Abstract
Purpose
The risk of anemia due to bevacizumab-based chemotherapy has not been well described, and new randomized controlled trials (RCTs) have been reported in recent years. We therefore conducted an up-to-date meta-analysis of RCTs to fully characterize the risk of anemia with bevacizumab.
Methods
We carried out an electronic search of Medline, Embase, and The Cochrane Central Register of Controlled Trials to investigate the effects of RCTs on bevacizumab treatment on cancer patients up to October 2014, and random or fixed-effect meta-analytical models were used to assess the risk ratio (RR) of anemia due to the use of bevacizumab according to the heterogeneity of included studies.
Results
A total of 13,173 patients were included in this analysis from 18 RCTs. Among those patients receiving bevacizumab and chemotherapy, the incidences of all-grade and high-grade (grade 3 and above) anemia were 24 % (95 % confidence interval (CI) 13–41 %) and 4.0 % (95 % CI 3.0–6.0 %), respectively. Bevacizumab-containing therapy did not significantly decreased the risk of developing all-grade anemia (RR 0.872, 95 % CI 0.739–1.029, P = 0.104) and high-grade anemia (RR 0.850, 95 % CI 0.720–1.002, P = 0.053), which is not in agreement with previous meta-analysis. On subgroup analysis, we did not find significant risk differences based on bevacizumab dosage, tumor types, and concomitant drugs. When stratified by dose level, a significantly decreased risk of high-grade anemia with bevacizumab was obtained in a lower dose level (2.5 mg/kg/week, RR 0.773, 95 % CI 0.611–0.978, P = 0.031) compared to control group.
Conclusions
Bevacizumab did not significantly reduce the risk of anemia with chemotherapy in cancer patients.
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References
Ebbers HC, van Meer PJ, Moors EH, Mantel-Teeuwisse AK, Leufkens HG, Schellekens H (2013) Measures of biosimilarity in monoclonal antibodies in oncology: the case of bevacizumab. Drug Discov Today 18:872–879. doi:10.1016/j.drudis.2013.05.004
Ferrara N, Hillan KJ, Gerber HP, Novotny W (2004) Discovery and development of bevacizumab, an anti-VEGF antibody for treating cancer. Nat Rev Drug Discov 3:391–400. doi:10.1038/nrd1381
Qi WX, Shen Z, Tang LN, Yao Y (2014) Bevacizumab increases the risk of gastrointestinal perforation in cancer patients: a meta-analysis with a focus on different subgroups. Eur J Clin Pharmacol 70:893–906. doi:10.1007/s00228-014-1687-9
Cohen MH, Gootenberg J, Keegan P, Pazdur R (2007) FDA drug approval summary: bevacizumab plus FOLFOX4 as second-line treatment of colorectal cancer. Oncologist 12:356–361. doi:10.1634/theoncologist.12-3-356
Cohen MH, Gootenberg J, Keegan P, Pazdur R (2007) FDA drug approval summary: bevacizumab (Avastin) plus Carboplatin and Paclitaxel as first-line treatment of advanced/metastatic recurrent nonsquamous non-small cell lung cancer. Oncologist 12:713–718. doi:10.1634/theoncologist.12-6-713
Friedman HS, Prados MD, Wen PY, Mikkelsen T, Schiff D, Abrey LE, Yung WK, Paleologos N, Nicholas MK, Jensen R, Vredenburgh J, Huang J, Zheng M, Cloughesy T (2009) Bevacizumab alone and in combination with irinotecan in recurrent glioblastoma. J Clin Oncol Off J Am Soc Clin Oncol 27:4733–4740. doi:10.1200/JCO.2008.19.8721
