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Martins-Branco D, Kassapian M, Debien V, Caparica R, Eiger D, Dafni U, Andriakopoulou C, El-Abed S, Ellard SL, Izquierdo M, Vicente M, Chumsri S, Piccart-Gebhart M, Moreno-Aspitia A, Knop AS, Lombard J, de Azambuja E. The impact of erythropoiesis-stimulating agents administration concomitantly with adjuvant anti-HER2 treatments on the outcomes of patients with early breast cancer: a sub-analysis of the ALTTO study. Breast Cancer Res Treat 2024; 203:497-509. [PMID: 37938495 PMCID: PMC11052564 DOI: 10.1007/s10549-023-07159-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 10/05/2023] [Indexed: 11/09/2023]
Abstract
PURPOSE To assess whether erythropoiesis-stimulating agents (ESA) administration impacts the outcomes of patients with HER2-positive early breast cancer (EBC). METHODS ALTTO (NCT00490139) patients were categorized by ESA use during adjuvant anti-HER2 treatment. Disease-free-survival (DFS), overall survival (OS), and time-to-distant recurrence (TTDR) were analyzed by ESA administration, with subgroup analyses according to prognostic factors. Log-rank tests and Cox modeling were performed. Adverse events (AEs) of ESA-interest were compared. RESULTS Among 8381 patients recruited in ALTTO, 123 (1.5%) received ESA concomitantly with study treatment. The median age of patients receiving ESA was 54 years, 39.0% premenopausal, most had tumor size > 2 cm (56.9%), node-positive (58.5%), and positive estrogen receptor expression (61.8%). Median follow-up was shorter in the ESA group [6.1 years (IQR 5.3-7.0) vs. 6.9 years (6.0-7.1); p < 0.001]. There was no DFS difference by ESA administration (log-rank p = 0.70), with 3- and 7-year DFS of 89.2% (95% CI 81.8-93.8%) and 81.6% (71.4-88.5%) in ESA group vs. 88.3% (87.6-89.0%) and 80.0% (79.1-80.9%) in No-ESA group. In subgroup analyses, the interaction of ESA administration with menopausal status was statistically significant (unadjusted p = 0.024; stratified p = 0.033), favoring premenopausal women receiving ESA. We observed no significant association of ESA administration with OS (log-rank p = 0.57; 7-year OS in ESA 88.6% vs. 90.0% in non-ESA) or TTDR. ESA-interest AEs were experienced by eight (6.5%) patients receiving ESA and 417 (5.1%) in the No-ESA group (p = 0.41). CONCLUSION ESA administration to patients receiving adjuvant anti-HER2 treatment for HER2-positive EBC was safe and not associated with a negative impact on survival outcomes.
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Affiliation(s)
- Diogo Martins-Branco
- Academic Trials Promoting Team (ATPT), Institut Jules Bordet, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Rue Meylemeersch, 90, Anderlecht, 1070, Brussels, Belgium
| | | | - Véronique Debien
- Academic Trials Promoting Team (ATPT), Institut Jules Bordet, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Rue Meylemeersch, 90, Anderlecht, 1070, Brussels, Belgium
| | - Rafael Caparica
- Academic Trials Promoting Team (ATPT), Institut Jules Bordet, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Rue Meylemeersch, 90, Anderlecht, 1070, Brussels, Belgium
| | - Daniel Eiger
- Academic Trials Promoting Team (ATPT), Institut Jules Bordet, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Rue Meylemeersch, 90, Anderlecht, 1070, Brussels, Belgium
| | - Urania Dafni
- National and Kapodistrian University of Athens & Frontier Science Foundation-Hellas, Athens, Greece
| | | | | | | | | | - Malou Vicente
- Academic Trials Promoting Team (ATPT), Institut Jules Bordet, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Rue Meylemeersch, 90, Anderlecht, 1070, Brussels, Belgium
| | - Saranya Chumsri
- Alliance Statistics and Data Center, Mayo Clinic, Rochester, MN, USA
| | - Martine Piccart-Gebhart
- Medical Oncology Department, Institut Jules Bordet, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Brussels, Belgium
| | | | - Ann Søegaard Knop
- Department of Oncology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Janine Lombard
- Calvary Mater Hospital & Australia and New Zealand Breast Cancer Trials Group (BCT-ANZ), Newcastle, Australia
| | - Evandro de Azambuja
- Academic Trials Promoting Team (ATPT), Institut Jules Bordet, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Rue Meylemeersch, 90, Anderlecht, 1070, Brussels, Belgium.
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Wu T, Tong Z, Ren T, Xie D, Sun X. Effect of erythropoiesis-stimulating agents on breast cancer patients: a meta-analysis. Clin Exp Med 2023; 23:1501-1513. [PMID: 36315312 DOI: 10.1007/s10238-022-00921-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 10/11/2022] [Indexed: 11/03/2022]
Abstract
Erythropoiesis-stimulating agents (ESAs) have been reported to increase the risk of death in cancer patients. In this study, we selected breast cancer, which is currently the most prevalent cancer worldwide, for a meta-analysis to re-examine the advantages and disadvantages of using ESAs. All relevant studies were searched by PubMed, Embase, Web of science, and Cochrane Library. Endpoints including mortality, incidence of thrombo-vascular events, hemoglobin, and transfusion requirements were meta-analyzed based on random-effects model or fixed-effect model. 10 studies were finally included, with a total sample size of 6785 patients. The risk of mortality was higher in patients using ESA than in controls (RR 1.07, 95% CI 1.01-1.13, P = 0.03); subgroup analysis found that the mortality rate was higher in patients treating with ESA for > 6 months (RR 1.27, 95% CI 1.05-1.55, P = 0.01) and epoetin α (RR 1.07, 95% CI 1.01-1.14, P = 0.03). The incidence of thrombo-vascular adverse events was higher in patients using ESA than in controls (RR 1.53, 95% CI 1.27-1.86, P < 0.0001). The ESA group was more effective in improving anemia in cancer patients (MD 1.20, 95% CI 0.77-1.63, P < 0.00001). The blood transfusion needs of patients in the ESA group were significantly lower (RR 0.52, 95%CI 0.44-0.60, P < 0.00001). There was no statistically significant difference between the two groups in disease progression-related conditions (HR 1.03, 95%CI 0.95-1.12, P = 0.52). ESAs increase the risk of mortality and the incidence of thrombo-vascular adverse events in breast cancer patients, while reducing their anemia symptoms and transfusion requirements. Registration PROSPERO CRD42022330450.
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Affiliation(s)
- Tong Wu
- Department of Pharmacy, General Hospital of Northern Theater Command, No.83, Wenhua Road, Shenyang, 110016, China
- Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai, 201203, China
- University of Chinese Academy of Sciences, 100049, Beijing, China
| | - Zhenhua Tong
- Department of Research and Training, General Hospital of Northern Theater Command, No.83, Wenhua Road, Shenyang, 110016, China
| | - Tianshu Ren
- Department of Pharmacy, General Hospital of Northern Theater Command, No.83, Wenhua Road, Shenyang, 110016, China
| | - Danni Xie
- Department of Pharmacy, General Hospital of Northern Theater Command, No.83, Wenhua Road, Shenyang, 110016, China
| | - Xue Sun
- Department of Pharmacy, General Hospital of Northern Theater Command, No.83, Wenhua Road, Shenyang, 110016, China.
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Adams A, Scheckel B, Habsaoui A, Haque M, Kuhr K, Monsef I, Bohlius J, Skoetz N. Intravenous iron versus oral iron versus no iron with or without erythropoiesis- stimulating agents (ESA) for cancer patients with anaemia: a systematic review and network meta-analysis. Cochrane Database Syst Rev 2022; 6:CD012633. [PMID: 35724934 PMCID: PMC9208863 DOI: 10.1002/14651858.cd012633.pub2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND Anaemia is common among cancer patients and they may require red blood cell transfusions. Erythropoiesis-stimulating agents (ESAs) and iron might help in reducing the need for red blood cell transfusions. However, it remains unclear whether the combination of both drugs is preferable compared to using one drug. OBJECTIVES To systematically review the effect of intravenous iron, oral iron or no iron in combination with or without ESAs to prevent or alleviate anaemia in cancer patients and to generate treatment rankings using network meta-analyses (NMAs). SEARCH METHODS We identified studies by searching bibliographic databases (CENTRAL, MEDLINE, Embase; until June 2021). We also searched various registries, conference proceedings and reference lists of identified trials. SELECTION CRITERIA We included randomised controlled trials comparing intravenous, oral or no iron, with or without ESAs for the prevention or alleviation of anaemia resulting from chemotherapy, radiotherapy, combination therapy or the underlying malignancy in cancer patients. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed risk of bias. Outcomes were on-study mortality, number of patients receiving red blood cell transfusions, number of red blood cell units, haematological response, overall mortality and adverse events. We conducted NMAs and generated treatment rankings. We assessed the certainty of the evidence using GRADE. MAIN RESULTS Ninety-six trials (25,157 participants) fulfilled our inclusion criteria; 62 trials (24,603 participants) could be considered in the NMA (12 different treatment options). Here we present the comparisons of ESA with or without iron and iron alone versus no treatment. Further results and subgroup analyses are described in the full text. On-study mortality We estimated that 92 of 1000 participants without treatment for anaemia died up to 30 days after the active study period. Evidence from NMA (55 trials; 15,074 participants) suggests that treatment with ESA and intravenous iron (12 of 1000; risk ratio (RR) 0.13, 95% confidence interval (CI) 0.01 to 2.29; low certainty) or oral iron (34 of 1000; RR 0.37, 95% CI 0.01 to 27.38; low certainty) may decrease or increase and ESA alone (103 of 1000; RR 1.12, 95% CI 0.92 to 1.35; moderate certainty) probably slightly increases on-study mortality. Additionally, treatment with intravenous iron alone (271 of 1000; RR 2.95, 95% CI 0.71 to 12.34; low certainty) may increase and oral iron alone (24 of 1000; RR 0.26, 95% CI 0.00 to 19.73; low certainty) may increase or decrease on-study mortality. Haematological response We estimated that 90 of 1000 participants without treatment for anaemia had a haematological response. Evidence from NMA (31 trials; 6985 participants) suggests that treatment with ESA and intravenous iron (604 of 1000; RR 6.71, 95% CI 4.93 to 9.14; moderate certainty), ESA and oral iron (527 of 1000; RR 5.85, 95% CI 4.06 to 8.42; moderate certainty), and ESA alone (467 of 1000; RR 5.19, 95% CI 4.02 to 6.71; moderate certainty) probably increases haematological response. Additionally, treatment with oral iron alone may increase haematological response (153 of 1000; RR 1.70, 95% CI 0.69 to 4.20; low certainty). Red blood cell transfusions We estimated that 360 of 1000 participants without treatment for anaemia needed at least one transfusion. Evidence from NMA (69 trials; 18,684 participants) suggests that treatment with ESA and intravenous iron (158 of 1000; RR 0.44, 95% CI 0.31 to 0.63; moderate certainty), ESA and oral iron (144 of 1000; RR 0.40, 95% CI 0.24 to 0.66; moderate certainty) and ESA alone (212 of 1000; RR 0.59, 95% CI 0.51 to 0.69; moderate certainty) probably decreases the need for transfusions. Additionally, treatment with intravenous iron alone (268 of 1000; RR 0.74, 95% CI 0.43 to 1.28; low certainty) and with oral iron alone (333 of 1000; RR 0.92, 95% CI 0.54 to 1.57; low certainty) may decrease or increase the need for transfusions. Overall mortality We estimated that 347 of 1000 participants without treatment for anaemia died overall. Low-certainty evidence from NMA (71 trials; 21,576 participants) suggests that treatment with ESA and intravenous iron (507 of 1000; RR 1.46, 95% CI 0.87 to 2.43) or oral iron (482 of 1000; RR 1.39, 95% CI 0.60 to 3.22) and intravenous iron alone (521 of 1000; RR 1.50, 95% CI 0.63 to 3.56) or oral iron alone (534 of 1000; RR 1.54, 95% CI 0.66 to 3.56) may decrease or increase overall mortality. Treatment with ESA alone may lead to little or no difference in overall mortality (357 of 1000; RR 1.03, 95% CI 0.97 to 1.10; low certainty). Thromboembolic events We estimated that 36 of 1000 participants without treatment for anaemia developed thromboembolic events. Evidence from NMA (50 trials; 15,408 participants) suggests that treatment with ESA and intravenous iron (66 of 1000; RR 1.82, 95% CI 0.98 to 3.41; moderate certainty) probably slightly increases and with ESA alone (66 of 1000; RR 1.82, 95% CI 1.34 to 2.47; high certainty) slightly increases the number of thromboembolic events. None of the trials reported results on the other comparisons. Thrombocytopenia or haemorrhage We estimated that 76 of 1000 participants without treatment for anaemia developed thrombocytopenia/haemorrhage. Evidence from NMA (13 trials, 2744 participants) suggests that treatment with ESA alone probably leads to little or no difference in thrombocytopenia/haemorrhage (76 of 1000; RR 1.00, 95% CI 0.67 to 1.48; moderate certainty). None of the trials reported results on other comparisons. Hypertension We estimated that 10 of 1000 participants without treatment for anaemia developed hypertension. Evidence from NMA (24 trials; 8383 participants) suggests that treatment with ESA alone probably increases the number of hypertensions (29 of 1000; RR 2.93, 95% CI 1.19 to 7.25; moderate certainty). None of the trials reported results on the other comparisons. AUTHORS' CONCLUSIONS When considering ESAs with iron as prevention for anaemia, one has to balance between efficacy and safety. Results suggest that treatment with ESA and iron probably decreases number of blood transfusions, but may increase mortality and the number of thromboembolic events. For most outcomes the different comparisons within the network were not fully connected, so ranking of all treatments together was not possible. More head-to-head comparisons including all evaluated treatment combinations are needed to fill the gaps and prove results of this review.
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Affiliation(s)
- Anne Adams
- Institute of Medical Statistics and Computational Biology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Benjamin Scheckel
- Institute of Health Economics and Clinical Epidemiology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Anissa Habsaoui
- Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Madhuri Haque
- Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Kathrin Kuhr
- Institute of Medical Statistics and Computational Biology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Ina Monsef
- Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Julia Bohlius
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Nicole Skoetz
- Cochrane Cancer, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
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Gergal Gopalkrishna Rao SR, Bugazia S, Dhandapani TPM, Tara A, Garg I, Patel JN, Yeon J, Memon MS, Muralidharan A, Khan S. Efficacy and Cardiovascular Adverse Effects of Erythropoiesis Stimulating Agents in the Treatment of Cancer-Related Anemia: A Systematic Review of Randomized Controlled Trials. Cureus 2021; 13:e17835. [PMID: 34527499 PMCID: PMC8432433 DOI: 10.7759/cureus.17835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Accepted: 09/08/2021] [Indexed: 11/13/2022] Open
Abstract
Anemia is a common complication of cancer. Treatment of anemia in cancer is crucial as anemia adversely affects the quality of life, therapeutic outcomes, and overall survival. Erythropoiesis stimulating agents (ESAs) are valuable drugs for treating cancer-related anemia. Cardiovascular adverse effects are a significant concern with ESA therapy, and there is wide variability in therapeutic goals and characteristics of patients who undergo treatment with ESAs. As a result, a careful analysis of the currently available data on the efficacy and safety of these drugs is necessary. This data analysis will aid in the rational use of ESAs for the treatment of anemia in cancer. The objective of this systematic review is to elucidate the pathogenesis of anemia in cancer, assess the effectiveness of ESAs in treating anemia in cancer, and the overall risk of cardiovascular adverse effects associated with the use of ESAs and their impact on prognosis. We searched literature from online databases - PubMed, PubMed Central, MEDLINE, Cochrane Library, and clinical trials register (clinicaltrials.gov) to identify prospective phase II and phase III randomized controlled trials (RCTs). We chose RCTs that directly compared patients with cancer who were treated with ESAs to those who were not treated with ESAs. January 2008 was taken as the lower date limit and May 2021 as the upper date limit. Only English language literature and human studies were included. The quality appraisal was completed using the Cochrane risk bias assessment tool, and data from a total of 10,738 patients with cancer in 17 RCTs were identified and included for systematic review. Our review concludes that ESAs effectively reduce the necessity for blood transfusions and increase mean hemoglobin levels in anemic cancer patients. ESA therapy is associated with cardiovascular adverse effects, including venous thromboembolism, thrombophlebitis, hypertension, ischemic heart disease, cardiac failure, arrhythmia, arterial thromboembolism, and cardiac arrest. Aggressive ESA dosing to achieve higher hemoglobin levels and preexisting uncontrolled hypertension increases these cardiovascular side effects. Venous thromboembolism is the most significant adverse effect attributed to ESA therapy. However, there is no major change in overall survival with ESA therapy, and administration of ESAs can be carried out in anemic cancer patients with careful assessment of thromboembolism risk factors, risk-benefit ratio, and monitoring of hemoglobin levels.
