Maintenance use of non-steroidal anti-inflammatory drugs and risk of gastrointestinal cancer in a nationwide population-based cohort study in Sweden

Cancer risks in patients with ankylosing spondylitis and the effects of biologic agents: a population-based study

OBJECTIVE

The objective of this study was to conduct a population-based analysis of the malignancy risks of patients with AS.

METHODS

A total of 1796 patients with AS and 7184 age- and sex-matched controls (1:4 ratio) were selected from the Korea National Health Insurance Service-National Sample Cohort database. Data of patients diagnosed with AS (code M45) according to the International Classification of Diseases (ICD) 10th edition, between 2002 and 2019, were reviewed. These data were extracted based on the ICD codes assigned to cancer patients.

RESULTS

Cancer developed in 168/1796 patients (9.3%) after the AS diagnosis. After adjusting for confounders, the cancer risk of patients with AS was not significantly increased compared with that of controls [adjusted hazard ratio (HR): 1.1; 95% CI: 0.93-1.31]. However, the risks for upper gastrointestinal (GI) cancer (adjusted HR: 1.51; 95% CI: 1.07-2.12) and haematologic malignancy (adjusted HR: 2.36; 95% CI: 1.2-4.65) were significantly higher in patients with AS than in controls. There were no significant differences in the risks for other major cancers between patients with AS and controls. Regarding medication for AS, the HR of upper GI cancer was higher in patients with AS compared with controls (adjusted HR: 1.51; 95% CI: 1.00-2.29).

CONCLUSION

The overall cancer risk in patients with AS was not significantly different compared with that in the controls. However, while the effect of NSAIDs on upper GI cancer cannot be ruled out, patients with AS exhibited a significant increase in the risk of both upper GI cancer and haematologic malignancy.

Metabolic dysfunction-associated steatotic liver disease and extrahepatic gastrointestinal cancers

Metabolic dysfunction-associated steatotic liver disease (MASLD) poses a significant and ever-increasing health and economic burden worldwide. Substantial epidemiological evidence shows that MASLD is a multisystem disease that is associated not only with liver-related complications but is also associated with an increased risk of developing cardiometabolic comorbidities and extrahepatic cancers (principally gastrointestinal [GI] cancers). GI cancers account for a quarter of the global cancer incidence and a third of cancer-related deaths. In this narrative review, we provide an overview of the literature on (a) the epidemiological data on the risk of non-liver GI cancers in MASLD, (b) the putative mechanisms by which MASLD (and factors linked with MASLD) may increase this risk, and (c) the possible pharmacotherapies beneficially affecting both MASLD and extrahepatic GI cancer risk. There are multiple potential pathophysiological mechanisms by which MASLD may increase extrahepatic GI cancer risk. Although further studies are needed, the current evidence supports a possible extrahepatic carcinogenic role for MASLD, regardless of obesity and diabetes status, thus highlighting the potential role of tailoring cancer screening for individuals with MASLD. Although there are conflicting data in the literature, aspirin, statins and metformin appear to exert some chemo-preventive effects against GI cancer.

Targeting the gut microbiota: a new strategy for colorectal cancer treatment

BACKGROUND

How to reduce the high incidence rate and mortality of colorectal cancer (CRC) effectively is the focus of current research. Endoscopic treatment of early-stage CRC and colorectal adenomas (CAC) has a high success rate, but although several treatments are available for advanced CRC, such as surgery, radiotherapy, chemotherapy, and immunotherapy, the 5-year survival rate remains low. In view of the high incidence rate and mortality of CRC, early rational drug prevention for high-risk groups and exploration of alternative treatment modalities are particularly warranted. Gut microbiota is the target of and interacts with probiotics, prebiotics, aspirin, metformin, and various Chinese herbal medicines (CHMs) for the prevention of CRC. In addition, the anti-cancer mechanisms of probiotics differ widely among bacterial strains, and both bacterial strains and their derivatives and metabolites have been found to have anti-cancer effects. Gut microbiota plays a significant role in early drug prevention of CRC and treatment of CRC in its middle and late stages, targeting gut microbiota may be a new strategy for colorectal cancer treatment.

The role of aspirin in the prevention of pancreatic cancer: A nested case-control study in the UK Biobank

BACKGROUND

Aspirin and other non-steroidal anti-inflammatory drugs (NSAIDs) usage has been associated with pancreatic ductal adenocarcinoma (PDAC) prevention, though epidemiological data have not reliably demonstrated this. The aim of this study is to identify if aspirin and other NSAIDs are effective in the primary prevention of PDAC in a large UK prospective cohort.

METHODS

A nested case-control study was conducted using the UK Biobank cohort. Incident PDAC cases (n = 1129 of whom 239 (21.2 %) were using aspirin) were age and sex-matched with cancer-free controls (n = 8822 of whom 1752 (19.9 %) were using aspirin). Conditional logistic regression models were used to generate odds ratios (ORs) and 95 % confidence intervals (CI) for risk of PDAC with and without regular use of aspirin, non-aspirin NSAIDs and all NSAIDs respectively. Exploratory analyses were carried out assessing interactions with diabetes mellitus (DM) as a condition with increased pancreatic cancer risk.

