Diverticular Disease And Colon Cancer

Does having diverticular disease (DD) increase the risk of colon cancer (CC)?  One expert would say “yes” and another would answer “no”. Much depends on the design of studies, choice of patients, what data is fed into the computer for statistical analysis, interpretation of the results and what opinions and conclusions are made.

Research can be based on the occurrence of the two separate diseases, how many people with DD have CC and how many people with CC have DD (1). Comparison can be made with the levels of CC and DD which would be expected in the general population. Information can be expanded by including different types of cancerous lesions and their position in the colon. The diagnosis of DD is not so stable. Diverticulitis but not diverticulosis was indicated to be in a long-term causal relationship with increased risk of left-sided CC (2). However, these conditions at diagnosis can change. Diverticulitis can revert to diverticulosis with few further problems, or, diverticulosis can later progress to diverticulitis or even further to serious complications. This is a basic problem in DD research. Loffeld et al. (3) found that patients with diverticula had a significantly lower incidence of CC than controls even though they were, on average, 22 years older. On the other hand, researchers in the Netherlands considered a diagnosis of diverticulosis before the age of 60 should be a “red flag” for the initiation of a cancer prevention programme because of increased risk of polyps (4).

Women, but not men, with extensive left-sided diverticulosis were more likely to have advanced neoplasia (5). This might reflect more advanced CC at diagnosis in women (6). The symptoms suggesting CC (7) – diarrhoea, constipation, rectal bleeding, abdominal pain, abdominal mass, anaemia and positive faecal occult blood test (FOB), are similar to some which can be found with DD or even gynaecological problems. Does DD mask the symptoms of CC or does a diagnosis of DD mean different symptoms are not taken seriously because they can be so variable?

Confusion and opinions about the relationship between DD and CC abound. However a majority of reports suggest that people with diverticulosis and uncomplicated diverticulitis had no more risk of CC than that of controls or the general population (8,9). Some patients in hospital with diverticulitis had a lower life-time risk of CC on follow-up (10), while other researchers found an increased risk of CC with complicated diverticulitis (8,11). It does appear that old age and complicated diverticulitis are the most likely conditions to be associated with concomitant CC.

Research has shown that neither bacteria in the colon with DD (12) nor constipation and the use of laxatives (13) have any relevance to the incidence of CC. Low levels of dietary fibre were once considered the cause of CC but this has been disproved (14,15,16). Similarly, recent research disputes the dietary fibre theory on the cause of DD (17,18,19,20). There is interest in colon inflammation with DD increasing the risk of CC as it does with inflammatory bowel disease (IBD) ie. Ulcerative colitis and Crohn’s disease (21). At a microscopic level, pre-cancerous colon structure is different from that found with DD (22) and a study results suggested DD and CC patients were separate groups (1).

DD and CC have the same epidemiology. They are both largely found in the same age group, same countries, same era and in people having the same lifestyle. This epidemiology can be applied to other cancer sites and modern day conditions collectively called “Western diseases”. In the 1970s, these were linked to levels of dietary fibre, but this theory is now in doubt (23). There are as yet fewer cases of DD and CC in Eastern countries. The predominance of DD in the right side colon in Eastern populations produces different symptoms than DD in the sigmoid colon and cancers in different colon sites (24). Nevertheless, DD was not associated with increased risk of CC after the first year of diagnosis in Taiwan (25). A parallel increase in the prevalence of DD and CC in the 20th century in Western countries has been known for some time (12). This was noted by Tsiamoulos et al. (26) who examined preliminary data from 5 years of the English National Bowel Cancer Screening Programme. They found that patients with DD were less likely to have CC than those without DD. Overall, CC was found in 3.4% of colonoscopies and DD in 28%.

Research has been directed to the question of whether DD causes or increases the risk of CC, sometimes the opposite was found. When a decrease was found by Tsiamoulos et al. (26) they introduced the concept that DD “protects” against CC which is difficult to justify. A consideration that something else may be paramount for both conditions also makes an association between DD and CC possible. These and other diseases and cancers follow a similar pattern of increase in the last century, the common associated factor is the smoking of Western cigarettes.

Studies show that cigarette smoking is the predominant cause of CC and dose/effect relationships have been demonstrated (27,28). Women with DD were at a greater risk of perforation or abscess complications if they were smokers (29). This confirmed the results of McGarr et al. (30) who also found the risk of diverticulitis increased by smoking. Other researchers have concluded that smoking increases the risk of complications of DD (31) or that development of complications proceeds more rapidly in smokers (32). Smoking was a significant risk factor for even uncomplicated diverticulosis in a Japanese study (33). That DD might be caused by smoking Western cigarettes has been proposed (34).

Gender, liver enzyme CYP 2A6, cigarette type, East v West countries, position of lesions, are all factors found to affect the relationship between smoking and CC (27,28,35,36,37,38). These same factors were relevant to observations on DD (34). This suggests that DD and CC are two unrelated diseases with a common major cause of cigarette smoking. The risk of development of DD or CC, or neither or both, probably depends on personal genetics and lifestyle factors which might affect the risk. Until the relationship between DD and CC is clarified and confirmed, stopping smoking can only be beneficial for bowel health.

© Mary Griffiths 2014


1         Krones CJ et al. The rare epidemiologic coincidence of diverticular disease and advanced colonic neoplasia. Int J Colorectal Dis. 2006, 21, 18.

2         Stefansson T et al. Association between sigmoid diverticulitis and left-sided colon cancer: a nested, population-based, case control study. Scand J Gastroenterol. 2004, 39, 743.

