# Get biomarker-directed aspirin after colorectal surgery into labels and guidelines

Source: https://onco.cc/ideas/idea-reg-aspirin-pik3ca-implementation/  
OnCo record `idea-reg-aspirin-pik3ca-implementation` (Idea). Data CC BY-NC 4.0, attribute "Data from OnCo (onco.cc)"; commercial use needs a licence.

## TL;DR

A Swedish trial found that cheap aspirin roughly halved recurrence in colorectal cancer patients with a particular tumour mutation. Nobody is going to market it, so health systems must adopt it deliberately.

## Summary

The ALASCCA randomised trial (reported 2025) found that low-dose aspirin for three years reduced recurrence in patients with PIK3CA-mutated colorectal cancer after surgery, following earlier observational signals, while broader trials (ASCOLT, Add-Aspirin ongoing) have shown smaller or no unselected effects. Because aspirin has no sponsor, the result risks slow and uneven adoption. The proposal is a coordinated implementation programme: guideline inclusion (ESMO, NCCN), routine PIK3CA testing at diagnosis as a reimbursed test, third-party label filings where pathways exist, and an implementation registry capturing uptake and outcomes.

## Fields

- Kind: Idea
- Last checked: 2026-09-08
- Hypothesis: Within three years, more than 70% of eligible PIK3CA-mutated colorectal cancer patients in participating health systems receive adjuvant aspirin, and registry data confirm a recurrence reduction consistent with the trial.
- Rationale: A proven, near-free intervention that reduces recurrence in a common cancer is exactly the case where the absence of a commercial sponsor costs lives; the barrier is testing infrastructure and awareness, both of which implementation programmes address.
- Proposed test: Audit PIK3CA testing and aspirin prescribing rates in five health systems, run an implementation intervention in half of them, and compare uptake and 3-year recurrence.
- Maturity: being-tested-at-scale
- Actor: clinic

## Sources

- ALASCCA trial, NEJM 2025: https://www.nejm.org/doi/full/10.1056/NEJMoa2504650

## Connected records

- cancers: [Colorectal cancer](https://onco.cc/cancers/colorectal/)
- targets: [PIK3CA / PI3K-alpha](https://onco.cc/targets/pik3ca/)
- institutions: [European Society for Medical Oncology (ESMO)](https://onco.cc/institutions/esmo/), [Karolinska University Hospital](https://onco.cc/institutions/karolinska/)
- pathways: [PI3K / AKT / mTOR](https://onco.cc/pathways/pi3k-akt-mtor/)
- bottlenecks: [Knowledge reaches practice too slowly](https://onco.cc/bottlenecks/b-knowledge-diffusion/), [No incentive to repurpose cheap drugs](https://onco.cc/bottlenecks/b-generic-repurposing/)
- key papers: [CAPP2: two years of aspirin cuts bowel cancer in Lynch syndrome by more than a third over 10 years](https://onco.cc/key-papers/paper-capp2-aspirin-lynch-lancet-2020/), [Evaluation of PIK3CA mutation as a predictor of benefit from nonsteroidal anti-inflammatory drug therapy in colorectal cancer](https://onco.cc/key-papers/paper-pik3ca-colorectal-j-clin-oncol-2013/), [KRAS, BRAF, PIK3CA, and PTEN mutations: implications for targeted therapies in metastatic colorectal cancer](https://onco.cc/key-papers/paper-pik3ca-colorectal-lancet-oncol-2011/), [The predictive value of KRAS, NRAS, BRAF, PIK3CA and PTEN for anti-EGFR treatment in metastatic colorectal cancer: A systematic review and meta-analysis](https://onco.cc/key-papers/paper-pik3ca-colorectal-acta-oncol-2014/)
- technologies: [Aspirin for cancer prevention and adjuvant therapy](https://onco.cc/technologies/aspirin-cancer-prevention/)
- trials: [ALASCCA](https://onco.cc/trials/alascca/)
- roadmaps: [Cancer prevention roadmap: tobacco control and vaccines → biomarker-guided chemoprevention → interception in carriers](https://onco.cc/roadmaps/prevention-roadmap/)

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