The use of recombinant erythropoietin for the treatment of chemotherapy-induced anemia in patients with ovarian cancer does not affect progression-free or overall survival

Prognostic impact of erythropoietin-stimulating agent use during front-line chemotherapy in patients with ovarian cancer: A Korean multicenter cohort study

OBJECTIVE

To evaluate whether treatment with erythropoiesis-stimulating agents (ESAs) for chemotherapy-induced anemia affects progression-free survival (PFS) in patients receiving front-line chemotherapy following surgery for ovarian cancer (OC).

METHODS

We retrospectively reviewed all consecutive patients who received front-line chemotherapy after surgery between 2013 and 2019 at six institutions. The patients were divided according to the use of ESAs during front-line chemotherapy. The primary endpoint was PFS. The secondary endpoint was the occurrence of thromboembolism. Propensity score matching (PSM) analysis was used to compare survival between matched cohorts.

RESULTS

Overall, 2147 patients (433 receiving ESA and 1714 for no-ESA) were identified, with a median follow-up of 44.0 months. The ESA group showed a significantly higher proportion of stage III/IV disease (81.8% vs 61.1%; P < 0.001) and postoperative gross residual disease (32.3% vs 21.2%; P < 0.001) than the no-ESA group. In the multivariable Cox regression analysis, the use of ESAs did not affect PFS (adjusted hazard ratio, 1.03; 95% confidence interval [CI]: 0.89-1.20; P = 0.661). The incidence of thromboembolism was 10.2% in the ESA group and 4.6% in the no-ESA group (adjusted odds ratio, 6.58; 95% CI: 3.26-13.28; P < 0.001). When comparing the well-matched cohorts after PSM, PFS did not differ between the ESA (median PFS 23.5 months) and no-ESA groups (median PFS 22.2 months) (P = 0.540, log-rank test).

CONCLUSIONS

The use of ESAs during front-line chemotherapy did not negatively affect PFS in patients with OC after surgery but increased the risk of thromboembolism.

Network pharmacology-based approach to understand the effect and mechanism of Danshen against anemia

ETHNOPHARMACOLOGICAL RELEVANCE

Danshen, the dried rhizome of Salvia miltiorrhiza Bge., is widely used to treat cardio-cerebrovascular diseases in China. However, its role in nourishing blood, which has been detailed in historical literature for thousands of years, is perpetually disputed in the academic field. Moreover, there is no systematic research on Danshen in treating anemia. This research aimed to investigate the effects and mechanisms of Danshen on anemia in a zebrafish model based on the results of a network pharmacology study.

MATERIALS AND METHODS

The network pharmacology study was based on the screening of chemical components and related targets from TCMSP and SwissADME database. The genes associated with anemia were obtained from DisgeNet database, and the genes with the intersection of Danshen target genes were screened out. The Cytoscape 3.7.2 software package was used to construct the "ingredient-target-pathway" network. The exploration of target interaction by String system and the enrichment analysis by Metascape system, was used to discover the possible anti-anemia action mechanism of Danshen. Then, a zebrafish anemia model was induced by vinorelbine followed by the administration of aqueous/ethanol extract of Danshen in contrast to SiWu Decoction (SWD), which is generally acknowledged as a positive drug for tonifying blood. Afterward, the red blood cell signal, cardiac output, and blood flow velocity were detected to evaluate their blood-enriching effects. Quantitative real-time polymerase chain reaction (qPCR) was used to analyze the mRNA levels of hematopoietic-related factors, which were predicted in network pharmacology.

RESULTS

Compounds and target screening hinted that 115 chemical targets from Danshen were related to anemia, KEGG pathway enrichment results suggested that the mechanism of Danshen in treating anemia was significantly related to the Jak-STAT signaling pathway. Pharmacodynamic results showed that aqueous extract of Danshen (DSAE) and ethanol extract of Danshen (DSEE) markedly enhanced the number of red blood cells, cardiac output, and blood flow velocity. Compared with DSAE, DSEE exerted anti-anemia effects at a lower dose; however, along with higher toxicity. PCR data demonstrated that DSAE and DSEE treatment both upregulated the mRNA expression of erythroid hematopoiesis-related factors in the Epo-JAK-STAT signaling pathway, such as Gata-1, Epo, EpoR, Jak2, STAT3, and STAT5. In general, DSAE exhibited higher activation of this signaling than DSEE.

