Proton Pump Inhibitors and Survival in Patients With Colorectal Cancer Receiving Fluoropyrimidine-Based Chemotherapy
Department of Medical Oncology, Flinders Centre for Innovation in Cancer, Flinders Medical Centre/Flinders University, Bedford Park, South Australia, Australia.
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Background: Concomitant use of proton pump inhibitors (PPIs) may negatively affect the efficacy of anticancer drugs such as fluoropyrimidines in patients with colorectal cancer (CRC). The primary objective of this study was to assess whether there is an association between concomitant PPI use and survival outcomes in patients with CRC treated with a fluoropyrimidine-based chemotherapy. Patients and Methods: A secondary analysis of 6 randomized controlled clinical trials in patients with advanced CRC was conducted using individual patient data through data-sharing platforms. The outcome measures were progression-free survival and overall survival in PPI users and nonusers. Subgroup analysis included the type of chemotherapy, capecitabine versus 5-FU, line of therapy, and addition of a vascular endothelial growth factor receptor inhibitor. Overall pooled hazard ratios (HRs) with 95% confidence intervals were calculated using a random effects model. Results: A total of 5,594 patients with advanced CRC across 6 trials and 11 trial arms were included; 902 patients were receiving a PPI at trial entry and initiation of chemotherapy. PPI use was significantly associated with worse overall survival (pooled HR, 1.20; 95% CI, 1.03–1.40; P=.02; I2 for heterogeneity = 69%) and progression-free survival (overall pooled HR, 1.20; 95% CI, 1.05–1.37; P=.009; I2 = 65%) after adjusting for clinical covariates. Furthermore, the association between concomitant PPI use and survival outcomes was similar across most treatment subgroups. Conclusions: We speculate that alterations in the gut microbiome, altered immune milieu within the tumor, and interactions through transporters are potential mechanisms behind this association between PPI use and chemotherapy in patients with CRC, which warrant further study. Concomitant use of PPIs is associated with worse survival outcomes in patients with CRC treated with fluoropyrimidine-based chemotherapy. Clinicians should cautiously consider the concomitant use of PPIs in such patients.
Submitted June 7, 2020; final revision received September 20, 2020; accepted for publication October 12, 2020.
Published online May 5, 2021.
Author contributions: Study concept and design: Kichenadasse, Hopkins, Sorich. Data acquisition: Hopkins, Sorich. Data analysis and interpretation: All authors. Statistical analysis: Kichenadasse. Funding acquisition: Hopkins, Sorich.Technical/Material support: Miners, Mangoni, Hopkins. Supervision: Miners, Mangoni, Hopkins, Sorich. Manuscript preparation: All authors. Critical revision for intellectual content: All authors.
Disclosures: Dr. Karapetis has reported serving on the advisory board of Merck Serono, MSD, Bristol Myers Squibb, Roche, and AstraZeneca. Dr. Sorich has reported receiving grant/research support from Pfizer. The remaining authors have reported that they have not received any financial consideration from any person or organization to support the preparation, analysis, results, or discussion of this article.
Funding: This work was supported by funding from Cancer Council South Australia (1159924 and 1127220 to M.J. Sorich) and from the National Breast Cancer Foundation (PF-17-007 to A.M. Hopkins).
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