The relation between 5 classes of flavonoids (flavanones, flavan-3-ols, flavonols, flavones and anthocyanidines) and esophageal cancer was investigated using data from a case-control study conducted between 1992 and 1997 in 3 areas of northern Italy. The study included 304 cases (275 men, 29 women) with a first diagnosis of squamous-cell carcinoma of the esophagus and 743 controls (593 men, 150 women) with no history of cancer, admitted for acute illnesses, unrelated to tobacco and alcohol consumption, to major hospitals of the areas under surveillance. Dietary habits were investigated using a validated food frequency questionnaire. Odds ratios (ORs) and 95% confidence intervals (CI) were computed after allowance for age, sex, study centre, years of education, alcohol drinking, tobacco smoking, body mass index and energy intake. An inverse association emerged between flavanone intake and esophageal cancer risk (OR 5 0.38 for the highest vs. the lowest quintile, 95% CI 5 0.23-0.66). The inverse relation between flavanones and esophageal cancer tended to be stronger in those who drank 6 drinks/day. In conclusion, this study suggests that flavanone intake is inversely associated with esophageal cancer risk and may account, with vitamin C, for the protective effect of fruit, especially citrus fruit, on esophageal cancer. ' 2006 Wiley-Liss, Inc.Key words: flavonoids; squamous cell esophageal cancer; flavanones; case-control study; risk factors Flavonoids are a large group of compounds contained in foods and beverages of plant origin, which cannot be synthesized by humans.1,2 As several flavonoids have antioxidant properties, as well as antimutagenic and antiproliferative properties in vitro, [3][4][5] these compounds have been investigated for possible inverse associations with chronic diseases, including various types of cancer, [6][7][8][9][10][11] and may explain at least in part, the protective effect of vegetable and fruit against cancer.12,13 Over 4,000 different flavonoids have been described, and they have been grouped into 6 classes, i.e. flavanones, flavan-3-ols, flavonols, flavones, anthocyanidines and isoflavones.14 Until recently, the lack of a comprehensive nutritional database has however hindered a thorough epidemiological investigation of their role in cancer prevention.As concerns esophageal cancer, several studies have reported a protective effect of fruit and vegetables. 15,16 To our knowledge, only 2 studies have investigated the relation between flavonoids and esophageal cancer risk, showing conflicting results. A casecontrol study from Uruguay, 17 including 66 esophageal cancer cases (of unspecified histology), found an inverse association between flavonoids and esophageal cancer risk [odds ratio (OR) 5 0.4 for the highest vs. the lowest tertile, 95% confidence interval, CI, 0.3-0.6]; while another study, conducted in China, 18 on a cohort that had generated 42 esophageal cancer cases (mostly squamous cell carcinomas) reported no association between urinary polyphenol markers deriving from tea...