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Gupta S, May FP, Kupfer SS, Murphy CC. Birth Cohort Colorectal Cancer (CRC): Implications for Research and Practice. Clin Gastroenterol Hepatol 2024; 22:455-469.e7. [PMID: 38081492 PMCID: PMC11304405 DOI: 10.1016/j.cgh.2023.11.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 11/21/2023] [Accepted: 11/28/2023] [Indexed: 01/06/2024]
Abstract
Colorectal cancer (CRC) epidemiology is changing due to a birth cohort effect, first recognized by increasing incidence of early onset CRC (EOCRC, age <50 years). In this paper, we define "birth cohort CRC" as the observed phenomenon, among individuals born 1960 and later, of increasing CRC risk across successive birth cohorts, rising EOCRC incidence, increasing incidence among individuals aged 50 to 54 years, and flattening of prior decreasing incidence among individuals aged 55 to 74 years. We demonstrate birth cohort CRC is associated with unique features, including increasing rectal cancer (greater than colon) and distant (greater than local) stage CRC diagnosis, and increasing EOCRC across all racial/ethnic groups. We review potential risk factors, etiologies, and mechanisms for birth cohort CRC, using EOCRC as a starting point and describing importance of viewing these through the lens of birth cohort. We also outline implications of birth cohort CRC for epidemiologic and translational research, as well as current clinical practice. We postulate that recognition of birth cohort CRC as an entity-including and extending beyond rising EOCRC-can advance understanding of risk factors, etiologies, and mechanisms, and address the public health consequences of changing CRC epidemiology.
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Affiliation(s)
- Samir Gupta
- Section of Gastroenterology, Jennifer Moreno San Diego VA Medical Center, San Diego, California; Division of Gastroenterology, Department of Medicine, and Moores Cancer Center, University of California, La Jolla, California.
| | - Folasade P May
- Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, California; Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, California; UCLA Kaiser Permanente Center for Health Equity, Jonsson Comprehensive Cancer Center, UCLA, Los Angeles, California
| | - Sonia S Kupfer
- Section of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Caitlin C Murphy
- Department of Health Promotion & Behavioral Sciences, University of Texas Health Science Center at Houston (UTHealth Houston) School of Public Health, Houston, Texas
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2
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Nelson DB, Fomina YY. Challenges in Using Progestin to Prevent Singleton Preterm Births: Current Knowledge and Clinical Advice. Int J Womens Health 2024; 16:119-130. [PMID: 38283999 PMCID: PMC10812715 DOI: 10.2147/ijwh.s394305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 10/23/2023] [Indexed: 01/30/2024] Open
Abstract
Preterm birth is the leading cause of infant morbidity and mortality in children younger than 5 years old and accounts for approximately 35% of newborn deaths worldwide. The use of progestogen therapy for prevention of preterm birth has been one of the most controversial topics in modern obstetrics. Progestogens can be classified as natural or synthetic. Progesterone is a natural progestogen while progestins such as 17-alpha-hydroxyprogesterone caproate (17OHP-C) are synthetic steroid hormones. Evidence supporting the use of progestogens varies by formulation and populations studied. After more than a decade, the US Food and Drug Administration has withdrawn accelerated approval of 17OHP-C for the prevention of recurrent preterm birth in pregnant individuals with a singleton gestation. With this decision, there is no current FDA-approved treatment for prevention of spontaneous preterm birth. In this review, we provide a historical context behind the rise and fall of 17OHP-C clinical application, highlight the challenges behind the data supporting progestogen use, and offer suggestions on how to make an impact on preterm birth moving forward.
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Affiliation(s)
- David B Nelson
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Yevgenia Y Fomina
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX, USA
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3
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Murphy CC, Zaki TA. Changing epidemiology of colorectal cancer - birth cohort effects and emerging risk factors. Nat Rev Gastroenterol Hepatol 2024; 21:25-34. [PMID: 37723270 DOI: 10.1038/s41575-023-00841-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/22/2023] [Indexed: 09/20/2023]
Abstract
Incidence and mortality of colorectal cancer (CRC) are increasing worldwide, suggesting broad changes in the epidemiology of CRC. In this Review, we discuss the changes that are becoming evident, including trends in CRC incidence and mortality by age and birth cohort, and consider the contributions of early-life exposures and emerging risk factors to these changes. Importantly, incidence of CRC has increased among people born since the early 1950s in nearly all regions of the world. These so-called birth cohort effects imply the involvement of factors that influence the earliest stages of carcinogenesis and have effects across the life course. Accumulating evidence supports the idea that early-life exposures are important risk factors for CRC, including exposures during fetal development, childhood, adolescence and young adulthood. Environmental chemicals could also have a role because the introduction of many in the 1950s and 1960s coincides with increasing incidence of CRC among people born during those years. To reverse the expected increases in the global burden of CRC, participation in average-risk screening programmes needs to be increased by scaling up and implementing evidence-based screening strategies, and emerging risk factors responsible for these increases need to be identified.
