In the Literature

TON - August 2021 Vol 14, No 4

Daily Aspirin Does Not Lower CRC Risk When Started After Age 70

Regular aspirin use is considered the best chemoprevention strategy to reduce colorectal cancer (CRC) risk in middle-aged adults. This supported the US Preventive Services Task Force’s (USPSTF) recommendation of daily aspirin for CRC prophylaxis in adults aged 50 to 59 years with certain cardiovascular risk factors. The USPSTF, however, also recommends aspirin use in people aged ≥70 years, but the evidence for this is inconsistent. Recent data from the ASPREE clinical trial of healthy adults aged ≥70 years showed that daily low-dose aspirin did not reduce CRC risk, suggesting that at some point, aspirin may no longer provide protection against CRC, but no evidence indicated what that age was. This led researchers to examine the association of aspirin use and CRC risk in adults aged ≥70 years.

This new prospective cohort study by Guo and colleagues was based on a pooled analysis of data from 2 large US cohort studies—the Nurses’ Health Study (1980-2014) and the Health Professionals Follow-up Study (1986-2014; JAMA Oncol. 2021;7:428-435). These 2 studies included 94,540 adults who used aspirin for >30 years, providing a unique opportunity to examine aspirin use across middle and late adulthood and the risk for CRC. The study’s primary end point was the link between incident CRC and use of aspirin in people aged ≥70 years.

Among the participants (mean age, 76.4 years for women, 77.7 years for men), 1413 incident cases of CRC were found during >996,463 person-years of follow-up. After adjusting for other risk factors, regular users of aspirin had a significantly lower risk of CRC at age ≥70 years versus nonregular users (hazard ratio [HR], 0.80; 95% confidence interval [CI], 0.72-0.90), but only among those who initiated regular aspirin use before age 70 years (HR, 0.80; 95% CI, 0.67-0.95). By contrast, people who started regular aspirin use only at age ≥70 years did not have reduced CRC risk with aspirin use (HR, 0.92; 95% CI, 0.96-1.11).

“Taken together with the results of the ASPREE trial, these findings suggest that initiation of aspirin use at an older age for the sole purpose of primary prevention of CRC should be discouraged,” concluded the researchers. “However, our findings appear to support recommendations to continue aspirin use if initiated at a younger age.”

Return to Top


Adjuvant Nivolumab Therapy Prolongs Disease-Free Survival in Patients with Esophageal Cancer

Esophageal cancer is a leading cause of cancer-related morbidity and mortality worldwide. Chemoradiotherapy followed by surgery is the standard of care for patients with resectable, locally advanced esophageal cancer. However, the risk for recurrence after this treatment remains high, especially among the majority of patients who do not have a pathologic complete response. Commenting on the recent publication of the CheckMate-557 study in an accompanying editorial published in the New England Journal of Medicine, David H. Ilson, MD, PhD, discussed the benefits and limitations of treatments for esophageal cancer, noting that the current debate is whether chemotherapy alone or chemoradiotherapy is the preferred strategy before surgery (Ilson DH. N Engl J Med. 2021;384:1269-1271).

“Improvement in survival among patients with esophageal cancer has been long awaited in those undergoing the arduous journey of chemotherapy, radiation, and surgery,” Dr Ilson emphasized, while discussing findings from the CheckMate-557 clinical trial, which were published in the same issue (Kelly RJ, et al. N Engl J Med. 2021;384:1191-1203). The study evaluated the checkpoint inhibitor nivolumab as adjuvant treatment after chemoradiotherapy and surgery for esophageal cancer or gastroesophageal junction (GEJ) cancer. “CheckMate-557 is a practice-changing trial in the treatment of esophageal cancer,” he said.

CheckMate-557 was a global, randomized phase 3 trial of 532 patients with resected stage II or III esophageal cancer or GEJ cancer who had received neoadjuvant chemoradiotherapy and had residual pathologic disease. Patients were randomized in a 2:1 ratio to nivolumab or to placebo. The maximum duration of the study intervention was 1 year. The primary end point was disease-free survival.

