substantial lesions. Urologists aim to remove “index lesions” from the prostate, generally defined as largest tumors with the highest grade, and this depends on accurate spatial characterization. Barqawi and colleagues rely on transperineal mapping biopsies, which take 100 or more cores from the gland in a grid pattern. The results generate a threedimensional volumetric map of the prostate that can be viewed many ways, but the method has also been criticized as being too invasive. Pinto published promising results with fusion-guided biopsy, which combines multiparametric (MP) MRI and transrectal ultrasound. Earlier this year, in the Journal of the American Medical Association, he reported that MP-MRI picks up 30% more high-grade tumors than standard biopsies. Pinto said the finding “improved confidence in our ability to offer focal therapy to our patients, which is all predicated on our ability to see the tumor.” Yet in a Journal of Clinical Oncology editorial last April, Gianluca Giannarini, M.D., from the University of Bern in Switzerland, cited a consensus position that even with MP-MRI, “predominantly anteriorly or apically located lesions cannot
be adequately targeted because of technical limitations.” Coleman said that “We’re not sure that current technologies allow us to localize the tumor and determine how much of it to treat. . . . the growth trajectory in focal therapy is large, but public expectations may not match what’s now technically possible.” However, he added that MP-MRI improvements are encouraging (MSKCC relies on a combination of template and fusion-guided biopsy both before and after treatment) and that patients do experience benefits from focal therapy, including fewer repeat biopsies. According to Coleman and other experts, the biggest unknown is whether focal therapy will change the natural history of the disease. Low-risk prostate tumors grow so slowly that detecting survival differences between focal therapy and active surveillance would take years. Scientists are debating surrogate endpoints that might predict overall survival for use in clinical trials. Workshop participants at last May’s American Urological Association annual meeting in New Orleans discussed potential candidates, but consensus remains elusive. Yet Coleman also points out that comparing focal therapy and active surveillance on
the basis of survival differences might not be appropriate since salvage treatment—namely, radiation or potentially curative surgery—is always available if patients’ cancers progress. FDA’s primary concern is that devices used in focal therapy be safe and efficacious. Its new policy is that such devices can now be brought to market through an alternative de novo classification process without need of a predicate (a substantially equivalent device with current market approval). Especially for studies that employ high-intensity focused ultrasound, a noninvasive technology that uses heat to kill cancer cells, the new policy offers opportunities. According to Pinto, the ablation technologies used in focal therapy matter much less than the appropriate imaging. And, he emphasizes, patients who undergo the procedure should contribute data. “We strongly recommend that all focal treatments take place in the context of a high-quality study,” he said. “Sadly, that is often not the case today.” © Oxford University Press 2015. DOI:10.1093/jnci/djv269 First published online September 4, 2015
On Trial: Evidence From Using Aspirin to Prevent Cancer By Nancy Nelson About half of U.S. citizens aged 45–75 years recently surveyed are taking aspirin daily or every other day, hoping to prevent stroke or a heart attack (Am. J. Prev. Med. 2015;48:501–7). But they may also be lowering their risk of gastrointestinal cancers, such as those of the colon, stomach, and esophagus. Data presented at the American Association of Cancer Research annual meeting in April showed that long-term, regular use of aspirin reduced overall cancer rates by 5%, including a 25% reduction in colorectal cancer and a 14% decrease in esophageal cancers. Researchers collected data over 32 years from 82,600 women in the Nurses’ Health Study and 47,651 men in the Health Professionals Follow-up Study. Participants benefiting from the drug took two or more tablets (325 mg each) per week for at least
16 years. Risk continued to decrease 4 years after stopping use. Senior study author Andrew Chan, M.D., M.P.H., associate professor in the department of medicine at Harvard Medical School and a gastroenterologist at Massachusetts General Hospital Boston, is one of several researchers examining the aspirin–cancer link. Studies over the past two decades have yielded “overwhelming evidence for a reduction in colorectal cancer incidence and mortality from regular aspirin use,” according to Jack Cuzick, Ph.D. Cuzick is from the center for Cancer Prevention at Queen Mary University of London. He is the principal author of a meta-analysis in January’s Annals of Oncology on the benefits and harms of aspirin use. This is the latest of several recent reviews of aspirin use and cancer risks.
