W.R. (1989) Effect of cal- pathology, 30, 201-207 cium supplementation on mucosal cell proliferation in Jen, J., Powell, SM., Papadopoulos, N., Smith, K.J., high risk patients for colon cancer. Gut, 30, 376-382 Hamilton, S.R., Vogelstein, B. & Kinzler, K.W. (1994) Grossman, S., Milos, M.L., Tekawa, I.S. & Jewell, N.P. Molecular determinants of dysplasia in colorectal (1989) Colonoscopic screening of persons with suspected lesions. Cancer Res., 54, 5523-5526 risk factors for colon cancer: II. Past history of colorectal Kampman, E., Giovarmucci, E., van 't Veer, P., Rimm, E., neoplasms. Gastroenterology, 96, 299-306 Stampfer, M.J., Colditz, G.A., Kok, F.J. & Willett, W.C. Hasegawa, Y., Takeda, S., lchll, S., Koizumi, K., (1994) Calcium, vitamin D, dairy foods, and the Maruyama, M., Fujii, A., Ohta, H., Nakajima, T., Okuda, occurrence of colorectal adenomas among men and M., Baba, S. & Nakamura, Y. (1995) Detection of 1<-ras women in two prospective studies. Am. J. EpidemioL, 139, mutations in DNAs isolated from feces of patients with 16-29 colorectal tumors by mutant-allele-specific amplification Kanemitsu, T., Koike, A. & Yamamoto, S. (1985) Study of (MASA) Oncogene, 10, 1441-1445 the cell proliferation kinetics in ulcerative colitis, adeno- Heinen, C.D., Shivapurkar, N., Tang, Z., Groden, J. & matous polyps, and cancer. Cancer, 56, 1094-1098 Alabaster, 0. (1996) Microsatellite instability in aberrant Karagas, M.R., Tosteson, T.D., Greenberg, ER., Rothstein, crypt foci from human colons. CancerRes., 56, 5339-5341 RI., Roebuck, BD., Herrin, M. & Ahnen, D. (1998) Hixson, L.J., Fennerty, M.B., Sampliner, R.E., McGee, D. Effects of milk and milk products on rectal mucosal cell & Garewal, H. (1990) Prospective study of the frequency proliferation in humans. Cancer Epidemiol. Biomarkers and size distribution of polyps missed by colonoscopy. J. Prev., 7, 757-766 Nad Cancer Inst., 82, 1769-1772
123 Biomarkers in Cancer Chemoprevention
Kaslitan, H., Gregoire, R.C., Hay, K. & Stern, H.S. (1993) Lacy, ER., Kuwayama, H., Cowart, K,S., King,J.S., Deutz, Colonic epithelial proliferation indices before and after A.H. & Sistrunk, S. (1991) A rapid, accurate, imrnunohis- colon cancer removal. Cancer Invest., 11, 113-117 tochemical method to label proliferating cells in the Kearney, J., Giovannucci, E., Rimm, LB., Ascherio, A., digestive tract. A comparison with tritiated thymidine. Stampfer, MJ., Colditz, G.A., Wing, A., Kampmars, E. & Gastroenterology, 100, 259-262 Willett, W.C. (1996) Calcium, vitamin D, and dairy foods Lanspa, SJ., Rouse, J., Smyrk, T., Watson, P., Jenkins, J.X. and the occurrence of colon cancer in men. Am. J. & Lynch, H.T. (1992) Epidemiologic characteristics of the EpidemioL, 143, 907-917 flat adenoma of Muto. A prospective study. Dis. Colon Rectum, 35, 543-546 Keku, TO., Galanko, J.A., Murray, S.C., Woosley, J.T. & Sandier, R.S. (1998) Rectal mucosal proliferation, dietary Levin, T.R., Palitz, A., Grossman, S., Conell, C., Finkler, L., factors, and the risk of colorectal adenomas. Cancer Ackerson, L., Rumore, G. & Selby, J.V. (1999) Predicting Epidemiol. Biomarkers Prev., 7, 993-999 advanced proximal colonie neoplasia with screening sig- Kikendall, J.W., Burgess, M., Bowen, P.E. & Walter Reed moidoscopy. J. Am. Med. Ass., 281, 1611-1617 Army Medical Center (1990) Effect of oral beta carotene