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Affiliation(s)
- Caitlin C Murphy
- Department of Health Promotion & Behavioral Sciences, University of Texas Health Science Center at Houston (UTHealth Houston) School of Public Health, Houston, TX, USA.
| | - Timothy A Zaki
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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4
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Nelson DB, Herrera CL, McIntire DD, Cunningham FG. The end is where we start from: withdrawal of 17-alpha hydroxyprogesterone caproate to prevent recurrent preterm birth. Am J Obstet Gynecol 2024; 230:1-9. [PMID: 37798189 PMCID: PMC10842149 DOI: 10.1016/j.ajog.2023.08.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 08/18/2023] [Accepted: 08/22/2023] [Indexed: 10/07/2023]
Affiliation(s)
- David B Nelson
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center at Dallas, Dallas, TX.
| | - Christina L Herrera
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center at Dallas, Dallas, TX
| | - Donald D McIntire
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center at Dallas, Dallas, TX
| | - F Gary Cunningham
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center at Dallas, Dallas, TX
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5
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Baxter C, Crary I, Coler B, Marcell L, Huebner EM, Rutz S, Adams Waldorf KM. Addressing a broken drug pipeline for preterm birth: why early preterm birth is an orphan disease. Am J Obstet Gynecol 2023; 229:647-655. [PMID: 37516401 PMCID: PMC10818026 DOI: 10.1016/j.ajog.2023.07.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 07/19/2023] [Accepted: 07/23/2023] [Indexed: 07/31/2023]
Abstract
Preterm birth remains one of the most urgent unresolved medical problems in obstetrics, yet only 2 therapeutics for preventing preterm birth have ever been approved by the United States Food and Drug Administration, and neither remains on the market. The recent withdrawal of 17-hydroxyprogesterone caproate (17-OHPC, Makena) marks a new but familiar era for obstetrics with no Food and Drug Administration-approved pharmaceuticals to address preterm birth. The lack of pharmaceuticals reflects a broad and ineffective pipeline hindered by extensive regulatory hurdles, soaring costs of performing drug research, and concerns regarding adverse effects among a particularly vulnerable population. The pharmaceutical industry has historically limited investments in research for diseases with similarly small markets, such as cystic fibrosis, given their rarity and diminished projected financial return. The Orphan Drug Act, however, incentivizes drug development for "orphan diseases", defined as affecting <200,000 people in the United States annually. Although the total number of preterm births in the United States exceeds this threshold annually, the early subset of preterm birth (<34 weeks' gestation) would qualify, which is predominantly caused by inflammation and infection. The scientific rationale for classifying preterm birth into early and late subsets is strong given that their etiologies differ, and therapeutics that may be efficacious for one subset may not work for the other. For example, antiinflammatory therapeutics would be expected to be highly effective for early but not late preterm birth. A robust therapeutic pipeline of antiinflammatory drugs already exists, which could be used to target spontaneous early preterm birth, in combination with antibiotics shown to sterilize the amniotic cavity. New applications for therapeutics targeting spontaneous early preterm birth could categorize as orphan disease drugs, which could revitalize the preterm birth therapeutic pipeline. Herein, we describe why drugs targeting early preterm birth should qualify for orphan status, which may increase pharmaceutical interest for this vitally important obstetrical condition.
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Affiliation(s)
- Carly Baxter
- School of Medicine, University of Washington, Seattle, WA
| | - Isabelle Crary
- School of Medicine, University of Washington, Seattle, WA
| | - Brahm Coler
- Elson S. Floyd College of Medicine, Washington State University, Spokane, WA
| | - Lauren Marcell
- School of Medicine, University of Washington, Seattle, WA
| | | | - Sara Rutz
- School of Medicine, University of Washington, Seattle, WA
| | - Kristina M Adams Waldorf
- Departments of Obstetrics and Gynecology and Global Health, University of Washington, Seattle, WA.
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Futterman ID, Gilroy L, Zayat N, Balhotra K, Weedon J, Minkoff H. Changes in use of 17-OHPC after the PROLONG trial: a physician survey. J Perinat Med 2023; 51:1013-1018. [PMID: 37192539 DOI: 10.1515/jpm-2023-0085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 04/27/2023] [Indexed: 05/18/2023]
Abstract
OBJECTIVES To determine if 17α-hydroxyprogesterone caproate (17OHPC) or vaginal progesterone use for patients at risk for preterm birth has changed since the publication of the 17-OHPC to Prevent Recurrent Preterm Birth in Singleton Gestations (PROLONG) trial, and to assess which organizations' (Food and Drug Administration's [FDA], American College of Obstetrics and Gynecology's [ACOG] or Society of Maternal Fetal Medicine's [SMFM]) statements most influenced change. METHODS Through a vignette-based physician survey, we sought to measure (by Likert scale) how counseling tendencies regarding 17OHPC and vaginal progesterone have changed since the PROLONG trial publication. Participants were also asked which organizations' statements most influenced change. RESULTS With response rate of 97 % (141/145), a pre-to-post PROLONG trial comparison revealed significant changes in counseling for progesterone. Respondents were less likely to recommend 17OHPC (p<0.001) and more likely to recommend vaginal (p<0.001). The FDA statement most influenced the decision not to recommend 17OHPC for the prevention of preterm birth (r=-0.23, p=0.005). CONCLUSIONS Providers have made significant changes in their counseling regarding progesterone use for patients at risk for preterm birth after the publication of the PRLONG trial.
