Abstract: In this review update, we included in total 142 completed studies (11 experimental and 131 nonexperimental) and two ongoing studies. This is an additional 10 experimental and 85 nonexperimental studies from those included in the previous version of the review. Eleven experimental studies allocated a total of 1795 participants to either green tea extract or placebo, all demonstrating an overall high methodological quality based on 'Risk of bias' assessment. For incident prostate cancer, the summary risk ratio (RR) in the green tea-supplemented participants was 0.50 (95% confidence interval (CI) 0.18 to 1.36), based on three studies and involving 201 participants (low-certainty evidence). The summary RR for gynaecological cancer was 1.50 (95% CI 0.41 to 5.48; 2 studies, 1157 participants; low-certainty evidence). No evidence of effect of non-melanoma skin cancer emerged (summary RR 1.00, 95% CI 0.06 to 15.92; 1 study, 1075 participants; low-certainty evidence). In addition, adverse effects of green tea extract intake were reported, including gastrointestinal disorders, elevation of liver enzymes, and, more rarely, insomnia, raised blood pressure and skin/subcutaneous reactions. Consumption of green tea extracts induced a slight improvement in quality of life, compared with placebo, based on three experimental studies. In nonexperimental studies, we included over 1,100,000 participants from 46 cohort studies and 85 case-control studies, which were on average of intermediate to high methodological quality based on Newcastle-Ottawa Scale 'Risk of bias' assessment. When comparing the highest intake of green tea with the lowest, we found a lower overall cancer incidence (summary RR 0.83, 95% CI 0.65 to 1.07), based on three studies, involving 52,479 participants (low-certainty evidence). Conversely, we found no association between green tea consumption and cancer-related mortality (summary RR 0.99, 95% CI 0.91 to 1.07), based on eight studies and 504,366 participants (low-certainty evidence). For most of the site-specific cancers we observed a decreased RR in the highest category of green tea consumption compared with the lowest one. After stratifying the analysis according to study design, we found strongly conflicting results for some cancer sites: oesophageal, prostate and urinary tract cancer, and leukaemia showed an increased RR in cohort studies and a decreased RR or no difference in case-control studies. Overall, findings from experimental and nonexperimental epidemiological studies yielded inconsistent results, thus providing limited evidence for the beneficial effect of green tea consumption on the overall risk of cancer or on specific cancer sites. Some evidence of a beneficial effect of green tea at some cancer sites emerged from the RCTs and from case-control studies, but their methodological limitations, such as the low number and size of the studies, and the inconsistencies with the results of cohort studies, limit the interpretability of the RR estimates. The studies also indicated the occurrence of several side effects associated with high intakes of green tea. In addition, the majority of included studies were carried out in Asian populations characterised by a high intake of green tea, thus limiting the generalisability of the findings to other populations. Well conducted and adequately powered RCTs would be needed to draw conclusions on the possible beneficial effects of green tea consumption on cancer risk.

Plain-language summary: In this review we included 142 studies with more than 1.1 million participants looking for an association between green tea consumption and cancers of the digestive tract and the female reproductive system, breast, prostate, kidney and urinary tract, nasopharynx, lung, blood, skin, thyroid and brain. The majority of the studies were of medium to high quality in terms of how they were conducted. Overall, the evidence from the studies showed that the consumption of green tea consumption to reduce the risk of cancer was inconsistent. Some studies suggested a beneficial effect on cancer risk, while others indicated no effect, and even suggested a slightly increased cancer risk. In particular, results from experimental studies suggested that green tea extract supplementation yielded a decreased risk for prostate cancer, but increased risk for gynaecological cancers. For non-melanoma skin cancer no difference in cancer cases emerged. Green tea supplementation seemed to slightly improve quality of life compared with placebo, although it was associated with some adverse effects including gastrointestinal disorders, higher levels of liver enzymes, and, more rarely, insomnia, raised blood pressure and skin reactions. In nonexperimental studies, comparing people consuming the highest amount of green tea to those in the lowest category of consumption, we found an indication of a lower occurrence of new cases of overall types of cancer, while no difference emerged for lethal cases. However, results according to the type of cancer and study design were inconsistent. A beneficial effect of green tea consumption on cancer prevention remains unproven so far. Caution is advised regarding supplementation with high-dose green tea extracts due to the possible adverse effects.