Candesartan-based therapy and risk of cancer in patients with systemic hypertension (Heart Institute of Japan Candesartan Randomized Trial for Evaluation in Coronary Artery Disease [HIJ-CREATE] substudy)

The effect of angiotensin receptor blockers and angiotensin-converting enzyme inhibitors on progression of gastric cancer: systematic review and meta-analysis

Angiotensin receptor blockers (ARB), as well as angiotensin-converting enzyme inhibitors (ACEI), are mostly used as therapy for hypertension and cardiovascular disease. However, they can increase the risk of cancer progression including gastric cancer. Here we aimed to analyze the assessment between ARB and ACEI on the progression of gastric cancer. Cochrane Library, PubMed and EMBASE were searched for articles and abstracts describing ARBs, ACEIs, and incidence of gastric cancer. Risk ratio, hazard ratio and 95% confidence interval (CI) were extracted from each outcome by using a random-effects model. Six studies met our inclusion criteria. These results demonstrated that there is a significant association between ARB with gastric cancer progression (risk ratio = 0.63; 95% CI, 0.5-0.7; P = 0.00; I2 = 27.299; df (Q) = 2; Q-value = 2.75). However, there was not any link between ACEIs and gastric cancer development (risk ratio = 1.1; 95% CI, 0.92-1.31; P = 0.26; I2 = 0.00; df (Q) = 3; Q-value = 1.26). All these findings indicated that using the ARBs has raised the progression of gastric cancer in these patients.

Risk of cancer with angiotensin-receptor blockers increases with increasing cumulative exposure: Meta-regression analysis of randomized trials

Angiotensin-receptor blockers (ARBs) are a class of drugs approved for the treatment of several common conditions, such as hypertension and heart failure. Recently, regulatory agencies have started to identify possibly carcinogenic nitrosamines and azido compounds in a multitude of formulations of several ARBs, resulting in progressive recalls. Furthermore, data from several randomized controlled trials suggested that there is also a clinically increased risk of cancer and specifically lung cancer with ARBs; whereas other trials suggested no increased risk. The purpose of this analysis was to provide additional insight into the ARB-cancer link by examining whether there is a relationship between degree of cumulative exposure to ARBs and risk of cancer in randomized trials. Trial-level data from ARB Trialists Collaboration including 15 randomized controlled trials was extracted and entered into meta-regression analyses. The two co-primary outcomes were the relationship between cumulative exposure to ARBs and risk of all cancers combined and the relationship between cumulative exposure and risk of lung cancer. A total of 74,021 patients were randomized to an ARB resulting in a total cumulative exposure of 172,389 person-years of exposure to daily high dose (or equivalent). 61,197 patients were randomized to control. There was a highly significant correlation between the degree of cumulative exposure to ARBs and risk of all cancers combined (slope = 0.07 [95% CI 0.03 to 0.11], p<0.001), and also lung cancer (slope = 0.16 [95% CI 0.05 to 0.27], p = 0.003). Accordingly, in trials where the cumulative exposure was greater than 3 years of exposure to daily high dose, there was a statistically significant increase in risk of all cancers combined (I2 = 31.4%, RR 1.11 [95% CI 1.03 to 1.19], p = 0.006). There was a statistically significant increase in risk of lung cancers in trials where the cumulative exposure was greater than 2.5 years (I2 = 0%, RR 1.21 [95% CI 1.02 to 1.44], p = 0.03). In trials with lower cumulative exposure to ARBs, there was no increased risk of all cancers combined or lung cancer. Cumulative exposure-risk relationship with ARBs was independent of background angiotensin-converting enzyme inhibitor treatment or the type of control (i.e. placebo or non-placebo control). Since this is a trial-level analysis. the effects of patient characteristics such as age and smoking status could not be examined due to lack of patient-level data. In conclusion, this analysis, for the first time, reveals that risk of cancer with ARBs (and specifically lung cancer) increases with increasing cumulative exposure to these drugs. The excess risk of cancer with long-term ARB use has public health implications.

Renin-angiotensin System Inhibitors and Development of Hepatocellular Carcinoma: A Systematic Review and Meta-analysis

Background:

There are controversial results available about using angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) and the development of cancers or improvement of clinical outcomes. Studies reported that using ACEI/ARB may enhance the development of hepatocellular carcinoma (HCC) and clinical outcomes.

Objective:

This meta-analysis aimed to assess the relationship between ACEI/ARB therapy and the development of HCC.