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Affiliation(s)
- Itamar D Futterman
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Maimonides Medical Center, Brooklyn, NY, USA
| | - Laura Gilroy
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Maimonides Medical Center, Brooklyn, NY, USA
| | - Nawras Zayat
- Department of Obstetrics and Gynecology, State University of New York, Brooklyn, NY, USA
| | - Kimen Balhotra
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Maimonides Medical Center, Brooklyn, NY, USA
| | - Jeremy Weedon
- Department of Epidemiology & Biostatistics, State University of New York, Brooklyn, NY, USA
| | - Howard Minkoff
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Maimonides Medical Center, Brooklyn, NY, USA
- Department of Obstetrics and Gynecology and School of Public Health State, University of New York, Brooklyn, NY, USA
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7
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Murphy CC, Cirillo PM, Krigbaum NY, Singal AG, Jones DP, Zaki T, Cohn BA. In-utero exposure to antibiotics and risk of colorectal cancer in a prospective cohort of 18 000 adult offspring. Int J Epidemiol 2023; 52:1448-1458. [PMID: 36692207 PMCID: PMC10555902 DOI: 10.1093/ije/dyad004] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 01/10/2023] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Incidence rates of colorectal cancer (CRC) are increasing among younger adults and in mid-life, implicating exposures in early life as risk factors. We examined the association between in-utero exposure to antibiotics and risk of CRC in adult offspring. METHODS The Child Health and Development Studies is a prospective cohort of women receiving prenatal care between 1959 and 1966 in Oakland, California, with deliveries through June 1967. Diagnosed conditions and all prescribed medications were abstracted from mothers' medical records beginning 6 months prior to pregnancy through delivery. We identified mothers who received antibiotics in pregnancy, including penicillins, tetracyclines, short-acting sulfonamides and long-acting sulfonamides. Diagnoses of CRC in adult (age ≥18 years) offspring were ascertained through 2021 by linkage with the California Cancer Registry. Cox proportional models were used to estimate adjusted hazard ratios (aHR), with follow-up accrued from birth through cancer diagnosis, death or last contact. RESULTS Of 18 751 liveborn offspring, about 15% (n = 2635) were exposed in utero to antibiotics: 5.4% (n = 1016) to tetracyclines, 4.9% (n = 918) to penicillins, 4.2% (n = 785) to short-acting sulfonamides and 1.5% (n = 273) to long-acting sulfonamides. Compared with offspring not exposed, associations between in-utero exposure and CRC in adult offspring were: aHR 1.03 (95% CI 0.32, 3.31) for tetracyclines; aHR 1.12 (95% CI 0.35, 3.58) for penicillins; aHR 0.83 (95% CI 0.20, 3.42) for short-acting sulfonamides; and aHR 4.40 (95% CI 1.63, 11.88) for long-acting sulfonamides. CONCLUSION Our findings support an association between in-utero exposure to long-acting sulfonamides and CRC in adulthood.
