Research

JAMA Oncology | Original Investigation

Preventable Incidence and Mortality of Carcinoma
Associated With Lifestyle Factors Among White Adults
in the United States
Mingyang Song, MD, ScD; Edward Giovannucci, MD, ScD

Editorial page 1131
IMPORTANCE Lifestyle factors are important for cancer development. However, a recent Author Audio Interview
study has been interpreted to suggest that random mutations during stem cell divisions are
the major contributor to human cancer. Supplemental content

CME Quiz at
OBJECTIVE To estimate the proportion of cases and deaths of carcinoma (all cancers except jamanetworkcme.com and
skin, brain, lymphatic, hematologic, and nonfatal prostate malignancies) among whites in the CME Questions page 1247
United States that can be potentially prevented by lifestyle modification.

DESIGN, SETTING, AND PARTICIPANTS This prospective cohort study analyzes cancer and
lifestyle data from the Nurses’ Health Study, the Health Professionals Follow-up Study, and US
national cancer statistics to evaluate associations between lifestyle and cancer incidence and
mortality.

EXPOSURES A healthy lifestyle pattern was defined as never or past smoking (pack-years <5),
no or moderate alcohol drinking (ⱕ1 drink/d for women, ⱕ2 drinks/d for men), BMI of at least
18.5 but lower than 27.5, and weekly aerobic physical activity of at least 75 vigorous-intensity
or 150 moderate-intensity minutes. Participants meeting all 4 of these criteria made up the
low-risk group; all others, the high-risk group.

MAIN OUTCOMES AND MEASURES We calculated the population-attributable risk (PAR) by
comparing incidence and mortality of total and major individual carcinomas between the low-
and high-risk groups. We further assessed the PAR at the national scale by comparing the
low-risk group with the US population.

RESULTS A total of 89 571 women and 46 339 men from 2 cohorts were included in the study:
16 531 women and 11 731 men had a healthy lifestyle pattern (low-risk group), and the
remaining 73 040 women and 34 608 men made up the high-risk group. Within the 2
cohorts, the PARs for incidence and mortality of total carcinoma were 25% and 48% in
women, and 33% and 44% in men, respectively. For individual cancers, the respective PARs
in women and men were 82% and 78% for lung, 29% and 20% for colon and rectum, 30%
and 29% for pancreas, and 36% and 44% for bladder. Similar estimates were obtained for
mortality. The PARs were 4% and 12% for breast cancer incidence and mortality, and 21% for
fatal prostate cancer. Substantially higher PARs were obtained when the low-risk group was Author Affiliations: Clinical and
Translational Epidemiology Unit and
compared with the US population. For example, the PARs in women and men were 41% and
Division of Gastroenterology,
63% for incidence of total carcinoma, and 60% and 59% for colorectal cancer, respectively. Massachusetts General Hospital and
Harvard Medical School, Boston,
CONCLUSIONS AND RELEVANCE A substantial cancer burden may be prevented through Massachusetts (Song); Departments
of Nutrition and Epidemiology,
lifestyle modification. Primary prevention should remain a priority for cancer control. Harvard T.H. Chan School of Public
Health, Boston, Massachusetts (Song,
Giovannucci); Channing Division of
Network Medicine, Department of
Medicine, Harvard Medical School,
Boston, Massachusetts
(Giovannucci).
Corresponding Author: Mingyang
Song, MD, ScD, Bartlett Hall
Extension, 55 Fruit St,
JAMA Oncol. 2016;2(9):1154-1161. doi:10.1001/jamaoncol.2016.0843 Room 906, Boston, MA 02114
Published online May 19, 2016. (msong2@mgh.harvard.edu).

1154 (Reprinted) jamaoncology.com

Copyright 2016 American Medical Association. All rights reserved.