Lieberman, D.A. & Smith, F.W. (1991) Screening for on recurrence of colonic adenomas. Gastroenterology, 98, colon malignancy with colonoscopy. Am. J. Gastro- A289 enterol., 86, 946-951 Kinzler, K.W. & Vogeistein, B. (1996) Lessons from hered- Lipkin, M. & Newmark, H. (1985) Effect of added dietary itary colorectal cancer. Cell, 87, 159-170 calcium on colonie epithelial-cell proliferation in sub- jects at high risk for familial colonic cancer. New Engl. J. Kleibeuker, J.H., Welberg, J.W., Mulder, NI-1., van der Med., 313, 1381-1384 Meer, R., Cats, A,, Limburg, A.J., Kreumer, W.M., Hardonk, MJ. & de Viles, E.G. (1993) Epithelial cell pro- Lipkin, M., Blattner, W.A., Gardner, E.J., Burt, R.W., liferation in the sigmoid colon of patients with adeno- Lynch, H., Deschner, E., Winawer, S. & Fraumeni, J.F., Jr matous polyps increases during oral calcium supple- (1984) Classification and risk assessment of individuals mentation. Br. J. Cancer, 67, 500-503 with familial polyposis, Gardner's syndrome, and familial non-polyposis colon cancer from ['Hithymidine Knoernschuld, H. (1963) Growth rate and malignant Cancer Res., potential of colonic polyps: early results. Surg. Forum, 14, labeling patterns in colonic epithelial cells. 137 44,4201-4207 Lipkin, M., Uehara, K, Winawer, S., Sanchez, A., Bauer, Konishi, E & Morson, B.C. (1982) Pathology of colo- C., Phillips, R., Lynch, H.T., Blattner, WA. & Fraumeni, rectal adenomas: a colonoscopic survey. J. Clin. PathoL, 35,830-841 J.F., Jr (1985) Seventh-Day Adventist vegetarians have a quiescent proliferative activity in colonic mucosa. Cancer Konstantakos, A.K., Siu, I.M., Pretlow, T.G., Stellato, T.A. Left., 26, 134-144 & Pretlow, T.P. (1996) Human aberrant crypt foci with Lipkin, M., Enker, W.E. & Winawer, SJ. (1987) Tritiated- carcinoma in situ from a patient with sporadic colon thymidine labeling of rectal epithelial cells in 'non-prep' cancer. Gastroenterology, 111, 772-777 biopsies of individuals at increased risk for colonie neD- Kubben, F.J., Peeters-Haesevoets, A., Engels, L.G., Baeten, plasia. Cancer Lett., 37, 153-161 CG., Schutte, B., Arends, J.W., Stockbrugger, R.W. & Blijham, G.H. (1994) Proliferating cell nuclear antigen Loktionov, A., O'Neill, 1K., Silvester, KR., Cummings, (PCNA): a new marker to study human colonic cell pro- J.H., Middleton, S.J. & Miller, R. (1998) Quantitation of DNA from exfoliated colonocytes isolated liferation. Gut, 35, 530-535 from human stool surface as a novel noninvasive Kune, S., Kune, G.A. & Watson, L.F. (1987) Case-control screening test for colorectal cancer. Clin. Cancer Res., 4, study of dietary etiological factors: the Melbourne 337-342 Colorectal Cancer Study. Nutr. Cancer, 9, 2142 Losi, L., Roncucci, L., di Gregorio, C., de Leon, M.P. Kune, GA., Kune, S., Read, A., MacGowan, K., Penfoid, & Benhattar, J. (1996) K-ras and p53 mutations in C. & Watson, L.F. (199 1) Colorectal polyps, diet, alcohol, human colorectal aberrant crypt foci. J. Pathol., 178, and family history of colorectal cancer: a case-control 259-263 study. Nutr. Cancer, 16, 25-30 Lotfi, A.M., Spencer, R.J., listrup, D.M. & Melton, L.J.D. Labayle, D., Fischer, D., Vieth, P., Drouhin, F., Patiente, (1986) Colorectal polyps and the risk of subsequent car- A., Bones, C., Duhamel, O., Trousset, M. &Attali, P. (199 1) cinoma. Mayo Clinic Proc., 61, 337-343 Sulindac causes regression of rectal polyps in familial ade- nomatous polyposis. Gastroenterology, 101, 635-639