RESULTS

Regular aspirin use at initial recruitment was independently associated with a decreased risk of PDAC (OR [95 % CI] = 0.80 [0.68-0.95] P = 0.01). Regular non-aspirin NSAID use was not associated with a risk reduction of PDAC (OR [95 % CI] = 1.01 [0.84-1.23] P = 0.88). Exploratory analyses showed that in those with DM; regular aspirin use reduced risk of PDAC (OR [95 % CI] = 0.60 [0.42-0.85] P = 0.004) compared to non-use.

DISCUSSION

Regular aspirin use is associated with a reduction in risk of PDAC. The reduced risk is more apparent in participants with DM.

Maintenance proton pump inhibitor use and risk of colorectal cancer: a Swedish retrospective cohort study

OBJECTIVES

We aimed to evaluate the risk of colorectal adenocarcinoma (CRA) associated with long-term use of proton pump inhibitors (PPIs) in a large nationwide cohort.

DESIGN

Retrospective cohort study.

SETTING

This research was conducted at the national level, encompassing the entire population of Sweden.

PARTICIPANTS

This study utilised Swedish national registries to identify all adults who had ≥180 days of cumulative PPI use between July 2005 and December 2012, excluding participants who were followed up for less than 1 year. A total of 754 118 maintenance PPI users were included, with a maximum follow-up of 7.5 years.

INTERVENTIONS

Maintenance PPI use (cumulative≥180 days), with a comparator of maintenance histamine-2 receptor antagonist (H2RA) use.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome measure was the risk of CRA, presented as standardised incidence ratios (SIRs) with 95% confidence intervals (CIs). Subgroup analyses were performed to explore the impact of indications, tumour locations, tumour stages and the duration of follow-up. A multivariable Poisson regression model was fitted to estimate the incidence rate ratios (IRRs) and 95% CIs of PPI versus H2RA use.

RESULTS

Maintenance PPI users exhibited a slightly elevated risk of CRA compared to the general population (SIR 1.10, 95% CI=1.06 to 1.13) for both men and women. Individuals aged 18-39 (SIR 2.79, 95% CI=1.62 to 4.47) and 40-49 (SIR 2.02, 95% CI=1.65 to 2.45) had significantly higher risks than the general population. Right-sided CRA showed a higher risk compared to the general population (SIR 1.26, 95% CI=1.20 to 1.32). There was no significant difference in the risk of CRA between maintenance PPI users and maintenance H2RA users (IRR 1.05, 95% CI=0.87 to 1.27, p<0.05).

CONCLUSIONS

Maintenance PPI use may be associated with an increased risk of CRA, but a prolonged observation time is needed.

Clostridioides difficile infection, recurrence and the associated healthcare consumption in Sweden between 2006 and 2019: a population-based cohort study

BACKGROUND

Clostridioides difficile infection (CDI) causes a major burden to individuals and society, yet the impact may vary depending on age, sex, underlying comorbidities and where CDI was acquired (hospital or community).

METHODS

This Swedish nationwide population-based cohort study (2006-2019) compared all 43,150 individuals with CDI to their 355,172 matched controls (first year and entire follow-up). Negative binomial regression models compared the cumulated length of stay, number of in-hospital admissions, outpatient visits and prescriptions after the first CDI episode expressed as incidence rate ratios (IRR) and 95% confidence intervals for the entire follow-up.

RESULTS

Overall, 91.6% of CDI cases were hospital acquired, and 16.8% presented with recurrence(s); 74.8%of cases were ≥ 65 years and 54.2% were women. Compared to individuals without CDI, in-hospital stay rates were 18.01 times higher after CDI (95% CI 17.40-18.63, first-year: 27.4 versus 1.6 days), 9.45 times higher in-hospital admission (95% CI 9.16-9.76, first-year: 2.6 versus 1.3 hospitalisations), 3.94 times higher outpatient visit (95% CI 3.84-4.05, first-year: 4.0 versus 1.9 visits) and 3.39 times higher dispensed prescriptions rates (95% CI 3.31-3.48, first-year: 25.5 versus 13.7 prescriptions). For all outcomes, relative risks were higher among the younger (< 65 years) than the older (≥ 65 years), and in those with fewer comorbidities, but similar between sexes. Compared to those without recurrence, individuals with recurrence particularly showed a higher rate of hospital admissions (IRR = 1.18, 95% 1.12-1.24). Compared to community-acquired CDI, those with hospital-acquired CDI presented with a higher rate of hospital admissions (IRR = 7.29, 95% CI 6.68-7.96) and a longer length of stay (IRR = 7.64, 95% CI 7.07-8.26).

CONCLUSION

CDI was associated with increased health consumption in all affected patient groups. The majority of the CDI burden could be contributed to hospital-acquired CDI (~ 9/10), older patients (~ 3/4) and those with multiple comorbidities (~ 6/10 Charlson score ≥ 3), with 1/5 of the total CDI burden contributed to individuals with recurrence. Yet, relatively speaking the burden was higher among the younger and those with fewer comorbidities, compared to their peers without CDI.

