Vitamin D/Calcium Polyp Prevention Study

Extensive experimental and observational data suggest that intake of calcium and of vitamin D exert protective effects on colorectal neoplasia. Building on their previous work, the investigators will investigate the chemopreventive effect of vitamin D in the large bowel, to study whether calcium with vitamin D is more effective than calcium alone, and to confirm their positive finding regarding calcium. The goal of this study is the development of chemopreventive combinations that will reduce risk of colorectal neoplasia sufficiently to permit the lengthening of surveillance intervals in most patients and to clarify important issues regarding the mechanisms of colorectal carcinogenesis and chemoprevention.

Study Overview

• Status: Completed
• Conditions: Colorectal Cancer; Polyps; Adenomas
• Intervention / Treatment: Drug: placebo; Drug: Calcium Carbonate; Drug: Vitamin D3

Detailed Description

This study is a double-blind, placebo-controlled trial of vitamin D and/or calcium supplementation for the prevention of large bowel adenomas. Subjects will be recruited from 11 Study Centers in North America. Eligible subjects will have had at least one large bowel adenoma removed in the 4 months prior to study entry and no remaining polyps in the bowel after complete colonoscopic examination. Participants will be randomized in a partial 2 x 2 factorial design to vitamin D (1000 IU/day), calcium carbonate (1200 mg elemental calcium/day), both agents, or placebo only (Full Factorial randomization). Women who decline to forego calcium supplementation will be randomized only to calcium alone or to calcium plus vitamin D (Two Arm randomization). Randomization will be stratified by gender, study center of recruitment, and anticipated follow-up interval (see below), and will be conducted separately for female subjects randomized only to vitamin D. We anticipate enrolling up to 3000 participants to reach a total of up to 2400 randomized subjects. As safety measures, blood levels of calcium, creatinine, and 25-(OH)-vitamin D will be obtained at baseline and 1 year after randomization, as well as 3 years after randomization for subjects with a 5-year surveillance cycle. Every six months after randomization subjects will complete a questionnaire regarding compliance with study agents, use of medications and vitamin/mineral supplements, illnesses, hospitalizations, and dietary intake of calcium and vitamin D. The primary endpoint of the study will be new adenomas detected on follow-up colonoscopy. These examinations are scheduled to occur either 3 years or 5 years after the qualifying examination, depending on the follow-up interval recommended by each patient's endoscopist. Some patients may, for medical reasons, have a colonoscopy at a time other than 3 or 5 years after the qualifying examination. Information from these exams will be included in analyses where appropriate. In the primary analyses, the occurrence of new adenomas in the interval between randomization and the follow-up exam will be compared between subjects randomized to vitamin D (with or without calcium) versus those randomized to no vitamin D (with or without calcium), between subjects randomized to calcium (with or without vitamin D) versus those randomized to no calcium (with or without vitamin D; excluding women electing to receive calcium who therefore cannot participate in the calcium component of the study), and between those randomized to calcium plus vitamin D versus those randomized to calcium alone. In secondary analyses, we will examine the impact of baseline vitamin D levels and vitamin D receptor (VDR) polymorphisms on the vitamin D effects. Effects on advanced adenomas will also be assessed as a secondary outcome. Participants will be invited to participate in an optional Observational Follow Up phase of the study that will begin following the end of treatment. In this phase of the study, subjects will continue to be followed on an observational basis (no study treatment) with annual questionnaires until the time of a subsequent colonoscopy that is at least three years from the follow up colonoscopy at which study treatment was ended. We will examine the occurrence of new adenomas in the interval between the colonoscopy exam at the end of study treatment and the exam at the end of observational follow up period.

• Study Type: Interventional
• Enrollment (Actual): 2813
• Phase: Phase 2; Phase 3

Contacts and Locations

Study Locations

• Puerto Rico
  • San Juan, Puerto Rico
    • University of Puerto Rico
• United States
  • California
    • Los Angeles, California, United States, 90089
      • University of Southern California
  • Colorado
    • Denver, Colorado, United States, 80220
      • University of Colorado
  • Georgia
    • Atlanta, Georgia, United States, 30322
      • Emory University
  • Iowa
    • Iowa City, Iowa, United States, 52242
      • University of Iowa
  • Minnesota
    • Minneapolis, Minnesota, United States, 55455
      • University of Minnesota
  • New Hampshire
    • Lebanon, New Hampshire, United States, 03766
      • Dartmouth Hitchcock Medical Center
  • North Carolina
    • Chapel Hill, North Carolina, United States, 27599
      • University of North Carolina
  • Ohio
    • Cleveland, Ohio, United States, 44195
      • Cleveland Clinic Foundation
  • South Carolina
    • Columbia, South Carolina, United States, 29203
      • University of South Carolina
  • Texas
    • Houston, Texas, United States, 77030
      • University of Texas

