CAROTENOIDS 5

Beta-carotene, carotenoids, and disease prevention in

humans
SUSAN TAYLOR MAYNE1
Department of Epidemiology and Public Health, Yale University School of Medicine and Yale Cancer Center, New
Haven, Connecticut 06520, USA

In this, the final article in the series on carotenoids, supplements are of little or no value in preventing
Susan Taylor Mayne has presented a balanced review cardiovascular disease and the major cancers occur-
of the potential role of beta-carotene and other carote- ring in well-nourished populations, and may actually
noids in human health and disease. Much of the data increase, rather than reduce, lung cancer incidence
indicating a beneficial effect of dietary carotenoids is in smokers. As a consequence of these findings, some
derived from epidemiological studies in which a lower of the ongoing trials of beta-carotene and disease
risk of a variety of chronic diseases including various prevention have been terminated or have dropped
cancers, cardiovascular disease, age-related macular beta-carotene from their interventions. Researchers
degeneration, and cataracts is correlated with the die- should now seek explanations for the apparently
tary conSUm[)tiOn of fruits and vegetables rich in ca- discordant findings of observational studies vs. inter-
rotenoids. However, to determine whether a specific vention trials. The most pressing research issues
compound (or compounds) of fruits and vegetables is include studies of interactions of carotenoids with
beneficial, human intervention studies, using either themselves and with other phytochemicals and
single components or mixtures, must be conducted. mechanistic studies of the actions of beta-carotene
These intervention studies have focused on beta-caro- in lung carcinogenesis and cardiovascular disease.
tene as the potential protective carotenoid. Somewhat Paradoxically, the finding that lung carcinogenesis
surprisingly, the results of the intervention studies and cardiovascular disease can be enhanced by sup-
through 1995 did not indicate any protective action of plemental beta-carotene may ultimately lead to a
supplementary beta-carotene with respect to cancer clearer understanding of the role of diet in the
prevention. In fact, the ATBC study from Finland re- etiology and prevention of these diseases. The con-
ported a negative effect of beta-carotene supplementa- clusion that major public health benefits could be
tion with respect to the incidence of lung cancer in achieved by increasing consumption of carotenoid-
smokers. Since then, two other major studies in the rich fruits and vegetables still appears to stand;
United States have shown either no effect or a negative however, the pharmacological use of supplemental
effect on chronic diseases. In concluding, the author beta-carotene for the prevention of cardiovascular
supports an increased consumption of fruits and vege- disease and lung cancer, particularly in smokers, can
tables and the avoidance of supplementary beta-caro- no longer be recommended.-Mayne, S. T. Beta-
tene for smokers. Her recommendations are timely. carotene, carotenoids, and disease prevention in
humans. FASEBJ. 10, 690-701 (1996)
-Norman I Krinsky, Coordinating Editor
Key Words: cancer prevention ‘cardiovascular disease
ABSTRACT A growing body of literature exists
regarding the effects of beta-carotene and other
Beta-carotene is one of a number of naturally occurring
carotenoids on chronic diseases in humans. This
compounds called carotenoids. More than 600 naturally
article reviews and critically evaluates this literature
occurring carotenoids have been identified, approximately
and identifies areas for further research. This review
50 of which have vitamin A activity (1). Carotenoids are
is restricted to studies in humans, with a major
widespread in plants and in photosynthetic bacteria,
emphasis on the most recent literature in the area of where they serve two essential functions: as accessory
carotenoids and selected cancers. Effects of carote-
pigments in photosynthesis and in photoprotection. These
noids on cardiovascular diseases, photosensitivity two functions are a consequence of the conjugated
diseases, cataracts, and age-related macular degen- polyene structure of carotenoids, which allows the mole-
eration are also discussed briefly. Numerous obser-
vational studies have found that people who ingest
more carotenoids in their diets have a reduced risk tAddress correspondence and reprint requests to Dr. Mayne, at: De-
of several chronic diseases. However, intervention partment of Epidemiology and Public Health, 60 College St., P.O. Box
trials of supplemental beta-carotene indicate that 208034, New Haven, CT 06520-8034, USA.

690 0892-6638/96/001 0-0690/$01 .50. © FASEB

cule to absorb light and to quench, or inactivate, singlet are complex mixtures of vitamins, minerals, fibers, and
oxygen and free radicals. numerous other phytochemicals. Thus, people who con-
Humans routinely ingest a variety of different carote- sume more carotenoids in their diet also consume more of
noids, including those occurring naturally in foods (pri- these other substances, many of which may have disease-
marily fruits and vegetables) and those added as food preventive properties (2). Also, individuals who consume
colorants. Functions of carotenoids in humans are not en- more fruits and vegetables may also consume less dietary
tirely clear. Provitamin A carotenoids can be converted fat or may be more health-conscious in other ways than
enzymatically in the intestinal mucosa to yield retinal individuals who consume relatively few fruits and vegeta-
and ultimately retinol; retinol (vitamin A) is required for bles. Observational epidemiologic studies of carotenoids
vision, maintenance of differentiated epithelia, mucus se- and human health must therefore be interpreted cau-
cretion, and reproduction. Not all dietary carotenoids are tiously, as it is entirely possible that effects observed may
metabolized in the intestinal mucosa following ingestion; result from dietary or other factors correlated with carote-
rather, significant quantities of provitamin as well as non- noid intake rather than from carotenoids themselves.
provitamin A carotenoids accumulate in human blood and Another complexity in the interpretation of observa-
tissues. A pressing research question is whether these ca- tional epidemiologic studies of carotenoids and disease
rotenoids serve any function in human tissues or whether arises from the lack of a standard, reproducible approach
they simply reflect passive accumulation from the diet. for quantifying carotenoid intake. The older literature is
A voluminous body of literature including in vitro stud- replete with terms such as “vitamin A from plants,” “caro-
ies, animal studies, human observational studies, and tene index,” and “yellow-green vegetables.” Exactly what
clinical trials has suggested a multiplicity of health ef- constitutes these indices is far from clear. This problem
fects of carotenoids in humans (Fig. 1). An exhaustive is a consequence of the lack of availability of adequate
review of this literature is beyond the scope of this arti- carotenoid food composition tables, which until recently
cle. Instead, this paper will focus on epidemiologic stud- have not contained information regarding the amounts of
ies in humans, with a primary emphasis on the most various carotenoids in foods commonly consumed. The
recent literature in the area of carotenoids and selected U.S. Department of Agriculture released a carotenoid
cancers. Effects of carotenoids on cardiovascular dis- food composition database in 1993 (3); the availability of
eases, photosensitivity diseases, cataracts, and age-re- this database now allows researchers to estimate intake of
lated macular degeneration are also briefly discussed. several major dietary carotenoids including alpha-caro-
tene, beta-carotene, beta-cryptoxanthin, the combination
of lutein plus zeaxanthin, and lycopene. These advances
OVERVIEW OF EPIDEMIOLOGIC STUDIES OF are enhancing observational epidemiologic studies of ca-
CAROTENOIDS rotenoids and disease.
Advances in analytical technology allow for the rela-
Observational studies of carotenoids and disease tively rapid measurement of a number of carotenoids in
human blood and/or tissues, facilitating the conduct of
Epidemiologic studies of carotenoids and disease can be biochemical epidemiologic studies of carotenoids and dis-
divided broadly into two categories: observational studies ease. However, carotenoid levels in blood have been
and intervention trials. Observational studies examine the shown to reflect fruit and vegetable intake (4), and thus
association between carotenoid intake and disease inci- biochemical assessment of carotenoid status in observa-
dence, or between blood or tissue levels of carotenoids tional studies does not overcome the problem of carote-
and disease incidence. Although these studies have con- tioids potentially acting as a marker for other correlated
tributed enormously to the literature regarding effects of etiologic factors.
carotenoids on disease, the interpretation of these studies
is difficult for many reasons. First, fruits and vegetables Interveiition trials of carotenoids and disease