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Affiliation(s)
- Sanjay Rao Gergal Gopalkrishna Rao
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
- Internal Medicine, Kasturba Medical College, Manipal, IND
| | - Seif Bugazia
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
- Faculty of Medicine, University of Benghazi, Benghazi, LBY
| | - Tamil Poonkuil Mozhi Dhandapani
- Internal Medicine/Family Medicine, California Institute of Behavioral Neuroscience & Psychology, Fairfield, USA
- Medicine, Kanyakumari Government Medical College, Nagercoil, IND
| | - Anjli Tara
- General Surgery, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
- General Surgery, Liaquat University of Medical and Health Sciences, Jamshoro, PAK
| | - Ishan Garg
- Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
- Department of Medicine, Ross University School of Medicine, Miami, USA
| | - Jaimin N Patel
- Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
- Medicine, St. Martinus University Faculty of Medicine, Curacoa, CUW
| | - Jimin Yeon
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
- College of Medicine, Hanyang University, Seoul, KOR
| | - Marrium S Memon
- Research, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Abilash Muralidharan
- Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
- Internal Medicine, State University of New York (SUNY) Downstate Health Science Center, New York, USA
| | - Safeera Khan
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
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Weiler S, Nairz M. TAM-ing the CIA-Tumor-Associated Macrophages and Their Potential Role in Unintended Side Effects of Therapeutics for Cancer-Induced Anemia. Front Oncol 2021; 11:627223. [PMID: 33842333 PMCID: PMC8027083 DOI: 10.3389/fonc.2021.627223] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Accepted: 03/01/2021] [Indexed: 12/21/2022] Open
Abstract
Cancer-induced anemia (CIA) is a common consequence of neoplasia and has a multifactorial pathophysiology. The immune response and tumor treatment, both intended to primarily target malignant cells, also affect erythropoiesis in the bone marrow. In parallel, immune activation inevitably induces the iron-regulatory hormone hepcidin to direct iron fluxes away from erythroid progenitors and into compartments of the mononuclear phagocyte system. Moreover, many inflammatory mediators inhibit the synthesis of erythropoietin, which is essential for stimulation and differentiation of erythroid progenitor cells to mature cells ready for release into the blood stream. These pathophysiological hallmarks of CIA imply that the bone marrow is not only deprived of iron as nutrient but also of erythropoietin as central growth factor for erythropoiesis. Tumor-associated macrophages (TAM) are present in the tumor microenvironment and display altered immune and iron phenotypes. On the one hand, their functions are altered by adjacent tumor cells so that they promote rather than inhibit the growth of malignant cells. As consequences, TAM may deliver iron to tumor cells and produce reduced amounts of cytotoxic mediators. Furthermore, their ability to stimulate adaptive anti-tumor immune responses is severely compromised. On the other hand, TAM are potential off-targets of therapeutic interventions against CIA. Red blood cell transfusions, intravenous iron preparations, erythropoiesis-stimulating agents and novel treatment options for CIA may interfere with TAM function and thus exhibit secondary effects on the underlying malignancy. In this Hypothesis and Theory, we summarize the pathophysiological hallmarks, clinical implications and treatment strategies for CIA. Focusing on TAM, we speculate on the potential intended and unintended effects that therapeutic options for CIA may have on the innate immune response and, consequently, on the course of the underlying malignancy.
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Affiliation(s)
- Stefan Weiler
- National Poisons Information Centre, Tox Info Suisse, Associated Institute of the University of Zurich, Zurich, Switzerland.,Department of Chemistry and Applied Biosciences, Institute of Pharmaceutical Sciences, Eidgenossische Technische Hochschule Zurich, Zurich, Switzerland
| | - Manfred Nairz
- Department of Internal Medicine II, Infectious Diseases, Immunology, Rheumatology, Pneumology, Medical University of Innsbruck, Innsbruck, Austria
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Griffiths EA, Alwan LM, Bachiashvili K, Brown A, Cool R, Curtin P, Geyer MB, Gojo I, Kallam A, Kidwai WZ, Kloth DD, Kraut EH, Lyman GH, Mukherjee S, Perez LE, Rosovsky RP, Roy V, Rugo HS, Vasu S, Wadleigh M, Westervelt P, Becker PS. Considerations for Use of Hematopoietic Growth Factors in Patients With Cancer Related to the COVID-19 Pandemic. J Natl Compr Canc Netw 2020; 19:1-4. [PMID: 32871558 PMCID: PMC9730290 DOI: 10.6004/jnccn.2020.7610] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 06/25/2020] [Indexed: 12/15/2022]
Abstract
Hematopoietic growth factors, including erythrocyte stimulating agents (ESAs), granulocyte colony-stimulating factors, and thrombopoietin mimetics, can mitigate anemia, neutropenia, and thrombocytopenia resulting from chemotherapy for the treatment of cancer. In the context of pandemic SARS-CoV-2 infection, patients with cancer have been identified as a group at high risk of morbidity and mortality from this infection. Our subcommittee of the NCCN Hematopoietic Growth Factors Panel convened a voluntary group to review the potential value of expanded use of such growth factors in the current high-risk environment. Although recommendations are available on the NCCN website in the COVID-19 Resources Section (https://www.nccn.org/covid-19/), these suggestions are provided without substantial context or reference. Herein we review the rationale and data underlying the suggested alterations to the use of hematopoietic growth factors for patients with cancer in the COVID-19 era.
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Affiliation(s)
| | - Laura M. Alwan
- Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance, Seattle, Washington
| | - Kimo Bachiashvili
- O’Neal Comprehensive Cancer Center at the University of Alabama, Birmingham, Alabama
| | - Anna Brown
- University of Michigan Rogel Cancer Center, Ann Arbor, Michigan
| | - Rita Cool
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Peter Curtin
- UC San Diego Moores Cancer Center, La Jolla, California
| | - Mark B. Geyer
- Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ivana Gojo
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, Maryland
| | - Avyakta Kallam
- University of Nebraska Medical Center, Fred & Pamela Buffett Cancer Center, Omaha, Nebraska
| | - Wajih Z. Kidwai
- Yale Cancer Center/Smilow Cancer Hospital, New Haven, Connecticut
| | | | - Eric H. Kraut
- The Ohio State University Comprehensive Cancer Center-James Cancer Hospital and Solove Research Institute, Columbus, Ohio
| | - Gary H. Lyman
- Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance, Seattle, Washington
| | - Sudipto Mukherjee
- Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute, Cleveland, Ohio
| | | | | | - Vivek Roy
- Mayo Clinic Cancer Center; Jacksonville, Florida
| | - Hope S. Rugo
- UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, California
| | - Sumithira Vasu
- The Ohio State University Comprehensive Cancer Center-James Cancer Hospital and Solove Research Institute, Columbus, Ohio
| | - Martha Wadleigh
- Dana Farber/Brigham and Women’s Cancer Center, Boston, Massachusetts
| | - Peter Westervelt
- Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine, Saint Louis, Missouri
| | - Pamela S. Becker
- Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance, Seattle, Washington
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Zhong L, Zhang H, Ding ZF, Li J, Lv JW, Pan ZJ, Xu DX, Yin ZS. Erythropoietin-Induced Autophagy Protects Against Spinal Cord Injury and Improves Neurological Function via the Extracellular-Regulated Protein Kinase Signaling Pathway. Mol Neurobiol 2020; 57:3993-4006. [PMID: 32647973 DOI: 10.1007/s12035-020-01997-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 06/22/2020] [Indexed: 12/12/2022]
Abstract
The objective of this study was to explore the neuroprotective molecular mechanisms of erythropoietin (EPO) in rats following spinal cord injury (SCI). First, a standard SCI model was established. After drug or saline treatment was administered, locomotor function was evaluated in rats using the Basso, Beattie, and Bresnahan (BBB) locomotor rating scale. H&E, Nissl, and TUNEL staining were performed to assess the ratio of cavities, number of motor neurons, and apoptotic cells in the damaged area. The relative protein and mRNA expressions were examined using western blot and qRT-PCR analyses, and the inflammatory markers, axon special protein, and neuromuscular junctions (NMJs) were detected by immunofluorescence. Both doses of EPO notably improved locomotor function, but high-dose EPO was more effective than low-dose EPO. Moreover, EPO reduced the cavity ratio, cell apoptosis, and motor neuron loss in the damaged area, but enhanced the autophagy level and extracellular-regulated protein kinase (ERK) activity. Treatment with an ERK inhibitor significantly prevented the effect of EPO on SCI, and an activator mimicked the benefits of EPO. Further investigation revealed that EPO promoted SCI-induced autophagy via the ERK signaling pathway. EPO activates autophagy to promote locomotor function recovery in rats with SCI via the ERK signaling pathway.
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Affiliation(s)
- Lin Zhong
- Department of Orthopedics, The First Affiliated Hospital of Anhui Medical University, #218 Jixi Road, Hefei, 230022, China.,Department of Orthopedics, The Third Affiliated Hospital of Anhui Medical University, Hefei, Anhui Province, China
| | - Hui Zhang
- Department of Orthopedics, The First Affiliated Hospital of Anhui Medical University, #218 Jixi Road, Hefei, 230022, China
| | - Zheng-Fei Ding
- Department of Orthopedics, The First Affiliated Hospital of Anhui Medical University, #218 Jixi Road, Hefei, 230022, China
| | - Jian Li
- Department of Toxicology, School of Public Health, Anhui Medical University, #81 Mei Shan Road, Hefei, 230032, China.,Key Laboratory of Environmental Toxicology of Anhui Higher Education Institutes, Hefei, China
| | - Jin-Wei Lv
- Department of Toxicology, School of Public Health, Anhui Medical University, #81 Mei Shan Road, Hefei, 230032, China.,Key Laboratory of Environmental Toxicology of Anhui Higher Education Institutes, Hefei, China
| | - Zheng-Jun Pan
- Department of Orthopedics, The Third Affiliated Hospital of Anhui Medical University, Hefei, Anhui Province, China
| | - De-Xiang Xu
- Department of Toxicology, School of Public Health, Anhui Medical University, #81 Mei Shan Road, Hefei, 230032, China. .,Key Laboratory of Environmental Toxicology of Anhui Higher Education Institutes, Hefei, China.
| | - Zong-Sheng Yin
- Department of Orthopedics, The First Affiliated Hospital of Anhui Medical University, #218 Jixi Road, Hefei, 230022, China.
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Wersal C, Keller A, Weiss C, Giordano FA, Abo-Madyan Y, Tuschy B, Sütterlin M, Wenz F, Sperk E. Long-term changes in blood counts after intraoperative radiotherapy for breast cancer-single center experience and review of the literature. Transl Cancer Res 2019; 8:1882-1903. [PMID: 35116939 PMCID: PMC8799206 DOI: 10.21037/tcr.2019.09.05] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 08/26/2019] [Indexed: 01/04/2023]
Abstract
Background Intraoperative radiotherapy (IORT) for breast cancer is used as an upfront boost or as accelerated partial breast irradiation (APBI). To date, no description of blood count changes after IORT are available. Our analysis shows blood count changes in breast cancer patients up to 5 years after IORT ± whole breast radiotherapy (WBRT). Methods IORT was given as APBI in 58 patients (IORT/APBI-group) and as a boost in 198 patients (IORT/WBRT-group). A median dose of 20 Gy was given intraoperatively with low energy X-rays [INTRABEAM (TM) System] and additionally 46 Gy/2 Gy per fraction to the whole breast, if WBRT was added. Blood counts were collected preoperatively, after 90 days and through year 1–5 of follow-up. Dunnett’s tests were used to calculate changes in blood counts over time. Additionally, platelet-to-lymphocyte ratio (PLR), neutrophil-to-lymphocyte ratio (NLR) and derived neutrophil-to-lymphocyte ratio (dNLR) were calculated for each time point. Results Significantly decreases in the IORT/WBRT-group were seen for erythrocytes, hemoglobin, platelets and leucocytes and an increase for lymphocytes for the total follow-up period. In the IORT/APBI-group significantly decreases were seen for erythrocytes and hemoglobin for the total follow-up period. Regarding changes during follow-up compared to the preoperative value, much more significant changes were seen in the IORT/WBRT-group compared to IORT/APBI-group without any relevant impact of chemotherapy. Regarding PLR-, NLR- and dNLR-values the rate of patients over the range improved over time in both groups. Conclusions IORT/APBI seems to have a smaller effect on blood counts compared to IORT/WBRT. Furthermore, PLR-, NLR- and dNLR-values improved over time, suggesting a positive effect on outcome after IORT in general.
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Affiliation(s)
- Cornelia Wersal
- Department of Radiation Oncology, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Anke Keller
- Department of Radiation Oncology, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Christel Weiss
- Department of Clinical Statistics, Biomathematics, Information Processing, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Frank A Giordano
- Department of Radiation Oncology, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Yasser Abo-Madyan
- Department of Radiation Oncology, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Benjamin Tuschy
- Department of Gynecology and Obstetrics, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Marc Sütterlin
- Department of Gynecology and Obstetrics, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | | | - Elena Sperk
- Department of Radiation Oncology, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
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Référentiels inter régionaux en Soins Oncologiques de Support. ONCOLOGIE 2017. [DOI: 10.1007/s10269-017-2723-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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10
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Surrogacy of progression free survival for overall survival in metastatic breast cancer studies: Meta-analyses of published studies. Contemp Clin Trials 2017; 53:20-28. [DOI: 10.1016/j.cct.2016.12.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2016] [Revised: 11/30/2016] [Accepted: 12/03/2016] [Indexed: 11/19/2022]
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11
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Leyland-Jones B, Vercammen E, Xiu L. Reply to T. Hasegawa et al and I. Gross et al. J Clin Oncol 2016; 34:3820-3821. [PMID: 27507880 PMCID: PMC5477934 DOI: 10.1200/jco.2016.68.7681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Brian Leyland-Jones
- Brian Leyland-Jones, Avera Cancer Institute, Sioux Falls, SD; Els Vercammen and Liang Xiu, Janssen Research & Development, Raritan, NJ
| | - Els Vercammen
- Brian Leyland-Jones, Avera Cancer Institute, Sioux Falls, SD; Els Vercammen and Liang Xiu, Janssen Research & Development, Raritan, NJ
| | - Liang Xiu
- Brian Leyland-Jones, Avera Cancer Institute, Sioux Falls, SD; Els Vercammen and Liang Xiu, Janssen Research & Development, Raritan, NJ
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12
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The tumor promoting roles of erythropoietin/erythropoietin receptor signaling pathway in gastric cancer. Tumour Biol 2016; 37:11523-33. [DOI: 10.1007/s13277-016-5053-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2016] [Accepted: 04/01/2016] [Indexed: 12/17/2022] Open
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13
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RADWAN ESAMM, ABDULLAH RASEDEE, AL-QUBAISI MOTHANNASADIQ, EL ZOWALATY MOHAMEDE, NAADJA SEÏFEDDINE, ALITHEEN NOORJAHANB, OMAR ABDULRAHMAN. Effect of recombinant human erythropoietin and doxorubicinin combination on the proliferation of MCF-7 and MDA-MB231 breast cancer cells. Mol Med Rep 2016; 13:3945-52. [DOI: 10.3892/mmr.2016.4989] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2015] [Accepted: 08/19/2015] [Indexed: 11/05/2022] Open
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14
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Leyland-Jones B, Bondarenko I, Nemsadze G, Smirnov V, Litvin I, Kokhreidze I, Abshilava L, Janjalia M, Li R, Lakshmaiah KC, Samkharadze B, Tarasova O, Mohapatra RK, Sparyk Y, Polenkov S, Vladimirov V, Xiu L, Zhu E, Kimelblatt B, Deprince K, Safonov I, Bowers P, Vercammen E. A Randomized, Open-Label, Multicenter, Phase III Study of Epoetin Alfa Versus Best Standard of Care in Anemic Patients With Metastatic Breast Cancer Receiving Standard Chemotherapy. J Clin Oncol 2016; 34:1197-207. [PMID: 26858335 DOI: 10.1200/jco.2015.63.5649] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE An open-label, noninferiority study to evaluate the impact of epoetin alfa (EPO) on tumor outcomes when used to treat anemia in patients receiving chemotherapy for metastatic breast cancer. METHODS Women with hemoglobin ≤ 11.0 g/dL, receiving first- or second-line chemotherapy for metastatic breast cancer, were randomly assigned to EPO 40,000 IU subcutaneously once a week or best standard of care. The primary end point was progression-free survival (PFS). Secondary end points included overall survival, time to tumor progression, overall response rate, RBC transfusions, and thrombotic vascular events. RESULTS In 2,098 patients randomly assigned, median PFS (based on investigator-determined disease progression [PD]) was 7.4 months in both groups (hazard ratio [HR], 1.089; 95% CI, 0.988 to 1.200); upper bound exceeded prespecified noninferiority margin of 1.15. Median PFS per independent review committee-determined PD was 7.6 months in both groups (HR, 1.028; 95% CI, 0.922 to 1.146); upper bound did not exceed prespecified noninferiority margin. Median overall survival at clinical cutoff (1,337 deaths) was 17.2 months in the EPO and 17.4 months in the best standard of care group (HR, 1.057; 95% CI, 0.949 to 1.177), median time to tumor progression was 7.5 months in both groups (HR, 1.094; 95% CI, 0.991 to 1.209), and overall response rate was 50% versus 51% (odds ratio, 0.950; 95% CI, 0.799 to 1.130). RBC transfusions were 5.8% versus 11.4% (P < .001), and thrombotic vascular events were 2.8% versus 1.4% (P = .038), respectively. CONCLUSION The primary end point, PFS based on investigator-determined PD, did not meet noninferiority criteria. As a consistency assessment with the primary finding, PFS based on independent review committee-determined PD met noninferiority criteria. Overall, this study did not achieve noninferiority objective in ruling out a 15% increased risk in PD/death. RBC transfusion should be the preferred approach for the management of anemia in this population.