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Affiliation(s)
- Caitlin C Murphy
- Department of Health Promotion and Behavioral Sciences, University of Texas Health Science Center at Houston (UTHealth Houston), School of Public Health, Houston, TX, USA
| | - Piera M Cirillo
- Child Health and Development Studies, Public Health Institute, Berkeley, CA, USA
| | - Nickilou Y Krigbaum
- Child Health and Development Studies, Public Health Institute, Berkeley, CA, USA
| | - Amit G Singal
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Dean P Jones
- Departments of Medicine and Biochemistry, Emory University School of Medicine, Atlanta, GA, USA
| | - Timothy Zaki
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Barbara A Cohn
- Child Health and Development Studies, Public Health Institute, Berkeley, CA, USA
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Manuck TA, Gyamfi-Bannerman C, Saade G. What now? A critical evaluation of over 20 years of clinical and research experience with 17-alpha hydroxyprogesterone caproate for recurrent preterm birth prevention. Am J Obstet Gynecol MFM 2023; 5:101108. [PMID: 37527737 PMCID: PMC10591827 DOI: 10.1016/j.ajogmf.2023.101108] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 07/08/2023] [Accepted: 07/14/2023] [Indexed: 08/03/2023]
Abstract
Spontaneous preterm birth is multifactorial, and underlying etiologies remain incompletely understood. Supplementation with progestogens, including 17-alpha hydroxyprogesterone caproate has been a mainstay of prematurity prevention strategies in the United States in the last 2 decades. Following a recent negative confirmatory trial, 17-alpha hydroxyprogesterone caproate was withdrawn from the US market and is currently available only through clinical research studies. This expert review summarized clinical and research data regarding the use of 17-alpha hydroxyprogesterone caproate in the United States from 2003 to 2023 for recurrent prematurity prevention. In 17-alpha hydroxyprogesterone caproate. The history of the use, mechanisms of action, clinical trial results, and efficacy by clinical and biologic criteria of 17-alpha hydroxyprogesterone caproate are presented. We report that disparate findings and conclusions between similarly designed rigorous studies may reflect differences in a priori risk and population incidence and extreme care should be taken in interpreting the studies and making decisions regarding efficacy of 17-alpha hydroxyprogesterone caproate for the prevention of preterm birth. The likelihood of improved obstetrical outcomes after receiving 17-alpha hydroxyprogesterone caproate may vary by clinical factors (eg, body mass index), plasma drug concentrations, and genetic factors, although the identification of individuals most likely to benefit remains imperfect. It is crucial for the medical community to recognize the importance of preserving the decades-long efforts invested in preventing recurrent preterm birth in the United States. Moreover, it is important that we thoroughly and thoughtfully evaluate 17-alpha hydroxyprogesterone caproate as a promising contender for future well-executed prematurity studies.
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Affiliation(s)
- Tracy A Manuck
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC (Dr Manuck); Institute for Environmental Health Solutions, Gillings School of Global Public Health, Chapel Hill, NC (Dr Manuck).
| | - Cynthia Gyamfi-Bannerman
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Diego, San Diego, CA (Dr Gyamfi-Bannerman)
| | - George Saade
- Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA (Dr Saade)
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9
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Cavestro GM, Mannucci A, Balaguer F, Hampel H, Kupfer SS, Repici A, Sartore-Bianchi A, Seppälä TT, Valentini V, Boland CR, Brand RE, Buffart TE, Burke CA, Caccialanza R, Cannizzaro R, Cascinu S, Cercek A, Crosbie EJ, Danese S, Dekker E, Daca-Alvarez M, Deni F, Dominguez-Valentin M, Eng C, Goel A, Guillem JG, Houwen BBSL, Kahi C, Kalady MF, Kastrinos F, Kühn F, Laghi L, Latchford A, Liska D, Lynch P, Malesci A, Mauri G, Meldolesi E, Møller P, Monahan KJ, Möslein G, Murphy CC, Nass K, Ng K, Oliani C, Papaleo E, Patel SG, Puzzono M, Remo A, Ricciardiello L, Ripamonti CI, Siena S, Singh SK, Stadler ZK, Stanich PP, Syngal S, Turi S, Urso ED, Valle L, Vanni VS, Vilar E, Vitellaro M, You YQN, Yurgelun MB, Zuppardo RA, Stoffel EM. Delphi Initiative for Early-Onset Colorectal Cancer (DIRECt) International Management Guidelines. Clin Gastroenterol Hepatol 2023; 21:581-603.e33. [PMID: 36549470 PMCID: PMC11207185 DOI: 10.1016/j.cgh.2022.12.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 12/01/2022] [Accepted: 12/01/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND & AIMS Patients with early-onset colorectal cancer (eoCRC) are managed according to guidelines that are not age-specific. A multidisciplinary international group (DIRECt), composed of 69 experts, was convened to develop the first evidence-based consensus recommendations for eoCRC. METHODS After reviewing the published literature, a Delphi methodology was used to draft and respond to clinically relevant questions. Each statement underwent 3 rounds of voting and reached a consensus level of agreement of ≥80%. RESULTS The DIRECt group produced 31 statements in 7 areas of interest: diagnosis, risk factors, genetics, pathology-oncology, endoscopy, therapy, and supportive care. There was strong consensus that all individuals younger than 50 should undergo CRC risk stratification and prompt symptom assessment. All newly diagnosed eoCRC patients should receive germline genetic testing, ideally before surgery. On the basis of current evidence, endoscopic, surgical, and oncologic treatment of eoCRC should not differ from later-onset CRC, except for individuals with pathogenic or likely pathogenic germline variants. The evidence on chemotherapy is not sufficient to recommend changes to established therapeutic protocols. Fertility preservation and sexual health are important to address in eoCRC survivors. The DIRECt group highlighted areas with knowledge gaps that should be prioritized in future research efforts, including age at first screening for the general population, use of fecal immunochemical tests, chemotherapy, endoscopic therapy, and post-treatment surveillance for eoCRC patients. CONCLUSIONS The DIRECt group produced the first consensus recommendations on eoCRC. All statements should be considered together with the accompanying comments and literature reviews. We highlighted areas where research should be prioritized. These guidelines represent a useful tool for clinicians caring for patients with eoCRC.
