A randomized trial published in the New England Journal of Medicine shows that aspirin can significantly reduce the risk of recurrence in colorectal cancer, but only in patients with specific genetic mutations in the tumor. The results open up the prospect of precision adjuvant therapy.
The idea that a common, low-cost drug likeaspirin can help prevent recurrence of colorectal cancer it has been circulating for years, especially on the basis of observational studies. Now, however, comes a key step: a randomized trial published on New England Journal of Medicine (NEJM) provides more solid evidence, but with one decisive point: the benefit seems to be above all patients selected based on the genetic profile of the tumor. The work (ALASCCA trial) enrolled patients with stage I–III rectal cancer or stage II–III colon cancer who, after surgery, had somatic alterations in the genes of the PI3K pathway (a set of mutations frequent in tumors). Participants were randomly assigned to aspirin 160 mg once a day or placebo, for example 3 yearsdouble blind. The main criterion was the relapse in patients with a specific mutation category: in this population, the estimated 3-year cumulative incidence of relapse was 7.7% with aspirin against 14.1% with placebo.
Why genetic tumor testing matters and what the risks are
The central message is not “aspirin for everyone”, but aspirin for some: The study selected patients based on specific tumor mutations. According to the reported analysis, alterations of the PI3K pathway were identified in 37% approximately patients with complete genomic data. In practice, the proposed strategy is that of one precision adjuvant therapywhere the decision passes from molecular profile of the resected tumor.
Aspirin, however, is not without risks. In the trial, the serious adverse events were more frequent in the aspirin group: 16.8% against 11.6% in the placebo group. This is crucial because aspirin can increase the risk of bleeding and gastrointestinal complications: aspects which, in oncology, must be balanced with extreme caution (age, comorbidities, concomitant therapies, individual bleeding risk).
What changes in practice today
Various scientific societies and international comments have underlined the importance of the result: for the first time, a randomized trial suggests a clinical benefit of low dose of aspirin as an adjuvant targeted in tumors with alterations of the PI3K pathway. But it’s not a free-for-all: the reasonable recommendation, in light of the data, is to talk to the oncologist only if the tumor was characterized genetically and only afterwards a personalized assessment of bleeding risk. The NEJM study does not endorse aspirin for preventing recurrence in every patient with colon cancer: rather, it indicates that, in the presence of specific mutations (PIK3CA and PI3K pathway)a daily treatment with 160 mg For 3 years can significantly reduce relapses, with a safety profile that requires caution and careful selection