For these reasons, effects of carotenoids on disease can

Ischemlc
Heart Disease Stroke be implied from observational studies; however, support-
data from intervention studies are important for
/
Cancer ing

causal inference. Intervention trials of carotenoids and

Photo- health primarily consist of beta-carotene supplementation
trials. Large-scale supplement trials have been restricted
Aging ,.____ (‘‘NOD’”)’”
to beta-carotene, as this is the only carotenoid that has
been readily available in large quantities in pill form and
Cataract for which data existed supporting the lack of toxicity of
Immuno- pharmacological doses in humans (safety concerns ex-
modulation Macular isted for canthaxanthin, as discussed below). Some fruit
Degeneration
and vegetable interventions are ongoing (5), but none has
Figure 1. Reported prOtective effects of carotenoids in humans. been completed.

CARflTfNflIflS ANn DISFASI IN HI IMANS i,q 1

 Randomized, placebo-controlled intervention trials, un- vention trials of beta-carotene in the prevention of lung
like the observational studies, generally are not subject to premalignant endpoints or lung cancer. The Tyler (Texas)
bias and confounding. However, the interpretation of in- Chemoprevention Trial randomized 755 asbestos workers
tervention trials of carotenoids and disease is also some- to receive beta-carotene (50 mg/day) and retinol (25,000
what complex, as detailed further below. IU every other day) vs. placebo to see whether the nutri-
ent combination could reduce the prevalence of atypical
CAROTENOIDS AND CANCER cells in sputum. After a mean intervention period of 58
months, the prevalence of sputum atypia was nonsignifi-
cantly increased, not reduced, in the subjects receiving
Lung
supplements (15). Supplemental beta-carotene (20
Numerous epidemiologic studies have shown that indi- mg/day), however, reduced micronuclei counts signifi-
viduals who consume a relatively large quantity of carote- cantly in sputum from heavy smokers in a 14 wk, ran-
noid-rich fruits and vegetables have a decreased risk of domized intervention trial (16). The relevance of
cancer at several tumor sites, as reviewed elsewhere (6). micronuclei to lung carcinogenesis is unknown.
The consistency of the results from observational studies Two trials using lung cancer as a primary endpoint
is particularly striking for lung cancer, where carotenoid have now been completed (Table 1). The Alpha-Toco-
and/or fruit and vegetable intake has been associated pherol Beta-Carotene (ATBC)2 Trial involved 29,133
with reduced lung cancer risk in 8 of 8 prospective stud- males age 50-69 years old from Finland (17) who were
ies and in 18 of 20 retrospective studies reviewed (7). heavy cigarette smokers at entry (average one pack/day
The majority of these studies examined protective effects for 36 years). The study design was a two-by-two factorial
of carotenoids against lung cancer in smokers; more re- with participants randomized to receive either supple-
cent studies have attempted to determine whether these mental alpha-tocopherol (50 mg/day), beta-carotene (20
effects extend to nonsmokers. Alavanja and colleagues (8) mg/day), the combination, or placebo for 5 to 8 years.
reported that beta-carotene, total vegetable intake, and Unexpectedly, participants receiving beta-carotene (alone
intake of yellow and green leafy vegetables were not sig- or in combination with vitamin E) had a significantly
nificantly protective against lung cancer in nonsmoking higher incidence of lung cancer (RR1.18; 95%
women. In contrast, we (9) reported that dietary beta- C11.03-1.36) and total mortality (RR1.08, 95%
carotene and fruit and vegetable intake were significantly C1 1.01-1.16) than participants receiving the placebo.
associated with a reduction in lung cancer risk in non- Supplemental beta-carotene did not affect the incidence
smoking men and women. Our data showed that risk re- of other major cancers occurring in this population (pros-
duction was greater from fruits and vegetables typically tate, bladder, colon/rectum, stomach). Tumor site-specific
consumed in a raw form vs. those typically cooked or data were not presented regarding the effects of supple-
processed in some manner. Cooking apparently increases mental beta-carotene on less common cancers. Within the
the bioavailability of some carotenoids such as alpha- placebo group, higher beta-carotene intake and serum
and beta-carotene (10), but even moderate cooking has beta-carotene concentrations at baseline were associated
been shown to destroy substantial quantities of some of with a lower subsequent lung cancer incidence, consis-
the xanthophyllic carotenoids in foods (11, 12). Thus, tent with other literature.
cooking has complex effects on carotenoid bioavailability, The finding of an increased incidence of lung cancer in
and some of the xanthophyllic carotenoids or other heat- beta-carotene-supplemented smokers has now been repli-
labile phytochemicals could be important in lung cancer cated in another major trial. Investigators of CARET (Cam-
prevention. Epidemiologic studies that specifically ad- tene and Retinol Efficacy Trial) held a press conference on
dress the effects of cooking/processing of fruits and vege- January 18, 1996, to announce that the intervention compo-
tables on cancer risk are needed, along with laboratory nent of CARET was being terminated nearly 2 years early.
studies of effects of food. preparation on levels of other CARET is a multicenter lung cancer prevention trial of sup-
phytochemicals in foods. plemental beta-carotene (30 mg/day) plus retinol (25,000
Studies of carotenoids other than beta-carotene and lung lU/day) vs. placebo in asbestos workers and smokers. Ac-
cancer risk are now becoming available. Le Marchand and cording to Dr. Gilbert Omenn, the lead investigator of
colleagues (13) found that dietary intake of alpha-carotene, CARET, the intervention was stopped early because interim
beta-carotene, and lutein was associated with reduced lung analyses of the data indicated that should the trial have
cancer risk in both men and women. Ziegler and colleagues continued for its planned duration, it is highly unlikely that
(14) also found significant inverse trends for dietary alpha- the intervention would have been found to be beneficial,
and beta-carotene, and a marginally significant effect for given the results as of late 1995. Furthermore, the interim
lutein. In both studies, high intake of a variety of vegetables results indicated that the supplemented group was develop-
was more strongly associated with reduced risk than high
intake of the individual carotenoids.
The consistency of the literature from observational 2Abbreviations: ATBC Trial, Alpha-Tocopherol Beta-Carotene Trial;
studies regarding carotenoids and lung cancer prevention CARET, Carotene and Retinol Efficacy Trial; EPP, erythropoietic proto-
served as the impetus for a number of large-scale inter- phorphyria; IHD, ischemic heart disease.

.Q) ‘./,-,l 10 kA,,, 1QO. Tk., CACCO

TABLE 1. Complet ed beta-carotene cancer prevention clinical trials: cancer incidence or mortality as primary endpoints

Tumor site Total n n-Carotene dose Relative risk (95% Cl)” Reference
Lung 29,133 20 mg/day 1.18 (1.03-1.36) 17
Lung 18,314 30 mg/day + 25,000 LU retinol/day 1.28 (1.04-1.57) CARETb
Esophagus/stomach 29,584 15 mg/day + 30 mg vitamin E + 50 .tg Selenium 0.79 (0.64-0.99) Stomach 26
0.96 (0.78-1.18) Esophagus
Esophagus/stomach 3,318 15 mg/day + multivitamin/multimineral 1.18 (0.76-1.85) Stomach 27
0.84 (0.54-1.29) Esophagus
Skin (nonmelanoma) 1805 50 mg/day 1.05 (0.91-1.22) 28
Total cancer 22,071 50 mg/every other day Not significantL Physicians’
Health Studyh

“Risk for site-specific cancer incidence (ATBC, CARET, Greenberg) or mortality (Blot, Li). tResults fmm NIH press release 1/18/96.

ing more lung cancer, not less, consistent with the results of human intervention trials using intermediate markers of oral
the Finnish trial. Overall, lung cancer incidence was in- carcinogenesis strongly suggest that beta-carotene plays a
creased by 28% in the supplemented subjects (RR = 1.28; protective role in the prevention of cancers of the oral cavity,
95% CI=1.04-1.57) and total mortality was also increased pharynx, and larynx (20). The etiology of these cancers, also
(RR 1.17, 95% CI 1.03-1.33). Although the P value for known as head and neck cancers, is thought to be multifacto-
the lung cancer increase (P0.032) is less than the conven- rial. Well-characterized risk factors include tobacco and al-
tional P value of 0.05, it cannot be concluded that this trial cohol exposures. A recent case-control study of oral cancer
provided statistically significant evidence of harm. This is from northern Italy attempted to estimate the relative contri-
because trials with interim analyses must have more strin- bution of beta-carotene intake, alcohol, and tobacco expo-
gent nominal significance levels for each repeated look at the sures to this cancer (21). In this study, smoking accounted
data, such that the overall significance level is kept at for 81-87% of oral cancer in males and 42-47% in females;
P0.05 (18). In other words, if investigators analyzed the alcohol explained about 60% of male cases vs. 15% of fe-
data often enough in a large trial one would expect to get P < male cases, and low beta-carotene intake accounted for 25%
0.05 eventually, regardless of whether there is a genuine of cases in males vs. 17% in females. Even though this study
treatment difference (18). provides new information regarding the relative importance
Major findings of one additional trial, the Physicians’ of diet in the etiology of these cancers, the calculated attrib-
Health Study of supplemental beta-carotene vs. placebo in utable risk for low beta-carotene intake should be inter-
22,071 male U.S. physicians, were also released at the same preted cautiously, as the beta-carotene index was derived
press conference. Dr. Charles Hennekens, lead investigator from a few selected indicator foods rather than from an analy-
of the Physicians’ Health Study, announced that there was no sis of the whole diet. Thus, some misclassification of intake is
significant effect-positive or negative-of 12 years of sup- likely.
plementation of beta-carotene (50 mg every other day) on Another recent study of relevance to the issue of ca-
cancer or cardiovascular disease. The apparent lack of an rotenoids and head and neck cancer risk is a nested
effect of long-term supplementation of beta-carotene on lung case-control study of serum micronutrients and sub-
cancer incidence in this cohort is noteworthy. Nonetheless, sequent risk of oral and pharyngeal cancer (22). Blood
these negative results should not be overinterpreted as only samples were collected and stored in 1974 from a cohort
11% of the cohort were current smokers at entry. of 25,802 adults in Maryland. During the next 15 years,
In contrast to these findings are results of an esophageal 28 individuals developed oral or pharyngeal cancer. Se-
and gastric cancer prevention trial in China (discussed be- rum analyses indicated that prediagnostic serum levels of
low). This trial had limited statistical power for lung cancer all the major individual carotenoids, and particularly
with only 31 total lung cancer deaths (19). However, the beta-carotene, were lower among the case group than
relative risk of death from lung cancer was 0.55 (95% among controls selected from the same cohort. Adjust-
CIO.26-1.14) among those receiving the combination of ment for smoking, which is known to be associated with
beta-carotene, alpha-tocopherol, and selenium. The smok- decreased serum carotenoid levels, attenuated the protec-
ing prevalence, including individuals who had ever smoked tive association slightly. The unadjusted and adjusted
cigarettes for6 or more months, was 30% in this study popu- relative odds of oral/pharyngeal cancer comparing the up-
lation. Possible reasons for the discrepant results of the per tertile of serum beta-carotene concentrations vs. the
CARET, ATBC, Physicians’ and Chinese trials are dis- lower tertile were 0.50 and 0.69, respectively.
cussed below (see “Carotenoids and Cancer: Overall Assess- These and other observational studies strongly suggest
ment”). that fruits and vegetables have cancer inhibitory proper-
ties for mouth and throat cancers. Human intervention
Oral, pharynx, and larynx trials using beta-carotene in the prevention and/or rever-
sal of oral micronuclei and oral leukoplakia (precancer-
As reviewed elsewhere, epidemiologic studies of diet and ous changes) lend further credence to the hypothesis that
serum, studies using the hamster buccal pouch model, and beta-carotene is at least one of the agents responsible for

CAflTFN1flIflc ANfl flISFASF IN HI MANS

protective effects of fruits and vegetables. Intervention beta-carotene (15 mg) reduced esophageal and gastric
trials of oral leukoplakia are summarized in Table 2. Al- cardia cancers in 3318 Linxian residents with esophageal
though many of these trials were not placebo-controlled, dysplasia (27). Cumulative esophageal/gastric cardia
and were thus subject to bias, the consistency of the re- death rates after an intervention period of 6 years were
sults strongly suggests a role for supplemental beta-caro- 8% lower (RRO.92, 95% C10.67-1.28), esophageal
tene in the prevention of oral cancers. cancer mortality was 16% lower (RRO.84, 95%
Based on these results, three trials involving beta-caro- CIO.54-1.29), total mortality was 7% lower (RRO.93,
tene and head and neck cancer prevention were initiated: 95% C10.75-1.16), and total cancer mortality was 4%
one in the U.S. (23), one in Italy (24), and one in Canada lower (RRO.96, 95% C10.71-1.29) in the supple-
(25). All are designed to determine whether supplemental mented group. Stomach cancer mortality, however, was
beta-carotene, alone (23, 24) or in combination with vita- 18% higher (RR1.18, 95% CIO.76-1.85) in the sup-
nsin E (25), reduces the incidence of second malignant plemented group. None of these results were statistically
cancers of the oral cavity, pharynx, larynx, esophagus, significant, as is evident from the confidence intervals,
and lung in patients who have been “cured” of an early- which all include 1.0. Therefore, this trial failed to dem-
stage head or neck cancer. More than 260 patients have onstrate a significant reduction in cancer incidence or
been randomized in the U.S. trial, approximately 200 in mortality during a 6-year vitamin/mineral intervention in
the Italian trial (24), and 145 in the Canadian trial (Dr. relatively high-risk participants.
Francois Meyer, personal communication). The results of
these studies will be followed with interest. Colon/rectum

Esophagus/stomach Many observational studies have suggested that dietary

intake of fruits and vegetables is inversely associated
Certain regions of the world have strikingly high inci- with colorectal cancer risk, as reviewed elsewhere (6).
dence rates of esophageal and gastric cancers; Linxian, Prevention trials of beta-carotene for this tumor site typi-
China is one such region. Blood levels of various micro- cally use colorectal adenomas, thought to be precursors of
nutrients including retinol, beta-carotene, riboflavin, vita- invasive cancer, as the primary endpoint. The largest
min C, and vitamin E have been shown to be consistently such completed trial studied 864 patients who had had
low in the Linxian population (26). Numerous investiga- an adenoma diagnosed and removed within the previous
tions indicate that intake of fresh fruits and vegetables is 3 months (28). Participants were randomized using a two-
inversely correlated with risk for esophageal and gastric by-two factorial design, with the active treatments being
cancers (6). These observations led to two related chemo- beta-carotene (25 mg/day) and the combination of 1 g of
prevention trials of esophageal and gastric cancer in vitamin C plus 400 mg vitamin E (equivalent to 400 IU).
Linxian County, China. There was no evidence that either beta-carotene and/or
The first trial was conducted in residents from the gen- vitamins C and E reduced the incidence of adenomas.
eral population of Linxian County (26). Nearly 30,000 The relative risk for beta-carotene was 1.01 (95%
men and women aged 40-69 took part in the study, C10.85-1.20); for vitamins C and E it was 1.08 (95%
which tested the efficacy of four different nutrient combi- C10.91-1.29). The lack of efficacy for supplemental
nations at inhibiting the development of esophageal and beta-carotene persisted when the analyses were restricted
gastric cancers. The nutrient combinations included reti- to those patients with the lowest quartile of serum beta-
nol plus zinc, riboflavin plus niacin, ascorbic acid plus carotene levels or to those with the lowest quartile of
molybdenum, and the combination of beta-carotene, sele- beta-carotene intake as reported at enrollment. The find-
nium, and alpha-tocopherol. After an intervention period ing that beta-carotene did not reduce the recurrence of
of 5 years, those given the combination of beta-carotene, colorectal adenomas is consistent with the results of a
vitamin E, and selenium had a 13% reduction in cancer smaller trial (n291) using a lower dose of 15 mg beta-
deaths (RRO.87; 95% CIO.75-1.00), a 9% reduction carotene/day (29).
in total deaths (RRO.91; 95% C10.84-O.99), a 4% The National Cancer Institute is coordinating an ongoing
reduction in esophageal cancer deaths (RRO.96; 95% adenoma prevention trial involving dietary intervention
C10.78-1.18), and a 21% reduction in gastric cancer rather than a nutrient supplement (5). The study is designed
deaths (RRO.79; 95% C10.64-0.99). None of the to determine whether a low-fat, high-fiber, vegetable- and
other nutrient combinations reduced gastric or esophageal fruit-enriched diet will decrease the recurrence rate of large
cancer deaths significantly in this trial. These encourag- bowel adenomatous polyps. The trial is a multicenter, ran-
ing results suggest that the concept of cancer prevention domized, controlled trial involving approximately 2000 men
via nutrient supplementation is still valid; however, the and women with a 4-year follow-up period. This trial will test
agents used, population studied, and endpoint may all be the assumption that fruit and vegetable intake can be modu-
critical in determining efficacy. lated successfully for a substantial period of time. Although
Along with the general population trial, a second and the trial will not be able to test chemopreventive effects of
smaller trial was done to determine whether supplementa- carotenoids per Se, its outcome is nonetheless relevant to
tion with a multivitamin/multimineral preparation plus investigations of carotenoids and cancer prevention.

