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Bessoles S, Chiron A, Sarrabayrouse G, De La Grange P, Abina AM, Hacein-Bey-Abina S. Erythropoietin induces tumour progression and CD39 expression on immune cells in a preclinical model of triple-negative breast cancer. Immunology 2024. [PMID: 38953295 DOI: 10.1111/imm.13832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Accepted: 06/14/2024] [Indexed: 07/04/2024] Open
Abstract
The adverse effects observed in some cancer patients treated with erythropoiesis-stimulating agents such as erythropoietin (EPO) might be due to the latter's well-known immunosuppressive functions. Here, we used a mouse model of syngeneic triple-negative breast cancer to explore EPO's immunomodulatory role in a tumour setting. Our results showed that EPO treatment promotes tumour growth, exacerbates the 'immune desert', and results in a 'cold tumour'. EPO treatment changed the immune cell distribution in peripheral blood, secondary lymphoid organs, and the tumour microenvironment (TME). Our in-depth analysis showed that EPO mainly impacts CD4 T cells by accelerating their activation in the spleen and thus their subsequent exhaustion in the TME. This process is accompanied by a general elevation of CD39 expression by several immune cells (notably CD4 T cells in the tumour and spleen), which promotes an immunosuppressive TME. Lastly, we identified a highly immunosuppressive CD39+ regulatory T cell population (ICOS+, CTLA4+, Ki67+) as a potential biomarker of the risk of EPO-induced tumour progression. EPO displays pleiotropic immunosuppressive functions and enhances mammary tumour progression in mice.
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Affiliation(s)
- Stéphanie Bessoles
- Université Paris Cité, CNRS, INSERM, UTCBS, Unité des Technologies Chimiques et Biologiques pour la Santé, Paris, France
| | - Andrada Chiron
- Université Paris Cité, CNRS, INSERM, UTCBS, Unité des Technologies Chimiques et Biologiques pour la Santé, Paris, France
- Clinical Immunology Laboratory, Groupe Hospitalier Universitaire Paris-Sud, Hôpital Kremlin-Bicêtre, Assistance Publique-Hôpitaux de Paris, Le-Kremlin-Bicêtre, France
| | - Guillaume Sarrabayrouse
- Université Paris Cité, CNRS, INSERM, UTCBS, Unité des Technologies Chimiques et Biologiques pour la Santé, Paris, France
| | | | - Amine M Abina
- Université Paris Cité, CNRS, INSERM, UTCBS, Unité des Technologies Chimiques et Biologiques pour la Santé, Paris, France
| | - Salima Hacein-Bey-Abina
- Université Paris Cité, CNRS, INSERM, UTCBS, Unité des Technologies Chimiques et Biologiques pour la Santé, Paris, France
- Clinical Immunology Laboratory, Groupe Hospitalier Universitaire Paris-Sud, Hôpital Kremlin-Bicêtre, Assistance Publique-Hôpitaux de Paris, Le-Kremlin-Bicêtre, France
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Neto BV, Tavares V, da Silva JB, Liz-Pimenta J, Marques IS, Salgado L, Carvalho L, Pereira D, Medeiros R. Haemostatic gene variations in cervical cancer-associated venous thrombosis: considerations for clinical strategies. J Thromb Thrombolysis 2024; 57:815-827. [PMID: 38643313 DOI: 10.1007/s11239-024-02983-2] [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] [Accepted: 04/09/2024] [Indexed: 04/22/2024]
Abstract
Venous thromboembolism (VTE) is a life-threatening haemostatic disease frequently diagnosed among the cancer population. The Khorana Score is currently the primal risk assessment model to stratify oncological patients according to their susceptibility to VTE, however, it displays a limited performance. Meanwhile, intensive research on VTE pathophysiology in the general population has uncovered a range of single-nucleotide polymorphisms (SNPs) associated with the condition. Nonetheless, their predictive ability concerning cancer-associated thrombosis (CAT) is controversial. Cervical cancer (CC) patients undergoing chemoradiotherapy often experience VTE, which negatively affects their survival. Thus, aiming for an improvement in thromboprophylaxis, new thrombotic biomarkers, including SNPs, are currently under investigation. In this study, the predictive capability of haemostatic gene SNPs on CC-related VTE and their prognostic value regardless of VTE were explored. Six SNPs in haemostatic genes were evaluated. A total of 401 CC patients undergoing chemoradiotherapy were enrolled in a retrospective cohort study. The implications for the time to VTE occurrence and overall survival (OS) were assessed. CAT considerably impacted the CC patients' OS (log-rank test, P < 0.001). SERPINE1 rs2070682 (T > C) showed a significant association with the risk of CC-related VTE (CC/CT vs. TT, log-rank test, P = 0.002; C allele, Cox model, hazard ratio (HR) = 6.99 and P = 0.009), while F2 rs1799963 (G > A) demonstrated an important prognostic value regardless of VTE (AA/AG vs. GG, log-rank test, P = 0.020; A allele, Cox model, HR = 2.76 and P = 0.026). For the remaining SNPs, no significant associations were detected. The polymorphisms SERPINE1 rs2070682 and F2 rs1799963 could be valuable tools in clinical decision-making, aiding in thromboprophylaxis and CC management, respectively.
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Affiliation(s)
- Beatriz Vieira Neto
- Molecular Oncology and Viral Pathology Group, Research Center of IPO Porto (CI-IPOP)/Pathology and Laboratory Medicine Dep, Clinical Pathology SV/ RISE@CI-IPOP (Health Research Network), Portuguese Oncology Institute of Porto (IPO Porto) / Porto Comprehensive Cancer Centre (Porto.CCC), Porto, 4200-072, Portugal
- Research Department, Portuguese League Against Cancer (NRNorte), Porto, 4200-172, Portugal
| | - Valéria Tavares
- Molecular Oncology and Viral Pathology Group, Research Center of IPO Porto (CI-IPOP)/Pathology and Laboratory Medicine Dep, Clinical Pathology SV/ RISE@CI-IPOP (Health Research Network), Portuguese Oncology Institute of Porto (IPO Porto) / Porto Comprehensive Cancer Centre (Porto.CCC), Porto, 4200-072, Portugal
- Faculty of Medicine, University of Porto (FMUP), Porto, 4200-072, Portugal
- Instituto de Ciências Biomédicas Abel Salazar, ICBAS, Universidade do Porto, Porto, Portugal
| | - José Brito da Silva
- Oncology Department, Portuguese Institute of Oncology of Porto (IPOP), Porto, 4200-072, Portugal
| | - Joana Liz-Pimenta
- Faculty of Medicine, University of Porto (FMUP), Porto, 4200-072, Portugal
- Department of Medical Oncology, Centro Hospitalar de Trás-os-Montes e Alto Douro (CHTMAD), Vila Real, 5000-508, Portugal
| | - Inês Soares Marques
- Molecular Oncology and Viral Pathology Group, Research Center of IPO Porto (CI-IPOP)/Pathology and Laboratory Medicine Dep, Clinical Pathology SV/ RISE@CI-IPOP (Health Research Network), Portuguese Oncology Institute of Porto (IPO Porto) / Porto Comprehensive Cancer Centre (Porto.CCC), Porto, 4200-072, Portugal
| | - Lurdes Salgado
- External Radiotherapy Department, Portuguese Institute of Oncology of Porto (IPOP), Porto, 4200-072, Portugal
| | - Luísa Carvalho
- External Radiotherapy Department, Portuguese Institute of Oncology of Porto (IPOP), Porto, 4200-072, Portugal
| | - Deolinda Pereira
- Oncology Department, Portuguese Institute of Oncology of Porto (IPOP), Porto, 4200-072, Portugal
| | - Rui Medeiros
- Molecular Oncology and Viral Pathology Group, Research Center of IPO Porto (CI-IPOP)/Pathology and Laboratory Medicine Dep, Clinical Pathology SV/ RISE@CI-IPOP (Health Research Network), Portuguese Oncology Institute of Porto (IPO Porto) / Porto Comprehensive Cancer Centre (Porto.CCC), Porto, 4200-072, Portugal.
- Research Department, Portuguese League Against Cancer (NRNorte), Porto, 4200-172, Portugal.
- Faculty of Medicine, University of Porto (FMUP), Porto, 4200-072, Portugal.
- Instituto de Ciências Biomédicas Abel Salazar, ICBAS, Universidade do Porto, Porto, Portugal.
- External Radiotherapy Department, Portuguese Institute of Oncology of Porto (IPOP), Porto, 4200-072, Portugal.
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Shim SH, Yang EJ, Jang EB, Lee S, Kim HS, Shin YK, Lee SW, Chang CS, Song H, Lee SJ, Kim J, Chang SJ, Lim MC, Choi CH. Prognostic impact of erythropoietin-stimulating agent use during front-line chemotherapy in patients with ovarian cancer: A Korean multicenter cohort study. Int J Gynaecol Obstet 2024. [PMID: 38682391 DOI: 10.1002/ijgo.15533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Revised: 03/24/2024] [Accepted: 04/02/2024] [Indexed: 05/01/2024]
Abstract
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.
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Affiliation(s)
- Seung-Hyuk Shim
- Department of Obstetrics and Gynecology, Research Institute of Medical Science, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Eun-Jung Yang
- Department of Obstetrics and Gynecology, Soonchunhyang University Cheonan Hospital, Cheonan, South Chungcheong, Republic of Korea
| | - Eun Bi Jang
- Department of Obstetrics and Gynecology, Research Institute of Medical Science, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Seungjun Lee
- Department of Obstetrics and Gynecology, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hee Seung Kim
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Yoon-Kyung Shin
- Department of Obstetrics and Gynecology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Shin-Wha Lee
- Department of Obstetrics and Gynecology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Chi-Son Chang
- Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Heekyoung Song
- Department of Obstetrics and Gynecology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sung Jong Lee
- Department of Obstetrics and Gynecology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jeeyeon Kim
- Department of Obstetrics and Gynecology, Gynecologic Cancer Center, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Suk-Joon Chang
- Department of Obstetrics and Gynecology, Gynecologic Cancer Center, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Myong Cheol Lim
- Center for Gynecologic Cancer and Center for Clinical Trial, National Cancer Center, Goyang, Korea
- Division of Tumor Immunology, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Chel Hun Choi
- Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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Boitano TKL, Kako T, Leath CA. New Paradigms in the Treatment of Cervical Cancer. Obstet Gynecol 2023; 142:1322-1332. [PMID: 37826852 PMCID: PMC10841100 DOI: 10.1097/aog.0000000000005413] [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: 05/30/2023] [Accepted: 08/17/2023] [Indexed: 10/14/2023]
Abstract
Despite effective screening strategies and the development and implementation of prophylactic high-risk human papillomavirus vaccination, cervical cancer remains a significant public health burden. This burden is most pronounced in under-resourced countries without fully developed screening and vaccination programs, although the disease remains present worldwide, including in industrialized countries. To that end, the World Health Organization (WHO) has an active focus on the elimination of cervical cancer, with objective metrics to be achieved by countries by the year 2030. Although increased vaccination and screening will be needed to approach potential eradication of cervical cancer, as recognized by the WHO initiative, treatment will need to continue to not only be effective in the near term, but to improve outcomes as well. Accordingly, assessments to improve primary treatment options, including surgery for women with early-stage disease, modification of chemoradiation for those with locally advanced cervical cancer, and systemic therapy for those with recurrent or metastatic presentations, are ongoing. Accordingly, we highlight important areas of both recent and ongoing focus as they relate to improving cervical cancer outcomes.
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Affiliation(s)
- Teresa K. L. Boitano
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Alabama at Birmingham, Birmingham, AL 35294, USA
| | - Tavonna Kako
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham School of Medicine, Birmingham, AL 35294, USA
| | - Charles A. Leath
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Alabama at Birmingham, Birmingham, AL 35294, USA
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Kunos CA, Fabian D, Fredericks T, Baldwin L, Dietrich C, Miller RW, Ueland FR. Hemoglobin level associates with survival in women from Appalachian Kentucky with uterine cervix cancer. Front Oncol 2023; 13:1132135. [PMID: 37483504 PMCID: PMC10358846 DOI: 10.3389/fonc.2023.1132135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Accepted: 06/22/2023] [Indexed: 07/25/2023] Open
Abstract
Introduction The purpose of this retrospective study was to determine the relationship between pretherapy hemoglobin levels and progression-free survival among women with uterine cervix cancer undergoing concurrent weekly cisplatin and radiotherapy followed by brachytherapy. Methods Patients with advanced-stage II-IVA uterine cervix cancer were grouped by hemoglobin level (Hgb ≥ 12.0, 11.9-10.0, or < 10.0 g/dL). Endpoints were progression-free survival, overall survival, and local control. Results Between 01/2001 and 07/2022, 168 patients contributed demographic, tumor, pretherapy hemoglobin, and outcome data with a median follow-up of 31 months. Progression-free survival at three years was 73% (95% confidence interval: 58%-84%), 71% (95% confidence interval: 56%-82%), and 62% (95% confidence interval: 44%-75%) for the Hgb ≥ 12.0, 11.9-10.0, or < 10.0 g/dL groups, respectfully (P < 0.001). In addition, pretherapy hemoglobin levels were significant with treatment outcome when included in a multivariate analysis of prognostic variables. Discussion In conclusion, the difference in pretherapy hemoglobin level was prognostic of progression-free survival.
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Affiliation(s)
- Charles A. Kunos
- Department of Radiation Medicine, University of Kentucky, Lexington, KY, United States
| | - Denise Fabian
- Department of Radiation Medicine, University of Kentucky, Lexington, KY, United States
| | - Tricia Fredericks
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Kentucky, Lexington, KY, United States
| | - Lauren Baldwin
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Kentucky, Lexington, KY, United States
| | - Charles Dietrich
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Kentucky, Lexington, KY, United States
| | - Rachel W. Miller
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Kentucky, Lexington, KY, United States
| | - Frederick R. Ueland
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Kentucky, Lexington, KY, United States
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Neto BV, Tavares V, da Silva JB, Liz-Pimenta J, Marques IS, Carvalho L, Salgado L, Pereira D, Medeiros R. Thrombogenesis-associated genetic determinants as predictors of thromboembolism and prognosis in cervical cancer. Sci Rep 2023; 13:9519. [PMID: 37308506 DOI: 10.1038/s41598-023-36161-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 05/30/2023] [Indexed: 06/14/2023] Open
Abstract
Venous thromboembolism (VTE) is a leading cause of death among cancer patients. Khorana score (KS) is the most studied tool to predict cancer-related VTE, however, it exerts poor sensitivity. Several single-nucleotide polymorphisms (SNPs) have been associated with VTE risk in the general population, but whether they are predictors of cancer-related VTE is a matter of discussion. Compared to other solid tumours, little is known about VTE in the setting of cervical cancer (CC) and whether thrombogenesis-related polymorphisms could be valuable biomarkers in patients with this neoplasia. This study aims to analyse the effect of VTE occurrence on the prognosis of CC patients, explore the predictive capability of KS and the impact of thrombogenesis-related polymorphisms on CC-related VTE incidence and patients' prognosis regardless of VTE. A profile of eight SNPs was evaluated. A retrospective hospital-based cohort study was conducted with 400 CC patients under chemoradiotherapy. SNP genotyping was carried on by using TaqMan® Allelic Discrimination methodology. Time to VTE occurrence and overall survival were the two measures of clinical outcome evaluated. The results indicated that VTE occurrence (8.5%) had a significant impact on the patient's survival (log-rank test, P < 0.001). KS showed poor performance (KS ≥ 3, χ2, P = 0.191). PROCR rs10747514 and RGS7 rs2502448 were significantly associated with the risk of CC-related VTE development (P = 0.021 and P = 0.006, respectively) and represented valuable prognostic biomarkers regardless of VTE (P = 0.004 and P = 0.010, respectively). Thus, thrombogenesis-related genetic polymorphisms may constitute valuable biomarkers among CC patients allowing a more personalized clinical intervention.
