Author(s): Anna Martling, M.D., Ph.D.1,2; Ida Hed Myrberg, M.Sc.3; Mef Nilbert, M.D., Ph.D.4; Henrik Grönberg, M.D., Ph.D.5; Fredrik Granath, Ph.D.3; Martin Eklund, Ph.D.5; Tom Öresland, M.D., Ph.D.6,7; Lene H. Iversen, M.D., Ph.D.8; Carola Haapamäki, M.D., Ph.D.9; Martin Janson, M.D., Ph.D.10; Karin Westberg, M.D., Ph.D.1,11; Josefin Segelman, M.D., Ph.D.1,12; Urban Ersson, M.D.13; Mattias Prytz, M.D., Ph.D.14,15; Eva Angenete, M.D., Ph.D.15,16; Rebecka Bergström, M.Sc.5; Markus Mayrhofer, Ph.D.5,17; Bengt Glimelius, M.D., Ph.D.18; Johan Lindberg, Ph.D.19; the ALASCCA Study Group*;
BACKGROUND
Aspirin reduces the incidence of colorectal adenoma and colorectal cancer among high-risk persons. Observational studies suggest that aspirin may also improve disease-free survival after diagnosis, particularly among patients with tumors harboring somatic PIK3CA mutations. However, data from randomized trials are lacking.
METHODS
We conducted a double-blind, randomized, placebo-controlled trial involving patients with stage I, II, or III rectal cancer or stage II or III colon cancer with somatic alterations in PI3K pathway genes. The patients were assigned in a 1:1 ratio to receive 160 mg of aspirin or matched placebo once daily for 3 years. Patients with prespecified PIK3CA hotspot mutations in exon 9 or 20 (group A alterations) and those with other moderate- or high-impact somatic variants in PIK3CA, PIK3R1, or PTEN (group B alterations) were eligible for randomization. The primary end point was colorectal cancer recurrence, assessed in a time-to-event analysis, in patients with group A alterations. Secondary end points included colorectal cancer recurrence in patients with group B alterations, disease-free survival, and safety. Research Summary Low-Dose Aspirin for PI3K-Altered Localized Colorectal Cancer
RESULTS
Alterations in PI3K pathway genes were detected in 1103 of 2980 patients (37.0%) with complete genomic data. Of 515 patients with group A alterations and 588 patients with group B alterations, 314 and 312, respectively, were assigned to receive aspirin or placebo. The estimated 3-year cumulative incidence of recurrence was 7.7% with aspirin and 14.1% with placebo (hazard ratio, 0.49; 95% confidence interval [CI], 0.24 to 0.98; P=0.04) among patients with group A alterations and 7.7% and 16.8%, respectively (hazard ratio, 0.42; 95% CI, 0.21 to 0.83), among those with group B alterations. The estimated 3-year disease-free survival was 88.5% with aspirin and 81.4% with placebo (hazard ratio, 0.61; 95% CI, 0.34 to 1.08) among patients with group A alterations and 89.1% and 78.7%, respectively (hazard ratio, 0.51; 95% CI, 0.29 to 0.88), among those with group B alterations. Severe adverse events occurred in 16.8% of aspirin recipients and 11.6% of placebo recipients.
CONCLUSIONS
Aspirin led to a significantly lower incidence of colorectal cancer recurrence than placebo among patients with PIK3CA hotspot mutations in exon 9 or 20 and appeared to have a similar benefit among those with other somatic alterations in PI3K pathway genes. (Funded by the Swedish Research Council and others; ALASCCA ClinicalTrials.gov number, NCT02647099; EudraCT number, 2015-004240-19.)
Author Affiliations
1Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm; 2Theme Cancer, Department of Pelvic Cancer, Karolinska University Hospital, Stockholm; 3Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm; 4Institute of Clinical Sciences, Lund University and Skane University Hospital Cancer Center, Lund, Sweden; 5Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm; 6Department of Gastrointestinal Surgery, Akershus University Hospital, Oslo; 7Clinic for Surgical Sciences, University of Oslo, Oslo; 8Department of Surgery, Aarhus University Hospital, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark; 9Department of Gastroenterologic Surgery, Helsinki University Hospital and University of Helsinki, Helsinki; 10Department of Clinical Science and Education, Stockholm South General Hospital, Stockholm; 11Danderyds Hospital, Department of Surgery, Stockholm; 12Ersta Hospital, Department of Surgery, Stockholm; 13Skaraborg Hospital, Skövde, Sweden; 14Department of Surgery, Region Västra Götaland, NU Hospital group, Trollhättan, Sweden; 15Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; 16Department of Surgery, Sahlgrenska University Hospital–Östra, Region Västra Götaland, Gothenburg, Sweden; 17National Bioinformatics Infrastructure Sweden, Science for Life Laboratory, Department of Cell and Molecular Biology, Uppsala University, Uppsala, Sweden; 18Department of Immunology, Genetics, and Pathology, Uppsala University, Uppsala, Sweden; 19Department of Medical Epidemiology and Biostatistics, Science for Life Laboratory, Karolinska Institutet, Stockholm