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Chen Q, van Rein N, van der Hulle T, Heemelaar JC, Trines SA, Versteeg HH, Klok FA, Cannegieter SC. Coexisting atrial fibrillation and cancer: time trends and associations with mortality in a nationwide Dutch study. Eur Heart J 2024; 45:2201-2213. [PMID: 38619538 PMCID: PMC11231645 DOI: 10.1093/eurheartj/ehae222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 02/24/2024] [Accepted: 03/26/2024] [Indexed: 04/16/2024] Open
Abstract
BACKGROUND AND AIMS Coexisting atrial fibrillation (AF) and cancer challenge the management of both. The aim of the study is to comprehensively provide the epidemiology of coexisting AF and cancer. METHODS Using Dutch nationwide statistics, individuals with incident AF (n = 320 139) or cancer (n = 472 745) were identified during the period 2015-19. Dutch inhabitants without a history of AF (n = 320 135) or cancer (n = 472 741) were matched as control cohorts by demographic characteristics. Prevalence of cancer/AF at baseline, 1-year risk of cancer/AF diagnosis, and their time trends were determined. The association of cancer/AF diagnosis with all-cause mortality among those with AF/cancer was estimated by using time-dependent Cox regression. RESULTS The rate of prevalence of cancer in the AF cohort was 12.6% (increasing from 11.9% to 13.2%) compared with 5.6% in the controls; 1-year cancer risk was 2.5% (stable over years) compared with 1.8% in the controls [adjusted hazard ratio (aHR) 1.52, 95% confidence interval (CI) 1.46-1.58], which was similar by cancer type. The rate of prevalence of AF in the cancer cohort was 7.5% (increasing from 6.9% to 8.2%) compared with 4.3% in the controls; 1-year AF risk was 2.8% (stable over years) compared with 1.2% in the controls (aHR 2.78, 95% CI 2.69-2.87), but cancers of the oesophagus, lung, stomach, myeloma, and lymphoma were associated with higher hazards of AF than other cancer types. Both cancer diagnosed after incident AF (aHR 7.77, 95% CI 7.45-8.11) and AF diagnosed after incident cancer (aHR 2.55, 95% CI 2.47-2.63) were associated with all-cause mortality, but the strength of the association varied by cancer type. CONCLUSIONS Atrial fibrillation and cancer were associated bidirectionally and were increasingly coexisting, but AF risk varied by cancer type. Coexisting AF and cancer were negatively associated with survival.
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Affiliation(s)
- Qingui Chen
- Department of Clinical Epidemiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Nienke van Rein
- Department of Clinical Epidemiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Tom van der Hulle
- Department of Medical Oncology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Julius C Heemelaar
- Department of Cardiology, Heart Lung Center, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
- Cardiovascular Imaging Research Center, Division of Cardiology, and Department of Radiology, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, USA
| | - Serge A Trines
- Department of Cardiology, Heart Lung Center, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Henri H Versteeg
- Department of Medicine, Section of Thrombosis and Hemostasis, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Frederikus A Klok
- Department of Medicine, Section of Thrombosis and Hemostasis, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Suzanne C Cannegieter
- Department of Clinical Epidemiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
- Department of Medicine, Section of Thrombosis and Hemostasis, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
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Potter AS, Hulsukar MM, Wu L, Narasimhan B, Karimzad K, Koutroumpakis E, Palaskas N, Deswal A, Kantharia BK, Wehrens XH. Kinase Inhibitors and Atrial Fibrillation. JACC Clin Electrophysiol 2023; 9:591-602. [PMID: 37100538 DOI: 10.1016/j.jacep.2022.11.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 10/13/2022] [Accepted: 11/30/2022] [Indexed: 02/24/2023]
Abstract
Recent advances have significantly expanded the options of available therapeutics for cancer treatment, including novel targeted cancer therapies. Within this broad category of targeted therapies is the class of kinase inhibitors (KIs), which target kinases that have undergone aberrant activation in cancerous cells. Although KIs have shown a benefit in treating various forms of malignancy, they have also been shown to cause a wide array of cardiovascular toxicities, with cardiac arrhythmias, in particular atrial fibrillation (AF), being 1 of the predominant side effects. The occurrence of AF in patients undergoing cancer treatment can complicate the treatment approach and poses unique clinical challenges. The association of KIs and AF has led to new research aimed at trying to elucidate the underlying mechanisms. Furthermore, there are unique considerations to treating KI-induced AF because of the anticoagulant properties of some KIs as well as drug-drug interactions with KIs and some cardiovascular medications. Here, we review the current literature pertaining to KI-induced AF.
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The Association of New-Onset Atrial Fibrillation and Risk of Cancer: A Systematic Review and Meta-Analysis. Cardiol Res Pract 2020; 2020:2372067. [PMID: 33062319 PMCID: PMC7537679 DOI: 10.1155/2020/2372067] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 08/03/2020] [Indexed: 12/02/2022] Open
Abstract
Background There are distinct results for the relationship between new-onset atrial fibrillation (NOAF) and subsequent incident cancer. To date, no systematic analysis has been conducted on this issue. This study aims to explore the relationship between NOAF and the risk of developing cancer through a meta-analysis with a large sample size. Methods Electronic databases, such as PubMed and EMBASE, were searched for published relevant studies on NOAF patients diagnosed with cancer after and during follow-ups, including reported records of baseline information and the statistical result of morbidity. Two investigators independently reviewed the articles and extracted the data using uniform standards and definitions. The meta-analysis was conducted using the Cochrane Program Review Manager. Results This meta-analysis consisted of five cohort studies and one case-control study, which comprised 533,514 participants. The pooled relative risk (RR) for incident cancer was 1.24 (95% CI: 1.10–1.39, P=0.0003). The temporal trend analysis demonstrated that an increased risk of cancer was observed during the initial 90 days (RR: 3.44, 95% CI: 2.29–5.57, P < 0.00001), but not after that. Lung cancer (RR: 1.51, 95% CI: 1.47–1.55, P < 0.00001) was associated with NOAF, but not colorectal cancer and breast cancer. Conclusion This meta-analysis provides evidence that NOAF is associated with increased risk of cancer. The risk of incident cancer particularly increases within 90 days after NOAF diagnosis, but not after that.
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Lateef N, Kapoor V, Ahsan MJ, Latif A, Ahmed U, Mirza M, Anwar F, Holmberg M. Atrial fibrillation and cancer; understanding the mysterious relationship through a systematic review. J Community Hosp Intern Med Perspect 2020; 10:127-132. [PMID: 32850047 PMCID: PMC7425610 DOI: 10.1080/20009666.2020.1726571] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Background Atrial Fibrillation (AFib) is the most common cardiac arrhythmia, occurring in ≈1% of the general population. An increased risk of malignancy among patients with AFib would be of substantial public health importance, given the high prevalence and associated economic burden of both disorders. Objectives To evaluate the relationship between atrial fibrillation (AFib) and cancer. Methods We conducted an extensive database search on PubMed, Google Scholar, ScienceDirect, and SEER Database from their inception to September 2019 for any study that evaluated the association between AFib and cancer. Results In the first 3 months of AFib diagnosis, Ostenfeld et al. reported an absolute cancer risk of 2.5% with a standardized incidence ratio of 7.02 and 3.53 for metastatic and localized cancer, respectively. Likewise, Saliba et al. detected an increase in the odds of cancer diagnosis in first 90 days after AF diagnosis with OR of 1.85. Moreover, in another study new-onset breast and colorectal cancer was especially associated with AF in the first 90 days after diagnosis with HR of 3.4 but not thereafter (HR 1.0). Similarly, Conen et al. reported high relative risk of cancer with HR of 3.54 in the first 3 months after new-onset AFib. However, beyond the initial 90 day period, the risk of cancer in AFib is only slightly increased. Conclusion Based on our review, there appears to be an increase in risk of subsequent diagnosis of cancer in patients with AF, likely owing to the shared risk factors between the two conditions. While the results of this study raise interesting questions for future search, they are not currently strong enough to justify initiating cancer screening for an occult cancer in a patient with AF. Regardless, measures to target modification of these shared risk factors remains an important consideration.
