1
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Ma S, La J, Swinnerton KN, Guffey D, Bandyo R, Pozas GDL, Hanzelka K, Xiao X, Hernandez CR, Amos CI, Chitalia V, Ravid K, Merriman KW, Flowers CR, Fillmore NR, Li A. Thrombosis risk prediction in lymphoma patients: A multi-institutional, retrospective model development and validation study. Am J Hematol 2024; 99:1230-1239. [PMID: 38654461 PMCID: PMC11166507 DOI: 10.1002/ajh.27335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 02/05/2024] [Accepted: 03/23/2024] [Indexed: 04/26/2024]
Abstract
Venous thromboembolism (VTE) poses a significant risk to cancer patients receiving systemic therapy. The generalizability of pan-cancer models to lymphomas is limited. Currently, there are no reliable risk prediction models for thrombosis in patients with lymphoma. Our objective was to create a risk assessment model (RAM) specifically for lymphomas. We performed a retrospective cohort study to develop Fine and Gray sub-distribution hazard model for VTE and pulmonary embolism (PE)/ lower extremity deep vein thrombosis (LE-DVT) respectively in adult lymphoma patients from the Veterans Affairs national healthcare system (VA). External validations were performed at the Harris Health System (HHS) and the MD Anderson Cancer Center (MDACC). Time-dependent c-statistic and calibration curves were used to assess discrimination and fit. There were 10,313 (VA), 854 (HHS), and 1858 (MDACC) patients in the derivation and validation cohorts with diverse baseline. At 6 months, the VTE incidence was 5.8% (VA), 8.2% (HHS), and 8.8% (MDACC), respectively. The corresponding estimates for PE/LE-DVT were 3.9% (VA), 4.5% (HHS), and 3.7% (MDACC), respectively. The variables in the final RAM included lymphoma histology, body mass index, therapy type, recent hospitalization, history of VTE, history of paralysis/immobilization, and time to treatment initiation. The RAM had c-statistics of 0.68 in the derivation and 0.69 and 0.72 in the two external validation cohorts. The two models achieved a clear differentiation in risk stratification in each cohort. Our findings suggest that easy-to-implement, clinical-based model could be used to predict personalized VTE risk for lymphoma patients.
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Affiliation(s)
- Shengling Ma
- Section of Hematology-Oncology, Baylor College of Medicine, Houston, TX
| | - Jennifer La
- Massachusetts Veterans Epidemiology Research and Information Center, VA Boston Healthcare System, Boston, MA
- Department of Medicine, Harvard Medical School, Boston, MA
| | - Kaitlin N Swinnerton
- Massachusetts Veterans Epidemiology Research and Information Center, VA Boston Healthcare System, Boston, MA
| | - Danielle Guffey
- Institute for Clinical & Translational Research, Baylor College of Medicine, Houston, TX
| | | | - Giordana De Las Pozas
- Department of Cancer Registry, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Katy Hanzelka
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Xiangjun Xiao
- Institute for Clinical & Translational Research, Baylor College of Medicine, Houston, TX
| | | | - Christopher I Amos
- Institute for Clinical & Translational Research, Baylor College of Medicine, Houston, TX
- Section of Epidemiology and Population Science, Baylor College of Medicine, Houston, TX
| | - Vipul Chitalia
- Massachusetts Veterans Epidemiology Research and Information Center, VA Boston Healthcare System, Boston, MA
- Department of Medicine and Whitaker Cardiovascular Institute, Boston University Chobanian and Advedisian School of Medicine, Boston, MA
- Institute of Medical Engineering and Sciences, Massachusetts Institute of Technology, Cambridge, MA
| | - Katya Ravid
- Department of Medicine and Whitaker Cardiovascular Institute, Boston University Chobanian and Advedisian School of Medicine, Boston, MA
| | - Kelly W Merriman
- Department of Cancer Registry, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Christopher R Flowers
- Department of Lymphoma-Myeloma, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Nathanael R Fillmore
- Massachusetts Veterans Epidemiology Research and Information Center, VA Boston Healthcare System, Boston, MA
- Department of Medicine, Harvard Medical School, Boston, MA
| | - Ang Li
- Section of Hematology-Oncology, Baylor College of Medicine, Houston, TX
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2
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Shevell L, Ochs M, Schaefer J. Prophylactic Anticoagulation in Patients with Cancer: When and How? Curr Oncol Rep 2023; 25:201-209. [PMID: 36705880 DOI: 10.1007/s11912-023-01358-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/27/2022] [Indexed: 01/28/2023]
Abstract
PURPOSE OF REVIEW Cancer-associated thrombosis is a leading cause of death among patients with cancer. Historically, thromboprophylaxis efforts have focused on the highest risk patients with cancer, including post-operative patients and hospitalized patients. This review covers not only thromboprophylaxis for these groups but also emerging data supporting prophylaxis in ambulatory medical oncology patients. RECENT FINDINGS Several leading guidelines, backed by clinical trial data, now support the use of direct oral anticoagulants for select high-risk outpatients for primary thromboprophylaxis. However, uptake of these findings remains low. Pharmacologic venous thromboembolism prophylaxis strategies continue to improve. However, it remains challenging to balance competing risks of bleeding and thrombosis. The morbidity and mortality associated with cancer associated thrombosis may be preventable. Understanding advancements in risk prediction, anticoagulant options, and implementation of existing data, is critical to provide optimal patient care.
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Affiliation(s)
- Lauren Shevell
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Madeleine Ochs
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Jordan Schaefer
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, 48109, USA.
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3
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Shah S, Karathanasi A, Revythis A, Ioannidou E, Boussios S. Cancer-Associated Thrombosis: A New Light on an Old Story. Diseases 2021; 9:34. [PMID: 34064390 PMCID: PMC8161803 DOI: 10.3390/diseases9020034] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 04/08/2021] [Accepted: 05/01/2021] [Indexed: 12/12/2022] Open
Abstract
Cancer-associated thrombosis (CAT) is a rising and significant phenomenon, becoming the second leading cause of death in cancer patients. Pathophysiology of CAT differs from thrombosis in the non-cancer population. There are additional risk factors for thrombosis specific to cancer including cancer type, histology, and treatment, such as chemotherapy. Recently developed scoring systems use these risk factors to stratify the degree of risk and encourage thromboprophylaxis in intermediate- to high-risk patients. Anticoagulation is safely used for prophylaxis and treatment of CAT. Both of these have largely been with low-molecular-weight heparin (LMWH), rather than the vitamin K antagonist (VKA); however, there has been increasing evidence for direct oral anticoagulant (DOAC) use. Consequently, international guidelines have also adapted to recommend the role of DOACs in CAT. Using DOACs is a turning point for CAT, but further research is warranted for their long-term risk profile. This review will discuss mechanisms, risk factors, prophylaxis and management of CAT, including both LMWH and DOACs. There will also be a comparison of current international guidelines and how they reflect the growing evidence base.
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Affiliation(s)
- Sidrah Shah
- Department of Hematology/Medical Oncology, Medway NHS Foundation Trust, Windmill Road, Gillingham ME7 5NY, UK; (S.S.); (A.K.); (A.R.)
| | - Afroditi Karathanasi
- Department of Hematology/Medical Oncology, Medway NHS Foundation Trust, Windmill Road, Gillingham ME7 5NY, UK; (S.S.); (A.K.); (A.R.)
| | - Antonios Revythis
- Department of Hematology/Medical Oncology, Medway NHS Foundation Trust, Windmill Road, Gillingham ME7 5NY, UK; (S.S.); (A.K.); (A.R.)
| | - Evangelia Ioannidou
- Department of Paediatrics and Child Health, West Suffolk Hospital NHS Foundation Trust, Hardwick Lane, Bury St Edmunds IP33 2QZ, UK;
| | - Stergios Boussios
- Department of Hematology/Medical Oncology, Medway NHS Foundation Trust, Windmill Road, Gillingham ME7 5NY, UK; (S.S.); (A.K.); (A.R.)