Combining data from about 60 observational studies, Cuzick found a 27% overall reduction in colorectal cancer (CRC) incidence. Similarly, two randomized trials with high-dose aspirin (300–1,500 mg/day) reported a 37% reduction in CRC incidence after 10 years and three other randomized trials reported a 25% reduction in CRC incidence with 20-year follow-up and low-dose aspirin (75–300 mg/day). The five randomized trials saw a 52% reduction in CRC mortality with at least 5 years of treatment. Esophagus and stomach are two other sites where aspirin appears to offer protection. Cuzick cites data from randomized trials, which show a 58% reduction in mortality for esophageal cancer and a 44% mortality reduction in cohort studies. Observational studies report a statistically significant reduction
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NEWS | 7 of 11
8 of 11 | JNCI J Natl Cancer Inst, 2015, Vol. 107, No. 9
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in incidence of esophageal cancers. Although not as extensive as CRC, the results are consistent. Likewise, statistically significant reductions in mortality and incidence of stomach cancer were seen in both randomized and cohort studies with aspirin use. Two observational trials reported a 41% lowering of mortality, whereas two others found a 39% and 25% reduction in stomach cancer incidence. Again, according to Cuzick, the data are neither as extensive nor as consistent as those for CRC. Chan said he agrees that both randomized trials and observational studies show that aspirin use is associated with lower incidence of overall cancer and particularly colorectal cancer. “The difference,” he said, “is the impact on other types of cancer. Some of the randomized trials have seen an association of aspirin in reducing risk of other cancer types that are not in the [gastrointestinal] tract, such as breast cancer. The associations for these nongastrointestinal cancers have not been as strong in observational studies.” The other issue is dose, Chan said. “Most observational studies suggest that higher doses are more strongly associated with lowering rates of cancer, whereas in randomized trials it looks like even low doses are as effective.” One example of this is the Woman’s Health Study, which reported a 43% lower colon cancer risk in women taking 100 mg of aspirin every other day for 10 years (Ann. Intern. Med. 2013;159:77–85). The U.S. Preventive Services Task Force is sifting through all these data to decide whether to recommend routine use of aspirin to prevent cancer in the general population. In 2007, the task force recommended against regular aspirin use to prevent colon cancer, saying that the harms outweighed the benefits. An updated recommendation is expected this year. The harms are fairly well documented: Aspirin increases incidence of gastrointestinal bleeding, as well as of hemorrhagic stroke and peptic ulcer. The most serious side effect, hemorrhagic stroke, is potentially fatal but also rare. Bleeding is the most common side effect. And according to the task force, age and sex are the most important risk factors for bleeding: Bleeding increases particularly after age 70 years, and men are twice as likely to experience gastrointestinal bleeding as women. Chan is cautious about how likely it is that the task force will make a broad recommendation about routine aspirin
use, since large randomized clinical trials of aspirin and cancer with long enough follow-up have not occurred. Such trials are typically the evidence that the task force requires to make widespread public health recommendations. Most of the data are either from observational trials, which cannot reliably prove cause and effect, or from randomized trials that study cardiovascular disease, not cancer. Unfortunately, at least in the U.S. he worries that doing such a randomized prevention trial is almost impossible now, not only because of cost and time but also because many people already take aspirin. Thus, ethically randomizing people to aspirin therapy is hard. “I think we need to think about making recommendations within the context of imperfect evidence.”