124 Intermediate effect markers for coloreclal cancer
Lyles, CM., Sandier, R.S., Keku, TO., Kopper, L.L., of vitamins C and E in the prevention of recurrence of Millikan, R.C., Murray, S.C., Bangdiwala SI. & Ulshen, colorectal polyps. Cancer Res., 48, 4701-4705 M.H. (1994) Reproducibility and variability of the rectal McKeown-Eyssen, G.E., Bright-See, E., Bruce, W.R., mucosal proliferation index using proliferating cell Jazmaji, V., Cohen, L.B., Pappas, S.C. & Saibil, EG. (1994) nuclear antigen immun ohistochemistry. Cancer A randomized trial of a low fat high fibre diet in the Epidemiol. Biomarkers Prev., 3, 597-605 recurrence of colorectal polyps. Toronto Polyp Lynch, H.T., Schuelke, G.S., Kimberling, W.J., Albano, Prevention Group [erratum appears in J. Clin, Epidemiol., WA., Lynch, J.L, Biscone, K.A., Lipkin, ML,, Deschner, 1995, 48(2):i]. J. Clin. EpidemioL, 47, 525-536 E.E., Mikol, YE., Sandberg, A.A. Elston, R.C., Bally- McLellan, RA., Medline, A. & Bird, R.P. (1991) Sequential Wilson, J.E. & Davis, B.S. (1985) Hereditary nonpolypo- analyses of the growth and morphological characteris- sis colorectal cancer (Lynch syndromes I and II) II. tics of aberrant crypt foci: putative preneoplastic lesions. Cancer, Biomarker studies. 56, 939-951 Cancer Res,, 51, 5270-5274 MacLennan, R., Macrae, F., Bain, C., Battistutta, D., McLellan, E.A., Owen, R.A., Stepniewska, K.A., Sheffield, Chapuis, P., Gratten, H., Lambert, J., Newland, R.C., Ngu, J.P. & Lemoine, N.R. (1993) High frequency of K-ras M., Russell A., Ward, M. & Wahlqvist, M.L., the mutations in sporadic colorectal adenomas. Gut, 34, Australian Polyp Prevention Project (1995) Randomized 392-396 trial of intake of fat, fiber, and beta carotene to prevent colorectal adenomas. The Australian Polyp Prevention McShane, L.M., Kulldorff, M., Wargovich, MJ., Woods, Project, J. Nad Cancer inst., 87, 1760-1766 C., Purewal, M., Freedman, L.S., Corte, D.K., Burt, RX, Mateski, DJ., Lawson, M., Lanza, E., O'Brien, B., Lake, Macrae, RA., Hughes, N.R., Bhathal, P.S., Tay, D., Selbie, W., Jr, Moler, J. & Schatzkin, A. (1998) An evaluation of L. & MacLennan, R. (1991) Dietary suppression of rectal rectal mucosal proliferation measure variability sources epithelial cell proliferation. Gastroenterology, 100, A383 in the polyp prevention trial: can we detect informative Macrae, EA., Kilias, D., Sharpe, K., Hughes, N., Young, differences among individuals' proliferation measures G.P. & MacLennan, R. (1994) Rectal epithelial cell pro- amid the noise? Cancer Epidemiol, Biomarkers Prev., 7, liferation: comparison of errors of measurement 605-612 withinter-subject variance. Australian Polyp Mills, S.J., Shepherd, N.A., Hall, P.A., Hastings, A., Prevention Project Investigators. J. Cell. Biochem., Mathers, J.C. & Gunn, A. (1995) Proliferative compart- Suppl., 19, 84-90 ment deregulation in the non-neoplastic colonic epithe- Macrae, EA., Kilias, D., Selbie, L., Abbott, M., Sharpe, K. lium of familial adenomatous polyposts. Gut, 36, & Young G.P. (199 7) Effect of cereal fibre source and pro- 391-394 cessing on rectal epithelial cell proliferation. Gut, 41, Morson, B.C. (1984) The polyp story. Postgrad. Med. J., 239-244 60,820-824 Martinez, M.E. & Willett, W.C. (1998) Calcium, vitamin