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Tsui JC, Willett K, Cohen JB, Yu Y, VanderBeek BL. Erythropoiesis-Stimulating Agents and the Risk of Vision-Threatening Diabetic Retinopathy. Ophthalmic Epidemiol 2024; 31:249-257. [PMID: 37427852 PMCID: PMC10776797 DOI: 10.1080/09286586.2023.2235001] [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: 09/14/2022] [Revised: 06/27/2023] [Accepted: 07/03/2023] [Indexed: 07/11/2023]
Abstract
PURPOSE Animal studies have suggested that Erythropoiesis-Stimulating Agents (ESAs) may increase vascular endothelial growth factor (VEGF)-related retinopathies, but this effect is unclear in humans. This study evaluates the risk of vision-threatening diabetic retinopathy (VTDR), defined as either diabetic macular edema (DME) or proliferative diabetic retinopathy (PDR), in patients exposed to an ESA. METHODS Two analyses were performed. First, a retrospective matched-cohort study was designed using a de-identified commercial and Medicare Advantage medical claims database. The ESA cohort of non-proliferative diabetic retinopathy patients who were new users of an ESA from 2000 to 2022 was matched to controls up to a 3:1 ratio. Exclusion criteria included less than 2 years in the plan, history of VTDR or history of other retinopathy. Multivariable Cox proportional hazards regression with inverse proportional treatment weighting (IPTW) was used to assess the hazard of developing VTDR, DME, and PDR. The second analysis was a self-controlled case series (SCCS) evaluating the incidence rate ratios (IRR) of VTDR during 30-day periods before and after initiating an ESA. RESULTS After inclusion of 1502 ESA-exposed patients compared with 2656 controls, IPTW-adjusted hazard ratios found the ESA cohort had an increased hazard of progressing to VTDR (HR = 3.0 95%CI:2.3-3.8;p < .001) and DME (HR = 3.4,95%CI:2.6-4.4,p < .001), but not PDR (HR = 1.0,95%CI:0.5-2.3,p = .95). Similar results were found within the SCCS which demonstrated higher IRRs for VTDR (IRRs = 1.09-1.18;p < .001) and DME (IRRs = 1.16-1.18;p < .001), but not increased IRRs in PDR (IRR = 0.92-0.97,p = .02-0.39). CONCLUSION ESAs are associated with higher risks for VTDR and DME, but not PDR. Those studying ESAs as adjunctive therapy for DR should be cautious of possible unintended effects.
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Affiliation(s)
- Jonathan C. Tsui
- Scheie Eye Institute, Department of Ophthalmology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Keirnan Willett
- Kittner Eye Center, Department of Ophthalmology, University of North Carolina, Chapel Hill, NC, USA
| | - Jordana B. Cohen
- Renal-Electrolyte and Hypertension Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania. Philadelphia, PA, USA
| | - Yinxi Yu
- Center for Preventative Ophthalmology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Brian L. VanderBeek
- Scheie Eye Institute, Department of Ophthalmology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Center for Pharmacoepidemiology Research and Training, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Leonard Davis Institute, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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2
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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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3
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Lim J, Auerbach M, MacLean B, Al-Sharea A, Richards T. Intravenous Iron Therapy to Treat Anemia in Oncology: A Mapping Review of Randomized Controlled Trials. Curr Oncol 2023; 30:7836-7851. [PMID: 37754484 PMCID: PMC10529066 DOI: 10.3390/curroncol30090569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 08/13/2023] [Accepted: 08/23/2023] [Indexed: 09/28/2023] Open
Abstract
Anemia is a common problem when patients present with cancer, and it can worsen during treatment. Anemia can directly impact the cognitive and physical quality of life and may impair fitness for oncological therapy. The most common cause of anemia is iron deficiency. Newer intravenous (IV) iron formulations offer a safe and rapidly effective treatment option. We performed a systematic mapping review of randomized controlled trials (RCTs) evaluating intravenous iron therapy in patients with cancer and anemia and their outcomes. A total of 23 RCTs were identified. The median number of patients enrolled was 104 (IQR: 60-134). A total of 5 were focused on surgical outcomes (4 preoperative, 1 postoperative), and 15 were in adjuvant therapies for a variety of tumor types (breast, colorectal, lung, gynecological, myeloid, and lymphomas), 10 of which were in combination with erythropoietin-stimulating agents (ESAs) therapy, 2 in radiotherapy, and 1 in palliative care. Overall, the studies reported that the use of IV iron increased hemoglobin concentration and decreased transfusion rates during different cancer treatment regimes. IV iron can be administered safely throughout the cancer treatment pathway from primary surgery to the palliative setting. More studies are needed to demonstrate net clinical outcomes.
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Affiliation(s)
- Jayne Lim
- School of Medicine, University of Western Australia, Perth, WA 6009, Australia
| | - Michael Auerbach
- Department of Medicine, Georgetown University, Washington, DC 20007, USA
| | - Beth MacLean
- School of Medicine, University of Western Australia, Perth, WA 6009, Australia
| | - Annas Al-Sharea
- School of Medicine, University of Western Australia, Perth, WA 6009, Australia
| | - Toby Richards
- School of Medicine, University of Western Australia, Perth, WA 6009, Australia
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Weller M, Le Rhun E, Van den Bent M, Chang SM, Cloughesy TF, Goldbrunner R, Hong YK, Jalali R, Jenkinson MD, Minniti G, Nagane M, Razis E, Roth P, Rudà R, Tabatabai G, Wen PY, Short SC, Preusser M. Diagnosis and management of complications from the treatment of primary central nervous system tumors in adults. Neuro Oncol 2023; 25:1200-1224. [PMID: 36843451 PMCID: PMC10326495 DOI: 10.1093/neuonc/noad038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Indexed: 02/28/2023] Open
Abstract
Central nervous system (CNS) tumor patients commonly undergo multimodality treatment in the course of their disease. Adverse effects and complications from these interventions have not been systematically studied, but pose significant challenges in clinical practice and impact function and quality of life, especially in the management of long-term brain tumor survivors. Here, the European Association of Neuro-Oncology (EANO) has developed recommendations to prevent, diagnose, and manage adverse effects and complications in the adult primary brain CNS tumor (except lymphomas) patient population with a specific focus on surgery, radiotherapy, and pharmacotherapy. Specifically, we also provide recommendations for dose adaptations, interruptions, and reexposure for pharmacotherapy that may serve as a reference for the management of standard of care in clinical trials. We also summarize which interventions are unnecessary, inactive or contraindicated. This consensus paper should serve as a reference for the conduct of standard therapy within and outside of clinical trials.
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Affiliation(s)
- Michael Weller
- Department of Neurology, University Hospital and University of Zurich, Zurich, Switzerland
| | - Emilie Le Rhun
- Department of Neurology, University Hospital and University of Zurich, Zurich, Switzerland
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Martin Van den Bent
- The Brain Tumour Center at the Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Susan M Chang
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Timothy F Cloughesy
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Roland Goldbrunner
- Center of Neurosurgery, Department of General Neurosurgery, University of Cologne, Cologne, Germany
| | - Yong-Kil Hong
- Brain Tumor Center, Hallym University Sacred Heart Hospital, Anyang, South Korea
| | - Rakesh Jalali
- Neuro Oncology Cancer Management Team, Apollo Proton Cancer Centre, Chennai, India
| | - Michael D Jenkinson
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust & University of Liverpool, Liverpool, UK
| | - Giuseppe Minniti
- Department of Medicine, Surgery and Neurosciences, University of Siena, Policlinico Le Scotte, Siena, Italy
- IRCCS Neuromed, Pozzilli, IS, Italy
| | - Motoo Nagane
- Department of Neurosurgery, Kyorin University Faculty of Medicine, Tokyo, Japan
| | - Evangelia Razis
- Third Department of Medical Oncology, Hygeia Hospital, Marousi, Athens, Greece
| | - Patrick Roth
- Department of Neurology, University Hospital and University of Zurich, Zurich, Switzerland
| | - Roberta Rudà
- Division of Neuro-Oncology, Department of Neuroscience, City of Health and Science and University of Turin, Turin, Italy
| | - Ghazaleh Tabatabai
- Department of Neurology & Neuro-Oncology, Hertie Institute for Clinical Brain Research, Center for Neurooncology, Comprehensive Cancer Center, German Cancer Consortium (DKTK), Partner site Tübingen, University Hospital Tübingen, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Patrick Y Wen
- Center for Neuro-oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts, USA
| | - Susan C Short
- Leeds Institute of Medical Research, University of Leeds, Leeds, UK
- Department of Clinical Oncology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Matthias Preusser
- Division of Oncology, Department of Medicine 1, Medical University, Vienna, Austria
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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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6
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Huang Y, Li M, Lin M, Ou S, Wang J, Huang C, Chou K, Fang H, Lee P, Hsu C, Chen J, Chen H. Erythropoiesis-stimulating agents and incident malignancy in chronic kidney and end-stage renal disease: A population-based study. Clin Transl Sci 2022; 15:2195-2205. [PMID: 35699124 PMCID: PMC9468572 DOI: 10.1111/cts.13353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 04/22/2022] [Accepted: 05/30/2022] [Indexed: 01/25/2023] Open
Abstract
Research investigating incident malignancy risk in erythropoiesis-stimulating agent (ESA) users with chronic kidney disease (CKD) is lacking. We aimed to compare the incident cancer risk between ESA and non-ESA users with CKD or end-stage renal disease (ESRD). In this retrospective cohort study, all adults newly diagnosed with CKD or ESRD between 2000 and 2012 were enrolled. The study population included 98,748 patients. After case-control matching, 7115 patients were included. The defined daily dose (DDD) of ESA was used as the unit for measuring the amount of ESA prescribed. The primary outcome was the risk of incident malignancy. The secondary outcomes were incident malignancy risk in different tertiles of cumulative ESA doses and the risk of different types of cancers. The risk of incident malignancy was 1.84 times higher with ESA treatment than without ESA treatment (hazard ratio, 1.84; 95% confidence interval, 1.43-2.36; p < 0.001). The malignancy risk was positively correlated with the cumulative dose of ESA (p-for-trend = 0.001) and a significant difference in the high annual cumulative DDD cohort (hazard ratio [HR], 2.39; 95% confidence interval [CI], 1.76-3.25; p < 0.001). The risk of genitourinary malignancy was 12.55 times higher with ESA treatment than without ESA treatment (HR, 12.55; 95% CI, 5.78-27.24; p < 0.001). ESA usage is associated with an increased risk of malignancy, particularly genitourinary cancers, in patients with CKD or ESRD. Clinicians should be aware of the occurrence of malignancy, and keep ESA dosage as low as possible.