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Affiliation(s)
- Beatriz Vieira Neto
- Molecular Oncology and Viral Pathology Group, Research Center of IPO Porto (CI-IPOP)/ Pathology and Laboratory Medicine Dep., Clinical Pathology SV/ RISE@CI-IPOP (Health Research Network), Portuguese Oncology Institute of Porto (IPO Porto) / Porto Comprehensive Cancer Centre (Porto.CCC), 4200-072, Porto, Portugal
- FMUP, Faculty of Medicine, University of Porto, 4200-072, Porto, Portugal
- Research Department, Portuguese League Against Cancer (NRNorte), 4200-172, Porto, Portugal
| | - Valéria Tavares
- Molecular Oncology and Viral Pathology Group, Research Center of IPO Porto (CI-IPOP)/ Pathology and Laboratory Medicine Dep., Clinical Pathology SV/ RISE@CI-IPOP (Health Research Network), Portuguese Oncology Institute of Porto (IPO Porto) / Porto Comprehensive Cancer Centre (Porto.CCC), 4200-072, Porto, Portugal
- FMUP, Faculty of Medicine, University of Porto, 4200-072, Porto, Portugal
- ICBAS, Abel Salazar Institute for the Biomedical Sciences, Rua de Jorge Viterbo Ferreira, 228, 4050-313, Porto, Portugal
- Research Department, Portuguese League Against Cancer (NRNorte), 4200-172, Porto, Portugal
| | - José Brito da Silva
- Oncology Department, Portuguese Institute of Oncology of Porto (IPOP), 4200-072, Porto, Portugal
| | - Joana Liz-Pimenta
- FMUP, Faculty of Medicine, University of Porto, 4200-072, Porto, Portugal
- Department of Medical Oncology, Centro Hospitalar de Trás-os-Montes e Alto Douro (CHTMAD), 5000-508, Vila Real, Portugal
| | - Inês Soares Marques
- Molecular Oncology and Viral Pathology Group, Research Center of IPO Porto (CI-IPOP)/ Pathology and Laboratory Medicine Dep., Clinical Pathology SV/ RISE@CI-IPOP (Health Research Network), Portuguese Oncology Institute of Porto (IPO Porto) / Porto Comprehensive Cancer Centre (Porto.CCC), 4200-072, Porto, Portugal
- FCUP, Faculty of Sciences, University of Porto, 4169-007, Porto, Portugal
| | - Luísa Carvalho
- External Radiotherapy Department, Portuguese Institute of Oncology of Porto (IPOP), 4200-072, Porto, Portugal
| | - Lurdes Salgado
- External Radiotherapy Department, Portuguese Institute of Oncology of Porto (IPOP), 4200-072, Porto, Portugal
| | - Deolinda Pereira
- Oncology Department, Portuguese Institute of Oncology of Porto (IPOP), 4200-072, Porto, Portugal
| | - Rui Medeiros
- Molecular Oncology and Viral Pathology Group, Research Center of IPO Porto (CI-IPOP)/ Pathology and Laboratory Medicine Dep., Clinical Pathology SV/ RISE@CI-IPOP (Health Research Network), Portuguese Oncology Institute of Porto (IPO Porto) / Porto Comprehensive Cancer Centre (Porto.CCC), 4200-072, Porto, Portugal.
- FMUP, Faculty of Medicine, University of Porto, 4200-072, Porto, Portugal.
- ICBAS, Abel Salazar Institute for the Biomedical Sciences, Rua de Jorge Viterbo Ferreira, 228, 4050-313, Porto, Portugal.
- FCUP, Faculty of Sciences, University of Porto, 4169-007, Porto, Portugal.
- Research Department, Portuguese League Against Cancer (NRNorte), 4200-172, Porto, Portugal.
- CEBIMED, Faculty of Health Sciences, Fernando Pessoa University, 4200-150, Porto, Portugal.
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Disparities in erythropoiesis-stimulating agent use after changes in medicare reimbursement and implementation of a risk evaluation and mitigation strategy. DRUGS & THERAPY PERSPECTIVES 2022. [DOI: 10.1007/s40267-022-00969-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Dahmen AS, Phuoc VH, Cohen JB, Sexton WJ, Patel SY. Bloodless surgery in urologic oncology: A review of hematologic, anesthetic, and surgical considerations. Urol Oncol 2022; 41:192-203. [PMID: 36470804 DOI: 10.1016/j.urolonc.2022.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 11/01/2022] [Accepted: 11/11/2022] [Indexed: 12/03/2022]
Abstract
The urologic oncology patient who refuses blood transfusion can present unique challenges in perioperative blood management. Since blood loss and associated transfusion can be expected in many complex urologic oncology surgeries, a multidisciplinary approach may be required for optimal outcomes. Through collaboration with the hematologist, anesthesiologist, and urologist, various techniques can be employed in the perioperative phases to minimize blood loss and the need for transfusion. We review the risks and benefits of these techniques and offer recommendations specific to the urologic oncology patient.
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Affiliation(s)
- Aaron S Dahmen
- Department of Urology, University of Chicago, Chicago, IL
| | - Vania H Phuoc
- Department of Medical Oncology, Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Jonathan B Cohen
- Department of Anesthesiology, Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Wade J Sexton
- Department of Genitourinary Oncology, Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Sephalie Y Patel
- Department of Anesthesiology, Moffitt Cancer Center and Research Institute, Tampa, FL.
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Adams A, Scheckel B, Habsaoui A, Haque M, Kuhr K, Monsef I, Bohlius J, Skoetz N. Intravenous iron versus oral iron versus no iron with or without erythropoiesis- stimulating agents (ESA) for cancer patients with anaemia: a systematic review and network meta-analysis. Cochrane Database Syst Rev 2022; 6:CD012633. [PMID: 35724934 PMCID: PMC9208863 DOI: 10.1002/14651858.cd012633.pub2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND Anaemia is common among cancer patients and they may require red blood cell transfusions. Erythropoiesis-stimulating agents (ESAs) and iron might help in reducing the need for red blood cell transfusions. However, it remains unclear whether the combination of both drugs is preferable compared to using one drug. OBJECTIVES To systematically review the effect of intravenous iron, oral iron or no iron in combination with or without ESAs to prevent or alleviate anaemia in cancer patients and to generate treatment rankings using network meta-analyses (NMAs). SEARCH METHODS We identified studies by searching bibliographic databases (CENTRAL, MEDLINE, Embase; until June 2021). We also searched various registries, conference proceedings and reference lists of identified trials. SELECTION CRITERIA We included randomised controlled trials comparing intravenous, oral or no iron, with or without ESAs for the prevention or alleviation of anaemia resulting from chemotherapy, radiotherapy, combination therapy or the underlying malignancy in cancer patients. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed risk of bias. Outcomes were on-study mortality, number of patients receiving red blood cell transfusions, number of red blood cell units, haematological response, overall mortality and adverse events. We conducted NMAs and generated treatment rankings. We assessed the certainty of the evidence using GRADE. MAIN RESULTS Ninety-six trials (25,157 participants) fulfilled our inclusion criteria; 62 trials (24,603 participants) could be considered in the NMA (12 different treatment options). Here we present the comparisons of ESA with or without iron and iron alone versus no treatment. Further results and subgroup analyses are described in the full text. On-study mortality We estimated that 92 of 1000 participants without treatment for anaemia died up to 30 days after the active study period. Evidence from NMA (55 trials; 15,074 participants) suggests that treatment with ESA and intravenous iron (12 of 1000; risk ratio (RR) 0.13, 95% confidence interval (CI) 0.01 to 2.29; low certainty) or oral iron (34 of 1000; RR 0.37, 95% CI 0.01 to 27.38; low certainty) may decrease or increase and ESA alone (103 of 1000; RR 1.12, 95% CI 0.92 to 1.35; moderate certainty) probably slightly increases on-study mortality. Additionally, treatment with intravenous iron alone (271 of 1000; RR 2.95, 95% CI 0.71 to 12.34; low certainty) may increase and oral iron alone (24 of 1000; RR 0.26, 95% CI 0.00 to 19.73; low certainty) may increase or decrease on-study mortality. Haematological response We estimated that 90 of 1000 participants without treatment for anaemia had a haematological response. Evidence from NMA (31 trials; 6985 participants) suggests that treatment with ESA and intravenous iron (604 of 1000; RR 6.71, 95% CI 4.93 to 9.14; moderate certainty), ESA and oral iron (527 of 1000; RR 5.85, 95% CI 4.06 to 8.42; moderate certainty), and ESA alone (467 of 1000; RR 5.19, 95% CI 4.02 to 6.71; moderate certainty) probably increases haematological response. Additionally, treatment with oral iron alone may increase haematological response (153 of 1000; RR 1.70, 95% CI 0.69 to 4.20; low certainty). Red blood cell transfusions We estimated that 360 of 1000 participants without treatment for anaemia needed at least one transfusion. Evidence from NMA (69 trials; 18,684 participants) suggests that treatment with ESA and intravenous iron (158 of 1000; RR 0.44, 95% CI 0.31 to 0.63; moderate certainty), ESA and oral iron (144 of 1000; RR 0.40, 95% CI 0.24 to 0.66; moderate certainty) and ESA alone (212 of 1000; RR 0.59, 95% CI 0.51 to 0.69; moderate certainty) probably decreases the need for transfusions. Additionally, treatment with intravenous iron alone (268 of 1000; RR 0.74, 95% CI 0.43 to 1.28; low certainty) and with oral iron alone (333 of 1000; RR 0.92, 95% CI 0.54 to 1.57; low certainty) may decrease or increase the need for transfusions. Overall mortality We estimated that 347 of 1000 participants without treatment for anaemia died overall. Low-certainty evidence from NMA (71 trials; 21,576 participants) suggests that treatment with ESA and intravenous iron (507 of 1000; RR 1.46, 95% CI 0.87 to 2.43) or oral iron (482 of 1000; RR 1.39, 95% CI 0.60 to 3.22) and intravenous iron alone (521 of 1000; RR 1.50, 95% CI 0.63 to 3.56) or oral iron alone (534 of 1000; RR 1.54, 95% CI 0.66 to 3.56) may decrease or increase overall mortality. Treatment with ESA alone may lead to little or no difference in overall mortality (357 of 1000; RR 1.03, 95% CI 0.97 to 1.10; low certainty). Thromboembolic events We estimated that 36 of 1000 participants without treatment for anaemia developed thromboembolic events. Evidence from NMA (50 trials; 15,408 participants) suggests that treatment with ESA and intravenous iron (66 of 1000; RR 1.82, 95% CI 0.98 to 3.41; moderate certainty) probably slightly increases and with ESA alone (66 of 1000; RR 1.82, 95% CI 1.34 to 2.47; high certainty) slightly increases the number of thromboembolic events. None of the trials reported results on the other comparisons. Thrombocytopenia or haemorrhage We estimated that 76 of 1000 participants without treatment for anaemia developed thrombocytopenia/haemorrhage. Evidence from NMA (13 trials, 2744 participants) suggests that treatment with ESA alone probably leads to little or no difference in thrombocytopenia/haemorrhage (76 of 1000; RR 1.00, 95% CI 0.67 to 1.48; moderate certainty). None of the trials reported results on other comparisons. Hypertension We estimated that 10 of 1000 participants without treatment for anaemia developed hypertension. Evidence from NMA (24 trials; 8383 participants) suggests that treatment with ESA alone probably increases the number of hypertensions (29 of 1000; RR 2.93, 95% CI 1.19 to 7.25; moderate certainty). None of the trials reported results on the other comparisons. AUTHORS' CONCLUSIONS When considering ESAs with iron as prevention for anaemia, one has to balance between efficacy and safety. Results suggest that treatment with ESA and iron probably decreases number of blood transfusions, but may increase mortality and the number of thromboembolic events. For most outcomes the different comparisons within the network were not fully connected, so ranking of all treatments together was not possible. More head-to-head comparisons including all evaluated treatment combinations are needed to fill the gaps and prove results of this review.
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Affiliation(s)
- Anne Adams
- Institute of Medical Statistics and Computational Biology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Benjamin Scheckel
- Institute of Health Economics and Clinical Epidemiology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Anissa Habsaoui
- Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Madhuri Haque
- Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Kathrin Kuhr
- Institute of Medical Statistics and Computational Biology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Ina Monsef
- Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Julia Bohlius
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Nicole Skoetz
- Cochrane Cancer, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
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Sud S, Weiner AA, Wang AZ, Gupta GP, Shen CJ. Prognostic and Predictive Clinical and Biological Factors in HPV Malignancies. Semin Radiat Oncol 2021; 31:309-323. [PMID: 34455986 DOI: 10.1016/j.semradonc.2021.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Human papillomavirus (HPV) causes the majority of oropharyngeal, cervical, and anal cancers, among others. These HPV-associated cancers cause substantial morbidity and mortality despite ongoing vaccination efforts. Aside from the earliest stage tumors, chemoradiation is used to treat most HPV-associated cancers across disease sites. Response rates are variable, and opportunities to improve oncologic control and reduce toxicity remain. HPV malignancies share multiple commonalities in oncogenesis and tumor biology that may inform personalized methods of screening, diagnosis, treatment and surveillance. In this review we discuss the current literature and identify promising molecular targets, prognostic and predictive clinical factors and biomarkers in HPV-associated oropharyngeal, cervical and anal cancer.
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Affiliation(s)
- Shivani Sud
- Department of Radiation Oncology, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Ashley A Weiner
- Department of Radiation Oncology, University of North Carolina School of Medicine, Chapel Hill, NC; Lineberger Comprehensive Cancer Center, University of North Carolina Hospitals, Chapel Hill, NC
| | - Andrew Z Wang
- Department of Radiation Oncology, University of North Carolina School of Medicine, Chapel Hill, NC; Lineberger Comprehensive Cancer Center, University of North Carolina Hospitals, Chapel Hill, NC
| | - Gaorav P Gupta
- Department of Radiation Oncology, University of North Carolina School of Medicine, Chapel Hill, NC; Lineberger Comprehensive Cancer Center, University of North Carolina Hospitals, Chapel Hill, NC
| | - Colette J Shen
- Department of Radiation Oncology, University of North Carolina School of Medicine, Chapel Hill, NC; Lineberger Comprehensive Cancer Center, University of North Carolina Hospitals, Chapel Hill, NC.
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11
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Zayed S, Nguyen TK, Lin C, Boldt G, Beriwal S, Creutzberg CL, Kamrava M, Mendez LC, Velker V, Doll C, Taggar A, Leung E, D’Souza DP. Red Blood Cell Transfusion Practices for Patients With Cervical Cancer Undergoing Radiotherapy. JAMA Netw Open 2021; 4:e213531. [PMID: 33818620 PMCID: PMC8022218 DOI: 10.1001/jamanetworkopen.2021.3531] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
IMPORTANCE Packed red blood cell (PRBC) transfusions are used to treat anemia in patients with cervical cancer undergoing radiotherapy (RT) owing to concerns of hypoxia-induced radioresistance. In the absence of high-quality evidence informing transfusion practices for patients receiving external beam RT (EBRT) and brachytherapy, various arbitrary hemoglobin target levels are used worldwide. OBJECTIVE To develop consensus statements to guide PRBC transfusion practices in patients with cervical cancer receiving curative-intent RT with EBRT and brachytherapy. DESIGN, SETTING, AND PARTICIPANTS This international Delphi consensus study was completed between November 1, 2019, and July 31, 2020. A total of 63 international clinical experts in gynecologic radiation oncology were invited; 39 (62%) accepted and consented to participate. Consensus building was achieved using a 3-round anonymous Delphi consensus method. Participants rated their agreement or disagreement with statements using a 5-point Likert scale. An a priori threshold of 75% or more was required for consensus. MAIN OUTCOMES AND MEASURES The preplanned primary outcome of this study was to assess hemoglobin transfusion thresholds and targets for both EBRT and brachytherapy by expert consensus. RESULTS Response rates of 100% (39 of 39), 92% (36 of 39), and 97% (35 of 36) were achieved for the first, second, and third rounds of surveys, respectively. Twenty-three experts (59%) practiced in Canada, 11 (28%) in the United States, 3 (8%) in South America, 1 (3%) in Europe, and 1 (3%) in Asia. Consensus was reached for 44 of 103 statements (43%), which were combined to form the final 27-statement consensus guideline. No specific hemoglobin transfusion threshold was agreed on by consensus for EBRT or brachytherapy. By consensus (89% [31 of 35]), a hemoglobin transfusion target for patients who receive a PRBC transfusion should be 9 g/dL or more and less than 12 g/dL. CONCLUSIONS AND RELEVANCE This study presents the first international expert consensus guideline informing PRBC transfusion practices for patients with cervical cancer undergoing EBRT and brachytherapy. A minimum hemoglobin transfusion target of 9 g/dL was endorsed to balance tumor radiosensitivity with appropriate use of a scarce resource. Randomized clinical trials are required to evaluate the optimal transfusion threshold and target that maximize clinical benefit in this patient population.