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Affiliation(s)
- Noman Lateef
- Department of Internal Medicine, Creighton University Medical Center, Omaha, NE, USA
| | - Vikas Kapoor
- Department of Internal Medicine, Creighton University Medical Center, Omaha, NE, USA
| | - Muhammad Junaid Ahsan
- Department of Internal Medicine, Creighton University Medical Center, Omaha, NE, USA
| | - Azka Latif
- Department of Internal Medicine, Creighton University Medical Center, Omaha, NE, USA
| | - Umair Ahmed
- Department of Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Mohsin Mirza
- Department of Internal Medicine, Creighton University Medical Center, Omaha, NE, USA
| | - Faiz Anwar
- Department of Hematology and Medical Oncology, Cleveland Clinic, Cleveland, OH, USA
| | - Mark Holmberg
- Department of Cardiovascular Medicine, Creighton University Medical Center, Omaha, NE, USA
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Affiliation(s)
| | - Javid Moslehi
- Division of Cardiovascular MedicineClinical PharmacologyCardio‐Oncology ProgramVanderbilt University Medical Center and Vanderbilt‐Ingram Cancer CenterNashvilleTN
- Division of OncologyVanderbilt University Medical Center and Vanderbilt‐Ingram Cancer CenterNashvilleTN
| | - Rudolf A. de Boer
- Department of CardiologyUniversity Medical Center GroningenUniversity of Groningenthe Netherlands
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Risk and predictors of subsequent cancers of patients with newly-diagnosed atrial fibrillation — A nationwide population-based study. Int J Cardiol 2019; 296:81-86. [DOI: 10.1016/j.ijcard.2019.08.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Revised: 07/14/2019] [Accepted: 08/07/2019] [Indexed: 11/19/2022]
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Association of Cancer and the Risk of Developing Atrial Fibrillation: A Systematic Review and Meta-Analysis. Cardiol Res Pract 2019; 2019:8985273. [PMID: 31110819 PMCID: PMC6487146 DOI: 10.1155/2019/8985273] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Revised: 02/18/2019] [Accepted: 03/03/2019] [Indexed: 12/18/2022] Open
Abstract
Aims Previous studies have demonstrated epidemiological evidence for an association between cancer and the development of new-onset atrial fibrillation (AF). However, these results have been conflicting. This systematic review and meta-analysis was conducted to examine the relationship between cancer and the risk of developing atrial fibrillation. Methods PubMed and Web of Science were searched for publications examining the association between cancer and atrial fibrillation risk published until June 2017. Adjusted odds ratios (ORs) or hazard ratios (HRs) and 95% CI were extracted and pooled. Results A total of five studies involving 5,889,234 subjects were included in this meta-analysis. Solid cancer patients are at higher risk developing atrial fibrillation compared to noncancer patients (OR 1.47, 95% CI 1.31 to 1.66, p < 0.00001; I2 = 67%, p=0.02). The risk of atrial fibrillation was highest within 90 days of cancer diagnosis (OR 7.62, 95% CI 3.08 to 18.88, p < 0.00001) and this risk diminished with time. Conclusions The risk of AF was highest within 90 days of cancer diagnosis. We should take into account the increased risk of atrial fibrillation development and, after this, study the embolic risk and potential indication of oral anticoagulation.
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Affiliation(s)
- Faisal Rahman
- Department of Medicine, Boston University Medical Center, Boston, Massachusetts
| | - Darae Ko
- Department of Medicine, Boston University Medical Center, Boston, Massachusetts
| | - Emelia J Benjamin
- Section of Cardiovascular Medicine, Preventive Medicine, and Epidemiology, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts3National Heart, Lung, and Blood Institute's and Boston University's Framingham Heart Study, Fram
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Mery B, Guichard JB, Guy JB, Vallard A, Barthelemy JC, Da Costa A, Magné N, Bertoletti L. Atrial fibrillation in cancer patients: Hindsight, insight and foresight. Int J Cardiol 2017; 240:196-202. [DOI: 10.1016/j.ijcard.2017.03.132] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Revised: 03/21/2017] [Accepted: 03/28/2017] [Indexed: 10/19/2022]
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Wassertheil-Smoller S, McGinn AP, Martin L, Rodriguez BL, Stefanick ML, Perez M. The Associations of Atrial Fibrillation With the Risks of Incident Invasive Breast and Colorectal Cancer. Am J Epidemiol 2017; 185:372-384. [PMID: 28174828 DOI: 10.1093/aje/kww185] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Accepted: 05/02/2016] [Indexed: 11/13/2022] Open
Abstract
Atrial fibrillation (AF) is a common arrhythmia that poses a significant risk of stroke. Cross-sectional and case-control studies have shown evidence of associations between AF and breast or colorectal cancer, but there have been no longitudinal studies in which this has been assessed. We prospectively examined a cohort of 93,676 postmenopausal women enrolled in the Women's Health Initiative from 1994 to 1998 to determine whether there are relationships between baseline AF and the development of invasive breast or colorectal cancer. The prevalence of self-reported physician diagnosis of AF at baseline was 5.1%. Over approximately 15 years of follow-up, the incidence of invasive breast cancer was 5.7%, and the incidence of colorectal cancer was 1.6%. Adjusted hazard ratios and 95% confidence intervals were obtained using Cox proportional hazards models. We found no significant association between AF and incident colorectal cancer, but we did see a 19% excess risk of invasive breast cancer among those with AF (adjusted hazard ratio (HR) = 1.19, 95% confidence interval (CI): 1.03, 1.38). Additional adjustment for baseline use of cardiac glycosides attenuated the association between AF and invasive breast cancer (HR = 1.01, 95% CI: 0.85, 1.20). Cardiac glycoside use was strongly associated with incident invasive breast cancer (HR = 1.68, 95% CI: 1.33, 2.12) independent of AF and other confounders. Mechanisms of the associations among breast cancer, AF, and cardiac glycosides need further investigation.
