The Impact of Cancer Associated Inflammation on Cytotoxic Drug Metabolism and Nutritional Status; the Sydney Cancer Centre Experience

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1 The Impact of Cancer Associated Inflammation on Cytotoxic Drug Metabolism and Nutritional Status; the Sydney Cancer Centre Experience Stephen J. Clarke, Christopher Liddle, Graham R. Robertson Department of Medicine, Level 1, Clinical Sciences Building, Concord Hospital, Concord NSW 2139, Australia ABSTRACT Cancer associated inflammation has long been recognised to be associated with worse cancer outcomes including survival. This process is driven by increased plasma cytokine concentrations, especially interleukin-6 (IL-6), derived either from the tumour or host immune cells. Research in the Clinical Pharmacology Unit at the Sydney Cancer Centre has focused on the impact of cancer-associated inflammation on hepatic cytotoxic drug metabolism and toxicity from chemotherapy. The majority of anti-cancer drugs are metabolised by the hepatic cytochrome P450 system of enzymes, in particular 3A4 (CYP3A4). This research has shown that an acute phase plasma protein reaction in cancer patients and murine tumour models is associated with reduced CYP3A4 metabolism. In addition, there is evidence of reduced hepatic expression of a range of drug transporters including Mdr2, Mrp2, Mrp3, Ntcp, Oatp2, Oatp-c and Bcrp. In combination, these changes lead to reduced plasma clearance and increased toxicity from chemotherapy. We have also shown that cancer associated inflammation is strongly correlated with nutritional status in cancer patients, creating a rationale for nutrition intervention strategies to reverse inflammation and improve cytotoxic drug metabolism. A range of anti-cytokine antibodies have been developed targeting IL-6, the IL-6 receptor and TNF-α, and these create the potential to reverse impaired drug metabolism prior to administration of chemotherapy, thereby improving toxicity. INTRODUCTION Symptoms, signs and biochemical evidence of an inflammatory response are commonly seen in patients with advanced cancer. In studies of patients presenting to hospital with pyrexia of unknown origin (PUO), up to 30% have been subsequently found to suffer from cancer. 1-3 However, the best-characterised example of cancer-associated inflammation has been with the lymphomas where B symptoms (weight loss of > 5% body weight, night sweats and temperature > 38 Celsius) are associated with worse response to treatment and reduced failure free and overall survival. More recently, it has been reported that elevation of markers of inflammation including C-reactive protein (CRP) are more common in cancer patients than healthy controls 4 and are associated with worse outcomes in many cancers, 5-13 including reduced survival in common tumours such as lung, breast and colorectal cancers. The elevated inflammatory markers appear to be driven by increased plasma concentrations of cytokines, especially interleukin- 6 (IL-6), produced either by the tumour itself or by host derived immune cells. These cytokines can affect numerous organs including the liver, brain, bone marrow, muscle and fat, as summarised in Figure 1. Protracted and/or marked elevation of cytokines leads to the cancer cachexia syndrome. In the non-cancer literature there has been clinical evidence since the 1970 s that inflammation can be associated with reduced hepatic drug metabolism, especially for drugs metabolised by cytochrome P450 3A4. In many instances, the reduction in CYP3A4 function, as indicated Corresponding author: Stephen J. Clarke, Department of Medicine, Level 1, Clinical Sciences Building, Concord Hospital, Concord NSW 2139, Australia. 163

2 Stephen J. Clarke Figure 1. Impact of cancer associated inflammation on the body by reduced clearance of anti-pyrine, was accompanied by increased plasma IL-6 concentration (reviewed in 14, 15 ). The research program of the Clinical Pharmacology Unit at the Sydney Cancer Centre in the last 10 years has focused on the impact of tumour derived inflammation on hepatic drug clearance. This has included clinical studies and the characterisation of animal models. In addition, we have attempted to correlate cancer-induced inflammation with nutritional status in the quest to identify factors that could be favourably influenced to improve drug metabolism. CHARACTERISATION OF PRE- CLINICAL MODELS OF TUMOUR INDUCED INFLAMMATION Robertson and colleagues have previously reported the development of a transgenic mouse model of human CYP3A4 gene regulation. 