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New Insights Into Erythropoietin and Epoetin Alfa:

Mechanisms of Action, Target Tissues,
and Clinical Applications
MITCHELL J. WEISS
The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA

Key Words. Erythropoietin · Signal transduction · Epoetin alfa · Anemia · Cancer · Central nervous system · Apoptosis

L EARNING O BJECTIVES
After completing this course, the reader will be able to:
1. Discuss the mechanism of action of endogenous erythropoietin and the therapeutic use of epoetin alfa to stimulate red blood
cell production and improve the quality of life in patients with cancer.
2. Explain how epoetin alfa is being investigated in alternate dosing regimens and for anemia prevention in patients with cancer.
3. Describe how functional endogenous erythropoietin receptor signaling pathways have been demonstrated in numerous non-
erythropoietic tissues, including in the central nervous system, and relate evidence for the roles of erythropoietin and epoetin
alfa beyond erythropoiesis, including the therapeutic implications of these nonerythroid functions.

CME Access and take the CME test online and receive one hour of AMA PRA category 1 credit at CME.TheOncologist.com

A BSTRACT
Recombinant human erythropoietin (epoetin alfa)
has proven beneficial for the treatment of various ane-
mias. The mechanism of action of endogenous erythro-
poietin and the therapeutic use of epoetin alfa to
stimulate red blood cell production and improve the
quality of life in cancer patients are reviewed here.
Epoetin alfa may also attenuate the cognitive dysfunc-
tion associated with cancer therapy. Interestingly,
functional endogenous erythropoietin receptor signal-
ing pathways have been demonstrated in numerous
nonerythropoietic tissues. Of particular importance,
epoetin alfa confers neurotrophic and neuroprotective
effects in cultured neurons and in several animal mod-
els for neurologic disease. In one clinical trial, epoetin
alfa appeared to limit functional and histologic damage
in patients with stroke. Therefore, in cancer patients
receiving chemotherapy, the beneficial effects of epo-
etin alfa could be mediated not only through enhanced
erythrocyte production but also via direct effects on the
nervous system. Further investigation into the non-
erythropoietic effects of epoetin alfa could broaden its
clinical utility for patients with cancer and also provide
new therapies for various neurologic disorders. The
Oncologist 2003;8(suppl 3):18-29

INTRODUCTION acts by binding to its receptor (EPO-R) and subsequently acti-

Erythropoietin (EPO) is an endogenous cytokine that vating intracellular signal transduction pathways [1]. EPO is
is essential for erythrocyte development [1]. In adults, the kid- essential for life: mice with deletions of the EPO gene or the
neys produce and release EPO in response to hypoxia [2]. EPO EPO-R die of anemia in utero [3, 4]. Recombinant human

Correspondence: Mitchell J. Weiss, M.D., The Children’s Hospital of Philadelphia, 316B Abramson Research Building,
Philadelphia, Pennsylvania 19104, USA. Telephone: 215-590-0565; Fax: 215-590-4834; e-mail: weissmi@email.chop.edu
Received August 29, 2003; accepted for publication October 3, 2003. ©AlphaMed Press 1083-7159/2003/$12.00/0

The Oncologist 2003;8(suppl 3):18-29 www.TheOncologist.com

Weiss 19

EPO (epoetin alfa) is used in clinical practice to reduce to the nucleus to activate numerous target genes [1], including
transfusion requirements during surgery [5] and to treat ane- the apoptosis inhibitor Bcl-x [14].
mia of various etiologies, including anemia of chronic kid- The inhibition of apoptosis by the EPO-activated
ney disease [6], cancer-related or cancer treatment-related JAK2/STAT5/Bcl-x pathway (Fig. 1) is important for ery-
anemia [7], anemia related to zidovudine therapy in HIV- throid differentiation. JAK2 deficiency causes embryonic
infected patients [8], and anemia related to ribavirin therapy death due to the absence of definitive erythropoiesis [15].
