Recombinant human erythropoietins and cancer patients: updated meta-analysis of 57 studies including 9353 patients

Transfusion risk in cancer patients with chemotherapy-induced anemia when initiating darbepoetin alfa therapy at a baseline hemoglobin level of <9 g/dL versus 9 to <10 g/dL versus ≥ 10 g/dL: an exploratory analysis of a phase 3 trial

Darbepoetin alfa (DA) is an erythropoiesis-stimulating agent (ESA) approved for treating chemotherapy-induced anemia (CIA). Safety concerns have prompted changes to the ESA-product information, which now recommends initiating ESAs at hemoglobin (Hb) levels < 10 g/dL (US) or ≤ 10 g/dL (EU). The present exploratory analysis of a DA trial examined how baseline-Hb levels at ESA initiation affect transfusion rates, Hb response, and safety outcomes in CIA patients. Data were retrospectively analyzed from a phase 3 trial of CIA patients randomised to 500 mcg DA every 3 weeks (Q3 W) or to 2.25 mcg/kg DA weekly (QW) for 15 weeks. In the current analysis, data were reanalyzed by baseline-Hb categories of <9 g/dL (n = 126), 9 to <10 g/dL (n = 225), and ≥ 10 g/dL (n = 354). The Q3 W and QW groups were combined. Transfusion rates were highest in the <9 g/dL baseline-Hb group in all time periods examined. The Kaplan-Meier percentage (95% CI) of patients achieving Hb ≥ 10 g/dL was 68% (59, 78) and 88% (82, 92) in the <9 g/dL and 9 to <10 g/dL baseline-Hb groups, respectively. With lower baseline-Hb, incidence of a ≥ 1 g/dL-Hb rise in 14 days progressively decreased. Incidence of venous thromboembolic events was similar in all baseline-Hb groups and similar between patients with or without a ≥ 1 g/dL-Hb rise in 14 days. Overall, transfusion risk increased and Hb response decreased at lower baseline-Hb levels in this exploratory analysis. When following ESA-product information to initiate ESAs at Hb ≤ 10 g/dL, the greatest benefit may be achieved when initiating close to 10 g/dL. Prospective studies are needed to further examine this hypothesis.

Randomised, phase III trial of epoetin-β to treat chemotherapy-induced anaemia according to the EU regulation

BACKGROUND

Erythropoietin-stimulating agents (ESAs) effectively decrease the transfusion requirements of patients with chemotherapy-induced anaemia (CIA). Recent studies indicate that ESAs increase mortality and accelerate tumour progression. The studies also identify a 1.6-fold increased risk of venous thromboembolism. The ESA labelling was thus revised in Europe and the United States in 2008. This is the first randomised, phase III trial evaluating the efficacy and safety of epoetin-β (EPO), an ESA, dosed in accordance with the revised labelling, which specifies that ESAs should be administered to CIA patients with a haemoglobin level of ≤ 10 g dl⁻¹ and that a sustained haemoglobin level of > 12 g dl⁻¹ should be avoided.

METHODS

A total of 186 CIA patients (8.0 g dl⁻¹ ≤ haemoglobin ≤ 10.0 g dl⁻¹) with lung or gynaecological cancer were randomised to receive EPO 36,000 IU or placebo weekly for 12 weeks.

RESULTS

The proportion of patients receiving transfusions or with haemoglobin < 8.0 g dl⁻¹ between week 5 and the end of the treatment period as the primary end point was significantly lower in the EPO group (n=89) than in the placebo group (n=92; 10.0% vs 56.4%, P < 0.001). The proportion receiving transfusions was significantly lower in the EPO group (4.5% vs 19.6%, P=0.002). Changes in quality of life were not different. No significant differences in adverse events - for example, the incidence of thromboembolic events was 1.1% for each group - or the 1-year overall survival were observed between groups.

CONCLUSION

Weekly EPO administered according to the revised labelling approved by the European Medicines Agency is effective and well tolerated for CIA treatment. Further investigations are needed on the effect of ESAs on mortality.

Anti-vascular endothelial growth factor antibody bevacizumab reduced the risk of anemia associated with chemotherapy-A meta-analysis

INTRODUCTION

Vascular endothelial growth factor (VEGF) may play a role in erythropoiesis. We performed a meta-analysis of randomized controlled trials (RCT) to determine the effect of the anti-VEGF antibody bevacizumab on anemia in cancer patients treated with chemotherapy.

METHODS

Databases from PUBMED, the Web of Science, Embase, the Cochrane Library, and abstracts presented at the American Society of Clinical Oncology (ASCO) conferences until May 2010 were searched to identify relevant studies. Eligible studies included prospective RCTs in which the combination of bevacizumab and chemotherapy was compared with chemotherapy alone. Summary incidence rate, relative risk (RR), and 95% confidence interval (CI) were calculated.

RESULTS

A total of 6439 patients with a variety of solid tumors were included for analysis from 11 RCTs. Among those patients receiving bevacizumab and chemotherapy, the incidences of all-grade and high-grade (grade 3 and above) anemia were 17.8% (95% CI: 11.1-27.1%) and 2.8% (95% CI: 1.6-5.0%) respectively. In comparison with chemotherapy alone, bevacizumab significantly reduced all-grade (RR, 0.79; 95% CI: 0.66-1.0, p = 0.007) and high-grade anemia (RR, 0.72; 95% CI: 0.57-0.90, p = 0.005). The effect did not vary significantly among bevacizumab doses (p = 0.88), tumor types (p = 0.75) or chemotherapy regimens (p = 0.98).

DISCUSSION

Bevacizumab may significantly reduce the risk of anemia with chemotherapy in cancer patients.