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This finding led some to conclude that only a third of the We identified 16 531 women from the NHS and 11 731 men variation in cancer risk among tissues is attributable to environ. we excluded from all cancers those in the skin.6 mil. obtained from all study participants.5-12 including the notion that external environ.com (Reprinted) JAMA Oncology September 2016 Volume 2. tality of total and major individual carcinomas. cancer deaths can be potentially prevented through lifestyle tality (67. such as UV exposure. pability of lifestyle modification for cancer prevention at the national scale by comparing the low-risk subgroup of our co.5%) during the same period.5.com/pdfaccess. body weight. while most is due low-risk group: (1) never smoking or past smoking (pack- to random mutations arising during stem cell divisions. and (4) weekly aerobic physical activity of at have been made. with 1. Given the concern about jamaoncology. to avoid any influence of reported on biennial questionnaires.9%) has been mod- population. Lifestyle Factors Associated With US Cancer Incidence and Mortality Original Investigation Research C ancer is the second leading cause of death in the United States. style (low-risk group) and those who did not (high-risk group) Chan School of Public Health. The response rates tions.2 However. have been 95. age-standardized to the 2000 US standard can be attributed to lifestyle factors? population. found a high correlation between the number of stem cell di- visions of a given tissue and the lifetime risk of cancer in that tissue. this substantial body Meaning Primary prevention should remain a priority for cancer of knowledge has been challenged by a recent study. we included those with at least 10 cases occur- when we first collected detailed lifestyle data. assessed with regard to the population of US whites. carcinomas. respectively enrolled 121 700 registered female nurses aged 30 to 55 years with about 70% response rate in 1976 and Outcome Ascertainment 51 529 male health professionals aged 40 to 75 years with The primary outcomes of this study were incidence and mor- about 25% response rate in 1986.1 The can. this decline (17.6 million new cancer cases and 0. ≤2 drinks/d for men). infec- frequency questionnaires every 4 years. In the present study. Downloaded From: http://jamanetwork.16 In brief. yet none of these reports has provided ommended by the 2008 Physical Activity Guidelines for original data to assess the preventability of cancer through Americans. Key Points lion cancer deaths projected to occur in 2016. Written informed consent was in 2 nationwide cohorts. view board at Brigham and Women’s Hospital and Harvard T. This study has been widely covered by the press and women.22 Methods which is designed to target food choices and macronutrient Study Population sources associated with reduced chronic disease risk.14. We further explored the potential ca. Height. and the Epidemiologic studies have established several lifestyle observations are potentially applicable to broader segments of the factors that increase cancer risk. ring in our low-risk subpopulation.19 The remaining 73 040 women and 34 608 men modification of extrinsic factors. Because our cohorts’ partici. The Nurses’ Health Study (NHS)14 and Health Professionals Detailed sources of US lifestyle data are provided in the Follow-up Study (HPFS) 15 are 2 ongoing US cohorts that eMethods in the Supplement. Many arguments against the bad luck hypothesis lower than 27. (2) no or moderate alcohol drinking (≤1 drink/d for bad luck. pants completed a detailed questionnaire about their medi. Question How many cancer cases and deaths in the United States cer mortality rate. we estimated the contributions of common life. and exposures to carcinogenic substances.4% in the NHS and 95.20 Alcohol use was self-reported every 4 years on the food frequency questionnaires.9% in the HPFS for each The total carcinomas we studied account for about 90% of all of the questionnaires though 2010.3 However. smoking. and physical inactivity. Similar follow-up proce. lymphatic. from the HPFS who met the 4 healthy lifestyle criteria for the mental factors or inherited predispositions.21 We calculated the overall di- etary score according to the Alternate Healthy Eating Index.18. This study was approved by the institutional re- and mortality between the participants who had a healthy life. US population.H. utes (7. data were classified into the high-risk group (eFigure 1 in the style factors to cancer burden by comparing cancer incidence Supplement). All rights reserved. least 75 vigorous-intensity or 150 moderate-intensity min- mental factors may influence cancer development through pro. about 20% to 40% of cancer cases and about half of est compared with the dramatic decrease in heart disease mor. These figures increased to 40% to 70% when for further efforts in cancer prevention and treatment. irradiation. such as smoking. we cancer deaths among the US white population.5 and ity of cancer. who did not meet all the 4 criteria and had complete lifestyle Therefore.ashx?url=/data/journals/oncology/935700/ by a Universidad de Costa Rica User on 05/03/2017 . (3) BMI of at least 18. we only included whites in the analysis. brain. For individual used as baseline 1980 for the NHS and 1986 for the HPFS. and hematopoietic tissues because these cancers cal history and lifestyle at baseline and every 2 years likely have other strong environmental causes than the ones thereafter. Lifestyle Assessment horts with the US population. For total car- dures have been used in the 2 cohorts. Dietary intake was assessed using validated food considered in the current study. cinoma. alcohol use. Dietary Guidelines for Americans17. obesity. Physical activity was cal- different racial distributions on the comparison with the culated by summing the products of time spent on a variety general population. of leisure-time activities with the average MET for that activity.5 metabolic-equivalent [METs] hours per week). as rec- motion of DNA damage13. so-called years <5). decreased from 199 to 163 per 100 000 between Findings In this cohort study of a portion of the US white 1969 and 2013. and physical activity were self- pants were predominantly whites.4 which control. Number 9 1155 Copyright 2016 American Medical Association. partici. highlighting the need modification. as recommended by the has created confusion for the public regarding the preventabil.

