How Soon To Stop Aspirin Before Skin Cancer

• Periodical Listing
• Oncol Lett
• five.9(3); 2015 Mar
• PMC4314970

Oncol Lett. 2015 Mar; ix(3): 1073–1080.

Aspirin for the primary prevention of peel cancer: A meta-analysis

YUN ZHU

^oneCancer Centre, Southern Medical Academy, Guangzhou, Guangdong 510515, P.R. China

YANG CHENG

^twoDigestive Department of Nanfang Infirmary, Southern Medical University, Guangzhou, Guangdong 510515, P.R. China

RONG-CHENG LUO

^aneCancer Center, Southern Medical Academy, Guangzhou, Guangdong 510515, P.R. China

^threeHospital of Integrated Traditional Chinese and Western Medicine, Southern Medical University, Guangzhou, Guangdong 510315, P.R. People's republic of china

AI-MIN LI

¹Cancer Heart, Southern Medical University, Guangzhou, Guangdong 510515, P.R. Red china

ⁱⁱⁱHospital of Integrated Traditional Chinese and Western Medicine, Southern Medical University, Guangzhou, Guangdong 510315, P.R. Prc

Received 2014 May ix; Accepted 2014 Dec viii.

Abstract

Pare cancer is one of the most common cancers worldwide. At that place are three major skin cancer types: basal cell carcinoma, squamous cell carcinoma and malignant melanoma. Full general take a chance factors for pare cancer include fair skin, a history of tanning and sunburn, family unit history of skin cancer, exposure to ultraviolet rays and a big number of moles. The incidence of skin cancer has increased in the USA in contempo years. Aspirin intake is associated with chemoprotection against the evolution of a number of types of cancer. Even so, whether aspirin intake can reduce the take chances of development of skin cancer is unclear. The present meta-analysis of available human studies is aimed at evaluating the clan between aspirin exposure and the risk of peel cancer. All available homo observational studies on aspirin intake for the primary prevention of skin cancer were identified by searching MEDLINE (Pubmed), BIOSIS, EMBASE, Cochrane Library and China National Knowledge Infrastructure prior to March 2013. The heterogeneity and publication bias of all studies were evaluated using Cochran's Q and I² statistics, followed by a random-effect model where applicative. The pooled data were analyzed by odds ratios (ORs) and 95% confidence intervals (CIs). A total of eight case-control and 5 prospective accomplice studies from xi publications were selected for this assay. There was no evidence of publication bias in these studies. Statistical analyses of the pooled data demonstrated that that a daily dose of l–400 mg aspirin was significantly associated with a reduced take a chance of skin cancers (OR, 0.94; 95% CI, 0.90–0.99; P=0.02). Stratification analysis indicated that the continual intake of low dose aspirin (≤150 mg) reduced the risk of developing pare cancer (OR, 0.95; CI, 0.xc–0.99; P=0.15) and that aspirin intake was significantly associated with a reduced risk of non-melanoma pare cancers (OR, 0.97; CI, 0.95–0.99; P=0.22). Overall, these findings indicated that aspirin intake was associated with a reduced risk of developing pare cancer. Nonetheless, more than well-designed randomized controlled trials to measure the effects of aspirin intake are required to ostend this.

Keywords: peel cancer, aspirin, chief prevention, meta-assay

Introduction

Skin cancer is one of the most common malignancies in the USA, where >2,000,000 cases are diagnosed annually (one). In that location are several types of pare cancers, including basal cell carcinoma (BCC), squamous cell carcinoma (SCC), and malignant melanoma (MM). BCC and SCC are collectively termed non-melanoma peel cancer (NMSC). BCC ordinarily presents equally a painless raised area of pare with an ulcer, which may damage surrounding tissues, however, it is unlikley to metastasize to distant organs. SCC may too class an ulcer, and often presents as a hard red lump with a apartment scaly surface. SCC is more likely to metastasize to distant organs. Melanomas are the nigh aggressive blazon of pare cancer, which present every bit a large, uneven mole that has changed in color (2). The incidence of skin cancer, especially MM, is increasing, with an annual growth rate of 3–5% in the U.s.a., and advisable preventive approaches are urgently required (three,iv). Currently, known risk factors for the evolution of skin cancers include fair skin, blueish or greenish optics, blond or red hair, multiple moles, excess ultraviolet (UV) radiation from sun exposure, and a history of astringent sunburn and skin cancer (5). Primary strategies to prevent the development and occurrence of skin cancers include reducing skin cancer-related adventure behaviors by avoidance of UV over-exposure, and by the regular utilise of sunscreen creams (6,7).