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Affiliation(s)
- Sondos Zayed
- Department of Radiation Oncology, London Health Sciences Centre, London, Ontario, Canada
| | - Timothy K. Nguyen
- Department of Radiation Oncology, London Health Sciences Centre, London, Ontario, Canada
| | - Cindy Lin
- Department of Radiation Oncology, London Health Sciences Centre, London, Ontario, Canada
| | - Gabriel Boldt
- Department of Radiation Oncology, London Health Sciences Centre, London, Ontario, Canada
| | - Sushil Beriwal
- Department of Radiation Oncology, UPMC Hillman Cancer Center, Pittsburgh, Pennsylvania
| | - Carien L. Creutzberg
- Department of Radiation Oncology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Mitchell Kamrava
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Lucas C. Mendez
- Department of Radiation Oncology, London Health Sciences Centre, London, Ontario, Canada
| | - Vikram Velker
- Department of Radiation Oncology, London Health Sciences Centre, London, Ontario, Canada
| | - Corinne Doll
- Department of Radiation Oncology, Tom Baker Cancer Centre, Calgary, Alberta, Canada
| | - Amandeep Taggar
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Eric Leung
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - David P. D’Souza
- Department of Radiation Oncology, London Health Sciences Centre, London, Ontario, Canada
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12
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Zagouri F, Dedes N, Papatheodoridi A, Liontos M, Dimopoulos MA. Supportive medication in cancer during pregnancy. BMC Pregnancy Childbirth 2020; 20:747. [PMID: 33261562 PMCID: PMC7706269 DOI: 10.1186/s12884-020-03432-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 11/16/2020] [Indexed: 02/08/2023] Open
Abstract
While pregnancy-related malignancies are quite rare, their incidence is increasing and thus affecting more and more women nowadays. Their management, however, with both chemotherapy and supportive agents remains quite challenging and it seems crucial to define the optimal treatment for this special population. Concerning supportive medication, it is clinically significant to determine whether commonly used agents, including Granulocyte Colony-Stimulating Factors, Erythropoiesis-stimulating agents, Bisphosphonates, Anticoagulation agents, Antiemetics and Glucocorticoids are indeed effective in ameliorating chemotherapy side effects. Meanwhile, it is of great importance that the administration of any of these agents is safe for both mother and fetus. This review aims to provide a précis of the current literature regarding both safety and efficacy of all categories of supportive medication during pregnancy.
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Affiliation(s)
- Flora Zagouri
- Haematology - Oncology Unit, Department of Clinical Therapeutics, Alexandra Hospital, National and Kapodistrian University of Athens, Vasilissis Sofias 80, 11528, Athens, Greece.
| | - Nikolaos Dedes
- Haematology - Oncology Unit, Department of Clinical Therapeutics, Alexandra Hospital, National and Kapodistrian University of Athens, Vasilissis Sofias 80, 11528, Athens, Greece
| | - Alkistis Papatheodoridi
- Haematology - Oncology Unit, Department of Clinical Therapeutics, Alexandra Hospital, National and Kapodistrian University of Athens, Vasilissis Sofias 80, 11528, Athens, Greece
| | - Michael Liontos
- Haematology - Oncology Unit, Department of Clinical Therapeutics, Alexandra Hospital, National and Kapodistrian University of Athens, Vasilissis Sofias 80, 11528, Athens, Greece
| | - Meletios Athanasios Dimopoulos
- Haematology - Oncology Unit, Department of Clinical Therapeutics, Alexandra Hospital, National and Kapodistrian University of Athens, Vasilissis Sofias 80, 11528, Athens, Greece
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13
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Musio F. Revisiting the treatment of anemia in the setting of chronic kidney disease, hematologic malignancies, and cancer: perspectives with opinion and commentary. Expert Rev Hematol 2020; 13:1175-1188. [PMID: 33028115 DOI: 10.1080/17474086.2020.1830371] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Anemia has and will continue to be a central theme in medicine particularly as clinicians are treating a burgeoning population of complex multi-organ system processes. As a result of multiple randomized controlled trials (RCTs), meta-analyses, and societal recommendations overly restrictive paradigms and under-administration of erythropoiesis stimulating agents (ESAs) have likely been followed by clinicians among all specialties. AREAS COVERED A review of anemia in the context of chronic kidney disease, hematologic malignancies, and cancer is presented with focus on the establishment of ESAs as integral in the treatment of anemia. Multiple RCTs and meta-analyses studying the use of ESAs are presented with focus upon their application to clinical practice. A 'compendium' is proffered describing the evolution, establishment, and implications of ESA administration initially among those with CKD with rapid subsequent application to the Hematology-Oncology population of patients. Literature search methodologies have included MEDLINE (1985-2020), PubMed (1996-2020), Cochrane Central Trials (1985-2020), EMBASE (2000-2020), and ClinicalTrials.gov (2000-2020). EXPERT OPINION Upon evaluation of risks and benefits of ESAs focused opinion and commentary is made supporting more liberal use of these agents and strongly suggesting that the current underlying treatment 'pendulum' has perhaps shifted too far to the 'under-treatment' side in many cases.
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Affiliation(s)
- Franco Musio
- Senior Partner, Nephrology Associates of Northern Virginia , VA, Fairfax, Virginia, USA.,Nephrology Division Chief, Inova Fairfax Hospital, Department of Medicine, Falls Church , Virginia, VA, USA.,Associate Professor of Medicine, Virginia Commonwealth University (Inova Fairfax Hospital Campus) , Richmond, Virginia, USA
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14
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Gennigens C, De Cuypere M, Seidel L, Hermesse J, Barbeaux A, Forget F, Albert A, Jerusalem G, Kridelka F. Correlation between hematological parameters and outcome in patients with locally advanced cervical cancer treated by concomitant chemoradiotherapy. Cancer Med 2020; 9:8432-8443. [PMID: 32954675 PMCID: PMC7666723 DOI: 10.1002/cam4.3465] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 08/23/2020] [Accepted: 08/25/2020] [Indexed: 01/28/2023] Open
Abstract
Background Hemoglobin (Hb), white blood cell (WBC), and polymorphonuclear neutrophil (PMN) blood counts may be correlated with outcomes in patients with locally advanced cervical cancer. Methods Hb, WBC, and PMN counts were measured at diagnosis and during concomitant cisplatin‐based chemoradiotherapy (CCRT) in a retrospective sample of 103 patients between 2010 and 2017. Red blood cell (RBC) transfusions were also recorded. The associations between hematological variables and patient overall survival (OS) and recurrence‐free survival (RFS) were assessed by Cox regression models. Results The 3‐year OS and RFS rates were 81.4% and 76.8%, respectively. In addition to tumor size and smoking, OS and RFS were found to be significantly associated with changes in WBC and PMN counts from the first to the last cisplatin cycle. Hb count throughout the treatment and RBC transfusions were not predictive of outcome. Conclusions This study found no association between Hb count or RBC transfusions and outcome. The daily practice of maintaining the Hb count above 12 g/dL during CCRT should be weighed against the potential risks of transfusions. Drops in WBC and PMN counts during treatment positively impacted OS and RFS and could, therefore, serve as biomarkers during CCRT to adapt the follow‐up and consider the need for adjuvant systemic treatments.
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Affiliation(s)
| | | | - Laurence Seidel
- Department of Biostatistics, CHU Liège and Liège University, Liège, Belgium
| | | | | | - Frédéric Forget
- Department of Medical Oncology, Libramont Hospital, Libramont, Belgium
| | - Adelin Albert
- Department of Biostatistics, CHU Liège and Liège University, Liège, Belgium
| | - Guy Jerusalem
- Department of Medical Oncology, CHU Liège and Liège University, Liège, Belgium
| | - Frédéric Kridelka
- Department of Obstetrics and Gynaecology, CHU Liège and Liège University, Liège, Belgium
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15
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Liu X, Tufman A, Behr J, Kiefl R, Goldmann T, Huber RM. Role of the erythropoietin receptor in Lung Cancer cells: erythropoietin exhibits angiogenic potential. J Cancer 2020; 11:6090-6100. [PMID: 32922549 PMCID: PMC7477424 DOI: 10.7150/jca.36924] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 07/08/2020] [Indexed: 11/12/2022] Open
Abstract
Background: Recombinant human erythropoietin (rHuEPO), a hormone regulating the proliferation and differentiation of erythroid cells, is one of the prescription drugs used to treat cancer-associated anemia. However, administration of rHuEPO to cancer patients has been reported to be associated with decreased survival, and the mechanism by which it acts remains controversial. The present study aimed to investigate the expression of the EPO-receptor in lung cancer cell lines and whether rHuEPO treatment affected its growth and migration. Moreover, the angiogenic effects of rHuEPO were also explored in vivo. Methods: Expression of the EPO-receptor in lung cancer cell lines was measured by Western blotting and enzyme linked immunosorbent assays (ELISAs). Proliferation of the lung cancer cells was monitored in the presence of rHuEPO. Human umbilical vein endothelial cells (HUVECs) were used for tube formation assays in vitro, and transwell migration assays were performed to detect migration under rHuEPO treatment. Matrigel plug technology was employed to observe the angiogenic effects in both nude mice and Matrigel-containing lung cancer cell lines H838 or H1975. Microvessel density (MVD) was measured using CD31 Immunohistochemistry (IHC) staining. Results: EPO-receptor (EPO-R) was only detected in the cell lines H838 and H1339 by ELISA. However, the EPO-R protein was detected in all cell lines by Western blotting, which is in contradiction to the ELISA results. Proliferation and migration were not affected by rHuEPO treatment. However, rHuEPO promoted HUVEC tube formation in vitro and significantly induced the formation of new blood vessels in vivo. Furthermore, rHuEPO did not antagonize the inhibitory effects of Afatinib (epidermal growth factor receptor-tyrosine kinase inhibitor; EGFR-TKI) in simultaneous treatment with rHuEPO. In a 3D cell co-culture model, rHuEPO did not enhance the secretion of vascular endothelial growth factor (VEGF) in lung cancer cells or human lung fibroblast cell line MRC-5. Conclusions: We have shown that the role of EPO goes beyond erythropoiesis, also playing a strong role in angiogenesis by participating in new blood vessel formation in lung cancer models. Thus, rHuEPO may raise the risk of thrombosis and metastasis in vivo. Additionally, our results suggest that studies using commercially available EPO-R antibodies should be reexamined; some of these antibodies may not in fact recognize EPO-R.
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Affiliation(s)
- Xiaoqing Liu
- Department of Internal Medicine V, Division of Respiratory Medicine and Thoracic Oncology, Ludwig-Maximilians University (LMU), Thoracic Oncology Centre Munich. Comprehensive Pneumology Center Munich, Member of the German Center for Lung Research (DZL), Munich, Bavaria, Germany
| | - Amanda Tufman
- Department of Internal Medicine V, Division of Respiratory Medicine and Thoracic Oncology, Ludwig-Maximilians University (LMU), Thoracic Oncology Centre Munich. Comprehensive Pneumology Center Munich, Member of the German Center for Lung Research (DZL), Munich, Bavaria, Germany
| | - Juergen Behr
- Department of Internal Medicine V, Division of Respiratory Medicine and Thoracic Oncology, Ludwig-Maximilians University (LMU), Thoracic Oncology Centre Munich. Comprehensive Pneumology Center Munich, Member of the German Center for Lung Research (DZL), Munich, Bavaria, Germany
| | - Rosemarie Kiefl
- Department of Internal Medicine V, Division of Respiratory Medicine and Thoracic Oncology, Ludwig-Maximilians University (LMU), Thoracic Oncology Centre Munich. Comprehensive Pneumology Center Munich, Member of the German Center for Lung Research (DZL), Munich, Bavaria, Germany
| | - Torsten Goldmann
- Pathology Department of the University Medical Center Schleswig-Holstein (UKSH), Lübeck Campus and the Borstel Research Center, Lübeck and Borstel, Germany; Airway Research Center North, Member of the German Center for Lung Research (DZL)
| | - Rudolf M Huber
- Department of Internal Medicine V, Division of Respiratory Medicine and Thoracic Oncology, Ludwig-Maximilians University (LMU), Thoracic Oncology Centre Munich. Comprehensive Pneumology Center Munich, Member of the German Center for Lung Research (DZL), Munich, Bavaria, Germany
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16
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Hoque S, Chen BJ, Schoen MW, Carson KR, Keller J, Witherspoon BJ, Knopf KB, Yang YT, Schooley B, Nabhan C, Sartor O, Yarnold PR, Ray P, Bobolts L, Hrushesky WJ, Dickson M, Bennett CL. End of an era of administering erythropoiesis stimulating agents among Veterans Administration cancer patients with chemotherapy-induced anemia. PLoS One 2020; 15:e0234541. [PMID: 32584835 PMCID: PMC7316310 DOI: 10.1371/journal.pone.0234541] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 04/18/2020] [Indexed: 11/18/2022] Open
Abstract
Erythropoisis stimulating agent (ESA) use was addressed in Food and Drug Administration (FDA) Oncology Drug Advisory Committee (ODAC) meetings between 2004 and 2008. FDA safety-focused regulatory actions occurred in 2007 and 2008. In 2007, black box warnings advised of early death and venous thromboembolism (VTE) risks with ESAs in oncology. In 2010, a Risk Evaluation Strategies (REMS) was initiated, with cancer patient consent that mortality and VTE risks were noted with ESAs. We report warnings and REMS impacts on ESA utilization among Veterans Administration (VA) cancer patients with chemotherapy-induced anemia (CIA). Data were from Veterans Affairs database (2003–2012). Epoetin and darbepoetin use were primary outcomes. Segmented linear regression was used to estimate changes in ESA use levels and trends, clinical appropriateness, and adverse events (VTEs) among chemotherapy-treated cancer patients. To estimate changes in level of drug prescription rate after policy actions, model-specific indicator variables as covariates based on specific actions were included. ESA use fell by 95% and 90% from 2005, for epoetin and darbepoetin, from 22% and 11%, respectively, to 1% and 1%, respectively, among cancer patients with CIA, respectively (p<0.01). Following REMS in 2010, mean hematocrit levels at ESA initiation decreased from 30% to 21% (p<0.01). Black box warnings preceded decreased ESA use among VA cancer patients with CIA. REMS was followed by reduced hematocrit levels at ESA initiation. Our findings contrast with privately- insured and Medicaid insured cancer patient data on chemotherapy-induced anemia where ESA use decreased to 3% to 7% by 2010–2012. By 2012, the era of ESA administration to VA to cancer patients had ended but the warnings remain relevant and significant. In 2019, oncology/hematology national guidelines (ASCO/ASH) recommend that cancer patients with chemotherapy-induced anemia should receive ESAs or red blood cell transfusions after risk-benefit evaluation.