1 46. we selected Table 1 lists the comparison of major lifestyle factors in low- data collected from participants 40 years or older. The number of cases for each groups (<45. Epidemi- ology. Alternative Healthy Eating Index22. Study on comparison within our cohorts and calculated as the dif- physicians.1. and participants who re.5 35. PAR can be interpreted as the proportion of cases that would dex. or end of follow-up (June 1.com/pdfaccess. overdiagnosis for indolent prostate cancer by prostate. as we than our high-risk group. Past vigorous-intensity aerobic physical activity or an equivalent combination.19 recommend that for substantial health population in 2000. and from and high-risk groups of our cohorts and the broader white US 1976 through 2012 for women and from 1986 through 2012 population. dence intervals (CIs) for PAR are provided in the eMethods in the Supplement.5 0. one was estimated by comparing the cancer incidence and mor- sponse to the follow-up questionnaires. a c All variables are age-adjusted based on the age distribution of the US The 2008 federal guidelines18. 2012. for the NHS. All rights reserved. The lifestyle profile in the white US did in our cohort population. All incidence and death rates population was generally even worse than that in our high- were age-standardized to the 2000 US standard population risk group. 80-84.and high-risk cal records to confirm cancer diagnosis. attributable risk (PAR.1 0. body mass index smokers were persons who had smoked at least 100 cigarettes in their lifetime (calculated as weight in kilograms divided by height in meters squared). which included 2 sets: one was based quire their medical records and pathologic reports. risk population.c 100 63 47 100 83 54 BMI. January 31. To parallel the age Results distribution and follow-up time of our cohorts. Comparison of Lifestyle Factors in the Low. 21%-29%) in women up. adults should perform at least 150 minutes (2 hours and 30 minutes) b Smoking and physical activity data in the United States were derived from the a week of moderate-intensity or 75 minutes (1 hour and 15 minutes) a week of National Health Interview Survey. women and 44% [95% CI.and High-Risk Groups and in the US White Population in 2010a Women Men Low-Risk High-Risk US White Low-Risk High-Risk US White Variable Group Group Population Group Group Population Smoking. 44%-53%] in dence analysis.4 39. questionnaire until the age at the date of death.ashx?url=/data/journals/oncology/935700/ by a Universidad de Costa Rica User on 05/03/2017 . mean 48. the follow-up data were avail.27 ity rates and the corresponding PAR estimates for total car- cinomas among the 2 risk groups of our cohorts and the Statistical Analysis whites in the US population. was observed for mortality (48% [95% CI. standard population. tained on biennial questionnaires.7 Abbreviations: AHEI. Number 9 (Reprinted) jamaoncology. follow-up was also censored when a partici. for the HPFS). More than 96% of deaths have been identified using these not occur if all individuals adopted the lifestyle of the low- methods. pant was diagnosed with any of the cancers under study.4 0. 75-79.vs high-risk participant from the age at the date of returning the baseline groups were 463 vs 618 in women.7 1. %b.1 0. For cancer mortality. For cancer inci.7 26. BMI. but no longer smoked at all. National Incidence and Mortality Data We obtained the US cancer incidence25 and mortality26 data from the National Cancer Institute’s Surveillance. 70-74. our low- for men. Although diet was not a specific criterion. 55-59.24 The cause of death was assigned by study physi. The incidence rates of total In our cohorts. 45-49.3 26. Age- specific antigen (PSA) screening. Most of the deaths were groups divided by the rate in the high-risk group.4 AHEI score. Our primary outcome measure was the population- ported a cancer diagnosis were asked for permission to ac. giving rise to a PAR of 25% (95% CI.8 40. mean 23. 60-64. A higher PAR 2012. 2012 (eMethods in the Supplement). The names of persistent nonresponders in the National Death In.5). We also searched the tality in our low-risk group with the national SEER rates. We included only white participants. Research Original Investigation Lifestyle Factors Associated With US Cancer Incidence and Mortality Table 1. 65-69.4 27. whichever came first. ference in the cancer rates between the low. Details about derivation of the 95% confi- cians blinded to exposure data. and 33% (95% CI.com Copyright 2016 American Medical Association. When further 1156 JAMA Oncology September 2016 Volume 2.9 24. risk group had a higher Alternate Healthy Eating Index score able up to 2011. and sex-specific rates were calculated for each of the 10 age tate cancer in our analysis.23 we included only fatal pros. %). median. and 283 vs 425 in men. we calculated person-years of follow-up for each carcinoma per 100 000 population in the low. Downloaded From: http://jamanetwork.4 26. 50-54. using the National Cancer Institute’s SEER*Stat software Table 2 lists the age-standardized incidence and mortal- (version 8. benefits. loss to follow.0 43.4 Alcohol consumption. and ≥85 years) and then standardized to the 2000 US In both cohorts. cancer is provided in eTable 1 in the Supplement. and End Results (SEER) Program. self-reported diagnoses of cancer were ob. drinks/d 0. 28%-38%) in men. %b Never 78 31 66 83 26 54 Past 22 61 18 17 69 25 Current 0 8 16 0 5 21 Met 2008 federal physical activity guidelines. and the other identified through family members or the postal system in re. blinded to exposure information. 39%-48%] in men). reviewed medi.