Recombinant human erythropoietin β: the effect of weekly dosing on anemia, quality of life, and long-term outcomes in pediatric cancer patients

Anemia, which is a common problem in cancer patients, has a negative effect on survival by decreasing the efficacy of chemotherapy and particularly of radiotherapy, as well as impairing the quality of life (QoL) of patients. Recombinant human erythropoietin (rHuEPO) decreases a patient's need for transfusions and increases their QoL. The aim of this study was to evaluate the effect of weekly single-dose EPO treatment on transfusion rates, QoL, and hemoglobin (Hb) levels. In addition, patients were followed up for a long period to assess the impact of EPO treatment on survival. The study was conducted from December 2001 to December 2002 in patients with newly diagnosed lymphoma or solid tumors using a prospective and controlled design. EPO-β was given as a single dose of 450 U/kg once a week for 12 weeks. The study and control groups included 16 patients each. Hb levels measured in the study group at the 4th, 8th, and 12th weeks were significantly higher than the values recorded before the start of chemotherapy. In the control group, Hb levels post chemotherapy were significantly lower than values recorded prior to treatment. The increased Hb levels in the study group were significant at the 8th and 12th weeks of treatment compared to levels measured prior to treatment. In the control group, Hb levels at the 4th and 8th weeks were significantly lower than pretreatment levels. When the percent increase of Hb levels of the study and control groups with respect to treatment week was compared, the difference was statistically significant at the 4th, 8th, and 12th weeks. Although the increase on the performance scale within each group during treatment was significant in both the study and control groups, the increase was more marked in the study group. The percent increase on the performance scale with respect to week of treatment was higher in the study group than in the control group. In EPO treatment group, side effects were seen in 38% of patients, with 19% being local pain in the injection area, 13% local hyperemia, and 6% headache. The mean follow-up period of the study and control group was 7.03 ± 0.41 (6.0-7.41) and 7.46 ± 0.45 (6.58-7.83) years, respectively; no statistically significant difference existed between these figures. Overall survival at the end of 7 years of follow-up was 68.8% and 81.3% for the study and control groups, respectively. The use of EPO-β in lymphoma and solid tumor patients on a once-weekly regimen (450 U/kg) was determined to be effective in increasing Hb levels, decreasing transfusion rates, and improving QoL. This regimen was safe, did not cause serious side effects, and can be recommended because of its high patient compliance and tolerability. An effect of EPO on prognosis was not evident. We could not have an explanation on the effect of EPO treatment on prognosis, as there were low number of patients and advanced-staged patients died earlier. Therefore, a larger number of patients are needed to clarify the effect of EPO treatment on prognosis.

Improving erythropoietin-stimulating agent administration in a multihospital system through quality improvement initiatives: a pre-post comparison study

INTRODUCTION

: Erythropoietin-stimulating agent (ESA) use is associated with serious adverse events in patients with hemoglobin levels of 12 g/dL or higher at the time of administration. Our aim was to determine whether inappropriate ESA use has changed over time since the implementation of new drug warning alerts and local quality improvement initiatives.

MATERIALS AND METHODS

: We performed a retrospective review of ESA administration practices at Memorial Hermann Healthcare System (Houston, Tex). Our primary outcome measure was the proportion of inpatient encounters (one entire inpatient hospital stay) with 1 or more inappropriate uses of ESA (defined as ESA administration for a patient with hemoglobin ≥12 g/dL). We analyzed the potential influence of local and national interventions on ESA utilization patterns.

RESULTS

: Between May 1, 2006, and May 31, 2009, 15,642 inpatients were treated with ESAs in our system. We classified inpatients as before intervention (n = 6350) and after intervention (n = 9292) based on the date of implementation of a synchronous alert in the electronic medical record. We found a significant decrease in inappropriate ESA administration before to after intervention (9.03%-6.21%; P < 0.001), which can be translated into a 31.25% (05% CI, 21.93%-40.75%) relative risk reduction. Reduced odds ratios for inappropriate ESA use changed little after controlling for relevant demographic variables and clinical characteristics.

CONCLUSIONS

: Following several quality improvement interventions to improve patient safety related to ESA use, we found a significant reduction in inappropriate ESA administration to inpatients in a large health care system.

Effect of treatment with epoetin Beta on thromboembolic events in anemic patients with cancer: a metaanalysis

PURPOSE

Epoetin therapy is associated with a slight increase in thromboembolic event (TEE) incidence, although causality is uncertain. This metaanalysis compared TEE incidence in patients with cancer-related anemia treated with epoetin beta versus a control group (placebo or standard treatment) and investigated the impact of hemoglobin (Hb) parameters on thromboembolic risk.

PATIENTS AND METHODS

Patients from 9 randomized trials were pooled (epoetin beta group, n = 800; control group, n = 613). Adverse event reports were reviewed for all TEEs recorded during treatment and 28 days thereafter. Thromboembolic event incidence was compared between 2 groups, and standard statistical analyses were conducted to investigate the potential of Hb parameters to modulate thromboembolic risk.

RESULTS

For epoetin beta, 5.9% of patients (n = 47) experienced >/= 1 TEE versus 4.2% of controls (n = 26; not significant).Thromboembolic-related mortality rates were 1% in both groups. Thromboembolic event rates in patients stratified by tumor type were consistent with the overall population. For epoetin beta, greater baseline-adjusted Hb area under the concentration-time curve and greater Hb increases during the first 4 weeks of treatment significantly correlated with reduced risk of TEEs. Conversely, treatment in those with higher baseline Hb levels was associated with increased TEE risk.

CONCLUSION

When administered in accordance with European Organization for Research and Treatment of Cancer guidelines, epoetin beta did not appear to be associated with increased thromboembolic risk. Although risk of TEEs might be marginally increased in patients with cancer treated with epoetin beta, there is no increased risk of thromboembolic mortality.

Erythropoiesis-stimulating agents: benefits and risks in supportive care of cancer

Anemia, already common in cancer patients, is often exacerbated by chemotherapy. Cancer patients who are anemic have been shown to have a blunted response for production of endogenous erythropoietin growth factor. This anemia can be corrected with exogenous erythropoietin growth factors, of which three available are worldwide: epoetin alfa, epoetin beta, and darbepoetin alfa. Collectively, these drugs are known as erythropoiesis-stimulating agents (ESAS). Orders for ESAS have been used not only to reverse anemia so as to avoid blood transfusion, but also to improve quality of life. Guidelines have been developed for initiation, dosage titration, and termination of these agents. Since the late 1990s, trials have been conducted using ESAS in unapproved dosing regimens or to reach hemoglobin levels outside of approved guidelines, raising several safety concerns. The present article explores the risks and benefits of ESAS.

Treatment of anemia with darbepoetin alfa in heart failure

Anemia is common in heart failure (HF) patients. A prespecified pooled analysis of 2 randomized, double-blind, placebo-controlled studies evaluated darbepoetin alfa (DA) in 475 anemic patients with HF (hemoglobin [Hb], 9.0-12.5 g/dL). DA was administered subcutaneously every 2 weeks and titrated to achieve and maintain a target Hb level of 14.0+/-1.0 g/dL. By week 27, mean (SD) Hb concentrations did not increase with placebo but increased with DA from 11.5 (0.7) to 13.3 (1.3) g/dL. Hazard ratios (HRs) for DA compared with placebo for all-cause death or first HF hospitalization (composite end point), all-cause death, and HF hospitalization by month 12 were 0.67 (95% confidence interval [CI], 0.44-1.03; P=.067), 0.76 (95% CI, 0.39-1.48; P=.419), and 0.66 (95% CI, 0.40-1.07; P=.093), respectively. Incidence of adverse events was similar in both groups. In post hoc analyses, improvement in the composite end point was significantly associated with the mean Hb change from baseline (adjusted HR, 0.40; P=.017) with DA treatment. There was no increased risk of all-cause mortality or first HF hospitalization with DA in patients with reduced renal function or elevated baseline B-type natriuretic peptide, a biomarker of worse HF. These results suggest that DA is well tolerated, corrects HF-associated anemia, and may have favorable effects on clinical outcomes.

Thromboembolic and bleeding complications in acute leukemia

The risk of both thromboembolic and bleeding complications is high in acute leukemia. This double hazard has a significant negative impact on the morbidity and mortality of patients with this disease. The clinical manifestations of both complications show special features specific to the form of acute leukemia. Recognition of these characteristics is important in the diagnosis and management of acute leukemia. In this article, several additional issues are addressed, including the features of bleeding and thrombosis in acute promyelocytic leukemia, the current understanding of the leukostasis syndrome and the iatrogenic complications including catheter-associated thrombosis, and the adverse effects of therapeutic agents used in acute leukemia. As regards the bleeding complications, thrombocytopenia is a major cause. Corrective measures, including recent guidelines on platelet transfusions, are provided.

Erythropoietin as a treatment of anemia in heart failure: systematic review of randomized trials

BACKGROUND

Anemia in heart failure is both common and associated with worse symptoms and increased mortality. Several small randomized controlled trials (RCTs) have assessed erythropoiesis-stimulating agents (ESAs), but definitive evaluation and clinical guidance are required. We sought to systematically review the effects of ESAs in chronic heart failure.

METHODS

An extensive search strategy identified 11 RCTs with 794 participants comparing any ESA with control over 2 to 12 months of follow-up. Published and additionally requested data were incorporated into a Cochrane systematic review (CD007613).

RESULTS

Nine studies were placebo controlled, and 5, double blinded. Erythropoiesis-stimulating agent treatment significantly improved exercise duration by 96.8 seconds (95% CI 5.2-188.4, P = .04) and 6-minute walk distance by 69.3 m (95% CI 17.0-121.7, P = .009) compared with control. Benefit was also noted for peak oxygen consumption (+2.29 mL/kg per minute, P = .007), New York Heart Association class (-0.73, P < .001), ejection fraction (+5.8%, P < .001), B-type natriuretic peptide (-226.99 pg/mL, P < .001), and quality-of-life indicators with a mean increase in hemoglobin level of 2 g/dL. There was a significantly lower rate of heart failure-related hospitalizations with ESA therapy (odds ratio 0.56, 95% CI 0.37-0.84, P = .005). No associated increase in adverse events or mortality (odds ratio 0.58, 95% CI 0.34-0.99, P = .047) was observed, although the number of events was limited.

CONCLUSION

Meta-analysis of small RCTs suggests that ESA treatment can improve exercise tolerance, reduce symptoms, and have benefits on clinical outcomes in anemic patients with heart failure. Confirmation requires larger, well-designed studies with careful attention to dose, attained hemoglobin level, and long-term outcomes.

Supportive therapy in multiple myeloma

In this chapter we want to give an overview on various supportive measures, which help to prevent or to fight complications of multiple myeloma, improve patient wellbeing and increase safety of administration of specific anti-myeloma therapy.

Management of anemia in cancer patients

Cancer-related anemia adversely affects quality of life and is associated with reduced overall survival. The correction of anemia in cancer patients has the potential to improve treatment efficacy and increase survival. A large number of studies demonstrate that treatment of anemia in cancer patients using erythropoiesis-stimulating agents (ESAs) significantly increases hemoglobin levels, decreases transfusion requirements and improves quality of life, predominantly by reducing fatigue. Some data on the use of ESAs in cancer patients indicate an increased risk of thromboembolic events and a possibly increased risk of mortality. However, there is ample evidence that when ESAs are used within current guidelines, they are valuable and safe drugs for the treatment of anemia in patients receiving radiotherapy and/or chemotherapy. There are increasing data from prospective, randomized trials demonstrating better responses to ESAs with the concurrent use of iron. Blood transfusions are also helpful in the management of anemia in cancer patients, especially when there is a need for immediate increases in hemoglobin levels. In this article, we discuss recent aspects relating to treatment modalities for anemia in cancer patients.

Characterization of haematological parameters with bortezomib-melphalan-prednisone versus melphalan-prednisone in newly diagnosed myeloma, with evaluation of long-term outcomes and risk of thromboembolic events with use of erythropoiesis-stimulating agents: analysis of the VISTA trial

Although haematological toxicities, such as anaemia, are common in multiple myeloma (MM), no clear consensus exists on the use and impact of erythropoiesis-stimulating agents (ESA) on outcomes in MM. This analysis characterizes haematological toxicities and associated interventions in the phase III VISTA (Velcade(®) as Initial Standard Therapy in Multiple Myeloma: Assessment with Melphalan and Prednisone) study of bortezomib plus melphalan/prednisone (VMP, n = 344) versus MP (n = 338) in previously untreated MM patients ineligible for high-dose therapy, and evaluates the impact of ESA use or red-blood-cell (RBC) transfusions on outcomes and thromboembolic risk. Incidence of haematological toxicities was similar with VMP and MP; similar rates of interventions and associated complications (e.g. bleeding, febrile neutropenia) were observed. Two hundred thirty three patients received ESA; 204 had RBC transfusions. Frequency of thromboembolic events was low and not affected by ESA use. Median time-to progression (TTP) was similar between ESA/non-ESA [hazard ratio: 1·03 (95% confidence interval 0·76-1·39); P = 0·8478] in both arms (VMP: 19·9/not reached; MP: 15·0/17·5 months). Three-year overall survival (OS) rates were similar between ESA/non-ESA in each arm. Patients receiving RBC transfusions had significantly shorter OS (P < 0·0001) versus non-RBC-transfusion patients. In conclusion, bortezomib did not add to melphalan haematological toxicity. Concomitant ESA use with VMP/MP in previously untreated MM patients did not adversely affect TTP or OS, or increase thromboembolic risk. However, RBC transfusion was associated with significantly shorter survival.

Thrombopoietin protects the brain and improves sensorimotor functions: reduction of stroke-induced MMP-9 upregulation and blood-brain barrier injury

This study was conducted to determine the protective efficacy and mechanisms of thrombopoietin (TPO) intervention in experimental focal stroke. Male rats underwent 2 hours of left middle cerebral artery occlusion (MCAO) followed by 22 hours of reperfusion. Vehicle or TPO (0.03 to 1.00 μg/kg) was administered intravenously immediately after reperfusion. Brain infarct and swelling, neurologic deficits, matrix metalloproteinase-9 (MMP-9), tissue inhibitor of metalloproteinase-1 (TIMP-1), TPO and c-Mpl (TPO receptor) mRNA, MMP-9 enzyme activity and protein expression, and the integrity of the blood-brain barrier (BBB) were subsequently measured. MCAO reperfusion produced a large infarct and swelling after stroke. Thrombopoietin significantly reduced these in a dose-dependent manner. The most effective TPO dose, 0.1 μg/kg, when administrated immediately or 2 hours after reperfusion, significantly reduced infarct and swelling and ameliorated neurologic deficits after stroke. Stroke-induced increases in cortical MMP-9 mRNA, enzyme activity and protein expression, TIMP-1 mRNA, and Evans blue extravasation were reduced by TPO intervention. Thrombopoietin did not alter cortical TPO or c-Mpl mRNA expression, blood pressure, heart rate, blood hematocrit, or platelets. This is the first demonstration of TPO's efficacy in reducing ischemic brain injury and improving functional outcome, partly by inhibiting the stroke-induced increase in MMP-9 and the early, negative effects on the BBB.

Effect of erythropoietin levels on mortality in old age: the Leiden 85-plus Study

BACKGROUND

The production of erythropoietin is triggered by impaired oxygen delivery to the kidney, either because of anemia or hypoxemia. High erythropoietin levels have been shown to predict the risk of death among patients with chronic heart failure. We investigated the prognostic value of elevated erythropoietin levels on mortality among very elderly people in the general population.

METHODS

The Leiden 85-plus Study is a population-based prospective follow-up study involving 599 people aged 85 years in Leiden, the Netherlands, enrolled between September 1997 and September 1999. Erythropoietin levels were determined at age 86. For this analysis, we included 428 participants with a creatinine clearance of at least 30 mL/min. Mortality data, recorded until Feb. 1, 2008, were obtained from the municipal registry.

RESULTS

During follow-up, 324 (75.7%) participants died. Compared with participants whose erythropoietin levels were in the lowest tertile (reference group), those whose levels were in the middle tertile had a 25% increased risk of death (hazard ratio [HR] 1.25, 95% confidence interval [CI] 0.95-1.64), and those whose levels were in the highest tertile had a 73% increased risk (HR 1.73, 95% CI 1.32-2.26) (p value for trend < 0.01). The association between erythropoietin levels and mortality remained largely unchanged after we adjusted for sex, creatinine clearance, hemoglobin level, comorbidity, smoking status and C-reactive protein level, and was similar for deaths from cardiovascular and noncardiovascular causes.

INTERPRETATION

Among people aged 85 years and older, elevated erythropoietin levels were associated with an increased risk of death, independent of hemoglobin levels.

High expression levels of erythropoietin and its receptor are not correlated with shorter survival in human glioblastoma

Erythropoietin (EPO) is used to treat anemia in neoplastic disease. EPO also exerts neuroprotective effects on neuronal cells, making a prophylactic use against the neurocognitive effects of radiochemotherapy probable. However, EPO/EPO-receptor (EPOR) signalling has been also detected in glioblastoma cells. Data collected in vitro and in vivo show conflicting results on the effect of EPO on malignant gliomas. The association between EPO and EPOR expression and the prognosis of human glioblastomas was analyzed. Probes of human glioblastomas with complete documentation of clinical course and treatment were assessed by immunohistochemistry for the expression of EPO and EPOR (n=80). Using univariate and multivariate survival analysis, the association with age, gender, radiation, chemotherapy and extent of resection was determined. High levels of EPOR were correlated with a median survival advantage of 7 months (p<0.01). By univariate, but not multivariate, analysis, high levels of EPO and EPOR were associated with a significant prolongation of 7 months median survival when compared to low levels of both molecules. In patients treated with radiochemotherapy adjuvant to surgery, the median survival was 6.5 months longer in patients with high levels of EPOR (p<0.04). According to previous studies, longer patient survival is associated with EPOR expression. Therefore, EPO appears to be safe for the treatment of anemia in glioblastoma patients. However, a prophylactic use, i.e., for neuroprotection, is not recommended in light of the functional studies described in the literature.

