Antihypertensive medication and their impact on cancer incidence: a mixed treatment comparison meta-analysis of randomized controlled trials

Long-term exposure to antihypertensive drugs and the risk of cancer occurrence: evidence from a large population-based study

OBJECTIVE

Available data on the association between antihypertensive drugs and cancer are characterized by a few years follow-up. Our aim has been to evaluate the association between long-term exposure to antihypertensive drugs and the risk of cancer occurrence.

METHODS

Using the healthcare utilization databases of the Lombardy region (Italy), individuals aged 40-85 years who had no previous history of cancer and were newly dispensed with at least one antihypertensive drug from the major drug classes between 2009 and 2011 were followed from the first drug dispensation to December 31, 2020. Data were analyzed according to the first drug used and the intention to treat principle, but also via an "as treated" approach, that is, by considering changes of and exposure to drugs during follow-up. The association between the duration of exposure to each drug class and the risk of cancer occurrence was evaluated using the adjusted Cox regression models.

RESULTS

The study cohort included 338 910 new drug users (median age, 59 years; 49.5% males). During a median follow-up of 10.2 years, 36 556 cancers occurred. There was no consistent significant association between the risk of cancer occurrence and angiotensin-converting-enzyme inhibitors, angiotensin-receptor blockers, or thiazides. A progressive, weak increase in cancer occurrence was associated with progressive exposure to calcium channel blockers and, limited to long-term exposure, to beta-blockers. A modest progressive increase in risk was observed also for thiazide-like and loop diuretics in the as treated, although not in the intention to treat approach.

CONCLUSIONS

Long-term evaluation of exposure to antihypertensive drugs did not show consistent associations between thiazides, angiotensin-receptor blockers, or angiotensin-converting-enzyme inhibitors and the risk of cancer occurrence. A weak association was observed between cancer and the duration of exposure to calcium channel blockers and beta-blockers.

Systematic review of Mendelian randomization studies on antihypertensive drugs

BACKGROUND

We systematically reviewed Mendelian randomization (MR) studies and summarized evidence on the potential effects of different antihypertensive drugs on health.

METHODS

We searched PubMed and Embase for MR studies evaluating the effects of antihypertensive drug classes on health outcomes until 22 May 2024. We extracted data on study characteristics and findings, assessed study quality, and compared the evidence with that from randomized controlled trials (RCTs).

RESULTS

We identified 2643 studies in the search, of which 37 studies were included. These studies explored a wide range of health outcomes including cardiovascular diseases and their risk factors, psychiatric and neurodegenerative diseases, cancer, immune function and infection, and other outcomes. There is strong evidence supporting the protective effects of genetically proxied antihypertensive drugs on cardiovascular diseases. We found strong protective effects of angiotensin-converting enzyme (ACE) inhibitors on diabetes whereas beta-blockers showed adverse effects. ACE inhibitors might increase the risk of psoriasis, schizophrenia, and Alzheimer's disease but did not affect COVID-19. There is strong evidence that ACE inhibitors and calcium channel blockers (CCBs) are beneficial for kidney and immune function, and CCBs showed a safe profile for disorders of pregnancy. Most studies have high quality. RCT evidence supports the beneficial effects of ACE inhibitors and CCBs on stroke, diabetes, and kidney function. However, there is a lack of reliable RCTs to confirm the associations with other diseases.

CONCLUSIONS

Evidence of the benefits and off-target effects of antihypertensive drugs contribute to clinical decision-making, pharmacovigilance, and the identification of drug repurposing opportunities.

Serum from Hypertensive Patients Induces Cancer-Supporting Phenotype of Vascular Endothelium In Vitro

BACKGROUND/OBJECTIVES

Large-scale epidemiological studies have established a bidirectional association between hypertension and cancer. However, the underlying mechanisms explaining this connection remain unclear. In our study, we investigated whether serum from patients with hypertension (HT) could enhance the aggressiveness of cancer cells in vitro through alterations in endothelial cell phenotype.

METHODS

Experiments were performed using EAhy926 endothelial cells and ovarian (SKOV-3), colorectal (SW480), pancreatic (PSN-1), breast (MCF-7), and lung (A549) cancer cell lines.

RESULTS

This study showed that conditioned medium (CM) produced by EAhy926 cells, when exposed to serum from patients with untreated hypertension (HT-CM), promotes the proliferation, migration, and invasion of every cancer cell line tested. In addition, endothelial cells subjected to HT serum promote the adhesion of all cancer cell types except PSN-1. An intensified transendothelial invasion of cancer cells was accompanied by decreased expression of junctional proteins (connexin 43, E-cadherin, occluding, desmoglein) in HT serum-treated endothelial cells. Quantitative analysis of the secretome of endothelial cells subjected to HT serum showed that they secrete increased amounts of CCL2, CXCL1, CXCL8, bFGF, HGF, IL-6, PAI-1, and TGF-β1. Moreover, cancer cells exposed to HT-CM display increased mRNA expression for several pro-cancerogenic agents, including CXCL8, tPA, and VEGF.

CONCLUSIONS

Our report shows that hypertension may potentiate cancer cell aggressiveness by modulating endothelial cell phenotype. Further tests with antihypertensive drugs are required to assess whether effective treatment of hypertension can mitigate its cancer-promoting potential.

Heart failure pharmacotherapy and cancer: pathways and pre-clinical/clinical evidence

Heart failure (HF) patients have a significantly higher risk of new-onset cancer and cancer-associated mortality, compared to subjects free of HF. While both the prevention and treatment of new-onset HF in patients with cancer have been investigated extensively, less is known about the prevention and treatment of new-onset cancer in patients with HF, and whether and how guideline-directed medical therapy (GDMT) for HF should be modified when cancer is diagnosed in HF patients. The purpose of this review is to elaborate and discuss the effects of pillar HF pharmacotherapies, as well as digoxin and diuretics on cancer, and to identify areas for further research and novel therapeutic strategies. To this end, in this review, (i) proposed effects and mechanisms of action of guideline-directed HF drugs on cancer derived from pre-clinical data will be described, (ii) the evidence from both observational studies and randomized controlled trials on the effects of guideline-directed medical therapy on cancer incidence and cancer-related outcomes, as synthetized by meta-analyses will be reviewed, and (iii) considerations for future pre-clinical and clinical investigations will be provided.

Thiazide Diuretics and Risk of Colorectal Cancer: A Population-Based Cohort Study

Evidence from clinical trials and observational studies on the association between thiazide diuretics and colorectal cancer risk is conflicting. We aimed to determine whether thiazide diuretics are associated with an increased colorectal cancer risk compared with dihydropyridine calcium channel blockers (dCCBs). A population-based, new-user cohort was assembled using the UK Clinical Practice Research Datalink. Between 1990-2018, we compared thiazide diuretic initiators with dCCB initiators and estimated hazard ratios (HR) with 95% confidence intervals (CIs) of colorectal cancer using Cox proportional hazard models. Models were weighted using standardized morbidity ratio weights generated from calendar time-specific propensity scores. The cohort included 377,760 thiazide diuretic initiators and 364,300 dCCB initiators, generating 3,619,883 person-years of follow-up. Compared with dCCBs, thiazide diuretics were not associated with colorectal cancer (weighted HR = 0.97, 95% CI: 0.90, 1.04). Secondary analyses yielded similar results, although an increased risk was observed among patients with inflammatory bowel disease (weighted HR = 2.45, 95% CI: 1.13, 5.35) and potentially polyps (weighted HR = 1.46, 95% CI: 0.93, 2.30). Compared with dCCBs, thiazide diuretics were not associated with an overall increased colorectal cancer risk. While these findings provide some reassurance, research is needed to corroborate the elevated risks observed among patients with inflammatory bowel disease and history of polyps.

