Risk stratification hinges on acceptance and feasibility. Three-quarters of providers, when surveyed, reported aspirin to be a suitable preventive treatment with more favorable views expressed by gastroenterologists and genetics providers, compared with colorectal surgeons.6 In Lynch syndrome, rates of aspirin chemoprevention recommendation by providers in real-world practices ranged from 35% to 67%; my own practice strives to discuss aspirin use with every Lynch patient at every clinic and endoscopy visit. Real-world data for uptake and adherence of aspirin CRC chemoprevention are sparse. Uptake and adherence of aspirin for cancer chemoprevention in clinical trials ranged from 41% to 80% with good adherence, although these findings likely are not generalizable to routine practice. Current blood pressure and cholesterol guidelines for primary prevention include calculation of 10-year cardiovascular risk using automatic calculators in the electronic health record; thus, it should be relatively straightforward to apply this approach for aspirin CRC chemoprevention as well. While calculation of bleeding risk is less well established, there are publicly available calculators that combine cardiovascular and bleeding risk for primary aspirin prevention and such decision aids should be explored for aspirin CRC chemoprevention. However, given the recent recommendation reversal by the USPSTF, I am concerned that recommendation and uptake of aspirin CRC chemoprevention will decline substantially.
In order to reduce CRC burden, we should employ everything in our armamentarium including aspirin chemoprevention. Individualized risk assessment for aspirin chemoprevention, as advised by the AGA practice guideline, will enable the right people to benefit while minimizing risks. Future studies should strengthen the evidence base for aspirin CRC chemoprevention and refine risk stratification, including for younger individuals given the rise in early-onset CRC. The optimal approach to aspirin chemoprevention was best summed up by the foremost expert in the field, Dr. Andy Chan, to the New York Times:7 “we need to think about personalizing who we give aspirin to, and move away from a one-size-fits-all solution”.
Dr. Kupfer is associate professor of medicine, director of the Gastrointestinal Cancer Risk and Prevention Clinic, and codirector of the Comprehensive Cancer Risk and Prevention Clinic at the University of Chicago. She reports no relevant conflicts of interest.
References
1. Liang PS et al. Clin Gastroenterol Hepatol. 2021 Jul;19(7):1327-36.
2. United States Preventive Services Task Force. “Aspirin Use to Prevent Cardiovascular Disease: Preventive Medication.” Accessed April 10, 2022.
3. Burn J et al. Lancet. 2020 Jun 13;395(10240):1855-63.
4. McNeil JJ et al. N Engl J Med. 2018 Oct 18;379(16):1519-28.
5. Guo CG et al. JAMA Oncol. 2021 Mar 1;7(3):428-35.
6. Lloyd KE et al. Prev Med. 2022 Jan;154:106872.
7. Rabin RC. “Aspirin Use to Prevent 1st Heart Attack or Stroke Should Be Curtailed, U.S. Panel Says.” New York Times. Oct. 13, 2021. Accessed April 10, 2022.