Muller, AD. & Sonnenberg, A. (1995) Prevention of D, and colorectal cancer: a review of the epidemiologic colorectal cancer by flexible endoscopy and polypec- evidence. CancerEpidemiol. Biomarkers Prev., 7, 163-168 tomy. A case-control study of 32,702 veterans. Ann. lut. Martinez, M.E., Giovannucci, E.L., Coiditz, GA., Med., 123,904-910 Stampfer, MJ., Hunter, D.J., Speizer, & FE., Wing, A. Murakami, R., Tsukuma, H., Kanamori, S., Imanishi, K., Willett, W.C. (1996) Calcium, vitamin D, and the occur- Otani, T., Nakanishi, K., Fujimoto, I. & Oshima, A. (1990) rence of colorectal cancer among women. J. NatI Cancer Natural history of colorectal polyps and the effect of Inst., 88,1375-138Z polypectomy on occurrence of subsequent cancer, mt. j. Martinez, M.E., Maltzman, T,, Marshall, JR., Einspahr, J., Cancer, 46, 159-164 Reid, ME., Sampliner, R., Ahnen, D.J., Hamilton, S.R. & Murray, S.C., Sandler, R.S.., Keku, TO., Lyles, CM., Alberts, D.S. (1999) Risk factors for Ki-ras protooncogene Millikan, R.C., Bangdiwala, S.I., Kupper, L.L., Jiang, W. Cancer Res., mutation in sporadic colorectal adenomas. & Ulshen, M.H. (1995) Comparison of rectal mucosal 59,5181-5185 proliferation measured by proliferating cell nuclear Matek, W., Hermanek, P. & Demling, L. (1986) Is the ade- antigen (PCNA) immunohistochemistry and whole noma-carcinoma sequence contradicted by the differing crypt dissection. Cancer Epidemiol. Biomarkers Prev., 4, location of colorectal adenomas and carcinomas? 715-720 Endoscopy, 18,17-19 Muto, T., Bussey, Hj. & Morson, B.C. (1975) The evolu- McKeown-F.yssen, G., Holloway, C., Jazmaji, V., Bright- tion of cancer of the colon and rectum. Cancer, 36, See, E., Dion, P. & Bruce, W.R. (19 88) A randomized trial 2251-2270
125 Biomarkers in Cancer Chemoprevention
Nakamura, S., Kino, I. & Baba, S. (1993) Nuclear Paganelli, G.M., Blasco, G., Santucci, R., Brandi, G., Lalli, DNA content of isolated crypts of background colonic A.A., Miglioli, M. & Barbara, L. (1991) Rectal cell prolif- mucosa from patients with familial adenomatous eration and colorectal cancer risk level in patients with polyposis and sporadic colorectal cancer. Gut, 34, nonfamilial adenomatous polyps of the large bowel. 1240-1244 Cancer, 68, 2451-2454 Nakamura, S., Goto, J., Kitayama, Y., Sheffield, J.P. & Paganelli, G.M., Blasco, G., Brandi, G., Santucci, R., Gizzi, Talbot, I.C. (1995) Flow cytometric analysis of DNA syn- G., Villani, V., Cianci, M., Miglioli, M. & Barbara, L. thetic phase fraction of the normal appearing colonic (1992) Effect of vitamin A, C, and E supplementation on mucosa in patients with colorectal neoplasms. Gut, 37, rectal cell proliferation in patients with colorectal ade- 398-401 nomas. J. Watt Cancer Inst., 84, 47-51 Nascimbeni, R., Villanacci, V., Mariani, P.P., Di Betta, E., Pasticha, P.J., Bedi, A., O'Connor, K., Rashid, A., Akhtar, Gliirardi, M., Donato, F. & Salerni, B. (1999) Aberrant A.J., Zahurak, ML., Piantadosi, S., Hamilton, S.R. & crypt foci in the human colon: frequency and histologic Giardiello, F.M. (1995) The effects of sulindac on patterns in patients with colorectal cancer or diverticular colorectal proliferation and apoptosis in familial adeno- disease. Am. J. Surg. Pathol., 23, 1256-1263 matous polyposis. Gastroenterology, 110, 994-998 