Taking aspirin with acid reducers can help patients with chronic acid reflux slow the advance of cancer of the oesophagus, the tube from the throat to the stomach, a study has found. The Guardian reports that the study looked at patients with Barrett’s oesophagus, damage to the lower portion of the tube usually caused by stomach acid, which is considered a precancerous condition.
People who complain of acid reflux are 10 times more likely to develop Barrett’s oesophagus, and patients with Barrett’s are at a 50-fold risk of developing oesophageal cancer.
“Based on these data, we believe people with heartburn should talk with their doctor about their risk of Barrett’s oesophagus,” said lead study author Dr Janusz Jankowski, deputy vice-chancellor at the Royal College of Surgeons Ireland. He added: “But they should not self-medicate with these medications.”
The research was presented at the annual meeting of the American Society of Clinical Oncology, the largest gathering of cancer doctors in the world. Oesophageal cancer is rare compared with other diseases, such as breast or prostate cancer, but nevertheless has ticked upward over the last three decades. Each year, 9,000 people in the UK are diagnosed with the disease, and 7,900 die because of it.
Oesophageal cancer is the fourth most common cause of cancer death for British men and sixth most common for British women, according to research from Cambridge University in 2014. Barrett’s oesophagus is believed to occur in 2% of western adults, and oesophageal cancer occurs within 2% of that population, researchers said.
“The risk of oesophageal cancer weighs on patients with Barrett’s oesophagus. This low-cost, over-the-counter regimen seems to be a win-win, delaying or preventing cancer and with little to no side effects,” said ASCO expert Andrew Epstein. “It’s an approach people with Barrett’s should consider and discuss with their doctors.”
However, Epstein cautioned against broadly interpreting the study. “Should anyone with heartburn, even if its long-term heartburn do this? No, the data do not bear that out,” he said. “These data definitely need to be treated with caution.”
Researchers looked at whether adding aspirin to the acid reducing medication would benefit patients with Barrett’s oesophagus, in an effort to prevent the aggressive treatment often recommended for the cancer.
Researchers followed a randomised group of 2,563 patients from Canadian and British hospitals for a median of nearly nine years. Of those parents, 313 developed cancer, worsened Barrett’s, or died.
The participants received either 20 or 40 milligrams of Nexium twice daily, taken with or without aspirin. Researchers then studied whether patients developed oesophageal cancer, worsened Barrett’s oesophagus, or if they died.
Researchers determined that a high dose of acid suppressant was superior to a low dose, and that taking aspirin with the high dose proton pump inhibitors showed a 20% overall risk reduction.
Currently, doctors treat Barrett’s oesophagus by monitoring the condition with frequent endoscopies, a way to look at and biopsy the oesophagus with a camera. Researchers said this approach has a “modest effect” on oesophageal cancer and is only “supported by low quality evidence”.
“The bottom line is if you have Barrett’s oesophagus, you probably ought to be on high-grade acid suppression therapy, maybe with aspirin,” said Dr Richard L Schilsky, senior vice-president and chief medical officer of ASCO. “The incremental benefit of aspirin was small but significant.”
However, scientists said more research is needed, noting that most of the participants in the study were white, and that the number of countries in which research occurred was limited.
Further, although the side effects of aspirin and acid reducers are mild compared to aggressive surgical or chemotherapy treatments for oesophageal cancer, there are still side effects. Patients sometimes experience diarrhoea with acid reducers, and aspirin can cause bleeding. As well, long-term use of acid reducing proton pump inhibitors is associated with adverse side effects including increased risk of dementia.
Abstract
Background: Esophageal adenocarcinoma (EA) is the sixth most common cause of global cancer death. We rely on endoscopy screening to identify and monitor patients with Barrett’s esophagus (BE) and find neoplastic lesions early enough to manage their EA. This approach has a modest effect on EA supported by low quality evidence. We evaluated the efficacy of aspirin and high dose acid suppression in preventing EA in patients with BE.
Methods: We recruited patients with ≥ 1cm of BE and no high grade dysplasia (HGD) or EA at baseline in UK and Canadian hospitals. To conceal allocation, a central trials unit randomized patients using a computer-generated schedule. Patients were randomized unblinded 1:1:1:1 in a 2X2 factorial design to high dose (40mg twice daily) or low dose (20mg once daily) esomeprazole proton pump inhibitor acid suppression (PPI), alone or combined with low dose aspirin 300mg/day (330mg in Canada). The primary composite endpoint was time to all-cause mortality or EA or HGD analyzed using accelerated failure time modelling adjusting for minimization factors (age, length of Barrett’s esophagus and presence of intestinal metaplasia).
Results: We recruited 2563 Barrett’s patients followed-up for a median of 8.9 years (interquartile range 8.2-9.8) with 20,095 years of follow up. There were 313 events of the composite primary endpoint. High dose PPI was statistically significantly superior to low dose PPI (p = 0.037, N = 2535, time ratio (TR) 1.27, 95% CI = 1.01-1.58). Aspirin therapy showed a trend to benefit but was not statistically significant (p = 0.068, N = 2280, TR = 1.24, 95% CI = 0.98 – 1.57). The combination of aspirin with high dose PPI had the strongest effect compared to low dose PPI with no aspirin (TR = 1.59, 95% CI = 1.14 to 2.23, p = 0.007). There were few serious adverse events reported (1.0% of patients), with 99.9% data collected.
Conclusions: This is the largest randomized controlled chemoprevention trial in patients with Barrett’s esophagus. We have shown that PPI high dose and aspirin chemoprevention therapy, especially in combination significantly reduces rates of death, EA or HGD occurrence and is safe.
Authors
Janusz Jankowski, John de Caestecker, Sharon Love, Gavin Reilly, Yeng Ang, Krish Ragunath, Arthur Tucker, Ian Penman, Colin Rodgers, Emma Roffe, Claire E Brooks, Stephen Attwood, Danielle Morris, Rebecca Harrison, Pradeep Bhandari, Peter Watson, Scott Sanders, Hugh Barr, Paul Moayyedi, James Neale, AspECT Trial Team
[link url="https://www.theguardian.com/society/2018/jun/04/taking-aspirin-with-acid-reducers-can-slow-advance-of-esophogeal-cancer"]The Guardian report[/link]
[link url="https://meetinglibrary.asco.org/record/160062/abstract"]ASCO 2018 abstract[/link]