Outcomes of beta blocker use in advanced hepatocellular carcinoma treated with immune checkpoint inhibitors

Impact of Antibiotics and Chronic Medications on Efficacy of Immune Checkpoint Inhibitors in Patients With Hepatocellular Carcinoma

BACKGROUND AND AIMS

The interaction of immune checkpoint inhibitors (ICI) and concomitant medications such as antibiotics, metformin, statins, beta-blockers, proton pump inhibitors (PPIs), nonsteroidal anti-inflammatory drugs (NSAIDs), and low-dose aspirin has been studied in other malignancies. Our study aims to investigate the relationship between these medications and ICI efficacy in patients with advanced hepatocellular carcinoma (aHCC).

METHODS

A retrospective review of patients who received at least one dose of ICIs between May 2015 and November 2019 was performed. The primary objectives were to compare the overall survival (OS) and progression-free survival (PFS) between patients with and without medication usage. Log rank test was used to assess for differences in survival. Hazard ratios were reported using Cox proportional hazard regression analysis. The data cutoff date was December 31, 2020.

RESULTS

A total of 168 patients were included. Median age was 69 years, 85.7% male, 60.7% ECOG 0, 78.0% Child-Pugh A liver cirrhosis, 57.7% hepatitis B etiology, 8.9% hepatitis C, and 33.3% nonviral. One hundred three patients (61.3%) received ICI monotherapy, while 38.7% received ICI in combination. Sixty-two patients (36.9%) had concomitant antibiotic usage, 26.8% metformin, 30.4% statin, 31.0% beta-blockers, 60.1% PPI, 6.5% NSAIDs, and 11.9% aspirin. Patients with aHCC receiving antibiotics did not have a shorter OS (adjusted HR [aHR] 1.40, 95% CI 0.94-2.09, p = 0.096) or shorter PFS (aHR 0.94, 95% CI 0.66-1.34, p = 0.73), as compared to those who did not receive antibiotics. However, patients with aHCC of viral hepatitis etiology receiving ICI treatment and concurrent antibiotics had shorter OS (5.5 vs. 14.2 months, aHR 1.93, 95% CI 1.17-3.17, p = 0.010) and PFS (1.1 vs. 2.6 months, aHR 2.69, 95% CI 1.28-5.65, p = 0.009), as compared to those who did not receive antibiotics.

CONCLUSIONS

The use of antibiotics may diminish ICI efficacy in patients with aHCC of viral hepatitis etiology, while the use of metformin, statins, beta-blockers, NSAIDs, and aspirin is not associated with significant clinical outcomes.

Nervous system in hepatocellular carcinoma: Correlation, mechanisms, therapeutic implications, and future perspectives

Hepatocellular carcinoma (HCC) is a highly heterogeneous and complex cancer influenced by both the tumor microenvironment and multi-level regulation of the nervous system. Increasing evidence highlights critical roles of the central nervous system (CNS) and peripheral nervous system (PNS) in modulating HCC progression. Psychological stress and emotional disturbances, representing CNS dysregulation, directly accelerate tumor growth, metastasis, and impair anti-tumor immunity in HCC. PNS involvement, particularly autonomic innervation, extensively reshapes the hepatic tumor microenvironment; specifically, sympathetic activation promotes immune suppression, tumor cell proliferation, epithelial-mesenchymal transition (EMT), and cancer stemness via β-adrenergic signaling and hypoxia-inducible factor 1-alpha (HIF-1α) stabilization, whereas parasympathetic signals generally exert anti-inflammatory and tumor-suppressive effects mediated by acetylcholine. Neurotransmitters including epinephrine, norepinephrine, dopamine, serotonin, and acetylcholine precisely regulate critical pathways such as AKT/mTOR, ERK, and NF-κB, thereby driving malignant cell behaviors, immune evasion, and chemoresistance. Neuro-targeted pharmacological interventions (e.g., SSRIs, β-blockers, dopamine antagonists) and behavioral therapies have shown efficacy in preclinical studies, underscoring their therapeutic potential. Additionally, neural-associated biomarkers like NEDD9, CNTN1, and nerve growth factor (NGF) exhibit prognostic significance, supporting their future clinical application. By systematically integrating neuroscience with oncology, this review identifies innovative neural-based therapeutic strategies, highlights key mechanistic insights, and outlines promising directions for future research and personalized clinical management of HCC.

The Impact of Beta Blockers on Survival in Cancer Patients: A Systematic Review and Meta-Analysis

BACKGROUND/OBJECTIVES

Beta adrenergic signaling has been implicated in cancer progression, leading to interest in repurposing beta blockers (BBs) as adjunctive anti-cancer agents. However, clinical findings are inconsistent. This systematic review and meta-analysis evaluates the association between BB use and survival outcomes in cancer patients.