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Affiliation(s)
- Yu‐Shan Huang
- Department of PediatricsKaohsiung Veterans General HospitalKaohsiungTaiwan
| | - Ming‐Feng Li
- Department of RadiologyKaohsiung Veteran General HospitalKaohsiungTaiwan,Department of Medical ImagingHualien Buddhist Tzu‐Chi General HospitalHualienTaiwan,Department of Medical Imaging and RadiologyShu‐Zen Junior College of Medicine and ManagementKaohsiungTaiwan
| | - Mei‐Chen Lin
- Management Office for Health DataChina Medical University HospitalTaichungTaiwan,College of MedicineChina Medical UniversityTaichungTaiwan
| | - Shih‐Hsiang Ou
- Division of NephrologyDepartment of Internal Medicine, Kaohsiung Veterans General HospitalKaohsiungTaiwan,School of MedicineNational Yang Ming Chiao Tung UniversityTaiwan
| | - Jen‐Hung Wang
- Department of Medical ResearchHualien Buddhist Tzu‐Chi General HospitalHualienTaiwan
| | - Chien‐Wei Huang
- Division of NephrologyDepartment of Internal Medicine, Kaohsiung Veterans General HospitalKaohsiungTaiwan,School of MedicineNational Yang Ming Chiao Tung UniversityTaiwan
| | - Kang‐Ju Chou
- Division of NephrologyDepartment of Internal Medicine, Kaohsiung Veterans General HospitalKaohsiungTaiwan,School of MedicineNational Yang Ming Chiao Tung UniversityTaiwan
| | - Hua‐Chang Fang
- Division of NephrologyDepartment of Internal Medicine, Kaohsiung Veterans General HospitalKaohsiungTaiwan,School of MedicineNational Yang Ming Chiao Tung UniversityTaiwan
| | - Po‐Tsang Lee
- Division of NephrologyDepartment of Internal Medicine, Kaohsiung Veterans General HospitalKaohsiungTaiwan,School of MedicineNational Yang Ming Chiao Tung UniversityTaiwan
| | - Chih‐Yang Hsu
- Division of NephrologyDepartment of Internal Medicine, Kaohsiung Veterans General HospitalKaohsiungTaiwan,School of MedicineNational Yang Ming Chiao Tung UniversityTaiwan
| | - Jin‐Shuen Chen
- Division of NephrologyDepartment of Internal Medicine, Kaohsiung Veterans General HospitalKaohsiungTaiwan
| | - Hsin‐Yu Chen
- Division of NephrologyDepartment of Internal Medicine, Kaohsiung Veterans General HospitalKaohsiungTaiwan,School of MedicineNational Yang Ming Chiao Tung UniversityTaiwan
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7
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Bennett CL, Olivieri N, Hoque S, Aboulafia D, Ventrone A, Lubaczewski C, Dong B, Schooley B, Witherspoon BJ, Ray PS, Hrushesky WJ, Restaino J, Thomsen HS, Mangano D, Mora-Mangano C, McKoy JM, Schoen M, Knopf K, Martin L, Rosen S. Davids versus Goliaths: Pharma and academia threats to individual scientists and clinicians. THE JOURNAL OF SCIENTIFIC PRACTICE AND INTEGRITY 2022. [DOI: 10.35122/001c.36564] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background We previously described experiences of clinicians who published adverse drug reaction reports. We now report on threats and intimidations leveled against clinicians and scientists who received publicly documented threats after communicating safety, efficacy, or data integrity findings contrary to corporate interests. Methods Data on threats and intimidations were obtained from transcripts of governmental hearings or agencies, university-affiliated reports, media interviews, and investigative journalism articles. Content and timing of threats and intimidation, subsequent harms, numbers of persons seriously injured or who died from individual toxicities, financial payments from sponsors related to safety, efficacy, or data integrity concerns, and civil settlements and criminal findings were evaluated. Findings Twenty-six individuals who communicated safety, efficacy, or data integrity concerns were targets of threats and intimidation from corporate employees (twenty-three individuals) or regulatory personnel (three). Seventeen individuals identified instances where pharmaceutical sponsors submitted fraudulent data in support of regulatory approval of a drug or device. Scientist and clinician communications were followed by drug/device withdrawals (fourteen drugs/devices), black box warnings (six drugs), withdrawal of a sponsor’s application for regulatory approval (one device), and delay of approval of a sponsor’s application for regulatory approval (one drug). Actions mainly occurred after persons communicated with pharmaceutical employees (fourteen). Intimidation efforts by corporate personnel included threats of lawsuits (eighteen individuals), hiring private investigators (nine), and public disparagement at conferences (eleven). Related intimidation efforts carried out by academia or regulatory agency superiors included threats of: loss of positions (six), loss of grant funding (two), delays in decisions regarding tenure (two); or reassignment to a low-level position (one). Academic harms included lost: hospital or university appointments (nine and six, respectively), grant funding (two), chairperson title of an international clinical trial group (one), and journal editorial board position (one). Corporate harms included payment of $1 million to defense attorneys in three cases filed against clinicians. Interpretation Threats and intimidation carried out by corporate employees and/or academic supervisors followed public communication of concerns regarding patient safety, drug efficacy, or data integrity, including instances where sponsors were identified as having submitted fraudulent data to regulatory or government agencies. Consideration should be given to filing criminal charges against pharmaceutical executives who are discovered by scientists or clinicians to have knowingly submitted fraudulent data to regulatory or governmental agencies, rather than causing the scientists and clinicians who submit such reports to risk losing their reputations and occupations.
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Affiliation(s)
- Charles L. Bennett
- The City of Hope National Cancer Institute Designated Comprehensive Center, Duarte, California; The SONAR project of the University of South Carolina, College of Pharmacy
| | | | - Shamia Hoque
- The SONAR project of the University of South Carolina
| | | | - Anne Ventrone
- The SONAR project of the University of South Carolina
| | | | - Betty Dong
- The University of California at San Francisco
| | | | | | - Paul S. Ray
- The SONAR project of the University of South Carolina
| | | | - John Restaino
- The SONAR project of the University of South Carolina
| | | | | | | | | | - Martin Schoen
- Saint Louis University; Washington University, School of Medicine
| | - Kevin Knopf
- The SONAR project of the University of South Carolina
| | - Linda Martin
- The SONAR project of the University of South Carolina
| | - Steven Rosen
- The City of Hope National Cancer Institute Designated Comprehensive Center, Duarte, California; The SONAR project of the University of South Carolina, College of Pharmacy
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8
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Makharadze T, Boccia R, Krupa A, Blackman N, Henry DH, Gilreath JA. Efficacy and safety of ferric carboxymaltose infusion in reducing anemia in patients receiving chemotherapy for nonmyeloid malignancies: A randomized, placebo-controlled study (IRON-CLAD). Am J Hematol 2021; 96:1639-1646. [PMID: 34653287 PMCID: PMC9298873 DOI: 10.1002/ajh.26376] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 09/30/2021] [Accepted: 10/04/2021] [Indexed: 12/03/2022]
Abstract
Erythropoiesis‐stimulating agents (ESA) are effective for chemotherapy‐induced anemia (CIA) but associated with serious adverse events. Safer alternatives would be beneficial in this population. The efficacy and safety of ferric carboxymaltose (FCM) as monotherapy for CIA was evaluated. This Phase 3, 18‐week, double‐blind, placebo‐controlled study randomized adults with ≥ 4 weeks of chemotherapy remaining for treatment of nonmyeloid malignancies with CIA to FCM (two 15 mg/kg infusions 7 days apart; maximum dose, 750 mg single/1500 mg total) or placebo. The primary efficacy endpoint was percentage of patients with decreases in hemoglobin (Hb) ≥ 0.5 g/dL from weeks 3 to 18; the key secondary efficacy endpoint was change in Hb from baseline to week 18. Inclusion criteria included: (Hb) 8–11 g/dL, ferritin 100–800 ng/mL, and transferrin saturation (TSAT) ≤35%. In 244 patients (n = 122, both groups), the percent of patients who maintained Hb within 0.5 g/dL of baseline from weeks 3 to 18 was significantly higher with FCM versus placebo (50.8% vs. 35.3%; p = 0.01). Mean change in Hb from baseline to week 18 was similar between FCM and placebo (1.04 vs. 0.87 g/dL) but significantly greater with FCM with baseline Hb ≤ 9.9 g/dL (1.08 vs. 0.42 g/dL; p = 0.01). The percent with ≥ 1 g/dL increase from baseline was significantly higher with FCM versus placebo (71% vs. 54%; p = 0.01), occurring in a median 43 versus 85 days (p = 0.001). Common adverse events in the FCM arm included neutropenia (17%), hypophosphatemia (16%), and fatigue (15%). FCM monotherapy effectively maintained Hb and was well tolerated in CIA.
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Affiliation(s)
| | - Ralph Boccia
- Center for Cancer and Blood Disorders Bethesda Maryland USA
| | - Anna Krupa
- College of Pharmacy and Health Sciences St. John's University Queens New York USA
| | | | - David H. Henry
- Abramson Cancer Center Pennsylvania Hospital Philadelphia Pennsylvania USA
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9
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Madeddu C, Neri M, Sanna E, Oppi S, Macciò A. Experimental Drugs for Chemotherapy- and Cancer-Related Anemia. J Exp Pharmacol 2021; 13:593-611. [PMID: 34194245 PMCID: PMC8238072 DOI: 10.2147/jep.s262349] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 04/21/2021] [Indexed: 01/03/2023] Open
Abstract
Anemia in cancer patients is a relevant condition complicating the course of the neoplastic disease. Overall, we distinguish the anemia which arises under chemotherapy as pure adverse event of the toxic effects of the drugs used, and the anemia induced by the tumour-associated inflammation, oxidative stress, and systemic metabolic changes, which can be worsened by the concomitant anticancer treatments. This more properly cancer-related anemia depends on several overlapping mechanism, including impaired erythropoiesis and functional iron deficiency, which make its treatment more difficult. Standard therapies approved and recommended for cancer anemia, as erythropoiesis-stimulating agents and intravenous iron administration, are limited to the treatment of chemotherapy-induced anemia, preferably in patients with advanced disease, in view of the still unclear effect of erythropoiesis-stimulating agents on tumour progression and survival. Outside the use of chemotherapy, there are no recommendations for the treatment of cancer-related anemia. For a more complete approach, it is fundamentally a careful evaluation of the type of anemia and iron homeostasis, markers of inflammation and changes in energy metabolism. In this way, anemia management in cancer patient would permit a tailored approach that could give major benefits. Experimental drugs targeting hepcidin and activin II receptor pathways are raising great expectations, and future clinical trials will confirm their role as remedies for cancer-related anemia. Recent evidence on the effect of integrated managements, including nutritional support, antioxidants and anti-inflammatory substances, for the treatment of cancer anemia are emerging. In this review article, we show standard, innovative, and experimental treatment used as remedy for anemia in cancer patients.
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Affiliation(s)
- Clelia Madeddu
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Manuela Neri
- Department of Gynecologic Oncology, A. Businco Hospital, ARNAS G. Brotzu, Cagliari, Italy
| | - Elisabetta Sanna
- Department of Gynecologic Oncology, A. Businco Hospital, ARNAS G. Brotzu, Cagliari, Italy
| | - Sara Oppi
- Hematology and Transplant Center, A. Businco Hospital, ARNAS G. Brotzu, Cagliari, Italy
| | - Antonio Macciò
- Department of Gynecologic Oncology, A. Businco Hospital, ARNAS G. Brotzu, Cagliari, Italy
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10
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Escobar Álvarez Y, de Las Peñas Bataller R, Perez Altozano J, Ros Martínez S, Sabino Álvarez A, Blasco Cordellat A, Brozos Vázquez E, Corral Jaime J, García Escobar I, Beato Zambrano C. SEOM clinical guidelines for anaemia treatment in cancer patients (2020). Clin Transl Oncol 2021; 23:931-939. [PMID: 33768441 PMCID: PMC8057996 DOI: 10.1007/s12094-021-02580-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/02/2021] [Indexed: 11/28/2022]
Abstract
Anaemia is defined by the presence of haemoglobin (Hb) levels < 13 g/dL in men and 12 g/dL in women. Up to 39% of cancer patients present it at the time of diagnosis and up to 40% have iron deficiency. Anaemia causes fatigue, functional deterioration and a reduction in the quality of life; it has also been associated with a poorer response to anti-tumour treatment and lower survival. Basic diagnostic tests for anaemia are simple and should be a routine part of clinical practice. These guidelines review the available evidence on the use of different therapies for treating anaemia: erythropoiesis-stimulating agents, iron supplements, and transfusion of blood products.
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Affiliation(s)
- Y Escobar Álvarez
- Department of Medical Oncology, Hospital General Universitario Gregorio Marañón, Madrid, Spain.
| | - R de Las Peñas Bataller
- Department of Medical Oncology, Consorcio Hospitalario Provincial de Castellón, Castellón de la Plana, Spain
| | - J Perez Altozano
- Department of Medical Oncology, Hospital Virgen de Los Lirios, Alcoy, Spain
| | - S Ros Martínez
- Department of Medical Oncology, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain
| | - A Sabino Álvarez
- Department of Medical Oncology, Hospital Universitario Puerta del Mar, Cádiz, Spain
| | - A Blasco Cordellat
- Department of Medical Oncology, Consorcio Hospital General Universitario, Valencia, Spain
| | - E Brozos Vázquez
- Department of Medical Oncology, Hospitalario Clínico Universitario de Santiago, la Coruña, Spain
| | - J Corral Jaime
- Department of Medical Oncology, Clínica Universidad de Navarra, Madrid, Spain
| | - I García Escobar
- Hospital General Universitario Virgen de las Nieves, Granada, Spain
| | - C Beato Zambrano
- Department of Medical Oncology, Hospital Universitario de Jerez de la Frontera, Cádiz, Spain
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11
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Thiruthaneeswaran N, Bibby BAS, Yang L, Hoskin PJ, Bristow RG, Choudhury A, West C. Lost in application: Measuring hypoxia for radiotherapy optimisation. Eur J Cancer 2021; 148:260-276. [PMID: 33756422 DOI: 10.1016/j.ejca.2021.01.039] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 01/21/2021] [Accepted: 01/28/2021] [Indexed: 12/15/2022]
Abstract
The history of radiotherapy is intertwined with research on hypoxia. There is level 1a evidence that giving hypoxia-targeting treatments with radiotherapy improves locoregional control and survival without compromising late side-effects. Despite coming in and out of vogue over decades, there is now an established role for hypoxia in driving molecular alterations promoting tumour progression and metastases. While tumour genomic complexity and immune profiling offer promise, there is a stronger evidence base for personalising radiotherapy based on hypoxia status. Despite this, there is only one phase III trial targeting hypoxia modification with full transcriptomic data available. There are no biomarkers in routine use for patients undergoing radiotherapy to aid management decisions, and a roadmap is needed to ensure consistency and provide a benchmark for progression to application. Gene expression signatures address past limitations of hypoxia biomarkers and could progress biologically optimised radiotherapy. Here, we review recent developments in generating hypoxia gene expression signatures and highlight progress addressing the challenges that must be overcome to pave the way for their clinical application.