ashx?url=/data/journals/oncology/935700/ by a Universidad de Costa Rica User on 05/03/2017 . 29% and cavity.com (Reprinted) JAMA Oncology September 2016 Volume 2. and different sources used to derive the relative risk enormous potential of primary prevention for cancer control. a large proportion of cancers are due to environmental fac- ample.3 In contrast.3 pharynx (75% in women and 57% in men). More detailed data are provided in eTable contribute to the variation in cancer incidence across differ- 2 in the Supplement. including differences in environmental factors considered vented. and End Results (SEER) program.30. comparing our low-risk group with the white US population. the estimated PAR ranging from 30% to 50%. breast. we found that countries accompanying the global shifts in lifestyle and overall. b The US rate was obtained from the Surveillance. 27% and 32% for liver. from 10% to 70% of deaths could be pre. which has a much worse lifestyle pattern than approach was often undertaken using the population preva- our cohorts.31 cinoma deaths can be potentially prevented through lifestyle Several previous studies have attempted to quantify the modification. from the literature for each risk factor. varied definitions and prevalence of expo- tance of environmental factors in cancer risk and reinforce the sures.29 Obesity increases risk of cancers in the esopha- oral cavity and pharynx. en. these figures increased to 40% contribution of environmental factors to cancer risk. respectively. pancreas.5% of deaths from the men for mortality. and the national rate divided by the national rate. other cancers. All rates are standardized based on the age distribution of d Calculated as the difference in the cancer rates between the low-risk group the US population in 2000. A gen. Smoking contributed to 48. Nonfatal prostate cancer is groups divided by the rate of the high-risk group. the resultant PARs were further increased. 12 for mortality.4 these influences would be unlikely to explain the wide variation in cancer rates within tissues that have similar lifetime numbers of stem cell divisions or between individuals with different exposure profiles. the PAR rose to 15% for breast cancer incidence and 45% tors and can be prevented by lifestyle modification. Downloaded From: http://jamanetwork. pancreas. Not surprisingly.26 a c Total carcinomas include all cancers other than skin cancer. and 59% in women and 67% in ous cancers. larynx. and probably 21% for endometrial.and high-risk neoplasms of lymphatic and hematopoietic tissues. excluded in men. ovarian and fatal prostate cancer. cohol consumption has been causally related to increased risk Within our cohorts. For colorectal cancer. physical activity has been a dramatic increase for some sites. Number 9 1157 Copyright 2016 American Medical Association. jamaoncology. brain cancer. and liver. Notably. prostate (advanced erally similar PAR was observed for cancer deaths except for only). and and 44% for bladder. Epidemiology. 16% and 38% for gallbladder. pharynx. population-attributable risk.32-34 A classic tion of whites. and gallbladder. Incidence and Mortality Rates of Total Carcinomas in the Low. increases risk of cancers in the ovaries.and High-Risk Groups and in the General US White Population. current study provide strong support for the argument that lation. estimates. esophagus. endometrium. were 82% and 78% for lung. and the Corresponding Estimates of Population Attributable Riska Participants. lence of exposure and the relative risk estimate derived cer deaths could be avoided if Americans adopted the life. For ex. the PARs for incident cancers in women of cancers in several sites. % (95% CI) Low-Risk Low-Risk Group Low-Risk High-Risk US White vs High-Risk vs US White Variable Group Group Populationb Groupsc Populationd Women Incidence 463 618 789 25 (21-29) 41 (39-44) Mortality 132 256 320 48 (44-53) 59 (55-62) Men Incidence 283 425 759 33 (28-38) 63 (60-65) Mortality 156 277 470 44 (39-48) 67 (64-69) Abbreviation: PAR. kidney. 36% and 4% for kidney. These compelling data together with the findings of the When the low-risk group was compared with the US popu. and oral cavity and endometrium. in each study.28 Heavy al- We then assessed individual cancers (Figure 1 and Figure 2). Lifestyle Factors Associated With US Cancer Incidence and Mortality Original Investigation Research Table 2. breast.25.com/pdfaccess. These results provide strong support for the impor. 36% a higher risk of cancers of the lung. and liver. 30% and 29% for pancreas. environmental exposures. 20% to 40% of carcinoma cases and about half of car. or the rapidly Discussion increasing burden of cancer in low.35 Therefore. the PARs increased to 50% Although the stochastic effects of DNA replication error may to 60% in both sexes. colorectum. stomach. 12 smoking-related cancers in the United States. and 62% and gus (adenocarcinoma). and Calculated as the difference in the cancer rates between the low. and possibly to 20% for colon and rectum. The 4 factors considered in the current study are among we obtained a substantially higher PAR: 41% in women and the most prevalent lifestyle factors convincingly linked to vari- 63% in men for incidence. approximately 80% to 90% of lung can.8. with to 70% when assessed with regard to the broader US popula.and middle-income In the 2 cohort studies of US white individuals. kidney in men (48%). All rights reserved. oral and men. No. The PARs were 4% for breast cancer and menopause). per 100 000 PAR. For factors can contribute to the variation in PAR estimates. linked to lower risk of cancers in the colorectum. including breast (12%). including colorectum. several style of the low-risk group. and dometrium (49%). breast (after 66% for esophagus. mainly by quitting smoking. ent tissues.