Causal relationship between several autoimmune diseases and renal malignancies: A two-sample mendelian randomization study

OBJECTIVE

Observational studies have shown an association between systemic autoimmune disease (AD) and multiple malignancies. However, due to the difficulty indetermining the temporal nature of the order, their causal relationship remains elusive. Based on pooled data from a large population-wide genome-wide association study (GWAS), this study explores the genetic causality between systemic autoimmune disease and renal malignancy.

METHODS

We took a series of quality control steps from a large-scale genome-wide association study to select single nucleotide polymorphisms (SNPs) associated with systemic autoimmune disease as instrumental variables(IVs) to analyze genetic causality with renal malignancies. Inverse variance weighting (IVW), MR- Egger, weighted median, simple model and weighted model were used for analysis. The results were mainly based on IVW (Random Effects), followed by sensitivity analysis. Inverse-Variance Weighted(IVW) and MR-Egger were used to test for heterogeneity. MR- Egger is also used for pleiotropic testing. A single SNP analysis was used to identify single nucleotide polymorphisms (SNPs) with potential impact. Odds ratio (OR) and 95% confidence interval (CI) were used to evaluate causality, and sensitivity analysis was performed to evaluate pleiotropy and instrumental validity.

RESULTS

Acute and subacute iridocylitis (P = 0.006, OR = 1.077), Ankylosing spondylitis (P = 0.002, OR = 1.051), and spondyloarthritis (P = 0.009, OR = 1.073) were positively associated with an increased risk of renal malignancy. Coxarthrosis (P = 0.008, OR = 0.483), Juvenile rheumatism (P = 0.011, OR = 0.897), and Systemic lupus erythematosus (P = 0.014, OR = 0.869) were negatively associated with an increased risk of renal malignancy. The results of sensitivity analysis were consistent without heterogeneity or pleiotropy.

CONCLUSION

Our study suggests a causal relationship between different systemic autoimmune diseases and renal malignancies. These findings prompt health care providers to take seriously the potential risk of systemic autoimmune disease and provide new insights into the genetics of kidney malignancies.

Chronic inflammation and cancer; the two sides of a coin

The correlation between chronic inflammation and cancer was initially identified in the 19th century. Biomolecules like interleukins, chemokines, tumor necrosis factors, growth factors, and adhesion molecules, which regulate inflammation, are recognized contributors to neoplastic transformation through various mechanisms, including oncogenic mutations, resistance to apoptosis, and adaptive responses like angiogenesis. This review aims to establish connections between the intricate and complex mechanisms of chronic inflammation and cancer. We illuminate implicit signaling mechanisms that drive the association between chronic inflammation and the initiation/progression of cancer, exploring potential impacts on other diseases. Additionally, we discuss the modalities of currently available therapeutic options for chronic inflammation and cancer, emphasizing the dual nature of such therapies. A thorough understanding of the molecular basis of chronic inflammation is crucial for developing novel approaches in the prevention and treatment of cancer.

Comparison between rheumatoid arthritis with malignant lymphoma and other malignancies: Analysis of a National Database of Rheumatic Disease in Japan

BACKGROUND

The background status and the current treatment options of patients with rheumatoid arthritis (RA) who develop malignant lymphoma (ML) and other malignancies are unclear. This study investigated the differences in background factors between ML and other malignancies that occur in RA patients and post-malignancy treatment.

METHODS

We identified 935 RA patients with new-onset malignancies among 110,571 person-years registered in the National Database of Rheumatic Disease in Japan from 2012 to 2018. Analysis cohorts 1 and 2 included 597 and 490 patients with available data for 1 year before and after the development of malignancies, respectively. Factors associated with the development of ML were longitudinally evaluated by multiple logistic regression analyses.

RESULTS

Of the 935 patients (mean age 70.5, standard deviation 9.9), 15.5% had ML; this was comparable to the rate of lung cancer (14.3%). In cohort 1, methotrexate (MTX), biological disease-modifying anti-rheumatic drugs (bDMARDs), and non-steroidal anti-inflammatory drugs (NSAIDs) were used in 74.4%, 23.4%, and 56.7% of ML and in 56.8%, 25.4%, and 35.3% of other malignancies 1 year before the occurrence of malignancies. Clinical disease activity index (CDAI) and C-reactive protein were similar between the two groups. Multivariable analysis showed that MTX use (odds ratio [OR]: 2.22, 95% CI [confidence interval]: 1.32-3.73, p=0.003) and NSAID use (OR: 2.51, 95% CI: 1.58-3.98, p <0.001) were significantly associated with the development of ML versus other malignancies. However, this association was not observed with bDMARDs. In cohort 2, one year after the development of malignancies, MTX was used in none of ML and 41.8% of patients who developed other malignancies. In both malignancy groups, approximately 15% of patients received bDMARDs and 50% received glucocorticoids. IL-6 inhibitors were preferentially prescribed in patients with ML versus those with other malignancies. At year 1, CDAI remission was achieved in 37.3% and 31.1% of patients in the ML and other malignancy groups, respectively.

CONCLUSION

Patients receiving long-term treatment with MTX and NSAIDs may be at a relatively high risk of developing ML. The treatment landscape after developing malignancies differed considerably between patients with ML and other malignancies, and different treatment strategies should be established.