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Affiliation(s)
- Niluja Thiruthaneeswaran
- Division of Cancer Sciences, The University of Manchester, Manchester, UK; Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia.
| | - Becky A S Bibby
- Division of Cancer Sciences, The University of Manchester, Manchester, UK
| | - Lingjang Yang
- Division of Cancer Sciences, The University of Manchester, Manchester, UK
| | - Peter J Hoskin
- Division of Cancer Sciences, The University of Manchester, Manchester, UK; Mount Vernon Cancer Centre, Northwood, UK
| | - Robert G Bristow
- Division of Cancer Sciences, The University of Manchester, Manchester, UK; CRUK Manchester Institute and Manchester Cancer Research Centre, Manchester, UK
| | - Ananya Choudhury
- Division of Cancer Sciences, The University of Manchester, Christie Hospital NHS Foundation Trust, Manchester, UK
| | - Catharine West
- Division of Cancer Sciences, The University of Manchester, Christie Hospital NHS Foundation Trust, Manchester, UK
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12
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Abstract
Despite increasing use of targeted therapies to treat cancer, anemia remains a common complication of cancer therapy. Physician concerns about the safety of intravenous (IV) iron products and erythropoiesis-stimulating agents (ESAs) have resulted in many patients with cancer receiving no or suboptimal anemia therapy. In this article, we present 4 patient cases that illustrate both common and complex clinical scenarios. We first present a review of erythropoiesis and then describe our approach to cancer-associated anemia by identifying the contributing causes before selecting specific treatments. We summarize clinical trial data affirming the safety and efficacy of currently available IV iron products used to treat cancer-associated anemia and illustrate how we use commonly available laboratory tests to assess iron status during routine patient management. We compare adverse event rates associated with IV iron vs red cell transfusion and discuss using first-line IV iron monotherapy to treat anemic patients with cancer, which decreases the need for ESAs. A possible mechanism behind ESA-induced tumor progression is discussed. Finally, we review the potential of novel therapies such as ascorbic acid, prolyl hydroxylase inhibitors, activin traps, hepcidin, and bone morphogenetic protein antagonists in treating cancer-associated anemia.
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13
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Anand S, Al-Mondhiry J, Fischer K, Glaspy J. Epoetin alfa-epbx: a new entrant into a crowded market. a historical review of the role of erythropoietin stimulating agents and the development of the first epoetin biosimilar in the United States. Expert Rev Clin Pharmacol 2020; 14:1-8. [PMID: 33307871 DOI: 10.1080/17512433.2021.1863786] [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: Erythropoietin stimulating agents (ESAs) have been established both to correct anemia and provide the clinical benefits of increased exercise capacity, reduced transfusion requirements, and improved quality of life. An increase in physician and patient adoption of biosimilars, as well as changes to healthcare reimbursement policies, have driven market competitors to innovate and expand the range of biosimilar products. While erythropoietin biosimilars have been approved by the EMA since 2007, the FDA's approval of epoetin alfa-epbx in 2018 marks the first erythropoietin biosimilar approved in the United States. Areas covered: In this article, we critically review the biology, clinical use, manufacturing, safety, and efficacy of ESAs and erythropoietin biosimilars. We then review the regulatory framework and potential impact on healthcare costs offered by erythropoietin biosimilars. Expert opinion: Due to the complex nature of manufacturing large-molecule biologics, it is important to recognize the challenges to quality assurance and overall safety posed by the introduction of biosimilars, which undergo much more limited clinical testing than their reference biologic product before coming to market. With many biologic therapies nearing patent expiration, biosimilars will become increasingly common in clinical practice. Ensuring patient safety with these products will require increased post-marketing surveillance and awareness from prescribers.
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Affiliation(s)
- Sid Anand
- Division of Hematology & Oncology, University of California , Santa Monica, CA, USA
| | - Jafar Al-Mondhiry
- Division of Hematology & Oncology, University of California , Los Angeles, CA, USA
| | - Katrina Fischer
- Division of Hematology & Oncology, University of California , Los Angeles, CA, USA
| | - John Glaspy
- Division of Hematology & Oncology, University of California , Los Angeles, CA, USA
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14
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Rund D. Intravenous iron: do we adequately understand the short- and long-term risks in clinical practice? Br J Haematol 2020; 193:466-480. [PMID: 33216989 DOI: 10.1111/bjh.17202] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Accepted: 09/28/2020] [Indexed: 12/31/2022]
Abstract
Intravenous (IV) iron as a therapeutic agent is often administered but not always fully understood. The benefits of IV iron are well proven in many fields, particularly in nephrology. IV iron is beneficial not only for true iron deficiency but also for iron-restricted anaemia (functional iron deficiency). Yet, the literature on intravenous iron has many inconsistencies regarding its adverse effects. Over the last several years, newer forms of iron have been developed, leading to the more regular use of iron and in larger doses. This review will summarize some of the older and newer literature regarding the differences among iron products, including the mechanisms and frequency of their adverse events (AEs). The pathway and frequency of an underrecognized adverse event (hypophosphataemia) will be discussed. Recent insights on infection risk and iron handling by macrophages are examined. Potential but presently unproven risks of iron overload due to IV iron are discussed. The impact of these on the risk:benefit ratio and dosing of intravenous iron are considered in different clinical settings, including pregnancy and cancer. IV iron is an essential component of the therapy of anaemia and understanding these issues will enable more informed treatment decisions and knowledgeable use of these drugs.
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Affiliation(s)
- Deborah Rund
- Hebrew University-Hadassah Medical Organization, Ein Kerem, Jerusalem, Israel
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15
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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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16
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De Bellis M, Girelli D, Ruzzenente A, Bagante F, Ziello R, Campagnaro T, Conci S, Nifosì F, Guglielmi A, Iacono C. Pancreatic resections in patients who refuse blood transfusions. The application of a perioperative protocol for a true bloodless surgery. Pancreatology 2020; 20:1550-1557. [PMID: 32950387 DOI: 10.1016/j.pan.2020.08.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 06/16/2020] [Accepted: 08/26/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND The refusal of blood transfusions compels surgeons to face ethical and clinical issues. A single-institution experience with a dedicated perioperative blood management protocol was reviewed to assess feasibility and short-term outcomes of true bloodless pancreatic surgery. METHODS The institutional database was reviewed to identify patients who refused transfusion and were scheduled for elective pancreatic surgery from 2010 through 2018. A protocol to optimize the hemoglobin values by administration of drugs stimulating erythropoiesis was systematically used. RESULTS Perioperative outcomes of 32 Jehovah's Witnesses patients were included. Median age was 67 years (range, 31-77). Nineteen (59.4%) patients were treated with preoperative erythropoietin. Twenty-four (75%) patients underwent pylorus-preserving pancreaticoduodenectomy, 4 (12.5%) distal pancreatectomy (DP) with splenectomy, 3 (9.4%) spleen-preserving DP, and 1 (3.1%) total pancreatectomy. Median estimated blood loss and surgical duration were 400 mL (range, 100-1000) and 470 min (range, 290-595), respectively. Median preoperative hemoglobin was 13.9 g/dL (range, 11.7-15.8) while median postoperative nadir hemoglobin was 10.5 g/dL (range, 7.1-14.1). The most common histological diagnosis (n = 15, 46.9%) was pancreatic ductal adenocarcinoma. Clavien-Dindo grade I-II complications occurred in fourteen (43.8%) patients while one (3.1%) patient had a Clavien-Dindo grade IIIa complication wich was an abdominal collection that required percutaneous drainage. Six (18.8%) patients presented biochemical leak or postoperative pancreatic fistula grade B. Median hospital stay was 16 days (range, 8-54) with no patient requiring transfusion or re-operation and no 90-day mortality. CONCLUSIONS A multidisciplinary approach and specific perioperative management allowed performing pancreatic resections in patients who refused transfusion with good short-term outcomes.
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Affiliation(s)
- Mario De Bellis
- Department of Surgery, Division of General and Hepato-Pancreato-Biliary Surgery, University of Verona, School of Medicine, Verona, Italy
| | - Domenico Girelli
- Department of Medicine, Section of Internal Medicine, University of Verona, School of Medicine, Verona, Italy
| | - Andrea Ruzzenente
- Department of Surgery, Division of General and Hepato-Pancreato-Biliary Surgery, University of Verona, School of Medicine, Verona, Italy
| | - Fabio Bagante
- Department of Surgery, Division of General and Hepato-Pancreato-Biliary Surgery, University of Verona, School of Medicine, Verona, Italy
| | - Raffaele Ziello
- Department of Surgery, Division of General and Hepato-Pancreato-Biliary Surgery, University of Verona, School of Medicine, Verona, Italy
| | - Tommaso Campagnaro
- Department of Surgery, Division of General and Hepato-Pancreato-Biliary Surgery, University of Verona, School of Medicine, Verona, Italy
| | - Simone Conci
- Department of Surgery, Division of General and Hepato-Pancreato-Biliary Surgery, University of Verona, School of Medicine, Verona, Italy
| | - Filippo Nifosì
- Department of Surgery, Division of General and Hepato-Pancreato-Biliary Surgery, University of Verona, School of Medicine, Verona, Italy
| | - Alfredo Guglielmi
- Department of Surgery, Division of General and Hepato-Pancreato-Biliary Surgery, University of Verona, School of Medicine, Verona, Italy
| | - Calogero Iacono
- Department of Surgery, Division of General and Hepato-Pancreato-Biliary Surgery, University of Verona, School of Medicine, Verona, Italy.
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17
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Griffiths EA, Alwan LM, Bachiashvili K, Brown A, Cool R, Curtin P, Geyer MB, Gojo I, Kallam A, Kidwai WZ, Kloth DD, Kraut EH, Lyman GH, Mukherjee S, Perez LE, Rosovsky RP, Roy V, Rugo HS, Vasu S, Wadleigh M, Westervelt P, Becker PS. Considerations for Use of Hematopoietic Growth Factors in Patients With Cancer Related to the COVID-19 Pandemic. J Natl Compr Canc Netw 2020; 19:1-4. [PMID: 32871558 PMCID: PMC9730290 DOI: 10.6004/jnccn.2020.7610] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 06/25/2020] [Indexed: 12/15/2022]
Abstract
Hematopoietic growth factors, including erythrocyte stimulating agents (ESAs), granulocyte colony-stimulating factors, and thrombopoietin mimetics, can mitigate anemia, neutropenia, and thrombocytopenia resulting from chemotherapy for the treatment of cancer. In the context of pandemic SARS-CoV-2 infection, patients with cancer have been identified as a group at high risk of morbidity and mortality from this infection. Our subcommittee of the NCCN Hematopoietic Growth Factors Panel convened a voluntary group to review the potential value of expanded use of such growth factors in the current high-risk environment. Although recommendations are available on the NCCN website in the COVID-19 Resources Section (https://www.nccn.org/covid-19/), these suggestions are provided without substantial context or reference. Herein we review the rationale and data underlying the suggested alterations to the use of hematopoietic growth factors for patients with cancer in the COVID-19 era.