absence of environmental risk factors do not confer substan- proach of direct comparison of cancer rates between partici.ashx?url=/data/journals/oncology/935700/ by a Universidad de Costa Rica User on 05/03/2017 . In contrast. is not sufficient to account for the observed cancer of relative risk estimates for each individual risk factor asso. studies provide complementary evidence for the predomi- tributions of multiple risk factors that are often difficult. risk. All rights reserved. It also takes account of the joint con. Therefore. estimated by assuming widely different muta- wide cohort studies and circumvents the need for derivation tion rates. This approach relies on demonstrates that accumulation of endogenous stem-cell mu- detailed lifestyle and cancer follow-up data from 2 nation.com/pdfaccess. impossible.37 who com. However. per 100 000 A and B. diet). if not nant role of extrinsic environmental factors in cancer risk. per 100 000 Incidence Rate. Research Original Investigation Lifestyle Factors Associated With US Cancer Incidence and Mortality Figure 1. The PAR estimates are reported as percentages. also important determinants for cancer risk (eg. Cancer Incidence and the Corresponding Population-Attributable Risk (PAR) Estimates in the 2 Study Cohorts and the US White Population A Women B Men 15% 90% Breast 4% Lung 78% [Reference] [Reference] 85% Lung 82% 59% [Reference] Colon and rectum 20% [Reference] 60% Colon and rectum 29% [Reference] 62% Bladder 44% 37% [Reference] Endometrium 21% [Reference] 40% 34% Fatal prostate 21% Ovary 21% [Reference] [Reference] Cancer Site Cancer Site 53% 36% Pancreas 30% Kidney 4% [Reference] [Reference] 49% Bladder 36% 83% Oral cavity and [Reference] 38% pharynx [Reference] 60% Kidney 36% [Reference] 33% Pancreas 29% 58% [Reference] Oral cavity and pharynx 16% [Reference] 71% 61% US population Esophagus 66% US population Esophagus 62% [Reference] High-risk group High-risk group [Reference] Low-risk group Low-risk group 47% 77% Liver 27% Liver 32% [Reference] [Reference] 0 50 100 150 200 250 300 0 40 80 120 160 200 Incidence Rate. our study used the more straightforward ap. tial cancer risk. tation errors. it should be noted that we selected the 4 major certainties about the interactions and complex relationships lifestyle cancer risk factors for characterization of the low- among risk factors. Downloaded From: http://jamanetwork.12 Taken together with our current empirical data. Number 9 (Reprinted) jamaoncology. that study pants with distinct lifestyle profiles. and the low-risk group serves as reference for both the general US white population and the high-risk groups. than to conclude causally that these were the only factors rel- pared US death rates with the lowest reliably observed death evant to cancer risk. we used a less stringent threshold for charac- ing that cell division–related intrinsic risk factors alone in the terization of the low-risk profile to allow for a meaningful 1158 JAMA Oncology September 2016 Volume 2.36 This approach based on direct rather than risk group to show the preventable potential of cancer rather derived data is similar to that used by Doll and Peto. Our results are also consistent with a recent study show. the PARs that we calculated rates in other populations and estimated that about 75% might include contributions from other behaviors that are of US cancer deaths could be attributed to lifestyle and other closely related to the 4 specified lifestyle factors and that are environmental factors. Moreover. the 2 ciated with each cancer. to estimate by the classic approach owing to un.com Copyright 2016 American Medical Association.12 Through mathematical modeling.