Do erythropoietic-stimulating agents relieve fatigue? A review of reviews

Interest in the efficacy and potential deleterious consequences of treatment with erythropoietic-stimulating agents (ESAs) is very high. Recently, the ESAs have come under intense scrutiny as several clinical trials have shown their use to be associated with an increased risk of thrombosis, and a concern for increased mortality risk in oncology. In this context, attention to the effect of ESAs upon fatigue and other aspects of quality of life has tended to be lost. To aid inclusion of this endpoint in the important consideration of risks and benefits of ESA therapy, we summarize the many reviews that have been conducted on this topic. The ten selected reviews were all conducted systematically or were otherwise comprehensive. While these reviews acknowledge an overall positive fatigue or quality-of-life effect, some were equivocal about the meaningfulness or magnitude of the benefit. The overall evidence from these reviews supports a fatigue and overall quality-of-life benefit from treatment with ESAs that is unlikely to be due to chance. This information should be included in the risk/benefit consideration of these controversial agents.

Ten years of meta-analyses on erythropoiesis-stimulating agents in cancer patients

BACKGROUND

Since erythropoiesis-stimulating agents (ESAs) were licensed in 1993, more than 70 randomized controlled trials and more than 20 meta-analyses and systematic reviews on their effectiveness were conducted. Here, we present a systematic review on the meta-analyses of trials evaluating ESAs in cancer patients.

METHODS

We included all published meta-analyses of at least five randomized controlled trials that evaluated the effects of ESAs versus control in patients with any type of cancer or myelodysplastic syndrome.

RESULTS

We included a total of 23 systematic reviews and meta-analyses (16 literature based and 7 based on individual patient data (IPD)) that assessed several outcomes. All 12 meta-analyses reporting on transfusion risks demonstrated that ESAs significantly reduce the risk of transfusions. Eleven meta-analyses (nine based on published data and two on IPD) evaluated thrombovascular events. An increased risk of thrombovascular events was observed in all but two meta-analyses (relative risks (RRs) ranging from 1.57 to 1.69). However, potential reporting and publication bias as well as detection bias call for a cautious interpretation of these results. Survival and mortality were evaluated in 18 meta-analyses, with the observed effect changing over time. While meta-analyses on studies conducted before 2002 showed beneficial effects of ESAs on survival, contrary results, i.e. worsened survival, was seen in meta-analyses including more recent studies.

DISCUSSION

The results from several meta-analyses show that ESAs in cancer patients reduce the risk for red blood cell transfusions and increase the risk for thrombovascular events and mortality. The effect of ESAs on mortality risk in patients receiving chemotherapy remains unclear. In clinical practice, the benefits and risks of ESAs should be carefully considered and decisions should be made based on each patient's situation and preferences.

Venous thromboembolism in the patient with cancer: focus on burden of disease and benefits of thromboprophylaxis

Venous thromboembolism (VTE) is a significant cause of morbidity and mortality in patients with cancer. The risk of VTE varies over the natural history of cancer, with the highest risk occurring during hospitalization and after disease recurrence. Patient and disease characteristics are associated with further increased risk of VTE in this setting. Specific factors include cancer type (eg, pancreatic cancer, brain cancer, lymphoma) and the presence of metastatic disease at the time of diagnosis. VTE is a significant predictor of increased mortality during the first year among all types and stages of cancer, with metastatic disease reported to be the strongest predictor of mortality. VTE is also associated with early death in ambulatory patients with cancer. These data highlight the need for close monitoring, prompt treatment, and appropriate preventive strategies for VTE in patients with cancer. The American Society of Clinical Oncology and the National Comprehensive Cancer Network have issued guidelines regarding the prophylaxis and treatment of patients with cancer. This review summarizes the impact of VTE on patients with cancer, the effects of VTE on clinical outcomes, the importance of thromboprophylaxis in this population, relevant ongoing clinical trials examining the prevention of VTE, and new pharmacologic treatment options.

A prospective, observational study describing the haematological response in patients undergoing chemotherapy treated by tri-weekly darbepoetin alfa for anaemia

OBJECTIVE

This prospective, observational study investigated the haematological response to darbepoetin alfa (DA) administered every three weeks for the treatment of anaemia. Response was also assessed according to baseline characteristics including iron, folate and vitamin B12 status.

RESEARCH DESIGN AND METHODS

Anaemic adult patients with malignant non-myeloid cancer, starting or having already undergone chemotherapy received DA on day of inclusionand were followed up for up to 24 weeks. Concentration of haemoglobin (Hb), as well as iron, vitamin B12 and folate status where available, were recorded at inclusion, after a treatment period of 9 weeks and up to a maximum of 24 weeks or cessation of DA treatment, whichever was sooner.

MAIN OUTCOME MEASURES

The main outcome measure assessed in this study was the percentage of patients reaching a Hb concentration of at least 11 g/dL at least once at any time during the study.

RESULTS

A total of 2912 patients were included. The mean Hb concentration increased from 10.0 g/dL at inclusion to 11.4 g/dL at 9 weeks and 11.8 g/dL at 24 weeks. In 74.6% of patients the target Hb level of 11.0 g/dL or above was reached. After initiation of DA treatment, 9.5% of patients required a blood transfusion by week 9, and 5.6% thereafter. Vitamin B12 and folate status were unknown for 80.3% of patients and the iron status for 73.2% of patients. Compared with patients who remained untreated for vitamin B12 or folate deficiency, a higher percentage of patients with vitamin status within normal limits achieved the target Hb concentration. However, achievement of target Hb level appeared not to be affected by iron status.

CONCLUSIONS

In this study, the mean Hb level increased in anaemic cancer patients treated with DA and the majority of patients achieved the target Hb level. In contrast to the recommendations of guidelines (EORTC) encouraging the measurement of iron and vitamin levels, the present study demonstrated that data were not routinely collected for these factors.