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 45 years to 75 years (ADULT, OLDER_ADULT)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• One or more histologically verified neoplastic polyp (adenoma) that is at least 2 mm in size removed from the large bowel with the entire large bowel examined by colonoscopy and documented to be free of further polyps or areas suspicious for neoplasia within 120 days of study entry
• Anticipated colonoscopic follow-up three years or five years after the qualifying colonoscopy
• Age between 45 and 75 years at enrollment
• (Women)Agreement to avoid pregnancy (i.e., use of standard contraception)
• Willingness to forego calcium supplementation (including multivitamins containing calcium) or, for women only, option of taking calcium supplementation of 1200 mg/daily (contained in the study pills)
• Willingness to forego vitamin D supplementation (including multivitamins containing vitamin D)
• Agreement to daily dietary intake of the equivalent of not more than 1200 mg calcium
• Agreement to daily dietary intake of the equivalent of not more than 400 IU vitamin D
• Blood calcium level within normal range
• Blood creatinine level not to exceed 20% above upper limit of normal
• Serum 25-(OH)-vitamin D within lower limit of normal to 70 ng/ml
• Ability and willingness to follow the study protocol, as indicated by provision of informed consent to participate
• Good general health, with no severely debilitating diseases or active malignancy that might compromise the patient's ability to complete the study

Exclusion Criteria:

General exclusionary criteria:

• Participation in another colorectal (bowel) study (intervention study) in the past 5 years
• Current participation in any other clinical trial (intervention study)
• Pregnancy or lactation
• A diagnosis of narcotic or alcohol dependence in the past 5 years
• A diagnosis of dementia (e.g. Alzheimer's) in the past 5 years
• A diagnosis of a significant psychiatric disability (e.g. Schizophrenia, refractory bipolar disorder, current severe depression) in the past 5 years

Exclusions due to derangement of calcium metabolism or indications /contraindications to study agents:

• Any diagnosis of kidney stones
• A diagnosis of granulomatous diseases, e.g. sarcoidosis, active chronic fungal or mycobacterial infections (tuberculosis, histoplasmosis, coccidioidomycosis, blastomycosis), berylliosis, Wegener's granulomatosis in the past 5 years
• A diagnosis of hyperparathyroidism or other serious disturbance of calcium metabolism in the past 5 years
• A diagnosis of severe kidney disease, e.g. chronic renal failure in the past 5 years
• A diagnosis of unexplained hypercalcemia in the past 5 years
• Any Diagnosis of osteoporosis with physician recommendation for treatment of low bone mass
• A diagnosis of two or more low trauma fractures in the past 5 years
• A diagnosis of a medical condition requiring treatment with vitamin D (e.g. osteomalacia) in the past 5 years

Exclusions due to intestinal or bowel problems:

• Any diagnosis of invasive carcinoma of the large bowel (even if confined to a polyp)
• Any diagnosis of familial colorectal cancer syndromes, e.g. Familial Adenomatous Polyposis (FAP) (including Gardner syndrome, Turcot's syndrome), Hereditary Nonpolyposis Colorectal Cancer (HNPCC), Hamartomatous Polyposis syndromes (including Peutz-Jeghers or Familial Juvenile Polyposis)
• Any diagnosis of inflammatory bowel disease, e.g. Crohn's Disease, Ulcerative Colitis
• A diagnosis of chronic intestinal malabsorption syndromes, e.g. celiac sprue, bacterial overgrowth, chronic pancreatitis, pancreatic insufficiency in the past 5 years
• Any large bowel resection

Exclusions due to poor health:

• A diagnosis of malignancy, other than non-melanoma skin cancer in the past 5 years
• A diagnosis of severe lung disease - class 3 or 4 (e.g. chronic obstructive pulmonary disease or emphysema requiring oxygen) in the past 5 years
• A diagnosis of severe heart disease: cardiovascular disease functional class 3 or 4 in the past 5 years
• Any diagnosis of severe liver disease, e.g. cirrhosis

Exclusions due to shipping regulations:

• Any current/past HIV positive diagnosis
• Active hepatitis B, defined as : Hep B surface antigen positive
• Active hepatitis C, defined as : measurable hepatitis C RNA

Drug exclusions:

• Use of chronic oral corticosteroid therapy in the past 5 years
• Use of lithium in the past 5 years
• Use of phenytoin's in the past 5 years
• Use of quinidine in the past 5 years
• Use of therapeutic vitamin D in the past 5 years

Study Plan

How is the study designed?

