851
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Mulder FI, Bosch FTM, van Es N. Primary Thromboprophylaxis in Ambulatory Cancer Patients: Where Do We Stand? Cancers (Basel) 2020; 12:E367. [PMID: 32033438 PMCID: PMC7072463 DOI: 10.3390/cancers12020367] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Revised: 01/31/2020] [Accepted: 02/02/2020] [Indexed: 02/07/2023] Open
Abstract
Venous thromboembolism (VTE), comprising deep-vein thrombosis and pulmonary embolism, is a frequent complication in ambulatory cancer patients. Despite the high risk, routine thromboprophylaxis is not recommended because of the high number needed to treat and the risk of bleeding. Two recent trials demonstrated that the number needed to treat can be reduced by selecting cancer patients at high risk for VTE with prediction scores, leading the latest guidelines to suggest such an approach in clinical practice. Yet, the interpretation of these trial results and the translation of the guideline recommendations to clinical practice may be less straightforward. In this clinically-oriented review, some of the controversies are addressed by focusing on the burden of VTE in cancer patients, discussing the performance of available risk assessment scores, and summarizing the findings of recent trials. This overview can help oncologists, hematologists, and vascular medicine specialists decide about thromboprophylaxis in ambulatory cancer patients.
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Affiliation(s)
- Frits I. Mulder
- Department of Vascular Medicine, Amsterdam Cardiovascular Science, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (F.T.M.B.); (N.v.E.)
- Department of Internal Medicine, Tergooi Hospitals, 1213 XZ Hilversum, The Netherlands
| | - Floris T. M. Bosch
- Department of Vascular Medicine, Amsterdam Cardiovascular Science, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (F.T.M.B.); (N.v.E.)
- Department of Internal Medicine, Tergooi Hospitals, 1213 XZ Hilversum, The Netherlands
| | - Nick van Es
- Department of Vascular Medicine, Amsterdam Cardiovascular Science, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (F.T.M.B.); (N.v.E.)
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852
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Godinho J, Casa‐Nova M, Moreira‐Pinto J, Simões P, Paralta Branco F, Leal‐Costa L, Faria A, Lopes F, Teixeira JA, Passos‐Coelho JL. ONKOTEV Score as a Predictive Tool for Thromboembolic Events in Pancreatic Cancer-A Retrospective Analysis. Oncologist 2020; 25:e284-e290. [PMID: 32043787 PMCID: PMC7011666 DOI: 10.1634/theoncologist.2019-0510] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Accepted: 09/30/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) is a frequent complication in patients with cancer and causes considerable morbidity and mortality. The risk of VTE is higher in patients with pancreatic cancer and is often associated with treatment delays or interruptions. Recently, the ONKOTEV score was proposed as a VTE risk predictor model for patients with cancer, but its validation is still ongoing. PATIENTS AND METHODS We conducted a retrospective study to determine the incidence of VTE and to evaluate the ONKOTEV score as a VTE predictive tool in a population of patients with pancreatic cancer. RESULTS Between February 2012 and May 2017, 165 patients were included in the study. The median age was 73 years, 45.5% of patients were female, and 55.8% had stage IV disease. Fifty-one patients had a VTE (30.9%); 23.5% had pulmonary embolism, 25.5% had deep venous thrombosis, and 51.0% had visceral VTE (VsT). At a median follow-up time of 6.3 months, cumulative incidence of VTE was less than 10% for ONKOTEV scores 0 or 1 and approximately 40% and 70% for scores 2 and ≥3, respectively. CONCLUSION The high VTE incidence observed in this study is consistent with prior reports. Patients at high risk for VTE with no increase in hemorrhagic risk should be considered for primary thromboprophylaxis. The ONKOTEV score may stratify VTE risk in patients with pancreatic cancer, with ONKOTEV score ≥2 being associated with a higher VTE occurrence. IMPLICATIONS FOR PRACTICE Venous thromboembolism (VTE) is a frequent complication of patients with pancreatic cancer and causes considerable morbidity, treatment delays or interruptions, and mortality. Thromboprophylaxis is not used routinely in ambulatory patients. Tools to stratify the risk of VTE are important to help select patients who may benefit from thromboprophylaxis. Recently, the ONKOTEV score was proposed as a VTE risk predictor model for patients with cancer, but its validation is still ongoing. In this patient series, ONKOTEV score ≥2 was associated with high VTE occurrence and may stratify VTE risk in patients with pancreatic cancer, suggesting that ONKOTEV can be considered to select patients with pancreatic cancer for primary thromboprophylaxis.