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Affiliation(s)
- Brian Leyland-Jones
- Brian Leyland-Jones, Avera Cancer Institute, Sioux Falls, SD; Igor Bondarenko, Dnepropetrovsk Medical Academy; and Iryna Litvin, Dnepropetrovsk Regional Oncological Dispensary, Dnepropetrovsk; Vitaliy Smirnov, Donetsk Regional Anticancer Center, Donetsk; Oksana Tarasova, Institute of Medical Radiology, Kharkiv; Yaroslav Sparyk, Lviv State Oncology Regional Treatment and Diagnostic Centre, Lviv; and Sergey Polenkov, Chernigov Regional Oncology Center, Chernigov, Ukraine; Gia Nemsadze, Institute of Clinical Oncology (LTD. K. Madichi Mammological Center); Irakli Kokhreidze, Martin D. Abeloff Laboratory Cancer Research Center; Lia Abshilava, Chemotherapy and Immunotherapy Clinic Medulla; Mikheil Janjalia, Tbilisi Cancer Center; and Beka Samkharadze, Research Institute of Clinical Medicine, Tbilisi, Georgia; Rubi Li, St. Luke's Medical Center, Quezon City, Philippines; Kuntegowda C. Lakshmaiah, Kidwai Memorial Institute of Oncology, Bangalore; and Ranjan Kumar Mohapatra, Apollo Specialty Hospital, Chennai, India; Vladimir Vladimirov, Pyatigorsk Oncology Dispensary, Pyatigorsk, Russian Federation; and Liang Xiu, Eugene Zhu, Bruce Kimelblatt, Kris Deprince, Ilya Safonov, Peter Bowers, and Els Vercammen, Janssen Research & Development, Raritan, NJ.
| | - Igor Bondarenko
- Brian Leyland-Jones, Avera Cancer Institute, Sioux Falls, SD; Igor Bondarenko, Dnepropetrovsk Medical Academy; and Iryna Litvin, Dnepropetrovsk Regional Oncological Dispensary, Dnepropetrovsk; Vitaliy Smirnov, Donetsk Regional Anticancer Center, Donetsk; Oksana Tarasova, Institute of Medical Radiology, Kharkiv; Yaroslav Sparyk, Lviv State Oncology Regional Treatment and Diagnostic Centre, Lviv; and Sergey Polenkov, Chernigov Regional Oncology Center, Chernigov, Ukraine; Gia Nemsadze, Institute of Clinical Oncology (LTD. K. Madichi Mammological Center); Irakli Kokhreidze, Martin D. Abeloff Laboratory Cancer Research Center; Lia Abshilava, Chemotherapy and Immunotherapy Clinic Medulla; Mikheil Janjalia, Tbilisi Cancer Center; and Beka Samkharadze, Research Institute of Clinical Medicine, Tbilisi, Georgia; Rubi Li, St. Luke's Medical Center, Quezon City, Philippines; Kuntegowda C. Lakshmaiah, Kidwai Memorial Institute of Oncology, Bangalore; and Ranjan Kumar Mohapatra, Apollo Specialty Hospital, Chennai, India; Vladimir Vladimirov, Pyatigorsk Oncology Dispensary, Pyatigorsk, Russian Federation; and Liang Xiu, Eugene Zhu, Bruce Kimelblatt, Kris Deprince, Ilya Safonov, Peter Bowers, and Els Vercammen, Janssen Research & Development, Raritan, NJ
| | - Gia Nemsadze
- Brian Leyland-Jones, Avera Cancer Institute, Sioux Falls, SD; Igor Bondarenko, Dnepropetrovsk Medical Academy; and Iryna Litvin, Dnepropetrovsk Regional Oncological Dispensary, Dnepropetrovsk; Vitaliy Smirnov, Donetsk Regional Anticancer Center, Donetsk; Oksana Tarasova, Institute of Medical Radiology, Kharkiv; Yaroslav Sparyk, Lviv State Oncology Regional Treatment and Diagnostic Centre, Lviv; and Sergey Polenkov, Chernigov Regional Oncology Center, Chernigov, Ukraine; Gia Nemsadze, Institute of Clinical Oncology (LTD. K. Madichi Mammological Center); Irakli Kokhreidze, Martin D. Abeloff Laboratory Cancer Research Center; Lia Abshilava, Chemotherapy and Immunotherapy Clinic Medulla; Mikheil Janjalia, Tbilisi Cancer Center; and Beka Samkharadze, Research Institute of Clinical Medicine, Tbilisi, Georgia; Rubi Li, St. Luke's Medical Center, Quezon City, Philippines; Kuntegowda C. Lakshmaiah, Kidwai Memorial Institute of Oncology, Bangalore; and Ranjan Kumar Mohapatra, Apollo Specialty Hospital, Chennai, India; Vladimir Vladimirov, Pyatigorsk Oncology Dispensary, Pyatigorsk, Russian Federation; and Liang Xiu, Eugene Zhu, Bruce Kimelblatt, Kris Deprince, Ilya Safonov, Peter Bowers, and Els Vercammen, Janssen Research & Development, Raritan, NJ
| | - Vitaliy Smirnov
- Brian Leyland-Jones, Avera Cancer Institute, Sioux Falls, SD; Igor Bondarenko, Dnepropetrovsk Medical Academy; and Iryna Litvin, Dnepropetrovsk Regional Oncological Dispensary, Dnepropetrovsk; Vitaliy Smirnov, Donetsk Regional Anticancer Center, Donetsk; Oksana Tarasova, Institute of Medical Radiology, Kharkiv; Yaroslav Sparyk, Lviv State Oncology Regional Treatment and Diagnostic Centre, Lviv; and Sergey Polenkov, Chernigov Regional Oncology Center, Chernigov, Ukraine; Gia Nemsadze, Institute of Clinical Oncology (LTD. K. Madichi Mammological Center); Irakli Kokhreidze, Martin D. Abeloff Laboratory Cancer Research Center; Lia Abshilava, Chemotherapy and Immunotherapy Clinic Medulla; Mikheil Janjalia, Tbilisi Cancer Center; and Beka Samkharadze, Research Institute of Clinical Medicine, Tbilisi, Georgia; Rubi Li, St. Luke's Medical Center, Quezon City, Philippines; Kuntegowda C. Lakshmaiah, Kidwai Memorial Institute of Oncology, Bangalore; and Ranjan Kumar Mohapatra, Apollo Specialty Hospital, Chennai, India; Vladimir Vladimirov, Pyatigorsk Oncology Dispensary, Pyatigorsk, Russian Federation; and Liang Xiu, Eugene Zhu, Bruce Kimelblatt, Kris Deprince, Ilya Safonov, Peter Bowers, and Els Vercammen, Janssen Research & Development, Raritan, NJ
| | - Iryna Litvin
- Brian Leyland-Jones, Avera Cancer Institute, Sioux Falls, SD; Igor Bondarenko, Dnepropetrovsk Medical Academy; and Iryna Litvin, Dnepropetrovsk Regional Oncological Dispensary, Dnepropetrovsk; Vitaliy Smirnov, Donetsk Regional Anticancer Center, Donetsk; Oksana Tarasova, Institute of Medical Radiology, Kharkiv; Yaroslav Sparyk, Lviv State Oncology Regional Treatment and Diagnostic Centre, Lviv; and Sergey Polenkov, Chernigov Regional Oncology Center, Chernigov, Ukraine; Gia Nemsadze, Institute of Clinical Oncology (LTD. K. Madichi Mammological Center); Irakli Kokhreidze, Martin D. Abeloff Laboratory Cancer Research Center; Lia Abshilava, Chemotherapy and Immunotherapy Clinic Medulla; Mikheil Janjalia, Tbilisi Cancer Center; and Beka Samkharadze, Research Institute of Clinical Medicine, Tbilisi, Georgia; Rubi Li, St. Luke's Medical Center, Quezon City, Philippines; Kuntegowda C. Lakshmaiah, Kidwai Memorial Institute of Oncology, Bangalore; and Ranjan Kumar Mohapatra, Apollo Specialty Hospital, Chennai, India; Vladimir Vladimirov, Pyatigorsk Oncology Dispensary, Pyatigorsk, Russian Federation; and Liang Xiu, Eugene Zhu, Bruce Kimelblatt, Kris Deprince, Ilya Safonov, Peter Bowers, and Els Vercammen, Janssen Research & Development, Raritan, NJ
| | - Irakli Kokhreidze
- Brian Leyland-Jones, Avera Cancer Institute, Sioux Falls, SD; Igor Bondarenko, Dnepropetrovsk Medical Academy; and Iryna Litvin, Dnepropetrovsk Regional Oncological Dispensary, Dnepropetrovsk; Vitaliy Smirnov, Donetsk Regional Anticancer Center, Donetsk; Oksana Tarasova, Institute of Medical Radiology, Kharkiv; Yaroslav Sparyk, Lviv State Oncology Regional Treatment and Diagnostic Centre, Lviv; and Sergey Polenkov, Chernigov Regional Oncology Center, Chernigov, Ukraine; Gia Nemsadze, Institute of Clinical Oncology (LTD. K. Madichi Mammological Center); Irakli Kokhreidze, Martin D. Abeloff Laboratory Cancer Research Center; Lia Abshilava, Chemotherapy and Immunotherapy Clinic Medulla; Mikheil Janjalia, Tbilisi Cancer Center; and Beka Samkharadze, Research Institute of Clinical Medicine, Tbilisi, Georgia; Rubi Li, St. Luke's Medical Center, Quezon City, Philippines; Kuntegowda C. Lakshmaiah, Kidwai Memorial Institute of Oncology, Bangalore; and Ranjan Kumar Mohapatra, Apollo Specialty Hospital, Chennai, India; Vladimir Vladimirov, Pyatigorsk Oncology Dispensary, Pyatigorsk, Russian Federation; and Liang Xiu, Eugene Zhu, Bruce Kimelblatt, Kris Deprince, Ilya Safonov, Peter Bowers, and Els Vercammen, Janssen Research & Development, Raritan, NJ
| | - Lia Abshilava
- Brian Leyland-Jones, Avera Cancer Institute, Sioux Falls, SD; Igor Bondarenko, Dnepropetrovsk Medical Academy; and Iryna Litvin, Dnepropetrovsk Regional Oncological Dispensary, Dnepropetrovsk; Vitaliy Smirnov, Donetsk Regional Anticancer Center, Donetsk; Oksana Tarasova, Institute of Medical Radiology, Kharkiv; Yaroslav Sparyk, Lviv State Oncology Regional Treatment and Diagnostic Centre, Lviv; and Sergey Polenkov, Chernigov Regional Oncology Center, Chernigov, Ukraine; Gia Nemsadze, Institute of Clinical Oncology (LTD. K. Madichi Mammological Center); Irakli Kokhreidze, Martin D. Abeloff Laboratory Cancer Research Center; Lia Abshilava, Chemotherapy and Immunotherapy Clinic Medulla; Mikheil Janjalia, Tbilisi Cancer Center; and Beka Samkharadze, Research Institute of Clinical Medicine, Tbilisi, Georgia; Rubi Li, St. Luke's Medical Center, Quezon City, Philippines; Kuntegowda C. Lakshmaiah, Kidwai Memorial Institute of Oncology, Bangalore; and Ranjan Kumar Mohapatra, Apollo Specialty Hospital, Chennai, India; Vladimir Vladimirov, Pyatigorsk Oncology Dispensary, Pyatigorsk, Russian Federation; and Liang Xiu, Eugene Zhu, Bruce Kimelblatt, Kris Deprince, Ilya Safonov, Peter Bowers, and Els Vercammen, Janssen Research & Development, Raritan, NJ
| | - Mikheil Janjalia
- Brian Leyland-Jones, Avera Cancer Institute, Sioux Falls, SD; Igor Bondarenko, Dnepropetrovsk Medical Academy; and Iryna Litvin, Dnepropetrovsk Regional Oncological Dispensary, Dnepropetrovsk; Vitaliy Smirnov, Donetsk Regional Anticancer Center, Donetsk; Oksana Tarasova, Institute of Medical Radiology, Kharkiv; Yaroslav Sparyk, Lviv State Oncology Regional Treatment and Diagnostic Centre, Lviv; and Sergey Polenkov, Chernigov Regional Oncology Center, Chernigov, Ukraine; Gia Nemsadze, Institute of Clinical Oncology (LTD. K. Madichi Mammological Center); Irakli Kokhreidze, Martin D. Abeloff Laboratory Cancer Research Center; Lia Abshilava, Chemotherapy and Immunotherapy Clinic Medulla; Mikheil Janjalia, Tbilisi Cancer Center; and Beka Samkharadze, Research Institute of Clinical Medicine, Tbilisi, Georgia; Rubi Li, St. Luke's Medical Center, Quezon City, Philippines; Kuntegowda C. Lakshmaiah, Kidwai Memorial Institute of Oncology, Bangalore; and Ranjan Kumar Mohapatra, Apollo Specialty Hospital, Chennai, India; Vladimir Vladimirov, Pyatigorsk Oncology Dispensary, Pyatigorsk, Russian Federation; and Liang Xiu, Eugene Zhu, Bruce Kimelblatt, Kris Deprince, Ilya Safonov, Peter Bowers, and Els Vercammen, Janssen Research & Development, Raritan, NJ
| | - Rubi Li
- Brian Leyland-Jones, Avera Cancer Institute, Sioux Falls, SD; Igor Bondarenko, Dnepropetrovsk Medical Academy; and Iryna Litvin, Dnepropetrovsk Regional Oncological Dispensary, Dnepropetrovsk; Vitaliy Smirnov, Donetsk Regional Anticancer Center, Donetsk; Oksana Tarasova, Institute of Medical Radiology, Kharkiv; Yaroslav Sparyk, Lviv State Oncology Regional Treatment and Diagnostic Centre, Lviv; and Sergey Polenkov, Chernigov Regional Oncology Center, Chernigov, Ukraine; Gia Nemsadze, Institute of Clinical Oncology (LTD. K. Madichi Mammological Center); Irakli Kokhreidze, Martin D. Abeloff Laboratory Cancer Research Center; Lia Abshilava, Chemotherapy and Immunotherapy Clinic Medulla; Mikheil Janjalia, Tbilisi Cancer Center; and Beka Samkharadze, Research Institute of Clinical Medicine, Tbilisi, Georgia; Rubi Li, St. Luke's Medical Center, Quezon City, Philippines; Kuntegowda C. Lakshmaiah, Kidwai Memorial Institute of Oncology, Bangalore; and Ranjan Kumar Mohapatra, Apollo Specialty Hospital, Chennai, India; Vladimir Vladimirov, Pyatigorsk Oncology Dispensary, Pyatigorsk, Russian Federation; and Liang Xiu, Eugene Zhu, Bruce Kimelblatt, Kris Deprince, Ilya Safonov, Peter Bowers, and Els Vercammen, Janssen Research & Development, Raritan, NJ
| | - Kuntegowda C Lakshmaiah
- Brian Leyland-Jones, Avera Cancer Institute, Sioux Falls, SD; Igor Bondarenko, Dnepropetrovsk Medical Academy; and Iryna Litvin, Dnepropetrovsk Regional Oncological Dispensary, Dnepropetrovsk; Vitaliy Smirnov, Donetsk Regional Anticancer Center, Donetsk; Oksana Tarasova, Institute of Medical Radiology, Kharkiv; Yaroslav Sparyk, Lviv State Oncology Regional Treatment and Diagnostic Centre, Lviv; and Sergey Polenkov, Chernigov Regional Oncology Center, Chernigov, Ukraine; Gia Nemsadze, Institute of Clinical Oncology (LTD. K. Madichi Mammological Center); Irakli Kokhreidze, Martin D. Abeloff Laboratory Cancer Research Center; Lia Abshilava, Chemotherapy and Immunotherapy Clinic Medulla; Mikheil Janjalia, Tbilisi Cancer Center; and Beka Samkharadze, Research Institute of Clinical Medicine, Tbilisi, Georgia; Rubi Li, St. Luke's Medical Center, Quezon City, Philippines; Kuntegowda C. Lakshmaiah, Kidwai Memorial Institute of Oncology, Bangalore; and Ranjan Kumar Mohapatra, Apollo Specialty Hospital, Chennai, India; Vladimir Vladimirov, Pyatigorsk Oncology Dispensary, Pyatigorsk, Russian Federation; and Liang Xiu, Eugene Zhu, Bruce Kimelblatt, Kris Deprince, Ilya Safonov, Peter Bowers, and Els Vercammen, Janssen Research & Development, Raritan, NJ