Newcomb, PA., Norfleet, E.G., Storer, B.E., Surawicz, T.S. & Patchett, S.F.., Alstead, EM., Saunders, BI',, Hodgson, S.V. Marcus, P.M. (1992) Screening siginoidoscopy and colorec- & Farthing, M.J. (1997) Regional proliferative patterns in tal cancer mortality. J. Nati Cancer Inst., 84, 1572-1575 the colon of patients at risk for hereditary nonpolyposis Colon Rectum, 40, 168-171 Nicholls, RJ., Springall, R.G. & Gallagher, P. (1988) colorectal cancer. Dis. Regression of rectal adenomas after colectomy and ileo- Peipins, L.A. & Sandier, R.S. (1994) Epidemiology of rectal anastomosis for familial adenomatous polyposis. colorectal adenomas. Epidetniol. Rev., 16, 273-297 Br. Med. J., 296, 1707-1708 Platz, E.A., Giovannucci, E., Rimm, E.B., Rockett, HR., Nollau, P., Moser, C., Weinland, G. & Wagener, C. (1996) Stampfer, MJ., Colditz, G.A. & Willett, W.C. (1997) Detection of K-ras mutations in stools of patients with Dietary fiber and distal colorectal adenoma in men. colorectal cancer by mutant-enriched PCR. lot. J. Cancer, Cancer Epidemiol. Biomarkers Prev., 6, 661-670 66,332-336 Polyak, K., Hamilton, SR., Vogeistein, B. & Kinzler, K.W. Nugent, K.P., Farmer, K.C., Spigelman, A.D., Williams, (1996) Early alteration of cell-cycle-regulated gene C.B. & Phillips, R.K, (1993) Randomized controlled trial expression in colorectal neoplasia. Am. J. Pat/wi., 149, of the effect of sulindac on duodenal and rectal polypo- 381-387 sis and cell proliferation in patients with familial adeno- Ponz de Leon, M., Roncucci, L., Di Donato, P., Tassi, L., matous polyposis. Br. J. Suiy., 80, 1618-1619 Smerieri, O., Amorico, MG., Malagoli, G., De Maria, D., Olivo, S. & Wargovich, MJ. (1998) Inhibition of aberrant Antonioli, A., Chahin, N.J., Perini, M., Rigo, G., crypt foci by chemopreventive agents. In Vivo, 12, Barberini, G., Manenti, A., Blasco, G. & Barbara, L. (1988) 159-466 Pattern of epithelial cell proliferation in colorectal mucosa of normal subjects and of patients with adeno- Otori, K., Sugiyama, K., Hasebe, T., Fukushima, S. & matous polyps or cancer of the large bowel. Cancer Res., Esumi, H. (1995) Emergence of adenomatous aberrant 48,4121-4126 crypt foci (ACF) from hyperplastic ACE with concomi- tant increase in cell proliferation. Cancer Res., 55, Potter, J.D. (1996) Nutrition and colorectal cancer. Cancer 4743-4746 Causes Control, 7, 127-146 Otori, K., Konishi, M., Sugiyama, K., Hasebe, T., Potter, J.D. (1999) Colorectal cancer: molecules and pop- Shimoda, T., Kikuchi-Yanoshita, R., Mukal, K., ulations. J. Nati Cancer Inst., 91, 916-932 Fukushima, S., Miyaki, M. & Esumi, H. (1998) Infrequent Powell, SM., Ziiz, N., Beazer-Barclay, Y., Bryan, T.M., somatic mutation of the adenomatous polyposis cou Hamilton, S.R., Thibodeau, S.N., Vogelstein, B. & Kinzler, gene in aberrant crypt foci of human colon tissue. K.W. (1992) MC mutations occur early during colorectal Cancer, 83, 896-900 tumorigenesis. Nature, 359, 235-237 Owen, D.A. (1996) Flat adenoma, flat carcinoma, and de Pretlow, T.P. (1995) Aberrant crypt foci and K-ras novo carcinoma of the colon. Cancer, 77, 3-6 mutations: earliest recognized players or innocent Paganelli, G.M., Santucci, R., Blasco, G., Miglioli, M. & bystanders in colon carcinogenesis? Gastroenterology, Barbara, L. (1990) Effect of sex and age on rectal cell 108,600-603 renewal in humans, Cancer Left., 53, 117-121
126 Intermediate effect markers for colorectal cancer
