Mediterranean Diet and Cancer: Meta-Analysis

Nicole DiMaio
Abstract
This research document was performed to combine the findings of multiple
studies in order to form a conclusive argument and evidence for the role of the
Mediterranean diet in the reduction of cancer risk. This was done by finding peerreviewed articles showing studies that had linked cancer and the Mediterranean
diet in some way. The findings of each article were combined in order to form a
clear conclusion on the topic. It was concluded that strict adherence to the
Mediterranean diet was a statistically significant way to reduce the risk of cancer.
Cancers that were considered include breast, pancreatic, prostate, colorectal, and
aerodigestive cancers. Counterarguments for this conclusion were evaluated and
found, with proof from credited studies, to have reached the conclusion against
reduced risk because of insufficient research data.
Mediterranean Diet and Cancer
The Mediterranean diet has been a topic of dispute among nutritionist. Yes, a
diet high in vegetables and fruits is nutritious, but how much does it affect overall
health? Does the diet have measurable benefits, such as prevention from cancer, or
cancer relapse?
There has been evidence found both supporting and supposedly denying the
diets ability to reduce cancer, but no conclusive data analysis has proven that the
diet does in fact help to reduce it. This dispute over the actual, clinical effectiveness

of the diet will be resolved by evaluating the findings of different studies to

determine the overall risk-reducing value of the Mediterranean diet.
Parameters of the Studies and the Diet
In order to ensure consistency in the arguments, the studies that will be
looked at consider the Mediterranean diet to consist of a high amount of vegetables,
fruits and legumes, some cereals, fish, olive oil and white meat, and limited dairy.
Some studies will be used that also factor in a small amount of red wine.
Each of the studies created a scale to measure each participants level of
adherence to the diet. The studies that looked at breast cancer factored in only
women, by the nature of the disease, but the others looked at both men and women
in both Mediterranean countries and non-Mediterranean countries. Therefore, the
studies focused on people who both followed the diet their whole lives and switched
to the diet later in life.
The risk of cancer was quantified using the number of incidences of and
deaths from the disease of interest in each of the participant categories, such as age
or level of adherence to the diet, throughout the time of the study. This was made
into a proportion out of the total number of participants.
Inconclusive Overall Data: Breast Cancer
Evidence against the effectiveness of the diet in reducing disease risk does in
fact exist, but is particular to a specific disease or only certain groups of people
susceptible to the disease. The studies found that show supposed evidence against
the effectiveness of the diet also often showed patterns linking the diet to reduced
risk, but these trends were not statistically significant. Therefore, the data could not

be considered even though an inverse relationship between disease incidence and

adherence to the diet was seen.
One of these studies performed found that the degree of adoption of the
Mediterranean diet was inversely related to risk of breast cancer in postmenopausal
women, but there was not for premenopausal women. This study included women
who followed the Mediterranean diet at varying levels, which were scored and
accounted for in the data. These women were from a number of European countries,
including Denmark, France, Germany, Greece, Holland, Italy, Norway, the United
Kingdom, Spain, and Sweden. The variety of locations of women provided
information from both women who changed to the diet and those who followed it
their whole lives. The diet also excluded alcohol, but included the other elements of
the diet as previously described.
The association of the diet with breast cancer did not show a strong
decreased probability, finding only a six percent decrease in overall cancer risk in
women, and seven percent in postmenopausal women. A significant risk reduction,
though, was found in postmenopausal women, reducing occurrences of receptornegative tumors by twenty percent (Buckland et al, 2013).
Similar findings were discovered in a study performed on Mediterranean
women specifically, where it was found that increased adherence to the diet had no
overall effect on risk of the entire populations considered for the 9.8-year study, but
a slight decreased risk in specifically postmenopausal women. The women studied
went through a similar screening in which their adherence to the diet was evaluated

and compared to their risk of breast cancer, and no correlation was found overall,
except in postmenopausal women by (Trichopoulou, 2010).
The first study, by Buckland et al (2013), is an example of a study in which,
statistically speaking, the Mediterranean diet did not have any effect on occurrence
of breast cancer except in the case of postmenopausal women, especially with
receptor negative tumors. But, this study did show a trend of decreased risk of
breast cancer in women overall, by six percent, and postmenopausal women, by
seven percent.
The second study, by Trichopulou (2010), supports this data, also showing
that there is not a statistically significant risk difference between premenopausal
women who eat according to the diet and those who do not, but that there is a
decrease in postmenopausal women. A summary of the findings of these studies can
be found in Table 1.
Table 1. Primary Breast Cancer Findings
Buckland et al (2013)
Women Overall
6% decrease
Premenopausal Women No significant difference
Postmenopausal
7% overall
Women
20% in receptor-negative
tumors