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Affiliation(s)
| | | | | | | | | | | | - Ana Faria
- Hospital Beatriz ÂngeloLouresPortugal
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853
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Douketis JD. Prevention of venous thromboembolism in medical cancer patients: Guidance or guideline? J Thromb Haemost 2020; 18:520-521. [PMID: 31999064 DOI: 10.1111/jth.14693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 11/16/2019] [Indexed: 12/01/2022]
Affiliation(s)
- James D Douketis
- Department of Medicine, St. Joseph's Healthcare Hamilton and McMaster University, Hamilton, Ontario, Canada
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854
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Koehl JL, Hayes BD, Al‐Samkari H, Rosovsky R. A comprehensive evaluation of apixaban in the treatment of venous thromboembolism. Expert Rev Hematol 2020; 13:155-173. [DOI: 10.1080/17474086.2020.1711731] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
- Jennifer L Koehl
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA
| | - Bryan D. Hayes
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA
| | - Hanny Al‐Samkari
- Division of Hematology & Oncology, Department of Medicine, Massachusetts Hospital, Boston, MA, USA
| | - Rachel Rosovsky
- Division of Hematology & Oncology, Department of Medicine, Massachusetts Hospital, Boston, MA, USA
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855
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Sorigue M, Cañamero E, Siguenza P, Nomdedeu M, López-Núñez JJ. Recent developments and persisting challenges in the prevention and treatment of venous thromboembolism in patients with hematological malignancies. Leuk Lymphoma 2020; 61:1277-1291. [DOI: 10.1080/10428194.2020.1713321] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Marc Sorigue
- Laboratory of Hematology, ICO-Hospital Germans Trias i Pujol, IJC, UAB, Badalona, Spain
| | - Eloi Cañamero
- Laboratory of Hematology, ICO-Hospital Germans Trias i Pujol, IJC, UAB, Badalona, Spain
| | - Patricia Siguenza
- Department of Internal Medicine, Hospital Germans Trias i Pujol, Badalona, Spain
| | - Meritxell Nomdedeu
- Laboratory of Hematology, ICO-Hospital Germans Trias i Pujol, IJC, UAB, Badalona, Spain
| | - Juan J. López-Núñez
- Department of Internal Medicine, Hospital Germans Trias i Pujol, Badalona, Spain
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856
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Li X, Partovi S, Gadani S, Martin C, Beck A, Vedantham S. Gastrointestinal Malignancies and Venous Thromboembolic Disease: Clinical Significance and Endovascular Interventions. ACTA ACUST UNITED AC 2020; 4:260-266. [PMID: 34296054 DOI: 10.1055/s-0040-1716739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Gastrointestinal malignancy encompasses a wide range of disease processes. Its incidence and mortality rate rank among the highest of all cancers. Venous thromboembolic disease is a common complication of gastrointestinal malignancy. Anticoagulation remains the first-line therapy. However, for patients who cannot tolerate or have failed anticoagulation, inferior vena cava (IVC) filter placement may be an option. Furthermore, to improve symptom resolution and reduce the severity of postthrombotic syndrome, catheter-directed thrombolysis (CDT) may be an option. Recent randomized trials including the ATTRACT (Acute Venous Thrombosis: Thrombus Removal with Adjunctive Catheter-Directed Thrombolysis) trial have shed new light on the efficacy and safety of CDT and related methods. Overall, the decision to proceed with IVC filter placement or CDT must be individualized.
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Affiliation(s)
- Xin Li
- Section of Interventional Radiology, Imaging Institute, Cleveland Clinic Main Campus, Cleveland, Ohio
| | - Sasan Partovi
- Section of Interventional Radiology, Imaging Institute, Cleveland Clinic Main Campus, Cleveland, Ohio
| | - Sameer Gadani
- Section of Interventional Radiology, Imaging Institute, Cleveland Clinic Main Campus, Cleveland, Ohio
| | - Charles Martin
- Section of Interventional Radiology, Imaging Institute, Cleveland Clinic Main Campus, Cleveland, Ohio
| | - Avi Beck
- Section of Interventional Radiology, Imaging Institute, Cleveland Clinic Main Campus, Cleveland, Ohio
| | - Suresh Vedantham
- Section of Interventional Radiology, Mallinckrodt Institute of Radiology, Washington University in St. Louis, St. Louis, Missouri
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857
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Tomić M. The current place of direct oral anticoagulants in the prevention/treatment of venous thromboembolism. ARHIV ZA FARMACIJU 2020. [DOI: 10.5937/arhfarm2005284t] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
Venous thromboembolism (VTE; includes deep venous thrombosis, DVT, and pulmonary embolism, PE) represents the third most common acute cardiovascular syndrome. Contemporary VTE management comprises primary prevention in high-risk patients, treatment of established VTE, and prevention of its recurrence (secondary prevention). Anticoagulants are the basis of VTE pharmacological prophylaxis and treatment. For several decades, parenteral (heparin and low-molecular-weight heparins, LMWHs) and oral anticoagulants (vitamin K antagonists, VKAs) have been the cornerstone of VTE prevention/treatment. The introduction of direct oral anticoagulants (DOACs: thrombin inhibitor dabigatran and Xa inhibitors rivaroxaban, apixaban, edoxaban, and betrixaban) markedly improved the management of VTE by overcoming many disadvantages of conventional anticoagulants. For primary VTE prevention in patients after total hip/knee arthroplasty, rivaroxaban, apixaban, and dabigatran are preferred over LMWHs, due to comparable efficacy and safety, but favourable acceptability (avoided everyday injections). In other high-risk populations (other surgical patients, acutely ill medical patients), LMWHs are still the recommended option. Betrixaban is currently the only DOAC approved for VTE prophylaxis in medically ill patients during and after hospitalization. For acute VTE treatment and secondary prevention, DOACs (rivaroxaban, apixaban, edoxaban, and dabigatran) are recommended as the first-line therapy in the general population. DOACs proved to be similarly effective but safer than VKAs. In some specific populations, DOACs also seem to be advantageous over conventional treatment (patients with renal impairment, elderly, long-term secondary prevention in cancer patients). Currently, there is no data from randomized head-to-head comparative studies between the DOAC classes or representatives so the choice is made mainly according to patient characteristics and pharmacokinetic properties of the drug.
