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Ageno W, Barni S, Di Nisio M, Falanga A, Imberti D, Labianca RF, Mantovani L. Treatment of venous thromboembolism with tinzaparin in oncological patients. Minerva Med 2019; 110:251-258. [PMID: 30990000 DOI: 10.23736/s0026-4806.19.06026-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Venous thromboembolism (VTE) is a major cause of morbidity and mortality in patients with cancer. For over a decade, the gold standard of treatment and secondary prevention of cancer-associated thrombosis (CAT) has been represented by low-molecular-weight heparins (LMWHs), which are currently recommended as the first-line treatment for CAT. Among the LMWHs that were more extensively tested in patients with CAT, tinzaparin is a LMWH produced by the enzymatic degradation of porcine-derived unfractionated heparin. The efficacy of tinzaparin in this setting is supported by well-grounded evidence. However, there is a need to discuss the positioning of tinzaparin in the continuously evolving treatment scenario of VTE therapy in cancer patients. In this paper, which was developed by a group of clinicians with wide experience in the treatment of VTE in cancer patients, we discuss the current therapeutic options and the role of tinzaparin for the treatment of CAT.
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Affiliation(s)
- Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy -
| | - Sandro Barni
- Department of Oncology, ASST Bergamo Ovest, Treviglio Hospital, Treviglio, Bergamo, Italy
| | - Marcello Di Nisio
- Department of Medicine and Ageing Sciences, G. D'Annunzio University of Chieti-Pescara, Chieti, Italy
| | - Anna Falanga
- Department of Immunohematology and Transfusion Medicine, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Davide Imberti
- Service of Internal Medicine, Thrombosis and Hemostasis Center, Piacenza Civil Hospital, Piacenza, Italy
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Vernieri C, Galli F, Ferrari L, Marchetti P, Lonardi S, Maiello E, Iaffaioli RV, Zampino MG, Zaniboni A, De Placido S, Banzi M, Damiani A, Ferrari D, Rosati G, Labianca RF, Bidoli P, Frassineti GL, Nicolini M, Pavesi L, Tronconi MC, Buonadonna A, Ferrario S, Re GL, Adamo V, Tamburini E, Clerico M, Giordani P, Leonardi F, Barni S, Ciarlo A, Cavanna L, Gori S, Cinieri S, Faedi M, Aglietta M, Antista M, Dotti KF, Galli F, Di Bartolomeo M. Impact of Metformin Use and Diabetic Status During Adjuvant Fluoropyrimidine-Oxaliplatin Chemotherapy on the Outcome of Patients with Resected Colon Cancer: A TOSCA Study Subanalysis. Oncologist 2019; 24:385-393. [PMID: 30606884 DOI: 10.1634/theoncologist.2018-0442] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Accepted: 10/19/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Type 2 diabetes mellitus (T2DM) is associated with increased risk of colon cancer (CC), whereas metformin use seems to be protective. However, the impact of metformin use on the risk of death or disease recurrence after radical surgery for CC remains uncertain. MATERIALS AND METHODS This is a substudy conducted in patients with high-risk stage II or stage III CC randomized in the TOSCA trial, which compared 3 versus 6 months of fluoropyrimidine-oxaliplatin adjuvant chemotherapy. Objective of the study was to investigate the impact of metformin exposure during adjuvant chemotherapy on overall survival (OS) and relapse-free survival (RFS). We also evaluated the impact of T2DM or metformin dosage on clinical outcomes. RESULTS Out of 3,759 patients enrolled in the TOSCA trial, 133 patients with diabetes (9.2%) and 1,319 without diabetes (90.8%) were recruited in this study. After excluding 13 patients with diabetes without information on metformin exposure, 76 patients with T2DM (63.3%) were defined as metformin users and 44 (36.7%) as metformin nonusers. After a median follow-up of 60.4 months, 26 (21.7%) patients relapsed and 16 (13.3%) died. Metformin use was neither associated with OS (adjusted hazard ratio [HR], 1.51; 95% confidence interval [CI], 0.48-4.77; p = .4781) nor with RFS (HR, 1.56; 95% CI, 0.69-3.54; p = .2881). Similarly, we found no association between T2DM or metformin dosage and OS or RFS. CONCLUSIONS Metformin use and T2DM did not impact on OS or RFS in patients with resected CC treated with adjuvant fluoropyrimidine-oxaliplatin chemotherapy. Larger studies and longer follow-up are required to clarify the potential efficacy of metformin in improving the prognosis of patients with CC. IMPLICATIONS FOR PRACTICE The role of the antidiabetic drug metformin in colon cancer prevention and treatment is highly debated. While low-dose metformin reduced the incidence of colorectal adenomas in two prospective studies, its effect in patients with already established colon cancer remains unclear. In this study, the potential impact of metformin on the survival of resected colon cancer patients who received adjuvant chemotherapy was investigated in the context of the TOSCA study. We did not find any association between metformin use or dosages and patient survival. Prospective studies are required to draw definitive conclusions about metformin impact on colon cancer recurrence and survival.
