High-dose esomeprazole plus aspirin can help prevent oesophageal carcinoma
High-dose esomeprazole in combination with aspirin can moderately reduce the risk of developing high-grade dysplasia or oesophageal cancer or delay death from any cause in patients with Barrett’s oesophagus (BE).
After a median follow-up of 8.9 years, findings from the phase III AspECT (Aspirin and Esomeprazole Chemoprevention in Barrett’s Metaplasia) trial in 2,563 patients with BE revealed that high-dose esomeprazole in combination with aspirin had strong effects in delaying the primary composite outcome of oesophageal cancer or all-cause mortality or high-grade dysplasia compared with low-dose esomeprazole with no aspirin (time ratio [TR], 1.59; p=0.007). [Jankowski J, ASCO 2018 abstract LBA 4008]
High-dose esomeprazole was also shown to be significantly superior to low-dose esomeprazole in terms of the primary composite endpoint (TR, 1.27; p=0.037). Aspirin showed a trend towards benefit that was not statistically significant (TR, 1.24; p=0.068).
The treatment combination was safe with only 1 percent of patients experiencing adverse events (AE). The most common AE reported was diarrhoea.
“These data tell us that people with heartburn should talk to their doctors about their risk of BE, but they should not self-medicate with these medications,” said lead study author Professor Janusz Jankowski of the University of Central Lancashire, UK.
“We hope that the National Institute for Health and Care Excellence in the UK and national bodies in other countries will consider our findings when developing guidelines for oesophageal cancer prevention,” he added.
“In this study, high-dose proton pump inhibitor [PPI] with low-dose aspirin seems to have reduced the risk of high-grade dysplasia, adenocarcinoma or death, but many questions remain,” said discussant Dr Zev Wainberg of the University of Californi, Los Angeles School of Medicine, US.
“Did the combination of PPI and aspirin reduce cancer-specific mortality? What is the number-needed-to-treat to prevent each of these endpoints? Until there is more data, the question of whether all patients with BE should receive treatment with high-dose PPIs plus low dose aspirin cannot be answered,” he added.
In addition, the study was conducted in five countries only and most of the participants were Caucasians. As such, it is unknown whether this chemoprevention strategy would be effective for other races.
This largest randomized controlled chemoprevention trial in BE included patients with BE of ≥1 cm with no high-grade dysplasia or oesophageal carcinoma at baseline. Patients were then randomized to receive either high-dose or low-dose esomeprazole alone or in combination with low-dose aspirin.
Oesophageal cancer is one of the most common causes of cancer mortality worldwide, with a 5-year survival rate of less than 10 percent and a rising incidence over the past four decades. [J Gastroenterol Hepatol 2016;31:1141-1146] Eighty to ninety percent of oesophageal cancers are preceded by BE and are detected by endoscopy screening. BE is associated with inflammation and reflux, which are responsive to aspirin and PPIs, respectively.