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Affiliation(s)
| | - Laura M. Alwan
- Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance, Seattle, Washington
| | - Kimo Bachiashvili
- O’Neal Comprehensive Cancer Center at the University of Alabama, Birmingham, Alabama
| | - Anna Brown
- University of Michigan Rogel Cancer Center, Ann Arbor, Michigan
| | - Rita Cool
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Peter Curtin
- UC San Diego Moores Cancer Center, La Jolla, California
| | - Mark B. Geyer
- Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ivana Gojo
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, Maryland
| | - Avyakta Kallam
- University of Nebraska Medical Center, Fred & Pamela Buffett Cancer Center, Omaha, Nebraska
| | - Wajih Z. Kidwai
- Yale Cancer Center/Smilow Cancer Hospital, New Haven, Connecticut
| | | | - Eric H. Kraut
- The Ohio State University Comprehensive Cancer Center-James Cancer Hospital and Solove Research Institute, Columbus, Ohio
| | - Gary H. Lyman
- Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance, Seattle, Washington
| | - Sudipto Mukherjee
- Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute, Cleveland, Ohio
| | | | | | - Vivek Roy
- Mayo Clinic Cancer Center; Jacksonville, Florida
| | - Hope S. Rugo
- UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, California
| | - Sumithira Vasu
- The Ohio State University Comprehensive Cancer Center-James Cancer Hospital and Solove Research Institute, Columbus, Ohio
| | - Martha Wadleigh
- Dana Farber/Brigham and Women’s Cancer Center, Boston, Massachusetts
| | - Peter Westervelt
- Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine, Saint Louis, Missouri
| | - Pamela S. Becker
- Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance, Seattle, Washington
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18
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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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19
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Sbrana A, Antonuzzo A, Brunello A, Petrelli F, Pronzato P, Tralongo A, Turrini M, Zoratto F, Danova M. Management of anemia in patients with cancer: 2019 Italian Association of Medical Oncology (AIOM) guidelines. TUMORI JOURNAL 2020; 106:337-345. [PMID: 32482149 DOI: 10.1177/0300891620921942] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This article summarizes the latest Italian Medical Oncology Association (AIOM) guidelines on the management of cancer-related and chemotherapy-related anemia with a particular attention to the use of erythropoiesis-stimulating agents and iron supplementation.
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Affiliation(s)
- Andrea Sbrana
- Medical Oncology Unit, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy.,Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Andrea Antonuzzo
- Medical Oncology Unit, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | | | - Fausto Petrelli
- Medical Oncology Unit, ASST Bergamo Ovest, Treviglio, Bergamo, Italy
| | - Paolo Pronzato
- Medical Oncology Unit, AOU San Martino IRCCS IST, Genova, Italy
| | - Antonino Tralongo
- Medical Oncology Unit, Ospedale di Circolo e Fondazione Macchi, Varese, Italy
| | - Marianna Turrini
- Medical Oncology Unit, Ospedale del Valdarno, Santa Maria La Gruccia, Azienda USL Toscana Sud-Est, Montevarchi, Toscana, Italy
| | - Federica Zoratto
- Medical Oncology Unit, Ospedale S. Maria Goretti, Latina, Lazio, Italy
| | - Marco Danova
- Internal Medicine and Medical Oncology, ASST Pavia, Pavia, Lombardia, Italy
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20
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Muñoz Martín AJ, Ramírez SP, Morán LO, Zamorano MR, Benéitez MCV, Salcedo IA, Escobar IG, Fernández JMS. Pharmacological cancer treatment and venous thromboembolism risk. Eur Heart J Suppl 2020; 22:C2-C14. [PMID: 32368194 PMCID: PMC7189737 DOI: 10.1093/eurheartj/suaa004] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Risk factors for cancer-associated thrombosis are commonly divided into three categories: patient-, cancer-, and treatment-related factors. Currently, different types of drugs are used in cancer treatment. Chemotherapy has been identified as an independent risk factor for venous thromboembolism (VTE). However, it should be noted, that the risk of VTE is not consistent among all cytotoxic agents. In addition, different supportive care drugs, such as erythropoiesis stimulating agents or granulocyte colony stimulating factors, and hormonotherapy have been associated to an increased risk of VTE. Immunotherapy and molecular-targeted therapies have significantly changed the treatment of cancer over the past decade. The main subtypes include tyrosine-kinase inhibitors, monoclonal antibodies, small molecules, and immunomodulatory agents. The relationship between VTE and targeted therapies remains largely unknown.
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Affiliation(s)
- Andrés J Muñoz Martín
- Medical Oncology Department, Hospital General Universitario Gregorio Marañón, Calle Doctor Esquerdo 46, 28007 Madrid, Spain
| | - Sara Pérez Ramírez
- Medical Oncology Department, Hospital General Universitario Gregorio Marañón, Calle Doctor Esquerdo 46, 28007 Madrid, Spain
| | - Laura Ortega Morán
- Medical Oncology Department, Hospital General Universitario Gregorio Marañón, Calle Doctor Esquerdo 46, 28007 Madrid, Spain
| | - Magdalena Ruiz Zamorano
- Department of Medicine, Faculty of Medicine, Universidad Complutense, Av. Séneca 2, 28040 Madrid, Spain
| | | | - Inmaculada Aparicio Salcedo
- Medical Oncology Department, Hospital General Universitario Gregorio Marañón, Calle Doctor Esquerdo 46, 28007 Madrid, Spain
| | - Ignacio García Escobar
- Medical Oncology Department, Hospital General Universitario de Ciudad Real, Calle Obispo Rafael Torija s/n, 13005 Ciudad Real, Spain
| | - José Manuel Soria Fernández
- Genomic of Complex Disease Unit, Institut d'investigació Sant Pau (IIB-SANT PAU), Joan Alcover, 7-2° 2ª, 08031 Barcelona, Spain
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21
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Prechemotherapy Hemoglobin Levels as a Predictive Factor of Ovarian Cancer Survival: A Systematic Review and Meta-Analysis. Am J Clin Oncol 2020; 42:725-731. [PMID: 31361606 DOI: 10.1097/coc.0000000000000570] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The impact of anemia on cancer survival has been previously mentioned in various oncological fields. To date, however, it remains unknown whether prechemotherapy hemoglobin (Hgb) levels are predictive of ovarian cancer survival (OC). The purpose of the present systematic review is to accumulate evidence in this field. MATERIALS AND METHODS We used the Medline, Scopus, Clinicaltrials.gov, EMBASE, Cochrane Central Register of Controlled Trials CENTRAL, and Google Scholar databases in our primary search. The date of our last search was set for July 30, 2018. Statistical meta-analysis was performed with the RevMan 5.3 software. RESULTS Overall, 11 articles were included that recruited 1816 women with OC. Five articles that involved 856 OC patients were included in the meta-analysis. Compared with patients with anemia, patients with Hgb levels >12 g/dL had increased odds of overall survival (odds ratio, 1.72; 95% confidence interval: 1.41, 2.10). Similarly, the progression-free survival of patients was significantly affected, although the available data could not be accumulated in a meta-analysis because of the heterogeneity in outcome reporting measures. CONCLUSIONS Current evidence suggests that prechemotherapy Hgb levels below the threshold of 12 g/dL can potentially predict worse overall survival of OC patients. Future research is required in the field to elucidate whether several independent variables such as the stage and histology of disease and rates of optimal debulking affect the clinical significance of this association.
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Marinho J, Leão I, Custódio S, Dias E, Moreira Pinto A, Costa T, Capela A, Dias M, Coelho H, Cunha Â, Macedo A, Amarelo A, Joaquim A. Ferric Carboxymaltose in the treatment of chemotherapy-induced anaemia: an effective, safe and cost- sparing alternative to blood transfusion. Sci Rep 2019; 9:20410. [PMID: 31892732 PMCID: PMC6938480 DOI: 10.1038/s41598-019-56999-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 12/11/2019] [Indexed: 11/09/2022] Open
Abstract
AbstractAnaemia is highly prevalent in cancer patients, adversely affects quality of life and impacts survival. The pathogenesis is multifactorial, with iron deficiency being a major and potentially treatable contributor. This study aimed to assess the effectiveness and economic impact of ferric carboxymaltose in chemotherapy-induced anaemia. This prospective cohort study between 2015–2016 of chemotherapy-treated patients for solid tumours, grade ≥2 anaemia and iron deficiency evaluated hematopoietic response four weeks after ferric carboxymaltose treatment. Transfusion rate of all cancer patients treated at our ambulatory unit during the two-year study period (2015–2016) was compared to a retrospective cohort (2013–2014) who received blood transfusion only. Between 2015–2016, 99 patients were included and treated with ferric carboxymaltose, the majority of whom (n = 81) had relative iron deficiency. Mean haemoglobin concentrations improved from 9.2 [6.7–10.8] g/dL to 10.6 [7.8–14.2] g/dL four weeks after treatment. A 26% reduction in the transfusion rate was observed from control retrospective to the prospective study group including ferric carboxymaltose treated patients [relative risk 0.74 (95% CI:0.66–0.83)]. The cost analysis showed a benefit for the use of ferric carboxymaltose in chemotherapy-induced anaemia. This study shows that ferric carboxymaltose is an effective, cost-saving support treatment, reducing the need for allogeneic transfusions saving blood units which are a limited resource.
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Thavarajah S, Choi MJ. The Use of Erythropoiesis-Stimulating Agents in Patients With CKD and Cancer: A Clinical Approach. Am J Kidney Dis 2019; 74:667-674. [DOI: 10.1053/j.ajkd.2019.04.022] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 04/18/2019] [Indexed: 01/13/2023]
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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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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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Choi MJ, Yee J. Erythropoiesis-Stimulating Agents and Cancer: Myth or Truth. Adv Chronic Kidney Dis 2019; 26:221-224. [PMID: 31477251 DOI: 10.1053/j.ackd.2019.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 04/22/2019] [Indexed: 11/11/2022]
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Park LC, Song YJ, Kim DJ, Kim MJ, Jo JC, Lee WS, Shin HJ, Oh SY, Do YR, Jeong JY, Lee HS. The effects of erythropoiesis-stimulating agents on the management of chemotherapy-induced anemia and tumor growth in diffuse large B-cell lymphoma patients. Int J Cancer 2019; 145:2459-2467. [PMID: 30973963 DOI: 10.1002/ijc.32328] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 03/20/2019] [Accepted: 04/02/2019] [Indexed: 11/11/2022]
Abstract
Erythropoiesis-stimulating agents (ESAs), such as erythropoietin (EPO) and darbepoetin, may alleviate anemia in diffuse large B-cell lymphoma (DLBCL) patients. However, many cancer cells express EPO receptors (EPOR), through which exogenously administered ESAs potentially promote cancer cell growth. We conducted preclinical/phase II studies to investigate the safety and efficacy of ESAs for managing chemotherapy-related anemia in DLBCL patients. We examined EPOR expression in germinal center B-cell (GCB)- and activated B-cell (ABC)-DLBCL cell lines, and investigated the effects of ESAs on cell proliferation, and rituximab-mediated complement-dependent cytotoxicity (CDC). The clinical study enrolled 50 histologically confirmed DLBCL patients receiving rituximab/cyclophosphamide/doxorubicin/vincristine/prednisolone (R-CHOP) who had hemoglobin levels <10.0 g/dl after a maximum of three R-CHOP cycles and received ≥4 doses of fixed-dose darbepoetin (360 μg) once every 3 weeks. EPOR mRNA was detected in all GCB-DLBCL cell lines, but little/none was detected in ABC-DLBCL cell lines. GCB-DLBCL and ABC-DLBCL cell proliferation was unaffected by EPO or darbepoetin. Rituximab-mediated CDC of DLBCL cell lines with/without EPOR expression was not affected adversely by EPO. In the clinical study, baseline mean hemoglobin was 9.19 g/dl; the overall mean change in hemoglobin was 1.59 ± 1.3 g/dl (16 weeks). Forty-eight percent of enrolled patients achieved a hematopoietic response. Our study shows that ESAs do not affect the growth of DLBCL cells or rituximab-mediated CDC under the experimental conditions that we used, and the appropriate use of ESAs may be effective and safe for DLBCL patients with anemia after R-CHOP.
