Two Simple Interventions May Cut Colorectal Cancer Recurrence Risk

 Hello. I'm Dr David Johnson, professor of medicine and chief of gastroenterology at Eastern Virginia Medical School and Old Dominion University in Norfolk, Virginia. 

New guidelines have lowered the age to begin screening for colon cancer to 45 years old. Although this change is positive, we're still seeing advanced cancer in younger patients who haven’t been screened in time. 

Once diagnosed, these patients undergo surgery and chemotherapy and often return to us asking, “What can I do now to help myself?”  

Two recent studies highlight interventions that are simple, affordable, and actionable today: exercise and aspirin. Let’s take a closer look at the results. 

Exercise’s Risk Reduction Potential

The idea that exercise reduces cancer recurrence and mortality is supported by observational data. The mechanistic effects behind this have been ascribed to metabolic growth factors, inflammatory changes, immune function changes, and perhaps even positive impact on sleep. 

A study just published in The New England Journal of Medicine examined structured exercise after adjuvant chemotherapy for colon cancer. The phase 3 randomized CHALLENGE trial, mostly conducted at Canadian and Australian centers, recruited patients with resected stage II or III colon cancer (9.8% and 90.2%, respectively) who had completed adjuvant chemotherapy. Patients with recurrences within a year of diagnosis were excluded, as they were more likely to have highly aggressive, biologically active disease. 

Patients were randomized to receive healthcare education materials alone or in conjunction with a structured exercise program over a 3-year follow-up period. 

The exercise intervention, delivered in person or virtually, focused on increasing recreational aerobic activity over baseline by at least 10 metabolic equivalent task (MET). An increment of 10 MET hours per week is not too vigorous. It is essentially the equivalent of adding about 45-60 minutes of brisk walking or 25-30 minutes of jogging 3-4 times a week.

Patients were asked to increase MET over the first 6 months and then maintain or further increase the amount over the next 2.5 years. They were permitted to structure their own exercise program by choosing the type, frequency, intensity, and duration of aerobic exercise. 

The primary endpoint was disease-free survival, with secondary endpoints assessing overall survival, patient-reported outcomes, and other outcomes. Although designed to detect differences at 3 years, follow-up was also performed out to 5 and 8 years.

At a median follow-up of 7.9 years, exercise reduced the relative risk of disease recurrence, new primary cancer, or death by 28% (P =.02). This benefit persisted — and even strengthened — over time, with disease-free survival increasing by 6.4 and 7.1 percentage points at 5 and 8 years, respectively. 

Musculoskeletal adverse events were slightly higher in the exercise group compared with the health education group (18.5% vs 11.5%, respectively), but only 10% were directly attributed to the exercise. 

There are considerations when interpreting these results. First, there was an attrition over time for compliance and training. It would be interesting to see whether that impacted the results. Second, it’s unclear whether patient pedigree or a genomic pathway may predispose to a benefit here for the exercise group. 

But overall, this phase 3 trial provides class 1 evidence supporting exercise as a low-cost, high-impact intervention to reduce cancer recurrence.

Adjuvant Aspirin in Colon Cancer Subset

That’s a perfect segue into another recent study looking at the effects of adjuvant aspirin on the prevention of recurrence.

The ALASCCA trial— conducted across centers in Sweden, Denmark, Finland, and Norway — assessed patients with stage I-III rectal cancer or stage II-III colon cancer. It focused on a subset of patients with an oncogenic abnormality called PIK3CA (phosphatidylinositol-4,5-bisphosphate 3-kinase catalytic subunit alpha). 

PIK3CA occurs in approximately a third of colon cancers and is associated with significant chemotherapy resistance and a higher rate of disease progression. 

Of the included patients, 1103 (37%) had alterations in the PIK3CA pathway. Researchers randomized patients to receive either 160 mg of aspirin or placebo daily for 3 years, starting within 3 months of surgery. 

Among patients with PIK3CA mutations, aspirin dramatically reduced the risk for time to recurrence by nearly 50% at 3 years (P =.044). Adverse events associated with aspirin were minimal, including one case each of gastrointestinal bleeding, hematoma, and allergic reaction. 