Design Details

• Primary Purpose: PREVENTION
• Allocation: RANDOMIZED
• Interventional Model: FACTORIAL
• Masking: QUADRUPLE

Number of Arms

6

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
EXPERIMENTAL: Full Factorial Placebo; subjects in 2X2 factorial design; randomized to daily placebo	Drug: placebo; placebo; two tablets per day
EXPERIMENTAL: Full Factorial Calcium; subjects in 2X2 factorial design; randomized to daily 1200 mg as calcium carbonate	Drug: Calcium Carbonate; 3 gm/daily; 1200 mg elemental calcium/daily; two tablets per day; 600 mg elemental calcium/tablet
EXPERIMENTAL: Full Factorial Vitamin D; Subjects in 2X2 factorial design; randomized to daily 1000 IU vitamin D3	Drug: Vitamin D3; 1000 IU/daily; two tablets per day; 500 IU per tablet
EXPERIMENTAL: Full Factorial Calcium Plus Vitamin D; Subjects in 2X2 factorial design; randomized to daily 1200 mg as calcium carbonate and 1000 IU vitamin D3	Drug: Calcium Carbonate; 3 gm/daily; 1200 mg elemental calcium/daily; two tablets per day; 600 mg elemental calcium/tablet; Drug: Vitamin D3; 1000 IU/daily; two tablets per day; 500 IU per tablet
EXPERIMENTAL: Two Arm Placebo; Women choosing to take daily 1200 mg as calcium carbonate randomized to daily placebo	Drug: Calcium Carbonate; 3 gm/daily; 1200 mg elemental calcium/daily; two tablets per day; 600 mg elemental calcium/tablet
EXPERIMENTAL: Two Arm Vitamin D; Women choosing to take daily 1200 mg as calcium carbonate randomized to daily 1000 IU vitamin D3	Drug: Calcium Carbonate; 3 gm/daily; 1200 mg elemental calcium/daily; two tablets per day; 600 mg elemental calcium/tablet; Drug: Vitamin D3; 1000 IU/daily; two tablets per day; 500 IU per tablet

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Time Frame
Colorectal Adenomas	1 to 10 years

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Advanced Colorectal Lesions	Includes: adenomas >=1 cm, adenomas with high grade dysplasia, adenomas with villous features, or cancer.	1 to 10 years

Collaborators and Investigators

• Sponsor: Dartmouth-Hitchcock Medical Center
• Collaborators: National Cancer Institute (NCI)
• Investigators: Principal Investigator: John A. Baron, MD, Dartmouth-Hitchcock Medical Center