the rate of incidence. reduction in cancer mortality was largely due to a reduction in horts in the uptake of screening.40. In women. However. Thus. including though direct comparison with the US data are difficult be- occupational exposures. certain behaviors cause of the differences in assessment methods and time (eg.com (Reprinted) JAMA Oncology September 2016 Volume 2. per 100 000 Mortality Rate. in men argues against a strong influence of better therapy in our PARs may have been overestimated. substantially higher than for incidence (41%). Downloaded From: http://jamanetwork. ized to the 2000 US population. especially con. therefore. the similar them easier access to cancer screening and better treatment op. Al- sidering other factors in the wider population. the up. Number 9 1159 Copyright 2016 American Medical Association. make them more health conscious and give tentially conferring access to better cancer therapy. and early-life exposures. these estimates are generally consistent with the over- tors. especially those in With regard to participants’ health professional status po- the low-risk group.39 all US screening uptake. we did not our low-risk group relative to the general population—the find substantial difference between the 2 risk groups of our co. For example.com/pdfaccess. scopic screening in the high-risk and low-risk groups were 63% tion may be even higher than our estimates. and 68% and 75% in men. per 100 000 A and B. analysis for some less common cancers. used to define normal body weight. additional dietary fac. For breast cancer. and the low-risk group serves as reference for both the general US white population and the high-risk groups. Cancer Mortality and the Corresponding Population-Attributable Risk (PAR) Estimates in the 2 Study Cohorts and the US White Population A Women B Men 45% 90% Breast 12% Lung 77% [Reference] [Reference] 84% Lung 84% 52% [Reference] Colon and rectum 26% [Reference] 59% Colon and rectum 29% [Reference] 58% Bladder 52% 53% [Reference] Endometrium 49% [Reference] 40% 39% Prostate 21% Ovary 29% [Reference] [Reference] Cancer Site Cancer Site 32% 60% Pancreas 26% Kidney 48% [Reference] [Reference] 30% Bladder 38% 71% Oral cavity and [Reference] 57% pharynx [Reference] 44% Kidney 34% [Reference] 28% Pancreas 27% 83% [Reference] Oral cavity and pharynx 75% [Reference] 68% 41% US population Esophagus 55% US population Esophagus 44% [Reference] High-risk group High-risk group [Reference] Low-risk group Low-risk group 50% 72% Liver 33% Liver 28% [Reference] [Reference] 0 20 40 60 80 100 0 40 80 120 160 200 Mortality Rate.5 rather than 25. Lifestyle Factors Associated With US Cancer Incidence and Mortality Original Investigation Research Figure 2. the age-standardized rates in 2010 of ever having lower endo- ventability of cancer that can be achieved by primary preven. For colorectal cancer.38. grounds of the participants in our cohorts. as commonly and 83% in the low-risk group in 2010. unlikely to have a substantial influence on our PAR estimates. frames. Two main jamaoncology. standard. and 70% in women. All rights reserved. PAR estimates for cancer mortality (67%) and incidence (61%) tions than would be true in the general population. infectious agents.41 suggesting that screening is It may be argued that the health professional back. The PAR estimates are reported as percentages. was 78% in the high-risk group per limit for BMI was set at 27. the PAR for mortality (59%) was mammographic screening within the past 2 years. the potential pre. respectively. postmenopausal estrogen use).ashx?url=/data/journals/oncology/935700/ by a Universidad de Costa Rica User on 05/03/2017 .

