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    2 Comments for this article
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    Aspirin should not substitute life style modification
    Kamran Lankarani, Professor of Medicine | Shiraz University of Medical Sciences, Iran
    Although the importance of use of ASA as a secondary preventive measure specially in cardiovascular disease has been well documented , there are controversial reports of its use as a primary preventive measure specially in elderly.(1) The possibility of death due to gastrointestinal or intracerebral hemorrhage is a real threat specially in this age group . While the reduced mortality from cancer specially colorectal cancer needs 5 to 8 years to be achieved, the risk of major bleeding is there from the beginning. (2)
    I read with interest the article by Loomans-Kropp and her colleagues to get an answer
    for this important question. (3) Unfortunately I found several obscured points which makes conclusion difficult. As this cohort were not randomized on receiving ASA, the direct effect of ASA could be due to confounders. For instance those who use ASA as a primary preventive measure may have more concerns about their health which may also lead to more healthier life style.This may confound the effect of ASA as a primary reason for reduced mortality .
    Some information on covariates are presented in supplement. All cause mortality, mortality from cancers and gastrointestinal cancers except for colorectal cancer were higher in those with body mass index of less than 20 even compared to overweight and obese persons. This is in contrast to the well established effect of obesity and overweight as a risk factor for all cause mortality and cancer mortality. The authors did not provide any explanation for this odd finding. Interestingly this group did not show any benefit with usage of ASA. Of interest there is no information on ethanol usage. There is possibility of contribution of effect of ethanol on this finding.
    In conclusion one important drawback of these type of studies is medicalization of public health and ignorance the importance of life style modification while exposing population to unwanted hazards of drugs even old drugs like ASA.



    1. McNeil JJ, Wolfe R, Woods RL, Tonkin AM, Donnan GA, Nelson MR, et al. Effect of Aspirin on Cardiovascular Events and Bleeding in the Healthy Elderly. New England Journal of Medicine. 2018;379(16):1509-18.
    2. B Lankarani K. Aspirin for the Primary Prophylaxis of Colorectal Cancer. Annals of Colorectal Research. 2013;1(3):7-8.
    3. Loomans-Kropp HA, Pinsky P, Cao Y, Chan AT, Umar A. Association of Aspirin Use With Mortality Risk Among Older Adult Participants in the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial. JAMA Network Open. 2019;2(12):e1916729-e.
    CONFLICT OF INTEREST: None Reported
    READ MORE
    BMI association not clear
    Jim Hendricks, Prof. (Kinesiology/Adptn) | Chicago State University
    I'm unclear of the correlation of ASA use in elderly persons with BMI > 20, especially the correlation of all cause mortality (in addition to the cancers outlined in the article). Is the issue of gastrointestinal and cerebral hemorrhage outweighed by ASA use in the elderly (3 times weekly or more)?
    CONFLICT OF INTEREST: None Reported
    Original Investigation
    Public Health
    December 4, 2019

    Association of Aspirin Use With Mortality Risk Among Older Adult Participants in the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial

    Author Affiliations
    • 1Cancer Prevention Fellowship Program, Division of Cancer Prevention, National Cancer Institute, Rockville, Maryland
    • 2Gastrointestinal and Other Cancers Branch, Division of Cancer Prevention, National Cancer Institute, Rockville, Maryland
    • 3Early Detection Research Branch, Division of Cancer Prevention, National Cancer Institute, Rockville, Maryland
    • 4Siteman Cancer Center, Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri
    • 5Clinical and Translational Epidemiology Unit, Massachusetts General Hospital, Harvard Medical School, Boston
    • 6Division of Gastroenterology, Massachusetts General Hospital, Boston
    • 7Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
    • 8Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
    JAMA Netw Open. 2019;2(12):e1916729. doi:10.1001/jamanetworkopen.2019.16729
    Key Points español 中文 (chinese)

    Question  Is aspirin use associated with reduced risk of mortality in older adults?

    Findings  This cohort study included 146 152 individuals from the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial and found that aspirin use 3 or more times per week was associated with reduced risk of all-cause, cancer, gastrointestinal cancer, and colorectal cancer mortality.

    Meaning  These findings suggest that prophylactic aspirin use may reduce risk of mortality among older individuals.

    Abstract

    Importance  Aspirin use has been associated with reduced risk of cancer mortality, particularly of the colorectum. However, aspirin efficacy may be influenced by biological characteristics, such as obesity and age. With the increasing prevalence of obesity and conflicting data regarding the effect of aspirin in older adults, understanding the potential association of aspirin use with cancer mortality according to body mass index (BMI) and age is imperative.

    Objectives  To investigate the association of aspirin use with risk of all-cause, any cancer, gastrointestinal (GI) cancer, and colorectal cancer (CRC) mortality among older adults and to perform an exploratory analysis of the association of aspirin use with mortality stratified by BMI.

    Design, Setting, Participants  This cohort study evaluated aspirin use among participants aged 65 years and older in the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial at baseline (November 8, 1993, to July 2, 2001) and follow-up (2006-2008). Analysis began in late 2018 and was completed in September 2019.

    Main Outcomes and Measures  All-cause, any cancer, GI cancer, or CRC mortality. Multivariable hazard ratios (HRs) and 95% CIs were calculated using time-varying Cox proportional hazards regression modeling, adjusting for additional factors.

    Results  A total of 146 152 individuals (mean [SD] age at baseline, 66.3 [2.4] years; 74 742 [51.1%] women; 129 446 [88.6%] non-Hispanic white) were included in analysis. The median (interquartile range) follow-up time was 12.5 (8.7-16.4) years, encompassing 1 822 164 person-years. Compared with no use, aspirin use 1 to 3 times per month was associated with reduced risk of all-cause mortality (HR, 0.84; 95% CI, 0.80-0.88; P < .001) and cancer mortality (HR, 0.87; 95% CI, 0.81-0.94; P < .001). Aspirin use 3 or more times per week was associated with decreased risk of mortality of all causes (HR, 0.81; 95% CI, 0.80-0.83; P < .001), any cancer (HR, 0.85; 95% CI, 0.81-0.88; P < .001), GI cancer (HR, 0.75; 95% CI, 0.66-0.84; P < .001), and CRC (HR, 0.71; 95% CI, 0.61-0.84; P < .001). When stratified by BMI (calculated as weight in kilograms divided by height in meters squared), aspirin use 3 or more times per week among individuals with BMI 20 to 24.9 was associated with reduced risk of all-cause mortality (HR, 0.82; 95% CI, 0.78-0.85; P < .001) and any cancer mortality (HR, 0.86; 95% CI, 0.79-0.92; P < .001). Among individuals with BMI 25 to 29.9, aspirin use 3 or more times per week was associated with reduced risk of all-cause mortality (HR, 0.82; 95% CI, 0.79-0.85; P < .001), any cancer mortality (HR, 0.86; 95% CI, 0.81-0.91; P < .001), GI cancer mortality (HR, 0.72; 95% CI, 0.60-0.86; P < .001), and CRC mortality (HR, 0.66; 95% CI, 0.51-0.85; P = .001).

    Conclusions and Relevance  In this cohort study, aspirin use 3 or more times per week was associated with a reduction in all-cause, cancer, GI cancer and CRC mortality in older adults.

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