F.c14 Vol 10 Mw The FASFR Ir,,,rnI kAAVkW

TABLE 2. completed beta-carotene trials: oral leukoplakia, oral dysplasia

Tumor site Total n fl-Carotene dose Outcome Reference

Oral leukoplakia 24 30 mg/day 71% Overall response#{176} 64
Oral leukoplakia 50 60 mg/day 52% Overall response 65
Oral leukoplakia 18 90 mg/day 44% Overall response 66
Oral leukoplakia 111 180 mg/wk 15% Complete response 67”
180 mg/wk + 100,000 IU vitamin AJwk 28% Complete response
Oral leukoplakia/esophagitis 384 40 mg/day + 100,000 IU vitamin AJwk 38% Decrease in leukoplakia 686
+ 80 mg vitamin E/wk (prevalence odds ratio)
291 40 mg/day + 100,000 LU vitamin AJwk 35% Decrease in risk of
+ 80 mg vitamin E/wk progression (esophagitis)
Oral dysplasia 18 120 mg/day 44% Overall response 69
Oral leukoplakia 79 30 mg/day + 1000 mg vitamin C/day 49% Overall responsec 70
+ 800 IU vitamin E/day

“Complete response plus partial response. bplaceba_contmlled studies. Clinical response in those patients who did not reduce tobacco use dunng 9 month
intervention (clinical response 90% in those who took supplements and reduced tobacco use).

Breast study (30), dietary change after diagnosis was not meas-
ured, and further research is needed to better understand
Even though most epidemiological studies of carotenoids whether increasing consumption of carotenoid-rich fruits
and human cancer have investigated a possible preven- and vegetables after cancer diagnosis affects survival.
tive role of these compounds, a relatively new research
area concerns prognostic and potentially therapeutic ef- Prostate
fects of carotenoid-rich diets. Ingram (30) interviewed
women with breast cancer 3 months after surgery, and Although several human studies have observed a direct
found that women with breast cancer who reported con- association between retinol intake and risk of prostate
suming more beta-carotene in their diets up until the cancer (32), studies of dietary beta-carotene and prostate
time of breast cancer diagnosis had a significant improve- cancer have shown mixed results. Data regarding carote-
ment in survival. More specifically, in the tertile of noids other than beta-carotene and prostate cancer risk
women who consumed the highest beta-carotene levels, are limited; however, one recent study evaluated associa-
only one woman died from breast cancer. In contrast, 8 tions between dietary beta-carotene, alpha-carotene,
women in the intermediate consumption group and 12 lutein, lycopene, and beta-cryptoxanthin and prostate
women in the lowest consumption group died from their cancer risk (33). The study was a prospective cohort
disease over a 6-year follow-up period. Dietary data were study of participants in the Health Professionals Follow-
not reassessed during the follow-up period; therefore, it is up Study, 812 of whom were diagnosed with prostate can-
unclear if diet at the time of diagnosis was important or cer during the 6-year follow-up. Intake of tomato-based
whether dietary changes made postdiagnosis affected sur- foods (tomato sauce, tomatoes, and pizza, but not tomato
vival in women with breast cancer. Also, although these juice) and the carotenoid lycopene, which is found pre-
results are intriguing, estimates were not adjusted for dominantly in tomato products, was associated with sig-
other known prognostic factors such as the stage of the nificantly lower prostate cancer risk.
disease at diagnosis. It is possible that women who con-
sumed relatively low levels of dietary carotenoids were Cervical
less health-conscious, and thus more likely to be diag-
nosed with late-stage disease with a correspondingly re- Two additional reports can be added to the body of litera-
duced survival. ture suggesting a role for beta-carotene and carotenoids
Using a different study design, Jam and colleagues in the prevention of cervical cancer. Batieha and col-
(31) studied a cohort of 678 women with breast cancer leagues (34) conducted a nested case-control study, ana-
from the National Breast Screening Study in Canada who lyzing a variety of carotenoids in sera stored from 50
had completed a diet history questionnaire before cancer women who had developed either invasive cervical cancer
diagnosis. Higher intake of saturated fats and lower in- or carcinoma in situ during a 15-year follow-up, and in
take of beta-carotene and vitamin C before diagnosis in- 99 controls pair-matched to the cases. The risk of cervi-
creased the risk of dying of breast cancer. The hazard cal cancer was significantly higher among women with
ratio for the highest quartile of dietary beta-carotene was the lowest prediagnostic serum levels of total carotenoids
0.48 (95% CI=0.23-0.99), with evidence of a significant (0R2.7; 95% CI, 1.1-6.4), alpha-carotene (0R3.1,
dose-response relationship. Information was available on 95% CI, 1.3-7.6), and beta-carotene (0R3.1; 95%
axillary lymph node status for a subset of cases; the in- CI,1.2-8.1) as compared to women in the upper ter-
clusion of the number of positive lymph nodes (an indica- tiles. Trends were also statistically significant. Mean se-
tor of stage of disease) in multivariate analyses did not rum levels of cryptoxanthin were also lower among cases
substantially alter the risk estimates. As with Ingram’s relative to controls (P0.03).

