Aspirin is the best
chemoprevention agent for
colorectal cancer risk reduction despite the fact that the evidence for a decrease in mortality is weak. The
cyclooxygenase-2 selective agents (
COXIBS) have an efficacy similar to that of
aspirin for most gastrointestinal (GI) lesions but not esophagus. Specifically, there are beneficial short term effects of
COXIBs on the risk of colorectal
adenoma as shown in the Approve, PreSAP, and APC studies. However, there is still an increased risk of upper GI complications with
COXIBs when compared with placebo, and this risk may increase further in some people when
aspirin is also consumed. Whereas
aspirin reduces the risk of cardiovascular events,
COXIBs and most traditional nonsteroidal anti-inflammatory drugs (but not all) are both associated with an increased risk of thrombotic cardiovascular events compared with placebo. In conclusion,
COXIBs have a niche role for patients with
familial adenomatous polyposis. The value of
aspirin remains with respect for efficacy, mainly in the esophagus, and the side effect profile, especially in the elderly if given with
acid suppression
therapy.
COXIBs should be used in younger populations, but if they are considered in the elderly because of increased GI risks, and the cardiovascular risk is also increased, then combination treatment with
aspirin and a
proton-pump inhibitor should also be considered instead, such as in the ASPECT trial.