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Herendeen JM, Lindley C. Use of NSAIDs for the Chemoprevention of Colorectal Cancer. Ann Pharmacother 2016; 37:1664-74. [PMID: 14565811 DOI: 10.1345/aph.1c489] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
OBJECTIVE: To discuss the role of nonsteroidal antiinflammatory drugs (NSAIDs) in the chemoprevention of colorectal cancer. DATA SOURCES: A MEDLINE search (1966–May 2003) was performed to identify key literature. Search items included, but were not limited to, NSAIDs, colorectal cancer, chemoprevention, cyclooxygenase-2 (COX-2)–specific inhibitors, and familial adenomatous polyposis (FAP). STUDY SELECTION AND DATA EXTRACTION: The search included experimental (in vitro and animal models) and clinical studies evaluating the use of NSAIDs for the chemoprevention of colorectal cancer. The MEDLINE search was supplemented by references from selected articles. DATA SYNTHESIS: Numerous experimental, epidemiologic, and clinical studies suggest that NSAIDs have promise as anticancer agents. The mechanism by which NSAIDs lead to decreased colon carcinogenesis is not fully understood, but may involve restoration of apoptosis and inhibition of prostaglandin-mediated angiogenesis. Compelling evidence from many observational studies has consistently documented a 40–50% reduction in the risk of adenomatous polyps, colorectal cancer incidence, and mortality in patients using NSAIDs. Recent randomized, controlled trials have demonstrated a benefit with aspirin in reducing the rate of development of new or recurrent adenomas in high-risk patients. In addition, randomized studies using sulindac and celecoxib in patients with FAP have documented significant regression of existing adenomatous polyps. CONCLUSIONS: Inhibition of COX-2 is an example of a targeted approach to the chemoprevention of colorectal cancer. However, controversy exists about the safety, efficacy, and optimal treatment regimen of NSAIDs as long-term chemopreventive agents in the general population. Ongoing studies in high-risk patients with both selective and nonselective COX inhibitors will provide important information in the area of colorectal chemoprevention, but clinical trials' use of adenomas as surrogate markers for chemoprevention trials makes their application to the general population limited.
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Affiliation(s)
- Jill M Herendeen
- University of North Carolina School of Pharmacy, Chapel Hill, NC, USA
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Cheng WL, Kao YH, Chen SA, Chen YJ. Pathophysiology of cancer therapy-provoked atrial fibrillation. Int J Cardiol 2016; 219:186-94. [PMID: 27327505 DOI: 10.1016/j.ijcard.2016.06.009] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Accepted: 06/11/2016] [Indexed: 02/07/2023]
Abstract
Atrial fibrillation (AF) occurs with increased frequency in cancer patients, especially in patients who undergo surgery or chemotherapy. AF disturbs the prognosis of cancer patients and challenges therapeutic outcomes of cancer treatment. Elucidating the mechanisms of cancer-induced AF would help identify specific strategies for preventing AF occurrence. In addition to concurrent risk factors of cancer and AF, cancer surgery, side effects of anticancer agents, and cancer-associated immune responses play critical roles in the genesis of AF. In this review, we provide succinct potential mechanisms of AF genesis in cancer patients.
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Affiliation(s)
- Wan-Li Cheng
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Yu-Hsun Kao
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; Department of Medical Education and Research, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Shih-Ann Chen
- School of Medicine, National Yang-Ming University, Taipei, Taiwan; Division of Cardiology and Cardiovascular Research Center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yi-Jen Chen
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; Division of Cardiovascular Medicine, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.
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Lee YJ, Park JK, Uhm JS, Kim JY, Pak HN, Lee MH, Sung JH, Joung B. Bleeding risk and major adverse events in patients with cancer on oral anticoagulation therapy. Int J Cardiol 2015; 203:372-8. [PMID: 26539960 DOI: 10.1016/j.ijcard.2015.10.166] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Accepted: 10/19/2015] [Indexed: 11/24/2022]
Abstract
BACKGROUND The efficacy of oral anticoagulation therapy (OAT) has not been revealed in atrial fibrillation (AF) patients with newly diagnosed cancers. This study evaluated the thromboembolic and bleeding events in AF patients with malignancies according to OAT. METHODS AND RESULTS In 2168 consecutive non-valvular AF patients with newly diagnosed malignancies, we analyzed the composite endpoints including major adverse cardiac events (MACEs) and major bleeding. Based on a propensity score matching, two groups with 690 matched pairs were created. Patient baseline characteristics were comparable between the matched groups. During a follow-up period of 3.9 ± 2.8 years, 72 (10%) and 65 (9%) patients had MACEs in the propensity score-matched OAT + and OAT − groups, respectively (p = 0.461). There was no significant difference in the major bleeding (10% vs. 8%, p = 0.300) and composite endpoints (18% vs. 16%, p = 0.181) between OAT + and OAT − patients. During the first year after the cancer diagnosis, 66 (48%) MACEs, 52 (41%) major bleedings, and 116 (49%) composite end points of all events occurred. The optimal international normalized ratio (2.0 to 3.0) level was achieved in only 85 (12%) patients. However, 1 year after cancer diagnosis, OAT + patients with the target therapeutic range of ≥ 60% demonstrated better cumulative survival free of composite end point than OAT − patients (p = 0.026). CONCLUSION During the first year after the cancer diagnosis, OAT did not improve the composite end point because of poor INR control caused by cancer treatment. However, after 1 year after diagnosis of cancer, optimal anticoagulation significantly reduced the composite end point.
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Affiliation(s)
- Yong-Joon Lee
- Division of Cardiology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jin-kyu Park
- Division of Cardiology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jae-Sun Uhm
- Division of Cardiology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jong-Yun Kim
- Division of Cardiology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hui-Nam Pak
- Division of Cardiology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Moon-Hyoung Lee
- Division of Cardiology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jung-Hoon Sung
- Division of Cardiology, Bundang CHA Medical Center, CHA University, Seongnam, Republic of Korea
| | - Boyoung Joung
- Division of Cardiology, Yonsei University College of Medicine, Seoul, Republic of Korea.
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Nouraie M, Kansal V, Belfonte C, Ghazvini M, Haidari T, Shahnazi A, Brim H, Soliman EZ, Ashktorab H. Atrial Fibrillation and Colonic Neoplasia in African Americans. PLoS One 2015; 10:e0135609. [PMID: 26317627 PMCID: PMC4552839 DOI: 10.1371/journal.pone.0135609] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Accepted: 07/24/2015] [Indexed: 01/15/2023] Open
Abstract
Background Colorectal cancer (CRC) and atrial fibrillation/flutter (AF) share several risk factors including increasing age and obesity. However, the association between CRC and AF has not been thoroughly examined, especially in African Americans. In this study we aimed to assess the prevalence of AF and its risk factors in colorectal neoplasia in an African American. Methods We reviewed records of 527 African American patients diagnosed with CRC and 1008 patients diagnosed with benign colonic lesions at Howard University Hospital from January 2000 to December 2012. A control group of 731 hospitalized patients without any cancer or colonic lesion were randomly selected from the same time and age range, excluding patients who had diagnosis of both CRC and/or adenoma. The presence or absence of AF was based upon ICD-9 code documentation. The prevalence of AF in these three groups was compared by multivariate logistic regression. Results The prevalence of AF was highest among CRC patients (10%) followed by adenoma patients (7.2%) then the control group (5.4%, P for trend = 0.002). In the three groups of participants, older age (P<0.008) and heart failure (P<0.001) were significantly associated with higher risk of AF. After adjusting for these risk factors, CRC (OR: 1.4(95%CI):0.9–2.2, P = 0.2) and adenoma (OR: 1.1(95%CI):0.7–1.6, P = 0.7) were not significantly associated AF compared to control group. Conclusions AF is highly prevalent among CRC patients; 1 in 10 patients had AF in our study. The predictors of AF in CRC was similar to that in adenoma and other patients after adjustment for potential confounders suggesting that the increased AF risk in CRC is explained by higher prevalence of AF risk factors.
