APACC, a French prospective study on aspirin efficacy in reducing colorectal adenoma recurrence: design and baseline findings

Aspirin use for cancer prevention: A systematic review of public, patient and healthcare provider attitudes and adherence behaviours

We undertook a systematic review to synthesise the data on attitudes and behaviour towards the use of aspirin for cancer prevention, and healthcare providers' attitudes towards implementing aspirin in practice. Searches were carried out across 12 databases (e.g. MEDLINE, EMBASE). We used the Mixed Methods Appraisal Tool to evaluate study quality, and conducted a narrative synthesis of the data. The review was pre-registered (PROSPERO: CRD42018093453). Thirty-eight studies were identified. Uptake and adherence data were all from trials. Trials recruited healthy participants, those at higher risk of cancer, and those with cancer. Four studies reported moderate to high (40.9-77.7%) uptake to an aspirin trial among people who were eligible. Most trials (18/22) reported high day-to-day adherence (≥80%). Three trials observed no association between gender and adherence. One trial found no association between adherence and colorectal cancer risk. Three studies reported moderate to high (43.6-76.0%) hypothetical willingness to use aspirin. Two studies found that a high proportion of healthcare providers (72.0-76.0%) perceived aspirin to be a suitable cancer prevention option. No qualitative studies were identified. The likelihood that eligible users of aspirin would participate in a trial evaluating the use of aspirin for preventive therapy was moderate to high. Among participants in a trial, day-to-day adherence was high. Further research is needed to identify uptake and adherence rates in routine care, the factors affecting aspirin use, and the barriers to implementing aspirin into clinical care.

Chemopreventive effect of nonsteroidal anti-inflammatory drugs on the development of a new colorectal polyp or adenoma in a high-risk population: a meta-analysis

BACKGROUND

Although many experimental, epidemiologic, and clinical studies have suggested that aspirin or other nonsteroidal anti-inflammatory drugs (NSAIDs) are effective in reducing and preventing colorectal adenomas, randomized, controlled trials (RCTs) are still being carried out to obtain statistically reliable results.

OBJECTIVE

The aim of this meta-analysis was to review long-term, prospective RCTs investigating the effect of NSAIDs on the relative risk (RR) for developing ≥1 new colorectal polyp or adenoma in a high-risk population.

METHODS

We conducted a comprehensive search of MEDLINE, PubMed, and other electronic databases (including Inter-Science, Science Direct, Ebsco, Synergy, and Proquest) (key terms: nonsteroidal anti-inflammatory drugs, aspirin, colorectal, and polyps; years: 1974-2004) for English-language articles. Eligible studies were analyzed in terms of demographic data, adverse effects, and effect of NSAIDs on the RRs.

RESULTS

Four long-term, prospective RCTs were used in the statistical analysis. A total of 2069 high-risk patients were enrolled; 1880 patients completed the studies, and 1127 were in active-treatment groups (aspirin 81-325 mg/d or sulindac 150-300 mg/d). Our meta-analysis of these studies revealed that the overall RR for developing ≥ 1 new colorectal polyp or adenoma was significantly reduced by using aspirin or other NSAIDs (RR = 0.809; 95% CI, 0.718-0.912).

CONCLUSIONS

The results of this meta-analysis suggest that regular use of aspirin 81 to 325 mg/d or sulindac 150 to 300 mg/d for ≥1 year was associated with a decrease in the RR for developing ≥ 1 new colorectal polyp or adenoma to 0.80 (95% CI, 0.718-0.912) in patients at high risk.