“This study puts us a step closer to being able to deliver preventive interventions to people more likely to benefit while withholding interventions from individuals with little likelihood of benefit or even risk of harm.” Asad Umar, D.V.M., Ph.D., chief of the gastrointestinal and other cancers research group at the National Cancer Institute’s division of cancer prevention, said he sees the need to clarify which doses have the best risk–benefit profile and how these profiles change with age. Despite these shortcomings, both he and Nancy Cook, Sc.D., of Brigham and Women’s Hospital and professor of medicine at Harvard Medical School in Boston, think that that the Preventive Task Force might recommend routine aspirin use. Cook said it might recommend aspirin for certain high-risk people—those with a family history of colorectal cancer or a history of polyps. “There’s a lot of controversy about whether aspirin should be used,” Cook said. “There are benefits for cardiovascular disease in those at high risk, but the incidence of CRC is not very high and there are also harms of bleeding, peptic ulcer, or GI hemorrhage. However, hemorrhagic stroke or serious GI hemorrhaging that requires hospitalization are
rare and are probably outweighed by the benefits. And peptic ulcer or other bleeding is not necessarily life-threatening. It’s not clear how to weigh these various factors.” One option that Peter Rothwell, M.D., Ph.D., F.R.C.P., of England’s University of Oxford, suggested in his recent review (Curr. Opin. Oncol. 2014;26:441–7) is to recommend aspirin use between the ages of 50 and 70 years, when the risk of bleeding is lower. He added that trials show that the incidence and mortality due to Richard Wender, M.D. cancer would be reduced for at least another 10 years after stopping. Rothwell also pointed out that aspirin improves the outcome and reduces metastases in patients who develop cancer while taking aspirin. Researchers have seen this effect for several tumor types, indicating that aspirin may be useful as a treatment option. So while the risk and dosage issues are being sorted out, researchers are proceeding with trials to test aspirin in various treatment settings. The ASCOUT trial, for example, is enrolling patients recently treated for colon cancer to see whether 200 mg of aspirin every day for 3 years will improve survival. The Add-Aspirin program is recruiting breast, colorectal, esophageal, and prostate cancer patients to test whether either 300 or 600 mg of daily aspirin will improve survival. Another trial, AspECT, is enrolling 2,500 people with Barrett esophagus to see whether aspirin added to an acid reflux drug used to treat this condition will reduce risk of esophageal cancer. (Clinicaltrials.gov lists more than 100 trials for aspirin and cancer.) While treatment trials progress, Chan said he believes that researchers now need to better understand individual factors that help predict which patients are more likely to benefit from aspirin use as well as which patients are more likely to experience complications such as bleeding. To get closer to that answer, Chan led a team looking for clues in DNA that could predict whether someone may respond to aspirin for chemoprevention. When they compared the genetic composition of about 8,600 people with colon cancer to that of the same number
NEWS | 9 of 11
responses, one mechanism by which aspirin is thought to act. The participants were from 10 large cohorts in United States, Canada, Australia, and Germany (JAMA 2015;313:1133–42). Validating these findings with a larger follow-up study could have a tremendous influence on which subset of the population would benefit from aspirin use and which would be harmed. “This study puts us a step closer to being able to deliver
preventive interventions to people more likely to benefit while withholding interventions from individuals with little likelihood of benefit or even risk of harm,” wrote Richard Wender, M.D., of Thomas Jefferson University in Philadelphia, in an accompanying editorial. © Oxford University Press 2015. DOI:10.1093/jnci/djv265 First published online September 4, 2015
news
without the disease, nearly all individuals using aspirin had a 30% reduction in CRC risk. But a small percentage of people with specific gene mutations on chromosomes 12 and 15 (5%–9%) were either not protected from developing CRC or had an increased risk of developing the disease. These mutations, single-nucleotide polymorphisms, were near two genes, MGST1 and IL16. Both genes may be involved in mediating inflammatory
SIDEBAR Risk of colorectal cancer increases with age and is greater in men. The tables below show the percentage of people who will get colorectal cancer over different periods based on current age. For example, 1.26% of men (one or two men per hundred) now aged 60 years will get colorectal cancer sometime before reaching age 70 years. © Oxford University Press 2015. DOI:10.1093/jnci/djv271
Percentage of U.S. Men Who Will Develop Colorectal Cancer Over 10-, 20-, and 30-Year Intervals, by Current Age, 2009–2011
Percentage of U.S. Women Who Develop Colorectal Cancer Over 10-, 20-, and 30-Year Intervals, by Current Age, 2009–2011
Current Age
Current Age
30 40 50 60 70
10 Years
20 Years
30 Years
0.07 0.26 0.68 1.26 1.96
0.32 0.91 1.84 2.93 3.46
0.97 2.04 3.39 4.20 N/A
P
Hersch J, Barratt A, Jansen J, et al.: Use of a decision aid including information on overdetection to support informed choice about breast cancer screening: a randomised controlled trial. Lancet 385 (9978): 1642–52, 2015. PMID:25701273 Hoffman RM, Lewis CL, Pignone MP, et al.: Decision-making processes for breast, colorectal, and prostate cancer screening: the DECISIONS survey. Med Decis Making 30 (5 Suppl): 53S-64S, 2010 Sep-Oct. PMID:20881154 The PDQ Cancer Screening Overview was updated with a new section
20 Years
30 Years
0.07 0.23 0.52 0.89 1.53
0.29 0.73 1.37 2.27 3.01
0.80 1.57 2.69 3.60 N/A
Source: Adapted from Howlader N, Noone AM, Krapcho M, et al. (eds). SEER Cancer Statistics Review, 1975–2011, National Cancer Institute. N/A, not applicable.