Burger RA, Brady MF, Bookman MA, Fleming GF, Monk BJ, Huang H, Mannel RS, Homesley HD, Fowler J, Greer BE, Boente M, Birrer MJ, Liang SX (2011) Incorporation of bevacizumab in the primary treatment of ovarian cancer. N Engl J Med 365:2473–2483. doi:10.1056/NEJMoa1104390
Frampton JE, Keating GM (2008) Bevacizumab: in first-line treatment of advanced and/or metastatic renal cell carcinoma. BioDrugs Clin Immunotherapeutics Biopharmaceuticals Gene Ther 22:113–120
Xue Y, Chen F, Zhang D, Lim S, Cao Y (2009) Tumor-derived VEGF modulates hematopoiesis. J Angiogenes Res 1:9. doi:10.1186/2040-2384-1-9
Xue Y, Religa P, Cao R, Hansen AJ, Lucchini F, Jones B, Wu Y, Zhu Z, Pytowski B, Liang Y, Zhong W, Vezzoni P, Rozell B, Cao Y (2008) Anti-VEGF agents confer survival advantages to tumor-bearing mice by improving cancer-associated systemic syndrome. Proc Natl Acad Sci U S A 105:18513–18518. doi:10.1073/pnas.0807967105
Tam BY, Wei K, Rudge JS, Hoffman J, Holash J, Park SK, Yuan J, Hefner C, Chartier C, Lee JS, Jiang S, Nayak NR, Kuypers FA, Ma L, Sundram U, Wu G, Garcia JA, Schrier SL, Maher JJ, Johnson RS, Yancopoulos GD, Mulligan RC, Kuo CJ (2006) VEGF modulates erythropoiesis through regulation of adult hepatic erythropoietin synthesis. Nat Med 12:793–800. doi:10.1038/nm1428
Harshman LC, Kuo CJ, Wong BY, Vogelzang NJ, Srinivas S (2009) Increased hemoglobin associated with VEGF inhibitors in advanced renal cell carcinoma. Cancer Investig 27:851–856. doi:10.1080/07357900902744528
Sher A, Wu S (2011) Anti-vascular endothelial growth factor antibody bevacizumab reduced the risk of anemia associated with chemotherapy—a meta-analysis. Acta Oncol (Stockholm, Sweden) 50:997–1005. doi:10.3109/0284186x.2011.581689
Schutz FA, Jardim DL, Je Y, Choueiri TK (2011) Haematologic toxicities associated with the addition of bevacizumab in cancer patients. Eur J Cancer (Oxford, England: 1990) 47:1161–1174. doi:10.1016/j.ejca.2011.03.005
Miles D, Chan A, Romieu G, Dirix LY, Cortes J, Pivot X et al (2008) Randomized, double-blind, placebo-controlled, phase III study of bevacizumab with docetaxel or docetaxel with placebo as first-line therapy for patients with locally recurrent or metastatic breast cancer (mBC):AVADO. J Clin Oncol (Meet Abstr) 26(15suppl):LBA1011
Miles DW, Chan A, Dirix LY, Cortes J, Pivot X, Tomczak P, Delozier T, Sohn JH, Provencher L, Puglisi F, Harbeck N, Steger GG, Schneeweiss A, Wardley AM, Chlistalla A, Romieu G (2010) Phase III study of bevacizumab plus docetaxel compared with placebo plus docetaxel for the first-line treatment of human epidermal growth factor receptor 2-negative metastatic breast cancer. J Clin Oncol Off J Am Soc Clin Oncol 28:3239–3247. doi:10.1200/jco.2008.21.6457
White D, Kassim A, Bhaskar B, Yi J, Wamstad K, Paton VE (2013) Results from AMBER, a randomized phase 2 study of bevacizumab and bortezomib versus bortezomib in relapsed or refractory multiple myeloma. Cancer 119:339–347. doi:10.1002/cncr.27745
Cameron D, Brown J, Dent R, Jackisch C, Mackey J, Pivot X, Steger GG, Suter TM, Toi M, Parmar M, Laeufle R, Im YH, Romieu G, Harvey V, Lipatov O, Pienkowski T, Cottu P, Chan A, Im SA, Hall PS, Bubuteishvili-Pacaud L, Henschel V, Deurloo RJ, Pallaud C, Bell R (2013) Adjuvant bevacizumab-containing therapy in triple-negative breast cancer (BEATRICE): primary results of a randomised, phase 3 trial. Lancet Oncol 14:933–942. doi:10.1016/s1470-2045(13)70335-8