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Affiliation(s)
- Giulia Martina Cavestro
- Gastroenterology and Gastrointestinal Endoscopy Unit, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - Alessandro Mannucci
- Gastroenterology and Gastrointestinal Endoscopy Unit, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesc Balaguer
- Department of Gastroenterology, Hospital Clínic de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), University of Barcelona, Barcelona, Spain
| | - Heather Hampel
- Department of Medical Oncology & Therapeutics Research, City of Hope National Medical Center, Duarte, California
| | - Sonia S Kupfer
- Department of Medicine, Section of Gastroenterology, Hepatology, and Nutrition, University of Chicago Medicine, Chicago, Illinois
| | - Alessandro Repici
- Gastrointestinal Endoscopy Unit, Humanitas University, Humanitas Research Hospital, Rozzano, Italy
| | - Andrea Sartore-Bianchi
- Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, and Department of Hematology Oncology, and Molecular Medicine, Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Toni T Seppälä
- Faculty of Medicine and Medical Technology, University of Tampere and TAYS Cancer Centre, Arvo Ylpön katu, Tampere, Finland; Unit of Gastroenterological Surgery, Tampere University Hospital, Elämänaukio, Tampere, Finland; Applied Tumor Genomics Research Program and Department of Surgery, Helsinki University and Helsinki University Hospital, Helsinki, Finland
| | - Vincenzo Valentini
- Department of Radiology, Radiation Oncology and Hematology, Università Cattolica del Sacro Cuore di Roma, Fondazione Policlinico Universitario A. Gemelli - IRCCS, Rome, Italy
| | - Clement Richard Boland
- Department of Medicine, Division of Gastroenterology, University of California San Diego, San Diego, California
| | - Randall E Brand
- Division of Gastroenterology, Hepatology & Nutrition, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Tineke E Buffart
- Department of Medical Oncology. Amsterdam UMC, Location de Boelelaan, Amsterdam, The Netherlands
| | - Carol A Burke
- Department of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic, Cleveland, Ohio
| | - Riccardo Caccialanza
- Clinical Nutrition and Dietetics Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Renato Cannizzaro
- SOC Gastroenterologia Oncologica e Sperimentale Centro di Riferimento Oncologico di Aviano (CRO) IRCCS 33081, Aviano, Italy
| | - Stefano Cascinu
- Oncology Department, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Andrea Cercek
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Emma J Crosbie
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, St Mary's Hospital, Manchester, United Kingdom; Division of Gynaecology, St Mary's Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Silvio Danese
- Gastroenterology and Gastrointestinal Endoscopy Unit, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Evelien Dekker
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Maria Daca-Alvarez
- Department of Gastroenterology, Hospital Clínic de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Francesco Deni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Mev Dominguez-Valentin
- Department of Tumor Biology, Institute of Cancer Research, The Norwegian Radium Hospital, Oslo, Norway
| | - Cathy Eng
- Department of Medicine, Division of Hematology and Oncology, Vanderbilt-Ingram Cancer Center, Nashville, Tennessee
| | - Ajay Goel
- Department of Molecular Diagnostics & Experimental Therapeutics, Beckman Research Institute of City of Hope Comprehensive Cancer Center, Duarte, California
| | - Josè G Guillem
- Department of Surgery and Lineberger Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Britt B S L Houwen
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Charles Kahi
- Department of Medicine, Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Matthew F Kalady
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Fay Kastrinos
- Division of Digestive and Liver Diseases, Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center and the Vagelos College of Physicians and Surgeons, New York, New York
| | - Florian Kühn
- Department of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Luigi Laghi
- Department of Medicine and Surgery, University of Parma, Parma, and Laboratory of Molecular Gastroenterology, IRCCS Humanitas Research Hospital, Rozzano-Milan, Italy
| | - Andrew Latchford
- Lynch Syndrome Clinic, Centre for Familial Intestinal Cancer, St Mark's Hospital, London North West University Healthcare NHS Trust, Harrow, United Kingdom
| | - David Liska
- Department of Colorectal Surgery and Edward J. DeBartolo Jr Family Center for Young-Onset Colorectal Cancer, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
| | - Patrick Lynch
- Department of Gastroenterology, M. D. Anderson Cancer Center, Houston, Texas
| | - Alberto Malesci