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858
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Prabhash K, Munot P, Noronha V, Patil V, Joshi A, Menon N. Cancer thrombosis: Narrative review. CANCER RESEARCH, STATISTICS, AND TREATMENT 2020. [DOI: 10.4103/crst.crst_18_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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859
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Qi Y, Hu X, Chen J, Ying X, Shi Y. The Risk Factors of VTE and Survival Prognosis of Patients With Malignant Cancer: Implication for Nursing and Treatment. Clin Appl Thromb Hemost 2020; 26:1076029620971053. [PMID: 33119403 PMCID: PMC7607791 DOI: 10.1177/1076029620971053] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 09/22/2020] [Accepted: 10/14/2020] [Indexed: 12/21/2022] Open
Abstract
Venous thromboembolism (VTE) is very common in patients with malignant cancer. We aimed to conduct a retrospective analysis on the risk factors of VTE and its survival prognosis of patients with malignant cancer, to provide evidence into the management of VTE. Patients with malignant cancer treated in our hospital were selected. The characteristic of patients and related lab detection results including activated partial thromboplastin time (APTT), plasma prothrombin time (PT) and thrombin coagulation time (TT), fibrinogen (FIB), thrombin AT-Ⅲ complex (TAT) and D-dimer (D-D) were collected and analyzed. And logistic regression analyses were performed to identify the potential risk factors. And ROC curves were established to evaluate their predictive ability of VTE for patients with malignant cancers. A total of 286 patients were included, of which 63 patients had VTE, the incidence of VTE in patients with malignant cancers was 22.03%. There were significant differences on the D-D, TAT level between VTE and no VTE patients (all P < 0.05). The survival condition of VTE patients was significantly worse than that of no VTE patients(P = 0.017). D-D (RR7.895, 3.228∼19.286) and TAT (6.122, 2.244∼16.695) were risk factors of VTE for patients with cancers (all P < 0.05). The area under the curve (AUC) of D-D, TAT and combined use was 0.764, 0.698, 0.794 respectively, and the cutoff value for D-D, TAT was 1.835mg/L and 4.58μg/L respectively. For cancer patients with D-D >1.835 mg/L and TAT >4.58 μg/L, early interventions are needed for the prophylaxis of VTE.
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Affiliation(s)
- Yan Qi
- School of Medicine, Jinggangshan University, Ji An, China
- Shanghai Tenth People’s Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Xin Hu
- Ji An Central Hospital, Ji An, China
| | - Jing Chen
- Shanghai Tenth People’s Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Xiaobin Ying
- Shanghai Tenth People’s Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Yan Shi
- Shanghai Tenth People’s Hospital, School of Medicine, Tongji University, Shanghai, China
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860
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Moik F, Pabinger I, Ay C. How I treat cancer-associated thrombosis. ESMO Open 2020; 5:e000610. [PMID: 31958288 PMCID: PMC7003382 DOI: 10.1136/esmoopen-2019-000610] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 11/09/2019] [Accepted: 11/15/2019] [Indexed: 12/21/2022] Open
Abstract
Patients with cancer are at an increased risk of symptomatic venous thromboembolism (VTE). In addition, an increasing number of patients with incidental thromboembolic events have been recorded in clinical practice. Therapeutic anticoagulation is crucial to prevent thrombus progression and reduce risk of recurrence; however, this comes at the price of an increased bleeding risk, which necessitates a personalised approach to choose the most appropriate type of therapy. Over the last decade, low-molecular-weight heparin has been the preferred anticoagulant agent for patients with cancer-associated thrombosis due to better efficacy and similar safety profile compared with vitamin K antagonists. While direct oral anticoagulants (DOAC) have emerged as new option for treatment of VTE in a general population, only limited data have been available specifically for patients with cancer until recently. Randomised, controlled trials have now been published, establishing DOAC as an alternative for the treatment of cancer-associated thrombosis. However, the improvement in the therapeutic armamentarium is accompanied by a number of special considerations. For instance, risk of bleeding is elevated in patients with cancer-associated VTE receiving DOAC, especially in certain tumour types (eg, gastrointestinal), and no guidance exists regarding their use in patients with severe thrombocytopaenia. Furthermore, DOAC are prone to certain drug-drug interactions and their effect might be altered due to nausea and vomiting in patients receiving chemotherapy. Here, we provide guidance on how to treat cancer-associated VTE and how new evidence from randomised controlled trials can be implemented in clinical practice. There are still clinical scenarios where robust evidence is lacking and treatment recommendations are based on extrapolations from other populations or expert opinion only. Therefore, additional research in special subpopulations is needed to optimise management of patients in challenging clinical scenarios.
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Affiliation(s)
- Florian Moik
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria
| | - Ingrid Pabinger
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria
| | - Cihan Ay
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria; I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia.
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861
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Otašević V, Antić D, Mihaljević B. Venous thromboembolic complications in lymphoma patients. MEDICINSKI PODMLADAK 2020. [DOI: 10.5937/mp71-29196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
Lymphomas represent a heterogeneous group of malignant hematological diseases with high risk for development of venous thromboembolic complications (VTE). Consequently, VTE significantly impacts morbidity and mortality in these patients. Another concern is the financial burden of the healthcare system caused by diagnostic and therapeutic procedures of cancer-associated thrombosis (CAT). The complex biology of lymphoma, in conjunction with patient and treatment related risk factors for the development of VTE, results in a procoagulant hemostatic dysregulation. Considering the incidence of VTE in patients with lymphoma, there is an emerging demand for both reliable risks assessment model (RAM) for prediction of VTE, as well as for effective VTE prophylaxis and treatment. The clinical course of patients with malignant diseases is accompanied by a wide range of potential treatment complications, making the task of prevention and treatment of VTE even more challenging. In recent years, great progress has been achieved in understanding the pathophysiological mechanisms of thrombotic complications, while the significant number of randomized controlled trials (RCT) have provided standards of prophylaxis and treatment of VTE complications in patients with malignancy. In comparison to previous recommendations and guidelines for CAT, the use of direct oral anticoagulants (DOAC) has been gradually approaching low molecular weight heparins (LMWH) in terms of efficacy and safety profile in these indications. This systematic review is focused on the latest pathophysiological advances, risk factors assessment, prophylactic and therapeutic recommendations and guidelines concerning VTE in patients with lymphoma.
