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Wright JD, Neugut AI, Wilde ET, Buono DL, Malin J, Tsai WY, Hershman DL. Physician characteristics and variability of erythropoiesis-stimulating agent use among Medicare patients with cancer. J Clin Oncol 2011; 29:3408-18. [PMID: 21810679 DOI: 10.1200/jco.2010.34.5462] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Drugs are usually approved for a specific indication on the basis of randomized trials. However, once approved, these treatments are often used differently than as tested in trials. We performed an analysis to determine the patterns of use of erythropoiesis-stimulating agents (ESAs). METHODS We used the Surveillance, Epidemiology, and End Results-Medicare database to identify patients age 65 years or older with breast, lung, or colon cancer diagnosed between 1995 and 2005 who had one ESA and chemotherapy claim. Associations of patient, tumor, and physician-related factors with receipt of ESAs were analyzed. RESULTS Of 21,091 patients analyzed, 5,099 (24.2%) received ESAs for 1 week or less (misuse), and 1,601 (7.6%) received ESAs for more than 14 weeks (prolonged use). Receipt of ESAs while not actively receiving chemotherapy (off label) occurred in 2,876 patients (13.6%). In a multivariable analysis, ESA misuse was associated with MD degree, female sex of physician, and earlier year of medical school graduation. Private practice physicians (odds ratio [OR], 0.78; 95% CI, 0.72 to 0.84) and high-volume physicians (OR, 0.78; 95% CI, 0.72 to 0.85) were less likely to use 1 week or less of ESA treatment. Treatment by high-volume oncologists (OR, 1.33; 95% CI, 1.14 to 1.55) and by oncologists who graduated from US medical schools (OR, 1.26; 95% CI, 1.12 to 1.42) predicted prolonged-duration ESA use, whereas female oncologists (OR, 0.79; 95% CI, 0.68 to 0.93) were less likely to prescribe prolonged ESA treatment. Private practice physicians (OR, 1.18; 95% CI, 1.02 to 1.38) and high-volume providers (OR, 1.58; 95% CI, 1.33 to 1.87) were more likely to prescribe more than 24 weeks of ESA treatment. CONCLUSION Our study demonstrated widespread variability in the use of ESAs. Physician characteristics exerted substantial influence on ESA use. Policies to discourage inappropriate use of cancer therapies are needed.
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Welsch T, Zschäbitz S, Becker V, Giese T, Bergmann F, Hinz U, Keleg S, Heller A, Sipos B, Klingmüller U, Büchler MW, Werner J, Giese NA. Prognostic significance of erythropoietin in pancreatic adenocarcinoma. PLoS One 2011; 6:e23151. [PMID: 21829709 PMCID: PMC3148251 DOI: 10.1371/journal.pone.0023151] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2011] [Accepted: 07/07/2011] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Erythropoietin (Epo) administration has been reported to have tumor-promoting effects in anemic cancer patients. We investigated the prognostic impact of endogenous Epo in patients with pancreatic ductal adenocarcinoma (PDAC). METHODOLOGY The clinico-pathological relevance of hemoglobin (Hb, n = 150), serum Epo (sEpo, n = 87) and tissue expression of Epo/Epo receptor (EpoR, n = 104) was analyzed in patients with PDAC. Epo/EpoR expression, signaling, growth, invasion and chemoresistance were studied in Epo-exposed PDAC cell lines. RESULTS Compared to donors, median preoperative Hb levels were reduced by 15% in both chronic pancreatitis (CP, p<0.05) and PDAC (p<0.001), reaching anemic grade in one third of patients. While inversely correlating to Hb (r = -0.46), 95% of sEPO values lay within the normal range. The individual levels of compensation were adequate in CP (observed to predicted ratio, O/P = 0.99) but not in PDAC (O/P = 0.85). Strikingly, lower sEPO values yielding inadequate Epo responses were prominent in non-metastatic M0-patients, whereas these parameters were restored in metastatic M1-group (8 vs. 13 mU/mL; O/P = 0.82 vs. 0.96; p<0.01)--although Hb levels and the prevalence of anemia were comparable. Higher sEpo values (upper quartile ≥ 16 mU/ml) were not significantly different in M0 (20%) and M1 (30%) groups, but were an independent prognostic factor for shorter survival (HR 2.20, 10 vs. 17 months, p<0.05). The pattern of Epo expression in pancreas and liver suggested ectopic release of Epo by capillaries/vasa vasorum and hepatocytes, regulated by but not emanating from tumor cells. Epo could initiate PI3K/Akt signaling via EpoR in PDAC cells but failed to alter their functions, probably due to co-expression of the soluble EpoR isoform, known to antagonize Epo. CONCLUSION/SIGNIFICANCE Higher sEPO levels counteract anemia but worsen outcome in PDAC patients. Further trials are required to clarify how overcoming a sEPO threshold ≥16 mU/ml by endogenous or exogenous means may predispose to or promote metastatic progression.