Inflammation is associated with the development of malignant tumors, peculiarly for epithelial prison cell tumors, including skin cancers (viii,nine). Cyclooxygenase-2 (COX-2) controls prostaglandin synthesis, regulating inflammation and the development and progression of cancerous tumors. Furthermore, COX-2 can positively regulate antiapoptotic, proangiogenic and other tumorigenic processes, and is upregulated in man peel cancers (10,11). Accordingly, chemotherapies with COX-ii inhibitors and not-steroidal anti-inflammatory drugs (NSAIDs) accept been tested for the prevention of tumors in humans (12). Epidemiologically, handling with aspirin/NSAIDs benefits patients with various solid cancers, such equally colon cancer, esophageal cancer, and breast cancer (13). However, a previous meta-analysis revealed no significant protective upshot of non-aspirin NSAIDs in preventing the development of peel cancers in humans (fourteen).

Aspirin, also known as acetylsalicylic acid, is a salicylate drug with analgesic, antipyretic and anti-inflammatory activeness. Aspirin is an inhibitor of COX-1 and COX-2, predominantly affecting COX-1 (xv). The efficacy of treatment with aspirin for the prevention of tumor development remains controversial. While several epidemiological studies have demonstrated that treatment with aspirin may reduce the incidence of peel cancers, other studies have yielded conflicting results (16–26). Therefore, in the nowadays written report, a meta-assay was performed to evaluate the effect of aspirin on the principal chemoprevention of pare cancer according to the bachelor clinical observational studies.

Materials and methods

Search strategy

A systematic literature search of MEDLINE (Pubmed), BIOSIS, EMBASE, Cochrane Library, and Communist china National Noesis Infrastructure was conducted to identify cohort and case-control studies on aspirin intake and pare cancer development, published between January 1980 and March 2013. The following medical subject headings or keywords were used, without linguistic communication restriction: i) 'Aspirin', 'non-steroidal anti-inflammatory drugs' or 'acetylsalicylic acid'; ii) 'skin cancer', 'skin tumor', 'melanoma skin cancer', 'non-melanoma skin cancer', 'squamous cell carcinoma', or 'basal cell carcinoma'. The cited references in retrieved articles were also screened to identify whatsoever additional relevant studies.

Written report pick

The titles and abstracts of private publications were screened, and the nature of each study was evaluated independently by 2 reviewers (Zhu and Cheng). The studies were included if they met all of the following criteria: i) Had a case-command or accomplice design, ii) evaluated exposure to aspirin, three) reported occurrence of skin cancer diagnosis, and four) reported the adjusted relative risks (RRs), hazard ratios (HRs), or odds ratios (ORs), every bit well as the corresponding 95% CI. If publications were duplicated or if manufactures came from the same report population, the study with the largest sample size was included.

Information extraction and quality assessment

Information were extracted from individual publications by ii reviewers (Zhu and Cheng), independently and in a blinded manner (without prior knowledge of the yr of publication, author and periodical). The extracted data included authors, publication year, population, sample size, medication type and frequency of use, information source for measurement of aspirin exposure and for identification of skin cancer cases (e.g. questionnaire, interview, pharmacy database), ORs or RRs with and without adjustment for potential confounders, potential confounders used for adjustment (e.g. age, skin colour) and the written report design (cohort vs. example-command). If there was a disagreement, the data were further discussed past two reviewers until a consensus was reached.

The methodological quality of each report was assessed using the Newcastle-Ottawa Scale (NOS) (27), by evaluation of the following three areas: The pick of study groups, comparability of groups, and ascertainment of either the exposure or consequence of interest for case-control or cohort studies, respectively. If a report had a score ≥5 out of a maximum score of 9, the study was considered to be of high-quality.

