Self-Care: Clinical Controversies in Oncology

JG is a 63-year-old woman who remembers seeing some recent news about the use of aspirin to reduce cancer risk and wonders if she should consider taking an aspirin a day to improve her health. She does not routinely see a primary care specialist because of issues with her health insurance coverage and instead relies on the media, her friends, and her family as sources for much of her health information. JG reports having a history of gastroesophageal reflux for which she takes omeprazole 20 mg daily. She is also a smoker and has smoked a half pack of cigarettes per day for the last 40 years. Should JG consider daily aspirin therapy for primary cancer prevention at this time?

Answer:

Daily aspirin has received attention for helping to reduce the incidence and mortality for certain types of cancers based on data from several recent large-scale clinical trials.^1-3 Most recently, an analysis of the Cancer Prevention Study II Nutrition Cohort data, which followed more than 100,000 patients without a history of cancer, most over age 60 years at enrollment, from 1997 to 2008, found that patients taking daily aspirin at enrollment had slightly lower (16% reduced) cancer mortality regardless of how long they had been taking aspirin.⁴ Despite limitations in the design of this analysis, the result is important.

Despite increasing evidence supporting aspirin’s anticancer effects, it is too early to recommend aspirin for all patients seeking to reduce their cancer risk; the risks and benefits of daily aspirin therapy must be considered as well. Finally, if JG is motivated to reduce her cancer risk, consider counseling her on the importance of smoking cessation and assessing her willingness to quit as a first step toward reducing her cancer risk—and improving her overall health.

Case 2: Multivitamin Supplementation to Reduce Cancer Risk

PM is a 67-year-old man who recently read in a men’s health magazine that taking a daily multivitamin can help prevent cancer. He hasn’t discussed this information with his doctor but would like your opinion on his need for supplementation. He has no known allergies and denies having any chronic medical conditions or taking medications. Is a multivitamin supplement a prudent recommendation for PM at this time?

Answer:

Like the use of aspirin for cancer prevention, the preventive potential of multivitamins has received attention due to recently released data from clinical studies. Nearly one-third of American adults consume a daily multivitamin for disease prevention despite the 2010 Dietary Guidelines for Americans and the National Institutes of Health—sponsored State-of-the-Science Conference having concluded there is insufficient evidence to support routine multivitamin use for primary prevention of chronic diseases.^5,6 The most recent study to shed new light on this topic was an analysis of data from the Physicians’ Health Study II, a large-scale, randomized, double-blind study evaluating the effects of multivitamin supplements on preventing chronic diseases, including cancer.⁷ In this study, which included more than 14,000 male physicians 50 years or older, participants without a family history of cancer who received the daily multivitamin (Centrum Silver) from 1997 through 2011 had a significantly reduced incidence of cancer. However, this effect was not observed in those with a family history of cancer, and the authors found no effect on the incidence of a specific type of cancer or of cancer-related mortality.⁷

Based on this data and on PM’s unremarkable medical history, recommending a daily senior multivitamin, such as Centrum Silver or a generic equivalent, would be reasonable. However, remind PM that cancer is a multifactorial disease. The intricacies and interplay between genetics and family history, diet, lifestyle, and other factors have yet to be fully understood.

Case 3: Immunization and the Cancer Patient

GO is a 61-year-old woman who approaches the pharmacy to inquire about receiving the herpes zoster vaccine. Five years earlier, GO underwent surgery, radiation, and chemotherapy (consisting of cyclophosphamide, doxorubicin, vincristine, and a steroid) as treatment for lymphoma. She has a history of heart failure secondary to her chemotherapy, hypothyroidism, and insomnia, for which she takes carvedilol 12.5 mg twice a day, lisinopril 20 mg daily, furosemide 20 mg daily as needed, levothyroxine 75 mcg daily, and zolpidem 5 mg daily, respectively. She has no known allergies to medications and has never had an adverse reaction to a previous dose of any vaccine. Is GO a candidate for the zoster vaccine at this time?

Answer:

Herpes zoster, also known as shingles, can be a devastating illness, associated with severe skin eruptions, secondary bacterial infections, scarring, and long-standing neuralgia even after wounds heal. A single dose of zoster vaccine is recommended by the CDC for adults aged 60 years and older regardless of whether they have previously experienced herpes zoster.⁸ In conducting a pharmacy-based immunization clinic that includes administration of the zoster vaccine, it is important to review any protocols and screening forms to ensure that patients with contraindications do not receive the vaccine. Since the zoster vaccine is a live vaccine product, it is contraindicated in patients with active cancer or an immunocompromising condition. Patients should be instructed to wait at least 3 months after receiving chemotherapy treatment to become vaccinated or at least 1 month after completing treatment with high-dose steroids, isoantibodies, immune-mediators, or immunomodulators. Further, according to the CDC, the zoster vaccine should not be administered to those who are pregnant or who have leukemia, lymphomas, HIV/AIDS, or malignancies affecting the bone marrow or lymphatic system.^8,9

In the case of GO, you should act in accordance with your local screening protocol. Since her disease is in remission and she has not received chemotherapy in the past 3 months, she could be eligible for zoster vaccination at this time.