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Affiliation(s)
- Thilo Welsch
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Stefanie Zschäbitz
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Verena Becker
- Division Systems Biology of Signal Transduction, German Cancer Research Center and Bioquant, Heidelberg University, Heidelberg, Germany
| | - Thomas Giese
- Institute of Immunology, University Hospital Heidelberg, Heidelberg, Germany
| | - Frank Bergmann
- Institute of Pathology, University Hospital Heidelberg, Heidelberg, Germany
| | - Ulf Hinz
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Shereen Keleg
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Anette Heller
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Bence Sipos
- Institute of Pathology, University Hospital Tübingen, Tübingen, Germany
| | - Ursula Klingmüller
- Division Systems Biology of Signal Transduction, German Cancer Research Center and Bioquant, Heidelberg University, Heidelberg, Germany
| | - Markus W. Büchler
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Jens Werner
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Nathalia A. Giese
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
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Mayeur D. Anémie et cancer. ONCOLOGIE 2011. [DOI: 10.1007/s10269-011-2034-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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154
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Gupta G, Choi MJ. Is it safe to use erythropoiesis-stimulating agents to treat anemia in chronic kidney disease patients with active malignancies? Semin Dial 2011; 24:379-81. [DOI: 10.1111/j.1525-139x.2011.00929.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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155
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Gabardi S. Understanding Risk Evaluation and Mitigation Strategies in Organ Transplantation. Pharmacotherapy 2011; 31:714-22. [DOI: 10.1592/phco.31.7.714] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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156
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Lévy-Chavagnat D. Agents stimulant l’érythropoïèse : point sur les recommandations internationales. ACTUALITES PHARMACEUTIQUES 2011. [DOI: 10.1016/s0515-3700(11)70963-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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159
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Erythropoietin for oncology supportive care. Exp Cell Res 2011; 317:1246-54. [DOI: 10.1016/j.yexcr.2011.03.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2011] [Revised: 03/03/2011] [Accepted: 03/03/2011] [Indexed: 12/11/2022]
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Scotté F. Les facteurs de croissance (CSF) biosimilaires : une avancée ? ONCOLOGIE 2011. [DOI: 10.1007/s10269-011-2019-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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161
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Tamási L, Müller V, Eszes N, Kardos T, Budai M, Vincze K, Losonczy G, Szilasi M. Patterns of erythropoiesis-stimulating agent use for chemotherapy-induced anemia in lung cancer: results of a retrospective Hungarian real-life clinical data analysis. Expert Opin Drug Saf 2011; 10:503-7. [PMID: 21480764 DOI: 10.1517/14740338.2011.571200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE Lung cancer carries a relatively high risk of chemotherapy-induced anemia, one of the most frequent hematological complications. Previous data show a lack of optimal anemia correction in patients with chemotherapy-induced anemia. This paper analyzes real-life data considering the prevalence and severity of chemotherapy-induced anemia, together with the frequency and efficacy of erythropoietin treatment of anemia in Hungarian lung cancer patients. RESEARCH DESIGN AND METHODS Data of 482 patients with histological or cytological confirmed lung cancer receiving chemotherapy were collected retrospectively between 1 January and 31 December, 2008. In all, 83 (17%) of them developed chemotherapy-induced moderate to severe anemia (44.6% male, 55.4% female; mean age 70 ± 8.6 years; NSCLC 67.5%, small cell lung cancer 32.5%). RESULTS More than 50% of the patients suffering from moderate to severe chemotherapy-induced anemia (hemoglobin below 10 g/dl) did not receive erythropoietin treatment. Chemotherapy had to be postponed due to anemia in 32.26% of the patients receiving erythropoietin supplementation, while this was seen in 41.94% of the group without erythropoietin treatment (p < 0.05). In patients not receiving erythropoietin, the severity of anemia increased, while erythropoietin treated patients maintained acceptable hemoglobin levels after the end of the chemotherapy. CONCLUSIONS The data draws attention to the fact that nowadays chemotherapy-induced anemia is not treated according to current guidelines in many lung cancer cases in Hungary.