There is no evidence that higher aspirin doses provide greater prevention of colorectal cancer recurrence. The 160 mg use in the current study is fairly normal, roughly equivalent to two low-dose (81 mg) aspirin tablets. 

Now, it’s worth noting that the use of aspirin for the primary prevention of cardiovascular disease was initially recommended by the US Preventive Task Services Force in 2016. This recommendation was then recanted in 2022, when the same group reported limited net benefit to this approach. 

Two Proactive Actions

These studies highlight two interventions — exercise and aspirin — that are low cost, accessible, and appeal to patients eager to help prevent their cancer from recurring. 

Exercise is broadly beneficial and can be recommended immediately. 

For aspirin, patients should work with their oncologist to determine their PIK3CA mutation status, as this subgroup appears to benefit the most. 

These findings offer patients meaningful, proactive interventions they can apply to support their recovery and reduce the risk of recurrence. Hopefully these new findings will help guide your clinical conversations. 

I’m Dr David Johnson. Thanks for listening.

David A. Johnson, MD, a regular contributor to Medscape, is professor of medicine and chief of gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia, and a past president of the American College of Gastroenterology. His primary focus is the clinical practice of gastroenterology. He has published extensively in the internal medicine/gastroenterology literature, with principal research interests in esophageal and colon disease, and more recently in sleep and microbiome effects on gastrointestinal health and disease.

https://www.medscape.com/viewarticle/these-two-simple-interventions-may-cut-colorectal-cancer-2025a1000k2q

The Next Gastric Cancer Surge?

 A study published in Nature Medicine estimated that Helicobacter pylori infection could lead to 11.8 million cases of gastric cancer over the lifetime of today’s children if current prevention strategies remain unchanged.

The International Agency for Research on Cancer, World Health Organization, analyzed global cancer incidence data 2022 and United Nations demographic information to estimate future mortality. The study focused on people born between 2008 and 2017 to estimate their lifetime cancer risk linked to chronic H pylori infection.

According to the study, gastric cancer is the fifth leading cause of cancer death worldwide. Two thirds of future cases are projected in Asia (10.6 million), followed by the Americas (2.0 million), Africa (1.7 million), and Europe (1.2 million), with 900,000 in Europe linked to H pylori. Researchers emphasized that gastric cancer is largely preventable and called for stronger global prevention strategies, including the development of a vaccine against H pylori. 

Speaking with Univadis Spain, Javier P. Gisbert, MD, PhD, highlighted the urgent need to address H pylori infection. He is the head of the Inflammatory Bowel Disease Unit at Hospital Universitario de La Princesa in Madrid, Spain, associate professor of medicine at Universidad Autónoma de Madrid, and affiliated researcher with the Instituto de Investigación Sanitaria Princesa, Madrid. “Gastric cancer is a major global health concern, ranking as the fifth most common cancer worldwide. The main cause is H pylori infection. If we could eradicate this bacterium, we would eliminate at least 90% of the gastric tumors it causes. In Spain alone, approximately 60,000 new cases of gastric cancer are expected in this birth cohort, with approximately 40,000 linked to H pylori infection. These figures show that this bacterium, and efforts to diagnose and prevent it, must be taken very seriously,” he said.

Preventive Measures

In 2021, the European Union launched the Beating Cancer Plan, followed by European Council recommendations that highlight population-based screening and treatment of H pylori, as key tools to prevent gastric cancer.

According to Gisbert, H pylori is usually acquired in early childhood, but the cancer it can cause typically appears decades later, often after the age of 50 or 60 years.

“Chronic H pylori infection gradually damages the stomach lining,” he explained. “It starts with superficial gastritis, progresses to atrophic gastritis, then intestinal metaplasia, and finally dysplasia the last stage before cancer. If we treat the infection early, before these changes occur, we can prevent gastric cancer.”

Despite this risk, the incidence of gastric cancer in Spain remains relatively low, under 10 cases per 100,000 people per year. For this reason, screening asymptomatic people for H pylori is not considered necessary nationwide.