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862
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Jiang R, Li T, Li H. [Perioperative Venous Thromboembolism (VTE) Prophylaxis in Thoracic Cancer Patients: Chinese Experts Consensus - Interpretation of Application Prospect of Direct Oral Anticoagulant]. ZHONGGUO FEI AI ZA ZHI = CHINESE JOURNAL OF LUNG CANCER 2019; 22:757-760. [PMID: 31874670 PMCID: PMC6935040 DOI: 10.3779/j.issn.1009-3419.2019.12.04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
胸部恶性肿瘤患者围术期静脉血栓栓塞症(venous thromboembolism, VTE)是一种需要引起重视的胸外科围术期并发症,中国胸外科静脉血栓栓塞研究协作组针对胸部恶性肿瘤患者围术期VTE的预防,发布了国际首部《胸部恶性肿瘤围术期静脉血栓栓塞症预防中国专家共识》(2018版)。本文将对直接口服抗凝药在胸部恶性肿瘤患者围术期的应用进行解读,以助于更好地理解共识相关内容。
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Affiliation(s)
- Ruiheng Jiang
- Department of Thoracic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China
| | - Tong Li
- Department of Thoracic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China
| | - Hui Li
- Department of Thoracic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China
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863
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Sun Y, Li H. [Perioperative Venous Thromboembolism (VTE) Prophylaxis in Thoracic Cancer Patients: Chinese Experts Consensus - Interpretation of Epidemiological Characteristics]. ZHONGGUO FEI AI ZA ZHI = CHINESE JOURNAL OF LUNG CANCER 2019; 22:741-746. [PMID: 31874667 PMCID: PMC6935037 DOI: 10.3779/j.issn.1009-3419.2019.12.01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
胸部恶性肿瘤患者围术期静脉血栓栓塞症(venous thromboembolism, VTE)是一种需要引起重视的胸外科围术期并发症,中国胸外科静脉血栓栓塞研究协作组针对胸部恶性肿瘤患者围术期VTE的预防,发布了国际首部《胸部恶性肿瘤围术期静脉血栓栓塞症预防中国专家共识》(2018版)。本文将对其中胸部恶性肿瘤围术期VTE的流行病学特征、国内外面临的挑战及预防现状进行解读,以助于更好地理解共识相关内容。
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Affiliation(s)
- Yixin Sun
- Department of Thoracic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China
| | - Hui Li
- Department of Thoracic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China
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864
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Development of a clinical prediction tool for cancer-associated venous thromboembolism (CAT): the MD Anderson Cancer Center CAT model. Support Care Cancer 2019; 28:3755-3761. [PMID: 31828489 DOI: 10.1007/s00520-019-05150-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 10/24/2019] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Cancer-associated venous thromboembolism (CAT) is a major complication of malignancy. Our goal was to develop a prediction model for VTE that better represented to the population seen at large referral cancer centers. MATERIALS AND METHODS This study was nested in a prospective cohort study at the University of Texas MD Anderson Cancer Center that evaluated adult patients during outpatient cancer-staging computed tomography to estimate the prevalence of incidental VTE. Data from patients in whom incidental VTE was not found on initial CT were collected until 24 months ± 7 days from the study inclusion date to determine the occurrence of new VTE events. Demographics, clinical data, current cancer treatment information, and the use of erythropoietin stimulating agents (ESAs) along with hematologic variables were collected in all patients and analyzed to determine differences between those who developed VTE versus those who did not. All candidate variables with significance p value (≤ 0.1) under univariate analysis were considered to enter the final multivariate model. RESULTS Data of 548 patients were analyzed. The presence of metastatic disease and the use of platinum-based chemotherapy were strongly associated with CAT occurrence. The use of ESAs and specific malignancies showed trends of association with CAT, while associations were not statistically significant.Those characteristics were utilized to develop a clinical prediction model for CAT readily available and effective (c-index = 0.74). CONCLUSION Our model is effective and easy to incorporate in busy clinical settings and it does not depend on esoteric or difficult-to-obtain laboratory testing. Future external validation studies may provide further evidence for the applicability of our results.
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865
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Al-Samkari H, Connors JM. Managing the competing risks of thrombosis, bleeding, and anticoagulation in patients with malignancy. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2019; 2019:71-79. [PMID: 31808892 PMCID: PMC6913483 DOI: 10.1182/hematology.2019000369] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
The association between malignancy and thrombosis has been recognized for over a century and a half. Patients with cancer have an elevated risk of both initial and recurrent venous thromboembolism (VTE) compared with patients without cancer owing to cancer- and patient-specific factors. Recurrent VTE is common despite anticoagulation, presenting additional management challenges. Patients with cancer also have an increased risk of bleeding when on anticoagulants compared with patients without cancer. This bleeding risk is heightened by the thrombocytopenia common in patients with hematologic malignancies and those treated with intensive myelosuppressive chemotherapy regimens. Despite the advancements in cancer-directed therapy made over the past 15 years, numerous large studies have confirmed that bleeding and VTE recurrence rates remain high in cancer patients. Balancing the increased and competing risks of clotting and bleeding in these patients can be difficult, because management of cancer-associated thrombosis requires anticoagulation despite known increased risks for bleeding. In the context of challenging illustrative cases, this review will describe management approaches to clinical scenarios in which data are sparse: cancer patients with recurrent VTE despite anticoagulation and cancer patients with a new VTE in the setting of severe thrombocytopenia.
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Affiliation(s)
- Hanny Al-Samkari
- Division of Hematology, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA; and
| | - Jean M Connors
- Harvard Medical School, Boston, MA; and
- Division of Hematology, Brigham and Women's Hospital, Boston, MA
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866
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Al-Samkari H, Connors JM. Managing the competing risks of thrombosis, bleeding, and anticoagulation in patients with malignancy. Blood Adv 2019; 3:3770-3779. [PMID: 31770442 PMCID: PMC6880899 DOI: 10.1182/bloodadvances.2019000369] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 09/18/2019] [Indexed: 01/19/2023] Open
Abstract
The association between malignancy and thrombosis has been recognized for over a century and a half. Patients with cancer have an elevated risk of both initial and recurrent venous thromboembolism (VTE) compared with patients without cancer owing to cancer- and patient-specific factors. Recurrent VTE is common despite anticoagulation, presenting additional management challenges. Patients with cancer also have an increased risk of bleeding when on anticoagulants compared with patients without cancer. This bleeding risk is heightened by the thrombocytopenia common in patients with hematologic malignancies and those treated with intensive myelosuppressive chemotherapy regimens. Despite the advancements in cancer-directed therapy made over the past 15 years, numerous large studies have confirmed that bleeding and VTE recurrence rates remain high in cancer patients. Balancing the increased and competing risks of clotting and bleeding in these patients can be difficult, because management of cancer-associated thrombosis requires anticoagulation despite known increased risks for bleeding. In the context of challenging illustrative cases, this review will describe management approaches to clinical scenarios in which data are sparse: cancer patients with recurrent VTE despite anticoagulation and cancer patients with a new VTE in the setting of severe thrombocytopenia.