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Affiliation(s)
- Mehdi Nouraie
- Cancer Research Center, and Department of Medicine, Howard University College of Medicine, Washington, District of Columbia, United States of America
- * E-mail: (MN); (HA)
| | - Vandana Kansal
- Cancer Research Center, and Department of Medicine, Howard University College of Medicine, Washington, District of Columbia, United States of America
| | - Cassius Belfonte
- Department of Medicine, Division of Cardiology, Howard University College of Medicine, Washington, District of Columbia, United States of America
| | - Mohammad Ghazvini
- Department of Medicine, Division of Cardiology, Howard University College of Medicine, Washington, District of Columbia, United States of America
| | - Tahmineh Haidari
- Cancer Research Center, and Department of Medicine, Howard University College of Medicine, Washington, District of Columbia, United States of America
| | - Anahita Shahnazi
- Cancer Research Center, and Department of Medicine, Howard University College of Medicine, Washington, District of Columbia, United States of America
| | - Hassan Brim
- Cancer Research Center, and Department of Pathology, Howard University College of Medicine, Washington, District of Columbia, United States of America
| | - Elsayed Z. Soliman
- Epidemiological Cardiology Research Center, Department of Epidemiology and Prevention, Wake Forest School of Medicine, Winston Salem, North Carolina, United States of America
- Department of Internal Medicine-Cardiology, Wake Forest School of Medicine, Winston Salem, North Carolina, United States of America
| | - Hassan Ashktorab
- Cancer Research Center, and Department of Medicine, Howard University College of Medicine, Washington, District of Columbia, United States of America
- * E-mail: (MN); (HA)
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O'Neal WT, Lakoski SG, Qureshi W, Judd SE, Howard G, Howard VJ, Cushman M, Soliman EZ. Relation between cancer and atrial fibrillation (from the REasons for Geographic And Racial Differences in Stroke Study). Am J Cardiol 2015; 115:1090-4. [PMID: 25711434 DOI: 10.1016/j.amjcard.2015.01.540] [Citation(s) in RCA: 97] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Revised: 01/13/2015] [Accepted: 01/13/2015] [Indexed: 11/26/2022]
Abstract
Atrial fibrillation (AF) is common in patients with life-threatening cancer and those undergoing active cancer treatment. However, data from subjects with a history of non-life-threatening cancer and those who do not require active cancer treatment are lacking. A total of 15,428 (mean age 66 ± 8.9 years; 47% women; 45% blacks) participants from the REasons for Geographic And Racial Differences in Stroke (REGARDS) study with baseline data on previous cancer diagnosis and AF were included. Participants with life-threatening cancer and active cancer treatment within 2 years of study enrollment were excluded. History of cancer was identified using computer-assisted telephone interviews. AF cases were identified from baseline electrocardiogram data and by a self-reported history of a previous diagnosis. Logistic regression was used to examine the cross-sectional association between cancer diagnosis and AF. A total of 2,248 (15%) participants had a diagnosis of cancer and 1,295 (8.4%) had AF. In a multivariable logistic regression model adjusted for sociodemographic characteristics (age, gender, race, education, income, and region of residence) and cardiovascular risk factors (systolic blood pressure, high-density lipoprotein cholesterol, total cholesterol, C-reactive protein, body mass index, smoking, diabetes, antihypertensive and lipid-lowering agents, left ventricular hypertrophy, and cardiovascular disease), those with cancer were more likely to have prevalent AF than those without cancer (odds ratio 1.19, 95% confidence interval 1.02 to 1.38). Subgroup analyses by age, sex, race, cardiovascular disease, and C-reactive protein yielded similar results. In conclusion, AF was more prevalent in participants with a history of non-life-threatening cancer and those who did not require active cancer treatment in REGARDS.
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Sakamoto A, Fujishiro M, Koike K, Nagai R, Ishizaka N. The prevalence of malignant neoplastic and non-malignant gastrointestinal lesions in cardiology inpatients. J Cardiol 2013. [DOI: 10.1016/j.jjcc.2012.10.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Gastrointestinal malignancies and cardiovascular diseases—Non-negligible comorbidity in an era of multi-antithrombotic drug use. J Cardiol 2011; 58:199-207. [DOI: 10.1016/j.jjcc.2011.08.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2011] [Revised: 07/19/2011] [Accepted: 08/18/2011] [Indexed: 12/23/2022]
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Prevention by Aspirin of Colorectal Adenoma Recurrence: Some Advances and Latest Results of the APACC Trial. CURRENT COLORECTAL CANCER REPORTS 2011. [DOI: 10.1007/s11888-010-0079-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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19
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Gao F, Liao C, Liu L, Tan A, Cao Y, Mo Z. The effect of aspirin in the recurrence of colorectal adenomas: a meta-analysis of randomized controlled trials. Colorectal Dis 2009; 11:893-901. [PMID: 19055515 DOI: 10.1111/j.1463-1318.2008.01746.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE Colorectal adenomas are precursors of most colorectal cancers and are important targets for chemoprevention. Aspirin is thought to play an important role in chemoprevention. However, the role of aspirin in preventing recurrence of adenomas is controversial. We performed a systematic review and meta-analysis to evaluate the effect of aspirin in preventing the recurrence of colorectal adenoma. METHOD Trials were located through Medline, Embase and the Cochrane Central Register of Controlled Trials (CENTRAL). From 14 articles screened, three were identified as randomized controlled trials and were included for data extraction. Main outcome measures were the recurrence of any new adenoma and advanced adenoma. The meta-analysis was performed with the fixed-effects model. RESULTS A total of 2338 participants were enrolled in the three studies and 2175 of them completed the follow-up colonoscopy. We found that the relative risks of any adenoma (when compared with the placebo group) were 0.859 in the high dose of aspirin groups (95% confidence interval (CI), 0.756-0.976, P = 0.019), 0.826 in the low dose of aspirin groups (95% CI 0.706-0.965, P = 0.016) and 0.836 in the both aspirin combined groups (95% CI 0.746-0.937, P = 0.002). For the recurrence of advanced adenoma, the relative risk (when compared with the placebo group) was 0.655 (95% CI 0.513-0.837, P = 0.001) in the aspirin groups without considering the dose. CONCLUSION This meta-analysis suggests that aspirin prevents recurrent colorectal adenomas among patients with a history of colorectal adenomas.
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Affiliation(s)
- F Gao
- Departments of Colorectal and Anal Surgery, First Affiliated Hospital, Guangxi Medical University, Nanning, Guangxi, P.R. China.
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Guzzetti S, Costantino G, Vernocchi A, Sada S, Fundarò C. First diagnosis of colorectal or breast cancer and prevalence of atrial fibrillation. Intern Emerg Med 2008; 3:227-31. [PMID: 18320149 DOI: 10.1007/s11739-008-0124-4] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2007] [Accepted: 01/02/2008] [Indexed: 02/02/2023]
Abstract
Aim of the present study was to assess the prevalence of atrial fibrillation (AF) in patients with two different types of cancer. Recent epidemiologic and clinical studies support the hypothesis that AF is promoted and maintained by a broad spectrum of modulating factors. A total of 2,339 patients admitted to the Surgery Department of "Luigi Sacco Hospital, Milan," over the period 1987-2004 were eligible for the study. One thousand three hundred and seventeen patients were admitted consecutively with a first diagnosis of colorectal or breast cancer (cases). The remaining 1,022 were patients admitted to undergo non-neoplastic surgery (controls). Routine pre-surgery electrocardiogram available in patient charts was analysed by a cardiologist who was not aware of the present study to evaluate the presence of atrial fibrillation or other arrhythmias. Overall, AF was present in 3.6% cases and 1.6% controls. This corresponded to at least two times higher likelihood of having AF in cases compared to controls. Prevalence of AF increased with age both in cases and controls. Our study describes an increased prevalence of AF in two different types of cancer. Autonomic, endocrine, coagulation, and inflammatory alterations were previously described in both AF and cancer, and can provide the physiopathological basis to our clinical observation.