“In countries with higher gastric cancer rates, H pylori screening would be cost-effective,” Gisbert said. “But in Spain, it’s not clearly justified.”

Practice Gaps

Gisbert is also a researcher at the Biomedical Research Network Centre for Liver and Digestive Diseases. He also serves as principal investigator of the European H pylori Registry, a multinational initiative tracking real-world management of the infection. He recently led a study assessing how Spanish gastroenterologists outside the registry manage H pylori infections.

The results, published in Helicobacter, revealed the following gaps in clinical practice: “17% of specialists did not test for H pylori in patients with gastrointestinal bleeding from peptic ulcers, and 35% did not start treatment at the time of diagnosis in these cases. Only 25% were aware of local clarithromycin resistance rates, and only 37% regularly assessed the effectiveness of eradication treatments. Additionally, 74% of the specialists did not confirm penicillin allergy before prescribing the treatment. Moreover, 32% did not investigate first-degree relatives of patients with gastric cancer,” summarized Gisbert.

Conclusion

“Given that gastric cancer is largely preventable, more active intervention and control programs should be implemented in these high-resource East Asian countries. This indicates that, as in human papillomavirus vaccine programs for cervical cancer prevention or hepatitis B vaccine programs to reduce the risk of liver cancer, an H pylori vaccine would greatly advance the fight against gastric cancer, given that vaccination is one of the most context-responsive prevention strategies and is highly adaptable, especially in low- and middle-income settings where we expect to see a high number of H pylori-attributable gastric cancer cases,” the authors concluded.

Gisbert reported having no conflicts of interest. 

https://www.medscape.com/viewarticle/your-practice-missing-next-gastric-cancer-surge-2025a1000kis

'Which Probiotics Are Doctors Prescribing for Kids?'

 At the recent Congress of the French Society of Pediatrics, held in Paris, France, Alexis Mosca, MD, a paediatric gastroenterologist at Robert Debré Hospital, Paris, France, and member of the French Society of Pediatrics’ gastroenterology group, said that the guidance helps clarify when probiotics should be used. He also previewed the upcoming European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) recommendations on probiotics in infant formula.

According to the ESPGHAN, only a few probiotic strains are effective in children, particularly in treating acute diarrhoea and infant colic.

Probiotic Guidance

Gut flora modulators, such as pre-, pro-, syn-, and postbiotics, are commonly used in paediatrics, but selecting the right one can be challenging. Experts from the ESPGHAN have reviewed the evidence on specific probiotic strains for various gastrointestinal disorders. Only strains supported by at least two randomised controlled trials for the same condition were recommended.

Probiotics are advised for selected digestive conditions in children, including acute gastroenteritis, antibiotic-associated diarrhoea, nosocomial diarrhoea, and necrotising enterocolitis in preterm infants.

ESPGHAN has identified a limited number of strains with proven benefits. These include Lactobacillus rhamnosus GG [ATCC 53103], Saccharomyces boulardii [CNCM I-745], Lactobacillus reuteri [DSM 17938], and a combination of L rhamnosus [19070-2] with L reuteri [DSM 12246].

To prevent antibiotic-associated diarrhoea in both outpatient and hospitalised children, ESPGHAN recommends S boulardii [CNCM I-745] and L rhamnosus GG [ATCC 53103], ideally started alongside antibiotic therapy. For nosocomial diarrhoea, L rhamnosus GG [ATCC 53103] is also advised.

In neonates at risk of necrotising enterocolitis, positive recommendations include L rhamnosus GG [ATCC 53103] and a combination of three strains of Bifidobacterium infantis [BB-02], Bifidobacterium lactis [BB-12], and Streptococcus thermophilus [TH-4]. For Helicobacter pylori infection, S boulardii [CNCM I-745] has been suggested, although the effect is modest and evidence is limited.

For functional gastrointestinal disorders, L reuteri [DSM 17938] and B lactis [BB-12] are recommended in breastfed infants with colic, although supporting data remain limited. In cases of functional abdominal pain disorders, including irritable bowel syndrome, ESPGHAN advises L reuteri [DSM 17938] and L rhamnosus GG [ATCC 53103].