Age-related changes in peripheral blood counts in humans

Anaemia has become a common concern in geriatric health. Since its prevalence varies quite significantly among different groups depending on factors such as ethnicity, lifestyle or fitness, the appropriateness of the current WHO definition of anaemia in the elderly may be questioned. We evaluated peripheral blood parameters from 1,724 individuals (908 women aged 18-101 years and 816 men aged 18-96 years), who were treated at the University of Heidelberg Medical Center with no known haematological history. Patients with a known malignant haematological or oncological disease or with chronic infection or inflammation were excluded. Patients with disorders affecting the kidneys, thyroid or stomach, as well as patients with a bleeding history, haemolysis or who had been previously diagnosed with anaemia were excluded from the study. Average haemoglobin levels for men beyond the age of 70 and for women beyond the age of 80 were found to fulfill the WHO criteria for the diagnosis of anaemia. While in our cohort ∼20% of men and women between 60-69 years of age were by definition anaemic, these numbers steadily increased to 63% in females and 76% in males beyond the age of 90. Based on the results of our study and in accordance with the literature on this topic, we suggest age-adjusted criteria for the diagnosis of anaemia in the elderly in conjunction with a geriatric assessment.

American Society of Clinical Oncology/American Society of Hematology clinical practice guideline update on the use of epoetin and darbepoetin in adult patients with cancer

PURPOSE

To update American Society of Clinical Oncology/American Society of Hematology recommendations for use of erythropoiesis-stimulating agents (ESAs) in patients with cancer.

METHODS

An Update Committee reviewed data published between January 2007 and January 2010. MEDLINE and the Cochrane Library were searched.

RESULTS

The literature search yielded one new individual patient data analysis and four literature-based meta-analyses, two systematic reviews, and 13 publications reporting new results from randomized controlled trials not included in prior or new reviews.

RECOMMENDATIONS

For patients undergoing myelosuppressive chemotherapy who have a hemoglobin (Hb) level less than 10 g/dL, the Update Committee recommends that clinicians discuss potential harms (eg, thromboembolism, shorter survival) and benefits (eg, decreased transfusions) of ESAs and compare these with potential harms (eg, serious infections, immune-mediated adverse reactions) and benefits (eg, rapid Hb improvement) of RBC transfusions. Individual preferences for assumed risk should contribute to shared decisions on managing chemotherapy-induced anemia. The Committee cautions against ESA use under other circumstances. If used, ESAs should be administered at the lowest dose possible and should increase Hb to the lowest concentration possible to avoid transfusions. Available evidence does not identify Hb levels ≥ 10 g/dL either as thresholds for initiating treatment or as targets for ESA therapy. Starting doses and dose modifications after response or nonresponse should follow US Food and Drug Administration-approved labeling. ESAs should be discontinued after 6 to 8 weeks in nonresponders. ESAs should be avoided in patients with cancer not receiving concurrent chemotherapy, except for those with lower risk myelodysplastic syndromes. Caution should be exercised when using ESAs with chemotherapeutic agents in diseases associated with increased risk of thromboembolic complications. Table 1 lists detailed recommendations.

American Society of Hematology/American Society of Clinical Oncology clinical practice guideline update on the use of epoetin and darbepoetin in adult patients with cancer

PURPOSE

To update American Society of Hematology/American Society of Clinical Oncology recommendations for use of erythropoiesis-stimulating agents (ESAs) in patients with cancer.

METHODS

An Update Committee reviewed data published between January 2007 and January 2010. MEDLINE and the Cochrane Library were searched.

RESULTS

The literature search yielded one new individual patient data analysis and four literature-based meta-analyses, two systematic reviews, and 13 publications reporting new results from randomized controlled trials not included in prior or new reviews.

RECOMMENDATIONS

For patients undergoing myelosuppressive chemotherapy who have a hemoglobin (Hb) level less than 10 g/dL, the Update Committee recommends that clinicians discuss potential harms (eg, thromboembolism, shorter survival) and benefits (eg, decreased transfusions) of ESAs and compare these with potential harms (eg, serious infections, immune-mediated adverse reactions) and benefits (eg, rapid Hb improvement) of RBC transfusions. Individual preferences for assumed risk should contribute to shared decisions on managing chemotherapy-induced anemia. The Committee cautions against ESA use under other circumstances. If used, ESAs should be administered at the lowest dose possible and should increase Hb to the lowest concentration possible to avoid transfusions. Available evidence does not identify Hb levels ≥ 10 g/dL either as thresholds for initiating treatment or as targets for ESA therapy. Starting doses and dose modifications after response or nonresponse should follow US Food and Drug Administration-approved labeling. ESAs should be discontinued after 6 to 8 weeks in nonresponders. ESAs should be avoided in patients with cancer not receiving concurrent chemotherapy, except for those with lower risk myelodysplastic syndromes. Caution should be exercised when using ESAs with chemotherapeutic agents in diseases associated with increased risk of thromboembolic complications. Table 1 lists detailed recommendations.

[Treatment with beta-erythropoietin in lung cancer--effectiveness and quality of life improvement in clinical practice]

Anemia is common among patients with malignant tumors, due to the disease and chemotherapy. Anemia decreases patient's quality of life, and worsens the dose-intensity of chemotherapy. The aim of this retrospective data-analysis was to evaluate quality of life and hemoglobin levels in 19 consecutive lung cancer patients receiving beta-erythropoietin, due to chemotherapy induced anemia. A self developed, patient source data based quality of life questionnaire was used. The mean pre-erythropoietin hemoglobin concentration of the patients was 96.31±6.72 g/L (mean±SD), the post-treatment hemoglobin concentration 111.63±14.05 g/L (p<0.05). During the chemotherapy of the 19 patients with lung cancer, transfusion was given only four times. The mean quality of life total score of the patients increased significantly during erythropoietin treatment that was resulted by the improvements of scores determining dizziness, tachycardia, and fatigue. Main limitations of this real life data analysis are low patient number and the lack of validation in the used questionnaire. In summary, according to our experiences, the use of beta-erythropoietin in patients with lung cancer results improved quality of life and a low rate of transfusions.