- Gastroenterology and Gastrointestinal Endoscopy Unit, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Gianluca Mauri
- Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, and Department of Hematology Oncology, and Molecular Medicine, Grande Ospedale Metropolitano Niguarda, Milan, Italy; IFOM ETS - The AIRC Institute of Molecular Oncology, Milan, Italy
| | - Elisa Meldolesi
- Department of Radiology, Radiation Oncology and Hematology, Università Cattolica del Sacro Cuore di Roma, Fondazione Policlinico Universitario A. Gemelli - IRCCS, Rome, Italy
| | - Pål Møller
- Department of Tumor Biology, Institute of Cancer Research, The Norwegian Radium Hospital, Oslo, Norway
| | - Kevin J Monahan
- Lynch Syndrome Clinic, Centre for Familial Intestinal Cancer, St Mark's Hospital, London North West University Healthcare NHS Trust, Harrow, United Kingdom; Faculty of Medicine, Department of Surgery & Cancer, Imperial College, London, United Kingdom
| | - Gabriela Möslein
- Surgical Center for Hereditary Tumors, Ev. BETHESDA Khs. Duisburg, Academic Hospital University of Düsseldorf, Düsseldorf, Germany
| | - Caitlin C Murphy
- School of Public Health, University of Texas Health Science Center at Houston, Houston, Texas
| | - Karlijn Nass
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Kimmie Ng
- Young-Onset Colorectal Cancer Center, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Cristina Oliani
- Medical Oncology, AULSS 5 Polesana, Santa Maria Della Misericordia Hospital, Rovigo, Italy
| | - Enrico Papaleo
- Centro Scienze della Natalità, Department of Obstetrics and Gynecology, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Swati G Patel
- University of Colorado Anschutz Medical Center and Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado
| | - Marta Puzzono
- Gastroenterology and Gastrointestinal Endoscopy Unit, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Andrea Remo
- Pathology Unit, Mater Salutis Hospital, ULSS9, Legnago, Verona, Italy
| | - Luigi Ricciardiello
- Department of Medical and Surgical Sciences, Universita degli Studi di Bologna, Bologna, Italy
| | - Carla Ida Ripamonti
- Department of Onco-Haematology, Fondazione IRCCS, Istituto Nazionale dei Tumori, Milan, Italy
| | - Salvatore Siena
- Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, and Department of Hematology Oncology, and Molecular Medicine, Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Satish K Singh
- Department of Medicine, Section of Gastroenterology, VA Boston Healthcare System and Boston University, Boston, Massachusetts
| | - Zsofia K Stadler
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Peter P Stanich
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Sapna Syngal
- Brigham and Women's Hospital, Harvard Medical School, Dana Farber Cancer Institute, Boston, Massachusetts
| | - Stefano Turi
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Emanuele Damiano Urso
- Chirurgia Generale 3, Department of Surgical, Oncological and Gastroenterological Sciences (DiSCOG), University Hospital of Padova, Padova, Italy
| | - Laura Valle
- Hereditary Cancer Program, Catalan Institute of Oncology, Oncobell Program, Bellvitge Biomedical Research Center (IDIBELL), Hospitalet de Llobregat, Barcelona, Spain; Centro de Investigación Biomédica en Red en Cáncer (CIBERONC), Madrid, Spain
| | - Valeria Stella Vanni
- Centro Scienze della Natalità, Department of Obstetrics and Gynecology, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Eduardo Vilar
- Department of Clinical Cancer Prevention, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Marco Vitellaro
- Unit of Hereditary Digestive Tract Tumours, Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Yi-Qian Nancy You
- Department of Colon & Rectal Surgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Matthew B Yurgelun
- Brigham and Women's Hospital, Harvard Medical School, Dana Farber Cancer Institute, Boston, Massachusetts
| | - Raffaella Alessia Zuppardo
- Gastroenterology and Gastrointestinal Endoscopy Unit, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Elena M Stoffel
- Division of Gastroenterology and Hepatology, Department of Internal Medicine and Rogel Cancer Center, University of Michigan Medical School, Ann Arbor, Michigan
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10
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Wennerholm UB, Bergman L, Kuusela P, Ljungström E, Möller AC, Hongslo Vala C, Ekelund AC, Liljegren A, Petzold M, Sjögren P, Svensson M, Strandell A, Jacobsson B. Progesterone, cerclage, pessary, or acetylsalicylic acid for prevention of preterm birth in singleton and multifetal pregnancies - A systematic review and meta-analyses. Front Med (Lausanne) 2023; 10:1111315. [PMID: 36936217 PMCID: PMC10015499 DOI: 10.3389/fmed.2023.1111315] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 02/06/2023] [Indexed: 03/05/2023] Open
Abstract