Data assay and risk of bias

All aspirin-related chemopreventive studies of skin cancer were analyzed simultaneously and further stratified, according to written report design (cohort vs. case-control), method for determining exposure to aspirin (i.due east. questionnaire vs. pharmacy database), method for identifying skin cancer cases (cocky-reported vs. medical records and pathology), histological blazon (SCC vs. BCC vs. MM), gender (men vs. women), duration of medication use, and written report population (American vs. European).

Potential publication bias was assessed using qualitative and quantitative methods. Initially, it was evaluated by funnel plots of the ORs versus their standard errors, and subsequently by the Begg's test (rank correlation method) (28) and Egger's test (linear regression method) (29). P>0.10 was considered to indicate no publication bias.

Statistical analysis

OR was used as a common mensurate across all studies for determining the degree of a potential association between aspirin intake and risk of development of skin cancer. The RRs and HRs were directly considered as ORs. The potential heterogeneity in the results across the studies was examined past Cochran'southward Q and I^two statistics (30). If a P value for heterogeneity was <0.ten or I² was >fifty%, substantial heterogeneity was considered and the summary was estimated on the basis of the random-outcome model, equally described past DerSimonian and Laird (31). The sensitivity was analyzed past excluding each report individually to evaluate the consistency of our results. All analyses were performed using STATA version 10.0 (StataCorp LP, College Station, TX, USA).

Results

Literature search

A full of 634 relevant publications were identified past a systematic literature search, and 623 out of 634 publications were excluded due to duplications or various other reasons (e.g. if the publications were review papers or news articles, or related to randomized controlled studies or creature experiments), co-ordinate to the titles and abstracts. Finally, viii case-control studies (16,xix,22,24–26) and 5 cohort studies (17,18,20,21,23) were included in the meta-analysis. A flow chart (Fig. 1) illustrates the process of choice of relevant studies.

Flow chart illustrating the literature search for studies on aspirin intake and a risk of skin cancer.

Written report characteristics and quality assessment

According to the inclusion criteria, a total of eight example-control studies with 21,356 cases and 187,037 controls and 5 cohort written report incorporating 294,377 participants were included in the meta-analysis. The main characteristics of these studies are summarized in Tabular array I. All inquiry literature was in English; three studies were based in Denmark (24), 1 in kingdom of the netherlands (25), and 9 in the United states of america (16–23). 7 studies (sixteen–xix,21,22,24–26) included both genders and two studies included merely females (20,23). The majority of studies had matched cases and controls, and had adjusted for a wide range of potential confounders, including historic period, gender, ethnicity, skin color, pilus color, amount of sun exposure, history of severe sunburns, number of moles, family history of skin cancer, smoking status and other factors.

Table I

Characteristics of epidemiological studies of aspirin intake and skin cancer risk included in the meta-analysis.

Study	Ethnicity	Design	Gender	Cancer blazon	Participants, northward	Patients, northward	Exposure source	Cancer confirmed	Confounders included in adapted estimates
Gamba 2013 (twenty)	U.s.a.	Cohort	Female simply	MM	59,806	548	Prescription records	Medical records	a1,a2,b,c1,d1,e1,h1,l,m,p1,r1,s1,s2,s3,t1
Jeter 2012 (23)	USA	Accomplice	Female merely	MM	92,125	658	Self-reported	Self-reported	a1,a2,b,f1,h2,northward,p1,p2,
				SCC		1,337		Self-reported	q,r1,s1,s3,s4,v1,v2
				BCC		fifteen,079		Medical records
Johannesdottir 2012[one] (24)	Denmark	Example-control	Female person and male person	MM	196,529	3,089	Prescription records	Pathology	a1,c2,d2,g1,g2,t2
Johannesdottir 2012[ii] (24)	Denmark	Case-control	Female and male	SCC		1,921	Prescription records	Pathology	a1,c2,d2,g1,g2,t2
Johannesdottir 2012[3] (24)	Denmark	Example-control	Female and male	BCC		12,864	Prescription records	Pathology	a1,c2,d2,g1,g2,t2
Cahoon, 2012 (xviii)	Usa	Accomplice	Female and male	BCC	58,213	2,291	Self-reported	Medical records and self-reported	a1,a2,g1,r1
Jeter 2011 (22)	USA	Case-command	Female and male person	MM	446	327	Self-reported	Medical records	a1,f1,g1,north,s5
Cruiel 2011 (19)	United states	Case-control	Female and male	MM	1,000	400	Cocky-reported	Self-reported	a1,g1, s4,t2
Torti 2011 (26)	USA	Case-control	Female person and male person	SCC	1,484	535	Self-reported	Medical records	a1,c1,g1,s3,s4,s5
				BCC		487
Asgari 2010 (16)	USA	Case-control	Female and male person	SCC	830	415	Self-reported and prescription records	Medical records	h2, o
Joosse 2009 (25)	Netherlands	Case-command	Female and male	MM	8,104	ane,318	Prescription records	Medical records	a1,d3,g1,g2,s7,t2,y
Asgari 2008 (17)	United states	Accomplice	Female person and male person	MM	63,809	349	Self-reported	Medical records	a1,c3,d3,e1,e2,f1, f2,g1,h1,h3,s4,v3
Jacobs 2007 (21)	United states of america	Cohort	Female and male	MM	xviii,127	1,049	Cocky-reported	Medical records	a1,b,d3,e1,g1, g2,m,r2,p1,s3

