Abstract
Hereditary forms of colorectal cancer account for less than 5 % of colorectal cancer but attract disproportionate attention because they offer an opportunity for effective surgical prophylaxis, influence the health of the wider family and give insight into the critical pathways of carcinogenesis. Familial Adenomatous Polyposis (FAP) due to loss of the APC gene and Lynch syndrome or Hereditary Non-Polyposis Colon Cancer (HNPCC) due to breakdown in MisMatch Repair are the principal syndromes of broader interest and both have been the subject of chemoprevention trials. There has been a longstanding interest in non-steroidal anti inflammatories in FAP where trials have shown regression of polyps with the “pro drug”sulindac and the selective COX2 inhibitors though impact on long-term cancer risk is not confirmed. The CAPP1 trial focused on two interventions in a factorial design, aspirin and resistant starch or fermentable fibre. Resistant starch is not absorbed in the small intestine and undergoes colonic fermentation to short-chain fatty acids including butyrate which have anti-cancer effects. Polyposis registry clinicians across Europe recruited adolescents with FAP to receive aspirin (600 mg as 2 tablets/d) and/or 30 g as 2 sachets/d in a 1:1 blend of potato starch and high amylose maize starch [Hylon VII]) with placebo control for at least a year or until surgery before age 21. Fifty-nine percent (133/227) of recruits had a baseline and at least one other endoscopy. After a median of 17 months , the primary endpoint of a risk of an increased polyp number in the rectum and sigmoid colon was not significantly reduced in either treatment group with relative risks of 0.77 (aspirin; 95 % CI, 0.54–1.10;) and 1.05 (RS; 95 % CI, 0.73–1.49. The diameter of the largest polyp detected tended to be smaller in the aspirin arm. The planned subgroup analyses of patients who elected to continue on study for more than one year found a significant reduction in the size of the largest polyp in the aspirin versus non-aspirin group (p = 0.02), Mean crypt length decreased significantly over time on study in the two combined RS groups, compared with the two combined non-RS groups (p < 0.0001 for interaction), in a model of the interaction between intervention and time. In CAPP2, 1009 Lynch syndrome gene carriers were recruited from 43 international centres. 937 commenced intervention: 600mg enteric coated aspirin and/or 30grams of the resistant starch Novelose in a 2 by 2 factorial placebo controlled design. After a mean of 29 months, intervention, there was no evidence that either agent influenced development of colonic neoplasia. However, the design included double blind follow-up for at least 10 years. After a mean of 55.7 months, and despite regular colonoscopy and polyp removal, 48 recruits developed CRC. Of these, 18 received aspirin and 30 received AP; the HR for CRC for aspirin was 0.63 (CI 0.35–1.13, p = 0.12). Five of the 48 people who developed CRC each had two primary colon cancers. Poisson regression analysis to allow for multiple primary events indicated a protective effect: IRR 0.56 (CI 0.32–0.99, p = 0.05). For those who took aspirin (or AP) for a minimum of 2 years (per protocol) the HR was 0.41 (CI 0.19–0.86 p = 0.02) and the IRR, 0.37 (CI 0.18–0.78 p = 0.008). Combined analysis of all LS cancers including CRC revealed a similar effect. On intention to treat analysis, the HR was 0.65 (CI 0.42–1.00, p = 0.05 and IRR was 0.59 (CI 0.39–0.90 p = 0.01), while the Per Protocol analysis HR was 0.45 (CI 0.26–0.79 p = 0.005,) and IRR was 0.42 (CI 0.25–0.72, p = 0.001). Adverse events in the aspirin and placebo groups were similar with 11 significant gastrointestinal bleeds or ulcers in the aspirin group and 9 in the placebo group. The evidence is now sufficient to recommend aspirin to all Lynch syndrome gene carriers. CAPP3 will recruit 3000 gene carriers into a dose inferiority study to test the relative benefits of 100mg, 300 or 600mg daily doses.