- Faculty of Life Sciences & Medicine, School of Cancer & Pharmaceutical Sciences, King’s College London, London SE1 9RT, UK
- AELIA Organization, 9th Km Thessaloniki-Thermi, 57001 Thessaloniki, Greece
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4
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Rutjes AW, Porreca E, Candeloro M, Valeriani E, Di Nisio M. Primary prophylaxis for venous thromboembolism in ambulatory cancer patients receiving chemotherapy. Cochrane Database Syst Rev 2020; 12:CD008500. [PMID: 33337539 PMCID: PMC8829903 DOI: 10.1002/14651858.cd008500.pub5] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Venous thromboembolism (VTE) often complicates the clinical course of cancer. The risk is further increased by chemotherapy, but the trade-off between safety and efficacy of primary thromboprophylaxis in cancer patients treated with chemotherapy is uncertain. This is the third update of a review first published in February 2012. OBJECTIVES To assess the efficacy and safety of primary thromboprophylaxis for VTE in ambulatory cancer patients receiving chemotherapy compared with placebo or no thromboprophylaxis, or an active control intervention. SEARCH METHODS For this update, the Cochrane Vascular Information Specialist searched the Cochrane Vascular, CENTRAL, MEDLINE, Embase and CINAHL databases and World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 3 August 2020. We also searched the reference lists of identified studies and contacted content experts and trialists for relevant references. SELECTION CRITERIA Randomised controlled trials comparing any oral or parenteral anticoagulant or mechanical intervention to no thromboprophylaxis or placebo, or comparing two different anticoagulants. DATA COLLECTION AND ANALYSIS We extracted data on risk of bias, participant characteristics, interventions, and outcomes including symptomatic VTE and major bleeding as the primary effectiveness and safety outcomes, respectively. We applied GRADE to assess the certainty of evidence. MAIN RESULTS We identified six additional randomised controlled trials (3326 participants) for this update, bringing the included study total to 32 (15,678 participants), all evaluating pharmacological interventions and performed mainly in people with locally advanced or metastatic cancer. The certainty of the evidence ranged from high to very low across the different outcomes and comparisons. The main limiting factors were imprecision and risk of bias. Thromboprophylaxis with direct oral anticoagulants (direct factor Xa inhibitors apixaban and rivaroxaban) may decrease the incidence of symptomatic VTE (risk ratio (RR) 0.43, 95% confidence interval (CI) 0.18 to 1.06; 3 studies, 1526 participants; low-certainty evidence); and probably increases the risk of major bleeding compared with placebo (RR 1.74, 95% CI 0.82 to 3.68; 3 studies, 1494 participants; moderate-certainty evidence). When compared with no thromboprophylaxis, low-molecular-weight heparin (LMWH) reduced the incidence of symptomatic VTE (RR 0.62, 95% CI 0.46 to 0.83; 11 studies, 3931 participants; high-certainty evidence); and probably increased the risk of major bleeding events (RR 1.63, 95% CI 1.12 to 2.35; 15 studies, 7282 participants; moderate-certainty evidence). In participants with multiple myeloma, LMWH resulted in lower symptomatic VTE compared with the vitamin K antagonist warfarin (RR 0.33, 95% CI 0.14 to 0.83; 1 study, 439 participants; high-certainty evidence), while LMWH probably lowers symptomatic VTE more than aspirin (RR 0.51, 95% CI 0.22 to 1.17; 2 studies, 781 participants; moderate-certainty evidence). Major bleeding was observed in none of the participants with multiple myeloma treated with LMWH or warfarin and in less than 1% of those treated with aspirin. Only one study evaluated unfractionated heparin against no thromboprophylaxis, but did not report on VTE or major bleeding. When compared with placebo or no thromboprophylaxis, warfarin may importantly reduce symptomatic VTE (RR 0.15, 95% CI 0.02 to 1.20; 1 study, 311 participants; low-certainty evidence) and may result in a large increase in major bleeding (RR 3.82, 95% CI 0.97 to 15.04; 4 studies, 994 participants; low-certainty evidence). One study evaluated antithrombin versus no antithrombin in children. This study did not report on symptomatic VTE but did report any VTE (symptomatic and incidental VTE). The effect of antithrombin on any VTE and major bleeding is uncertain (any VTE: RR 0.84, 95% CI 0.41 to 1.73; major bleeding: RR 0.78, 95% CI 0.03 to 18.57; 1 study, 85 participants; very low-certainty evidence). AUTHORS' CONCLUSIONS In ambulatory cancer patients, primary thromboprophylaxis with direct factor Xa inhibitors may reduce the incidence of symptomatic VTE (low-certainty evidence) and probably increases the risk of major bleeding (moderate-certainty evidence) when compared with placebo. LMWH decreases the incidence of symptomatic VTE (high-certainty evidence), but increases the risk of major bleeding (moderate-certainty evidence) when compared with placebo or no thromboprophylaxis. Evidence for the use of thromboprophylaxis with anticoagulants other than direct factor Xa inhibitors and LMWH is limited. More studies are warranted to evaluate the efficacy and safety of primary prophylaxis in specific types of chemotherapeutic agents and types of cancer, such as gastrointestinal or genitourinary cancer.
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Affiliation(s)
- Anne Ws Rutjes
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
| | - Ettore Porreca
- Department of Medical, Oral and Biotechnological Sciences, University "G. D'Annunzio" of Chieti-Pescara, Chieti, Italy
| | - Matteo Candeloro
- Internal Medicine Unit, "University G. D'Annunzio" Foundation, Chieti, Italy
| | - Emanuele Valeriani
- Internal Medicine Unit, "University G. D'Annunzio" Foundation, Chieti, Italy
| | - Marcello Di Nisio
- Department of Medicine and Ageing Sciences, University "G. D'Annunzio" of Chieti-Pescara, Chieti Scalo, Italy
- Department of Vascular Medicine, Academic Medical Center, Amsterdam, Netherlands
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5
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Barni S, Rosati G, Lonardi S, Pella N, Banzi M, Zampino MG, Dotti KF, Rimassa L, Marchetti P, Maiello E, Artioli F, Ferrari D, Labianca R, Bidoli P, Zaniboni A, Sobrero A, Iaffaioli V, De Placido S, Frassineti GL, Ciarlo A, Buonadonna A, Silvestris N, Piazza E, Pavesi L, Moroni M, Clerico M, Aglietta M, Giordani P, Galli F, Galli F, Petrelli F. Khorana score and thromboembolic risk in stage II-III colorectal cancer patients: a post hoc analysis from the adjuvant TOSCA trial. Ther Adv Med Oncol 2020; 12:1758835919899850. [PMID: 32010236 PMCID: PMC6974756 DOI: 10.1177/1758835919899850] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Accepted: 12/09/2019] [Indexed: 11/16/2022] Open
Abstract
Background: The risk of venous thromboembolic events (VTE) during adjuvant chemotherapy
for colorectal cancer (CRC) is unknown. We aim to evaluate if the Khorana
score (KS) can predict this risk, and if it represents a prognostic factor
for overall survival (OS) through a post hoc analysis of
the phase III TOSCA trial of different durations (3- versus
6-months) of adjuvant chemotherapy. Methods: A logistic regression model was used to test the associations between the
risk of VTE and the KS. The results are expressed as odds ratios (OR) with
95% confidence intervals (95% CI). To assess the effect of the KS on OS,
multivariable analyses using Cox regression models were performed. The
results are expressed as hazard ratios (HR) with 95% CI. Results: Among 1380 CRC patients with available data, the VTE risk
(n = 72 events: 5.2%) was similar in the two duration arms
(5.5% versus 4.9%), with 0.2% of patients belonging to the
high-risk KS group. Rates of VTE were similar in the low- and
intermediate-risk groups (4.8% versus 6.4%). KS did not
represent an independent predictive factor for VTE occurrence. Chemotherapy
duration was not associated with VTE risk. In addition, KS was not
prognostic for OS in multivariate analysis (HR: 0.92, 95% CI, 0.63–1.36;
p = 0.6835). Conclusions: The use of the KS did not predict VTEs in a low–moderate thromboembolic risk
population as CRC. These data did not support the use of KS to predict VTE
during adjuvant chemotherapy, and suggest that other risk assessment models
should be researched.