16 In this model, a construct comprising the upstream regulatory region of the human CYP3A4 gene linked to the lacz reporter gene was inserted into mice. Using this model, it is possible to analyse the molecular mechanisms involved in the regulation of CYP3A4. The Engelbreth-Holm-Swarm (EHS) sarcoma was injected into the immune competent transgenic mice. In tumour bearing transgenic animals, there was approximately a 60% reduction in transgene expression compared to saline injected control transgenic animals. 17 Similar changes were seen in the native murine Cyp3a11 gene. In addition, immunoblotting with CYP3A4 specific antibodies showed approximately a 50% reduction in murine CYP3A4 protein. These changes were associated with increased mrna levels in hepatic tissues of serum amyloid protein (SAP), the murine equivalent of CRP, and increased plasma concentrations of IL-6. There was no detectable plasma concentration of tumour necrosis factor (TNF) - α. To evaluate the pharmacological impact of these changes, the comparative durations of midazolam induced (CYP3A4 substrate) sleep were compared between tumour bearing and control animals. Tumour bearing animals slept for significantly longer periods. Similar changes have been demonstrated in other syngeneic murine tumour types, including the E0771 breast and B16 melanoma models. 18 Further studies have demonstrated that in addition to repression of hepatic Cyp3a11 mrna expression, there is reduction in the 164

3 The Impact of Cancer Associated Inflammation on Cytotoxic Drug Metabolism and Nutritional Status:... expression of a number of hepatic drug transporters including Mdr2, Mrp2, Mrp3, Ntcp, Oatp2, Oatp-c and Bcrp, but not Mdr1a. CLINICAL STUDIES OF INFLAMMATION AND CYTOTOXIC DRUG METABOLISM Dose selection for the majority of cytotoxic drugs is based on body surface area even though this process has been repeatedly shown to lack validity. 19, 20 Only with the predominantly renally excreted agent, carboplatin, can a predictably safe and effective dose be chosen, using an equation incorporating a patient s glomerular filtration rate. 21 CYP3A4 is responsible for the metabolism of a number of classes of cytotoxic drug classes, including: the taxanes, paclitaxel and docetaxel; the vinca alkaloids, vincristine, vinblastine, vindesine and vinorelbine; the epipodophyllotoxins, etoposide and teniposide; and molecularly targeted agents such as gefitinib, imatinib and erlotinib. Thus, the ability to predict an individuals CYP3A4 capacity could lead to improvements in the safety and effectiveness of chemotherapy prescribing. Although there are numerous allelic variants of CYP3A, there is no evidence that these impact on inter-individual variability in toxicity from chemotherapy. A range of analyses have been evaluated to phenotype patients for their CYP3A4 metabolic capacity (reviewed in 22, 23 ). The most popular assessments used in cancer patients have been measurement of the clearance of orally or intravenously administered midazolam, the erythromycin breath test and measurement of the total amount of 6β-hydroxycortisol in a 24-hour urine collection after intravenous administration of 300mg hydrocortisone. 24 Our group has refined the erythromycin breath test for use in this circumstance. 25, 26 Patients are administered a tracer dose of 14 C-erythromycin and asked to breathe into a metal balloon at 5 minute intervals. The exhaled breath is subsequently expelled into scintillation fluid and the radioactivity counted. 14 CO 2 is produced following the metabolism of 14 C-erythromycin by CYP3A4 (Figure 2). Figure 2. The erythromycin breath test (top left) and correlation of the novel parameter T max -1 with: plasma clearance of erythromycin lactobionate (A); plasma C-reactive plasma concentration (B); and toxicity from the CYP3A4 substrate docetaxel administered weekly intravenously (C). 165