for hepatitis C virus infection [9]. Furthermore, mice deficient in STAT5a/5b have anemia that
The mechanism of action of EPO in erythropoiesis and correlates with the decreased expression of Bcl-x and
the effects of epoetin alfa in cancer patients are reviewed here. increased apoptosis in early erythroblasts [16]. Finally, full
Subsequently, evidence for the roles of EPO and epoetin alfa Bcl-x knockout mice died in embryogenesis with extensive
outside erythropoiesis and potential therapeutic uses of epo- apoptosis of immature hematopoietic cells [17], and condi-
etin alfa beyond anemia treatment are explored. This review tional hematopoietic-specific Bcl-x knockout mice had
is based on an educational session presented at the American severe anemia [18]. In both models, Bcl-x was required for
Society of Hematology (ASH) meeting held in December the survival of erythroid cells during terminal maturation
2002, updated and expanded as necessary. Accordingly, [18, 19]. A recent study also demonstrated that enforced
many abstracts on EPO biology that were presented at the Bcl-x expression can rescue maturation of EPO-deprived
meeting are discussed herein. While these studies have not yet erythroid progenitors in vitro, suggesting that the major ery-
been published in full in peer-reviewed journals, they reflect thropoietic function of EPO is to prevent apoptosis and that
the current research in this therapeutic area. Bcl-x is a critical effector gene [20]. However, it is impor-
tant to note that EPO and EPO-R null mice exhibit a more
MECHANISM OF ACTION OF EPO IN ERYTHROPOIESIS severe erythropoietic defect than that seen in Bcl-x null ani-
In adult kidneys, hypoxia gives rise to increased EPO mals, indicating that EPO fosters erythropoiesis through
expression stimulated by the DNA binding protein, hypoxia- additional effectors. In addition, the erythroid defect in the
induced factor-1 (HIF-1) [2, 10]. EPO is secreted into the absence of STAT5a/5b is milder than that produced by loss
plasma and, upon arrival in the bone marrow, binds to EPO-Rs of Bcl-x, indicating that STAT5-independent mechanisms
on the surface of erythroid progenitor cells [11]. This asso- for Bcl-x induction exist.
ciation triggers a conformational change that brings EPO-R- In addition to STAT5, EPO induces JAK2-mediated tyro-
associated Janus family tyrosine protein kinase 2 (JAK2) sine phosphorylation and activation of several other intracel-
molecules into close proximity, stimulating their activation lular proteins [1]. Examples include: Shc [21], which, in turn,
by transphosphorylation [1, 12, 13]. Subsequently, JAK2 mol- may activate the signaling pathway involved in erythroid cell
ecules phosphorylate eight tyrosine residues in the cytoplasmic proliferation [22]; phosphatidylinositol 3-kinase (PI3K) [23],
domain of the EPO-R, which then
serve as docking sites for various
Epo
Src homology 2-domain-containing
EpoR P SHC
Grb2
intracellular signaling proteins [1]. RAS
P Jak2 GAB1 SOS
These proteins, in turn, are tyrosine P
P P Vav
phosphorylated and activated. One P SHP1 P
GAP Ca2+
of these proteins is a signal trans- P
P Giα2
SHP2 MAPKKK RAF-1 P
ducer and activator of transcription P P
IRS-2 MAPK
(STAT5) that, on phosphorylation
P
by JAK2, dissociates from the EPO- P STAT5
R, dimerizes, and then translocates PI 3-K
P P
Bcl-x
p70S6K STAT5
P activation Ca2+
Figure 1. JAK2/STAT5/Bcl-x signal AKT DNA Ca2+, Mg2+ - Depend,
transduction pathway of the EPO-R. OSM Endonuclease
PKC
Adapted with permission from Cheung Giα2 c-myb, c-myc,
TF P
CaM kinase
and Miller [1]. Molecular mechanisms c-fos, c-Jun Nuclear NF-κB
of erythropoietin signaling. Nephron Ca2+ GATA-1 EpoR Ca2+ - Calmodulin inhibits E2A SCL
2001;87:215-222. Adapted with per- SCL DNA
mission of S. Karger AG, Medical
and Scientific Publishers, Basel,
Switzerland.
20
which may promote survival of erythroid cells [22], and
phospholipase C-γ1, which may play a role in erythroid cell
proliferation [24]. In this regard, loss of the p85α subunit of
PI3K impairs fetal liver erythropoiesis, although this mutation
appears to inhibit signaling through the c-Kit receptor to a
greater extent than does mutation of the EPO-R [25].
