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New meta-analysis reassuring on ARBs and cancer, but

questions remain
November 29, 2010 | Lisa Nainggolan

New York, NY - A new meta-analysis of almost 325 000 individuals from 70 clinical trials has found no
excess risk of cancer or cancer death with any single antihypertensive drug [1]. The results counter the
conclusions of a review published earlier this summer—by Dr Ilke Sipahi (University Hospitals Case
Medical Center, Cleveland, OH) and colleagues—which indicated that angiotensin-receptor blockers
(ARBs) were associated with a modest increased risk of developing cancer.

"Our new paper refutes the findings from the analysis by Sipahi et al," lead author Dr Sripal Bangalore
(New York University School of Medicine, New York) told heartwire, "and it extends [this reassurance] to
other classes of antihypertensive agents."

Our new paper refutes the findings from the analysis by Sipahi et al.

However, a statistically significant increase in cancers among patients taking an ARB in combination with
an ACE inhibitor of roughly 10% means the authors "cannot rule out" an increased risk of cancer with the
combination of these two medications.

In an accompanying comment [2], hypertension experts Drs Lars H Lindholm and Bo Carlberg (Umea
University, Sweden) say: "Bangalore and colleagues' comprehensive analyses do not lend support to the
hypothesis that any of the blood-pressure-lowering drug classes promote cancer." With regard to the possible
signal with the concomitant use of an ACE inhibitor and ARB, they note that this "is not a preferred
combination for long-term treatment of high blood pressure."

Others feel differently. Sipahi says there are methodological reasons why this new study comes up with
different findings from his own, and Dr Steven E Nissen (Cleveland Clinic, OH), who wrote an editorial
accompanying the Sipahi paper, told heartwire: "It hasn't completely put to rest the question about these
drugs. We are in an area where the evidence isn't strong enough to warrant regulatory action but where it
does warrant looking very carefully." He urged regulatory bodies to complete their review of this issue

The Sipahi paper prompted a safety review by the European Medicines Agency and the US FDA [3,4].
FDA spokesperson Sandy Walsh told heartwire: "We have asked for data from the ARB drug
sponsors. Companies have submitted data to us and the data are currently under review. We will review all
of the data in total and then communicate any follow-up information. There is not yet a certain timeframe for
the completion of that review."

Follow-up may not be long enough to see cancer signal

The meta-analysis by Sipahi et al found an 8% to 11% increased risk of cancer with ARBs, which was
mainly driven by a significant 25% increased risk of lung cancer. At the time, Sipahi acknowledged that this
risk was small for the individual but could be important at a population level. Dr Michael D Peake
(Glenfield Hospital, Leicester, UK), a spokesperson for the UK Lung Cancer Coalition, agreed; at the time,
he told heartwire: "It's a relatively small risk, but if applied to large numbers of people, it might be quite

It hasn't completely put to rest the question about these drugs.

The Sipahi paper caused a huge furor in the hypertension community, with leading figures calling it deeply
flawed, and some arguing that it should not even have been published. There were grave concerns that the
media attention surrounding the article would lead to patients stopping their antihypertensive therapy,
putting themselves at increased risk of cardiovascular and renal events.

The new meta-analysis does not specify cancer types but is much bigger than the one performed by Sipahi et
al. "Although [Bangalore et al] did not replicate the ARB evidence that Sipahi et al reported, they do show
evidence that the combination of ACE inhibitor and ARB may be associated with an increased risk of
cancer," says Nissen. "So now you've got a second, much larger, study that raises some questions about the
class, since ACE inhibitors alone are pretty definitively known not to induce an increase in malignancies."

Nissen says it's also important to remember that "patients may take these drugs for decades, so if there is a
risk, it may emerge later on."

It's very difficult to know what this means. We don't know the exact latency time for lung cancer.

Bangalore agrees. He told heartwire the mean follow-up period in this meta-analysis was 3.5 years, with a
treatment duration range of one to nine years. "These drugs are given for many decades, and I think we
should be really careful in interpreting the results, because cancer is not going to develop overnight."
However, he says he believes the findings "provide reassurance to patients and physicians."

Peake, too, has reservations about the time frame, both of this study and the meta-analysis of Sipahi et al,
which had an average follow-up of four years. "It's very difficult to know what this means. We don't know
the exact latency time for lung cancer, but it is probably in the region of 15 to 25 years," he commented.

No evidence of increase in relative risk of cancer with any class

Bangalore et al include 70 randomized controlled trials with 324 168 participants in their new meta-analysis,
which Bangalore points out uses three different methods of analysis and is therefore "more robust" than the
one Sipahi et al employed.

In the network meta-analysis (fixed-effect model), they found no difference in the risk of cancer with any
antihypertensive agent vs placebo. They did, however, find an increased risk of cancer with the combination
of ACE inhibitor plus ARB (odds ratio 1.14 compared with placebo), but this risk was not apparent in the
random-effects model, they note.

In direct-comparison meta-analyses, similar results were recorded for all antihypertensive drug classes,
except for an increased risk of cancer with the ACE-inhibitor/ARB combination (odds ratio 1.14; p=0.004)
and with calcium-channel blockers (CCBs; OR 1.06; p=0.02). However, they noted no significant
differences in cancer-related mortality.