Prevalence of Nonsteroidal Antiinflammatory Drugs Prescribed for Osteoarthritis: A Systematic Review and Meta-Analysis of Observational Studies

OBJECTIVE

Our systematic review aimed to investigate the proportion of participants with osteoarthritis who were prescribed nonsteroidal antiinflammatory drugs (NSAIDs) by their health care provider.

METHODS

Electronic databases were searched for observational studies reporting NSAID prescribing to participants with diagnosed osteoarthritis of any region. Risk of bias was assessed using a tool designed for observational studies measuring prevalence. Random and fixed-effects meta-analysis was used. Meta-regression investigated study-level factors associated with prescribing. The overall evidence quality was assessed using Grading of Recommendations Assessment, Development, and Evaluation criteria.

RESULTS

Fifty-one studies were included, published between 1989 and 2022, with 6,494,509 participants. The mean age of participants was 64.7 years (95% confidence interval [95% CI] 62.4, 67.0; n = 34 studies). Most studies were from Europe and Central Asia (n = 23 studies), and North America (n = 12 studies). Most studies were judged to be at low risk of bias (75%). Heterogeneity was eliminated when removing studies with a high risk of bias, to give a pooled estimate of NSAIDs prescribing to participants with osteoarthritis of 43.8% (95% CI 36.8, 51.1; moderate quality of evidence). Meta-regression determined that prescribing was associated with year (decreased prescribing over time; P = 0.05) and geographic region (P = 0.03; higher in Europe and Central Asia and in South Asia than in North America) but not with clinical setting.

CONCLUSION

Data from over 6.4 million participants with osteoarthritis between 1989 and 2022 indicate that NSAID prescribing has decreased over time and that prescribing differs between geographic locations.

Clostridioides difficile infection-associated cause-specific and all-cause mortality: a population-based cohort study

OBJECTIVES

Clostridioides difficile infection (CDI) is a common healthcare-associated infection and leading cause of gastroenteritis-related mortality worldwide. However, data on CDI-associated mortality are scarce. We aimed to examine the association between CDI and all-cause and cause-specific mortality. We additionally explored contributing causes of mortality, including recurrent CDI, hospital- or community-acquired CDI, chronic comorbidities, and age.

METHODS

This nationwide population-based cohort study (from 2006 to 2019) compared individuals with CDI with the entire Swedish background population using standardized mortality ratios. In addition, a matched-cohort design (1:10), utilizing multivariable Poisson-regression models, provided incidence rate ratios (IRRs) with 95% CIs.

RESULTS

This study included 43 150 individuals with CDI and 355 172 controls. In total, 69.7% were ≥65 years, and 54.9% were female. CDI was associated with a 3- to 7-fold increased mortality rate (IRR = 3.5, 95% CI: 3.3-3.6; standardized mortality ratio = 6.8, 95% CI: 6.7-6.9) compared with the matched controls and Swedish background population, respectively. Mortality rates were highest for hospital-acquired CDI (IRR = 2.4, 95% CI: 1.9-3.2) and during the first CDI episode (IRR = 0.2, 95% CI: 0.2-0.3 for recurrent versus first CDI). Individuals with CDI had more chronic comorbidities than controls, yet mortality remained higher among CDI cases even after adjustment and stratification for comorbidity; CDI was associated with increased mortality (IRR = 6.1, 95% CI: 5.5-6.8), particularly among those without any chronic comorbidities.

DISCUSSION

CDI was associated with elevated all-cause and cause-specific mortality, despite possible confounding by ill health. Mortality rates were consistently increased across sexes, all age groups, and comorbidity groups.

The Effect of Aspirin Use on Incident Hepatocellular Carcinoma-An Updated Systematic Review and Meta-Analysis

An increasing number of observational studies have described an association between aspirin use and a reduced risk of incident hepatocellular carcinoma. We performed this meta-analysis to provide a comprehensive and updated aggregate assessment of the effect of aspirin on HCC incidence. Two independent authors performed a systematic search of the literature, utilising the Medline, Embase, Scopus, and PubMed databases. A total of 16 studies (12 cohort studies, and 4 case-control studies) were selected for inclusion, with a large number of studies excluded, due to an overlapping study population. The pooled analysis of cohort studies involving a total population of approximately 2.5 million subjects, 822,680 aspirin users, and 20,626 HCC cases demonstrated a 30% reduced risk of HCC associated with aspirin use (adjusted HR 0.70, 95%CI 0.60-0.81). There was a similar but non-significant association observed across the case-control studies (adjusted OR 0.60, 95%CI 0.32-1.15, p = 0.13), which involved a total of 1961 HCC cases. In a subgroup meta-analysis of patients with cirrhosis, the relationship between aspirin use and incident HCC diminished to non-significance (adjusted HR 0.96, 95%CI 0.84-1.09). Aspirin use was associated with a statistically significant increase in bleeding events when all relevant studies were pooled together (adjusted HR 1.11, 95%CI 1.02-1.22). Prospectively collected data should be sought, to define the optimal patient group in which aspirin is safe and effective for the chemoprophylaxis of HCC.