Pretlow, TP., O'Riordan, M.A., Pretlow, T.G. & Stellato, in human colon. Cancer Epiderniol, Biomarkers Prev., 1, T.A. (1992) Aberrant crypts in human colonic mucosa: 57-60 putative preneoplastic lesions. J. Cell. Biochem., Suppl., Roncucci, L., Ponz de Leon, M., Scalmati, A., Malagoli, 16G, 55-62 G., Pratissoli, S., Perini, M. & Chahin, N.J. (1988) The Pret1ow, T.P., Brasitus, TA., Fulton, NC., Cheyer, C. & influence of age on colonie epithelial cell proliferation. Kaplan, E.L. (1993) K-ras mutations in putative preneo- Cancer, 62, 2373-2377 plastic lesions in human colon. J. Nat! Cancer Inst., 85, Roncucci, L., Scalmati, A. & Ponz de Leon, M. (1991) 2004-2007 Pattern of cell kinetics in colorectal mucosa of patients Ratto, C., Flamini, G., Sofo, L., Nucera, P., Ippoliti, M., with different types of adenomatous polyps of the large Curigliano, G., Ferretti, G., Sgambato, A., Merico, M., bowel. Cancer, 68,873-878 Doglietto, G.B., Cittadini, A. & Crucitti, F. (1996) Roncucci, L., Modica, S., Pedroni, M., Tamassia, MG., Detection of oncogene mutation from neoplastic colonic Ghidoni, M., Los!, L,, Fante, R., Di Gregorio, C., Manenti, cells exfoliated in feces. Dis. Colon Rectum, 39, 1238-1244 A., Gafa, L. & Ponz de Leon, M. (1998) Aberrant crypt Rex, D.K., Cutler, C.S., Lemmel, G.T., Rahmani, E.Y., foci in patients with colorectal cancer. Br. J. Cancer, 77, Clark, D.W., Helper, D.J., Lehman, GA. & Mark, D.G. 2343-2348 (1997) Colonoscopic miss rates of adenomas determined Rooney, P.S., Hunt, L.M., Clarke, P.A., Gifford, K.A., by back-to-back colonoscopies. Gastroenterology, 112, Hardcastle,J.D. & Armitage, N.C. (1994) Wheat fibre, lac- 24-28 tulose and rectal mucosal proliferation in individuals Richter, F., Richter, A., Yang, K. & Lipkin, M. (1992) Cell with a family history of colorectal cancer. Br. J. Surg., 81, proliferation in rat colon measured with bromo- 1792-1794 deoxyuridine, proliferating cell nuclear antigen, and Rozen, P. (1992) An evaluation of rectal epithelial prolif- Pilithymidine. Cancer Epidemiol. Biomarkers Prev., 1, eration measurement as biomarker of risk for colorectal 561-566 neoplasia and response in intervention studies. Ear. ). Risio, M. (1994) Methodological aspects of using Cancer Prey., 1, 215-224 immunohistochemical cell proliferation biomarkers in Samowitz, WS., Powers, M.D., Spirio, L.N., Nollet, F., van colorectal carcinoma chemoprevention. J. Cell. Biochern., Roy, F. & Slattery, M.L. (1999) Beta-catenin mutations are Suppl., 19, 61-67 more frequent in small colorectal adenomas than in Risio, M., Coverlizza, S., Ferrari, A., Candelaresi, G.L. & larger adenomas and invasive carcinomas. Cancer Res., Rossini, F.P. (1988) Immunohistochemical study of 59,1442-1444 epithelial cell proliferation in hyperplastic polyps, ade- Schatzkin, A., Lanza, E., Corle, D., Lance, P., Iber, F., nomas, and adenocarcinomas of the large bowel. Caan, B., Shike, M., Weissfeld, J., Burt, R., Cooper, M.R., Gastroenterology, 94, 899-906 Kikendall, W., Cahill, J. & Polyp Prevention Trial Study Risio, M., Lipkin, M., Candelaresi, G., Bertone, A., Group (2000) Lack of effect of a low-fat, high-fiber diet Coverlizza, S. & Rossini, F.P. (1991) Correlations between on the recurrence of colorectal adenomas. New Eng!. J. rectal mucosa cell proliferation and the clinical and Med., 342,1149-1155 pathological features