Willett WC.6(1):49-62. 1984. Arizona. Epidemiology.529(7584):43-47. Tomasetti C. explained by the number of stem cell divisions. registries for their help: Alabama. preparation. South Carolina.S.108(3):djv343. and exercising at a moderate intensity for at cer progression. Wild C. Test North Dakota. Georgia. 2015.338 take responsibility for the integrity of the data and (8765):464-468. et al. Tennessee. Department of Agriculture and U. Texas. Science. Ashford NA. Research Original Investigation Lifestyle Factors Associated With US Cancer Incidence and Mortality factors may have contributed to this difference. Physical 1991. 4. McCullough ML. Cancer Research. analysis. UM1 CA186107. and decision to submit the manuscript physical activity questionnaire for male health for publication. primary prevention should remain a priority rectly (eg. Willett WC. men with healthy lifestyles. by limiting aggressive therapy).314(16):1731-1739. 2010. Washington. we only included whites in our PAR estimates. Rimm EB. 2016. Science. (Giovannucci). Stampfer MJ.0843. Stampfer MJ. Bauman P. risk: role of environment. Straif K. Acquisition. Giovannucci EL. 1160 JAMA Oncology September 2016 Volume 2. Illinois. et al. Study supervision: Giovannucci. Rimm EB. Washington. Stampfer MJ. Lancet. Cancer risk: many professionals. for his assistance with literature. Louisiana. 3. Siegel RL. Intern Med. Spinelli J. 7th ed. California. Dietary Statistical analysis: Song. In conclusion. et al. Plummer M. has a predominant effect that results in a much higher PAR for which may not be generalizable to other ethnic groups. trends in mortality in the United States. Cancer statistics. Stampfer MJ.8(9):762-764. Feskanich D. PAR for mortality than for incidence.347(6223):728. Rhode Island. lung cancer is much more factors in diverse ethnic groups. New York.175(6):959-967. Dummer T. (6223):727. Rimm EB. Department of Nutrition. Colditz GA. et al. The Accepted for Publication: March 9. for Cancer Research. 2015. Washington. management. ARTICLE INFORMATION Pennsylvania. Perspective.42 In addition. et al.43-45 Furthermore. Drafting of the manuscript: Song. Cancer 24. 2015. Gotay C. for his contribution. contributions as well as the following state cancer underlying stem cell divisions? J Natl Cancer Inst. Ohio. Harvard T. Brennan P. Substantial screening: lessons from U. JAMA role in design and conduct of the study. although there could be fatal than breast cancer. the accuracy of the data analysis. Brown HS. Obtained funding: Giovannucci. Bray F. Washington. Am J Clin Nutr. 8.76(6):1261-1271. analysis. 2015. We also thank the participants risk. First. Giovannucci. thus contributing relatively more to the differences in the magnitudes of the associations. Chiuve SE. Cancer risk: 20. Are most cancers caused by men and women: moving toward improved dietary Professionals Follow-up Study for their valuable specific risk factors acting on tissues with high guidance. Colditz G. Indiana. 12. 2. Prospective study of alcohol consumption and risk had full access to all of the data in the study and 2016. Committee Report.347(6217):78-81. maintaining a BMI between survival by causing more aggressive cancers. Leisure time (Giovannucci) and UM1 CA167552. 2015. doi:10. Science. Cancer risk: role of chance overstated. Florida. 2015. Prentice RL. 2015. Downloaded From: http://jamanetwork. 1997. the lifestyle risk factors lower minutes every week.2016. understanding of health among women. Giovannucci. cancer cases and even more deaths among US white indi- tection of early or indolent cancer. Song M. Arem H.S. Jemal A.com Copyright 2016 American Medical Association. 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