Epoetin alfa improves survival after chemoradiation for Stage III esophageal cancer: Final results of a prospective observational study

Predictive value of dynamic change of haemoglobin levels during therapy on treatment outcomes in patients with Enneking stage IIB extremity osteosarcoma

Background

We aimed to investigate the roles of hemoglobin (Hb) concentrations and dynamic change during treatment on outcomes of patients with extremity osteosarcoma.

Methods

We retrospectively analysed 133 patients with Enneking stage IIB extremity osteosarcoma who underwent standard treatments, including univariate and multivariate analyses of patient charateritics, Hb concentrations and changes during pretreatment, neoadjuvant, adjuvant chemotherapy, and decreased Hb levels (ΔHb) to assess their prognostic value in 5-year overall survival (OS) and lung metastasis-free survival (LMFS).

Results

Five-year OS or LMFS were similar between patients who were anaemic and non-anaemic during pretreatment, neoadjuvant or adjuvant chemotherapy. Patients with continuously decreasing Hb had lower 5-year OS (52.3%) than those without continuous Hb decrease (68.5%, P = 0.04). Patients with ΔHb > 7.6 g/L had lower 5-year OS (57.5%) than those with ΔHb ≤7.6 g/L (75.8%, P = 0.04). However, continuous Hb decrease had no prognostic effect on 5-year LMFS. Subgroup analyses showed that patients who were anaemic during pretreatment, neoadjuvant, or adjuvant chemotherapy with ΔHb ≤7.6 g/L had better outcomes than those with ΔHb > 7.6 g/L (P < 0.05, for both).

Conclusion

Dynamic Hb decrease and ΔHb > 7.6 predicted poor5-year OS in patients with Enneking stage IIB extremity osteosarcoma. Attempts to correct anaemia and their effects on outcomes for osteosarcoma patients should be investigated in future trials.

Nutrition in peri-operative esophageal cancer management

Nutritional status and dietary intake are increasingly recognized as essential areas in esophageal cancer management. Nutritional management of esophageal cancer is a continuously evolving field and comprises an interesting area for scientific research. Areas covered: This review encompasses the current literature on nutrition in the pre-operative, peri-operative, and post-operative phases of esophageal cancer. Both established interventions and potential novel targets for nutritional management are discussed. Expert commentary: To ensure an optimal pre-operative status and to reduce peri-operative complications, it is key to assess nutritional status in all pre-operative esophageal cancer patients and to apply nutritional interventions accordingly. Since esophagectomy results in a permanent anatomical change, a special focus on nutritional strategies is needed in the post-operative phase, including early initiation of enteral feeding, nutritional interventions for post-operative complications, and attention to long-term nutritional intake and status. Nutritional aspects of pre-optimization and peri-operative management should be incorporated in novel Enhanced Recovery After Surgery programs for esophageal cancer.

Enhanced recovery for esophagectomy: a systematic review and evidence-based guidelines

OBJECTIVE

This article aims to provide the first systematic review of enhanced recovery after surgery (ERAS) programs for esophagectomy and generate guidelines.

BACKGROUND

ERAS programs use multimodal approaches to reduce complications and accelerate recovery. Although ERAS is well established in colorectal surgery, experience after esophagectomy has been minimal. However, esophagectomy remains an extremely high-risk operation, commonly performed in patients with significant comorbidities. Consequently, ERAS may have a significant role to play in improving outcomes. No guidelines or reviews have been published in esophagectomy.

METHODS

We undertook a systematic review of the PubMed, EMBASE, and the Cochrane databases in July 2012. The literature was searched for descriptions of ERAS in esophagectomy. Components of successful ERAS programs were determined, and when not directly available for esophagectomy, extrapolation from related evidence was made. Graded recommendations for each component were then generated.

RESULTS

Six retrospective studies have assessed ERAS for esophagectomy, demonstrating favorable morbidity, mortality, and length of stay. Methodological quality is, however, low. Overall, there is little direct evidence for components of ERAS, with much derived from nonesophageal thoracoabdominal surgery.