Genetic proxies for calcium channel blockers and cancer: a Mendelian randomization study

Calcium channel blockers (CCBs) are commonly prescribed antihypertensives. However, concerns exist about potential off-target effects on cancer. This Mendelian randomization (MR) study examined the associations of genetic proxies for CCBs with the risk of cancer. We used published genetic proxies in the target genes of CCBs as instruments, and obtained MR estimates by applying them to large studies of 17 site-specific cancers (non-Hodgkin lymphoma, melanoma, leukemia, thyroid, rectal, pancreatic, oral cavity/pharyngeal, kidney, esophagus/stomach, colon, bladder, endometrial, cervical and breast, prostate, lung and ovarian cancer) from the Pan-Cancer study, with replication for breast cancer (133,384 cases, 113,789 controls from the Breast Cancer Association Consortium), prostate cancer (79,148 cases, 61,106 controls from the Prostate Cancer Association Group to Investigate Cancer Associated Alterations in the Genome consortium), lung cancer (11,348 cases, 15,861 controls from the International Lung Cancer Consortium), and ovarian cancer (25,509 cases, 40,941 controls from the Ovarian Cancer Association Consortium). We used inverse variance weighting for the main analysis and the weighted median, MR-Egger and Mendelian Randomization Pleiotropy Residual Sum and Outlier as sensitivity analyses. Genetic proxies for CCBs were not associated with any cancer after Bonferroni-correction (at the threshold of p < 0.003). Associations were robust to different MR methods. In conclusion, our study suggests no association of genetic proxies for CCBs with 17 different cancers. While the findings add some support to the safety profile of CCBs in long-term use, future replication is necessary to provide definitive evidence.

Dihydropyridine Calcium Channel Blockers and Risk of Pancreatic Cancer: A Population-Based Cohort Study

Background Recent studies have reported that dihydropyridine calcium channel blockers (dCCBs) may increase the risk of pancreatic cancer, but these studies had methodological limitations. We thus aimed to determine whether dCCBs are associated with an increased risk of pancreatic cancer compared with thiazide diuretics, a clinically relevant comparator. Methods and Results We conducted a new user, active comparator, population-based cohort study using the UK Clinical Practice Research Datalink. We identified new users of dCCBs and new users of thiazide diuretics between 1990 and 2018, with follow-up until 2019. Cox proportional hazards models were used to estimate hazard ratios (HRs) with 95% CIs for pancreatic cancer, comparing dCCBs with thiazide diuretics. Models were weighted using standardized morbidity ratio weights based on calendar time-specific propensity scores. We also conducted secondary analyses by cumulative duration of use, time since initiation, and individual drugs and assessed for the presence of effect modification by age, sex, smoking status, body mass index, history of chronic pancreatitis, and diabetes. The cohort included 344 480 initiators of dCCBs and 357 968 initiators of thiazide diuretics, generating 3 360 745 person-years of follow-up. After a median follow-up of 4.5 years, the weighted incidence rate per 100 000 person-years was 37.2 (95% CI, 34.1-40.4) for dCCBs and 39.4 (95% CI, 36.1-42.9) for thiazide diuretics. Overall, dCCBs were not associated with an increased risk of pancreatic cancer (weighted HR, 0.93; 95% CI, 0.80-1.09). Similar results were observed in secondary analyses. Conclusions In this large, population-based cohort study, dCCBs were not associated with an increased risk of pancreatic cancer compared with thiazide diuretics. These findings provide reassurance regarding the long-term pancreatic cancer safety of these drugs.

Antihypertensive Drugs and Cancer Risk

Hypertension is the most prevalent comorbidity in cancer patients. Consequently, many cancer patients are prescribed antihypertensive drugs before cancer diagnosis or during cancer treatment. However, whether antihypertensive drugs affect the incidence, treatment efficacy, or prognosis of cancer remains unanswered. For instance, renin-angiotensin and β-adrenergic signaling may be involved not only in blood pressure elevation but also in cell proliferation, angiogenesis, and tissue invasion. Therefore, the inhibition of these pathways may have beneficial effects on cancer prevention or treatment. In this article, we reviewed several studies regarding antihypertensive drugs and cancer. In particular, we focused on the results of clinical trials to evaluate whether the use of antihypertensive drugs affects future cancer risk and prognosis. Unfortunately, the results are somewhat inconsistent, and evidence demonstrating the effect of antihypertensive drugs remains limited. We indicate that the heterogeneity in the study designs makes it difficult to clarify the causal relationship between antihypertensive drugs and cancer. We also propose that additional experimental studies, including research with induced pluripotent cells derived from cancer patients, single-cell analyses of cancer cell clusters, and clinical studies using artificial intelligence electronic health record systems, might be helpful to reveal the precise association between antihypertensive drugs and cancer risk.

The Impact of the Association between Cancer and Diabetes Mellitus on Mortality

The prevalence of cancer, diabetes mellitus (DM), and hypertension is increasing in ageing populations. We analyzed the association of DM with cancer and its effects on cancer mortality. The data of 2009–2018 from the Korea National Hospital Discharge In-depth Injury Survey were used; 169,959 adults with cancer as the main diagnosis were identified. The association rule for unsupervised machine learning was used. Association rule mining was used to analyze the association between the diseases. Logistic regression was performed to determine the effects of DM on cancer mortality. DM prevalence was 12.9%. Cancers with high DM prevalence were pancreatic (29.9%), bile duct (22.7%), liver (21.4%), gallbladder (15.5%), and lung cancers (15.4%). Cancers with high hypertension prevalence were bile duct (31.4%), ureter (30.5%), kidney (29.5%), pancreatic (28.1%), and bladder cancers (27.5%). The bidirectional association between DM and hypertension in cancer was the strongest (lift = 2.629, interest support [IS] scale = 0.426), followed by that between lung cancer and hypertension (lift = 1.280, IS scale = 0.204), liver cancer and DM (lift = 1.658, IS scale = 0.204), hypertension and liver cancer and DM (lift = 3.363, IS scale = 0.197), colorectal cancer and hypertension (lift = 1.133, IS scale = 0.180), and gastric cancer and hypertension (lift = 1.072, IS scale = 0.175). DM increased liver cancer mortality (p = 0.000), while hypertension significantly increased the mortality rate of stomach, colorectal, liver, and lung cancers. Our study confirmed the association between cancer and DM. Consequently, a patient management strategy with presumptive diagnostic ability for DM and hypertension is required to decrease cancer mortality rates.

