Article

Underutilization of Aspirin in Patients With Advanced Colorectal Polyps

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Abstract

Background: Colorectal cancer is the third-most common cause of cancer deaths in the United States, and advanced colorectal polyps are a major risk factor. Although there are no large-scale individual trials designed a priori to test the hypothesis, in meta-analyses of trials in primary prevention of cardiovascular disease, aspirin reduces risk of colorectal cancer. The US Preventive Services Task Force used a microsimulation model, including baseline risk factors, and concluded that aspirin reduces risk of colorectal cancer by 40%. Their guidelines suggest that without a specific contraindication, clinicians should routinely prescribe aspirin to patients with advanced colorectal polyps. Methods: Written informed consent was obtained, and brief telephone interviews were conducted by trained interviewers for 84 men and women with biopsy-proven advanced colorectal polyps from 55 clinical practices. Results: Of the 84, 39 (46.4%) were men. The mean age was 66 with a range from 41 to 91 years. Among the 84, 36 (42.9%) reported taking aspirin. Conclusions: These data suggest underutilization of aspirin by patients with advanced colorectal polyps. These data pose major challenges that require multifactorial approaches by clinicians and their patients, which include therapeutic lifestyle changes, adjunctive drug therapies, and screening. Lifestyle changes include treating overweight status and obesity and engaging in regular physical activity; adjunctive drug therapies include aspirin. These multifactorial approaches will be necessary to achieve the most good for the most patients with regard to prevention, as well as, early diagnosis and treatment of colorectal cancer in patients with advanced colorectal polyps.