Risk of cancer and cancer death with different antihypertensives, placebo and controls

Drug class Cancer proportion, % (fixed- Odds Cancer-related death, % (fixed- Odds
effect model) ratio* effect model) ratio*
Placebo 2.02 1.00 1.32 1.00
ARBs 2.04 1.01 1.33 1.00
ACE inhibitors 2.03 1.00 1.25 0.95
Beta blockers 1.97 0.97 1.23 0.93
CCBs 2.11 1.05 1.27 0.96
Diuretics 2.02 1.00 1.30 0.98
ACE 2.30 1.14 1.45 1.10
Other controls 1.95 0.97 1.43 1.08
*vs placebo
In a third look, on the basis of trial sequential analysis, "our results suggest no evidence of even a 5% to 10%
relative risk [RR] increase of cancer and cancer-related deaths with any individual class of antihypertensive
drug studied," the researchers note.

But for the ACE-inhibitor/ARB combination, the figures, "driven largely by the ONTARGET trial," suggest
"firm evidence" of at least a 10% RR increase in cancer risk, they note. This finding "has to be interpreted in
the context of the short duration of follow-up of these trials," they note. Bangalore added to heartwire: "It is
a signal that needs to be followed up."

In their comment, Lindholm and Carlberg say that although the ACE-inhibitor/ARB combination is little
used in hypertension, it is "frequently prescribed for patients with severe heart failure." But the expected
survival time of such patients "is short," they observe, and "ruling out cancer risk is a difficult task to
undertake, since elderly patients are likely to die of either cancer or of cardiovascular disease."

Cancer underreported in some trials; indirect meta-analysis inappropriate

Sipahi says there a number of reasons that Bangalore et al got different results: inclusion of trials where
cancer was not a prespecified end point, which in some cases led to "massive underreporting of cancers,
[which] skews the findings"; the addition of the VALUE trial, because nobody in this study was taking
valsartan at the clinically recommended target dose of 320 mg, and "to study the safety of a drug, patients
actually have to be taking the drugs . . . at recommended doses"; and finally, Bangalore and colleagues
mainly use the approach of indirect meta-analysis. The latter takes as a major assumption the fact that all
trials have to be homogenous in several regards. "The trials that they include span a period from 1974 to
2008, with huge variations in most study characteristics. Indirect meta-analysis is not an appropriate method
in this context to say that ARBs are safe," Sipahi asserts.

Indirect meta-analysis is not an appropriate method in this context, to say that ARBs are safe.

In response, Bangalore told heartwire that while he and his colleagues have "clearly identified some of these
[same issues] in our study limitations, we do not completely agree with the viewpoint of Sipahi. Our
analyses and conclusion are not based on one single analysis—as we have clearly pointed out, we looked for
consistency of effect with the [three] different methodologies used—as well as analysis based on trials where
cancer was a prespecified end point. These analytic techniques offer complementary information.

No matter how you slice or dice the data, we did not see a consistent increase in the risk of cancer
with . . . antihypertensive agents.

"No matter how you slice or dice the data, we did not see a consistent increase in the risk of cancer with the
currently used antihypertensive agents," Bangalore stresses. "While there is underreporting of cancer in trials
where cancer was a not a prespecified end point, the biases and underreporting are likely similar across the
arms of a randomized trial. And direct comparison analysis is also not without any drawbacks," he notes.

Nissen concludes: "The FDA needs to look at everything, they are the only people that have all of the data;
not every trial is published, and not all trials report cancer data—these authors were able to include only
those studies that they had access to data for, and that's not everything. The burden is now on the regulatory
community to answer the question of whether or not there is a signal here."

Bangalore has no conflicts of interest. Disclosures for the coauthors are listed in the paper; none of the authors
received any compensation for their work on this report. Lindholm is past president of the International Society of
Hypertension; Carlberg has no disclosures. Sipahi has received an educational grant and lecture honoraria from
Pfizer and lecture honoraria from AstraZeneca and Ranbaxy. Peake reports no conflicts of interest. Nissen reports
receiving support for clinical trials from Pfizer, AstraZeneca, Novartis, Novo Nordisk, Roche, Daiichi-Sankyo, Takeda,
Sanofi-Aventis, Resverlogix, and Eli Lilly. He consults for many pharmaceutical companies but requires them to donate
all honoraria or consulting fees directly to charity so that he receives neither income nor tax deductions.
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1. Bangalore S, Kumar S, Kjeldsen SE, et al. Antihypertensive drugs and risk of cancer: network meta-analyses
and trial sequential analyses of 324 168 participants from randomised trials. Lancet Oncol 2010;
DOI:10.1016/S1470-2045(10)70260-6. Available at:
2. Lindholm L and Carlberg B. Blood pressure drugs and cancer: much ado about nothing? Lancet Oncol 2010;
DOI:10.1016/S1470-2045(10)70271-0. Available at:
3. European Medicines Agency. Monthly report: Committee for Medicinal Products for Human Use (CHMP). June
21-24, 2010. Available here.
4. Food and Drug Administration. FDA drug safety communication: Ongoing safety review of the angiotensin
receptor blockers and cancer. July 15, 2010. Available here.

Related links

• EMA to review ARBs and cancer, infuriating experts, who point to missing data and adverse consequences
[Hypertension > Hypertension; Jun 25, 2010]
• Modest lung-cancer signal with angiotensin-receptor blockers
[Hypertension > Hypertension; Jun 13, 2010]

Your comments
New meta-analysis reassuring on ARBs and cancer, but questions remain
# 1 of 2 December 1, 2010 09:48 (EST)
José Thalenberg What about the "ARB-MI paradox"?
In my opinion, this discussion about ARBs and cancer is a diversionary maneuver. The real stuff
is the significant increase in miocardial infarction due to the ARBs, observed in many studies, the
so called "ARB-MI paradox".

José Marcos Thalenberg

Sao Paulo, Brazil

# 2 of 2 December 3, 2010 02:17 (EST)

gebhard long arbs and mi
i think i agree with you Jose.I am aware of the FDA comments. would you be so kind as to give
me some published citations on this association?