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Affiliation(s)
- Sandro Barni
- Oncology Unit, Medical Science Department, ASST Bergamo Ovest, Treviglio (BG), Italy
| | - Gerardo Rosati
- Medical Oncology Unit, Ospedale San Carlo, Potenza, Italy
| | - Sara Lonardi
- Medical Oncology Unit 1, Istituto Oncologico Veneto-IRCCS, Padova, Italy
| | - Nicoletta Pella
- Medical Oncology Unit, Azienda Ospedaliero Universitaria Santa Maria della Misericordia, Udine, Italy
| | - Maria Banzi
- Medical Oncology Unit, Arcispedale Santa Maria Nuova-IRCCS, Reggio Emilia, Italy
| | - Maria G Zampino
- Gastrointestinal Medical Oncology Unit and Neuroendocrine Tumors, Istituto Europeo di Oncologia-IRCCS, Milano, Italy
| | - Katia F Dotti
- Medical Oncology Unit, Fondazione Istituto Nazionale Tumori-IRCCS, Milano, Italy
| | - Lorenza Rimassa
- Medical Oncology and Hematology Unit, Humanitas Cancer Center, Humanitas Clinical and Research Center, Rozzano (MI), Italy
| | - Paolo Marchetti
- Medical Oncology Unit, Sant'Andrea Hospital, Sapienza University of Rome and IDI-IRCCS, Roma, Italy
| | - Evaristo Maiello
- Medical Oncology Unit, Hospital Casa Sollievo della Sofferenza-IRCCS, San Giovanni Rotondo, Italy
| | | | - Daris Ferrari
- Medical Oncology Unit, Azienda Ospedaliera San Paolo, Milano, Italy
| | | | - Paolo Bidoli
- Medical Oncology Unit San Gerardo dei Tintori Hospital, Monza, Italy
| | | | | | - Vincenzo Iaffaioli
- Abdominal Medical Oncology, National Cancer Institute, IRCCS Foundation Pascale, Napoli, Italy
| | - Sabino De Placido
- Department of Clinical Medicine and Surgery, Federico II University, Napoli, Italy
| | - Gian Luca Frassineti
- Department of Medical Oncology, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori IRST, IRCCS, Meldola, Italy
| | | | - Angela Buonadonna
- Medical Oncology Unit Centro di Riferimento Oncologico Aviano-IRCCS, Aviano, Italy
| | - Nicola Silvestris
- Medical Oncology Unit Ospedale Oncologico 'Giovanni Paolo II' and Scientific Directorate-IRCCS, Bari, Italy
| | - Elena Piazza
- Medical Oncology Unit AOU Sacco Hospital, Milano, Italy
| | - Lorenzo Pavesi
- Medical Oncology Unit Fondazione Maugeri-IRCCS, Pavia, Italy
| | - Mauro Moroni
- Medical Oncology Unit AO San Carlo Borromeo, Milano, Italy
| | - Mario Clerico
- Medical Oncology Department ASL Biella, Biella, Italy
| | - Massimo Aglietta
- Candiolo Cancer Institute FPO-IRCCS, Candiolo, Italy, Department of Oncology, University of Torino, Torino, Italy
| | - Paolo Giordani
- Medical Oncology Unit AO Ospedali Riuniti Marche Nord, Pesaro, Italy
| | - Francesca Galli
- Laboratory of Methodology for Clinical Research, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milano, Italy
| | - Fabio Galli
- Laboratory of Methodology for Clinical Research, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milano, Italy
| | - Fausto Petrelli
- Oncology Unit, Medical Science Department, ASST Bergamo Ovest, Piazzale Ospedale 1, Treviglio (BG), 24047, Italy
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6
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Paulsen B, Skille H, Smith EN, Hveem K, Gabrielsen ME, Brækkan SK, Rosendaal FR, Frazer KA, Gran OV, Hansen JB. Fibrinogen gamma gene rs2066865 and risk of cancer-related venous thromboembolism. Haematologica 2019; 105:1963-1968. [PMID: 31582554 PMCID: PMC7327659 DOI: 10.3324/haematol.2019.224279] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 10/03/2019] [Indexed: 12/21/2022] Open
Abstract
Venous thromboembolism (VTE) is a frequent complication in patients with cancer. Homozygous carriers of the fibrinogen gamma gene (FGG) rs2066865 have a moderately increased risk of VTE, but the effect of the FGG variant in cancer is unknown. We aimed to investigate the effect of the FGG variant and active cancer on the risk of VTE. Cases with incident VTE (n=640) and a randomly selected age-weighted sub-cohort (n=3,734) were derived from a population-based cohort (the Tromsø study). Cox-regression was used to estimate hazard ratios (HR) with 95% confidence intervals (CI) for VTE according to categories of cancer and FGG. In those without cancer, homozygosity at the FGG variant was associated with a 70% (HR 1.7, 95% CI: 1.2–2.3) increased risk of VTE compared to non-carriers. Cancer patients homozygous for the FGG variant had a two-fold (HR 2.0, 95% CI: 1.1–3.6) higher risk of VTE than cancer patients without the variant. Moreover, the six-months cumulative incidence of VTE among cancer patients was 6.4% (95% CI: 3.5–11.6) in homozygous carriers of FGG and 3.1% (95% CI: 2.3–4.7) in those without risk alleles. A synergistic effect was observed between rs2066865 and active cancer on the risk of VTE (synergy index: 1.81, 95% CI: 1.02–3.21, attributable proportion: 0.43, 95% CI: 0.11–0.74). In conclusion, homozygosity at the FGG variant and active cancer yielded a synergistic effect on the risk of VTE.