CONCLUSIONS

ERAS in principle seems logical and safe for esophagectomy. However, the underlying evidence is poor and lacking. Despite this, a number of recommendations for practice and research can be made.

Abnormal tumor vasculatures and bone marrow-derived pro-angiogenic cells in cancer

Tumor-derived factors affect the stroma of cancer tissue by activating pro-angiogenic signals. One of the key components of this response is the mobilization of the pro-angiogenic cells from bone marrow (BM), which contribute to the development of abnormal tumor vasculature. Evidence is accumulating that the pro-angiogenic cells derived from BM are involved in the physiological processes of tissue repair and wound healing. However, vascular structure in cancer tissue is impaired, resulting in the formation of chaotic neo-vessels and hypoxic microenvironments. Ultimately, these structural and functional abnormalities result in the limited delivery of chemotherapeutic agents and create regions of metabolic derangement, both of which enhance resistance to chemotherapy. In spite of recent advances in targeted therapy using anti-vascular agents, clinical results from studies using individual agents have unsatisfactory, necessitating the combinatorial use of anti-cancer drugs and a targeting agent. We suggest the possibility of a new therapeutic approach in which aberrant tumor vessels are normalized by BM-derived pro-angiogenic cells, and the delivery of anti-cancer drugs is maximized. In this review, we focus on the current understanding of the structure and function of tumor vessels, and an alternative approach to the repair of abnormal tumor vasculature by the use of BM-derived pro-angiogenic cells. This approach may improve both the delivery and the efficacy of anti-cancer drugs by restoring aberrant tumor vascularization and hypoxia.

Transplanting normal vascular proangiogenic cells to tumor-bearing mice triggers vascular remodeling and reduces hypoxia in tumors

Blood vessels deliver oxygen and nutrients to tissues, and vascular networks are spatially organized to meet the metabolic needs for maintaining homeostasis. In contrast, the vasculature of tumors is immature and leaky, resulting in insufficient delivery of nutrients and oxygen. Vasculogenic processes occur normally in adult tissues to repair "injured" blood vessels, leading us to hypothesize that bone marrow mononuclear cells (BMMNC) may be able to restore appropriate vessel function in the tumor vasculature. Culturing BMMNCs in endothelial growth medium resulted in the early outgrowth of spindle-shaped attached cells expressing CD11b/Flt1/Tie2/c-Kit/CXCR4 with proangiogenic activity. Intravenous administration of these cultured vascular proangiogenic cells (VPC) into nude mice bearing pancreatic cancer xenografts and Pdx1-Cre;LSL-Kras(G12D);p53(lox/+) genetically engineered mice that develop pancreatic ductal adenocarcinoma significantly reduced areas of hypoxia without enhancing tumor growth. The resulting vasculature structurally mimicked normal vessels with intensive pericyte coverage. Increases in vascularized areas within VPC-injected xenografts were visualized with an ultrasound diagnostic system during injection of a microbubble-based contrast agent (Sonazoid), indicating a functional "normalization" of the tumor vasculature. In addition, gene expression profiles in the VPC-transplanted xenografts revealed a marked reduction in major factors involved in drug resistance and "stemness" of cancer cells. Together, our findings identify a novel alternate approach to regulate abnormal tumor vessels, offering the potential to improve the delivery and efficacy of anticancer drugs to hypoxic tumors.

Extracts from The Cochrane Library: Erythropoietin as an adjuvant treatment with (chemo) radiation therapy for head and neck cancer

The "Cochrane Corner" is a quarterly section in the Journal that highlights systematic reviews relevant to otolaryngology-head and neck surgery, with invited commentary to aid clinical decision making. This installment features a Cochrane Review entitled "Erythropoietin as an adjuvant treatment with (chemo) radiation therapy for head and neck cancer," which concludes that erythropoietin should not be administered as an addition to radiation therapy outside the experimental setting.