However, probiotics are not recommended for inflammatory bowel disease, constipation, celiac disease, or small intestinal bacterial overgrowth.

The French-speaking Pediatric Hepatology-Gastroenterology and Nutrition Group has published a fact sheet on the “Role of probiotics in the management of digestive disorders in children,” summarising ESPGHAN’s recommendations and specifying the dosages to follow.

Experts caution that prescribing probiotics remains complex. Many commercial products fail to list essential details, such as strain designation, dosage, or potential contaminants. Clinicians are urged to the exact strain or product not just write “a probiotic.”

Although France permits the term “probiotic” in food supplements (per Directorate General for Competition Policy, Consumer Affairs and Fraud Control guidance, December 2022), product quality remains a major concern. An analysis of 16 probiotic products marketed for infants revealed that only one matched the composition listed on its label. Some products lacked the advertised strains, some showed signs of contamination, and there were notable inconsistencies between batches. Similar concerns were raised in another study involving probiotics administered to premature infants.

A global study found major differences between what probiotic product labels claimed and what they contained. Out of the 30 products tested, only 57% correctly listed the species inside. The remaining 43% were not accurate: Six had more species than declared, three were missing one or more listed species, and four contained species that were not mentioned on the label.

Probiotics in Infant Formula

Mosca and colleagues examined whether biotics should be routinely added to infant formula in the Journal of Pediatric Gastroenterology and Nutrition.

“Unless the text changes before publication which is unlikely,” Mosca said, “We found no clear evidence to support or oppose the routine use of the probiotic strains studied.” These include B lactis [CNCM I-3446], S thermophilus, and Lactobacillus johnsonii La1. None of the tested doses showed a meaningful clinical benefit.

Certain human milk oligosaccharides, such as 2’-fucosyllactose, 3-fucosyllactose, lacto-N-tetraose, 3’-sialyllactose, and 6’-sialyllactose may soften stools when used at high doses. However, no significant clinical benefits have been demonstrated.

Synbiotic combinations, such as Bifidobacterium breve strain M-16V with a 9:1 blend of short-chain galacto-oligosaccharides and long-chain fructo-oligosaccharides, are generally well tolerated and may influence stool consistency and gut microbiota. However, current evidence does not support a consistent clinical advantage over standard infant formulas.

Prebiotics, such as galacto-oligosaccharides, fructo-oligosaccharides, oligofructose, and enriched inulin, have shown only a modest effect, typically limited to a slight increase in stool frequency or softening. Among these, only the specific galacto-oligosaccharide/fructo-oligosaccharide (9:1) mixture demonstrated a measurable effect on stool consistency.

Disclosure

Mosca reported having no conflicts of interest. He has participated in one-time engagements over the past 5 years with BioGaia, Calmosine, PiLeJe, Biocodex, Lacteol, Fresenius Kabi, MaaT Pharma, Danone, Nestlé, Novalac, Modilac, Mead Johnson, and Nutribio.

https://www.medscape.com/viewarticle/which-probiotics-are-doctors-prescribing-kids-2025a1000kid

Chemotherapy Linked to Brain Atrophy in Patients With Breast Cancer

 Patients with breast cancer who undergo chemotherapy may face an increased risk for brain atrophy and cognitive decline, new findings from a pilot study suggested.

Memory problems in patients with cancer may not stem solely from stress or anxiety related to their diagnosis but could reflect underlying changes in brain structure, study investigator Paul Edison, PhD, MPhil, professor of neuroscience and clinical professor of neurology at Imperial College London, London, England, told Medscape Medical News.

While the findings suggest that chemotherapy may contribute to neuronal damage, the researchers noted that many aspects of the relationship between treatment and brain changes remain unclear.

Edison highlighted three key areas that require further investigation — uncovering the mechanisms driving brain atrophy, determining the proportion of patients affected, and identifying effective prevention strategies.