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Affiliation(s)
- Lee Chun Park
- Department of Internal Medicine, Kosin University College of Medicine, Busan, South Korea
| | - Yeon-Joo Song
- Central Medical Research Institute, Kosin University Gospel Hospital, Busan, South Korea.,Cancer Research Institute, Kosin University College of Medicine, Busan, South Korea
| | - Da Jung Kim
- Department of Internal Medicine, Kosin University College of Medicine, Busan, South Korea
| | - Min-Jung Kim
- Cancer Research Institute, Kosin University College of Medicine, Busan, South Korea.,Department of Biochemistry, Kosin University College of Medicine, Busan, South Korea
| | - Jae-Cheol Jo
- Department of Hematology and Oncology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, South Korea
| | - Won Sik Lee
- Department of Internal Medicine, Busan Paik Hospital, Busan, South Korea
| | - Ho-Jin Shin
- Department of Internal Medicine, Busan National University Hospital, Busan, South Korea
| | - Sung Yong Oh
- Department of Internal Medicine, Dong-A University College of Medicine, Busan, South Korea
| | - Young Rok Do
- Department of Hemato-Oncology, Keimyung University Dongsan Medical Center, Daegu, South Korea
| | - Jee-Yeong Jeong
- Cancer Research Institute, Kosin University College of Medicine, Busan, South Korea.,Department of Biochemistry, Kosin University College of Medicine, Busan, South Korea
| | - Ho Sup Lee
- Department of Internal Medicine, Kosin University College of Medicine, Busan, South Korea
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Will there still be a role for the originator erythropoiesis-simulating agents after the biosimilars and the hypoxia-inducible factor stabilizers approval? Curr Opin Nephrol Hypertens 2019; 27:339-344. [PMID: 29846220 DOI: 10.1097/mnh.0000000000000432] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW To discuss if there will still be a role for the originator ESAs after the already available biosimilars and the approval of HIF stabilizers in the near future. RECENT FINDINGS Current treatment with erythropoiesis-simulating agents (ESAs) is effective and generally well tolerated, but requires parenteral injections. It is also surrounded by safety concerns and is still expensive. Functional iron deficiency is the major obstacle for efficient ESA therapy. ESA resistance may develop, calling for high ESA doses, further increasing the side effects associated with ESA use. Biosimilars were introduced for reducing costs. In searching for an ideal antianemic drug, new investigational strategies have been proposed including the attractive alternative hypoxia-inducible factor (HIF) stabilizers, which stimulate endogenous EPO production. However, we should caution in translating the historical results referring to the side effects of ESAs to current clinical practice, considering that hemoglobin targets and ESAs doses are now much lower. We could anticipate that side effects will be much less. SUMMARY According to preliminary data, orally administered HIF stabilizers could provide pharmacological advantages over the existing ESAs. These will need confirmation by the findings of large, phase-3, clinical trials. Finally, cost will be an important issue determining their future use.
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Gómez-Ramírez S, Bisbe E, Shander A, Spahn DR, Muñoz M. Management of Perioperative Iron Deficiency Anemia. Acta Haematol 2019; 142:21-29. [PMID: 30970362 DOI: 10.1159/000496965] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Accepted: 01/16/2019] [Indexed: 01/28/2023]
Abstract
Preoperative anemia affects 30-40% of patients undergoing major surgery and is an independent risk factor for perioperative blood transfusion, morbidity, and mortality. Absolute or functional iron deficiency is its leading cause. Nonanemic hematinic deficiencies are also prevalent and may hamper preoperative hemoglobin optimization and/or recovery from postoperative anemia. As modifiable risk factors, anemia and hematinic deficiencies should be detected and corrected prior to major surgical procedures. Postoperative anemia is even more common (up to 80-90%) due to surgery-associated blood loss, inflammation-induced blunted erythropoiesis, and/or preexisting anemia. Preoperative oral iron may have a role in mild-to-moderate anemia, provided there is sufficient time (6-8 weeks) and adequate tolerance of oral preparations. Postoperative oral iron is of little value and rife with gastrointestinal adverse events. Intravenous iron should preferentially be used in cases of moderate-to-severe iron deficiency anemia, concomitant use of erythropoiesis-stimulating agents, short time to surgery or nonelective procedures, and for postoperative anemia management. Minor infusion reactions to intravenous iron are rare, the incidence of severe anaphylactic reactions is extremely low, and there is no increase in infections with intravenous iron. Currently available intravenous iron formulations allowing administration of large single doses are preferred.
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Affiliation(s)
- Susana Gómez-Ramírez
- Department of Internal Medicine, University Hospital Virgen de la Victoria, Málaga, Spain
| | - Elvira Bisbe
- Department of Anesthesiology, University Hospital Mar-Esperanza, Barcelona, Spain
| | - Aryeh Shander
- Departments of Anesthesiology, Critical Care, and Hyperbaric Medicine, Englewood Hospital and Medical Center, Englewood, New Jersey, USA
- TeamHealth Research Institute, Englewood Health, Englewood, New Jersey, USA
| | - Donat R Spahn
- Institute of Anesthesiology, University and University Hospital of Zurich, Zurich, Switzerland
| | - Manuel Muñoz
- Department of Surgical Specialties, Biochemistry, and Immunology, School of Medicine, University of Málaga, Málaga, Spain,
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Dai D, Han S, Li L, Guo Y, Wei Y, Jin H, Wang X. Anemia is associated with poor outcomes of metastatic castration-resistant prostate cancer, a systematic review and meta-analysis. Am J Transl Res 2018; 10:3877-3886. [PMID: 30662637 PMCID: PMC6325522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Accepted: 11/16/2018] [Indexed: 06/09/2023]
Abstract
Androgen deprivation therapy (ADT) was an important management for metastatic prostate cancer. However, patients would finally progress to the metastatic castration-resistant prostate cancer (mCRPC) and lose sensitivity to ADT. In addition to lower testosterone level, ADT could cause anemia, which might impair the chemotherapy efficiency and worsen the outcomes of cancer patients. However, inconsistent results were found between anemia and mCRPC prognosis. Our study was the first systematic review to evaluate the influence of anemia in mCRPC prognosis. Thirteen studies with 6,484 samples were involved in this meta-analysis. We found anemia would worsen the Overall survival (OS) of mCRPC patients in both prognostic designed studies (HR = 1.55, 95% CI = 1.24-1.94) and retrospective designed studies (HR = 1.82, 95% CI = 1.52-2.18). Prognostic analyses also demonstrated that anemia associated with poor Progression free survival (PFS) (HR = 1.47, 95% CI = 1.22-1.75). In conclusion, we found that anemia was significantly associated with poor OS and PFS of mCRPC patients. Larger RCTs are needed for future study, especially for the evaluation of treatment value for anti-anemia in mCRPC.
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Affiliation(s)
- Dongjun Dai
- Department of Medical Oncology, Sir Run Run Shaw Hospital, Medical School of Zhejiang UniversityHangzhou, China
| | - Shuting Han
- Department of Medical Oncology, Sir Run Run Shaw Hospital, Medical School of Zhejiang UniversityHangzhou, China
| | - Ling Li
- Laboratory of Cancer Biology, Key Lab of Biotherapy, Sir Run Run Shaw Hospital, Medical School of Zhejiang UniversityHangzhou, China
| | - Yan Guo
- Laboratory of Cancer Biology, Key Lab of Biotherapy, Sir Run Run Shaw Hospital, Medical School of Zhejiang UniversityHangzhou, China
| | - Yuping Wei
- Department of Medical Oncology, Sir Run Run Shaw Hospital, Medical School of Zhejiang UniversityHangzhou, China
| | - Hongchuan Jin
- Laboratory of Cancer Biology, Key Lab of Biotherapy, Sir Run Run Shaw Hospital, Medical School of Zhejiang UniversityHangzhou, China
| | - Xian Wang
- Department of Medical Oncology, Sir Run Run Shaw Hospital, Medical School of Zhejiang UniversityHangzhou, China
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Aapro M, Beguin Y, Bokemeyer C, Dicato M, Gascón P, Glaspy J, Hofmann A, Link H, Littlewood T, Ludwig H, Österborg A, Pronzato P, Santini V, Schrijvers D, Stauder R, Jordan K, Herrstedt J. Management of anaemia and iron deficiency in patients with cancer: ESMO Clinical Practice Guidelines. Ann Oncol 2018; 29:iv96-iv110. [PMID: 29471514 DOI: 10.1093/annonc/mdx758] [Citation(s) in RCA: 121] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/08/2023] Open
Affiliation(s)
- M Aapro
- Genolier Cancer Centre, Clinique de Genolier, Genolier, Switzerland
| | - Y Beguin
- University of Liège, Liège
- CHU of Liège, Liège, Belgium
| | - C Bokemeyer
- Department of Oncology, Hematology and BMT with Section Pneumology, University of Hamburg, Hamburg, Germany
| | - M Dicato
- Hématologie-Oncologie, Centre Hospitalier de Luxembourg, Luxembourg, Luxembourg
| | - P Gascón
- Department of Haematology-Oncology, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - J Glaspy
- Division of Hematology and Oncology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, USA
| | - A Hofmann
- Medical Society for Blood Management, Laxenburg, Austria
| | - H Link
- Klinik für Innere Medizin I, Westpfalz-Klinikum, Kaiserslautern, Germany
| | - T Littlewood
- Department of Haematology, John Radcliffe Hospital, Oxford, UK
| | - H Ludwig
- Wilhelminen Cancer Research Institute, Wilhelminenspital, Vienna, Austria
| | - A Österborg
- Karolinska Institute and Karolinska Hospital, Stockholm, Sweden
| | - P Pronzato
- Medica Oncology, IRCCS Asiana Pedaliter Universitaria San Martino - IST, Institutor Nazionale per la Ricercars sol Chancre, Genova
| | - V Santini
- Department of Experimental and Clinical Medicine, Haematology, University of Florence, Florence, Italy
| | - D Schrijvers
- Department of Medical Oncology, Ziekenhuisnetwerk Antwerpen, Antwerp, Belgium
| | - R Stauder
- Department of Internal Medicine V (Haematology and Oncology), Innsbruck Medical University, Innsbruck, Austria
| | - K Jordan
- Department of Medicine V, University of Heidelberg, Heidelberg, Germany
| | - J Herrstedt
- Department of Oncology, Zealand University Hospital Roskilde, Roskilde
- University of Copenhagen, Copenhagen, Denmark
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Busti F, Marchi G, Ugolini S, Castagna A, Girelli D. Anemia and Iron Deficiency in Cancer Patients: Role of Iron Replacement Therapy. Pharmaceuticals (Basel) 2018; 11:E94. [PMID: 30274354 PMCID: PMC6315653 DOI: 10.3390/ph11040094] [Citation(s) in RCA: 77] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 09/27/2018] [Accepted: 09/28/2018] [Indexed: 12/21/2022] Open
Abstract
Anemia in cancer patients is quite common, with remarkable negative impacts on quality of life and overall prognosis. The pathogenesis is complex and typically multifactorial, with iron deficiency (ID) often being a major and potentially treatable contributor. In turn, ID in cancer patients can be due to multiple concurring mechanisms, including bleeding (e.g., in gastrointestinal cancers or after surgery), malnutrition, medications, and hepcidin-driven iron sequestration into macrophages with subsequent iron-restricted erythropoiesis. Indeed, either absolute or functional iron deficiency (AID or FID) can occur. While for absolute ID there is a general consensus regarding the laboratory definition (that is ferritin levels <100 ng/mL ± transferrin saturation (TSAT) <20%), a shared definition of functional ID is still lacking. Current therapeutic options in cancer anemia include iron replacement, erythropoietic stimulating agents (ESAs), and blood transfusions. The latter should be kept to a minimum, because of concerns regarding risks, costs, and limited resources. Iron therapy has proved to be a valid approach to enhance efficacy of ESAs and to reduce transfusion need. Available guidelines focus mainly on patients with chemotherapy-associated anemia, and generally suggest intravenous (IV) iron when AID or FID is present. However, in the case of FID, the upper limit of ferritin in association with TSAT <20% at which iron should be prescribed is a matter of controversy, ranging up to 800 ng/mL. An increasingly recognized indication to IV iron in cancer patients is represented by preoperative anemia in elective oncologic surgery. In this setting, the primary goal of treatment is to decrease the need of blood transfusions in the perioperative period, rather than improving anemia-related symptoms as in chemotherapy-associated anemia. Protocols are mainly based on experiences of Patient Blood Management (PBM) in non-oncologic surgery, but no specific guidelines are available for oncologic surgery. Here we discuss some possible approaches to the management of ID in cancer patients in different clinical settings, based on current guidelines and recommendations, emphasizing the need for further research in the field.
