RESPONSE TO AN EDITORIAL IN THE BMJ: Kurth T. Aspirin and cancer prevention. BMJ 2012;344.
Dear Sir,
An editorial on 7th April urges caution on prophylactic aspirin and calls for further targeted research before aspirin is ‘prescribed’ to ‘treat’ all adults.1 The use of the words quoted indicate what is surely an inappropriate concept of prophylaxis.
There is a fundamental difference between ‘therapy’ and ‘prophylaxis’. The treatment of disease has been delegated to health care practitioners working within the NHS. The prevention of disease is a subjects’ own responsibility. It is my choice, and my responsibility whether or not I smoke, what diet I consume, what exercise I take….. and whether or not I take a protective drug. In fact, it is estimated that around one third of adults aged over 40 take statins, and surveys in Wales2 show that 38% of subjects aged over 50 take aspirin regularly.
The decision whether or not to take prophylactic aspirin rests largely on the balance between the risks and the benefits of the drug. The evidence from trials is that deaths from stomach bleed attributable to aspirin are no more frequent than deaths from spontaneous bleeds,3,4 and further evidence from the recent trials,5 acknowledged in the Editorial, is that the rate of extracranial bleeds decrease over time.
The balance between risks and benefits of a prophylactic measure is crucial, but who should make the evaluation? Is colorectal screening for cancer to be withdrawn because of undesirable side-effect – bleeding in 2.4 per 1,000 subjects, and 9.7 perforations in those screened?6 One presumes that subjects invited to attend for screening are told these risks, encouraged to make their own evaluation and their own decision whether or not to be screened?
In the UK, the recent Department of Health White Paper ‘Healthy Lives, Healthy People’7 states “individuals should feel they are true partners..so decisions are shared as far as possible, based on the right information and genuine dialogue with health practitioners”. The voice of the public is seldom heard in such situations, yet in a Citizens’ Jury8 held to examine prophylaxis and the use of low-dose aspirin, the ‘jurors’ agreed that the preservation of health is their own responsibility and the role of government, doctors and health care professionals is to provide adequate evidence on risks and benefits to enable healthy subjects to make informed decisions about the preservation of their own health ‘….even before there is agreement amongst doctors’. Furthermore, the jurors urged the involvement of the public together with professionals in thinking these issues through and epitomised the sentiment, “Nothing about me without me.”9
1. Kurth T. Aspirin and cancer prevention. BMJ 2012;344.
2. Elwood P., Hughes J., Morgan G., Brown G., Longley M. A survey of aspirin use for vascular prophylaxis in Wales. Quality in Primary Care 2005;119:734-737.
3. Morgan G. Aspirin for the primary prevention of vascular events? Public Health 2009;123:787-8
4. Antithrombotic Trialists’ Collaboration. Collective meta-analysis of randomised trial of antiplatelet therapy for prevention of death, myocardial infarction and stroke in high risk patients. Brit Med J 2002;324:71-86.
5. R Rothwell PM, Price JF, Fowkes FGR et al. Short-term effects of daily aspirin on cancer incidence, mortality and non-vascular death: analysis of the time course of risks and benefits in 51 randomised trials. Lancet March 21, 2012 DOI:10.1016/s0140-6736(11)61720-0
6. Logan RFA, Patnick J, Nickerson C et al. Outcomes of the bowel cancer screening programme (BCSP) in England after the first 1 million tests. Gut: Dec. 7th. 10.1136/gutinl-2011-300843
7. Department of Health. Healthy lives, healthy people White Paper: Our strategy for public health in England. London: 2010.
8. Elwood PC White J, Fone D, Dunstan F, Morgan G, Pickering J, Mitchell C. Aspirin taking in the community: a cross-sectional survey. Brit J Cardiol. 2011;18:238-230
9. Valerie Billingham, Through the Patient's Eyes, Salzburg Seminar Session 356, 1998.
Competing interests:
Peter Elwood has taken part in a number of discussions on aspirin prophylaxis and has received several honoraria for his contributions to meetings.