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... Existing studies on aspirin use report mixed findings that merit further investigation [26][27][28][29][30]. The USPTF guidelines suggest routine prescribing of aspirin in patients presenting with advanced colorectal polyps unless contraindicated [9]. ...
... The USPTF guidelines suggest routine prescribing of aspirin in patients presenting with advanced colorectal polyps unless contraindicated [9]. Despite this, studies still report low aspirin use in these populations [26]. Other evidence suggests that aspirin may impact on FIT performance. ...
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Background Several epidemiological and cohort studies suggest that regular low-dose aspirin use independently reduces the long-term incidence and risk of colorectal cancer deaths by approximately 20%. However, there are also risks to aspirin use, mainly gastrointestinal bleeding and haemorrhagic stroke. Making informed decisions depends on the ability to understand and weigh up benefits and risks of available options. A decision aid to support people to consider aspirin therapy alongside participation in the NHS bowel cancer screening programme may have an additional impact on colorectal cancer prevention. This study aims to develop and user-test a brief decision aid about aspirin to enable informed decision-making for colorectal screening-eligible members of the public. Methods We undertook a qualitative study to develop an aspirin decision aid leaflet to support bowel screening responders in deciding whether to take aspirin to reduce their risk of colorectal cancer. The iterative development process involved two focus groups with public members aged 60–74 years (n = 14) and interviews with clinicians (n = 10). Interviews (n = 11) were used to evaluate its utility for decision-making. Analysis was conducted using a framework approach. Results Overall, participants found the decision aid acceptable and useful to facilitate decision-making. They expressed a need for individualised risk information, more detail about the potential risks of aspirin, and preferred risk information presented in pictograms when offered different options. Implementation pathways were discussed, including the possibility of involving different clinicians in the process such as GPs and/or community pharmacists. A range of potentially effective timepoints for sending out the decision aid were identified. Conclusion An acceptable and usable decision aid was developed to support decisions about aspirin use to prevent colorectal cancer.
... Over 1/3 of American adults report taking aspirin regularly, with higher use in those with cardiovascular disease and diabetes mellitus [7]. Nationwide rates of aspirin/NSAID use specifically for CRC prevention are uncertain, but small studies suggest uptake is low [8]. ...
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Purpose of review To critically examine recently published research in the area of chemoprevention in hereditary polyposis and gastrointestinal cancers, and to briefly review several ongoing chemoprevention trials testing novel agents in this population. Recent findings Four recent chemoprevention trials in patients with familial adenomatous polyposis (FAP) were identified and reviewed. In the FAPEST trial, the combination of erlotinib + sulindac (compared to placebo) met its primary outcome of decreased duodenal polyp burden. A secondary analysis of lower gastrointestinal tract outcomes also demonstrated significant benefits. Two randomized trials in FAP patients examining combination regimens (celecoxib + DFMO and sulindac + DFMO) failed to meet their primary endpoints. Benefits of further research into these combinations were suggested by efficacy signals seen in secondary and post hoc analyses. Finally, a randomized trial found curcumin (versus placebo) to have no benefit in reducing colorectal polyp count or size in patients with FAP. Summary Progress in developing new and more effective preventive options for patients with hereditary gastrointestinal syndromes continues to be made through the efforts of investigators conducting chemoprevention research. Trial registration NCT02961374, NCT03333265, NCT03649971, NCT04296851, NCT03806426, NCT04230499, NCT01725490, CaPP3 trial, NCT02813824, NCT03831698, NCT04379999, NCT02052908
... We have read with great interest the article "Underutilization of Aspirin in Patients with Advanced Colorectal Polyps" by Fiedler et al, 1 and we found it of importance with a view to clinical prevention. ...
Article
Introduction: Colorectal cancer (CRC) is a worldwide problem of public health and arises mainly from polyps. In last 25 years, a strategy called chemoprevention that consists of food intake like purple corn and turmeric or chemical substances like acetyl salicylic acid (ASA) and non-steroidal anti-inflammatory drugs (NSAIDs) that prevent effectively carcinogenesis reducing the risk of polyp development. Objective: To determine the efficacy and safety of lyophilized concentrate of purple corn (Zea mays L.) 200 mg in the prevention of colonic polyps development in private gastroenterological practice Methods: we randomly assigned 112 patients (cases) to receive this product and 112 patients (controls) to receive placebo, during 3 years. Both groups had similar demographic, clinical and medical history characteristics. Results: we found that cases developed 83% less polyps than controls (p <0.001). The cases that developed polyps were smaller in number, size and histology than at the beginning of the trial. The adverse events that cases presented were 4.5% similar to controls, mainly petechiae. Conclusion: We conclude that the lyophilized concentrate of purple corn (Zea mays L.) 200 mg was effective and safe in preventing the developmentof colonic polyps.
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Background: The term health literacy refers to the abilities and resources required to find, understand and use health information in managing health. This definition is reflected in the recent development of multidimensional health literacy tools that measure multiple facets of health literacy. The aim of this study was to determine the health literacy profile of a randomly selected, population-based sample of Australian women using a multidimensional tool, the Health Literacy Questionnaire (HLQ). A second aim was to investigate associations between independent HLQ scales, sociodemographic characteristics and lifestyle and anthropometric risk factors for chronic disease. Methods: We surveyed women involved in the Geelong Osteoporosis Study (GOS), a longitudinal, population-based study. We included demographic data, lifestyle information and anthropometric measures as well as the HLQ. The HLQ has 44 items, scored on either 4- or 5-point scales, within nine conceptually distinct scales. Means for each scale were calculated, and HLQ scales were regressed on educational level and socioeconomic status. Risk factors for chronic disease were investigated using analysis of variance (ANOVA) and calculation of effect sizes. Results: Higher mean scores were seen for the scales 'Feeling understood and supported by healthcare professionals' (mean 3.20, ± SD 0.52) and 'Understanding health information well enough to know what to do' (mean 4.28, ±SD 0.54), and lower mean scores were seen for 'Appraisal of health information' (mean 2.81, ±SD 0.48) and 'Navigating the healthcare system' (mean 4.09, ± SD 0.57). Associations were also seen between lower HLQ scores and poor health behaviours including smoking and being more sedentary, in addition to greater body mass index and waist circumference. Positive gradients were seen between several HLQ scales and education level, as well as SES. For some HLQ scales, these associations were non-linear. Conclusions: The profile of this population-based cohort of women demonstrated associations between low health literacy and low SES, lower levels of education, increasing age, and anthropometric and lifestyle risk factors for chronic disease. These findings suggest implications of health literacy for health policy makers focusing on improving lifestyle prevention of chronic disease and promoting health equity at a population level.
Article
Description: Update of the 2009 USPSTF recommendation on aspirin use to prevent cardiovascular disease (CVD) events and the 2007 recommendation on aspirin and nonsteroidal anti-inflammatory drug use to prevent colorectal cancer (CRC). Methods: The USPSTF reviewed 5 additional studies of aspirin for the primary prevention of CVD and several additional analyses of CRC follow-up data. The USPSTF also relied on commissioned systematic reviews of all-cause mortality and total cancer incidence and mortality and a comprehensive review of harms. The USPSTF then used a microsimulation model to systematically estimate the balance of benefits and harms. Population: This recommendation applies to adults aged 40 years or older without known CVD and without increased bleeding risk. Recommendation: The USPSTF recommends initiating low-dose aspirin use for the primary prevention of CVD and CRC in adults aged 50 to 59 years who have a 10% or greater 10-year CVD risk, are not at increased risk for bleeding, have a life expectancy of at least 10 years, and are willing to take low-dose aspirin daily for at least 10 years. (B recommendation) The decision to initiate low-dose aspirin use for the primary prevention of CVD and CRC in adults aged 60 to 69 years who have a 10% or greater 10-year CVD risk should be an individual one. Persons who are not at increased risk for bleeding, have a life expectancy of at least 10 years, and are willing to take low-dose aspirin daily for at least 10 years are more likely to benefit. Persons who place a higher value on the potential benefits than the potential harms may choose to initiate low-dose aspirin. (C recommendation) The current evidence is insufficient to assess the balance of benefits and harms of initiating aspirin use for the primary prevention of CVD and CRC in adults younger than 50 years. (I statement) The current evidence is insufficient to assess the balance of benefits and harms of initiating aspirin use for the primary prevention of CVD and CRC in adults aged 70 years or older. (I statement).
Article
Advances in medical knowledge proceed on several fronts, optimally simultaneously. Each discipline provides unique, relevant, and complementary information to a totality of evidence. When the totality of evidence is sufficient, health care professionals can make the most rational decisions for individual patients and policy makers can make the most rational decisions for the health of the general public.1 When the totality of evidence is incomplete, it is appropriate to remain uncertain.2 Nonetheless, health care professionals and policy makers are always faced with decision making. Although medical researchers are likely to be familiar with these concepts, this commentary is primarily for clinicians and policy makers to increase their knowledge and understanding of the unique contributions of different types of evidence to the conclusion of a valid statistical association as well as the need to evaluate the totality of evidence to judge causality.
Preventive Services Task Force Recommendation Statement
S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2016;164(12):836-845. https://doi.org/10.7326/M16-0577.
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