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Frere C, Benzidia I, Marjanovic Z, Farge D. Recent Advances in the Management of Cancer-Associated Thrombosis: New Hopes but New Challenges. Cancers (Basel) 2019; 11:cancers11010071. [PMID: 30634638 PMCID: PMC6357110 DOI: 10.3390/cancers11010071] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Revised: 12/31/2018] [Accepted: 01/08/2019] [Indexed: 12/13/2022] Open
Abstract
Venous thromboembolism (VTE) is a common cause of morbidity and mortality in cancer patients and leads to a significant increase in health care costs. Cancer patients often suffer from multiple co-morbidities and have both a greater risk of VTE recurrence and bleeding compared to non-cancer patients. Anticoagulation is therefore challenging. For many years, long-term therapy with Low-Molecular-Weight Heparin (LMWH) was the standard of care for the management of cancer-associated VTE. Direct oral anticoagulants (DOAC), which offer the convenience of an oral administration and have a rapid onset of action, have recently been proposed as a new option in this setting. Head-to-head comparisons between DOAC and LMWHs for the treatment of established VTE are now available, and data on the efficacy and safety of these drugs for primary prophylaxis of VTE in ambulatory cancer patients receiving systemic anticancer therapy are emerging. This narrative review aims to summarize the main recent advances in the prevention and treatment of cancer-associated VTE, including recent data on the use of individualized factors to stratify the risk of VTE in each individual patient, quality-of-life in patients treated with LMWH, and the place that DOACs will likely take in the cancer-associated VTE management landscape.
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Affiliation(s)
- Corinne Frere
- Institute of Cardiometabolism And Nutrition, INSERM UMRS_1166, Sorbonne Université, F-75013 Paris, France.
- Department of Haematology, Pitié-Salpêtrière Hospital, Assistance Publique Hôpitaux de Paris, F-75013 Paris, France.
| | - Ilham Benzidia
- Autoimmune and Vascular Disease Unit, Internal Medicine (UF04), Center of reference for rare systemic autoimmne diseases (FAI2R), Saint-Louis Hospital, Assistance Publique Hôpitaux de Paris, F-75010 Paris, France.
| | - Zora Marjanovic
- Department of Haematology, Saint-Antoine Hospital, Assistance Publique Hôpitaux de Paris, F-75012 Paris, France.
| | - Dominique Farge
- Autoimmune and Vascular Disease Unit, Internal Medicine (UF04), Center of reference for rare systemic autoimmne diseases (FAI2R), Saint-Louis Hospital, Assistance Publique Hôpitaux de Paris, F-75010 Paris, France.
- Department of Medicine, McGill University, Montreal, QC H3A 0E7, Canada.
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202
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Abstract
Venous thromboembolism (VTE) including pulmonary embolism (PE) and deep vein thrombosis (DVT) is one of the leading causes of preventable cardiovascular disease in the United States (US) and is the number one preventable cause of death following a surgical procedure. Post-operative VTE is associated with multiple short and long-term complications. We will focus on reviewing the many faces of VTE in detail as they represent common challenging scenarios in clinical practice.