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Affiliation(s)
- Lilla Tamási
- Semmelweis University, Department of Pulmonology, Budapest, Hungary.
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Abstract
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.
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Affiliation(s)
- Aknar Calabrich
- Clinica AMO, Rua Altino Serbeto de Barros, 119, 12° andar, Itaigara, Salvador, Bahia 41825-010, Brazil
- Oncology Center, Hospital Sírio-Libanês, R Adma Jafet, 91, São Paulo 01308-050, Brazil
| | - Artur Katz
- Oncology Center, Hospital Sírio-Libanês, R Adma Jafet, 91, São Paulo 01308-050, Brazil
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Rosebraugh M, Widness JA, Veng-Pedersen P. Receptor-based dosing optimization of erythropoietin in juvenile sheep after phlebotomy. Drug Metab Dispos 2011; 39:1214-20. [PMID: 21460232 DOI: 10.1124/dmd.110.036855] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The primary objective of this work was to determine the optimal time for administration of an erythropoietin (Epo) dose to maximize the erythropoietic effect using a simulation study based on a young sheep pharmacodynamic model. The dosing optimization was accomplished by extending a Hb production pharmacodynamic model, which evaluates the complex dynamic changes in the Epo receptor (EpoR) pool from the changes in Epo clearance. Fourteen healthy 2-month-old sheep were phlebotomized to Hb levels of 3 to 4 g/dl. Epo clearance was evaluated longitudinally in each animal by administering tracer doses of (125)I-recombinant human Epo multiple times during the experiment. Kinetic parameters were estimated by simultaneously fitting to Hb data and Epo clearance data. The phlebotomy caused a rapid temporary increase in the endogenous Epo plasma level. The Hb began to increase after the increased in the Epo level with a lag time of 1.13 ± 0.79 days. The average correlation coefficients for the fit of the model to the Hb and clearance data were 0.953 ± 0.018 and 0.876 ± 0.077, respectively. A simulation study was done in each sheep with fixed individual estimated model parameters to determine the optimal time to administer a 100 U/kg intravenous bolus Epo dose. The optimal dose administration time was 11.4 ± 6.2 days after phlebotomy. This study suggests that the Hb produced from Epo administration can be optimized by considering the dynamic changes in the EpoR pool.
