Use of Calcium Channel Blockers and Risk of Breast Cancer: A Population-based Cohort Study

Several first-line anti-hypertensives act on fibrosarcoma progression and PD1ab blockade therapy

PURPOSE

Patients are typically diagnosed with both hypertension and fibrosarcoma. Medical oncologists must prescribe suitable anti-hypertensive medications while considering anti-tumor drugs. Recently, immunotherapy has become prominent in cancer treatment. Nonetheless, it is unknown what role anti-hypertensive medications will play in immunotherapy.

METHODS

We examined the effects of six first-line anti-hypertensive medications on programmed cell death protein 1 antibody (PD1ab) in tumor treatment using a mouse model of subcutaneous fibrosarcoma. The drugs examined were verapamil, losartan, furosemide, spironolactone, captopril, and hydrochlorothiazide (HCTZ). The infiltration of CD8+ T cells was examined by immunohistochemistry. Additionally, several in vitro and in vivo assays were used to study the effects of HCTZ on human fibrosarcoma cancer cells to explore its mechanism.

RESULTS

Verapamil suppressed tumor growth and showed an improved effect on the tumor inhibition of PD1ab. Captopril did not affect tumor growth but brought an unexpected benefit to PD1ab treatment. In contrast, spironolactone and furosemide showed no effect on tumor growth but had an offset effect on the PD1ab therapy. Consequently, the survival time of mice was also significantly reduced. Notably, losartan and HCTZ, especially HCTZ, promoted tumor growth and weakened the effect of PD1ab treatment. Consistent results were observed in vivo and in vitro using the human fibrosarcoma cell line HT1080. We determined that the Solute Carrier Family 12 Member 3 (SLC12A3), a known target of HCTZ, may be the principal factor underlying its effect-enhancing properties through mechanism studies employing The Cancer Genome Atlas (TCGA) data and in vivo and in vitro assays.

CONCLUSION

Verapamil and captopril potentiated the anti-tumor effect of PD1ab, whereas spironolactone and furosemide weakened the effect of PD1ab on tumor inhibition. Alarmingly, losartan and HCTZ promoted tumor growth and impaired the effect of PD1ab. Furthermore, we preliminarily found that HCTZ may promote tumor progression through SLC12A3. Based on this study, futher mechanism researches and clinical trials should be conducted in the future.

Use of calcium channel blockers and risk of breast cancer among women aged 55 years and older: a nationwide population-based cohort study

This retrospective cohort study was aimed to compare the incidence of breast cancer among women aged ≥55 who received calcium channel blockers and angiotensin converting enzyme inhibitors/angiotensin II receptor blockers. We used the 2002-2015 Health and Welfare Database in Taiwan. Women 55 years and older who initiated antihypertensive treatment were included. Breast cancer risk for patients receiving calcium channel blockers was compared to those receiving angiotensin converting enzyme inhibitors/angiotensin II receptor blockers. Cox proportional hazards models were used to generate adjusted hazard ratios for breast cancer. We found that the risk of breast cancer was similar between calcium channel blockers users and angiotensin converting enzyme inhibitors/angiotensin II receptor blockers (adjusted hazard ratio [aHR] and 95% CI = 1.03 [0.80 to 1.34]). No significant risk increase was observed in the stratified analysis by dihydropyridine (aHR = 1.02 [0.78 to 1.33]) and non-dihydropyridine calcium channel blockers (aHR = 1.23 [0.48 to 3.20]). No difference in the risk of breast cancer associated with calcium channel blockers exposure was observed in patients who used hormone replacement therapy (aHR = 1.02 [0.29 to 3.58]). The risk for breast cancer was observed to be significantly lower in patients receiving calcium channel blockers than in those receiving angiotensin converting enzyme inhibitors/angiotensin II receptor blockers at a treatment duration of 5 or more years (aHR = 0.57 [0.33 to 0.98]). In conclusion, the risk for breast cancer is similar for calcium channel blockers and angiotensin converting enzyme inhibitors/angiotensin II receptor blocker users in an Asian population.

Verapamil modulates NFAT2 to inhibit tumor growth and potentiates PD1ab immune checkpoint inhibitor therapy in cervical cancer treatment

PURPOSE

Current evidence suggests a high co-prevalence of hypertension and cervical cancer. Accordingly, blood pressure control is indicated during anti-tumor drug therapy in this patient population. Over the past few years, immunotherapy has made great strides in treating different cancers. However, the role and clinical significance of verapamil as a first-line anti-hypertensive drug during immunotherapy remain poorly understood, emphasizing the need for further studies.