Background Preterm birth is the leading cause of childhood mortality and morbidity. We aimed to provide a comprehensive systematic review on randomized controlled trials (RCTs) on progesterone, cerclage, pessary, and acetylsalicylic acid (ASA) to prevent preterm birth in asymptomatic women with singleton pregnancies defined as risk of preterm birth and multifetal pregnancies. Methods Six databases (including PubMed, Embase, Medline, the Cochrane Library) were searched up to February 2022. RCTs published in English or Scandinavian languages were included through a consensus process. Abstracts and duplicates were excluded. The trials were critically appraised by pairs of reviewers. The Cochrane risk-of-bias tool was used for risk of bias assessment. Predefined outcomes including preterm birth, perinatal/neonatal/maternal mortality and morbidity, were pooled in meta-analyses using RevMan 5.4, stratified for high and low risk of bias trials. The certainty of evidence was assessed using the GRADE approach. The systematic review followed the PRISMA guideline. Results The search identified 2,309 articles, of which 87 were included in the assessment: 71 original RCTs and 16 secondary publications with 23,886 women and 32,893 offspring. Conclusions were based solely on trials with low risk of bias (n = 50).Singleton pregnancies: Progesterone compared with placebo, reduced the risk of preterm birth <37 gestational weeks: 26.8% vs. 30.2% (Risk Ratio [RR] 0.82 [95% Confidence Interval [CI] 0.71 to 0.95]) (high certainty of evidence, 14 trials) thereby reducing neonatal mortality and respiratory distress syndrome. Cerclage probably reduced the risk of preterm birth <37 gestational weeks: 29.0% vs. 37.6% (RR 0.78 [95% CI 0.69 to 0.88]) (moderate certainty of evidence, four open trials). In addition, perinatal mortality may be reduced by cerclage. Pessary did not demonstrate any overall effect. ASA did not affect any outcome, but evidence was based on one underpowered study.Multifetal pregnancies: The effect of progesterone, cerclage, or pessary was minimal, if any. No study supported improved long-term outcome of the children. Conclusion Progesterone and probably also cerclage have a protective effect against preterm birth in asymptomatic women with a singleton pregnancy at risk of preterm birth. Further trials of ASA are needed. Prevention of preterm birth requires screening programs to identify women at risk of preterm birth. Systematic Review Registration [https://www.crd.york.ac.uk/prospero/], identifier [CRD42021234946].
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Affiliation(s)
- Ulla-Britt Wennerholm
- Region Västra Götaland, Sahlgrenska University Hospital, Department of Obstetrics and Gynecology, Gothenburg, Sweden
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Lina Bergman
- Region Västra Götaland, Sahlgrenska University Hospital, Department of Obstetrics and Gynecology, Gothenburg, Sweden
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Obstetrics and Gynecology, Stellenbosch University, Cape Town, South Africa
- Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden
| | - Pihla Kuusela
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Södra Älvsborg Hospital, Department of Obstetrics and Gynecology, Borås, Sweden
| | - Elin Ljungström
- Region Västra Götaland, Sahlgrenska University Hospital, Department of Obstetrics and Gynecology, Gothenburg, Sweden
| | - Anna C. Möller
- Region Västra Götaland, Sahlgrenska University Hospital, Department of Obstetrics and Gynecology, Gothenburg, Sweden
| | | | - Ann-Catrin Ekelund
- Region Västra Götaland, Skaraborg Hospital, Medical Library, Skövde, Sweden
| | - Ann Liljegren
- Region Västra Götaland, Sahlgrenska University Hospital, Medical Library, Gothenburg, Sweden
| | - Max Petzold
- School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | | | - Mikael Svensson
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, FL, United States
| | - Annika Strandell
- Region Västra Götaland, Sahlgrenska University Hospital, Department of Obstetrics and Gynecology, Gothenburg, Sweden
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, HTA-centrum, Gothenburg, Sweden
| | - Bo Jacobsson
- Region Västra Götaland, Sahlgrenska University Hospital, Department of Obstetrics and Gynecology, Gothenburg, Sweden
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Genetics and Bioinformatics, Division of Health Data and Digitalization, Institute of Public Health, Oslo, Norway
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11
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Aaron DG, Cohen IG, Adashi EY. The FDA Struggle to Withdraw Makena: Problems With the Accelerated Approval Process. JAMA 2022; 328:2394-2395. [PMID: 36480209 DOI: 10.1001/jama.2022.22986] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
This Viewpoint discusses the controversy surrounding the FDA’s efforts to withdraw Makena from the market and the broader implications for the accelerated approval pathway.