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Affiliation(s)
- Hanny Al-Samkari
- Division of Hematology, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA; and
| | - Jean M Connors
- Harvard Medical School, Boston, MA; and
- Division of Hematology, Brigham and Women's Hospital, Boston, MA
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867
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Piechotta V, Jakob T, Langer P, Monsef I, Scheid C, Estcourt LJ, Ocheni S, Theurich S, Kuhr K, Scheckel B, Adams A, Skoetz N. Multiple drug combinations of bortezomib, lenalidomide, and thalidomide for first-line treatment in adults with transplant-ineligible multiple myeloma: a network meta-analysis. Cochrane Database Syst Rev 2019; 2019:CD013487. [PMID: 31765002 PMCID: PMC6876545 DOI: 10.1002/14651858.cd013487] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Multiple myeloma is a bone marrow-based hematological malignancy accounting for approximately two per cent of cancers. First-line treatment for transplant-ineligible individuals consists of multiple drug combinations of bortezomib (V), lenalidomide (R), or thalidomide (T). However, access to these medicines is restricted in many countries worldwide. OBJECTIVES To assess and compare the effectiveness and safety of multiple drug combinations of V, R, and T for adults with newly diagnosed transplant-ineligible multiple myeloma and to inform an application for the inclusion of these medicines into the World Health Organization's (WHO) list of essential medicines. SEARCH METHODS We searched CENTRAL and MEDLINE, conference proceedings and study registries on 14 February 2019 for randomised controlled trials (RCTs) comparing multiple drug combinations of V, R and T for adults with newly diagnosed transplant-ineligible multiple myeloma. SELECTION CRITERIA We included RCTs comparing combination therapies of V, R, and T, plus melphalan and prednisone (MP) or dexamethasone (D) for first-line treatment of adults with transplant-ineligible multiple myeloma. We excluded trials including adults with relapsed or refractory disease, trials comparing drug therapies to other types of therapy and trials including second-generation novel agents. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed risk of bias of included trials. As effect measures we used hazard ratios (HRs) for overall survival (OS) and progression-free survival (PFS) and risk ratios (RRs) for adverse events. An HR or RR < 1 indicates an advantage for the intervention compared to the main comparator MP. Where available, we extracted quality of life (QoL) data (scores of standardised questionnaires). Results quoted are from network meta-analysis (NMA) unless stated. MAIN RESULTS We included 25 studies (148 references) comprising 11,403 participants and 21 treatment regimens. Treatments were differentiated between restricted treatment duration (treatment with a pre-specified amount of cycles) and continuous therapy (treatment administered until disease progression, the person becomes intolerant to the drug, or treatment given for a prolonged period). Continuous therapies are indicated with a "c". Risk of bias was generally high across studies due to the open-label study design. Overall survival (OS) Evidence suggests that treatment with RD (HR 0.63 (95% confidence interval (CI) 0.40 to 0.99), median OS 55.2 months (35.2 to 87.0)); TMP (HR 0.75 (95% CI 0.58 to 0.97), median OS: 46.4 months (35.9 to 60.0)); and VRDc (HR 0.49 (95% CI 0.26 to 0.92), median OS 71.0 months (37.8 to 133.8)) probably increases survival compared to median reported OS of 34.8 months with MP (moderate certainty). Treatment with VMP may result in a large increase in OS, compared to MP (HR 0.70 (95% CI 0.45 to 1.07), median OS 49.7 months (32.5 to 77.3)), low certainty). Progression-free survival (PFS) Treatment withRD (HR 0.65 (95% CI0.44 to 0.96), median PFS: 24.9 months (16.9 to 36.8)); TMP (HR 0.63 (95% CI 0.50 to 0.78), median PFS:25.7 months (20.8 to 32.4)); VMP (HR 0.56 (95% CI 0.35 to 0.90), median PFS: 28.9 months (18.0 to 46.3)); and VRDc (HR 0.34 (95% CI 0.20 to 0.58), median PFS: 47.6 months (27.9 to 81.0)) may result in a large increase in PFS (low certainty) compared to MP (median reported PFS: 16.2 months). Adverse events The risk of polyneuropathies may be lower with RD compared to treatment with MP (RR 0.57 (95% CI 0.16 to 1.99), risk for RD: 0.5% (0.1 to 1.8), mean reported risk for MP: 0.9% (10 of 1074 patients affected), low certainty). However, the CIs are also compatible with no difference or an increase in neuropathies. Treatment with TMP (RR 4.44 (95% CI1.77 to 11.11), risk: 4.0% (1.6 to 10.0)) and VMP (RR 88.22 (95% CI 5.36 to 1451.11), risk: 79.4% (4.8 to 1306.0)) probably results in a large increase in polyneuropathies compared to MP (moderate certainty). No study reported the amount of participants with grade ≥ 3 polyneuropathies for treatment with VRDc. VMP probably increases the proportion of participants with serious adverse events (SAEs) compared to MP (RR 1.28 (95% CI 1.06 to 1.54), risk for VMP: 46.2% (38.3 to 55.6), mean risk for MP: 36.1% (177 of 490 patients affected), moderate certainty). RD, TMP, and VRDc were not connected to MP in the network and the risk of SAEs could not be compared. Treatment with RD (RR 4.18 (95% CI 2.13 to 8.20), NMA-risk: 38.5% (19.6 to 75.4)); and TMP (RR 4.10 (95% CI 2.40 to 7.01), risk: 37.7% (22.1 to 64.5)) results in a large increase of withdrawals from the trial due to adverse events (high certainty) compared to MP (mean reported risk: 9.2% (77 of 837 patients withdrew)). The risk is probably slightly increased with VMP (RR 1.06 (95% CI 0.63 to 1.81), risk: 9.75% (5.8 to 16.7), moderate certainty), while it is much increased with VRDc (RR 8.92 (95% CI 3.82 to 20.84), risk: 82.1% (35.1 to 191.7), high certainty) compared to MP. Quality of life QoL was reported in four studies for seven different treatment regimens (MP, MPc, RD, RMP, RMPc, TMP, TMPc) and was measured with four different tools. Assessment and reporting differed between studies and could not be meta-analysed. However, all studies reported an improvement of QoL after initiation of anti-myeloma treatment for all assessed treatment regimens. AUTHORS' CONCLUSIONS Based on our four pre-selected comparisons of interest, continuous treatment with VRD had the largest survival benefit compared with MP, while RD and TMP also probably considerably increase survival. However, treatment combinations of V, R, and T also substantially increase the incidence of AEs, and lead to a higher risk of treatment discontinuation. Their effectiveness and safety profiles may best be analysed in further randomised head-to-head trials. Further trials should focus on consistent reporting of safety outcomes and should use a standardised instrument to evaluate QoL to ensure comparability of treatment-combinations.