ERYTHROPOIETIC EFFECTS OF EPOETIN ALFA IN
PATIENTS WITH CANCER
Rationale for Treatment of Cancer-Related Anemia
Up to 75% of patients with cancer experience anemia dur-
ing the course of their disease, either due to the cancer itself
(tumor infiltration of the bone marrow and/or anemia of
chronic disease) or to the myelosuppressive effects of
chemotherapy or radiation therapy [7, 26]. Several lines of evi-
dence indicate that aggressive treatment of anemia is an impor-
tant aspect of cancer therapy. First, a quantitative review of
published data from patients with cancer suggests that anemia
may be an independent prognostic factor for survival, with a
65% overall estimated greater relative risk of death [27]. In a
retrospective analysis of patients undergoing chemotherapy
and thoracic radiotherapy for stage IIIA/IIIB non-small cell
lung cancer, declining hemoglobin (Hb) levels were highly
predictive of survival [28]. The 2-year survival rates were 51%
for patients whose Hb level decreased <10% from baseline,
33% when Hb declined by 10%-30%, and 0% when Hb
declined by >30% [28]. While these observations might sim-
ply reflect impaired erythrocyte production in patients with
more aggressive malignancies or greater systemic illness, there
are some indications that anemia can interfere with cancer
therapy. For example, anoxic tumor cells are two to three times
more resistant to radiation therapy than are normally oxy-
genated cells [29, 30]. In addition, low Hb levels have been
associated with tumor hypoxia, lower rates of local failures,
and lower survival rates during radiation therapy for multiple
tumor types [30-36].
In addition to the possible negative effects of anemia on
cancer treatment and clinical outcomes, chronic anemia and the
resulting fatigue impair the quality of life (QOL) of patients
with cancer, and the use of epoetin alfa to boost erythrocyte
production in those patients with cancer-related anemia has
resulted in clinically important and statistically significant
improvements in QOL [37]. Although red blood cell transfu-
sion is also a treatment option for anemia, its associated prob-
lems include the potential for transmission of infections, limited
availability of adequate blood supplies, and short-term resolu-
tion of symptoms. Epoetin alfa is more convenient to adminis-
ter, reduces infectious risks, and maintains more constant
steady-state Hb levels. Epoetin alfa also may offer potential
benefits beyond stimulating erythropoiesis (described later).
EPO: Functions Beyond Erythropoiesis
Clinical Practice Guidelines for the Use of Epoetin Alfa in
Cancer-Related Anemia
Evidence-based clinical practice guidelines for the use of
epoetin alfa in patients with cancer have been developed by the
American Society of Clinical Oncology (ASCO) in conjunc-
tion with ASH [38] and by the National Comprehensive
Cancer Network (NCCN) [39]. The ASCO/ASH guidelines
provide a thorough overview of the use of epoetin alfa therapy
in patients with various forms of cancer based on data included
in an evidence report assembled by the Blue Cross Blue Shield
Association Technology Evaluation Center [38]. The panel
reviewed and summarized many clinical studies involving
patients with solid tumors or hematologic malignancies and
with chemotherapy- or cancer-related anemia. Briefly, the
ASCO/ASH guidelines recommend the use of epoetin alfa in
patients with chemotherapy-associated anemia when Hb levels
decline to ≤10 g/dl, with the decision of whether to treat less
severe anemia (i.e., Hb of >10 g/dl to <12 g/dl) determined by
clinical circumstance [38]. Guidelines published by the NCCN
also recommend the use of erythropoietic agents for the treat-
ment of cancer-related anemia, but suggest intervention for Hb
levels ≤11 g/dl [39]. For anemia associated with hematologic
malignancies, the ASCO/ASH guidelines support the use of
epoetin alfa therapy in patients with low-grade myelodysplas-
tic syndrome [38]. The authors of those guidelines suggest that
evidence for epoetin alfa use is less robust in anemic (Hb ≤10
g/dl) patients with multiple myeloma (MM), non-Hodgkin’s
lymphoma (NHL), or chronic lymphocytic leukemia (CLL)
not receiving chemotherapy, although some significant
improvements in Hb levels have been reported with epoetin
alfa treatment [38]. To optimize epoetin alfa therapy for the
treatment of cancer-related anemia, it is important to monitor
iron status regularly and to treat iron deficiency [40].
Clinical Experience With Epoetin Alfa in the Treatment of
Cancer- and Cancer-Treatment-Related Anemia
In both community-based studies and randomized,
placebo-controlled clinical trials, epoetin alfa, 150-300 U/kg
or 10,000-20,000 U administered three times weekly (TIW)
[41-43] or 40,000-60,000 U once weekly (QW) [44-46], has
been shown to significantly increase Hb levels and reduce
transfusion requirements in anemic patients (generally, Hb
≤11 g/dl) with various solid and hematologic malignancies
who are undergoing chemotherapy and/or radiation therapy.