Another investigator on the study, Laura Kenny, MD, PhD, associate professor and consultant medical oncologist at Imperial College London, noted that the issue has received limited attention to date but expressed hope that the findings will raise awareness and encourage further research, given its clinical importance.

The findings were presented on July 29 at the Alzheimer’s Association International Conference (AAIC) 2025.

Investigating Cognitive Impact

Advances in chemotherapeutic agents have improved survival rates in patients with cancer. However, challenges persist regarding the long-term impact of these drugs.

Chemotherapy-associated cognitive impairment, often referred to as “brain fog” or “chemobrain,” affects approximately one third of patients with breast cancer following treatment.

While cognitive decline resolves within 12 months for some patients, others experience persistent effects that may elevate the risk for neurodegenerative conditions, Edison explained.

To evaluate the impact of chemotherapy on the brain, investigators studied 328 women with nonmetastatic breast cancer who had undergone chemotherapy within the past 12 months.

Patients received either anthracycline — a drug derived from the Streptomyces peucetius bacterium — or taxanes such as docetaxel and paclitaxel, both commonly used in breast cancer treatment, or a combination of these agents. In addition, some patients may also have had hormone therapy at some point during treatment, said Kenny.

Participants completed neurocognitive prescreening tests every 3 months using a specialized artificial intelligence-driven platform, allowing them to take detailed memory assessments online from home.

Among those prescreened, 18 individuals with lower neurocognitive scores (mean age, approximately 55 years) and 19 cognitively normal control individuals without breast cancer (mean age, approximately 67 years) underwent comprehensive, in-person, neurocognitive evaluations and MRI scans.

Researchers analyzed the scans using region of interest (ROI) and voxel-based morphometry (VBM), which uses sophisticated computer software, to assess grey matter volumes and surface areas.

The ROI analysis revealed significant reductions in gray matter volume (measured in mm³) and surface area (measured in mm²) among patients experiencing chemobrain, particularly affecting the isthmus cingulate and pars opercularis, with changes extending into the orbitofrontal and temporal regions.

Significant Atrophy

The VBM analysis confirmed significant atrophy in the frontal, parietal, and cingulate regions of patients with chemobrain compared with control individuals (P < .05). Edison noted that this pattern overlaps with brain changes typically observed in Alzheimer’s disease and vascular cognitive impairment.

For both analyses, “we demonstrated there is some amount of shrinkage in the brain among patients with chemobrain.” he said. “The fact that controls are older means the results are even more significant as there’s more brain atrophy as people age.”

Some of the affected brain regions may be linked to impaired memory, a hallmark of Alzheimer’s disease, but Edison cautioned that given the small sample size this finding should be interpreted with caution.

While the analysis demonstrated overall lower brain volumes in patients with “chemobrain” compared with controls, Edison emphasized that this finding reflects a single time point and does not indicate brain shrinkage over time.

Other events, including stroke — can also cause brain changes.

Edison highlighted the importance of determining the significance of these brain changes, how they affect patients and whether they can be prevented.

In-person neurocognitive testing revealed significantly reduced semantic and verbal fluency, as well as lower Mini-Mental State Examination scores in patients with chemobrain. Edison noted that these results support the MRI findings.

The team plans to follow patients to track brain changes and memory recovery, Kenny said. While patients with breast cancer are a common focus, the researchers intend to expand the study to other cancers in both men and women, said Kenny. Anecdotally, many patients report memory problems during chemotherapy, she added.

Based on discussions with her oncology colleagues, Kenny noted that many patients anecdotally report experiencing memory problems during chemotherapy.

More Research Needed

Commenting for Medscape Medical News, Rebecca M. Edelmayer, PhD, vice president, Scientific Engagement, at the Alzheimer’s Association, said the research may help shed light on why women are more likely to develop dementia than men.

For years now, experts have been trying to figure out what puts women at higher risk for AD and other dementias, said Edelmayer.

“We still don’t understand whether this involves biologically driven risk factors or socially driven risk factors.”