| | - Beka Samkharadze
- Brian Leyland-Jones, Avera Cancer Institute, Sioux Falls, SD; Igor Bondarenko, Dnepropetrovsk Medical Academy; and Iryna Litvin, Dnepropetrovsk Regional Oncological Dispensary, Dnepropetrovsk; Vitaliy Smirnov, Donetsk Regional Anticancer Center, Donetsk; Oksana Tarasova, Institute of Medical Radiology, Kharkiv; Yaroslav Sparyk, Lviv State Oncology Regional Treatment and Diagnostic Centre, Lviv; and Sergey Polenkov, Chernigov Regional Oncology Center, Chernigov, Ukraine; Gia Nemsadze, Institute of Clinical Oncology (LTD. K. Madichi Mammological Center); Irakli Kokhreidze, Martin D. Abeloff Laboratory Cancer Research Center; Lia Abshilava, Chemotherapy and Immunotherapy Clinic Medulla; Mikheil Janjalia, Tbilisi Cancer Center; and Beka Samkharadze, Research Institute of Clinical Medicine, Tbilisi, Georgia; Rubi Li, St. Luke's Medical Center, Quezon City, Philippines; Kuntegowda C. Lakshmaiah, Kidwai Memorial Institute of Oncology, Bangalore; and Ranjan Kumar Mohapatra, Apollo Specialty Hospital, Chennai, India; Vladimir Vladimirov, Pyatigorsk Oncology Dispensary, Pyatigorsk, Russian Federation; and Liang Xiu, Eugene Zhu, Bruce Kimelblatt, Kris Deprince, Ilya Safonov, Peter Bowers, and Els Vercammen, Janssen Research & Development, Raritan, NJ
| | - Oksana Tarasova
- Brian Leyland-Jones, Avera Cancer Institute, Sioux Falls, SD; Igor Bondarenko, Dnepropetrovsk Medical Academy; and Iryna Litvin, Dnepropetrovsk Regional Oncological Dispensary, Dnepropetrovsk; Vitaliy Smirnov, Donetsk Regional Anticancer Center, Donetsk; Oksana Tarasova, Institute of Medical Radiology, Kharkiv; Yaroslav Sparyk, Lviv State Oncology Regional Treatment and Diagnostic Centre, Lviv; and Sergey Polenkov, Chernigov Regional Oncology Center, Chernigov, Ukraine; Gia Nemsadze, Institute of Clinical Oncology (LTD. K. Madichi Mammological Center); Irakli Kokhreidze, Martin D. Abeloff Laboratory Cancer Research Center; Lia Abshilava, Chemotherapy and Immunotherapy Clinic Medulla; Mikheil Janjalia, Tbilisi Cancer Center; and Beka Samkharadze, Research Institute of Clinical Medicine, Tbilisi, Georgia; Rubi Li, St. Luke's Medical Center, Quezon City, Philippines; Kuntegowda C. Lakshmaiah, Kidwai Memorial Institute of Oncology, Bangalore; and Ranjan Kumar Mohapatra, Apollo Specialty Hospital, Chennai, India; Vladimir Vladimirov, Pyatigorsk Oncology Dispensary, Pyatigorsk, Russian Federation; and Liang Xiu, Eugene Zhu, Bruce Kimelblatt, Kris Deprince, Ilya Safonov, Peter Bowers, and Els Vercammen, Janssen Research & Development, Raritan, NJ
| | - Ranjan Kumar Mohapatra
- Brian Leyland-Jones, Avera Cancer Institute, Sioux Falls, SD; Igor Bondarenko, Dnepropetrovsk Medical Academy; and Iryna Litvin, Dnepropetrovsk Regional Oncological Dispensary, Dnepropetrovsk; Vitaliy Smirnov, Donetsk Regional Anticancer Center, Donetsk; Oksana Tarasova, Institute of Medical Radiology, Kharkiv; Yaroslav Sparyk, Lviv State Oncology Regional Treatment and Diagnostic Centre, Lviv; and Sergey Polenkov, Chernigov Regional Oncology Center, Chernigov, Ukraine; Gia Nemsadze, Institute of Clinical Oncology (LTD. K. Madichi Mammological Center); Irakli Kokhreidze, Martin D. Abeloff Laboratory Cancer Research Center; Lia Abshilava, Chemotherapy and Immunotherapy Clinic Medulla; Mikheil Janjalia, Tbilisi Cancer Center; and Beka Samkharadze, Research Institute of Clinical Medicine, Tbilisi, Georgia; Rubi Li, St. Luke's Medical Center, Quezon City, Philippines; Kuntegowda C. Lakshmaiah, Kidwai Memorial Institute of Oncology, Bangalore; and Ranjan Kumar Mohapatra, Apollo Specialty Hospital, Chennai, India; Vladimir Vladimirov, Pyatigorsk Oncology Dispensary, Pyatigorsk, Russian Federation; and Liang Xiu, Eugene Zhu, Bruce Kimelblatt, Kris Deprince, Ilya Safonov, Peter Bowers, and Els Vercammen, Janssen Research & Development, Raritan, NJ
| | - Yaroslav Sparyk
- Brian Leyland-Jones, Avera Cancer Institute, Sioux Falls, SD; Igor Bondarenko, Dnepropetrovsk Medical Academy; and Iryna Litvin, Dnepropetrovsk Regional Oncological Dispensary, Dnepropetrovsk; Vitaliy Smirnov, Donetsk Regional Anticancer Center, Donetsk; Oksana Tarasova, Institute of Medical Radiology, Kharkiv; Yaroslav Sparyk, Lviv State Oncology Regional Treatment and Diagnostic Centre, Lviv; and Sergey Polenkov, Chernigov Regional Oncology Center, Chernigov, Ukraine; Gia Nemsadze, Institute of Clinical Oncology (LTD. K. Madichi Mammological Center); Irakli Kokhreidze, Martin D. Abeloff Laboratory Cancer Research Center; Lia Abshilava, Chemotherapy and Immunotherapy Clinic Medulla; Mikheil Janjalia, Tbilisi Cancer Center; and Beka Samkharadze, Research Institute of Clinical Medicine, Tbilisi, Georgia; Rubi Li, St. Luke's Medical Center, Quezon City, Philippines; Kuntegowda C. Lakshmaiah, Kidwai Memorial Institute of Oncology, Bangalore; and Ranjan Kumar Mohapatra, Apollo Specialty Hospital, Chennai, India; Vladimir Vladimirov, Pyatigorsk Oncology Dispensary, Pyatigorsk, Russian Federation; and Liang Xiu, Eugene Zhu, Bruce Kimelblatt, Kris Deprince, Ilya Safonov, Peter Bowers, and Els Vercammen, Janssen Research & Development, Raritan, NJ
| | - Sergey Polenkov
- Brian Leyland-Jones, Avera Cancer Institute, Sioux Falls, SD; Igor Bondarenko, Dnepropetrovsk Medical Academy; and Iryna Litvin, Dnepropetrovsk Regional Oncological Dispensary, Dnepropetrovsk; Vitaliy Smirnov, Donetsk Regional Anticancer Center, Donetsk; Oksana Tarasova, Institute of Medical Radiology, Kharkiv; Yaroslav Sparyk, Lviv State Oncology Regional Treatment and Diagnostic Centre, Lviv; and Sergey Polenkov, Chernigov Regional Oncology Center, Chernigov, Ukraine; Gia Nemsadze, Institute of Clinical Oncology (LTD. K. Madichi Mammological Center); Irakli Kokhreidze, Martin D. Abeloff Laboratory Cancer Research Center; Lia Abshilava, Chemotherapy and Immunotherapy Clinic Medulla; Mikheil Janjalia, Tbilisi Cancer Center; and Beka Samkharadze, Research Institute of Clinical Medicine, Tbilisi, Georgia; Rubi Li, St. Luke's Medical Center, Quezon City, Philippines; Kuntegowda C. Lakshmaiah, Kidwai Memorial Institute of Oncology, Bangalore; and Ranjan Kumar Mohapatra, Apollo Specialty Hospital, Chennai, India; Vladimir Vladimirov, Pyatigorsk Oncology Dispensary, Pyatigorsk, Russian Federation; and Liang Xiu, Eugene Zhu, Bruce Kimelblatt, Kris Deprince, Ilya Safonov, Peter Bowers, and Els Vercammen, Janssen Research & Development, Raritan, NJ
| | - Vladimir Vladimirov
- Brian Leyland-Jones, Avera Cancer Institute, Sioux Falls, SD; Igor Bondarenko, Dnepropetrovsk Medical Academy; and Iryna Litvin, Dnepropetrovsk Regional Oncological Dispensary, Dnepropetrovsk; Vitaliy Smirnov, Donetsk Regional Anticancer Center, Donetsk; Oksana Tarasova, Institute of Medical Radiology, Kharkiv; Yaroslav Sparyk, Lviv State Oncology Regional Treatment and Diagnostic Centre, Lviv; and Sergey Polenkov, Chernigov Regional Oncology Center, Chernigov, Ukraine; Gia Nemsadze, Institute of Clinical Oncology (LTD. K. Madichi Mammological Center); Irakli Kokhreidze, Martin D. Abeloff Laboratory Cancer Research Center; Lia Abshilava, Chemotherapy and Immunotherapy Clinic Medulla; Mikheil Janjalia, Tbilisi Cancer Center; and Beka Samkharadze, Research Institute of Clinical Medicine, Tbilisi, Georgia; Rubi Li, St. Luke's Medical Center, Quezon City, Philippines; Kuntegowda C. Lakshmaiah, Kidwai Memorial Institute of Oncology, Bangalore; and Ranjan Kumar Mohapatra, Apollo Specialty Hospital, Chennai, India; Vladimir Vladimirov, Pyatigorsk Oncology Dispensary, Pyatigorsk, Russian Federation; and Liang Xiu, Eugene Zhu, Bruce Kimelblatt, Kris Deprince, Ilya Safonov, Peter Bowers, and Els Vercammen, Janssen Research & Development, Raritan, NJ
| | - Liang Xiu
- Brian Leyland-Jones, Avera Cancer Institute, Sioux Falls, SD; Igor Bondarenko, Dnepropetrovsk Medical Academy; and Iryna Litvin, Dnepropetrovsk Regional Oncological Dispensary, Dnepropetrovsk; Vitaliy Smirnov, Donetsk Regional Anticancer Center, Donetsk; Oksana Tarasova, Institute of Medical Radiology, Kharkiv; Yaroslav Sparyk, Lviv State Oncology Regional Treatment and Diagnostic Centre, Lviv; and Sergey Polenkov, Chernigov Regional Oncology Center, Chernigov, Ukraine; Gia Nemsadze, Institute of Clinical Oncology (LTD. K. Madichi Mammological Center); Irakli Kokhreidze, Martin D. Abeloff Laboratory Cancer Research Center; Lia Abshilava, Chemotherapy and Immunotherapy Clinic Medulla; Mikheil Janjalia, Tbilisi Cancer Center; and Beka Samkharadze, Research Institute of Clinical Medicine, Tbilisi, Georgia; Rubi Li, St. Luke's Medical Center, Quezon City, Philippines; Kuntegowda C. Lakshmaiah, Kidwai Memorial Institute of Oncology, Bangalore; and Ranjan Kumar Mohapatra, Apollo Specialty Hospital, Chennai, India; Vladimir Vladimirov, Pyatigorsk Oncology Dispensary, Pyatigorsk, Russian Federation; and Liang Xiu, Eugene Zhu, Bruce Kimelblatt, Kris Deprince, Ilya Safonov, Peter Bowers, and Els Vercammen, Janssen Research & Development, Raritan, NJ
| | - Eugene Zhu
- Brian Leyland-Jones, Avera Cancer Institute, Sioux Falls, SD; Igor Bondarenko, Dnepropetrovsk Medical Academy; and Iryna Litvin, Dnepropetrovsk Regional Oncological Dispensary, Dnepropetrovsk; Vitaliy Smirnov, Donetsk Regional Anticancer Center, Donetsk; Oksana Tarasova, Institute of Medical Radiology, Kharkiv; Yaroslav Sparyk, Lviv State Oncology Regional Treatment and Diagnostic Centre, Lviv; and Sergey Polenkov, Chernigov Regional Oncology Center, Chernigov, Ukraine; Gia Nemsadze, Institute of Clinical Oncology (LTD. K. Madichi Mammological Center); Irakli Kokhreidze, Martin D. Abeloff Laboratory Cancer Research Center; Lia Abshilava, Chemotherapy and Immunotherapy Clinic Medulla; Mikheil Janjalia, Tbilisi Cancer Center; and Beka Samkharadze, Research Institute of Clinical Medicine, Tbilisi, Georgia; Rubi Li, St. Luke's Medical Center, Quezon City, Philippines; Kuntegowda C. Lakshmaiah, Kidwai Memorial Institute of Oncology, Bangalore; and Ranjan Kumar Mohapatra, Apollo Specialty Hospital, Chennai, India; Vladimir Vladimirov, Pyatigorsk Oncology Dispensary, Pyatigorsk, Russian Federation; and Liang Xiu, Eugene Zhu, Bruce Kimelblatt, Kris Deprince, Ilya Safonov, Peter Bowers, and Els Vercammen, Janssen Research & Development, Raritan, NJ
| | - Bruce Kimelblatt
- Brian Leyland-Jones, Avera Cancer Institute, Sioux Falls, SD; Igor Bondarenko, Dnepropetrovsk Medical Academy; and Iryna Litvin, Dnepropetrovsk Regional Oncological Dispensary, Dnepropetrovsk; Vitaliy Smirnov, Donetsk Regional Anticancer Center, Donetsk; Oksana Tarasova, Institute of Medical Radiology, Kharkiv; Yaroslav Sparyk, Lviv State Oncology Regional Treatment and Diagnostic Centre, Lviv; and Sergey Polenkov, Chernigov Regional Oncology Center, Chernigov, Ukraine; Gia Nemsadze, Institute of Clinical Oncology (LTD. K. Madichi Mammological Center); Irakli Kokhreidze, Martin D. Abeloff Laboratory Cancer Research Center; Lia Abshilava, Chemotherapy and Immunotherapy Clinic Medulla; Mikheil Janjalia, Tbilisi Cancer Center; and Beka Samkharadze, Research Institute of Clinical Medicine, Tbilisi, Georgia; Rubi Li, St. Luke's Medical Center, Quezon City, Philippines; Kuntegowda C. Lakshmaiah, Kidwai Memorial Institute of Oncology, Bangalore; and Ranjan Kumar Mohapatra, Apollo Specialty Hospital, Chennai, India; Vladimir Vladimirov, Pyatigorsk Oncology Dispensary, Pyatigorsk, Russian Federation; and Liang Xiu, Eugene Zhu, Bruce Kimelblatt, Kris Deprince, Ilya Safonov, Peter Bowers, and Els Vercammen, Janssen Research & Development, Raritan, NJ
| | - Kris Deprince
- Brian Leyland-Jones, Avera Cancer Institute, Sioux Falls, SD; Igor Bondarenko, Dnepropetrovsk Medical Academy; and Iryna Litvin, Dnepropetrovsk Regional Oncological Dispensary, Dnepropetrovsk; Vitaliy Smirnov, Donetsk Regional Anticancer Center, Donetsk; Oksana Tarasova, Institute of Medical Radiology, Kharkiv; Yaroslav Sparyk, Lviv State Oncology Regional Treatment and Diagnostic Centre, Lviv; and Sergey Polenkov, Chernigov Regional Oncology Center, Chernigov, Ukraine; Gia Nemsadze, Institute of Clinical Oncology (LTD. K. Madichi Mammological Center); Irakli Kokhreidze, Martin D. Abeloff Laboratory Cancer Research Center; Lia Abshilava, Chemotherapy and Immunotherapy Clinic Medulla; Mikheil Janjalia, Tbilisi Cancer Center; and Beka Samkharadze, Research Institute of Clinical Medicine, Tbilisi, Georgia; Rubi Li, St. Luke's Medical Center, Quezon City, Philippines; Kuntegowda C. Lakshmaiah, Kidwai Memorial Institute of Oncology, Bangalore; and Ranjan Kumar Mohapatra, Apollo Specialty Hospital, Chennai, India; Vladimir Vladimirov, Pyatigorsk Oncology Dispensary, Pyatigorsk, Russian Federation; and Liang Xiu, Eugene Zhu, Bruce Kimelblatt, Kris Deprince, Ilya Safonov, Peter Bowers, and Els Vercammen, Janssen Research & Development, Raritan, NJ
| | - Ilya Safonov