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Affiliation(s)
- Shamia Hoque
- Department of Civil and Environmental Engineering, College of Engineering and Computing, University of South Carolina, Columbia, South Carolina, United States of America
- * E-mail:
| | - Brian J. Chen
- Arnold School of Public Health, University of South Carolina, Columbia, South Carolina, United States of America
| | - Martin W. Schoen
- Department of Medicine, Saint Louis University School of Medicine, Saint Louis, Missouri, United States of America
| | - Kenneth R. Carson
- The Washington University School of Medicine and the Saint Louis VA Medical Center, St. Louis, Missouri, United States of America
| | - Jesse Keller
- The Washington University School of Medicine and the Saint Louis VA Medical Center, St. Louis, Missouri, United States of America
| | | | - Kevin B. Knopf
- College of Pharmacy, University of South Carolina, Columbia, South Carolina, United States of America
| | - Y. Tony Yang
- George Washington University, Washington, DC, United States of America
| | - Benjamin Schooley
- Department of Integrated Information Technology, College of Engineering and Computing, University of South Carolina, Columbia, South Carolina, United States of America
| | - Chadi Nabhan
- College of Pharmacy, University of South Carolina, Columbia, South Carolina, United States of America
| | - Oliver Sartor
- Tulane University School of Medicine, New Orleans, Louisiana, United States of America
| | - Paul R. Yarnold
- Medical University of South Carolina, Charleston, South Carolina, United States of America
- College of Pharmacy, University of South Carolina, Columbia, South Carolina, United States of America
| | - Paul Ray
- College of Pharmacy, University of South Carolina, Columbia, South Carolina, United States of America
| | - Laura Bobolts
- Oncology Analytics, Plantation, Florida, United States of America
- College of Pharmacy, Nova Southeastern University, Fort Lauderdale, Florida, United States of America
| | - William J. Hrushesky
- The Washington University School of Medicine and the Saint Louis VA Medical Center, St. Louis, Missouri, United States of America
- Medical University of South Carolina, Charleston, South Carolina, United States of America
- College of Pharmacy, University of South Carolina, Columbia, South Carolina, United States of America
| | - Michael Dickson
- College of Pharmacy, University of South Carolina, Columbia, South Carolina, United States of America
| | - Charles L. Bennett
- College of Pharmacy, University of South Carolina, Columbia, South Carolina, United States of America
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Gascón P, Nagarkar R, Šmakal M, Syrigos KN, Barrios CH, Sánchez JC, Zhang L, Henry DH, Gordon D, Hirsh V, Kubota K, Orlov S, Thomas G, Steinmetz T, Kang JH, Tomita DK, Fleishman AN, Park JK, De Oliveira Brandao C. A Randomized, Double-Blind, Placebo-Controlled, Phase III Noninferiority Study of the Long-Term Safety and Efficacy of Darbepoetin Alfa for Chemotherapy-Induced Anemia in Patients With Advanced NSCLC. J Thorac Oncol 2019; 15:190-202. [PMID: 31629060 DOI: 10.1016/j.jtho.2019.10.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 09/30/2019] [Accepted: 10/03/2019] [Indexed: 10/25/2022]
Abstract
INTRODUCTION This study evaluated noninferiority of darbepoetin alfa versus placebo for overall survival (OS) and progression-free survival (PFS) in anemic patients with NSCLC treated to a 12.0-g/dL hemoglobin (Hb) ceiling. METHODS Adults with stage IV NSCLC expected to receive two or more cycles of myelosuppressive chemotherapy and Hb less than or equal to 11.0 g/dL were randomized 2:1 to blinded 500 μg darbepoetin alfa or placebo every 3 weeks. The primary endpoint was OS; a stratified Cox proportional hazards model was used to evaluate noninferiority (upper confidence limit for hazard ratio [HR] < 1.15). Secondary endpoints were PFS and incidence of transfusions or Hb less than or equal to 8.0 g/dL from week 5 to end of the efficacy treatment period. RESULTS The primary analysis set included 2516 patients: 1680 were randomized to darbepoetin alfa; 836 to placebo. The study was stopped early per independent Data Monitoring Committee recommendation after the primary endpoint was met with no new safety concerns. Darbepoetin alfa was noninferior to placebo for OS (stratified HR = 0.92; 95% confidence interval [CI]: 0.83‒1.01) and PFS (stratified HR = 0.95; 95% CI: 0.87‒1.04). Darbepoetin alfa was superior to placebo for transfusion or Hb less than or equal to 8.0 g/dL from week 5 to end of the efficacy treatment period (stratified odds ratio = 0.70; 95% CI: 0.57‒0.86; p < 0.001). Objective tumor response was similar between the groups (darbepoetin alfa, 36.4%; placebo, 32.6%). Incidence of serious adverse events was 31.1% in both groups. No unexpected adverse events were observed. CONCLUSIONS Darbepoetin alfa dosed to a 12.0-g/dL Hb ceiling was noninferior to placebo for OS and PFS and significantly reduced odds of transfusion or Hb less than or equal to 8.0 g/dL in anemic patients with NSCLC receiving myelosuppressive chemotherapy.
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Affiliation(s)
- Pere Gascón
- Department of Hematology-Oncology, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain.
| | | | - Martin Šmakal
- Nemocnice Hořovice, NH Hospital a.s., Hořovice, Czech Republic
| | | | | | | | - Li Zhang
- Sun Yat-Sen University Cancer Center, East Guangzhou, China
| | - David H Henry
- University of Pennsylvania, Philadelphia, Pennsylvania
| | - David Gordon
- Cancer Care Centers of South Texas and US Oncology Research Network, San Antonio, Texas
| | - Vera Hirsh
- MUHC Royal Victoria Hospital, Montreal, Quebec, Canada
| | | | - Sergey Orlov
- Saint Petersburg State Medical University, Saint Petersburg, Russian Federation
| | - Gary Thomas
- South Carolina Cancer Specialists, Hilton Head Island, South Carolina
| | - Tilman Steinmetz
- Gemeinschaftspraxis für Hämatologie und Onkologie, Köln, Germany
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18
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Abstract
Cancer and kidney disease are linked by causality and comorbidities. Observational data show an increased risk of malignancy as renal function declines. Erythropoietin stimulating agents (ESAs), which are the cornerstone therapy for anemia patients with chronic kidney disease and cancer, are associated with increased risks for cancer, cancer-related mortality, progression of disease, and thromboembolic events. This article examines the recently published guidelines for ESA use in cancer patients from the American Society of Clinical Oncology and American Society of Hematology and attempts to contextualize them to the care of patients with coexistent CKD, cancer, and anemia.
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Affiliation(s)
- Sheron Latcha
- Renal Division, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
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19
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Bohlius J, Bohlke K, Lazo-Langner A. Management of Cancer-Associated Anemia With Erythropoiesis-Stimulating Agents: ASCO/ASH Clinical Practice Guideline Update. J Oncol Pract 2019. [DOI: 10.1200/jop.19.00111] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | - Kari Bohlke
- American Society of Clinical Oncology, Alexandria, VA
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20
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Bohlius J, Bohlke K, Castelli R, Djulbegovic B, Lustberg MB, Martino M, Mountzios G, Peswani N, Porter L, Tanaka TN, Trifirò G, Yang H, Lazo-Langner A. Management of Cancer-Associated Anemia With Erythropoiesis-Stimulating Agents: ASCO/ASH Clinical Practice Guideline Update. J Clin Oncol 2019; 37:1336-1351. [DOI: 10.1200/jco.18.02142] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
PURPOSE To update the American Society of Clinical Oncology (ASCO)/American Society of Hematology (ASH) recommendations for use of erythropoiesis-stimulating agents (ESAs) in patients with cancer. METHODS PubMed and the Cochrane Library were searched for randomized controlled trials (RCTs) and meta-analyses of RCTs in patients with cancer published from January 31, 2010, through May 14, 2018. For biosimilar ESAs, the literature search was expanded to include meta-analyses and RCTs in patients with cancer or chronic kidney disease and cohort studies in patients with cancer due to limited RCT evidence in the cancer setting. ASCO and ASH convened an Expert Panel to review the evidence and revise previous recommendations as needed. RESULTS The primary literature review included 15 meta-analyses of RCTs and two RCTs. A growing body of evidence suggests that adding iron to treatment with an ESA may improve hematopoietic response and reduce the likelihood of RBC transfusion. The biosimilar literature review suggested that biosimilars of epoetin alfa have similar efficacy and safety to reference products, although evidence in cancer remains limited. RECOMMENDATIONS ESAs (including biosimilars) may be offered to patients with chemotherapy-associated anemia whose cancer treatment is not curative in intent and whose hemoglobin has declined to < 10 g/dL. RBC transfusion is also an option. With the exception of selected patients with myelodysplastic syndromes, ESAs should not be offered to most patients with nonchemotherapy-associated anemia. During ESA treatment, hemoglobin may be increased to the lowest concentration needed to avoid transfusions. Iron replacement may be used to improve hemoglobin response and reduce RBC transfusions for patients receiving ESA with or without iron deficiency. Additional information is available at www.asco.org/supportive-care-guidelines and www.hematology.org/guidelines .
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Affiliation(s)
| | - Kari Bohlke
- American Society of Clinical Oncology, Alexandria, VA
| | | | | | | | - Massimo Martino
- Azienda Ospedaliera Bianchi Melacrino Morelli, Reggio Calabria, Italy
| | | | | | | | | | | | - Hushan Yang
- Thomas Jefferson University, Philadelphia, PA
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21
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Bohlius J, Bohlke K, Castelli R, Djulbegovic B, Lustberg MB, Martino M, Mountzios G, Peswani N, Porter L, Tanaka TN, Trifirò G, Yang H, Lazo-Langner A. Management of cancer-associated anemia with erythropoiesis-stimulating agents: ASCO/ASH clinical practice guideline update. Blood Adv 2019; 3:1197-1210. [PMID: 30971397 PMCID: PMC6482353 DOI: 10.1182/bloodadvances.2018030387] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 01/28/2019] [Indexed: 12/15/2022] Open
Abstract
PURPOSE To update the American Society of Clinical Oncology (ASCO)/American Society of Hematology (ASH) recommendations for use of erythropoiesis-stimulating agents (ESAs) in patients with cancer. METHODS PubMed and the Cochrane Library were searched for randomized controlled trials (RCTs) and meta-analyses of RCTs in patients with cancer published from January 31, 2010, through May 14, 2018. For biosimilar ESAs, the literature search was expanded to include meta-analyses and RCTs in patients with cancer or chronic kidney disease and cohort studies in patients with cancer due to limited RCT evidence in the cancer setting. ASCO and ASH convened an Expert Panel to review the evidence and revise previous recommendations as needed. RESULTS The primary literature review included 15 meta-analyses of RCTs and two RCTs. A growing body of evidence suggests that adding iron to treatment with an ESA may improve hematopoietic response and reduce the likelihood of RBC transfusion. The biosimilar literature review suggested that biosimilars of epoetin alfa have similar efficacy and safety to reference products, although evidence in cancer remains limited. RECOMMENDATIONS ESAs (including biosimilars) may be offered to patients with chemotherapy-associated anemia whose cancer treatment is not curative in intent and whose hemoglobin has declined to < 10 g/dL. RBC transfusion is also an option. With the exception of selected patients with myelodysplastic syndromes, ESAs should not be offered to most patients with nonchemotherapy-associated anemia. During ESA treatment, hemoglobin may be increased to the lowest concentration needed to avoid transfusions. Iron replacement may be used to improve hemoglobin response and reduce RBC transfusions for patients receiving ESA with or without iron deficiency. Additional information is available at www.asco.org/supportive-care-guidelines and www.hematology.org/guidelines.
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Affiliation(s)
| | - Kari Bohlke
- American Society of Clinical Oncology, Alexandria, VA
| | | | | | | | - Massimo Martino
- Azienda Ospedaliera Bianchi Melacrino Morelli, Reggio Calabria, Italy
| | | | | | | | | | | | - Hushan Yang
- Thomas Jefferson University, Philadelphia, PA; and
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22
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Chang Lee R, Sukumaran S, Koczwara B, Woodman R, Kichenadasse G, Roy A, Vatandoust S, Karapetis C. Patterns of care in Jehovah's Witnesses patients with solid tumours and lymphoma. Cancer Rep (Hoboken) 2019; 2:e1148. [PMID: 32721085 DOI: 10.1002/cnr2.1148] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Revised: 10/08/2018] [Accepted: 10/08/2018] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Supportive care of Jehovah's Witnesses (JWs) diagnosed with cancer can be challenging, as they do not accept red blood cell (RBC) transfusions. AIM The study was designed to determine treatment preferences and pattern of care offered to JWs diagnosed with cancer and its impact on cancer management. METHODS AND RESULTS A retrospective cohort study of JWs with solid malignancies or lymphoma in our institution between 2005 and 2015 was conducted. Survival statistics were estimated using Kaplan Meier survival curves and Cox proportional regression model. A total of 63 JWs were identified with a median age of 70 years. At diagnosis, 34% (n = 22) had anaemia. All 63 declined RBC transfusion, including 19 patients who later developed transfusion threshold during anti-cancer treatment. Forty-three percent (n = 27) JWs had advanced (stage 4) disease, and 76% (n = 48) had Eastern Cooperative Oncology Group of 0 to 1. JWs were willing to accept surgery and radiation rather than chemotherapy. Treatment was deemed to be suboptimal in 22% (n = 14) JWs due to early treatment discontinuation, administration of non-standard chemotherapy regimen, or dose reduction due to anaemia and denial of blood transfusion. Twenty-seven percent (n = 17) received hematopoietic growth factors (erythropoiesis-stimulating agents and pegfilgrastim). There was no mortality directly attributed to anaemia or refusal of blood transfusion in the entire cohort. CONCLUSION Jehovah's Witnesses declined RBC transfusion at diagnosis and during cancer therapy even if medically indicated. Management pathways need to be prospectively defined for this group of patients.
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Affiliation(s)
| | - Shawgi Sukumaran
- Flinders Medical Centre, FCIC, Bedford Park, SA, 5042, Australia.,Flinders University, Bedford Park, SA, 5042, Australia
| | - Bogda Koczwara
- Flinders Medical Centre, FCIC, Bedford Park, SA, 5042, Australia.,Flinders University, Bedford Park, SA, 5042, Australia
| | | | - Ganessan Kichenadasse
- Flinders Medical Centre, FCIC, Bedford Park, SA, 5042, Australia.,Flinders University, Bedford Park, SA, 5042, Australia
| | - Amitesh Roy
- Flinders Medical Centre, FCIC, Bedford Park, SA, 5042, Australia.,Flinders University, Bedford Park, SA, 5042, Australia
| | - Sina Vatandoust
- Flinders Medical Centre, FCIC, Bedford Park, SA, 5042, Australia.,Flinders University, Bedford Park, SA, 5042, Australia
| | - Chris Karapetis
- Flinders Medical Centre, FCIC, Bedford Park, SA, 5042, Australia.,Flinders University, Bedford Park, SA, 5042, Australia
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23
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Gadducci A, Guerrieri ME, Cosio S. Adenocarcinoma of the uterine cervix: Pathologic features, treatment options, clinical outcome and prognostic variables. Crit Rev Oncol Hematol 2019; 135:103-114. [PMID: 30819439 DOI: 10.1016/j.critrevonc.2019.01.006] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 01/16/2019] [Indexed: 12/11/2022] Open
Abstract
Adenocarcinoma accounts for 10-25% of all cervical cancers, and its relative and absolute rate has raised over the past decades. Most, but not all the authors, reported that adenocarcinoma has a greater propensity to lymph node, ovarian and distant metastases and a worse prognosis compared with squamous cell carcinoma. However, whether histologic type is an independent prognostic factor is still a debated issue. Moreover, adenocarcinoma is a very heterogenous disease, including different histological subtypes. Whereas radical hysterectomy and definitive radiotherapy achieve the same clinical outcome in early stage squamous cell carcinoma, surgery seems to obtain better survival compared with definitive radiotherapy in early stage adenocarcinoma. Chemoradiation is the standard treatment for locally advanced cervical cancer regardless of histologic type, although several retrospective studies showed that patients with adenocarcinoma were more likely to die than those with squamous cell carcinoma both before and after concurrent chemoradiation era. The prognostic relevance of biological variables, such as cyclin-dependent kinase inhibitors, p53, cyclooxygenase-2 [COX-2], cell surface tyrosine-kinases and programmed death-ligand [PD-L1], is still under investigation. Palliative chemotherapy is the only treatment option for persistent or recurrent cervical adenocarcinoma not amenable with surgery and radiotherapy. The use of immune checkpoint inhibitors as well as a therapeutic strategy targeting cell surface tyrosine kinases should be adequately explored in this clinical setting.
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Affiliation(s)
- Angiolo Gadducci
- Department of Clinical and Experimental Medicine, Division of Gynecology and Obstetrics, University of Pisa, Italy.
| | - Maria Elena Guerrieri
- Department of Clinical and Experimental Medicine, Division of Gynecology and Obstetrics, University of Pisa, Italy
| | - Stefania Cosio
- Department of Clinical and Experimental Medicine, Division of Gynecology and Obstetrics, University of Pisa, Italy
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24
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Leath CA, Monk BJ. Twenty-first century cervical cancer management: A historical perspective of the gynecologic oncology group/NRG oncology over the past twenty years. Gynecol Oncol 2018; 150:391-397. [PMID: 29954593 PMCID: PMC6102091 DOI: 10.1016/j.ygyno.2018.06.023] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 06/13/2018] [Accepted: 06/20/2018] [Indexed: 02/04/2023]
Abstract
Since 1970, the Gynecologic Oncology Group (GOG) has been at the forefront of evaluating and helping to implement ground breaking and paradigm changing research in the management of cervical cancer. While the most dramatic example of this impact was a series of clinical trials published in 1999 that evaluated chemoradiation therapy versus radiation therapy alone for patients with various clinical scenarios, including both locally advanced as well as post radical hysterectomy patients, investigation has continued to further refine and improve therapy. In 2014, based on the results of GOG protocol 240, bevacizumab became the first approved targeted therapy in a gynecologic cancer in the United States. Most recently, clinical trial work from the GOG is changing the standard of care for all clinical scenarios. Finally, an emphasis on survivorship and special populations are now top priorities.
