Although there are no prospective randomized trials that address the hypothesis that a gluten-free diet protects against the development of malignancy, the available literature does support this hypothesis. As reviewed in recent articles by Loftus and Loftus  and by Catassi et al. , studies published over several decades and from various countries indicate the risk of malignancies is reduced or decreases to baseline after being on a gluten-free diet. There are inherent methodological flaws with many of the studies including reliance on self-reporting of whether subjects were gluten free and to what degree they were able to comply with the diet over time. In spite of the limitations of the studies, the findings that a gluten free-diet reduces cancer risks are consistent with the observation that chronic inflammation is generally associated with an increased risk of malignancy and thus a reduction in immune stimulation on a gluten-free diet should be of benefit.
As in any condition where a disease is associated with a complication that might be detected earlier or even prevented by screening, celiac disease is one condition in which such screening may be considered. However, given the prevalence of the malignancies in the general population and the relatively small increased risks conferred by celiac disease, screening is not advocated. The incidence of non-Hodgkin lymphoma in western populations is 0.5-1 per million per year, and for small bowel adenocarcinoma it is estimated at 0.6-0.7 per 100,000 per year . This situation is in contrast with ulcer-ative colitis where the risks of colon cancer are high in the general population, the relative risk is significant, and there is also a stage that precedes the development of cancer that screening may detect. In general, searches for malignancy in celiac disease are based on clinical presentations concerning the development of cancer. Although it would no longer be considered screening, the development of refractory celiac disease or other symptoms concerning malignancy would justify a search for EATCL as discussed above, as well as for intestinal adeno-carcinoma.
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