The quality scores of these studies are summarized in Table IIA and IIB. The range of quality scores was from 6–9. The average scores of case-control studies and cohort studies were 7.8 and 8.0, respectively. All studies were considered to be of loftier-quality.

Table II

A, Methodological quality of instance-control studies
	Choicea					Exposurea
Study	Acceptable definition of cases	Representativeness of cases	Selection of command subjects	Definition of control subjects	Comparabilityb	Exposure assessment	Same method of observation for all subjects	Non-response rate	Total scores
Johannesdottir 2012[one] (24)	*	*	*	*	**	*	*	-	8
Johannesdottir 2012[two] (24)	*	*	*	*	**	*	*	-	8
Johannesdottir 2012[3] (24)	*	*	*	*	**	*	*	-	eight
Jeter 2011 (22)	*	*	-	*	*	*	*	-	6
Cruiel 2011 (19)	*	*	*	*	**	*	*	-	viii
Torti 2011 (26)	*	*	*	*	**	*	*	-	8
Asgari 2010 (16)	*	*	*	*	**	*	*	-	8
Joosse 2009 (25)	*	*	*	*	**	*	*	-	8
B, Methodological quality of accomplice studies
	Choicea					Consequencea
Report	Representativeness of exposed cohort	Representativeness of nonexposed cohort	Ascertainment of exposure	Upshot of involvement	Comparabilityb	Assessment of issue	Length of follow-upc	Adequacy of follow-upwardsd	Total scores
Gamba 2013 (20)	*	*	*	*	**	*	*	*	9
Jeter 2012 (23)	-	*	*	*	*	*	*	*	7
Cahoon 2012 (eighteen)	*	*	*	*	**	*	-	*	8
Asgari 2008 (17)	*	*	*	*	**	*	-	*	8
Jacobs 2007 (21)	*	-	*	*	**	*	*	*	8

Overall analyses and bias assessment

All studies reported OR and 95% CI for aspirin exposure and risk of pare cancer subsequently adjusting for confounding factors. The pooled results indicated that regular aspirin exposure decreased the take a chance of developing skin cancers by 6% (OR, 0.94; 95% CI, 0.90–0.99). Statistical analyses revealed significant heterogeneity amid the studies (P=0.02; I^two=50.9%; Fig. 2). The sensitivity analyses, by excluding any single study in each step, revealed that only one [Jeter et al (23)] out of 13 studies included was considered to have a high take chances of differential-verification bias. Exclusion of this written report decreased the heterogeneity, only did non alter the results (OR, 0.95; 95% CI, 0.91–0.98; P=0.04; Iⁱⁱ= 47.1%). No indication of a publication bias was identified either from the funnel plot (Fig. 3), or from the Egger's exam (P=0.17) or Begg's examination (P=0.67).

Forest plot showing the association between aspirin intake and reduced risk of skin cancer. CI, conviction interval.

Funnel plot of studies on aspirin intake and risk of skin cancer.