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Affiliation(s)
- Benedikte Paulsen
- K.G. Jebsen Thrombosis Research and Expertise Center (TREC), Department of Clinical Medicine, UiT - The Arctic University of Norway, Tromsø, Norway
| | - Hanne Skille
- K.G. Jebsen Thrombosis Research and Expertise Center (TREC), Department of Clinical Medicine, UiT - The Arctic University of Norway, Tromsø, Norway
| | - Erin N Smith
- Department of Pediatrics and Rady's Children's Hospital, University of California, San Diego, La Jolla, CA, USA
| | - Kristian Hveem
- St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway.,HUNT Research Centre, Department of Public Health and General Practice, Norwegian University of Science and Technology, Levanger, Norway.,K. G. Jebsen Center for Genetic Epidemiology, Department of Public Health, Norwegian University of Science and Technology, Trondheim, Norway
| | - Maiken E Gabrielsen
- HUNT Research Centre, Department of Public Health and General Practice, Norwegian University of Science and Technology, Levanger, Norway.,K. G. Jebsen Center for Genetic Epidemiology, Department of Public Health, Norwegian University of Science and Technology, Trondheim, Norway
| | - Sigrid K Brækkan
- K.G. Jebsen Thrombosis Research and Expertise Center (TREC), Department of Clinical Medicine, UiT - The Arctic University of Norway, Tromsø, Norway.,Division of Internal Medicine, University Hospital of North Norway, Tromsø, Norway
| | - Frits R Rosendaal
- K.G. Jebsen Thrombosis Research and Expertise Center (TREC), Department of Clinical Medicine, UiT - The Arctic University of Norway, Tromsø, Norway.,Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Kelly A Frazer
- K.G. Jebsen Thrombosis Research and Expertise Center (TREC), Department of Clinical Medicine, UiT - The Arctic University of Norway, Tromsø, Norway.,Department of Pediatrics and Rady's Children's Hospital, University of California, San Diego, La Jolla, CA, USA
| | - Olga V Gran
- K.G. Jebsen Thrombosis Research and Expertise Center (TREC), Department of Clinical Medicine, UiT - The Arctic University of Norway, Tromsø, Norway
| | - John-Bjarne Hansen
- K.G. Jebsen Thrombosis Research and Expertise Center (TREC), Department of Clinical Medicine, UiT - The Arctic University of Norway, Tromsø, Norway.,Division of Internal Medicine, University Hospital of North Norway, Tromsø, Norway
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7
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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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8
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Di Nisio M, Porreca E, Candeloro M, De Tursi M, Russi I, Rutjes AWS. Primary prophylaxis for venous thromboembolism in ambulatory cancer patients receiving chemotherapy. Cochrane Database Syst Rev 2016; 12:CD008500. [PMID: 27906452 PMCID: PMC6463937 DOI: 10.1002/14651858.cd008500.pub4] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Venous thromboembolism (VTE) often complicates the clinical course of cancer. The risk is further increased by chemotherapy, but the trade-off between safety and efficacy of primary thromboprophylaxis in cancer patients treated with chemotherapy is uncertain. This is the second update of a review first published in February 2012. OBJECTIVES To assess the efficacy and safety of primary thromboprophylaxis for VTE in ambulatory cancer patients receiving chemotherapy compared with placebo or no thromboprophylaxis. SEARCH METHODS For this update the Cochrane Vascular Information Specialist searched the Cochrane Vascular Group Specialised Register (June 2016). In addition, the Information Specialist searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2016, Issue 5). Clinical trials registries were searched up to June 2016. SELECTION CRITERIA Randomised controlled trials comparing any oral or parenteral anticoagulant or mechanical intervention to no thromboprophylaxis or placebo, or comparing two different anticoagulants. DATA COLLECTION AND ANALYSIS We extracted data on methodological quality, participant characteristics, interventions, and outcomes including symptomatic VTE and major bleeding as the primary effectiveness and safety outcomes, respectively. MAIN RESULTS We identified five additional randomised controlled trials (2491 participants) in the updated search, considering in this update 26 trials with a total of 12,352 participants, all evaluating pharmacological interventions and performed mainly in people with locally advanced or metastatic cancer. The quality of the evidence ranged from high to very low across the different outcomes and comparisons. The main limiting factors were imprecision and risk of bias. One large trial of 3212 participants found a 64% (risk ratio (RR) 0.36, 95% confidence interval (CI) 0.22 to 0.60) reduction of symptomatic VTE with the ultra-low molecular weight heparin (uLMWH) semuloparin relative to placebo, with no apparent difference in major bleeding (RR 1.05, 95% CI 0.55 to 2.00). When compared with no thromboprophylaxis, LMWH significantly reduced the incidence of symptomatic VTE (RR 0.54, 95% CI 0.38 to 0.75; no heterogeneity, Tau2 = 0.00%) with a non-statistically significant 44% higher risk of major bleeding events (RR 1.44, 95% CI 0.98 to 2.11). In participants with multiple myeloma, LMWH was associated with a significant reduction in symptomatic VTE compared with the vitamin K antagonist warfarin (RR 0.33, 95% CI 0.14 to 0.83), while the difference between LMWH and aspirin was not statistically significant (RR 0.51, 95% CI 0.22 to 1.17). Major bleeding was observed in none of the participants treated with LMWH or warfarin and in less than 1% of those treated with aspirin. Only one study evaluated unfractionated heparin against no thromboprophylaxis but did not report on VTE or major bleeding. When compared with placebo, warfarin was associated with a non-statistically significant reduction of symptomatic VTE (RR 0.15, 95% CI 0.02 to 1.20). Antithrombin, evaluated in one study involving paediatric patients, had no significant effect on VTE or on major bleeding when compared with no antithrombin. The direct oral factor Xa inhibitor apixaban was evaluated in a phase II dose-finding study that suggested a low rate of major bleeding (2.1% versus 3.4%) and symptomatic VTE (1.1% versus 13.8%) in comparison with placebo. AUTHORS' CONCLUSIONS In this second update, we confirmed that primary thromboprophylaxis with LMWH significantly reduced the incidence of symptomatic VTE in ambulatory cancer patients treated with chemotherapy. In addition, the uLMWH semuloparin, which is not commercially available, significantly reduced the incidence of symptomatic VTE. The risk of major bleeding associated with LMWH, while not reaching statistical significance, suggest caution and mandate additional studies to determine the risk-to-benefit ratio of LMWH in this setting. Despite the encouraging results of this review, routine prophylaxis in ambulatory cancer patients cannot be recommended before safety issues are adequately addressed. We need additional studies investigating targeted primary prophylaxis in people with specific types or stages of cancer associated with a higher risk of VTE.
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Affiliation(s)
- Marcello Di Nisio
- University "G. D'Annunzio" of Chieti‐PescaraDepartment of Medical, Oral and Biotechnological Sciencesvia dei Vestini 31ChietiItaly66013
- Academic Medical CenterDepartment of Vascular MedicineAmsterdamNetherlands
| | - Ettore Porreca
- University "G. D'Annunzio" of Chieti‐PescaraDepartment of Medical, Oral and Biotechnological Sciencesvia dei Vestini 31ChietiItaly66013
| | - Matteo Candeloro
- "University G. D'Annunzio" FoundationInternal Medicine UnitChietiItaly
| | - Michele De Tursi
- "University G. D'Annunzio" FoundationInternal Medicine UnitChietiItaly
| | - Ilaria Russi
- University "G. D'Annunzio" of Chieti‐PescaraDepartment of Medical, Oral and Biotechnological Sciencesvia dei Vestini 31ChietiItaly66013
| | - Anne WS Rutjes
- Fondazione "Università G. D'Annunzio"Centre for Systematic ReviewsVia dei Vestini 31ChietiChietiItaly66100
- University of BernCTU BernBernBernSwitzerland3012
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9
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Abstract
Venous thromboembolism (VTE) is a highly prevalent complication of malignancy with emerging changes in incidence, diagnosis and treatment paradigms. This manuscript, initiated by the Anticoagulation Forum, provides clinical guidance based on existing guidelines and consensus expert opinion where guidelines are lacking. We address a) the appropriate workup to search for occult malignancy in patients with idiopathic VTE, b) identification of high-risk cancer patients for primary thromboprophylaxis, c) the appropriate immediate and long-term treatment for people with cancer diagnosed with acute thromboembolism, d) the appropriate duration of anticoagulation and e) the appropriate treatment strategy in patients with recurrent VTE on anticoagulation. Areas of controversy and future directions in this field are highlighted.