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Affiliation(s)
- Stefano Guzzetti
- Medicina Interna I, Ospedale Luigi Sacco, Polo Universitario dell'Università degli Studi di Milano, Via GB Grassi, 74, 20157, Milan, Italy.
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Chan AT, Giovannucci EL, Meyerhardt JA, Schernhammer ES, Wu K, Fuchs CS. Aspirin dose and duration of use and risk of colorectal cancer in men. Gastroenterology 2008; 134:21-8. [PMID: 18005960 PMCID: PMC2719297 DOI: 10.1053/j.gastro.2007.09.035] [Citation(s) in RCA: 177] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2007] [Accepted: 09/13/2007] [Indexed: 12/20/2022]
Abstract
BACKGROUND & AIMS Long-term data on the risk of colorectal cancer according to dose, duration, and consistency of aspirin therapy are limited. METHODS We conducted a prospective study of 47,363 male health professionals who were ages 40-75 years at enrollment in 1986. Biennially, we collected data on aspirin use, other risk factors, and diagnoses of colorectal cancer. We confirmed all reports of colorectal cancer through 2004 by review of medical records. RESULTS During 18 years of follow-up, we documented 975 cases of colorectal cancer over 761,757 person-years. After adjustment for risk factors, men who regularly used aspirin (>/=2 times per week) had a multivariate relative risk (RR) for colorectal cancer of 0.79 (95% confidence interval, [CI], 0.69-0.90) compared with nonregular users. However, significant risk reduction required at least 6-10 years of use (P for trend = .008) and was no longer evident within 4 years of discontinuing use (multivariate RR, 1.00; CI, 0.72-1.39). The benefit appeared related to increasing cumulative average dose: compared with men who denied any aspirin use, the multivariate RRs for cancer were 0.94 (CI, 0.75-1.18) for men who used 0.5-1.5 standard aspirin tablets per week, 0.80 (CI, 0.63-1.01) for 2-5 aspirin tablets per week, 0.72 (CI, 0.56-0.92) for 6-14 aspirin tablets per week, and 0.30 (CI, 0.11-0.81) for >14 aspirin tablets per week (P for trend = .004). CONCLUSIONS Regular, long-term aspirin use reduces risk of colorectal cancer among men. However, the benefit of aspirin necessitates at least 6 years of consistent use, with maximal risk reduction at doses greater than 14 tablets per week. The potential hazards associated with long-term use of such doses should be carefully considered.
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Affiliation(s)
- Andrew T. Chan
- Gastrointestinal Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Channing Laboratory, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston
| | - Edward L. Giovannucci
- Channing Laboratory, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Cancer Epidemiology Program, Dana-Farber/Harvard Cancer Center, Boston, Department of Epidemiology, Harvard School of Public Health, Boston, Department of Nutrition, Harvard School of Public Health, Boston
| | - Jeffrey A. Meyerhardt
- Cancer Epidemiology Program, Dana-Farber/Harvard Cancer Center, Boston, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston
| | - Eva S. Schernhammer
- Channing Laboratory, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston
| | - Kana Wu
- Department of Nutrition, Harvard School of Public Health, Boston
| | - Charles S. Fuchs
- Channing Laboratory, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Cancer Epidemiology Program, Dana-Farber/Harvard Cancer Center, Boston, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston
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Hoffmeister M, Chang-Claude J, Brenner H. Do older adults using NSAIDs have a reduced risk of colorectal cancer? Drugs Aging 2006; 23:513-23. [PMID: 16872234 DOI: 10.2165/00002512-200623060-00006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
BACKGROUND AND OBJECTIVES Colorectal cancer (CRC) is primarily a disease of older adults. Although NSAIDs are thought to protect from CRC, and long-term use of NSAIDs is common in the elderly, little is known about the impact of NSAID use on CRC risk at advanced age. We specifically reviewed current evidence regarding the effects of NSAIDs on CRC risk in individuals aged > or =65 years, a rapidly growing age group. STUDY DESIGN We searched all articles in PubMed published before August 2005. Studies were included if a subgroup analysis of older adults (> or =65 years of age) was performed, or if long-term use of NSAIDs for > or =5 years and CRC risk was investigated. From the selected studies, relevant information, including sample characteristics and association with CRC risk, was extracted and compared. RESULTS Altogether 19 studies were identified. Only four studies specifically considered NSAID use in people > or =65 years of age; of these, two showed risk reduction for CRC comparable to that seen in younger age groups or in all age groups. The most informative observational studies found decreasing relative risk of CRC with increasing duration of NSAID use, suggesting substantial risk reduction after 10-20 years of regular use. CONCLUSIONS The available data on long-term effects of NSAID use in elderly people are sparse but predominantly indicate risk reduction for CRC comparable to that seen in younger age groups or all ages. Whether and to what degree initiating NSAID use in old age prevents CRC is essentially unknown. In light of the potential adverse effects of NSAIDs, including recent data on adverse cardiovascular outcomes, more information is needed on the minimum effective dose of NSAIDs and the duration of use required in order to evaluate individual risks and benefits in older adults.
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Affiliation(s)
- Michael Hoffmeister
- Department of Epidemiology, German Centre for Research on Ageing (DZFA), Heidelberg, Germany
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Stürmer T, Buring JE, Lee IM, Kurth T, Gaziano JM, Glynn RJ. Colorectal cancer after start of nonsteroidal anti-inflammatory drug use. Am J Med 2006; 119:494-502. [PMID: 16750963 PMCID: PMC1475702 DOI: 10.1016/j.amjmed.2005.11.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2005] [Indexed: 11/28/2022]
Abstract
PURPOSE Nonsteroidal anti-inflammatory drugs (NSAIDs), including aspirin, have been consistently shown to reduce the risk of colorectal cancer (CRC) in non-experimental studies, but little is known of the factors associated with starting and continuing regular NSAID use and their effect on the NSAID and CRC association. SUBJECTS AND METHODS We performed a prospective cohort study of 22,071 healthy male physicians aged 40 to 84 years without indications or contraindications to regular NSAID use at baseline. Annual questionnaires assessed quantity of NSAID use, occurrence of cancer, and risk factors for CRC. Propensity for regular NSAID use (>60 days/year) was estimated using generalized estimating equations. We used a time-varying Cox proportional hazards model to estimate the association between duration since initiation of regular NSAID use and risk for CRC. RESULTS Regular non-aspirin and any NSAID use increased from 0% to 12% and 1% to 56% over time, respectively and was predicted by age, body mass index, alcohol consumption, medication use, coronary artery disease, gastrointestinal diseases, arthritis, hypertension, and headaches. Over a median follow-up of 18 years, 495 physicians were diagnosed with CRC. There was no trend of CRC risk with increased duration of regular NSAID use. Five or more years of regular use of any NSAID were associated with a relative risk for CRC of 1.0 (95% confidence interval: 0.7-1.5), after adjustment for predictors of regular NSAID use. CONCLUSION Regular NSAID use was not associated with a substantial risk reduction of CRC after controlling for time-varying predictors of both NSAID use and CRC.