von Minckwitz G, Eidtmann H, Rezai M, Fasching PA, Tesch H, Eggemann H, Schrader I, Kittel K, Hanusch C, Kreienberg R, Solbach C, Gerber B, Jackisch C, Kunz G, Blohmer JU, Huober J, Hauschild M, Fehm T, Muller BM, Denkert C, Loibl S, Nekljudova V, Untch M (2012) Neoadjuvant chemotherapy and bevacizumab for HER2-negative breast cancer. N Engl J Med 366:299–309. doi:10.1056/NEJMoa1111065
Jadad AR, Moore RA, Carroll D, Jenkinson C, Reynolds DJ, Gavaghan DJ, McQuay HJ (1996) Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control Clin Trials 17:1–12
Choueiri TK, Schutz FA, Je Y, Rosenberg JE, Bellmunt J (2010) Risk of arterial thromboembolic events with sunitinib and sorafenib: a systematic review and meta-analysis of clinical trials. J Clin Oncol Off J Am Soc Clin Oncol 28:2280–2285. doi:10.1200/jco.2009.27.2757
Miller K, Wang M, Gralow J, Dickler M, Cobleigh M, Perez EA, Shenkier T, Cella D, Davidson NE (2007) Paclitaxel plus bevacizumab versus paclitaxel alone for metastatic breast cancer. N Engl J Med 357:2666–2676. doi:10.1056/NEJMoa072113
Miller KD, Chap LI, Holmes FA, Cobleigh MA, Marcom PK, Fehrenbacher L, Dickler M, Overmoyer BA, Reimann JD, Sing AP, Langmuir V, Rugo HS (2005) Randomized phase III trial of capecitabine compared with bevacizumab plus capecitabine in patients with previously treated metastatic breast cancer. J Clin Oncol Off J Am Soc Clin Oncol 23:792–799. doi:10.1200/jco.2005.05.098
Niho S, Kunitoh H, Nokihara H, Horai T, Ichinose Y, Hida T, Yamamoto N, Kawahara M, Shinkai T, Nakagawa K, Matsui K, Negoro S, Yokoyama A, Kudoh S, Kiura K, Mori K, Okamoto H, Sakai H, Takeda K, Yokota S, Saijo N, Fukuoka M (2012) Randomized phase II study of first-line carboplatin-paclitaxel with or without bevacizumab in Japanese patients with advanced non-squamous non-small-cell lung cancer. Lung Cancer (Amst Neth) 76:362–367. doi:10.1016/j.lungcan.2011.12.005
Reck M, von Pawel J, Zatloukal P, Ramlau R, Gorbounova V, Hirsh V, Leighl N, Mezger J, Archer V, Moore N, Manegold C (2009) Phase III trial of cisplatin plus gemcitabine with either placebo or bevacizumab as first-line therapy for nonsquamous non-small-cell lung cancer: AVAil. J Clin Oncol Off J Am Soc Clin Oncol 27:1227–1234. doi:10.1200/jco.2007.14.5466
Herbst RS, O’Neill VJ, Fehrenbacher L, Belani CP, Bonomi PD, Hart L, Melnyk O, Ramies D, Lin M, Sandler A (2007) Phase II study of efficacy and safety of bevacizumab in combination with chemotherapy or erlotinib compared with chemotherapy alone for treatment of recurrent or refractory non small-cell lung cancer. J Clin Oncol Off J Am Soc Clin Oncol 25:4743–4750. doi:10.1200/jco.2007.12.3026
Sandler A, Gray R, Perry MC, Brahmer J, Schiller JH, Dowlati A, Lilenbaum R, Johnson DH (2006) Paclitaxel-carboplatin alone or with bevacizumab for non-small-cell lung cancer. N Engl J Med 355:2542–2550. doi:10.1056/NEJMoa061884
Rini BI, Halabi S, Rosenberg JE, Stadler WM, Vaena DA, Archer L, Atkins JN, Picus J, Czaykowski P, Dutcher J, Small EJ (2010) Phase III trial of bevacizumab plus interferon alfa versus interferon alfa monotherapy in patients with metastatic renal cell carcinoma: final results of CALGB 90206. J Clin Oncol Off J Am Soc Clin Oncol 28:2137–2143. doi:10.1200/jco.2009.26.5561