Overall, approximately two-thirds of patients responded to
epoetin alfa treatment, experiencing an increase in Hb of 1
g/dl after 4 weeks or ≥2 g/dl (or achieving Hb ≥12 g/dl) after
8 weeks of treatment [47]. Epoetin alfa therapy also has been
shown to significantly increase Hb levels and significantly
improve QOL in anemic (Hb ≤11 g/dl) cancer patients who
are not undergoing chemotherapy [48].
Weiss
The effects of epoetin alfa in patients with hematologic
malignancies, including MM, lymphoma, and CLL, have
been the subjects of more recent investigations. For example,
in a randomized, open-label study in patients with these
malignancies and mild anemia (Hb ≥10 g/dl and ≤12 g/dl)
undergoing chemotherapy, QW epoetin alfa therapy signifi-
cantly increased Hb levels and significantly improved QOL
[49]. In a pilot study, patients with MM or lymphoma
treated with epoetin alfa before high-dose therapy and autol-
ogous peripheral stem cell transplantation required fewer
transfusions after transplantation, and the median number of
units of red blood cells transfused was significantly lower
than that of historic controls [50].
Effects of Epoetin Alfa on QOL
Numerous studies have demonstrated that epoetin alfa
improves QOL (such as energy level and ability to perform
daily activities) in anemic patients with various tumor types.
In the community-based studies and the randomized, placebo-
controlled clinical trial discussed above, TIW [41-43] or QW
[44, 46] epoetin alfa therapy significantly improved QOL.
Moreover, in studies that assessed the impact of disease
progression as a confounder of QOL, functional improve-
ments with epoetin alfa therapy occurred independently of
tumor response [41, 42]. Using data from the randomized,
placebo-controlled trial [43], a multivariate analysis
revealed a positive correlation between increased Hb levels
and improvements in QOL in patients treated with epoetin
alfa [51]. Even in patients with mild anemia (Hb ≥10.5 g/dl),
Hb levels increased significantly and were associated with
both statistically and clinically significant improvements in
functional status [37, 43]. In two additional studies that eval-
uated the effect of epoetin-alfa-associated increases in Hb on
QOL in anemic cancer patients receiving chemotherapy with
or without sequential radiation therapy [52, 53], the greatest
incremental gain in QOL occurred when Hb rose from 11 g/dl
to 12 g/dl (range, 11-13 g/dl). These data demonstrate that
correction of anemia, including mild anemia, leads to signifi-
cant improvements in functional ability and well-being.
Effects of Epoetin Alfa on Survival of Patients With Cancer
While a positive effect of epoetin alfa on QOL in
patients with cancer is firmly established, its effects on
tumor progression and survival are less clear. Lower mor-
tality in patients receiving epoetin alfa was reported in a
randomized, placebo-controlled study [43]. However, the
protocol was not designed or powered to assess this para-
meter and did not control for factors that could influence
survival, such as disease stage, bone marrow involvement,
chemotherapy intensity, and disease progression. An asso-
ciation between low Hb level and survival has also been
21
demonstrated. For example, a correlation between Hb level
and survival was reported in patients with testicular cancer
receiving first-line, sequential, high-dose chemotherapy
[54]. Patients whose Hb levels were ≥10.5 g/dl after com-
pletion of four cycles of chemotherapy had a 3-year overall
survival rate of 87%, compared with 68% for patients
whose Hb levels were <10.5 g/dl (p < 0.03) [54]. Together,
these data suggest that further investigation of the effects of
epoetin alfa on survival is warranted.
Early Intervention With Epoetin Alfa for Cancer-Treatment-
Related Anemia
Two recent studies have evaluated the impact of early
intervention with epoetin alfa therapy on patients with breast
cancer and baseline Hb levels of ≥9 g/dl and ≤14 g/dl receiv-
ing or scheduled to receive adjuvant chemotherapy [55, 56].
In both studies, treatment with epoetin alfa, 40,000 U QW for
at least 12 weeks, maintained or improved Hb levels and
QOL, whereas decreases in Hb levels and deterioration of
QOL were observed with historical controls (i.e., no epoetin
alfa therapy) and in patients treated with placebo [55-57].