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Affiliation(s)
- Til Stürmer
- Division of Preventive Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass 02215, USA.
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Chan AT, Giovannucci EL, Meyerhardt JA, Schernhammer ES, Curhan GC, Fuchs CS. Long-term use of aspirin and nonsteroidal anti-inflammatory drugs and risk of colorectal cancer. JAMA 2005; 294:914-23. [PMID: 16118381 PMCID: PMC1550973 DOI: 10.1001/jama.294.8.914] [Citation(s) in RCA: 332] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
CONTEXT Randomized trials of short-term aspirin use for prevention of recurrent colorectal adenoma have provided compelling evidence of a causal relationship between aspirin and colorectal neoplasia. However, data on long-term risk of colorectal cancer according to dose, timing, or duration of therapy with aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) remain limited. OBJECTIVE To examine the influence of aspirin and NSAIDs in prevention of colorectal cancer. DESIGN, SETTING, AND PARTICIPANTS Prospective cohort study of 82 911 women enrolled in the Nurses' Health Study providing data on medication use biennially since 1980 and followed up through June 1, 2000. MAIN OUTCOME MEASURE Incident colorectal cancer. RESULTS Over a 20-year period, we documented 962 cases of colorectal cancer. Among women who regularly used aspirin (> or =2 standard [325-mg] tablets per week), the multivariate relative risk (RR) for colorectal cancer was 0.77 (95% confidence interval [CI], 0.67-0.88) compared with nonregular users. However, significant risk reduction was not observed until more than 10 years of use (P< or =.001 for trend). The benefit appeared related to dose: compared with women who reported no use, the multivariate RRs for cancer were 1.10 (95% CI, 0.92-1.31) for women who used 0.5 to 1.5 standard aspirin tablets per week, 0.89 (95% CI, 0.73-1.10) for 2 to 5 aspirin per week, 0.78 (95% CI, 0.62-0.97) for 6 to 14 aspirin per week, and 0.68 (95% CI, 0.49-0.95) for more than 14 aspirin per week (P<.001 for trend). Notably, women who used more than 14 aspirin per week for longer than 10 years in the past had a multivariate RR for cancer of 0.47 (95% CI, 0.31-0.71). A similar dose-response relationship was found for nonaspirin NSAIDs (P = .007 for trend). The incidence of reported major gastrointestinal bleeding events per 1000 person-years also appeared to be dose-related: 0.77 among women who denied any aspirin use; 1.07 for 0.5 to 1.5 standard aspirin tablets per week; 1.07 for 2 to 5 aspirin per week; 1.40 for 6 to 14 aspirin per week; and 1.57 for more than 14 aspirin per week. CONCLUSIONS Regular, long-term aspirin use reduces risk of colorectal cancer. Nonaspirin NSAIDs appear to have a similar effect. However, a significant benefit of aspirin is not apparent until more than a decade of use, with maximal risk reduction at doses greater than 14 tablets per week. These results suggest that optimal chemoprevention for colorectal cancer requires long-term use of aspirin doses substantially higher than those recommended for prevention of cardiovascular disease, but the dose-related risk of gastrointestinal bleeding must also be considered.
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Affiliation(s)
- Andrew T Chan
- Gastrointestinal Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Mass 02114, USA.
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25
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Abstract
BACKGROUND & AIMS Chemoprevention of esophageal adenocarcinoma using nonsteroidal anti-inflammatory drugs (NSAIDs) may reduce the risk of cancer in patients with Barrett's esophagus. The aim of the study was to assess the cost-effectiveness of this strategy. METHODS The incremental cost-effectiveness ratio (ICER) of chemoprevention (compared with endoscopic surveillance or with no surveillance) was analyzed with a computer model of a Markov process. RESULTS Under baseline conditions for all patients with Barrett's esophagus (neoplastic and nonneoplastic), the ICER of chemoprevention ranges between $12,700 and $18,500 US dollars per life-year saved. However, these cost values are sensitive to variations in the costs of chemoprevention, incidence of cancer in patients with Barrett's esophagus, and efficacy of NSAIDs in reducing the incidence of cancer, which can shift the ICER into a cost range that is prohibitively expensive. Conversely, in those patients with Barrett's esophagus and high-grade dysplasia, the ICER ranges between $3900 and $5000 US dollars. Chemoprevention remains a cost-effective option even under rather unfavorable conditions, such as higher cost and lower efficacy of chemoprevention and lower incidence of cancer. CONCLUSIONS This model suggests that a high incidence of esophageal adenocarcinoma in high-grade dysplasia renders chemoprevention cost-effective even in the presence of less-favorable conditions. However, chemoprevention may not be a cost-effective measure in the general population of all patients with Barrett's esophagus, depending on unknown factors such as cost and efficacy of chemoprevention as well as true incidence of cancer.
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Affiliation(s)
- Amnon Sonnenberg
- Portland VA Medical Center P3-G1, 3710 SW US Veterans Hospital Road, Portland, OR 97239, USA.
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Abstract
Colorectal cancer is an ideal target for population screening because it is a prevalent disease with an identifiable precursor lesion that, when treated, favorably alters the natural history of the disease. Several strategies for screening have illustrated efficacy, including fecal occult blood testing, sigmoidoscopy and colonoscopy. Cost-effectiveness analyses have been performed to determine whether the resources required to implement screening are justified by potential gains. The U.S. Preventive Services Task Force recently commissioned a study on the cost-effectiveness of colorectal cancer screening, which revealed that screening was cost-effective compared to no screening. However, it could not be confirmed which strategy would save the most life-years, nor which was most cost-effective. Since publication of this review, several additional cost-effectiveness analyses have been performed. These studies confirm that screening average risk patients at age 50 by a variety of available strategies is likely to be reasonable by current standards for resource utilization, and that either colonoscopy every 10 years (or once at age 65) or the combination of annual fecal occult blood testing with sigmoidoscopy every 5 years are viable alternatives. Additional economic analyses have examined the use of aspirin chemoprophylaxis to prevent colorectal cancer either alone or as an adjunct to screening strategies. These studies reaffirm the cost-effectiveness of colorectal cancer screening, but illustrate that aspirin chemoprophylaxis is unlikely to be associated with gains for which society would be willing to pay. At present, the decision to choose one colorectal screening strategy over another is based on availability of screening modalities, patient and provider preferences, and associated adherence to screening recommendations. Assessment of preference and development of interventions to increase adherence to screening should be a focus of research in the future.
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Affiliation(s)
- John M Inadomi
- VA Center for Practice Management and Outcomes Research, and the Division of Gastroenterology, Department of Medicine, the University of Michigan School of Medicine, Ann Arbor, Michigan, USA.