Non-steroidal anti-inflammatory drugs and biomarkers: A new paradigm in colorectal cancer

Colorectal cancer is a sporadic, hereditary, or familial based disease in its origin, caused due to diverse set of mutations in large intestinal epithelial cells. Colorectal cancer (CRC) is a common and deadly disease that accounts for the 4^th worldwide highly variable malignancy. For the early detection of CRC, the most common predictive biomarker found endogenously are KRAS and ctDNA/cfDNA along with SEPT9 methylated DNA. Early detection and screening for CRC are necessary and multiple methods can be employed to screen and perform early diagnosis of CRC. Colonoscopy, an invasive method is most prevalent for diagnosing CRC or confirming the positive result as compared to other screening methods whereas several non-invasive techniques such as molecular analysis of breath, urine, blood, and stool can also be performed for early detection. Interestingly, widely used medicines known as non-steroidal anti-inflammatory drugs (NSAIDs) to reduce pain and inflammation have reported chemopreventive impact on gastrointestinal malignancies, especially CRC in several epidemiological and preclinical types of research. NSAID acts by inhibiting two cyclooxygenase enzymes, thereby preventing the synthesis of prostaglandins (PGs) and causing NSAID-induced apoptosis and growth inhibition in CRC cells. This review paper majorly focuses on the diversity of natural and synthetic biomarkers and various techniques for the early detection of CRC. An approach toward current advancement in CRC detection techniques and the role of NSAIDs in CRC chemoprevention has been explored systematically. Several prominent governing mechanisms of the anti-cancer effects of NSAIDs and their synergistic effect with statins for an effective chemopreventive measure have also been discussed in this review paper.

Does Chronic Use of High Dose Proton Pump Inhibitors Increase Risk for Pancreatic Cancer?

OBJECTIVES

To analyze whether use of proton pump inhibitors increase the risk for pancreatic cancer in a mouse model and human clinical cohorts.

METHODS

p48-Cre/LSL-KrasG12D mice that develop precancerous pancreatic intraepithelial neoplasia (PanINs) were treated with low- or high-dose proton pump inhibitors (PPIs) orally for 1 and 4 months. The mechanism for the cholecystokinin receptor 2 (CCK-2R) activation was investigated in vitro. Two resources were employed to analyze the risk of pancreatic cancer in human subjects with PPI use.

RESULTS

Serum gastrin levels were increased 8-fold (P < 0.0001) in mice treated with chronic high-dose PPIs, and this change correlated with an increase (P = 0.02) in PanIN grade and the development of microinvasive cancer. The CCK-2R expression was regulated by microRNA-148a in the p48-Cre/LSL-KrasG12D mice pancreas and in human pancreatic cancer cells in vitro. Proton pump inhibitor consumption in human subjects was correlated with pancreatic cancer risk (odds ratio, 1.54). A validation analysis conducted using the large-scale United Kingdom Biobank database confirmed the correlation (odds ratio, 1.9; P = 0.00761) of pancreatic cancer risk with PPI exposure.

CONCLUSIONS

This investigation revealed in both murine models and human subjects, PPI use is correlated with a risk for development of pancreatic cancer.

Non-aspirin non-steroidal anti-inflammatory drugs in colorectal cancer: a review of clinical studies

Colorectal cancer (CRC) chemoprevention is an area of interest. Non-steroidal anti-inflammatory drugs (NSAIDs) are anti-inflammatory agents which have been identified as cancer chemoprevention agents given that inflammation is thought to contribute to tumorigenesis. Most studies have demonstrated that the NSAID, aspirin, plays a beneficial role in the prevention of CRC and colonic adenomas. Non-aspirin NSAIDs (NA-NSAIDs) have also been studied in CRC chemoprevention. There is increasing literature around their role in pre-cancerous polyp prevention and in decreasing CRC incidence and CRC-related outcomes in certain high-risk subgroups. However, the use of NA-NSAIDs may be accompanied by increased risks of toxicity. Further studies are required to establish the associations between concurrent aspirin and NA-NSAID use, and CRC-related outcomes.

Aspirin, statins, non-aspirin NSAIDs, metformin and the risk of Biliary Cancer: A Swedish population-based cohort study

BACKGROUND

Chemoprevention for biliary tract cancers (BTCs), which comprise intrahepatic cholangiocarcinoma (iCCA), extrahepatic cholangiocarcinoma (eCCA) and gallbladder cancer (GBC), is controversial. We examined associations between low-dose aspirin, statins, NSAIDs, and metformin with BTC risk.

METHODS

We used a population-based cohort of 5.7 million persons over age 18 without personal history of cancer (except non-melanoma skin cancer), receiving at least one commonly-prescribed drug between July 1, 2005, and December 31, 2012, from the Swedish Prescribed Drug Registry. Hazard ratios (HRs) were calculated using age-scaled multivariable-adjusted Cox models.