Methods:

PubMed, EMBASE and the Cochrane library were reviewed to identify clinical studies investigating the association between ACEI/ARB therapy and the risk of HCC development. The pooled risk ratio (RR) with 95% confidence intervals collected for the association between using ACEIs/ARBs and HCC development.

Results:

Patients with HCC benefit from the treatment with both ACEIs and ARBs (RR 0.704, 95% CI 0.526- 0.944, p = 0.019). However, only using ARBs was related to HCC risk (0.545 95% CI 0.470-0.632, P<0.0001). Moreover, the study types were significantly related to the observed effects of using both ARBs and ACEIs. Only cohort studies were significantly related to achieving better results (RR=0.513, 95% CI= 0.442-0.597, P<0.0001).

Conclusion:

Despite the small number and heterogeneity of the studies evaluating the relationship between treatment with ARBs and ACEIs and the development of HCC, our meta-analysis demonstrates that they may reduce the risk of HCC.

Antihypertensive medications are associated with the risk of kidney and bladder cancer: a systematic review and meta-analysis

Several studies have indicated that the use of antihypertensive medications may influence the incidence of bladder/kidney cancer, with some scholars refuting any such association. Hence, a systematic review is needed to verify this linkage. we comprehensively searched PubMed, Embase, Web of Science, and the Cochrane Library for original studies reporting a relationship between antihypertensive medications and risk of bladder/kidney cancer. We included 31 articles comprising 3,352,264 participants. We found a significant association between the risk of kidney cancer and any antihypertensive medications use (relative risk (RR) = 1.45, 95% CI 1.20-1.75), as well as angiotensin-converting enzyme inhibitors (RR = 1.24, 95% CI 1.04-1.48), angiotensin II receptor blockers (ARB) (RR = 1.29, 95% CI:1.22-1.37), beta-blockers (RR = 1.36, 95% CI 1.11-1.66), calcium-channel blockers (RR = 1.65, 95% CI 1.54-1.78) and diuretics (RR = 1.34, 95% CI 1.19-1.51). In case of bladder cancer, a statistical significance was observed with the use of ARB (RR = 1.07, 95% CI 1.03-1.11) but not with the other antihypertensive medications. There was a linear association between the duration of antihypertensive medications and the risk of kidney cancer (P = 0.061 for a non-linear trend) and the pooled RR for the per year increase in antihypertensive medications duration of use was 1.02 (95% CI: 1.01-1.02). Our results indicate that there is a significant association between each class of antihypertensive medications and the risk of kidney cancer, and this trend presented as a positive linear association. Furthermore, the use of ARB has been linked to the risk of bladder cancer.

Randomized trials are frequently fragmented in multiple secondary publications

OBJECTIVE

To assess the frequency and features of secondary publications of randomized controlled trials (RCTs).

STUDY DESIGN AND SETTING

For 191 RCTs published in high-impact journals in 2009, we searched for secondary publications coauthored by at least one same author of the primary trial publication. We evaluated the probability of having secondary publications, characteristics of the primary trial publication that predict having secondary publications, types of secondary analyses conducted, and statistical significance of those analyses.

RESULTS

Of 191 primary trials, 88 (46%) had a total of 475 secondary publications by 2/2014. Eight trials had >10 (up to 51) secondary publications each. In multivariable modeling, the risk of having subsequent secondary publications increased 1.32-fold (95% CI 1.05-1.68) per 10-fold increase in sample size, and 1.71-fold (95% CI 1.19-2.45) in the presence of a design article. In a sample of 197 secondary publications examined in depth, 193 tested different hypotheses than the primary publication. Of the 193, 43 tested differences between subgroups, 85 assessed predictive factors associated with an outcome of interest, 118 evaluated different outcomes than the original article, 71 had differences in eligibility criteria, and 21 assessed different durations of follow-up; 176 (91%) presented at least one analysis with statistically significant results.

CONCLUSIONS

Approximately half of randomized trials in high-impact journals have secondary publications published with a few trials followed by numerous secondary publications. Almost all of these publications report some statistically significant results.

Renin-angiotensin system blockade for the risk of cancer and death

INTRODUCTION

The effects of renin-angiotensin system blockade with angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II type 1 receptor blockers (ARBs) on cancer remain inconsistent.

METHODS

We searched existing databases from 1960 to August 2015, for randomised controlled trials and observational studies (case-control studies and cohort studies) of ARB/ACEI therapy with a minimal one year of follow-up. Outcomes were incidence and mortality of cancer.