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203
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Alexander M, Ball D, Solomon B, MacManus M, Manser R, Riedel B, Westerman D, Evans SM, Wolfe R, Burbury K. Dynamic Thromboembolic Risk Modelling to Target Appropriate Preventative Strategies for Patients with Non-Small Cell Lung Cancer. Cancers (Basel) 2019; 11:cancers11010050. [PMID: 30625975 PMCID: PMC6356389 DOI: 10.3390/cancers11010050] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 12/29/2018] [Indexed: 12/24/2022] Open
Abstract
Prevention of cancer-associated thromboembolism (TE) remains a significant clinical challenge and priority world-wide safety initiative. In this prospective non-small cell lung cancer (NSCLC) cohort, longitudinal TE risk profiling (clinical and biomarker) was undertaken to develop risk stratification models for targeted TE prevention. These were compared with published models from Khorana, CATS, PROTECHT, CONKO, and CATS/MICA. The NSCLC cohort of 129 patients, median follow-up 22.0 months (range 5.6—31.3), demonstrated a hypercoagulable profile in >75% patients and TE incidence of 19%. High TE risk patients were those receiving chemotherapy with baseline fibrinogen ≥ 4 g/L and d-dimer ≥ 0.5 mg/L; or baseline d-dimer ≥ 1.5 mg/L; or month 1 d-dimer ≥ 1.5 mg/L. The model predicted TE with 100% sensitivity and 34% specificity (c-index 0.67), with TE incidence 27% vs. 0% for high vs. low-risk. A comparison using the Khorana, PROTECHT, and CONKO methods were not discriminatory; TE incidence 17–25% vs. 14–19% for high vs. low-risk (c-index 0.51–0.59). Continuous d-dimer (CATS/MICA model) was also not predictive of TE. Independent of tumour stage, high TE risk was associated with cancer progression (HR 1.9, p = 0.01) and mortality (HR 2.2, p = 0.02). The model was tested for scalability in a prospective gastrointestinal cancer cohort with equipotency demonstrated; 80% sensitivity and 39% specificity. This proposed TE risk prediction model is simple, practical, potent and can be used in the clinic for real-time, decision-making for targeted thromboprophylaxis. Validation in a multicentre randomised interventional study is underway (ACTRN12618000811202).
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Affiliation(s)
- Marliese Alexander
- Department of Epidemiology and Preventive Medicine Monash University, 99 Commercial Road, Melbourne, VIC 3004, Australia.
- Pharmacy Department, Peter MacCallum Cancer Centre, 305 Grattan St, Melbourne, VIC 3000, Australia.
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, VIC 3010, Australia.
| | - David Ball
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, VIC 3010, Australia.
- Department of Radiation Oncology Peter MacCallum Cancer Centre, 305 Grattan St, Melbourne, VIC 3000, Australia.
| | - Benjamin Solomon
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, VIC 3010, Australia.
- Department of Medical Oncology, Peter MacCallum Cancer Centre, 305 Grattan St, Melbourne, VIC 3000, Australia.
| | - Michael MacManus
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, VIC 3010, Australia.
- Department of Radiation Oncology Peter MacCallum Cancer Centre, 305 Grattan St, Melbourne, VIC 3000, Australia.
| | - Renee Manser
- Department of Respiratory and Sleep Disorders Medicine, Royal Melbourne Hospital, Grattan Street, Parkville, VIC 3050, Australia.
| | - Bernhard Riedel
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, VIC 3010, Australia.
- Department of Anaesthesia, Perioperative and Pain Medicine, Peter MacCallum Cancer Centre, 305 Grattan St, Melbourne, VIC 3000, Australia.
| | - David Westerman
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, VIC 3010, Australia.
- Department of Pathology, Peter MacCallum Cancer Centre, 305 Grattan St, Melbourne, VIC 3000, Australia.
- Department of Haematology, Peter MacCallum Cancer Centre, 305 Grattan St, Melbourne, VIC 3000, Australia.
| | - Sue M Evans
- Department of Epidemiology and Preventive Medicine Monash University, 99 Commercial Road, Melbourne, VIC 3004, Australia.
| | - Rory Wolfe
- Department of Epidemiology and Preventive Medicine Monash University, 99 Commercial Road, Melbourne, VIC 3004, Australia.
| | - Kate Burbury
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, VIC 3010, Australia.
- Department of Pathology, Peter MacCallum Cancer Centre, 305 Grattan St, Melbourne, VIC 3000, Australia.
- Department of Haematology, Peter MacCallum Cancer Centre, 305 Grattan St, Melbourne, VIC 3000, Australia.