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Affiliation(s)
- Vanessa Piechotta
- Faculty of Medicine and University Hospital Cologne, University of Cologne, Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Kerpener Str. 62, Cologne, NRW, Germany, 50937
| | - Tina Jakob
- Faculty of Medicine and University Hospital Cologne, University of Cologne, Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Kerpener Str. 62, Cologne, NRW, Germany, 50937
| | - Peter Langer
- Faculty of Medicine and University Hospital Cologne, University of Cologne, Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Kerpener Str. 62, Cologne, NRW, Germany, 50937
| | - Ina Monsef
- Faculty of Medicine and University Hospital Cologne, University of Cologne, Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Kerpener Str. 62, Cologne, NRW, Germany, 50937
| | - Christof Scheid
- Faculty of Medicine and University Hospital Cologne, University of Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Stem Cell Transplantation Program, Kerpener Str. 62, Cologne, NRW, Germany, 50937
| | - Lise J Estcourt
- NHS Blood and Transplant, Haematology/Transfusion Medicine, Level 2, John Radcliffe Hospital, Headington, Oxford, UK, OX3 9BQ
| | - Sunday Ocheni
- University of Nigeria, Department of Haematology & Immunology, Ituku-Ozalla Campus, Enugu, Enugu State, Nigeria
| | - Sebastian Theurich
- University Hospital LMU, Ludwig-Maximilians-Universität München, Department of Medicine III, Marchioninistrasse 15, Munich, Bavaria, Germany, 81377
| | - Kathrin Kuhr
- Faculty of Medicine and University Hospital Cologne, University of Cologne, Institute of Medical Statistics and Computational Biology, Kerpener Str. 62, Cologne, Germany, 50937
| | - Benjamin Scheckel
- Faculty of Medicine and University Hospital Cologne, University of Cologne, Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Kerpener Str. 62, Cologne, NRW, Germany, 50937
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Institute of Health Economics and Clinical Epidemiology, Gleueler Str. 176-178, Cologne, NRW, Germany, 50935
| | - Anne Adams
- Faculty of Medicine and University Hospital Cologne, University of Cologne, Institute of Medical Statistics and Computational Biology, Kerpener Str. 62, Cologne, Germany, 50937
| | - Nicole Skoetz
- Faculty of Medicine and University Hospital Cologne, University of Cologne, Cochrane Cancer, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Kerpener Str. 62, Cologne, Germany, 50937
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868
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Paivana G, Mavrikou S, Kaltsas G, Kintzios S. Bioelectrical Analysis of Various Cancer Cell Types Immobilized in 3D Matrix and Cultured in 3D-Printed Well. BIOSENSORS 2019; 9:E136. [PMID: 31739597 PMCID: PMC6956196 DOI: 10.3390/bios9040136] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 11/05/2019] [Accepted: 11/11/2019] [Indexed: 12/21/2022]
Abstract
Cancer cell lines are important tools for anticancer drug research and assessment. Impedance measurements can provide valuable information about cell viability in real time. This work presents the proof-of-concept development of a bioelectrical, impedance-based analysis technique applied to four adherent mammalian cancer cells lines immobilized in a three-dimensional (3D) calcium alginate hydrogel matrix, thus mimicking in vivo tissue conditions. Cells were treated with cytostatic agent5-fluoruracil (5-FU). The cell lines used in this study were SK-N-SH, HEK293, HeLa, and MCF-7. For each cell culture, three cell population densities were chosen (50,000, 100,000, and 200,000 cells/100 μL). The aim of this study was the extraction of mean impedance values at various frequencies for the assessment of the different behavior of various cancer cells when 5-FU was applied. For comparison purposes, impedance measurements were implemented on untreated immobilized cell lines. The results demonstrated not only the dependence of each cell line impedance value on the frequency, but also the relation of the impedance level to the cell population density for every individual cell line. By establishing a cell line-specific bioelectrical behavior, it is possible to obtain a unique fingerprint for each cancer cell line reaction to a selected anticancer agent.