RESULTS

2,160 individuals developed BTC. Low-dose aspirin was not associated with BTC risk (HR 0.93; 95%CI:0.81-1.07), iCCA (HR 1.21; 95%CI:0.93-1.57), eCCA (HR 0.80; 95%CI:0.60-1.07) or GBC (HR 0.87; 95%CI:0.71-1.06). Statins were associated with lower risk of BTC (HR 0.66; 95%CI:0.56-0.78), iCCA (HR 0.69; 95%CI:0.50-0.95), eCCA (HR 0.54; 95%CI:0.38-0.76), and GBC (HR 0.72; 95%CI:0.57-0.91). For all BTC subtypes, combined low-dose aspirin and statins were not associated with lower risk than statins alone. NSAIDs were associated with higher risk of BTC and its subtypes. Metformin was not associated with BTC risk (HR 0.98; 95%CI:0.82-1.18), iCCA (HR 1.06; 95%CI:0.77-1.48), eCCA (HR 1.15; 95%CI:0.82-1.61) or GBC (HR 0.84; 95%CI:0.63-1.11).

CONCLUSION

Statins were associated with a decreased risk of BTC and its subtypes. Low-dose aspirin alone was not associated with a decreased risk and use of both was not associated with further decrease in risk beyond statins alone.

IMPACT

Statins were most consistently associated with a decreased risk of BTC and its subtypes.

Comorbidities and Health-Related Quality of Life in Subjects with Spine Osteoarthritis at 50 Years of Age or Older: Data from the Korea National Health and Nutrition Examination Survey

Background and Objective: This study assessed comorbidities and health-related quality of life (HRQOL) in subjects with lumbar spine osteoarthritis (OA) in the Korean population. Materials and Methods: We analyzed 3256 subjects who were 50 years or older and underwent plain radiography of the lumbar spine as part of the Korea National Health and Nutrition Examination Survey (KNHANES) 2012. Radiographic assessment was based on Kellgren–Lawrence (K-L) grade ranging from 0 to 2, with K-L grade 2 defined as lumbar spine OA. HRQOL was assessed by EuroQol-5 dimensions (EQ-5D), which include the EQ-5D index and visual analogue scale (EQ-VAS) measurements. Results: Comorbidities such as hypertension, myocardial infarction, angina, cerebral infarction, and diabetes mellitus were more frequent in spine OA than in controls, while dyslipidemia was less common. Subjects with spine OA had higher mean number of comorbid conditions than controls (1.40 (SE 0.05) vs. 1.20 (SE 0.03), p = 0.001). Subjects with spine OA had much lower EQ-5D index than controls (p < 0.001) but not lower EQ-VAS score. Multivariate binary logistic analysis showed that hypertension and colon cancer were associated with spine OA compared to controls (OR 1.219, 95% CI 1.020–1.456, p = 0.030 and OR 0.200, 95% CI 0.079–0.505, p = 0.001, respectively) after adjustment for confounding factors. Lower EQ-5D index was related to spine OA (95% CI 0.256, 95% CI 0.110–0.595, p = 0.002) but not EQ-VAS score. Conclusion: In this study, we found that comorbidities such as hypertension and colon cancer as well as lower HRQOL were associated with spine OA.

Association between proton-pump inhibitors and the risk of gastric cancer: a systematic review with meta-analysis

INTRODUCTION

The use of proton-pump inhibitors (PPI) may be associated with an increased risk of gastric cancer (GC).

OBJECTIVE

To review and meta-analyse available literature investigating the association between PPI use and GC risk.

METHODS

Two independent reviewers systematically searched Ovid MEDLINE, EMBASE, and Cochrane Library (inception to July 2020) for case-control and cohort studies assessing the association between PPI use and GC according to a predefined protocol in PROSPERO (CRD42018102536). Reviewers independently assessed study quality, extracted data, and meta-analysed available and newly calculated odds ratios (ORs) using a random-effects model, and stratified for GC site (cardia versus non-cardia) and PPI duration (<1 year, 1-3 years, >3 years).

RESULTS

We screened 2,396 records and included five retrospective cohort and eight case-control studies comprising 1,662,881 individuals in our meta-analysis. In random-effect models, we found an increased GC risk in PPI users [OR: 1.94, 95% confidence interval (95% CI): 1.47-2.56] with high statistical heterogeneity (I ² = 82%) and overall moderate risk of bias. Stratified analyses indicated a significant risk increase in non-cardia (OR: 2.20, 95% CI: 1.44-3.36, I ² = 77%) with a similar non-significant trend in cardia regions (OR: 1.77, 95% CI: 0.72-4.36, I ² = 66%). There was no GC increase with longer durations of PPI exposure (<1 year: OR: 2.29, 95% CI: 2.13-2.47, I ² = 0%; 1-3 years: OR: 1.46, 95% CI: 0.53-4.01, I ² = 35%; >3 years: OR: 2.08, 95% CI: 0.56-7.77, I ² = 61%).

CONCLUSION

We found a twofold increased GC risk among PPI users, but this association does not confirm causation and studies are highly heterogeneous. PPI should only be prescribed when strictly indicated.

Association Between Proton Pump Inhibitor Use and Biliary Tract Cancer Risk: A Swedish Population-Based Cohort Study

BACKGROUND AND AIMS

Biliary tract cancer is a group of highly aggressive malignant disorders, yet risk factors are poorly understood. In this study, we aim to assess whether prolonged use of proton pump inhibitors (PPIs) increases the risk of incident biliary tract carcinoma in a nation-wide population-based cohort in Sweden.