Similar results were found in an interim analysis of a phase
III randomized study of early initiation of epoetin alfa,
40,000 U QW, in patients with various tumor types [58].
Patients who received epoetin alfa, 40,000 U QW at the start
of chemotherapy, maintained higher Hb levels and reported
less fatigue than patients who received epoetin alfa once their
Hb levels decreased to <10 g/dl [58]. Together, these data
suggest that epoetin alfa treatment initiated at the start of
chemotherapy may maintain Hb levels and QOL in patients
with cancer. Early intervention with epoetin alfa may be
particularly effective during high-dose chemotherapy [59].
Alternate Epoetin Alfa Dosing Regimens
Epoetin alfa, 40,000 U QW, has been shown to be clin-
ically equivalent to 150 U/kg TIW in healthy subjects [1]. In
addition, alternate dosing regimens of epoetin alfa are cur-
rently under investigation to determine the optimal dose and
schedule that will elicit an early and significant increase in
Hb level while improving flexibility of administration. In an
interim analysis of an open-label, nonrandomized study in 11
anemic (Hb ≤11 g/dl) cancer patients receiving chemother-
apy with or without concomitant or sequential radiation ther-
apy, epoetin alfa, 60,000 U QW, increased Hb levels by 1.1
g/dl at week 4 and by 2.6 g/dl at week 8 [60]. Similar results
were obtained in an open-label, nonrandomized, mainte-
nance study of 20 anemic (Hb ≤11 g/dl) cancer patients
undergoing chemotherapy [61]. Epoetin alfa administered at
a higher starting dose of 60,000 U QW increased Hb levels
by 1.0 g/dl at week 4 and by 2.9 g/dl at week 8, with 86% of
patients achieving increases in Hb of ≥2 g/dl or reaching an
22
Hb level of ≥12 g/dl by week 8. In patients who achieved Hb
increases of ≥2 g/dl and then moved into maintenance ther-
apy, epoetin alfa, 120,000 U every 3 weeks, successfully
maintained the Hb levels achieved during initial therapy [61].
These data suggest that epoetin alfa, 60,000 U QW, followed
by maintenance dosing of 120,000 U every 3 weeks is a fea-
sible treatment strategy for cancer patients with mild anemia
who are undergoing chemotherapy.
In summary, epoetin alfa treatment of anemic cancer
patients receiving cytotoxic therapy leads to significant
increases in Hb levels and reductions in transfusion utiliza-
tion, effects associated with both statistically and clinically
significant improvements in QOL. Additional data suggest a
potential survival benefit associated with epoetin alfa ther-
apy, although it is not known whether this effect could be due
to the correction of anemia or whether epoetin alfa may have
an intrinsic effect on survival. Administration of epoetin alfa
by either the TIW or the more convenient QW regimen
results in clinically equivalent effects on Hb, transfusions,
and QOL. The availability of darbepoetin alfa, an altered gly-
cosylated form of erythropoietin with an extended circulating
half-life, provides additional opportunities to increase dosing
intervals in cancer patients with chemotherapy-related ane-
mia. The recommended starting dose is 2.25 mcg/kg SC QW
[62], although less frequent dosing regimens may be possible
[63, 64]. Additional alternate dosing regimens of epoetin alfa
are presently being investigated to further determine their
clinical utility.
NONERYTHROID FUNCTIONS OF EPO
The EPO-R is expressed in numerous embryonic and adult
tissues in humans and mice. Based on these observations, EPO
signaling has been suggested to have various nonerythroid
functions. The EPO-R is present in nonerythroid blood lines
including myeloid cells, lymphocytes, and megakaryocytes, as
well as in multiple nonhematopoietic cells, such as endothelial
cells; mesangial, myocardial, and smooth muscle fiber cells;
neural cells; prostate cells, and renal cells (Table 1) [65-73].
Moreover, many of these cell types exhibit active EPO signal-
ing pathways and biologic responses. For example, EPO stim-
ulates survival and proliferation of endothelial cells in vitro
and promotes new blood vessel formation in vivo [66, 67, 70].
In a murine model, EPO stimulated angiogenesis in wound
healing [74]. In that model, macrophages in granulation tissue
formed during wound healing expressed EPO-R, and EPO was
shown to stimulate transforming growth factor (TGF)-β1 pro-
duction by activated macrophages [74]. In mice expressing a
constitutively active EPO-R, EPO signaling in endothelial
cells was found to function in vascular repair [75]. Some addi-
tional actions of EPO on nonerythroid tissues, in particular the
nervous system, are discussed later.