26 April 2012
Peter Elwood
Professor, Medical Epidemiologist
Mohammed Mustafa
Cochrane Institute of Primary Care and Public Health,Cardiff University School of Medicine
Rapid Response:
Re: Aspirin and cancer prevention
RESPONSE TO AN EDITORIAL IN THE BMJ: Kurth T. Aspirin and cancer prevention. BMJ 2012;344.
Dear Sir,
An editorial on 7th April urges caution on prophylactic aspirin and calls for further targeted research before aspirin is ‘prescribed’ to ‘treat’ all adults.1 The use of the words quoted indicate what is surely an inappropriate concept of prophylaxis.
There is a fundamental difference between ‘therapy’ and ‘prophylaxis’. The treatment of disease has been delegated to health care practitioners working within the NHS. The prevention of disease is a subjects’ own responsibility. It is my choice, and my responsibility whether or not I smoke, what diet I consume, what exercise I take….. and whether or not I take a protective drug. In fact, it is estimated that around one third of adults aged over 40 take statins, and surveys in Wales2 show that 38% of subjects aged over 50 take aspirin regularly.
The decision whether or not to take prophylactic aspirin rests largely on the balance between the risks and the benefits of the drug. The evidence from trials is that deaths from stomach bleed attributable to aspirin are no more frequent than deaths from spontaneous bleeds,3,4 and further evidence from the recent trials,5 acknowledged in the Editorial, is that the rate of extracranial bleeds decrease over time.
The balance between risks and benefits of a prophylactic measure is crucial, but who should make the evaluation? Is colorectal screening for cancer to be withdrawn because of undesirable side-effect – bleeding in 2.4 per 1,000 subjects, and 9.7 perforations in those screened?6 One presumes that subjects invited to attend for screening are told these risks, encouraged to make their own evaluation and their own decision whether or not to be screened?
In the UK, the recent Department of Health White Paper ‘Healthy Lives, Healthy People’7 states “individuals should feel they are true partners..so decisions are shared as far as possible, based on the right information and genuine dialogue with health practitioners”. The voice of the public is seldom heard in such situations, yet in a Citizens’ Jury8 held to examine prophylaxis and the use of low-dose aspirin, the ‘jurors’ agreed that the preservation of health is their own responsibility and the role of government, doctors and health care professionals is to provide adequate evidence on risks and benefits to enable healthy subjects to make informed decisions about the preservation of their own health ‘….even before there is agreement amongst doctors’. Furthermore, the jurors urged the involvement of the public together with professionals in thinking these issues through and epitomised the sentiment, “Nothing about me without me.”9
1. Kurth T. Aspirin and cancer prevention. BMJ 2012;344.
2. Elwood P., Hughes J., Morgan G., Brown G., Longley M. A survey of aspirin use for vascular prophylaxis in Wales. Quality in Primary Care 2005;119:734-737.
3. Morgan G. Aspirin for the primary prevention of vascular events? Public Health 2009;123:787-8
4. Antithrombotic Trialists’ Collaboration. Collective meta-analysis of randomised trial of antiplatelet therapy for prevention of death, myocardial infarction and stroke in high risk patients. Brit Med J 2002;324:71-86.
5. R Rothwell PM, Price JF, Fowkes FGR et al. Short-term effects of daily aspirin on cancer incidence, mortality and non-vascular death: analysis of the time course of risks and benefits in 51 randomised trials. Lancet March 21, 2012 DOI:10.1016/s0140-6736(11)61720-0
6. Logan RFA, Patnick J, Nickerson C et al. Outcomes of the bowel cancer screening programme (BCSP) in England after the first 1 million tests. Gut: Dec. 7th. 10.1136/gutinl-2011-300843
7. Department of Health. Healthy lives, healthy people White Paper: Our strategy for public health in England. London: 2010.
8. Elwood PC White J, Fone D, Dunstan F, Morgan G, Pickering J, Mitchell C. Aspirin taking in the community: a cross-sectional survey. Brit J Cardiol. 2011;18:238-230
9. Valerie Billingham, Through the Patient's Eyes, Salzburg Seminar Session 356, 1998.
Competing interests: Peter Elwood has taken part in a number of discussions on aspirin prophylaxis and has received several honoraria for his contributions to meetings.