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Affiliation(s)
- Charles A Leath
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology, University of Alabama at Birmingham, Birmingham, AL, United States of America.
| | - Bradley J Monk
- Division of Gynecologic Oncology, Arizona Oncology (US Oncology Network), University of Arizona College of Medicine, Creighton University School of Medicine at St. Joseph's Hospital Phoenix, AZ, United States of America
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25
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Cho O, Chun M, Oh YT, Noh OK, Chang SJ, Ryu HS, Lee EJ. Prognostic implication of simultaneous anemia and lymphopenia during concurrent chemoradiotherapy in cervical squamous cell carcinoma. Tumour Biol 2017; 39:1010428317733144. [PMID: 29022484 DOI: 10.1177/1010428317734303] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Radioresistance often leads to poor survival in concurrent chemoradiotherapy-treated cervical squamous cell carcinoma, and reliable biomarkers can improve prognosis. We compared the prognostic potential of hemoglobin, absolute neutrophil count, and absolute lymphocyte count with that of squamous cell carcinoma antigen in concurrent chemoradiotherapy-treated squamous cell carcinoma. We analyzed 152 patients with concurrent chemoradiotherapy and high-dose-rate intracavitary brachytherapy-treated cervical squamous cell carcinoma. Hemoglobin, absolute neutrophil count, absolute lymphocyte count, and squamous cell carcinoma antigen were quantitated and correlated with survival, using Cox regression, receiver operating characteristic curve analysis, and Kaplan-Meier plots. Both hemoglobin and absolute lymphocyte count in the second week of concurrent chemoradiotherapy (Hb2 and ALC2) and squamous cell carcinoma antigen in the third week of concurrent chemoradiotherapy (mid-squamous cell carcinoma antigen) correlated significantly with disease-specific survival and progression-free survival. The ratio of high-dose-rate intracavitary brachytherapy dose to total dose (high-dose-rate intracavitary brachytherapy ratio) correlated significantly with progression-free survival. Patients with both low Hb2 (≤11 g/dL) and ALC2 (≤639 cells/µL) showed a lower 5-year disease-specific survival rate than those with high Hb2 and/or ALC2, regardless of mid-squamous cell carcinoma antigen (mid-squamous cell carcinoma antigen: ≤4.7 ng/mL; 5-year disease-specific survival rate: 85.5% vs 94.6%, p = 0.0096, and mid-squamous cell carcinoma antigen: >4.7 ng/mL; 5-year disease-specific survival rate: 43.8% vs 66.7%, p = 0.192). When both Hb2 and ALC2 were low, the low high-dose-rate intracavitary brachytherapy ratio (≤0.43) subgroup displayed significantly lower 5-year disease-specific survival rate compared to the subgroup high high-dose-rate intracavitary brachytherapy ratio (>0.43) (62.5% vs 88.2%, p = 0.0067). Patients with both anemia and lymphopenia during concurrent chemoradiotherapy showed poor survival, independent of mid-squamous cell carcinoma antigen, and escalating high-dose-rate intracavitary brachytherapy ratio might improve survival.
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Affiliation(s)
- Oyeon Cho
- 1 Department of Radiation Oncology, School of Medicine, Ajou University, Suwon, Republic of Korea
| | - Mison Chun
- 1 Department of Radiation Oncology, School of Medicine, Ajou University, Suwon, Republic of Korea
| | - Young-Taek Oh
- 1 Department of Radiation Oncology, School of Medicine, Ajou University, Suwon, Republic of Korea
| | - O Kyu Noh
- 1 Department of Radiation Oncology, School of Medicine, Ajou University, Suwon, Republic of Korea
| | - Suk-Joon Chang
- 2 Department of Obstetrics and Gynecology, School of Medicine, Ajou University, Suwon, Republic of Korea
| | - Hee-Sug Ryu
- 2 Department of Obstetrics and Gynecology, School of Medicine, Ajou University, Suwon, Republic of Korea
| | - Eun Ju Lee
- 3 Department of Radiology, School of Medicine, Ajou University, Suwon, Republic of Korea
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26
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Cybulska P, Goss C, Tew WP, Parameswaran R, Sonoda Y. Indications for and complications of transfusion and the management of gynecologic malignancies. Gynecol Oncol 2017; 146:416-426. [PMID: 28528916 PMCID: PMC5527999 DOI: 10.1016/j.ygyno.2017.05.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Revised: 05/01/2017] [Accepted: 05/08/2017] [Indexed: 02/06/2023]
Abstract
Anemia, which is highly prevalent in oncology patients, is one of the most established negative prognostic factors for several gynecologic malignancies. Multiple factors can cause or contribute to the development of anemia in patients with gynecologic cancers; these factors include blood loss (during surgery or directly from the tumor), renal impairment (caused by platinum-based chemotherapy), and marrow dysfunction (from metastases, chemotherapy, and/or radiation therapy). Several peri- and intra-operative strategies can be used to optimize patient management and minimize blood loss related to surgery. Blood transfusions are routinely employed as corrective measures against anemia; however, blood transfusions are one of the most overused healthcare interventions. There are safe and effective evidence-based blood transfusion strategies used in other patient populations that warrant further investigation in the surgical oncology setting. Blood is a valuable healthcare resource, and clinicians can learn to use it more judiciously through knowledge of the potential risks and complications of blood interventions, as well as the ability to properly identify the patients most likely to benefit from such interventions.
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Affiliation(s)
- Paulina Cybulska
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Cheryl Goss
- Hematology and Coagulation Laboratory Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - William P Tew
- Gynecologic Medical Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Rekha Parameswaran
- Transfusion Medicine Service, Department of Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Hematology Service, Department of Medicine, Division of Hematologic Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Yukio Sonoda
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, NY, USA.
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27
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Koulis TA, Kornaga EN, Banerjee R, Phan T, Ghatage P, Magliocco AM, Lees-Miller SP, Doll CM. Anemia, leukocytosis and thrombocytosis as prognostic factors in patients with cervical cancer treated with radical chemoradiotherapy: A retrospective cohort study. Clin Transl Radiat Oncol 2017; 4:51-56. [PMID: 29594208 PMCID: PMC5833917 DOI: 10.1016/j.ctro.2017.05.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 05/05/2017] [Accepted: 05/10/2017] [Indexed: 12/17/2022] Open
Abstract
Introduction Anemia has long been associated with poor prognosis in patients with cervical cancer. Recently, additional hematologic parameters have emerged as potential indicators of worse outcome in this patient group. In a cohort of cervical cancer patients treated with chemoradiotherapy (CRT) and brachytherapy, we report on the prognostic significance of hematologic parameters including anemia, leukocytosis, neutrophil to lymphocyte ratio (NLR), and thrombocytosis, the effect of combining anemia with other hematologic parameters, and the effect of changes in hemoglobin levels during treatment. Materials and methods Two-hundred fifty-seven cervical cancer patients were retrospectively identified from a single cancer institution’s database. Hematologic parameters were categorized as: anemia (hemoglobin ≤115 g/L), leukocytosis (white blood cell count >10 × 109/L), thrombocytosis (platelets >400 × 109/L), and NLR (ratio >5). The association between clinical factors and hematologic parameters on progression-free survival (PFS) and overall survival (OS) were assessed at 5 years. Results At 5 years, both pre-treatment anemia (PFS: 60% vs 34%, p < 0.0001; OS: 68% vs 41%, p < 0.0001) and on-treatment anemia (PFS: 62% vs 40%, p < 0.0001; OS: 70% vs 48%, p < 0.0001) were significantly associated with worse survival. This adverse effect on 5-year PFS and OS was increased in patients with both pre-treatment anemia and leukocytosis (PFS: 72% vs 42%, p < 0.0001; OS: 68% vs 37%, p < 0.0001) and pre-treatment anemia and elevated NLR (PFS: 61% vs 30%, p < 0.0001; OS: 68% vs 37%, p < 0.0001). Five-year PFS (50% vs 31%) and OS (60% vs 36%) was better in patients whose pre-treatment anemia improved to normal hemoglobin levels on treatment vs those patients who were anemic both pre- and on-treatment. Conclusion Pre-treatment and on-treatment anemia were significant, independent predictors of worse PFS and OS. Anemia and other hematologic parameters remain prognostic markers for cervical cancer patients. Improvement in PFS and OS was seen in patients with normalization of hemoglobin.
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Key Words
- AOTHgb, average on treatment hemoglobin
- Anemia
- BT, brachytherapy
- CRT, chemoradiotherapy
- Cervical cancer
- EBRT, external beam radiotherapy
- HDR, high dose rate
- Hgb, hemoglobin
- LDR, low dose rate
- Leukocytosis
- NLR, neutrophil-to-lymphocyte ratio
- OS, overall survival
- PA, paraortic
- PFS, progression free survival
- PTHgb, pre-treatment hemoglobin
- Plt, platelet
- Prognosis
- Thrombocytosis
- WBC, white blood cell
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Affiliation(s)
- Theodora A Koulis
- Department of Oncology, University of Calgary, Cumming School of Medicine, 3330 Hospital Dr. NW, Calgary, AB T2N 4N1, Canada.,Division of Radiation Oncology, Tom Baker Cancer Centre, 1331 29 St NW, Calgary, AB T2N 4N2, Canada
| | - Elizabeth N Kornaga
- Translational Laboratories, Tom Baker Cancer Centre, Alberta Health Services, 1331 29 St NW, Calgary, AB T2N 4N2, Canada
| | - Robyn Banerjee
- Department of Oncology, University of Calgary, Cumming School of Medicine, 3330 Hospital Dr. NW, Calgary, AB T2N 4N1, Canada.,Division of Radiation Oncology, Tom Baker Cancer Centre, 1331 29 St NW, Calgary, AB T2N 4N2, Canada
| | - Tien Phan
- Department of Oncology, University of Calgary, Cumming School of Medicine, 3330 Hospital Dr. NW, Calgary, AB T2N 4N1, Canada.,Division of Radiation Oncology, Tom Baker Cancer Centre, 1331 29 St NW, Calgary, AB T2N 4N2, Canada
| | - Prafull Ghatage
- Department of Oncology, University of Calgary, Cumming School of Medicine, 3330 Hospital Dr. NW, Calgary, AB T2N 4N1, Canada.,Division of Gynecologic Oncology, Tom Baker Cancer Centre, 1331 29 St NW, Calgary, AB T2N 4N2, Canada
| | - Anthony M Magliocco
- Translational Laboratories, Tom Baker Cancer Centre, Alberta Health Services, 1331 29 St NW, Calgary, AB T2N 4N2, Canada
| | - Susan P Lees-Miller
- Department of Biochemistry and Molecular Biology and Oncology, University of Calgary, 3280 Hospital Drive NW, Calgary, AB T2N 4Z6, Canada
| | - Corinne M Doll
- Department of Oncology, University of Calgary, Cumming School of Medicine, 3330 Hospital Dr. NW, Calgary, AB T2N 4N1, Canada.,Division of Radiation Oncology, Tom Baker Cancer Centre, 1331 29 St NW, Calgary, AB T2N 4N2, Canada
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28
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Reduced cancer mortality at high altitude: The role of glucose, lipids, iron and physical activity. Exp Cell Res 2017; 356:209-216. [PMID: 28344053 DOI: 10.1016/j.yexcr.2017.03.048] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2017] [Accepted: 03/22/2017] [Indexed: 12/21/2022]
Abstract
Residency at high altitude (HA) demands adaptation to challenging environmental conditions with hypobaric hypoxia being the most important one. Epidemiological and experimental data suggest that chronic exposure to HA reduces cancer mortality and lowers prevalence of metabolic disorders like diabetes and obesity implying that adaption to HA modifies a broad spectrum of physiological, metabolic and cellular programs with a generally beneficial outcome for humans. However, the complexity of multiple, potentially tumor-suppressive pathways at HA impedes the understanding of mechanisms leading to reduced cancer mortality. Many adaptive processes at HA are tightly interconnected and thus it cannot be ruled out that the entirety or at least some of the HA-related alterations act in concert to reduce cancer mortality. In this review we discuss tumor formation as a concept of competition between healthy and cancer cells with improved fitness - and therefore higher competitiveness - of healthy cells at high altitude. We discuss HA-related changes in glucose, lipid and iron metabolism that may have an impact on tumorigenesis. Additionally, we discuss two parameters with a strong impact on tumorigenesis, namely drug metabolism and physical activity, to underpin their potential contribution to HA-dependent reduced cancer mortality. Future studies are needed to unravel why cancer mortality is reduced at HA and how this knowledge might be used to prevent and to treat cancer patients.