Publications and helpful links

General Publications

• Passarelli MN, Mott LA, Barry EL, Rees JR, Baron JA. Oral Antibiotics and Risk of New Colorectal Adenomas During Surveillance Follow-up. Cancer Epidemiol Biomarkers Prev. 2021 Oct;30(10):1974-1976. doi: 10.1158/1055-9965.EPI-21-0323. Epub 2021 Jul 21.
• Passarelli MN, Karagas MR, Mott LA, Rees JR, Barry EL, Baron JA. Risk of keratinocyte carcinomas with vitamin D and calcium supplementation: a secondary analysis of a randomized clinical trial. Am J Clin Nutr. 2020 Dec 10;112(6):1532-1539. doi: 10.1093/ajcn/nqaa267.
• Crockett SD, Barry EL, Mott LA, Ahnen DJ, Robertson DJ, Anderson JC, Wallace K, Burke CA, Bresalier RS, Figueiredo JC, Snover DC, Baron JA. Calcium and vitamin D supplementation and increased risk of serrated polyps: results from a randomised clinical trial. Gut. 2019 Mar;68(3):475-486. doi: 10.1136/gutjnl-2017-315242. Epub 2018 Mar 1.
• Anderson JC, Morris CB, Robertson DJ, Barry ELR, Figueiredo JC, Cruz-Correa M, Bostick RM, Ahnen DJ, Baron JA. Can the Sum of Adenoma Diameters (Adenoma Bulk) on Index Examination Predict Risk of Metachronous Advanced Neoplasia? J Clin Gastroenterol. 2018 Aug;52(7):628-634. doi: 10.1097/MCG.0000000000000899.
• Barry EL, Peacock JL, Rees JR, Bostick RM, Robertson DJ, Bresalier RS, Baron JA. Vitamin D Receptor Genotype, Vitamin D3 Supplementation, and Risk of Colorectal Adenomas: A Randomized Clinical Trial. JAMA Oncol. 2017 May 1;3(5):628-635. doi: 10.1001/jamaoncol.2016.5917.
• Rees JR, Mott LA, Barry EL, Baron JA, Bostick RM, Figueiredo JC, Bresalier RS, Robertson DJ, Peacock JL. Lifestyle and Other Factors Explain One-Half of the Variability in the Serum 25-Hydroxyvitamin D Response to Cholecalciferol Supplementation in Healthy Adults. J Nutr. 2016 Nov;146(11):2312-2324. doi: 10.3945/jn.116.236323. Epub 2016 Sep 28.
• Rees JR, Mott LA, Barry EL, Baron JA, Figueiredo JC, Robertson DJ, Bresalier RS, Peacock JL. Randomized controlled trials: who fails run-in? Trials. 2016 Jul 29;17:374. doi: 10.1186/s13063-016-1451-9.
• Baron JA, Barry EL, Mott LA, Rees JR, Sandler RS, Snover DC, Bostick RM, Ivanova A, Cole BF, Ahnen DJ, Beck GJ, Bresalier RS, Burke CA, Church TR, Cruz-Correa M, Figueiredo JC, Goodman M, Kim AS, Robertson DJ, Rothstein R, Shaukat A, Seabrook ME, Summers RW. A Trial of Calcium and Vitamin D for the Prevention of Colorectal Adenomas. N Engl J Med. 2015 Oct 15;373(16):1519-30. doi: 10.1056/NEJMoa1500409.
• Barry EL, Mott LA, Melamed ML, Rees JR, Ivanova A, Sandler RS, Ahnen DJ, Bresalier RS, Summers RW, Bostick RM, Baron JA. Calcium supplementation increases blood creatinine concentration in a randomized controlled trial. PLoS One. 2014 Oct 15;9(10):e108094. doi: 10.1371/journal.pone.0108094. eCollection 2014.
• Barry EL, Rees JR, Peacock JL, Mott LA, Amos CI, Bostick RM, Figueiredo JC, Ahnen DJ, Bresalier RS, Burke CA, Baron JA. Genetic variants in CYP2R1, CYP24A1, and VDR modify the efficacy of vitamin D3 supplementation for increasing serum 25-hydroxyvitamin D levels in a randomized controlled trial. J Clin Endocrinol Metab. 2014 Oct;99(10):E2133-7. doi: 10.1210/jc.2014-1389. Epub 2014 Jul 29.
• Rees JR, Hendricks K, Barry EL, Peacock JL, Mott LA, Sandler RS, Bresalier RS, Goodman M, Bostick RM, Baron JA. Vitamin D3 supplementation and upper respiratory tract infections in a randomized, controlled trial. Clin Infect Dis. 2013 Nov;57(10):1384-92. doi: 10.1093/cid/cit549. Epub 2013 Sep 6.
• Bischoff-Ferrari HA, Rees JR, Grau MV, Barry E, Gui J, Baron JA. Effect of calcium supplementation on fracture risk: a double-blind randomized controlled trial. Am J Clin Nutr. 2008 Jun;87(6):1945-51. doi: 10.1093/ajcn/87.6.1945.

Study record dates

Study Major Dates

• Study Start (ACTUAL): July 1, 2004
• Primary Completion (ACTUAL): October 1, 2013
• Study Completion (ACTUAL): June 1, 2016

Study Registration Dates

• First Submitted: September 7, 2005
• First Submitted That Met QC Criteria: September 7, 2005
• First Posted (ESTIMATE): September 12, 2005

Study Record Updates

• Last Update Posted (ACTUAL): March 15, 2017
• Last Update Submitted That Met QC Criteria: February 6, 2017
• Last Verified: February 1, 2017

More Information

Terms related to this study

• Keywords: Colorectal neoplasms; Adenomatous polyps
• Additional Relevant MeSH Terms: Neoplasms by Histologic Type; Neoplasms; Neoplasms, Glandular and Epithelial; Pathological Conditions, Anatomical; Adenoma; Polyps; Physiological Effects of Drugs; Molecular Mechanisms of Pharmacological Action; Gastrointestinal Agents; Micronutrients; Vitamins; Bone Density Conservation Agents; Calcium-Regulating Hormones and Agents; Antacids; Vitamin D; Cholecalciferol; Calcium; Calcium Carbonate
• Other Study ID Numbers: 5R01CA098286-03 (NIH); 5R01CA098286-10 (NIH)