EPO: Functions Beyond Erythropoiesis
POTENTIAL FUNCTIONS OF EPO IN THE CENTRAL
NERVOUS SYSTEM
Both EPO and the EPO-R are present in the central ner-
vous system [65, 76-79], including the retina [80, 81]. Epoetin
alfa has been shown to actively cross the blood-brain barrier
in animals (although at significantly higher doses than are
conventionally used in the treatment of anemia in humans)
[82] and in human subjects at doses of 40,000 U or 1,500
U/kg administered intravenously [83]. In vitro, EPO protects
neurons against ischemia-induced glutamate toxicity, the pri-
mary factor responsible for neuronal cell death related to
hypoxia [65, 84].
In rodent models, the systemic administration of epo-
etin alfa attenuated the extent of concussive brain injury
and the toxicity of kainate, which is representative of the
excitotoxicity found in many forms of brain injury [82].
Systemic epoetin alfa also reduced immune damage [82]
and inflammation [85] in an experimental model of multi-
ple sclerosis and enhanced neurologic recovery from exper-
imental spinal cord trauma [79, 86]. Systemic epoetin alfa
also has been shown to reduce injury from brain ischemia
both in an experimental animal model [87] and in patients
at doses similar to those used in clinical practice [88]. In
addition, epoetin alfa was shown to protect photoreceptors
from light-induced damage [81] and retinal neurons from
acute ischemia and reperfusion injury in rodents [86].
Mouse embryos with null mutations of EPO or the EPO-R
die from severe anemia in midgestation [3, 4] and also exhibit
Table 1. EPO-R expression and potential functions in normal
nonerythroid cells
EPO-R Expression Function
Astrocytes Decreased apoptotic cell death [65]
Cardiomyocytes Mitogenic [65, 66]
Endothelial cells Mitogenic [65, 67-69]
Endothelin-1 synthesis and release
[65, 67, 69]
Angiogenic response (proliferation and
migration) [65, 67, 70]
Megakaryocytes Maturation [65, 71]
Mesangial cells Increased proliferation in vitro [65]
Myeloid cells Multilineage increase in vitro [65]
Immunomodulation [65]
Neurons Trophic effect [65]
Increased monoamine concentration [65]
Decreased apoptotic cell death [65]
Renal cells Mitogenesis [72]
Prostate epithelial cells Mitogenesis [73]
Vascular smooth Contraction [65]
muscle cells
Weiss
increased apoptosis in the brain [90]. However, mice reported
to express EPO-R exclusively in hematopoietic tissues develop
normally and exhibit no apparent neurologic deficits [91].
While extended neurologic testing was not reported for these
animals, the data indicate that EPO-R may not be required for
the development or basal function of the nervous system.
Considering the pleiotropic effects of EPO on neuronal tissues
discussed previously, it is possible that EPO-R signaling plays
an adaptive role in limiting the damage incurred from various
neurologic stresses. If this is the case, then mice expressing the
EPO-R solely in hematopoietic tissues should be more sensitive
to experimentally induced neurotoxicity.
Mechanisms of EPO Action in the Central Nervous System
The underlying mechanisms of EPO as a neuroprotec-
tive agent are hypothesized to be multifactorial, with both
direct and indirect beneficial effects on neurons. EPO may
antagonize the cytotoxic effect of glutamate, increase
expression of antioxidant enzymes, reduce nitric-oxide-
mediated formation of free radicals, normalize cerebral
blood flow, influence neurotransmitter release, and promote
neoangiogenesis [65]. Hypoxia and injury increase produc-
tion of EPO and EPO-R in the brain [78, 92, 93]. Hypoxia
also induced EPO expression in the retina through the pro-
duction of HIF-1 [81]. Epoetin alfa may mediate neuropro-
tection indirectly by restoring blood flow to the injured
tissue [94] or act directly on neurons via the activation of
several signaling molecules, which also function in EPO
signaling in erythropoiesis. EPO downregulates tyrosine
phosphatase Src homology 2 domain-containing protein
tyrosine phosphatase and activates the extracellular signal-
regulated kinases ERK1 and ERK2 in cortical neurons,
which may enhance the magnitude and duration of signaling
[95]. In rat hippocampal neurons, epoetin alfa was shown to
protect against hypoxia-induced death through activation of
ERK1 and ERK2 and Akt [96]. In rat cortical neurons, EPO-
mediated protection from excitotoxin- and nitric-oxide-
induced apoptosis involved a novel pathway with crosstalk
between the JAK2 and nuclear factor (NF)-κB signaling
cascades; EPO-R-induced activation of JAK2 led to activa-
tion of NF-κB and subsequent increased expression of the
inhibitor-of-apoptosis genes, XIAP and c-IAP2 [97]. In the
hippocampus of gerbils, EPO was shown to protect neurons
against ischemic injury by upregulating the antiapoptotic
gene Bcl-x [98]. In addition to inhibition of apoptosis, neu-
roprotection may also occur through reduction of inflamma-
tion [86, 87, 96], which plays a key role in many forms of
brain injury. NF-κB, which is activated by EPO under
oxidative or nitrosative stress [97], is a regulator of inflam-
matory genes [99]. Epoetin alfa has further been shown to
have a neurotrophic effect [96] and to affect neuronal
23
excitability [82], a prominent component of many forms of
brain injury [100].