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204
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Mulder FI, Candeloro M, Kamphuisen PW, Di Nisio M, Bossuyt PM, Guman N, Smit K, Büller HR, van Es N. The Khorana score for prediction of venous thromboembolism in cancer patients: a systematic review and meta-analysis. Haematologica 2019; 104:1277-1287. [PMID: 30606788 PMCID: PMC6545838 DOI: 10.3324/haematol.2018.209114] [Citation(s) in RCA: 178] [Impact Index Per Article: 35.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Accepted: 01/02/2019] [Indexed: 12/13/2022] Open
Abstract
We aimed to evaluate the performance of the Khorana score in predicting venous thromboembolic events in ambulatory cancer patients. Embase and MEDLINE were searched from January 2008 to June 2018 for studies which evaluated the Khorana score. Two authors independently screened studies for eligibility, extracted data, and assessed risk of bias. Additional data on the 6-month incidence of venous thromboembolism were sought by contacting corresponding authors. The incidence in each Khorana score risk group was estimated with random effects meta-analysis. A total of 45 articles and eight abstracts were included, comprising 55 cohorts enrolling 34,555 ambulatory cancer patients. For 27,849 patients (81%), 6-month follow-up data were obtained. Overall, 19% of patients had a Khorana score of 0 points, 64% a score of 1 or 2 points, and 17% a score of 3 or more points. The incidence of venous thromboembolism in the first six months was 5.0% (95%CI: 3.9-6.5) in patients with a low-risk Khorana score (0 points), 6.6% (95%CI: 5.6-7.7) in those with an intermediate-risk Khorana score (1 or 2 points), and 11.0% (95%CI: 8.8-13.8) in those with a high-risk Khorana score (3 points or higher). Of the patients with venous thromboembolism in the first six months, 23.4% (95%CI: 18.4-29.4) had been classified as high risk according to the Khorana score. In conclusion, the Khorana score can be used to select ambulatory cancer patients at high risk of venous thromboembolism for thromboprophylaxis; however, most events occur outside this high-risk group.
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Affiliation(s)
- Frits I Mulder
- Tergooi Hospitals, Department of Internal Medicine, Hilversum, the Netherlands .,Amsterdam UMC, University of Amsterdam, Department of Vascular Medicine, Amsterdam Cardiovascular Science, Amsterdam, the Netherlands
| | - Matteo Candeloro
- University G. D'Annunzio, Department of Medicine and Ageing Sciences, Chieti, Italy
| | - Pieter W Kamphuisen
- Tergooi Hospitals, Department of Internal Medicine, Hilversum, the Netherlands
| | - Marcello Di Nisio
- University G. D'Annunzio, Department of Medicine and Ageing Sciences, Chieti, Italy
| | - Patrick M Bossuyt
- Amsterdam UMC, University of Amsterdam, Department of Vascular Medicine, Amsterdam Cardiovascular Science, Amsterdam, the Netherlands
| | - Noori Guman
- Amsterdam UMC, University of Amsterdam, Department of Vascular Medicine, Amsterdam Cardiovascular Science, Amsterdam, the Netherlands
| | - Kirsten Smit
- Amsterdam UMC, University of Amsterdam, Department of Vascular Medicine, Amsterdam Cardiovascular Science, Amsterdam, the Netherlands
| | - Harry R Büller
- Amsterdam UMC, University of Amsterdam, Department of Vascular Medicine, Amsterdam Cardiovascular Science, Amsterdam, the Netherlands
| | - Nick van Es
- Amsterdam UMC, University of Amsterdam, Department of Vascular Medicine, Amsterdam Cardiovascular Science, Amsterdam, the Netherlands
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205
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Phillips BT, Boehm KS, Cho MJ, Drinane JJ, Egro FM, Frojo G, Goldman JJ, Mundy LR, Teven CM, Gosain AK. Spotlight in Plastic Surgery. Plast Reconstr Surg 2019. [DOI: 10.1097/prs.0000000000005183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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206