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Oo TH. Outpatient thromboprophylaxis with low-molecular-weight heparin in solid tumors: Where do we stand today? J Thromb Thrombolysis 2016; 41:539-40. [PMID: 26931102 DOI: 10.1007/s11239-016-1346-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Thein Hlaing Oo
- Section of Thrombosis & Benign Hematology, The University of Texas M.D. Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1464, Houston, TX, 77030, USA.
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García Escobar I, Antonio Rebollo M, García Adrián S, Rodríguez-Garzotto A, Muñoz Martín A. Safety and efficacy of primary thromboprophylaxis in cancer patients. Clin Transl Oncol 2016; 19:1-11. [DOI: 10.1007/s12094-016-1500-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Accepted: 03/07/2016] [Indexed: 10/21/2022]
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Di Nisio M, Peinemann F, Porreca E, Rutjes AWS. Treatment for superficial infusion thrombophlebitis of the upper extremity. Cochrane Database Syst Rev 2015; 2015:CD011015. [PMID: 26588711 PMCID: PMC6885032 DOI: 10.1002/14651858.cd011015.pub2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Although superficial thrombophlebitis of the upper extremity represents a frequent complication of intravenous catheters inserted into the peripheral veins of the forearm or hand, no consensus exists on the optimal management of this condition in clinical practice. OBJECTIVES To summarise the evidence from randomised clinical trials (RCTs) concerning the efficacy and safety of (topical, oral or parenteral) medical therapy of superficial thrombophlebitis of the upper extremity. SEARCH METHODS The Cochrane Vascular Group Trials Search Co-ordinator searched the Specialised Register (last searched April 2015) and the Cochrane Register of Studies (2015, Issue 3). Clinical trials registries were searched up to April 2015. SELECTION CRITERIA RCTs comparing any (topical, oral or parenteral) medical treatment to no intervention or placebo, or comparing two different medical interventions (e.g. a different variant scheme or regimen of the same intervention or a different pharmacological type of treatment). DATA COLLECTION AND ANALYSIS We extracted data on methodological quality, patient characteristics, interventions and outcomes, including improvement of signs and symptoms as the primary effectiveness outcome, and number of participants experiencing side effects of the study treatments as the primary safety outcome. MAIN RESULTS We identified 13 studies (917 participants). The evaluated treatment modalities consisted of a topical treatment (11 studies), an oral treatment (2 studies) and a parenteral treatment (2 studies). Seven studies used a placebo or no intervention control group, whereas all others also or solely compared active treatment groups. No study evaluated the effects of ice or the application of cold or hot bandages. Overall, the risk of bias in individual trials was moderate to high, although poor reporting hampered a full appreciation of the risk in most studies. The overall quality of the evidence for each of the outcomes varied from low to moderate mainly due to risk of bias and imprecision, with only single trials contributing to most comparisons. Data on primary outcomes improvement of signs and symptoms and side effects attributed to the study treatment could not be statistically pooled because of the between-study differences in comparisons, outcomes and type of instruments to measure outcomes.An array of topical treatments, such as heparinoid or diclofenac gels, improved pain compared to placebo or no intervention. Compared to placebo, oral non-steroidal anti-inflammatory drugs reduced signs and symptoms intensity. Safety issues were reported sparsely and were not available for some interventions, such as notoginseny creams, parenteral low-molecular-weight heparin or defibrotide. Although several trials reported on adverse events with topical heparinoid creams, Essaven gel or phlebolan versus control, the trials were underpowered to adequately measure any differences between treatment modalities. Where reported, adverse events with topical treatments consisted mainly of local allergic reactions. Only one study of 15 participants assessed thrombus extension and symptomatic venous thromboembolism with either oral non-steroidal anti-inflammatory drugs or low-molecular-weight heparin, and it reported no cases of either. No study reported on the development of suppurative phlebitis, catheter-related bloodstream infections or quality of life. AUTHORS' CONCLUSIONS The evidence about the treatment of acute infusion superficial thrombophlebitis is limited and of low quality. Data appear too preliminary to assess the effectiveness and safety of topical treatments, systemic anticoagulation or oral non-steroidal anti-inflammatory drugs.
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Affiliation(s)
| | - Frank Peinemann
- University of CologneChildren's HospitalKerpener Str. 62CologneGermany50937
| | - Ettore Porreca
- "University G. D'Annunzio" FoundationDepartment of Medicine and Aging; Centre for Aging Sciences (Ce.S.I.), Internal Medicine Unit31 Via dei VestiniChietiItaly66100
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Khalil J, Bensaid B, Elkacemi H, Afif M, Bensaid Y, Kebdani T, Benjaafar N. Venous thromboembolism in cancer patients: an underestimated major health problem. World J Surg Oncol 2015; 13:204. [PMID: 26092573 PMCID: PMC4486121 DOI: 10.1186/s12957-015-0592-8] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Accepted: 04/24/2015] [Indexed: 12/12/2022] Open
Abstract
Venous thromboembolism (VTE) is a major health problem among patients with cancer, its incidence in this particular population is widely increasing. Although VTE is associated with high rates of mortality and morbidity in cancer patients, its severity is still underestimated by many oncologists. Thromboprophylaxis of VTE now considered as a standard of care is still not prescribed in many institutions; the appropriate treatment of an established VTE is not yet well known by many physicians and nurses in the cancer field. Patients are also not well informed about VTE and its consequences. Many studies and meta-analyses have addressed this question so have many guidelines that dedicated a whole chapter to clarify and expose different treatment strategies adapted to this particular population. There is a general belief that the prevention and treatment of VTE cannot be optimized without a complete awareness by oncologists and patients. The aim of this article is to make VTE a more clear and understood subject.
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Affiliation(s)
- Jihane Khalil
- Radiation Oncology Department, National Institute of Oncology, Hay Riad, Rabat, 10000, Morocco.
| | - Badr Bensaid
- Vascular Surgery Department, Ibn Sina Hospital, Souissi, Rabat, 10000, Morocco.
| | - Hanan Elkacemi
- Radiation Oncology Department, National Institute of Oncology, Hay Riad, Rabat, 10000, Morocco.
| | - Mohamed Afif
- Radiation Oncology Department, National Institute of Oncology, Hay Riad, Rabat, 10000, Morocco.
| | - Younes Bensaid
- Vascular Surgery Department, Ibn Sina Hospital, Souissi, Rabat, 10000, Morocco.
| | - Tayeb Kebdani
- Radiation Oncology Department, National Institute of Oncology, Hay Riad, Rabat, 10000, Morocco.
| | - Noureddine Benjaafar
- Radiation Oncology Department, National Institute of Oncology, Hay Riad, Rabat, 10000, Morocco.