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Affiliation(s)
- Daniel G Aaron
- Harvard Law School, Cambridge, Massachusetts
- US Court of Appeals for the Sixth Circuit, Louisville, Kentucky
| | - I Glenn Cohen
- Harvard Law School, Petrie-Flom Center for Health Law Policy, Biotechnology, and Bioethics, Harvard University, Cambridge, Massachusetts
| | - Eli Y Adashi
- Department of Medical Science, Brown University, Providence, Rhode Island
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12
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Murphy CC, Cohn BA. Early Life: An Important Window of Susceptibility for Colorectal Cancer. Gastroenterology 2022; 163:532-533. [PMID: 35007514 PMCID: PMC9259754 DOI: 10.1053/j.gastro.2022.01.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 01/05/2022] [Indexed: 12/02/2022]
Affiliation(s)
- Caitlin C. Murphy
- University of Texas Health Science Center at Houston (UTHealth) School of Public Health, Houston, TX
| | - Barbara A. Cohn
- Child Health and Development Studies, Public Health Institute, Oakland, CA
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13
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Immune effects of 17α-hydroxyprogesterone caproate. Am J Obstet Gynecol 2022; 227:671-675. [PMID: 35779586 DOI: 10.1016/j.ajog.2022.06.056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 06/23/2022] [Indexed: 01/04/2023]
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14
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Boelig RC, Locci M, Saccone G, Gragnano E, Berghella V. Vaginal progesterone compared with intramuscular 17-alpha-hydroxyprogesterone caproate for prevention of recurrent preterm birth in singleton gestations: a systematic review and meta-analysis. Am J Obstet Gynecol MFM 2022; 4:100658. [PMID: 35562009 DOI: 10.1016/j.ajogmf.2022.100658] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 04/12/2022] [Accepted: 04/27/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Randomized trials have found benefits of both vaginal progesterone and 17-alpha-hydroxyprogesterone caproate in the prevention of recurrent preterm birth. A previous meta-analysis directly comparing the two was limited by low-quality evidence, and national and international society guidelines remain conflicting regarding progestin formulation recommended for prevention of recurrent preterm birth. The aim of this updated systematic review with meta-analysis was to evaluate the efficacy of vaginal progesterone compared with 17-alpha-hydroxyprogesterone caproate in the prevention of spontaneous preterm birth in patients with singleton gestations and previous spontaneous preterm birth. DATA SOURCES Searches were performed in MEDLINE, Ovid, Scopus, ClinicalTrials.gov, the International Prospective Register of Systematic Reviews (PROSPERO), SciELO, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL) with the use of a combination of keywords and text words related to "preterm birth," "preterm delivery," "singleton," "cervical length," "progesterone," "progestogens," "vaginal," "17-alpha-hydroxy-progesterone caproate," and "intramuscular" from inception of each database to September 2021. No restrictions for language or geographic location were applied. STUDY ELIGIBILITY CRITERIA We included all randomized controlled trials of asymptomatic singleton gestations with previous spontaneous preterm birth that were randomized to prophylactic treatment with either vaginal progesterone (ie, intervention group) or intramuscular 17-alpha-hydroxyprogesterone caproate (ie, comparison group). Post hoc sensitivity analysis was performed for studies with low risk of bias and studies with protocol registration. METHODS The primary outcome was preterm birth <34 weeks' gestation. The summary measures were reported as relative risks with 95% confidence intervals. RESULTS Seven randomized controlled trials including 1910 patients were included in the meta-analysis. Patients who received vaginal progesterone had a significantly lower rate of preterm birth at <34 weeks (14.7% vs 19.9%; relative risk, 0.74; 95% confidence interval, 0.57-0.96), preterm birth at <37 weeks (36.0% vs 46.6%; relative risk, 0.76; 95% confidence interval, 0.69-0.85), and preterm birth at <32 weeks of gestation (7.9% vs 13.6%; relative risk, 0.58; 95% confidence interval, 0.39-0.86), compared with women who received intramuscular 17-alpha-hydroxyprogesterone caproate. There were no significant differences in the rate of preterm birth at <28 weeks' gestation. Adverse drug reactions were significantly lower in the vaginal progesterone group than in the 17-alpha-hydroxyprogesterone caproate group (15.6% vs 22.2%; relative risk, 0.71; 95% confidence interval, 0.54-0.92). Perinatal mortality was lower in the vaginal progesterone group than in the 17-alpha-hydroxyprogesterone caproate group (2.2% vs 4.4%; relative risk, 0.51; 95% confidence interval, 0.25-1.01). In sensitivity analysis including trials rated with at least 4 Cochrane tools as of "low risk of bias," 4 trials were included (N=575), and there was no longer a significant difference in preterm birth at <34 weeks' gestation between vaginal progesterone and 17-alpha-hydroxyprogesterone caproate (12.2% vs 13.9%; relative risk, 0.87; 95% confidence interval, 0.57-1.32). CONCLUSION Overall, vaginal progesterone was superior to 17-alpha-hydroxyprogesterone caproate in the prevention of preterm birth at <34 weeks' gestation in singleton pregnancies with previous spontaneous preterm birth. Although sensitivity analysis of high-fidelity studies showed the same trend, findings were no longer statistically significant.
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Affiliation(s)
- Rupsa C Boelig
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA (Drs Boelig and Berghella)
| | - Mariavittoria Locci
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy (Drs Locci and Saccone and Ms Gragnano)
| | - Gabriele Saccone
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy (Drs Locci and Saccone and Ms Gragnano)
| | - Elisabetta Gragnano
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy (Drs Locci and Saccone and Ms Gragnano)
| | - Vincenzo Berghella
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA (Drs Boelig and Berghella).
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