Markers of mitochondrial dysfunction during the diclofenac-induced apoptosis in melanoma cell lines

Melanoma is an aggressive cutaneous cancer, whose incidence is growing in recent years, especially in the younger population. The favorable therapy for this neoplasm consists in its early surgical excision; otherwise, in case of late diagnosis, melanoma becomes very refractory to any conventional therapy. Nevertheless, the acute inflammatory response occurring after excision of the primary melanoma can affect the activation and/or regulation of melanoma invasion and metastasis. Nonsteroidal anti-inflammatory drugs (NSAIDs), widely employed in clinical therapy as cyclooxygenase inhibitors, also display a cytotoxic effect on some cancer cell lines; therefore, their possible usage in combination with conventional chemo- and radio-therapies of tumors is being considered. In particular, diclofenac, one of the most common NSAIDs, displays its anti-proliferative effect in many tumor lines, through an alteration of the cellular redox state. In this study, the possible anti-neoplastic potential of diclofenac on the human melanoma cell lines A2058 and SAN was investigated, and a comparison was made with the results obtained from the nonmalignant fibroblast cell line BJ-5ta. Either in A2058 or SAN, the diclofenac treatment caused typical apoptotic morphological changes, as well as an increase of the number of sub-diploid nuclei; conversely, the same treatment on BJ-5ta had only a marginal effect. The observed decrease of Bcl-2/Bax ratio and a parallel increase of caspase-3 activity confirmed the pro-apoptotic role exerted by diclofenac in melanoma cells; furthermore, the drug provoked an increase of the ROS levels, a decrease of mitochondrial superoxide dismutase (SOD2), the cytosolic translocation of both SOD2 and cytochrome c, and an increase of caspase-9 activity. Finally, the cytotoxic effect of diclofenac was amplified, in melanoma cells, by the silencing of SOD2. These data improve the knowledge on the effects of diclofenac and suggest that new anti-neoplastic treatments should be based on the central role of mitochondrion in cancer development; under this concern, the possible involvement of SOD2 as a novel target could be considered.

Host-derived MCP-1 and MIP-1α regulate protective anti-tumor immunity to localized and metastatic B16 melanoma

Leukocytic infiltration into malignant melanoma lesions is tightly regulated by chemokines. To assess the role of the CC chemokines monocyte chemotactic protein-1 (MCP-1/chemokine ligand 2) and macrophage inflammatory protein-1α (MIP-1α/chemokine ligand 3) in this process, s.c. primary and metastatic B16 F10 melanoma tumor growth levels were examined in mice lacking MCP-1 or MIP-1α. Primary s.c. B16 F10 melanoma growth was augmented by loss of MCP-1 or MIP-1α. Similarly, lung metastasis was enhanced by the deficiency of MCP-1 or MIP-1α. Enhanced tumor outgrowth was associated with decreased percentages of infiltrating CD4(+) T cells, CD8(+) T cells, and natural killer cells. In the absence of MCP-1 or MIP-1α, melanoma outgrowth was correlated with reduced local expression of interferon-γ, IL-6, tumor necrosis factor-α, and transforming growth factor-β. Among these cytokines, reduced expression levels of interferon-γ and tumor necrosis factor-α on leukocytes from the spleen were associated with the development of lung metastasis in chemokine-deficient mice. The local s.c. administration of these four cytokines significantly augmented another chemokine's expression and suppressed primary melanoma growth in mice deficient for MCP-1 or MIP-1α. The s.c. injection of MCP-1 or MIP-1α significantly inhibited the primary tumor growth in wild-type mice. These results indicate that host-derived MCP-1 and MIP-1α regulate protective anti-tumor immunity to B16 F10 melanoma by promoting lymphocyte infiltration into the tumor and subsequent cytokine production.

Acid reflux and oesophageal cancer

Barrett's metaplasia is one of the commonest premalignant lesions in the western world following colorectal adenomas. One in 50 of the adult population develops Barrett's as a consequence of chronic gastro-oesophageal reflux. The mucosal inflammation seen within patients with gastro-oesophageal reflux seems likely to drive the growth of the metaplastic mucosa and also help direct further oncological change, yet the molecular events that characterize the pathway from inflammation to metaplasia to dysplasia and adenocarcinoma are poorly understood. There is hope that understanding the role of oesophageal inflammation will provide important insight into the development of Barrett's metaplasia and oesophageal cancer. This chapter will discuss the inflammation seen within context of Barrett's oesophagus and also clinical trials which hope to address this common premalignant disease. There are several ongoing clinical trials which are aiming to provide data using anti-inflammatory therapies to tackle this important premalignant condition. There is new data presented which suggests that data from the aspirin esomeprazole chemoprevention trial (AspECT) may hold the clue to disease treatment and that the cytokine TNF-α seems to be a key signalling molecule in the metaplasia-dysplasia-carcinoma sequence. Specifically it appears that both epigenetic and inherited genetics cooperate to modulate the prognosis.