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Di Nisio M, Peinemann F, Porreca E, Rutjes AWS. Primary prophylaxis for venous thromboembolism in patients undergoing cardiac or thoracic surgery. Cochrane Database Syst Rev 2015; 2015:CD009658. [PMID: 26091835 PMCID: PMC11024391 DOI: 10.1002/14651858.cd009658.pub2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Cardiac and thoracic surgery are associated with an increased risk of venous thromboembolism (VTE). The safety and efficacy of primary thromboprophylaxis in patients undergoing these types of surgery is uncertain. OBJECTIVES To assess the effects of primary thromboprophylaxis on the incidence of symptomatic VTE and major bleeding in patients undergoing cardiac or thoracic surgery. SEARCH METHODS The Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched May 2014) and CENTRAL (2014, Issue 4). The authors searched the reference lists of relevant studies, conference proceedings, and clinical trial registries. SELECTION CRITERIA Randomised controlled trials (RCTs) and quasi-RCTs comparing any oral or parenteral anticoagulant or mechanical intervention to no intervention or placebo, or comparing two different anticoagulants. DATA COLLECTION AND ANALYSIS We extracted data on methodological quality, participant characteristics, interventions, and outcomes including symptomatic VTE and major bleeding as the primary effectiveness and safety outcomes, respectively. MAIN RESULTS We identified 12 RCTs and one quasi-RCT (6923 participants), six for cardiac surgery (3359 participants) and seven for thoracic surgery (3564 participants). No study evaluated fondaparinux, the new oral direct thrombin, direct factor Xa inhibitors, or caval filters. All studies had major study design flaws and most lacked a placebo or no treatment control group. We typically graded the quality of the overall body of evidence for the various outcomes and comparisons as low, due to imprecise estimates of effect and risk of bias. We could not pool data because of the different comparisons and the lack of data. In cardiac surgery, 71 symptomatic VTEs occurred in 3040 participants from four studies. In a study of 2551 participants, representing 85% of the review population in cardiac surgery, the combination of unfractionated heparin with pneumatic compression stockings was associated with a 61% reduction of symptomatic VTE compared to unfractionated heparin alone (1.5% versus 4.0%; risk ratio (RR) 0.39; 95% confidence interval (CI) 0.23 to 0.64). Major bleeding was only reported in one study, which found a higher incidence with vitamin K antagonists compared to platelet inhibitors (11.3% versus 1.6%, RR 7.06; 95% CI 1.64 to 30.40). In thoracic surgery, 15 symptomatic VTEs occurred in 2890 participants from six studies. In the largest study evaluating unfractionated heparin versus an inactive control the rates of symptomatic VTE were 0.7% versus 0%, respectively, giving a RR of 6.71 (95% CI 0.40 to 112.65). There was insufficient evidence to determine if there was a difference in the risk of major bleeding from two studies evaluating fixed-dose versus weight-adjusted low molecular weight heparin (2.7% versus 8.1%, RR 0.33; 95% CI 0.07 to 1.60) and unfractionated heparin versus low molecular weight heparin (6% and 4%, RR 1.50; 95% CI 0.26 to 8.60). AUTHORS' CONCLUSIONS The evidence regarding the efficacy and safety of thromboprophylaxis in cardiac and thoracic surgery is limited. Data for important outcomes such as pulmonary embolism or major bleeding were often lacking. Given the uncertainties around the benefit-to-risk balance, no conclusions can be drawn and a case-by-case risk evaluation of VTE and bleeding remains preferable.
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Affiliation(s)
- Marcello Di Nisio
- University "G. D'Annunzio" of Chieti‐PescaraDepartment of Medical, Oral and Biotechnological Sciencesvia dei Vestini 31ChietiItaly66013
- Academic Medical CenterDepartment of Vascular MedicineAmsterdamNetherlands
| | - Frank Peinemann
- Children's Hospital, University of ColognePediatric Oncology and HematologyKerpener Str. 62CologneNWGermany50937
| | - Ettore Porreca
- "University G. D'Annunzio" FoundationDepartment of Medicine and Aging; Centre for Aging Sciences (Ce.S.I.), Internal Medicine Unit31 Via dei VestiniChietiChietiItaly66100
| | - Anne WS Rutjes
- University "G. D'Annunzio" of Chieti‐PescaraDepartment of Medical, Oral and Biotechnological Sciencesvia dei Vestini 31ChietiItaly66013
- Fondazione "Università G. D'Annunzio"Centre for Systematic Reviewsvia dei Vestini 31ChietiChietiItaly66100
- University of BernInstitute of Social and Preventive Medicine (ISPM)Finkenhubelweg 11BernBernSwitzerland3012
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15
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Zalpour A, Oo TH. Clinical utility of apixaban in the prevention and treatment of venous thromboembolism: current evidence. DRUG DESIGN DEVELOPMENT AND THERAPY 2014; 8:2181-91. [PMID: 25395835 PMCID: PMC4226443 DOI: 10.2147/dddt.s51006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Anticoagulation with heparin and vitamin K antagonist has been the mainstay of prevention and treatment of venous thromboembolism (VTE) for many years. In recent years, novel oral anticoagulants such as dabigatran etexilate (a direct thrombin inhibitor) and rivaroxaban, apixaban, and edoxaban (a direct factor Xa inhibitor) have emerged for the prevention and treatment of VTE. Novel oral anticoagulants have been shown to be noninferior to vitamin K antagonist or heparin in the prevention and treatment of VTE. This review specifically examines the role of apixaban in the prevention and treatment of VTE based on the available literature. The management of apixaban in the perioperative setting is also explored because some patients on apixaban may require surgical intervention. Finally, we discuss the management of apixaban-induced major bleeding complications, the relevance of drug–drug interactions, and patient education.
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Affiliation(s)
- Ali Zalpour
- Division of Pharmacy - Clinical Programs, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Thein Hlaing Oo
- Section of Thrombosis and Benign Hematology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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16
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Muñoz Martín AJ, Font Puig C, Navarro Martín LM, Borrega García P, Martín Jiménez M. Clinical guide SEOM on venous thromboembolism in cancer patients. Clin Transl Oncol 2014; 16:1079-90. [PMID: 25366189 PMCID: PMC4239786 DOI: 10.1007/s12094-014-1238-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Accepted: 09/26/2014] [Indexed: 12/21/2022]
Abstract
Venous thromboembolism (VTE) is a common event in cancer patients and one of the major causes of cancer-associated mortality and a leading cause of morbidity. In recent years, the incidence rates of VTE have notably increased; however, VTE is still commonly underestimated by oncologists. VTE is considered an adverse prognostic factor in cancer patients in all settings. In 2011 the Spanish Society of Medical Oncology (SEOM) first published a clinical guideline of prophylaxis and treatment of VTE in cancer patients. In an effort to incorporate evidence obtained since the original publication, SEOM presents an update of the guideline for thrombosis and cancer in order to improve the prevention and management of VTE.