Efficacy of chemoradiotherapy with low-dose cisplatin and continuous infusion of 5-fluorouracil for unresectable squamous cell carcinoma of the esophagus

We retrospectively investigated the efficacy of a chemoradiotherapy regimen using daily low-dose cisplatin and continuous 5-fluorouracil infusion in 71 registered patients with unresectable esophageal cancer. The overall response rate (complete response plus partial response) was 59%. The major toxicities observed were leukopenia and anorexia. The 1- and 3-year overall survival rates were 54.6% and 18.4%, respectively. A low preoperative C-reactive protein level was found to be associated with a good response. The pretreatment performance status and response results were both shown to be prognostic factors for overall survival. These findings confirmed that the chemoradiotherapy regimen had curative potential for unresectable esophageal cancer.

Pre and peri-operative erythropoietin for reducing allogeneic blood transfusions in colorectal cancer surgery

BACKGROUND

Patients with colorectal cancer are frequently anaemic and many receive allogeneic red blood cell transfusions peri and post-operatively. Transfusions are accompanied by complications and may increase the rate of recurrence in patients who have a colorectal resection. Recombinant erythropoietin was first used in dialysis patients and more recently in orthopedic surgery to facilitate autologous transfusions. Erythropoietin levels are thought to be lower in cancer patients and erythropoietin is widely used in chemotherapy to treat anaemia and improve quality of life. There may be adverse events associated with its use. Several studies have investigated erythropoietin in colorectal cancer surgery.

OBJECTIVES

The primary objective of this systematic review was to evaluate the efficacy of erythropoietin pre and peri-operatively, in reducing allogeneic blood transfusions in patients undergoing colorectal cancer surgery. Secondary objectives were to determine whether pre and peri-operative erythropoietin improves hematologic parameters (hemoglobin, hematocrit and reticulocyte count), quality of life, recurrence rate, and survival, without increasing the occurrence of thrombotic events and the peri-operative mortality.

SEARCH STRATEGY

A literature search was performed using MEDLINE, EMBASE, abstracts from the annual meetings of the American Society of Clinical Oncology and the American Society of Colon and Rectal Surgeons until May 2008.

SELECTION CRITERIA

Randomized controlled trials of erythropoietin versus placebo or no treatment/standard of care were eligible for inclusion. The study must have reported one of the primary or secondary outcomes and included anaemic patients undergoing surgery for colorectal cancer.

DATA COLLECTION AND ANALYSIS

The methodological quality of the trials was assessed using the information provided. Data were extracted and effect sizes were estimated and reported as relative risks(RR) and mean differences (MD) as appropriate.

MAIN RESULTS

Four eligible studies were identified of ten retrieved in full. There were no statistically significant differences in the proportion of patients transfused between the erythropoietin group and control group. One of the studies showed a small difference in the median number of units transfused per patient favouring treatment. Reporting of hematologic parameters was varied however, there is no evidence for clinically significant changes. There were no significant differences in post-operative mortality or thrombotic events between groups. No included study evaluated recurrences, survival, or quality of life. Studies were of fair methodologic quality and the overall sample size was small therefore results should be interpreted with caution.

AUTHORS' CONCLUSIONS

There is no sufficient evidence to date to recommend pre and peri-operative erythropoietin use in colorectal cancer surgery.

Effect of Once-Weekly Epoetin Beta on Survival in Patients With Metastatic Breast Cancer Receiving Anthracycline- and/or Taxane-Based Chemotherapy: Results of the Breast Cancer—Anemia and the Value of Erythropoietin (BRAVE) Study

Purpose

The Breast Cancer—Anemia and the Value of Erythropoietin (BRAVE) study evaluated whether epoetin beta would improve survival in patients with metastatic breast cancer (MBC).

