Folic acid for the prevention of colorectal adenomas - A randomized clinical trial

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 (similar to 25% villous features, high-grade dysplasia, size similar to 1 cm, or invasive cancer) and adenoma multiplicity ( 0, 1-2, or similar to 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.