Sirtuin 1 (SIRT1), a histone deacetylase, is involved in maintenance of genetic stability, inflammation, immune response, metabolism (energy-sensing molecule) and colorectal tumorigenesis. We investigated SIRT1's specific role in colorectal tumorigenesis by studying SIRT1 polymorphisms in relation to colorectal cancer (CRC) risk by microsatellite instability (MSI) and CpG island methylator phenotype (CIMP) status. The Netherlands Cohort study (NLCS) was initiated in 1986 and includes 120,852 participants in a case-cohort design. CRC tumour samples were available for incident cases between 1989 and 1993. Toenail deoxyribonucleic acid (DNA) was used for genotyping of two SIRT1 tagging variants (rs10997870 and rs12778366). Excluding the first 2.3 years of follow-up, subcohort members and CRC cases with no toenail DNA available and those with low sample call rates, and CRC cases with no tumour DNA available left 3478 subcohort members and 533 CRC cases. Cox regression was utilised to estimate hazard ratios (HRs) for MSI and CIMP positive and negative tumours by SIRT1 genotypes. The results were that the rs12778366 TC/CC versus TT genotype was inversely associated with MSI CRC (HR = 0.41, 95% confidence interval: 0.20, 0.88), while no association was found with the risk of an MSS tumour (TC/CC versus TT carriers: HR = 1.13, 95% CI: 0.89, 1.44). No significant associations were found between other SIRT1 genotypes and CRC subtypes. In conclusion, the results suggest a role for SIRT1 polymorphisms in colorectal tumorigenesis, particularly MSI CRC. Colorectal cancer (CRC) heterogeneity depends in part on the genetic alterations of the tumorous tissue, which are thought to reflect different CRC aetiology 1-4. Several CRC pathways have been characterised, and these include the Microsatellite Instability (MSI) and the CpG Island Methylator Phenotype (CIMP) pathways 5. The underlying mechanism of MSI related CRC is a defect in deoxyribonucleic acid (DNA) mismatch repair function, driven by hypermethylation of the human MutL Homolog 1 (hMLH1) gene. In this sense, there is overlap between the CIMP and MSI pathways, since hMLH1 can be one of multiple methylation targets. MSI can be detected in about 15% of CRC cases, and is associated with a proximal location, older age, female sex and better disease outcome 6. The CIMP pathway is characterized by hypermethylation of multiple genetic loci that contain CpG islands, often located in regulatory regions of genes. This in turn abrogates transcription of the affected genes. CIMP positive tumours can be detected in approximately 20% of CRC cases, although percentages vary greatly between studies, as there is a lack of consensus on the definition of CIMP 7. CIMP tumours have similar characteristics as MSI tumours (proximal location, older age, female sex), with the exception that the majority of studies on clinical outcomes show evidence of a poor outcome, in contrast to MSI tumours 8,9. We have previously shown that body mass index (BMI) was more strongly and significantly associated w...