Cancer Risk of Angiotensin II Receptor Blocker Valsartan: A Population-based Study

ABSTRACT

Nitrosamine contamination of generic valsartan was found in 2018. This study aimed to investigate whether long-term use of valsartan increases cancer risk. Patients prescribed valsartan or amlodipine (control group) from 1 January 1, 2003, to June 30, 2010, were identified using the Clinical Data Analysis and Reporting System of the Hong Kong Hospital Authority, a territory-wide database in Hong Kong. Patients previously diagnosed with cancer, prescribed both medications, taking the medication, or followed up for <1 year were excluded. Cancer incidence, adjusted for age, sex, and Charlson Comorbidity Index, was the primary outcome and was estimated using Poisson regression in R version 3.6.1. Among 5023 valsartan users and 3692 amlodipine users, 887 and 740 were diagnosed with cancers during median follow-up periods of 10.97 and 12.12 years, respectively. The adjusted incidence of cancer in valsartan and amlodipine users was 165.29 (95% confidence interval 154.76-175.53) and 180.12 (167.35-193.67) per 10,000 person-years, respectively. The cancer incidence rate ratio of valsartan relative to amlodipine was 0.94 (0.88-1.01). Adjusted incidence rate ratios of valsartan relative to amlodipine were significant for breast cancer (0.63, 0.46-0.86) only. Our findings do not suggest an increase in incidence of cancer with long-term valsartan use. The duration of follow-up of more than 10 years of the study provides the reassurance that an increase in cancer risk is unlikely. Further studies are needed to elucidate the long-term effect of valsartan use on the risk of specific types of cancer.

Frequency and association of self-reported oral cancer among individuals with type 2 diabetes at a tertiary care diabetes centre in South India - A retrospective study

AIM

To assess the frequency of self-reported oral cancer and associated factors among individuals with type 2 diabetes (T2D) at a tertiary care diabetes centre in South India.

METHODS

Individuals with T2D who reported that they had oral cancer were included from the Diabetes Electronic Medical Records (DEMR) database. To assess the association of oral cancer with T2D, a retrospective nested case-control study design was adopted. Individuals with T2D and oral cancer diagnosed after the diagnosis of T2D (n = 78) were considered 'cases', while T2D without oral cancer were considered 'controls' (312) [in a ratio of 1:4 for cases and controls]. The cases and controls were matched for age, gender and duration of diabetes. Logistic regression was used to model predictors of oral cancer in T2D patients.

RESULTS

Oral cancer was reported in 78 out of 379,138 (0.02%) individuals with T2D registered at the centre. Logistic regression analysis showed that a HbA1c value ≥ 9% had a significant association with oral cancer with an odds ratio of 2.3 (95% CI: 1.2-4.6) after adjusting for confounding factors. Among individuals with T2D, higher frequency of oral cancer prevalence and risk was observed among those who used any form of tobacco (32.6%, OR = 2.52, 95% CI: 1.5-4.3), consumed alcohol (29.2%, OR = 2.01, 95% CI: 1.2-3.3), and those with hypertension (23.9%, OR = 2.05, 95% CI: 1.2-3.6) and hypertriglyceridemia (24.7%, OR = 1.66, 95% CI: 1.01-2.7). Significant independent predictors of oral cancer among T2D were tobacco use (OR = 2.06, 95% CI: 1.1-4.00), high HbA1c (OR = 1.3, 95% CI: 1.03-1.5), hypertension (OR = 2.3, 95% CI: 1.3-4.2) and insulin use (OR = 1.8, 95% CI: 1.03-3.2).

CONCLUSIONS

Regular dental check-ups as part of the follow-up for individuals with T2D will identify and diagnose oral cancer earlier. Further research is required to assess the physiological and biological mechanisms leading to oral cancer in individuals with T2D.

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.

Association between Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers and Lung Cancer

OBJECTIVES

Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) are the most commonly prescribed antihypertensives, with prior studies identifying a possible association between long-term use and increased rates of lung cancer. This study evaluated this potential association in a large population using propensity matching.

METHODS

This was a population-based cohort study in a large healthcare system in three regions of the United States. Pairwise propensity score matching was performed using demographics and comorbidities. All of the adult patients in the healthcare system from January 1, 2000 to April 30, 2018 with at least 1 year of follow-up were included.

RESULTS

In total, 3,253,811 patients with a median age of 59 (range 18-103) years were included. The ACEI group had a higher freedom from lung cancer versus controls at 15 years (98.47%, 95% confidence interval [CI] 98.41-98.54) versus 98.26%, (95% CI 98.20-98.33), whereas ARBs had similar rates versus controls at all time points. For patients diagnosed as having lung cancer, median all-cause survival was significantly higher in the ACEI (34.7 months, 95% CI 32.8-36.6) and ARB (30.9 months, 95% CI 28.1-33.8) groups than the control group (20.6 months, 95% CI 20.1-21.1).

CONCLUSIONS

This study showed lower rates of lung cancer with ACEI use and no difference in risk with ARBs. In addition, use of these medications was found to be associated with increased survival in those diagnosed as having lung cancer. This study supports the continued use of these medications without concern for increasing the risk of lung cancer.

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.

Long-term antihypertensive drug use and risk of cancer: The Japan Public Health Center-based prospective study

Antihypertensive drugs have been reported as both promotors and suppressors of cancers and this relationship has been known for several decades. We examined a large‐scale prospective cohort study in Japan to assess the relationship between long‐term antihypertensive drug use, for 10 y, and carcinogenesis. We divided participants into 4 categories according to the period of antihypertensive drug use, and calculated the hazard ratios (HRs), 95% confidence intervals (CIs), and P trends using the Cox proportional hazard model. In all cancers, there was a significant difference in the medication period and the adjusted HR, as well as a significant difference in the P trend. Furthermore, more than 10 y use of antihypertensive drugs significantly increased the adjusted HR in colorectal cancer (multivariable HR: 1.18, 95% CI: 1.01‐1.37 in the >10 y use group; P for trend = .033) and renal cancer (multivariable HR: 3.76, 95% CI: 2.32‐6.10 in the 5‐10 y use group; multivariable HR: 2.14, 95% CI: 1.29‐3.56 in the >10 y use group; P for trend < .001). The highest adjusted HR in renal cancer among antihypertensive drug users was observed in the analysis performed on patients in which the outcomes were calculated from 3 y after the 10‐y follow‐up survey and by sex. A large‐scale cohort study in Japan suggested that long‐term use of antihypertensive drugs may be associated with an increased incidence of colorectal and renal cancer.

Anesthetic Management for Squamous Cell Carcinoma of the Esophagus

While surgery plays a major role in the treatment and potential cure of esophageal cancers, esophagectomy remains a high-risk operation with significant perioperative morbidity and mortality compared to other oncosurgical procedures. Perioperative management for esophagectomy is complex, and close attention to detail in various areas of anesthetic and perioperative management is crucial to improve postoperative outcomes. Patients undergoing esophagectomy should be offered an evidence-based risk assessment for their postoperative outcomes to allow active participation and informed, shared-decision making. Novel perioperative risk scores have been developed to predict both short-term and long-term outcomes in patients with esophageal cancer, although independent validation of such scoring systems is still required. Apart from accurate preoperative risk assessment, further efforts to improve morbidity and mortality from esophagectomy is achieved through comprehensive Enhanced Recovery after Surgery (ERAS) protocols, which comprise an individualized bundle of care throughout the perioperative journey for each patient and should be implemented as a standard practice. Furthermore, anesthetic practice and perioperative anesthetic drug usage can potentially affect cancer progression and recurrence. This chapter reviews current evidence for various factors that contribute to the improvement of perioperative outcomes, including prehabilitation, preoperative optimization of anemia, thoracic epidural analgesia, intraoperative protective ventilatory strategies, goal-directed fluid therapy, as well as special attention to other perioperative issues that potentially reduce anastomotic and cardiopulmonary complications. In summary, it is difficult to show a measurable benefit from any one single intervention, and a multidisciplinary approach that encompasses multiple aspects of perioperative care is necessary to improve outcomes after esophagectomy.

The Relationship Between Anti-Hypertensive Drugs and Cancer: Anxiety to be Resolved in Urgent

Hypertension is the prevailing independent risk factor for cardiovascular disease worldwide. Anti-hypertensive drugs are the common and effective cure for lowering blood pressure in patients with hypertension. However, some large-scale clinical studies have pointed out that long-term ingestion of some oral anti-hypertensive drugs was associated with risks of incident cancer and the survival time. In contrast, other studies argue that anti-hypertensive drugs are not related to the occurrence of cancer, even as a complementary therapy of tumor treatment. To resolve the dispute, numerous recent mechanistic studies using animal models have tried to find the causal link between cancer and different anti-hypertensive drugs. However, the results were often contradictory. Such uncertainties have taken a toll on hypertensive patients. In this review, we will summarize advances of longitudinal studies in the association between anti-hypertensive drugs and related tumor risks that have helped to move the field forward from associative to causative conclusions, in hope of providing a reference for more rigorous and evidence-based clinical research on the topic to guide the clinical decision making.

Calcium channel blockers are associated with lower gastric cancer risk: A territory-wide study with propensity score analysis

Prior studies showed that calcium channel blockers (CCBs) could modify cancer risk, but data on gastric cancer (GC) are limited. We aimed to investigate whether CCBs could modify GC risk in Helicobacter pylori-eradicated patients. H pylori-infected patients with hypertension who are aged ≥50 and had received clarithromycin-based triple therapy between 2003 and 2016 were identified from a territory-wide healthcare database. Patients with eradication failure, GC diagnosed within 6 months after HP eradication, and gastric ulcer were excluded. Time-fixed Cox model with one-to-one propensity score matching was used to calculate hazard ratio (HR) of GC with CCBs. Sensitivity analysis using time-dependent multivariable Cox model in which CCB use was treated as time-varying covariate was also performed to address immortal time bias. 17 622 (29.6%) H pylori-eradicated patients with hypertension were included. During a median follow-up of 8.6 years, 105 (0.6%) developed GC. After PS matching, CCBs were associated with a lower GC risk (HR: 0.56; 95% CI: 0.32-0.97). Time-dependent analysis showed consistent result (aHR: 0.50; 95% CI: 0.33-0.75). A longer duration of CCB use was associated with even lower GC risk (adjusted HR [aHR]: 0.69; 95% CI: 0.61-0.79 for every 1-year increase in use). Long-acting CCBs (aHR: 0.47; 95% CI: 0.29-0.76) and dihydropyridines (aHR: 0.49; 95% CI: 0.32-0.73) conferred greater benefit than short-acting ones (aHR: 0.60; 95% CI: 0.36-1.03) and nondihydropyridines (aHR: 0.76; 95% CI: 0.24-2.48). The aHR was 0.57 (95% CI: 0.34-0.97) for noncardia and 0.59 (95% CI: 0.27-1.31) for cardia cancer. Use of CCBs was associated with lower risk of GC development in H pylori-eradicated patients, in a duration- and dose-response manner.

Hypertension is associated with oral, laryngeal, and esophageal cancer: a nationwide population-based study

Several studies have reported an association between hypertension and upper aerodigestive tract cancer, but no large-scale, population-based studies have been conducted to confirm this.The aim of this study was to explore the association between hypertension and risk of upper aerodigestive tract cancer in Koreans. Participants who underwent a national health screening examination from January 1 to December 31, 2009 (n = 9,746,606) were enrolled. We assessed the development of oral, laryngeal, or esophageal cancer until 2016 using records from the Korean Health Insurance claims database during the study period. During the seven-year follow-up period, 6,062, 2,658, and 4,752 subjects were newly diagnosed with oral, laryngeal, and esophageal cancer, respectively. Participants with metabolic syndrome had the highest risk of developing oral cancer (hazard ratio (HR) 1.09, 95% confidence interval (CI) 1.03-1.16), laryngeal cancer (HR 1.27, 95% CI 1.17-1.38), and esophageal cancer (HR 1.11, 95% CI 1.04-1.19). Hypertension was a remarkable risk factor for each cancer (HR 1.11, 95% CI 1.04-1.17 for oral cancer; HR 1.23, 95% CI 1.13-1.33 for laryngeal cancer; HR 1.25, 95% CI 1.18-1.33 for esophageal cancer) after adjusting for age and other variables including gender, smoking status, alcohol intake, exercise, body mass index, and diabetes. Patients with untreated hypertension were at highest risk of developing oral cancer (HR 1.15; 95% CI 1.05-1.26), laryngeal cancer (HR 1.25; 95% CI 1.09-1.44), and esophageal cancer (HR 1.47; 95% CI 1.33-1.63) after adjusting for confounders. Hypertension was associated with the risk of oral, laryngeal, and esophageal cancer, despite of the lack of detailed biochemical information including the cancer cell types (squamous cell carcinoma or adenocarcinoma), cancer stage, physical findings and other medical history. Further studies are warranted to determine the reasons for this association and to establish effective interventions in this vulnerable population.

Angiotensin Receptor Blockers and the Risk of Cancer: Insights from Clinical Trials and Recent Drug Recalls

PURPOSE OF REVIEW

The purpose of this review is to familiarize readers with issues surrounding angiotensin receptor blockers (ARBs) and the risk of cancer, both from the perspective of clinical trial data and the more recent concerns about impurities in certain ARB products.

RECENT FINDINGS

Approximately 45.6% of adults in the USA have hypertension. ARB-containing medications are widely used in the USA, with tens of millions of prescriptions written yearly. Whether exposure to certain ARB drug products contributes to the development of cancer has been the topic of a series of publications. Nonetheless, ARBs' link to cancer, if any, remains inconclusive. Any mechanistic link between ARBs and cancer is poorly understood, with a variety of basic science studies suggesting that ARBs should exert a protective effect. Due to the presence of potentially carcinogenic nitrosamine impurities in certain ARB products, a series of large recalls in the USA and in countries around the world has occurred since 2018. These recalls have occurred in the context of two recent trends affecting antihypertensive drugs: nearly ubiquitous reliance on generic drugs and increased use of manufacturing facilities in China and India to supply the USA. Despite substantial efforts directed toward understanding whether ARBs have the potential to cause cancer, the available studies do not provide a consistent answer, and a causal link remains speculative. The principal conclusion must be that there is not a definitive signal for cancer associated with ARB exposure, although the possibility has not been fully excluded. The problem of nitrosamine impurities in certain ARB products (and some other drug products) is in need of further investigation, so that the risks can be mitigated by eliminating these impurities from the drug supply chain.

Borrowing of strength from indirect evidence in 40 network meta-analyses

OBJECTIVES

Network meta-analysis (NMA) is increasingly being used to synthesize direct and indirect evidence and help decision makers simultaneously compare multiple treatments. We empirically evaluate the incremental gain in precision achieved by incorporating indirect evidence in NMAs.

STUDY DESIGN AND SETTING

We performed both network and pairwise meta-analyses on 40 published data sets of multiple-treatment comparisons. Their results were compared using the recently proposed borrowing of strength (BoS) statistic, which quantifies the percentage reduction in the uncertainty of the effect estimate when adding indirect evidence to an NMA.

RESULTS

We analyzed 915 possible treatment comparisons, from which 484 (53%) had no direct evidence (BoS = 100%). In 181 comparisons with only one study contributing direct evidence, NMAs resulted in reduced precision (BoS < 0) and no appreciable improvements in precision (0 < BoS < 30%) for 104 (57.5%) and 23 (12.7%) comparisons, respectively. In 250 comparisons with at least two studies contributing direct evidence, NMAs provided increased precision with BoS ≥ 30% for 166 (66.4%) comparisons.

CONCLUSION

Although NMAs have the potential to provide more precise results than those only based on direct evidence, the incremental gain may reliably occur only when at least two head-to-head studies are available and treatments are well connected. Researchers should routinely report and compare the results from both network and pairwise meta-analyses.

The Risk for Lung Cancer Incidence with Calcium Channel Blockers: A Systematic Review and Meta-Analysis of Observational Studies

INTRODUCTION

There are conflicting findings regarding the association between the use of calcium channel blockers (CCBs) and the risk of lung cancer. Considering the public health importance of lung cancer prevention, and emerging evidence of a significant biologic role of calcium channel regulation in the development of lung cancer, we conducted a meta-analysis to assess the risk of lung cancer in CCB users compared with non-CCB users.

MATERIALS AND METHODS

We conducted a comprehensive systematic search of leading medical databases for observational studies published up to December 2017 that examined CCB use and the risk of lung cancer. We used random-effects models to pool results. The impact of duration of CCB use on the estimated effect size was explored using random effects meta-regression.

RESULTS

Ten studies (six cohort and four case-control studies) that evaluated the overall cancer risk among 38,758 CCB users were included in the analysis. Overall risk ratio (RR) for CCB use and lung cancer was 1.15 (95% confidence interval [CI] 1.01-1.32). Subgroup analysis by duration of CCB use suggested that the observed increase in lung cancer risk was driven by the results of five studies with prolonged (≥ 4 years) exposure (RR 1.18; 95% CI 1.08-1.30).

CONCLUSIONS

Our analysis suggests exposure to CCBs is associated with an increased risk of lung cancer. Considering their widespread use, and the paucity of data on the long-term effects of chronic exposure to CCBs, these results are reason for concern and warrant further investigation.

SYSTEMATIC REVIEW REGISTRATION

The protocol for this study was registered at the PROSPERO registry of systematic reviews (registry number: CRD42017056362).

Association between perioperative beta blocker use and cancer survival following surgical resection

BACKGROUND

Recent studies have demonstrated an association between beta-blocker exposure and improved survival in multiple cancer types. We sought to investigate the effects of beta-blockers at the time of index surgery for breast, lung, and colorectal cancer.

MATERIALS AND METHODS

Using linked data from a provincial cancer registry, we conducted a retrospective matched cohort study comparing disease-specific and overall survival between patients over age 64 exposed and not exposed to beta-blockers before and after index surgical resection for breast, lung and colorectal cancer between April 1st, 2002 and December 31st, 2010. A high-dimensional propensity score was used to match patients and Cox proportional hazard models were used to estimate relative risks of the outcomes.

RESULTS

30,020 patients were included in the final matched cohorts. Mean follow up time for breast, lung, and colorectal cancer was 57.6 ± 30.5, 43.1 ± 28.7, and 53.4 ± 31.0 months, respectively. The adjusted hazard ratio for disease-specific mortality for patients exposed to beta-blockers was 1.03 (0.83-1.29) for breast, 1.05 (0.92-1.20) for lung, and 1.10 (0.96-1.25) for the colorectal cancer cohort.

CONCLUSIONS

In this large population-based study, no association between perioperative beta-blocker exposure and improved cancer-specific survival for breast, lung, or colorectal cancer was demonstrated.

Nifedipine stimulates proliferation and migration of different breast cancer cells by distinct pathways

Nifedipine is widely used to treat high blood pressure and angina. Were nifedipine able to promote the proliferation and migration of breast cancer, it would pose a significant threat for patients. Thus, it is important to determine the effects of nifedipine on breast cancer and the mechanism involved. The present study identified that nifedipine significantly promoted the proliferation and migration of breast cancer cells in vitro. The mechanism of nifedipine on different breast cancer cells was investigated and it was identified that the effects of nifedipine on MCF‑7 cells were via the protein kinase B‑endothelial constitutive nitric oxide synthase‑nitric oxide axis, and on MDA‑MB‑231 cells via activation of the extracellular signal‑regulated kinase pathway. These results identified the distinct pathways in the activation of cell proliferation and migration presented in different cell lines by nifedipine. The present study advises that nifedipine can promote breast cancer and should be avoided for women who suffer from breast cancer and hypertension.

The use of drugs acting on the renin-angiotensin system and the incidence of pancreatic cancer

Background:

Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) are commonly used antihypertensives. Recently, these drugs have been associated with a protective effect against pancreatic cancer, but data on this putative association remain limited. Thus, the objective of this study was to determine whether the use of ACEIs and/or ARBs is associated with a decreased risk of pancreatic cancer.

Methods:

We conducted a population-based cohort study, using a nested case–control analysis within the UK Clinical Practice Research Datalink population. The cohort consisted of all patients newly treated with antihypertensive drugs between 1 January 1995 and 31 December 2009, with follow-up until 31 December 2010. Cases were patients with newly diagnosed pancreatic cancer, which were matched with up to 10 controls on age, sex, calendar year of cohort entry, and duration of follow-up. Conditional logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) of pancreatic cancer incidence associated with ever use of ACEIs and ARBs. A secondary analysis was conducted to assess whether the incidence of pancreatic cancer varied with cumulative duration of use of these drugs.

Results:

A cohort of 547 566 was assembled. During 3 040 332 person-years of follow-up, a total of 866 patients were newly diagnosed with pancreatic cancer (rate: 3/10 000 per year) and matched to 8636 controls. Overall, when compared with other antihypertensive drugs, the use of ACEIs was not associated with a decreased risk of pancreatic cancer overall (OR: 1.01, 95% CI: 0.86–1.17) or according to cumulative duration of use. The use of ARBs was not associated with a decreased risk of pancreatic cancer overall (OR: 0.93, 95% CI: 0.75–1.15), whereas a cumulative duration of use of 1–3 years was associated with a 38% decrease (OR: 0.62, 95% CI: 0.41–0.94), which returned to the null after >3 years of use (OR: 1.04, 95% CI: 0.74–1.46).

Conclusions:

The use of ARBs and ACEIs was not associated with an overall decreased risk of pancreatic cancer when compared with patients using other antihypertensive drugs. Additional research is needed to determine whether ARBs may confer a short-term protective effect.

Impact of Angiotensin I-converting Enzyme Inhibitors and Angiotensin II Type-1 Receptor Blockers on Survival of Patients with NSCLC

It has been shown that angiotensin I-converting enzyme inhibitors (ACEIs) and angiotensin II type-1 receptor blockers (ARBs) can decrease tumor growth and tumor-associated angiogenesis and inhibit metastasis. Epidermal growth factor receptor (EGFR) mutations are found in approximately 30% of patients with advanced non-small cell lung cancer (NSCLC) in East Asia and in 10–15% of such patients in Western countries. We retrospectively identified 228 patients with histologically confirmed advanced NSCLC and 73 patients with early stage disease; 103 of these patients took antihypertensive drugs, and 112 received treatment with EGFR tyrosine kinase inhibitors (TKIs). There was a significant difference in progression-free survival after first-line therapy (PFS₁) between the ACEI/ARB group and the non-ACEI/ARB group. For the patients treated with TKIs, there was a significant difference in PFS but not in overall survival (OS) between the ACEI/ARB group and the non-ACEI/ARB group. For the patients with advanced NSCLC, there was a significant difference in PFS₁ between the ACEI/ARB group and the non-ACEI/ARB group. ACEI/ARB in combination with standard chemotherapy or TKIs had a positive effect on PFS₁ or OS, regardless of whether the lung cancer was in the early or advanced stage.

Association between colorectal polyps and hypertension treatment

OBJECTIVE

Patients who take drugs regularly are increasing, not least due to metabolic and orthopedic diseases. In the present study we aimed to investigate the association between the use of drugs, such as non-steroidal anti-inflammatory drugs (NSAIDs) and low-dose aspirin, and colorectal polyps diagnosed based on colonoscopic findings.

METHODS

In total, 1318 consecutive patients who underwent total colonoscopy for the first time were cross-sectionally analyzed. Personal data including comorbidities and all medications were obtained by a questionnaire. Their blood pressure, body weight and waist circumference were measured just before the colonoscopic examination.

RESULTS

Colorectal polyps were found in 577 (43.8%) patients, with a prevalence of 57.6% (296/514) in patients receiving antihypertensive treatment and 35.0% (281/804) in patients not undergoing such treatment. A multivariate analysis showed that age, waist circumference, alcohol consumption, smoking and the use of antihypertensive drugs were independent risk factors for colorectal polyps. In a secondary multivariate analysis incorporating the parameters of measured blood pressure and medication status, the number of antihypertensive drugs was strongly associated with the risk of colorectal polyps, whereas blood pressure showed no significant association.

CONCLUSIONS

The use of antihypertensive drug may be a risk factor for colorectal polyps. Furthermore, this risk increases with the intensive use of antihypertensive drugs.

Propranolol Reduces Cancer Risk: A Population-Based Cohort Study

β-Blockers have been reported to exhibit potential anticancer effects in cancer cell lines and animal models. However, clinical studies have yielded inconsistent results regarding cancer outcomes and cancer risk when β-blockers were used. This study investigated the association between propranolol and cancer risk.Between January 1, 2000 and December 31, 2011, a patient cohort was extracted from the Longitudinal Health Insurance Database 2000, a subset of the Taiwan National Health Insurance Research Database. A propranolol cohort (propranolol usage >6 months) and nonpropranolol cohort were matched using a propensity score. Cox proportional hazard models were used to estimate the hazard ratio (HR) and 95% confidence intervals (CIs) of cancer associated with propranolol treatment.The study sample comprised 24,238 patients. After a 12-year follow-up period, the cumulative incidence for developing cancer was low in the propranolol cohort (HR: 0.75; 95% CI: 0.67-0.85; P < 0.001). Patients with propranolol treatment exhibited significantly lower risks of cancers in head and neck (HR: 0.58; 95% CI: 0.35-0.95), esophagus (HR: 0.35; 95% CI: 0.13-0.96), stomach (HR: 0.54; 95% CI: 0.30-0.98), colon (HR: 0.68; 95% CI: 0.49-0.93), and prostate cancers (HR: 0.52; 95% CI: 0.33-0.83). The protective effect of propranolol for head and neck, stomach, colon, and prostate cancers was most substantial when exposure duration exceeded 1000 days.This study supports the proposition that propranolol can reduce the risk of head and neck, esophagus, stomach, colon, and prostate cancers. Further prospective study is necessary to confirm these findings.

Infantile hemangiomas, retinopathy of prematurity and cancer: a common pathogenetic role of the β-adrenergic system

The serendipitous demonstration that the nonselective β-adrenergic receptor (β-AR) antagonist propranolol promotes the regression of infantile hemangiomas (IHs) aroused interest around the involvement of the β-adrenergic system in angiogenic processes. The efficacy of propranolol was related to the β2-AR blockade and the consequent inhibition of the production of vascular endothelial growth factor (VEGF), suggesting the hypothesis that propranolol could also be effective in treating retinopathy of prematurity (ROP), a retinal pathology characterized by VEGF-induced neoangiogenesis. Consequent to the encouraging animal studies, a pilot clinical trial showed that oral propranolol protects newborns from ROP progression, even though this treatment is not sufficiently safe. Further, animal studies clarified the role of β3-ARs in the development of ROP and, together with several preclinical studies demonstrating the key role of the β-adrenergic system in tumor progression, vascularization, and metastasis, prompted us to also investigate the participation of β3-ARs in tumor growth. The aim of this review is to gather the recent findings on the role of the β-adrenergic system in IHs, ROP, and cancer, highlighting the fact that these different pathologies, triggered by different pathogenic noxae, share common pathogenic mechanisms characterized by the presence of hypoxia-induced angiogenesis, which may be contrasted by targeting the β-adrenergic system. The mechanisms characterizing the pathogenesis of IHs, ROP, and cancer may also be active during the fetal-neonatal development, and a great contribution to the knowledge on the role of β-ARs in diseases characterized by chronic hypoxia may come from research focusing on the fetal and neonatal period.

A review of clinical studies on angiotensin II receptor blockers and risk of cancer

Angiotensin II receptor blockers (ARBs) are one of the most frequently used antihypertensive drugs with good tolerability and are indicated for treatment of many cardiovascular morbidity. Findings from clinical studies conducted in the past decade, suggest a possible relationship between some ARB-active substances, and certain malignancies cannot be excluded. Despite a lack of agreement, clinical results do not rule out the possibility that type 2 angiotensin II receptor stimulation during ARB therapy may also have unfavorable consequences, such as the development of certain malignancies. However, according to the current official position of FDA, the cardiovascular benefits of ARB therapy far outweigh the risks. Based on the limited information available, this review aims to provide medical practitioners with a clearer view on the balance of the benefits and risks of ARBs.

The incidence of cancer deaths among hypertensive patients in a large Chinese population: a cohort study

Current evidence is mixed regarding the association between antihypertensive prescriptions and cancer mortality. We evaluated this association in a large Chinese hypertensive population. We followed for five years all patients who were prescribed their first-ever antihypertensive agents between 2001 and 2005 in a public healthcare sector of Hong Kong. The association between antihypertensive drug class and cancer mortality was evaluated by Cox proportional hazard models with propensity score matching. Age, gender, socioeconomic status, service settings, district of residence, proportion of days covered reflecting medication adherence, and the number of comorbidities were adjusted. From 217,910 eligible patients, 9500 (4.4%) died from cancer within five years after their first-ever antihypertensive prescription. Most cancer deaths occurred in the digestive (38.9%) and respiratory system (30.4%); the breast (6.2%); and the lympho-hematopoietic tissues (5.3%). The proportion of patients who died from cancer was the highest in the calcium channel blocker (CCB) group (6.5%), followed by thiazide diuretics (4.4%), angiotensin converting enzyme inhibitors (4.2%) and β-blockers (2.6%). When compared with β-blockers, patients prescribed CCBs (Adjusted Hazard Ratio [AHR]=1.406, 95% C.I. 1.334-1.482, p<0.001) were more likely to die from cancer. Thiazide users were also more likely to suffer from cancer deaths (AHR=1.364, 95% C.I. 1.255-1.483, p<0.001), but became insignificant in stratified analysis. The association between cancer mortality and use of CCB, and perhaps thaizide, may alert physicians to the need for more meticulous and comprehensive care of these patients in clinical practice. We recommend prospective studies to evaluate cause-and-effect relationships of these associations.

Drug development: how academia, industry and authorities interact

Unfortunately, abundant examples could be given of pitfalls in the current drug development paradigm-including in the design, conduct and evaluation of phase III clinical trials. This article discusses issues of particular relevance to clinical trials in nephrology, including the inappropriate use of placebo, publication of reports that emphasize potential treatment benefits over adverse reactions, the sometimes dubious impartiality of independent guidelines, and inadequate recruitment of elderly patients. This Perspectives article aims to highlight and summarize the flaws in the current drug development process, while suggesting a way forward that equally satisfies the requirements of academia, patients and the pharmaceutical industry. We suggest improvements to the drug development process and related legislation that intend to balance public needs with commercial aims and ensure effective drug evaluation by regulatory authorities.

Potential increased risk of cancer from commonly used medications: an umbrella review of meta-analyses

Several commonly used medications have been associated with increased cancer risk in the literature. Here, we evaluated the strength and consistency of these claims in published meta-analyses. We carried out an umbrella review of 74 meta-analysis articles addressing the association of commonly used medications (antidiabetics, antihyperlipidemics, antihypertensives, antirheumatics, drugs for osteoporosis, and others) with cancer risk where at least one meta-analysis in the medication class included some data from randomized trials. Overall, 51 articles found no statistically significant differences, 13 found some decreased cancer risk, and 11 found some increased risk (one reported both increased and decreased risks). The 11 meta-analyses that found some increased risks reported 16 increased risk estimates, of which 5 pertained to overall cancer and 11 to site-specific cancer. Six of the 16 estimates were derived from randomized trials and 10 from observational data. Estimates of increased risk were strongly inversely correlated with the amount of evidence (number of cancer cases) (Spearman's correlation coefficient = -0.77, P < 0.001). In 4 of the 16 topics, another meta-analysis existed that was larger (n = 2) or included better controlled data (n = 2) and in all 4 cases there was no statistically significantly increased risk of malignancy. No medication or class had substantial and consistent evidence for increased risk of malignancy. However, for most medications we cannot exclude small risks or risks in population subsets. Such risks are unlikely to be possible to document robustly unless very large, collaborative studies with standardized analyses and no selective reporting are carried out.

Rediscovering ACE: novel insights into the many roles of the angiotensin-converting enzyme

Angiotensin-converting enzyme (ACE) is best known for the catalytic conversion of angiotensin I to angiotensin II. However, the use of gene-targeting techniques has led to mouse models highlighting many other biochemical properties and actions of this enzyme. This review discusses recent studies examining the functional significance of ACE tissue-specific expression and the presence in ACE of two independent catalytic sites with distinct substrates and biological effects. It is these features which explain why ACE makes important contributions to many different physiological processes including renal development, blood pressure control, inflammation, and immunity.

Renin-angiotensin system blocking drugs

The two major classes of drugs that target the RAS are the angiotensin-converting enzyme (ACE) inhibitors and the selective AT1 receptor blockers (ARBs). Although both of these drug classes target angiotensin II, the differences in their mechanisms of action have implications for their effects on other pathways and receptors that may have therapeutic implications. Both ACEIs and ARBs are effective antihypertensive agents that have been shown to reduce the risk of cardiovascular and renal events. Direct inhibition of renin -the most proximal aspect of the RAS -became clinically feasible from 2007 with the introduction of aliskiren. This latter drug has been shown to be efficacious for the management of hypertension. Combined therapy of direct renin-inhibitors with ACEIs or ARBs has been tested in some clinical situations as congestive HF and proteinuria with diverse results. This article tries to offer an updated review of current knowledge on the use of RAS blocking drugs in clinical settings.

Further data on beta-blockers and cancer risk: observational study and meta-analysis of randomized clinical trials

BACKGROUND

The aim of the present paper is to provide some further data on the relationship between β-blocker treatment and the incidence of cancer, using two different approaches (epidemiological study and meta-analysis of clinical trials).

METHODS

In a consecutive series of 1340 diabetic patients starting insulin therapy, 112 cases of cancer during a mean follow-up of 75.9 months were identified as first hospital admission or death. For each case, the controls were chosen randomly from those members of the cohort matched for age, sex and BMI. The main predefined analysis was the comparison of cases and controls for length of exposure to β-blockers and proportion of patients exposed using a conditional logistic regression which takes into account the matching structure. For the meta-analytic sub-study, an extensive search of Medline and the Cochrane Library (any date up to December 31st, 2011) was performed for all trials in which a β-blocker was used. Mantel-Haenszel Odds Ratios (MH-OR) with 95% confidence intervals for incident malignancies were calculated using a random effect model.

RESULTS

After adjusting for mean daily dose of glargine and metformin, and ischemic heart disease, exposure to β-blockers was associated with a reduced overall risk of cancer (HR 0.33 [0.13; 0.83], p = 0.019; HR for each month of exposure 0.87 [0.77; 0.98], p = 0.025). In the meta-analysis sub-study, performed on nine trials, β-blockers were associated with a non-significant trend toward lower risk of cancer (MH-OR 0.93 [0.86; 1.01], p = 0.070).

STUDY LIMITATION

Limitations of the observational study are the small sample size that limits the statistical power of analyses, that it was performed on diabetic patients only, and that diagnoses of malignancies were derived from administrative data.

CONCLUSIONS

In conclusion, this research seem to confirm a possible beneficial effect of β-blockers against the risk of cancer development.

Methods used to conduct and report Bayesian mixed treatment comparisons published in the medical literature: a systematic review

OBJECTIVES

To identify published closed-loop Bayesian mixed treatment comparisons (MTCs) and to summarise characteristics regarding their conduct and reporting.

DESIGN

Systematic review.

METHODS

We searched multiple bibliographic databases (January 2006-31 July 2011) for full-text, English language publications of Bayesian MTCs comparing the effectiveness or safety of ≥3 interventions based on randomised controlled trials and having at least one closed loop. Methodological and reporting characteristics of MTCs were extracted in duplicate and summarised descriptively.

RESULTS

We identified 34 Bayesian MTCs spanning 13 clinical areas. Publication of MTCs increased over the 5-year period; with 76.5% published during or after 2009. MTCs included a mean (±SD) of 35.9±30.1 trials (n=33 459±71 233 participants) and 8.5±4.3 interventions (85.7% pharmacological). Non-informative and informative prior distributions were reported to be used in 44.1% and 8.8% of MTCs, respectively, with the remainder failing to specify the prior used. A random-effects model was used to analyse the networks of trials in 58.5% of MTCs, all using WinBUGS; however, code was infrequently provided (20.6%). More than two-thirds of MTCs (76.5%) also conducted traditional meta-analysis. Methods used to evaluate convergence, heterogeneity and inconsistency were infrequently reported, but from those providing detail, methods appeared varied. MTCs most often used a binary effect measure (85.3%) and ranking of interventions based on probability was common (61.8%), although rarely displayed in a figure (8.8% of MTCs). MTCs were published in 24 different journals with a mean impact factor of 9.20±8.71. While 70.8% of journals imposed limits on word counts and 45.8% limits on the number of tables/figures, online supplements/appendices were allowed in 79.2% of journals. Publication of closed-loop Bayesian MTCs is increasing in frequency, but details regarding their methodology are often poorly described. Efforts in clarifying the appropriate methods and reporting of Bayesian MTCs should be of priority.

Angiotensin receptor blockers and tumorigenesis: something to be (or not to be) concerned about?

The possibility of carcinogenic side effects of antihypertensive therapies due to their chronic administration has been raised multiple times in the past. Recently, the issue has again drawn attention, this time in relation to angiotensin receptor blockers (ARBs). This, among others, caused both American and European drug regulation authorities to review the underlying evidence concerning the relationship between this class of medications and potential adverse carcinogenic outcome. A plethora of both basic science and preclinical evidence has been generated, and three meta-analyses and one nationwide cohort have focused on this specific question. The current review aims to summarize the contemporary multidisciplinary evidence on whether ARBs may be associated with an increased risk of tumorigenesis.

A primer on network meta-analysis for dental research

In the last decade, a new statistical methodology, namely, network meta-analysis, has been developed to address limitations in traditional pairwise meta-analysis. Network meta-analysis incorporates all available evidence into a general statistical framework for comparisons of all available treatments. A further development in the network meta-analysis is to use a Bayesian statistical approach, which provides a more flexible modelling framework to take into account heterogeneity in the evidence and complexity in the data structure. The aim of this paper is therefore to provide a nontechnical introduction to network meta-analysis for dental research community and raise the awareness of it. An example was used to demonstrate how to conduct a network meta-analysis and the differences between it and traditional meta-analysis. The statistical theory behind network meta-analysis is nevertheless complex, so we strongly encourage close collaboration between dental researchers and experienced statisticians when planning and conducting a network meta-analysis. The use of more sophisticated statistical approaches such as network meta-analysis will improve the efficiency in comparing the effectiveness between multiple treatments across a set of trials.

Effect of Biologic Agents on Non-PASI Outcomes in Moderate-to-Severe Plaque Psoriasis: Systematic Review and Meta-Analyses

Introduction

The objective of this review was to conduct a systematic review with meta-analysis and Bayesian mixed treatment comparisons (MTC) evaluating the impact of biologics on non-Psoriasis Area and Severity Index (PASI) health outcomes in patients with moderate-to-severe plaque psoriasis.

Methods

MEDLINE and Cochrane Central Register of Controlled Trials were searched from 1966 to May 2009. Citations were screened for randomized, controlled trials of biologics versus either placebo or each other in adults with moderate-to-severe plaque psoriasis and reported any of several outcomes. Traditional and Bayesian MTC meta-analyses were conducted for each endpoint using either a random- or fixed-effect model where appropriate.

Results

Thirty-eight studies met eligibility criteria. All biologics showed significant improvement in achieving a good response on the static physician’s global assessment (PGA) versus placebo while, in the MTC, differences were noted between individual drugs. In achieving a good response on the dynamic PGA, all biologics showed significant improvements over placebo, while the MTC showed significant improvements with the anti-interleukins versus anti-T cells. Relative to placebo, antitumor necrosis factor (TNF) agents and anti-interleukins showed significant improvements in the Dermatology Life Quality Index (DLQI). Compared with placebo, the anti-TNF agents showed significant improvements in both 36-item Medical Outcomes Study Short-Form General Health Survey (SF-36) mental and physical component scores, while anti-T cell agents showed no improvements. The MTC showed no differences between any biologics for either the DLQI or SF-36.

Conclusion

Individual biologics and classes showed consistent benefits across non-PASI health outcomes in patients with moderate-to-severe plaque psoriasis while MTC meta-analyses suggested that some differences exist.

Does β-adrenoceptor blocker therapy improve cancer survival? Findings from a population-based retrospective cohort study

AIMS

To examine the effect of β-adrenoceptor blocker treatment on cancer survival.

METHODS

In a UK primary care database, we compared patients with a new cancer diagnosis receiving β-adrenoceptor blockers regularly (n= 1406) with patients receiving other antihypertensive medication (n= 2056).

RESULTS

Compared with cancer patients receiving other antihypertensive medication, patients receiving β-adrenoceptor blocker therapy experienced slightly poorer survival (HR = 1.18, 95% CI 1.04, 1.33 for all β-adrenoceptor blockers; HR = 1.21, 95% CI 0.94, 1.55 for non-selective β-adrenoceptor blockers). This poorer overall survival was explained by patients with pancreatic and prostate cancer with no evidence of an effect on survival for patients with lung, breast or colorectal cancer. Analysis in a cancer-free matched parallel cohort did not suggest selection bias masked a beneficial effect.

CONCLUSION

Our study does not support the hypothesis that β-adrenoceptor blockers improve survival for common cancers.

Critical review of cancer risk associated with angiotensin receptor blocker therapy

The role of drugs in new cancer occurrence and cancer-related death is a major concern. Recently, a meta-analysis raised the possibility that angiotensin receptor blockers (ARBs) might have an adverse effect on patients. This generated a significant debate until the publication of two further meta-analyses, neither of which demonstrated an increased risk of new cancer occurrence or cancer-related death with the use of ARBs in patients with hypertension, heart failure, and/or nephropathy. This illustrates that the results of meta-analyses should be interpreted cautiously and critically as bias, such as selection bias, might lead to erroneous conclusions. Overall, the bulk of evidence today indicates that ARBs are not associated with increased cancer risk.