METHODS

Murine cervical cancer models were employed to assess the effect of verapamil monotherapy and combination with PD1ab. Immunohistochemistry was conducted to quantify the abundance of CD8+ T cell and Ki67+ cells. Several in-vitro and in-vivo assays were used to study the effects of verapamil and explore the preliminary mechanism.

RESULTS

Monotherapy with verapamil or PD1ab immune checkpoint inhibitor significantly suppressed the growth of subcutaneously grafted U14 cells in WT BABL/c mice, respectively, with increased survival time of mice. Consistent results were observed in the melanoma model. Furthermore, we substantiated that verapamil significantly impaired tumor proliferation and migration of SiHa human cervical cancer cells in vitro and in vivo. In silico analysis using TCGA data revealed that NFAT2 expression negatively correlated with patient survival. The CCK8 assay revealed that verapamil abrogated the stimulatory effect of NFAT2 after knockdown of NFAT2.

CONCLUSIONS

Our results suggest that verapamil inhibits tumor growth by modulating NFAT2 expression and enhancing tumor immune responses to PD1ab, which can be harnessed for cervical cancer therapy, especially for patients with comorbid hypertension. Indeed, further clinical trials are warranted to increase the robustness of our findings.

The risk of second primary malignancies in colorectal cancer patients using calcium channel blockers

Calcium channel blockers are among the most commonly used agents in the treatment of cardiovascular diseases. There are several known side-effects associated with their long-term use, whereas other potential adverse effects are yet to be proven. This study aims to evaluate the association between calcium channel blockers exposure and the incidence of second primary malignancy. We established a cohort of 1401 patients with colorectal cancer diagnosed in our institution between January 2003 and December 2016. Patients were followed-up until December 2020. The tumor characteristics and basic clinical data including medication information were obtained from the hospital information system database. Second malignancy was detected in 301 patients (21.5%), and occurred in 27.8% of patients who used calcium channel blockers compared to only 19.9% among non-users. Their use was associated with an increased incidence of bladder cancer in particular. Subanalysis of patients with second malignancy displayed a higher proportion of right-sided colon cancer compared to rectal carcinoma in non-users. Survival analysis revealed significantly better outcomes in early-stage colorectal cancer patients without a history of calcium channel blockers treatment or second primary malignancy.

Calcium Channel Blocker Use and the Risk for Breast Cancer: A Population-Based Nested Case-Control Study

Simple Summary

Calcium channel blockers (CCBs) are widely used among hypertension and heart disease patients. These drugs are effective and well-tolerated. Some studies have found that patients who used CCBs have a higher incidence of breast cancer (BCa). However, other studies did not find such an association. We investigate whether exposure to CCBs in patients with hypertension is associated with an increased risk of BCa. From a cohort of patients prescribed their first antihypertensive medication between 2000 and 2016, we detected 4875 BCa cases. For each case, we matched ten patients without BCa (controls). We found no association between CCB users and an increased risk of BCa compared to the use of other antihypertensive medications. There was no increase in risk even with longer exposure to CCBs (above eight years) and high doses. Considering that CCBs are a widely used antihypertensive drug class, our results provide important safety information on a population level, especially for patients with increased BCa risk.

Abstract

We investigated whether long-term exposure to calcium channel blockers (CCBs) is associated with an increased risk of breast cancer (BCa). We designed a nested case–control study based on data from the Clalit electronic database, the largest Israeli Health Services organization. All newly diagnosed breast cancer (BCa) cases were selected from a cohort of patients with hypertension. Ten controls were matched for each BCa case. The odds ratios (ORs) of BCa among CCBs users were calculated using multivariate conditional logistic regression analyses. A total of 4875 patients with newly diagnosed BCa were identified from the cohort with a median follow-up of 5.15 years. The exposure to CCBs was not associated with an increased risk of BCa (OR = 0.98; 95% CI, 0.92–1.04). Additionally, there was no association between long-term exposure to CCBs (above eight years) and increased BCa risk (OR = 0.91; 95% CI, 0.67–1.21). Higher cumulative doses of CCBs were not associated with an elevated risk of BCa (OR = 0.997; 95% CI, 0.962–1.034, calculated per 1000 DDD). Based on this large population-based study, long-term exposure to CCBs was not associated with an increased risk of BCa. Considering that CCBs are widely used medications, our results provide important safety information on a population level, especially for patients with an increased risk of BCa.