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Hawk ET, Viner JL, Umar A, Anderson WF, Sigman CC, Guyton KZ. Cancer and the Cyclo-oxygenase Enzyme. ACTA ACUST UNITED AC 2003. [DOI: 10.2165/00024669-200302010-00003] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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Abstract
In cost-effectiveness analyses of cancer prevention, the ratio of cost and medical effectiveness serves as the primary measure for comparing various strategies, effectiveness being measured in terms of (quality adjusted) life-years gained through medical intervention. Such analyses are reliable in comparing different medical management strategies and revealing the most important factors to influence their cost-effectiveness ratios, but less helpful in judging the general merit of a given medical strategy. Models of medical decision making are used to simulate the natural history of colorectal cancer and test how it becomes affected by various means of screening and prevention. The analyses suggest that, compared with no prevention, a single colonoscopy at age 65 is the most cost-effective means of cancer prevention in the general population, followed by screening colonoscopy every ten years or screening colonoscopy every ten years plus chemoprevention with daily aspirin. Other means of prevention, involving annual fecal occult blood testing or flexible sigmoidoscopy every 5-10 years, are dominated by cheaper and more effective strategies. Economic and decision models do not obviate the primacy of clinical data gathered through controlled clinical trials, since they cannot account for all factors that may eventually determine the cost-effectiveness of actual screening and cancer prevention.
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Affiliation(s)
- Amnon Sonnenberg
- Department of Veterans Affairs Medical Center, University of New Mexico, Albuquerque, NM, USA.
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Abstract
Numerous studies report the relationship between aspirin and other nonsteroidal anti-inflammatories (NSAIDs) and cancer incidence, in particular for colorectal cancer. This paper systematically reviews the evidence of the effect of aspirin and other NSAIDs on the primary prevention of colorectal and other gastrointestinal cancers in the general population. In 25 investigations of NSAIDs and colorectal cancer, 23 observational studies reported a relative risk reduction but estimates vary widely. Cohort studies generally indicate lesser reductions than case-control studies suggesting possible biases in the latter. Clear evidence of a dose relationship generally appears lacking but data do not indicate useful effects of aspirin in cardioprophylactic doses. Differences have otherwise not been detected between aspirin and other NSAIDs, nor between non-aspirin NSAIDs. There is some evidence that the risk of colorectal cancer reduces with increased duration of NSAID use. The lower incidence of oesophageal and gastric cancers results in smaller numbers of cases in the studies reporting these cancers, particularly in the cohort studies. The trend is for a risk reduction for oesophageal and gastric cancers in people taking NSAIDs, which is more likely to be statistically significant in the case-control studies. A very small number of observational studies have reported the relationship between NSAIDs and the incidence of pancreatic, gallbladder and liver cancers. These show no consistent relationship. In view of the inadequate information about optimal dose and duration of NSAIDs for colorectal cancer reduction, and the adverse effects of NSAIDs, we are not yet in a position to recommend NSAIDs for the primary prevention of colorectal cancer in the general population.
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Affiliation(s)
- Kate Jolly
- Department of Public Health and Epidemiology, University of Birmingham, Edgbaston, Birmingham, UK.
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Husain SS, Szabo IL, Tamawski AS. NSAID inhibition of GI cancer growth: clinical implications and molecular mechanisms of action. Am J Gastroenterol 2002; 97:542-53. [PMID: 11922545 DOI: 10.1111/j.1572-0241.2002.05528.x] [Citation(s) in RCA: 81] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Epidemiological studies suggest that aspirin and other non-steroidal anti-inflammatory drugs (NSAIDs) reduce the incidence of and mortality from colorectal, gastric, and esophageal cancers. The precise mechanisms by which NSAIDs exert their chemopreventive effects are not fully explained, but likely involve inhibition of cyclo-oxygenase, the enzyme that converts arachidonic acid to prostaglandins. Two isoforms of this enzyme, cyclo-oxygenase 1 (COX-1) and COX-2, have been identified. COX-2 is absent in normal mucosa but is overexpressed in colonic, gastric, and esophageal cancers, as well as their precursor lesions. The inhibition of COX-2 through either pharmacological agents or gene deletion results in suppression of colonic polyp formation. NSAIDs reduce colonic, gastric, and esophageal cancer cell growth, in part, by inducing apoptosis. However, the antineoplastic effects of NSAIDs may be partly independent of their ability to inhibit COX-2. The mechanisms involved in the antineoplastic actions of NSAIDs include inhibition of angiogenesis (essential for delivery of oxygen and nutrients to a growing tumor), induction of apoptosis (which is usually reduced in cancer cells) by stimulation of proapoptotic genes, and direct inhibition of cancer cell growth by blocking signal transduction pathways responsible for cell proliferation.
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Affiliation(s)
- Syeda S Husain
- Medical Service, Department of Veterans Affairs Medical Center, Long Beach, California, USA
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Thun MJ, Henley SJ, Patrono C. Nonsteroidal anti-inflammatory drugs as anticancer agents: mechanistic, pharmacologic, and clinical issues. J Natl Cancer Inst 2002; 94:252-66. [PMID: 11854387 DOI: 10.1093/jnci/94.4.252] [Citation(s) in RCA: 1018] [Impact Index Per Article: 46.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Numerous experimental, epidemiologic, and clinical studies suggest that nonsteroidal anti-inflammatory drugs (NSAIDs), particularly the highly selective cyclooxygenase (COX)-2 inhibitors, have promise as anticancer agents. NSAIDs restore normal apoptosis in human adenomatous colorectal polyps and in various cancer cell lines that have lost adenomatous polyposis coli gene function. NSAIDs also inhibit angiogenesis in cell culture and rodent models of angiogenesis. Many epidemiologic studies have found that long-term use of NSAIDs is associated with a lower risk of colorectal cancer, adenomatous polyps, and, to some extent, other cancers. Two NSAIDs, sulindac and celecoxib, have been found to inhibit the growth of adenomatous polyps and cause regression of existing polyps in randomized trials of patients with familial adenomatous polyposis (FAP). However, unresolved questions about the safety, efficacy, optimal treatment regimen, and mechanism of action of NSAIDs currently limit their clinical application to the prevention of polyposis in FAP patients. Moreover, the development of safe and effective drugs for chemoprevention is complicated by the potential of even rare, serious toxicity to offset the benefit of treatment, particularly when the drug is administered to healthy people who have low annual risk of developing the disease for which treatment is intended. This review considers generic approaches to improve the balance between benefits and risks associated with the use of NSAIDs in chemoprevention. We critically examine the published experimental, clinical, and epidemiologic literature on NSAIDs and cancer, especially that regarding colorectal cancer, and identify strategies to overcome the various logistic and scientific barriers that impede clinical trials of NSAIDs for cancer prevention. Finally, we suggest research opportunities that may help to accelerate the future clinical application of NSAIDs for cancer prevention or treatment.
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Affiliation(s)
- Michael J Thun
- Department of Epidemiology and Surveillance Research, American Cancer Society, National Home Office, Atlanta, GA 30329-4251, USA.
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Abstract
To fulfill their role in host-defense, granulocytes secrete chemically reactive oxidants, radicals, and electrophilic mediators. While this is an effective way to eradicate pathogenic microbes or parasites, it inevitably exposes epithelium and connective tissue to certain endogenous genotoxic agents. In ordinary circumstances, cells have adequate mechanisms to reduce the genotoxic burden imposed by these agents to a negligible level. However, inflammation persisting for a decade eventually elevates the risk of cancer sufficiently that it is discernible in case control epidemiological studies. Advances in our understanding of tumor suppressors and inflammatory mediators offer an opportunity to assess the molecular and cellular models used to guide laboratory investigations of this phenomenon. Disappointing results from recent clinical trials with anti-oxidant interventions raise questions about the risks from specific endogenous agents such as hydrogen peroxide and oxy radicals. Simultaneously, the results from the anti-oxidant trials draw attention to an alternate hypothesis, favoring epigenetic inactivation of key tumor suppressors, such as p53, and the consequent liability this places on genomic integrity.