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Crathorne L, Huxley N, Haasova M, Snowsill T, Jones-Hughes T, Hoyle M, Briscoe S, Coelho H, Long L, Medina-Lara A, Mujica-Mota R, Napier M, Hyde C. The effectiveness and cost-effectiveness of erythropoiesis-stimulating agents (epoetin and darbepoetin) for treating cancer treatment-induced anaemia (including review of technology appraisal no. 142): a systematic review and economic model. Health Technol Assess 2016; 20:1-588, v-vi. [PMID: 26907163 DOI: 10.3310/hta20130] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Anaemia is a common side effect of cancer treatments and can lead to a reduction in quality of life. Erythropoiesis-stimulating agents (ESAs) are licensed for use in conjunction with red blood cell transfusions to improve cancer treatment-induced anaemia (CIA). OBJECTIVE To investigate the effectiveness and cost-effectiveness of ESAs in anaemia associated with cancer treatment (specifically chemotherapy). DATA SOURCES The following databases were searched from 2004 to 2013: The Cochrane Library, MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, EMBASE, Web of Science, Cumulative Index to Nursing and Allied Health Literature, British Nursing Index, Health Management Information Consortium, Current Controlled Trials and ClinicalTrials.gov. The US Food and Drug Administration and European Medicines Agency websites were also searched. Bibliographies of included papers were scrutinised for further potentially includable studies. REVIEW METHODS The clinical effectiveness review followed principles published by the NHS Centre for Reviews and Dissemination. Randomised controlled trials (RCTs), or systematic reviews of RCTs, of ESAs (epoetin or darbepoetin) for treating people with CIA were eligible for inclusion in the review. Comparators were best supportive care, placebo or other ESAs. Anaemia- and malignancy-related outcomes, health-related quality of life (HRQoL) and adverse events (AEs) were evaluated. When appropriate, data were pooled using meta-analysis. An empirical health economic model was developed comparing ESA treatment with no ESA treatment. The model comprised two components: one evaluating short-term costs and quality-adjusted life-years (QALYs) (while patients are anaemic) and one evaluating long-term QALYs. Costs and benefits were discounted at 3.5% per annum. Probabilistic and univariate deterministic sensitivity analyses were performed. RESULTS Of 1457 titles and abstracts screened, 23 studies assessing ESAs within their licensed indication (based on start dose administered) were included in the review. None of the RCTs were completely aligned with current European Union licenses. The results suggest a clinical benefit from ESAs for anaemia-related outcomes and an improvement in HRQoL scores. The impact of ESAs on AEs and survival remains highly uncertain, although point estimates are lower, confidence intervals are wide and not statistically significant. Base-case incremental cost-effectiveness ratios (ICERs) for ESA treatment compared with no ESA treatment ranged from £ 19,429 to £ 35,018 per QALY gained, but sensitivity and scenario analyses demonstrate considerable uncertainty in these ICERs, including the possibility of overall health disbenefit. All ICERs were sensitive to survival and cost. LIMITATIONS The relative effectiveness of ESAs was not addressed; all ESAs were assumed to have equivalent efficacy. No studies were completely aligned with their European labelling beyond the starting dose evaluated. There is questionable generalisability given that the included trials were published >20 years ago and there have been many changes to chemotherapy as well as to the quality of supportive treatment. Trial quality was moderate or poor and there was considerable unexplained heterogeneity for a number of outcomes, particularly survival, and evidence of publication bias. Adjustments were not made to account for multiple testing. CONCLUSIONS ESAs could be cost-effective when used closer to licence, but there is considerable uncertainty, mainly because of unknown impacts on overall survival. STUDY REGISTRATION This study is registered as PROSPERO CRD42013005812. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Louise Crathorne
- Peninsula Technology Assessment Group (PenTAG), University of Exeter Medical School, Exeter, UK
| | - Nicola Huxley
- Peninsula Technology Assessment Group (PenTAG), University of Exeter Medical School, Exeter, UK
| | - Marcela Haasova
- Peninsula Technology Assessment Group (PenTAG), University of Exeter Medical School, Exeter, UK
| | - Tristan Snowsill
- Peninsula Technology Assessment Group (PenTAG), University of Exeter Medical School, Exeter, UK
| | - Tracey Jones-Hughes
- Peninsula Technology Assessment Group (PenTAG), University of Exeter Medical School, Exeter, UK
| | - Martin Hoyle
- Peninsula Technology Assessment Group (PenTAG), University of Exeter Medical School, Exeter, UK
| | - Simon Briscoe
- Peninsula Technology Assessment Group (PenTAG), University of Exeter Medical School, Exeter, UK
| | - Helen Coelho
- Peninsula Technology Assessment Group (PenTAG), University of Exeter Medical School, Exeter, UK
| | - Linda Long
- Peninsula Technology Assessment Group (PenTAG), University of Exeter Medical School, Exeter, UK
| | | | - Ruben Mujica-Mota
- Peninsula Technology Assessment Group (PenTAG), University of Exeter Medical School, Exeter, UK
| | | | - Chris Hyde
- Peninsula Technology Assessment Group (PenTAG), University of Exeter Medical School, Exeter, UK
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Chen L, Jiang H, Gao W, Tu Y, Zhou Y, Li X, Zhu Z, Jiang Q, Zhan H, Yu J, Fu C, Gao Y. Combination with intravenous iron supplementation or doubling erythropoietin dose for patients with chemotherapy-induced anaemia inadequately responsive to initial erythropoietin treatment alone: study protocol for a randomised controlled trial. BMJ Open 2016; 6:e012231. [PMID: 27855097 PMCID: PMC5073518 DOI: 10.1136/bmjopen-2016-012231] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Erythropoietin (EPO) is a commonly used option in the treatment of chemotherapy-induced anaemia (CIA). However, ∼30-50% of patients fail to achieve an adequate response after initial treatment. Prior studies have demonstrated that intravenous iron might synergistically improve therapeutic response to EPO treatment in this patient population. METHODS AND ANALYSIS We will perform this multicentre, randomised, open-label, parallel-group, active controlled non-inferiority study to compare the two combination therapies of EPO plus intravenous iron regimen versus doubling the dose of EPO in patients with CIA who have an inadequate response to initial EPO treatment at a routine dose. A total of 603 patients with an increase in haemoglobin (Hb) <1 g/dL will be enrolled and randomised to one of the three study treatment groups at a 1:1:1 ratio Group 1: EPO treatment at the original dose plus intravenous iron dextran 200 mg every 3 weeks (Q3W) for 15 weeks; Group 2: EPO treatment at the original dose plus intravenous iron dextran 100 mg, twice a week for 5 weeks; Group 3: the control group, doubling the EPO dose without preplanned iron supplementation. The primary outcome measure to compare is the Hb response rate at week 15 and the secondary end points involve therapeutic blood transfusions. Time-to-progression, adverse events and quality of life will also be evaluated. ETHICS AND DISSEMINATION All participants will provide informed consent; the study protocol has been approved by the independent ethics committee of Shanghai East Hospital. This study would clearly demonstrate the potential benefit of combining epoetin treatment with intravenous iron supplementation. Findings will be shared with participating hospitals, policymakers and the academic community to promote the clinical management of CIA in China. TRIAL REGISTRATION NUMBER NCT02731378.
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Affiliation(s)
- Lin Chen
- Department of Oncology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Hong Jiang
- Department of Oncology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Wei Gao
- Department of Gastrointestinal Surgery, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Ye Tu
- Department of Oncology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Ying Zhou
- Department of Oncology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Xi Li
- Department of Oncology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Zhe Zhu
- Department of Gastrointestinal Surgery, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Qixin Jiang
- Department of Gastrointestinal Surgery, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Haifeng Zhan
- Department of Gynecology, Jing'an District Centre Hospital of Shanghai (Huashan Hospital Fudan University Jing'an Branch), Shanghai, China
| | - Jiangming Yu
- Department of Orthopaedics, Changzheng Hospital, Shanghai, China
| | - Chuangang Fu
- Department of Gastrointestinal Surgery, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yong Gao
- Department of Oncology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
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Shahid S. Review of hematological indices of cancer patients receiving combined chemotherapy & radiotherapy or receiving radiotherapy alone. Crit Rev Oncol Hematol 2016; 105:145-55. [PMID: 27423975 DOI: 10.1016/j.critrevonc.2016.06.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 05/09/2016] [Accepted: 06/01/2016] [Indexed: 01/18/2023] Open
Abstract
We observed the outcomes of chemotherapy with radiotherapy (CR) or radiotherapy (RT) alone for cancer patients of larynx, breast, blood and brain origins through complete blood count (CBC). Following were more depressed in CR patients: mean corpuscular hemoglobin-MCH & lymphocytes-LYM, hematocrit, mean corpuscular hemoglobin concentration-MCHC, hemoglobin-HB and red blood cells-RBC. In RT patients, following were more depressed: LYM, MCH and MCHC. Overall, in all cancer patients, the lymphocytes were depressed 52%. There existed a significant difference between white blood cells and RBC in both CR and RT patients. A significant moderate negative correlation is found in HB with the dose range 30-78 (Gray) given to the CR cancer patients. More number of CBC parameters affected in patients treated with CR and RT; but in less percentage as compared to patients who treated with RT alone. The cancer patients suffered from anemia along with immune modulations from the treatments.
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Affiliation(s)
- Saman Shahid
- Department of Sciences and Humanities, National University of Computer and Emerging Sciences (NUCES)-Foundation for Advancement of Science and Technology (FAST), Lahore, Pakistan.
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The tumor promoting roles of erythropoietin/erythropoietin receptor signaling pathway in gastric cancer. Tumour Biol 2016; 37:11523-33. [DOI: 10.1007/s13277-016-5053-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2016] [Accepted: 04/01/2016] [Indexed: 12/17/2022] Open
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Mackay HJ, Wenzel L, Mileshkin L. Nonsurgical management of cervical cancer: locally advanced, recurrent, and metastatic disease, survivorship, and beyond. Am Soc Clin Oncol Educ Book 2016:e299-309. [PMID: 25993189 DOI: 10.14694/edbook_am.2015.35.e299] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Despite the declining incidence of cervical cancer as a result of the introduction of screening programs, globally it remains a leading cause of cancer-related death in women. Outcomes for patients who are diagnosed with anything but early-stage disease remain poor. Here we examine emerging strategies to improve the treatment of locally advanced disease. We discuss emerging biologic data, which are informing our investigation of new therapeutic interventions in persistent, recurrent, and metastatic cervical cancer. We recognize the importance of interventions to improve quality of life and to prevent long-term sequelae in women undergoing treatment. Finally, and perhaps most importantly, we recognize the need for global collaboration and advocacy to improve the outcome for all women at risk of and diagnosed with this disease.
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Affiliation(s)
- Helen J Mackay
- From the Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre/Deptartment of Medicine, University of Toronto, Ontario, Canada; Department of Medicine and Public Health, University of California, Irvine, Irvine, CA; Division of Cancer Medicine, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Lari Wenzel
- From the Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre/Deptartment of Medicine, University of Toronto, Ontario, Canada; Department of Medicine and Public Health, University of California, Irvine, Irvine, CA; Division of Cancer Medicine, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Linda Mileshkin
- From the Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre/Deptartment of Medicine, University of Toronto, Ontario, Canada; Department of Medicine and Public Health, University of California, Irvine, Irvine, CA; Division of Cancer Medicine, Peter MacCallum Cancer Centre, Melbourne, Australia
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Marchetti C, De Felice F, Palaia I, Musio D, Muzii L, Tombolini V, Benedetti Panici P. Erythropoiesis-stimulating agents in gynecological malignancies: A study-level meta-analysis. Crit Rev Oncol Hematol 2015; 99:123-8. [PMID: 26748593 DOI: 10.1016/j.critrevonc.2015.12.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Revised: 11/04/2015] [Accepted: 12/22/2015] [Indexed: 11/15/2022] Open
Abstract
This meta-analysis was planned to define the role of erythropoiesis-stimulating agents (ESAs) in gynecological cancer patients, receiving myelosuppressive treatment. Pubmed, Medline and Scopus were searched to select English-language articles. Only randomized controlled trials (RCTs) were included. Endpoints were incidence of transfusions, thrombotic events (TE), deaths, and failures. Odd ratio (OR) with 95% confidence interval (CI) was calculated using fixed or random effects model. In seven RCTs ESAs studies of 892 patients under treatment, use of ESAs correlates with a significant reduction of transfusions rate (OR=0.35; 95% CI: 0.19-0.65; p=0.008). OR for overall mortality was 1.10 (95% CI 0.82-1.49; p=0.53). ESAs OR for disease failure in 5 studies was 1.71 (95% CI: 0.90-3.24; p=0.1). This meta-analysis, even if limited by few RCTs, suggests that ESAs reduce transfusions without increasing mortality or disease progression in gynecological cancer patients receiving treatment.
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Affiliation(s)
- C Marchetti
- Department of Gynecological and Obstetrical Sciences and Urological Sciences, "Sapienza" University of Rome, Viale Regina Elena 326, Rome 00161 Italy
| | - F De Felice
- Department of Radiotherapy, Policlinico Umberto I "Sapienza" University of Rome, Viale Regina Elena 326, Rome 00161, Italy.
| | - I Palaia
- Department of Gynecological and Obstetrical Sciences and Urological Sciences, "Sapienza" University of Rome, Viale Regina Elena 326, Rome 00161 Italy
| | - D Musio
- Department of Radiotherapy, Policlinico Umberto I "Sapienza" University of Rome, Viale Regina Elena 326, Rome 00161, Italy
| | - L Muzii
- Department of Gynecological and Obstetrical Sciences and Urological Sciences, "Sapienza" University of Rome, Viale Regina Elena 326, Rome 00161 Italy
| | - V Tombolini
- Department of Radiotherapy, Policlinico Umberto I "Sapienza" University of Rome, Viale Regina Elena 326, Rome 00161, Italy
| | - P Benedetti Panici
- Department of Gynecological and Obstetrical Sciences and Urological Sciences, "Sapienza" University of Rome, Viale Regina Elena 326, Rome 00161 Italy
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Lessons from the past: Long-term safety and survival outcomes of a prematurely terminated randomized controlled trial on prophylactic vs. hemoglobin-based administration of erythropoiesis-stimulating agents in patients with chemotherapy-induced anemia. Mol Clin Oncol 2015; 4:211-220. [PMID: 26893865 DOI: 10.3892/mco.2015.693] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Accepted: 09/10/2015] [Indexed: 11/05/2022] Open
Abstract
Prophylactic erythropoiesis-stimulating agent (ESA) administration for chemotherapy-induced anemia (CIA) is not supported by current guidelines. Long-term follow-up of patients WHO had been treated with ESA for CIA in the past may provide useful information. In 2002, we undertook a prospective, randomized phase III trial of prophylactic vs. hemoglobin (Hb)-based (threshold: 11 mg/dl) ESA administration in patients with solid tumors and CIA. ESA administration FOR CIA was permanently suspended in 2007 in view of published data at that time, while patient surveillance continued. Among 630 evaluable patients, 38.6% were male, 50.9% had advanced cancer at diagnosis, 40.6% had Hb levels <12 mg/dl at baseline and 47.9% received ESA prophylactically (1:1 randomization). The major tumor types included colorectal (36.0%), breast (20.6%), non-prostate genitourinary (11.0%) and lung CANCER (8.4%). After a median follow-up of 85.4 months, 358 patients had relapsed and 380 had succumbed to the disease. Patients in the prophylactic ESA group (GROUP A; experimental arm), as compared with those in the Hb-based group (GROUP B; iron supplementation alone), exhibited A significantly more prominent increase in median Hb levels, particularly in the subset of patients with non-metastatic disease (two-sided P<0.01) among patients receiving chemotherapy for advanced cancer, those who received ESAs prophylactically exhibited a lower incidence of CIA (all grades: P=0.014, grades 3-4: P=0.034) and fatigue (all grades: P<0.001, grades 3-4: P=0.055), but a higher rate of a composite outcome encompassing all thrombosis-related events (all grades: P=0.043, grades 3-4: P=0.099). These differences were less prominent in the group of patients who received adjuvant treatment. There were no significant differences in overall mortality and relapse/progression rates between the two groups. therefore, prophylactic, compared with Hb-based, administration of ESAs for CIA in patients with solid tumors, was found to be associated with a significantly lower incidence of anemia and fatigue, but with a marginally higher rate of thrombosis-related adverse events, particularly in patients receiving first-line chemotherapy for advanced cancer.
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Butler AM, Kshirsagar AV, Olshan AF, Nielsen ME, Wheeler SB, Brookhart MA. Trends in Anemia Management in Hemodialysis Patients with Cancer. Am J Nephrol 2015; 42:206-15. [PMID: 26439712 DOI: 10.1159/000440771] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Accepted: 08/13/2015] [Indexed: 02/02/2023]
Abstract
BACKGROUND Erythropoiesis-stimulating agents (ESAs), intravenous iron, and blood transfusion are used to treat anemia in both end-stage renal disease (ESRD) and cancer. However, anemia treatment patterns have not been described among ESRD patients undergoing hemodialysis with concurrent cancer, especially in the recent era of ESA-related safety concerns. METHODS We analyzed Medicare data from a cohort of hemodialysis patients diagnosed with incident cancer. We used multivariable generalized linear models to estimate trends and patterns in ESA use, iron use, transfusion use, epoetin alfa (EPO) dose, iron dose, and resulting hemoglobin levels (2000-2011). RESULTS Of 43,760 eligible patients, quarterly ESA use declined slightly from a peak of 94.1 to 90.0%. Quarterly EPO dose increased from 2000 to 2004, then declined; quarterly hemoglobin levels followed a similar pattern. Iron use increased rapidly from 46.9 to 79.3%. Iron dose increased until 2010 and then declined. There was an increase in the quarterly transfusion use (6.3-11.7%) and in the mean number of transfusion days per year (1.4-1.8). Anemia treatment patterns varied by demographic/clinical subgroups, especially among patients receiving chemotherapy, who required higher ESA use, EPO dose, and frequency of transfusions. CONCLUSIONS Despite safety concerns about ESAs in both the ESRD and cancer populations, the proportion of hemodialysis patients with cancer who used ESAs between 2000 and 2011 remained extremely high. EPO dose and hemoglobin levels increased and then decreased. Iron use, iron dose, and transfusions increased substantially. Future research examining the risk-benefit profile of different anemia management strategies in the dialysis population with cancer is needed.