Regulation of local and metastatic host-mediated anti-tumour mechanisms by L-selectin and intercellular adhesion molecule-1

Malignant melanoma is often accompanied by a host response of inflammatory cell infiltration that is highly regulated by multiple adhesion molecules. To assess the role of adhesion molecules, including L-selectin and intercellular adhesion molecule-1 (ICAM-1), in this process, subcutaneous primary growth and metastasis to the lung of B16 melanoma cells not expressing L-selectin, ICAM-1 or their ligands were examined in mice lacking L-selectin, ICAM-1 or both. Primary subcutaneous growth of B16 melanoma was augmented by loss of L-selectin, ICAM-1 or both, while pulmonary metastasis was enhanced by the loss of L-selectin or combined loss of L-selectin and ICAM-1. In both situations, the combined loss of L-selectin and ICAM-1 exhibited the greatest effect. This enhancement was associated generally with a reduced accumulation of natural killer (NK) cells, CD4+ T cells and CD8+ T cells and also with a diminished release of interferon (IFN)-gamma and tumour necrosis factor (TNF)-alpha but not interleukin (IL)-6. Cytotoxicity against melanoma was not defective by the absence of ICAM-1, L-selectin or both, suggesting that the enhancement of tumour growth and metastasis caused by the loss of adhesion molecules results from an impaired migration of effector cells into the tissue rather than from a suppression of the cytotoxic response. The results indicate that L-selectin and ICAM-1 contribute co-operatively to the anti-tumour reaction by regulating lymphocyte infiltration to the tumour.

Melanoma cell migration is upregulated by tumour necrosis factor-alpha and suppressed by alpha-melanocyte-stimulating hormone

We reported recently that the inflammatory cytokine tumour necrosis factor α (TNF-α) can upregulate integrin expression, cell attachment and invasion of cells through fibronectin in a human melanoma cell line (HBL). Furthermore, the actions of TNF-α were suppressed by the addition of an anti-inflammatory peptide α-melanocyte-stimulating hormone (α-MSH). In the current study, we extend this work investigating to what extent TNF-α might stimulate melanoma invasion by promoting cell migration and whether α-MSH is also inhibitory. Two human melanoma cell lines were examined in vitro (HBL and C8161) using a scratch migration assay. Analysis using either time-lapse video microscopy or imaging software analysis of migrating ‘fronts’ of cells revealed that C8161 cells migrated more rapidly than HBL cells. However, when cells were stimulated with TNF-α both cell types responded with a significant increase in migration distance over a 16–26 h incubation time. α-Melanocyte-stimulating hormone had an inhibitory effect on TNF-α-stimulated migration for HBL cells, completely blocking migration at 10⁻⁹ M. In contrast, C8161 cells did not respond to α-MSH (as these cells have a loss-of-function melanocortin-1 receptor). However, stable transfection of C8161 cells with the wild-type melanocortin-1 receptor produced cells whose migration was significantly inhibited by α-MSH. In addition, the use of a neutralising antibody to the β₁-integrin subunit significantly reduced migration in both cell types. This data therefore supports an inflammatory environment promoting melanoma cell migration, and in addition shows that α-MSH can inhibit inflammatory stimulated migration. The data also support a fundamental role of the β₁-integrin receptor in melanoma cell migration.