4 Stephen J. Clarke In an initial study, 16 patients with incurable cancer underwent an erythromycin breath test with breath sampling undertaken at 11 time points over a 2 hour period. 25 The following day the breath test was repeated midway through a 10-minute infusion of 100mg of erythromycin lactobionate, following which the pharmacokinetics (PK) of erythromycin were determined. Parameters reflecting the early appearance of 14 CO 2 in the breath were strongly correlated with the clearance of erythromycin, in particular T max -1 (Figure 2). In a subsequent study 68 patients were treated with weekly schedules of docetaxel, a CYP3A4 substrate. 27, 28 All patients underwent the erythromycin breath test prior to receiving docetaxel and had venous sampling for evaluation of docetaxel PK performed after treatment. In addition, plasma inflammatory proteins including CRP, AAGP and IL-6 were measured at baseline in all patients. Plasma CRP and AAGP concentrations were inversely correlated with hepatic drug clearance as assessed by the erythromycin breath test. Patients with CRP concentrations > 10mg/l had on average a 30% reduction in drug metabolism. 28 This reduction was also associated with reduced plasma clearance of docetaxel. Patients with slower formation of 14 CO 2 and elevated concentrations of AAGP and CRP also experienced more severe toxicities after treatment with docetaxel 27 (Figure 2). The plasma concentrations of CRP and IL-6 were also strongly correlated (Figure 3). Surprisingly, plasma TNF-α concentrations were only detectable in 2 patients. In an attempt to confirm the hypothesis that cancer associated inflammation adversely impacts on toxicity from cytotoxic drugs, we have re-analysed data from a British National Lymphoma Group study that compared 2 chemotherapy regimens (CHOP and PMitCEBO) in patients aged > 60 with aggressive non-hodgkin lymphoma (NHL). Of 784 patients with diffuse large B-cell lymphoma who were enrolled on study, approximately 50% had B symptoms. Patients with B symptoms had significantly more advanced disease stage, worse performance status, higher International Prognostic Index (IPI) scores and higher lactate dehydrogenase levels than patients with A symptoms. Myelosuppression and treatment associated Figure 3. Relationships involving inflammation or nutritional status in cancer patients: A correlation of plasma CRP and IL-6 concentration, B CRP and nutritional status category, C nutritional score and survival, D CRP and ECOG performance status. 166

5 The Impact of Cancer Associated Inflammation on Cytotoxic Drug Metabolism and Nutritional Status:... infection were statistically significantly worse in patients with B symptoms. Fifty seven percent of B symptom patients experienced grades 3-4 leucopenia. Response rates, failure free and overall survivals were all significantly worse in patients with B symptoms (S.Clarke - personal communication). NUTRITION AND INFLAMMATION As mentioned earlier, elevated inflammatory markers have been associated with the development and progression of the cancer cachexia syndrome. Therefore it is likely that nutritional status might be impaired in other inflammatory states, such as we have described in association with impaired hepatic drug metabolism. As nutritional status is potentially modifiable by therapeutic interventions, confirmation of an association between nutritional status and inflammation, and therefore with reduced drug metabolism might provide a means by which impaired cytotoxic drug metabolism might be improved, thereby reducing toxicity. In 2 studies we evaluated the nutritional status of advanced cancer patients at time of initial presentation to a medical oncology unit. In the first we assessed nutritional status in 73 consecutive patients using the mini-nutritional assessment (MNA), a tool that has been previously validated in a geriatric population. 29 A wide range of cancer types was represented. Of these patients, 63% were scored to be nutritionally at risk, while an additional 13% were malnourished. CRP was elevated in 67% of patients, while AAGP was elevated in 71% of patients. There was a strong relationship between CRP and each of MNA and percentage weight loss (Spearman rho co-efficient of 2 x 10-4 for each). CRP was also strongly correlated with Eastern Clinical Oncology Group performance status (ECOG PS) with patients with higher PS scores also having higher mean CRP concentrations (Figure 3). In a subsequent study we evaluated nutritional status with the patient generated scored global assessment (PGSGA) tool which has been shown to be the gold standard for nutritional assessment in cancer patients. The PGSGA has been shown by us to correlate well with the MNA, but provides greater specificity in the classification of nutritional risk. 30 In a study of 141 consecutive new patients with advanced cancer attending a medical oncology clinic, 34% were well nourished, 56% were at risk of malnutrition and 10% were malnourished. 