of nonfamilial neoplasia of the Schoen, RE., Cone, D., Cranston, L., Weissfeld, J.L., large intestine. Cancer Res., 51, 1917-1921 Lance, P., Burt, R., Iber, F., Shike, M., Kikendall, J.W., Risio, M., Candelaresi, G. & Rossini, F.P. (1993) Hasson, M., Lewin, KJ., Appelman, H.D., Paskett, E., Bromodeoxyuridine uptake and proliferating cell nuclear Selby, J.V., Lanza, R. & Schatzkin, A. (1998) Is antigen expression throughout the colorectal tumor colonoscopy needed for the nonadvanced adenoma sequence. Cancer Epidemiol. Biomarkers Prev., 2, 3 63-36 7 found on sigmoidoscopy? The Polyp Prevention Trial. Risio, M., Arrigoni, A., Pennazio, M., Agostinucci, A., Gastroenterology, 115, 533-541 Spandre, M. & Rossini, EP. (1995) Mucosal cell prolifera- Selby, J.V., Friedman, G.D., Quesenberry, C.P.,Jr & Weiss, tion in patients with hyperplastic colorectal polyps. N.S. (1992) A case-control study of screening sigmoi- Scand. J. Gastroentero!., 30, 344-348 doscopy and mortality from colorectal cancer. New Engl. Roncucci, L. (1992) Early events in human colorectal car- J. Med., 326, 653-657 cinogenesis. Aberrant crypts and microadenoma. flat. J. Shike, M., Al-Sabbach, M.R., Friedman, E., Steephen, A., Gas troenterol., 24, 498-501 Bloch, A., Turtel, P. & Winawer, S.J (1991) The effect of Roncucci, L., Medline, A. & Bruce, W.R. (1991) dietary fat on human colonic cell proliferation. Classification of aberrant crypt foci and microadenomas Gastroenterology, 100, A401
127 Biomarkers in Cancer Chemoprevention
Sbinya, H. & Wolff, W.I. (1979) Morphology, anatomic Stadler, J., Yeung, K.S., Furrer, R., Marcon, N., Himal, H.S. distribution and cancer potential of colonic polyps. Ann. & Bruce, W.R. (1988) Proliferative activity of rectal Surg., 190, 679.-683 mucosa and soluble fecal bile acids in patients with normal colons and in patients with colonic polyps or Shpitz, B., Hay, K., Medline, A., Bruce, W.R., Bull, SB., cancer. Cancer Letters, 38, 315-320 Gallinger, S. & Stern, H. (1996) Natural history of aber- rant crypt foci. A surgical approach. Dis. Colon Rectum, Stern, H.S., Gregoire, R.C., Kashtan, H., Stadler, J. & 39,763-767 Bruce, R.W. (1990) Long-term effects of dietary calcium on risk markers for colon cancer in patients with Shpitz, B., Bornstein, Y., Mekori, Y., Cohen, R., Kaufman, familial polyposis. Surgery, 108, 528-533 Z., Grankin, M. & Bernheim, J. (1997) Proliferating cell nuclear antigen as a marker of cell kinetics in aberrant Stryker, Sj., Wolff, B.G., Gulp, C.E., Libbe, S.D., listrup, crypt foci, hyperplastic polyps, adenomas, and adeno- D.M. & MacCarty, R.L. (1987) Natural history of carcinomas of the human colon. Am. J. Surg., 174, untreated colonic polyps. Gastroenterology, 93, 425-430 1009-1013 Shpitz, B., Bornstein, Y., Mekori, Y., Cohen, R., Kaufman, Takayama, T., Katsuki, S., Takahashi, Y., Oh, M., Noiri, S., Z., Neufeld, D., Galkin, M. & Bernheim, J. (1998) Sakamaki, S., Kato, J., Kogawa, K., Miyake, H. & Niitsu, Y. Aberrant crypt foci in human colons: distribution and (1998) Aberrant crypt foci of the colon as precursors histomorphologic characteristics. Human Patho!., 29, of adenoma and cancer. New Engi. J. Men., 339, 1277-1284 469-475 Terpstra, 0.1., van Blankenstein, M., Dees, J. & Filers Sidransky, D., Tokino, T., Hamilton, S.R., J 128 Intermediate effect markers for colorectal cancer