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Affiliation(s)
- Matthew Rosebraugh
- Department of Pediatrics, University of Iowa, College of Pharmacy, 115 S. Grand Ave., Iowa City, IA 52242, USA
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Yong M, Riis AH, Fryzek JP, Møller BK, Johnsen SP. Predictors and patterns of red blood cell transfusion use among newly diagnosed cancer patients with chemotherapy-associated anemia in Western Denmark (1998-2003). Clin Epidemiol 2011; 3:91-9. [PMID: 21487448 PMCID: PMC3072151 DOI: 10.2147/clep.s17146] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2011] [Indexed: 11/23/2022] Open
Abstract
Objective: Cancer patients receiving chemotherapy are at increased risk of anemia. We conducted a population-based historical cohort study in newly diagnosed cancer patients with chemotherapy-associated anemia in order to characterize red blood cell transfusion (RBCT) use. Design: This study evaluated cancer patients diagnosed between January 1, 1998 and December 31, 2003 using Danish National Patient Registry data. Patients were receiving chemotherapy and had a hemoglobin level ≤10.9 g/dL during the 4 months following cancer diagnosis. We characterized patterns of RBCT use and inpatient and outpatient hospitalization for transfusion. Adjusted Poisson regression models were used to evaluate the likelihood of RBCT, estimated by relative risk (RR), based on demographic and clinical factors. Results: Women constituted 58% of 1782 patients studied; the median age was 58 years. Two-thirds (67%) had solid tumors; 67% had stage III or IV disease at diagnosis. Overall, 713 (40%) patients received an RBCT within 120 days of cancer diagnosis, of which 94% were administered in the inpatient setting; 84% of these patients required subsequent transfusions. The median (Q1, Q3) pretransfusion hemoglobin level was 9.0 (8.4, 9.8) g/dL. Patients aged <20 years were more likely to receive an RBCT than older patients (RR 1.89; 95% confidence interval [CI] 1.44–2.49). Compared with stage IV disease, those with stage II or III disease had a lower likelihood of RBCT (stage II: RR 0.52, 95% CI: 0.37–0.72; stage III: RR 0.68, 95% CI: 0.55–0.83). Patients diagnosed with breast cancer were less likely to receive an RBCT than patients with hematologic cancers (RR 0.34, 95% CI: 0.21–0.55). Conclusion: In this study, 40% of cancer patients with chemotherapy-associated anemia in Western Denmark received an RBCT, usually in the inpatient setting; of these, most required subsequent transfusions. Younger age increased the likelihood of receiving an RBCT, and earlier stage or breast cancer decreased RBCT likelihood.
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Affiliation(s)
- Mellissa Yong
- Department of Global Biostatistics and Epidemiology, Amgen Inc, Thousand Oaks, CA, USA
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Rizzo JD, Brouwers M, Hurley P, Seidenfeld J, Somerfield MR, Temin S. 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. J Oncol Pract 2010; 6:317-20. [PMID: 21358963 PMCID: PMC2988667 DOI: 10.1200/jop.2010.000132] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/23/2010] [Indexed: 11/20/2022] Open
Abstract
This guideline update addresses two clinical questions: (1) What are the defining features of patients with a malignancy who are appropriate candidates for ESA treatment? (2) For patients who are appropriate candidates for treatment with ESAs, what are the optimal approaches to ESA therapy?
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Affiliation(s)
- J. Douglas Rizzo
- Medical College of Wisconsin, Milwaukee, WI; McMaster University, Hamilton, Ontario, Canada; American Society of Clinical Oncology, Alexandria, VA
| | - Melissa Brouwers
- Medical College of Wisconsin, Milwaukee, WI; McMaster University, Hamilton, Ontario, Canada; American Society of Clinical Oncology, Alexandria, VA
| | - Patricia Hurley
- Medical College of Wisconsin, Milwaukee, WI; McMaster University, Hamilton, Ontario, Canada; American Society of Clinical Oncology, Alexandria, VA
| | - Jerome Seidenfeld
- Medical College of Wisconsin, Milwaukee, WI; McMaster University, Hamilton, Ontario, Canada; American Society of Clinical Oncology, Alexandria, VA
| | - Mark R. Somerfield
- Medical College of Wisconsin, Milwaukee, WI; McMaster University, Hamilton, Ontario, Canada; American Society of Clinical Oncology, Alexandria, VA
| | - Sarah Temin
- Medical College of Wisconsin, Milwaukee, WI; McMaster University, Hamilton, Ontario, Canada; American Society of Clinical Oncology, Alexandria, VA
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