Patients and Methods

BRAVE was an open-label, randomized, multicenter study in patients with MBC treated with anthracycline- and/or taxane-based chemotherapy. Patients (hemoglobin [Hb] < 12.9 g/dL) were randomly assigned (1:1) to epoetin beta 30,000 U subcutaneously once weekly or control for 24 weeks. The primary efficacy variable was overall survival. Secondary efficacy outcomes included progression-free survival, transfusion- and severe anemia–free survival, Hb response, safety, and quality of life (QoL).

Results

After 18 months of follow-up, 62 (27%) of 231 patients survived with epoetin beta therapy and 63 (27%) of 232 with control. No difference was detected in overall survival (hazard ratio [HR] = 1.07; 95% CI, 0.87 to 1.33, P = .522) or progression-free survival (HR = 1.07; 95% CI, 0.89 to 1.30, P = .448). There was a statistically significant benefit on transfusion- and severe anemia–free survival compared with control (HR = 0.59; P = .0097). Median Hb level increased with epoetin beta (11.7 g/dL at baseline to 13.3 g/dL at 24 weeks) but did not change with control (11.5 v 11.4 g/dL). Patients receiving epoetin beta experienced more thromboembolic events (TEEs) compared with controls (13% v 6%; P = .012) with no difference in serious TEEs (4% v 3%). Epoetin beta did not significantly improve QoL in this study where patients had a high baseline Hb value.

Conclusion

In patients with MBC receiving chemotherapy and initial Hb less than 12.9 g/dL, epoetin beta increased Hb. No difference was detected in overall survival. Because of its superiority design, this study cannot, however, exclude clinically important differences in survival with absolute certainty.

Prognostic significance of blood transfusions in patients with esophageal cancer treated with combined chemoradiotherapy

OBJECTIVE

Anemia occurs commonly in patients with esophageal cancer. This study evaluates the effect of blood transfusion on survival outcomes in patients with esophageal cancer treated with combined chemoradiotherapy (CRT).

PATIENTS AND METHODS

Fifty-six consecutive patients with unresectable esophageal cancer received 50 Gy in 25 fractions over 5 weeks concurrent with cycles 2 and 3 of cisplatin and 5-fluorouracil chemotherapy. Data on hemoglobin before and during radiation therapy (RT) and blood transfusion use were abstracted by chart review. Each patient had a blood count before every chemotherapy cycle, and the test was repeated if the blood count was low. Five-year Kaplan-Meier overall survival (OS) and relapse-free survival (RFS) estimates were compared according to pre-RT hemoglobin levels and transfusion use. Multivariate analysis using Cox regression modeling was performed to determine the prognostic significance of pre-RT hemoglobin and transfusion use on survival outcomes.

RESULTS

The 5-year OS and RFS rates were 30% and 37%, respectively. Seventeen patients (30%) received transfusions during CRT. Among 18 patients (32%) with a hemoglobin of < or =12 g/dL at the start of RT, 9 received transfusions. Pre-RT hemoglobin levels of < or =12 g/dL were strongly associated with the use of blood transfusions (P = 0.03). Five-year Kaplan-Meier OS was 65% versus 21% in patients treated with, versus without, a transfusion (P = 0.006). On multivariate analysis, the use of blood transfusion was associated with improved OS (hazard ratio, 0.26; 95% confidence interval, 0.09-0.75, P = 0.01).

CONCLUSIONS

The use of blood transfusion is a significant treatment-related factor associated with improved survival in patients undergoing CRT for esophageal cancer.

The impact of tumor expression of erythropoietin receptors and erythropoietin on clinical outcome of esophageal cancer patients treated with chemoradiation

BACKGROUND

To investigate the impact of tumor erythropoietin receptors (Epo-R) and erythropoietin (Epo) expression in 64 patients with Stage III esophageal cancer receiving or not receiving erythropoietin during chemoradiation.