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Affiliation(s)
- F A Fitzpatrick
- Huntsman Cancer Institute, University of Utah, Salt Lake City 84112-5550, USA.
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Arber N, DuBois RN. Nonsteroidal anti-inflammatory drugs and prevention of colorectal cancer. Curr Gastroenterol Rep 1999; 1:441-8. [PMID: 10980984 DOI: 10.1007/s11894-999-0027-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Increasing evidence suggests that aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) reduce the risk of colorectal cancer. This observation is supported by results from animal studies that show fewer tumors per animal and fewer animals with tumors after administration of several different NSAIDs. Results from clinical studies with humans consistently support these findings as well. The intervention data in familial adenomatous polyposis patients establishes that the antineoplastic effect may target human adenoma formation. Supportive evidence comes with both aspirin and non-aspirin NSAIDs. Earlier detection of lesions as a result of drug-induced gastrointestinal bleeding does not seem to account for these findings. The molecular mechanism responsible for the chemopreventive action of this class of drugs is not clear. Protection may affect several pathways, with results including cell cycle arrest, induction of apoptosis, and angiogenesis. This review focuses primarily on the potential chemopreventive activity of NSAIDS in sporadic human colon cancer and adenomas and outlines current concepts for the biologic and biochemical mechanisms for this protective effect.
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Affiliation(s)
- N Arber
- Gastrointestinal Oncology Unit, Department of Gastroenterology, Tel-Aviv Sourasky Medical Center, 6 Weitzmann Street, Tel-Aviv 64-239, Israel
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35
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Abstract
Epidemiologic studies indicate strongly that aspirin use reduces the risk of colorectal cancer and adenoma by approximately 40 to 50%. Perhaps up to ten years of use may be required before a benefit is apparent in colorectal cancer. The chemo-preventive actions of aspirin and other non-steroidal anti-inflammatory agents (NSAIDs) in colorectal carcinogenesis are also supported by animal studies, and by intervention studies that demonstrate that the anti-inflammatory agent sulindac causes regression of adenomas in familial adenomatous polyposis. Despite this evidence, the clinical implications are not clear because of increased gastro-intestinal irritation and bleeding episodes related to chronic aspirin use. Emerging evidence suggests that the anti-tumor properties of NSAIDs may be related primarily to the inhibition of cyclooxygenase-2 (COX-2), one of the two isoenzymes of the COX enzyme family. If confirmed, a new generation of selective COX-2 inhibitors may retain some of the chemo-preventive properties of NSAIDs with fewer side-effects. Firm recommendations regarding the use of aspirin or other NSAIDs to prevent colorectal cancer must await further research. For now, the decision must lie with the patient, in consultation with his or her healthcare provider, after a careful weighing of all potential risks and benefits.
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Affiliation(s)
- E Giovannucci
- Department of Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA
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Sawaoka H, Kawano S, Tsuji S, Tsujii M, Murata H, Hori M. Effects of NSAIDs on proliferation of gastric cancer cells in vitro: possible implication of cyclooxygenase-2 in cancer development. J Clin Gastroenterol 1999; 27 Suppl 1:S47-52. [PMID: 9872498 DOI: 10.1097/00004836-199800001-00009] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The roles of cyclooxygenase-2 (COX-2) in the development of gastric cancer are unknown. We investigated the effects of nonsteroidal antiinflammatory drugs (NSAIDs), which are specific and nonspecific inhibitors of COX-2, on proliferation of the gastric cancer cell lines KATOIII, MKN28, and MKN45. The protein level of COX-2 was examined in these cell lines by Western analysis, and mRNA levels of COX-1/2 by Northern analysis. These cell lines expressed comparable levels of COX-1 mRNA. However, mRNA and protein expression of COX-2 in these cell lines was different. MKN45 expressed higher levels of COX-2 mRNA and protein than KATOIII and MKN28. We also examined the effects of NS-398 and indomethacin, specific and nonspecific inhibitors of COX-2, on the increase in cell number and [3H]thymidine uptake of these cell lines. NS-398 and indomethacin suppressed proliferation of MKN45 cells that overexpressed COX-2, although they exerted minimal effects on proliferation of KATOIII and MKN28, which expressed lower levels of COX-2. These results are consistent with the hypothesis that COX-2 is expressed in certain groups of gastric cancers and is related to their cell proliferation. It was proposed that COX-2 plays an important role in development of gastric cancer cells. Furthermore, NSAIDs may exert antiproliferative activity against gastric adenocarcinomas that overexpress COX-2.
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Affiliation(s)
- H Sawaoka
- First Department of Medicine, Osaka University School of Medicine, Suita, Japan
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Abstract
The accumulating evidence suggests that aspirin or other NSAIDs may prevent or inhibit the development of colon and perhaps other digestive tract cancers. Although the clinical, experimental, and epidemiologic evidence is promising, the hypothesis remains unproven except in the models of chemically induced colon cancer in rodents and adenomatous polyps in patients with FAP. Clinicians should await the results of randomized trials before using NSAIDs for cancer prevention or treatment. Recommendations are as follows: 1. Experimental studies should define the mechanism or mechanisms by which NSAIDs inhibit tumorigenesis in the rodent model. 2. Experimental and clinical studies should define the optimal drug, dosage, and treatment regimen. The new, selective COX-2 inhibitors should be studied for efficacy and toxicity. 3. Epidemiologic studies should continue to explore the issues of dosage, duration, drug, and toxicity. Because full-scale, randomized trials are feasible only for studying intermediate end points such as polyp recurrence or proliferative indices in high-risk populations, epidemiologic studies have an ongoing role. 4. Carefully designed randomized, clinical trials, now underway, are needed to test the efficacy of NSAIDs in inhibiting colorectal polyps or cancer in humans. 5. Better criteria are needed as to who should take aspirin and who should not.
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Affiliation(s)
- M J Thun
- Department of Epidemiology and Surveillance, American Cancer Society, Atlanta, GA, USA
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Weiss HA, Forman D. Aspirin, non-steroidal anti-inflammatory drugs and protection from colorectal cancer: a review of the epidemiological evidence. SCANDINAVIAN JOURNAL OF GASTROENTEROLOGY. SUPPLEMENT 1996; 220:137-41. [PMID: 8898452 DOI: 10.3109/00365529609094766] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
There is substantial experimental, clinical and epidemiological evidence that regular use of non-steroid anti-inflammatory drugs (NSAIDs), particularly aspirin, is associated with a reduced risk of colorectal cancer. The protective effect is thought to arise from inhibition of prostaglandin synthesis, although the precise mechanism remains unclear. Of the epidemiological studies carried out, all but one have found that regular use of NSAIDs reduces the risk of colorectal cancer by 30-50%. The consistency of this finding across studies and the magnitude of the reduced risk tend to support a causal association between NSAID use and reduced risk of colorectal cancer. Further, the protective effect increases with longer duration of use, and persists after controlling for other colorectal cancer risk factors. However, these observational studies are limited by inherent biases, potential confounding with other lifestyle factors, and sparse information on dose and duration of use. Only one randomized controlled trial has been carried out, and no reduction in risk was associated with intake of one aspirin per day, though this may be due to the short follow-up period and the low dose of aspirin taken. Further observational studies and randomized controlled trials are needed to confirm the association, to quantify the dosage required for a protective effect, and to identify those patients most likely to benefit.
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Affiliation(s)
- H A Weiss
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD 20892-7374, USA
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