APPROACH AND RESULTS

Using nation-wide registries, we identified all adults who received maintenance PPIs (≥180 days) according to the Swedish Prescribed Drug Register from 2005 through 2012. Data on incident biliary tract cancer were retrieved from the Swedish Cancer, Death and Outpatient Registers. Risk of biliary tract cancer in persons who received PPI treatment was compared with the general population of the corresponding age, sex, and calendar year yielding standardized incidence ratios (SIRs) with 95% CIs. Of 738,881 PPI users (median follow-up of 5.3 years), 206 (0.03%) developed gallbladder cancer and 265 (0.04%) extrahepatic and 131 (0.02%) intrahepatic bile duct cancer corresponding to SIRs of 1.58 (95% CI, 1.37-1.81), 1.77 (95% CI, 1.56-2.00), and 1.88 (95% CI, 1.57-2.23), respectively. In sensitivity analyses restricted to persons without a history of gallstones or chronic liver or pancreatic diseases, SIRs were 1.36 (95% CI, 1.17-1.57) and 1.47 (95% CI, 1.19-1.80) for extra- and intrahepatic duct cancer, respectively. The risk remained higher than the corresponding general population with ≥5 years of PPIs use, ruling out confounding by indication.

CONCLUSIONS

In this study, long-term use of PPIs was associated with an increased risk of gallbladder, intrahepatic, and extrahepatic bile duct cancer compared with the general population.

Association between proton pump inhibitors after percutaneous coronary intervention and risk of gastric cancer

BACKGROUND

Previous studies showing an association between chronic use of proton pump inhibitor (PPI) and gastric cancer are limited by confounding by indication. This relationship has not been studied in patients receiving PPI for prophylaxis, such as those undergoing percutaneous coronary intervention (PCI).

METHOD

This was a retrospective cohort study including 14 hospitals under the Hospital Authority of Hong Kong between 1 January 2004 and 31 December 2017. Participants were patients who underwent first-ever PCI, were not on PPI prescription within 30 days before admission for PCI, had no known malignancy and survived for 365 days after PCI. Propensity score matching was used to balance baseline characteristics and other prescription patterns. The primary outcome was diagnosis of gastric cancer made >365 days after PCI as a time-to-first-event analysis. The secondary outcome was death from gastric cancer.

RESULTS

Among the 13 476 patients (6738 pairs) matched by propensity score, gastric cancer developed in 17 (0.25%) PPI users and 7 (0.10%) PPI non-users after a median follow-up of 7.1 years. PPI users had a higher risk of gastric cancer (HR 3.55; 95% CI 1.46 to 8.66, p=0.005) and death from gastric cancer (HR 4.18; 95% CI 1.09 to 16.08, p=0.037), compared with non-users. The association was duration-dependent and patients who took PPI for ≥365 days were at increased risk.

CONCLUSIONS

Chronic use of PPI was significantly associated with increased risk of gastric cancer and death from gastric cancer in patients for whom it was prescribed as prophylaxis. Physicians should judiciously assess the relevant risks and benefits of chronic PPI use before prescription.

Aspirin and Statin Use and the Risk of Gallbladder Cancer

Simple Summary

The effects of aspirin on various gastrointestinal cancers have been extensively studied, but the potential protective effect of aspirin and statins on the prevention of gallbladder cancer (GBC) has not been adequately evaluated. The anticancer effect of aspirin has been attributed to direct inhibition of cyclooxygenase (COX)-2. Interestingly, increased expression of COX-2 has been documented in GBC. Hence, we hypothesized that aspirin could potentially have a preventive role in decreasing the risk of GBC. In this study, we demonstrated that the use of aspirin either alone or in combination with statins was associated with a strong reduction in risk of GBC.

Abstract

Aspirin and statin drugs have been associated with reduced risk of several gastrointestinal cancers, but their association with gallbladder cancer (GBC) has not been well established. We evaluated the association of aspirin and statins with the risk of GBC. Patients with GBC managed at Mayo Clinic between 2000 and 2019 were matched 1:2 with a general patient pool by age and sex. Univariable and multivariable logistic regression models were used to assess associations between GBC and aspirin or statin use. The analysis included 795 cases and 1590 controls, with a median age of 67 years. Aspirin or statin use alone or in combination was higher in controls (p < 0.001). Univariate analysis showed that the use of aspirin [odds ratio (OR): 0.11; 95%CI: 0.08–0.15] or statins (OR: 0.29; 95%CI: 0.20–0.40) and their combined use (OR: 0.18; 95%CI: 0.13–0.24) was associated with lower risk of GBC. Multivariable analysis revealed that aspirin (OR: 0.12; 95%CI: 0.09–0.16) and combined statins and aspirin (OR: 0.46; 95%CI: 0.31–0.67) were associated with lower risk of GBC. Aspirin alone or in combination with statins is associated with a strongly reduced risk of GBC. Further prospective studies are needed to confirm these results and to elucidate their mechanisms.

Risks of solid cancers in elderly persons with osteoarthritis or ankylosing spondylitis

OBJECTIVES

Patients with osteoarthritis and ankylosing spondylitis have lower cancer-related mortality than the general population. We examined risks of solid cancers at 16 sites in elderly patients with knee or hip osteoarthritis (KHOA) or ankylosing spondylitis.