Case 4: Fiber Supplementation and Colon Cancer

BP is a 54-year-old man seeking a recommendation for a fiber supplement. He has a history of colon cancer and, after his last colonoscopy, remembered reading that increased fiber intake can help reduce cancer risk. He is concerned about his cancer risk because his father died from this disease. He also has a history of diabetes, hypertension, and dyslipidemia, for which he is taking the combination metformin 500 mg and pioglitazone 15 mg twice daily, losartan 100 mg daily, and atorvastatin 40 mg daily. He has no known medication allergies. Should BP consider fiber supplementation at this time?

Answer:

For several years, consuming a diet high in fiber was widely recommended for individuals seeking to reduce their colon cancer risk. Unfortunately, clinical evidence that dietary fiber prevents colon cancer is largely unclear. A meta-analysis of 25 clinical studies evaluating the effects of dietary fiber, including cereals and whole grains, concluded that those consuming more than 10 g of dietary fiber per day were likely to have reduced colon cancer risk compared with those consuming less than 10 g per day.¹⁰ Further, a case-control study evaluating the dietary habits of more than 579 patients who developed colon cancer and 1996 patients who did not develop colon cancer found that those consuming 24 g of dietary fiber per day had a 30% lower risk of colon cancer than those consuming 10 g per day or less.¹¹ However, the effect of fiber supplementation on cancer risk reduction has not to date been evaluated in large-scale prospective studies.

In counseling BP, assess his dietary and bowel habits. If he is experiencing occasional constipation that would benefit from increased insoluble fiber to improve laxation, then supplementation could be considered. In any case, emphasize to BP that a supplement alone may not reduce cancer risk, but that a diet rich in fruits, vegetables, and grains may have a positive effect on his overall health and glycemic control.

Dr. Bridgeman is an internal medicine clinical pharmacist in New Brunswick, New Jersey, and clinical assistant professor, Ernest Mario School of Pharmacy, Rutgers University. Dr. Mansukhani is a clinical pharmacist in South Plainfield, New Jersey, and clinical assistant professor, Ernest Mario School of Pharmacy, Rutgers University.

References

• Rothwell PM, Fowkes FG, Belch JF, et al. Effect of daily aspirin on long-term risk of death due to cancer: analysis of individual patient data from randomized trials. Lancet. 2011;377(9759):31-41.
• Bardia A, Ebbert JO, Vierkant RA, et al. Association of aspirin and non-aspirin nonsteroidal anti-inflammatory drugs with cancer incidence and mortality. J Natl Cancer Inst. 2007;99(11):881-889.
• Chan AT, Manson JE, Feskanich D, et al. Long-term aspirin use and mortality in women. Arch Intern Med. 2007;167(6):562-572.
• Jacobs EJ, Newton CC, Gapstur SM, et al. Daily aspirin use and cancer mortality in a large US cohort. J Natl Cancer Inst. 2012;104(16):1208-1217.
• Cook NR, Albert CM, Gaziano JM, et al. A randomized factorial trial of vitamins C and E and beta carotene in the secondary prevention of cardiovascular events in women: results from the Women’s Antioxidant Cardiovascular Study. Arch Intern Med. 2007;167(15):1610-1618.
• Lee IM, Cook NR, Gaziano JM, et al. Vitamin E in the primary prevention of cardiovascular disease and cancer: the Women’s Health Study: a randomized controlled trial. JAMA. 2005;294(1):56-65.
• Gaziano JM, Sesso HD, Christen WG, et al. Multivitamins in the prevention of cancer in men: the Physicians’ Health Study II randomized controlled trial. JAMA. 2012;308(18):1871-1880.
• Centers for Disease Control and Prevention. Advisory Committee on Immunization Practices (ACIP) recommended immunization schedule for adults aged 19 years and older: United States, 2013. www.cdc.gov/vaccines/schedules/downloads/adult/mmwr-adult-schedule.pdf. Accessed July 10, 2013.
• Centers for Disease Control and Prevention. Prevention of herpes zoster: recommendations from the Advisory Committee on Immunization Practice (ACIP). MMWR Early Release. 2008;57[June 6]:20.
• Aune D, Chan DSM, Lau R, et al. Dietary fibre, whole grains, and risk of colorectal cancer: systematic review and dose-response meta-analysis of prospective studies. BMJ. 2011; 343:d6617.
• Dahm CC, Keogh RH, Spencer EA, et al. Dietary fiber and colorectal cancer risk: a nested case-control study using food diaries. J Natl Cancer Inst. 2010;102(9):614-626.