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References
Bodmer WF, Bailey CJ et al (1987) Localization of the gene for familial adenomatous polyposis on chromosome 5. Nature 328: 614
Boland CR, Thibodeau SN et al (1998) The international workshop on microsatellite instability and rer phenotypes in cancer detection and familial predisposition. Cancer Research 58:5248–5257
Boland CR, Thibodeau SN et al (1997) The international workshop on microsatellite instability and rer phenotypes in cancer detection and familial predisposition: 1–35
Burn J, Bishop DT et al (2011a) A randomized placebo-controlled prevention trial of aspirin and/or resistant starch in young people with familial adenomatous polyposis. Cancer Prev Res (Phila) 4(5):655–665
Burn J, Gerdes AM et al (2011b) Long-term effect of aspirin on cancer risk in carriers of hereditary colorectal cancer: an analysis from the CAPP2 randomised controlled trial. Lancet 378:2081–2087
Burn J, Bishop DT et al (2008) Effect of aspirin or resistant starch on colorectal neoplasia in the lynch syndrome. N Engl J Med 359(24):2567–2578
Burn J, Chapman P et al (1991) The UK Northern Region genetic register for familial adenomatous polyposis coli: use of age of onset, congenital hypertrophy of the retinal pigment epithelium, and DNA markers in risk calculations. J Med Genet 28:289–296
Cassidy A, Bingham SA et al (1994) Starch intake and colorectal cancer risk: an international comparison. Br J Cancer (London) 69:937–942
Chan AT, Arber N et al (2011) Aspirin in the chemoprevention of colorectal neoplasia: an overview. Cancer Prev Res (Phila)
Clark S (ed) (2009) A guide to cancer genetics in clinical practice, tfm Publishing Ltd
Cole BF, Logan RF et al (2009) Aspirin for the chemoprevention of colorectal adenomas: meta-analysis of the randomized trials. J Natl Cancer Inst 101(4):256–266
Cruz-Correa M, Hylind LM et al (2002) Long-term treatment with sulindac in familial adenomatous polyposis: a prospective cohort study. Gastroenterology 122: 641–645
Cuzick J, Otto F et al (2009) Aspirin and non-steroidal anti-inflammatory drugs for cancer prevention: an international consensus statement. Lancet Oncol 10(5):501–507
de la Chapelle A (2004) Genetic predisposition to colorectal cancer. Nat Rev Cancer 4(10): 769–780
Dunstone GH, Knaggs TWL (1972) Familial cancer of the colon and rectum. J Med Genet 9:451–454
Fishel R, Lescoe MK et al (1993) The human mutator gene homolog MSH2 and its association with hereditary nonpolyposis colon cancer. Cell 75(Dec 3): 1027–1038
Giardiello FM, Hamilton SR et al (1993) Treatment of colonic and rectal adenomas with sulindac in familial adenomatous polyposis. N Engl J Med 328:1313–1316
Giardiello FM, Yang VW et al (2002) Primary chemoprevention of familial adenomatous polyposis with sulindac. New England J Med 346(14):1054–1059
Giovannucci E, Egan KM et al (1995) Aspirin and the risk of colorectal cancer in women. N Engl J Med 333(10):609–614
Grubben M, Braak CVD et al (2001) Effect of resistant starch on potential biomarkers for colonic cancer risk in patients with colonic adenomas: a controlled trial. Dig Dis Sci 46(4):750–756
Hampel H, Frankel WL et al (2008) Feasibility of screening for Lynch syndrome among patients with colorectal cancer. J Clin Oncol 26(35):5783–5788
Herrera L, Kakati S et al (1986) Gardner syndrome in a man with an interstitial deletion of 5q. Am J Med Genet 25:473–476
Huang K, Gutierrez LP et al (2011) Clinical characteristics and outcomes in familial adenomatous polyposis patients with a long-term treatment of celecoxib: a matched cohort study. Fam Cancer 10(2):303–308
Hylla S, Gostner A et al (1998) Effects of resistant starch on the colon in healthy volunteers: possible implications for cancer prevention. Am J Clin Nutr 67:136–142
Jaeger E, Leedham S, Lewis A et al (2012) Hereditary mixed polyposis syndrome is caused by a 40kb upstream duplication that leads to increased and ectopic expression of the BMPantagonist GREM1 Nature Genetics Epub 6 May doi:10.1038/ng2263