THERAPEUTIC IMPLICATIONS
The observed neuroprotective and vascular effects of
EPO and epoetin alfa in various experimental models sug-
gest that epoetin alfa may benefit patients with spinal cord
injuries, stroke, myocardial infarction, multiple sclerosis, or
retinal diseases (macular degeneration, retinitis pigmentosa,
and glaucoma [101]). In one recent study of stroke patients,
a 33,333-U i.v. dose of epoetin alfa, administered within 8
hours after the onset of symptoms and at 24 hours and also
48 hours later, appeared to limit the extent of histologic
damage and improve functional outcomes [88]. Additional
clinical trials are required to confirm these findings.
Implications for Cancer Therapy
The discovery that nonerythroid tissues respond to
EPO challenges the relatively simple model that its effects
in patients with cancer derive exclusively from enhanced
red blood cell production. These potential effects of EPO
have both positive and negative theoretical implications.
For example, epoetin alfa could activate intracellular sig-
naling pathways directly in tumors that express EPO-R. In
addition, the ability of EPO to stimulate new blood vessel
formation could enhance perfusion to tumors and support
their growth or, alternatively, potentiate antitumor thera-
pies by enhancing blood delivery, as previously discussed.
The demonstrated neuroprotective effects of EPO could
prevent or reduce the neurotoxicities associated with
chemotherapy and radiation therapy. These issues are
discussed in detail below.
Potential Direct Effects of Epoetin Alfa on EPO-R-Expressing
Tumors
Because some cancer cells express EPO-R, treatment
with epoetin alfa could produce a variety of direct effects on
tumors. For example, it has been suggested that, in certain
tumor cell lines and xenografts that express both EPO and
EPO-R, EPO signaling may promote cancer progression [73,
102-104]. In cell lines of colon carcinoma, the Ewing’s sar-
coma family of tumors, and neuroblastoma, EPO reduced
chemotherapy-induced apoptosis through upregulation of
antiapoptotic genes [105]. EPO also induced the release of
angiogenic growth factors in cell lines of colon carcinoma, the
Ewing’s sarcoma family of tumors, glioma, and medulloblas-
toma [105]. In xenografts and blocks of uterine and ovarian
tumors, EPO antagonists induced apoptosis and decreased the
number of blood vessels [106, 107]. Phosphorylation of JAK2
and STAT5 appeared to be abolished in tumor blocks treated
with EPO antagonists [107].
24
Despite these studies, only a few rare case reports have
been published that describe a possible effect of epoetin alfa
on cancer progression in humans, and no causal relationship
has been identified. One patient with MM reportedly devel-
oped plasma cell leukemia upon receiving treatment with epo-
etin alfa [108]. In another cancer patient treated with epoetin
alfa, rapid growth of a vestibular schwannoma was reported,
but the exact cause was not determined [109].
