protective effect was largely related to less ferment-
able and more insoluble fibers, especially wheat bran.
However, a recent prospective study found a reduced
risk of distal colon adenoma with increasing intake of
fiber from fruit but not cereals or vegetables. This
result suggests that soluble fiber is more protective.
0019 Studies in humans have not yet provided a convin-
cing answer as to whether or not fiber is truly protect-
ive. In the Health Professionals Follow-up Study, a
large prospective cohort trial, dietary fiber was in-
versely associated with a risk of developing colorectal
adenomas in men, and all sources of fiber were asso-
ciated with a decreased risk of adenoma. However,
data from the Nurses’ Health Study, a parallel study
in women by the same investigators, failed to indicate
any protective effect of dietary fiber on the develop-
ment of colorectal cancer. A subsequent analysis of
the latter cohort, with 10 additional years of follow-
up and more thorough adjustment for confounding
factors, also showed no protective effect in women
with regard to adenomas or cancer. These large
prospective epidemiologic studies raise the question
as to whether the protective effect of dietary fiber
against colorectal cancer may be a gender-specific
phenomenon.
0020 A few human intervention trials have demon-
strated that wheat-bran supplementation favorably
alters a number of biomarkers related to the risk of
colorectal cancer, including fecal mutagenecity, fecal
secondary bile acids, and rectal cell proliferation.
However, two recent well-performed trials which
utilized the most widely accepted intermediary bio-
marker of colon cancer, development of adenomatous
polyps, have both yielded negative results: neither a
daily dietary supplement containing 13.5 g of wheat
bran fiber nor a low-fat, high-fiber diet over 3–4 years
reduced the incidence of recurrent adenomas. The
results of these two recent studies strongly suggest
that dietary supplementation of fiber is not an effect-
ive chemopreventive strategy for the prevention of
colorectal adenoma recurrence. Nevertheless, the
results of these two trials should not be construed as
definitive evidence that fiber is ineffective: the follow-
up in these trials was relatively brief, and the research
question that was addressed (adenoma prevention) is
related, but not identical, to the question of cancer
prevention.
Antioxidant Nutrients
0021 The antioxidant micronutrients, including vitamin A,
carotenoids, vitamin C, vitamin E, selenium, zinc,
copper, and manganese, are part of the body’s defense
against free radicals and reactive oxygen species.
These antioxidants are thought to possibly convey
protective effects against a number of chronic degen-
erative diseases through a host of different mechan-
isms. In some animal studies, vitamins A, C, and E
have been shown to have a direct inhibitory effect on
tumor growth and damage to both cellular mem-
branes and DNA. However, the epidemiologic litera-
ture for the protective effect of antioxidant vitamins
in colorectal cancer has little in the way of a consen-
sus. Although early clinical intervention trials sug-
gested a possible preventive role for vitamin E, two
recent prospective randomized trials with a more
definitive endpoint (adenoma recurrence) have shown
no benefit.
0022Selenium is an essential trace mineral found in
cereal grains and seafood. Epidemiologic studies in-
dicate an increased incidence of colorectal cancer in
humans in geographic regions where selenium levels
are low in the soil and a lower mortality rate of color-
ectal cancer in areas with high soil selenium levels.
The selenium content of foods is determined by the
soil in which the food is grown, so assessment of
individual dietary intakes using a food content data-
base is of limited value. Results from one study indi-
cate that patients with low plasma selenium levels are
at four times the risk for colorectal adenomas. Selen-
ium may alter carcinogen metabolism, affect immune
function, protect against oxidant stress, inhibit cell
proliferation, and impair tumor metabolism. The
most compelling data to data are from a randomized,
placebo-controlled intervention trial, where daily
supplementation of 200 mg of selenium reduced the
incidence of colorectal cancer by 60%.
Folate
0023Findings from animal and epidemiologic studies indi-
cate that decreased dietary intake of folate or reduced
serum or RBC folate levels increases the incidence of
colorectal cancer and adenomas. This relationship is
underscored in patients with ulcerative colitis, where
folate deficiency is commonly induced by increased
requirements related to the high turnover of the
colonic epithelium, reduced oral intake of nutritious
diets, and reduced intestinal absorption resulting
from competitive inhibition of folate absorption due
to sulfasalazine. Two case-control studies found that
folate intake may protect against neoplasia in ulcera-
tive colitis, and the overwhelming consensus of over
15 epidemiologic studies in the general population
suggests folate is equally protective in sporadic colo-
rectal cancer. Results from a recent follow-up of the
Nurses’ Health Study confirmed that colorectal
cancer risk was reduced with increased folate intake,
as had previously been shown with adenoma recur-
rence. Interestingly, the study suggested that more
1546 COLON/Cancer of the Colon