Jass JR, Walsh MD et al (2002) Distinction between familial and sporadic forms of colorectal cancer showing DNA microsatellite instability. Eur J Cancer 38(7):858–866
Kune GA, Kune S et al (1988) Colorectal cancer risk, chronic illness, operations, medications: case control results from the Melbourne colorectal cancer study. Cancer Res 48:4399–4404
Labayle D, Fischer D et al (1991) Sulindac causes regression of rectal polyps in familial adenomatous polyposis. Gastroenterology 101: 635–639
Lichtenstein DR, Wolfe MM (2000) COX-2-Selective NSAIDs. J Am Med Assoc 284(10):1297–1299
Lynch HT, Krush AJ (1971) Cancer family “G” revisited: 1895–1970. ) Cancer 27: 1505–1511
Lynch HT, Smyrk T et al (1995) Hereditary nonpolyposis colorectal cancer and colonic adenomas: aggressive adenomas? Semin Surg Oncol 11(6):406–410
Lynch HT, Thorson AG et al (1995) Rectal cancer after prolonged sulindac chemoprevention. Cancer 75(4): 936–938
McIlhatton MA, Tyler J et al (2011) Aspirin and low dose nitric oxide-donating aspirin increase life span in a lynch syndrome mouse model. Cancer Prev Res 4(5):684–693
Mills SJ, Mathers JC et al (2001) Colonic crypt cell proliferation state assessed by whole crypt microdissection in sporadic neoplasia and familial adenomatous polyposis. GUT 48:41–46
Nugent KP, Farmer KC et al (1993) Randomized controlled trial of the effect of sulindac on duodenal and rectal polyposis and cell proliferation in patients with familial adenomatous polyposis. Br J Surg 80(12):1618–1619
Rothwell PM, Fowkes FG et al (2011) Effect of daily aspirin on long-term risk of death due to cancer: analysis of individual patient data from randomised trials. Lancet 377(9759):31–41
Rothwell PM, Wilson M et al (2010) Long-term effect of aspirin on colorectal cancer incidence and mortality: 20-year follow-up of five randomised trials. Lancet 376(9754):1741–1750
Ruschoff J, Wallinger S et al (1998) Aspirin suppresses the mutator phenotype associated with hereditary nonpolyposis colorectal cancer by genetic selection. Proc Natl Acad Sci U S A 95(19):11301–11306
Steinbach G, Lynch PM et al (2000) The effect of celecoxib, a cyclooxygenase-2 inhibitor, in familial adenomatous polyposis. New England J Med 342(26):1946–1952
Schwitalle Y, Kloor M (2008) Immune response against frameshift-induced neopeptides in HNPCC patients and healthy HNPCC mutation carriers. Gastroenterology 134:988-997
Thun MJ, Namboodiri MM et al (1991) Aspirin use and reduced risk of fatal colon cancer. N Engl J Med 325:1593–1596
Tomlinson IP, Carvajal-Carmona LG et al (2011) Multiple common susceptibility variants near BMP pathway loci GREM1, BMP4, and BMP2 explain part of the missing heritability of colorectal cancer. PLoS Genet 7(6):e1002105
van Munster IP, Tangerman A et al (1994) Effect of resistant starch on colonic fermentation, bile acid metabolism, and mucosal proliferation. Dig Dis Sci 39(4):834–842
Vasen HF (2008) Can the identification of high risk groups increase the effectiveness of colon cancer screening programmes? Z Gastroenterol 46(Suppl 1):S41–S42
Vasen HF, Moslein G et al (2007) Guidelines for the clinical management of Lynch syndrome (hereditary non-polyposis cancer). J Med Genet 44(6):353–362
Williams EA, Coxhead JM et al (2003) Anti-cancer effects of butyrate: use of micro-array technology to investigate mechanisms. Proc Nutr Soc 62(1):107–115
Young G, Leu RL (2004) Resistant starch and colorectal neoplasia. J AOAC Int 87(3):775–786
Lynch HT, Thorson AG et al (1995) Rectal cancer after prolonged sulindac chemoprevention. Cancer 75(4): 936–938
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Burn, J., Mathers, J., Bishop, D.T. (2013). Genetics, Inheritance and Strategies for Prevention in Populations at High Risk of Colorectal Cancer (CRC). In: Chan, A., Detering, E. (eds) Prospects for Chemoprevention of Colorectal Neoplasia. Recent Results in Cancer Research, vol 191. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-642-30331-9_9
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