Venous thromboembolism and cancer: a systematic review

Venous thromboembolism (VTE) is a serious and potentially fatal disorder, which is often associated with a significant impact on the quality of life and on the clinical outcome of cancer patients. The pathophysiology of the association between thrombosis and cancer is complex: malignancy is associated with a baseline hypercoagulable state due to many factors including release of inflammatory cytokines, activation of the clotting system, expression of hemostatic proteins on tumor cells, inhibition of natural anticoagulants, and impaired fibrinolysis. Several risk factors, related to the patient, the disease, and the therapeutic interventions, have been identified as contributing to the occurrence of VTE. There is convincing evidence to recommend the use of heparins or fondaparinux for prevention of VTE in selected cancer patients, and, especially in some particular types of malignancies and cancer treatments. Management of VTE in patients with cancer is more challenging and bleeding complications associated with the use of anticoagulants are significantly higher in cancer patients than in those without malignancy. Important issues that need to be considered in all cases are interference with anticancer therapy, inconvenience of treatment, and impact on quality of life.

Biosimilar epoetins and other "follow-on" biologics: update on the European experiences

After the patents of biopharmaceuticals have expired, based on specific regulatory approval pathways copied products ("biosimilars" or "follow-on biologics") have been launched in the EU. This article summarizes experiences with hematopoietic medicines, namely the epoetins (two biosimilars traded under five different brand names) and the filgrastims (two biosimilars, six brand names). Physicians and pharmacists should be familiar with the legal and pharmacological specialities of biosimilars: The production process can differ from that of the original, clinical indications can be extrapolated, glycoproteins contain varying isoforms, the formulation may differ from the original, and biopharmaceuticals are potentially immunogenic. Only on proof of quality, efficacy and safety, biosimilars are a viable option because of their lower costs.

Changes in erythropoiesis-stimulating agent (ESA) dosing and haemoglobin levels in US non-dialysis chronic kidney disease patients between 2005 and 2009

BACKGROUND

Recent clinical trials in cancer patients treated with erythropoiesis-stimulating agents (ESAs) and in CKD patients treated to haemoglobin (Hb) targets above the labeled range of 10-12 g/dL with ESAs raised safety concerns regarding ESA therapy. Subsequently, product labeling was revised including addition of a black-box warning and removal of many quality of life claims not supported by current standards, and there were changes in reimbursement and anaemia guidelines. The extent to which these events influenced ESA dosing and Hb levels in patients with chronic kidney disease not on dialysis (CKD-NOD) is not known.

METHODS

We used data collected in a series of cross-sectional surveys between March 2005 and July 2009. Patients with CKD-NOD were selected from a random sample of free-standing US nephrology clinics. Information on demographics, insurance information, laboratory data and ESA use was abstracted from medical records by site investigators. We evaluated ESA treatment (use and dosing) and Hb levels over time and used multivariate linear regression to assess changes in ESA doses and Hb levels over time adjusting for case-mix differences.

RESULTS

Between 2005 and 2009, 15 836 CKD-NOD patients were sampled. During this period, ESA use declined from 60 to 46%, and the mean dose declined from 176 to 136 mcg/month; the largest decline in use and in dose occurred beginning in 2007. Simultaneously, the mean (standard deviation) Hb level in ESA-treated patients declined from 11.5 (1.4) to 10.6 (1.2) g/dL, though the decline was most pronounced starting in 2007. As the mean Hb declined, the percent of treated patients with an Hb > 12 g/dL dropped from 27 to 12%, and the mean dose in this sub-population declined from 173 to 111 mcg/month.

CONCLUSION

The emergence of safety concerns and the subsequent changes in product labeling, reimbursement and clinical practice guidelines all appear to have influenced physician dosing practices resulting in less frequent use of ESAs, lower ESA doses and lower achieved Hb levels in CKD-NOD patients.

Age-related changes in peripheral blood counts in humans

Anaemia has become a common concern in geriatric health. Since its prevalence varies quite significantly among different groups depending on factors such as ethnicity, lifestyle or fitness, the appropriateness of the current WHO definition of anaemia in the elderly may be questioned. We evaluated peripheral blood parameters from 1,724 individuals (908 women aged 18-101 years and 816 men aged 18-96 years), who were treated at the University of Heidelberg Medical Center with no known haematological history. Patients with a known malignant haematological or oncological disease or with chronic infection or inflammation were excluded. Patients with disorders affecting the kidneys, thyroid or stomach, as well as patients with a bleeding history, haemolysis or who had been previously diagnosed with anaemia were excluded from the study. Average haemoglobin levels for men beyond the age of 70 and for women beyond the age of 80 were found to fulfill the WHO criteria for the diagnosis of anaemia. While in our cohort ∼20% of men and women between 60-69 years of age were by definition anaemic, these numbers steadily increased to 63% in females and 76% in males beyond the age of 90. Based on the results of our study and in accordance with the literature on this topic, we suggest age-adjusted criteria for the diagnosis of anaemia in the elderly in conjunction with a geriatric assessment.

Erythropoietin in cancer patients: pros and cons

PURPOSE OF REVIEW

Anaemia is a frequent complication of cancer. Recently, some concerns have appeared regarding the safety of erythropoiesis-stimulating agents (ESAs) for the treatment of anaemia in cancer patients. The current review will analyse the main arguments in favour of erythropoietin (EPO), as well as those against EPO in chemotherapy-induced anaemia and in cancer-related anaemia. The principal concerns are tumour progression, increased mortality and the risk of venous thromboembolic events (VTEs). Recent meta-analyses have come to divergent conclusions.

RECENT FINDINGS

Several meta-analyses have reviewed the data regarding VTEs, EPO receptors on tumours and tumour progression as well as mortality.

SUMMARY

As of now, ESAs should only be used within the indications as given in the various guidelines.

Final results of a phase I/II pilot study of capecitabine with or without vinorelbine after sequential dose-dense epirubicin and paclitaxel in high-risk early breast cancer

BACKGROUND

The integration of the non-cross-resistant chemotherapeutic agents capecitabine and vinorelbine into an intensified dose-dense sequential anthracycline- and taxane-containing regimen in high-risk early breast cancer (EBC) could improve efficacy, but this combination was not examined in this context so far.

METHODS

Patients with stage II/IIIA EBC (four or more positive lymph nodes) received post-operative intensified dose-dense sequential epirubicin (150 mg/m(2) every 2 weeks) and paclitaxel (225 mg/m(2) every 2 weeks) with filgrastim and darbepoetin alpha, followed by capecitabine alone (dose levels 1 and 3) or with vinorelbine (dose levels 2 and 4). Capecitabine was given on days 1-14 every 21 days at 1000 or 1250 mg/m2 twice daily (dose levels 1/2 and 3/4, respectively). Vinorelbine 25 mg/m2 was given on days 1 and 8 of each 21-day course (dose levels 2 and 4).

