Aspirin for Dukes C and High Risk Dukes B Colorectal Cancers

We hypothesize through this randomized, placebo-controlled adjuvant study, that Aspirin in patients with dukes C or high risk dukes B colorectal cancer (ASCOLT) can improve survival in this patient population over placebo control. If indeed found to be beneficial, because aspirin is cheap and easy to administer, it will positively impact the lives of many individuals in Asia and globally. STUDY OBJECTIVE To assess the effectiveness of Aspirin against placebo control in patients with dukes C or high risk dukes B colorectal cancer in terms of Disease Free Survival (DFS) and Overall Survival (OS) Primary endpoints * DFS among all eligible subjects (high risk Dukes B colon cancer, Dukes C colon cancer and rectal cancer patient sub-groups); * DFS among patients with colon cancer (high-risk Dukes B and Dukes C colon cancer). Secondary endpoints * Overall survival (OS) over 5 years * DFS and OS in * Chinese, Malay, Indian and other ethnic groups * Resected high risk Dukes B colon cancer, Dukes C colon cancer and rectal cancer sub-groups, individually * Compliant versus non-compliant subjects * PIK3CA mutated tumors (where samples are available)

Sex

All

Minimum age

18 Years

Inclusion Criteria

* Male or female outpatient of ≥ 18 years of age or ≥ country's legal age for adult consent
* Dukes C colon cancer, high risk Dukes B colon cancer, Dukes B rectal cancer or Dukes C rectal cancer (see Appendix 1 for definition of High Risk Dukes B)
* Undergone complete resection of primary tumour
* Completed standard therapy ( at least 3 months of chemotherapy ± radiotherapy )
* Within 120 days of completion of standard therapy (surgery, chemotherapy ± radiotherapy)
* ECOG performance status 0 to 2
* Satisfactory haematological or biochemical functions (tests should be carried out within 8 weeks prior to randomisation): Results of clinical investigations carried out within 8 weeks prior to randomisation can be used in place of the required screening investigations. Patients with mild laboratory abnormalities can be included at the discretion by the site principal investigator, and after approval by ASCOLT Trial Management Group
* ANC ≥ 1.0 x 109/L
* Platelets ≥ 100 x 109/L
* Creatinine clearance ≥ 30 mL/min
* Total bilirubin ≤ 2.0 x the upper limit normal
* AST \& ALT ≤ 5 x the upper limit normal
* Completed the following investigations
* Colonoscopy(or CT colonogram(within 16 months prior to randomization)
* Imaging of abdomen (CT or CT colonogram or MRI or PET or Ultrasound) within 16 months prior to randomization
* Written informed consent

Exclusion Criteria

* Pre-existing Familial adenomatous polyposis, inflammatory bowel disease or ulcerative colitis
* Active gastritis or active peptic ulcer
* History of continuous daily use of PPI more than 1 year prior to consent
* Gastrointestinal bleeding within the past one year
* Haemorrhagic diathesis (i.e. haemophilia)
* Uncontrolled hypertension (untreated systolic blood pressure \> 160 mmHg, or diastolic blood pressure \> 95 mmHg)
* History of recent cancers (except for colorectal cancers, non-melanoma skin cancers, basal cell carcinomas, squamous cell carcinomas) in the past 5 years
* History of stroke, coronary arterial disease, angina, or vascular disease
* Patients who are on current long term treatment (≥ 4 consecutive weeks) with Aspirin, NSAID or Cox-2 inhibitors
* History of erosive GERD or active erosive GERD on gastroscopy.
* Patient on active current treatment of antiplatelet agents (i.e. off-study Aspirin, clopidogrel, ticlopidine)
* Patient receiving active treatment of anticoagulants (i.e. warfarin, low molecular weight heparins)
* Pregnant, lactating, or not using adequate contraception
* Patient having known allergy to NSAID or Aspirin
* Unexplained rise of CEA (i.e. smoker with elevated CEA will not be excluded)
* Patient on other investigational drug
* Patients with HNPCC (Lynch Syndrome)

• BACKGROUNDSegelov E, Prenen H, Day D, Macintyre CR, Foo EMJ, Ali R, Wang Q, Wei X, Lopes GL Jr, Ding K, Chen G, Chia JWK, Toh HC; ASCOLT Investigators. Impact of the COVID-19 Epidemic on a Pan-Asian Academic Oncology Clinical Trial. JCO Glob Oncol. 2020 Apr;6:585-588. doi: 10.1200/GO.20.00072. No abstract available. PMID 32293940
• BACKGROUNDDay D, Toh HC, Ali R, Foo EMJ, Simes J, Chia JWK, Segelov E; ASCOLT Investigators. Operational Challenges of an Asia-Pacific Academic Oncology Clinical Trial. JCO Glob Oncol. 2023 Jun;9:e2300040. doi: 10.1200/GO.23.00040. PMID 37364220
• DERIVEDSegelov E, Li S, Li I, Mouradov D, Yip S, Day D, Jeffery M, Zielinski R, Nott L, Sun Y, Christie M, Ho GF, Chao TY, Rahman N, Foo E, Chia J, Gebski V, Toh HC, Sieber OM, Simes J. Adjuvant aspirin for colorectal cancer with PIK3CA-mutated and COX-2 overexpressed tumours: the ASCOLT translational research study and meta-analysis. EBioMedicine. 2026 Aug;130:106389. doi: 10.1016/j.ebiom.2026.106389. Epub 2026 Jul 20. PMID 42475879
• DERIVEDChia JWK, Segelov E, Deng Y, Ho GF, Wang W, Han S, Sharma A, Ding K, Chen G, Jeffery MG, Tham CK, Ahn JB, Nott L, Zielinski R, Chao TY, van Hagen T, Wei PL, Day F, Mehta S, Yau T, Peng J, Hayes TM, Li Y, Gandhi M, Foo EMJ, Rahman N, Rothwell P, Ali R, Simes J, Toh HC. Aspirin after completion of standard adjuvant therapy for colorectal cancer (ASCOLT): an international, multicentre, phase 3, randomised, double-blind, placebo-controlled trial. Lancet Gastroenterol Hepatol. 2025 Mar;10(3):198-209. doi: 10.1016/S2468-1253(24)00387-X. Epub 2025 Jan 14. PMID 39824200
• DERIVEDAli R, Toh HC, Chia WK; ASCOLT Trial Investigators. The utility of Aspirin in Dukes C and High Risk Dukes B Colorectal cancer--the ASCOLT study: study protocol for a randomized controlled trial. Trials. 2011 Dec 14;12:261. doi: 10.1186/1745-6215-12-261. PMID 22168568