Individualised benefit–harm balance of aspirin as primary prevention measure – a good proof-of-concept, but could have been better… | BMC Medicine | Full Text

open access

Commentary

BMC Medicine201614:101

Published: 6 July 2016

Open Peer Review reports

Abstract

Guidelines from different organisations regarding the use of aspirin for primary prevention vary despite being based on similar evidence. Translating these in practice presents a further major challenge. The benefit–harm balance tool developed by Puhan et al. (BMC Med 13:250, 2015) for aspirin can overcome some of these difficulties and is therefore an important step towards personalised medicine. Although a good proof-of-concept, this tool has some important limitations that presently preclude its use in practice or for further research. One of the major benefits of aspirin that has become apparent in the last decade or so is its effect in preventing cancer and cancer-related deaths. However, this benefit is clear and consistent in randomised as well as observational evidence only for specific cancers. Additionally, it has long lag-time and carry-over periods. These nuances of aspirin’s effects demand a specific and a more sophisticated model such as a time-varying model. Further refinement of this tool with respect to these aspects is merited to make it ready for evaluation in qualitative and quantitative studies with the goal of clinical utility.

Please see related article: http://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-015-0493-2

....After a thorough review of the evidence [8], we concluded that a clear and large benefit exists for colorectal, oesophageal and stomach cancer, and the benefit for lung, breast and prostate cancer is smaller and less clear. Many aspirin experts agree with a beneficial effect on only three gastrointestinal (GI) tract cancers due to the biological and pharmacological plausibility of such an effect [19], as well as due to some uncertainty regarding aspirin’s effects on lung, breast and prostate cancer. Therefore, we provided sensitivity analyses with aspirin’s beneficial effect being limited to three GI cancers as well as colorectal cancer alone [8]. Recent analyses by the U.S. Preventive Services Task Force also take into account only the beneficial effect on colorectal cancer [20]. Therefore, assuming aspirin’s effect on cancers other than colorectal, oesophageal, stomach, lung, breast and prostate cancers is not correct, even when simulations and repetitions consider the statistical uncertainty of effect on other cancers.....