Non steroidal anti-inflammatory drugs (NSAID) and Aspirin for preventing colorectal adenomas and carcinomas

EDITORIAL NOTE

This review was split in 2012 and the review question was to be addressed according to three new protocols: (See: http://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD010267.pub2; http://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD010291.pub2; http://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD010325.pub2). These titles were withdrawn at the protocol stage in 2020 as the authors did not make any progress on the reviews. This original review will no longer be updated and may be superseded by new titles hosted by Cochrane Gut in the future.

BACKGROUND

There is evidence from experimental animals studies, prospective and retrospective observational studies that nonsteroidal anti-inflammatory drugs (NSAIDS) may reduce the development of sporadic colorectal adenomas (CRAs) and cancer (CRC) and may induce the regression of adenomas in familial adenomatous polyposis (FAP).

OBJECTIVES

To conduct a systematic review to determine the effect of NSAIDS for the prevention or regression of CRAs and CRC.

SEARCH STRATEGY

Randomized controlled trials (RCTs) up to September 2003 were identified.

SELECTION CRITERIA

NSAIDS and aspirin (ASA) were the interventions. The primary outcomes were the number of subjects with at least one CRA, the change in polyp burden, and CRC. The secondary outcome was adverse events.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed trial quality. Dichotomous outcomes were reported as relative risks (RR) with 95% confidence intervals (CI). The data were combined with the random effects model if clinically and statistically reasonable.

MAIN RESULTS

Nine trials with 150 familial adenomatous polyposis (FAP) and 24,143 population subjects met the inclusion criteria. The interventions included sulindac, celecoxib, or aspirin (ASA). From the combined results of three trials, significantly fewer subjects in the low dose ASA group developed recurrent sporadic CRAs [RR 0.77 (95% CI 0.61, 0.96), (NNT 12.5 (95% CI 7.7, 25)] after one to three years. In another three trials, phenotypic FAP subjects that received sulindac or celecoxib had a greater proportional reduction (range: 11.9% to 44%) in the number of CRAs compared to those in the control group (range: 4.5% to 10%). There was no significant difference for the outcomes of CRC or adverse events in any of the trials.

REVIEWERS' CONCLUSIONS

There was evidence from three pooled RCTs that ASA significantly reduces the recurrence of sporadic adenomatous polyps after one to three years. There is evidence from short-term studies to support regression, but not elimination or prevention of CRAs in FAP.

Daily soluble aspirin and prevention of colorectal adenoma recurrence: one-year results of the APACC trial

BACKGROUND & AIMS

Epidemiologic and experimental studies have suggested that aspirin intake reduces the risk for colorectal carcinogenesis. However, the available data are not sufficient to serve as the basis for firm recommendations.

METHODS

We randomly assigned 272 patients with a history of colorectal adenomas (at least one more than 5 mm in diameter, or more than 3) to daily lysine acetylsalicylate (160 or 300 mg/day) or placebo for 4 years. The primary end points were adenoma recurrence after 1 and 4 years. These results are those of the year 1 colonoscopy.

RESULTS

Among the 238 patients who completed the year 1 colonoscopy, at least one adenoma was observed in 38 patients of the 126 (30%) in the aspirin group and in 46 of the 112 (41%) in the placebo group; relative risk was 0.73 (95% confidence interval [CI]: 0.52-1.04; P = 0.08). At least one adenoma of more than 5 mm diameter was observed in 13 patients (10%) in the aspirin group and 26 (23%) in the placebo group (P = 0.01). The corresponding numbers for adenomas more than 10 mm in diameter were one (1%) and 7 (6%) (P = 0.05). Stepwise regression showed that independent factors associated with lower adenoma recurrence are aspirin treatment (adenoma >5 mm, P = 0.01), absence of personal history of adenoma before the entry colonoscopy (P = 0.01), and initial adenomatous polyp burden less than 10 mm (P = 0.001).

CONCLUSIONS

Daily soluble aspirin is associated with a reduction in the risk for recurrent adenomas found at colonoscopy 1 year after starting treatment.