31 There was no difference in nutritional status or inflammatory markers for patients older or younger than 65 years of age. CRP concentrations were again higher in patients with nutritional impairment than in those who were well nourished (Figure 3). Thus, nutritional status is highly correlated with inflammatory markers and is therefore likely to be associated with reduced CYP3A4 metabolism. In patients with advanced colorectal cancer, we have shown that nutritional status and inflammatory markers are prognostic (Figure 3), with patients with impaired nutritional status and elevated inflammatory markers (CRP > 10 mg/l) having significantly worse survival than those with normal nutritional status and CRP. 32 This study also confirmed the prevalence of cancer-associated inflammation as 69% of patients had an elevated CRP (median 21.1 mg/l) and 56% were nutritionally at risk. However, in a pilot study we demonstrated that nutritional education and ingestion of an eicosapentaenoic acid (EPA) containing supplement could prevent further deterioration in nutritional status and maintain levels of CRP. 33 CONCLUSIONS AND FUTURE PLANS Our research has conclusively demonstrated that cancer associated inflammation is associated with impaired hepatic drug metabolism and increased toxicity from chemotherapy. Cancer associated inflammation is also strongly correlated with nutritional status, creating the potential for nutritional intervention strategies used prior to chemotherapy, with the intent to reverse inflammation, improve drug metabolism and reduce toxicity from chemotherapy. In addition, cancer associated inflammation appears to be principally driven by elevated plasma concentrations of cytokines, in particular, IL-6. A number of new anti-cytokine antibodies have been developed targeting molecules such as IL-6, IL-6 receptor and TNF-α, and these create the potential to reverse inflammation and improve drug metabolism prior to administration of chemotherapy. This area is an exciting new realm of research that is likely to result in improved use of chemotherapy worldwide. REFERENCES 1 Gaeta GB, Fusco FM, Nardiello S. Fever of unknown origin: a systematic review of the literature for Nucl Med Commun Mar;27(3): Knockaert DC, Vanderschueren S, Blockmans D. Fever of unknown origin in adults: 40 years on. J Intern Med Mar;253(3): Vanderschueren S, Knockaert D, Adriaenssens T, Demey W, Durnez A, Blockmans D, et al. From prolonged febrile illness to fever of unknown origin: the challenge continues. Arch Intern Med May 12;163(9): Heikkila K, Ebrahim S, Lawlor DA. A systematic review of the association between circulating concentrations of C reactive protein and cancer. J Epidemiol Community Health Sep;61(9): Al Murri AM, Wilson C, Lannigan A, Doughty JC, Angerson WJ, McArdle CS, et al. Evaluation of the relationship between 167

6 Stephen J. Clarke the systemic inflammatory response and cancer-specific survival in patients with primary operable breast cancer. Br J Cancer Mar 26;96(6): Canna K, Hilmy M, McMillan DC, Smith GW, McKee RF, McArdle CS, et al. The relationship between tumour proliferative activity, the systemic inflammatory response and survival in patients undergoing curative resection for colorectal cancer. Colorectal Dis Nov Canna K, McArdle PA, McMillan DC, McNicol AM, Smith GW, McKee RF, et al. The relationship between tumour T- lymphocyte infiltration, the systemic inflammatory response and survival in patients undergoing curative resection for colorectal cancer. Br J Cancer Feb 28;92(4): Crozier JE, McKee RF, McArdle CS, Angerson WJ, Anderson JH, Horgan PG, et al. The presence of a systemic inflammatory response predicts poorer survival in patients receiving adjuvant 5-FU chemotherapy following potentially curative resection for colorectal cancer. Br J Cancer Jun 19;94(12): Crumley AB, McMillan DC, McKernan M, McDonald AC, Stuart RC. Evaluation of an inflammation-based prognostic score in patients with inoperable gastro-oesophageal cancer. Br J Cancer Mar 13;94(5): Elahi MM, McMillan DC, McArdle CS, Angerson WJ, Soukop M, Johnstone