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Affiliation(s)
- Anne M Butler
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, N.C., USA
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Abbett SK, Kaufman RM, Gustafson M, Greenberg JO. Multifaceted approach to reducing unnecessary red blood cell utilization. Healthcare (Basel) 2015; 3:67-73. [DOI: 10.1016/j.hjdsi.2014.07.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2014] [Revised: 05/30/2014] [Accepted: 07/15/2014] [Indexed: 11/16/2022] Open
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Moore KN, Rowland MR. Treatment Advances in Locoregionally Advanced and Stage IVB/Recurrent Cervical Cancer: Can We Agree That More Is Not Always Better? J Clin Oncol 2015; 33:2125-8. [PMID: 25987695 DOI: 10.1200/jco.2015.61.0998] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Kathleen N Moore
- Stephenson Oklahoma Cancer Center, University of Oklahoma, Oklahoma City, OK
| | - Michelle R Rowland
- Stephenson Oklahoma Cancer Center, University of Oklahoma, Oklahoma City, OK
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Rose PG, Java J, Whitney CW, Stehman FB, Lanciano R, Thomas GM, DiSilvestro PA. Nomograms Predicting Progression-Free Survival, Overall Survival, and Pelvic Recurrence in Locally Advanced Cervical Cancer Developed From an Analysis of Identifiable Prognostic Factors in Patients From NRG Oncology/Gynecologic Oncology Group Randomized Trials of Chemoradiotherapy. J Clin Oncol 2015; 33:2136-42. [PMID: 25732170 DOI: 10.1200/jco.2014.57.7122] [Citation(s) in RCA: 120] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To evaluate the prognostic factors in locally advanced cervical cancer limited to the pelvis and develop nomograms for 2-year progression-free survival (PFS), 5-year overall survival (OS), and pelvic recurrence. PATIENTS AND METHODS We retrospectively reviewed 2,042 patients with locally advanced cervical carcinoma enrolled onto Gynecologic Oncology Group clinical trials of concurrent cisplatin-based chemotherapy and radiotherapy. Nomograms for 2-year PFS, five-year OS, and pelvic recurrence were created as visualizations of Cox proportional hazards regression models. The models were validated by bootstrap-corrected, relatively unbiased estimates of discrimination and calibration. RESULTS Multivariable analysis identified prognostic factors including histology, race/ethnicity, performance status, tumor size, International Federation of Gynecology and Obstetrics stage, tumor grade, pelvic node status, and treatment with concurrent cisplatin-based chemotherapy. PFS, OS, and pelvic recurrence nomograms had bootstrap-corrected concordance indices of 0.62, 0.64, and 0.73, respectively, and were well calibrated. CONCLUSION Prognostic factors were used to develop nomograms for 2-year PFS, 5-year OS, and pelvic recurrence for locally advanced cervical cancer clinically limited to the pelvis treated with concurrent cisplatin-based chemotherapy and radiotherapy. These nomograms can be used to better estimate individual and collective outcomes.
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Affiliation(s)
- Peter G Rose
- Peter G. Rose, Cleveland Clinic Foundation and Case Western Reserve University, Cleveland, OH; James Java, Gynecologic Oncology Group Statistical and Data Center, Roswell Park Cancer Institute, Buffalo, NY; Charles W. Whitney, Christiana Gynecologic Oncology, Apex Medical Center, Newark, DE; Frederick B. Stehman, Mel and Bren Simon Cancer Center, Indiana University School of Medicine, Indianapolis, IN; Rachelle Lanciano, Delaware County Regional Cancer Center, Drexel Hill, PA; Gillian M. Thomas, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Ontario, Canada; and Paul A. DiSilvestro, Women and Infants Hospital, Brown University, Providence, RI.
| | - James Java
- Peter G. Rose, Cleveland Clinic Foundation and Case Western Reserve University, Cleveland, OH; James Java, Gynecologic Oncology Group Statistical and Data Center, Roswell Park Cancer Institute, Buffalo, NY; Charles W. Whitney, Christiana Gynecologic Oncology, Apex Medical Center, Newark, DE; Frederick B. Stehman, Mel and Bren Simon Cancer Center, Indiana University School of Medicine, Indianapolis, IN; Rachelle Lanciano, Delaware County Regional Cancer Center, Drexel Hill, PA; Gillian M. Thomas, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Ontario, Canada; and Paul A. DiSilvestro, Women and Infants Hospital, Brown University, Providence, RI
| | - Charles W Whitney
- Peter G. Rose, Cleveland Clinic Foundation and Case Western Reserve University, Cleveland, OH; James Java, Gynecologic Oncology Group Statistical and Data Center, Roswell Park Cancer Institute, Buffalo, NY; Charles W. Whitney, Christiana Gynecologic Oncology, Apex Medical Center, Newark, DE; Frederick B. Stehman, Mel and Bren Simon Cancer Center, Indiana University School of Medicine, Indianapolis, IN; Rachelle Lanciano, Delaware County Regional Cancer Center, Drexel Hill, PA; Gillian M. Thomas, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Ontario, Canada; and Paul A. DiSilvestro, Women and Infants Hospital, Brown University, Providence, RI
| | - Frederick B Stehman
- Peter G. Rose, Cleveland Clinic Foundation and Case Western Reserve University, Cleveland, OH; James Java, Gynecologic Oncology Group Statistical and Data Center, Roswell Park Cancer Institute, Buffalo, NY; Charles W. Whitney, Christiana Gynecologic Oncology, Apex Medical Center, Newark, DE; Frederick B. Stehman, Mel and Bren Simon Cancer Center, Indiana University School of Medicine, Indianapolis, IN; Rachelle Lanciano, Delaware County Regional Cancer Center, Drexel Hill, PA; Gillian M. Thomas, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Ontario, Canada; and Paul A. DiSilvestro, Women and Infants Hospital, Brown University, Providence, RI
| | - Rachelle Lanciano
- Peter G. Rose, Cleveland Clinic Foundation and Case Western Reserve University, Cleveland, OH; James Java, Gynecologic Oncology Group Statistical and Data Center, Roswell Park Cancer Institute, Buffalo, NY; Charles W. Whitney, Christiana Gynecologic Oncology, Apex Medical Center, Newark, DE; Frederick B. Stehman, Mel and Bren Simon Cancer Center, Indiana University School of Medicine, Indianapolis, IN; Rachelle Lanciano, Delaware County Regional Cancer Center, Drexel Hill, PA; Gillian M. Thomas, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Ontario, Canada; and Paul A. DiSilvestro, Women and Infants Hospital, Brown University, Providence, RI
| | - Gillian M Thomas
- Peter G. Rose, Cleveland Clinic Foundation and Case Western Reserve University, Cleveland, OH; James Java, Gynecologic Oncology Group Statistical and Data Center, Roswell Park Cancer Institute, Buffalo, NY; Charles W. Whitney, Christiana Gynecologic Oncology, Apex Medical Center, Newark, DE; Frederick B. Stehman, Mel and Bren Simon Cancer Center, Indiana University School of Medicine, Indianapolis, IN; Rachelle Lanciano, Delaware County Regional Cancer Center, Drexel Hill, PA; Gillian M. Thomas, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Ontario, Canada; and Paul A. DiSilvestro, Women and Infants Hospital, Brown University, Providence, RI
| | - Paul A DiSilvestro
- Peter G. Rose, Cleveland Clinic Foundation and Case Western Reserve University, Cleveland, OH; James Java, Gynecologic Oncology Group Statistical and Data Center, Roswell Park Cancer Institute, Buffalo, NY; Charles W. Whitney, Christiana Gynecologic Oncology, Apex Medical Center, Newark, DE; Frederick B. Stehman, Mel and Bren Simon Cancer Center, Indiana University School of Medicine, Indianapolis, IN; Rachelle Lanciano, Delaware County Regional Cancer Center, Drexel Hill, PA; Gillian M. Thomas, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Ontario, Canada; and Paul A. DiSilvestro, Women and Infants Hospital, Brown University, Providence, RI
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Izzedine H, Perazella MA. Onco-nephrology: an appraisal of the cancer and chronic kidney disease links. Nephrol Dial Transplant 2015; 30:1979-88. [PMID: 25648910 DOI: 10.1093/ndt/gfu387] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Accepted: 11/20/2014] [Indexed: 01/20/2023] Open
Abstract
A bidirectional relationship has been observed for kidney disease and cancer. On the one hand, cancer is an important complication noted in kidney disease as well as a major cause of morbidity and mortality in this group. On the other hand, improved cancer treatment has prolonged survival, but also increased the development of acute and chronic kidney disease. The combination of cancer and kidney disease makes it challenging for clinicians to provide comprehensive and safe therapies for this group of patients. As such, clinicians caring for this group must develop expertise and become competent in the practice of a newly evolving subspecialty of nephrology known as 'onco-nephrology'. This brief narrative review will focus on the cancer risk in patients with underlying kidney disease, the therapies such as erythropoiesis-stimulating agents on cancer progression and other outcomes, and the appropriate dosing of anti-cancer agents in patients with underlying kidney disease.
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Affiliation(s)
- Hassan Izzedine
- Department of Nephrology, Monceau Park International Clinic, Paris, France
| | - Mark A Perazella
- Department of Nephrology, Yale University School of Medicine, New Haven, CT, USA
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Rose PG, Java JJ, Whitney CW, Stehman FB, Lanciano R, Thomas GM. Locally advanced adenocarcinoma and adenosquamous carcinomas of the cervix compared to squamous cell carcinomas of the cervix in gynecologic oncology group trials of cisplatin-based chemoradiation. Gynecol Oncol 2014; 135:208-12. [PMID: 25152438 DOI: 10.1016/j.ygyno.2014.08.018] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2014] [Revised: 08/14/2014] [Accepted: 08/15/2014] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Conflicting results have been reported for adeno- and adenosquamous carcinomas of the cervix with respect to their response to therapy and prognosis. The current study sought to evaluate impact of adeno- and adenosquamous histology in the randomized trials of primary cisplatin-based chemoradiation for locally advanced cervical cancer. METHODS Patients with adeno- and adenosquamous cervical carcinomas were retrospectively studied and compared to squamous cell carcinomas in GOG trials of chemoradiation. RESULTS Among 1671 enrolled in clinical trials of chemoradiation, 182 adeno- and adenosquamous carcinomas were identified (10.9%). A higher percentage of adeno- and adenosquamous carcinomas were stage IB2 (27.5% versus 20.0%) and fewer had stage IIIB (21.4% versus 28.6%). The mean tumor size was larger for squamous than adeno- and adenosquamous. Adeno- and adenosquamous carcinomas were more often poorly differentiated (46.2% versus 26.8%). When treated with radiation therapy alone, the 70 patients with adeno- and adenosquamous carcinoma of the cervix showed a statistically poorer overall survival (p=0.0499) compared to the 647 patients with squamous cell carcinoma of the cervix. However, when treated with radiation therapy with concurrent cisplatin-based chemotherapy, the 112 patients with adeno- and adenosquamous carcinomas had a similar overall survival (p=0.459) compared the 842 patients with squamous cell carcinoma. Adverse effects to treatment were similar across histologies. CONCLUSION Adeno- and adenosquamous carcinomas of the cervix are associated with worse overall survival when treated with radiation alone but with similar progression-free and overall survival compared to squamous cell carcinomas of the cervix when treated with cisplatin based chemoradiation.
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Affiliation(s)
- Peter G Rose
- Gynecologic Oncology, Department of Obstetrics & Gynecology, Cleveland Clinic Foundation and Case Western Reserve University, Cleveland, OH 44195, United States.
| | - James J Java
- Gynecologic Oncology Group Statistical & Data Center, Roswell Park Cancer Institute, Buffalo, NY 14263, United States
| | - Charles W Whitney
- Christiana Gynecologic Oncology, LLC, Apex Medical Center, Newark DE 19713, United States
| | - Frederick B Stehman
- Gynecologic Oncology, Indiana University School of Medicine, Mel and Bren Simon Cancer Center, Indianapolis, IN 46202, United States
| | - Rachelle Lanciano
- Radiation Oncology, Delaware County Regional Cancer Center, Drexel Hill, PA 19026, United States
| | - Gillian M Thomas
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, ON M4N 3 M5 Canada
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Debus J, Drings P, Baurecht W, Angermund R. Prospective, randomized, controlled, and open study in primarily inoperable, stage III non-small cell lung cancer (NSCLC) patients given sequential radiochemotherapy with or without epoetin alfa. Radiother Oncol 2014; 112:23-9. [PMID: 25129551 DOI: 10.1016/j.radonc.2014.06.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Revised: 06/02/2014] [Accepted: 06/08/2014] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND PURPOSE Induction chemotherapy is associated with anemia in non-small cell lung cancer (NSCLC) patients undergoing radiotherapy. This randomized, open-label study compared the effect of sequential radiochemotherapy (RCHT) versus RCHT + epoetin alfa (RCHT + EPO), with respect to 2-year overall survival (OS). MATERIAL AND METHODS Patients ⩾18 years received sequential RCHT; one arm also received EPO (chemotherapy day 1, when Hb<12 g/dL). Kaplan-Meier analysis with log-rank test, and Cox-regression methods were performed. RESULTS Of the 385 patients randomized (RCHT + EPO: n = 195; RCHT: n = 190), 78 (RCTH + EPO: 46 [23.6%]; RCHT: 32 [16.8%]) were anemic at baseline. Two-year OS was higher in RCHT + EPO-treated versus RCHT-treated (28.5% [95% CI: 22.2-35.1%] versus 20.6% [95% CI: 15.1-26.8%] [p = 0.2278]), and requirement for RBC transfusion was lower (24/195 [12.3%] versus 61/190 [32.1%]). In anemic (baseline) patients (post hoc analysis), median survival was shorter in RCTH-treated (212 days) versus RCHT + EPO-treated (343 days) (Hazard ratio = 1.62 [95% CI: 0.99-2.63], p = 0.0525). Adverse events were documented in 72.7% (RCHT + EPO: 75.0%; RCHT: 70.5%) patients, and thrombovascular events (TVEs) in 45 patients (RCHT + EPO: 16.7%; RCHT: 7.9%; p = 0.0099). CONCLUSIONS A statistically non-significant trend for 2-year OS was observed in a sub-group of EPO-treated NSCLC-patients with baseline anemia, although this trend was not maintained in the overall population with inoperable NSCLC.
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Li X, Yan Z, Kong D, Zou W, Wang J, Sun D, Jiang Y, Zheng C. Erythropoiesis-stimulating agents in the management of cancer patients with anemia: a meta-analysis. Chin J Cancer Res 2014; 26:268-76. [PMID: 25035653 DOI: 10.3978/j.issn.1000-9604.2014.05.03] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Accepted: 05/26/2014] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Erythropoiesis-stimulating agents (ESAs) are widely used in the management of anemia in cancer patients. Despite their apparent effectiveness, recent studies have suggested that ESAs could result in serious adverse events and even higher mortality. The aim of the current study was to evaluate the benefits and risks of ESAs in the management of cancer patients with anemia using a meta-analysis. METHODS The initial literature search covered Medline, PubMed, Embase, and the Cochrane Center Register of Controlled Trials, and identified 1,569 articles. The final meta-analysis included eight randomized controlled trials (n=2,387) in cancer patients with <11 g/dL hemoglobin (Hb) at the baseline and target Hb (for stopping ESA treatment) at no more than 13 g/dL. The assessment measures included Hb response, blood transfusion rate and adverse events that included venous thromboemblism (VTE), hypertension, and on-study mortality. The results are expressed as pooled odds ratio (OR). Publication bias was assessed using funnel plot analysis. RESULTS ESAs significantly increased the Hb concentration [OR 7.85, 95% confidence interval (CI): 5.85 to 10.53, P<0.001] and reduced the red blood cell (RBC) transfusion rate (OR 0.52, 95% CI: 0.42 to 0.65, P<0.001). ESAs did not increase the accumulated adverse events (OR 0.95, P=0.82), or the on-study mortality (OR 1.09, P=0.47). CONCLUSIONS ESAs are not associated with increased frequency of severe adverse events in anemic cancer patients when the target Hb value is no more than 13 g/dL.