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Affiliation(s)
- A J Muñoz Martín
- Medical Oncology Service, Gregorio Marañón University General Hospital, Madrid, Spain,
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17
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Clinical use and the Italian demand for antithrombin. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2014; 11 Suppl 4:s86-93. [PMID: 24333319 DOI: 10.2450/2013.014s] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Alikhan R, Forster R, Cohen AT. Heparin for the prevention of venous thromboembolism in acutely ill medical patients (excluding stroke and myocardial infarction). Cochrane Database Syst Rev 2014; 2014:CD003747. [PMID: 24804622 PMCID: PMC6491079 DOI: 10.1002/14651858.cd003747.pub4] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Venous thromboembolic disease has been extensively studied in surgical patients. The benefit of thromboprophylaxis is now generally accepted, but it is medical patients who make up the greater proportion of the hospital population. Medical patients differ from surgical patients with regard to their health and the pathogenesis of thromboembolism and the impact that preventative measures can have. The extensive experience from thromboprophylaxis studies in surgical patients is therefore not necessarily applicable to non-surgical patients. This is an update of a review first published in 2009. OBJECTIVES To determine the effectiveness and safety of heparin (unfractionated heparin or low molecular weight heparin) thromboprophylaxis in acutely ill medical patients admitted to hospital, excluding those admitted to hospital with an acute myocardial infarction or stroke (ischaemic or haemorrhagic) or those requiring admission to an intensive care unit. SEARCH METHODS For this update the Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched November 2013) and CENTRAL (2013, Issue 10). SELECTION CRITERIA Randomised controlled trials comparing unfractionated heparin (UFH) or low molecular weight heparin (LMWH) with placebo or no treatment, or comparing UFH with LMWH. DATA COLLECTION AND ANALYSIS One review author identified possible trials and a second review author confirmed their eligibility for inclusion in the review. Two review authors extracted the data. Disagreements were resolved by discussion. We performed the meta-analysis using a fixed-effect model with the results expressed as odds ratios (ORs) with 95% confidence intervals (CIs). MAIN RESULTS Sixteen studies with a combined total of 34,369 participants with an acute medical illness were included in this review. We identified 10 studies comparing heparin with placebo or no treatment and six studies comparing LMWH to UFH. Just under half of the studies had an open-label design, putting them at a risk of performance bias. Descriptions of random sequence generation and allocation concealment were missing in most of the studies. Heparin reduced the odds of deep vein thrombosis (DVT) (OR 0.38; 95% CI 0.29 to 0.51; P < 0.00001). The estimated reductions in symptomatic non-fatal pulmonary embolism (PE) (OR 0.46; 95% CI 0.19 to 1.10; P = 0.08), fatal PE (OR 0.71; 95% CI 0.43 to 1.15; P = 0.16) and in combined non-fatal PE and fatal PE (OR 0.65; 95% CI 0.42 to 1.00; P = 0.05) associated with heparin were imprecise. Heparin resulted in an increase in major haemorrhage (OR 1.81; 95% CI 1.10 to 2.98; P = 0.02). There was no clear evidence that heparin had an effect on all-cause mortality and thrombocytopaenia. Compared with UFH, LMWH reduced the risk of DVT (OR 0.77; 95% CI 0.62 to 0.96; P = 0.02) and major bleeding (OR 0.43; 95% CI 0.22 to 0.83; P = 0.01). There was no clear evidence that the effects of LMWH and UFH differed for the PE outcomes, all-cause mortality and thrombocytopaenia. AUTHORS' CONCLUSIONS The data from this review describe a reduction in the risk of DVT in patients presenting with an acute medical illness who receive heparin thromboprophylaxis. This needs to be balanced against an increase in the risk of bleeding associated with thromboprophylaxis. The analysis favoured LMWH compared with UFH, with a reduced risk of both DVT and bleeding.
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Affiliation(s)
- Raza Alikhan
- University Hospital of WalesHaemophilia and Thrombosis CentreHeath ParkCardiffUKCF14 4XW
| | - Rachel Forster
- University of EdinburghUsher Institute of Population Health Sciences and InformaticsEdinburghUKEH8 9AG
| | - Alexander T Cohen
- Kings College HospitalDepartment of Vascular SurgeryDenmark HillLondonUKSE5 9RS
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Kreher S, Riess H. [Prophylaxis and treatment of venous thromboembolism in cancer patients. Clinical value of low-molecular-weight heparins]. Internist (Berl) 2014; 55:448-54. [PMID: 24599489 DOI: 10.1007/s00108-014-3476-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Venous thromboembolism (VTE) is a common complication in patients with cancer. Because of their improved subcutaneous bioavailability and reliable antithrombotic efficiency low-molecular-weight heparins (LMWH) are preferably used for prevention and treatment of cancer-related VTE. Thromboprophylaxis with LMWH is well established in patients undergoing cancer surgery and hospitalized cancer patients, while outpatient prophylaxis remains contentious. LMWH are recommended over unfractionated heparins and vitamin K antagonists for initial treatment and secondary prophylaxis (3-6 months) after cancer-related VTE. Long-term secondary prophylaxis should be considered for patients with ongoing active malignancy and low bleeding risk. Due to absence of clinical studies in cancer patients, the use of novel oral anticoagulants is currently not recommended.
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Affiliation(s)
- S Kreher
- Medizinische Klinik mit Schwerpunkt Hämatologie, Onkologie und Tumorimmunologie, Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12200, Berlin, Deutschland,
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Phan M, John S, Casanegra AI, Rathbun S, Mansfield A, Stoner JA, Tafur AJ. Primary venous thromboembolism prophylaxis in patients with solid tumors: a meta-analysis. J Thromb Thrombolysis 2014; 38:241-9. [PMID: 24233387 PMCID: PMC4427894 DOI: 10.1007/s11239-013-1014-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Venous thromboembolism (VTE) is a leading cause of death among outpatient chemotherapy patients. However the VTE preventive measures for outpatients are not widely advocated. We did a meta-analysis to evaluate the outpatient VTE prevention's effectiveness and safety. We searched electronic databases until the end of December 2012 and reviewed the abstracts and manuscripts following the PRISMA guidelines. Occurrence of first VTE event was the efficacy outcome. The safety end point was major bleeding. We calculated Q statistic and a homogeneity formal test. The odds ratio (OR) estimates were pooled by using the Mantel-Haenszel fixed-effects method in the absence of heterogeneity. Data were analyzed using the R META package). We identified 1,485 articles and reviewed 37 articles based on initial screening. The number of patients included in 11 selected trials was 7,805. The odds of VTE was lower in the prophylaxis group (OR 0.56; 95% CI 0.45-0.71) and improved when heparin-based prevention was analyzed (OR 0.53; 95% CI 0.41-0.70). We found strong prevention among patients with lung cancer (OR 0.46; 95% CI 0.29-0.74) and pancreatic cancer (OR 0.33; 95% CI 0.16-0.67). Major bleeding events were frequent in the intervention group (OR 1.65; 95% CI 1.12-2.44). Thromboprophylaxis reduced VTE episodes. The VTE events were reduced by 47% in heparin-based prophylaxis trials compared to placebo. The patients receiving heparin-based prophylaxis had a 60% increase in bleeding events. Improving risk stratification tools to personalize prevention strategies may enhance the VTE prevention applicability in cancer patients.
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Affiliation(s)
- Minh Phan
- Internal Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
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Abstract
Venous thromboembolism (VTE), including deep vein thrombosis and pulmonary embolism, are common problems experienced by patients with lung cancer that can impact treatment plans, prognoses, and survival. Patients with lung cancer are at greatest risk for development of VTE in the ambulatory care treatment setting. Literature does exist on VTE management for medical and surgical oncology inpatients, as well as clinical guidelines for inpatient prophylaxis; however, published evidence is lacking on outpatient risk and thromboprophylaxis in medical oncology outpatients, particularly patients with lung cancer. Because patients with lung cancer treated in the ambulatory setting have established risks for VTE, they may benefit from thromboprophylaxis. Clinical guidelines for outpatient thromboprophylaxis direct the clinical practice for thromboprophylaxis in lung cancer treatment. The purpose of the current article is to explore the VTE risks associated with ambulatory lung cancer treatment and to review the recommended guidelines for thromboprophylaxis to guide clinical decision making for patients with lung cancer.
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Affiliation(s)
- Loretta Cavaliere
- Jefferson School of Nursing, Thomas Jefferson University, Philadelphia, PA, USA.