- Brian Leyland-Jones, Avera Cancer Institute, Sioux Falls, SD; Igor Bondarenko, Dnepropetrovsk Medical Academy; and Iryna Litvin, Dnepropetrovsk Regional Oncological Dispensary, Dnepropetrovsk; Vitaliy Smirnov, Donetsk Regional Anticancer Center, Donetsk; Oksana Tarasova, Institute of Medical Radiology, Kharkiv; Yaroslav Sparyk, Lviv State Oncology Regional Treatment and Diagnostic Centre, Lviv; and Sergey Polenkov, Chernigov Regional Oncology Center, Chernigov, Ukraine; Gia Nemsadze, Institute of Clinical Oncology (LTD. K. Madichi Mammological Center); Irakli Kokhreidze, Martin D. Abeloff Laboratory Cancer Research Center; Lia Abshilava, Chemotherapy and Immunotherapy Clinic Medulla; Mikheil Janjalia, Tbilisi Cancer Center; and Beka Samkharadze, Research Institute of Clinical Medicine, Tbilisi, Georgia; Rubi Li, St. Luke's Medical Center, Quezon City, Philippines; Kuntegowda C. Lakshmaiah, Kidwai Memorial Institute of Oncology, Bangalore; and Ranjan Kumar Mohapatra, Apollo Specialty Hospital, Chennai, India; Vladimir Vladimirov, Pyatigorsk Oncology Dispensary, Pyatigorsk, Russian Federation; and Liang Xiu, Eugene Zhu, Bruce Kimelblatt, Kris Deprince, Ilya Safonov, Peter Bowers, and Els Vercammen, Janssen Research & Development, Raritan, NJ
| | - Peter Bowers
- Brian Leyland-Jones, Avera Cancer Institute, Sioux Falls, SD; Igor Bondarenko, Dnepropetrovsk Medical Academy; and Iryna Litvin, Dnepropetrovsk Regional Oncological Dispensary, Dnepropetrovsk; Vitaliy Smirnov, Donetsk Regional Anticancer Center, Donetsk; Oksana Tarasova, Institute of Medical Radiology, Kharkiv; Yaroslav Sparyk, Lviv State Oncology Regional Treatment and Diagnostic Centre, Lviv; and Sergey Polenkov, Chernigov Regional Oncology Center, Chernigov, Ukraine; Gia Nemsadze, Institute of Clinical Oncology (LTD. K. Madichi Mammological Center); Irakli Kokhreidze, Martin D. Abeloff Laboratory Cancer Research Center; Lia Abshilava, Chemotherapy and Immunotherapy Clinic Medulla; Mikheil Janjalia, Tbilisi Cancer Center; and Beka Samkharadze, Research Institute of Clinical Medicine, Tbilisi, Georgia; Rubi Li, St. Luke's Medical Center, Quezon City, Philippines; Kuntegowda C. Lakshmaiah, Kidwai Memorial Institute of Oncology, Bangalore; and Ranjan Kumar Mohapatra, Apollo Specialty Hospital, Chennai, India; Vladimir Vladimirov, Pyatigorsk Oncology Dispensary, Pyatigorsk, Russian Federation; and Liang Xiu, Eugene Zhu, Bruce Kimelblatt, Kris Deprince, Ilya Safonov, Peter Bowers, and Els Vercammen, Janssen Research & Development, Raritan, NJ
| | - Els Vercammen
- Brian Leyland-Jones, Avera Cancer Institute, Sioux Falls, SD; Igor Bondarenko, Dnepropetrovsk Medical Academy; and Iryna Litvin, Dnepropetrovsk Regional Oncological Dispensary, Dnepropetrovsk; Vitaliy Smirnov, Donetsk Regional Anticancer Center, Donetsk; Oksana Tarasova, Institute of Medical Radiology, Kharkiv; Yaroslav Sparyk, Lviv State Oncology Regional Treatment and Diagnostic Centre, Lviv; and Sergey Polenkov, Chernigov Regional Oncology Center, Chernigov, Ukraine; Gia Nemsadze, Institute of Clinical Oncology (LTD. K. Madichi Mammological Center); Irakli Kokhreidze, Martin D. Abeloff Laboratory Cancer Research Center; Lia Abshilava, Chemotherapy and Immunotherapy Clinic Medulla; Mikheil Janjalia, Tbilisi Cancer Center; and Beka Samkharadze, Research Institute of Clinical Medicine, Tbilisi, Georgia; Rubi Li, St. Luke's Medical Center, Quezon City, Philippines; Kuntegowda C. Lakshmaiah, Kidwai Memorial Institute of Oncology, Bangalore; and Ranjan Kumar Mohapatra, Apollo Specialty Hospital, Chennai, India; Vladimir Vladimirov, Pyatigorsk Oncology Dispensary, Pyatigorsk, Russian Federation; and Liang Xiu, Eugene Zhu, Bruce Kimelblatt, Kris Deprince, Ilya Safonov, Peter Bowers, and Els Vercammen, Janssen Research & Development, Raritan, NJ
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The effects of erythropoiesis-stimulating agents on the short-term and long-term survivals in metastatic breast cancer patients receiving chemotherapy: a SEER population-based study. Breast Cancer Res Treat 2015; 153:407-16. [PMID: 26264468 DOI: 10.1007/s10549-015-3532-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Accepted: 08/07/2015] [Indexed: 10/23/2022]
Abstract
Current clinical guidelines state that the use of erythropoiesis-stimulating agents (ESAs) may be considered to treat chemotherapy-induced anemia in the non-curative setting to alleviate anemia-related symptoms. However, no convincing survival benefit has been demonstrated to support the use of ESAs in these patients. Using the comprehensive data collected in the National Cancer Institute (NCI)-surveillance epidemiology and end results (SEER) and Medicare-linked database, we analyzed the effect of ESA use on the short-term (18-month) and long-term (60-month) survival rates of chemotherapy-treated metastatic breast cancer patients. Confounding variables were adjusted using a propensity score approach. We also analyzed the effects of ESA on the survival of patients receiving trastuzumab, a commonly prescribed targeted therapy agent in treating HER2-positive tumors. Metastatic breast cancer patients who received ESA treatment exhibited similar 60-month survival rate to those without ESA treatment (22.8 vs. 24.9%, p = 0.8). ESA-treated patients had a trend toward better 18-month survival [crude hazard ratio (HR) 0.86, 95% confidence intervals (CI) 0.68-1.09, p = 0.21]. This protective effect during the first 18 months of chemotherapy became marginally significant after adjusting for the propensity of receiving ESAs (HR 0.80, 95% CI 0.63-1.01, p = 0.070). An interaction effect between ESA and trastuzumab on patient survival was noticeable but not statistically significant. ESAs did not negatively affect the long-term survival of metastatic breast cancer patients. Moreover, ESAs improved patients' survival during the first 18 months of chemotherapy treatment. These findings endorse the current clinical guideline. Given the short survival of these patients, the potential short-term beneficial effects of ESAs are clinically meaningful.
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16
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Beauchemin C, Johnston JB, Lapierre MÈ, Aissa F, Lachaine J. Relationship between progression-free survival and overall survival in chronic lymphocytic leukemia: a literature-based analysis. ACTA ACUST UNITED AC 2015; 22:e148-56. [PMID: 26089725 DOI: 10.3747/co.22.2119] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The endpoints of progression-free survival (pfs) and time-to-progression (ttp) are frequently used to evaluate the clinical benefit of anticancer drugs. However, the surrogacy of those endpoints for overall survival (os) is not validated in all cancer settings. In the present study, we used a trial-based approach to assess the relationship between median pfs or ttp and median os in chronic lymphocytic leukemia (cll). METHODS The pico (population, interventions, comparators, outcomes) method was used to conduct a systematic review of the literature. The population consisted of patients with cll; the interventions and comparators were standard therapies for cll; and the outcomes were median pfs, ttp, and os. Two independent reviewers screened titles, abstracts, and full papers for eligibility and then extracted data from selected studies. Correlation coefficients were calculated to assess the relationship between median pfs or ttp and median os. Subgroup correlation analyses were also conducted according to the characteristics of the selected studies (such as line of treatment and type of treatment under investigation). RESULTS Of the 1263 potentially relevant articles identified during the literature search, twenty-three were included. On average, median pfs or ttp was 16.0 months (standard deviation: 12.4 months) and median os was 43.5 months (standard deviation: 31.2 months). Results of the correlation analysis indicated that median pfs or ttp is highly correlated with median os (Spearman correlation coefficient: 0.813; p ≤ 0.001). A significant correlation between median pfs or ttp and median os was observed in second- and subsequent-line therapies, but not in the first-line setting. CONCLUSIONS Our study demonstrates a strong correlation between median pfs or ttp and median os in previously treated cll, which reinforce the hypothesis that pfs and ttp could be adequate surrogate endpoints for os in this cancer setting.
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Affiliation(s)
| | - J B Johnston
- Manitoba Institute of Cell Biology, Winnipeg, MB
| | | | - F Aissa
- Lundbeck Canada, Montreal, QC
| | - J Lachaine
- Faculty of Pharmacy, University of Montreal, QC
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17
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Aapro M, Moebus V, Nitz U, O'Shaughnessy J, Pronzato P, Untch M, Tomita D, Bohac C, Leyland-Jones B. Safety and efficacy outcomes with erythropoiesis-stimulating agents in patients with breast cancer: a meta-analysis. Ann Oncol 2015; 26:688-695. [DOI: 10.1093/annonc/mdu579] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
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18
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Galli L, Ricci C, Egan CG. Epoetin beta for the treatment of chemotherapy-induced anemia: an update. Onco Targets Ther 2015; 8:583-91. [PMID: 25784818 PMCID: PMC4356683 DOI: 10.2147/ott.s77497] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Epoetin beta belongs to the class of erythropoiesis-stimulating agents (ESAs) that are currently available to treat anemic patients receiving chemotherapy. Chemotherapy-induced anemia affects a high percentage of cancer patients and, due to its negative effects on disease outcome and the patient’s quality of life, should be treated when first diagnosed. Initial trials with ESAs have shown efficacy in improving quality of life and reducing the need for blood transfusions in patients with chemotherapy-induced anemia. However, recent meta-analyses have provided conflicting data on the impact of ESAs on survival and tumor progression. Here we provide an overview of these recent data and review the role of epoetin beta in the treatment of chemotherapy-induced anemia over the past 20 years.
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Affiliation(s)
- Luca Galli
- Oncology Unit 2, University Hospital of Pisa, Pisa, Italy
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19
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Erythropoiesis stimulating agents and clinical outcomes of invasive breast cancer patients receiving cytotoxic chemotherapy. Breast Cancer Res Treat 2014; 148:175-85. [PMID: 25261294 DOI: 10.1007/s10549-014-3152-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Accepted: 09/21/2014] [Indexed: 10/24/2022]
Abstract
The use of erythropoiesis stimulating agents (ESAs) to treat anemia in breast cancer patients who are treated with chemotherapy is a matter of ongoing debate. Several recent randomized trials challenged conventional wisdom, which holds that ESAs are contraindicated for breast cancer patients undergoing curative treatment. We aimed to perform the first large national population-based study to analyze the association between ESA use and breast cancer patient outcomes. Cytotoxic chemotherapy-treated invasive breast cancer patients were identified from the Surveillance, Epidemiology, and End Results (SEER)-Medicare database. Non-ESA users were sequentially 1:1 matched to 2,000 randomly sampled ESA users on demographics (age, diagnosis year, race, marital status, and socioeconomic status), tumor presentation (stage, grade, and status of hormone receptors), and treatments (surgery, radiation, and sub-types of chemotherapy) using a minimum distant strategy. Breast cancer-specific survival of ESA and matched non-ESA users was compared using Fine and Gray competing risk model. Compared to ESA users, non-ESA users exhibited dramatically different baseline characteristics such as less advanced tumor, and fewer co-morbidities. Non-ESA users had a significantly more favorable breast cancer-specific survival (subdistribution hazard ratio [sHR] = 0.75, p < 0.0001). This survival disparity was progressively diminished in the sequential matching of demographics (sHR = 0.74, p = 0.0004), presentation (sHR = 0.86, p = 0.06), and treatment (sHR = 0.89, p = 0.17) variables. Stratified analyses identified subgroups of patients whose breast cancer-specific survival were not different between ESA and non-ESA users. In the SEER-Medicare database, ESA usage does not seem to be associated with unfavorable breast cancer-specific survival in breast cancer patients receiving cytotoxic chemotherapy. The ESA-breast cancer prognosis association is complex and requires more intensive investigations.