Research linking treatments for other health conditions to increased memory problems may offer some clues, she noted, suggesting a potential avenue for further investigation into the intersection of chemotherapy and neurodegenerative diseases such as Alzheimer’s.

However, Edelmayer emphasized that this line of research is still in its infancy. Much more work is needed to determine whether there is a direct cause-and-effect relationship with specific chemotherapy drugs, and whether some patients may already be predisposed or at higher risk for cognitive decline, she said.

Also commenting for Medscape Medical News, Eric Brown, MD, associate scientist and associate chief of geriatric psychiatry at the Centre for Addiction and Mental Health in Toronto, Ontario, Canada, raised concerns about the study’s design.

One issue, he noted, is that the researchers did not image all patients who received chemotherapy but instead selected those with the most significant cognitive impairment. As a result, the findings may not have reflected outcomes in the average post-chemotherapy patients but rather represent the most severely affected subgroup.

Brown also pointed out that the study did not clarify whether this subgroup had comorbid conditions. It’s possible, he said, that some individuals may have had Alzheimer’s disease or other forms of dementia unrelated to chemotherapy.

He agreed that tracking longitudinal changes in both cognitive scores and neuroimaging — comparing patients who receive chemotherapy with those who do not — would be a valuable next step.

The investigators, Edelmayer and Brown, reported no relevant conflicts of interest.

https://www.medscape.com/viewarticle/chemotherapy-linked-brain-atrophy-patients-breast-cancer-2025a1000kip

Biden stumbles through speech at Chicago gala as he warns US in ‘dark days’

 Former President Joe Biden looked lost and slurred through his remarks at a Chicago lawyers’ gala Thursday night — months after the 82-year-old revealed he was battling aggressive prostate cancer.

The white-haired, wide-eyed Biden received a standing ovation as he slowly stepped on stage at the 100th annual awards gala for the National Bar Association — the oldest and largest network of predominently black lawyers or judges in the US.

Flanked by two of his granddaughters, the former president gingerly crossed the stage and shook hands with the emcee before turning around and trying to locate his seat, video shows.

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Raising his voice, Biden said, “Folks, in all our lives, the life of our nation, there are moments so stark that they divide all that came before from everything that followed.”REUTERS

Biden was directed back to his place by others on the dais and slowly slouched into his chair before flashing a smile and pointing finger guns at the crowd.

Later in the evening, Biden stumbled over his words at several different points during his 20-minute remarks, in which he accused the Trump administraiton of waging an “existential” fight with minority communities and touted his civil rights record.

“These are dark days, but you’re all here for the same reason I left that prestigious law firm to go to the defender’s office years ago,” he said. “It’s because our future is literally on the line and we must be unapologetic of fighting for the future.” 

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Biden stumbled over his words at several different points of his speech.National Bar Association

Biden also joked about his age in lighter moments.

“When I was elected [in 1972], I had the dubious distinction to be elected the youngest senator in American history and the oldest president in American history. It’s hell turning 40 twice,” he quipped to chuckles.

Biden has largely shied away from public appearances since departing the White House in January after foregoing a second bid for the presidency due to his evident mental and physical decline.

His vice president, Kamala Harris, was defeated by President Trump in a landslide.

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The former president’s address comes two months after his son Hunter agreed to a voluntary disbarment stemming from drug use and alleged gun law violations.REUTERS

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Mike Donilon, senior adviser to President Biden.Getty Images

In May, Biden revealed that he was suffering from an advanced case of prostate cancer that had spread to his bones.

The 46th commander in chief was presented Thursday with the National Bar Association’s C. Francis Stradford Award, the highest honor bestowed by the organization.

Biden was part of a speaking program that included far-left Rep. Jasmine Crockett (D-Texas), Minnesota Attorney General Keith Ellison, Nevada Attorney General Aaron Ford, Supreme Court Justice Ketanji Brown Jackson, former MSNBC pundit Joy-Ann Reid and New York state Attorney General Letitia James.

https://nypost.com/2025/08/01/us-news/biden-takes-aim-at-trump-as-existential-threat-to-black-americans-in-speech-to-lawyers-group/