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22
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Schoot RA, Kremer LCM, van de Wetering MD, van Ommen CH. Systemic treatments for the prevention of venous thrombo-embolic events in paediatric cancer patients with tunnelled central venous catheters. Cochrane Database Syst Rev 2013:CD009160. [PMID: 24026801 DOI: 10.1002/14651858.cd009160.pub2] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Venous thrombo-embolic events (VTEs) occur in 2.2% to 14% of paediatric cancer patients and cause significant morbidity and mortality. The malignant disease itself, the cancer treatment and the presence of central venous catheters (CVCs) increase the risk of VTE. OBJECTIVES The primary objective of this review was to investigate the effects of preventive systemic treatments in paediatric cancer patients with tunnelled CVCs on (a)symptomatic VTE. Secondary objectives of this review were to investigate adverse effects of systemic treatments for the prevention of (a)symptomatic VTE in paediatric cancer patients with tunnelled CVCs; and to investigate the effects of systemic treatments in the prevention of (a)symptomatic VTE with CVC-related infection in paediatric cancer patients with tunnelled CVCs. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 8 2012), MEDLINE (1966 to August 2012) and EMBASE (1966 to August 2012). In addition, we searched reference lists from relevant articles and conference proceedings of the International Society for Paediatric Oncology (SIOP) (from 2006 to 2011), the American Society of Clinical Oncology (ASCO) (from 2006 to 2011), the American Society of Hematology (ASH) (from 2006 to 2011) and the International Society of Thrombosis and Haematology (ISTH) (from 2006 to 2011). We scanned the International Standard Randomised Controlled Trial Number (ISRCTN) Register and the National Institute of Health (NIH) Register for ongoing trials (www.controlled-trials.com) (August 2012), and we contacted the authors of eligible studies if additional information was required. SELECTION CRITERIA Randomised controlled trials (RCTs) and controlled clinical trials (CCTs) comparing systemic treatments to prevent venous thrombo-embolic events (VTEs) in paediatric cancer patients with tunnelled CVCs with a control intervention or no systemic treatment. For the description of adverse events, cohort studies were eligible for inclusion. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies, extracted data and performed risk of bias assessment of included studies. Analyses were performed according to the guidelines of the Cochrane Handbook for Systematic Reviews of Interventions. MAIN RESULTS Three RCTs and three CCTs (including 1291 children) investigated the prevention of VTE (low molecular weight heparin (LMWH) n = 134, antithrombin (AT) supplementation n = 37, low-dose warfarin n = 31, cryoprecipitate and/or fresh frozen plasma (FFP) supplementation n = 240, AT supplementation and LMWH n = 41). AT, cryoprecipitate and FFP were supplemented only in cases of AT or fibrinogen deficiency. Of the six included RCTs/CCTs, five investigated the prevention of VTE compared with no intervention (n = 737), and one CCT compared AT supplementation and LMWH with AT supplementation (n = 71). All studies had methodological limitations, and clinical heterogeneity between studies was noted.We found no significant effects of systemic treatments compared with no intervention in preventing (a)symptomatic VTE and no differences in adverse events (such as major and/or minor bleeding; none of the studies reported thrombocytopenia, heparin-induced thrombocytopenia (HIT), heparin-induced thrombocytopenia with thrombosis (HITT), death as a result of VTE, removal of CVC due to VTE, CVC-related infection, and post-thrombotic syndrome (PTS)) between experimental and control groups. Two studies with comparable participant groups and interventions were included for meta-analyses (n = 182). In the experimental group, 1/68 (1.5%) children were diagnosed with symptomatic VTE, as were 4/114 (3.5%) in the control group (best case scenario: risk ratio (RR) 0.65, 95% confidence interval (CI) 0.09 to 4.78). These studies also evaluated asymptomatic CVC-related VTE: In the experimental group, 22/68 (32.4%) were diagnosed with asymptomatic VTE, as were 35/114 (30.7%) in the control group (best case scenario: RR 1.02, 95% CI 0.40 to 2.55). Heterogeneity was substantial for this analysis: I(2) = 73%.The attribution of LMWH to AT supplementation resulted in a significant reduction in symptomatic VTE (Fisher's exact test, two-sided P = 0.028) without bleeding complications; asymptomatic VTE, thrombocytopenia, HIT, HITT, death as a result of VTE, removal of CVC due to VTE, CVC-related infection and PTS were not assessed.Four cohort studies were included for the evaluation of adverse events. Three studies provided information on bleeding episodes: One participant developed an ischaemo-haemorrhagic stroke. One study provided information on other adverse events: None occurred. AUTHORS' CONCLUSIONS We found no significant effects of systemic treatments compared with no intervention in preventing (a)symptomatic VTE in paediatric oncology patients with CVCs. However, this could be a result of the low number of included participants, which resulted in low power. In one CCT, which compared one systemic treatment with another systemic treatment, we identified a significant reduction in symptomatic VTE with the addition of LMWH to AT supplementation.All studies investigated the prevalence of major and/or minor bleeding episodes, and none found a significant difference between study groups. None of the studies reported thrombocytopenia, HIT, HITT, death as a result of VTE, removal of CVC due to VTE, CVC-related infection or PTS among participants.On the basis of currently available evidence, we are not able to give recommendations for clinical practise. Additional well-designed international RCTs are needed to further explore the effects of systemic treatments in preventing VTE. Future studies should aim for adequate power with attainable sample sizes. The incidence of symptomatic VTE is relatively low; therefore, it might be necessary to select participants with thrombotic risk factors or to investigate asymptomatic VTE instead.
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Affiliation(s)
- Reineke A Schoot
- Department of Paediatric Oncology, Emma Children's Hospital / Academic Medical Center, PO Box 22660, Amsterdam, Netherlands, 1100 DD
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23
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[Risk of venous thromboembolism in patients with cancer treated with cisplatin: A systematic review and meta-analysis]. Strahlenther Onkol 2013; 189:704-5. [PMID: 23793866 DOI: 10.1007/s00066-013-0386-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Abstract
Venous thromboembolism (VTE) is common throughout the course of disease in high-grade glioma (HGG). The interactions between the coagulation cascade, endothelium, and regulation of angiogenesis are complex and drive glioblastoma growth and invasion. We reviewed the incidence of VTE in HGG, the biology of the coagulome as related to glioblastoma progression, prevention and treatment of thrombosis, and the putative role of anticoagulants as anti-cancer therapy. VTE can be significantly reduced during the postoperative period with adherence to the use of mechanical and medical thromboprophylaxis. Activation of the coagulation cascade occurs throughout the course of disease because of a variety of complex interactions, including tumor hypoxia, upregulation of VEGR expression, and increases in both tumor cell-specific tissue factor (TF) expression and inducible TF expression in numerous intrinsic regulatory pathways. Long-term anticoagulation to prevent VTE is an attractive therapy; however, the therapeutic window is narrow and current data do not support its routine use. Most patients with proven symptomatic VTE can be safely anticoagulated, including those receiving anti-VEGF therapy, such as bevacizumab. Initial therapy should include low molecular weight heparin (LMWH), and protracted anticoagulant treatment, perhaps indefinitely, is indicated for patients with HGG because of the ongoing risk of thrombosis. A variety of coagulation- and tumor-related proteins, such as TF and circulating microparticles, may serve as potential disease-specific biomarkers in relation to disease recurrence, monitoring of therapy, and as potential therapeutic targets.
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Affiliation(s)
- James R Perry
- Division of Neurology and Odette Cancer Centre, University of Toronto, Canada.
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