Antihypertensive drugs and the risks of cancer: More fakes than facts

In the last century, the diffusion of medical news to the public has been profoundly changed by the progressive spread of more pervasive, but at the same time often unreliable, means of communication. The misinterpretation of scientific evidence or fallacious presentation through social media could play as a great drawback to the success in the management of many diseases. This may become particularly alarming when concerning chronic diseases widely affecting the population. Arterial hypertension is still today one of the major causes of mortality and morbidity in most countries, and its management generally requires chronic therapy lasting for decades. Therefore, a recent debate about the potential oncogenic effect of antihypertensive drugs has been made widely available to patients mostly through social media. Since this is a topic of great impact for millions of patients and of main relevance for the scientific community, it must not be contaminated by the spread of fake or twisted news. The objective of this article is to briefly discuss the almost complete lack of hard evidence about the potential oncogenic effect of the major classes of antihypertensive drugs as opposed to the exaggerated mediatic communication and impact of scattered and unconfirmed observations. We believe that it is of key importance to provide authoritative support for patients and clinicians from scientific societies and guidelines to balance an unopposed widespread penetration of twisted or even fake news.

Antihypertensive drugs and the risk of cancer: a critical review of available evidence and perspective

: The issue of a potential danger of antihypertensive drugs related to cancer susceptibility is currently generating a major debate in the scientific community, concerns in the public and emphasized interest from the media. The present article is a thorough review of what is known on the various classes of antihypertensive drugs concerning the risk of developing different neoplasms and about the suggested pathophysiological mechanisms, whenever available. The main limitations of evidence derived from studies currently available in this setting are also discussed, high-lightening the need for newly developed approaches to generate more accurate recommendations and informed advice for physicians.

Association Between Antihypertensive Medication Use and Breast Cancer: A Systematic Review and Meta-Analysis

Background: The prevalence rate of hypertension and breast cancer increases with advancing age. Renin-angiotensin system inhibitors (RASIs), β-blockers (BBs), calcium channel blockers (CCBs), and diuretics are widely used to treat patients with hypertension. Although, the association between the use of antihypertensive medication and breast cancer has been highly debated, recent evidence supporting this association remains controversial. Objective: To evaluate the association between the use of antihypertensive medication and the risk of breast cancer and its prognosis. Methods: This study was conducted using data from the PubMed, Embase, and Cochrane Library databases retrieved for the period from January 2000 to April 2021. Articles and their references were checked and summary effects were calculated using random- and fixed-effects models. Heterogeneity test and sensitivity analysis were also performed. Results: This meta-analysis included 57 articles, which were all related to breast cancer risk or prognosis. Assessment of breast cancer risk using the pooled data showed that the use of BBs or CCBs or diuretics was associated with increased cancer risk [BB: relative risk (RR) = 1.20, 95% confidence interval (CI) = 1.09-1.32; CCBs: RR = 1.06, 95% CI 1.03-1.08; diuretics: RR = 1.06, 95% CI 1.01-1.11]. Long-term use of diuretic increased the risk of breast cancer (RR = 1.10, 95% CI 1.01-1.20), whereas long-term RASIs treatment reduced the risk (RR = 0.78, 95% CI 0.68-0.91). In addition, we found that diuretic users may be related to elevated breast cancer-specific mortality [hazard ratio (HR) = 1.18, 95% CI 1.04-1.33], whereas using other antihypertensive medications was not associated with this prognosis in patients with breast cancer. Conclusion: Using CCBs, BBs, and diuretics increased the risk of breast cancer. In addition, diuretics may elevate the risk of breast cancer-specific mortality. The long-term use of RASIs was associated with a significantly lower breast cancer risk, compared with non-users. Thus, this analysis provides evidence to support the benefits of the routine use of RASIs in patients with hypertension, which has important public health implications.

Antihypertensive Drugs and Risk of Cancer: Between Scylla and Charybdis

Antihypertensive drugs namely angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, calcium channel blockers, beta blockers, and diuretics are among the most clearly documented regimens worldwide with an overall cardioprotective benefit. Given that malignancy is the second leading cause of mortality, numerous observational studies aimed to investigate the carcinogenic potential of these agents with conflicting results. The purpose of this review was to summarize current data in an effort to explore rare side effects and new mechanisms linking antihypertensive drugs with the risk of developing cancer.

Cardiovascular Drug Use and Risk of Actinic Keratosis: A Case-Control Study

INTRODUCTION

Actinic keratosis (AK) is a precancerous skin lesion. Currently, many experts treat actinic keratosis as squamous cell carcinoma in situ. It is well established that exposure of the skin to ultraviolet radiation is a major risk factor for the development of actinic keratosis. Some studies suggest an association between keratinocyte cancers and photosensitizing cardiovascular drugs. The aim of this study was to establish an association between cardiovascular drug use and the presence of AK.