Trichopulou (2010)
No significant decrease
No significant decrease
10% decrease

Accounting for Lack of Support in Breast Cancer Studies

Overall, the research found which did not fully link strict adherence to the
Mediterranean diet to reduced cancer risks showed reduced occurrences of breast
cancer in only postmenopausal women. Though the results did not show significant

findings in premenopausal women, the trend of decreased risk in the first study,
Buckland et al 2013, showed that women in general do experience a slight decrease.
Further research was done on premenopausal women and breast cancer in
order to account for the inconclusive data found in that particular group. The
inclusion of premenopausal women in the studies is important in getting results that
cross categories of possible victims, but their inclusion could be causing the
inconclusive results. Each of the studies looked at postmenopausal women, where
most breast cancer diagnoses occur, meaning that breast cancer in premenopausal
women is rare. It would be expected that since premenopausal women have lower
risks of breast cancer, overall, the studies would have shown the opposite results.
These opposing results could have been found because each of the studies screened
women with genetic risk factors for breast cancer. Factoring this information into
the studies, the higher presence of breast cancer in the premenopausal women
could have occurred, despite the diet, because of their high genetic risk of the
disease. Upon further research, the majority of premenopausal women who do have
breast cancer have a very large genetic predisposition for the disease (Motion et al
2014). Women with a genetic predisposition for breast cancer who come through
menopause without the disease could have some other factors helping to prevent its
occurrence that are enhanced by the Mediterranean diet, while the diet cannot
overcome the large obstacle of genetic predisposition in the premenopausal, at-risk,
women.
Schwingshackl et al. (2014) Meta-Analysis

Research found that supported the reduced risk of cancer with a strict
adherence to the Mediterranean diet included studies of gastric cancer and two
articles that combined findings from different studies, analyzing many cancers.
One of these articles combined findings of twenty-one different studies,
considered mortality from cancer overall, and specifically colorectal, breast,
prostate, gastric, aerodigestive, and pancreatic cancers. There was found to be a
statistically significant decreased risk of any mortality from cancer (10%), colorectal
cancer (14%), prostate cancer (4%), and aerodigestive (56%) cancer. There was not
a significant decrease found in gastric, breast, or pancreatic cancer. A summary of
these findings with specific percentages can be found in Table 2. The experimenters
noted a necessity for more research in the areas of breast, gastric, and pancreatic
cancers because decreased risks were found, but the trends were not statistically
significant (Schwingshackl et al 2014).
Table 2. Schwingshackl et al. Study
Cancer Form
Cancer Risk Overall (any form)
Colorectal
Breast
Prostate
Gastric
Aerodigestive
Pancreatic

Effect of Diet on Risk

10% decrease
14% decrease
No significant decrease
4% decrease
No significant decrease
56% decrease
No significant decrease

Accounting for Discrepancies in Schwingshackl et al. (2014)

Other studies were sought out that would account for the necessary further
investigation into gastric, breast and pancreatic cancers described in the
Schwingshackl article.

Gastric Cancer
First, a study on gastric cancer was found which examined Italian men and
women with varying levels of adherence to the Mediterranean diet. This varying
observance was measured according to nine different food items: vegetables, fruits,
legumes, cereals or potatoes, meat and processed meat, milk or dairy products, fish,
and alcohol intake. Each individual dietary component was studied separately and it
was found that incidences of cancer were inversely related to high consumption of
vegetables, fruits, legumes, fish, and moderate alcohol intake. The other
components, dairy products, cereals, and meats, in high consumption, were found to
be directly proportional to risk of gastric cancer. Since the Mediterranean diet
necessitates a low intake of those dietary components directly related to cancer risk
and a high intake of those that are inversely related to cancer risk, it was found that
if this Italian population shifted to high adherence to the Mediterranean diet, twenty
percent of all gastric cancers would be avoided (Praud et al 2012).
Breast Cancer
Due to the lack of sufficient findings of the effect of diet adherence on breast
cancer, a study with more conclusive evidence about the reduced risk in that
particular disease was found. The experimenters focused on one important aspect of
the Mediterranean diet, extra virgin olive oil. It was found that, with a diet rich in
extra virgin olive oil, the aggressiveness of breast cancer tumors drastically
decreased. The oil affected the tumor cells by changing their membrane
compositions, signaling abilities, and lowering the DNA damage present (Escrich et
al 2011).

