Safety of Endoscopy in Cancer Patients on Antiangiogenic Agents

Abstract

Introduction: Antiangiogenic agents (AA) such as Bevacizumab and Aflibercept are inhibitors of vascular endothelial growth factors and offer survival benefit in combination with cytotoxic chemotherapy. Their use has expanded significantly in the last few years leading to an increased awareness of potential toxicities including gastrointestinal perforation(GIP) and bleeding. It is currently recommended that AA be held for 28 days before and after surgery. There is no data or recommendation regarding the safety of endoscopy (endo) while on AA. This study investigated the incidence of adverse events (AE) in patients undergoing endo within 31 days of administration of AA. Methods: Data regarding AA administration, procedures and maneuvers were retrieved from coding records at 5 cancer centers between Apr-2008 and Aug-2014. Retrospective chart review was performed on all patients undergoing endo within 31 days of administration of AA. The primary outcome measures were procedure-related AE and death within 31 days of endo. Data collected included age, cancer type, timing of AA and maneuvers performed. Results: 449 patients (Cancers were 229 colorectal, 69 pulmonary, 57 breast, 37 gynecologic, 57 unspecified; mean age 54 yrs) underwent a total of 561 endo. Mean time from AA to endo was 12.1 days. There were 345 upper endoscopies, 129 colonoscopies, 39 sigmoidoscopies, 44 Endoscopic ultrasounds (EUS) and 4 endoscopic retrograde cholangiopancreatographies. Maneuvers included 168 biopsies, 58 gastrostomy tube placement (PEG), 17 celiac neurolysis or fine needle aspiration (FNA), 6 hemostasis, 5 foreign body removals among other maneuvers. There were 4 procedure-related AE: Mucosal esophageal tear 2 days after upper EUS, esophageal bleeding a day after banding of esophageal varices, pancreatitis a day after upper EUS/FNA, bleeding from the gastrostomy site 2 days after PEG placement. None of the AE was higher than grade 2 (Common terminology Criteria for AE). 36 patients died within 31 days of the procedure with none of the deaths considered procedure related. Conclusion: Endo related AE in patients on AA appear to be low when performed in specialized cancer centers with no procedure related perforation. Careful attention to risk and benefits of endoscopy should be made and if the patient is perceived to benefit from endoscopy while on AA, the risk should not be prohibitive. Prospective studies are needed to confirm these findings.