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20
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Bohlius J, Tonia T, Nüesch E, Jüni P, Fey MF, Egger M, Bernhard J. Effects of erythropoiesis-stimulating agents on fatigue- and anaemia-related symptoms in cancer patients: systematic review and meta-analyses of published and unpublished data. Br J Cancer 2014; 111:33-45. [PMID: 24743705 PMCID: PMC4090721 DOI: 10.1038/bjc.2014.171] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2013] [Revised: 02/27/2014] [Accepted: 03/10/2014] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Erythropoiesis-stimulating agents (ESAs) reduce the need for red blood cell transfusions; however, they increase the risk of thromboembolic events and mortality. The impact of ESAs on quality of life (QoL) is controversial and led to different recommendations of medical societies and authorities in the USA and Europe. We aimed to critically evaluate and quantify the effects of ESAs on QoL in cancer patients. METHODS We included data from randomised controlled trials (RCTs) on the effects of ESAs on QoL in cancer patients. Randomised controlled trials were identified by searching electronic data bases and other sources up to January 2011. To reduce publication and outcome reporting biases, we included unreported results from clinical study reports. We conducted meta-analyses on fatigue- and anaemia-related symptoms measured with the Functional Assessment of Cancer Therapy-Fatigue (FACT-F) and FACT-Anaemia (FACT-An) subscales (primary outcomes) or other validated instruments. RESULTS We identified 58 eligible RCTs. Clinical study reports were available for 27% (4 out of 15) of the investigator-initiated trials and 95% (41 out of 43) of the industry-initiated trials. We excluded 21 RTCs as we could not use their QoL data for meta-analyses, either because of incomplete reporting (17 RCTs) or because of premature closure of the trial (4 RCTs). We included 37 RCTs with 10581 patients; 21 RCTs were placebo controlled. Chemotherapy was given in 27 of the 37 RCTs. The median baseline haemoglobin (Hb) level was 10.1 g dl(-1); in 8 studies ESAs were stopped at Hb levels below 13 g dl(-1) and in 27 above 13 g dl(-1). For FACT-F, the mean difference (MD) was 2.41 (95% confidence interval (95% CI) 1.39-3.43; P<0.0001; 23 studies, n=6108) in all cancer patients and 2.81 (95% CI 1.73-3.90; P<0.0001; 19 RCTs, n=4697) in patients receiving chemotherapy, which was below the threshold (≥ 3) for a clinically important difference (CID). Erythropoiesis-stimulating agents had a positive effect on anaemia-related symptoms (MD 4.09; 95% CI 2.37-5.80; P=0.001; 14 studies, n=2765) in all cancer patients and 4.50 (95% CI 2.55-6.45; P<0.0001; 11 RCTs, n=2436) in patients receiving chemotherapy, which was above the threshold (≥ 4) for a CID. Of note, this effect persisted when we restricted the analysis to placebo-controlled RCTs in patients receiving chemotherapy. There was some evidence that the MDs for FACT-F were above the threshold for a CID in RCTs including cancer patients receiving chemotherapy with Hb levels below 12 g dl(-1) at baseline and in RCTs stopping ESAs at Hb levels above 13 g dl(-1). However, these findings for FACT-F were not confirmed when we restricted the analysis to placebo-controlled RCTs in patients receiving chemotherapy. CONCLUSIONS In cancer patients, particularly those receiving chemotherapy, we found that ESAs provide a small but clinically important improvement in anaemia-related symptoms (FACT-An). For fatigue-related symptoms (FACT-F), the overall effect did not reach the threshold for a CID.
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Affiliation(s)
- J Bohlius
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Finkenhubelweg 11, 3012 Bern, Switzerland
| | - T Tonia
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Finkenhubelweg 11, 3012 Bern, Switzerland
| | - E Nüesch
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Finkenhubelweg 11, 3012 Bern, Switzerland
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | - P Jüni
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Finkenhubelweg 11, 3012 Bern, Switzerland
- Department of Clinical Research, CTU Bern, University of Bern, Finkenhubelweg 11, 3012 Bern, Switzerland
| | - M F Fey
- Department of Medical Oncology, Inselspital, Bern University Hospital, 3010 Bern, Switzerland
| | - M Egger
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Finkenhubelweg 11, 3012 Bern, Switzerland
| | - J Bernhard
- Department of Medical Oncology, Inselspital, Bern University Hospital, 3010 Bern, Switzerland
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Dose Efficiency of Erythropoiesis-Stimulating Agents for the Treatment of Patients With Chemotherapy-Induced Anemia: A Systematic Review. Clin Ther 2014; 36:594-610. [DOI: 10.1016/j.clinthera.2014.02.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2013] [Revised: 01/29/2014] [Accepted: 02/07/2014] [Indexed: 11/20/2022]
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Erythropoietin-stimulating agents and clinical outcomes in metastatic breast cancer patients with chemotherapy-induced anemia: a closed debate? Tumour Biol 2014; 35:5095-100. [DOI: 10.1007/s13277-014-1730-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2013] [Accepted: 02/04/2014] [Indexed: 10/25/2022] Open
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Wauters I, Vansteenkiste J. Erythropoiesis-stimulating agents in cancer patients: reflections on safety. Expert Rev Clin Pharmacol 2014; 4:467-76. [DOI: 10.1586/ecp.11.22] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Del Prete S, Cinieri S, Lorusso V, Maiorino L, Pizza C, Pisano A, Montesarchio V, Leo L, Savastano C, Pistolese G, Bianco M, Mabilia R, Tonachella R, Febbraro A, Manzione L, Palazzo S, Filippelli G, Vincenzi B, Barbato E, Cennamo G, Riccardi F, Misso G, Caraglia M, Addeo R. Impact of anemia management with EPO on psychologic distress in cancer patients: results of a multicenter patient survey. Future Oncol 2014; 10:69-78. [DOI: 10.2217/fon.13.161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
ABSTRACT: Aim: We investigated the role of erythropoietin (EPO) in reducing anemia and preventing the development of psychological distress in patients treated with chemotherapy. Patients & methods: This prospective observational study enrolled 591 adult patients receiving EPO at a dose of 30,000 IU administered once weekly for chemotherapy-induced anemia (mean baseline hemoglobin [Hb] level was 9.55 g/dl) over a 12-month period. Results: The majority of patients (371 [71%] patients) achieved a Hb increase >2 g/dl after 4 weeks of treatment. Interestingly, the nonresponder group had a statistically significant deterioration of their psychological conditions as indicated by psychological distress score (p = 0.01). However, within the group of responders to EPO, the Psychological Distress Inventory score remained unchanged. In the present study, severe side effects associated with EPO were not recorded. Conclusion: Hb increase, induced by EPO, ameliorates the psychological conditions of cancer patients.
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Affiliation(s)
- Salvatore Del Prete
- Salvatore Del Prete, Medical Oncology Division, ‘San Giovanni di Dio’ Frattamaggiore Hospital, ASLNA2 NORD, Naples, Italy
| | - Saverio Cinieri
- Saverio Cinieri, Medical Oncology Division & Breast Unit, A Perrino Hospital, Brindisi, Italy
| | - Vito Lorusso
- Vito Lorusso, Medical Oncology Unit, Vito Fazzi Hospital, Lecce, Italy
| | - Luigi Maiorino
- Maiorino Luigi, Oncology Unit ‘San Gennaro’ Hospital, ASLNA1 Naples, Italy
| | - Carmine Pizza
- Carmine Pizza, Medical Oncology Division, ‘S. Maria della Pieta’, ASLNA3 SUD Nola, Italy
| | - Agata Pisano
- Agata Pisano, Medical Oncology ‘San Maria delle Grazie’ Pozzuoli Hospital, ASLNA2 NORD, Naples, Italy
| | - Vincenzo Montesarchio
- Vincenzo Montesarchio, Medical Oncology Division, ‘Cotugno’ Hospital AORN dei Colli, Naples, Italy
| | - Luigi Leo
- Luigi Leo, Oncology Unit, Day Hospital, Piedimonte Matese Hospital, ASLCE Caserta, Italy
| | | | - Giuseppe Pistolese
- Giuseppe Pistolese, Hematology Department, AORN ‘Ruggi d’Aragona’, Salerno, Italy
| | - Maddalena Bianco
- Maddalena Bianco, Oncology Unit ‘San Leonardo’ Hospital, Castellammare di Stabia, ASL NA3SUD, Naples, Italy
| | - Roberto Mabilia
- Roberto Mabilia, Oncology Unit ‘Rizzoli’ Hospital, Ischia, ASL NA3SUD, Naples, Italy
| | - Riccardo Tonachella
- Riccardo Tonachella, Medical Oncology Unit, Istituto Regina Elena per lo Studio e la Cura dei Tumori, Rome, Italy
| | - Antonio Febbraro
- Antonio Febbraro, Medical Oncology Unit, Fatebenefratelli Hospital, Benevento, Italy
| | - Luigi Manzione
- Luigi Manzione, Medical Oncology Unit, S. Carlo Hospital, Potenza, Italy
| | - Salvatore Palazzo
- Salvatore Palazzo, Medical Oncology Unit, Ospedale Mariano Santo, Cosenza, Italy
| | | | - Bruno Vincenzi
- Bruno Vincenzi, Section of Oncology, Campus Biomedico University, Rome, Italy
| | - Enrico Barbato
- Enrico Barbato, Medical Oncology Unit, Aversa Hospital, ASLCE, Caserta, Italy
| | - Gregorio Cennamo
- Gregorio Cennamo, Medical Oncology Division, ‘San Giovanni di Dio’ Frattamaggiore Hospital, ASLNA2 NORD, Naples, Italy
| | | | - Gabriella Misso
- Gabriella Misso, Department of Biochemistry & Biophysics, Second University of Naples, Naples, Italy
| | - Michele Caraglia
- Michele Caraglia, Department of Biochemistry & Biophysics, Second University of Naples, Naples, Italy
| | - Raffaele Addeo
- Raffaele Addeo, Medical Oncology Division, ‘San Giovanni di Dio’ Frattamaggiore Hospital, ASLNA2 NORD, Naples, Italy
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Erythropoietin is a JAK2 and ERK1/2 effector that can promote renal tumor cell proliferation under hypoxic conditions. J Hematol Oncol 2013; 6:65. [PMID: 24004818 PMCID: PMC3844377 DOI: 10.1186/1756-8722-6-65] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2013] [Accepted: 08/24/2013] [Indexed: 12/31/2022] Open
Abstract
Background Erythropoietin (EPO) provides an alternative to transfusion for increasing red blood cell mass and treating anemia in cancer patients. However, recent studies have reported increased adverse events and/or reduced survival in patients receiving both EPO and chemotherapy, potentially related to EPO-induced cancer progression. Additional preclinical studies that elucidate the possible mechanism underlying EPO cellular growth stimulation are needed. Methods Using commercial tissue microarray (TMA) of a variety of cancers and benign tissues, EPO and EPO receptor immunohistochemical staining was performed. Furthermore using a panel of human renal cells (Caki-1, 786-O, 769-P, RPTEC), in vitro and in vivo experiments were performed with the addition of EPO in normoxic and hypoxic states to note phenotypic and genotypic changes. Results EPO expression score was significantly elevated in lung cancer and lymphoma (compared to benign tissues), while EPOR expression score was significantly elevated in lymphoma, thyroid, uterine, lung and prostate cancers (compared to benign tissues). EPO and EPOR expression scores in RCC and benign renal tissue were not significantly different. Experimentally, we show that exposure of human renal cells to recombinant EPO (rhEPO) induces cellular proliferation, which we report for the first time, is further enhanced in a hypoxic state. Mechanistic investigations revealed that EPO stimulates the expression of cyclin D1 while inhibiting the expression of p21cip1 and p27kip1 through the phosphorylation of JAK2 and ERK1/2, leading to a more rapid progression through the cell cycle. We also demonstrate an increase in the growth of renal cell carcinoma xenograft tumors when systemic rhEPO is administered. Conclusions In summary, we elucidated a previously unidentified mechanism by which EPO administration regulates progression through the cell cycle, and show that EPO effects are significantly enhanced under hypoxic conditions.
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Gao S, Ma JJ, Lu C. Venous thromboembolism risk and erythropoiesis-stimulating agents for the treatment of cancer-associated anemia: a meta-analysis. Tumour Biol 2013; 35:603-13. [DOI: 10.1007/s13277-013-1084-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2013] [Accepted: 08/05/2013] [Indexed: 10/26/2022] Open
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Efficacy of epoetin-beta 30,000 IU/week in correcting anaemia in patients with gastrointestinal tumours subjected to concomitant chemoradiotherapy. Clin Transl Oncol 2013; 12:843-8. [PMID: 21156416 DOI: 10.1007/s12094-010-0607-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE The aim of the project was to assess the effectiveness and safety of weekly epoetin-beta (EB) in patients with gastrointestinal cancer (GIC) subjected to concomitant chemoradiotherapy (CCTRT). METHODS In this clinical prospective and multicentre cohort study EB was administered at a dose of 30,000 IU/ week, during CCTRT and in the four weeks thereafter, and suspended if haemoglobin (Hb) increased >2 g/dl or Hb >12-13 g/dl. Effectiveness was defi ned as Hb increase ≥1 g/dl vs. baseline. Time to response, treatment toxicity and transfusion requirements were also assessed. RESULTS EB was effective in 75.8% of the evaluable population within a median of four weeks from EB initiation, without blood transfusions. Over 80% of all patients remained below the threshold (Hb ≤13 g/dl) and no study drug-related adverse reactions were recorded. CONCLUSION Weekly EB proved to be effective and well tolerated by patients with GIC subjected to CCTRT.
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Erythropoietin treatment in chemotherapy-induced anemia in previously untreated advanced esophagogastric cancer patients. Int J Clin Oncol 2013; 19:288-96. [PMID: 23532629 DOI: 10.1007/s10147-013-0544-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2012] [Accepted: 02/17/2013] [Indexed: 12/18/2022]
Abstract
BACKGROUND The impact of erythropoiesis-stimulating agents in chemotherapy-induced anemia has been a constant topic of debate over recent years. We prospectively assessed the efficacy of epoetin beta (Epo-b) in improving hemoglobin (Hb) levels and outcome in patients within an open label, randomized clinical phase II trial with advanced or metastatic gastric/esophagogastric cancer. METHODS Previously untreated patients were randomized to receive 3-weekly cycles of capecitabine (1000 mg/m(2) bid) for 14 days plus on day 1 either irinotecan 250 mg/m(2) or cisplatin 80 mg/m(2). Epo-b (30000 IU once weekly) was initiated in patients with Hb <11 g/dl and continued until Hb ≥12 g/dl was reached. If after 4 weeks the Hb increase was <0.5 g/dl, Epo-b was increased to 30000 IU, twice weekly. RESULTS Of 118 patients enrolled, 32 received Epo-b treatment; of these, 65 % achieved an increase in Hb levels of at least 2 g/dl, with 74 % achieving the target Hb of ≥12 g/dl. Within the study population, patients receiving Epo-b showed better overall survival (median 14.5 vs. 8.0 months, P = 0.056) as well as a significantly improved disease control rate (78 vs. 55 %, P = 0.025). Patients in the irinotecan group profited significantly (P < 0.05) in terms of progression-free survival and overall survival under Epo-b treatment (median 6.5 vs 4.1 months and median 15.4 vs 8.4 months, respectively). CONCLUSIONS Epo-b was effective in raising Hb levels in patients with advanced esophagogastric cancer. Patients receiving Epo-b had a significantly increased response to chemotherapy and a clear trend to improved survival.