J, et al. The systemic inflammatory response predicts overall and cancer specific survival in patients with malignant lymphoma. Med Sci Monit Feb;11(2):CR Hilmy M, Bartlett JM, Underwood MA, McMillan DC. The relationship between the systemic inflammatory response and survival in patients with transitional cell carcinoma of the urinary bladder. Br J Cancer Feb 28;92(4): McArdle PA, Mir K, Almushatat AS, Wallace AM, Underwood MA, McMillan DC. Systemic inflammatory response, prostatespecific antigen and survival in patients with metastatic prostate cancer. Urol Int. 2006;77(2): Scott HR, McMillan DC, Forrest LM, Brown DJ, McArdle CS, Milroy R. The systemic inflammatory response, weight loss, performance status and survival in patients with inoperable non-small cell lung cancer. Br J Cancer Jul 29;87(3): Aitken AE, Richardson TA, Morgan ET. Regulation of drugmetabolizing enzymes and transporters in inflammation. Annu Rev Pharmacol Toxicol. 2006;46: Renton KW. Alteration of drug biotransformation and elimination during infection and inflammation. Pharmacol Ther Nov-Dec;92(2-3): Robertson GR, Field J, Goodwin B, Bierach S, Tran M, Lehnert A, et al. Transgenic mouse models of human CYP3A4 gene regulation. Mol Pharmacol Jul;64(1): Charles KA, Rivory LP, Brown SL, Liddle C, Clarke SJ, Robertson GR. Transcriptional repression of hepatic cytochrome P450 3A4 gene in the presence of cancer. Clin Cancer Res Dec 15;12(24): Sharma R, Kacevska M, London R, Clarke SJ, Liddle C, Robertson G. Downregulation of drug transport and metabolism in mice bearing extra-hepatic malignancies. Br J Cancer Dec Gurney H. Dose calculation of anticancer drugs: a review of the current practice and introduction of an alternative. J Clin Oncol Sep;14(9): Felici A, Verweij J, Sparreboom A. Dosing strategies for anticancer drugs: the good, the bad and body-surface area. Eur J Cancer Sep;38(13): Calvert AH, Newell DR, Gumbrell LA, O Reilly S, Burnell M, Boxall FE, et al. Carboplatin dosage: prospective evaluation of a simple formula based on renal function. J Clin Oncol Nov;7(11): Streetman DS, Bertino JS, Jr., Nafziger AN. Phenotyping of drug-metabolizing enzymes in adults: a review of in-vivo cytochrome P450 phenotyping probes. Pharmacogenetics Apr;10(3): Fuhr U, Jetter A, Kirchheiner J. Appropriate phenotyping procedures for drug metabolizing enzymes and transporters in humans and their simultaneous use in the cocktail approach. Clin Pharmacol Ther Feb;81(2): Yamamoto N, Tamura T, Kamiya Y, Sekine I, Kunitoh H, Saijo N. Correlation between docetaxel clearance and estimated cytochrome P450 activity by urinary metabolite of exogenous cortisol. J Clin Oncol Jun;18(11): Rivory LP, Slaviero K, Seale JP, Hoskins JM, Boyer M, Beale PJ, et al. Optimizing the erythromycin breath test for use in cancer patients. Clin Cancer Res Sep;6(9): Rivory LP, Slaviero KA, Hoskins JM, Clarke SJ. The erythromycin breath test for the prediction of drug clearance. Clin Pharmacokinet. 2001;40(3): Charles KA, Rivory LP, Stockler MR, Beale P, Beith J, Boyer M, et al. Predicting the toxicity of weekly docetaxel in advanced cancer. Clin Pharmacokinet. 2006;45(6): Rivory LP, Slaviero KA, Clarke SJ. Hepatic cytochrome P450 3A drug metabolism is reduced in cancer patients who have an acute-phase response. Br J Cancer Jul 29;87(3): Slaviero KA, Read JA, Clarke SJ, Rivory LP. Baseline nutritional assessment in advanced cancer patients receiving palliative chemotherapy. Nutr Cancer. 2003;46(2): Read JA, Crockett N, Volker DH, MacLennan P, Choy ST, Beale P, et al. Nutritional assessment in cancer: comparing the Mini-Nutritional Assessment (MNA) with the scored Patient- Generated Subjective Global Assessment (PGSGA). Nutr Cancer. 2005;53(1): Read JA, Choy ST, Beale P, Clarke SJ. An evaluation of the prevalence of malnutrition in cancer patients attending the outpatient oncology clinic. Asia-Pacific Journal of Clinical Oncology ;2: Read JA, Choy ST, Beale PJ, Clarke SJ. Evaluation of nutritional and inflammatory status of advanced colorectal cancer patients and its correlation with survival. Nutr Cancer. 2006;55(1): Read JA, Beale PJ, Volker DH, Smith N, Childs A, Clarke SJ. Nutrition intervention using an eicosapentaenoic acid (EPA)- containing supplement in patients with advanced colorectal cancer. Effects on nutritional and inflammatory status: a phase II trial. Support Care Cancer Mar;15(3):