Résumé
Objectifs
De nombreuses recommandations sur le suivi après polypectomie ou sur la surveillance des maladies inflammatoires chroniques intestinales (MICI) sont disponibles. À côté du risque conféré par les antécédents familiaux, ou l’acromégalie reconnus en 2004 par l’Anaes, d’autres facteurs sont susceptibles d’augmenter le risque de néoplasie colorectale. Leur connaissance permet d’aider à évaluer et à individualiser le niveau de risque individuel de chaque patient pour porter, si besoin, l’indication d’une coloscopie.
Méthodes
Nous avons revu les méta-analyses publiées depuis 2004 dans Pubmed ou Embase database sur le risque de néoplasie colorectale : cancer colorectal (CCR) et adénome colorectal (ACR). Nous avons uniquement extrait les résultats avec un risque relatif (RR) significatif (IC 95 % supérieur ou inférieur à 1) et considéré comme ayant un impact clinique si ce RR était supérieur ou égal à 1,5. Cette revue a concerné les méta-analyses publiées depuis janvier 2004 jusqu’à janvier 2014 en excluant, parmi les 97 études, 5 méta-analyses sur le facteur « antécédent familial ».
Résultats
Parmi les 92 méta-analyses publiées en dix ans, les facteurs de risque significatifs sont : 1) l’obésité, facteur de risque de CCR plus marqué chez l’homme que chez la femme et qui augmente également le risque d’ACR de 24 à 39 % ; 2) le diabète qui augmente le risque de CCR, plus nettement chez l’homme que chez la femme alors que son traitement, particulièrement par la metformine, diminue ce risque ; 3) le tabagisme présent ou passé qui augmente le risque de CCR comme celui d’ACR surtout pour les gros fumeurs (≥ 20 paquets-année) ; 4) l’infection par Helicobacter pylori qui est associée à une augmentation du risque de CCR et d’ACR, mais le lien entre les adénomes proximaux et les souches CAG-positif peut expliquer certaines différences ; 5) la diététique, avec une diminution du risque de CCR chez les consommateurs de fruits et légumes et dans une moindre mesure chez les forts consommateurs de café ou de produits laitiers, alors que ce risque augmente significativement mais faiblement chez les consommateurs de viande rouge ou grillée ainsi que celle modérée ou forte d’alcool ; les autres aliments étudiés dans ces méta-analyses (magnésium, acide gras n-3, folate, vitamine B6, antioxydant et bêtacarotènes) n’ont pas d’impact sur le risque de CCR ou d’ACR ; 6) les médicaments, avec un rôle protecteur confirmé par cinq méta-analyses pour les biphosphonates, deux pour les statines, deux pour les estroprogestatifs et une pour l’aspirine, l’insulinothérapie augmentant le risque ; 7) la sédentarité est un facteur de cancer colique mais pas rectal dans deux méta-analyses.
Conclusion
Les facteurs de risque environnementaux sont nombreux et ont été pour beaucoup confirmés par des métaanalyses avec un risque augmenté de façon significative mais modérée (RR entre 1,2 et 1,8). Ces facteurs doivent être considérés même si à eux seuls ils ne peuvent définir un groupe à risque élevé de CCR pour être combinés et déterminer le risque individuel de CCR ainsi que la méthode de dépistage utilisée, en particulier la coloscopie de prévention.
Abstract
Aims
There are numerous guidelines regarding post-polypectomy follow-up and the monitoring of CIBD available. As well as the risk due to a family history of the condition or acromegaly, which was recognised in 2004 by ANAES (French National Agency for Accreditation and Healthcare Assessment), other factors are likely to increase the risk of colorectal neoplasia. Knowledge provides help in assessing and personalising the level of individual risk for each patient in order to indicate a colonoscopy if required.
Methods
We have reviewed the meta-analysis published since 2004 in the Pubmed and Embase databases on the risk of colorectal neoplasia: colorectal cancer (CRC) and colorectal adenoma (CRA). We have only extracted the results with a significant relative risk (RR) (CI 95% greater than or less than 1) and considered as having a clinical impact if this RR was ≥ 1.5. This review concerned the meta-analyses published since January 2004 and up to January 2014, excluding 5 meta-analyses on the “family history” factor among 97 studies.
Results
From the 92 meta-analyses published over the 10 years, the significant risk factors are: 1) obesity, with the risk factor for CRC more marked in men than in women. Obesity also increases the risk of CRA from 24% to 39%; 2) diabetes increases the risk of CRC, more so for men than for women however, its treatment, especially with metformin, reduces this risk; 3) current or past smoking increases both the risk of CRC and CRA, especially in those who are heavy smokers (≥ 20 packet-years); 4) infection with Helicobacter pylori is associated with an increase in the risk of CRC and CRA, however the link between proximal adenoma and CagA-positive strains may explain some of the differences; 5) diet, with a reduction in the risk of CRC in those who consume plenty of fruit and vegetables and to a lesser extent in those who consume large amounts of coffee or dairy products, while this risk increases significantly but slightly for consumers of red or grilled meat as well as those with moderate to high levels of alcohol consumption; other nutritional components studied in these meta-analyses (magnesium, n-3 fatty acid, vitamin B6, antioxidants and beta-carotenes) did not have an impact on the risk of CRC or CRA; 6) medication, with a protective role confirmed by five meta-analyses for bisphosphonates, two for statins, two for combined oestrogen and progestogens and one for aspirin with insulin therapy increasing the risk; 7) A sedentary lifestyle is a factor in colon cancer, however not for rectal cancer in two meta-analyses
Conclusion
There are numerous environmental risk factors and, for many, these have been confirmed through the metaanalyses, with a significant but moderate increased risk (RR between 1.2 and 1.8). These factors should be considered even if on their own they cannot define a group at an elevated risk of CRC, they can be combined in order to determine the individual risk of CRC as well as the screening method used, in particular preventive colonoscopy.
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Heresbach, D., Bulois, P. Risque de néoplasie colorectale, comorbidités et facteurs environnementaux. Faut-il revoir les recommandations de dépistage en 2014 ?. Acta Endosc 44, 240–257 (2014). https://doi.org/10.1007/s10190-014-0401-1
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DOI: https://doi.org/10.1007/s10190-014-0401-1