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Affiliation(s)
- Fabiana Busti
- Department of Medicine, Section of Internal Medicine, University of Verona, and EuroBloodNet Referral Center for Iron Disorders, Azienda Ospedaliera Universitaria Integrata Verona, Policlinico G.B. Rossi, 37134 Verona, Italy.
| | - Giacomo Marchi
- Department of Medicine, Section of Internal Medicine, University of Verona, and EuroBloodNet Referral Center for Iron Disorders, Azienda Ospedaliera Universitaria Integrata Verona, Policlinico G.B. Rossi, 37134 Verona, Italy.
| | - Sara Ugolini
- Department of Medicine, Section of Internal Medicine, University of Verona, and EuroBloodNet Referral Center for Iron Disorders, Azienda Ospedaliera Universitaria Integrata Verona, Policlinico G.B. Rossi, 37134 Verona, Italy.
| | - Annalisa Castagna
- Department of Medicine, Section of Internal Medicine, University of Verona, and EuroBloodNet Referral Center for Iron Disorders, Azienda Ospedaliera Universitaria Integrata Verona, Policlinico G.B. Rossi, 37134 Verona, Italy.
| | - Domenico Girelli
- Department of Medicine, Section of Internal Medicine, University of Verona, and EuroBloodNet Referral Center for Iron Disorders, Azienda Ospedaliera Universitaria Integrata Verona, Policlinico G.B. Rossi, 37134 Verona, Italy.
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Horváth-Puhó E, Suttorp MM, Frederiksen H, Hoekstra T, Dekkers OM, Pedersen L, Cannegieter SC, Dekker FW, Sørensen HT. Erythropoiesis-stimulating agents and cardiovascular events in patients with myelodysplastic syndrome and multiple myeloma. Clin Epidemiol 2018; 10:1371-1380. [PMID: 30310329 PMCID: PMC6167129 DOI: 10.2147/clep.s172306] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Introduction Erythropoiesis-stimulating agent (ESA) treatment has been associated with an increased risk of venous thromboembolism (VTE) in patients with solid tumors and with an increased risk of cardiovascular events in patients with chronic kidney disease. The ESA-related risk in patients with hematological neoplasms remains unclear. We, therefore, aimed to assess the ESA-related risk of VTE, myocardial infarction (MI), and stroke in patients with multiple myeloma (MM) and myelodysplastic syndrome (MDS). Materials and methods We conducted a population-based cohort study in Denmark, using medical databases to identify 2,114 MDS patients and 3,105 MM patients diagnosed in 2004–2013. Incidence rates per 1,000 person-years and hazard ratios (HRs) with 95% confidence intervals (CIs) for VTE, MI, and stroke associated with ESA treatment were computed. HRs were calculated in time-dependent Cox regression and adjusted for age, sex, MDS prognosis group, comorbidities, and treatments. Results Incidence rates per 1,000 person-years for VTE, MI, and stroke were 10.8, 8.2, and 16.0 in MDS patients, and 21.9, 10.2 and 9.9 in MM patients without ESA treatment, respectively. MDS patients with ESA treatment had a 1.6-fold increased risk of MI (HR 1.60 [95% CI 0.90–2.86]) and an almost twofold increased risk of stroke (HR 1.94 [95% CI 1.28–2.94]). Adjusted HR for VTE was 1.04 (95% CI 0.57–1.89) compared with MDS patients without ESAs. In MM patients with ESAs compared with patients without ESAs, HRs were 1.41 (95% CI 0.96–2.08) for VTE, 1.23 (95% CI 0.68–2.20) for MI, and 1.63 (95% CI 0.96–2.77) for stroke. Conclusion ESA use was associated with stroke in MDS patients. Among MM patients, ESA treatment was associated with a higher risk of all cardiovascular events, although all CIs included equivalence.
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Affiliation(s)
| | - Marit M Suttorp
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Henrik Frederiksen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark, .,Department of Haematology, Odense University Hospital, Odense, Denmark
| | - Tiny Hoekstra
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Olaf M Dekkers
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark, .,Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Lars Pedersen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark,
| | - Suzanne C Cannegieter
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Friedo W Dekker
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Henrik Toft Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark,
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Evans M, Carrero JJ, Bellocco R, Barany P, Qureshi AR, Seeberger A, Jacobson SH, Hylander-Rössner B, Rotnitzky A, Sjölander A. Initiation of erythropoiesis-stimulating agents and outcomes: a nationwide observational cohort study in anaemic chronic kidney disease patients. Nephrol Dial Transplant 2018; 32:1892-1901. [PMID: 27672090 DOI: 10.1093/ndt/gfw328] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 06/14/2016] [Indexed: 11/12/2022] Open
Abstract
Background In 2012, new clinical guidelines were introduced for use of erythropoiesis-stimulating agents (ESA) in chronic kidney disease (CKD) patients, recommending lower haemoglobin (Hb) target levels and thresholds for ESA initiation. These changes resulted in lower blood levels in these patients. However, there is limited evidence on just when ESA should be initiated and the safety of a low Hb initiation policy. Methods In this observational inception cohort study, Swedish, nephology-referred, ESA-naïve CKD patients (n = 6348) were enrolled when their Hb dropped below 12.0 g/L, and they were followed for mortality and cardiovascular events. Four different ESA treatments were evaluated applying dynamic marginal structural models: (i) begin ESA immediately, (ii) begin ESA when Hb <11.0 g/dL, (iii) begin ESA when Hb <10.0 g/dL and (iv) never begin ESA in comparison with 'current practice' [the observed (factual) survival of the entire study cohort]. The adjusted 3-year survival following ESA begun over a range of Hb (from <9.0 to 12.0 g/dL) was evaluated, after adjustment for covariates at baseline and during follow-up. Results Overall, 36% were treated with ESA. Mortality during follow-up was 33.4% of the ESA-treated and 27.9% of the non-treated subjects. The adjusted 3-year survival associated with ESA initiation improved for subjects with initial Hb <9.0 to 11 g/dL and then decreased again for those with Hb above 11.5 g/dL. Initiating ESA at Hb <11.0 g/dL and <10.0 g/dL was associated with improved survival compared with 'current practice' [hazard ratio (HR) 0.83; 95% confidence interval (CI) 0.79-0.89 and 0.90; 95% CI 0.86-0.94, respectively] and did not increase the risk of a cardiovascular event (HR 0.93; 95% CI 0.87-1.00). Conclusion In non-dialysis patients with CKD, ESA initiation at Hb < 10.0-11.0 g/dL is associated with improved survival in patients otherwise treated according to guidelines.
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Affiliation(s)
- Marie Evans
- CLINTEC Renal Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Juan-Jesus Carrero
- CLINTEC Renal Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.,Center for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Rino Bellocco
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.,Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
| | - Peter Barany
- CLINTEC Renal Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Abdul R Qureshi
- CLINTEC Renal Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Astrid Seeberger
- CLINTEC Renal Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Stefan H Jacobson
- Division of Nephrology, Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
| | - Britta Hylander-Rössner
- CLINTEC Renal Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | | | - Arvid Sjölander
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
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Cortinovis D, Beretta G, Piazza E, Luchena G, Aglione S, Bertolini A, Buzzoni R, Cabiddu M, Carnaghi C, Danova M, Farina G, Ferrari V, Frascaroli M, Reni M, Tansini G. Chemotherapy-Induced Anemia and Oncologist Perception on Treatment: Results of a Web-Based Survey. TUMORI JOURNAL 2018; 99:45-50. [DOI: 10.1177/030089161309900108] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Aims and background Anemia prevalence and incidence in chemotherapy-treated patients is high. Erythropoiesis-stimulating agents (ESAs) are frequently employed in the management of chemotherapy-induced anemia. However, other treatments such as red blood transfusion or iron supplementation are normally used. Recent international guidelines raised some concern about ESAs employment with a possible impact in chemotherapy-induced anemia management and changes in clinical practice behavior. Methods To evaluate opinions about chemotherapy-induced anemia clinical management preference, the Associazione Italiana Oncologia Medica (AIOM) Lombardy section coordinators sent via email a 12-item questionnaire about their knowledge on CIA and usual therapeutic strategies to manage this adverse event to AIOM Lombardy onco-hematologist members. Results From January 2011 to March 2011, 81 questionnaires were collected with an approximated share of 30%. The survey was completed mainly by oncologists (91%) aged 35–50 years (50%). Chemotherapy-induced anemia was considered to have clinical impact in changing cancer therapeutic strategy by nearly 60% of the respondents. ESAs were administered largely (80%) with concomitant iron supplementation in 52%; 38% jointly used blood transfusion as part of the therapy. Nearly 20% of those who replied correctly employed transferrin saturation levels as a marker to guide iron supplementation. Physician prescribers strictly followed the guidelines to start and stop ESAs even if 14% were negatively influenced by new ASCO recommendations. ESA biosimilars were considered future substitutes of originators in 45% of the cases. Conclusions Chemotherapy-induced anemia was perceived as an adverse event with a mild impact on clinical practice. ESAs were largely employed, however the number of transfusions and lack of employment of markers of iron depletion suggested that adherence to guidelines could be theoretically met but with some discordances regarding the most appropriate strategies in daily clinical practice.
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Affiliation(s)
| | | | | | | | | | | | | | - Roberto Buzzoni
- DH & Terapia Ambulatoriale Oncologica, Fondazione IRCCS Istituto Nazionale Tumori, Milan
| | - Mary Cabiddu
- Oncologia Medica, Ospedale Treviglio-Caravaggio, Bergamo
| | - Carlo Carnaghi
- Oncologia Medica, Humanitas Mater Domini, Castellanza (VA), Onco-Ematologia, Humanitas Cancer Center, Rozzano (MI)
| | - Marco Danova
- Medicina oncologica, Ospedale Civile, Vigevano (PV)
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René É, Lazrak HH, Laurin LP, Elftouh N, Vallée M, Lafrance JP. Association of erythropoiesis-stimulating agents and the incidence risk of cancer diagnosis among chronic dialysis patients: a nested case-control study. Nephrol Dial Transplant 2018; 32:1047-1052. [PMID: 27448671 DOI: 10.1093/ndt/gfw268] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Accepted: 05/04/2016] [Indexed: 11/14/2022] Open
Abstract
Background Erythropoiesis-stimulating agents (ESAs) are the cornerstone of the treatment for anemia in end-stage renal disease (ESRD) patients. Although a correlation has been established between ESAs and increased tumor growth among patients with cancer-related anemia, an association with a higher incidence of cancer among chronic dialysis patients remains relatively unclear. Methods We completed a nested case-control study in a cohort of 4574 patients who began chronic dialysis treatment between 1 January 2001 and 31 December 2007 in Quebec, Canada, utilizing dialysis registry and administrative databases exclusively to extract our data. We excluded patients with a prior diagnosis of cancer. Eligible cases were identified by the time of initial cancer diagnosis obtained from either the hospital's discharge or physician billing form. We then randomly selected up to 10 controls for each case. ESA exposure was evaluated between 6 and 9 months prior to the initial cancer diagnosis. The mean weekly exposure was used to categorize ESA usage as either a low dose (<30 µg/week), moderate dose (30-70 µg/week) or high dose (>70 µg/week). We estimated the association between ESAs and the risk of developing cancer using a multivariable conditional logistic regression. Results We identified 419 cases of cancer and 3895 matched controls during the study period. The use of ESAs was associated with a higher risk of cancer {odds ratio [OR] 1.04 [95% confidence interval (CI) 1.02-1.07]}. Specifically, patients in the high exposure group (>70 µg/week) had an increased risk of developing cancer [OR 1.77 (95% CI 1.18-2.66)] compared with patients in the unexposed group. Conclusion High-dose ESA was associated with an increased incidence risk of new cancer diagnosis among chronic dialysis patients.