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Affiliation(s)
- Georgia Paivana
- Laboratory of Cell Technology, Department of Biotechnology, Agricultural University of Athens, 118 55 Athens, Greece; (G.P.); (S.K.)
| | - Sophie Mavrikou
- Laboratory of Cell Technology, Department of Biotechnology, Agricultural University of Athens, 118 55 Athens, Greece; (G.P.); (S.K.)
| | - Grigoris Kaltsas
- microSENSES Laboratory, Department of Electrical and Electronic Engineering, University of West Attica, 122 44 Athens, Greece;
| | - Spyridon Kintzios
- Laboratory of Cell Technology, Department of Biotechnology, Agricultural University of Athens, 118 55 Athens, Greece; (G.P.); (S.K.)
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869
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Affiliation(s)
- Alok A Khorana
- Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA.,Case Comprehensive Cancer Center, Cleveland, OH, USA
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870
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McBane RD, Loprinzi CL, Ashrani A, Lenz CJ, Houghton D, Zemla T, Le-Rademacher JG, Wysokinski WE. Extending venous thromboembolism secondary prevention with apixaban in cancer patients: The EVE trial. Eur J Haematol 2019; 104:88-96. [PMID: 31606897 DOI: 10.1111/ejh.13338] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 10/01/2019] [Accepted: 10/04/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Cancer-associated venous thromboembolism (VTE) carries a high rate of recurrence and death. Guidelines recommend continued anticoagulation therapy as long as active cancer persists. Apixaban 2.5 mg twice daily is the FDA-approved dose for secondary prevention regardless of VTE causation. Whether this apixaban dose is appropriate for secondary VTE prevention in cancer patients is not clear. The rationale and design of this investigator initiated phase III, multicenter, randomized, double-blind, trial assessing apixaban 2.5 mg vs 5 mg twice daily for 12 months for the secondary VTE prevention in cancer patients (n = 370) who have completed 6 months (but no more than 12 months) of anticoagulation is provided (NCT03080883). METHODS/DESIGN The primary study objective is to estimate differences in the combined rate of major plus clinically relevant non-major bleeding for apixaban 2.5 mg vs 5 mg twice daily. Secondary efficacy outcome is to assess rates of venous or arterial thromboembolism. Participating centers are chosen from the Academic and Community Cancer Research United (ACCRU) consortium. CONCLUSION We anticipate these trial results to provide evidence supporting low-dose apixaban as a safe agent for secondary prevention of cancer-associated VTE for patients who have already completed 6-12 months of anticoagulation.
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Affiliation(s)
- Robert D McBane
- Vascular Medicine Division, Gonda Vascular Center, Mayo Clinic, Rochester, Minnesota.,Hematology Division, Mayo Clinic, Rochester, Minnesota
| | | | - Aneel Ashrani
- Hematology Division, Mayo Clinic, Rochester, Minnesota
| | - Charles J Lenz
- Vascular Medicine Division, Gonda Vascular Center, Mayo Clinic, Rochester, Minnesota
| | - Damon Houghton
- Vascular Medicine Division, Gonda Vascular Center, Mayo Clinic, Rochester, Minnesota.,Hematology Division, Mayo Clinic, Rochester, Minnesota
| | - Tyler Zemla
- Health Science Research Biomedical Statistics and Informatics, Mayo Clinic, Rochester , Minnesota
| | - Jennifer G Le-Rademacher
- Health Science Research Biomedical Statistics and Informatics, Mayo Clinic, Rochester , Minnesota
| | - Waldemar E Wysokinski
- Vascular Medicine Division, Gonda Vascular Center, Mayo Clinic, Rochester, Minnesota.,Hematology Division, Mayo Clinic, Rochester, Minnesota
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871
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Recio-Boiles A, Veeravelli S, Vondrak J, Babiker HM, Scott AJ, Shroff RT, Patel H, Elquza E, McBride A. Evaluation of the safety and effectiveness of direct oral anticoagulants and low molecular weight heparin in gastrointestinal cancer-associated venous thromboembolism. World J Gastrointest Oncol 2019; 11:866-876. [PMID: 31662825 PMCID: PMC6815918 DOI: 10.4251/wjgo.v11.i10.866] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 09/03/2019] [Accepted: 09/12/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Gastrointestinal cancer (GICA) is associated with a higher incidence of venous thromboembolism (VTE) compared to other solid tumors, moreover, recurrent VTE and major bleeding (MB) complications during anticoagulation treatment have an associated increase rate. GICA-VTE remains a challenging clinical scenario with MB concerns for utilization of direct oral anticoagulants (DOAC), especially with active cancer therapies.
AIM To evaluate patient risk factors, effectiveness (VTE) and safety (MB) of DOACs and low molecular weight heparin (LMWH) in patients with active GICA-VTE.
METHODS A retrospective chart review of patients receiving DOACs and LMWH with GICA and symptomatic or incidental VTE treated at comprehensive cancer center from November 2013 to February 2017 was performed. Inclusion criteria included active GI cancer diagnosed at any stage or treatment +/- 6 mo of VTE diagnosis, whom were prescribed 6 mo or more of DOACs or LMWH. The Chi-squared test was used for overall and the Fisher exact test for pairwise comparisons of the proportions of patients experiencing recurrent VTE and MB events. Odds ratios were used to compare the relative odds of the occurrence of the outcome given exposure to the risk factor.
RESULTS A total of 144 patients were prescribed anticoagulation, in which 106 fulfilled inclusion criteria apixaban (27.3%), rivaroxaban (34.9%) and enoxaparin (37.7%), and 38 were excluded. Patients median age was 66.5 years at GICA diagnosis and 67 years at CAVTE event, with 62% males, 80% Caucasian, 70% stage IV, pancreatic cancer (40.5%), 30% Khorana Score (≥ 3 points), and 43.5% on active chemotherapy. Sixty-four percent of patients completed anticoagulation therapy (range 1 to 43 mo). Recurrent VTE at 6 mo was noted in 7.5% (n = 3), 6.8% (n = 2) and 2.7% (n = 1) of patients on enoxaparin, apixaban and rivaroxaban, respectively (all P = NS). MB at 6 mo were 5% (n = 2) for enoxaparin, 6.8% (n = 2) for apixaban and 21.6% (n = 8) for rivaroxaban (overall P = 0.048; vs LMWH P = 0.0423; all other P = NS). Significant predictors of a primary or secondary outcome for all anticoagulation therapies included: Active systemic treatment (OR = 5.1, 95%CI: 1.3-19.3), high Khorana Score [≥ 3 points] (OR = 5.5, 95%CI: 1.7-17.1), active smoker (OR = 6.7, 95%CI: 2.1-21.0), pancreatic cancer (OR = 6.8, 95%CI: 1.9-23.2), and stage IV disease (OR = 9.9, 95%CI: 1.2-79.1).
