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BMJ Open BMJ Open: first published as 10.1136/bmjopen-2014-006604 on 14 November 2014. Downloaded from Exposure to sodium channel-inhibiting drugs and cancer survival: protocol for a cohort study using the QResearch primary care database For peer review only Journal: BMJ Open Manuscript ID: bmjopen-2014-006604 Article Type: Protocol Date Submitted by the Author: 11-Sep-2014 Complete List of Authors: Fairhurst, Caroline; University of York, Health Sciences Watt, Ian; University of York, Health Sciences Martin, Fabiola; Hull York Medical School, Bland, Martin; University of York, Health Sciences Brackenbury, William; University of York, Biology <b>Primary Subject Oncology Heading</b>: Secondary Subject Heading: Epidemiology, Pharmacology and therapeutics PRIMARY CARE, Epilepsy < NEUROLOGY, Breast tumours < ONCOLOGY, Keywords: Epidemiology < ONCOLOGY, STATISTICS & RESEARCH METHODS, Clinical trials < THERAPEUTICS http://bmjopen.bmj.com/ on September 29, 2021 by guest. Protected copyright. For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 1 of 36 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2014-006604 on 14 November 2014. Downloaded from 1 2 3 Exposure to sodium channel-inhibiting drugs and cancer survival: 4 5 protocol for a cohort study using the QResearch primary care database 6 7 8 9 Caroline Fairhurst1, Ian Watt1,2, Fabiola Martin2,3, Martin Bland1, and William 10 11 J. Brackenbury3* 12 13 1Department of Health Sciences, University of York, York, UK 14 15 2HullFor York Medical peer School, York, review UK only 16 17 3Department of Biology, University of York, York, UK 18 19 20 21 *Corresponding author: 22 23 William J. Brackenbury 24 25 Department of Biology, University of York, Heslington, York, YO10 5DD, UK 26 27 E-mail: [email protected] 28 29 Telephone: +44 (0) 1904 328 284 30 31 32 33 Keywords: Anticonvulsants / Breast neoplasms / Colonic neoplasms / Prostatic 34 http://bmjopen.bmj.com/ 35 36 neoplasms / Sodium channels 37 38 39 40 Word count, excluding title page, abstract, references, figures and tables: 2327. 41 42 on September 29, 2021 by guest. Protected copyright. 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml 1 BMJ Open Page 2 of 36 BMJ Open: first published as 10.1136/bmjopen-2014-006604 on 14 November 2014. Downloaded from 1 2 3 ABSTRACT 4 5 6 7 Introduction: Metastasis from solid tumours is associated with significant 8 9 morbidity and mortality, and is the leading cause of cancer-related deaths. Voltage- 10 11 gated sodium channels (VGSCs) are drug targets for the treatment of epilepsy. 12 13 VGSCs are also present in cancer cells, where they regulate metastatic cell 14 15 behaviours,For including peer cellular movement review and invasion. Treating only cancer cells with the 16 17 VGSC-inhibiting anticonvulsant phenytoin reduces cellular invasion and migration. 18 19 Together, these suggest that VGSCs may be useful targets for inhibiting metastasis. 20 21 The purpose of this study is to test the hypothesis that use of VGSC-inhibiting drugs 22 23 will reduce metastasis, and therefore increase survival time in cancer patients. 24 25 26 27 Methods and analysis: A cohort study based on primary care data from the 28 29 QResearch database will include patients with one of three common tumours: breast, 30 31 bowel, and prostate. The primary outcome will be overall survival from date of cancer 32 33 diagnosis. Cox proportional hazards regression will be used to compare the survival 34 http://bmjopen.bmj.com/ 35 36 of cancer patients taking VGSC-inhibiting drugs (including anticonvulsants and Class 37 38 I antiarrhythmic agents) with cancer patients not exposed to these drugs, adjusting 39 40 for age and sex. Exposure to VGSC-inhibiting drugs will be defined as having at 41 42 least one prescription for these drugs prior to cancer diagnosis. High and low on September 29, 2021 by guest. Protected copyright. 43 44 exposure groups will be identified based on length of use. A number of sensitivity and 45 46 secondary analyses will be conducted. 47 48 49 50 Ethics and dissemination: The protocol has been independently peer- 51 52 reviewed and approved by the QResearch Scientific Board. The project has also 53 54 been approved by the University of York Ethical Review Process. The results will be 55 56 presented at international conferences and published in an open access peer- 57 58 reviewed journal, in accordance with the STROBE criteria. 