rAROTFNOInS AND DISFASF IN HI IMANS 69S

 Promising results regarding supplemental beta-carotene Regarding the first possibility, a few reports in the lit-
and cervical cancer prevention have been reported in a erature have suggested that pharmacological doses of
recently completed phase II intervention trial (35). Thirty beta-carotene may adversely affect vitamin E levels in
women with cervical dysplasia received oral beta-caro- blood (39, 40) or tissues (40). Both studies (39, 40) were
tene supplements (30 mg/day) for 6 months. Women were fairly small, consisting of 45 and 58 total subjects, re-
considered “responders” if they had negative Pap smears spectively. The report of an adverse effect of supplemen-
and either negative colposcopic findings or a negative bi- tal beta-carotene on plasma vitamin E levels in 1992 (39)
opsy. After 6 months, 21 women (70%) responded, and at prompted further investigations of interactions between
1 year (6 months off therapy) 30% continued to respond. beta-carotene and vitamin E in data available from other
These results are in contrast to those of an earlier nega- ongoing trials. Nierenberg and colleagues (41) analyzed
tive clinical trial that randomized women to a much lower data from more than 500 patients enrolled in a polyp pre-
dose of 10 mg beta-carotene/day vs. placebo (36). vention trial. Blood vitamin E levels did not change after
9 months of supplementation with 25 mg beta-caro-
Skin tene/day (2% increase relative to baseline measurement).
Similarly, Goodman and colleagues (42) analyzed serum
Greenberg and colleagues (37) demonstrated that supple- alpha-tocopherol levels in 2319 participants enrolled in
mentation with 50 mg beta-carotene/day for 5 years did CARET, who had taken daily supplements of 30 mg beta-
not reduce the occurrence of new skin cancers (relative carotene and 25,000 IU retinol for up to 6 years. A small
ratel.05; 95% C10.91-1.22) in 1805 persons with a but statistically significant increase in serum aipha-toco-
previous nonmelanoma skin cancer. pherol levels was observed in the supplemented subjects
in this very robust study. There was no evidence of a de-
crease in vitamin E levels in any of the subgroups exam-
CAROTENOIDS AND CANCER: OVERALL ined. These and other reports do not support an adverse
ASSESSMENT effect of long-term supplemental beta-carotene on vitamin
E levels in blood, although data are lacking regarding ef-
Taking the epidemiological evidence regarding carote- fects on tissue stores of vitamin E.
noids and cancer as a whole, the consistent protective ef- Adverse effects of supplemental beta-carotene on
fects found in the observational studies are strikingly at plasma levels of other carotenoids also have been consid-
odds with the findings of the large supplement interven- ered. Micozzi and colleagues (43) showed that supple-
tion trials, only one of which showed a decrease in cancer mentation with either 12 or 30 mg beta-carotene/day for 6
incidence with supplementation (26), three of which wk reduced plasma lutein levels relative to placebo (five
showed essentially no effect (28, 37, Physicians’ Health subjects/group). Kostic and colleagues (44) gave single
Study), and two of which showed an increase in cancer oral doses of lutein with and without beta-carotene (both
incidence (17, CARET). The discrepant results in these 0.5 p.mollkg body weight) and showed that when both ca-
trials may be a consequence of the use of different popu- rotenoids were administered together, the mean area un-
lations with varying baseline nutritional status and smok- der-the-curve for plasma lutein was reduced significantly.
ing habits, different tumor sites, combination In contrast to these relatively small, short-term studies,
supplements vs. single agent supplements, and perhaps Wahlqvist and colleagues (45) reported that supplemen-
even different formulations. tation of 20 mg beta-carotene/day for 24 months not only
The failure to see a protective effect of supplemental elevated plasma alpha-carotene levels (211% in men and
beta-carotene in the null studies could be due to many 166% in women), but also lycopene levels (176% in
factors: 1) dietary, blood, or tissue carotenoids might pri- men; lycopene levels were elevated nonsignificantly in
marily serve as a marker for other protective factors; 2) women; total n224). Lutein/zeaxanthin levels were un-
beta-carotene may interact synergistically with other ca- affected by beta-carotene supplementation. Omenn and
rotenoids and phytochemicals found in a natural food ma- colleagues (46) reported that supplemental beta-carotene
trix to inhibit carcinogenesis, but not when given as a plus retinol increased blood levels of alpha-carotene in
high-dose supplement; 3) beta-carotene may have been participants in the Asbestos Workers Pilot Study for
administered too late in the carcinogenic process; and 4) CARET (n721). Although the results of the latter two
the duration of supplementation may have been inade- studies appear reassuring, an increase in plasma alpha-
quate. Explanations for the apparent enhancement of lung carotene could reflect subdetectable alpha-carotene or
carcinogenesis are more difficult. The publication of the other substances that coelute with alpha-carotene in beta-
CARET results, anticipated by Spring of 1996, will un- carotene capsules. The observed increase in lycopene
doubtedly be accompanied by a plethora of possible (45) also must be interpreted cautiously, as this study
mechanisms. Some that have been proposed include inhi- was done within a polyp prevention trial with a 2 X 2 X 2
bition of the intestinal absorption of other nutrients by factorial design, the other factors being fat reduction and
daily large doses of beta-carotene and a possible prooxi- wheat bran supplementation. Changes in lycopene could
dant effect of beta-carotene in the damaged lungs of long- have resulted from dietary change over the 2-year period,
term heavy smokers (38). although the authors attempted to adjust their estimates