METHODS

A total of 400 patients were enrolled into the study (200 with AK; 200 healthy persons in the control group). The group of patients with AK consisted of 106 women and 94 men (mean age 71 years). The control group included 102 women and 98 men (mean age 69 years). An analysis of the risk factors for developing actinic keratosis was performed in all patients with AK on the basis of a detailed, standardized interview.

RESULTS

The statistical analysis showed that features independently associated with increased risk of AK included: age > 80 years (OR 4.14; 95% CI 2.4-7.3), positive cancer history (OR 1.94; 95% CI 1.0-3.6), positive history of sunburns when < 18 years old (OR 2.18; 95% CI 1.3-3.7) and taking angiotensin-converting enzyme inhibitors (OR 2.28; 95% CI 1.2-4.3), angiotensin receptor AT1 blockers (OR 2.90; 95% CI 1.1-7.9) and calcium channel blockers (OR 2.4; 95% CI 1.0-5.3).

CONCLUSION

In conclusion, our study presented an association between cardiovascular drug use and the risk of developing AK.

Protective Association Between Calcium Channel Blocker Use and Breast Cancer Recurrence in Postsurgical Women: A Population-Based Case-Control Study in Taiwan

Neoadjuvant chemotherapy induces metastasis of residual breast cancers through activation of tumor-associated macrophages. Previous studies have indicated that calcium channel blockers (CCBs) exert anti-inflammatory and antimigratory effects on macrophages via attenuating Ca²⁺ entry into macrophages. However, no existing empirical research has addressed the relationship between previous CCB use and breast cancer recurrence. In this study, 4840 Taiwanese women aged ≥20 years with breast cancer who underwent breast surgery from January 1, 2007, to December 31, 2015, were enrolled. The date of cancer recurrence was defined as the index date. Logistic regression was performed to evaluate the relationship between previous CCB exposure and cancer recurrence among female patients who underwent surgery for breast cancer. After adjusting for demographic characteristics, comorbidities, and tumor-node-metastasis stage, the adjusted odds ratio (OR) for CCB exposure within 5 years before the index date in women with recurrence compared with nonrecurrent controls was 0.73 (95% confidence interval [CI], 0.53-0.97). Further analysis revealed that the adjusted OR for CCB exposure between the surgery and index dates in women with recurrence relative to nonrecurrent controls was 0.72 (95%CI, 0.66-0.95). In particular, prior CCB use was significantly associated with a lower risk (34%) of breast cancer recurrence among women 20 to 54 years old (OR, 0.66; 95%CI, 0.47-0.83). This study uncovered a protective association between previous CCB use and breast cancer recurrence.

Gender-specific therapeutic approach in arterial hypertension - Challenges ahead

Hypertension was thought to be more important cardiovascular risk factor in men than in women. However, studies showed that overall incidence of hypertension-related cardiovascular diseases is higher in women comparing with men and this is particularly valid in menopause when prevalence of hypertension and its complications sharply and suddenly rises. It was also noticed that the effect of various antihypertensive groups was different in women and men. Some medications are prescribed more often in women, but it does not necessary mean that these drugs are more effective in this gender. There are several important reasons that could explain gender-induced differences in blood pressure levels, blood pressure control and antihypertensive treatment. They involve sex hormones, the renin-angiotensin-aldosterone and sympathetic nervous system, and arterial stiffness. However, taking into account many observational studies and trials, there are no consistent data regarding the impact of gender on effect of antihypertensive medications. Longitudinal study focused on gender and current antihypertensive groups would significantly help to understand the impact of gender. This might change therapeutic approach and improve cost-effectiveness in antihypertensive therapy in both genders. A full understanding of the pathophysiological characteristics of variations between genders demands additional research. This review article summarized the current knowledge regarding differences in the prevalence and awareness of arterial hypertension in women and men; alterations in pathophysiological mechanisms of hypertension between sexes; as well as the impact of sex on the effects of main antihypertensive groups of medications.

Effect of antihypertensive drugs on breast cancer risk in female hypertensive patients: Evidence from observational studies

This systematic review aimed to evaluate the association between antihypertensive drugs and risk of breast cancer, and provide therapeutic implications for female hypertensive patients with different physical appearance. The prevalence of hypertension and female breast cancer is on the rise with age. It has been suggested that ARBs (angiotensin receptor blockers), ACEi (angiotensin-converting enzyme inhibitor), CCBs (calcium channel blockers), and BBs (beta-blockers) were widely used in hypertensive patients. Some researches have shown ARBs, ACEis, and beta-blockers to be effective drugs for blood pressure lowering as well as for reducing the risk of breast cancer in women. However, the research conclusions were inconsistent. To address the conflicting evidence from previous study, the study evaluates the risk of breast cancer in hypertensive women. In conclusion, we report the evidence that beta-blockers can reduce the risk of breast cancer recurrence, while ACEi and CCBs were not associated with an increased risk of breast cancer.