Pancreatic Cancer
Finally, evidence in favor of reduced risk for pancreatic cancer was found in a
study done on men and women in Italy. It was found that, as with other studies,
increased adherence to the diet was inversely related to the risk of cancer. The
experimenters hypothesized that the parts of the diet that most affected this risk
decline were the high amount of fruits and vegetables due to their increased levels
of vitamin C, folate, and phenolic compounds. Extra virgin olive oil was also
considered to be another important component, with its high amount of
antioxidants and vitamin E. Red meat has been found to play a large role in
pancreatic cancer, so the low amount of meat and presence of only white meat and
fish, adds another beneficial aspect to the Mediterranean diet. The intake of these
many beneficial factors as a part of this diet confer with findings of a seventeen
percent decreased occurrence of pancreatic cancer in this study (Boscetti et al
2013).
A summary of the findings showing sufficient evidence for the reduced risk of
gastric, breast, and pancreatic cancers can be found in Table 3.
Table 3. Gastric, Breast, and Pancreatic Cancer
Cancer Form
Risk Reduction
Gastric
20% decrease
Breast
Decreased tumor aggressiveness
Pancreatic
17% decrease

Conclusions
Though studies were conducted that did not provide sufficient evidence for
the reduced risk in breast cancer, especially in premenopausal women, further

investigation found that there in fact is a reduced risk in all women, especially with
moderate consumption of extra virgin olive oil (Escrich et al 2011). The same
benefits came with the further research into gastric and pancreatic cancers, both of
which were found to have significant reduced risk with the diet in citizens of Italy
(Boscetti et al 2013) (Praud et al 2012). The findings with contrary data, against the
benefits of the Mediterranean diet, were found to have come to these conclusions
because of a lack of sufficient research, as determined by research proving
otherwise. With the combined effort of the many researchers represented in the
studies referenced, it has been found that the Mediterranean diet, high in fruits,
vegetables, and olive oil, and low in meat and alcohol, is a statistically significant
means to reduce risk of cancer.

Literature Cited
Buckland, G., Travier, N., Cottet, V., Gonzalez, C. a, Lujan-Barroso, L., Agudo, A.,
Riboli, E. (2013). Adherence to the mediterranean diet and risk of breast cancer
in the European prospective investigation into cancer and nutrition cohort
study. [Miscellaneous Article]. International Journal Of Cancer June, 132(12),
29182927. doi:10.1002/ijc.27958
Trichopoulou, A., Bamia, C., Lagiou, P., & Trichopoulos, D. (2010). Conformity to
traditional Mediterranean diet and breast cancer risk in the Greek EPIC
(European Prospective Investigation into Cancer and Nutrition) cohort. The
American Journal of Clinical Nutrition, 92(3), 6205.
doi:10.3945/ajcn.2010.29619
Motion, J., Ashcroft, L., Dowsett, M., Cuzick J., Hickman, J., ... Howell, A. (2012) The
RAZOR trial: a phase II prevention trial of screening plus goserilin and
raloxifene versus screening alone in pre-menopausal women at increased risk
of breast cancer. Cancer Research 72(24) doi: 10.1158/0008-5472.SABCS12P1-09-05
Schwingshackl, L., & Hoffmann, G. (2014). Adherence to Mediterranean diet and risk
of cancer: a systematic review and meta-analysis of observational studies.
International Journal of Cancer. Journal International Du Cancer, 135(8), 1884
97. doi:10.1002/ijc.28824
Praud, D., Bertuccio, P., Bosetti, C., Turati, F., Ferraroni, M., & La Vecchia, C. (2014).
Adherence to the Mediterranean diet and gastric cancer risk in Italy.
International Journal of Cancer. Journal International Du Cancer, 134(12), 2935
41. doi:10.1002/ijc.28620
Escrich, E., Moral, R., & Solanas, M. (2011). Olive oil, an essential component of the
Mediterranean diet, and breast cancer. Public Health Nutrition, 14(12A), 2323
32. doi:10.1017/S1368980011002588
Bosetti, C., Turati, F., Dal Pont, a, Ferraroni, M., Polesel, J., Negri, E., Zeegers, M. P.
(2013). The role of Mediterranean diet on the risk of pancreatic cancer. British
Journal of Cancer, 109(5), 13606. doi:10.1038/bjc.2013.345