First published online September 4, 2015
DQ (Physician Data Query) is the National Cancer Institute’s source of comprehensive cancer information. It contains peer-reviewed, evidence-based cancer information summaries on treatment, supportive care, screening, prevention, genetics, and complementary and alternative medicine. The summaries are regularly updated by six editorial boards. The following PDQ summaries were recently updated:
30 40 50 60 70
10 Years
entitled Informed Medical Decision Making. This new section discusses the importance of individuals making informed decisions about participating in cancer screening and shared decision making. For many cancer screening decisions, shared decision making is suggested, whereby the provider helps the patient make an informed, values-based choice from among two or more medically reasonable alternatives. This is especially important when the screening test has potential harms and limited benefits. The new section mentions three components of shared decision making: 1. The provider shares screening options with evidence-based information about benefits, harms, and uncertainties. 2. The patient shares preferences with the provider, who helps the patient evaluate these options and preferences and make a decision. 3. The provider assists with recording and implementing the patient’s preferences.
This new section also mentions that patient decision aids can be useful in providing information and helping patients make a decision. Decision aids are available in many different formats, including leaflets, booklets, videos, and websites. They encourage patients to interpret evidence in the context of their own goals and concerns. In some cases, decisions aids have also been noted to reduce the number of patients choosing major elective invasive surgery over more conservative options and in fewer patients choosing cancer screening. Betterinformed individuals may be less likely to choose to participate in cancer screening. h t t p : / / w w w. c a n c e r . g o v / a b o u t cancer/screening/hp-screening-overview-pdq#section/ all Hajek P, McRobbie H, Myers K: Efficacy of cytisine in helping smokers quit: systematic review and meta-analysis. Thorax 68 (11): 1037–42, 2013. PMID:23404838 Walker N, Howe C, Glover M, et al.: Cytisine versus nicotine for smoking
be adequately targeted because of technical limitations.” Coleman said that “We’re not sure that current technologies allow us to localize the tumor and determine how much of it to treat. . . . the growth trajectory in focal therapy is large, but public expectations may not match what’s now technically possible.” However, he added that MP-MRI improvements are encouraging (MSKCC relies on a combination of template and fusion-guided biopsy both before and after treatment) and that patients do experience benefits from focal therapy, including fewer repeat biopsies. According to Coleman and other experts, the biggest unknown is whether focal therapy will change the natural history of the disease. Low-risk prostate tumors grow so slowly that detecting survival differences between focal therapy and active surveillance would take years. Scientists are debating surrogate endpoints that might predict overall survival for use in clinical trials. Workshop participants at last May’s American Urological Association annual meeting in New Orleans discussed potential candidates, but consensus remains elusive. Yet Coleman also points out that comparing focal therapy and active surveillance on
the basis of survival differences might not be appropriate since salvage treatment—namely, radiation or potentially curative surgery—is always available if patients’ cancers progress. FDA’s primary concern is that devices used in focal therapy be safe and efficacious. Its new policy is that such devices can now be brought to market through an alternative de novo classification process without need of a predicate (a substantially equivalent device with current market approval). Especially for studies that employ high-intensity focused ultrasound, a noninvasive technology that uses heat to kill cancer cells, the new policy offers opportunities. According to Pinto, the ablation technologies used in focal therapy matter much less than the appropriate imaging. And, he emphasizes, patients who undergo the procedure should contribute data. “We strongly recommend that all focal treatments take place in the context of a high-quality study,” he said. “Sadly, that is often not the case today.” © Oxford University Press 2015. DOI:10.1093/jnci/djv269 First published online September 4, 2015
On Trial: Evidence From Using Aspirin to Prevent Cancer By Nancy Nelson About half of U.S. citizens aged 45–75 years recently surveyed are taking aspirin daily or every other day, hoping to prevent stroke or a heart attack (Am. J. Prev. Med. 2015;48:501–7). But they may also be lowering their risk of gastrointestinal cancers, such as those of the colon, stomach, and esophagus. Data presented at the American Association of Cancer Research annual meeting in April showed that long-term, regular use of aspirin reduced overall cancer rates by 5%, including a 25% reduction in colorectal cancer and a 14% decrease in esophageal cancers. Researchers collected data over 32 years from 82,600 women in the Nurses’ Health Study and 47,651 men in the Health Professionals Follow-up Study. Participants benefiting from the drug took two or more tablets (325 mg each) per week for at least