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Affiliation(s)
- Xiaomei Li
- 1 Cancer Center of the Second Hospital, 2 Institute of Biotherapy for Hematological Malignancies, 3 Cardiovascular Department of the Second Hospital, 4 Hematology Department of the Second Hospital, 5 Pharmacology Department of the Second Hospital, Shandong University, Jinan 250100, China
| | - Zhi Yan
- 1 Cancer Center of the Second Hospital, 2 Institute of Biotherapy for Hematological Malignancies, 3 Cardiovascular Department of the Second Hospital, 4 Hematology Department of the Second Hospital, 5 Pharmacology Department of the Second Hospital, Shandong University, Jinan 250100, China
| | - Dexiao Kong
- 1 Cancer Center of the Second Hospital, 2 Institute of Biotherapy for Hematological Malignancies, 3 Cardiovascular Department of the Second Hospital, 4 Hematology Department of the Second Hospital, 5 Pharmacology Department of the Second Hospital, Shandong University, Jinan 250100, China
| | - Wen Zou
- 1 Cancer Center of the Second Hospital, 2 Institute of Biotherapy for Hematological Malignancies, 3 Cardiovascular Department of the Second Hospital, 4 Hematology Department of the Second Hospital, 5 Pharmacology Department of the Second Hospital, Shandong University, Jinan 250100, China
| | - Jihua Wang
- 1 Cancer Center of the Second Hospital, 2 Institute of Biotherapy for Hematological Malignancies, 3 Cardiovascular Department of the Second Hospital, 4 Hematology Department of the Second Hospital, 5 Pharmacology Department of the Second Hospital, Shandong University, Jinan 250100, China
| | - Dianshui Sun
- 1 Cancer Center of the Second Hospital, 2 Institute of Biotherapy for Hematological Malignancies, 3 Cardiovascular Department of the Second Hospital, 4 Hematology Department of the Second Hospital, 5 Pharmacology Department of the Second Hospital, Shandong University, Jinan 250100, China
| | - Yuhua Jiang
- 1 Cancer Center of the Second Hospital, 2 Institute of Biotherapy for Hematological Malignancies, 3 Cardiovascular Department of the Second Hospital, 4 Hematology Department of the Second Hospital, 5 Pharmacology Department of the Second Hospital, Shandong University, Jinan 250100, China
| | - Chengyun Zheng
- 1 Cancer Center of the Second Hospital, 2 Institute of Biotherapy for Hematological Malignancies, 3 Cardiovascular Department of the Second Hospital, 4 Hematology Department of the Second Hospital, 5 Pharmacology Department of the Second Hospital, Shandong University, Jinan 250100, China
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Bohlius J, Tonia T, Nüesch E, Jüni P, Fey MF, Egger M, Bernhard J. Effects of erythropoiesis-stimulating agents on fatigue- and anaemia-related symptoms in cancer patients: systematic review and meta-analyses of published and unpublished data. Br J Cancer 2014; 111:33-45. [PMID: 24743705 PMCID: PMC4090721 DOI: 10.1038/bjc.2014.171] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2013] [Revised: 02/27/2014] [Accepted: 03/10/2014] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Erythropoiesis-stimulating agents (ESAs) reduce the need for red blood cell transfusions; however, they increase the risk of thromboembolic events and mortality. The impact of ESAs on quality of life (QoL) is controversial and led to different recommendations of medical societies and authorities in the USA and Europe. We aimed to critically evaluate and quantify the effects of ESAs on QoL in cancer patients. METHODS We included data from randomised controlled trials (RCTs) on the effects of ESAs on QoL in cancer patients. Randomised controlled trials were identified by searching electronic data bases and other sources up to January 2011. To reduce publication and outcome reporting biases, we included unreported results from clinical study reports. We conducted meta-analyses on fatigue- and anaemia-related symptoms measured with the Functional Assessment of Cancer Therapy-Fatigue (FACT-F) and FACT-Anaemia (FACT-An) subscales (primary outcomes) or other validated instruments. RESULTS We identified 58 eligible RCTs. Clinical study reports were available for 27% (4 out of 15) of the investigator-initiated trials and 95% (41 out of 43) of the industry-initiated trials. We excluded 21 RTCs as we could not use their QoL data for meta-analyses, either because of incomplete reporting (17 RCTs) or because of premature closure of the trial (4 RCTs). We included 37 RCTs with 10581 patients; 21 RCTs were placebo controlled. Chemotherapy was given in 27 of the 37 RCTs. The median baseline haemoglobin (Hb) level was 10.1 g dl(-1); in 8 studies ESAs were stopped at Hb levels below 13 g dl(-1) and in 27 above 13 g dl(-1). For FACT-F, the mean difference (MD) was 2.41 (95% confidence interval (95% CI) 1.39-3.43; P<0.0001; 23 studies, n=6108) in all cancer patients and 2.81 (95% CI 1.73-3.90; P<0.0001; 19 RCTs, n=4697) in patients receiving chemotherapy, which was below the threshold (≥ 3) for a clinically important difference (CID). Erythropoiesis-stimulating agents had a positive effect on anaemia-related symptoms (MD 4.09; 95% CI 2.37-5.80; P=0.001; 14 studies, n=2765) in all cancer patients and 4.50 (95% CI 2.55-6.45; P<0.0001; 11 RCTs, n=2436) in patients receiving chemotherapy, which was above the threshold (≥ 4) for a CID. Of note, this effect persisted when we restricted the analysis to placebo-controlled RCTs in patients receiving chemotherapy. There was some evidence that the MDs for FACT-F were above the threshold for a CID in RCTs including cancer patients receiving chemotherapy with Hb levels below 12 g dl(-1) at baseline and in RCTs stopping ESAs at Hb levels above 13 g dl(-1). However, these findings for FACT-F were not confirmed when we restricted the analysis to placebo-controlled RCTs in patients receiving chemotherapy. CONCLUSIONS In cancer patients, particularly those receiving chemotherapy, we found that ESAs provide a small but clinically important improvement in anaemia-related symptoms (FACT-An). For fatigue-related symptoms (FACT-F), the overall effect did not reach the threshold for a CID.
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Affiliation(s)
- J Bohlius
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Finkenhubelweg 11, 3012 Bern, Switzerland
| | - T Tonia
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Finkenhubelweg 11, 3012 Bern, Switzerland
| | - E Nüesch
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Finkenhubelweg 11, 3012 Bern, Switzerland
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | - P Jüni
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Finkenhubelweg 11, 3012 Bern, Switzerland
- Department of Clinical Research, CTU Bern, University of Bern, Finkenhubelweg 11, 3012 Bern, Switzerland
| | - M F Fey
- Department of Medical Oncology, Inselspital, Bern University Hospital, 3010 Bern, Switzerland
| | - M Egger
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Finkenhubelweg 11, 3012 Bern, Switzerland
| | - J Bernhard
- Department of Medical Oncology, Inselspital, Bern University Hospital, 3010 Bern, Switzerland
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The impact of perioperative packed red blood cell transfusion on survival in epithelial ovarian cancer. Int J Gynecol Cancer 2014; 23:1612-9. [PMID: 24172098 DOI: 10.1097/01.igc.0000436089.03581.6b] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
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.
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Hedenus M, Ludwig H, Henry DH, Gasal E. Pharmacovigilance in practice: erythropoiesis-stimulating agents. Cancer Med 2014; 3:1416-29. [PMID: 24890561 PMCID: PMC4302692 DOI: 10.1002/cam4.275] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2013] [Revised: 03/17/2014] [Accepted: 04/18/2014] [Indexed: 11/11/2022] Open
Abstract
Pharmacovigilance (PV) is the science and activities relating to the detection, assessment, understanding, and prevention of adverse effects or other problems related to medical products after they have been licensed for marketing. The purpose of PV is to advance the safe use of marketed medical products. Regulatory agencies and license holders collaborate to collect data reported by health care providers, patients, and the public as well as data from systematic reviews, meta-analyses, and individual clinical and nonclinical studies. They validate and analyze the data to determine whether safety signals exist, and if warranted, develop an action plan to mitigate the identified risk. Erythropoiesis-stimulating agents (ESAs) provide an example of how PV is applied in reality. Among other approved indications, ESAs may be used to treat anemia in patients with chemotherapy-induced anemia. ESAs increase hemoglobin levels and reduce the need for transfusions; they are also associated with a known increased risk of thromboembolic events. Starting in 2003, emerging data suggested that ESAs might reduce survival. As a result of PV activities by regulatory agencies and license holders, labeling for ESAs addresses these risks. Meta-analyses and individual clinical studies have confirmed that ESAs increase the risk of thromboembolic events, but when used as indicated, ESAs have not been shown to have a significant effect on survival or disease progression. Ongoing safety studies will provide additional data in the coming years to further clarify the risks and benefits of ESAs.
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DiSilvestro PA, Ali S, Craighead PS, Lucci JA, Lee YC, Cohn DE, Spirtos NM, Tewari KS, Muller C, Gajewski WH, Steinhoff MM, Monk BJ. Phase III randomized trial of weekly cisplatin and irradiation versus cisplatin and tirapazamine and irradiation in stages IB2, IIA, IIB, IIIB, and IVA cervical carcinoma limited to the pelvis: a Gynecologic Oncology Group study. J Clin Oncol 2014; 32:458-64. [PMID: 24395863 DOI: 10.1200/jco.2013.51.4265] [Citation(s) in RCA: 85] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
PURPOSE This prospective, randomized phase III intergroup trial of the Gynecologic Oncology Group and National Cancer Institute of Canada Clinical Trials Group was designed to test the effectiveness and safety of adding the hypoxic cell sensitizer tirapazamine (TPZ) to standard cisplatin (CIS) chemoradiotherapy in locally advanced cervix cancer. PATIENTS AND METHODS Patients with locally advanced cervix cancer were randomly assigned to CIS chemoradiotherapy versus CIS/TPZ chemoradiotherapy. Primary end point was progression-free survival (PFS). Secondary end points included overall survival (OS) and tolerability. RESULTS PFS was evaluable in 387 of 402 patients randomly assigned over 36 months, with enrollment ending in September 2009. Because of the lack of TPZ supply, the study did not reach its original target accrual goal. At median follow-up of 28.3 months, PFS and OS were similar in both arms. Three-year PFS for the TPZ/CIS/RT and CIS/RT arms were 63.0% and 64.4%, respectively (log-rank P = .7869). Three-year OS for the TPZ/CIS/RT and CIS/RT arms were 70.5% and 70.6%, respectively (log-rank P = .8333). A scheduled interim safety analysis led to a reduction in the starting dose for the TPZ/CIS arm, with resulting tolerance in both treatment arms. CONCLUSION TPZ/CIS chemoradiotherapy was not superior to CIS chemoradiotherapy in either PFS or OS, although definitive commentary was limited by an inadequate number of events (progression or death). TPZ/CIS chemoradiotherapy was tolerable at a modified starting dose.
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Affiliation(s)
- Paul A DiSilvestro
- Paul A. DiSilvestro and Margaret M. Steinhoff, Women and Infants Hospital, Providence, RI; Shamshad Ali, Roswell Park Cancer Institute, Buffalo; Yi-Chun Lee, State University of New York Health Science Center, Brooklyn, NY; Peter S. Craighead, Tom Baker Cancer Center, Calgary, Alberta, Canada; Joseph A. Lucci, University of Miami School of Medicine, Miami, FL; David E. Cohn, Ohio State University, Columbus, OH; Nicola M. Spirtos, Women's Cancer Center of Nevada, Las Vegas, NV; Krishnasu S. Tewari, University of California Medical Center, Irvine, Orange, CA; Carolyn Muller, University of New Mexico Memorial Medical Center, Albuquerque, NM; Walter H. Gajewski, Zimmer Cancer Center, Wilmington, NC; and Bradley J. Monk, Creighton University School of Medicine, Phoenix, AZ
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Erythropoietin is a JAK2 and ERK1/2 effector that can promote renal tumor cell proliferation under hypoxic conditions. J Hematol Oncol 2013; 6:65. [PMID: 24004818 PMCID: PMC3844377 DOI: 10.1186/1756-8722-6-65] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2013] [Accepted: 08/24/2013] [Indexed: 12/31/2022] Open
Abstract
Background Erythropoietin (EPO) provides an alternative to transfusion for increasing red blood cell mass and treating anemia in cancer patients. However, recent studies have reported increased adverse events and/or reduced survival in patients receiving both EPO and chemotherapy, potentially related to EPO-induced cancer progression. Additional preclinical studies that elucidate the possible mechanism underlying EPO cellular growth stimulation are needed. Methods Using commercial tissue microarray (TMA) of a variety of cancers and benign tissues, EPO and EPO receptor immunohistochemical staining was performed. Furthermore using a panel of human renal cells (Caki-1, 786-O, 769-P, RPTEC), in vitro and in vivo experiments were performed with the addition of EPO in normoxic and hypoxic states to note phenotypic and genotypic changes. Results EPO expression score was significantly elevated in lung cancer and lymphoma (compared to benign tissues), while EPOR expression score was significantly elevated in lymphoma, thyroid, uterine, lung and prostate cancers (compared to benign tissues). EPO and EPOR expression scores in RCC and benign renal tissue were not significantly different. Experimentally, we show that exposure of human renal cells to recombinant EPO (rhEPO) induces cellular proliferation, which we report for the first time, is further enhanced in a hypoxic state. Mechanistic investigations revealed that EPO stimulates the expression of cyclin D1 while inhibiting the expression of p21cip1 and p27kip1 through the phosphorylation of JAK2 and ERK1/2, leading to a more rapid progression through the cell cycle. We also demonstrate an increase in the growth of renal cell carcinoma xenograft tumors when systemic rhEPO is administered. Conclusions In summary, we elucidated a previously unidentified mechanism by which EPO administration regulates progression through the cell cycle, and show that EPO effects are significantly enhanced under hypoxic conditions.
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Moebus V, Jackisch C, Schneeweiss A, Huober J, Lueck HJ, du Bois A, Thomssen C, Kurbacher C, Kuhn W, Nitz U, Runnebaum IB, Hinke A, Kreienberg R, Untch M. Adding epoetin alfa to intense dose-dense adjuvant chemotherapy for breast cancer: randomized clinical trial. J Natl Cancer Inst 2013; 105:1018-26. [PMID: 23860204 PMCID: PMC3714019 DOI: 10.1093/jnci/djt145] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Background The AGO-ETC trial compared 5-year relapse-free survival of intense dose-dense (IDD) sequential chemotherapy with epirubicin (E), paclitaxel (T), and cyclophosphamide (C) (IDD-ETC) every 2 weeks vs conventional scheduled epirubicin/cyclophosphamide followed by paclitaxel (EC→T) (every 3 weeks) as adjuvant treatment in high-risk breast cancer patients. The objective of this study was to evaluate the safety and efficacy of epoetin alfa in a second randomization of the intense dose-dense arm. Methods One thousand two hundred eighty-four patients were enrolled; 658 patients were randomly assigned to the IDD-ETC treatment group. Within the IDD-ETC group, 324 patients were further randomly assigned to the epoetin alfa group, and 319 were randomly assigned to the non–erythropoiesis-stimulating agent (ESA) control group. Primary efficacy endpoints included change in hemoglobin level from baseline to Cycle 9 and the percentage of subjects requiring red blood cell transfusion. Relapse-free survival, overall survival, and intramammary relapse were secondary endpoints estimated with Kaplan-Meier and Cox regression methods. Except for the primary hypothesis, all statistical tests were two-sided. Results Epoetin alfa avoided the decrease in hemoglobin level (no decrease in the epoetin alfa group vs –2.20g/dL change for the control group; P < .001) and statistically significantly reduced the percentage of subjects requiring red blood cell transfusion (12.8% vs 28.1%; P < .0001). The incidence of thrombotic events was 7% in the epoetin alfa arm vs 3% in the control arm. After a median follow-up of 62 months, epoetin alfa treatment did not affect overall survival, relapse-free survival, or intramammary relapse. Conclusions Epoetin alfa resulted in improved hemoglobin levels and decreased transfusions without an impact on relapse-free or overall survival. However, epoetin alfa had an adverse effect, resulting in increased thrombosis.
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Affiliation(s)
- Volker Moebus
- Department of Gynecology and Obstetrics, Klinikum Frankfurt Höchst, Frankfurt, Germany.
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Prognostic impact of the combination of erythropoiesis-stimulating agents to cancer treatment: literature review. Support Care Cancer 2013; 21:2359-69. [PMID: 23775155 DOI: 10.1007/s00520-013-1866-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2013] [Accepted: 05/21/2013] [Indexed: 10/26/2022]
Abstract
Cancer patients commonly develop anaemia. Erythropoiesis-stimulating agents (ESAs) are frequently used in cancer treatment. Numerous controlled studies indicate that ESAs can raise haemoglobin levels, reduce transfusion requirements and improve quality of life in anaemic cancer patients receiving chemotherapy. They were previously used to enhance response to radiation therapy, via increasing tumour cell oxygenation. Since the 2002 guideline, there has been increasing attention to the safety of ESA treatment in patients with cancer. Two placebo-controlled phase III randomised clinical trials published in 2003 showed evidence of harmful effects of ESAs on survival and/or tumour outcomes. Subsequently, recent trials and several large meta-analyses have confirmed negative impact on survival and/or disease progression. To comprehensively examine whether ESA use affects safety outcomes in cancer patients in different settings (chemotherapy, radiotherapy and targeted therapies), we conducted a literature review of all clinical trials, small and large meta-analyses from 1990 to 2012.
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