MATERIALS AND METHODS

The impact of tumor Epo-R expression, Epo expression, and 10 additional factors (age, Karnofsky-Performance-Score [KPS], tumor length, T and N stage, histology and grading, hemoglobin during radiotherapy, erythropoietin administration, surgery) on overall survival (OS) and locoregional control (LC) was evaluated.

RESULTS

Improved OS was associated with low (< or =20%) Epo expression (p = 0.049), KPS >80 (p = 0.008), T3 stage (p = 0.010), hemoglobin > or =12 g/dL (p < 0.001), and surgery (p = 0.010). Erythropoietin receptor expression showed a trend (p = 0.09). Locoregional control was associated with T stage (p = 0.005) and hemoglobin (p < 0.001), almost with erythropoietin administration (p = 0.06). On multivariate analyses, OS was associated with KPS (p = 0.045) and hemoglobin (p = 0.032), LC with hemoglobin (p < 0.001). Patients having low expression of both Epo-R and Epo had better OS (p = 0.003) and LC (p = 0.043) than others. Two-year OS was nonsignificantly better (p = 0.25) in patients with low Epo-R expression receiving erythropoietin (50%) than in those with higher Epo-R expression receiving erythropoietin (21%), low Epo-R expression/no erythropoietin administration (29%), or higher Epo-R expression/no erythropoietin administration (18%). Two-year LC rates were, respectively, 65%, 31%, 26%, and 29% (p = 0.20). Results for Epo expression were similar.

CONCLUSIONS

Higher Epo-R expression or Epo expression seemed to be associated with poorer outcomes. Patients with low expression levels receiving erythropoietin seemed to do better than patients with higher expression levels or not receiving erythropoietin. The data need to be confirmed in a larger series of patients.

EPO in cancer anemia: Benefits and potential risks

Anemia has an incidence both on the quality of life and the evolution of cancer. Anemia may result in cancer from either a bone marrow infiltration of cancer cells or a cytotoxic effect of chemotherapy and/or radiotherapy, or both. EPO is a glycoprotein which stimulates erythrocyte formation by bone marrow progenitory cells. Recombinant EPO has considerably improved treatment of anemic patients, by increasing hemoglobin serum levels and reducing the need for blood transfusion. The quality of life of cancer patients is thus improved and several studies highlight the beneficial role of EPO on the clinical outcome. A preclinical background and some clinical data suggest however a detrimental role of EPO in cancer by a possible stimulation of tumor growth. There is a need of more clinical trials in order to assess the effects of EPO on tumors and their treatment.

Recombinant human erythropoietin alpha modulates the effects of radiotherapy on colorectal cancer microvessels

Recent data suggest that recombinant human erythropoietin (rhEPO) modulates tumour growth and therapy response. The purpose of the present study was to examine the modulation of radiotherapy (RT) effects on tumour microvessels by rhEPO in a rat colorectal cancer model. Before and after 5 × 5 Gy of RT, dynamic contrast-enhanced -magnetic resonance imaging was performed and endothelial permeability surface product (PS), plasma flow (F), and blood volume (V) were modelled. Imaging was combined with pO₂ measurements, analysis of microvessel density, microvessel diameter, microvessel fractal dimension, and expression of vascular endothelial growth factor (VEGF), hypoxia-inducible factor-1 α (HIF-1α), Bax, and Bcl-2. We found that RT significantly reduced PS and V in control rats, but not in rhEPO-treated rats, whereas F was unaffected by RT. Oxygenation was significantly better in rhEPO-treated animals, and RT induced a heterogeneous reoxygenation in both groups. Microvessel diameter was significantly larger in rhEPO animals, whereas VEGF expression was significantly lower in the rhEPO group. No differences were observed in HIF-1α, Bax, or Bcl-2 expression. We conclude that rhEPO results in spatially heterogeneous modulation of RT effects on tumour microvessels. Direct effects of rhEPO on neoplastic endothelium are likely to explain these findings in addition to indirect effects induced by increased oxygenation.