CONCLUSION Rivaroxaban compared to apixaban and enoxaparin had a significantly higher risk of MB on GICA-VTE patients with equivocal efficacy.
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Affiliation(s)
- Alejandro Recio-Boiles
- Department of Medicine, Hematology and Medical Oncology, University of Arizona Cancer Center, Tucson, AZ 85724, United States
| | - Sumana Veeravelli
- Department of Medicine, Internal Medicine Residency Program, University of Arizona, Tucson, AZ 85725, United States
| | - Jessica Vondrak
- Department of Medicine, Internal Medicine Residency Program, University of Arizona, Tucson, AZ 85725, United States
| | - Hani M Babiker
- Department of Medicine, Hematology and Medical Oncology, University of Arizona Cancer Center, Tucson, AZ 85724, United States
| | - Aaron J Scott
- Department of Medicine, Hematology and Medical Oncology, University of Arizona Cancer Center, Tucson, AZ 85724, United States
| | - Rachna T Shroff
- Department of Medicine, Hematology and Medical Oncology, University of Arizona Cancer Center, Tucson, AZ 85724, United States
| | - Hitendra Patel
- UC San Diego Health Moores Cancer Center, La Jolla, CA 92093, United States
| | - Emad Elquza
- Department of Medicine, Hematology and Medical Oncology, University of Arizona Cancer Center, Tucson, AZ 85724, United States
| | - Ali McBride
- University of Arizona College of Pharmacy, Tucson, AZ 85725, United States
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872
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Abstract
Cancer and kidney disease are linked by causality and comorbidities. Observational data show an increased risk of malignancy as renal function declines. Erythropoietin stimulating agents (ESAs), which are the cornerstone therapy for anemia patients with chronic kidney disease and cancer, are associated with increased risks for cancer, cancer-related mortality, progression of disease, and thromboembolic events. This article examines the recently published guidelines for ESA use in cancer patients from the American Society of Clinical Oncology and American Society of Hematology and attempts to contextualize them to the care of patients with coexistent CKD, cancer, and anemia.
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Affiliation(s)
- Sheron Latcha
- Renal Division, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
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873
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Mahé I, Elalamy I, Gerotziafas GT, Girard P. Treatment of Cancer-Associated Thrombosis: Beyond HOKUSAI. TH OPEN 2019; 3:e309-e315. [PMID: 31535076 PMCID: PMC6746618 DOI: 10.1055/s-0039-1696659] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 07/25/2019] [Indexed: 12/18/2022] Open
Abstract
Direct oral anticoagulants (DOACs) represent an attractive alternative to low-molecular-weight heparins (LMWHs) for the long-term treatment of cancer-associated thrombosis (CT) since they avoid the burden of daily injections. Analyses in subgroups of cancer patients from large randomized trials suggested that DOACs were at least as effective as vitamin K antagonists, while indirect comparisons suggested that DOACs' efficacy and safety profile were comparable to those of LMWHs. In the randomized controlled HOKUSAI-VTE Cancer study, currently the only completed phase III trial on DOACs in CT patients, edoxaban was shown noninferior to dalteparin on the composite primary endpoint of time to first recurrent venous thromboembolism or major bleeding during the 12 months after randomization. Study results suggest that both agents had comparable benefit/risk ratio in patients with CT. Even though this conclusion was valid from a strict statistical viewpoint, it was potentially misleading when interpreting benefit/risk ratios. Besides the obvious heterogeneity of the study population (e.g., 23% of patients no longer had cancer) and significantly different treatment durations between arms, secondary outcomes for efficacy were in favor of edoxaban for recurrent deep-vein thrombosis but not for recurrent pulmonary embolism, and major bleeding episodes were significantly more frequent in the edoxaban group, with an excess of gastrointestinal (GI) bleeding episodes observed mainly but not only in patients with GI cancers. More research is needed regarding specific patients' profiles, cancer types, and treatment period to better clarify the respective roles of DOACs and LMWHs in CT patients.
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Affiliation(s)
- Isabelle Mahé
- Université de Paris, Innovations Thérapeutiques en Hémostase, INSERM, Paris, France
- Service de médecine Interne, AH-HP, Hôpital Louis Mourier, Colombes, Université de Paris, France
- F-CRIN INNOVTE, Saint Etienne, France
| | - Ismaïl Elalamy
- F-CRIN INNOVTE, Saint Etienne, France
- Hematology and Thrombosis Center, Tenon University Hospital, Sorbonne University, INSERM U938, Paris, France
- Department of Obstetrics and Gynecology, The First I.M. Sechenov Moscow State Medical University, Moscow, Russia
| | - Grigoris T. Gerotziafas
- Research Group “Cancer, Haemostasis and Angiogenesis,” INSERM UMR_S 938, Centre de Recherche Saint-Antoine, Faculty of Medicine, Institut Universitaire de Cancérologie, Sorbonne Universities, Paris, France
- Service d’Hématologie Biologique Hôpital Tenon, Hôpitaux Universitaires de l’Est Parisien, APHP.6, Paris, France
| | - Philippe Girard
- F-CRIN INNOVTE, Saint Etienne, France
- Institut du Thorax Curie-Montsouris, l’Institut Mutualiste Montsouris, Paris, France
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