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Affiliation(s)
- Émilie René
- Maisonneuve-Rosemont HospitalResearch Center, Montreal, QC, Canada
| | - Hind H Lazrak
- Maisonneuve-Rosemont HospitalResearch Center, Montreal, QC, Canada
| | - Louis-Philippe Laurin
- Maisonneuve-Rosemont Hospital Research Center, Montreal, QC, Canada
- Department of Medicine, University of Montreal, Montreal, QC, Canada
- Division of Nephrology, Maisonneuve-Rosemont Hospital, 5415, boul. de l'Assomption, Montreal, QC H1T 2M4, Canada
| | - Naoual Elftouh
- Maisonneuve-Rosemont HospitalResearch Center, Montreal, QC, Canada
| | - Michel Vallée
- Department of Medicine, University of Montreal, Montreal, QC, Canada
- Division of Nephrology, Maisonneuve-Rosemont Hospital, 5415, boul. de l'Assomption, Montreal, QC H1T 2M4, Canada
| | - Jean-Philippe Lafrance
- Maisonneuve-Rosemont Hospital Research Center, Montreal, QC, Canada
- Department of Medicine, University of Montreal, Montreal, QC, Canada
- Division of Nephrology, Maisonneuve-Rosemont Hospital, 5415, boul. de l'Assomption, Montreal, QC H1T 2M4, Canada
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38
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Patient Blood Management in the Intensive Care Unit. Transfus Med Rev 2017; 31:264-271. [DOI: 10.1016/j.tmrv.2017.07.007] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Revised: 07/14/2017] [Accepted: 07/25/2017] [Indexed: 01/28/2023]
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39
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2015 Japanese Society for Dialysis Therapy: Guidelines for Renal Anemia in Chronic Kidney Disease. RENAL REPLACEMENT THERAPY 2017. [DOI: 10.1186/s41100-017-0114-y] [Citation(s) in RCA: 110] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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40
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Biete A, Holub K. Haemoglobin monitoring in endometrial cancer patients undergoing radiotherapy. Clin Transl Oncol 2017; 19:1518-1523. [DOI: 10.1007/s12094-017-1698-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Accepted: 05/29/2017] [Indexed: 02/06/2023]
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Broccoli A, Argnani L, Stefoni V, Gandolfi L, Zinzani PL. Efficacy and safety of biosimilar epoetin alpha in patients with chronic lymphoid neoplasms and chemotherapy-induced anaemia: An observational, retrospective, monocentric analysis. Hematol Oncol 2017; 36:136-143. [PMID: 28332724 DOI: 10.1002/hon.2412] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Revised: 02/13/2017] [Accepted: 02/17/2017] [Indexed: 11/12/2022]
Abstract
Epoetin biosimilars are an alternative to originator erythropoietic agents in the treatment of chemotherapy-induced anaemia; however, their effects in patients with lymphoproliferative disorders remain unclear. This analysis examined the response of patients with lymphoproliferative disorders experiencing chemotherapy-induced anaemia to 4- or 8-week treatment with the biosimilar epoetin alpha. Treatment was initiated at first occurrence of haemoglobin (Hb) < 10 g/dL during chemotherapy and was stopped when Hb was >11 g/dL, when chemotherapy was completed, or in case of transfusion dependency. Response to epoetin alpha was defined as an increase in Hb of >1 g/dL or as an Hb > 11 g/dL. Stability was defined as change in Hb of ±1 g/dL, and no response was indicated by a decrease in Hb of >1 g/dL or acquired transfusion dependence. Overall, 65 patients were enrolled (median age 69 years; 47.7% ≥ 70 years old). Mean Hb levels at the initiation of epoetin alpha was 9.3 ± 0.5 g/dL. Mean Hb levels reached 10.7 ± 1.4 and 10.6 ± 1.5 g/dL at weeks 4 and 8, respectively, in patients on first-line chemotherapy and 11.4 ± 1.6 and 9.7 ± 1.3 g/dL in those on a second- or higher-line regimen. Overall, 70.8% of patients responded, 26.1% had stable Hb, and 3.1% did not respond. Delays or interruption of any chemotherapy cycle due to anaemia occurred in 18 patients. The biosimilar epoetin alpha was well tolerated and allowed patients with non-Hodgkin lymphoma or chronic lymphoproliferative disorders to continue their course of chemotherapy by effectively increasing and maintaining adequate concentrations of Hb.
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Affiliation(s)
- Alessandro Broccoli
- Institute of Hematology "L. e A. Seràgnoli", University of Bologna, Bologna, Italy
| | - Lisa Argnani
- Institute of Hematology "L. e A. Seràgnoli", University of Bologna, Bologna, Italy
| | - Vittorio Stefoni
- Institute of Hematology "L. e A. Seràgnoli", University of Bologna, Bologna, Italy
| | - Letizia Gandolfi
- Institute of Hematology "L. e A. Seràgnoli", University of Bologna, Bologna, Italy
| | - Pier Luigi Zinzani
- Institute of Hematology "L. e A. Seràgnoli", University of Bologna, Bologna, Italy
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Robles NR. The Safety of Erythropoiesis-Stimulating Agents for the Treatment of Anemia Resulting from Chronic Kidney Disease. Clin Drug Investig 2016; 36:421-31. [PMID: 26894799 DOI: 10.1007/s40261-016-0378-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Chronic kidney disease (CKD) anemia treatment was revolutionized in the late 1980s with the introduction of recombinant human erythropoietin. This and related erythropoiesis-stimulating agents (ESAs) greatly benefited patients by decreasing debilitating symptoms, improving their quality of life, and freeing them from dependence on blood transfusions with their associated complications such as infections, sensitization impeding transplantation, and secondary iron overload. However, even in the initial studies, untoward effects were noted in patients receiving ESAs, including worsening hypertension, seizures, and dialysis access clotting. Later, increased mortality, malignancy progression and even stroke were reported in renal patients. This review focuses on the safety issues of ESAs in CKD patients.
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Affiliation(s)
- Nicolas Roberto Robles
- Cardiovascular Risk Institute, Facultad de Medicina, Universidad de Salamanca, Salamanca, Spain. .,Unidad de Hipertensión Arterial, Hospital Infanta Cristina, Carretera de Portugal s/n, 06070, Badajoz, Spain.
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43
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Deak AT, Troppan K, Rosenkranz AR. Anemia management in cancer patients with chronic kidney disease. Eur J Intern Med 2016; 36:13-19. [PMID: 27640913 DOI: 10.1016/j.ejim.2016.08.036] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 08/06/2016] [Accepted: 08/19/2016] [Indexed: 12/27/2022]
Abstract
Anemia is a common complication of cancer and chronic kidney disease (CKD) associated with decreased physical performance as well as poor prognosis for life expectancy. Renal and cancer-induced anemia share common features regarding pathogenesis and therapeutic strategies. It is typically treated with iron substitution, erythropoiesis-stimulating agents (ESA) and in refractory cases with red blood cell transfusions. However, studies of the past few years unveiled numerous setbacks in the use of ESAs. These included a higher risk of cerebrovascular events and increased mortality without the improvement of cardiovascular outcomes in patients with CKD. Moreover, particularly negative results were observed in patients with previous cancer history under ESA therapy. These unfavorable findings have forced the clinicians to reevaluate the management of renal anemia. This led to decrease of ESA usage, while iron substitution and alternative therapeutic options gained more significance. Iron supplementation is also accompanied with certain risks ranging from gastrointestinal complications to severe allergic reactions and increased rate of infections. Furthermore, the evaluation of the long-term safety of excessive iron therapy is still lacking, especially in CKD patients with cancer. In the absence of these clinical studies, this review aims to summarize the currently available therapeutic strategies in anemia management of CKD patients with concomitant cancer.
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Affiliation(s)
- Andras T Deak
- Clinical Division of Nephrology, Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 27, 8036 Graz, Austria
| | - Katharina Troppan
- Clinical Division of Haematology, Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 38, 8036 Graz, Austria
| | - Alexander R Rosenkranz
- Clinical Division of Nephrology, Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 27, 8036 Graz, Austria.
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Wood MA, Goldman N, DePierri K, Somerville J, Riggs JE. Erythropoietin increases macrophage-mediated T cell suppression. Cell Immunol 2016; 306-307:17-24. [PMID: 27262376 PMCID: PMC4983461 DOI: 10.1016/j.cellimm.2016.05.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Revised: 05/06/2016] [Accepted: 05/25/2016] [Indexed: 12/22/2022]
Abstract
Erythropoietin (EPO), used to treat anemia in cancer patients, has been reported to accelerate tumor progression and increase mortality. Research of the mechanism for this effect has focused upon EPOR expression by tumor cells. We model the high macrophage to lymphocyte ratio found in tumor microenvironments (TMEs) by culturing peritoneal cavity (PerC) cells that naturally have a high macrophage to T cell ratio. Following TCR ligation, C57BL/6J PerC T cell proliferation is suppressed due to IFNγ-triggered inducible nitric oxide synthase (iNOS) expression. EPO was tested in the PerC culture model and found to increase T cell suppression. This effect could be abrogated by inhibiting iNOS by enzyme inhibition, genetic ablation, or blocking IFNγ signaling. Flow cytometry revealed the EPOR on CD11b(+)F4/80(+) macrophages. These results suggest that EPO could increase T cell suppression in the TME by acting directly on macrophages.
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Affiliation(s)
- Michelle A Wood
- Department of Biology, Rider University, Lawrenceville, NJ 08648, USA
| | - Naomi Goldman
- Department of Biology, Rider University, Lawrenceville, NJ 08648, USA
| | - Kelley DePierri
- Department of Biology, Rider University, Lawrenceville, NJ 08648, USA
| | - John Somerville
- Department of Biology, Rider University, Lawrenceville, NJ 08648, USA
| | - James E Riggs
- Department of Biology, Rider University, Lawrenceville, NJ 08648, USA.
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Poonawalla IB, Piller LB, Lairson DR, Chan W, Du XL. Use of Hematopoietic Growth Factors and Risk of Thromboembolic and Pulmonary Toxicities in Elderly Patients with Advanced Ovarian Cancer. Womens Health Issues 2016; 26:574-83. [PMID: 27365286 DOI: 10.1016/j.whi.2016.05.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Revised: 05/24/2016] [Accepted: 05/24/2016] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To evaluate the risk of thromboembolic and pulmonary toxicities associated with hematopoietic growth factor (HGF) use (i.e., erythropoietin-stimulating agent [ESA] and/or colony-stimulating factor [CSF]) in a community-dwelling cohort of elderly patients with advanced ovarian cancer. METHODS We studied 8,188 women, 65 years and older from the Surveillance, Epidemiology and End Results-Medicare linked database, diagnosed from January 1, 2000 to December 31, 2009. Patients were categorized into five groups: no chemotherapy and no ESA/CSF (n = 2,616), chemotherapy but no ESA/CSF (n = 1,854), ESA only (n = 1,313), CSF only (n = 743), and ESA + CSF (n = 1,662). We reported the cumulative incidence of toxicities for 2, 6, and greater than 6 months, and the incidence density for the overall follow-up. Cox-proportional hazards regression was performed to determine risk of toxicities. RESULTS Of the 5,572 patients receiving chemotherapy, 66.7% (n = 3,718) received HGF supportive treatment, 29.8% received ESA + CSF, 23.6% received ESA only, and 13.3% received CSF only. Patients who received chemotherapy and also ESA + CSF had a 14.1% cumulative incidence of thromboembolic event (TEE) at 6 months of follow-up compared with 8.0% in those who received chemotherapy without growth factor and 3.2% in those with neither chemotherapy nor growth factor. Those with chemotherapy who received ESA + CSF had a significantly higher risk of TEE (adjusted hazard ratio, 1.22; 95% confidence interval, 1.01-1.47) as compared with patients with chemotherapy and no ESA/CSF, although patients aged 85 years and older may experience up to a five-fold increased risk. The risk of pulmonary toxicities did not significantly differ by HGF use. CONCLUSIONS An increased risk of TEEs was observed in elderly patients with ovarian cancer who received ESA + CSF. The risk-benefit ratio for administering HGF should be carefully evaluated, especially among those 85 years and older.