16 years. Risk continued to decrease 4 years after stopping use. Senior study author Andrew Chan, M.D., M.P.H., associate professor in the department of medicine at Harvard Medical School and a gastroenterologist at Massachusetts General Hospital Boston, is one of several researchers examining the aspirin–cancer link. Studies over the past two decades have yielded “overwhelming evidence for a reduction in colorectal cancer incidence and mortality from regular aspirin use,” according to Jack Cuzick, Ph.D. Cuzick is from the center for Cancer Prevention at Queen Mary University of London. He is the principal author of a meta-analysis in January’s Annals of Oncology on the benefits and harms of aspirin use. This is the latest of several recent reviews of aspirin use and cancer risks.
Combining data from about 60 observational studies, Cuzick found a 27% overall reduction in colorectal cancer (CRC) incidence. Similarly, two randomized trials with high-dose aspirin (300–1,500 mg/day) reported a 37% reduction in CRC incidence after 10 years and three other randomized trials reported a 25% reduction in CRC incidence with 20-year follow-up and low-dose aspirin (75–300 mg/day). The five randomized trials saw a 52% reduction in CRC mortality with at least 5 years of treatment. Esophagus and stomach are two other sites where aspirin appears to offer protection. Cuzick cites data from randomized trials, which show a 58% reduction in mortality for esophageal cancer and a 44% mortality reduction in cohort studies. Observational studies report a statistically significant reduction
news
NEWS | 7 of 11
8 of 11 | JNCI J Natl Cancer Inst, 2015, Vol. 107, No. 9
news
in incidence of esophageal cancers. Although not as extensive as CRC, the results are consistent. Likewise, statistically significant reductions in mortality and incidence of stomach cancer were seen in both randomized and cohort studies with aspirin use. Two observational trials reported a 41% lowering of mortality, whereas two others found a 39% and 25% reduction in stomach cancer incidence. Again, according to Cuzick, the data are neither as extensive nor as consistent as those for CRC. Chan said he agrees that both randomized trials and observational studies show that aspirin use is associated with lower incidence of overall cancer and particularly colorectal cancer. “The difference,” he said, “is the impact on other types of cancer. Some of the randomized trials have seen an association of aspirin in reducing risk of other cancer types that are not in the [gastrointestinal] tract, such as breast cancer. The associations for these nongastrointestinal cancers have not been as strong in observational studies.” The other issue is dose, Chan said. “Most observational studies suggest that higher doses are more strongly associated with lowering rates of cancer, whereas in randomized trials it looks like even low doses are as effective.” One example of this is the Woman’s Health Study, which reported a 43% lower colon cancer risk in women taking 100 mg of aspirin every other day for 10 years (Ann. Intern. Med. 2013;159:77–85). The U.S. Preventive Services Task Force is sifting through all these data to decide whether to recommend routine use of aspirin to prevent cancer in the general population. In 2007, the task force recommended against regular aspirin use to prevent colon cancer, saying that the harms outweighed the benefits. An updated recommendation is expected this year. The harms are fairly well documented: Aspirin increases incidence of gastrointestinal bleeding, as well as of hemorrhagic stroke and peptic ulcer. The most serious side effect, hemorrhagic stroke, is potentially fatal but also rare. Bleeding is the most common side effect. And according to the task force, age and sex are the most important risk factors for bleeding: Bleeding increases particularly after age 70 years, and men are twice as likely to experience gastrointestinal bleeding as women. Chan is cautious about how likely it is that the task force will make a broad recommendation about routine aspirin
use, since large randomized clinical trials of aspirin and cancer with long enough follow-up have not occurred. Such trials are typically the evidence that the task force requires to make widespread public health recommendations. Most of the data are either from observational trials, which cannot reliably prove cause and effect, or from randomized trials that study cardiovascular disease, not cancer. Unfortunately, at least in the U.S. he worries that doing such a randomized prevention trial is almost impossible now, not only because of cost and time but also because many people already take aspirin. Thus, ethically randomizing people to aspirin therapy is hard. “I think we need to think about making recommendations within the context of imperfect evidence.”