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Tonia T, Mettler A, Robert N, Schwarzer G, Seidenfeld J, Weingart O, Hyde C, Engert A, Bohlius J. Erythropoietin or darbepoetin for patients with cancer. Cochrane Database Syst Rev 2012; 12:CD003407. [PMID: 23235597 PMCID: PMC8145276 DOI: 10.1002/14651858.cd003407.pub5] [Citation(s) in RCA: 101] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Anaemia associated with cancer and cancer therapy is an important clinical factor in the treatment of malignant diseases. Therapeutic alternatives are recombinant human erythropoiesis stimulating agents (ESAs) and red blood cell transfusions. OBJECTIVES To assess the effects of ESAs to either prevent or treat anaemia in cancer patients. SEARCH METHODS This is an update of a Cochrane review first published in 2004. We searched the Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE and other databases. Searches were done for the periods 01/1985 to 12/2001 for the first review, 1/2002 to 04/2005 for the first update and to November 2011 for the current update. We also contacted experts in the field and pharmaceutical companies. SELECTION CRITERIA Randomised controlled trials on managing anaemia in cancer patients receiving or not receiving anti-cancer therapy that compared the use of ESAs (plus transfusion if needed). DATA COLLECTION AND ANALYSIS Several review authors assessed trial quality and extracted data. One review author assessed quality assessment and extracted data, a second review author checked for correctness. MAIN RESULTS This update of the systematic review includes a total of 91 trials with 20,102 participants. Use of ESAs significantly reduced the relative risk of red blood cell transfusions (risk ratio (RR) 0.65; 95% confidence interval (CI) 0.62 to 0.68, 70 trials, N = 16,093). On average, participants in the ESAs group received one unit of blood less than the control group (mean difference (MD) -0.98; 95% CI -1.17 to -0.78, 19 trials, N = 4,715). Haematological response was observed more often in participants receiving ESAs (RR 3.93; 95% CI 3.10 to 3.71, 31 trials, N = 6,413). There was suggestive evidence that ESAs may improve Quality of Life (QoL). There was strong evidence that ESAs increase mortality during active study period (hazard ratio (HR) 1.17; 95% CI 1.06 to 1.29, 70 trials, N = 15,935) and some evidence that ESAs decrease overall survival (HR 1.05; 95% CI 1.00 to 1.11, 78 trials, N = 19,003). The risk ratio for thromboembolic complications was increased in patients receiving ESAs compared to controls (RR 1.52, 95% CI 1.34 to 1.74; 57 trials, N = 15,498). ESAs may also increase the risk for hypertension (fixed-effect model: RR 1.30; 95% CI 1.08 to 1.56; random-effects model: RR 1.12; 95% CI 0.94 to 1.33, 31 trials, N = 7,228) and thrombocytopenia/haemorrhage (RR 1.21; 95% CI 1.04 to 1.42; 21 trials, N = 4,507). There was insufficient evidence to support an effect of ESA on tumour response (fixed-effect RR 1.02; 95% CI 0.98 to 1.06, 15 trials, N = 5,012). AUTHORS' CONCLUSIONS ESAs reduce the need for red blood cell transfusions but increase the risk for thromboembolic events and deaths. There is suggestive evidence that ESAs may improve QoL. Whether and how ESAs affects tumour control remains uncertain. The increased risk of death and thromboembolic events should be balanced against the potential benefits of ESA treatment taking into account each patient's clinical circumstances and preferences. More data are needed for the effect of these drugs on quality of life and tumour progression. Further research is needed to clarify cellular and molecular mechanisms and pathways of the effects of ESAs on thrombogenesis and their potential effects on tumour growth.
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Affiliation(s)
- Thomy Tonia
- University of BernInstitute of Social and Preventive MedicineBernSwitzerland3012
| | - Annette Mettler
- University of BernInstitute of Social and Preventive MedicineBernSwitzerland3012
| | - Nadège Robert
- Kantonsspitalapotheke WinterthurPharmacyBrauerstrasse 15WinterthurSwitzerlandCH‐8400
| | - Guido Schwarzer
- Institute of Medical Biometry and Medical Informatics, University Medical Center FreiburgGerman Cochrane CentreStefan‐Meier‐Str. 26FreiburgGermanyD‐79104
| | - Jerome Seidenfeld
- American Society of Clinical OncologyDepartment of Quality and Guidelines1900 Duke Street, Suite 200AlexandriaVAUSA22314
| | | | - Chris Hyde
- University of Exeter Medical School, University of ExeterPeninsula Technology Assessment Group (PenTAG)Veysey BuildingSalmon Pool LaneExeterUKEX2 4SG
| | - Andreas Engert
- University Hospital of CologneCochrane Haematological Malignancies Group, Department I of Internal MedicineKerpener Str. 62CologneGermany50924
| | - Julia Bohlius
- University of BernInstitute of Social and Preventive MedicineBernSwitzerland3012
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Wauters I, Vansteenkiste J. Darbepoetin alfa in the treatment of anemia in cancer patients undergoing chemotherapy. Expert Rev Anticancer Ther 2012; 12:1383-90. [PMID: 23113603 DOI: 10.1586/era.12.117] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
For years, the treatment of chemotherapy-induced anemia (CIA) consisted of red blood cell transfusions. Major disadvantages of transfusions are their temporary effect and limitation to treatment of severe anemia. In an extensive clinical trial program in patients with CIA, darbepoetin alfa (DA) - a long-acting recombinant human erythropoietin - was proven to be very effective in reducing transfusion needs in patients developing CIA. The administration is suitable with most chemotherapy schemes. Caution is needed in patients with a history of thrombo-embolic events, as a slightly higher incidence of these events is noted in patients treated with darbepoetin alfa or erythropoietin substitution agents (ESAs) in general. In recent years, concerns have been raised about a potential negative influence of these agents on survival. In this respect, it is important to make the distinction between studies on the treatment of existing CIA versus treatment with ESAs outside this indication. On the other hand, it has always been assumed that transfusions were a completely safe treatment, but concerns about a potential negative effect on survival have been raised for transfusions as well. The safety concerns with DA and ESAs in general led to a pharmacovigilance program and an adaptation of the guidelines for treatment of CIA, focusing on treatment of moderate CIA but no longer on mild CIA. Now that the most recent safety data of the pharmacovigilance program of ESAs is almost completed, the clinical impact of the shift to the treatment of only moderate anemia is discussed in this review, which provides a critical view on the indications of DA and the benefit-risk assessment, in order to provide good supportive care without harm to the patient.
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Affiliation(s)
- Isabelle Wauters
- Respiratory Oncology Unit (Pulmonology) and Leuven Lung Cancer Group, University Hospital Gasthuisberg, Catholic University, Leuven, Belgium
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Michallet M, Goldet K, Sobh M, Morisset S, Chelghoum Y, Thomas X, Barraco F, Ducastelle S, Labussière H, Renzullo C, Paillet C, Pivot C, Straaten PBV, Denis A, Termoz A, Detrait M, Nicolini FE, Jaisson-Hot I. Prospective study of erythropoietin use on quality of life and cost effectiveness in acute myeloid leukemia and allogeneic hematopoietic stem cell transplantation patients. Cancer 2012; 119:107-14. [DOI: 10.1002/cncr.27686] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2012] [Revised: 04/05/2012] [Accepted: 04/16/2012] [Indexed: 01/19/2023]
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Oster HS, Neumann D, Hoffman M, Mittelman M. Erythropoietin: the swinging pendulum. Leuk Res 2012; 36:939-44. [PMID: 22579365 DOI: 10.1016/j.leukres.2012.04.017] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2011] [Revised: 04/14/2012] [Accepted: 04/16/2012] [Indexed: 11/24/2022]
Abstract
Erythropoiesis stimulating agents (ESAs) have been used widely for anemic patients, especially those on dialysis and with cancer. However, reports have suggested shorter survival in erythropoietin (EPO)-treated cancer patients. The purpose of this review is to summarize and evaluate critically the current information about ESA treatment and its possible association with mortality in cancer patients. The pendulum that initially swung in the direction of widespread ESA treatment, and then in the direction of no treatment, is swinging back toward a stable position. This review also provides tools to decide how and when to use ESAs safely, according to accepted guidelines.
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Affiliation(s)
- Howard S Oster
- The Department of Medicine, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.
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Aapro M, Jelkmann W, Constantinescu SN, Leyland-Jones B. Effects of erythropoietin receptors and erythropoiesis-stimulating agents on disease progression in cancer. Br J Cancer 2012; 106:1249-58. [PMID: 22395661 PMCID: PMC3314780 DOI: 10.1038/bjc.2012.42] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Erythropoiesis-stimulating agents (ESAs) increase red blood cell (RBC) production in bone marrow by activating the erythropoietin receptor (EpoR) on erythrocytic-progenitor cells. Erythropoiesis-stimulating agents are approved in the United States and Europe for treating anaemia in cancer patients receiving chemotherapy based on randomised, placebo-controlled trials showing that ESAs reduce RBC transfusions. Erythropoiesis-stimulating agent-safety issues include thromboembolic events and concerns regarding whether ESAs increase disease progression and/or mortality in cancer patients. Several trials have reported an association between ESA use and increased disease progression and/or mortality, whereas other trials in the same tumour types have not provided similar findings. This review thoroughly examines available evidence regarding whether ESAs affect disease progression. Both clinical-trial data on ESAs and disease progression, and preclinical data on how ESAs could affect tumour growth are summarised. Preclinical topics include (i) whether tumour cells express EpoR and could be directly stimulated to grow by ESA exposure and (ii) whether endothelial cells express EpoR and could be stimulated by ESA exposure to undergo angiogenesis and indirectly promote tumour growth. Although assessment and definition of disease progression vary across studies, the current clinical data suggest that ESAs may have little effect on disease progression in chemotherapy patients, and preclinical data indicate a direct or indirect effect of ESAs on tumour growth is not strongly supported.
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Affiliation(s)
- M Aapro
- Institut Multidisciplinaire d' Oncologie, Clinique de Genolier, Route du Muids 3, PO Box 100, Genolier CH-1272, Switzerland.
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Does severe anemia caused by dose-dense paclitaxel-Carboplatin combination therapy have an effect on the survival of patients with epithelial ovarian cancer? Retrospective analysis of the Japanese gynecologic oncology group 3016 trial. Int J Gynecol Cancer 2012; 21:1585-91. [PMID: 22123713 DOI: 10.1097/igc.0b013e318229266a] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION To evaluate the incidence of anemia in patients with epithelial ovarian cancer receiving paclitaxel-carboplatin combination therapy (TC) using data from the Japanese Gynecologic Oncology Group (JGOG) 3016 trial, and to examine the effect of severe anemia on survival during dose-dense TC. METHODS Retrospective analysis was conducted in patients enrolled in the JGOG 3016 trial who underwent at least one cycle of the protocol therapy (n = 622). Hemoglobin values at enrollment and during each cycle of TC were collected. One-to-one matching was performed between patients with and patients without grade 3/4 anemia during TC (anemia and nonanemia groups) to adjust the baseline characteristics of the patients. The cumulative survival curve and median progression-free survival were estimated using the Kaplan-Meier method. RESULTS Grades 2 to 4 anemia was observed in 19.8% of patients before first-line TC. The incidence of grade 3/4 anemia rapidly increased to 56.1% after the fourth cycle of dose-dense TC. After matching, the median progression-free survival in the anemia (hemoglobin <8.0 g/dL) and nonanemia (hemoglobin >8.0 g/dL) groups was 777 and 1100 days, respectively (P = 0.3493) for patients receiving dose-dense TC. The median progression-free survival in patients receiving conventional TC was similar between the 2 groups. CONCLUSIONS The difference in progression-free survival between patients with epithelial ovarian cancer with and those without severe anemia during TC was not statistically significant, but for patients receiving dose-dense TC, severe anemia seems to have prognostic relevance. Prospective trials are needed to investigate whether the optimal management of chemotherapy-induced anemia, including appropriate use of erythropoiesis-stimulating agents, would further improve the survival of patients with ovarian cancer receiving dose-dense TC.
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Scotté F, Launay-Vacher V, Rey JB. Colony stimulating factors (CSF) biosimilars. Progress? Target Oncol 2012; 7 Suppl 1:S17-24. [PMID: 22249656 DOI: 10.1007/s11523-011-0189-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2011] [Accepted: 08/01/2011] [Indexed: 11/29/2022]
Abstract
Biosimilars are equivalent drugs for other biotechnological drugs for which patent has expired. These biopharmaceuticals are often looked upon as simple copies of parent drugs whose goal is solely to potentially generate costs savings. The expansion of available drugs is a subject of attention, criticism and quarrels, often related to a lack of product knowledge. These drugs are copies but need scientific development that must meet many strict rules. Many questions arise in connection with the marketing of several biosimilar drugs in the field of hematopoietic growth factors of white and red cells. Many of them should be discussed.
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Affiliation(s)
- Florian Scotté
- European Hospital Georges Pompidou, 20, rue Leblanc, 75015 Paris, France.
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Randomised, phase III trial of epoetin-β to treat chemotherapy-induced anaemia according to the EU regulation. Br J Cancer 2011; 105:1267-72. [PMID: 21959870 PMCID: PMC3241560 DOI: 10.1038/bjc.2011.395] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Background: Erythropoietin-stimulating agents (ESAs) effectively decrease the transfusion requirements of patients with chemotherapy-induced anaemia (CIA). Recent studies indicate that ESAs increase mortality and accelerate tumour progression. The studies also identify a 1.6-fold increased risk of venous thromboembolism. The ESA labelling was thus revised in Europe and the United States in 2008. This is the first randomised, phase III trial evaluating the efficacy and safety of epoetin-β (EPO), an ESA, dosed in accordance with the revised labelling, which specifies that ESAs should be administered to CIA patients with a haemoglobin level of ⩽10 g dl–1 and that a sustained haemoglobin level of >12 g dl–1 should be avoided. Methods: A total of 186 CIA patients (8.0 g dl–1⩽ haemoglobin ⩽10.0 g dl–1) with lung or gynaecological cancer were randomised to receive EPO 36 000 IU or placebo weekly for 12 weeks. Results: The proportion of patients receiving transfusions or with haemoglobin <8.0 g dl–1 between week 5 and the end of the treatment period as the primary end point was significantly lower in the EPO group (n=89) than in the placebo group (n=92; 10.0% vs 56.4%, P<0.001). The proportion receiving transfusions was significantly lower in the EPO group (4.5% vs 19.6%, P=0.002). Changes in quality of life were not different. No significant differences in adverse events – for example, the incidence of thromboembolic events was 1.1% for each group – or the 1-year overall survival were observed between groups. Conclusion: Weekly EPO administered according to the revised labelling approved by the European Medicines Agency is effective and well tolerated for CIA treatment. Further investigations are needed on the effect of ESAs on mortality.
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Mayeur D. Anémie et cancer. ONCOLOGIE 2011. [DOI: 10.1007/s10269-011-2034-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Scotté F. Les facteurs de croissance (CSF) biosimilaires : une avancée ? ONCOLOGIE 2011. [DOI: 10.1007/s10269-011-2019-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Addeo R, Caraglia M, Frega N, Del Prete S. Two faces for Janus: recombinant human erythropoiesis-stimulating agents and cancer mortality. Expert Rev Hematol 2011; 2:513-5. [PMID: 21083017 DOI: 10.1586/ehm.09.41] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Untreated anemia in cancer patients has severe consequences for many organ systems. Erythropoiesis-stimulating agents (ESAs) are indicated for the treatment of chemotherapy-induced anemia in cancer patients. Several studies in patients with solid tumors have shown that these agents effectively increase hemoglobin levels, improve the quality of life and reduce the requirement for emergency blood transfusions, regardless of the type of concomitantly administered chemotherapy. The meta-analysis evaluates the impact of ESAs during the active study period on mortality and the overall survival during the longest available follow-up, irrespective of anticancer treatment, with little heterogeneity between trials. A total of 10,441 patients on chemotherapy were enrolled in 38 trials. There was little evidence for a difference between trials of patients administered different anticancer treatments (p for interaction = 0.42). The meta-analysis demonstrated that ESAs increased mortality by 17% during the active study periods and worsened overall survival in patients with cancer. However, 62% of patients evaluated in this analysis started the ESA therapy with basal hemoglobin values over that recommended by ASCO/ASH guidelines. However, the high quality of meta-analysis and the novelty of the information do not represent an obstacle for the continued the use of ESAs within the revised European Organisation for Research and Treatment of Cancer (EORTC) guidelines and the revised labels.
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Affiliation(s)
- Raffaele Addeo
- Oncology Department, S. Giovanni di Dio Hospital, Via Giovanni XXIII, Frattaminore, Naples, Italy.