Subgroup assay

The effects of aspirin intake on the take a chance of pare cancer in subgroup meta-analyses are shown in Table III. Compared with the overall analysis, the results from individual subgroup analyses were similar: Example-control studies (OR, 0.90; 95% CI, 0.82–0.99; P=0.03; I²=53.ix%), medical record of skin cancer (OR, 0.95; 95% CI, 0.92–0.99; P=0.08; I²=40.1%), and continual intake of depression dose aspirin (OR, 0.95; 95% CI, 0.xc–0.99; P=0.15; Iⁱⁱ=40.0%). Aspirin intake exerted meaning protective furnishings against the development of SCC (OR, 0.ninety; 95% CI, 0.82–0.98; P=0.22; I²=31.7%) and in the non-American population (OR, 0.94; 95% CI, 0.90–0.99; P=0.29; I²=20.7%), whilst it had marginal protective effects on the development of BCC (OR, 0.98; 95% CI, 0.95–1.00; P=0.64; I²=0%). All the same, no significant protective effects were observed in the other relevant strata.

Tabular array 3

Summary odds ratios of the association between aspirin intake and skin cancer take a chance.

	ORa	95% CIa	Itwo, %	P-value for homogeneity	Studies, n
Study design
Example-control	0.90	0.82–0.99	53.nine	0.03	8
Cohort	0.99	0.96–1.02	20.three	0.29	v
Histological blazon
NMSC	0.97	0.95–0.99	25.9	0.22	6
SCC	0.90	0.82–0.98	31.7	0.22	4
BCC	0.98	0.95–1.00	0.0	0.64	four
MM	0.96	0.82–one.12	69.3	0.00	7
Exposure determination
Prescription records	0.92	0.84–1.01	52.6	0.06	6
Cocky-reported	0.98	0.96–i.01	45.6	0.07	7
Illness determination
Medical records	0.95	0.92–0.99	40.ane	0.08	xi
Self-reported	0.87	0.64–1.19	81.vii	0.02	two
Gender
Female	0.88	0.74–1.04	62.1	0.05	4
Male	0.85	0.68–1.07	0.0	0.34	ii
Duration of aspirin use
Short term	0.92	0.83–1.04	66.0	0.00	eight
Long term	0.90	0.78–i.05	69.i	0.00	viii
Dose effects
High dose	1.01	0.90–ane.14	0.0	five.39	seven
Low dose	0.95	0.90–0.99	40.3	0.15	5
Report population
American	0.95	0.88–ane.02	56.5	0.02	9
Not-American	0.94	0.xc–0.99	20.7	0.29	four

Sensitivity analysis

In the sensitivity analyses, the combined results were recalculated by excluding one study per iteration. Afterwards excluding one detail study [Jeter et al (23)], the remaining studies retained significant heterogeneity, and indicated that aspirin exposure had meaning protective effects on MM. However, exclusion of the Jeter et al (23) study reduced the heterogeneity among the remaining studies and indicated that short term aspirin intake may decrease the hazard of skin cancer in females (data non shown).

Discussion

The results of the current study extend and support the previous observation that aspirin intake is associated with a decreased risk of developing peel cancer. However, the results must exist interpreted with caution, due to the substantial heterogeneity amidst the studies included in this meta-analysis. This was anticipated given the difference in the report populations, written report designs, gender and historic period of the participants, the method of observation of patients and dosage and duration of medication, follow-up time and adjustment variables beyond studies. The sensitivity analyses indicated that the written report conducted by Jeter et al (23) potentially caused meaning heterogeneity in the pooled data, as this study was conducted in well-educated nurses with greater sensation of health concerns.

The current written report included high-quality observational studies on aspirin intake for the main prevention of skin cancer. The results from the case-control studies indicated a significant protective clan betwixt aspirin intake and a reduced run a risk of chief skin cancers, while the results from the cohort studies indicated merely a deadline significance in the protective effects of aspirin intake against skin cancer.