Escudier B, Pluzanska A, Koralewski P, Ravaud A, Bracarda S, Szczylik C, Chevreau C, Filipek M, Melichar B, Bajetta E, Gorbunova V, Bay JO, Bodrogi I, Jagiello-Gruszfeld A, Moore N (2007) Bevacizumab plus interferon alfa-2a for treatment of metastatic renal cell carcinoma: a randomised, double-blind phase III trial. Lancet 370:2103–2111. doi:10.1016/s0140-6736(07)61904-7
Kindler HL, Niedzwiecki D, Hollis D, Sutherland S, Schrag D, Hurwitz H, Innocenti F, Mulcahy MF, O’Reilly E, Wozniak TF, Picus J, Bhargava P, Mayer RJ, Schilsky RL, Goldberg RM (2010) Gemcitabine plus bevacizumab compared with gemcitabine plus placebo in patients with advanced pancreatic cancer: phase III trial of the Cancer and Leukemia Group B (CALGB 80303). J Clin Oncol Off J Am Soc Clin Oncol 28:3617–3622. doi:10.1200/jco.2010.28.1386
Van Cutsem E, Vervenne WL, Bennouna J, Humblet Y, Gill S, Van Laethem JL, Verslype C, Scheithauer W, Shang A, Cosaert J, Moore MJ (2009) Phase III trial of bevacizumab in combination with gemcitabine and erlotinib in patients with metastatic pancreatic cancer. J Clin Oncol Off J Am Soc Clin Oncol 27:2231–2237. doi:10.1200/jco.2008.20.0238
Guan ZZ, Xu JM, Luo RC, Feng FY, Wang LW, Shen L, Yu SY, Ba Y, Liang J, Wang D, Qin SK, Wang JJ, He J, Qi C, Xu RH (2011) Efficacy and safety of bevacizumab plus chemotherapy in Chinese patients with metastatic colorectal cancer: a randomized phase III ARTIST trial. Chin J Cancer 30:682–689. doi:10.5732/cjc.011.10188
Ohtsu A, Shah MA, Van Cutsem E, Rha SY, Sawaki A, Park SR, Lim HY, Yamada Y, Wu J, Langer B, Starnawski M, Kang YK (2011) Bevacizumab in combination with chemotherapy as first-line therapy in advanced gastric cancer: a randomized, double-blind, placebo-controlled phase III study. J Clin Oncol Off J Am Soc Clin Oncol 29:3968–3976. doi:10.1200/jco.2011.36.2236
Kelly WK, Halabi S, Carducci M, George D, Mahoney JF, Stadler WM, Morris M, Kantoff P, Monk JP, Kaplan E, Vogelzang NJ, Small EJ (2012) Randomized, double-blind, placebo-controlled phase III trial comparing docetaxel and prednisone with or without bevacizumab in men with metastatic castration-resistant prostate cancer: CALGB 90401. J Clin Oncol Off J Am Soc Clin Oncol 30:1534–1540. doi:10.1200/jco.2011.39.4767
Kindler HL, Karrison TG, Gandara DR, Lu C, Krug LM, Stevenson JP, Janne PA, Quinn DI, Koczywas MN, Brahmer JR, Albain KS, Taber DA, Armato SG 3rd, Vogelzang NJ, Chen HX, Stadler WM, Vokes EE (2012) Multicenter, double-blind, placebo-controlled, randomized phase II trial of gemcitabine/cisplatin plus bevacizumab or placebo in patients with malignant mesothelioma. J Clin Oncol Off J Am Soc Clin Oncol 30:2509–2515. doi:10.1200/jco.2011.41.5869
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Wang, ZP., Zhang, HF., Zhang, F. et al. Bevacizumab did not reduce the risk of anemia associated with chemotherapy: an up-to-date meta-analysis. Eur J Clin Pharmacol 71, 517–524 (2015). https://doi.org/10.1007/s00228-015-1818-y
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DOI: https://doi.org/10.1007/s00228-015-1818-y