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Chavez-MacGregor M, Zhao H, Fang S, Srokowski TP, Hortobagyi GN, Giordano SH. Complications associated with erythropoietin-stimulating agents in patients with metastatic breast cancer: a Surveillance, Epidemiology, and End Results-Medicare study. Cancer 2011; 117:3641-9. [PMID: 21656514 DOI: 10.1002/cncr.25972] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2010] [Revised: 12/01/2010] [Accepted: 01/03/2011] [Indexed: 11/12/2022]
Abstract
BACKGROUND The authors evaluated the patterns of use and the risk of thromboembolic events (TEE) associated with erythropoietin-stimulating agents (ESAs) in older patients with metastatic breast cancer who were receiving chemotherapy. METHODS The study was retrospective and used the SEER-Medicare linked database. Stage IV breast cancer patients diagnosed from 1995-2005, treated with chemotherapy, ≥66 years old, with full coverage of Medicare A and B were included. The World Health Organization's International Classification of Diseases (ICD-9) and the Healthcare Common Procedure Coding System (HCPCS) were used to identify the use of ESAs, chemotherapy, and complications of therapy. Analyses included descriptive statistics and logistic regression. RESULTS Of 2266 women, 980 (43.3%) received ESAs, and 1286 (56.7%) did not. Patients diagnosed after 1999 or who received treatment with taxanes, anthracyclines, or vinorelbine were more likely to receive ESAs. Patients receiving ESAs had higher rates of stroke (18.5% vs 15.1%, P = .031); deep-vein thrombosis (DVT; 21.3% vs 14.4%, P<.001), other/unspecified thromboembolic event (TEE; 19.8% vs 14.7%, P = .001), and any clot (31.3% vs 23.4%, P<.0001). In multivariate analysis, patients receiving ESAs had increased risk for DVT (odds ratio [OR], 1.36; 95% confidence interval [CI], 1.05-1.75), and any clot (OR, 1.26; 95% CI, 1.02-1.57). A dose-dependent effect was evident for stroke, DVT, other TEE, and any clot. CONCLUSIONS In this cohort of patients, the use of ESAs increased the risk of TEEs, with a dose-dependent effect for stroke, DVT, other TEE, and any clot. The data show that among patients treated with chemotherapy and ESAs for metastatic breast cancer, TEEs are a common event. Therefore, caution is recommended when using these agents.
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Affiliation(s)
- Mariana Chavez-MacGregor
- Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030, USA
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Lemieux J, Goodwin PJ, Bordeleau LJ, Lauzier S, Théberge V. Quality-of-life measurement in randomized clinical trials in breast cancer: an updated systematic review (2001-2009). J Natl Cancer Inst 2011; 103:178-231. [PMID: 21217081 DOI: 10.1093/jnci/djq508] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Quality-of-life (QOL) measurement is often incorporated into randomized clinical trials in breast cancer. The objectives of this systematic review were to assess the incremental effect of QOL measurement in addition to traditional endpoints (such as disease-free survival or toxic effects) on clinical decision making and to describe the extent of QOL reporting in randomized clinical trials of breast cancer. METHODS We conducted a search of MEDLINE for English-language articles published between May-June 2001 and October 2009 that reported: 1) a randomized clinical trial of breast cancer treatment (excluding prevention trials), including surgery, chemotherapy, hormone therapy, symptom control, follow-up, and psychosocial intervention; 2) the use of a patient self-report measure that examined general QOL, cancer-specific or breast cancer-specific QOL or psychosocial variables; and 3) documentation of QOL outcomes. All selected trials were evaluated by two reviewers, and data were extracted using a standardized form for each variable. Data are presented in descriptive table formats. RESULTS A total of 190 randomized clinical trials were included in this review. The two most commonly used questionnaires were the European Organization for Research and Treatment of Cancer QOL Questionnaire and the Functional Assessment of Cancer Therapy/Functional Assessment of Chronic Illness Therapy. More than 80% of the included trials reported the name(s) of the instrument(s), trial and QOL sample sizes, the timing of QOL assessment, and the statistical method. Statistical power for QOL was reported in 19.4% of the biomedical intervention trials and in 29.9% of the nonbiomedical intervention trials. The percentage of trials in which QOL findings influenced clinical decision making increased from 15.2% in the previous review to 30.1% in this updated review for trials of biomedical interventions but decreased from 95.0% to 63.2% for trials of nonbiomedical interventions. Discordance between reviewers ranged from 1.1% for description of the statistical method (yes vs no) to 19.9% for the sample size for QOL. CONCLUSION Reporting of QOL methodology could be improved.
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Affiliation(s)
- Julie Lemieux
- Santé des populations: Unité de recherche en santé des populations (URESP), Centre de recherche FRSQ du Centre hospitalier affilié universitaire de Québec (CHA), Service d'hémato-oncologie du CHA and Centre des Maladies du Sein Deschênes-Fabia du CHA, Quebec City, QC, Canada.
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Glaspy JA. Randomized controlled trials of the erythroid-stimulating agents in cancer patients. Cancer Treat Res 2011; 157:195-215. [PMID: 21052958 DOI: 10.1007/978-1-4419-7073-2_12] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Affiliation(s)
- John A Glaspy
- Division of Hematology and Oncology, Department of Medicine, David Geffen School of Medicine/UCLA, University of California-Los Angeles, CA 90095, USA.
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Cardiac toxicity in breast cancer patients: from a fractional point of view to a global assessment. Cancer Treat Rev 2010; 37:321-30. [PMID: 20864260 DOI: 10.1016/j.ctrv.2010.08.007] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2010] [Revised: 08/19/2010] [Accepted: 08/20/2010] [Indexed: 11/20/2022]
Abstract
When focusing on heart disease, most available studies split the two different parts of the adjuvant treatment, i.e., systemic therapies and radiation therapy, making it difficult to implement efficient strategies for preventing treatment-induced cardiac toxicity. This paper reviews the current understanding of treatments-induced cardiac toxicity in a global approach. Many factors should be considered when assessing the cardiac hazard. Treatment-related risk factors include heart dose exposure, chemotherapy, targeted agents such as HER2 inhibitors, but also endocrine agents, or anesthetic procedure. Patients' characteristics should also be taken into account. Age, menopausal status, stress, previous history of cardiac disease, genetic profile, and body mass index could all impact on cardiac function after adjuvant therapies. Cardiac toxicity should not be analyzed as the consequence of a specific therapy, but should be considered as the result of additive or supra-additive toxicities. By this way, it will be possible to implement new strategies for preventing treatment-induced cardiac toxicity.
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Abstract
PURPOSE OF REVIEW Anaemia is a frequent complication of cancer. Recently, some concerns have appeared regarding the safety of erythropoiesis-stimulating agents (ESAs) for the treatment of anaemia in cancer patients. The current review will analyse the main arguments in favour of erythropoietin (EPO), as well as those against EPO in chemotherapy-induced anaemia and in cancer-related anaemia. The principal concerns are tumour progression, increased mortality and the risk of venous thromboembolic events (VTEs). Recent meta-analyses have come to divergent conclusions. RECENT FINDINGS Several meta-analyses have reviewed the data regarding VTEs, EPO receptors on tumours and tumour progression as well as mortality. SUMMARY As of now, ESAs should only be used within the indications as given in the various guidelines.
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[Epoetin beta for the treatment of chemotherapy-induced anaemia in solid and haematological malignancies. Results of an open-label, multicentric clinical trial]. Bull Cancer 2010; 97:969-78. [PMID: 20538545 DOI: 10.1684/bdc.2010.1139] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIM Evaluate efficacy and safety of epoetin beta in anaemic patients receiving chemotherapy for a non-myeloid malignancy. PATIENTS AND METHODS This open-label, multicentric, clinical trial was conducted in France among 691 anaemic patients (haemoglobin < or = 12 g/dL) with a solid or haematological malignancy to evaluate the benefit of epoetin beta 30,000 IU/week subcutaneously for 16 weeks. The primary endpoint was the rate of therapeutic response. RESULTS The overall response rate was 60.4% (CI 95%: [56.6%-64.1]). According to initial haemoglobin level < 11 g/dL or between 11 and 12 g/dL, it was 61.2% and 57.5% respectively. Response rates by tumour type (solid and haematological) were similar. The mean haemoglobin level increases were respectively 1.1 g/dL, approximately 2 and 2.2 g/dL at 4, 9, and 12 weeks after treatment initiation. In patients with haemoglobin level < 11 g/dL at inclusion the mean increases in haemoglobin level were respectively 1.17, 2.03 and 2.45 g/dL at 4, 9 and 12 weeks. During study period, 23% of patients required red blood cell transfusion. Overall treatment with epoetin beta was well-tolerated and 7.1% of patients only experienced thromboembolic events. CONCLUSION For treating chemotherapy-induced anaemia in patients with solid or haematological malignancy (especially if haemoglobin level < 11 g/dL), epoetin beta 30.000 IU subcutaneously once-weekly (450 IU/kg/week) is rapidly effective and overall well-tolerated.
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Pronzato P, Cortesi E, van der Rijt CC, Bols A, Moreno-Nogueira JA, de Oliveira CF, Barrett-Lee P, Ostler PJ, Rosso R. Epoetin alfa improves anemia and anemia-related, patient-reported outcomes in patients with breast cancer receiving myelotoxic chemotherapy: results of a European, multicenter, randomized, controlled trial. Oncologist 2010; 15:935-43. [PMID: 20798194 PMCID: PMC3228044 DOI: 10.1634/theoncologist.2009-0279] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2009] [Accepted: 06/16/2010] [Indexed: 11/17/2022] Open
Abstract
PURPOSE To evaluate the effects of epoetin alfa on patient-reported outcomes (PROs) in patients with breast cancer receiving myelotoxic chemotherapy. MATERIALS AND METHODS Women with hemoglobin concentrations ≤ 12.0 g/dl and an Eastern Cooperative Oncology Group performance status (ECOG PS) score of 0-3 were randomized 1:1 to receive epoetin alfa (10,000 IU 3 times weekly) or best standard care (BSC) during chemotherapy. The primary endpoint was the change from baseline in the total anemia subscale assessed by the Functional Assessment of Cancer Therapy-Anemia (FACT-An) questionnaire after 12 weeks of treatment. The fatigue and nonfatigue subscales from the FACT-An, the Cancer Linear Analog Scale (CLAS), hemoglobin changes, ECOG PS score, tumor response, overall survival, and safety also were evaluated. RESULTS Of 223 patients randomized, 216 constituted the modified intent-to-treat population. Percentage changes in the total anemia subscale of the FACT-An were significantly different between epoetin alfa treatment (14.2%) and BSC (-0.5%; p = .002), favoring epoetin alfa; so were changes in the FACT-An fatigue subscale (epoetin alfa, 17.5%; BSC, -0.9%; p = .003) and nonfatigue subscale (epoetin alfa, 8.8%; BSC, 0.2%; p = .008). Similar results were observed with the CLAS. Hemoglobin concentrations > 12 g/dl were more common with epoetin alfa (62.0%) than with BSC (27.6%). Tumor response, ECOG PS score, 12-month survival rate, and the incidence of serious treatment-emergent adverse events were similar between groups. CONCLUSION Early intervention with epoetin alfa was well tolerated and improved anemia-related PROs in patients with breast cancer receiving myelotoxic chemotherapy.
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Affiliation(s)
- Paolo Pronzato
- Department of Medical Oncology A, Istituto Nazionale per la Ricerca sul Cancro, Genova, Italy.
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Klarenbach S, Manns B, Reiman T, Reaume MN, Lee H, Lloyd A, Wiebe N, Hemmelgarn B, Tonelli M. Economic evaluation of erythropoiesis-stimulating agents for anemia related to cancer. Cancer 2010; 116:3224-32. [PMID: 20564645 DOI: 10.1002/cncr.25052] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Erythropoiesis-stimulating agents (ESA) administered to cancer patients with anemia reduce the need for blood transfusions and improve quality-of-life (QOL). Concerns about toxicity have led to more restrictive recommendations for ESA use; however, the incremental costs and benefits of such a strategy are unknown. METHODS The authors created a decision model to examine the costs and consequences of ESA use in patients with anemia and cancer from the perspective of the Canadian public healthcare system. Model inputs were informed by a recent systematic review. Extensive sensitivity analyses and scenario analysis rigorously assessed QOL benefits and more conservative ESA administration practices (initial hemoglobin [Hb] <10 g/dL, target Hb < or =12 g/dL, and chemotherapy induced anemia only). RESULTS Compared with supportive transfusions only, conventional ESA treatment was associated with an incremental cost per quality-adjusted life year (QALY) gained of $267,000 during a 15-week time frame. During a 1.3-year time horizon, ESA was associated with higher costs and worse clinical outcomes. In scenarios where multiple assumptions regarding QOL all favored ESA, the lowest incremental cost per QALY gained was $126,000. Analyses simulating the use of ESA in accordance with recently issued guidelines resulted in incremental cost per QALY gained of > $100,000 or ESA being dominated (greater costs with lower benefit) in the majority of the scenarios, although greater variability in the cost-utility ratio was present. CONCLUSIONS Use of ESA for anemia related to cancer is associated with incremental cost-effectiveness ratios that are not economically attractive, even when used in a conservative fashion recommended by current guidelines.
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Affiliation(s)
- Scott Klarenbach
- Department of Medicine, University of Alberta Edmonton, Alberta, Canada.
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Szenajch J, Wcislo G, Jeong JY, Szczylik C, Feldman L. The role of erythropoietin and its receptor in growth, survival and therapeutic response of human tumor cells From clinic to bench - a critical review. Biochim Biophys Acta Rev Cancer 2010; 1806:82-95. [PMID: 20406667 DOI: 10.1016/j.bbcan.2010.04.002] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2010] [Revised: 04/05/2010] [Accepted: 04/11/2010] [Indexed: 12/27/2022]
Abstract
Recombinant human erythropoietin (rhEPO) has been used clinically to alleviate cancer- and chemotherapy-related anemia. However, recent clinical trials have reported that rhEPO also may adversely impact disease progression and survival. The expression of functional EPO receptors (EPOR) has been demonstrated in many human cancer cells where, at least in vitro, rhEPO can stimulate cell growth and survival and may induce resistance to selected therapies. Responses to rhEPO measured by alterations in tumor cell growth or survival, activation of signaling pathways or modulation of sensitivity to anticancer agents are variable. Both methodological and inherent biological issues underlie the differential cell responses, including reported difficulties in EPOR protein detection, potential involvement of EPOR isoforms or of cytoplasmic EPOR, possible differential structure and/or binding affinities of hematopoietic versus non-hematopoietic cell EPOR, possible aberrant regulation of EPOR activity, and a functional EPO/EPOR autocrine/paracrine loop. The modulation by rhEPO of tumor cell response to anticancer agents is coincident with modulation of multiple signaling pathways, BCL-2 family proteins, caspases and NFkB. The molecular interplay of pro-survival and pro-death signals, triggered by EPO and/or by anticancer agents, is multifactorial and tightly coordinated. Expression microarray analysis may prove critical for deciphering this potentially novel network and its broad spectrum of genes and proteins.
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Affiliation(s)
- Jolanta Szenajch
- Laboratory for Molecular Oncology, Military Institute of Medicine, Warsaw, Poland
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Glaspy J, Crawford J, Vansteenkiste J, Henry D, Rao S, Bowers P, Berlin JA, Tomita D, Bridges K, Ludwig H. Erythropoiesis-stimulating agents in oncology: a study-level meta-analysis of survival and other safety outcomes. Br J Cancer 2010; 102:301-15. [PMID: 20051958 PMCID: PMC2816662 DOI: 10.1038/sj.bjc.6605498] [Citation(s) in RCA: 182] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND: Cancer patients often develop the potentially debilitating condition of anaemia. Numerous controlled studies indicate that erythropoiesis-stimulating agents (ESAs) can raise haemoglobin levels and reduce transfusion requirements in anaemic cancer patients receiving chemotherapy. To evaluate recent safety concerns regarding ESAs, we carried out a meta-analysis of controlled ESA oncology trials to examine whether ESA use affects survival, disease progression and risk of venous-thromboembolic events. METHODS: This meta-analysis included studies from the 2006 Cochrane meta-analysis, studies published/updated since the 2006 Cochrane report, and unpublished trial data from Amgen and Centocor Ortho Biotech. The 60 studies analysed (15 323 patients) were conducted in the settings of chemotherapy/radiochemotherapy, radiotherapy only treatment or anaemia of cancer. Data were summarised using odds ratios (ORs) with 95% confidence intervals (CIs). RESULTS: Results indicated that ESA use did not significantly affect mortality (60 studies: OR=1.06; 95% CI: 0.97–1.15) or disease progression (26 studies: OR=1.01; 95% CI: 0.90–1.14), but increased the risk for venous-thromoboembolic events (44 studies: OR=1.48; 95% CI: 1.28–1.72). CONCLUSION: Though this meta-analysis showed no significant effect of ESAs on survival or disease progression, prospectively designed, future randomised clinical trials will further examine the safety and efficacy of ESAs when used according to the revised labelling information.
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Affiliation(s)
- J Glaspy
- Department of Medicine-Hematology and Oncology, David Geffen School of Medicine at University of California, Los Angeles, 100 UCLA Medical Plaza, Suite 550, Los Angeles, CA 90095-6996 USA.
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