Recent literature does not identify diverticular disease as a long-term risk factor for colorectal cancer (CCR, 2,3). However, the risk of JRC is increased in the short term after hospitalization related to diverticular disease (4). Evidence on relationship between diverticular disease and other malignancies beyond JRC is scarce to date, but recent studies help clarify this relationship.
Revisions
According to a systematic review and meta-analysis, the prevalence of colorectal cancer is 1.6% in patients with acute diverticulitis undergoing colonoscopy (4).The risk of colorectal cancer after an episode of acute diverticulitis is 44 times higher than in an age- and sex-adjusted reference population. Despite being lower among patients with uncomplicated episode, JRC cancer risk remains 40-fold higher in this subpopulation than in the reference subpopulation (4).
The incidence of early-onset colorectal cancer (EOCRC, in patients <50 years) increased at an alarming rate, at the same time as the overall age-adjusted incidence rate of CCR decreased by 0.92% between 1975 and 2010 (5).
Several factors have been related to EOCRC, including: inflammatory bowel disease, obesity, diet, sedentary lifestyle, alcohol consumption, smoking. In addition to mutations that cause multiple tumors and predisposing syndromes such as hereditary nonpolyposis colon cancer (HNPCC), familial adenomatous polyposis (FAP) and familial CCR.
Diverticular disease is a common condition that can lead to inflammation, perforation, and bleeding of the colon.EOCRC and diverticular disease share many risk factors including obesity, smoking, diet (insufficient fiber, red meat, and high fat), and both are considered prevalent diseases in the Western world. In the United States the incidence of EOCRC progressively increased in patients with and without diverticular disease and was 4-6 times higher among patients with diverticular disease. Young adult patients with pre-existing diverticular disease had a significantly increased risk of EOCRC (5).
The Swedish study
A Swedish study of a population of 75,704 individuals diagnosed with diverticular disease and colorectal histopathology adds original information about cancer risk in these patients. The analysis showed that a diagnosis of diverticular disease was associated with a 33% increase in cancer risk in general (6).
Specific tumors (T) with a higher risk ratio (HR) than the presence of diverticular disease were:
- T.colon (HR = 1.71, 95% CI 1.60-1.82),
- T. of the liver (HR = 1.72, 95% CI 1.41 — 2.10),
- T. of the pancreas (HR = 1.62, 95% CI 1.42 — 1.84)
- T. of the lung (HR = 1.50, 95% CI 1.39 — 1.61)
The association with the JRC was mainly limited to the first year of follow-up, consistent with what has already been described above (2,3,4) and could be related to the misclassification of undiagnosed cancer as diverticular disease (7). The finding of a reduction in the risk of rectal cancer (HR = 0.87, 95% CI = from 0.79 to 0.97) of subjects with diverticular disease compared to reference individuals, is a datum to be investigated taking into account the rare presence of diverticula in the rectum.
The increased risk of malignancy persists long after the diagnosis of diverticular disease and is an element that has encouraged speculation by the authors on their possible biological link, an aspect supported by common lifestyle risk factors, including a diet low in dietary fiber and high intake of red meat, physical inactivity, obesity and smoking, as well as inflammation and alteration of the intestinal microbiota.
Finally, one of the strongest estimates for diverticular disease and the risk of any malignancy was observed among individuals in the younger age group (age 18-29 years; HR = 1.71, 95% CI = 1.17 to 2.50), suggesting the possible role of a potential genetic link.However, the findings do not have immediate practical implications, but stimulate the study of the biological mechanisms underlying the association between diverticular disease and cancer, particularly in non-gastrointestinal cancers.
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