RESULTS

We included 14 randomised controlled trials and 17 observational studies of 3,957,725 participants (350,329 ARB/ACEI users). The users had a lower incidence of cancer in the observational studies (RR 0.82, 95% CI 0.73-0.93) but not in the randomised controlled trials (RR 1.00, 95% CI 0.92-1.08). The protection persisted for lung cancer (RR 0.85, 95% CI 0.75-0.97) but not for other sites of cancer. The relative risk of cancer associated with renin-angiotensin system blockade was reduced along with time of follow-up. Mortality reduction with ARB/ACEI was marginally significant in the observational studies (RR 0.71, 95% CI 0.55-0.93) but not in the randomised controlled trials (RR 0.99, 95% CI 0.89-1.09).

CONCLUSIONS

The significant benefits of renin-angiotensin system blockade observed in case-control studies and cohort studies might diminish in randomised controlled trials. Clinical design, site of cancer and duration of follow-up may affect the clinical outcomes.

Angiotensin II Receptor Blockers and Cancer Risk: A Meta-Analysis of Randomized Controlled Trials

Angiotensin II receptor blockers (ARB) are widely used drugs that are proven to reduce cardiovascular disease events; however, several recent meta-analyses yielded conflicting conclusions regarding the relationship between ARB and cancer incidence, especially when ARB are combined with angiotensin-converting enzyme inhibitors (ACEI).We investigated the risk of cancer associated with ARB at different background ACEI levels.Search of PubMed and EMBASE (1966 to December 17, 2015) without language restriction.Randomized, controlled trials (RCTs) had at least 12 months of follow-up data and reported cancer incidence was included.Study characteristics, quality, and risk of bias were assessed by 2 reviewers independently.Nineteen RCTs including 148,334 patients were included in this study. Random-effects model meta-analyses were used to estimate the risk ratio (RR) of cancer risk. No excessive cancer risk was observed in our analyses of ARB alone versus placebo alone without background ACEI use (risk ratio [RR] 1.08, 95% confidence interval [CI] 1.00-1.18, P = 0.05); ARB alone versus ACEI alone (RR 1.03, 95%CI 0.94-1.14, P = 0.50); ARB plus partial use of ACEI versus placebo plus partial use of ACEI (RR 0.97, 95%CI 0.90-1.04, P = 0.33); and ARB plus ACEI versus ACEI (RR 0.99, 95%CI 0.79-1.24, P = 0.95).Lack of long-term data, inadequate reporting of safety data, significant heterogeneity in underlying study populations, and treatment regimens.ARB have a neutral effect on cancer incidence in randomized trials. We observed no significant differences in cancer incidence when we compared ARB alone with placebo alone, ARB alone with ACEI alone, ARB plus partial use of ACEI with placebo plus partial use of ACEI, or ARB plus ACEI combination with ACEI.

[Oncology-related issues of angiotensin-receptor blockers]

Recently controversial data emerged regarding the cancer inducing activity of angiotensin-receptor blockers. There may be several reasons which may explain the controversial data published in the scientific literature including wrong trial design or misinterpretation of data. Considering the large number of patients receiving treatment for hypertension, it is essential to have a clear view of the cancer-related safety of these drugs. This paper tries to give an overview on this issue based on data available in the literature. According to our present knowledge, angiotensin-receptor blockers exert more likely anticancer activity rather than carcinogenesis inducing effect. In fact, some oncologic trials point to this direction, because angiotensin-receptor blockers are suggested as co-treatment to chemotherapy in cases of pancreatic, oesophageal and gastric cancers.

Lack of an association between angiotensin receptor blocker based therapy and increased risk of cancer: evidence from large observational studies

Background

A previous meta-analysis of randomized controlled studies that were not designed to investigate cancer as a primary outcome suggested that ARB-based therapy is associated with increased risk of cancer; however, results of recent observational studies considering the association have been contradictory. This study sought to evaluate the association between angiotensin receptor blocker (ARB)-based therapy and risk of cancer by conducting a meta-analysis of observational studies.

Methods

Relevant articles published before February 2014 were identified by searching PubMed and the Cochrane Library. Pooled relative risks (RRs) were determined using a random effects model and were used to assess the strength of association between use of ARB-based therapy and risk of cancer.

Results

Six retrospective cohort studies involving a total of 3,827,109 participants and four case-control studies involving a total of 193,029 cases were included. The present study found that ARB-based therapy was not significantly associated with an increased risk of cancer (RR = 0.87, 95%CI: [0.75, 1.01]). However, an analysis including only cohort studies suggested a significantly decreased risk of cancer among individuals with any history of ARB use as compared to those with no history of ARB use (RR = 0.80, 95%CI: [0.55, 0.95]); no significant association was found between ARB use and risk of cancer when the case-control studies were separately considered (RR = 1.03, 95%CI: [0.93, 1.13]). Subgroup analyses showed that use of ARB-based therapy was associated with decreased risk of lung cancer (RR = 0.81, 95%CI: [0.69, 0.94]); however, no significant associations were found with the other cancer sites investigated. Furthermore, no association was observed upon adjustment by type of ARB drug. No publication bias was detected.