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Michel L, Rassaf T, Totzeck M. Biomarkers for the detection of apparent and subclinical cancer therapy-related cardiotoxicity. J Thorac Dis 2018; 10:S4282-S4295. [PMID: 30701097 DOI: 10.21037/jtd.2018.08.15] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Progress in cancer therapy over the past decades improved long-term survival but increased cancer therapy-related cardiotoxicity. Many novel treatment options have been implemented with yet incompletely characterized cardiovascular side effects including heart failure, coronary artery disease, arrhythmias, valvular disease, venous thromboembolism and myocarditis. Diagnosis of potential cardiotoxic side effects is essential for an optimal treatment but remains challenging. Cardiac biomarkers troponin and brain natriuretic peptide/N-terminal proBNP (BNP/NT-proBNP) have been extensively studied in heart failure and acute coronary syndromes. Emerging evidence implicates a significant role in the detection of cardiotoxicity and guidance of therapy in cancer patients. Elevated troponin or BNP/NT-proBNP levels were associated with increased all-cause mortality in cancer patients and have been shown to predict manifest heart failure. BNP/NT-proBNP may be useful for the prediction of cancer therapy-related heart failure and response to heart failure therapy in adult and pediatric cancer patients while troponin can indicate acute myocardial infarction in patients with cancer therapy-related risk for coronary artery disease. Furthermore, troponin may be used for the identification of immune checkpoint inhibitor-related myocarditis with very high sensitivity. Finally, even D-dimer levels have been shown to improve risk stratification and diagnosis in cancer-associated venous thromboembolism. This review aims to summarize the current knowledge about biomarkers in cancer therapy-related cardiotoxicity. We also outline possible clinical recommendations for the detection and treatment of subclinical and clinically apparent cardiotoxic effects using biomarkers.
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Affiliation(s)
- Lars Michel
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, Medical Faculty, University Hospital Essen, Essen, Germany
| | - Tienush Rassaf
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, Medical Faculty, University Hospital Essen, Essen, Germany
| | - Matthias Totzeck
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, Medical Faculty, University Hospital Essen, Essen, Germany
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207
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Pachón V, Trujillo-Santos J, Domènech P, Gallardo E, Font C, González-Porras JR, Pérez-Segura P, Maestre A, Mateo J, Muñoz A, Peris ML, Lecumberri R. Cancer-Associated Thrombosis: Beyond Clinical Practice Guidelines-A Multidisciplinary (SEMI-SEOM-SETH) Expert Consensus. TH OPEN 2018; 2:e373-e386. [PMID: 31249964 PMCID: PMC6524906 DOI: 10.1055/s-0038-1675577] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 09/17/2018] [Indexed: 02/07/2023] Open
Abstract
Despite the growing interest and improved knowledge about venous thromboembolism in cancer patients in the last years, there are still many unsolved issues. Due to the limitations of the available literature, evidence-based clinical practice guidelines are not able to give solid recommendations for challenging scenarios often present in the setting of cancer-associated thrombosis (CAT). A multidisciplinary expert panel from three scientific societies—Spanish Society of Internal Medicine (SEMI), Spanish Society of Medical Oncology (SEOM), and Spanish Society Thrombosis and Haemostasis (SETH)—agreed on 12 controversial questions regarding prevention and management of CAT, which were thoroughly reviewed to provide further guidance. The suggestions presented herein may facilitate clinical decisions in specific complex circumstances, until these can be made leaning on reliable scientific evidence.