RESULTS

Fifty-one patients were treated. There was one dose-limiting toxicity (DLT) at dose level 1. At dose level 2 (capecitabine and vinorelbine), five of 10 patients experienced DLTs. Therefore evaluation of vinorelbine was abandoned and dose level 3 (capecitabine monotherapy) was expanded. Hand-foot syndrome and diarrhoea were dose limiting with capecitabine 1250 mg/m2 twice daily. At 35.2 months' median follow-up, the estimated 3-year relapse-free and overall survival rates were 82% and 91%, respectively.

CONCLUSIONS

Administration of capecitabine monotherapy after sequential dose-dense epirubicin and paclitaxel is feasible in node-positive EBC, while the combination of capecitabine and vinorelbine as used here caused more DLTs.

Impact of erythropoiesis-stimulating agent prescribing at an Asian cancer center, after release of safety advisories

BACKGROUND

Erythropoiesis-stimulating agents (ESAs) provide symptom relief and decrease blood transfusion support among patients with chemotherapy-induced anemia. However, due to increased cardiovascular events associated with off-labeled usage of ESAs, the FDA incorporated black box warnings in 2007 to include the following key points: (a) ESAs should be used only to treat anemia due to concomitant chemotherapy of a noncurative intent and (b) target hemogloblin level should not exceed 12 g/dL. Thus, this study was designed to compare the prescribing of epoetin alfa at National Cancer Centre Singapore before and after FDA black box updates. The secondary objective of this study was to evaluate the appropriateness of efficacy and toxicity monitoring of epoetin alfa.

METHODS

This was a retrospective, single-centered, drug utilization review. Patients who received at least one dose of epoetin alfa were included in this study. Utilization of epoetin alfa was segregated into two time periods: January 1, 2005 to October 15, 2007 (S1, Pre-safety advisories changes) and October 16, 2007 to December 10, 2009 (S2, Post-safety advisories changes).

RESULTS

A total of 171 patients were prescribed epoetin alfa at NCCS during the two time periods. However, only 139 patients were eligible for analysis, with 91 and 48 patients in S1 and S2 respectively. After safety advisory changes, there were more (18.2%) metastatic patients and fewer (19.1%) patients with cardiovascular co-morbidities who were prescribed epoetin alfa, the mean hemogloblin level when epoetin alfa was initiated was lowered by 0.46 g/dL, more (43%) dose adjustments were made for 'excessive' responders and more (40.7%) patients had fewer blood transfusions after epoetin alfa therapy (p < 0.05). However, blood pressure control, iron studies, and supplementation did not improve (p > 0.05).

CONCLUSION

This study suggested that oncologists have generally adopted the new ESA safety warnings and adjusted prescribing habits.

Practical management of tyrosine kinase inhibitor-associated side effects in GIST

Patients diagnosed with advanced gastrointestinal stromal tumor (GIST) are currently treated with oral tyrosine kinase inhibitors (TKIs). Imatinib mesylate is the standard first-line treatment, and sunitinib malate is administered second-line for patients who are intolerant or progress on imatinib. Imatinib has recently been approved for adjuvant treatment of GIST patients who have a significant risk for relapse. In both the metastatic and adjuvant settings, patients may be on these TKIs for many years. Low plasma imatinib levels have been reported to be associated with a short median time to progression of advanced GIST, stressing the importance of maintaining optimal drug levels. We summarize management of the most frequent and clinically significant adverse effects of imatinib and sunitinib in the treatment of GIST in the context of current guidelines, published literature, and the experience of three large GIST referral centers. The adverse events reviewed include nausea and vomiting, diarrhea, skin rash, musculoskeletal complaints, fatigue, hemorrhage, edema, hand-foot skin reaction, skin and hair discoloration, mucositis, hypertension, cardiac toxicity, hypothyroidism, liver transaminase changes, and hematological toxicity of imatinib and sunitinib. Potential drug-drug interactions with each respective agent are also discussed. With prudent use of supportive care measures, many side effects can be managed without dose reduction or interruption of treatment. On the other hand, individualized tailoring of the dose is often required to manage severe toxicity, such as painful hand-foot skin reactions, fatigue, hepatotoxicity, or cardiac toxicity. Management of many TKI-related adverse effects require further evaluation in prospective clinical trials.

Epidemiology and pathophysiology of cancer-associated thrombosis

Venous thromboembolism (VTE) is a common complication in patients with malignant disease. First recognised by Bouillard in 1823 and later described by Trousseau in 1844, multiple studies have since provided considerable evidence for a clinical association between VTE and cancer. Across all cancers, the risk for VTE is elevated 7-fold; in certain malignancies, the risk for VTE may be increased up to 28-fold. Venous thromboembolism is the second leading cause of death in patients with cancer; among survivors, complications commonly include recurrent VTE and post-thrombotic syndrome, and (more rarely) chronic thromboembolic pulmonary hypertension, which are costly, and have a profound impact on the patient's quality of life. Tumour cells can activate blood coagulation through multiple mechanisms, including production of procoagulant, fibrinolytic, and proaggregating activities, release of proinflammatory and proangiogenic cytokines, and interacting directly with host vascular and blood cells (e.g., endothelial cells, leukocytes, and platelets) through adhesion molecules. Increasing evidence suggests that elements of the haemostatic system also have a direct role in eliciting or enhancing angiogenesis, cell survival, and metastasis. Despite the problem posed by VTE in the setting of cancer, it is evident that a significant number of oncologists do not recognise the link between cancer, its treatment, and thrombogenesis. On 22 May 2009, a group of UK-based physicians met in London, UK, to evaluate recent data on cancer thrombosis. This article (1 of 4) briefly reviews key data on the epidemiology and pathophysiology of VTE as a context for a discussion and consensus statement developed by meeting attendees, on the implications of this information for UK clinical practice.