CONCLUSIONS

These results indicated that DSAE and DSEE both possess blood-enriching functions related with their ability to promote Jak-STAT signaling. DSAE exerted lower toxicity and attenuated anemia over a wider dose range than DSEE, which suggests that DSAE may be more suitable for the treatment for anemia. These results presented experimental evidence for the clinical use of Danshen as an intervention for anemia, especially in chemotherapy-induced anemia.

Impact of Hematopoietic Growth Factors on Blood Transfusion Needs, Incidence of Neutropenia, and Overall Survival Among Elderly Advanced Ovarian Cancer Patients Treated With Chemotherapy

OBJECTIVE

To determine the effectiveness of erythropoietin-stimulating agent (ESA) and granulocyte colony-stimulating factor (CSF) in reducing blood transfusion needs and neutropenia incidence in community-dwelling elderly ovarian cancer patients.

METHODS

The SEER (Surveillance Epidemiology and End Results)-Medicare database was used to identify 5572 women with stage III/IV ovarian cancer who received chemotherapy. To assess clinical effectiveness, we categorized patients based on the number of administrations of ESA (ie, epoetin-alfa and darbepoetin-alfa) and CSF (ie, filgrastim and pegfilgrastim). To evaluate effect on survival, patients were categorized as receiving ESA only, CSF only, ESA + CSF, and no ESA/CSF.

RESULTS

Two thirds of patients received growth factor support (24% ESA only, 13% CSF only, 30% ESA + CSF). Depending on the number of epoetin-alfa administrations, ESA was associated with 48% to 56% lower need for blood transfusion compared with no ESA (hazard ratio for 1-3 claims, 0.47; 4-6 claims, 0.52; 7-10 claims, 0.48; ≥11 claims, 0.44). Patients who received at least 3 prophylactic filgrastim administrations had 71% to 98% lower risk of developing neutropenia (hazard ratio for 3-4 claims, 0.29; ≥5 claims, 0.02) compared with those without CSF. Effectiveness was comparable for darbepoetin-alfa and pegfilgrastim use. Overall survival was longer in those who received CSF only; however, the risk of mortality after 24 months was higher in those who received ESA (P = 0.0005). All models were adjusted for relevant covariates.

CONCLUSIONS

Erythropoietin-stimulating agents were effective in reducing blood transfusion need. Granulocyte colony-stimulating factors were effective in lowering neutropenia incidence and also were associated with improved survival in elderly ovarian cancer patients. Findings are consistent with clinical trials and clinical guidelines.

Erythropoietin and cancer: the unintended consequences of anemia correction

Until 1990, erythropoietin (EPO) was considered to have a single biological purpose and action, the stimulation of red blood cell growth and differentiation. Slowly, scientific and medical opinion evolved, beginning with the discovery of an effect on endothelial cell growth in vitro and the identification of EPO receptors (EPORs) on neuronal cells. We now know that EPO is a pleiotropic growth factor that exhibits an anti-apoptotic action on numerous cells and tissues, including malignant ones. In this article, we present a short discussion of EPO, receptors involved in EPO signal transduction, and their action on non-hematopoietic cells. This is followed by a more detailed presentation of both pre-clinical and clinical data that demonstrate EPO’s action on cancer cells, as well as tumor angiogenesis and lymphangiogenesis. Clinical trials with reported adverse effects of chronic erythropoiesis-stimulating agents (ESAs) treatment as well as clinical studies exploring the prognostic significance of EPO and EPOR expression in cancer patients are reviewed. Finally, we address the use of EPO and other ESAs in cancer patients.

The impact of perioperative packed red blood cell transfusion on survival in epithelial ovarian cancer

OBJECTIVE

Perioperative packed red blood cell transfusion (PRBCT) has been implicated as a negative prognostic marker in surgical oncology. There is a paucity of evidence on the impact of PRBCT on outcomes in epithelial ovarian cancer (EOC). We assessed whether PRBCT is an independent risk factor of recurrence and death from EOC.

METHODS

Perioperative patient characteristics and process-of-care variables (defined by the National Surgical Quality Improvement Program) were retrospectively abstracted from 587 women who underwent primary EOC staging between January 2, 2003, and December 29, 2008. Associations with receipt of PRBCT were evaluated using univariate logistic regression models. The associations between receipt of PRBCT and disease-free survival and overall survival were evaluated using multivariable Cox proportional hazards models and using propensity score matching and stratification, respectively.

RESULTS

The rate of PRBCT was 77.0%. The mean ± SD units transfused was 4.1 ± 3.1 U. In the univariate analysis, receipt of PRBCT was significantly associated with older age, advanced stage (≥ IIIA), undergoing splenectomy, higher surgical complexity, serous histologic diagnosis, greater estimated blood loss, longer operating time, the presence of residual disease, and lower preoperative albumin and hemoglobin. Perioperative packed red blood cell transfusion was not associated with an increased risk for recurrence or death, in an analysis adjusting for other risk factors in a multivariable model or in an analysis using propensity score matching or stratification to control for differences between the patients with and without PRBCT.