Cohort studies are regarded to be the most authentic observational studies, nevertheless, the value of a cohort study depends on its overall quality. The written report past Jeter et al (23) only comprised nurses, whilst Jacobs et al (21) and Asgari et al (fifteen) did not ostend skin reactions to sun exposure, family history, and the number of moles, which are the main take chances factors for skin cancers. Studies have reported a marked increment in the incidence amid the younger population, particularly in females <twoscore years of age, which increased from 28.viii individuals per 100,000 of the population in 1990 to 33.i individuals per 100,000 of the population in 2000 (32). Still, Gamba et al (20) studied postmenopausal females merely and Asgari et al (17) studied subjects aged betwixt 50 and 76 years, therefore these two accomplice studies were not representative of the whole population. The absenteeism of validated reports of aspirin use with prescription records should also exist taken into account when interpreting these results.

The results from case-command studies in full general must be interpreted with circumspection due to the methodological limitations. Jeter et al (22) studied the spouses of patients every bit the controls, and this may cause have potential choice bias in the command group as a number of spouses of the studied subjects did not participate in the study. Johannesdottir et al (24), studied cases identified through the Danish Cancer Registry, in which simply ~60% of SCC and BCC cases were recorded. The incompleteness of tumor records may also cause a potential bias affecting the results. In addition, a number of the instance-control studies had a moderate sample size, which may overestimate the treatment event.

Stratification analyses indicated that aspirin intake reduced the risk of development of NMSC, merely not of MM. Similarly, aspirin intake had a more than significant protective effect against the development of SCC than BCC. This difference may be attributed to the differential levels of COX expression in these unlike types of skin cancers. Indeed, COX-ii expression is upregulated in SCC, whilst levels of COX expression in BCC and MM are controversial (33–35).

In addition, nosotros observed that aspirin intake exerted borderline statistically pregnant effects on the development of skin cancers between females (OR, 0.88; 95% CI, 0.74–ane.04) and males (OR, 0.85; 95% CI, 0.68–1.07). Gamba et al (xx) demonstrated that aspirin intake may be chemopreventive against the development of melanoma in postmenopausal women, consistent with a previous written report that indicated a similar issue confronting colorectal cancer (36). Yet, two studies on aspirin intake for preventing breast cancer obtained conflicting results in postmenopausal females (37,38). Farther studies into the potential clan of aspirin intake with protection from pare cancer in postmenopausal females are required to gain farther insight.

Stratification analyses also revealed that low dose aspirin intake (≤150 mg) exerted a marginal protective event on the development of peel cancer, while high dose aspirin intake (>150 mg) did non prove any protective issue. However, the categories of aspirin dosages varied across the studies, and the estimated dose in private studies was based on study-specific definitions; 150 mg was ready as a cut off value. A daily dose of ≤150 mg was considerd to exist a 'depression-dose' while a daily dose of >150 mg was considerd to be a 'high-dose'. Thus, the consequence of aspirin intake may be ameliorate considered as an changed dose-risk correlation.

Additionally, stratification analyses indicated that aspirin intake for a short (≤5 years) or long (>5 years) time flow was associated with a reduced take a chance of development of skin cancers. These results may stem from limited sample sizes in some groups of subjects, leading to less power to accomplish a meaningful determination. Continual intake of aspirin has, however, been associated with a reduced risk of other types of tumors (39).

Aspirin intake had a marginal protective event confronting the development of skin cancer in Americans, still, the study also revealed a significant protective effect against skin cancer in other Caucasian populations. The varying clan levels may be due to the dissimilarities in the baseline run a risk of skin cancer between these populations.

There were several potential limitations to the nowadays meta-analysis. Firstly, the analysis was based solely on observational studies, which identify but the potential association between the two factors, and non causality. Secondly, considerable heterogeneity was present amongst the included trials, which may have impacted the results. Thirdly, some patients taking aspirin may besides have taken other NSAIDs, which may confound the results, yet few studies take adjusted for this factor. Further large-calibration, well-designed randomized controlled trials are needed to validate the protective effect of aspirin intake on the development of peel cancer.

In summary, the current meta-assay of observational studies indicated that aspirin intake, particularly with continual modest doses, was significantly associated with a reduced take chances for the development of skin cancer, primarily SCC and BCC, in both females and males. These findings may have of import public health implications. However, the causative protection against skin cancers by aspirin intake remains to be confirmed.

Acknowledgements

The authors would like to thank Medjaden Bioscience Express for assisting in the preparation of this manuscript.

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Articles from Oncology Messages are provided here courtesy of Spandidos Publications

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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4314970/

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