“This study puts us a step closer to being able to deliver preventive interventions to people more likely to benefit while withholding interventions from individuals with little likelihood of benefit or even risk of harm.” Asad Umar, D.V.M., Ph.D., chief of the gastrointestinal and other cancers research group at the National Cancer Institute’s division of cancer prevention, said he sees the need to clarify which doses have the best risk–benefit profile and how these profiles change with age. Despite these shortcomings, both he and Nancy Cook, Sc.D., of Brigham and Women’s Hospital and professor of medicine at Harvard Medical School in Boston, think that that the Preventive Task Force might recommend routine aspirin use. Cook said it might recommend aspirin for certain high-risk people—those with a family history of colorectal cancer or a history of polyps. “There’s a lot of controversy about whether aspirin should be used,” Cook said. “There are benefits for cardiovascular disease in those at high risk, but the incidence of CRC is not very high and there are also harms of bleeding, peptic ulcer, or GI hemorrhage. However, hemorrhagic stroke or serious GI hemorrhaging that requires hospitalization are
rare and are probably outweighed by the benefits. And peptic ulcer or other bleeding is not necessarily life-threatening. It’s not clear how to weigh these various factors.” One option that Peter Rothwell, M.D., Ph.D., F.R.C.P., of England’s University of Oxford, suggested in his recent review (Curr. Opin. Oncol. 2014;26:441–7) is to recommend aspirin use between the ages of 50 and 70 years, when the risk of bleeding is lower. He added that trials show that the incidence and mortality due to Richard Wender, M.D. cancer would be reduced for at least another 10 years after stopping. Rothwell also pointed out that aspirin improves the outcome and reduces metastases in patients who develop cancer while taking aspirin. Researchers have seen this effect for several tumor types, indicating that aspirin may be useful as a treatment option. So while the risk and dosage issues are being sorted out, researchers are proceeding with trials to test aspirin in various treatment settings. The ASCOUT trial, for example, is enrolling patients recently treated for colon cancer to see whether 200 mg of aspirin every day for 3 years will improve survival. The Add-Aspirin program is recruiting breast, colorectal, esophageal, and prostate cancer patients to test whether either 300 or 600 mg of daily aspirin will improve survival. Another trial, AspECT, is enrolling 2,500 people with Barrett esophagus to see whether aspirin added to an acid reflux drug used to treat this condition will reduce risk of esophageal cancer. (Clinicaltrials.gov lists more than 100 trials for aspirin and cancer.) While treatment trials progress, Chan said he believes that researchers now need to better understand individual factors that help predict which patients are more likely to benefit from aspirin use as well as which patients are more likely to experience complications such as bleeding. To get closer to that answer, Chan led a team looking for clues in DNA that could predict whether someone may respond to aspirin for chemoprevention. When they compared the genetic composition of about 8,600 people with colon cancer to that of the same number
NEWS | 9 of 11
responses, one mechanism by which aspirin is thought to act. The participants were from 10 large cohorts in United States, Canada, Australia, and Germany (JAMA 2015;313:1133–42). Validating these findings with a larger follow-up study could have a tremendous influence on which subset of the population would benefit from aspirin use and which would be harmed. “This study puts us a step closer to being able to deliver
preventive interventions to people more likely to benefit while withholding interventions from individuals with little likelihood of benefit or even risk of harm,” wrote Richard Wender, M.D., of Thomas Jefferson University in Philadelphia, in an accompanying editorial. © Oxford University Press 2015. DOI:10.1093/jnci/djv265 First published online September 4, 2015
news
