Bevacizumab in older patients with advanced colorectal or breast cancer

The incidence of colorectal and breast cancer is growing among the 550 million living people aged 65 or older. Bevacizumab was the first anti-angiogenic agent approved for the treatment of the advanced phase of these cancers. Although older chronological age still hampers the use of modern treatments, there is a widespread awareness that chronological and physiological (i.e. functional) ages may largely differ, and that seniority itself should not be a stringent limit for the introduction of anti-angiogenics. However, the use of bevacizumab in the general older population is questionable. There is limited evidence of a favorable risk-to-benefit ratio, with efficacy data deriving from clinical trials that selected only elderly patients in rather good health. While summarizing the recent advances, this review highlights specific clinical features characterizing those older patients who may benefit the most from receiving bevacizumab.

Noncardiac vascular toxicities of vascular endothelial growth factor inhibitors in advanced cancer: a review

The introduction of molecularly targeted anticancer therapies has brought the promise of longer survival times for select patients with cancers previously considered untreatable. However, it has also brought new toxicities that require understanding and management, sometimes for long periods of time. Vascular endothelial growth factor inhibitors are associated with a broad range of adverse effects, with vascular toxicity being particularly serious. This review focuses on the current understanding of the pathophysiology and mechanisms of macrovascular toxicities (hypertension, hemorrhage, and thromboembolism), their incidence and severity, the current clinical management, and implications in the advanced cancer setting. Movement of these agents into the early disease setting will alter the impact of these toxicities. Search Strategy and Selection Criteria. Information for this review was collected by searching PubMed/Medline and American Society of Clinical Oncology abstract databases. The medical subject heading terms used included toxicity, hypertension, thromboembolism, hemorrhage, intestinal perforation, risk factors, pharmacokinetics, and metabolism, combined with free text search terms including, but not limited to, VEGF inhibitor*, bevacizumab, sunitinib, and sorafenib. Articles published in English before March 2010 were included, in addition to information from case reports and pharmaceutical agent package inserts.

Bleeding events in bevacizumab-treated cancer patients who received full-dose anticoagulation and remained on study

Background:

Bevacizumab provides clinical benefit in multiple solid tumours, but is associated with some increase in bleeding risk. Thrombotic events necessitating therapeutic anticoagulation (TA) are common in cancer. This report describes the safety of concurrent bevacizumab and TA in three large placebo-controlled clinical studies.

Methods:

Study 1 (metastatic colorectal cancer (mCRC)), study 2 (mCRC), and study 3 (advanced non-small cell lung cancer) were blinded phase III studies. Eligibility criteria excluded patients on TA. Patients on protocol treatment who developed thrombotic events requiring TA were permitted to continue bevacizumab or placebo under specified conditions. Adverse events in patients who received bevacizumab and TA concurrently were assessed using the NCI–CTCAE scale.

Results:

While experience is limited, venous thrombotic events were the most common reason for TA initiation in the three studies. Severe bleeding event rates for patients receiving TA in the bevacizumab-treated groups were similar in frequency to the placebo groups, ranging from 0 to 8% or 0 to 67 events per 100 patient-years. No severe pulmonary bleeding was reported in any of the TA-treated populations.

Conclusions:

These data suggest that bevacizumab did not increase the risk of severe bleeding in cancer patients who received TA.

Safety of bevacizumab treatment in combination with standard chemotherapy for metastatic colorectal cancer: a retrospective review of 65 Japanese patients

BACKGROUND

Bevacizumab (BV) prolongs overall survival and progression-free survival when combined with standard chemotherapy for metastatic colorectal cancer (mCRC). However, because this drug was approved in Japan only in 2007, there has been little experience in Japan. This study was conducted to evaluate retrospectively the safety of BV in clinical practice.

METHODS

Sixty-five consecutive mCRC patients who received BV at our institution between June 2007 and March 2008 were selected. All patients were treated with chemotherapy in combination with BV. We surveyed the medical records of all patients for adverse events (AEs). We assessed the AEs using the Common Terminology Criteria for Adverse Events version 3.0.

RESULTS

The characteristics of the subjects were: male, 45 patients; median age, 57 years; Eastern Cooperative Oncology Group (ECOG) performance status (PS) 0-1, 62 patients; number of prior chemotherapy regimens 0/1/ > 2, 15/28/22 patients. The incidence of BV therapy-related AEs of all grades was: hypertension, 47.7%; proteinuria, 33.8%; bleeding, 35.3%; gastrointestinal (GI) perforation, 3.1%; thrombosis, 7.7%; and wound-healing complications, 6.2%. The incidence of grade 3/4 AEs related to BV therapy was: hypertension, 13.8%; bleeding, 1.5%; GI perforation, 1.5%; and thrombosis, 4.6%. Four patients (6.2%) had to stop chemotherapy because of the development of BV therapy-related AEs. New events of hypertension, bleeding, and proteinuria emerged until 120 days and thereafter.

CONCLUSION

The incidence of BV therapy-related AEs in this study was consistent with that observed in Western prospective clinical trials, with the exception of hypertension and proteinuria. A careful follow up is recommended for up to 120 days after the initiation of BV administration.

Evolving treatment of advanced colon cancer

Colorectal cancer is a common malignancy worldwide. Despite significant developments in the treatment of this disease, it still causes considerable morbidity and mortality. Recent advances include both newer cytotoxic chemotherapies and novel biologic agents. Although overall progress has been more modest than had been hoped, substantial benefits have been achieved for some patients, and the number of treatment options has substantially increased. Perhaps most importantly, treatment regimens can now be selected and tailored toward the individual patient following an informed discussion between the patient and the treating oncologist. We present in detail these recent advances and provide some insight into several promising future strategies.

Intricacies of bevacizumab-induced toxicities and their management

OBJECTIVE

To review the serious and common toxicities of bevacizumab and describe their incidence, risk factors, presentation, pathophysiology, and management.

DATA SOURCES

Literature for this review article was collected from PubMed, MEDLINE, and the proceedings of the American Society of Clinical Oncology (2000-November 2008). The key terms used in the search were: bevacizumab, vascular endothelial growth factor, angiogenesis inhibitors, toxicity, toxicity management, and adverse event.

STUDY SELECTION AND DATA EXTRACTION

Review articles, preclinical studies, and all published Phase 1-3 clinical trials were reviewed. The references listed in identified articles were examined for additional publications.

DATA SYNTHESIS

The biomedical literature from 2000 to 2008 confirms that bevacizumab carries serious and potentially life-threatening toxicity risks and emphasizes the importance of early recognition, continuous monitoring, and prompt management of these toxicities. Such toxicities include hemorrhage/bleeding, wound healing complications, gastrointestinal perforation, arterial thromboembolism, congestive heart failure, hypertension, proteinuria/nephrotic syndrome, infusion-related hypersensitivity reactions, and reversible posterior leukoencephalopathy syndrome. Patients at the highest risk for these toxicities are individuals with a history of hypertension, thromboembolism, bleeding, cardiovascular disease, or preexisting proteinuria, as these conditions may be exacerbated by bevacizumab use. Additionally, particular tumor types correlate with risk for individual toxicities; for example, patients with squamous non-small-cell lung cancer or rectal cancer have a higher risk of bleeding, those with renal cell carcinoma have a higher proteinuria risk, and patients with colorectal cancer have a higher risk of gastrointestinal perforation. Further investigation is warranted to develop effective management strategies for these toxicities.

CONCLUSIONS

As bevacizumab is becoming widely used in general oncology practice, it is important to understand the toxicities that can arise and to develop practice guidelines for their management.