Conclusion

Overall, ARB-based therapy was not associated with increased risk of cancer. However, its use may be related to decreased incidence of lung cancer; this finding should be considered carefully and confirmed with further studies.

Lowered cancer risk with ACE inhibitors/ARBs: a population-based cohort study

There are conflicting reports on cancer risk associated with angiotensin-converting enzyme (ACE) inhibitors/angiotensin receptor blockers (ARBs). This retrospective cohort study was conducted to analyze the risk of cancer development in patients who received ACE inhibitors/ARBs as treatment for essential hypertension. Using the Taiwan National Health Insurance Research Database, 297,688 eligible study patients with essential hypertension were identified. According to their antihypertensive prescriptions, the study patients were stratified into an ACE inhibitor group, an ARB group, or a control group. After matching, participants were observed for the occurrence of cancer. In the ACE inhibitor group compared with the control group, the hazard ratio was 0.51 (95% confidence interval, 0.39-0.68). In the ARB group compared with the control group, the hazard ratio was 0.8 (95% confidence interval, 0.65-0.97). Regular use of ACE inhibitors/ARBs was not associated with an increased risk of cancer development and was actually found to decrease overall cancer risk in this study.

Use of ACE Inhibitors and Angiotensin Receptor Blockers and Primary Breast Cancer Outcomes

BACKGROUND

ACE inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) may have anti-tumor properties. We investigated whether the use of ACEI/ARBs affects the clinical outcomes of primary breast cancer patients receiving taxane and anthracycline-based neoadjuvant chemotherapy.

METHODS

We included 1449 patients with diagnosis of invasive primary breast cancer diagnosed at the MD Anderson Cancer Center between 1995 and 2007 who underwent neoadjuvant chemotherapy. Of them, 160 (11%) patients were identified by review of their medical record, as ACEI/ARBs users. We compared pathologic complete response (pCR) rates, relapse-free survival (RFS), disease-specific survival (DSS) and overall survival (OS) between ACEI/ARB users and non-users. Descriptive statistics and Cox proportional hazards model were used in the analyses.

RESULTS

There was no difference in the pCR rates between ACEI/ARB users and non-users (16% vs 18.1%, p-=0.50). After adjustment for important demographic and clinical characteristics, no significant differences between ACEI/ARB users and nonusers were observed in RFS (HR=0.81; 95% CI=0.54-1.21), DSS (HR=0.83; 95% CI=0.52-1.31), or OS (HR=0.91; 95% CI =0.61-1.37). In a subgroup analysis, the 5-year RFS was 82% in ARB only users versus 71% in ACEI/ARB non-users (P=0.03). In the multivariable analysis, ARB use was also associated with a decreased risk of recurrence (HR=0.35; 95% CI=0.14-0.86). No statistically significant differences in DSS or OS were seen.

CONCLUSION

No differences in pCR and survival outcomes were seen between ACEI/ARB users and non-users among breast cancer patients receiving neoadjuvant chemotherapy. ARB use may be associated with improved RFS. Further research is needed to validate this finding.

An evaluation of the latest evidence relating to renin-angiotensin system inhibitors

INTRODUCTION

In the last few years, a number of important clinical trials have been completed that have investigated the inhibition of the renin-angiotensin system. New drugs, focusing on this system, have now emerged as a result.

AREAS COVERED

The authors review the most relevant information available, reported from the last 5 years, pertaining to the most important clinical trials on renin-angiotensin system blockers (ARBs). The authors' data review includes the trials of aliskiren, telmisartan, olmesartan and azilsartan. The authors also review the possible risk of cancer with ARBs.

EXPERT OPINION

The results of ASPIRE and ALTITUDE trials strongly suggested that dual inhibition of aliskiren with either ARBS or angiotensin converting enzyme inhibitors (ACEi) should be avoided. Olmesartan is an effective and safe antihypertensive agent, but special attention should be paid to high-risk patients, such as those with coronary disease, to avoid an excessive reduction in blood pressure. The authors also note that while azilsartan is probably the most potent ARB, there is still a lack of data regarding potential organ damage and the incidence of cardiovascular events. Lastly, recent evidence has shown a lack of a relationship between ARB therapy and the occurrence of cancer.