METHODS

A systematic search of OVID Medline, EMBASE, and CENTRAL was conducted through 13 September 2023, for studies comparing survival outcomes in solid tumor patients using BBs versus non-users. Eligible studies reported hazard ratios (HRs) for overall survival (OS), progression-free survival (PFS), or cancer-specific survival (CSS). Perioperative studies and those without BB-specific HRs were excluded. Data extraction and quality assessment were performed in duplicate using ROBINS-I. A random-effects model was used, with heterogeneity assessed by the I2 statistic.

RESULTS

Seventy-nine studies (492,381 patients) met the inclusion criteria; 2.5% were prospective. The most frequently studied cancers were breast (n = 33), ovarian (n = 30), and colorectal (n = 28). BB use was associated with improved PFS (HR 0.78, 95% CI: 0.66-0.92, I2 = 79.8%), with significance maintained after excluding high-bias studies (HR 0.74, 95% CI: 0.61-0.91, I2 = 36.6%). No significant associations were observed for OS (HR 0.99, 95% CI: 0.94-1.04, I2 = 84.9%) or CSS (HR 0.95, 95% CI: 0.91-1.00, I2 = 77.4%).

CONCLUSIONS

BB use may be associated with longer PFS in cancer patients, but findings are limited by study design and heterogeneity; high-quality prospective studies are needed.

Targeting the peripheral neural-tumour microenvironment for cancer therapy

As the field of cancer neuroscience expands, the strategic targeting of interactions between neurons, cancer cells and other elements in the tumour microenvironment represents a potential paradigm shift in cancer treatment, comparable to the advent of our current understanding of tumour immunology. Cancer cells actively release growth factors that stimulate tumour neo-neurogenesis, and accumulating evidence indicates that tumour neo-innervation propels tumour progression, inhibits tumour-related pro-inflammatory cytokines, promotes neovascularization, facilitates metastasis and regulates immune exhaustion and evasion. In this Review, we give an up-to-date overview of the dynamics of the tumour microenvironment with an emphasis on tumour innervation by the peripheral nervous system, as well as current preclinical and clinical evidence of the benefits of targeting the nervous system in cancer, laying a scientific foundation for further clinical trials. Combining empirical data with a biomarker-driven approach to identify and hone neuronal targets implicated in cancer and its spread can pave the way for swift clinical integration.

Management of Portal Hypertension in Patients with Hepatocellular Carcinoma on Systemic Treatment: Current Evidence and Future Perspectives

The management of CSPH in patients undergoing systemic treatment for HCC has emerged as a critical concern due to the absence of reliable diagnostic criteria and uncertainties surrounding therapeutic approaches. This review aims to underscore the primary pathophysiological aspects linking HCC and PH, while also addressing the current and emerging clinical strategies for the management of portal hypertension. A review of studies from January 2003 to June 2023 was conducted using the PubMed database and employing MeSH terms, such as "hepatocellular carcinoma", "immune checkpoint inhibitors", "systemic therapy", "portal hypertension", "variceal bleeding" and "tyrosine kinase inhibitors". Despite promising results of tyrosine kinase inhibitors in animal models for PH and fibrosis, only Sorafenib has demonstrated similar effects in human studies, whereas Lenvatinib appears to promote PH development. The impact of Atezolizumab/Bevacizumab on PH remains uncertain, with an increasing risk of bleeding related to Bevacizumab in patients with prior variceal hemorrhage. Given the absence of specific guidelines, endoscopic surveillance during treatment is advisable, and primary and secondary prophylaxis of variceal bleeding should adhere to the Baveno VII recommendations. Furthermore, in patients with advanced HCC, refinement of diagnostic criteria for CSPH and guidelines for its surveillance are warranted.

Repurposing beta-blockers for combinatory cancer treatment: effects on conventional and immune therapies

Beta-adrenergic receptor signaling regulates cellular processes associated with facilitating tumor cell proliferation and dampening anti-tumor immune response. These cellular processes may lead to compromised tumor control and cancer progression. Based on this ramification, Beta-blockers (BBs) have emerged as a potential treatment by inhibiting beta-adrenergic receptor signaling. This review aimed to investigate the relationship between the use of BBs and tumor progression and treatment response. Therefore, the authors explored several aspects: the potential synergistic relationship of BBs with chemotherapy and immunotherapy in enhancing the effectiveness of chemotherapeutic and immunotherapeutic treatments and their role in boosting endogenous immunity. Further, this review explores the distinctions between the major types of BBs: Non-selective Beta Blockers (NSBBs) and Selective Beta Blockers (SBBs), and their contributions to combinatory cancer treatment. In this review, we presented a perspective interpretation of research findings and future directions. Overall, this review discusses the potential and challenge that BBs present in improving the effectiveness and outcome of cancer treatment.