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Affiliation(s)
- Vanessa Pachón
- Department of Oncology, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | | | - Pere Domènech
- Thrombosis and Haemostasis Unit, Hospital Universitario Bellvitge, L'Hospitalet de Llobregat, Catalonia, Spain
| | - Enrique Gallardo
- Department of Oncology, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain
| | - Carmen Font
- Department of Medical Oncology, Hospital Clinic, Barcelona, Spain
| | | | | | - Ana Maestre
- Department of Internal Medicine, Hospital del Vinalopó, Elche, Spain
| | - José Mateo
- Hematology Service, Hospital Santa Creu i Sant Pau, Barcelona, Spain
| | - Andrés Muñoz
- Department of Oncology, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - María Luisa Peris
- Department of Internal Medicine, Hospital Provincial de Castellón, Castellón, Spain
| | - Ramón Lecumberri
- Hematology Service, Clínica Universidad de Navarra, IDISNA, CIBER-CV, Pamplona, Spain
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208
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Ferroni P, Roselli M, Zanzotto FM, Guadagni F. Artificial intelligence for cancer-associated thrombosis risk assessment. LANCET HAEMATOLOGY 2018; 5:e391. [PMID: 30172343 DOI: 10.1016/s2352-3026(18)30111-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 07/05/2018] [Indexed: 10/28/2022]
Affiliation(s)
- Patrizia Ferroni
- Department of Human Sciences and Quality of Life Promotion, San Raffaele Roma Open University, Rome 00166, Italy; InterInstitutional Multidisciplinary Biobank, IRCCS San Raffaele Pisana, Rome, Italy.
| | - Mario Roselli
- Department of Systems Medicine, Medical Oncology, Policlinico Tor Vergata Biospecimen Cancer Repository, University of Rome Tor Vergata, Rome, Italy
| | - Fabio M Zanzotto
- Department of Enterprise Engineering, University of Rome Tor Vergata, Rome, Italy
| | - Fiorella Guadagni
- Department of Human Sciences and Quality of Life Promotion, San Raffaele Roma Open University, Rome 00166, Italy; InterInstitutional Multidisciplinary Biobank, IRCCS San Raffaele Pisana, Rome, Italy
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209
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Khorana AA. Artificial intelligence for cancer-associated thrombosis risk assessment - Author's reply. Lancet Haematol 2018; 5:e391-e392. [PMID: 30172344 DOI: 10.1016/s2352-3026(18)30118-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Accepted: 07/16/2018] [Indexed: 06/08/2023]
Affiliation(s)
- Alok A Khorana
- Cleveland Clinic, Taussig Cancer Institute and Case Comprehensive Cancer Center, Cleveland, OH 44106, USA.
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210
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Abstract
PURPOSE OF REVIEW This review aims to summarize the epidemiology, current pathophysiologic understanding, and state-of-the-art treatment of venous thromboembolism (VTE) in cancer patients. RECENT FINDINGS The risk of VTE varies among cancer patients. Recently introduced prediction models better identify those at high risk of VTE. New mechanisms underlying hypercoagulability in cancer have been uncovered. Initial data on the efficacy of direct oral anticoagulants (DOACs) compared with low-molecular weight heparin to treat VTE in patients with cancer are promising. However, they may be associated with higher risk of gastrointestinal bleeding. VTE causes significant morbidity and mortality in cancer patients. Our understanding of the mechanisms of VTE, including those associated with cancer treatments, has significantly grown. The assessment of the benefit/risk balance of VTE treatment remains challenging in many patients with cancer. The introduction of DOACs has expanded treatment options, but knowledge on their efficacy and safety is incomplete.
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Affiliation(s)
- Alec A Schmaier
- Brigham & Women's Hospital, 75 Francis St. AB378, Boston, MA, 02115, USA
| | - Paurush Ambesh
- Maimonides Medical Center, Department of Internal Medicine, 4802 10th Ave, Brooklyn, NY, 11219, USA
| | - Umberto Campia
- Brigham & Women's Hospital, 75 Francis St. AB378, Boston, MA, 02115, USA.
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211
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Simplicity versus complexity: an existential dilemma as risk tools evolve. LANCET HAEMATOLOGY 2018; 5:e273-e274. [DOI: 10.1016/s2352-3026(18)30067-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 04/30/2018] [Indexed: 12/21/2022]
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