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Affiliation(s)
- Insiya B Poonawalla
- Department of Epidemiology, Human Genetics, and Environmental Science, University of Texas Health Science Center Houston - School of Public Health, Houston, Texas
| | - Linda B Piller
- Department of Epidemiology, Human Genetics, and Environmental Science, University of Texas Health Science Center Houston - School of Public Health, Houston, Texas
| | - David R Lairson
- Department of Management Policy and Community Health, University of Texas Health Science Center Houston - School of Public Health, Houston, Texas
| | - Wenyaw Chan
- Department of Biostatistics, University of Texas Health Science Center Houston - School of Public Health, Houston, Texas
| | - Xianglin L Du
- Department of Epidemiology, Human Genetics, and Environmental Science, University of Texas Health Science Center Houston - School of Public Health, Houston, Texas.
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Robles Perez-Monteoliva NR. [Erythropoietin, chronic renal failure and cancer]. Med Clin (Barc) 2016; 146:539-40. [PMID: 26832198 DOI: 10.1016/j.medcli.2015.12.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Revised: 12/06/2015] [Accepted: 12/09/2015] [Indexed: 11/27/2022]
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Current trends in the management of anaemia in solid tumours and haematological malignancies. Curr Opin Support Palliat Care 2016; 10:189-94. [DOI: 10.1097/spc.0000000000000209] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Del Vecchio L, Locatelli F. An overview on safety issues related to erythropoiesis-stimulating agents for the treatment of anaemia in patients with chronic kidney disease. Expert Opin Drug Saf 2016; 15:1021-30. [PMID: 27149639 DOI: 10.1080/14740338.2016.1182494] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Erythropoiesis stimulating agents (ESA) are effective drugs, which have been used for decades in patients with chronic kidney disease (CKD) with few side effects. More recently, concern has been raised around their safety, from higher cardiovascular and thrombosis risk to cancer progression and increased mortality. AREAS COVERED We made a literature search on PubMed looking for adverse effects of ESA in CKD patients. The topics covered are cardiovascular adverse events, thrombosis, increased mortality, hypertension, cancer progression, diabetic retinopathy, pure red cell aplasia and anaphylactic reactions. EXPERT OPINION Concerns around ESA therapy have questioned treatment indications in high-risk CKD patients (those with cancer, diabetes and cardiovascular comorbidities). A more cautious approach has then prevailed. In our opinion, intermediate Hb values (Hb 10-12 g/dl) should be aimed with ESA therapy, being more cautious in high-risk patients. As a consequence, IV iron is administered more frequently. However, excessive iron use may cause iron overload and in rare cases severe anaphylactic reactions. There are expectations of new erythropoietic agents, such as those manipulating the hypoxia-inducible transcription factors (HIF) system. Differing from ESAs, they stimulate the production of endogenous EPO, avoiding over-physiological plasmatic levels.
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Affiliation(s)
- Lucia Del Vecchio
- a Department of Nephrology and Dialysis , A. Manzoni Hospital , Lecco , Italy
| | - Francesco Locatelli
- a Department of Nephrology and Dialysis , A. Manzoni Hospital , Lecco , Italy
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Gross I, Trentino KM, Andreescu A, Pierson R, Maietta RA, Farmer S. Impact of a Patient Blood Management Program and an Outpatient Anemia Management Protocol on Red Cell Transfusions in Oncology Inpatients and Outpatients. Oncologist 2016; 21:327-32. [PMID: 26865590 DOI: 10.1634/theoncologist.2015-0406] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2015] [Accepted: 12/28/2015] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Patient blood management (PBM) programs are associated with reduced transfusion usage, reduced hospital costs, and improved patient outcomes. The application of PBM principles in patients with malignant disease might achieve similar results. However, this population presents unique challenges. The aim of the present study was to investigate the impact of a PBM program on blood usage and patient outcomes in cancer patients, particularly in the setting of restricted use of erythropoiesis-stimulating agents (ESAs). MATERIALS AND METHODS A retrospective observational study was performed of patients admitted with a primary diagnosis of malignancy treated at Eastern Maine Medical Center as inpatients or outpatients, or both, from January 2008 through July 2013. RESULTS The proportion of inpatients and outpatients receiving ESAs decreased from 2.9% in 2008 to 1.1% in 2013 (p < .001). During the same period, an increase occurred in the mean dose of intravenous (IV) iron from 447 mg (95% confidence interval [CI], 337-556) to 588 mg (95% CI, 458-718). The mean red blood cell (RBC) units transfused per inpatient and outpatient episode decreased from 0.067 to 0.038 unit (p < .001). In inpatients, significant increases occurred in the proportion of single-unit RBC transfusions (p < .001) and patients infused with IV iron (p = .02), and significant decreases in the mean pretransfusion hemoglobin (p = .02) and RBC transfusion rate (p = .04). In-hospital mortality and length of stay did not change significantly during this period. CONCLUSION Despite the decreased use of ESA therapy, the implementation of a PBM program and outpatient anemia management protocol in cancer patients at our medical center was associated with significant reductions in RBC usage.
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Affiliation(s)
- Irwin Gross
- Eastern Maine Medical Center, Bangor, Maine, USA Accumen LLC, San Diego, California, USA
| | - Kevin M Trentino
- Performance Unit, South Metropolitan Health Service, Perth, Western Australia, Australia
| | | | | | | | - Shannon Farmer
- School of Surgery, Faculty of Medicine Dentistry and Health Sciences, University of Western Australia, Perth, Western Australia, Australia Centre for Population Health Research, Faculty of Health Sciences, Curtin University, Perth, Western Australia, Australia
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Mhaskar R, Wao H, Miladinovic B, Kumar A, Djulbegovic B. The role of iron in the management of chemotherapy-induced anemia in cancer patients receiving erythropoiesis-stimulating agents. Cochrane Database Syst Rev 2016; 2:CD009624. [PMID: 26845108 PMCID: PMC8765740 DOI: 10.1002/14651858.cd009624.pub2] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Erythropoiesis-stimulating agents (ESAs) are commonly used to treat chemotherapy-induced anemia (CIA). However, about half of patients do not benefit. OBJECTIVES To evaluate the benefits and harms related to the use of iron as a supplement to ESA and iron alone compared with ESA alone in the management of CIA. SEARCH METHODS We searched for relevant trials from the Cochrane Central Register of Controlled Trials (CENTRAL) (issue 1 January 2016), MEDLINE (1950 to February 2016), and www.clinicaltrials.gov without using any language limits. SELECTION CRITERIA All randomized controlled trials (RCTs) comparing 'iron plus ESA' or 'iron alone' versus 'ESA alone' in people with CIA were eligible for inclusion. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. MAIN RESULTS We included eight RCTs (12 comparisons) comparing ESA plus iron versus ESA alone enrolling 2087 participants. We did not find any trial comparing iron alone versus ESAs alone in people with CIA. None of the included RCTs reported overall survival. There was a beneficial effect of iron supplementation to ESAs compared with ESAs alone on hematopoietic response (risk ratio (RR) 1.17, 95% confidence interval (CI) 1.09 to 1.26; P < 0.0001; 1712 participants; 11 comparisons; high-quality evidence). Assuming a baseline risk of 35% to 80% for hematopoietic response without iron supplementation, between seven and 16 patients should be treated to achieve hematopoietic response in one patient. In subgroup analyses, RCTs that used intravenous (IV) iron favored ESAs and iron (RR 1.20 (95% CI 1.10 to 1.31); P < 0.00001; 1321 participants; eight comparisons), whereas we found no evidence for a difference in hematopoietic response in RCTs using oral iron (RR 1.04 (95% CI 0.87 to 1.24); P = 0.68; 391 participants; three comparisons). There was no evidence for a difference between the subgroups of IV and oral iron (P = 0.16). There was no evidence for a difference between the subgroups of types of iron (P = 0.31) and types of ESAs (P = 0.16) for hematopoietic response.The iron supplementation to ESAs might be beneficial as fewer participants treated with iron supplementation required red blood cell (RBC) transfusions compared to the number of participants treated with ESAs alone (RR 0.74 (95% CI 0.60 to 0.92); P = 0.007; 1719 participants; 11 comparisons; moderate-quality evidence). Assuming a baseline risk of 7% to 40% for RBC transfusion without iron supplementation, between 10 and 57 patients should be treated to avoid RBC transfusion in one patient.We found no evidence for a difference in the median time to hematopoietic response with addition of iron to ESAs (hazard ratio (HR) 0.93 (95% CI 0.67 to 1.28); P = 0.65; 1042 participants; seven comparisons; low-quality evidence). In subgroup analyses, RCTs in which dextran (HR 0.95 (95% CI 0.36 to 2.52); P = 0.92; 340 participants; three comparisons), sucrose iron (HR 1.15 (95% CI 0.60 to 2.21); P = 0.67; 102 participants; one comparison) and sulfate iron (HR 1.24 (95% CI 0.99 to 1.56); P = 0.06; 55 participants; one comparison) were used showed no evidence for difference between iron supplementation versus ESAs alone compared with RCTs in which gluconate (HR 0.78 (95% CI 0.65 to 0.94); P = 0.01; 464 participants; two comparisons) was used for median time to hematopoietic response (P = 0.02). There was no evidence for a difference between the subgroups of route of iron administration (P = 0.13) and types of ESAs (P = 0.46) for median time to hematopoietic response.Our results indicated that there could be improvement in the hemoglobin (Hb) levels with addition of iron to ESAs (mean difference (MD) 0.48 (95% CI 0.10 to 0.86); P = 0.01; 827 participants; seven comparisons; low-quality evidence). In RCTs in which IV iron was used there was evidence for a difference (MD 0.84 (95% CI 0.21 to 1.46); P = 0.009; 436 participants; four comparisons) compared with oral iron (MD 0.07 (95% CI -0.19 to 0.34); P = 0.59; 391 participants; three comparisons) for mean change in Hb level (P = 0.03). RCTs in which dextran (MD 1.55 (95% CI 0.62 to 2.47); P = 0.001; 102 participants; two comparisons) was used showed evidence for a difference with iron supplementation versus ESAs alone compared with RCTs in which gluconate (MD 0.54 (95% CI -0.15 to 1.22); P = 0.12; 334 participants; two comparisons) and sulfate iron (MD 0.07 (95% CI -0.19 to 0.34); P = 0.59; 391 participants; three comparisons) were used for mean change in Hb level (P = 0.007). RCTs in which epoetin was used showed evidence for a difference with iron supplementation versus ESAs alone (MD 0.77 (95% CI 0.25 to 1.29); P = 0.004; 337 participants; five comparisons) compared with darbepoetin use (MD 0.10 (95% CI -0.13 to 0.33); P = 0.38; 490 participants; two comparisons) for mean change in Hb level (P = 0.02).We found no evidence for a difference in quality of life with addition of iron to ESAs (standardized mean difference 0.01 (95% CI -0.10 to 0.12); P = 0.88; 1124 participants; three RCTs; high-quality evidence).We found no evidence for a difference in risk of grade III-IV thromboembolic events (RR 0.95 (95% CI 0.54 to 1.65); P = 0.85; 783 participants; three RCTs; moderate-quality evidence). The incidence of treatment-related mortality (TRM) was 0% (997 participants; four comparisons; high-quality evidence).Other common adverse events included vomiting, asthenia, and leukopenia, and were similar in both arms.Overall the risk of bias across outcomes was high to low. Since the included RCTs had shorter follow-up duration (up to 20 weeks), the long-term effects of iron supplementation are unknown. Our main reasons for downgrading the quality of evidence were inconsistency across the included studies and imprecision of results. AUTHORS' CONCLUSIONS Our systematic review shows that addition of iron to ESAs offers superior hematopoietic response, reduces the risk of RBC transfusions, and improves Hb levels, and appears to be well tolerated. None of the included RCTs reported overall survival. We found no evidence for a difference in quality of life with iron supplementation.
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Affiliation(s)
- Rahul Mhaskar
- University of South FloridaCenter for Evidence Based Medicine and Health Outcomes ResearchTampaFloridaUSA
| | - Hesborn Wao
- University of South FloridaCenter for Evidence Based Medicine and Health Outcomes ResearchTampaFloridaUSA
| | - Branko Miladinovic
- University of South FloridaCenter for Evidence Based Medicine and Health Outcomes ResearchTampaFloridaUSA
| | - Ambuj Kumar
- University of South FloridaCenter for Evidence Based Medicine and Health Outcomes ResearchTampaFloridaUSA
| | - Benjamin Djulbegovic
- Moffitt Cancer Center, Division of Oncologic Sciences, University of South FloridaDepartment of Blood and Marrow TransplantationTampaFloridaUSA
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