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                    Celiac and Malignant Tumors<4>
                    ------------------------------

In its May 16, 1996 issue, the New England Journal of Medicine
discussed in detail the relationship between celiac and
malignancies.<5>

This article notes that "...an increased risk of malignant tumors has
been long noted in patients with celiac disease."  The risk of
adenocarcinoma throughout the gastrointestinal tract is elevated.  The
most striking increase in incidence, however, occurs in intestinal
lymphomas.  Most of these tumors are T-cell which usually occur in the
gastrointestinal tract.

It is postulated, the authors point out, that the sensitivity to
gluten increases the number of activated T-cells in the intestinal
mucosa and that at some point a clonal T-cell lymphoma develops.  The
relative risk of lymphoma in patients with celiac disease, the article
adds, is a subject of debate with most estimates ranging from a
40-fold to 100-fold greater risk than in persons without celiac
disease.

"However, these numbers may be related to the lack of strict adherence
to a gluten-free diet.  A recent 10-year follow-up study in Finland of
335 patients with celiac disease who were highly compliant with
dietary treatment showed no increase in the frequency of
lymphoma....as compared with age-matched controls."

There is debate in the literature whether some cases of adult-onset
celiac disease are actually a smoldering lymphoma from the outset, the
authors continue.

In response to the article, the New England Journal of Medicine
subsequently published a letter<6> [which stated]:

"Screening for celiac disease, rather than screening for lymphoma in
patients with established celiac disease, is more likely to improve
the outcome in this condition.  There are two reasons for this
suggestion.  First, many cases of celiac disease are undiagnosed, and
the reported prevalence of the disease varies greatly, ranging from
21.8 cases per 100,000 in North America to more than 300 per 100,000
in the west of Ireland...

"Second, there is mounting evidence that a prolonged and strict
gluten-free diet provides protection against cancer in patients with
celiac disease."<7>,<8>

The letter writers add that many patients with gluten-sensitive
enteropathy may have subclinical or only mildly symptomatic disease,
and the classic presentation with steatorrhea, weight loss, or
dermatitis herpetiformis represents the more severe end of the
spectrum.

"In addition to patients with classic presentations, others suitable
for serologic screening are those with clinical characteristics that
have strong statistical association with CD; such as type I diabetes
mellitus, thyroid disease, iron or folic acid deficiency, and a family
history of celiac disease.

"We should switch our focus from the early detection of
celiac-associated lymphoma to its prevention by screening for and
treating celiac disease," Drs. Egan, Stevens, and McCarthy concluded.