Wargovich, M.J., Isbell, G., Shabot, M., Winn, R., Lanza, R,C., Hornsby-Lewis, L., Gerdes, H., Stewart, E.T., and the F., Hochman, L., Larson, E., Lynch, P., Roubein, L. & National Polyp Study Workgroup (1993) Randomized Levin, B. (1992) Calcium supplementation decreases rec- comparison of surveillance intervals after colonoscopic tal epithelial cell proliferation in subjects with sporadic removal of newly diagnosed adenomatous polyps. The adenoma. Gastroenterology, 103, 92-97 National Polyp Study Workgroup. New Engl. J. Med., 328, Wargovich, M.J., Chen, CD., Jimenez, A., Steele, \T.R., 901-906 Velasco, M., Stephens, L.C., Price, R., Gray, 1<, & IKelloff, Wong, A.J., Kohn, G.J., Schwartz, Hj., Ruebner, B.H. & G.J. (1996) Aberrant crypts as a biomarker for colon Lawson, M.J. (1995) Colorectal cancer and noncancer cancer: evaluation of potential chemopreventive agents patients have similar labeling indices by microscopy and in the rat, Cancer Epidemiol. Biomarkers Prev., 5, 355-3 60 computed image analysis. Human Pathol., 26, 13 29-1332 Weisgerber, U.M., Boeing, H., Nemitz, R., Raedsch, R. & World Cancer Research Fund & American Institute for Waldherr, R. (1993) Proliferation cell nuclear antigen Cancer Research (199 7) Food, Nutrition and the Prevention (clone 19A2) correlates with 5-bromo-2-deoxyuridine of Cancer: a Global Perspective, Washington, DC, labelling in human colonic epithelium. Gut, 34, American Institute for Cancer Research 1587-1592 Yamao, T., Matsumura, Y., Shimada, Y., Moriya, Y., Weisgerber, U.M., Boeing, H., Owen, RX, Waldherr, R., Sugihara, K., Akasu, T., Fujita, S. & Kakizoe, T. (1998) Raedsch, R. & Wahrendorf, J. (1996) Effect of longterm Abnormal expression of CD44 variants in the exfoliated placebo controlled calcium supplementation on sig- cells in the feces of patients with colorectal cancer. moidal cell proliferation in patients with sporadic ade- Gastroenterology, 114, 1333-1335 nomatous polyps. Gut, 38, 396-402 Yamashita, N., Minamoto, T., Ochiai, A. & Onda, M. Welin, S., Youker, J. & Spratt, J. (1963) The rates and pat- (1995) Frequent and characteristic K-ras activation and terns of growth of 375 tumors of the large intestine and absence of p53 protein accumulation in aberrant crypt rectum observed serially by double contrast enema study foci of the colon. Gastroenterology, 108, 434-440 (Malmo technique) Am. J. Roentgenol. Radium Ther. Nue!. Yang, G., Zheng, W., Sun, Q.R., Shu, X.O., Li, W.D., Yu, Med., 90, 6 73-68 7 FL, Shen, G.F., Shen, Y.Z., Potter, J.D. & Zheng, S. (1998) Wilson, R.G., Smith, A.N. & Bird, C.C. (1990) Pathologic features of initial adenomas as predictors for Immunohistochemical detection of abnormal cell prolif- metachronous adenomas of the rectum. J. Nat!. Cancer eration in colonie mucosa of subjects with polyps. J. Clin. Inst., 90,1661-1665 PathoL, 43, 744.747 Zarchy, T.M. & Ershoff, D. (1994) Do characteristics of Winawer, Sj., Zamber, A.G., Ho, MN., O'Brien, M.J., adenomas on flexible sigmoidoscopy predict advanced Gottleib, L.S., Sternberg, S.S., Waye, J.D., Schapiro, M., lesions on baseline colonoscopy? Gastroenterology, 106, Bond, J.H., Panish, J.F., Ackroyd, F., Shike, M., Kurtz, 1501-1504 Corresponding author. J. A. Baron Departments of Medicine, and Community & Family Medicine Dartmouth Hitchcock Medical Center One Medical Center Drive Lebanon NH 03767 USA 129