Calcium channel blockers and breast cancer incidence: An updated systematic review and meta-analysis of the evidence

Controversy exists regarding the potential association between taking calcium channel blockers (CCBs) and the development of breast cancer. As a positive association would have important public health implications due to the widespread use of CCBs, this study aimed to incorporate new evidence to determine whether an association is likely to exist. We searched MEDLINE, EMBASE and the Cochrane Library to 28 June 2016 for relevant literature. References and citing articles were checked and authors contacted as necessary. Two authors independently selected articles and extracted data. Twenty-nine studies were reviewed; 26 were non-randomised studies (NRS). Meta-analysis of study data where adjustment for 'confounding by indication' was judged to be present suggests that an association, if any, is likely to be modest in magnitude (pooled odds/risk ratio 1.09 (95% confidence interval (CI) 1.03-1.15, I²=0%, 8 sub-studies; pooled hazard ratio 0.99 (95% CI 0.94-1.03, I²=35%, 9 sub-studies)). There are credible study data showing an increased relative risk with long-term use of CCBs, but the results of our meta-analysis and of meta-regression of log relative risk against minimum follow-up time are mixed. The current summative evidence does not support a clear association between taking CCBs and developing breast cancer. However, uncertainty remains, especially for long-term use and any association might not be uniform between different populations and/or breast cancer sub-types. We thus recommend further NRS in settings where CCB use is highly prevalent and population-based cancer, prescription and health-registries exist, to resolve this continuing uncertainty. PROSPERO, CRD42015026712.

Antihypertensive drug use and breast cancer risk: a meta-analysis of observational studies

We conducted a meta-analysis of observational studies to examine the hypothesized association between breast cancer and antihypertensive drug (AHT) use. Fixed- or random- effect models were used to calculate pooled risk ratios (RRs) and 95% confidence intervals (CIs) for all AHTs and individual classes (i.e., angiotensin-converting enzyme inhibitors, [ACEi]; angiotensin-receptor blockers, [ARBs]; calcium channel blockers, [CCBs]; beta-blockers, [BBs], and diuretics). Twenty-one studies with 3,116,266 participants were included. Overall, AHT use was not significantly associated with breast cancer risk (RR = 1.02, 95% CI: 0.98-1.06), and no consistent association was found for specific AHT classes with pooled RRs of 1.02 (95% CI: 0.96-1.09) for BBs, 1.07 (95% CI: 0.99-1.16) for CCBs, 0.99 (95% CI: 0.93-1.05) for ACEi/ARBs, and 1.05 (95% CI: 0.99-1.12) for diuretics. When stratified by duration of use, there was a significantly reduced breast cancer risk for ACEi/ARB use ≥10 years (RR = 0.80, 95% CI: 0.67-0.95). Although there was no significant association between AHT use and breast cancer risk, there was a possible beneficial effect was found for long-term ACEi/ARB. Large, randomized controlled trials with long-term follow-up are needed to further test the effect of these medications on breast cancer risk.

Hypertension and breast cancer risk: a systematic review and meta-analysis

Observational studies examining the relationship between hypertension and breast cancer risk have reported conflicting findings. We conducted this systematic review and meta-analysis to summarize the evidence regarding the association between hypertension and risk of breast cancer. Eligible studies were identified through a comprehensive literature search of PubMed, EMBASE, and the Cochrane library until August 2016. We included observational studies that reported relative risks (RR) with corresponding 95% confidence intervals (CIs). Results from individual studies were pooled by using a random-effects model. 29 articles of 30 studies, with totally 11643 cases of breast cancer, were eligible for inclusion in the meta-analysis. We observed a statistically significant association between hypertension and increased breast cancer risk (RR: 1.15; 95% CI: 1.08, 1.22). In the subgroup analysis, we found a positive association between hypertension and breast cancer incidence among postmenopausal women (RR: 1.20; 95% CI: 1.09, 1.31). In contrast, hypertension was not associated with risk of breast cancer among premenopausal women (RR: 0.97; 95% CI: 0.84, 1.12) and Asian population (RR: 1.07; 95% CI: 0.94, 1.22).This meta-analysis collectively suggests a significantly association between hypertension and breast cancer risk, specifically for postmenopausal hypertensive women.