f.Q(. Vol 10 Mv qq The FAcFR ln,,rn,I kA AMC

for changes in carotenoid intake. Additional investiga- certain photosensitivity diseases for more than 25 years.
tions of carotenoid interactions clearly are needed. This clinical application derived from the recognition that
Regarding the possibility that beta-carotene might have carotenoids protect photosynthetic bacteria, algae, and
acted as a prooxidant, two in vitro studies-one in a solvent- green plants against photosensitization (50). As reviewed
based system (47) and one in rat liver microsomes (48)-re- elsewhere (50), many studies have demonstrated that the
ported that beta-carotene acted as a prooxidant at majority of patients with the genetic disease erythropoie-
supraphysiological oxygen concentrations and as an antioxi- tic protoporphyria (EPP) benefit from high-dose supple-
dant at physiological oxygen concentrations. Handelman mentation of beta-carotene and/or canthaxanthin.
and colleagues (49) demonstrated that the gas phase of ciga- Recommended beta-carotene doses for adults with EPP
rette smoke led to the depletion of carotenoids and alpha-to- are approximately 180 mg/day, substantially higher than
copherol in freshly obtained human plasma. They the doses investigated for cancer prevention purposes
commented that “it would be especially interesting if ciga- (15-50 mg/day). Despite these relatively high doses,
rette smoke-induced biotransformations in antioxidant some patients with EPP do not respond to carotenoid
molecules themselves could influence respiratory tract epi- therapy, due either to poor absorption of the carotenoids
thelial cell function(s).” Additional studies of oxidation, or to markedly elevated blood porphyrin levels.
simulating the environment found in lung tissue exposed to No serious side effects from high-dose beta-carotene
tobacco smoke, could help to clarify the likelihood of prooxi- supplements have been reported in EPP patients, and no
dant activity in contributing to lung carcinogenesis. long-term toxicity has been observed (50). High-dose
Mechanistic considerations should also take into account supplementation with canthaxanthin, however, has been
dose-response effects. This analysis is not straightforward, shown to produce deposition of pigmented granules in the
however, in that the bioavailability of a given oral dose of retinas of some patients, with occasional effects on night
beta-carotene could be affected by coadministration of other vision (51). Because many patients with EPP have been
agents such as retinol, may differ with different formulations, maintained on high doses of beta-carotene for a relatively
and is affected by dietary variables such as fat intake. These long time, a retrospective cohort analysis of these patients
and other factors may account for the fact that populations to assess the incidence of chronic disease would be in-
appear to differ in their plasma responses to supplemental structive. The problem with this approach is difficulty in
beta-carotene. For example, median serum beta-carotene assembling a suitable control group (EPP patients without
levels in the participants receiving 20 mg beta-carotene/day carotenoid therapy).
(Hoffmann-LaRoche product) in the Finnish trial rose from
0.18 mg/i at baseline to 3.0 mg/l at 3 years (17). In contrast, Cardiovascular diseases
median plasma beta-carotene levels in the participants re-
ceiving 50 mg beta-carotene/day in the skin cancer preven- Epidemiologic studies, including descriptive, cohort, and
tion trial (BASF product) rose from 0.18 mg/i at baseline to case control studies, suggest that carotenoid- and/or beta-
only 1.7 mg/l at 3 years (37). In our experience, median carotene-rich diets may prevent cardiovascular disease,
plasma beta-carotene levels of patients with a prior head or as reviewed elsewhere (52). For example, Gey and col-
neck malignancy, who received the same 50 mg beta-caro- leagues (53) reported data from the Vitamin Substudy of
tene/day supplement used by Greenberg and colleagues, rose the WHO/MONICA Project, in which plasma was ob-
from 0.18 mg/l at baseline to approximately 1.2 mg/lat 3 and tained from approximately 100 healthy males from each
12 months (unpublished data). Thus, an analysis of dose-re- of 16 study sites within Europe for antioxidant nutrient
sponse effects should consider blood and tissue levels of analyses. Median antioxidant nutrient levels were then
beta-carotene, as well as oral dose levels, due to wide discrep- compared with concurrent age-specific ischemic heart
ancies in physiologic responses to a given oral dose. disease (IHD) mortality in the 16 study populations. Re-
The currently available data indicate that supplemental sults showed a striking inverse correlation of IHD mortal-
beta-carotene is unlikely to be beneficial in reducing the ity with plasma vitamin E levels (r20.63). A similar
major cancers occurring in westernized populations. These comparison between median plasma beta-carotene levels
findings, however, may not extend to less common malignan- and IHD mortality revealed no association when consid-
cies. In this regard, supplemental beta-carotene has been ering all 16 study sites (r20.04). However, a reasonably
shown to reduce precancerous lesions of the oral cavity (Table strong inverse association was evident (r20.50) when
2) and cervix (35), but not of the lung (15). Thus, the possible three study sites, all apparent outliers (and all Finnish
efficacy of beta-carotene and othercarotenoids in the preven- sites), were excluded from the analysis.
tion of oral and cervical neoplasia should be explored further. Gey and colleagues (53) also presented data from the
Basel Prospective study, which revealed that men who
OTHER HEALTH EFFECTS OF CAROTENOIDS had low concentrations of beta-carotene and vitamin C in
their blood had a significantly increased risk of sub-
sequent ischemic heart disease (RR1.96; PO.022)
Photosensitivity disorders
and stroke (RR4.17; PO.002). The Health Profession-
Carotenoids, including beta-carotene and to a lesser ex- als Follow-up Study (54) reported protective effects of
tent canthaxanthin, have been used successfully to treat dietary carotene, with a relative risk for coronary heart