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml 2 Page 3 of 36 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2014-006604 on 14 November 2014. Downloaded from 1 2 3 4 5 STRENGTHS AND LIMITATIONS OF THIS STUDY 6 7 8 9 • Primary care research data 10 11 • Large sample size and statistical power 12 13 • Planned sensitivity analyses 14 15 • Prescription-basedFor peer study review only 16 17 • No direct information on metastasis, estimation is via overall survival 18 19 20 • Some variables of interest may be missing and/or poor quality in GP data 21 22 23 24 INTRODUCTION 25 26 27 28 Bowel, breast and colon cancer are common cancers, which if diagnosed late have 29 30 often already spread to secondary sites (metastasised). Metastasis is associated with 31 32 significant morbidity and mortality. Metastasis is the leading cause of cancer-related 33 34 deaths[1] because a metastatic cancer is rarely amenable to cure, and interventions http://bmjopen.bmj.com/ 35 36 are largely limited to palliation.[2] Therefore, there is an urgent need to identify and/or 37 38 develop new metastasis prevention strategies. 39 40 41 42 The classical role of voltage-gated sodium channels (VGSCs) is to transmit action on September 29, 2021 by guest. Protected copyright. 43 44 potentials in electrically excitable cells, e.g. neurons and cardiomyocytes.[3] VGSCs 45 46 also regulate neuronal growth and migration.[4-7] Related to these functions, VGSCs 47 48 are clinical targets for a range of disorders, including epilepsy, cardiac arrhythmias, 49 50 neuropathic pain and depression.[8] The mode of action of a number of commonly 51 52 prescribed antiepileptic drugs (anticonvulsants), including phenytoin, lamotrigine, 53 54 carbamazepine and valproate, is to inhibit VGSCs.[9] Similarly, the principal mode of 55 56 action of Class I antiarrhythmic drugs is to inhibit VGSCs.[10] 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml 3 BMJ Open Page 4 of 36 BMJ Open: first published as 10.1136/bmjopen-2014-006604 on 14 November 2014. Downloaded from 1 2 3 4 5 More recently, VGSCs have been identified in cells from a number of major cancers, 6 7 including carcinomas of the breast, prostate and colon.[11 12] In these cells, VGSCs 8 9 promote in vitro cellular behaviours that are associated with metastasis, including 10 11 migration and invasion.[13-18] Overexpression of the VGSC β1 subunit in breast 12 13 cancer cells increases metastasis in mice.[19-21] The VGSC-inhibiting 14 15 anticonvulsantFor phenytoin peer significantly review reduces migration and only invasion of metastatic 16 17 breast and prostate cancer cells in vitro[22 23] and has been shown to reduce 18 19 metastasis in a mouse model of breast cancer (M. Nelson, M. Yang, A. A. Dowle, J. 20 21 R. Thomas and W. J. Brackenbury, manuscript under review, 2014). Together, these 22 23 data suggest that VGSCs may be useful targets for anti-metastatic therapy, and that 24 25 VGSC-inhibiting drugs may improve survival from certain cancers.[11 24] Although 26 27 28 the effect of several anticonvulsants on risk of developing various cancers has been 29 30 studied before (reviewed in[25]), the relationship between VGSC-inhibiting drugs and 31 32 survival of cancer patients has not been investigated. 33 34 http://bmjopen.bmj.com/ 35 36 The purpose of this study is to test the hypothesis that use of VGSC-inhibiting drugs 37 38 will predict increased time to metastasis and thus improved survival time in cancer 39 40 patients. The objectives are to investigate: 41 42 • The relationship between use of all VGSC-inhibiting (anticonvulsant and on September 29, 2021 by guest. Protected copyright. 43 44 Class I antiarrhythmic) drugs and overall survival of cancer patients. We will 45 46 focus on carcinomas of the breast, colon and prostate because they are the 47 48 most common and VGSC expression has been extensively studied in these 49 50 tumours.[11 13-17 26-30] 51 52 • The relationship between use of all VGSC-inhibiting drugs and cancer specific 53 54 survival. 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml 4 Page 5 of 36 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2014-006604 on 14 November 2014. Downloaded from 1 2 3 • The relationship between individual VGSC-inhibiting drugs and overall 4 5 survival. 6 7 8 9 There are no systematic reviews exploring this area and we are addressing this gap 10 11 by conducting a review concurrent to this study [PROSPERO registration number 12 13 CRD42014013574]. 14 15 For peer review only 16 17 METHODS AND ANALYSIS 18 19 20 21 Data source and sample selection 22 23 24 25 This study will use general practice data accessed from QResearch 26 27 (http://www.qresearch.org), a large consolidated database derived from the 28 29 anonymised health records of over 13 million patients from 753 general practices 30 31 32 (representing around 7% of UK practices).
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