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Affiliation(s)
- Claudio Vernieri
- Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
- The Italian Foundation for Cancer Research Institute of Molecular Oncology, Milan, Italy
| | - Fabio Galli
- IRCCS Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy
| | - Laura Ferrari
- Azienda Ospedaliero Universitaria Santa Maria della Misericordia, Udine, Italy
| | - Paolo Marchetti
- Sant'Andrea Hospital, Sapienza University of Rome and IRCCS Istituto Dermopatico dell'Immacolata, Rome, Italy
| | | | - Evaristo Maiello
- Ospedale Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | | | | | | | | | - Maria Banzi
- IRCCS Arcispedale Santa Maria Nuova, Reggio Emilia, Italy
| | | | | | | | | | | | - Giovanni L Frassineti
- IRCCS Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori, Meldola, Italy
| | | | | | | | | | | | - Giovanni Lo Re
- Azienda Ospedaliera S. Maria degli Angeli Pordenone, Pordenone, Italy
| | - Vincenzo Adamo
- Dipartimento Universitario di Patologia Umana & Azienda Ospedaliera Papardo, Messina, Italy
| | | | | | | | | | - Sandro Barni
- Ospedale Treviglio Caravaggio Treviglio, Bergamo, Italy
| | | | | | | | | | | | | | - Maria Antista
- Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Katia F Dotti
- Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Francesca Galli
- IRCCS Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy
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Abstract
Colorectal cancer is still a majorhealth and social problem. However, many important advances in treatment have been made in the last 4 to 5 years, and more optimism is now justified both among clinicians and patients. In surgically resectable disease, adjuvant chemotherapy has been clearly demonstrated as able to increase overall survival in patients with colon cancer Dukes' stage C, whereas the role of medical treatment in patients with Dukes' stage B colon cancer is still controversial. At present, the standard regimen is bolus fluorouracil (5-FU) modulated by folinic acid (leucovorin) for 6 months. For rectal cancer, the best adjuvant treatment seems to be represented by radiotherapy (better if administered preoperatively) combined with chemotherapy (usually based on modulated or continuously infused 5-FU). In advanced disease, many new drugs have recently emerged: the most active regimens are those combining an optimal modality of 5-FU administration (i.e. continuous infusion) and one of the most active innovative compounds (irinotecan or oxaliplatin). The role of the oral drugs (e.g. tegafur/uracil, capecitabine) is still under investigation as is the combination of agents excluding 5-FU. It is now recognised that first-line treatment must be offered to all suitable pa- tients, even though asymptomatic, and that a second-line therapy (chiefly with irinotecan) is of value in many patients with cancer that progresses during treatment with 5-FU. From a strategic point of view, the best sequence of drugs/regimens has not yet been defined, while the duration and timing of chemotherapy is still a matter for clinical research. Finally, there is an increasing interest in the role of biological prognostic factors as an aid to a patient-tailored therapy, both in the adjuvant setting and in advanced disease. To achieve further progress in knowledge in this field, we strongly recommended that more and more patients are included in clinical trials.
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Affiliation(s)
- R F Labianca
- Medical Oncology Unit, Ospedali Riuniti, Bergamo, Italy.
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