Nivolumab significantly prolonged disease-free survival (22.4 months vs 11 months for placebo). Both distant and locoregional recurrence occurred less often with nivolumab than with placebo (29% and 12% vs 39% and 17%, respectively).

“Although overall survival data are not mature, the doubling of median disease-free survival will almost certainly translate into an overall survival benefit,” Dr Ilson noted. The benefit of nivolumab compared with placebo in patients with esophageal cancer or

GEJ cancer was seen across all subgroups, including patients with squamous-cell carcinoma, adenocarcinoma, node-negative disease, and node-positive disease. No new safety signals with nivolumab were observed, and only 9% of patients discontinued nivolumab therapy because of adverse events. Grade 3/4 adverse events occurred in 13% of patients who received nivolumab versus 6% of patients receiving placebo. Health-related quality of life was maintained during the treatment period.

“The trial shows the first true advance in the adjuvant therapy of esophageal cancer in recent years and will become a new standard of care,” noted Dr Ilson. However, he added, “despite the improvement observed, most patients will not gain benefit from adjuvant therapy with nivolumab. More contemporary biomarkers, including the presence of persistent circulating tumor DNA after surgery, should be explored to better define high-risk populations.”

Return to Top


New Data Reveal Mismatched Need and Supply of Oncology Physicians and Pharmacists

Previous analyses have pointed to alarming shortages of oncology providers in the face of growing demand. No oncology workforce study, however, has assessed the link between geographic need for oncology services and the codependency between oncologists and nonphysician health professionals with an oncology subspecialty. A recent report on the state of cancer care in the United States examined the availability of physicians and oncology pharmacists and their geographic distributions throughout the country and compared it with the need for oncology services in each county (Shih YCT, et al. JCO Oncol Pract. 2021;17:e1-e10).

The researchers used data from the 2019 National Provider Identifier using the healthcare provider taxonomy codes and categorized the oncology workforce into 2 groups: oncology physicians and oncology pharmacists with an oncology subspecialty. They calculated the availability of the physician and pharmacist oncology workforce in each geographic county and the percentages of counties and their surrounding counties without primary oncology practices, and the percentages of counties with, and then analyzed the cancer rates for each county and categorized them into quartiles, to designate the level of demand for the oncology workforce.

Of the 30,553 healthcare providers in the oncology workforce in 2019, a total of 28,681 were medical oncologists and 1090 were oncology pharmacists, using the 2019 National Provider Identifier. By comparison, 2014 data from the American Society of Health-System Pharmacists reported 1863 board-certified oncology pharmacists. More than 65% of the oncologists were in the South Atlantic, Middle Atlantic, Pacific, and East North Central. The mean density of oncologists by county was 2.94 per 100,000 persons. The analysis of the oncology workforce showed that 64% of US counties had no oncologists with a primary practice site located in that county, and 12% of counties did not have any oncologists within that county or in the adjacent counties.

“Using county cancer rates as proxies of demand for oncology care, we found an alarming pattern that oncologists tended to be less available in counties with higher demand, suggesting that patients with cancer residing in higher-demand counties will either need to travel farther to receive cancer treatment or rely on physicians or other health professions not specialized in oncology to provide the cancer care they need,” the researchers noted.

Counties in the top quartile of cancer rates had the highest percentage without any primary oncology practice located in the county (75%) or without any oncologists in the local and adjacent counties (16%) versus counties in the lowest quartile without oncologists (52%) or in the adjacent counties (11%). A large discrepancy in the supply of oncologists across geographic regions was also observed.

The researchers noted that one strategy is to expand the role of nonphysician health professionals, such as pharmacists, “to alleviate shortage in the supply of oncologists, especially for survivorship and palliative care.”

“This highlights the importance to develop and standardize core competencies for health professions not specialized in oncology to deliver quality cancer care,” they concluded.

Return to Top

Related Items


Subscribe Today!

To sign up for our newsletter or print publications, please enter your contact information below.

I'd like to receive: