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Li J, Zhang L, Ge T, Liu J, Wang C, Yu Q. Understanding Sorafenib-Induced Cardiovascular Toxicity: Mechanisms and Treatment Implications. Drug Des Devel Ther 2024; 18:829-843. [PMID: 38524877 PMCID: PMC10959117 DOI: 10.2147/dddt.s443107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 03/09/2024] [Indexed: 03/26/2024] Open
Abstract
Tyrosine kinase inhibitors (TKIs) have been recognized as crucial agents for treating various tumors, and one of their key targets is the intracellular site of the vascular endothelial growth factor receptor (VEGFR). While TKIs have demonstrated their effectiveness in solid tumor patients and increased life expectancy, they can also lead to adverse cardiovascular effects including hypertension, thromboembolism, cardiac ischemia, and left ventricular dysfunction. Among the TKIs, sorafenib was the first approved agent and it exerts anti-tumor effects on hepatocellular carcinoma (HCC) and renal cell carcinoma (RCC) by inhibiting angiogenesis and tumor cell proliferation through targeting VEGFR and RAF. Unfortunately, the adverse cardiovascular effects caused by sorafenib not only affect solid tumor patients but also limit its application in curing other diseases. This review explores the mechanisms underlying sorafenib-induced cardiovascular adverse effects, including endothelial dysfunction, mitochondrial dysfunction, endoplasmic reticulum stress, dysregulated autophagy, and ferroptosis. It also discusses potential treatment strategies, such as antioxidants and renin-angiotensin system inhibitors, and highlights the association between sorafenib-induced hypertension and treatment efficacy in cancer patients. Furthermore, emerging research suggests a link between sorafenib-induced glycolysis, drug resistance, and cardiovascular toxicity, necessitating further investigation. Overall, understanding these mechanisms is crucial for optimizing sorafenib therapy and minimizing cardiovascular risks in cancer patients.
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Affiliation(s)
- Jue Li
- Engineering Research Center of Brain Health Industry of Chinese Medicine, Key Laboratory of Pharmacodynamics and Material Basis of Chinese Medicine of Shaanxi Administration of Traditional Chinese Medicine, Pharmacology of Chinese medicine, Shaanxi University of Chinese Medicine, Xianyang, 712046, People’s Republic of China
| | - Lusha Zhang
- Shaanxi Key Laboratory of Ischemic Cardiovascular Diseases and Institute of Basic and Translational Medicine, Xi’an Medical University, Xi’an, 710021, People’s Republic of China
| | - Teng Ge
- Shaanxi Key Laboratory of Ischemic Cardiovascular Diseases and Institute of Basic and Translational Medicine, Xi’an Medical University, Xi’an, 710021, People’s Republic of China
| | - Jiping Liu
- Engineering Research Center of Brain Health Industry of Chinese Medicine, Key Laboratory of Pharmacodynamics and Material Basis of Chinese Medicine of Shaanxi Administration of Traditional Chinese Medicine, Pharmacology of Chinese medicine, Shaanxi University of Chinese Medicine, Xianyang, 712046, People’s Republic of China
| | - Chuan Wang
- Engineering Research Center of Brain Health Industry of Chinese Medicine, Key Laboratory of Pharmacodynamics and Material Basis of Chinese Medicine of Shaanxi Administration of Traditional Chinese Medicine, Pharmacology of Chinese medicine, Shaanxi University of Chinese Medicine, Xianyang, 712046, People’s Republic of China
| | - Qi Yu
- Engineering Research Center of Brain Health Industry of Chinese Medicine, Key Laboratory of Pharmacodynamics and Material Basis of Chinese Medicine of Shaanxi Administration of Traditional Chinese Medicine, Pharmacology of Chinese medicine, Shaanxi University of Chinese Medicine, Xianyang, 712046, People’s Republic of China
- Shaanxi Key Laboratory of Ischemic Cardiovascular Diseases and Institute of Basic and Translational Medicine, Xi’an Medical University, Xi’an, 710021, People’s Republic of China
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Wu H, Ding X, Zhang Y, Li W, Chen J. Incidence and risk of hypertension with lenvatinib in treatment of solid tumors: An updated systematic review and meta-analysis. J Clin Hypertens (Greenwich) 2022; 24:667-676. [PMID: 35538636 PMCID: PMC9180318 DOI: 10.1111/jch.14463] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 02/23/2022] [Accepted: 02/26/2022] [Indexed: 12/26/2022]
Abstract
This meta‐analysis was performed to assess the relationship between Lenvatinib use for malignancy and hypertension (HTN). A total of 2483 patients met inclusion criteria. The relative risk (RR) for all‐grade and high‐grade (≧3) HTN were 2.61 (p ≦ .001) and 3.35 (p≦ .001), respectively, for Lenvatinib compared with other multitarget tyrosine kinase inhibitors or placebo. The cumulative incidence of all‐grade and high‐grade HTN was 70% and 34%, respectively. The studies with median treatment duration (TD) longer than 7.4 months demonstrated a higher incidence of high‐grade HTN than studies with shorter TD (34% vs 28%). The incidence of all levels of HTN increased with TD (68% vs 49%). Trials with median progression‐free survival (PFS) longer than nine months had a higher incidence of both all‐grade (37% vs 28%) and high‐grade (71% vs 48%) HTN. Lenvatinib, a drug commonly used in cancer treatment, is a risk factor for the development of HTN. A longer duration of Lenvatinib treatment was associated with higher frequency of HTN. Further investigation for Lenvatinib of the association between the occurrence of HTN and prognosis will be warranted.
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Affiliation(s)
- Hongxiao Wu
- Cancer Center, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Xiaoyan Ding
- Cancer Center, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Yongchao Zhang
- Cancer Center, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Wei Li
- Cancer Center, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Jinglong Chen
- Cancer Center, Beijing Ditan Hospital, Capital Medical University, Beijing, China
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Nukala SB, Jousma J, Cho Y, Lee WH, Ong SG. Long non-coding RNAs and microRNAs as crucial regulators in cardio-oncology. Cell Biosci 2022; 12:24. [PMID: 35246252 PMCID: PMC8895873 DOI: 10.1186/s13578-022-00757-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 02/10/2022] [Indexed: 12/23/2022] Open
Abstract
Cancer is one of the leading causes of morbidity and mortality worldwide. Significant improvements in the modern era of anticancer therapeutic strategies have increased the survival rate of cancer patients. Unfortunately, cancer survivors have an increased risk of cardiovascular diseases, which is believed to result from anticancer therapies. The emergence of cardiovascular diseases among cancer survivors has served as the basis for establishing a novel field termed cardio-oncology. Cardio-oncology primarily focuses on investigating the underlying molecular mechanisms by which anticancer treatments lead to cardiovascular dysfunction and the development of novel cardioprotective strategies to counteract cardiotoxic effects of cancer therapies. Advances in genome biology have revealed that most of the genome is transcribed into non-coding RNAs (ncRNAs), which are recognized as being instrumental in cancer, cardiovascular health, and disease. Emerging studies have demonstrated that alterations of these ncRNAs have pathophysiological roles in multiple diseases in humans. As it relates to cardio-oncology, though, there is limited knowledge of the role of ncRNAs. In the present review, we summarize the up-to-date knowledge regarding the roles of long non-coding RNAs (lncRNAs) and microRNAs (miRNAs) in cancer therapy-induced cardiotoxicities. Moreover, we also discuss prospective therapeutic strategies and the translational relevance of these ncRNAs.
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Affiliation(s)
- Sarath Babu Nukala
- Department of Pharmacology & Regenerative Medicine, The University of Illinois College of Medicine, 909 S Wolcott Ave, COMRB 4100, Chicago, IL, 60612, USA
| | - Jordan Jousma
- Department of Pharmacology & Regenerative Medicine, The University of Illinois College of Medicine, 909 S Wolcott Ave, COMRB 4100, Chicago, IL, 60612, USA
| | - Yoonje Cho
- Department of Pharmacology & Regenerative Medicine, The University of Illinois College of Medicine, 909 S Wolcott Ave, COMRB 4100, Chicago, IL, 60612, USA
| | - Won Hee Lee
- Department of Basic Medical Sciences, University of Arizona College of Medicine, ABC-1 Building, 425 North 5th Street, Phoenix, AZ, 85004, USA.
| | - Sang-Ging Ong
- Department of Pharmacology & Regenerative Medicine, The University of Illinois College of Medicine, 909 S Wolcott Ave, COMRB 4100, Chicago, IL, 60612, USA.
- Division of Cardiology, Department of Medicine, The University of Illinois College of Medicine, 909 S Wolcott Ave, COMRB 4100, Chicago, IL, 60612, USA.
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Hong S, Daniels B, van Leeuwen MT, Pearson SA, Vajdic CM. Incidence and risk factors of hypertension therapy in Australian cancer patients treated with vascular signalling pathway inhibitors. Discov Oncol 2022; 13:6. [PMID: 35201530 PMCID: PMC8777550 DOI: 10.1007/s12672-022-00468-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 01/11/2022] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Clinical trials report systemic hypertension is an adverse effect of vascular signalling pathway inhibitor (VSPi) use. There are limited data from routine clinical practice. We aimed to estimate the real-world incidence and risk factors of new-onset and aggravated hypertension for cancer patients dispensed VSPi in whole-of-population Australian setting. METHODS We used dispensing records for a 10% random sample of Australians to identify treatment with subsidised VSPi from 2013 to 2018. We further identified dispensings of oral antihypertensive medicines 6 months before and 12 months after VSPi therapy. We defined (i) new-onset hypertension in people first dispensed antihypertensives after VSPi and (ii) aggravated hypertension in people with prior antihypertensive use dispensed an additional, or higher strength, antihypertensive after VSPi. We applied the Fine-Gray cumulative incidence function and Cox proportional hazard regression. RESULTS 1802 patients were dispensed at least one VSPi. The mean age of the cohort was 65 years and 57% were male. The incidence of new-onset treated hypertension was 24.3% (95%CI: 21.2-27.8); age ≥ 60 years (HR 1.74; 95%CI: 1.32-2.31) and treatment with oral tyrosine kinase inhibitors compared to bevacizumab (HR 1.96; 95%CI: 1.16-3.31) were risk factors. The incidence of aggravated hypertension was 25.2% (95%CI: 22.0-28.7) and risk was elevated for patients with renal cancer (HR 2.84; 95%CI: 1.49-5.41) and cancers other than colorectal (HR 1.85; 95%CI: 1.12-3.03). CONCLUSIONS Our real-world estimates of incident hypertension appear comparable to those observed in clinical trials (21.6-23.6%). Our population-based study provides some insight into the burden of hypertension in patients commencing VSPi in routine practice.
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Affiliation(s)
- Soojung Hong
- Centre for Big Data Research in Health, UNSW Sydney, Sydney, Australia.
- Division of Oncology-Hematology, Department of Internal Medicine, National Health Insurance Service, Ilsan Hospital, Ilsan-ro 100, Goyang, Republic of Korea.
| | - Benjamin Daniels
- Centre for Big Data Research in Health, UNSW Sydney, Sydney, Australia
| | | | | | - Claire M Vajdic
- Centre for Big Data Research in Health, UNSW Sydney, Sydney, Australia
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Unravelling the tangled web of hypertension and cancer. Clin Sci (Lond) 2021; 135:1609-1625. [PMID: 34240734 DOI: 10.1042/cs20200307] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 06/29/2021] [Accepted: 07/01/2021] [Indexed: 01/11/2023]
Abstract
Cardiovascular disease remains the primary cause of mortality globally, being responsible for an estimated 17 million deaths every year. Cancer is the second leading cause of death on a global level with roughly 9 million deaths per year being attributed to neoplasms. The two share multiple common risk factors such as obesity, poor physical exercise, older age, smoking and there exists rare monogenic hypertension syndromes. Hypertension is the most important risk factor for cardiovascular disease and affects more than a billion people worldwide and may also be a risk factor for the development of certain types of cancer (e.g. renal cell carcinoma (RCC)). The interaction space of the two conditions becomes more complicated when the well-described hypertensive effect of certain antineoplastic drugs is considered along with the extensive amount of literature on the association of different classes of antihypertensive drugs with cancer risk/prevention. The cardiovascular risks associated with antineoplastic treatment calls for efficient management of relative adverse events and the development of practical strategies for efficient decision-making in the clinic. Pharmacogenetic interactions between cancer treatment and hypertension-related genes is not to be ruled out, but the evidence is not still ample to be incorporated in clinical practice. Precision Medicine has the potential to bridge the gap of knowledge regarding the full spectrum of interactions between cancer and hypertension (and cardiovascular disease) and provide novel solutions through the emerging field of cardio-oncology. In this review, we aimed to examine the bidirectional associations between cancer and hypertension including pharmacotherapy.
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Chung R, Tyebally S, Chen D, Kapil V, Walker JM, Addison D, Ismail-Khan R, Guha A, Ghosh AK. Hypertensive Cardiotoxicity in Cancer Treatment-Systematic Analysis of Adjunct, Conventional Chemotherapy, and Novel Therapies-Epidemiology, Incidence, and Pathophysiology. J Clin Med 2020; 9:jcm9103346. [PMID: 33081013 PMCID: PMC7603211 DOI: 10.3390/jcm9103346] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 10/05/2020] [Accepted: 10/10/2020] [Indexed: 02/07/2023] Open
Abstract
Cardiotoxicity is the umbrella term for cardiovascular side effects of cancer therapies. The most widely recognized phenotype is left ventricular dysfunction, but cardiotoxicity can manifest as arrhythmogenic, vascular, myocarditic and hypertensive toxicities. Hypertension has long been regarded as one of the most prevalent and modifiable cardiovascular risk factors in the general population, but its relevance during the cancer treatment journey may be underestimated. Hypertensive cardiotoxicity occurs de novo in a substantial proportion of treated cancer patients. The pathology is incompletely characterized—natriuresis and renin angiotensin system interactions play a role particularly in conventional treatments, but in novel therapies endothelial dysfunction and the interaction between the cancer and cardiac kinome are implicated. There exists a treatment paradox in that a significant hypertensive response not only mandates anti-hypertensive treatment, but in fact, in certain cancer treatment scenarios, hypertension is a predictor of cancer treatment efficacy and response. In this comprehensive review of over 80,000 patients, we explored the epidemiology, incidence, and mechanistic pathophysiology of hypertensive cardiotoxicity in adjunct, conventional chemotherapy, and novel cancer treatments. Conventional chemotherapy, adjunct treatments, and novel targeted therapies collectively caused new onset hypertension in 33–68% of treated patients. The incidence of hypertensive cardiotoxicity across twenty common novel therapies for any grade hypertension ranged from 4% (imatinib) to 68% (lenvatinib), and high grade 3 or 4 hypertension in <1% (imatinib) to 42% (lenvatinib). The weighted average effect was all-grade hypertension in 24% and grade 3 or 4 hypertension in 8%.
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Affiliation(s)
- Robin Chung
- Cardio-Oncology Service, Barts Heart Centre, St Bartholomew’s Hospital, London EC1A 7BE, UK; (R.C.); (S.T.); (D.C.)
- Cardio-Oncology Service, University College London Hospital, London WC1E 6HX, UK;
| | - Sara Tyebally
- Cardio-Oncology Service, Barts Heart Centre, St Bartholomew’s Hospital, London EC1A 7BE, UK; (R.C.); (S.T.); (D.C.)
| | - Daniel Chen
- Cardio-Oncology Service, Barts Heart Centre, St Bartholomew’s Hospital, London EC1A 7BE, UK; (R.C.); (S.T.); (D.C.)
- Cardio-Oncology Service, University College London Hospital, London WC1E 6HX, UK;
- Hatter Cardiovascular Institute, University College London, London WC1E 6HX, UK
| | - Vikas Kapil
- Barts Blood Pressure Centre of Excellence, Barts Heart Centre, St Bartholomew’s Hospital, London EC1A 7BE, UK;
- Centre for Cardiovascular Medicine and Devices, NIHR Barts Biomedical Research Centre, William Harvey Research Institute, Queen Mary University of London, London EC1M 6BQ, UK
| | - J. Malcolm Walker
- Cardio-Oncology Service, University College London Hospital, London WC1E 6HX, UK;
- Hatter Cardiovascular Institute, University College London, London WC1E 6HX, UK
| | - Daniel Addison
- Cardio-Oncology Program, Division of Cardiology, The Ohio State University Medical Center, Columbus, OH 43210, USA; (D.A.); (A.G.)
| | - Roohi Ismail-Khan
- Cardio-oncology Program, H. Lee Moffitt Cancer Center, Tampa, FL 33559, USA;
| | - Avirup Guha
- Cardio-Oncology Program, Division of Cardiology, The Ohio State University Medical Center, Columbus, OH 43210, USA; (D.A.); (A.G.)
- Harrington Heart and Vascular Institute, Case Western Reserve University, Cleveland, OH 44106, USA
| | - Arjun K Ghosh
- Cardio-Oncology Service, Barts Heart Centre, St Bartholomew’s Hospital, London EC1A 7BE, UK; (R.C.); (S.T.); (D.C.)
- Cardio-Oncology Service, University College London Hospital, London WC1E 6HX, UK;
- Hatter Cardiovascular Institute, University College London, London WC1E 6HX, UK
- Correspondence: ; Tel.: +44-20-7377-7000
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Abstract
BACKGROUND Cardio-oncology aims to mitigate adverse cardiovascular manifestations in cancer survivors, but treatment-induced hypertension or aggravated hypertension has received less attention in these high cardiovascular risk patients. METHODS In this systematic review, we searched literature for contemporary data on the prevalence, pathophysiologic mechanisms, treatment implications and preventive strategies of hypertension in patients under antineoplastic therapy. RESULTS Several classes of antineoplastic drugs, including mainly vascular endothelial growth factor inhibitors, proteasome inhibitors, cisplatin derivatives, corticosteroids or radiation therapy were consistently associated with increased odds for new-onset hypertension or labile hypertensive status in previous controlled patients. Moreover, hypertension constitutes a major risk factor for chemotherapy-induced cardiotoxicity, which is the most serious cardiovascular adverse effect of antineoplastic therapy. Despite the heterogeneity of pooled studies, the pro-hypertensive profile of examined drug classes could be attributed to common structural and functional disorders. Importantly, certain antihypertensive drugs are considered to be more effective in the management of hypertension in this population and may partially attenuate indirect complications of cancer treatment, such as progressive development of cardiomyopathy and/or cardiovascular death. Nonpharmacological approaches to alleviate hypertension in cancer patients are also described, albeit adjudicated as less effective in general. CONCLUSION A growing body of evidence suggests that multiple antineoplastic agents increase the rate of progression of hypertension. Physicians need to balance the life-saving cancer treatment and the inflated risk of adverse cardiovascular events due to suboptimal management of hypertension in order to achieve improved clinical outcomes and sustained survival for their patients.
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Fleeman N, Houten R, Bagust A, Richardson M, Beale S, Boland A, Dundar Y, Greenhalgh J, Hounsome J, Duarte R, Shenoy A. Lenvatinib and sorafenib for differentiated thyroid cancer after radioactive iodine: a systematic review and economic evaluation. Health Technol Assess 2020; 24:1-180. [PMID: 31931920 PMCID: PMC6983913 DOI: 10.3310/hta24020] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Thyroid cancer is a rare cancer, accounting for only 1% of all malignancies in England and Wales. Differentiated thyroid cancer (DTC) accounts for ≈94% of all thyroid cancers. Patients with DTC often require treatment with radioactive iodine. Treatment for DTC that is refractory to radioactive iodine [radioactive iodine-refractory DTC (RR-DTC)] is often limited to best supportive care (BSC). OBJECTIVES We aimed to assess the clinical effectiveness and cost-effectiveness of lenvatinib (Lenvima®; Eisai Ltd, Hertfordshire, UK) and sorafenib (Nexar®; Bayer HealthCare, Leverkusen, Germany) for the treatment of patients with RR-DTC. DATA SOURCES EMBASE, MEDLINE, PubMed, The Cochrane Library and EconLit were searched (date range 1999 to 10 January 2017; searched on 10 January 2017). The bibliographies of retrieved citations were also examined. REVIEW METHODS We searched for randomised controlled trials (RCTs), systematic reviews, prospective observational studies and economic evaluations of lenvatinib or sorafenib. In the absence of relevant economic evaluations, we constructed a de novo economic model to compare the cost-effectiveness of lenvatinib and sorafenib with that of BSC. RESULTS Two RCTs were identified: SELECT (Study of [E7080] LEnvatinib in 131I-refractory differentiated Cancer of the Thyroid) and DECISION (StuDy of sorafEnib in loCally advanced or metastatIc patientS with radioactive Iodine-refractory thyrOid caNcer). Lenvatinib and sorafenib were both reported to improve median progression-free survival (PFS) compared with placebo: 18.3 months (lenvatinib) vs. 3.6 months (placebo) and 10.8 months (sorafenib) vs. 5.8 months (placebo). Patient crossover was high (≥ 75%) in both trials, confounding estimates of overall survival (OS). Using OS data adjusted for crossover, trial authors reported a statistically significant improvement in OS for patients treated with lenvatinib compared with those given placebo (SELECT) but not for patients treated with sorafenib compared with those given placebo (DECISION). Both lenvatinib and sorafenib increased the incidence of adverse events (AEs), and dose reductions were required (for > 60% of patients). The results from nine prospective observational studies and 13 systematic reviews of lenvatinib or sorafenib were broadly comparable to those from the RCTs. Health-related quality-of-life (HRQoL) data were collected only in DECISION. We considered the feasibility of comparing lenvatinib with sorafenib via an indirect comparison but concluded that this would not be appropriate because of differences in trial and participant characteristics, risk profiles of the participants in the placebo arms and because the proportional hazard assumption was violated for five of the six survival outcomes available from the trials. In the base-case economic analysis, using list prices only, the cost-effectiveness comparison of lenvatinib versus BSC yields an incremental cost-effectiveness ratio (ICER) per quality-adjusted life-year (QALY) gained of £65,872, and the comparison of sorafenib versus BSC yields an ICER of £85,644 per QALY gained. The deterministic sensitivity analyses show that none of the variations lowered the base-case ICERs to < £50,000 per QALY gained. LIMITATIONS We consider that it is not possible to compare the clinical effectiveness or cost-effectiveness of lenvatinib and sorafenib. CONCLUSIONS Compared with placebo/BSC, treatment with lenvatinib or sorafenib results in an improvement in PFS, objective tumour response rate and possibly OS, but dose modifications were required to treat AEs. Both treatments exhibit estimated ICERs of > £50,000 per QALY gained. Further research should include examination of the effects of lenvatinib, sorafenib and BSC (including HRQoL) for both symptomatic and asymptomatic patients, and the positioning of treatments in the treatment pathway. STUDY REGISTRATION This study is registered as PROSPERO CRD42017055516. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Nigel Fleeman
- Liverpool Reviews and Implementation Group, University of Liverpool, Liverpool, UK
| | - Rachel Houten
- Liverpool Reviews and Implementation Group, University of Liverpool, Liverpool, UK
| | - Adrian Bagust
- Liverpool Reviews and Implementation Group, University of Liverpool, Liverpool, UK
| | - Marty Richardson
- Liverpool Reviews and Implementation Group, University of Liverpool, Liverpool, UK
| | - Sophie Beale
- Liverpool Reviews and Implementation Group, University of Liverpool, Liverpool, UK
| | - Angela Boland
- Liverpool Reviews and Implementation Group, University of Liverpool, Liverpool, UK
| | - Yenal Dundar
- Liverpool Reviews and Implementation Group, University of Liverpool, Liverpool, UK
| | - Janette Greenhalgh
- Liverpool Reviews and Implementation Group, University of Liverpool, Liverpool, UK
| | - Juliet Hounsome
- Liverpool Reviews and Implementation Group, University of Liverpool, Liverpool, UK
| | - Rui Duarte
- Liverpool Reviews and Implementation Group, University of Liverpool, Liverpool, UK
| | - Aditya Shenoy
- The Clatterbridge Cancer Centre NHS Foundation Trust, Birkenhead, UK
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