Folic Acid for the Prevention of Colorectal Adenomas: A Randomized Clinical Trial

JAMA. 2007 Jun 6;297(21):2351-9. doi: 10.1001/jama.297.21.2351.

Abstract

Context: Laboratory and epidemiological data suggest that folic acid may have an antineoplastic effect in the large intestine.

Objective: To assess the safety and efficacy of folic acid supplementation for preventing colorectal adenomas.

Design, setting, and participants: A double-blind, placebo-controlled, 2-factor, phase 3, randomized clinical trial conducted at 9 clinical centers between July 6, 1994, and October 1, 2004. Participants included 1021 men and women with a recent history of colorectal adenomas and no previous invasive large intestine carcinoma.

Intervention: Participants were randomly assigned in a 1:1 ratio to receive 1 mg/d of folic acid (n = 516) or placebo (n = 505), and were separately randomized to receive aspirin (81 or 325 mg/d) or placebo. Follow-up consisted of 2 colonoscopic surveillance cycles (the first interval was at 3 years and the second at 3 or 5 years later).

Main outcome measures: The primary outcome measure was occurrence of at least 1 colorectal adenoma. Secondary outcomes were the occurrence of advanced lesions (> or =25% villous features, high-grade dysplasia, size > or =1 cm, or invasive cancer) and adenoma multiplicity (0, 1-2, or > or =3 adenomas).

Results: During the first 3 years, 987 participants (96.7%) underwent colonoscopic follow-up, and the incidence of at least 1 colorectal adenoma was 44.1% for folic acid (n = 221) and 42.4% for placebo (n = 206) (unadjusted risk ratio [RR], 1.04; 95% confidence interval [CI], 0.90-1.20; P = .58). Incidence of at least 1 advanced lesion was 11.4% for folic acid (n = 57) and 8.6% for placebo (n = 42) (unadjusted RR, 1.32; 95% CI, 0.90-1.92; P = .15). A total of 607 participants (59.5%) underwent a second follow-up, and the incidence of at least 1 colorectal adenoma was 41.9% for folic acid (n = 127) and 37.2% for placebo (n = 113) (unadjusted RR, 1.13; 95% CI, 0.93-1.37; P = .23); and incidence of at least 1 advanced lesion was 11.6% for folic acid (n = 35) and 6.9% for placebo (n = 21) (unadjusted RR, 1.67; 95% CI, 1.00-2.80; P = .05). Folic acid was associated with higher risks of having 3 or more adenomas and of noncolorectal cancers. There was no significant effect modification by sex, age, smoking, alcohol use, body mass index, baseline plasma folate, or aspirin allocation.

Conclusions: Folic acid at 1 mg/d does not reduce colorectal adenoma risk. Further research is needed to investigate the possibility that folic acid supplementation might increase the risk of colorectal neoplasia.

Trial registration: clinicaltrials.gov Identifier: NCT00272324.

Publication types

  • Clinical Trial, Phase III
  • Comparative Study
  • Multicenter Study
  • Randomized Controlled Trial
  • Research Support, N.I.H., Extramural

MeSH terms

  • Adenoma / epidemiology
  • Adenoma / etiology
  • Adenoma / prevention & control*
  • Adult
  • Aged
  • Anti-Inflammatory Agents, Non-Steroidal / therapeutic use
  • Aspirin / therapeutic use
  • Chi-Square Distribution
  • Colorectal Neoplasms / epidemiology
  • Colorectal Neoplasms / prevention & control*
  • Double-Blind Method
  • Female
  • Folic Acid / administration & dosage
  • Folic Acid / adverse effects
  • Folic Acid / therapeutic use*
  • Follow-Up Studies
  • Humans
  • Incidence
  • Male
  • Middle Aged
  • Neoplasms / etiology
  • Risk
  • Treatment Failure

Substances

  • Anti-Inflammatory Agents, Non-Steroidal
  • Folic Acid
  • Aspirin

Associated data

  • ClinicalTrials.gov/NCT00272324