Prof. dr. Freek Verheugt: “Role of aspirin in cancer mortality far from clear”
PACE asked professor Freek Verheugt (cardiologist, OLVG Amsterdam, NL) to give his view on the publication of Cuzick et al., in Ann Oncol of last week, about the effect of prophylactic aspirin use in light of cancer and CVD events. He places some critical remarks with this publication.
It was already known, that daily use of acetylic salicylic acid can reduce growth of adenomas in the colorectal trajectory, and of course it is also known, that with acetyl salicylic acid had a powerful preventive effect in secondary prevention of cardiovascular disease. The research of Cuzick  suggests that long term use of acetyl salicylic acid for secondary prevention of cardiovascular disease ultimately leads to a lower incidence of neoplasms, including a lower cancer mortality, but without an effect on cardiovascular mortality. This was mostly true for men.
It is an interesting finding and the results are not implausible on theoretical grounds. They may, due to extremely low costs, ultimately lead to cost-effective reduction of cancer mortality. There are, however, a few critical remarks to be made.
The findings of this research have been collected from important studies from vascular medicine and oncology. The selected research projects had reduction of ischaemic events, or malignancies, as primary endpoint. Only in a few studies the long term cause of death could be determined based on an official death certificate. Therefore, no hard evidence is available that acetyl salicylic acid actually reduces mortality due to certain forms of cancer.
The most important limitation of such a meta-analysis is, that studies have been done on the one hand by specialists from vascular medicine, who are focussed on the primary vascular endpoint, and on the other hand oncologists who are focussed on malignancies. The finding of lower cancer mortality on the long term is therefore disputable. A good example of a similar mistake, is the strongly criticised meta-analytic research that showed that nutrition supplements with calcium would cause more myocardial infarctions in patients with a risk of osteoporosis . In addition to the primary endpoint (osteoporosis), an additional endpoint (myocardial infarction) was considered. The found relation is therefore most likely not causal, but associative.
Thus, it is premature to advise long-term use of acetyl salicylic acid to reduce cancer mortality. If anyone, patients at high risk of gastro-intestinal adenocarcinoma may be candidates, or patients in whom such a tumour has previously been removed. Obviously, a well-designed, large randomised double-blind trial is needed to evaluate the role of acetyl salicylic acid in secondary prevention of gastro-intestinal malignancies.
News • 11-8-2014
Prophylactic aspirin use for at least 5 years at doses between 75 and 325 mg/day seems to have a favourable benefit-harm profile, with regard to cancer and CVD events.
1. Cuzick J, Thorat MA, Bosetti C, et al. Estimates of benefit and harms of prohylactic use of aspirin in the general population Ann Oncol 2014, Epub Aug 8.
2. Boland MJ, Avenell A, Baron JA, et al. Effect of calcium supplements on risk of myocardial infarction and cardiovascular events: meta-analysis. BMJ 2010;341:c3691