CONCLUSIONS

Perioperative packed red blood cell transfusion does not seem to be directly associated with recurrence and death in EOC. However, lower preoperative hemoglobin was associated with a higher risk for recurrence. The need for PRBCT seems to be a stronger prognostic indicator than the receipt of PRBCT.

Cytokine use and survival in the first-line treatment of ovarian cancer: a Gynecologic Oncology Group Study

BACKGROUND

Granulocyte colony stimulating factor (G-CSF) and erythropoietin stimulating agents (ESA) may be used to support patients during chemotherapy. We assessed whether G-CSF or ESA were associated with progression or death in patients with ovarian cancer.

METHODS

Patients with ovarian cancer following surgery, were on a protocol to evaluate bevacizumab with chemotherapy. Guidelines for administering G-CSF and ESA were specified in the protocol. Overall survival (OS) was analyzed with landmark procedures and multivariate, time-dependent hazard models.

RESULTS

Eighteen-hundred-seventy-three women were enrolled, with no differences in clinical and pathologic variables among treatment group. Performance status, hemoglobin, and white cell counts were associated with G-CSF and/or ESA usage during treatment. Nine patients received no protocol directed therapy, leaving 1864 patients for this review. One-thousand-one-hundred-twenty-five patients received neither ESA nor G-CSF; 311 received G-CSF but no ESA; 241 received ESA but no G-CSF; and 187 received both. Median survival following a five month landmark from the start of treatment was 34 versus 38 months for those who did versus did not receive ESA (multivariate hazard ratio: 0.989; 95% confidence interval: 0.849-1.15) and 40 versus 37 months for those who did versus did not receive G-CSF (multivariate hazard ratio: 0.932; 95% confidence interval: 0.800-1.08).

CONCLUSIONS

Neither ESA nor G-CSF had a negative impact on survival after adjustment of prognostic factors among patients with ovarian cancer receiving chemotherapy. ESA may appear to be associated with shorter survival in univariate analyses because factors prognostic for ESA use are also prognostic for progression-free survival.

Use of darbepoetin alfa in European clinical practice for the management of chemotherapy-induced anaemia in four tumour types: final data from the CHOICE study

OBJECTIVES

The CHOICE study was a prospective, multicentre, observational study designed to assess levels of adherence in current clinical practice to the European product label and EORTC guidelines for the treatment of chemotherapy-induced anaemia (CIA) with darbepoetin alfa (DA). Here we present data split by tumour types: breast, colorectal, ovarian and lung.

METHODS

Haemoglobin (Hb) levels and red blood cell transfusion requirements were evaluated among patients with solid tumours in 11 European countries. The primary outcome measure was the proportion of patients with a target Hb level of ≥10-≤12 g/dL.

RESULTS

The full analysis set included 1887 patients (mean ± SD 62.4 ± 11.4 years); 1585 (84%) had a current disease stage of ≥3. Common chemotherapy regimens were non-platinum + non-taxane based (n = 696 [37%]) or platinum + non-taxane based (n = 660 [35%]). Breast cancer (n = 575): The mean ± SD Hb level at baseline was 9.9 ± 0.8 g/dL (n = 568). Target Hb level was reached by 187 (55%) patients. Colorectal cancer (n = 310): At baseline the mean ± SD Hb level was 9.8 ± 0.8 g/dL (n = 306). Target Hb level was reached by 107 patients (56%). Ovarian cancer (n = 301): The mean ± SD Hb level at baseline was 9.7 ± 0.8 g/dL (n = 294). Target Hb level was reached by 81 patients (44%). Lung cancer (n = 701): At baseline the mean ± SD Hb level was 9.8 ± 0.9 g/dL (n = 692). Target Hb level was reached by 142 patients (39%).

SAFETY

Five severe or life-threatening adverse drug reactions were seen (three patients with breast cancer, one patient with colorectal cancer and one patient with ovarian cancer).

LIMITATIONS

Potential bias could not be excluded due to the study's observational nature.

CONCLUSIONS

This study demonstrates that the recommendations are adhered to in clinical practice, with the mean starting Hb level <10 g/dL irrespective of tumour type. Furthermore, DA is likely to be effective and well tolerated for the treatment of CIA in patients with breast, colorectal, ovarian or lung cancer.