Antitumorigenic effects of EPO and epoetin alfa have
also been reported. Epoetin alfa alone had no effect on
growth of a lung carcinoma xenograft; however, in synergy
with cisplatin, it induced a fivefold reduction in tumor mass
[110]. In addition, epoetin alfa treatment, either in the
absence of chemotherapy or concomitant with mild chemo-
therapy for a short duration, produced an antimyeloma effect
and prolonged survival in a small study of patients with MM
(n = 5) who had advanced disease and an expected survival
of less than 6 months [111]. Despite a poor prognosis,
patients survived an additional 42-82 months after initiation
of epoetin alfa therapy [111]. These findings are consistent
with data from a murine model of MM, where tumor regres-
sion believed to be mediated via activated CD8+ T cells
occurred in 50% of mice inoculated with MM cells [112]. In
addition, severe combined immunodeficient (SCID) mice
bearing small subcutaneous ovarian cancer xenografts exhib-
ited significantly greater tumor regression (p < 0.05) when
treated with epoetin alfa and cisplatin compared with those
treated with cisplatin alone [113]. Correction of chemother-
apy-induced anemia with epoetin alfa has also been shown to
completely restore the antitumor efficacy of photodynamic
therapy [114] and increase tumor sensitivity to cyclophos-
phamide in rodent models [115].
Overall, data from more than 10 years of epoetin alfa use
in millions of patients indicate that the drug is safe and ben-
eficial for use in cancer [116], with no evidence of associated
tumor progression reported in clinical trials. In a randomized,
placebo-controlled trial, no differences in adverse events
were found between anemic cancer patients receiving epo-
etin alfa and those receiving placebo TIW for up to 28 weeks
[43]. The proportions of deaths in that study were compara-
ble in the epoetin alfa group (14%, 34/251) and the placebo
group (18%, 22/124) [43]. Although some patients who died
had experienced disease progression, none of the deaths were
considered related to the study medication [43], with the pos-
sible exception of a stroke that occurred in an elderly patient
treated with epoetin alfa who had a history of dyspnea and
paresthesia [43]. Hence, while EPO-R has been shown to
exist in some tumors and their associated vasculature, the
overall broad experience has been that epoetin alfa does not
produce major effects, either positive or negative, on tumor
growth or progression in most patients.
EPO: Functions Beyond Erythropoiesis
Potential Neuroprotective Effects of Epoetin Alfa in Patients
With Cancer
Neuroprotective effects of EPO could benefit cancer
patients, whose neurocognitive function may be affected
directly by cancer within the central nervous system or indi-
rectly by paraneoplastic effects, toxicities of certain cancer
treatments, or coexisting neurologic or psychiatric disor-
ders [117]. Recently published studies suggest that cogni-
tive dysfunction is experienced by about 10% of breast
cancer survivors who did not receive chemotherapy and by
approximately 15%-25% of patients with breast cancer
treated with chemotherapy [118-124]. Data from a pilot
trial in patients with breast cancer receiving adjuvant
chemotherapy indicate that those receiving QW epoetin
alfa experienced less cognitive decline than patients receiv-
ing placebo [56]. At a 6-month follow-up, both the epoetin
alfa group and the placebo group exhibited a restoration of
cognitive function [56]. Although the difference between
groups was not statistically significant, improvements were
generally greater in the epoetin alfa group [56]. The cogni-
tive improvement demonstrated by placebo-treated patients
may suggest that a learning response occurred with the
repeated cognitive assessments. Hence, additional studies
are required to determine the efficacy of epoetin alfa as a
neuroprotective agent for use in cancer treatment. In partic-
ular, it is possible that pretreatment with epoetin alfa could
limit some of the neurotoxic effects of radiation therapy or
select chemotherapeutic agents.
CONCLUSIONS
The ability of epoetin alfa to stimulate red blood cell pro-
duction has benefited patients with a variety of anemias,
including those of renal and cancer origin. Just how EPO
stimulates erythropoiesis is not fully understood, although one
important mechanism is by enhancing erythroid precursor
survival by inducing the antiapoptotic molecule Bcl-x. More
recently, studies have illustrated various biologic effects of
EPO on nonerythroid tissues, including vascular endothelial
cells, the nervous system, and selected tumors. These obser-
vations have clinical implications for patients with cancer as
well as neurologic and ischemic disorders. It is likely that fur-
ther research into EPO-R signaling will enhance insight into
its actions outside the hematopoietic system and provide fur-
ther opportunities to extend the therapeutic role of epoetin alfa
within and beyond the oncology practice.
ACKNOWLEDGMENT
The author thanks Rosemary Mazanet for reviewing the
manuscript.
Dr. Weiss is the recipient of a Focused Giving Award
from Johnson & Johnson and is a consultant for Pfizer.
Weiss
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