without the disease, nearly all individuals using aspirin had a 30% reduction in CRC risk. But a small percentage of people with specific gene mutations on chromosomes 12 and 15 (5%–9%) were either not protected from developing CRC or had an increased risk of developing the disease. These mutations, single-nucleotide polymorphisms, were near two genes, MGST1 and IL16. Both genes may be involved in mediating inflammatory
SIDEBAR Risk of colorectal cancer increases with age and is greater in men. The tables below show the percentage of people who will get colorectal cancer over different periods based on current age. For example, 1.26% of men (one or two men per hundred) now aged 60 years will get colorectal cancer sometime before reaching age 70 years. © Oxford University Press 2015. DOI:10.1093/jnci/djv271
Percentage of U.S. Men Who Will Develop Colorectal Cancer Over 10-, 20-, and 30-Year Intervals, by Current Age, 2009–2011
Percentage of U.S. Women Who Develop Colorectal Cancer Over 10-, 20-, and 30-Year Intervals, by Current Age, 2009–2011
Current Age
Current Age
30 40 50 60 70
10 Years
20 Years
30 Years
0.07 0.26 0.68 1.26 1.96
0.32 0.91 1.84 2.93 3.46
0.97 2.04 3.39 4.20 N/A
P
Hersch J, Barratt A, Jansen J, et al.: Use of a decision aid including information on overdetection to support informed choice about breast cancer screening: a randomised controlled trial. Lancet 385 (9978): 1642–52, 2015. PMID:25701273 Hoffman RM, Lewis CL, Pignone MP, et al.: Decision-making processes for breast, colorectal, and prostate cancer screening: the DECISIONS survey. Med Decis Making 30 (5 Suppl): 53S-64S, 2010 Sep-Oct. PMID:20881154 The PDQ Cancer Screening Overview was updated with a new section
20 Years
30 Years
0.07 0.23 0.52 0.89 1.53
0.29 0.73 1.37 2.27 3.01
0.80 1.57 2.69 3.60 N/A
Source: Adapted from Howlader N, Noone AM, Krapcho M, et al. (eds). SEER Cancer Statistics Review, 1975–2011, National Cancer Institute. N/A, not applicable.
First published online September 4, 2015
DQ (Physician Data Query) is the National Cancer Institute’s source of comprehensive cancer information. It contains peer-reviewed, evidence-based cancer information summaries on treatment, supportive care, screening, prevention, genetics, and complementary and alternative medicine. The summaries are regularly updated by six editorial boards. The following PDQ summaries were recently updated:
30 40 50 60 70
10 Years
entitled Informed Medical Decision Making. This new section discusses the importance of individuals making informed decisions about participating in cancer screening and shared decision making. For many cancer screening decisions, shared decision making is suggested, whereby the provider helps the patient make an informed, values-based choice from among two or more medically reasonable alternatives. This is especially important when the screening test has potential harms and limited benefits. The new section mentions three components of shared decision making: 1. The provider shares screening options with evidence-based information about benefits, harms, and uncertainties. 2. The patient shares preferences with the provider, who helps the patient evaluate these options and preferences and make a decision. 3. The provider assists with recording and implementing the patient’s preferences.
This new section also mentions that patient decision aids can be useful in providing information and helping patients make a decision. Decision aids are available in many different formats, including leaflets, booklets, videos, and websites. They encourage patients to interpret evidence in the context of their own goals and concerns. In some cases, decisions aids have also been noted to reduce the number of patients choosing major elective invasive surgery over more conservative options and in fewer patients choosing cancer screening. Betterinformed individuals may be less likely to choose to participate in cancer screening. h t t p : / / w w w. c a n c e r . g o v / a b o u t cancer/screening/hp-screening-overview-pdq#section/ all Hajek P, McRobbie H, Myers K: Efficacy of cytisine in helping smokers quit: systematic review and meta-analysis. Thorax 68 (11): 1037–42, 2013. PMID:23404838 Walker N, Howe C, Glover M, et al.: Cytisine versus nicotine for smoking