METHODS

In this population-based retrospective cohort study, we used US Medicare data from 1999 to 2010 to identify cohorts of persons with KHOA or ankylosing spondylitis, and a general population group without either condition, who were followed through 2015. We compared cancer incidence among groups, adjusted for age, sex, race, socioeconomic characteristics, geographic region, smoking and comorbidities.

RESULTS

We studied 2 701 782 beneficiaries with KHOA, 13 044 beneficiaries with ankylosing spondylitis, and 10 859 304 beneficiaries in the general population group. Beneficiaries with KHOA had lower risks of cancer of the oropharynx, oesophagus, stomach, colon/rectum, hepatobiliary tract, pancreas, larynx, lung, and ovary than the general population. However, beneficiaries with KHOA had higher risks of melanoma, renal cell cancer, and cancer of the bladder, breast, uterus and prostate. Associations were similar in ankylosing spondylitis, with lower risks of cancer of the oesophagus, stomach, and lung, and higher risks of melanoma, renal cell cancer, and cancer of the renal pelvis/ureter, bladder, breast, and prostate.

CONCLUSION

Lower risks of highly prevalent cancers, including colorectal and lung cancer, may explain lower cancer-related mortality in patients with KHOA or ankylosing spondylitis. Similarities in cancer risks between KHOA and AS implicate a common risk factor, possibly chronic NSAID use.

Prognostic and Clinical Significance of Cyclooxygenase-2 Overexpression in Endometrial Cancer: A Meta-Analysis

Objective: Cyclooxygenase-2 (COX-2) is a critical enzyme associated with inflammation and tumorigenesis. Although several studies have compared the expression of COX-2 in endometrial cancer tissues and normal tissues, the results have been inconsistent thus far. This study aims to conduct a meta-analysis to elucidate the role of COX-2 in the determination of the risk, prognosis, and clinical features of endometrial cancer. Methods: We retrieved the suitable studies on the association between COX-2 expression and endometrial cancer from PubMed, EMBASE, and Web of Science databases that were published between 1999 and September 31st, 2019. The hazard ratio (HR) and 95% confidence intervals (CIs) were retrieved to assess the relationship between COX-2 expression and the prognosis of endometrial cancer. The odds ratio (OR) and 95% CIs were calculated to evaluate the correlation between COX-2 expression and the risk and clinical features of endometrial cancer. Results: To investigate the association between COX-2 expression and the susceptibility, clinical features, and prognosis of endometrial cancer, we performed a meta-analysis on data from selected studies that collectively involved 273 normal individuals and 1,376 patients with endometrial cancer. Overall, the pooled analysis indicated that COX-2 expression was significantly associated with susceptibility (Caucasians, OR = 3.94, 95% CI = 2.17-7.17, P < 0.05; Asians, OR = 20.51, 95% CI = 8.54-49.26, P < 0.05), cancer stage (OR = 3.01, 95% CI = 1.95-4.67, P < 0.05), myometrial invasion (OR = 1.59, 95% CI = 1.17-2.15, P < 0.05), lymph node metastasis (OR = 1.63, 95% CI = 1.18-2.26, P < 0.05), and prognosis (OR = 2.91, 95% CI = 1.17-4.66, P < 0.05) in endometrial cancer. Conclusions: Our findings suggested that COX-2 overexpression is significantly associated with poor prognosis and advanced clinical features in endometrial cancer. Therefore, COX-2 may function as an effective prognostic biomarker and a potential therapeutic target for endometrial cancer.

Long-term proton pump inhibitor usage and the association with pancreatic cancer in Sweden

BACKGROUND

The long-term safety of proton pump inhibitors (PPIs) is increasingly questioned. The aim of our study was to assess the risk of pancreatic cancer among long-term PPI users in Sweden.

METHODS

This population-based nationwide Swedish cohort study including 796,492 adult long-term PPI users has been used to calculate the standardized incidence rate ratios (SIRs) and 95% confidence intervals (CI) for pancreatic cancer, stratifying by indications of use, age, sex, and duration of use. The risk among all 20,210 long-term H2-receptor antagonist users was assessed as comparison.

RESULTS

Pancreatic cancer was found in 1733 long-term PPI users, and 25 H2-receptor antagonist users. For PPI users, the risk of pancreatic cancer was increased overall (SIRs = 2.22; 95% CI 2.12-2.32) and in all subgroup analyses, with the highest risk among PPI-users younger than 40 years (SIR = 8.90, 95% CI 4.26-16.37), and among individuals with a history of Helicobacter pylori (SIR = 2.99, 95% CI 2.54-3.49). After the first year after enrolment (during which PPI use may be because of early symptoms of pancreatic cancer), the risk remained increased over time, with SIR = 1.57 (95% CI 1.38-1.76) after 5 years. No associations were found for H2-receptor antagonists (SIR = 1.02, 95% CI 0.66-1.51).

CONCLUSIONS

This large study showed an increased risk of pancreatic cancer in long-term users of PPIs in Sweden, in particular among the youngest users.