CAPC1TrMC1IDc AND nicicr IN HI MANS (,07

disease of 0.71 (95% C10.55-0.92) for those at the top study that 12 years of supplementation of beta-carotene
quintile of total carotene intake (>19,034 lU/day) rela- (50 mg every other day) had no significant effect, positive
tive to the lowest quintile of intake. Effect modification or negative, on cardiovascular disease or cancer.
by smoking was evident: among current smokers, the In conclusion, the consumption of beta-carotene-rich
relative risk was 0.30 (95% C10.11-0.82); among for- foods has been associated consistently with a decreased
mer smokers, the risk was 0.60 (95% C10.38-O.94), risk of cardiovascular disease. In contrast, supplementa-
and among nonsmokers, the risk was 1.09 (95% tion with beta-carotene in major intervention trials gener-
C10.66-1.79). Total serum carotenoids, measured at ally has failed to reduce the incidence of cardiovascular
baseline in the placebo group of the Lipid Research Clin- disease. The lack of benefit seen for both cardiovascular
ics Coronary Primary Prevention Trial, were inversely re- disease and lung cancer simplifies public health recom-
lated to subsequent coronary heart disease events (55). mendations for individuals who smoke. An appropriate
Men in the highest quartile of total serum carotenoids public health recommendation for smokers is 1) quit
had an adjusted relative risk of 0.64 (95% smoking; 2) ingest more carotenoid-containing fruits and
C10.44-0.92); among those who had never smoked, the vegetables; and 3) do not rely on beta-carotene supple-
relative risk was 0.28 (95% CIO.11-0.73). ments for protection from chronic disease.
Using a different approach for quantifying beta-caro-
tene status, Kardinaal and colleagues (56) measured Age-related macular degeneration/cataract
beta-carotene concentrations in adipose tissue samples
collected by needle aspiration from the buttocks of 683 Dietary carotenoids may be important in the prevention of
people with myocardial infarction and 727 age-matched two ocular conditions: age-related macular degeneration
controls. Risk of myocardial infarction in the lowest quin- and senile cataract. The macula is a small, yellow region
tile of adipose beta-carotene compared with the highest in the center of the retina. Degeneration of the macula is
was 2.62 (95% C11.79-3.83), and was primarily con- the most common cause of irreversible blindness in peo-
fined to current smokers (0R2.39; 95% C11.35-4.25 ple over the age of 65 (58). Cataracts are also problem-
vs. 0R1.07 for nonsmokers). atic, with cataract extraction being the most frequently
These observational studies suggest that carotenoid- performed surgical procedure in the elderly (59). Al-
containing diets are protective against cardiovascular dis- though the etiologies of these conditions are not known,
ease; evidence that beta-carotene per se is protective can oxidative processes may play a role. Cataracts are thought
best be obtained by randomized trials. Some of the first to result from photooxidation of lens proteins resulting in
such data to become available were early analyses of 333 protein damage, accumulation, aggregation, and precipi-
men enrolled in the Physicians’ Health Study who were tation in the lens (59). The cornea and lens filter out ul-
known to have stable angina or a previous coronary re- traviolet light, but visible blue light reaches the retina
vascularization procedure. Among subjects who received and may contribute to photic damage or other oxidative
supplemental beta-carotene for 5 years, there was a 51% insults (58). Carotenoids could potentially interfere with
reduction in risk of major coronary events and a 54% re- both processes.
duction in risk of major vascular events (57). In the Seddon and colleagues (58) analyzed the association
esophageal/gastric cancer prevention trial in the general between carotenoid intake and advanced age-related
population in Linxian, China, the combination of beta- macular degeneration in a multicenter case-control study
carotene, vitamin E, and selenium resulted in a 10% re- involving 356 cases and 520 control subjects with other
duction in mortality due to cerebrovascular disease ocular conditions. Those in the highest quintile of carote-
(RRO.90; 95% CIO.76-1.O7), with this disease ac- noid intake had a 43% lower risk for macular degenera-
counting for approximately 25% of all deaths in this tion compared with those in the lowest quintile
population (26). In individuals with esophageal dysplasia (0R0.57, 95% C10.35-0.92). Among the specific ca-
(27), supplementation of a multivitamin/multimineral rotenoids, intake of lutein and zeaxanthin (grouped in the
preparation plus 15 mg beta-carotene reduced cere- carotenoid food composition database) was most strongly
brovascular mortality by 38% (RRO.62, 95% associated with reduced risk. Increased consumption of
CI=O.37-1.06). spinach and collard greens, rich dietary sources of
In contrast, the recently completed Finnish lung cancer lutein/zeaxanthin, was also associated with a significant
prevention trial found no reduction in cardiovascular risk reduction. Protective effects of lutein/zeaxanthin
deaths in the men supplemented with beta-carotene (17). against macular degeneration are biologically plausible,
Rather, the men taking beta-carotene had 11% more total as these carotenoids selectively accumulate in the macula
cardiovascular deaths including deaths from ischemic (60, 61) and account for the yellow color observed in this
heart disease, all types of stroke, and other cardiovascu- region of the retina.
lar disease. An even more pronounced increase in cardio- Dietary intake of carotenoids also has been found to be
vascular mortality was noted in the CARET trial of protective against various forms of cataract, as reviewed
supplemental beta-carotene pius retinol: the relative risk by Taylor (59). Regarding intervention trials, the cancer
was 1.26 (95% CIO.99-1.61). These results are tem- prevention trials in Linxian, China, included special end-
pered by the announcement from the Physicians’ Health of-trial ocular examinations of participants in the dys-

698 Vol. lOMav 1996 The FASEB Iournal MAVNF

plasia trial and a subset of participants in the general CONCLUSIONS
population trial. The combination of beta-carotene, alpha-
tocopheroi, and selenium did not reduce the prevalence Numerous observational studies have found that people
of cataract in the population trial. In contrast, in the dys- who ingest more carotenoids or more fruits and vegeta-
plasia trial there was a statistically significant 36% re- bles-the primary dietary sources of carotenoids-have a
duction in the prevalence of nuclear cataract for persons reduced risk of several chronic diseases including, but
aged 65 to 74 years who were supplemented with multi- not limited to, cancer, cardiovascular disease, age-related
ple vitamins and minerals plus beta-carotene (15 mg/day) macular degeneration and cataract. However, with the no-
for 6 years (62). table exception of certain photosensitivity diseases, pro-
tective effects of individual carotenoids have yet to be
established for most chronic diseases. Recent studies
POUCY IMPLICATIONS even suggest that supplemental beta-carotene may in-
crease risk of cardiovascular disease and lung cancer,
Observational studies suggest that increased consumption particularly in smokrs. These recent results emphasize
of various carotenoids in the diet is associated with a the value of well-designed, randomized clinical trials for
lower risk of several common chronic diseases. No spe- demonstrations of efficacy. Clinical intervention trials,
cific recommendation for carotenoid intake exists; how- however, also have limitations: 1) only a single dosage
ever, recommendations to increase consumption of fruits level is usually tested; 2) thus far, only beta-carotene has
and vegetables are likely to increase intake of at least been used; and 3) the results may not apply to popula-
some carotenoids. In 1993, before the release of the tions other than those studied. Due to the inherent limita-
ATBC or CARET Trial results, Gey suggested estab- tions of both observational studies and intervention trials,
lishment of thresholds of “optimum” plasma levels of anti- public health recommendations must consider the full
oxidant vitamins, including a threshold for alpha- plus weight of the evidence regarding carotenoids and disease
beta-carotene in the plasma of >0.4-0.5 j.tmol/l (63). Al- prevention. At present, such an assessment indicates that
though the concept of such a threshold is appealing, the major public health benefits could be achieved by gener-
setting of an optimum threshold level for alpha- and beta- ally increasing consumption of fruits and vegetables, in-
carotene might be interpreted as scientific endorsement cluding those rich in carotenoids. However,
of their “known” disease-preventive properties. In fact, supplementation of pharmacological doses of beta-caro-
these relationships are solely associative. Thus, an inordi- tene for the prevention of common chronic diseases is not
nate emphasis might mistakenly be placed on the inges- recommended, at least in well-nourished populations, and
tion of these two carotenoids rather than on the intake of particularly not in current smokers.
fruits and vegetables.
The author wishes to thank the following individuals for comments on
this manuscript: Drs. James Olson and Norman Krinsky. This work was
RECOMMENDATIONS FOR FURTHER supported in part by NIH grants CA42101 and CA64567.

RESEARCH
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