3         Loffeld RJ et al. Diverticular disease of the colon and concomitant abnormalities in patients undergoing endoscopic evaluation of the large bowel. Colorectal Dis, 2002, 4, 189.

4         Rondagh EJ et al. Diverticulosis and colorectal polyps at younger age: a possible link? Eur J Gastroenterol Hepatol. 2011, 23, 1050.

5         Kieff BJ et al. Is diverticulosis associated with colorectal noeplasia? A cross-sectional colonoscopic study. Am J Gastroenterol. 2004, 99, 2007.

6         Woods SE et al. The influence of gender on colon cancer stage. J Womens Health 2005, 14, 502.

7         Barrett J et al. Pathways to the diagnosis of colorectal cancer: an observational study in three UK cities. Fam Pract. 2006, 23, 15.

8         Brar MS et al. Colonoscopy following nonoperative management of uncomplicated diverticulitis may not be warranted. Dis Colon Rectum. 2013, 56, 1259.

9         Meurs-Szojda MM et al. Diverticulosis and diverticulitis form no risk for polyps and colorectal neoplasia in 4,241 colonoscopies. Int J Colorectal Dis. 2008, 23, 979.

10     Lam TJ et al. There is no increase in the incidence and prevalence of colorectal carcinoma and adenomas in patients with diverticulitis: a retrospective longitudinal study. Colorectal Dis. 2010, 12, 1122.

11     Sharma PV et al. Systematic review and meta-analysis of the role of routine colonic evaluation after radiologically confirmed acute diverticulitis. Ann Surg 2014, 259, 263.

12     Morini S et al. Epithelial cell proliferation of the colonic mucosa in diverticular disease: a case-control study. Aliment Pharmacol Ther 2005, 21, 1385.

13     Dukas L et al. Prospective study of bowel movement, laxative use, and risk of colorectal cancer among women. Am J Epidemiol. 2000, 151, 958.

14     Nakaji S et al. No preventative effect of dietary fibre against colon cancer in the Japanese population: a cross-sectional analysis. Nutr Cancer. 2003, 45, 156.

15     Fuchs CS et al. Dietary fibre and the risk of colorectal cancer and adenoma in women. N Eng J Med. 1999, 340, 169.

16     Park Y et al. Dietary fiber intake and risk of colorectal cancer: a pooled analysis of prospective cohort studies. JAMA. 2005, 294, 2849.

17     Peery AF et al. A high-fiber diet does not protect against asymptomatic diverticulosis. Gastroenterology. 2012 142, 266e1.

18     Strate LL. Diverticulosis and dietary fiber: rethinking the relationship. Gastroenterology. 2012, 142, 205.

19     Maconi G et al. Treatment of diverticular disease of the colon and prevention of acute diverticulitis: a systematic review. Dis Colon Rectum. 2011, 54, 1326.

20     Smith J et al. Should we treat uncomplicated symptomatic diverticular disease with fibre? BMJ 2011, 342, d2951.

21     Morini S et al. Diverticulosis and colorectal cancer: between lights and shadows. J Clin Gastroenterol. 2008, 42, 763.

22     Klinge U et al. Different matrix micro-environments in colon cancer and diverticular disease. Int J Colorectal Dis. 2007, 22, 515.

23     Coffin CS et al. The hot air and cold facts of dietary fibre. Can J Gastroenterol. 2006, 20, 255.

24     Lee KM et al. Clinical significance of colonic diverticulosis associated with bowel symptoms and colon polyp. J Korean Med Sci. 2010, 25, 1323.

25     Huang WY et al. Association between colonic diverticular disease and colorectal cancer: a nationwide population-based study. Clin Gastroenterol Hepatol. 2013, Dec 17. (PMID 24361412).

26     Tsiamoulos ZP et al. Does diverticular disease protect against sigmoid colon cancer? Colorectal Dis. 2014, 16, 70.

27     Tsoi KK et al. Cigarette smoking and the risk of colorectal cancer: a meta-analysis of prospective cohort studies. Clin Gastroenterol Hepatol. 2009, 7, 682.

28     Luchtenborg M et al. Smoking and colorectal cancer: different effects by type of cigarettes? Cancer Epidemiol biomarkers Prev. 2007, 16, 1341.

29     Hjern F et al. Smoking and the risk of diverticular disease in women. Br J Surg. 2011, 98, 997.

30     McGarr S et al. Cigarette smoking increases the risk of infectious complications associated with diverticular disease of the colon. Am J Gastroenterol. 2000, 95, 2543.

31     Papagrigoriadis S et al. Smoking may be associated with complications in diverticular disease. Br J Surg. 1999, 86, 923.

32     Turunen P et al. Smoking increases the incidence of complicated diverticular disease of the sigmoid colon. Scand J Surg. 2010, 99, 14.

33     Nagata N et al. Alcohol and smoking affect risk of uncomplicated diverticulosis in Japan. PLoS One, 2013, 8, e81137.

34     Griffiths M. Cigarette smoking: the cause of diverticular disease? mydiverticulitis.co.uk June 19th 2013.

35     Parajuli R et al. The increased risk of colon cancer due to cigarette smoking may be greater in women than men. Cancer Epidemiol Biomarkers Prev. 2013, 22, 862.

36     Sweeny C et al. Novel markers of susceptibility to carcinogens in diet: associations with colorectal cancer. Toxicology. 2002, 181-182, 83.

37     Wakai K et al. Smoking and colorectal cancer in a non-Western population: a prospective cohort study in Japan. J Epidemiol. 2003, 13, 323.

38     Zhao J et al. Tobacco smoking and colorectal cancer: a population-based case-control study in Newfoundland and Labrador. Can J Public Health. 2010, 101, 281.

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